Differences In Referral Patterns Research Articles

1598P Differences in referral patterns to the palliative care team among specialized physicians in patients with terminal cancer

1598P Differences in referral patterns to the palliative care team among specialized physicians in patients with terminal cancer

The role of traditional social determinants of health in referral patterns, timing of surgery, and Chiari Health Index for Pediatrics-determined quality of life in children with symptomatic Chiari type I malformation.

Understanding the impact of the social determinants of health on the utilization of healthcare resources is an important step in eliminating inequalities. The goal of this study was to determine the role of social determinants of health in referral patterns, timing of consultation/intervention, and quality of life in children with Chiari malformation type I (CM-I). A retrospective study was conducted of children aged 0 to 18 years who underwent surgical treatment for CM-I at a single pediatric facility from 2015 to 2019. The variables included demographic and socioeconomic characteristics, referral patterns, timing, and quality of life data based on the Chiari Health Index for Pediatrics (CHIP). The cohort consisted of 103 surgically treated CM-I patients. No differences were seen in race, sex, insurance, or household income when evaluating referral source (community, specialist, or emergency department) or when comparing patients with incidental versus symptomatic findings. In the evaluation of timing from initial evaluation to surgery, no statistical differences were seen between racial, sex, insurance status, or income groups. Children from households of lower median family income were significantly more likely to report pain at the time of consultation (pain group median [interquartile range] $46,660 [$41,004-$50,367] vs nonpain group $53,604 [$41,427-$59,828], p = 0.004). Those in the lower-income group also reported lower CHIP scores corresponding to increased symptomatology in the nonpain physical symptoms (p = 0.004) and psychosocial domains (p = 0.018). There was no evidence of a difference in referral patterns or a delay in time from clinic presentation to surgery based on the traditional social determinants of health categories. Children from households in the lower-income group were associated with increased severity of pain and nonpain symptoms.

Referring and Specialist Physician Gender and Specialist Billing

While a gender pay gap in medicine has been well documented, relatively little research has addressed mechanisms that mediate gender differences in referral income for specialists. To examine gender-based disparities in medical and surgical specialist referrals in Ontario, Canada. This cross-sectional study included referrals for specialist care ascertained from Ontario Health Insurance Plan physician billings for fiscal year 2018 to 2019. Participants were specialist physicians who received new patient consultations from April 1, 2018, to March 31, 2019, and the associated referring physicians. Data were analyzed from April 2018 to March 2020, including a 12-month follow-up period. Specialist and referring physician gender (female or male). Revenue per referral was defined based on an episode-of-care approach as total billings for a 12-month period from the initial consultation. Mean total billings for female and male specialists were compared and the differential divided into the portion owing to referral volume vs referral revenue. Difference-in-differences multivariable regression analysis was used to estimate gender-based differences in revenue per referral. For each referring physician, gender-based differences in referral patterns were examined using case-control analysis, in which specialists who received a referral were compared with matched control specialists who did not receive a referral. This analysis considered the gender of the specialist and concordance between the gender of the referring physician and specialist, among other characteristics. Of 7 621 365 new referrals, 32 824 referring physicians, of whom 13 512 (41.2%) were female (mean [SD] age, 46.3 [11.6] years) and 19 312 (58.8%) were male (mean [SD] age, 52.9 [13.5] years), made referrals to 13 582 specialists, of whom 4890 (36.0%) were female (mean [SD] age, 45.6 [11.0] years) and 8692 (64.0%) were male (mean [SD] age, 51.8 [13.0] years). Male specialists received more mean (SD) referrals than did female specialists (633 [666] vs 433 [515]), and the mean (SD) revenue per referral was higher for males ($350 [$474]) compared with females ($316 [$393]). Adjusted analysis demonstrated a -4.7% (95% CI, -4.9% to -4.5%) difference in the revenue per referral between male and female specialists. Multivariable regression analysis found that physicians referred more often to specialists of the same gender (odds ratio, 1.04; 95% CI, 1.03-1.04) but had higher odds of referring to male specialists (odds ratio, 1.10; 95% CI, 1.09-1.11). In this cross-sectional study of the gender pay gap in specialist referral income, the number and revenue from referrals received differed by gender, as did the odds of receiving a referral from a physician of the same gender. Future research should examine the effectiveness of different policies to address this gap, such as a centralized, gender-blinded referral system.

