Specialist Appointments Research Articles

P0687DO ALL PATIENTS BENEFIT FROM MULTIDISCIPLINARY CHRONIC KIDNEY DISEASE CLINICS?

Abstract Background and Aims: Multidisciplinary clinics (MDC’s) were established in Canada to offer a variety of support systems (diabetes care, social support, easy access to pharmacists, dietitians, specialty trained nurses), to monitor and delay progression through timed lab investigations and visits in conjunction with the Nephrologist. The reasons for better outcomes have been identified as better education, focus on self-care, dietary interventions, timely transplant referrals, modality education, lower hospitalizations and mortality. Treating all patients with chronic kidney disease (CKD) as part of a multidisciplinary care team runs the risk of adding unwarranted labs, interventions, polypharmacy and costs. Kidney Failure Risk Equation (KFRE) uses routine laboratory and clinical data, to stratify patients into three risk categories (low, medium, and high risk) of progression. KFRE has been shown to accurately estimate progression to kidney failure in adults with CKD. The objectives of the study were to i) validate the KFRE in our CKD patients, ii) evaluate health care utilization of patients based on the risk of progression in our province, Saskatchewan. iii) identify the subgroup of patients that benefit most from follow up in MDC. Methods: We conducted a retrospective study on 1007 patients with CKD stages G3 and G4 in two CKD multidisciplinary clinics in the province of Saskatchewan, Canada (January 2004-December 2012). The predicted risk of kidney failure (low, medium high) for each patient was calculated using the 8-variable KFRE. Patients were followed for five years to validate the KFRE; data on initiation of dialysis or death was collected. Cost of delivery of care per patient per year in the CKD clinic was determined. Health care utilization was evaluated by measuring the number/cost of hospital admissions, cardiovascular and thoracic (CVT) surgery, non-nephrology specialist appointments, and medications. Results: There were more patients in G 3 (n= 533) than in G 4 (n=474). 313 (59%), 150 (28%), and 70 (13%) were in low, medium and high-risk categories for G 3 CKD. 275 (58%), 86 (18%), and 113 (24%) were in similar categories for G 4. The mean age (SD) was 71 (12.8) years. The number of patients > 65 years of age was 75%. 57% were men, mean GFR (mls/min/1.73m2) for G3 was 40 (7.8) and 23 (4) for G4. Of the G3 patients, 4% of low risk, 11% of the medium risk and 26% of the high risk progressed to dialysis by 5 years. In G 4 patients, 7% of low risk, 17% of medium risk and 48% of high risk progressed to dialysis over 2 years. These results validate the KFRE in our population. The cost of care per patient in MDC was $ 3800 (CAD) per year. There was a difference in the cost of medications, number and cost of (inpatient hospitalizations, cardiovascular surgeries, non-Nephrology specialist visits, and day surgeries) between low risk patients vs high risk patients in G4 patients. Conclusion: We performed a cost-effectiveness analysis of our MDC’s and show that very few patients at low-risk of progression advance to ESRD. They are also unlikely to benefit from intensive care management and better managed in primary care with advice from tertiary centres. Individual programs have significant opportunity to improve health care delivery by identifying the sub- groups that benefit the most from MDC based on the risk of progression to allow optimal utilization of resources. At $ 3800 (CAD) per patient, we suggest that MDC’s are best utilized by patients with medium and high risk of progression. Further, we show that patients that the low-risk patients were older, had fewer inpatient visits, had lesser drug costs, underwent fewer cardiovascular surgeries, had fewer day surgery visits, and fewer non-nephrology specialist visits. This is the first study to our knowledge that focuses on health care utilization based on the risk of disease progression rather than the stage of CKD.

ISUOG Consensus Statement on organization of routine and specialist obstetric ultrasound services in context of COVID‐19

ISUOG Consensus Statement on organization of routine and specialist obstetric ultrasound services in context of COVID‐19

Blood-based biomarkers for Alzheimer's pathology and the diagnostic process for a disease-modifying treatment: Projecting the impact on the cost and wait times.

