Patient Contact Research Articles

Assessing Adherence to Acute Stroke Therapy Guidelines: An Audit Study

Abstract Background The 2023 National Clinical Guidelines for stroke for the UK and Ireland recommended that people with motor recovery goals post stroke should receive at least 3 hours (180 minutes) of rehabilitation per day on at least 5 out of 7 days a week. This is a significant change to previous guidelines that recommended that patients receive at least 45 minutes of each therapy for a minimum of 5 days (NICE 2013). In 2022, the UK Sentinel Stroke National Audit Programme found that only 11.9% received more than 45 minutes of physiotherapy. This highlights that many services were not achieving previous recommendations. Methods In an Irish hospital, two new stroke assistant posts were funded with the aim to maximise therapy time. An audit was performed on compliance with the 2023 national guidelines on an acute stroke unit in august 2023 for patients that were identified as having motor goals post stroke. Data was collected in the form of minutes of direct patient contact time by each therapy –physiotherapy, occupational therapy, speech and language therapy and therapy assistants. This data was compared against recommended therapy time and presented as a percentage of this. Results 9 acute stroke patients who were identified as having motor goals were randomly selected. It was found that none of these patients were meeting current therapy guidelines. When compared to the recommendations, the average amount of therapy that patients received per day ranged from 44 minutes – 132 minutes. On average, patients received 49.1% of recommended therapy. It was also found that therapy assistants were providing, on average, 59.3% of the actual therapy received. Conclusion Stroke patients are not receiving the recommended amount of therapy as per the most recent guidelines. Although the addition of stroke assistants significantly increased therapy time, guidelines were still not achieved.

The impact of the COVID-19 pandemic on antibiotic prescription rates in out-of-hours primary care – a register-based study in Denmark

Background Antibiotic prescription rates can be affected by pandemic measures such as lockdowns, social distancing, and remote consultations in general practice. Therefore, such emergency states may negatively affect antimicrobial stewardship, specifically in out-of-hours (OOH) primary care. As contact patterns changed in the COVID-19 pandemic, it would be relevant to explore the impact on antimicrobial stewardship. Aim To study the impact of the pandemic on antibiotic prescription rates in OOH primary care, overall and per age group. Methods This cross-sectional register-based study used routine data from OOH primary care in the Central Denmark Region. We included all patient contacts in two equivalent time periods: pre-pandemic and pandemic period. The main outcome measure was defined as the number of antibiotic prescriptions per contact (antibiotic prescription rate). Results The overall antibiotic prescription rate decreased during the first year of the pandemic compared to the pre-pandemic period (RR = 0.97, 95%CI: 0.96–0.98). Likewise, the rate decreased for clinic consultations (RR = 0.63, 95%CI: 0.62–0.64). However, an increase was seen for telephone consultations (RR = 1.73, 95%CI: 1.70–1.76). The decline in clinic consultations was largest for consultations involving children aged 0–10 years (RR = 0.53, 95%CI: 0.51–0.56). Conclusion Antibiotic prescription rates in Danish OOH primary care decreased during the first year of the COVID-19 pandemic, especially for young children. Prescription rates decreased in clinic consultations, whereas the rates increased in telephone consultations. Further research should explore if antibiotic prescription rates have returned to pre-pandemic levels, and if the introduction of video consultations has affected antibiotic prescription patterns in OOH primary care.

Leaving the profession as a medical assistant: a qualitative study exploring the process, reasons and potential preventive measures

BackgroundWorldwide growing shortages among health care staff are observed. This also holds true for medical assistants in Germany. Medical assistants mainly work in outpatient care and are the first point of contact for patients while performing clinical and administrative tasks. We sought to explore profession turnover among medical assistants, that is, in terms of the underlying decision-making process, the reasons for leaving the medical assistant profession and potential retention measures from the perspective of former medical assistants.MethodsFor this qualitative study, we conducted semi-structured telephone interviews with 20 former medical assistants between August and November 2023. Eligible for participation were medical assistants who (i) were of legal age, (ii) completed medical assistant vocational training and ii) were formerly employed as a medical assistant, but currently employed in another profession. The interviews were recorded, transcribed verbatim and content-analyzed.ResultsFormer medical assistants expressed various, often interrelated reasons for leaving the profession. These were changes in priorities throughout their career (e.g., in terms of working hours and salary), a constant high workload, barriers to further training, poor career prospects, and poor interpersonal relationships particularly with supervisors, but also within the team and with patients as well as the perception of insufficient recognition by politics and society. Suggestions of former medical assistants to motivate medical assistants to stay in their profession included amongst others higher salaries, more flexible work structures, improved career prospects, and more recognition from supervisors, patients, and society.ConclusionOur study provides insights into the complex decision-making process underlying ultimate medical assistant profession turnover. In light of an already existing shortage of medical assistants, we suggest to further explore how the suggested interventions that aim at retention of working medical assistants can be implemented.

