Referral Program Research Articles

Assessing improvements in emergency department referrals to a hospital-based violence intervention program

BackgroundYouth violence is a major public health concern in the United States. Hospital-based Violence Intervention Programs (HVIPs) are integral in connecting youth sustaining interpersonal violence-related injuries to medical, mental health, and social services. At our pediatric emergency department, our baseline referral rate to the established HVIP was 32.5%. From November 2018–2019, we aimed to increase the percent of eligible patients referred to our HVIP from 32.5 to 70% for patients aged 7–18 years who present to our Level 1 emergency department/trauma center with a violent injury.MethodsFor this quality improvement project, we recorded key aspects of the referral process, such as patient eligibility, who placed referrals, and when referrals were placed in relation to the ED admission. Key stakeholders were interviewed to identify specific interventions. Our key interventions were: 1. Educating providers on eligibility requirements. 2. Encouraging nurses to enter consults at the time of admission. 3. Publishing information about program referrals in the weekly nursing newsletter. 4. Updating social workers on eligibility requirements for the HVIP. We used PDSA cycles to inform our project. Our primary outcome measure was the number of eligible patients referred to our HVIP and measures were analyzed using statistical process control charts.ResultsThe HVIP-eligible population had the following demographics: 31.1% female and a mean age 14.3 ± 2.7, 82.6% assaults and 17.4% gunshot wounds. From 11/2018 to 11/2019, there were 78 referrals to the HVIP, out of 167 eligible patients. The referral rate improved from 32.5% pre-interventions to 61.1% post-interventions, showing an 88% increase.Conclusion(s)We noted an increase in referrals to our HVIP following our interventions that centered on educating, advertising, and encouraging. Future studies will focus on analyzing other aspects of the enrollment process, such as obtaining patient consent.

Utilization Patterns of a Clinic‐Based Food Referral Program: Findings from the Mid‐Ohio Farmacy

Research ObjectiveEvidence suggests that clinic‐based food referral programs (FRP) offer health benefits to food insecure patients, yet little attention has been paid to understanding patient utilization of such programs. Our study addresses this gap by reporting on the patient characteristics associated with uptake and utilization of a FRP—the Mid‐Ohio Farmacy (MOF). The MOF is a partnership between a Midwestern regional foodbank and local healthcare providers, including a large, academic medical center (AMC). The MOF uses a variation on food vouchers: an electronic referral from a patient's primary care provider to one of 14 partner food pantries in the metropolitan area. Referred patients who visit a participating pantry are eligible to receive fresh produce once weekly.Study DesignThis observational study leverages data from two AMC family medicine clinics offering the MOF referral from September 2019 to November 2020. Using multivariable logistic regression, we examined the association between filling a MOF referral (i.e., pantry visitor vs. non‐visitor) and patient demographic and clinical characteristics. Patients and their pantry visits were characterized based on their pre‐referral utilization (i.e., new or existing patrons; pre‐ or post‐referral pantry visit) to assess patterns of pantry utilization.Population StudiedAMC patients 18 years or older who screened positive for food insecurity and had an eligible chronic condition. Eligible conditions included a diagnosis of diabetes with hemoglobin A1c (HbA1C) >9%, obesity (BMI ≥ 30 kg/m2), or hypertension; uncontrolled diabetes defined as a HbA1C > 9% with or without a diabetes diagnosis; or uncontrolled hypertension defined as blood pressure > 140/90 with a hypertension diagnosis.Principal FindingsIn total, 51% (164/322) of patients who received a MOF referral visited a pantry at least once during the study period. Three factors were associated with an increased likelihood of filling a MOF referral: a 1‐year increase in age (0.7%; p < 0.01); diabetes diagnosis (11%; p < 0.05); and pantry visits prior to referral (36%; p < 0.001). Patients with uncontrolled hypertension were 19% (p < 0.001) less likely to visit a pantry following their referral. Relative to new visitors, existing visitors had a greater total number of visits following referral, shorter days to their first visit following referral, and travelled shorter distances. Existing visitors had more total pantry visits and more produce‐specific visits in the 90‐days following their referral relative to the 90‐days prior to their referral.ConclusionsOur results suggest that while the MOF can connect patients to food resources, further attention may be needed to encourage its use among patients who have not previously accessed pantries.Implications for Policy or PracticeChanges to the MOF program may be necessary such as adding one additional question to the food insecurity screening process (e.g., “Have you used a food pantry in the last year?”), so that potential first‐time users could be targeted for resources (e.g., transportation support such as Lyft credits or bus passes) to address barriers to pantry use. Additionally, reminding patients about the opportunity to visit the pantry, for instance through text message reminders or secure health portal messages, could help encourage patients to use this community resource.Primary Funding SourceCrisafi‐Monte Foundation.

