Health Care Contacts Research Articles

Epidemiology, Clinical, and Microbiological Characteristics of Multidrug-Resistant Gram-Negative Bacteremia in Qatar.

Antimicrobial resistance is a global healthcare threat with significant clinical and economic consequences peaking at secondary and tertiary care hospitals where multidrug-resistant Gram-negative bacteria (MDR GNB) lead to poor outcomes. A prospective study was conducted between January and December 2019 for all invasive bloodstream infections (BSIs) secondary to MDR GNB in Qatar identified during routine microbiological service to examine their clinical, microbiological, and genomic characteristics. Out of 3238 episodes of GNB BSIs, the prevalence of MDR GNB was 13% (429/3238). The predominant MDR pathogens were Escherichia coli (62.7%), Klebsiella pneumoniae (20.4%), Salmonella species (6.6%), and Pseudomonas aeruginosa (5.3%), while out of 245 clinically evaluated patients, the majority were adult males, with the elderly constituting almost one-third of the cohort and with highest observed risk for prolonged hospital stays. The risk factors identified included multiple comorbidities, recent healthcare contact, previous antimicrobial therapy, and admission to critical care. The in-hospital mortality rate was recorded at 25.7%, associated with multiple comorbidities, admission to critical care, and the acquisition of MDR Pseudomonas aeruginosa. Resistant pathogens demonstrated high levels of antimicrobial resistance but noticeable susceptibility to amikacin and carbapenems. Genomic analysis revealed that Escherichia coli ST131 and Salmonella enterica ST1 were the predominant clones not observed with other pathogens.

GPs' perspectives on diagnostic tests for children: a qualitative interview study.

Most healthcare contacts for children in the UK occur in general practice. Diagnostic tests can be beneficial in narrowing differential diagnoses; however, there is substantial variation in the use of tests for children in general practice. Unwarranted variation in testing can lead to variation in quality of care and may exacerbate health inequities. To our knowledge, no previous study has tried to understand why variation in testing exists for children in general practice. To explore GPs' perspectives on using diagnostic tests for children in primary care and the underlying drivers of variation. Qualitative study in which semi-structured interviews were conducted with GPs and trainee GPs in England. Interviews were conducted with 18 GPs and two trainee GPs between April and June 2023. The interviews were transcribed and analysed using reflexive thematic analysis. GPs reflected that their approach to testing in children differed from their approach to testing in adults: their threshold to test was higher, and their threshold to refer to specialists was lower. GPs' perceptions of test utility varied, including objective testing for asthma. Perceived drivers of variation in testing were intrinsic (clinician-specific) factors relating to their risk tolerance and experience; and extrinsic factors, including disease prevalence, parental concern and expectations of health care, workforce changes leading to fragmentation in care, time constraints, and differences in guidelines. The findings of this study identify actionable issues for clinicians, researchers, and policymakers to address gaps in education, evidence, and guidance, reduce unwarranted differences in test use, and improve the quality of health care delivered to children in general practice.

Artificial-Intelligence-Based Clinical Decision Support Systems in Primary Care: A Scoping Review of Current Clinical Implementations.

Primary Care Physicians (PCPs) are the first point of contact in healthcare. Because PCPs face the challenge of managing diverse patient populations while maintaining up-to-date medical knowledge and updated health records, this study explores the current outcomes and effectiveness of implementing Artificial Intelligence-based Clinical Decision Support Systems (AI-CDSSs) in Primary Healthcare (PHC). Following the PRISMA-ScR guidelines, we systematically searched five databases, PubMed, Scopus, CINAHL, IEEE, and Google Scholar, and manually searched related articles. Only CDSSs powered by AI targeted to physicians and tested in real clinical PHC settings were included. From a total of 421 articles, 6 met our criteria. We found AI-CDSSs from the US, Netherlands, Spain, and China whose primary tasks included diagnosis support, management and treatment recommendations, and complication prediction. Secondary objectives included lessening physician work burden and reducing healthcare costs. While promising, the outcomes were hindered by physicians' perceptions and cultural settings. This study underscores the potential of AI-CDSSs in improving clinical management, patient satisfaction, and safety while reducing physician workload. However, further work is needed to explore the broad spectrum of applications that the new AI-CDSSs have in several PHC real clinical settings and measure their clinical outcomes.