Abstract WP62: Skilled Nursing Facilities As A Bridge For Acute Rehabilitation In Acute Stroke Patients Who Are Not Immediate Candidates For Intensive Therapy

Background: Rehabilitation after hospital discharge is an essential component of stroke recovery. However, many stroke patients are not immediately ready for an Inpatient Rehabilitation Facility (IRF) after hospital discharge because of poor endurance, weakness, cognitive status, or medical condition. The purpose of this study is to demonstrate the efficacy of skilled nursing facilities (SNF) as a bridge to improve the number of post-stroke IRF admissions, and better understand the factors that allow transfer from a SNF to IRF by assessing differences between patients who are discharged from a SNF with vs. without an IRF referral. Methods: We included subjects with a primary diagnosis of ischemic stroke, subarachnoid hemorrhage, or intracerebral hemorrhage who were admitted to an urban CSC and discharged to a SNF from 1/2015 to 12/2021. Baseline demographics including gender, race, age, and risk factors were abstracted. Data were retrieved from both our EMR and Get With the Guidelines Stroke Database. Wilcoxon rank sum tests and chi square tests were used to analyze the data. Results: 1120 patients with a stroke diagnosis were discharged to a SNF, of which 173 (15%) received an IRF referral after SNF discharge. Nine to 19% (mean=15, SD=3) of SNF patients received an IRF referral between 2015 and 2021. Patients with an IRF referral were younger (mean age: 61.90, SD=14.05 vs 73.09, SD=12.12; p < 0.0001). There were no statistically significant differences in length of stay, discharge mRS, and prevalence of hypertension, diabetes mellitus, coronary artery disease, dyslipidemia, heart failure, and smoking. Men more frequently received an IRF referral (20% vs 11%, p < 0.0001). Racial differences in referral patterns were not significant (p = 0.19). Conclusions: SNFs are an effective bridge between the hospital and IRF settings, given that 15% of all stroke patients discharged to a SNF were ultimately referred to an IRF. SNFs should be considered as an alternate route for post-stroke patients who are not immediately ready for IRFs after hospital discharge but may still benefit from IRF therapy.

P606 Significant regional differences in referral patterns for bowel resection in Crohn’s disease patients

Abstract Background Preoperative factors - mainly patients’ condition and disease phenotype – are main determinants of postoperative outcome. However, those factors might be strongly dictated by regional traditions and treatment patterns of referring gastroenterologists. The present prospective observational study compared two German IBD-referral centers located in two different geographical regions regarding patients’ characteristics and postoperative outcome. Methods Consecutive patients referred to undergo intestinal resections at two different regional centers of IBD-surgery were included in present prospective observational study. Both surgical departments were headed by same surgeon, thus, decisions to perform surgery, preoperative routine and the postoperative management did not differ between hospitals. One hospital (Hospital 1) was located in Bavaria. Patients underwent intestinal surgery at this hospital between 2019 and 2021. The second hospital (Hospital 2) was located in North Rhine-Westphalia. All surgeries at Hospital 2 were performed 2022. The distance between both hospitals was about 600km. Results 181 patients underwent bowel resections – 102 at Hospital 1 and 79 at Hospital 2. There were significant differences between both hospitals regarding preoperative variables: Azathioprine intake (8% vs. 23%, p=0.005), Steroid intake (13% vs. 29%, p=0.008) and presence of colonic disease (27% vs. 46%, p=0.013). Also, the frequency of some intraoperative procedures differed significantly: ostomy formation at surgery (16% vs. 29%, p=0.044), ileocolic resections (78% vs. 58%, p=0.001), colonic resections (15% vs. 34%, p=0.003). Postoperatively, there was difference in incidence of postoperative ileus (8% vs. 18%, p=0.041). Also, overall complication rate was lower in Hospital 1 (21% vs. 31%), however, the difference was not statistically significant (p=0.12). Conclusion Different referral patterns might exist between various hospitals and regions leading to different perioperative outcomes. This should be taken in consideration when results of studies are compared.

Characterizing gastrointestinal dysfunction after pancreatic resection: a single-center retrospective study

BackgroundThere are many well-described potential gastrointestinal (GI) side effects of pancreatic resection that can cause patients to suffer from chronic malabsorption, diarrhea, and persistent nausea. These GI symptoms can affect postoperative recovery, initiation of adjuvant therapy, and overall quality of life (QOL). The purpose of this study is to quantify the incidence of post-procedural complications and identify patients at higher risk for experiencing GI dysfunction after pancreatectomy.MethodsA retrospective review of patients who underwent pancreatic resection at a single institution between January 2014 and December 2019 was performed. Demographics, operative factors, and postoperative gastrointestinal symptomatology and treatments were obtained by chart review. Significance tests were performed to compare GI dysfunction between patient subgroups.ResultsA total of 545 patients underwent pancreatic resection; within the cohort 451 patients (83%) underwent a pancreaticoduodenectomy (PD) and the most common indication was pancreatic adenocarcinoma. Two-thirds of patients (67%) reported gastrointestinal symptoms persisting beyond hospitalization. Only 105 patients (20%) were referred to gastroenterology for evaluation with 30 patients (5.5%) receiving a formal diagnosis. Patients who underwent PD were more likely to report GI symptoms and patients who identified as Caucasian were more likely to be referred to gastroenterology for evaluation.ConclusionsGastrointestinal dysfunction after pancreatic resection occurs frequently yet only a small percentage of patients are referred for formal testing and diagnosis. There also appears to be a racial difference in referral patterns. Patients would benefit if earlier attention was dedicated to the diagnosis and corresponding treatment for postoperative digestive health disorders to optimize treatment planning and QOL.

