Non-referred Patients Research Articles

Palliative care referral and associated outcomes among patients with cancer in the last 2 weeks of life

BackgroundPalliative care (PC) improves the quality of life of patients with advanced cancer. Our aim was to describe PC referral among patients with advanced cancer, and associated outcomes in an...

Factors associated with geographic tongue and fissured tongue

Objectives: The primary objective of this study was to investigate the association of systemic diseases, use of medications, allergies and tobacco habits with geographic tongue (GT) and fissured tongue (FT) lesions. The secondary objectives were to evaluate the clinical characteristics of tongue lesions and to compare the overall results for referred and non-referred patients.Methodology: Non-referred patients with GT (GTgp; n = 130) and FT (FTgp; n = 62) were examined by general practitioners (gp) and compared to a control group without oral mucosal lesions (C; n = 1029). Referred patients with GT (GTs; n = 166) and FT (FTs; n = 15) were examined by oral medicine specialists (s) and compared to GTgp and FTgp. Statistical analyses were performed using unpaired t-test or Fisher’s exact test. A multiple logistic regression model was developed to control for age and gender as confounders.Results: Compared to the C group, GTgp patients used more anti-hypertensive medications and Swedish snus (p < 0.01). The GTgp group consisted of older males (p < 0.001) compared to C. Compared to the GTgp group, the GTs group was younger, more likely to have symptomatic lesions (p < 0.0001) and comprised of more females. Among the groups examined, FT patients had the highest mean age.Conclusion: This study identified an association between GT and anti-hypertensive medications, as well as the use of Swedish snus. It also found differences in the activities and symptoms of the lesions between referred patients and their counterparts who were seen in general dental practice; these parameters influenced the results when these conditions were taken into account.

Internato Médico: o Desafio da Diversificação dos Cenários da Prática

A formação do aluno no curso de Medicina precisa se aproximar dos campos de prática vivenciados pelo médico atualmente. Este estudo objetivou caracterizar as experiências educacionais dos internos dentro de atividades em Atenção Primária, Secundária e Terciária à saúde, com vistas a otimizá-las. Inicialmente, foi descrita a criação de um estágio em atendimento secundário, antes inexistente na instituição, e avaliada a percepção dos alunos envolvidos. Posteriormente, foram caracterizados os atendimentos prestados pelos alunos em três cenários (primário, secundário e terciário) durante 30 dias. A criação do estágio na Unidade de Pronto Atendimento foi bem recebida pelos alunos, que sentiram necessidade de investir mais carga horária neste cenário. Foram avaliadas 201 consultas realizadas por internos, sendo a maioria na Atenção Primária. Houve grande diversificação dos motivos das consultas conforme o cenário de prática, e a preceptoria do interno ocorreu em todos os atendimentos. Concluímos que os diferentes cenários realmente oferecem oportunidades de aprendizado complementares que devem ser valorizadas institucionalmente.

Education of Physicians and Implementation of a Formal Referral System Can Improve Cardiac Rehabilitation Referral and Participation Rates after Percutaneous Coronary Intervention

Cardiac rehabilitation (CR) is an effective preventive measure that remains underutilised in the United States. The study aimed to determine the CR referral rate (RR) after percutaneous coronary intervention (PCI) at an academic tertiary care centre, identify barriers to referral, and evaluate awareness of CR benefits and indications (CRBI) among cardiologists. Subsequently, it aimed to evaluate if an intervention consisting of physicians' education about CRBI and implementation of a formal CR referral system could improve RR and consequently participation rate (PR). Data were retrospectively collected for all consecutive patients who underwent PCI over 12 months. Referral rate was determined and variables were compared for differences between referred and non-referred patients. A questionnaire was distributed among the physicians in the Division of Cardiology to assess awareness of CRBI and referral practice patterns. After implementation of the intervention, data were collected retrospectively for consecutive patients who underwent PCI in the following six months. Referral rate and changes in PRs were determined. Prior to the intervention, RR was 17.6%. Different barriers were identified, but the questionnaire revealed lack of physicians' awareness of CRBI and inconsistent referral patterns. After the intervention, RR increased to 88.96% (Odds Ratio 37.73, 95% CI 21.34-66.70, p<0.0001) and PR increased by 32.8% to reach 26%. Personal endorsement of CRBI by cardiologists known to patients increased CR program graduation rate by 35%. Cardiologists' awareness of CRBI increases CR RR and their personal endorsement improves PR and compliance. Education of providers and implementation of a formal referral system can improve RR and PR.

