Telephone Encounters Research Articles

Lessons learned from a lung cancer screening patient navigation program at a safety-net hospital system.

121 Background: As part of a CPRIT prevention services grant led by UTSW, Parkland Health adapted a patient navigation model previously piloted in 2017 to optimize low-dose computed tomography (LDCT) imaging for lung cancer screening and evidence-based tobacco cessation services. Methods: Non-clinical patient navigators (PN) contacted patients with a LDCT order to discuss their lung scan and smoking cessation options via telephone encounters. The PN has three planned touchpoints to assess patient knowledge, identify barriers, and refer to appropriate resources. Program evaluation data has been collected monthly for enrolled patients (n = 460) from August 2021-June 2022 via REDCap and EPIC. Navigation excluded patients who were incarcerated, had no phone number listed in medical record, or patients opted out of the program on intake. Results: Of the LDCT-eligible patients, PNs were able to complete two or more navigation calls with 55.62% of patients assigned. 77% of patients completed their first LDCT, compared to 80% in the initial trial. The most common barriers to screening completion included transportation (n = 38), insurance coverage (n = 22), and cost (n = 9). Of the navigated patients who were active smokers (75%), 33% scheduled at least one smoking cessation-related visit. Some patients unresponsive to conversations about quitting, were responsive to language around “reducing” tobacco use. Conclusions: Disproportionately under- and uninsured, Parkland Health patients face a variety of barriers to screening. As a result, PN staff must balance reaching all patients with a LDCT order and spending additional time navigating patients with complex barriers. To address these barriers, the PN program facilitates coordination of patients between primary care providers, radiology operations, smoking cessation clinics, patient financial services, lung diagnostic clinic, and social work. For example, patients can schedule a smoking cessation visit directly with our PN instead of being referred. As Parkland has a decentralized LCS program model, having embedded non-clinical PNs within existing roles in the cancer center, like medical practice assistants, increases continuity of care. These individuals have the benefit from day-to-day knowledge of downstream services that bolster their ability to connect patients to external services to address barriers.

The design of the Dashboard Activated Services and Telehealth for Heart Failure (DASH-HF) study: A pragmatic quality improvement randomized implementation trial for patients with heart failure with reduced ejection fraction

BackgroundGaps in the receipt and dosing of guideline-directed medical therapy (GDMT) persist for patients with heart failure with reduced ejection fraction (HFrEF) [1]. In 2020, the Veterans Affairs (VA) developed a heart failure (HF) specific population dashboard to monitor care quality and performance on standard HFrEF performance measures [2]. MethodsThe Dashboard Activated Services and Telehealth for HF (DASH-HF) study is a pragmatic randomized quality improvement study designed to evaluate the utility of proactive population management clinics using the VA's HF dashboard to optimize GDMT for patients with HFrEF. Panel management telemedicine clinics incorporated multidisciplinary clinicians to perform chart review and impromptu telephone encounters to evaluate current HFrEF management and opportunities to optimize GDMT. The study will evaluate the efficacy of proactive panel management to usual care at 6 months as quantified by the GDMT optimization potential score. Secondary outcomes include hospitalizations, mortality, and clinician time per intervention. The study completed enrollment and randomization of 300 participants. The intervention was performed from September to December 2021. ConclusionDASH-HF will contribute to the literature by evaluating use of the existing VA dashboard to identify HF patients with the lowest adherence to GDMT and proactively target this group for the intervention.Registration:https://clinicaltrials.gov/. Unique identifier: NCT05001165.

Physician satisfaction with telemedicine and in-person visits in otolaryngology

ObjectivesTo investigate the differential factors associated with physician satisfaction between telemedicine and in-person visits in otolaryngology. MethodsStudy data included 646 telemedicine and 365 in-person encounters delivered from May–June 2020 at a tertiary center outpatient setting. Encounter-specific physician satisfaction was rated by 15 otolaryngologists using Provider Satisfaction Questionnaire (range 0–100) consisted of 5 items (patient needs addressed, patient involvement, adequacy of information given, quality of emotion support provided, and general interaction satisfaction). A multivariable linear mixed-effects model was used to explore patient demographic and clinical factors associated with physician satisfaction. ResultsPhysician satisfaction scores for telemedicine and in-person visits were 83.0 [95 % CI: 77.0–88.9] and 88.1 [95 % CI: 82.5–93.6], respectively. Among telemedicine visits, physician satisfaction scores were significantly higher for follow-up (vs. new), videoconference (vs. telephone) encounters, and English-speaking patients in a multivariable model. New encounters had significantly lower satisfaction subdomain scores for adequacy of information given to the patient (β = −4.7 [95 % CI: −7.3 to −2.0], p = 0.001) and addressing the needs of the patient among telemedicine visits (β = −4.1, [95 % CI: −7.1 to −1.1], p = 0.007) while there were no differences in satisfaction scores between new vs follow-up visits among in-person visits. For non-English speaking patients, the physician satisfaction scores were significantly lower for subdomain scores assessing active patient participation (β = −13.1, [95 % CI: −13.1 to −17.4], p < 0.001) and emotional support given to the patient (β = −7.8, [95 % CI: −11.0 to −4.5], p < 0.001) for telemedicine visits. ConclusionsTelemedicine has been broadly adopted as an alternative option to deliver care in otolaryngology since COVID-19 pandemic. Appropriate triaging based on patient and encounter characteristics may enhance physician satisfaction and overall experiences with telemedicine. Further efforts are needed to provide adequate interpretation and videoconference services during telemedicine visits.