Abstract 11197: Gender Differences and Temporal Trends in Clinical Characteristics and Use of Myocardial Scintigraphy in Evaluation of Stable CAD

Introduction: Data on temporal and gender differences in referral patterns and clinical characteristics of patients referred for myocardial scintigraphy for suspected coronary artery disease (CAD), is lacking. Furthermore, the differential impact of COVID-19 pandemic on gender differences in referrals and clinical risk profile of referred patients is not known. Methods: This is a cross-sectional observational single center study of patients evaluated across 3 yearly time intervals in 2000, 2010 and 2020. We evaluated 2,615 patients (68% women) with mean age 65.9 years, who were referred for stress/rest myocardial scintigraphy. Trends in clinical characteristics and test results were compared in women and men across these intervals. Results: Men were more likely to be referred for testing than women, however there was a consistent increase in proportion of women referred over time, including the time of COVID pandemic in 2020. Men were more likely to present with typical symptoms, compared to women. Among women, there is a significant increase in prevalence of active smoking and a decrease in age at presentation and hypertension, over time (p<0.05). Among men, there was a significant decrease in history of previous MI, with no change in other risk factors over time. Across time intervals, in both men and women, there was a significant increase in EF (Ejection Fraction) and decrease in presence of ischemic myocardium at risk, identified by semi-quantitative scores including summed rest score (SRS), summed stress score (SSS) at rest (p<0.05). Conclusions: There are gender differences in proportion of men and women who are referred for stress testing, for evaluation of stable CAD. There was a substantial change in risk of inducible myocardial ischemia among male and female patients with known or suspected CAD. Our findings are relevant to understand the implications of gender differences on risk assessment and diagnostic accuracy in known or suspected CAD, over time.

Racial Disparity in Referral for Catheter Ablation for Atrial Fibrillation at a Single Integrated Health System.

Background Guidelines recommend catheter ablation of atrial fibrillation (AFCA) as an option for rhythm control. Studies have shown that Black patients are less likely to undergo AFCA compared with White patients. We investigated whether differences in referral patterns play a role in this observed disparity. Methods and Results Using an integrated repository from the electronic medical record at Northwestern Medicine, we conducted a retrospective cohort study of outpatients with newly diagnosed atrial fibrillation. Baseline characteristics by race and ethnicity were compared. Logistic regression models adjusted for socioeconomic and health factors were constructed to determine the association between race and ethnicity and binary dependent variables including referrals and visits to general cardiology and cardiac electrophysiology (EP) and AFCA. Of 5445 patients analyzed, 4652 were non-Hispanic White (NHW) and 793 were non-Hispanic Black (NHB). In adjusted models, NHB patients initially diagnosed with atrial fibrillation in internal medicine and primary care had a significantly greater odds of referral to general cardiology; among all patients in the cohort, there was no significant difference in the odds of referral to EP between NHB and NHWpatients; and there were no differences in the odds of completing a visit in general cardiology or EP. Among patients completing an EP visit, NHB patients were less likely to undergo AFCA (odds ratio, 0.63 [95% CI, 0.40-0.98], P=0.040). Conclusions Similar referral rates to general cardiology and EP were observed between NHB and NHWpatients. Despite this, NHB patients were less likely to undergo AFCA.

Abstract P3-04-04: Multi-institutional perspective on screening mammography and breast cancer stage at diagnosis during the COVID-19 pandemic