Abstract A091: Beliefs and behaviors regarding non-cigarette tobacco use cessation care differ between providers at substance use treatment centers and community health centers serving rural and/or medically underserved areas of Texas

Abstract Purpose: Cancer mortality rates are higher in rural versus urban areas of the US, partly due to elevated tobacco use (including non-cigarette tobacco products (NCTPs); e.g., dip, snuff, vapes). Clinical practice guidelines call for tobacco use screening and brief intervention at every patient contact. Limited literature examines actual practices with respect to NCTP use in healthcare centers in rural and/or medically underserved areas (MUAs). This study examines if providers at substance use treatment centers (SUTCs) and community health centers (CHCs; e.g., Federally Qualified Health Centers) in such areas of Texas view NCTP cessation counseling as an important part of their job and if they use the 5As (Ask, Advise, Assess, Assist, Arrange) and motivational interventions to address their patients’ NCTP use. Methods: Providers from 21 healthcare centers (12 SUTCs, 9 CHCs) that had been solicited to later receive resources to improve their tobacco cessation care responded to face-valid survey items about their tobacco use screening and intervention delivery over the last month, along with their view on whether NCTP cessation counseling is an important part of their job. In total, 347 providers from SUTCs (n=174) and CHCs (n=173) serving 126 of Texas’ 254 counties responded. Linear mixed models and generalized linear mixed models were used to assess the differences between SUTCs and CHCs for continuous and binary variables, respectively. Results: Only 52% of providers agreed that NCTP cessation counseling is an important part of their job, with a significantly greater percentage (p=0.0023) agreeing at CHCs (63%) than at SUTCs (40%). Providers Asked 62% of their patients whether they used NCTPs. Of patients who endorsed use (20%), providers Advised 58% to quit and Assessed 53% about their interest in quitting. However, providers only Assisted 34% of use-endorsing patients in making a quit attempt and only Arranged follow-up for 23% of them. A significantly greater percentage (p=0.0025) of those patients were Advised to quit at CHCs (72%) than at SUTCs (44%). Providers delivered brief motivational interventions to 74% of patients who were not ready to quit, with significantly greater percentages advising patients to consider quitting in the future (p=0.0365) and telling patients they would revisit the topic at the next visit (p=0.0264) at CHCs (63% and 37%, respectively) than at SUTCs (45% and 24%, respectively). However, providers encouraged only 39% of use-endorsing patients to stop NCTP use completely, with a significantly greater percentage (p=0.0010) doing so at CHCs (50%) than at SUTCs (28%). Conclusion: Providers surveyed at healthcare centers in rural and/or MUAs of Texas were more likely to deliver evidence-based NCTP cessation care at CHCs than at SUTCs. Patients at both CHCs and SUTCs would benefit from their providers placing greater value on NCTP cessation care and more consistently delivering such care per guidelines. These data will inform healthcare centers’ implementation of best practices in treating their patients’ NCTP use. Citation Format: Brian J. Carter, Maggie Britton, Tzuan A. Chen, Isabel Martinez Leal, Ammar D. Siddiqi, Teresa Williams, Kathleen Casey, Hector Sanchez, Sriya Kakarla, Lorraine R. Reitzel. Beliefs and behaviors regarding non-cigarette tobacco use cessation care differ between providers at substance use treatment centers and community health centers serving rural and/or medically underserved areas of Texas [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A091.

Abstract A095: Differences in providers’ perceived preparedness and actual delivery of screening and intervention practices for patients who smoke cigarettes between two types of healthcare centers serving rural and/or medically underserved areas of Texas

