Type Of Referral Research Articles

The Fragmentation of Specialty Care. The Role of Referral Location, Type of Referral, and Demographic Factors in Determining Completion Rates for Uninsured Patients in a Student-Run Free Clinic.

Little is known about how location of specialty care affects accessibility for uninsured patients at free clinics. To address this gap, the specialty referral completion rate by location and role of demographic and referral-specific factors were analyzed at an urban-based free clinic. A retrospective review was performed at a single site, student-run free clinic exclusively serving uninsured patients. Referral completion rate and predictors of referral completion were examined including age, race, ethnicity, sex, referral type, and location of referral. Significant predictors (p < 0.05) were included in the adjusted model if the associated odds ratio (OR) was meaningful. A total of 351 referrals met criteria. Completion rate was 53.6%. Co-location of specialty services was associated with a higher completion rate (64.7%, p < 0.001) and counseling referral type had a lower completion rate (11.5%, p < 0.001). Significant predictors of referral completion included sex, ethnicity, location of referral, and referral type (p < 0.001). Hispanic patients had higher rates of completion (68.4%, p < 0.001). On multivariable analysis, non-co-located fee-for-service hospital referrals had lower odds of completion when compared to co-located referrals at the free clinic (OR = 0.25, CI 95% [0.12-0.54], p < 0.001). Also, when compared to other types of referrals, counseling referrals had a 25 times lower odds of referral completion (p < 0.001). There was a higher completion rate of co-located referrals suggesting that multiple locations and health systems may deter patients from seeking necessary care. The lower rate of counseling referral completion indicates that additional efforts are needed to make these services more accessible to uninsured patients.

The cancer diagnostic clinic: A rapid access clinic to improve outcomes for patients with a suspected cancer diagnosis.

77 Background: Patients with suspected cancer often face challenges navigating complex health systems, resulting in delays in diagnosis and time to treatment, which are associated with adverse outcomes and patient dissatisfaction. To improve patient access and bridge this healthcare gap, the Cancer Diagnostic (CDx) clinic was established to streamline the evaluation for patients with a new suspected cancer. The CDx clinic prioritizes expedited cancer evaluation, timely and accurate diagnostic testing, and transition of care to subspecialty Oncologists, to improve the patient experience and cancer-related outcomes. Methods: Leaders in the Abramson Cancer Center (ACC) initiated a pilot project to facilitate timely appointments to Oncologists for patients in the Emergency Department with a new suspected cancer. Patient access lead time and time to diagnosis and treatment were tracked. This pilot was formally expanded across the health system to become the CDx clinic for eligible adult patients with suspicious symptoms, lab abnormalities, or imaging findings concerning for cancer. Patient data was extracted using an EMR-based form and supplemented by chart review. Study period was March 2023 to April 2024 and included socio-demographics, cancer subtype, referral type, time from referral to new patient appointment (access lead time), time from first appointment to diagnosis and treatment (surgery, systemic or radiation therapy), patient retention, complications, and mortality. Results: Over 12 months, 108 patients were evaluated in the CDx clinic. Most patients were male (56%), White (58%), and non-residents of Philadelphia County (65%). There were 8 referrals (range: 6-13) per month with the majority of patients from external referrals (60.2%). Compared to baseline, CDx resulted (median pre/post in days) in similar time to first appointment (7 vs. 7 days), improved time to diagnosis (21 vs. 8 days), and improved time to treatment (42 vs. 29.5 days). 71 patients were diagnosed with cancer with Gastrointestinal (47%) and Thoracic (24%) cancers being most common. 98.6% (70/71) of patients were retained at ACC and transitioned to subspecialty care. 80.3% (57/71) of patients received cancer-directed treatment. After the initial consult date, for the patients diagnosed with cancer, there were 4 ED visits and 20 hospitalizations within 30 days, 19 hospice enrollments, and 16 deaths. Conclusions: The CDx clinic has been a valuable resource for patients with suspected cancer by optimizing time to diagnosis and time to treatment. Additional navigation pathways are underway to expand the CDx patient population to target a more underserved population in an effort to promote health equity in cancer care.

Real-World Analysis of Barriers to Timely Administration of Chimeric Antigen Receptor T Cell (CAR T) Therapy in Diffuse Large B-cell Lymphoma

