Total Number Of Visits Research Articles

Promene u primarnoj zdravstvenoj zaštiti kao odgovor na pandemiju KOVID-19 oboljenja u Crnoj Gori

Introduction: Primary health care is considered the basis, not only for meeting healthcare needs, but also for responding to crisis situations, such as the crisis caused by the outbreak of the COVID-19 pandemic. Aim: The aim of this study is to describe changes in primary health care caused by the outbreak of COVID-19 in Montenegro, with a focus on the organization and provision of health services. Methods: This is a descriptive observational study with the following main outcome measures: number and manner of visits and services, including e-services, prescribed antibiotics and prescriptions according to the diagnosis, per 1,000 inhabitants, in the year 2020, as compared to the same indicators in 2019. Data were generated from the health statistics information system of the Institute of Public Health of Montenegro. Demographic data from official statistics were used. Results: The global pandemic has changed the functioning of primary health care, and ad hoc solutions have been found, in terms of infrastructure, the health workforce, and new e-health services. As compared to 2019, in 2020, the total number of visits per 1,000 inhabitants decreased by 12%, while home visits increased by 15%, in the third quarter. Online scheduling (e-order) was the most commonly used e-service (accessed 983,212 times in 2020). The prescribed antibiotics did not exceed the monthly rates from 2019 (per 1,000 inhabitants). The number of prescriptions issued (per 1,000 inhabitants), in 2020, increased by 8% for the diagnoses for which doctors prescribed the most prescriptions (per 1,000 inhabitants). Conclusion: The COVID-19 pandemic has changed the functioning of primary health care, with a transition from office visits to - home visits, telephone consultations, and e-services, without physical contact. However, there is room for improvement in meeting health needs in the area of prevention and treatment of other diseases.

P127: HEALTHCARE RESOURCE UTILIZATION PATTERNS AND RELATED COSTS IN PATIENTS WITH SICKLE CELL DISEASE IN NORTH LEBANON- A REAL-WORLD EXPERIENCE

Background: Despite a reduction in morbidity and mortality associated with the use of disease modifying therapies, sickle cell disease (SCD) remains associated with high healthcare resource utilization (HRU), primarily attributed to vaso-occlusive crisis (VOC). (1, 2) There are limited national estimates on HRU, cost of medical care, and treatment expenditures for patients with SCD in Lebanon. A better understanding of these estimates may provide new perspectives to improve access to high-quality cost-effective health care services. Aims: We aimed to evaluate patterns of HRU and related cost in a cohort of patients with SCD receiving care in a Comprehensive SCD referral center at NINI hospital in North Lebanon. Methods: A retrospective non-interventional observational study was conducted among 136 patients (54.4% females) with confirmed diagnosis of SCD in North Lebanon. Data on HRU including emergency department (ED) visits, ambulatory visits and hospitalizations collected in a patient health information (PHI)-anonymized format during the period 01 May2018 - 30 Apr 2020 were obtained from patients’ paper and electronic medical files, as well as hospital and ED files. Uncomplicated VOCs were defined as pain crises, whereas complicated VOCs were defined as acute chest syndrome, acute splenic sequestration, acute hepatic sequestration or priapism. The annual rate of HRU visits was calculated as a ratio of the total number of visits to the total number of years of follow-up across all patients. The average annual cost was similarly calculated as the ratio of total cost of these visits to the total number of years of follow-up, based on available data. Results: In the present study, the median age of patients at the time of study was 10.8 years (IQR 5.3 to 19.6 years). Majority of patients were diagnosed with SS (72.1%) and Sβ0 (21.3%) genotype across all age groups. Pain crisis (90.4%), fever (43.4%), acute chest syndrome (33.1%), and acute splenic sequestration (22.8%) were the most common SCD-related complications. The annual rate of HRU visits (per patient) was 5.7. Uncomplicated VOCs led to majority of hospitalizations, ICU and ED visits in adult patients (age >16 years). The average annual costs of HRU were 8,270,920 Lebanese pounds (LBP) amounting to 5,514 USD (per patient per year) of which 92.1% was for hospitalizations, 4% for ED visits and 3.9% for ambulatory visits. Annual costs for ED, ICU and hospitalizations were highest for uncomplicated VOC. Costs related to medications, diagnostics, non-hematologist medical consults, uncompensated care and lost productivity are not included in this analysis. Analgesics, folic acid and hydroxyurea were the most frequently administered medications across all age groups with 84% of patients being treated with hydroxyurea. Conclusion: This real world study reveals that SCD and its related complications resulted in significant acute HRU. VOCs remain the primary factor for resource use, ICU admission and costs with the largest proportion of annual cost being attributed to hospitalizations. Despite the high HRU rate in this relatively young SCD cohort, the cost of HRU in a comprehensive setting with effective outpatient management as that in North Lebanon appears affordable for the health care system. However when additional SCD related and non SCD related costs of care are included, the economic burden of SCD care is likely to be significantly higher than the figures reported.

