Date Of Referral Research Articles

ThP3.8 - General Practitioner Compliance to Scottish Referral Guidelines for Urgent Suspicion of Oesophago-gastric Cancer

Abstract Aim The referral guidelines in Scotland stipulate that patients with urgent suspicion of cancer (USOC) should commence treatment within 62 days of diagnosis from the date of primary care referral. In this study, we assessed the adherence of general practitioners (GPs) to the Scottish Referral Guidelines for USOC. Methods This was a retrospective cohort study of all consecutive USOC referrals from GP who were given clinic appointment for Upper GI Surgeons in a single centre for suspected oesophago-gastric cancer between April to September 2022. Patient’s electronic case notes were analysed and the referral indication audited against the Scottish referral guidelines. This study was registered with Clinical Quality Project (LanQIP 14746). Results 361 patients were identified, median age was 63 years (IQR 52-72) and 200 (55.4%) were female. Median Scottish Index of Multiple Deprivation was 4 (IQR 3-7). 138 (38.3%) were referred for dysphagia. 5 (1.4%) were vetted straight to the test and had endoscopy prior the clinic consultation. 275 (76.2%) of the GP referrals for USOC were compliant with the Scottish referral guidelines. Median time from the referral to the clinic consultation was 44 days (IQR 31-63). 35 (9.7%) of patients did not attend the clinic. Conclusions The criteria outlined in the Scottish referral guidelines for USOC provide clear parameters for clinic referrals. Our findings reveal that the majority of GP referrals align appropriately with the USOC criteria. Increasing education and awareness among GPs can further enhance compliance with these guidelines and reduce pressure on the clinic waiting time.

Optimizing tracking and completion of follow-up colonoscopy after abnormal stool tests at health systems participating in the Centers for Disease Control and Prevention's Colorectal Cancer Control Program.

We present findings from an assessment of award recipients' partners from the Centers for Disease Control and Prevention's Colorectal Cancer Control Program (CRCCP). We describe partners' processes of identifying and tracking patients undergoing stool-based screening. We analyzed data from eight CRCCP award recipients purposively sampled and their partner health systems from 2019 to 2023. The data included number of stool-based tests distributed and returned; abnormal findings; referrals and completion of follow-up colonoscopies; and colonoscopy findings. We also report on strategies to improve tracking of stool-based tests and facilitation of follow-up colonoscopies. Five of eight CRCCP award recipients reported that all or some partner health systems were able to report stool test return rates. Six had health systems that were able to report abnormal stool test findings. Two reported that health systems could track time to follow-up colonoscopy completion from date of referral, while four could report colonoscopy completion but not the timeframe. Follow-up colonoscopy completion varied substantially from 24.2 to 75.5% (average of 47.9%). Strategies to improve identifying and tracking screening focused mainly on the use of electronic medical records; strategies to facilitate follow-up colonoscopy were multi-level. Health systems vary in their ability to track steps in the stool-based screening process and few health systems can track time to completion of follow-up colonoscopy. Longer time intervals can result in more advanced disease. CRCCP-associated health systems participating in this study could support the implementation of multicomponent strategies at the individual, provider, and health system levels to improve tracking and completion of follow-up colonoscopy.

Comprehensive computerized gait analysis: Barriers to access for children and adolescents

BackgroundComprehensive computerized gait analysis (CGA) alters orthopedic surgical plans and improves outcomes. Despite these documented benefits, CGA is not widely available to all patients who could be helped by it.Research Question: Do social determinants of health impact access to CGA? MethodsRetrospective review of patients seen for CGA from 2021 to 2022. Dates of referral, insurance approval and completion of CGA, demographics and insurance type were extracted from patient records. Zip codes were used to determine the neighborhood socioeconomic status (SES). Data were analyzed using non-parametric statistics. ResultsInsurance type affected time to authorization (private insurance/self-pay: median 9 days; HMO insurance: median 51.5 days; public insurance: median 27 days; p=0.0004). Once authorized, insurance type did not affect time to schedule and complete CGA (p=0.76). Lower neighborhood SES was associated with longer time to authorization but shorter time to complete CGA once authorized. Rescheduling was associated with longer time to complete CGA once authorized (median 29.5 vs. 16 days, p<0.0001). White, non-Hispanic families tended to reschedule more often than non-white or Hispanic families (35 % vs. 18 %, p=0.07). SignificanceKnowledge of barriers to CGA is necessary in order to design and implement effective strategies to widen its availability to all whom it could benefit. Social determinants of health and insurance type are associated with delays in authorization for CGA. Families with public insurance and HMO coverage experience delays in obtaining insurance authorization compared to PPO/self-pay patients, whose tests did not require prior authorization. However, there can also be delays in scheduling and completing CGA once authorized. This is a multi-faceted issue that requires further research.

