Patient Journey Research Articles

Efficacy and Safety of Fixed-Dose Clindamycin Phosphate 1.2%/Adapalene 0.15%/Benzoyl Peroxide 3.1% Gel in Participants with Moderate-to-Severe Acne: The Patient Journey

Introduction: The main goal of acne treatment is to clear lesions quickly to manage and/or mitigate sequelae. Topical clindamycin phosphate 1.2%/adapalene 0.15%/benzoyl peroxide 3.1% (CAB) gel is the only fixed-dose, triple-combination approved for acne. In three published clinical studies of participants with moderate to severe acne, CAB gel demonstrated superior efficacy to vehicle and component dyads, with good safety/tolerability. Herein are presented detailed efficacy and safety data from 5 clinical study patients to document their CAB treatment journey. Methods: In two phase 3 (NCT04214652, NCT04214639), double-blind, 12-week studies, participants aged ≥9 years with moderate-to-severe acne were randomized to once-daily CAB or vehicle gel. Endpoints included percentage of participants achieving treatment success (≥2-grade reduction from baseline in Evaluator’s Global Severity Score and clear/almost clear skin) and percent change from baseline in inflammatory/ noninflammatory lesion counts. Dosing compliance, treatment-emergent adverse events (TEAEs) and cutaneous safety/tolerability were also assessed. Descriptive data from 5 selected cases who completed 12 weeks of CAB treatment are summarized. Results: Participants (n=5) ranged from 13-32 years. At week 12, 3 achieved treatment success, 1 achieved a 2-grade reduction from severe to mild, and 1 achieved a 1-grade reduction from moderate to mild. Reductions from baseline to week 12 in inflammatory/ noninflammatory lesion counts ranged from 74.7-100%. No participants reported TEAEs/serious AEs. Some cutaneous safety/tolerability scores increased at weeks 2, 4, or 8, but generally decreased back to/below baselines levels by week 12, similar to the overall study populations. Most scores at week 12 were 0 (none) or 1 (mild), with only one participant reporting scores of 2 (moderate) for itching, burning, and stinging. Conclusions: In the overall phase 3 clinical trials, fixed-dose, triple-combination CAB gel has demonstrated good efficacy, safety, and tolerability. All 5 cases presented here achieved substantial (>70%) acne lesion reductions, with 4/5 cases achieving treatment success or a 2-grade EGSS reduction by week 12. While patterns in cutaneous safety/tolerability were variable across cases, transient increases with CAB generally resolved to baseline values within two months of treatment. These clinical study cases reinforce the importance of patient education regarding efficacy and safety of acne treatment, including the importance of treatment adherence, managing patient expectations, and the potential for cutaneous effects, which are often transient. Support: Ortho Dermatologics

Visualizing the Real Time Reduction of Pulled Elbow Using Point of Care Ultrasound (POCUS)

POCUS is a useful tool for correctly identifying pulled elbow. We believe that clinicians working in Pediatric Emergency Departments should be encouraged to embrace using it in cases which are less straightforward – either due to an atypical history or based on examination findings. This will serve to not only increase safety and improve the patient journey, but also to improve the clinician’s confidence in their practice. This is the first ever documented instance where the reduction of pulled elbow has been demonstrated in real time using POCUS.

Patient journey in cystinosis: focus on non-adherence and disease management

Patient journey in cystinosis: focus on non-adherence and disease management

Characteristics and Management of Uncontrolled Gout Prior to Pegloticase Therapy: A 2-year Claims Analysis.

Gout is a progressive form of arthritis that causes significant pain and disability. Patients with treatment-refractory (or uncontrolled) gout experience a higher prevalence and severity of comorbidities than those whose gout is controlled. Pegloticase is a recombinant PEGylated uricase indicated for the treatment of gout in patients refractory to conventional therapy. We evaluated the treatment journey of patients with chronic uncontrolled gout before initiation of pegloticase therapy. Using IQVIA's PharMetrics® Plus database, we conducted a retrospective observational analysis of adults with ≥ 1 pegloticase claim between April 1, 2011, and August 31, 2020. Demographics were assessed at baseline. Clinical outcomes, health care resource utilization (HCRU), and associated costs were compared over two 12-month periods (months 13-24 and 1-12) prior to the first pegloticase claim (index date). The study included 408 patients. Prevalence of all gout-associated conditions increased between months 1-12 and 13-24 (P < 0.05 for all). The percentage of patients with tophi increased from 15.4% to 61.5%, the percentage with ≥ 1 flare increased from 49% to 84%, and mean number of flares per patient increased from 1.0 to 2.1 (P < 0.0001 for all). The frequency of all categories of HCRU except emergency department visits also increased (P < 0.0001 for all), as did gout-related healthcare utilization (P£0.005). Patients with uncontrolled gout experienced an increase in the clinical burden of disease and HCRU in the 2years before the initiation of pegloticase. Earlier patient identification and initiation of potentially effective therapy may help alleviate these burdens.

