Referral Practices Research Articles

Comorbidity, Racial, and Socioeconomic Disparities in Total Knee and Hip Arthroplasty at High Versus Low-Volume Centers.

The purpose of this study was to compare the epidemiologic and demographic profiles and inpatient postoperative complication and economic outcomes of patients undergoing total joint arthroplasty of the hip and knee (TJA) at high-volume centers (HVCs) versus low-volume centers (LVCs) using a large national registry. This retrospective cohort study used data from the National Inpatient Sample from 2006 to the third quarter of 2015. Discharges representing patients aged 40 years or older receiving a primary total hip arthroplasty or total knee arthroplasty were included. Patients were stratified into those undergoing their procedure at HVCs versus LVCs. Epidemiologic, demographic, and inpatient postoperative complications and economic outcomes were comparatively analyzed between groups. A total of 7,694,331 TJAs were conducted at HVCs while 1,044,358 were conducted at LVCs. Patients at LVCs were more likely to be female, be Hispanic, be non-Hispanic Black, and use Medicare and Medicaid than patients at HVCs. Of the 29 Elixhauser comorbidities examined, 14 were markedly higher at LVCs while 11 were markedly higher at HVCs. Patients who underwent TJA at LVCs were more likely to develop cardiac, respiratory, gastrointestinal, genitourinary, hematoma/seroma, wound dehiscence, and postoperative infection complications and were more likely to die during hospitalization. Patients at HVCs were more likely to develop postoperative anemia. Length of stay and total charges were higher at LVCs compared with HVCs. There are notable differences in the demographics, epidemiologic characteristics, and inpatient outcomes of patients undergoing TJA at HVCs versus LVCs. Attention should be directed to identifying and applying the specific resources, processes, and practices that improve outcomes at HVCs while referral practices and centralization efforts should be mindful to not worsen already existing disparities.

Prevalence of Dental and Skeletal Malocclusions in Mesaticephalic and Dolichocephalic Dogs-a Retrospective Study (2015-2018).

Medical records of dogs with dolico- or mesaticephalic conformation who were presented to a private veterinary referral dental practice with malocclusion of the deciduous or permanent dentition were retrospectively reviewed from a 3-year period (2015-2018). Records were evaluated to determine the type(s) of malocclusions and 198 dogs were evaluated with permanent malocclusions. Of the dogs with deciduous malocclusions, 45 (60%) had variations of a MAL1, 28 (38%) had a MAL2, 13 (17.6%) had a MAL3, and four (5.4%) had a MAL4, with 19 (26%) having more than one type of malocclusion. Poodles, Labrador Retrievers, and Cavalier King Charles Spaniels consisted of 37 (50%) of the dogs with deciduous malocclusions. Fifty-five (74%) dogs proceeded with interceptive orthodontics. Of the dogs with permanent malocclusions, 128 (65%) had a variant of a MAL1, 60 (30%) had a MAL2, 75 (38%) had a MAL3, and 11 (5.6%) had a MAL4, with a MAL1 occurring concurrently with 49 (82%) MAL2 cases. The most common type of MAL1 was linguoversion of one or both mandibular canine teeth in 92 (72%) dogs. The five most commonly affected breeds with permanent malocclusions were Poodles, Labrador Retrievers, Chihuahuas, Pit Bull Terriers, and Cavalier King Charles Spaniels. Overall, 39 (18%) dogs presented with malocclusions observed in this study were associated with the Poodle breed and 20 (9%) dogs were associated with the Labrador Retriever breed. This trend among Poodle mixes and Labrador Retrievers supports a familial pattern to malocclusions.

Comparison of Persistent Epithelial Defect Treatment With Sutureless Cryopreserved and Dehydrated Amniotic Membrane

