Primary Care Specialists Research Articles

Challenges in Diagnosing Psoriatic Arthritis in Primary Care: A Meta-Ethnographic Study.

Psoriatic arthritis (PsA) is a complex and debilitating chronic inflammatory joint disorder that is often associated with psoriasis and presents significant challenges in its early diagnosis and management. Therefore, this study aimed to investigate the diagnostic intricacies of PsA in primary care settings to shed light on the prevalence, barriers, and implications of delayed diagnosis. To achieve our research objectives, we conducted a qualitative synthesis using the meta-ethnographic method, which is a robust approach for synthesizing qualitative data. We systematically searched the PubMed, Web of Science, and Embase databases for relevant articles using predefined search terms such as "psoriatic arthritis," "diagnosis," and "primary care." The inclusion criteria were narrative articles in English that provided insights into the diagnostic challenges of PsA in primary care. Conference presentations, original articles, and duplicate articles were excluded. Our analysis revealed four key themes that elucidated the multifaceted nature of PsA diagnosis in primary care: (1) a variety of initial and non-specific symptoms, highlighting the diverse clinical presentations that can mimic other conditions; (2) the lack of experience with PsA among primary care professionals, underscoring the importance of education and training; (3) the lack of skin lesions, which can complicate diagnosis when not present; and (4) a delay in diagnosis, with potentially severe consequences for patients' health and quality of life. This study highlights the challenges inherent in the diagnosis of PsA in primary care settings. The multifaceted nature of the disease, coupled with limited experience among primary care providers, often results in delayed diagnosis and subsequent treatment initiation. Early recognition and intervention are pivotal for optimizing patient outcomes. Addressing these challenges necessitates a comprehensive approach involving heightened clinical suspicion, continuous medical education, interdisciplinary collaboration, and utilization of standardized diagnostic criteria. Collaboration between primary care physicians and specialists is crucial for enhancing the accuracy and timeliness of PsA diagnosis and ultimately improving patient well-being and quality of life.

Patients pathways before and after treatments in emergency departments: A retrospective analysis of secondary data in Germany

Increasing emergency department (ED) utilization induces considerable pressure on ED staff and organization in Germany. Reasons for certain ED attendances are seen partly in insufficient continuity of care outside of hospitals. To explore the health care patterns before and after an ED attendance in Germany, we used claims data from nine statutory health insurance funds, covering around 25 % of statutory health insurees (1). We descriptively analyzed ED attendances for adult patients in 2016 according to their sociodemographic characteristics and diagnoses (2). Based on the ED attendance as initial event, we investigated health care provider utilization 180 days before and after the respective ED treatment and are presented by means of Sankey diagrams. In total, 4,757,536 ED cases of 3,164,343 insured individuals were analyzed.Back pain was the most frequent diagnosis in outpatient ED cases (5.0 %), and 80.2 % of the patients visited primary care physicians or specialists 180 days before and 78.8 % 180 days after ED treatment. Among inpatient cases, heart failure (4.6 %) was the leading diagnosis and 74.6 % used primary care physicians or specialists 180 days before and 65.1 % 180 days after ED treatment. The ED re-attendance slightly increased for back pain (4.9 % to 7.9 %) and decreased for heart failure (13.4 % to 12.6 %).

Supportive Services at End of Life can Help Reduce Acute Care Services: Observations From the Medicare Care Choices Model.

This study identifies the mechanisms through which supportive and palliative care services at the end-of-life helped prevent unnecessary use of acute care services. From 2016 to 2021, the Medicare Care Choices Model (MCCM) tested whether offering Medicare beneficiaries the option to receive supportive and palliative care services through hospice providers, concurrently with treatments for their terminal conditions, improved patients' quality of life and care and reduced Medicare expenditures. Previous MCCM evaluation results showed that the model achieved its goals, but did not examine in depth the causal mechanisms leading to these results. Mixed-methods evaluation based on descriptive analysis of MCCM encounter data and qualitative analysis of interviews with staff from high-performing MCCM hospices. MCCM hospices provided 217 156 encounters to 7263 enrollees over 6years. Enrollees received on average 30 encounters with hospice staff while enrolled in the model, representing about 10 encounters per month enrolled. Most encounters were delivered by clinically trained staff in the patient's home. Hospice staff identified five services critical for keeping patients from seeking acute care services: early and frequent needs assessments, direct observation of patients in their homes, immediate responses to patients' medical complaints, round-the-clock telephone access to nursing staff, and communication and coordination of care with primary care physicians and specialists. Palliative care approaches that are high-touch, employ clinically trained staff who visit patients in their homes, routinely evaluate how to manage patient symptoms, and are available when needs arise can improve outcomes and decrease costs at the end of life.

