Return Visit Research Articles

Comparison of Delivery of Care Before and During COVID-19 Within an Academic Outpatient Psychiatry Practice.

Introduction: The COVID-19 pandemic has challenged outpatient mental health clinics. This article compares care delivery and patient characteristics before and during the COVID-19 pandemic in outpatient mental health clinics within an academic health system. Methods: A retrospective cohort study was conducted in patients who received outpatient psychiatric services at two clinics (A and B). The investigators compared care delivery with patients with mental health conditions prepandemic (January 1-December 31, 2019) and midpandemic (January 1-December 31, 2020) periods. Care delivery was defined as the number and type of new and return visits (telehealth and face-to-face visits), patients with recorded measurement-based care (MBC) outcomes, and communication capability between patients and providers. Results: During the prepandemic period, 6,984 patients were seen in Clinics A and B, resulting in 57,629 visits. In the midpandemic period, 7,110 patients were served, resulting in 61,766 total visits. Medication management visits increased from 2019 to 2020; number of visits with documented outcome measures increased by 90% in Clinic A and 15% in Clinic B. The number of MyChart messages per patient increased more than twofold during the midpandemic period. The number of new visits with primary diagnosis of anxiety disorders increased in CY2020 and the number of visits with primary diagnosis of major depressive/mood disorders decreased in CY2020. Payor mix did not vary between the two periods although there was variability between payor mix at the two primary clinic locations. Discussion: The study suggests that there was no detrimental impact on access to care between the prepandemic and midpandemic periods within the health system. Mental health visits while pivoting to telehealth increased during the midpandemic period. Transition to telepsychiatry improved the ability to administer and document MBC.

Return emergency department visits for recurrent pulmonary embolism symptoms in children and adolescents

AbstractRates of pulmonary embolism (PE) in children have steadily increased over the past 2 decades. Patient outcomes after hospital discharge are poorly understood, and many patients experience recurrent or persistent chest pain or dyspnea, prompting a return to care. This retrospective cohort study of patients diagnosed with PE at a large children’s hospital over a 9.5-year period was performed to evaluate rates of return to the emergency department (ED) for PE-related symptoms, and to determine the utility of repeat computed tomography angiography (CTA) in this population. Ninety-six patients were diagnosed with PE during the study period. Forty-two percent of patients (n = 40) returned to the ED for PE-related symptoms and a total of 74 repeat CTAs were performed. Among those who had return visits, the mean number of return visits was 3 and the mean number of repeat CTAs was 1.8. The median time to return to the ED was 34 days. Logistic regression analysis identified increased age and female sex as risk factors for return ED visits. Eight percent of the cohort experienced PE recurrence. Recurrent PE was observed only in those with persistent or new thrombotic risk factors and was uncommon in those who remained on appropriate anticoagulation. Future work should focus on the development of a risk stratification system to identify patients at low risk of recurrence in order to minimize repeat CTA imaging.

Characteristics of Suspected COVID-19 Discharged Emergency Department Patients Who Returned During the First Wave.

Limited information exists on patients with suspected coronavirus disease 2019 (COVID-19) who return to the emergency department (ED) during the first wave. In this study we aimed to identify predictors of ED return within 72 hours for patients with suspected COVID-19. Incorporating data from 14 EDs within an integrated healthcare network in the New York metropolitan region from March 2-April 27, 2020, we analyzed this data on predictors for a return ED visit-including demographics, comorbidities, vital signs, and laboratory results. In total, 18,599 patients were included in the study. The median age was 46 years old [interquartile range 34-58]), 50.74% were female, and 49.26% were male. Overall, 532 (2.86%) returned to the ED within 72 hours, and 95.49% were admitted at the return visit. Of those tested for COVID-19, 59.24% (4704/7941) tested positive. Patients with chief complaints of "fever" or "flu" or a history of diabetes or renal disease were more likely to return at 72 hours. Risk of return increased with persistently abnormal temperature (odds ratio [OR] 2.43, 95% CI 1.8-3.2), respiratory rate (2.17, 95% CI 1.6-3.0), and chest radiograph (OR 2.54, 95% CI 2.0-3.2). Abnormally high neutrophil counts, low platelet counts, high bicarbonate values, and high aspartate aminotransferase levels were associated with a higher rate of return. Risk of return decreased when discharged on antibiotics (OR 0.12, 95% CI 0.0-0.3) or corticosteroids (OR 0.12, 95% CI 0.0-0.9). The low overall return rate of patients during the first COVID-19 wave indicates that physicians' clinical decision-making successfully identified those acceptable for discharge.

