Hospital-based Clinic Research Articles

Same day access: a viable alternative for outpatient clinical care

To present our experience with a novel, same-day access (SDA) scheduling model for outpatient clinical care in oral and maxillofacial surgery (OMS). The primary outcome variable was OMS patient scheduling in a hospital-based outpatient clinic. Patients were given a specific appointment time to be seen the same day they contacted the clinic. This SDA clinic was compared to previous patient scheduling models for patient satisfaction, appointment wait times, annual clinic volume, no-show rates, and access to care. Patient satisfaction increased to 80% with SDA scheduling compared with 20% to 40% with prior models. The average wait time for patients improved to 19 minutes compared with 330 minutes with the walk-in model. Forty patients were scheduled on the same day, and 96% of all patients who called the clinic were seen within 14 days with the SDA approach. Same-day access was the only model that met its volume and budgetary goals. The incorporation of SDA scheduling improves patient satisfaction and is a viable alternative to more traditional scheduling protocols for clinics suffering from volume, revenue, and access to care issues.

An eConsultant versus a hospital-based outpatient consultation for general (internal) medicine: a costing analysis

BackgroundThe eConsultant model of care is an outpatient substitution approach which has been evaluated and implemented extensively internationally. It provides an asynchronous, digital, clinician-to-clinician advice service, giving primary care physicians remote access to specialist support for patient care within 3 business days. Results from initial trials of the eConsultant model in Australia support international evidence of reduced wait times and improved access to specialist input, avoidance of face-to-face hospital outpatient visits, and better integrated care. This study compared the cost of delivery of an eConsultant episode of care with that of a hospital-based outpatient appointment.MethodsA cost-minimisation analysis, using a decision analytic model, was used to compare the two approaches. eConsultant costs were calculated from specialist reported data (minutes spent preparing the response; the number of patients referred subsequently for a hospital-based outpatient appointment) and administration staff data (time spent recording the occasion-of-service). Outpatient costs were calculated using finance data and information from outpatient clinic managers at the hospital-based outpatient clinic. The primary outcome was incremental cost saving per patient from a hospital system perspective. Uncertainty was explored using one-way sensitivity analyses and characterised with probabilistic sensitivity analysis using 10,000 Monte Carlo simulations.ResultsThe traditional referral pathway cost estimate was $587.20/consult compared to $226.13/consult for an eConsultant episode: an efficiency saving of $361.07 per patient. The incremental difference between eConsultant and traditional care was most sensitive to the cost estimate of an outpatient attendance, the time for a specialist to complete an eConsult, and the probability of a patient requiring a face-to-face hospital-based attendance following an eConsult. However, at the upper bounds of each of these estimates, an eConsult remained the most cost-efficient model. In 96.5% of the Monte Carlo simulations eConsult was found to be more cost efficient than the traditional approach.ConclusionsThe eConsultant model of care was associated with a 61.5% efficiency gain, allowing diversion of support to hospital-based outpatient appointments.

COVID-19 Pandemic Effect on Tubal Sterilization Accessibility [ID: 1376950

INTRODUCTION: The COVID-19 pandemic preferentially allocated medical resources to emergent and urgent services with postponement of “elective” procedures such as surgical sterilization. This study aims to examine effect of postponing surgical sterilization on patients’ reproductive lives. METHODS: This retrospective review assesses patient consultations for tubal sterilization in a hospital-based clinic in 2019 (n=75) and 2020 (n=61). An IRB waiver was obtained. The primary outcome was the rate of unintended pregnancies within 1 year of consultation. The secondary outcomes included length of time between consultation and procedure, expiration of Medicaid sterilization consent, and alternate contraceptive uptake. RESULTS: There was no difference between unintended pregnancies between 2019 and 2020 (8% versus 11%, P=.49). There was no difference between procedure completion rate (65% versus 59%, P=.45). The rate of expiration of Medicaid sterilization consent was statistically different (7% versus 21%, P=.012). Initial consultation to procedure completion averaged 1.8 months in 2019 and 4.0 months in 2020. Of patients who did not undergo sterilization procedure, 96% received an alternate method of contraception in 2019 compared to 88% in 2020. CONCLUSION: No statistical difference was found between unintended pregnancy or rate of procedure completion despite the difference in delay, suggesting that tubal sterilization may be appropriately delayed during resource shortages. The difference in expiration of Medicaid sterilization consent may pose a significant burden to the patient who needs to return to clinic and reconsent prior to the procedure.

