Specialist Appointments Research Articles

Inequalities in access to healthcare for older adults during COVID-19 pandemics in Lithuania

Abstract Background During COVID-19 pandemic, healthcare systems experienced unprecedented shock. Older adults were the most vulnerable group of Lithuanian society, facing distinctive health challenges and highest mortality rates. The aim of the study was to examine perceived inequalities and challenges in access to healthcare of Lithuanian population over 65 years old during COVID-19 pandemic. Methods Representative sample of Lithuanian population over 65 years old (1503 individuals) was involved in the anonymous questionnaire survey, performed in January, 2024. Results 22 % of respondents reported not using healthcare services during COVID-19 pandemics. Among them, 76% did not have any need for healthcare services, while 13.6% did not approach healthcare due to fear of getting infected by Covid-19, and the other 10.4% had various accessibility challenges. 15.8% reported frequent problems in registering with family doctors, and 20.0% - with the specialist appointment. There was a clear social gradient observed among those underserved: it was associated with educational level and place of residence. Those with lower education and living in smaller towns and rural areas reported more common healthcare accessibility problems. Higher education, income and better self-perceived health correlated with higher satisfaction with travel time reaching health care services and registering for the appointment (p < 0.05). Conclusions Health system resilience reflects the ability to continue service delivery in the face of extraordinary shocks. Limited health care accessibility and clear social gradient could increase vulnerability of older adults, which resulted in exceptionally high mortality rates during COVID-19 pandemics. Results of the survey will be used for further development of transformative capabilities of healthcare system, responding to public health disasters and protection of the vulnerable groups of the society. Key messages • Limited health care accessibility and clear social gradient could increase vulnerability of older adults, which resulted in exceptionally high mortality rates during COVID-19 pandemics. • Results of the survey will be used for further development of transformative capabilities of healthcare system, responding to public health disasters.

Intravitreal therapy in neovascular age-related macular degeneration-adapting to increasing demand and changing times.

To report the outcomes of patients with neovascular age-related macular degeneration (nAMD) at Palmerston North Eye Clinic (PNEC) during 2020 and 2021, comparing time to treatment initiation based on nurse-injector availability and during COVID-19 restrictions. Data were recorded from a prospective database for patients with nAMD at PNEC. Each patient's electronic health record was reviewed to ensure the accuracy of the database and to fill in missing data points. Statistics were done using Microsoft Excel and R. One hundred and fifty-six eyes were diagnosed with nAMD during the study. Mean time from referral triage to first injection was 13.08 days across the study period. Time to treatment initiation was not statistically different by level of COVID-19 restriction but there was a significant difference in first specialist appointment to injection interval when three nurse-injectors were available compared to four. The effect seemed most evident in subsequent months after reduced nurse-injector availability began. Despite an increase in nAMD diagnoses each year, PNEC continues to meet national guidelines for interval from referral to treatment initiation through innovations in practice. As demand for intravitreal injections continues to increase, further resourcing and research into newer agents will be required to keep wait times compliant with guidelines.

Effect of cancer waiting time standards in the English National Health Service: a threshold analysis

BackgroundThe English National Health Service has multiple waiting time standards relating to cancer diagnosis and treatment. Targets can have unintended effects, such as prioritisation based on targets instead of clinical need. In this case, a `threshold effect’ will appear as a spike in hospitals just meeting the target.MethodsWe conducted a retrospective study of publicly available cancer waiting time data, including a 2-week wait for a specialist appointment, a 31-day decision to first treatment and a 62-day referral to treatment standard that attracted a financial penalty. We examined the performance of hospital trusts against these targets by financial year to look for threshold effects, using Cattaneo et al. manipulation density test.ResultsTrust performance against cancer waiting targets declined over time, and this trend accelerated since the start of the Covid-19 pandemic. Statistical evidence of a threshold effect for the 2-week and 31-day standard was only present in a few years. However, there was strong statistical evidence of a threshold effect for the 62-day standard across all financial years (p < 0.01).ConclusionThe data suggests that the effect of threshold targets alters hospital behaviour at target levels but does not do so equally for all standards. Evidence of threshold effects for the 62-day standard was particularly strong, possibly due to some combination of a smaller volume of eligible patients, a larger penalty, multiple waypoints where hospitals can intervene, baseline performance against the target and where the target is set (i.e. how much headroom is available). RCTs of the use of threshold targets and of different designs for such targets in the future would be extremely informative.

