Physician Encounters Research Articles

Health services use by children identified as heterozygous hemoglobinopathy mutation carriers via newborn screening

BackgroundNewborn screening (NBS) for sickle cell disease incidentally identifies heterozygous carriers of hemoglobinopathy mutations. In Ontario, Canada, these carrier results are not routinely disclosed, presenting an opportunity to investigate the potential health implications of carrier status. We aimed to compare rates of health services use among children identified as carriers of hemoglobinopathy mutations and those who received negative NBS results.MethodsEligible children underwent NBS in Ontario from October 2006 to March 2010 and were identified as carriers or as screen-negative controls, matched to carriers 5:1 based on neighbourhood and timing of birth. We used health care administrative data to determine frequencies of inpatient hospitalizations, emergency department (ED) visits, and physician encounters through March 2012, using multivariable negative binomial regression to compare rates of service use in the two cohorts. We analyzed data from 4987 carriers and 24,935 controls.ResultsAdjusted incidence rate ratios (95% CI) for service use in carriers versus controls among children < 1 year of age were: 1.11 (1.06–1.17) for ED visits; 0.97 (0.89–1.06) for inpatient hospitalization; and 1.02 (1.00–1.04) for physician encounters. Among children ≥1 year of age, adjusted rate ratios were: 1.03 (0.98–1.07) for ED visits; 1.14 (1.03–1.25) for inpatient hospitalization and 0.92 (0.90–0.94) for physician encounters.ConclusionsWhile we identified statistically significant differences in health services use among carriers of hemoglobinopathy mutations relative to controls, effect sizes were small and directions of association inconsistent across age groups and health service types. Our findings are consistent with the assumption that carrier status is likely benign in early childhood.

Perinatal outcomes after bariatric surgery

Bariatric surgery is a widely used treatment option for obesity that often provides long-term weight control and health benefits. Although a growing number of women are becoming pregnant after bariatric surgery, only a few population-based studies have assessed the impact thereof on perinatal outcomes. This study aimed to examine the association between bariatric surgery and adverse perinatal outcomes in pregnant women and to examine whether the risk for adverse perinatal outcomes is modified by the postsurgery weight, gestational weight gain, type of bariatric surgery, timing of pregnancy after bariatric surgery, and maternal comorbidities. A retrospective cohort study was performed with the use of the Bariatric Surgery Registry and hospital inpatient and outpatient physician encounter records. The International Classification of Diseases, Ninth and Tenth Revision codes from hospitalizations during pregnancy and infant birth records were used to ascertain the outcomes of interest. Women eligible for BS who delivered at ≥20 weeks of gestation (n=20,213) at Kaiser Permanente Southern California hospitals (January 1, 2007 to December 31, 2018) were included in the study. Adjusted odds ratios were derived from logistic regression models with inverse probability of treatment weighting to adjust for confounding using propensity scores. Bariatric surgery was associated with a reduction in the risks for gestational diabetes (adjusted odds ratio, 0.60; 95% confidence interval, 0.53-0.69; P<.001), preeclampsia (adjusted odds ratio, 0.53; 95% confidence interval, 0.46-0.61; P<.001), chorioamnionitis (adjusted odds ratio, 0.45; 95% confidence interval, 0.32-0.63; P<.001), cesarean delivery (adjusted odds ratio, 0.65; 95% confidence interval, 0.59-0.72; P<.001), large for gestational age neonate (adjusted odds ratio, 0.23; 95% confidence interval, 0.19-0.29; P<.001), macrosomia (adjusted odds ratio, 0.24; 95% confidence interval, 0.19-0.30; P<.001), and neonatal intensive care unit admission (adjusted odds ratio, 0.70; 95% confidence interval, 0.61-0.81; P<.001). However, bariatric surgery was also associated with a significantly increased risk for small for gestational age neonates (adjusted odds ratio, 2.46; 95% confidence interval, 2.16-2.79; P<.001). The risk for the adverse outcomes is independent of the time interval between the surgery and subsequent pregnancy. These data suggest that there are many pregnancy outcome benefits for women with severe obesity who undergo bariatric surgery; however, women who have undergone bariatric surgery before pregnancy should be monitored closely to reduce the risk for small for gestational age neonates and postpartum hemorrhage.