ANALISIS DAMPAK KEBIJAKAN PROGRAM RUJUKAN ONLINE BERJENJANG BPJS TERHADAP PELAYANAN RAWAT JALAN DI POLI PENYAKIT DALAM RSUD DELI SERDANG

The era of National Health Security (NHS) enacted tiered referral system start in first level health services, then the hospital type D, type C, type B and type A. Community complaints and a significant decrease in the number of patients in type B hospital especially in outpatient services, the occurrence of patient accumulation and long queues in hospital type C, this indicates that the implementation of this tiered referral system policy program has not run well. The purpose of this study was to look at the impact of the implementation of this tiered referral program policy on outpatient care in poly Internal medicine at the Regional General hospital Deli Serdang Lubuk Pakam. This research is a qualitative research with a prosfective case study approach and uses a fixed case design. This study triangulation to obtain in-depth information on document from SIMRS data, in-depth interviews, Focus Group Discussion (FGD), direct observation in the field without intervention. This reseach was carried out at the Regional General Hospital Deli Serdang Lubuk Pakam , start from January until April 2019. The result of the study show that the implementation of the program has been carried out in accordance with the regulation of Director of Health Service No. 4 of 2014 regarding the referral system for health services carried out in stages. But there were several impacts from the implemention of the program, namely there was a decrease in the number of patient visits, patients cannot get the doctor’s service they want, patients service time is long because the patient must go through several referral procedur first. Recommendation for BPJS as The National Health Insurance Organizing Body to evaluate and improve existing regulations. If it is necessary to make new regulations so that people do not feel like they are being complicated to get services. Recommendation for the hospital to provide better facilities, both facilities and infrastructure, more competent medical personnel and paramedics.

The Evolving Role of Instagram in General Surgery Residency Programs and Keys to Successful Use in Yours: Input from an Academic, Tertiary Referral Program

Social media has been used as a resource for the dissemination of information in the medical profession. To date, information regarding Instagram use amongst general surgery residency programs is lacking. Our study seeks to detail the use of Instagram amongst general surgery residency programs and to provide suggestions for the practical and successful use of Instagram by general surgery residency programs. We performed a cross-sectional search of general surgery residency program Instagram accounts through June 30, 2020. Descriptive details, the pattern of Instagram use by general surgery residency programs, and the use of Instagram by general surgery residency programs over time were investigated. Ninety-six (29.1%) of the 330 Accreditation Council for Graduate Medical Education (ACGME) general surgery residency programs were identified on Instagram, of which 86 (89.6%) accounts had at least one post. Academic programs (N = 67; 77.9%) were the most common type of program to have an Instagram account (N = 67). The most popular category of posts was promotion of the residents and faculty. In terms of Instagram activity, nearly 20% of Instagram posts were made in the last three-month block of our study period. Using Pearson correlations, positive associations were found between the number of posts and number of followers (0.62, p < 0.0001), the number of posts and the number of likes (0.42, p < 0.0001) and the number of followers and the number of likes (0.78, p < 0.0001). None of these variables were significantly associated with region or program type. To our knowledge, this is the first description of the use of Instagram by general surgery residency programs. Based on the pattern of use of Instagram by general surgery residency programs, we believe that there are five key elements to the successful use of Instagram by general surgery residency programs, including: Interact, Name, Promote, Utilize, and Team (INPUT).

