Routine Appointments Research Articles

Great expectations? GPs’ estimations of time required to deliver BMJ’s ‘10 minute consultations’

ObjectivesTo estimate the time required to undertake consultations according to BMJ’s 10-minute consultation articles.To quantify the tasks recommended in 10-minute consultation articles.To determine if, and to what extent, the time...

Screening for juvenile idiopathic arthritis associated uveitis with laser flare photometry in the pediatric rheumatology office: a prospective observational study

BackgroundJuvenile Idiopathic Arthritis (JIA) Associated Uveitis (JIA-U) remains one of the most serious complications of JIA in children. Historically, pediatric JIA is diagnosed by an Optometrist or Ophthalmologist; however, barriers to scheduling increase wait times that may delay diagnosis and treatment. The purpose of this study was to evaluate laser flare photometry (LFP) use to diagnose JIA-U in the Pediatric Rheumatology clinic for patients with JIA.MethodsThis prospective, observational study assessed pediatric patients diagnosed with JIA without a previous history of uveitis between January 2020 and September 2022. All patients underwent at least one evaluation of both eyes using a Kowa FM-600 laser flare photometer during a routine Rheumatology appointment, as well as a standard slit lamp examination (SLE) by optometry or ophthalmology during routine clinical care. Data collected at patient visits included demographics, JIA characteristics, treatment, LFP readings, and anterior chamber (AC) cell grade score utilizing the SUN grading system. Data were summarized using descriptive analyses and the uveitis false positive rate was calculated.ResultsThe study cohort included 58 pediatric patients diagnosed with JIA. The mean age was 8.4 years (1.2–16.3 years) at diagnosis and 11.9 (4.8–16.5 years) at enrollment. The mean duration of disease at time of enrollment was 42 months (range; 0-157 months). Participants were predominantly female (n = 43, 74.1%) and white/Caucasian race (n = 37, 63.8%). The most common JIA subtypes included persistent oligoarticular JIA (n = 19, 32.8%), and RF negative polyarticular JIA (n = 12, 20.7%). There were 12 ANA positive patients (20.7%). At enrollment, 16 patients (27.6%) were not on medications, with 20 (34.5%) on methotrexate, 20 (34.5%) on adalimumab, 6 (10.3%) on tocilizumab, and 5 (8.6%) on etanercept. During the study period, no eye exams detected active uveitis based on SLE with a SUN grade over 0. However, of the 135 LFP readings, 131 (97.0%) were normal, yielding a false positive rate of 3% (95% CI: 0.8%, 7.4%).ConclusionsLFP is a non-invasive tool that can be utilized in the pediatric rheumatology clinic to evaluate for JIA-U. There is a low false positive rate of LFP when compared with standard slit lamp exam.

P1145 Assessing disease control in inflammatory bowel disease (IBD) – a real world cross-sectional study in the UK

Abstract Background There is a paucity of data on disease control in patients with inflammatory bowel disease (IBD) in clinical practice. The Proportion Of suboptimal Disease Control And Strategy of Treatment in IBD (PODCAST-IBD) multicentre, non-interventional study aimed to quantify real-world rates of disease control using the STRIDE-II recommendations, explore contributors to, and the economic burden of, suboptimal disease control. Methods Cross sectional assessment of patients with IBD attending routine clinic appointments was carried out in four UK centres between Oct 2022 and Jan 2023. Clinician-reported outcomes, patient-reported outcomes and retrospective data from medical chart review were used to assess IBD control against red flags aligned to the STRIDE-II recommendations (Table). Health care resource utilisation (HCRU) was calculated using NHS reference costs. Results Data was available from 198 patients (Crohn's disease [CD]: 103, ulcerative colitis [UC]: 95) and most were currently receiving long-term IBD-specific treatment (CD: 85%, UC: 78%). IBD was suboptimally controlled in 52.4% (54/103) of patients with CD and 45.3% (49/95) with UC. Impaired quality of life (QOL), defined as Short inflammatory bowel disease questionnaire (SIBDQ) score <50, was the most frequent contributor to suboptimal disease control for both UC and CD. Other frequent contributors were systemic steroid overuse, extraintestinal manifestations (EIM), failure to achieve clinical improvement and perianal disease (Figure). Suboptimal disease control has a detrimental impact on fatigue and disability, demonstrated by lower (indicating more fatigue) mean total FACIT-F score in suboptimally controlled disease (CD: 81.5 vs 125, UC: 87.4 vs 122.8) and IBD Disk, a 10-item self-questionnaire used to assess IBD-related disability. HCRU more than doubled in patients with suboptimal vs optimal control (CD: £4,746 vs £1,924; UC: £2,428 vs £1,121), driven by more hospital admissions and emergency room visits in patients with suboptimal disease control. Patients with suboptimal disease control had higher rates of work productivity loss than those with optimal control (CD: 41.7% vs 11.9%, UC: 38.0% vs 22.6%). Conclusion This UK cross-sectional study found that IBD was suboptimally controlled in around one-half of patients based on STRIDE-II recommendations. Of those with suboptimally controlled disease one-third had impaired QOL making it the most common contributor. Suboptimal control of IBD had a considerable economic impact; HCRU more than doubled and productivity fell. Physicians could consider regular QOL assessments to prompt timely disease monitoring to enable identification of early active disease and ensure appropriate treatment.

