Ambulatory Care Patients Research Articles

Online patient portal-based management of medication renewal and refill pickup in ambulatory care settings: A retrospective utilization study at tertiary care hospital in Saudi Arabia

BackgroundThe prescription pickup and renewal process in ambulatory care settings requires numerous steps, such as making an appointment with a physician to renew prescriptions and direct pharmacy visits to pick up medications. This process can be difficult or cumbersome for some patients; however, digital health-associated patient portals can reduce the burden on both patients and healthcare professionals. MethodsA retrospective study was conducted in an ambulatory care setting of Johns Hopkins Aramco Healthcare. We analyzed the utilization pattern of MyChart for medication renewal and refill pickup services for ambulatory care patients of all specialties from October 1, 2018, to September 30, 2020. The data were extracted electronically from the Epic-Hyperspace EHR system, and the effects of factors such as year of access and COVID-19 on MyChart utilization were analyzed. ResultsA total of 125,538 patients were registered using MyChart. In the first and second year of this study, MyChart was utilized by 44,063 (8.7%) and 59,622 (13.6%) patients, respectively, for medication pickup. Additionally, in these two years, 92,997 (21.6%) and 156,020 (38.9%) medication refills were requested through MyChart (with no direct pharmacy visit) and collected from different pickup locations, respectively. In two years, there were 363,159 medications sent to physicians for renewal through Epic-MyChart, of which 347,244 (95.6%) were approved and 15,915 (4.4%) were denied. A significant increasing (p less than 0.05) trend in utilization, medication requests, and renewal requests using the MyChart were observed over a period of 24 months and during quarantine due to COVID-19. Although there was a decrease in physicians denying renewal request, these were not significantly affected by time or COVID-19. ConclusionThe high and consistent utilization of the patient portal MyChart indicates its broad acceptance, significantly minimizing the barriers to medication pickup and renewal processes in ambulatory care settings. The year of access and COVID-19 were significantly associated with an increasing trend in MyChart utilization. With increased utilization and higher acceptability, the internet-based patient portal MyChart continues to hold great potential for providing quality healthcare services by increasing access and making patients decision-makers in their healthcare.

Health Care Disparities in the Utilization of Type 2 Diabetes Prevention Services Among Ambulatory Care Patients in the United States

Background: Exercise routines, diet management, education and Medication Therapy Management (MTM) have shown to improve glycemic control, lower blood pressure and body weight. While the majority of patients are on some form of weight management, many do not receive professional guidance to create their diet plan. Objective: The aim of this study was to determine if the utilization of type 2 diabetes mellitus prevention services were impacted by patient and physician characteristics in visits to ambulatory providers in the United States. Findings: A total of 1,932 patients with a primary diagnosis of Type 2 Diabetes Mellitus were extracted from the 2017 National Ambulatory Medical Care Survey database, collected by the National Center of Health Statistics. The patients’ age, sex, race, gender, region, insurance and physician characteristics were among the demographic variables studied. The prevalence of lifestyle preventive services, including exercise therapy, nutrition therapy, patient education or counseling, were analyzed. Patients older than 61 years and white patients were offered more exercise therapy than their comparable demographics. The southern region of the U.S. and patients with Medicaid or state insured plans were offered and utilized the most exercise therapy, nutrition therapy and education. Family practice physicians and internists defined as primary care physicians offered the most exercise therapy, nutrition therapy and education services. Majority of the studied population were not offered exercise therapy, nutrition therapy, or education services, indicating the need for more preventative lifestyle services. Conclusions: Overall, the findings of this study revealed that there was a significant difference in the utilization and offering of preventive resources amongst various demographic groups and physician characteristics. This confirms the prevalence of disparities in the U.S. Healthcare System and calls for the need to narrow this gap both at the policy and community level.

