Primary Care Referrals Research Articles

The Impact of the COVID-19 Lockdown on Cancer Referrals in Primary Care in the UK: Two Years On

Background: Cancer is common, with most cancer patients presenting initially to a general practitioner. The COVID-19 pandemic led to changes in the delivery of primary care, which could have affected cancer referrals. This observational study looked at two-week cancer referrals (2WRs) made before, during and after the first UK COVID-19 lockdown in 2020, at a GP practice in the Wirral, England. Methods: A search was conducted to find the cancer referrals made between 23rd March 2020 - 1st July 2020, during the first lockdown. Using the same methodology, cancer referral data was collected for the corresponding time periods in 2019 and 2021. The number of 2WRs and positive diagnostic yields were then compared. Results: The number of cancer referrals decreased by 40.4% in 2020, compared to 2019. In 2021, the number of referrals then increased by 225%, compared to 2020. Overall, the number of cancer referrals increased between 2019-2021. The positive diagnostic yield for the 2020 2WRs increased by 251.4%, compared to that of 2019. The calculated yield for the 2021 data then decreased by 10.8% compared to 2020. Overall, the positive diagnostic yield increased between 2019-2021. Conclusion: The numbers and outcomes of cancer referrals at this Wirral GP practice have changed considerably following the first UK COVID-19 lockdown in 2020, and the influence of the pandemic was still affecting cancer referrals in 2021. A greater focus on early cancer detection in primary care could help overcome the ways in which the pandemic has affected primary care delivery.

Getting a colonoscopy at The Valley Hospital.

71 Background: Colorectal cancer (CRC) is the 3rd most common cancer in the U.S., yet it is preventable with evidence-based strategies such as early screening. The Valley Hospital (TVH) located in Bergen County NJ, is recognized for its high insured payer mix and median household income. According to the 2016 TVH Community Health Needs Assessment, only 71.4% of patients in TVH service area have had a CRC screening. The American Cancer Society National Colorectal Cancer Roundtable (NCCRT) campaigned to reach CRC screening rates of 80% and higher in communities across the nation. The Fast Track Screening Colonoscopy Program (FTSCP) at TVH was created to streamline the process of obtaining a screening colonoscopy and reach the NCCRT’s goal. Through the FTSCP, patients can omit the initial consultation with a gastroenterologist or colorectal surgeon. Patients are instead screened via a telephone call by a Physician Assistant (PA) or Advanced Practice Nurse (APN). The FTSCP is cost effective for patients as it potentially eliminates the initial consultation copayment and/or coinsurance. Methods: The purpose of the FTSCP is to achieve the NCCRT’s 80% goal of CRC screenings in TVH service area. An interdisciplinary team of gastroenterologists, colorectal surgeons, oncologists, anesthesiologists, and administration collaborated to create the FTSCP. A screening questionnaire was developed using the Lincoln Hospital in NYC’s existing criteria for patients who are eligible for a direct endoscopy referral. The questionnaire criteria ensures patients are safe to eliminate the initial consultation. A PA or APN determines the patients’ eligibility for the FTSCP over a screening telephone call. To qualify, patients cannot have significant medical comorbidities or exhibit signs or symptoms of CRC. If deemed eligible, the PA or APN sends a bowel preparation prescription to the patient’s pharmacy, reviews the instructions with them, and meets with them on the day of the procedure at TVH to perform a pre-procedural physical exam. To promote awareness and education of the FTSCP, multiple ongoing outreach events are held in the community. Patients also learn about the FTSCP through primary and specialty care referrals. Results: Since the inception of FTSCP in 2018, over 1300 patients have been screened for CRC. Additionally, adenocarcinomas, carcinoid tumors and tubular adenomas with high grade dysplasia have been detected. 394 tubular adenomas (30%) were identified and removed. In 2018, 59 patients were screened. The number of patients increased by 500% to 296 in 2023. The 2022 TVH Community Health Needs Assessment showed an increase to 79.6% of patients in TVH service area who have undergone CRC screening. Conclusions: The FTSCP at TVH is maximizing patient’s access to the prevention and timely screening for CRC. Additionally, TVH’s relocation from Ridgewood, NJ to Paramus, NJ offers further opportunities to educate a new community on CRC prevention.