Use of a Novel Electronic Auto-Notification Process to Manage Transitions of Care in Patients With Rheumatic Disease Receiving Disease-Modifying Antirheumatic Drug Therapy.

To integrate an auto-notification system into clinical workflow, so timely communication of sentinel events (elective surgery, hospital admission, or emergency room [ER] visit) in immunosuppressed patients with rheumatic disease happened by design. We developed an algorithm that triggered auto-notification within the electronic medical record to rheumatology when a patient experienced a sentinel event. A telephone encounter was created that included event type, baseline therapy, and event date. This was forwarded to the rheumatologist, who recorded guideline-driven recommendations and returned it to nursing. Instructions were included to communicate recommendations to the patient, inpatient rheumatology team, or other clinician. This was studied over 4 months at a multispecialty medical practice in Central Pennsylvania. Primary outcomes were percentage of total notifications, notifications by sentinel event type where a change in care plan was recommended, as well as percentage of time where rheumatologists were notified of sentinel events compared to prior to the intervention. The secondary outcome was staff work effort. Two hundred forty notifications were received (57% for elective surgeries, 39% for ER visits, and 4% for admissions). The need for change in care plan was only 17% for ER visits but was 25% for hospital admissions and 44% for elective surgeries. The percentage of time that rheumatologists were notified of events increased from 57.6% to 100%. The average number of messages received per week was 2.2, requiring a weekly average of 13 minutes of work per physician. We developed an easy, well-received process that hardwires rheumatologist notification sentinel events to facilitate timely care.

267 Impact of COVID-19 healthcare disruption on delays in melanoma treatment in rural and urban Iowa

Previous studies have shown delays in skin cancer diagnosis and treatment due to disrupted care as a result of the COVID-19 pandemic. Diagnoses of melanoma in rural areas are associated with higher all-cause mortality when compared to metropolitan areas. Patients with melanoma treated after three months of diagnosis experience higher mortality than patients treated after one month. This study aimed to determine how COVID-19 shutdowns affected time to treatment of melanoma and patient outcomes between patients who lived in rural vs. urban areas. Patients with a pathologic diagnosis of melanoma at a large academic tertiary referral center were identified from 1/1/2019 to 12/31/2020 (n=408). Data from pathologic reports and demographic information regarding rurality (address and zip code) were collected from medical records. Documented telephone encounters were utilized to determine delays due to COVID-19. Average Breslow depth increased from 1.16 mm to 1.50 mm and proportion of clinical lymphadenopathy increased from 1.12% to 6.76% from 2019 to 2020. Conversely, average time to treatment from diagnosis decreased from 2019 to 2020 (29.55 vs. 23.76 days). These findings suggest that the COVID-19 pandemic resulted in a higher proportion of later stage tumors at presentation, but with no significant treatment delay once melanoma diagnosis was established. These results characterize the impacts of pandemic shutdowns on medical care and can aid health systems in designing optimal strategies to better serve patients from rural backgrounds.

Preliminary Findings from a Telephone-Based Cognitive Screening of an Adult HIV Research Cohort during the COVID-19 Pandemic.

ObjectivesFew publications have documented the utility of in-home telephone-based cognitive screeners during COVID-19. This manuscript describes the adaptation of select face-to-face (FTF) neuropsychological tests to telephonic administration in a longitudinal cohort of people with HIV (PWH). Using the cohort’s pre-pandemic neuropsychological data, we explore the utility of telephonic administration in this population.MethodsOf a longitudinal cohort of 170 adult PWH, 59 completed telephonic medical and cognitive screenings with comparable pre-pandemic FTF data. Telephone screeners and FTF evaluations were compared using repeated measures ANCOVAs to examine whether test performance differed between administration types and levels of pre-pandemic cognitive performance. Individuals with pre-pandemic test scores more than a standard deviation below the demographically-corrected mean were categorized as “below average” cognitive performance (n = 23), and the remainder as “average” (n = 36).ResultsOver 90% of participants gave positive feedback about the telephone encounter. The average cognitive performance group scored higher than the below average group on all measures across both administration types. Telephone and FTF test scores did not differ significantly for measures of category fluency, letter fluency, and verbal learning. However, the below average group scored higher on a verbal memory measure administered via telephone compared with FTF.ConclusionsSupport for telephonic adaptation of select FTF measures in longitudinal research is mixed, with verbal fluency tasks showing the strongest equivalency. When employed carefully with a clear understanding of their limitations, telephone adaptations can provide an opportunity to continue study objectives, promote equity, and monitor participant well-being during times of duress.