Analysing student achievement of advanced pharmacy practice experience learning outcomes

Objectives: To assess the learning outcome achievement of the required Advanced Pharmacy Practice Experiences (APPE) for the purposes of accreditation, quality improvement, and practice readiness. Methods: At the end of each APPE rotation, students were evaluated on 11 professionalism criteria and 25 skills criteria via a rubric. For the four required rotations (ambulatory patient care, community pharmacy, inpatient general medicine patient care and hospital/health system pharmacy), professionalism and skills outcomes data for the class of 2020 were analysed. Results: A total of 6,293/6,303 (99.84%) of the professionalism ratings met expectations (received a score > 2). The median professionalism rating was 3. A total of 14,286/14,325 (99.7%) of the skills ratings met expectations (received a score > 3). The median skills rating was 4. Conclusion: Calculating and analysing APPE student achievement of learning outcomes supports accreditation standards, can be used for quality improvement and measures practice readiness.

Telemedicine During COVID-19 Pandemic: Endocrine Surgery Patient Perspective.

IntroductionIn response to the COVID-19 pandemic, many medical providers have turned to telemedicine as an alternative method to provide ambulatory patient care. Perspectives of endocrine surgery patients regarding this mode of healthcare delivery remains unclear. The purpose of this study is to evaluate the opinions and perspectives of endocrine surgery patients regarding telemedicine.MethodsThe first 100 adult patients who had their initial telemedicine appointment with two endocrine surgeons were contacted at the conclusion of their visit. The survey administered assessed satisfaction with telemedicine, the provider, and whether attire or video background played a role in their perception of the quality of care received using a 5-point Likert scale. Differences in responses between new and returning patients were also evaluated.ResultsTelemedicine endocrine surgery patients stated excellent satisfaction with their visit (4.89 out of 5) and their provider (4.96 out of 5). Although there was less consensus that telemedicine was equivalent to in-person or face-to-face clinic visits (4.15 out of 5), patients would recommend a telemedicine visit to others and most agreed that this modality made it easier to obtain healthcare (4.7 out of 5). Attire of the provider and video background did not influence patient opinion in regard to the quality of care they received. Returning patients were more likely to be satisfied with this modality (4.94 versus 4.73, P = 0.02) compared to new patients.ConclusionsThis study shows that telemedicine does not compromise patient satisfaction or healthcare delivery for patients and is a viable clinic option for endocrine surgery.

The risks of polypharmacy in ambulatory and home care patients affected with dementia: The PharE Study

AbstractBackgroundOlder patients affected with comorbidities often take a lot of potentially inappropriate drugs. This can cause side effects, hospitalization and even death.AimThe aim of the present study was to assess dangerous drug interactions and potentially inappropriate drugs administered to a sample of ambulatory and home care patients affected with dementia.Methods41 ambulatory outpatients and 53 home care patients affected with dementia were selected randomly between January 1st 2017 and December 31st 2019. They were visited at the Center for Cognitive Disorders and Dementia, Catanzaro Lido, Italy.Personal, clinical data and drugs taken were collected; comorbidities were assessed through CIRS, ADL, IADL, MMSE. Beers criteria were used in order to assess the potentially inappropriate drugs.ResultsOf 100 patients, 64 were women and 36 men, mean age 83,7 ± 4,9 and 82,1 years old ± 11,8 years old respectively. 50% of them were affected with mixed dementia, 13% Alzheimer’s dementia, 9% Parkinsonism, 10% depression with associated cognitive impairment, 18% dementia of other kind. Mean MMSE score was 15,99 ± 8,84. Each patient was taking 9,17 ± 3,31 drugs on the average, 56% of them 5‐9 drugs and 39% 10 drugs or more. 66% of patients was taking one inappropriate drugs or more, proton pump inhibitors (PPI) (51%), atypical and conventional antipsychotics (23% and 6% respectively), benzodiazepines, amiodarone, calcium antagonists (3%), tricyclic antidepressants and a‐blockers (2%), old generation anti‐histamine drugs (1%). 56% of them were taking a drug with anticholinergic properties.ConclusionsThe study shows a high percentage of drugs with anticholinergic properties, which can increase the risk for dementia or even worsen cognitive impairment. Furthermore, inappropriate drugs were stopped and changed with more tolerated compounds. PPI use was dramatically reduced. The study suggests the need for a careful check of treatment in every patient, and for personalizing treatment in older patients with dementia. A larger sample could bring more information to healthcare providers as well as the use of softwares for helping doctors to limit the risk for drug interactions.