Non-Specialist Treatment Model for Hepatitis C Virus (HCV) in Canadian Carceral Settings: A Telemedical Focus


 
 
 Hepatitis C virus (HCV) is a pronounced health problem in carceral settings globally. For Canadian prisons, it is estimated that approximately 25% of those incarcerated have been previously exposed to HCV. Despite being a high prevalence context, Canadian corrections facilities have largely failed to provide adequate care to those with HCV due to their reliance on traditional treatment models. Specifically, this involves hospital-based specialist clinics for patients in corrections facilities nearby – a practice known to be associated with a low incidence of treatment initiation. This paper will explore the use of a contemporary model premised on empowering non-specialist care and the use of telemedicine. This model has found success within other global settings, as will be discussed using case studies from Australia and the United States, and other HCV literature. With the WHO setting an ambitious 90% HCV global reduction goal by 2030, it has become imperative that Canada prioritizes high prevalence populations, such as those in carceral settings, and in turn, looks to more efficient and targeted models of HCV care for these individuals.
 
 

The association of patient age, race, and demographic features on reported pain and sedation dosing during procedural abortion: A retrospective cohort study

ObjectivesTo explore impact of age, racial, demographic, and psychosocial factors on patients’ dosage of analgesia and maximum pain score during procedural abortion. Study designWe performed retrospective chart review of pregnant individuals undergoing procedural abortion at our hospital-based abortion clinic from October 2019 through May 2020. Patients were stratified into age groups,<19 years, 19 to 35 years, and>35 years. We conducted the Kruskal-Wallis H test to evaluate for medication dosing or maximum pain score differences among groups. ResultsWe included 225 patients in our study. We found no difference in fentanyl or midazolam dosing by age. The median fentanyl dose was 75 mcg and median midazolam dose was 2 mg in all three groups (p = 0.61, p = 0.99). White patients received higher median midazolam dosing than Black patients (2 and 3 mg, respectively, p < 0.01) despite similar pain scores. Despite no difference in pain scores, patients terminating for genetic anomaly received more fentanyl than those terminating for socioeconomic reasons (75 and 100 mcg, respectively, p < 0.01). ConclusionsIn our limited study, we found that White race and induced abortion for genetic anomaly were associated with increased medication dosing, though age was not. Multiple demographic and psychosocial factors, as well as perhaps provider bias, play into both a patient’s perception of pain and the dosage of fentanyl and midazolam they receive during abortion procedures. ImplicationsBy acknowledging both patient factors and provider biases in medication dosing, we can provide more equitable abortion care.

‘It's about developing a trustful relationship’: A Realist Evaluation of midwives’ relational competencies and confidence in a Danish antenatal psychosocial assessment programme

Objectiveto explore how contextual conditions influence midwives’ relational competencies, ability and confidence to undertake psychosocial assessment of pregnant women and their partners during the first antenatal consultation that identifies expectant parents in vulnerable positions. Designa realist evaluation carried out through three phases: 1) development 2) testing and 3) refinement of programme theories. Data was generated through realist interviews and observations. Settingnine community-based and hospital-based midwife clinics in the North Region of Denmark. Interventiona dialogue-based psychosocial assessment programme in the the North Region of Denmark was evaluated. Participants and data15 midwives were interviewed and 16 observations of midwives undertaking psychosocial assessment during the first antenatal consultation were conducted. Findingscontextual conditions at multiple levels which supported midwives’ relational competencies, autonomy and the power of peer reflection—and thus facilitation of a woman-centred approach and trust—were identified, i.e., being experienced, having interest, organisational prioritisation of peer reflection and flexibility. Where midwives lacked experience, competency development regarding psychosocial assessment, opportunities for peer reflection and autonomy to individualise care for expectant parents in vulnerable positions, the approach to assessment tended to become institution-centred which caused a distant dialogue and instrumental assessment which potentially harmed the midwife-woman/couple relationship. Conclusionmidwives’ ability and confidence to undertake psychosocial assessment were affected by whether individual and organisational contextual conditions empowered them to assess and care for expectant parents within a philosophy of woman-centred care. Accordingly, development of trustful midwife-woman/couple relationships — which is essential for disclosure — was achievable. These conditions become fundamental for securing quality of antenatal care for expectant parents in vulnerable positions.

