Specialist Outpatient Clinics Research Articles

A Next Available Appointment (NAA) Tool to Better Manage Patient Delay Risk and Patient Scheduling Expectations in Specialist Clinics.

Every year there are approximately 3 million new outpatient specialist clinic appointments at local hospital networks in Victoria, Australia. Growing daily demand for these services leads to high-volume waiting lists and therefore long appointment delays for patients. This phenomenon emphasises the importance of providing analytics and tools to assist with waiting list management in outpatient specialist clinics. In this paper, we developed a novel Next Available Appointment (NAA) tool, to assist clinicians to manage delayed-appointment risk and improve the patient experience by aligning the expected and actual day of the appointment. The NAA uses simulation to determine the earliest available week for a patient appointment on or after the timeframe requested by the clinician, considering the current waiting list and future planned clinician availability. It was validated using 3years of historical waiting list information across several scenarios chosen to capture operational diversity. As a practical example, a scenario chosen for implementation within the clinic's operational setting achieved a simulated reduction in overdue appointments from 41% to 25% (i.e., a reduction of 47,000 overdue appointments over 3years). We also provided early details on the implementation of the tool currently underway.

The patterns of presentation, management and outcomes of breast cancer patients at a tertiary health facility in Sierra Leone

BackgroundBreast cancer is the leading cause of cancer among women globally and the most common cancer among women in Sierra Leone. This study aimed to evaluate the patterns of clinical presentation, management and outcomes among breast cancer patients who presented at the Connaught Teaching Hospital Complex in Sierra Leone.MethodA retrospective, cross-sectional study was conducted at the specialist outpatient clinic at the Connaught Hospital. The medical records of 253 breast cancer patients were selected through convenience sampling on the basis of the completeness of their data from 2018 to 2021. The patients’ sociodemographics, obstetrics-gynecological history, clinicopathological characteristics, treatment modalities, and outcomes were analysed via SPSS version 24.ResultsAmong the 253 patients with breast cancer, 246 (97.2%) were female, and the mean age of the patients was 47 ± 14 years. The mean age at menarche was 12 ± 3 years, and 35 (13.8%) patients had a family history of breast cancer. The left breast of 130 (51.2%) patients was the most commonly affected; approximately 119 (47%) patients presented with stage III B disease, and 35 (13.8%) presented with metastasis. With respect to treatment modalities, surgery, chemotherapy, and hormonal therapy were provided to patients — with 120 (48%) mastectomies, 73 (29.2%) neoadjuvant chemotherapy, 84 (33.6%) adjuvant chemotherapy, 98 (39.2%) hormonal therapy, 35 (14.0%) palliative care and approximately 38 (15.2%) refused or did not initiate any treatment. Among the outcomes of breast cancer patients, 19 (32.8%) was the highest mortality rate in 2019, and 10 (27.8%) was the lowest in 2018.ConclusionOur study revealed that over half of our breast cancer patients presented with advanced-stage disease, and mastectomy was the most common modality of treatment. Further studies are needed to understand the factors responsible for their late presentation and improve histological services and access to radiotherapy facilities for our patients.

Association between serum urate levels and all-cause mortality, cardiovascular and renal outcomes among gout patients in Singapore

ObjectivesWe investigated the longitudinal association between Serum Urate (SU) level and Acute Myocardial Infarction (AMI), Stroke, End Stage Renal Failure (ESRF) and all-cause mortality.DesignWe conducted a retrospective hospital-based cohort study of individuals with gout managed in specialist outpatient clinics. Cox proportional hazards regression was used to estimate HR and 95% CI, with adjustments for potential confounders. Where the proportional hazard assumption was violated, stratified Cox regression was applied instead.SettingAn acute care tertiary hospital in Singapore.ParticipantsIndividuals with a first gout diagnosis between 2007–2017, identified through (i) primary discharge diagnosis, (ii) diagnosis from the Rheumatology SOC (iii) patient history of a clinical encounter at the Rheumatology SOC plus use of urate-lowering therapy/colchicine.Main outcome measuresAll-cause mortality, AMI, Stroke and ESRF ascertained through data linkage with the National Registry of Diseases Office.ResultsThe final cohort comprised 2,866 individuals. Post follow-up, there were 800 deaths and 362, 218 and 191 occurrences of AMI, ESRF and stroke respectively. Compared to the reference (second-lowest) SU quartile, being in the highest SU quartile was associated with a significantly increased hazard for mortality (HR:1.66, 95% CI:1.36–2.03), incident ESRF (HR:3.02, 95% CI:2.00-4.56), and increased hazard for incident AMI (HR:1.42, 95% CI:1.06–1.91). The p-trend for all 3 outcomes was significant. No significant association was found between SU quartile and hazard for incident stroke.ConclusionsThis study found that individuals with gout managed at SOC who had higher baseline SU levels had an increased hazard for all-cause mortality, ESRF, and AMI.Clinical trial numberNot applicable.

