Outpatient Primary Care Clinics Research Articles

A case of severe opioid and methamphetamine use disorder in a 14 year old

We present the case of a 14-year-old who established care at our primary care clinic after hospitalization for unintentional fentanyl overdose. They were diagnosed with severe opioid use disorder (OUD) and stimulant use disorder (StUD) and initiated buprenorphine while inpatient. They were then transitioned to the only known outpatient primary care clinic in her county who was actively providing medications for opioid use disorder (MOUD) in adolescents.At the first visit, they reported a history of 20 overdoses, struggling with adherence to buprenorphine and continued opioid cravings. An overdose safety plan was reviewed with them and their parent including providing them naloxone kits, fentanyl test strips, and education handout sheets. Due to their significant overdose history and adherence challenges with sublingual buprenorphine, they were started on long-acting injectable buprenorphine (LAIB) with weekly provider visits and urine toxicology screening. In collaboration with the treatment team, they initiated behavioral treatment with contingency management (CM), with incentives for appointment completion, expected urine results, and successful medication administration. Over the next 19 months, and to date, they have increasingly engaged with care and have remained abstinent. LAIB may be an appealing alternative for adolescents with OUD to improve adherence and reduce risk of recurrent use and overdose. Adjunctive treatment with CM may improve retention in MOUD and have the benefit of treating StUD. There is a need for further research to explore innovative, community-based treatment for youth with OUD.

Collaborative Care for Depression and Anxiety: Racial-Ethnic Differences in Treatment Engagement and Outcomes.

This study aimed to examine racial-ethnic differences in engagement with and clinical outcomes of a collaborative care model (CoCM) implemented in primary care outpatient clinics in an urban academic medical center. Adult patients (N=4,911) who screened positive for symptoms of depression, anxiety, or both on the Patient Health Questionnaire-9 or the Generalized Anxiety Disorder-7 scale and who identified as non-Hispanic Black, Hispanic, or non-Hispanic White were offered participation in a CoCM implementation. The primary outcome was treatment engagement, defined as receipt of any follow-up visit, minimally adequate 4-week follow-up (at least one visit), and minimally adequate 16-week follow-up (at least three visits) after initial assessment. Secondary outcomes were response and remission of depression or anxiety. After adjustment of analyses for sociodemographic covariates, Black and Hispanic participants were significantly less likely than White participants to have received any or minimally adequate follow-up. Black and Hispanic participants who received any or minimally adequate 16-week follow-up were more likely than White participants to demonstrate depression symptom response and remission of anxiety symptoms. This CoCM implementation appears to have been effective in treating depression and anxiety among Black and Hispanic patients. However, significant disparities in receipt of follow-up care were observed. Efforts must be made to improve the retention of patients from racial-ethnic minority groups in collaborative care.

Implementation of a virtual community of practice to promote the empowerment of middle-aged people with multimorbidity: study protocol of a randomised controlled trial

IntroductionEmpowering people living with multimorbidity (multiple chronic conditions) to gain greater confidence in managing their health can enhance their quality of life. Education focused on self-management is a key tool...

A quality improvement project to improve treatment of severe hypertriglyceridemia in veterans.

Severe hypertriglyceridemia (sHTG) is associated with an increased risk of acute pancreatitis. Prompt recognition and treatment of sHTG is key for prevention of acute pancreatitis and its associated life-threatening complications. Patients with sHTG at a primary care clinic within the Veterans Affairs Eastern Colorado Health Care System were receiving suboptimal treatment that did not align with evidence-based guidelines. We initiated a quality improvement (QI) project to improve the management of sHTG in an outpatient primary care clinic. Veterans with a triglyceride level between 500 and 1,500 mg/dl were included in the project. Project interventions included provider education, patient education, and targeted electronic consultations (e-consults) with treatment recommendations. The primary outcome was to decrease the percentage of patients with triglycerides ≥500 mg/dl by 25%. The secondary outcome was to decrease the mean triglyceride level of the patient population by 15%. Education on evaluation and treatment of sHTG was given to 100% (n = 21) of primary care clinicians. Overall, 72.8% (95% CI [62.6-81.6%]) of patients (n = 67) received appropriate written education materials, and 72.8% (95% CI [62.6-81.6%]) of patients (n = 67) received a targeted e-consult. The percentage of patients with sHTG decreased by 47%. Average triglyceride level decreased from 651 to 483 mg/dl (25.8% decrease). A multipronged QI project consisting of provider education, patient education, and targeted e-consults resulted in decreased triglyceride levels and improved access to specialist expertise. Clinical implications include decreased prevalence of sHTG and risk of acute pancreatitis among patients in the project.

