Physician Contact Research Articles

M152. IS MEDICAL SERVICES UTILISATION A MODERATING FACTOR OF EARLY EXCESS MORTALITY IN PATIENTS WITH SCHIZOPHRENIA

BackgroundUnlike the general population, patients with schizophrenia have an excess of chronic physical morbidities such as diabetes, cardiovascular and respiratory disorders. In addition, they do no gain from primary and secondary medical services due to gaps in the accessibility and quality of those services. The result is a shorter life expectancy of about 20 years mostly due to preventable physical illnesses, of otherwise people with an exclusive brain disorder.In this study, we aimed to explore how does utilization of medical services moderate the association between physical morbidity and early mortality in schizophrenia patientsMethodsA retrospective cohort study derived from Clalit Health Services electronic database (the largest health provider in Israel, covers 53% of the national population). A three years follow-up (2012–2014) of 24,679 individuals with a diagnosis of schizophrenia (ICD 10 Code: F.20) and control general population (N=2,295,579), up to 75 years old age.ResultsSchizophrenia was associated with HR 3.52 (95% CI 3.35–3.72) for mortality, adjusted for age, sex and socioeconomic status. Patients’ mortality rate was 5.6% with about half dying from physical illnesses (cardiovascular, neoplasms, respiratory, and digestive disorders). Metabolic syndrome parameters were more prevalent in the schizophrenia population, with the exception of hypertension. While the adjusted Odd Ratio (OR) for primary physician (GP) contact was 0.42 for schizophrenia patients, the OR for hospitalization was 1.25 with more than double mean length of hospitalization. A higher number of contacts with GP or specialists was associated with lower mortality in patients with metabolic disturbancesDiscussionPatients with schizophrenia tend to die earlier, mostly from preventable physical illnesses also in Israel. Utilizing primary and secondary medical services was associated with better survival rates when having metabolic dysregulation. The main health policy implication of the study results is a call to establish a national system to detect and manage physical morbidity by increasing the accessibility of primary and secondary medical services for this high-risk population

Shingles Vaccination of U.S. Adults Aged 50–59 Years and ≥60 Years Before Recommendations for Use of Recombinant Zoster Vaccine

In 2006, zoster vaccine live was recommended for adults aged ≥60 years. In 2011, zoster vaccine live was approved for use but not recommended for adults aged 50-59 years. This study assessed zoster vaccine live coverage among adults aged 50-59 years and ≥60 years. Data from the 2013-2017 National Health Interview Surveys were analyzed in 2019 to estimate national zoster vaccine live coverage among adults aged ≥50 years. State-specific zoster vaccine live coverage among adults aged ≥50 years was assessed using 2017 Behavioral Risk Factor Surveillance System data. Among adults aged 50-59 years, zoster vaccine live coverage was 5.7% in 2017, ranging from 4% to 6% during 2013-2017 (test for trend, p>0.05). Zoster vaccine live coverage among adults aged 50-59 years ranged from 5.8% in Pennsylvania to 14.7% in South Dakota. By 2017, zoster vaccine live was received by 34.9% of adults aged ≥60 years, a significant increase from 24.2% in 2013. Zoster vaccine live coverage among adults aged ≥60 years in 2017 ranged from 26.0% in Mississippi to 51.8% in Vermont. In 2017, major characteristics significantly associated with increased likelihood of zoster vaccine live vaccination among adults aged 50-59 years and ≥60 years were older age, having 4 to 9 physician contacts in the past 12 months, and having a usual place for health care. This study provides an assessment of zoster vaccine live coverage among adults aged ≥50 years before the newly recommended recombinant zoster vaccine came into widespread use. Providers should routinely assess adults' vaccination status and strongly recommend or offer needed vaccines to their patients.

Epidemiology, characteristics and treatment of patients with relapsing remitting multiple sclerosis and incidence of high disease activity: Real world evidence based on German claims data.