Access to clinical genetic services: An evaluation of patient referral characteristics and identifying barriers in Michigan.

The utilization of genetics in medical care has enhanced the utility of precision medicine and hence increased the need for clinical genetic services. These services have reduced the costs and expanded the availability of genetic testing, but their use is limited in certain populations. This study explores the access to clinical genetic services for Michigan patients referred to a genetics clinic on the western side of the state. Factors included the travel distance (miles), wait time for appointment (days from the referral date to the date of first appointment), population demographics, and cultural characteristics. A retrospective record review of all aged patients (n = 568) referred to a genetics clinic in 2018 demonstrated that all patients were insured (100%), of which majority were white-non-Hispanic (90.7%), more than half were < 10 years of age at referral (53.3%), and most of them kept their first appointment (93.5%). Our analysis showed that the wait time was associated with referral non-compliance, p < 0.01. Adjusting for all variables, for each additional day in wait time, patients had 1% increased risk of not seeking clinical genetic services (OR = 1.01, 90% CI [1.01, 1.02]). Policies to encourage genetic service utilization and improve equitable access to precision health are needed. An opportunity exists for strategies that broaden and add diverse populations to those receiving genetic services.

Regional Periprosthetic Joint Infection Centers: The Time Has Come for a Paradigm Change in the Treatment of Periprosthetic Joint Infection

BackgroundPeriprosthetic joint infection (PJI) is a rare, yet devastating complication with high mortality rates, unpredictable treatment outcomes, and high costs. The purpose of this study was to determine 90-day and 1-year mortality rates at a specialized PJI center, assess the impact of delayed referral to a PJI center on outcomes, and determine the cost of PJI treatment prior to referral to a PJI center. MethodsA review of our institution’s PJI registry was performed to identify patients who had a chronic PJI treated with a 2-stage exchange arthroplasty at our PJI Center from 2017 to 2021. Patients not referred from an external location were excluded. Mortality at 90 days and 1 year was collected. The date of infection diagnosis until the date of referral was recorded. Outcomes were documented as failure of treatment at the final clinical follow-up. The number and type of prior infection treatments were documented for each patient. The estimated cost was calculated using established PJI literature. ResultsThere were 172 patients (182 joints) who met inclusion criteria during this timeframe. The 90-day and 1-year mortality rates were 0 and 3.9%, respectively. There was a higher failure rate in patients referred >90 days after the diagnosis of chronic PJI (23 versus 11%, P = 0.031). The total cost of PJI treatment prior to referral for this group of patients was $6.9 million. ConclusionsImplementation of a specialized PJI referral center leads to lower mortality rates, improved outcomes, and decreased cost for the health-care system.

Relationship between wait times and postatrial fibrillation ablation outcomes: A population-based study

BackgroundRhythm control is a cornerstone of atrial fibrillation (AF) management. Shorter time between diagnosis of AF and receipt of catheter ablation is associated with greater rates of therapy success. Previous work considered diagnosis-to-ablation time as a binary or categorical variable and did not consider the unique risk profile of patients after a referral for ablation was made. ObjectiveThe purpose of this study was to comprehensively assess the impact of diagnosis-to-ablation and referral-to-ablation time on postprocedural outcomes at a population level. MethodsThis observational cohort study included patients who received catheter ablation to treat AF in Ontario, Canada. Patient demographics, medical comorbidities, AF diagnosis date, ablation referral date, and ablation date were collected. The primary outcomes of interest included a composite of death and hospitalization/emergency department visit for AF, heart failure, or ischemic stroke. Multivariable Cox models assessed the impact of diagnosis-to-ablation and referral-to-ablation times on the primary outcome. ResultsOur cohort included 7472 patients who received ablation for de novo AF between April 1, 2016, and March 31, 2022. Median [interquartile range] diagnosis-to-ablation time was 718 [399–1274] days and median referral-to-ablation time was 221 [117–363] days. Overall, 911 patients (12.2%) had the composite endpoint within 1 year of ablation. Increasing diagnosis-to-ablation time was associated with a greater incidence for the primary outcome (hazard ratio [HR]1.02; 95% confidence interval [CI] 1.01–1.02 per month). Increasing referral-to-ablation time did not impact the primary outcome (HR 1.00; 95% CI 0.98–1.01 per month). ConclusionDelays between AF diagnosis and ablation referral may contribute to adverse postprocedural outcomes and provide an opportunity for health system quality improvements.

