Hospital-based Clinic Research Articles

Improving Sickle Cell Patient Appointment Compliance in a Hospital-Based Pediatric Ophthalmology Clinic

This quality improvement initiative aimed to reduce the no-show rate at a hospital-based tertiary sickle cell ophthalmology clinic. Missed appointments place a significant burden on the healthcare system, resulting in prolonged waiting times and underutilized clinical resources that impact the quality of care provided. Individuals with sickle cell disease commonly require multiple appointments to address the myriads of comorbidities associated with their disease. Nevertheless, the sickle cell ophthalmology clinic experienced an alarmingly high no-show rate of 49% from June to September of 2021 despite offering same-day appointments with the hematology clinic. To address this issue, we conducted a study in which we compared the baseline no-show rate with the rate after relocating both clinics to the same floor, aiming to overcome patient-related barriers. Following 3.5 months of the clinics sharing the same floor, the no-show rate decreased to 39%, reflecting a 10% improvement from the baseline rate. In summary, co-locating two related clinics can alleviate patient burdens, foster communication between multidisciplinary specialties, and contribute to an overall improvement in the quality of care and treatment provided.

Low-Magnitude Mechanical Signals to Preserve Skeletal Health in Female Adolescents With Anorexia Nervosa

Malnourished adolescents and young adults with anorexia nervosa (AN) are at high risk for skeletal deficits. To examine whether low-magnitude mechanical signals (LMMS) could preserve bone mineral density (BMD) throughout 6 months in adolescents and young adults with AN. This double-blind, sham-controlled randomized clinical trial, conducted in a hospital-based specialty clinic, assessed female adolescents and young women without medical comorbidity or medication use that would compromise bone health. A total of 837 female adolescents were screened from January 1, 2012, to December 31, 2019, of whom 317 met the study criteria. Data analysis was performed from 2020 to 2024. Platform delivering low-magnitude mechanical signals (LMMS) (0.3 g at 32-37 Hz) or sham (ie, placebo) signals for 10 minutes daily for 6 months. The primary outcome was trabecular volumetric BMD (vBMD) as measured by peripheral quantitative computed tomography of the tibia at baseline and 6 months. Secondary outcomes included cortical vBMD, cross-sectional area (CSA), areal BMD and body composition measured by dual-energy x-ray absorptiometry, and serum bone turnover markers. Forty female adolescents and young women (median [IQR] age, 16.3 [15.1-17.6] years; median [IQR] percentage median BMI for age, 87.2% [81.0%-91.6%]) completed the trial. Total bone vBMD changes were nonsignificant in both groups (95% CI for difference in median change between groups, -57.11 to 2.49): in the LMMS group, vBMD decreased from a median (IQR) of 313.4 (292.9-344.6) to 309.4 (290.4-334.0) mg/cm3, and in the placebo group, it increased from a median (IQR) of 308.5 (276.7-348.0) to 319.2 (309.9-338.4) mg/cm3. Total CSA at the 4% tibia site increased from a median (IQR) of 795.8 (695.0-844.8) mm2 to 827.5 (803.0-839.4) mm2 in the LMMS group, whereas in the placebo group, it decreased from 847.3 (770.5-915.3) mm2 to 843.3 (828.9-857.7) mm2 (95% CI for difference in median change between groups, 2.94-162.53). Median (IQR) trabecular CSA at the 4% tibia site increased from 616.3 (534.8-672.3) mm2 to 649.2 (638.0-661.4) mm2 in the LMMS group but decreased in the placebo group from 686.4 (589.0-740.0) mm2 to 647.9 (637.3-661.9) mm2 (95% CI for difference in median change between groups, 2.80-139.68 mm2). Changes in cortical vBMD, cortical section modulus, and muscle CSA were not significant between groups. The 6-month changes in trabecular and total bone CSA at the tibia 4% site (weight-bearing trabecular bone) were significantly different between groups (these measures increased in the LMMS group but decreased in the placebo group; total bone CSA: 95% CI, 2.94-162.53; P = .01; trabecular CSA: 95% CI, 2.80-139.68; P = .02). Greater increases in body mass index were seen in the placebo group (median [IQR] gain, 0.5 [-0.3 to +2.1]) than in the LMMS group (median [IQR] gain, +0.4 [-0.3 to +2.1]), perhaps due to differences in fat mass accrual. No adverse events occurred related to the LMMS intervention. In this randomized clinical trial of female adolescents and young women with AN, a 6-month LMMS intervention did not yield improvement in tibial trabecular vBMD. However, LMMS led to increases in total and trabecular CSA at the tibia. These results suggest an early positive response of increased bone turnover and trabecular bone quantity due to the LMMS intervention. Future studies should use a longer duration of intervention, consider strategies to optimize adherence, and potentially focus on a more profoundly malnourished patient population. ClinicalTrials.gov Identifier: NCT01100567.