Primary Care Management Pathways to Reduce Wait Times in Hematology: Monoclonal Gammopathy of Undetermined Significance

Background:Prolonged wait times are a worsening barrier to accessing specialist care in Canada and other countries across the globe. The flow of patients between primary care and specialists has been a recognized area for improvement (Liddy et al., 2020; Moir & Barua, 2021). Kingston Health Sciences Centre (KHSC) has aimed to optimize referrals through the implementation of primary care management pathways (PCMPs). PCMPs are diagnostic and/or treatment algorithms, co-developed by local primary care physicians and specialists with input from patients. They are designed to support primary care providers in managing low risk medical conditions in the community while more quickly identifying patients with higher risk conditions to be seen by specialists. A PCMP was implemented in June 2021 for Monoclonal Gammopathy of Undetermined Significance (MGUS) (https://kingstonhsc.ca/refer/hematology). This asymptomatic condition with low levels of monoclonal protein in the blood or urine has an approximately 1% per year risk of transforming to a hematological malignancy such as multiple myeloma (Kyle et al., 2018). The MGUS PCMP outlines diagnostic criteria, management, and monitoring instructions for low-risk MGUS along with patient information. “Red flag” features, such as renal impairment, anemia or significantly increased monoclonal protein levels, are used to highlight those who need urgent referral. The aim of this study is to evaluate the impact of an MGUS PCMP on wait times in Hematology in Kingston, Ontario. Methods:All consecutive outpatient Hematology referrals received at KHSC from January 2021 to December 2022 were reviewed. Monthly outcome measures included the number of new referrals and median wait times for patients seen. Number of MGUS referrals deferred to the PCMP was included as a process measure. Monthly balancing measures included number of re-referrals of PCMP patients, number of deaths without being seen for MGUS, and number of new multiple myeloma diagnoses. To compare 6-month pre-PCMP implementation (January 2021 to June 2021) with 18-month post-PCMP implementation (July 2021 to December 2022), generalized linear regression analysis was conducted. p < 0.05 was considered statistically significant. A survey of primary care providers was distributed through the regional Primary Care Physicians' Council to assess primary care satisfaction with the PCMP. Results: Between January 2021 and December 2022, 4504 Hematology referrals were received, 278 (6%) of which were MGUS referrals. 76 (27%) of MGUS referrals were deferred to the PCMP. There was a significant increase in monthly Hematology referrals from a mean (± standard deviation (SD)) of 163.0 (± 13.9) pre-PCMP to 195.9 (± 27.3) post-PCMP (p<0.0001). There was no significant difference in mean monthly MGUS referrals pre-and post-PCMP (11.7 ± 4.7 versus 11.6 ± 3.5). Hematology's median wait time for those seen fell from a median (interquartile range (IQR)) of 51.3 days (13) pre-PCMP to 28.5 days (11) post-PCMP (p < 0.0001). The MGUS median wait time also fell from a median (IQR) of 40.5 days (59) to 37.0 days (32.5) (p < 0.0001). No significant difference was noted in the balancing measures. Pre-PCMP to post-PCMP, the mean number of deaths without being seen for MGUS (0.17 ± 0.41 versus 0.17 ± 0.38, p=0.36) and mean monthly new multiple myeloma diagnoses (5.17 ± 1.94 versus 5.17 ± 2.50, p = 0.54) remained stable. There were 7/76 (9.2%) re-referrals of patients deferred to the PCMP, with a median (IQR) time to re-referral of 64 days (348). A survey to assess primary care provider satisfaction with the PCMP included a total of 28 respondents; 19/28 (67.9%) reported using PCMPs. On a scale of 0 to 5, where 5 is the highest satisfaction, the median (IQR) overall experience was 4/5 (1.5) and impacts on supporting patient care and changing management were also 4/5 (1). The most common concern, raised by 7/28 respondents (25%), was the downloading of more work to primary care. Conclusion: The MGUS PCMP was associated with reduction in wait times for overall Hematology and MGUS despite an increase in referrals. Limitations of this study include concurrent changes in the program, including staffing and the COVID-19 pandemic. These results suggest that PCMPs may be an effective tool to address Hematology wait times, likely best complemented with other strategies to avoid overburdening primary care providers.