Falls in older ambulatory care patients with cancer in Iran: Implications for clinical practice.

Falls can have severe consequences particularly for older patients with cancer undergoing ambulatory care. The aim of the study is to identify the predictors of falls in older patients receiving cancer ambulatory care and evaluate the accuracy of the final multivariable model in detecting older patients with falls. A retrospective study was conducted on 300 older patients aged 60 years and above that were referred for ambulatory care in three oncology clinics based at hospitals in Tehran, Iran. Participants completed a questionnaire comprising demographic, history of falls, and cancer-related factors. Logistic regression was used to determine risk factors associated with falls. A total of 35.3% of the older patients with cancer had experienced a fall in the 6 months following the start of their ambulatory care. The most important predictors of falls include the fourth stage of cancer (odds ratio [OR]: 6.47, 95% confidence interval [CI]: 3.20-13.08, p < 0.001), fear of falling (OR: 5.64, 95% CI: 2.58-12.33, p < 0.001), use of hearing (OR: 2.38, 95% CI: 1.07-5.29, p = 0.033) and visual aids (OR: 2.36, 95% CI: 1.12-5.01, p = 0.025), and the number of visits to the doctor (OR: 1.10, 95% CI: 1.01-1.21, p = 0.035). The results indicate that a reduction in falls is possible by introducing strategies to improve care for older patients in the advanced stage of cancer, eliminating the causes of fear of falling, examining and improving vision and hearing, and identifying and addressing the underlying causes of visits to the doctor.

Hospital Management and Ambulatory Patient Care After COVID-19 Infection in Kidney Transplant

BackgroundA large number of registries have been collected for kidney transplant recipients infected with COVID-19.MethodsFrom March 2020 to April 2021, our team conducted an observational study, which included all patients who showed a polymerase chain reaction positive for COVID-19. Patients were divided into 2 groups: patients who required ambulatory care and patients who needed hospital admission.ResultsA total of 76 kidney transplant recipients were infected with COVID-19. A total of 33% required hospital admission and 65% received ambulatory treatment; 28% of our patients were asymptomatic and 6.8% died. Immunosuppressive treatment was modified in both study groups, and there were not any acute rejection episodes or changes in the human leukocyte antigen antibodies profile in our patients during our clinical trial.ConclusionsIn our study there was a significant percentage of patients who did not require hospital admission compared with other studies. In addition, we think that the reduction of immunosuppression can be a safe and reliable treatment.

The role of patient navigators in ambulatory care: overview of systematic reviews

BackgroundPatient navigators have been introduced across various countries to enable timely access to healthcare services and to ensure completion of diagnosis and follow-up of care. There is an increasing evidence on the the role of patient navigation for patients and healthcare systems. The aim of this study was to analyse the evidence on patient navigation interventions in ambulatory care and to evaluate their effects on individuals and health system outcomes.MethodsAn overview of reviews was conducted, following a prespecified protocol. All patients in ambulatory care or transitional care setting were included in this review as long as it was related to the role of patient navigators. The study analysed patient navigators covering a wide range of health professionals such as physicians, nurses, pharmacists, social workers and lay health workers or community-based workers with no or very limited training. Studies including patient-related measures and health system-related outcomes were eligible for inclusion. A rigorous search was performed in multiple data bases. After reaching a high inter-rater agreement of 0.86, title and abstract screening was independently performed. Of an initial 14,248 search results and an additional 62 articles identified through the snowballing approach, a total of 7159 hits were eligible for title/abstract screening. 679 articles were included for full-text screening.ResultsEleven systematic reviews were included covering various patient navigation intervention in cancer care, disease screening, transitional care and for various chronic conditions and multimorbidity. Nine systematic reviews primarily tailored services to ethnic minorities or other disadvantaged groups. Patient navigators performed tasks such as providing education and counselling, translations, home visits, outreach, scheduling of appointments and follow-up. Eight reviews identified positive outcomes in expanding access to care, in particular for vulnerable patient groups. Two reviews on patient navigation in transitional care reported improved patient outcomes, hospital readmission rates and mixed evidence on quality of life and emergency department visits. Two reviews demonstrated improved patient outcomes for persons with various chronic conditions and multimorbidity.ConclusionsPatient navigators were shown to expand access to screenings and health services for vulnerable patients or population groups with chronic conditions who tend to underuse health services.