A high-touch outreach model to re-engage patients in mammogram screening.

e18555 Background: Disparities in cancer screening have been well documented during the Covid-19 pandemic. However, there are limited patient-reported data describing the prevalence and drivers of patient hesitancy towards cancer screening and willingness to resume screening. As health systems continue to experience pandemic-related capacity strain, there is an urgent need for innovative models of re-engaging patients in preventive screening. To address this issue, we developed a medical student-led, high-touch outreach model to re-engage primary care patients at Brookside Community Health Center in cancer screening. Methods: We iteratively optimized semi-structured call scripts and surveys in English and Spanish to contact patients overdue for mammography screening. Student callers included medical and pre-medical students with native Spanish fluency. Using the call script, students identified patient-reported barriers and facilitated mammogram scheduling for consenting patients. For consenting patients, student callers placed a telephone encounter with a pended screening mammogram order in the electronic medical record. PCP confirmation of the order triggered outreach by the radiology department for mammogram scheduling. Patients also received reminder calls from students the week of their appointment. Primary outcomes include screening consent rates, mammogram scheduling and completion rates, and screening results. Patient survey responses were securely recorded using the REDCap survey platform. Results: 198 patients were eligible for the intervention. 60% are primarily Spanish-speaking and 81% are insured by Medicaid. 145 patients (73%) have successfully been contacted, of which 129 (89%) consented for mammogram screening. 74 (57%) of the consenting patients have scheduled their mammogram and 38 (29%) have completed their mammogram. 36% of consenting Spanish-speaking patients with active mammogram orders did not have a mammogram scheduled, compared to 9% of consenting English-speaking. To date, 6 patients had abnormal mammograms requiring subsequent diagnostic imaging, and 1 patient was diagnosed with ductal carcinoma in situ requiring oncologic care. Qualitative analysis of patient surveys found that primary barriers to screening included factors associated with the Covid-19 pandemic (32.9% of contacted patients), lack of awareness of overdue status (25.9%) and patient unavailability (e.g. outside of country) (20%). Conclusions: In this single-center quality improvement study, we found that patients had a high willingness to engage in cancer screening during the pandemic and that trainees can play a vital role in re-engaging patients in preventative care. The disparity between Spanish and English-speaking patients’ ability to schedule a mammogram after the consent process suggests that patients with limited English proficiency face additional challenges in accessing screenings.

0360 PAP Adherence, Follow-Up, and Telehealth During the COVID-19 Pandemic

Abstract Introduction Positive airway pressure (PAP) is the gold standard therapy for OSA. However, patient follow-up and adherence to PAP therapy remains variable. With the onset of the COVID-19 pandemic, many sleep centers shifted towards telemedicine. In order to evaluate the impact of telehealth, we assessed the rates of follow-up and PAP adherence among patients newly diagnosed with OSA prior to and after the onset of the COVID-19 pandemic. Methods Patients aged 18-75 years enrolled in our military sleep center who met eligibility criteria were divided into a pre-pandemic group and a pandemic group. For the pre-pandemic group, initial and follow-up clinic appointments occurred via face-to-face encounters. For the pandemic group, these clinic appointments occurred via telephone encounters. PAP follow-up was defined as a clinic appointment occurring within 6 months of the initial OSA diagnosis and the onset of PAP therapy. Adequate PAP adherence was defined as usage of the device ≥ 4 hours per night on ≥ 70% of nights during a consecutive 30-day period. Differences among the two groups regarding PAP follow-up, PAP adherence, and demographic data were analyzed. Results Eligible patients (n=234) were divided into a pre-pandemic group (n=117) and a pandemic group (n=117). Demographic data for the pre-pandemic group vs. pandemic group included the following: mean age 42.2 vs. 40.3 years; 78.6% vs. 88.0% male; 60.7% vs. 76.9% active duty military, mean BMI 30.1 vs. 30.1; mean AHI 28.5/hr vs. 27.7/hr; mean Epworth Sleepiness Scale score 11.7 vs. 12.0; mean Insomnia Severity Index 16.9 vs. 16.8. The rates of PAP follow-up were 59.0% (pre-pandemic group) vs. 41.0% (pandemic group). The rates of adequate PAP adherence were 34.8% (pre-pandemic group) vs. 25.0% (pandemic group). Conclusion There were higher rates of PAP follow-up and PAP adherence among patients seen via face-to-face encounters occurring prior to the onset of the COVID-19 pandemic. While utilization of telehealth in our center did not result in improved outcomes, there may still be utility in offering telehealth to the sleep patient population. Additional studies are needed to identify effective interventions that can be implemented to improve rates of PAP follow-up and PAP adherence. Support (If Any) There were higher rates of PAP follow-up and PAP adherence among patients seen via face-to-face encounters occurring prior to the onset of the COVID-19 pandemic. While utilization of telehealth in our center did not result in improved outcomes, there may still be utility in offering telehealth to the sleep patient population. Additional studies are needed to identify effective interventions that can be implemented to improve rates of PAP follow-up and PAP adherence.

