Need For Specialty Care Research Articles

Specialty Care Referral for Underrepresented Minorities Living with HIV in the United States: Experiences, Barriers, and Facilitators.

The increased incidence of chronic diseases among people with HIV (PWH) is poised to increase the need for specialty care outside of HIV treatment settings. To reduce outcome disparities for HIV-associated comorbidities in the United States, it is critical to optimize access to and the quality of specialty care for underrepresented racial and ethnic minority (URM) individuals with HIV. We explored the experiences of URM individuals with HIV and other comorbidities in the specialty care setting during their initial and follow-up appointments. We conducted qualitative interviews with participants at three large academic medical centers in the United States with comprehensive health care delivery systems between November 2019 and March 2020. The data were analyzed using applied thematic analysis. A total of 27 URM individuals with HIV were interviewed. The majority were Black or African American and were referred to cardiology specialty care. Most of the participants had positive experiences in the specialty care setting. Facilitators of the referral process included their motivation to stay healthy, referral assistance from HIV providers, access to reliable transportation, and proximity to the specialty care health center. Few participants faced individual, interpersonal, and structural barriers, including the perception of individual and facility stigma toward PWH, a lack of transportation, and a lack of rapport with providers. Future case studies are needed for those URM individuals with HIV who face barriers and negative experiences. Interventions that involve PWH and health care providers in specialty care settings with a focus on individual- and structural-level stigma can support the optimal use of specialty care.

Multi-Institution Survey of Accepting Physicians' Perception of Appropriate Reasons for Interhospital Transfer: A Mixed-Methods Evaluation.

There is a lack of evidence-based guidelines to direct best practices in interhospital transfers (IHTs). We aimed to identify frontline physicians' current and ideal reasons for accepting IHT patients to inform future IHT research and guidelines. We conducted a cross-sectional survey of hospitalist physicians across 11 geographically diverse hospitals. The survey asked respondents how frequently they currently consider and should consider various factors when triaging IHT requests. Responses were dichotomized into "highly considered" and "less considered" factors. Frequencies of the "highly considered" factors (current and ideal) were analyzed. Write-in responses were coded into themes within a priori domains in a qualitative analysis. Of the 666 hospitalists surveyed, 238 (36%) responded. Respondents most frequently identified the need for specialty procedural and nonprocedural care and bed capacity as factors that should be considered when triaging IHT patients in current and ideal practice, whereas the least frequently considered factors were COVID-related care, insurance/financial considerations, and patient/family preference. More experienced respondents considered patient/family preference more frequently in current and ideal practice compared with less experienced respondents (33% versus 11% [ P = 0.0001] and 26% versus 9% [ P = 0.01], respectively). Qualitative analysis identified several themes in the domains of Criteria for Acceptance, Threshold for Acceptance, and Indications for Physician-to-Physician Communication. This geographically diverse sample of hospitalist physicians responsible for accepting IHT patients showed general agreement between primary factors that are currently and that should be considered for IHT acceptance, with greatest weight placed on patients' need for specialty care.

Experiences of rural nurses with emergency patient transport in a resource limited setting

BackgroundRegistered nurses are primary care providers during most patient transfers from rural areas. Various local conditions and circumstances impact the provision of nursing care prior to and during transportation. These include clinic staffing, uneven access to functioning equipment and other necessary infrastructure across settings, the wide-ranging clinical need for specialty care, and complex social and interpersonal circumstances that play a role in care-seeking and transport decision-making. This study explored the experiences of nurses with emergency patient transport in rural health facilities in Botswana. MethodA qualitative descriptive approach was used using a semi structured interview. Twenty-six registered nurses from four remote, isolated rural health districts in Botswana participated in this study. Purposive convenience sampling technique was employed. ResultsThe ten main themes under transporter were infringement of scope of practice, inadequate knowledge and skills, distressful practice, restriction from making decisions, challenges with staffing, Ineffective facilities clustering, lack of support from the managers, shortage of technology and tools, non-enabling infrastructure, and transport related tasks. Discussion and ConclusionThe perceived ineffective emergency transfer of patients was associated with work system shortfalls. The work system needs to be balanced and consider the requirements of the various stakeholders involved in the processes for optimal performance of patient transport.