Outcomes of rural generalist internship training in Victoria, Australia.

Victoria, Australia commenced its first Rural Community Internship Training program in 2012 to support the development of rural generalist (RG) doctors. These general practitioners have additional skills to work at a broad scope to deliver the range of primary care and additional specialist services that communities need. Unlike most internships, which are wholly hospital-based and delivered mostly within larger metropolitan and regional centres, this RG internship training model involves completing general practice experience in smaller rural communities working with RGs and visiting specialists. This study aimed to explore the characteristics and satisfaction of doctors who participate in RG internship training in Victoria and their workforce outcomes. Between October and November 2021, a retrospective 10-minute anonymous survey invitation was sent to all contactable interns (n=222) who had completed/were completing the RG internship training (2012-2021). The survey was co-designed with RG internship managers and other stakeholders of a statewide evaluation advisory group, informed by the latest evidence regarding RG medicine and rural training predictors, and outcomes of interest. Participants completed the survey using Microsoft Forms, with three invitations circulated to an up-to-date email address maintained by the internship program. Collected data were analysed descriptively, by subgroup, to explore training pathway outcomes by region, training stage and specialty choice. Workforce distribution outcomes were defined in line with objectives of the program and predetermined indicators of RG scope. Results were compared with the benchmarks of rural workforce training outcomes in Australia using recent research. There were 59 participants (27% response rate); 81% were in postgraduate years 3-7. Respondents included 54% male, 17% rurally bonded, 39% of rural origin, 34% having had more than 3 months rural undergraduate training and 48% doing RG training where they previously did undergraduate training. All were satisfied/very satisfied with the RG training and 61% were working in general practice (excluding the prevocational group). Overall, 40% were currently working in the same rural region as their internship (including three who were currently interns), 56% continued to complete some prevocational training in the same region as their RG internship, while 20% had gone on to be currently based in smaller rural communities (Modified Monash Model locations 4-7) and 44% to be working part-time in smaller rural communities. Overall, 42% self-identified as working as an RG and nearly all (97%) met at least one of the key indicators of extended (RG) scope. In all areas the RG internship outcomes were better than the national benchmarks from published evidence about rural training. This study provides evidence from doctors up to 9 years after completing their RG internship. Compared with industry benchmarks, the RG internships attract rurally intentioned and rurally experienced doctors who may be likely to remain in the same rural region as their undergraduate rural medical training and continue their postgraduate training in the same region. They were all satisfied with RG internship training, had high propensity to follow a general practice career and work at broad scope in smaller communities. Importantly, they intended to stay in the region where they trained. This suggests RG internship programs are a positive intervention for promoting an RG workforce.

Semmelweis Caring University Model Program: A Holistic Approach to Promoting Healthy Ageing through a Longitudinal Cohort Study, Preventive Services and Workplace Health Promotion

Abstract Hungary is facing an alarming public health situation due to the unhealthy ageing of its population, calling for innovative and effective approaches to promote healthy ageing. This presentation showcases the Semmelweis Caring University Model Program, a unique and holistic program developed by the leading health sciences university in Hungary to address this societal challenge. The program serves as a model for the ongoing primary care reform, which incorporates preventive services, the first study to address determinants of unhealthy ageing in Hungary, and includes a workplace-based health promotion program that could be implemented nationally. The Semmelweis Caring University Model Program aims to promote the health and wellbeing of its 8500 employees and provides potential answers to the unfavorable public health situation in Hungary. The Semmelweis Study, a longitudinal occupational cohort of university employees, investigates the complex relationships between lifestyle, environmental, and occupational risk factors and the development and progression of chronic age-associated diseases. Data is collected through computer-assisted questionnaires, physical health examination, physiological measurements, biomarker assessment and data linkage to national registers. The results of the Semmelweis Study inform the development of the Centre of Preventive Services (CPS), which provides health risk assessment, screening, and counseling services to employees, with medical specialists in preventive medicine and primary care, public health professionals, dieticians, physiotherapists, and psychologists. The CPS units also serve as practical training sites for medical and health sciences students. The Semmelweis Workplace Health Promotion Program is a personalized public health model program that utilizes infrastructure and human resources of Semmelweis University to encourage healthy behaviors and environments in the workplace, with a potential for nationwide implementation.