PD52-07 OUTCOMES AND SATISFACTION AFTER PENILE SILICONE IMPLANT SURGERY

You have accessJournal of UrologyCME1 May 2022PD52-07 OUTCOMES AND SATISFACTION AFTER PENILE SILICONE IMPLANT SURGERY Morgan Salkowski, Kevin Alter, and Laurence Levine Morgan SalkowskiMorgan Salkowski More articles by this author , Kevin AlterKevin Alter More articles by this author , and Laurence LevineLaurence Levine More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002629.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Penuma®, a penile silicone sleeve implant, first developed in 2004, is the first FDA-cleared penile implant for cosmetic enhancement. The company endorses that on average, girth and flaccid length are increased by one to two inches. Given the novelty of the device and the scarcity of surgeons trained in placement, data regarding surgical outcomes as well as patient satisfaction are limited. It is thought that patient selection is a critical contributor to the ultimate success of the surgery. Post-operative complications have previously been described and can include seroma, infection, and erosion. METHODS: Retrospective chart review was performed on patients that were six months or greater from initial date of surgery. Progress notes from follow up appointments as well as telephone encounters were reviewed to look for patient complaints, post-operative physical exams, and post operative procedures. Subsequent operative reports apart from initial implant were also reviewed. An electronic survey assessing various aspects of penile satisfaction before and after the implant was sent to patients who were six months or greater from surgery and still had the device in place. RESULTS: From April 2019 to February 2021, 70 patients underwent insertion of subcutaneous soft silicone penile implant (Penuma®) with two surgeons. Post operatively, flaccid penile length base to tip increased on average 4.0-6.0 cm, mid-shaft girth increased 2.5-5.0 cm, and there was no increase in erect length. 8 of these patients (11%) subsequently underwent removal of the device, reasons for which included pain (2), dissatisfaction with the device (1), erosion (4), and loss of skin after frostbite (1). 19 patients (27%) experienced postoperative seromas, of which 14 required drainage. Four patients (6%) required operative revision for edge protrusion (2), proximal dislodgement (1) and improved placement (1). A follow up survey was sent to two surgeons’ patient populations of 66 patients, for which we had a 40% response rate. With regards to patient satisfaction, 65% of patients self-reported being “dissatisfied” or “very dissatisfied” with the appearance of their penis before the implant compared to 96% who reported being “satisfied” or “very satisfied” after the implant. 85% of patients reported being “satisfied” or “very satisfied” with how natural their penis looks after the implant, with 4% reporting being “very dissatisfied.” 65% reported feeling “very dissatisfied” with self-confidence with regards to their penis prior to surgery, while 92% felt “satisfied” or “very satisfied” regarding the same after surgery. Overall, 85% of responders “agreed” or “somewhat agreed” that they would opt to undergo surgery again. CONCLUSIONS: The Penuma® penile sleeve implant can improve patient self-satisfaction and self-confidence with regards to the appearance of their penis while maintaining a natural feel. Post operative complications, including need for re-operation, are low but not negligible. The number of surgeons that currently offer the Penuma® implant surgery in the United States is quite small, and this study suggests that it may be a successful potential option for men with penile dysmorphic disorder. Source of Funding: No funding was needed for this study © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e907 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Morgan Salkowski More articles by this author Kevin Alter More articles by this author Laurence Levine More articles by this author Expand All Advertisement PDF DownloadLoading ...