150 A Mixed Methods Pilot Study of Telemedicine Group Visits for Chronic Migraine in a Safety Net Health System

OBJECTIVES/GOALS: Limited specialty care within safety net health systems reduces availability of follow-up appointments for chronic conditions. We evaluated patient acceptability of a 6 month series of telemedicine group medical visits for chronic migraine at a county hospital-based clinic as a potential method to improve access to specialty care in this setting. METHODS/STUDY POPULATION: We developed and implemented a pilot program of monthly physician-led telemedicine group visits to provide routine follow-up care for adults with chronic migraine. Visits were conducted through the neurology clinic at LAC+USC medical center, a safety net hospital in Los Angeles and included an educational component, peer support, and the opportunity to address individual needs or refill medications. We assessed headache severity (HIT-6) and mood (PHQ-9) through telephone surveys before and 6 months after patients’ first telemedicine group visit and compared timepoints using paired t-tests. Patient acceptability of the group visits was elicited through focus groups and key themes identified using grounded field theory. RESULTS/ANTICIPATED RESULTS: Baseline data was available for 18/20 pilot participants. Patients were predominantly female (89%) with mean age of 46 (SD 8.6). Mean HIT-6 was 65/78 reflecting a very severe impact on daily life, and mean PHQ-9 was 8.7 reflecting mild depressive symptoms. There was no statistically significant change in either HIT-6 (mean difference 2.36, p=0.34) or PHQ-9 (mean difference 2.09, p=0.12) after group participation. Key themes from the focus groups included lack of prior exposure to other people with similar headache burden and logistical barriers to care, such as difficulty contacting a provider or extended clinic wait times. Primary patient-reported benefits included more frequent access to a provider and peer support. DISCUSSION/SIGNIFICANCE: Telemedicine group visits for chronic migraine are feasible in a safety net context and were well-received by patients. However, this pilot study did not show a benefit of telemedicine group visits for headache control or mood symptoms.

“I was Treated by the Program, the Therapist, and Myself”: Feasibility of an Internet-Based Treatment Program for Gambling Disorder

The majority of people with problematic gambling behavior never seek or receive professional help. Internet-based treatment approaches have been shown to help patients overcome practical and psychological barriers associated with face-to-face therapy. In this uncontrolled pilot study, we explored the feasibility of the eight-module therapist-guided internet-based treatment program SpilleFri (“Free from Gambling”) for patients with gambling disorder (GD). We included 24 patients seeking treatment at a Danish hospital-based treatment clinic. The focus of the feasibility study was evaluation of recruitment and retention rates, data completion rates, treatment response, satisfaction, and program utility. In addition, a series of semi-structured interviews were conducted to explore patient-perceived acceptability and potential barriers to treatment completion and positive outcome. Treatment acceptability among therapists was examined in a focus group interview. Sixteen of the included patients completed the program, yielding an acceptable treatment dropout rate (29.17%), and 82.35% of treatment completers provided full data at all assessment points. Overall, patients were satisfied with the treatment received, and patient interviews highlighted multiple psychological as well as practical benefits associated with the treatment form and content. Patients with more severe gambling symptoms at baseline might be more likely to drop out before treatment completion than patients with less severe symptoms. The results suggest that SpilleFri may be a feasible alternative to face-to-face treatment for GD. However, the uncontrolled design and small sample size of the study limit the robustness of the findings. In the future, the effect of SpilleFri treatment should be examined in a randomized controlled trial.Clinical trial registrations: The study protocol was prospectively registered at clinicaltrials.gov (TRN: NCT05051085; registration date: September 21, 2021).

Parent-identified barriers to accessing exposure therapy: A qualitative study using process mapping.

