Clinic Visit Attendance Research Articles

Neighborhood Poverty and Clinic Attendance in the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine Program.

Higher neighborhood-level poverty is associated with greater odds of missing a free eye disease screening appointment, underscoring the importance of community-based interventions to address upstream social determinants of health. To investigate the association between neighborhood-level characteristics and attendance for a free eye disease screening. The MI-SIGHT program is conducted in two community clinics in Southeastern Michigan. Participant-level demographics were extracted from electronic health records. Neighborhood level-characteristics including Area Deprivation Index (ADI), median household income (HHI), percent of households with >30% rent burden, percent of households without vehicles, percent of households in subsidized housing, and energy burden were obtained from the Wisconsin Neighborhood Atlas and the United States census. Logistic regression was used to model the probability of clinic visit attendance, which was the main outcome measure. 1431 participants were scheduled for screening appointments between July 2020 to November 2021, with a no-show rate of 23%. Individuals lived an average of 7.7 miles from each clinic (SD=8.1) and in neighborhoods with a mean ADI of 6.8 (SD=3.2, 1-10 scale where 10 is the most deprived). After adjusting for age, sex, race, and ethnicity, participants from neighborhoods with higher deprivation were more likely to have missed clinic visits. For example, there was an 8% higher odds of missed clinic visits for every 1-point increase in ADI (odds ratio, OR=1.08, P=0.020) and an 18% higher odds of a missed visit with every 10% increase in households without a vehicle (OR=1.18, P=0.013). Higher neighborhood-level poverty was associated with greater odds of missing a free eye disease screening appointment after adjusting for individual characteristics. Increased neighborhood-level resources are likely needed to bolster engagement in preventive eye care.

O 11 - Assessing equity of family members’ roles in supporting children receiving proton radiation: A retrospective study of parent/guardian clinic visit attendance

O 11 - Assessing equity of family members’ roles in supporting children receiving proton radiation: A retrospective study of parent/guardian clinic visit attendance

Improved outcomes and cost savings for patients with bleeding disorders: a quality improvement project

BackgroundProviding optimal care for patients with bleeding disorders according to national standards remains a challenge at designated Hemophilia Treatment Centers (HTCs). Improved care may reduce bleeds and costs. ObjectivesTo improve care and demonstrate cost savings by 1) reducing preventable hospitalizations and emergency room visits (PHER) for bleeding, 2) increasing use of prophylaxis in severe hemophilia, and 3) improving patient-HTC communication and primary care engagement. MethodsProspective quality improvement project using the Define, Measure, Analyze, Improve, and Control methodology to implement uniform guideline-based bleeding disorder care at a rural HTC (N = 88). Intervention used a standardized physician checklist, improved communication, and reserved physician time for urgent management. Outcomes were determined by retrospective chart review; urgent management was tracked prospectively. ResultsIntervention significantly reduced PHER by 85.4%. Use of prophylaxis in persons with severe hemophilia increased from 58.8% to 100%; attainment of a primary care physician and electronic portal enrollment met outcomes for intervention success. HTC clinic visit attendance was low at 55.2%. The majority of patients (71.6%) had at least 1 outpatient urgent episode (mean, 0.72 episode per year), and 93% had nonurgent management (mean, 9.3 episodes per year) occurring outside of a clinic visit. Hospital PHER factor cost in the group was reduced by 94.5%, from $11,800 to $640 per patient per year—a cost savings of $982,088 yearly. ConclusionThis collaborative study shows that implementation of a carefully designed quality improvement project, such as uniform guidelines with focus on strengthening ambulatory management, led to improved outcomes and cost savings.

Characteristics and Attendance of Patients Eligible for the PASS Clinic: A Transition of Care Model After Acute Symptomatic Seizures.