Use of exercise tests in primary care: importance for referral decisions and possible bias in the decision process; a prospective observational study.

BackgroundThe utility of clinical exercise tests depends on their support of treatment decisions. We sought to assess the utility of exercise tests for the selection of primary-care patients for referral to cardiologic care, and to determine whether referral decisions were biased by gender or socioeconomic status. We also evaluated referral rates and cardiovascular events in patients with positive exercise tests.MethodsWe designed a prospective observational study of 438 men and 427 women from 28 Swedish primary-care clinics who were examined with exercise testing for suspected coronary disease. All participants were followed-up with respect to cardiologist referrals and cardiovascular events (hospitalisation for unstable angina, myocardial infarction, and cardiovascular death) within six months and revascularisation within 250 days. Variables associated with referral were identified by multivariable logistic regression. Socioeconomic status was determined by educational level and employment.ResultsPositive/inconclusive exercise tests and exertional chest pain predicted referral in men and women. Of 865 participants, patients with positive, inconclusive, or negative exercise tests were referred to cardiologists in 67.3%, 26.1%, and 3.5% of cases, respectively. Overall, there was no significant difference in referral rates related to gender or socioeconomic level. Self-employed women were referred more frequently compared to other women (odds ratio (OR) 3.62, 95% confidence interval (CI) 1.19-10.99). Among non-manual employees, women were referred to cardiologic examination less frequently than men (OR 0.40, 95% CI 0.16-1.00; p = 0.049; ORs adjusted for age, exertional chest pain, and exercise test result). In patients with positive exercise tests, the referral rate decreased continuously with age (OR 0.48, 95% CI 0.23-0.97; adjusted for cardiovascular co-morbidity). Cardiovascular events occurred in 22.2% (4/18) of non-referred patients with positive exercise tests; 56% (10/18) of these patients were not considered for cardiologic care, with continuity problems in primary care as one possible contributing cause.ConclusionsExercise tests are important for selecting patients for referral to cardiologic care. Interactions related to gender and socioeconomic status affected referral rates. In patients with positive exercise tests, referral rates decreased with age. An increased awareness of possible bias regarding age, gender, and socioeconomic status, which may influence medical decisions, is therefore necessary.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-014-0182-9) contains supplementary material, which is available to authorized users.

Abstract 4136: Comparison of overall survival of Chronic Lymphocytic Leukemia (CLL) patients referred or not referred to a specialized CLL clinic: A Canadian population-based study

