Open-access Clinic Research Articles

Alcy R. Torres, MD

Dr Alcy Torres is a pediatric neurologist who specializes in traumatic brain injury. Much of his clinical work takes place around the Pediatric Concussion Program at Boston Medical Center; a multidisciplinary center coordinating care between the Emergency Room, the inpatient and outpatient services but also the common referrals to Physical, Vestibular, Ocular, Speech therapies and Neuropsychology services. His aim is to provide the highest level of care to children and adolescents who have sustained a brain injury by understanding the pathophysiology of the pediatric patient through research and enhancing the health and well-being of patients, minimizing distress, and preventing longer-term difficulties.In order to achieve this goal, he has developed a Standardized Clinical Assessment and Management Plans, now adopted by the Adult Concussion Clinic at Boston University to continuously review individual patient data for areas in our practice that need improvement, thus ensuring that the Brain Injury program always provides the best, most cost-effective care for our patients. Another goal of the center is access to acute and follow-up care, to which end we began developing an open access clinic in 2013 to provide services at Boston Medical Center, our satellites and across different different specialties.

A better way to detect head and neck cancer recurrences

<b>Introduction:</b> To examine the prevalence of recurrence following multidisciplinary, multimodality curative head and neck cancer (H&NC) treatment, to determine how, when and where recurrences are identified and, most pertinently, who was identifying them; patients, clinicians or routine imaging. <b>Methods:</b> We reviewed all H&NC cases that presented to the Blenheim Head and Neck unit over 2.5 years and were discussed in MDT, and isolated those which represented recurrences at clinically detectable anatomical regions. We explored the types of cancers most commonly recurring, the primary sites and the initial treatment they were provided. We examined the frequency and mode of surveillance they underwent and we explored how these clinically identifiable recurrences were being discovered. <b>Results:</b> 1108 cases of head and neck cancer were discussed in MDT over this period. Of these 736 met the inclusion criteria. 11% of these represented confirmed recurrent disease. 91% of cases were biopsied as SCCs. The most common primary sites were the tongue (33%) and tonsils (11%). 67% of recurrences presented with symptoms identified by the patients. Of those, 61% were seen in clinic, most commonly during an expedited routine follow-up appointment, and 31% attended their GP. Imaging and clinicians picked up most of the remainder. We found no significant reduction in the pick-up rate related to COVID-19. <b>Conclusions:</b> Studies have found no surveillance protocol post H&NC fits all, and follow-up should be considered on a case-by-case basis. Here we show that patients play a crucial role in the identification of recurrence, and increased education and regular open access clinics for follow-up with the MDT may be a safe and cost-effective approach.

A Stochastic Programming Model for Service Scheduling with Uncertain Demand: an Application in Open-Access Clinic Scheduling

This paper addressed a scheduling problem which handles urgent tasks along with existing schedules. The uncertainties in this problem come from random process of existing schedules and unknown upcoming urgent tasks. To deal with the uncertainties, this paper proposes a stochastic integer programming (SIP) based aggregated online scheduling method. The method is illustrated through a study case from the outpatient clinic block-wise scheduling system which is under a hybrid scheduling policy combining regular far-in-advance policy and the open-access policy. The COVID-19 pandemic brings more challenges for the healthcare system including the fluctuations of service time and increasing urgent requests which this paper is designed for. The schedule framework designed in the method is comprehensive to accommodate various uncertainties in the healthcare service system, such as: no-shows, cancellations and punctuality of patients as well as preference of patients over time slots and physicians.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43069-021-00089-6.

Melatonin may slow disease progression in amyotrophic lateral sclerosis: Findings from the Pooled Resource Open-Access ALS Clinic Trials database.

We utilized the Pooled Resource Open-Access Clinical Trials (PRO-ACT) database to investigate whether melatonin use among patients with amyotrophic lateral sclerosis (ALS) was associated with slower disease progression and prolonged survival. This retrospective analysis of the PRO-ACT database addresses the impact of melatonin on progression and overall survival of ALS. A Cox proportional hazards ratio model was performed to investigate the effect that melatonin had on time to death. For secondary outcome measures, linear mixed effects regression models were used to ascertain the effect of melatonin on change in standardized ALS Functional Rating Scale (sALSFRS) and percentage predicted forced vital capacity (FVC) scores. Melatonin users had a significantly decreased annualized hazard death rate compared with the non-melatonin users (hazard ratio, 0.241; 95% confidence interval, 0.088-0.659; P = .0056). The melatonin users also had a slower rate of decline in sALSFRS score (t = 2.71; P = .0069) and change in percent predicted FVC score (t = 2.94; P = .0035) compared with the non-melatonin users. Our findings suggest that melatonin may be beneficial for patients with ALS. Due to the nature of this database, our results are solely intended to be hypothesis-generating and no strong associations can be made. Given the low cost and favorable safety profile of melatonin, the hypotheses generated warrant further investigation.

