Changes In Care Delivery Research Articles

Increased Inpatient Mortality for Cardiovascular Patients During the First Wave of the COVID-19 Epidemic in New York.

BackgroundThe acuity and magnitude of the first wave of the COVID‐19 epidemic in New York mandated a drastic change in healthcare access and delivery of care.Methods and ResultsWe retrospectively studied patients admitted with an acute cardiovascular syndrome as their principal diagnosis to 13 hospitals across Northwell Health during March 11 through May 26, 2020 (first COVID‐19 epidemic wave) and the same period in 2019. Three thousand sixteen patients (242 COVID‐19 positive) were admitted for an acute cardiovascular syndrome during the first COVID‐19 wave compared with 9422 patients 1 year prior (decrease of 68.0%, P<0.001). During this time, patients with cardiovascular disease presented later to the hospital (360 versus 120 minutes for acute myocardial infarction), underwent fewer procedures (34.6% versus 45.6%, P<0.001), were less likely to be treated in an intensive care unit setting (8.7% versus 10.8%, P<0.001), and had a longer hospital stay (2.91 [1.71–6.05] versus 2.87 [1.82–4.95] days, P=0.033). Inpatient cardiovascular mortality during the first epidemic outbreak increased by 111.1% (3.8 versus 1.8, P<0.001) and was not related to COVID‐19‐related admissions, all cause in‐hospital mortality, or incidence of out‐of‐hospital cardiac deaths in New York. Admission during the first COVID‐19 surge along with age and positive COVID‐19 test independently predicted mortality for cardiovascular admissions (odds ratios, 1.30, 1.05, and 5.09, respectively, P<0.0001).ConclusionsA lower rate and later presentation of patients with cardiovascular pathology, coupled with deviation from common clinical practice mandated by the first wave of the COVID‐19 pandemic, might have accounted for higher in‐hospital cardiovascular mortality during that period.

Evaluating consumer and clinical sleep technologies: an American Academy of Sleep Medicine update

Evaluating consumer and clinical sleep technologies: an American Academy of Sleep Medicine update

Pharmacogenomic-based personalized medicine: Multistakeholder perspectives on implementational drivers and barriers in the Canadian healthcare system.

Pharmacogenomics (PGx)‐based personalized medicine (PM) is increasingly utilized to guide treatment decisions for many drug‐disease combinations. Notably, London Health Sciences Centre (LHSC) has pioneered a PGx program that has become a staple for London‐based specialists. Although implementational studies have been conducted in other jurisdictions, the Canadian healthcare system is understudied. Herein, the multistakeholder perspectives on implementational drivers and barriers are elucidated. Using a mixed‐method qualitative model, key stakeholders, and patients from LHSC’s PGx‐based PM clinic were interviewed and surveyed, respectively. Interview transcripts were thematically analyzed in a stepwise process of customer profiling, value mapping, and business model canvasing. Value for LHSC located specialist users of PGx was driven by the quick turnaround time, independence of the PGx clinic, and the quality of information. Engagement of external specialists was only limited by access and awareness, whereas other healthcare nonusers were limited by education and applicability. The major determinant of successful adoption at novel sites were institutional champions. Patients valued and approved of the service, expressed a general willingness to pay, but often traveled far to receive genotyping. This paper discusses the critical pillars of education, awareness, advocacy, and efficiency required to address implementation barriers to healthcare service innovation in Canada. Further adoption of PGx practices into Canadian hospitals is an important factor for advancing system‐level changes in care delivery, patient experiences, and outcomes. The findings in this paper can help inform efforts to advance clinical PGx practices, but also the potential adoption and implementation of other innovative healthcare service solutions.

Changes in Short-term, Long-term, and Preventive Care Delivery in US Office-Based and Telemedicine Visits During the COVID-19 Pandemic.

