Hospital-based Clinic Research Articles

Risk Assessment Tool in Predicting the Therapeutic Outcomes of Antiseizure Medication in Adults with Epilepsy.

Identifying a patient's risk for poor outcomes after starting antiseizure medication (ASM) therapy is crucial in managing epilepsy pharmacologically. To date, there is a lack of designated tools to assess such risks. To develop and validate a risk assessment tool for the therapeutic outcomes of ASM therapy. A cross-sectional study was carried out in a hospital-based specialist clinic from September 2022 to August 2023. Data was analyzed from patients' medical records and face-to-face assessments. The seizure control domain was determined from the patients' medical records while seizure severity (SS) and adverse effects (AE) of ASM were assessed using the Seizure Severity Questionnaire and the Liverpool Adverse Event Profile respectively. The developed tool was devised from prediction models using logistic and linear regressions. Concurrent validity and interrater reliability methods were employed for validity assessments. A total of 397 patients were included in the analysis. For seizure control, the identified predictors include ≥10 years' epilepsy duration (OR:1.87,95% CI:1.10-3.17), generalized onset (OR:7.42,95% CI:2.95-18.66), focal onset seizure (OR:8.24,95% CI:2.98-22.77), non-adherence (OR:3.55,95% CI:1.52-8.27) and having ≥3 ASM (OR:3.29,95% CI:1.32-8.24). Younger age at epilepsy onset (≤40) (OR:3.29,95% CI:1.32-8.24) and neurological deficit (OR:3.55,95% CI:1.52-8.27) were significant predictors for SS. For AE, the positive predictors were age >35 (OR:0.12,95% CI:0.03-0.20), <13 years epilepsy duration (OR:2.89,95% CI:0.50-5.29) and changes in ASM regimen (OR:2.93,95% CI: 0.24-5.62). The seizure control domain showed a good discriminatory ability with a c-index of 0.711. From the Bonferroni (ANOVA) analysis, only SS predicted scores generated a linear plot against the mean of the actual scores. The AE domain was omitted from the final tool because it did not meet the requirements for validity assessment. This newly developed tool (RAS-TO) is a promising tool that could help healthcare providers in determining optimal treatment strategies for adults with epilepsy.

Are Nurse-Led Eczema Clinics Effective in Reducing the Severity of Atopic Dermatitis and Its Impact on Children and Families?

BACKGROUND Initiation and expansion of nurse-led eczema clinics at a large tertiary hospital in Melbourne has improved timely access to treatment and education for many children with eczema and their families. OBJECTIVE The aim of this study was to determine the effectiveness of nurse-led eczema clinics in treating eczema and reducing its impact on quality of life and also the level of parent or guardian satisfaction with the clinical experience. METHODS All families attending two weekly community-based nurse-led eczema clinics and two weekly hospital-based nurse-led eczema clinics were invited to take part in a survey-based evaluation. A parent or guardian completed surveys at initial and follow-up clinic visits, and eczema severity was assessed at both visits using SCORAD. RESULTS There were 342 participants. Eczema severity was reduced by 62% (18 points), and the quality-of-life impact scores fell by at least 50% for individuals and families. More than 90% of parents rated the clinician and overall clinic experience as “excellent” or “very good.” CONCLUSION The nurse-led eczema clinics were effective in reducing the severity of eczema and the negative impact of eczema on the individual and the family unit. The magnitude of this reduction was clinically and statistically significant. Participants' clinic experience was highly positive.

Categories of the Patient-Specific Functional Scale Activities in Chronic Neck Pain and Their Relationship to the Neck Disability Index.

Intoduction: Common outcome measures for chronic neck pain are the Patient-Specific Functional Scale (PSFS) and the neck disability index (NDI). The primary aim was to categorize the top-rated, patient-selected functional activity limitations of the PSFS to determine if there were consistent limited functional activities for individuals with chronic neck pain and how these compared to the constructs of activities on the NDI. The secondary aim was to determine the relationship between scores for individuals who completed both the NDI and PSFS. Design: A retrospective review of data extracted from the electronic medical record, EPIC, within two hospital-based outpatient physical therapy clinics within a health care system. Methods: Retrospective analysis was performed on individual's characteristics, self-selected functional activity limitations, and total scores of the PSFS and NDI. Most common categories of self-selected functional activity limitations were developed by practicing physical therapists. These functional activity limitation categories of the PSFS were compared to the activities of the NDI. Mean PSFS total scores were correlated with the NDI total scores with Spearman's test. Results: Participants were individuals with chronic neck pain from January 2013-September 2018 (n = 2283). Movement-based activities accounted for 60.8% of the functional activity limitations of the PSFS with the top functional activity limitations being cervical motion and exercise (32%). The PSFS total score moderately correlated with NDI (r = -0.50, p = <0.01) which may relate to the differences in constructs of the NDI and the top patient-selected PSFS functional activity limitations found in this analysis. Conclusion: The results suggest that individuals with chronic neck pain present with similar categories of self-selected functional activity limitations that differ from activities of the NDI. Additional research is needed to improve outcome measures to capture patient-selected functional activity limitations and an individual's pain experience.

Feasibility and Acceptability of Antenatal Hepatitis C Screening: A Pilot Study.