Lisdexamfetamine in the treatment of methamphetamine dependence: A randomised, placebo-controlled trial.

This study tested the efficacy and safety of a 12-week course of lisdexamfetamine in reducing methamphetamine use, an outcome which is associated with improvements in health and wellbeing, in people dependent on methamphetamine. This study was a randomised double-blind placebo-controlled trial conducted in six specialist outpatient clinics in Adelaide, Melbourne, Newcastle and Sydney, Australia (2018-2021). Participants were164 adults with methamphetamine dependence, reporting at least 14 use days out of the previous 28 days (62% male, 38% female, < 1% other; mean age 39 years). Participants were randomly allocated 1:1 to a 15-week regimen of lisdexamfetamine (1-week induction to 250 mg, 12-week maintenance regimen, 2-week reduction; n = 80) or matched placebo (n = 84), followed-up to Week 19. The primary efficacy measure was past 28-day methamphetamine use at Week 13. Safety was assessed by adverse event rates. Secondary measures included methamphetamine use during the 12-week treatment period and treatment satisfaction. Nine randomized participants did not start treatment (five were allocated to lisdexamfetamine and four allocated to placebo) and were excluded from the analyses. Fifty-seven per cent of participants were retained on study medication to primary end-point. There was only weak evidence of a lisdexamfetamine benefit at 13 weeks [adjusted difference in days of methamphetamine use = 2.2, 95% confidence interval (CI) = -0.5 to5.0; P = 0.49]. However, throughout the whole 12-week treatment maintenance phase, the lisdexamfetamine group had fewer days of methamphetamine use in total (difference = 8.8, 95% CI = 2.7-15.0; P = 0.005). The lisdexamfetamine group reported greater self-reported treatment effectiveness [odds ratio (OR) = 2.89, 95% CI = 1.67-5.02; P < 0.001] and treatment satisfaction (OR = 3.80, 95% CI = 1.93-7.47; P < 0.001). Adverse events with lisdexamfetamine included nausea. Serious adverse events occurred in four (5%) of participants who received lisdexamfetamine. Lisdexamfetamine appears to reduce methamphetamine use over a 12-week treatment period, although there is only weak evidence that reduced use is maintained during the last 4 weeks.

Study on the Application Effect of Walk-around Management Mode in Special Outpatient Clinics

Objective: To explore and analyze the application effect of the walking management mode in special outpatient clinics. Methods: Data on patient satisfaction, complaint volume, consultation efficiency, and nursing service workload before and after implementing the walking management mode in the hospital’s special outpatient clinics were compared. Results: After implementing the walking management mode, patient satisfaction and consultation efficiency were significantly improved, the average number of complaints per person was reduced, and the average number of daily services was increased. The differences were statistically significant. Conclusion: The use of the walking management mode in special outpatient clinic nursing work can improve the quality and efficiency of outpatient nursing, increase patient satisfaction by increasing the number of proactive services, and is worthy of promotion and application.

Excess costs of depression among a population-based older adults with chronic diseases in Singapore

BackgroundThere is limited evidence on the economic burden of depression among the older population in Singapore.ObjectiveWe aim to evaluate the impact of depression on healthcare expenditure and productivity loss among older adults with chronic diseases in Singapore.MethodsUsing the data from the Well-being of the Singapore Elderly study (WiSE), a 2011 national representative survey of older adults aged 60 years and above, 2510 respondents were included in this study. The sample comprised 44% male and 56% female respondents with 75% respondents aged between 60 and 74 years old. Healthcare utilisation data was obtained from respondents and healthcare cost was tabulated by multiplying each service unit by the unit cost price. These services include care from polyclinic doctors, private general practitioners (GP), outpatient specialists and inpatient care. We modelled the relationship of healthcare cost and depression using two-part models (probit & generalised linear model - loglink and gamma distribution).ResultsFor total healthcare expenditure, older adults with both depression and chronic diseases were associated with an average annual incremental cost of $7940 (95% CI 1490–14400; p = 0.016), compared to those without these conditions. They were also associated with an average incremental cost of $257 (95% CI 38.7–475; p = 0.021) for primary care. Likewise, in the case of specialist outpatient clinics, they had an average incremental cost of $970 (95% CI 163–1780; p = 0.018). However, for inpatient setting, the average incremental cost of $6180 (95% CI 418–12800; p = 0.066) was not significant. Additionally, older adults with depression and chronic diseases contribute to an annual productivity loss of $676 (95% CI 346–1010; p < 0.001).DiscussionThis study provides evidence that there are significant incremental costs associated with depression amongst the older adults with chronic diseases in Singapore’s primary healthcare setting. The increased somatic presentations among the depressed older adults and the underdiagnosis of depression in primary care may contribute to higher utilisation of healthcare resources which entail higher expenditure. This is one of the first studies to look at the cost of depression using a representative sample of Singaporean older adults and taking into account the multi-ethnic nature of the population. Analyses were restricted to a cross-sectional design, and data relied heavily on the accuracy of self-report utilisation on health care services which was subjected to recall bias.ConclusionDepression was found to inflate the total healthcare expenditure among older adults with chronic disease by two-fold. This study provides evidence that there are significant incremental costs associated with depression among the older adults with chronic diseases, demonstrating a need for more resources to improve systematic and clinical care for depressed older adults with chronic diseases.