To compare cryopreserved sutureless amniotic membrane (C-SAM) and dehydrated SAM (D-SAM) outpatient treatment outcomes for persistent epithelial defects (PEDs), analyze risk factors for treatment failure, and identify adverse events. Retrospective, interventional comparative clinical study. This study was a multicenter retrospective interventional cohort from 2 tertiary corneal referral practices from 2016 to 2020. The inclusion criteria were as follows: (1) PEDs treated (2) outpatient with (3) either C-SAM or D-SAM. PEDs were defined as epithelial defects present for ≥7 days after failing prior conservative therapy. The primary outcome measure was the resolution or improvement of a PED. The secondary outcomes included analysis of treatment failures and identification of adverse events. A total of 220 PEDs from 204 eyes (197 patients) treated with either C-SAM or D-SAM met the inclusion criteria. A total of 100 PEDs (45.5%) resolved after single amniotic membrane administration, 46.5% (59 of 127) in the C-SAM group and 44.1% (41 of 93) in the D-SAM group (P=.727). Forty-nine PEDs neither improved nor resolved without a significant difference between the C-SAM (21.3%) and D-SAM groups (23.7%, P=.673).There was no statistically significant difference for PED resolution, PED improvement, PEDs that did not resolve/improve, or those requiring surgery between the 2 groups for initial SAM. C-SAM and D-SAM were both effective for treating PEDs with comparable outcomes for resolution, improvement, and need for additional surgical intervention. Specific differences in adverse events may help dictate clinical use. Inflammatory disease was a risk factor for nonresolution of all PEDs.

Canadian Spine Society

# Abstract 57. Radiographic reporting in adolescent idiopathic scoliosis: Is there a discrepancy comparing radiologists’ reports and surgeons’ assessments? {#article-title-2} Cobb angle measurement is the standard method for quantification of scoliosis in adolescent idiopathic scoliosis (AIS),

Owner Survey of 55 Dogs That Underwent Full Mouth Extraction Procedures in a Referral Practice.

Full mouth extraction (FME) in dogs is a common procedure performed in veterinary dental referral practice. Clients may be apprehensive to have FME performed, with concerns for ability to eat and quality of life. These concerns may be barriers to electing to proceed. This study used a cross-sectional survey to identify concerns clients had regarding FME. Medical records of 168 dogs that underwent FME at a referral practice from 2013 to 2019 were sent surveys. A total of 55 responses were obtained. This study demonstrated that after extractions, 52.7% of the patients ate the same diet as before the surgery. Regarding enthusiasm for eating, 12 (21.7%) reported an increase in enthusiasm, 15 (27.3%) reported slightly more enthusiasm, 25 (45.5%) reported the same enthusiasm, two (3.6%) reported less enthusiasm, and one (1.8%) showed a complete lack of interest. Fifty-one (92.7%) reported improved postoperative oral comfort. Twenty-five respondents (45.5%) had a great deal of anxiety before the procedure, specifically regarding eating postoperatively, 13 (24.1%) were extremely concerned, 31 (57.4%) were somewhat concerned. Twenty-six (47.3%) were extremely anxious about anesthesia. This study demonstrated high client satisfaction with 45 (81.8%) of the respondents reporting high satisfaction. This survey demonstrated that FME is a successful procedure with a high rate of client satisfaction.

Embedding electronic patient-reported outcome measures into routine care for patients with stage III MELanoma (ePROMs-MEL): protocol for a prospective, longitudinal, mixed-methods pilot study

IntroductionThe benefits of patient-reported feedback, using questionnaires that allow patients to report how they feel and function without any interpretation from healthcare professionals, are well established. However, patient-reported outcomes measures...

Late Life Depression Education: Impact on Acute Care Nurses' Knowledge, Attitude, and Screening Practices.

Late life depression (LLD) in hospitalized older adults is associated with poor outcomes. Unfortunately, LLD is often unrecognized by health care providers because of inadequate knowledge and unfavorable attitudes. The purpose of the current study was to measure the effectiveness of LLD education on acute care nurses' knowledge, attitudes, and screening and referral practices. A one-group pre-/post-test design was used. Data were collected using the Late Life Depression Quiz, Revised Depression Attitude Questionnaire, and closed and open-ended practice questions. Forty nurses attended a 15-minute presentation on LLD and the 5-item Geriatric Depression Scale. Nurses were educated to screen adults aged ≥65 years for depression and refer those who screened positive to a social worker. There was a significant increase between pre- and posttest knowledge and attitude scores (p < 0.001). Screening increased significantly (p = 0.006) post-intervention, but no difference was noted in referrals to social workers. Findings support that a brief educational intervention increased nurses' knowledge and attitudes toward depression and depression screening in hospitalized older adults. [Journal of Gerontological Nursing, 48(12), 43-51.].

