Mean Number Of Visits Research Articles

Facilitators and barriers to revaccination after hematopoietic stem cell transplantation among pediatric patients in Ecuador

Abstract Background Revaccination after hematopoietic stem cell transplantation (HSCT) is a challenge in areas where there is variability of access to vaccines and where special schedules are unfamiliar to physicians and primary care providers. We report the experience of re-immunization practices in pediatric patients after HSCT in Ecuador. Methods The database and medical charts of pediatric patients who had been in follow after HSCT from 2021 to 2023 in Solca Guayaquil was reviewed in order to assess the completeness of the revaccination schedule and to identify facilitators and barriers in implementation of the process. Patients with pediatric infectious diseases follow up where included. Results There were 30 patients who underwent HSCT during the reviewed period. Among them, 7 were excluded because they had not been seen by pediatric infectious diseases. Four patients who had their HSCT before the studied period were later added as they received follow-up by the specialty, therefore a total of 27 patients were included. There were 16 (59.3%) boys, mean age was 11 years (SD 3.6), and 16 (59.3%) lived outside Guayaquil. The most common diseases prompting HSCT were 14 (51.9%) lymphoblastic leukemia, 4 (14.8%) myeloid leukemia, 3 (11.1%) for Hodgkin lymphoma and 3 (11.1%) aplastic anemia. HSCT was performed outside Ecuador in 15 (55.6%) cases. Reimmunization schedule had been initiated in 21 (77.7%) of patients. Public health system was used exclusively in 11 (52.4%) cases, a combination of private and public system in 8 (38.1%) cases and exclusively private system in 2 (9.5%) cases. Among them, 9 (42.9%) had completed all recommended inactivated vaccines. Mean number of visits required for this was 5.1 (SD 1.9). After completion of inactivated vaccines, live vaccines where recommended and had been completed by 2 (9.5%) patients. The main facilitator identified was vaccine confidence and adherence to physician recommendations while the main barriers identified where health system related: a) Lack of awareness in public vaccination centers about special schedules, b) lack of availability of age licensed vaccines in public system and c) Lack of documentation of immunization administrated. Conclusion Health system related logistics (vaccine availability, knowledge of special schedules, coordination with immunization centers) continues to be a main barrier to complete recommended reimmunization schedule after HSCT while confidence in vaccines and adherence is the main facilitator in Ecuador. Government interventions need to be implemented in order to facilitate the process for this population of patients. Figure 1. Revaccination after hematopoietic stem cell transplantation in Solca Guayaquil (2021 – 2023).

National Trends in the Utilization and Expenditure of Chiropractic Care in U.S. Adults: Analysis of the 2007-2016 Medical Expenditure Panel Survey

ObjectiveThis study aimed to examine the trends in the utilization and expenditure of chiropractic care in a representative sample of US adults, aged ≥18 years. MethodsSerial cross-sectional data (2007-2016) from the Medical Expenditure Panel Survey (MEPS) were examined. Weighted descriptive statistics were analyzed to obtain national estimates of chiropractic utilization and expenditure, and time-series linear regression was used to assess trends over time. Socio-demographic characteristics and musculoskeletal diagnoses associated with chiropractic use were also reported. ResultsA statistically significantly increasing trend was observed for the number of adults receiving chiropractic care (p < .05), number of visits (p < .05) and utilization rate (P < .05) from 2007 to 2016. A similar trend was not found for chiropractic expenditure during this period (P > .05). The mean number of visits was 8.3 visits per year, with a mean expenditure of $86.94 USD per visit and $721.43 USD per person per year. Mean age of adult chiropractic users each year ranged between 48.6 and 51.2 years old, and users were primarily female (56.3%-60.4%), White persons (90.1%-93.5%), and privately insured (77.3%-82.8%). The most prevalent musculoskeletal diagnoses associated with chiropractic use were low back conditions (45.4%-58.1%), inflammatory/degenerative disc or joint conditions (21.2%-26.8%) and head and neck complaints (9.8%-13.7%). ConclusionThe findings showed statistically significant increasing trends for the number of adult chiropractic users, the number of visits, and percent utilization of chiropractic care from 2007 to 2016. Conversely, we found a statistically null trend for the total annual expenditure on chiropractic care during the same time period. Findings from this analysis imply that, while chiropractic care appears to be growing, it may still be under-utilized, and more efforts should be devoted to ensuring sustained growth and a larger role in the management of musculoskeletal health.

P-672 Is there a sweet spot for follicular size and/or estradiol level for the initiation of micronized progesterone to optimize natural proliferative phase (NPP) cryo-cycle outcome?