Symptom Shifting From Nonsuicidal Self-Injury to Substance Use and Borderline Personality Pathology

A decline in nonsuicidal self-injury (NSSI) behavior is often viewed as an indication of mental health improvement when treating adolescents and young adults with borderline personality pathology. However, evidence shows that an initial decrease in NSSI behavior does not always signal recovery, and potential symptom shifting needs to be considered. To examine the codevelopment of NSSI and substance use in adolescents and young adults receiving treatment for NSSI behavior and to explore whether shifting from NSSI behavior to substance use is associated with emerging or persistent borderline personality pathology. This cohort study used data from the AtR!Sk study. The study included a consecutive sample of adolescents and young adults with NSSI behavior who presented to a specialized outpatient clinic for early intervention of borderline personality pathology. A baseline assessment (between May 3, 2016, and December 19, 2019) and 2 annual follow-up assessments were conducted. Data were analyzed from April 15, 2023, to September 5, 2024. The frequencies of NSSI behavior and substance use were self-reported. Diagnostic interviews were carried out to assess borderline personality pathology. Growth mixture models were specified to identify latent classes with different joint trajectories of NSSI behavior and substance use, and the classes were compared for the number of fulfilled borderline personality disorder (BPD) diagnostic criteria. Overall, 277 adolescents and young adults (249 [89.9%] female; mean [SD] age at baseline, 14.9 [1.5] years) were included in the study (number at first follow-up, 135; number at second follow-up, 82). Three latent classes were extracted from the data. A decline in NSSI behavior following treatment was common. Class 1 (estimated class count: 32.5; 11.7% of participants) was further characterized by a decline in substance use; class 2 (210.1; 75.9% of participants), by a moderate increase in substance use; and class 3 (34.4; 12.4% of participants), by a strong increase in substance use. The number of fulfilled BPD diagnostic criteria in class 1 (mean [SE], 4.64 [0.40]; comparison: χ2, 11.64; P < .001) and class 3 (mean [SE], 4.29 [0.41]; comparison: χ2, 5.98; P = .01) was greater than that in class 2 (mean [SE], 3.18 [0.15]) at baseline. The number of fulfilled BPD criteria remained high at the second follow-up assessment in class 3 (mean [SE], 5.15 [0.84]) but not in class 1 (mean [SE], 2.05 [0.54]). In this cohort study of adolescent patients with NSSI behavior, a decline in this behavior was commonly paired with an increase in substance use. This finding suggests that a decrease in NSSI behavior alone may be insufficient to indicate treatment success. Monitoring the joint trajectories of NSSI behavior and substance use may be a promising avenue toward early detection and targeted treatment of adolescent borderline personality pathology.

Right-Siting Care and Decongesting Specialist Outpatient Clinics - A Singapore Case Study

