Primary Care Referrals Research Articles

Effectiveness of physical activity promotion and exercise referral in primary care: protocol for a systematic review and meta-analysis of randomised controlled trials

BackgroundPhysical inactivity is the fourth leading risk factor for global mortality. Reducing sedentary behaviour and increasing physical activity are efficacious for improving many physical and mental health conditions including cardiovascular disease, type 2 diabetes and depression. Reducing sedentary behaviour and increasing physical activity can also be effective at reducing obesity; however, sedentary behaviour and reduced physical activity are also associated with mortality independently. Despite this, most adults in the UK do not currently meet the UK Chief Medical Officers’ guidelines for weekly physical activity. As most adults visit their general practitioner at least once a year, the primary care consultation provides a unique opportunity to deliver exercise referral or physical activity promotion interventions. This is a protocol for a systematic review of randomised controlled trials for the effectiveness of physical activity promotion and referral in primary care.MethodsA comprehensive literature search of Embase, MEDLINE (Ovid), Web of Science (Core Collection), Scopus, CINAHL, PsycINFO, and The Cochrane Library (CENTRAL) will be conducted for studies with a minimum follow-up of 12 months that report physical activity as an outcome measure (by either self-report or objective measures) including an intention to treat analysis. The authors will screen papers, first by title and abstract and then by full text, independently assess studies for inclusion, appraise risk of bias and extract data. The quality of the evidence will be assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluations) approach. The primary outcome will be participation in physical activity at 12 months. Pooled effects will be calculated using random effects models. Results will be submitted for publication in a peer-reviewed journal and for presentation at UK national primary care conferences.DiscussionThis systematic review and meta-analyses will summarise the evidence for the effectiveness of physical activity promotion and referral as interventions for improving physical activity, as well as whether studies using objective measures of physical activity have similar effects to those studies using self-report measures. This knowledge has importance for primary care clinicians, patients and, given the focus of the recent NHS long-term plan on preventive medicine, those making policy decisions.Systematic review registrationThe protocol is registered with PROSPERO the international prospective register of systematic reviews, ID CRD42019130831

Evaluation of secondary care in endodontics at a Dental Specialties Center (DSC).

This study aimed to evaluate secondary endodontic care at a Dental Specialties Center (DSC) in Belo Horizonte, MG. Data collection used two forms: (1) on endodontic treatment, completed by the endodontists (2) on the restorative treatment, with data from the medical records. The SPSS 22.0 program was used to analyze the results using frequency and percentiles. In total, 452 endodontic procedures were completed in adult patients. The patients had a median of 39 years of age, most were female (69.7%) and had a primary care referral order (96.2%). Most endodontic treatments were performed in upper premolars (23.7%) followed by lower molars (22.3%), using a mixed technique (74.1%) and in a single session (64.2%). The referral for restorative treatment was for the DSC in 81.2% of cases and finished in 24.1% (n = 109). The counter-referral following restorative treatment occurred in 58.7% of the completed cases. It is necessary to jointly plan the dental treatment between primary and secondary care and, within the latter, among the specialties, in addition to an adequate referral and counter-referral process aimed at ensuring comprehensive care and efficient and effective service.