Moral Injury.

Moral Injury.

How to Effectively Design Referral Rewards to Increase the Referral Likelihood for Green Products

Interpersonal referrals can effectively promote purchases. In view of the low sales of green products, this study introduces the referral reward program into green marketing and investigates the impact of reward type on customers’ referral likelihood for green product. Through a lab experiment with 302 participants in China involved, this study reveals the differential effects of monetary versus donation rewards on existing customers’ referral likelihood. Specifically, compared with monetary rewards, donation rewards are more effective in promoting recommendations. It is also indicated that the perceived fit between the reward and green products partially mediates the relationship between the reward type and referral likelihood. In addition, the relationship between the reward type and perceived fit is moderated by consumers’ green product knowledge. This research not only extends the literature on green marketing and referral reward programs, but also provides feasible suggestions for government and enterprises to promote green products and to improve social wellbeing.

Nurse Navigators' Views on Patient and System Factors Associated with Navigation Needs among Women with Breast Cancer.

Coordinating breast cancer treatment is a complex task that can overwhelm patients and their support networks. Though the Cancer Patient Navigator (CPN) program in Nova Scotia (NS) provides professional assistance to patients, certain groups of patients may still face barriers to accessing its services. Employing interviews and a modified Delphi approach with CPN participants, this study sought to identify factors associated with the need for navigation to help better target CPN program referrals among breast cancer patients. Six CPNs were recruited directly through the CPN program manager for interviews and surveys. The CPNs identified 27 different factors, which were divided into 4 categories: sociodemographic, psychological, clinical and health systems. While these patient factors (particularly sociodemographic) are not directly modifiable, awareness of their association with the need for navigation could be used to better target patients with a high need for navigation for referral to CPN services.

Oral health clinical training and dental referral program for nurses: An interprofessional collaborative project

IntroductionThe overall objective of this study was to establish an interprofessional oral health training program for nursing personnel at Oregon Health & Science University. MethodsFifteen registered nurses participated in didactic and clinical training and screened the oral health of patients. Nurses completed confidence assessments and patients completed satisfaction surveys. Data analysis included descriptive statistics and non-parametric tests for comparisons of mean scores. ResultsPre- and post-training surveys demonstrated significant increases in nurses’ knowledge, confidence in discussing dental problems, performing dental screenings, and referring patients to dentists (p < 0.05). Patient satisfaction surveys (n = 89) denoted satisfaction with oral screenings and willingness for nurses to perform them. ConclusionsNurses participating in oral health and clinical screening training programs supervised by dentists significantly increased their confidence in providing dental referrals. Longitudinal studies are needed to determine the impact of such training programs on patient health.

Sex-based differences in program completion and clinical outcomes in patients following outpatient cardiac rehabilitation

