Individual Appointments Research Articles

Hypoglycaemia unawareness in young people with type 1 diabetes transferred to an adult center

AimTo evaluate frequency of hypoglycaemia unawareness (HU) in patients with type 1 diabetes(T1D) transferred from Paediatrics following a specific therapeutic education programme (TEP) in an adult hospital. Patients and methodYoung patients transferred from 2009-2011 were evaluated. The TEP included a coordinated transfer process, individual appointments and a group course. At baseline and at 12 months we evaluated glycated haemoglobin (HbA1c) frequency of severe (SH) hypoglycaemia/patient/year and non severe hypoglycaemia (NSH). The patients were classified into two groups and compared: hypoglycaemia awareness (HA) and HU according to the Clarke Test <3R or > 3R respectively. ResultsFifty-six patients (age 18.1 ± 0.3 years, 46% females, HbA1c 8.0 ± 1.2%) underwent the TEP. In the baseline evaluation 16% presented HU. The number of SH was higher in the HU Group (0.33 ± 0.50 vs. 0.09 ± 0.28 p < 0.05). The percentage of patients with >2 NSH/week was higher, albeit not significantly, in the HU group (66% vs. 34%, p = 0.06). At 12 months 11% of the patients continued to present HU. The number of SH remained higher in the HU group (0.38 ± 1.06 vs.0.02 ± 0.15 p = 0.04). ConclusionsThe percentage of young people with T1D with HU is quite high at transfer. Although the TEP improves hypoglycaemia awareness it does not solve this important problem. Patients with HU more frequently present SH. It is necessary to identify HU in order to reduce SH which continues to be a problem in people with T1D.

Increased Protein Density During Weight Loss Is Correlated with Reduced Abdominal Obesity and Body Mass Index and Improved Body Composition

Abstract Objectives There is a clear link between abdominal obesity and chronic diseases. Dietary changes leading to substantial weight loss reduce obesity and improve health; however, no viable dietary treatment program exists that produces clinically significant, cost-effective, and sustainable weight loss. To test the hypothesis that a diet dense in lean proteins and fiber is inversely associated with abdominal obesity while maintaining skeletal muscle mass (SMM), we evaluated the correlation between mean protein and fiber density and changes in BMI, waist circumference and SMM during weight loss. Methods Thirty adult males and females participated in this ongoing, 2-year dietary weight loss program. The Individualized Dietary Improvement Program focused on reducing caloric intake and increasing protein (7–11 g/100 kcal) and fiber (1.8–3.2 g/100 kcal) density to desired ranges. Participants attended 19 group educational sessions, 3 individual counseling appointments, self-weighed daily, and submitted monthly 24-hour dietary recalls. BMI, waist circumference and body composition (InBody) measurements were collected at baseline and after 6 months. Results At 6 months, 25 participants (24–70y) remained in the study with 18 completing all body measurements. Mean weight loss (n = 25) was −2.2 ± 0.5 BMI points (–5.2 ± 1.3% of initial body weight) and mean waist circumference reduction (n = 18) was −6.5 ± 1.3 cm from baseline. Significant increases in protein and fiber density were seen from baseline to month 2 (P &amp;lt; 0.05). There were direct inverse associations between mean protein density and both reduced waist circumference (P &amp;lt; 0.01) and reduced BMI (P &amp;lt; 0.01). Fiber intake had no significant impact on weight loss, and maintenance of SMM did not significantly correlate with mean protein density. However, only 11.0 ± 3.2% of weight lost was due to the loss of SMM, supporting the efficacy of the program. A significant positive correlation (P &amp;lt; 0.01) existed between fat mass loss and protein density, with 74.3 ± 4.7% of excess body fat accounting for total weight lost. Conclusions Increased protein density correlates with accelerated loss of fat mass, greater reductions in abdominal adiposity, and may protect SMM from degradation during weight loss. Funding Sources This research is supported by the NIBIB of the NIH and the USDA NIFA.