Abstract Issue Globally, Specialist Outpatient Clinics (SOCs) face a growing burden due to rising chronic diseases. This strain on resources leads to long appointment wait times (LAWTs), delaying diagnoses and treatments. This is particularly of concern in countries with rapidly ageing populations such as Singapore. Description The Right-Site Care Program is a healthcare transformation initiative implemented by individual healthcare clusters within Singapore to improve access to timely SOC care by directing patients to the most appropriate care level (right-siting). This transitions stable chronic disease patients to primary care providers (PCPs) for ongoing management. A standardised approach utilises evidence-based guidelines for patient selection, followed by identification and transfer of suitable patients to PCPs. This multi-center program offers a real-world example of healthcare system optimisation for chronic disease management. Results A multi-source data analysis, including program reports and peer-reviewed studies from participating healthcare clusters, was conducted to evaluate program impact. The analysis focused on LAWTs, patient outcomes and implementation challenges. Right-siting yielded mixed results across various conditions. Right-sited patients had better survival rates, likely due to closer monitoring and management of chronic conditions with higher total outpatient attendance frequencies. (1) Improvements were particularly significant for diabetes mellitus patients who successfully transitioned to PCPs. (2) However, challenges such as patient scepticism about PCP competence and a preference for specialist care have been identified. (3) Lessons learned Right-siting care can improve patient outcomes for certain chronic diseases. The program’s impact varied across different chronic diseases, highlighting the need for tailored strategies. Educational interventions addressing patient concerns can facilitate smoother patient transitions and program success. Key messages • Right-siting care shows promise, with improved patient outcomes for conditions like diabetes mellitus. • Patient education is crucial to overcome patient scepticism and preference for specialists.

Visit-to-visit HbA1c variability and risk of potentially avoidable hospitalisations in adults with type 2 diabetes receiving outpatient care at a tertiary hospital.

This study aims to investigate the relationship between long-term visit-to-visit within-person HbA1c variability and hospitalisation outcomes in adults with type 2 diabetes (T2D). We conducted a cohort study at a tertiary hospital in Singapore involving people aged 21 to 101 years with T2D who had ≥3 HbA1c tests over 2 years. HbA1c variability was assessed using coefficient of variation (CV), variability independent of the mean (VIM) and HbA1c variability score (HVS). A 1-year follow-up was performed after the last HbA1c measurement to identify all-cause and potentially avoidable hospitalisations (PAH), categorised as overall, acute, chronic and diabetes composites. The study included 14 923 patients (mean age: 62.9 ± 12.9 years; 55% male). The median HbA1c variability was 8.6% CV (IQR: 5.1-14.3). Higher quartiles of HbA1c variability were associated with greater risks of PAH and all-cause hospitalisations, independent of glycaemic control. Compared to Q1, for example, the risk ratios and 95% confidence intervals for diabetes-related PAH based on HbA1c CV were as follows: Q2, 1.32 (0.93-1.88); Q3, 1.65 (1.18-2.31) and Q4, 2.16 (1.54-3.03). For all-cause hospitalisations, they were as follows: Q2, 0.97 (0.90-1.05); Q3, 1.08 (1.00-1.17) and Q4, 1.16 (1.07-1.26). When stratified by glycaemic control, elevated risk of PAH persisted even in those with optimal glycaemic control. Consistent findings were observed using HbA1c VIM and HVS measures. In individuals receiving care at specialist outpatient clinics of a tertiary hospital, HbA1c variability is associated with a higher risk of PAH. Comprehensive diabetes management strategies addressing both glycaemic control and variability may offer benefits.

Self-management behavior preferences and influencing factors in Chinese patients with recurrent gout: A qualitative study

ObjectivesThis study aimed to explore the preferences and influencing factors of self-management behaviors in patients with recurrent gout and provide a theoretical basis for developing targeted strategies to improve self-management preferences. MethodsA total of 10 patients with recurrent gout were recruited from the gout specialist outpatient clinic at a tertiary hospital in Shenyang, Liaoning Province, China. Semi-structured interviews were conducted with these patients, and the Kawakita Jiro (KJ) method was used to analyze the interview data. ResultsAfter four rounds of screening by five researchers, 35 codes were selected from an initial 132. After three rounds of discussion and induction, the KJ method identified seven domains of self-management behavior preferences in patients with recurrent gout: 1) extensive knowledge of gout, yet difficulty in distinguishing between accurate and inaccurate information; 2) a passive attitude of “no pain, no management”; 3) the challenge of changing entrenched daily habits; 4) the optimistic but unrealistic belief of “self-delusion”; 5) a tendency to seek medical attention late due to hopelessness of cure and familiarity with recurrences; 6) preference for analgesics for gout recurrences while neglecting long-term urate-lowering therapy (ULT); and 7) gout-related stigma. ConclusionThe results of this study showed that the self-management behavior of patients with recurrent gout could be improved, especially in the aspects of medical seeking behavior, medication compliance, daily management and emotional management. At the same time, we found that gout stigma, difficulty in distinguishing true and false knowledge of gout and negative attitude of “ignoring pain” were significantly associated with self-management behavior.

Objective Determination of Site-of-Lesion in Auditory Neuropathy.