Risk of Thyroid Cancer in People With Type 1 Diabetes by Autoimmune Thyroid Diseases and Tumor Histology.

Thyroid cancer is the most common endocrine cancer, but little is known about it in type 1 diabetes (T1D) and its potential association with autoimmune diseases. This study aims to assess the risk of thyroid cancer in adults with long-term T1D compared to individuals without diabetes and the proposed association of thyroid autoimmune diseases with thyroid cancer. The study included 4758 individuals with T1D participating in the Finnish Diabetic Nephropathy Study and 12 710 controls. Thyroid cancers were obtained from the Finnish Care Registers for Health Care. 27 (0.57%) individuals with T1D had thyroid cancer compared to 27 (0.21%) in the controls (standardized incidence ratio 2.43; 95% confidence interval 1.59-3.56). The absolute increase in incidence was modest, with a 0.36%-unit rise. This translates to 17 additional cases among 4710 individuals with T1D. Cancer type was papillary in 81.5% of individuals with T1D and 88.9% of the controls; the rest were follicular. In T1D the distribution of hypothyreosis was similar between those with (n = 5, 18.5%) and without (18.1%) cancer, but hyperthyreosis was diagnosed more often with thyroid cancer (n = 3, 11.1%) than without (2.3%, P = .003). None of the thyroid cancers were invasive or had metastatic characteristics. Although there is an excess risk of thyroid cancer, it is only marginally increased (0.36%-unit) in individuals with T1D compared to control individuals and was not associated with increased morbidity or mortality. An overdiagnosis effect due to regular health care contacts is the most likely explanation for the higher risk.

Health Care Contact Days Among Older Cancer Survivors.

Health care contact days-days spent receiving health care outside the home-represent an intuitive, practical, and person-centered measure of time consumed by health care. We linked 2019 Medicare Current Beneficiary Survey and traditional Medicare claims data for community-dwelling older adults with a history of cancer. We identified contact days (ie, spent in a hospital, emergency department, skilled nursing facility, or inpatient hospice or receiving ambulatory care including an office visit, procedure, treatment, imaging, or test) and described patterns of total and ambulatory contact days. Using weighted Poisson regression models, we identified factors associated with contact days. We included 1,168 older adults representing 4.51 million cancer survivors (median age, 76.4 years, 52.8% women). The median (IQR) time from cancer diagnosis was 65 (27-126) months. In 2019, these adults had mean (standard deviation) total contact days of 28.4 (27.6) and ambulatory contact days of 24.2 (23.6). These included days for tests (8.0 [8.8]), imaging (3.6 [4.1]), visits with any clinicians (12.4 [11.5]), and visits with primary care clinicians (4.4 [4.7]), and nononcology specialists (7.1 [9.4]) specifically. Sixty-four percent of days with a nonvisit ambulatory service (eg, a test) were not on the same day as a clinician visit. Factors associated with more total contact days included younger age, lower income, more chronic conditions, poor self-rated health, and tendency to "go to doctor as soon as feel bad." Older adult cancer survivors spent nearly 1 month of the year receiving health care outside the home. This care was largely ambulatory, often delivered by nononcologists, and varied by factors beyond clinical characteristics. These results highlight the need to recognize patient burdens and improve survivorship care delivery, including through care coordination.

Pain management after tonsil surgery in children and adults-A national survey related to pain outcome measures from the Swedish Quality Register for tonsil surgery.

