Outpatient Management Research Articles

Trends in Discharge Rates for Acute Pulmonary Embolism in U.S. Emergency Departments.

Outpatient management of select patients with low-risk acute pulmonary embolism (PE) has been proven to be safe and effective, yet recent evidence suggests that patients are still managed with hospitalization. Few studies have assessed contemporary real-world trends in discharge rates from U.S. emergency departments (EDs) for acute PE. To evaluate whether the proportion of discharges from EDs for acute PE changed between 2012 and 2020 and which baseline characteristics are associated with ED discharge. Serial cross-sectional analysis. U.S. EDs participating in the National Hospital Ambulatory Medical Care Survey. Patients with ED visits for acute PE between 2012 and 2020. National trends in the proportion of discharges for acute PE and factors associated with ED discharge. Between 2012 and 2020, there were approximately 1635300 visits for acute PE. Overall, ED discharge rates remained constant over time, with rates of 38.2% (95% CI, 17.9% to 64.0%) between 2012 and 2014 and 33.4% (CI, 21.0% to 49.0%) between 2018 and 2020 (adjusted risk ratio, 1.01 per year [CI, 0.89 to 1.14]). No baseline characteristics, including established risk stratification scores, were predictive of an increased likelihood of ED discharge; however, patients at teaching hospitals and those with private insurance were more likely to receive oral anticoagulation at discharge. Only 35.9% (CI, 23.9% to 50.0%) of patients who were considered low-risk according to their Pulmonary Embolism Severity Index (PESI) class, 33.1% (CI, 21.6% to 47.0%) according to simplified PESI score, and 34.8% (CI, 23.3% to 48.0%) according to hemodynamic stability were discharged from the ED setting. Cross-sectional survey design and inability to adjudicate diagnoses. In a representative nationwide sample, rates of discharge from the ED for acute PE appear to have remained constant between 2012 and 2020. Only one third of low-risk patients were discharged for outpatient management, and rates seem to have stabilized. Outpatient management of low-risk acute PE may still be largely underutilized in the United States. None.

The 2021 Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) guidelines and the outpatient management: Examining physician adherence and its effects on patient outcome.

Chronic obstructive pulmonary disease (COPD) is a common preventable illness that carries a large global economic and social burden. The global initiative for chronic obstructive lung disease (GOLD) guidelines has been utilized as a global strategy for the continued COPD diagnosis, assessment, and treatment. We aimed to determine if the adherence to the 2021 GOLD guideline directed management influenced outcomes. Retrospective medical records review of adult patients with COPD, who received care in our office during the entire year of 2021. Patients managed as per the 2021 GOLD guidelines were compared with those who received usual care. Among 242 patients, 171 (70.7%) were GOLD management adherent (GA) and 71 (29.3%) were GOLD non-adherent (GNA). Certain comorbidities were associated with higher frequencies in the GA group, such as allergic rhinitis (63.2 vs. 18.3%; P < 0.001), coronary artery disease (55.9 vs. 38.0%; P = 0.011), GERD (63.2 vs. 32.4%; P < 0.001), anemia (38.6 vs. 19.7%; P = 0.004), malignancy (34.5 vs. 19.7%; P = 0.023), and immunodeficiency (12.3 vs. 1.4%; P = 0.007). There was no significant difference in the mortality between the GA and GNA groups (5.3 vs. 9.9%; P = 0.254). Although the frequency of number of exacerbations was greater in the GA group, the difference in the mean number of exacerbations was not statistically significant (0.39 ± 1.08 vs. 0.39 ± 1.14; P = 0.984). We found no significant difference in the patient outcomes, such as number of exacerbations of COPD and mortality, when comparing the 2021 GOLD guideline adherent versus GOLD guideline non-adherent management of COPD.

Reexamining predictors of trial outcomes in New York State's sex offender civil management process.

