Clinical Referrals Research Articles

Impact of Community Eye Clinics (CEC) on Specialist Eye Clinic Referrals

ABSTRACT Purpose Community Eye Clinics (CEC) increase accessibility of specialist ophthalmic services in the community, reducing demand for tertiary eye services. This paper aims to evaluate the impact of CEC on first-visit referrals from Hougang Polyclinic (HOU) to Tan Tock Seng Hospital Ophthalmology Specialist Outpatient Clinic (SOC). Methods A retrospective analysis was performed on first-visit referrals from Hougang Polyclinic (HOU) to Tan Tock Seng Hospital Ophthalmology Specialist Outpatient Clinic (SOC) over a similar 3-months period before and after the introduction of CEC in August 2018 (1 January to 31 March in 2018 and 2019, respectively). Data pertaining to patients’ presenting complaints, referral reasons, final diagnoses, follow-up plans, and need for ophthalmic intervention were obtained. Results We included 978 patients in our study. There was a 27.5% reduction in the number of first-visit referrals seen at SOC after the establishment of CEC. Patients were more likely to be referred on to sub-specialty eye clinics (10.8% vs. 12.9%, p= p = .304) and receive more ophthalmic interventions (15% vs. 16.3%, p = .066) than prior to CEC. Conclusion The CEC provides greater accessibility to eye care within the community. Optometrists are upskilled to manage patients with stable eye conditions, whilst eye specialists can provide timely care to the SOC for patients with more severe eye conditions.

Does the duration of ambulatory consultations affect the quality of healthcare? A systematic review

BackgroundThe objective is to examine and synthesise the best available experimental evidence about the effect of ambulatory consultation duration on quality of healthcare.MethodsWe included experimental studies manipulating the length of...

Clinical Genetics Assessment Triangle (CGAT): A simple tool to identify patients with genetic conditions

ObjectiveThe objective of this study was to develop a simple tool for general physicians to promptly identify and refer pediatric patients with a higher probability of having a genetic condition. Study designThis retrospective, descriptive study was conducted at a tertiary pediatric hospital's Clinical Genetics Unit from June 2019 to January 2020. We included patients under 18 years of age who visited the unit, excluding those without genetic testing. Epidemiological, clinical, and genetic variables were collected from electronic medical records. The primary outcome was the diagnosis of a genetic condition based on genetic testing. ResultsAmong 445 patients, 304 were included; 163 (53.6%) were male, and mean age was 7.4 years (SD 5.1 years). A genetic condition was diagnosed in 139 patients (45.7%). Using a multiple logistic regression model, five variables significantly contributed to reaching a diagnosis: suspected diagnosis at referral (OR 3.45, P < 0.001), short stature (OR 3.11, P < 0.001), global developmental delay/intellectual disability (OR 2.65, P < 0.001), dysmorphic craniofacial features (OR 1.99, P = 0.035), and multiple congenital anomalies (OR 2.54, P = 0.033). The association strength (OR) increased when these variables were paired with each other. The study's findings are presented in the form of a triangle, known as the Clinical Genetics Assessment Triangle (CGAT), which summarizes the results. A decision tree model is applied to guide clinical department referrals based on the affected sides of the triangle. ConclusionsThe CGAT has the potential to enable general physicians to promptly identify pediatric patients with an increased probability of having a genetic condition.

Abstract PO-058: Piloting a novel strategy to rapidly implement smoking cessation treatment for newly-diagnosed head and neck cancer patients