Hepatitis C virus (HCV) is not currently included in the United Kingdom routine antenatal screening program, but the latest guidelines from the Centers for Disease Control and Prevention, American Association for the Study of Liver Diseases, and Infectious Diseases Society of America recommend HCV screening for all pregnant women during each pregnancy. The aim of this study was to collect qualitative data on the feasibility and acceptability of antenatal HCV screening in pregnant women at the time of routine antenatal screening at 12 weeks, to estimate patient knowledge about HCV and identify the prevalence of HCV infection in antenatal women. This was a pilot study targeting a single hospital-based antenatal clinic in Birmingham, initially conducted for eight weeks with a further extension of the study period to enhance recruitment to meet the feasibility target of 500 patients. Data collected included demographic and epidemiological details. Pregnant women attending the antenatal unit were given information regarding HCV and antenatal screening for HCV prior to their initial antenatal visit. During the antenatal visit, research nurses provided further information about the study and HCV infection. Consent was obtained for taking part in the study and testing for HCV using blood samples taken at the same time as other routine antenatal screening blood tests. All women who agreed to participate in the study were asked to complete an acceptability and knowledge questionnaire. All women had HCV antibody testing as the primary screening assay. The test result was communicated in writing to the women and their general practitioner. Confirmatory positive antibody tests were followed up with quantitative HCV PCR and genotype analysis. The outcomes of testing were no evidence of HCV infection and evidence of past HCV infection or current HCV infection. Five hundred and forty-nine women were approached in the antenatal clinic; 30 women refused consent while 29 women were excluded from the study (blood tests not performed after consenting, age less than 18 years, and consent form lost). Four hundred and ninety women were included in the study. The median age of the study population was 29 years (range, 18-46). Knowledge about blood-borne viruses was limited; 75% of women had some understanding about antenatal hepatitis B (HBV) and human immunodeficiency virus (HIV) testing. Previous awareness about hepatitis C was reported by 55%. Ninety-one percent of women found the information they were given about hepatitis C helpful. Ninety-six percent of the women included in this study found the counselling they received about HCV useful and felt that the delivery of this information was carried out in an acceptable manner. Once given information about HCV, 99% felt that universal screening for HCV should be implemented. HCV antibody was negative in 489 women. One patient with a positive HCV antibody (prevalence: 0.2%) had a negative HCV PCR. Routine antenatal screening for HCV is not currently recommended in the UK. Our study suggests that antenatal HCV screening would be both feasible and acceptable to most pregnant women attending antenatal clinics. Though the awareness of HCV was low, with appropriate counselling and communication, 99% of pregnant women were in favor of antenatal screening for HCV. Antenatal screening would identify HCV-positive mothers and allow follow-up of their infants so that any infected mothers and infants could be offered effective curative therapy and prevent the progression of liver disease. The inclusion of HCV antenatal screening would complete the blood-borne virus profile and enhance the WHO target to eliminate HCV in the UK.

Assessing mental health transition readiness in youth with medical conditions

PurposeMany youth with medical conditions also have co-occurring mental health concerns. Limited attention has been given to the mental health transition needs of these youth. We explore bringing transition readiness assessment into the mental health care of youth with co-occurring disorders. Design and MethodsMental health transition readiness was assessed in transition-aged youth seen in a hospital-based specialty mental health clinic for youth with co-occurring medical and mental health conditions. Patients and/or parents reported on their awareness of transition policies and experiences. Clinicians formally assessed youth mental health transition readiness using the TRXANSITION Index. ResultsOnly 46.53 % of families knew about the clinic’s transition policy. Less than 1/3 reported their provider ever mentioning transition and only 6.93 % knew the deadline for transfer to adult care. Few patients had a transition goal in their treatment plan, even when required by the payor. By assessing transition readiness, clinicians were able to identify deficits in need of remediation in 95 % of patients. Transition readiness was highest in the following domains of the TRXANSITION Index: Ongoing support (85.15 %), Adherence (78.38 %), and Trade/School (71.29 %). Transition readiness was lowest in New Providers (30.94 %), Rx/Medications (37.99 %), and Insurance (42.57 %). Few knew when their current health insurance coverage would end (10.89 %) or how to get health insurance coverage when they became an adult (11.88 %). Mental health transition readiness and medical condition transition readiness did not differ in a sub-sample of youth with available data, t(14) = −1.33, p =.20. ConclusionMental health transition readiness is suboptimal in youth with co-occurring mental health and medical conditions. Findings point to specific targets for future intervention to improve patient mental health transition readiness and patient/family awareness of transition practices.

