Referral Criteria Research Articles

Multidisciplinary Panel Consensus for the Management of Patients with Type 2 Diabetes: A Delphi Study

To reach a multidisciplinary consensus on managing patients with type 2 diabetes among specialists in family medicine, cardiology, endocrinology, internal medicine, and nephrology. A two-round Delphi study was conducted using a questionnaire with 68 positive/negative statements distributed in four thematic blocks on diabetes management: early diagnosis and prediabetes, referral criteria, treatment and comorbidities, and clinical management. The expert panel was composed of 105 physicians from different specialties (family medicine, cardiology, endocrinology, internal medicine, and nephrology) with experience in managing patients with diabetes and who were members of a diabetes-related society. Response rates for the first and second rounds were 86.7 and 75.2%, respectively. After both rounds, a consensus was reached on 52 (76.5%) items. The recommendations with the highest degree of consensus (median=10, IQR=0.00) were related to anti-smoking education, cardiovascular risk factor target control, and diabetic kidney disease. There were significant differences between family physicians and other specialties for some items. This study provides a set of recommendations for diabetes management agreed upon by specialists from different healthcare settings.

Cochlear Implant Referral Criteria for the Spanish-Speaking Adult Population.

To evaluate the effectiveness of the "60/60 Guideline" in a diverse patient population. Retrospective review. Tertiary referral center. Data were collected for adult patients (18 years and older) who underwent a cochlear implant evaluation (CIE) between January 2016 and March 2021. Development of the "60/60 Guideline" has provided better clarity on when to refer English-speaking patients for a CIE. Our study evaluated the effectiveness of this referral tool in the Spanish-speaking population. In our group of patients who underwent a traditional CIE (n = 402), 209 met unaided and aided traditional cochlear implant (CI) candidacy criteria. Of the 193 individuals who did not meet both components of traditional candidacy criteria, a majority met the aided component (86%) but only 4.6% met the unaided component. When applying the 60/60 Guideline to patients who met traditional criteria, there is a sensitivity rating of 84.7% and a specificity index of 50.3%. For English and Spanish speakers who met traditional criteria but did not meet the 60/60 Guideline, a majority (83.3% English, 87.5% Spanish) had a better ear word recognition score (WRS) greater than 60%, suggesting the unaided WRS is the more restrictive component of the "60/60 Guideline." Application of the "60/60 Guideline" is an effective method to identify potential CI candidates in the English-speaking population; however, it was less effective in the Spanish-speaking population. Spanish-speaking adults should be referred for a CIE when better ear pure tone average is greater than 60 dB hearing loss, regardless of their unaided WRS. This study highlights the need for inclusion of nonlinguistic test measures in the CI referral criteria and test battery to reduce CI access barriers for patients who speak a language other than English.

Knowledge of head and neck cancer among medical students in the UK

Head and neck cancer (HNC) refers to malignancies found in mucosal surfaces anywhere from the paranasal sinuses to the larynx, including the various glands and cavities. Between the years 2016 and 2018, there were about 3900 new cases every year in women and 8600 in men, making it the thirteenth most common cancer in women and fourth most common in men. The aim of our study was to evaluate the amount and type of teaching United Kingdom (UK) medical students receive on HNC, and to assess their current knowledge of these cancers. An online survey distributed via university representatives was responded to by 311 final year medical students from 25 medical schools across the UK. Regarding HNC teaching, 72 students (23.2%) reported receiving no teaching at their medical school. Of the 239 who reported receiving teaching, 169 (54.3%) received it in the format of a non-interactive, large group lecture. A total of 271 respondents (87.1%) believed that medical students at their university would benefit from more teaching on HNC. Based on our sample, there appears to be an overall dissatisfaction and lack of confidence surrounding HNC in the undergraduate curriculum. With its increasing prevalence in the UK, it is vital that red-flag symptoms and referral criteria are understood by the future medical workforce.

A cross-sectional survey study exploring provision and delivery of expanded community tier 2 behavioural weight management services in England.

