Group Visits Research Articles

MicroShunt versus Trabeculectomy for Surgical Management of Glaucoma: A Retrospective Analysis.

This case-control study aims to compare the efficacy, safety, and postoperative burden of MicroShunt versus trabeculectomy. The first consecutive cohort of MicroShunt procedures (n = 101) was matched to recent historical trabeculectomy procedures (n = 101) at two London hospital trusts. Primary endpoints included changes in intraocular pressure (IOP) and glaucoma medications. Secondary outcome measures included changes in retinal nerve fibre layer (RNFL) thickness, rates of complications, further theatre interventions, and the number of postoperative visits. From the baseline to Month-18, the median [interquartile range] IOP decreased from 22 [17–29] mmHg (on 4 [3–4] medications) to 15 [10–17] mmHg (on 0 [0–2] medications) and from 20 [16–28] mmHg (on 4 [3–4] medications) to 11 [10–13] mmHg (on 0 [0–0] medications) in the MicroShunt and trabeculectomy groups, respectively. IOP from Month-3 was significantly higher in the MicroShunt group (p = 0.006), with an increased number of medications from Month-12 (p = 0.024). There were greater RNFL thicknesses from Month-6 in the MicroShunt group (p = 0.005). The rates of complications were similar (p = 0.060) but with fewer interventions (p = 0.031) and postoperative visits (p = 0.001) in the MicroShunt group. Therefore, MicroShunt has inferior efficacy to trabeculectomy in lowering IOP and medications but provides a better safety profile and postoperative burden and may delay RNFL loss.

Complete Telehealth for Multidisciplinary Preoperative Workup Does Not Delay Time to Metabolic and Bariatric Surgery: a Pilot Study.

PurposeThe COVID-19 pandemic accelerated implementation of telehealth throughout the US healthcare system. At our institution, we converted a fully integrated multidisciplinary bariatric clinic from face-to-face visits to entirely telehealth video/telephone visits. We hypothesized telehealth would increase the number of provider/patient encounters and therefore delay time to surgery.MethodsThis is a retrospective review of consecutive patients who underwent total telehealth preoperative workup. Demographics, comorbidities, and surgical characteristics were compared to the same number of consecutive patients who underwent a face-to-face approach 12 months prior, using a Wilcoxon test for continuous variables and chi-square or Fisher’s exact test for categorical variables. Differences between time and surgery were compared using inverse probability of treatment-weighted estimates and number of preoperative visits using Poisson regression with distance to hospital as a confounder. Noninferiority margin for time to surgery was set to 60 days, and the number of visits was set to 2 visits.ResultsBetween March of 2020 and December of 2021, 36 patients had total telehealth workup, and were compared to 36 patients in the traditional group. Age, sex, body mass index, and comorbidities did not differ between groups. The average number of days to surgery was 121.1 days shorter in the telehealth group (90% bootstrap CI [− 160.4, − 81.8]). Estimated shift in the total number of visits was additional .76 visits in the traditional group (90% CI [.64, .91).ConclusionsThe total telehealth approach to preoperative bariatric multidisciplinary workup did not delay surgery and decreased number of total outpatient visits and time to surgery.Graphical abstract

Hip function in patients undergoing conservative treatment for osteonecrosis of the femoral head.

Once collapsed, osteonecrosis of the femoral head (ONFH) generally obtains collapse cessation naturally and surgical intervention can be avoided in the long term. This study aimed to investigate the process of hip function and secondary osteoarthritis changes in ONFH patients undergoing conservative treatment. We included 54 patients with symptomatic ONFH at the first visit with a minimum follow-up of threeyears with conservative treatment. Patients were divided into two groups based on collapse cessation < 3mm (stable group) or progression to > 3mm (progression group). Additionally, we investigated age, sex, body mass index (BMI), etiology, contralateral side hip joint, the Japanese Investigation Committee (JIC) type classification, Harris hip score (HHS), Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), and survival rate with secondary osteoarthritis as the endpoint. The stable and progression groups had 31 and 23 patients, respectively. No significant differences in age, sex, BMI, and aetiology were observed between the two groups, except for the contralateral side hip joint and JIC type classification. The HHS and JHEQ were significantly improved at the final follow-up than at the first visit in the stable group. However, there were no significant differences in HHS and JHEQ at the final follow-up than at the first visit in the progression group. The fiveyear survival rates with secondary osteoarthritis as the endpoint were significantly higher in the stable group (100%) than in the progression group (32.5%). Hip joint function improved by continuing conservative treatment in ONFH patients with collapse cessation < 3mm.