BackgroundMultiple Sclerosis (MS) is a chronic inflammatory, immune mediated disease of the central nervous system, with Relapsing Remitting MS (RRMS) being the most common type. Within the last years, the status of high disease activity (HDA) has become increasingly important for clinical decisions. Nevertheless, little is known about the incidence, the characteristics, and the current treatment of patients with RRMS and HDA in Germany. Therefore, this study aims to estimate the incidence of HDA in a German RRMS patient population, to characterize this population and to describe current drug treatment routines and further healthcare utilization of these patients.MethodsA claims data analyses has been conducted, using a sample of the InGef Research Database that comprises data of approximately four million insured persons from around 70 German statutory health insurances (SHI). The study was conducted in a retrospective cohort design, including the years 2012–2016. Identification of RRMS population based on ICD-10 code (ICD-10-GM: G35.1). For identification of HDA, criteria from other studies as well as expert opinions have been used. Information on incidence, characteristics and current treatment of patients with RRMS and HDA was considered.ResultsThe overall HDA incidence within the RRMS population was 8.5% for 2016. It was highest for the age group of 0–19 years (29.4% women, 33.3% men) and lowest for the age group of ≥ 50 years (4.3% women, 5.6% men). Mean age of patients with RRMS and incident HDA was 38.4 years (SD: 11.8) and women accounted for 67.8%.Analyses of drug utilization showed that 82.4% received at least one disease-modifying drug (DMD) in 2016. A percentage of 49.8% of patients received drugs for relapse therapy. A share of 55% of RRMS patients with HDA had at least one hospitalization with a mean length of stay of 13.9 days (SD: 18.3 days) in 2016. The average number of outpatient physician contacts was 28.1 (SD: 14.0).ConclusionsThis study based on representative Germany-wide claims data from the SHI showed a high incidence of HDA especially within the young RRMS population. Future research should consider HDA as an important criterion for the quality of care for MS patients.

Patient and primary care physician characteristics associated with billing incentives for chronic diseases in British Columbia: a retrospective cohort study.

Incentive payments for chronic diseases in British Columbia were intended to support primary care physicians in providing more comprehensive care, but research shows that not all physicians bill incentives and not all eligible patients have them billed on their behalf. We investigated patient and physician characteristics associated with billing incentives for chronic diseases in BC. We conducted a retrospective cohort analysis using linked administrative health data to examine community-based primary care physicians and patients with eligible chronic conditions in BC during 2010-2013. Descriptive analyses of patients and physicians compared 3 groups: no incentives in any of the 4 years, incentives in all 4 years, and incentives in any of the study years. We used hierarchical logistic regression models to identify the patient- and physician-level characteristics associated with billing incentives. Of 428 770 eligible patients, 142 475 (33.2%) had an incentive billed on their behalf in all 4 years, and 152 686 (35.6%) never did. Of 3936 physicians, 2625 (66.7%) billed at least 1 incentive in each of the 4 years, and 740 (18.8%) billed no incentives during the study period. The strongest predictors of having an incentive billed were the number of physician contacts a patient had (odds ratio [OR] for > 48 contacts 134.77, 95% confidence interval [CI] 112.27-161.78) and whether a physician had a large number of patients in his or her practice for whom incentives were billed (OR 42.38 [95% CI 34.55-52.00] for quartile 4 v. quartile 1). The findings suggest that primary care physicians bill incentives for patients based on whom they see most often rather than using a population health management approach to their practice.