Abstract Study question Is there an optimal follicular size and/or estradiol level for the initiation of micronized progesterone to optimize outcomes in NPP cycles potentially restricting scheduling flexibility? Summary answer All follicular sizes &amp;gt;12 mm and estradiol levels &amp;gt;120 pg./mL do not significantly correlate with ongoing pregnancy rates (OPR) or pregnancy loss (PL). What is known already Planning of a frozen embryo transfer (FET) is feasible within either a natural (NC) or artificial cycle (AC). While AC-FETs offer flexibility in planning, concerns have raised due to studies indicating a higher risk for obstetric complications. Conversely, NC-FETs show a protective effect against these complications but are usually less flexible in planning and ask for more monitoring. Recently, the natural proliferative phase (NPP) protocol was described, in which luteal phase support is initiated as soon as the endometrium reaches 7mm. NPP-FETs were associated with ongoing pregnancy rates comparable to AC- and NC-FETs. Study design, size, duration A retrospective single-centre study including a total of 300 consecutive single frozen embryo transfers (FET), performed at a tertiary fertility centre between March 2023 and December 2023. All cycles were single blastocyst transfer cycles retained from IVF/ICSI cycles with autologous oocytes. Participants/materials, setting, methods A total of 227 patients underwent one or more frozen embryo transfer cycles. Administration of MVP 800mg BID was initiated after fulfilling the following criteria: follicular size &amp;gt; 12mm, estradiol level ≥120ng/mL and endometrium thickness ≥7mm. Blastocyst transfers were scheduled on the fifth day of MVP administration. Serum progesterone (P4) levels were determined on the day of transfer. Associations between treatment outcome, patient and cycle characteristics were explored using generalized estimating equations analyses. Main results and the role of chance The follicular size and estradiol level on the day of MVP initiation was not significantly associated with pregnancy rate (PR), ongoing pregnancy rate (OPR) or pregnancy loss (PL) (p = 0.386 and p = 0.260; p = 0.830 and p = 0.467; p = 0.978 and p = 0.313 respectively). Mean number of visits needed prior to the initiation of the MVP for scheduling the embryo transfer was 2.4 (SD 1.3). PR, but not OPR, was significantly associated with both the duration of the follicular phase as well as the number of visits (p = 0.008 and p = 0.006 respectively). For 91.3 % (274/300) of patients, embryo transfer could be scheduled on a weekday. 49% (146/300) of patients had a positive hCG test after the fresh blastocyst transfer in the NPP cycle. Ongoing pregnancy rate was 35 % (104/300), whereas pregnancy loss (early clinical miscarriage and biochemical pregnancy) was 23% (33/146). The OPR was significantly related to the age of the patient (p = 0.029). Both the PR as the OPR were significantly related the blastocyst quality (p = 0.008 and 0.009 respectively). The incidence of pregnancy loss was only significantly associated with blastocyst quality (p = 0.027). Mean serum P4 level at day of transfer was 19.4 ng/ml (SD 6.1) with a P4 level above 10ng/ml in 97% of cycles. Limitations, reasons for caution The retrospective character is a limitation of this study as well as the absence of live birth rate as a clinical outcome variable. Wider implications of the findings Flexibility about the required follicular sizes and estradiol levels open the perspective for exploring more flexible planning criteria such as lower thresholds for endometrial thickness. Further studies are needed to investigate whether ovulation occurs with formation of functional corpora lutea to effectively protect against hypertensive disorders. Trial registration number ONZ-2024-0015

Changes in primary care visits for respiratory illness during the COVID-19 pandemic: a multinational study by the International Consortium of Primary Care Big Data Researchers (INTRePID).

The majority of patients with respiratory illness are seen in primary care settings. Given COVID-19 is predominantly a respiratory illness, the INTernational ConsoRtium of Primary Care BIg Data Researchers (INTRePID), assessed the pandemic impact on primary care visits for respiratory illnesses. Definitions for respiratory illness types were agreed on collectively. Monthly visit counts with diagnosis were shared centrally for analysis. Primary care settings in Argentina, Australia, Canada, China, Norway, Peru, Singapore, Sweden and the United States. Over 38 million patients seen in primary care settings in INTRePID countries before and during the pandemic, from January 1st, 2018, to December 31st, 2021. Relative change in the monthly mean number of visits before and after the onset of the pandemic for acute infectious respiratory disease visits including influenza, upper and lower respiratory tract infections and chronic respiratory disease visits including asthma, chronic obstructive pulmonary disease, respiratory allergies, and other respiratory diseases. INTRePID countries reported a marked decrease in the average monthly visits for respiratory illness. Changes in visits varied from -10.9% [95% confidence interval (CI): -33.1 to +11.3%] in Norway to -79.9% (95% CI: -86.4% to -73.4%) in China for acute infectious respiratory disease visits and - 2.1% (95% CI: -12.1 to +7.8%) in Peru to -59.9% (95% CI: -68.6% to -51.3%) in China for chronic respiratory illness visits. While seasonal variation in allergic respiratory illness continued during the pandemic, there was essentially no spike in influenza illness during the first 2 years of the pandemic. The COVID-19 pandemic had a major impact on primary care visits for respiratory presentations. Primary care continued to provide services for respiratory illness, although there was a decrease in infectious illness during the COVID pandemic. Understanding the role of primary care may provide valuable information for COVID-19 recovery efforts and planning for future global emergencies.

Male Partner Involvement in Birth Preparedness, Complication Readiness and Obstetric Emergencies in Central Rural India: A Cross-Sectional Study.