Implementing the Get SET Early Model in a Community Setting to Lower the Age of ASD Diagnosis.

The objective of this study was to implement a validated, university-based early detection program, the Get SET Early model, in a community-based setting. Get SET was developed to improve Screening, Evaluation, and Treatment referral practices. Specifically, its purpose was to lower the age of diagnosis and enable toddlers with autism spectrum disorder (ASD) to begin treatment by 36 months. One hundred nine pediatric health care providers were recruited to administer the Communication and Symbolic Behavior Scales Developmental Profile Infant-Toddler Checklist at 12-month, 18-month, and 24-month well-baby visits and referred toddlers whose scores indicated the need for a developmental evaluation. Licensed psychologists were trained to provide diagnostic evaluations to toddlers as young as 12 months. Mean age of diagnosis was compared with current population rates. In 4 years, 45,504 screens were administered at well-baby visits, and 648 children were evaluated at least 1 time. The overall median age for ASD diagnosis was 22 months, which is significantly lower than the median age reported by the CDC (57 months). For children screened at 12 months, the age of first diagnosis was significantly lower at 15 months. Of the 350 children who completed at least 1 follow-up evaluation, 323 were diagnosed with ASD or another delay, and 239 (74%) were enrolled in a treatment program. Toddlers with ASD were diagnosed nearly 3 years earlier than the most recent CDC report, which allowed children to start a treatment program by 36 months. Overall, Get SET Early was an effective strategy for improving the current approach to screening, evaluation, and treatment. Efforts to demonstrate sustainability are underway.

Primary Care Providers’ Referral Practices for Concussion Management: A Health Services Study

<h3>Research Objectives</h3> To examine primary care providers' (PCPs) referral practices for concussion specialty care for patients who have a new concussion and potential pre-injury risk factors (i.e., anxiety, depression, ADHD, migraine), across the first year after diagnosis. <h3>Design</h3> Retrospective data analysis of an electronic health record system. <h3>Setting</h3> University medical center. <h3>Participants</h3> 1761 adults who received a new diagnosis of concussion between January 1 and December 31, 2018 and remained alive during the study period. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> Concussion specialty referrals early (0 to 3 months) vs. later (4-12 months) after diagnosis. <h3>Results</h3> 448 (25.4%) patients received at least one specialty care referral by a PCP within one-year of their injury. Of those patients, most were female (64.3%), White (73.2%), non-Hispanic (85.0%), and had at least one pre-injury risk factor (53.6%). Most of these patients received between 1 and 2 (60.5%) specialty referrals. Of all referrals placed by PCPs, the most common specialty referral was to physical therapy both early (12.6%) and later (11.2%), followed by referrals to specialty medical disciplines (neurology 6.1% & 4.0%, sports medicine 3.5% & 4.1%, rehabilitation medicine 4.7% & 1.4%). <h3>Conclusions</h3> To our knowledge, this is the first health services study to examine PCPs' referral practices for concussion management. In this sample PCPs did not commonly refer to concussion specialists despite the high prevalence of pre-injury risk factors associated with protracted recovery. When they did, PCPs most often referred to physical therapy. Referrals are inconsistent with known symptom profiles following concussion with few referrals for cognitive and behavioral management of symptoms. <h3>Author(s) Disclosures</h3> The authors do not have any disclosures.

Why the Individual Provider Approach to Pediatric Palliative Care Consultation Exacerbates Healthcare Disparities: A Moral Argument for Standard Referral Criteria

Pediatric palliative care is specialized medical care for children who live with serious and life-limiting illnesses, with the central goal to improve quality of life for both children and their families. Presently, a majority of pediatric palliative care referrals are based on the traditional consultative model, in which primary providers serve as the gatekeepers to palliative care access. It is well-known that racial and ethnic healthcare disparities exist across the continuum of care, fraught with healthcare providers' biases that impact the care delivered. This includes the referral practices, allocation and utilization of palliative care services, and leaving vulnerable children and families with potentially unmet palliative care needs. We make the moral argument that the establishment of standard referral criteria for pediatric palliative care services is one simple step that must be taken to begin to address and hopefully ameliorate the impact of providers' biases and disparities that exist within pediatric palliative care.