Accelerometer-measured physical activity pattern in older patients with frailty and heart failure

Abstract Background Physical activity (PA) assessed by accelerometers represents a novel method to understand the PA profile of older patients with heart failure (HF). We hypothesized that PA level and pattern vary in HF patients across the spectrum of frailty status. Aim To report the duration, intensity and volume of PA in older patients with HF according to frailty status. Methods We recruited 150 HF patients≥65 years from a hospital-based HF clinic between March and October 2023. Frailty was assessed using the Short Physical Performance Battery (SPPB); patients with SPPB 10-12, 7-9, 4-6 and ≤3 was classified as robust, mildly, moderately and severely frail respectively. To evaluate PA profile, all patients wore a wrist accelerometer on their non-dominant hand for 7 days (24 hours/ day). PA parameters including average acceleration over 24 hours (proxy of volume of activity); time spent in inactive, light, moderate and vigorous intensity activities; intensity gradient (more negative gradient equates to poorer intensity profile) and time of most active continuous bouts of PA, were compared amongst frailty groups. Results 146 participants with good quality accelerometer data were included in the analysis; median age 80 (range 65-94 years), 65% male. Thirty-eight percent had heart failure with reduced ejection fraction (HFrEF); 21% had NYHA class III/IV symptoms; median NT-proBNP was 2040 ng/L (IQR = 1110 - 4930). Frail patients were more likely to be older with more comorbidities; they also had more severe HF symptoms and higher NT-proBNP. Frail patients had lower volume of PA compared to robust patients, evidenced by lower average acceleration (milligravity-mg) over 24 hours [20.4 (robust); 16.0 (mildly frail); 13.5 (moderately frail); 13.2 (severely frail), p<0.001]. PA intensity profile was poorer in frail patients compared to robust patients [median intensity gradient: -2.72 (robust); -2.92 (mildly frail); -3.00 (moderately frail); -3.07 (severely frail), p<0.001]. (Table 1) Frail patients spent more time inactive compared to robust patients [median time spent inactive (minutes): 654 (robust); 689 (mildly frail); 780 (moderately frail); 720 (severely frail), p<0.001]. The median time (minutes) spent in light [225 (robust); 190 (mildly frail); 164 (moderately frail); 159 (severely frail)] and moderate to vigorous activity [62 (robust), 23 (mildly frail), 15 (moderately frail) and 13 (severely frail), p<0.001] were significantly shorter in frail compared to robust patients. (Figure 1) The most active continuous bout of PA of patients across the frailty spectrum appeared to between 10 AM to 2 PM. Conclusion The duration, volume and intensity of PA was generally low in older patients with HF. Worse frailty status was associated with longer duration of physical inactivity, shorter duration of light, moderate or vigorous activity, poorer PA intensity profile and lower volume of PA.

23 Probing bias: Understanding the experiences of Black, Indigenous and People of Colour (BIPOC) caregivers for children with developmental disabilities and their involvement with child protection