A novel method for predicting the progression rate of ALS disease based on automatic generation of probabilistic causal chains.

Causal discovery is considered as a major concept in biomedical informatics contributing to diagnosis, therapy, and prognosis of diseases. Probabilistic causality approaches in epidemiology and medicine is a common method for finding relationships between pathogen and disease, environment and disease, and adverse events and drugs. Bayesian Network (BN) is one of the common approaches for probabilistic causality, which is widely used in health-care and biomedical science. Since in many biomedical applications we deal with temporal dataset, the temporal extension of BNs called Dynamic Bayesian network (DBN) is used for such applications. DBNs define probabilistic relationships between parameters in consecutive time points in the form of a graph and have been successfully used in many biomedical applications. In this paper, a novel method was introduced for finding probabilistic causal chains from a temporal dataset with the help of entropy and causal tendency measures. In this method, first, Causal Features Dependency (CFD) matrix is created on the basis of parameters changes in consecutive events of a phenomenon, and then the probabilistic causal graph is constructed from this matrix based on entropy criteria. At the next step, a set of probabilistic causal chains of the corresponding causal graph is constructed by a novel polynomial-time heuristic. Finally, the causal chains are used for predicting the future trend of the phenomenon. The proposed model was applied to the Pooled Resource Open-Access Clinical Trials (PRO-ACT) dataset related to Amyotrophic Lateral Sclerosis (ALS) disease, in order to predict the progression rate of this disease. The results of comparison with Bayesian tree, random forest, support vector regression, linear regression, and multivariate regression show that the proposed algorithm can compete with these methods and in some cases outperforms other algorithms. This study revealed that probabilistic causality is an appropriate approach for predicting the future states of chronic diseases with unknown cause.

352 – Point-Of-Care Hepatitis C Screening and Open Access Clinic Improves Linkage to Care and Treatment Uptake Among Ex Drug Users Population in Singapore: A Cluster Randomized Study

352 – Point-Of-Care Hepatitis C Screening and Open Access Clinic Improves Linkage to Care and Treatment Uptake Among Ex Drug Users Population in Singapore: A Cluster Randomized Study

Individual treatment effect prediction for amyotrophic lateral sclerosis patients.

A treatment for a complicated disease might be helpful for some but not all patients, which makes predicting the treatment effect for new patients important yet challenging. Here we develop a method for predicting the treatment effect based on patient characteristics and use it for predicting the effect of the only drug (Riluzole) approved for treating amyotrophic lateral sclerosis. Our proposed method of model-based random forests detects similarities in the treatment effect among patients and on this basis computes personalised models for new patients. The entire procedure focuses on a base model, which usually contains the treatment indicator as a single covariate and takes the survival time or a health or treatment success measurement as primary outcome. This base model is used both to grow the model-based trees within the forest, in which the patient characteristics that interact with the treatment are split variables, and to compute the personalised models, in which the similarity measurements enter as weights. We applied the personalised models using data from several clinical trials for amyotrophic lateral sclerosis from the Pooled Resource Open-Access Clinical Trials database. Our results indicate that some amyotrophic lateral sclerosis patients benefit more from the drug Riluzole than others. Our method allows gradually shifting from stratified medicine to personalised medicine and can also be used in assessing the treatment effect for other diseases studied in a clinical trial.