Youth with anxiety and obsessive-compulsive disorder (OCD) rarely access exposure therapy, an evidence-based treatment. Known barriers include transportation, waitlists, and provider availability. Efforts to improve access to exposure require an understanding of the process that families take to find therapists, yet no prior studies have examined parents' perspectives of the steps involved. Parents of children who have received exposure therapy for anxiety and/or OCD (N = 23) were recruited from a hospital-based specialty anxiety clinic where the majority of their children previously received exposure. Recruitment was ongoing until thematic saturation was reached. Parents completed questionnaires and attended an online focus group during which they were asked to describe each step they took-from recognizing their child needed treatment to beginning exposure. A process map was created and shown in real-time, edited for clarity, and emailed to parents for member checking. Authors analyzed process maps to identify common themes. Several themes emerged, as visually represented in a final process map. Participants identified a "search-outreach" loop, in which they repeated the cycle of looking for therapists, contacting them, and being unable to schedule an appointment due to factors such as cost, waitlists, and travel time. Parents often did not know about exposure and reported feeling guilty about their lack of knowledge and inability to find a suitable provider. Parents reported frustration that medical providers did not often know about exposure and sometimes dismissed parents' concerns. Participants emphasized the difficulty of navigating the mental health system; many reported that it took years to find an exposure therapist, and that the search was sometimes stalled due to fluctuating symptoms. A common thread among identified barriers was the amount of burden placed on parents to find treatment with limited support, and the resultant feelings of isolation and guilt. Findings point to several directions for future research, such as the development of parent support groups for navigating the mental health system; enhancing coordination of care between medical and mental health providers; and streamlining referral processes.

Fertility awareness education improves fertility cycle knowledge and may reduce time-to-pregnancy in subfertile women

Research suggests that low fertility awareness (FA) may be a contributing factor to infertility. The aim of this study was to determine whether education improves knowledge in FA and to explore the associations between FA knowledge and time to pregnancy (TTP). A 20-point self-administered FA questionnaire (FAQ) was completed by 180 subfertile women on their first visit to a hospital-based fertility assessment and research clinic, followed by an education session on FA. Women completed the same FAQ after receiving the education session. There was an increase in the FAQ score after the women received FA education (post-education FAQ score: mean, M = 15.68, SD = 1.8) compared with the score before the session [(pre-education FAQ score: M = 13.87, SD = 1.9), t(179)=–10.547, p < 0.001]. Pregnancy was achieved in 88 women (49%). Women with a higher post-education FAQ score (≥15 points) had a shorter TTP (M = 6.4 months, SD = 4.1) than women with post-education FAQ scores <15 [M = 8.8 months, SD = 6.0, t(86)=2.231, p = 0.028]. Greater time trying to conceive was negatively predictive of the hazard for achieving a pregnancy (b=–0.021, se = 0.008, p = 0.005), while age had no significant effect. FA knowledge in women attending a fertility clinic significantly improved after education. Higher FA may reduce TTP in subfertile women who are actively trying to conceive naturally.

Cost of improved test and treat strategies in Indonesia.

To estimate and compare the cost of improved test and treat strategies in Indonesia under HIV Awal (Early) Testing and Treatment Indonesia (HATI) implementation trial in community-based and hospital-based clinics. The cost and outcome [i.e. CD4 + cell count] and viral load (VL) at the beginning of interventions and their change overtime) analysis of Simplifying ART Initiation (SAI), Community-based Organization and community-based ART Service (CBO), Motivational Interviewing (MI), Oral Fluid-based Testing (OFT), and Short Message Service (SMS) reminder in community-based and hospital-based clinics in 2018-2019. We estimated the total and unit costs per patient (under HATI implementation trial interventions) per year from societal perspective in various settings, including costs from patients' perspective for SAI and MI. We also analyzed the outcome variables (i.e. CD4 + cell count and VL at the beginning of each intervention, the change in CD4 + cell count and VL over time, and adherence rate). The unit cost per patient per year of SAI and SMS were lower at the community-based clinics, and more patients visited community-based clinics. The cost per patient visit from patient perspective for SAI and MI was mostly lower than 10% of the patients' household monthly expenditure. Average CD4 + cell count was higher and average VL was lower at the start of interventions at the community-based clinics, while average CD4 + cell count and VL changes and adherence rate were similar between the two types of clinics. Community-based clinics hold the potential for scaling up the interventions as it costs less from societal perspective and showed better outcome improvement during the HATI implementation trial.

