Outpatient Consultations Research Articles

Bridging distances and saving costs: insights from a pilot project of telerheumatology in a rural area of Pakistan.

Enhancing access to healthcare remains a formidable challenge in rural regions of low- and lower-middle-income countries. Amid evolving healthcare challenges, telerheumatology provides opportunities to bridge gaps and expand access to rheumatology care, particularly in remote areas. We describe a pilot telerheumatology program and its cost-, time-, and travel-saving potential in a remote rural setting in northern Pakistan. The telerheumatology program commenced at the Pakistan Institute of Medical Sciences Islamabad, providing services through video consultations to a basic health unit in the Gilgit-Baltistan region. Patients visiting from the Gilgit-Baltistan region willing to participate were recruited in the program. Demographics and logistical metrics were recorded in a dedicated registry. A total of 533 consultations were carried out from April 2022 to April 2023. The majority of the patients were female (318/533, 59.7%). The median age of patients was 50 ± 15.7 years. The average wait time for consultation was 20 ± 13 min. The average travel time to reach telecentre was 59 ± 53 min. The average travel cost to reach telecentre was 379 ± 780 PKR (1.85 ± 3.81 USD). The average duration of consultation was 15 ± 5 min. The most common diagnosis for consultation was knee osteoarthritis (237, 44.5%), chronic low back pain (118, 22.1%), and rheumatoid arthritis (42, 7.9%). On average, patients saved 787 ± 29 km of distance, 15 ± 1 h of traveling, and 6702 ± 535 PKR (33 ± 3 USD) that would have been required to travel to our tertiary care hospital. Telerheumatology substantially reduced travel time, distance, and cost for patients. It has the potential to deliver outpatient rheumatology consultation in an economically efficient manner, effectively breaking geographical barriers and expanding access to essential services for patients in remote areas.

The Burden of Respiratory Syncytial Virus (RSV) in Germany: A Comprehensive Data Analysis Suggests Underdetection of Hospitalisations and Deaths in Adults 60Years and Older.

In Germany, the estimation of the disease burden of respiratory syncytial virus (RSV) in older adults is limited. This makes it challenging for public health decision-makers to develop evidence-based recommendations for newly available vaccines against RSV for individuals aged 60years and older (60+). This study investigates publicly available data sources in Germany to address the current gaps in evidence regarding the burden of RSV. Hospitalisation databases from the German Federal Statistical Office and national mortality statistic between 2000 and 2023, as well as regular surveillance reports from the national public health institute since 2014, were utilised to extract, combine and analyse data on RSV-related morbidity and mortality. These data were used to triangulate the age-specific burden of RSV. The data indicate that the number of RSV-related outpatient consultations ranges between 1,313,100 and 3,911,800 cases per season from 2014/2015 to 2022/2023 for all age groups, with approximately 13.0% of outpatient consultations occurring in adults 60+. The significant increase in hospitalisations over time suggests that heightened testing due to the coronavirus disease 2019 (COVID-19) pandemic revealed the underdetection of inpatient RSV cases in pre-pandemic seasons. In the most recent season recorded, 2022/2023, the data show 12,800 RSV-related hospitalisations in adults 60+ (24% of all RSV-related hospitalisations) and 1340 in-hospital deaths in adults 60+ (93% of all RSV-related deaths). The comparison of pre- to post-pandemic seasons strongly suggest up to a sevenfold underdetection of RSV in individuals 60+, and the analysis of in-hospital mortality reveals higher mortality rates compared with the general German mortality statistics. These findings highlight the urgent need to improve surveillance and implement targeted prevention strategies to mitigate the impact of RSV in older adults.

Multicentric Assessment of a Multimorbidity-Adjusted Disability Score to Stratify Depression-Related Risks Using Temporal Disease Maps: Instrument Validation Study.