Multiple primary synchronous malignant skin neoplasms (case report and literature review)

The non-melanoma skin cancer is a leader among malignant tumours over last decades. Also, the incidence of multiple primary malignant neoplasms is increasing. We reported the case of a 68-year-old woman with locally advanced multiple primary synchronous malignant skin neoplasms (basal cell carcinoma and sarcomatoid carcinoma of skin) who was successfully treated. Thanks to individualized multimodal treatment, the basis of which is radical surgical intervention, careful follow-up was possible to achieve a complete cure of the patient with a good cosmetic and functional result. Our case report represents the need to increase the level of oncological alertness among primary care specialists and conduct educational work among the population in order to early diagnose tumors.

Overview article: Impact of primary and secondary care collaboration on hospitalization for chronic heart failure: Two comparative studies

IntroductionIn the past decade, a legal framework was created in Germany that promotes intense collaboration at the interface between primary and secondary care. This overview article distinguishes between the effects of two complementary programs aimed at improving ambulatory care in Baden-Wuerttemberg: (1) general practitioner-centered care (GPCC), which strengthens the role of general practitioners, and (2) collaborative cardiology care (CCC), which coordinates primary and cardiology care. MethodsThe overview article presents two already published studies that assess the impact of the programs on hospitalizations in patients with chronic heart failure (CHF) based on claims data from 2016. The hospitalization rate of patients enrolled in GPCC (N=75,096) and CCC (N=13,404) were compared with corresponding control groups (N=65,618 and N=8,776 respectively). ResultsThe hospitalization rate in GPCC was lower than in the control group (risk ratio 0.97; 95% CI: 0.95–0.99, P=0.0024). GPCC patients with CHF that received specialist cardiology care as part of CCC had significantly lower hospitalization rates than those receiving standard cardiology care (risk ratio 0.92; 0.88–0.97, P=0.0014). DiscussionThis overwiew study shows that reforming medical care and compensation at the interface between general practice and specialist care can lead to fewer hospital admissions in patients with CHF. ConclusionOverall, this article underlines the importance of collaboration between primary care physicians and specialists for patients with CHF that are receiving ambulatory care.

THU250 Therapeutic Inertia In Primary Care With Poor Information Transfer To Specialist Care - A Rural Irish Experience

Abstract Disclosure: C.T. Coughlan: None. T.M. O'Sullivan: None. M.C. O'Donovan: None. M.J. Hannon: None. The burden of diabetes management in Ireland is shared between primary care physicans and specialists in secondary care, using current international management guidelines (1). However, long waiting lists and resource constraints limit the ability of secondary care to respond rapidly to all referrals. This study was designed to identify missed opportunities for early intervention in the management of diabetes in primary care. Written referrals of diabetes patients from primary care physicians to a specialist endocrinology service in a rural Irish hospital were audited to assess both the appropriateness of the referrals and to identify any missed opportunities for starting adjunctive treatments in primary care. We analysed all 74 referrals - mean age 58, 45% female – that were on the hospital diabetes clinic waiting list at the time of data collection. 61/74 (82%) had type 2 diabetes. The average time between date of referral and date of data collection was 231 days. Only 43/74 (58%) included a HbA1c value in the referral document. Of the type 2 diabetes referrals, only 12/61 (20%) included a BMI value. Mean HbA1c in the type 2 diabetes cohort was 71 mmol/mol (8.6%), and mean BMI was 30.6 kg/m2. Despite this, 19/61 (40%) were on monotherapy at time of referral, only 15/61 (25%) were on a GLP1 analog, and only 17/61 (28%) were on an SGLT2 inhibitor. Of the type 2 patients with documented BMI > 30 kg/m2, only 2/5 (40%) were on a GLP1 analog and only 2/5 (40%) were on an SGLT2 inhibitor. Lipid values were included in the referrals of 26/74 patients (35%), and blood pressure values in 25/74 (34%). Despite this, 44/74 (59%) were on a statin and 40/74 (54%) were on an ACE inhibitor or ARB. The renal function (serum creatinine or eGFR) was provided in 22/74 (30%), and information regarding microalbuminuria was provided in only 12/74 (16%). Foot examination was documented in 13/74 referrals (18%), and retinal screening status was documented in 17/74 (23%). Given the exponential increase in the numbers of patients with obesity and diabetes and increasing evidence on the importance of early multifactorial risk reduction, it is essential that cardiovascular risk factors and diabetes complications are documented and appropriate initial management commenced while patients await secondary care evaluation. Our study shows that referrals lack critical information which makes appropriate prioritization difficult. Also, the major classes of oral hypoglycaemic agents are under utilized in primary care, which exposes patients to damaging hyperglycaemia for an unnecessarily long time prior to secondary care evaluation. 1. Davies MJ, Aroda VR, Collins BS, Gabbay RA, Green J, Maruthur NM, et al. Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2022;65(12):1925-66. Presentation: Thursday, June 15, 2023