A retrospective audit of general practitioner's referrals to Guys and St Thomas' specialist menopause clinic between 2021 and 2022.

Purpose: We performed a retrospective audit of General Practitioners' (GPs) referrals to the specialist Menopause Clinic at Guys and St Thomas's (GSTT) between 2021 and 2022. We aim to establish the indication for the referrals and whether they were compliant with the National Institute for Health and Care Excellence Guidance NICE.Background: GSTT is a teaching hospital in central London that educates gynaecologists in training as well as (GP) for specialist certification in Menopause. The menopause clinic receives approximately 580 GP referrals per month from South East London practices. The current waiting time for an initial appointment is up to 1year. This delay reflects an increase in demand for menopause care and a deficit in service provision in many areas of the UK.NICE has recommended that GPs refer complicated cases to menopause specialists, with 11 specific criteria.Study Sample and Data Collection: We randomly selected 50 patients referred to the GSTT clinic by a GP between 2021 and 2022. Patient data were collected, including patient demographics, date of referral, indication for referral, date of consultation, waiting time, past medical history, investigations, and treatment instigated during the appointment.Results: The majority of referrals to the GSTT menopause Specialist clinic met the NICE guidelines (76%). One-sixth of the referrals could have been prevented or managed through alternative routes. Finally, although this is a small study, some patient unmet needs (PUNS) and GPs' educational needs have been identified.

Using online search activity for earlier detection of gynaecological malignancy

BackgroundOvarian cancer is the most lethal and endometrial cancer the most common gynaecological cancer in the UK, yet neither have a screening program in place to facilitate early disease detection. The aim is to evaluate whether online search data can be used to differentiate between individuals with malignant and benign gynaecological diagnoses.MethodsThis is a prospective cohort study evaluating online search data in symptomatic individuals (Google user) referred from primary care (GP) with a suspected cancer to a London Hospital (UK) between December 2020 and June 2022. Informed written consent was obtained and online search data was extracted via Google takeout and anonymised. A health filter was applied to extract health-related terms for 24 months prior to GP referral. A predictive model (outcome: malignancy) was developed using (1) search queries (terms model) and (2) categorised search queries (categories model). Area under the ROC curve (AUC) was used to evaluate model performance. 844 women were approached, 652 were eligible to participate and 392 were recruited. Of those recruited, 108 did not complete enrollment, 12 withdrew and 37 were excluded as they did not track Google searches or had an empty search history, leaving a cohort of 235.ResultsThe cohort had a median age of 53 years old (range 20–81) and a malignancy rate of 26.0%. There was a difference in online search data between those with a benign and malignant diagnosis, noted as early as 360 days in advance of GP referral, when search queries were used directly, but only 60 days in advance, when queries were divided into health categories. A model using online search data from patients (n = 153) who performed health-related search and corrected for sample size, achieved its highest sample-corrected AUC of 0.82, 60 days prior to GP referral.ConclusionsOnline search data appears to be different between individuals with malignant and benign gynaecological conditions, with a signal observed in advance of GP referral date. Online search data needs to be evaluated in a larger dataset to determine its value as an early disease detection tool and whether its use leads to improved clinical outcomes.

Improving Interprofessional Communication in the Outpatient Hematology Clinic at a Metropolitan Cancer Center