Why is it so hard to do the right thing? Reflections on the fourth trimester

Why is it so hard to do the right thing? Reflections on the fourth trimester

Outcomes and Satisfaction after Penile Silicone Implant Surgery

ABSTRACT Introduction Penuma®, a penile silicone sleeve implant, first developed in 2004, is the first FDA-approved penile implant for cosmetic enhancement. The company endorses that on average, girth and flaccid length are increased by one to two inches. Given the novelty of the device and the scarcity of surgeons trained in placement, data regarding surgical outcomes as well as patient satisfaction are limited. It is thought that patient selection is a critical contributor to the ultimate success of the surgery. Post-operative complications have previously been described and can include seroma, infection, and explanation. Objective This study aims to characterize the outcomes of two surgeon's experience with the Penuma device and to analyze patient's perspective regarding the effects of the surgery on penile size, perceived appearance and self-esteem. Methods Retrospective chart review was performed on patients that were six months or greater from initial date of surgery. Progress notes from follow up appointments as well as telephone encounters were reviewed to look for patient complaints, post-operative physical exams, and post operative procedures. Subsequent operative reports apart from initial implant were also reviewed. An electronic survey assessing various aspects of penile satisfaction before and after the implant was sent to patients who were six months or greater from surgery and still had the device in place. Results From April 2019 to February 2021, 70 patients underwent insertion of subcutaneous soft silicone penile implant (Penuma ®) with two surgeons. 8 of these patients (11%) subsequently underwent removal of the device, reasons for which included pain, dissatisfaction with the device, and device erosion. 19 patients (27%) experienced postoperative seromas, of which 14 required drainage. Four patients (5.7%) required operative revision. A follow up survey was sent to one surgeon's patient population of 26 patients, for which we received a 100% response rate. With regards to patient satisfaction, 65.4% of patients self-reported being “dissatisfied” or “very dissatisfied” with the appearance of their penis before the implant compared to 96% who reported being “satisfied” or “very satisfied” after the implant. 84.6% of patients reported being “satisfied” or “very satisfied” with how natural their penis looks after the implant, with 3.8% reporting being “very dissatisfied.” 65.4% reported feeling “very dissatisfied” with self-confidence with regards to their penis prior to surgery, while 92.4% felt “satisfied” or “very satisfied” regarding the same after surgery. Overall, 84.6% of responders “agreed” or “somewhat agreed” that they would opt to undergo surgery again. Conclusions The Penuma® penile sleeve implant can improve patient self-satisfaction and self-confidence with regards to the appearance of their penis while maintaining a natural feel. Post operative complications, including need for re-operation, are low but not negligible. The number of surgeons that currently offer the Penuma® implant surgery in the United States is quite small, and this study suggests that it may be a successful potential option for men with penile dysmorphic disorder. Disclosure No

Telemedicine for Cranial Radiosurgery Patients in a Rural U.S. Population: Patterns and Predictors of Patient Utilization

Introduction: Telemedicine retains potential for increasing access to specialty providers in underserved and rural communities. COVID-19 accelerated adoption of telehealth beyond rural populations, serving as a primary modality of patient-provider encounters for many nonemergent diagnoses. Methods: From 2020 to 2021, telemedicine was incorporated in management of stereotactic radiosurgery patients. Retrospective data on diagnoses, demographics, distance to primary clinic, and encounter type were captured and statistically analyzed using descriptive measures and Cox proportional regression modeling. Graphical representation of service areas was created using geo-mapping software. Results: Patients (n = 208) completed 331 telemedicine encounters over 12 months. Metastases and meningiomas comprised 60% of diagnoses. Median age was 62 years with median household income and residential population of $44,752 and 7,634 people. The one-way mean and median travel distances were 74.6 and 66.3 miles. The total potential road mileage for all patients was 44,596 miles. A total of 118 (57%) patients completed video visits during the first encounter, whereas 90 (43%) opted for telephone encounters. At 12 months, 138 patients (66%) utilized video visits and 70 (34%) used telephone visits. Predictors of video visit use were video-enabled visit during the first encounter (hazard ratio [HR] 2.806, p < 0.001), total potential distance traveled (HR 1.681, p < 0.05), and the need for more than one visit per year (HR 2.903, p < 0.001). Discussion: Telemedicine can be effective in radiosurgery practice with predictors of video-enabled use being pre-existing patient comfort levels with videoconferencing, total annual travel distance, and number of visits per year. Age, rural population status, and household income did not impact telemedicine use in our patient cohort.

Hip and Knee Arthroplasty Alternative Payment Model Successes and Challenges.

Hip and Knee Arthroplasty Alternative Payment Model Successes and Challenges.

Deployment of an Interventional Radiology Telemedicine Program During the COVID-19 Pandemic: Initial Experience With 10,056 Visits.

ObjectiveTo evaluate the clinical, operational, and financial effects of using telemedicine services in an academic interventional radiology setting during the coronavirus disease 2019 pandemic and to identify potential barriers to equitable telemedicine access for patients.MethodsEvaluation and management (E&M) data over a 104-week period from September 2019 to August 2021 were reviewed. Data related to the visits were recorded including visit type, billing provider, patient demographic information, Current Procedural Terminology code charged, and reimbursement received. The ZIP code pertaining to the patient’s primary residence was matched with median household income from the US Census Bureau.ResultsIn all, 14,754 E&M encounters were performed over the study period, of which 10,056 were conducted using telemedicine. Twenty-two percent of visits were performed with interactive video; the remainder were performed using audio only. Female patients were more likely than male patients to use interactive video visits for telemedicine encounters (23.7% versus 20.4%, P < .001). Patients availing of video visits (mean age, 58.1 years, SD = 14.0) were also significantly younger than those patients who used audio-only (telephone) encounters (mean age, 62.5 years, SD = 13.3). Patients with private insurance and those living in neighborhoods with higher median household income were more likely to avail of interactive video visits (P < .001). Professional E&M monthly revenue was between 23.3% and 53.2% of peak prepandemic levels (mean 37.7%).ConclusionTelemedicine services allowed for rapid restoration of E&M encounter volumes over the study period. Further work is required to determine the potential implementation barriers to increasing the use of video visits.