Integration, effectiveness and costs of different models of primary health care provision for people who are homeless: an evaluation study.

There is a high prevalence of health problems among single people who are homeless. Specialist primary health care services for this population have been developed in several locations across England; however, there have been very few evaluations of these services. This study evaluated the work of different models of primary health care provision in England to determine their effectiveness in engaging people who are homeless in health care and in providing continuity of care for long-term conditions. It concerned single people (not families or couples with dependent children) staying in hostels, other temporary accommodation or on the streets. The influence on outcomes of contextual factors and mechanisms (service delivery factors), including integration with other services, were examined. Data from medical records were collated on participants' use of health care and social care services over 12 months, and costs were calculated. The evaluation involved four existing Health Service Models: (1) health centres primarily for people who are homeless (Dedicated Centres), (2) Mobile Teams providing health care in hostels and day centres, (3) Specialist GPs providing some services exclusively for patients who are homeless and (4) Usual Care GPs providing no special services for people who are homeless (as a comparison). Two Case Study Sites were recruited for each of the specialist models, and four for the Usual Care GP model. People who had been homeless during the previous 12 months were recruited as 'case study participants'; they were interviewed at baseline and at 4 and 8 months, and information was collected about their circumstances and their health and service use in the preceding 4 months. Overall, 363 participants were recruited; medical records were obtained for 349 participants. Interviews were conducted with 65 Case Study Site staff and sessional workers, and 81 service providers and stakeholders. The primary outcome was the extent of health screening for body mass index, mental health, alcohol use, tuberculosis, smoking and hepatitis A among participants, and evidence of an intervention if a problem was identified. There were no overall differences in screening between the models apart from Mobile Teams, which scored considerably lower. Dedicated Centres and Specialist GPs were more successful in providing continuity of care for participants with depression and alcohol and drug problems. Service use and costs were significantly higher for Dedicated Centre participants and lower for Usual Care GP participants. Participants and staff welcomed flexible and tailored approaches to care, and related services being available in the same building. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services. There were difficulties recruiting mainstream general practices for the Usual Care GP model. Medical records could not be accessed for 14 participants of this model. Participant characteristics, contextual factors and mechanisms were influential in determining outcomes. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were relatively favourable. They had dedicated staff for patients who were homeless, 'drop-in' services, on-site mental health and substance misuse services, and worked closely with hospitals and homelessness sector services. This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (HSDR 13/156/03) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 16. See the NIHR Journals Library website for further project information.

French lay Persons’ judgments of the possibility of a heart attack when experiencing various physical manifestations

BackgroundThe aim of the study was to characterize the different ways in which, based on certain physical manifestations that an individual suddenly experiences, people judge the possibility that these manifestations indicate the onset of a heart attack. MethodsOne hundred ninety-four French adults--plus six physicians--were presented with a set of realistic vignettes composed by orthogonally crossing the levels of four factors: the type of pain felt, and the presence or absence of nausea, excess sweating, and of difficulty breathing. ResultsFour qualitatively different reactions were found among the lay people. The majority reaction (54%) was close to the physicians’ reaction. It consisted of suspecting a heart attack as soon as intense pain occurs in the chest or back. The second reaction (25%) retained from the first one only the idea that a heart attack should be suspected if the pain is localized to the chest. The third reaction (14%) reflected some people’s uncertainty in the face of disturbing manifestations that they find difficult to interpret. The fourth reaction (7%) was that no set of symptoms could mean, for them, the onset of a heart attack. ConclusionOnly about half of the participants appeared to be able to consider unpleasant physical manifestations as a whole and integrate that information into an overall warning judgment that can lead into prompt life-saving actions. We recommend that judgment training on warning symptoms and signs be performed, especially for high-risk patients, in the offices of primary care providers and specialists.