Orthoptists Services: A Review of Benefits Paid By Medical Schemes, South Africa

Background: Orthoptists are specialists in diagnosing and treating ocular movement disorders and problems related to how the eyes work together, known as binocular vision. There is currently about 1 100 orthoptist registered and working in the UK. The comparative figure to South Africa is much lower at only nine registered orthoptists. Study design and objectives: This was a cross-sectional research study of claims paid for Orthoptists services by medical schemes. The study's primary objectives were to assess benefits paid for Orthoptists services, the level of co-payment subjected to members of medical schemes, and the funding model employed by medical schemes. The study entailed secondary data collected from the Council for Medical Schemes Annual Statutory returns. Results: The total number of beneficiaries with at least one orthoptist visit was 204, and the total number of visits paid by schemes was 256. This translates to the average number of one visit per beneficiary per annum. Each visit amounted to an average expenditure of R540. These services attracted a co-payment to the rand amount of R148 per visit. Nearly half of these benefits were paid from the person's medical savings account, accounting for 48% of benefits. Conclusion and recommendations: Coupled with evidence that there are currently no training schools for orthoptists and a low revenue base, this study shows that the demand for the services is lower than in previous years. The study recommends a review of the current model to a more multidisciplinary team across all specialties, particularly seeing that the first world countries still utilise the services of orthoptists in various health sectors, including child development and mainstream schools.

Treatment patterns and cost of exacerbations in patients with chronic obstructive pulmonary disease using multiple inhaler triple therapy in South Korea

BackgroundMultiple inhaler triple therapy (MITT), comprising inhaled corticosteroids (ICS), long-acting beta-agonists (LABA), and long-acting muscarinic antagonists (LAMA), has been used as an escalation treatment for patients with chronic obstructive pulmonary disease (COPD). However, real-world use of MITT has not been investigated in Asia, including South Korea. This study reports baseline characteristics of patients with COPD initiated on MITT in South Korea, and their treatment patterns. Healthcare resource utilization (HRU) and costs associated with COPD exacerbations following MITT initiation were also assessed.MethodsThis was a retrospective cohort study using the South Korea National Health Insurance database (2014–2018). Included patients were ≥ 40 years, had a COPD diagnosis, were newly initiated on MITT and had ≥ 12 months’ data both before (baseline) and after index date (the first day with overlapping supply of all MITT components). Treatment immediately before initiation and immediately following discontinuation of MITT were identified, and proportion of days covered (PDC) by MITT was calculated. HRU and costs (per person per year [PPPY]) associated with exacerbations were identified following MITT initiation; costs were calculated using the average 2020 exchange rate (0.0008 USD/KRW).ResultsAmong 37,400 patients, the mean age was 69 (SD 10) years and 73% were males; 56% had ≥ 1 COPD exacerbation during the baseline period, with a mean of 2 (SD 5) events/year. ICS/LABA was the most frequent regimen prescribed immediately before initiation (37%) and immediately following discontinuation (41% of 34,264 patients) of MITT. At 3, 6, and 12 months from treatment initiation, mean PDC was 81%, 63% and 49%, respectively; median treatment duration was 102 days. The mean (95% confidence interval [CI]) number of total visits for severe COPD exacerbations was 0.77 PPPY (0.75–0.78); mean PPPY total healthcare costs were 2093 USD.ConclusionsPatients with COPD in South Korea experienced frequent exacerbations prior to MITT, and PDC by MITT was low. Patients may benefit from early optimization of COPD therapy, and greater emphasis on adherence to inhaled COPD therapy. Severe exacerbations were found to incur substantial costs; treatment alternatives that can reduce the rate of severe exacerbations are likely to minimize healthcare costs.

The Analysis of Carrying Capacity for Tourism Object in Melasti Beach Ungasan Bali

Carrying capacity (DDK) is the ability of the environment to support human life, other living things, and maintain the balance of the ecosystem. Conditions that over-carrying capacity cause human discomfort and create environmental degradation. Melasti Beach is a tourism object that is in demand by tourists. The frequency of tourist visits continues to increase along with the risk of environmental damage. This study aims to determine the unit of the area, the duration of activities, furthermore to calculate the value of carrying capacity. The data used are primary data obtained by questionnaire method to 50 tourist respondents and secondary data derived from literature study based on conditions in Melasti Beach. The results showed that the average area for tourism activities (Lt) was 232.7 m2 and the duration of activities (Wp) was 2.4 hours/day. The total time provided by the beach manager for tourism activities is 12 hours/day and the total area is 94.632 m2. The DDK value at Melasti Beach uses the Lt and Wp values, namely 2.008 people/day, 60.227 people/month and 722.724 people/year. These conditions show that tourist visits to Melasti Beach do not exceed DDK throughout the month and the total number of visits in 2020.