A value-based comparison of the management of respiratory diseases in walk-in clinics and emergency departments.

Our aim was to compare some of the health outcomes and costs associated with value of care in emergency departments (ED) and walk-in clinics for ambulatory patients presenting with an acute respiratory disease. A health records review was conducted from April 2016 through March 2017 in one ED and one walk-in clinic. Inclusion criteria were: (i) ambulatory patients at least 18years old, (ii) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Primary outcome was the proportion of patients returning to any ED or walk-in clinic within three and seven days of the index visit. Secondary outcomes were the mean cost of care and the incidence of antibiotic prescription for URTI patients. The cost of care was estimated from the Ministry of Health's perspectives using time-driven activity-based costing. The ED group included 170 patients and the walk-in clinic group 326 patients. The return visit incidences at three and seven days were, respectively, 25.9% and 38.2% in the ED vs. 4.9% and 14.7% in the walk-in clinic (adjusted relative risk (arr) of 4.7 (95% CI 2.6-8.6) and 2.7 (1.9-3.9)). The mean cost ($Cdn) of the index visit care was 116.0 (106.3-125.7) in the ED vs. 62.5 (57.7-67.3) in the walk-in clinic (mean difference of 56.4 (45.7-67.1)). Antibiotic prescription for URTI was 5.6% in the ED vs. 24.7% in the walk-in clinic (arr 0.2, 0.01-0.6). This study is the first in a larger research program to compare the value of care between walk-in clinics and the ED. The potential advantages of walk-in clinics over EDs (lower costs, lower incidence of return visits) for ambulatory patients with respiratory diseases should be considered in healthcare planning.

MP16-02 WORK PRODUCTIVITY OF PATIENTS UNDERGOING TRIAL OF PASSAGE FOR URETERAL STONES

You have accessJournal of UrologyCME1 Apr 2023MP16-02 WORK PRODUCTIVITY OF PATIENTS UNDERGOING TRIAL OF PASSAGE FOR URETERAL STONES Ian Berger, Alexandria Spellman, Vishnukamal Golla, Michael Lipkin, Gary Faerber, Jodi Antonelli, Charles Scales, and Deborah Kaye Ian BergerIan Berger More articles by this author , Alexandria SpellmanAlexandria Spellman More articles by this author , Vishnukamal GollaVishnukamal Golla More articles by this author , Michael LipkinMichael Lipkin More articles by this author , Gary FaerberGary Faerber More articles by this author , Jodi AntonelliJodi Antonelli More articles by this author , Charles ScalesCharles Scales More articles by this author , and Deborah KayeDeborah Kaye More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003236.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral stones affect patients of working age and disrupt daily activities. Patient reported outcomes during trial of passage are understudied which hinders counseling and expectation setting. We sought to characterize work productivity losses for patients with a ureteral stone undergoing a trial of passage. METHODS: We identified employed, English speaking patients aged 18-64 years and discharged from Duke University Health System EDs with unilateral ureteral stones on CT scan from February-October 2022. Patients were contacted by phone 4 weeks after discharge and administered the Institute for Medical Technology Assessment Productivity Cost Questionnaire which evaluates three domains of productivity loss over a four-week period: absenteeism (missed work), presenteeism (decreased productivity at work), and volunteerism (help with unpaid work or domestic tasks). Patients were designated as reporting passage of their stone if they noticed it in the toilet or identified a day with symptom resolution that did not return. RESULTS: We enrolled 64 patients who completed the survey. 71% (46/64) had distal stones and 14% (9/64) had symptoms at the time of the survey. 73% (47/64) of patients missed work after discharge (Figure 1), missing a median of 2 days (interquartile range [IQR] 1.0-4.0). 58% (37/64) had pain at work, with a median of 3 days of pain (IQR 1.5-6.5) and a median of 40% reduction in productivity (IQR 20%-50%) on symptomatic days. 38% (24/64) required help with unpaid work for a median of 2.5 days (IQR 1.0-5.8) and median of 3.5 hours per day (IQR 2.0-5.0). 58% (37/64) of patients passed their stone with a median passage time of 3.5 days (IQR 2.0-7.8). Of patients who passed their stone, 68% (25/37) missed work, with a median of 2 days missed (IQR 1-2) or 50% of work days until their stone passed (IQR 21%-83%). Of patients who reported not passing their stone, 74% (20/27) missed work for a median of 4.5 days (IQR 1-7). This was a median of 14% (IQR 3%-22%) of days until surgery or survey completion. CONCLUSIONS: The majority of patients miss work during passage of a ureteral stone. While time off work is less than published rates after ureteroscopy, it is common to miss half of work days until the stone passes. This information may aid patient counselling and help to prevent return ED visits. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e201 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ian Berger More articles by this author Alexandria Spellman More articles by this author Vishnukamal Golla More articles by this author Michael Lipkin More articles by this author Gary Faerber More articles by this author Jodi Antonelli More articles by this author Charles Scales More articles by this author Deborah Kaye More articles by this author Expand All Advertisement PDF downloadLoading ...