Abstract Purpose The purpose of this study is to evaluate a novel, bimodal strategy to implement smoking cessation treatment prior to oncologic therapy in newly-diagnosed head and neck cancer (HNC) patients. Background Among the 65,000 people who develop HNC in the United States (US) annually, 20-30% smoke cigarettes and 50-80% will continue smoking throughout survivorship. Quitting smoking before oncologic therapy correlates with improved health outcomes. However, the window of opportunity to quit smoking is narrow since cancer treatment often begins 4-5 weeks after the first oncology visit. The failure to rapidly implement evidence-based smoking cessation treatment is a major cause of this problem. Offering both behavioral therapy and pharmacotherapy increases abstinence rates by 2-3-fold. Despite this, only 4-17% of cancer patients receive both therapies at any time. Methods We conducted a pragmatic, quasi-experimental, pilot study using a pre-post design to evaluate a strategy to rapidly implement behavioral therapy and pharmacotherapy. The pre-test period was from 1/21-3/22 and the strategy was deployed from 4/22-10/22. The population included newly-diagnosed patients with mucosal HNC or salivary gland cancer. The setting was an academic medical center with an established tobacco treatment program (TTP). The implementation strategy involved bimodal administration of the evidence-based Ask, Advise, Connect (AAC) approach before and at the first surgical oncology visit. First, a dedicated medical assistant (MA) used an electronic health record (EHR)-based tool to identify, ask, advise, and connect (i.e. refer) smokers to the TTP at the time of clinic referral, or ~1-2 weeks before the first surgical oncology visit. Second, the AAC strategy was delivered by the triage MA and nurse at the time of the first surgical oncology visit. Some surgeons opportunistically offered patients pharmacotherapy. Results Among the 383 eligible, newly-diagnosed HNC patients, and 48 (12.5%) were current smokers. Twelve smokers were diagnosed between 4/22-10/22 and were eligible for the bimodal AAC strategy. However, only six of 12 patients received the AAC strategy before the first oncology visit. Among the 48 smokers, 75% were male, the median age was 65.5-years, and cancer treatment was started a median 34 days after the first oncology visit. Within 30 days of the first surgical oncology visit, 67% were advised to quit, 25% were referred to the TTP, 6% completed a comprehensive TTP visit, 21% had pharmacotherapy ordered, and 17% received both behavioral therapy and pharmacotherapy. While there were otherwise no differences in outcomes between pre- and post-strategy groups, more bimodal AAC strategy-eligible patients received pharmacotherapy (42%) compared to pre-strategy patients (14%, p=0.040). Conclusions Our bimodal AAC strategy correlated with increased use of pharmacotherapy, despite suboptimal fidelity to the approach. Additional strategies to improve delivery of timely behavioral therapy and pharmacotherapy for smoking cessation are needed. Citation Format: Sahajveer Mann, Julia Casazza, Dalia Mitchell, Quynh-Chi Dang, Dequan Weston, Brette Harding, Baran D. Sumer, Brittny Tillman, Heather Kitzman, George Jackson, Robert Schnoll, Amit Singal, Andrew T. Day. Piloting a novel strategy to rapidly implement smoking cessation treatment for newly-diagnosed head and neck cancer patients [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Innovating through Basic, Clinical, and Translational Research; 2023 Jul 7-8; Montreal, QC, Canada. Philadelphia (PA): AACR; Clin Cancer Res 2023;29(18_Suppl):Abstract nr PO-058.

Factors Affecting Healthcare Provider Referral to Heart Function Clinics: A Mixed-Methods Study.

Heart failure (HF) care providers are gatekeepers for patients to appropriately access lifesaving HF clinics. The aim of this study was to investigate referring providers' perceptions regarding referral to HF clinics, including the impact of provider specialty and the coronavirus disease pandemic. An exploratory, sequential design was used in this mixed-methods study. For the qualitative stage, semistructured interviews were performed with a purposive sample of HF providers eligible to refer (ie, nurse practitioners, cardiologists, internists, primary care and emergency medicine physicians) in Ontario. Interviews were conducted via Microsoft Teams. Transcripts were analyzed concurrently by 2 researchers independently using NVivo, using a deductive-thematic approach. Then, a cross-sectional survey of similar providers across Canada was undertaken via REDCap (Research Electronic Data Capture), using an adapted version of the Provider Attitudes toward Cardiac Rehabilitation and Referral scale. Saturation was achieved upon interviewing 7 providers. Four themes arose: knowledge about clinics and their characteristics, providers' clinical expertise, communication and relationship with their patients, and clinic referral process and care continuity. Seventy-three providers completed the survey. The major negative factors affecting referral were skepticism regarding clinic benefit (4.1 ± 0.9/5), a bad patient experience and believing they are better equipped to manage the patient (both 3.9). Cardiologists more strongly endorsed clarity of referral criteria, referral as normative and within-practice referral supports as supporting appropriate referral versus other professionals ( P s < .02), among other differences. One-third (n = 13) reported the pandemic impacted their referral practices (eg, limits to in-person care, patient concerns). Although there are some legitimate barriers to appropriate clinic referral, greater provider education and support could facilitate optimal patient access.

Association of Delay in Breast Cancer Diagnosis With Survival in Addis Ababa, Ethiopia: A Prospective Cohort Study.

