Return Visit Research Articles

Nationwide implementation of best practices in pancreatic cancer care (PACAP-1): Stepped-wedge cluster randomized trial.

4152 Background: Implementation of new treatment strategies in cancer care is often inadequate and slow. We aimed to implement best practices in pancreatic cancer care using a nationwide stepped wedge design and assess the impact on overall survival. Methods: Nationwide multicenter stepped-wedge cluster randomized controlled trial comparing implementation of best practices with usual care (May 22, 2018 – May 29, 2020). Best practices included adequate use of perioperative and palliative chemotherapy, pancreatic enzyme replacement therapy (PERT), and metal biliary stents. The 6-week implementation period in all 17 Dutch pancreatic centers and their regional referral networks included monitoring, return visits, and provider feedback in combination with education and reminders. Primary outcome was one-year overall survival for all disease stages and secondary outcomes included guideline compliance and quality of life. Results: Overall, 5580 patients diagnosed with pancreatic cancer were included; 2939 after implementation of best practices versus 2641 before. One-year survival did not differ among the groups (HR 0.98, 95 CI 0.88-1.08). Overall use of perioperative chemotherapy (neoadjuvant and adjuvant) did not significantly differ, but use of palliative chemotherapy significantly increased (23.9% to 30.3%, OR 1.38, 95 CI 1.10-1.74). Also the use of PERT (34.2% to 45.2%, OR 1.64, 95 CI 1.28-2.11); and metal biliary stents (74.1.% to 83.3%, OR 1.78, 95 CI 1.13-2.08) significantly increased. The Global Health Score did not differ (AUC 43.8 to 42.7, median difference -1.12, 95 CI -3.13-0.80, n=655). Conclusions: This nationwide population-based trial to enhance implementation of best practices in pancreatic cancer care showed successful implementation of most best practices, but no increase in one-year survival and quality of life. Clinical trial information: NCT03513705 .

Touched and Changed: Self-Reflexivity and Reciprocity in Fieldwork

Touched and Changed: Self-Reflexivity and Reciprocity in Fieldwork

Trends and disparities in oncology telehealth after the initial pandemic era.

1606 Background: While the COVID pandemic elevated the usage of telehealth to unprecedented levels, it remains unclear whether telehealth use is sustained after the initial pandemic era, and whether there remain demographic differences in telehealth utilization. In this study, we compared telehealth trends amongst different demographic populations in a large integrated healthcare system. Methods: Utilization of various visit types (office, video, telephone) was investigated in this population-based retrospective cohort study at 22 Kaiser Permanente Northern California Hematology and Oncology clinics from 10/1/2020 to 6/1/2022. We explored trends associated with the COVID 19 pandemic and after the initial pandemic era as well as demographic differences, using Chi-square for categorical and the Mann-Whitney U Test for non-parametric comparisons. Results: During the study period, there were 341,089 hematology/oncology visits with MD/DO providers, including 83,756 (24.5%) office, 125,162 (36.7%) video, and 132,171 (38.7%) telephone. Total monthly visits remained stable, with a monthly average of 1,765 (10.9%) for new visits and 14,476 (89.1%) for return visits. Monthly telehealth visits (telephone + video) peaked in January, 2021 (85.6% of total visits) and subsequently declined by June, 2022 (68.7% of total visits). Telephone visits increased from 46.1% of telehealth visits to 58.9% over the study period. Amongst telehealth visits, video visits remained popular for new appointments (56.9%) while telephone visits were more common for return appointments (60.7%). After the initial pandemic era, telehealth utilization continued to differ amongst different demographic populations. Video visits remained a significantly higher fraction of all visits (p<0.01) in: (1) less than 45 year-old (60.0%) compared to older than 80 year-old (33.2%); (2) primary English speakers (50.7%) compared to those who require an interpreter (41.5%); (3) patients with commercial insurance (58.2%) compared to those with Medicaid (47.0%) or Medicare (45.2%); (4) non-Hispanic Whites (51.4%) and Asians (52.2%) compared to Hispanic Whites (45.0%) and Blacks (43.6%); (5) patients with the lowest neighborhood deprivation index (NDI) quartile (living in the least deprived neighborhood) (54.0%) vs the highest quartile (46.1%). Conclusions: After the initial pandemic era, telehealth utilization declined slightly over time but remained a common method of providing oncology care. Video visits continued to be widely utilized for initial visits whereas there was a shift to telephone visits for follow up appointments over time. Disparities in telehealth, especially in video visits, continued to be seen in various demographic populations by age, English proficiency, insurance plan, race/ethnicity and neighborhood deprivation index. Continued high utilization of telehealth should inform policy and practices in the post-pandemic era.

