Clinic Visit Research Articles

Implementing a letter template to expedite specialty medication appeal letter submission

BackgroundPrior authorizations (PAs) for biologic medications, used to treat inflammatory bowel disease (IBD), are often denied by pharmacy benefits managers and can require a complex appeal process for patients to gain access to medication. ObjectiveThis quality improvement project evaluated the impact of implementing a standardized appeal letter template and customizable clinical rationale letter content on specialty pharmacist workflow and workload in an integrated hospital health system specialty pharmacy (HSSP) IBD clinic. Practice descriptionThis initiative was conducted in an IBD outpatient clinic at a tertiary academic medical center with an integrated HSSP whose specialty pharmacists work collaboratively with providers to manage specialty medications. Practice innovationA letter template was created in the electronic health record (EHR) for pharmacists to use when submitting appeal letters. The template automatically populates patient results from recent labs, imaging, and clinic visit notes as part of the appeal documentation. Clinical rationale letter content was developed for the most common appeal reasons using EHR functionality that allows the creation of standardized notes that can be shared among team members and customized at time of use. Evaluation methodAn analysis of 2 months of data preimplementation/postimplementation was conducted using descriptive statistics to report the number of appeals submitted, time from PA denial to appeal submission, and appeal approval rate. A pharmacist postimplementation satisfaction score was also collected. ResultsThe number of appeals submitted preimplementation (n = 73) and postimplementation (n = 73) was the same. Postimplementation, 89% of appeals were submitted within 3 days of PA denial compared to 29% preimplementation. PA approval rate was high (93%) preimplementation and postimplementation. Overall pharmacist satisfaction was 9.7 out of 10. ConclusionImplementation of an appeal letter template and standardized clinical rationale letter content in the EHR led to decreased time to appeal submission and high specialty pharmacist satisfaction.

Prevalence and Predictors of Inflammatory Arthritis in Hidradenitis Suppurativa.

Hidradenitis Suppurativa (HS) is a chronic, debilitating, auto-inflammatory condition often associated with inflammatory arthritis, significantly impacting patients' quality of life. Early diagnosis of both conditions is crucial for optimal management. The objective of this study was to determine the prevalence and factors associated with the development of inflammatory arthritis among HS patients. A cross-sectional study was conducted between November 2021 and February 2023 at an academic dermatology centre in Canada. Adult patients with HS were consecutively sampled, and 52 patients consented to participate and completed assessments. Variables examined included age, sex, HS severity, treatment, ethnicity, family history, lifestyle factors and comorbidities. The main outcomes were rheumatologist-confirmed inflammatory arthritis diagnosis and associated risk factors. Among 52 patients (24 males, 28 females; mean age: 37.4 years), 12 had inflammatory arthritis. Multivariate analysis revealed that Blacks (OR = 0.10, p < 0.001, CI: 0.026-0.343) and Asians (OR = 0.02, p < 0.001, CI: 0.005-0.109) had lower inflammatory arthritis odds compared to Whites. Every 1-year increase in age at HS onset correlated with a 1.17-fold increase in the odds of developing inflammatory arthritis (OR: 1.17, p < 0.001, CI: 1.12-1.24). Smoking (OR = 0.01, p < 0.001, CI: 0.002-0.49), hypertension (OR: 0.23, p = 0.04, CI: 0.057-0.930) and depression (OR: 0.12, p < 0.001, CI: 0.041-0.330) reduced inflammatory arthritis odds. White ethnicity and older age at HS onset were positively associated with inflammatory arthritis, while smoking, hypertension and depression were negatively associated. These findings suggest a distinct subset of HS patients with inflammatory arthritis that warrant further prospective studies. This study contributes to the understanding of inflammatory arthritis in HS patients and emphasises the importance of rheumatology referral during dermatologic clinic visits.

The integral co-management role of the medical pediatric urologist: Improving the care of children with urological conditions