The primary aim of this study was to describe the current practice regarding pain management in relation to tonsil surgery among Ear Nose and Throat (ENT) clinics in Sweden. The secondary aim was to determine the impact of the provider's regime of rescue analgesics on the pain related Patient Reported Outcome Measures (pain-PROMs) from the Swedish Quality Register for Tonsil Surgery (SQTS). A descriptive cross-sectional study originating from a validated web-based questionnaire. The survey enrolled one respondent from each ENT clinic (47/48 participated) nationally. Pain-PROMs from the SQTS, recorded from October 2019 to October 2022, were included (8163 tonsil surgeries). Paracetamol was used by all enrolled ENT clinics as preemptive analgesia. The addition of COX inhibitors was used in 40% of the clinics. Betamethasone was usually administered, to prevent pain and nausea (92%). All clinics gave postdischarge instructions on multimodal analgesia with COX inhibitors and paracetamol. Rescue analgesics were prescribed after tonsillectomy for 77% of adults, 62% of older children, 43% of young children and less often after tonsillotomy. The most frequently prescribed rescue analgesic was clonidine in children (55%) and oxycodone in adults (72%). A high proportion of patients reported contact with health care services due to postoperative pain (pain-PROMs/ SQTS). Tonsillectomy procedures were associated with the highest rates of contacts (children/adolescents 13-15%; adults 26%), while tonsillotomy were associated with lower rates, (5-7% of children/adolescents). There was no significant difference in the frequency of health care contacts due to pain regarding whether clinics routinely prescribed rescue analgesics or not after tonsillectomy. The Swedish analgesic regimen after tonsil surgery is good overall. Nevertheless, there is a need for increased awareness and knowledge to achieve optimal patient recovery. Pain-PROM data demonstrate the call for improvement in pain management after tonsil surgery.

Incidence, Healthcare Resource Use and Costs Associated With Incisional Hernia Repair.

Background: Incisional hernia (IH) is a common complication of abdominal surgery affecting between 12.8% and 30% of patients. In spite of this, rates of IH repair remain low, at around 5% in the literature. We aimed to assess the rate of IH repair in the UK across surgical specialties and the cost burden associated with IH repair. Methods: This is a retrospective observational study of patients undergoing abdominal surgery in England between 2012 and 2022 using the Hospital Episode Statistics (HES) database. Index abdominal surgery was identified between March 2014 and March 2017. Diagnostic and surgical procedure codes were used to identify pre-operative risk factors, index surgeries, IH repair and healthcare contact. Healthcare resource use (HCRU) costs were derived for index surgery and all post-index, non-elective inpatient admissions and outpatient visits using Healthcare Resource Group (HRG) codes within HES. Results: Of 297,134 patients undergoing abdominal surgery, 5.1% (n = 15,138) subsequently underwent incisional hernia repair. By specialty, rates were higher in Colorectal (10.0%), followed by Hepatobiliary (8.2%), Transplant (6.8%), Urological (4.0%), Bariatric (3.5%), Vascular (3.2%) and Gynaecological (2.6%) surgery. Patients undergoing IH repair had more healthcare contacts, longer length of inpatient stays and more A+E visits vs. those with no IH repair post index surgery (83% ≥ 1 A+E visit vs. 69%), as well as higher rates of referral to mental health services (19.8% vs. 11.5%). IH repair was associated with an average HCRU cost of £23,148 compared to £12,321 in patients with no IH repair. Conclusion: Patients undergoing IH repair have a greater morbidity than those not undergoing repair, shown by higher HCRU and more healthcare contacts. Despite this, rates of surgery for IH are low, suggesting that most patients with hernias are not undergoing repair. Emphasis must be placed squarely on primary prevention, rather than cure.

Health care utilization, mental disorders and behavioural disorders among perpetrators of intimate partner homicide in 2000-2016: A registry-based case-control study from Sweden.

Little is known about intimate partner homicide (IPH) perpetrator´s healthcare contacts and mental health problems before the killing. The aim was to compare male and female IPH perpetrators with matched controls from the general population by analysing differences in healthcare utilization and mental and behavioural disorders. This study includes 48 males and 10 females who perpetrated IPH between 2000 and 2016 in the Västra Götaland Region of Sweden. Controls (n = 458) were randomly selected from the general population and matched for sex, birth year and residential area. Data were retrieved from the Swedish National Patient Register and the Western Swedish Healthcare Register. Mental and behavioural disorders were classified according to ICD-10 (F00-F99). The Mann-Whitney U test was used to test for differences in health care utilization and mental and behavioural disorders. Compared to their controls, male perpetrators had more registered contacts with primary care ≤ 30 (p = < .001) and ≤ 365 days (p = .019), respectively, before the homicide; with specialist outpatient care ≤ 30 (p = < .001) and ≤ 365 days (p = < .001), respectively, before the homicide: and with inpatient care ≤ 30 (p = < .001) and ≤ 365 days (p = .024), respectively, before the homicide. Female perpetrators had more specialized outpatient care (p = .040) and inpatient care (p = .003) contacts ≤ 365 days before the homicide, compared to controls. Male perpetrators had at least one mental or behavioral disorder diagnosed in any studied healthcare setting except in inpatient care ≤ 30 days before homicide. Female perpetrators had more mental health disorders diagnosed in specialized outpatient care ≤ 365 days before the homicide (p < .001). Perpetrators had more healthcare contacts and mental disorders one year and one month prior to the homicide compared to their controls. Health care professionals should obtain necessary skills in routinely enquiring about intimate partner violence perpetration.