33906 Dermatology rural outreach clinics are feasible and decrease barriers to care in patients with skin cancer

Rural populations have higher skin cancer incidence and cancer-related deaths, likely due to lack of access to health care, environmental exposures, and lower socioeconomic status. To address the pressing need for specialty care in rural communities, in 2018, faculty from the University of Utah Department of Dermatology established monthly rural outreach clinics in Moab, Utah (population: 5268) and later Rock Springs, Wyoming (population: 23,319). We performed a retrospective chart review to evaluate the impact of the dermatology rural outreach clinics, focusing on patients diagnosed with biopsy-proven skin cancer. Distance to the nearest dermatologist was an average of 122.6 miles (Moab to Grand Junction, CO) and 171.2 miles (Rock Springs to Park City, UT). With the outreach clinics, this was reduced to an average of 14.1 miles (P < .0001) and 18.1 miles (P < .0001), respectively. Skin cancer was diagnosed in 17% (116/682) of all outreach clinic patients (median age 67.7 years, 54.3% male, 100% White, 67.5% Medicare). 58.8% had a personal history of skin cancer. Of the 188 total skin cancers diagnosed, squamous cell carcinoma was most common (52.1%), followed by basal cell carcinoma (41.5%), malignant melanoma (2.7%), and melanoma in situ (3.7%). Forty-two patients (36.2%) received Mohs surgery referrals; 90.5% were completed at the University of Utah. We did not find significant differences between the Moab and Rock Springs clinics. These results highlight the importance and feasibility of outreach clinics in providing access to dermatologic care, specifically in diagnosing and treating skin cancers in rural populations.

Simple diagnostic algorithm identifying at-risk nonalcoholic fatty liver disease patients needing specialty referral within the United States.

BACKGROUNDThere is an urgent need to risk stratify patients with suspected nonalcoholic fatty liver disease (NAFLD) and identify those with fibrotic nonalcoholic steatohepatitis. This study aims to apply a simple diagnostic algorithm to identify subjects with at-risk NAFLD in the general population.AIMTo apply a simple diagnostic algorithm to identify subjects with at-risk NAFLD in the general population.METHODSAdult subjects were included from the National Health and Nutrition Examination Survey database (2017-2018) if they had elevated alanine aminotransferase (ALT) and excluded if they had evidence of viral hepatitis or significant alcohol consumption. A fibrosis-4 (FIB4) cutoff of 1.3 differentiated patients with low risk vs high risk disease. If patients had FIB4 > 1.3, a FAST score < 0.35 ruled out advanced fibrosis. Patients with FAST > 0.35 were referred to a specialist. The same algorithm was applied to subjects with type 2 diabetes mellitus (T2DM).RESULTSThree thousand six hundred and sixty-nine patients were identified who met all inclusion and exclusion criteria. From this cohort, 911 (28.6%) patients had elevated ALT of which 236 (22.9%) patients had elevated FIB4 scores ≥ 1.3. Among patients with elevated FIB4 score, 75 (24.4%) had elevated FAST scores, ruling in advanced fibrosis. This accounts for 2.0% of the overall study population. Applying this algorithm to 737 patients with T2DM, 213 (35.4%) patients had elevated ALT, 85 (37.9%) had elevated FIB4, and 42 (46.1%) had elevated FAST scores. This accounts for 5.7% of the population with T2DM.CONCLUSIONThe application of this algorithm to identify at-risk NAFLD patients in need for specialty care is feasible and demonstrates that the vast majority of patients do not need subspecialty referral for NAFLD.

Emergency Medical Services Clinicians' Pediatric Destination Decision-Making: A Qualitative Study.

ObjectiveThis study sought to identify factors that influence emergency medical services (EMS) clinicians’ destination decision-making for pediatric patients. We also sought EMS clinicians’ opinions on potential systems improvements, such as protocol changes and the use of evidence-based transport guidelines.MethodsThirty-six in-depth phone interviews were conducted using a semi-structured format. We utilized a modified Grounded Theory approach to understand the complicated decision-making processes of EMS personnel. Memo writing was used throughout the data collection and analysis processes in order to identify emerging themes. The research team utilized hierarchical coding of interview transcripts to organize data into sub-categories for final analysis. ResultsEMS clinicians cited the perceived need for specialty care, the presence of a medical home, a desire for improved continuity of care, and the availability of aeromedical transport as factors that promoted transport to a pediatric specialty center. They voiced that children with emergent stabilization needs should be transported to the closest facility, however, they did not identify any specific medical conditions suitable for transport to non-specialty centers. EMS clinicians recommended improvements in pediatric-specific education, improved clarity of hospitals’ pediatric capabilities, and the creation of a pediatric-specific destination decision-making tool.ConclusionThis study describes specific factors that influence EMS clinicians’ transport destination decision-making for pediatric patients. It also describes potential systems and educational improvements that may increase pediatric transport directly to definitive care. EMS clinicians are in support of specific designations for hospitals’ pediatric capabilities and were in favor of the creation of a formal destination decision-making tool.