Antibiotic use in first opinion equine practice in the United Kingdom: Serial point prevalence surveys in 17 practices

SummaryBackgroundMonitoring antibiotic use (AMU) is a key component of antimicrobial stewardship. Published data on AMU in first opinion equine practice are limited.ObjectivesTo document AMU in first opinion equine practices.Study designRepeated point prevalence surveys.MethodsAMU was recorded one day every month for 12 consecutive months in 17 equine practices.ResultsTwo hundred and fifty‐two horses were prescribed antibiotics across 2273 consultations (excluding routine appointments) (11.1%; 95% CI 9.8%–12.4%). Median number of consultations per practice was 121 (IQR 112–159; range 27–303). Across 17 practices, the proportion of horses receiving antibiotics varied by practice from 0% to 26.4%. Commonest indications for AMU included cellulitis (66; 26.8%), wounds (46; 18.7%), surgical prophylaxis (36; 14.6%), respiratory infection (27; 11.0%) and skin infection (20; 8.1%). Commonest antibiotics prescribed were potentiated sulphonamides (109; 43.6%), oxytetracycline (58; 23.2%), procaine penicillin (40; 16.0%) and doxycycline (36; 14.4%). 45.0% of oxytetracycline use was for surgical prophylaxis. 44.8% of procaine penicillin use was for cellulitis. 28.6% of ‘other antimicrobial’ use was for pyrexia of unknown origin. Use of antibiotics differed significantly depending on the underlying diagnosis (p < 0.001). Median antibiotic dose rates were: potentiated sulphonamides 30 mg/kg (IQR 27–75; range 10–75; n = 96); procaine penicillin 19 mg/kg (IQR 15–23; range 7–30; n = 35); oxytetracycline 6 mg/kg (IQR 5–6; range 4–30; n = 55); doxycycline 10 mg/kg (IQR 10–20; range 7–30; n = 34).Main limitationsWeight of horses were often estimated. Duration of antibiotic courses was not recorded.ConclusionsAntibiotics were prescribed in 11% of nonroutine consultations. Commonest indication for AMU was cellulitis. Potentiated sulphonamides, oxytetracycline and procaine penicillin were the commonest prescribed drugs. Critically important antibiotic use was infrequent. Dose rates varied, but median values were generally appropriate.

Direct discharge for children with a greenstick or torus fracture of the wrist is a non-inferior satisfactory solution to traditional treatment.

Direct Discharge protocols (DD) can alleviate strain on healthcare systems by reducing routine outpatient follow-up. These protocols include low-complex musculoskeletal injuries, such as isolated greenstick fractures or torus fractures of the wrist in children. While there is consensus on the effectiveness of DD, there is a lack of injury-specific powered studies. This study compares treatment satisfaction between DD and traditional treatment in children with a greenstick fracture or torus fractures of the wrist. Children with isolated torus or greenstick fractures of the distal radius or ulna were eligible for inclusion before (pre-DD cohort) and after (DD cohort) the implementation of DD in four hospitals. Traditionally, patients receive a (soft) cast and minimally one routine outpatient follow-up appointment. With DD, patients are discharged directly from the ED after receiving a brace and information, summarized in a smartphone app and a helpline for questions during recovery. The primary outcome was patient or proxy treatment satisfaction (0 to 10), and a power analysis was performed to assess non-inferiority. Secondary outcomes included complications, functional outcomes measured in Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE), primary healthcare utilisation, and secondary healthcare utilisation (follow-up appointments and imaging). In total, 274 consecutive children were included to analyse the primary endpoint. Of these, 160 (58%) were male with a median age of 11years (IQR 8 to 12). Pre-DD and DD treatment satisfaction did not vary statistically significantly for greenstick fractures (p = 0.09) and torus fractures (p = 0.93). No complications were observed. PROMIS UE showed no statistically significant differences before and after implementation of direct discharge protocol for torus (p = 0.99) or greenstick (p = 0.45) fractures. Secondary healthcare utilisation regarding follow-up was significantly lower in the DD-torus cohort compared to the pre-DD torus cohort, with a mean difference (MD) of -1.00 follow-up appointments (95% Confidence Interval (CI) -0.92 to -1.13). Similar results were found in the pre DD-greenstick cohort compared to the pre-DD-greenstick cohort (MD): -1.17 follow-up appointments, 95% CI -1.09 to -1.26). Direct Discharge is non-inferior to traditional treatment in terms of treatment satisfaction for paediatric patients with greenstick or torus fractures of the wrist compared to children treated with rigid immobilisation and routine follow-up. Furthermore, the results demonstrate no complications, comparable functional outcomes, and a statistically significant reduction of secondary healthcare utilisation, making DD a good solution to cope with strained resources for children with an isolated greenstick fracture or torus fracture of the wrist.