Childbirth is mainly thought to be a woman'sconcern, and mortality can be prevented by making a birth plan constituting birth preparedness and complication readiness with the entire family as one unit. Indian National Plans aim to increase male involvement, but the policies lack directions and monitoring systems; hence, it becomes important to address this issue. A cross-sectional study conducted in a rural hospital and a community-based setup included 350 male participants, consisting of new fathers or expecting fathers, who were interviewed with the help of a questionnaire. Only 28.29% of male participants were well involved in the process of birth preparedness and complication readiness. 83% of the husbands accompanied their respective wives during ANC visits (mean number of visits: 5.76). 33% of males were aware of various danger signs and complications related to pregnancy. The males with better education (p-value < 0.005) and economic status (p-value < 0.0001) had better birth preparedness. Several variables in the study were positively correlated with the amount of money saved. Interpretation and conclusion: Male involvement during pregnancy significantly impacts maternal and child health outcomes. However, this study highlights a lack of awareness and involvement among males. We strongly recommend enhancing existing maternal and child health (MCH) programs to include components focused on male partner engagement in birth preparedness, complication readiness, and obstetric emergencies.

Clinical impact of remote heart failure management using the multiparameter ICD HeartLogic alert

Introduction and objectivesThe multiparametric implantable cardioverter-defibrillator HeartLogic index has proven to be a sensitive and timely predictor of impending heart failure (HF) decompensation. We evaluated the impact of a standardized follow-up protocol implemented by nursing staff and based on remote management of alerts. MethodsThe algorithm was activated in HF patients at 19 Spanish centers. Transmitted data were analyzed remotely, and patients were contacted by telephone if alerts were issued. Clinical actions were implemented remotely or through outpatient visits. The primary endpoint consisted of HF hospitalizations or death. Secondary endpoints were HF outpatient visits. We compared the 12-month periods before and after the adoption of the protocol. ResultsWe analyzed 392 patients (aged 69±10 years, 76% male, 50% ischemic cardiomyopathy) with implantable cardioverter-defibrillators (20%) or cardiac resynchronization therapy defibrillators (80%). The primary endpoint occurred 151 times in 86 (22%) patients during the 12 months before the adoption of the protocol, and 69 times in 45 (11%) patients (P<.001) during the 12 months after its adoption. The mean number of hospitalizations per patient was 0.39±0.89 pre- and 0.18±0.57 postadoption (P<.001). There were 185 outpatient visits for HF in 96 (24%) patients before adoption and 64 in 48 (12%) patients after adoption (P<.001). The mean number of visits per patient was 0.47±1.11 pre- and 0.16±0.51 postadoption (P<.001). ConclusionsA standardized follow-up protocol based on remote management of HeartLogic alerts enabled effective remote management of HF patients. After its adoption, we observed a significant reduction in HF hospitalizations and outpatient visits.

Assistance Burden Comparison Between Age-Related Macular Degeneration and Retinal Angiomatous Proliferation Over a Three-Year Follow-up.

We compared assistance burden between neovascular age-related macular degeneration (nAMD) and retinal angiomatous proliferation (RAP) under intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment on a treat-and-extend (T&E) regimen in a third-level hospital in a developed country. This retrospective study using data from the Fight Retinal Blindness! Registry included patients treated between January 2016 and December 2020. Final event was established as best corrected visual acuity (BCVA) lower than 20 Early Treatment Diabetic Retinopathy Study letters. According to choroidal neovascularization (CNV), three different study groups were established: type 1, 2, and 3. A total of 285 eyes of 227 patients were included. Mean age was 80.1 ± 6.5, 79.1 ± 7.9, and 81.2 ± 7.2 years, for the three study groups, respectively. Mean injections were 16.0 ± 4.8, 16.5 ± 4.1, and 14.1 ± 5.7, respectively; and mean number of visits were 17.9 ± 4.3, 18.2 ± 3.1, and 16.8 ± 5.3, respectively. No differences were found (P > 0.05). Survival curves and log-rank analysis also showed no differences (P = 0.344). Cox proportional hazard models showed that a lower baseline BCVA, subfoveal geographic atrophy (GA), and subfoveal fibrosis (SF) were associated with a higher risk of reaching ≤ 20 letters. nAMD and RAP under a T&E regimen indicate a high assistance burden during the first three years. The presence of subfoveal GA or SF are associated with a BCVA lower than 20 letters. [Ophthalmic Surg Lasers Imaging Retina 2024;55:197-203.].

“The more the better?” Association between number of antenatal care visits and components of care received: analysis of the Burundi Demographic and Health Survey 2016/2017