Variation in Access to Kidney Transplantation Across Renal Programs in Ontario, Canada.

In the United States, kidney transplant rates vary significantly across end-stage renal disease (ESRD) networks. We conducted a population-based cohort study to determine whether there was variability in kidney transplant rates across renal programs in a health care system distinct from the United States. We included incident chronic dialysis patients in Ontario, Canada, from 2003 to 2013 and determined the 1-, 5-, and 10-year cumulative incidence of kidney transplantation in 27 regional renal programs (similar to U.S. ESRD networks). We also assessed the cumulative incidence of kidney transplant for "healthy" dialysis patients (aged 18-50 years without diabetes, coronary disease, or malignancy). We calculated standardized transplant ratios (STRs) using a Cox proportional hazards model, adjusting for patient characteristics (maximum possible follow-up of 11 years). Among 23 022 chronic dialysis patients, the 10-year cumulative incidence of kidney transplantation ranged from 7.4% (95% confidence interval [CI] 4.8-10.7%) to 31.4% (95% CI 16.5-47.5%) across renal programs. Similar variability was observed in our healthy cohort. STRs ranged from 0.3 (95% CI 0.2-0.5) to 1.5 (95% CI 1.4-1.7) across renal programs. There was significant variation in kidney transplant rates across Ontario renal programs despite patients having access to the same publicly funded health care system.

Access to primary and specialty care and emergency department utilization of medicaid enrollees needing specialty care.

Medicaid enrollees are more likely to use the emergency department (ED) than the privately insured and uninsured, yet little is known about enrollees' problems in accessing primary care and specialty care providers among those needing specialty care. The study sample is from the 2003-2010 Medical Expenditure Panel Survey (MEPS) of 2,733 Medicaid enrollees reporting a need for specialty care. This paper estimates a two-part model to analyze the relationship between enrollees' access to providers and ED visits. Perceived problems accessing a primary care physician are associated with ED use among Medicaid enrollees. Despite reporting need and facing barriers, access to specialty care is not significantly related to ED use. As states prepare for the impending expansion of Medicaid funded via the Affordable Care Act, they should address barriers to accessing primary care providers for Medicaid enrollees with high need.

Performance measures of the specialty referral process: a systematic review of the literature.

BackgroundPerformance of specialty referrals is coming under scrutiny, but a lack of identifiable measures impedes measurement efforts. The objective of this study was to systematically review the literature to identify published measures that assess specialty referrals.MethodsWe performed a systematic review of the literature for measures of specialty referral. Searches were made of MEDLINE and HealthSTAR databases, references of eligible papers, and citations provided by content experts. Measures were eligible if they were published from January 1973 to June 2009, reported on validity and/or reliability of the measure, and were applicable to Organization for Economic Cooperation and Development healthcare systems. We classified measures according to a conceptual framework, which underwent content validation with an expert panel.ResultsWe identified 2,964 potentially eligible papers. After abstract and full-text review, we selected 214 papers containing 244 measures. Most measures were applied in adults (57%), assessed structural elements of the referral process (60%), and collected data via survey (62%). Measures were classified into non-mutually exclusive domains: need for specialty care (N = 14), referral initiation (N = 73), entry into specialty care (N = 53), coordination (N = 60), referral type (N = 3), clinical tasks (N = 19), resource use (N = 13), quality (N = 57), and outcomes (N = 9).ConclusionsPublished measures are available to assess the specialty referral process, although some domains are limited. Because many of these measures have been not been extensively validated in general populations, assess limited aspects of the referral process, and require new data collection, their applicability and preference in assessment of the specialty referral process is needed.

International Travel and the Elite Athlete

International travel is a frequent occurrence in the life of the elite athlete; such travel can pose challenges to the sport medicine practitioner. Travel is also the reality of many recreational level or sub-elite athletes as opportunities for international competition and training proliferate. An appreciation of the range of responsibilities associated with the preparation for and the strategies to facilitate such travel is essential for any physician charged with the care of athletes and teams. An appreciation of (1) the medical and public health challenges associated with competition in a particular setting; (2) the requirements for vaccination and immunization; (3) the strategies for the management of jet lag and climatic or environmental extremes; (4) the range of supplies and equipment necessary for travel to certain locales; (5) the need to ensure the availability of ample familiar and nutritious foods; (6) the potential need for specialty care in strange settings; (7) the management of common travel-associated illness; and (8) the challenges associated with the evacuation of an injured athlete are fundamental to the successful management of international travel involving athletes and teams. The adoption of a methodical approach to pre-trip planning can ensure an enhanced travel experience, illness-free training and competition, and facilitate optimal performance.

