Follow-up Encounters Research Articles

Synchronous telehealth for outpatient allergy consultations: A 2-year regional experience

BackgroundTelehealth continues to advance as a health care modality; however, reported experience for synchronous TeleAllergy is limited. ObjectiveTo determine the percentage of new and follow-up visits conducted via TeleAllergy in a hospital-based clinic. MethodsA retrospective study evaluating the first 2 years of a synchronous patient-to-allergist TeleAllergy platform. ResultsA total of 112 synchronous TeleAllergy encounters were conducted from January 2014 through December 2015; 66 (59%) of these were new consultations. The mean (SD) age was 26.9 (15.3) years, and 54% of the participants were female. Food allergy (30%), allergic rhinitis (20%), and urticaria (16%) represented the top 3 consultation reasons. Sixteen of 66 patients (24.2%) and 3 of 46 patients (6.5%) attending new and follow-up TeleAllergy visits, respectively, were recommended for an in-person appointment (P = .02). No difference was found between new and follow-up TeleAllergy visits regarding subsequent telephone communication (41% vs 26%, P = .11) or prescriptions ordered (50% vs 33%, P = .08). New TeleAllergy visits were more likely to have more than 1 laboratory test ordered (45% vs 17%, P = .002). On the basis of patient location, the 112 TeleAllergy visits resulted in an estimated savings of 200 workdays or schooldays, US$58,000 in travel-related costs, and 80,000 kilometers not driven. ConclusionBoth new and follow-up visits to the allergist/immunologist were well received by patients and demonstrated significant indirect cost savings, with less than one fourth of the patients recommended for an in-person visit. This appears to be the first systematic assessment of TeleAllergy for new and follow-up patient encounters in a clinic-based allergy/immunology practice.

Implementation of standardized follow-up care significantly reduces peritonitis in children on chronic peritoneal dialysis

The Standardizing Care to improve Outcomes in Pediatric End stage renal disease (SCOPE) Collaborative aims to reduce peritonitis rates in pediatric chronic peritoneal dialysis patients by increasing implementation of standardized care practices. To assess this, monthly care bundle compliance and annualized monthly peritonitis rates were evaluated from 24 SCOPE centers that were participating at collaborative launch and that provided peritonitis rates for the 13 months prior to launch. Changes in bundle compliance were assessed using either a logistic regression model or a generalized linear mixed model. Changes in average annualized peritonitis rates over time were illustrated using the latter model. In the first 36 months of the collaborative, 644 patients with 7977 follow-up encounters were included. The likelihood of compliance with follow-up care practices increased significantly (odds ratio 1.15, 95% confidence interval 1.10, 1.19). Mean monthly peritonitis rates significantly decreased from 0.63 episodes per patient year (95% confidence interval 0.43, 0.92) prelaunch to 0.42 (95% confidence interval 0.31, 0.57) at 36 months postlaunch. A sensitivity analysis confirmed that as mean follow-up compliance increased, peritonitis rates decreased, reaching statistical significance at 80% at which point the prelaunch rate was 42% higher than the rate in the months following achievement of 80% compliance. In its first 3 years, the SCOPE Collaborative has increased the implementation of standardized follow-up care and demonstrated a significant reduction in average monthly peritonitis rates.

Etonogestrel Implants in Adolescents: Experience, Satisfaction, and Continuation

PurposeFew studies have evaluated the use of etonogestrel subdermal implants (ESI) by U.S. adolescents. We assessed several factors, including continuation rates, the association of implant removal with postimplant management of nuisance bleeding, and the relation between bleeding and body mass index. MethodsWe reviewed 116 charts from all adolescent females with ESI placement in our adolescent medicine clinic from January 2010 to August 2013. Data were obtained from follow-up encounters up to 36 months after insertion. ResultsOf the 116 adolescents, 94% were nulliparous. Follow-up data were available for 81% (n = 94). Early ESI removal was defined as removal <32 months. ESI continuation rates at 12, 24, and 32 months were 78%, 50%, and 40%, respectively; this represents an early removal rate of 35% (33 of 94). Nuisance bleeding occurred in 48% (45 of 94). Of those complaining of bleeding, 63% (25 of 40) received medication management. Resolution of bleeding occurred in 25% of those in the early removal group versus 15% in the full retention group. Early implant removal due to nuisance bleeding occurred in 18% (17 of 94). There was no significant association between body mass index, nuisance bleeding, and early ESI removal. ConclusionsImplant continuation rates were quite high at 12 and 24 months, with 40% of patients reaching 32 months retention, providing a significant period of pregnancy prevention. Treatments for nuisance bleeding were often not prescribed and when they were, medication regimens varied among providers. An evidence-based protocol for medication management, combined with more routine use of appropriate medications and preventive or long-term therapies, may help improve continuation of ESI.