Guidelines recommend provision of local behavioural weight management (tier 2) programmes for adults living with overweight and obesity. Following the publication of the UK Government's publication 'Tackling Obesity: empowering adults and children to live healthier lives' in July 2021, Government invested around £30 million of additional funding to support the expansion of local authority commissioned tier 2 provision for adults living with excess weight. We conducted a cross-sectional survey study to scope the types of services available, to whom they were made available, and barriers and facilitators to service delivery. An e-survey was disseminated to local authority commissioned tier 2 service providers in England from September to October 2022. Through a combination of closed and open (qualitative) questions, the survey collected data on referral routes, participant eligibility criteria, service content and format, and challenges and enablers to service delivery. Quantitative data were analysed descriptively whilst thematic content analysis was applied to qualitative data. We received 52 responses (estimated response rate = 59%) representing all nine England regions and 89 unique local authorities. Most services were multi-component (84.3%), were 12 weeks duration (78.0%), were group-based (90.0%), were primarily delivered in-person (86.0%), and were free to participants (90.2%). Five responses indicated provision of support for other health and wellbeing issues, for example, mental health, assistance with debt. To improve future WMS service commissioning and delivery, WMS providers need to be allowed adequate time and resource to properly prepare for service delivery. Referral systems and criteria should be made clear and straightforward to both referrers and service users, and strategies to manage surplus referrals should be explored.

Diagnosis and management of diabetic kidney disease–Part 1

This first of two articles seeks to explain the nature, classification and clinical implications of diabetic kidney disease. The importance of screening and monitoring is discussed. Practical information on avoidance of acute kidney injury and criteria for referral of diabetic kidney disease are covered. By David Morris

Outcomes of complex burn injury patients managed at two primary and one tertiary level burns facilities in the Western Cape province of South Africa - a retrospective review.

This study aimed to compare factors contributing to a positive outcome of adult burn injury patients managed at two primary and one tertiary level Western Cape hospitals. These patients from the primary hospitals (PLHs) met the referral criteria for specialised care at the Tygerberg Hospital burns unit (TBU) but were not accepted or were accepted late. A total of 1034 adult burn injury patients seen at two primary level ("A" and "B") hospitals and the TBU between 2016 and 2019 were retrospectively analysed. One hundred and eleven (111) primary level patients ("A" 71, "B" 40) met the criteria for referral to the TBU. The outcomes and factors contributing to positive outcome of these patients were compared with the 859 patients treated at the TBU during the same period. Patients treated at the TBU showed longer theatre waiting times, more operations, and higher complication and death rates than their primary level counterparts. The PLHs showed no factors significantly contributing to hospital discharge. At TBU, pregnancy status, younger age, hot water burns, lower abbreviated burns severity index (ABSI) score, and longer time to theatre were associated with hospital discharge. A shortage of beds was the main reason for denial of admission to the TBU. The PLHs showed good outcomes in managing severe burn injuries, although no significant contributors to a positive outcome were identified. Patient- and facility-related factors contributed to positive outcomes at the TBU. Upgrading both the Western Cape's primary level capabilities and the TBU's accessibility and efficiency are necessary to improve burns services.

Abstract B057: Nutrition-related clinical characteristics of patients in a safety net hospital oncology program and perspectives on wellness programming during cancer care