Abstract Chronic Lymphocytic Leukemia (CLL) patients in Manitoba are either referred to the CancerCare Manitoba (CCMB) CLL clinic or receive care from other hematologists/general practitioners. However, it is unknown whether referral to the CLL-specialized clinic alters patients' outcome. All CLL/SLL diagnoses in Manitoba 2007-2011 were obtained from the Manitoba Cancer Registry to create an immunophenotipically confirmed population-based cohort. Referred patients to the CLL-specialized clinic were identified from the CCMB charts. Association between age and treatment was measured by chi-squared test. Hazard ratio (HR) was determined using Cox Proportional Hazard Regression model. Of 555 CLL/SLL diagnoses, 281 (51%) were referred to the CLL-specialized clinic. For referred and non-referred patients the median age was 68y (39-99) and 72y (45-96), treated patients were 77 (27%) and 31 (11%), time to first treatment was 5m (0-5.5y) and 3m (0-2.5y), respectively. M:F was 1.7:1 for both groups. CLL was the primary cause of death in both referred and non-referred patients (57% and 35%, respectively). Comorbidities such as cardiovascular diseases had equal contributions to mortality in both populations (7% and 9.5% in referred and non-referred patients, respectively). When patients older than 70 years were investigated, elderly patients that were referred to the clinic were more likely to receive treatment (p = 0.0002). When adjusted for age (≥80y HR 10.79, p: &amp;gt;0.0001; 71-79y HR 5.44, p: 0.0007; 62-70y HR 4.07, p: 0.0051; &amp;lt;62 HR 1.00), gender (male HR 1.61, p: 0.0414), pre-CLL cancer (HR 1.85, p: 0.0187) and post-CLL Cancer (HR 2.31 p: 0.0208), patients seen by CLL-specialists had a &amp;gt;2-fold increased OS compared to non-referred patients (HR 2.39, p: 0.0003) in the Manitoba population. In the non-referred population, there was a striking correlation between advancing age and decreasing OS. This correlation was almost eliminated in the referred population. Thus, patients seen in a specialized clinic have an improved survival compared to non-referred patients and this appears to be primarily related to improved OS in the elderly. Whether this observation is related to improved therapy/supportive care in the specialized clinic or to referral bias is under investigation. Citation Format: Sara Beiggi, Versha Banerji, Angela Deneka, Jane Griffith, Spencer Gibson, James Johnston. Comparison of overall survival of Chronic Lymphocytic Leukemia (CLL) patients referred or not referred to a specialized CLL clinic: A Canadian population-based study. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4136. doi:10.1158/1538-7445.AM2014-4136

THU0204 Factors Associated with the Setting and Content of Care in Patients with Osteoarthritis of the Hip or Knee

BackgroundStudies determining factors associated with the setting and content of care in patients with hip/knee osteoarthritis (OA) are mainly confined to patient demographics or disease-related factors associated with total joint...

Access to Neuropsychologic Services After Pediatric Brain Tumor

BackgroundIncreasing survival rates for children with brain tumors creates a greater need for neuropsychologic follow-up and intervention. The aim of this study was to evaluate rates of referral by medical doctors to neuropsychologic services and patient and treatment factors that differentiated referred and nonreferred patients. MethodsData were retrieved from medical records of all pediatric brain tumor patients in southern Sweden diagnosed between 1993 and 2004 who survived more than 1 year (n = 132). Characteristics of the patients, the cancer, and treatment received were then compared for patients who were and were not referred for neuropsychologic examination during that period. ResultsSixty-four (48%) of the pediatric brain tumor patients were referred for neuropsychologic evaluation. These patients had significantly larger tumors, more recurrences of cancer, and increased intracranial pressure at diagnosis when compared with the nonreferred group (n = 68). However, most of the patients in the nonreferred group either had significant risk factors for cognitive impairment or were reporting impairments that would suggest a referral was warranted. ConclusionsGiven the high rates of cognitive impairment in children with brain tumors, referral to neuropsychologic services should be considered in all survivors. In addition to improving long-term adjustment, systematic referral can provide data on cognitive impairments, making it possible to evaluate different cancer treatment protocols not only in terms of survival but also in terms of quality of survival. Greater efforts are needed to disseminate and raise awareness about published guidelines on the long-term care of pediatric brain tumor patients.

Differences between referred and nonreferred patients in cancer research

In Canada, provincial cancer registries have been established to provide rigorous population-based data for patients with colorectal cancer. Databases maintained by regional cancer agencies contain a broader scope of information and have been used as a surrogate source of information for colorectal cancer research. It is unclear whether these data can be reliably extrapolated to all patients affected by colorectal cancer. We sought to determine whether patients included in a referral-based database are systematically different from patients who are not included. We conducted a retrospective cohort study to compare patients referred to the British Columbia Cancer Agency with those who were not referred. Comparison was based on age, sex and geographic location. We used univariate and logistic regression analysis to identify significant differences between the cohorts. Univariate analysis demonstrated that the referral and nonreferral cohorts differed in sex, age and geographic location. For patients with rectal cancer, the referral and nonreferral cohorts varied in age and geographic location. Multivariate analysis demonstrated significant differences in age and geographic location but not sex for patients with colon and rectal cancer. Patients included in the referral database differed in age and geographic location from those included only in the provincial database. Studies using large data sets from referral centres must be interpreted with caution and may not be representative of the entire patient population.