Emergency department-based medication review on outpatient health services utilization: interrupted time series

BackgroundOne in nine emergency department (ED) visits in Canada are caused by adverse drug events, the unintended and harmful effects of medication use. Medication reviews by clinical pharmacists are interventions designed to optimize medications and address adverse drug events to impact patient outcomes. However, the effect of medication reviews on long-term outpatient health services utilization is not well understood. This research studied the effect of medication review performed by clinical pharmacists on long-term outpatient health services utilization.MethodsData included information from 10,783 patients who were part of a prospective, multi-centre quality improvement evaluation from 2011 to 2013. Outpatient health services utilization was defined as total ED visits and physician contacts, aggregated to four physician specialty groups: general and family practitioners (GP); medical specialists; surgical specialists; and imaging and laboratory specialists. During triage, patients deemed high-risk based on their medical history, were systematically allocated to receive either a medication review (n = 6403) or the standard of care (n = 4380). Medication review involved a critical examination of a patient’s medications to identify and resolve medication-related problems and communicate these results to community care providers. Interrupted time series analysis compared the effect of the intervention on health services utilization relative to the standard of care controlling for pre-intervention differences in utilization.ResultsED-based pharmacist-led medication review did not result in a significant level or trend change in the primary outcome of total outpatient health services utilization. There were also no differences in the secondary outcomes of primary care physician visits or ED visits relative to the standard of care in the 12 months following the intervention. Our findings were consistent when stratified by age, hospital site, and whether patients were discharged on their index visit.ConclusionThis was the first study to measure long-term trends of physician visits following an ED-based medication review. The lack of differences in level and trend of GP and ED visits suggest that pharmacist recommendations may not have been adequately communicated to community-based providers, and/or recommendations may not have affected health care delivery. Future studies should evaluate physician acceptance of pharmacist recommendations and should encourage patient follow-up to community providers.

Electronic charting of transfusion medicine consults: implementation, challenges and opportunities.

The Joint Commission lists improving staff communication (handoffs) as part of several National Safety Goals. In this study, we developed an electronic web-based charting system for clinical pathology handoffs, which primarily consist of transfusion medicine calls, and evaluated the advantages over a paper-based handwritten call log. A secure online web browser application using Research Electronic Data Capture (REDCap) was designed to document on-call pathology resident consults. A year after implementation, an online survey was administered to our pathology residents in order to evaluate and compare the usability of the electronic application (e-consults) to the previous handwritten call log, which was a notebook where trainees hand wrote different components of the consult. The REDCap web-based application includes discrete fields for patients' information, requesting physician contact, type of consult, action items for follow-up and faculty responses, as well as other information. These components have eventually progressed to be an online consult call catalog. With approximately 1079 consults per year, transfusion medicine-related calls account for ~90% of the encounters, while clinical chemistry, microbiology and immunology calls constitute the remainder. The overall response rate of the survey was 96% (29 of 30 participants). Of the 16 respondents who experienced both call log systems, 100% responded that REDCap was an improvement over the handwritten call log (P<0·0001). E-consult documentation entered into a web-based application was a user-friendly, secure clinical information access and effective handoff system as compared to a paper-based handwritten call log.

Case Study: Daily Review of Telemonitoring Data by a Critical Care Nurse Improves Outcomes in a Patient with Class IV, Stage D Heart Failure with Reduced Ejection Fraction Receiving Home Intravenous Dobutamine for Palliation.