Provision of care for diabetic retinopathy in New Zealand: are there ethnic disparities?

Ethnic disparities have been observed in treatment at first specialist appointments across various specialties within New Zealand. This study aimed to examine documentation and treatment decisions for diabetic retinopathy by ethnicity. Retrospective audit of first specialist diabetic retinopathy clinic appointments for 388 patients at the Department of Ophthalmology, Te Whatu Ora Te Toka Tumai Auckland. Multiple domains of care were assessed, including comprehensiveness of history taking, examination, investigations and treatment decisions. Europeans comprised 42%, Māori only 9.5%, Pacific peoples 13.19%, Asian 32.7% and Middle Eastern/Latin American/African in 2%. Māori patients were eligible for a significantly greater number of treatments (p=0.001). The comprehensiveness of history taking (p=0.809), examination (p=0.513), investigations (p=0.623) and proportion of eligible treatments provided (p=0.788) was similar but did not reach the gold standard of care across all ethnicities. The standard of care provided in first specialist appointments for diabetic retinopathy appear to be similar across all ethnic groups, although Māori were underrepresented and had a higher disease burden at presentation. Our data highlights the need to reduce barriers faced by Māori in accessing GP, optometry and retinopathy screening referrals in Auckland, and improving local consultation and treatment guidelines.

The Medicines Intelligence Data Platform: A Population-Based Data Resource From New South Wales, Australia.

The Medicines Intelligence (MedIntel) Data Platform is an anonymised linked data resource designed to generate real-world evidence on prescribed medicine use, effectiveness, safety, costs and cost-effectiveness in Australia. The platform comprises Medicare-eligible people who are ≥18 years and residing in New South Wales (NSW), Australia, any time during 2005-2020, with linked administrative data on dispensed prescription medicines (Pharmaceutical Benefits Scheme), health service use (Medicare Benefits Schedule), emergency department visits (NSW Emergency Department Data Collection), hospitalisations (NSW Admitted Patient Data Collection) plus death (National Death Index) and cancer registrations (NSW Cancer Registry). Data are currently available to 2022, with approval to update the cohort and data collections annually. The platform includes 7.4 million unique people across all years, covering 36.9% of the Australian adult population; the overall population increased from 4.8 M in 2005 to 6.0 M in 2020. As of 1 January 2019 (the last pre-pandemic year), the cohort had a mean age of 48.7 years (51.1% female), with most people (4.4 M, 74.7%) residing in a major city. In 2019, 4.4 M people (73.3%) were dispensed a medicine, 1.2 M (20.5%) were hospitalised, 5.3 M (89.4%) had a GP or specialist appointment, and 54 003 people died. Anti-infectives were the most prevalent medicines dispensed to the cohort in 2019 (43.1%), followed by nervous system (32.2%) and cardiovascular system medicines (30.2%). The MedIntel Data Platform creates opportunities for national and international research collaborations and enables us to address contemporary clinically- and policy-relevant research questions about quality use of medicines and health outcomes in Australia and globally.

Communicating effectively to patients about a cancer referral.

The UK's National Institute for Health and Care Excellence (NICE) advises GPs to inform patients referred to the Urgent Suspected Cancer (USC) pathway about their impending service and expectations. However, little is known about patient experiences and information needs post-referral. GPs often grapple with conveying the urgency of referrals while offering reassurance. This study explores GP communication regarding cancer and USC referrals. A secondary analysis of 23 audio-recorded GP-patient consultations, selected from a larger dataset of 200 consultations in Surrey and London (2017-2018), was conducted, focusing on discussions related to cancer. We found that most GPs informed patients that they might have cancer and engaged in reassurance about the patient's low risk of cancer using personalised risk statements. Some GPs, however, avoided all mention of cancer, using symptom-led language instead. GPs tended to focus on communicating practical rather than support-based information when discussing the referral. While most GPs informed patients that they would be seen by a specialist within two weeks, few discussed patients' support needs during the referral or specialist appointment. This presentation will offer language recommendations for clear communication about cancer referrals. This plays an important role in promoting shared decision-making and driving patient attendance for investigations. The study highlights the need for further research on communication practices around cancer referral to improve patient understanding and experience. Our recommendations for enhanced communication may improve patient outcomes by optimising routes to diagnosis via primary care.