Abstract 4129223: Large Language Modeling-Enabled Analysis of Atrial Fibrillation Topics and Sentiments on Social Media

Purpose: We utilized large language modeling (LLM) and automated topic modeling techniques to describe public perceptions regarding AF on Reddit, a social media platform. Methods: In this qualitative study, we curated all AF-related discussions on Reddit from 2006 to 2023 by searching for all posts and comments containing AF-related terms (“atrial fibrillation”, “afib”, and “atrial flutter”). Discussions were embedded using a state-of-the-art embedding model (BAAI/bge-base-en-v1.5). Embeddings are reduced in dimensionality using Uniform Manifold Approximation and Project and clustered using K-Means Clustering to find topics and groups. Topic and group labels are enhanced using large language models (Llama2 and GPT4, respectively). Results: We identified a total of 86,323 discussions related to AF from 38,183 unique users between April 14, 2006 and November 20, 2023. Discussions around wearables and ablations increased over time, while discussions around anticoagulation had periodic spikes. The topic modeling pipeline automatically identified 64 topics and 9 groups (Figure 1). Groups emphasized the following themes: lifestyle factors and triggers associated with AF (groups 1, 5, 7); patient experiences with management strategies including anticoagulation, rate control, pharmacological rhythm control, and ablation (groups 2, 4, 5); experiences with wearable devices (group 8); psychological burden of living with AF (group 6); and online advertisements for AF-related medications (groups 3, 9). Conclusions: Our AI-enabled topic modeling analysis revealed public perceptions about AF including triggers, experiences with different management strategies, impact of wearables, and psychological burden of the diagnosis, which may help guide potential strategies for improving shared decision making around the AF patient journey.

Time Efficient &amp; Cost Effective Online teaching tool with iConcepts in Orthodontics for DDS students @ UoM

Background Traditional teaching methods in Orthodontics include plaster models and photos which have been used for decades, however due to the nature of being static still images its difficult for 3-Dimensional (3D) changes in Orthodontics teaching, which has posed immense challenges as the learner is unable to clear concepts on the different planes that affect the final tooth positions not to mention the protracted treatment time ranges from 12 months (simple cases) to 36 months (complex cases). In 2024 with variety of platforms such as videos, 3D animations, interactive changes in face and teeth can be added to teaching tools for Orthodontics. Furthermore, orthodontic movements can pose difficulty in understanding the changes particularly in growing children adding to the 4th dimension. At UQ (Naser-ud-Din, 2015) and internationally (Bridges, 2015) provided experience with creating online teaching modules highlighting its strengths of flexibility, ease of access on demand and global presence. UQ developed SBLi -Scenario Based Learning interactive for Postgraduate Orthodontic students who found it highly engaging, with self-reflective and self-assessment elements useful. (Khoo et al., 2023; Naser-ud-Din, 2016). Generally simulations can be expensive to create (Kröger et al., 2017) and it’s essential to explore cost effective simulation teaching tools with industry partners for authentic learning experience. Aims There is a gap in the dental education sector, particularly with emerging CADCAM (Computer Assisted Design and Computer Assisted Manufacture), which can be used to enhance the learning of core concepts in biomechanics with the aid of 3D simulated online learning. This is reflected particularly for the university students in undergraduate courses who need to feel confident and clinically ready on graduation as Dentists. Thus, greater expectations to be aligned with current technological processes in dentistry. Over the past 5 years, in particular, there has been exponential improvements by the industry providing 3D simulations for treatment planning and patient communication, commonly referred to as the GPS for smile transformations. The aim of this presentation is to highlight the time efficiency and cost effectiveness of the learning tool in sync with contemporary demands in Orthodontics to provide authentic learning platform that prepares the clinician for real patients. Material &amp; Methods Currently the CAD CAM technology provide 3D simulations as open access to general public and doctors portal which can be utilized for teaching core concepts related to biomechanics foundations for student learning, engagement and self-assessment. This project envisages to create a novel forum encompassing education revolution as massive changes in delivery will occur with speed and efficiency internationally with onlinelearning demands. Hence, robust online presence with an interactive textbook such as iConcepts in Orthodontics under the banner of UoM to assist students in Doctor of Dental Surgery at MDS shall pave the way to learning needs for the future. Results The purpose of iConcepts a digital interactive online textbook is to create lifelong learning opportunities in safe space for visual, auditory and kinesthetic with quizzes for interactive learning of concepts without pressure in class learning and feeling judged by peers. Interactive 3D Orthodontic learning directly translates into clinical applications for various orthodontic cases. In the past decade CAD CAM has become clinically relevant particularly with Clear Aligner Therapy adding to higher precision and patient satisfaction. Moreover, it is imperative to have Long Term Retention (LTR) (Irvine, 2020) of learning new tasks. It is essential that students in dentistry are aware of the digital workflows and have clinical preparedness on graduation as it’s the future and certainly here to stay. Both qualitative and quantitative data on student experience shall be collected and analysed to seek out the best practices and processes for instruction of delivery in Orthodontics for DDS cohort in particular and lifelong learning for all ages in general encompassing time efficiency and cost effectiveness. Conclusion The current iConcepts is developed by the author with Apple Education and prototype is being assessed with MSc Data Science cohort at UoM. Furthermore, it is refined by Master of Science Software Engineering students at UoM. Future Recommendations Novel teaching tools shall be marketed to developing universities internationally assisting the dissemination of information a flagship for UoM and revenue generation for department of Education at UoM. In future there will be more and more demand towards interactive concepts clarification (Poblete et al., 2020) and self-assessments hence iConcepts provides that ideal platform. Such technologies will become more prevalent in the future particularly with AI and translated into different languages/ sectors of education. Various faculties that showcase start to finish particularly lengthy/complex outcomes can benefit with timelapse videos and 3D CADCAM for clarity and comprehension for the entire process such as patient journey throughout treatment in Orthodontics.