Abstract Funding Acknowledgements Type of funding sources: None. Background Females have greater reduction in mortality compared to males, following completion of a cardiac rehabilitation (CR) program, yet they continue to have lower referral rates and program completion. Since 1996, a local rehabilitation program has been the main provider of CR in our health zone. A standardized rapid referral program was implemented in 2008 to improve referral rates of hospitalized patients. Since then, the relationship between sex and CR completion is unknown. Purpose To evaluate the relationship between sex and CR completion and to evaluate the association between CR completion and clinical outcomes, stratified by sex. Methods: We included consecutive patients who were referred to CR and who 1) were hospitalized for an acute coronary syndrome (ACS) or stable angina between 2008 and 2016; 2) had angiographic evidence of at least one-vessel coronary disease; and 3) had revascularization with percutaneous intervention, coronary artery bypass or medical management. The outcomes of interest were CR completion, anxiety and depression categories, exercise capacity, death, and need for revascularization. Logistics regression models were used to determine the association between sex and CR completion. The association between sex, CR completion, and the outcomes of interest were assessed using multivariable cox proportional hazards models. Results A total of 726 females and 2645 males were included in this study. The rate of CR completion was lower in females compared to males (64.6% vs 69.98%, p = 0.006). Following adjustment for baseline characteristics, female sex independently predicted lower rates of CR completion, OR 0.81 (95%CI 0.67-0.97). Both sexes displayed improvements in peak metabolic equivalents (METs) achieved during exercise testing (W: initial 5.99 ± 1.93; 12-week 7.22 ± 1.92; M: initial 7.62 ± 2.04; 12-week 8.81 ± 1.93, p = 0.001). Amongst CR completers, one-year mortality was similar between sex (W: 1.84% vs M: 3.27%, p = 0.118), as was revascularization (W: 14.29% vs M: 11.97%, p = 0.193), however both sexes had higher one-year mortality in CR non-completers. Conclusion Despite a standardized CR referral protocol, a sex-difference in CR completion remains. In CR completers, one-year mortality and revascularization was similar in both sexes, however mortality was higher in CR non-completers. Our study suggests that addressing the causes of female CR non-completion following ACS or stable angina may improve outcomes. Outcomes by CR Completion and Sex All NC (n = 1051) W-NC (n = 257) M-NC (n = 794) p-value All C (n = 2320) W-C (n = 469) M-C (n = 1851) p-value Revascularization-1 year (%) 146 (14.94) 28 (11.72) 118 (15.59) 0.107 267 (12.44) 62 (14.29) 205 (11.97) 0.193 Death-1 year (%) 67 (6.86) 19 (7.95) 48 (6.50) 0.442 64 (2.98) 8 (1.84) 56 (3.27) 0.118 W = Women;M = Men;NC = Non-Completers;C = Completers

Screening for Diabetes-Related Distress in an Outpatient Endocrine Clinic

Background: Identification and treatment of diabetes-related distress (DD) are essential for diabetes management, quality of life, and reducing health care costs for people with diabetes. There is no standardized workflow for DD screening in an outpatient endocrine clinic that manages approximately 2000 persons with diabetes. Aim: This quality improvement (QI) project aims to implement a DD screening and referral program in an outpatient endocrine clinic. Methods: The Mobilize, Assess, Plan, Implement, Track (MAP-IT) model was used to design the QI project. Patients without a diagnosis of diabetes, age less than 18 years, and pregnant women were excluded from the screening. DD was measured using the Problem Areas in Diabetes-5 (PAID-5) scale (0 - 20) points (1). An ambulatory systems analyst created a flowsheet in Epic for the PAID-5 questionnaire and routed the PAID-5 to MyChart. During the implementation phase, patients completed the PAID-5 on MyChart one week before their appointment or in-person during the encounter. Providers referred patients with a PAID-5 score ≥ 8 to a mental health provider (MHP). The primary outcomes were PAID-5 screening compliance and mental health referral compliance. Secondary outcomes include PAID-5 scores and hemoglobin A1C value percentage; changes in the PAID-5 scores and A1C values were compared pre- and post-intervention. Results: The project was implemented on August 31st, 2020. As of October 29th, 2020, the PAID-5 screening compliance was 66% (n = 385/585). The patient sample was 57% female and 43% male. It was identified that 113 (29%) patients had a PAID-5 score ≥ 8. Of these, only 33 (29%) patients received a referral to a MHP. Thirty-three patients (29%) refused a referral, and 5% were already seeing a MHP. Pre-intervention, the average PAID-5 score was 5, and the average baseline A1C value was 8% (< 5.7%). Conclusion: Based on the preliminary data, screening for DD in adults with diabetes utilizing the PAID-5 questionnaire is feasible and can facilitate the referral of distressed patients to mental health providers. Long-term implications for the practice change include a holistic and comprehensive approach to the management of diabetes and diabetes-related outcomes, including reduction of PAID-5 scores and A1C values in individuals referred to a MHP.