Abstract This study aimed to explore cardiometabolic disease rates and related factors among a sample of oncology patients in a safety net hospital setting, as well as preferences for wellness programming from the perspective of both patients and providers. This multiple methods study included a retrospective review of electronic health record (EHR) data (n=5,136) and qualitative interviews with cancer survivors (n=31) seen at the Harris Health LBJ Hospital (LBJ Hospital) in the last five years, as well as healthcare providers (n=21) in the LBJ Oncology program. LBJ Hospital is part of Harris Health System, the safety-net public healthcare provider for the third largest county in the U.S.. The University of Texas MD Anderson Cancer Center provides oncology care at LBJ Hospital. Overall, the EHR data revealed high rates of comorbid cardiometabolic disease among patients with cancer being treated at LBJ Hospital. Over 67% of patients were prediabetic or diabetic based on HbA1c levels, and 66% had overweight or obesity. Weight fluctuated over the course of treatment, with acute weight loss at diagnosis followed by amplified weight regain into survivorship. Additionally, EHR data indicated high symptom burden was reported in the areas of tiredness, sleep, pain, well-being, poor appetite, shortness of breath, and anxiety. In interviews, survivors (including 11 still on active treatment and 20 off treatment) reported high interest in healthy eating and exercise programs, and preferred programs that were community-based and offered throughout cancer treatment and survivorship. Survivors highlighted the importance of getting information or referrals from providers regarding healthy eating and physical activity. Among interviewed healthcare providers, 90% said they would be interested in an automated referral program for healthy eating and exercise programming and 90% thought programming should start as soon as a patient was diagnosed. Ensuring the referral system was criteria-based and simple were top priorities for healthcare providers. Example metrics providers suggested using as referral criteria included BMI, weight changes, symptoms, and markers of cardiometabolic health. When asked to consider potential programs for patients to encourage healthy eating and exercise, free food/voucher programs, group classes and structural additions were mentioned, and several providers specifically mentioned the need to have programs based in a patient’s local community and/or near their primary care provider. Together, these findings suggest that there is a high need for diet and exercise interventions among the LBJ oncology population, as well as high interest in community-based programs and the integration of referrals to these programs as part of care. Citation Format: Margaret Raber, Ruth Rechis, Thy Ho-Pham, Darya Kizub, Denise LaRue, Hilary Ma, Michael T Walsh, Miranda Baum, Preena Loomba, Haley Gardiner, Karen Basen-Engquist. Nutrition-related clinical characteristics of patients in a safety net hospital oncology program and perspectives on wellness programming during cancer care [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B057.

Changing Knowledge and Attitudes towards Bariatric Surgery in Primary Care: a 10-Year Cross-Sectional Survey.

Some 28% of the Scottish population suffer from obesity. Bariatric procedures per population carried out in England when compared to Scotland (NBSR 2018) are significantly higher. Primary care practitioners (PCP) influence equality of access to secondary care bariatrics and frequently manage post-operative bariatric patients. Examining changes in PCP knowledge and attitude could improve access to bariatric procedures in Scotland. Following a sample pilot, all PCPs within three Scottish NHS health boards were emailed a questionnaire-based survey (2011; n = 902). A subsequent 10-year follow-up encompassed a greater scope of practice, additionally distributed to all PCPs in five further health boards (2021; n = 2049). Some 452 responses were achieved (2011, 230; 2021, 222). PCPs felt bariatric surgery offered a greater impact in both weight management and that of obesity-related diseases (p < .0001). More PCPs were aware of local bariatric surgical referral criteria (2011, 43%; 2021, 57% (p = .003)), and more made referrals (2011, 60%; 2021, 72% (p = .018)) but were less familiar with national bariatric surgical guidelines (2011, 70%; 2021, 48% (p < .001)). Comfort at managing post-operative bariatric surgical patients were unchanged (2011, 24%; 2021, 27% (p = .660)). Minimal progress through dietetic-lead weight management services, plus rejection of patients thought to be good candidates, was reasons for referral hesitancy. Over 10years, PCPs were more aware of local referral criteria, making increased numbers of referrals. Knowledge deficits of national guidelines remain, and overwhelmingly PCPs do not feel comfortable looking after post-operative bariatric surgical patients. Further research into PCP educational needs, in addition to improving the primary to secondary care interface, is required.

Keratoconus Management in the Community: A Survey of Optometrists.

Defining the patterns of practice and referral criteria of optometrists within New Zealand to investigate the diagnosis and management of keratoconus. Optometrists recruited through the New Zealand Association of Optometrists, Cornea and Contact Lens Society of New Zealand, and private practices were invited to complete an anonymous survey. Responses were received from 168 optometrists (representing 20.0% of the optometrist population). Half (48%) of optometrists had ≥15 years of experience, and 22% prescribed soft contact lenses daily, whereas only 6.4% prescribed rigid gas-permeable (RGP) lenses daily. The main barriers to prescribing RGPs were experience with fitting, low market demand, and patient discomfort. When referring to an ophthalmologist, 41% reported referring on progression of corneal parameters, 27% on initial diagnosis, 21% at no set time, and 10% with a reduction in visual acuity. Most optometrists (64%) would refer for possible surgery when visual acuity dropped between 6/9 and 6/12. Optometrists with greater experience were more likely to prescribe RGP lenses and co-manage patients with ophthalmologists. Ownership of a corneal imaging unit suggested an increased likelihood of prescribing RGP lenses but did not alter referral patterns. This survey provides an overview of current practice and highlights the importance of optometrists in the diagnosis and management of keratoconus. There was a significant discrepancy in keratoconus management, regarding optical correction modality and referral criteria for ophthalmology review. Further interdisciplinary work is required between optometry and ophthalmology to standardize referral guidelines and enhance visual outcomes.