The complexities of modern medicine prompt a re-evaluation of traditional patient care models to enhance safety and quality. We implemented a one-year pilot Medical Pediatric Urology fellowship, jointly developed by Urology and Pediatric Hospital Medicine, where a pediatrician received postgraduate training in both specialties. This innovative program aimed to augment knowledge and expertise in non-surgical aspects of pediatric urology. Upon completion of the fellowship, the trained pediatrician assumed the role of medical pediatric urologist (MPU), integrating into both Pediatrics and Urology faculties. Unlike the traditional specialist consultation model, the MPU became integral member of the Urology Division, working full-time and sharing responsibilities for both inpatient and outpatient pediatric urology care at a tertiary pediatric hospital in Canada. This study aims to delineate the training curriculum, role, clinical outcomes, and educational impact of the MPU over eight years. We retrospectively analyzed clinical outcomes, including patient volumes seen annually by MPU, urologists, and nurse practitioners from 2021 to 2023. Clinic wait times and patient satisfaction were compared between MPU's community and tertiary hospital pediatric urology clinics. Educational impact was assessed through pediatric residents' ratings for the MPU as a clinical teacher during urology rotations using a Likert scale. Integration of MPU led to the establishment of specialized clinics, including those for neurogenic bladder and posterior urethral valves. MPU accounted for approximately 34.7% of all outpatient clinic visits. Subjective feedback highlighted enhanced quality of care with MPU co-management in the inpatient setting. Additionally, in a community-based medical urology clinic (CUC) staffed by the MPU and a pediatric urology nurse practitioner, patients experienced shorter wait times and higher satisfaction (53±36 days and 194±108 days) (p<0.01), with 97% vs. 91% of families reported feeling highly satisfied with care (p<0.01) compared with hospital clinics, respectively. The MPU received ratings of 4/5 or 5/5 as a clinical teacher from 81.82% of pediatric residents. Our novel co-management approach in pediatric urology integrates medical and surgical expertise. However, limitations include the retrospective design and single-center setting. Nonetheless, this framework presents a potential model for other surgical specialties, offering a unique practice niche for trainees interested in the medical management of surgical conditions. The medical pediatric urologist plays a pivotal role as an educator, hospitalist, and director of the outpatient clinic, effectively integrating medical and surgical expertise. The MPU model is promising for optimizing safety and quality of care in pediatric urology.

Urgent palliative care: An effective intervention to improve end-of-life experience and outcomes for patients with advanced cancer.

203 Background: Early integration of palliative care services for advanced oncology patients has a well-documented benefit on quality-of-life measures including symptom management, quality-of-death measures, cost-effectiveness, care-giver burden, and patient satisfaction metrics. However many barriers exist, including delayed referrals and negative perceptions of hospice/palliative care by patients and families. Furthermore, wait times from referral to visit can vary from weeks to months. For patients with late-stage disease, rapidly advancing disease or symptoms, this delay can lead to unnecessary acute care utilization, impoverished quality-of-life, and discordant end-of-life care. Methods: The CU Cancer Center CARE clinic provides advanced symptom management and urgent care services to oncology patients, often seeing patients with high symptom burden and advanced disease. A recent unpublished case-based analysis demonstrated that patients seen in CARE clinic 4 times or more in a month have a high risk of inpatient mortality within 3 months. In response, the CARE clinic created an urgent palliative care program wherein patients have the ability to see a palliative care provider within 1 week of referral who could provide ongoing advanced symptom management/medication titration and facilitate conversations around goal-concordant care in late-stage illness. A 1-year feasibility pilot took place from 2022-2023. Referrals required patients to meet the following criteria: 1) Not already being seen by an ambulatory palliative care professional; and 2) any of the following: prognosis of weeks without an end-of-life care plan; symptoms likely to require hospitalization if not addressed within a week; or seen in CARE clinic 4 or more times in the last month From 09/2022-08/2023, 55 patients were seen. Outcomes were followed for 3 months following final CARE clinic visit and were compared to patients who had received palliative care referrals from the CARE clinic in the preceding year (9/2021-9/2022). Results: In-hospital deaths, hospital days in the last 30 days of life, and palliative care/hospice involvement were all positively affected in our initial pilot. Notably, in-hospital deaths were reduced by 50%. There was also a 14% increase in deaths with hospice care in the pilot group compared to the control group. Conclusions: Data from this feasibility pilot suggest that urgent palliative care can improve key metrics in oncology quality-of-care, and improve cost effectiveness. Further delineation of the outcomes compared in a rigorously controlled population will further define the relative clinical benefit and fiscal implications of such interventions. Urgent palliative care outcomes. Historical Control (2021-2022) Pilot (2022-2023) N 44 55 Hospitalizations 101 52 Deaths 30 (68%) 40 (72%) Deaths in the Hospital 8 (18%) 5 (9%) Deaths With Hospice Care 21 (47%) 34 (61%)

The Canadian Heart Failure (CAN-HF) Registry: A Canadian Multicentre, Retrospective Study of Outpatients with Heart Failure