A love of Lego and curiosity about fixing things led to a cracking career

Fascinated by how things worked and mending anything broken, Matthew Hibberd naturally gravitated to a career in orthopaedics, now owning peripatetic referral practice Rata Vet Surgery.

Translating pediatric primary care best practice guidelines for addressing tobacco in the WIC system.

Tobacco smoke exposure (TSE) adversely affects child health. Intervention research on reducing childhood TSE and uptake of evidence-based smoking cessation programs has had limited reach in high-risk communities. Intervening in clinics delivering the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) could address overlapping public health priorities essential for healthy child development-nutrition and smoke-free environments. The Babies Living Safe and Smokefree (BLiSS) trial addresses existing gaps by implementing and evaluating a WIC in-clinic evidence-based training based on Ask, Advise, and Refer (AAR) guidelines. WIC nutrition staff (n = 67) completed surveys pre- and post-training as part of the larger BLiSS trial. Staff sociodemographic data, knowledge, and attitudes about maternal smoking and child TSE prevention, and AAR practices in clinic were collected using self-administered surveys. Pre-post outcomes were assessed using bivariate statistics and multiple regression models. Controlling for baseline AAR-related practices and other covariates, nutrition managers were more likely to engage in post-training AAR practices than nutrition assistants. Sociodemographics and smoking status were not related to post-training AAR. Lower perceived barriers and higher reported frequency of tobacco intervention practices at baseline were associated with higher engagement in post-test AAR practices. WIC-system interventions aimed at reducing child TSE and maternal tobacco smoking may be more effective if nutrition management-level staff are involved in assessment and by addressing barriers related to TSE among nutrition assistants. Findings suggest that WIC in-clinic training may help to increase self-efficacy for staff engagement in brief screening, intervention, and referral practices.

Real-World Experience of Monitoring Practice of Endocrinopathies Associated with the Use of Novel Targeted Therapies among Patients with Solid Tumors.

Cancer treatments have gradually evolved into targeted molecular therapies characterized by a unique mechanism of action instead of non-specific cytotoxic chemotherapies. However, they have unique safety concerns. For instance, endocrinopathies, which are defined as unfavorable metabolic alterations including thyroid disorders, hyperglycemia, dyslipidemia, and adrenal insufficiency necessitate additional monitoring. The aim of this study was to assess the prevalence of monitoring errors and develop strategies for monitoring cancer patients who receive targeted therapies. A retrospective chart review was used to assess the prevalence of monitoring errors of endocrinopathies among cancer patients who received targeted therapies over one year. All of the adult cancer patients diagnosed with a solid tumor who received targeted therapies were included. The primary outcome was to determine the prevalence of monitoring errors of endocrinopathies. The secondary outcomes were to assess the incidences of endocrinopathies and referral practice to endocrinology services. A total of 128 adult patients with solid tumors were involved. The primary outcome revealed a total of 148 monitoring errors of endocrinopathies. Monitoring errors of the lipid profile and thyroid functions were the most common error types in 94% and 92.6% of the patients treated with novel targeted therapies, respectively. Subsequently, 57% of the monitoring errors in the blood glucose measures were identified. Targeted therapies caused 63 events of endocrinopathies, hyperglycemia in 32% of the patients, thyroid disorders in 15.6% of them and dyslipidemia in 1.5% of the patients. Our study showed a high prevalence of monitoring errors among the cancer patients who received targeted therapies which led to endocrinopathies. It emphasizes the importance of adhering to monitoring strategies and following up on the appropriate referral process.

Revisiting microsurgical principles for the minimally invasive surgeon

To demonstrate basic microsurgical techniques and revisit the importance of following microsurgical principles in minimally invasive surgery. Video demonstration of various surgical cases portraying proper microsurgical techniques as well as the consequences of deviating from these principles. Tertiary referral practice. Reproductive-aged women with a desire to preserve reproductive organs and fertility potential. We present surgical cases demonstrating the management of tubal and paratubal pathologies in which extra care must be taken to avoid inadvertent injuries of normal anatomic structures. We also portray the proper management of ovarian dermoid cysts and endometriomas to maximize the preservation of ovarian reserve and minimize complications. We have stressed the importance of ensuring safe tissue containment and extraction to avoid complications such as port site metastasis along with parasitic and iatrogenic myomas. Implementation of microsurgical techniques including delicate tissue handling, judicious use of energy sources, and proper tissue containment and extraction. Nonadherence to microsurgical principles can result in detrimental surgical outcomes, including adhesions, parasitic myomas, port site metastasis, peritonitis, and compromised ovarian reserve. Microsurgical principles are of paramount importance to improve patient outcomes in reproductive surgeries. These tenets should be uniformly applied in all surgical procedures. As surgeons who perform minimally invasive surgeries, we must revisit these principles and advocate for their training and universal implementation.