Efficacy of Depression Management in an Integrated Psychiatric-Diabetes Education Clinic for Comorbid Depression and Diabetes Mellitus Types 1 and 2

ObjectivesPatients with type 1 and type 2 diabetes mellitus (DM) are 2 times as predisposed to developing mood disorders, such as major depressive disorder (MDD), compared with patients without diabetes. Management of comorbid MDD and DM remains a challenge because patients often suffer from poor medication compliance, lifestyle factors and refractory depression. Integration of psychiatric care into diabetes education clinics (DECs) has been suggested as an effective method of managing the comorbid conditions. As this strategy is being implemented into clinical care, its effectiveness in practice warrants further research. MethodsA retrospective chart review of 24 patients (10 men and 14 women) followed by an integrated psychiatry-DEC in Newmarket, Ontario, Canada, between April 2016 and July 2019 was performed. Depressive symptom severity at each appointment was assessed with the Patient Health Questionnaire-9 (PHQ-9) depression rating scale. ResultsThere was no significant change in PHQ-9 depression rating scale scoring between the first and most recent appointments (paired t test, p=0.356); however, patients who had improved PHQ-9 scoring were more likely to have more clinic visits (analysis of variance, p=0.0271). A significant negative correlation was found between both number of visits (Pearson coefficient, −0.56; p=0.005) and overall time the patients were followed by DEC (Pearson coefficient, −0.42; p=0.040) and PHQ-9 score changes between the first and most recent appointments. PHQ-9 change between individual appointments also displayed a positive correlation with time between appointments (Pearson coefficient, 0.26; p=0.027). ConclusionsRegular follow up in a psychiatry-DEC service might be beneficial in managing MDD symptom severity for comorbid MDD and DM.

A Qualitative Evaluation of Patient Experiences With Group Medical and Individual Education Appointments for Type 2 Diabetes Management in Saskatchewan, Canada.

The purpose of this study was to capture information on patient experiences and perspectives of group medical appointments (GMAs) and compare them to those attending individual appointments (IAs) with the diabetes education team (usual care) for managing type 2 diabetes. Adults (N = 18; 61% male; 83% 50-70 years old ) with type 2 diabetes (or prediabetes) living in rural Saskatchewan were recruited to complete a semistructured interview on their experiences with GMAs or IAs. To be eligible to participate, individuals must have attended at least 2 GMAs or 2 IAs. Transcripts were coded and analyzed using content analysis. Overall, participants spoke highly of their respective appointment type. Results indicated that both appointment types positively influenced understanding of diabetes management, with the most notable difference being greater understanding of stress management in the GMAs. Participants identified several positive aspects of each appointment type, which included convenience, supportive and enjoyable, and informative for GMAs and time and tailored information for IAs. Participants provided some suggestions to improve diabetes related-care for their respective appointment type. Participants of GMAs and IAs for type 2 diabetes each reported unique strengths to their respective care plan and reported benefiting from their care.

Association between shared medical appointments and weight loss outcomes and anti-obesity medication use in patients with obesity.

SummaryObjectiveIn shared medical appointments (SMAs), multiple patients with a similar clinical diagnosis are seen by a multidisciplinary team for interactive group sessions. Very few studies have specifically studied SMAs and weight loss in patients with obesity. This study compared weight loss outcomes and anti‐obesity medication (AOM) access between patients with obesity managed through (SMAs) versus individual appointments.MethodsRetrospective study of adults seen for obesity between September 2014 and February 2017 at Cleveland Clinic Institute of Endocrinology and Metabolism. Percent weight loss from baseline was compared between two propensity score‐matched populations: patients who attended ≥1 SMA and patients managed with individual medical appointments.ResultsFrom all eligible patients identified (n=310 SMA, n=1,993 non‐SMA), 301 matched pairs were evaluated for weight loss. The SMA group (n=301) lost a mean of 4.2%, 5.2% and 3.8% of baseline weight over 6, 12 and 24 months; the non‐SMA group (n=301) lost significantly less weight (1.5%, 1.8% and 1.6%, respectively) (paired t‐test, P<.05). All patients were eligible for US Food and Drug Administration‐approved AOMs based on obesity diagnosis; however, 49.8% (150/301) of matched SMA patients were prescribed an AOM versus 12.3% (37/301) of matched non‐SMA patients.ConclusionThis study suggests that SMAs may offer a promising alterative for obesity management and one that may facilitate greater utilization of AOMs. In propensity score‐matched cohorts, SMAs were associated with greater weight loss outcomes when compared to usual care facilitated through individual medical appointments alone.