TELEMONITORING IN ONCOLOGICAL PALLIATIVE CARE: PERSPECTIVES OF PATIENTS AND CAREGIVERS

Over the years, care during the oncology patient's journey has demonstrated benefits for physical, social, psychological and spiritual well-being. Palliative Care (PC) is offered to all patients diagnosed with life-threatening diseases, regardless of curative interventions. The focus is on the person, for whom there is always something to offer, even with active disease and limited time to live. Telecare has shown positive results when employing electronic technology in patients undergoing palliative care and with advanced cancer, improving symptom control and reducing the use of emergency rooms and hospitalizations, being a promising approach for maintaining quality of life.

The journey to diagnosis of wild-type transthyretin-mediated (ATTRwt) amyloidosis: a path with multisystem involvement

BackgroundWild-type and hereditary transthyretin-mediated amyloidosis (ATTRwt and ATTRv amyloidosis, respectively) are progressive, fatal diseases with a broad range of clinical presentations and multisystem effects. Despite having a higher prevalence, ATTRwt amyloidosis is less well characterized due to its non-hereditary nature, and its relatively poorer disease awareness delays diagnosis. Understanding of its natural history has evolved in recent years, but this is largely based on physician-collected data rather than patients’ reports of their own experiences. A mixed methods approach was used to evaluate how the healthcare journeys of patients with ATTRv and ATTRwt amyloidosis compare.MethodsA quantitative survey was administered to US-patients diagnosed with both ATTRwt amyloidosis and ATTRv amyloidosis identified through a patient support group. Subsequent in-depth interviews with participants with ATTRwt amyloidosis were conducted. Quantitative data with related qualitative quotes from patients were produced to characterize their paths to diagnosis and the disease burden experienced.ResultsA total of 47 respondents completed the survey (ATTRv, n = 20 and ATTRwt, n = 27) and a total of 14 survey respondents with ATTRwt amyloidosis were interviewed. Survey results reported a high disease burden for patients with both conditions, with patients with ATTRwt amyloidosis reporting more diagnoses and procedures prior to their final diagnosis. Interviews with participants with ATTRwt amyloidosis revealed that patients face a high symptomatic burden of disease. Diagnosis was often delayed due to three key factors: (1) early signs of ATTRwt amyloidosis were often assumed to be related to old age; (2) many medical specialists working in silos were involved in participants’ diagnostic; and (3) there was a general lack of disease awareness. Early indicators such as carpal tunnel syndrome were often overlooked. Participants were typically diagnosed after the disease had progressed to include severe cardiac symptoms such as atrial fibrillation and severe shortness of breath. Sleep apnoea was also reported by a number of participants, with a considerable impact on quality of life.ConclusionsOur study provides insight into the overall impact of the patient journey on their quality of life and demonstrates how increased awareness of ATTRwt amyloidosis and more coordinated engagement with physicians could reduce the time to diagnosis.