The point of diminishing returns in juvenile probation: Probation requirements and risk of technical probation violations among first-time probation-involved youth.

Technical probation violations are common among probation-involved youth, and across many jurisdictions, may result in detention or residential placement. The current study examined prevalence of technical violations occurring during one's first probation period, the average time to technical violation, and individual-level and justice-related factors related to technical violations among probation-involved youth in a juvenile justice system. We analyzed electronic criminal records of 18,289 probation-involved youth following their first arrest (68.7% male, 53.9% Black, Mage=15.2). Technical violation was defined as a violation resulting from a non-criminal incident. We examined effects of charge severity, probation conditions (e.g., electronic monitoring) and program referrals (e.g., mental health) on likelihood of technical violation utilizing survival analysis stratified by race. Across 18,289 youth, 15.3% received a technical violation during their first probation; Black youth violated more quickly compared to White youth (log-rank test p<.001). In multivariate survival analyses, the hazard for time to technical violation was higher for Black youth compared to white youth (p<.001), males (p=.04), and younger youth (p<.001). Youth assigned to more probation requirements violated more quickly. Electronic monitoring and education, mental health, and drug programs were associated with shorter time to violation, controlling for race, ethnicity, and charge severity. Black youth violate more quickly compared to White youth. Across all youth, assignment to more probation requirements increased risk of technical violation and shorter time to violation. Despite the benefit of probation interventions, system-level efforts are needed to help youth adhere to probation requirements and successfully complete probation.

Application of extracorporeal membrane oxygenation regional treatment pattern in patients with severe cardiopulmonary diseases

To assess the application of extracorporeal membrane oxygenation (ECMO) regional treatment pattern in patients with severe cardiopulmonary diseases. A retrospective analysis was conducted. Patients with severe cardiopulmonary disease who were transferred to Henan Provincial People's Hospital after ECMO treatment in cooperative hospitals were selected. The patients who received regular ECMO treatment from June 2017 to May 2018 were enrolled as the control group, and the patients who received ECMO regional treatment from June 2018 to May 2019 were selected as the observation group. The ECMO regional treatment pattern referred to implement a referral program for critical patients in primary hospitals, which mainly included the establishment of ECMO regional cooperative treatment network and ECMO referral team, the formulation of ECMO referral management standards, and the promotion of the merging of high-quality medical resources. Time of establishment of ECMO, ECMO regional treatment satisfaction, and the incidence of adverse events were also compared. There were 27 patients enrolled in the control group and 64 patients in the observation group. There were no significant differences in gender, age, body mass index (BMI), ECMO mode, hypertension or coronary heart disease history between the two groups. Compared with the control group, the time for establishment of ECMO in the observation group was significantly shorter (minutes: 38.10±17.19 vs. 54.67±41.30, t = 2.715, P = 0.008), the ECMO treatment satisfaction of the observation group was also significantly higher than that of the control group (98.4% vs. 88.9%, χ2 = 4.120, P = 0.042), and the incidence of ECMO referral adverse events was significantly lower than that of the control group (6.25% vs. 25.93%, χ2 = 6.918, P = 0.009). The ECMO regional collaborative pattern in patients with severe cardiopulmonary diseases can shorten the time for establishment of ECMO, improve the satisfaction of ECMO treatment, and reduce the incidence of adverse events in ECMO referral.

Examining the feasibility and characteristics of realistic weight management support for patients: Focus groups with rural, micropolitan, and metropolitan primary care providers.

