Emergency Primary Care Research Articles

Nurses' Experience With End-of-Life Care in Geriatric Centers: A Systematic Review.

Geriatric nurses provide end-of-life care based on the five pillars of aging. This systematic review assesses the emotions and feelings of geriatric nurses during end-of-life care. It considers the prevalence, triggers, and intensity of emotional responses among geriatric nurses. It also expounds on the strategies for overcoming the emotional challenges. The study embarked on a systematic review of literature materials on nurses' emotions and feelings. The eligibility criteria involve literature materials published in the past 5 years, peer reviews, English language, geriatric nurses, and nurses in emergency department, primary care, and intensive care unit. Three databases (Cochrane Library, PubMed, and CINAHL) and Google Scholar were used. Using a PRISMA flow chart, the literature search led to the discovery of nine significant writings on the emotions and feelings of nurses attending to geriatric patients. Sample sizes in these studies varied from 6 to 126 nurses while three articles involved integrated, scoping, and literature review of published studies. The common emotions and feelings among nurses caring for elderly patients in the geriatric center are compassion fatigue, burnout, grief, and moral distress. These emotions and feelings affect the performance of nurses. They also influence their physical and mental wellbeing. This situation calls for developing effective coping strategies to address this challenge.

P-1133. Preferred (Spoken) Language was a Major Correlate of Disparate Antibiotic Prescribing in the Pediatric Outpatient Setting Throughout the COVID-19 Pandemic

Abstract Background No studies have explored sociodemographic variation in antibiotic prescribing across phases of the COVID-19 pandemic. We explored relationships between race, language, socioeconomic measures, and outpatient antibiotic prescribing patterns at our institution before and during the pandemic. Methods Data were obtained across all Cincinnati Children’s outpatient primary care centers, urgent cares, and emergency departments (n = 24) from 2018-2023. Outpatients aged 0-18 years with an acute respiratory tract infection were included. Our primary outcomes were the proportion of encounters with antibiotics prescribed. Sociodemographic factors included race, ethnicity, primary language, insurance status, and a socioeconomic deprivation index (SDI) linked to a child’s geocoded home address (with higher scores showing more deprivation). We examined associations between such factors and antibiotic prescribing before (2018-19) and during (2020-21 and 2022-23) the COVID-19 pandemic. Chi-square analyses evaluated associations of proportions across groups. Results A total of 185,338 clinical encounters of 99,037 children with median age 3.6 years (IQR 1.3-7.5), 58% White, 9% Hispanic, and 93% English-speaking were captured from 2018-2023. Table 1 shows associations of sociodemographic variables and antibiotic prescribing. While only small differences were noted in prescribing across race and insurance, patients preferring languages other than English had significantly more antibiotic use (Spanish (79%), Nepali (78%), Arabic (77%), Other (74%)) than those who preferred English (69%, p< 0.001). No clinically significant differences (≥5%) were found across SDI quartiles. Antibiotic use decreased early in the COVID-19 pandemic among all sociodemographic groups, rebounding to or above prior pre-pandemic levels and maintaining sociodemographic differences later in the pandemic (Table 2). Conclusion At our institution, contrary to prior studies, children who preferred languages other than English received more antibiotics than English-speaking peers, associations which persisted across the COVID-19 pandemic. Next steps include investigating language-based differences in infectious diagnoses and antibiotic prescribing across individual outpatient sites. Disclosures All Authors: No reported disclosures

P-1637. Four-year Experience on Ambulatory Antibiotic Prescribing for Viral Respiratory Infections

Abstract Background In 2019, our institution implemented the MITIGATE (a Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection for Adult and Children in Emergency Department and Urgent Care Settings) Toolkit, a multimodal antimicrobial stewardship strategy using education, data, and feedback to reduce unnecessary antibiotic prescribing for viral respiratory infections (RTIs) in ambulatory care settings. Methods This was a single center observational study. Prescribers in emergency department (ED), primary care (PC), and urgent care (UC) were notified of their individual unnecessary antibiotic prescribing from 9/2019 - 3/2022 via email. We reduced rate of feedback from notifying all prescribers, to half after the first year, and none after 2 years and observed the impact on antibiotic prescribing. Prescribers were labeled as a top performer or not a top performer compared to their peers. Unnecessary antibiotic prescribing for RTI was evaluated 4 years after the intervention began. Results In 2019 Pre-toolkit intervention, 14,247 patient visits had a qualifying viral RTI. 17.9%, 9.8%, and 6.4% received an antibiotic unnecessarily in the ED, PC, and UC, respectively. After 2-years of direct feedback, antibiotics were prescribed in 13.4%, 4.3% , and 4.7% , in the ED, PC, and UC (N = 48,192) (p< 0.001). In 2023, after feedback stopped, unnecessary prescribing remained lower in ED (14.4%, p< 0.001) and PC (5.8%, p< 0.001), but not UC (7.2%, p=0.015), N =53,496. Conclusion Rates of unnecessary antibiotic prescribing for viral RTI dropped most significantly following two years of varying degrees of direct feedback. Although prescribing rates in the ED and PC remain lower after 4 years compared to pre-intervention, current data demonstrate an uptrend. Although labor-intensive, this supports that feedback with peer comparison is an instrumental intervention. Strategies to ensure successful intervention maintenance should be considered when implementing outpatient stewardship. Disclosures All Authors: No reported disclosures