Improving Diagnosis and Management of Opioid-Induced Constipation (OIC) in Clinical Practice: An Italian Expert Opinion

Opioid-induced constipation (OIC) is a very common and troublesome gastrointestinal side effect following the use of opioids. Despite existing international guidelines, OIC is largely underdiagnosed and undertreated. ECHO OIC is a European project designed to improve the diagnosis and management of OIC at the primary care level. The next phase of the ECHO OIC project is to review and adapt the proposed European pathway at national level, considering the local patient journey and clinical practice. A multidisciplinary group of 12 Italian experts reviewed and discussed the European path and formulated a seven-step guide for the practical management of OIC that is also easily applicable in primary care: 1. When prescribing long-term opioids, the physician should inform the patient of the possibility of the onset of OIC; 2. At opioid prescription, doctors should also prescribe a treatment for constipation, preferably macrogol or stimulant laxatives; 3. The patient should be evaluated for OIC within the second week of initiating opioid treatment, by clinical history and Rome IV criteria; 4. In the presence of constipation despite laxatives, prescription of a PAMORA (Peripherally Acting Mu Opioid Receptor Antagonist) should be considered; 5. When prescribing a PAMORA, prescribing information should be carefully reviewed, and patients should be accurately instructed for appropriate use; 6. Efficacy and tolerability of the PAMORA should be monitored regularly by Bowel Function Index, considering a cut-off of 30 for the possible step-up of OIC treatment; 7. After 4 weeks of treatment, if the efficacy of PAMORA is deemed inadequate, discontinuation of the PAMORA, addition of an anti-constipation drugs, change of opioid type, or referral to a specialist should be considered. Spreading knowledge about the OIC problem as much as possible to the health community is crucial to obtain not only an early treatment of the condition but also to promote its prevention.

The impact of lactose intolerance diagnosis: costs, timing, and quality-of-life.

Lactose intolerance (LI) is a very common condition but, despite many efforts of the Italian National Health Service to reduce diagnostic delay of chronic disorders and provide prompt treatments, its early diagnosis remains an unmet need. In addition, the COVID-19 pandemic has exacerbated this problem, due to the conversion of many public health services to COVID centers. This study aims to analyze the diagnostic journey of patients suffering from LI, taking into account the duration of the process, associated costs, and impact on quality of life. Anonymous surveys were designed and distributed to patients with LI as well as physicians involved in LI management. The data were analyzed to determine the time required for a reliable LI diagnosis and average costs. Diagnostic delay of LI proved to be longer than 2years, its impact on quality of life proved to be moderate to high in most of participants, especially in their psychosocial domain, and average costs proved to be high. Further investigations are needed to determine the economic burden of maintaining an asymptomatic status in patients with LI.

The journey of patients affected by metastatic hormone receptor-positive/HER2-negative breast cancer from CDK 4/6 inhibitors to second-line treatment: A real-world analysis of 701 patients enrolled in the GIM14/BIOMETA study

PurposeThe aim of this study was to evaluate the effectiveness of CDK 4/6 inhibitors (CDK 4–6i) according to HER2 status (low/zero), and endocrine resistance/sensitivity, as well as the efficacy of second-line treatments, in a large real-world cohort. MethodsThe GIM14/BIOMETA study (NCT02284581) is a retrospective/prospective study of the Gruppo Italiano Mammella evaluating treatment patterns and survival outcomes in patients with metastatic breast cancer (MBC). We retrieved data on patients with hormone receptor-positive/HER2-negative MBC receiving first-line CDK 4/6i. ResultsAmong 3832 patients enrolled in the GIM14-BIOMETA study, 701 were eligible. At a median follow-up of 24.80 months, no significant differences were found between HER2-zero and HER2-low subgroups in terms of first-line time to treatment discontinuation (TTD) (26.16 months [IQR 12.84-NR] vs. 27.60 months [IQR 12.12–64.44], p = 0.972) or overall survival (OS) (mOS>60 months for both groups, p = 0.398). Median TTD was 33.24 months (IQR 16.32-NR) for the endocrine sensitive subgroup, 19.92 months (IQR 8.88–51.24) for the secondary endocrine resistant subgroup and 17.40 months (IQR 7.44–24.72) for the primary endocrine resistant subset, respectively (p < 0.001). Among 239 patients receiving second-line treatment, no significant difference (p = 0.188) was found in terms of second-line TTD between those treated with capecitabine (6.11 months, IQR 2.96–11.47), taxane-based chemotherapy (5.06 months, IQR 2.99–9.99), everolimus plus exemestane (5.39 months, IQR 2.53–9.03) or fulvestrant (6.44 months, IQR 3.38-NR). ConclusionsEndocrine therapy plus CDK 4/6i represents an effective treatment, regardless of HER2 status (low/zero). Second-line agents did not differ significantly in terms of TTD. Endocrine resistant cancers exhibit poor response to CDK 4/6i.