Long Term Implications of Home Healthcare Management on Mortality in Older Adults with Functional Difficulties in the Saudi Community.

Background: This study aims to investigate whether certain demographic factors of patients receiving home healthcare (HHC) interventions have any positive impact on mortality. Methods: the study included all patients who were enrolled in the HHC program in a referred medical complex, Jeddah, Saudi Arabia between the years 2017 and 2020 (593 patients). Results: A total of 6548 HHC visits were received during the study period. From the total number of visits, 3592 (54.9%) HHC visits were scheduled in the year 2020 compared to 157 (2.4%) scheduled HHC visits in 2017 (p < 0.001). The most successful HHC visits were provided in 2020 compared with the year 2017 (2193 vs. 132; p < 0.001). The cancelled HHC visits were observed to be the lowest (194) in 2019. Three explanatory variables of mortality [age, having a major diagnosis (diabetes mellitus, cerebrovascular diseases, and bedridden), and having more cancelled visits] made a statistically significant contribution to the logistic regression model after controlling for other variables. Suffering from cerebrovascular diseases and/or bedridden were the strongest predictor of death in patients receiving HHC. Conclusions: During the 2020 pandemic, there was a sharp increase in HHC compared to previous years. Three significant explanatory variables of mortality [age, having a major diagnosis (diabetes mellitus, cerebrovascular diseases, and bedridden), and having more cancelled visits] were reported.

Relationship Between Caregiver Attendance at Wound Clinic Visits and Wound Healing in Patients With Diabetes: A Retrospective Multicenter Evaluation

Lower extremity wounds in patients with diabetes are significant and burdensome. To evaluate retrospectively the correlation between lower limb wound outcomes in patients with diabetes and the presence of a caregiver during clinic visits. The study was conducted in 3 outpatient wound centers in North Carolina. Patients (N = 85) were categorized into 2 groups: those who were accompanied by a caregiver at 50% or more of their visits to the wound clinic (n = 30) and those accompanied by a caregiver at fewer than 50% of their visits (n = 55). Data were evaluated using descriptive statistics and 2 sample t-tests. Although significant findings between the 2 groups were seen in age, race, Visit Count, Weeks in Service, Accompanied Count, and percentage of visits accompanied, the strongest meaningful correlation was in the Accompanied group between Percent Accompanied and Visit Count. In this group, the number of accompanied visits was 7.47 (range [standard deviation], 1-23 [5.2]) and the percentage was 87% (range [standard deviation], 52-100 [15]). This was stastically significant and with a moderately negative correlation (P = .04; r = -0.38). Despite negative predictors of healing, those who were accompanied by a caregiver at 50% or more of their visits demonstrated a higher healing rate and a lower number of total visits than those who were accompanied by a caregiver at fewer than 50% of their visits.

126. Outpatient Antimicrobial Stewardship Utilizing a Decentralized Model

BackgroundThe majority of human antimicrobial utilization occurs in the outpatient setting. Despite being mainly viral in etiology, upper respiratory tract infections (URIs) were the most common indication for outpatient antimicrobial prescriptions at our institution.MethodsThrough our electronic health record (EHR), we were able to determine our rate of antibiotic prescriptions for inappropriate URI diagnosis at our primary care practice sites. We selected staff volunteers from each our primary care practice sites to serve as stewardship champions. They were given training in stewardship best practices, and an URI stewardship toolkit which included viral URI prescription pad, EHR order panel, and patient education signage. They were tasked with providing education and feedback to their practice sites. We meet with them on a monthly basis to disseminate prescribing data and education. They also provided feedback from practice sites to the stewardship committee. ResultsOur decentralized model was put in place in November 2020. In the 6 months prior to the intervention, the average prescribing rate was 29.1%. In the 6 months after the intervention, the average prescribing rate decreased by 15% to 24.8%. During the intervention phase, there was an increase in number of non-COVID URIs diagnosed at our primary care sites. Temporal Trend in Inappropriate Antibiotics Prescribing Rates for Viral URIs Pre- and Post- Intervention Inappropriate antibiotic prescribing rate for viral upper respiratory tract infections from May 2020 until May 2021. Intervention started in December 2021 (arrow). Pre-intervention average was 29.1%. Post-intervention age was 24.8% which is a 15% decline in prescribing rate.Viral Upper Respiratory Infections Visits The total number of visits for presumed viral upper respiratory infections to primary care sites from May 2020 until May 2021. The majority of COVID-19 precautions in the area expired at the end of March 2021.ConclusionWe have been able to lower our inappropriate prescriptions for URIs utilizing a decentralized model of stewardship champions. This result was especially notable as the intervention phase corresponded with the end of COVID-19 precautions and an increase in non-COVID URIs diagnosed. The advantage of this approach includes an advocate embedded at each practice site who is familiar with the opportunities and challenges of the site, and a two-way flow of information from practice sites to the stewardship committee. This model provided additional benefit during the COVID-19 pandemic as the ability of centralized staff to travel to off campus clinic sites was curtailed. Disclosures All Authors: No reported disclosures