Analysis of an accessibility strategy for deaf people: Videos on a traveling science center

IntroductionBrazilian traveling science centers have difficulties in providing sign language accessibility to the deaf people that visit them. The main objective of this study was to analyze the contribution of accessible video guides in Brazilian Sign Language (BSL) in helping deaf visitors understand the activities proposed by the traveling science center “Ciências Sob Tendas”.MethodsThis research used a critical quali-quantitative approach that involved 128 deaf students from middle and high schools. Data were gathered via an online survey and video recording.Results and discussionThe results indicated successful use of the video guides by deaf participants. Within this specific research, in which 745 questionnaires were answered, we found that the videos, along with interactive activities, contributed to the interest, curiosity, and understanding of the themes presented. Furthermore, the return visits of deaf people to revisit activities a second and third time may indicate the potential of this science communication strategy to stimulate their interest in scientific knowledge. However, 15% of responses showed that they had some difficulty understanding the video's explanation. This may indicate that, although videos are a well-accepted alternative for accessibility, the presence of an interpreter guide or a deaf visitor guide, when possible, is ideal. Essentially, a professional interpreter can use several BSL resources and strategies to make themselves understood.ConclusionThus, we considered that accessible video guides in BSL are a viable resource for providing accessibility to deaf people in traveling science centers.

Change in Pediatric Adenotonsillectomy Postoperative Visit Patterns After Opioid Food and Drug Administration Warning.

This study aimed to determine the association between opioid prescriptions given after tonsillectomy with adenoidectomy (T + A) and pain-related return visit rates in pediatric patients. Determine association between Food and Drug Administration (FDA) black box warning against opioid use in this population and pain-related return visit rates. This was a single-institution retrospective cohort study of pediatric patients who underwent T + A between April 2012 and December 2015 and had return visits to the emergency department or urgent care center. Data were obtained from the hospital electronic warehouse using International Classification of Diseases-9/10 procedure codes. Odds ratios (ORs) with 95% confidence intervals (CIs) for return visits were calculated. Multivariate logistic regression analysis was used to measure association between opioid prescriptions and return visit rates as well as FDA warning and return visit rates adjusting for confounders. There were 4778 patients who underwent T + A, median age, 5 years. Of these, 752 (15.7%) had return visits. Pain-related return visits were higher in patients who received opioid prescriptions (adjusted OR, 1.31; 95% CI, 1.09-1.57). After FDA warning, opioids were prescribed at a lower rate (47.9%) compared with previous (98.6%) (OR, 0.01; 95% CI, 0.008-0.02). Pain-related return visits were lower after FDA warning (OR, 0.73; 95% CI, 0.61-0.87). Steroid prescription rate increased after FDA warning (OR, 415; 95% CI, 197-874). Opioid prescriptions were associated with higher pain-related return visits after T + A, whereas issuance of FDA black box warning against codeine use was associated with lower pain-related return visits. Our data suggest that the black box warning potentially had unintended benefits in pain management and health care usage.