Comprehensive management of multimorbidity can significantly benefit from advanced health risk assessment tools that facilitate value-based interventions, allowing for the assessment and prediction of disease progression. Our study proposes a novel methodology, the Multimorbidity-Adjusted Disability Score (MADS), which integrates disease trajectory methodologies with advanced techniques for assessing interdependencies among concurrent diseases. This approach is designed to better assess the clinical burden of clusters of interrelated diseases and enhance our ability to anticipate disease progression, thereby potentially informing targeted preventive care interventions. This study aims to evaluate the effectiveness of the MADS in stratifying patients into clinically relevant risk groups based on their multimorbidity profiles, which accurately reflect their clinical complexity and the probabilities of developing new associated disease conditions. In a retrospective multicentric cohort study, we developed the MADS by analyzing disease trajectories and applying Bayesian statistics to determine disease-disease probabilities combined with well-established disability weights. We used major depressive disorder (MDD) as a primary case study for this evaluation. We stratified patients into different risk levels corresponding todifferentpercentiles of MADS distribution. We statistically assessed the association of MADS risk strata with mortality, health care resource use, and disease progression across 1 million individuals from Spain, the United Kingdom, and Finland. The results revealed significantly different distributions of the assessed outcomes across the MADS risk tiers, including mortality rates; primary care visits; specialized care outpatient consultations; visits in mental health specialized centers; emergency room visits; hospitalizations; pharmacological and nonpharmacological expenditures; and dispensation of antipsychotics, anxiolytics, sedatives, and antidepressants (P<.001 in all cases). Moreover, the results of the pairwise comparisons between adjacent risk tiers illustrate a substantial and gradual pattern of increased mortality rate, heightened health care use, increased health care expenditures, and a raised pharmacological burden as individuals progress from lower MADS risk tiers to higher-risk tiers. The analysis also revealed an augmented risk of multimorbidity progression within the high-risk groups, aligned with a higher incidence of new onsets of MDD-related diseases. The MADS seems to be a promising approach for predicting health risks associated with multimorbidity. It might complement current risk assessment state-of-the-art tools by providing valuable insights for tailored epidemiological impact analyses of clusters of interrelated diseases and by accurately assessing multimorbidity progression risks. This study paves the way for innovative digital developments to support advanced health risk assessment strategies.Further validation is required to generalize its use beyond the initial case study of MDD.

The Efficacy of a Multidisciplinary Approach and Diagnostic-Therapeutic Algorithm for Vertebral Metastases with Spinal Cord Compression.

Background and Objectives: Metastatic spinal cord compression represents a substantial risk to patients, given its potential for spinal cord and/or nerve root compression, which can result in severe morbidity. This study aims to evaluate the effectiveness of a diagnostic-therapeutic algorithm developed at our hospital to mitigate the devastating consequences of spinal cord compression in patients with vertebral metastases. Materials and Methods: The algorithm, implemented in our practice in January 2022, is based on collective clinical experience and involves collaboration between emergency room physicians, oncologists, spine surgeons, neuroradiologists, radiation oncologists, and oncologists. To minimize potential confounding effects from the COVID-19 pandemic, data from the years 2019 and 2021 (pre-protocol) were collected and compared with data from the years 2022 and 2023 (post-protocol), excluding the year 2020. Results: From January 2022 to December 2023, 488 oncological patients were assessed, with 45 presenting with urgency due to suspected spinal cord compression. Out of these, 44 patients underwent surgical procedures, with 25 performed in emergency settings and 19 cases in elective settings. Comparatively, in 2019 and 2021, 419 oncological patients were evaluated, with 28 presenting with urgency for suspected spinal cord compression. Of these, 17 underwent surgical procedures, with 10 performed in emergency scenarios and 7 in elective scenarios. Comparing the pre-protocol period (years 2019 and 2021) to the post-protocol period (years 2022 and 2023), intrahospital consultations (commonly patients neurologically compromised) for spine metastasis decreased (105 vs. 82), while outpatient consultations increased remarkably (59 vs. 124). Discussion: Accurate interpretation of symptoms within the context of metastatic involvement is crucial for patients with a history of malignancy, whether presenting in the emergency room or oncology department. Even in the absence of a cancer history, careful interpretation of pain characteristics and clinical signs is crucial for diagnosing vertebral metastasis with incipient or current spinal cord compression. Early surgical or radiation intervention is emphasized as it provides the best chance to prevent deficits or improve neurological status. Preliminary findings suggest a notable increase in both the number of patients diagnosed with suspected spinal cord compression and the proportion undergoing surgical intervention following the implementation of the multidisciplinary protocol. The reduced number of intrahospital consultations (commonly patients neurologically compromised) and the increased number of visits of outpatients with vertebral metastases indicate a heightened awareness of the issue, leading to earlier identification and intervention before neurological worsening necessitating hospitalization. Conclusions: A comprehensive treatment planning approach is essential, and our multidisciplinary algorithm is a valuable tool for optimizing patient outcomes. The protocol shows potential in improving timely management of spinal cord compression in oncological patients. Further analysis of the factors driving these changes is warranted. Limitations: This study has limitations, including potential biases from the retrospective nature of data collection and the exclusion of 2020 data due to COVID-19 impact. To enhance the robustness of our results, long-term studies are required. Moreover, the single-center study design may limit the validity of the findings. Further multicenter studies would be beneficial for validating our results and exploring underlying factors in detail.

Attention to the Values, Wishes and Needs of Patients With Advanced Cancer by Hospital Clinicians, an Exploratory Qualitative Study.