There are limited data on the association between delay in breast cancer diagnosis after breast symptom recognition and survival, particularly in sub-Saharan Africa. The recently launched Global Breast Cancer Initiative by WHO includes measuring delay as the core indicator for quality of breast cancer care. Herein, we examined the association between delay in breast cancer diagnosis with overall survival among women in Addis Ababa, Ethiopia. A total of 439 women diagnosed with breast cancer from January 1, 2017, to June 30, 2018, in Addis Ababa were followed for survival to the end of 2019. Survival rates were estimated using the Kaplan-Meier method. The association between delay in diagnosis (>3 months after symptom recognition) and overall survival was computed using the multivariable Cox regression model after adjusting for demographic and clinical factors. Nearly 70% (303/439) of women with breast cancer were delayed in diagnosis of their cancer. During a median follow-up period of 25.1 months, 2-year overall survival rate was 73.5% (95% CI, 68.0 to 78.2) in women with diagnosis delay compared with 79.1% (95% CI, 71.2 to 85.1) in those women without diagnosis delay. In the multivariable Cox regression model, the risk of death was 73% higher (hazard ratio, 1.73; 95% CI, 1.09 to 2.74) in women with diagnosis delay compared with those without diagnosis delay. Delay in diagnostic confirmation of breast cancer after recognition of breast symptoms was negatively associated with overall survival in Addis Ababa, Ethiopia, underscoring the need to increase awareness about the importance of prompt presentation for clinical evaluation and referral for diagnostic confirmation to mitigate the undue high burden of the disease.

What It’s Like Being A Midwife With Attention Deficit Hyperactivity Disorder

Some women with attention deficit hyperactivity disorder (ADHD) may go their entire lives without receiving a diagnosis. This diagnosis gap exists in part because the disorder was once assumed to mostly afflict men but also because women typically exhibit less socially disruptive symptoms than men.1 Most ADHD clinic referrals for nearly a century were for young, hyperactive boys.2 The data characterising boys’ behaviours served as the foundation for early diagnostic standards. Since hyperactivity was demonstrated to be the hallmark, only rarely were young females diagnosed. The primary symptoms of inattention that most girls with ADHD encountered did not meet the diagnostic criteria, therefore ADHD was thought to be a typically male condition. The Nursing and Midwifery Council (NMC) recorded that 99.7% of midwives in the UK are women, while 3.7% of midwives have disclosed a disability.3 This could be suggestive of high numbers of UK midwives working and living with undiagnosed (therefore untreated) ADHD. This article explores the personal experience of being a midwife with ADHD with guidance on how colleagues can be supportive of each other.

1325 Impact of the VFC in Fracture Clinic Referral Times

Abstract Aim According to BOAST guidelines, patients should be seen in fracture clinic within 72 hours of presentation, following acute traumatic orthopaedic injury. Our audit aimed to assess the efficacy of a Virtual Fracture Clinic (VFC) in meeting the standard of care outlined by the guidelines. Method A retrospective review of notes was carried out for patients seen in fracture clinic on a random week before the VFC was introduced and a random week after VFC was introduced. Incomplete records and follow up referrals were excluded. Results A total of 51 new patients were seen on a random week in clinic prior to VFC introduction. The range of time before clinic review was 1 - 17 days, with a mean of 6 days. 83% of patients were seen later than 72 hours. After introduction of VFC, 44 patients were seen on a random week. Range was 1 - 11 days, with a mean 3.6 days. Only 5% were seen later than 72 hours. Conclusions Introduction of the VFC ensured BOAST guidelines for time to be seen in clinic were met for 95% of patients. Delays in seeing patients are generally cut to at least half. Suggestions for further improvement in time to be seen include increasing the capacity of virtual clinics and making a separate triage for trauma patients in A&amp;E.

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.

An Exploratory Pilot Study of Neuropsychological Performance in Two Huntington Disease Centers of Excellence Clinics.

To describe the characteristics of patients receiving a clinical referral for neuropsychological evaluation in two Huntington's Disease Society of America Centers of Excellence (HDSA COE). In this exploratory pilot study, we used an empirically supported clinical neuropsychological battery to assess differences in cognitive performance between premanifest and manifest HD patient groups (compared with each other and normative expectations). Clinical data from 76 adult genetically confirmed patients referred for neuropsychological evaluations was retrospectively collected from two HDSA COEs. ANOVA and Chi-square tests were used to compare variables between pre-manifest (n = 14) and manifest (n = 62) groups for demographic, cognitive, neuropsychiatric, and disease severity variables. Our clinics serviced a disproportionate number of motor manifest patients. Six measures were excluded from analyses due to infrequent administration. The full WAIS-IV Digit Span was disproportionately administered to the manifest group. The premanifest group showed stronger cognitive performance with effect sizes in the large range on subtests of the WAIS-IV Digit Span, HVLT-R, SDMT, and verbal fluency. This is the first study to assess an empirically supported neuropsychological research battery in a clinical setting with a relatively large sample size given the rarity of HD. The battery adequately captured areas of impairment across the disease spectrum. Application of the current battery with larger premanifest samples is warranted.