Group plus \u201cmini\u201d individual pre-test genetic counselling sessions for hereditary cancer shorten provider time and improve patient satisfaction

BackgroundGenetic counselling (GC) is an integral component in the care of individuals at risk for hereditary cancer predisposition syndromes (CPS). In many jurisdictions, access to timely counselling and testing is limited by financial constraints, by the shortage of genetics professionals and by labor-intensive traditional models of individual pre and post-test counselling. There is a need for further research regarding alternate methods of GC service delivery and implementation. This quality improvement project was initiated to determine if pretest group GC followed immediately by a ‘mini’ individual session, would be acceptable to patients at risk for hereditary breast and colon cancer.MethodsPatients on waitlists for GC at the Provincial Medical Genetics Program in St. John’s, NL, Canada (n = 112), were contacted by telephone and offered the option of a group counselling session (GGC), followed by a “mini” individual session, versus (TGC) traditional private appointments. GGC sessions consisted of a cancer genetics information session given to groups of 6–20 followed by brief 20 min “mini” individual sessions with the patient and genetic specialist. TGC individual appointments provided the same cancer genetics information and counselling to one patient at a time in the classic model. All but 2 participants selected group+mini session. A de-identified confidential 12-item, Likert scale survey was distributed at the conclusion of mini-sessions to measure perceptions of GGC and satisfaction with this counselling model.ResultsSixty participants completed questionnaires. The majority of participants strongly agreed that they were comfortable with the group session (58/60); the explanation of cancer genetics was clear (54/59); they understood their cancer risks (50/60); and they would recommend such a session to others (56/59). 38/53 respondents disagreed or strongly disagreed that they would prefer to wait for a traditional private appointment. All 5 participating genetic counselors reported a preference for this model. At the end of the pilot project, the waitlist for counselling/testing was reduced by 12 months.ConclusionsGroup pre-test genetic counselling combined with immediate “mini” individual session is strongly supported by patients and reduces wait times. Additional formal investigation of this approach in larger numbers of patients is warranted.

Parent coaching increases conversational turns and advances infant language development

Parental language input is one of the best predictors of children's language achievement. Parentese, a near-universal speaking style distinguished by higher pitch, slower tempo, and exaggerated intonation, has been documented in speech directed toward young children in many countries. Previous research shows that the use of parentese and parent-child turn-taking are both associated with advances in children's language learning. We conducted a randomized controlled trial to determine whether a parent coaching intervention delivered when the infants are 6, 10, and 14 mo of age can enhance parental language input and whether this, in turn, changes the trajectory of child language development between 6 and 18 mo of age. Families of typically developing 6-mo-old infants (n = 71) were randomly assigned to intervention and control groups. Naturalistic first-person audio recordings of the infants' home language environment and vocalizations were recorded when the infants were 6, 10, 14, and 18 mo of age. After the 6-, 10-, and 14-mo recordings, intervention, but not control parents attended individual coaching appointments to receive linguistic feedback, listen to language input in their own recordings, and discuss age-appropriate activities that promote language growth. Intervention significantly enhanced parental use of parentese and parent-child turn-taking between 6 and 18 mo. Increases in both variables were significantly correlated with children's language growth during the same period, and children's language outcomes at 18 mo. Using parentese, a socially and linguistically enhanced speaking style, improves children's social language turn-taking and language skills. Research-based interventions targeting social aspects of parent-child interactions can enhance language outcomes.

Appointment Scheduling at Outpatient Clinics Using Two-Stage Stochastic Programming Approach

Clinics with a large volume of patients are often burdened with limited resources such as nurses and providers. Also, an efficient health system seeks short wait times for the patients to see the provider (indirect wait time) and within the clinic (direct wait time) during the day of the appointment. Additionally, the appointment duration, volume of patients, no-show behavior are uncertain. The direct and indirect wait times, stochastic parameters, rising treatment costs, and increased demand of patients motivate the need for efficient appointment schedules and clinic operations. In this paper, we develop a two-stage stochastic mixed-integer linear programming model (SMILP) integrated with a simulation model to generate a scheduling template for the providers to schedule individual patient appointments and resources. The model minimizes the expected wait times for the patients with a fair and equitable utilization of the resources. Computational experiments were conducted using a data-driven simulation model, and the results indicate that the proposed approach can significantly decrease patients’ direct and indirect wait times when compared to a deterministic indexing policy used for scheduling appointments.