Background The World Health Organization promotes antenatal care (ANC) as a package of health interventions women receive during pregnancy. This study examined the association between the number of ANC visits and the number of ANC components received in Burundi. Methods This cross-sectional study used data from the most recent Burundi Demographic and Health Survey (DHS) 2016/2017. The Burundi DHS is a household survey using a stratified two-stage sampling design. We included all women aged 15-49 years who had a live birth in the two years preceding the survey, and ANC for the pregnancy leading to the most recent live birth in this period was analysed. We analysed women’s self-report of receipt of eight routine ANC components. We used chi-square and ANOVA tests to examine the distribution of the number of ANC visits and the number of components received among ANC users, and linear regression to investigate the crude and adjusted association between the number of ANC visits and number of ANC components received. Results Nearly all women (99.4%, 95% confidence interval, CI=99.2-99.6) reported receiving some ANC; half (51.7%, 95% CI=49.8-53.6) reported receiving 4+ visits. The mean number of visits among ANC users was 4.44, and this was only marginally higher (4.63) among women who received 4+ ANC visits. Among ANC users, blood sample taken was the most commonly reported ANC component (88.3%); urine sample taken was the least received component (28.3%). Women’s report of blood pressure having been measured and iron tablets or syrup taken were not significantly associated with number of ANC visits (P&gt;0.05); the probability of receiving the other six components increased with higher number of ANC visits. The number of ANC visits was significantly associated with an increasing number of components received in both bivariate (regression coefficient= 0.23; 95% CI=0.18–0.28; P&lt;0.001) and multivariable (adjusted regression coefficient= 0.21; 95% CI=0.16–0.25; P&lt;0.001) models. Conclusions Coverage with routine ANC components is suboptimal in Burundi among women who receive the recommended four visits or more. While an increasing number of ANC visits was associated with an increased number of ANC components reported, rigorous mixed-methods research is needed to understand barriers and facilitators for improving the quality of care according to the national guidelines, and thus also contributing to achieving a high retention rate in the continuum of care.

Healthcare resource utilization among critically-ill COVID-19 survivors: results from the NUTRICOVID study.

critically ill patients admitted to the intensive care unit (ICU) are often associated with malnutrition and nutrition therapy is recommended. Previous studies on COVID-19 focused on the recovery of critically ill patients after hospital discharge; however, there are limited data on healthcare resource utilization (HRU) after discharge. to describe and analyze the HRU and nutritional status of COVID-19 patients during hospitalization and one year after discharge. during hospitalization and 12-month follow-up after discharge, we collected data on hospital and ICU length of stay, ventilatory support therapies, medical nutrition therapy, and outpatient visits. Factors contributing to outpatient visits and readmissions during the follow-up period were also analyzed. a total of 199 patients were included, with a median hospital and ICU length of stay of 53.0 and 23.5 days, respectively. During hospitalization, 86.4 % of the patients needed invasive ventilation and 51.5 % non-invasive ventilation; 50.3 % of the patients required parenteral nutrition, while 84.3 % required enteral nutrition and 66.0 % oral nutritional supplements. After discharge a mean number of visits per patient to general practitioner, specialized care, and emergency department of 4.5, 14.7, and 0.8, respectively, were registered, most of them directly or possibly related to COVID-19. Additionally, a better health-related quality of life (HRQoL) at discharge and lower weight loss during hospitalization were associated with lower HRU during follow-up. our study shows a high HRU among patients with COVID-19 admitted to ICU in the year following discharge and highlights the importance of the nutrition status during admission and its relation to HRU.

Using “Appointment Tickets” to Track Visit Duration as a Quality Improvement Initiative After Incorporating Laser Epilation in a Pilonidal Care Clinic

BackgroundLaser epilation (LE) is effective in decreasing pilonidal disease (PD) recurrence, but laser use has not been a standard practice in pediatric surgery clinic. We hypothesized that “appointment tickets” can 1) track utilization and clinic visit delays, 2) inform patients of their clinic progress in real time. MethodsAn observation study was performed on LE patients treated at our PD clinic 3/2021-7/2022. Two exam rooms were utilized for manual shaving and one for LE. After gluteal cleft hair shaving, various anesthetic (topical lidocaine, ice, or cryotherapy) was applied prior/during LE. At each visit, patient received an “appointment ticket” on which providers recorded the visit start/end time, manual shaving duration, local anesthetic application/wait time, LE duration. Visits were scheduled for 20 min-slots. Clinic staff recorded any delays (>20 min). Results1317 visits were recorded. Mean number of visits per week was 18 ± 6. Mean total visit length was 60 ± 22 min, mean shaving time 15 ± 11 min, mean anesthetic application/wait time 16 ± 11 min, mean LE time 14 ± 9 min. Over the study period, average visit length has decreased, and average visits/clinic day has increased. Most delays occurred in months April, May, October–December. Delays due to patient late arrival occurred in May, July, and August of 2021, none in 2022. ConclusionsLE visits have multiple components that required close coordination to ensure no clinic delays. Clinic delays spiked prior to summer and winter holidays. “Appointment tickets” provided patients with real-time visit progress tracked clinic utilization to improve the quality of pilonidal care delivery. Level of evidenceLevel IV.

The association between 73 Alzheimer’s disease risk variants and white matter microstructural decline in aging