Abstract Background In Canada and abroad, a disproportionate number of Black Indigenous and Persons of Colour (BIPOC) experience referral to child protective services (CPS). Children with developmental disabilities, including Autism Spectrum Disorders (ASD) and intellectual disabilities (IDD), are also disproportionately CPS-involved. Recent Canadian research has suggested that almost a quarter of children from a complex care paediatric program are CPS-involved, however there is no known research for ASD/IDD populations seen in a general paediatric clinic. Further, intersections of race/ethnicity and ASD/IDD and CPS involvement have not been examined. Objectives We are conducting a mixed methods study to explore the intersections of race, developmental disabilities and involvement with CPS for our paediatric population. Design/Methods Phase 1: We completed a retrospective cohort study of 349 patients (0-18 years of age) who were seen by a paediatrician and social worker at a large, hospital-based paediatric clinic in Toronto, Canada in 2019. Electronic medical record data was reviewed and the following binary variables (yes/no) coded CPS-involved or referral made, 1+ caregiver identify as BIPOC, and primary language of caregiver(s) not English. Results Preliminary analyses indicate that 11.7% of our sample is CPS-involved. Contrary to over-representation of BIPOC families in the general CPS population, we found that the proportion of families involved with CPS was lower for BIPOC than non-BIPOC families. A similar pattern was observed for primary language, with a trend towards caregivers who reported English as a second language being less likely to be CPS-involved. In our presentation, we will present analyses regarding the type and intensity of CPS involvement and include other demographic characteristics of the family. These findings will be interpreted with findings from Phase 2 (currently underway), which explores lived experiences of 40 caregivers involved with CPS drawn from Phase 1. Conclusion Within an ASD/IDD patient sample, BIPOC families were less likely to be involved with CPS than non-BIPOC families. This finding is in stark contrast to provincial rates that suggest a 2.2 times greater likelihood of CPS-involvement for Black youth. While these results on the surface suggest equity, they may still reflect bias. It is possible that the concerns of BIPOC families are being downplayed in comparison to non-BIPOC families, reducing their access to supportive services.

The relationships between unmet social needs, oral health measures, and dental service utilization in a pediatric population.

Social Determinants of Health (SDoH) have been linked to health, including oral health and oral health behaviors. Objectives of this retrospective records review were to evaluate the relationships between self-reported unmet social needs and (1) oral health measures and (2) dental service utilization in a pediatric population at a hospital-based dental clinic. Children 2-5 years of age whose families had completed a SDoH survey and who had an encounter with one United States (U.S.) urban children's hospital dental clinic within 6 months (± 3 months) of the survey date were included. A chart review was performed, and information was collected about the child's (1) oral health (e.g., plaque level, presence of caries) and (2) dental service utilization (e.g., no-show rates, number of dental surgeries). The data of patients with one or more parental/caretaker-reported unmet social needs were compared with that of patients with no unmet social needs. Inclusion criteria were met by 2646 children. Those with unmet social needs had significantly higher no-show rates at scheduled appointments than those without unmet social needs (p-value <0.001). Patients who identified as African/Black were more likely to report unmet social needs. There was no statistically significant difference in oral health measures of patients with or without unmet social needs. Children in this population demonstrated varying associations between unmet social needs, health measures, and health behaviors, suggesting a likely complicated association between unmet social needs and health.

Assessing Eye Clinic Accessibility: A Study Validating and Applying the SiteWise Survey.

To validate the SiteWise survey as a reliable tool for assessing the accessibility of outpatient ophthalmology clinics for visually impaired patients and to compare accessibility between hospital-based and satellite clinics. This quality improvement study, conducted from January to December 2023, used the SiteWise survey to assess design features in seven satellite and two hospital-based clinics within the Wilmer Eye Institute network. Independent surveyors evaluated elements such as parking, sidewalks, entrances, and interior areas. Reliability was measured using Krippendorf's alpha, and accessibility scores were compared using generalized estimated equations, analyses of variance, and t tests. The SiteWise survey demonstrated high reliability with a Krippendorf's alpha of 0.99. Hospital-based clinics had higher accessibility scores (mean 78.9%) compared to satellite clinics (mean 71.3%, P < 0.05). Areas such as hallways (mean 89%) and waiting areas (mean 87%) scored highest, whereas parking lots/sidewalks (mean 61%) and stairways (mean 61%) scored lowest, indicating significant room for improvement in these areas. The SiteWise tool is reliable and effective in identifying accessibility deficiencies in outpatient ophthalmology clinics. Although indoor areas generally scored well, outdoor and transitional spaces require significant enhancements to improve accessibility for visually impaired patients. This study bridges the gap between basic research and clinical care by providing a validated tool to assess and improve the accessibility of eye care facilities, ensuring they meet the needs of visually impaired patients.

Identifying idiopathic intracranial hypertension in a hospital-based chronic headache population: Utility of magnetic resonance imaging, magnetic resonance venography and trans-orbital sonography.