BackgroundGuideline-directed medical therapy (GDMT) reduces events in patients with heart failure (HF) with reduced ejection fraction (HFrEF). Despite this impact, underutilization of GDMT persists. This report sought to describe HF management in Canadian outpatients treated at specialized HF clinics (HFCs). MethodsThe Canadian Heart Failure (CAN-HF) study was retrospective and observational, and it included 1775 patients from 6 Canadian outpatient HFCs, from the period January 2017-April 2020. ResultsWe observed improvement in prescription rates in patients with HFrEF, between their first visit and their most-recent clinic visit, across all GDMT classes, in those who were followed at the HFC for ≥ 6 months. The largest prescription rate increases were observed for angiotensin receptor–neprilysin inhibitors and mineralocorticoid-receptor antagonists. However, more than half of the patients remained on angiotensin-converting enzyme inhibitors and/or angiotensin-receptor blockers, despite being symptomatic, according to their New York Heart Association class. Most patients (50%) were on triple therapy, as of their most-recent visit, with fewer (36%) on dual therapy, monotherapy (13%), or no GDMT (2%). Our data also suggest that patients who had been managed at the HFC for > 6 months had higher prescription rates of GDMT and were on higher doses of GDMT, compared to those who were new to the clinic. For patients with HF with preserved ejection fraction, few patients were on candesartan and less than half were on a mineralocorticoid-receptor antagonist. ConclusionsOur data from HFCs that in most cases were affiliated with academic centres compare favourably with data from other analyses of ambulatory patients with HFrEF, evidence that supports the use of a specialized patient-care model.

Health care contact days in older adults enrolled in SWOG cancer clinical trials.

64 Background: Health care contact days—days with health care contact outside the home—are a measure of how much of a patient’s life is consumed by health care. This number of contact days are especially relevant for older adults with advanced cancer facing limited survival. One concern is that patients with different sociodemographic and clinical backgrounds may be at particular risk of increased contact days. Thus, there is a critical need to understand factors associated with contact days. Methods: We linked data from 6 SWOG trials in advanced cancer to Medicare claims data. These trials encompassed a variety of primary cancer types [prostate (S9916, S0421), lung (S0003, S0124, S0819), and pancreas (S0205)]. Health care contact days (days with ambulatory, emergency department, inpatient, or facility-based care) in the first 12 months were calculated using Medicare database files. A day with &gt;1 source of contact counted as 1. We examined sociodemographic (age, race, ethnicity, sex, insurance status, rurality, area deprivation index) and clinical (prognostic risk, cancer type, performance status) predictors of contact days, using negative binomial regression, with a log link and clustering by study ID, including an offset variable for duration of observation. We examined predictors in univariate and multivariable analysis. We report relative risk (RRs) estimates and 95% CI. Results: We included 1,429 patients (median age, 71 years, 7.6% Black, 2.7% Hispanic, 21.4% female, and 23.5% rural residence). Of these, 741 (51.9%) patients died in the first year. The median number of contact days was 48, out of a median of 350 days of observation. At a trial level, median percentage of contact days ranged from 14% (prostate) to 27% (lung). The most common sources of contact days were ambulatory clinician visits (median=17), tests (median=12), and treatments (median=11). In multivariable regression, factors associated with increased contact days included increasing age (per year, RR=1.02 [1.01-1.02], p&lt;.001), insurance status (Medicare alone or with Private or Medicaid insurance, vs Military/VA, none, or other insurance, RR=2.47 [2.16-2.83], p&lt;.001), higher prognostic risk score (RR=1.14 [1.04-1.25], p=.004), and type of cancer (pancreas, RR=1.69 [1.51-1.89] and lung, RR=1.69 [1.54-1.85] vs prostate, p&lt;.001 for both). Conclusions: This novel linkage of trial and claims data to evaluate contact days and associated factors found that older trial participants spent up to one in four days with health care contact. Ambulatory appointments were the most common source of contact days. Encouragingly, rural residence and neighborhood deprivation were not associated with contact days, increasing confidence that participants from diverse geographic areas may receive equitable care in trials. These data highlight the frequency of contact days for trial participants, while identifying factors to consider when benchmarking contact days.

CLINICAL OUTCOMES OF MONO-THERAPY VERSUS DUAL ANTIHYPERTENSIVE THERAPY IN PATIENTS PRESENTING AT TEHSIL HOSPITAL IN PAKISTAN