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.

Obesity and overweight as an international public health problem

The study aimed to analyze the theoretical references of obesity as a public health problem at the international level. Obesity has been associated with a high risk of chronic diseases such as hypertension, heart failure, and diabetes mellitus type II. However, it is unpredictable to calculate the social costs and losses of psychosocial well-being, causing stress and depression. However, to correctly treat this pathology that affects us so much, it is necessary to start with a correct and effective diagnosis, which should be carried out by physicians, nutritionists and other specialists in primary health care. To this end, a review of the literature on the subject was carried out in the databases of academic journals: Web of Science (Core Collection) Scopus, Medline through Pubmed and Scielo. Obesity is a severe social health problem since it affects many people worldwide, and only through scientific and technological development can it be adequately treated, diagnosed and prevented. Keywords: obesity; health; quality of life; chronic diseases

Impact of Long-COVID on Health Care Burden: A Case Control Study

The objective was to identify the chronic impact of SARS-CoV-2 virus infection in new diagnostics, pharmacological prescriptions, and use of healthcare resources in patients after acute infection in a case-control study. Methods: Case-control study with observation of new diagnostics codified in the Electronic Health Recordings, with a total population of 604,000 subjects. Cases included patients diagnosed with acute infection. Matched controls in the absence of infection using a Propensity Score were also included. Observational period was 6 months. New diagnostic (CIE10), prescriptions and visits to Health Care Resources were identified. Results: 38,167 patients with a previous COVID infection and the same number of controls were analyzed. Population included < 18 years old, 7586 (mean age 10.2 years, girls 49%), and 30,581 adults (mean age 46.6 years, females 53%). In adults, 25% presented new diagnoses, while the prevalence was 16% in youth. A total of 40 new diagnostics were identified. The most frequent were diagnostics in the neuropsychiatric sphere, with older age, female, and previous admission in the Critical Care Unit being the factors related in adults, while in youth higher age was also a factor. Prescription of psychoanaleptic, psycholeptic and muscle relaxants had increased. An increment of around 20% in visits to Primary Care Physicians, Specialists and Emergency Departments was registered. Conclusion: Compared with a control group, an increment in the number of new diagnostics, new prescriptions and higher use of Health Care resources were observed. Many of the new diagnoses also occur in non-infected subjects, supporting the complex origin of so-called Long-COVID.

The COVID-19 impact on severe uncontrolled asthma costs and biologic use.

Background: Patients with severe uncontrolled asthma (SUA) overwhelmingly contribute to the economic burden of asthma and may require biologic therapy. However, the impact of the CoronaVirus Disease of 2019 (COVID-19) on asthma costs and biologic use has yet to be evaluated. Objective: The objective was to test the hypothesis that SUA costs and biologic use decreased during the pandemic. Methods: We analyzed medical costs and biologic use in patients with SUV from January 2017 to December 2021, by using claims data from a large managed care organization and electronic health record data from Robert Wood Johnson Barnabas Health, according to provider specialty. Results: Of the 3817 managed care organization enrollees within Robert Wood Johnson Barnabas Health with a primary diagnosis of asthma, 348 were identified as having SUA. A nested sample of 151 patients revealed that 50% were managed by primary care physicians (PCP) and specialists, 43% by PCPs only, and 4% by specialists only. The total costs of the claims were $10.8 million over 5 years ($2.2 million per year), with 60% generated from patients seeing PCPs and specialists, 27% from PCPs only, and 15% from specialists only. During the pandemic, total average costs decreased for all care groups (34% PCP-only patients and 45% for both specialist-only and PCP and specialist patients). Inpatient and outpatient costs also decreased and were lowest for patients who saw specialists and highest for patients who saw PCPs and specialists. In contrast, prescription costs increased during the pandemic. Biologic use was steadily increasing until a twofold decrease was observed during the pandemic. Thirteen patients were on biologics: two were managed by PCPs, four by specialists, and seven by both. Conclusion: Inpatient and outpatient costs decreased during the COVID-19 pandemic, but prescription costs increased. Biologic use was increasing among patients with SUA before the pandemic but then drastically decreased and remained lower during the observational interval.

