Referral Of Adults Research Articles

Improving access to treatment for alcohol dependence in primary care: A qualitative investigation of factors that facilitate and impede treatment access and completion.

Timely intervention for people with alcohol dependence in primary care is needed. Primary care services have a key role in supporting adults with alcohol dependence and require appropriate provision of services. To examine the perceptions of both primary care practitioners and adults with alcohol dependence regarding service provision and to describe help seeking behaviours for adults with alcohol dependence. Qualitative study consisting of semi-structured interviews with adults with alcohol dependence, healthcare professionals and staff members of specialist alcohol services who had previous or current experience in the management, treatment, or referral of adults with alcohol dependence in Northwest England. Interviews were conducted with ten adults with alcohol dependence and 15 staff. Data were analysed thematically, applying principles of constant comparison. Three themes were identified following inductive thematic analysis. The first theme, point of access relates to current service provision being reactive rather than preventative, the stigma associated with alcohol dependence and a person's preparedness to change. The second theme identified was treatment process and pathways that highlights difficulties of engagement, mental health support, direct access and person-centred support. The third theme was follow-up care and discusses the opportunities and threats of transitional support or aftercare for alcohol dependence, signposting and peer support. There are clear opportunities to support adults with alcohol dependence in primary care and the need to increase provision for timely intervention for alcohol related issues in primary care.

What influences referral for mental health support in audiology clinics? A qualitative exploratory approach of barriers and facilitators

ABSTRACT Objective This study aimed to gain an in depth understanding of factors influencing mental health referrals for adults with hearing loss in the audiology setting. Method A semi-structured focus group with hearing care practitioners (HCPs) and reception staff (N = 12, M age = 45 ± 12 years, 10 female) from a large hearing services provider in Western Australia in 2020. Results Three themes were identified: (1) beliefs about and the recognition of the need for referral, (2) knowledge, skills, and training for mental health referral, and (3) outcomes and consequences of referring clients for mental health support. Discussion This study identified a wide range of factors influencing referral of adults with hearing loss for mental health support. The findings of this research may be used to inform intervention development targeting mental health referral behaviours within the audiology setting.

The dental triage method at Rothschild Hospital during the first lockdown due to the COVID-19 pandemic.

This study aims to (1) assess the efficacy of a face-to-face emergency protocol in children and adults and (2) measure the efficacies of prediagnosis at the triage level and clinical diagnosis at the emergency department level during the COVID-19 pandemic. A triage protocol was applied for patients at the entry of the Rothschild Hospital (AP-HP) between March 18th and May 11th, 2020. First, patients underwent a triage based on self-reported symptoms. If their condition was deemed urgent, they were oriented toward dental professionals, who performed an intraoral examination leading to a clinical diagnosis. Triage and diagnoses were categorized into four emergency groups: infectious, prosthetic, traumatic, and others. The agreement between triage and clinical diagnosis was tested (χ2 test). Positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity for each diagnostic category were assessed to evaluate the performance and efficacy of the triage. Out of 1562 dental visits, 1064 were included in this analysis. The most frequently reported symptoms by children at triage were pain (31.5%) and trauma (22%). Adults mainly complained of abscesses (45.1%) and pulpitis (20.5%). The most frequent clinical diagnoses were abscesses (29.2%) and pulpitis (20.5%) among children and adults, respectively. Tooth extraction was the most frequent treatment modality. Systemic antibiotics were prescribed for 49.2% of patients. Regardless of the age class, the PPV was high for groups 1 to 3, ranging from 78.9% to 100%. The NPV was high in all groups, ranging from 68.8% to 99.1%. This study demonstrates that the triage implanted during the first COVID-19 lockdown was effective and is an appropriate tool for the referral of adults and children before clinical examination.

Intervention components of link worker social prescribing programmes: A scoping review.