Hypertension, a prevalent and potentially life-threatening condition, remains a significant public health concern in Pakistan. This article aims to investigate and compare the clinical outcomes of antihypertensive monotherapy versus combination therapy in patients treated at Tehsil Hospital, a critical healthcare facility in the Tehsil region of Pakistan. Objective: To assess and compare the clinical outcomes of hypertensive patients treated with monotherapy and those receiving a combination of antihypertensive medications at Tehsil Hospital, Pakistan. Methods: The study was carried out at Tehsil Hospital, Punjab-Pakistan. All adult participants (30 ≥ and ≤70 years) who were on antihypertensive medicine for at least 6 weeks and were diagnosed as hypertensive (average blood pressure of &gt;140/90 mm Hg on at least two clinic visits) were included in the study from April 11 to June 20, 2022. The data was analyzed by SPSS 20. Statistical tests like chi-square were applied to obtain the required results. Results: A total of 136 study subjects were enrolled. Out of these, 113(81%) were male subjects, 23(17%) were female, 12(17.6%) smokers, and patients suffering from chronic liver disease were as 26(38.2%) treated with mono-therapy as compared with dual therapy with significant p-value 0.00 and 0.001. Other co-morbidities like the previous history of IHD, DM, and chronic kidney disease were treated with both therapies with insignificant p-values as &gt; 0.05. Clinical outcomes were observed, and it was shown that more patients with stroke were treated with mono-therapy as p-value &gt; 0.05 while comparing with major bleeding and control of hypertension showed a significant p-value of &lt;0.05. Conclusion: Treatments in combination are effective and advised. The most important element in the management of hypertension, irrespective of whether medication is utilized, the goal is to get blood pressure down to the desired amount. Effective communication is essential for doctors, other healthcare professionals, and patients to treat patients.

Effect of high-dose multivitamin supplements on alanine aminotransferase elevations among adults living with HIV on antiretroviral therapy in Tanzania.

HIV infection can cause malabsorption and rapid utilization of nutrients. A randomized trial of multivitamin supplementation among people living with HIV/AIDS (PLWHA) initiating antiretroviral therapy (ART) in Tanzania was stopped early due to increased alanine aminotransferase (ALT) concentrations in the multiple recommended dietary allowances (RDA) multivitamin group. We conducted detailed analysis to assess the effect of multivitamins on ALT elevations and evaluate whether subgroups of PLWHA have greater hepatotoxicity risks associated with the use of high-dose multivitamins. We utilized data from a randomized, double-blind trial conducted in 2006-2009 that assessed the effect of high-dose multivitamins that contained vitamin B complex, vitamin C, and vitamin E at multiple RDA as compared to standard-dose multivitamins containing single RDAs among adults initiating ART in Tanzania. We evaluated the effect of high-dose multivitamins on incident mild/moderate ALT elevations > 40 IU/L, persistent ALT elevations > 40 IU/L (2 + clinic visits), and severe ALT elevations > 200IU/L using Cox proportional hazard models. We then evaluated effect modification by patient characteristics to determine if subgroups of PLWHA experienced different magnitudes of risk for ALT elevations associated with high-dose multivitamins. High-dose multivitamins increased the risk of incident mild/moderate ALT elevations > 40 IU/mL as compared to standard-dose multivitamins (hazard ratio (HR): 1.41; 95%CI: 1.26,1.58) as well as incident sustained mild/moderate ALT elevations (HR: 1.19; 95%CI: 1.04,1.36), but there was no overall effect on severe ALT elevations (HR: 1.44; 95% CI: 0.91,2.28). There was no evidence that the effect of high-dose multivitamins on any or sustained mild/moderate ALT elevations was modified by any patient characteristic. However, CD4 T-cell count was found to modify the effect of high-dose multivitamins on severe ALT elevations (p-value for interaction:0.01). Among participants with a baseline CD4 T-cell count ≤ 100 cells/µL, individuals receiving high-dose multivitamins had 3.74 times (95%CI: 1.52-9.17) the risk of incident severe ALT elevations compared to standard-dose multivitamins, while participants with CD4 T-cell counts > 100 cells/µL, appeared to have no effect of high-dose multivitamins on severe ALT elevations (HR:0.92; 95% CI: 0.50,1.67). High-dose RDA multivitamin supplementation increased the incidence of any mild to moderate ALT elevations among adults starting ART in Tanzania and the magnitude of the risk does not appear to differ by patient characteristics. However, immunocompromised PLWHA with CD4 T-cell counts < 100 cells/µL may experience greater risk of severe ALT elevations associated with the use of high-dose multivitamins. Although the study findings offer significant insights, it is essential to take into account limitations imposed by newer cART regimes.

Indigenous, Black, and Latine Adolescents Disproportionately Experience Barriers to Pediatric Gender-Affirming Care

Although prior studies have explored the barriers that transgender and nonbinary (TNB) adolescents experience in receiving gender-affirming medical care (GAMC), few have sought to understand how these barriers may differ among racial and ethnic minority groups. Accordingly, this study used data from a survey of TNB young adults (ages 18–20 years) to explore how barriers to GAMC during adolescence varied by race and ethnicity. Differences in the impact of 11 potential barriers when comparing the members of each racial and ethnic group with those who did not identify with that racial or ethnic group were evaluated usingttests. The results showed that Indigenous respondents indicated that parental unwillingness to consent for GAMC and attend a clinic visit and not being able to find a clinic contributed significantly more compared with those who did not identify as Indigenous. Black respondents indicated that not knowing it was possible to receive GAMC during adolescence and previous negative experiences in healthcare related to race or ethnicity contributed significantly more to their inability to receive GAMC during adolescence compared with those who did not identify as Black. Latine respondents indicated that parental unwillingness to consent for GAMC and attend a clinic visit, worries about cost, and previous negative experiences in healthcare due to race or ethnicity contributed significantly more compared with those who did not identify as Latine. Overall, the results suggest disproportionate barriers in access to GAMC during adolescence among Indigenous, Black, and Latine TNB individuals and illustrate a need for additional resources and interventions to promote more equitable access.

