Hospital Outpatient Appointments Research Articles

Enhancing Health Equity by Predicting Missed Appointments in Health Care: Machine Learning Study.

The phenomenon of patients missing booked appointments without canceling them-known as Did Not Show (DNS), Did Not Attend (DNA), or Failed To Attend (FTA)-has a detrimental effect on patients' health and results in massive health care resource wastage. Our objective was to develop machine learning (ML) models and evaluate their performance in predicting the likelihood of DNS for hospital outpatient appointments at the MidCentral District Health Board (MDHB) in New Zealand. We sourced 5 years of MDHB outpatient records (a total of 1,080,566 outpatient visits) to build the ML prediction models. We developed 3 ML models using logistic regression, random forest, and Extreme Gradient Boosting (XGBoost). Subsequently, 10-fold cross-validation and hyperparameter tuning were deployed to minimize model bias and boost the algorithms' prediction strength. All models were evaluated against accuracy, sensitivity, specificity, and area under the receiver operating characteristic (AUROC) curve metrics. Based on 5 years of MDHB data, the best prediction classifier was XGBoost, with an area under the curve (AUC) of 0.92, sensitivity of 0.83, and specificity of 0.85. The patients' DNS history, age, ethnicity, and appointment lead time significantly contributed to DNS prediction. An ML system trained on a large data set can produce useful levels of DNS prediction. This research is one of the very first published studies that use ML technologies to assist with DNS management in New Zealand. It is a proof of concept and could be used to benchmark DNS predictions for the MDHB and other district health boards. We encourage conducting additional qualitative research to investigate the root cause of DNS issues and potential solutions. Addressing DNS using better strategies potentially can result in better utilization of health care resources and improve health equity.

#6431 THE DEVELOPMENT OF AN INTEGRATED COMMUNITY, CONSERVATIVE KIDNEY CARE AND PALLIATIVE-RENAL CARE SERVICE

Abstract Background and Aims Conservative kidney care is the chosen therapeutic strategy for approximately 6% of renal patients. It is estimated that a third of renal units in the United Kingdom have a dedicated conservative kidney care service. Equally, other units manage this cohort of patients in general nephrology/ low-clearance clinics or alternatively, discharge to community services. Walsall Together, is a collaborative initiative between community and speciality services, driven to provide multi-agency, patient-focused care. By combining specialist input and community resources, we aimed to optimally manage individuals on the conservative kidney care and palliative-renal pathways at home. Method Community, nephrology and palliative care teams devised a service for those individuals identified for conservative kidney care or individuals with renal disease requiring palliative care management. Two separate, yet linked services; the community, conservative care pathway feeding into the community, palliative-renal pathway. Individuals suitable for community conservative care pathway were identified from routine nephrology inpatient and outpatient workstreams. Prior to a telephone consultation with a nephrologist, phlebotomy for routine bloods were performed at the GP surgery or at the patients home by the community phlebotomy service. Any alterations to medications would be performed directly by the community pharmacist. Symptoms were assessed using the integrated palliative outcome score (IPOS)-renal survey. The IPOS renal-survey asks individuals to rate symptom burden from; not at all, to slightly, moderately, severely and overwhelmingly. Home visits were offered to unwell or symptomatic patients. Individuals requiring palliative care were identified from both palliative and nephology services. A bi-weekly palliative-renal multidisciplinary team (MDT) meeting was established. Results To date 40 individuals have been managed on both the community conservative care and renal-palliative care pathway. 94% of patients felt that the community approach did not waste time waiting for appointments/treatments. 87% of patients felt that the community approach provided them with sufficient information to understand their healthcare condition and relevant management strategies. Patients reported pain, nausea and reduced appetite as the three most common symptoms that generated discomfort in the three days prior to taking the IPOS-renal survey. On detailed assessment; significant symptom burden was attributed to reduced mobility (82% scoring slightly to overwhelmingly), pain (65% scoring slightly to overwhelmingly) and bowel concerns (65% scoring slightly to overwhelmingly). Itching affected a third of the cohort, scoring moderately to overwhelmingly. Importantly, as a result of the service, patients reported that either all or most renal-related problems were addressed. To date all patients who died while under the renal-palliative care service, died in their chosen place of death, and not in hospital. Conclusion The Walsall Together initiative has demonstrated that utilising a collaborative approach to managing complications of advanced kidney disease can result in the reduction of hospital admissions, face-to-face hospital outpatient appointments and time wasted attending healthcare appointments. Furthermore, the cooperative multi-speciality approach, has led to improve patient satisfaction and the attainment of patient healthcare goals.