IntroductionConcerns have been raised about the limited health system capacity for identification of patients who are eligible for a disease‐modifying Alzheimer's treatment (DMT). Blood‐based biomarker (BBBM) tests are a promising tool to improve triaging at the primary care level. We projected their impact on cost of and wait times during the diagnostic process.MethodsWe compare four scenarios for triaging patients at the primary care level from the perspective of the U.S. health care system: (1) cognitive test only (Mini Mental State Examination [MMSE]), (2) BBBM test only, (3) MMSE followed by BBBM if positive, and (4) BBBM followed by MMSE if positive.ResultsReferring patients to dementa specialists based on MMSE or BBBM results alone would continuously require more specialist appointments than projected to be available until 2050. Combining MMSE and BBBM would eliminate wait lists after the first 3 years and reduce average annual cost by $400 to 700 million, while increasing correctly identified cases by about 120,000 per year.DiscussionThe combination BBBM with MMSE is projected to increase the efficiency and value of the triage process for DMT eligibility.

PNS197 WAITING TIMES FOR HEALTH CARE SERVICES IN HUNGARY - RESULTS OF A REPRESENTATIVE POPULATION SURVEY

We aimed to assess waiting times (WT) to schedule an appointment and at the health care facility for general practice (GP), public and private specialist care in Hungary. We also aimed to identify population groups for whom WT was perceived as problematic. An online survey was carried out on a representative sample (n=1000) of Hungary's population, based on a set of questions developed by the OECD. Perceived health status was measured. Median WT were calculated. Logistic regression was performed to identify respondents` characteristics who reported that WT was a problem for them. Among respondents who had an outpatient visit in the last 12 months prior to the survey (n=731), median WT to schedule an appointment were 0 days (same day) for GP, between 8-14 days for specialists in the public sector and 6-7 days for specialists in the private sector. The share of patients who got an appointment within one week were 90%, 42.5%, 62.4% respectively. Nevertheless, 38.1% of the patients waited more than a month to schedule a specialist appointment in the public system. Median WT at the health facilities prior to the visit were between 30-60 minutes for GP and specialists in the public sector, and 0-15 minutes for specialists in the private sector. Regression results show that women were significantly more likely to report that WT to schedule an appointment was a problem for them. Waiting prior to the visit was more likely a problem for patients younger than 35 years of age. Perceived health status was not an important determinant of WT as a problem. Although the majority of patients reported accessing GP and private outpatient services within a week, long waiting times are reported in the public sector that can limit the timely accessibility of specialist care in Hungary.

\u2018Teach-back\u2019 is a simple communication tool that improves disease knowledge in people with chronic hepatitis B \u2013 a pilot randomized controlled study

BackgroundThe low diagnosis rate and poor access to clinical care among people with CHB is a major barrier to reducing HBV-related morbidity and mortality in Australia. One explanation for this is a lack of disease-specific knowledge among people living with CHB. Health literacy has been shown to be important for maximising engagement with medical care and adherence to recommended management. The ‘teach-back’ communication strategy has been shown to improve patient understanding in other clinical areas. This study aims to assess disease-specific knowledge; and evaluate the efficacy of the teach-back strategy for improving HBV knowledge, compared to a standard medical consultation.MethodA randomized pilot study was conducted between February and June 2017. Participants were recruited from the liver clinic at an inner-city tertiary hospital. English-speaking patients aged ≥18 years and diagnosed with CHB were eligible for the study. Participants were randomised to a control group (medical specialist appointment) and intervention group (teach-back). Knowledge was assessed at baseline, immediately post-intervention and at one month using a validated questionnaire. Participants in the intervention group received a one-on-one teach-back session about CHB. The main outcome measure was a combined knowledge score of the domains assessed – transmission, natural history, epidemiology and prevention and clinical management.ResultsSeventy participants were recruited (control n = 32, teach-back n = 38). Mean baseline knowledge score was 19.1 out of 23 with 55 (79%) participants scoring ≥17.3 (defined as high knowledge) (7). Sub-analysis of CHB knowledge domains identified focal deficits concerning transmission and whether HBV is curable. Knowledge scores were found to be positively associated with English proficiency and antiviral treatment experience (p < 0.05). Teach-back was associated with a significant increase in CHB knowledge at early recall (22.5 vs 18.7, p < 0.001) and at 1-month follow-up (21.9 vs 18.7, p < 0.001); there was no improvement in CHB knowledge associated with standard clinical consultant (early recall: 19.6 vs 19.4, p = 0.49, one-month follow-up: 19.5 vs 19.4, p = 0.94).ConclusionIn a tertiary hospital liver clinic population, baseline knowledge about CHB was good, but there were focal deficits concerning transmission and potential for cure. Teach-back was associated with improvement in CHB knowledge and it is a simple communication tool suitable for incorporation into a standard medical consultation.