An exploratory study of COVID-19-related changes in abortion service availability and use in Washington, DC, Maryland, and Virginia.

This exploratory study aimed to assess COVID-19-related changes in abortion service availability and use in Washington, DC, Maryland, and Virginia. Data came from a convenience sample of eight abortion clinics in this region. We implemented a cross-sectional survey and collected retrospective aggregate monthly abortion data overall and by facility type, abortion type, and patient characteristics for March 2019-August 2020. We evaluated changes in the distribution of the total number of patients for March-August in 2019 compared to March-August 2020. We also conducted segmented regression analyses and produced scatter plots of monthly abortion patients overall and by facility type, abortion type, and patient characteristics, with separate fitted regression lines from the segmented regression models for the pre- and during-COVID-19 periods. Five clinics reported a reduced number of appointments early in the pandemic while four reported increased call volume. There were declines in the monthly abortion trend at hospital-based clinics at the outset of the pandemic. Monthly number of medication abortions increased from March 2020 through August 2020 compared to pre-COVID-19 trends while instrumentation abortions 11 up to 19 weeks decreased. The share of abortions to Black individuals increased during the early phase of the pandemic, as did the monthly trend in abortions among this group. We also saw changes in payment type, with declines in patients paying out-of-pocket. Results revealed differences in abortion services, numbers, and types during the early stages of the COVID-19 pandemic in Washington, DC, Maryland, and Virginia.

Local corticosteroid injection versus placebo for carpal tunnel syndrome.

Carpal tunnel syndrome (CTS) is a very common clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Direct and indirect costs of CTS are substantial, with estimated costs of two billion US dollars for CTS surgery in the USA in 1995 alone. Local corticosteroid injection has been used as a non-surgical treatment for CTS many years, but its effectiveness is still debated. To evaluate the benefits and harms of corticosteroids injected in or around the carpal tunnel for the treatment of carpal tunnel syndrome compared to no treatment or a placebo injection. We used standard, extensive Cochrane search Methods. The searches were 7 June 2020 and 26 May 2022. We included randomised controlled trials (RCTs) or quasi-randomised trials of adults with CTS that included at least one comparison group of local injection of corticosteroid (LCI) into the wrist and one group that received a placebo or no treatment. We used standard Cochrane methods. Our primary outcome was 1. improvement in symptoms at up to three months of follow-up. Our secondary outcomes were 2. functional improvement, 3. improvement in symptoms at greater than three months of follow-up, 4. improvement in neurophysiological parameters, 5. improvement in imaging parameters, 6. requirement for carpal tunnel surgery, 7. improvement in quality of life and 8. We used GRADE to assess the certainty of evidence for each outcome. We included 14 trials with 994 participants/hands with CTS. Only nine studies (639 participants/hands) had useable data quantitatively and in general, these studies were at low risk of bias except for one quite high-risk study. The trials were conducted in hospital-based clinics across North America, Europe, Asia and the Middle East. All trials used participant-reported outcome measures for symptoms, function and quality of life. There is probably an improvement in symptoms measured at up to three months of follow-up favouring LCI (standardised mean difference (SMD) -0.77, 95% confidence interval (CI) -0.94 to -0.59; 8 RCTs, 579 participants; moderate-certainty evidence). Up to six months this was still evident favouring LCI (SMD -0.58, 95% CI -0.89 to -0.28; 4 RCTs, 234 participants/hands; moderate-certainty evidence). There is probably an improvement in function measured at up to three months favouring LCI (SMD -0.62, 95% CI -0.87 to -0.38; 7 RCTs, 499 participants; moderate-certainty evidence). We are uncertain if there is a difference in median nerve DML at up to three months of follow-up (mean difference (MD) -0.37 ms, 95% CI -0.75 to 0.02; 6 RCTs, 359 participants/hands; very low-certainty evidence). The requirement for surgery probably reduces slightly in the LCI group at one year (risk ratio 0.84, 95% CI 0.72 to 0.98; 1 RCT, 111 participants, moderate-certainty evidence). Quality of life, measured at up to three months of follow-up using the Short-Form 6 Dimensions questionnaire (scale from 0.29 to 1.0; higher is better) probably improved slightly in the LCI group (MD 0.07, 95% CI 0.02 to 0.12; 1 RCT, 111 participants; moderate-certainty evidence). Adverse events were uncommon (low-certainty evidence). One study reported 2/364 injections resulted in severe pain which resolved over "several weeks" and 1/364 injections caused a "sympathetic reaction" with a cool, pale hand that completely resolved in 20 minutes. One study (111 participants) reported no serious adverse events, but 65% of LCI-injected and 16% of the placebo-injected participants experienced mild-to-moderate pain lasting less than two weeks. About 9% of participants experienced localised swelling lasting less than two weeks. Four studies (229 participants) reported that they experienced no adverse events in their studies. Three studies (220 participants) did not specifically report adverse events. Local corticosteroid injection is effective for the treatment of mild and moderate CTS with benefits lasting up to six months and a reduced need for surgery up to 12 months. Where serious adverse events were reported, they were rare.