Auditory neuropathy (AN), a complex hearing disorder, presents challenges in diagnosis and management due to limitations of current diagnostic assessment. This study aims to determine whether diffusion-weighted magnetic resonance imaging (MRI) can be used to identify the site and severity of lesions in individuals with AN. This case-control study included 10 individuals with AN of different etiologies, 7 individuals with neurofibromatosis type 1 (NF1), 5 individuals with cochlear hearing loss, and 37 control participants. Participants were recruited through the University of Melbourne's Neuroaudiology Clinic and the Murdoch Children's Research Institute specialist outpatient clinics. Diffusion-weighted MRI data were collected for all participants and the auditory pathways were evaluated using the fixel-based analysis metric of apparent fiber density. Data on each participant's auditory function were also collected including hearing thresholds, otoacoustic emissions, auditory evoked potentials, and speech-in-noise perceptual ability. Analysis of diffusion-weighted MRI showed abnormal white matter fiber density in distinct locations within the auditory system depending on etiology. Compared with controls, individuals with AN due to perinatal oxygen deprivation showed no white matter abnormalities ( p > 0.05), those with a neurodegenerative conditions known/predicted to cause VIII cranial nerve axonopathy showed significantly lower white matter fiber density in the vestibulocochlear nerve ( p < 0.001), while participants with NF1 showed lower white matter fiber density in the auditory brainstem tracts ( p = 0.003). In addition, auditory behavioral measures of speech perception in noise and gap detection were correlated with fiber density results of the VIII nerve. Diffusion-weighted MRI reveals different patterns of anatomical abnormality within the auditory system depending on etiology. This technique has the potential to guide management recommendations for individuals with peripheral and central auditory pathway abnormality.

Two thirds of patients may not need routine 12-month specialist review in an epilepsy clinic: A cross-sectional study of clinic appointments

ObjectivesTimely access to specialist outpatient clinics can be difficult to achieve as outpatient services are often oversubscribed leading to unacceptable wait times. New patients, or those with emergent issues may wait for appointments whilst existing patients are booked in for routine reviews “just in case” there is a problem, using considerable clinic resources. We investigated routine 12-month review appointments to assess whether these appointments changed patient management. MethodsThe medical records of 100 randomly selected adult patients attending annual review appointments over 12 months at a publicly-funded specialist outpatient epilepsy clinic in Melbourne, Australia were audited. Demographic and clinical data as well as information about the content of each appointment were analysed to determine whether the appointment resulted in changes to epilepsy management (eg medication change), administrative actions (eg drivers license approval) or the provision of information or education. Logistic regression was performed to assess what clinical factors were associated with changes in patient care arising from the 12-month review appointment. ResultsAlmost half (47%) of appointments resulted in no change to patient care and 37% had only administrative outcomes, such as the completion of a regulatory driving report. Only 16% of appointments resulted in a change in medical management. The only factor that independently predicted a change in medical management was the occurrence of a seizure in the previous year. The only factor independently associated with not having any change in medical management or administrative action was having an unknown seizure type. Conclusions/ significanceOnly a small number of patients experience a change in medical management when attending a 12-month epilepsy clinic appointment, with a need for management change associated with the presence of ongoing seizure. Outpatient services should limit the use of routine annual follow up to those patients most likely to need intervention or support, creating “just in time” capacity for timely access to review as issues arise.

Patient experience and satisfaction with shared decision-making: A cross-sectional study among outpatients

ObjectivesThis study aimed to investigate how doctor-patient communication, trust in doctors impacted patients’ experience and satisfaction in shared decision-making (SDM). MethodsThis study is based on the data from a cross-sectional survey (n = 12,401) conducted in 27 public specialist outpatient clinics in Hong Kong. ResultsThe multivariable regression models revealed that doctors’ better communication skills were associated with lower decision-making involvement (odd ratio, 0.75 [95 % CI, 0.88–0.94], P < .001) but higher satisfaction with involvement (odd ratio, 6.88 [95 % CI, 5.99–7.93], P < .001). Similarly, longer consultation durations were associated with reduced involvement in decision-making (odd ratio, 0.71 [95 % CI, 0.66–0.73], P < .001) but increased satisfaction with involvement (odd ratio, 1.91 [95 % CI, 1.80–2.04], P < .001). Trust in doctors significantly mediated these associations, except for the association between consultation duration and patients’ satisfaction with decision-making involvement. ConclusionDoctors’ better communication skills and longer consultations might not necessarily increase patient involvement in SDM but correlated with increased satisfaction with involvement. Trust in doctors emerged as a mediator for participation and satisfaction in decision-making. Practice implicationsClinics should consider patients’ preferences and capabilities when tailoring communication strategies about decision-making and optimizing patient satisfaction.