In 2007, New York enacted the Sex Offender Management and Treatment Act, empowering the state to civilly manage individuals who have committed sexual offenses (respondents) and are deemed to have a mental abnormality (MA) that predisposes them to sexually recidivate after serving their criminal sentences. We sought to replicate and extend a previous study (Lu et al., 2015) to identify factors predicting legal decisions. We predicted, on the basis of previous research, that clinical information (e.g., diagnosis) as well as empirically supported risk factors (e.g., sexual deviance) would predict trial outcomes. We analyzed multiple pieces of demographic, criminogenic, and clinical data on three nested subsamples of respondents on the basis of the legal process: MA consent (n = 713), MA trial (n = 316), and disposition hearing (n = 643). The binary outcomes of interest were as follows: For the MA consent subsample, it was whether the respondent waived their MA trial; for the MA trial subsample, it was whether the respondent was found at trial to have an MA; and for the disposition hearing, it was whether the respondent was ordered to inpatient or outpatient civil management. The strongest predictor of waiving the trial was geographic location; respondents outside New York City and Long Island were more likely to waive their trials (ORs = 2.38-3.37). The strongest predictors of MA trial and disposition hearing outcomes were Diagnostic and Statistical Manual of Mental Disorders diagnoses; pedophilia (ORs = 4.05-7.22) and sexual sadism (ORs = 2.68-7.03) diagnoses increased the likelihood of an MA finding and confinement order. Judges and juries give significant weight to clinical information, particularly pedophilia diagnoses, when making civil management legal decisions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Cost-effectiveness of the ONCORAL multidisciplinary programme for the management of outpatients taking oral anticancer agents at risk of drug-related event: protocol for a pragmatic randomised controlled study

IntroductionThe development of oral anticancer agents (OAA) has profoundly changed cancer care, leading patients to manage their chemotherapy treatment on an outpatient basis. The prevention of iatrogenic effects of OAA...

Outpatient Management of CAR-T and Teclistamab for Patients with Lymphoma and Multiple Myeloma

Outpatient Management of CAR-T and Teclistamab for Patients with Lymphoma and Multiple Myeloma

Protocolo diagnóstico y terapéutico de la ingesta de cáusticos

The ingestion of caustic agents is a medical emergency due to the serious injuries they can cause to the upper digestive tract. It is estimated to have a frequency of 38.7 cases/100,000 inhabitants and a mortality rate of 1%–4% in Western countries. There are two typical scenarios: accidental ingestion, of small quantity and with a more benign course, and ingestion with the purpose of self-harm, of larger quantity and with a worse prognosis. The initial management consists of ensuring hemodynamic stability and airway permeability, avoiding actions such as inducing vomiting or the use of neutralizing substances. Radiological tests together with endoscopy allow for assessing severity and stratifying the risk of complications. Treatment varies according to the Zargar classification, ranging from outpatient management to emergency surgery in cases of perforation. Long-term follow-up allows for the detection of complications such as esophageal stricture, esophagobronchial fistulas, and esophageal cancer.

Exploring Factors That Prolong the Diagnosis of Myasthenia Gravis.

Myasthenia gravis (MG) is a condition with significant phenotypic variability, posing a diagnostic challenge to many clinicians worldwide. Prolonged diagnosis can lead to reduced remission rates and morbidity. This study aimed to identify factors leading to a longer time to diagnosis in MG that could be addressed in future to optimize diagnosis time. One hundred and ten patients from 3 institutions in Melbourne, Australia, were included in this retrospective cohort study. Demographic and clinical data were collected for these patients over the first 5 years from diagnosis and at 10 years. Nonparametric statistical analysis was used to identify factors contributing to a longer diagnosis time. The median time for MG diagnosis was 102 (345) days. 90% of patients were diagnosed before 1 year. Female patients took longer than male patients to be diagnosed (p = 0.013). The time taken for first presentation after symptom onset contributed most to diagnosis time (median 17 [141] days), with female patients and not working as contributory factors. Neurology referral took longer if patients had diplopia (p = 0.022), respiratory (p = 0.026) symptoms, or saw an ophthalmologist first (p < 0.001). Outpatient management compared with inpatient was associated with a longer time to be seen by a neurologist from referral (p < 0.001), for the first diagnostic result to return (p = 0.001), and for the result to be reviewed (p < 0.001). Ocular MG had a median greater time to neurologist review than generalized MG (median 5 [25] days vs 1 [13] days, p = 0.035). Electrophysiology tests took longer for outpatients than inpatients (median 21 [35] days vs 2 [8] days, p < 0.001). Outpatients were also started on treatment later than inpatients (p < 0.001). There was no association of MG severity, ethnicity, age, medical and ocular comorbidities, and public or private health service on diagnosis time. There was also no impact of time to diagnosis on Myasthenia Gravis Foundation of America outcomes, number of follow-ups or hospitalizations, or prevalence of treatments used. This study is limited by low patient numbers and its retrospective nature. This study identified several factors that can contribute to a prolonged diagnosis time of MG. Patient and clinician education about MG and outpatient diagnostic efficiency needs emphasis. Further studies are also needed to explore the delayed presentation time of women and nonworking patients in MG.