MRI order appropriateness for chronic neck pain: Comparison of ordering practices and treatment outcomes for primary care physicians and specialists.

Chronic neck pain is a common reason for doctor visits in the United States. This diagnosis can be evaluated through patient history, physical examination, and judicious use of radiographs. However, possible inappropriate magnetic resonance imaging (MRI) ordering persists. We hypothesized that no difference in ordering practices, ordering appropriateness, and subsequent intervention would be appreciated regarding physician specialty, location, patient characteristics, and history and physical exam findings. A multisite retrospective review of cervical spine MRIbetween 2014 and 2018 was performed. A total of 332 patients were included. Statistical analysis was used to assess MRI order appropriateness, detail of history and physical exam findings, and intervention decision-making among different specialties. If significant differences were found, multiple linear regression was performed to evaluate the association of MRI order appropriateness regarding physician specialty, location, patient characteristics and history, and physical exam findings. The significance level for all tests was set at <0.05 Orthopedic surgeons ordered MRIs most appropriately with an average American College of Radiology(ACR) score of 8.4 (p < 0.005). Orthopedic surgeons had more comprehensive physical exams as compared to the remaining specialties. The decision for intervention did not vary by physician specialty or ACR score, except for patients of pain medicine physicians who received pain management (p = 0.000). Orthopedic surgeons utilize MRI most appropriately and have more comprehensive physical exams. These findings suggest a need for increased physician education on what indicates an appropriate MRI order to improve the use of resources and further protect patient risk-benefit profiles. Further research elucidating factors to minimize negative findings in "appropriate" MRIs is indicated.Clinical significance:More detailed physical exams may lead to more appropriately ordered MRIs, subsequently resulting in surgery or procedures being performed when appropriately indicated. This suggests the need for increased physician education on when MRI ordering is appropriate for chronic neck pain to improve the use of resources and further protect patient risk-benefit profiles.

Healthcare Costs at the End of Life for Patients with Non-cancer Diseases and Cancer in Denmark.

To examine costs of care from a healthcare sector perspective within 1year before death in patients with non-cancer diseases and patients with cancer. This nationwide registry-based study identified all Danish citizens dying from major non-cancer diseases or cancer in 2010-2016. Applying the cost-of-illness method, we included costs of somatic hospitals, including hospital-based specialist palliative care, primary care, prescription medicine and hospice expressed in 2022 euros. Costs of patients with non-cancer diseases and cancer were compared using regression analyses adjusting for sex, age, comorbidity, residential region, marital/cohabitation status and income level. Within 1year before death, mean total healthcare costs were €27,185 [95% confidence interval (CI) €26,970-27,401] per patient with non-cancer disease (n=109,723) and €51,348 (95% CI €51,098-51,597) per patient with cancer (n=108,889). The adjusted relative total healthcare costs, i.e. the ratio of the mean costs, of patients with non-cancer diseases was 0.64 (95% CI 0.63-0.66) at 12months before death and 0.91 (95% CI 0.90-0.92) within 30days before death compared with patients with cancer. Mean costs of hospital-based specialist palliative care and hospice in the year leading up to death were €17 (95% CI €13-20) and €90 (95% CI €77-102) per patient with non-cancer disease but €1552 (95% CI €1506-1598) and €3411 (95% CI €3342-3480) per patient with cancer. Within 1year before death, total healthcare costs, mainly driven by hospital costs, were substantially lower for patients with non-cancer diseases compared with patients with cancer. Moreover, the costs of hospital-based specialist palliative care and hospice were minimal for patients with non-cancer diseases.

Healthcare resource use and costs reduction with aripiprazole once-monthly in schizophrenia: AMBITION, a real-world study.