Safety of same day administration of pegfilgrastim in breast cancer patients.

e18850 Background: Myelosuppressive therapy plays a crucial role in the treatment plan of patients with cancer; one common toxicity associated with myelosuppressive regimens is neutropenic fever. Pegfilgrastim is approved for use no sooner than 24 hours after receiving cytotoxic therapy, based on the initial FDA indication, requiring a return to clinic or the use of a patented on-body injector placed at the time of treatment. However, alternative schedules assessing earlier administration were never examined in the FDA registration studies. Small studies have suggested that same-day administration of pegfilgrastim can be carried out safely, including a prior safety study at UAB. The present analysis sought to test the non-inferiority of same day pegfilgrastim compared to administration 24-72 hours after cytotoxic chemotherapy. Methods: We undertook a retrospective analysis of 241 breast cancer patients receiving cytotoxic therapy from May 2016 through October 2018. The patient population was predominately Caucasian women with 28% African American or Asian women, and a median age of 55 (33-81). I2B2 codes identified patients with breast cancer receiving adjuvant or neoadjuvant therapy patients receiving same day versus next day pegfilgrastim were compared. Blood counts, delays in therapy, and neutropenic hospitalizations were analyzed for same day versus 24-hour delayed pegfilgrastim at two separate institutions. Dose reduced metastatic regimens were excluded from this review. Results: We comparedthe rate of neutropenia resulting in dose-delay for breast cancer patients receiving standard chemotherapy with administration of pegfilgrastim on both schedules. Overall, neutropenia with fever resulting in delay of subsequent chemotherapy was similar in both groups with same day administration being non-inferior to the standard administration schedule. Other treatment delays due to non-neutropenic conditions included mucositis, port malfunction, COPD, fatigue, and transportation delays. Conclusions: Policies requiring 24-hour delays following chemotherapy for pegfilgrastrim administration, reduce utilization of biosimilars and make the on-body injector, Onpro, a more convenient, albeit expensive option, for patients and the health system. These data suggest that same day administration of pegfilgastrim are non-inferior to delayed administration and may provide both substantial cost savings and quality of life benefits to patients and health care systems by increasing utilization of biosimilars and removing the need for a return visit after chemotherapy. In addition, same day administration also reduces the risk of complications associated with on body injector use, where failure rates of up to 10% are reported.

Multidisciplinary teams, efficient communication, procedure services, and telehealth improve cirrhosis care: A qualitative study.

Cirrhosis care and outcomes are improved with access to subspecialty gastroenterology and hepatology care. In qualitative interviews, we investigated clinicians' perceptions of factors that optimize or impede cirrhosis care. We conducted 24 telephone interviews with subspecialty clinicians at 7 Veterans Affairs medical centers with high- and low-complexity services. Purposive sampling stratified Veterans Affairs medical centers on timely post-hospitalization follow-up, a quality measure. We asked open-ended questions about facilitators and barriers of care coordination, access to appointments, procedures, transplantation, management of complications, keeping up to date with medical knowledge, and telehealth use. Key themes that facilitated care were structural: multidisciplinary teams, clinical dashboards, mechanisms for appointment tracking and reminders, and local or virtual access to transplant and liver cancer specialists through the "specialty care access network extension for community health care outcomes" program. Coordination and efficient communication between transplant and non-transplant specialists and between transplant and primary care facilitated timely care. Same-day access to laboratory, procedural, and clinical services is an indicator of high-quality care. Barriers included lack of on-site procedural services, clinician turnover, patient social needs related to transportation, costs, and patient forgetfulness due to HE. Telehealth enabled lower complexity sites to obtain recommendations for complex patient cases. Barriers to telehealth included lack of credit (eg, VA billing equivalent), inadequate staff, lack of audiovisual technology support, and patient and staff discomfort with technology. Telehealth was optimal for return visits, cases where physical examination was nonessential, and where distance and transportation precluded in-person care. Rapid telehealth uptake during the COVID-19 pandemic was a positive disruptor and facilitated use. We identify multi-level factors related to structure, staffing, technology, and care organization to optimize cirrhosis care delivery.