Process Mining on National Health Care Data for the Discovery of Patient Journeys of Older Adults

ObjectiveUnderstanding the longitudinal patterns of health care utilization among older adults is crucial for designing effective patient journeys and enhancing care coordination across settings. This study aims to uncover the most common patient journeys of older adults. DesignThis explorative study used process mining techniques to analyze national health care data from 2017 to 2019, focusing on patient care journeys of older adults (aged ≥65 years) in the Netherlands. Setting and ParticipantsData were sourced from Statistics Netherlands, encompassing all residents aged ≥65 years as of January 1, 2017. Health care usage declarations from various care settings during 2017-2019 were included. Patient journeys were exclusively selected if their initiation points were certain. MethodsData underwent rigorous preprocessing, merging, and filtering to create a single event log file suitable for process mining. Patients were categorized by age and medication use, and differences in patient journeys were analyzed. Process mining techniques generated visualizations illustrating the connections between care forms and the impact of changes in one form on others. ResultsThe study included 3,177,203 individuals aged 65 years and older, with 44% experiencing 1 or more patient journeys totaling 2,469,663 journeys in 2017-2019. Most care journeys for older adults were simple and short. The top 10 most frequent journeys had 4 or fewer care forms, with 95% of journeys for the 65+ population and 90% for the 85+ population having 4 or fewer care transitions. Long-term care forms, such as home care, personal care, and long-term care, accounted for the majority of time spent in the system. Conclusions and ImplicationsThis pioneering study used process mining to show that most older adults tend to have a straightforward health care need, often involving the emergency department and hospitalizations. However, a smaller group among the population requires more complex and prolonged care, especially in the 85+ population. Reducing the number of transitions for this population, although impacting fewer people, might result in a larger effect on the overall system.

Evaluating Virtual Reality Patient Education in Cardiac Surgery: Impact on Preoperative Anxiety and Postoperative Patient Satisfaction.

Background/Objectives: Preoperative anxiety in cardiac surgery patients can adversely affect mental well-being and postoperative outcomes. Virtual reality (VR) patient education has been proposed as a novel method to enhance patient education and potentially reduce preoperative anxiety. The VR Patient Journey Trial aimed to evaluate the impact of VR patient education on preoperative anxiety and patient satisfaction compared to traditional education methods. Methods: This randomized controlled trial included 121 patients undergoing cardiac surgery. Participants were randomized to receive either VR patient education (intervention group) or traditional education (control group). Preoperative anxiety was measured using the State-Trait Anxiety Inventory (STAI) and the Amsterdam Preoperative Anxiety and Information scale (APAIS). Patient satisfaction was assessed postoperatively through a custom questionnaire. Statistical analyses included linear regression and non-parametric testing. Results: Neither STAI nor APAIS scores showed differences in preoperative anxiety between both groups. However, the intervention group reported significantly higher patient satisfaction with the information provided (median score 9 vs. 8; p < 0.001). Furthermore, women reported higher levels of anxiety than men (p = 0.01), and open-ended feedback from participants indicated a need for more detailed information on postoperative rehabilitation and potential risks. Conclusions: The VR Patient Journey Trial revealed that, although VR patient education did not significantly reduce preoperative anxiety levels, it significantly improved patient satisfaction with the information provided. These results suggest that VR patient education can be a valuable addition to preoperative patient programs.

Considerations on Multimorbidity and Frailty in Inflammatory Bowel Diseases.

There are growing numbers of older people with inflammatory bowel diseases [IBD]. These older patients are more likely to have other comorbidities and polypharmacy, which can make recognizing and treating IBD complex. Frailty is a newer concept in the IBD field, and we are beginning to recognize the importance of this as a marker of biological age and its association with risk of adverse IBD-related outcomes. In this review article we aim to provide practical insight into the specific challenges facing older patients and their clinicians at each stage of the patient journey. We also discuss the latest understanding of the impact of frailty for these patients with IBD and highlight areas for future research.