Improved inhaler handling after repeated inhalation guidance for elderly patients with bronchial asthma and chronic obstructive pulmonary disease.

Accurate evaluation of inhaler handling is essential for improved treatment of bronchial asthma (BA) and chronic obstructive pulmonary disease (COPD). Many studies have described the correlation between age, inhalation guidance, and procedure improvement. Elderly patients should receive proper inhalation guidance. This was a retrospective open cohort study conducted at a single hospital with outpatient open pharmacies that provided inhalation guidance to patients of BA and COPD. A total of 525 cases were included in the study. The median age was 71 years with no significant difference between genders (males: 71 ± 16.0 years; females: 72 ± 16.1 years; P = .24). There were 226 males (43.0%) and 299 females (57.0%; P = .03). BA was significantly more prevalent than COPD (P < .001). There was no significant difference in dry powder inhaler (DPI) and pressurized metered-dose inhaler (pMDI) visits in those <60 years of age (P = .23). pMDI was used significantly more often than DPI in those aged 60 to 90 years of age (P < .001). In both <70 and >70 years of age, the most common error with DPI use was improper inhalation speed, which reduced (improved) at the third visit. Gargling errors were most common with DPI use at the second visit and with pMDI at the first visit in both age groups, which subsequently reduced rapidly. Continuous repeated guidance steadily and significantly decreased errors with all devices (P < .001 for DPI, pMDI, and soft mist inhaler). Elderly cases (>70 years of age) should undergo continuous repeated guidance to reduce inhalation errors like inhalation speed and gargling errors.

Comparing exposed and buried Kirschner wires in fixation for pediatric supracondylar humerus fractures: A propensity score-matched study.

To thoroughly compare the outcomes between exposed and buried Kirschner wires (K-wires) in fixation for pediatric supracondylar humerus fractures. We examined patients who underwent surgery at our institution between January 2007 and June 2021. We investigated their age, sex, fracture pattern, number of K-wires used, whether they were exposed or buried, operative time, postoperative complications, number of outpatient visits, duration from surgery to K-wire removal, total length of hospitalization, and perioperative radiographic parameters. After propensity score matching, intergroup comparisons were performed to assess the differences in postoperative complication rate, number of outpatient visits, duration from surgery to K-wire removal, total length of hospitalization, and loss of reduction. Propensity score matching resulted in 43 pairs in both groups. Although more patients complained of skin irritation in the buried K-wire group, there was more backing out of the K-wire in the exposed K-wire group (p < 0.01). There were no significant differences in other complications. There were more outpatient visits in the buried K-wire group (p < 0.01). The duration from surgery to K-wire removal and the total length of hospitalization were significantly longer in the buried K-wire group (p < 0.01). There was no significant difference in the loss of Baumann's angle (p = 0.61), tilting angle (p = 0.48), or the development of rotation (p > 0.99) between groups. More outpatient visits and longer lengths of hospitalization in the buried K-wire group may lead to increased costs and burden on parents.