Physical activity behaviour and barriers to activity in adults at high risk of obstructive sleep apnoea.

INTRODUCTION Physical inactivity is a risk factor for disease severity among people with obstructive sleep apnoea. AIM To determine physical activity levels in patients at risk of obstructive sleep apnoea and explore their perceptions about barriers to participation in physical activity. METHODS This was a cross-sectional observational study. Eligible participants were adults with symptoms of obstructive sleep apnoea hypopnea syndrome and Epworth Sleepiness Scale score ≥11, awaiting prioritisation for a diagnostic overnight sleep study at the local sleep clinic. Sixty participants (mean age±standard deviation: 51±12 years) each attended an individual appointment. Anthropometric measurements were taken and standardised questionnaires regarding quality of life, physical activity behaviour and perceptions of physical activity were completed. RESULTS Over one-third of the cohort did not meet World Health Organization guidelines for weekly physical activity. Hypertension, type 2 diabetes and obesity were also more prevalent in this subgroup. Low motivation and pain were commonly reported barriers to activity in participants not meeting the physical activity guidelines. Overall, 53 (88%) participants stated they would like to be more active. DISCUSSION Physical inactivity represents an additional risk factor for adults at high risk of obstructive sleep apnoea. Lack of motivation and pain were the most commonly perceived barriers to participation in activity. Physical activity interventions tailored to the individual, and including a motivational component, need to be included as integral components of management to reduce cardiovascular and metabolic risk factors more effectively in this group.

Is Peer Support in Group Clinics as Effective as Traditional Individual Appointments? The First Study in Patients With Celiac Disease.

INTRODUCTION:Celiac disease (CD) is common, affecting approximately 1% of the population. The cornerstone of management is a gluten-free diet, with dietetic advice being the key to aiding implementation. The aim of the study was to assess group clinics in comparison with traditional individual appointments.METHODS:Patients with a new diagnosis of CD, confirmed histologically, were prospectively recruited over 18 months in Sheffield, United Kingdom. Patients received either a group clinic or traditional one-to-one appointment, led by a dietitian. Quality-of-life questionnaires were completed at baseline, as well as biochemical parameters being recorded. Patients were followed up at 3 months, where adherence scores were assessed as well as biochemical parameters and quality of life questionnaires being completed.RESULTS:Sixty patients with CD were prospectively recruited and received either an individual (n = 30) or group clinic (n = 30). A statistically significant reduction in tissue transglutaminase was noted following group clinics (mean 58.5, SD 43.4 U/mL vs mean 13.2, SD 5.7 U/mL, P < 0.01). No significant differences in baseline and follow-up biochemical parameters between one-to-one and group clinics were noted. At follow-up, there was no statistically significant difference between mean gluten-free diet adherence scores (mean 3.1, SD 0.4 vs mean 3.1, SD 0.7, P = 0.66) between one-to-one and group clinics.DISCUSSION:This first study assessing group clinics in CD demonstrates they are as effective as traditional one-to-one clinics, with the added benefits of peer support and greater efficiency, with an estimated 54% reduction of dietetic resources.

On Selecting a Probabilistic Classifier for Appointment No-show Prediction

[enter Abstract Body]Appointment no-shows are disruptive to healthcare clinics, and may increase patient waiting time and clinic overtime, resulting in increased clinic costs. Appointment scheduling models typically mitigate the negative effects of no-shows through appointment overbooking. Recent work has proposed a predictive overbooking framework, where a probabilisitic classifier predicts the no-show probability of individual appointment requests, and a scheduling algorithm uses those predictions to optimally schedule appointments. Because predicting no-shows is typically an imbalanced classification problem, the preferred classifier is often chosen based upon the area under the receiver operator characteristic curve (AUC), which is a commonly used metric for many other imbalanced classification problems. Contrary to intuition, in this paper we show that employing the AUC to select a classifier results in significantly lower schedule efficiency than using other metrics such as Log Loss or Brier Score. Our computational experiments, validated on large real-world appointment data, suggest that by using Log Loss or Brier Score instead of AUC, practitioners can improve the schedule quality by up to 7%.