The purpose of this investigation was to understand perspectives of physicians, nurses, and staff regarding the feasibility of implementing an evidence-based weight management program to support primary care practice. An exploratory aim was to examine differences in responses based on the clinic location. Ten focus groups were conducted with primary care staff from rural, micropolitan, and metropolitan clinics. The Promoting Action on Research in Health Services (PARIHS) framework was used to inform the interview guide. Transcripts were reviewed to identify common themes among PARIHS constructs (evidence, context, and facilitation). Presence of comorbidities (e.g., diabetes, hypertension) were typical prompts for provider-led discussions about patient weight. Metropolitan clinics reported the availability of health coaching, diabetes education, or dietician consultation, but no clinic reported offering a comprehensive weight management program. Participants agreed it is possible to implement a weight management program through primary care, but cited potential facilitation challenges such as costs, clinic resources, and individual patient barriers. More enthusiasm arose for a referral program with patient tracking. Program characteristics such as proven efficacy, individual tailoring, program accessibility, and patient feedback to the providers were desired. Rural focus group participants reported unique barriers (lack of local resources) and facilitators (more flexibility in practice changes) to weight management when compared to metropolitan and micropolitan focus groups. Primary care staff are interested in weight management solutions for their patients and would prefer an evidence-based program to which they could refer patients, receive feedback on patient progress, and sustainably include as part of their regular services.

The intersection of sociopolitical trends and Aging Network training: an analysis of national conference proceedings

ABSTRACT The Aging Network provides services to over 11 million older adults and their caregivers annually. Three national conferences (AIRS, n4a, and NASUAD) support the diffusion of critical information to members of the Aging Network. This study employed a content analysis of these national conferences held between 2009 and 2018. An a priori coding scheme including major codes and subcodes utilized in an earlier study was modified for use in the current study. Reflexivity, triangulation, and audits were utilized to maximize the trustworthiness of results. Across the 2,395 sessions, the most frequent major codes included planning and program development, housing, Medicaid, information and referral (I&R), and service-specific sessions. The most frequent subcodes included planning and program development, Medicaid waiver, general policy, long-term services and supports reform and systems change, and data and database use. The greatest changes between studies concerned planning and program development, I&R, population-specific sessions, consumer-directed support, service-specific sessions, and government-related sessions. Results provide insight into practice and service innovation designed to meet the needs of millions of older adults and caregivers.

Checklists Improve Team Performance During Simulated Extracorporeal Membrane Oxygenation Emergencies: A Randomized Trial.

Randomized simulation-based trial. A quaternary-care academic hospital with a regional extracorporeal membrane oxygenation referral program. Extracorporeal membrane oxygenation specialists and other healthcare providers. We designed six read-do checklists for use during extracorporeal membrane oxygenation emergencies using a modified Delphi process. Teams of two to three providers were randomized to receive the checklists or not. All teams then completed four simulated extracorporeal membrane oxygenation emergencies. Simulation sessions were video-recorded, and the number of critical tasks performed and time-to-completion were compared between groups. A survey instrument was administered before and after simulations to assess participants' attitudes toward the simulations and checklists. We recruited 36 subjects from a single institution, randomly assigned to 15 groups. The groups with checklists completed more critical tasks than participants in the control groups (90% vs 75%; p < 0.001). The groups with checklists performed a higher proportion of both nontechnical tasks (71% vs 44%; p < 0.001) and extracorporeal membrane oxygenation-specific technical tasks (94% vs 86%; p < 0.001). Both groups reported an increase in reported self-efficacy after the simulations (p = 0.003). After adjusting for multiple comparisons, none of the time-to-completion measures achieved statistical significance. The use of checklists resulted in better team performance during simulated extracorporeal membrane oxygenation emergencies. As extracorporeal membrane oxygenation use continues to expand, checklists may be an attractive low-cost intervention for centers looking to reduce errors and improve response to crisis situations.

Mindfulness-Based Stress Reduction Interventions for Mood in Older Adults: How Do Qualitative Experiences Inform Clinical Response?