Outcome Disparities and Resource Utilization Among Limited English Proficient Patients After Tonsillectomy.

There is evidence to suggest adverse outcomes on patients' medical and surgical care when there is language discordance in patient-physician relationships. No studies have evaluated the impact of limited English proficiency (LEP) on complications after common surgical procedures in otolaryngology. Furthermore, no studies have evaluated how patients with LEP utilize remote resources to connect with otolaryngology providers to better triage such complications. The purpose was to evaluate the incidence of post-tonsillectomy hemorrhage (PTH) comparing patients with LEP to those with English proficiency (EP). Patients with PTH were retrospectively evaluated to identify preceding telephone encounters, a marker of resource utilization. Demographics, English proficiency, and PTH management (surgical vs non-surgical) were evaluated in addition to PTH-associated triage telephone encounters with otolaryngology providers. Of 2466 tonsillectomies, there were 141 episodes of reported hemorrhage (50 LEP vs 91 EP) in the 5 years studied. Rates were not significantly different between LEP and EP patients (4.9% vs 6.3%, P = .127). There was no statistically significant difference in rate of preceding telephone encounters between LEP and EP patients (24% vs 40%, P = .062). Of patients presenting directly to the Emergency Department without a triage telephone encounter, there was no difference in operative versus non-operative management when comparing LEP versus EP patients. However, patients presenting directly to the Emergency Department were nearly twice as likely to undergo operative intervention compared to patients with preceding telephone encounters (RR = 1.79). Patients with limited English proficiency are not at increased risk for developing PTH. There is equitable access to remote otolaryngologic triage care, although overall the utilization rate of this resource was low for both cohorts.

Multidisciplinary Telehealth-Focused Approach to Chronic Limb-Threatening Ischemia Prevents Increased Amputation Rates During COVID-19 Pandemic

Introduction and ObjectiveDuring the Coronavirus Disease 2019 (COVID-19) pandemic, global reports have surfaced describing patient- and system-level delays in care secondary to scarcity of resources, fear of exposure, and even reassignment of providers, with subsequent adverse outcomes for patients. After early reports suggested increased major amputation rates among patients with chronic limb-threatening ischemia (CLTI), our healthcare system employed a multidisciplinary strategy to monitor these patients closely. The objective of our study was to evaluate primary amputation rates and disease severity among Veterans who presented with CLTI during the COVID-19 pandemic.MethodsA retrospective cohort study of all patients treated at our Veterans Affairs Medical Center (VAMC) for CLTI was performed. Veterans with CLTI (Rutherford Classification 4-6) who underwent lower extremity revascularization (LER) within the first 7 months of the pandemic (COVID cohort) were compared to those who underwent LER within the same 7-month period one year prior to the pandemic (pre-COVID cohort). Exclusion criteria included acute limb ischemia presentation and LER within 3 months prior to the study period. During the COVID study period, a multidisciplinary team of vascular surgeons, podiatrists, advanced practice providers, and trainees screened all upcoming Veteran appointments for peripheral artery disease or leg wounds. Those with known or suggested CLTI were scheduled for either telehealth or telephone encounters based on access to compatible devices.Table 1Table 1. Comparison of patients undergoing lower extremity revascularization (LER) for chronic limb threatening ischemia (CLTI) before versus during the COVID-19 pandemic.Table 1Image, table 1ResultsThe pre-COVID and COVID cohorts consisted of 32 and 35 patients, respectively. Both displayed similar demographics (Table 1Table 1Comparison of patients undergoing lower extremity revascularization (LER) for chronic limb threatening ischemia (CLTI) before versus during the COVID-19 pandemic.Table 1Image, table 1). Nearly 80% of all patients presented with Rutherford 5-6 disease. WIfI (Wound, Ischemia, and Foot Infection) stage did not significantly differ between the two cohorts. Primary major amputation rate was 15.7% in the pre-COVID cohort compared to 14.3% in the COVID cohort (p=0.980). Based on WIfI score, primary amputation was driven by ischemia (versus infection) in both the pre-COVID and COVID cohorts. During the first 7 months of the pandemic, vascular surgery alone increased monthly telehealth encounters nearly 14-fold, with overall improvement in the number of successful multidisciplinary telehealth visits as the pandemic persisted (Figure 1).Figure 1Progression of successful telehealth visits during the first seven months of the COVID-19 pandemic, by month.Figure 1ConclusionsOur institution did not experience increased amputation rates or advanced disease presentation for patients with CLTI during the COVID-19 pandemic. This may be due to the coordinated approach that has capitalized on continued collaboration between vascular surgery and podiatric surgery, as well as the rapid roll-out of a robust tele-wound program to surveil high-risk Veterans. Further investigation is necessary to determine how telehealth can be leveraged to improve limb outcomes.