Collaborative Physician-Pharmacist Multiple Myeloma Clinic Improves Guideline Adherence and Prevents Treatment Delays

Although survival of patients with multiple myeloma (MM) has improved in the last decade, achieving optimal outcomes requires timely delivery of anti-myeloma therapy as well as adherence to supportive care guidelines and patient education. We hypothesized that a multidisciplinary approach of a collaborative physician-pharmacist MM clinic would have a positive impact on clinical measures such as guideline adherence as well as improve the workflow process and prevent treatment delays.From March 2014 to February 2015, we initiated a collaborative MM clinic at our institution, whereby in addition to normal physician care, a dedicated board-certified oncology pharmacist provided consultation on all new and continuing patients. The pharmacist provided education and medication lists, completed medication reconciliation, monitored for adherence and side effects, recommended management of toxicity and supportive care, and navigated issues involving enrollment and access to oral specialty medications. All consultations were documented in the patient's medical chart using a template addressing these key components. Outcomes were compared to those of patients being treated by the same physician during the previous year, when ad-hoc pharmacist consultation was available (traditional model). We compared clinical measures related to guideline adherence and analyzed delays in obtaining immunomodulator drugs (IMiDs) using available dispensing records.Patient characteristics were similar between the collaborative and traditional models including age, sex, race, ISS stage, protein subtype, treatment type, and prior number of therapies. During the 12-month study period when a collaborative model was implemented, 399 pharmacist consultations occurred during 551 physician visits (n=57 patients). During the prior year when a traditional model existed, there were 26 pharmacist consultations on 355 physician encounters (n=44 patients) (7.3% versus 72.4%, p<0.0001).We observed improved adherence to bisphosphonates (BP) in the collaborative clinic (55 (96%) versus 30 (68%) patients, p=0.0002). Among patients receiving BP, the time to initiation from diagnosis and re-initiation after autologous stem cell transplant (ASCT) was 5.5 versus 97.5 days (p<0.001) and 12.5 versus 135 days (p<0.001) among the collaborative and traditional clinic, respectively. One hundred percent of patients in the collaborative clinic versus 41% of patients in the traditional clinic received concomitant calcium and vitamin D (p<0.001). In patients receiving IMID-based regimens, appropriate VTE prophylaxis was prescribed in 52 (100%) versus 29 (76%) patients in the collaborative and traditional clinic, respectively (p<0.0002). Appropriate use of acyclovir prophylaxis in patients receiving proteasome inhibitor-based treatment was observed more frequently in the collaborative clinic (98% versus 56%, p=0.004). Although the number of patients receiving Pneumocystis Jirovecii pneumonia prophylaxis post-ASCT was similar (93 versus 100 percent, p=0.4), the time to initiation of prophylaxis was shorter in the collaborative clinic (11 versus 40.5 days, p<0.0001). Finally, influenza vaccination administration was higher in the collaborative clinic (76 versus 24 percent, p<0.001). When analyzing delays in obtaining IMiD therapy, we found that the median time from when the treatment plan was noted in the medical chart to when the IMiD was first filled was 7 (range: 0-32) vs. 15 (range: 3-62) days in the collaborative and traditional clinic, respectively (p=0.002). Finally, there was a significant reduction in treatment delays observed in the collaborative compared to the traditional clinic (21% vs. 85% of patients undergoing a delay, p<0.0001).Here we pilot a multidisciplinary approach that leads to increased guideline adherence and prevents delay in anti-myeloma treatment. The collaborative clinic model could be applied to several different practice sites in order to establish an improved and more systematic approach in the management of MM patients. Prospective studies analyzing clinical outcomes, patient satisfaction and cost effectiveness of this approach are warranted. DisclosuresWirth:Celgene: Consultancy, Honoraria. Patel:Celgene: Consultancy, Honoraria.