Comparison of the Quality of Discharge Letters Written by Large Language Models and Junior Clinicians: Single-Blinded Study.

Discharge letters are a critical component in the continuity of care between specialists and primary care providers. However, these letters are time-consuming to write, underprioritized in comparison to direct clinical care, and are often tasked to junior doctors. Prior studies assessing the quality of discharge summaries written for inpatient hospital admissions show inadequacies in many domains. Large language models such as GPT have the ability to summarize large volumes of unstructured free text such as electronic medical records and have the potential to automate such tasks, providing time savings and consistency in quality. The aim of this study was to assess the performance of GPT-4 in generating discharge letters written from urology specialist outpatient clinics to primary care providers and to compare their quality against letters written by junior clinicians. Fictional electronic records were written by physicians simulating 5 common urology outpatient cases with long-term follow-up. Records comprised simulated consultation notes, referral letters and replies, and relevant discharge summaries from inpatient admissions. GPT-4 was tasked to write discharge letters for these cases with a specified target audience of primary care providers who would be continuing the patient's care. Prompts were written for safety, content, and style. Concurrently, junior clinicians were provided with the same case records and instructional prompts. GPT-4 output was assessed for instances of hallucination. A blinded panel of primary care physicians then evaluated the letters using a standardized questionnaire tool. GPT-4 outperformed human counterparts in information provision (mean 4.32, SD 0.95 vs 3.70, SD 1.27; P=.03) and had no instances of hallucination. There were no statistically significant differences in the mean clarity (4.16, SD 0.95 vs 3.68, SD 1.24; P=.12), collegiality (4.36, SD 1.00 vs 3.84, SD 1.22; P=.05), conciseness (3.60, SD 1.12 vs 3.64, SD 1.27; P=.71), follow-up recommendations (4.16, SD 1.03 vs 3.72, SD 1.13; P=.08), and overall satisfaction (3.96, SD 1.14 vs 3.62, SD 1.34; P=.36) between the letters generated by GPT-4 and humans, respectively. Discharge letters written by GPT-4 had equivalent quality to those written by junior clinicians, without any hallucinations. This study provides a proof of concept that large language models can be useful and safe tools in clinical documentation.

Overlap of obsessive compulsive and psychosis risk symptoms in a specialized clinic.

Psychotic disorders and obsessive-compulsive disorder (OCD) commonly co-occur. Likewise, subthreshold psychosis symptoms (clinical high risk for psychosis; CHR) and obsessive compulsive symptoms (OCS) often overlap and may be difficult to differentiate. This study aimed to replicate research investigating the prevalence of OCD in a CHR clinic sample, validate and investigate factor structure of a self-report OCS measure in a CHR sample, explore how OCS may relate to CHR and co-occurring symptoms, and investigate whether real-world CHR treatment improves OCS and CHR symptoms. This study analysed archival clinical data from baseline and 6-month follow-up assessments collected by a specialist outpatient CHR clinic. Data included assessments of CHR symptoms, OCS, and clinician-rated diagnosis. Exploratory factor analysis examined the OCS measure. Within this CHR clinic sample, 13.5% experienced co-morbid OCD. The self-report OCS measure had two factors: (1) checking and counting behaviours and (2) intrusive thoughts and images of harm/guilt. The checking and counting factor correlated with depression and social anxiety. The intrusive thoughts and images of harm/guilt factor significantly correlated with unusual thought content and social anxiety. Between baseline to 6-month follow-up, clients exhibited CHR symptom improvement regardless of OCD diagnosis. However, OCS did not change. These findings support validity of a self-report OCS measure in a CHR clinic sample and that types of OCS experiences may exhibit different clinical patterns. Additionally, it appears that individuals with comorbid OCD responded similarly to CHR treatment compared to those without OCD.

Inappropriate Emergency Department Visits: Insights on Incidence, Associated, and Predictive Factors From 5,429 Visits.