Treating patients with advanced heart failure in a community-based multidisciplinary team clinic is associated with significant reduction of healthcare utilization and costs

Abstract Background/Introduction Heart failure (HF) care imposes a major economic burden, accounting for 1–3% of healthcare expenditure in developed countries. The greatest proportion of this cost (60%-70%) is accounted for by hospitalizations. A multidisciplinary team (MDT) approach in HF management is a key recommendation in international guidelines, to reduce mortality and HF hospitalization. Purpose To investigate whether a community-based MDT in an HF unit (HFU) had an impact on patients' healthcare utilization (HCU), and their associated costs. Methods A retrospective cohort study was conducted among members of the country's largest HMO, who visited at least once in a regional community-based HFU, established to provide ambulatory specialist care for patients with advanced HF, emphasizing patients in NYHA functional class III and IV, especially those with recurrent hospitalizations. HCU data were obtained from the HMO's claims data for 12 months before and after first HFU visit. Results Our cohort consisted of 962 patients, of whom 843 (87.6%) completed at least 12 months of follow-up, and 119 (12.4%) died during the 12 months following their first HFU visit. Both groups were comparable with regard to sex, socioeconomic status, Charlson comorbidity index, prevalence of IHD and/or carotid artery disease, AF, obesity, and chronic pulmonary disease. Those who died within 12 months were older, had more hypertension, hyperlipidaemia, diabetes, chronic renal disease and malignancy but were less likely to be smokers or to have supplementary health insurance coverage. There was a significant reduction in the total average HCU costs of the entire study population 12 months after the first HFU visit ($12,675 after vs. $13,188 before, p=0.014). However, while a reduction in these costs was observed among patients who completed 12 months of follow-up ($11,955 after vs. $13,112 before, p&amp;lt;0.001), an increase in these costs was observed among patients who died during follow-up ($17,774 after vs. $13,728 before, p=0.015). These opposite trends stem from a decrease ($3,540 after vs. $4,941 before, p&amp;lt;0.001) versus increase ($10,932 after vs. $6,733 before, p=0.002) in hospitalization costs of these groups, respectively, and an increase ($1,272 after vs. $928 before, p&amp;lt;0.001) versus decrease ($799 after vs. $1,116 before, p&amp;lt;0.001) in medication costs of these subgroups, respectively. Conclusion(s) Intensification of therapy by a dedicated MDT significantly reduced costs of HCU, predominantly because of a decrease in hospitalizations. This saving was noted even when including patients who died within a year of commencing treatment in our HFU (a group in whom healthcare costs are known to be excessive). A widespread establishment of dedicated community-based units, should be encouraged. Funding Acknowledgement Type of funding sources: None.

Comparative Analyses of Three Point-of-Care Urine Drug Test Devices'Performance Characteristics for Use in Ambulatory Clinic Settings.