High Age Predicts Low Referral of Hyperthyroid Patients to Specialized Hospital Departments: Evidence for Referral Bias

Hospital-based studies may be hampered by referral bias. We investigated how the phenomenon may influence studies of hyperthyroid patients. By means of a computer-based linkage to the laboratory database and subsequent detailed evaluation of subjects with abnormal test results, we prospectively identified all 1148 patients diagnosed with overt hyperthyroidism in a four-year period in and around Aalborg City, Denmark. Each patient was classified according to nosological type of hyperthyroidism. We studied the referral pattern of patients to local hospital units, and analyzed how referral depended on subtype of disease, sex, age, and degree of biochemical hyperthyroidism. In a 4-year period, 1032 hyperthyroid patients were diagnosed at primary care offices, and 435 of these (42.2%) were referred to specialized units, 92 patients had hyperthyroidism diagnosed in other hospital departments (referral: 43, 46.7%), and 24 patients had hyperthyroidism diagnosed at the specialized unit after referral for other diseases. Patients suffering from Graves' disease (GD; n=474, median age=65.8 years) were referred more often (odds ratio=1.7 [95% confidence interval 1.3-2.2]) than those diagnosed with multinodular toxic goiter (MNTG; n=525, median age=74.6 years). Higher age was associated with less referral of patients suffering from MNTG (referred vs. nonreferred patients, 64.0 vs. 77.4 years, p<0.001) and GD (43.9 vs. 56.4 years, p<0.001), whereas GD patients referred to a hospital had more severe biochemical hyperthyroidism (serum total triiodothyronine, 4.86 vs. 3.79 nmol/L; serum total thyroxine, 204 vs. 180 nmol/L; both p<0.001). Findings were confirmed in multivariate models reporting age as a significant predictor for referral in both GD and MNTG patients (both p<0.001). Among referred hyperthyroid patients (all combined), those aged up to 40 years (referral rate, 66.8%) were represented 11.6 (6.6-20.6) times more often than those aged 80 years and above (referral rate, 14.8%). Hyperthyroid patients referred to a specialized hospital unit were younger (GD+MNTG) and had more severe biochemical hyperthyroidism (GD) compared to nonreferred patients. Thus, referral bias may influence hospital-based studies of hyperthyroid patients, and may hamper external generalization of such studies. Whether the referral bias of hyperthyroid patients in Denmark can be generalized to other countries or cultures remains unknown.

Nutrition screening by nurses in dialysis

To determine whether a nurse-completed dialysis nutritional screening tool improves referral rates for nutritional support and compare nutrition sensitive biochemical indices, mortality rates and patient-centred quality of life outcomes between referred and non-referred dialysis patients. People with chronic kidney disease requiring dialysis are nutritionally at risk. Nutrition screening has been shown to identify dialysis patients who are nutritionally at risk to refer to dietitian expertise. Prospective cluster-randomised control trial. Monthly nurse-completed nutrition screening was completed for six consecutive months using a validated four-item instrument measuring weight change, serum phosphate, serum potassium and appetite. Participants (n = 81) were haemodialysis patients from four satellite haemodialysis centres in one Australian metropolitan health service. Primary outcome measure was rate of referral to dietetic services for nutrition support for intervention vs. control groups at six months. Secondary outcome measures were blood pressure, biochemical indices and mortality for referred vs. non-referred patients at six and nine months, and generic and dialysis-specific quality of life for referred vs. non-referred at nine months was examined. There were three times as many dietetic referrals in the intervention group than in the control group (26·3 vs. 9·3%). Serum phosphate increased significantly more in the referred patients than the non-referred patients. There were no clinically significant changes between groups in quality of life, blood pressure, mortality rates or other biochemical indices at either six or nine months. Nurse-completed nutritional screening can lead to appropriate dietetic referrals for nutritional support by nutritional expert clinicians. This study is the first to demonstrate that monthly systematic nurse-completed nutritional screening can facilitate appropriate dietetic referrals that may lead to increased nutritional care for people in satellite dialysis centres.