Urgent Direct Access to Diagnostic Services for General Practitioners: Bridging the Gap in Cancer Diagnosis.

Urgent direct access to diagnostic services for general practitioners (GPs)is a new pathway to capture any cancer diagnoses that may have been missed due to vague symptom presentations. Hence, GPs should look out for the keysymptoms mentioned by NHS England that should prompt urgent direct access referrals for chest X-ray (CXR), computed tomography (CT) chest, MRIbrain, ultrasound (US) abdomen and pelvis, and CT abdomen and pelvis. By implementing this approach, we can significantly reduce the time to diagnosis, while minimizing the number of visits to GP and specialist appointments prior to initiating investigations. However, the use of this pathway can only improve if access to diagnostic scans is improved. This needs to be done by ensuring all GPs in the country have access to directly request MRI brains, CT chest, abdomen, and pelvis.Further research into the impact of the urgent direct access pathway as well as investigating the number of GPs without access to these vital diagnostic services is required to fully improve and measure the progress of this referral pathway.

Differences between the healthcare systems of Quebec and France for the treatment of pain due to spinal disorders.

In Quebec, Canada, the public healthcare system offers free medical services. However, patients with spinal pain often encounter long waiting times for specialist appointments and limited physiotherapy coverage. In contrast, private clinics provide expedited care but are relatively scarce and entail out-of-pocket expenses. Once a patient with pain caused by a spinal disorder meets a pain medicine specialist, spinal intervention is quickly performed when indicated, and patients are provided lifestyle advice. Transforaminal epidural steroid injections are frequently administered to patients with radicular pain, and steroid injections are administered on a facet joint to control low back or neck pain. Additionally, medial branch blocks are performed prior to thermocoagulation. France's universal healthcare system ensures accessibility at controlled costs. It emphasizes physical activity and provides free physical therapy services. However, certain interventions, such as transforaminal and interlaminar epidural injections, are not routinely used in France owing to limited therapeutic efficacy and safety concerns. This underutilization may be a potential cause of chronic pain for many patients. By examining the differences, strengths, and weaknesses of these two systems, valuable insights can be gained for the enhancement of global spinal pain management strategies, ultimately leading to improved patient outcomes and satisfaction.

Follow-up care compliance among patients diagnosed with unruptured intracranial aneurysms

ObjectivesPeriodic imaging follow-up for patients with unruptured intracranial aneurysms (UIA) is crucial, as studies indicate higher rupture risk with aneurysm growth. However, few studies address patient adherence to follow-up recommendations. This study aims to identify compliance rates and factors influencing follow-up adherence. MethodsPatients with a UIA were identified from our institution's database from 2011-2021. Follow-up imaging (CT/MR Angiogram) was advised at specific intervals. Patients were categorized into compliant and non-compliant groups based on first-year compliance. Factors contributing to compliance were assessed through multivariate logistic regression. Phone interviews were conducted with non-compliant patients to understand reasons for non-adherence. ResultsAmong 923 UIA diagnosed patients, 337 were randomly selected for analysis. The median follow-up period was 1.4 years, with a 42% first-year compliance rate. The mean aneurysm size was 3.3 mm. Five patients had a rupture during follow-up, of which 4 died. Compared with patients consulting specialists at the initial diagnosis, those seen by non-specialists exhibited lower compliance (OR 0.25, p < 0.001). Loss to follow-up was greatest during transition from emergency service to specialist appointments. Patients who spoke languages other than English exhibited poorer compliance than those speaking English (OR 0.20, p = 0.01). ConclusionsSignificant amounts of UIA patients at low rupture risk were lost to follow-up before seeing UIA specialists. Main non-compliance factors include inadequate comprehension of follow-up instructions, poor care transfer from non-specialists to specialist, and insurance barriers.

An Economic Evaluation of a Web-Based Management Support System for Children With Urinary Incontinence: The eADVICE Trial.