Urine drug testing (UDT) is a standard practice used for monitoring controlled and illicit substances in ambulatory care patients. Point-of-care (POC) UDTs are useful tools that allow for drug identification within minutes, providing rapid and objective diagnostic assistance for clinicians. The objective of this study was to evaluate the performance characteristics of 3 different POC UDT devices compared to reference methods. A total of 106 residual urine specimens were collected to evaluate the 3 POC UDT devices: the Profile®-V MEDTOX Scan® drugs of abuse test, Quidel Triage® TOX Drug screen, and Quidel Triage Rapid OXY-BUP-MDMA panel. Device performance was assessed by their ability to identify drug classes/compounds compared to manufacturer and reference method (mass spectrometry) cutoffs. The results from quantitative mass spectrometry showed that 77% (84/106) of the samples were positive for one or more drugs. Each device had variable performance across each drug class. Overall, the specificity of the Profile-V MEDTOX Scan test was 90.1%, while the Quidel Triage TOX Drug Screen and Rapid OXY-BUP-MDMA devices had specificities of 89.0% and 50.0% using their respective manufacturer-stated cutoffs. Overall sensitivity was determined to be 98.6%, 97.0%, and 100% for the Profile-V MEDTOX Scan, Quidel Triage TOX Drug Screen, and Rapid OXY-BUP-MDMA, respectively. Of the 3 POC UDT devices evaluated, the Profile-V MEDTOX Scan demonstrated the best overall sensitivity and specificity compared to reference methods. False positive and negative results are possible with UDTs, ultimately the best device may depend on patient population and drugs of interest.

Predictors of adherence to patient reported outcomes and psychosocial needs questionnaire in a culturally diverse ambulatory oncology setting: The My Wellness Check Program.

173 Background: Electronic health record (EHR) integrated symptom monitoring using patient reported outcomes (PRO) has been associated with improved outcomes, including health-related quality of life (HRQoL), in cancer survivors. However, these improvements have been documented through reasonably high completion rates of PRO measures in predominantly non-Hispanic White patient populations using only English language assessments. This study aimed to 1) examine factors associated with the completion of PRO assessments and 2) test differences in referrals to cancer support services between PRO responders and non-responders in a cohort of cancer survivors with significant racial, ethnic, and primary language diversity. Methods: A retrospective analysis (October 2019-February 2021) was performed for patients who were assigned the My Wellness Check (MWC) program at a tertiary, comprehensive cancer center. MWC is an EHR-based PRO assessment and referral program that uses PROMIS computer adaptive tests for depression, anxiety, pain, fatigue, and physical function as well as a psychosocial needs assessment. MWC PRO questionnaire is available in English or Spanish based on patient preference. Demographic and clinical characteristics of patients were collected and incorporated in multivariable binary logistic regression model to examine factors associated with completion of the MWC PRO questionnaires. The frequency of referrals to cancer support services was compared by Chi-square test between MWC PRO responders and non-responders. Adjusted odds ratio (aOR) and 95% confidence interval (95%CI) were calculated. Results: Of the 5306 patients eligible to complete MWC PRO questionnaire, the majority were female (64.1%), White (86.9%), Hispanic (65.8%), English speaker (55.4%), and 46.0% were responders. Patients who were younger than 65 (aOR 1.39; 95%CI 1.22-1.59; p &lt; 0.0001), female (1.23; 1.09-1.41; p = 0.0019), non-Hispanic/Latino (1.43; 1.25-1.64; p &lt; 0.0001), living with partners ( = 1.28; 1.13-1.46; p = 0.0001), and receipt of active treatment (1.37; 1.18-1.58; p &lt; 0.0001) were significantly associated with MWC PRO completion. Responders were referred to cancer support services more often than non-responders (16.6% vs 5.4%, p &lt; 0.0001). Conclusions: Patient-level and clinical factors predict completion of PRO measures, and responders were more likely to have a referral to cancer support services. To optimize supportive care for ambulatory cancer patients, further research is needed to identify factors that can promote patient engagement, particularly in patients who are under-utilizers of such services.

The impact of COVID-19 pandemic on the utilization of ambulatory care for patients with chronic neurological diseases in Japan: Evaluation of an administrative claims database.