Do all women with indeterminate pregnancies need a formal ultrasound before discharge from the emergency department?

The identification of ectopic pregnancy is the primary concern for pregnant patients with an indeterminate ultrasound (an empty uterus or gestational sac). The absence of free fluid and adnexal masses by ultrasound combined with the absence of ectopic risk factors are used to place women in a "low-risk" category. We believe that women in a "low-risk" category with a β-human chorionic gonadotropin (β-hCG) below 3,000 mIU/mL can be discharged with only an emergency department (ED) ultrasound, provided there is 48 to 72 hours obstetric follow-up. Follow-up encounters from August 2010 to March 2011 were reviewed. The inclusion criteria were women who only received an ED performed indeterminate ultrasound and an acute follow-up appointment with concern for ectopic pregnancy. Forty-nine women met inclusion criteria. Twenty-nine women (59.2%, 95% CI: 45.4%-73%) had a spontaneous abortion; 18 women (36.7%, 95% CI: 23.2%-50.2%) had a normal pregnancy, and 2 women (4.1%, 95% CI: 1.5%-9.7%) had an ectopic pregnancy. Both ectopic pregnancies had no risk factors with β-hCG values of 96 and 197 mIU/mL. This study suggests that low-risk indeterminate pregnancies by an ED ultrasound and β-hCG level <3,000 mIU/mL can be safely discharged without formal ultrasonography provided a 48 to 72 hours follow-up with an obstetrician.

The natural history of peanut sensitization and allergy in a birth cohort

Information on the natural history of peanut-induced allergic sensitization (PAS) and clinical peanut allergy (PA) remains limited. Most previous studies selected children who were given a diagnosis of PA, which does not provide the population perspective and probably ignores those with low levels of sensitization.1,2 There are no population-based studies on the natural history of PAS or PA. To provide a population perspective, we used the Isle of Wight birth cohort (n = 1456) and determined the natural history of PAS and PA, focusing on incidence, persistence, and remission.

Dog bites of the head and neck: an evaluation of a common pediatric trauma and associated treatment

PurposeTo identify which patients and canines are involved in dog bites of the head and neck, and how they impact health systems. Materials and methodsThis is a single center, retrospective cohort study conducted from January 2012 to June 2013 in an academic, tertiary care center situated between multiple suburban and urban communities. Patients were identified by queried search for all bite-related diagnoses codes. Results334 unique dog bites were identified, of which 101 involved the head and neck. The mean patient age was 15.1±18.1years. Of the more than 8 different breeds identified, one-third were caused by pit bull terriers and resulted in the highest rate of consultation (94%) and had 5 times the relative rate of surgical intervention. Unlike all other breeds, pit bull terriers were relatively more likely to attack an unknown individual (+31%), and without provocation (+48%). Injuries of the head and neck had an average follow-up of 1.26±2.4 visits, and average specialty follow-up of 3.1±3.5 visits. ConclusionsThe patients most likely to suffer dog bite injuries of the head and neck are children. Although a number of dog breeds were identified, the largest group were pit bull terriers, whose resultant injuries were more severe and resulted from unprovoked, unknown dogs. More severe injuries required a greater number of interventions, a greater number of inpatient physicians, and more outpatient follow-up encounters. Healthcare utilization and costs associated with dog bites warrant further investigation.

