Hospital Outpatient Setting Research Articles

Arteriovenous Fistula Creation and Care in an Office-Based Practice Compared to Hospital Based Care.

This study evaluates and compares outcomes of arteriovenous fistulas (AVFs) created in a dialysis access dedicated office-based laboratory (OBL) and outpatient hospital setting. All consecutive outpatient surgical autologous AVFs created at an academic hospital, community hospital, and an OBL from 2016-2020 were reviewed. Demographics, comorbidities, surgical procedure, complications, maturation, patency, and procedures for maintenance were assessed from time of surgical evaluation to latest available documentation. Complications, maturation, and patency were compared by location of surgery and post-operative access-related care, creating three groups: surgery and follow-up in hospital (Hospital), surgery in hospital and follow-up in OBL (Hybrid), or surgery and follow-up in OBL (OBL). 389 AVFs were included. 138 were in the Hospital group, 125 in the Hybrid group, and 126 in the OBL group. Median follow-up time was 34.7 months. Mean age was 59 years. Percentage of male patients was 58%. The three groups did not differ with respect to demographics and comorbidities. Peri-operative complication rate was 6.4% among 263 hospital outpatient procedures and 1.6% among 126 OBL procedures (p=0.043). Maturation rate was lower in the Hospital group (54%) than the Hybrid (86%) and OBL (93%) groups irrespective of AVF type (p<0.001) (Figure 1). Mean time to approval for use was 52 days in the OBL group, 66 days in the Hybrid group, and 98 days in the Hospital group (p<0.001). The OH group had the highest primary patency, but the lowest functional patency (Figure II). During the follow-up period, there was a significant difference in number of procedures per year of functional patency, with 0.7 in the Hospital group, 2.1 in the Hybrid group, and 2.1 in the OBL group (p<0.001). Surgical AVF creation in a dialysis access dedicated OBL is safe and associated with lower perioperative complications, higher maturation rate, better functional patency, and decreased time to approval for use as compared to patients receiving hospital-based care only. Similar results were seen among hospital created fistula patients who received subsequent care at an OBL. Dialysis access creation and care in AV Access dedicated OBLs is associated with improved outcomes as compared to hospital-based care.

Sex-specific temporal trends in incidence and prevalence of chronic kidney disease: a Danish population-based cohort study.

Rates of chronic kidney disease (CKD) may change with ageing populations, rising metabolic and cardiovascular disease prevalence, increasing CKD awareness and new treatments. We examined sex-specific temporal trends in CKD incidence and prevalence from 2011 through 2021. We conducted a population-based cohort study among adults residing in the North and Central Denmark Regions (population ∼1.5 million in 2021), utilizing routinely collected individual-level laboratory data. We identified individuals with incident or prevalent CKD, using data on plasma creatinine and urine albumin-creatinine ratios from samples performed in outpatient hospital settings or primary care. We estimated annual sex-specific crude and age-standardized incidence and prevalence and tabulated clinical characteristics. Throughout 2011-2021, CKD incidence and prevalence remained higher among females than males. A transient increase in the crude incidence was observed during 2011-2013, followed by a decrease from 11.8 per 1000 person-years in 2013 [95% confidence interval (CI) 11.5-12.1] to 10.7 in 2021 (95% CI 10.5-11.0) among females and from 10.9 (95% CI 10.7-11.2) to 10.6 (95% CI 10.3-10.8) among males. During 2011-2021, the crude prevalence increased among females from 85.1 per 1000 individuals (95% CI 84.4-85.8) to 99.9 (95% CI 99.2-100.6), and among males from 55.3 (95% CI 54.7-55.9) to 82.4 (95% CI 81.8-83.0). After age standardization, declines in incidence persisted, while the prevalence was stable among females, and the increase persisted among males. The CKD incidence and prevalence remained higher among females than males during 2011-2021. Despite a notable decline in incidence rates from 2013 onwards, the crude prevalence increased during 2011-2021.

Examining the clinical role and educational preparation of heart failure nurses across Europe. A survey of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) and the Association of Cardiovascular Nursing and Allied Professions (ACNAP) of the ESC.