Men’s views on causes and consequences of erectile dysfunction or premature ejaculation in a primary care population: a qualitative study

Objective To explore men’s views on the causes and consequences of two common sexual dysfunctions – erectile dysfunction and premature ejaculation – and how this affects physical and mental health as well as social life and intimate or close relations. Design A qualitative design with semi-structured interviews using open-ended questions was employed. Individual interviews were conducted, audio recorded and transcribed, and a qualitative content analysis of the text was performed. Setting Informants were recruited from an outpatient primary care clinic in Sweden that offers consultation about sexual health to primarily younger men, age 20 years and above. Subjects A total of 18 participants were included in the study, ten with erectile dysfunction and eight with premature ejaculation or both. Main outcome measures Using the content analysis, different views and strategies of erectile dysfunction and premature ejaculation were presented to illustrate a range of perceptions. Results The main theme emerged as ‘Striving to understand and deal with the problem’, which was divided into four categories: ‘Reasons for seeking healthcare’, ‘Own perceptions/images about the problem and its cause’, ‘Experienced consequences on sex life’ and ‘Relationship qualities’. Participants experienced their problems in relation to a partner. Feelings of shame and fear of not being fit for desired sexual practices were common. They thought that underlying physical illness or previous sexual activities could have caused their problems. Decreased sexual desire and low self-esteem were seen as consequences, and participants wished for both medical treatment and counselling as support. Conclusion Sexual dysfunction impairs general health and relationships with partners. While counselling is the basic treatment, those who are offered pharmaceutical treatment need follow-up concerning effectiveness and potential concerns.

Attitudes, Beliefs, and Behaviors of Topical Antibiotic Prescribing among Primary Care Providers in Saudi Arabia: A Cross-Sectional Study.

The World Health Organization (WHO) estimates that 20-50% of antibiotics are misused in society. In addition to the development of antimicrobial resistance, topical antibiotics have been associated with adverse effects such as allergic contact dermatitis (ACD) and inadequate wound healing. This study investigated the appropriateness of topical antibiotic prescriptions among primary care providers in Saudi Arabia. A cross-sectional survey was conducted among Saudi Arabian primary care providers (physicians (general, family, and internal medicine)) employed in governmental and non-governmental healthcare facilities (primary care centers and outpatient clinics). In total, 222 participants were included in the analysis. A total of 73% agreed that inappropriate topical antibiotic use puts patients at risk, and 43% reported antibiotic resistance in daily practice. Many respondents lacked knowledge of the proper indications for topical antibiotics, and 66.2% attributed this to a lack of updated knowledge, while 45% blamed inadequate supervision. Antibiotic prescription patterns deviated from the standards recommended by WHO. This calls for continuous review at all levels of healthcare, providing more physician education and ensuring that antibiotic therapy guidelines are easily accessible and effectively used to avoid the negative consequences of inappropriate antibiotic prescription.

Implementing mobile text messaging on glycemic control in patients with diabetes mellitus.

Uncontrolled blood glucose may lead to serious complications in patients with type two diabetes mellitus (T2DM). Patients may not have the support, motivation, or encouragement to adhere to the lifestyle changes necessary to control their T2DM. More than 75% of the primary care clinic's patients are diagnosed with T2DM, with most patients at the practice site having an average hemoglobin A1c (HbA1c) level of 8.5%. The primary care clinic did not use text messaging to disseminate diabetes self-management education and support (DSMES) as outlined in Standard 4 of the American Diabetic Association's (ADA) clinical practice guideline. This evidence-based quality improvement project was conducted in a rural outpatient primary care clinic to determine whether implementing the ADA's 2022 National Standards for DSMES using text messaging would affect HbA1C levels among adult patients with T2DM. Patients were sent weekly text messages over a 12-week period. Text messages contained information promoting self-care, tips about healthy diet, exercise reminders, instructions about proper blood glucose monitoring, and reminders about medication adherence. A total of 160 patients were included. A paired-sample t-test showed a reduction in HbA1c levels after the intervention from baseline (M = 7.53, SD = 1.72) to postimplementation (M = 6.91, SD = 0.89), t (159) = 11.88, p = .001. Based on the results, implementing the ADA's National Standards for DSMES Standard 4 may affect HbA1c levels in this population.