P-1683. Evaluation of Outpatient Clindamycin Prescriptions Across a Large Military Healthcare Network

Abstract Background Introduction: While clindamycin has broad Gram-positive and anaerobic activity, its use has been limited by toxicity and increasing resistance. Multiple clinical practice guidelines (CPGs) at Joint Base San Antonio recommend against clindamycin usage due to poor coverage of Gram-positive bacteria in local antibiograms. Despite this recommendation, a significant number of clindamycin outpatient prescriptions are ordered each year. The driver of these prescriptions is unknown. This study describes prescriber, diagnostic, and patient factors contributing to outpatient clindamycin usage at a large military medical system.Table 1Characteristics of 882 Patients Who Received an Outpatient Clindamycin Prescription at Joint Base San Antonio, 2023 Methods Outpatient clindamycin prescriptions from January-December 2023 filled at pharmacies on Joint Base San Antonio were evaluated to determine prescription duration, diagnostic indication, age, antibiotic allergies, prescriber, and prescribing clinic. Antibiotic indication was compared between those with beta-lactam allergies to those without beta-lactam allergies by Chi-squared.Table 2Prescriptions by Diagnostic Group and Beta-Lactam Allergy Status of Patient Results During the study period there were 941 prescriptions in 882 patients. The cohort was predominately female (52%) with a median age of 51 [IQR 40-68] (Table 1). Of these scripts, 229 (24%) were written by clinicians outside the military facility. The clinics with the most prescriptions were the Emergency Department (33%), Dental clinics (21%), Primary Care (16%), and Surgical clinics (14%). Patients with beta-lactam allergies were significantly more likely to have a dental indication (39.7% vs. 16.9%, p=< 0.0001) and those without beta-lactam allergies were more likely to have a skin and soft tissue infection (49.8% vs. 22.2%, p=< 0.0001) (Table 2). While there were 491 prescribers in this study, ten (2%) clinicians (six from the Emergency Department) prescribed 18% of all clindamycin prescriptions, 67% of which were in the absence of a beta-lactam allergy. Conclusion Patterns of outpatient clindamycin use across large health systems have not been well described. This study identifies potential areas for local stewardship interventions that have not previously been considered, including focused CPGs for emergency room clinicians as well as penicillin allergy de-labeling in outpatient dental clinics. Disclosures All Authors: No reported disclosures

Nurse management of minor problems in primary care emergencies: a non-randomized controlled trial

BackgroundHealth systems must implement strategies to adapt to the high demand in primary care caused by social changes. Since 2009, the Catalan Institute of Health has been expanding the Nurse Demand Management programme through which nursing autonomously addresses minor health problems. This study aims to analyse whether this programme is a factor in improving the efficiency and quality of care in a primary care emergency centre. The results come from a non-randomised controlled experimental study that tested the implementation of the programme applied to an experimental group treated by nurses versus a control group treated by doctors. The study was approved on 14 July 2022 by the Research Ethics Committee of the Jordi Gol University Institute following the guidelines of the TREND statement.ResultsA total of 312 patients were included in the study, all of whom came to the emergency centre with five types of minor problems. Exactly half (156) were seen by nurses and half were seen by doctors. The experimental group had an average waiting time of 15.1 min and the control group 33.25 min. There was no significant difference in the assessment of the quality of care received and there were no differences in the total number of consultations for the same problem. There were fewer prescriptions given out by nurses, with an average of 1.79 medicines per participant versus 2.26 medicines prescribed by doctors. The results of the study suggest that the Nurse Demand Management programme was a factor in improving the efficiency and in the emergency centre. Nurse resolution capacity, after applying algorithms, offered quality care, with fewer prescriptions and good patient satisfaction without increasing the total number of consultations due to the same problem.Trial registrationThe protocol for the current study was registered at Clinicaltrials.gov, with identification NCT06298240, retrospectively registered February 29, 2024.