Patient referrals audit: Evaluation of local cardiovascular risk clinic referrals to help aid patient triage and wait times

Patient referrals audit: Evaluation of local cardiovascular risk clinic referrals to help aid patient triage and wait times

Virtual Echocardiography Screening Tool Identifies Pulmonary Arterial Hypertension Significantly Earlier Than High-Risk Clinical Diagnosis

Pulmonary arterial hypertension (PAH) is often a progressive, fatal disease. Because of nonspecificity of symptoms and limited awareness of PAH, patients are often diagnosed and referred late to accredited pulmonary hypertension (PH) centers, contributing to worsening survival and overall prognosis. The objective of the present study was to determine if the virtual echocardiography screening tool (VEST), a simple scoring system using routinely reported echocardiographic metrics, could capture earlier diagnoses of PAH before clinical recognition and referral to expert PH centers. This study is a retrospective analysis of 132 patients with PAH evaluated consecutively at 2 accredited referral PH centers. VEST scores and time to evaluation at PH center were quantified based on the first available echocardiogram before referral. Clinical risk assessment was calculated at initial evaluation by the PH center using the REVEAL (Registry to Evaluate Early and Long-term PAH Disease Management) 2.0 calculator. An overwhelming majority (93%) of the study participants had markedly abnormal VEST scores predictive of PAH before evaluation at a PH referral center. The median delay from VEST to evaluation was >6months at 206days (quartile 1, quartile 3: 55, 757). At initial evaluation, 72% were intermediate or high-risk based on REVEAL 2.0 risk assessment. In conclusion, we propose that VEST is a powerful yet simple scoring tool that can capture high-risk patients with PAH, prompting earlier diagnosis and referrals to accredited PH centers, and allowing for earlier expert implementation of PH medical therapies.

O-033 A randomised control trial of an online decision-aid for women considering elective egg-freezing

Abstract Study question Does a Decision-Aid for those considering elective egg-freezing impact decisional conflict, the decision-making process, and quality of the decision made, compared to existing information? Summary answer The Decision-Aid significantly reduced decisional conflict and improved preparedness for decision-making. What is known already Elective egg-freezing offers women the potential to extend their reproductive years. The decision to freeze eggs is complex, and our previous data shows that 78% of women had high decisional conflict (uncertainty) when they considered elective egg-freezing. Decision-Aids are the gold-standard for supporting complex health-related decisions. They have been shown to reduce decisional conflict and improve knowledge, risk perception, and decision alignment with personal values, when compared to standard care alone across a range of health conditions. We developed an online Decision-Aid to support women considering elective egg-freezing. Study design, size, duration A single-blinded, two-arm parallel group Randomised Control Trial. Participants were recruited September 2020-March 2021 (target n = 286). Randomisation was 1:1 to the intervention (Decision-Aid plus existing information) or control (existing information only) group, stratified by Australian state/territory and prior consultation with an IVF specialist about elective egg-freezing. Existing information was the Victorian Assisted Reproductive Treatment Authority website. Online surveys were completed at recruitment (baseline), 6, and 12-months. Participants/materials, setting, methods Australian women aged ≥18 years, considering elective egg-freezing, proficient in English, and with internet access were recruited using various methods including social media, Google advertising, newsletters, and clinic referrals. Participants completing the baseline survey were randomised (intervention n = 150, control n = 156) and emailed their allocated resources. Subsequent surveys were emailed 6 and 12-months post-randomisation. Surveys covered decisional conflict (primary outcome), distress, egg-freezing and fertility knowledge, decision made/not made, preparedness for decision-making, informed choice, and decisional regret. Main results and the role of chance Of 306 participants (mean age=30 years, SD: 5.2), 50% were single and 65% worked in professional occupations. At 6-months, the intervention group was substantially more prepared for decision-making than the control (Preparation for Decision-Making Scale; mean score difference: 9.22 [95% CI: 2.35, 16.08], p = 0.009). Overall, 77% of participants completed the primary outcome at 12-months (intervention n = 113, control n = 124). Between baseline and 12-months, the mean reduction in Decisional Conflict Scale (DCS) scores was greater for the intervention group than the control (mean score difference: -6.99 [95% CI: -12.96, -1.02], p = 0.022), whilst there were no group differences in distress (Depression Anxiety and Stress Scale; mean score difference: 0.61 [95% CI: -3.72, 4.93], p = 0.783), knowledge (study-specific scale; mean score difference: 0.23 [95% CI: -0.21, 0.66], p = 0.309) and whether a decision had been made about egg-freezing (odds ratio: 1.95 (95% CI: 0.67, 5.69), p = 0.221). No differences were observed between groups in informed choice (Multi-Dimensional Measure of Informed Choice; relative risk: 1.00 [95% CI: 0.81, 1.25]) or decision regret (Decisional Regret Scale; median score difference: -5.00 [95% CI: -15.30, 5.30]) for participants who had made their decision about egg-freezing at 12-months (intervention n = 48, control n = 45). Limitations, reasons for caution The total eligible population reached cannot be calculated due to the broad recruitment methods used. Adaption of some scales to improve relevancy may impact validity. Biases from self-selection and the use of self-reported data are possible, and some results had small sample sizes limiting the inferences made. Wider implications of the findings This is the first study to evaluate the effectiveness of a Decision-Aid for women considering elective egg-freezing. It demonstrates the benefit of a Decision-Aid in supporting women’s decision-making. Given these results, the Decision-Aid will be made publicly available. There is also potential to adapt the tool for international relevancy. Trial registration number ACTRN12620001032943