One of the most underestimated types of chronic headaches is headaches as a result of cerebro-spinal fluid dysregulation disorders. Idiopathic intracranial hypertension (IIH) presents with headache and visual symptoms and usually is associated with papilledema. We identified patients with IIH in a chronic headache population presenting to a hospital-based headache clinic, and studied its associations with clinical, sonographic and magnetic resonance imaging (MRI) findings. Of 168 patients, 141 chronic headache patients were identified and completed the study procedures (semi-structured medical interview, fundus examination, MRI brain with magnetic resonance venography (MRV) and trans-orbital sonography (TOS)). Patients with abnormal findings underwent lumbar puncture for opening pressure. The prevalence of IIH was 27%. IIH patients were of higher age, had gnawing/throbbing headache in the vertex in most cases, and had higher body mass index. Fundus examination had a sensitivity of 79% and a specificity of 98% for the detection of IIH cases. Approximately 23% of IIH patients had no papilledema. The most sensitive MR sign was found to be transverse sinus stenosis. TOS showed optic nerve sheath dilation in 35.7% of IIH without papilledema cases. The prevalence of IIH is high in the chronic headache population and should be suspected in the headache clinic setting, particularly because there is significant overlap with migraine symptomatology. MRI/MR venography and TOS can be useful adjunct tests to identify IIH patients.

Ten years trajectories of estimated glomerular filtration rate (eGFR) in a multiethnic cohort of people with type 1 diabetes and preserved renal function

ObjectivesWe aim to evaluate estimated glomerular filtration rate (eGFR) patterns of progression in a multiethnic cohort of people with type I diabetes mellitus and with baseline eGFR ≥45 mL/min/1.73 m2.DesignObservational...

Low-Dose Triple-Pill vs Standard-Care Protocols for Hypertension Treatment in Nigeria

With the high burden of hypertension in sub-Saharan Africa, there is a need for effective, safe and scalable treatment strategies. To compare, among Black African adults, the effectiveness and safety of a novel low-dose triple-pill protocol compared with a standard-care protocol for blood pressure lowering. Randomized, parallel-group, open-label, multicenter trial conducted in public hospital-based family medicine clinics in Nigeria. Black African adults with uncontrolled hypertension (≥140/90 mm Hg) who were untreated or receiving a single blood pressure-lowering drug. Participants were randomly allocated to low-dose triple-pill or standard-care protocols. The triple-pill protocol involved a novel combination of telmisartan, amlodipine, and indapamide in triple one-quarter, one-half, and standard doses (ie, 10/1.25/0.625 mg, 20/2.5/1.25 mg, and 40/5/2.5 mg), with accelerated up-titration. The standard-care protocol was the Nigeria hypertension treatment protocol starting with amlodipine (5 mg). The primary effectiveness outcome was the reduction in home mean systolic blood pressure, and the primary safety outcome was discontinuation of trial treatment due to adverse events, both from randomization to month 6. The first participant was randomized on July 19, 2022, and the last follow-up visit was on July 18, 2024. Among 300 randomized participants (54% female; mean age, 52 years; baseline mean home blood pressure, 151/97 mm Hg; and clinic blood pressure, 156/97 mm Hg), 273 (91%) completed the trial. At month 6, mean home systolic blood pressure was on average 31 mm Hg (95% CI, 28 to 33 mm Hg) lower in the triple-pill protocol group and 26 mm Hg (95% CI, 22 to 28 mm Hg) lower in the standard-care protocol group (adjusted difference, -5.8 mm Hg [95% CI, -8.0 to -3.6]; P < .001]). At month 6, clinic blood pressure control (<140/90 mm Hg) was 82% vs 72% (risk difference, 10% [95% CI, -2% to 20%]) and home blood pressure control (<130/80 mm Hg) was 62% vs 28% (risk difference, 33% [95% CI, 22% to 44%]) in the triple-pill compared with the standard-care protocol group; these were 2 of 21 prespecified secondary effectiveness end points. No participants discontinued trial treatment due to adverse events. Among Black African adults with uncontrolled hypertension, a low-dose triple-pill protocol achieved better blood pressure lowering and control with good tolerability compared with the standard-care protocol. Pan African Clinical Trials Registry Identifier: PACTR202107579572114.

Eliciting patient past experiences of healthcare discrimination as a potential pathway to reduce health disparities: A qualitative study of primary care staff.