Inappropriate visits (IVs) and overcrowded emergency departments (EDs) can result in many complications for patients and medical staff. This study aimed to assess the incidence, associated factors, and predictive factors of IVs to ED. This retrospective cohort single-center study was conducted in the ED of King Abdulaziz Medical City, Jeddah, Saudi Arabia. All ED visits in February 2023 were included. They were considered appropriate if the patient required investigation tests, underwent a procedure, was admitted to an inpatient ward, was admitted to the short-stay unit, was referred for follow-up at a specialist outpatient clinic after discharge from the ED, or was referred to the ED of another hospital. Failure to have at least one of these factors led to the visit being considered inappropriate. A total of 5,429 visits were included. The incidence rate of IVs was 1128 (20.7%). Of the visits, 1,028 (18.9%) were attended by patients aged <10 years, and 2,825 (52.0%) by female patients. The most reported complaints were pulmonological in 1,029 visits (18.9%). Patients with appropriate visits (AVs) had significantly higher median BMI scores than those with IVs (25.9 (20 - 3) vs. 23.7 (16.36 - 29), P= <0.0001). Visits with pulmonological (447 (39.6%) vs. 582 (13.5%)) and otorhinolaryngologic (54 (4.7%) vs. 94 (2.1%)) complaints were significantly more likely to be inappropriate (P= <0.0001). In multiple logistic regression, being a male (OR: 1.3, CI: 1.1 - 1.5, P= <0.0001), being non-Saudi (OR: 2.7, CI: 2.0 - 3.6, P= <0.0001), and visiting on the weekend (OR: 1.1, CI:1.0 - 1.3, P= 0.0366) were significantly predictive of the visits being inappropriate. Our findings revealed a high incidence of IVs in the ED, with several factors predictive of IVs. Highlighting these factors can help minimize the incidence of IVs and, therefore, improve the quality of healthcare delivered to patients in need and their clinical outcomes.

QUALITY OF LIFE OF PATIENTS AFTER SURGICAL INTERVENTION AT THE CLINIC FOR EYE DISEASES TUZLA

Visual impairment negatively affects the quality of life of people and it is an important parameter of the outcome of treatment of patients diagnosed with cataracts, glaucoma, strabismus or injuries. The goal of the research was to assess the psychological aspects of the quality of life of patients with the above-mentioned diagnoses.The research included 99 patients of both sexes, who, after surgery at the Clinic for Eye Diseases Tuzla, were monitored on an outpatient basis in the Clinic's Specialist Outpatient Clinic. For the purposes of the research, the Vision Questionnaire (NEI VFQ-25), version 2000, was used.The age of the respondents ranged from 5 to 78 years. The majority of respondents were men 50 (50.50%). The average chronological age of male respondents is 47.50±21.56 years, and female respondents 50.12±20.85. In the total sample, 45.5% of respondents have cataracts, 29.3% glaucoma, 11.1% strabismus and 14.1% have an eye injury. Of these 99 respondents, 47.5% consider their health to be average, 44.4% consider it to be above average, while 8.1% of respondents consider it to be below average. A higher percentage of male respondents have glaucoma (38%) and injuries/trauma (20%) compared to female respondents. A higher percentage of female respondents (55.1%) state that their quality of life is above average, while the percentage of male respondents is 34%. The quality of life is average for 56% of male respondents and 38.8% of female respondents. The results of the chi-square test showed that there is no statistically significant difference in relation to the gender and quality of life of the respondents (χ2= 4.48; df= 2; p= 0.106). The results of the univariate analysis of variance in relation to the cause of visual impairment, and the vision problems experienced by the subjects showed that there is a statistically significant difference between the subjects in relation to the cause of visual impairment. In relation to the overall results of vision problems, it may be concluded that subjects with cataracts and glaucoma at the statistical significance level of 0.05 state that they have more vision problems compared to subjects with strabismus and injury. Subjects with cataracts at the significance level of 0.05 state that they have more vision problems compared to subjects with glaucoma.Although the self-assessment of the psychological and spiritual components of the quality of life of the subjects gave satisfactory results, it is necessary to provide specific support in order to prevent and eliminate negative reactions to the postoperative condition of operated patients. Keywords: quality of life (QoL), NEI VFQ-25 questionnaire, visual impairment.

Do video or telephone consultations impact attendance rates in an addiction medicine specialist outpatient clinic?