Supporting parents of children aged 2-13 with toileting difficulties: Group-based workshops versus individual appointments.

Toileting is a key activity of daily living and an important milestone in children's development. Difficulties with this process can cause stress to both child and parents and negatively affect their wellbeing. This study compared the perceived parental competence and child wellbeing of families attending a group-based workshop on toileting issues with families attending an individual appointment at a continence clinic. All parents attending the workshops and attending the clinic between July 2016 and December 2017 were invited to participate in the study. The children were aged between 2 and 13 years. Three measures were used: 1) Parenting Sense of Competence Scale; (2) the Revised Quality of Life Questionnaire for Children (KINDLR) and (3) Parent self-assessment of information and support needs. Participants completed all measures at three points: prior to intervention, 1 week and 1 month post-intervention. Data were collected from 89 parents attending the workshops and 46 parents attending the clinic. Children were not assessed. Non-parametric tests were used to examine between group differences. Within group changes overtime were examined using Friedman's two-way analysis of variance. Parents who attended the workshop showed significant increases in parenting sense of competence and perceived child quality of life post-intervention. Although there were significant differences between and pre- and post-measures for workshop attendees, there were no significant differences found between the two groups indicating that both forms of intervention had beneficial results. These results suggest that group-based workshops can positively impact parents' perceived competence in managing their child's toileting issues and wellbeing. Further research is recommended to explore the relationship between parenting competence and child wellbeing and to determine which aspects of the workshops were most beneficial.

Hipoglucemia desapercibida en jóvenes con diabetes tipo 1 trasladados a un centro de adultos

ObjectiveTo evaluate frequency of hypoglycaemia unawareness (HU) in patients with type 1 diabetes (T1D) transferred from Paediatrics following a specific therapeutic education programme (TEP) in an adult hospital. Patients and methodsYoung patients transferred from 2009-2011 were evaluated. The TEP included a coordinated transfer process, individual appointments and a group course. At baseline and at 12 months we evaluated glycated haemoglobin (HbA1c) frequency of severe (SH) hypoglycaemia/patient/year and non severe hypoglycaemia (NSH). The patients were classified into two groups and compared: hypoglycaemia awareness (HA) and HU according to the Clarke Test <3R or>3R respectively. ResultsFifty-six patients (age 18.1±0.3 years, 46% females, HbA1c 8.0±1.2%) underwent the TEP. In the baseline evaluation 16% presented HU. The number of SH was higher in the HU Group (0.33±0.50 vs. 0.09±0.28 P<.05). The percentage of patients with>2 NSH/week was higher, albeit not significantly, in the HU group (66% vs. 34%, p=0.06). At 12 months 11% of the patients continued to present HU. The number of SH remained higher in the HU group (0.38±1.06 vs. 0.02±0.15 P=.04). ConclusionsThe percentage of young people with T1D with HU is quite high at transfer. Although the TEP improves hypoglycaemia awareness it does not solve this important problem. Patients with HU more frequently present SH. It is necessary to identify HU in order to reduce SH which continues to be a problem in people with T1D.

Effects of shared medical appointments compared to individual appointments in children with atopic dermatitis: A pragmatic randomized controlled trial

Atopic dermatitis (AD) needs intensive treatment and has a negative impact on quality of life. Shared medical appointments (SMAs) showed to be effective in clinical outcomes of chronic diseases, but little is known about the effects on children and families. To evaluate the effects of SMAs compared to individual appointments (IA) for children with AD and their parents on coping and clinical outcomes. In a pragmatic randomized controlled trial, new patients in UMC Utrecht with AD, younger than 18years, and their parents were assigned to the SMA group or the IA group using a covariate adaptive randomization method, controlled for age. Before the intervention, 2months (primary time-point) and 6months thereafter, we assessed parental emotional coping (primary outcome), quality of life, anxiety about corticosteroids and patient disease activity. Patients, parents and healthcare professionals could not be blinded to group assignment. Of 140 patients, enrolled in the trial, 69 patients were assigned to the SMA and 71 to the IA intervention of whom 114 completed the intervention (SMA: 49; IA: 65). After 2months, there were no differences between SMAs and IAs in effects on emotional coping: b 0.66, 95% CI -0.7 to 2.03; P=0.33 (mean difference: 0.30; 95% CI -1.56 to 2.16; N SMA: 11; IA: 24), quality of life, anxiety about corticosteroids and disease activity. From the initial appointment to long-term follow-up, both groups showed substantial improvements, but not significant in disease activity and significant reduction in anxiety about corticosteroids. This study is limited by a low response rate; therefore, linear mixed models and dropout analyses were performed. No serious adverse events were reported. For children with AD and their parents, there were no additional benefits of GMAs in parental emotional coping, anxiety about corticosteroids, quality of life and disease activity. www.ISRCTN.org, ISRCTN08506572.