Most acute symptomatic seizure (ASyS) patients stay on antiseizure medications (ASM) long-term, despite low epilepsy development risk. The Post-Acute Symptomatic Seizure (PASS) clinic is a transition of care model for ASyS patients who individualize ASM management with the goal of a safe deprescription. We evaluated patients discharged on ASMs after a witnessed or suspected ASyS to analyze their PASS clinic visit attendance and its predictors. A single-center, retrospective cohort study of adults without epilepsy who were discharged from January 1, 2019, to September 30, 2019, on first-time ASMs due to witnessed or suspected ASyS (PASS clinic-eligible). We fit a cause-specific Cox proportional hazards model to analyze factors associated with PASS clinic attendance, which depends on survival in this patient population that has a high early postdischarge mortality (a competing risk). We checked for multicollinearity and the assumption of proportional hazards. Among 307 PASS clinic-eligible patients, 95 (30.9%) attended the clinic and 136 (44.3%) died during a median follow-up of 14 months (interquartile range = 2-34). ASyS occurred in 60.2% (convulsive 47%; electrographic 26.7%) of patients. ASMs were continued in the absence of ASyS or epileptiform abnormalities (EAs) in 27% of patients. Multivariable analysis revealed that the presence of EAs (HR = 1.69, 95% CI 1.10-2.59), PASS clinic appointments provided before discharge (HR = 3.39, 95% CI 2.15-5.33), and less frequently noted ASyS etiologies such as autoimmune encephalitis (HR = 2.03, 95% CI 1.07-3.86) were associated with an increased clinic attendance rate. Medicare/Medicaid insurance (HR = 0.43, 95% CI 0.24-0.78, p = 0.005) and the presence of progressive brain injury (i.e., tumors; HR = 0.55, 95% CI 0.32-0.95, p = 0.032) were associated with reduced rate of PASS clinic attendance. Our real-world data highlight the need for appropriate postdischarge follow-up of ASyS patients, which can be fulfilled by the PASS clinic model. Modest PASS clinic attendance can be significantly improved by adhering to a structured discharge planning process whereby appointments are provided before discharge. Future research comparing patient outcomes, specifically safe ASM discontinuation in a PASS clinic model to routine clinical care, is needed.

Reducing Preventable Bleeding Visits and Institutional Factor Costs for Patients with Bleeding Disorders with a Prospective Quality Improvement Project

Providing optimal care to patients with bleeding disorders requires specialized physician, laboratory, pharmacy, nursing, and institutional resources best achieved at Hemophilia Treatment Centers (HTCs). Current systems for managing the care of a resource intensive patient population may be suboptimal. We observed frequent bleeding related hospitalizations and emergency room (ER) visits in patients with bleeding disorders treated at our HTC that could have been potentially prevented by changes in outpatient care delivery. We initiated a prospective quality improvement (QI) project to improve care delivery and to reduce preventable bleeding related hospitalizations and ER visits for adult patients treated at our HTC. The interventions targeted patient-level and systems-level factors contributing to preventable visits, and barriers to care in our patient population. We compared preventable bleeding related hospitalizations and ER visits, institutional factor cost, use of prophylaxis in severe hemophilia, primary care physician attainment, and patient electronic portal enrollment before and after the QI intervention. In our population of adult patients with bleeding disorders (N=88), the intervention significantly reduced the primary outcome of preventable bleeding hospitalization or ER visit (P=0.0082, Figure), and reduced such visits by 85.4%, meeting the pre-specified criteria for success. Institutional factor acquisition costs to treat preventable bleeding were reduced by 94.5%, from $11,800 to $640 per patient per year; a projected savings of $982,088 yearly. Use of factor prophylaxis in patients with severe hemophilia increased from 58.8% to 100%, attainment of a primary care physician increased from 69.4% to 86.4%, and use of the electronic patient portal increased from 53.2% to 83%; all secondary outcomes met pre-specified criteria of success and were statistically significant. HTC clinic visit attendance was low at 55.2%. The majority of patients (71.6%) had at least one outpatient urgent episode (mean 0.72 episode per year), and 93% had non-urgent management (mean 9.3 episodes per year) occurring outside of a clinic visit. These data demonstrate that concerted outpatient management of patients with bleeding disorders with a quality improvement framework can reduce preventable hospitalization and ER visits. Decreased inpatient utilization resulted in substantial reductions in factor costs at the health system level. The clinical effort required to achieve these results was substantial, and required frequent provider engagement outside of regular clinic visits. The HTC can improve patient outcomes and reduce institutional costs from preventable bleeding episodes by supporting a collaborative quality improvement process led by physician, nursing, and laboratory coagulation experts.