Evaluating the network adequacy of vision care services for children in Arizona: A cross sectional study.

Vision challenges are among the most prevalent disabling conditions in childhood, affecting up to 28% of school-age children. These issues can impact the development, learning, and literacy skills of affected children. While vision problems are correctable with timely diagnosis and treatment, insufficient networks can impede children's access to comprehensive, and high-quality care. The study aims to determine where pediatric vision care network adequacy exists in the state of Arizona and where there are gaps in receiving vision care for children. This cross-sectional study assessed the adequacy of pediatric vision care networks in Arizona through a "secret shopper" phone survey. Calls were made to practices that accept Arizona's Medicaid program, Arizona Health Care Cost Containment System (AHCCCS) and/or commercial insurance. Providers were contacted following a standardized script to schedule routine appointments on behalf of 10 and 3-year-old patients enrolled in either Medicaid or commercial health insurance plans. The study examined various components of children's access to vision care services, including the reliability of provider directory information, time until the next available appointment, bilingual service offerings, ages served, region of practice and types of care available. A total of 556 practices in Arizona were evaluated through simulations as patients on AHCCCS, and 510 practices were assessed through simulations as patients with commercial health insurance plans. The average wait time for the next available appointment was 13 days for both insurance types. Alarmingly, up to 74% of vision care practices in Arizona do not serve children covered by AHCCCS. Furthermore, only 41% provide services to children 5 years and younger. Our findings underscore the need to improve access to vision care services for children in Arizona, especially racial/ethnic minorities, low-income groups, and rural residents.

Spontaneous closure of perimembranous ventricular septal defect in a cat

We discuss the case of a 5-month-old male British Shorthair referred to our hospital following the detection of a heart murmur during a routine vaccination appointment. Two-dimensional echocardiography revealed a 1.18 mm ventricular septal defect (VSD) located immediately below the aortic valve, without signs of secondary cardiac remodeling. Given the absence of cardiac dysfunction, no treatment was administered, and the cat was periodically monitored over the next 2 years. Echocardiography at 29 months of age revealed no signs of the VSD. Future studies are needed to increase the evidence base for spontaneous VSD closure in small animals.

Survivorship care in breast cancer: understanding implementation barriers through the lens of the Theoretical Domains Framework.

Breast cancer survivorship guidelines with specific recommendations on managing long-term effects are available, but uptake in clinical practice remains low. Using the lens of the Theoretical Domains Framework, we aimed to understand key factors in guideline-concordant management of long-term effects to inform future implementation efforts in clinical practice contexts. As part of a broader survey of oncologists, a theory-guided questionnaire was developed. Oncologists were asked to report level of agreement with Theoretical Domains Framework-based statements, current usage and perceived value of survivorship resources, and frequency of managing long-term effects in routine care. Data analyses included psychometric assessment of the questionnaire, descriptive summaries of theoretical domains and survivorship resources, and multivariable logistic regression models. In total, 217 oncologists completed the Theoretical Domains Framework-based questionnaire; 54% of oncologists reported "always or almost always" evaluating physical effects at routine survivorship appointments, while 34% did so for psychosocial effects. In regression models, Environmental Context and Resources was the only theoretical domain found to be statistically significantly associated with "always or almost always" evaluating both physical (odds ratio = 0.29, 95% confidence interval = 0.09 to 0.80) and psychosocial (odds ratio = 0.09, 95% confidence interval = 0.02 to 0.35) effects. Findings support application of the Theoretical Domains Framework in understanding oncologists' behaviors and perceived barriers in managing long-term effects in breast cancer survivors. In future implementation efforts, this theory-informed approach can be used to target relevant domains and strategies focused on embedding guideline recommendations in the clinical context through structured resources and environmental supports.