Follow-up encounters within 30 days of a substance abuse-related inpatient discharge.

O treatment for substance use disorders promotes recovery and reduces readmission (1,2).Wemeasured the annual percentage of individuals aged 13–64 who were covered under employer health plans and who received outpatient treatment for a substance use disorder within 30 days of a related inpatient stay. All data (2001–2012) were from the Truven Health MarketScan Commercial Claims and Encounters Database, which includes claims of employed individuals and dependents from all U.S. Census divisions. Data were weighted to be nationally representative of individuals with employer-sponsored insurance, 48% of the U.S. population in 2012 (3). The denominator was number of claims that met these criteria: discharge from an inpatient acute or residential facility, age 13–64, primary ICD-9-CM discharge diagnosis of drug or alcohol abuse or dependence, discharge date between January 1 and December 1 (to allow for 30 days of December follow-up), discharge status was not death or transfer to another facility, and continued plan enrollment for 30 days after discharge. The numerator was number of denominator stays for which there was an outpatient visit related to a substance use disorder within 30 days, defined by a primary ICD-9-CM diagnosis or code pertaining to mental health or substance abuse. We captured both types of diagnoses because substance use disorders are often recorded as mental disorders. Since 2003 the rate at which individuals have received outpatient treatment for a substance use disorder within 30 days of a related inpatient stay has alternated between plateaus and periods of increase (Figure 1). The rate has grown at least a little every year since 2005, reaching 66.1% in 2012. A single measure in the Healthcare Effectiveness Data and Information Set (HEDIS) tracks the rate of outpatient follow-up within seven or 30 days of an inpatient psychiatric discharge. There is no exact analog for substance use disorders. Themost similarHEDIS measure, “engagement” in substance use disorder treatment, requires two outpatient visits related to a substance use disorder within 30 days of “initiation,” which does not require a hospital stay. The dissimilarity of the two follow-up measures makes it difficult to compare outcomes for persons with substance use disorders and those with othermental disorders. A 30-day followup measure for substance use disorders would promote care delivery, research, policy making, and advocacy. The figure presented here represents a first step toward that goal.

Cumulative incidence of outcomes and urologic procedures after augmentation cystoplasty

ObjectiveAugmentation cystoplasty (AC) is a major surgery that can be associated with long-term morbidity. This study aimed to describe the cumulative incidence of outcomes and urologic procedures in a large cohort of children who underwent AC, identify significant sources of morbidity, and to evaluate baseline factors associated with outcomes of interest. MethodsChildren ≤18 years who underwent AC in the Pediatric Health Information System from 1999 to 2010 were included. All follow-up encounters up to June 2012 were included. Cumulative incidences for 15 outcomes and urologic procedures were calculated using non-informative censoring. Sensitivity analyses were performed to determine effect of censoring assumptions and including hospitals without complete datasets. As an exploratory analysis, baseline patient factors were evaluated for associations with outcomes and urologic procedures of interest using multivariable Cox proportional hazards models adjusted for clustering by hospital. Results2831 AC patients were identified. Based on cumulative incidence calculations and sensitivity analyses; the cumulative incidence ranges of outcomes and procedures at 1, 3, 5, and 10 years were calculated. Examples of 10-year cumulative incidence ranges are given for the following outcomes and procedures: bladder rupture (2.9–6.4%), small bowel obstruction (5.2–10.3%), bladder stones (13.3–36.0%), pyelonephritis (16.1–37.1%), cystolithopaxy (13.3–35.1%), and reaugmentation (5.2–13.4%). The development of chronic kidney disease was strongly associated with a diagnosis of lower urinary tract obstruction (HR 13.7; 95% CI 9.4–19.9). Bladder neck surgery and stoma creation at time of AC were associated with an increased hazard of bladder rupture (HR 1.9; 95% CI 1.1–3.3) and bladder stones (HR 1.4; 95% CI 1.1–1.8) respectively. ConclusionsOutcomes of interest and urologic procedures after AC are common. Results from this large cohort can be used to counsel patients and families about expectations after AC. Pyelonephritis, chronic kidney disease, further reconstructive surgery, and calculus disease appear to cause significant morbidity. Collaborative efforts are needed to further reduce morbidity in this patient population.

