Clinic Implementation Research Articles

ROS-Responsive Ferrocenyl Amphiphilic PAMAM Dendrimers for On-Demand Delivery of siRNA Therapeutics to Cancer Cells.

Small interfering RNA (siRNA) therapeutics, characterized by high specificity, potency, and durability, hold great promise in the treatment of cancer and other diseases. However, the clinic implementation of siRNA therapeutics critically depends on the safe and on-demand delivery of siRNA to the target cells. Here, we reported a family of ferrocenyl amphiphilic dendrimers (Fc-AmDs) for on-demand delivery of siRNA in response to the high ROS content in cancer cells. These dendrimers bear ROS-sensitive ferrocene moieties in the hydrophobic components and positively chargeable poly(amidoamine) dendrons as the hydrophilic entities, possessing favorable safety profiles and ROS responsive properties. One of these ferrocenyl amphiphilic dendrimers, Fc-C8-AmD 8A, outperforms in siRNA delivery, benefiting from its optimal balance of hydrophobicity and hydrophilicity. Its ROS feature facilitates specific and efficient disassembly of its complex with siRNA in ROS-rich cancer cells for effective siRNA delivery and gene silencing. Moreover, Fc-C8-AmD 8A also integrates the features and beneficial properties of both lipid and dendrimer vectors. Therefore, it represents a novel on-demand delivery system for cancer cell-specific siRNA delivery. This work opens new perspectives for designing self-assembly nanosystems for on-demand drug delivery.

Implementation and Outcome of Clinical Pharmacist-led Anticoagulation Clinic at Cardiac Center: A Retrospective Cohort Study

Abstract Context: Managing patients on anticoagulant therapy, such as warfarin, can be challenging due to various factors. Implementing a specialized care model can be a useful strategy to address this issue. Studies have demonstrated that pharmacist-led anticoagulation therapy leads to improved outcomes. Aims: We aimed to assess the anticoagulation quality of warfarin therapy achieved by the implementation of a Clinical Pharmacist-led Anticoagulation Clinic at a cardiac center. Materials and Methods: In conjunction with the cardiac center, the hospital’s pharmaceutical care department established a clinic. The anticoagulation quality was evaluated by determining the time in the therapeutic range (TTR), which was calculated using the Rosendaal method. Data were collected from February 1, 2021, to July 31, 2022, in a retrospective manner. Statistical Analysis Used: Both descriptive and inferential analyses were performed and are presented as counts, percentages, and means ± standard deviation, as appropriate. A paired t test was used to compare the mean TTR, and the outcomes were logistically regressed against candidate factors. Statistical significance was set at P < 0.05. Results: A total of 66 patients were eligible for inclusion in the study. The mean TTR was 73.4% ± 21.1%, compared to 46.9% ± 29.5% before clinic implementation. After clinic implementation, the proportion of patients who were able to reach a TTR of ≥70% increased from 28.8% to 60.6%. During clinical pharmacist care, there was one major bleeding event (0.7%/year), nine minor bleeding events (6%/year), and one thromboembolic event (0.7%/year). Age, comorbidities, and warfarin dose were not found to affect the TTR. However, females had a reduced likelihood of a TTR ≥70% (95% confidence interval, 0.11–0.89; P = 0.029). Conclusions: A clinical pharmacist-led anticoagulation clinic was implemented successfully, which resulted in positive outcomes in patient care by achieving a good TTR (≥70%) and low warfarin-related adverse events.

Promoting Rural-Residing Parents' Receptivity to HPV Vaccination: Targeting Messages and Mobile Clinic Implementation.