While the COVID-19 pandemic has been associated with some substitution of telemedicine for office-based care in the US, to our knowledge, little is known regarding the pandemic's association with the clinical content of ambulatory care. To characterize changes in the clinical content of ambulatory care among office-based vs telemedicine encounters in the US before vs during the COVID-19 pandemic. This analysis of serial cross-sectional data from the IQVIA National Disease and Therapeutic Index was a 2-stage, stratified nationally representative audit of outpatient care in the US from January 1, 2018, through December 31, 2020. The National Disease and Therapeutic Index generates approximately 33 617 quarterly visits that are projected to 306.7 million national visits based on the survey design. (1) Prevalence of common diagnoses and (2) mix of long-term, short-term, and preventive care. The mean (SD) number of projected quarterly, in-person, office-based visits was 282.1 (1.4) million in 2018 and 284.7 (10.3) in 2019 before declining to 250.8 million in quarter 1 of 2020 and 147.8 million in quarter 2 of 2020 and then increasing moderately to 181.5 million in quarter 3 of 2020 and 180.2 million in quarter 4 of 2020. The mean (SD) number of telemedicine visits was 2.8 (0.4) million in 2018 and 3.0 (0.1) million in 2019 before increasing to 8.6 million in quarter 1 of 2020 and 72.2 million in quarter 2 of 2020 and then declining notably to 43.8 million in quarter 3 of 2020 and 44.2 million in quarter 4 of 2020. Office-based care during the second through fourth quarters of 2020 involved 58.0% long-term, 23.0% short-term, and 25.6% preventive care. In contrast to office-based care, 4 of the top 10 diagnoses that were treated by telemedicine during 2020 were for psychiatric or behavioral conditions: depression, attention deficit/hyperactivity, anxiety, and bipolar disorders. Throughout this period, approximately half of office-based visits and nearly two-thirds of telemedicine visits were for established rather than new patients. This cross-sectional study's findings suggest that while telemedicine rapidly increased early during course of the COVID-19 pandemic, its use declined modestly since then. In contrast to office-based care, telemedicine was more commonly used for established patients and substantially greater delivery of psychiatric or behavioral treatments rather than preventive care.

The impact of resource limitations on care delivery and outcomes: routine variation, the coronavirus disease 2019 pandemic, and persistent shortage.

Purpose of reviewResource limitation, or capacity strain, has been associated with changes in care delivery, and in some cases, poorer outcomes among critically ill patients. This may result from normal variation in strain on available resources, chronic strain in persistently under-resourced settings, and less commonly because of acute surges in demand, as seen during the coronavirus disease 2019 (COVID-19) pandemic.Recent findingsRecent studies confirmed existing evidence that high ICU strain is associated with ICU triage decisions, and that ICU strain may be associated with ICU patient mortality. Studies also demonstrated earlier discharge of ICU patients during high strain, suggesting that strain may promote patient flow efficiency. Several studies of strain resulting from the COVID-19 pandemic provided support for the concept of adaptability – that the surge not only caused detrimental strain but also provided experience with a novel disease entity such that outcomes improved over time. Chronically resource-limited settings faced even more challenging circumstances because of acute-on-chronic strain during the pandemic.SummaryThe interaction between resource limitation and care delivery and outcomes is complex and incompletely understood. The COVID-19 pandemic provides a learning opportunity for strain response during both pandemic and nonpandemic times.

Implementing Family-Centered Rounds in Hospital Pediatric Settings: A Scoping Review.

The American Academy of Pediatrics and Institute for Patient and Family-Centered Care issued a joint policy statement in 2012 recommending family and nurse participation in rounds as a standard practice. To synthesize available evidence on the state of the implementation of family-centered rounds (FCRs), including identified barriers to stakeholder acceptance and participation in FCRs in pediatric inpatient settings and implementation strategies to increase adherence and related outcomes. PubMed and Medline and the Cochrane Database of Systematic Reviews. Observational and experimental studies from January 2009 to July 2020. Two reviewers independently screened each study to determine eligibility and extract data. Initial evidence quality was evaluated on the basis of study design. A total of 53 studies were included in the final synthesis. FCRs are increasingly accepted by stakeholders, although participation lags. Structural barriers to nurse and family attendance persist. Limited high-quality evidence exists regarding the effectiveness of FCRs and related implementation strategies in improving patient outcomes. The lack of a clear, consistent definition of the elements that combine for a successful FCR encounter remains a significant barrier to measuring its effect. Standardized research methods for improving the quality and comparability of FCR studies are needed to enhance the existing guidelines for FCR use. Structural changes in care delivery may be required to ensure the rounding process remains amenable to the needs of patients and their families.