The implementation of chimeric antigen receptor T (CAR T) therapy in the real-world setting is hindered by logistical and financial barriers, impacting timely access to this life-saving treatment. Clinical trials have reported the time from leukapheresis to CAR T cell infusion (vein-to-vein time) but not the time from CAR T referral to infusion (decision-to-vein time). Herein, we report the barriers to CAR T therapy in a real-world setting. We evaluated the factors influencing the decision-to-vein time and explored the association with clinical outcomes in patients with relapsed or refractory diffuse large B cell lymphoma (DLBCL) who received CAR T therapy. We conducted a retrospective study of adult patients with relapsed/refractory DLBCL who underwent consultation for CAR T cell therapy at Levine Cancer Institute and Wake Forest Comprehensive Cancer Center and collected information regarding demographic data, referral type, insurance type, CAR T product, and survival outcomes. The effects of variables on decision-to-vein time were analyzed by Fisher's exact test for categorial variables and Wilcoxon rank-sum test for continuous variables. Survival analyses were performed using Kaplan-Meier and Cox Proportional Hazard models. The study included 142 patients who were referred for CAR T of which 99 patients received CAR T. Median decision-to-vein time was 62 days compared to median vein-to-vein time of 32 days. Patients with private insurance took longer to obtain financial clearance compared to patients with government insurance (median 25 versus 9 days, P < .001). Of those with private insurance (n = 63), 35% needed a single-case agreement (SCA) which led to significant delay in receiving financial clearance (median 50.5 versus 19 days, P < .001) and increased decision-to-vein time (median 75 versus 55 days, P < .001) compared to those who did not need SCA. Decision-to-vein time was significantly different among various products, clinical trial being the shortest (median 47 days, n = 9) and non-conforming products being the longest (median 94.5 days, n = 6) (P< .001). Axi-cel had the shortest median decision-to-vein time at 61 days compared to 81 days with tisa-cel and 85 days with liso-cel. Although delays in receiving CAR T therapy did not impact survival, the median overall survival for patients who were referred for CAR T therapy but did not receive it, was significantly lower than those who received CAR T cell therapy (9.0 versus 21.0 months, P < .001). Decision-to-vein time is a major cause of delay in receiving CAR T therapy. SCAs lead to significant increase in decision-to-vein time leading to delays in CAR T therapy in a real-world setting. Patients who were referred for CAR T but are not able to receive it, have inferior survival compared to CAR T recipients. Our findings underscore the significance of addressing administrative hurdles, such as SCAs and insurance approvals, for timely access to CAR T therapy for patients with DLBCL.

The Diagnostic Role of Antinuclear Antibody: A Study of Clinical Utility in a Tertiary Hospital

Abstract Introduction: Various studies reported unnecessary and inappropriate serology testing of rheumatic diseases leading to a significant waste in healthcare utilization. The purpose of this study is to evaluate the clinical utility of antinuclear antibody (ANA) testing in a real-world setting within a tertiary hospital for systemic lupus erythematosus (SLE) and other ANA-associated rheumatic diseases (AARDs), as well as to identify patient characteristics and test results that predict rheumatic disease association. Subjects and Methods: This is a retrospective study of patients aged 15 years or older who underwent ANA testing at Aseer Central Hospital from January 2018 to December 2022. Data collected included patient demographics, clinical presentations, referral physician type, ANA test results, and final diagnoses. Descriptive statistics characterized patient demographics and ANA test results. Sensitivity, specificity, and predictive values of ANA testing were calculated for SLE and AARD diagnoses. Chi-squared test was used to identify the predictive values of AARDs. Results: Of the 2141 patients tested for ANA at Aseer Central Hospital, 583 (27.2%) tested positive, with a higher proportion of females (80.8%). Notably, 85.1% of patients who tested ANA positive were under 55 years old. The highest ANA test-positive proportion was noticed by rheumatologist physician’s referral (67.6%), referral symptoms including joint symptoms (38.3%), mucocutaneous symptoms (19.7%), renal disease symptoms (14.4%), and hematological abnormalities (14.2%). The sensitivity and specificity of ANA for diagnosing SLE were 86.4% and 79.3%, respectively, with a positive predictive value (PPV) of 31.7% and a negative predictive value (NPV) of 98.1%. The sensitivity and specificity of other AARDs were 85.4% and 73.9%, respectively, with a PPV of 6% and an NPV of 99.6%. Significant associated factors with AARDs included younger age (&lt;55 years), female patients, higher ANA titer, rheumatologist referral, and clinical indications such as sicca symptoms, myopathy, mucocutaneous symptoms, and hematological abnormalities (P &lt; 0.001). Conclusion: In this study, ANA testing showed a good sensitivity and NPV in ruling out AARDs; however, its poor specificity and PPV suggest that positive ANA findings should be interpreted cautiously. Younger age, female gender, higher ANA titer, rheumatologist referral, and specific clinical indications were significantly associated with AARDs, suggesting the importance of targeted ANA testing in clinical practice.

Is Dental Specialty Referral Associated With Earlier Presentation of Oral Cavity Squamous Cell Carcinoma?