#5059 EXTERNAL VALIDATION OF THE KFRE AND GRAMS PREDICTION MODELS FOR DEATH AND KRT IN A SPANISH POPULATION WITH ADVANCED CHRONIC KIDNEY DISEASE

Abstract Background and Aims The Kidney Failure Risk Equation (KFRE) is used to predict the risk of kidney replacement therapy (KRT) initiation in the following 2 and 5 years, in patients with chronic kidney disease (CKD) stages G3-G5. The Grams model is applied exclusively to stage G4-G5 patients who have a higher risk of dying or requiring KRT. This model predicts both events, KRT and death, at 2 and 4 years, but unlike the KFRE, it considers the patient's death as a competing event with respect to the start of RRT. It has been suggested that the Grams model makes a more accurate prediction of the onset of KRT in the long term, since by including mortality as a competing event it does not overestimate the risk of KRT. However, there are few external validations of the Grams model to predict mortality in patients with CKD G4+. We performed an external validation of both models with respect to the start of KRT and mortality in a Spanish population with CKD G4+, followed up prospectively during 4-9 years. Method We conducted a prospective cohort analysis of incident patients followed in the Advanced Chronic Kidney Disease clinic of the Hospital Universitario Fundación Alcorcón, Spain between 1-1-2014 and 31-12-2018 who had CKD G4-G5. Clinical data was registered prospectively in a database at each visit to the clinic. Follow-up ended on 31-12-2022. For each patient, the follow-up time ranged from 4 to 9 years. The outcomes were: observed incidence of KRT (haemodialysis, peritoneal dialysis, or pre-emptive kidney transplantation) by 2, 4 and 5 years and death at 2 and 4 years before starting KRT. The predictors used in the study were calculated at the time of initial clinic referral and included the 2-year and 4-year Grams’ calculator risk scores (Grams-2 and Grams-4, respectively) for KRT and death and the 2-year and 5-year 4-variable KFRE scores for KRT (KFRE-2 and KFRE-5 respectively). We performed calibration and discrimination analyses to evaluate the performance of both predictive models. Discrimination was assessed by calculating the area under the ROC curve (C-statistic with 95% confidence interval). Calibration was assessed by using the Hosmer-Lemeshow test, through calculation of the slope and intercept, and visually by generating a calibration plot, evaluating the level of agreement between predicted probabilities versus observed outcomes. Overall model performance was evaluated using the Brier score as a composite measure of both model discrimination and calibration. Results We studied 347 patients, 31.1% were women, with a mean age of 72.1 ± 12.7 years, 52.4% with cardiovascular disease and 58.8% diabetics. At the start, the mean eGFR was 20.7 ± 5.0 ml/min and the median urine albumin-creatinine ratio was 327 (IQR 52-1118) mg/g. At 2, 4 and 5 years the percentage of patients who required KRT was 20.2%, 38.3% and 45.7% respectively, while 12.7% and 23.6% died at 2 and 4 years respectively, before starting KRT. For KTR both models had an excellent discrimination. For KFRE-2 and Grams-2 the AUC was 0.896 (95% CI 0.858-0.933) and 0.904 (95% CI 0.866-0.941) respectively, for Grams-4 the AUC was 0.842 (95% CI 0.801-0.884), and for KFRE-5 the AUC was 0.805 (95% CI 0.751-0.859). For death before KTR the Grams model demonstrated an acceptable discrimination, with an AUC of 0.726 (95% CI 0.646-0.806) and 0.749 (95% CI 0.690-0.809) for Grams-2 and Grams-4 respectively. There was excellent calibration for KRT for both models, the Hosmer-Lemeshow test presented a p&amp;gt;0.05 in all cases, the Brier score was less than 0.20. The adjustment was very precise and only in the event of estimated risks greater than 70% at 2 and 4 years is the observed risk overestimated. The calibration of the Grams model to estimate mortality before starting KTR was also excellent, although for estimated risks greater than 50% at 4 years the observed risk is underestimated. Conclusion In a Spanish cohort of patients with CKD G4+, the Grams and KFRE models adequately estimate the risk of KRT. The Grams model provides an acceptable estimate of the risk of death before starting KRT at both 2 and 4 years. It can be considered for treatment planning and information for patients with CKD G4+.