Abstract Introduction: Rural populations in the US bear a disproportionate burden of cancer mortality. This is partly due to their elevated tobacco use rates. Best practice guidelines promote tobacco use screening and brief intervention at every patient contact; however, limited literature evaluates compliance in healthcare centers in rural and/or medically underserved areas (MUAs). Here, we examine providers’ use of the 5As (Ask, Advise, Assess, Assist, Arrange) and motivational interventions (for those not ready to quit; e.g., 5Rs: Relevance, Risks, Rewards, Roadblocks, Repetition) with their patients in substance use treatment centers (SUTCs) and medical healthcare centers (MHCs; e.g., Federally Qualified Health Centers) located in rural and/or MUAs in Texas to identify screening and intervention gaps. Methods: Providers from participating healthcare centers (12 SUTCs, 9 MHCs) responded to a solicitation assessing interest in (later) receiving tobacco use intervention training and resources. In total, 347 providers from SUTCs (n=174) and MHCs (n=173) serving 126 counties responded to an anonymized survey about their smoking screening and intervention delivery over the last month, along with their rating of how prepared they thought their healthcare center’s provider workforce was to help patients stop using tobacco (completely or somewhat prepared vs neutral, somewhat unprepared, or not at all prepared). Linear mixed models and generalized linear mixed models were used to assess the differences between SUTCs and MHCs for continuous and binary variables, respectively. Results: Overall, providers Asked 68.31% of their last-month patients whether they smoked cigarettes. Of patients who endorsed smoking (23.94%), providers Advised 58.68% to quit and Assessed 51.90% about their interest in quitting. However, providers only Assisted 35.87% of patients who endorsed smoking in making a quit attempt and 22.79% in Arranging a follow-up. A significantly greater percentage of patients were Asked (p=.0226) and Advised (p=.0025) to quit at MHCs (Ask=77.21%, Advise=72.35%) than at SUTCs (Ask=59.57%, Advise=45.34%). Providers delivered brief motivational interventions to 70.16% of patients who were not ready to quit smoking, with no significant differences between SUTCs and MHCs. Finally, 56.07% of providers at MHCs reported their workforce was prepared to help their patients quit tobacco, significantly greater than the 40.80% reported at SUTCs (p=.0268). Conclusion: Patients at MHCs were more likely to receive comprehensive tobacco cessation care than those at SUTCs in this sample of healthcare centers serving rural and/or MUAs in Texas. However, providers at both types of healthcare centers would benefit from greater workforce preparation to enable the provision of consistent tobacco use screening and brief intervention delivery in line with best practice guidelines. Future work will use these data for intervention and implementation strategy planning to improve centers’ capacity to comprehensively address their patients’ tobacco use. Citation Format: Ammar D. Siddiqi, Maggie Britton, Tzuan A. Chen, Isabel Martinez Leal, Brian J. Carter, Teresa Williams, Kathleen Casey, Kim Skeene, Hector Sanchez, Sriya Kakarla, Lorraine R. Reitzel. Differences in providers’ perceived preparedness and actual delivery of screening and intervention practices for patients who smoke cigarettes between two types of healthcare centers serving rural and/or medically underserved areas of Texas [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A095.

Using a combination of cognitive behavioral therapy, case management and eHealth components for patients with depression or panic disorders in primary care practices in Hesse, Germany: an exploration of healthcare professionals’ lived experiences

BackgroundDepression and panic disorders have high prevalence rates in primary care. Given the crucial role of general practitioners in diagnosing and treating mental disorders, the two-arm cluster-randomized, controlled PREMA trial was designed. PREMA was aimed at investigating a new intervention combining cognitive behavioral therapy, case management and eHealth components for patients with depression and/or panic disorder with or without agoraphobia in primary care practices in Germany. This qualitative study, embedded in the PREMA trial, explores primary healthcare professionals’ lived experiences in using the new treatment program. Using a qualitative design, we conducted eleven interviews with general practitioners and medical assistants from Hesse, Germany, between July 2021 and March 2022. For both groups we relied on a semi-structured interview guide covering the following subjects: study procedures, implementation, practicality, and individual components of the treatment program. Interviews were audio-recorded, transcribed verbatim and analyzed by two researchers using content analysis. A deductive-inductive approach was used for the analysis according to Kuckartz.ResultsWe narratively summarized the facilitators and barriers from two different stakeholders across five key themes regarding experiences of feasibility and practicability of the new treatment program: study instruction materials, individual components of the treatment program, practicality, target population, and benefits of the treatment program. Facilitators to become familiar with the study include study instruction materials that are easy to understand and not too complex, considering the limited time resources available; barriers included text-heavy instruction materials, lack of collegial exchange, and issues especially with digital materials also involved access and log-in difficulties on the online platform. Facilitators for using the treatment program include the combination of face-to-face consultations and the use of an online platform, enabling a structured approach and regularity; barriers included patients feeling unsupported in performing anxiety exercises independently at home. For practicality, the professional skills of medical assistants and their central role as points of contact for patients facilitated the implementation; barriers included time-intensive organization and planning of monitoring phone calls and consultations. Regarding the target population, general practitioners and medical assistants state that the treatment program would be most appropriate for patients with mild to moderate depression and for those waiting for psychotherapeutic treatment; it would be less suitable for older patients, and those with negative attitudes towards technological tools. For benefits of the program, facilitating factors included free and low-threshold access to the online platform and strengthening the relationship between medical assistants and patients; barriers included a preference for in-person conversations and the inability of some people to use online applications.ConclusionsThe complexity of the new treatment program and the associated high workload underline the need for further adjustments to the treatment approach. Team-based care and the expanded responsibilities of medical assistants demonstrated promising results.Trial registrationThe study was registered in the German Clinical Trials Register (DRKS00016622) on February 22, 2019.