Context: Insight into patients' personal values, wishes, and needs (VWN) by clinicians is essential to guide appropriate palliative care. Objective: To gain insight into the exploration and monitoring of the VWN of patients with advanced cancer during the illness trajectory by hospital oncology clinicians. Method: A generic qualitative study was conducted from February 2022 to July 2022. Specialized nurses, nurse practitioners and medical specialists (in training) providing care to adult patients with advanced cancer were recruited at an outpatient clinic in a Dutch academic hospital. Data were collected using in-depth semi-structured interviews and participatory observations of outpatient clinic consultations. Data were analyzed collaboratively by two researchers using thematic analysis. Results: Eleven clinicians, aged 33-64, 8 females, participated; 7 interviews and 13 observations were conducted. How clinicians explored and monitored patients' VWN was based on their opinions, originating from the clinicians' personal values and work experiences. These were influenced by the local collaboration. Three key opinions were identified: (1) providing safety, (2) supporting medical decision-making, and (3) ensuring alignment. Individual clinicians' approaches varied. The alignment of care and treatment with the patient's VWN was observed to be limited. Conclusion: Clinicians acknowledged the importance of exploring and monitoring patients' VWN but lacked a systematic approach in discussing these topics. Patients should be actively engaged in communication regarding their VWN rather than primarily being provided with medical information. Patient-Reported Outcome Measures may be beneficial in facilitating communication regarding the patient's VWN and could improve appropriate palliative care in hospital cancer care.

Association Between Healthy Behaviors and Health Care Resource Use With Subsequent Positive Airway Pressure Therapy Adherence in OSA

BackgroundThe healthy adherer effect (HAE) has gained increasing attention as potential source of bias in observational studies examining the association of positive airway pressure (PAP) adherence with health outcomes in obstructive sleep apnea (OSA). Research questionIs adherence to PAP associated with healthy behaviors and healthcare resource use prior to device prescription? MethodsData from the IRSR Pays de la Loire Sleep Cohort were linked to health administrative data to identify proxies of heathy behaviors (HB) including adherence to cardiovascular (CV) drugs (medication possession ratio, [MPR]), cancer screening tests, influenza vaccination, alcohol and smoking consumption, and drowsiness-related road accidents during the two years preceding PAP onset in OSA patients. Multivariable regression analyses were conducted to evaluate the association of HB with subsequent PAP adherence. Healthcare resource use was evaluated according to subsequent PAP adherence. FindingsWe included 2,836 patients who had started PAP therapy between 2012 and 2018 (65% of whom were PAP adherent with mean daily use ≥4h/night). Being adherent to CV active drugs (MPR≥80%) and non-smoker were associated with a higher likelihood of PAP adherence (odds ratio, OR [95% confidence interval]: 1.43 [1.15; 1.77] and 1.37 [1.10; 1.71] respectively). Patients with no history of drowsiness-related road accidents were more likely to continue PAP (OR: 1.39 [1.04; 1.87]). PAP adherent patients used less healthcare resources 2 years before PAP initiation, than non-adherents (mean number of outpatient consultations: 19.0 vs 17.2, P=.003; hospitalization days: 5.7 vs 5.0, P=.04; emergency room visit: 30.7 vs 24.0% P=.0002). InterpretationPatients who adhere to PAP therapy of OSA were more health seeking and less healthcare users prior to device initiation than non-adherent patients. Until the HAE associated with PAP adherence is better understood, caution is warranted when interpreting the association of PAP adherence with CV health outcomes and healthcare resource use in non-randomized cohorts.

Outpatient Consultation of Diabetes and Cardiovascular Diseases Patients in Abuja Public Hospitals Based on Selected Indicators

AIM. Diabetes and cardiovascular diseases are among the reasons for most outpatient consultations. The study aimed to evaluate the reported experiences of patients being managed for diabetes and cardiovascular diseases in the outpatient clinics of Abuja public hospitals. METHOD. A prospective cross-sectional study of 787 systematically sampled patients receiving care in five public hospitals in Abuja was conducted. A structured questionnaire was used to collect data on the number of yearly consultations, problems encountered in accessing trained health personnel, time spent on hospital appointments, major treatment challenges, and ways to improve their experience on hospital visits. Consultation experience was defined as good or poor. Patients who consulted at least four times in a year, reported no problems in accessing trained health personnel, and had no treatment challenges were regarded as having a good consultation experience. Frequency, percentage, mean, and standard deviation were used to summarize the data. Logistic regression was used to predict and classify the binary outcomes. A p-value ≤ 0.05 was considered significant. RESULTS. More of the patients (66.2%) had up to four consultations in a year. Long waiting time (56.1%) was the common problem encountered when accessing trained medical personnel. The major treatment challenge was hospital waiting time (49.4%). The mean time spent in the hospital on appointment days was 5.04±1.80. Approximately 40% of the patients suggested proper scheduling of hospital appointments as the major way to improve treatment experiences. Poor consultation was recorded by 96.6% of the patients. Logistic regression showed that a higher educational level (OR = 0.031, 95% CI [0.008-0.119], _P=_0.001) was associated with reporting poor management. CONCLUSION. The average number of yearly consultations was below the minimum standard, and patients spent long hours on consultation days before meeting with healthcare personnel. Most patients were dissatisfied with the services received and rated them poor.