Sickle Cell Disease Electronic Health Record Population Management Approach to Support Delivery of High-Quality Care: Leaving Paper Lists behind

Children and young adults with sickle cell disease (SCD) require complex health care services to screen for early signs of disease-related complications and to initiate and monitor disease-modifying therapies. Care coordination is challenging as it involves multiple team members across multiple subspecialties. Evidence-based clinical protocols and quality metrics are essential for SCD programs to deliver high-quality care. Systems to track this care delivery are crucial to ensure equitable, accessible care is consistently provided. In 2016, the Comprehensive Sickle Cell Center (CSCC) and the Population Health Innovation Team at Children's Hospital of Philadelphia (CHOP) developed and implemented an electronic health record (EHR)-based system, the SCD patient registry and proactive care outreach tools, to facilitate processes needed to ensure patient service delivery in a timely fashion. We selected Transcranial Doppler (TCD) ultrasounds, hydroxyurea therapy initiation, and annual clinic visits to monitor stroke risk screening, disease-modification therapy, and general chronic illness care. Between January 2015 and June 2023, approximately 1400 patients with SCD were tracked across two CHOP outpatient clinics, the CHOP Philadelphia and CHOP Voorhees campuses. We tracked TCD completion, hydroxyurea prescriptions, and clinic visits per year for age-eligible patients with SS and SB0thal. Prior to implementation of the EHR-based tools and new workflows in October 2016, for age-eligible patients, on average 75% of patients had received annual TCD screening, 55% of patients had received hydroxyurea prescriptions within the prior 6 months, and 85% had attended outpatient hematology clinic at least twice within the year. As of June 2023, on average, completed TCD visits had increased to 91%, patients prescribed hydroxyurea had increased to 78%, and patients attending 2 clinic visits within a year had increased to 89%. These metrics remained consistent and improvement was sustained despite the COVID-19 pandemic. Table 1 describes the drivers influencing these improvements, which included various interventions involving social work, nursing, community health workers, registrars, care coordinators, and physicians. Figure 1 illustrates the changes achieved over time in rates of TCD completion, hydroxyurea prescriptions, and clinic visit attendance. This implementation of an SCD EHR-based population health tool and new care team workflows facilitated more efficient processes for various care team members and improved our ability to consistently provide timely services to children and young adults with SCD. This resulted in sustained improvement in all metrics and high-quality care for our patients.

A Longitudinal Assessment of Interruptions in HIV Clinic Visits and Virologic Failure among Pregnant and Postpartum Women in the Kabeho Study

Background: Antiretroviral therapy (ART) for women with HIV is recommended for life, yet most studies measure retention in HIV care and treatment as a binary outcome rather than patterns of intermittent clinic attendance. Pregnancy and the post-partum period are critical times to study interruptions in care, as retention among these women is particularly challenging and can affect the outcomes of both the mother and her child. Methods: The Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) study was an observational prospective cohort of 608 pregnant and postpartum women with HIV followed for 2 years. Clinic visit attendance was used to construct an interruption variable defined as a missed visit followed by a return to care. In multivariate analyses, we examined interruption patterns as predictors of virologic failure and detectable viral load. Results: During the study period, 48% of women had multiple visit interruptions and 29% had an interruption that lasted more than one month. Adjusting for age, ART regimen, time on ART, and CD4 count, the odds of virologic failure among women with multiple interruptions were almost 3 times higher than for women with one or no interruptions (aOR=2.72, 95%CI: 1.09, 6.77). The odds of virologic failure were nearly 3.5 times higher among women with an interruption lasting more than one month compared with women with shorter or no interruptions (aOR=3.47, 95%CI: 1.59, 7.66). Conclusions: Interruptions in HIV care visits are common with significant increases in virologic failure among women with multiple and long-term interruptions. Measuring patterns of interruption, rather than a single binary measure captures the fluid nature of lifetime and health-seeking behavior.

Ethnicity and trends in pediatric specialty care clinic attendance at an academic medical center in the rural southeastern US.

Following the 2016 US Presidential election, immigration enforcement became more aggressive, with variation by state and region depending on local policies and sentiment. Increases in enforcement created an environment of risk for decreased use of health care services among especially among Latino families. of Hispanic ethnicity and/or from Latin American origin (as a group subsequently referred to as Latino). For Latino children with chronic health conditions, avoidance of routine health care can result in significant negative health consequences such as disease progression, avoidable use of acute health care services, and overall increased costs of care. To investigate for changes in visit attendance during the periods before and since increased immigration enforcement, we extracted data on children followed by subspecialty clinics of one healthcare system in the US state of North Carolina during 2015-2019. For each patient, we calculated the proportion of cancelled visits and no-show visits out of all scheduled visits during the 2016-2019 follow-up period. We compared patient characteristics (at the 2015 baseline) according to whether they cancelled or did not show to any visits in subsequent years by clinic and patient factors, including ethnicity. Data were analyzed using multinomial logistic regression of attendance at each visit, including an interaction between visit year and patient ethnicity. Among 852 children 1 to 17 years of age (111 of Latino ethnicity), visit no-show was more common among Latino patients, compared to non-Latino White patients; while visit cancellation was more common among non-Latino White patients, compared to Latino patients. There was no significant interaction between ethnicity and trends in visit no-show or cancellation. Although differences in pediatric specialty clinic visit attendance by patient ethnicity were seen at study baseline, changing immigration policy and negative rhetoric did not appear to impact use of pediatric subspecialty care.