Abstract Background: During the SARS-CoV-2 pandemic in 2020, the use of routine screening mammography (SM) and diagnostic mammography (DM) was limited for several months in order to reduce patient exposure and redeploy medical personnel. Previous studies suggest such delays result in more late-stage breast cancer diagnoses. We hypothesized that this impact would vary between institutions depending on regional variations in shutdown periods and the ability and willingness of patients to resume screening. Methods: Patients diagnosed with invasive breast cancers from 2016-2020 were identified using the Beth Israel Deaconess Medical Center (BIDMC) and the Duke University Medical Center (DUMC) cancer registries. Rates of mammography were ascertained from billing data. Baseline patient characteristics, demographics, and clinical information were gathered and cross-referenced with the electronic medical record. Late-stage was defined as Anatomic Stage III-IV disease (AJCC 8th edition). Chi-squared analysis was used to examine monthly distributions in stage at presentation for diagnosis in 2016-2019 compared to in 2020 at each institution. Results: There were 5907 patients diagnosed with invasive breast cancer between 2016-2019 (1597 at BIDMC and 4310 at DUMC) and 1075 in 2020 (333 and 742, respectively). Mammography was limited from 3/16/20-6/8/20 at BIDMC and from 3/16/20-4/20/20 at DUMC. There were fewer SM at each institution during their respective shutdown periods in 2020 than in the same months in 2019: BIDMC 1713 versus 8566 (80% reduction) and at DUMC 1649 versus 5698 (71% reduction). Following the pandemic shutdown, SM volume increased in July-December 2020 compared to July-December 2019 (108% at BIDMC and 116% at DUMC). The proportion of patients diagnosed with late-stage disease at BIDMC was greater in 2020 than in 2016-2019, at 12.6% and 6.6%, respectively (p < 0.001); 86% of late-stage diagnoses and 68% of all diagnoses in 2020 at BIDMC occurred from July-December following the initial shutdown period. The proportion of patients diagnosed with late-stage disease at DUMC in these two cohorts were 14.3% in 2020 and 16.2%% in 2016-2019 (p = 0.1); 50% of late-stage diagnoses and 51% of all diagnoses in 2020 at DUMC occurred in the period following the initial shutdown from July-December. Conclusion: We identified variation between two large academic medical centers in the impact of the SARS-CoV-2 pandemic shutdown on the proportion of late-stage breast cancer diagnoses. These dissimilar outcomes may be the result of differences in referral patterns as well as regional differences in the approach to SM during the pandemic. In particular, a shorter closure time and substantial increase in SM volume following the initial shutdown period in the Southeast region may have prevented an increase in late-stage diagnoses. Further information and analysis may help suggest additional strategies to minimize adverse effects of reduced cancer screening in future public-health emergencies. Table 1.Proportion of SM in 2020 compared to 2019 and proportion of late disease per month in 2020BIDMC 2020JanFebMarAprMayJunJulAugSepOct NovDecSM, %96109480034104106112105113112Late Disease, n(%)0 (0)2 (10)1 (3)0 (0)0 (0)3 (21)1 (7)9 (21)10 (15)10 (19)5 (12)1 (8)DUMC 2020JanFebMarAprMayJunJulAugSepOctNovDecSM, %565860040123111109127116120119Late Disease, n(%)12 (11)13 (19)14 (19)4 (18)4 (12)6 (11)12 (13)10 (13)6 (10)12 (19)7 (13)5 (13) Citation Format: Sarah J Stephens, Maxwell R Lloyd, Julian C Hong, Tejas Mehta, Ted A James, Rachel Blitzblau, Abram Recht, Daphna Y Spiegel. Multi-institutional perspective on screening mammography and breast cancer stage at diagnosis during the COVID-19 pandemic [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-04-04.

Assessment of Racial Disparities in Primary Care Physician Specialty Referrals

Disparities in quality of care according to patient race and socioeconomic status persist in the US. Differential referral patterns to specialist physicians might be associated with observed disparities. To examine whether differences exist between Black and White Medicare beneficiaries in the observed patterns of patient sharing between primary care physicians (PCPs) and physicians in the 6 specialties to which patients were most frequently referred. This cross-sectional observational study of Black and White Medicare beneficiaries used claims data from 2009 to 2010 on 100% of traditional Medicare beneficiaries who were seen by PCPs and selected high-volume specialists in 12 health care markets with at least 10% of the population being Black. Statistical analyses were conducted from December 20, 2017, to September 30, 2020. Differences in patterns of patient sharing among Black and White patients. Primary care physician and specialist degree (the number of other PCPs or specialists to whom each physician is connected) and strength (the number of shared patients per connection, overall, for Black patients and White patients and after equalizing the numbers of Black and White patients per PCP), as well as distance between PCP and patient and specialist zip code centroids. The 12 selected markets ranged in size from Manhattan, New York (187 054 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 9794 total physicians), to Tallahassee, Florida (44 644 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 847 total physicians). The percentage of Black beneficiaries ranged from 11.5% (Huntsville, Alabama) to 46.8% (Chicago, Illinois). The mean PCP-specialist degree (number of specialists with whom a PCP shares patients) was lower for Black patients than for White patients. For instance, the mean PCP-cardiologist degree across all markets for White patients was 17.5 compared with 8.8 for Black patients. After sampling White patients to equalize the numbers of patients seen, the degree differences narrowed but were still not equivalent in many markets (eg, for all specialties in Baton Rouge, Louisiana: 4.5 for Black patients vs 5.7 for White patients). Specialist networks among White patients were much larger than those constructed based just on Black patients (eg, for cardiology across all markets: 135 for Black patients vs 330 for White patients), even after equalizing the numbers of patients seen per PCP (123 for Black patients vs 211 for White patients). The overall test for differences in referral patterns was statistically significant for all 6 specialties examined in 7 of the 12 markets and in 5 specialties for another 3. This study suggests that differences exist in specialist referral patterns by race among Medicare beneficiaries. This is an observational study, and thus some differences might have resulted from patient-initiated visits to specialists.