Adult Children as Companions in Geriatric Consultations: An Interpersonal Perspective from China

ABSTRACT Despite the prevalence of accompanied medical visits all over the world, most literature on triadic medical communication shares an Anglo-American background; little is known about non-dyadic medical interactions in Asian societies such as China. This article explores triadic interactions in Chinese geriatric outpatient consultations, focusing on the interpersonal dynamics between doctors, older patients, and the adult children who accompany them throughout the consultation. From an interpersonal pragmatic approach, we conduct a conversation analysis of the transcription of 36 audio-recorded encounters. Our findings demonstrate three patterns of companions’ communicative actions during geriatric visits: enhancing rapport, mitigating face threats, and adding tension. These patterns reveal the multi-faceted nature of adult children’s participation in geriatric care, highlighting their capacity to simultaneously facilitate a positive interpersonal atmosphere and pose challenges to their older parents’ face. Delving into the nuanced mechanisms through which these patterns of engagement are triggered, warranted, and negotiated by all participants in the local contingencies, we further illuminate the institutional and cultural context that informs companions’ intervention. Our analysis demonstrates that the influence of Chinese familial values and institutional constraints in Chinese tertiary hospitals, including restricted time and limited privacy within the clinic room, have shaped the interpersonal dynamic in triadic geriatric care. Our research calls for the development of nuanced and targeted interventions and training for healthcare professionals and companions of older patients alike.

Comparison of Outpatient and Inpatient Consultations Requested from Child and Adolescent Psychiatry

Objective: This study aims to examine the sociodemographic and clinical characteristics of child and adolescent psychiatry consultations and to compare characteristics of outpatient and inpatient consultations. Methods: A total of 354 patients who were consulted to child and adolescent psychiatry department of a university hospital were included in the study. Data were collected regarding sociodemographic characteristics of patients, departments requesting consultation, diagnoses, and treatment methods. Results: The cases included in the study had a mean age of 10.6±4.8 years,with 51.4% being girls. Adolescent girls formed the majority of the inpatient group. The pediatric neurology outpatient clinic had the highest frequency of requested consultations (22.3%), and the most common reason for consultation was a suicide attempt (12.1%). Of the cases for which consultation was requested, 67.8% were diagnosed with at least one psychiatric disorder, and the most common diagnoses were anxiety disorders, with 12.7%. In the inpatient group, impulsive suicide attempts and depressive disorders were more frequent compared to the outpatient group, while intellectual disability was less common. Parent education was provided for 97.2% of the cases, pharmacological treatment was recommended for 44.6% of the cases, and the most commonly prescribed medications were selective serotonin reuptake inhibitors. Psychotherapy and special education were significantly more common in the outpatient group compared to the inpatient treatment group. Conclusion: The current study revealed significant differences in consultations requested from child and adolescent psychiatry between the outpatient and inpatient groups regarding consultation reasons, diagnoses, and treatment modalities. The findings provide valuable information for clinical practice and service development.

Implementation of a Web-Based Outpatient Asynchronous Consultation Service: Mixed Methods Study.