Home Telemedicine (CoYoT1 Clinic): A Novel Approach to Improve Psychosocial Outcomes in Young Adults With Diabetes

To assess the impact of a home telemedicine clinic model (CoYoT1 Clinic) on psychosocial and behavioral outcomes designed for young adults (YAs) with type 1 diabetes (T1D). YAs self-selected to participate in the CoYoT1 Clinic or serve as a usual care control. CoYoT1 Clinic visits consisted of an individual appointment with a provider and a group appointment with other YAs with T1D using home telemedicine. Psychosocial and behavioral functioning was assessed by 4 measures: Diabetes Distress Scale, Self-Efficacy for Diabetes Scale, Self-Management of Type 1 Diabetes in Adolescence Scale, and Center for Epidemiologic Studies Depression Scale. Forty-two patients participated in the CoYoT1 Clinic and 39 patients served as controls. CoYoT1 participants reported lower levels of distress (P = .03), increased diabetes self-efficacy (P = .01), and improved ability to communicate with others about diabetes (P = .04) over the study period compared to controls. YA males in the control group reported increases in depressive symptoms (P = .03) during the study period, but CoYoT1 participants showed no changes. Group home telemedicine for YAs with T1D positively affects diabetes distress, self-efficacy, and diabetes-specific communication. These positive findings have the potential to also affect the YAs' long-term diabetes outcomes. Further investigation of the model is needed.

201-OR: ADA Presidents' Select Abstract: Shared Medical Appointments (SMA) Improve Psychosocial Outcomes in Adolescents with Type 1 Diabetes (T1D)

Background: T1D care delivery via SMA is associated with increased attendance and satisfaction in adolescents, but the impact of the model on clinical and psychosocial outcomes remains unclear. Objective: Evaluate the efficacy of SMA for improving psychosocial outcomes in adolescents with T1D. Methods: Participants in the prospective Team Clinic study were randomized to attend SMA or individual appointments (usual care). They completed the Children’s Depression Inventory (CDI), Problem Areas in Diabetes (PAID), Diabetes Family Conflict Scale (DFCS), and Diabetes Strengths and Resilience (D-STAR) measures at baseline and after one year. Results: Eighty-six adolescents (51% female; 74% white; 10% Latinx) completed at least one study visit. Team Clinic participants (n = 44) attended more visits than patients in usual care (n = 42; p &amp;lt; 0.0001), and they attended all four study visits more frequently (66%) than those in usual care (33%). Although all adolescents reported nearly equal levels of depressive symptoms, emotional distress, and family conflict associated with diabetes care at baseline, significant differences emerged over the course of the study. Specifically, adolescents in Team Clinic reported reduced levels of conflict with family, while those in usual care reported slightly increased levels of conflict (p=0.03). Team Clinic adolescents also reported reduced depressive symptoms when compared to usual care, including more positive mood (p=0.001), greater self-esteem (p=0.03), improved effectiveness in completing daily tasks (p=0.03), and reduced anhedonia (p=0.04). Team Clinic adolescents also reported improved resilience and reduced emotional distress in diabetes care compared to controls, but these results were only marginally significant. Conclusions: SMA may support adolescents with T1D in reducing familial conflict associated with diabetes care, while providing a decrease in comorbid depressive symptoms. Disclosure J. Raymond: Other Relationship; Self; Insulet Corporation. M.W. Reid: None. C. Berget: Consultant; Self; Insulet Corporation, Medtronic. C.L. Cain: None. B. Anderson: None. G.J. Klingensmith: Consultant; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Takeda Pharmaceutical Company Limited. Research Support; Self; Novo Nordisk Foundation. Stock/Shareholder; Spouse/Partner; Dexcom, Inc. Funding The Leona M. and Harry B. Helmsley Charitable Trust