Interventions are needed to increase low HPV vaccination rates within rural areas in the United States, particularly in the state of Florida, which has the seventh highest number of HPV-related cancers. Florida also ranks low compared to other states in terms of HPV vaccination. Rural-residing parents may benefit from two evidence-based strategies to increase vaccination rates: reminder messages informing and prompting vaccination appointments and mobile clinics to reduce transportation barriers. We sought to identify parental attitudes towards (1) message features that promote rural-residing parents' receptivity to HPV vaccination; (2) parents' acceptability of three reminder message modalities (text, postcard, phone); and (3) implementation factors that promote parents' acceptability of using a mobile clinic for vaccination. We recruited 28 rural-residing parents of 9- to 12-year-old children (unvaccinated for HPV) for focus group and individual interviews and thematically analyzed transcripts. Three features promoted parents' receptivity to HPV vaccination messages: source credibility, specific information coverage, and personalization (name and birthday wishes). Parents most preferred text messages and identified three factors promoting parents' mobile clinic use: convenience and feasibility, trustworthiness, and detailed information. The findings indicate rural-residing parents' acceptability of reminder messages and mobile clinics as well as the importance of trust and feasibility when implementing these evidence-based strategies for rural-residing parents.

Establishment of a clinical pharmacist-led multiple myeloma clinic with collaborative prescribing model at the national center for cancer care and research in Qatar

BackgroundMultiple myeloma (MM) is a chronic and incurable hematologic malignancy that is prevalent among the elderly. Interprofessional patient care showed superiority over physician-only care in multiple settings, including MM. ObjectiveThe primary objective of this study was to evaluate the impact of clinical pharmacist (CP)-led clinic and CPs interventions on MM patient care. Practice descriptionReal-world analysis of ambulatory patients with MM showed that CPs were central to the optimization of therapy and adherence to treatment schedules and supportive medications. Practice innovationThe CP-led MM Clinic was established with a collaborative prescribing agreement (CPA) in 2022 at the National Center for Cancer Care and Research in Qatar and was the first of its kind in the Middle East and North Africa region. This CPA allowed CPs to issue refills for supportive medications and order required laboratory tests. Evaluation methodsData collected included the number of CP interventions, refills ordered by CPs, documentation of patient education, and medication reconciliations. The data were retrospectively collected and analyzed comparing ambulatory patients with MM treated before (2021) to those treated after the clinic implementation in 2022. ResultsThe study population comprised 22 patients. A higher number of CPs interventions were documented post-clinic than preclinic (343 vs. 76, P = 0.004), with earlier initiation of bisphosphonate post-clinic (25 vs. 206 days, P = 0.008). There were also significant improvements in the introduction of risk appropriate venous thromboembolism prophylaxis (43% vs. 6%, P = 0.001) as well as vitamin D and calcium supplementation (100% vs. 68%, P = 0.02) post-clinic. Twenty-two medication refills for supportive medications and eight prechemotherapy laboratory investigations were ordered by CPs. ConclusionThe CP-led clinic provided a timely link to care optimization for ambulatory MM patients. This innovative CPA model implemented in the clinic could potentially be applied to different cancer settings to optimize safe and effective patient care.

Stakeholder Implementation Considerations for PATH (Plan for Appropriate Tailored Healthcare in Pregnancy) Social Needs Recommendations [ID 2683568

INTRODUCTION: Unmet social needs negatively affect health care access and outcomes, and are disproportionately experienced by groups marginalized by racism, socioeconomic status, and geography. The Plan for Appropriate Tailored Healthcare in Pregnancy (PATH), a consensus-based prenatal care recommendation developed by a multidisciplinary panel of prenatal care experts, includes two recommendations regarding social needs: 1) early screening for medical and social determinants of health; and 2) management of social needs in prenatal care. A national listening tour was conducted to capture stakeholder feedback for implementing social needs recommendations into practice. METHODS: We conducted nine, 120-minute virtual focus groups with more than 25 organizations including professional (8), patient advocacy (8), public health (5), and payer groups (4). Focus groups were transcribed, coded by recommendation, and analyzed with matrix coding across patient, clinic, and policy level implementation considerations. RESULTS: Focus groups included 110 participants. Patient-level considerations for implementation included the importance of relationship building, shared decision-making, resources-first screening, and delivery of trauma-informed, culturally concordant care. On the clinic level, participants stressed robust clinic-level processes for providing effective social needs care, including multidisciplinary care navigation, social needs toolkit utilization, dynamic patient needs assessments, and provision of closed-loop referrals. Policy-level considerations included the need for improved provider incentives, interprofessional group collaboration, evidence-based research, and social needs infrastructure. CONCLUSION: Key considerations for implementing social needs care at the individual, clinic, and policy levels must be operationalized for successful integration into routine prenatal care. Further evidence is needed to identify and test the best approaches to addressing unmet social needs across practice settings.