Who Places High Value on the Uterus? A Cross-sectional Survey Study Evaluating Predictors for Uterine Preservation

ABSTRACT The prevalence of inpatient hysterectomy, a common surgical procedure in the United States, decreased by 36.4% between 2002 and 2010 in women with benign gynecologic conditions. One major factor contributing to the decline in inpatient hysterectomies was the growing number of uterine-preserving treatment options. Alternatives to hysterectomy include hormonal management, endometrial ablation, myomectomy, or uterine artery embolization. Additional reasons for desiring uterine preservation among women who do not desire future fertility may include the belief that the uterus provides improved sense of self, relationship, and femininity. There are ethnic and racial disparities in the number and route of hysterectomies performed. Rates are higher among Black women than among White women. Variations in hysterectomy rates are likely exacerbated in marginalized racial groups who have less access to uterine-sparing treatments or delayed care at earlier disease states. Although patient preferences may influence the choice of hysterectomy or uterine-preserving therapy, the contribution of race and socioeconomic status to one's preference for uterine preservation is unknown. The aim of this cross-sectional survey was to determine predictors for uterine preservation among patients who no longer desire fertility. A secondary aim was to identify reasons for placing high value on the uterus. The study was conducted at 3 hospital-based clinics in a large health care system in the United States. Participants were new patients 45 years or older seeking care for benign gynecologic conditions (including abnormal uterine bleeding, uterine fibroids, pelvic organ prolapse, endometriosis, or pelvic pain). The primary study outcome was the summative score of the VALUS ( Value of Uterus) instrument in predicting that a woman will undergo uterine preservation. The VALUS, a validated and reliable instrument, measures patient preferences and value placed on uterine preservation. Respondents placed either “low value” versus “high value” for the uterus in ovarian preservation. Secondary outcomes included individual questions within the VALUS instrument to determine drivers of uterine preservation. There were no prior data. Of the 230 surveys distributed, 206 (89.6%) were returned for analysis, and 163 of these (79.2%) met the criteria for completion. Using the VALUS cutoff, 64 patients (45.7%) were considered to have low value for their uterus (VALUS score &lt;14), whereas 76 patients (54.3%) were considered to have high value for their uterus (VALUS score ≥14). Among women who wanted to be sexually active in the future, the likelihood of a high value for the uterus was substantially higher compared with those who did not; the adjusted odds ratio was 5.06, with a 95% confidence interval (CI) of 1.55 to 16.52, P = 0.01. Sexually active patients were substantially more likely to place a higher value on the uterus compared with those not sexually active or those who did not wish to be (adjusted odds ratio, 3.94; 95% CI, 1.36–11.43; P = 0.01). Non-White race, religion, and personal history of cancer were not statistically significant. These findings show that sexually active women and those who desire future sexual activity have 5- and 4-times higher odds of placing high value on the uterus compared with patients who are not sexually active. Patients who highly value the uterus believe that it is important for sexual function, sexual pleasure, sense of self, and staying complete as a woman. Future large-scale studies are needed to determine whether patient preferences contribute to the racial disparities in hysterectomy rates.

Lead Time from First Suspicion of Malignant Melanoma in Primary Care to Diagnostic Excision: a Cohort Study Comparing Teledermatoscopy and Traditional Referral to a Dermatology Clinic at a Tertiary Hospital.