Mental Health Services during the COVID‐19 pandemic in Abu Dhabi, UAE

United Arab Emirates is demonstrating a model to the world in its response to the crisis and dealing with a pandemic that has provoked unprecedented health care delivery changes. Here, the authors describe how services were remodeled to safely manage patients with mental disorders in the largest admitting psychiatric facility in the capital city Abu Dhabi, the Behavioral Science Pavilion in Sheikh Khalifa Medical City. The article illustrates the changes in admission rates, outpatient clinic and emergency room visits, paving the way for a pliable mental health service that copes with unpredictable circumstances.

P0183 - Impact of the COVID-19 pandemic on urologic care delivery in the United States

Plain language summaryOutpatient visits and surgical procedures declined and recovered, and the magnitude of both varied by many factors, such as race, insurance type, location, urgency of diagnosis and procedure. The impact of delayed treatment and the differences in decline and recovery should inform approaches for the ongoing treatment of patients both during and post pandemic. Purpose We examined changes in urologic care delivery due to COVID-19 in the US based on patient, practice, and local/regional demographic and pandemic response features. Materials and methods We analyzed real-world data from the American Urological Association Quality (AQUA) Registry collected from electronic health record systems. Data represented 157 outpatient urologic practices and 3,165 providers across 48 US states and territories, including 3,297,721 unique patients, 12,488,831 total outpatient visits, and 2,194,456 procedures. The primary outcome measure was the number of outpatient visits and procedures performed (inpatient or outpatient) per practice per week, measured from January 2019 to February 2021. Results We found large (>50%) declines in outpatient visits from March 2020 to April 2020 across patient demographic groups and states, regardless of timing of state stay-at-home orders. Non-urgent outpatient visits decreased more across various non-urgent procedures (49-59%) than for procedures performed for potentially urgent diagnoses (38-52%); surgical procedures for non-urgent conditions also decreased more (43-79%) than those for potentially urgent conditions (43-53%). African American patients had similar decreases in outpatient visits compared with Asians and Caucasians, but also slower recoveries back to baseline. Medicare-insured patients had the steepest declines (55%) while those on Medicaid and Government insurance had the lowest percentage of recovery to baseline (73, and 69% respectively). Conclusions This study provides real-world evidence on the decline in urologic care across demographic groups and practice settings, and demonstrates a differential impact on the utilization of urologic health services by demographics and procedure type.

COVID-19: changing the care process for women’s health-the patient’s perspective

Objective Assess women’s perceptions of the impact of COVID-19 on their health care and well-being, access to and satisfaction with medical care due to the changes in delivery of care triggered by the pandemic. Methods An online survey of women having health care appointments in the outpatient facilities across all divisions of a Department of Obstetrics and Gynecology at a tertiary care referral center in North Central Florida. Patients had outpatient appointments that were scheduled, canceled or rescheduled, in person or by telemedicine, between 11 March 2020 and 11 May 2020, a time during which a COVID-19 stay-at-home order was enacted across our state. A total of 6,697 visits were planned. Patients with multiple visits were unified, leaving 6,044 unique patients to whom the survey was emailed between 20 July 2020 and 31 July 2020. The survey was closed on 21 August 2020. Analyses were focused on simple descriptive statistics to assess frequency of responses. Analyses of variance and chi-square analyses were conducted to compare outcomes when all cells were ≥ 10, based on sub-specialty and insurance status; otherwise, frequencies were examined for the entire sample only. Missing data were excluded listwise. Results A total of 6044 patients were contacted. Completed surveys numbered 1,083 yielding a response rate of 17.9%. The most common sub-specialty visit was gynecology (56.7%) followed by obstetrics (31.5%,), pelvic floor disorders (4.8%), gynecological oncology (2.9%,), and reproductive endocrinology (0.5%). A substantial percentage of women had visits canceled (19.2%), rescheduled (32.8%) or changed (42.1%) to telemedicine. In our patient population, 32.6% were worried about visiting the clinic and 48.1% were worried about visiting the hospital. COVID-19 triggered changes were perceived to have a negative impact by 26.1% of respondents. Refusal of future telemedicine visits was by 17.2%, however, 75.2% would prefer to use both in-person and telemedicine visits. Conclusion During the initial COVID-19 surge with lockdown, the majority of survey respondents were following public health precautions. However, there were significant concerns amongst women related to obstetric and gynecologic medical appointments scheduled during that period. During pandemics, natural disasters and similar extreme circumstances, digital communication and telemedicine have the potential to play a critical role in providing reassurance and care. Nevertheless, given the concerns expressed by survey respondents, communication and messaging tools are needed to increase comfort and ensure equity with the rapidly changing methods of care delivery.

