Primary Care Appointments Research Articles

Clinician response to the 2021 USPSTF recommendation for colorectal cancer screening in average risk adults aged 45-49 years

IntroductionIn 2021, the USPSTF lowered the recommended age of colorectal cancer (CRC) screening initiation from 50 to 45 years. We assessed clinician response to the updated guideline in a major health system. MethodsThis was a retrospective cohort study of average-risk, CRC screening-naïve adults aged 45-50 years with a primary care appointment between July 2018 and February 2023. We defined the pre-guideline change period as July 2018-February 2020 (pre-period) and the post-guideline change period as July 2021-February 2023 (post-period). Clinician ordering of any CRC screening type was assessed. Mixed effects Poisson regression was used to model the incidence rate ratio (IRR) of a patient receiving a screening order, including an interaction between age (45-49 years versus 50 years) and time-period (pre- versus post-guideline change.) Variation in screening orders were also described by calendar quarter and clinician. ResultsThere were 28,114 patients in the pre-period and 22,509 in the post-period. Compared to patients aged 40-49 years in the pre-period, those in the post-period were more likely to have screening ordered (IRR:12.1; 95%CI:11.3-13.0). The screening ordering rate increased for 50-year-olds from the pre- to the post-period (IRR:1.08;95%CI:1.01-1.16) and was slightly higher than that of 45-49-year-olds in the post-period (IRR:1.08; 95%CI:1.02-1.14). All clinicians increased their ordering rate for patients aged 45-49 years. Within five months of the guideline change, the ordering rate for 45-49-year-olds and 50-year-olds was nearly the same. ConclusionsRapidly following the guideline change, clinicians increased their screening ordering rate for 45-49-year-olds, indicating almost complete uptake of the recommendation.

5144 Lessons Learned: Evaluation of a Fracture Liaison Service Quality Improvement Efforts

Abstract Disclosure: M.S. Rothman: None. D.R. Fixen: None. L.M. Schilling: None. A.M. Elsheikh: None. A.M. Marcus: None. S.J. Billups: None. Background: The Fracture Liaison Service (FLS) care model, a care coordination program for patients experiencing a fragility fracture, is proven to improve management of patients with an osteoporotic fracture, but treatment initiation gaps persist. We describe the evolution of a centralized FLS within a university-based healthcare system, including impact of adding clinical pharmacist consultation and describe circumstances surrounding continued care gaps. Design: Cohort analysis of osteoporosis medication initiation before FLS, after initial implementation, and after addition of pharmacist consultation. Patients: Individuals aged 65 and older experiencing any fragility fracture between 7/1/16 - 3/31/22. Intervention: A centralized team outreached eligible patients, ordered dual x-ray absorptiometry and laboratory tests as needed, and scheduled an osteoporosis-focused primary care appointment. Three years after FLS implementation, clinical pharmacist consultative review was added prior to the primary care visit. Main Measures: Initiation of osteoporosis pharmacologic therapy, completion of DXA, primary care follow-up rate, and description of circumstances where therapy was not initiated. Key Results: Of 1204 new fractures between 7/1/16-3/31/22, 315 patients were enrolled in one of two FLS phases, and 89 eligible historical controls were identified. Medication initiation rates went from 22/89 (25%) pre-FLS to 201/428 (47%) after-FLS phase 1 [POST1], (p<0.001) and to 106/187 (57%) after FLS phase 2 (POST2), when clinical pharmacist consultation was added (p=0.03 versus POST1). DXA was completed in 56/89 (67%) of pre-FLS patients, 364/428 (85%) POST1 patients (p<0.001 versus pre), and 163/187 (87%) POST2 (p< 0.001 versus PRE, p=0.59 versus POST1). Of 375 patients who did not initiate osteoporosis medication, more in the combined post-FLS cohorts attended a follow-up primary care appointment (233/308, 76% attended, versus pre-FLS 41/67, 61% , p=0.016). Conclusion: An FLS including centralized outreach and care coordination significantly improved patient follow-up, DXA, and medication initiation. Addition of de-centralized pharmacist consultation further improved medication initiation rates. Presentation: 6/3/2024

Implementation of hereditary cancer risk assessment in primary care: Intervention strategies and proximal outcomes.