Cardiac rehabilitation for children and young people (CardioActive): protocol for a single-blind randomised feasibility and acceptability study of a centre-based cardiac rehabilitation programme versus usual care in 11–16 years with heart conditions

BackgroundCongenital heart conditions are among the most common non-communicable diseases in children and young people (CYP), affecting 13.9 million CYP globally. While survival rates are increasing, support for young people...

Acute hemorrhagic edema of infancy: 20-year experience from an Italian tertiary referral center.

Data on acute hemorrhagic edema of infancy (AHEI) are derived from small case series or case reports. We report a 20-year experience at a national referral center. We performed a single-center retrospective study including patients who were diagnosed with AHEI from January 1, 2004, to June 30, 2023. We identified 21 patients (57.1% females) with a median age of 18 months (range 7-33 months). Thirteen (61.9%) patients were admitted to the pediatric ward, the remaining eight (38.1%) presented to the emergency department and were discharged for outpatient management. The median length of hospitalization was 5 days (range 3-9 days). Twenty patients (95.2%) had prodromal symptoms. The most common cutaneous findings were targetoid purpuric plaques. The lesions were most localized on the face (13, 61.9%) and on the upper limbs (18 patients, 85.7%). Sixteen (76%) patients presented with nonpitting and tender edema, localized on the feet (9/16, 56%) and hands (6/16, 37.5%). Systemic involvement was rare, and no patients experienced complications or sequelae. Twelve (57.1%) patients underwent infectious disease investigations, with positive results in only four (33.3%). None of the patients diagnosed after the SARS-CoV-2 outbreak (March 2020) had positive nasopharyngeal swabs for the virus. For the 13 patients who were admitted to the pediatric ward, the median length of hospitalization was five days (3-9 days). The 21-patient single-center cohort of children affected by AHEI confirmed a generally benign course of AHEI, despite a 62% rate of hospitalization.

Effects of Decompression therapy in leg pain and straight leg rise in patient with lumbar radiculopathy due to disc protrusion

One among many disc problems is disc protrusion, which has more prevalence in outpatient department physical therapy management Centre globally. The purpose of this study was to compare the effect of lumbar spine decompression therapy and standard physical therapy treatment in patients with lumbar radiculopathy due to disc protrusion. The single-blind randomized control trial of 71 patients was conducted at Max Rehab &amp; Physical Therapy Centre Islamabad, Pakistan. After setting inclusion criteria all the patients were randomly allocated into treatment and control group. Both group received standard physical therapy treatment including, Moist Hot pack, Lumbar Mobilization, Stretching &amp; strengthening exercises. The only difference was that Decompression Group received additional Decompression therapy. The data included demographics and Numeric Pain Rating Scale score in supine lying position for the painful leg and Straight Leg Raise Range for the painful side. The values for leg pain for control group decreased from 6 to 3 and the value for straight leg raise increased from 15° to 49°. The values for leg pain for the Decompression Group decreased from 6 to 2 and the value for the straight leg raise increased from 10° to 48°, the p value for both the variables was &lt;.001 showing statistically significant difference between pre and post values in treating patients leg pain and straight leg raise range of motion. It is concluded that decompression therapy is more effective in managing lumbar radiculopathy.