BackgroundOral cavity squamous cell carcinoma (OSCC) may mimic other more common odontogenic processes such as infection, trauma, and benign pathology. Delays in diagnosis and treatment are known to result in poorer survival outcomes. PurposeThe study purpose was to measure the association between referral type and OSCC stage at time of presentation.Study design, setting, sample: This was a retrospective cohort study composed of newly diagnosed OSCC patients treated with surgical resection from 2014 to 2023 at Roswell Park Comprehensive Cancer Center (RPCCC). Patients who presented with self-referrals or had surgical treatment outside of RPCCC were excluded. PredictorThe primary predictor was referral source (dental versus medical specialty). Main outcome variableThe primary outcome was pathological T stage (pT). The secondary outcome was overall survival (OS). CovariatesCovariates included demographic data and cancer-related variables (symptomatology, subsite, and risk factors). AnalysesA multivariate logistical regression model for pT stage was constructed using all significant covariates as well as preoperative patient and tumor characteristics. For OS, Kaplan-Meier survival curves were constructed and compared with the log-rank test. A p<0.05 was considered statistically significant. ResultsA total of 215 subjects were included in the study sample. The majority were referred by a dental provider (n=132, 62.3%). Dental referrals presented with significantly earlier T stage disease (RRpT3/T4 0.65, p<0.01) and had lower rates of cervical nodal positivity (RRpN1-N3 0.62, p=0.01). Dental referral independently increased the odds of early pT stage presentation (OR 5.10, p<0.01) after controlling for age, sex, oral pain symptoms, social history (smoking and drinking), head neck cancer history, and tumor subsite. Dental referrals had significantly improved OS (p=0.03) and were also associated with lower rates of oral pain symptoms (RRoral pain 0.80, p=0.02), LVI (RRLVI 0.50 ; p=0.04), and PNI (RRPNI 0.63, p=0.04). ConclusionsAmong subjects with similar risk factors, those referred from dental providers were found to have earlier stage disease. Unfortunately, over half of dental referrals still presented with pain symptoms and more than a third presented with locally advanced disease. Dental providers appear to be positioned to detect earlier OSCC, however there is room for improvement.

Exploring Patterns and Disparities in E-Consult Referrals: An Analysis of Patient and Community Factors in Colorado Health Care.

Objective: Electronic consultations (e-consults) provide a strategic solution to address challenges in health care systems related to cost management and access to care. This study aims to investigate the multilevel patient characteristics associated with higher frequency of receiving e-consults and increased likelihood of completion. Materials and Methods: University of Colorado's electronic medical record were analyzed to study factors influencing referral types (e-consult vs. standard) and their completion rates from April 2018 to September 2023. Multivariate probit regression assessed the impact of patient-level and community-level factors (urban-rural classification, Social Vulnerability Index, and technology accessibility) on e-consult referrals and completion. Results: In 263,882 records, 92.5% were standard referrals, and 7.4% were e-consult referrals. Analysis showed that females were less likely than males (OR = 0.95, 95%CI[0.93, 0.96]), and Blacks were more likely than Whites (OR = 1.03, 95%CI[1.01,1.06]) to receive e-consult referrals. Medicaid patients had lower odds compared to those with Medicare only (OR = 1.04, 95%CI[1.00,1.07]), and rural residency was associated with lower odds (OR = 0.80, 95%CI[0.73,0.88]) of e-consult referral. Factors such as areas with higher population without internet subscription (OR = 1.03, 95%CI[1.01,1.04]) and higher social vulnerabilities (OR = 1.26, 95%CI[1.16,1.37]) increased e-consult odds. Black patients were less likely to have their referrals completed compared to Whites. Patients who resided in regions with limited computer and smartphone access, as well as higher social vulnerabilities, showed decreased odds of referral completion. Discussions and Conclusion: This study highlights the need for partnering with a variety of health care organizations, especially those serving low-income and disadvantaged populations, to enhance health care access equity through the use of e-consults.

Codesigned standardised referral form: simplifying the complexity

BackgroundReferring providers are often critiqued for writing poor-quality referrals. This study characterised clinical referral guidelines and forms to understand which data consultant providers require. These data were then used to...

Structured reporting for efficient epidemiological and in-hospital prevalence analysis of pulmonary embolisms.

Structured reporting (SR) not only offers advantages regarding report quality but, as an IT-based method, also the opportunity to aggregate and analyze large, highly structured datasets (data mining). In this study, a data mining algorithm was used to calculate epidemiological data and in-hospital prevalence statistics of pulmonary embolism (PE) by analyzing structured CT reports.All structured reports for PE CT scans from the last 5 years (n = 2790) were extracted from the SR database and analyzed. The prevalence of PE was calculated for the entire cohort and stratified by referral type and clinical referrer. Distributions of the manifestation of PEs (central, lobar, segmental, subsegmental, as well as left-sided, right-sided, bilateral) were calculated, and the occurrence of right heart strain was correlated with the manifestation.The prevalence of PE in the entire cohort was 24% (n = 678). The median age of PE patients was 71 years (IQR 58-80), and the sex distribution was 1.2/1 (M/F). Outpatients showed a lower prevalence of 23% compared to patients from regular wards (27%) and intensive care units (30%). Surgically referred patients had a higher prevalence than patients from internal medicine (34% vs. 22%). Patients with central and bilateral PEs had a significantly higher occurrence of right heart strain compared to patients with peripheral and unilateral embolisms.Data mining of structured reports is a simple method for obtaining prevalence statistics, epidemiological data, and the distribution of disease characteristics, as demonstrated by the PE use case. The generated data can be helpful for multiple purposes, such as for internal clinical quality assurance and scientific analyses. To benefit from this, consistent use of SR is required and is therefore recommended. · SR-based data mining allows simple epidemiologic analyses for PE.. · The prevalence of PE differs between outpatients and inpatients.. · Central and bilateral PEs have an increased risk of right heart strain.. · Jorg T, Halfmann MC, Graafen D et al. Structured reporting for efficient epidemiological and in-hospital prevalence analysis of pulmonary embolisms. Fortschr Röntgenstr 2024; DOI 10.1055/a-2301-3349.