Asynchronous outpatient patient-to-provider communication is expanding in UK health care, requiring evaluation. During the pandemic, Aberdeen Royal Infirmary in Scotland expanded its outpatient asynchronous consultation service from dermatology (deployed in May 2020) to gastroenterology and pain management clinics. We conducted a mixed methods study using staff, patient, and public perspectives and National Health Service (NHS) numerical data to obtain a rounded picture of innovation as it happened. Focus groups (3 web-based and 1 face-to-face; n=22) assessed public readiness for this service, and 14 interviews with staff focused on service design and delivery. The service's effects were examined using NHS Grampian service use data, a patient satisfaction survey (n=66), and 6 follow-up patient interviews. Survey responses were descriptively analyzed. Demographics, acceptability, nonattendance rates, and appointment outcomes of users were compared across levels of area deprivation in which they live and medical specialties. Interviews and focus groups underwent theory-informed thematic analysis. Staff anticipated a simple technical system transfer from dermatology to other receptive medical specialties, but despite a favorable setting and organizational assistance, it was complicated. Key implementation difficulties included pandemic-induced technical integration delays, misalignment with existing administrative processes, and discontinuity in project management. The pain management clinic began asynchronous consultations (digital appointments) in December 2021, followed by the gastroenterology clinic in February 2022. Staff quickly learned how to explain and use this service. It was thought to function better for pain management as it fitted preexisting practices. From May to September 2022, the dermatology (adult and pediatric), gastroenterology, and pain management clinics offered 1709 appointments to a range of patients (n=1417). Digital appointments reduced travel by an estimated 44,712 miles (~71,956.81 km) compared to the face-to-face mode. The deprivation profile of people who chose to use this service closely mirrored that of NHS Grampian's population overall. There was no evidence that deprivation impacted whether digital appointment users subsequently received treatment. Only 18% (12/66) of survey respondents were unhappy or very unhappy with being offered a digital appointment. The benefits mentioned included better access, convenience, decreased travel and waiting time, information sharing, and clinical flexibility. Overall, patients, the public, and staff recognized its potential as an NHS service but highlighted informed choice and flexibility. Better communication-including the use of the term assessment instead of appointment-may increase patient acceptance. Asynchronous pain management and gastroenterology consultations are viable and acceptable. Implementing this service is easiest when existing administrative processes face minimal disruption, although continuous support is needed. This study can inform practical strategies for supporting staff in adopting asynchronous consultations (eg, preparing for nonlinearity and addressing task issues). Patients need clear explanations and access to technical support, along with varied consultation options, to ensure digital inclusion.

Early provision of clinical information with an ‘opt in’ approach improves patient experience in tonsillectomy referrals

Patients referred by their general practitioner (GP) with a definite diagnosis, for example, recurrent sore throat for consideration of tonsillectomy in adults, may wait for months without receiving any further...

Obstacles to receiving postoperative radiation therapy following separation surgery for metastatic spine disease.

Obtaining timely postoperative radiotherapy (RT) following separation surgery is critical to avoid local recurrence of disease yet can be a challenge due to scheduling conflicts, insurance denials, and travel arrangements. In patients undergoing metastatic spine surgery for spinal cord compression, the authors sought to: 1) report the rate of postoperative RT, 2) describe reasons for patients not receiving postoperative RT, and 3) investigate factors that may predict whether a patient receives postoperative RT. A single-center retrospective case series was undertaken of all patients who underwent metastatic spine surgery for extradural disease between January 2010 and January 2021. Inclusion criteria were patients with intermediate or radioresistant tumors with evidence of spinal cord compression who underwent surgery. The primary outcome was the occurrence of RT within 3 months following surgery. Multivariable logistic regression analysis was performed controlling for age, BMI, race, total number of decompressed levels, tumor size, other organ metastasis, and preoperative RT or chemotherapy to predict patients receiving postoperative RT. Of 239 patients undergoing spine surgery for metastatic disease, 113 (47.3%) received postoperative RT while 126 (52.7%) did not. In the postoperative RT group, 24 (21.2%) received stereotactic body radiation therapy while 89 (78.8%) received conventional external-beam radiation therapy. The most common reasons for patients not receiving postoperative RT included death or transfer to hospice (31.0%), RT not being recommended by radiation oncology (30.2%), and loss to follow-up (23.8%). On critical review with the radiation oncology department, the authors estimated that 101 of 126 (80.2%) patients who did not receive postoperative RT were potential candidates for postoperative RT. Patients who received postoperative RT had more documented inpatient (48.7% vs 32.5%, p < 0.001) and outpatient (100.0% vs 65.1%, p < 0.001) radiation oncology consultations than those who did not. Additionally, patients who received postoperative RT had a higher rate of postoperative chemotherapy (53.1% vs 25.4%, p < 0.001), while patients who did not receive postoperative RT had a higher rate of preoperative RT (7.1% vs 31.0%, p < 0.001). Multivariable analysis confirmed that patients who received preoperative RT had lower odds of undergoing postoperative RT (OR 0.14, 95% CI 0.06-0.34; p < 0.001), and patients who underwent postoperative chemotherapy had higher odds of undergoing postoperative RT (OR 3.83, 95% CI 2.05-7.17; p < 0.001). In the current study reflecting real-world care of patients with metastatic spine disease after undergoing separation surgery, 47% of patients did not receive postoperative RT, and 80% of those patients were potential candidates for postoperative RT. Radiation oncology consultation and postoperative chemotherapy were significantly associated with receiving postoperative RT, whereas preoperative RT was significantly associated with not receiving postoperative RT. The lack of timely postoperative RT highlights a potential gap in metastatic spine tumor care and underscores the necessity for prompt radiation oncology consultation and effective planning.

Reversible acute heart failure induced by thyrotoxic cardiomyopathy: A case report.