Palliative care assessment and outcomes in patients admitted for heart failure in an Australian quaternary healthcare service

Abstract Background/Introduction Heart failure (HF) has high mortality and healthcare utilisation, and despite patients having similar palliative care needs to cancer patients(1), they are much less likely to have their PC needs assessed and managed (2-3). Expert consensus guidelines from cardiology and palliative care groups recommend early integration of a palliative approach in addition to usual care, but the complex and unpredictable trajectory of HF, lack of referral criteria and misunderstandings about PC are potential barriers that affect specialist PC referrals. Given the issues surrounding integration of PC in HF patients, we sought to understand the use of PC by patients with HF at our institution. Purpose To characterise the pattern and predictors of referrals of HF patients to the inpatient PC service in an Australian quaternary health service. Methods A single-centre retrospective cohort study was performed using electronic medical record data in consecutive patients admitted for HF at a quaternary health service in Australia, over a 12 month period from July 2019 to June 2020. All adults ≥ 18 years of age and admitted for HF were identified using the Diagnostic Related Group (DRG) admission code for ‘Heart Failure and Shock’. Results The 502 patients admitted for HF were elderly (median age 82 years, IQR 15) and 50% were male. Functional status was poor, with 29% unable to care for themselves and 56% requiring some level of assistance. General medicine was the major admitting unit with 67% (n=338 of 502) of patients, and the cardiology and advanced heart failure units admitted 12% (n=59) and 5% (n=26) of patients, respectively. Conversely, the main treating team in the ambulatory setting was cardiology in 51% (n=253). HF patients had high mortality rate at 32% during the median follow up time of 27 months (interquartile range 8 months). Seven percent (n=37 of 502) were referred to inpatient specialist PC, and often in the terminal phase. High dependency (defined as Australian-modified Karnofsky Performance Status 10-40) (62% vs 28%, p&amp;lt;0.01) and New York Heart Association class III-IV symptoms (86% vs 42%, p&amp;lt;0.01) were associated with referral, but one or more previous admission for HF in the last 12 months was not (35% vs. 28%, p=0.35). In all HF patients, symptoms were poorly assessed and discussion about prognosis occurred in 10% despite the high mortality. Referral to inpatient PC resulted in more prescribing of symptom medications on discharge (41% vs 2%, p&amp;lt;0.01) and referral to community PC (46% vs 1%, p&amp;lt;0.01). Conclusion Referral to inpatient specialist PC in hospitalised HF patients is low relative to the morbidity and mortality in these patients. In addition, treating teams do not routinely assess symptoms or discuss disease trajectory. More work is needed to ensure that HF patients’ PC needs are integrated into care as recommended by expert consensus.Table 1

Abstract 14599: A Pilot Rheumatic Heart Disease Screening Program Using Portable, Handheld Echocardiography in Rivas, Nicaragua