AbstractBackgroundAlthough several prior diffusion MRI studies have indicated a role of medial temporal lobe (MTL) white matter microstructural decline in Alzheimer’s disease (AD), it is unclear which AD risk genes are associated with this decline. The goal of this study is to leverage multi‐site harmonized diffusion MRI data to investigate the relationship between 73 AD risk variants and microstructural decline in MTL tracts.MethodThe dataset used in this study was collated from three longitudinal cohorts of aging [Alzheimer’s Neuroimaging Initiative (ADNI), Baltimore Longitudinal Study of Aging (BLSA), Vanderbilt Memory &amp; Aging Project (VMAP)]. In total, this dataset included 1,308 participants (70% cognitively unimpaired, 27% MCI, 3% AD) aged 50+ who had both diffusion MRI and genotype data and includes a total of 3,442 imaging sessions (mean number of visits: 2.68 ± 1.66, interval range: 1 ‐ 12 years). Genotype data was preprocessed using a standardized approach, and the dosage of the 73 AD risk variants was extracted. Diffusion MRI data was preprocessed using the PreQual pipeline and free‐water (FW) correction was conducted to obtain FW and FW‐corrected fractional anisotropy (FAFWcorr) maps. FW and FAFWcorr were quantified within 5 MTL tracts, including the cingulum, fornix, uncinate fasciculus, inferior longitudinal fasciculus, which were subsequently harmonized using the Longitudinal ComBat package. Linear regression was conducted to investigate the association between AD risk variants and MTL microstructure at baseline, while linear mixed effects regression was used for longitudinal analysis. All models were corrected for age at baseline and sex and corrected for multiple comparisons using the FDR approach.ResultAt baseline, APOE‐e4 dosage was strongly associated with MTL FW in all tracts, with additional associations for TMEM106B and CR1 dosages with fornix FW (Table 1). Longitudinally, APOE‐e4 dosage was a strong predictor of MTL FW decline in all tracts, and KAT8, CR1, and TMEM106B dosages exhibited significant associations with fornix microstructural decline (Table 2 and Figure 1).ConclusionThis study suggests that although APOE‐e4 is the strongest predictor of white matter microstructural decline, several other AD risk genes (i.e., CR1, SPI1, TMEM106B, KAT8) contribute to decline, particularly in the fornix.

Public healthcare system utilization for chronic hepatitis C infection in Vietnam

BackgroundHealthcare utilization is typically adversely affected when the treatment is expensive and requires multiple visits. We examined the determinants of healthcare-seeking for Hepatitis C virus (HCV) infection which is asymptomatic, chronic, and requires costly treatment in an urban tertiary care referral hospital in Vietnam.MethodsWe conducted a secondary analysis of hospital data for patients attending the Hospital for Tropical Diseases in Ho Chi Minh City, Vietnam between 2017 and 2020 specifically for HCV infection treatment. Poisson regression was used to determine the effect of personal factors (age, sex, comorbidities) and structural factors (health insurance, proximity to the facility, seasonality, year of visit) on the number of hospital visits.ResultsFrom 2017 to 2020 a total of 22,052 eligible patients sought treatment in the hospital. Among the patients, 50.4% were males and 58.7% were > 50 years of age. The mean number of visits per person was 2.17. In the multivariate analysis compared to 2017, the number of hospital visits increased by 4% in 2018 and then significantly decreased in 2019 and 2020. Visit numbers were significantly lower (6%) among South East region residents compared to those from Central Highlands and for those who lived further away from the hospital. The visit numbers were significantly higher among older age groups (5–11%), those with health insurance (6%), and those with comorbidities (5%) compared to others. Although the number of hospital visits by females was higher (7%) than males in 2017, it significantly decreased in subsequent years.ConclusionsOur study indicated that there are both structural and individual factors affecting the number of visits for HCV treatment. To meet the global strategy for elimination of HCV, Vietnam Government needs to address the structural and personal barriers to healthcare seeking, with a special focus on women.

Functional neurological disorder in Saudi Arabia: A retrospective study.

To describe the clinical profile of a sample of Saudi patients with Functional Neurological Disorder (FND). A retrospective chart review of FND patients seen from 2021-2023 at a neuropsychiatry clinic at an academic tertiary care center in Jeddah, Saudi Arabia. Out of 473 patients seen in the clinic during the review period, 52 (11%) had FND. Mean age was 34 years (standard deviation = 10.7), and 77% were female. Family dispute (39%) was the most reported risk factor, followed by sexual abuse (15%). The most common FND symptoms were nonepileptic seizures (61.5%) and abnormal movements (30.8%). Pain was reported by 57.7% and cognitive symptoms by 36.5%. FND symptoms were frequently attributed to supernatural causes (67.3%). During the last follow-up visit, 53.9% of patients reported FND symptom improvement, whereas 21.2% reported no change, 10.2% reported worsening, and 15% were lost to follow-up. The proportion of patients without symptom improvement was higher among patients with cognitive symptoms (45.5% vs 18% respectively, X2 = 10.08, df = 3, p = .018). The mean number of visits was highest in patients reporting worsening and the lowest was among patients reporting no change (F = 4.21, p = .017). The role of family disputes in FND in the Middle East, the role of supernatural concepts in how FND is perceived, and the relatively high rate of subjective improvement within this sample of Saudi FND patients merit further exploration. Cognitive symptoms may be another prognostic indicator. Prospective multicenter studies of those with FND using standardized assessment measures are needed.

Leveraging longitudinal diffusion MRI data to quantify differences in white matter microstructural decline in normal and abnormal aging.