Thyrotoxic cardiomyopathy is a rare but severe complication of thyrotoxicosis, leading to episodes of acute heart failure. This case report highlights a rare presentation of thyrotoxic cardiomyopathy with low-output heart failure, emphasizing the importance of early diagnosis and comprehensive management. The report aims to increase awareness among clinicians about the potential reversibility of this condition and the effective strategies for managing such complex cases. This patient presented with dyspnea and chest constriction, without any antecedent predisposing factors. Subsequently, the patient abruptly manifested symptoms indicative of acute heart failure during outpatient consultation. Electrocardiography revealed rapid atrial fibrillation with type A preexcitation syndrome, whereas cardiac ultrasonography demonstrated global cardiac enlargement with a diminished ejection fraction (EF). After a comprehensive evaluation, the patient was diagnosed with thyrotoxic cardiomyopathy, acute heart failure, and atrial fibrillation with preexcitation syndrome. Immediate interventions comprised diuretic administration, oxygen therapy, and antiarrhythmic agents, addressing acute heart failure concomitant with preexcitation syndrome. Following a fortnight of comprehensive therapeutic measures, the patient was discharged with a prescription for oral medications, notably methimazole. Following the intervention, the patient showed significant improvement with the resolution of heart failure symptoms and dyspnea, restoration of sinus rhythm, improved left ventricular ejection fraction (LVEF improved from 36% to 45%), and normalization of thyroid function. These outcomes underscore the efficacy of the intervention strategy and offer a hopeful prognosis for similar cases. Thyrotoxicosis may cause cardiomyopathy in patients with heart failure that manifests as dilated cardiac chambers. Clinicians should carefully screen patients for this reversible condition. Diagnosis requires a comprehensive assessment of various tests, and the therapeutic goal is to restore normal thyroid function.

#2465 How do renal clinicians present treatment options to older patients with advanced kidney disease and what difference does it make?

Abstract Background and Aims For older people with kidney failure, especially those with comorbidities or poor performance status, the survival benefits of dialysis are uncertain and its quality of life impact greatest. Conservative kidney management (CKM) can be a beneficial alternative. However, there is significant variation in treatment rates among older patients with kidney failure; the CKMAPPS study [1] found rates of older people receiving dialysis ranged from 5-95% across UK renal units. How clinicians communicate about treatment options influences patients’ decision-making, but this has been under-researched. The OSCAR study (Optimising Staff-Patient Communication in Advanced Renal disease) aimed to describe how kidney failure treatment options are presented by renal clinicians to older people (age 65+) with advanced chronic kidney disease (eGFR ≤20 mls/min/1.73 m2 within the last 6 months) and the implications of this for patient engagement with the decision. Method Outpatient consultations between doctors/nurses and eligible patients were recorded at 4 UK renal units with varying rates of CKM. Recorded consultations were screened to identify cases where clinicians presented treatment options for advanced kidney disease. Consultations where clinicians presented both dialysis and CKM were transcribed and analysed in detail using Conversation Analysis, focused on how dialysis and CKM were framed. Post-consultation, patients completed the Shared Decision-Making Questionnaire (SDM-Q-9). Comparisons were made between groups according to how treatment options were presented, using a non-parametric Median Test. Results A total of 110 outpatient consultations were recorded (104 audiovisual, 6 audio). Recordings included 38 doctors and nurses and 94 patients; mean patient age 77 (65-97), 33 female/61 male, mean eGFR 15 (range 4-23). Sequences where clinicians presented both dialysis and CKM as treatment options were analysed (n = 21). Two approaches to presenting CKM were identified: 1) CKM as a main option (n = 6; see Fig. 1), 2) CKM as a subordinate option (n = 15; see Fig. 2). The mean consultation length was the same in both groups (23 mins). Recurrent features of the first approach included: framing CKM as having potential personal benefits to the patient; explicitly labelling it as a treatment option; not framing it as an option preferred by or relevant to only a minority of patients. In contrast, when CKM was presented as a subordinate option, recurrent features included: framing CKM as not having benefit to the patient; not explicitly labelling CKM as a treatment option; appending CKM to the main decision-making sequence; framing CKM as an option only chosen by a minority of patients. Presenting CKM as a main option alongside dialysis was a less common approach (n = 6 vs. n = 15), but associated with more interactional opportunities for patients to ask questions about CKM, assert their perspective, and assess CKM as a relevant option, as well as significantly higher patient ratings of shared decision-making (total SDM-Q-9 score, p = 0.041). Conclusion This is the first fine-grained analysis of the relationship between the conversational practices used by clinicians and their impact on patient engagement with treatment options and ratings of shared decision-making. Despite evidence that dialysis does not reliably extend older patients’ lives at acceptable costs to quality of life, we found that clinicians tend to present dialysis as the default treatment and CKM as subordinate, if at all. Our findings demonstrate that presenting treatment options is not enough; how clinicians present options has important implications for patient engagement in shared decision-making. To provide patients with the opportunity to evaluate CKM as a valid option requires clinicians to clearly detail the advantages and disadvantages of both treatments. Study findings will form the basis of a new communication training intervention for clinicians.