To understand whether and how primary care providers and staff elicit patients' past experiences of healthcare discrimination when providing care. Twenty qualitative semi-structured interviews were conducted with healthcare staff in primary care roles to inform future interventions to integrate data about past experiences of healthcare discrimination into clinical care. Qualitative study. Data were collected via semi-structured qualitative interviews between December 2018 and January 2019, with health care staff in primary care roles at a hospital-based clinic within an urban safety-net health system that serves a patient population with significant racial, ethnic, and linguistic diversity. Providers did not routinely, or in a structured way, elicit information about past experiences of healthcare discrimination. Some providers believed that information about healthcare discrimination experiences could allow them to be more aware of and responsive to their patients' needs and to establish more trusting relationships. Others did not deem it appropriate or useful to elicit such information and were concerned about challenges in collecting and effectively using such data. While providers see value in eliciting past experiences of discrimination, directly and systematically discussing such experiences with patients during a primary care encounter is challenging for them. Collecting this information in primary care settings will likely require implementation of multilevel systematic data collection strategies. Findings presented here can help identify clinic-level opportunities to do so.

Screening and early intervention for substance use during pregnancy: A retrospective case note review of antenatal care records.

Screening for substance use during pregnancy is critical for enhancing maternal health and perinatal outcomes. However, disparities persist in screening and intervention rates within maternity services. This retrospective case note review explored contemporaneous practices around screening and interventions for substance use among pregnant women during routine antenatal care. A random sample of 100 sets of maternity records were reviewed. Eligible cases included any woman attending initial pregnancy assessments at one of two South Australian metropolitan Hospital-based antenatal clinics, from July 2019-September 2020. Screening rates for past and current alcohol, tobacco and other substance use were identified and compared with data from a subset of a nationally representative survey. Intervention details and referral pathways were also assessed. The final sample of eligible cases (n = 93) demonstrated prioritisation of screening for current use, over past use, across all substances (p < 0.001). Screening was most likely for tobacco and least likely for e-cigarettes (p < 0.001). Significant underreporting of past use compared with the benchmark was identified for all substances (except tobacco, p = 0.224). Interventions typically involved written resources, which were usually declined by clients. Despite longstanding recommendations, screening and intervention practices for substance use appear inconsistent. With the recent emergence of vaping, no evidence of updated approaches to identifying e-cigarette consumption in pregnant women was found. Several opportunities for enhancing routine screening and intervention practices within antenatal clinics were identified, and will inform the development of policy directives, targeted training modules, and other resources for health professionals working in these services.

COVID-19 Vaccination in Historically Marginalized Communities: Examining Barriers and Facilitators in a Pediatric Population

ObjectiveCoronavirus disease (COVID-19) hospitalization rates among unvaccinated children are double that of vaccinated children, and this difference is greater among racial and ethnic minority children. Vaccination rates among children remain suboptimal. Few studies have characterized barriers to COVID-19 vaccination among historically marginalized communities. MethodsFrom January 2022 to May 2022, parents, and guardians of children ages 12 months to 18 years presenting for pediatric care at a hospital-based primary care clinic were surveyed about perceptions of COVID-19 vaccines, intentions to vaccinate their child, and trusted sources of information. Results113 parents/guardians participated, with 92% self-identifying with a historically marginalized racial/ethnic group. 54% of respondents either did not plan to vaccinate their child against COVID-19 or were unsure. The obstacles to vaccination most frequently cited were related to: 1) unknown side effects, 2) the rapid development of the vaccine, and 3) unsafe ingredients. Worries about being used as experimental subjects and potential impacts on fertility were also reported. Parents who planned to vaccinate their child reported higher rates of trust in doctors, local clinics, hospitals, and health departments. ConclusionsHigh rates of COVID-19 vaccination hesitancy exist among parents/guardians from historically marginalized groups. Barriers to vaccination were frequently related to side effects, while a high level of trust in healthcare providers as sources of information may be a facilitator. Strategies to improve health outcomes and boost vaccination rates should focus on equipping pediatric healthcare providers with the knowledge and skills necessary to address these known barriers to COVID-19 vaccination.