Women’s Barriers to Weight Loss, Knowledge of Future Diabetes Risk and Opinions of Diet Strategies Following Gestational Diabetes: An Online Survey (OR08-01-19)

ObjectivesWeight loss after gestational diabetes (GDM) significantly reduces the risk of developing type 2 diabetes (T2DM) however weight loss is not easily achieved or maintained. The purpose of this survey was to examine knowledge of future risk of T2DM after GDM, barriers to weight loss and to identify diet strategies that these women feel might work for them. Opinions of intermittent energy restriction (IER) were of particular interest. MethodsAustralian women aged ≥18 years who ever had GDM were invited to participate in this cross-sectional online survey. The survey was developed by a dietitian using the Theoretical Domains Framework and underwent expert review (n = 6) and piloted (n = 20) prior to the final survey being run. ResultsThere were 429 partial and 328 complete responses (age 37.2 ± 7.2 years, n = 429, years post GDM 4.9 ± 6.3 years, n = 428, BMI 30.9 ± 7.3 kg/m2n = 394). Overweight (n = 110) or obese (n = 200) responders mostly knew they were overweight and three-quarters thought they were either high (n = 144, 33.6%) or moderate risk (n = 176, 41.1%) for developing T2DM. Most women reported they knew what sorts of food to eat to lose weight (n = 332, 86.7%), that their families would support them (n = 320, 87%) and they were motivated to lose weight (n = 213, 58.4%). The most common barriers were family responsibilities taking priority (n = 240, 63%) and finding it hard to deal with hunger (n = 206, 55.8%). Weight loss programs by a dietitian were popular as individual appointments (n = 242, 65.1%) or an online program (n = 200, 53.5%). Nearly three-quarters of responders had or would use the internet to seek weight loss information (n = 308, 71.8%). Exercising was the most tried method of weight loss (n = 234, 71.1%). Most women had heard of IER (the “5:2 diet”) (n = 284, 73%) but only 34 had tried the diet. Of the women who hadn’t heard of the 5:2 diet, 51.5% (n = 52) answered that it sounded like a good option and 15.8% (n = 16) didn’t think the diet would suit them. ConclusionsDespite most women reporting knowledge of their risk of T2DM, motivation to lose weight and family support, family responsibilities can make weight loss efforts difficult for mothers. Exercising, the 5:2 diet and use of the internet is an appealing option for some women however individual circumstances should be taken into consideration. Funding SourcesThe University of South Australia.

Understanding barriers to uptake of 17 alpha-hydroxyprogesterone caproate (17-OHP) in women with history of preterm birth

Background: Premature birth is responsible for approximately 38% of infant deaths as well as a host of complications, including abnormal lung development, infection, and long-term disabilities. For women with a history of spontaneous preterm birth in a singleton pregnancy, use of 17 alpha-hydroxyprogesterone caproate (17-OHP) can reduce the risk of a recurrent preterm birth by up to 42%. However, less than half of eligible women currently receive 17-OHP.Objectives: The purpose of this study was to understand the barriers to access and acceptability of 17-OHP use from the patient perspective.Study design: A qualitative study was conducted of women with a history of a prior spontaneous, singleton preterm birth who were eligible for 17-OHP during a subsequent singleton pregnancy. Researchers recruited 118 eligible women during the Spring and Summer of 2018 from a safety-net hospital in Denver, CO, USA, a hospital that provides healthcare for individuals regardless of their insurance status or ability to pay. Responses from 35 participants were analyzed, looking at themes surrounding knowledge of and counseling received regarding 17-OHP, hesitations, and barriers toward receiving the treatment.Results: Among respondents (34.0% response rate), the mean age was 31.5 years and mean gestational age at delivery was 32.1 weeks. Major themes from interviews included reasons that encouraged women to use 17-OHP, such as the desire to do anything for the health of their baby and reasons that women felt discouraged from using 17-OHP, including unknown complications and lack of information. Other barriers to this treatment method included the time commitment, specifically the length of clinic appointments and concerns about the safety of the 17-OHP injection.Conclusions: One of the strongest reasons for women choosing to use 17-OHP was a desire to do anything possible to support their babies. Somewhat surprisingly, there was not a significant relationship with the participants between gestational age of prior preterm deliveries and subsequent use of 17-OHP. There were two important reasons women cited most frequently for choosing not to use 17-OHP. One was feeling that they lacked information or knowledge about 17-OHP to make an informed decision, which is crucial because the study also showed that all eligible women are not being appropriately counseled on the option of 17-OHP. In terms of time commitment, it was the length of individual appointments, rather than frequency that was a barrier to receiving weekly injections.