It is unclear how rates of white matter microstructural decline differ between normal aging and abnormal aging. Diffusion MRI data from several well-established longitudinal cohorts of aging (Alzheimer's Disease Neuroimaging Initiative [ADNI], Baltimore Longitudinal Study of Aging [BLSA], Vanderbilt Memory & Aging Project [VMAP]) were free-water corrected and harmonized. This dataset included 1723 participants (age at baseline: 72.8±8.87 years, 49.5% male) and 4605 imaging sessions (follow-up time: 2.97±2.09 years, follow-up range: 1-13 years, mean number of visits: 4.42±1.98). Differences in white matter microstructural decline in normal and abnormal agers was assessed. While we found a global decline in white matter in normal/abnormal aging, we found that several white matter tracts (e.g., cingulum bundle) were vulnerable to abnormal aging. There is a prevalent role of white matter microstructural decline in aging, and future large-scale studies in this area may further refine our understanding of the underlying neurodegenerative processes. Longitudinal data were free-water corrected and harmonized.Global effects of white matter decline were seen in normal and abnormal aging.The free-water metric was most vulnerable to abnormal aging.Cingulum free-water was the most vulnerable to abnormal aging.

P-653 Natural proliferative phase frozen embryo transfers: a novel, safe and efficient transfer strategy

Abstract Study question How do natural proliferative phase for frozen embryo transfers (NPP-FET) compare to traditional artificial and natural cycle FETs in terms of pregnancy and neonatal outcomes? Summary answer NPP-FETs were associated with similar ongoing pregnancy rates after 22 weeks, but with less miscarriage rates comparing to artificial cycles. What is known already The best FET protocol for endometrial preparation is still controversial. A natural cycle (NC) FET may require more visits to the clinic and provides less flexibility. Conversely, artificial cycles (AC), although being more flexible in terms of scheduling, have been previously associated with higher rates of miscarriage and maternal morbidity. Here we describe an alternative FET strategy (NPP-FET) in which, during an unmediated ovulatory cycle, progesterone is initiated as soon as the endometrium proliferation reaches 7 mm of thickness, regardless of the size of the dominant follicle and without the administration of exogenous hCG or spontaneous LH peak. Study design, size, duration We performed a single center retrospective cohort study of FET cycles performed between January 2020 and June 2022 (n = 2158). Only single embryo blastocyst stage transfers were included. The main outcome was ongoing pregnancy rate after 22 weeks. Secondary outcomes included the number of visits to the clinic during monitoring, serum levels of progesterone on the day of FET, livebirth (LBR) and miscarriage rates, and maternal/perinatal outcomes. Participants/materials, setting, methods FETs cycles were divided in three subgroups: NC, NPP and AC. For the main outcome measures, a multivariable logistic regression was performed, to adjust for potential confounding (oocyte age/source, use of PGT-A and embryo quality), followed by pairwise comparisons whenever statistically significant. Main results and the role of chance In total, 2158 FET cycles were analysed (1219 NC, 277 NPP and 662 AC). The mean number of visits before FET planning were 2.14, 1.83 and 1.33 for NC, NPP and AC FETs, respectively (p &amp;lt; 001 for all pairwise comparisons). Mean progesterone levels on the day of transfer were significantly higher after NPP and NC (29.4 ng/mL and 40.2ng/mL, respectively), compared to AC (12.7 ng/mL). Progesterone rescue therapy (administered whenever serum progesterone &amp;lt;8.8 ng/mL) was also significantly more frequently needed following AC (24,9% for AC versus 0.6% and 2.6% in NC and NPP, respectively). The ongoing pregnancy rates after 22 weeks were 57.3% for NC, 55.6% for NPP and 54.5% for AC. LBRs following NPP were comparable with NC (38.9% and 42.7%, respectively), and significantly lower with AC (36.0%) compared to NC. The miscarriage rates were significantly lower after NPP and NC-FET when compared to AC (18.4%, 24.3% and 30.7% respectively). Considering maternal outcomes, NPP and NC were associated with a significantly lower risk of first trimester bleeding compared to AC (17.5%, 13.8% and 36.7%, respectively). The rate of gestational hypertensive disorders did not vary significantly (7.5% for NPP, 9.9% for NC and 12.6% for AC). Limitations, reasons for caution While serum progesterone and miscarriage rates comparable to NC-FET allude to the possibility that ovulation may still occur in NPP-FETs, this study cannot establish such causality due to its retrospective design. Moreover, the study may have been underpowered to detect clinically relevant subgroup differences such as for hypertensive disorders. Wider implications of the findings NPP-FETs seems to be an effective and safe alternative, potentially wielding both the advantages of the natural proliferative endometrium of the NC with the ease for scheduling of ACs. Nonetheless, further investigation is warranted attempting also to confirm whether ovulation does indeed still occur despite the progesterone administration. Trial registration number not applicable

1446-P: Success of a Hybrid Care Model to Maintain Glycemic Control in Older Adults with Type 1 Diabetes (T1D)