Background: Effective communication within a healthcare team leads to improved patient safety, more effective interventions, enhanced employee morale, and increased patient and family satisfaction. Our study aims to improve interprofessional communication between hematologists and referring providers in our ambulatory hematology clinic. First, we assessed the frequency with which hematologists communicated patient care recommendations to referring providers. After we identified a gap in communication, we implemented a quality improvement intervention to address the gap. Methods: A retrospective review was conducted to identify new patients ≥18 years old referred to the hematology clinic from January 1, 2022, to July 31, 2022. The data assessed included demographics, reason for referral, show rate, time from referral to first visit, and whether there was documentation of recommendations communicated from the hematologist to the referring provider. Communication was also counted if the patient was referred from an internal provider who had access to the medical record. After a gap in communication was identified, we implemented a quality improvement measure to document referring providers' names and contact information in every initial office visit note and then fax over all new patient notes with hematology recommendations to the referring provider at the end of each week. All fax communications were documented in patients' electronic charts. Results: A total of 217 new patients were referred to the hematology clinic from January 1, 2022, to July 31, 2022. The median age was 53 (range, 18-94) years; 43% of patients were seen in the clinic, and 56% were no-shows. Primary referral reasons were anemia (44%), thrombosis (21%), leukocyte abnormalities (12%), and thrombocytopenia (11%). The average time between referral date and first visit was 95 days. Of the 43% (n=93) of patients seen in the clinic, only 3% (n=3) had documented communication between the hematologist and referring provider prior to the quality intervention. In the second phase of the study, data was collected after implementation of the intervention from October 1, 2022, to June 30, 2023. There were 245 new patient referrals, with 49% of patients seen in clinic. The average time between referral date and first visit was 70 days. The rate of communication between the referring provider and hematologist improved to 86%. Conclusion: At our outpatient hematology clinic, we identified a gap in communication between the referring providers and hematologists. Often a provider refers a patient to hematology but is unaware of the recommendations that were made. This can lead to unclear recommendations and treatment plans, poor patient care, and frustration among patients and providers. We implemented an intervention to improve communication with referring providers. Our intervention was successful in improving the communication flow and enhanced communication from 3% to 86%. We recommend adoption of our intervention by other clinics at our institution to enhance their communication flow between referring providers and specialists. Our study identified additional issues, including a high no-show rate and long wait time from referral date to first visit. Although this was not the primary focus of our quality improvement project, additional quality improvement measures aimed at addressing these gaps are needed.

Impact of Time from Referral to Treatment on Outcomes and Cost of Therapy for Patients Undergoing Chimeric Antigen Receptor T-Cell Therapy for B-Cell Lymphoma: An Intention to Treat Analysis

BACKGROUND: Chimeric antigen receptor (CAR) T-cell therapy has changed the treatment landscape for B-cell non-Hodgkin lymphoma (B-NHL). Results from recent studies have expanded patient access to this treatment. However, little data is available evaluating the impact of time from referral to treatment on outcomes or cost for patients receiving CAR-T. METHODS: Patients (pts) aged ≥18 years with B-NHL who were referred either internally or externally between November 2017 and March 2023 for commercial CAR-T at Vanderbilt University Medical Center were included. Pts who died prior to leukapheresis or infusion were not excluded. Pts on a clinical trial were excluded. Date of referral was defined by presentation at an internal consensus meeting shortly after the initial provider visit. Other key time points were date of leukapheresis and date of CAR-T infusion. Cox regression analysis and the Kaplan Meier method were used for survival outcomes. Results were stratified by time to leukapheresis (within vs. greater than 45 days) as a proxy for a reasonable timeline, including evaluation, insurance approval, line placement, and scheduling. Pts who died prior to leukapheresis were included in the greater than 45 day group. Post referral therapy included treatment given between referral and leukapheresis, and bridging therapy included treatment given after leukapheresis. A crude cost estimate of therapies prior to CAR-T infusion was performed accounting for drug costs by type and number of cycles, administration (inpatient vs. outpatient), and estimated related costs of complications. Dollar amounts were obtained by review of CMS and previously published studies. Mann-Whitney U test was used to compare mean cost differences. RESULTS: Baseline characteristics are shown in Table 1. A total of 51 pts received axicabtagene ciloleucel (axi-cel, 78%), tisagenlecleucel (tisa-cel, 7%), or brexucabtagene autoleucel (brexu-cel, 15%) with a median follow up of 280 days. There were 9 pts (15%) who died while awaiting leukapheresis. The median age at referral was 62 (range 22-84). More pts had relapsed (43%) disease than relapsed/refractory (22%) or primary refractory disease (35%). Most patients had stage 3 or 4 disease (72%) and elevated LDH (75%). Private insurance (63%) was more common than Medicare (37%). The median time from referral to leukapheresis was 67 days (range 21-182) and median time from referral to CAR-T infusion was 99 days (range 49-212). There were 43 pts (73%) who underwent leukapheresis after 45 days. Most pts (85%) required post-referral therapy and many pts (21%) required two or more lines. Post referral therapy regimens were platinum-based (39%), polatuzumab-based (29%), other systemic chemotherapy (16%), and oral targeted agents (16%). Few pts (35%) required bridging therapy after leukapheresis with only two pts getting steroid monotherapy as bridging. The 12-month overall (OS) and progression free (PFS) survival for the cohort were 59.3% and 54.5% respectively. There was no difference in survival outcomes when stratified by early vs. late leukapheresis. Time from referral to leukapheresis or CAR-T infusion were not associated with survival outcomes in multivariate analysis. Excluding costs for leukapheresis and CAR-T infusion, the median cost of post-referral and bridging therapies was $43,700 USD (range $22,680 - $133,570). The median cost of therapies (Figure 1) for pts who underwent early leukapheresis was lower than for pts who underwent late leukapheresis (median $23,900 vs. $48,550, p=0.01). In a multivariate regression analysis, time from referral to leukapheresis (p=0.008) and the receipt of bridging therapy (p=0.010) were associated with increased costs. A sensitivity analysis performed based on year of referral did not change survival or cost outcomes. CONCLUSION: In this intention to treat analysis, we showed that time from referral to CAR-T infusion is longer than expected but did not impact survival in multivariate analysis. Prior to leukapheresis, most pts required one or more lines of systemic therapy. Given increased healthcare utilization, the cost of therapies prior to CAR-T was high, reflecting a pressing need to minimize logistic barriers prior to CAR-T to reduce costs and improve patient quality of life. Future multicenter studies should be conducted to better understand the impact of time from referral to treatment on costs, outcomes, and quality of life.