In the United Kingdom (UK), link worker social prescribing has emerged as an option to improve long-term condition management and address primary care patients' non-medical needs by linking patients with community-based activities and support. Social prescribing is a complex, heterogenous intervention, and there is currently no taxonomy of components to guide its implementation and evaluation. This study aimed to identify and categorise the components of link worker social prescribing schemes in the United Kingdom. A scoping review of peer-reviewed literature was conducted. Six databases were used to identify papers that met inclusion criteria. Eligible articles were original research studies in the United Kingdom describing interventions that included (1) initial referral of adults with chronic physical health conditions and/or unmet social needs from primary care to a link worker or equivalent role, (2) consultation with a link worker or equivalent role and (3) referral to a community-based or government service. Of the 1078 articles identified, 32 met study eligibility criteria, representing 22 social prescribing schemes. We drew from the template for intervention description and replication (TIDieR) to identify, organise and report intervention components. We found wide variations in geography, target populations and intervention components such as activities and procedures conducted by primary care staff and link workers, organisational and staffing configurations and use of tools and financing approaches to facilitate adoption. Intervention components are summarised into a taxonomy to guide future research, policy and practice efforts in addition to supporting standardised intervention reporting.

0794 Understanding Barriers and Communication Behaviors Impacting Referral to Sleep Surgery: Qualitative Patient Perspectives

Abstract Introduction Shared decision-making is a process when patients, families, and clinicians work together to make optimal, personalized medical choices in the face of more than one reasonable treatment option. These interactions can influence the joint decision and may have lasting impressions for future healthcare encounters. Considering the American Academy of Sleep Medicine’s recent clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation, we aimed to understand patient experiences, in terms of barriers and communication behaviors in the referral process to sleep surgery consultation. Methods We performed a qualitative study consisting of in-depth semi-structured virtual interviews with adult patients (aged ≥18 years) with OSA (apnea-hypopnea index ≥5 events per hour of sleep, scored by AASM-accredited standards) and who were recommended for sleep surgery at a tertiary Sleep Surgery Clinic. Open ended questions focused on patient experiences during healthcare encounters from diagnosis, trials with noninvasive management options and ultimate referral to sleep surgery. The interviews were audio-recorded, transcribed, and analyzed using content analysis to identify themes. Results Ten adult patients with OSA who were evaluated in sleep surgery clinic were approached and enrolled from March through April 2021. Barriers to sleep surgery clinic included delays in OSA diagnosis due to limited OSA awareness and perceived inconvenience of sleep study, providers faulting patient for persistent sleep symptoms, patient-reported lack of urgency by providers in troubleshooting noninvasive management options, scheduling delays and waitlists, and cost. Patients were open to trialing noninvasive treatment options, though opportunities for reevaluation and shared decision-making may address unmet needs, as inadequate improvements led to frustration after multiple encounters. Patients appreciated providers who were empathetic and provided information sharing, in terms of transparent and understandable explanations. Conclusion This study focused on experiences of patients with OSA and barriers faced to reach sleep surgery consultation. Improved communication structure to discuss unresolved concerns and remaining management options, as well as vetted resources, would set the foundation for effective shared decision-making and timely referral for sleep surgery consultation. Support (If Any) Academy of Otolaryngology Head and Neck Surgery Resident Research Centralized Otolaryngology Research Efforts (CORE). NIH T32 DC000018.

Suicide intervention among aging network providers

ABSTRACT Older adults are at risk for mental health concerns, such as social isolation and suicide. Risk factors to suicide among older adults, such as loneliness and social isolation, may be impacted by the COVID-19 pandemic. Gatekeepers in the community are a significant source of identification and referral of older adults at risk of mental and physical health concerns. In this study, we sought to discover whether natural helpers in the Aging Service Network (ASN), including volunteers and providers (n = 93) obtain and utilize suicide-intervention skills with older adults who receive home-delivered meals (HDM) after being trained in a 14-hour evidenced based training. Paired-sample t-tests yielded significant results at pre- and post-test measures of suicide intervention response skill acquisition, and over 19% of trained participants reported using suicide intervention skills over six months. Implications for future training and research are discussed.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment.

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation. The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence for making recommendations. The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and oxygen desaturation index (ODI); an increase in lowest oxygen saturation (LSAT) and sleep quality; and an improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI and an increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, and ODI and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggested that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations. Kent D, Stanley J, Aurora RN, etal. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(12):2507-2531.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline.