Pediatric behavioral health care utilization in integrated primary care and hospital-based clinics during the pandemic – Implications for virtual care

Introduction: The COVID-19 pandemic forced health care organizations and providers to adapt innovative approaches to ensure patient care needs are met. In particular, improving patient access to behavioral health services is essential to improving population health. &#x0D; Methods and Aims: Clinical visit volume and utilization data were analyzed via the Tableau platform for behavioral health visits by providers within the division of Pediatric Psychology at the University of Michigan Health (UM) during the pandemic through the present. UM is a publicly funded academic medical center that manages a total of approximately 2.5 million patient visits per year. Psychologists provide care within hospital-based specialty clinics or primary care clinics, both of which utilize integrated models of care. Unprecedented changes were made with regards to care delivery format and workforce allocation, and the present paper examines the corresponding impact on patient behavior health care. &#x0D; Results: During Fiscal Year 22 (July 2021 to June 2022), 24 pediatric psychology providers completed a total of 8,252 visits within 12,802 available patient slots, a utilization rate of 64.5%. Utilization was significantly higher in primary care clinics (80.9%) than in hospital-based clinics (51.6%), Z = 34.47, p &lt; .00001. Services were delivered virtually in 100% of the 4549 visits completed in primary care and 72.6% of the 3703 completed hospital visits. These data are currently being analyzed for the present Fiscal Year 23. Patient satisfaction data revealed barriers impacting access to care, including scheduling issues, setting up virtual care and managing, technology problems. &#x0D; Conclusions: Utilization data provides strong support for delivery of behavioral health services in primary care via virtual care means. However, patients area likely to encounter significant barriers to initiating and participating in care when systems are designed to exclusively or primarily support remote users. &#x0D;

An Integrated Stroke Transitional Care Intervention Improves Physical Functioning, Self-Management and Patient Experience in Older Adults with Stroke and Multimorbidity: A Multisite Pragmatic Randomized Controlled Trial

Background: The hospital-to-home transition for older adults with stroke is often fragmented, resulting in hospital readmissions and reduced quality of life, patient satisfaction and safety. There is limited evidence for strategies to improve transitions in care for older adults with stroke and multimorbidity. This study aimed to test, in real-world clinical practice, the effectiveness of the Transitional Care Stroke Intervention (TCSI) versus usual care on health outcomes, patient experience, and health and social service use costs in older adults (&gt; 55 years) with stroke and multimorbidity (&gt; 2 chronic conditions).&#x0D; Methods: This pragmatic randomized controlled trial was conducted among older adults with a stroke and multimorbidity discharged from the hospital to the community using outpatient stroke rehabilitation services in two communities in Ontario, Canada. Participants were randomized 1:1 to usual care (control group) or usual care plus the 6-month TCSI (intervention group). The TCSI was delivered virtually by an interprofessional team from hospital-based outpatient stroke rehabilitation clinics (Physiotherapist, Occupational Therapist, Speech Language Pathologist, Registered Nurse, and Social Worker). The TCSI is a complex, integrated intervention which includes care coordination/system navigation support, phone/video visits, monthly interprofessional case conferences, and an online resource to support system navigation. Data analysis was performed by intention to treat. The primary outcome was risk of hospital readmission (all-cause) after 6 months. Secondary outcomes were mental and physical functioning, depressive symptoms, stroke self-management, patient experience, number of hospital days and readmissions, number of ED visits, survival rates to first hospital and ED visit, risk of ED visits, and health and social service use costs. Older adults with stroke were engaged as co-investigators and informed the research design, implementation, and evaluation through participation in the Patient Partner Advisory and the TCSI Steering Committees.&#x0D; &#x0D; Results: Ninety participants were enrolled (44 intervention, 46 control); 11 (12%) participants were lost to follow-up, leaving 79 (39 intervention, 40 control). Most participants were men (60%), with an average of 7 comorbid conditions, and 78% had experienced their first-ever stroke. No significant group differences were seen for the baseline to six-month risk of hospital readmission (all-cause). However, stroke survivors in the intervention group reported higher levels of physical functioning (SF-12 Physical Component Summary Score mean difference: 5.10; 95% CI: 1.58-8.62, p=0.005), stroke self-management (Southampton Stroke Self-Management Questionnaire mean difference: 6.00; 95% CI: 0.51—11.50, p=0.03), and patient experience (Person-Centred Coordinated Care Experiences Questionnaire mean difference: 2.64, 95% CI: 0.81, 4.47, p=0.005) compared with the usual care group. No significant group differences were seen for the other secondary outcomes.&#x0D; Discussion: The TCSI improved physical functioning, stroke self-management and patient experience in older adults with stroke and multimorbidity without increasing total healthcare costs compared to usual care.&#x0D; Conclusion:The results provide evidence for the effectiveness of an integrated intervention to optimize transitional care outcomes for older adults with stroke and multimorbidity receiving outpatient stroke rehabilitation services.&#x0D; Suggestions for future research: Future research is needed to further evaluate this intervention in diverse settings and populations, with a larger sample size and a full economic evaluation. &#x0D; &#x0D; &#x0D;

Quantification and Predictors of Visual Field Variability in Healthy, Glaucoma Suspect, and Glaucomatous Eyes Using SITA-Faster