Leisure constraint and mental health: The case of park users in Ningbo, China

Parks with green spaces afford many opportunities for and encourage a variety of outdoor leisure activities, which improves park users' physical and mental health in Western countries. However, little is known about whether and how leisure constraint factors relate to the mental health of park users in non-Western countries. This study explored the relationship between leisure constraint factors, demographic variables, and park users’ mental health using multivariate multiple regression analysis. Data were collected from June 22 to July 19, 2021, from 506 respondents in seven major parks in Ningbo, China. Analysis yielded five leisure constraint factors (facilities and environment, accessibility, stress, intrapersonal, time) and three mental health factors (social dysfunction, general dysphoria, anxiety) among park users, and further found accessibility and stress among constraint factors to be significant predictors of social dysfunction among mental health factors; in addition, stress and facilities and environment were significant predictors of general dysphoria, and stress was a significant predictor of anxiety, while intrapersonal and time predicted none. Of the demographic variables, group composition, visit frequency, education, and income were significant predictors of social dysfunction; sex and marital status were significant predictors of general dysphoria; and group composition and visit frequency were significant anxiety predictors. The findings have implications for urban managers and policymakers in urban parks and recreation in a Chinese urban park context. Firstly, we found the accessibility constraint factor and visit frequency were positively related to park users' mental health. Hence, managers may consider building more parks and green spaces, providing more urban park information, and holding more activities to reduce accessibility constraints and encourage more frequent urban park uses. Second, the facilities and environment constraint factors, such as old leisure facilities and old-fashioned leisure activities, were associated with lower mental health perceptions. Managers may consider designing more modern, livable, and user-friendly facilities and offer programs and leisure activities to attract more park users. Third, managers may consider holding social gatherings in parks to improve the mental health of solo visitors. Finally, the stress constraint factor was the most significant factor hindering park users' mental health. Therefore, to enhance people's mental health, urban governance should include planning and managing urban environments and make every effort to offer free and accessible urban parks where park users may relieve their daily life pressure and stress.

Multi-sector stakeholder's perceptions of determinants of successful implementation of a pediatric weight management intervention.

BackgroundMulti-sector stakeholder engagement is essential in the successful implementation, dissemination, and sustainability of pediatric weight management interventions (PWMI), particularly in low-income settings where sustainability relies on external policies and reimbursement. The objective of this study was to engage stakeholders (1) to inform the creation of the intervention with adaptations needed for a successful PWMI in a primary care and community setting and (2) to identify barriers and facilitators to implementation and dissemination.MethodsWe sought to examine the perspectives of local, state, and national clinic and community stakeholders during the pre-implementation period of a two-arm, randomized trial of a Health Weight Clinic PWMI conducted in two health centers and a modified—Healthy Weight and Your Child PWMI at two local YMCAs that serve a predominantly lower income, Hispanic community. The Consolidated Framework for Implementation Research interview guide served as a template for the study but was modified to fit the PWMIs and the various professional roles. Interviews were transcribed and analyzed using the framework analysis approach and themes were linked to the CFIR domains and constructs.ResultsTwenty-six stakeholders perceived the following as needed components of a PWMI: a formal curriculum with illustrative examples, a patient- and family-centered program, group visits, and high-quality multidisciplinary personnel. These findings led to the creation of a group visit curriculum, implementation trainings and cross-site collaborative technical assistance. Additionally, creating partnerships between community and clinical organizations, and addressing patient barriers and unmet social needs (i.e., transportation, food) were identified as facilitators to successful implementation. These results led to the creation of community resource guides, connections to community organizations, and screening and referring for unmet social needs. Perceived facilitators of dissemination included proving cost-effectiveness of the PWMI to inform insurance reimbursement for long-term sustainability. Therefore, we collected cost data and engaged with Medicaid officials to discuss reimbursement.ConclusionFindings highlight the importance of engaging multi-sector stakeholders pre-implementation to ensure the components valued are included, ensuring the program minimizes barriers to participation, considering how staff training can improve implementation and how collected outcomes can inform sustainability and dissemination of PWMIs in clinic and community settings.

Traumatic Brain Injury and Risk of Long-Term Nursing Home Entry among Older Adults: An Analysis of Medicare Administrative Claims Data.

Traumatic brain injury (TBI) is a leading cause of injury-related disability among older adults, and there is increasing interest in post-discharge management as this population grows. We evaluated the association between TBI and long-term nursing home (NH) entry among a nationally representative sample of older adults. We identified 207,355 adults aged ≥65 years who received a diagnosis of either a TBI, non-TBI trauma, or were uninjured between January 2008 and June 2015 from a 5% sample of Medicare beneficiaries. The NH entry was operationalized as the first NH admission that resulted in a stay ≥100 days. Time to NH entry was calculated as the difference between the NH entry date and the index date (the date of TBI, non-TBI trauma, or inpatient/outpatient visit in the uninjured group). We used cause-specific Cox proportional hazards models with stabilized inverse probability of exposure weights to model time to NH entry as a function of injury in the presence of death as a competing risk and generated hazard ratios (HR) and 95% confidence intervals (CI). After excluding beneficiaries living in a NH at index, there were 60,600 TBI, 63,762 non-TBI trauma, and 69,893 uninjured beneficiaries in the sample. In weighted models, beneficiaries with TBI entered NHs at higher rates relative to the non-TBI trauma (HR 1.15; 95% CI 1.10, 1.20) and uninjured (HR 1.67; 95% CI 1.60, 1.74) groups. Future research should focus on interventions to retain older adult TBI survivors within the community.