Safety and efficacy of an artificial intelligence-enabled decision tool for treatment decisions in neovascular age-related macular degeneration and an exploration of clinical pathway integration and implementation: protocol for a multi-methods validation study

IntroductionNeovascular age-related macular degeneration (nAMD) management is one of the largest single-disease contributors to hospital outpatient appointments. Partial automation of nAMD treatment decisions could reduce demands on clinician time. Established...

Attendance at, and experiences of, urban hospital outpatient appointments: informing a new model of care for urban-dwelling Aboriginal and Torres Strait Islander patients.

ObjectivesTo compare outpatient attendance rates for Aboriginal and Torres Strait Islander ('Aboriginal') and non-Aboriginal patients at a large metropolitan health service in Melbourne, Australia, and to describe the barriers and enablers experienced by urban-dwelling Aboriginal patients in attending hospital outpatient appointments.MethodsThis study used a mixed-method approach. Proportions of referred patients who booked and attended outpatient appointments were extracted from a health service database. Aboriginal versus non-Aboriginal cohorts were compared using chi-squared tests. Eleven patients, one parent of a patient and two community nurses were interviewed by telephone to investigate perceived barriers and enablers to attending outpatient appointments among Aboriginal patients.ResultsOutpatient referrals were greater among Aboriginal than non-Aboriginal people; however, referrals were significantly less likely to result in an outpatient clinic booking and attendance for Aboriginal compared to non-Aboriginal people. Interview participants reported several barriers to attending appointments, related to logistical, quality of care and cultural factors. Suggested facilitators to make appointment attendance easier included: provision of transport support, improving clinic scheduling, utilising a variety of appointment reminder formats, providing food in waiting rooms, flexible appointment timing options, outreach services, access to Aboriginal support workers, improving communication and relationships with Aboriginal people, cultural awareness training for staff and the provision of culturally appropriate spaces.ConclusionSome barriers faced by Aboriginal patients in attending hospital outpatient appointments in urban areas can be addressed through implementation of enablers suggested by participants. Data have informed the development of a tailored, inclusive, culturally and consumer-focused appropriate hospital outpatient service model of care.

Diverting paediatric patients from hospital outpatient appointments to integrated care clinics

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

Reducing non-attendance in outpatient appointments: predictive model development, validation, and clinical assessment

BackgroundNon-attendance to scheduled hospital outpatient appointments may compromise healthcare resource planning, which ultimately reduces the quality of healthcare provision by delaying assessments and increasing waiting lists. We developed a model for predicting non-attendance and assessed the effectiveness of an intervention for reducing non-attendance based on the model.MethodsThe study was conducted in three stages: (1) model development, (2) prospective validation of the model with new data, and (3) a clinical assessment with a pilot study that included the model as a stratification tool to select the patients in the intervention. Candidate models were built using retrospective data from appointments scheduled between January 1, 2015, and November 30, 2018, in the dermatology and pneumology outpatient services of the Hospital Municipal de Badalona (Spain). The predictive capacity of the selected model was then validated prospectively with appointments scheduled between January 7 and February 8, 2019. The effectiveness of selective phone call reminders to patients at high risk of non-attendance according to the model was assessed on all consecutive patients with at least one appointment scheduled between February 25 and April 19, 2019. We finally conducted a pilot study in which all patients identified by the model as high risk of non-attendance were randomly assigned to either a control (no intervention) or intervention group, the last receiving phone call reminders one week before the appointment.ResultsDecision trees were selected for model development. Models were trained and selected using 33,329 appointments in the dermatology service and 21,050 in the pneumology service. Specificity, sensitivity, and accuracy for the prediction of non-attendance were 79.90%, 67.09%, and 73.49% for dermatology, and 71.38%, 57.84%, and 64.61% for pneumology outpatient services. The prospective validation showed a specificity of 78.34% (95%CI 71.07, 84.51) and balanced accuracy of 70.45% for dermatology; and 69.83% (95%CI 60.61, 78.00) for pneumology, respectively. The effectiveness of the intervention was assessed on 1,311 individuals identified as high risk of non-attendance according to the selected model. Overall, the intervention resulted in a significant reduction in the non-attendance rate to both the dermatology and pneumology services, with a decrease of 50.61% (p<0.001) and 39.33% (p=0.048), respectively.ConclusionsThe risk of non-attendance can be adequately estimated using patient information stored in medical records. The patient stratification according to the non-attendance risk allows prioritizing interventions, such as phone call reminders, to effectively reduce non-attendance rates.

