Unscheduled Clinic Visits Research Articles

Identifying Infants and Young Children at Risk of Unplanned Hospital Admissions and Clinic Visits in Dar es Salaam, Tanzania.

Pediatric inpatient mortality rates are as high as 11% in parts of sub-Saharan Africa. Unscheduled clinic visits also burden children in sub-Saharan Africa. Our objective was to identify factors associated with hospital admissions and unscheduled clinic visits among Tanzanian children < 24 months of age. We conducted a secondary analysis of 2 trials conducted in Dar es Salaam, Tanzania. We performed univariate and Poisson multivariable regression analyses to identify factors associated with hospital admissions and unscheduled clinic visits. Of 4784 children < 24 months of age, 293 (6.1%) were hospitalized at least once and 1308 (27.3%) had ≥ 1 unscheduled clinic visit. Infants and children who were exposed to but HIV-negative had increased risk of hospital admission [adjusted risk ratios (aRR): 3.67; 95% CI: 2.45-5.50; P < 0.001] compared with HIV-unexposed children. Those who were HIV-positive had even higher risk of hospital admission compared with those not exposed to HIV (aRR: 10.87; 95% CI: 7.01-16.89; P < 0.001). Birth weight and breast-feeding status were not associated with increased risk of hospital admission. Children with Apgar scores < 7 (aRR: 1.32; 95% CI: 1.03-1.69; P = 0.001), not exclusively breast-fed up to 6 months of age (aRR: 1.34; 95% CI: 1.12-1.60; P = 0.001), and who were HIV-exposed and HIV-negative (aRR: 2.35; 95% CI: 2.08-2.66; P < 0.001) or HIV-positive (aRR: 3.02; 95% CI: 2.52-3.61; P < 0.001) had higher risk of unscheduled clinic visits. Exposure to HIV and being HIV-positive were associated with the greatest risk for hospital admission and unplanned clinic visits among infants and children in Tanzania. Targeting these vulnerable populations in interventional studies may reduce morbidity.

Frequency and prediction of non-medical opioid use behaviors (NMOU) among advanced cancer patients referred to a supportive care center (SCC).

12086 Background: One of the methodological barriers to conducting research on interventions for NOMU (Aberrant Opioid Use Behaviors) among cancer patients is the lack of data on the frequency of this problem. Although the frequency of risk factors has been established by our group and others, not all the patients with risk factors will be diagnosed with having NMOU behaviors, and some patients with no previous risk factors will engage in NMOU. AIM: To characterize the overall frequency of NMOU for a duration of 3 months, as well independent predictors for NMOU. Methods: In this retrospective study, 1558 consecutive patients referred to supportive care clinic (SCC) from 3/18/2016 to 6/6/2018 were reviewed for development of NMOU using established diagnostic criteria. Patients were eligible if they were ≥18 years, had a diagnosis of cancer, and were on opioids for pain for at least a week. All patients were assessed with the Edmonton Symptom Assessment Scale (ESAS), SOAPP-14, and CAGE-AID. Descriptive statistics, spearman correlation coefficient, multivariate analysis were performed. Results: 299 patients (19%) had ≥1 NMOU behavior. The median (IQR) NMOU behavior was 1 (1-2); range 1-10. Most NMOU occurred at 1st and 2nd follow up visits. The most frequent NMOU behavior was unscheduled clinic visit for inappropriate refills. 29/299 (10%) NMOU patients received specialized care for high-risk for aberrant opioid misuse by interdisciplinary team. Results of multivariate logistic regression model showed Marital status (Divorced vs. Married, OR=1.47, 95% CI: 0.98, 2.22, p=0.654 (marginally significant); Single vs. Married, OR=1.68, 95% CI: 1.15, 2.46, p=0.0079), SOAPP (Positive vs. Negative, OR=1.42, 95% CI: 1.05, 1.93, p=0.0238), morphine equivalent daily dose (MEDD) (OR=1.004, 95% CI: (1.003, 1.006), p&lt;0.0001) and ESAS pain (OR=1.11, 95% CI: 1.06, 1.17, p&lt;0.0001) were independently associated with the presence of NMOU during follow-up visits. Conclusions: 19% cancer patients followed at SCC had detectable NMOU behaviors. Being single, SOAPP+, pain severity and high MEDD were independent predictors for NMOU. This information will assist clinicians and investigators designing clinical and research programs in this important field.