To describe the clinical practice and educational preparation of heart failure (HF) nurses across Europe and determine the key differences between countries. A survey tool was developed, in English, by the Heart Failure Association Patient Care committee of the European Society of Cardiology (ESC). It was translated into eight languages, before electronically disseminated by nurse ambassadors, presidents of HF national societies and through social media. A total of 837 nurses involved in the daily care of patients with HF from 15 countries completed the survey. Most nurses, 78% (n = 395) worked within a hospital outpatient setting, and 51% (n = 431) had access to a specialized HF multidisciplinary team. Nurses performed a range of activities including patient education to promote self-care, virtual and in-person symptom monitoring. A third had more than 5-year experience in cardiac care and 22% (n = 182) prescribed HF medications. There was a significant correlation between HF nurses that prescribed HF medications and access to a specialist multidisciplinary team (p = 0.04). A small number of nurses, mainly from Belgium, supported invasive monitoring (n = 68, 8%) with 14% (n = 120) of mostly Danish nurses supporting exercise programmes. The majority of nurses surveyed were committed to further academic professional development, with 41% (n = 343) having completed a HF course. The role of the HF nurse varies across Europe, however involvement in patient education, symptom monitoring and follow-up remain core to their practice. In specific activities including the prescribing of HF medications and involvement in invasive monitoring, practice has advanced with collaboration in the multidisciplinary team. Consequently, harmonization of education, training and career pathways are required to standardize HF care aligned with expert guidelines across Europe.

Associations between general practice and outpatient care continuity in people with multimorbidity

Abstract Background Relational continuity in primary and secondary care is linked to better health outcomes for patients, but it is unclear whether metrics of continuity in each setting are associated. Our study examined the association between relational continuity in general practice (GP) and continuity of hospital outpatient specialties in people with clusters of multimorbidity. Methods We used GP records from the Clinical Practice Research Datalink, linked to Hospital Episode Statistics outpatient records. Included were patients ≥18 years, with two or more of 212 Long-Term Conditions (LTCs), registered throughout 2019 and with at least three GP and three outpatient appointments. The Continuity of Care Index (COCI) was calculated separately for visits to the same i) GP and ii) hospital specialty, where 0 represents no continuity and 1 represents all visits to the same GP or specialty. We assessed the association between the indices using univariable and multivariable fractional logit regression. We calculated expected COCI scores for each LTC and assessed variation in the COCI between LTCs assigned to one of 15 clusters of co-occurring diseases derived previously. A sensitivity analysis repeated analysis using the Sequential Continuity (SECON) score, which captures longitudinal continuity. Results Of 1,135,903 patients, 56.2% were ≥60 years. The median (IQR) COCI in GP was 0.22 (0.11-0.40) and in outpatients was 0.33 (0.20-0.52). Although statistically significant (p &amp;lt; 0.001) the relationship between the two measures was clinically insignificant in both univariable and multivariable models. No strong relationships were found between COCI scores and LTC clusters. Similar patterns were found using the SECON score. Conclusions We found no strong association between continuity of care in GP and outpatient settings, and no clear patterns with LTC clusters. This suggests that lack of continuity in secondary care is not compensated for by increased continuity of care in primary care. Key messages • We found no meaningful association between measures of continuity of care in general practice and hospital outpatient settings. • Our findings suggest that lack of continuity of outpatient care is not compensated for by increased continuity in primary care.

12420 Effects Of A Continuous Glucose Monitoring (CGM) Optimization Program On Prescribing Behavior And Glycemic Outcomes