Opening clinical encounters in an adult musculoskeletal setting

Effective communication between healthcare professionals and their patients is crucial for successful consultations, and can profoundly affect patients' adherence to treatment. Despite this evidence, communication within the physiotherapy profession is still underexplored, in particular, how ‘best’ to open clinical encounters. This study explores the issue by seeking the preferences of physiotherapists for opening encounters in the adult musculoskeletal outpatient setting. Initially, 42 consultations and 17 first follow-up encounters were observed between qualified physiotherapists and patients with back pain. These encounters were audio-recorded, analysed and used to develop a questionnaire to determine clinicians' preferences for opening encounters. From these findings, a synopsis of the questionnaire was posted on the four most-relevant professional networks of the national, interactive Chartered Society of Physiotherapy (iCSP) website, to canvass opinion more widely. Among the 43 physiotherapists who responded, the preferred ‘key clinical question’ for an initial encounter was: “Do you want to just tell me a little bit about [your ‘problem presentation’] first of all?”; and for follow-up encounters: ‘How have you been since I last saw you?’ These results provide an important and novel contribution to the profession, as debate on this issue has not previously been published. Although the sample size in this study is small, the aim of this paper is to generate reflection and debate among clinicians on their preferences for opening patient encounters and optimising the non-specific treatment effects.

Long‐term visual outcomes in patients with orbitotemporal neurofibromatosis

The study aimed to review the presentation and long-term visual outcomes of patients with orbitotemporal neurofibromatosis. Retrospective case series. Patients with orbitotemporal neurofibromatosis presenting from 1981 to 2009. Demographic data, examination findings, causes of vision impairment and interventions performed were recorded for each patient from presentation through subsequent follow-up encounters. Visual impairment was defined as an ipsilateral Snellen acuity of <6/12. The proportion of patients with visual impairment or enucleation, the rate of new vision loss during follow up; and causes for vision loss or enucleation. Thirty-seven patients (17 female) were included. Median presenting age was 15 years (range 2-45) with an average follow up of 7.4 years (range 0.5-20.3). Visual impairment occurred in 54% of patients at presentation. Causes were amblyopia (13 of 37), optic atrophy (4 of 37), previous enucleation/evisceration (2 of 37), and optic nerve glioma (1 of 37). At presentation, 76% of patients had ptosis, and 51% had strabismus. Thirty-one patients had surgery, with an average of two procedures per patient. At final follow up, 62% had visual impairment. The rate of visual decline was 2% per patient-years. Causes of visual decline were two patients with optic nerve atrophy, one with exposure keratitis and one whose cause was unknown. Five blind patients had enucleation. The first series of orbitotemporal neurofibromatosis to focus on visual outcomes was presented. Vision loss is common, with a high prevalence of amblyopia. Close monitoring from an early age is needed to prevent visual impairment.

Remote monitoring of patients with cardiac implantable electronic devices: maximizing gains by addressing workflow

This editorial refers to ‘Effectiveness of remote monitoring of CIEDs in detection and treatment of clinical and device-related cardiovascular events in daily practice: the HomeGuide Registry’ by R.P. Ricci et al. , on page 970 and ‘Incidence and predictors of pacemaker reprogramming: potential consequences for remote follow-up’ by E.O. Udo et al. , on page 978. Innovations are usually greeted guardedly, especially those demanding changes in clinical habits. When and how these should be applied are obvious questions to physicians and patients alike. Automatic remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) is no exception, over a decade after its introduction. This, despite the need stated by professional societies and impressive trial data.1–3 However, diffidence in the community is reflected in slow adoption. In this issue of the Journal , two large (>1500 patients) prospective registries address some critical aspects of the operating mechanics of this technology. First, Udo et al. 4 aimed to define the candidate population for RM (although, importantly, did not actually test its application). They measured the frequency of non-actionable follow-up encounters in a large cohort of patients with pacemakers. This concept is critical—remote follow-up can only replace conventional in-person scheduled evaluation if the bulk of such appointments do not trigger any changes in patient management, i.e. are ‘non-actionable’. If, on the other hand they are frequently actionable, then discoveries from remote data download will require those patients to be contacted and brought to hospital, duplicating effort rather than promoting efficiencies. The results, however, confirmed that the vast majority (>80%) of patients studied did not need reprogramming changes (‘visits-with-reprogramming’), in keeping with conclusions from implantable cardioverter-defibrillator (ICD) trials. The authors looked at this from another vantage—whether it is possible to identify those patients at high risk of requiring management changes and assign these to …