COVID-19 Disruptions to Social Care Delivery: A Qualitative Study in Two Large, Safety-Net Primary Care Clinics

BackgroundSocial care integration refers to the incorporation of activities into health systems that assist patients with health-related social needs (HRSNs) that negatively impact the health outcomes of their patients, such as food insecurity or homelessness. Social care integration initiatives are becoming more common. The COVID-19 pandemic strained health systems while simultaneously increasing levels of unmet social needs.ObjectiveTo describe the effects of the COVID-19 pandemic on established social care delivery in a primary care setting.DesignWe used qualitative semi-structured interviews of stakeholders to assess barriers and facilitators to social care delivery in the primary care setting during the COVID-19 health emergency. Data was analyzed using a hybrid inductive/deductive thematic analysis approach with both the Consolidated Framework for Implementation Research (CFIR) and the Screen-Navigate-Connect-Address-Evaluate model of social care integration.SettingTwo safety-net, hospital-based primary care clinics with established screening for food insecurity, homelessness, and legal needs.ParticipantsSix physicians, six nurses, six members of the social work team (clinical social workers and medical case workers), six community health workers, and six patients (total N = 30) completed interviews.ResultsFour major themes were identified. (1) A strained workforce experienced challenges confronting increased levels of HRSNs. (2) Vulnerable populations experienced a disproportionate negative impact in coping with effects of the COVID-19 pandemic on HRSNs. (3) COVID-19 protections compounded social isolation but did not extinguish the sense of community. (4) Fluctuations in the social service landscape led to variable experiences.ConclusionsThe COVID-19 pandemic disrupted established social care delivery in a primary care setting. Many of the lessons learned about challenges to social care delivery when health systems are strained are important considerations that can inform efforts to expand social care delivery.

The Impact of Health Status on Health Care Utilization of Children in Foster Care.

This study sought to understand the health status of children in foster care; the relationship between their health status and health care utilization; and demographic and placement factors associated with health care utilization. To estimate relationships between health status and health care utilization, this study used electronic health records from 4976 children in foster care seen at a children's hospital in the southwestern United States, 2017 to 2020. An algorithm classified patients' health status as nonchronic, noncomplex chronic, or complex chronic. Descriptive statistics were used to describe patients and utilization. The χ 2 , Kruskal-Wallis, and pairwise comparison post hoc tests were used to examine relationships between health status and health care utilization. Zero-inflated negative binomial (ZINB) regression further estimated relationships between health status and health care utilization while factoring in demographic and placement characteristics. Within the sample, 35.6% had complex chronic health status. Significant differences were found among health status groups in age, gender, ethnicity, and maltreatment exposure. Both nonparametric pairwise comparisons and the ZINB regression model showed that having complex chronic health was associated with higher utilization of all hospital resources: emergency, admission, primary and specialty care, and various therapies, relative to having noncomplex chronic and nonchronic health. A high percentage of children in foster care had complex chronic health, and these patients used significantly more resources. This study suggests that hospital-based health clinics focused on children in foster care and care coordination may be warranted.

S113 - Provider Perspectives on Facilitators and Barriers to Providing HIV Pre-Exposure Prophylaxis (PrEP) in Hospital-Based Addiction Treatment Bridge Clinics to Women Sex Workers who Use Drugs

S113 - Provider Perspectives on Facilitators and Barriers to Providing HIV Pre-Exposure Prophylaxis (PrEP) in Hospital-Based Addiction Treatment Bridge Clinics to Women Sex Workers who Use Drugs

Real-World Patients' Diagnosis-to-Treatment Journey with Nontuberculous Mycobacterial Pulmonary Disease: A Cross-Sectional Survey.