A Pilot Project to Implement a Pharmacist-Managed Remote Blood Pressure Monitoring Service

Background: Clinicians often hesitate to adjust antihypertensive medications based solely on clinic blood pressure (BP) readings. Limitations to obtaining home readings include access to sphygmomanometers and ability to provide accurate, reliable readings upon follow-up. Objective: This study examined whether an online platform linked to remote BP monitoring improved BP management and facilitated effective clinical interventions by pharmacists. Methods: Thirty patients with uncontrolled hypertension were enrolled and provided a remote BP monitor for home use. BP data downloaded to an online platform were monitored by two clinic pharmacists. Daily BP checks were requested (up to twice daily), and pharmacists called patients approximately weekly for 6 months. Through approved protocols, pharmacists individualized interventions to improve patient care. Descriptive statistics were used for demographic and clinical data. Results: The average systolic BP reduction was 39 mmHg (IQR = 17-52.5) for the 21 patients included in analysis. A target BP <140/<90 was achieved by 67%, and 76% had improved BP control. Patients utilized the cuff 2-4 times (n = 10) or >5 times weekly (n = 11). Through 261 patient contact attempts, the pharmacists requested more BP checks (n = 62), changed medications (n = 57), or provided non-pharmacologic counseling (n = 24) most often. Medication changes commonly included dose increases (n = 35) and additional agents (n = 17) for BP control. Spironolactone (n = 5) and thiazide diuretics (n = 5) were the most added medications. Conclusions: Most patients were willing to check their BP when provided with devices. The majority achieved a clinically significant decrease in home BP readings, demonstrating that pharmacist-driven home-monitoring programs can improve the optimization of hypertension regimens.

Population Pharmacokinetics of Casirivimab and Imdevimab in Pediatric and Adult Non-Infected Individuals, Pediatric and Adult Ambulatory or Hospitalized Patients or Household Contacts of Patients Infected with SARS-COV-2

IntroductionCasirivimab (CAS) and imdevimab (IMD) are two fully human monoclonal antibodies that bind different epitopes on the receptor binding domain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and block host receptor interactions. CAS + IMD and was developed for the treatment and prevention of SARS-CoV-2 infections.MethodsA population pharmacokinetic (PopPK) analysis was conducted using pooled data from 7598 individuals from seven clinical studies to simultaneously fit concentration–time data of CAS and IMD and investigate selected covariates as sources of variability in PK parameters. The dataset comprised CAS + IMD-treated pediatric and adult non-infected individuals, ambulatory or hospitalized patients infected with SARS-CoV-2, or household contacts of patients infected with SARS-CoV-2.ResultsCAS and IMD concentration–time data were both appropriately described simultaneously by a two-compartment model with first-order absorption following subcutaneous dose administration and first-order elimination. Clearance estimates of CAS and IMD were 0.193 and 0.236 L/day, respectively. Central volume of distribution estimates were 3.92 and 3.82 L, respectively. Among the covariates identified as significant, body weight and serum albumin had the largest impact (20–34%, and ~ 7–31% change in exposures at extremes, respectively), while all other covariates resulted in small differences in exposures. Application of the PopPK model included simulations to support dose recommendations in pediatrics based on comparable exposures of CAS and IMD between different weight groups in pediatrics and adults following weight-based dosing regimens.ConclusionsThis analysis provided important insights to characterize CAS and IMD PK simultaneously in a diverse patient population and informed pediatric dose selection.

Bacterial contamination and greenhouse gas emissions: A randomised study of reuse versus single-use of infusion-set components for intravenous anaesthesia.

Reusing anaesthesia infusion-set components may reduce the climate impact from plastic waste and discarded medications. Infusion-set contents can be shielded from patient contact by single use of an infusion line fitted with dual antireflux valves, preventing retrograde entry of microorganisms, and eliminating the risk for patient-to-patient cross-contamination. However, infusion-set contamination from compromised aseptic handling could affect quality of care. To determine the prevalence of infusion-set bacterial contamination and compare the climate effects, we randomised operating rooms scheduled for total intravenous anaesthesia to handle procedures by infusion-set reuse or single-use. Both methods used dual single-use antireflux valves. The primary outcome was infusion-set bacterial contamination assessed by aerobic culture of infusion-set fluid collected after each procedure. The secondary outcome was CO 2 emissions (CO 2 -eq) estimated by life cycle assessment of component and medication use. To assess feasibility of detecting an inter-method difference in bacterial contamination, an interim analysis was planned after including at least 150 procedures per group. After allocating 54 operating rooms per method, 189 and 159 procedures of reuse and single use were included. Reuse permitted a median of three procedures per infusion set (range 1 to 8). Positive cultures occurred in two procedures per method [mean (95% CI)]; prevalence 1.15% (0.03 to 2.27); relative risk of reuse versus single use 0.84 (0.12 to 5.93), P = 0.861. As prespecified, inclusion was stopped due to futility. The median (95% CI) per-procedure climate emissions were 0.43 (0.41 to 0.47) and 1.39 (1.37 to 1.40) kg CO 2 -eq for reuse and single-use respectively; difference -0.96 (-0.99 to -0.93), P < 0.0005. The main sources for climate emissions were production of infusion-set components and waste handling. We conclude that the prevalence of bacterial contamination was low for both methods. A much larger study would be needed to detect an inter-method difference. Reuse of infusion-set components allowed significantly reduced intravenous anaesthesia climate emissions.