Return Rates for Opioid versus Nonopioid Management of Patients with Abdominal Pain in the Emergency Department

BackgroundResearch suggests that opioid treatment for abdominal pain, which comprises a large proportion of patients presenting to the emergency department (ED), may contribute to long-term opioid use without significant benefits with regard to symptom management. ObjectivesThis study seeks to assess the association between opioid use for management of abdominal pain in the ED and return ED visits for abdominal pain within 30 days for patients discharged from the ED at initial presentation. MethodsWe conducted a retrospective, multicenter observational study of adult patients presenting to and discharged from 21 EDs with a chief concern of abdominal pain between November 2018 and April 2020. The proportion of 30-day return visits to the ED for patients who received opioid analgesics was compared with a reference group of patients who only received acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or both. ResultsOf the 4745 patients, 1304 (27.5%) received opioids and 1101 (23.2%) only received either acetaminophen, NSAIDs, or both. Among those given opioids, 287 (22.0%) returned to the ED for abdominal pain within 30 days, compared with 162 (14.7%) of those in the reference group (odds ratio 1.57, 95% confidence interval 1.27–1.95, p-value < 0.001). ConclusionPatients given opioids for abdominal pain in the ED had 57% increased odds of a return ED visit within 30 days compared with those given only acetaminophen or NSAIDs. This warrants further research on the use of nonopioid analgesics in the ED, especially in patients with anticipated discharge.

Case report: Diagnosis and treatment of a chinchilla’s old radius and ulna fracture

The cortex of the limb bones of chinchillas is very thin and brittle, so it is prone to fractures of the limb bones, among which fractures of the tibia, radius and ulna are the most frequent types. When a chinchilla has a closed fracture, it can be immobilized with a splint, cast, or bandage. If the broken end of the fracture pierces the skin, it is best to choose internal fixation or external fixation brackets for treatment. In this report, a 0.661 kg, 2-year-old male uncastrated chinchilla was presented to the Veterinary Teaching Hospital of Huazhong Agricultural University due to an old fracture of the right forearm. With the consent of the owner, we decided to use a 25-gauge needle as an IM pin to fix the fracture. Ten days after surgery, the wound had healed well, and the limb could support body weight, but the palm did not show a grasping position. Twenty four days after the operation, the affected limb had not regained the ability to grasp. The X-ray showed a slight rotation of the IM pin and good callus growth in the ulna, but not in the radius. One month after the operation, it was found that the function of the affected limb of the chinchilla was normal and the grasping ability was restored through follow-up consultation and the return visit.

Early unplanned return visits to pediatric emergency departments in Israel during the SARS-CoV-2 pandemic

IntroductionDuring the SARS-CoV-2 pandemic there was a considerable drop in the number of visits to Pediatric Emergency Departments (PED). Unplanned return visits (URV) might represent inadequate emergency care. We assessed the impact of the pandemic on early URV to PEDs in Israel. MethodsThis multicenter cross-sectional study analyzed the 72-h URV to PEDs among patients under the age of 18 years during a one-year pandemic period (March 1st, 2020, to February 28th, 2021), and compared them with the 72-h URV of the corresponding pre-pandemic period (March 1st, 2019, to February 28th, 2020). Data was extracted from Clalit Health Services (CHS), the largest public health care organization in Israel. ResultsThe pandemic and pre-pandemic early URV rates were 5465 (5.1%) and 8775 (5.6%), respectively (OR = 0.90, 95% CI 0.92–0.99). The rate of return-visit admissions to hospital wards during these periods were 29.5% and 32.1%, respectively (OR = 0.83, 95% CI 0.86–0.98). The rate of return-visit admissions to ICUs during these periods were 0.64% and 0.52%, respectively (OR = 1.11, 95% CI 0.67–1.62). On return-visit, 3 (0.055%) and 5 (0.057%) URV patients were declared dead on arrival during the pandemic and pre-pandemic periods, respectively (OR = 0.96, 95% CI 0.23–4.03). The distributions of the time interval from index visit to return visit remained consistent between the periods. DiscussionIn our study, early URV to PED's were only mildly influenced by the SARS-CoV-2 pandemic.