#2910 Renal toxicities in oncology at a secondary level hospital within the first 6 months of outpatient consultation establishment

Abstract Background and Aims In recent years the discovery of targeted therapies in oncology have been a revolution with spectacular results for patients with advanced neoplasia and metastasis. Representing a more precise approach to interfering with tumorigenesis, these therapies exhibit superior tolerability profile in terms of toxicity and have significantly improved overall survival (1). Numerous studies have demonstrated the increased risk of cancer patients developing acute renal failure and progressing to chronic kidney disease, both contributing to higher mortality. The use of these novel drugs, alongside traditional chemotherapy, coupled with the extended survival of patients with neoplasms has led to a rise in kidney pathologies (2.3). Addressing the need to provide a comprehensive and optimized treatment to this group of patients, the field of Onconephrology has emerged. Its primary objective is to assist in the diagnosis and management of kidney diseases associated with the underlying oncological condition and/or oncotherapeutics. While well-established Onconephrology Clinics predominantly operate in tertiary hospitals worldwide, acknowledging the growing significance of this field, we established an Onconephrology outpatient consultation at our secondary level hospital. In this study, we aim to delineate the incidence of renal toxicities secondary to oncotherapeutics within the first six months of initiating our Onconephrology outpatient consultation. Method Forty-six patients were retrospectively included, and an analysis of oncological and renal variables was conducted to determine the incidence of renal toxicities. Results Out of the forty-six patients evaluated, 12 exhibited renal toxicity secondary to oncotherapeutics, with a mean age of 73.3 years. The most frequent malignancy was lung cancer (n = 6), followed by gastrointestinal tract cancer (n = 2). Most patients presented with metastatic disease (n = 9), and their malignant disease was either in remission (n = 4) or stable (n = 5). Reasons for referral included acute kidney injury (n = 7), acute kidney injury over chronic kidney disease (n = 3), proteinuria (n = 1), and electrolyte abnormalities (n = 1). The diagnoses included acute immune-mediated tubulointerstitial nephritis secondary to checkpoint inhibitors (n = 5), cisplatin renal toxicity (n = 3), acute tubular necrosis secondary to tyrosine kinase inhibitors (n = 2), hypomagnesemia induced by EGFR inhibitor (n = 1), and nephrotic syndrome related to anti-VEGF. Following multidisciplinary intervention, most patients experienced recovery of kidney function (n = 9), while some progressed to chronic kidney disease (n = 2), and other maintained electrolyte imbalances (n = 1). Conclusion This study describes 12 patients with renal toxicities secondary to oncotherapeutics over a 6-month period at a secondary hospital. Most patients exhibited recovery of kidney function, emphasizing the positive outcomes achievable through multidisciplinary care, particularly in the context of the Onconephrology outpatient consultation, even in institutions with limited resources.

#2737 “The right choice for you.” How descriptions of treatment options in information resources may influence patient understanding and decision-making

Abstract Background and Aims For people over the age of 65 with comorbidities and/or poor performance status, and for patients over the age of 80, the choice between receiving conservative kidney management (CKM) or receiving dialysis can be complex, and involves weighing possible benefits, risks and effects on quality and length of life. Patients often rely on information resources from renal units, to support their decision-making. We describe how information resources present living with and dying of kidney disease in relation to CKM, haemodialysis and peritoneal dialysis, and consider implications for patients’ treatment decision making. Method Information resources were collected between June 2021 and January 2023 from four UK renal units with varying CKM treatment rates, as part of the OSCAR study (Optimising Staff-Patient Communication in Advanced Renal Disease). Physical and digital copies of information resources were collected from outpatient waiting areas, consultation rooms, and group patient education sessions. We included resources which focused on the treatment options of CKM, haemodialysis, peritoneal dialysis and transplant. Documents were categorised as: Direct Treatment Option Information Resources, focusing specifically on treatment options, either individually or in comparison (category A); Indirect Information Resources, focusing on broader contextual information related to treatment options, such as lifestyle, holiday and diet guidance, and the logistics of receiving treatment, e.g. transport (category B). Document analysis of the information resources was conducted, informed by critical discourse analysis. We examined how documents describe and explain living and dying with kidney failure in relation to treatment options, and how treatment options were placed in context, identifying themes, ‘frames’ and discourse. Results 72 resources were identified across the four renal units, with 46 documents included after deduplication and screening (Fig. 1). Analysis identified three global themes (see Table 1 for illustrative data extracts): Conclusion UK information resources typically present unbalanced explanations of dialysis and CKM, and equate CKM with death and dying. Despite the focus on patients’ “right” to choose a treatment option, it may therefore be challenging for a patient to choose CKM, even when this treatment choice is the best fit for their goals and values. Furthermore, for patients who choose dialysis, information resources often exclude important end-of-life information, limiting their opportunity to consider and participate in advance care planning.