Is Pain in the Uninjured Leg Associated With Unhelpful Thoughts and Distress Regarding Symptoms During Recovery From Lower Extremity Injury?

Patients recovering from lower extremity injuries often interpret discomfort associated with increased use of the uninjured leg as a potential indication of harm. If expressed concerns regarding contralateral leg pain are associated with unhelpful thinking regarding symptoms, they can signal orthopaedic surgeons to gently reorient these thoughts to help improve comfort and capability during recovery. We asked: (1) Among people recovering from isolated traumatic lower extremity injury, is pain intensity in the uninjured leg associated with unhelpful thoughts and feelings of distress regarding symptoms, accounting for other factors? (2) Are pain intensity in the injured leg, magnitude of capability, and accommodation of pain associated with unhelpful thoughts and feelings of distress regarding symptoms? Between February 2020 and February 2022, we enrolled 139 patients presenting for an initial evaluation or return visit for any traumatic lower extremity injury at the offices of one of three musculoskeletal specialists. Patients had the option to decline filling out our surveys, but because of the cross-sectional design, required fields on the electronic survey tools, and monitored completion, there were few declines and few incomplete surveys. The median age of participants was 41 years (IQR 32 to 58), and 48% (67 of 139) were women. Fifty percent (70 of 139) injured their right leg. Sixty-five percent (91 of 139) had operative treatment of their fracture. Patients completed measures of pain intensity in the uninjured leg, pain intensity in the injured leg, lower extremity-specific magnitude of capability, symptoms of depression, symptoms of health anxiety, catastrophic thinking, and accommodation of pain. Multivariable analysis sought factors independently associated with pain intensity in the uninjured leg, pain intensity in the injured leg, magnitude of capability, and pain accommodation, controlling for other demographic and injury-related factors. Greater pain intensity in the uninjured leg (regression coefficient [RC] 0.09 [95% CI 0.02 to 0.16]; p < 0.01) was moderately associated with more unhelpful thinking regarding symptoms. This indicates that for every one-unit increase in unhelpful thinking regarding symptoms on the 17-point scale we used to measure pain catastrophizing, pain intensity in the uninjured leg increases by 0.94 points on the 11-point scale that we used to measure pain intensity, holding all other independent variables constant. Greater pain intensity in the injured leg (RC 0.18 [95% CI 0.08 to 0.27]; p < 0.01) was modestly associated with more unhelpful thinking regarding symptoms. Greater pain accommodation (RC -0.25 [95% CI -0.38 to -0.12]; p < 0.01) was modestly associated with less unhelpful thinking regarding symptoms. Greater magnitude of capability was not independently associated with less unhelpful thinking regarding symptoms. A patient's report of concerns regarding pain in the uninjured limb (such as, "I'm overcompensating for the pain in my other leg") can be considered an indicator of unhelpful thinking regarding symptoms. Orthopaedic surgeons can use such reports to recognize unhelpful thinking and begin guiding patients toward healthier thoughts and behaviors. Level II, prognostic study.

Preterm and Term Infants Evaluated for Sepsis: Differences in Management and Clinical Outcomes.