Older adulthood presents unique challenges to mental health. We explored how a mindfulness training intervention adapted for older adults addressed these challenges, contributing to a qualitative profile of mindfulness pedagogy for older adults. Mindfulness-based stress reduction (MBSR) was adapted for a geriatric community sample with elevated depressive symptoms. Intervention effects were examined through a combination of scale-based assessment and qualitative interviews. Scales measured depressive symptoms, cognitive function, quality of life, and mindful attitudes. Interviews assessed stressors, goals, perceived obstacles, outcomes, and practice habits. A grounded-theory approach was used to identify responses in each category. Multiple regression analyses were used to identify qualitative responses that best predicted symptom reduction. The program was well-tolerated, positively endorsed, and associated with reduced depressive symptoms. Qualitatively, participants who identified family and mood as their primary stressors benefitted the most from course participation. A focus on present moment awareness was associated with decreased depressive symptoms, whereas a focus on hedonics, i.e., “feeling good,” was associated with poorer treatment outcomes. Participants maintained strong future practice intentions and preferred guided meditations to self-directed practice. The adapted MBSR program was well-tolerated and efficacious in a geriatric community sample. Efficacy may be improved by emphasizing skill development outcomes rather than achievement of positive feeling states, and by prioritizing program referrals for coping with socioemotional rather than environmental stressors. Future research could extend this mixed-methods approach to deepen our understanding of the relationship between participants’ lived experiences and clinical outcomes.

Experiences and perceptions of referrals to a community-based physical activity program for cancer survivors: a qualitative exploration

BackgroundPhysical activity rates in cancer survivors continue to be low despite the known benefits and availability of evidence-based programs. LIVESTRONG at the Y is a national community-based physical activity program offered cost-free to cancer survivors, though is underutilized. We explored perceptions and experiences of staff and participating survivors to better understand program awareness, referrals and participation.MethodsLIVESTRONG at the Y program staff [directors (n = 16), instructors (n = 4)] and survivors (n = 8) from 8 United States YMCAs took part in 30-min semi-structured phone interviews between March–May 2019. Interviews were digitally recorded, transcribed, and evaluated using a thematic analysis approach.ResultsProgram staff themes included: 1) Program awareness should be further developed for both the general public and medical providers; 2) Strong relationships with medical providers increased program referrals; 3) Electronic referral systems between providers and LIVESTRONG would help to streamline the referral process; and 4) Bi-directional communication between program staff and medical providers is key to providing patient progress updates. Survivor themes included: 1) Survivors trust their medical team and the information they provide about physical activity; 2) Providers need to incorporate an action plan and referrals for survivors to be active once treatments are completed; and 3) Personal experiences of those who participated in LIVESTRONG resonate with survivors and increase participation.ConclusionsLIVESTRONG staff reported the need for an integrated electronic referral system and bi-directional communication with providers about participant progress. Survivors want physical activity education, electronic referrals and follow-up from their healthcare team, coupled with peer support from other survivors. Cancer care provider knowledge and electronic referrals during and after treatment may expedite and increase participation in this community-based program.

Disparities in access to palliative care facilities for patients with and without cancer: A retrospective review

Background: To date, little is known about the characteristics of patients who are admitted to a palliative care bed for end-of-life care. Previous data suggest that there are disparities in access to palliative care services based on age, sex, diagnosis, and socioeconomic status, but it is unclear whether these differences impact access to a palliative care bed. Aim: To better identify patient factors associated with the likelihood/rate of admission to a palliative care bed. Design: A retrospective chart review of all initiated palliative care bed applications through an electronic referral program was conducted over a 24-month period. Setting/participants: Patients who apply and are admitted to a palliative care bed in a Canadian metropolitan city. Results: A total of 2743 patients made a total of 5202 bed applications to 9 hospice/palliative care units in 2015–2016. Referred and admitted cancer patients were younger, male, and more functional than compared to non-cancer patients (all p < 0.001). Referred and admitted patients without cancer were more advanced in their illness trajectory, with an anticipated prognosis <1 month and Palliative Performance Status of 10%–20% (all p < 0.001). On multivariate analysis, a diagnosis of cancer and a prognosis of <3 months were associated with increased likelihood and/or rate of admission to a bed, whereas the presence of care needs, a longer prognosis and a PPS of 30%–40% were associated with decreased rates and/or likelihood of admission. Conclusion: Patients without cancer have reduced access to palliative care facilities at end-of-life compared to patients with cancer; at the time of their application and admission, they are “sicker” with very low performance status and poorer prognoses. Further studies investigating disease-specific clinical variables and support requirements may provide more insights into these observed disparities.