Observational Comparative Effectiveness Studies of Drug Therapies

Observational Comparative Effectiveness Studies of Drug Therapies

Bias in Amputation Research; Impact of Subjects Missed from a Prospective Study

For research findings to be generalized, a sample must be representative of the actual population of interest. Lower limb amputation is most frequently performed in older patients with vascular disease, a population that is often under-represented in research. The aim of this study was to explore the impact of selection bias by comparing characteristics from a sample included in a prospective study of phantom pain with the actual population who underwent amputation. Only 27% of all potential patients were referred during the first year of the prospective study. The referred patients were 8 years younger (p<0.001) and less likely to have had amputation because of a vascular condition, diabetes or infection (p = 0.003) than those not referred. There was also a significant difference in one year survival between the groups; 67% of referred patients survived compared with just 40% of non-referred patients (p = 0.004). The biased population in the phantom pain study may have resulted in an underestimation of phantom pain in the original study and subsequent protective factors should be considered within the context of the younger population reported. Selection bias is common in amputation research, and research methods to minimize its impact must be given greater attention.

Osteoarthritis of the hip and/or knee in Dutch general practice and physiotherapy practice

Purpose: To describe demographic characteristics and the treatment process of patients with hip osteoarthritis (OA) or knee OA treated in Dutch general practice (GP) and/or physiotherapy practice. Additionally, to investigate whether there are differences in characteristics between referred and non-referred patients with hip or knee OA in GP and physiotherapy practice. Methods: Data from two, separate national registration networks were used. Patients who visited their general practitioner and/or physiotherapist between 2006 and 2009 on account of hip or knee OA were included. Demographic data concerned prevalence and incidence rates, gender and age. In GP, prescriptions and referrals were analyzed. In physiotherapy practice, the health problem, the number of treatment sessions, the duration of a treatment episode, the applied interventions and the treatment results were investigated. In case of continue data, two sample t-tests were used to compare between patients with hip OA and patients with knee OA, respectively between referred patients and non-referred patients in GP and in physiotherapy practice. Chi square tests were used to compare categorical variables. Results: In total, 7477 patients were included. Prevalence rates for hip/knee OA comprised 10.4 / 1000 patients in GP and 18.4 / 1000 patients in physiotherapy practice. Both in GP and physiotherapy practice, the OA population included more females than males and more patients with knee OA than hip OA. Forty-five percent of the patients in GP received a medicine, mostly a NSAID. Prescriptions were significantly more common in patients with knee OA than in patients with hip OA. About 5% of the hip/knee population was referred to a physiotherapist. Referred patients were more often treated pharmacologically than non-referred patients. In physiotherapy practice, patients with hip OA were faced significantly longer with complaints than patients with knee OA. There were no significant differences in treatment characteristics between referred patients (68%) and patients who seek help from a physiotherapist on their own initiative (32%). Patients with hip or knee OA in GP who are referred to a physiotherapist were significantly older and more often females in comparison to patients with hip or knee OA in physiotherapy practice who are referred by their GP. Conclusion: In GP, patients with knee OA are more often treated pharmacologically than patients with hip OA. The same applies to patients who are referred for physiotherapy compared to non-referred patients. General practitioners should reconsider the frequent use of NSAID's, because guidelines recommend the use of analgesics as first medicine of choice. In physiotherapy practice, the duration of complaints differs between patients with hip OA and patients with knee OA. There are no differences referred and non-referred patients. At this moment, patient- and treatment characteristics of patients with hip or knee OA are extracted from two separate registration networks. Patient characteristics differed significantly between referred patients in GP and referred patients in physiotherapy practice. Therefore, to enable longitudinal observation of care in patients with hip or knee OA, it is desirable to create a multidisciplinary registration network in which patient oriented data from different care providers is clustered. (aut. ref.)