Improving measurement-based care implementation in youth mental health through organizational leadership and climate: a mechanistic analysis within a randomized trial

BackgroundTheory and correlational research indicate organizational leadership and climate are important for successful implementation of evidence-based practices (EBPs) in healthcare settings; however, experimental evidence is lacking. We addressed this gap using data from the WISDOM (Working to Implement and Sustain Digital Outcome Measures) hybrid type III effectiveness-implementation trial. Primary outcomes from WISDOM indicated the Leadership and Organizational Change for Implementation (LOCI) strategy improved fidelity to measurement-based care (MBC) in youth mental health services. In this study, we tested LOCI’s hypothesized mechanisms of change, namely: (1) LOCI will improve implementation and transformational leadership, which in turn will (2) mediate LOCI’s effect on implementation climate, which in turn will (3) mediate LOCI’s effect on MBC fidelity.MethodsTwenty-one outpatient mental health clinics serving youth were randomly assigned to LOCI plus MBC training and technical assistance or MBC training and technical assistance only. Clinicians rated their leaders’ implementation leadership, transformational leadership, and clinic implementation climate for MBC at five time points (baseline, 4-, 8-, 12-, and 18-months post-baseline). MBC fidelity was assessed using electronic metadata for youth outpatients who initiated treatment in the 12 months following MBC training. Hypotheses were tested using longitudinal mixed-effects models and multilevel mediation analyses.ResultsLOCI significantly improved implementation leadership and implementation climate from baseline to follow-up at 4-, 8-, 12-, and 18-month post-baseline (all ps < .01), producing large effects (range of ds = 0.76 to 1.34). LOCI’s effects on transformational leadership were small at 4 months (d = 0.31, p = .019) and nonsignificant thereafter (ps > .05). LOCI’s improvement of clinic implementation climate from baseline to 12 months was mediated by improvement in implementation leadership from baseline to 4 months (proportion mediated [pm] = 0.82, p = .004). Transformational leadership did not mediate LOCI’s effect on implementation climate (p = 0.136). Improvement in clinic implementation climate from baseline to 12 months mediated LOCI’s effect on MBC fidelity during the same period (pm = 0.71, p = .045).ConclusionsLOCI improved MBC fidelity in youth mental health services by improving clinic implementation climate, which was itself improved by increased implementation leadership. Fidelity to EBPs in healthcare settings can be improved by developing organizational leaders and strong implementation climates.Trial registrationClinicalTrials.gov identifier: NCT04096274. Registered September 18, 2019.

The Children's Justice Clinic: Ensuring high‐quality legal representation for children through clinical legal education

AbstractJuvenile and family law uniquely require interdisciplinary education and experience to balance children's and families' legal rights with their best interests. Clinical legal education provides third‐year law students with advanced and applied experience in a specific area of law to prepare them for legal practice. Recent developments in clinical legal education advance this experience by integrating interdisciplinary experts and reflective practice into clinics. The Children's Justice Clinic is one such clinic that integrates classroom teaching, clinical legal practice, multidisciplinary expert consultation, and reflective practice to train practice‐ready Guardians ad Litem. Evaluation results from the first 5 years of the Children's Justice Clinic demonstrates that the Clinic is making progress toward its goals to provide third‐year law students with the knowledge and skills necessary to be effective Guardians Ad Litem, increase interest in child welfare and juvenile law practice among law students, and increase access to high‐quality legal representation for children. This paper presents the results from the evaluation and shares lessons learned during clinic development and implementation.