Assessing the impact and resource implications of contrast-enhanced ultrasound on workflow of patients with incidental focal liver lesions on the UK national health service.

Focal liver lesions (FLL) are abnormal growths that require timely identification. Contrast-enhanced ultrasound (CEUS) is a cost-effective imaging modality for characterising FLL with similar sensitivity to computed tomography (CT) and magnetic resonance imaging (MRI). Despite being recommended by NICE, its adoption within the national health service (NHS) is limited due to low clinical demand, limited referral, and lack of knowledge. To evaluate the impact of CEUS on patients with incidental FLL and assess the resource implications of introducing CEUS as a diagnostic service within the NHS. A patient flow review and cost-minimisation analysis were conducted. This involved a targeted literature review, NHS Trust stakeholder consultations, and development of a Microsoft Excel cost-minimisation model to explore potential value of CEUS use versus CT and MRI by episode. A scenario analysis of the base-case explored increasing CEUS use to 50% and 90%. A sensitivity analysis was performed to assess how changes in assumptions impacted the model and the resulting cost estimates. The model, comparing a world with and without CEUS, showed that current use (base-case: 5%) resulted in cost savings of £224,790/year. The sensitivity analysis indicated that regardless of changes to the assumptions, CEUS still resulted in cost savings to the NHS. By increasing CEUS use to 50% and 90%, cost savings of up to £2,247,894/year and £4,046,208/year could be achieved, respectively. By standardising CEUS use for characterising FLL, substantial cost savings could be realised, whilst reducing wait times and expanding diagnostic capacity, thus preserving limited CT and MRI capacity for high-priority cases.

Care cascade of anal dysplasia screening among MSM living with HIV from a single-center outpatient clinic.

e18607 Background: Anal cancer is the fourth most common cancer among people living with HIV with an incidence estimated to be 89 per 100,000 among men living with HIV who have sex with men (MSM). In comparison, the incidence of anal cancer in the general population is 1.6 per 100,000. The ANCHOR study which was a randomized control trial found that treating anal high-grade squamous intraepithelial lesions (HSIL) reduces the incidence of anal cancer by more than half. These findings provide a rationale for screening for anal dysplasia in people with HIV and could have an impact on recommendations for screening and treatment. The study also highlights the need for effective strategies to improve the screening and treatment of anal HSIL and providers trained in high-resolution anoscopy (HRA). Our goal was to determine the rate of screening for anal dysplasia among men who have sex with men (MSM) living with HIV attending our clinic and subsequent referral for HRA and completion of HRA in case of abnormal results. Methods: We assessed the rate of screening for anal dysplasia among the patients identifying as MSM (n = 305) at a large HIV clinic in Brooklyn, New York. An anal dysplasia care cascade was completed. The number of patients screened for anal dysplasia and the results of the screening were obtained from the EMR. All patients with results of Atypical Squamous cell of undetermined significance (ASCUS), Low-grade intra-epithelial neoplasia (LSIL), or High-grade intra-epithelial neoplasia (HSIL) on anal cytology were evaluated for evidence of referral for HRA and the number who completed the HRA was included in the descriptive analysis. Results: 60% of the total eligible patients included in the study were screened by anal cytology, 72% of those with abnormal cytology were referred for HRA and 37% completed the anoscopy (table 1). The patients in the age group 20-40 years were more likely to be screened. The number of patients with HSIL was low. Conclusions: The engagement of MSM clients in anal dysplasia screening and management was low based on our care cascade. Considering the results of our study, we aim to identify the barriers to screening as well as to referral and completion of HRA among MSM living with HIV in our patient population. [Table: see text]

Reduced blood product utilization via implementation of an anemia clinic and consult service in a large health system hospital.