PurposeThe newly released SITA-Faster (SFR) has significantly shorter testing durations compared to older SITA algorithms, but its variability is uncertain. This study quantifies and establishes threshold limits of intra-subject test-retest variability among normal subjects, glaucoma suspects and manifest glaucoma patients across the 24-2 test grid using SFR. DesignCross-sectional study with prospective longitudinal arm Subjects1426 eyes of 787 patients with normal, suspect, or manifest glaucoma from hospital-based and university-based eye clinics. MethodsTwo SFR tests (T1, T2) per eye at a baseline visit and at two follow up visits. Main outcome measuresPointwise variability measured by test-retest difference in pointwise sensitivity between test 1 and test 2, mean global variability (test-retest variance) measured by average of pointwise variability for each subject, global sensitivity, and reliability indices of each eye. ResultsOf the 1426 eyes, 540 (37.9%) had a diagnosis of glaucoma, 753 (52.8%) were glaucoma suspects and the remaining 133 eyes (9.3%) were healthy. Of 74,152 pointwise sensitivities obtained, the mean test-retest difference was 2.17 ± 2.9 dB while the mean test-retest variance for each subject was 2.17 ± 1.2 dB. Pointwise and global variability increased with worsening threshold sensitivity and MD respectively and was greater for peripheral compared to central test locations. In the longitudinal cohort, there was no significant difference in mean test-retest variance across the three visits (mean variability 2.10 vs 2.16 vs 2.16 dB at visits F0 vs F1 vs F2, repeated measures ANOVA, p = 0.53). Baseline MD (-0.19dB; 95% CI -0.22—0.16; p < 0.0001) and abnormally high sensitivity on glaucoma hemifield test (1.14dB; 95% CI 0.78-1.51; p < 0.0001) were significantly associated with increased variability. Finally, test-retest MD showed minimal change around the recommended 15% false positive cut off threshold. ConclusionThe variability of SFR increases with worsening threshold sensitivity, is stable over time and is greater for peripheral compared to central test locations. Worse baseline MD and abnormally high sensitivity are significant predictors of increased variability. A cut-off value of 15% in false positives may be inappropriate as a threshold for judging test reliability in SFR.

Prevalence and burden of diabetes mellitus-related symptoms in patients with type 2 diabetes mellitus: A cross-sectional study.

Type 2 diabetes mellitus (T2DM) is a significant non-communicable disease in Malaysia, with a prevalence of 18.1%, per the National Health and Morbidity Survey. This study aimed to determine the prevalence and burden of diabetes mellitus-related symptoms and whether these symptoms were addressed by primary care doctors. This 1-month cross-sectional study was conducted at an urban hospital-based primary care clinic in Malaysia. Patients with T2DM were recruited using systematic random sampling. Participants answered a self-administered questionnaire adapted from the Diabetes Symptom Checklist-Revised, which evaluated the sociodemographic characteristics, burden of diabetes mellitus-related symptoms in the past month and post-consultation feedback about symptoms. Data were analysed using SPSS. Four hundred eighteen participants were included, yielding a response rate of 97.7%. Hyperglycaemia was the most prevalent symptom, with 48.1% of the participants reporting a frequent need to empty their bladder. Most participants experienced a low symptom burden, so 56.7% did not report their symptoms to their doctors. The participants who reported their symptoms had a higher symptom burden. Among them, 97.5% indicated that their doctors addressed their symptoms. Approximately 78% reported satisfaction and good coping skills when their symptoms were addressed. Hyperglycaemia was the most prevalent diabetes mellitus-related symptom among the patients with T2DM. The symptom burden was generally low, so most patients did not report their symptoms to their doctors. Those who reported their symptoms had a higher symptom burden. Further studies must explore why patients do not report their symptoms and how doctors address patients' symptoms.

Effect of a Patient Engagement, Education, and Restructuring of Cognitions (PEERC) approach on conservative care in rotator cuff related shoulder pain treatment: a randomized control trial

BackgroundDespite similar outcomes for surgery and physical therapy (PT), the number of surgeries to treat rotator cuff related shoulder pain (RCRSP) is increasing. Interventions designed to enhance treatment expectations for PT have been shown to improve patient expectations, but no studies have explored whether such interventions influence patient reports of having had surgery, or being scheduled for surgery. The purpose of this randomized clinical trial was to examine the effect of a cognitive behavioral intervention aimed at changing expectations for PT on patient-report of having had or being scheduled for surgery and on the outcomes of PT.MethodsThe Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention, was designed to change expectations regarding PT. PEERC was evaluated in a randomized, pragmatic “add-on” trial in by randomizing patients with RCRSP to receive either PT intervention alone (PT) or PT + PEERC. Fifty-four (54) individuals, recruited from an outpatient hospital-based orthopedic clinic, were enrolled in the trial (25 randomized to PT, 29 randomized to PT + PEERC). Outcomes assessed at enrollment, 6 weeks, discharge, and six months after discharge included the patient report of having had surgery, or being scheduled for surgery (primary) and satisfaction with PT outcome, pain, and function (secondary outcomes).ResultsThe average age of the 54 participants was 51.81; SD = 12.54, and 63% were female. Chronicity of shoulder pain averaged 174.61 days; SD = 179.58. Study results showed that at the time of six months follow up, three (12%) of the participants in the PT alone group and one (3.4%) in the PT + PEERC group reported have had surgery or being scheduled for surgery (p = .32). There were no significant differences between groups on measures of satisfaction with the outcome of PT (p = .08), pain (p = .58) or function (p = .82).ConclusionsIn patients with RCRSP, PT plus the cognitive behavioral intervention aimed at changing expectations for PT provided no additional benefit compared to PT alone with regard to patient report of having had surgery, or being scheduled to have surgery, patient reported treatment satisfaction with the outcome of PT, or improvements in pain, or function.Trial registrationThe trial is registered on ClinicalTrials.gov: NCT 03353272 (27/11/2017).