Consuming Patients' Days: Time Spent on Ambulatory Appointments by People With Cancer.

In qualitative work, patients report that seemingly short trips to clinic (eg, a supposed 10-minute blood draw) often turn into "all-day affairs." We sought to quantify the time patients with cancer spend attending ambulatory appointments. We conducted a retrospective study of patients scheduled for oncology-related ambulatory care (eg, labs, imaging, procedures, infusions, and clinician visits) at an academic cancer center over 1 week. The primary exposure was the ambulatory service type(s) (eg, clinician visit only, labs and infusion, etc.). We used Real-Time Location System badge data to calculate clinic times and estimated round-trip travel times and parking times. We calculated and summarized clinic and total (clinic + travel + parking) times for ambulatory service types. We included 435 patients. Across all service day type(s), the median (IQR) clinic time was 119 (78-202) minutes. The estimated median (IQR) round-trip driving distance and travel time was 34 (17-49) miles and 50 (36-68) minutes. The median (IQR) parking time was 14 (12-15) minutes. Overall, the median (IQR) total time was 197 (143-287) minutes. The median total times for specific service type(s) included: 99 minutes for lab-only, 144 minutes for clinician visit only, and 278 minutes for labs, clinician visit, and infusion. Patients often spent several hours pursuing ambulatory cancer care on a given day. Accounting for opportunity time costs and the coordination of activities around ambulatory care, these results highlight the substantial time burdens of cancer care, and support the notion that many days with ambulatory health care contact may represent "lost days."

Improving TB detection among children in routine clinical care through intensified case finding in facility-based child health entry points and decentralized management: A before-and-after study in Nine Sub-Saharan African Countries.

In 2022, an estimated 1.25 million children <15 years of age developed tuberculosis (TB) worldwide, but >50% remained undiagnosed or unreported. WHO recently recommended integrated and decentralized models of care as an approach to improve access to TB services for children, but evidence remains limited. The Catalyzing Paediatric TB Innovation project (CaP-TB) implemented a multi-pronged intervention to improve TB case finding in children in nine sub-Saharan African countries. The intervention introduced systematic TB screening in different facility-based child-health entry-points, decentralisation of TB diagnosis and management, improved sample collection with access to Xpert® MTB/RIF or MTB/RIF Ultra testing, and implementation of contact investigation. Pre-intervention records were compared with those during intervention to assess effect on paediatric TB cascade of care. The intervention screened 1 991 401 children <15 years of age for TB across 144 health care facilities. The monthly paediatric TB case detection rate increased significantly during intervention versus pre-intervention (+46.0%, 95% CI 36.2-55.8%; p<0.0001), with variability across countries. The increase was greater in the <5 years old compared to the 5-14 years old (+53.4%, 95% CI 35.2-71.9%; p<0.0001 versus +39.9%, 95% CI 27.6-52.2%; p<0.0001). Relative contribution of lower-tier facilities to total case detection rate increased from 37% (71.8/191.8) pre-intervention to 50% (139.9/280.2) during intervention. The majority (89.5%) of children with TB were identified through facility-based intensified case-finding and primarily accessed care through outpatient and inpatient departments. In this multi-country study implemented under real-life conditions, the implementation of integrated and decentralized interventions increased paediatric TB case detection. The increase was driven by lower-tier facilities that serve as the primary point of healthcare contact for most patients. The effect was greater in children < 5 years compared to 5-14 years old, representing an important achievement as the TB detection gap is higher in this subpopulation. (Study number NCT03948698).