The COVID-19 pandemic has affected not only the emergency medical system, but also patients' regular ambulatory care, as such decrease in the number of patients visiting outpatient clinics decreased in 2020 than in 2019, or the ban lifting of subsequent visits by telephone for outpatient clinics since March 2020 in lieu of ambulatory care for chronic diseases. In this context, we investigate the impact of the COVID-19 pandemic on ambulatory care at Japanese outpatient clinics for patients with chronic neurological diseases during 2020. We collected data from the administrative claims database (DeSC database) covering more than 1 million individuals. Serial changes in the frequency of subsequent outpatient visits to clinics or hospitals (excluding large hospitals) for chronic ambulatory care of epilepsy, migraine, Parkinson's disease (PD), and Alzheimer's disease (AD) in 2020 were measured. As a result, since April 2020, the monthly outpatient visits for epilepsy, PD, and AD decreased slightly but significantly (approximately 0.90 in relative risk [RR]) but visits for migraine increased (RR = 1.15). Telephone visit was most frequently used in April-May, in less than 5% of monthly outpatient clinic visits for the examined neurological diseases. Outpatient visits for migraine treatment were more likely to be done by telephone than in case of other diseases (adjusted Odds ratio = 2.08). These results suggest that the impact of COVID-19 pandemic on regular ambulatory care for several chronic neurological diseases yielded different effect depending on the disease, in terms of the frequency or type of outpatient visits.

Screening and treatment of familial hypercholesterolemia in a French sample of ambulatory care patients: A retrospective longitudinal cohort study.

Untreated Familial Hypercholesterolemia (FH) leads to premature morbidity and mortality. In France, its epidemiology and management are understudied in ambulatory care. We described the clinical profile, pharmacological management, and clinical outcomes in a French sample of FH patients. This was a retrospective longitudinal study on patients from The Health Improvement Network (THIN®) database in France, between October 2016-June 2019. Patients ≥18 years, with probable/definite FH based on the Dutch Lipid Clinic Network (DLCN) criteria were included. Baseline characteristics, lipid profile, lipid-lowering therapy (LLT), low-density lipoprotein-cholesterol (LDL-C) goal achievement; and disease management at 6-month of follow-up were analyzed. 116 patients with probable (n = 70)/definite (n = 46) FH were included (mean age:57.8±14.0 years; 56.0% women; 9.5% with personal history of cardiovascular events); 90 patients had data available at follow-up. At baseline, 77.6% of patients had LDL-C>190 mg/dL, 27.6% were not receiving LLTs, 37.9% received statins alone, 20.7% statins with other LLTs, and 7.7% other LLTs. High-intensity statins were prescribed to 11.2% of patients, 30.2% received moderate-intensity statins, and 8.6% low-intensity statins. Only 6.0% of patients achieved LDL-C goal. At 6-month of follow-up, statins discontinuation and switching were 22.7% and 2.3%, respectively. None of the patients received proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors at baseline nor follow-up. Despite the existence of effective LLTs, FH patients are suboptimally-treated, do not achieve LDL-C goal, and exhibit worsened pharmacological management over time. Future studies with longer follow-up periods and assessment of factors affecting LDL-C management, including lifestyle and diet, are needed.

Patient characteristics associated with the successful transition to virtual care: Lessons learned from the first million patients

Introduction The increased use of telehealth to maintain ambulatory care during the COVID-19 pandemic had potential to exacerbate or diminish disparities in access to care. Objective The purpose of this study was to describe patient characteristics associated with successful transition from in-person to virtual care, and video vs audio-only participation. Methods This was a retrospective analysis of electronic health record data from all patients with ambulatory visits from 1 October 2019–30 September 2020 in a large integrated health system in the Northeast USA. The outcome of interest was receipt of virtual care, and video vs audio-only participation. We matched home addresses with census-tract level area social vulnerability index (SVI) and Internet access. Among ambulatory care patients, we used logistic regression to identify characteristics associated with virtual participation. Among virtual participants, we identified characteristics associated with video vs audio-only visits. Results Among 1,241,313 patients, 528,542 (42.6%) were virtual participants. Relative to in-person only, virtual participants were older, more often English-proficient and with activated patient portal. Characteristics associated with virtual participation included patients with: only behavioural health visits, COVID patients, highest quartile of visit frequency, and multiple visit types. Characteristics associated with video participation (relative to audio-only) included being younger and patients with: only behavioural health visits, highest quartile of visit frequency, non-Hispanic black race, limited English proficiency and inactivated portal account. Discussion In our regional healthcare system, the transition to virtual care during COVID was vital for continued access to care, but substantial inequity remained. Without audio-only visits, access to care would have been even more limited for our most vulnerable patients.