Abstract TP122: Identifying Predictors of Seizure Recurrence After Nonconvulsive Seizures Recorded on Continuous Electroencephalogram (cEEG) in Ischemic Stroke

INTRODUCTION: Seizures are well-recognized complications of ischemic strokes (IS). The risk of subsequent development of epilepsy has been shown to be 2-4% in acute IS and much higher in remote IS. However, the risk of epilepsy in IS who have nonconvulsive seizures on cEEG is not well characterized. We present here a five-year retrospective study of IS patients who have nonconvulsive seizures on cEEG identifying risk factors for the development of epilepsy. METHODS: We retrospectively reviewed prospectively collected cEEG and clinical data on consecutive patients monitored from January 1, 2007, to December 31, 2011. We identified those patients with cEEG seizures that were secondary to either acute (&lt;30 days) or remote (&gt;30 days) ischemic stroke (IS; n=109) and then included in this study only those patients with follow-up encounters. Statistical analyses were performed with JMP 9.0. RESULTS: Sixty-five (41.5% acute IS, 58.5% remote IS) patients met inclusion criteria for this study. All patients were discharged on at least one antiepileptic. Nineteen (29.2%) patients were found to have seizure recurrence (i.e., epilepsy) with 84.2% being remote IS (p=0.0116). Periodic lateralized epileptiform discharges (PLEDs) were seen on cEEG in 21.5% (22.2% acute IS, 21.1% remote IS). 15.8% with PLEDs on initial cEEG developed epilepsy (p=0.74). 33.3% of patients classified as stupor/coma at the time of nonconvulsive seizures were found to have seizure recurrence compared to 24.1% of patients classified as awake/lethargy (p=0.5841). On follow up EEG (mean (SEM) 384.4 (59.1) days), the finding of sharp wave/spike (12.1%) significantly correlated with seizure recurrence (p=0.0175). DISCUSSION: This retrospective study found that patients with remote IS are at a higher risk of developing epilepsy when nonconvulsive seizures are recorded on cEEG in the hospital. Additionally, the finding of sharp waves on follow-up routine EEG further identifies those at risk for recurrence. This study highlights the usefulness of cEEG in patients in patients with acute or remote strokes and provides guidance on utility of follow-up EEG.

Establishing a referral system for MTM services

Last month's MTM Pearls column discussed how patients may be more willing to attend a pharmacist-managed MTM service if their physician or primary care provider encouraged or referred them to the service. Establishing a referral system is not an easy task and requires some effort and ongoing communication with other providers. Benefits of a successful referral system are an increase in patient acceptance and number of MTM interventions, and ultimately improvement in drug therapy. In a recent article, authors described their process for establishing a referral system for MTM services in an integrated health system.

Maximizing medication therapy management services through a referral initiative

The implementation and effects of an initiative to refer patients to receive medication therapy management (MTM) services after hospital discharge are described. A check box to order an MTM appointment was added to the discharge medication order form printed for hospitalized patients in an integrated health system. Hospitalists were informed about MTM services and encouraged to refer hospitalized patients to the service who were at risk for adverse drug events or medication nonadherence. A retrospective case series review was conducted to evaluate documented MTM encounters, comparing the number of patients seen at the MTM practice for hospital follow-up during the four months before and after the initiative's implementation. Secondary endpoints included revenue generated by MTM encounters and the percentage of patients with documented drug therapy problems due to medication nonadherence. A total of 313 encounters were included in the analysis (142 preimplementation and 171 postimplementation). The percentage of MTM hospital follow-up encounters significantly increased from the preimplementation period to the post-implementation period, from 30.28% (n = 43) to 63.74% (n = 109) (p < 0.001). After the referral initiative was implemented, MTM hospital follow-up encounters were more likely to reveal medication nonadherence, compared with regular office visits (odds ratio, 2.1; 95% confidence interval, 1.01-4.34; p = 0.039). The implementation of an initiative to refer hospitalized patients to an MTM service in an integrated health system increased the percentage of recently discharged patients seen in an MTM practice; patients seen postimplementation were more likely to be nonadherent to their medication regimen.