Evolving oncology provider perspectives on care delivery during the COVID-19 pandemic.

e18609 Background: The COVID-19 pandemic prompted rapid changes in cancer care delivery. We sought to examine oncology provider perspectives on clinical decisions and care delivery during the pandemic and to compare provider views early versus late in the pandemic. Methods: We invited oncology providers, including attendings, trainees and advanced practice providers, to complete a cross-sectional online survey using a variety of outreach methods including social media (Twitter), email contacts, word of mouth and provider list-serves. We surveyed providers at two time points during the pandemic when the number of COVID-19 cases was rising in the United States, early (March 2020) and late (January 2021). The survey responses were analyzed using descriptive statistics and Chi-squared tests to evaluate differences in early versus late provider responses. Results: A total of 132 providers completed the survey and most were white (n = 73/132, 55%) and younger than 49 years (n = 88/132, 67%). Respondents were attendings in medical, surgical or radiation oncology (n = 61/132, 46%), advanced practice providers (n = 48/132, 36%) and oncology fellows (n = 16/132, 12%) who predominantly practiced in an academic medical center (n = 120/132, 91%). The majority of providers agreed patients with cancer are at higher risk than other patients to be affected by COVID-19 (n = 121/132, 92%). However, there was a significant difference in the proportion of early versus late providers who thought delays in cancer care were needed. Early in the pandemic, providers were more likely to recommend delays in curative surgery or radiation for early-stage cancer (p &lt; 0.001), delays in adjuvant chemotherapy after curative surgery (p = 0.002), or delays in surveillance imaging for metastatic cancer (p &lt; 0.001). The majority of providers early in the pandemic responded that “reducing risk of a complication from a COVID-19 infection to patients with cancer” was the primary reason for recommending delays in care (n = 52/76, 68%). Late in the pandemic, however, providers were more likely to agree that “any practice change would have a negative impact on patient outcomes” (p = 0.003). At both time points, the majority of providers agreed with the need for other care delivery changes, including screening patients for infectious symptoms (n = 128/132, 98%) and the use of telemedicine (n = 114/132, 86%) during the pandemic. Conclusions: We found significant differences in provider perspectives of delays in cancer care early versus late in the pandemic which reflects the swiftly evolving oncology practice during the COVID-19 pandemic. Future studies are needed to determine the impact of changes in treatment and care delivery on outcomes for patients with cancer.

Patient-Reported Experiences in Outpatient Telehealth Heart Failure Management.

BackgroundWith the onset of coronavirus disease 2019 (COVID-19), the delivery of routine outpatient heart failure (HF) care abruptly shifted to telehealth. Appropriate HF management extensively relies upon patient-reported symptoms. With the growing attention towards patient-centered care, our team recognized an invaluable opportunity to solicit patient-reported subjective experiences regarding telehealth.MethodsIn total, 127 patients with a known diagnosis of HF were contacted by phone for participation in an online questionnaire. The tool consisted of questions generated by the investigators and from prior validated patient-reported experience measures. The intention was to assess the quality of care in our HF clinic and to solicit feedback regarding telehealth.ResultsThirty-five patients provided a response. Questions with the most favorable outcomes were in line with our predetermined themes of interpersonal matter, communication, and perceived quality of care. The worst performing questions exhibited a lack of satisfaction with and perceived quality of telehealth. Only 9% (n = 3) preferred follow-up via telehealth, 69% (n = 22) preferred in-person, and 22% (n = 7) were indifferent.ConclusionsGiven the multitude of benefits of telehealth, especially appropriate social distancing, telehealth is quite likely here to stay. In sum, with the rapid change in care delivery, patients currently perceive the care delivered via telehealth to be of inferior quality. This lack of quality can be largely attributed to the lack of physical examination, depersonalization of healthcare, and likely, a lack of familiarity with the platform. We urge our colleagues to solicit similar feedback from their patients to improve their own telehealth efforts.