To describe differences in practice patterns and outcomes of young preterm versus age-matched term infants evaluated for sepsis, because evaluation and management of this group are not well defined. We conducted a retrospective single-center study at an academic, freestanding children's hospital of previously healthy preterm and term infants aged 0 to 60 days, who presented for initial evaluation of fever and/or hypothermia from 2014 to 2019. We classified infants by gestational age as preterm (32-36 6/7 weeks) and term (37-42 weeks) and compared diagnostic evaluation, management, and clinical outcomes. Out of 363 preterm infants evaluated for sepsis, 336 met inclusion criteria; within the same study period, 2331 term infants were evaluated for sepsis, of which 600 were randomly selected and 554 were included. Clinicians performed inflammatory marker testing and chest x-rays more frequently in preterm infants 31% vs 25% (P = .034) and 50% vs 32% (P < .001), respectively. Preterm infants had a higher rate of bacteremia 5.9% vs 2.5% (P = .035), were hospitalized more frequently 72% vs 63% (P = .006), and required ICU level of care more often 32% vs 5% (P < .001) than term infants. They had lower rates of viral infections 33% vs 42% (P = .015) and no significant increased return visits. Febrile preterm and term infants, and older hypothermic preterm infants had relatively higher rates of serious bacterial infections. Hypothermic preterm infants had the longest hospitalizations. Preterm infants had increased rates of bacteremia and required higher level of care compared with age-matched term infants, likely reflecting their increased risk for sepsis and other concomitant morbidities associated with preterm birth.

Ten-Year Analysis of Complications Related to Simple Basilar Skull Fractures in Children Presenting to a Trauma Center.

Head trauma is a common presenting complaint among children requiring urgent medical attention, accounting for more than 600,000 emergency department (ED) visits annually, 4% to 30% of which identify skull fractures among the patient's injuries. Previous literature shows that children with basilar skull fractures (BSFs) are usually admitted for observation. We studied whether children with an isolated BSF have complications precluding them from safe discharge home from the ED. We performed a retrospective review of ED patients aged 0 to 18 years given a simple BSF diagnosis (defined by nondisplaced fracture, with normal neurologic examination, Glasgow Coma Score of 15, no intracranial hemorrhage, no pneumocephalus) during a 10-year period to identify complications associated with their injury. Complications were defined as death, vascular injury, delayed intracranial hemorrhage, sinus thrombosis, or meningitis. We also considered hospital length of stay (LOS) longer than 24 hours or any return visit within 3 weeks of the original injury. Of the 174 patients included in the analysis, there were no deaths, cases of meningitis, vascular injury, nor delayed bleeding events. Thirty (17.2%) patients required a hospital LOS longer than 24 hours and 9 (5.2%) returned to the hospital within 3 weeks of discharge. Of those with LOS longer than 24 hours, 22 (12.6%) patients needed subspecialty consultation or intravenous fluids, 3 (1.7%) had cerebrospinal fluid leak, and 2 (1.2%) had a concern for facial nerve abnormality. On the return visits, only 1 (0.6%) patient required readmission for intravenous fluids because of nausea and vomiting. Our findings suggest that patients with uncomplicated BSFs can be safely discharged from the ED if the patient has reliable follow-up, is tolerating oral fluids, has no evidence of cerebrospinal fluid leak, and has been evaluated by appropriate subspecialists before discharge.

The Pediatric Emergency Department Nurse and Gastrostomy Tube Replacement: How Safe Is it?