A retrospective cohort study of clinical factors, visit patterns, and demographic factors associated with use of remote communications in patients with headache.

To identify the characteristics associated with high utilization of remote communications (RCs) in patients with headache. Patients with headache frequently communicate with their providers using secure portal messaging and telephone calls. However, clinical and demographic factors as well as visit patterns associated with RC utilization remain poorly characterized. We retrospectively analyzed data from patients with headache who were evaluated in the ambulatory neurology faculty practice at the Icahn School of Medicine at Mount Sinai in New York between January 1 and June 30, 2019. We extracted clinical and demographic characteristics, total office visits, secure MyChart portal messages, and telephone encounters from our institutional data warehouse. We defined high RC and MyChart utilization as the top tertile of RC and MyChart message volume, respectively, and assessed the relationship between patient characteristics and high RC (primary outcome), as well as high MyChart utilization (secondary outcome). We characterized the relationship between clinicodemographic characteristics and the ratio of MyChart messages to total RCs (secondary outcome). We identified 1390 patients, of whom 477 (34.3%) were high RC utilizers and 321 (23.1%) were high MyChart utilizers. High RC utilizers generated 3306/3921 (84.3%) RCs. The presence of chronic headache (aOR 2.31, 95% CI 1.75-3.03, p<0.0001), cluster headache (aOR 18.3, 95% CI 5.0-71.7, p=0.001), and migraine (aOR 3.82, 95% CI 1.93-9.3, p=0.011) was associated with high RC utilization. Patients ≥65years of age were less likely to engage in MyChart messaging as a proportion of RC (191/680, 28.1%) compared with patients 18-30years of age (243/620, 39.2%, p=0.049) and 30-64years of age (1172/2721, 43.1%, p<0.0001). A minority of patients with headache (477/1390; 34.3%) generated the majority (3306/3921; 84.3%) of RCs. Our findings should be validated in external patient cohorts with the objective of developing strategies to optimize RC utilization.

Clinical genetic counselor experience in the adoption of telehealth in the United States and Canada during the COVID-19 pandemic.

The COVID‐19 pandemic has significantly impacted the service delivery model (SDM) of clinical genetic counseling across the United States and Canada. A cross‐sectional survey was distributed to 4,956 genetic counselors (GCs) from the American Board of Genetic Counselors and Canadian Association of Genetic Counselors mailing lists in August 2020 to assess the change in utilization of telehealth for clinical genetic counseling during the COVID‐19 pandemic compared with prior to the pandemic. Data from 411 eligible clinical genetic counselors on GC attitudes and their experiences prior to and during the pandemic were collected and analyzed to explore the change in SDM, change in appointment characteristics, change in billing practices, GC perceived benefits and limitations of telehealth, and prediction of future trends in SDM in the post‐pandemic era. The study showed the overall utilization of audiovisual and telephone encounters increased by 43.4% and 26.2%, respectively. The majority of respondents who provided audiovisual and telephone encounters reported increased patient volume compared with prior to the pandemic, with an average increase of 79.4% and 42.8%, respectively. There was an increase of 69.4% of GCs rendering genetic services from home offices. The percentage of participants who billed for telehealth services increased from 45.7% before the pandemic to 80.3% during the pandemic. The top GC perceived benefits of telehealth included safety for high‐risk COVID patients (95.2%) and saved commute time for patients (94.7%). The top GC perceived limitations of telehealth included difficulty to conduct physician evaluation/coordinating with healthcare providers (HCP) (73.7%) and difficulty addressing non‐English speaking patients (68.5%). Overall, 89.6% of GCs were satisfied with telehealth; however, 55.3% reported uncertainty whether the newly adopted SDM would continue after the pandemic subsides. Results from this study demonstrate the rapid adoption of telehealth for clinical genetic counseling services as a result of the COVID‐19 pandemic, an increase in billing for these services, and support the feasibility of telehealth for genetic counseling as a longer term solution to reach patients who are geographically distant.