Assessment of Outpatient Management of Diabetes and Cardiovascular Diseases in Abuja Public Hospitals

AIM. Diabetes and cardiovascular diseases are among the reasons for most outpatient consultations. The study aimed to evaluate the reported experiences of patients being managed for diabetes and cardiovascular diseases in the outpatient clinics of Abuja public hospitals. METHOD. A prospective cross-sectional study of 787 systematically sampled patients receiving care in five public hospitals in Abuja was conducted. A structured questionnaire was used to collect data on the number of yearly consultations, problems encountered in accessing trained health personnel, time spent on hospital appointments, major treatment challenges, and ways to improve their experience on hospital visits. Management experience was defined as good or poor. Patients who consulted at least four times in a year, reported no problems in accessing trained health personnel, and had no treatment challenges were regarded as having a good management experience. Frequency, percentage, mean, and standard deviation were used to summarize the data. Logistic regression was used to predict and classify the binary outcomes. A p-value ≤ 0.05 was considered significant. RESULTS. More of the patients (66.2%) had up to four consultations in a year. Long waiting time (56.1%) was the common problem encountered when accessing trained medical personnel. The major treatment challenge was hospital waiting time (49.4%). The mean time spent in the hospital on appointment days was 5.04±1.80. Approximately 40% of the patients suggested proper scheduling of hospital appointments as the major way to improve treatment experiences. Poor management was recorded by 96.6% of the patients. Logistic regression showed that a higher educational level (OR = 0.031, 95% CI [0.008-0.119], _P=_0.001) was associated with reporting poor management. CONCLUSION. The average number of yearly consultations was below the minimum standard, and patients spent long hours on consultation days before meeting with healthcare personnel. Most patients were dissatisfied with the services received and rated them poor.

Safety and feasibility of in-hospital autonomous transportation using a driverless mobility for patients with musculoskeletal disorders: preliminary clinical study to achieve mobility as a service in medical care

BackgroundRecent advancements in and the proliferation of autonomous mobility technology, such as intelligent wheelchairs, have made it possible to provide mobility services for patients with reduced mobility due to musculoskeletal disorders. In the present study, we conducted a preliminary clinical study to assess the safety and feasibility of in-hospital autonomous transportation using a driverless mobility (wheelchair) for patients with musculoskeletal disorders.MethodsFrom January to February 2022, 51 patients with musculoskeletal disorders exhibiting gait disturbance who presented to our institution were included in the present study. Driverless mobility rides were conducted over a straight-line distance of 100 m from the orthopaedic outpatient reception to the payment counter after the outpatient consultation. We assessed the quality of life using an EQ-5D-5 L index and pain using a VAS score before riding the mobility to investigate the patient’s condition. After the ride, a questionnaire survey was conducted to assess patient satisfaction on a 5-point scale. In addition, adverse events during the mobility ride were investigated.ResultsOverall satisfaction levels showed that 44 out of 51 (86%) patients rated the level as 3 or higher. There were no significant differences in the level of satisfaction based on the cause of disorders or EQ-5D-5 L Index. Among 19 patients who rated the level of satisfaction as 2–3, the ratio of postoperative patients and those with pain tended to be higher (p < 0.05). While 26 of 51 (51%) patients reported moments of feeling unsafe during the mobility ride, no actual adverse events, such as collisions, were observed.ConclusionsAn in-hospital autonomous transportation service using a driverless mobility for patients with musculoskeletal disorders demonstrated high satisfaction levels and was safe with no severe adverse events observed. The expansion of autonomous mobility deployment is expected to achieve mobility as a service in medical care.

Evaluation of adherence to pharmacological treatments by undocumented migrants with chronic diseases: a 10-year retrospective cohort study

ObjectivesTo investigate the time course of medication adherence and some of the factors involved in this process in undocumented migrants with chronic diseases.DesignRetrospective cohort study.SettingA big non-governmental organisation in Milano,...

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Cough is one of the most common reasons for outpatient medical consultation. Most of the time it is self-limiting so doctors tend not to give it much importance. However, cough can be caused by serious pathologies such as cancer, fibrosis and pulmonary tuberculosis. Furthermore, when the cough is intense or prolonged it can cause significant alterations in the quality of life of patients. In this article we will review the main guidelines for diagnosis and treatment of cough, how to suspect serious etiologies, when to define a treatment according to clinical information and when to request tests. Finally, we will discuss two clinical cases in order to illustrate some concepts.