Children who require specialist outpatient care typically wait substantial periods during which their condition may progress, making treatment more difficult and costly. Timely and effective therapy during this period may reduce the need for lengthy specialist care. This study evaluated the cost-effectiveness of an individualized, evidence-informed, web-based program for children with urinary incontinence awaiting a specialist appointment (Electronic Advice and Diagnosis Via the Internet following Computerized Evaluation [eADVICE]) compared to usual care. eADVICE was supervised by a primary physician and delivered by an embodied conversational agent. A trial-based cost-effectiveness analysis was performed from the perspective of the health care funder as a substudy of eADVICE, a multicenter, waitlist-controlled, randomized trial. Outcomes measures were incremental cost per incremental change in continence status and quality of life on an intention-to-treat basis. Uncertainty was examined using cost-effectiveness planes, scenarios, and 1-way sensitivity analyses. Costs were valued in 2021 Australian dollars. The use of eADVICE was found to be cost saving and beneficial (dominant) over usual care, with a higher proportion of children dry over 14 days at 6 months (risk difference 0.13; 95%CI 0.02-0.23, P = .03) and mean health care costs reduced by $188 (95%CI $61-$315) per participant. An individualized, evidence-informed, web-based program delivered by an embodied conversational agent is likely cost saving for children with urinary incontinence awaiting a specialist appointment. The potential economic impact of such a program is favorable and substantial, and may be transferable to outpatient clinic settings for other chronic health conditions.

Abstract 924: Patterns of specialty referral in cancer patients treated with immunotherapy regimens

Abstract Background: Specialty referral rates have been steadily increasing, as much as 94% within a 10-year period (1). Previous studies have shown the benefits of specialty referral in oncology management in specific populations such as lung cancer patients (2). However, there have yet to be larger-scale studies on general trends in specialty referral in oncology. In particular, patients on immune checkpoint inhibitors frequently develop immune-related adverse events (irAEs) affecting a variety of organ systems and may benefit from specialty care (3). Objectives: To evaluate the patterns of specialty referral in patients treated with immune checkpoint inhibitors and identify referral patterns that affect patient outcomes. Methods: This was a retrospective study of all specialty referral for patients on an immunotherapy regimen from 6/1/2022-6/1/2023 at a single-institution cancer center. The specialties consulted included cardiology, dermatology, endocrinology, gastroenterology, infectious disease, neurology, pulmonology, and nephrology. Results: In total, there were 5,602 patients on an immunotherapy regimen, of whom 3,519 patients (62.8%) were referred to a specialist. Of these patients, 2,017 (57.3%) attended a specialist appointment. A majority of the patients were male (n=1038, 51.5%), had a mean age of 64.1 years (SD=13.8) at initial consult, and were White/non-Hispanic (n=1414, 70.1%). The mean and median number of consults per patient were 1.7 (SD=1.3) and 1 (IQR=1), respectively. The maximum number of consultations for a patient was 17. Dermatology was the most commonly consulted service (n=841, 25.9%), followed by neurology (n=781, 24.0%), and endocrinology (n=446, 13.7%). For dermatology, the most common reason for consultation was evaluation of a rash (n=500, 59.5%). Dermatology also had the highest ratio of outpatient to inpatient consultations at 10.4 to 1. The next closest service was endocrinology at 3.0 to 1. The pulmonary service had the shortest time between consult request and patient visit (10 days), followed by dermatology (13 days), and gastroenterology (15 days). Prior to their initial consultation, the vast majority of patients (82.6%) were on a single therapy, and the most common single therapy was pembrolizumab (n=1589, 59.2%). The most common combination therapy was ipilimumab plus nivolumab, accounting for 59.3% of combinations. Fifty percent of patients (n=1008) who saw a specialist were able to continue their immunotherapy regimen. Conclusions: There is a range of specialty and multidisciplinary care that is necessary for the management of patients on immunotherapy regimens. Citation Format: Anna Chen, Stephen Dusza, David Faleck, Neil Shah, Mario E. Lacouture. Patterns of specialty referral in cancer patients treated with immunotherapy regimens [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 924.

General practitioner prescription patterns for atopic eczema in children-Are they affected by telemedicine advice?

Traditionally, patients presenting to primary care with severe eczema would be referred to a dermatology clinic for an in-person specialist appointment. With the rise of teledermatology, dermatologists are instead dispensing tailored written advice based on information provided in the referral. However, there is currently minimal literature assessing whether this advice translates into relevant prescriptions. This clinical audit examines GP prescribing practices and how they correlate to dermatologist recommendations with the objective of assessing whether this form of teledermatology is a viable method of providing care to paediatric eczema patients.