The increasing use of teledermatoscopy in clinical practice has led to demands to evaluate the effects of this new technology on traditional healthcare systems. To study lead times from first consultation in primary care to diagnostic excision of suspected malignant melanoma lesions in traditional referrals to a tertiary hospital-based dermatology clinic compared with mobile teledermatoscopy referrals. A retrospective cohort study design was used. Data on sex, age, pathology, caregivers, clinical diagnosis, date for first visit to primary care unit, and date for diagnostic excision were collected from medical records. Patients managed through traditional referral (n=53) were compared with patients managed at primary care units using teledermatoscopy (n=128) regarding lead time from first visit to diagnostic excision. Mean time from date of first visit at primary care unit to diagnostic excision did not differ between the traditional referral and teledermatoscopy groups (16.2 vs. 15.7 days, median 10 vs. 13 days, p=0.657). Lead times from date of referral to diagnostic excision did not significantly differ (15.7 vs. 12.8 days, median 10 vs. 9 days, p=0.464). Our study indicates that lead time to diagnostic excision for patients with suspected malignant melanoma managed by teledermatoscopy was comparable and not inferior to that of the traditional referral pathway. If teledermatoscopy is used at first consultation in primary care, it could potentially be more efficient than traditional referral.

Patient Religiosity and Desire for Chaplain Services in an Outpatient Primary Care Clinic.

Outpatient chaplaincy is a new specialty in healthcare, with a relative paucity of research studies exploring the need for spiritual care interventions in ambulatory settings. Over the past 3 years, our interdisciplinary team at the Duke Outpatient Clinic has piloted the extension of professional spiritual care into this hospital-based resident teaching clinic offering primary care to underserved populations in Durham, NC. In this article, we report the results of a series of surveys that we conducted at the clinic to assess patients' perceptions of chaplain services, understanding of Chaplains' roles, and desire for chaplain services in specific hypothetical scenarios. As part of this survey, we also asked patients about their personal levels of extrinsic and intrinsic religiosity using the well-validated Duke University Religion Index. Our results indicate which chaplain interventions are most desired among this patient population in relation to patients' self-reported religiosity. We hypothesized that only our more religious patients would strongly desire chaplain support for the majority of scenarios presented. We were surprised to find that a majority of our patients-regardless of their own level of religiosity-express desire for support from an outpatient healthcare chaplain when they need a listening ear, are grieving a loss, or are seeking prayer.

1226 A MULTI-DISCIPLINARY APPROACH TO TRANSFORMING EYE CARE SERVICES FOR CARE HOME RESIDENTS

Abstract Introduction Care home residents can have variable access to eye care services and treatments. We developed a collaborative approach between optometrists, care homes, and primary and secondary care to enable personalised patient-centred care. Objective To develop and evaluate an integrated model of eye care for care home residents. Methods Small scale plan-do-study-act (PDSA) service tests were completed in three care-homes in Southwark (2 residential, 1 nursing) between November 2021 to May 2022. Processes were compared to historical feedback and hospital-based ophthalmology clinic attendances (Mar 2019-2020). Hospital-like assessments were piloted at two care homes for feasibility and acceptability. Further piloting utilised usual domiciliary optometry-led assessment with multidisciplinary meeting access (including optometrist, GP, geriatrician, ophthalmologist and care home nurse) to reduce duplication of assessments and to evaluate MDM processes and referral rates. Results Examination was 100% successful at home (visual acuity and pressure measurement) compared to hospital outpatients (71.7% success visual acuity, 54.5% pressures). Examination was faster than in hospital settings (16 minutes vs 45 minutes-1 hour). Residents were away from usual activities for 32 minutes vs 6 hours for hospital visits including transport. Residents were less distressed with home-based assessments. Did-Not-Attend (DNA) rates reduced (26.7% to 0%), secondary care discharge rates improved (8.4% to 32%). Hospital eye service referral were indicated in 19% -23%, half of which were for consideration of cataract surgery. Alternative conservative plans were agreed at MDM for nursing home residents who were clinically too frail or would not have been able to comply with treatments avoiding 33% unnecessary referrals. Conclusions Home-based eye care assessments appear better tolerated and are more efficient for residents, health and care staff. Utilising an MDM for optometrists to discuss residents with ophthalmologists and wider MDT members enabled personalised patient-centred decision-making. Future work to test this borough wide is in progress.