Sexual network characteristics and partnership types among men who have sex with men diagnosed with syphilis, gonorrhoea and/or chlamydia in Lima, Peru

ObjectivesSexual networks are known to structure sexually transmitted infection (STI) transmission among men who have sex with men (MSM). We sought to estimate the risks of STI diagnosis for various...

Screening for HPV-Related Oropharyngeal Cancer in Gay and Bisexual Men: Acceptability and Predicting Possible Use of "Oral Selfies" by Smartphone as a Secondary Prevention Approach.

Oropharyngeal cancers (OPCa) caused by HPV have emerged as one of the leading causes of malignancies caused by HPV infection. They are also significantly more likely to occur in males and in people with a history of oral sex with multiple partners. Gay and bisexual men are disproportionately affected by HPV-positive oropharyngeal cancers. We studied 1699 gay and bisexual men on 2 major dating sites in the US to assess their knowledge about HPV-related OPCa, attitudes toward screening for it, beliefs about oropharyngeal cancer screening based on the Health Belief Model, and attitudes toward possible screening approaches for OPCa. Knowledge on a 12-item scale was low, with a median of 5 items correct: 72% knew of the benefits of HPV vaccination. Significant predictors of needing OPCa screening included perception of risk for OPCa, seeing it as severe, having lower barriers, fewer reasons to avoid screening, higher knowledge, and being HPV vaccinated were significant predictors, explaining half the total variance. Most participants would accept routine, virtual/online doctor or dental appointments, and over half would accept an in-person screening. Nearly two-thirds stated that they would accept getting checked for OPCa if they could do self-screening at home, and half were prepared to use an online screening tool or app, where they could take an "oral selfie" and send it to a healthcare provider for examination. One-third stated that they would trust the results of a home screening completed by themselves and posted to a website equally as cancer screening completed online by a healthcare provider. Data indicate that despite low OPCA knowledge levels, the risk of HPV-associated OPCa was known. Being at personal risk and having knowledge of disease severity had 70% of the sample thinking about, or preparing to get, screening. Self-screening by a smartphone "oral selfie" transmitted to a screening website was acceptable to many gay and bisexual men, and online screening by a doctor or dentist was acceptable to most. OPCa screening in this population using electronic technology, together with the increasing incidence of HPV-associated OPCa in gay and bisexual men, brings together an opportunity to detect OPCa early.

Exploring the Experiences of Virtual Inflammatory Bowel Disease Care in Saskatchewan.

Individuals with inflammatory bowel disease (IBD) require life-long interactions with the healthcare system. Virtual care (VC) technologies are becoming increasingly utilized for accessing healthcare services. Research related to the use of VC technology for the management of IBD in Canada is limited. This study aimed to examine the VC experiences from the perspectives of individuals with IBD and gastroenterology care providers (GCPs). A patient-oriented, qualitative descriptive approach was used. Semi-structured interviews were completed with individuals with IBD and GCPs. Data were analyzed using an inductive content analysis approach. A total of 25 individuals with IBD and five GCPs were interviewed. Three categories were identified: benefits of virtual IBD care delivery, challenges of virtual IBD care delivery, and optimizing IBD care delivery. Individuals with IBD and GCPs were satisfied with the use of VC technology for appointments. Participants believed VC was convenient and allowed enhanced access to care. However, VC was not considered ideal in some instances, such as during disease flares or first appointments. Thus, a blended use of virtual and in-person appointments was suggested for individualized care. The virtual method of connecting patients and providers is deemed useful for routine appointments and for persons living in rural areas. VC is becoming more common in the IBD care environment. Nurses are in a key position to facilitate and enhance virtual IBD care delivery for the benefit of both individuals living with IBD and providers.

The Role of Neighborhood Disadvantage, Systemic Inflammation, and Acute Chest Syndrome in Children with Sickle Cell Disease