Improving diabetic patients’ adherence to treatment and prevention of cardiovascular disease (Office Guidelines Applied to Practice—IMPACT Study)—a cluster randomized controlled effectiveness trial

BackgroundDespite nationwide improvements in cardiovascular disease (CVD) mortality and morbidity, CVD deaths in adults with type 2 diabetes (T2DM) are 2–4 times higher than among those without T2DM. A key contributor to these poor health outcomes is medication non-adherence. Twenty-one to 42% of T2DM patients do not take blood sugar, blood pressure (BP), or statin medications as prescribed. Interventions that foster and reinforce patient-centered communication show promise in improving health outcomes. However, they have not been widely implemented, in part due to a lack of compelling evidence for their effectiveness in real-life primary care settings.MethodsThis pragmatic cluster-randomized trial randomizes 17 teams in 12 Federally Qualified Healthcare Centers (FQHCs) to two experimental groups: intervention (group 1): Office-Gap + Texting vs. control (group 2): Texting only. Office-GAP (Office-Guidelines Applied to Practice) is a patient activation intervention to improve communication and patient-provider partnerships through brief patient and provider training in shared decision-making (SDM) and use of a guideline-based checklist. The texting intervention (Way2Health) is a cell phone messaging service that informs and encourages patients to adhere to goals, adhere to medication use and improve communication. After recruitment, patients in groups 1 and 2 will both attend (1) one scheduled group visit, (90–120 min) conducted by trained research assistants, and (2) follow-up visits with their providers after group visit at 0–1, 3, 6, 9, and 12 months. Data will be collected over 12-month intervention period. Our primary outcome is medication adherence measured using eCAP electronic monitoring and self-report. Secondary outcomes are (a) diabetes-specific 5-year CVD risk as measured with the UK Prospective Diabetes Study (UKPDS) Engine score, (b) provider engagement as measured by the CollaboRATE Shared-Decision Making measure, and (c) patient activation measures (PAM).DiscussionThis study will provide a rigorous pragmatic evaluation of the effectiveness of combined mHealth, and patient activation interventions compared to mHealth alone, targeting patients and healthcare providers in safety net health centers, in improving medication adherence and decreasing CVD risk. Given that 20–50% of adults with chronic illness demonstrate medication non-adherence, increasing adherence is essential to improve CVD outcomes as well as healthcare cost savings.Trial registrationThe ClinicalTrials.gov registration number is NCT04874116.

Anxiety prior to delivery and birth satisfaction, in primigravidas given an individualised introduction to labour after 37 weeks of gestation: A randomised control trial

: A randomised Controlled trial to assess the role of an individualised introduction to labour given after 37 weeks of gestation in allaying anxiety prior to delivery and birth satisfaction, in primi-gravidas: After obtaining approval from ethics committee, antenatal mothers, booked for delivery in this hospital, who gave written informed consent, were randomized to Group A (Interventional group) and Group B (comparator group). The Anxiety Assessment Scale for Pregnant Woman in Labour (AASPWL) was administered to all participants at first contact in the antenatal clinic, after 37 weeks of gestation by the investigator. The post-intervention AASPWL questionnaire was administered to all participants in the first stage of labour by a blinded assessor. The birth satisfaction of all participants was assessed after delivery using the Birth Satisfaction Scale (BSS) by a blinded assessor in the ward. The difference in mean anxiety score measured in the first stage of labour and during antenatal visit (&amp;#62;37 weeks of gestation) in Group A and Group B was analysed. It was found that the two groups were homogenous, but the increase in anxiety during labour was less in group A compared to group B, however the difference was not statistically significant. The Birth Satisfaction Scale score in the intervention group was significantly higher compared to the comparator group (p&amp;#60;0.001). An individualised structured introduction to labour reduced the AASPWL scores in first-time parturient mothers who received the intervention, compared to mothers who did not receive the intervention. This reduction, however, was not statistically significant. We also found that the individualised structured introduction to labour enhanced the birth satisfaction of first-time parturient mothers, measured by the Birth Satisfaction Scale (BSS) significantly and resulted in higher scores in the subdomains of the BSS.