To review the outcomes of a nurse-only guideline for replacement of gastrostomy tubes (g-tubes) in a pediatric emergency department (ED) and compare rates of success, failure, length of stay (LOS), and return visits with that of ED physicians. Nursing g-tube guidelines, created by a nurse educator and nursing council, were instigated on January 31, 2018. Variables examined included LOS, age at visit, return visit within 72 hours, reason for replacement, and any postplacement complications. Data of g-tube placement by nurses and physicians were compared using t test or χ 2 analysis (IBM-SPSS version 20, New Orchard Road, Armonk, NY). The institutional review board determined the study to be exempt from human subjects. The STROBE checklist was used and completed accordingly. Chart abstraction and data were collected from January 1, 2011 through April 13, 2020, and medical records were obtained using International Classification of Diseases, Tenth Revision (ICD-10) codes for g-tubes: Z93.1, K94.23. A total of 110 patients were included in our study. Fifty-eight underwent nursing-only replacements; 52 were replaced by physicians. Nurse replacement success rate was 98.3% with an average stay of 22 minutes. Physician success rate was 100% with an average stay of 86 minutes. The difference between nursing and physician LOS was 64.6 minutes. No patient in either group experienced postreplacement complications. The initiation of nurse-only management of dislodged g-tubes was successful, safe, and had a shorter LOS when compared with physicians in the pediatric ED. Our study determined the implications of nurse-only replacement of g-tubes in a pediatric ED. We found that nurses replacing g-tubes was equally safe and effective as physician counterparts. In addition, we found that it significantly reduced the LOS for patients, which has consequences on patient satisfaction and billing. Nursing staff were trained in g-tube replacement using guidelines created by a nurse educator and nursing council. Patients either had their dislodged g-tubes replaced by the trained nurse or a physician and comparisons on the outcomes were made. Patients were aware of the study and consented to have their medical records accessed to make the data comparisons. With more than 189,000 children in the United States relying on g-tubes, nursing staff will inevitably be involved in the care of patients with such a device. In addition, as pediatric EDs continue to develop longer and longer waiting times, we must learn how to better use our nursing staff for procedures within their scope and minimize LOS. Our research demonstrates the safety, feasibility, and general benefits of having the pediatric nursing staff replace g-tubes in the ED, and it is hoped that this will lead to beneficial policy changes. - Demonstrates the safety and effectiveness of nurse-only g-tube replacement- Reports on the statistically significant difference in LOS between physician and nurse replacement of g-tubes in a pediatric ED- Has the ability to lead to policy change in the pediatric ED that will allow for greater patient satisfaction and decrease patient cost.

Frequencies and reasons for unplanned emergency department return visits by older adults: a cohort study

BackgroundAs unplanned Emergency Department (ED) return visits (URVs) are associated with adverse health outcomes in older adults, many EDs have initiated post-discharge interventions to reduce URVs. Unfortunately, most interventions fail to reduce URVs, including telephone follow-up after ED discharge, investigated in a recent trial. To understand why these interventions were not effective, we analyzed patient and ED visit characteristics and reasons for URVs within 30 days for patients aged ≥ 70 years.MethodsData was used from a randomized controlled trial, investigating whether telephone follow-up after ED discharge reduced URVs compared to a satisfaction survey call. Only observational data from control group patients were used. Patient and index ED visit characteristics were compared between patients with and without URVs. Two independent researchers determined the reasons for URVs and categorized them into: patient-related, illness-related, new complaints and other reasons. Associations were examined between the number of URVs per patient and the categories of reasons for URVs.ResultsOf the 1659 patients, 222 (13.4%) had at least one URV within 30 days. Male sex, ED visit in the 30 days before the index ED visit, triage category “urgent”, longer length of ED stay, urinary tract problems, and dyspnea were associated with URVs. Of the 222 patients with an URV, 31 (14%) returned for patient-related reasons, 95 (43%) for illness-related reasons, 76 (34%) for a new complaint and 20 (9%) for other reasons. URVs of patients who returned ≥ 3 times were mostly illness-related (72%).ConclusionAs the majority of patients had an URV for illness-related reasons or new complaints, these data fuel the discussion as to whether URVs can or should be prevented.Trial registrationFor this cohort study, we used data from a randomized controlled trial (RCT). This trial was pre-registered in the Netherlands Trial Register with number NTR6815 on the 7th of November 2017.

Value-Based Care for Healthy Children With First Episode of Febrile Neutropenia.

There is a lack of guidance on the management of febrile neutropenia in otherwise healthy children, including the need for hospitalization and antibiotic administration, leading to significant practice variation in management. The aim of this initiative was to decrease the number of unnecessary hospitalizations and empirical antibiotics prescribed by 50% over a 24-month period for well-appearing, previously healthy patients older than 6 months presenting to the emergency department with a first episode of febrile neutropenia. A multidisciplinary team of stakeholders was assembled to develop a multipronged intervention strategy using the Model for Improvement. A guideline for the management of healthy children with febrile neutropenia was created, coupled with education, targeted audit and feedback, and reminders. Statistical control process methods were used to analyze the primary outcome of the percentage of low-risk patients receiving empirical antibiotics and/or hospitalization. Balancing measures included missed serious bacterial infection, emergency department (ED) return visit, and a new hematologic diagnosis. Over the 44-month study period, the mean percentage of low-risk patients hospitalized and/or who received antibiotics decreased from 73.3% to 12.9%. Importantly, there were no missed serious bacterial infections, no new hematologic diagnoses after ED discharge, and only 2 ED return visits within 72 hours without adverse outcomes. A guideline for the standardized management of febrile neutropenia in low-risk patients increases value-based care through reduced hospitalizations and antibiotics. Education, targeted audit and feedback, and reminders supported sustainability of these improvements.