Global health disparities in childhood cancers.

The high cure rates of children with cancer in high-income countries (HICs) are due to the impact of biomedical innovations on children with highly fatal diseases. We discuss why these innovations have not benefitted most children with cancer globally and propose broad strategies to reduce these disparities. Over 85% of children with cancer in HIC are cured while less than 20% in many low-income countries survive the disease. Hence, childhood cancer survival is poor globally since over 80% of children with cancer live in low-income and middle-income countries (LMICs). Inadequate skilled workforce and health infrastructure across all disciplines of pediatrics in LMIC are the main reasons for these disparities. Although biological differences may contribute to these disparities as well, many are unconfirmed because they are confounded by differences in referral patterns and clinical capacity. HIC partnerships with LMIC that focus on locally based pediatrics training and clinical infrastructure building are beginning to close the gap. Pediatric oncology is symbolic of the significant disparities in childhood survival arising from poverty, inadequate pediatric infrastructure, and skilled workforce in LMIC. Partnerships with HIC that build multidisciplinary pediatrics capacity and clinical infrastructure are beginning to make transformative improvements.

Does Shifting Surgeries from Inpatient to Outpatient Settings Save Money? The Case of Hysterectomy in Massachusetts

Research ObjectiveTechnological advances have allowed for the shifting of many surgeries from hospital inpatient to outpatient settings. This shift should lead to net cost savings as fewer resources are required. There could also be distributional and other market consequences due to differences in referral patterns, individual hospital resources, and benefit design. Scheduled hysterectomies (eg, those that are unrelated to maternity episodes) represent an example of this trend. The objective of this study is to analyze the impact of shifting surgeries from inpatient to outpatient settings of care on the distribution of surgeries across types of hospitals and on overall costs.Study DesignWe identified hysterectomies performed in Massachusetts in both inpatient and outpatient settings among members of five large private insurers in the state’s all‐payer claims database from 2015 to 2017. We further subset these procedures to define “shiftable” hysterectomies as procedures that were not maternity related or related to cancer and did not involve major complications. We estimated the average payment for the hysterectomy episode which was defined to include all claims taking place on the same day as the procedure and included both hospital and professional payments. We grouped hospitals by type and system to evaluate the distributional effects of inpatient to outpatient shifts.Population StudiedCommercially insured inpatient stays and outpatient surgery encounters for hysterectomies in Massachusetts during 2015‐2017 period.Principal FindingsDespite shifting of about one‐fifth of inpatient hysterectomies to outpatient settings, the average system‐wide payment per hysterectomy in our commercially insured population increased 9.5% over the study period. When examined in more detail, this paradox appears to be partly explained by a shift from hospitals with lower‐than‐average‐priced inpatient and outpatient surgeries to hospitals with higher‐than‐average priced outpatient surgeries. Absent such a shift, total spending would have increased only 6.3% due to price increases within settings. For example, the average payment for an outpatient hysterectomy procedure at one of the AMCs with highest increase in outpatient hysterectomies, while lower than the cost of a procedure on their own inpatient wards, was 37% higher than the inpatient cost of the procedure at a local community hospital that lost the most inpatient volume. Overall, nonteaching hospitals, especially those with a high mix of public payers, lost commercial hysterectomy volume, and consequently revenue, while outpatient hysterectomies accumulated in a handful of academic hospital systems.ConclusionsThe promise of shifting surgeries to outpatient settings to reduce total spending has not materialized for hysterectomy—a surgery that underwent a dramatic shift in just 2 years. However, there are winners and losers among providers. The financial well‐being of community hospitals may partly depend on their ability to retain their commercial volume in their own outpatient settings.Implications for Policy or PracticeHysterectomy as a case study suggests that the promise of more efficient modes of care delivery may not yield net savings to consumers if high‐priced systems capture a large share of the shifted volume.Primary Funding SourceXxxx.