The nature of inappropriate referrals to wellness services in primary care setting in Qatar: Outcome of multifaced interventions on rate and quality of referrals

ObjectivesThe objectives of this study were to explore the rate and types of inappropriate referrals to the wellness services and to assess the impact of multi-level interventions on the rate of inappropriate referrals at Rawdat Al-Khail health center in Qatar. MethodsThis study employed a retrospective analysis of all referrals data to Rawdat Al-Khail wellness services extracted from the Electronic Health Records (EHRs) between July 2022 and August 2023. The monthly rates and types of inappropriate referrals were calculated. In this study, pre-post analyses were performed to evaluate the impact of two sets of interventions on reducing inappropriate referral rates. The first set involved the development and distribution of e-referral pathways training manual in September 2022. The second set, implemented in April 2023, included close monitoring the rate and types of referrals, and the initiation of feedback communication between wellness services supervisors and referring physicians for advice and corrective actions. ResultsA total of 966 referrals were received during the study period, with 1:5 male-to-female ratio. Of all referrals, 34.9 % were classified as inappropriate, exhibiting considerable variations among different referring health centers. The most common reason for inappropriate referrals was due to the lack of “exercise wellness gym assessment form” (23.8 %). While interventions aimed at enhancing the referral process, they did not result in a significant overall reduction in inappropriate referral rates. However, there was a noteworthy reduction in the inappropriate referrals caused by the lack of “exercise wellness gym assessment form” observed from March to August 2023 (41 %–18 %). ConclusionThis study sheds light on the complexities of wellness services referrals, revealing a high rate of inappropriate referrals that require closer scrutiny. Despite interventions not significantly reducing the rate of these referrals, it emphasizes the need for ongoing improvement strategies. Structured, periodic interventions at higher levels are recommended to enhance referral appropriateness.

Observed Differences in Patient Comorbidities and Complications Undergoing Primary Total Joint Arthroplasty Between Non-orthopaedic and Orthopaedic Referral Patients.

Value-based total joint arthroplasty (TJA) has resulted in decreasing surgeon reimbursement which has created concern that surgeons are being incentivized to avoid medically complex patients. The purpose of this study was to determine if patients who underwent primary total knee (TKA) and total hip arthroplasty (THA) had different comorbidities and complication rates based on referral type: 1) non-orthopaedic referral (NOR), 2) outside orthopaedic referral (OOR) or 3) self-referral (SR). At a single tertiary care centre, patients undergoing primary TJA between July 2019 and January 2020 were identified using current procedural codes. Data were abstracted from the Institutional National Surgical Quality Improvement Program (NSQIP) along with electronic medical records which included referral type, primary insurance, demographics, comorbidities, and comorbidity scores, including an American Society of Anesthesiology (ASA) score. Complications and outcomes were tracked for 90 days post-operatively. Referral groups were compared using Chi-square exact tests for categorical variables and t-tests or Wilcoxon Rank Sum tests for continuous variables, as appropriate. Of the 393 patients included in this study, there were 249 (63%) NOR, 104 (26%) OOR, and 40 (10%) SR. The OOR versus NOR group had a significantly greater proportion of patients with obesity (79 vs 64%, p=0.047) and an ASA score ≥3 (59 vs 43%, p=0.007). There was a significantly greater proportion of patients with wound complications (10 vs 4%, p=0.023) and ≥2 complications (14 vs 3%, p<0.001) in OOR versus NOR, respectively. Patients who underwent primary TJA and were referred by an orthopaedic surgeon tended to have more comorbid conditions and higher rates of severe complications. The observed difference in referrals may be explained by monetary incentivization in the context of current reimbursement trends. Organizations utilizing bundled payment programs to reimburse surgeons should use a risk-stratification model to mitigate incentivizing surgeons to avoid medically complex patients.

Knowledge About the Importance of Early Diagnosis and Treatment of Oral Potentially Malignant Disorders Among the South Indian Population: An Institutional Retrospective Study.