Implementation of warfarin to direct oral anticoagulant conversion initiative in pharmacist-run anticoagulation clinics during COVID-19 pandemic.

Due to community transmission of coronavirus disease 2019 (COVID‐19), social distancing and stay‐at‐home orders were implemented statewide in an effort to limit the spread of disease. This posed unique challenges for patients on medications requiring close and continued monitoring by clinic staff, such as anticoagulation clinics. Thus, innovative measures were implemented at Cleveland Clinic Health System (CCHS) to maintain the health and care of ambulatory patients. An initiative to evaluate patients for warfarin to direct oral anticoagulants (DOAC) conversion was used in the pharmacist‐run anticoagulation clinics. This article describes how patients were screened for eligibility, the education to pharmacists, the utilization of student learners in the process, and the workflow for provider notification of conversion. Follow up monitoring, challenges encountered, and future directions are also described.

Evaluating Nutrition Services in Outpatient Cancer Centers in New Mexico – A Pilot Study Protocol

ObjectivesNationally, 50% of all cancer patients experience malnutrition upon diagnosis or during the course of treatment. When registered dietitian nutritionists (RDNs) are involved in oncology treatment, outcomes improve, with a reduction in financial burden for the patient and health delivery system. Despite the high prevalence of outpatient treatment utilization (up to 90% of cancer patients), RDN understaffing is common in outpatient cancer treatment settings. The goal of this pilot project is to characterize and understand factors at the organizational level (e.g., policies and practices) and provider level (e.g., knowledge, attitudes, practices and needs) that affect implementation of nutrition standards of practice at outpatient oncology clinics in New Mexico (NM). Characterizing current nutrition resources in distinct regions across the state is crucial to the development of effective interventions to improve access to RDN nutrition care across NM. MethodsWe will conduct a comprehensive, 7-domain, nutrition-focused environmental scan of ∼15 treatment centers and surrounding areas. Data collected will include clinic catchment area information; patient and area census demographics; clinic screening and referral policies; clinic technical, financial, and personnel resources; and community nutrition resources. We will then conduct ∼50 semi-structured interviews of stakeholders, including administrators and medical and RDN providers, at ∼10 of these treatment facilities to contextualize the results of the environmental scan. Qualitative interviews will explore facilitators and barriers to provision of guideline concordant nutrition care. We will perform a case study analysis (both within-case and cross-case) of sites and examine the identified resources and gaps to care in each region and will note differences across settings (e.g., urban vs. rural centers). ResultsN/A. ConclusionsThis innovative, mixed-methods study will provide a context-driven inventory of nutrition processes, services, and resources at outpatient cancer treatment clinics in NM. These data will inform a tailored intervention to improve access to nutrition care for ambulatory oncology patients throughout NM. Funding SourcesAmerican Cancer Society Institutional Research Grant; NCI Cancer Center Support Grant.

Assessment of adherence to pneumonia guidelines and its determinants in an ambulatory care clinic in Ghana: findings and implications for the future.

BackgroundAdherence to local standard guidelines is seen as a pragmatic way to measure and improve the quality of future prescribing in ambulatory care to reduce morbidity, mortality and healthcare costs.ObjectivesTo evaluate adherence to the Ghana Standard Treatment Guidelines (STGs) for the empirical antibiotic treatment of ambulatory care patients with community-acquired pneumonia (CAP) in a region in Ghana and factors associated with it.MethodsA cross-sectional survey was conducted using a checklist to collect data from the hospital electronic database, which included sociodemographic details, payment type and clinical information of all ambulatory patients attending Keta Municipal Hospital, diagnosed and managed for CAP from September 2018 to January 2019. Prescriptions were assessed for adherence to the Ghana STG based on choice of antibiotics. A χ2 test and multiple logistic regression were subsequently conducted.ResultsA total of 1929 patient records with diagnosis of CAP within the study period at the ambulatory clinic were identified. The overall rate of adherence to the Ghana STG was 32.50% (n = 627). From the patient records collected, 62.50% were female, 41.84% were children (0–12 years), and 97.15% had a valid national health insurance status. Adherence was associated with the duration of antibiotic prescribing, number of additional antibiotics prescribed and some patients’ clinical characteristics.ConclusionsThe rate of adherence to Ghana STG among the study population was low. Efforts must be made to train and encourage prescribers to follow empirical guidelines to reduce inappropriate selection of antibiotics in the ambulatory care settings.