Exploring the link between chronic illness adaptation and health anxiety: insights from a primary care outpatient clinic in Turkeyy

Exploring the link between chronic illness adaptation and health anxiety: insights from a primary care outpatient clinic in Turkeyy

Patient-caregiver twinned mobile phone application to promote medication adherence

Background Poor medication adherence (MA) is prevalent globally. MA assessment, often based on scales or pill count, lacks actionability. A mobile application (app), MediEasy, targeting patients on multiple daily medications, has been developed to engage their caregivers to enhance their MA. Objectives This pilot single-arm study aimed to determine the feasibility, acceptability, utility and glycaemic control of the MediEasy-app by patients with type-2 diabetes mellitus and their caregivers. Methods 20 Multi-ethnic Asian patients aged 51 to 70 years with suboptimal glycaemic control (HbA1c>7.5%) and their caregivers were recruited at a Primary care outpatient clinic in Singapore. The Medieasy app that contains the following major functionalities such as the alerts to take medications, embedded medication details, personalized dosing options (such as frequency and scheduling dosage settings) is twinned to their designated caregivers. The Caregivers can remind the patients who missed the scheduled medication intake when the paired device was alerted. Results 85% (17/20) of the participants used the app for the entire 4 weeks, reflecting feasibility; 3 dropped out due to technical glitches or failure to adhere to protocol. The app was activated with an average of 2.8 times per day showing adequate utility. The 17 participants and their caregivers agreed that the app supported medication adherence. Their mean HbA1c decreased by 0.2% after 12 weeks of app usage. Conclusions The results showed feasibility, utility and acceptability of the MediEasy-app, with improved glycaemic control after its usage.

Specialized outpatient care for maternal and child health in PlanificaSUS areas.

To describe the organization of specialized outpatient clinics, according to the Secondary Outpatient Care Unit (SOCU) model according to the health care planning (HCP) methodology. This is a descriptive and cross-sectional study, which used secondary data from the PlanificaSUS project. It was carried out in 16 outpatient clinics specialized in maternal and child care, distributed in the five Brazilian geographic regions. A structured questionnaire was used for self-assessment on the implementation of 12 parameters in two moments, in 2019 and in 2020. These parameters are related to the care, educational, and supervisory functions set out in the SOCU model. In 2019, only 37.5% (six) of the outpatient clinics completed at least one parameter related to the care function, most frequently the multiprofessional team with interdisciplinary action (completed in 18.8% of the outpatient clinics). No parameters from the educational and supervisory functions were completed at this initial stage. In 2020, on the other hand, parameters related to the care function also showed higher frequency, higlighting the use of the same criterion by primary care teams and outpatient clinics for risk stratification (completed in 68.8% of the outpatient clinics). In the educational and supervisory functions, parameters related to the encounter between primary care teams and outpatient clinics for case management development, integrated training promotion, and close communication bond among these professionals also increased. Completion of these three parameters was identified in 25%, 25%, and 37.5% of the outpatient clinics, respectively. The planning methodology fostered reflection and discussion about the (re)organization of the work process and contributed to changes in maternal and child health care practices within specialized outpatient care, integrated with primary health care (PHC), from the perspective of care networks. We believe that such advances enhance access and equitable care for high-risk pregnant women and children in different geographical regions of Brazil.