279 Background: Family history-based risk assessment for hereditary breast and ovarian cancer and Lynch syndrome is guideline recommended and has strong evidence supporting its implementation into clinical practice, especially primary care. Yet, adoption has been impeded by limited awareness of genetic evaluation guidelines among primary care providers (PCPs), time constraints in screening during appointments, and limited resources for follow-up within primary care. To close this gap, we implemented a hereditary cancer risk assessment program that addresses these barriers and evaluated proximal implementation outcomes. Methods: We used intervention mapping for adaptation (IM-Adapt), a modified version of Intervention Mapping to guide the adaptation and implementation of the evidence-based 7-question family history screening (FHS-7) at a primary care clinic within an academic medical center. FHS-7 was adapted for administration via electronic patient portal prior to PCP visit or in-person at PCP visit. All clinic patients were offered screening and follow-up genetic counseling and testing per guidelines. Administrative, programmatic, and electronic medical record data were analyzed for program evaluation. Results: Between February 2023 and March 2024, 4,540 primary care patients were offered hereditary cancer risk assessment and 3,497 (77%) completed screening. Patient portals were used to complete screening more frequently than in-person at the clinic (86.6% vs 13.4%). Among patients with qualifying family history of cancer (n=1,267, 36%), 1,117 (88%) were eligible for navigation as they completed their primary care appointment and did not undergo genetic counseling within the last 5 years. Of the eligible patients, 62% were successfully contacted by a navigator and offered genetic counseling. Program implementation was facilitated by key personnel (clinical champion, informatics staff, genetic patient navigator) and adaptations to fit the implementation setting (adapting FHS7 for patient self-report rather than administration by PCP, patient population with high patient-portal adoption rate and in-house genetic service resources). Conclusions: We demonstrate the feasibility of hereditary cancer risk assessment within primary care and describe actionable aspects of the implementation context that influence screening uptake that can be incorporated into the design of future implementation for maximum impact. Findings advance the state of science in identification of unaffected individuals with inherited cancer susceptibility and genetic service delivery.

332 An Emergency Department-Based Care-at-Home Program Increases Access to Post-Discharge Primary Care Appointments

332 An Emergency Department-Based Care-at-Home Program Increases Access to Post-Discharge Primary Care Appointments

Downstream Emergency Department and Hospital Utilization Comparably Low Following In-Person Versus Telemedicine Primary Care for High-Risk Conditions.

Telemedicine use expanded greatly during the COVID-19 pandemic. More data is needed to understand how this shift may impact other venues of acute care delivery. We evaluate the association of visit modality (telephone, video, or office) and downstream emergency department (ED) and hospital visits among primary care visits for acute, time-sensitive conditions. Observational study of patient-scheduled primary care telemedicine and office visits for acute conditions (cardiac, gastrointestinal, neurologic, musculoskeletal, and head and neck) in a large, integrated healthcare delivery system. Adults with a new self-booked primary care appointment for an eligible acute condition from January 1, 2022, to December 31, 2022 (with no primary care, ED, or hospital visits in prior 30 days). Visit modality, including office, video, or telephone. Seven-day ED and hospital utilization, adjusted for patient and visit characteristics. Among 258,958 primary care visits by 239,240 adult patients, 57.7% were telemedicine visits; of these, 72.4% were telephone and 27.6% were video. Telephone visits were the timeliest, with over 70% of visits scheduled within 1 day of booking. Rates of 7-day ED utilization were low, and varied by condition group, with cardiac visits having the highest rates (4.8%) and musculoskeletal visits having the lowest (0.8%). There was less than a 1% absolute difference in ED use by visit modality for all condition types; however, telephone visits were associated with slightly higher rates than video visits. The 7-day hospitalization rate was less than 1% and observed between visit type differences varied by clinical condition. Among office, telephone, and video visits in primary care for potentially high-risk, time-sensitive conditions, downstream ED and hospital use were uncommon. ED utilization was lower for video visits than telephone visits, although telephone visits were timelier and may offer a safe and accessible option for acute care.