Adherence to Recommended Care in Type-1 Diabetes Mellitus Among Adolescents and Youths Attending the Diabetes Camp in Ogun State, Nigeria

Background: Adolescents and youths living with Type 1 diabetes mellitus (T1DM) are known to have challenges in managing the condition and may be prone to poor glycaemic control and complications. Objectives: To assess the level and adequacy of care for adolescents and youths living with T1DM. Methods: A cross-sectional, descriptive study was conducted among adolescents and youths living with T1DM who attended the 2023 Ogun Youth Diabetes Camp. An interviewer-administered questionnaire was used to obtain information. Results: Twenty-five participants with a mean age of 18.0±3.9 years (range 13-24 years) were recruited, with 80% being females. The mean HbA1c was 7.1 ± 1.8%, and in-camp postprandial glucose values were mostly high (76%). The mean age at diagnosis of T1DM was 11.7±4.8 years. One participant had T1DM for &lt; 2 years, 11 for 2-5 years, and 13 for &gt; 5 years. Among those who had lived with T1DM for more than 5 years, ten had been referred to a dietitian, nine to an ophthalmologist, and two to a neurologist. One participant had been screened for thyroid disorder. Conclusion: The adolescents and youths living with T1DM in this survey had suboptimal glycaemic control, and evaluation by their care providers during clinic visits was also suboptimal. Therefore, they may be at increased risk of developing complications. It is recommended that all stakeholders lend timely and aggressive support to these individuals to ensure adequate management and prevent complications.

Use of a Set-up Fee to Encourage Survey Participation and Electronic Health Record Submission for a National Health Care Survey.

In 2021, the National Ambulatory Medical Care Survey Health Center (NAMCS HC) Component modernized its data collection and began collecting clinical visit data from health centers using transmission of electronic health record (EHR) data. With this redesign, there are potential cost implications for a health center to participate. Beginning in 2021, a one-time set-up fee (i.e., payment) of up to $10,000 was offered to centers who participated in the NAMCS HC Component. Starting in 2022, a Set-up Fee Questionnaire was used to capture data on the use of this money. Results show on average the fee appeared adequate in covering participation costs, with the fee most often used to cover costs of health center and EHR vendor information technology staff. Although this fee was offered only during the initial year of participation, retention rates for centers appeared high. Implications from the findings of this case study on use of a set-up fee in establishment surveys are also briefly discussed.

Impact of mental disorders on low adherence to antiretroviral therapy in people living with HIV in Spain

ABSTRACT The relationship between mental disorders other than depression or anxiety, and low adherence to both antiretroviral treatment (ART) and linkage to HIV care are unclear. The aim of our study was to compare the prevalence of mental disorders in people living with HIV (PLHIV) in Spain who present low versus high adherence to ART. We performed a cross-sectional study comparing two groups of PLHIV: 20 PLHIV with low adherence and 80 PLHIV with high adherence to ART. PLHIV who met at least one of the following criteria were included in the low-adherence group: virological failure (HIV-VL > 50 copies/mL in two consecutive blood samples); low attendance to scheduled clinical visits (≥2 missed visits in last year); irregular administration of ART (≥10 forgotten doses in the last month); and interruption of ART for more than 1 week. Inclusion criteria for high adherence were: PLHIV who had been on stable ART for more than 1 year with an HIV-VL below 50 copies/mL and without missed visits over the previous 12 months. The Millon Clinical Multiaxial Inventory was administered to participants. PLHIV with low adherence showed higher scores for all mental disorders compared with those with high adherence. And, in the multivariate binary logistic regression analysis, drug dependence and post-traumatic stress disorder were independently associated with low adherence (Nagelkerke R2 = 0.0686). In conclusion, PLHIV with poorly controlled HIV infection presented important psychological vulnerabilities. Mental health should be checked at the beginning of ART and during follow-up, especially in PLHIV with low adherence or low linkage to the health care system.