Abstract B107: Disparities in lung cancer screening rates: A retrospective observational study

Abstract Introduction: Lung cancer is a leading cause of cancer deaths worldwide. Despite advances in cancer care, the low five-year survival rate for lung cancer is due to late-stage diagnoses. Early detection through lung cancer screening is vital for improving patient outcomes. However, racial disparities persist, with Black individuals experiencing higher rates and advanced stages of the disease. This retrospective study assessed racial and gender disparities in lung cancer screening rates among different racial groups at WakeMed Health and Hospital outpatient primary care clinics. Study design: The study utilized data from the lung cancer screening registry, focusing on the period between Jan 1st 2017 and May 15th 2023. The data was obtained from the EPIC electronic medical record system and exported to Excel. We implemented filters to narrow down the patient population that met the U.S. Preventive Services Task Force inclusion criteria for lung cancer screening. Eligible patients for lung cancer screening are those aged 50 to 80 years, either current smokers or individuals who quit smoking within the past 15 years and have a smoking history of at least 20 pack years. The study focused on three racial groups: Asian, Black, and White populations. Results: Among the 2,098 patients who met the inclusion criteria, 15.5% were Black (n=326), 0.01% were Asian (n=23), and 83.4% were White (n=1,749). The screening rates for lung cancer were calculated for each racial group. The Asian population had a screening rate of 26% (6 out of 23 patients), the Black population had a rate of 32% (103 out of 326 patients), and the White population had a rate of 31% (543 out of 1,749 patients). Among the Asian population, the screening rate for Asian males was 20% (4 out of 20 patients), while for Asian females, it was relatively higher at 67% (2 out of 3 patients). For the Black male population, the screening rate was 31% (52 out of 167 patients), while among females, it was 32% (51 out of 159 patients). Among the White population, white males were screened at a rate of 33% (313 out of 962 patients), while among females, it was slightly lower at 29% (230 out of 787 patients). Conclusion: The findings reveal no significant difference in lung cancer screening rates between racial groups or genders. Caution must be exercised when interpreting the findings for the Asian population due to the small sample size. Further research using a larger and more diverse dataset is necessary to draw more robust conclusions regarding potential disparities in lung cancer screening rates. This study underscores the importance of improving overall lung cancer screening rates, as the majority of the eligible population did not receive screening. Efforts will be made to implement interventions that enhance lung cancer screening rates, ensuring timely detection and improving patient outcomes. Addressing disparities in lung cancer screening access and utilization is crucial for achieving equitable healthcare and reducing the burden of lung cancer on vulnerable populations. Citation Format: Giuseppina Jacob, Amanpreet Dhaliwal, Praveen Namireddy. Disparities in lung cancer screening rates: A retrospective observational study [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B107.

Psychometric Properties of the Acceptance and Action Questionnaire-II (AAQ-II) in Older Adult Primary Care Patients

ABSTRACT Objectives Considering that the examination of psychological flexibility measures among older adults is scant, this study explores the psychometric properties of the Acceptance and Action Questionnaire-II (AAQ-II) among outpatient geriatrics primary care clinic patients in a university-affiliated medical center in the Deep South. Methods On average, patients who consented to participate in research (N = 119) were 75.42 (SD = 9.14) years old. Approximately 74% were women, 91% were non-Hispanic white, and 86% lived in urban areas. Measures included psychological inflexibility, subjective health literacy, depression, anxiety, and global cognitive functioning. Results The AAQ-II demonstrated adequate internal reliability, Cronbach’s α = 0.79, and good test-retest reliability, r(28) = .84, p < .001. With the removal of item 4, confirmatory factor analysis demonstrated adequate construct validity for the use of AAQ-II with older adults. As predicted, the AAQ-II exhibited concurrent, predictive, discriminant, and incremental validity within this older adult sample. Conclusions These results demonstrate meaningful scientific and clinical implications. This is the first study to examine the psychometric properties of the Acceptance and Action Questionnaire-II (AAQ-II) in an older adult sample. Clinical Implications The AAQ-II is a psychometrically sound measurement that can be clinically used on older adults.