Abstract Disclosure: A. Sterbenz: None. J. Fuentes Rosales: None. S. Abraham: None. P. Siroya: None. R. Middelbeek: None. J. Mitri: None. F. Rossitto: None. E. Cabana: None. A. Gharse: None. L. Collins: None. L. Aliaga: None. A. Millan Ferro: None. J. Cifuni: None. A. Schwartz: None. E. Kelley: None. C. Gomez: None. M. Aballay: None. Introduction: Continuous glucose monitoring (CGM) improves glucose control in patients with diabetes, as demonstrated in clinical trials. There is limited information available on the real-world application of CGM adoption in a resource-limited setting or safety net outpatient hospital setting. This intervention's aim was to assess the impact of a multifaceted approach on improving CGM utilization and on glycemic control among patients with diabetes. Methods: Wyckoff Heights Medical Center, located in Brooklyn, NY is a resource-limited setting that in partnership with the Joslin Diabetes Center, Boston, MA launched a CGM Clinical Care Optimization Program. This quality improvement (QI) initiative included establishing a diabetes technology team (DTT) which met weekly (n=24 sessions) to establish a highly specialized interprofessional group. The DTT activities included: 1) Establishing a CGM workflow; 2) Expanding Medical Assistant responsibilities related to diabetes technology and training; 3) Creating five bilingual (English-Spanish) patient handouts; 4) Building CGM vendor relationships; 5) Developing a CGM manual for data download, billing and coding, and education to increase CGM knowledge across the system. Data were collected prior to CGM initiation and at most recent visit. Results: The intervention occurred between February and November 2023. Prior to this intervention, 49 patients had a CGM prescription. After 9 months, CGM prescriptions were written for 333 patients (680% increase) with the following baseline characteristics (mean ± SD): age (61.2 ± 14.7 yrs.); 56% female; 44% male; 71% Latino; Race: 67% Other (63% Hispanic or Latino), 25% Black or African American, 4% White, Asian 2%, American Indian or Alaska Native 2%; 38% Spanish-speaking, 59% English-Speaking, 3% Other; 81% government insurance (63% Medicaid, 18% Medicare), 19% commercial insurance. The majority of patients had been diagnosed with type 2 diabetes (91%) and 9% had type 1 diabetes. Baseline HbA1C was 9.7 ± 1.5%. Of note, prior to CGM, 34% of patients had A1C&amp;gt;9%. The impact of CGM use was evaluated on 116 patients that met the following criteria: baseline A1C value within 60 days before or up-to 30 days after prescription, and a A1C &amp;gt;90 days after. After an average duration of 154 days of CGM use, HbA1c decreased significantly by -0.51% (p=0.001), demonstrating improved glycemic control post-CGM use. In those with A1c &amp;gt;9%, HbA1c decreased from 10.5% to 8.8% (p&amp;lt;0.01). Conclusion: Creating a CGM optimization program in a resource-limited setting is critical in improving patient self-awareness and provider insight in glycemic control in patients diagnosed with type 1 and type 2 diabetes. These data demonstrate the feasibility of implementing a CGM optimization program in a resource-limited setting, which is critically important in improving clinical care for people with diabetes. Presentation: 6/2/2024

Pediatric Weight Management Group Classes: Improving Productivity and Patient Retention in Outpatient Hospital Settings

Pediatric Weight Management Group Classes: Improving Productivity and Patient Retention in Outpatient Hospital Settings

A Psycholinguistic Approach to the Management of Aphasia in a Case of Left Parietal Stroke

Purpose: The purpose of this study was to illustrate the use of a psycholinguistic model of aphasia as a guide to inform clinical management in a case of left parietal stroke, in a typical hospital outpatient setting. Method: This study used a case report with retrospective chart review. Results: A 79-year-old man developed acute speaking difficulty and was diagnosed with a left ischemic parietal stroke. A psycholinguistic approach was applied to conceptualize the underlying nature of the aphasia as well as to navigate various treatment decisions. Based upon the resultant aphasia profile demonstrating broad phonological impairment of word production, phonomotor treatment was implemented. Conclusion: Incorporating psycholinguistic theories and practices into the clinical management of aphasia can provide clinicians with a relevant framework to guide clinical decision making through precise delineation of the nature of aphasia and selection of correspondingly targeted interventions.

Vascular Care Delivery during the COVID-19 Pandemic: Impact of Office-Based Laboratory and Ambulatory Surgery Center