Improving health outcomes in Northamptonshire’s Homeless population

Abstract Issue Homeless people experience inequalities and barriers to accessing healthcare. Northamptonshire had significantly higher number of homeless compared to the England average. This pilot aimed to provide health screening and interventions for Northampton’s homeless population using an integrated system wide approach. This would inform commissioning and contribute to the database. Description The project used a collaborative resource pooling approach by 24 NHS and non-NHS partners. Planning was reliant on information from voluntary sector so budgets were estimated. Health outreach clinics were planned over 3 months and delivered over 3 weeks at 10 voluntary centres offering blood borne viruses (BBV) and latent tuberculosis screening; basic health checks; and Hepatitis B and seasonal flu vaccinations. Unregistered people were supported to register with a GP. Evaluation will determine how to better collect data and promote and offer such a service. Results 127 people received basic health checks; 27 were overweight and 20 had high blood pressure. Of the 102 tested for BBVs, 5 were Hep C +ive and 2 were Hep B +ive. A fifth of those tested for LTBI were positive. In total, 67 Hepatitis B and 12 seasonal-flu vaccinations were given. 12 people required GP registrations. Primary and secondary care referrals were made. Following the pilot, services will provide wrap around care for Northamptonshire’s homeless. Clinics at various times and locations will enable homeless people to engage with health and social services. Lessons Difficult to stratify the homeless and identify needs This innovative project was used as a case study by other areas Published data underestimates numbers of homeless Allow Adequate preparation for such events Consider health and safety risk assessment of venues during planning Staff continuity ensures consistent team working Dedicated communications lead support required Key messages Wraparound health promoting services are required to enable this cohort of population to engage with and seek health and social care. A multisectoral approach is required to improve and address inequalities of vulnerable groups.

1673. Gendered Patterns of HIV, TB, and Other Primary Care Referrals in Rural South Africa

BackgroundMen’s lack of engagement in healthcare hinders HIV efforts in sub-Saharan Africa. Masculine norms and lack of accessibility in a female-dominated healthcare system deter male health-seeking behavior. Community interventions combat the gender gap. In South Africa (SA), alcohol-based venues (ABV) are common locales for men. We created an ABV community health screening to determine the need.MethodsCommunity Health Workers targeted ABV in rural SA, offering screenings for HIV, TB, Isoniazid Preventive Therapy, STI, hypertension, diabetes, circumcision, with referral to primary care services (PCS) for any positive screenings. Participants completed questionnaires, including socioeconomic (SE), healthcare use, and alcohol use evaluated by AUDIT scores. Multivariable logistic regression identified factors associated with referral to PCS.ResultsFrom July 2018 to March 2019, 1356 were screened, 74% were men, median age was 30 (IQR 22–46), 26% employed and 30% had running water. Men are more likely to have never gone to a PCS compared with women (15.9% vs. 9.7%, P = 0.004) and have lengthier time since the last clinic visit (1.4 years vs. 0.6 years, P < 0.001). Men are significantly more likely than women to report hazardous drinking (49% vs. 28%, P < 0.001) Overall, positive screenings were noted in 537 (53.9%) community members, and χ 2 analysis show men more likely to require referrals after screening (P = 0.08). Multivariate analysis shows among men, referrals were associated with older age, hazardous drinking, any health concerns; while higher SE was protective. For women, only age and health concerns were associated with referral. Similarly, alcohol contributed to HIV and TB referrals for men, while higher SE was protective of TB referrals for men (Table 1).ConclusionABV males in this rural community, although disengaged from health care, required more referrals than women. HIV, TB, and any referrals for men screened at ABV in rural SA were associated with lower SE and hazardous drinking, highlighting the challenges that this population faces in seeking health care. Differentiated and targeted community-based services may facilitate care for these hard to reach men in sub-Saharan Africa. Next steps include determining clinical outcomes of referrals. Disclosures All authors: No reported disclosures.