Factors associated with mild bronchiolitis in young infants.

Bronchiolitis within the first 3 months of life is a risk factor for more severe illness. We aimed to identify characteristics associated with mild bronchiolitis in infants ≤90 days old presenting to the emergency department (ED). We conducted a secondary analysis of infants ≤90 days old with clinically diagnosed bronchiolitis using data from the 25th Multicenter Airway Research Collaboration prospective cohort study. We excluded infants with direct intensive care unit admissions. Mild bronchiolitis was defined as (1) sent home after the index ED visit and did not have a return ED visit or had a return ED visit without hospitalization, or (2) were hospitalized from the index ED visit to the inpatient floor for<24hours. Multivariable logistic regression, adjusting for potential clustering by hospital site, was used to identify factors associated with mild bronchiolitis. Of 373 infants aged ≤90 days, 333 were eligible for analysis. Of these, 155 (47%) infants had mild bronchiolitis, and none required mechanical ventilation. Adjusting for infant characteristics, clinical factors associated with mild bronchiolitis included older age (61-90 days vs 0-60 days) (odds ratio [OR] 2.72, 95% confidence interval [CI] 1.52-4.87), adequate oral intake (OR 4.48, 95% CI 2.08-9.66), and lowest ED oxygen saturation ≥94% (OR 3.12, 95% CI 1.55-6.30). Among infants aged ≤90 days presenting to the ED with bronchiolitis, about half had mild bronchiolitis. Mild illness was associated with older age (61-90 days), adequate oral intake, and oxygen saturation ≥94%. These predictors may help in the development of strategies to limit unnecessary hospitalization in young infants with bronchiolitis.

Financial Impact of the Indiana University Student-Run Free Clinic.

Student-run free clinics (SRFCs) serve as an important public safety-net for un- and under-insured patients. Few studies have investigated their financial impact or return of investment to the community. The aim of this study was to estimate the financial impact of the Indiana University Student Outreach Clinic (IUSOC) using national market values of medical visits and lab services in 2021.From internal triage classification records maintained from March to December 2021, Current Procedural Terminology (CPT) codes were assigned corresponding to "New Patient," "Returning Quick or Long" and "Fast Track" visits. Total Work Relative Value Units (wRVUs) were calculated to then estimate the total monetary value for medical services. Similarly, the collection of laboratory services rendered from March to December 2021 were assigned costs using the 2021 Center for Medicare and Medicaid Services (CMS) fee schedule.There were a total of 1475 medical visits identified in this study under the triage categories of interest, with 440 New Patient visits, 1032 Returning Quick and Long visits, and 3 Fast Track visits. From the calculated total wRVUs, the estimated monetary value for medical services was $95,413.79. Additionally, there were 3633 eligible lab tests ordered; almost half of these (1523, 41.9%) were categorized as routine lab tests (CMP, BMP, CBC, lipid panel). The estimated value of lab services was $56,296.81.Our estimates reveal that the IUSOC provided nearly $150,000 worth of free healthcare to the community in 2021. Further, most patients were seen for return visits, revealing the opportunity to streamline logistics.

Cost-effectiveness analysis of direct admission to acute geriatric unit versus admission after an emergency department visit for elderly patients