Barriers and facilitators to a task-shifted stroke prevention program for children with sickle cell anemia in a community hospital: a qualitative study

BackgroundChildren with sickle cell anemia (SCA) are at high risk for stroke. Protocols for stroke prevention including blood transfusions, screening for abnormal non-imaging transcranial Doppler (TCD) measurements, and hydroxyurea therapy are difficult to implement in low-resource environments like Nigeria. This study aimed to examine the contextual factors around TCD screening in a community hospital in Nigeria using qualitative interviews and focus groups.MethodsWe conducted a descriptive qualitative study in a community hospital in Kaduna, Nigeria, using focus groups and interviews. Interview guides and analysis were informed by the Consolidated Framework for Implementation Research (CFIR) framework and the Theory of Planned Behavior. Transcripts were coded and analyzed using an iterative deductive (CFIR)/Inductive (transcribed quotes) qualitative methodology.ResultsWe conducted two focus groups and five interviews with health care workers (nurses and doctors) and hospital administrators, respectively. Themes identified key elements of the inner setting (clinic characteristics, resource availability, implementation climate, and tension for change), characteristics of individuals (normative, control, and behavioral beliefs), and the implementation process (engage, implement, and adopt), as well as factors that were influenced by external context, caregiver needs, team function, and intervention characteristics. Task shifting, which is already being used, was viewed by providers and administrators as a necessary strategy to implement TCD screening in a clinic environment that is overstressed and under-resourced, a community stressed by poverty, and a nation with an underperforming health system.ConclusionTask shifting provides a viable option to improve health care by making more efficient use of already available human resources while rapidly expanding the human resource pool and building capacity for TCD screening of children with SCD that is more sustainable.Trial registrationNCT05434000.

THE COGNITION IN PRIMARY CARE PROGRAM: A STEP-BY-STEP CLINIC WORKFLOW PUTTING THE GSA KAER TOOLKIT INTO ACTION

Abstract In 2020 University of Washington (UW) Medicine began developing Cognition in Primary Care (CPC), a quality improvement program adapting the GSA KAER Toolkit to help primary care providers (PCPs) detect patients with cognitive impairment in their 16-clinic primary care network. The CPC consists of a 3-part training program to help PCPs diagnose, manage and counsel patients; a set of tools embedded into the electronic health record to facilitate cognitive evaluation; and an in-clinic workflow providing on-site support for providers within their own clinic setting. During this process we interviewed providers and developed a hybrid remote and in-person orientation for clinics to initiate a workflow to support improved cognitive evaluations. Utilizing pre-implementation input, the CPC in-clinic workflow was pilot-tested at two UW primary care clinics in 2021/2022. This presentation will describe content of the clinic orientation and implementation of CPC to include 1) the typical timeframe and content of orientation; 2) meetings with clinic leadership; 3) overview of provider/staff meetings; 4) in-person walk-through for placement of materials; 5) invitation to training; 6) a 12-page handbook outlining steps in the workflow; 7) other printed CPC materials, e.g., dementia warning signs, MoCA and AD8 forms, Alzheimer Association referral cards; and 8) follow-up focus group feedback. Evaluation of the pilot clinics following implementation found significant use of all tools by PCPs and an increase in diagnoses of mild cognitive impairment. This clinic workflow may be useful as a model for other health care systems to initiate cognitive evaluation programs in primary care.