This guideline establishes clinical practice recommendations for referring adults with obstructive sleep apnea (OSA) for surgical consultation. The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine, otolaryngology, and bariatric surgery to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using the GRADE process. The task force evaluated the relevant literature and the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations that support the recommendations. The AASM Board of Directors approved the final recommendations. The following recommendations are intended as a guide for clinicians who treat adults with OSA. Each recommendations statement is assigned a strength ("Strong" or "Conditional"). A "Strong" recommendation (ie, "We recommend…") is one that clinicians should follow under most circumstances. A "Conditional" recommendation is one that requires that the clinician use clinical knowledge and experience and strongly consider the patient's values and preferences to determine the best course of action. (1) We recommend that clinicians discuss referral to a sleep surgeon with adults with OSA and BMI <40 kg/m2 who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options (STRONG). (2) We recommend that clinicians discuss referral to a bariatric surgeon with adults with OSA and obesity (class II/III, BMI ≥35 kg/m2) who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options (STRONG). (3) We suggest that clinicians discuss referral to a sleep surgeon with adults with OSA, BMI <40 kg/m2, and persistent inadequate PAP adherence due to pressure-related side effects as part of a patient-oriented discussion of adjunctive or alternative treatment options (CONDITIONAL). (4) We suggest that clinicians recommend PAP as initial therapy for adults with OSA and a major upper airway anatomic abnormality prior to consideration of referral for upper airway surgery (CONDITIONAL). Kent D, Stanley J, Aurora RN, etal. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(12):2499-2505.

Identifying enablers and barriers to referral, uptake and completion of lifestyle modification programmes: a rapid literature review

ObjectiveTo identify current, policy-relevant evidence about barriers and enablers associated with referral, uptake and completion of lifestyle modification programmes (LMPs) for secondary prevention of chronic disease in adults.DesignA rapid review,...

Mind the caretaker: ED referrals of community-dwelling older adult patients by their primary caregivers are accurate.

ED referral of older adults on the initiative of their family or paid live-in caregiver is common but not previously studied. ED-presenting community-dwelling patients ≥65 years were studied, emphasizing the referring agent, and correct (admitted or discharged +changed diagnosis/treatment) vs. incorrect referral (discharged, no change made). Of 448 consecutive patients (median age 83 years), 231 were referred by their primary physician (PCP) (73% admitted, 17% discharged +change). 117 ED referrals were initiated by their family (78% admitted, 6% discharged +change), and 100 by their paid caregiver (66% admitted, 21% discharged +change). Differences were non-significant, as was the distribution of main diagnoses. ED referral of older adults from the community by laymen who know the patient well (family or caregiver) is non-inferior to a referral by their PCP. ED physicians should regard non-physician ED presentations as seriously as a referral by a physician, pending confirmation in future studies.

2239-PUB: Best Practices for Implementing Diabetes Prevention in Health Care Settings

One in 3 adults in the U.S. has prediabetes and 90 percent don’t even know they have it. If left untreated or treated with usual care, many will go on to develop type 2 diabetes. The Centers for Disease Control and Prevention’s National Diabetes Prevention Program (DPP) was created in 2010 to address the increasing burden of prediabetes and type 2 diabetes in the United States. Despite the demonstrated effectiveness of an intensive lifestyle invention program, there are still millions of undiagnosed and untreated individuals with prediabetes. Identification of prediabetes and referral of eligible adults to a lifestyle change program is recommended in both the ADA and USPSTF clinical guidelines and standards of care. However, only a minority of clinicians are systematically addressing prediabetes in their patient population or referring their patients to a lifestyle change program. Although existing research has evaluated the uptake of clinical guidelines regarding diabetes prevention and the availability of coverage for lifestyle change programs, there is a gap in collecting and sharing best practices for building a diabetes prevention strategy that includes the CDC’s National DPP lifestyle change program. The AMA convened a diverse group of leading health care organizations that were successful in establishing system-based strategies. This session will describe a best practice implementation framework for health systems to consider when establishing or expanding a diabetes prevention strategy and engaging with clinical champions to improve identification and treatment of patients with prediabetes. Disclosure J. Williams: None. N. Sachdev: None. T. Moin: None. O. Duru: None.