Purpose The purpose of this case study is to demonstrate how a robust telemonitoring program, which includes daily critical care nurse review of heart failure symptoms, vital signs, oxygen saturation, weight, and blood glucose levels, prompts clinical interventions that result in overall improved symptom management and decreased hospital readmissions for a patient requiring home inotrope infusion. Objectives 1. To summarize particular telemonitoring data that triggered nursing telephonic outreach for further patient evaluation 2. To summarize clinical interventions resulting from data and nursing telephonic outreach 3. To report patient outcomes (symptom improvement and avoidance of hospitalizations) Methods A retrospective review of this patient's medical record was performed, which consisted of telemonitoring data, physician order changes, and clinical assessments performed by critical care nurses. Results This 50-year-old male with Class IV, Stage D heart failure with reduced ejection fraction was admitted to this home infusion provider on 03/26/2015 to receive palliative treatment with continuous intravenous dobutamine 2.5 mcg/kg/min and daily telemonitoring. He was not a candidate for advanced heart failure therapies, such as left ventricular assist device or heart transplant, due to prior noncompliance with his treatment plan. The first telemonitoring data was transmitted on 03/28/2015. The patient was largely compliant with daily data transmissions throughout the course of care, which ended 06/03/2015 when the patient's insurance changed and the payor mandated transfer of care to another home infusion provider. A telephonic assessment performed by a critical care nurse occurred each day the transmitted data triggered an alert. A total of 25 alerts were received and are summarized as follows: 1 increased lower extremity edema, 5 weight increased more than 2 pounds in 24 hours, 7 heart rate and blood pressure elevations, 2 blood glucose elevations, 1 increased orthopnea, 1 significant weight loss in 24 hours, and 8 missing daily data transmissions. These alerts and resulting telephonic assessments prompted 61 clinical interventions, which included: 32 nursing visits for IV furosemide administration, 7 patient education sessions, 1 additional dose of oral furosemide, 7 rechecks of blood pressure and heart rate, 6 physician contacts, and 8 patient contacts requesting health check/data transmission. Conclusions Daily critical care nurse telemonitoring resulted in nearly daily interventions with gradual stabilization of weight and vital signs, no decline in respiratory status, and no hospitalizations throughout 69 days of service. Of particular significance is the fact that telemonitoring improved the patient's compliance to his treatment plan, which resulted in an evaluation for a left ventricular assist device placement. Results

Impact of a Student Pharmacist Pilot Focused on the Transitions of Care Process From Emergency Department Visits to Family Medicine Follow-Up in a Rural Patient Setting

Introduction: Few would argue that emergency department utilization volumes do not tax the health system. Currently, there is not a process defined by Centers for Medicare and Medicaid Services for transitioning this patient population back to their primary physicians following emergency department visits. Resource limitations in a rural family medicine setting create barriers to dedicate focus on this important transitional care management from urgent care visits to primary care office. Objective: To describe a novel pilot process for transitional care management from the emergency department utilizing pharmacy student extenders to overcome resource limitation at a rural family medicine clinic and establish follow-up primary physician contact. Methods: From a master list provided, student pharmacists proactively telephoned patients and reviewed medication changes while assisting with scheduling follow-up appointments at the patient’s primary physician clinic. Results: The result of these efforts increased the communication with patients and resulted in a 26% (10/38) increase in follow-up appointments scheduled with a total increase of an additional 7 patients adhering to follow-up transitional appointment. Conclusion: This approach utilizing student extenders is a feasible and sustainable process that can increase patient contact when resources are limited, while serving as an educational tool for next generation providers.

Appropriateness of End-of-Life Care in People Dying With Dementia: Applying Quality Indicators on Linked Administrative Databases

ObjectivesDementia is a progressive incurable life-limiting illness. Previous research suggests end-of-life care for people with dementia should have a symptomatic focus with an effort to avoid burdensome interventions that would not improve quality of life. This study aims to assess the appropriateness of end-of-life care in people who died with dementia in Belgium and to establish relative performance standards by measuring validated population-level quality indicators. DesignWe conducted a retrospective observational study. Setting and ParticipantsWe included all persons deceased with dementia in 2015 in Belgium. Data from 8 administratively collected population-level databases was linked. MeasuresWe used a validated set of 28 quality indicators for end-of-life dementia care. We compared quality indicator scores across 14 healthcare regions to establish relative benchmarks. ResultsIn Belgium in 2015, 10,629 people died with dementia. For indicators of appropriate end-of-life care, people who died with dementia had on average 1.83 contacts with their family physician in the last week before death, whereas 68.4% died at home or in their nursing home of residence. For indicators of inappropriate end-of-life care, 32.4% were admitted to the hospital and 36.3% underwent diagnostic testing in the last 30 days before death, whereas 25.1% died in the hospital. In the last 30 days, emergency department admission varied between 19% and 31%, dispensing of gastric protectors between 18% and 42%, and antihypertensives between 40% and 53% between healthcare regions, with at least 25% of health regions below 46%. Conclusions and ImplicationsOur study found indications of appropriate as well as inappropriate end-of-life care in people with dementia, including high rates of family physician contact, as well as high percentages of diagnostic testing, and emergency department and hospital admissions. We also found high risk-adjusted variation for multiple quality indicators, indicating opportunity for quality improvement in end-of-life dementia care.