COVID-19 Vaccination Status and Operative Outcomes after Kidney Transplantation.

Kidney transplantation remains the best available treatment for end-stage renal disease. However, promoting graft longevity and preventing allosensitization requires strict adherence with a stringent immunosuppression regimen. The COVID-19 pandemic has offered new challenges for kidney transplant patients and many transplant centers are denying transplantation to unvaccinated patients. The aim of this study was to evaluate whether unvaccinated patients had inferior adherence after kidney transplantation along with a reduction in graft survival. Patients undergoing a deceased donor kidney transplantation at a single academic medical center from February 2021 to May 2022 were retrospectively reviewed. February 2021 was chosen as the start date for record review because it was 3 months after the first COVID-19 vaccination was authorized for emergency use. Patients were considered to be vaccinated if they received at least 1 dose of any mRNA vaccine by their transplantation date. Of the 301 patients who met study criteria, 234 were vaccinated and 67 were unvaccinated. Cohorts stratified by vaccination status were well matched. Younger age was an independent risk factor for nonvaccination. Interestingly, unvaccinated patients had worse postoperative adherence with a greater average number of missed postoperative clinic visits (p = 0.03) and a strong trend toward missing 3 or more postoperative clinic visits (p = 0.07). Finally, unvaccinated patients had statistically more subtherapeutic tacrolimus troughs (p = 0.01). Patients not vaccinated against COVID-19 had higher rate of postoperative nonadherence in key areas of immunosuppression monitoring and clinic visit attendance. Providers should be cognizant that an unvaccinated status may be a harbinger for poor adherence; therefore, stricter strategies for patient outreach are critical to ensure graft success in this vulnerable patient population.

Six-month outcomes of the HOPE smartphone application designed to support treatment with medications for opioid use disorder and piloted during an early statewide COVID-19 lockdown

BackgroundMorbidity and mortality related to opioid use disorder (OUD) in the U.S. is at an all-time high. Innovative approaches are needed to address gaps in retention in treatment with medications for opioid use disorder (MOUD). Mobile health (mHealth) approaches have shown improvement in engagement in care and associated clinical outcomes for a variety of chronic diseases, but mHealth tools designed specifically to support patients treated with MOUD are limited.MethodsFollowing user-centered development and testing phases, a multi-feature smartphone application called HOPE (Heal. Overcome. Persist. Endure) was piloted in a small cohort of patients receiving MOUD and at high risk of disengagement in care at an office-based opioid treatment (OBOT) clinic in Central Virginia. Outcomes were tracked over a six-month period following patient enrollment. They included retention in care at the OBOT clinic, usage of various features of the application, and self-rated measures of mental health, substance use, treatment and recovery.ResultsOf the 25 participants in the HOPE pilot study, a majority were retained in care at 6 months (56%). Uptake of bi-directional features including messaging with providers and daily check-ins of mood, stress and medication adherence peaked at one month, and usage persisted through the sixth month. Patients who reported that distance to clinic was a problem at baseline had higher loss to follow up compared to those without distance as a reported barrier (67% vs 23%, p = 0.03). Patients lost to in-person clinic follow up continued to engage with one or more app features, indicating that mHealth approaches may bridge barriers to clinic visit attendance. Participants surveyed at baseline and 6 months (N = 16) scored higher on scales related to overall self-control and self-efficacy related to drug abstinence.ConclusionsA pilot study of a novel multi-feature smartphone application to support OUD treatment showed acceptable retention in care and patient usage at 6 months. Further study within a larger population is needed to characterize ‘real world’ uptake and association with outcomes related to retention in care, relapse prevention, and opioid-associated mortality.