Impact of the Advanced Practice Nurse in triage of Primary Care Emergency Departments

This study aimed to compare the time spent on episodes seen by primary care emergency departments before (2017) and after (2019) the inclusion of an advanced practice nurse in patient classification. Records from 3 primary care emergency departments in 2017 (n= 18,663) and 2019 (n= 22,632) were compared using Student t and chi-square tests. Waiting time for classification, classification time, and total time spent in the consultation area were compared for total episodes, levels of priority, reasons for consultation, and previous clinical processes. Mean waiting time decreased in 2019 for all episodes (P < .001), priorities IV (P < .001) and V (P < .001), respiratory (P < .001) and skin and subcutaneous tissue diseases (P= .015), and previous chronic processes (P= .042). Mean classification time increased in 2019 for all episodes (P< .001); priorities III (P < .001), IV (P < .001), and V (P= .045); several reasons for consultation, and previous processes. Mean total time spent in the consultation area decreased in 2019 for all (P= .002), priority V (P < .001), skin and subcutaneous tissue diseases (P= .010), and fever episodes (P= .021). The inclusion of nurses with advanced nursing practice roles reduces the waiting time and length of stay in the emergency department, but increases the classification time, which could be linked to early interventions.

Healthcare Priorities, Barriers, and Preferences According to a Community Health Needs Assessment in Jazan, Saudi Arabia: A Cross-Sectional Study.

Background: Community needs assessments can provide valuable insights concerning the health of communities. This study aims to measure health priorities according to community members in Jazan, Saudi Arabia, to assess healthcare service utilization, barriers to accessing these services, and preferences for utilizing government or private healthcare services. Method: Multistage sampling was utilized to reach a sample of adults in community settings. The assessment was performed via personal interviews utilizing a structured questionnaire to measure demographics, health priorities, service utilization, barriers, and preferences for healthcare settings. Chi-squared tests, Student's t-tests, and multivariate regression analysis were used to assess the differences between demographics and service utilization according to the preferred healthcare settings. Results: A total of 3411 participants were recruited for the assessment. The mean age of the participants was 34 years, and 51% were male. The participants viewed diabetes as the most important health condition. Emergency services and primary care were viewed as the most important healthcare services, and time constraints were the main barriers to healthcare accessibility. Thirty-six percent of the participants preferred to utilize healthcare services in the private sector, where age, gender, nationality, education, income, housing type, and family size were statistically associated with the preference for seeking healthcare in either the private or government sectors (p < 0.05). Conclusions: Future assessment is required to recruit healthcare providers and decision-makers to understand the process of strengthening multidisciplinary collaboration to tackle chronic diseases such as diabetes, strengthen the role of emergency and primary healthcare services, and address time constraints pertaining to healthcare accessibility.

Pelvic sheet binders: Are doctors placing them in the correct position?

Unstable pelvic fractures cause significant bleeding, morbidity, and mortality. Commercially available Pelvic Circumferential Compression Devices (PCCDs) are used in the initial resuscitation and management of these cases. In the trauma-burdened, resource limited setting of Southern Africa, the available alternative is a pelvic sheet binder (PSB). For optimal results placement should be at the greater trochanters (GTs). Prior studies have shown that practitioners are inaccurate in their placement. This study aimed to describe placement of PSBs by doctors and factors influencing placement. This was a multicentre, prospective, observational, simulation-based study. Doctors working in Emergency Departments (EDs) and Trauma Emergency Units (TEUs) in Johannesburg were asked to place a PSB on two healthy male models of differing body mass index (BMI), as simulated patients (SPs). Outcomes were based on PSB position relative to the GTs, marked using an ultraviolet pen, and photographed under ultraviolet light. Data on techniques of placement, as well as practitioner factors, were also collected to investigate their influence on accuracy. In this study 147/176 (83.5 %) of the PSBs placed were correct (trochanteric). Of those placed on the normal BMI SP 71/88 (81 %) were correct and 76/88 (86 %) of those on the increased BMI SP. BMI did not appear to influence accuracy of placement. Practitioner factors that had statistically significant association with accurate placement included the following: Working in the TEU, work experience of ≥6 years, a diploma in primary emergency care (DipPEC, College of emergency medicine, South Africa), all methods of placing the PSB and inspecting to find the GTs. The overall accuracy of PSBs placement was high (83.5 %). Additional postgraduate training (DipPEC) and work experience improved placement accuracy. This study highlighted the importance of additional trauma training and areas of possible future research, such as optimal binder width and method of securing PSBs.

In the face of confounders: Atrial fibrillation detection - Practitioners vs. ChatGPT.