Outpatient management of cancer-associated pulmonary embolism: A post-hoc analysis from the HOME-PE trial

IntroductionCancer-related pulmonary embolism (PE) is associated with poor prognosis. Some decision rules identifying patients eligible for home treatment categorize cancer patients at high risk of complications, precluding home treatment. We sought to assess the effectiveness and the safety of outpatient management of patients with low-risk cancer-associated PE. MethodsIn the HOME-PE trial, hemodynamically stable patients with symptomatic PE were randomized to either triaging with Hestia criteria or sPESI score. We analyzed 3 groups of low-risk PE patients: 47 with active cancer treated at home (group 1), 691 without active cancer treated at home (group 2), and 33 with active cancer as the only sPESI criterion qualifying them for hospitalization (group 3). The main outcome was the composite of recurrent venous thromboembolism, major bleeding, and all-cause death within 30 days after randomization. ResultsPatients treated at home had composite outcome rates of 4.3 % (2/47) for those with cancer vs. 1.0 % (7/691) for those without (odds ratio (OR) 4.98, 95%CI 1.15–21.49). Patients with cancer had rates of complications of 4.3 % when treated at home vs. 3.0 % (1/33) when hospitalized (OR 1.19, 95%CI 0.15–9.47). In multivariable analysis, active cancer was associated with an increased risk of complications for patients treated at home (OR 7.95; 95%CI 1.48–42.82). For patients with active cancer, home treatment was not associated with the primary outcome (OR 1.19, 95%CI 0.15–9.74). ConclusionsAmong patients treated at home, active cancer was a risk factor for complications, but among patients with active cancer, home treatment was not associated with adverse outcomes.

Effects of Digitization of Self-Monitoring of Blood Glucose Records Using a Mobile App and the Cloud System on Outpatient Management of Diabetes: Single-Armed Prospective Study.

In recent years, technologies promoting the digitization of self-monitoring of blood glucose (SMBG) records including app-cloud cooperation systems have emerged. Studies combining these technological interventions with support from remote health care professionals have reported improvements in glycemic control. To assess the use of an app-cloud cooperation system linked with SMBG devices in clinical settings, we evaluated its effects on outpatient management of diabetes without remote health care professional support. In this multicenter, open-label, and single-armed prospective study, 48 patients with diabetes (including type 1 and type 2) at 3 hospitals in Japan treated with insulin or glucagon-like peptide 1 receptor agonists and performing SMBG used the app-cloud cooperation system for 24 weeks. The SMBG data were automatically uploaded to the cloud via the app. The patients could check their data, and their attending physicians reviewed the data through the cloud prior to the patients' regular visits. The primary outcome was changes in glycated hemoglobin (HbA1c) levels. Although HbA1c levels did not significantly change in all patients, the frequency of daily SMBG following applying the system was significantly increased before induction at 12 (0.60 per day, 95% CI 0.19-1.00; P=.002) and 24 weeks (0.43 per day, 95% CI 0.02-0.84; P=.04). In the subset of 21 patients whose antidiabetic medication had not been adjusted during the intervention period, a decrease in HbA1c level was observed at 12weeks (P=.02); however, this significant change disappeared at 24 weeks (P=.49). The Diabetes Treatment Satisfaction Questionnaire total score and "Q4: convenience" and "Q5: flexibility" scores significantly improved after using the system (all P<.05), and 72% (33/46) patients and 76% (35/46) physicians reported that the app-cloud cooperation system helped them adjust insulin doses. The digitization of SMBG records and sharing of the data by patients and attending physicians during face-to-face visits improved self-management in patients with diabetes. Japan Registry of Clinical Trials (jRCT) jRCTs042190057; https://jrct.niph.go.jp/en-latest-detail/jRCTs042190057.

Characterizing emergency department and inpatient health care utilization after seizure-related hospitalization: A retrospective cohort study.