Characterizing breast conditions at an open-access breast clinic in South Africa: a model that is more than cancer care for a resource-limited setting

BackgroundWhile most breast-related research focuses on cancer, presentation of symptomatic persons in non-screened environments requires understanding the spectrum of breast diseases so as to plan services in resource-constrained settings. This study presents the variety of breast disease managed at a government, open-access breast clinic in South Africa.MethodsWe performed a retrospective file review using a systematic random sample of patients 18 years and above presenting for breast care over a 14-month period. We collected demographics, clinical characteristics, management and final diagnoses from the first visit and twelve subsequent months.ResultsThe final sample contained 365 individuals (97 · 5% women). Most were black, unmarried and South African citizens with a median age of 43 years (IQR 31–55) . Of those reporting their status (24 · 1%) 38 · 6% were HIV-positive. A mass (57 · 0%) and/or pain (28 · 5%) were the most common symptoms. Imaging and breast biopsies were required in 78 and 25% of individuals, respectively. Nearly half of biopsies identified breast cancer (44 · 1% of women ≤40 and 57 · 3% for women >40). Benign conditions (47 · 7%) and no abnormality (18 · 2%) were common final classifications among women. There was no difference between the final classifications of patients who self-referred versus those who were formally referred from another health care provider. Nearly half of the participants (46 · 6%) travelled 20 km or more to attend the clinic.ConclusionsBenign breast conditions far outweighed cancer diagnoses. As breast cancer awareness increases in resource-limited countries, facilities offering breast care require administrative and clinical preparation to manage a range of non-cancer related conditions.

The aetiology of acute neurological decline in multiple sclerosis: Experience from an open-access clinic

Background: Multiple sclerosis (MS) relapses contribute to disability and influence treatment decisions. Many centres now provide open access to specialist services for patients with new symptoms. However, there is scarce literature on the spectrum of presentations encountered in this setting. Objective: The objective of this paper is to characterise presentations to an open, rapid-access MS relapse clinic and the impact on disease management. Methods: A retrospective review of outpatient episodes over a three-year period was conducted. Demographic and service data, symptoms, disability, diagnosis and management were recorded according to a standardised proforma. Results: A total of 371 attendances were analysed. A new MS relapse was diagnosed in 216 (58%) episodes, of which 56 (26%) patients had an additional diagnosis which had also contributed to their presentation. Of 266 reports of non-relapse-related symptoms, 73 were unrelated to MS. Treatment interventions were made in almost all relapsing patients and in 70% of patients presenting with acute, non-relapse-related symptoms of MS. Changes to disease-modifying therapies were considered in 28% of consultations. Conclusion: Diagnosing MS relapses is crucial for disease management and yet remains challenging. Clinicians should be aware of differential diagnoses and confounding factors. The high incidence of therapeutic interventions observed suggests that rapid-access clinics represent an effective platform for responsive disease management.

A hybrid simulation and genetic algorithm approach to determine the optimal scheduling templates for open access clinics admitting walk-in patients

With the pressing demand for improving patient accessibility, the traditional scheduling system may not be effective for mitigating the adverse effects caused by no-shows, appointment cancellations and late arrivals. For this reason, open access scheduling, which specifies that a portion of clinic appointment slots be reserved for short-notice appointments, was proposed and adopted in recent years. In literature, many studies have developed a variety of approaches and models to optimize the open access scheduling systems, while few considers the inclusion of walk-in patients and the optimal allocation of reserved slots on the scheduling template under the open access configuration. In this paper, we propose a Discrete Event Simulation and Genetic Algorithm (DES–GA) approach to find the heuristic optimal scheduling template under the clinic setting that allows both open access and walk-in patients. The solution can provide scheduling templates consisting of not only the optimal number of reservations for open access appointments and walk-ins, but also the optimized allocation of these reserved slots, by minimizing the average cost per admission of open access or walk-in patient. In this approach, the cost is measured by the weighted summation of patient waiting time, provider idle time, and provider overtime. A case study and sensitivity analysis are conducted to show how the heuristic optimal scheduling template generated from the proposed approach could vary under different scenarios. This also illustrates the viability of our model. The results show that the heuristic optimal scheduling templates are significantly affected by the patient attendance rate, level of demands of same-day appointment and walk-in admissions, as well as the cost coefficients associated with patient waiting time, provider idle time and provider overtime.