Introduction: Acute chest syndrome (ACS) is a frequent pulmonary complication of sickle cell disease (SCD) and is a leading cause of morbidity and mortality in both children and adults with SCD. In addition to biological factors, there is increasing recognition that social and environmental factors, such as low socioeconomic status and air pollution, respectively, play a role in disease processes. Current evidence suggests that neighborhood disadvantage influences cardiopulmonary outcomes in non-SCD populations. The disproportionate presence of polluting industries and major roadways near disadvantaged neighborhoods could impact lung health in children with SCD, and exposure to toxic metals has also been linked to worsening systemic inflammation. Yet, the impact of neighborhood disadvantage on inflammation in ACS has not been assessed. The goal of this study is to investigate the effects of neighborhood disadvantage on inflammatory markers in children presenting with ACS. Methods: We enrolled children in our institution with SCD (all genotypes) aged 2-21 years of age with and without a history of ACS. We abstracted clinical information including sex, age, number of ACS episodes up to enrollment, and residential address. In addition, blood samples were collected during routine hematology appointments and hospitalizations for ACS. Plasma cytokine levels were measured using multiplex assays on a subset of participants. Using census tract-level data on poverty, education, housing and employment from the US Census, we computed the area deprivation index (ADI) for census tracts across the greater Houston area and assigned an ADI score to each study subject based on their geocoded address at the time of visit. We dichotomized ADI at the median value (99.0; minimum 42.4, maximum of 156.5) across the study area into “high” and “low” deprivation categories. Results: Forty-four participants met inclusion criteria with complete ADI, clinical and cytokine data. Mean age was 11.6 years (SD 5.1), 52% were male, and 66% lived in a high ADI tract. In children over 10 years of age (n=24), there were higher levels of IL-4, IL-6, IL-8, and IL-13 in those from high ADI areas compared to those from low ADI areas [median concentrations (pg/mL): 139.2 vs 75.7, p=0.53; 17.18 vs 11.92, p=0.67; 15.85 vs 5.38, p=0.20; 19.28 vs 8.30, p=0.38, respectively]. Similarly, IL-4, IL-6, and IL-13 levels were higher in children 10 years and younger from high ADI areas, though not statistically significant. There were no differences between median ADI for patients without a history of ACS and those with recurrent ACS (107.7 vs 108.1, p=0.9). Conclusion: In Houston children with SCD, especially 10 years and older, there were overall higher levels of systemic inflammation in those from high ADI areas compared to those from low ADI areas. However, these findings did not reach statistical significance. There was also no significant difference in ADI scores based on frequency of admissions for ACS. Future studies are needed to analyze cytokines from a larger cohort of patients with SCD and compare ACS outcomes to other regions for a more powered, comprehensive investigation.

A Snapshot Audit of Symptom Burden in Patients with Indolent Systemic Mastocytosis Utilising the ISM-SAF © within a UK Centre of Excellence: Guy's and St Thomas' NHS Foundation Trust

Background: Indolent systemic mastocytosis (ISM) is a rare, clonal haematological neoplasm driven by the KIT D816V mutation in up to 95% of cases. It is characterized by a debilitating, heterogenous and unpredictable symptom burden due to mast cell mediator release among patients. Treatment is limited to symptom management with no approved targeted therapies in the UK. The Indolent Systemic Mastocytosis Symptom Assessment Form (ISM-SAF ©) (Taylor et al. [2021]) is a validated symptom-assessment tool developed specifically for ISM patients focusing on 11 symptoms over a 24-hour recall period: bone pain, abdominal pain, nausea, skin spots, itch, flushing, fatigue, dizziness, brain fog, headache and diarrhoea. Each symptom is scored on a scale from 0-10. To date, there has not been any published UK data examining symptom burden in ISM patients. Subsequently we assessed symptom burden utilising the ISM-SAF © in our patient cohort at Guy's and St Thomas' Hospital. Method: All adult ISM patients who had a routine outpatient appointment between May 2022 and May 2023 were identified retrospectively. Over a four-week period, patients were invited to complete the ISM-SAF © by telephone or in person. Additionally we collected demographic data, clinical data, anti-mediator therapy, anaphylaxis history and the impact of SM on their work and quality of life. All consultations were conducted by a clinical member of the mastocytosis team. Results: 95 adult patients with ISM were identified within our database, of which 76 consented to take part in this study. There was a slight female predominance (41% male; 59% female) and the median age at diagnosis was 46 years (range 21 - 78). Median time to ISM diagnosis was 4.6 years (range 0.5-18.5). Median serum tryptase was 35 mcg/L (range 9-632). 66 patients (88%) were noted to have the KIT D816V mutation (6% D816V-negative, 6% not available). The median Total Symptom Score (TSS) was 24 (range 0-110). The highest scoring symptoms were fatigue (mean score 4.66), skin spots (3.97), brain fog (3.43) and itch (2.83). 33 patients (43%) had a TSS ≥28 which is the threshold determined by psychometric analysis to identify patients with moderate to severe symptoms, and is used for screening in clinical trials (Shields et al. [2023]). 46 patients (61%) were prescribed ≥2 anti-mediator therapies; at the time of the study, current therapies included H1 antihistamines (n=64), H2 antihistamines (n=28), proton pump inhibitors (n=20), sodium cromoglycate (n=18), montelukast (n=12), corticosteroid (n=5) and omalizumab (n=1). 12 patients (16%) were on a bisphosphonate. The number of patients with both a TSS ≥28 and on ≥2 anti-mediator therapies was 27 (36%). 30 patients (39%) reported a history of anaphylaxis at least once in their lifetime while 12% (n=9) reported using an adrenaline autoinjector within the last 12 months. There was no statistically significant correlation between TSS and serum tryptase (Pearson correlation coefficient r= -0.08, p=0.48). Some patients reported having to reduce their working hours, needing adjustments or retiring early due to symptoms attributed to their ISM diagnosis. Conclusions: Our data demonstrate a significant real-world symptom burden among the ISM patient cohort within the UK Mastocytosis Centre of Excellence and reflect the findings of other centres, in particular fatigue being the most severe symptom (van Anrooij et al. [2016]; Mesa et al. [2022]). The ISM-SAF © is an effective tool for capturing a snapshot of symptom severity and has utility in the outpatient setting. Importantly, we found over one third of patients in our centre had a TSS ≥28 and were on ≥2 anti-mediator therapies, meaning they could potentially be eligible to access tyrosine kinase inhibitors within the clinical trial setting.