23 Implementation of a Substance Use Disorder Bridge Clinic

Despite the availability of substance use disorder (SUD) treatment programs, many patients have difficulty accessing treatment partly due to long wait times. In order to facilitate timely linkage to treatment, our health system implemented a rapid access, low-barrier SUD clinic with the goal of providing prompt initial treatment (including buprenorphine on-demand) and then transitioning to longitudinal care once possible, regardless of insurance status or current substance use. The clinic, which is located close to the ED inside the hospital, opened in April 2018. The goal of this study is to describe the clinic implementation and outcomes for patients treated in the first year of the clinic. This was a retrospective analysis of patients seen at the clinic between April 2018 and March, 2019. Clinic staff includes a medical provider who can prescribe medication for addiction treatment (MAT), a resource specialist who connects patients to housing, phone service, ID cards and other social services, and recovery coaches, who use their own lived experience to coach other patients through their recovery. The data were obtained at the clinic as part of a quality improvement project to monitor the progress of patients treated in the clinic. IRB approval was obtained to use the dataset for this research. In one year, there were 325 patients referred to the clinic and 242 patients (74.8%) who had at least one visit to the clinic. Top sources of referral were: inpatient wards (n=111, 34.2%), emergency department (n=68, 20.9%), primary care (n=50, 15.4%), or other clinic referral (n=55, 16.9%). The patients were 68.3% (n=222) male, with a mean age of 43.4 (SD 11.9) years. 66% of patients had opioid use disorder, 39% had alcohol use disorder, and 31% had polysubstance use. Of the 242 patients who made it to at least one appointment, 131 patients (54.1%) are still active in the clinic, 85 (35.1%) have been bridged to other facilities and 26 (10.7%) were lost to follow-up. Amongst patients treated for opioid use disorder at the clinic, 142 (93%) were taking buprenorphine, 7 (5%) were taking methadone, and 4 (3%) received extended-release naltrexone. For 98 patients who have data 6 months prior and 6 months post clinic referral, ED visits in our health system decreased by 45% (from 276 before to after 151) and hospital admissions in our health system decreased by 37% (from 153 before to 96 after). Creation of a low-barrier, rapid-access, hospital-based substance use disorder bridge clinic is feasible. Outcomes are promising, with high rates of retention and linkage to treatment, and decreased rate of subsequent ED utilization and hospitalization. Keys to success are a multidisciplinary team, harm reduction model, and support from the health system.

A cross-sectional study of the public health response to non-alcoholic fatty liver disease in Europe

Non-alcoholic fatty liver disease (NAFLD) is a growing public health problem worldwide and has become an important field of biomedical inquiry. We aimed to determine whether European countries have mounted an adequate public health response to NAFLD and non-alcoholic steatohepatitis (NASH). In 2018 and 2019, NAFLD experts in 29 European countries completed an English-language survey on policies, guidelines, awareness, monitoring, diagnosis and clinical assessment in their country. The data were compiled, quality checked against existing official documents and reported descriptively. None of the 29 participating countries had written strategies or action plans for NAFLD. Two countries (7%) had mentions of NAFLD or NASH in related existing strategies (obesity and alcohol). Ten (34%) reported having national clinical guidelines specifically addressing NAFLD and, upon diagnosis, all included recommendations for the assessment of diabetes and liver cirrhosis. Eleven countries (38%) recommended screening for NAFLD in all patients with either diabetes, obesity and/or metabolic syndrome. Five countries (17%) had referral algorithms for follow-up and specialist referral in primary care, and 7 (24%) reported structured lifestyle programmes aimed at NAFLD. Seven (24%) had funded awareness campaigns that specifically included prevention of liver disease. Four countries (14%) reported having civil society groups which address NAFLD and 3 countries (10%) had national registries that include NAFLD. We found that a comprehensive public health response to NAFLD is lacking in the surveyed European countries. This includes policy in the form of a strategy, clinical guidelines, awareness campaigns, civil society involvement, and health systems organisation, including registries. We conducted a survey on non-alcoholic fatty liver disease with experts in European countries, coupled with data extracted from official documents on policies, clinical guidelines, awareness, and monitoring. We found a general lack of national policies, awareness campaigns and civil society involvement, and few epidemiological registries.

Postpartum Depression Screening, Referral, and Follow-Up in Pediatric Primary Care: The HealthySteps Effect

Postpartum Depression Screening, Referral, and Follow-Up in Pediatric Primary Care: The HealthySteps Effect

Anal fissure: diagnosis, management, and referral in primary care.

Anal fissures are tears of the anal mucosa. They can cause extreme pain (often up to 1–2 hours post-defaecation) and in many cases bleeding. Acute anal fissures are classified as lasting 6 weeks. Primary fissures have no clear underlying cause. This is in contrast to secondary fissures, which are thought to be caused by another principal condition. If not treated effectively, anal fissures can lead to recurrence, infection, or abscesses. They can also lead to faecal impaction as patients avoid defaecation, not to mention the overall reduced quality of life.1 The lifetime incidence of anal fissures is estimated to be around 11%, with males and females equally at risk.2 Although many anal fissures are primary fissures without any underlying cause, secondary causes should also be explored. These can include: Examination is best performed in the lateral position, gently parting the buttocks …

Recurrent Urinary Tract Infection in Women: Primary Care Referral Patterns in a Tertiary Care Center.