BackgroundElderly individuals represent an increasing proportion of emergency department (ED) users. In the Greater Paris University Hospitals (APHP) direct-admission study, direct admission (DA) to an acute geriatric unit (AGU) was associated with a shorter hospital length of stay (LOS), lower post-acute care transfers, and lower risk of an ED return visit in the month following the AGU hospitalization compared with admission after an ED visit. Until now, no economic evaluation of DA has been available.MethodsWe aimed to evaluate the cost-effectiveness of DA to an AGU versus admission after an ED visit in elderly patients. This was conducted alongside the APHP direct-admission study which used electronic medical records and administrative claims data from the Greater Paris University Hospitals (APHP) Health Data Warehouse and involved 19 different AGUs. We included all patients ≥ 75 years old who were admitted to an AGU for more than 24 h between January 1, 2013 and December 31, 2018. The effectiveness criterion was the occurrence of ED return visit in the month following AGU hospitalization. We compared the costs of an AGU stay in the DA versus the ED visit group. The perspective was that of the payer. To characterise and summarize uncertainty, we used a non-parametric bootstrap resampling and constructed cost-effectiveness accessibility curves.ResultsAt baseline, mean costs per patient were €5113 and €5131 in the DA and ED visit groups, respectively. ED return visit rates were 3.3% (n = 81) in the DA group and 3.9% (n = 160) in the ED group (p = 0.21). After bootstrap, the incremental cost-effectiveness ratio was €-4249 (95%CI= -66,001; +45,547) per ED return visit averted. Acceptability curves showed that DA could be considered a cost-effective intervention at a threshold of €-2405 per ED return visit avoided.ConclusionThe results of this cost-effectiveness analysis of DA to an AGU versus admission after an ED visit for elderly patients argues in favor of DA, which could help provide support for public decision making.

Effectiveness of a Self-Administered Computerized Mental Health Screening Tool in the Emergency Department.

The authors sought to determine the effectiveness of a self-administered computerized mental health screening tool in a general acute care emergency department (ED). Changes in patient care (diagnosis of a past-year psychiatric disorder, request for psychiatric consultation, psychiatric referral at discharge, or transfer to psychiatric facility) and patient ED return visits (3 months after discharge vs. 3 months before) were assessed among ED physicians (N=451) who received patients' computerized screening reports (N=207) and those who did not (N=244). All patients received copies of screening results. The computerized mental health screening tool identified previously undiagnosed psychiatric problems. However, no statistically significant differences were found in physician care or patient ED return visits. Computerized mental health screening did not result in further psychiatric diagnoses or treatment; it also did not significantly reduce patient ED return visits. Collaboration among EDs and mental health treatment agencies, organizations, and researchers is needed to facilitate appropriate treatment referrals and linkage.

Brand Management of Natural Spaces: The Impact of Natural Space Authenticity on Consumer Outcomes

Perceived authenticity of publicly owned natural parks is an important yet often overlooked driver of consumer experience, enjoyment, and well-being. Given the U.S. National Park Service's charge to operate parks for the enjoyment of the public while conserving them for the future, it is important for park agencies to understand how visitors perceive the authenticity of parks and how they can increase perceived authenticity of the spaces they manage. The authors use the construct of brand authenticity as the foundation of a natural space authenticity framework and draw on attention restoration theory to highlight the importance of viewing the marketing of natural spaces as a form of brand management. In a survey of 2,646 visitors to state parks and a series of three experiments, the authors examine the impact of natural space authenticity (perceived continuity, credibility, and symbolism) on consumer outcomes. Findings indicate that these three dimensions of natural space authenticity improve outcomes of return visit intentions, recommendation intentions, decreased stress, and perceived health for prior and potential visitors of state parks. The authors present managerial and policy implications to assist park managers and guide future research.

Nonspecific Diagnoses and Return Visits Among Children Discharged From the Emergency Department.

Previous work has suggested an association between diagnostic uncertainty and the use of nonspecific diagnostic billing codes. We sought to evaluate differences in emergency department (ED) return visits among children discharged from the ED with specific and nonspecific discharge diagnosis codes. We performed a retrospective study including children (aged <18 years) discharged from 40 pediatric EDs between July 2021 and June 2022. Our primary and secondary outcomes were 7-day and 30-day ED return visits, respectively. Our predictor of interest was diagnosis, classified as nonspecific (only signs/symptoms diagnoses, e.g., "cough") or specific (≥1 specific diagnosis, e.g., "pneumonia"). We evaluated for associations using Cox proportional hazard models adjusted for race/ethnicity, payer status, age, medical complexity, and neighborhood opportunity. Among 1870100 discharged children, 7-day return visits occurred in 73956 (4.0%); of these, 15.8% had nonspecific discharge diagnoses. The adjusted hazard ratio (aHR) of a return visit among children with a nonspecific diagnosis on their index visit was 1.08 (95% confidence interval, 1.06-1.10). Nonspecific diagnoses with the highest aHR of return visits were for fever, convulsions, digestive system, abdominal signs/symptoms, and headache. Respiratory and emotional/behavior signs or symptoms had a lower aHR of 7-day return visits. The aHR of nonspecific diagnosis on 30-day return visits was 1.01 (95% confidence interval 1.01-1.03). Children with nonspecific diagnoses discharged from the ED had distinct patterns of health care utilization compared with those having specific diagnoses. Further research is required to evaluate the role of diagnostic uncertainty with diagnosis code application in the ED.