Aim: During the COVID-19 pandemic, a hybrid care (in-office and telemedicine) model was urgently implemented. Impact of this hybrid model on clinical visit frequency and glycemic outcomes in older adults with T1D warrants study. Methods: Demographics, clinical characteristics, and clinical visits of older adults (aged ≥65 years) with T1D were retrieved from electronic medical records covering 2 time periods, before the pandemic (pre-pandemic: April 1, 2019-March 1, 2020) and during the pandemic (pandemic: September 1, 2020 to August 31, 2021) periods, with adjustment for length of follow-up. Results: 661 (45% male) unique older adults with T1D received care and had HbA1c measurements in both periods at a tertiary diabetes center. Mean age was 72±5 years; 59% were CGM users, 38% were pump users. Clinic visits in the pre-pandemic period were almost all in-person, averaging 4.2 visits/person/year (CI 3.9-4.4), with &amp;lt;2% as phone visits. During the pandemic period, the mean number of visits was significantly greater than in the pre-pandemic period, at 6.3 visits/person/year (CI 5.7-6.9), with 30% in-office, 38% by video, and 32% by phone. HbA1c values were similar between periods (pre-pandemic: 7.6% (CI 7.5-7.8) vs pandemic: 7.4% (CI 7.3-7.6)). However, there was a significant, favorable shift in HbA1c distribution &amp;lt;7%, 7-8%, &amp;gt;8% when using hybrid care model: pre-pandemic period 21, 42, 37%, respectively; pandemic period 35, 36, 29%, respectively (pre-pandemic vs pandemic period p&amp;lt;.0.001). Conclusion: Compared with the pre-pandemic care model, the hybrid care model during pandemic for older adults with T1D allowed for increased visit frequency and preserved HbA1c values while favorably increasing the proportion with HbA1c &amp;lt;7% and decreasing proportion at the higher end of the distribution. This data support ongoing use of a hybrid care model for older adults with T1D. Disclosure A.Adam: None. M.Munshi: Consultant; Sanofi. R.Hurlbert: None. C.Slyne: None. L.M.Laffel: Advisory Panel; Medtronic, Lilly Diabetes, Novo Nordisk, Vertex Pharmaceuticals Incorporated, Roche Diagnostics, Provention Bio, Inc., Consultant; Dexcom, Inc., Janssen Pharmaceuticals, Inc., Medscape. E.Toschi: Advisory Panel; Eli Lilly and Company. Funding Thomas J. Beatson, Jr. Foundation

Prevalence of opioid and nonopioid pain management therapies among Medicare beneficiaries with musculoskeletal pain conditions from 2016 to 2019

IntroductionPain treatment guidelines prioritize nonopioid therapies over opioid medications to prevent opioid-related harms. We examined trends in receipt and intensity of nonpharmacologic, nonopioid medication, and opioid therapies among Medicare beneficiaries. MethodsUsing a 20% national random sample of Medicare data from 2016 to 2019, we identified fee-for-service beneficiaries with ≥2 diagnoses of back, neck, fibromyalgia, or osteoarthritis/joint pain annually. We excluded beneficiaries with cancer. We calculated annual proportions of beneficiaries who received physical therapy (PT), chiropractic care, gabapentin, and opioids, overall and in demographic, geographic, and clinical subgroups. We estimated the intensity of therapies using the annual number of visitsor prescription fills, prescription days’ supply, and opioid dose. ResultsDuring 2016–2019, PT receipt increased (22.8% to 25.5%) and the mean number of visits among recipients of PT went from 12 to 13. Chiropractic receipt (~18%) and mean annual visits (~10) remained unchanged. The prevalence of gabapentin receipt was stable at ~22% and the mean annual number of fills was unchanged though gabapentin days increased slightly. Opioid prescribing decreased (56.7% to 46.5%) and reductions in opioid dose and duration were observed. Opioid receipt was high among beneficiaries who were under 65 years, American Indian/Alaska Native, Black/African American, or had opioid use disorder (OUD), in whom nonpharmacologic therapies were also received the least. ConclusionUtilization of nonopioid therapies lagged opioids among Medicare beneficiaries with musculoskeletal pain, with limited changes from 2016 to 2019. As opioid prescribing declines and alternative pain therapy receipt remains low, there are potential increasing risks of pain going untreated or undertreated and individuals seeking illicit opioids to alleviate their pain.

Racial Inequality in Receipt of Medications for Opioid Use Disorder

BackgroundSince 2010, Black persons in the United States have had a greater increase in opioid overdose–related mortality than other groups, but national-level evidence characterizing racial and ethnic disparities in the use of medications for opioid use disorder (OUD) is limited.MethodsWe used Medicare claims data from the 2016–2019 period for a random 40% sample of fee-for-service beneficiaries who were Black, Hispanic, or White; were eligible for Medicare owing to disability; and had an index event related to OUD (nonfatal overdose treated in an emergency department or inpatient setting, hospitalization with injection drug use–related infection, or inpatient or residential rehabilitation or detoxification care). We measured the receipt of medications to treat OUD (buprenorphine, naltrexone, and naloxone), the receipt of high-risk medications (opioid analgesics and benzodiazepines), and health care utilization, all in the 180 days after the index event. We estimated differences in outcomes according to race and ethnic group with adjustment for beneficiary age, sex, index event, count of chronic coexisting conditions, and state of residence.ResultsWe identified 25,904 OUD-related index events among 23,370 beneficiaries, with 3937 events (15.2%) occurring among Black patients, 2105 (8.1%) among Hispanic patients, and 19,862 (76.7%) among White patients. In the 180 days after the index event, patients received buprenorphine after 12.7% of events among Black patients, after 18.7% of those among Hispanic patients, and after 23.3% of those among White patients; patients received naloxone after 14.4%, 20.7%, and 22.9%, respectively; and patients received benzodiazepines after 23.4%, 29.6%, and 37.1%, respectively. Racial differences in the receipt of medications to treat OUD did not change appreciably from 2016 to 2019 (buprenorphine receipt: after 9.1% of index events among Black patients vs. 21.6% of those among White patients in 2016, and after 14.1% vs. 25.5% in 2019). In all study groups, patients had multiple ambulatory visits in the 180 days after the index event (mean number of visits, 6.6 after events among Black patients, 6.7 after events among Hispanic patients, and 7.6 after events among White patients).ConclusionsRacial and ethnic differences in the receipt of medications to treat OUD after an index event related to this disorder among patients with disability were substantial and did not change over time. The high incidence of ambulatory visits in all groups showed that disparities persisted despite frequent health care contact. (Funded by the National Institute on Drug Abuse and the National Institute on Aging.)