FRI073 Use Of Obesogenic Medications Among Patients With Type 2 Diabetes In The Dominican Republic

Abstract Disclosure: S.P. Agramonte Villar: None. C.R. Gil Vega: None. J.M. Reynoso Ortiz: None. L.R. Sosa Pinedo: None. R.A. Vasquez Morel: None. C.M. Polanco Santos: None. V.T. San Martin: None. Background: Obesity is a major risk factor for the development and progression of type 2 diabetes mellitus (T2DM). Among the modifiable factors that can promote weight gain is the use of obesogenic medications (OM). The prevalence of the use of OM in patients with T2DM in the Dominican Republic (DR) is unknown. Objective: This study aimed to evaluate the use of OM among patients with T2DM in the DR. Methods: Cross-sectional study based on patient surveys and anthropometric measurements obtained in an outpatient primary care clinic in Santo Domingo, DR between October 2022 and November 2022. Patients aged ≥18 years with a known diagnosis of T2DM were included. Weight status was categorized according to body mass index (BMI). OM were defined according to the study by Hales et al1. Results: A total of 220 patients were surveyed and analyzed. Overall, 57.7% (127/220) of the patients reported a current use of one or more OM; 50.0% (110/220) were using one OM, 6.4% (14/220) were using two OM, and 1.3% (3/220) were using three OM. Among the patients using at least one OM, 45.7% (58/127) had overweight (BMI 25.0-29.9 kg/m2) and 40.9% (52/127) had obesity (BMI &amp;gt;30 kg/m2). The most frequently used antidiabetes OM was insulin [any type] (n=83), followed by glyburide (n=17) and glimepiride (n=13). The most commonly used non-antidiabetes OM was metoprolol (n=8), followed by atenolol (n=6) and pregabalin (n=6). Conclusion: More than half of the patients with T2DM were using at least one OM. The use of OM can contribute to weight gain and may hinder weight loss efforts in these patients, thus potentially negatively impacting the management of their underlying chronic disease. Reference: 1. Hales CM et al. Use of prescription medications associated with weight gain among US adults, 1999-2018: A nationally representative survey. Obesity (Silver Spring). 2022;30:229-239. Presentation: Friday, June 16, 2023

THU669 Time To Achieve Euthyroidism In Graves Disease Using Methimazole In An Urban Population

Abstract Disclosure: S.S. Habbsa: None. E. Yunasan: None. A. Krishnan: None. K.M. Munir: None. Context: Previous studies of treatment response in Graves disease have shown that that the mean time to reach euthyroidism with methimazole (MMI) was several weeks to months. In 1987 Okamura et al. concluded that the average period was 6-7 weeks with MMI 30mg daily. Nakamura et al. showed similar data in 2007 (5.8 +/- 4 weeks). These studies were performed in Japanese hospitals over 15 years ago. Limited data exists regarding treatment response times with different doses in a diverse urban population, which may vary with regards to typical dietary patterns, thyroid hormone metabolism and thionamide pharmacokinetics. Objective: The objective of this retrospective chart review was to determine the mean time to achieve euthyroidism with MMI in patients with newly diagnosed Graves disease in Baltimore City. Methods: Patients with Graves hyperthyroidism newly diagnosed in the last 5 years were identified from outpatient endocrine and primary care clinics within the University of Maryland Medical Center healthcare system. Time to achieve euthyroidism (from the start of thionamide therapy to date of euthyroid labs, defined as normal free T4 level) was assessed. Results: 128 patients with recently diagnosed Graves hyperthyroidism were identified (126 patients treated with MMI only and 2 with PTU only). 78% of subjects were female and the mean age at diagnosis was 47 years. The average daily dose of MMI ranged from 2.5mg to 60mg. On average, Free T4 decreased by 0.47 ng/dL per week. The mean time to achieve euthyroidism was 10.1 weeks (8.6, 11.6) overall, similar in males and females. On sub analysis, time to achieve euthyroidism was lower in younger males (age &amp;lt; 40 years) [6.6 weeks (3.9, 9.3)] and older females (age &amp;gt; 40 years) [8.3 (6.9, 9.7)]. Conclusion: The above data may inform expectations for treatment response for newly diagnosed Graves disease, specifically in an urban population on a Westernized diet. Patient forums have shown increasing interest in therapeutic alternatives to thionamides, including specialized diets. This data may help to determine whether other proposed therapies for initial treatment of Graves hyperthyroidism are more or less efficacious. Presentation: Thursday, June 15, 2023