The significant malignant transformation rates of oral potentially malignant disorders (OPMDs) demand early diagnosis and proper management of OPMDs not only to reduce symptoms but also to prevent their aggressive outcomes. This retrospective study aimed to quantify the need for patient-related awareness in identifying OPMDs by quantitatively evaluating the association between the type of referral in OPMD cases. This study also aims to analyze the association between gender and types of referral in OPMDs. The sample size of n=1577 (500-leukoplakia, 500-oral submucous fibrosis (OSMF), 500-lichen planus, 77-lichenoid reaction) was considered in the present retrospective study. Data regarding the sample cases were extracted from the common patient database of the Saveetha Dental College and Hospitals from June 2019 to February 2024. Random sampling method was used, and the OPMDs were categorized into two groups based on the chief complaint as self-referred and specialist-referred cases. The segregated data were tabulated in Microsoft Excel (Microsoft® Corp., Redmond, WA) and then exported to IBMSPSSStatistics for Windows, Version 23 (Released 2015; IBM Corp., Armonk, New York, United States) for statistical analysis. Pearson's chi-square test was conducted to analyze the association of referral type, OPMDs, and gender. Out of 1577 OPMD cases, 929 (58.9%) were specialist-referral cases and 648 (41.1%) were self-referral cases. Among OPMDs, lichen planus was the most self-referred 310 (62%) and leukoplakia was the most specialist-referred 470 (78.6%) category. This study found a statistically significant correlation between the type of referrals and the type of OPMDs (p=0.000). Self-referral was more commonly observed in females (23.3%) than males (17.8%) in general and among all categories of OPMDs except lichenoid reactions. This observation was also statistically significant (p=0.000). Conclusion: Among OPMDs selected in the present study, lichen planus and OSMF were more self-referred and leukoplakia cases were mostly specialist-referred. This study highlights the need of detecting less symptomatic lesions, such as leukoplakia, which has a high risk of malignant transformation. The lack of awareness about the identification of OPMDs among patients can result in delayed diagnosis and treatment, which may further result in progression to aggressive outcomes.

Analysis of the demand for mental health consultation and liaison programmes: a comprehensive view.

IntroductionThe mental health consultation and liaison programme plays a crucial role in comprehensive medical care by addressing psychiatric co-morbidities in hospitalised patients.ObjectivesThe aim of this study is to analyse demand and assess referral patterns to the mental health consultation and liaison programme in order to identify areas for improvement and optimise the provision of care.Methods A descriptive cross-sectional study was conducted by analysing records of referrals to the mental health consultation and liaison programme over a one-year period. Demographic data, origin of demand, type of request, episodic diagnosis, psychiatric diagnoses, follow-up and discharge referral were collected.ResultsA total of 1180 referrals to the mental health consultation and liaison programme were reviewed. Most of the episodic diagnoses were related to anxious-depressive symptomatology, acute stress reaction and acute confusional syndrome. The majority of patients followed up did not require further referral to mental health facilities.ConclusionsAnalysis of the demand for the mental health consultation and liaison programme helps us to optimise care on psychiatric co-morbidities. These results support the importance of integrated care that addresses both medical and psychiatric aspects of inpatient health. Strategies to improve collaboration between different services should be implemented to ensure optimal care and provide a holistic approach.Disclosure of InterestNone Declared

Diagnostic Accuracy of Pediatrician-performed Digital Retinal Imaging with 3nethra neo for ROP Screening.

To evaluate the accuracy of pediatrician-performed wide-field digital retinal imaging (WFDRI) for diagnosing Retinopathy of prematurity (ROP), as compared to binocular indirect ophthalmoscopy (BIO) as the reference standard. Eligible infants undergoing ROP screening were enrolled consecutively. BIO was performed by trained ophthalmologists, followed by WFDRI (using "3nethra neo" camera) by a pediatrician. An expert pediatric ophthalmologist reviewed de-identified images for quality, presence, and severity of ROP. She was masked to the findings of BIO and the pediatrician. Diagnostic accuracy for detecting any ROP, ROP requiring treatment (Type 1), and ROP requiring referral (Type 1 or 2) were calculated for WFDRI, considering BIO as the reference standard. The analysis included 427 eyes. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic accuracy, and diagnostic odds ratio of WFDRI were 0.88 (95% CI: 0.81, 0.93), 0.89 (0.85, 0.92), 7.8 (5.7, 10.9), 0.14 (0.09, 0.21), 0.89 (0.85, 0.91), and 58.3 (31, 110) respectively for detection of 'any ROP'. For detecting ROP requiring treatment (Type 1), the sensitivity, specificity, NLR, and diagnostic accuracy were 0.90 (0.75, 0.97), 1.00 (0.99, 1.00), 0.11 (0.04, 0.27), and 0.99 (0.98, 1.00) respectively. For ROP requiring referral, the sensitivity, specificity, NLR, and diagnostic accuracy of pediatrician-performed WFDRI were 0.92 (0.80, 0.98), 1.00 (0.99, 1.00), 0.08 (0.03, 0.21), and 0.99 (0.98, 1.00) respectively. No serious adverse events were noted. The pediatrician and ophthalmologist had a near-perfect (k-1.00) and strong (k-0.88) agreement for ROP requiring treatment and any ROP, respectively. Pediatrician-performed WFDRI is feasible, safe, and has excellent diagnostic accuracy for identifying ROP requiring treatment.