Exploring how the uptake of childhood immunisations can be improved in England: A systematic review

Background: Childhood immunisations protect communities against preventable and infectious diseases. Coverage for childhood immunisations in the UK is declining and coverage for the MMR vaccine stands at 85.5%, significantly below the target set by the Department of Health and Social Care to achieve herd immunity and prevent sustained disease transmission. Methods: Three medical databases were searched using PICO, supported by the application of inclusion and exclusion criteria and critical appraisal. Results: Reminder and recall activities are identified as a cost-effective method for improving childhood immunisation uptake but targeted, individualised and family-centred interventions should be utilised to promote access to childhood immunisations for underserved populations. Vaccination data should remain up to date and a child's vaccination status should be reviewed and meaningfully discussed at every healthcare contact and staff involved in immunisation should have access to appropriate education, training and support. Recommendations: Understanding how to provide services and improve vaccine coverage for patients who frequently are not brought is identified as an opportunity for further research, as well as analysing the role of public health teams in identifying local inequalities and supporting GP practices to design and deliver bespoke interventions for their community. It is recommended that communication emphasises the safety and effectiveness of vaccines, while highlighting a child's susceptibility or risk to developing complications. Further research is needed to evaluate how best to communicate this to ensure that the information provided is clear and factual and comprehensible to all parents and carers.

Days spent with healthcare contact by patients with metastatic castrate-resistant prostate cancer in the last year of life.

100 Background: Days spent with healthcare contact while pursuing cancer treatment (i.e., “time toxicity”) may be particularly relevant when life expectancy is most limited. Patients with metastatic castrate resistant prostate cancer (mCRPC) ultimately choose whether to pursue further cancer directed therapies or receive supportive care and reduce expected healthcare contact. We sought to define the evolution of time toxicity over the last year of life in patients with mCRPC. Methods: Contact days, defined as any day with healthcare contact outside the home, were retrospectively assessed and categorized (e.g., infusion, ER visit) in 96 patients at an academic cancer center. The primary objective was to compare contact days in the 90-day period between 12 and 9 months prior to date of death (“first quarter”) and the 90-day period prior to death (“last quarter”) using the Wilcoxon signed rank test. Additional exploratory analyses were performed evaluating the association between clinicodemographic variables and systemic treatments received. Results: There were higher median [IQR] total contact days in the last quarter (6 [2,17]) compared to the first quarter (4 [3,6], p &lt; 0.01), driven by ER visits and hospitalizations. Compared to patients off treatment/supportive care (4 [3,4]) in the first quarter, chemotherapy (5 [4,6], p = 0.02) and radiotherapeutics (5 [4,9], p = 0.03) were associated with greater contact days, but androgen signaling inhibitors were not (3 [2,5], p = 0.20). However, there were no significant differences in contact days between any treatment vs non-treatment in the last quarter. Non-White patients (n = 27) and those without higher education (n = 30) had more contact days in the last quarter (9 [2,19], p &lt; 0.01 for both). Patients who enrolled on hospice 7 days (n = 11) or 30 days (n = 39) before date of death had more contact days in the last quarter than those with earlier enrollment (23 [7,28], p &lt; 0.01; 13 [4,24], p &lt; 0.01 respectively). Conclusions: Healthcare contact was higher in the last 3 months of life due to increased number of days with inpatient level of care. Further studies to define healthcare exposure and time toxicity of mCRPC treatments are warranted to inform patient expectations towards the end-of-life. [Table: see text]

Abstract TP237: Acute Risk Factors Associated With Health Service Use Within 90 Days Before Stroke: A Systematic Review and Meta-Analysis

Background: While traditional risk factors are chronic in nature, it is difficult to predict the risk of stroke with respect to time. Identifying certain acute risk factors, particularly associated with a health service contact, may help to prevent stroke. We performed a systematic review to understand the acute risk factors having health service contact within 90 days before incident strokes. Methods: PubMed, Embase and Scopus were searched for studies within last 10 years (2013- September 2022). Studies selected using PRISMA guidelines underwent quality assessment with Newcastle Ottawa scale. Three reviewers independently reviewed and included case control, case-crossover, self-controlled case series and cohort studies that reported raw data or estimates of association between acute events having healthcare contact within 90 days and stroke. Results: 106 studies across 14 countries were included from 12,628 records. Most studies reported all types of strokes as the outcome, with the most evaluated risk-periods being 30 and 90 days before stroke. Groups of acute risk factors were identified based on the reason for healthcare contact. Surgeries(n=43) and medical conditions(n=37) were the commonest groups identified for contacting health services in the acute period before stroke, followed by medications(n=14) and other reasons(n=12) including vaccinations and pathology tests. Subgroups were identified based on the type of acute risk factor (Figure 1). The most commonly examined acute risk factors included infections, myocardial infarction, cardiac surgeries, use of antipsychotics and influenza vaccines. Detailed meta-analyses summarizing the magnitude of effect under each sub-group will be presented. Conclusion: Potential acute risk factors having healthcare contact within 90 days preceding stroke have been identified. Further research to assess the role of interventions in health services addressing the risk of stroke from these events is warranted.