e18716 Background: An Anemia Clinic program was started Sept. 2016 as part of system wide implementation of Patient Blood Management (PBM) initiated in 2015. Methods: The Anemia Clinic accepted referrals for non-cancer anemia, predominantly preoperative cardiovascular surgery (CVS) Pts. Hgb thresholds were &lt; 13 g/dL in men and &lt; 12 g/dL in women. Non-anemia cytopenias triggered Hematology referral. All Pts were screened for iron, B12, folate, and reticulocyte count. Nutrient deficiencies were supplemented. Pts with CKD or chronic disease were considered for erythropoiesis stimulating agents. Results: PBM implementation resulted in a drop in packed red blood cell (PRBC) usage (Table). Of CVS Pts pre-operatively anemic in 2022, 211 were referred to the Anemia Clinic and 373 were not. The percentage of Pts who received PRBCs after Anemia Clinic referral was not statistically different from those who were not referred (61.1% vs. 54.2% chi-square p = 0.10). Of preoperatively anemic Pts who were transfused in 2022, an average of 2.41 PRBCs were used in the referred group vs. an average of 2.21 PRBCs in those in the not referred group (negative binomial p = 0.25). Length of stay (LOS) which was a median 10d ( P25= 6d, P75 =17d) in the referred group vs a median 10d ( P25= 7d, P75 =17d) in the non-referred group was not statistically different between groups (Kolmogorov-Smirnov p = 0.84). LOS analyses of observed-to-expected (O/E) ratios used the Premier Healthcare Providers Alliance Database (PHD) which contains data on approximately 45% of US hospital discharges. For 2022 through Nov. the referred group had an O/E = 0.93 (observed LOS μgeo = 10.51 days, expected LOS μgeo = 11.32 days, N = 183). The not referred group had an O/E = 1.10 (observed LOS μgeo = 10.44 days, expected LOS μgeo = 9.50 days, N = 321). Conclusions: PBM decreased PRBC use through systematization of best practices during the initial year, and that decrease has persisted for seven years. Subsequent addition of Anemia Clinic services did not decrease PRBC use further. A trend toward shorter LOS for patients referred to Anemia Clinic was not observed this year, but the difference in LOS from the not referred group is not statistically significant and observed LOS for the referred group was lower than expected LOS. Our methods improved nutrient deficiency identification which may improve both later health outcomes not detected here and access to treatment for hematologic malignancies. [Table: see text]

0490 Under-Recognition and Undertreatment of Obesity Hypoventilation Syndrome (OHS) After Hospital Discharge: A Persistent Challenge

Abstract Introduction Hospitalization for acute-on-chronic hypercapnic respiratory failure (ACHRF) in OHS is associated with increased short-term mortality. The 2019 American Thoracic Society’s guidelines recommend that hospitalized OHS patients be discharged on nocturnal noninvasive ventilation (NIV). However, this was graded as a weak recommendation given that the data was retrospective and derived from European/Australian studies limiting generalizability to other healthcare systems. We aimed to assess post-discharge therapeutic plans for hospitalized patients with ACHRF and suspected OHS in an urban, tertiary care center in Chicago serving a large minority population. Methods We retrospectively queried the electronic health record of University of Chicago from 2008 to 2020 for hospitalized adults with BMI ≥35 kg/m2 admitted from the emergency department, requiring NIV/mechanical ventilation with evidence of respiratory acidosis on first blood gas (pH &amp;lt; 7.35 with PaCO2 ≥ 45 mmHg or PvCO2 ≥ 50mmHg). Subjects were excluded for obstruction on spirometry, greater than 20-pack year smoking history, CT evidence of parenchymal lung disease, acute neurologic process, significant left-sided heart failure and neuromuscular disease. Results Of the 797 obese patients requiring NIV/mechanical ventilation, we excluded 672 for lack of acute hypercapnia or low suspicion for OHS. The remaining 125 patients were predominantly Black (n = 116, 93%) and female (n = 94, 75%), mean age of 53±13.9 years, mean BMI of 50.8±12.8 kg/m2, mean first pH of 7.22±0.097, PaCO2 79.9±24.5 mmHg (n = 31) and PvCO2 74.7± 20.2mmHg (n = 94). On admission, 84 patients (67%) did not carry a diagnosis of OHS and 66 patients (53%) were PAP-naïve. 54% were discharged on PAP (43% CPAP, 43% Bilevel, and 14% other). Patients discharged on PAP were more obese (p = 0.001) and more hypercapnic (p = 0.002). Post-discharge polysomnography/sleep clinic referral was planned for 40% of patients. The 1-year mortality rate was 8% with no association recognized between 1-year mortality and PAP on discharge. Conclusion In our cohort, the proportion of patients discharged on nocturnal NIV was low. In contrast to the guideline recommendation, we did not find an association between being discharged on PAP therapy and mortality. Larger studies in more diverse populations are needed. Support (if any)

Demographic and Socioeconomic Factors in Prospective Retina-Focused Clinical Trial Screening and Enrollment.