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice, yet interpretation concerns among healthcare providers persist. Confounding factors contribute to false-positive and false-negative AF diagnoses, leading to potential omissions. Artificial intelligence advancements show promise in electrocardiogram (ECG) interpretation. We sought to examine the diagnostic accuracy of ChatGPT-4omni (GPT-4o), equipped with image evaluation capabilities, in interpreting ECGs with confounding factors and compare its performance to that of physicians. Twenty ECG cases, divided into Group A (10 cases of AF or atrial flutter) and Group B (10 cases of sinus or another atrial rhythm), were crafted into multiple-choice questions. Total of 100 practitioners (25 from each: emergency medicine, internal medicine, primary care, and cardiology) were tasked to identify the underlying rhythm. Next, GPT-4o was prompted in five separate sessions. GPT-4o performed inadequately, averaging 3 (±2) in Group A questions and 5.40 (±1.34) in Group B questions. Upon examining the accuracy of the total ECG questions, no significant difference was found between GPT-4o, internists, and primary care physicians (p=0.952 and=0.852, respectively). Cardiologists outperformed other medical disciplines and GPT-4o (p<0.001), while emergency physicians followed in accuracy, though comparison to GPT-4o only indicated a trend (p=0.068). GPT-4o demonstrated suboptimal accuracy with significant under- and over-recognition of AF in ECGs with confounding factors. Despite its potential as a supportive tool for ECG interpretation, its performance did not surpass that of medical practitioners, underscoring the continued importance of human expertise in complex diagnostics.

Cannabinoid hyperemesis syndrome-an emerging gastrointestinal disorder and clinical challenge

Nausea and vomiting are not uncommon symptoms resulting in emergency department (ED) or primary care visits. One of the emerging etiologies – Cannabinoid Hyperemesis Syndrome (CHS) remains significantly under-diagnosed, often resulting in unnecessary repeat ED visits and testing. This is in part due to lack of experience with and knowledge about CHS by health care professionals. Characterized by cyclic vomiting, often severe and intractable, it is frequently associated with a form of self-treatment; the compulsive need to take hot showers, and in the context of chronic cannabis use. With increased legalization and resultant accessibility to cannabis containing products, the risk of adverse events is significantly rising. Lack of clinical familiarity with the range of potential deleterious physical and mental health effects associated with cannabis leads to delays in appropriate diagnosis and effective treatment of CHS. Moreover, commonly utilized anti-emetics, such as ondansetron, and similar 5 HT drugs may not fully attenuate symptoms of CHS, and other interventions may be necessary; ultimately abstinence being the most effective long term clinical preventive approach. The objective of this review article is to assist the clinician in identifying the specific clinical characteristics of CHS, distinguishing it from other causes of CVS or nausea and vomiting, to facilitate more rapid, effective interventions. Collaboration with substance use professionals should also be considered during CHS treatment.

Association of Opioid Tapering with Pain-Related Emergency Department Visits, Hospitalizations, and Primary Care Visits: A Retrospective Cohort Study.

Tapering of chronic opioids has increased, with subsequent reports of exacerbated pain among patients who tapered. We aimed to evaluate the association between opioid dose tapering and subsequent pain-related healthcare utilization (ED visits, hospitalizations and primary care visits). We conducted a retrospective cohort study from 2015-2019 using data from the Optum Labs Data Warehouse that contains de-identified retrospective administrative claims data for commercial and Medicare Advantage enrollees in the US. Adults aged ≥18 years who were prescribed stable doses of opioids, ≥50 morphine milligram equivalents (MME)/day, during a 12-month baseline period. Tapering was defined as ≥ 15% relative reduction in mean daily opioid dose during one of 6 overlapping 60-day periods. Tapered patient-periods were subclassified as tapered-and-continued (MME > 0) vs. tapered-and-discontinued (MME = 0). We modeled monthly counts of visits for pain diagnoses up to 12 months after cohort entry using negative binomial regression as a function of tapering, baseline utilization, and patient level-covariates. Among 47,033 patients, 13,793 patients tapered. Compared to no taper, any taper was associated with more ED visits for pain (adjusted incidence rate ratio [aIRR] 1.21, 95% CI: 1.11-1.30), tapered then continued status was associated with more ED visits (aIRR 1.23, CI: 1.14-1.32) and hospitalizations (aIRR 1.14, CI: 1.03-1.27) for pain, and tapered-and-discontinued was associated with fewer primary care visits for pain (aIRR 0.68, CI: 0.61-0.76). These associations suggest that opioid tapering may lead to increased emergency and hospital utilization for acute pain and possibly a decreased perceived need for primary care for those whose opioids were discontinued.

Oral Corticosteroid-Related Healthcare Resource Utilization and Associated Costs in Patients with COPD.