Effective alcohol and other drugs (AODs) treatment has been proven to increase productivity and reduce costs to the community. Telehealth has previously been proven effective at delivering AOD treatment in the right settings. Yet, Australia's current Medicare funding restricts telephone consultations. We hypothesise that treatment modality influences attendance rates. Specifically, telephone consultations can remove barriers to accessing treatment and, therefore, can increase attendance. We conducted a retrospective audit on our addiction medicine specialist outpatient service from 1 July 2022 to 30 June 2023. A mixed-effects logistic regression model was used to analyse factors associated with attendance rates. There were 576 participants in the study, and 3354 appointments were booked over the 12-month study period. Of these, 2695 were face-to-face, 541 were telephone and 118 were video. The unadjusted raw attendance rate was highest in the telephone group (87.24%), followed by face-to-face (73.02%) and video (44.92%). After adjusting for covariates, telephone consultation was associated with significantly increased odds of attending compared to face-to-face (odds ratio (OR) = 2.60, 95% confidence interval (CI) = 1.90-3.54, P < 0.001). Video consultation was associated with a 69% reduction in the odds of attending compared to face-to-face (OR = 0.31, 95% CI = 0.019-0.49, P < 0.001). While physical attendance may be required for specific clinical care, telephone consultations are associated with increased attendance and can form an important adjunct to delivering addiction treatment. Given the substantial costs of substance use disorders, this could inform government policies and funding priorities to further improve access and treatment outcomes.

The evaluation of a stepped care approach for early intervention of borderline personality disorder

BackgroundThe current study evaluated the stepped care approach applied in AtR!Sk; a specialized outpatient clinic for adolescents with BPD features that offers a brief psychotherapeutic intervention (Cutting Down Program; CDP) to all patients, followed by a more intensive Dialectical Behavioral Therapy for Adolescents (DBT-A) for those whose symptoms persist.MethodsThe sample consisted of 127 patients recruited from two AtR!Sk clinics. The number of BPD criteria, psychosocial functioning, severity of overall psychopathology, number of days with non-suicidal self-injury (NSSI; past month), and the number of suicide attempts (last 3 months) were assessed at clinic entry (T0), after CDP (T1), and at 1- and 2-year follow-up (T2, T3). Based on the T1 assessment (decision criteria for DBT-A: ≥ 3 BPD criteria & ZAN-BPD ≥ 6), participants were allocated into three groups; CDP only (n = 74), CDP + DBT-A (eligible and accepted; n = 36), CDP no DBT-A (eligible, but declined; n = 17).ResultsCDP only showed significantly fewer BPD criteria (T2: β = 3.42, p < 0.001; T3: β = 1.97, p = 0.008), higher levels of psychosocial functioning (T2: β = -1.23, p < 0.001; T3: β = -1.66, p < 0.001), and lower severity of overall psychopathology (T2: β = 1.47, p < 0.001; T3: β = 1.43, p = 0.002) over two years compared with CDP no DBT-A, while no group differences were found with regard to NSSI and suicide attempts. There were no group differences between CDP + DBT-A and CDP no DBT-A, neither at T2 nor at T3.DiscussionThe findings support the decision criterion for the offer of a more intense therapy after CDP. However, there was no evidence for the efficacy of additional DBT-A, which might be explained by insufficient statistical power in the current analysis.

Rapid Access From Primary Care to a Multidisciplinary Clinic at Tertiary Care Improves Clinical Outcomes for Patients With Diabetic Foot Ulcers: Results From Diabetic Foot in Primary and Tertiary (DEFINITE) Care's Lower Extremity Amputation Prevention Program (LEAPP) Clinic.

Diabetic Foot in Primary and Tertiary (DEFINITE) Care is an inter-institutional, multidisciplinary team (MDT) program for patients with diabetic foot ulcers (DFU) within a healthcare cluster in Singapore. This is one of our subgroup analyses within DEFINITE Care, assessing clinical outcomes of lower extremity amputation prevention program (LEAPP), a multidisciplinary diabetic foot clinic, and non-LEAPP patients within the program. From June 2020 to June 2022, 2798 patients within the DEFINITE cohort completed a minimum of 12-month follow up. Of these patients, 20.6% were managed by LEAPP, whereas 79.4% were non-LEAPP patients. Patients in the LEAPP cohort were older with co-existing metabolic conditions and complications of diabetes. Using non-LEAPP cohort as the reference group and after adjusting for age, gender, ethnicity, comorbidities, and medications, there was a significantly lower risk of death (odds ratio [OR] 0.60, P = .001) and composite major lower extremity amputation (LEA) or death (OR 0.66, P = .002) among LEAPP patients at 1 year with longer mean days from enrollment to minor LEA, major LEA, and death. The adjusted 1-year healthcare utilization outcomes for LEAPP patients demonstrated an increase in inpatient admissions, primary care polyclinic visits, hospital specialist outpatient clinic (SOC) visits and elective day surgery procedures. Despite the increased in inpatients admissions, cumulative hospital length of stay in LEAPP patients were lower. This subgroup analysis has demonstrated that the MDT approach to caring for patients with DFU in tertiary centers not only improves mortality by 40%, but also delayed the incidence of minor LEA, major LEA, and death.