139. Social Support Decreases No-Show Rates Among Patients with Injection-Drug-Use-Related Infections and Opioid Use Disorder

Abstract Background Opioid overdose is the leading cause of injury-related death in the United States. Kentucky ranks in the top 5 states for overdose death and has one of the highest rates of acute hepatitis C (HCV). Fifty-four of Kentucky’s counties are among the 220 U.S. counties identified as high risk for rapid dissemination of HIV and HCV. Poverty, legal issues, and transportation are barriers to effective treatment of opioid use disorder (OUD) and related infections. The WRAP project (Wrap-around Recovery for Addiction and infectious Diseases project) is an ongoing multi-disciplinary program to expand access to OUD treatment at University of Kentucky HealthCare. This program provides social support including transportation assistance, case management, and counseling. Missed visits have been associated with multiple adverse outcomes. Methods We compared missed infectious diseases clinic visits (n=620) of patients enrolled in WRAP to those of patients who were referred and eligible, but not enrolled using chi-square tests for odds ratios. Results We enrolled 35% of eligible, referred patients. The majority (70%) of patients not enrolled were referred while inpatient and discharged before they could be enrolled. WRAP-enrolled patients missed 21% of visits, whereas WRAP-eligible, non-enrolled patients missed 31% of visits (OR 0.59, 95% CI 0.49 to 0.72, p-value < 0.001), Figure 1. This finding was consistent for WRAP-referred patients with a diagnosis of HIV who were also eligible for Ryan White support services: WRAP-enrolled patients missed 17% of visits and WRAP-eligible, non-enrolled patients missed 25% of visits (OR 0.26, 95% CI 0.20 to 0.35, p-value 0.002). For HCV patients who were mostly referred as outpatients, WRAP-enrolled patients missed 25% of visits while WRAP-eligible, non-enrolled patients missed 39% (OR 0.54, 95% CI 0.41 to 0.72 , p-value 0.0003), Figure 2. Figure 1. ID clinic visit attendance among WRAP eligible, non-enrolled and WRAP enrolled patients. WRAP-enrolled patients missed 21% of visits, whereas WRAP-eligible, non-enrolled patients missed 31% of visits (OR 0.59, 95% CI 0.49 to 0.72, p-value < 0.001). Figure 2. ID clinic attendance among WRAP eligible, non-enrolled and WRAP enrolled patients with HIV and hepatitis C primary diagnoses. A. WRAP-enrolled patients with a primary diagnosis of HIV missed 17% of visits and WRAP-eligible, non-enrolled patients missed 25% of visits (OR 0.26, 95% CI 0.20 to 0.35, p-value 0.002). B. WRAP-enrolled patients with a primary diagnosis of hepatitis C missed 25% of visits while WRAP-eligible, non-enrolled patients missed 39% (OR 0.54, 95% CI 0.41 to 0.72, p-value 0.0003). Conclusion Providing patients with social support services to address barriers to attending clinic visits was associated with fewer missed ID clinic visits. Higher engagement in care is a step towards implementing evidence-based treatment to lessen overdose deaths and injection-related infections. Future projects will include investigating whether WRAP enrollment is associated with fewer hospital admission and ER visits. Disclosures All Authors: No reported disclosures

Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania

IntroductionEvidence on the effects of community health worker (CHW) interventions and conditional cash transfers (CCTs) on child growth and development in sub-Saharan Africa remains sparse.MethodsWe conducted a single-blind, cluster-randomised controlled...

Pretreatment Assessment of Psychosocial Readiness Is Not Associated with Improved Treatment Outcomes in a Safety-Net HCV Treatment Clinic.

Hepatitis C virus (HCV) is highly curable with antiviral therapy, and traditionally, treatment adherence has been critical for treatment success. We sought to determine whether assessing HCV treatment readiness with a structured treatment readiness tool was associated with increased rates of adherence and cure among patients at a safety-net HCV clinic. We administered the Psychosocial Readiness Evaluation and Preparation for HCV Treatment (PREP-C) tool to 50 patients and compared them with 50 patients who received the usual care. The outcome measures included achievement of treatment milestones (eg, adherence to treatment, clinic visit attendance) and sustained virologic response (cure). We found no association between receiving the PREP-C assessment and outcomes, including referral to or starting HCV treatment, adherence to treatment, and HCV cure. We found that receiving the PREP-C assessment did not improve treatment outcomes, suggesting that targeted pretreatment assessment is unnecessary even in a medically and psychosocially complex population.