Telemedicine or In-Person: Referral Letter Content Influencing How a Patient Receives Treatment

Objective:This study investigated hospital-based specialist services that provide both traditional hospital outpatient appointments (in-person) or through a live videoconferencing session (telehealth) to referred patients. Referral letters submitted to these clinics were assessed against an inclusion criterion and grouped according to which of delivery method the patient received for their appointment (in-person or telehealth). These groups were then compared for differences to see what factors, if any, influence the likelihood of a patient being offered a telehealth appointment.Methods:An extract of all referral letters meeting inclusion criteria between July 01, 2019 and June 30, 2020 were collected (n = 441). Letters were grouped according to delivery modality (in-person or telehealth) and differences between the groups, including variables such as patient demographics, clinical condition, and urgency and the reviewing clinician were assessed for associations.Results:This study observed that where the referring clinician suggested a telehealth appointment for their patient, this was more likely to be offered (38.25%) compared with referrals that did not (7.36%) (x21 = 28.33, p = 0.1857, odds ratio = 2.77). Patients were more likely to be offered a telehealth appointment the further they lived from the treating facility (T = −4.51 on 106.59 df, p = 1.622 e-05). Variation in the selection of delivery modality among reviewing clinicians was also observed (x21 = 42.334, p < 1.42e-08).Discussion:Existing research indicates there is a strong link between the perceptions clinicians as individuals have of telehealth and a willingness to offer this modality to patients. Despite this, specific information about a patient contained within a referral letter may influence the delivery modality that the patient will be offered for their initial appointment. It is important that this information is more routinely included in letters sent by referring clinicians to hospital-based specialist services. It is equally important that when included, this information is identified and actioned by reviewing clinicians in a consistent way. Doing so will benefit patients by increasing the likelihood that they will receive specialist outpatient care in a manner that suits them best.

Outcomes from birth to 6months of publicly insured infants born to mothers with severe acute respiratory syndrome coronavirus 2 infection in the United States.

We evaluated inpatient management, transition to home, breastfeeding, growth, and clinical outcomes of infants born to mothers diagnosed with SARS-CoV-2 infection in pregnancy and followed in a Federally Qualified Health Center (FQHC), that serves a diverse and low-income patient population, from birth through 6months of life. Infants born between 4/3/20 and 7/26/20 at Prentice Women's Hospital with mothers who received prenatal care at Erie Family Health Center (Erie), the second largest FQHC in Illinois, and had confirmed SARS-CoV-2 during pregnancy were included. Data were abstracted from delivery hospital admission and outpatient follow-up appointments between 4/8/20 and 2/4/21. Thirty-three infants met inclusion criteria. Average gestational age was 38.9weeks (IQR 37.6-40.4), 3 (10%) were premature and 5 (15%) required NICU admission. Nearly all (97%) mothers expressed intent to breastfeed. Outpatient follow-up rates were similar to historical cohorts and 82% (23/28) of infants were vaccination compliant. Growth parameters showed normal distributions at all time points. At 6months, any and exclusive breast milk feeding rates were lower compared to historic cohorts (18 vs. 36%, p<0.05, 0 vs. 21%, p<0.01). Three infants (10%) received development-related referrals, one carried an underlying genetic diagnosis. Outpatient visits were predominantly face-to-face with telemedicine use comprising only 6% of visits (11/182). Longitudinal follow-up of 33 publicly insured infants born to mothers with SARS-CoV-2 infection in pregnancy followed in an FQHC showed high rates of follow-up and vaccination compliance, normal growth patterns and reassuring clinical status, and lower than expected rates of breastfeeding.