Abstract TP389: Collaborative Approach to Improving Tele Stroke Call Back Times

Background/Purpose: Emergency stroke evaluation requires rapid access to stroke experts for treatment decisions and advice, in many community settings this is facilitated through a hub and spoke telemedicine relationship. Since widespread adoption of the expanded endovascular time window, volume of calls to a single large academic hub stroke center have drastically increased and it was identified that there was a delay in achieving rapid connection to the hub sites which may result in delayed tPA evaluations. We sought to implement a focused process review to improve timely access to the hub stroke team. Methods: Leadership from the hub and spoke hospitals collaboratively reviewed and implemented steps to improve the time from spoke call out to hub call back for acute stroke. Interventions included: 1) Establishing a goal of less than 10 minutes for physician contact on all cases, 2) Revising spoke protocol to call out immediately following CT instead of after CT read, 3) Development of a stroke call out log that is shared between sites, 4) Hub hospital revised protocol to have cases within tPA time window bypass phone call and go directly to camera, 5) Exchange of direct cell phone numbers for follow-up questions on existing patients, 6) Weekly calls to discuss any video case time delays and time flow review, 7) development of a hub hospital call center escalation process for when the primary call physician has multiple calls coming in. Results: Data we analyzed through retrospective review of a prospectively collected database over a five month period. Results are displayed in the table 1. Conclusions: Improved process flow times within tele-stroke networks may be achieved through a focused collaborative relationship between hub and spoke hospitals with transparency of data and open discussion about barriers to achieving desired results.

A study on knowledge and self-care practices about Diabetes Mellitus among patients with type 2 Diabetes Mellitus attending selected tertiary healthcare facilities in coastal Karnataka

ObjectiveTo assess knowledge and self-care practices about Diabetes among patients with type 2 Diabetes Mellitus attending selected tertiary health care institutions. MethodsCross-sectional study was conducted to assess the knowledge and self-care practices about Diabetes among diagnosed Type 2 Diabetes Mellitus patients attending the out-patient facilities of Medicine Department at selected tertiary healthcare institutions of Udupi Taluk. The data collection occurred from January to March 2017. A total of 166 participants were included in the study and they were selected using consecutive sampling. Knowledge about Diabetes Mellitus was assessed using structured pre-tested questionnaire. Diabetes Self-Management Questionnaire-Revised version was used to assess self-care practices regarding Diabetes Mellitus. ResultsMost of the participants (>65%) had knowledge about different aspects of Diabetes. The Mean total score of self-care practices among participants without and with intensive insulin treatment was 6.25 ± 1.25SD and 6.20 ± 1.01SD respectively. Mean subscales score related to dietary control, glucose management and physician contact was almost the same as that of total mean scale score except for physical activity subscale score in both the group of patients. ConclusionThis study emphasizes the need to strengthen the initiatives related to generating awareness about diabetes and improving self-care practices related to it.

Impact of Physician Contact on Patient Anxiety During the Waiting Period After Embryo Transfer

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Development of a Sensor to Measure Physician Consultation Times.