Empowering minoritized Alabamians screened for lung cancer-The Alabama Lung Cancer Awareness Screening and Education (ALCASE) project.

In Alabama only 4% of those eligible have been screened for lung cancer. The ALCASE project focused on navigating eligible individuals to lung cancer screening. Trained local staff enrolled screen eligible individuals from seven rural counties and one urban county. Demographics and knowledge of and barriers to lung cancer screening were collected using questionnaires. Education was provided and individuals were navigated to undergo screening. Descriptive statistics for enrolled and screened participants were computed using SAS 9.4. Debriefing interviews were conducted with the ALCASE staff regarding facilitators/barriers to implementing this project and lessons learned. Using NVivo, themes were identified through a combined deductive and inductive process. In total, 447 people were contacted of which 257 were enrolled. Participants were predominantly African American (86.8%), female (56.8%), and 86.4% had health insurance. Study participants acknowledged the need for more education of lung cancer/screening procedures; help navigating clinics for screening services and having healthcare facilities close to home. The top five barriers to getting screened were transportation, financial issues, emotional concerns, healthcare insurance, and COVID-19. Of the 257, 106 participants (41%) completed a primary care referral and were screened for lung cancer. Debriefing interviews revealed: (i) Overall impressions of implementing ALCASE were positive. (ii) Barriers in implementing ALCASE were identified predominantly at the physician and institutional level. (iii) Facilitators in implementing ALCASE were identified at multiple levels. (iv) Suggestions on improving lung cancer screening leaned toward mitigating barriers at the institutional and structural level. Ability to get screened is severely challenged by both personal and structural barriers.

The Influence of Wait Time on Surgical Outcomes in Elective Lumbar Degenerative Spine Conditions: A Retrospective Multicentre Cohort Study.

Retrospective cohort study. The impact of delayed access to operative treatment on patient reported outcomes (PROs) for lumbar degenerative conditions remains unclear. The goal of this study is to evaluate the association between wait times for elective lumbar spine surgery and post-operative PROs. This study is a retrospective analysis of patients surgically treated for a degenerative lumbar conditions. Wait times were calculated from primary care referral to surgery, termed the cumulative wait time (CWT). CWT benchmarks were created at 3, 6 and 12months. A multivariable logistic regression model was used to measure the associations between CWT and meeting the minimally clinically important difference (MCID) for the Oswestry Disability Index (ODI) score at 12months post-operatively. A total of 2281 patients were included in the study cohort. The average age was 59.4years (SD 14.8). The median CWT was 43.1weeks (IQR 17.8 - 60.6) and only 30.9% had treatment within 6months. Patients were more likely achieve the MCID for the ODI at 12months post-operatively if they had surgery within 6 months of referral from primary care (OR 1.22; 95% CI 1.11 - 1.34). This relationship was also found at a benchmark CWT time of 3months (OR 1.33; 95% CI 1.15 - 1.54) though not at 12months (OR 1.08; 95% CI 0.97 - 1.20). Patients who received operative treatment within a 3- and 6-month benchmark between referral and surgery were more likely to experience noticeable improvement in post-operative function.

WP4.2 - Covid positivity: the pandemic surgical referral telephone triage legacy lives on

Abstract Introduction Covid restrictions provided opportunities for novel approaches to patient assessment. Innovative telephone triage of surgical referrals at Great Western Hospital, a UK District General Hospital, resulted in reduction in those patients reviewed and discharged the same day from 56% to 23.6%. Furthermore, 28.4% of admissions were avoided by triage. This novel work was adapted for the Ambulatory Emergency Care (AEC) department of Yeovil District Hospital, in response to exponential increases in Primary Care and Emergency Department referrals. Aims To develop a telephone triage system to get the right patient to the right place at the right time, reviewed by the right team. Methods Over the two-week study period (18/9–29/9/2023) a dedicated triage telephone line enabled a discussion between referring clinician and an experienced surgeon. Four outcomes were offered:AdviceOutpatient review within 1 weekHot clinic review within 24-48 hoursSame-day review by the on-call team Prospective referral data (18/9–29/9/2023) and retrospective non-triage data (1/9–14/9/2023) were gathered. Triage effects were measured by outcome comparison with non-triage data. Results A total of 193 patients were discussed. 48% were Emergency Department referrals, 25% from General Practitioners. Same-day reviews reduced by 35%. Overall, the on-call workload decreased by 68%. Return to AEC for review reduced by 99%. Reduction in average time spent by patients in AEC from 6.9 to 1.29 hours, saved up to 6 bed-days per day and facilitated significant cost savings. Conclusions Novel approaches can be cost effective and positively impact patient care.