Patient Concerns Regarding Suspended Ophthalmic Care Due to COVID-19.

Purpose:The temporary cessation and profound changes in ophthalmic care delivery that occurred as a result of the coronavirus disease 2019 (COVID-19) pandemic have yet to be fully understood. Our objective is to assess patients’ self-reported impact of health care lockdown measures on their fears and anxieties during the crisis period of the COVID-19 pandemic in New York City.Methods:We conducted a digital, self-reported, patient care survey distributed by an e-mail at Columbia University’s Department of Ophthalmology outpatient faculty practice. Inclusion criteria were age greater than or equal to 18 years, a diagnosis of either retinal disease or glaucoma, and a canceled or rescheduled ophthalmology established patient appointment during the acute phase of the COVID-19 pandemic in New York City. Patients without an e-mail address listed in their electronic medical records were excluded. The survey occurred between March 2, 2020, to May 30, 2020. Primary measures were survey responses to assess key areas of patient anxiety or concern during the pandemic including the safety of care delivery in a COVID pandemic, difficulties contacting or being seen by their ophthalmologist, concern of vision loss or disease progression, and concern over missed or access to treatments. Secondary measures were correlating survey response to factors such as visual acuity, intraocular pressure, diagnosis, disease severity, follow-up urgency, recent treatments, and diagnostic testing data.Results:Of the 2594 surveys sent out, 510 (19.66%) were completed. Over 95% of patients were at least as concerned as in normal circumstances about their ocular health during the peak of the pandemic. Overall, 76% of respondents were more concerned than normal that they could not be seen by their ophthalmologist soon enough. Increased concern over ocular health, disease progression, and access to care all showed positive correlations (P<0.05) with worse disease severity as measured with testing such as visual fields and optical coherence tomography. In addition, 55% of patients were afraid of contracting COVID-19 during an office visit.Conclusion and Relevance:We found a majority of our patients were concerned about limitations in access to ophthalmic care and were fearful of disease progression. In addition, we found a number of demographic and clinical factors that correlated with increased anxiety in our patients.

Association of ACO Shared Savings Success and Serious Illness Spending.

Accountable care organizations (ACOs) need confidence in their return on investment to implement changes in care delivery that prioritize seriously ill and high-cost Medicare beneficiaries. The objective of this study was to characterize spending on seriously ill beneficiaries in ACOs with Medicare Shared Savings Program (MSSP) contracts and the association of spending with ACO shared savings. The population included Medicare fee-for-service beneficiaries identified with serious illness (N = 2,109,573) using the Medicare Master Beneficiary Summary File for 100% of ACO-attributed beneficiaries linked to MSSP beneficiary files (2014-2016). Lower spending for seriously ill Medicare beneficiaries and risk-bearing contracts in ACOs were associated with achieving ACO shared savings in the MSSP. For most ACOs, the seriously ill contribute approximately half of the spending and constitute 8%-13% of the attributed population. Patient and geographic (county) factors explained $2,329 of the observed difference in per beneficiary per year spending on seriously ill beneficiaries between high- and low-spending ACOs. The remaining $12,536 may indicate variation as a result of potentially modifiable factors. Consequently, if 10% of attributed beneficiaries were seriously ill, an ACO that moved from the worst to the best quartile of per capita serious illness spending could realize a reduction of $1,200 per beneficiary per year for the ACO population overall. Though the prevalence and case mix of seriously ill populations vary across ACOs, this association suggests that care provided for seriously ill patients is an important consideration for ACOs to achieve MSSP shared savings.