The incidence and prevalence of nontuberculous mycobacterial pulmonary disease (NTM-PD) are increasing globally. Approximately 80% of NTM-PD cases in Japan and five countries within Europe (Eur5; France, Germany, Italy, Spain, and the UK) are caused by Mycobacterium avium complex (MAC). This study describes the clinical decision-making process associated with the management of patients with NTM-PD in Japan and the Eur5. We analyzed data from a survey conducted between July 2013 and October 2013 among physicians treating patients with NTM-PD in clinical practice to compare the healthcare settings, clinical presentation, and patient management in Japan and the Eur5. Overall, 619 physicians (Japan, 173; Eur5, 446) participated in the survey. Most patients in Japan (85%) and the Eur5 (79%) were diagnosed with MAC-PD. Patients were managed generally in hospital-based outpatient clinics (117/173, 68%) in Japan and research/teaching hospitals affiliated with medical schools (140/446, 31%) in the Eur5. The most common reason for delaying treatment was the patient's symptoms not being considered serious enough for treatment (55/128, 43%) in Japan and awaiting results of antimicrobial susceptibility testing (44/151, 29%) in the Eur5. Culture negativity was less commonly achieved after treatment in patients in Japan versus those in the Eur5 (31% [73/238] vs. 70% [300/426], p < 0.0001). In treatment phases that were either completed or discontinued, the primary goal was symptomatic improvement, followed by achieving culture conversion, in both Japan and the Eur5. Overall, 19% (16/85) of physicians in Japan and 43% (220/511) in the Eur5 were "entirely satisfied" with their patients' treatment outcomes. Similarities and differences exist in the healthcare settings, clinical presentation, and management of patients with NTM-PD in Japan and the Eur5. Insufficient consideration of culture status by physicians, delayed treatment initiation, and symptom-based cessation emphasize the need for educational efforts on the guideline-based strategies.

Implementation of an EHR-integrated web-based depression assessment in primary care: PORTAL-Depression.

To integrate a computerized adaptive test for depression into the electronic health record (EHR) and establish systems for administering assessments in-clinic and via a patient portal to improve depression care. This article reports the adoption, implementation, and maintenance of a health information technology (IT) quality improvement (QI) project, Patient Outcomes Reporting for Timely Assessment of Life with Depression (PORTAL-Depression). The project was conducted in a hospital-based primary care clinic that serves a medically underserved metropolitan community. A 30-month (July 2017-March 2021) QI project was designed to create an EHR-embedded system to administer adaptive depression assessments in-clinic and via a patient portal. A multi-disciplinary team integrated 5 major health IT innovations into the EHR: (1) use of a computerized adaptive test for depression assessment, (2) 2-way secure communication between cloud-based software and the EHR, (3) improved accessibility of depression assessment results, (4) enhanced awareness and documentation of positive depression results, and (5) sending assessments via the portal. Throughout the 30-month observational period, we collected administrative, survey, and outcome data. Attending and resident physicians who participated in the project were trained in depression assessment workflows through presentations at clinic meetings, self-guided online materials, and individual support. Developing stakeholder relationships, using an evaluative and iterative process, and ongoing training were key implementation strategies. The PORTAL-Depression project was a complex and labor-intensive intervention. Despite quick adoption by the clinic, only certain aspects of the intervention were sustained in the long term due to financial and personnel constraints.

Primary care optometry-based diabetic retinopathy review clinics - a new model of care and comparison with virtual diabetic retinopathy clinics.

Given the increasing prevalence of diabetes and diabetic retinopathy (DR) in the UK, this study evaluates a novel primary care optometry-based DR review service against traditional hospital-based virtual DR clinics. In the hospital-based virtual DR service, patients attended for data capture (visual acuity, fundus photography, macular OCT scanning) with asynchronous review at a later data by a hospital clinician. In the primary care optometry DR review clinic, patients attended an optometry practice for a face-to-face(F2F) review (with imaging) by an optometrist with additional training in DR. Data from both clinic types were analysed. Metrics included DR grading, management plans, grading concordance between primary care optometrists and consultant ophthalmologists, and the assessment of "ungradable" retinopathy referrals. One thousand seven hundred and sixty patients attended the virtual clinic between January 2021 and September 2023.954 patients attended the primary care review clinic between August 2022 and September 2023. Grading agreements between primary care optometrists and hospital consultants on those patients referred for consultant opinion were significant with Weighted Kappa scores of 0.61(95% CI 0.52-0.69) for DR grade and 0.69(95% CI 0.56-0.82) for diabetic macular oedema (DMO) status. Additionally, the primary care optometry clinic reported a considerably reduced non-attendance rate of 5%, in contrast to 21% in virtual clinics. The primary care optometry-based DR service emerges as an efficient, safe alternative to hospital services. It offers notable advantages over virtual clinics and addresses a care gap for those unsuitable for virtual consultations. The results highlight the potential of primary care-based models in managing DR.