Objective: To evaluate how access to an office-based laboratory (OBL) and ambulatory surgery center (ASC) impacted vascular care during the Coronavirus Disease 2019 (COVID-19) pandemic. Methods: Vascular procedures performed by our group during the 6-week period before COVID-19 restrictions (group 1) and in the first 6-week period during the COVID-19 restrictions (group 2) were reviewed. The number of procedures performed was categorized as hospital inpatient (HIP), hospital outpatient (HOP), OBL, ASC, and vein center (VC). The procedures were also grouped by type: aneurysm (AAA), carotid (CAR), peripheral arterial disease (PAD), amputation/wound care (AMP), vascular access (VA), deep vein thrombosis (DVT), and venous reflux (CVI). The number of healthcare provider contact points for each patient undergoing care at the HOP, OBL, and ASC were also collected and compared between groups 1 and 2. Differences between groups were determined using the two-way ANOVA. Results: There were no statistically significant differences between groups 1 and 2 for procedure location or type of procedure (p &gt; 0.05). Patient contact with healthcare providers decreased between groups 1 and 2 for ambulatory care. However, projecting the number of contacts for patients in group 2 if they had to have ambulatory care in the HOP setting (913) compared to contacts in the OBL and ASC setting (588) was statistically significant (p &lt; 0.05). No patient or staff member at the OBL or ASC developed COVID-19 infection because of the care received at these venues. Conclusions: The ability to provide essential care for patients in an ambulatory environment was enhanced using our OBL and ASC without compromising safety, efficacy, or transmission of the virus to patients or staff during the height of the COVID-19 pandemic and limited their contact with healthcare workers and therefore reduced the consumption of personal protective equipment by healthcare personnel.

Re-PROGRAM: The evaluation of a brief intervention program for patients with functional seizures in an outpatient hospital setting.

Functional seizures (FS) account for 20%-25% of referrals to specialist epilepsy clinics. They are associated with major disability, increased mortality, and frequent and costly health care use. Current guidelines emphasize the importance of implementing clinical pathways to coordinate and deliver effective treatment, but there are few targeted evidence-based interventions that reliably improve patient outcomes, and treatment resources are limited. We conducted a retrospective evaluation of Re-PROGRAM, a novel, brief intervention for functional seizure patients, to assess its feasibility in an outpatient setting. Twenty-nine patients with FS undertook Re-PROGRAM between August 2020 and January 2022 at the Alfred Hospital Functional Seizures Clinic, Melbourne, Australia. The intervention comprised five 60-90-min consecutive weekly appointments via telehealth, where psychologists engaged patients in a structured program of seizure management skills, lifestyle modification, and behavioral activation strategies. Following the intervention, patient feedback was collected in routine clinical follow-up as well as with a 24-item self-report pre-/postintervention comparison questionnaire. All 29 patients who enrolled in Re-PROGRAM completed the scheduled sessions. Of those who returned the postintervention questionnaire (n = 16), 15 reported a reduction in seizure frequency. Four patients were lost to follow-up. Of the remaining nine, eight reported seizure frequency reduction during clinical follow-up. Qualitative analysis of the feedback revealed the majority of patients reported reduced seizure duration, intensity, and bothersomeness, and patients felt improvements in their sense of control over seizures, confidence to use seizure control strategies, assertive communication, problem solving, coping skills, relationships with others, and their day-to-day functioning. This retrospective evaluation demonstrates the feasibility and acceptability of Re-PROGRAM as a brief intervention for individuals diagnosed with FS delivered in a clinical outpatient setting and warrants further investigation in larger scale, randomized controlled studies.

Guttae Morphology After Cultured Corneal Endothelial Cell Transplant in Fuchs Endothelial Corneal Dystrophy

Whether guttae in Fuchs endothelial corneal dystrophy (FECD) can be removed by polishing without Descemet stripping and whether postoperative maintenance of reduced guttae can be achieved through cultured corneal endothelial cell (CEC) transplant therapy are critical issues to be addressed. To investigate the decrease of guttae through polishing degenerated CECs and abnormal extracellular matrix (ECM) without Descemet stripping and to observe the behavior of guttae following cultured CEC transplant. This case series prospective observational study was conducted in a hospital outpatient clinic setting. Between December 2013 and January 2019, 22 eyes with corneal endothelial failure caused by FECD received cultured CEC transplant therapy at Kyoto Prefectural University Hospital. Of these, 15 eyes were consistently monitored at the same central corneal area during the preoperative phase, as well as in the early (within 1 year) and late (after 3 years) postoperative phases. The images from these phases were categorized into 3 groups: typical guttae, atypical guttae, and no guttae. Cultured CEC transplant therapy. Proportion of guttae in the observable area was measured, comparing the early and late postoperative phases for each group. The mean age of the patients at the time of surgery was 69 years (range, 49-79 years). All 15 eyes exhibited the presence of confluent guttae preoperatively (100%). Among these, 3 of 15 eyes belonged to male patients. The early postoperative phase of guttae morphologies was classified into 3 groups: 5 eyes with typical guttae, 7 with atypical guttae, and 3 with no guttae. The decrease in the number of these guttae was achieved by surgical procedures. The median percentage of guttae in the typical guttae, atypical guttae, and no guttae groups was 41.8%, 44.4%, and 16.2%, respectively, in the early phase, and 42.2%, 38.2%, and 18.8%, respectively, in the late phase. The findings demonstrate that in some cases of FECD, guttae can be removed by scraping and polishing abnormal ECM and degenerated CECs, while preserving the Descemet membrane. Furthermore, cultured CEC transplant resulted in no increase in guttae for up to 3 years, providing insights into surgically eliminating guttae.