Le recours représente 42 % de l’activité d’une consultation mémoire neurologique d’un centre mémoire de ressources et de recherche

Evaluate demographic and aetiological characteristics of patients referred by specialist doctors (neurologists, geriatricians and psychiatrists) to an Academic Memory Clinic in Lyon, for the year 2008. These specialist-referred patients (SRP) constitute a specific mission of the French Academic Memory Clinics. The outpatients consecutively referred in 2008 to our memory clinic by any persons (patients, families, general practitioners, specialist doctors) were all evaluated using clinical, neuropsychological and imaging information. We examined the distribution of patients diagnosis and differences in gender, education, and cognitive severity (MMSE). For each patient, diagnoses used clinical criteria at the first visit, and ranged from normal subjects to cognitive impaired patients with or without dementia. Among 384 patients, 160 (41.7%; 68 men and 92 women) were referred by specialist doctors. These 160 SRP were younger (P<0.0001) but did not differ from other patients on gender (P=0.55) nor Mini Mental State Examination (P=0.15). SRP were more often demented than the non-referred patients (respectively, 64.4% vs 39.7%; P=0.0001), and the demented SRP had less often Alzheimer's disease (AD) (30.1% vs 65.6%; P=0,0001). Dementia was present in 64.4% of the 160 SRP: among the 160, AD was the most frequent cause (19.4%), followed by Lewy body dementia (11.3%), neurological diseases (12.5% - multiple sclerosis, vascular cognitive impairment, epilepsy) and Mild Cognitive Impairment (10%). Normal subjects were present in 8.1% of the SRP. As compared to non-SRP, SRP are younger, more demented (64,4%) and more prone to have non-AD dementia (69,9%). However, AD represented the most frequent diagnosis (19.4% of SRP). SRP are an important part of the activity of an Academic Memory Clinic in Lyon. As compared to GPs, young and demented patients are more likely to be sent in a specialized referral center by specialist doctors.

Nonreferral of Nursing Home Patients With Suspected Breast Cancer

People with suspected breast cancer who are not referred for diagnostic testing remain unregistered and are not included in cancer statistics. Little is known about the extent of and motivation for nonreferral of these patients. A Web-based survey was sent to all elderly care physicians (ECPs) registered at the National Association of Elderly Care Physicians and Social Geriatricians in the Netherlands, inquiring about the number of patients with suspected breast cancer they encountered and subsequent choices regarding referral. Surveys were completed by 419 (34%) of 1239 ECPs; 249 (60%) of these had encountered one or more patients with suspected breast cancer in the past year. Seventy-four (33%) ECPs reported not referring the last patient. Reasons for nonreferral were end-stage dementia (57%), patient/family preference (29%), and limited life expectancy (23%). Referral was frequently thought to be too burdensome (13%). For 16% of nonreferred patients, hormonal treatment was started by the ECP without diagnostic confirmation of cancer. In this survey, more than 33% of nursing home patients with suspected breast cancer were not referred for further testing, in particular those with advanced dementia, limited life expectancy, and poor functional status. As the combination of dementia and suspected breast cancer is expected to double in the coming decades, now is the time to optimize cancer care for these vulnerable patients.

The Prevalence of Serious Infectious Complications in a Cohort of Non-Referred Patients with Newly Diagnosed Chronic Lymphocytic Leukemia (CLL) Compared to Controls: Results of a Cohort Study