Clinical Topics in Addiction: Updates From Advances in Psychiatric Treatmentedited by Ed Day. London, Royal College of Psychiatrists, 2007, 428 pp., $55.00.

Back to table of contents Previous article Next article Book ForumFull AccessClinical Topics in Addiction: Updates From Advances in Psychiatric TreatmentGEORGE E. WOODY M.D.,GEORGE E. WOODY M.D.Search for more papers by this author,Published Online:1 May 2008https://doi.org/10.1176/appi.ajp.2008.08010004AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail This book, written by clinicians and researchers in the United Kingdom and edited by Dr. Day, Senior Lecturer in Addiction Psychiatry at the University of Birmingham, consists of 22 chapters, each touching on a different area relevant to the practice of addiction medicine. The scope of the chapters is broad and ranges from a summary of what works in treating persons with substance use disorders to the treatment system in England, including also a discussion of stimulant use, adverse effects of khat, pathological gambling, laboratory testing, treatment of patients with dual diagnoses, motivational interviewing, substance misuse in adolescents and pregnancy, legal defenses in substance-related cases, and the role of forensic psychiatry in addiction medicine. The scope of the areas that are addressed and the information that each chapter presents is a wonderful overview of the growth of addiction medicine over the past 50 years. Each chapter contains recent information and many details that will be of interest to a wide range of practitioners, both within the United Kingdom and elsewhere.Of special interest to me were the excellent chapter on stimulants, the discussion on emerging efforts aimed at reducing the reincarceration of drug abusing criminal offenders by expanding access to treatment in the criminal justice system, and the discussions of studies showing that integrated care is the most effective way to deliver services to patients with co-occurring psychiatric and medical disorders. On the latter topic, the authors emphasize the need to better involve primary care physicians in screening for substance-related problems and referring patients who have a substance use disorder to treatment, but without the expectation that this process will decrease the need for specialty care. The inclusion of a chapter on pathological gambling and the similarities that are drawn between its clinical features and those of substance dependence might be of particular interest to those working on DSM-V, in view of the longstanding uncertainties about whether this condition should be classified as an addictive disorder.A final area that I found of particular interest was the discussions found in various chapters about the mechanism by which national efforts are being made to improve the treatment system in the United Kingdom. These efforts are reflected in the work of various commissions who are charged with addressing specific topics and making recommendations based on a review of published studies. It is difficult for an “outsider” to understand the degree to which the recommendations are carried out, but it was interesting to read about how England’s National Health Service seems to be a vehicle through which systematic, evidence-based recommendations to improve treatment can be coordinated and implemented on a national level.This book presents a great deal of specific, current, and clinically relevant information on a wide range of topics that are relevant to the practice of addiction medicine and is likely to be of interest to clinicians, administrators, and researchers. In addition, this book makes the reader think about the potential of a national health care system to implement evidence-based medicine, improve treatment for persons with substance use disorders, and improve public health.Philadelphia, Pa.Book review accepted for publication January 2008 (doi:10.1176/appi.ajp.2008.08010004). FiguresReferencesCited byDetailsCited ByNone Volume 165Issue 5 May, 2008Pages 655-656THE AMERICAN JOURNAL OF PSYCHIATRY May 2008 Volume 165 Number 5 Metrics PDF download History Published online 1 May 2008 Published in print 1 May 2008

Holes in the safety net: a case study of access to prescription drugs and specialty care.

The health care safety net in the United States is intended to fill gaps in health care services for uninsured and other vulnerable populations. This paper presents a case study of New Brunswick, NJ, a small city rich in safety net resources, to examine the adequacy of the American model of safety net care. We find substantial gaps in access to care despite the presence of a medical school, an abundance of primary care and specialty physicians, two major teaching hospitals, a large federally qualified health center and other safety net resources in this community of about 50,000 residents. Using a blend of random-digit-dial and area probability sampling, a survey of 595 households was conducted in 2001 generating detailed information about the health, access to care, demographic and other characteristics of 1,572 individuals. Confirming the great depth of the New Brunswick health care safety net, the survey showed that more than one quarter of local residents reported a hospital or community clinic as their usual source of care. Still, barriers to prescription drugs were reported for 11.0% of the area population and more than two in five (42.8%) local residents who perceived a need for specialty care reported difficulty getting those services. Bivariate analyses show significantly elevated risk of access problems among Hispanic and black residents, those in poor health, those relying on hospital and community clinics or with no usual source of care, and those living at or below poverty. In multivariate analysis, lack of health insurance was the greatest risk factor associated with both prescription drug and specialty access problems. Few local areas can claim the depth of safety net resources as New Brunswick, NJ, raising serious concerns about the adequacy of the American safety net model, especially for people with complex and chronic health care needs.