Reminiscence Therapy as a Potential Method to Improve Psychological Health and Quality of Life in Elderly Hepatocellular Carcinoma Patients: A Randomized, Controlled Trial.

BackgroundReminiscence therapy mitigates psychological issues and improves the quality of life of cancer survivors. However, its role in elderly patients with hepatocellular carcinoma (HCC) is unclear. Thus, we aimed to detect the effect of reminiscence therapy on anxiety, depression, and the quality of life of elderly patients with HCC.MethodsIn total, 106 elderly patients with HCC after resection were randomized in a 1:1 ratio to the reminiscence therapy group (N = 54) and control care group (N = 52) and then received intervention for 12 months. Anxiety and depression were evaluated by the Hospital Anxiety and Depression Scale (HADS) at baseline [Month (M) 0], 3 months (M3), 6 months (M6), 9 months (M9), and 12 months (M12). Meanwhile, quality of life was assessed using the European Organization for Research and Treatment of Cancer quality of life Questionnaire—Core 30 (QLQ-C30) at M0, M6, and M12.ResultsThe HADS for anxiety score at M9 (6.8 ± 2.3 vs. 7.8 ± 2.4, P = 0.039) and M12 (6.6 ± 2.4 vs. 7.8 ± 2.6, P = 0.013) and the anxiety proportion at M12 (27.8% vs. 46.2%, P = 0.050) were reduced in the reminiscence therapy group compared with those in the control care group. Moreover, the HADS for depression score declined at M9 (6.6 ± 2.0 vs. 7.5 ± 2.2, P = 0.025) and M12 (6.3 ± 2.3 vs. 7.7 ± 2.6, P = 0.005), but the proportion of those with depression was not different at each visit (P > 0.05) in the reminiscence therapy group compared with that of the control care group. In addition, the QLQ-C30 global health status score increased at M6 (71.3 ± 12.8 vs. 66.3 ± 12.9, P = 0.048) and M12 (74.5 ± 12.9 vs. 68.2 ± 13.3, P = 0.014) in the reminiscence therapy group compared to that in the control care group.ConclusionReminiscence therapy effectively mitigates anxiety and depression and improves the quality of life of elderly patients with HCC.

Regional variation in healthcare usage for Medicare beneficiaries: a cross-sectional study based on the health and retirement study

ObjectivesTo investigate whether regional variation changes with different beneficiary health insurance coverage types.DesignA cross-sectional study of the Health and Retirement Study (HRS) in 2018 was used.SettingMedicare beneficiaries only covered by...

Impact of a Dental Storybook on Parents' Knowledge of Children's Oral Health: A Randomized Controlled Trial.

PurposeTo evaluate the effectiveness of a dental storybook on parents’ knowledge about oral health of their children and to assess their perception of its effect in reducing dental anxiety levels among their children, as well as improving their oral health knowledge.Patients and MethodsThis was a two-arm parallel, single-blind, randomized controlled trial (RCT) which was performed at the pediatric dental clinics in the Dental University Hospital, King Saud University, Riyadh, Saudi Arabia. Parents of 88 children (6–8 years old) were included in the present study. Parents and their children were randomly divided into two groups as follows: the intervention group (received the storybook and verbal oral hygiene instructions) and the control group (only received verbal oral hygiene instructions; same information included in the book). Three dental visits, including screening, examination/cleaning and treatment, were provided for each child. In the screening visit, baseline parental oral health knowledge was evaluated for all parents. Afterward, parental oral health knowledge was re-evaluated in the examination visit. In the treatment visit, a parental perception questionnaire was administered to parents following treatment to evaluate their satisfaction regarding the use of the storybook in reducing anxiety levels among their children.ResultsThere was a significant improvement in the total knowledge score at the follow-up visit in the intervention group compared to the control group (P<0.0001). Overall, the majority of parents perceived the storybook as a useful source of information, and they found it to be effective in reducing dental anxiety levels among their children.ConclusionThe dental storybook is an effective educational tool that can help parents become more knowledgeable about their children’s oral health. Moreover, parents perceived the storybook as an effective tool for enhancing their oral health knowledge and lowering their children’s dental anxiety.