Oral corticosteroids (OCS) are used to manage chronic obstructive pulmonary disease (COPD) exacerbations but are associated with adverse outcomes that may increase healthcare resource utilization and costs. We compared attendance/costs associated with OCS-related adverse outcomes in patients who ever used OCS versus those who never used OCS and examined associations between cumulative OCS exposure and attendance/costs. This direct matched observational cohort study used the UK Clinical Practice Research Datalink GOLD database (data range 1987-2019). Patients with a COPD diagnosis on/after April 1, 2003, and Hospital Episode Statistics linkage were included. Emergency room, specialist or primary care outpatient, and inpatient attendance were analyzed. Costs, estimated using Health and Social Care 2019 and National Health Service Reference Costs 2019-2020 reports, were adjusted for sex, age, exacerbation number, and inhaler type used in the 12months before index date. The OCS cohort had higher annualized disease-specific (excluding respiratory) total attendance/costs versus the non-OCS cohort (adjusted incidence rate ratio [aIRR] with 95% confidence intervals [CIs]) ranging from 37% (1.37 [1.31, 1.43]) for emergency room attendances to 149% (2.49 [2.36, 2.63]) for specialist consultations. Disease-specific (excluding respiratory) attendance/costs increased in a positive dose-response relationship for most attendance categories versus the < 0.5g reference dose. For the 0.5 to < 1.0g cumulative dose category, the greatest increases in disease-specific (excluding respiratory) attendance/costs occurred for primary care consultations (aIRR [95%CI] 1.38 [1.32, 1.44]). For the ≥ 10g cumulative dose category, the greatest increases were observed for primary care consultations (aIRR [95%CI] 2.83 [2.66, 3.00]), non-elective long stays (≥ 2days; 2.54[2.15, 2.99]), and non-elective short stays (≤ 1day; 2.51 [2.12, 2.98]). Similar findings were observed for all-cause attendance/costs. Among patients with COPD, OCS-related adverse outcomes were associated with higher attendance and costs, with a positive dose-response relationship. A graphical abstract is available with this article.

Defining the Care Pathway in Patients with Psoriasis and Atopic Dermatitis.

This study aims to map the clinical pathway for psoriasis and atopic dermatitis (AD) in a tertiary hospital to better understand patient needs and experiences, thereby suggesting improvements in patient-centered care. A mixed-method approach was utilised involving a literature review, a questionnaire for healthcare professionals (HCPs), and two focus groups (one with HCPs and the other with patients with psoriasis or AD). Ethical approvals were obtained, and informed consent was acquired from all participants. Patients and HCPs identified significant delays in the pre-diagnosis phase, extending up to five years for psoriasis and three years for AD, adversely affecting the timely initiation of effective treatment. In addition, there were reported difficulties in obtaining appointments during flares, a lack of dermatologic emergencies, a need to increase human resources and physical space, and a need for telematic consultations for urgent cases. Discrepancies between HCPs' perceptions and patients' experiences highlighted unmet needs, particularly in primary care settings and emergency departments. Several strengths were also identified, including satisfactory experience in dermatology, the hospital's high level of specialisation in the management of complex patients, optimal communication between services, consideration of patient preferences, and proper advice on hospital pharmacy care and administration support of treatment and adherence monitoring. The findings underscore the necessity for interventions to reduce wait times and improve treatment immediacy and effectiveness post-diagnosis. The insights from this study can direct enhancements in patient management and satisfaction for individuals with psoriasis and AD.

Rapid rule-out of acute myocardial infarction using the 0/1-hour algorithm for cardiac troponins in emergency primary care: the OUT-ACS implementation study

Abstract Background Acute chest pain in primary care often results in defensive and unnecessary hospital referrals due to the limited ability to rule out an acute myocardial infarction (AMI) outside of hospital. In a previous prospective observational study (OUT-ACS; One-hoUr Troponin in a low-prevalence population of Acute Coronary Syndrome), we demonstrated that the ESC 0/1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) would be safe and cost-effective if implemented to assess low-risk patients with chest pain in emergency primary care. Purpose We evaluated the real-world applicability, personnel adherence, and disposition of low-risk patients with chest pain following the implementation of the ESC 0/1-hour algorithm in emergency primary care. Methods In April 2023, the ESC 0/1-hour algorithm for hs-cTnT was implemented at a large emergency primary care clinic in Norway. The clinic is located close to a hospital, enabling the patient to wait at the clinic while blood samples are analysed for hs-cTnT at the hospital laboratory. For the following six months, all patients ≥18 years with acute non-traumatic chest discomfort, offered hs-cTnT measurements at the clinic, were anonymously registered, including their discharge diagnoses and disposition from the clinic. By applying the ESC 0/1-hour algorithm, patients were assigned to rule-out, rule-in or further observation. Patients in the observation group were offered a 4-hour hs-cTnT measurement before a final decision. Results During the six-month period, 10.3% (n=3,053/29,631) of the clinic's consultations involved chest complaints. Hs-cTnT measurements were conducted in 32.6% (n=995/3,053) with a median age of 58 years (IQR 45-68), 50.6% being female. A single hs-cTnT &amp;lt;5 ng/L, sampled ≥3 hours since symptom onset, triaged 24.1% (n=240/995) of the patients towards the rule-out group, increasing to 63.8% after adding a 1-hour measurement. In the rule-in group (n=42/995, 4.2%), 16 patients were diagnosed with an AMI. The intermediate observation group (n=318/995, 32.0%, 4 AMIs) was reduced to 23.0 % after a 4-hour hs-cTnT measurement. Healthcare personnel adhered well to the algorithm, with a median sampling interval of 63 minutes (IQR 60-66) and 4.5 hours (IQR 4.1-5.5) for the 1- and 4-hour measurements, respectively. The algorithm was misinterpreted or overruled in 8.8% of the cases. Ultimately, only 14.8% required hospital transfer following troponin assessment at the clinic. The remaining patients were sent home or managed in the outpatient setting. Conclusions The OUT-ACS strategy, utilizing a 0/1/4-hour algorithm for hs-cTnT measurements in emergency primary care, is safe, effective and applicable, and the strategy contributes to reduced hospital referrals for low-risk patients with chest pain.0/1/4-hour algorithm for hs-cTnTDisposition