Billing of cataract surgery as complex versus routine for Medicare beneficiaries

To estimate ophthalmologist-level variation in cataract surgery billing and evaluate patient and ophthalmologist characteristics associated with complex cataract surgery coding. Cross-sectional study. Retrospective case series. Medicare beneficiaries aged 65years or older who had cataract surgery between January 1, 2016, and December 31, 2017, were included. Billing of cataract surgery as complex versus routine and patient and physician characteristics associated with billing of cataract surgery as complex were evaluated. An estimated 3.5 million cataract procedures were performed on Medicare beneficiaries in 2016 and 2017. Men (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.75-1.82), patients 75years or older (versus those aged 65 to 74years: OR, 1.35; 95% CI, 1.33-1.36), and racial minorities (blacks versus whites: OR, 1.80; 95% CI, 1.75-1.85) had increased odds of having cataract surgery coded as complex. The mean rate of coding for complex cataract surgery by individual surgeons (n=10 075) in the United States was 11.2%, with significant variation. A high-risk clinical diagnosis code was associated with 40.0% of complex cataract surgeries. Adjusted for patient characteristics, ophthalmologists who graduated from medical school within the past 10years (OR, 1.35; 95% CI, 1.22-1.49) were more likely to code for complex cataract surgery. Higher volume ophthalmologists were less likely to code for complex cataract surgery than low-volume ophthalmologists. There was marked variation among ophthalmologists in the use of complex cataract surgery. Some variability might represent inaccurate coding and was not entirely based on differences in referral patterns for more complex patients.

Medical Referral Patterns and Etiologies for Children With Mild-to-Severe Hearing Loss.

To (1) identify the etiologies and risk factors of the patient cohort and determine the degree to which they reflected the incidence for children with hearing loss and (2) quantify practice management patterns in three catchment areas of the United States with available centers of excellence in pediatric hearing loss. Medical information for 307 children with bilateral, mild-to-severe hearing loss was examined retrospectively. Children were participants in the Outcomes of Children with Hearing Loss (OCHL) study, a 5-year longitudinal study that recruited subjects at three different sites. Children aged 6 months to 7 years at time of OCHL enrollment were participants in this study. Children with cochlear implants, children with severe or profound hearing loss, and children with significant cognitive or motor delays were excluded from the OCHL study and, by extension, from this analysis. Medical information was gathered using medical records and participant intake forms, the latter reflecting a caregiver's report. A comparison group included 134 children with normal hearing. A Chi-square test on two-way tables was used to assess for differences in referral patterns by site for the children who are hard of hearing (CHH). Linear regression was performed on gestational age and birth weight as continuous variables. Risk factors were assessed using t tests. The alpha value was set at p < 0.05. Neonatal intensive care unit stay, mechanical ventilation, oxygen requirement, aminoglycoside exposure, and family history were correlated with hearing loss. For this study cohort, congenital cytomegalovirus, strep positivity, bacterial meningitis, extracorporeal membrane oxygenation, and loop diuretic exposure were not associated with hearing loss. Less than 50% of children underwent imaging, although 34.2% of those scanned had abnormalities identified. No single imaging modality was preferred. Differences in referral rates were apparent for neurology, radiology, genetics, and ophthalmology. The OCHL cohort reflects known etiologies of CHH. Despite available guidelines, centers of excellence, and high-yield rates for imaging, the medical workup for children with hearing loss remains inconsistently implemented and widely variable. There remains limited awareness as to what constitutes appropriate medical assessment for CHH.

Substitution of hospital care with Primary Care Plus: differences in referral patterns according to specialty, specialist and diagnosis group

BackgroundPrimary Care Plus (PC+) is an intervention where patients consult specialists in a primary care setting outside the hospital. Two facilities have been founded in the city of Maastricht, the Netherlands. Main aim is to achieve substitution of hospital care with primary care and hence reduce costs. The objective of this study is to evaluate referral patterns per specialty, specialist and diagnosis group, as input for deliberations to optimise substitution.MethodsProspectively collected referral data after PC+ consultations between November 2014 and March 2016 was analysed for eight participating specialties. Primary outcomes were differences in referral patterns per specialty, specialist and diagnosis group. Absolute counts and percentages were recorded for categorical variables, means and standard deviations for continuous variables. Statistical analyses were performed using IBM SPSS Statistics 23 (SPSS Inc., Chicago, IL).ResultsIn total 4536 patients were seen in PC+; 3132 (69.0%) were referred back to the general practitioner (GP), whereas 1275 (28.1%) were referred to secondary care. Referral information of 130 (2.9%) patients was unknown. Large differences in referral numbers to secondary care after PC+ consultation were found between specialties (from 8.6% (gynaecology) to 43.8% (orthopaedic surgery)), specialists (14.5 to 65.2%) and diagnosis groups (11.1 to 93.4%).ConclusionsWide variation in referral numbers to secondary care between specialties, specialists and diagnosis groups exists after PC+ consultations. This data indicates that deliberation and further research is needed in order to optimize substitution initiatives like PC+.