The effectiveness of social media-based microlearning in improving knowledge, self-efficacy, and self-care behaviors among adult patients with type 2 diabetes: an educational intervention

BackgroundThe purpose of this study is to investigate the impact of social media-based microlearning (SMBM) on enhancing the knowledge, self-care, and self-efficacy behaviors of patients with type 2 diabetes (T2D) receiving care at a hospital-based diabetes clinic in Zahedan, Iran.MethodsThis intervention study was conducted from September 2021 to the end of 2022, with an intervention group (SMBM) and a control group (conventional-based training) consisting of patients with T2D. A total of 80 eligible patients were selected using a convenience sampling method and randomly assigned to either the intervention group (n = 40) or the control group (n = 40). The knowledge level, self-care, and self-efficacy of the samples were assessed before and two weeks after the educational intervention. Data analysis was conducted using SPSS version 24, and independent and paired T-tests were used for analysis.ResultsThe results of the study revealed that after the intervention, the levels of knowledge, self-care, and self-efficacy in the intervention group were significantly higher than those in the control group (p-value < 0.001).ConclusionIn conclusion, the SMBM appears to be an effective tool for improving self-efficacy, self-care, and knowledge among patients with type 2 diabetes.

Collaborative Care for Chronic Pain After Traumatic Brain Injury

Chronic pain after traumatic brain injury (TBI) is prevalent and associated with poor outcomes. By providing multidisciplinary care through expert consultation, a collaborative care (CC) treatment approach may reduce pain interference. To compare CC with usual care (UC) in decreasing pain interference. This randomized clinical trial was conducted from July 2018 through April 2021 at 2 hospital-based academic rehabilitation medicine clinics in Seattle, Washington. Participants included adults with mild-to-severe TBI (at least 6 months before enrollment) and chronic pain. Data analysis was performed from March 30, 2022, to August 30, 2023. The CC intervention (called TBI Care) included up to 12 in-person or telephone visits over 16 weeks with a care manager (CM) who provided person-centered cognitive behavioral treatment. The CM met weekly with members of the expert team to review participants and discuss recommendations to optimize treatment. The primary outcome was pain interference on the Brief Pain Inventory at treatment conclusion (4 months after randomization). Secondary outcomes included pain interference at 8 months; pain severity; symptoms of depression, anxiety, and sleep disturbance; pain-related emergency department visits; community participation; and participant satisfaction. Linear mixed-effects regression was used for analysis. A total of 1379 individuals were screened for eligibility, and 158 were randomized (79 to CC and 79 to UC). The participants were mostly women (92 participants [58%]) with a mean (SD) age of 46.8 (13.2) years and a mean (SD) of 15.3 (3.0) years of education. TBI occurred a mean (SD) of 4.0 (5.9) years (median [IQR], 1.9 [0.8-4.5] years) before enrollment. All TBI severities were included, and of 149 participants for whom TBI severity was known, the majority (97 participants [65%]) had mild TBI. In the CC group, 71 participants (90%) completed at least 11 sessions, and, at 4 months, this group had significantly lower pain interference scores compared with the UC group (mean [SD], 3.46 [2.17] vs 5.03 [2.28]). This difference was maintained at 8 months after randomization, with mean (SD) TBI care pain interference scores of 3.61 (2.22) for CC vs 4.68 (2.51) for UC. At 4 months, there was significantly lower pain severity in the CC group vs UC group (mean [SD] score, 3.63 [1.95] vs 4.90 [1.96]), as well as symptoms of depression (mean [SD] score, 8.07 [5.34] vs 11.31 [6.37]) and anxiety (mean [SD], 6.20 [5.17] vs 9.58 [6.00]). Satisfaction with pain treatment (mean [SD] score, 2.99 [1.23] vs 2.52 [1.25]), clinical care (mean [SD] score, 3.28 [1.00] vs 2.84 [1.26]), and overall health care (mean [SD] score, 3.25 [0.88] vs 2.82 [1.00]) were significantly higher in the CC group vs the UC group; global impression of change was significantly lower in the CC group vs the UC group (mean [SD] score, 2.74 [1.02] vs 3.47 [1.26]) (lower scores denote a better impression of change). In this randomized clinical trial of CC compared with UC for patients with TBI, CC was effective at reducing pain interference and was sustained at 8-month follow-up. Further research is needed to examine the implementation and cost-effectiveness of CC for TBI in other health care settings. ClinicalTrials.gov Identifier: NCT03523923.