Seizure care is a significant driver of health care costs in both emergency department (ED) and inpatient settings, but the majority of studies have focused on inpatient admissions as the only metric of health care utilization. This study aims to better characterize ED and inpatient encounters among patients with seizure to inform care and policy. Using statewide administrative data from the Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases from Florida and New York, we identified patients with a seizure-related index hospitalization between January 1, 2016, and December 31, 2018. Among this cohort, we examined the incidence and characteristics of subsequent acute care visits in the ED and inpatient settings for 365 days after initial hospital discharge. A total of 54 456 patients had an eligible seizure-related hospitalization. Patients were 49% female, predominantly White (64%) and non-Hispanic (84%), and used a public primary payer (68%). There were 36 838 (68%) patients with at least one acute care visit in the year following discharge. Overall, patients had a median of 2 (interquartile [IQR] = 1-5) subsequent acute care visits and the median time to first acute care visit was 53 days (IQR = 15-138). Of the 154 369 subsequent acute care visits, 97 399 (63%) were ED-only visits, 56 970 (37%) were readmissions, and 37 176 (24%) were seizure-related. There were 18 786 patients (35%) with four or more acute care visits over 365 days of follow-up. Patients with four or more visits contributed 84% of acute care visits and 78% of costs after initial hospitalization. The majority of patients hospitalized for seizure return to the ED or hospital at least once in the year after discharge. A small portion of patients account for the majority of ED and inpatient visits as well as health care costs associated with this population, identifying a subgroup of patients who may benefit from improved inpatient and outpatient management.

Oral Ketorolac for Renal Colic in Outpatient Settings

What Is the Issue?&#x0D; &#x0D; Renal colic is a common problem that is primarily caused by kidney stones. Renal colic, specifically kidney stones, can be a recurrent condition that can negatively impact a person’s quality of life and health system utilization.&#x0D; Ketorolac through IV or intramuscular routes is a common nonsteroidal anti-inflammatory drug (NSAID) used in hospital to treat renal colic. Oral ketorolac for the management of renal colic may reduce patients’ need for opioids after discharge but it is unclear if it is clinically effective when compared to alternative analgesics or whether it is recommended for use in the management of people with renal colic.&#x0D; &#x0D; What Did We Do?&#x0D; &#x0D; To inform decisions about oral ketorolac for the management of outpatients with renal colic, we sought to identify and summarize literature comparing the clinical effectiveness of oral ketorolac and alternative analgesics. We also searched for evidence-based guidelines that provide recommendations about the use of oral ketorolac for the management of people with renal colic.&#x0D; A research information specialist conducted literature searches of peer-reviewed and grey literature sources published between January 1, 2013, and December 4, 2023. The search was limited to English-language documents. One reviewer screened articles for inclusion based on predefined criteria.&#x0D; &#x0D; What Did We Find?&#x0D; &#x0D; The tailored search for this rapid review did not find any studies evaluating the clinical effectiveness of oral ketorolac versus alternative analgesics for the management of people with renal colic in outpatient settings that met our criteria for this review. There is therefore no specific evidence available on the efficacy oral ketorolac in the management of renal colic in the community setting in this review.&#x0D; We did not find any eligible evidence-based guidelines concerning the use of oral ketorolac for the management of people with renal colic in outpatient settings. NSAIDs have been generally mentioned as an option for renal colic in the available guidance.&#x0D; Research regarding ketorolac for renal colic published since 2013 has focused on IV or intramuscular administration. Research regarding oral ketorolac focused on indications other than renal colic (e.g., postoperative pain) may be of interest; these are listed in the appendix. These studies suggest the effectiveness of ketorolac for pain management for other indications, such as pain management following endoscopy.&#x0D; &#x0D; What Does It Mean?&#x0D; &#x0D; Without comparative evidence, decision-makers may want to consider how oral ketorolac is used for related indications (e.g., procedures for removing kidney stones, ureteroscopies) to examine how it performed compared with alternative analgesics.&#x0D; Research focused on the management of renal colic is needed to evaluate the clinical effectiveness of oral ketorolac and inform guidance concerning oral ketorolac in outpatient settings.&#x0D;