Open-Access Oesophagogastroduodenoscopy as an Effective and Safe Strategy for Patients With Non-alarming Symptoms.

Open-access oesophagogastroduodenoscopy (OAO) is defined as the performance of oesophagogastroduodenoscopy (OGD) requested by referring physicians without a prior specialist consultation. With the increasing demand for specialist appointments, the use of OAO has helped to reduce healthcare utilization by decreasing prior clinic visits. This also allows endoscopies to be scheduled and performed earlier. This study aims to evaluate our experience in providing OAO services to patients with non-alarming dyspepsia symptoms under the age of 60. The records of patients scheduled for OAO from January 2019 to December 2022 at Singapore General Hospital (SGH) Department of Gastroenterology were analyzed. Five hundred sixty-nine patients were scheduled for OAO, and 436 patients underwent the procedure. The mean age of patients was 45.7 (SD=10.9) years old. Thirty-six percent were males, and there were 80.8% Chinese, 5.3% Malay, 8.6% Indian, and 5.3% others. The median waiting time for endoscopy was 23 days (IQR 16-36), and no major adverse events were reported. Over half of the endoscopies were unremarkable (n=231, 53%). There were 25 (5.7%) patients with major findings; three had upper gastrointestinal adenocarcinoma (one oesophageal and two gastric), one had oesophageal varices, and 21 had peptic ulcer disease (10 gastric and 11 duodenal ulcers). A rapid urease test was conducted on 409 patients, and 55 (13.4%) were positive. OAO is a safe and effective strategy for providing timely diagnostic OGD to normal-risk patients at our center. Primary care physicians are encouraged to refer non-alarming dyspepsia symptoms patients under 60 years for OAO over the conventional route.

Is loneliness associated with cancellation of medical appointments during the COVID-19 pandemic? Evidence from the Hamburg City Health Study (HCHS)

BackgroundThe COVID-19 pandemic engendered numerous societal and economic challenges in addition to health-related concerns. Maintenance of healthcare utilization assumed immense significance during this period. However, few studies have examined the association between loneliness and cancelled medical appointments during the COVID-19 pandemic. This study aimed to examine whether medical appointments are less likely to be cancelled with increased loneliness during a pandemic. We analyzed the association between loneliness and both patient- and provider-initiated appointment cancellations.MethodsCross-sectional data from the Hamburg City Health Study (HCHS) were collected during April 2020–November 2021. The analytical sample included 1,840 participants with an average age of 55.1 years (standard deviation: 6.5, range 45–76 years). Medical appointments cancelled by individuals—medical appointments in general, and GP, specialist, and dentist appointments—and appointments cancelled by healthcare providers served as outcome measures. Loneliness was quantified using a single item ranging from 0 to 10. Accordingly, we created empirical loneliness tertiles. Covariates were selected based on the Andersen model. Several penalized maximum likelihood logistic regressions were utilized to examine the association between loneliness and cancellation of medical appointments during the COVID-19 pandemic.ResultsThe penalized maximum likelihood logistic regressions showed that, compared to individuals in the lowest loneliness tertiles, individuals in the other two tertiles reported a higher chance of medical appointments cancellation by individuals, particularly driven by cancelled GP appointments. Except for age and sex, none of the covariates were comparably associated with the outcomes. When appointments cancelled by healthcare providers served as outcomes, only a higher number of chronic conditions was significantly positively associated with it.ConclusionsIndividuals scoring higher in loneliness had a greater chance of cancelling medical (particularly GP) appointments. This may contribute to a potential cascade of loneliness and skipped medical appointments in the future, resulting in adverse health outcomes over the medium-to-long term. Future research should examine whether lonely people are more likely to lack the social motivation to visit the doctor.

Effect of an algorithm for automatic placing of standardised test order sets on low-value appointments and attendance rates at four Spanish teaching hospitals: an interrupted time series analysis

ObjectiveReducing backlogs for elective care is a priority for healthcare systems. We conducted an interrupted time series analysis demonstrating the effect of an algorithm for placing automatic test order sets...

A Randomized Controlled Trial of a Web-Based Management Support System for Children With Urinary Incontinence: The eADVICE Trial.