With more than 150 million urinary tract infections (UTIs) diagnosed globally per year, the impact on patient care is significant. We sought to examine appropriateness of management of recurrent UTI before referral to a female pelvic medicine and reconstructive surgery practice, as well as the characteristics of patients referred. The medical records of 100 consecutive women with a diagnosis of "recurrent UTI" at a single institution between November 2010 and December 2015 were reviewed. The baseline clinical characteristics, laboratory testing, and treatments before and at referral to the female pelvic medicine and reconstructive surgery were examined by descriptive statistics. The evaluation and treatment patterns for recurrent UTI before specialist referral varied widely. Pelvic examination was performed in only 20.8% of patients before referral. Although most women had at least 1 culture performed (65.2%), treatments were variable. Only 42.7% of patients received recommended first-line antibiotic therapy. At symptom recurrence, only 47.2% of patients received a urine culture; most were empirically treated. Approximately 35.0% of patients received the same antibiotic upon their first recurrence. A large proportion of patients referred for recurrent UTI to a specialty practice had no prior culture, physical examination, or symptom-specific evaluation before referral. Despite existing guidelines, the evaluation, treatment, and referral patterns for recurrent UTI are highly varied and rarely conform to recommendations. Further studies are needed to confirm these trends and determine interventions to improve the efficacy and efficiency of primary care for women with recurrent UTI.

SUN-231 THE CKD EXPRESS ©: THE VALUE CONTRIBUTION TO CHRONIC KIDNEY DISEASE CARE USING AN INNOVATIVE REMOTE EMR-BASED MONITORING SYSTEM - A VERMONT POPULATION HEALTH INITIATIVE

Chronic kidney disease (CKD) as defined by an estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 sq. m BSA affects about 20 million Americans. Existing CKD care models are predicated on Adult Primary Care referrals to Nephrology Clinics of patients with this arbitrary CKD staging criterion. Increasing referrals of CKD patients have far surpassed the capacity of Nephrology Clinics. Arguably, since most CKD patients remain stable over the years, Nephrology Clinic visits may represent expensive unnecessary care in the majority of referrals.

Does the source of referral affect outcomes for paediatric testicular torsion?

This single centre study retrospectively analysed the intraoperative findings relative to source of referral for emergency scrotal explorations performed in a tertiary level paediatric surgery department. All patients who underwent emergency scrotal exploration under the care of paediatric surgeons in our unit between April 2008 and April 2016 were identified. Clinical data were obtained from contemporaneous records. Over the 8-year study period, 662 boys underwent emergency scrotal exploration: 6 (1%) were internal referrals, 294 (44%) attended our emergency department (ED) directly, 271 (41%) were referred from primary care and 91 (14%) were transferred from other hospitals. Excluding procedures in neonates, testicular torsion was present in 100 cases (15%). Testicular detorsion with bilateral 3-point testicular fixation was performed in 66 (66%) and orchidectomy with contralateral fixation in 34 (34%) where the torted testis was non-viable intraoperatively. The orchidectomy rate in the presence of torsion was 23% in ED referrals (12/52), 43% in primary care referrals (12/28) and 50% for transfers (10/20). The difference in rates between ED referrals and patients transferred from other hospitals was significant (p=0.026). There was no significant difference in median age between any of the groups (p=0.10). Boys undergoing emergency scrotal exploration had a higher orchidectomy rate when transferred from other hospitals to our unit. This difference was statistically significant when compared with boys presenting directly to our ED. This supports advice from The Royal College of Surgeons of England for undertaking paediatric scrotal explorations in the presenting hospital when safe to do so rather than delaying the care of these patients by transferring them to a tertiary paediatric surgical unit.