Implementation outcomes of evidence-based quality improvement for depression in VA community based outpatient clinics

BackgroundCollaborative-care management is an evidence-based practice for improving depression outcomes in primary care. The Department of Veterans Affairs (VA) has mandated the implementation of collaborative-care management in its satellite clinics, known as Community Based Outpatient Clinics (CBOCs). However, the organizational characteristics of CBOCs present added challenges to implementation. The objective of this study was to evaluate the effectiveness of evidence-based quality improvement (EBQI) as a strategy to facilitate the adoption of collaborative-care management in CBOCs.MethodsThis nonrandomized, small-scale, multisite evaluation of EBQI was conducted at three VA Medical Centers and 11 of their affiliated CBOCs. The Plan phase of the EBQI process involved the localized tailoring of the collaborative-care management program to each CBOC. Researchers ensured that the adaptations were evidence based. Clinical and administrative staff were responsible for adapting the collaborative-care management program for local needs, priorities, preferences and resources. Plan-Do-Study-Act cycles were used to refine the program over time. The evaluation was based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) Framework and used data from multiple sources: administrative records, web-based decision-support systems, surveys, and key-informant interviews.ResultsAdoption: 69.0% (58/84) of primary care providers referred patients to the program. Reach: 9.0% (298/3,296) of primary care patients diagnosed with depression who were not already receiving specialty care were enrolled in the program. Fidelity: During baseline care manager encounters, education/activation was provided to 100% (298/298) of patients, barriers were assessed and addressed for 100% (298/298) of patients, and depression severity was monitored for 100% (298/298) of patients. Less than half (42.5%, 681/1603) of follow-up encounters during the acute stage were completed within the timeframe specified. During the acute phase of treatment for all trials, the Patient Health Questionnaire (PHQ9) symptom-monitoring tool was used at 100% (681/681) of completed follow-up encounters, and self-management goals were discussed during 15.3% (104/681) of completed follow-up encounters. During the acute phase of treatment for pharmacotherapy and combination trials, medication adherence was assessed at 99.1% (575/580) of completed follow-up encounters, and side effects were assessed at 92.4% (536/580) of completed follow-up encounters. During the acute phase of treatment for psychotherapy and combination trials, counseling session adherence was assessed at 83.3% (239/287) of completed follow-up encounters. Effectiveness: 18.8% (56/298) of enrolled patients remitted (symptom free) and another 22.1% (66/298) responded to treatment (50% reduction in symptom severity). Maintenance: 91.9% (10/11) of the CBOCs chose to sustain the program after research funds were withdrawn.ConclusionsProvider adoption was good, although reach into the target population was relatively low. Fidelity and maintenance were excellent, and clinical outcomes were comparable to those in randomized controlled trials. Despite the organizational barriers, these findings suggest that EBQI is an effective facilitation strategy for CBOCs.Trial registrationClinical trial # NCT00317018.