Examining the Association Between the COVID-19 Pandemic and the Rate of Diagnostic Tests for Breast, Cervical, and Colorectal Cancer in Manitoba, Canada.

Background: Strategies to minimize the impact of the COVID-19 pandemic led to a reduction in diagnostic testing. It is important to assess the magnitude and duration of this impact to plan ongoing care and avoid long-lasting impacts of the pandemic. Objective: We examined the association between the COVID-19 pandemic and the rate of diagnostic tests for breast, cervical, and colorectal cancer in Manitoba, Canada. Design and Participants: A population-based, cross-sectional study design with an interrupted time series analysis was used that included diagnostic tests from January 1, 2015 until August 31, 2022. Setting: Manitoba, Canada. Main Outcomes: Outcomes included mammogram, breast ultrasound, colposcopy, and colonoscopy rates per 100,000. Cumulative and percent cumulative differences between the fitted and counterfactual number of tests were estimated. Mean, median, and 90th percentile number of days from referral to colonoscopy date by referral type (elective, semiurgent, urgent) were determined. Results: In April 2020, following the declaration of the COVID-19 public health emergency, bilateral mammograms decreased by 77%, unilateral mammograms by 70%, breast ultrasounds by 53%, colposcopies by 63%, and colonoscopies by 75%. In Winnipeg (the largest urban center in the province), elective and semiurgent colonoscopies decreased by 76% and 39%, respectively. There was no decrease in urgent colonoscopies. As of August 2022, there were an estimated 7270 (10.7%) fewer bilateral mammograms, 2722 (14.8%) fewer breast ultrasounds, 836 (3.3%) fewer colposcopies, and 11 600 (13.8%) fewer colonoscopies than expected in the absence of COVID-19. As of December 2022, in Winnipeg, there were an estimated 6030 (23.9%) fewer elective colonoscopies, 313 (2.6%) fewer semiurgent colonoscopies, and 438 (27.3%) more urgent colonoscopies. Conclusions: In Manitoba, the COVID-19 pandemic was associated with sizable decreases in diagnostic tests for breast, colorectal, and cervical cancer. Two and a half years later, there remained large cumulative deficits in bilateral mammograms, breast ultrasounds, and colonoscopies.

Multidisciplinary working in a community HIV specialist service.

A documentation audit was performed to explore the multidisciplinary working of a community HIV specialist service (CHSS). The audit identified the wide range of services to which people living with HIV are referred as part of the care they receive within the CHSS. A retrospective documentation audit was used. The CHSS, consisting of three teams covering a wide geographical area across West Sussex and Brighton and Hove. A total of 30 patients' notes were audited, including 10 patients from each team to ensure the results were representative of the service as a whole. The audit showed that, on average, each person received five onward referrals to other health care, social care, or HIV-specific services, with a range of between 1 and 12, as a result of being under the care of the CHSS. The types of referrals varied, with 46% being to HIV specialist services and the remaining 54% to non-HIV specific services, including GPs, social services and other health services. Overall, the audit showed not only the holistic care and assessments completed but also the benefit and increased access to other services and care as a result of community HIV team involvement. The audit highlights the importance of continuing to develop HIV community services to cater for this changing population, as well as identifying possible areas of development. The results also demonstrate the vital role that CHSSs have in supporting hard-to-reach patients.

WORKING TOGETHER TO PROVIDE GERIATRIC CARE: INTERDISCIPLINARY TEAM CREATION AND EVALUATION IN CANADA

Abstract Prince Edward Island is Canada’s smallest province (pop. 160,000) and has one of the oldest populations in Canada. While there is a robust and growing geriatrics program through provincial healthcare, it consists exclusively of medical providers (i.e., geriatricians and nurse practitioners). An opportunity for formal interprofessional collaboration presented itself when the University of Prince Edward Island began a Doctor of Psychology (PsyD) program in 2019. Soon thereafter, we established an interdisciplinary team between the PsyD and the provincial geriatrics programs. The goals of the team included: 1) enhancing care for older adults on the island, 2) providing training for PsyD students, and 3) increasing interprofessional collaboration and learning. In an evaluation of the first year of the collaboration, we collected data on the types of referrals and characteristics of the patients referred (e.g., number of medications), and asked all providers on the team (N=4 geriatricians, N=9 nurse practitioners, and N=4 psychology student clinicians) to answer open ended questions on the highlights and challenges of establishing the team, the organization of formal team meetings, and provision of patient care. Of the 74 patients seen by psychology, reasons included cognitive or psychodiagnostic assessment (N=22, 30%), psychotherapy (N=20, 27%), caregiver support (N= 25, 34%), or multiple services (i.e., both assessment and intervention; n=7, 10%). Additional patient characteristics will be shared, as well as themes from provider survey responses. Our program has implications for other areas in rural North America, particularly training opportunities built into our team functioning.