Pooling of primary care electronic health record (EHR) data on Huntington’s disease (HD) and cancer: establishing comparability of two large UK databases

ObjectivesTo explore whether UK primary care databases arising from two different software systems can be feasibly combined, by comparing rates of Huntington’s disease (HD, which is rare) and 14 common...

P1167 Inflammatory Bowel Disease: a phenome-wide pre- and post-diagnostic association study

Abstract Background Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), is known to be associated with various extra-intestinal manifestations, impacting organ systems beyond the gastrointestinal tract. Identifying comorbidities in IBD and the timing of their development can provide valuable insight into the mechanisms underlying IBD development. Methods We conducted the first population- and disease-wide phenomic association study in IBD, using &amp;gt;6 million ICD-10 coded healthcare contacts from 10 years before and up to 17 years after IBD diagnosis to investigate associations with 1583 diseases. To explore co-morbidities with potential aetiological significance with IBD, we additionally assessed the strength of association with all diseases in the pre-diagnostic compared with the post-diagnostic period. To correct for multiple testing, we adjust our significance threshold (p&amp;lt;0.05) with the Bonferroni correction, resulting in an adjusted p-value of 7.90×10, which we refer to as disease-wide statistical significance. Results We identified 312 disease-wide statistically significant associations with 125 of these diseases appearing up to 10 years before diagnosis. The risk of immune-mediated diseases and extra-intestinal manifestations are among those diseases increased up to 10 years prior to IBD diagnosis (psoriasis: CD-RR: 2.57, 95% CI: 2.00-3.29; UC-RR: 1.54, 95% CI: 1.25-1.87; enteropathic arthropathies: CD-RR: 3.57, 95% CI: 2.65-4.78; UC-RR: 1.8, 95% CI: 1.38-2.32). This was also the case for gastroenterological and liver disorders (gall stones: CD-RR: 1.82, 95% CI: 1.62-2.04; UC-RR: 1.26, 95% CI: 1.15-1.37; acute pancreatitis: CD-RR: 1.83, 95% CI: 1.30- 2.53; UC-RR: 2.27, 95% CI: 1.84-2.79). The risk of cardiometabolic diseases and neuropsychological disorders had increased disease-wide statistical significance both pre- and post-diagnostically, whereas potential sequelae of treatment, such as osteoporosis (CD-HR: 2.56, 95% CI: 2.30-2.86; UC-HR: 1.92, 95% CI: 1.79-2.07) or herpes simplex infections (CD-HR: 4.04, 95% CI: 2.76-5.91; UC-HR: 1.69, 95% CI: 1.2-2.38) were primarily seen post-diagnostically. Of potential aetiological importance to CD, diagnosis with infectious mononucleosis (RR: 1.87, 95% CI: 1.37-2.52) was significantly associated with the pre- compared to the post-diagnostic period. Conclusion Our results demonstrate IBD as an essentially multisystemic disease, particularly manifesting as gastrointestinal, metabolic, immune, and neuropsychological disorders, present up to 10 years prior to IBD diagnosis. Infectious diseases of aetiological interest identified warrant further investigation.

Health Care Contact Days Among Older Adults in Traditional Medicare : A Cross-Sectional Study.