The cost of living with cancer during the second wave of COVID-19: A mixed methods study of Danish cancer patients' perspectives.

This study investigated experiences and levels of distress and resilience of Danish cancer patients during the second wave of the COVID-19 pandemic. The mixed methods design included a subset of cancer patients who responded to a cross-sectional survey in May 2020. Data were collected through telephone interviews. The National Comprehensive Cancer Network Distress Thermometer (NCCN DT), and Connor-Davidson-Resilience Scale (CD-RISC2) were used to measure distress and resilience. Data were analysed by thematic analysis and descriptive statistics. Forty patients with lung, breast, colorectal and skin (melanoma) cancer were included; 65% were women. Mean age was 62.2 years (standard deviation [SD], 13.2). Most patients had curable disease (65%); 50% were in treatment and 50% in post-treatment follow up. The interviews revealed four themes: 1) the cost of living with cancer during COVID-19, 2) changes in cancer care delivery, 3) particularly vulnerable, and 4) importance of family support. Mean NCCN DT score was 2.3 (SD, 2.6) while the mean CD-RISC2 score was 7.25 (SD, 1.1). Despite drastic changes in daily life imposed by COVID-19 restrictions, Danish cancer patients had remarkably low levels of distress and high levels of resilience. Patients in active treatment, with comorbidities or elderly felt vulnerable. Family support was invaluable in critical times.

Uptake of influenza vaccination among persons with inflammatory bowel disease, multiple sclerosis or rheumatoid arthritis: a population-based matched cohort study

Background:Individuals with immune-mediated inflammatory diseases, such as inflammatory bowel disease, multiple sclerosis and rheumatoid arthritis, are at increased risk for influenza and related complications. We examined and compared the uptake of influenza vaccination among people with and without these diseases, as well as the influence of psychiatric comorbidity on vaccine uptake.Methods:Using administrative data from Apr. 1, 1984, to Mar. 31, 2016, we conducted a retrospective matched cohort study in Manitoba, Canada. We matched persons 18 years of age or older who had a diagnosis of inflammatory bowel disease, multiple sclerosis or rheumatoid arthritis (the immune-mediated inflammatory disease cohorts) with persons who did not have these diagnoses (the control cohorts) on age, sex and region. We then identified cohort members with any mood or anxiety disorder (depression, anxiety disorders, bipolar disorder). We identified influenza vaccinations through billing codes. Using binomial regression, we modelled the difference in the proportion of the immune-mediated inflammatory disease and matched cohorts vaccinated annually, with adjustment for sociodemographic characteristics, comorbidity and immune therapy. We tested additive interaction effects between a person’s cohort and presence of a mood or anxiety disorder.Results:We identified 32 880 individuals with 1 or more immune-mediated inflammatory diseases (10 148 with inflammatory bowel disease, 6158 with multiple sclerosis and 16 975 with rheumatoid arthritis) and a total of 164 152 controls. In fiscal year 2015, 8668 (41.3%, 95% confidence interval [CI] 40.6% to 42.0%) of the 20 982 persons with an immune-mediated inflammatory disease received an influenza vaccination, a rate higher than among controls (35 238 of 104 634; 33.7%, 95% CI 33.4% to 34.0%). After adjustment, participants with an immune-mediated inflammatory disease but no mood or anxiety disorder had 6.44% (95% CI 5.79% to 7.10%) greater uptake of vaccination than participants without such a disease. Among participants without an immune-mediated inflammatory disease, having a mood or anxiety disorder was associated with 4.54% (95% CI 4.20% to 4.89%) greater uptake of vaccination. However, we observed a subadditive interaction between immune-mediated inflammatory disease and psychiatric status (−1.38%, 95% CI −2.26% to −0.50%).Interpretation:Uptake of influenza vaccination was consistently low in populations with immune-mediated inflammatory disease, and although psychiatric morbidity is associated with greater vaccine uptake by Manitobans, it negatively interacts with these diseases to reduce uptake. Changes in care delivery are needed to mitigate this gap in care.