767. Can Integration of Addiction Treatment Facilitate Safe Discharge on OPAT for Patients with Infectious Complications of Injection Drug Use?

BackgroundWhile there is a growing body of evidence that suggests outpatient parental antibiotic treatment (OPAT) for people who inject drugs (PWID) may be safe, research on integrating OPAT with addiction treatment for PWID has been limited.MethodsAdults hospitalized for infectious complications of injection drug use (IDU) requiring prolonged IV antibiotics were included in this study. The suitability for OPAT was determined by the infectious disease and addiction consultation services. Eligibility criteria included safe housing, attendance at infectious disease (ID) clinic visits, and engagement with addiction treatment. Demographic and clinical outcomes were summarized, and compared with patients without any IDU history enrolled in OPAT during the same time at the same institution.ResultsEighteen OPAT episodes among 17 individuals were included, with 9 (50.0%) males. Mean age was 38.4 (SD 9.5). Types of infection included endocarditis (38.9%), epidural abscess (38.9%), and bone/joint infections (33.3%). Opioid use disorders (OUD) were most common (94.4%), followed by cocaine (33.3%) and benzodiazepines (16.7%). All individuals completed the recommended course of IV antibiotics. All OUD patients received buprenorphine (52.9%) or methadone (47.1%). Two (11.1%) relapsed to drug use during OPAT, but no instances of line tampering, thrombosis, line infection or line dislodgement were identified. No deaths or overdoses were reported. Collectively, 504 inpatient days were avoided. Compared with 390 individuals without any history of IDU, those with IDU history were significantly younger (38.4 vs. 59.0, P < 0.0001), had fewer episodes of endocarditis (38.9% vs. 43.6%) and bone/joint infections (33.3% vs. 41.8%), but more epidural abscesses (38.9% vs. 3.1%). There were no statistical differences in rates of readmission (22.2% vs. 11.3%), line complications (0% vs. 3.5%), mortality (0% vs. 1.0%), ID clinic visit attendance (100.0% vs. 82.0%), or number of days on OPAT (28.0 vs. 30.1).ConclusionResults add further evidence of OPAT’s safety among PWID and that integration of addiction treatment may be feasible. OPAT outcomes were similar to those without any IDU history. More research is needed to study the impact of integrating addiction treatment with OPAT for PWID. Disclosures All authors: No reported disclosures.

Distance to clinic is a barrier to PrEP uptake and visit attendance in a community in rural Uganda.

IntroductionGeographic and transportation barriers are associated with poorer HIV‐related health outcomes in sub‐Saharan Africa, but data on the impact of these barriers on prevention interventions are limited. We estimated the association between distance to clinic and other transportation‐related barriers on pre‐exposure prophylaxis (PrEP) uptake and initial clinic visit attendance in a rural community in southwestern Uganda enrolled in the ongoing SEARCH study (NCT01864603).MethodsCommunity‐wide HIV testing was conducted and offered to adult (≥15 years) participants in Ruhoko. Participants were eligible for PrEP based on an empiric risk score, having an HIV‐discordant partner, or self‐referral at either the community health campaign or during home‐based testing from March to April 2017. We collected data from PrEP‐eligible households on GPS‐measured distance to clinic, walking time to clinic and road difficulty. A sample of participants was also asked to identify their primary barriers to PrEP use with a semi‐quantitative questionnaire. We used multivariable logistic regression to evaluate the association between transportation barriers and (1) PrEP uptake among PrEP‐eligible individuals and (2) four‐week clinic visit attendance among PrEP initiators.ResultsOf the 701 PrEP‐eligible participants, 272 (39%) started PrEP within four weeks; of these, 45 (17%) were retained at four weeks. Participants with a distance to clinic of ≥2 km were less likely to start PrEP (aOR 0.34; 95% CI 0.15 to 0.79, p = 0.012) and less likely to be retained on PrEP once initiated (aOR 0.29; 95% CI 0.10 to 0.84; p = 0.024). Participants who were deemed eligible during home‐based testing and did not have the option of same‐day PrEP start were also substantially less likely to initiate PrEP (aOR 0.16, 95% CI 0.07 to 0.37, p < 0.001). Of participants asked to name barriers to PrEP use (N = 98), the most frequently cited were “needing to take PrEP every day” (N = 18) and “low/no risk of getting HIV” (N = 18). Transportation‐related barriers, including “clinic is too far away” (N = 6) and “travel away from home” (N = 4) were also reported.ConclusionsDistance to clinic is a significant predictor of PrEP uptake and four‐week follow‐up visit attendance in a community in rural Uganda. Interventions that address geographic and transportation barriers may improve PrEP uptake and retention in sub‐Saharan Africa.