Evaluating an Art Therapy Program in an Outpatient Psychiatric Hospital Setting for Individuals With Mood Disorders

The aim of this program evaluation was to assess the impact of an 8-week art therapy intervention for adults in a hospital-based outpatient mood disorders clinic on depressive symptoms and overall quality of life and to examine how these symptoms may change over time by primary psychiatric diagnosis. Following a convergent mixed-methods approach, data collection included quantitative and qualitative patient feedback regarding program implementation to improve delivery. Pre- and post-treatment results from this evaluation are presented (n = 88), including patient feedback on the program (n = 34). Independent of primary diagnosis, patients experienced improvements in depressive symptoms (p &lt; .001, ηp2 = .33), anxiety symptoms (p &lt; .001, ηp2 = .16), and stress symptoms (p &lt; 0.01, ηp2 = 15), as measured by the Depression Anxiety Stress Scales-21. In addition, patients experienced improvement in scores on the Quality of Life Enjoyment and Satisfaction Questionnaire—Short Form (p &lt; .001, ηp2 = .37). Findings suggest that structured group art therapy can reduce symptoms of depression, anxiety, and stress and can improve quality of life in a Canadian outpatient psychiatric setting. Participants were generally satisfied with the quality of this service delivery and provided constructive qualitative feedback to help improve the service.

Association Between Medicare Site-Based Payment Policy, Physician Practice Characteristics, and Vertical Integration Among Oncologists.

Medicare's differential payments for services delivered in physician offices versus hospital outpatient settings incentivize hospital-physician integration (ie, vertical integration) across many specialties, but evidence for oncologists is mixed. We examined the association of Medicare site-based payment policy and physician practice characteristics, including service volume and diversity, with vertical integration among oncologists in 2013-2019. Using the Medicare Provider Utilization and Payment Data and Medicare Data on Provider Practice and Specialty in 2013-2019, we extracted nonintegrated medical/hematologic oncologists (hereafter oncologists) in 2013 and followed them through 2019. We quantified the incentives from Medicare site-based payment policy using the hospital-office ratio-total Medicare payments if all services were delivered in the hospital outpatient department (HOPD) versus physician office. Vertical integration was defined as billing >10% of services to HOPD in a year. Multivariable linear probability regressions estimated the association between hospital-office ratio and vertical integration in 2014-2019 with and without accounting for provider characteristics. In 2013, the average hospital-office ratio was 1.63, which increased to 1.99 in 2018. A 25th-to-75th percentile increase in the hospital-office ratio was negatively associated with integration (-1.01 percentage points [ppts], 95% CI = -1.45 to -0.57, p < .001) not accounting for physician practice characteristics; this association was attenuated (-0.30 ppts, 95% CI = -0.67 to 0.07, p = .11) after adjusting for these characteristics. Higher baseline (ie, 2013) service volume (Quartile4 v Quartile1 = -3.00 ppts, 95% CI = -4.42 to -1.59, p < .001), more diverse services (Quartile4 v Quartile1 = -3.55 ppts, 95% CI = -4.97 to -2.13, p < .001), and urban location (-5.23 ppts, 95% CI = -6.89 to -3.57, p < .001) were more strongly associated with vertical integration. Compared to Medicare site-based payment policy, oncologists' practice characteristics emerged as more potent factors for integration and should be considered to ensure the intended impacts of site-based payment reform. Our finding raises questions about the effectiveness of ongoing movements toward site-neutral payment for drug administration services to deter vertical integration in oncology.