Understanding Fright and Differential Materia Medica: A case series

Objectives: To successfully prescribe a homoeopathic remedy, it is important to have not only good knowledge of symptomatology but also an ability to closely differentiate a remedy from others indicated for similar conditions. Despite good knowledge of Materia Medica, its clinical application often fails. Therefore, the best way to understand Materia Medica is to study it in an actual clinical setting. Fright which is an extreme fear excited by sudden danger; something strange, ugly or shocking, is one such emotion that the homoeopathic physician encounters in his practice. Materials and Methods: Five successfully treated cases with prominent shades of fright from the author’s practice were studied to understand the causation, evolution and expressions of fright. The qualified expressions were studied through repertory and their finer shades were studied through Materia Medica to understand the key differential indications of the remedies prescribed. Results: The events or life situations that lead to fright and the patients’ response and its evolution lend a characteristic value to individualisation and prescribing based on differentiating from other remedies. Aconite, Opium, Stramonium and Gelsemium were drugs found in this study. Aconite has sudden and extreme effects of fright or repeated sudden effects leading to febrile expressions. Opium has prolonged effects of fright at the sensorium in the form of insomnia, but lacks the intensity or violence of Aconite. Stramonium has a fear of imminent danger or being attacked. The fears are intense, to the extent of terrors; the patient desires company and clings to persons OR hides and tries to escape from the situation. Gelsemium has fright leading to anticipation as well as fear of falling and/or receiving injury. Conclusion: In this study, plant remedies prescribed in higher potencies and infrequent repetition brought about effective resolution of fright in all five cases. The remedies also mitigated the consequences of fright on the mind and body and improved the overall susceptibility in all cases.

Systematic Assessment of Medical Diagnoses Preceding the First Diagnosis of Multiple Sclerosis.

To explore the occurrence of diseases and symptoms in the 5 years before diagnosis in patients with multiple sclerosis (MS) in a case-control study. Using ambulatory claims data, we systematically assessed differences in the occurrence of diseases and symptoms in the 5 years before first diagnosis in patients with MS (n = 10,262) compared to patients with 2 other autoimmune diseases, Crohn disease (n = 15,502) and psoriasis (n = 98,432), and individuals without these diseases (n = 73,430). Forty-three ICD-10 codes were recorded more frequently for patients with MS before diagnosis compared to controls without autoimmune disease. Many of these findings were confirmed in a comparison to the other control groups. A high proportion of these ICD-10 codes represent symptoms suggestive of demyelinating events or other neurologic diagnoses. In a sensitivity analysis excluding patients with such recordings before first diagnosis, no association remained significant. Seven ICD-10 codes were associated with lower odds ratios of MS, 4 of which represent upper respiratory tract infections. Here, the relations with MS were even more pronounced in the sensitivity analysis. Our analyses suggest that patients with MS are frequently not diagnosed at their first demyelinating event but often years later. Symptoms and physician encounters before MS diagnosis seem to be related to already ongoing disease rather than a prodrome. The observed association of upper respiratory tract infections with lower odds ratios of MS diagnosis suggests a link between protection from infection and MS that, however, needs to be validated and further investigated.

Intensity of outpatient physician care in the last year of life: a population-based retrospective descriptive study.

Background:For many patients, health care needs increase toward the end of life, but little is known about the extent of outpatient physician care during that time. The objective of this study was to describe the volume and mix of outpatient physician care over the last 12 months of life among patients dying with different end-of-life trajectories.Methods:We conducted a retrospective descriptive study involving adults (aged ≥ 18 yr) who died in Ontario between 2013 and 2017, using linked provincial health administrative databases. Decedents were grouped into 5 mutually exclusive end-of-life trajectories (terminal illness, organ failure, frailty, sudden death and other). Over the last 12 months and 3 months of life, we examined the number of physician encounters, the number of unique physician specialties involved per patient and specialty of physician, the number of unique physicians involved per patient, the 5 most frequent types of specialties involved and the number of encounters that took place in the home; these patterns were examined by trajectory.Results:Decedents (n = 359 559) had a median age of 78 (interquartile range 66–86) years. The mean number of outpatient physician encounters over the last year of life was 16.8 (standard deviation [SD] 13.7), of which 9.0 (SD 9.2) encounters were with family physicians. The mean number of encounters ranged from 11.6 (SD 10.4) in the frailty trajectory to 24.2 (SD 15.0) in the terminal illness trajectory across 3.1 (SD 2.0) to 4.9 (SD 2.1) unique specialties, respectively. In the last 3 months of life, the mean number of physician encounters was 6.8 (SD 6.4); a mean of 4.1 (SD 5.4) of these were with family physicians.Interpretation:Multiple physicians are involved in outpatient care in the last 12 months of life for all end-of-life trajectories, with family physicians as the predominant specialty. Those who plan health care models of the end of life should consider support for family physicians as coordinators of patient care.