Single- versus multi-visit approach for fragment reattachment in complicated crown-root fractures: a cohort study

BackgroundComplicated crown-root fractures are a type of tooth fracture that involves the enamel, dentin, and cementum and accompanied by pulp exposure. The treatment of a complicated crown-root fracture is always challenging due to the difficulties in achieving a hermetic seal and a stable restoration with a fracture level close to the crestale bone level. This study aimed to evaluate and compare the efficacy of single-visit and multi-visit approaches for fragment reattachment in complicated crown-root fractures of anterior teeth.MethodsTwo cohort consist of 10 adolescent patients in each group at both genders, who suffered from permanent anterior tooth complicated crown-root fracture were included. Fragment reattachment with root canal treatment was performed with either single or multiple-visit approach. Single visit fragment attachement combined with root cannel therapy was conducted in single-visit approach group immediately after injury. Fragment attachment, root cananel therapy and post resoration were performed during three times ‘ clinical visit in multi-visit approach group.ResultsAll the patients in both groups achieved satisfactory aesthetic results one year after fragment reattachment. Patients who underwent a multi-visit approach had a significantly shorter operative duration, less intra-operative pain and fatigue, slightly better periodontal health at an early stage, and a decreased incidence of temporomandibular joint disorders compared to those who underwent a single-visit approach. However, multiple visits approach may increase the risk of fragment detachment postoperatively.ConclusionFragment reattachment a reliable but temporary technique for adolescent patients who have suffered from complicated crown-root fractures. Multi-visit approach showed similar effecacy to single-visit approach but with slightly less complications. The choose of these two merhos should depend on the specific patient situation and patient compliance.Trial registrationThis prospective cohort study was retrospectively registered in Chinese Clinical Trial Registry (ChiCTR2300076811) on 19/10/2023.

Cervical cancer screening adoption behaviours among Nigerian women in academics: using a health belief model

BackgroundCervical Cancer is the commonest and one of the leading causes of death from cancer among women in developing countries. Screening has been shown to reduce morbidity and mortality from the illness, yet its uptake is low. This study investigated the pattern of utilization and preferences relating to the adoption of cervical screening among female postgraduate students at the University of Ibadan.MethodologyThe study was a descriptive cross-sectional survey involving the use of a multi-stage sampling technique to recruit 372 women undergoing postgraduate studies (20–52 years with a mean age of 27.3 ± 5.4) at the University of Ibadan, Nigeria. A pretested semi-structured, self-administered questionnaire was used for data collection and the coded data were analyzed using SPSS (version 20).ResultsOnly 4.0% of the respondents had been screened for Cervical Cancer at the time of study while 86.3% expressed their desire to be screened if given the opportunity. Most participants showed a favourable perception with 70.4% disagreeing that cervical cancer is a mild disease and 50.5% agreeing that the benefits of cervical cancer screening outweigh the stress of the screening procedure. Female doctors (73.2%) topped the list of health professionals’ respondents who preferred to conduct the screening. A majority (70.7%) of the respondents preferred these screenings to be done during antenatal clinic visits. There is a significant association (p.value = 0.0007) between cervical cancer screening behaviors and sexual activity among women.ConclusionPoor utilization of Cervical cancer screening services is seen among Nigerian women undergoing postgraduate studies but a high willingness to utilize the services in the future with consideration to professionals delivering the service and specific locations where it can be obtained. The poor rate of cervical cancer screening from the study depicts the large extent to which cases of this cancer go without being detected till the advanced stages. Rolling out more screening strategies that will explore different service delivery points/preferences as highlighted in the study is needed for larger coverage.

Effects of structured contraceptive counseling in young women: Secondary analyses of a cluster randomized controlledtrial (the LOWE trial).

Unwanted pregnancy constitutes a huge health issue. Long-acting reversible contraception (LARC) are the most effective methods for preventing unwanted pregnancy, especially among young women. This study evaluates the intervention effect of structured contraceptive counseling on the choice, initiation, and use of LARC in young women. This is a secondary analysis of women aged 18-25, enrolled in a multicenter cluster randomized controlled trial performed in abortion, youth, and maternal health clinics across the Stockholm County in Sweden. Clinics were randomized (1:1) to provide structured contraceptive counseling (intervention) or standard counseling (control). Surveys were administered at the clinic visit and follow-ups at 3, 6, and 12 months. Primary outcome focused on the choice of LARC among women 18-25 years of age. Secondary outcomes included initiation, and use of LARC at 3 and 12 months, satisfaction with the counseling received and information on extended use of combined hormonal contraceptives. The study was registered at Clinicaltrials.gov (NCT03269357). From September 2017 to May 2019, 770 women aged 18-25 years from 28 clinics/clusters were recruited. There was a significant intervention effect on LARC choice (aOR 5.96, 95% CI 3.25-10.94), initiation (aOR 4.43, 95% CI 2.32-8.46), and use at 12 months (aOR 2.21, 95% CI 1.31-3.73). The odds of LARC choice at pre-booked visits were higher and more women received information about extended-use regimen for short-acting reversible contraception in the intervention group compared to the control group. The intervention package was well received, but with higher satisfaction at pre-booked compared to drop-in visits. Our study demonstrates that comprehensive structured contraceptive counseling significantly increases LARC choice, initiation and use, with high satisfaction among young participants, especially at pre-booked visits. The results highlight an approach that merits implementation to increase quality of care in contraceptive services, to enhance reproductive health for adolescents and young adults.