A descriptive study of the connections between social risk and healthcare utilization with supportive oncology care

Objective This study utilized social risk data in the electronic heath record collected as part of routine clinical practice and examined relationships with supportive oncology care contacts and healthcare utilization. Methods A total of 2,807 cancer patients were screened for four social determinants of health (SDOH) domains (financial resource strain, housing instability, food insecurity, and transportation need) and categorized to low or high risk SDOH groups. The number of patient contacts with supportive oncology was compared amongst the groups. The data were analyzed for demographic and outcome differences including emergency department visits, inpatient admissions, and appointment adherence. Results Heightened social risk was associated with more total contacts with supportive oncology care. Patients with high SDOH risk had more contacts across all outcomes examined including emergency department visits (M = 13), inpatient admissions (M = 14), and missed appointments (M = 11). Conclusions Patients with both greater social risks and acute care utilization are associated with more psychosocial interventions in supportive oncology follow-up. These findings highlight the need for comprehensive action to respond to social risk factors identified in SDOH screening.

Epidemiological characteristic of nails, skin of the feet and hands mycoses in the Perm region

Introduction. Mycoses of the skin and their derivatives are one of the most common groups of fungal infections. Lesion to the nails and skin of the feet and hands occupies a leading place in the structure of this pathology. These diseases are characterized by a long course and often ineffective therapy. Onychomycosis and fungal infections of the skin of the feet and hands are characterized by certain epidemiological features and have a diverse etiology.Aim. To study of the epidemiological characteristic of mycoses of the nails, skin of the feet and hands according to the data of the Regional Clinical Dermatovenerological Dispensary of Perm over a ten-year period to optimize the detection and further treatment of this pathologyMaterials and methods. For the study, statistical data from the Regional Clinical Dermatovenerological Dispensary in Perm were used. Data were analyzed for the period 2012–2021 to assess the dynamics of the prevalence of mycoses of the skin and nails of the feet and hands, their etiological structure. Cases recorded during direct patient contact were taken into account. For laboratory confirmation of mycoses, a culture method was used.Results and discussion. The number of cases of mycoses of the skin and nails of the feet and hands for the period from 2012 to 2021 was analyzed. It was established that the share of this pathology in the structure of superficial mycoses averaged 49.9%. There was no significant dynamics in the number of recorded cases of fungal infection of this location during the analyzed period. This pathology was more often observed in females than in males throughout the study period. The most significant etiological factors were representatives of Trichophyton spp., Candida spp., as well as molds. There has been a change in the etiological structure of mycoses of the nails, skin of the feet and hands over the observed period: there is a tendency towards a decrease in the proportion of dermatophytes and an increase in the proportion of yeast fungi.Conclusion. The relevance of the studied group of mycoses was confirmed using the example of the Perm region. The main cause of fungal infections of the nails and skin of the feet and hands were representatives of dermatophytes and Candida spp. It is recommended to focus on identifying this pathology in males during preventive examinations due to the low frequency of their visits to medical specialists.

Data-Driven Strategies for Carbimazole Titration: Exploring Machine Learning Solutions in Hyperthyroidism Control.

University Hospitals Dorset (UHD) has over 1,000 thyroid patient contacts annually. These are primarily patients with autoimmune hyperthyroidism treated with Carbimazole titration. Dose adjustments are made by a healthcare professional (HCP) based on the results of thyroid function tests, who then prescribes a dose and communicates this to the patient via letter. This is time-consuming and introduces treatment delays. This study aimed to replace some time-intensive manual dose adjustments with a machine learning model to determine Carbimazole dosing. This can in the future serve patients with rapid and safe dose determination and ease the pressures on HCPs. Data from 421 hyperthyroidism patients at UHD were extracted and anonymised. A total of 353 patients (83.85%) were included in the study. Different machine-learning classification algorithms were tested under several data processing regimes. Using an iterative approach, consisting of an initial model selection followed by a feature selection method the performance was improved. Models were evaluated using weighted F1 scores and Brier scores to select the best model with the highest confidence. The best performance is achieved using a random forest (RF) approach, resulting in good average F1 scores of 0.731. A model was selected based on a balanced assessment considering the accuracy of the prediction (F1 = 0.751) and the confidence of the model (Brier score = 0.38). To simulate a use-case, the accumulation of the prediction error over time was assessed. It was determined that an improvement in accuracy is expected if this model was to be deployed in practice.