Abstract 4610 IntroductionInfections are a major cause of morbidity and mortality in patients with chronic lymphocytic leukemia (CLL). Up to 50% of CLL patients develop infectious complications, and 30–50% of all deaths in CLL patients are attributed to infections. Despite these data, the available research on infectious complications in CLL is primarily limited to patients participating in clinical trials of chemotherapy, obscuring the distinction between the risk of infection due to the disease's natural history relative to the risk associated with therapy related immune suppression. METHODS:The Mayo Clinic Rochester (MCR), a tertiary referral center in rural southeastern Minnesota, is also the primary hematology center for southeastern Minnesota, northern Iowa, and western Wisconsin. There are no metropolitan areas or hematology specialty centers within a ∼50 mile radius. To explore the natural history of infection in a community-based cohort of CLL patients, we used the Mayo Clinic CLL database to identify all patients with newly diagnosed CLL who resided within 50 miles of MCR and diagnosed between January, 1999 and December, 2009. The comparison cohort consisted of 689 adult patients who also resided within 50 miles of MCR who were seen for a general medical examination between September, 2002 and December, 2009 and who were enrolled as controls in a case-control study of non-Hodgkin lymphoma. All hospitalizations at MCR among both cohorts were audited to document hospitalization with infection and cross-referenced with the Mayo Clinic infection database, which includes all culture results obtained from hospitalized MCR patients. Serologies and viral assays were also reviewed. Patients whose cultures were negative but who were given a clinical diagnosis of infection (e.g. pneumonia) and who were treated with a full course of antibiotic therapy were considered to have a culture negative infection. RESULTS:In May 2010, there were 2022 CLL patients in the Mayo Clinic CLL Database diagnosed between 1999 and 2009. Of these, 174 (9%) were local CLL patients residing within 50 miles of MCR. Median age at diagnosis for these non-referred CLL patients was 69 years (range 27–97). Most had early stage disease (60% stage 0; 32% stage I-II). On prognostic evaluation, 121 (75%) patients were CD38 negative, 66 (61%) ZAP-70 negative, 47 (50%) IGHV mutated, and 56 (62%) had either no abnormality or 13q14- as a sole abnormality on FISH analysis. 64 (37%) patients progressed to require treatment for CLL during follow-up.After median follow-up of 4.0 years (range 0–11), 32 (18.4%) CLL patients were hospitalized with infection at least once as compared to 20/689 (2.9%) individuals in the control cohort (odds ratio=7.5; p<0.0001) Figure 1A. Even prior to receiving treatment for CLL, the rate of hospitalization for infection remained higher than the control cohort (p=0.002; Figure 1B). The 32 CLL patients hospitalized with infection were admitted with infection a total of 89 times (median 1 hospitalization for infection per patient). A specific infectious organism was identified by cultures or serologies in 60 (63%) of the 89 infections in CLL cases and 10/27 (37%) infections among controls. Hospitalization for an opportunistic infection (e.g. cytomegalovirus, cryptococcus, filamentous fungi, mycobacteria, Pneumocystis) occurred in 5/174 (3%) CLL patients during follow-up compared to 0/689 controls (p<0.001). [Display omitted] [Display omitted] Finally, we performed a pooled multivariable analysis of all patients (n=863) to identify factors (age, sex, CLL diagnosis, CLL treatment) associated with infection risk. Most factors were independently associated with hospitalization for infection [Age (per year, OR=1.03, p=0.02), sex (male, OR=4.0, p<0.001), diagnosis of CLL (OR=2.1, p=0.09), and treatment for CLL (OR=5.9, p<0.001)]. In univariate analysis of CLL patients [sex (OR=4.2, p=0.01), higher Rai stage (p=0.046), unfavorable (del 17p13; del 11q23) FISH [OR=4.6, p=0.02] and unmutated IGHV [OR=2.8, p=0.07]) were associated with risk of infection. CONCLUSIONS:In this cohort study, patients with newly diagnosed CLL had a 7.5-fold risk of hospitalization for infection relative to the control cohort. After 4 year follow-up, ∼1 in 5 CLL patients required hospitalization for infection. Although CLL treatment was a substantial risk factor for infection, the risk of infection among untreated patients remained higher than controls. Disclosures:Kay:Biothera: Research Funding; Clegene: Research Funding; Cephalon: Research Funding; Genentech: Research Funding; Glaxo Smith Kline: Research Funding; Hospira: Research Funding; Novartis: Research Funding; Supergen: Research Funding; Calistoga: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Emergent Biosolutions (Formerly Trubion): Membership on an entity's Board of Directors or advisory committees. Zent:GlaxoSmithKline: Research Funding; Genentech: Research Funding; Genzyme: Research Funding.