‘Maru Dharmaj’: Gujarati Patidar diaspora and transnational engagement

ABSTRACT This article examines the transnational engagement of the Gujarati Patidar diaspora with its village of origin—Dharmaj, India—through return visits. ‘Dharmaj Day’ is a homecoming event that demonstrates how return visits shape and are shaped by migrant subjectivity concerning the Patidar diaspora. It analyzes the emergence of Dharmaj Day, the experiences of the Gujarati Patidar diaspora regarding this day, and Dharmaj Day as a transnational field based on a phenomenological approach. In-depth interviews with transmigrants and Dharmaj residents revealed that Dharmaj Day originated from the return visits of the transmigrants, strengthening transnational networks established between the two groups to share difficulties faced abroad and to reminisce about the home or the ‘gam’ (village). Simultaneously, Dharmaj day highlights the status of the Gujarati Patidar diaspora in transnational networks and strengthens their hold over Dharmaj, thereby deepening social divisions. Concurrently, it also makes the village and residents ‘transnational’.

Differences in the characteristics and patterns of adult emergency department return visits before and after the coronavirus disease 2019 outbreak

Data about changes in the characteristics of ED return visits before and after the COVID-19 outbreak are limited. This study aimed to report the differences on utility in ED return visits after the COVID-19 outbreak. This retrospective cohort study was conducted from 2019 to 2020. Adult patients with ED return visits were included in the analysis. Variables including demographic characteristics, pre-comorbidities, triage levels, vital signs, chief complaints, management, and diagnosis were recorded and confirmed via a manual assessment. The proportion of patients with ED visits decreased by 23%. Hence, that of patients with ED return visits also reduced from 2580 to 2020 patients (22%) after the COVID-19 outbreak. The average age (60-57.8 years) of patients with return visits was significantly younger, and the proportion of female patients decreased remarkably. Further, the proportion of patients with chronic pre-existing diseases at the return visit significantly differed after the COVID-19 outbreak. The proportion of patients with chief complaints including dizziness, dyspnea, cough, vomiting, diarrhea, and chills during the return visits significantly differed before and after the COVID-19 pandemic. In the multivariable logistic regression model, age, high triage level were significantly associated with unfavorable outcome return visit. The use of services in the ED has changed since the COVID-19 outbreak. Hence, the proportion of patients with unplanned return visits within 72h decreased. After the COVID-19 outbreak, people are now cautious whether they should return to the ED, as in the pre-pandemic situation, or just treat conservatively at home.

The effect of short-term preoperative nutritional intervention for cleft surgery eligibility