166 HEALTH TRAJECTORIES OF FRAIL, OLDER PEOPLE WHILE COCOONING DURING THE COVID-19 PANDEMIC

Abstract Background Cocooning, i.e. staying at home and reducing interaction with others, was a key part of the strategy to protect older people during the COVID-19 pandemic. Unfortunately, there are concerns this has had a negative impact on the physical and mental wellbeing of those who have been isolated. Methods We completed a survey of 150 patients (55% female, mean age 79.8 years, average Clinical Frailty Scale 4.8) attending ambulatory medical services in a large university hospital. Questions were focused on: access to healthcare services, mental health, physical health, and attitudes to COVID-19 restrictions. Results Almost 40% reported that their mental health was ‘worse’ or ‘much worse’ while cocooning, while over 40% reported a decline in their physical health. Over 57% had a scheduled healthcare-related visit cancelled while cocooning, most frequently hospital outpatient appointments. Worryingly, almost 1/6 reported not seeking medical attention for an illness that they would usually. Of these, half did not as they were worried about catching COVID and 46% did not as this service was not currently available to them. Conclusion The COVID-19 pandemic and lack of access to essential services, both medical and social, has had a devastating impact on older people. This is evident in both the acute presentations to hospital and the longer-term impact it has had on health and function. It is important that in the future clear policies are in place to enable older people to access care when they need it.

Implementation and evaluation of a university&#x2013;hospital partnership program for Type 2 diabetes.

Objective The aims of this study were to determine whether a university-hospital partnership program for Type 2 diabetes (T2D) would: be well attended; reduce the number of patients on the diabetes out-patient waiting list who have been waiting longer than the recommended; increase discharge from the hospital clinic; increase university health clinic (UHC) occasions of service; be sustainable; and be acceptable to participants. Method A prospective observational study was conducted between 2016 and 2019. Participants with T2D were referred to a UHC, initially from a hospital diabetes wait list. The final program consisted of 10 weeks: before and after individual assessments, as well as 8 weeks of exercise and education facilitated by health professionals and students. Participant demographic characteristics and data on attendance, discharge and follow-up requirements, the percentage of patients waiting longer than the recommended for a new hospital out-patient appointment, university activity and patient satisfaction were collected. Results In all, 130 participants commenced the program, 80% completed at least six of eight group sessions and 80% attended the final assessment. The percentage of people waiting longer than recommended decreased from 63% to 16%. The hospital discharged 87% and 59% of participants from the dietitian and endocrinologist respectively. The UHC recorded 2056 occasions of service and 2056 student experiences including dietetics, exercise physiology, psychology, nursing, optometry, social work and podiatry students relating to the program. Satisfaction was high, as measured by the Short Assessment of Patient Satisfaction, with a mean score of 23.9 from a possible score of 28.0 (n = 93). Conclusion The partnership resulted in a new model of care for patients with T2D and increased learning experiences for students. What is known about the topic? Diabetes is the fastest growing disease in Australia, placing unsustainable demands on the health system. Access to patient-centred care and self-management education is essential to optimise glycaemic control, prevent or delay complications and maintain quality of life. The increasing demand of diabetes on the health system affects access to timely care, with unacceptably long wait times reported, resulting in an increase in morbidity and mortality and poor patient satisfaction. A potential solution is the use of clinical students to contribute to service delivery. Student-assisted and student-led health clinics have increased access to care across the globe for many years. What does the paper add? Although group education has the potential to reduce the burden on clinical service delivery, it was unclear whether a partnership program using students and university and hospital resources would be acceptable to people with T2D and whether this model delivered at a UHC would be sustainable and of benefit to both the health service and university. The results of the evaluation suggest that a university-hospital partnership program is well accepted by participants, well attended, reduces the number of patients waiting for a hospital appointment longer than the acceptable waiting times, increases UHC activity and provides interdisciplinary student experiences. As such, this paper provides evidence that this model of care offers a potential solution to increasing demands for health services for diabetes and student clinical experience. What are the implications for practitioners? Partnerships between UHCs and hospitals offer a sustainable solution to increasing demand for diabetes services and student training requirements. The description of the development, implementation and evaluation processes can be used by practitioners and educators as a framework for the translation of similar models of care to meet demands in other areas where demand for health services exceeds capacity.