Accuracy of Trained Community-based Rehabilitation Volunteers in Identification and Appropriate Referral of Adults with Perceived Visual Disability in an Urban-slum Setting in Southern India

ABSTRACT Purpose The integration of primary eyecare into existing primary healthcare systems requires simple yet effective tools that do not overburden the grass-root level worker. The objective of this study was to test the accuracy of a questionnaire-based tool administered by trained community-based rehabilitation volunteers (CBRVs) in identifying persons with visual disability, proportions accessing referral pathway and barriers to uptake of eyecare services. Methods CBRVs working in the urban-slum service area of a teaching hospital were trained in administering a questionnaire-based tool derived from the World Health Organization (WHO) “Training in the community for people with disabilities” to a responsible adult member of the household. Post-training, they screened and referred adults with perceived visual problems. This tool was tested against two reference standards: (i) history of visual disability elicited by ophthalmologist; (ii) pre-set visual acuity and diagnosis criteria. Results Ten CBRVs screened 950 individuals of whom 805 (84.7%) were examined by an optometrist and ophthalmologist. Sensitivity and specificity of this method were 75% (95% CI 72–78%), 95.8% (95% CI 94–98%) respectively, using history and 60.2% (95% CI 57–63%), 91.8% (95% CI 90–94%) using clinical criteria as reference standard. Referral pathway was used by 91/221 (41.2%) referred individuals. The commonest barriers to accessing eye care were ‘did not feel the need’ (32.2%) and ‘busy with work/household responsibilities’ (30.2%). Conclusions This questionnaire-based tool administered by grass-root level health workers to a responsible adult member of the family may be a promising screening method for identification and appropriate referral of persons with visual disability in the community.

What works and why in the identification and referral of adults with comorbid obesity in primary care: A realist review.

SummaryPrimary care practitioners (PCPs) are well placed to identify individuals with obesity and weight‐related comorbidities and to refer them to weight management services (WMS), but this does not often happen in practice. In this realist review, we searched six databases for intervention studies targeted at PCPs to improve the identification and referral of adults with comorbid obesity. Realist analysis was used to identify context‐mechanism‐outcome (CMO) configurations across 30 included papers (reporting on 27 studies). Most studies used multiple intervention strategies, categorised into: (a) training, (b) tools to improve identification, (c) tools to improve ease of referral, (d) audit/feedback, (e) working in networks/quality circles, and (f) other. The realist synthesis identified 12 mechanisms through which interventions work to improve identification and referral, including increasing knowledge about obesity and awareness of and confidence in WMS among practitioners, improved communication and trust between practitioners and WMS, and higher priority given to weight management among primary care teams. The theory of “candidacy” (a person's eligibility for medical attention and intervention) provided a robust explanatory framework but required refinement: (a) to take account of the different services (primary care and weight management) that patients must navigate to access support; and (b) to acknowledge the importance of wider contextual factors.

Wilms tumor, medulloblastoma, and rhabdomyosarcoma in adult patients: lessons learned from the pediatric experience.

Wilms tumor (or nephroblastoma), rhabdomyosarcoma, and medulloblastoma, common embryonal tumors in children, can occasionally occur in adults, for whom survival is significantly inferior than pediatric patients. Available data on adults with Wilms tumor consist of case or case series reports. Among other factors, the unfamiliarity of adult oncologists and pathologists with nephroblastoma and consequent delays in initiating the appropriate risk-adapted chemotherapy may negatively influence outcomes. The survival decrement in adults with rhabdomyosarcoma has been attributed to the lack of centralized care, the inconsistent use of standard protocol-driven multimodal therapy, and lower chemotherapy tolerance in adult patients. In children with medulloblastoma, evidence from randomized clinical trials has led to risk-tailored therapies tuned on histology, extent of initial disease, and biological features. Such refinements are still missing for adults due to the lack of similar trials and studies that might provide the same or a different understanding regarding patients' individual prognosis, treatment morbidity, and quality of life. Recent experiences have suggested that applying or adjusting pediatric protocols to adult patients with these tumors is feasible and can improve survival. Here, we provide an evaluation of the current evidence for the management of Wilms tumor, rhabdomyosarcoma, and medulloblastoma arising in adults. This review aims to promote the referral of adolescents and adults with pediatric tumors to pediatric centers for inclusion into pediatric protocols, or into protocols and studies specifically designed for that age group with the cooperation between pediatric and adult oncologists.