Introduction: Portable, handheld echocardiography offers several advantages for rheumatic heart disease (RHD) screening in low-resource settings. Analyses of focused protocols using handheld echocardiography have yielded acceptable sensitivity and specificity for diagnosis of RHD, including in those performed by non-expert sonographers. Previous studies estimate high burden of RHD in Nicaragua. We conducted a pilot community-based RHD screening program using handheld echocardiography in Rivas, Nicaragua using contemporary RHD diagnostic criteria. Methods: Non-expert sonographers were trained using the GE Vscan Extend TM device and a simplified version of the 2012 World Heart Federation criteria for diagnosis of RHD. Referral criteria for complete echocardiogram included the presence of a mitral regurgitant jet of &gt; 2.0 cm, aortic regurgitant jet &gt; 1.0 cm, or any morphologic abnormality of the mitral or aortic valve, as well as left ventricular dysfunction or significant congenital heart disease. Participants were recruited by convenience-based sampling in communities throughout Rivas, Nicaragua. Participants were notified at the point-of-care of need for complete echocardiogram. All studies were overread asynchronously by expert readers for diagnostic accuracy. Results: Between March 2022 and April 2023, 494 screening echocardiographic studies were performed and evaluated for diagnostic accuracy. The median age was 36.3 years (IQR 19.2, 56.2), 22% of participants were &lt;18 years of age, and 60% of participants were female. There were 17.6% of participants referred for complete echocardiogram at the point-of-care compared with 13.0% meeting referral criteria on expert review. Negative and positive predictive values for non-expert vs. expert assessment were 92.4% and 62.1%, respectively. Cohen’s kappa for inter-rater reliability was 0.338, suggesting fair agreement. Conclusions: This pilot program demonstrated the feasibility of a screening program for RHD in rural Nicaragua with non-expert sonographers. Lessons from this program are intended to inform future epidemiological studies to determine the population prevalence and longitudinal outcomes of RHD in this region.

Understanding GPs' referral decisions for younger patients with symptoms of cancer: a qualitative interview study.

Cancer incidence increases with age, so some clinical guidelines include patient age as one of the criteria used to decide whether a patient should be referred through the urgent suspected cancer (USC) pathway. Little is known about how strictly GPs adhere to these age criteria and what factors might influence their referral decisions for younger patients. To understand GPs' clinical decision making for younger patients with concerning symptoms who do not meet the age criteria for USC referral. Qualitative study using in-depth, semi-structured interviews with GPs working in surgeries across England. Participants (n = 23) were asked to recall consultations with younger patients with cancer symptoms, describe factors influencing their clinical decisions, and discuss their overall attitude to age thresholds in cancer referral guidelines. A thematic analysis guided by the Framework approach was used to identify recurring themes. GPs' decision making regarding younger patients was influenced by several factors, including personal experiences, patients' views and behaviour, level of clinical concern, and ability to bypass system constraints. GPs weighted potential benefits and harms of a referral outside guidelines both on the patient and the health system. If clinical concern was high, GPs used their knowledge of local systems to ensure patients were investigated promptly even when not meeting the age criteria. While most GPs interpret age criteria flexibly and follow their own judgement and experience when making clinical decisions regarding younger patients, system constraints may be a barrier to timely investigation.

Predictors of Improvement in Parental Stress After the First Three Months at Home with a Medically Fragile Infant.

Little is known about the early stress experiences of parents of infants with serious life-limiting/life-threatening conditions during the initial months after discharge from hospital. The aim of the study was to measure change, and predictors of change, in parenting stress at the time of transition from hospital to home (T1) with a medically fragile infant, and after a 3-month period (T2). Parents of infants identified as meeting ≥ 1 palliative care referral criterion were recruited in a Midwestern United States tertiary pediatric hospital (2012-2014) within 2 weeks of hospital discharge. A repeated measures design was used to assess change on a validated parenting stress inventory over the two timepoints (T1 and T2). Fifty-two parents (61 infants) participated at T1 and 44 (85%) at T2. On discharge (T1) stress was moderately high 3 months post discharge (T2) overall and domain-specific stress scores improved, except stress related to parent role functioning and participation in their child's medical care. Independent predictors of improvement in overall parenting stress scores (T2-T1) were being a younger parent and having experienced prior pregnancy-related loss. The time of discharge from hospital to home is often stressful for parents of medically fragile infants. Improvements were found during the first 3 months at home, but improvement was minimal for stress related to role function and providing medical care. Past experience with pregnancy-related loss and being younger were associated with improvement in stress across theoretical domains. Screening for stress should be included as part of routine pre- and post-neonatal intensive care unit discharge psychosocial assessments of parents caring for infants with serious illness to ensure their unique support needs continue to be met over time.

Perceived Needs Among Healthcare Providers Caring for Seriously Ill Adults Regarding Electronic Health Record Triggers for Palliative Care Referral.