Self-injurious thoughts and behaviours as the reason for contact to Norwegian emergency primary care centres: an observational study

Objective To describe and compare contacts regarding self-injurious thoughts and behaviours to other contacts to emergency primary care. Design Observational study. Setting A sentinel network of seven emergency primary care centres throughout Norway. Subjects Initial contacts regarding patients 10 years and older during 12 consecutive months (11/2021–10/2022). Main outcome measures Contacts due to self-injurious thoughts and behaviours. Results Self-injurious thoughts and behaviours were the reason for contact for 0.6% (n = 478) of initial contacts for patients aged 10 years or older (n = 77 344). When compared to other contacts, self-injurious thoughts and behaviours were associated with female gender, younger age, occurrence during evening and nighttime, higher urgency, and more physician consultations and call-outs. Of contacts about self-injurious thoughts and behaviours, 58.2% were regarding thoughts and 41.8% about behaviours, and in 75.0% a history of similar contacts was recorded. Contacts regarding thoughts often concerned threats (30.6%) and were more often handled by telephone advice than contacts regarding behaviours. Contacts regarding behaviours with suicidal intent were associated with higher urgency and more physician call-outs than contacts regarding non-suicidal behaviours. Conclusion Self-injurious thoughts and behaviours are rare reasons for contact to emergency primary care but are assessed as more urgent than other contact reasons and trigger more extensive medical help. Many of the patients are known to the service through a history of similar contacts. Implications The infrequency and severity of these encounters might necessitate training, decision support and procedures to compensate for the health care personnel’s limited exposure.

The benefits of active management of coronary heart disease (CHD) in Wales: how the use of routine collected administrative data can drive efficiency and encourage best practice in condition management.

Objective and ApproachWe analysed the effect on subsequent costs of the setting of the first contact for patients with coronary heart disease in Wales. By categorising health events as proactive or reactive, from the event data source (proactive = primary care (general practice) interactions, elective hospital bed days and outpatient attendances. Reactive = accident and emergency (A&amp;E) attendances and emergency hospital bed days). A standard cost was applied to obtain an annualised cost for each patient. The unit cost for each source was GP £36, bed days £398, outpatient £143, A&amp;E £188. ResultsWe found 42,563 people having CHD events during 2015-2019. Of these, 18,390 had a proactive event as their first event, 23,840 had a reactive event first. The ratio of proactive to reactive events was 1: 3.7 (ratio of costs were £1: £6.30). When the first event was proactive the ratio of events was 1: 0.85 (costs were £1: £1.33). When the first event was reactive the ratio was 1: 4.4 (costs were £1: £33.00). Conclusion and ImplicationsThe setting of the first contact appears to be key, with costs reducing by a factor of 14 if the first contact was carried out in a planned environment. Can investment in more active management of a condition reduce overall costs? The work has highlighted the power of using anonymised population-scale linked individual-level data and indicates the health resource reductions possible from improved managed care of patients.

Changes in Access to Alcohol-Based Hand Rub and Hand Hygiene Adherence among Healthcare Workers after a Hand Rub Production and Distribution Program in Rural Uganda before and during the COVID-19 Pandemic.

During the COVID-19 pandemic, the use of alcohol-based hand rubs (ABHRs) was critical for improving hand hygiene (HH) among healthcare workers (HCWs). Before and during the pandemic, we supported district-led production and district-wide distribution of ABHRs and one-time provision of portable handwashing stations to select healthcare facilities (HCFs) in five rural districts in Uganda. Comparison between baseline and follow-up assessments showed an overall increase in access to HH materials and HH adherence (HHA; handwashing with soap and water or use of ABHR) among HCWs. However, large differences in the changes in HH material coverage and HHA across districts may have been heavily influenced by the COVID-19 disease burden and its risk perception when the assessments were conducted. Using data collected at multiple time points before and during the pandemic across districts and estimating and controlling for pandemic effects in an exploratory multivariate analysis, the adjusted odds ratio of HHA in district HCFs was 4.6 (95% CI: 1.8-11.8) after (versus before) the ABHR intervention. This increase appeared to be primarily in larger HCFs, where the perceived need for ABHRs may have been greater. Additional strategies are needed to further increase HHA, especially in the smallest HCFs, among laboratory technicians and nurses and before patient contact. However, district-scale ABHR interventions seemed successful in ensuring the continued availability of HH materials.