Healthcare utilization impacts of an eConsult program for headache at an academic medical center.

Interprofessional consultations ("eConsults") can reduce healthcare utilization. However, the impact of eConsults on healthcare utilization remains poorly characterized among patients with headache. We performed a retrospective, 1:1 matched cohort study comparing patients evaluated for headache via eConsult request or in-person referral at the Mount Sinai Health System in New York. Groups were matched on clinical and demographic characteristics. Our primary outcome was one or more outpatient headache-related encounters in 6 months following referral date. Secondary outcomes included one or more all-cause outpatient neurology and headache-related emergency department (ED) encounters during the same period. We used univariable and multivariable logistic regression to model associations between independent variables and outcomes. We identified 74 patients with headache eConsults who were matched to 74 patients with in-person referrals. Patients in the eConsult group were less likely to achieve the primary outcome (29.7% vs 62.2%, P < 0.0001) or have an all-cause outpatient neurology encounter (33.8% vs 79.7%, P < 0.0001) than patients in the comparison group. Both groups did not significantly differ by headache-related ED encounters. In multivariable analyses, patients in the eConsult group had significantly lower odds of having one or more headache-related or all-cause neurology encounters than patients in the comparison group (odds ratio (OR) 0.3, 95% confidence interval (CI) 0.1-0.6; OR 0.1, 95% CI 0.1-0.3, respectively). In comparison to in-person referrals, eConsult requests for headache were associated with reduced likelihood of outpatient neurology encounters in the short-term but not with differential use of headache-related ED encounters. Larger-scale, prospective studies should validate our findings and assess patient outcomes.

Implementation of a dedicated cascade testing clinic for patients at risk for hereditary cancer syndromes.

Cascade testing, the site-specific genetic testing of relatives within families with an inherited condition, is underutilized. Long wait times for appointments in specialty genetics clinics are a known barrier to genetic testing access. In our cancer genetics, New Patient Clinic (NPC), the long wait time for an appointment (on average 5 months for routine referrals), was identified by both providers and patients as a barrier to uptake of cascade testing. Timely testing of at-risk relatives is essential to maximize the benefits of cascade testing and reduce cancer morbidity and mortality. Our objective was to improve access via implementation of a different clinical model that designated appointments for patients seeking cascade testing. A secondary goal was to improve use of genetic counselor time. We implemented a dedicated Cascade Testing Clinic (CTC) with an expedited triaging and unique scheduling model to decrease patient wait time to appointment and optimize clinician time. We report on the process and outcomes here. Between October 2016 and February 2020, the average wait time between referral date and first scheduled appointment date was 46 days for the CTC compared to 144 days for the NPC (p < 0.0001). No-show/cancelation/rescheduling rate was 11.7% in the CTC compared to 29.7% in the NPC (p < 0.0001). Genetic counselors saw approximately twice as many patients per half-day clinic in the CTC compared to the NPC (p < 0.00001). Modifications to clinic staffing and appointment times were made based on provider feedback. Implementation of a dedicated clinic specifically for patients seeking cascade testing significantly shortened wait times for this population, reduced patient drop-off, and improved clinician efficiency. The relatively straightforward indications and generally uncomplicated medical histories made this an ideal population for expedited appointments.