Influence of doctor-patient conversations on behaviours of patients presenting to primary care with new or persistent symptoms: a video observation study

BackgroundMost cancers are diagnosed following contact with primary care. Patients diagnosed with cancer often see their doctor multiple times with potentially relevant symptoms before being referred to see a specialist,...

Creation of value for business from the importance-performance analysis: the case of health clubs

Purpose The blue ocean strategy refers to how rebuilding the inputs that customers value in the designing of a new value curve fundamentally requires a four field of action structure: reduce, eliminate, create and raise. However, this does not propose a methodology to identify these fields of action. Hence, the purpose of this study is to present importance-performance analysis (IPA), as a support tool to identify these fields of action given their relevance and utility to managers. Design/methodology/approach The 101 ex-customers of health club answered a survey to determine the cut-off boundaries for IPA, and therefore, maximising the discriminatory power of the logistical regression model. This correspondingly incorporated the evaluation of both the area below the receiver operating characteristic curve (ROC) and the adoption of coefficients for concordance and correlation. Findings The research results demonstrate the need to concentrate efforts on the attributes of: price, responses to complaints, emergency procedures, innovative services, changing rooms, support for selecting the activities members choose to undertake and an appropriate number of members per activity. With low levels of performance and importance, are candidates for elimination, specifically, the availability of specialist appointments, member socialisation activities, maintaining memories of members, bar services and services for children. Originality/value The contribution: presenting an IPA methodology applicable to identify the fields of action recognised by the blue ocean strategy as the literature currently only covers concrete situations in which organisations achieve success through reducing, eliminating, creating and elevating and does not set out any methodology to identify those same fields of action; the definition of the cut-off points in IPA based on the ROC curve, which is a more rigorous and exact statistical method than that applied in other studies; the study population, the ex-customers, who not only represent a very important source of latent demand but also because ex-customers are likely to return more impartial.

جودة البيئة المدرسية وعلاقتها بالمواطنة التنظيمية لدى معلمي مدارس محافظة أضم

جودة البيئة المدرسية وعلاقتها بالمواطنة التنظيمية لدى معلمي مدارس محافظة أضم

Timeliness of treatment for patients referred urgently with a high suspicion of cancer in New Zealand.

e18147 Background: Delays in diagnosis and treatment have the potential to impact negatively on clinical outcomes for cancer patients. Guidelines for timeliness have been established for many cancer types and national targets have been established in some countries. At the end of 2014 New Zealand introduced a target for patients referred urgently with a high suspicion of cancer, aiming to have 90% of patients from referral to first treatment within 62 days. Methods: Timeliness data from 13,865 patients who were referred for their first specialist appointment in the years 2015-7 were obtained from the Ministry of Health. Z-tests for proportions were used to compare target performance across the time period. Cox regression was used to establish whether age, gender, and ethnicity were associated with timeliness. Results: The proportion of patients meeting the 62 day target increased significantly from 2015 (72.7%, 95%CI: 71.3-74.0; Median: 46 days) to 2016 (80.2%, 95%CI: 79.0-81.3; Median 43 days), but was not significantly higher in 2017 (80.7%, 95%CI: 79.6-81.8; Median 41 days). The Cox regression found that males (HR 0.965; 95% CI, 0.933–0.999) and older people (HR 0.996; 95% CI, 0.995–0.998) at a small but significantly higher risk of longer times to treatment. Much larger differences in risk of delay were found for Maori (HR 0.789; 95% CI, 0.748–0.832), Pacific (HR 0.754; 95% CI, 0.692–0.822) and Asian (HR 0.885; 95% CI, 0.816–0.960), compared to European/Other ethnic group patients. Conclusions: This research has produced evidence that the introduction of the 62 day target was associated with a significant improvement in timeliness of treatment for this subgroup of patients. The results also highlight the large ethnic disparities in timeliness that exist both in New Zealand and in other countries. These are also reflected in ethnic disparities in outcomes across many cancer types. Further policy, system and practice changes are necessary to try to reduce these.