Identifying low-risk chest pain in out-of-hours primary care: the diagnostic performance of preHEAR and preHEART scores based on two European cohorts

Abstract Background Distinguishing cardiac from non-cardiac acute chest pain presents a diagnostic challenge. Risk stratification tools, such as the HEART score, have been developed for decision support for hospital-based settings. For prehospital settings, the preHEART score was developed as an alternative to the HEART score, with refinements made to meet prehospital conditions, as illustrated in Figure 1. While promising for use by emergency medical services, the diagnostic performance in primary care is unknown. Purpose In this study, we aim to evaluate the preHEART score (with and without high-sensitivity cardiac troponin (hs-cTn)) as a risk stratification tool to rule out acute myocardial infarction (MI) in patients evaluated in out-of-hours primary care. Methods We relied on retrospective data from two cohorts, namely, the OUT-ACS study involving 1,711 consecutive patients (47.7% female, median age: 56 (25th-75th percentiles: 45-68)) evaluated at a Norwegian primary care emergency centre from 2016-2018; and the TRACE study involving 664 consecutive patients (56.9% female, median age: 48 (25th-75th percentiles: 32-67) from a Dutch primary care emergency centre in 2017. We evaluated the preHEAR (OUT-ACS &amp; TRACE without hs-cTn) and preHEART scores (OUT-ACS). The threshold of ≤3 points was considered low-risk and previously determined as optimal for rule-out purposes. The primary outcome was the diagnostic performance for ruling out MI at the index episode, and the secondary outcome was the composite of 90-day all-cause death or MI. Results In the OUT-ACS cohort, 61 (3.6%) patients were diagnosed with an MI; for the TRACE study, MI was diagnosed in 20 (3.0%) patients. The percentage of patients deemed at low risk by preHEAR was 49.3% (n=843) and 82.7% (n=549) for OUT-ACS and TRACE, respectively. For preHEART, only 33.6% (n=575) of OUT-ACS patients were deemed low-risk. As shown in Figure 2, the corresponding sensitivity/specificity indices for index MI were 63.9%/49.8% (OUT-ACS) and 65.0%/84.2% (TRACE) for preHEAR and 93.4%/34.6% for preHEART. Positive predictive values were low (preHEAR 5.0-11.3%, preHEART 5.0%), whereas negative predictive values were high (preHEAR 97.4-98.7%, preHEART 99.3%). For the secondary outcome, similar diagnostic performance metrics were found. All missed MI cases (n=4) in the low-risk preHEART group were female. Conclusion The preHEAR and preHEART scores did not result in adequate rule-out safety for an emergency primary care setting despite a low a priori MI risk. Moreover, the score appears to underestimate the risk for MI in females.preHEAR(T) risk scoresPerformance of the risk scores

Safety and efficiency of modified HEART scores without troponin or electrocardiography: an analysis based on two European out-of-hours primary care cohorts