The duration of patient–physician contact is an important factor for the optimisation of treatment processes in healthcare systems. Available methods can be labour-intensive and the quality is, in many cases, poor. A part of this research project is to develop a sensor system, which allows the detection of people passing through a door, including the direction. For this purpose, two time of flight sensors are combined with a door sensor and a motion detection sensor (for redundancy) on one single side of the door frame. The period between two single measurements could be reduced to 50 ms, which allows the measurement of walking speed up to 2 ms. The accuracy of the time stamp for each event is less than one second and ensures a precise documentation of the consultation time. This paper presents the development of the sensor system, the miniaturisation of the installation and first measurement results, as well as the measurement’s concept of quality analysis, including multiple door applications. In future steps, the sensor system will be deployed at different medical practices to determine the exact duration of the patient–physician interaction over a longer time period.

Cross-sectional study on patient-physician aggression in Belgium: physician characteristics and aggression types

ObjectivesThe aim of this Belgian research study was to describe the characteristics of physicians who are at increased risk for patient-physician aggression. Second, aggression subtypes were described and data were...

Sickle Cell Disease Post-Transplant Care Challenges in Nigeria: Systematic Institutional Neglect of Medical Tourism

Introduction: Allogeneic hematopoietic stem cell transplantation (Allo-HCT) is potentially curative in eligible patients with sickle cell disease (SCD). Long term survival remains a challenge following allo-HCT and factors that predict for longer term complications and late mortality include increased hospitalization within the first 100 days, low socioeconomic status and poor access to healthcare. A new cottage industry of medical tourism associated with allo-HCT has emerged where children and adults with SCD living in Africa are traveling to countries that provide allo-HCT. Recent advances in improved disease-free survival and overall survival has resulted in families seeking curative options outside of their low resource-setting. The decision for allo-HCT is heavily weighed to family preference without regards to post-transplant care in their local environment. Unfortunately, the long-term care required for many children following an allo-HCT transplant is usually not available in their home country. Thus, the family desiring an allo-HCT is put in an awkward situation where they may need to have follow-up care in their primary country at a medical facility where neither the expertise nor the resources are available to manage long-term complications of allo-HCT. To explore the relationship between transplant medical tourism and patients with SCD, we report a case series of children who received their allo-HCT in another country only to return back to Nigeria. Methods: We recently established a post-transplant care clinic at the Lagos University Teaching Hospital, Idi-Araba, Nigeria. This includes a multidisciplinary team of providers, physicians and nurses with expertise in transplant care, and collaboration from Vanderbilt University Medical Center, USA. All cases described received allo-HCT outside Nigeria and returned within 60-100 days post-transplant. Parental preference for curative option was main indication for seeking allo-HCT. Records were obtained through electronic and paper medical records. Results: All the four cases reported had sickle cell anemia (Hb SS). Cases 1-3 received reduced intensity haploidentical HCT with post-transplant cyclophosphamide (Haplo-HCT), using G-mobilized peripheral blood stem cell grafts from parental donors with sickle cell trait. They all received preconditioning with hydroxycarbamide, azacytidine, and hypertransfusion (Table). Case-1 was 2years old, initially evaluated at day +135 post-transplant, complications included grade-II acute GI graft-versus-host disease (GVHD) at day+37 post-transplant, febrile illness and pseudo-membranous colitis requiring repeat endoscopies and prolonged steroid therapy. Case 2 was 5-years-old, seen day+395 post-transplant self-discontinued immunosuppression and antimicrobial prophylaxis with no guidance (despite the original haplo-HCT required a minimum of 12 months of immunosuppression therapy). Similarly, Case 3 was 7-years-old, off immunosuppression prematurely, and yet to commence routine post-transplant immunizations. Case 4 was 5-year-old who received matched related myeloablative bone marrow transplant. He was seen at day +138 post-transplant. He had poor graft function, EBV reactivation requiring Rituximab chemotherapy. Other management challenges encountered by patient's post-transplant include timely monitoring of immunosuppression and graft function, provision of irradiated blood component transfusion support, provision of anti-malaria and anti-helminthic prophylaxis which are endemic locally. Further, no physician to physician contact was made to transfer the patient back to a hematologist or oncologist with knowledge about post-transplant medical care. Discussion: The argument for performing the allo-HCT in children moving back to a low-income country has to be weighed against the availability of a strategy for management of late complications of allo-HCT, such as chronic GVHD, infectious complications related to immune reconstitution, as well as endocrine and chronic metabolic syndromes. Ultimately, the decision to perform an allo-HCT in such situations must be done on a case-by-case basis with a clear contingency plan to manage transplant-related complications for at least 2 years after the procedure at a hospital with adequate transplant expertise and support measures. Disclosures No relevant conflicts of interest to declare.