Maryland’s Global Budget Revenue Payment Model and Shifts in the Surgical Site of Care Among Medicare Beneficiaries

Objective: To assess the association between the Global Budget Revenue (GBR) payment model and shifts to the outpatient setting for surgical procedures among Medicare fee-for-service beneficiaries in Maryland versus control states. Summary Background Data: The GBR model provides fixed global payments to hospitals to reduce spending growth and incentivize hospitals to reduce the costs of care while improving care quality. Since surgical care is a major contributor to hospital spending, the GBR model might accelerate the ongoing shift from the inpatient to the outpatient setting to generate additional savings. Methods: A difference-in-differences (DiD) design was used to compare changes in surgical care settings over time from pre-GBR (2011-2013) to post-GBR (2014-2018) for Maryland versus control states for common surgeries that could be performed in the outpatient setting. A cross-sectional approach was used to compare the difference in care settings in 2018 for total knee arthroplasty which was on Medicare’s Inpatient-Only List before then. Results: We studied 47,542 surgical procedures from 44,410 beneficiaries in Maryland and control states. GBR’s 2014 implementation was associated with an acceleration in the shift from inpatient to outpatient settings for surgical procedures in Maryland (DiD: 3.9 percentage points, 95% CI: 2.3, 5.4). Among patients undergoing total knee arthroplasty in 2018, the proportion of outpatient surgeries in Maryland was substantially higher than that in control states (difference: 27.6 percentage points, 95% CI: 25.6, 29.6). Conclusions: Implementing Maryland’s GBR payment model was associated with an acceleration in the shift from inpatient to outpatient hospital settings for surgical procedures.

Practice patterns of peripheral vascular interventions for peripheral artery disease in the office-based laboratory setting versus outpatient hospital

ObjectiveControversy exists regarding the value and limitations of different sites of service for peripheral artery disease treatment. We aimed to examine practice patterns associated with peripheral vascular interventions (PVIs) performed in the office-based laboratory (OBL) vs outpatient hospital site of service using a nationally representative database. MethodsUsing 100% Medicare fee-for-service claims data, we identified all patients undergoing PVI for claudication or chronic limb-threatening ischemia (CLTI) between January 2017 and December 2022. We evaluated the associations of patient and procedure characteristics with site of service using multivariable hierarchical logistic regression. We used multinomial regression models to estimate the relative risk ratios (RRRs) of site of service and intervention type (angioplasty, stent, or atherectomy) and intervention anatomic level (iliac, femoropopliteal, or tibial) after adjusting for baseline patient characteristics and clustering by physician. ResultsOf 848,526 PVI, 485,942 (57.3%) were performed in an OBL. OBL use increased significantly over time from 48.3% in 2017 to 65.5% in 2022 (P < .001). Patients treated in OBLs were more likely to be Black (adjusted odds ratio [aOR], 1.14; 95% confidence interval [CI], 1.11-1.18) or other non-White race (aOR, 1.13; 95% CI, 1.08-1.18), have fewer comorbidities, and undergo treatment for claudication vs CLTI (aOR, 1.30; 95% CI, 1.26-1.33) compared with patients treated in outpatient hospital settings. Physicians with majority practice (>50% procedures) in an OBL were more likely to practice in urban settings (aOR, 21.58; 95% CI, 9.31-50.02), specialize in radiology (aOR, 18.15; 95% CI, 8.92- 36.92), and have high-volume PVI practices (aOR, 2.15; 95% CI, 2.10-2.29). The median time from diagnosis to treatment was shorter in OBLs, particularly for patients with CLTI (29 vs 39 days; P < .001). The OBL setting was the strongest predictor of patients receiving an atherectomy alone (adjusted RRR [aRRR] 6.67; 95% CI, 6.59-6.76) or atherectomy + stent (aRRR, 10.84; 95% CI, 10.64-11.05), and these findings were consistent in subgroup analyses stratified by PVI indication. The OBL setting was also associated with higher risk of tibial interventions for both claudication (aRRR, 3.18; 95% CI, 3.11-3.25) and CLTI (aRRR, 1.89; 95% CI, 1.86-1.92). The average reimbursement (including professional and facility fees) was slightly higher for OBLs compared with the hospital ($8742/case vs $8459/case; P < .001). However, in a simulated cohort resetting the OBL's intervention type distribution to that of the hospital, OBLs were associated with a hypothetical cost savings of $221,219,803 overall and $2602 per case. ConclusionsThe OBL site of service was associated with greater access to care for non-White patients and a shorter time from diagnosis to treatment, but more frequently performed high-cost interventions compared with the outpatient hospital setting. The benefit to patients from improved access to peripheral artery disease care in OBL settings must be balanced with the potential limitations of receiving differential care.