Facets of mindfulness are associated with inflammation biomarkers in a sample of sexual minority men with HIV

ABSTRACT Sexual minority men (SMM) are disproportionately impacted by HIV and thus, HIV related-health complications. HIV has been linked to earlier onset of multi-morbid chronic diseases and declines in physical and cognitive functioning attributable to chronic HIV immune activation and resulting inflammation. Inflammation has been targeted with mindfulness-based interventions (MBIs); however, hypothesized negative associations between mindfulness and inflammation need to be confirmed in SMM with HIV. This is a secondary data analysis of baseline data from a randomized clinical trial (RCT) of SMM living with HIV with biologically confirmed recent methamphetamine use (ARTEMIS). Mindfulness was assessed with the Five Factor Mindfulness Questionnaire (FFMQ). Inflammation was assessed via cytokines interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). Separate adjusted (for age, viral load, CD4 count, and methamphetamine use) regression models evaluated associations between four facets of mindfulness (description, awareness, non-judgement, and non-reactivity) with IL-6 and TNF-α. The average age of the participants was 43.86 (SD = 8.95). Both description (b = .54, se = .24) and awareness (b = .50, se=.23) were positively associated with IL-6. All other associations between mindfulness and inflammation were non-significant in adjusted models. There was also some evidence to suggest that engagement in care moderated associations between description and non-reactivity with IL-6 (ΔR 2 = .03, F = 3.64), such that description and non-reactivity were each positively associated with inflammation among those who attended <100% of primary care appointments (b = 1.04, se=.34 and b = 1.23, se=.39, respectively), but was not associated with inflammation among those who attended 100% of appointments (b =.16, se=.32 and b=-.17, se=.40, respectively). There was also a significant interaction between 12-step program attendance and awareness with IL-6 (ΔR2= .03, F = 4.26), such that awareness was positively associated with inflammation among those who attended 12-step programming (b = 1.25, se = .41), but not associated with inflammation among those who did not (b = .22, se = .28). Further research is needed to understand how and under what circumstances mindfulness is associated with pro- versus anti-inflammatory processes.Trial Registration: NCT01926184.

Patient-Directed Education to Promote Deprescribing

Patient-directed educational materials are a promising implementation strategy to expand deprescribing reach and adoption, but little is known about the impact across medication groups with potentially different perceived risks. To examine the impact of a patient-directed education intervention on clinician deprescribing of potentially low-benefit (proton pump inhibitors) or high-risk medications (high-dose gabapentin, diabetes agents with hypoglycemia risks). This pragmatic multisite nonrandomized clinical trial took place at 3 geographically distinct US Veterans Affairs (VA) medical centers from April 2021 to October 2022. The total study sample was composed of the intervention cohort and the historical control cohort cared for by 103 primary care practitioners (PCPs). The primary intervention component was a medication-specific brochure, mailed during the intervention time frame to all eligible patients 2 to 3 weeks prior to upcoming primary care appointments. Patients seen by the same PCPs at the same sites 1 year prior to the study intervention served as controls. The primary binary outcome variable was deprescribing 6 months after the intervention, defined as complete cessation or any dose reduction of the target medication using VA pharmacy dispensing data. The total study sample included 5071 patients. The overall rate of deprescribing among the intervention cohort (n = 2539) was 29.5% compared with 25.8% among the controls (n = 2532). In an unadjusted model, the intervention cohort was statistically significantly more likely to have deprescribing (odds ratio [OR], 1.17 [95% CI, 1.03-1.33]; P = .02). In a multivariable logistic regression model nesting patients within PCPs within sites and controlling for patient and PCP characteristics, the odds of deprescribing in the intervention cohort were 1.21 times that of the control cohort (95% CI, 1.05-1.38; P = .008). The difference in deprescribing prevalence between the intervention and control cohorts (proton pump inhibitors: 29.4% vs 25.4%; gabapentin: 40.2% vs 36.2%; hypoglycemia risk: 27.3% vs 25.1%) did not statistically significantly differ by medication group (P = .90). This nonrandomized clinical trial found that patient-directed educational materials provided prior to scheduled primary care appointments can effectively promote deprescribing for potentially low-benefit and high-risk medication groups. ClinicalTrials.gov Identifier: NCT0429490.