Comparing Health Administrative and Clinical Registry Data: Trends in Incidence and Prevalence of Pediatric Inflammatory Bowel Disease in British Columbia.

PurposeCanada maintains robust health administrative databases and British Columbia Children’s Hospital (BCCH), as the only tertiary care pediatric hospital in British Columbia (BC), maintains a comprehensive clinical inflammatory bowel disease (IBD) registry. To evaluate the strengths and weaknesses of utilizing health administrative and clinical registry data to study the epidemiology of IBD in BC, we conducted a population-based retrospective cohort study of all children <18 years of age who were diagnosed with IBD between 1996 and 2008 in BC.MethodsIBD cases from health administrative data were identified using a combination of IBD-coded physician encounters and hospitalizations while a separate IBD cohort was identified from the BCCH clinical registry data. Age and gender standardized incidence and prevalence rates were fitted to Poisson regression models.ResultsThe overall incidence of pediatric IBD identified in health administrative data increased from 7.1 (95% CI 5.5–9.2) in 1996 to 10.3 (95% CI 8.2–12.7) per 100,000 children in 2008. Similarly, the incidence of the BCCH cohort increased from 4.3 (95% CI 3.0–6.0) to 9.7 (95% CI 7.6–12.1) per 100,000. Children aged 10–17 had the highest rise in incidence in both data sources; however, the administrative data identified significantly more 10–17-year-olds and significantly less 6–9-year-olds (p<0.05) compared to clinical registry data.ConclusionWhile the application of both health administrative and clinical registry data demonstrates that the incidence of IBD is increasing in BC, we identify strengths and limitations to both and suggest that the utilization of either data source requires unique considerations that mitigate misclassification biases.

Human Immunodeficiency Virus (HIV) Care Models During the Coronavirus Disease 2019 (COVID-19) Era.

The COVID-19 pandemic is an unprecedented global challenge that substantially risks reversing the progress in ending HIV. At the same time, it may offer the opportunity for a new era of HIV management. This viewpoint presents the impact of COVID-19 on HIV care, including the Joint United Nations Programme on HIV/AIDS (UNAIDS) “three 90s” targets. It outlines how to enhance a patient-centered care approach, now known as the "fourth 90,” by integrating face-to-face patient–physician and telemedicine encounters. It suggests a framework for prevention and treatment of multimorbidity and frailty, to achieve a good health-related quality of life and preserve intrinsic capacity in all people living with HIV.

Evaluation of Infectious Disease Test Ordering and Positivity Rates in Illicit Fentanyl Users.

The emergence of illicit fentanyl use has resulted in considerable morbidity and mortality. Although illicit use of other opioids has been associated with transmission of viral and bacterial infections, limited data exist for the prevalence of infectious diseases among illicit fentanyl users. The purpose of this study was to assess the likelihood of infectious disease testing and infection prevalence among illicit fentanyl users. Results from urine drug screens (UDSs) performed from August 13, 2019, to October 16, 2019, were obtained from the laboratory information system with concurrent microbial testing. Patients were categorized based on UDS results, and illicit drug use was inferred from physician encounter notes in the electronic medical record. Suspected illicit drugs users with fentanyl detected by UDS were more likely to be screened [odds ratio (OR): 1.7; 95% CI, 1.26-2.4] and test positive for hepatitis C virus (HCV) by immunoassay (OR: 5.89; 95% CI, 2.93-11.31) than patients without drugs detected. Patients with suspected illicit fentanyl use who were discharged from the emergency department (ED) were less likely to be tested for HCV than patients in outpatient settings (OR: 3.47; 95% CI, 1.05-10.4) and inpatient settings (OR: 17.43; 95% CI, 6.53-45.88). Patients with suspected illicit fentanyl use were more likely to have infected abscesses or wounds (OR: 5.12; 95% CI, 2.07-13.7) and Staphylococcus aureus infections (OR: 4.5; 95% CI, 1.59-12.28) than patients without drugs detected. Patients with a positive UDS for fentanyl and suspected illicit use were more likely to test positive for HCV, were rarely screened for HCV in the ED, and had an increased risk of invasive S. aureus wound or abscess infection. These findings may represent considerable barriers to care for patients who use fentanyl illicitly.