The outcomes of triaging rheumatology referrals at a single point of access

BackgroundEast Surrey Clinical Commissioning Group established a musculoskeletal triage service for primary care referrals in December 2017 in order to reduce pressure on secondary care.AimTo analyse the processing of rheumatology referrals through the single point of access.MethodA total of 158 referrals over an 8-month period were triaged, 50 of which had available final outcome data. Using a standardised form for GPs, data including initial GP diagnosis, appropriateness for secondary care, any requirement for additional information, relevant blood tests needed before the appointment, and if the patient could be seen by a GP with an extended role in rheumatology were recorded. The resultant rheumatological diagnosis from secondary care was recorded.ResultsOf 158 referrals, 86% were triaged to secondary care, the remainder were referred back to primary care or an alternative healthcare professional. Additional information from the EMIS record was added to 67% of all referrals and additional blood tests were requested in 26%. Of the 50 patients with outcome data, 40% were thought to have non-inflammatory conditions and could be seen in the community setting; this was confirmed in 85% after rheumatology assessment. The most frequent diagnosis in this group was fibromyalgia. Where an inflammatory condition was suspected by the referrer this was confirmed in 68%.ConclusionA significant number of referrals could be seen by a specialist GP in a community setting, the biggest single sub-set of these patients have chronic non-inflammatory pain. The provision of community GP-led rheumatology clinics could improve patient experience, reduce costs, and reduce the burden on secondary care.

Referral of patients to diabetes prevention programmes from community campaigns and general practices: mixed-method evaluation using the RE-AIM framework and Normalisation Process Theory

BackgroundEach year around 5–10% of people with non-diabetic hyperglycaemia will develop type 2 diabetes mellitus. Diabetes prevention is a national and global public health concern. Diabetes Prevention Programmes, which seek to identify at-risk individuals and support entry to health improvement initiatives, recognise that enhanced identification and referral of at-risk individuals is required within primary care and beyond, through community-focused prevention approaches. We report an evaluation of a demonstrator site for the NHS Diabetes Prevention Programme in the UK, which piloted an enhanced Primary Care referral programme (sampling from patients identified as at-risk from general practice databases) and a Community identification programme (sampling from the general population through opportunistic identification in community locations) in an effort to maximise participation in prevention services.MethodsWe used mixed-methods evaluation to assess the impact of the two referral routes on participation in the Diabetes Prevention Programmes in line with the RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation and Maintenance). Individual level patient data was descriptively analysed to assess identifications and eligible referrals made in each route. Semi-structured interviews conducted with referral staff and key stakeholders were analysed using thematic analysis and informed by Normalisation Process Theory.ResultsThe nurse facilitated primary care referral route provided 88% of all referrals to the telephone DPP, compared to the community referral route which provided 5%, and the proportion joining the programme was higher among primary care referrals (45%) than community referrals (22%), and retention rates were higher (73% compared to 50%). The nurse-facilitated route integrated more easily into existing clinical processes. The community programme was impeded by a lack of collaborative inter-agency working which obscured the intended focus on high-risk populations despite conversion rates (numbers identified at risk who entered prevention programmes) being highest in areas of high deprivation.ConclusionsThe study demonstrates the interaction of components, with effective Adoption and Implementation necessary to support Reach. The NPT analysis demonstrated the importance of consensus around not only the need for such programmes but agreement on how they can be delivered. Future programmes should support inter-agency communication and collaboration, and focus identification efforts on areas of high-risk.