Influence of patient trust in provider and health literacy on receipt of guideline-concordant chronic opioid therapy in HIV care settings.

Persons with HIV (PWH) frequently receive opioids for pain. Health literacy and trust in provider may impact patient-provider communication, and thus receipt of guideline-concordant opioid monitoring. We analyzed baseline data of HIV-positive patients on chronic opioid therapy (COT) in a trial to improve guideline-concordant COT in HIV clinics. Retrospective cohort study. Two hospital-based safetynet HIV clinics in Boston and Atlanta. A cohort of patients who were ≥18 years, HIV-positive, had received ≥ 3 opioid prescriptions from a study site ≥21 days apart within a 6-month period during the prior year and had ≥1 visit at the HIV clinic in the prior 18 months. Adjusted logistic regression models examined whether health literacy and trust in provider (scale scored 11-55, higher indicates more trust) were associated with: (1) ≥ 2 urine drug tests (UDTs) and (2) presence of an opioid treatment agreement. Among 166 PWH, mean trust in provider was 47.4 (SD 6.6); 117 (70 percent) had adequate health literacy. Fifty patients (30 percent) had ≥ 2 UDTs and 20 (12 percent) had a treatment agreement. The adjusted odds ratio (aOR) for a one-point increase in trust in provider was 0.97 for having ≥ 2 UDTs (95 percent CI 0.92-1.02) and 1.03 for opioid treatment agreement (95 percent CI 0.95-1.12). The aOR for adequate health literacy was 0.89 for having ≥ 2 UDTs (95 percent CI 0.42-1.88) and 1.66 for an opioid treatment agreement (95 percent CI 0.52-5.31). Health literacy and trust in provider were not associated with chronic opioid therapy quality outcomes.

Using the Diabetes Care System for a County-Wide Hepatitis C Elimination: An Integrated Community-Based Shared Care Model in Taiwan.

Despite the serious risks of diabetes with hepatitis C virus (HCV) infection, this preventable comorbidity is rarely a priority for HCV elimination. We aim to examine how a shared care model could eliminate HCV in patients with diabetes (PwD) in primary care. There were 27 community-based Diabetes Health Promotion Institutes in each township/city of Changhua, Taiwan. PwD from these institutes from January 2018 to December 2020 were enrolled. HCV screening and treatment were integrated into diabetes structured care through collaboration between diabetes care and HCV care teams. Outcome measures included HCV care continuum indicators. Township/city variation in HCV infection prevalence and care cascades were also examined. Of the 10,684 eligible PwD, 9,984 (93.4%) underwent HCV screening, revealing a 6.18% (n = 617) anti-HCV seroprevalence. Among the 597 eligible seropositive individuals, 507 (84.9%) completed the RNA test, obtaining 71.8% positives. Treatment was initiated by 327 (89.8%) of 364 viremic patients, and 315 (86.5%) completed it, resulting in a final cure rate of 79.4% (n = 289). Overall, with the introduction of antivirals in this cohort, the prevalence of viremic HCV infection dropped from 4.44% to 1.34%, yielding a 69.70% (95% credible interval 63.64%-77.03%) absolute reduction. Although HCV prevalence varied, the care cascades achieved consistent results across townships/cities. We have further successfully implemented the model in county-wide hospital-based diabetes clinics, eventually treating 89.6% of the total PwD. A collaborative effort between diabetes care and HCV elimination enhanced the testing and treatment in PwD through an innovative shared care model.

Impact of a Pharmacist-Managed Telemedicine Pharmacotherapy Clinic in the Era of COVID-19

Purpose: Telemedicine has been essential during the coronavirus disease 2019 (COVID-19) pandemic. In March 2020, pharmacist-led chronic disease state management services at our family care centers and primary care clinics were converted to telemedicine. This study aimed to determine the impact of expanding telemedicine services on appointment adherence, clinical outcomes, and financial reimbursement. Methods: This was a single-center, retrospective, quasi-experimental study of the impact of expanding telemedicine services on adult patients with diabetes, hypertension, and/or hyperlipidemia. The study included patients scheduled with a pharmacist at a hospital-based (HB) or physician-based (PB) clinic. The primary outcome was the difference in the mean no-show rate. The secondary outcomes were differences in mean change in HbA1c, LDL, blood pressure, and reimbursement. Mean differences between pre- and post-telemedicine groups of each clinic were measured for all outcomes. Results: The mean difference (SE) in the no-show rate in the HB clinic was -12.09% (4.862; P = .014), compared to 2.88% (3.656; P = .431) in the PB clinic. The mean difference (SE) in the change in HbA1c in the HB clinic was .00% (.338; P = .992), compared to .01% (.239; P = .945) in the PB clinic. The mean difference (SE) in reimbursement in the HB clinic was $1.93 (4.209; P = .647), compared to $20.46 (3.210; P < .0001) in the PB clinic. Conclusion: Expansion of pharmacy telemedicine services provided evidence for improved appointment adherence in the HB clinic and increased reimbursement in the PB clinic. No change in healthcare outcomes was observed.