Assessing the Feasibility of a Social Media to Promote Weight Management Engagement in Adolescents with Severe Obesity: Pilot Study.

BackgroundSevere obesity in adolescents has deleterious physical and psychological complications necessitating frequent multi-disciplinary clinic visits. Greater treatment engagement has been equated with weight-loss. However, traditional medical weight-loss programs for adolescents have high attrition rates. Social media is widely used by adolescents and may enhance medical weight management engagement and success.ObjectiveThe first objective was to examine the acceptability and feasibility of using a private social media group as an adjunct to medical weight management in youth ages 14 to 20 years with severe obesity [body mass index (BMI) ≥ 35 kg/m2]. The second objective was to pilot test the use of social media to improve treatment engagement and decrease attrition rates.MethodsIn this single arm, 12 week pre-post study, participants attended individual clinic visits and participated in a moderated private social media group that received nutrition, exercise, and behavior change social media communications or “posts” 3 to 4 times/week. Youth commented and/or liked posts from the moderator and each other. Social media engagement was measured with the number of likes and comments on social media. Clinic attrition was compared, measuring clinic visit attendance 12 weeks prior, during, and after the intervention with mixed linear regression models. Correlations of social media engagement with changes from baseline for BMI, BMI-z score, and psychosocial measures were fit.ResultsAll 13 enrolled youth completed the study and reported that the group was enjoyable, helpful, reinforced their weight management program, and would recommend using social media to support other youth. The pilot trial was acceptable and feasible. Youth mean weekly engagement (likes + comments) in social media was greater than once a day (8.6 ±3.6). Compared to 12 weeks prior to the intervention, there was no significant decrease in clinic visit attendance at the end of the intervention (M=.231, P=.69) or 12 weeks at the conclusion of the intervention (M=.589, P=.28). Increased social media comments correlated with weight change (r=–.633, P=.04).ConclusionsThis pilot trial demonstrated that the use of social media as an adjunct to medical weight management was feasible and acceptable to adolescents with severe obesity. Based upon these preliminary findings, social media may be an effective way to mitigate attrition from obesity treatment programs, and improve health outcomes in this high-risk population.

Progesterone and Postpartum Smoking Relapse: A Pilot Double-Blind Placebo-Controlled Randomized Trial.

Pregnancy is a strong motivator to quit smoking, yet postpartum relapse rates are high. Growing evidence suggests a role of sex hormones in drug abuse behavior and given the precipitous drop in sex hormones at delivery, they may play a role in postpartum relapse. This pilot study evaluates the feasibility and potential role of exogenous progesterone in postpartum smoking relapse. This 12-week double-blind placebo-controlled randomized pilot trial randomized 46 abstinent postpartum women to active progesterone (PRO; 200mg twice a day) versus placebo (PBO) for 4 weeks. Participants were followed for relapse for 12 weeks. Main study outcomes include abstinence (point prevalence), feasibility (compliance per number of clinic visits attended, pill counts and Electronic Data Capture [EDC] completed) and self-reported acceptability. Safety was also measured by depressive symptom scores, adverse events, and breastfeeding. Overall retention rate was 87% at week 12. At week 4, abstinence rates were 75% in the PRO group and 68.2% in the PBO group (p = .75). Medication adherence was 68% and clinic visit attendance was 80%, with no differences by randomization. Depressive symptom scores, adverse events, and breastfeeding did not vary by randomization. Although the study was not powered to evaluate abstinence rates, we did observe a higher prevalence of abstinence at week 4 in the PRO group. Further, exogenous progesterone was well tolerated and did not adversely affect depressive symptoms or breastfeeding. Thus, the results of this pilot study indicate further investigation into progesterone as a postpartum relapse prevention strategy is warranted. This innovative pilot trial determined the feasibility of delivering exogenous progesterone as a potential prevention of postpartum smoking relapse. We observed high retention and moderate adherence rates, as well as high acceptability among participants. Further, though not statistically significant, more women in the treatment group remained abstinent from smoking during follow-up. This project adds to the growing body of literature on the role of sex hormones in smoking relapse and also provides support for a fully powered clinical trial.