Exercise on Prescription - Patients' Perceptions on Effectiveness and Change in Physical Activity Behavior

So far physical activity counseling and exercise referral in primary health care are not well established Germany. The exercise referral scheme "Rezept für Bewegung" ("exercise on prescription", "EoP") represents an appropriate tool. The initiative aims to reinforce the physicians' verbal advice via the written prescription. The aim of this study was to assess patients' perceptions of the counseling and their self-reported intention to increase their level of physical activity. 3.9 ± 1.0 months after physical activity counseling and referral 173 patients were invited to fill out a 17-item self-administered questionnaire regarding counseling satisfaction and the impact on physical activity behavior. Study participants were recruited through 12 medical offices in 8areas of the sports association in Hessen. Data of 51 patients (aged 56.1 ± 13.3; 35 female) were included in the evaluation. Almost 2/3 of patients reported ≤ 60 min/week physical activity prior to counseling. 63 % of the interviewees rated the counseling good to very good. Following the counseling more than 1/2 of the respondents attended a course at a sports club and 51 % increased their physical activity in daily life. Overall satisfaction with counseling was associated with higher rates of sports participation OR 3.16 (95 % CI 1.07 - 9.33). 49 % of the respondents wished more support from their health insurance to find an appropriate course. "EoP" may be effective in raising patients' awareness for exercise and health and in increasing participation in physical activity.

Evaluation of the Diagnostic Stability of the Early Autism Spectrum Disorder Phenotype in the General Population Starting at 12 Months

Universal early screening for autism spectrum disorder (ASD) in primary care is becoming increasingly common and is believed to be a pivotal step toward early treatment. However, the diagnostic stability of ASD in large cohorts from the general population, particularly in those younger than 18 months, is unknown. Changes in the phenotypic expression of ASD across early development compared with toddlers with other delays are also unknown. To examine the diagnostic stability of ASD in a large cohort of toddlers starting at 12 months of age and to compare this stability with that of toddlers with other disorders, such as developmental delay. In this prospective cohort study performed from January 1, 2006, to December 31, 2018, a total of 2241 toddlers were referred from the general population through a universal screening program in primary care or community referral. Eligible toddlers received their first diagnostic evaluation between 12 and 36 months of age and had at least 1 subsequent evaluation. Diagnosis was denoted after each evaluation visit as ASD, ASD features, language delay, developmental delay, other developmental issue, typical sibling of an ASD proband, or typical development. Diagnostic stability coefficients were calculated within 2-month age bands, and logistic regression models were used to explore the associations of sex, age, diagnosis at first visit, and interval between first and last diagnosis with stability. Toddlers with a non-ASD diagnosis at their first visit diagnosed with ASD at their last were designated as having late-identified ASD. Among the 1269 toddlers included in the study (918 [72.3%] male; median age at first evaluation, 17.6 months [interquartile range, 14.0-24.4 months]; median age at final evaluation, 36.2 months [interquartile range, 33.4-40.9 months]), the overall diagnostic stability for ASD was 0.84 (95% CI, 0.80-0.87), which was higher than any other diagnostic group. Only 7 toddlers (1.8%) initially considered to have ASD transitioned into a final diagnosis of typical development. Diagnostic stability of ASD within the youngest age band (12-13 months) was lowest at 0.50 (95% CI, 0.32-0.69) but increased to 0.79 by 14 months and 0.83 by 16 months (age bands of 12 vs 14 and 16 months; odds ratio, 4.25; 95% CI, 1.59-11.74). A total of 105 toddlers (23.8%) were not designated as having ASD at their first visit but were identified at a later visit. The findings suggest that an ASD diagnosis becomes stable starting at 14 months of age and overall is more stable than other diagnostic categories, including language or developmental delay. After a toddler is identified as having ASD, there may be a low chance that he or she will test within typical levels at 3 years of age. This finding opens the opportunity to test the impact of very early-age treatment of ASD.