Many healthcare facilities in the United States currently utilize electronic health record triggers to promote and facilitate palliative care referral. The purpose of this study was to explore perceived needs regarding electronic health record trigger criteria for palliative care referral among healthcare providers caring for seriously ill adult hospitalized patients in a teaching hospital in New York State. A qualitative descriptive approach was utilized with use of individual semistructured interviews. Braun and Clarke's Reflexive Thematic Analysis method was used to analyze data. Data analysis generated one overarching theme, I'm in Favor of an Electronic Health Record Automatic Trigger for Palliative Care, and three key themes, Build a Checklist Screening Tool Into Epic With Predefined Conditions and a Palliative Consult in the Admission Order Set, If Providers Call a Palliative Care Consult Sooner, We Give Patients a Better Quality of Life, and Providers Need to Be Aware of the Different Facets of What Palliative Care Actually Does. Findings revealed that all participants supported incorporating electronic health record palliative care triggers. Future research is needed exploring provider palliative care education approaches to promote understanding of palliative care services and to address personal and/or professional bias.

Referral Criteria to Specialist Palliative Care for People with Advanced Chronic Kidney Disease: A Systematic Review.

People with advanced chronic kidney disease (CKD) have significant morbidity, yet for many, access to palliative care occurs late, if at all. This study sought to examine criteria for referral to specialist palliative care for adults with advanced CKD with a view to improving use of these essential services. Systematic review of studies detailing referral criteria to palliative care in advanced CKD conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guideline and registered (PROSPERO: CRD42021230751). Electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed) were used to identify potential studies, which were subjected to double review, data extraction, thematic coding, and descriptive analyses. Searches yielded 650 unique titles ultimately resulting in 56 studies addressing referral criteria to specialist palliative care in advanced CKD. Of 10 categories of referral criteria, most commonly discussed were: Critical times of treatment decision making (n = 23, 41%); physical or emotional symptoms (n = 22, 39%); limited prognosis (n = 18, 32%); patient age and comorbidities (n = 18, 32%); category of CKD/ biochemical criteria (n = 13, 23%); functional decline (n = 13, 23); psychosocial needs (n = 9, 16%); future care planning (n = 9, 16%); anticipated decline in illness course (n = 8, 14%); and hospital use (n = 8, 14%). Clinicians consider referral to specialist palliative care for a wide range of reasons, with many related to care needs. As palliative care continues to integrate with nephrology, our findings represent a key step towards developing consensus criteria to standardize referral for patients with chronic kidney diseases.

Evaluation of a national genetic testing service for monogenic endocrine disease in Scotland; enforcement of referral criteria may result in missed opportunities for genetic diagnosis

Evaluation of a national genetic testing service for monogenic endocrine disease in Scotland; enforcement of referral criteria may result in missed opportunities for genetic diagnosis

High Lipoprotein(a) May Explain One-Quarter of Clinical Familial Hypercholesterolemia Diagnoses in Danish Lipid Clinics.

Cholesterol carried in lipoprotein(a) adds to measured low-density lipoprotein cholesterol (LDL-C) and may therefore drive some diagnoses of clinical familial hypercholesterolemia (FH). We investigated plasma lipoprotein(a) in individuals referred to Danish lipid clinics and evaluated the effect of plasma lipoprotein(a) on a diagnosis of FH. Individuals referred to 15 Danish lipid clinics who were suspected of having FH according to nationwide referral criteria were recruited between September 1, 2020 and November 30, 2021. All individuals were classified according to the Dutch Lipid Clinical Network criteria for FH before and after LDL-C was adjusted for 30% cholesterol content in lipoprotein(a). We calculated the fraction of individuals fulfilling a clinical diagnosis of FH partly due to elevated lipoprotein(a). We included a total of 1166 individuals for analysis, of whom 206 fulfilled a clinical diagnosis of FH. Median lipoprotein(a) was 15 mg/dL (29 nmol/L) in those referred and 28% had lipoprotein(a) greater than or equal to 50 mg/dL (105 nmol/L), while 2% had levels greater than or equal to 180 mg/dL (389 nmol/L). We found that in 27% (55/206) of those fulfilling a clinical diagnosis of FH, this was partly due to high lipoprotein(a). Elevated lipoprotein(a) was common in individuals referred to Danish lipid clinics and in one-quarter of individuals who fulfilled a clinical diagnosis of FH, this was partly due to elevated lipoprotein(a). These findings support the notion that the LPA gene should be considered an important causative gene in patients with clinical FH and further support the importance of measuring lipoprotein(a) when diagnosing FH as well as for stratification of cardiovascular risk.