Blood-based tests for multicancer early detection (PATHFINDER): a prospective cohort study

Multicancer early detection (MCED) blood tests can detect a cancer signal from circulating cell-free DNA (cfDNA). PATHFINDER was a prospective cohort study investigating the feasibility of MCED testing for cancer screening. In this prospective cohort study done in oncology and primary care outpatient clinics at seven US health networks, a convenience sample of adults aged 50 years or older without signs or symptoms of cancer consented to MCED testing. We collected blood, analysed cfDNA, and returned results to participants' doctors. If a methylation signature indicative of cancer was detected, predicted cancer signal origin(s) informed diagnostic assessment. The primary outcome was time to, and extent of, diagnostic testing required to confirm the presence or absence of cancer. This trial is registered at ClinicalTrials.gov, NCT04241796, and is completed. Between Dec 12, 2019, and Dec 4, 2020, we recruited 6662 participants. 4204 (63·5%) of 6621 participants with analysable results were women, 2417 (36·5%) were men, and 6071 (91·7%) were White. A cancer signal was detected in 92 (1·4%) of 6621 participants with analysable results. 35 (38%) participants were diagnosed with cancer (true positives) and 57 (62%) had no cancer diagnosis (false positives). Excluding two participants whose diagnostic assessments began before MCED test results were reported, median time to diagnostic resolution was 79 days (IQR 37-219): 57 days (33-143) in true-positive and 162 days (44-248) in false-positive participants. Most participants had both laboratory tests (26 [79%] of 33 with true-positive results and 50 [88%] of 57 with false-positive results) and imaging (30 [91%] of 33 with true-positive results and 53 [93%] of 57 with false-positive results). Fewer procedures were done in participants with false-positive results (17 [30%] of 57) than true-positive results (27 [82%] of 33) and few had surgery (one with a false-positive result and three with a true-positive result). This study supports the feasibility of MCED screening for cancer and underscores the need for further research investigating the test's clinical utility. GRAIL.

Early Access to Testosterone Therapy in Transgender and Gender-Diverse Adults Seeking Masculinization

Testosterone treatment is a necessary component of care for some transgender and gender-diverse individuals. Observational studies have reported associations between commencement of gender-affirming hormone therapy and improvements in gender dysphoria and depression, but there is a lack of data from randomized clinical trials. To assess the effect of testosterone therapy compared with no treatment on gender dysphoria, depression, and suicidality in transgender and gender-diverse adults seeking masculinization. A 3-month open-label randomized clinical trial was conducted at endocrinology outpatient clinics and primary care clinics specializing in transgender and gender-diverse health in Melbourne, Australia, from November 1, 2021, to July 22, 2022. Participants included transgender and gender-diverse adults aged 18 to 70 years seeking initiation of testosterone therapy. Immediate initiation of testosterone commencement (intervention group) or no treatment (standard care waiting list of 3 months before commencement). This design ensured no individuals would be waiting longer than the time to standard care. The primary outcome was gender dysphoria, as measured by the Gender Preoccupation and Stability Questionnaire. Secondary outcomes included the Patient Health Questionnaire-9 (PHQ-9) to assess depression and the Suicidal Ideation Attributes Scale (SIDAS) to assess suicidality. Questionnaires were undertaken at 0 and 3 months. The evaluable cohort was analyzed. Sixty-four transgender and gender-diverse adults (median [IQR] age, 22.5 [20-27] years) were randomized. Compared with standard care, the intervention group had a decrease in gender dysphoria (mean difference, -7.2 points; 95% CI, -8.3 to -6.1 points; P < .001), a clinically significant decrease in depression (ie, change in score of 5 points on PHQ-9; mean difference, -5.6 points; 95% CI, -6.8 to -4.4 points; P < .001), and a significant decrease in suicidality (mean difference in SIDAS score, -6.5 points; 95% CI, -8.2 to -4.8 points; P < .001). Resolution of suicidality assessed by PHQ-9 item 9 occurred in 11 individuals (52%) with immediate testosterone commencement compared with 1 (5%) receiving standard care (P = .002). Seven individuals reported injection site pain/discomfort and 1 individual reported a transient headache 24 hours following intramuscular administration of testosterone undecanoate. No individual developed polycythemia. In this open-label randomized clinical trial of testosterone therapy in transgender and gender-diverse adults, immediate testosterone compared with no treatment significantly reduced gender dysphoria, depression, and suicidality in transgender and gender-diverse individuals desiring testosterone therapy. ANZCTR Identifier: ACTRN1262100016864.