Addressing disparities in Pre-exposure Prophylaxis (PrEP) access: implementing a community-centered mobile PrEP program in South Florida

BackgroundPre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but disparities in PrEP access remain considerable, particularly among Black and Latino men who have sex with men (MSM). To address this, the University of Miami Mobile PrEP Program was created, offering mobile HIV prevention/PrEP services in areas throughout South Florida where HIV incidence is high and PrEP access is geographically limited. Using a community-centered participatory approach, the program strategized and executed expansion into the Liberty City neighborhood of Miami. This study qualitatively assessed factors affecting Mobile PrEP implementation as perceived by community stakeholders, clients, and program staff.MethodsForty-one in-depth interviews were conducted with 21 Mobile PrEP clients, 10 key informants from local health organizations, and 10 program staff. Interview questions queried perceived organizational and positional barriers and facilitators to mobile clinic implementation. Service satisfaction, setting preferences, social factors, and likelihood of recommending Mobile PrEP were also assessed. A thematic content analysis was performed using the Consolidated Framework for Implementation Research (CFIR) taxonomy as the guiding constructs for the analysis.ResultsParticipant statements indicated that providing no-cost services, convenient location, program-covered rideshares, individualized patient navigation, and a community-centric approach to patient care, which included staff members with shared lived experiences to increase positive interactions and renewed trust among poorly served communities, were facilitators of PrEP access and intervention uptake. The importance of program familiarization with the community before implementation, particularly for Black and African American communities, who may experience unique barriers to accessing sexual healthcare was strongly emphasized by participants.ConclusionsThe Mobile PrEP intervention was found to be an acceptable and accessible mode of HIV/STI preventive care. The importance of pre-implementation community engagement and preparation is emphasized. Future research is needed to refine understanding of the intervention’s components and evaluate implementation determinants in other highly impacted neighborhoods.

9753 Examining the Impact of Minimally Invasive Gynecologic Surgery Clinic Implementation in an Urban Safety-Net Clinic

9753 Examining the Impact of Minimally Invasive Gynecologic Surgery Clinic Implementation in an Urban Safety-Net Clinic

Multicomponent Strategy Improves Human Papillomavirus Vaccination Rates Among Adolescents with Sickle Cell Disease

ObjectiveTo evaluate the effectiveness of a vaccine strategy bundle to increase HPV vaccine initiation and completion in a specialty clinic setting. Study DesignOur Hematology clinic utilized an implementation framework from October 1, 2018, to December 31, 2019, involving nurses, nursing coordinators, and clinicians in administering the HPV vaccination series to our adolescent sickle cell sample of nearly 500 patients. The bundle included education for staff on the need for HPV vaccine administration, provider incentives, vaccines offered to patients in SCD clinics, and verification of patients' charts of vaccine completion. ResultsFollowing the implementation of the bundle, the cumulative incidence of HPV vaccination initiation and completion improved from 28% to 46% and 7% to 49%, respectively. Both rates remained higher post-implementation as well. HPV vaccination series completion was associated with a decreased distance to the healthcare facility, lower state deprivation rank, and increased hospitalizations. ConclusionOur clinic's implementation strategy successfully improved vaccine completion rates among adolescents with SCD while continuing to educate staff, patients, and families on the importance of cancer prevention among people living with SCD.

Adapting group care to the postpartum period using a human-centered design approach in Malawi

BackgroundResponsive and resilient strategies to reduce high rates of maternal and infant mortality and clinician shortages are needed in low- and middle-income countries (LMICs). Malawi has some of the highest maternal and infant mortality rates globally. Group healthcare is a service delivery model that integrates these strategies. Although primarily implemented during the prenatal period, its potential for improving both maternal and infant health outcomes during the postpartum period has not been realized. The purpose of this study was to adapt and co-design the prototype for an evidence-based group care model for the postpartum period using a human-centered design approach with key stakeholders in Malawi.MethodsWe completed steps of a framework guiding the use of human-centered design: 1) define the problem and assemble a team; 2) gather information through evidence and inspiration; 3) synthesize; and 4) intervention design: guiding principles and ideation. Qualitative methods were used to complete steps 2–4. In-depth interviews (n = 24), and incubator sessions (n = 6) that employed free listing, pile sorting and ranking were completed with key stakeholders. Data analysis consisted of content analysis of interviews and framework analysis for incubator sessions to produce the integrated group postpartum and well-child care model prototype. The fifth step is detailed in a separate paper.ResultsAll stakeholders reported a desire to participate in and offer group care in the postpartum period. Stakeholders worked collaboratively to co-create the prototype that included a curriculum of health promotion topics and interactive activities and the service delivery structure. Health promotion topic priorities were hygiene, breastfeeding, family planning, nutrition, and mental health. The recommended schedule included 6 sessions corresponding with the child vaccination schedule over the 12-month postpartum period.ConclusionsUsing a human-centered design approach to adapt an evidence-based group care model in an LMIC, specifically Malawi, is feasible and acceptable to key stakeholders and resulted in a prototype curriculum and practical strategies for clinic implementation.