Incidence, antimicrobial prescribing practice and associated healthcare costs of paediatric otorrhoea in primary care in the UK: A longitudinal population study.

Background Paediatric otorrhoea (PO) is a symptom-based diagnosis encompassing acute and chronic ear infections which cause otorrhoea in children and young people (CYP). Aim To understand the burden of PO on primary care services. Design and Setting A longitudinal population study in UK primary care. Methods Data from the Clinical Practice Research Datalink (CPRD Aurum), January 2005 to December 2019, was analysed. CYP under 17 years of age with otorrhoea were included. Standardised annual incidence and presentation rates were estimated. Poisson regression modelling was used to determine risk ratios comparing sex, age and IMD. A probabilistic simulation scaled-up estimates for the UK population. Results The cohort included 6,605,193 CYP, observed over 32,942,594 person-years. There were 80,454 incident cases and 106,318 presentations of PO during the 15-year period, equating to standardised annual incidence and presentation rates per 1000 patient-years of 2.42 (95% CI: 2.40-2.44) and 3.15 (3.13-3.17) respectively. In the UK this equates to 41,141 primary care appointments per year. Incidence was higher in males, those aged 0-2 years, and those living in the least deprived quintile. Treatment involved oral antibiotics (57.1%), no prescription (28.1%), topical antibiotics (9.7%), or combination (4.9%). The cost to NHS primary care is estimated at £1.97 million per year. Conclusions This is the first longitudinal population-based study investigating PO which demonstrates the burden on primary care. Antimicrobial prescribing predominantly follows NICE guidelines using oral amoxicillin. Aminoglycosides are the most frequently prescribed topical antibiotic despite the concern of ototoxicity.

The Association of Established Primary Care with Postoperative Outcomes Among Medicare Patients with Digestive Tract Cancer.

Primary care (PC) is essential to overall wellness and management of comorbidities. In turn,patients without adequate access to PC may face healthcaredisparities. We sought to characterize the impact of established PC on postoperative outcomes among patients undergoing a surgical procedure for adigestive tract cancer. Medicare beneficiaries with a diagnosis of hepatobiliary, pancreas, and colorectal cancer between 2005 and 2019 were identified within the Surveillance, Epidemiology, and End Results program and Medicare-linked database. Individuals who did versus did not have PC encounters within 1-year before surgery were identified. A postoperative textbook outcome (TO) was defined as the absence of complications, no prolonged hospital stay, no readmission within 90 days, and no mortality. Among 63,177 patients, 50,974 (80.7%) had at least one established PC visit before surgery. Patients with established PC were more likely to achieve TO (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.09-1.19) with lower odds for complications (OR, 0.85; 95% CI, 0.72-0.89), extended hospital stay (OR, 0.86; 95% CI, 0.81-0.94), 90-day readmission (OR, 0.94; 95% CI, 0.90-0.99), and 90-day mortality (OR, 0.87; 95% CI, 0.79-0.96). In addition,patients with established PC had a 4.1% decrease in index costs and a 5.2% decrease in 1-year costs. Notably, patients who had one to five visits with their PC in the year before surgery had improved odds of TO (OR, 1.21; 95% CI, 1.16-1.27), whereas individuals with more than 10 visits had lower odds of a postoperativeTO (OR, 0.91; 95% CI, 0.84-0.98). Most Medicare beneficiaries with digestive tract cancer had established PC within the year before their surgery. Established PC was associated with a higher probability of achieving ideal outcomes and lower costs. In contrast, patients with more than 10 PC appointments, which was likely a surrogate of overall comorbidity burden, experienced no improvementin postoperative outcomes.