Labour migration of doctors and nurses and the impact on the quality of health care in Eastern European countries: The case of Poland

The purpose of this commentary article is to explain the causes and effects of the economic migration of health care workers from Poland to Western countries, and to analyse the impact of the migration of doctors and nurses on the functioning of the public health system. We use data from the National Central Statistical Office, our own preliminary research, social surveys and the Watch Health Care database. Domestic data are analysed and compared with trends in Western Europe as described in Eurostat and Organisation for Economic Co-operation and Development reports. The decreasing number of active physicians remaining in the health care system results in long waits for specialist appointments. The demand for doctors from Central and Eastern Europe will continue to grow. Consequently, there will be a further outflow of medical staff from Poland and other countries in the region and the current problems with access to health care will continue. JEL Codes: I00, I11, J61

Neck lump clinic: a new initiative at North Shore Hospital.

Neck lumps can cause significant patient anxiety and benefit from a multidisciplinary diagnostic approach, with an ultrasound scan and fine needle aspirate. Internationally, 'one-stop' clinics are used for the evaluation of neck lumps, to date no such clinic has been established in the New Zealand public hospital system. The objective of this study was to demonstrate the feasibility of a one-stop diagnostic neck lump clinic (NLC), aiming for improved patient experience and efficiency. A consultant-led pilot NLC was instituted with the involvement of a head and neck surgeon, radiologist and pathologist, allowing ultrasound scan and fine needle aspirate investigations to be performed simultaneously. A retrospective audit of patients in the 12 months prior to commencement of the NLC provided a comparison group. The median number of clinic visits was 2 in the control group and 1 in the NLC (P < 0.001). Time from first specialist appointment to surgery was 192 days compared to 134.5 days for NLC (P = 0.057). Median time from first specialist appointment to treatment decision was 108.5 days compared to 0 days in the NLC (P < 0.001). Eighty-eight percent of patients in the NLC were given a diagnosis at their first appointment. The median number of investigations required was 2 in the control group and 1 in the NLC (P < 0.001). Median cost per patient in the NLC was $794 and $1470 in the control group. This pilot trial demonstrates streamlined decision-making and efficient utilization of services with a reduction in clinic visits, investigations and cost. High patient satisfaction was reported with this service.

Medication Reconciliation Across Care Transitions in the Pediatric Medical Home

To characterize medication discrepancies for patients with chronic illnesses seen at outside facilities. This was a retrospective evaluation of a medication reconciliation across care transitions (MRAT) program developed and piloted for one year in an academic pediatric primary care medical home. The MRAT involved chart review and contacting caregivers upon receiving external specialist notes or hospital discharge summaries. Data obtained from the program were used to determine the frequency and types of medication discrepancies for children with complex and noncomplex chronic conditions. MRATs for 124 encounters were evaluated, 74.0% in response to specialist appointments. Chart review revealed a mean of 3.64 discrepancies per patient, and telephone calls revealed 1.39 additional discrepancies per patient. The number of medication discrepancies from both chart review and telephone calls between complex and noncomplex patients was statistically significant, with a mean of 5.63 vs. 3.77 per patient (p = 0.005). Therapy delays occurred in 16.1% of patients due to insurance rejections, family not starting a new medicine, or confusion about the medication change. Mean time required for reconciliation was 24 minutes. In addition to medication reconciliation, 107 interventions completed during MRATs included patient education, adjusting drug therapy, coordinating care between providers, recommending laboratory monitoring, and facilitating patient appointments. Children with chronic illness often experience medication changes and delays in therapy when seen in the hospital or by specialists. Timely identification of these changes improves communication and offers the opportunity to identify and prevent problems with medication therapy.

Patterns of care for stage III non-small cell lung cancer in Australia.