ThP3.8 - General Practitioner Compliance to Scottish Referral Guidelines for Urgent Suspicion of Oesophago-gastric Cancer

Abstract Aim The referral guidelines in Scotland stipulate that patients with urgent suspicion of cancer (USOC) should commence treatment within 62 days of diagnosis from the date of primary care referral. In this study, we assessed the adherence of general practitioners (GPs) to the Scottish Referral Guidelines for USOC. Methods This was a retrospective cohort study of all consecutive USOC referrals from GP who were given clinic appointment for Upper GI Surgeons in a single centre for suspected oesophago-gastric cancer between April to September 2022. Patient’s electronic case notes were analysed and the referral indication audited against the Scottish referral guidelines. This study was registered with Clinical Quality Project (LanQIP 14746). Results 361 patients were identified, median age was 63 years (IQR 52-72) and 200 (55.4%) were female. Median Scottish Index of Multiple Deprivation was 4 (IQR 3-7). 138 (38.3%) were referred for dysphagia. 5 (1.4%) were vetted straight to the test and had endoscopy prior the clinic consultation. 275 (76.2%) of the GP referrals for USOC were compliant with the Scottish referral guidelines. Median time from the referral to the clinic consultation was 44 days (IQR 31-63). 35 (9.7%) of patients did not attend the clinic. Conclusions The criteria outlined in the Scottish referral guidelines for USOC provide clear parameters for clinic referrals. Our findings reveal that the majority of GP referrals align appropriately with the USOC criteria. Increasing education and awareness among GPs can further enhance compliance with these guidelines and reduce pressure on the clinic waiting time.

Evaluating current acute aortic syndrome pathways: Collaborative Acute Aortic Syndrome Project (CAASP)

Abstract Background Diagnosis of acute aortic syndrome is challenging and associated with high perihospital mortality rates. The study aim was to evaluate current pathways and understand the chronology of acute aortic syndrome patient care. Method Consecutive patients with acute aortic syndrome imaging diagnosis between 1 January 2018 and 1 June 2021 were identified using a predetermined search strategy and followed up for 6 months through retrospective case note review. The UK National Interventional Radiology Trainee Research and Vascular and Endovascular Research Network co-ordinated the study. Results From 15 UK sites, 620 patients were enrolled. The median age was 67 (range 25–98) years, 62.0% were male and 92.9% Caucasian. Type-A dissection (41.8%) was most common, followed by type-B (34.5%); 41.2% had complicated acute aortic syndrome. Mode of presentation included emergency ambulance (80.2%), self-presentation (16.2%), and primary care referral (3.6%). Time (median (i.q.r.)) to hospital presentation was 3.1 (1.8–8.6) h and decreased by sudden onset chest pain but increased with migratory pain or hypertension. Time from hospital presentation to imaging diagnosis was 3.2 (1.3–6.5) h and increased by family history of aortic disease and decreased by concurrent ischaemic limb. Time from diagnosis to treatment was 2 (1.0–4.3) h with interhospital transfer causing delay. Management included conservative (60.2%), open surgery (32.2%), endovascular (4.8%), hybrid (1.4%) and palliative (1.4%). Factors associated with a higher mortality rate at 30 days and 6 months were acute aortic syndrome type, complicated disease, no critical care admission and age more than 70 years (P < 0.05). Conclusions This study presents a longitudinal data set linking time-based delays to diagnosis and treatment with clinical outcomes. It can be used to prioritize research strategies to streamline patient care.