A realist review of the causes of, and current interventions to address 'missingness' in health care.

This protocol describes a realist review exploring the problem of "missingness" in healthcare, defined as the repeated tendency not to take up offers of care that has a negative impact on the person and their life chances. More specifically, the review looks at the phenomenon of patients missing multiple appointments in primary care in the UK - at the causal factors that influence how patients come to be "missing" in this way, and what interventions might support uptake and "presence" in healthcare. Background research informing this project suggests that a high rate of missed appointments predicted high premature death rates, and patients were more likely to have multiple long-term health conditions and experience significant socioeconomic disadvantage. Most research in this field focuses on population- or service-level characteristics of patients who miss appointments, often making no distinction between causes of single missed appointments and of multiple missed appointments. There have therefore been no interventions for 'missingness', accounting for the complex life circumstances or common mechanisms that cause people to repeatedly miss appointments. We use a realist review approach to explore what causes missingness - and what might prevent or address it - for whom, and in what circumstances. The review uses an iterative approach of database searching, citation-tracking and sourcing grey literature, with selected articles providing insight into the causal dynamics underpinning missed appointments and the interventions designed to address them. The findings of this review will be combined with the findings of a qualitative empirical study and the contributions of a Stakeholder Advisory Group (STAG) to inform the development of a programme theory that seeks to explain how missingness occurs, whom it affects and under what circumstances. This will be used to develop a complex intervention to address multiple missed appointments in primary care. CRD42022346006.

Investigating How the Use of Technology Can Reduce Missed Appointments: Quantitative Case Study at a General Practitioner Surgery.

SMS texting systems have been considered a potential solution to reduce missed appointments in primary care. Existing research in this area focuses on qualitative studies investigating the attitudes of SMS text users and receivers. This study aimed to examine appointment data from an independent general practitioner (GP) surgery in Wrexham, United Kingdom, with approximately 15,000 patients, to determine the impact of text messaging systems on reducing missed appointments. The objective of this study was to investigate whether the use of text messages can effectively reduce missed appointments. To collect data for the study, SQL reports were run on EMIS Web, the United Kingdom's most widely used clinical system. The data spanned 10 years, from September 1, 2010, to March 31, 2020. Data accuracy was verified by cross-referencing with appointment diary records. Mann-Whitney and Kruskal-Wallis tests, chosen for their suitability in comparing groups in nonparametric settings, were conducted in Microsoft Excel due to its accessibility. Statistical analyses were conducted to compare data before and after implementation of the text messaging system. The results revealed a significant 42.8% reduction in missed appointments (before: 5848; after: 3343; P<.001). Further analysis of demographic characteristics revealed interesting trends, with no significant difference in missed appointments between genders, and variations observed across different age groups. The median number of missed appointments was not significantly different between genders (women: 1.55, IQR 1.11-2.16; men: 1.61, IQR 1.08-2.12; P=.73). Despite the prevalence of mobile phone use among young adults aged 20-25 years, the highest rates of missed appointments (848/7256, 11.7%) were noted in this group, whereas the lowest rates were noted in the 75-80 years age group (377/7256; 5.2%; P<.001). Analysis by age and gender indicated inconsistencies: women aged 20-25 years (571/4216) and men aged 35-40 years (306/3040) had the highest rates of missed appointments, whereas women aged 70-75 years (177/4216) and men aged 75-80 years (129/3040) had the lowest rates (P<.001 for both). This study demonstrates that SMS text messaging in primary care can significantly reduce missed appointments. Implementing technology such as SMS text messaging systems enables patients to cancel appointments on time, leading to improved efficiency in primary care settings.

NYC Care: A Large Health Care Access Program for Uninsured New York City Residents.