Does "MyChart" Benefit "My" Surgery? A Look at the Impact of Electronic Patient Portals on Patient Experience.

Electronic patient portals can be beneficial in providing direct engagement and clarity to avoid unnecessary extra provider encounters. In this study we assessed whether portal usage among endourology patients affected telephone call frequency, unscheduled physician visits, emergency department presentations and complication rates. We conducted a retrospective chart review of patients undergoing elective endourology procedures by a single surgeon at a tertiary urology center from July 2017 to July 2018. Patient demographics, operative details, patient portal (MyChart) registration, patient initiated MyChart messages, telephone encounters, unscheduled physician visits and emergency department presentations during a 1-month period before and after the procedure were identified. Logistic regression analysis assessed relationships between MyChart use and study outcomes. We identified 313 patients (200 MyChart users, 113 nonusers) who underwent 374 procedures. MyChart users were younger (age 56 vs 61, p=0.0011) and more likely to be married (69.5% vs 48.7%, p=0.0004). MyChart users made fewer telephone calls before (1.1 vs 1.2, p=0.005) and after procedure (0.9 vs 1.3, p=0.029), and had fewer emergency department visits (8 vs 18, p=0.0005) than nonusers. On multivariable analysis MyChart nonusers were 4.55 (95% CI 1.92-11.11) times more likely to have an unscheduled clinic visit (p=0.0006), 1.92 (95% CI 1.075-3.333) times more likely to have an emergency department visit (p=0.028) and 2.7 (95% CI 1.43-5.26) times more likely to have a postoperative complication (p=0.0026). Patients undergoing endourology procedures who use MyChart make fewer telephone calls and are significantly less likely to have an unscheduled clinic/emergency department visit or a complication.

Too Well for an LVAD?

There is a lack of data regarding the outcomes of patients who were subjectively assessed to have advanced heart failure (AdvHF) and therefore offered evaluation for left ventricular assist devices (LVADs) only to be determined to be "too well". We retrospectively reviewed all referrals to our Advanced Heart Failure outpatient clinic for LVAD evaluation from 1/1/13 to 12/31/17. Those individuals who were above the age of 18, subjectively determined to have a syndrome of AdvHF as assessed by a HF Faculty, but deemed "too well" for implantation after formal VAD evaluation and multidisciplinary Medical Review Board (MRB) discussion were included for analysis. 62 patients met inclusion criteria. 75% were male, median age at time of presentation to MRB was 57.5 years. Median time to MRB presentation from initial out-patient consultation was 33.5 days. Medication titration was recommended to nearly all (98%), while concomitant evaluation for stem cell therapy and inotropic support was recommended in 17% and 15% respectively. Median time to initial follow-up after MRB presentation was 29.5 days. Beyond initial follow-up 26% were lost to follow-up. Men were 31% more likely than women to be lost to follow up (p = 0.019). Of those who continued to follow in our system, survival 1 year after MRB presentation was 94%, during which time 28% required at least one unscheduled clinic visit, 25% required ED treatment and 27% required at least one hospitalization. 10 patients ultimately were represented to the MRB at a median time of 391 days after initial presentation. Of these, 3 patients were ultimately implanted with an LVAD. 26% of patients given the label of "too well" were noted to have relative contraindications precluding them from consideration. Patients determined to be "too well" for LVAD despite a subjective assessment suggestive of a syndrome of AdvHF have good 1 year survival. However, the rates of follow-up and MRB re-discussion, as well as rates of implantation at later dates for "too well" patients is relatively low, despite the known progressive nature of HF. The "too well" label may diminish the perceived need for these patients to have close follow-up with an advanced heart failure team. Additionally, its use may be inaccurate and therefore should be avoided.