Characteristics, Preferences and Health Care Utilization in Patients Using a Dietary Supplement for Improving Sleeping Disturbances: Results from an Explorative Online Survey.

PurposeSleeping disturbances are highly prevalent in the general population, and pharmacological drug treatment harbours the risk of serious side effects. Many affected persons use dietary supplements for self-treating their symptoms, but little is known about the specific characteristics and preferences of these patients. Even less evidence exists about the consequences of a specific dietary supplement usage on health care utilization. The aim of this study was to explore characteristics, preferences and the impact on health care utilization in patients using a specific over-the-counter dietary supplement, which is promoted for improving sleeping disturbances.Patients and MethodsWe conducted a structured survey and invited a sample of 297 customers of a specific dietary supplement to participate. The survey was open between June and September 2020. Participants were invited by email. All participants accepted an informed consent.ResultsA total of 127 customers participated in the survey (participation rate: 42.8%). Of them, 87.7% were female and the mean age 50.5 years. Participants reported an overall good improvement of symptoms (7.66 on a ten-point Likert-scale) and showed a strong belief in the effectiveness of supplements in general; 67% of participants reported that the intake led to fever physician encounters, and 48.3% reported that they could stop the intake of other pharmaceutical sleeping drugs.ConclusionA significant proportion of participants reported a substantial reduction in pharmaceutical drug use and health care utilization. While these self-reports lack an adequate control, they are still real consumer experiences, and the large beneficial effects – whether placebo or not – explain the popularity of such supplements and their therapeutic potential in sleeping disorders.

Detecting Patients With Nonvalvular Atrial Fibrillation and Atrial Flutter in the Canadian Primary Care Sentinel Surveillance Network: First Steps

BackgroundA recent feasibility assessment of quality indicators for nonvalvular atrial fibrillation/atrial flutter (NVAF/AFL) identified the Canadian Primary Care Sentinel Surveillance Network, a national outpatient electronic medical record (EMR) system, as a data source for measurement. As a first step, we adapted and validated an existing EMR case definition. MethodsA diagnosis of NVAF/AFL was defined using International Classification of Disease, 9th Revision, Clinical Modification codes (427.3) in either the physician billing, encounter diagnosis, or health condition fields. We identified all presumed cases in a single clinical site with the algorithm and selected a random sample of those who were presumed NVAF/AFL negative with the same algorithm. A chart audit diagnosis of “definite” NVAF/AFL was confirmed by electrocardiogram and nonvalvular diagnosis confirmed after echocardiogram, attending physician, or specialist letter review. To demonstrate face validity, clinical characteristics were compared for patients with and without NVAF/AFL. ResultsThe case definition identified a possible 184 patients with and 184 without NVAF/AFL. The case validation resulted in a sensitivity of 100% (95% confidence interval [CI], 100-100), specificity of 84.3% (95% CI, 78.8-89.9), and positive and negative predictive value of 74.7% (95% CI, 66.4-83.2) and 100% (95% CI 100-100), respectively. Patients with NVAF/AFL were older (63 vs 42 years) and had a higher proportion of cardiovascular comorbidities and relevant medications. ConclusionsWe think it is possible that with further validation work, NVAF/AFL can be accurately identified using this large pan-Canadian EMR system and used as a future tool to measure quality of care in the outpatient setting.