Video as an alternative to in-person consultations in outpatient renal transplant recipient follow-up: a qualitative study

BackgroundRenal transplant recipients have to see a nephrologist for regular follow-up for the rest of their lives. To reduce the burden for the patients, video consultation can be an alternative to traditional in-person hospital consultations. The aim of the current study was, from the perspectives of patients and health care providers, to investigate the perceived benefits and challenges of using video consultations in outpatient renal transplant recipient follow-up.MethodsPatients (i.e., renal transplant recipients; n = 18) alternated between regular in-person follow-up consultations and video consultations. Patients and health care providers were then invited to participate in semi-structured interviews. The interviews were analyzed using thematic analysis.ResultsPatients interviewed (n = 15) were median 53 years old (range 37–64) and 53% female. The video consultation solution used in the study turned out to have major technical deficiencies. Despite the technical challenges, however, the majority of the patients reported appreciating being able to alternate between video and in-person hospital consultations. Main benefits reported included not needing to travel to the hospital and thereby saving time, less focus on being chronically ill and potential economic benefits for patients and society. The health care providers (n = 3) also valued the benefits provided by the use of video consultations, but described the reoccurring technical challenges as disruptive. The fact that patients were in a stable phase of their health condition and already had an established, trusting relationship with their nephrologist, acted as facilitators for success. Possible challenges and harms described included concerns related to security, confidentiality and interruptions, as well as the potential need for physical examinations.ConclusionsBenefits from using video consultations as an alternative to in-person consultations may outweigh potential technological challenges for patients as well as health care providers. A long-lasting mutually trusting relationship between patient and provider may be an important prerequisite for the experienced benefits of using video consultation. Findings also indicate that starting such care delivery changes in a small-scale, with a few selected patients in a stable phase of their condition, may be an important factor for success.

Telehealth utilization among multi-ethnic patients with obesity during the COVID-19 pandemic

Introduction The science of telemedicine has shown great advances over the past decade. However, the field needs to better understand if a change in care delivery from in-person to telehealth as a result of the COVID-19 pandemic will yield durable patient engagement and health outcomes for patients with obesity. The objective of this study was to examine the association of mode of healthcare utilization (telehealth versus in-person) and sociodemographic factors among patients with obesity during the COVID-19 pandemic. Methods A retrospective medical chart review identified patients with obesity from a university outpatient obesity medicine clinic and a community bariatric surgery practice. Patients completed an online survey (1 June 2020–24 September 2020) to assess changes in healthcare utilization modality during subsequent changes in infection rates in the geographic area. Logistic regression analysis examined the association of mode of healthcare utilization and key sociodemographic characteristics. Results A total of 583 patients (87% female, mean age 51.2 years (standard deviation 13.0), mean body mass index 40.2 (standard deviation 6.7), 49.2% non-Hispanic white, 28.7% non-Hispanic black, 16.4% Hispanic, 7% other ethnicity, 33.1% completed bariatric surgery) were included. Adjusted logistic regression models showed older age was inversely associated with telehealth use (adjusted odds ratio = 0.58, 95% confidence interval 0.34–0.98) and non-Hispanic black were more likely to use telehealth compared to non-Hispanic white (adjusted odds ratio = 1.72, 95% confidence interval 1.05–2.81). Conclusions The COVID-19 pandemic is impacting access to healthcare among patients with obesity. Telehealth is an emerging modality that can maintain healthcare access during the pandemic, but utilization varies by age and ethnicity in this high-risk population.

Changes in Diagnostic and Demographic Characteristics of Patients Seeking Mental Health Care During the Early COVID-19 Pandemic in a Large, Community-Based Health Care System.