The impact of the adoption of a patient rostering model on primary care access and continuity of care in urban family practices in Ontario, Canada

BackgroundGreater continuity and access to primary care results in improved patient health, satisfaction, and reduced healthcare costs. Although patient rostering is considered to be a cornerstone of a high performing primary care system and is believed to improve continuity and access, few studies have examined these relationships. This study examined the impact of the adoption of a patient rostering enhanced fee-for-service model (eFFS) on continuity, coordination of specialized care, and access.MethodA population-based longitudinal study was conducted using health administrative data from urban family practices in Ontario, Canada. Family physicians that transitioned from traditional FFS (tFFS) to eFFS between 2004 and 2013 were followed overtime. Physicians providing comprehensive primary care that had at least 4 years of pre-transition and 2 years of post-transition data were eligible. Patients were attributed to physicians on an annual basis by determining the provider that billed the largest dollar amount over a 2 year period. Outcomes of interest were the usual provider of care index (UPC), a referral index (RI) (% of total primary care referrals for a physician’s roster made by the main provider), and emergency department (ED) visits for family practice sensitive conditions (FPSCs). Mixed-effects segmented linear and logistic regressions were used to examine changes in outcomes while controlling for patient and provider contextual factors.ResultsPrior to transitioning, UPC was decreasing at a rate of 0.27%/year (95% CI: -0.34 to − 0.21, p < 0.0001). Following the transition, UPC began decreasing by an additional 0.59%/year (95% CI: -0.69 to − 0.49, p < 0.0001) relative to the pre-transition rate. RI decreased by an additional 0.34%/year (95% CI: -0.43 to − 0.24, p < 0.0001) relative to the pre-transition period, where it had been stable. The transition had minimal impact on FPSC ED visits.ConclusionContinuity and coordination of specialized care slightly decreased upon transition from tFFS to eFFS. This is likely due to physicians working in groups and sharing patients following the transition to the eFFS model. Adoption of an enrolment model with after-hours care did not decrease non-urgent ED use, which may reflect the small impact that primary care access has on these types of ED visits.

MON-170 Low Plasma Glucose Results from Primary Care Are Not Associated with Morbidity, Mortality, or Underlying Hypoglycemic Disorders

Background: Low glucose is a relatively common primary care referral to specialist endocrine services. However the prevalence of endocrine disease causing endogenous hypoglycemia is extremely rare. We sought to determine whether low plasma glucose in primary care was associated with adverse clinical outcomes or underlying hypoglycemic disorders. Methods: We obtained all plasma glucose results <72mg/dl originating from primary care within our catchment population (n = 800,00), in non-diabetic individuals (20,145 people [77.6% female]) aged 18 - 40 years, between 2002 and 2017. These data were linked to national admission, mortality, cancer and diabetes registers to assess associations with mortality and morbidity. Results: Median follow-up was 4.8 years (IQR 2.6 - 7.8). Median age was 29 years (24 - 34). Glucose was marginally higher in women 65 mg/dl vs. 63 mg/dl, P < 0.0001. Only 0.3% of patients were assessed in an endocrine clinic for evaluation of hypoglycaemia. Glucose concentration was < 40 mg/dl in 0.63% (category A), 40 - <54 mg/dl in 8.7% (category B), 54 - <63 mg/dl in 28.0% (category C) and ≥63 mg/dl in 62.6% (category D). A history of eating disorder was present in 2.4% (A), 1.1% (B), 0.4% (C) and 0.3% (D), P < 0.0001. Likelihood of admission to hospital with hypoglycaemia (P < 0.001) and electrolyte disturbance (P < 0.001) was also greater in those in the lower glucose categories. Increasing age (HR 1.03, P < 0.001) and male gender (HR 4.20, P < 0.001), but not glucose < 54 mg/dl (HR 0.89, P = 0.79), were associated with mortality (n = 72). The risk of a subsequent new diagnosis of cancer or hospital admission with incident cardiovascular, renal or liver disease was not related to glucose category. Hospital admission with infectious disease was more likely (3.3%) in those with glucose ≥ 54mg/dl compared to those with lower glucose (2.2%), P = 0.01. Incident diabetes was observed in 0.2% of those with glucose < 54 mg/dl and in 0.6% of those with glucose ≥ 54mg/dl (OR 3.0, P = 0.009). No cases of insulinoma were detected based on the results of these tests. Conclusion: Low plasma glucose results from primary care are almost never indicative of an endogenous hyperinsulinemic disorder and are not associated with adverse outcomes in adults up to 40 years of age. Underlying eating disorder should be considered in this context. Assessment by an endocrinologist should be limited to cases where Whipple’s triad is present.