Antenatal care attendance and risk of low birthweight in Burkina Faso: a cross-sectional study

BackgroundLow birthweight is a major contributor to infant mortality. We evaluated the association between antenatal care (ANC) attendance and low birthweight among newborns in 5 regions of Burkina Faso.MethodsWe utilized data from the baseline assessment of a randomized controlled trial evaluating azithromycin distribution during the neonatal period for prevention of infant mortality. Neonates were eligible for the trial if the weighed at least 2500 g at enrollment and were 8–27 days of age. Data on ANC attendance and birthweight was extracted from each child’s carnet de santé, a government-issued health card on which pregnancy and birth-related data are recorded. We used linear and logistic regression models adjusting for potentially confounding variables to evaluate the relationship between ANC attendance (as total number of visits and ≥ 4 antenatal care visits) and birthweight (continuously and categorized into < 2500 g versus ≥2500 g).ResultsData from 21,223 births were included in the analysis. The median number of ANC visits was 4 (interquartile range 3 to 5) and 69% of mothers attended at least 4 visits. Mean birthweight was 2998 g (standard deviation 423) and 8.1% of infants were low birthweight (< 2500 g). Birthweight was 63 g (95% CI 46 to 81 g, P < 0.001) higher in newborns born to mothers who had attended ≥4 ANC visits versus < 4 visits. The odds of low birthweight among infants born to mothers with ≥4 ANC visits was 0.71 (95% CI 0.63 to 0.79, P < 0.001) times the odds of low birthweight among infants born to mothers who attended < 4 ANC visits.ConclusionsWe observed a statistically significant association between ANC attendance and birthweight, although absolute differences were small. Improving access to ANC for all women may help improve birth outcomes.Trial registrationThe parent trial is registered at clinicaltrials.gov: NCT03682653; first registered 24 September 2018.

Age and socioeconomic status affect access to telemedicine at an urban level 1 trauma center.

Objectives:Despite clinical and economic advantages, routine utilization of telemedicine remains uncommon. The purpose of this study was to examine potential disparities in access and utilization of telehealth services during the rapid transition to virtual clinic during the coronavirus pandemic.Design:Retrospective chart review.Setting:Outpatient visits (in-person, telephone, virtual—Doxy.me) over a 7-week period at a Level I Trauma Center orthopaedic clinic.Intervention:Virtual visits utilizing the Doxy.me platform.Main Outcome Measures:Accessing at least 1 virtual visit (“Virtual”) or having telephone or in-person visits only (“No virtual”).Methods:All outpatient visits (in-person, telephone, virtual) during a 7-week period were tracked. At the end of the 7-week period, the electronic medical record was queried for each of the 641 patients who had a visit during this period for the following variables: gender, ethnicity, race, age, payer source, home zip code. Data were analyzed for both the total number of visits (n = 785) and the total number of unique patients (n = 641). Patients were identified as accessing at least 1 virtual visit (“Virtual”) or having telephone or in-person visits only (“No virtual”).Results:Weekly totals demonstrated a rapid increase from 0 to greater than 50% virtual visits by the third week of quarantine with sustained high rates of virtual visits throughout the study period. Hispanic and Black/African American patients were able to access virtual care at similar rates to White/Caucasian patients. Patients of ages 65 to 74 and 75+ accessed virtual care at lower rates than patients ≤64 (P = .003). No difference was found in rates of virtual care between payer sources. A statistically significant difference was found between patients from different zip codes (P = .028).Conclusion:A rapid transition to virtual clinic can be performed at a level 1 trauma center, and high rates of virtual visits can be maintained. However, disparities in access exist and need to be addressed.