Abstract 27: A Randomized Clinical Trial for Asymptomatic Elevated Blood Pressure in Patients Discharged from Emergency Department

Introduction: Hypertension is a prevalent condition that is often asymptomatic. Emergency Department (ED) patients commonly present with underlying and undiagnosed hypertension. As EDs serve as critical access points for healthcare, they present a unique opportunity for hypertension screening and intervention, and ED-based interventions could target patients who are often missed in other healthcare settings. Hypothesis: We hypothesize that an Education and mHealth Empowerment intervention would be effective when compared to standard discharge instructions in reducing systolic blood pressure by 6-month follow-up among patients with asymptomatic elevated blood pressure discharged from the ED. Methods: A randomized clinical trial was designed to enroll patients with asymptomatic elevated blood pressure (> 140/90 mm Hg and ≤ 180/110 mm Hg) discharged from an urban academic ED that predominantly serves patients from minoritized racial and ethnic groups. Patients were randomized to either usual care (standard discharge with outpatient follow-up referral) or the intervention arm (education and mHealth Empowerment intervention at discharge – the intervention included a consultation with a clinical pharmacist or an advanced practice nurse, and use of mHealth to educate on and facilitate self-monitoring and behavior change along with a primary care referral, and follow-up visits at 3 and 6 months). Results: Of the 574 enrolled, 289 were randomized to the intervention group. The mean age of the sample was 51.1 (±12.5) years, and 57% were female, 72% were Black, and 20% Hispanic. There were no statistically significant differences between the two arms by demographics or mean blood pressure at baseline. At 6 months follow up, the intervention arm showed a greater reduction in systolic blood pressure compared to the usual care group, and the difference was statistically significant (mean difference: 4.9 mm Hg, 95% CI [0.8, 9.0], p=0.02). Conclusions: The Education and mHealth Empowerment intervention was more effective than standard discharge instructions in reducing systolic blood pressure in a predominantly Black and Latino patient population with elevated blood pressure discharged from the ED. This intervention, and other similar ED-based interventions could be a viable and scalable strategy for blood pressure control in asymptomatic patients for preventing secondary cardiovascular complications due to uncontrolled hypertension.

Implementation of a Standardized Screening Process to Increase Palliative Care Referrals in Primary Care: An Evidence-Based Quality Approach.

Despite initiatives to increase palliative care awareness, referrals in primary care settings are still primarily based on provider judgment, causing a lack of appropriate referrals and disparities in access to palliative care resources. The purpose of this quality improvement project was to develop and implement an evidence-based, standardized palliative care referral protocol to increase the palliative care referral rate for eligible patients at a primary care clinic. The project used a preimplementation and postimplementation design with the use of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to successfully implement and evaluate the standardized referral process. Over the 10-month project period, the palliative care referral rate increased from 2% (4/193) preimplementation to 11% (16/147) postimplementation of the standardized referral process, which is an increase of 9%. Taking into consideration the potential impact of multiple extraneous variables, there was an overall decrease of 69% in emergency room visits and 73% in hospitalizations for patients who received a palliative care referral. These outcomes support expansion of the standardized referral process throughout other primary care clinics to increase palliative care referrals and sustain a high level of quality patient care.

The incidence of lung cancer amongst primary care chest radiograph referrals-an evaluation of national and local datasets within the United Kingdom.

To determine the incidence of lung cancer amongst primary care referrals for investigation with a chest radiograph (CXR). Retrospective evaluation of datasets from the national Clinical Practice Research Datalink (CPRD) and from a single large regional centre. Data were extracted for cohorts of consecutive adults aged over 40 years for whom a CXR had been performed between 2016 and 2018. Using cancer registry data, the incidence of lung cancer within a 2 years of the CXR referral and the variations with age, gender, and smoking status were evaluated. A total of 291294 CXR events were evaluated from the combined datasets. The incidence of lung cancer amongst primary care CXR referrals was 1.4% in CPRD with a consistent correlation with increasing age and smoking status. The incidence of lung cancer within two-years of the CXR varied between 0.03% (95%CI, 0.0-0.1) amongst never smokers aged 40-45 years to 4.8% (95%CI, 4.2-5.5) amongst current-smokers aged 70-75 years. The findings were similar for the single large centre data, although cancer incidence was higher. A simple estimation and stratification of the risk of lung cancer amongst primary care referrals for investigation with a CXR is possible using age and smoking status. This is the first estimate of the incidence of lung cancer amongst primary care CXR referrals and a demonstration of how the demographic information contained within a request could be used to optimize investigations and interpret test results.

An approach to globus pharyngeus.