Predicting non-attendance in hospital outpatient appointments using deep learning approach

ABSTRACT The hospital outpatient non-attendance imposes a substantial financial burden on hospitals and roots in multiple diverse reasons. This research aims to build an advanced predictive model for predicting non-attendance regarding the whole spectrum of probable contributing factors to non-attendance that could be collated from heterogeneous sources including electronic patients records and external non-hospital data. We proposed a new non-attendance prediction model based on deep neural networks and machine learning models. The proposed approach works upon sparse stacked denoising autoencoders (SDAEs) to learn the underlying manifold of data and thereby compacting information and providing a better representation that can be utilised afterwards by other learning models as well. The proposed approach is evaluated over real hospital data and compared with several well-known and scalable machine learning models. The evaluation results reveal the proposed approach with softmax layer and logistic regression outperforms other methods in practice.

P095 The impact of COVID-19 lockdown on clinical care, self-management, and mental health in patients with inflammatory arthritis

Background/Aims COVID-19 lockdown affected access to clinical care for many vulnerable patients, including those with inflammatory arthritis (IA). It also had the potential to alter self-management behaviours. These changes could in turn impact mental health, especially given that IA patients are already at higher risk of mental health disorders. Thus, the aims of this study were to determine how IA care and self-management were affected by lockdown and assess the impact of these changes on disease outcomes and mental health. Methods Online questionnaires were completed by 338 participants between June and July 2020. The questionnaires assessed demographics, IA condition, IA self-management, COVID-19 clinical information, quality of life, and mental health. Visual analogue scale (VAS) scores for patient global assessment (PGA) of disease activity, pain, fatigue, and emotional distress were completed relating to the previous week and retrospectively for pre-lockdown (March) and early-lockdown (April). Improvement/worsening in each VAS was considered as a change of 10 points or more from pre-lockdown to the current rating. Linear regressions were conducted to determine factors associated with worse outcomes, controlling for potential confounders including self-reported pre-lockdown status. Results Mean VAS scores worsened during lockdown for all outcome measures, with over half reporting a more than 10-point worsening (Table 1). Changes to clinical care affected 87% of patients. The most commonly affected services were hospital outpatient appointments (77%), GP appointments (59%), and blood tests (53%). Changes to clinical care were significantly associated with worse PGA (b = 8.95, p=0.01), pain (b = 7.13, p=0.05), fatigue (b = 17.01, p<0.00) and emotional distress (b = 12.78, p<0.01). Regarding self-management, 64% of patients reported changes to diet while 51% reduced physical activity. Change in diet was not significantly associated with any of the outcomes, whereas physical activity was associated with PGA (b=-2.42, p<0.01), pain (b=-2.43, p<0.01), fatigue (b=-2.5, p < 0.01), and emotional distress (b=-2.41, p<0.01). Conclusion Most patients (87%) had at least one area of clinical care affected by the lockdown. These changes in IA clinical care were associated with worse disease outcomes across all measures and greater emotional distress. In self-management, reduced physical activity was associated with worse outcomes in all physical and mental health measures. P095 Table 1:Mean VAS (0-100) scores and percent changesPGAMarch April June/JulyMean (SD) 44.51 (23.70) 53.18 (24.67) 57.69 (25.29)Better Same WorsePercent 7.9936.6855.33[95% CI] [5.33-11.41][31.54-42.07][49.85-60.71]PainMarch April June/July42.60 (25.60) 51.11 (26.01) 56.66 (26.40)Better Same Worse7.6937.8754.44[5.09-11.07] [32.68-43.28][48.96-59.84]FatigueMarch April June/July46.86 (26.17) 57.11 (25.83) 61.35 (26.51)Better Same Worse10.0634.0255.92[7.07-13.77] [28.98-39.35][50.44-61.29]Emotional DistressMarch April June/July30.96 (26.28) 49.06 (29.09) 48.75 (29.15)Better Same Worse8.2833.14 58.58[5.58-11.75] [28.14-38.43][53.12-63.88] Disclosure M. Sweeney: None. L. Carpenter: None. S. de Souza: None. H. Chaplin: None. H. Tung: None. E. Caton: None. J. Galloway: None. A. Cope: None. M. Yates: None. S. Norton: None.