Long-term prognostic counselling in people with multiple sclerosis using an online analytical processing tool

Background: Prognostic counselling is a sensitive issue in medicine and especially so in MS due to the highly heterogeneous disease course. However, people with MS (pwMS) seek prognostic information. The web-based ‘Evidence-Based Decision Support Tool in Multiple Sclerosis’ (EBDiMS) uses data of 717 patients from the London/Ontario cohort to calculate personalized long-term prognostic information. Objective: The aim of this study was to investigate the feasibility and effect of long-term prognostic counselling in pwMS using EBDiMS. Methods: Ninety consecutive pwMS were provided with personalized estimations of expected time to reach Expanded Disability Status Scale (EDSS) scores of 6 and 8 and time to conversion to secondary-progressive MS. Participants gave estimates on their own putative prognosis and rated the tool’s acceptability on six-step Likert-type scales. Results: Participants rated EBDiMS as highly understandable, interesting and relevant for patient–physician encounters, coping and therapy decisions. Although it provoked a certain degree of worry in some participants, 95% would recommend using the tool. Participants’ own prognosis estimates did not change significantly following EBDiMS. Conclusion: Long-term prognostic counselling using an online tool has been shown to be feasible in a clinical setting. EBDiMS provides pwMS with relevant, easy-to-understand, long-term prognostic information without causing relevant anxiety.

Ethical and Legal Considerations of Patients Audio Recording, Videotaping, and Broadcasting Physician Encounters

Ethical and Legal Considerations of Patients Audio Recording, Videotaping, and Broadcasting Physician Encounters

Is Implant Placement in the Operating Room a Risk Factor for the Development of Peri-Implantitis? A Retrospective Cohort Analysis

This study aims to identify if preoperative antibiotic administration is a protective factor for the development of peri-implantitis in implants placed in the operating room vs outpatient clinic. A retrospective cohort study was conducted at the Philadelphia Veterans Affairs Medical Center from 2006 to 2013. Physician encounter notes within 3 months of implant placement were used to gather data about patients’ health status, including the setting of implant placement in the operating room vs outpatient clinic. Operative report notes were used to assess administration of antibiotic prophylaxis, recorded as none, oral, or intravenous administrations. Implant status was assessed using dental encounter notes and radiographs from follow-up appointments at 1, 3, 5, and 10 years. Peri-implantitis was defined as radiographic evidence of changes in the crestal bone level, clinical evidence of bleeding on probing, with or without suppuration.1 Electronic medical records of 942 implants placed in 398 unique patients were retrospectively analyzed. Descriptive statistics were computed using the SAS System (SAS Institute Version 9.4, 2002-2012, Cary, NC). Predictor variables were implant placement in the operating room or outpatient clinic and administration of preoperative antibiotics. The primary outcome variable was the presence of peri-implantitis. Descriptive, bivariate, and multiple logistic regression analyses were performed to measure the association between predictive variables and development of peri-implantitis. Of the 942 implants placed, 205 (22%) developed peri-implantitis. Overall, placement of implants in an operating room was shown to be associated with an increased risk in the presence of peri-implantitis (P ≤ .0001) when compared to implants placed in the outpatient clinic. When controlling for preoperative antibiotics, patients who received implants in the operating room were still found to be at risk for developing peri-implantitis (P = .0015). The data from this study show that implants placed in the operating room were 4 times more likely to develop peri-implantitis compared to implants placed in the outpatient clinic (OR = 4.056, 95% Cl 2.697-6.102). To our knowledge, no existing literature demonstrates this significant relationship. Our data show that preoperative antibiotics are protective against the development of peri-implantitis in patients who receive implants in the operating room. When controlling for preoperative antibiotics, operating room patients’ risk of developing peri-implantitis decreased by nearly 35% (OR = 2.633, 95% Cl 1.448-4.788). Studies have demonstrated that in a peri-implantitis model, antibiotic-treated specimens attenuated natural bone loss. The authors suggest that preoperative antibiotic administration may decrease the occurrence of peri-implantitis by reversing inflammatory responses and decreasing attachment loss via attenuation of pathogenic oral bacteria at the site of implant placement.2 Therefore, the administration of preoperative antibiotics, especially in medically complex patients who cannot tolerate implant placement in an outpatient clinic, may temper the progression of pathological processes around the peri-implant tissues. Analysis of implants placed at the Philadelphia VA Medical Center revealed an important association between the setting of implant placement, use of preoperative antibiotics, and the development of peri-implantitis. Our study shows that a standardized preoperative antibiotic regimen can play an important role in decreasing the development of peri-implantitis in patients who receive implants in an operating room. Administration of preoperative antibiotics in these patients may provide an opportunity to abate inflammatory reactions as a result of an existing complex disease and provide protection against the development of peri-implantitis. In addition to completing prospective studies, identification of other protective factors in this high-risk patient population is a necessity.