Globus pharyngeus, or globus, is characterised by the sensation of a lump or tightness in the throat. Symptoms can be persistent, difficult to treat and often reoccur. Globus is a common issue in the community, with lifetime prevalence occurring in up to 45% of the population. This article aims to provide a narrative review of potential causes of globus, aswell as a suggested guideline for work-up and management in the primarycare setting. Causes for globus remain uncertain; however, current opinion focuses on a mixture of muscle tension and mucosal irritation. It is estimated that globus makes up 4% of all primary care referrals to otolaryngologists. There are a handful of proposed causes, with treatments often able to be initiated in the primary care setting. Although most causes are benign, it is important for clinicians to maintain suspicion for malignancy, because this is often the patient's main concern.

Barriers and risk factors associated with non-treatment-seeking for suicidality onset during the COVID-19 pandemic among young adults

IntroductionResearchers predict long-term increases in suicide deaths following the COVID-19 pandemic. Little is known about risk factors for suicidal ideation (SI) and suicidal attempts (SA) or treatment barriers and promoters during the pandemic. We examine these factors in a young adult sample. MethodsAnalyses used a 2022 cross-sectional survey dataset (N = 1,956). Logistic regression identified factors associated with pandemic suicidality (i.e., SI, SA). Non-treatment seekers reported barriers to seeking treatment. Logistic regression identified promotive factors associated with treatment-seeking. Results28.6 % of our sample developed suicidality during the pandemic, of whom 49.6 % did not seek treatment. Asian race and sexual minority status were strongly associated with increased odds of pandemic suicidality. Among SI non-treatment-seekers, barriers were primarily attitudinal (e.g., “symptoms are not serious enough for treatment”); among non-treatment-seekers with SA, barriers were mostly structural (e.g., insufficient funds). Previous depression treatment was strongly associated with increased odds of treatment-seeking. ConclusionAsian American individuals were at increased risk for pandemic suicidality, which may reflect interpersonal risks related to COVID-19-related anti-Asian racism. Our findings point to a “foot-in-the-door” effect: past treatment-seeking was positively associated with future treatment-seeking. To promote this effect and decrease barriers, we suggest integrated mental health screening and referrals in primary care.

Welcoming new neighbors: Minnesota's rapid response model to address the urgent health needs of Afghan newcomers, 2021-2022.

As a result of the United States withdrawal from Afghanistan in fall 2021, 1,260 Afghan evacuees arrived in Minnesota between October 2021 and February 2022. Several contextual factors including an overtaxed health system under duress from COVID-19 and uncertain benefit eligibility prompted a coordinated public health response to appropriately address the acute and pressing medical concerns of our new neighbors. This community case study describes the State of Minnesota's cross-sectoral response that created a welcoming environment, identified public health concerns, and addressed acute medical needs. Medical volunteers provided an initial health and safety check for Afghan families upon arrival. Volunteers also offered onsite culturally and linguistically appropriate mental health assessments, group therapy, women's clinics, vaccine clinics, medication refills, and ongoing walk-in primary care. Care coordinators facilitated primary care and specialty care referrals. The majority (96%) of eligible arrivals were screened as part of this response and the median time between arrival to Minnesota and initial health screening was 2 days. Half of all arrivals screened reported at least one health concern and 56% were referred to a specialty for further evaluation. Almost one in four adults (24%) reported mental health concerns. Existing partnerships across local sectors can be leveraged to provide comprehensive physical and mental health services to newcomers in an emergency response.

Reducing disparities in behavioral health treatment in pediatric primary care: a randomized controlled trial comparing Partnering to Achieve School Success (PASS) to usual ADHD care for children ages 5 to 11 – study protocol