Millions of people living in the United States are excluded from health insurance due to income or immigration status. These 2 groups are more likely to lack access to health care or a regular source of care. NYC Health + Hospitals is addressing this need with NYC Care, a health care access program. The program is designed to be the single point of access for uninsured care citywide and includes a membership card, a 24-hour customer service line, and direct access to primary care medical homes. Health care is coordinated across NYC Health + Hospitals using integrated electronic referrals and a medical record system. The program uses a single enrollment process across safety net health care resources of NYC Health + Hospitals. A 24-hour call center was established to answer questions, make primary care appointments, and make warm handoffs to enrollment staff. Once eligibility is confirmed and patients are enrolled, they are mailed a membership card, a member handbook, and offered a primary care appointment. A multipronged public awareness campaign including citywide, multilingual marketing and outreach via community-based organizations was essential to build trust. NYC Care had 119 203 members at the end of June 2023. Fifty-eight percent had not seen a primary care doctor in the NYC Health + Hospitals system in the prior 36 months. In total, 76 439 had completed 1 or more primary care visits; 53.1% of enrollees with diabetes had improved hemoglobin A 1c , and 73.4% of enrollees with hypertension had improved blood pressure control after 6 months of enrollment. NYC Care demonstrates that municipalities can improve access to care for the uninsured by simplifying steps to affordable health care services, connecting patients directly to patient-centered medical homes, and improving the patient experience. A comprehensive public awareness campaign is also crucial.

Identity and access: Gender-based preferences and physician availability in primary care

Patient preferences for physicians may be influenced by shared characteristics such as gender. We analyzed experimental data from a survey of US adults in which respondents were asked to choose between physician profiles that on average varied only by gender. We find that female patients prefer female physicians to male physicians by 51.8 percentage points (95 % CI: 0.470 to 0.566, p < 0.01), and that result holds across Black, White, and Hispanic sub-groups. With no countervailing preference among male patients, this result holds in the overall sample at 26.8 percentage points (95 % CI: 0.228 to 0.307, p < 0.01). We also analyzed data from a simulated patient field experiment concerning access to primary care appointments and find that female physicians, on average, offer appointments 7.1 days later than male physicians (95 % CI: 5.1 to 9.1, p < 0.01), consistent with the finding that female physicians are preferred. Female physicians’ offices appear to favor female patients, offering appointments to them 2.6 days earlier compared to male patients (95 % CI: -5.3 to 0.195, p = 0.07). However, Hispanic female patients were offered 4.2-percentage-points fewer appointments compared to Hispanic males (95 % CI: -0.069 to -0.014, p < 0.01) by female physicians’ offices. Similarly, Black female patients were told that the physician is “not taking new patients” 3.5 percentage points more often (95 % CI: -0.004 to 0.073, p = 0.08) and were offered appointments that were 2.6 minutes shorter compared to Black males (95 % CI: -4.8 to -0.44, p = 0.02). Overall, our analysis suggests that female primary care physicians are in high demand relative to their supply, and that access to scarce female physicians is mediated by race and ethnicity.

The association between primary care appointment lengths and opioid prescribing for common pain conditions

BackgroundWhile brief duration primary care appointments may improve access, they also limit the time clinicians spend evaluating painful conditions. This study aimed to evaluate whether 15-minute primary care appointments resulted in higher rates of opioid prescribing when compared to ≥ 30-minute appointments.MethodsWe performed a retrospective cohort study using electronic health record (EHR), pharmacy, and administrative scheduling data from five primary care practices in Minnesota. Adult patients seen for acute Evaluation & Management visits between 10/1/2015 and 9/30/2017 scheduled for 15-minute appointments were propensity score matched to those scheduled for ≥ 30-minutes. Sub-groups were analyzed to include patients with acute and chronic pain conditions and prior opioid exposure. Multivariate logistic regression was performed to examine the effects of appointment length on the likelihood of an opioid being prescribed, adjusting for covariates including ethnicity, race, sex, marital status, and prior ED visits and hospitalizations for all conditions.ResultsWe identified 45,471 eligible acute primary care visits during the study period with 2.7% (N = 1233) of the visits scheduled for 15 min and 98.2% (N = 44,238) scheduled for 30 min or longer. Rates of opioid prescribing were significantly lower for opioid naive patients with acute pain scheduled in 15-minute appointments when compared to appointments of 30 min of longer (OR 0.55, 95% CI 0.35–0.84). There were no significant differences in opioid prescribing among other sub-groups.ConclusionsFor selected indications and for selected patients, shorter duration appointments may not result in greater rates of opioid prescribing for common painful conditions.