Optimization of Workup Pathways to Decrease Radiotherapy Wait Times and Improving Patient Experience: A Single Centre Study

Wait-times are challenging for certain radiotherapy (RT) centers, and benchmarking is challenging, given the different standards used. Beyond the standards of referral to consult and consult to treatment, certain centers have established a "ready-to-treat" (RTT) definition to address the reality of patients requiring further investigations from consult to enable a treatment plan. In this single RT center study, a Timely Access and Patient Support (TAPS) model of care has been implemented aiming to improve access to care and, ultimately, patient outcomes. Thiscomparative cohort study was conducted in a single mid-size RT center serving mainly rural communities as part of a larger multi-center academic institution. In collaboration with a Radiation Oncologist (RO), the TAPS clinic is run by a Nurse Practitioner who provides patient assessment and submits requisitions to ensure the patient has support services and is RTT by the time of RO consult. All newly suspected/diagnosed adult cancer patients referred to the center with a triage priority of ≥2 weeks were eligible. Non-metastatic breast and prostate cancers were excluded. Retrospective and prospective data were collected from patient medical records, and descriptive statistical analysis was performed. Pre- and post-TAPS clinic comparison was made for wait times and patient-reported outcomes (PROs) using the Edmonton Symptom Assessment System-revised. During the first 6 months of the study, 66 eligible patients were assessed in the TAPS clinic, prompting 177 orders including referrals (52%) (top 3: social worker 30%, dietitian 20%, and cancer patient navigator 11%), investigations (27%) (top 3: CT 21%, MRI 19%, and biopsy 25%), and interventions (21%). The most common cancers were thoracic (33%), GI (23%) and head and neck (14%). The mean wait time from referral to TAPS consult was 5 days compared to 15 days for pre-TAPS patients to be seen in RO consult. The mean wait time from referral to RTT was 33 days VS 40 days in the post- VS pre-TAPS setting.71% of post-TAPS patients were RTT at RO consult compared with 43% pre-TAPS. Post-TAPS patients reported less fatigue and anxiety and better overall well-being during CT simulation compared to pre-TAPS patients. Preliminary data of TAPS clinic implementation has shown the potential to positively impact RTT times and PROs for psychosocial distress by the time of RT planning. This data also sheds light on the topic of wait time definitions, the investigations required before RTT and the potential role of physician extenders within the health care team to facilitate accelerated workup of malignancies. While TAPS study data will help to inform local cancer care program operations, it is also considered relevant to the broader RT community and professional RT societies addressing standards related to RT access.

Implementation of a Multidisciplinary Medication Refill Protocol.