BackgroundIntegrating behavioral health services into pediatric primary care can improve access to care, especially for children marginalized by poverty and racial/ethnic minority status. In primary care, a common presenting concern is attention-deficit/hyperactivity disorder (ADHD). Services in primary care for marginalized children with ADHD typically include medication alone; therapy to improve skills and build relationships is less available. This study evaluates the effectiveness of a behavioral intervention offered through primary care for marginalized families coping with ADHD (Partnering to Achieve School Success, PASS) compared to treatment as usual (TAU).MethodThree hundred participants will be randomly assigned to PASS or TAU. Participants include children ages 5 to 11 who have ADHD and are from economically marginalized families. PASS is a personalized, enhanced behavioral intervention that includes evidence-based behavior therapy strategies and enhancements to promote family engagement, increase caregiver distress tolerance, and provide team-based care to improve academic and behavioral functioning. TAU includes services offered by primary care providers and referral for integrated behavioral health or community mental health services. Outcomes will be assessed at mid-treatment (8 weeks after baseline), post-treatment (16 weeks), and follow-up (32 weeks) using parent- and teacher-report measures of service use, child academic, behavioral, and social functioning, parenting practices, family empowerment, and team-based care. Mixed effects models will examine between-group differences at post-treatment and follow-up. Analyses will examine the mediating role of parenting practices, family empowerment, and team-based care. Subgroup analyses will examine differential effects of intervention by child clinical characteristics and socioeconomic factors.DiscussionThis study is unique in targeting a population of children with ADHD marginalized by low socioeconomic resources and examining an intervention designed to address the challenges of families coping with chronic stress related to poverty.Trial registrationThis study was registered on clinicaltrials.gov (NCT04082234) on September 5, 2019, prior to enrollment of the first participant. The current version of the protocol and IRB approval date is October 4, 2023. Results will be submitted to ClinicalTrials.gov no later than 30 days prior to the due date for the submission of the draft of the final research report to the Patient-Centered Outcomes Research Institute.

CSP2023: 353 - Understanding exercise referrals in primary care: a qualitative study of General Practitioners and Physiotherapists

CSP2023: 353 - Understanding exercise referrals in primary care: a qualitative study of General Practitioners and Physiotherapists

Understanding exercise referrals in primary care: a qualitative study of GPs and physiotherapists.

Physical inactivity is estimated to cost the UK NHS over £1 billion per year. Healthcare practitioners have a key role in supporting increases in physical activity (PA) levels, including referring to exercise referral schemes (ERS). To date, there has been little research into practitioner perspectives on referrals to ERS. To explore the views and experiences of GPs and physiotherapists in relation to factors that influence referral and adherence to ERS. Qualitative study of primary care-based practitioners in Glasgow, UK. Semi-structured interviews were conducted with 14 practitioners (seven GPs and seven physiotherapists). Interviews were recorded and analysed thematically. Four themes are presented. First, healthcare practitioners bring inherent biases to a consultation that impact their approach to PA promotion. Second, clinical time pressures are a major barrier to effective PA promotion. Third, patient-led, compassionate care is the most vital component of behaviour change, with suggestions that promoting peer support and the use of personal anecdotes to normalise vulnerabilities might be helpful. Last, providing ongoing support for change was beneficial to PA promotion. This is often accessed through ERS and is improved by better collaboration between exercise providers and referring practitioners. Practitioners believed ERS referrals could be improved with more targeted training, support for multidisciplinary working, and enhanced communication between the programmes and referrers. Additionally, supporting behaviour change requires time to develop rapport and understand patients' motivations and beliefs. Lack of time is the greatest current barrier to effective PA promotion.

Pediatric Primary Care of Children With Intrauterine Opioid Exposure: Survey of Academic Teaching Practices

ObjectiveIntrauterine opioid exposure (IOE) has increased over the last 2 decades and is associated with additional needs after birth. To date, no clinical guidelines address the primary care of children with IOE. We aimed to characterize clinician-reported screening and referral practices, barriers to effective primary care for children with IOE, and clinician- and practice-level characteristics associated with perceived barriers. MethodsWe conducted a cross-sectional survey of pediatric residents, pediatricians, and advanced practitioners at 28 primary care clinics affiliated with 7 pediatric residency programs (April–June 2022). We assessed screening and other clinical practices related to IOE and perceived barriers to addressing parental opioid use disorder (OUD). We used descriptive statistics to analyze survey responses, assessed the distribution of reported barriers, and applied a 2-stage cluster analysis to assess response patterns. ResultsOf 1004 invited clinicians, 329 (32.8%) responses were returned, and 325 pediatric residents and pediatricians were included in the final analytic sample. Almost all (99.3%) reported parental substance use screening as important, but only 11.6% screened routinely. Half of the respondents routinely refer children with IOE to early intervention services and social work. Lack of standard screening for substance use was the most frequently selected barrier to addressing parental OUD. Participants reporting fewer barriers to addressing parental OUD identified having greater access to OUD treatment programs and home visiting programs. ConclusionsPediatricians report variations in primary care screenings and referrals for children with IOE. Access to parental OUD treatment programs may mitigate perceived barriers to addressing parental OUD in the pediatric office.