Introducing online narrated video animations to facilitate patients' understanding of cardiac procedures in a high-volume tertiary centre

Abstract Introduction Discussions about the benefits and risks of invasive procedures, including their alternatives, are an integral part of certain patient consultations in Cardiology. However, patients absorb only a fraction of the information shared during a single encounter, often due to time constraints, leading to an incomplete understanding. Video animation tools were designed to better facilitate communication and consolidate patient (and family members) understanding in advance of their procedure. Purpose We are a high-volume tertiary cardiac centre, and we aimed to assess real-world patient feedback having introduced an online cardiac video animation tool into our organisation. Methods In July 2022, we obtained unlimited patient access to a digital tool that offers short, multi-language narrated video animations covering the breadth of cardiac procedures (cardiac intervention, electrophysiology, structural and cardiac surgery). It is accessible on any device, including a desktop, laptop, or mobile phone. Specifically, we purchased password protected access to 31 video animations in three local languages. Web-links and QR codes for each video animation were designed. These were shared with patients and family members during different stages of the patients’ journey through the hospital. We sampled qualitative feedback from a cohort of patients attending pre-assessment clinic, measured on our electronic patient record via a 3-point Likert scale. Results As illustrated in Figure 1, we adapted our patient pathway to integrate use of this resource in the patient journey by 1) notifying patients during their out-patient cardiologist consultation; 2) emailing video links integrated within an e-consent process; 3) introducing video links as QR codes in patient letters; 4) reminding patients during their nurse-led pre-assessment clinic; 5) via hospital poster advertisements; 6) and on the front page of the hospital website. Since its introduction 18 months ago, 20,607 animation views have occurred, with 90% watched to completion. The three most popular animations were "angiogram/angioplasty" (4135), atrial fibrillation ablation (1415), and TAVI (1243). From July 2022 to December 2023, 1,878 patients have attended our nurse led pre-assessment clinic, and we sampled qualitative feedback from about 20% (342 patients). As demonstrated in Figure 2, 84% of patients felt the procedural video animations were quite helpful/very helpful. The remaining 16% found it "not helpful", with anecdotal reasons being "inability to access the technology", "feeling already adequately informed", or "not wanting to know". Conclusion In our high-volume tertiary centre, online narrated video animations discussing cardiac procedures were successfully implemented into our patient pathway and deemed helpful by the majority of our patients.Fig1.Process map of the patient journeyFig2.Patients’ feedback regarding video

Patient journey from the appearance of red flags to the diagnosis of transthyretin cardiac amyloidosis (ATTR-CM) in Japan: a nationwide retrospective study using a medical claims database

Abstract Introduction Transthyretin amyloid cardiomyopathy (ATTR-CM) is an under-recognized cause of common cardiovascular conditions in the elderly, with relatively high rates among patients diagnosed with heart failure (HF) with preserved ejection fraction. In addition to cardiac symptoms such as HF, extracardiac symptoms such as carpal tunnel syndrome (CTS) and lumbar spinal stenosis (LSS) are also red flags for ATTR-CM. Tafamidis is currently the only disease-modifying therapy approved for the treatment of patients with ATTR-CM and is likely to be more effective in the earlier stage. Patients with ATTR-CM often undergo a long and difficult diagnostic journey because of the nonspecificity of clinical manifestations, resulting in delays in establishing the correct diagnosis. Purpose To identify the timing of appearance of comorbidities in patients with ATTR-CM during diagnosis. Methods In this retrospective, non-interventional, observational study using a claims database (dataset period: April 1, 2014–August 31, 2021), adult patients with a diagnosis of ATTR-CM or prescription for tafamidis 80 mg were included. The index date was defined as the first date of recording ATTR-CM diagnosis or the prescription of tafamidis 80 mg, whichever was earlier. The baseline period was defined as the period between the index date and 6 months before the index date. The onset date was defined as the first date of recording diagnosis of the first red-flags that was suspicious for ATTR-CM. Results Of 11,101,578 patients in the database, 246 patients with ATTR-CM met the inclusion criteria. A total of 239 patients were included, of whom 139 had received tafamidis 80 mg. The median (range) age at the index date was 79.0 (46.0–95.0) years, and 79.9% (191/239) were male. The most frequently reported comorbidity defined as onset of ATTR-CM was conduction disorders (88.7%) followed by atrial fibrillation/atrial flutter (50.6%), hypertensive heart disease (19.7%), aortic stenosis (15.9%), and hypertrophic cardiomyopathy (11.7%), with the median (interquartile range [IQR]) time to the index date being 15.5 (5.0–24.5), 14.0 (5.0–22.0), 9.0 (2.0–18.0), 5.0 (2.0–16.0), and 12.0 (6.5–21.5) months, respectively (Fig. 1). LSS (23.9%), neuropathy (13.0%), and CTS (7.5%) were frequently observed as extracardiac symptoms at baseline, and the median (IQR) time from appearance to the index date was 19 (9.0–28.0), 5.0 (1.0–16.0), and 18.0 (14.0–25.0) months, respectively (Fig. 2). Conclusions This study elucidated the time lag between the appearance of cardiac and extracardiac complications of ATTR-CM and its diagnosis in real-world clinical settings. These novel findings highlight the potential for earlier detection of ATTR-CM.