Abstract 167: Consistency of Blood Pressure Control Predicts Vascular Outcome after Ischemic Stroke

Background: Hypertension is the leading modifiable risk factor for stroke. Uncontrolled hypertension increases cardiovascular risk, independent of type of treatment. Analysis of blood pressure (BP) control using mean follow-up BP may not provide a complete picture of BP control during a study, because BP may be in control at one visit and out of control at the next visit or vice versa. Objective: To assess the independent association between consistency of BP control at follow-up encounters and occurrence of future vascular events among recent ischemic stroke patients. Methods: We reviewed the trial dataset of 3680 recent (&lt;120 days) ischemic stroke patients, aged ≥ 35 years, recruited from 56 centers from 1996 to 2003, and followed for 2 years. Consistency of BP control was defined as the proportion of visits in which BP was in control (&lt;140 mm Hg systolic and 90 mm Hg diastolic). Patients were grouped according to proportion of visits in which BP was in control (&lt;25%, 25-49%, 50-74% and ≥75%). The primary outcome was time to stroke, myocardial infarction (MI) or vascular death; while time to stroke alone was the secondary outcome. Stepwise Cox proportional hazard models were used to determine the relationship between BP control and primary and secondary outcomes before and after adjusting for demographic (age, sex, and race-ethnicity) and clinical variables (vascular risk factors and cardiovascular medications use). Interaction effects were assessed for age, sex, race, history of hypertension, history of diabetes, and baseline (measured after the qualifying stroke) systolic BP (SBP). Results: Among the cohort, 35%, 16%, 19%, and 30% had BP controlled &lt;25%, 25-49%, 50-74%, and ≥75% of the time. After adjustment for covariates, those who maintained their BP within the target range ≥75% of the time did not have significantly lower rates of primary or secondary outcomes compared to those with BP within target range &lt;25% of the time; however, there was an interaction with baseline SBP such that a higher proportion of visits within target BP control was significantly associated with vascular risk reduction benefit starting from a baseline SBP of 132 mm Hg. Among patients with baseline SBP in the 75 th percentile (≥ 153 mmHg), having BP controlled at least 75% of the time conferred a lower risk of stroke, MI or vascular death (HR 0.51, 95% CI 0.32-0.83, p=0.007) and stroke (HR 0.48, 95% CI 0.26-0.87, p=0.02), compared to having BP controlled &lt;25% of the time. Individuals with mean follow-up BP under control had a lower risk of stroke, MI or vascular death (HR 0.76, 95% CI 0.62-0.92, p=0.006) and stroke (HR 0.76, 95% CI 0.59-0.98, p=0.03). Conclusions: While achieving a mean follow-up BP within target range is independently associated with a reduction in stroke, MI or vascular death, consistency of BP control among those with elevated baseline SBP is independently linked to an even greater reduction in vascular events. These findings highlight the importance of ensuring BP is controlled at each post-stroke clinical encounter, particularly among those patients who have elevated baseline SBP in the post-acute period following their index stroke.

The Spiral Flap for Nasal Alar Reconstruction: Our Experience with 63 Patients

To describe our patient selection, design, execution, and results with the spiral flap for distal nasal surgical defects after Mohs micrographic surgery. We performed a retrospective analysis of all spiral flaps performed over a 5-year period. Sixty-three patients were identified, and charts and photographs were examined. Surgical defects were classified according to alar location. All follow-up encounters were reviewed to assess for complications and need for revisionary procedures. Intraoperative photographs were taken of representative cases to describe the surgical technique. Sixty-three patients on whom the spiral flap was performed were identified over a 5-year period. The flap was used to successfully reconstruct alar defects ranging in size from 5 to 15mm in diameter. No persistent complications were noted. The spiral flap is a reproducible, one-stage flap for small to medium-sized defects of the nasal ala and alar groove that consistently produces topographic restoration with minimal risk of aesthetic or functional complication.

A population-based study of emergency department presentations for asthma in regions of Alberta

We describe the epidemiology of asthma presentations to emergency departments (EDs) for 3 main regions in the province of Alberta. We used a comprehensive ED database to identify ED visits in Alberta from April 1999 to March 2005. We linked the visits to other provincial administrative databases to obtain all data on follow-up encounters for asthma during that period. Information extracted included demographics, regions of residence (Edmonton, Calgary or non-major urban [NMU]), timing of ED visits, and subsequent visits to non-ED settings. Data analysis included descriptive summaries and directly standardized visit rates. During the 6-year study period, 93 146 patients made 199 991 ED visits for asthma. Crude rates in 2004/05 were 7.9/1000, 6.5/1000 and 15.4/1000 in the Edmonton, Calgary and NMU regions, respectively. The Edmonton and Calgary regions had consistently lower visit rates than the NMU regions. The ED visits were followed by low rates of follow-up visits in a variety of non-ED settings, at different intervals. Asthma is a relatively common presenting problem in Alberta EDs. This study identified relatively stable rates of presentation during the study period, and variation among regions in terms of age and sex. This study provides further understanding of the variation associated with ED presentation and indicates possible targets for specific interventions to reduce asthma-related ED visits.