Machine Learning Techniques to Predict Timeliness of Care among Lung Cancer Patients.

Delays in the assessment, management, and treatment of lung cancer patients may adversely impact prognosis and survival. This study is the first to use machine learning techniques to predict the quality and timeliness of care among lung cancer patients, utilising data from the Victorian Lung Cancer Registry (VLCR) between 2011 and 2022, in Victoria, Australia. Predictor variables included demographic, clinical, hospital, and geographical socio-economic indices. Machine learning methods such as random forests, k-nearest neighbour, neural networks, and support vector machines were implemented and evaluated using 20% out-of-sample cross validations via the area under the curve (AUC). Optimal model parameters were selected based on 10-fold cross validation. There were 11,602 patients included in the analysis. Evaluated quality indicators included, primarily, overall proportion achieving "time from referral date to diagnosis date ≤ 28 days" and proportion achieving "time from diagnosis date to first treatment date (any intent) ≤ 14 days". Results showed that the support vector machine learning methods performed well, followed by nearest neighbour, based on out-of-sample AUCs of 0.89 (in-sample = 0.99) and 0.85 (in-sample = 0.99) for the first indicator, respectively. These models can be implemented in the registry databases to help healthcare workers identify patients who may not meet these indicators prospectively and enable timely interventions.

23 Rapid access stroke prevention clinic, are we adhering to international recommendations?

Abstract Background Transient Ischaemic attack (TIA), accounted for over 2000 hospital admissions in Ireland in 2020. 25% of all TIA presentations develop stroke. The European Stroke Organisation (ESO) and National Stroke Strategy have recommended the development of rapid access stroke prevention (RASP) clinics, to reduce morbidity associated with devastating stroke event and reduce unnecessary hospital admissions. This project reviews the functionality of a RASP clinic in an Irish hospital and compares it to international recommendations. Methods A retrospective chart review of patients who had been referred to the clinic over a three month period was performed. The initial referral date, clinic review date, date of any appropriate investigations and final diagnosis were collected and compared against the current recommendations. Quantitative analysis was performed on this data. Results A total of 43 patients were included, 18 were referred by the emergency department (ED), 25 by general practitioners (GP). On average GP referrals were waiting 5.8 days, and ED referrals 3.5 days, to be seen by a specialist. Current ESO recommendation is for specialist review within 24 hours. Of those referred, 34 underwent the recommended carotid imaging. 7 of the 43 were diagnosed with TIA, highlighting the poor sensitivity of the current risk stratification tool (ABCD2). The average time from symptom onset to referral was 3.7. With 15 patients waiting 35 days prior to seeking medical advice. Conclusion It is clear that, at present, the RASP clinic is not meeting the international recommendations. A number of improvements to the referral process have been proposed. The move to an electronic referral process would reduce unnecessary steps in the current pathway and would ensure the appropriate investigations were carried out, at the time of initial contact. Improved patient education on symptoms of TIA is needed. A repeat audit will take place to review if these changes have had a significant impact.

The journey of cancer patients and the quest to equity: findings from Morocco

ObjectivesRapid diagnostic and assessment pathways for cancer patients provide timely and effective care. This study took place in Morocco, where the majority of patients treated in the public sector are diagnosed at an advanced stage. The aim of this study was to determine the duration of different time intervals along the cancer patient pathway and to highlight problem areas so that strategies can be implemented to make the process more equitable and effective. Study designCross-sectional study. MethodsRecently diagnosed cancer patients were recruited from four major oncology centres in Morocco; namely, Marrakech, Casablanca, Rabat, and Fez. A questionnaire survey was administered, including sociodemographic and medical information and questions on access to the oncology centre, beliefs, and opinions on the medical staff. The dates of symptom recognition, assessment, diagnosis referral, biopsy, and treatment initiation were collected. Different time intervals (patient, diagnosis, biopsy, and treatment) were estimated and their determinants were investigated. ResultsA total of 812 patients were interviewed. The majority of participants were breast cancer patients. In total, 60% of participants were at stage III–IV. The main facilitators of cancer diagnosis confirmation and treatment initiation were easy access to diagnosis and treatment facilities, financial resources, personal history of cancer, time availability, late stage at diagnosis, advanced age, and private health insurance. The patient interval (i.e., time from symptom recognition to initial healthcare assessment) had a median duration of 30 days. The biopsy and treatment intervals were within the current international recommendations (7 and 28 days, respectively). However, the diagnosis interval (52 days) was twice as long as the recommended timeframes from the UK, Australia, and the World Health Organization (<28 days). ConclusionsInterval targets should be defined to encourage health systems to be more equitable and effective and to ensure that cancer patients are treated within a defined timeframe.