Disparities in Diabetes Care: Differences Between Rural and Urban Patients Within a Large Health System.

We sought to ascertain factors associated with the quality of diabetes care, comparing rural vs urban diabetic patients in a large health care system. We conducted a retrospective cohort study assessing patients' attainment of the D5 metric, a diabetes care metric having 5 components (no tobacco use, glycated hemoglobin [A1c] level less than 8%, blood pressure less than 140/90 mm Hg, low-density lipoprotein cholesterol level at goal or statin prescribed, and aspirin use consistent with clinical recommendations). Covariates included age, sex, race, adjusted clinical group (ACG) score as a marker of complexity, insurance type, primary care clinician type, and health care use data. The study cohort consisted of 45,279 patients with diabetes, 54.4% of whom resided in rural locations. The D5 composite metric was met in 39.9% of rural patients and 43.2% of urban patients (P <.001). Rural patients were significantly less likely to have attained all metric goals than urban counterparts (adjusted odds ratio [AOR] = 0.93; 95% CI, 0.88-0.97). The rural group had fewer outpatient visits (mean number of visits = 3.2 vs 3.9, P <.001) and less often had an endocrinology visit (5.5% vs 9.3%, P <.001) during the 1-year study period. Patients with an endocrinology visit were less likely to have met the D5 metric (AOR = 0.80; 95% CI, 0.73-0.86), whereas the more outpatient visits patients had, the greater their likelihood of attainment (AOR per visit = 1.03; 95% CI, 1.03-1.04). Rural patients had worse diabetes quality outcomes than their urban counterparts, even after adjustment for other contributing factors and despite being part of the same integrated health system. Lower visit frequency and less specialty involvement in the rural setting are possible contributing factors.

Effect of telehealth-based versus in-person nutritional and exercise intervention on type II diabetes mellitus improvement and efficiency of human resources utilization inpatients with obesity.

Telehealth became a patient necessity during the COVID pandemic and evolved into a patient preference in the post-COVID era. This study compared the % total body weight loss (%TBWL), HbA1c reduction, and resource utilization among patients with obesity and diabetes who participated in lifestyle interventions with or without telehealth. A total of 150 patients with obesity and diabetes who were followed every 4-6weeks either in-person (n=83) or via telehealth (n=67), were included. All patients were provided with an individualized nutritional plan that included a weight-based daily protein intake from protein supplements and food, an activity/sleep schedule-based meal times, and an aerobic exercise goal of a 2000-calorie burn/week, customized to patient's preferences, physical abilities, and comorbidities. The goal was to lose 10%TBWL. Telehealth-based follow-up required transmission via texting of weekly body composition measurements and any blood glucose levels below 100mg/dl for medication adjustments. Weight, BMI, %TBWL, HbA1c (%), and medication effect score (MES) were compared. Patient no-show rates, number of visits, program duration, and drop-out rate were used to assess resource utilization based on cumulative staff and provider time spent (CSPTS), provider lost time (PLT) and patient spent time (PST). Mean age was 47.2±10.6years and 74.6% were women. Mean Body Mass Index (BMI) decreased from 44.1±7.7-39.7±6.7kg/m2 (p<0.0001). Mean program duration was 189.4±169.3days. An HbA1c% unit decline of 1.3±1.5 was achieved with a 10.1±5.1%TBWL. Diabetes was cured in 16% (24/150) of patients. %TBWL was similar in regards to telehealth or in-person appointments (10.6%±5.1 vs. 9.6%±4.9, p=0.14). Age, initial BMI, MES, %TBWL, and baseline HbA1c had a significant independent effect on HbA1c reduction (p<0.0001). Program duration was longer for in-person follow-up (213.8±194 vs. 159.3±127, p=0.019). The mean annual telehealth and in-person no-show rates were 2.7% and 11.2%, respectively (p<0.0001). Mean number of visits (5.7±3.0 vs. 8.6±5.1) and drop-out rates (16.49% vs. 25.83%) were lower in telehealth group (p<0.0001). The CSPTS (440.4±267.5min vs. 200.6±110.8min), PLT (28.9±17.5min vs. 3.1±1.6min), and PST (1033±628min vs. 113.7±61.4min) were significantly longer (p<0.0001) for the in-person group. Telehealth offered comparable %TBWL and HbA1c decline as in-person follow-up, but with a shorter follow-up, fewer appointments, and no-shows. If improved resource utilization is validated by other studies, telehealth should become the standard of care for the management of obesity and diabetes.