The utility of the necessity-concerns framework (NCF) in explaining adherence and parental beliefs about controller medication in Saudi Arabian children with asthma

Objective This study aims to assess beliefs about asthma controller medications among parents of Saudi Arabian children with asthma and the association between these beliefs and medication adherence using the Necessity-Concerns Framework. Methods A cross-sectional survey was provided to parents of children with asthma when they brought their children to routine appointments at local public clinics between May 16 and July 10, 2018. Participants electronically filled out validated Arabic versions of the Medication Adherence Reported Scale (MARS) and Beliefs About Medications Questionnaire (BMQ). Descriptive statistics were used to characterize the study participants, while hierarchical linear regression analysis assessed associations between parental beliefs about controller medications and medication adherence. Results A total of 381 parents of children with asthma completed the study survey. The vast majority (89%) of study participants were non-adherent to their children’s prescribed medications while only 11% were adherent. Additionally, our study revealed a significantly positive association between adherence and parents’ beliefs in the necessity of the medication (p < .001), with concerns about the adverse effects of medication being negatively associated with parental adherence. A higher mean score for medication adherence was reported among the ambivalent groups compared to the accepting, indifferent, and skeptical groups. Conclusions Medication adherence among parents of children with asthma was relatively low. In addition, necessity beliefs were significantly associated with parental adherence to controller medications for their children with asthma. Further studies are warranted to investigate potential factors contributing to poor parental adherence and develop tailored interventions that support parental medication adherence for their asthmatic children.

The COVID‐19 pandemic and primary care appointment availability by physician age and gender

AbstractUsing data generated through simulated patient calls to a national random sample of primary care physicians between February and July 2020, we examine the effects of the first wave of COVID‐19 on the availability of the U.S. primary care physician workforce for routine new patient appointments. As states enacted stay‐at‐home orders, physicians overall became less selective by insurance, and there was a 7 percentage‐point increase in acceptance of patient insurance. Telemedicine appointment offers increased 10.2 percentage points from near zero. However, relative to younger counterparts, physicians older than the sample mean (53.1 years) became 18.1 percentage points less likely to offer appointments and decreased their estimated appointment duration by 7.1 min. Compared to male physicians, female physicians became 10 percentage points more likely to accept new patients. These insights into appointment offers during the first wave of COVID‐19 may help policymakers seeking to ensure an adequate physician workforce during future crises.

Women’s awareness of perinatal mental health conditions and the acceptability of being asked about mental health in two regions in India: a qualitative study