28 Medication Compliance Aids and Acute Hospitals

Abstract Introduction An estimated 64 million Medication Compliance Aids (MCAs) are dispensed by pharmacies in England each year as a method of reasonable adjustment to improve medication adherence (NICE 2009) and support medicines administration by carers (RPS 2013). Complexities exist when implementing medication changes for patients using MCAs, particularly at hospital discharge or outpatient appointments, where practices seem to vary. This National Survey is the first to determine the current policy and service provision of MCAs by acute hospitals in England. Methods An electronic survey was emailed to Chief Pharmacists via the Regional Medicines Information Services in Spring 2019. Initial non-responders were contacted by email and telephone. Results 51% (73/144) of acute hospital trusts in England responded. 77% (56/73) dispensed medication in MCAs at discharge. Of these, 62.5% would initiate MCAs and 61% supplied a different length of MCA vs non-MCA prescription (see table). 41 hospitals had designated staff completing MCAs. The median time to complete an MCA was 59.5 minutes (range 10–200). The median time from prescription receipt in pharmacy to MCA arrival on ward was 144.5 minutes (range 60–1,440). Of the 17 hospitals not providing MCAs, the majority would, upon discharge, contact the community pharmacy that provided the MCA pre-admission to update any medication changes and request the provision of a new supply of medicines. Conclusion Despite the ubiquitous nature of the MCA, there is no standard approach to the supply of these devices from acute hospitals across England. When hospitals do provide MCAs their preparation is time consuming, often requiring additional staff. A national approach to MCAs might help patients and carers, and reduce medication-related problems and costs.

96 Impact of COVID19 Restrictions on Older Patients Attending An Outpatient Service

IntroductionDuring the Covid19 pandemic older adults (>70 years) in Ireland were advised to stay at home and avoid unnecessary physical contact—termed “cocooning”. During this time hospital outpatient appointments were conducted virtually (via telephone). This project aimed to assess patients experience of Covid19 cocooning and the virtual outpatient service.MethodsPatients attending an outpatient geriatric medicine service were invited to participate in this project following their routine virtual assessment. A proforma questionnaire was administered to participants contacted virtually within one week of consent. Data was anonymised, imported into excel and analysed using SPSS (chi-squared test).Results31 patients were included, median age was 83 years. 52% were male, 25% lived alone and 52% had cognitive impairment. 77% had heard of “cocooning”, of which 79% correctly understood the term. Three-quarters stated that cocooning had negatively impacted their quality of life (QoL); anxiety, loneliness and depression were reported in 49%, 36% and 29% respectively. 39% strongly feared getting Covid19. Cognition and living status did not correlate significantly with the psychological impact of Covid19. 61% did not use modern social media, its use did not impact QoL scores (p = 0.075). 45% experienced a reduction in support services. 87% found the OPD telephone service useful and 77% reported their needs were addressed. Three-quarters favoured future virtual assessments.ConclusionOne third of patients poorly understood “cocooning”. Necessary Covid19 restrictions impacted negatively psychologically on this older cohort. Novel virtual clinics proved a positive experience and a useful future outpatient resource even amongst our oldest patients with dementia.

Predicting Hospital Outpatient Attendance Using Random Forest Classifiers

Background: Patient non-attendance of outpatient appointments is a major concern for healthcare providers. These non-attendances are detrimental to the patient's health and a major cost to the provider. However, non-targeted interventions may cost more in administrative resources than the missed appointments themselves. Methods: In this work, a random forest classification algorithm was trained to predict whether an appointment will be missed for patients of all ages and appointments with all specialties at a major London hospital. Findings: The model achieves an AUROC score of 0.76 and accuracy of 73\% on test data which contained only appointments from patients who did not appear in the training data. Further, the model achieves an AUROC score of 0.75 in a second test set which contains only patients from the year 2020. Interpretation: Our model is strongly predictive of whether a hospital outpatient appointment will be attended. Its performance on both patients who did not appear in the training data and appointments from a different time period which covers the Covid-19 pandemic indicate it generalized well and could be used to target resources towards those patients who are likely to miss an appointment. Funding: This study was partially funded by STFC DiRAC innovation fellowships which funded the work of Jonathan Holdship and Harpreet Dhanoa.Declaration of Interests: The authors declare that there is no conflict of interest regarding the publication of this article.Ethics Approval Statement: The Trust Quality Improvement & Audit Committee at Guy’s & St Thomas NHS Foundation Trust approved audit/service evaluation number 116298 registered on the trust database.