Appropriate usage of post-exposure prophylaxis-in-pocket for HIV prevention by individuals with low-frequency exposures.

PEP-In-Pocket (Post-Exposure Prophylaxis-In-Pocket, or "PIP") is a biobehavioural HIV prevention strategy wherein patients are proactively identified and given a prescription for HIV post-exposure prophylaxis (PEP) medications to self-initiate in case of high-risk exposures. We evaluated this strategy in a prospective observational study at two hospital-based clinics in Toronto, Canada. HIV-negative adults using PIP underwent chart review and completed quarterly electronic questionnaires over 12months. The primary objective was to quantify appropriate PIP initiation, defined as starting PIP within 72h of a high-risk exposure. Secondary objectives were to quantify HIV seroconversions, changes in sexual risk behaviour, sexual satisfaction, and satisfaction with the PIP strategy. From 11/2017 to 02/2020, 43 participants enrolled and completed ≥1 questionnaire. PIP was self-initiated on 27 occasions by 15 participants, of which 24 uses (89%) were appropriate, 2 were unnecessary, and 1 was for an unknown exposure. Chart review identified no inappropriate non-use. Over 32 person-years of testing follow-up, we observed zero HIV seroconversions. Sexual risk declined modestly over follow-up, with a HIRI-MSM (HIV Incidence Risk Index for MSM) change of -0.39 (95% CI = -0.58, -0.21 per 3months, p < .001). Sexual satisfaction was stable over time. At 12months, 31 (72%) remained on PIP, 8 (19%) had transitioned to pre-exposure prophylaxis and 4 (9%) were lost-to-follow-up. Among participants who remained on PIP and completed questionnaires at 12months, 24/25 (96%) strongly/somewhat agreed that PIP decreased their anxiety about contracting HIV and 25/25 (100%) strongly/somewhat agreed that they would recommend PIP to a friend. PIP is a feasible HIV prevention strategy in carefully selected individuals at modest HIV risk.

Demographic and socioeconomic disparities in the hybrid ophthalmology telemedicine model.

As telemedicine use expands, it is important to evaluate demographic and socioeconomic disparities among patients receiving ophthalmic care through new hybrid telemedicine models. To evaluate whether there are demographic and socioeconomic disparities in the delivery of the hybrid telemedicine model. Retrospective, cross-sectional, case-control analysis of patient encounters from April to December 2020. A single, academic, hospital-based eye clinic in Boston, Massachusetts. Electronic medical records of all patient encounters from April to December 2020 were reviewed and categorized into hybrid, virtual-only, and standard in-person visits. Patient-level data for all visits were extracted including age, sex, race/ethnicity, primary language, Area Deprivation Index (ADI), insurance type, and marital status. Visit-level data for all hybrid visits were also extracted from the medical record including the visit dates and patient adherence. Demographics for the cohort of patients with at least one no-show visit were compared with demographics for the cohort of patients who only had completed visits. The primary study outcomes were the differences in demographic characteristics between the hybrid visit show and no-show groups. The secondary outcomes included demographic characteristics of patients who did not complete their hybrid visit versus a time-matched cohort of patients who did not complete their standard in-person visit. Continuous variables for patient characteristics were compared with independent samples t-tests and categorical variables were compared using Pearson chi-square tests. Multivariate logistic regression was used to examine the differences between the cohorts. Variables with missing values other than suppressed ADI values were imputed using multiple imputations by chained equations. Of a total of 1025 patients who were scheduled for a hybrid visit, 145 (14.1%) patients failed to complete their visit. Primary language and insurance were found to be statistically different between patients who completed and did not complete their hybrid visits. More English speakers and fewer Haitian Creole speakers completed their hybrid visits (p = 0.007) while more patients with private insurance and fewer patients with Medicaid completed their hybrid telemedicine visits (p = 0.026). No associations were found between hybrid telemedicine visit adherence and age, sex, race/ethnicity, marital status, or ADI. When the 145 patients who failed to complete their hybrid visits were compared to a time-matched cohort of patients who failed to complete their standard in-person visit, we found that patients who missed hybrid visits were similar to those who missed standard in-person visits except for patients insured by Medicare. These patients were more likely to miss a hybrid visit than a standard in-person visit (Odds Ratio 2.199, 95% confidence interval 1.136-4.259, p = 0.019). No associations were found between patient nonadherence with hybrid telemedicine versus with standard in-person visits based on age, sex, primary language, race/ethnicity, marital status, or ADI. The hybrid telemedicine model was associated with insurance and language-based disparities. Patients with non-English primary language and Medicaid recipients were more likely to miss a hybrid visit than their counterparts. Our findings support developing deliberate interventions to ensure hybrid telemedicine care is delivered equitably to all patients.