Days spent obtaining health care outside the home can represent not only access to needed care but also substantial time, effort, and cost, especially for older adults and their care partners. Yet, these "health care contact days" have not been characterized. To assess composition of, variation and patterns in, and factors associated with contact days among older adults. Cross-sectional study. Nationally representative 2019 Medicare Current Beneficiary Survey data linked to claims. Community-dwelling adults aged 65 years and older in traditional Medicare. Ambulatory contact days (days with a primary care or specialty care office visit, test, imaging, procedure, or treatment) and total contact days (ambulatory days plus institutional days in a hospital, emergency department, skilled-nursing facility, or hospice facility); multivariable mixed-effects Poisson regression to identify patient factors associated with contact days. In weighted results, 6619 older adults (weighted: 29 694 084) had means of 17.3 ambulatory contact days (SD, 22.1) and 20.7 total contact days (SD, 27.5) in the year; 11.1% had 50 or more total contact days. Older adults spent most contact days on ambulatory care, including primary care visits (mean [SD], 3.5 [5.0]), specialty care visits (5.7 [9.6]), tests (5.3 [7.2]), imaging (2.6 [3.9]), procedures (2.5 [6.4]), and treatments (5.7 [13.3]). Half of the test and imaging days were not on the same days as office visits (48.6% and 50.1%, respectively). Factors associated with more ambulatory contact days included younger age, female sex, White race, non-Hispanic ethnicity, higher income, higher educational attainment, urban residence, more chronic conditions, and care-seeking behaviors (for example, "go to the doctor…as soon as (I)…feel bad"). Study population limited to those in traditional Medicare. On average, older adults spent 3 weeks in the year getting care outside the home. These contact days were mostly ambulatory and varied widely not only by number of chronic conditions but also by sociodemographic factors, geography, and care-seeking behaviors. These results show factors beyond clinical need that may drive overuse and underuse of contact days and opportunities to optimize this person-centered measure to reduce patient burdens, for example, via care coordination. National Institute on Aging.

Healthcare contact days among older adults living with dementia.

For older adults with dementia and their care partners, accessing health care outside the home involves substantial time, direct and indirect costs, and other burdens. While prior studies have estimated days spent by these individuals in or out of hospitals and nursing homes, ambulatory care burdens are likely substantial yet poorly understand. Therefore, we characterized "health care contact days"-days spent receiving ambulatory or institutional care-in this population. We used 2019 Medicare Current Beneficiary Survey data linked to claims for community-dwelling, ≥65-year-old adults with dementia in Traditional Medicare. We measured contact days including ambulatory days (with an office visit, test, imaging, procedure, or treatment) and institutional days (spent in an emergency department, hospital, skilled nursing facility, or hospice facility). We described variation and patterns in contact days. Using multivariable Poisson regression, we identified sociodemographic and clinical factors associated with contact days. In weighted analyses, 887 older adults with dementia (weighted: 2.9 million) had mean (SD) 31.1 (33.7) total contact days/year, of which 21.7 (20.6) were ambulatory. Ten percent had ≥68 contact days in the year. One-third (34%) of ambulatory contact days involved multiple services. In multivariable models, receipt of more ambulatory contact days was associated with younger age (65-74 reference vs. -32.3% [95% CI: -42.2%, -20.7%] for 85+), higher income (>200% Federal Poverty Level [FPL] reference versus -16.6% [95% CI: -26.7%, -5.0%] for ≤200% FPL), and lack of functional impairment (reference versus -14.6% [95% CI: -23.7%, -4.4%]). Each additional chronic condition was associated with 8.2% (95% CI: 6.7%, 9.8%) more ambulatory contact days. Older adults with dementia spent 31 days a year accessing care which was mostly ambulatory. These days varied widely by both clinical and sociodemographic factors. These results highlight the need to reduce patient burden through strategies such as reducing unneeded care, coordinating care, and shifting care to home settings through telemedicine and home care.

Detection and Control of Pregnancy Hypertension Using Self-Monitoring of Blood Pressure With Automated Telemonitoring: Cost Analyses of the BUMP Randomized Trials.