Edmonton Symptom Assessment Scale may reduce medical visits in patients undergoing chemotherapy for breast cancer.

BACKGROUNDAdjuvant chemotherapy is recommended in high-risk breast cancer. However, no universally accepted guidelines exist on pre-chemotherapy assessment. In particular, the number and frequency of medical visits vary according to each institution’s policy. We hypothesised that the Edmonton Symptom Assessment Scale (ESAS) may have a favourable impact on the pre-treatment assessment in candidates for adjuvant chemotherapy.AIMTo investigate whether the ESAS can be used to safely reduce the number of medical visits in women with breast cancer undergoing adjuvant chemotherapy.METHODSIn a retrospectively prospective matched-pair analysis, 100 patients who completed the ESAS questionnaire before administration of adjuvant chemotherapy (ESAS Group) were compared with 100 patients who underwent chemotherapy according to the traditional modality, without ESAS (no-ESAS Group). Patients of the ESAS Group received additional visits before treatment if their ESAS score was > 3. The primary endpoint was the total number of medical visits during the entire duration of the chemotherapy period. The secondary endpoints were the occurrence of severe complications (grade 3-4) and the number of unplanned visits during the chemotherapy period.RESULTSThe study variables did not statistically differ between patients of the ESAS Group and no-ESAS Group (age P = 0.880; breast cancer stage P = 0.56; cancer histology P = 0.415; tumour size P = 0.258; lymph node status P = 0.883; immunohistochemical classification P = 0.754; type of surgery P = 0.157), except for premenopausal status (P = 0.015). The study variables did not statistically differ between patients of the ESAS Group and no-ESAS Group regarding age, cancer stage, histology, tumour size, lymph node status, immunohistochemical classification, and type of surgery. Unplanned visits during the entire duration of chemotherapy were 8 in the ESAS Group and 18 in the no-ESAS Group visits (P = 0.035). Grade 3-4 toxicity did not differ between the study groups (P = 0.652). Forty-eight patients of the ESAS Group received additional visits due to an ESAS score > 3. The mean number of medical visits was 4.38 ± 0.51 in the ESAS Group and 16.18 ± 1.82 in the no-ESAS group (P < 0.001). With multivariate analysis, women of the ESAS group were more likely to undergo additional visits for an ESAS score > 3 if they were aged 60 or older, received a mastectomy, or had tumour stage II/III.CONCLUSIONThe ESAS score may safely reduce the number of medical visits in candidates for adjuvant chemotherapy for early breast cancer. Our results suggest that the ESAS score may be used for selecting a group of breast cancer patients for whom it is safe to reduce the number of medical visits in the setting of adjuvant chemotherapy. This may translate into several advantages, such as a more rational utilization of human resources and a possible reduction of coronavirus pandemic infection risk in oncologic patients.

"Advancing" Advance Care Planning to Veterans in the Veterans Health Administration.