Office-Based Tunneled Hemodialysis Catheter Removals: Evaluating Safety, Quality, and Cost

<h3>Introduction/Objective</h3> Many surgical procedures have moved from the hospital environment to an office-based setting, giving providers and patients more flexibility without sacrificing safety nor quality of care. Dialysis patients are in a more vulnerable state and the chance of significant secondary morbidies are increased. Tunneled hemodialysis catheters (TDC's) are used for temporary dialysis access ports, commonly serving as a placeholder until an AV graft ormaturated fistula is ready for hemodialysis. Prolonged use of TDC's has an increased risk of bacteremia, catheter malfunction, sepsis, exit site infections, catheter fracture, and are also associated with increased mortality rates. Bedside removal of TDC's has been deemed a safe procedure in previous studies. Office-based settings are able to provide another site-of-service that could expedite and improve access to care. <h3>Methods</h3> A retrospective review of our office based TDC removals. All patients who had TDC removals from 1/22/2007 to 4/7/2020 were identified (13-year period). Procedures were performed in a vascular surgery in-office setting with sterile technique. The data recorded included: date of procedure, patient name, sex of patient, post-procedural complications, dateof last follow-up, performing physician, and whether the patient is deceased. Complications during and post procedure were recorded. Follow-up visits were done by means of office visitsand telephone encounters. Post-operative follow-up protocol for this study include the initial nurse visit (usually 1 week following the procedure), the subsequent 2 clinical post-proceduralencounters, and the last visit that the patient had at the office. <h3>Results</h3> A total of 524 TDC removals were performed from January 2007 to April 2020 (13-year period). 498 had follow-up. The average follow-up of patients after the procedure was 2.5 yrs. 33/429 patients had complications reported (7.69%). 69 of the patients who followed up were on paper charts that could not be accessed. Complications were classified as exit site erythema (n=13, 3.0%), infection (n=7, 1.6%), bruising (n=7, 1.6%), drainage without infection (n=2, 0.47%), and tenderness (n=4, 0.93%). Infection=assessed by physician and placed on antibiotics.None of the patients required hospitalization post-procedure due to procedural-related complications nor were there any procedural-related mortalities. The national average outpatient/ASC cost for TDC removal is $461 versus an average in-hospital cost of $733 (https://www.medicare.gov/procedure-price-lookup/cost/36589). Our office-setting average (per 60 min case) cost was $241.33. (Physician fee $143, Supplies $65, Staffing $20, Room $33.33/hour). Cost was evaluated per hour, so if the procedure can be performed faster thenthe costs will be less. Room costs are from patient entry to patient exit. <h3>Conclusion</h3> Hemodialysis patients need better access to care. TDC's should be removed as soonas possible, due to the high rate of complications associated with them. The office-setting provides an easier and expedited access for TDC removals in hemodialysis patients compared tothe hospital setting. TDC catheter removals are able to be taken out safely in an office-based setting. Offices provide low morbidity rate: 7.69%, all of which were minor, and none required hospital admission. There were no mortalities associated with the procedure. The office setting is more cost effective than the hospital setting for TDC removals: $461 ASC/ Hospital Outpatient vs. $733 in- hospital, and our costs being $ 241.33 per hour. TDC removals should be performed in a physician's office to provide a safer more cost-effective option for hemodialysis patients and the healthcare system.

Clinical findings post hospital discharge in patients with covid-19: A telephone interview study

Importance:Active COVID-19 symptoms like cough, shortness of breath, fever, sore throat and others are well established. However, there is limited information on the persistence of symptoms post infection. Objective:To identify the post discharge symptoms amongst adult patients discharged from the hospital after having been hospitalized and treated for COVID-19 from March to the end of May of 2020. Design, setting, and participants:Adult patients discharged from the hospital after admission for COVID-19 infection were contacted via a telephone encounter as a post-discharge follow-up, which ranged from 9 to 92 days with an average of 57 days post discharge. A standardized questionnaire was used during post discharge telephone encounter for the patients to assess presence or absence of symptoms following discharge. Main outcomes and measures:Chi-square statistics were used to calculate unadjusted associations between predictors and the symptom status outcome, and Fisher’s exact statistic was used in the case of rare events/low cell counts. A multivariable logistic regression model was used to determine any association between the predictors and the outcome of still being symptomatic versus having improved symptoms at follow-up date. Firth’s logistic regression was applied to the analysis in order to handle sample bias as well as low cell counts. Results:Out of the 337 patients who were discharged after COVID-19 hospitalization, 180 had successful post discharge telephone encounters. The majorities of the patients were male, 108 (60%) and belonged to the age group, 35-64 years. Out of 180 patients, 151 (83.88%) were asymptomatic and 29 (16.11%) were still symptomatic. Of the 29 symptomatic patients, the most common symptoms reported were persistent fever, 19 (65.52%), shortness of breath, 19 (65.52%) and cough, 25 (86.21%). Conclusion and relevance:The majority of patients discharged from the hospital where they had been attended for COVID-19 were asymptomatic post discharge. Our study identified that a proportion of patients could remain symptomatic after COVID 19 hospitalization. The importance of follow up post hospital discharge is highlighted in this study.