Patient and paramedic experiences with a direct electronic referral programme for focused hypoglycaemia education following paramedic service assist‐requiring hypoglycaemia in London and Middlesex County, Ontario, Canada

Hypoglycaemia is a common treatment consequence in diabetes mellitus. Prior studies have shown that a large proportion of people with paramedic assist-requiring hypoglycaemia prefer not to be transported to hospital. Thus, these episodes are "invisible" to their usual diabetes care providers. A direct electronic referral programme where paramedics sent referrals focused hypoglycaemia education at the time of paramedic assessment was implemented in our region for 18months; however, referral programme uptake was low. In this study, we examined patient and paramedic experiences with a direct electronic referral programme for hypoglycaemia education postparamedic assist-requiring hypoglycaemia, including barriers to programme referral and education attendance. We surveyed paramedics and conducted semistructured telephone interviews of patients with paramedic-assisted hypoglycaemia who consented to the referral programme and were scheduled for an education session in London and Middlesex County, Canada. Paramedics and patient participants felt that the direct referral programme was beneficial. A third of paramedics who responded to our survey used the referral programme for each encounter where they treated patients for hypoglycaemia. Patients felt very positive about the referral programme and their paramedic encounter; however, they described embarrassment, guilt and prior negative experience as key barriers to attending education. Paramedics and patients felt that direct referral for focused hypoglycaemia education postparamedic assist-requiring hypoglycaemia was an excellent strategy. Despite this, referral programme participation was low and thus there remain ongoing barriers to implementation and attendance. Future iterations should consider how best to meet patient needs through innovative delivery methods.

Postoperative Opioid Pain Medication Usage Following Adult Tonsillectomy.

The purpose of this study was to determine if short-term, high-quantity opioid use following adult tonsillectomy in active duty military members results in opioid misuse, using a proxy measure of referrals to substance abuse rehabilitation programs. An Institutional Review Board-approved retrospective chart review was performed of 741 active duty patients who underwent tonsillectomy between 2012 and 2017. Data collection included preoperative medications within 60 days of surgery, all postoperative opioid prescriptions up to 12 months following surgery, and referrals to substance abuse rehabilitation within a year of surgery. Out of 741 patients, 658 met inclusion criteria. Fifty-one percent were women and the average age was 26 years. Fifty-nine percent of patients received 5 mg/325 mg oxycodone/acetaminophen as their initial postoperative pain medication. The average number of opioid tablets prescribed was 70 ± 18. Ninety three percent of patients received at least 60 tabs. The refill rate within 30 days of tonsillectomy was 38.6%. In the year following surgery, 25.4% of patients received additional doses of outpatient opioids for other indications. Nineteen patients (2.9%) were referred for substance abuse treatment within 1 year of tonsillectomy: seventeen for alcohol abuse, one for marijuana, and one for alcohol/marijuana. There were no referrals for opiate misuse or abuse. Short-term, high-quantity opioid treatment of post-tonsillectomy pain in active duty adults does not result in long-term opioid misuse, as measured by substance abuse treatment program referrals within a year after surgery. This finding supports the appropriateness of adequate short-term narcotic medication treatment. The long-term readiness of these patients appears unaffected by long-term opioid misuse or abuse. Even with this finding, there is an institutional shift to multi-modality pain management and appropriate opioid reduction to further mitigate the risk of opioid misuse. Extrapolation of these findings to all adult tonsillectomy patients should be done with caution, as there are several protective factors in the active duty population such as stable full-time employment with mandatory random drug screening.