Differences in referral patterns based on race for women at high-risk for ovarian cancer in the southeast: Results from a Gynecologic Cancer Risk Assessment Clinic

ObjectiveTo compare referral patterns, genetic testing and pathogenic variant rates in Black women (BW) and White women (WW) in a large academic Gynecologic Cancer Risk Assessment Clinic (GCRAC). MethodsCross sectional study of an IRB-approved prospective, cohort study from a GCRAC. Data evaluated included: age, race, referral provider specialty and indication, genetic testing frequency, as well as frequency and types of pathogenic variants. Results588 WW and 57 BW were evaluated from 1/2010–12/2015. Although approximately one-third of BW and WW were referred for family history alone, referral indications varied. BW were more likely referred for a known pathogenic variant (20.0% vs. 6.2%) although less likely referred for a personal history of ovarian cancer (24.0% vs. 46.8%; p = 0.0023). While gynecologic oncologists referred most patients (BW 43.6% vs. WW 63.0%), BW were more likely to be referred by surgical oncologist (23.0% vs. 12.8%) or genetic counselor (12.8% vs. 5.9%) than WW (p = 0.0234). Referral from non-OBGYN primary care providers was <3% in both groups. Genetic testing rates were similar in both races (82.4% vs. 85.5%). Rates of BRCA1 mutations (12.7% vs. 11.5%) were similar; however, BW had more BRCA2 mutations (21.3% vs. 9.5%; p = 0.0194). ConclusionsSince BW are more likely to be referred by surgical oncology or genetics counselor, breast clinics might be an entry point to ensure genetic counseling and testing. Continued efforts to increase awareness regarding the importance of patient referral at the primary care level may help identify the subset of women not currently undergoing counseling and testing.

SUN-255 PATRO Children, a Multi-Center, Non-Interventional Study of the Long-Term Safety and Efficacy of Omnitrope® in Children Requiring Growth Hormone Treatment: Comparing United States (US) and Rest of World (ROW) Data

Introduction: PATRO Children is a non-interventional, international, longitudinal study of the long-term safety of a recombinant human growth hormone (rhGH; Omnitrope®, Sandoz) in patients requiring this therapy. Here we compare data from participants in the US with the ROW. Methods: The study population includes infants, children and adolescents receiving Omnitrope® therapy according to local prescribing information. All adverse events (AEs) are monitored and recorded for evaluation of rhGH safety. Laboratory values (including glucose metabolism and anti-hGH antibodies) are requested at least once a year. Height standard deviation score (HSDS), height velocity (HV) and HVSDS are calculated using height measurements and country-specific reference tables to evaluate rhGH efficacy. Results: As of September 2018, 294 US patients (including 65.6% GHD, 21.1% ISS, 2.7% SGA) and 6500 ROW patients (including 57.9% GHD, 25.8% SGA, 3.0% ISS) had been enrolled in the study. Mean (± standard deviation [SD]) age at enrollment was 10.44 ± 3.64 years for US patients and 72.8% were male. For ROW, mean ± SD age at enrollment was 8.95 ± 3.90 years and 58.7% were male. Overall, 53.1% (US) and 86.3% (ROW) of patients were rhGH naïve. Mean ± SD Omnitrope® treatment duration was 40.24 ± 17.39 and 38.18 ± 26.89 months in US and ROW patients, respectively; 49.66% (US) and 42.35% (ROW) of patients had completed 3 years’ treatment. Mean ± SD doses at study baseline and after 3 years were 0.0473 ± 0.0144 and 0.0541 ± 0.0289 mg/kg/day in the US group, and 0.0321 (0.0094) and 0.0359 (0.0106) mg/kg/day in the ROW group. In total, 886 AEs were recorded in 194 (66.0%) US patients; 5 AEs in 5 patients were considered treatment-related, and 3 (1.3%) patients discontinued therapy due to an AE. For ROW, 11716 AEs were recorded in 2977 (48.0%) patients, 636 (452 patients) of which were considered treatment-related; 105 (1.7%) discontinued due to an AE. Serious AEs were noted in 14 (4.8%) US patients (19 events) and 738 (11.9%) ROW patients (1429 events). No clinically relevant positive anti-hGH antibody titers have been found after the start of rhGH therapy in patients tested so far. After 3 years, improvement from baseline in HSDS and HVSDS among prepubertal, treatment-naïve GHD patients was similar between the US (+1.34; +3.06) and ROW (+1.35; +3.55) groups. Conclusions: Based on this snapshot of data from the ongoing PATRO Children study, Omnitrope® treatment appears to be similarly well tolerated and effective in patients enrolled from the US and ROW. Some differences between the US and ROW patients are apparent, likely reflecting differences in referral patterns, rhGH treatment practices and approved indications across different regions.