Exploring the clinical reasoning of an advanced clinical practitioner through a respiratory case encountered in primary care

Advanced clinical practitioners work autonomously, utilising a high degree of complex decision making within situations of clinical uncertainty. This case report examines the clinical reasoning surrounding the decision to refer a patient for a chest X-ray to confirm the presence of lung cancer. Although advocated for within clinical guidelines, the sensitivity of X-ray in the detection of early lung cancer has been questioned, and the value of alternative imaging in the form of low-dose computed tomography proposed. Conditions within clinical practice, including time constraints and fatigue, may negatively impact clinical reasoning. A national move towards 15-minute appointments in primary care would aid this.

Time Series Analysis: Associations Between Temperature and Primary Care Utilization in Philadelphia, Pennsylvania

IntroductionEarth's temperature has risen by an average of 0.11°Fahrenheit per decade since 1850 and experts predict continued global warming. Studies have shown that exposure to extreme temperatures is associated with adverse health outcomes. Missed primary care visits can lead to incomplete preventive health screenings and unmanaged chronic diseases. This study examines the associations between extreme temperature conditions and primary care utilization among adult Philadelphians. Methods1,048,575 appointments from 91,580 patients age ≥ 18 years enrolled in the study at thirteen university-based outpatient clinics in Philadelphia from January 1, 2009, to December 31, 2019. Statistical analysis was performed from June to December 2023. Data on attended and missed appointments was linked with measures of daily maximum temperature and precipitation, stratified by warm and cold seasons. Sociodemographic variables and associations with chronic disease status were explored. ResultsRates of missed appointments increased by 0.72% for every 1°F decrease in daily maximum temperatures below 39°F and increased by 0.64% for every 1°F increase above 89°F. Individuals≥65 years and those with chronic conditions had stronger associations with an increased rate of missed appointments. ConclusionsTemperature extremes were associated with higher rates of missed primary care appointments. Individuals with chronic diseases were more likely to have missed appointments associated with extreme temperatures. The findings suggest the need for primary care physicians to explore different modes of care delivery to support vulnerable populations, such as making telemedicine during extreme weather events a viable and affordable option.

Mortality, morbidity and educational outcomes in children of consanguineous parents in the Born in Bradford cohort

Background Children of consanguineous parents have a higher risk of infant and childhood mortality, morbidity and intellectual and developmental disability. Methods Using a prospective UK based longitudinal family cohort study we quantify differences according to the consanguinity status of children from birth to age 10 in mortality, health care usage, two health and three educational outcomes. Results Compared to children whose parents were not related children whose parents were first cousins were more likely to die by the age of 10 years (odds ratio 2.81, 95% CI 1.82-4.35) to have higher rates of primary care appointments (incident rate ratio 1.39, 95% CI 1.34-1.45) and more prescriptions (incident rate ratio 1.61, 95% CI 1.50-1.73). Rates of hospital accident and emergency attendance (incident rate ratio 1.21,95% CI 1.12-1.30) and hospital outpatients’ appointments (incident rate ratio 2.21,95% CI 1.90-2.56) are higher. Children whose parents are first cousins have higher rates of speech/ language development difficulties (odds ratio 1.63, 95% CI 1.36-1.96) and learning difficulties (odds ratio 1.89, 95% CI 1.28-2.81). When they begin school children whose parents are first cousins are less likely to reach phonics standards (odds ratio 0.73, 95% CI 0.63-0.84) and less likely to show a good level of development (odds ratio 0.61, 95% CI 0.54-0.68). At age 10 there are higher numbers with special educational needs who are from first cousin unions when compared to all children whose parents are not blood relations (odds ratio 1.38, 95% CI 1.20-1.58). Effect sizes for consanguinity status are similar in univariable and multivariable models where a range of control variables including deprivation are added. Conclusions There is higher childhood mortality and greater use of health care as well as higher rates of learning difficulties, speech and language development challenges and substantive differences in education outcomes in children whose parents are first cousins