Early Fever Resolution in Early Childhood Influenza Treated with Baloxavir Marboxil: A Retrospective Study Compared to Those with Oseltamivir.

Background and Objectives: Baloxavir marboxil is a novel cap-dependent endonuclease inhibitor prescribed for influenza treatment. Unlike neuraminidase inhibitors like oseltamivir, which impair viral release from infected host cells, baloxavir blocks influenza virus proliferation by inhibiting viral mRNA transcription. This study aimed to compare the effectiveness of baloxavir and oseltamivir for the treatment of early childhood influenza. Materials and Methods: Of 1410 patients diagnosed with influenza between 2015 and 2018 at a Japanese primary care outpatient clinic, 1111 pediatric patients aged 0-6 years who were treated with baloxavir (n = 555) or oseltamivir (n = 556) were enrolled retrospectively. The following clinical factors were compared between patients treated with baloxavir and oseltamivir: age, sex, time from fever onset to drug administration (<24 h or 24-48 h), time from drug administration to fever reduction, influenza type (A or B), and influenza vaccination before disease onset. The duration of the fever, which was used as an index of clinical effectiveness, was compared using the log-rank test. Clinical factors associated with fever duration were determined using multivariate logistic regression analysis. Results: Median age (3.0 vs. 2.5 years), influenza type A (99% vs. 47%), median duration from drug administration to fever resolution (1 day vs. 2 days), and influenza vaccination (done, 41% vs. not done, 65%) were significantly different between the baloxavir and oseltamivir groups (p < 0.001). The number of patients with a fever duration of one day was 553 (99.6%) in the baloxavir group and 6 (1.1%) in the oseltamivir group (p < 0.001). Baloxavir use was only significantly associated with fever duration in the multivariate analysis (odds ratio 50,201, p < 0.001). Apparent adverse effects were not observed in the baloxavir-treated group. Conclusions: Baloxavir treatment resulted in a shorter fever duration than oseltamivir treatment in early childhood influenza.

Improving glucose control in patients with type 2 diabetes using retrospective continuous glucose monitoring.

The prevalence and cost of type 2 diabetes mellitus (T2DM) is rising. Diabetes care should be individualized based on patient risk factors and goals. Professional continuous glucose monitoring (CGM) is a tool for primary care providers to assist patients with diabetes management. Nurse practitioners at an outpatient primary care practice began using CGM in patients with T2DM in 2019 to guide treatment due to the high number of patients not reaching glucose targets. There was no policy in place to guide patient selection for CGM. This quality improvement (QI) project, conducted in an outpatient primary care clinic, evaluated the effect of retrospective CGM use in patients with T2DM through a retrospective chart review to create a policy for use. Hemoglobin A1c (HbA1c) measurements pre-CGM and post-CGM use were compared. CGM reports were evaluated for the presence of hypoglycemia. Additionally, number of times a patient used CGM between HbA1c laboratory examinations as well as insulin status were determined by reviewing the electronic health record. Patients using CGM for HbA1c higher than goal (n = 60) noted a 1.01% decrease in HbA1c (p < .01). The decrease was similar regardless of exogenous insulin status. Hypoglycemia was detected in 54.3% of patients (n = 44), including 45% (n = 27) of those with elevated HbA1c levels. Retrospective CGM is a cost-effective tool to individualize management of patients with T2DM in primary care. A policy was created to guide CGM use in patients not reaching glucose goals and those with concern for hypoglycemia.