Stage III non-small cell lung cancer (NSCLC) makes up a third of all NSCLC cases and is potentially curable. Despite this 5-year survival rates remain between 15% and 20% with chemoradiation treatment alone given with curative intent. With the recent exciting breakthroughs in immunotherapy use (durvalumab) for stage III NSCLC, further improvements in patient survival can be expected. Most patients with stage III NSCLC present initially to their general practitioner (GP). The recommended time from GP referral to first specialist appointment is less than 14 days with treatment initiated within 42 days. Our review found that there is a shortfall in meeting these recommendations, however a number of initiatives have been established in Australia to improve timely and accurate diagnosis and treatment patterns. The lung cancer multidisciplinary team (MDT) is critical to consistency of evidence-based diagnosis and treatment and can improve patient survival. We aimed to review current patterns of care and clinical practice recommendations for stage III NSCLC across Australia and identify opportunities to improve practice in referral, diagnosis and treatment pathways.

\u2018HepCheck Dublin\u2019: an intensified hepatitis C screening programme in a homeless population demonstrates the need for alternative models of care

BackgroundHepatitis C virus (HCV) is one of the main causes of chronic liver disease worldwide. Prevalence of HCV in homeless populations ranges from 3.9 to 36.2%. The HepCheck study sought to investigate and establish the characterisation of HCV burden among individuals who attended an intensified screening programme for HCV in homeless services in Dublin, Ireland.MethodsThe HepCheck study was conducted as part of a larger European wide initiative called HepCare Europe. The study consisted of three phases; 1) all subjects completed a short survey and were offered a rapid oral HCV test; 2) a convenience sample of HCV positive participants from phase 1 were selected to complete a survey on health and social risk factors and 3) subjects were tracked along the referral pathway to identify whether they were referred to a specialist clinic, attended the specialist clinic, were assessed for cirrhosis by transient elastography (Fibroscan) and were treated for HCV.ResultsFive hundred ninety-seven individuals were offered HCV screening, 73% were male and 63% reported having had a previous HCV screening. We screened 538 (90%) of those offered screening, with 37% testing positive. Among those who tested positive, 112 (56%) were ‘new positives’ and 44% were ‘known positives’. Undiagnosed HCV was prevalent in 19% of the study sample. Active past 30-day drug use was common, along with attendance for drug treatment. Unstable accommodation was the most common barrier to attending specialist appointments and accessing treatment. Depression and anxiety, dental problems and respiratory conditions were common reported health problems. Forty-six subjects were referred to specialised services and two subjects completed HCV treatment.ConclusionsThis study demonstrates that the current hospital-based model of care is inadequate in addressing the specific needs of a homeless population and emphasises the need for a community-based treatment approach. Findings are intended to inform HepCare Europe in their development of a community-based model of care in order to engage with homeless individuals with multiple co-morbidities including substance abuse, who are affected by or infected with HCV.

Clinical pathways of breast cancer patients treated in the Federal District, Brazil.

ABSTRACTOBJECTIVE:To identify the clinical pathways of women with breast cancer treated in public hospitals, and to analyze the factors that influence the time interval between the first appointment and the start of therapy.METHODS:A cross-sectional study was conducted with 600 women with breast cancer treated in nine public hospitals in the Brazilian Federal District. Patients were interviewed between September 2012 and September 2014. Simple and multiple logistic regression models were adjusted to evaluate the variables associated with the time interval studied. The most frequent pathway was the one that started in primary care with following care in the therapy service (28.9%). In the multiple adjustment, factors associated to a longer time interval between the first appointment and therapy were: lower family income (OR = 1.89; 95%CI 1.32–2.68), the first appointment in public services (OR = 1.78; 95%CI 1.20–2.64), care in more than two health services in the clinical pathway (OR = 1.71; 95%CI 1.19–2.44); and obtaining the anatomopathological analysis of the biopsy in public services instead of private health services (OR = 1.87; 95%CI 1.29–2.71). Independently, the implementation of specialist appointment scheduling, with care regulation, was associated with a shorter time interval between first appointment and therapy (OR = 0.33; 95%CI 0.16–0.65).CONCLUSIONS:We observed that multiple pathways were covered by women with breast cancer treated in public services of the Federal District. Socioeconomic iniquities and several aspectos of the pathways covered were associated with a longer time interval between the first appointment and the start of breast cancer therapy.

Patient Navigation to Enhance Access to Care for Underserved Patients with a Suspicion or Diagnosis of Cancer.