Utilización por cuenta propia de los Servicios de Urgencias Hospitalarias: razones que dan las personas con problemas de salud de baja complejidad para utilizar estos servicios

Objectives: The objectives of this study are: 1) To understand the reasons of non-urgent non-referred patients to use the Emergency Department (ED), 2) To understand the “urgency” and “concern” perceptions of non-urgent non-referring patients. 3) To determinate the associated factors with the use the ED for non-urgent non-referred patients. Methods: Design: Descriptive cross-sectional study. Setting: Emergency Department (ED) of “Infanta Cristina” General Hospital, Parla, Madrid, Spain. Patients: non-referred non-urgent adult patients were selected by Emergency Department Triage system in levels IV and V, on weekdays between 10:00 and 22:00 hours, from April 26 to July 30, 2010, to be surveyed using a structured face-to-face interview. Main outcome measures: sociodemographic characteristics, personal experience with the health care centre (HCC) and ED, urgency and concern of symptoms, previous health care use regarding current health problem, reasons to visit the ED, comparative evaluation of ED and HCC. Results: 73% of the patients came directly to the ED. More efficient technical services (42%), the HCC was closed in this time (35%), promptly resolution of the health problem (22%) and more accessibility (20%) were the most important reasons to come directly to ED. 27% of the patients went previously to the HCC and then they came to the ED because they did not get better with the treatment prescribed (71%) and they went to know a second opinion (39%). 70% of the patients considered that their health problem was not serious but they thought this situation had to be resolved promptly. 63% of the patients were very worried for their health problem and the same proportion considered that their family doctor could not resolve this problem. Finally, 50% considered that the ED had more technical capacity to resolve their health problem. conclusions: High efficacy and effectiveness, in terms of technical resources and promptness, were the main reasons of non-referred non-urgent adult patients to use the ED. The high preoccupation, but not the perception of seriousness perception, of the health problem was the most important factor to seek care in an active and quickly way. The previous institutional experience in HCC could influence those reasons.

Optimisation of the diagnostic strategy for suspected deep-vein thrombosis in primary care

Recently, a diagnostic score was developed to safely exclude deep-vein thrombosis (DVT) in primary care. A large prospective study, in which general practitioners used this diagnostic score to decide which patients needed referral, revealed that the number of referrals for ultrasound measurements was reduced by almost 50%, at the cost of an acceptably low risk (1.4%, 95% confidence interval [CI] 0.6% to 2.9%) of venous thromboembolic events in non-referred patients. However, simple adjustments to the diagnostic score (so-called updating) might further improve the accuracy; i.e. reduce the proportion of missed diagnoses (safety) or increase the proportion of patients who do not need to be referred (efficiency). We applied two updating methods to determine whether adjusting the weights of the predictors or adding new predictors could further improve the accuracy of the diagnostic score. The weights of the predictors did not need to be adjusted, but inclusion of 'history of DVT' and 'prolonged travelling' significantly added predictive value (p-values 0.014 and 0.023, respectively). However, adding these predictors to the diagnostic score did not improve the safety and efficiency: at equal safety (1.4% missed diagnoses among the non-referred patients), the efficiency was lower (43.5%, 95% CI 40.4% to 46.6% compared to 49.4%, 95% CI 46.3% to 52.5%). The diagnostic score for excluding DVT in primary care has good accuracy in its original form and could not be improved by including additional predictors. This suggests that the original diagnostic score can be used to safely exclude clinically suspected DVT in primary care.

Different characteristics of patients with gastro-oesophageal reflux disease on their path through healthcare: a population follow-up study

Only a minority of patients with gastro-oesophageal reflux symptoms (GORS) seek medical advice. Little is known about patient characteristics associated with consultation in primary care and referral to secondary care. We compared the characteristics of patients with GORS in the general population, those who consulted their general practitioner (GP) and those referred to secondary care for upper endoscopy. We aimed to identify differences between patients with short term (<90 days) and chronic symptoms, and differences between patients with symptoms in primary and secondary care. The study was performed in a primary care based prospective dynamic population. In total, 16% of 7237 adult patients were identified with GORS. Twenty-five percent of these patients consulted the GP, of whom 40% were referred for endoscopy. Patients with chronic GORS were older, had a higher body mass index, were more often referred for upper endoscopy (all P<0.001) and more frequently had relevant findings during endoscopy (oesophagitis: 50% and Barrett's oesophagus: 10%). Patients referred for upper endoscopy were older than nonreferred patients (P<0.001). Only a minority of people with GORS visit their GP. After consulting referral for endoscopy occurs relatively often. Underlying endoscopic abnormalities are frequently found in patients with chronic GORS.