BackgroundMental health conditions are common during pregnancy and the first year after childbirth. Early detection allows timely support and treatment to be offered, but identifying perinatal mental health conditions may be challenging due to stigma and under-recognition of symptoms. Asking about symptoms of mental health conditions during routine antenatal and postnatal appointments can help to identify women at risk. This study explores women’s awareness of perinatal mental health conditions, their views on the acceptability of being asked about mental health and any preference for specific assessment tools in two regions in India.MethodsFocus group discussions (FGDs) were conducted with pregnant, post-partum and non-perinatal women in Kangra, Himachal Pradesh (northern India) and Bengaluru, Karnataka (southern India). Settings included a hospital antenatal clinic and obstetric ward, Anganwadi Centres and Primary Health Centres. FGDs were facilitated, audio-recorded and transcribed. Narratives were coded for emerging themes and analysed using thematic analysis.ResultsSeven FGDs including 36 participants were conducted. Emerging themes were: manifestations of and contributors to mental health conditions; challenges in talking about mental health; and the acceptability of being asked about mental health. Difficult familial relationships, prioritising the needs of others and pressure to have a male infant were cited as key stressors. Being asked about mental health was generally reported to be acceptable, though some women felt uncomfortable with questions about suicidality. No preference for any specific assessment tool was reported.ConclusionsWomen face many stressors during the perinatal period including difficult familial relationships and societal pressure to bear a male infant. Being asked about mental health was generally considered to be acceptable, but questions relating to suicidality may be challenging in a community setting, requiring sensitivity by the interviewer. Future studies should assess the acceptability of mental health assessments in ‘real world’ antenatal and postnatal clinics and explore ways of overcoming the associated challenges in resource-constrained settings.

Designing Worthy Waiting Spaces: A Cross-Cultural Study of Waiting Room Features and Their Impact on Women's Affective States.

This study examines the impact of ambulatory waiting room characteristics on patients' emotional states and investigates whether these states are universally experienced or influenced by social and cultural factors among women aged 18-35 from the three largest demographic groups in the United States: Black, Hispanic/Latina, and White. Patients typically spend more time waiting for routine medical appointments than receiving care, and evidence suggests that waiting can reinforces power dynamics that benefit privileged groups, leading to different experiences for minority women seeking preventative care. Still, literature addressing the impact of waiting areas is largely limited to universal measures, and little is known about how different ethnic/race groups respond to waiting spaces. This inquiry used a questionnaire assessing 15 waiting room characteristics and testing four variables (furniture arrangement, room-scale, color saturation, and quantity of positive distractions) in a 2 × 3 quasiexperiment using a fractional randomized block design with 24 waiting room images. Responses from 1,114 participants revealed mutual preferences for sociopetal seating, positive distractions, neutral colors, and welcoming and calming environments. Yet, Black participants indicated significantly greater importance in seeing ethnically/racially similar patients and healthcare providers and strategies that promote transparency, including image-based provider directories and views into the clinic. By investigating the impact of the waiting room environment on patient affect and comparing perceptions across three demographic groups of women, this study offers insights into potential strategies for improving access to preventative care services by creating more welcoming ambulatory care waiting environments.

Mapping barriers to midwives’ educational role in Cyprus guided by the Theoretical Domains Framework

Abstract Issue The high caesarean section (C/S) rate in Cyprus (&amp;gt;60%) led to the formation of a National Committee to address this Public Health priority. Among WHO recommendations for C/S reduction are midwifery-led educational interventions; yet, medicalization of birth in Cyprus is curtailing the autonomous role of midwives. Description of problem While midwives could “make every contact count” during routine appointments, antenatal education (AE) is reduced to a formal activity within the antenatal class space with documented low attendance. This formative research mapped barriers to the educational role of Cypriot midwives guided by behaviour theory. A context-specific understanding is needed to shape an appropriate intervention and promote a common understanding among stakeholders. Results One in three midwives islandwide (N = 119, response: 34%) rated 83 determinants (from 1=more to 6=less problematic), guided by the Theoretical Domains Framework (TDF). “Beliefs about AE importance” (M = 5.57, SD = 0.96) and “Professional role” (M = 5.58, SD = 0.57) received the highest scores. Lack of organizational resources (M = 3.39, SD = 0.97), institutional and inter-professional support (M = 3.77, SD = 1.4) and acceptance (M = 4.25, SD = 0.85) were identified as problematic. While perceived capabilities and intentions were rated favourably, achieving “Goals” was difficult, mainly due to competing priorities (M = 3.86, SD = 0.84). Self-efficacy and behavioural control were lower among less experienced midwives (p &amp;lt; 0.01) and in the private sector (p = 0.08), which accounts for &amp;gt;70% of births. Lessons Beyond the antenatal class, AE is a ‘bad fit’ with routine practice. The phenomenon pertains to organizational arrangements but also norms and perceptions of other providers and service users. While current Healthcare reforms present prospects in re-defining the role of midwives, the educational role is not adequately supported or promoted given the limited number of visits and reimbursement restrictions imposed. Key messages • Barriers to routine antenatal education originate from an unsupportive system and socio-cultural norms which alienate midwives in an already medicalized environment. • This theory-driven formative study described the issue in behaviour terms in the context of shaping an intervention to strengthen the health education role of midwives.