Primary care clinicians spend significant time managing nonvisit activities, including processing of requests for prescription renewal. Delays in processing refills may lead to patient dissatisfaction and impact provider productivity. Having nonclinicians process refills can be more efficient and time-saving. We aimed to evaluate the use of a multidisciplinary medication refill protocol to decrease the time to complete refill requests. We implemented nursing-driven management of refill requests within two family medicine residency clinics in Milwaukee, Wisconsin (Phase 1: single clinic implementation [March 2017-June 2019]; Phase 2: added second clinic prepandemic [June 2019-March 2020] and postpandemic [April 2020-December 2020]). The multidisciplinary refill protocol was created by faculty, residents, pharmacy, and nursing. Data were collected using electronic health record time stamps to determine when refill requests were initiated and filled by faculty, residents, and nurses. We used Mood's median test to compare the median time for medication refill completion. We used Levene's test to test for equal variance surrounding the median of each caregiver group. We used Fisher's exact test or χ2 test with Yates' correction for 2×2 contingency tables. In both phases, we identified a significant reduction in median time to refill completion ( P<.001) and variability of time to refill completion ( P<.001). Notably, in Phase 1, reduction in median refill time was most apparent among residents (383 vs 79 min postimplementation); and in Phase 2, the percentage of refills completed within 48 hours significantly increased between the pre-COVID-19 and COVID-19 pandemic among faculty and nursing in Clinic 1 and residents and faculty in Clinic 2 (all P's<.001). Implementation of a multidisciplinary refill protocol significantly improved time and predictability of refill completion in both phases.

397 The Effects of a Virtual Specialist Nurse-Led Clinic on Plastics Outpatient Services at a Major Trauma Centre: A Closed Loop Audit

Abstract Aim To reduce the number of plastic surgery clinics working over capacity due to the effects of both increasing caseload and the COVID-19 pandemic by implementing a virtual specialist nurse-led clinic. Method Outpatient activity was audited due to the number of patients being overbooked into the plastic surgery outpatient clinics. A virtual specialist nurse-led clinic was implemented to bridge gaps between appointments, maintain early triaging of complications, and reduce clinics working over-capacity. Suitable patients were identified and offered virtual follow-up in place of face-to-face appointments. Outpatient activity was re-audited after implementation, to assess effects on force bookings and number of new/follow-ups seen in consultant clinics. Results Following virtual clinic implementation, there was a significant reduction in consultant clinics working over-capacity (95% to 71.8%, p = 0.002) and forced bookings (54 to 10, p = 0.006) in the audited period. The average number of new patients seen in consultant clinics each month increased by 15.3% (p = 0.019). Conclusions Introduction of a virtual clinic reduced forced bookings and clinics working over-capacity. This increased capacity for new patients to be seen face-to-face, created a manageable clinic while maintaining early identification of complications, and reduced delays between clinic appointments. Early virtual assessment of wounds and identification of complications enabled patients to be booked into urgent face-to-face plastic appointments, triaging them away from A&amp;E and GP services. The virtual clinic also allowed the team to reassure patients with ongoing concerns between appointments, further reducing A&amp;E and GP burden.

Integrating Opioid Use Disorder Treatment Into Primary Care Settings

Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist. To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD. This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022. Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services. Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods. Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care. The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.

Outcomes following implementation of a pediatric cardio-oncology program

BackgroundWith improved survival following childhood cancer, cardiovascular disease has emerged as a significant source of long-term morbidity and mortality. Oncology patients require comprehensive cardiac screening and monitoring throughout their treatment and beyond. The complexity of these patients has led to increasing numbers of pediatric cardio-oncology specialty clinics. ObjectivesTo describe the characteristics and 1-year outcomes following cardio-oncology clinic implementation at a large pediatric quaternary care institution. MethodsPatients with history of chest radiation, high-dose anthracycline, or decreased left ventricular function were referred and reviewed. Initiation of oral heart failure therapy or advanced cardiac therapies within 1 year following referral were identified, and risk factors for these were evaluated. ResultsNinety-seven patients aged 5 days to 21 yrs. old were referred from 2017 to 2021. Average age at cancer diagnosis was 8.1 ± 5.5 years, with 48 % receiving high-dose anthracycline and 36 % chest radiation. Left ventricular dysfunction was present in 28 % at presentation. Oral heart failure therapy was initiated in 31 %, and none required advanced cardiac therapies. Patients who required oral heart failure therapy were more likely to be older at the age of cancer diagnosis, 10.8 ± 5.1 vs. 7.0 ± 5.3 yrs. (p = 0.001). A higher proportion of patients who received both high-dose anthracycline and chest radiation were on oral heart failure therapy (4/8, 50 %) compared to patients with high-dose anthracycline (18/46, 39 %) or chest radiation (9/35, 26 %) exposure alone, although not statistically significant. ConclusionImplementation of a pediatric cardio-oncology clinic led to increased referrals, appropriate assessment, and initiation of oral heart failure therapy. Patients older at the time of cancer diagnosis were more likely to require treatment. However, it does remain unclear if starting a COC provides long-term benefits for this particularly high-risk patient population.