Understanding the causes of missingness in primary care: a realist review

BackgroundAlthough missed appointments in healthcare have been an area of concern for policy, practice and research, the primary focus has been on reducing single ‘situational’ missed appointments to the benefit of services. Little attention has been paid to the causes and consequences of more ‘enduring’ multiple missed appointments in primary care and the role this has in producing health inequalities.MethodsWe conducted a realist review of the literature on multiple missed appointments to identify the causes of ‘missingness.’ We searched multiple databases, carried out iterative citation-tracking on key papers on the topic of missed appointments and identified papers through searches of grey literature. We synthesised evidence from 197 papers, drawing on the theoretical frameworks of candidacy and fundamental causation.ResultsMissingness is caused by an overlapping set of complex factors, including patients not identifying a need for an appointment or feeling it is ‘for them’; appointments as sites of poor communication, power imbalance and relational threat; patients being exposed to competing demands, priorities and urgencies; issues of travel and mobility; and an absence of choice or flexibility in when, where and with whom appointments take place.ConclusionsInterventions to address missingness at policy and practice levels should be theoretically informed, tailored to patients experiencing missingness and their identified needs and barriers; be cognisant of causal domains at multiple levels and address as many as practical; and be designed to increase safety for those seeking care.

CSP2023: 305 - Access to First Contact Physiotherapy appointments in Primary Care; a scoping review

CSP2023: 305 - Access to First Contact Physiotherapy appointments in Primary Care; a scoping review

Implementation of patient navigation services to improve colorectal cancer health literacy in a vulnerable community health center population.

e23208 Background: Under-served community populations face social and health inequities which contribute to sub-optimal colorectal cancer (CRC) screening rates and excess mortality risk. Furthermore, these populations may not have the health literacy or food security necessary to mitigate the well-established nutrition-related risk of CRC. This quality improvement study aimed to improve CRC-related health literacy and dietary habits, with the additional goal of improving screening rates in our disadvantaged community health center population. Methods: This single-institutional study utilized the Plan-Do-Study-Act (PDSA) model to implement patient navigation services and administer a cross-sectional survey evaluating nutrition-related CRC risk. Patients eligible for screening were contacted by patient outreach coordinators prior to scheduled primary care appointments, and the survey was administered. During patient visits, outreach coordinators met with them to provide 1:1 education addressing CRC prevention, screening and nutrition. Information on free or low-cost fresh food options was provided to help address barriers such as food insecurity. The outreach coordinators also liaised with physicians to assist with coordination to services. Results: Prior to the intervention 58% of survey respondents (25/43) were not aware of any foods or dietary habits that decreased the risk of colorectal cancer; 51% (22/43) were not aware of foods that increased the risk of colorectal cancer. Most respondents (54%) were in fact not at all worried about possibly developing CRC in their lifetimes (22/41), while 34% (14/41) were a little worried, and the remainder (12%) very or extremely worried. 97% of respondents (33/34) felt more knowledgeable about CRC screening and felt more confident about improving their nutrition to reduce CRC risk after receiving the educational intervention, while 94% of respondents (31/33) stated they would subsequently make dietary changes. Conclusions: Health literacy regarding colorectal cancer was low in this underserved community population. Implementation of a patient navigation intervention led to increased knowledge and confidence in modifying dietary risk factors. However, preliminary data review did not reveal significant change in CRC screening rates during the initial phase of the intervention. One of the initially identified barriers included system-level delays in colonoscopy access. During the Act phase of the PDSA model, patient navigation services will be further optimized by workflow adaptation based on the response of outreach coordinators and patient-reported barriers regarding stool-based testing. [Table: see text]