P049Characterizing physician concerns with publicly supporting abortion

<h3>Objectives</h3> To examine factors associated with physicians' level of concern with, and perceived consequences of, publicly supporting abortion. <h3>Methods</h3> We surveyed physicians at Wisconsin's largest medical school about their knowledge, attitudes, and referral practices regarding abortion care from February to May 2019. Three survey items gauged participant level of concern that taking a strong public stance on abortion would result in: 1) alienating patients; 2) alienating coworkers; and 3) harassment or harm from protestors who held opposing views. Among those who expressed support for abortion (n=701), we analyzed sample characteristics and perceived concerns about publicly supporting abortion. <h3>Results</h3> Nearly one-quarter (22%) of respondents felt very or extremely concerned that taking a strong public stance on abortion would alienate patients, and 17% felt very or extremely concerned that doing so would alienate coworkers. More than one-quarter (27%) felt very or extremely concerned that publicly supporting abortion would lead to harassment or harm — including approximately one-third of radiologists (33%), anesthesiologists (36%), and obstetrician gynecologists (31%), and nearly half (46%) of emergency medicine physicians. Those with greater concerns about expressing public support for abortion were comparatively less willing to refer for or participate in abortion care themselves. <h3>Conclusions</h3> Many physicians who support abortion reported worries over publicizing their support for this common healthcare service. These concerns may render physicians less likely to refer patients for abortion care or weigh in on abortion policy, as well as undermine physicians' potential to be powerful and effective advocates against abortion stigma and other barriers to abortion access.

Evaluation of distress management in inpatients with cancer by means of the distress thermometer: A mixed methods approach.

To improve psychosocial care for oncology inpatients, we implemented screening for distress by means of distress thermometer (DT) at the Comprehensive Cancer Centre Zurich in 2011. Since then, several screening barriers have been reported regarding the application of the DT. This study aimed to evaluate the distress screening process between 2012 and 2016 to identify barriers preventing sustainability. In this sequential explanatory mixed methods study, we synthesized the results of 2 quantitative retrospective descriptive studies and 1 qualitative focus group study. To compare and analyze the data, we used thematic triangulation. Nurses screened 32% (N=7034) of all newly admitted inpatients with the DT, and 47% of the screenings showed a distress level ≥5. Of these cases, 9.7% were referred to psycho-oncological services and 44.7% to social services. In 15.7% of these cases, nurses generated a psychosocial nursing diagnosis. In focus group interviews, nurses attributed the low screening rate to the following barriers: adaptation to patients' individual needs, patient-related barriers and resistance, timing, communication challenges, established referral practice, and lack of integration in the nursing process. To improve distress screening performance, the screening process should be tailored to patients' needs and to nurses' working conditions (e.g., timing, knowledge, and setting-specific factors). To gain more evidence on distress management as a basis for practical improvements, further evaluations of distress screening are required.

Evaluation of 13,466 Fecal Immunochemical Tests in Patients Attending Primary Care for High- and Low-Risk Gastrointestinal Symptoms of Colorectal Cancer.

Quantitative fecal immunochemical tests (FIT) were recommended by NICE for patients in primary care presenting with low-risk symptoms of colorectal cancer (CRC). FIT is more accurate in the detection of CRC than symptom criteria. Despite this, CRC still occurs with a negative FIT and the importance of safety netting for patients with severe or persistent symptoms is paramount. We aimed to evaluate the utilization and accuracy of FIT for CRC in low and high-risk symptom groups presenting to primary care, the effectiveness of safety netting in primary care, referral practices with FIT utilization for symptomatic patients and the clinical features of FIT negative patients with CRC. Medical records and databases of all patients undertaking a FIT sample in the Herts Valleys CCG between June 2019 and November 2021 were reviewed. 13,466 consecutive FIT samples were requested for 12,231 patients between June 2019 and November 2021. Analysis of diagnostic accuracy was undertaken for the first 5341 patients with a minimum of 12months follow up. Sensitivity for CRC, in FIT ≥ 4µg Hb/g, ≥ 10µg Hb/g and ≥ 100µg Hb/g was 93% (95% CI 85-98%), 91% (95% CI 82-96%) and 72% (95% CI 60-81%) with a number needed to investigate of 36, 19 and 6, respectively. A FIT ≥ 10µg Hb/g in conjunction with ongoing GP clinical concern within 8weeks had a sensitivity for CRC of 97% (95% CI 90-100%), a PPV of 3.6% (95% CI 3.4-3.7%) and a number needed to investigate to detect one CRC of 28.