Outpatient medical management of later second trimester abortion (18–23.6 weeks) with procedural evacuation backup: A large case series

ObjectiveDocument the clinical outcomes of an outpatient medical management with procedural evacuation backup procedure for abortions between 18 weeks zero days to 23 weeks six days gestation. Study designWe conducted a retrospective medical records review of adult patients who received mifepristone and repeated misoprostol for second trimester abortion with procedural evacuation backup at an Arizona clinic between October 2017 and November 2021. We extracted patient demographics; pregnancy and medical history; and preoperative, intraoperative, and postoperative data. We assessed abortion outcomes, including procedure timing, mode of completion (medication alone or medications and procedural evacuation), and safety. ResultsAll 359 patients had a complete abortion with 63.5% of patients completing with medication alone and 36.5% with procedural evacuation backup. The median time from first dose of misoprostol to fetal expulsion was six hours, among those who completed the abortion with medications alone. Of those who received procedural evacuation as backup, the median time for procedural evacuation was 10 minutes. The vast majority of patients (99.4%) did not have any adverse events. Two safety incidents (0.6%) occurred, a broad right ligament tear and a uterine rupture. ConclusionPatients in one outpatient setting safely and effectively received medical management of second trimester abortion with procedural evacuation backup, and two thirds completed with medications alone. ImplicationsOutpatient settings may consider medical management of abortion between 18 and 24 weeks with procedural evacuation back-up as a safe, effective, and manageable second trimester abortion option. Additional research is needed on patient experience and satisfaction.

Transitioning Pediatric Patients with Ventricular Assist Devices Home: Key Components of the Discharge Process and Outpatient Management

Transitioning Pediatric Patients with Ventricular Assist Devices Home: Key Components of the Discharge Process and Outpatient Management

Glaucoma Ex-PRESS Implantation Surgery: Is There a Difference in Efficacy and Safety between Inpatient and Outpatient Management?

Glaucoma Ex-PRESS Implantation Surgery: Is There a Difference in Efficacy and Safety between Inpatient and Outpatient Management?

Management of Kidney Transplant Outpatients With COVID-19: A Single Center Experience.

Patients undergoing kidney transplant are at risk of severe COVID-19. Our single-center retrospective analysis evaluated the outcomes of kidney transplant outpatients with COVID-19 who were managed with reduced immunosuppression and treatment with molnupiravir. Between January 2022 and May 2023, we included 93 patients (62 men, average age 56years), serum creatinine 127 (101-153) µmol/L. Molnupiravir was administered, and immunosuppressive therapy was reduced immediately following the confirmation of SARS-CoV-2 infection by PCR, which was 2 (1-3) days after the onset of symptoms. Only three (3.2%) patients required hospitalization, and one patient died. Acute kidney injury was observed in two patients. During the follow-up period of 19 (15-22) months, there was no significant increase in proteinuria, no acute or new chronic graft rejection, and kidney graft function remained stable; serum creatinine was 124 (106-159) µmol/L post-COVID-19 infection and 128 (101-161) µmol/L at the end of the follow-up period. Our results demonstrate that early initiation of molnupiravir treatment combined with a temporary reduction in immunosuppressive therapy results in favorable clinical outcomes in patients with COVID-19, with preservation of good graft function and no episodes of graft rejection.

Reduced Heart Failure 30-day Readmission With Implementation Of A Cohesive And Structured Nurse Practitioner Led Inpatient And Outpatient Heart Failure Disease Management Program

Reduced Heart Failure 30-day Readmission With Implementation Of A Cohesive And Structured Nurse Practitioner Led Inpatient And Outpatient Heart Failure Disease Management Program

Racial Disparities In Outpatient Medical Management Of Patients With Heart Failure With Reduced Ejection Fraction

Racial Disparities In Outpatient Medical Management Of Patients With Heart Failure With Reduced Ejection Fraction