Validation of the FIMA Questionnaire for Health-Related Resource Use Against Medical Claims Data: The Role Played by Length of Recall Period

Self-reported health care use of 1,552 participants was validated against medical claims data. Reliability was measured by intraclass correlation coefficient (ICC), sensitivity, specificity, and Cohen's Kappa. Linear regression models were used to investigate the association between validity and individual characteristics, health state, recall period (3, 6, or 12 months), or frequency of resource use. On average, participants were 74 years old; 95% rated the questionnaire as easy. The number of physician contacts was underestimated depending on recall period by 9 to 28% and the ICC was moderate (3/6/12 months, ICC 0.46/0.48/0.55), whereas contacts with physiotherapists were remembered quite well (ICC>0.75). Remembering the number of days in rehabilitation and hospital differed by recall periods (3/6/12 months); rehabilitation ICC=0.88/0.51/0.87; hospital ICC=0.69/0.88/0.66. Very good reliability of self-reported long-term care insurance benefits was found for all recall periods (Kappa>0.90) while agreement in self-reported medical aid was poor (Kappa<0.30); agreement in intake of medication was good (Kappa>0.40). The chance of agreement between self-reports and claims data significantly decreased with the number of contacts. Individuals with better health had a significantly higher chance of reporting contacts with physiotherapists accurately. The FIMA largely demonstrated good reliability. The FIMA is a coherent and valid instrument to collect health-related resource use in health economic studies in an elderly population.

The Ecology of Medical Care Before and After the Affordable Care Act: Trends From 2002 to 2016.

The initial ecology of medical care study was published in 1961, offering a framework by which to investigate individuals' contact with the medical system. We studied changes in the framework around the implementation of the Patient Protection and Affordable Care Act (ACA) within longer-term trends. The 2002-2016 Medical Expenditure Panel Survey was used to determine rates of visit/contact per 1,000 individuals per month for physicians, primary care physicians, specialty physicians, emergency departments, inpatient hospitalizations, dental visits, and home health visits for the overall population and by age group, poverty category, health status, and race/ethnicity. Adjusted Wald tests were used to investigate differences between the pre-ACA (2012-2013) and post-ACA (2014-2015) periods. Multivariable linear regression was used to determine trends over the study period (2002-2016). The survey included 525,804 person-years. The uninsured rate decreased from 12.8% (95% CI, 12.0%-13.7%) in 2013 to 7.6% (95% CI, 7.0%-8.3%) in 2016. From 2002 to 2016, the numbers of individuals in a month who had contact with primary care physicians, dental care, and inpatient hospitalizations decreased. Primary care physician contact decreased most among the elderly and those reporting fair/poor health. After ACA implementation, few significant changes were identified in the overall population or by age, poverty category, race/ethnicity, or health status. The medical ecology framework was not notably altered 2 years after implementation of the ACA. The long-term decrease in primary care contact does not appear to have been interrupted after implementation of the ACA, was observed across income and age categories, and was most evident among the elderly and individuals reporting fair/poor health.