Children referred to specialist outpatient clinics by primary care providers often have long waiting times before being seen. We assessed whether an individualized, web-based, evidence-informed management support for children with urinary incontinence while waiting reduced requests for specialist appointments. A multicenter, waitlisted randomized controlled trial was conducted for children (5-18 years) with urinary incontinence referred to tertiary pediatric continence clinics. Participants were randomized to the web-based eHealth program electronic Advice and Diagnosis Via the Internet following Computerized Evaluation (eADVICE), which used an embodied conversational agent to engage with the child at the time of referral (intervention) or 6 months later (control). The primary outcome was the proportion of participants requesting a clinic appointment at 6 months. Secondary outcomes included persistent incontinence, and the Paediatric incontinence Questionnaire (PinQ) score. From 2018 to 2020, 239 children enrolled, with 120 randomized to eADVICE and 119 to the control arm. At baseline, participants' mean age was 8.8 years (SD 2.2), 62% were males, mean PinQ score was 5.3 (SD 2.2), 36% had daytime incontinence, and 97% had nocturnal enuresis. At 6 months, 78% of eADVICE participants vs 84% of controls requested a clinic visit (relative risk 0.92, 95% CI 0.79, 1.06, P = .3), and 23% eADVICE participants vs 10% controls were completely dry (relative risk 2.23, 95% CI 1.10, 4.50, P = .03). The adjusted mean PinQ score was 3.5 for eADVICE and 3.9 for controls (MD -0.37, 95% CI -0.71, -0.03, P = .03). The eADVICE eHealth program for children awaiting specialist appointments doubled the proportion who were dry at 6 months and improved quality of life but did not reduce clinic appointment requests.

Community-based screening enhances hepatitis B virus linkage to care among West African migrants in Spain

BackgroundChronic infection with HBV is responsible for >50% of all hepatocellular cancer cases globally and disproportionately affects sub-Saharan African (sSA) countries. Migration from these countries to Europe has increased substantially in recent years, posing unique challenges to health systems. The aim of this study was to carry out a community-based intervention to increase HBV screening, vaccination, and linkage to care among sSA migrants in Catalonia, Spain.MethodsThis was a prospective cohort study. Participants ≥18 years were offered community-based HBV screening between 20/11/20 and 21/01/22. Rapid HBV testing and blood sample collection utilizing plasma separation cards were carried out and linkage to care was offered to all participants. HBV vaccination and post-test counseling were performed at a second visit in the community. The main outcome was the odds of those with current HBV infection being successfully linked to hepatology. Rates of completing the care cascade of this model were analyzed.ResultsIn the present study, 444 people undergo screening, with 50.6% of participants showing evidence of past or current HBV infection, including an HBsAg prevalence of 9.2%. Migrants with current HBV infection exhibit 5.2 times higher odds of successful linkage to care compared to those in need of post-test counseling or vaccination. The study achieves a successful linkage to care rate of 72% for all participants, with specialist appointments arranged within 15.5 days.ConclusionsThis community-based HBV screening program provides evidence of a successful model for identifying and providing care, including vaccination, to west African migrants at high risk of HBV infection who may otherwise not engage in care.

Access to Healthcare in Rural Communities: A Bibliometric Analysis.

Access to healthcare is defined by being able to receive regular checkups, specialist appointments, immunizations, procedures, and surgeries within a reasonable timeframe and without restrictive barriers. The Web of Science database was used to collect 4,745 articles published relating to the keywords "rural", "access", and "healthcare". These articles then underwent bibliometric cataloging by country, journal, and keyword using VOSviewer 1.6.19. Between the years 2015 and 2022, the United States emerged as the predominant publisher in the field. From 2015 to 2019, the United States accounted for 47 percent of the total articles published. However, in the subsequent years of 2020 to 2022, there was a slight decline of 3 percent in the volume of U.S. publications. Australia secured the second position in terms of publications within the aforementioned timeframe of 2015 to 2022. England had the third most publications during the time between 2015 to 2022. The prevalence of articles containing the keyword "disparity" ranged between 7 percent and 12 percent throughout this period. Plus One exhibited prominence by contributing 5.025381 percent of all publications pertaining to access to rural medicine during the years 2015 to 2019 thereby establishing itself as the leading publisher in this domain. However, in 2020, the International Journal of Environment suppressed Plus One by publishing the highest number of articles related to rural healthcare. Subsequently, the BMC Health Services Research claimed the leading position in the years 2021 to 2022. An exploration of who is contributing to the discussion of access to healthcare in rural communities shows that the field and number of publications is growing, and that a focus on disparities is emerging, creating an environment surrounding rural health focused on researching equitable care.