Emergency Department Bridge Model and Health Services Use Among Patients With Opioid Use Disorder

Little is known about the effectiveness of bridge clinics as transitional care programs for people with opioid use disorder in emergency departments (EDs). We assessed the effect of bridge clinic referral on health services use among patients with opioid use disorder identified in the ED. We used data for individuals aged 18 years and over with active opioid use disorder and no history of medication for opioid use disorder who were administered medication for opioid use disorder while in the ED between January 2013 and August 2022. Bridge clinic referrals started in January 2021. Eligible patients after this date comprised the intervention group. The usual care group included eligible patients before bridge clinic implementation, who were a 1:1 propensity score matched to intervention patients. We estimated risk differences and 95% confidence limits for linkage to long-term care, ED use, and inpatient admission within 120 days of the index ED visit. Our study population comprised 928 observations after matching. Patients referred to the bridge clinic had a higher risk of linkage to long-term care (risk differences=25%; 95% confidence limits: 20%, 30%), higher risk of ED use (risk differences=7.5%, 95% confidence limits: 1.6%, 13%), and lower risk of inpatient admission (risk differences= -1.9%, 95% confidence limits: -5.9%, 2.1%). Inpatient admission increased among patients with serious mental illness but decreased among patients without serious mental illness. Our overall results suggest that bridge clinic referral increases linkage to long-term care. Nevertheless, qualitatively different effects on inpatient admission between patients with and without serious mental illness warrant consideration of unmet needs among patients with serious mental illness.

Free and Charitable Clinic Telehealth Adoption and Utilization During the COVID-19 Era: The North Carolina Experience.

The emergence of the COVID-19 pandemic led health care systems and providers worldwide to rapidly adopt telehealth solutions to minimize risk and comply with isolation mandates. This article explores telehealth utilization trends in North Carolina (NC) free and charitable clinics-an ambulatory health care delivery setting where traditional third-party reimbursement policies are not a primary consideration. We surveyed NC free and charitable clinic administrators regarding clinic decisions to adopt an externally sponsored telehealth system, what services are provided by telehealth, clinic implementation processes, which populations used telehealth, how telehealth was incorporated into current clinic workflows, and perceptions of telehealth outcomes. Telehealth was rapidly adopted among free and charitable clinics after the COVID-19 outbreak. Reasons for implementing telehealth included the ability to continue providing services during a public health emergency and to increase access to patients. However, clinics report that telehealth utilization has dropped significantly since the initial pandemic surge. Patient and provider preferences for in-person services are a common reason cited for this drop. Free and charitable clinics report a strong interest in continuing to deliver services through telehealth. The majority reported continuing to offer telehealth services, but primarily as a supplement to in-person visits rather than as a replacement. They perceive that implementing telehealth has increased access to care but are less certain about the impact on cost of care and patient satisfaction. However, clinic administrators believe improvements in interoperability with other data systems, workflows, scheduling, and care delivery approaches are needed to achieve telehealth's fullest utilization. Telehealth can play a significant role in expanding access to services in the free and charitable clinic setting. However, continued refinements in the technology to facilitate integration with other systems and workflow processes are needed to reach its full potential.