Exploring help-seeking patterns of UK veterans with mental health difficulties: Referrals to Combat Stress 2012–2022

BackgroundExploration of help-seeking by UK veterans with mental health difficulties has traditionally focused on barriers and facilitators to action. Comparatively little is known concerning referral patterns to specialist veteran mental health services. AimsTo explore patterns of help-seeking over the decade to 2022 to a national specialist mental health service for UK military veterans. MethodsA dataset was created from electronic patient records for referrals between 2012 and 2022. Data included demographics, dates of referral, military service details including service length and operational deployments. ResultsThe mean time taken for veterans to seek help after leaving service appeared to modestly increase, when compared to previous studies. This is contrary to predictions from previous studies and potentially driven by a cohort effect of older veterans continuing to take longer to seek support than their younger peers. Further, early service leavers took longer to seek help. Over the course of the decade, the proportion of veterans with experience of operations in Iraq and/or Afghanistan increased; these individuals appeared to seek help more quickly than veterans who had served on previous deployments. The proportion of female veterans seeking referral increased over time. ConclusionsAlthough older veterans continue to present with mental health difficulties, those younger and with more recent deployment to Afghanistan are likely to represent the largest group seeking help in the coming years. These trends indicate that adequate specialist veteran mental health care provision is contingent on meeting the needs of veterans with a range of demographic and military profiles.

Predictors of Subspecialty Appointment Scheduling and Completion for Patients Referred From a Pediatric Primary Care Clinic.

Failure to complete subspecialty referrals decreases access to subspecialty care and may endanger patient safety. We conducted a retrospective analysis of new patient referrals made to the 14 most common referral departments at Boston Children's Hospital from January 1 to December 31, 2017. The sample included 2031 patient referrals. The mean wait time between referral and appointment date was 39.6 days. In all, 87% of referrals were scheduled and 84% of scheduled appointments attended, thus 73% of the original referrals were completed. In multivariate analysis, younger age, medical complexity, being a non-English speaker, and referral to a surgical subspecialty were associated with a higher likelihood of referral completion. Black and Hispanic/Latino race/ethnicity, living in a Census tract with Social Vulnerability Index (SVI) ≥ 90th percentile, and longer wait times were associated with a lower likelihood of appointment attendance. Future interventions should consider both health care system factors such as appointment wait times and community-level barriers to referral completion.

Infective endocarditis and oral surgery input before cardiac surgery: time to prick the paradigm of pre-cardiac surgery assessments?

Purpose To review current practice regarding oral surgery input for patients awaiting cardiac valvular surgery and who are at risk of infective endocarditis (IE) in the context of the COVID-19 pandemic, and to stimulate debate around the indications for pre-operative oral surgery assessment. It also opens the way to developing a new research-based approach which is patient-centred, safe, effective and efficient.Methods A desk-top based patient review was undertaken between 27 March 2020 and 1 July 2022 to record the outcome of patients undergoing cardiac valvular surgery in Northern Ireland, following the revision of the referral guidelines for oral surgery intervention. Data were collected for all cardiac referrals to the oral surgery on-call service in the Royal Victoria Hospital, Belfast. Complications were recorded at two weeks, two months, and six months post-surgery, using Northern Ireland Electronic Care Records.Results In total, 67 cardiac patients were identified between 27 March 2020 and 1 July 2022: 65.7% of patients were male and had an average age of 68, while the female patients had an average age of 61. The mean interval of date of cardiology referral to surgery date was 9.7 working days, with 36% of patients referred within five days of the planned surgery date. Moreover, 39% had valvular surgery in combination with another type of cardiac surgery. No complications linked to dental aetiology were noted.Conclusions This paper raises questions about the advisability of oral surgery input before cardiac surgery for anything other than pain relief, management of acute dental sepsis, or IE whose source has been identified as an oral commensal. The COVID-19 pandemic has presented an opportunity to review current practice and open the way to developing a new approach which is patient-centred, safe, effective and efficient.