Adolescent psychiatric outpatient care rapidly switched to remote visits during the COVID-19 pandemic

BackgroundThe COVID-19-pandemic and especially the physical distancing measures drastically changed the conditions for providing outpatient care in adolescent psychiatry.MethodsWe investigated the outpatient services of adolescent psychiatry in the Helsinki University Hospital (HUH) from 1/1/2015 until 12/31/2020. We retrieved data from the in-house data software on the number of visits in total and categorized as in-person or remote visits, and analysed the data on a weekly basis. We further analysed these variables grouped according to the psychiatric diagnoses coded for visits. Data on the number of patients and on referrals from other health care providers were available on a monthly basis. We investigated the data descriptively and with a time-series analysis comparing the pre-pandemic period to the period of the COVID-19 pandemic.ResultsThe total number of visits decreased slightly at the early stage of the COVID-19 pandemic in Spring 2020. Remote visits sharply increased starting in 3/2020 and remained at a high level compared with previous years. In-person visits decreased in Spring 2020, but gradually increased afterwards. The number of patients transiently fell in Spring 2020.ConclusionsRapid switch to remote visits in outpatient care of adolescent psychiatry made it possible to avoid a drastic drop in the number of visits despite the physical distancing measures during the COVID-19 pandemic.

Information maintenance of food sources is associated with environment, spatial cognition and age in a food-caching bird

Traditionally, exploration and exploitation of resources have been viewed as mutually exclusive behaviours in which animals can either allocate time to gathering information or to using known resources. But these behaviours can also be viewed as opposite ends of a continuum, with intermediate behaviours that balance exploration and exploitation, such as information maintenance. Updating previously acquired information through information maintenance can allow animals in unpredictable environments to track changing environmental conditions. Theoretical studies predict that the degree of involvement in information maintenance should depend on environmental predictability – when the overall environment is less predictable, animals should update previously acquired information more frequently because such information is less certain and could change quickly. We tested this hypothesis by allowing wild food-caching mountain chickadees, Poecile gambeli , to visit and sample multiple feeders with temporarily stable, unlimited food for five consecutive winters. We used an index of feeder use breadth to explore how feeder visits across multiple feeders varied with environmental conditions. Each feeder visit is associated with information updating, and more information maintenance should be associated with distributing more visits across more feeders. While controlling for the total number of visits by each individual, we found that (1) chickadees redistributed feeder use among more feeders when environmental conditions were harsh and unpredictable, (2) juveniles had a higher feeder use breadth than adults, and individuals reduced their feeder use breadth as they aged, (3) better spatial learning and memory ability but not spatial cognitive flexibility was associated with smaller feeder use breadth and (4) learning associated with decreased food availability reduced subsequent feeder use breadth. Our data supported our predictions that factors affecting the predictability of resource information (environmental conditions and individual characteristics such as cognition and age) affect how individuals engage in information maintenance. • Animals should update information more frequently when the environment is unpredictable. • Food-caching chickadees updated information about previously discovered food locations. • Chickadees updated food information more frequently in years with harsher winters. • Birds with better spatial cognition updated food information less. • Older birds with more experience updated food information less.

Comparative analysis of the takzdorovo.ru internet portal within the framework of a communication campaign aimed at the motivation of citizens of the Russian Federation to lead a healthy lifestyle

Objective. To evaluate the results of the information and communication campaign to promote a healthy lifestyle through a comparative analysis of the use of the takzdorovo.ru Internet portal in 2018–2019.Methods. Comparative analysis of the use of the Internet portal takzdorovo.ru in 2018–2019. was carried out by analyzing the data of the Yandex.Metrica web analytics system. As a source of information on the prevalence of risk factors from 2018 to 2019 we used data from a sample observation of behavioral factors affecting the health status of the population and the compilation “Healthcare in Russia – 2019” by Rosstat, as well as data from surveys of VTsIOM and the Public Opinion Foundation.Results. The total number of visits to the Internet portal takzdorovo.ru after the information and communication campaign increased by 6,4 times. In 2018, the number of unique visitors to the Internet portal reached 449,302 people, in 2019 – 1,82 million people, an increase of 4 times. The number of page views on the site during the reporting period increased by 8,6 times. Also, a number of behavioral characteristics of users of the takzdorovo.ru Internet portal have improved, for example, attendance by time of day, from various types of devices, page viewing depth, number of failures and duration of the visit on the takzdorovo.ru Internet portal.Conclusion. Conducting a communication campaign within the framework of the federal project “Strengthening Public Health” of the national project “Demography” made it possible to attract citizens to use a reliable Internet resource about healthy lifestyles, which is filled by leading experts in the field of health protection.The conducted communication campaign has demonstrated the effectiveness of attracting the target audience to information materials on the preservation and promotion of health, and indicates the need to support and replicate this experience in order to attract and further motivate the population to lead a healthy lifestyle.