How can the detection of AF be improved? Insights from patient journeys and primary care clinicians

Abstract Background Atrial fibrillation (AF) is underdiagnosed and it is estimated that a third of people with AF remain undiagnosed. AF is complex to detect because it can be intermittent and some patients are asymptomatic. When symptoms are present they can be non-specific. In the absence of a screening programme to detect AF it is important to identify ways to improve its detection of AF in order to reduce the risk of AF-related stroke. Purpose We conducted a qualitative study in primary care to explore the patient path to diagnosis of AF and identify ways to improve detection Methods We recruited patients with a recent diagnosis of AF (&amp;lt; 6 months) and interviewed them to understand their path to diagnosis. We interviewed GPs and practice nurses to explore their experience of detecting AF in primary care. The interviews were audio-recorded and transcribed, and the data were analysed using framework analysis. Results Thirty patients and ten primary care clinicians were interviewed. The presence and nature of symptoms experienced by patients and how they interpreted these were significant in the pathways to diagnosis. Patients with acute symptoms presented to A &amp;E and had a quick diagnosis while asymptomatic patients were diagnosed incidentally. Patients with non-specific symptoms generally did not perceive the symptoms as serious, and many delayed seeing a healthcare professional. Their experiences in primary care aligned with findings from interviews with primary care clinicians, who acknowledged AF may not necessarily be the initial suspicion when a patient presents with certain non-specific symptoms. Primary care clinicians described narratives of good practice in the form of opportunistic pulse palpation, as well as challenges of detecting AF in primary care. These included lack of access to 24-hour ambulatory ECG in primary care and limited opportunities to detect AF due to healthcare assistants taking on more responsibilities. Conclusions A number of opportunities to improve the detection of AF can be drawn from these findings. Public education about AF, its signs and symptoms would increase patient knowledge and presentation to healthcare professionals. Standardizing good practice of opportunistic pulse palpation in primary care and training healthcare assistants to perform this is also indicated. Access to 24-hour ambulatory ECG in primary care will reduce delays in diagnosis. Further research on which patients are likely to have undiagnosed AF will facilitate detection in primary care.

The Treatment Alliance and the Provision of Removable Dentures: Exploring the Emotional Work of the Dental Team

Background: Research has demonstrated that the loss of one or more natural teeth can be an emotionally traumatic experience that mirrors processes associated with bereavement. There remains scant literature examining the role of emotions in dental encounters. One such exception is the literature on the idea of the ‘treatment alliance’ in dental encounters. The aim of this paper is to explore the role of the ‘treatment alliance’ in dentist–patient encounters. Methods: Data were collected from clinical observations, semi-structured interviews and focus groups exploring the experience of tooth loss and how the treatment alliance shaped the patient journey. Data analysis was conducted using the grounded theory method influenced by phenomenology. Coding was conducted using NVIVO and the unit of analysis was the treatment alliance. Results: Twenty participants took part in the interviews (eleven male; nine female; 22–86 years; mean age = 58.9 years). Observations were carried out with a further fourteen participants (seven male; seven female; 50–101 years; mean age = 62.2 years). The paper draws on four cases taken from the observational data to illustrate important dynamics underpinning how the treatment alliance varied. These case studies are then used as the basis for a critical discussion of the importance of the treatment alliance in dentistry. Conclusions: The treatment alliance acted as an important moderator in the clinical encounter, helping to influence successful outcomes. An important foundational component of the treatment alliance was the degree of emotional work the dental team conducted when ‘getting to know’ unfamiliar patients. Whilst emotions were an important factor in dental encounters, their acknowledgement and management were not essential to all successful outcomes. Much more research is therefore needed into the role of emotional labour in dental encounters.