Knowledge, Compliance, and Satisfaction: An Evaluation of the SIMPLE Program

Evaluate the increase in medication use knowledge, participants' compliance, and satisfaction with the pharmacist through the SIMPLE program (Sepa [Know] Información correcta sobre [Correct information about] Medicinas [Medicines], Pregunte [Ask], Lea la etiqueta [Read the label], y Evite problemas [and Avoid problems]). Quasi-experimental type using a convenience sample. Community pharmacies in Puerto Rico. 60 years of age or older in need of education for appropriate use of medications, using three or more medications for chronic diseases, were functional, and signed an informed consent and privacy agreement. A total of 316 elderly were enrolled. Complete documentation for the six encounters was obtained for 250 participants. The program was implemented through six encounters between pharmacists and participants in community pharmacies. Medication use knowledge and participants' compliance were measured by analyzing the baseline data and follow-up encounters. Participants' satisfaction with the pharmacist was evaluated using the Satisfaction With Pharmacist (SWiP) scale. Medication use knowledge, participant's compliance, and satisfaction with the pharmacist. Compliance improved from 55.2% before the program to 90.0% after the program. Knowledge of medication use improved from 36.8% before the program to 94.4% after the program. There was an increase in the "very much" response for all items in the SWiP scale. An increase in knowledge and compliance with medication therapy by the participants was observed after participation in the program. Participant-pharmacist relationship was reaffirmed and enhanced after participation in the program.

Reliability associated with the Roter Interaction Analysis System (RIAS) adapted for the telemedicine context

Objective This study's purpose was to adapt the Roter Interaction Analysis System (RIAS) for telemedicine clinics and to investigate the adapted measure's reliability. The study also sought to better understand the volume of technology-related utterance in established telemedicine clinics and the feasibility of using the measure within the telemedicine setting. This initial evaluation is a first step before broadly using the adapted measure across technologies and raters. Methods An expert panel adapted the RIAS for the telemedicine context. This involved accounting for all consultation participants (patient, provider, presenter, family) and adding technology-specific subcategories. Ten new and 36 follow-up telemedicine encounters were videotaped and double coded using the adapted RIAS. These consisted primarily of follow-up visits (78.0%) involving patients, providers, presenters, and other parties. Reliability was calculated for those categories with 15 or more utterances. Results Traditional RIAS categories related to socioemotional and task-focused clusters had fair to excellent levels of reliability in the telemedicine setting. Although there were too few utterances to calculate the reliability of the specific technology-related subcategories, the summary technology-related category proved reliable for patients, providers, and presenters. Overall patterns seen in traditional patient–provider interactions were observed, with the number of provider utterances far exceeding patient, presenter, and family utterances, and few technology-specific utterances. Conclusion The traditional RIAS is reliable when applied across multiple participants in the telemedicine context. Reliability of technology-related subcategories could not be evaluated; however, the aggregate technology-related cluster was found to be reliable and may be especially relevant in understanding communication patterns with patients new to the telemedicine setting. Use of the RIAS instrument is encouraged to facilitate comparison between traditional, face-to-face clinics and telemedicine; among diverse consultation mediums and technologies; and across different specialties. Future research is necessary to further investigate the reliability and validity of adding technology-related subcategories to the RIAS. The limited number of technology-related utterances, however, implies a certain degree of comfort with two-way interactive video consultation among study participants. Practice implications Telemedicine continues to increase access to healthcare. The technology-related categories of the adapted RIAS were reliable when aggregated, thereby providing a tool to better understand how telemedicine affects provider–patient communication and outcomes.