General practice referral of \u2018at risk\u2019 populations to community leisure services: applying the RE-AIM framework to evaluate the impact of a community-based physical activity programme for inactive adults with long-term conditions

BackgroundIn the UK a high proportion of adults with long-term conditions do not engage in regular physical activity. General practice (GP) referral to community-based physical activity is one strategy that has gained traction in recent years. However, evidence for the real-world effectiveness and translation of such programmes is limited. This study aimed to evaluate the individual and organisational impacts of the ‘CLICK into Activity’ programme - GP referral of inactive adults living with (or at risk of) long-term conditions to community-based physical activity.MethodsA mixed methods evaluation using the RE-AIM framework was conducted with data obtained from a range of sources: follow-up questionnaires, qualitative interviews, and programme-related documentation, including programme cost data. Triangulation methods were used to analyse data, with findings synthesised across each dimension of the RE-AIM framework.ResultsA total of 602 individuals were referred to CLICK into Activity physical activity sessions. Of those referred, 326 individuals participated in at least one session; the programme therefore reached 30.2% of the 1080 recruitment target. A range of individual-, social-, and environmental-level factors contributed to initial physical activity participation. Positive changes over time in physical activity and other outcomes assessed were observed among participants. Programme adoption at GP surgeries was successful, but the GP referral process was not consistently implemented across sites. Physical activity sessions were successfully implemented, with programme deliverers and group-based delivery identified as having an influential effect on programme outcomes. Changes to physical activity session content were made in response to participant feedback. CLICK into Activity cost £175,000 over 3 years, with an average cost per person attending at least one programme session of £535.ConclusionsDespite not reaching its recruitment target, CLICK into Activity was successfully adopted. Positive outcomes were associated with participation, although low 6- and 12-month follow-up response rates limit understanding of longer-term programme effects. Contextual and individual factors, which may facilitate successful implementation with the target population, were identified. Findings highlight strategies to be explored in future development and implementation of GP referral to community-based physical activity programmes targeting inactive adults living with (or at risk of) long-term conditions.

Clinical Identification and Referral of Adults With Prediabetes to a Diabetes Prevention Program.

Purpose and ObjectivesCommunity programs to prevent or delay the onset of type 2 diabetes are effective, but implementing these programs to maximize their reach and impact remains a challenge. The American Medical Association (AMA) partnered with the YMCA of the USA, as part of a Centers for Medicare and Medicaid Innovation demonstration project, to develop, implement, and evaluate innovative quality improvement strategies to increase routine screening, testing, and referral of Medicare patients with prediabetes to diabetes prevention programs (DPPs) at local YMCAs.Intervention ApproachAMA recruited 26 primary care practices and health systems in 17 US communities to implement point-of-care and retrospective methods (or a combination of both) for screening, testing, and referral of Medicare patients with prediabetes. Evaluation MethodsWe assessed changes in rates of referral and enrollment of patients among participating practices. We used a mixed-methods pretest–posttest evaluation design to determine if use of certain tools and resources, coupled with systems changes, led to increased screening and referrals.ResultsPractices referred a total of 5,640 patients, of whom 1,050 enrolled in a YMCA DPP (19%; range, 2%–98%). Practices (n = 12) that used retrospective (ie, electronic medical record [EMR]) systems to identify eligible Medicare patients via a registry referred more people (n = 4,601) to the YMCA DPP than practices (n = 10) that used a point-of-care method alone (n = 437 patients) or practices (n = 4) that used a combination of these approaches (n = 602 patients). All approaches showed increased enrollment with point-of-care methods being most successful.Implications for Public HealthLessons learned from this intervention can be used to increase diabetes prevention in the United States and support the Centers for Medicare and Medicaid Services (CMS) decision to expand Medicare coverage to include the DPP for all Medicare beneficiaries.

Development and implementation of an online clinical pathway for adult chronic kidney disease in primary care: a mixed methods study.