BackgroundChildren with orofacial clefts are highly susceptible to malnutrition, with severe malnutrition restricting their eligibility to receive safe surgery. Ready-to-use therapeutic foods (RUTF) are an effective treatment for malnutrition; however, the effectiveness has not been demonstrated in this patient population prior to surgery. We studied the effectiveness of short-term RUTF use in transitioning children with malnutrition, who were initially ineligible for surgery, into surgical candidates.MethodsA cohort of patients from Ghana, Honduras, Malawi, Madagascar, Nicaragua, and Venezuela enrolled in a nutrition program were followed by Operation Smile from June 2017 to January 2020. Age, weight, and length/height were tracked at each visit. Patients were included until they were sufficiently nourished (Z > = -1) with a secondary outcome of receiving surgery. The study was part of a collaborative program between Operation Smile (NGO), Birdsong Peanuts (peanut shellers and distributors), and MANA Nutrition (RUTF producer).ResultsA total of 556 patients were recruited between June 2017 and January 2020. At baseline 28.2% (n = 157) of patients were diagnosed with severe, 21.0% (n = 117) moderate, and 50.7% (n = 282) mild malnutrition. 324 (58.3%) presented for at least one return visit. Of those, 207 (63.7%) reached optimal nutrition status. By visit two, the mean z-score increased from -2.5 (moderate) to -1.7 (mild) (p < 0·001). The mean time to attain optimal nutrition was 6 weeks. There was a significant difference in the proportion of patients who improved by country(p < 0.001).ConclusionMalnutrition prevents many children with orofacial clefts in low- and middle-income countries from receiving surgical care even when provided for free. This creates an even larger disparity in access to surgery. In an average of 6 weeks with an approximate cost of $25 USD per patient, RUTF transitioned over 60% of patients into nutritionally eligible surgical candidates, making it an effective, short-term preoperative nutritional intervention. Through unique partnerships, the expansion of cost-effective, large-scale nutrition programs can play a pivotal role in ensuring those at the highest risk of living with unrepaired orofacial clefts receive timely and safe surgical care.

Ambulatory follow-up among publicly insured children discharged from the emergency department.

While children discharged from the emergency department (ED) are frequently advised to follow up with ambulatory care providers, the extent to which this occurs is unknown. We sought to characterize the proportion of publicly insured children who have an ambulatory visit following ED discharge, identify factors associated with ambulatory follow-up, and evaluate the association of ambulatory follow-up with subsequent hospital-based health care utilization. We performed a cross-sectional study of pediatric (<18 years) encounters during 2019 included in the IBM Watson Medicaid MarketScan claims database from seven U.S. states. Our primary outcome was an ambulatory follow-up visit within 7 days of ED discharge. Secondary outcomes were 7-day ED return visits and hospitalizations. Logistic regression and Cox proportional hazards were used for multivariable modeling. We included 1,408,406 index ED encounters (median age 5 years, IQR 2-10 years), for which a 7-day ambulatory visit occurred in 280,602 (19.9%). Conditions with the highest proportion of 7-day ambulatory follow-up included seizures (36.4%); allergic, immunologic, and rheumatologic diseases (24.6%); other gastrointestinal diseases (24.5%); and fever (24.1%). Ambulatory follow-up was associated with younger age, Hispanic ethnicity, weekend ED discharge, ambulatory encounters prior to the ED visit, and diagnostic testing performed during the ED encounter. Ambulatory follow-up was inversely associated with Black race and ambulatory care-sensitive or complex chronic conditions. In Cox models, ambulatory follow-up was associated with a higher hazard ratio (HR) of subsequent ED return (HR range 1.32-1.65) visit and hospitalization (HR range 3.10-4.03). One-fifth of children discharged from the ED have an ambulatory visit within 7 days, which varied by patient characteristics and diagnoses. Children with ambulatory follow-up have a greater subsequent health care utilization, including subsequent ED visit and/or hospitalization. These findings identify the need to further research the role and costs associated with routine post-ED visit follow-up.

Patients' experiences and reasons for unplanned return visits to the emergency department: A qualitative study.