Interventions aimed at improving access to timely cancer care for patients in low- and middle-income countries (LMIC) are urgently needed. We aimed to evaluate a patient navigation (PN) program to reduce referral time to cancer centers for underserved patients with a suspicion or diagnosis of cancer at a public general hospital in Mexico City. From January 2016 to March 2017, consecutive patients aged >18 years with a suspicion or diagnosis of cancer seen at Ajusco Medio General Hospital in Mexico City who required referral to a specialized center for diagnosis or treatment were enrolled. A patient navigator assisted patients with scheduling, completing paperwork, obtaining results in a timely manner, transportation, and addressing other barriers to care. The primary outcome was the proportion of patients who obtained a specialized consultation at a cancer center within the first 3 months after enrollment. Seventy patients (median age 54, range 19-85) participated in this study. Ninety-six percent (n = 67) identified >1 barrier to cancer care access. The most commonly reported barriers to health care access were financial burden (n = 50) and fear (n = 37). Median time to referral was 7 days (range 0-49), and time to specialist appointment was 27 days (range 1-97). Ninety-one percent of patients successfully obtained appointments at cancer centers in <3 months. Implementing PN in LMIC is feasible, and may lead to shortened referral times for specialized cancer care by helping overcome barriers to health care access among underserved patients. A patient navigation program for patients with suspicion or diagnosis of cancer in a second-level hospital was feasible and acceptable. It reduced patient-reported barriers, and referral time to specialized appointments and treatment initiation were within international recommended limits. Patient navigation may improve access to care for underserved patients in developing countries.

Satisfaction With Care Coordination for Families of Children With Disabilities

Children with disabilities have significant health care needs, and receipt of care coordinator services may reduce caregiver burdens. The present study assessed caregivers' experience and satisfaction with care coordination. Caregivers of Medicaid-enrolled children with disabilities (n = 2,061) completed a survey (online or by telephone) collecting information on the caregivers' experiences and satisfaction with care coordination using the Family Experiences with Coordination of Care questionnaire. Eighty percent of caregivers with a care coordinator reported receiving help making specialist appointments, and 71% reported help obtaining community services. Caregivers who reported that the care coordinator helped with specialist appointments or was knowledgeable, supportive, and advocating for children had increased odds of satisfaction (odds ratio = 3.46, 95% confidence interval = [1.01, 11.77] and odds ratio = 1.07, 95% confidence interval = [1.03, 1.11], respectively). Findings show opportunities for improving care coordination in Medicaid-enrolled children with disabilities and that some specific elements of care coordination may enhance caregiver satisfaction with care.

Insights Into Older Adult Patient Concerns Around the Caregiver Proxy Portal Use: Qualitative Interview Study.

BackgroundElectronic patient portals have become common and offer many potential benefits for patients’ self-management of health care. These benefits could be especially important for older adult patients dealing with significant chronic illness, many of whom have caregivers, such as a spouse, adult child, or other family member or friend, who help with health care management. Patient portals commonly contain large amounts of personal information, including diagnoses, health histories, medications, specialist appointments, lab results, and billing and insurance information. Some health care systems provide proxy accounts for caregivers to access a portal on behalf of a patient. It is not well known how much and in what way caregivers are using patient portals on behalf of patients and whether patients see any information disclosure risks associated with such access.ObjectiveThe objective of this study was to examine how older adult patients perceive the benefits and risks of proxy patient portal access by their caregivers.MethodsWe conducted semistructured interviews with 10 older adult patients with chronic illness. We asked them about their relationship with their caregivers, their use of their patient portal, their caregiver’s use of the portal, and their perceptions about the benefits and risks of their caregiver’s use of the portals. We also asked them about their comfort level with caregivers having access to information about a hypothetical diagnosis of a stigmatized condition. Two investigators conducted a thematic analysis of the qualitative data.ResultsAll patients identified caregivers. Some had given caregivers access to their portals, in all cases by sharing log-in credentials, rather than by setting up an official proxy account. Patients generally saw benefits in their caregivers having access to the information and functions provided by the portal. Patients generally reported that they would be uncomfortable with caregivers learning of stigmatized conditions and also with caregivers (except spouses) accessing financial billing information.ConclusionsPatients share their electronic patient portal credentials with caregivers to receive the benefits of those caregivers having access to important medical information but are unaware of all the information those caregivers can access. Better portal design could alleviate these unwanted information disclosures.