Elective Surgery in People with Dementia in Northern Ireland

AbstractBackgroundElective care is defined as care that is planned in advance for those that require a procedure or treatment for an existing condition. Elective surgery aims to improve the physical or psychological quality of life for a patient and may extend the life of an individual. Evidence has shown that surgery in people with dementia (PwD) carry even more risk than those in the general ageing population particularly in terms of post‐operative complications and mortality rates. Whilst thousands of elective surgeries take place every year, it is unclear how many of these are conducted on PwD. This study explores the types and rates of elective surgery in PwD in Northern Ireland and the contributing factors to patient referral for elective surgery.MethodData was accessed through the Honest Broker Service (NI) and was retrospectively analysed. Dementia was defined in people who received one or more dementia medications (as outlined in the British National Formulary (BNF)) or when dementia was identified as a primary or secondary cause of death. Elective surgeries were identified by elective surgery referrals (Patient Administration System) (dementia cohort: n = 26,780; control: n = 24,056).ResultOverall, significantly less PwD were referred for an elective surgery compared to controls. Within the PwD group those who had higher odds to undergo an elective surgery were male, of younger age, lived in rural areas, did not transition to a care home, and were married instead of single or widowed. PwD were less likely to have an elective surgery if they received antipsychotics, but they were more likely to have a surgery if they received lipid lowering drugs, antihypertensives, hypnotics and anxiolytics, antidepressants, or antiarrhythmics. The most common surgeries from both PwD and controls were surgeries for lens, bladder and skin. Having an elective surgery was associated with lower odds of death for PwD and controls compared to people who did not undergo a surgery.ConclusionThis paper can inform health policy through insight into factors contributing to the rate and types of elective surgery referrals for PwD to ensure PwD are afforded the same care when it comes to elective surgery compared with the general population.

Real-World Analysis of Barriers to Timely Administration of Chimeric Antigen Receptor T-Cell (CART) Therapy in Diffuse Large B-Cell Lymphoma (DLBCL)

Introduction: CAR T-cell therapy has made a significant impact in the treatment of relapsed and refractory (R/R) DLBCL. However, there are significant barriers to timely administration of CAR T. Vein-to-vein time (time between leukapheresis and CAR T infusion) is an important barrier reported by clinical trials. In the real world, administration of CAR T may be further delayed due to financial clearance or single case agreement (SCA), shortage of leukapheresis slots, disease progression and death, among others. The time between CAR T referral and infusion (brain-to-vein) in the real-world is unknown. Understanding the barriers to timely administration of CAR T is crucial to expanding the access to CAR T for patients with R/R DLBCL. Methods: Adult patients (pts) with R/R DLBCL who underwent consultation for CAR T at our center from 2018 to 2022 were included in the study. The following information was collected from each subject and analyzed with descriptive statistics: referral type (internal/external), insurance type (private/government), private insurance subtype (SCA/non-SCA), and CAR T product (liso-cel/axi-cel/clinical trial/non-conforming product). For continuous variables, we reported the median and range, while categorical variables were reported as frequencies and percentages. The brain-to-vein time was classified as high (70-130 d), medium (45-70 d), and low (27-45 d). The effects of variables on brain-to-vein time were analyzed by Fisher's exact test for categorical variables, and Wilcoxon rank-sum test for continuous variables. Survival analyses were performed using the Kaplan-Meier and Cox Proportional Hazard model. Results: The study included 78 consecutive pts who were referred for consideration of CAR T for DLBCL. Thirteen (16.6%) pts did not receive CAR T therapy due to disease progression and death (n=5), lack of social support or caregiver (n=4), lack of financial clearance (n=2), and complete response to bridging therapy (n=2). Sixty-five (83.3%) pts received CAR T therapy. Median age was 61 y (27-83), 72% were male, and 18.4% belonged to racial or ethnic minority groups. The median time (range) from consultation to financial clearance, leukapheresis, and CAR T infusion were 15 (-50, 89), 30 (3, 91) and 61 d (27, 130), respectively. For some pts financial clearance was obtained prior to consultation. The median vein-to-vein time was 31 d (16, 76). There was no difference in brain-to-vein time (p=0.66) for external and internal referrals. Although pts with private insurance took longer to obtain financial clearance compared to pts with government insurance (median, 20 vs 9 d, p=0.01) (Table 1), there was no significant difference in the brain-to-vein time between the 2 groups (p=0.24). 20% of pts with private insurance needed SCA. Compared to those who did not need SCA, pts who needed SCA had a significant delay in time from consultation to financial clearance (median, 30 vs 19 d, p=0.01) and CAR T infusion (median 79 vs 55 d, p&amp;lt;0.001) (Table 2). Brain-to-vein time was significantly different among different products, with clinical trial the shortest (47 d, n= 9), non-conforming products the longest (99 d, n=5), and axi-cel (57 d, n=40), liso-cel (75 d, n=11) in between (p&amp;lt;0.001; Table 3). Of the 5 pts who received non-conforming products, 4 were intended for liso-cel and 1 for axi-cel. Brain-to-vein time did not significantly impact the progression-free survival [hazard ratio (HR)=0.988, 95% confidence interval (CI) = 0.973-1.003, p=0.11) or overall survival (HR=0.990, 95%CI=0.972-1.009, p=0.30) (Table 4). There was concordance when the time from consultation to CAR T therapy was used as a continuous variable and when it was separated into low, medium, and high quartiles and tested as categorical variables (Tables 2-4). Conclusion: We have identified multiple factors that prolonged brain-to-vein time for CAR T-cell therapy in the real-world. Pts whose insurance required SCA or who received non-conforming products had significant delay in receiving CAR T. Although delay in receiving CAR T therapy did not impact survival at our institution, several patients who could have benefited from CAR T did not receive it due to disease progression/death (6.4%) or lack of financial clearance (2.6%). Rapid financial clearance and eliminating the need for SCA could abbreviate the brain-to-vein time and expand access to patients with rapidly progressive DLBCL.