Comparison of intralesional bleomycin versus salicylic acid 16.5% and lactic acid 16.5% combination paint in management of plantar warts

BackgroundSalicylic and lactic acid (SAL) paint is commonly used to treat warts due to ease of application without any instrumentation. Intralesional bleomycin has been used for the treatment of warts since the 1970s with high efficacy even at low concentration. The aim of this study was to assess the efficacy of single dose of intralesional bleomycin in the treatment of plantar warts in comparison with a control group of similar sample receiving SAL paint application. MethodsPatients were randomly divided into two groups to receive either single dose of intralesional bleomycin injection or SAL paint application daily for maximum of two months. Plantar warts of the patients were assessed at baseline and with each return visit including a post-treatment follow-up of six months. ResultsOf the 100 patients enrolled in the study, 50 (50%) patients were treated with intralesional bleomycin, and 50 (50%) were treated with SAL paint. Out of total 441 treated warts in 100 patients, 198 (44.89%) warts were treated with intralesional bleomycin, and 243 (55.1%) warts were treated with SAL paint. The clearance rates in the context of number of patients and number of warts were 94% (47 out of 50) and 97.97% (194 out of 198) for bleomycin and 36% (18 out of 50) and 27.5% (67 out of 243) for SAL paint, respectively. ConclusionSingle dose of intralesional bleomycin injection is significantly more effective than SAL paint for the treatment of plantar warts.

PENGARUH CITRA DESTINASI TERHADAP MINAT BERKUNJUNG KEMBALI KE OBYEK WISATA WADUK KEDUNG OMBO

This study researches the effect of destination image on the interest in revisiting the Kedung Ombo Reservoir tourist attraction using a quantitative approach. Data collection in this study was carried out using a questionnaire questionnaire distributed online to visitors to the tourist attraction. The sample size of this study was 100 respondents, and data processing was conducted using IBM SPSS Statistics software version 21. The t-test analysis showed that partly cognitive and partly conative factors had a positive and significant effect on revisit interest, while Affective had a significant but weak effect. The implication of this study is that destination managers should prioritise improving cognitive and conative factors to increase visitors' interest in returning to Kedung Ombo Reservoir. The novelty of this study lies in its empirical findings, which contribute to the destination management literature regarding the influence of destination image on return visit interest.

Elements affecting emergency department rate of return within 72 hours: a retrospective cross-sectional study

Background: Many patients view emergency departments (EDs) as their top choice for medical problems because they act as an easily accessible entry point into the healthcare system. The frequency of ED visits, the causes, and the burden must be considered to evaluate the quality and outcome of care. The researcher aimed to investigate the elements that affect the rate of return to the emergency department within 72 hours. In addition, to determine the underlying factors associated with unplanned ED return visits. Methods: It was a retrospective cross-sectional study. Results: The result of this study shows that 1535 unplanned ED return visits out of 53387. The rate was 2.9%. A total of 339 (22%) patients of unplanned ED returned visits were admitted to the hospital which is representing 8% of the total hospital admission from ED. Conclusions: The study found that certain types of presenting complaints, such as fever, cough, and throat pain related to respiratory tract infection, were associated with a higher rate of unplanned return at a rate of 33% (513). The results of this study suggest that interventions aimed at improving access to follow-up care, and patient education with effective communication. In addition, continuously monitoring the rate of unplanned ED return and linking that rate to the ED physician's individual performance review might effectively reduce the rate and improve the quality and outcome of care.