Chronic Coronary Syndromes with/without obstructive coronary arteries: are there differences in ongoing chest pain?

Abstract Background Stable coronary artery disease (CAD) is the archetype chronic coronary syndrome, clinically manifesting as angina with obstructive CAD on angiography and managed via evidence-based guidelines. In contrast, patients with Angina with Non-Obstructive Coronary Arteries (ANOCA) are often diagnosed with ‘non-specific chest pain’ and not appropriately managed. Purpose To compare the Seattle Angina Questionnaire (SAQ) responses and 3-year rates of chest pain hospital presentations in patients with ANOCA compared to Stable CAD. Methods Consecutive angina patients undergoing elective coronary angiography enrolled in the CADOSA (Coronary Angiogram Database of South Australia) Registry between 2012-18 were included. Consenting patients participated in a longitudinal health status assessment utilising the SAQ. In-hospital clinical data was extracted from CADOSA and mortality and hospitalisation data over 12-months was extracted via administrative records. Results Of 6,372 consecutive patients undergoing elective angiography for the investigation of chest pain 2,287 had ANOCA and 4,085 Stable CAD. ANOCA patients were younger (61±11 vs 66±11, p&amp;lt;0.05) and more often female (59% vs 27%, p&amp;lt;0.05) compared to Stable CAD. The SAQ health status assessment was completed at baseline, 1 and 12-months for 377 patients (ANOCA n=156, Stable CAD n=221). At 12-month follow-up, there were no differences in SAQ scores amongst all domains (physical limitation- 92±16 vs 92±15, angina stability- 64±25 vs 62 ±24, angina frequency- 91±17 vs 92±16, treatment satisfaction- 94±13 vs 94±13 and quality of life- 78±22 vs 81±21) between ANOCA and Stable CAD, all p&amp;gt;0.05. However, in the 12-month follow-up, ANOCA patients were less likely to have a chest pain hospital emergency department presentation (10% vs 15%, p&amp;lt;0.001) or admission (6% vs 12%, p&amp;lt;0.005) compared to the Stable CAD cohort. Conclusion Although patient-reported outcomes were identical between Stable CAD and ANOCA patients, the latter were less likely to present to emergency department or be admitted to hospital than their Stable CAD counterparts, reflecting the clinical nihilism encountered in the ANOCA patient journey.

A CDSS based Integrated Pathway for Influenza Vaccination Across Primary and Secondary Care

Abstract Background In Italy, influenza vaccination coverage in people ≥ 65 years is unsatisfactory (56.7%), underlining the need to improve current vaccination strategies. The objectives of this study have been: to define a novel pathway to increase influenza vaccination adherence among ≥ 65 years population in the Lazio region; to provide a predictive estimate of the epidemiological and economic pathway’s potential impact. Methods A multidisciplinary working group (WG) featuring cross-sectoral expertise was created and WG periodic meetings were held to define the patient journey and its flow-chart representation. The pathway’s potential impact was assessed through epidemiological and economic indicators and scenario analyses. Results An integrated pathway across primary and secondary care was defined, based on the active patient in-Hospital recruitment and vaccination and enhanced by a Clinical Decision Support System relying on a digital algorithm to identify eligible patients. Assuming an increase of influenza vaccination coverage from the current rate of 60% (scenario 1) to 65% (scenario 2) in ≥ 65 years population in the Lazio region thanks to the pathway implementation, an increase of 8% in avoided influenza cases, influenza- or pneumonia-related hospitalizations and influenza-related outpatient visits was estimated with a relative increase in savings for hospitalizations and outpatients visits of up 2,367,310 euros. Setting the vaccination coverage at 70% (scenario 3), an increase of 16% in avoided influenza cases, hospitalizations and outpatient visits was estimated with a relative increase in savings for hospitalizations and outpatients’ visits of up to 4,833,259 euros. Conclusions Alongside offering a predictive estimate of the relevant pathway’s potential impact, both epidemiological and economic, this project, with its robust methodology, may serve as a scalable and transferable model for enhancing vaccination coverage at national and international level. Key messages • The proposed pathway, offering the option of receiving flu vaccination within the Hospital, supports the paradigm shift towards primary prevention pathways in secondary care settings. • Another relevant aspect of the integrated pathway is the adoption of an Artificial Intelligence tool to identify suitable patients and improve their recruitment and adherence to vaccination.