Effect of an In-Home Palivizumab Administration Program for Children with Medical Complexity.

In-home palivizumab administration programs (PH) have shown promise in reducing RSV-associated infections. These programs may be particularly beneficial for children with medical complexity (CMC) by limiting their exposure to healthcare-associated infections (HAIs) from non-RSV-related pathogens during transportation and visits to medical facilities. In this prospective study, 41 children with CMC less than 2 years of age were randomized by their health insurance to receive PH or in the clinic (PC) during the RSV season (October 2018-April 2019). Patients were stratified by home ventilation. The primary outcome was the total number of face-to-face encounters. Secondary outcomes were unscheduled clinic visits and hospitalizations secondary to the non-RSV LRTIs. Standard frequentist and Bayesian analyses were performed. All demographic factors and strata were matched between PH ("n" = 13, mean age 22 mo. SD ± 1), and PC ("n" = 28, mean age: 18 mo. SD ± 1). There was a decrease in the number of total face-to-face encounters (adjusted for mechanical ventilation and baseline diagnosis) [(4.5 vs. 8.8), (RR: 1.8, 95% CI: 1.3-2.5, p = 0.001)], and hospitalizations [(0.3 vs. 1.25), (RR: 3.8, 95% CI: 1.3-11.3, p = 0.016)], in the PH vs PC groups. Bayesian analysis showed a 93% probability of benefit in favor of fewer face-to-face encounters in the PH group. This study suggests that PH administration may reduce healthcare utilization in CMC. Minimizing exposure to healthcare facilities and supporting home-based interventions are promising strategies for this population.

Effect of missed clinic visits on treatment outcomes among people with tuberculosis: a quasi-experimental study utilizing instrumental variable analysis

ObjectivesMissed clinic visits disrupt the continuity of care and potentially impact tuberculosis (TB) treatment outcomes negatively. We evaluated the effect of missed clinic visits on mortality and treatment success among people with bacteriologically confirmed pulmonary TB in rural eastern Uganda. MethodsUsing routine TB clinic data, we designed a quasi-experimental study and used instrumental variable analysis to estimate a cause-effect. The exposure was one or more missed clinic visit(s), the instrumental variable was patient residence in the same sub-county as the TB clinic, and the outcomes were mortality and treatment success. We performed a two-stage least squares logistic regression for causal analysis and reported the odds ratio (OR) and 95% confidence interval (CI). ResultsOf 762 participants with similar baseline characteristics, 186 (24.4%) missed ≥1 clinic visit(s), 342 (44.9%) resided in the same sub-county as the TB clinic, 61 (8.0%) had died, and 687 (90.2%) were successfully treated for TB. Missed clinic visits increased mortality (OR 2.88, 95% CI 1.36-6.13) and reduced TB treatment success (OR 0.41, 95% CI 0.20-0.82). ConclusionsMissed clinic visits increase mortality and negatively impact treatment success among people with TB. The reasons for missed clinic visits should be identified and tackled through context-specific measures.

Heart Failure Care Facilitators and Barriers in Rural Haiti: A Qualitative Study

Background: Heart failure (HF) is a leading cause of hospitalizations in Haiti. However, few patients return for outpatient care. The factors contributing to chronic HF care access are poorly understood. Objective: The purpose of this study is to investigate the facilitators and barriers to accessing care for chronic HF from the patients’ perspectives. Methods: We conducted a qualitative descriptive study of 13 patients with HF participating in three group interviews and one individual interview. We recruited patients after discharge from a nongovernmental organization-supported academic hospital in rural Haiti. We employed thematic analysis using emergent coding and categorized themes using the socioecological model. Findings: Facilitators of chronic care included participants’ knowledge about the importance of treatment for HF and engagement with health systems to manage symptoms. Social support networks helped participants access clinics. Participants reported low cost of care at this subsidized hospital, good medication accessibility, and trust in the healthcare system. Participants expressedstrong spiritual beliefs, with the view that the healthcare system is an extension of God’s influence. Barriers to chronic care included misconceptions about the importance of adherence to medications when symptoms improve and remembering follow-up appointments. Unexpectedly, participants believed they should take their HF medications with food and that food insecurity resulted in missed doses. Lack of social support networks limited clinic access. The nonhealthcare costs associated with clinic visits were prohibitive for many participants. Participants expressed low satisfaction regarding the clinic experience. A barrier to healthcare was the belief that heart disease caused by mystical and supernatural spirits is incurable. Conclusions: We identified several facilitators and barriers to chronic HF care with meaningful implications for HF management in rural Haiti. Future interventions to improve chronic HF care should emphasize addressing misconceptions about HF management and fostering patient support systems for visit and medication adherence. Leveraging local spiritual beliefs may also promote care engagement.