Feasibility, efficacy and safety of early and rapid initiation of evidence-based treatment for patients with HFrEF- a real world experience of the "four drugs in four weeks" strategy

Abstract Background Evidence-based treatment for heart failure with reduced ejection fraction (HFrEF) is associated with improved outcomes for patients. However, there is uncertainty as to how treatment with these foundational drugs should best be implemented. Objectives To evaluate whether early and rapid initiation of medications for patients with HFrEF using a 4 x 4 approach (4 pillars of HFrEF therapy in 4 weeks) is feasible, safe, and effective. Methods We recruited consecutive patients from April to July 2021 with a new diagnosis of HFrEF who were either assessed at our urgent HF clinic or had a recent HF hospitalisation. All patients had regular reviews (every 1-2 weeks, combination of telephone and face-to-face) at our hospital-based HF clinic by a HF consultant or senior HF specialist nurse for initiation and up-titration of guideline-recommended therapy including angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor neprilysin inhibitor (ARNI), beta blockers (BB), mineralocorticoid receptor antagonist (MRA) and sodium glucose co-transporter inhibitor (SGLT2i). Results Of 100 patients approached, 19 patients were considered unsuitable for the 4x4 pathway (79% due to severe frailty or significant comorbidities). 81 patients were enrolled (61% male, median (IQR) age: 73 (67-82) years, median (IQR) NT-proBNP: 3764 (1597-7487) ng/L); 39 (48%) patients achieved "4 drugs at 4 weeks". Of the 42 patients who did not, 33 (79%) had contraindication to one or more of the drug classes at the outset, including renal impairment (28%), bradycardia (18%) and hyperkalaemia (15%). Patients who did not achieve "4 drugs at 4 weeks" were older, more symptomatic, and had higher NTproBNP and worse renal function. During a median follow up of 554 days, 6 (7%) patients died and 31 (38%) experienced the combined outcome of all-cause death / hospitalisation. Patients who did not achieve "4 drugs at 4 weeks", compared to those who did, had a 2.5 fold increased risk of the combined outcome (Figure 1). They were also less likely to be up-titrated to targeted doses of HF medications (Figure 2). There was noticeable improvement in NTproBNP with no significant change in renal function or systolic BP in both groups. Compared to those who did not achieve "4 drugs at 4 weeks", those who did showed larger improvement in LVEF (8% vs 2%) at 6 months. 5 patients (6%) experienced significant side effects during medication up-titration: 4 had symptomatic hypotension and 1 had hyperkalaemia. Conclusion The 4x4 strategy is clinically feasible and safe when implemented in selected patients with HFrEF and may be associated with improved outcomes. Our results support larger studies to further investigate the generalisability and effectiveness of the 4x4 strategy.

Worse long term prognosis in new onset HFpEF treated in HF clinics compared to HFrEF and HFmrEF patients; reflecting need for effective treatment in HFpEF. Results from the Stockholm PREFERS Study

Abstract Background/Introduction Few contemporary studies are available for long term outcome in patients with new onset heart failure (HF) of the three 3 phenotypes; HF with preserved ejection fraction (HFpEF), mildly reduced (HFmrEF) and reduced EF (HFrEF). The Stockholm PREFERS study (Preserved and Reduced Ejection Fraction Epidemiological Regional Study) included new onset HF patients between 2014-18. Purpose To report and compare long term outcomes for patients with new onset HFpEF, vs HFmrEF and HFrEF. Methods Totally 547 patients, HFpEF n = 137 (25%), HFmrEF n = 61 (11%) and HFrEF n = 349 (64%) were included and followed to end of August 2021. Time to total and cardiovascular (CV) mortality and CV mortality and first HF hospitalizations were compared by log rank test and Cox regression models. All patients were followed at hospital-based HF clinics for guideline directed information and treatment. HFpEF patients were recommended optimal treatment for comorbidities including hypertension, diabetes, ischemic heart disease and atrial fibrillation, and RAAS-inhibition or diuretics. Primary endpoint: CV mortality and HF hospitalizations. Results Mean age was 76 (HFpEF), 71 (HFmrEF) and 67 (HFrEF) years (p&amp;lt;0.001). Female sex 49% (HFpEF), 30% (HFmrEF) and 30% (HFrEF) (p&amp;lt;0.001). Median follow up was 3.8 years (IQR 3.0;4.7). Median EF was 55%, 45% and 30% in HFpEF, HFmrEF, and HFrEF, respectively (p&amp;lt;0.001). All-cause mortality was 13% (n = 70), and CV mortality 7.3% (n = 40). The overall CV hospitalization rate was 13.9% (n = 76). The combined endpoint of CV mortality and HF hospitalizations was 21.2% (n = 116) and higher in HFpEF compared to HFrEF (Univariate Hazard ratio (HR) 2.3 (95% CI 2.0-2.5, p&amp;lt;0.001) and vs HFmrEF (HR 2.5; 2.1-2.6, p&amp;lt;0.001). In analysis adjusted for age, sex and diabetes, HFpEF had worse outcome vs HFrEF and HFmrEF (HR 1.5; 0.2-2.0, p&amp;lt;0.05). Conclusions New onset HFpEF patients have worse long term outcome vs new onset HFrEF and HFmrEF patients. There is a need for effective evidence based treatment in HFpEF.Figure 1

Palliative Care and Advance Care Planning Integration into the Dialysis Team: A Quality Improvement Intervention at a Hospital-Based Outpatient Hemodialysis Clinic

Palliative Care and Advance Care Planning Integration into the Dialysis Team: A Quality Improvement Intervention at a Hospital-Based Outpatient Hemodialysis Clinic