Reception of patients with chronic renal failure, COVID-19

The renal disease center of the university hospital of Caen Normandy (14) is dedicated to the ambulatory care of patients with chronic renal disease, including those treated by dialysis or transplanted. These are fragile patients and, for many of them, coming to the center is inevitable for their care. Faced with the COVID-19 pandemic, the care teams have shown a great capacity to adapt, even to be creative, in order to welcome and care for them in optimal safety conditions.

Staff wellbeing: a matter for quality indicators or a concern in its own right?

Despite assurance measures being developed alongside expanding scopes of practice, poor NHS ambulance staff wellbeing means high-quality job performance and patient care are not guaranteed. The UK's service is struggling to cope with growing demand and is not fully adapting from its historical emergency response role to meet modern-day urgent care needs. This puts unnecessary pressures and risks of stress from exhausting, intense work on to its most valuable resource: staff. Detrimental workplace cultures exacerbate this, along with added target-driven strain from non-evidence-based ambulance quality indicators. With poor support, communication, leadership and mental wellbeing provision, staff are increasingly dissatisfied, demoralised and experiencing a myriad of health problems. Consequences include excessive staff sickness absences and turnover as well as an up to 75% higher suicide risk. Trusts should collaborate to identify and address the causes of demand that cannot be met, and chief executives and boards should work with staff to prioritise structured wellbeing assessment and improvement. Further research is also needed.

Differences between Frequentist and Bayesian inference in routine surveillance for influenza vaccine effectiveness: a test-negative case-control study

BackgroundRoutine influenza vaccine effectiveness (VE) surveillance networks use frequentist methods to estimate VE. With data from more than a decade of VE surveillance from diverse global populations now available, using Bayesian methods to explicitly account for this knowledge may be beneficial. This study explores differences between Bayesian vs. frequentist inference in multiple seasons with varying VE.MethodsWe used data from the United States Influenza Vaccine Effectiveness (US Flu VE) Network. Ambulatory care patients with acute respiratory illness were enrolled during seasons of varying observed VE based on traditional frequentist methods. We estimated VE against A(H1N1)pdm in 2015/16, dominated by A(H1N1)pdm; against A(H3N2) in 2017/18, dominated by A(H3N2); and compared VE for live attenuated influenza vaccine (LAIV) vs. inactivated influenza vaccine (IIV) among children aged 2–17 years in 2013/14, also dominated by A(H1N1)pdm. VE was estimated using both frequentist and Bayesian methods using the test-negative design. For the Bayesian estimates, prior VE distributions were based on data from all published test-negative studies of the same influenza type/subtype available prior to the season of interest.ResultsAcross the three seasons, 16,342 subjects were included in the analyses. For 2015/16, frequentist and Bayesian VE estimates were essentially identical (41% each). For 2017/18, frequentist and Bayesian estimates of VE against A(H3N2) viruses were also nearly identical (26% vs. 23%, respectively), even though the presence of apparent antigenic match could potentially have pulled Bayesian estimates upward. Precision of estimates was similar between methods in both seasons. Frequentist and Bayesian estimates diverged for children in 2013/14. Under the frequentist approach, LAIV effectiveness was 62 percentage points lower than IIV, while LAIV was only 27 percentage points lower than IIV under the Bayesian approach.ConclusionBayesian estimates of influenza VE can differ from frequentist estimates to a clinically meaningful degree when VE diverges substantially from previous seasons.