Lessons from Covid-19 and the potential benefit of the implementation of Axon’s personal electronic health records (PEHR) into aesthetic care, plastic and reconstructive surgery

BackgroundCovid-19 pandemic highlighted the need for implementing Personal Electronic Health Records (PEHR) for patients’ data management. Furthermore, this pandemic underscored the relevance for integrated and interoperable Electronic Health Records (EHR) to support disease surveillance, hospital capacity planning and resource management (Peek N, Sujan M, Scott P (2020) Digital health and care in pandemic times: impact of COVID-19. BMJ Health Care Inf 27(1):e100166. https://doi.org/10.1136/bmjhci-2020-100166). Due to the lack of comprehensive patients’ record in plastic, reconstructive and aesthetic surgery, Axon’s myHealth app offers a break-through patient-centric design allowing patients to be in control of their records and updating them in real-time for their plastic and aesthetic care providers to have a clearer understanding of patients’ history and progress from pre-op to post-op.MethodsThe Axon Dublin survey took place during Covid-19 pandemic in two phases: Phase 1 aimed to assess the feasibility of patients integrating the Axon myHealth application into their clinical visits. Testing occurred in a clinical environment, where patients were encouraged to download and use the Axon system with a health practitioner (HP) present. Phase 2 focused on home testing, evaluating patients’ willingness to manage their health remotely with HP assistance. This phase included self-testing activities such as performing rapid Covid-19 antigen tests, recording medical history, and measuring blood pressure at home.ResultsThe Axon Dublin Study aimed to assess patient engagement, clinical impact, and cost-effectiveness of the Axon myHealth application. Over 85% of patients showed interest in owning a Personal Electronic Health Record. Notably, 36% continuously monitored chronic conditions. Clinical decisions, informed by patient data, saw 61.9% compliance. Noteworthy, 23% of hypertensive participants required immediate medication changes. Patient self-capture of data reduced consultation time. Public health implications were significant, with 39% vaccinated and 31% reporting complications. High user satisfaction (97%) demonstrated the app’s effectiveness in infection control and chronic care.ConclusionsOffering patients the ability to update and control their data is a growing interest, with a clear need in plastic and aesthetic surgery to have a better understanding of a patient’s medical past and progress throughout the surgical process and period. This platform, which is time and cost efficient, can only facilitate personalised care and improve outcomes while maintaining patient’s confidentiality.Level of evidenceNot gradable.

Challenges of patients with intrathecal baclofen pump therapy during COVID-19 pandemic in Saudi Arabia

Background: This study was carried out to analyze the effects of the COVID-19 pandemic on patients with intrathecal baclofen (ITB) therapy. Methods: Patients who came for ITB refill during the COVID-19 pandemic between March 2020 and August 2020 were contacted, and a survey was conducted regarding challenges faced during the COVID-19 pandemic. Data obtained from the chart review included demographics, diagnoses, pump information, baclofen dose, and COVID triage. Information was collected regarding travel arrangements, appointments, and problems related to ITB therapy or travel. The survey included 12 multiple-choice questions related to travel, appointment scheduling, and difficulties faced during the travel restrictions. Results: The study included 19 patients with ITB (mean age: 38.1±14.4) from outside Riyadh city who came for ITB refill during the COVID-19 pandemic. The majority of the patients were males. Spinal cord injury with paraplegia was the most common diagnosis (52.6%). In total, 7 patients had either clinical (31.6%) or travel-related difficulties (15.8%). No patient had ITB withdrawal at the time of the clinic visit. Nearly half (47.4%) of the patients had to change their appointment for refill. The percentage of patients who used a car as a mode of travel pre-COVID was 42.1%, which increased to 78.9% during the pandemic. They traveled 747.4±356.6 km (7.4±3.7 h) to reach the hospital for refill. Patients needed 1–4 accompanied persons for assistance during travel, with the majority (68.4%) requiring 2 accompanied persons. Statistical analysis did not reveal any significant associations between clinical or travel difficulties and appointment changes. Conclusions: A pandemic or similar disaster can pose challenges to patients on ITB therapy living in areas with limited access to specialized care. In this study, none of the patients had serious complications or adverse outcomes; however, the main difficulties were attributed to travel. It is crucial to establish strategies at institutional, regional, or national levels to formulate guidelines for managing patients with ITB therapy during a pandemic.