Abstract Background Differentiating between acute chest pain of cardiac versus non-cardiac origin poses a diagnostic challenge. Risk stratification tools, such as the HEART (History, ECG, Age, Risk and Troponin) score, have been developed to aid in decision-making. These scores typically rely on troponin or electrocardiography (ECG), often unavailable in (low-resource) community-based healthcare settings. Purpose We evaluated the diagnostic performance of the HEART score in a low-risk setting when one of its five metrics is missing Methods We relied on data from two cohorts, OUT-ACS (n=1,711; for analyses with and without troponin) and TRACE (n=664; for analyses without troponin) of consecutive patients evaluated at primary care emergency clinics in respectively Norway (2016-2018; 47.7% female, median age: 56, 25th-75th percentiles:45-68) and the Netherlands (2017, 56.9% female, median age: 48, 25th-75th percentiles:32-67). We evaluated the HEAR score (all elements except troponin) and the HART score (all elements except ECG). The primary outcome was the diagnostic performance for ruling out myocardial infarction (MI) at index presentation, with a secondary outcome consisting of the composite of all-cause death or MI at 90-day follow-up. Results Among study participants, 61 (3.6%) were diagnosed with an MI in the OUT-ACS and 20 (3.0%) in the TRACE cohort. The percentages of patients deemed at low risk by HEAR (&amp;lt;=3) were 925 (54.1%) and 527 (79.4%) in OUT-ACS and TRACE, respectively. Sensitivity and specificity were 70.5% (95 % confidence interval 57.4-81.5) and 55.0% (52.5-57.4), and 75.0% (50.9-91.3) and 81.1% (77.8-84.0) for HEAR in the two respective cohorts. For the HART score, low risk was found in 696 (40.7%) OUT-ACS participants, with a respective sensitivity and specificity of 96.7% (88.7-99.6) and 42.1% (39.7-44.5), Positive predictive values ranged from 5.5-15.3%, whilst negative predictive values were 98.1-99.1% for HEAR and 99.7% for HART. By comparison, the HEART score determined 639 (37.3%) patients as low risk, had a sensitivity and specificity of 98.4% (91.2-100) and 38.7% (36.3-41.1), and positive and negative predictive values of 5.6% (5.3-5.9) and 99.8% (98.9-100). Similar findings were found for analyses using the secondary outcome. Conclusion HEART score variants in which troponin or ECG are omitted have higher efficiency but at the cost of decreased safety, particularly when leaving out troponin. Therefore, these biomarkers are paramount for adequate safety, despite the overall high negative predictive values in this low-prevalence primary care setting.

Geographic Socioeconomic Influences on Disease Activity in Rheumatoid Arthritis in an Academic and Safety Net Hospital System.

The objective of this study was to analyze the impact of the Area Deprivation Index (ADI) on disease activity and cardiovascular comorbidity in rheumatoid arthritis (RA). A retrospective analysis of adult patients with RA was conducted to highlight differences in academic and safety net hospital clinics. Demographics, RA medication history, patient portal engagement, primary care presence, emergency or inpatient visits, RA disease activity and functional scores, Charlson Comorbidity Index (CCI), and cardiovascular disease (CVD) presence were captured. The ADI rank was assigned using nine-digit zip codes. Patients were stratified by the upper versus lower ADI decile group and matched by age, sex, race, ethnicity, insurance, and CCI using propensity score analysis. Patients with RA from the academic practice (n = 542) and the safety net hospital (n = 496) were assessed. In the academic cohort, those with high ADI scores (>8, more deprivation) had higher RA disease activity scores (Routine Assessment of Patient Index Data 3 mean ± SD: high 13.83 ± 6.94 vs low 11.17 ± 7.37, P < 0.0001; Clinical Disease Activity Index mean ± SD: high 11.97 ± 11.74 vs low 9.40 ± 7.97, P < 0.05), more functional impairment (Multidimensional Health Assessment Questionnaire mean ± SD: high 2.99 ± 2.29 vs low 2.34 ± 2.23, P < 0.01), lower MyChart use (P < 0.001), and different smoking history (P < 0.01) compared to those with low ADI scores (<3, less deprivation). In the safety net cohort, there was a statistically significant difference only in smoking status (P < 0.05). CVD was not significantly different in either cohort. The absence of differences in RA disease activity and functional impairment in patients suggests that the ADI may not be as effective at predicting RA disease activity specifically in a safety net health care context. Identifying the discrepancies between the two systems may elucidate areas of improvement for patient care.

The Impact of Tele-Stewardship on Rural Antibiotic Prescribing Practices

Abstract Background Antibiotic prescribing for children is highest in rural areas. Tele-stewardship allows for implementation of antimicrobial stewardship (AS) via telecommunication with providers. There has been limited research on the effectiveness of tele-stewardship in the outpatient setting. In this study, we address the need for better AS in rural areas by developing, implementing, and evaluating AS interventions using tele-stewardship. Methods We employed bundled outpatient AS implementation strategies in rural pediatric primary care (PC) clinics and emergency departments (EDs) affiliated with Vanderbilt University Medical Center (VUMC) using tele-stewardship. The bundle includes (1) patient/guardian educational materials, (2) antibiotic use commitment posters (3) provider education through quarterly teaching pearls on common pediatric infections, communication skills training (DART modules), app-based microlearning modules (QuizTime), and implicit/explicit bias education and (4) quarterly audit and feedback with peer comparison on guideline-concordant antibiotic use. Participants are pediatric prescribers (physician, physician assistant, nurse practitioner). We compared antibiotic prescription data for children &amp;lt;18 years collected during the “baseline” period (Jan-Dec 2022) to the intervention period (Jan-Sept 2023). Two academic urban primary care clinics and one academic urban ED at which the interventions were not implemented were included as “control” sites. The primary outcome is percent of all encounters that result in an antibiotic prescription. Pre- and post-intervention data were analyzed in aggregate (not at the provider-level). Significance was determined via calculating a 95% confidence interval (CI) for the difference of proportions. Results To date, there have been 140,077 PC patient encounters (98,409 baseline and 41,065 intervention) and 94,205 ED encounters (61759 baseline and 32,446 intervention) across all sites. Change from baseline to intervention periods in academic PC sites was 0.9 percentage points (95% CI 0.556 to 1.243; 6.6% baseline, 7.5% intervention) while change in rural intervention sites was -1.05 percentage points (95% CI -0.409 to -1.667; 11.8% baseline, 10.75% intervention; Figure 1a). Only 1 of 3 rural EDs had a decrease in percent of encounters with an antibiotic prescription (Figure 1b). Overall the academic ED showed a 3.1 percentage point increase (95% CI 2.430 to 3.769; 18.0% baseline, 21.1% intervention) while the rural sites showed a 1.0 percentage point increase (95% CI -0.817 to 2.817; 24.2% baseline, 25.2% intervention). Conclusion Interim analysis shows that bundled implementation strategies using tele-AS led to significantly decreased overall antibiotic use in rural primary care clinics compared to urban academic control sites. The study is ongoing and will continue to evaluate outcomes over a longer intervention period to reduce seasonal bias.