1640. A Clinical Audit and Cost Analysis of Tuberculosis Management at a Tertiary Referral Centre in the Republic of Ireland

BackgroundIreland is a low tuberculosis (TB) incidence country. Effective TB services are important in the efforts to meet WHO End TB Targets. A dedicated TB clinic was established in our tertiary referral centre in 2018. Our aim is to describe the patients with TB attending our service and evaluate the care provided to them in terms of cost and clinical effectiveness.MethodsWe performed a retrospective review of patients attending our service from 01/07/2018-31/12/2019. We included patients who were referred for assessment of symptoms of active tuberculosis. We collected data on patients risk factors for TB, time from illness onset to diagnosis and resources utilized (including hospital admissions, outpatient appointments, investigations and drug treatment). We estimated the productivity losses due to TB in our cohort following the Hanover Consensus. Using national TB notifications data we used our estimate treatment cost and productivity losses to estimate the total national cost of TB in Ireland in 2019.ResultsFifty-four patients were assessed for TB in our clinic. Most patients (68.5%) referred had a diagnosis of TB made, 5.6% had a non-tuberculosis mycobacterial infection and the remainder had no mycobacterial infection diagnosed. Over half (51.4%) of patients with TB had respiratory TB. The most prevalent risk factor was being from a country of high TB incidence (59.5% of TB patients). Five patients (13.5%) had drug resistance. Patients were referred most frequently from the emergency department (54.1%). The median time from symptom onset to diagnosis was 14.1 weeks (IQR 5.3-30) in patients with respiratory TB compared to 25.9 weeks (IQR 6.3-55.9) in patients with non-respiratory TB. Out of 35 patients who remained within our service 97.1% (34/35) completed treatment and 2.9% (1/35) are still on treatment.We estimate that the median cost of managing a case of TB in our centre was €6088 (€1,003-17,588). The estimated cost of managing all 267 cases of TB in Ireland in 2019 was €9,048,380 which incurred productivity losses of €791,421. The total cost of TB to Ireland in 2019 was €9,839,801.ConclusionOur clinic had a high rate of treatment success. Interventions to reduce diagnostic delay and cost are needed.Disclosures All Authors: No reported disclosures

Integrated diagnostic pathway for patients referred with suspected OSA: a model for collaboration across the primary–secondary care interface

BackgroundObstructive sleep apnoea (OSA) presents a major healthcare challenge with current UK data suggesting that only 22% of individuals have been diagnosed and treated. Promoting awareness and improving access to...

Is COVID-19 affecting the epidemiology of STIs? The experience of syphilis in Rome

Dear Editor, In response to the COVID-19 pandemic, on 9 March 2020, the Italian government announced a nationwide lockdown programme of social distancing, self-isolation for contacts and prohibition of public...

Patient-initiated appointment systems for adults with chronic conditions in secondary care.