Telerheumatology Shared-Care Model: Leveraging the Expertise of an Advanced Clinician Practitioner in Arthritis Care (ACPAC)-Trained Extended Role Practitioner in Rural-Remote Ontario.

A shortage of rheumatologists has led to gaps in inflammatory arthritis (IA) care in Canada. Amplified in rural-remote communities, the number of rheumatologists practicing rurally has not been meaningfully increased, and alternate care strategies must be adopted. In this retrospective chart review, we describe the impact of a shared-care telerheumatology model using a community-embedded Advanced Clinician Practitioner in Arthritis Care (ACPAC)-extended role practitioner (ERP) and an urban-based rheumatologist. A rheumatologist and an ACPAC-ERP established a monthly half-day hub-and-spoke-telerheumatology clinic to care for patients with suspected IA, triaged by the ACPAC-ERP. Comprehensive initial assessments were conducted in-person by the ACPAC-ERP (spoke); investigations were completed prior to the telerheumatology visit. Subsequent collaborative visits occurred with the rheumatologist (hub) attending virtually. Retrospective analysis of demographics, time-to-key care indices, patient-reported outcomes, clinical data, and estimated travel savings was performed. Data from 124 patients seen between January 2013 and January 2022 were collected; 98% (n = 494/504 visits) were virtual. The average age of patients at first visit was 55.6 years, and 75.8% were female. IA/connective tissue disease (CTD) was confirmed in 65% of patients. Mean time from primary care referral to ACPAC-ERP assessment was 52.5 days, and mean time from ACPAC-ERP assessment to the telerheumatology visit was 64.5 days. An estimated 493,470 km of patient-related travel was avoided. An ACPAC-ERP (spoke) and rheumatologist (hub) telerheumatology model of care assessing and managing patients with suspected IA in rural-remote Ontario was described. This model can be leveraged to increase capacity by delivering comprehensive virtual rheumatologic care in underserved communities.

Implementing a Primary Care Referral Pathway for Further Investigations and Management of Fatty Liver Disease (FLD) in the Absence of Fibrosis Identified in Patients Who Have Undergone a Fibroscan Within the Belfast Addictions Service

Implementing a Primary Care Referral Pathway for Further Investigations and Management of Fatty Liver Disease (FLD) in the Absence of Fibrosis Identified in Patients Who Have Undergone a Fibroscan Within the Belfast Addictions Service

Il paziente diabetico di tipo 2 con insufficienza renale cronica: le raccomandazioni delle linee guida italiane

Background/aim: This editorial is aimed at providing a reference for the pharmacological treatment in patients with type 2 diabetes and glomerul filtration rate (eGFR)<60 ml/min, as recommended by the new Italian guidelines for the treatment of type 2 diabetes and its 2023-Update. Methods and results: the present paper revised the recently published Italian guidelines for the treatment of type 2 diabetes (outpatients) and its update, either in primary care or specialist referral. The guideline has been developed following the methods described in the Manual of the National Guideline System (http://www.snlg-iss.it) by a panel nominated by the Società Italiana di Diabetologia (SID) and Associazione Medici Diabetologi (AMD). Available literature on nutritional therapy showed a greater efficacy of SGLT-2 inhibitors (SGLT-2i) in reducing the risk of incident micro and macrovascular complications in patients with chronic renal disease. As second-line treatment, metformin and GLP-1 receptor agonists (GLP-1RA) are to be preferred in comparison with other molecules. Insulin-secretagogues are not indicated for the treatment of patients with type 2 diabetes, including those with renal insufficiency. Conclusions: The present paper illustrates the recommendations of the Italian guidelines (and its 2023-update) for the treatment of type 2 diabetic patients with eGFR<60 ml/min. In synthesis, the panel suggests SGLT-2i as first line therapy and metformin and GLP-1RA as second-line options. The other glucose-lowering agents should be considered only as third-line treatments. Insulin-secretagogues are no more indicated as therapeutic option for the treatment of patients with type 2 diabetes.