BackgroundPrimary care physicians and other primary health care professionals from Alberta, Canada identified a clinical pathway as a potential tool to facilitate uptake of clinical practice guidelines for the diagnosis, management and referral of adults with chronic kidney disease. We describe the development and implementation of a chronic kidney disease clinical pathway (CKD-CP; www.ckdpathway.ca).MethodsThe CKD-CP was developed and implemented based on the principles of the Knowledge-To-Action Cycle framework. We used a mixed methods approach to identify the usability and feasibility of the CKD-CP. This included individual interviews, an online survey and website analytics, to gather data on barriers and facilitators to use, perceived usefulness and characteristics of users. Results are reported using conventional qualitative content analysis and descriptive statistics.ResultsEighteen individual interviews were conducted with primary care physicians, nephrologists, pharmacists and nurse practitioners to identify themes reflecting both barriers and facilitators to integrating the CKD-CP into clinical practice. Themes identified included: communication, work efficiency and confidence. Of the 159 participants that completed the online survey, the majority (52 %) were first time CKD-CP users. Among those who had previously used the CKD-CP, 94 % agreed or strongly agreed that the pathway was user friendly, provided useful information and increased their knowledge and confidence in the care of patients with CKD. Between November 2014 and July 2015, the CKD-CP website had 10,710 visits, 67 % of which were new visitors. The 3 most frequently visited web pages were home, diagnose and medical management. Canada, Indonesia and the United States were the top 3 countries accessing the website during the 9 month period.ConclusionsAn interactive, online, point-of-care tool for primary care providers can be developed and implemented to assist in the care of patients with CKD. Our findings are important for making refinements to the CKD –CP website via ongoing discussions with end-users and the development team, along with continued dissemination using multiple strategies.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-016-0350-z) contains supplementary material, which is available to authorized users.

Community pharmacist targeted screening for chronic kidney disease.

More than 1 in 10 adults in Canada is living with chronic kidney disease (CKD),1 defined as a reduction in kidney function (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2) or markers of kidney damage (albuminuria ≥3 mg/mmol or abnormalities in urine sediment or renal imaging) for more than 3 months.2 Individuals with CKD require more intensive follow-up due to their reduced renal function, increased cardiovascular risk and multiple associated comorbidities.3 Early detection can help optimize the treatment, prevent or slow the progression of the disease and ultimately improve the quality of life of patients with CKD.4-6 Early stages of CKD are often asymptomatic, making preventive efforts difficult. Indeed, Mitra and Bradley7 identified that a large proportion of patients in the community are underdiagnosed and undertreated for CKD. As such, the use of comprehensive evidence-based guidelines to aid in targeted screening, early detection and management of such patients has been recommended.1 The CKD Clinical Pathway was developed to provide guidance on these issues in this high-risk population.8 The CKD Clinical Pathway is an online tool modeled after the successful National Institute for Health and Care Excellence (NICE) clinical pathways. It was developed by a team of stakeholders that included nephrologists, pharmacists, primary care physicians, nurses, other health care professionals, information technology specialists, web developers and designers to aid in the diagnosis, management and referral of adults with CKD in the community. The content in the CKD Clinical Pathway is evidence based and combines a group of national and international guidelines.2,9-14 This ensures that the recommendations are relevant and harmonized across Canada. More information on the CKD Clinical Pathway is available at www.ckdpathway.ca. Pharmacists are frontline health care professionals who see patients with, and at risk of, CKD frequently and therefore could systematically identify these individuals and assist in their management. Moreover, pharmacists’ scope of practice has expanded in Alberta, allowing them to order and view laboratory tests. As such, we undertook this study to evaluate pharmacists’ application of the CKD Clinical Pathway in the screening and identification of patients with CKD, particularly those with previously unrecognized CKD.