Temporally informed random forests for suicide risk prediction.

Suicide is one of the leading causes of death worldwide, yet clinicians find it difficult to reliably identify individuals at high risk for suicide. Algorithmic approaches for suicide risk detection have been developed in recent years, mostly based on data from electronic health records (EHRs). Significant room for improvement remains in the way these models take advantage of temporal information to improve predictions. We propose a temporally enhanced variant of the random forest (RF) model-Omni-Temporal Balanced Random Forests (OT-BRFs)-that incorporates temporal information in every tree within the forest. We develop and validate this model using longitudinal EHRs and clinician notes from the Mass General Brigham Health System recorded between 1998 and 2018, and compare its performance to a baseline Naive Bayes Classifier and 2 standard versions of balanced RFs. Temporal variables were found to be associated with suicide risk: Elevated suicide risk was observed in individuals with a higher total number of visits as well as those with a low rate of visits over time, while lower suicide risk was observed in individuals with a longer period of EHR coverage. RF models were more accurate than Naive Bayesian classifiers at predicting suicide risk in advance (area under the receiver operating curve = 0.824 vs. 0.754, respectively). The proposed OT-BRF model performed best among all RF approaches, yielding a sensitivity of 0.339 at 95% specificity, compared to 0.290 and 0.286 for the other 2 RF models. Temporal variables were assigned high importance by the models that incorporated them. We demonstrate that temporal variables have an important role to play in suicide risk detection and that requiring their inclusion in all RF trees leads to increased predictive performance. Integrating temporal information into risk prediction models helps the models interpret patient data in temporal context, improving predictive performance.

The impact of COVID-19 on paediatric emergency department visits. A one-year retrospective study.

BackgroundThe number of paediatric emergency department (ED) visits and hospital admissions was recorded in a tertiary referral centre during the first year of the COVID-19, March 2020–February 2021, and compared with those of the preceding year.MethodsThe number of visits and admissions and the reason of visit and admission were prospectively recorded from 15,087 patients’ files.ResultsA substantial decline in the total number of visits and increase in the admission rate were documented during the COVID-19 year compared to the preceding year (10691 vs 4396 patients, 22.59% vs 18.15% (OR: 1.316, CI 95%: 1.208–2.242, p < 0.0001), respectively). Fever and/or respiratory symptoms were the commonest reported symptoms in both periods. Possible explanations include: (i) restricted overall infection transmission due to confinement and self-protective measures, (ii) avoidance of unnecessary hospital visits in the absence of severe symptoms and (iii) reduced or delayed access to medical care due to parental fear of children’s exposure to COVID-19.ConclusionThis study is the first worldwide to investigate the impact of COVID-19 on ED visits and admissions throughout the whole year of the pandemic, and to highlight the need for re-evaluation of future protective strategies to infections, adjustment of health-care systems and parental education so that medical care in a health-care setting is sought in a more appropriate manner.Impact A significant decline in paediatric ED visits and increase in the admission rate was observed during the first year of COVID-19 in a tertiary referral centre, possibly due to reduced overall infection transmission, limited ED overuse, but also ED underuse due to parental fear of children’s exposure to SARS-CoV-2.COVID-19 may serve as an opportunity for societies to re-evaluate future strategies to infections, adjust health-care systems accordingly, and reinforce parents to seek medical care more appropriately.Although the incidence of critical illness in children due to COVID-19 and in general is low, special attention should be devoted to identifying children at risk early.

Predicting Fitness Centre Dropout.

The phenomenon of dropout is often found among customers of sports services. In this study we intend to evaluate the performance of machine learning algorithms in predicting dropout using available data about their historic use of facilities. The data relating to a sample of 5209 members was taken from a Portuguese fitness centre and included the variables registration data, payments and frequency, age, sex, non-attendance days, amount billed, average weekly visits, total number of visits, visits hired per week, number of registration renewals, number of members referrals, total monthly registrations, and total member enrolment time, which may be indicative of members’ commitment. Whilst the Gradient Boosting Classifier had the best performance in predicting dropout (sensitivity = 0.986), the Random Forest Classifier was the best at predicting non-dropout (specificity = 0.790); the overall performance of the Gradient Boosting Classifier was superior to the Random Forest Classifier (accuracy 0.955 against 0.920). The most relevant variables predicting dropout were “non-attendance days”, “total length of stay”, and “total amount billed”. The use of decision trees provides information that can be readily acted upon to identify member profiles of those at risk of dropout, giving also guidelines for measures and policies to reduce it.

Evaluation of an oncology diagnostic and screening clinic at a large safety net hospital.