72 Neurocognitive and Emotional Symptoms of Pediatric Concussion Due to Physical Assault: A Case Series

Objective:Much of the pediatric concussion literature focuses on sports and recreation related injuries, while there is a relative paucity of research on the cognitive and psychological sequelae associated with assault. However, it is understood that children with assault-related injuries demonstrate a longer recovery time. This case series reviews the data of four teenagers who were administered cognitive, emotional, and behavioral screeners after sustaining an assault related concussion.Participants and Methods:Four pediatric female patients (ages 13,14,15,15) with a recent history of concussion due to physical assault presented for evaluation at a hospital-based concussion clinic. All four patients were administered a computerized cognitive screener as well as self-report measures for mood, anxiety, post-traumatic stress disorder (PTSD), and sleep disturbance.Results:All four of the pediatric cases reported significant symptoms of PTSD, depression, anxiety, and sleep disturbance. For all four patients, the most notable problems across cognitive performance measures were observed in the areas of simple and complex attention.Conclusions:Results of this case series revealed clinically significant anxiety, depression, PTSD-symptoms, and sleep disturbance in conjunction with poor simple and complex attention. These pediatric cases illustrate the potential link between assault-related concussions, emotional and behavioral symptoms, and cognitive functioning. Furthermore, assault-related concussions may elevate risk toward attentional problems associated with psychological distress. Early evaluation of PTSD and mood related symptomatology is suggested to best support treatment planning and recovery in this population. Future studies are needed to explore the nature of the relationship between cognitive and emotional sequelae in patients who present with assault-related concussions.

16 Relative Contributions of Motor and Non-Motor Symptoms to Caregiver Burden in Parkinson’s Disease Patients Being Evaluated for Deep Brain Stimulation

Objective:Parkinson’s disease (PD) is a neurodegenerative disorder affecting over 10 million people worldwide. PD is characterized by both motor (e.g., tremor, rigidity, and bradykinesia) and non-motor (including cognitive impairment and neuropsychiatric symptoms such as apathy, disinhibition, executive dysfunction) symptoms. Caregiver burden is prevalent in those providing care for patients with PD and can result in negative health complications. Past work shows associations between motor symptoms, cognitive impairment, neuropsychiatric symptoms, and caregiver burden in PD. However, their relative contributions are poorly understood. This study examined these relationships, hypothesizing that while motor symptoms, cognitive impairment, and neuropsychiatric symptoms would all affect caregiver burden, neuropsychiatric symptoms would predict burden above and beyond the contribution of the other factorsParticipants and Methods:Participants were 42 people living with PD who were assessed at a hospital-based tertiary movement disorders specialty clinic for deep brain stimulation (DBS) candidacy evaluation with their caregiver. Motor exam was assessed by a PD specialist using the Unified Parkinson’s Disease Rating Scale (UPDRS). The Mini Mental State Examination (MMSE) assessed global cognition. Frontal Systems Behavior Scale (FrSBe) Family Form captured caregiver ratings of neuropsychiatric symptoms under 3 subscales: apathy, disinhibition, and executive dysfunction. The Multidimensional Caregiver Strain Index (MCSI) captured caregiver burden. Linear regression analyses examined relationships between caregiver burden (MCSI) and motor symptoms (UPDRS), cognitive impairment (MMSE), and neuropsychiatric symptoms (FrSBe).Results:Using linear regression analyses, cognitive impairment (R2=0.08, F(1,41)=4.42, p=0.04) and neuropsychiatric symptoms (R2=0.35, F(1, 41)=21.0, p&lt;0.01) predicted caregiver burden but motor symptoms did not (R2=0.03, F(1,41)=1.30, p=0.26). Hierarchical linear regression revealed that neuropsychiatric symptoms predicted caregiver burden above and beyond the contribution of cognitive impairment (AR2=0.28, AF(1)=12.7, p=0.001), accounting for an additional 28% of the variance in caregiver burden. Follow-up linear regression to examine the relationships between caregiver burden and the FrSBe subscales indicated that apathy (p&lt;0.001), versus disinhibition (p=0.16) and dysexecutive behaviors (p=0.80), was the driver of the significant relationship.Conclusions:Consistent with our hypothesis, results revealed that cognitive impairment and neuropsychiatric symptoms (specifically apathy) were independent predictors of caregiver burden, with neuropsychiatric symptoms predicting caregiver burden above and beyond the contribution of cognitive impairment. Somewhat surprisingly, motor symptoms were not a predictor of caregiver burden contrary to some previous research, though findings are mixed. Results highlight the importance of assessing for neuropsychiatric symptoms in PD, which may be overlooked by care providers relative to motor or cognitive symptoms, but which appear stressful to caregivers. Future directions include reexamining results in a larger more heterogenous sample including people living with PD at different disease stages (i.e., everyone in the present sample had severe enough symptoms to be considering DBS). Cognitive measures of executive functioning (which are more specific to PD than measures of global cognition) should also be included in future works. Development of supportive caregiver interventions specifically targeting apathy in PD may be useful. Longitudinal designs would be helpful to reexamine relationships following DBS surgery, as there are some reports of increased neuropsychiatric symptoms following the procedure.