29 Examining the Relationship between Symptom and Performance Validity Measures Across Referral Subtypes

Objective:Performance validity (PVT) and symptom validity tests (SVT) have become standard practice in assessing credibility of neuropsychological profiles and symptom report. While PVTs assess cognitive task engagement, SVTs assess credibility of patient symptom report. Although prior research aimed to conceptualize the relationship between the two validity measure types, it generally focused on SVTs from the Minnesota Multiphasic Personality Inventory (MMPI-2 &amp;RF) and the Structured Inventory of Malingered Symptoms (SIMS; Ord et al., 2021, MMPI-2; Van Dyke et al., 2013). Further studies have demonstrated mixed results, with many studies concluding that symptom and performance validity are separate but related constructs. The current study aimed to assess the relationship between PVTs and SVTs utilizing symptom validity measures from the Personality Assessment Inventory (PAI) across three samples, including neurodevelopmental, psychiatric, and traumatic brain injury groups.Participants and Methods:Participants included 634 individuals consecutively referred for neuropsychological assessment who completed the Test of Memory Malingering (TOMM) and the PAI (mean Age = 41.7, SD = 15.7; mean Education = 13.7, SD = 2.7; 53% female; 89% Caucasian). Participants were divided into three groups based on referral, including neurodevelopmental (mean Age = SD = 10.7; mean Education = 13.4, SD = 2.5; 39% female; 79% Caucasian), psychiatric (mean Age = 44.7, SD = 15.0; mean Education = 13.8, SD = 2.8; 58% female; 90% Caucasian), and traumatic brain injury samples (mean Age = SD = 15.5; mean Education = 13.3, SD = 2.3; 50% female; 91% Caucasian). Four structural equation models (latent variable models) were constructed. The first model was fit across the entire sample while the remaining three were fit for the aforementioned subsamples. TOMM trials modeled the performance validity latent variable while SVTs from the PAI modeled the symptom validity latent variable (Positive Impression Management and Defensiveness Index modeled underreporting; Negative Impression Management, Malingering Index, and Cognitive Bias Scale modeled overreporting).Results:In the full sample model overreporting significantly predicted performance validity (p &lt; 0.001, r = -0.31), indicating higher symptom overreporting related to poorer performance validity while symptom underreporting did not significantly predict performance validity (p = 0.09, r = 0.08). In the neurodevelopmental model overreporting did not significantly predict performance validity (p = 0.44, r = 0.10). Further, symptom underreporting did not significantly predict performance validity (p = 0.40, r = 0.10). Similarly, for the TBI model, overreporting did not significantly predict performance validity (p = 0.82, r = -0.02) and symptom underreporting did not significantly predict performance validity (p = 0.50, r = -0.08). For the psychiatric sample symptom underreporting did not significantly predict performance validity (p = 0.06, r = 0.11); however, symptom overreporting significantly predicted performance validity (p &lt; 0.001, r = - 0.39).Conclusions:The current study expands on prior research comparing the relationship between SVTs and PVTs in neuropsychological evaluation utilizing SVTs from the PAI. Results of the present study suggest the relationship between the SVTs and PVTs varies by referral type and further supports using both PVTs and SVTs in neuropsychological assessment.

AN EQUILIBRIUM LABOR MARKET MODEL WITH INTERNAL AND EXTERNAL REFERRALS

AbstractAbout 40% of workers find their jobs through referrals. We distinguish between two types of referrals based on whether the referrer works at the hiring firm (internal referrals) or not (external referrals). Interestingly, jobs found through internal (external) referrals pay more (less) than those found through formal methods. An equilibrium labor market model is then built by introducing an incentive‐compatible mechanism through which workers can share job opening information. A nondegenerate wage distribution arises in equilibrium with a wage premium (penalty) for internal (external) referrals. When calibrated, our model can capture these salient features of the U.S. labor market.