94 Background: Increasingly, dedicated clinics have been established to expedite patients with suspicion of malignancy into cancer care. The Lyndon B. Johnson General Hospital (LBJGH) is part of the Harris County Hospital District (HCHD), serving the third largest county in the United States. A 2012 study at our institution found long mean ambulatory wait times for the diagnosis of breast, colon, and lung cancers (77.1 days, 65.4 days, and 70.8 days, respectively). The LBJGH Oncology Diagnostic and Screening clinic (DSC) was subsequently established to reduce ambulatory diagnostic times, decrease frequency of admissions, and improve patient outcomes. Our present study sought to establish the effectiveness of the DSC in bringing patients into care. Methods: The charts of 100 new patients seen in the DSC between August 2018 and November 2020 were reviewed. Demographic data, insurance status, date of referral to the DSC, date of first DSC visit, date biopsy or outside pathology ordered, date biopsy performed or outside pathology obtained, total number of visits to the DSC, and total time from initial DSC visit to initial oncology clinic visit were collected, as well as cancer stage upon arrival to the oncology clinic. The project was approved by the MD Anderson Quality Improvement Assessment Board and the Harris Health Quality Improvement Committee. Results: 57% of patients seen in the DSC were referred by the emergency department, and 23% by a PCP. The median time from referral to initial visit in the DSC was 19 days. 26% of patients had a known cancer diagnosis at the time of referral. The median time from biopsy ordered to performed was 39 days, and the median time from pathology requested to obtained was 23 days. The median total number of visits per patient to the DSC was 2. 48% of patients seen in the DSC were ultimately diagnosed with cancer, 29% had a benign condition, and 23% were lost to follow up. Of those patients with confirmed malignancy, 46% of patients had stage IV disease at their first oncology clinic visit. The average time from initial DSC visit to initial visit at the oncology clinic was 53 days. Conclusions: Establishment of an oncology DSC has improved the ambulatory wait time for entry into oncologic care from an average of approximately 70 days to an average of 53 days. However, almost half of patients referred from the DSC had stage IV disease at their initial oncology visit, indicating an urgent need to further expedite entry of these patients into oncologic care. Avenues for future quality improvement efforts include an expedited process to obtain outside pathology results, implementation of an “e-consult” option for PCPs to avoid unnecessary referrals, and a close analysis of insurance and financial barriers to entry into care. Reference: Mougalian SS, Wang J, Zarzour M et al. Feasibility and savings of a suspicion of cancer clinic at a large county hospital. JCO 2012; 30 (34 supplement): 104.

258EMF Urgent Care Centers Deter Some Emergency Department Visits But, On Net, Increase Spending

Urgent care clinics (UCCs) have been proliferating rapidly and have the potential to alter many aspects of unscheduled care delivery. These clinics offer low wait times and convenient sites of care. Therefore they could lower emergency department (ED) utilization, but may also increase the total number of visits for minor ailments, offsetting these cost savings. Little is known about their impact on emergency department visits or overall health care utilization. We utilize claims from a large, national insurer involving 14.1 million urgent care clinic visits and 9.8 million ED visits from 2008 to 2018. We use a differences-in-differences framework to study how low acuity ED visits in each ZIP code change when low acuity UCC visits increase. We combine these estimates with the insurer’s cost data to determine how out-of-pocket and overall costs changed in the difference-in-differences framework. Population studied: All individuals covered by a single insurer across 50 states in ZIP codes with greater than 30 enrollees any year in the study period. Values were weighted by the number of enrollees. We confirm a secular decrease in low acuity ED visits and increase in UCC claims over the study period. Overall, mean UCC visits per 1,000 enrollees increased from 56.1 to 129.9 between the early period (2008-2011) and the later period (2015-2018), representing a 73.8 [(73.0, 74.7) 95% CI] increase in visits per 1,000 enrollees. ED visits dropped from 63.7 to 59.9 per 1,000 enrollees, representing a -3.8 [(-4.1, -3.5) 95% CI] decrease. At the ZIP code level, there were 3,895 ZIP codes with a decline or no change in the number of UCC visits, and 20,272 with an increase. In ZIP codes with a decline in UCC visits, ED visits per 1,000 enrollees increased from 55.4 to 57.0 (change of 1.6 per enrollee [(0.7, 2.5) 95% CI]). ZIP codes with an increase in UCC visits experienced 81.8 more UCC visits per 1,000 enrollees but fewer ED visits: from 64.3 per 1,000 enrollees to 60.0 (change of -4.2 per enrollee [(-4.5, -3.9) 95% CI]). Lower acuity ED visits have declined in areas where urgent care visits have increased. However, urgent care visits have expanded much more rapidly than lower acuity emergency department visits have declined. Implications for policy or practice: Unlike retail clinics and telemedicine, urgent care clinics offer the possibility of offsetting some emergency department visits for lower acuity diagnoses. Their impact on the total costs of unscheduled care visits may be more ambiguous.