Distance management of inflammatory bowel disease: Systematic review and meta-analysis

To review the effectiveness of distance management methods in the management of adult inflammatory bowel disease (IBD) patients. A systematic review and meta-analysis of randomized controlled trials comparing distance management and standard clinic follow-up in the management of adult IBD patients. Distance management intervention was defined as any remote management method in which there is a patient self-management component whereby the patient interacts remotely via a self-guided management program, electronic interface, or self-directs open access to clinic follow up. The search strategy included electronic databases (Medline, PubMed, CINAHL, The Cochrane Central Register of Controlled Trials, EMBASE, KTPlus, Web of Science, and SCOPUS), conference proceedings, and internet search for web publications. The primary outcome was the mean difference in quality of life, and the secondary outcomes included mean difference in relapse rate, clinic visit rate, and hospital admission rate. Study selection, data extraction, and risk of bias assessment were completed by two independent reviewers. The search strategy identified a total of 4061 articles, but only 6 randomized controlled trials met the inclusion and exclusion criteria for the systematic review and meta-analysis. Three trials involved telemanagement, and three trials involved directed patient self-management and open access clinics. The total sample size was 1463 patients. There was a trend towards improved quality of life in distance management patients with an end IBDQ quality of life score being 7.28 (95%CI: -3.25-17.81) points higher than standard clinic follow-up. There was a significant decrease in the clinic visit rate among distance management patients mean difference -1.08 (95%CI: -1.60--0.55), but no significant change in relapse rate or hospital admission rate. Distance management of IBD significantly decreases clinic visit utilization, but does not significantly affect relapse rates or hospital admission rates.

Open-access community child health clinics

In Australia, Community Child Health Services (CCHS) is the primary health care service which seeks to strengthen and support families, prevent illness and manage risks. Several nursing models of care exist within CCHS, and limited research has investigated which is the best way to provide child health surveillance and parenting support during the early years. This study qualitatively explored the everyday lived experience of parents and child health nurses involved with an open-access (appointment-free, parent-led) group child health surveillance clinic. Findings showed that participants considered the open-access clinic provided a helpful and supportive way of delivering child health surveillance and parental support to families with infants aged 0-18 months, without identified risk factors. The perspectives of multiple parents, nurses and other health workers found it effective, flexible and parent-directed, which may be in contrast to some traditional individual appointment child health surveillance methods.

The Evolving Role of Open Access Journals and Clinical &amp; Experimental Pharmacology Journal

The Evolving Role of Open Access Journals and Clinical &amp; Experimental Pharmacology Journal

Improving Access to VA Care

Improving Access to VA Care

Does Open Access Improve the Process and Outcome of Podiatric Care?

BackgroundOpen access to clinics is a management strategy to improve healthcare delivery. Providers are sometimes hesitant to adopt open access because of fear of increased visits for potentially trivial complaints. We hypothesized open access clinics would result in decreased wait times, increased number of podiatry visits, fewer “no shows”, higher rates of acute care visits, and lower minor amputation rates over control clinics without open access.MethodsThis study was a national retrospective case-control study of VHA (Veterans Hospital Administration) podiatry clinics in 2008. Eight case facilities reported to have open podiatry clinic access for at least one year were identified from an email survey. Sixteen control facilities with similar structural features (e.g., full time podiatrists, health tech, residency program, reconstructive foot surgery, vascular, and orthopedic surgery) were identified in the same geographic region as the case facilities.ResultsTwenty-two percent of facilities responded to the survey. Fifty-four percent reported open access and 46% did not. There were no differences in facility or podiatry panel size, podiatry visits, or visit frequency between the cases and controls. Podiatry visits trended higher for control facilities but didn’t reach statistical significance. Case facilities had more new consults seen within 30 days (96%, 89%; P = 0.050) and lower minor amputation rates (0.62/1,000, 1.0/1,000; P = 0.041).ConclusionsThe VHA is the world’s largest managed care organization and it relies on clinical efficiencies as one mechanism to improve the quality of care. Open access clinics had more timely access for new patients and lower rates of minor amputations.KeywordsHealth care; Quality; Access; Evaluation; Delivery of health care; Amputation; Amputation prevention

Modeling the effect of patient choice on the performance of open access scheduling

Open access scheduling, introduced in recent years, is a revolutionary concept for improving healthcare access and reducing patient no-shows. In this paper, a Markov chain model is presented to capture appointment scheduling in open access clinics when considering patient choice of appointments. Due to the curse of dimensionality, it is impossible to solve the steady-state distribution of the Markov chain model for a typical-size open access primary care clinic. Therefore, an approximate approach is proposed to efficiently estimate the performance of a provider capacity policy based on the Markov chain model. This approach can accurately estimate the performance of a practical capacity policy in a significantly shorter time. Using this approach, the impact of patient choice on the performance of provider capacity policies is investigated.

Implementing a multidisciplinary open-access clinic at a private practice-based community hospital.

With the acquisition of emerging technologies in the treatment of primary and metastatic hepatic malignancy by interventional radiology, a multidisciplinary tumor board was created by the authors to improve treatment planning for these diseases.