Changing Medical Student Perceptions of Mental Illness Through a Psychiatry Clinical Clerkship: A Longitudinal Qualitative Study

Abstract Objective This study sought to understand whether perceptions of mental illness change during the course of students’ psychiatry clerkships, and what facilitates such change. Methods Using a longitudinal qualitative study design, the authors followed up 14 medical students, interviewing them before, during, and after their psychiatric clerkship. Results Prior to clerkships, students perceived psychiatric patients to be dangerous, fragile, hard to treat, and to exert a disproportionate emotional toll on clinicians. Stigma was reinforced by safety measures including the provision of alarms, but this improved following “real life” engagement with patients. Students experienced little emotional distress from clinical contacts, particularly those where they led the consultation. Pre-existing beliefs about mental illness being hard to “fix” showed less change over time. Although uncommon, when staff referred to patients using pejorative language, students emulated these negative attitudes. Conclusions Among medical students, direct patient contact plays an important role in counteracting pre-existing negative attitudes towards mental illness. This can be facilitated by supportive supervisors, clinical teams allocating students a clear practical role, involving patients in teaching, and roleplay to alleviate potential concerns about seeing patients.

Application of the behaviour-centred design to understand facilitators and deterrents of hand hygiene among healthcare providers: findings from a formative phase of a cluster randomised trial in the Kampala Metropolitan area

BackgroundHand hygiene is known to reduce healthcare-associated infections. However, it remains suboptimal among healthcare providers. In this study, we used the Behaviour-centered Design approach to explore the facilitators and deterrents to hand hygiene among healthcare providers in the Kampala Metropolitan area, Uganda.MethodsWe conducted a formative qualitative study as part of a cluster randomised trial in 19 healthcare facilities (HCFs). The study used 19 semi-structured and 18 key informant interviews to collect data on hand hygiene status and facilitators and deterrents of hand hygiene. Research assistants transcribed verbatim and used a thematic framework aided by Nvivo 14.0. to undertake analysis. We used thick descriptions and illustrative quotes to enhance the credibility and trustworthiness of our findings.ResultsAbout 47.4% of the HCFs had sufficient hand hygiene infrastructure, and 57.9% did not report total compliance with hand hygiene during patient care. The physical facilitator for hand hygiene was the presence of constant reminders such as nudges, while the biological included the frequency of patient contact and the nature of clinical work. The only biological deterrent was the heavy workload in HCFs. The executive brain facilitators included knowledge of workplace health risks, infection prevention and control (IPC) guidelines, and a positive attitude. A negative attitude was the executive brain deterrent to hand hygiene. Recognition, rewards, and fear of infections were the only motivated brain facilitators. Behavioural setting facilitators included proximity to functional hand hygiene infrastructure, the existence of active IPC committees, good leadership, and the availability of a budget for hand hygiene supplies. Behavioural setting deterrents included the non-functionality and non-proximity to hand hygiene infrastructure and inadequate supplies.ConclusionsThe study revealed low compliance with hand hygiene during the critical moments of patient care and inadequacy of hand hygiene infrastructure. The deterrents to hand hygiene included a heavy workload, negative attitude, inadequate supplies, non-functionality, and long distance to hand washing stations. Facilitators included constant reminders, fear of infections, frequency of patient contact and nature of clinical work, positive attitude, knowledge of IPC guidelines, recognition and reward, good leadership, availability of budgets for hand hygiene supplies, availability and proximity to hand hygiene supplies and infrastructure and active IPC committees.Trial registrationISRCTN Registry with number ISRCTN98148144. The trial was registered on 23/11/2020.

A qualitative study of negative sociocultural experiences of accessing primary health care services among Africans from refugee backgrounds in Australia: implications for organisational health literacy

BackgroundPrimary health care is the first point of contact for patients from refugee backgrounds in the Australian health system. Sociocultural factors, including beliefs and value systems, are salient determinants of health literacy and access to primary health care services. Although African refugees in Australia have diverse sociocultural backgrounds, little is known about the influence of sociocultural factors on their experiences of accessing primary health care services. Guided by the theoretical framework of access to health care, this study examined from the perspective of African refugees how culturally and religiously conditioned, constructed and bound health beliefs, knowledge and practices influence their experiences of access to, acceptance and use of primary health care services and information in Australia.MethodsThis exploratory, qualitative study involved 19 African refugees from nine countries living in New South Wales, Australia. Semi-structured interviews were conducted and recorded using Zoom software. The interviews were transcribed verbatim and analysed using a bottom-up thematic analytical approach for theme generation.ResultsFour main themes were identified. The themes included: participants' experiences of services as inaccessible and monocultural and providing information in a culturally unsafe and insensitive manner; the impact of the clinical care environment; meeting expectations and needs; and overcoming access challenges and reclaiming power and autonomy through familiar means. The findings generally support four dimensions in the access to health care framework, including approachability, acceptability, availability and accommodation and appropriateness.ConclusionAfrican refugees experience significant social and cultural challenges in accessing primary health care services. These challenges could be due to a lack of literacy on the part of health services and their providers in servicing the needs of African refugees. This is an important finding that needs to be addressed by the Australian health care system and services. Enhancing organisational health literacy through evidence-informed strategies in primary health systems and services can help reduce disparities in health access and outcomes that may be exacerbated by cultural, linguistic and religious differences.