Digital Decision Support Tool and Education to Optimize Primary Care Referral Process and Increase Access to Outpatient Headache Neurologists (S50.005)

Digital Decision Support Tool and Education to Optimize Primary Care Referral Process and Increase Access to Outpatient Headache Neurologists (S50.005)

Prospective evaluation of a primary care referral pathway for patients with non-alcoholic fatty liver disease

The development of non-invasive liver fibrosis tests may enable earlier identification of patients with non-alcoholic fatty liver disease (NAFLD) requiring referral to secondary care. We developed and evaluated a pathway for the management of patients with NAFLD, aimed at improving the detection of cases of advanced fibrosis and cirrhosis, and avoiding unnecessary referrals. This was a prospective longitudinal cohort study, with analyses performed before and after introduction of the pathway, and comparisons made to unexposed controls. We used a 2-step algorithm combining the use of Fibrosis-4 score followed by the ELF™ test if required. In total, 3,012 patients were analysed. Use of the pathway detected 5 times more cases of advanced fibrosis (Kleiner F3) and cirrhosis (odds ratio [OR]5.18;95%CI2.97-9.04; p <0.0001), while reducing unnecessary referrals from primary care to secondary care by 81% (OR0.193; 95%CI 0.111-0.337; p <0.0001). Although it was used for only 48% of referrals, significant benefits were observed in practices exposed to the pathway compared to those which were not, with unnecessary referrals falling by 77% (OR0.23; 95% CI0.658-0.082; p = 0.006) and a 4-fold improvement in detection of cases of advanced fibrosis and cirrhosis (OR4.32; 95% CI1.52-12.25; p = 0.006). Compared to referrals made before the introduction of the pathway, unnecessary referrals fell from 79/83 referrals (95.2%) to 107/152 (70.4%), representing an 88% reduction in unnecessary referrals when the pathway was followed (OR0.12; 95%CI0.042-0.349; p <0.0001). The use of non-invasive blood tests for liver fibrosis improves the detection of advanced fibrosis and cirrhosis, while reducing unnecessary referrals in patients with NAFLD. This strategy improves resource use and benefits patients. Non-alcoholic fatty liver disease effects up to 30% of the population but only a minority of cases develop liver disease. Our study has shown that established blood tests can be used in primary care to stratify patients with fatty liver disease, leading to a reduction in unnecessary referrals by 80% and greatly improving the detection of cases of advanced fibrosis and cirrhosis.

Description of an Innovative Pediatric Individualized Therapeutics Clinic: Working toward Precision Drug Therapy.

The GOLDILOKs® (Genomic and Ontogeny-Linked Dose Individualization and cLinical Optimization for KidS) Clinic aims to provide families and physicians with data to make more informed decisions with regard to pharmacological therapy by using innovative therapy and genomic technologies. The objectives are two-fold: (1) To describe the utility of the GOLDILOKs® Clinic to referring prescribers by evaluating the type of referrals made to the GOLDILOKs® Clinic and (2) to assess the most often utilized technologies (e.g., genotyping) completed to formulate therapy recommendations. Patient data from July 2010 to June 2016 was retrospectively reviewed following Institutional Review Board (IRB) approval. The GOLDILOKs® Clinic evaluated 306 patients and had increases in annual referrals from 14 in 2010–2011 to 84 in 2016–2017. The children that were referred were predominately Caucasian (82%) and male (59%) with an average age of 12.4 ± 5.9 years. Subspecialty versus primary care referrals accounted for 82% and 18% of referrals, respectively. Adverse drug reactions (n = 166) and poor medication response (n = 179) were the major reasons for referral. However, it must be noted that patients could have multiple reasons for referral. Pharmacogenetic results were extensively used to provide guidance for future therapy in patients with medication-related problems. Genotyping of drug metabolizing enzymes and drug target receptors was performed in 221 patients (72.2%). Recommendations were fully accepted by 63% and partially accepted by 22% of internal provider referrals.