Characterization and Identification of Variations in Types of Primary Care Visits Before and During the COVID-19 Pandemic in Catalonia: Big Data Analysis Study.

BackgroundThe COVID-19 pandemic has turned the care model of health systems around the world upside down, causing the abrupt cancellation of face-to-face visits and redirection of the model toward telemedicine. Digital transformation boosts information systems—the more robust they are, the easier it is to monitor the health care system in a highly complex state and allow for more agile and reliable analysis.ObjectiveThe purpose of this study was to analyze diagnoses from primary care visits and distinguish between those that had higher and lower variations, relative to the 2019 and 2020 periods (roughly before and during COVID-19), to identify clinical profiles that may have been most impaired from the least-used diagnostic codes for visits during the pandemic.MethodsWe used a database from the Primary Care Services Information Technologies Information System of Catalonia. We analyzed the register of visits (n=2,824,185) and their International Classification of Diseases (ICD-10) diagnostic codes (n=3,921,974; mean 1.38 per visit), as approximations of the reasons for consultations, at 3 different grouping levels. The data were represented by a term frequency matrix and analyzed recursively in different partitions aggregated according to date.ResultsThe increase in non–face-to-face visits (+267%) did not counterbalance the decrease in face-to-face visits (–47%), with an overall reduction in the total number of visits of 1.36%, despite the notable increase in nursing visits (10.54%). The largest increases in 2020 were visits with diagnoses related to COVID-19 (ICD-10 codes Z20-Z29: 2.540%), along with codes related to economic and housing problems (ICD-10 codes Z55-Z65: 44.40%). Visits with most of the other diagnostic codes decreased in 2020 relative to those in 2019. The largest reductions were chronic pathologies such as arterial hypertension (ICD-10 codes I10-I16: –32.73%) or diabetes (ICD-10 codes E08-E13: –21.13%), but also obesity (E65-E68: –48.58%) and bodily injuries (ICD-10 code T14: –33.70%). Visits with mental health–related diagnostic codes decreased, but the decrease was less than the average decrease. There was a decrease in consultations—for children, adolescents, and adults—for respiratory infections (ICD-10 codes J00-J06: –40.96%). The results show large year-on-year variations (in absolute terms, an average of 12%), which is representative of the strong shock to the health system.ConclusionsThe disruption in the primary care model in Catalonia has led to an explosive increase in the number of non–face-to-face visits. There has been a reduction in the number of visits for diagnoses related to chronic pathologies, respiratory infections, obesity, and bodily injuries. Instead, visits for diagnoses related to socioeconomic and housing problems have increased, which emphasizes the importance of social determinants of health in the context of this pandemic. Big data analytics with routine care data yield findings that are consistent with those derived from intuition in everyday clinical practice and can help inform decision making by health planners in order to use the next few years to focus on the least-treated diseases during the COVID-19 pandemic.

Impact of the COVID-19 Pandemic on Urological Care Delivery in the United States.

We examined changes in urological care delivery due to COVID-19 in the U.S. based on patient, practice, and local/regional demographic and pandemic response features. We analyzed real-world data from the American Urological Association Quality (AQUA) Registry collected from electronic health record systems. Data represented 157 outpatient urological practices and 3,165 providers across 48 U.S. states and territories, including 3,297,721 unique patients, 12,488,831 total outpatient visits and 2,194,456 procedures. The primary outcome measure was the number of outpatient visits and procedures performed (inpatient or outpatient) per practice per week, measured from January 2019 to February 2021. We found large (>50%) declines in outpatient visits from March 2020 to April 2020 across patient demographic groups and states, regardless of timing of state stay-at-home orders. Nonurgent outpatient visits decreased more across various nonurgent procedures (49%-59%) than for procedures performed for potentially urgent diagnoses (38%-52%); surgical procedures for nonurgent conditions also decreased more (43%-79%) than those for potentially urgent conditions (43%-53%). African American patients had similar decreases in outpatient visits compared with Asians and Caucasians, but also slower recoveries back to baseline. Medicare-insured patients had the steepest declines (55%), while those on Medicaid and government insurance had the lowest percentage of recovery to baseline (73% and 69%, respectively). This study provides real-world evidence on the decline in urological care across demographic groups and practice settings, and demonstrates a differential impact on the utilization of urological health services by demographics and procedure type.