The completion rate of Advance Directive (ADs) in the Veterans Health Administration (VHA) is unknown. There is substantial literature on the need for effective Advance Care Planning (ACP) that leads to an AD to ensure that health care preferences for patients are known. Advance Directive are essential to consider since ACP, which explains and plans Advance Directive, does not reach all individuals. Health inequities, such as those experienced in rural areas, continue to exist. While ACP may disproportionately affect rural-residing veterans and their providers, a VHA program was specifically designed to increase ACP engagement with rural veterans and to address several systemic barriers to ACP. This descriptive analysis seeks to identify patient, provider, and geographic characteristics associated with higher rates of ACP participation in VHA. An observational examination of the profile of veterans and the types of ACP (e.g., individual or in groups) using administrative data for all beneficiaries receiving VHA health care services in federal fiscal year (FY) 2020 was conducted as part of a national program evaluation. The measures include patient-level data on demographics (e.g., race, ethnicity, gender), unique patient identifiers (e.g., name, social security number), geographic characteristics of patient's location (e.g., rurality defined as Rural-Urban Commuting Areas [RUCA]), VHA priority group; provider-level data (e.g., type of document definition, clinic stop codes, visit date used to verify Advance Care Planning via Group Visits [ACP-GV] attendance; data not shown), and electronic health record note titles that indicated the presence of ACP in VHA (e.g., "Advance Directive [AD] Discussion" note title, "ACP-GV CHAR 4 code"). Pearson's chi-square statistics were used for between-group comparisons based on a two-sided test with a significance level of 0.05. The overall rate of AD discussions among unique VHA users in FY2020 was 5.2% (95% CI: 5.2%-5.2%) and for Advance Care Planning via Group Visits, which targets rural veterans using groups, it was 1.8% (95% CI: 1.8%-1.9%). Advance Directive discussions in VHA are more successful at reaching middle age (M = 64; SD = 16), African Americans, males, veterans living in urban areas, and veterans with a VA disability (Priority Group 1-4). Advance Care Planning delivered in groups is reaching slightly younger veterans under the age of 75 years (M = 62; SD = 15), African Americans, females, disabled veterans (e.g., Priority Group 1-4), and more veterans residing in rural communities compared to the national population of VHA users. Advance Directive discussion rates are low across VHA, yet intentional efforts with ACP via group visits are reaching veterans who are considered underserved owing to residing in rural areas. Advance Care Planning needs to be a well-informed clinical priority for VHA to engage with the entire veteran population and to support the completion of ADs.

Modeling the Likelihood of Low Birth Weight: Findings from a Chicago-Area Health System.

This study presents a statistical model of the incidence of low birth weight (LBW) births in a large, Chicago-area hospital system. The study was undertaken to provide a strategic framework for future health system interventions. Administrative and electronic health records were matched to census Zip Code Tabulation Area (ZCTA) household poverty data for 42,681 births in 2016-2019 at seven system hospitals, serving a diverse patient population. A logistic regression model of LBW incidence was estimated to test the independent significance of maternal sociodemographic characteristics after controlling for clinical risk factors. The incidence of LBW was 6.3% overall but 11.3% among non-Hispanic Black patients as compared to 5.1% among non-Hispanic White patients. LBW incidence ranged from 9.2% for patients from the poorest ZCTA (20% + poor households) compared to 5.6% of patients from the most affluent (< 5% poor) ZCTA. Nulliparous patients, patients with pre-existing chronic conditions, and patients with hypertensive disorders of pregnancy were significantly more likely to have LBW births. After controlling for clinical risk factors and poverty level, non-Hispanic Black patients were still over 80% more likely and to have a LBW birth. Studyfindings reveal the joint effects of social and clinical risk factors. Findings profile our highest-risk populations for targeted interventions. Promising prenatal care redesign programs include pregnancy patient navigators, home and group visits, eHealth telemonitoring, improved mental health screening, and diversification of the maternity care workforce. Decreasing LBW births should be a national public health policy priority and will require major investments in the most impacted communities.

Hypertension Control and Medication Titration Associated With Lifestyle Medicine Virtual Group Visits and Home Blood Pressure Monitoring

Less than a quarter of the 116 million adults with hypertension in the United States have blood pressure (BP) lower than the guideline-recommended goal of 130/80 mmHg. There is a critical need for novel interventions that integrate evidence-based recommendations—such as lifestyle medicine and home BP monitoring (HBPM)—into clinical care. In this study, we tested the hypothesis that a four-part, primary care physician-led Virtual Group Visit (VGV) series combining lifestyle medicine, Health and Wellness Coaching (HWC), and HBPM could lead to a reduction in BP and antihypertensive medications. There was a decrease in systolic (β = −.108 mmHg per day; P = .046) and diastolic (β = −.058 mmHg per day; P = .026) BP. Thirteen of the 22 patients (59%) who started the VGV series on medications had at least one medication dosage reduced or discontinued during the VGV series, and 8 of the 18 patients (44%) who finished the VGV series on medications had at least one medication dosage reduced or discontinued in the 180 days after the VGV series. This pilot study demonstrates for the first time that lifestyle medicine VGVs, coupled with HWC and HBPM, are associated with improved BP control and medication deprescribing.