Feasibility of a low-intensity intervention to improve antimicrobial use in outpatient settings

Background: Overall, ~12% of outpatient visits result in an antibiotic prescription, and 30% of those prescriptions are inappropriate. Behavioral nudges help influence practitioner behavior. We hypothesized that peer comparison combined with a behavioral nudge (a patient alert letter) would influence prescribers to reduce antibiotic prescriptions and improve antimicrobial stewardship in the outpatient setting. We pilot-tested this intervention in outpatient primary care clinics associated with a large Veterans Affairs (VA) medical center. Methods: We conducted a clustered randomized controlled trial of 12 community-based outpatient clinics. All practitioners in the intervention arm received quarterly comparative feedback reports and, when indicated, quarterly patient alert letters. Comparative feedback reports gave personalized feedback about antibiotic prescriptions for upper respiratory tract infections, comparing the recipient’s antibiotic prescriptions to the average for all practitioners at the primary care clinics included in our study. Patient alert letters notified practitioners to patients in their panel with recently detected Clostridioides difficile or resistant organism and their antibiotic exposures. We assessed outpatient visits during the preintervention period (April–September 2020), the intervention period (October 2020–September 2021), and the postintervention period (October 2021–September 2022). A mixed-effects logistic regression model predicting antibiotic prescriptions compared the arms across these periods. Results: The outpatient populations observed in the intervention and control arms were similar during each phase of the study. Prior to the intervention, the average proportion of visits with an antibiotic prescription was lower among clinics in the intervention arm (1.4% vs 1.8% in control arm; P = .45). This difference broadened slightly during the intervention period (1.4% vs 2.1%, respectively; P = .03) and the postintervention period (1.3% vs 2.1%, respectively; P = .01) (Fig. 1). Throughout the study, clinics in the intervention arm typically used more doxycycline and azithromycin and less amoxicillin-clavulanate and sulfamethoxazole-trimethoprim compared to clinics in the control arm. (Fig. 2). In the 6-month preintervention period, which coincided with the early phase of the COVID-19 pandemic, antibiotic prescriptions in the intervention compared to control clinics were similar. During the intervention and postintervention periods, the proportion of visits with an antibiotic prescription remained steady for clinics in the intervention arm and increased for those in the control arm. These results suggest that this pilot study using a low-intensity intervention consisting of comparative feedback reports and patient alert letters was successful in influencing the antibiotic prescribing behavior of primary care clinicians practicing in community-based outpatient clinics affiliated with a VA medical center.Financial support: This study was funded by Merck.Disclosures: None

Introducing a healthcare-assistive robot in primary care: a preliminary questionnaire survey.

A Healthcare-assistive Infection-control RObot (HIRO) is a healthcare-assistive robot that is deployed in an outpatient primary care clinic to sanitise the premises, monitor people in its proximity for their temperature and donning of masks, and usher them to service points. This study aimed to determine the acceptability, perceptions of safety, and concerns among the patients, visitors, and polyclinic healthcare workers (HCWs) regarding the HIRO. A cross-sectional questionnaire survey was conducted from March to April 2022 when the HIRO was at Tampines Polyclinic in eastern Singapore. A total of 170 multidisciplinary HCWs serve approximately 1,000 patients and visitors daily at this polyclinic. The sample size of 385 was computed using a proportion of 0.5, 5% precision, and 95% confidence interval. Research assistants administered an e-survey to gather demographic data and feedback from 300 patients/visitors and 85 HCWs on their perceptions of the HIRO using Likert scales. The participants watched a video on the HIRO's functionalities and were given the opportunity to directly interact with it. Descriptive statistics was performed and figures were presented in frequencies and percentages. The majority of the participants viewed the HIRO's functionalities favourably: sanitising (96.7%/91.2%); checking proper mask donning (97%/89.4%); temperature monitoring (97%/91.7%); ushering (91.7%/81.1%); perceived user friendliness (93%/88.3%), and improvement in the clinic experience (96%/94.2%). A minority of the participants perceived harm from the HIRO's liquid disinfectant (29.6%/31.5%) and that its voice-annotated instructions may be upsetting (14%/24.8%). Most of the participants accepted the HIRO's deployment at the polyclinic and perceived it to be safe. The HIRO used ultraviolet irradiation for sanitisation during after-clinic hours instead of disinfectants due to the perceived harm.