Historically marginalized populations are disproportionately affected by many diseases that commonly affect the retina, yet they have been traditionally underrepresented in prospective clinical trials. This study explores whether this disparity affects the clinical trial enrollment process in the retina field and aims to inform future trial recruitment and enrollment. Age, gender, race, ethnicity, preferred language, insurance status, social security number (SSN) status, and median household income (estimated using street address and zip code) for patients referred to at least one prospective, retina-focused clinical trial at a large, urban, retina-based practice were retrospectively extracted using electronic medical records. Data were collected for the 12-month period from 1 January 2022, through 31 December 2022. Recruitment status was categorized as Enrolled, Declined, Communication (defined as patients who were not contacted, were contacted with no response, were waiting for a follow-up, or were scheduled for screening following a clinical trial referral.), and Did Not Qualify (DNQ). Univariable and multivariable analyses were used to determine significant relationships between the Enrolled and Declined groups. Among the 1477 patients, the mean age was 68.5 years old, 647 (43.9%) were male, 900 (61.7%) were White, 139 (9.5%) were Black, and 275 (18.7%) were Hispanic. The distribution of recruitment status was: 635 (43.0%) Enrolled, 232 (15.7%) Declined, 290 (19.6%) Communication, and 320 (21.7%) DNQ. In comparing socioeconomic factors between the Enrolled and Declined groups, significant odds ratios were observed for age (p < 0.02, odds ratio (OR) = 0.98, 95% confidence interval (CI) [0.97, 1.00]), and between patients who preferred English versus Spanish (p = 0.004, OR = 0.35, 95% CI [0.17, 0.72]. Significant differences between the Enrolled and Declined groups were also observed for age (p < 0.05), ethnicity (p = 0.01), preferred language (p < 0.05), insurance status (p = 0.001), and SSN status (p < 0.001). These factors may contribute to patient participation in retina-focused clinical trials. An awareness of these demographic and socioeconomic disparities may be valuable to consider when attempting to make clinical trial enrollment an equitable process for all patients, and strategies may be useful to help address these challenges.

83 Screen &amp; Intervene : Mental Health Screening in the Burn Clinic

Abstract Introduction Studies have demonstrated an increased prevalence of depression and PTSD in individuals with burn injuries during the first year of recovery. Mental health screening of patients at all burn centers is recommended. With the addition of an outpatient social worker, our burn center identified a need to standardize the burn clinic’s mental health screening process to address the mental health needs of patients. This performance improvement project sought to improve mental health screening in the burn clinic and subsequent referrals to community resources. Methods From March to August of 2022, the PHQ-2 and PC-PTSD were administered to 99 clinic patients during one of the patient’s initial visits. Patients completed the screening independently using a paper form. For pediatric patients &amp;lt; 12 years old, the primary caregiver filled out the form. Of the 99 patients who completed the screening, 51 were previously admitted to our inpatient burn center and 48 were treated only as outpatients (F=36, M=63). The age range of patients was 10 months to 88 years old. TBSA % burned ranged from .15% to 70%. A score of 2 or more on either of the screening tools resulted in further assessment by the social worker to determine appropriate next steps. The chi-square test was used to analyze the data collected. Results A total of 36/99 patients screened positive for depressive symptoms, 33/99 screened positive for Acute Stress Disorder (ASD)/Post Traumatic Stress Disorder (PTSD) symptoms, and 23/99 screened positive for both depressive and ASD/PTSD symptoms. All patients with a positive screen on either tool were provided with education regarding mental health resources and offered a referral for services. Of the 99 patients screened, 26 accepted a referral to the local burn foundation and/or an alternate mental health provider for support services. The other 73/99 declined a referral for follow up. There were statistically significant correlations between positive ASD/PTSD screenings and inpatient hospitalization (22/99 p=0.033), PTSD and median TBSA (p= 0.011), and PTSD and age (45-64yo, p=0.028). Females (19/36, p=0.01) were more likely than males to report symptoms of depression and both PTSD &amp; depression (p=0.001), while females (12/36) and males (21/63) were equally likely to report symptoms of PTSD. Conclusions Mental health screening of individuals in our burn clinic yielded a significant number of positive screens for depression and ASD/PTSD symptoms, validating the need for a standardized screening process. Positive screens resulted in increased referrals to community and mental health resources. Applicability of Research to Practice Performing mental health screenings in the outpatient arena is vital to address the mental health needs of individuals with burn injuries.