Pre- and Perinatal Risk Factors for Youth with Autism Spectrum Disorder Versus Youth with Other Mental Health Disorders.

Research has linked pre- and perinatal complications (PPCs) with increased risk for autism spectrum disorder (ASD). However, PPCs are also known risk factors for other mental health disorders. This study explored which PPCs are specific risk factors for ASD, as opposed to other forms of psychopathology, among a large sample of clinically-referred youth. Archival data were used from 1177 youth who were evaluated at a hospital-based autism clinic. Results from logistic regressions indicated that use of tobacco, alcohol, or drugs, or experiencing amniocentesis predicted inclusion in the non-ASD group, while physical difficulties with delivery predicted inclusion in the ASD group. Possible explanations and implications for these findings are discussed.

Vaccine effectiveness of recombinant and standard dose influenza vaccines against outpatient illness during 2018–2019 and 2019–2020 calculated using a retrospective test-negative design

ABSTRACT Newer influenza vaccine formulations have entered the market, but real-world effectiveness studies are not widely conducted until there is sufficient uptake. We conducted a retrospective test-negative case-control study to determine relative vaccine effectiveness (rVE) of recombinant influenza vaccine or RIV4, compared with standard dose vaccines (SD) in a health system with significant RIV4 uptake. Using the electronic medical record (EMR) and the Pennsylvania state immunization registry to confirm influenza vaccination, VE against outpatient medically attended visits was calculated. Immunocompetent outpatients ages 18–64 years seen in hospital-based clinics or emergency departments who were tested for influenza using reverse transcription polymerase chain reaction (RT-PCR) assays during the 2018–2019 and 2019–2020 influenza seasons were included. Propensity scores with inverse probability weighting were used to adjust for potential confounders and determine rVE. Among this mostly white and female cohort of 5,515 individuals, 510 were vaccinated with RIV4 and 557 were vaccinated with SD, with the balance of 4,448 (81%) being unvaccinated. Adjusted influenza VE estimates were 37% overall (95% CI = 27, 46), 40% (95% CI = 25, 51) for RIV4 and 35% (95% CI = 20, 47) for standard dose vaccines. Overall, rVE of RIV4 compared to SD was not significantly higher (11%; 95% CI = −20, 33). Influenza vaccines were moderately protective against medically attended outpatient influenza during the 2018–2019 and 2019–2020 seasons. Although the point estimates are higher for RIV4, the large confidence intervals around VE estimates suggest this study was underpowered to detect significant rVE of individual vaccine formulations.

Predicting Fitness to Drive for Medically At-Risk Drivers Using Touchscreen DriveSafe DriveAware

Occupational therapists require valid cognitive fitness-to-drive tools to advise drivers in this high-stakes area. To examine the psychometric properties and predictive validity of data gathered with the touchscreen DriveSafe DriveAware (DSDA). Prospective study that compared a screening tool with a criterion standard. Ten community- and hospital-based driver assessment clinics in Australia and New Zealand. Older and cognitively impaired drivers (N = 134) ages 18 to 91 years (Mage= 68) who were referred for an assessment to determine the impact of a medical condition on driving. The inclusion criteria were a valid driver's license, vision within license authority guidelines, completion of at least 1 year of high school, and English as a first language. The results of the touchscreen DSDA, a standardized assessment of awareness of the driving environment and one's own driving abilities, were compared with those of a standardized occupational therapist-administered on-road assessment. Rasch analysis provided evidence for the construct validity and internal reliability of data gathered with the touchscreen DSDA. Optimal upper and lower cutoff scores were set to trichotomize drivers into three categories: likely to pass an on-road assessment, likely to fail an on-road assessment, and further testing required. Specificity of the touchscreen DSDA was 86%, and sensitivity was 91%; positive predictive value was 83%, negative predictive value was 92%, and overall accuracy of classification was 88%. Evidence supports the utility of the touchscreen DSDA for accurately predicting which participants require on-road assessment. What This Article Adds: The touchscreen DSDA is a promising screen for occupational therapists and other health professionals to use in conjunction with other clinical indicators to determine whether drivers require further assessment.