The aim of this study was to explore the reasons for and experiences of patients who make an unplanned return visit to the emergency department. This study forms the qualitative phase of a larger explanatory sequential mixed methods study and is informed by interpretive description. The paper was prepared using the consolidated criteria for reporting qualitative research. Semi-structured patient interviews were conducted over a 3-month period (July-September 2021). Data were analysed using reflexive thematic analysis. Interviews from 13 participants generated findings related to experiences at and following their initial visit that contributed to their decision to return to the emergency department. Four themes were developed: (1) Patients experience barriers to feeling heard and having their concerns addressed; (2) Patients have little choice but to place their trust in clinicians; (3) Patients unexpectedly experience persistent symptoms which cannot be managed at home; and (4) Patients develop a sense of urgency about having their condition treated. A negative experience at the initial ED visit may have dual conflicting impacts. It can contribute to patients' perceived need for a return visit because they are ill-equipped to manage their condition at home, and it can also contribute to their initial reluctance to return to the ED when symptoms persist. Nurses and other clinicians working in ED need to actively build patient's experiential trust through clear communication, timely consultation and shared decision-making at discharge, which in turn can increase patient's confidence and capability to self-manage their condition. This study adds to the current body of literature about return visits by highlighting that a more positive experience of ED may assist patients to make better-informed decisions about when and how to seek treatment and minimize unnecessary and unplanned return visits. Whilst not an intended topic for exploration in this study, the COVID-19 pandemic influenced patients' experiences at both initial and return ED visits and limited their ability to access primary healthcare options. These experiences contributed to patients' decisions to make a return visit.

Justify Return Visits

The Major Gifts ReportVolume 25, Issue 4 p. 2-2 Briefs Justify Return Visits First published: 06 March 2023 https://doi.org/10.1002/mgr.32107Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume25, Issue4April 2023Pages 2-2 RelatedInformation

Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network

BackgroundDiagnostic errors, reframed as missed opportunities for improving diagnosis (MOIDs), are poorly understood in the paediatric emergency department (ED) setting. We investigated the clinical experience, harm and contributing factors related...

Abstract Number ‐ 278: Transient Ischemic Attack Evaluation Pathways: Inpatient Versus Expedited Outpatient Comparative Analysis

Introduction Transient Ischemic Attack (TIA) evaluation requires urgent etiology identification and targeted stroke prevention, traditionally performed via hospital admission. The literature suggests that outpatient evaluation may be safe and cost‐effective. Hence, we implemented an expedited outpatient pathway (OP) for patients presenting to our institution’s Emergency Department (ED) with TIA. To further guide future practice, we compared clinical features and outcomes between expedited OP and our well‐established inpatient pathway (IP). Methods We implemented an algorithm of direct communication between ED providers and Vascular Neurologists for all TIA patients. Certain screening studies (head CT, CT angiogram, basic laboratories) and acute therapies were implemented in the ED, whereas others (brain MRI, echocardiogram, etc) and Vascular Neurology consultations were expedited outpatient within 48–72 hours.We included all patients that underwent OP evaluation from May 2021‐May 2022. Further, we extracted patients with a final diagnosis of TIA and compared them with IP TIA patients hospitalized (2017‐2021), matched by age, gender, and clinical severity (ABCD2). Descriptive statistics were used to summarize patient demographics, clinical data, treatments, and 3‐month outcomes. Continuous variables were summarized with mean and standard deviations while categorical variables were shown as counts and percentages. Chi‐square test was used for categorical variables and Mann‐Whitney U test was used to compare continuous variables. P‐values &lt; 0.05 were considered statistically significant and all tests were two‐sided. Statistical Analysis was completed in R 4.0.3. Results Of 43 patients who underwent expedited OP TIA workup, TIA or minor stroke was diagnosed in 21/43 (48.9%). 18 TIAs underwent comparative analyses. Mean symptom duration was longer in the IP (2.06 hours) than OP (0.99 hours), p = 0.370%. TIA was more likely to be diagnosed in the OP 14/18 (78%) versus IP 12/18 (67%), (p = 0.423). OP had more transesophageal echocardiograms (17% vs 5%, p = 0.630) and longer duration of ambulatory cardiac monitoring (mean 574.3 vs 381.7 hours, p = 0.100). IP patients were more likely to get started on anticoagulation compared to OP (38% vs 11%, p = 0.258) and high‐intensity statin (38% vs 17%, p = 0.260). All laboratories, echocardiograms and brain MR imaging were performed significantly sooner for the IP (p&lt; 0.05 for all). IP had higher rate of return ED visits (22%) and readmissions at 3 months (11%), whereas OP had none. OP had no deaths or recurrent strokes, whereas 11% and 5.6% respectively were noted in the IP at 3 months (p = 0.310, p = 0.310). Conclusions Our study shows that routine IP evaluation for patients presenting with TIA in the ED may not offer diagnostic superiority nor lead to improvement of short‐term clinical outcomes, as compared to the expedited OP evaluation. Careful evaluation of TIA patients in the ED followed by expedited OP evaluation might be a plausible approach to help lower costs and avoid hospitalization without compromising the safety of these patients.