Educational Intervention on Pediatricians’ Knowledge, Attitude and Practice on Child Oral Health: A Hospital Based Longitudinal Study

Background: Pediatricians provide multiple early childhood screenings and are in a privileged position to promote child oral health by enacting timely dental referrals. Our primary objective included assessing the pre- and post- educational intervention knowledge, attitude and practice of pediatricians on child oral health. The secondary objective included the assessment of prevalence of oral health problems in children attending Pediatrics out-patient department (OPD). Methods: This one-year hospital based longitudinal study involved conveniently selected 400 children (6 months to 14-years-old) from Pediatrics OPD and 12 pediatricians (complete enumeration) from a university hospital, BPKIHS, Dharan, Nepal. Screening for oral health problems in children was performed. Pre- and post-educational intervention knowledge and attitude towards child oral health of the pediatricians were assessed using a validated questionnaire. The practice component was assessed through pre- questionnaire and pre- and post-intervention dental referral paper practice. Data analysis included descriptive statistics, chi-square and paired t-tests. Results: Educational intervention significantly increased the knowledge score of the pediatricians but not their attitude (p = 0.72) or the paper dental referral practice. Oral health problems were observed in 59.3% of the children attending pediatrics OPD, dental caries being the most prevalent (49.9%). Conclusion: More than half of the children attending pediatrics OPD had oral health problems. Educational intervention was effective in improving pediatricians’ knowledge but not their attitude and the paper dental referral practice.

Pediatric and Adult Cardiologists' and Respirologists' Referral Practices to Palliative Care.

Children and adults with advanced cardiac or respiratory disease may benefit from specialized palliative care (SPC), but there has been little SPC research in this area. To explore pediatric cardiologists' and respirologists' (pediatric clinicians) beliefs about and referral practices to SPC and compare these results to adult cardiologists and respirologists (adult clinicians). Pediatric and adult clinicians were sent a survey exploring SPC referral practices and beliefs. Responses were summarized with descriptive statistics. Pediatric and adult clinicians' responses were compared using Pearson's chi-square test. The response rate was 56% (989/1759); 9% (87/989) were pediatric clinicians. Pediatric clinicians were more likely than adult clinicians to be female, work in an academic center, and experience fewer patient deaths (P<0.001). Pediatric clinicians reported better access to SPC clinical nurse specialists, spiritual care specialists and bereavement counselors (P<0.001), while adult clinicians reported better access to palliative care units (P<0.001). Pediatric clinicians referred to SPC earlier, while adult clinicians tended to refer after disease directed therapies were stopped (P<0.001). More than half of all clinicians felt patients had negative perceptions of the phrase "palliative care". Although most clinicians were satisfied with SPC quality (73-82%), fewer adult clinicians were satisfied with SPC availability (74 vs. 47%; P<0.001). Fewer pediatric clinicians felt that SPC prioritized oncology patients (13 vs. 53%; P<0.001). There are important differences between pediatric and adult clinicians' beliefs about and referral practices to SPC. This may reflect unique features of pediatric diseases, provider characteristics, care philosophies, or service availability.

An Algorithmic Approach to the Treatment of Kienböck Disease

The algorithm and rationale described is a reflection of our own surgical experience for this challenging disorder and can be compared with other publications. Our algorithm has evolved from treatment of a large volume of patients with Kienböck disease in a referral practice. However, it is limited to the management that we have found logical, effective, and within our scope of experience. The treatment guidelines for our specialty as a whole will evolve as our understanding of the etiology and our ability to quantify efficacy improves.