Hepcare europe: Hepcheck; reaching vulnerable populations

Introduction: HepCare Europe is a three year EU funded project involving collaboration with four member states. The vision for the project is to create an innovative, integrated system for Hepatitis C HCV testing & treatment among key ‘at-risk’ groups, including people who inject drugs PWID’s and the homeless, through outreach to the community and integration of primary and secondary care services. With clinical sites in Dublin, London, Seville and Bucharest, and economic evaluation in Bristol UK, the consortium has developed a number of work packages focused on operationalizing the multiple components of testing, care and cure that are key components of the strategy to eradicate HCV in the European Union. Consortium members include UCD Ireland SAS Spain SVB Romania University of Bristol UK and University College London UK Theory/Method: The HepCheck component of the project offered screening across the four clinical sites in Dublin, London, Seville and Bucharest. Point of care testing was offered to ‘at- risk’ groups who are frequently marginalized with respect to health service engagement. Screening was conducted in prisons, opioid substitution treatment clinics and in homeless services. Results: A total of 1,749 individuals were screened, 31.2 % n=559 tested HCV antibody positive. To date 40% n= 222 individuals have attended a specialist appointment for HCV treatment. In-depth analysis of the data is ongoing including identification of risk factors for HCV infection, levels of HCV related liver disease, prevalence of blood borne viruses and linkage to care. Discussion: In order to achieve World Health Organisation WHO HCV elimination targets by 2030 we need to identify and successfully treat the most vulnerable HCV individuals in the community. Conclusion: Community based screening intervention can enhance HCV diagnosis for at risk populations but referrals to/ attendance at secondary care remains a challenge for this cohort. Lessons Learned: The HepCheck data highlights the potential for developing interventions to enhance engagement with HCV screening and entry to the cascade of care required to cure HCV. Suggestions for future Research: Based on the findings of this study further research is required to develop community based interventions to ensure that the most vulnerable populations are engaged with the HCV care pathway and have the opportunity of treatment and cure.

Factors Affecting Diagnostic Timeliness and Safety in Symptomatic Patients Subsequently Diagnosed With Bladder and Kidney Cancer: A Systematic Review

Background: Timely diagnosis of cancer is important for good clinical outcomes and patient experience. Bladder and kidney cancer, being two relatively common cancers, can pose diagnostic challenges. Symptoms such as hematuria and urinary tract infections in some patients have a higher than 3% positive predictive value for cancer, a threshold above which English GPs are advised to consider the referral of patients for, under the 2015 NICE guidelines. However, the majority of patients with these symptoms will end up not having cancer. Therefore, the decision to perform further investigations or refer patients with these common urinary symptoms may differ despite the existence of guidelines. Studying in whom, and why, some patients may experience a longer than average time to diagnosis is important to understanding how avoidable diagnostic delay can be reduced, so that targeted interventions to improve early diagnosis can be developed to improve, ultimately, the outcome of these cancers. Aim: A systematic review was therefore performed to identify the factors that affect the diagnostic timeliness and safety of patients with urological symptoms that may be suggestive of kidney and bladder cancer. Methods: We searched Embase and Medline (Ovid) between 2000 and January 2018, for publications on symptoms/conditions including hematuria and urinary tract infection (UTI). We focused on clinical features that are listed in the English 2015 NICE guidelines for suspected cancer to examine the population that are most likely to have cancer, and in whom a timely diagnosis is the most crucial for outcomes. We also included symptoms that might be suggestive of a UTI (including dysuria, urinary frequency, urgency, incontinence and nocturia) to be overinclusive in our search. Results: Our initial search identified 7787 articles. Following title and abstract screening, 37 full texts were assessed for eligibility. A final 23 relevant studies were included. Our preliminary findings include evidence on patient, clinician and system factors contributing to diagnostic timeliness and safety issues (such as completeness of evaluation/investigations and referrals) in patients with possible urological cancer. These include patient sociodemographic factors (age, gender, ethnicity), clinician type (generalist, urologist vs gynecologist) and experience, and system factors such as delay in specialist appointment scheduling and patient no-shows. Conclusion: Our findings will provide a granular understanding of the factors contributing to avoidable diagnostic delay of patients with possible urological cancers globally. This is particularly important so that targeted interventions can be developed to help clinicians and health systems to better identify and manage at-risk patients with symptoms, so as to improve early diagnosis and outcomes of urological cancers.