Assessing an Interprofessional Polypharmacy and Deprescribing Educational Intervention for Primary Care Post-graduate Trainees: a Quantitative and Qualitative Evaluation.

Polypharmacy and potentially inappropriate medications (PIMs) are increasingly common and associated with adverse health effects. However, post-graduate education in polypharmacy and complex medication management for older adults remain limited. The Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) polypharmacy clinic was created to provide a platform for teaching internal medicine (IM) and nurse practitioner (NP) residents about outpatient medication management and deprescribing for older adults. We aimed to assess residents' knowledge of polypharmacy and perceptions of this interprofessional education intervention. A prospective cohort study with an internal comparison group. IM residents and NP residents; Veterans ≥ 65years and taking ≥ 10 medications. IMPROVE consists of a pre-clinic conference, shared medical appointment, individual appointment, and interprofessional precepting model. We assessed residents' performance on a pre-post knowledge test, residents' qualitative assessment of the educational impact of IMPROVE, and the number and type of medications discontinued or decreased. The IMPROVE intervention group (n= 18) had a significantly greater improvement in test scores than the control group (n= 18) (14% ± 15% versus - 1.3% ± 16%) over a period of 6months (Wilcoxon rank sum, p= 0.019). In focus groups, residents (n= 17) reported perceived improvements in knowledge and skills, noting that the experience changed their practice in other clinical settings. In addition, residents valued the unique interprofessional experience. Veterans (n= 71) had a median of 15 medications (IQR 12-19), and a median of 2 medications (IQR 1-3) was discontinued. Vitamins, supplements, and cardiovascular medications were the most commonly discontinued medications, and cardiovascular medications were the most commonly decreased in dose or frequency. Overall, IMPROVE is an effective model of post-graduate primary care training in complex medication management and deprescribing that improves residents' knowledge and skills, and is perceived by residents to influence their practice outside the program.

04:21 PM Abstract No. 42 Utilization of an automated phone call reminder system for an ambulatory interventional radiology clinic: a quality improvement initiative

The purpose of this quality improvement project was to assess the use of an automated phone call reminder system on the number of patient “no shows” and cancellations in an ambulatory IR clinic. Our institution opened an ambulatory IR clinic on December 1, 2016. At the outset, patients received a letter in the mail approximately two weeks prior to their appointment. In order to improve the number of patients arriving for their appointments, we sent a series of automated phone calls to patients to remind them about their clinic appointments. To assess the efficacy of the automated phone calls, we performed a review of all clinic appointments that occurred both prior to and after the initiation of the automated phone call system. All appointments in the sampling period were categorized as either “arrived,” “early cancellation” (>48h notice), “late cancellation” (<48h notice), or “no shows.” The rates of arrivals, early cancellations, late cancellations, and no shows between the pre- and post-intervention periods was compared. There were a total of 1,489 individual clinic appointments during the sampling period. In the pre-intervention period, 51.1% of patients (n=495) arrived, 23.9% (n=232) cancelled late, 18.7% (n=181) cancelled early, and 6.3% (n=61) did not show up for their appointment. In the post-intervention period, 49.8% of patients (n=259) arrived, 19.4% (n=101) cancelled early, 17.1% (n=89) cancelled late, and 13.7% (n=71) did not show up for their appointment. There was no statistically significant difference in the rates of arrived patients (p=0.86) or patients who cancelled early (p=0.73) between the two groups. There was a statistically significant decrease in late cancellations (p=0.002). The implementation of automated reminder phone calls to patients prior to their scheduled appointment did result in a decrease in the number of late cancellations but no changes to the rates of arrived, early cancellations, or no-show appointments.