Dental practice to dental hospital referrals—upgraded to urgent suspected cancer pathways: A three year service review

AbstractIntroductionInappropriate General Dental Practitioner (GDP) patient referrals may delay cancer diagnoses, increasing the risk of late‐stage presentation. Urgent suspected cancer (USC) referrals from GDPs are reviewed swiftly by clinicians. Non‐USC referrals may wait up to a week before being reviewed by clinicians.Aims and objectivesTo investigate upgraded‐to‐USC GDP referrals to a University Dental Hospital (UDH) following the establishment of the pan‐Wales electronic referral management system (e‐RMS) in 2019. To examine reasons for their upgrade to the USC pathway, and to assess diagnostic outcomes, diagnostic delay and compliance with The National Institute for Health and Care Excellence (NICE) referral recommendations.MethodologyUpgraded‐to‐USC e‐Referrals were reviewed and cross‐referenced against the electronic patient management system and patient files to assess waiting times from referral date to first appointment. Each e‐Referral was reviewed to determine the reason for upgrade to a USC referral. Patient outcomes and diagnoses were also examined.Results83 patient records were identified. Upgraded e‐Referrals accounted for 18.6% of all USC e‐Referrals. The majority of upgraded e‐Referrals (66.3%) were upgraded because they included words describing key malignancy features. Malignant and oral potentially malignant disorders (OPMDs) accounted for 3.8% and 17.5% of diagnostic outcomes respectively. Overall, 18.8% of upgraded‐to‐USC e‐Referrals did not meet the NICE guideline requirement of having a first appointment within 2 weeks.ConclusionEarly diagnosis of malignancies is fundamental in improving oral cancer survival outcomes. Some GDPs' clinical judgement and referral pathway choice needs improvement. Reinforcing GDP education in regard to USC referrals will likely reduce inappropriate referrals.

MP72-09 SELF-SCHEDULING IMPROVES QUALITY OF CARE FOR HOSPITAL DISCHARGE FOLLOW UP OF URINARY RETENTION PATIENTS

You have accessJournal of UrologyCME1 Apr 2023MP72-09 SELF-SCHEDULING IMPROVES QUALITY OF CARE FOR HOSPITAL DISCHARGE FOLLOW UP OF URINARY RETENTION PATIENTS Avi Baskin, Matthew Chou, Thomas Chi, and Michelle Van Kuiken Avi BaskinAvi Baskin More articles by this author , Matthew ChouMatthew Chou More articles by this author , Thomas ChiThomas Chi More articles by this author , and Michelle Van KuikenMichelle Van Kuiken More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003340.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Delays in patient care after discharge from the hospital can lead to poor quality care and outcomes. At UCSF, one source of patient discontinuity of care has been the inability to consistently obtain an expedited follow up appointment in the urology outpatient clinic after hospital discharge when patients had a new foley placed during their hospital stay. This quality improvement project sought to improve the process for these patients. METHODS: To understand barriers to prompt follow up for patients discharging from UCSF, we employed LEAN A3 methodology. A total of 2 PDSA cycles were completed with two total interventions implemented. The first intervention was to create standing appointments with advanced practice providers that were reserved in the urology clinic for these discharge referrals. The second intervention was the creation of a novel patient self-scheduling approach using the existing electronic medical record. Patients who need referral for a voiding trial with urology were identified by their primary team and a new discharge order was placed. Placement of the referral order generated a ticket in the patient’s portal, allowing patients to select a date and time for their follow up voiding trial. RESULTS: Prior to intervention, there was a median time of 2.0 days from referral placement to appointment scheduling and 9.5 days between referral placement and appointment date. (Figure 1) 20% of patients with referrals were lost to follow up. After the intervention, patients where were scheduled via the self-scheduling work flow had a median of 1.5 days from referral to scheduled appointment compared to 5.5 days from the prior work flow. The post intervention median time between referral placement and appointment scheduling was 8.0 days. 5% of patients in the post intervention period were lost to follow up. CONCLUSIONS: Automation and infrastructure enhancement improved the quality of care and shorted time to follow up for patients who had foley catheters placed during their hospital stay. Efforts like this can be scaled to improve urological quality of care and transitions in care. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1027 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Avi Baskin More articles by this author Matthew Chou More articles by this author Thomas Chi More articles by this author Michelle Van Kuiken More articles by this author Expand All Advertisement PDF downloadLoading ...