The impact of an Acute Knee Clinic

The aim of this audit was to analyse the impact of an open access clinic for the treatment of soft tissue knee injuries with regard to delay to treatment. Data from 100 consecutive patients seen in our sports clinic in 2000 were collected. Following this audit, an Acute Knee Clinic was introduced and took place once per week. In 2006, the audit loop was closed and data from 100 consecutive patients seen in the Acute Knee Clinic were collected. The time from injury to the first review by a specialist is referred to as the time to diagnosis. The introduction of the Acute Knee Clinic led to an 89% reduction in the time to diagnosis for accident and emergency referrals and a 32% reduction for general practitioner referrals. The average number of visits of any sort made by the patient prior to review by a specialist in 2000 was five as opposed to one in 2006. An Acute Knee Clinic with open access is a simple method of dramatically reducing the delay to diagnosis. This decreases the total delay to treatment which is of particular importance in patients requiring anterior cruciate ligament (ACL) reconstruction due to the risk of secondary meniscal and chondral injuries. Decreasing the delay to diagnosis and appropriate treatment reduces the recovery time. This not only reduces the socio-economic cost of soft tissue knee injuries but may also decrease the psychosocial consequences for the patient. By reducing the number of times a patient is seen by medical practitioners prior to review by a specialist has the potential to decrease the total cost of treatment. The socio-economic impact and potential actual cost savings of treatment are particularly important with the current economic climate.

Effect of two-level provider capacities on the performance of open access clinics

The successful implementation of open access scheduling requires the match of daily healthcare provider capacity and patient demand at the high level of total capacity and the low levels of individual capacities for different types of appointments. In this paper, we introduce 12 scheduling rules for determining the two-level provider capacities and compare them in terms of four performance metrics: the probabilities of granting requests for fixed and open appointments, and the expectation and the variance of the number of patients consulted. Our analytical results show that adjusting low level provider capacities can reduce the difference between the two probabilities. When the ratios of low level capacities to the high level provider capacity are fixed, the two probabilities increase with the increase in the high level capacity. Meanwhile, our numerical results demonstrate that the expectation and the variance of the number of patients consulted increase with the increase in the high level capacity. The results provide insights in determining optimal two-level provider capacities to match daily patient demand. Potential approaches to optimality are also proposed based on the results.

Indications and Diagnostic Yield of Double Balloon Enteroscopy in a Tertiary Care Setting: An Analysis of 527 Cases with Suspected Small Bowel Diseases

Background and Aims: Double-balloon enteroscopy (DBE) has been recognized as a good tool for diagnostic and treatment means. However, selection of the cases and diagnostic yields, and optimal setting of this modality remain subjects to debate. This study evaluated the diagnostic value of the double-balloon enteroscopy using a multi-center database in tertiary care general hospitals. Methods: Between July 2004 and August 2007, 527 patients with suspected small-bowel disease were examined for by DBE (1083 procedures) in endoscopic centers within 6 general hospitals in an urban area of Japan. Indication, endoscopic findings, and patients' demography were registered to and analyzed in the database. Results: The subjects included 224 female and 303 male (mean age: 60.0 years), all of whom were referred from primary care physician, secondary care institution or hospitals' own open-access clinics to the centers. DBE were performed after hospitalization. The indications for DBE included obscure gastrointestinal bleeding (n = 233), incomplete total colonoscopy (n = 54), stenotic symptoms (n = 51), abdominal pain/discomfort (n = 45). Positive diagnosis was obtained by DBE in 256 cases, including ulcers or erosions (n = 151), tumors or polyps (n = 48), vascular diseases (n = 39). In the 264 DBE cases with obscure bleeding or anemia, 30 cases revealed angiodysplasia followed by Crohn's disease (n = 12) and malignant lymphomas (n = 5) small bowel cancers (n = 4). There were some cases with Meckel's diverticula, and submucosal tumors. In contrast, no relevant pathology was found in 129 cases (49%). Conclusions: This large multi-center series shows that DBE is a well tolerated technique with a high diagnostic yield in patients with small bowel disease. Furthermore, DBE offers hemostases and other treatment modalities for small bowel lesions, which is appropriate for tertiary care hospitals. The results warrant further study for optimal time window and optimal indication of DBE in order to establish higher diagnostic efficacy for the obscure GI bleeding.