Estimates of Current Capacity for Diagnosing Alzheimer’s Disease in Sweden and the Need to Expand Specialist Numbers

BackgroundThe emergence of disease-modifying Alzheimer’s (AD) treatments provides new hope to patients and families but concerns have been raised about the preparedness of healthcare systems to provide timely access to such treatments because of a combination of a complex diagnostic process and a large prevalent pool.ObjectivesWe assess the preparedness of Sweden, a high-income country known for its dementia-friendly policies, to diagnose AD patients eligible for treatment within a six-month window, given current capacity for specialist evaluations and biomarker testing. We calculate the investment requirements for Sweden to achieve this target over a timeframe of 20 years.DesignDesk research to identify data for population, mortality, disease burden, cost of services and current capacity, expert consultation to inform assumptions about patient journey, and use of a Markov model to predict waiting times. The model simulates the patients’ journey through different evaluation stages: initial evaluation by a primary care specialist, neurocognitive testing by an AD specialist, and confirmatory biomarker testing with PET scanning or cerebrospinal fluid (CSF) testing. The model assumes specialist appointments and PET scans are capacity constrained, and patients progress from cognitively normal to MCI and from MCI to dementia in the resulting waiting times.MeasurementsProjected waiting times for diagnosis of eligibility for disease-modifying Alzheimer’s treatment from 2023 to 2042 assuming current capacity, assuming 20% of Swedish residents aged 60 years and above would seek an evaluation for cognitive decline. Investments required to scale capacity up to reach target of providing diagnosis within six months on average.ResultsInitial average waiting times for AD specialist appointments would be around 21 months in 2023 and remain around 55 months through 2042, as demand would continue to outstrip supply throughout the 20-year model horizon. Waiting times for biomarker testing would be stable at less than four weeks, as patients would be held up in the queue for their first specialist consultations, and use of CSF testing is widely accepted in Sweden. An additional 25% of AD specialists would have to be added above the current growth trend to reduce waiting times to less than 6 months at an average annual cost of approximately 805 million SEK. The increased cost of volume of biomarker testing would amount to about 106 million SEK per year.ConclusionsAt current capacity, the Swedish healthcare system is unable to provide timely diagnosis of patients eligible for disease-modifying AD treatment. Although future diagnostic technologies, such as digital cognitive assessments and blood tests for the AD pathology, might decrease demand for capacity-constrained services, substantial investments will be required to meet a target of less than six months of waiting time for a diagnosis.

Family physicians’ perspectives on collaboration challenges between primary care and specialist care during the COVID-19 pandemic in Canada: A qualitative study

BackgroundPrior to the COVID-19 pandemic, Canada had longer wait-times for specialist appointments compared to other Commonwealth countries. During the pandemic, many specialist services were postponed or suspended, impacting access. The purpose of this study was to explore family physicians’ perspectives on specialist care availability during the pandemic and implications for family physician workload and patient management. These experiences can inform future pandemic plans. MethodsUsing semi-structured interviews, we explored family physicians’ experiences during COVID-19 across regions within four Canadian provinces (British Columbia, Ontario, Nova Scotia, Newfoundland and Labrador). Thematic and framework analyses were used to identify themes from the interviews. ResultsWe interviewed 68 family physicians between October 2020 and June 2021. Of these 68 participants, 27 discussed their interactions with specialists during the pandemic. We identified themes around access to, and collaboration with, specialists. At times, specialists were less available for patient care and family physician consultations, and communications were uncoordinated across the system. Family physicians took on additional work to address the lack of access and identified pandemic planning challenges. Participants offered recommendations for improving collaboration and access post-pandemic. InterpretationThe COVID-19 pandemic exacerbated existing challenges in the Canadian healthcare system pertaining to specialist access. Pandemic plans should reflect the importance of specialist consultations. Decision-makers should consider innovations to facilitate collaboration between family physicians and specialists.