A comparison of four dementia palliative care services using the RE-AIM framework

BackgroundLiving with a life-limiting illness, people with dementia benefit from palliative care which considers the holistic needs of the person and their family. However, little is known about how palliative care may be best provided to people living with dementia at home in the community. We examined four exemplary dementia palliative care services for people with dementia in the community, to see what activities they were providing, what were the commonalities and differences, and what lessons could be learned.MethodsA long-list of dementia palliative care services in Ireland, Northern Ireland, England, Scotland, and Wales, was identified through a survey, and four exemplar services were chosen based on criteria including: in operation >six months; provides identifiable activities; availability of routinely collected service data; not exclusively for people with dementia in final hours or days of life. Mixed-methods of data collection included interviews, focus-groups and surveys with service staff, surveys of service users, and routinely collected service data. The RE-AIM framework was used to describe and understand the sample of dementia palliative care services.ResultsThe four services had varied organisational structures and were led by different disciplines. However, they all provided common core activities including holistic and person-centred care, early advance care planning with service user involvement, carer support, integrated healthcare services, continuity of care, 24/7 support, bereavement support. All had needs-based referral criteria, accepting any age or dementia sub-type. All supported people with dementia to remain living at home and to have a comfortable, dignified death in their preferred place.ConclusionsAn effective dementia palliative care service may take different forms. Whether the service is dementia-led or Specialist Palliative Care-led, efficacy is associated with providing a range of key activities and implementing them effectively. The data collected strongly suggests the benefits of the dementia palliative care services to a person with dementia and their families and offers valuable insight into the key factors for the establishment and successful running of such services.

Concordance of National Insurance Criteria with WPATH Standards of Care for Gender-Affirming Surgery.

Given that gender-affirming surgery (GAS) is considered medically necessary for transgender and gender-diverse individuals who desire it, the aim of this study was to assess the concordance of insurance criteria for GAS with the most recent World Professional Association for Transgender Health Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Insurance policies for coverage of gender-affirming genital surgery ("bottom surgery"), chest surgery ("top surgery"), and facial reconstruction from companies representing 80% of the market coverage in each state were evaluated. Policies were classified into 3 categories: no coverage, case by case, or preauthorization. Among preauthorization policies, criteria for coverage of specific procedures were analyzed for adherence to the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Bottom-surgery policies were most concordant for age and gender dysphoria criteria, and transmasculine top surgery policies were most concordant for hormone therapy, continuous living in a congruent gender role, and referral criteria. Transfeminine top surgery criteria were more restrictive than transmasculine criteria. The most discordant criteria were for hormone therapy, being required for at least 12 months before surgery in the majority of surveyed policies. Many specific procedures and treatments were excluded, especially facial GAS with cosmetic overlap. Reversal and revisionary procedures were covered by less than 25% of policies. Compared with previous literature, insurance coverage and criteria alignment are becoming more concordant with medical guidelines. However, significant barriers to care for GAS remain.

Abordaje integral del vértigo: algoritmo diagnóstico, causas, tratamientos y criterios de derivación desde la perspectiva de atención primaria. Documento de consenso SEMERGEN

Vertigo is a common symptom that can have various causes and may require a comprehensive approach for its diagnosis and treatment from primary care. A diagnostic algorithm based on the classification proposed by the Otoneurology Commission of the SEORL-PCF is suggested, which facilitates the classification of the different types of vertigo and provides referral criteria for patients from primary care to other specialties. A review of the available treatments based on the underlying cause is conducted for appropriate therapeutic management. This document is expected to become a valuable tool for professionals treating patients with vertigo. The document is based on scientific evidence and on the experience of experts in the field from various medical specialties; and seeks to improve the understanding and clinical approach to acute vertigo from primary care.