Impact of COVID-19 Pandemic on Healthcare Utilization in People with Diabetes: A Time-Segmented Longitudinal Study of Alberta's Tomorrow Project.

The objective is to characterize the impact of COVID-19 on major healthcare for diabetes, including hospitalization, emergency department (ED) visits and primary care visits in Alberta, Canada. Participants from Alberta's Tomorrow Project (ATP) with pre-existing diabetes prior to 1 April 2018 were included and followed up to 31 March 2021. A time-segmented regression model was used to characterize the impact of COVID-19 on healthcare utilization after adjusting for seasonality, socio-demographic factors, lifestyle behaviors and comorbidity profile of patients. Among 6099 participants (53.5% females, age at diagnosis 56.1 ± 9.9 y), the overall rate of hospitalization, ED visits and primary care visits was 151.5, 525.9 and 8826.9 per 1000 person-year during the COVID-19 pandemic (up to 31 March 2021), which means they reduced by 12% and 22% and increased by 6%, compared to pre-pandemic rates, respectively. Specifically, the first COVID-19 state of emergency (first wave of the outbreak) was associated with reduced rates of hospitalization, ED visits and primary care visits, by 79.4% (95% CI: 61.3-89.0%), 93.2% (95% CI: 74.6-98.2%) and 65.7% (95% CI: 47.3-77.7%), respectively. During the second state of emergency, healthcare utilization continued to decrease; however, a rebound (increase) of ED visits was observed during the period when the public health state of emergency was relaxed. The declared COVID-19 states of emergency had a negative impact on healthcare utilization for people with diabetes, especially for hospital and ED services, which suggests the importance of enhancing the capacity of these two healthcare sectors during future COVID-19-like public health emergencies.

A New Hospital-At-Home Model for Integrated Geriatric Care: Data from a Preliminary Italian Experience

ObjectiveHospital-at-home (HaH) has emerged as an alternative to conventional in-hospital care in older adults, possibly reducing hospital admissions and related complications. This study aimed to describe the characteristics and outcomes of patients referred to “Gruppo di Intervento Rapido Ospedale-Territorio” (GIROT), a HaH service based on comprehensive geriatric assessment, developed in Florence, Italy, during the postpandemic period. DesignRetrospective longitudinal study. Setting and ParticipantsGIROT provided home-based care to patients with acute or exacerbated chronic diseases and a high risk of hospital-related complications (ie, patients with moderate-to-severe disability and/or dementia), referred from primary care, emergency departments, or in-hospital units. MethodsAll-cause mortality and hospitalization rates were assessed at 1, 3, and 6 months, and predictors of 6-month mortality were investigated. ResultsAmong 391 patients (mean age, 88.4 years; 62.4% female) referred from emergency departments (58.6%), primary care (27.9%), and acute medical units (13.6%), the main diagnoses were respiratory failure (28.4%), acute heart failure (25.3%), and delirium (13.6%). Patients referred from primary care were older and showed a higher prevalence of severe disability and hypomobility. After 1, 3, and 6 months, mortality rates were 34.5%, 45.6%, and 53.8%, and hospitalization rates 7.2%, 21.5%, and 37.9%, respectively. Predictors of 6-month mortality included age [odds ratio (OR), 1.039], severe disability (OR, 3.446), impossible/assisted walking (OR, 4.450) and referral from primary care (OR, 2.066). High global satisfaction with the service was reported. Conclusions and ImplicationsThe GIROT model may help expanding acute health care capacity for older adults at high risk of hospital-related complications. Customized care plans are needed in patients with severe disability/hypomobility, considering also simultaneous palliative care.