Influence of socioeconomic factors and region of residence on cancer stage of malignant melanoma: a Danish nationwide population-based study.

BackgroundSocioeconomic differences in survival after melanoma may be due to late diagnosis of the disadvantaged patients. The aim of the study was to examine the association between educational level, disposable income, cohabitating status and region of residence with stage at diagnosis of melanoma, including adjustment for comorbidity and tumor type.MethodsFrom The Danish Melanoma Database, we identified 10,158 patients diagnosed with their first invasive melanoma during 2008–2014 and obtained information on stage, localization, histology, thickness and ulceration. Sociodemographic information was retrieved from registers of Statistics Denmark and data on comorbidity from the Danish National Patient Registry. We used logistic regression to analyze the associations between sociodemographic factors and cancer stage.ResultsShorter education, lower income, living without partner, older age and being male were associated with increased odds ratios for advanced stage of melanoma at time of diagnosis even after adjustment for comorbidity and tumor type. Residence in the Zealand, Central and Northern region was also associated with advanced cancer stage.ConclusionSocioeconomically disadvantaged patients and patients with residence in three of five health care regions were more often diagnosed with advanced melanoma. Initiatives to increase early detection should be directed at disadvantaged groups, and efforts to improve early diagnosis of nodular melanomas during increased awareness of the Elevated, Firm and Growing nodule rule and “when in doubt, cut it out” should be implemented. Further studies should investigate regional differences in delay, effects of number of specialized doctors per inhabitant as well as differences in referral patterns from primary to secondary health care across health care regions.

Comparison of the assessment by doctors and nurses of deliberate self-harm

AIMS AND METHOD To compare the assessment by community psychiatric nurses and junior psychiatric doctors of individuals following deliberate self-harm (DSH) and, in particular, to elicit differences in referral practices and perceptions of mental illness. The health professionals involved completed questionnaires after carrying out DSH assessment. RESULTS There was a significant difference in referral patterns between doctors and nurses after DSH assessment. Doctors were significantly more likely to refer individuals for psychiatric follow-up which involved direct contact with other doctors (51 of 72 (71%) compared with 60 of 175 (34%)). Doctors were also significantly more likely than nurses to perceive individuals as having a mental illness (57 of 72 (79%) compared with 86 of 175 (49%)). CLINICAL IMPLICATIONS Further research is warranted to establish the precise reasons for these differences, and to determine whether the widespread introduction of nurse-led services is an effective and efficient use of resources.

Racial disparities in the diagnosis and management of trigeminal neuralgia.

OBJECTIVE A number of studies have documented inequalities in care and outcomes for a variety of clinical conditions. The authors sought to identify racial and socioeconomic disparities in the diagnosis and treatment of trigeminal neuralgia (TN), as well as the potential underlying reasons for those disparities, which could serve as areas of focus for future quality improvement initiatives. METHODS The medical records of patients with an ICD-9 code of 350.1, signifying a diagnosis of TN, at the Henry Ford Medical Group (HFMG) in the period from 2006 to 2012 were searched, and clinical and socioeconomic data were retrospectively reviewed. Analyses were conducted to assess potential racial differences in subspecialty referral patterns and the specific type of treatment modality undertaken for patients with TN. RESULTS The authors identified 652 patients eligible for analysis. Compared with white patients, black patients were less likely to undergo percutaneous ablative procedures, stereotactic radiosurgery, or microvascular decompression (p < 0.001). However, there was no difference in the likelihood of blacks and whites undergoing a procedure once they had seen a neurosurgeon (67% vs 70%, respectively; p = 0.712). Blacks and whites were equally likely to be seen by a neurologist or neurosurgeon if they were initially seen in either the emergency room (38% vs 37%, p = 0.879) or internal medicine (48% vs 50%, p = 0.806). Among patients diagnosed (268 patients) after the 2008 publication of the European Federation of Neurological Societies and the American Academy of Neurology guidelines for medical therapy for TN, fewer than 50% were on medications sanctioned by the guidelines, and there were no statistically significant racial disparities between white and black patients (p = 0.060). CONCLUSIONS According to data from a large database from one of the nation's largest comprehensive health care systems, there were significant racial disparities in the likelihood of a patient undergoing a procedure for TN. This appeared to stem from outside HFMG from a difference in referral patterns to the neurologists and neurosurgeons.