Associations between shared care and patient experiences among older cancer survivors.

Cancer survivors have unique medical care needs. "Shared care," delivered by both oncologists and primary care providers (PCPs), may better address these needs. Little information is available on differences in outcomes among survivors receiving shared care versus oncologist-led or PCP-led care. This study compared experiences of care for survivors receiving shared care, oncologist-led, PCP-led, or other care patterns. We used SEER-CAHPS data, including NCI's SEER registry data, Medicare claims, and Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses. Medicare Fee-for-Service beneficiaries age ≥ 65years in SEER-CAHPS with breast, cervical, colorectal, lung, renal, or prostate cancers or hematologic malignancies who responded to a Medicare CAHPS survey ≥ 18months post-diagnosis were included. CAHPS measures included ratings of overall care, personal doctor, specialist physician, health plan, prescription drug plan, and five composite scores. Survivorship care patterns were identified using proportions of oncologist, PCP, and other physician encounters. Multivariable regressions examined associations between care patterns and CAHPS outcomes. Among 10,132 survivors, 15% received shared care, 10% oncologist-led, 33% PCP-led, and 42% other. Compared with shared care, we found no significant differences in experiences of care except for getting needed drugs (lower scores for PCP-led and other care patterns). Sensitivity analyses using different patterns of care definitions similarly showed no associations between survivorship care pattern and experience of care. Within the limitations of the study dataset, survivors age 65+ receiving shared care reported similar experiences of care to those receiving oncologist-led, PCP-led, and other patterns of care. Shared care may not provide survivor-perceived benefits compared with other care patterns.

When duty house calls

A neurologist conducts her first "house call" during the Covid-19 pandemic: the quaint nostalgia of a bygone era and seeming anachronism meet the conveniences of modernity and uncover the timeless qualities of medicine.The phrase "house call" conjures up nostalgia for an era most of us have never experienced, painted with cheerful and tender Norman Rockwell-style strokes. The avuncular physician, likely a man, clad in a crisp suit, with a capacious leather satchel filled with tinctures of now-illegal substances clinking in glass bottles. The cherubic child clad in a white nightgown, tucked under a patchwork quilt, curls against the pillow, clutching a beloved doll. The worried parent, likely a woman, hovering over the bedside with a cool compress against the fevered forehead.While I have only sepia photos and phonograph recordings to inform me of such a time, my patient Mary actually lived through it. She was born in the thick of such a period, in the 1930's, an era when 40% of physician encounters were house calls. When I had established care for dementia in her 80's, she still had a razor wit, mischievous grin, and twinkling blue eyes. I could tell she had been a kind, but firm, schoolteacher, likely not one to have put up with tomfoolery.

Medical oncology referral and systemic therapy of patients with advanced stage urothelial carcinoma

Aim: To understand physician visit patterns among patients with stage IV (including nonmetastatic [M0] and metastatic [M1] disease) urothelial carcinoma (UC) and understand factors associated with a timely referral to a medical oncologist and systemic treatment. Patients & methods: Retrospective analysis of Surveillance, Epidemiologyand End Results-Medicare data. Results: First physician encounter was with a urologist (M0: 69%; M1: 53%) or primary care physician ([PCP]; M0: 19%, M1: 25%) for the majority of patients around UC diagnosis. After the index urologist encounter, most patients had a subsequent medical oncologist visit at a median of 52days (M0: 69.5days, M1: 33days). In an adjusted model, older age, index PCP visit, higher comorbidities and M0 disease were negatively associated with a medical oncologist referral. Among those referred to a medical oncologist, older age, Hispanic or non-Hispanic Black race and not being married were negatively associated with subsequent chemotherapy receipt (p< 0.05). Conclusion: Many patients with advanced UC encounter multiple specialists during their disease course. Older patients or those with a first UC-related encounter with a PCP are less likely to be referred to medical oncology. Once referred to medical oncology, social determinants, including race and marital status, are relevant predictors of receiving chemotherapy.