Determinants of frequent use of primary care in the German healthcare system

Abstract Background In Germany, patients are consulting general practitioners increasingly frequently, resulting in a high burden on the healthcare system. This study aimed to identify factors associated with frequent primary care attendance in the German healthcare system. Methods The German Health Interview and Examination Survey for Adults (DEGS) is part of Germany’s national health monitoring, and includes a large representative sample of the German population aged 18-79 years. We defined the 10% of participants with the highest number of physician contacts in the preceding 12 months as frequent attenders. Binary logistic regression models with average marginal effects were used to identify determinants for the frequent use of primary care services. Results The sample comprised 7,956 participants. Significant effects on frequent use of primary care were observed for low socioeconomic status, stressful life events, and factors related to objective need for medical care and subjective health status. In the full model, the number of non-communicable diseases and subjective health status had the strongest effect on frequent primary care use. We found an interaction effect between subjective health status and number of non-communicable diseases, indicating the association of disease with frequent use was highly moderated by subjective perception of health. Conclusions We observed strong associations between frequent primary care attendance and objective and subjective health-related factors. These findings suggest that better coordination of care may be a preferred method to manage health services utilization behaviour and avoid redundant examinations and uncoordinated clinical pathways. Further research is needed to clarify moderating and mediating factors contributing to high utilization of primary care services. Key messages The number of NCDs diseases and subjective health had the strongest effect on frequent primary care use. The findings suggest that better coordination of care may be the preferred method to manage health services utilization.

Health Research Using Facebook to Identify and Recruit Pregnant Women Who Use Electronic Cigarettes: Internet-Based Nonrandomized Pilot Study.

BackgroundParticipant recruitment is often a challenge, particularly enrolling individuals with relatively rare characteristics. The wide reach of social media may provide a mechanism to overcome these challenges.ObjectiveThis paper aimed to provide information to researchers who seek to recruit participants from rare populations using social media for studies with demanding protocols. We aimed to describe a pilot study protocol that identified and enrolled pregnant women (second or third trimester) who were exclusive users of electronic cigarettes (e-cigarettes). We have described the recruitment methods, time, and cost; examined advertisement types that were more or less successful; discussed participant retention and relationship management; and described the process of collecting biological data.MethodsIn an open-access, nonrandomized pilot study, we placed Facebook advertisements that were selectively targeting women who were likely to be pregnant and interested in e-cigarettes or vaping. The advertisements invited individuals to complete a fully automated eligibility screener based on Qualtrics. Eligible participants were asked to (1) complete a Web-based survey that collected detailed information on the use of e-cigarettes, including the exact type of device and electronic liquid, (2) report the frequency and intensity of e-cigarette use for 3 months before pregnancy and during each trimester, and (3) provide a saliva specimen for a nicotine biomarker assay. We collected a photograph of each participant’s e-cigarette device, 8 weeks after the mother’s due date, to allow corroboration of the self-report and the baby’s birth weight and gestational age from the participant’s physician.ResultsParticipants were recruited between August 19 and October 26, 2017. We enrolled 20 participants in 2 months at a cost of US $3421.28. Baseline data were collected for all 20 participants. Of the 20 women enrolled, 16 provided a saliva sample, 4 provided a photo of the e-cigarette device, and 10 provided physician contact information. Of the 10 physicians contacted by mail, 6 responded with information on the participants and their babies.ConclusionsStudy findings suggest that Facebook’s targeting criteria should focus on e-cigarette users to maximize advertisement exposure of potentially eligible women. In addition, saliva sample collection was feasible among pregnant women (second or third trimester) who were exclusive e-cigarette users, but obtaining photographs and physician reports was problematic and called for further refinement. These lessons are likely useful to others who are seeking to use social media to recruit participants from rare populations into studies with demanding protocols.

284 Using Community Tele-Paramedicine to Reduce Unnecessary Emergency Department Visits and 30-Day Readmissions Among High-Risk Patients With Heart Failure

Heart failure (HF) patients have high rates of 30-day readmission and emergency department (ED) utilization. Early physician contact within 7 days of discharge is optimal, but successful implementation has been limited by barriers such as appointment availability, low show rates and patient transport. We aim to assess the feasibility of an innovative program, Community Tele-Paramedicine (CTP), among HF patients at high risk for early readmission at a large, urban tertiary care center.