A144 A MULTIDISCIPLINARY TEAM APPROACH REDUCES PEG SITE COMPLICATIONS

Abstract Background Education provided to patients and their family on how to care for the percutaneous enteroscopic gastrotomy (PEG) tube is limited and varies widely. This can result in site and tube complications, patient discomfort and increased health care utilization. In addition, a lack of practitioner expertise and variability in practice can affect timely treatment of PEG site complications. Continuous Levodopa/Carbidopa Intestinal Gel (LCIG) has become a standard of treatment option for patients with advanced Parkinson Disease. This medication is delivered by a jejunal tube through a PEG tube (PEG-J). Previous studies in this population reported up to 40% of adverse events related to the PEG site. At Toronto Western Hospital, we developed a multidisciplinary team (MDT), involving a gastroenterologist, a clinical nurse specialist (CNS) with expertise in wound and stoma care and the movement disorder clinical nurse to care for the PEG-J in this patient population. Aims To evaluate the effectiveness of our MDT in reducing PEG site complications and health care utilization. Methods Consecutive PEG-J patients (n=33) assessed by the MDT between October 2018 and September 2019 were provided standard education on the routine care and maintenance of PEG site complications. The CNS uses a systematic approach to prevent, assess and treat PEG site complications. Before and after the MDT approach, patients were seen the day after the PEG insertion (POD 1), 2 weeks after (titration) and then ad hoc determined by incidence of mild, moderate and severe complications. Post implementation of a MDT approach, patients are seen POD 1, at titration and every 3–6 months during routine visits to the Movement Disorder Clinic. Table 1 outlines classification and suggested treatment based on severity for mild, moderate and severe PEG site complications. Results The systematic MDT approach completely eliminated all unscheduled, urgent contact to the health care providers by patients who have been assessed and provided education by the MDT (n=33), including new PEG-J (n=7) and previously inserted PEG-J (n=26). 28.5% of new PEG-J patients had moderate or severe site complication rate, 71.5% had mild or no complications. In the group of patients with previously inserted PEG-J tubes, 58% had moderate or severe site complications, 42% had mild or no complications. Conclusions An interprofessional MDT systematic approach drastically reduces PEG site complications and urgent health care utilization. Patients who receive standardized education pre- and post-insertion have a lower incidence of moderate or severe classification of PEG site complications and unscheduled clinic visits. Funding Agencies None

The association between patient-reported readiness for hospital discharge and outcomes in patients diagnosed with anxiety disorders: A prospective and observational study.

WHAT IS KNOWN ON THE SUBJECT?: Readiness for hospital discharge (RHD) has been an important topic for nurses. RHD can be measured by the Readiness for Hospital Discharge Scale (RHDS), including 4 subscales: personal status, knowledge, coping ability and expected support. There are few studies that focus on RHD in patients diagnosed with mental disorders. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: Improving patient-reported RHD can decrease the risks of unscheduled post-discharge clinic visits, readmission and poor quality of life (QOL) in patients diagnosed with anxiety disorders. Improving patient-reported personal status can decrease the risk of poor QOL in patients diagnosed with anxiety disorders. Improving patient-reported knowledge can decrease the risks of unscheduled post-discharge clinic visits and readmission in patients diagnosed with anxiety disorders. Improving patient-reported expected support can decrease the risk of unscheduled post-discharge clinic visits in patients diagnosed with anxiety disorders. Improving the methods of discharge teaching and anxiety severity can enhance RHD in patients diagnosed with anxiety disorders. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses could enhance patient-reported RHD to reduce unscheduled post-discharge medical resource utilization or improve QOL by facilitating knowledge acquisition and skill development and improving social support systems. Nurse managers could add RHD assessment to patients' discharge process and train nurses in the methods of discharge education. Nurses could advance their methods of discharge education, such as listening to and answering patients' questions, choosing a convenient time and engaging in online education. ABSTRACT: Introduction The association between readiness for hospital discharge (RHD) and post-discharge outcomes remains unclear in individuals with anxiety disorders. Aim To explore the factors of RHD and the effect of patient-reported RHD on post-discharge outcomes. Method In the observational study, 373 patients diagnosed with anxiety disorders completed the self-administered Readiness for Hospital Discharge Scale (RHDS) on discharge. After 30days, phone interviews were conducted to collect data on post-discharge outcomes, including self-reported unscheduled medical service utilization, symptom severity and quality of life (QOL). Multiple logistic regression models were built to explore the relationships among sociodemographic characteristics, the RHDS and its subscales, and post-discharge outcomes. Results The unscheduled clinic visits were significantly associated with low RHD, knowledge and expected support. Readmission was significantly associated with low RHD and knowledge. Poor QOL was significantly associated with low RHD and personal status. Delivery, received content and anxiety severity were the predictors of RHD. Discussion Improved RHD is associated with fewer unscheduled clinic visits and readmissions and better QOL. Enhancing discharge education can improve RHD. Implications for practice Nurses should enhance patient-reported RHD to improve post-discharge outcomes by advancing the quality of discharge education in patients diagnosed with anxiety disorders.