The early COVID-19 pandemic resulted in great psychosocial disruption and stress, raising speculation that psychiatric disorders may worsen. This study aimed to identify patients vulnerable to worsening mental health during the COVID-19 pandemic. This retrospective observational study used electronic health records from March 9 to May 31 in 2019 (n = 94,720) and 2020 (n = 94,589) in a large, community-based health care system. Percent change analysis compared variables standardized to the average patient population for the respective time periods. Compared to 2019, psychiatric visits increased significantly (P < .0001) in 2020, with the majority being telephone/video-based (+264%). Psychiatric care volume increased overall (7%), with the greatest increases in addiction (+42%), behavioral health in primary care (+17%), and adult psychiatry (+5%) clinics. While patients seeking care with preexisting psychiatric diagnoses were mainly stable (−2%), new patients declined (−42%). Visits for substance use (+51%), adjustment (+15%), anxiety (+12%), bipolar (+9%), and psychotic (+6%) disorder diagnoses, and for patients aged 18–25 years (+4%) and 26–39 years (+4%), increased. Child/adolescent and older adult patient visits decreased (−22.7% and −5.5%, respectively), and fewer patients identifying as White (−3.8%) or male (−5.0) or with depression (−3%) or disorders of childhood (−2%) sought care. The early COVID-19 pandemic was associated with dramatic changes in psychiatric care facilitated by a rapid telehealth care transition. Patient volume, demographic, and diagnostic changes may reflect comfort with telehealth or navigating the psychiatric care system. These data can inform health system resource management and guide future work examining how care delivery changes impact psychiatric care quality and access.

Scaling Up Patient-Centered Interdisciplinary Care for Multimorbidity: A Pragmatic Mixed-Methods Randomized Controlled Trial.

To measure the effectiveness of a 4-month interdisciplinary multifaceted intervention based on a change in care delivery for patients with multimorbidity in primary care practices. A pragmatic randomized controlled trial with a mixed-methods design in patients aged 18 to 80 years with 3 or more chronic conditions from 7 family medicine groups (FMGs) in Quebec, Canada. Health care professionals (nurses, nutritionists, kinesiologists) from the FMGs were trained to deliver the patient-centered intervention based on a motivational approach and self-management support. Primary outcomes: self-management (Health Education Impact Questionnaire); and self-efficacy. health status, quality of life, and health behaviors. Quantitative analyses used multi-level mixed effects and generalized linear mixed models controlling for clustering within FMGs. We also conducted in-depth interviews with patients, family members, and health care professionals. The trial randomized 284 patients (144 in intervention group, 140 in control group). The groups were comparable. After 4 months, the intervention showed a neutral effect for the primary outcomes. There was significant improvement in 2 health behaviors (healthy eating with odds ratios [OR] 4.36; P = .006, and physical activity with OR 3.43; P = .023). The descriptive qualitative evaluation revealed that the patients reinforced their self-efficacy and improved their self-management which was divergent from the quantitative results. Quantitatively, this intervention showed a neutral effect on the primary outcomes and substantial improvement in 2 health behaviors as secondary outcomes. Qualitatively, the intervention was evaluated as positive. The combination of qualitative and quantitative designs proved to be a good design for evaluating this complex intervention.

How Does Black History Help Doctors? Addressing Cultural Competency through Cinemeducation at a Diverse Medical School.

Racial minorities will account for >50% of the United States population by 2045, yet race and ethnicity persist as leading predictors of morbidity. Although minorities achieve better outcomes when treated by racially concordant providers, the number of minority physicians is disproportionately low compared with the rapidly growing minority population. This imbalance creates a cultural gap between many minority patients and their healthcare providers. Research suggests that educational initiatives addressing health inequity through a historical lens can help providers better understand the root causes of disparities; however, extensive clinical demands severely limit the time providers can dedicate to non-medical learning. To address this gap, the University of Miami/Jackson Memorial Hospital System developed and piloted a short film about the history of Black people in South Florida, highlighting significant events that shaped the health-seeking behaviors of this population. A 20-minute documentary exploring the sociocultural history of Black communities in Miami-Dade County was presented to 188 first-year postgraduate residents in June 2017. Residents completed pre-post surveys to measure changes in knowledge and care delivery intentions. Analyses performed between March and July 2018 revealed moderate improvements in the knowledge and awareness of the socioeconomic history of Miami's Black communities. Before watching the video, a majority indicated that increasing awareness of the sociocultural history of their patient population was a valuable learning activity. These findings suggest that brief videos focused on the history of culturally distinct populations may be a successful pedagogical strategy to introduce physicians to the communities they serve and improve provider knowledge.