Abstract P372: Drivers of Visit Modality in Primary Care Clinics at an Academic Medical Center

Background: Informed by drivers of visit modality in specialty clinics, we sought to identify factors associated with visit modality selection (telemedicine vs. in-person) for new and return visits in primary care clinics at a large academic medical center (AMC). Methods: We used electronic health record data from 3/2020 - 5/2022 from 13 primary care clinics with 98 unique clinicians for new and 131 for return visits (21,031 new &amp; 207,292 return visits), with about 55% telemedicine (telephone and video) use. We used hierarchical logistic regression and cross-validation methods to estimate the variation in visit modality associated with the patient, clinician, and visit factors (measured with Area Under the Curve). Results: For both new and return visits, there was significant variation in telemedicine use among clinicians (ranging from 0 - 100%) for specific clinical diagnoses (Figure 1). Most variation in telemedicine use was attributed to the clinician seen (new visits) and primary visit diagnosis (return visits). Other visit and patient characteristics were less predictive. For new visits, the clinician model had an AUC of 0.79, followed by clinic site 0.69, whereas for return visits, the primary diagnosis was 0.77, followed by the clinician seen at 0.65. Diagnoses most commonly seen via telemedicine include acute respiratory infection and suspected COVID-19 exposure. Diagnoses commonly seen in-person include annual physical and gynecological exams. Conclusions: Our findings show high variability in telemedicine use for the same diagnosis and differential drivers of visit modality between new and return visits in primary care clinics at a large AMC. Provider ID was the most predictive factor of visit modality for new patients, indicating that clinician preference and individual practice patterns influence the modality of care much more than patient preference. Primary care clinics may reduce the variability in visit modality through standardized processes that integrate clinical factors and patient preference.

Return to the Emergency Department Within 3 Months Following Pediatric Acute Concussion.

To determine the proportion of concussed children returning to the emergency department (ED) for a concussion-related reason within 3 months of initial presentation and to determine which clinical composite score (5P or Post-Concussion Symptom Inventory) best predicts a return visit. We combined a secondary analysis of data from the prospectively collected 5P study with a retrospective medical record review of children aged 5 to 18 years who returned to the Children's Hospital of Eastern Ontario (CHEO) ED for a concussion-related reason within 3 months of an acutely diagnosed concussion. Among 770 eligible participants, 632 children (median age: 11.8 [interquartile range (IQR), 9.0-14.5] years; 58.9% male) were included in the study. The primary outcome was the number of patients who returned to CHEO ED for a concussion-related reason within 3 months of an acute concussion diagnosed at CHEO ED. The secondary outcome was number of patients who returned within 14 days. Forty-seven children (7.4%; 95% confidence interval [CI]: 5.6-9.7) had a concussion-related return to the ED within 3 months, the majority of which occurred in the first 14 days (29/47; 61.7%; 95% CI: 47.4-74.2). History of migraines (21.3% vs 9.7%; P = .03) were more common in those with a return visit. Headache was the most frequently reported symptom (87.2%) on revisit. Females aged 13 to 18 years had the highest return rate (survival rate: 85.8% [95% CI: 79.8-92.3]) compared with males and younger age groups. In multivariable Cox hazards regression modeling, inclusion of risk scores improved prognostication (pseudo R2 = 8%). The difference in pseudo R2 between 5P and Post-Concussion Symptom Inventory is small. Most children and adolescents do not return to the ED following an acute concussion. Female youth with medium to high 5P scores at the index concussion visit may benefit from early referral to interdisciplinary specialty concussion care to guide treatment in anticipation of prolonged symptoms. By identifying these risk factors at the initial ED visit, healthcare and patient burden may be reduced.