Interfacility Transport of the Critically Ill Pediatric Patient

Care of the critically ill and injured child has evolved over the last 20 years, with growth of regional pediatric critical care services, attendant subspecialties, and the proliferation of pediatric critical care training programs nationally. Concurrent with this evolution has been recognition of the need for specialty care of the critically ill child during air or ground transport to a regional pediatric center. The American Academy of Pediatrics Section on Transport Medicine has provided standards that have been adopted by many neonatal and pediatric transport teams. Team composition varies, but all share the mission of specialized transport for critically ill and injured children in a safe and expeditious process while ultimately improving patient outcome. Specialized pediatric transport teams are costly to maintain. Declining reimbursement for specialized care and reduced profit margins have resulted in extended roles for transport team members within children's hospitals. More stringent budgetary constraints have created challenges for pediatric transport teams in our constantly changing medical environment.

Unmet need for routine and specialty care: data from the National Survey of Children With Special Health Care Needs.

To assess the prevalence of unmet needs for routine and specialty care among children with special health care needs (CSHCN) and to identify factors associated with the likelihood of having unmet need for medical care. Data come from the respondents for 38 866 children interviewed for the National Survey of Children With Special Health Care Needs. Bivariate analyses were used to assess differences in unmet need for medical care by various environmental, predisposing, enabling, and need factors. Logit analyses were used to determine independent effects of these variables on the likelihood of having an unmet need for medical care. Nationally, 74.4% and 51.0% of CSHCN needed routine and subspecialty physician care, respectively. Of those reporting that they needed routine care, 3.2% were unable to obtain these services. Of those reporting a need for specialty care, 7.2% reported not obtaining all needed specialty care. The prevalence of unmet need for specialty care significantly exceeded the prevalence of unmet need for routine care. In logit analyses, African American children and children whose mothers had less than a high-school education faced twice the odds of having an unmet need for routine care. Compared with nonpoor children, children living below the federal poverty level were significantly more likely to have an unmet need for routine (adjusted odds ratio [aOR]: 1.97; 95% confidence interval [CI]: 1.23-3.14) and specialty (aOR: 2.50; 95% CI: 1.49-4.18) care. Near-poor children were also significantly more likely than nonpoor children to have unmet needs for routine and specialty care. Uninsured children were significantly more likely than continuously insured children to report an unmet need for routine (aOR: 7.51; 95% CI: 4.99-11.30) and specialty (aOR: 4.29; 95% CI: 2.99-6.15) care. Our findings also show that higher levels of general pediatrician supply, relative to the pediatric population, are associated with a significantly lower likelihood of having an unmet need for routine care. Likewise, a greater supply of pediatric subspecialists is associated with a decreased likelihood of having an unmet need for specialty care. Compared with previous reports of the general pediatric population, CSHCN have higher levels of unmet need for medical services. Our regression results emphasize that children vulnerable because of their social circumstances (eg, poverty, etc) have significantly greater odds of having unmet need for routine and specialty physician care. Furthermore, our findings highlight the importance of insurance coverage in ensuring access to needed routine and specialty medical services.

C HARACTERISTICS OF T WICE - TRANSFERRED , R URAL T RAUMA P ATIENTS

Objective: Undertriage has seldom been evaluated in the trauma population. In rural states patients often go to the nearest hospital first, where they are evaluated and, if necessary, transferred to another hospital. If they are undertriaged when transferred to the second hospital, they will require a second transfer to a higher-level trauma center. Methods: The authors retrospectively reviewed the charts of all trauma patients at a level I trauma center from 1996 to 1999 who were seen at two acute care facilities because of a single acute traumatic event before reaching the trauma center. Ninety-three patient charts were analyzed. Results: Forty-six percent of the patients were victims of a motor vehicle crash. Patients were mostly transferred to the level I trauma center for non-spine orthopedic injuries (28%), followed by spine injuries (14%) and head injuries (13%). These patients were stable, as manifested by an average trauma score of 11.6. However, there was a significant positive interaction between injury severity score and time to definitive care. Conclusions: The authors infer from the data analysis that more serious or complex injuries took longer to evaluate. Since these patients were physiologically stable, reducing the number of twice-transferred trauma patients will involve refining transfer protocols concerning the need for specialty care.