Persistent socioeconomic inequalities in location of death and receipt of palliative care: A population-based cohort study

Background: Providing equitable care to patients in need across the life course is a priority for many healthcare systems. Aim: To estimate socioeconomic inequality trends in the proportions of decedents that died in the community and that received palliative care within 30 days of death (including home visits and specialist/generalist physician encounters). Design: Cohort study based on health administrative data. Socioeconomic position was measured by area-level material deprivation. Inequality gaps were quantified annually and longitudinally using the slope index of inequality (absolute gap) and relative index of inequality (relative gap). Setting/Participants: A total of 729,290 decedents aged ⩾18 years in Ontario, Canada from 2009 to 2016. Results: In 2016, the modelled absolute gap (corresponding 95% confidence interval) between the most- and least-deprived neighbourhoods in community deaths was 4.0% (2.9–5.1%), which was 8.6% (6.2–10.9%) of the overall mean (46.6%). Relative to 2009, these inequalities declined modestly. Inequalities in 2016 were evident for palliative home visits (6.8% (5.8–7.8%) absolute gap, 26.3% (22.5–30.0%) relative gap) and for physician encounters (6.8% (5.7–7.9%) absolute gap, 13.2% (11.0–15.3%) relative gap), and widened from 2009 for physician encounters only on the absolute scale. Inequalities varied considerably across disease trajectories (organ failure, terminal illness, frailty, and sudden death). Conclusion: Key measures of end-of-life care are not achieved equally across socioeconomic groups. These data can be used to inform policy strategies to improve delivery of palliative and end-of-life services.

Quality and Safety in Healthcare, Part LX: Additional Aspects of Programs to Increase Physician Wellness.

Improving the culture of the community the physician encounters at work is very important to combat burnout and improve joyfulness and wellness. This includes better relationships between doctors, and between doctors and other healthcare professionals and administrators. Engaging the physicians in their clinical work and other meaningful activities such as research, teaching, and important administrative activities is also important. Wellness in its broadest sense is not merely the absence of burnout or other maladies; it is also about achieving the individual's full potential for a successful life.

Universal SARS-Cov-2 Screening in Women Admitted for Delivery in a Large Managed Care Organization.

Objective The coronavirus disease 2019 (COVID-19) pandemic has created a need for data regarding the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnant women. After implementing universal screening for COVID-19 in women admitted for delivery, we sought to describe the characteristics of COVID-19 in this large cohort of women. Study Design An observational study of women admitted to labor and delivery units in Kaiser Permanente Southern California (KPSC) hospitals between April 6 and May 11, 2020 who were universally offered testing for SARS-CoV-2 infection ( n = 3,963). Hospital inpatient and outpatient physician encounter, and laboratory records were used to ascertain universal testing levels, test results, and medical and obstetrical histories. The prevalence of SARS-CoV-2 infection was estimated from the number of women who tested positive during labor per 100 women delivered. Results Of women delivered during the study period, 3,923 (99.0%) underwent SARS-CoV-2 testing. A total of 17 (0.43%; 95% confidence interval: 0.23–0.63%) women tested positive, and none of them were symptomatic on admission. There was no difference in terms of characteristics between SARS-CoV-2 positive and negative tested women. One woman developed a headache attributed to COVID-19 3 days postpartum. No neonates had a positive test at 24 hours of life. Conclusion The findings suggest that in pregnant women admitted for delivery between April 6 and May 11, 2020 in this large integrated health care system in Southern California, prevalence of SARS-CoV-2 test positive was very low and all patients were asymptomatic on admission. Key Points The prevalence of SARS-CoV-2 infection in a large diverse cohort of term pregnant women was 0.43%.99% of women accepted SARS-CoV-2 screening on admission to labor and delivery.All women with positive test results were asymptomatic at the time of testing.