Using "Real-World Data" to Study Cleft Lip/Palate Care: An Exploration of Speech Outcomes from a Multi-Center US Learning Health Network.

To assess the ability of a cleft-specific multi-site learning health network registry to describe variations in cleft outcomes by cleft phenotypes, ages, and treatment centers. Observed variations were assessed for coherence with prior study findings. Cross-sectional analysis of prospectively collected data from 2019-2022. Six cleft treatment centers collected data systematically during routine clinic appointments according to a standardized protocol. 714 English-speaking children and adolescents with non-syndromic cleft lip/palate. Routine multidisciplinary care and systematic outcomes measurement by cleft teams. Speech outcomes included articulatory accuracy measured by Percent Consonants Correct (PCC), velopharyngeal function measured by Velopharyngeal Competence (VPC) Rating Scale (VPC-R), intelligibility measured by caregiver-reported Intelligibility in Context Scale (ICS), and two CLEFT-Q™ surveys, in which patients rate their own speech function and level of speech distress. 12year-olds exhibited high median PCC scores (91-100%), high frequency of velopharyngeal competency (62.50-100%), and high median Speech Function (80-91) relative to younger peers parsed by phenotype. Patients with bilateral cleft lip, alveolus, and palate reported low PCC scores (51-91%) relative to peers at some ages and low frequency of velopharyngeal competency (26.67%) at 5 years. ICS scores ranged from 3.93-5.0 for all ages and phenotypes. Speech Function and Speech Distress were similar across phenotypes. This exploration of speech outcomes demonstrates the current ability of the cleft-specific registry to support cleft research efforts as a source of "real-world" data. Further work is focused on developing robust methodology for hypothesis-driven research and causal inference.

THU096 When TSH Alone Is Not Enough

Abstract Disclosure: S.S. Awasty: None. L. Ghalib: None. Background: A Thyrotropinoma or TSHoma is the rarest of all pituitary adenomas approximately 1-2%. TSHomas are often only found due to symptoms from co-secreting tumors with TSHomas or routine laboratory testing. Misinterpretation of laboratory values can cause misdiagnosis and inappropriate treatment. Clinical Case: A 45-year-old female presented to her primary care physician for a routine appointment. The patient reported concerns regarding weight and a TSH was ordered, TSH 7.00 uIU/mL (0.49 - 4.67) with no other thyroid function values. The physician prescribed levothyroxine 50mcg treating for primary hypothyroidism and over the next 37 months the patient was prescribed increasing doses of levothyroxine based on TSH values. This patient was eventually referred to Endocrinology. At the initial Endocrinology visit TSH 7.59 uIU/mL (0.27 - 4.2 uIU/mL) and fT4 3.2 ng/dL (0.7 - 1.7) on levothyroxine 125mcg. Levothyroxine was discontinued and labs were repeated 6 weeks later TSH 5.9 uIU/mL (0.27 - 4.2), fT4 4.8 ng/dL (0.7 - 1.7), fT3 2.1 pg/mL (2 - 4.4), and alpha-subunit 1.5ng/mL (&amp;lt;=1.2 premenopausal female, &amp;lt;=1.8 postmenopausal female). A pituitary macroadenoma was discovered on MRI. The patient was referred to Pituitary Clinic and noted to have a prolactin of 53.8 ng/mL (non-pregnant females 2.8-29.2) and IGF-1 291.6 ng/mL (60.0 - 240.0). The patient underwent transsphenoidal pituitary surgery; pathology reported a plurihormonal subtype pituitary adenoma which stained positive for Prolactin, HGH, and TSH. One week after removal of the TSHoma, TSH 0.014 uIU/mL (0.550 - 4.780) fT4 0.65 ng/dL (0.89 - 1.76), and levothyroxine replacement was initiated with plans for continued outpatient monitoring to assess need for levothyroxine replacement. Conclusion: This case primarily demonstrates the importance of evaluating TSH levels in conjunction with free T4 levels to effectively interpret central versus primary causes of thyroid dysfunction. The high molar ratio of the alpha-subunit to the TSH level lends itself to a TSHoma differentiating it from a diagnosis of syndrome of resistance to thyroid hormone. While rare missing a TSHoma diagnosis could have devastating consequences. Checking other pituitary hormones pre-operatively even without symptoms also gave the indication that this was a co-secreting tumor. After adenoma removal rechecking pituitary hormones is of great importance as exemplified by pituitary-thyroid axis suppression noted post-operatively in this case. Presentation: Thursday, June 15, 2023