This study aims to compare the hospitalization rate in individuals with schizophrenia who started their treatment with aripiprazole once monthly (AOM400) or atypical oral antipsychotics (OA) in Spain. This is an observational and retrospective study based on the electronic medical records from the BIG-PAC database. The study population consisted of individuals diagnosed with schizophrenia who initiated their treatment with AOM400 (AOM cohort) or atypical OA (OA cohort) from 01/01/2017 to 31/12/2019. A 1:1 propensity score matching (PSM) procedure was conducted to match individuals of both cohorts. The number and duration of hospitalizations, persistence to treatment, healthcare resources use, and costs were analyzed after 12 months. After the PSM, 1,017 individuals were included in each cohort [age: 41.4 years (SD: 10.6); males: 54.6%]. During the follow-up period, the AOM cohort had a 40% lower risk of hospitalization than the OA group [HR: 0.60 (95% confidence interval, CI: 0.49-0.74)]. The median time to the first hospitalization was longer in individuals with AOM400 compared to those with OA (197 days compared to 174 days; p < 0.004), whereas hospital admissions were shorter (AOM400: 6 compared to OA: 11 days; p < 0.001). After 12 months, individuals receiving AOM400 were more persistent than those with OA (64.9% compared to 53.7%; p < 0.001). The OA cohort required more healthcare resources, mainly visits to primary care physicians, specialists, and emergency rooms than those receiving AOM400 (p ≤ 0.005 in all comparisons). AOM400 reduced the costs of hospitalizations, and emergency room, specialist and primary care visits by 50.4, 36.7, 16.1, and 10.9%, respectively, in comparison to the treatment with atypical OA. AOM400 led to annual cost savings of €1,717.9 per individual, from the societal perspective. Aripiprazole once monthly reduces the number and duration of hospitalizations, together with the treatment costs of schizophrenia, as it reduces the use of healthcare resources and productivity losses in these individuals.

Participance in time of the different stages of medical help is the necessary factor for the success of realization of practical medical activity (with the description of own observations of ovarian cancer clinical case and its using at classes in State l

Ovarian cancer is a second by the rate gynecological malignant disorder in developed countries and has one of the worst prognosis and mortality rate. In comparison to other gynecological malignant disorders (cervical, uterіne, vaginal, vulvar), patients with ovarian cancer suffer from the biggest mortality rate. Because of the absence of the early detection methods patients most common are identified at developed stage (III or IV by FIGO), thus with limited possibilities for treatment. Epithelial ovarian cancer is the most common type of ovarian cancer with 90 % of all reported cases. This cancer is divided in five histotypes: highgrade serous, low-grade serous, mucinous, endometrioid and clear-cell. Histotypes are different in morphology of tumor cells, clinical manifestations intensity, systemic effect and response to treatment. General clinical hardship of ovarian cancer detection on early stages due to the lack of definite semiotic picture produces the big role of primary care specialists for the systemic evaluation of the female health state with consideration of the “small signs” of the disorder, which progress constantly and with time will be transformed to obvious morphological oncomanifestations. Article contains the results of own clinical observations of the features of ovarian cancer. We consider this description as demonstrative for the analysis at practical classes in State language and in English.

Specialist use among privately insured children with disabilities.

To investigate primary care practice ownership and specialist-use patterns for commercially insured children with disabilities. A national commercial claims database and the Health Systems and Provider Database from 2012 to 2016 are the data sources for this study. This cross-sectional, descriptive study examines: (1) the most visited type of pediatric primary care physician and practice (independent or system-owned); (2) pediatric and non-pediatric specialist-use patterns; and (3) how practice ownership relates to specialist-use patterns. This study identifies 133,749 person-years of commercially insured children with disabilities aged 0-18 years with at least 24 months of continuous insurance coverage by linking a national commercial claims data set with the Health Systems and Provider Database and applying the validated Children with Disabilities Algorithm. Three-quarters (75.9%) of children with disabilities received their pediatric primary care in independent practices. Nearly two thirds (59.6%) used at least one specialist with 45.1% using nonpediatric specialists, 28.8% using pediatric ones, and 17.0% using both. Specialist-use patterns varied by both child age and specialist type. Children with disabilities in independent practices were as likely to see a specialist as those in system-owned ones: 57.1% (95% confidence interval [95% CI] 56.7%-57.4%) versus 57.3% (95% CI 56.6%-58.0%), respectively (p = 0.635). The percent using two or more types of specialists was 46.1% (95% CI 45.4%-46.7%) in independent practices, comparable to that in systems 47.1% (95% CI 46.2%-48.0%) (p = 0.054). However, the mean number of specialist visits was significantly lower in independent practices than in systems-4.0 (95% CI 3.9%-4.0%) versus 4.4 (95% CI 4.3%-4.6%) respectively-reaching statistical significance with p < 0.0001. Recognizing how privately insured children with disabilities use pediatric primary care from pediatric and nonpediatric primary care specialists through both independent and system-owned practices is important for improving care quality and value.