Initial Impact of the COVID-19 Pandemic on a US Orthopaedic Foot and Ankle Clinic.

Background:In the United States, the COVID-19 pandemic led to a nationwide quarantine that forced individuals to adjust their daily activities, potentially impacting the burden of foot and ankle disease. The purpose of this study was to compare diagnoses made in an orthopaedic foot and ankle clinic during the shelter-in-place period of the COVID-19 pandemic to diagnoses made during the same months of the previous year.Methods:A retrospective review of new patients presenting to the clinics of 4 fellowship-trained orthopaedic foot and ankle surgeons in a major United States city was performed. Patients in the COVID-19 group presented between March 22 and July 1, 2020, during the peak of the quarantine for this city. Patients in the control group presented during the same period of 2019. Final diagnosis, chronicity of symptoms (acute: ≤1 month), and mechanism of disease were compared between groups.Results:A total of 1409 new patient visits were reviewed with 449 visits in the COVID-19 group and 960 visits in the control group. The COVID-19 group had a significantly higher proportion of ankle fractures (8.7% vs 5.4%, P = .020) and stress fractures (4.2% vs 2.2%, P = .031), but a smaller proportion of Achilles tendon ruptures (0.7% vs 2.5%, P = .019). The COVID-19 group had a higher proportion of acute injuries (35.4% vs 23.5%, P < .001).Conclusion:There was a shift in prevalence of pathology seen in the foot and ankle clinic during the COVID-19 pandemic, which may reflect the adoption of different activities during the quarantine period and reluctance to present for evaluation of non-urgent injuries.Level of Evidence:Level III, retrospective cohort study.

Naturopathic Medicine and Group Visits: A Natural Alignment

Group visits are a delivery mode well-suited to the principles of naturopathic medicine. Group visits are cost-effective, allowing practitioners to provide thorough lifestyle education to more participants, an important domain of both prevention and management of health concerns. The interactive nature of group visits adds unique support, motivation and learning opportunities that one-on-one appointments often cannot provide. When structured opportunities are created for reflection, peer exchange and goal setting, the likelihood of behaviour change appears to be enhanced. Group visits may also benefit practitioners, allowing for greater efficiency and reduced risk of burnout, ultimately enabling greater impact. This paper maps the alignment of group visits to naturopathic principles, highlighting benefits, risks and strategies to harness this effective approach to health care.

Cessation of group battlefield acupuncture visits due to COVID-19: a pilot study.

Prior to the COVID-19 pandemic, battlefield acupuncture (BFA) was offered to veterans with chronic pain in multidisciplinary group visits. We aimed to assess the impact of cessation of BFA due to COVID-19 and to determine the utility of different aspects of the group visits for chronic pain management. Participants who had attended at least three BFA group visits completed questionnaires assessing the impact of treatment interruption on pain, overall function and desire to resume treatment. Thirty-nine veterans were surveyed; 49% responded to the questionnaire. Ninety percent (17/19) agreed that BFA was an important part of pain management and that their pain had worsened after treatment interruption. Seventy-four percent (14/19) responded that they were taking more pain medications since BFA had ended. Ninety-five percent (18/19) responded that BFA improved daily function; 79% (15/19) agreed that BFA improved their sleep. Ninety-five percent (18/19) were interested in resuming BFA. Camaraderie was mentioned as the most helpful aspect of the group by 8/19 (42%) of participants. Participation of health psychology and nutrition were each mentioned as a most helpful aspect of the group by 5/19 (26%) of participants. Our results suggest that participants may have believed that BFA, camaraderie, and input from nutrition and health psychology services were important contributors to their pain control. The results also suggest that veterans may have suffered worsening pain, used more pain medications, and had worsening quality of sleep and daily function during the COVID-related clinic disruption, and that they were interested in resumption of the program.