Missed hospital outpatient appointments is a commonly reported problem in healthcare services around the world; for example, they cost the National Health Service (NHS) in the UK millions of pounds every year and can cause operation and scheduling difficulties worldwide. In 2002, the World Health Organization (WHO) published a report highlighting the need for a model of care that more readily meets the needs of people with chronic conditions. Patient-initiated appointment systems may be able to meet this need at the same time as improving the efficiency of hospital appointments. To assess the effects of patient-initiated appointment systems compared with consultant-led appointment systems for people with chronic or recurrent conditions managed in secondary care. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and six other databases. We contacted authors of identified studies and conducted backwards and forwards citation searching. We searched for current/ongoing research in two trial registers. Searches were run on 13 March 2019. We included randomised trials, published and unpublished in any language that compared the use of patient-initiated appointment systems to consultant-led appointment systems for adults with chronic or recurrent conditions managed in secondary care if they reported one or more of the following outcomes: physical measures of health status or disease activity (including harms), quality of life, service utilisation or cost, adverse effects, patient or clinician satisfaction, or failures of the 'system'. Two review authors independently screened all references at title/abstract stage and full-text stage using prespecified inclusion criteria. We resolved disagreements though discussion. Two review authors independently completed data extraction for all included studies. We discussed and resolved discrepancies with a third review author. Where needed, we contacted authors of included papers to provide more information. Two review authors independently assessed the risk of bias using the Cochrane Effective Practice and Organisation of Care 'Risk of bias' tool, resolving any discrepancies with a third review author. Two review authors independently assessed the certainty of the evidence using GRADE. The 17 included randomised trials (3854 participants; mean age 41 to 76 years; follow-up 12 to 72 months) covered six broad health conditions: cancer, rheumatoid arthritis, asthma, chronic obstructive pulmonary disease, psoriasis and inflammatory bowel disease. The certainty of the evidence using GRADE ratings was mainly low to very low. The results suggest that patient-initiated clinics may make little or no difference to anxiety (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.68 to 1.12; 5 studies, 1019 participants; low-certainty evidence) or depression (OR 0.79 95% CI 0.51 to 1.23; 6 studies, 1835 participants; low-certainty evidence) compared to the consultant-led appointment system. The results also suggest that patient-initiated clinics may make little or no difference to quality of life (standardised mean difference (SMD) 0.12, 95% CI 0.00 to 0.25; 7 studies, 1486 participants; low-certainty evidence) compared to the consultant-led appointment system. Results for service utilisation (contacts) suggest there may be little or no difference in service utilisation in terms of contacts between the patient-initiated and consultant-led appointment groups; however, the effect is not certain as the rate ratio ranged from 0.68 to 3.83 across the studies (median rate ratio 1.11, interquartile (IQR) 0.93 to 1.37; 15 studies, 3348 participants; low-certainty evidence). It is uncertain if service utilisation (costs) are reduced in the patient-initiated compared to the consultant-led appointment groups (8 studies, 2235 participants; very low-certainty evidence). The results suggest that adverse events such as relapses in some conditions (inflammatory bowel disease and cancer) may have little or no reduction in the patient-initiated appointment group in comparison with the consultant-led appointment group (MD -0.20, 95% CI -0.54 to 0.14; 3 studies, 888 participants; low-certainty evidence). The results are unclear about any differences the intervention may make to patient satisfaction (SMD 0.05, 95% CI -0.41 to 0.52; 2 studies, 375 participants) because the certainty of the evidence is low, as each study used different questions to collect their data at different time points and across different health conditions. Some areas of risk of bias across all the included studies was consistently high (i.e. for blinding of participants and personnel and blinding of outcome assessment, other areas were largely of low risk of bias or were affected by poor reporting making the assessment unclear). Patient-initiated appointment systems may have little or no effect on patient anxiety, depression and quality of life compared to consultant-led appointment systems. Other aspects of disease status and experience also appear to show little or no difference between patient-initiated and consultant-led appointment systems. Patient-initiated appointment systems may have little or no effect on service utilisation in terms of service contact and there is uncertainty about costs compared to consultant-led appointment systems. Patient-initiated appointment systems may have little or no effect on adverse events such as relapse or patient satisfaction compared to consultant-led appointment systems.

Exploring the acceptability and feasibility of patient-initiated follow-up for women treated for stage I endometrial cancer.

There is a strong shift away from hospital-based approaches to follow-up after active treatment for cancer with supported self-management being promoted as an approach to long term recovery. We aimed to determine the acceptability and feasibility of patient-initiated follow-up (PIFU), supported by a self-management approach, for patients treated for Stage I endometrial cancer. A mixed methods study was undertaken. Participants were asked to forego hospital outpatient follow-up appointments, supported by a self-management approach. Outcome measures included satisfaction with information and service, psychological morbidity, quality of life and preferences for follow-up. Qualitative interviews were carried out with study participants to determine their views on follow-up in general and PIFU in particular. We recruited 17 patients. High levels of satisfaction were evident with no physical or psychological detriment. Self-management was a favoured option. Participants questioned the value of hospital follow-up and were willing to engage in self-management if they knew who to contact if they had a problem and were aware of the signs and symptoms of recurrence. However, uptake to the study was low and further work is needed to explore if recruitment to a randomised controlled trial (RCT) is a viable option. Alternative approaches to hospital-based follow-up need to demonstrate that patients feel supported, knowing what symptoms to report and to whom. This study shows acceptability of a supported self-management approach but raises some concerns about the feasibility of recruitment to a future RCT.