Online clinical pathway for managing adults with chronic kidney disease

Around one-tenth of the adults in Canada are affected by chronic kidney disease (CKD), which is defined as estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2.1 Early recognition of CKD is important, since timely implementation of lifestyle and pharmacological interventions can prevent it or slow its progression.2-4 Such interventions can also reduce the incidence of cardiovascular disease (CVD)5,6—the primary cause of death in these patients.7 However, patients with CKD are often not recognized and do not receive optimal treatment because of complexities in care and failure to disseminate best practices.8-10 The Kidney Disease Improving Global Outcomes (KDIGO) CKD clinical practice guidelines provide evidence for the evaluation and management of CKD.11 While clinical practice guidelines summarize evidence and provide recommendations, they are often difficult to apply in routine daily clinical activities. Clinical pathways are often derived from clinical practice guidelines but differ by providing more explicit and practical information about the sequence, timing and provision of interventions.12 A clinical pathway can be an effective tool to increase uptake of evidence-based health care by pharmacists and other primary care professionals in the community, who care for the majority of patients with CKD.13-15 Pharmacists in Canada have an expanding scope of practice; pharmacists can order laboratory tests, adapt new prescriptions, perform therapeutic substitutions, issue prescriptions for continuity of care and prescribe in emergency situations.16 In Alberta, pharmacists who have Additional Prescribing Authorization can prescribe at initial access or manage ongoing therapy based on their own assessment or in collaboration with another regulated health care professional.17 An integral part of pharmacists’ practice is working collaboratively and communicating with physicians and other health care providers.17 As pharmacists’ expanded scope of practice develops,16 tools such as the CKD Clinical Pathway (Figure 1) can assist pharmacists to implement evidence-based guidelines into their daily practice. This manuscript provides an overview of the clinical pathway for diagnosis, management and referral of adults with CKD and its potential clinical use for pharmacists. Figure 1 Overview of the adult CKD Clinical Pathway Development of the adult CKD Clinical Pathway The CKD Clinical Pathway is an online tool/guideline modeled after the successful National Institute for Health and Clinical Excellence (NICE) clinical pathways (http://pathways.nice.org.uk). It was developed by a team of stakeholders that included pharmacists, nephrologists, primary care physicians, nurses, other health care professionals, IT specialists, web developers and designers. Usability and heuristic testing with primary care professionals has been completed, and the CKD Clinical Pathway has been available online since November 4, 2014 (www.CKDpathway.ca). The content in the CKD Clinical Pathway is evidence based and uses international and national guidelines, including the KDIGO CKD guidelines,11 KDIGO Lipid guidelines,18 C-CHANGE,19 Canadian Diabetes Association (CDA) guidelines,20 Canadian Cardiovascular Society Lipid and Antiplatelet guidelines21,22 and Canadian Hypertension Education Program guidelines.23 This ensures that the recommendations are relevant and harmonized across Canada. Some of the content, such as the specialist referral form, is tailored to practice in Alberta. Users of the pathway should be aware that their local laboratory may report different reference ranges and units of measure than the laboratories in Alberta. Currently, laboratories in Alberta report estimated GFR using the CKD-EPI equation.24

Factors associated with hematopoietic cell transplantation (HCT) among patients in a population-based study of myelodysplastic syndrome (MDS) in Minnesota.

Myelodysplastic syndrome (MDS) is a clonal hematopoietic stem cell disorder characterized by dysplastic changes in the bone marrow, ineffective erythropoiesis, and an increased risk of developing acute myeloid leukemia. Treatment planning for patients with MDS is a complex process, and we sought to better characterize hematopoietic cell transplantation (HCT) outcomes and the factors that play into decision-making regarding referral of adults with MDS for definitive therapy with HCT. Patients enrolled in a population-based study of MDS between April 2010 and January 2013 who underwent HCT within the first year after enrollment were included in this analysis. Age- and risk-matched MDS patient controls also enrolled during that time period were used as a comparison. Survival was significantly better in the HCT group (48 vs. 21%, log-rank p value 0.009). Non-HCT patients were more likely to have comorbidities, and HCT patients were more likely to have a college degree and an income >$80,000. All three of these variables were independently associated with HCT, but none impacted survival. Patients with MDS in our study who underwent HCT had better survival than a comparable group of patients who did not undergo HCT. With refined treatment techniques, more patients may be able to be considered for this therapy. More work needs to be done to determine why education and income appear to impact the decision to pursue HCT, but these factors may impact referral to an academic center where aggressive therapy like HCT is more likely to be considered.