Pregnancy hypertension continues to cause maternal and perinatal morbidity. Two linked UK randomized trials showed adding self-monitoring of blood pressure (SMBP) with automated telemonitoring to usual antenatal care did not result in earlier detection or better control of pregnancy hypertension. This article reports the trials' integrated cost analyses. Two cost analyses. SMBP with usual care was compared with usual care alone in pregnant individuals at risk of hypertension (BUMP 1 trial [Blood Pressure Monitoring in High Risk Pregnancy to Improve the Detection and Monitoring of Hypertension], n=2441) and with hypertension (BUMP 2 trial, n=850). Clinical notes review identified participant-level antenatal, intrapartum, and postnatal care and these were costed. Comparisons between trial arms used means and 95% CIs. Within BUMP 2, chronic and gestational hypertension cohorts were analyzed separately. Telemonitoring system costs were reported separately. In BUMP 1, mean (SE) total costs with SMBP and with usual care were £7200 (£323) and £7063 (£245), respectively, mean difference (95% CI), £151 (-£633 to £936). For the BUMP 2 chronic hypertension cohort, corresponding figures were £13 384 (£1230), £12 614 (£1081), mean difference £323 (-£2904 to £3549) and for the gestational hypertension cohort were £11 456 (£901), £11 145 (£959), mean difference £41 (-£2486 to £2567). The per-person cost of telemonitoring was £6 in BUMP 1 and £29 in BUMP 2. SMBP was not associated with changes in the cost of health care contacts for individuals at risk of, or with, pregnancy hypertension. This is reassuring as SMBP in pregnancy is widely prevalent, particularly because of the COVID-19 pandemic. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03334149.

Real-World Evaluation of the Feasibility, Acceptability and Safety of a Remote, Self-Management Parkinson's Disease Care Pathway: A Healthcare Improvement Initiative.

There is significant unmet need for effective and efficiently delivered care for people with Parkinson's disease (PwP). We undertook a service improvement initiative to co-develop and implement a new care pathway, Home Based Care (HBC), based on supported self-management, remote monitoring and the ability to trigger a healthcare contact when needed. To evaluate feasibility, acceptability and safety of Home Based Care. We evaluated data from the first 100 patients on HBC for 6 months. Patient monitoring, performed at baseline and 6-monthly, comprised motor (MDS-UPDRS II and accelerometer), non-motor (NMSQ, PDSS-2, HADS) and quality of life (PDQ) measures. Care quality was audited against Parkinson's UK national audit standards. Process measures captured feasibility. Acceptability was assessed using a mixed-methods approach comprising questionnaires and semi-structured interviews. Between October 2019 and January 2021, 108 PwP were enrolled onto HBC, with data from 100 being available at 6 months. Over 90% of all questionnaires were returned, 97% were complete or had < 3 missing items. Reporting and communications occurred within agreed timeframes. Compared with baseline, after 6m on HBC, PD symptoms were stable; more PwP felt listened to (90% vs. 79%) and able to seek help (79% vs. 68%). HBC met 93% of national audit criteria. Key themes from the interviews included autonomy and empowerment. We have demonstrated acceptability, feasibility and safety of our novel remotely delivered Parkinson's care pathway. Ensuring scalability will widen its reach and realize its benefits for underserved communities, enabling formal comparisons with standard care and cost-effectiveness evaluation.

Treatment of patients with screen-detected colorectal cancer is less strenuous: a nationwide cohort study with long-term follow-up

ObjectiveDuring the last two decades, organised colorectal cancer (CRC) screening has been widely implemented. It remains to be established if screen-detected CRC (SD-CRC) is associated with reduced long-term requirements for treatment as compared with patients with non-screen-detected CRC (NSD-CRC). Study design and methodsThis nationwide cohort study evaluated differences in treatment and healthcare contacts from the date of diagnosis to two years after comparing patients with SD-CRC and NSD-CRC. Data were collected from national healthcare registers, including patients aged 50–75 years and diagnosed with CRC between January 1st 2014 and March 31st 2018. Analyses were stratified into UICC stages and adjusted for sex, 5-year age groups, type of cancer (colonic/rectal), and Charlson comorbidity index score to address healthy user bias. ResultsIn total, 12,040 patients were included, 4708 with SD-CRC and 7332 with NSD-CRC. In patients with SD-CRC, the duration of hospitalisation and rate of emergency surgery were reduced by 38 % (relative risk [RR] = 0.62) and 66 % (RR = 0.34), respectively. Moreover, this group was characterised by a 75 % reduction in oncological outpatient visits (RR = 0.35) and a reduced number of treatments with chemotherapy (RR = 0.57) and radiotherapy (RR = 0.50). There were no significant differences between the two populations in the rates of metastasectomy and the number of contacts with primary healthcare providers. ConclusionCompared to patients with NSD-CRC, patients with SD-CRC experience less hospitalisation and treatment within the first two years after diagnosis.