Efficacy and safety of rechallenge with [177Lu]Lu-PSMA-I&T radioligand therapy in metastatic castration resistant prostate cancer.

The purpose of this study was to evaluate the safety and outcome of rechallenge [177Lu]Lu-PSMA-I&T in newly progressed mCRPC patients after response to initial [177Lu]Lu-PSMA radioligand therapy(PRLT). We retrospectively included 18 patients who underwent rechallenge with [177Lu]Lu-PSMA-I&T. All patients presented with (i) newly progressed disease after response to initial PRLT; (ii) a [68Ga]Ga-PSMA-11 PET/CT confirming the presence of PSMA-positive metastases; iii)ECOG performance status 0-1.Adverse events were graded according to CTCAE v5.0. Response was assessed by PSA and classified according to PCWG3 recommendations. For patients who underwent restaging with [68Ga]Ga-PSMA-11 PET/CT, imaging response was categorised according to adapted PERCIST v1.0. In patients with discordant [68Ga]Ga-PSMA-11 PET/CT and PSA, other available imaging modalities were evaluated to confirm disease status. Overall survival (OS) was calculated from the first cycle of initial PRLT and rechallenge PRLT, respectively, until last patient contact or death. Patients were initially treated with a median of 5 cycles (range 4-7) and were rechallenged after a median of 9 months (range 3-13). Each patient received a median of 4 (range 2-7) rechallenge cycles (median cumulative activity 26.1GBq). None of the patients experienced life-threatening G4 adverse events during either treatment period. Grade 3 adverse events included one case of anaemia, one case of thrombocytopenia, and one case of renal failure. In 8/18 patients long-term toxicities were evaluated. Serious toxicities (≥ Grade 3) occurred in 3/8 patients (n = 1 G4 thrombocytopenia, n = 1 G4 renal failure and n = 1 pancytopenia and G4 renal failure). Best PSA50%-response was observed in 44% of patients and PSA-disease control was confirmed in 56% of patients at the last cycle. Of the 12/18 patients restaged by imaging, 6/12 (50%) patients had disease control (partial response/stable disease), 1/12 had a mixed response, and 5/12 had progression. After a median follow-up time of 25 months (range 14-44), 10 patients had died, 7 were still alive, and one patient was lost at follow-up. The median OS was 29 months (95%CI,14.3-43.7 months) for the initial treatment and 11 months (95%CI,8.1-13.8 months) for the first rechallenge course. More than half of patients benefit from rechallenge PRLT. Our analysis suggests that rechallenge may prolong survival in selected patients, with an acceptable safety profile.

3HP preventive treatment among children and adolescents with HIV and child household contacts of TB patients

&lt;sec&gt;&lt;title&gt;INTRODUCTION&lt;/title&gt;India’s National TB Elimination Programme plans to roll out short-course TB preventive therapy (TPT) using 3 months of rifapentine and isoniazid (3HP). Understanding the feasibility and safety of children in programmatic settings is critical for widespread implementation. We present the findings of a targeted scale-up of 3HP among children and adolescents living with HIV (CALHIV) and child household contacts (&gt;2 to &lt;6 years) of pulmonary TB patients (CHHC).&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;METHODS&lt;/title&gt;Between December 2021 and July 2023, eligible CALHIV and CHHC participants were given weekly dosages of 3HP for 3 months at antiretroviral therapy (ART) and TB clinics, respectively, of a public hospital in Pune, India.&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;RESULTS&lt;/title&gt;Of 97 children screened, 91 initiated 3HP (32 CALHIV and 59 CHHC). The median age of CALHIV was 14 years; 66% were male and on dolutegravir-based ART. The median age of CHHC was 4 years; 47% were males. Thirty-one (97%) CALHIV and 56 (95%) CHHC completed 3HP without dolutegravir dose adjustment. None of the child participants discontinued 3HP due to adverse events. No child participant developed TB during 1 year of follow-up post-3HP.&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;CONCLUSION&lt;/title&gt;Our study provides evidence of the uptake and feasibility of the planned nationwide rollout of 3HP.&lt;/sec&gt;