Acceptability of Audiovestibular Assessment in the Home-A Patient Survey.

The COVID-19 pandemic dramatically changed health service delivery with vulnerable patients advised to isolate and appointments provided virtually. This change affected recruitment into an observational cohort study, undertaken at a single site, where participants with mitochondrial disorders were due to have specialist hospital-based audiovestibular tests. To ensure study viability, the study protocol was amended to allow home-based assessment for vulnerable participants. Here, we report outcomes of an online survey of participants who underwent home-based assessment, related to the experience, perceived benefits, and drawbacks of home audiovestibular assessments. Seventeen participants underwent home-based neuro-otological assessment, due to the need to isolate during COVID-19. Following the assessment, 16 out of 17 participants completed an anonymised online survey to share their experiences of the specialist home-based assessment. One hundred percent of participants rated the home-based assessment 'very positively' and would recommend it to others. Sixty-three percent rated it better than attending hospital outpatient testing settings. The benefits included no travel burden (27%) and reduced stress (13%). A majority reported no drawbacks in having the home visit. The patient-reported feedback suggests a person-centred approach where audiovestibular assessments are conducted in their homes is feasible for patients, acceptable and seen as beneficial to a vulnerable group of patients.

Safe Penicillin Allergy Delabeling in Primary Care: A Systematic Review and Meta-Analysis

BackgroundTen % of the population is labeled as allergic to penicillin(s), when in fact 90% of these labels are inappropriate. Recent studies have shown that inpatient de-labelling by a direct drug challenge (dDC) is safe in low-risk patients. However, there is a need for outpatient and non-allergist de-labelling. ObjectiveTo assess the safety of de-labelling low-risk adults by means of dDC in primary care. MethodsWe searched MEDLINE, EMBASE and the Conchrane Library databases, from inception to March 15, 2022 (updated June 5, 2023) for studies performing dDC in adults in primary care or other outpatient settings. Two researchers independently screened studies for eligibility. The data extraction and critical appraisal was performed by one reviewer and we pooled the results in a meta-analysis. ResultsOut of 2,138 results, 12 studies (1070 participants) were eligible for inclusion. Three studies evaluated de-labelling in primary care and 9 studies in an outpatient hospital setting. There were no critical adverse events during dDC. No reaction occurred in 97.13% of the 1070 patients, who previously labeled as penicillin-allergic, and were safely de-labelled. Ten patients (<1%) developed an immediate reaction: three had self-limiting reactions, and seven needed antihistaminics, steroids, epinephrine and/or salbutamol. ConclusionNo serious allergic reactions are observed during direct amoxicillin challenge in adults in an outpatient setting. However, with the exception of one recent report, these studies are of low to moderate quality. Non-specialist de-labelling is promising but further research is required on correct risk stratification and safety assessment in large cohort studies evaluating dDC in primary care.

Improving symptom screening rates for patients with head and neck cancer.