Predictors and outcomes of adolescent bariatric support group attendance

BackgroundAttending support groups connects adults undergoing bariatric surgery to peers and may improve weight loss efficacy. Predictors and outcomes of support group attendance of adolescents undergoing bariatric surgery are unknown. The objective of this cohort study was to determine the rate, predictors, and outcomes of support group attendance in a free-standing adolescent bariatric program. MethodsCharts of 68 consecutive adolescents who underwent laparoscopic Roux-en-Y gastric bypass or vertical sleeve gastrectomy were retrospectively reviewed, and demographic and anthropometric variables and support group and clinic visit attendance were recorded. Prospectively collected vitamin adherence data were also analyzed. Univariate analyses evaluated characteristics and multivariate analyses evaluated predictors of support group attendance, clinic visit attendance, and vitamin adherence. ResultsOf the 68 patients, one third attended 1–3 support sessions, one third attended ≥4, and one third were nonattenders. Greater distance from clinical center (P = .01) and caregiver bariatric history (P = .05) were associated with decreased attendance. Only high preoperative body mass index (P<.01) and caregiver bariatric history (P<.01) were independently associated with decreased attendance. Increased attendance was associated with higher 6-month (P = .03) and 12-month (P<.01) clinic visit attendance but not with multivitamin adherence (P = .33). ConclusionsCaregiver bariatric history and higher preoperative body mass index were associated with decreasing attendance at an adolescent bariatric support group program. This highlights a need to encourage attendance in these patients, because adolescent attendance at support group sessions was positively associated with greater adherence to scheduled clinic visits postoperatively, which may positively influence long-term outcomes.

Influencing Factors of Healthcare-Seeking Behaviors in Taiwanese Patients With Hepatitis C

The purpose of this study was to determine factors that influence the frequency of hospital clinic visits for hepatitis C patients in Taiwan and identify data related to healthcare-seeking behaviors of patients by using a developed questionnaire based on the Health Belief Model. Consistent clinic visits for follow-up and treatment are required of the hepatitis C patient to be compliant with therapy guidelines. Recent studies targeted only Western communities in which hepatitis C is nonepidemic, unlike hepatitis C virus-endemic regions of Taiwan where patients may exhibit 10-20 times higher seroprevalence. Influences on hospital clinic visit attendance were identified as educational level, income, and aspartate aminotransferase level at diagnosis. Perceived benefits from and barriers to action were similar among the 390 evaluable subjects at various frequencies of hospital clinic visits (both p > .05); however, subjects who visited the hospital clinic between 1 and 6 months exhibited significantly higher scores of perceived susceptibility to disease and severity of disease than those who visited the hospital clinic at 7-9 months or less often (all p ≤ .001). Findings lay the foundation for future studies to address strategies to increase compliance with treatment regimens for Taiwanese patients with hepatitis C.

Implementation of a diabetes clinic‐in‐a‐clinic project in a family practice setting: using the plan, do, study, act model

The American Association of Diabetic Educators suggests that educating patients about their diabetes management facilitates problem solving and coping skills. This paper will describe a clinic-in-a-clinic model of care delivery founded on the principles of the Chronic Care Model and focused towards the outcomes proposed by the American Association of Diabetic Educators. The reader will be introduced to the use of the 'plan, do, study, act' process used to develop this model in a clinical setting. Self-management support, a key component of the Chronic Care Model, focuses on providing patients with the skills to make healthcare decisions. Self-management encourages patient to be responsible for his/her own health care. Because diabetes outcomes and complication prevalence are related to the degree of self involvement in illness care, self-management support is an important component of disease management. Plan, do, study, act model for program development. The 'plan, do, study, act' cycles outlined the steps needed to implement the clinic-in-a-clinic program with success related to coordination of all components and continual assessment and revision. Each cycle was initiated in a sequential order allowing for evaluation and goal adjustment before the next cycle was implemented. The majority of patients seen were middle-aged, obese, females with HbA1cs greatly above the recommended 7.0. Patients selected a variety of topics related to diabetes management for their clinical session. Participation rates were consistent with regular clinic visit attendance. Barriers to success of the program were related to both structure and process. The clinic-in-a-clinic design moves disease management from individual practice into a property of the health systems and places importance on the collaboration of patient, provider and delivery system in reducing the consequences of chronic illness. Use of the 'plan, do, study, act' cycle model offers a method for changing the process of care delivery in a structured, sequential approach.