e23246 Background: Effective symptom management in cancer care relies on regular and accurate reporting using validated patient-reported outcome measures (PROMs), such as the Edmonton Symptom Assessment System (ESAS). The ESAS measures nine common cancer symptoms, rating them on a scale from 0 to 10 to improve monitoring and communication regarding patient symptoms and prevent adverse outcomes such as emergency department visits. There is a need to enhance completion rates to ensure that head and neck cancer (HNC) symptoms are effectively addressed. High completion rates provide valuable data for cancer centers and clinicians to intervene early and support patients through their cancer journey. This makes it an important target for quality improvement (QI) with wide-ranging implications for patient outcomes and care quality. Our objectives were to: Investigate underlying reasons for poor ESAS completion rates. Lay the groundwork for strategic interventions aimed at bolstering symptom screening among HNC patients. Methods: This was a QI project targeting the HNC patient population at a regional cancer centre (RCC). Our approach included stakeholder engagement meetings alongside the expertise of QI specialists. Comprehensive data collection was conducted to analyze symptom screening rates and identify potential barriers to ESAS completion. We tracked ESAS completion on weekly HNC clinic days from 2022-2023 via manual and automated chart abstraction. Patient, staff, and volunteer interviews, along with direct clinic observations, provided data for Ishikawa diagrams, facilitating a root cause analysis. Results: We identified a marked decline in ESAS completion rates, steadily decreasing from an average of 29.4% during the 2022-2023 fiscal year to an average of 7.6% between April-November 2023, with rates dropping as low as 3.3% in September 2023. Root cause analysis pinpointed several barriers to ESAS completion, including the transition from paper-based assessments used during the pandemic to electronic formats, low patient awareness of the purpose of symptom screening, perceived lack of value in screening by patients and staff, and the absence of direct guidance from staff in helping patients complete their ESAS. Variable communication practices and inconsistencies in registration staff directing patients to kiosks was also observed. Improving infrastructure and support for volunteer services was identified as a potential solution, which may optimize their effectiveness in symptom screening roles. Conclusions: The project has laid the foundation for targeted QI interventions aimed at improving ESAS screening adherence. By addressing the identified barriers, this work endeavors to re-engage patients in active symptom reporting and to integrate this critical aspect of care into the daily routine of the outpatient hospital setting, thereby enhancing the overall management of HNC symptoms.

'My sexual desires, everything, my normal life just stops'; a qualitative study of male sexual health in inflammatory bowel disease.

To describe and interpret the sexual health experiences of men with IBD. Interpretive qualitative study. In-depth, semi-structured interviews were conducted with 22 men with a diagnosis of Inflammatory Bowel Disease. Interviews were digitally audio-recorded and transcribed verbatim. Data were analysed using constant comparative, thematic analysis. Three themes were identified from interview data: (1) the disease shapes intimate connections, (2) the disease thwarts sexual experiences and (3) the disease disrupts male gender norms. Men reported that active disease lowered libido and could change pre-, inter- and post-coital sexual practices. All participants noted that health professionals did not initiate the discussion of sexual health and well-being needs in the outpatient hospital setting. Men who engaged in receptive anal sex reported a lack of disease-specific guidance and understanding from professionals. Inflammatory bowel disease can negatively impact the sexual well-being, gender identity and activities of men. Further research is required to identify the care preferences of men with IBD and clarify the barriers and facilitators to sexual health assessment so that nurses may better support the health needs of this population. This study highlights the need for sexual health and well-being support that is specific to disease and gender in IBD. There is a paucity of information and guidance for men with peri-anal disease and proctitis who engage in receptive anal sex, which requires urgent attention. Reporting follows the COREQ checklist. A patient and public involvement group informed the development of the study design. The group reviewed public facing documents and interview guides. One member of the group provided comments on the identified themes.

Medicare Patients With Peripheral Artery Disease Are Treated More Quickly but Undergo Higher Cost Interventions in Office-Based Laboratories vs Outpatient Hospital Settings

Medicare Patients With Peripheral Artery Disease Are Treated More Quickly but Undergo Higher Cost Interventions in Office-Based Laboratories vs Outpatient Hospital Settings

A Grounded Theory of Interdisciplinary Communication and Collaboration in the Outpatient Setting of the Hospital for Patients with Multiple Long-Term Conditions.

Interdisciplinary communication and collaboration are crucial in the care of people with multiple long-term conditions (MLTCs) yet are often experienced as insufficient. Through the lens of complexity science, this study aims to explain how healthcare professionals (HCPs) adapt to emerging situations in the care of patients with MLTC by examining interdisciplinary communication and collaboration in the outpatient hospital setting. We used the constant comparative method to analyze transcribed data from seven focus groups with twenty-one HCPs to generate a constructivist grounded theory of 'interdisciplinary communication and collaboration in the outpatient setting of the hospital for patients with multiple long-term conditions'. Our theory elucidates the various pathways of communication and collaboration. Why, when, and how team members choose to collaborate influences if and to what degree tailored care is achieved. There is great variability and unpredictability to this process due to internalized rules, such as beliefs on the appropriateness to deviate from guidelines, and the presence of an interprofessional identity. We identified organizational structures that influence the dynamics of the care team such as the availability of time and financial compensation for collaboration. As we strive for tailored care for patients with MLTC, our theory provides promising avenues for future endeavors.