Distinct Symptom Experience Among Subgroups of Patients With ESRD Receiving Maintenance Dialysis

ContextPatients with end-stage renal disease receiving dialysis experience multiple concurrent symptoms. A person-centered understanding of patients' symptom experiences may offer insights into individualized management. ObjectivesWe identified subgroups of patients based on their symptom experiences and the characteristics that differentiated among these subgroups. Outcomes associated with these subgroups were evaluated. MethodsA total of 354 patients on dialysis were recruited at two regional hospitals in Hong Kong. While the Dialysis Symptom Index was adopted to assess symptoms, the Kidney Disease Quality of Life 36 and Karnofsky Performance Status Scale were used to evaluate the quality of life outcomes. Information on health care utilization and mortality were retrieved from medical records. Subgroups of patients were identified using latent class analysis based on the occurrence ratings. Differences in characteristics and outcomes were determined using Chi-squared test, analysis of variance, and Cox regression analysis. ResultsThree latent classes were identified: low (37.8%), moderate physical-low psychological (29.7%), and moderate physical-high psychological (32.5%). Higher comorbidity burden and lower serum albumin levels differentiated between the low and moderate physical-low psychological classes. The moderate physical-high psychological class had the highest number of symptoms, poorest quality of life outcomes, and more unscheduled clinic visits. A shorter mean survival time (421 vs. 431 days) was also found. ConclusionConsistent with findings in other chronic conditions, subgroups of patients on dialysis have unique symptom experiences. Therefore, an individualized approach to symptom management is warranted. Our findings offer a phenotypic characterization for research on the underlying mechanisms for these symptom experiences.

1073: Timing of discharge after cesarean delivery and maternal readmissions

Legislation in some states mandate a minimum hospital stay of 4 days following cesarean delivery (CD) to minimize complications after discharge. We hypothesize that following CD, the risk of maternal readmission or unscheduled visits is no less in those discharged on post-operative day (POD) 3 or at least 4 days (4+) compared to those discharged on POD2. Secondary analysis of data from a multi-center, randomized trial of adjunctive azithromycin vs. standard cefazolin to prevent infection in women undergoing unscheduled CD. Pregnancies complicated by infection before POD2 or by hypertensive disorders of pregnancy were excluded. The exposure was categorized as POD 2, 3 and 4+. The primary outcome was the composite of any maternal readmission, ER visit or unscheduled clinic visit within 6 weeks of CD. Secondary outcomes were neonatal readmission rates. The chi-square test of trend examined outcome rates across groups and multivariable logistic regression modeled outcome odds while adjusting for potential confounders. Of 1421 eligible women, 293 were discharged on POD2, 722 on POD3 and 406 on POD4+ (Table 1). Timing of hospital discharge mirrored trends in several patient characteristics (Table 1). As timing of hospital stay increased from POD2 to 4+, the composite of readmission or unscheduled visits (Table 2) increased from 5.8% to 11.1% (p trend< 0.01). The pattern generally remained the same after adjusting for differences in characteristics relative to POD2: aOR 2.4 for POD 3 and 2.7 for POD 4. Infections accounted for the majority for readmissions. Neonatal readmissions did not show similar patterns. Under usual care for unscheduled CD, maternal readmission or unscheduled visits were no less frequent following discharge on POD 3 or POD4+ compared to POD2; in fact longer stay was inherently associated with a higher chance of readmission. These data do not support mandating a minimum hospitalization period of up to 4 days for CD.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Patient related outcomes in cancer patients in Croatia.

TPS6650 Background: Accurate evaluation of symptom intensities is essential for optimal cancer care and improving the quality of life of patients. An inappropriate interpretation of symptoms may lead to treatment outcomes failure, overdose of medication, or may leave the patients undertreated. However, the perception of symptoms can vary between the treating physician and patient. Physicians appear to underestimate the patient symptoms. And this variation in the perception of side effects can lead to wrong assumptions and subsequent treatment changes, affecting treatment effectiveness and quality of life. There is growing interest to enhance symptom monitoring during routine cancer care using patient-reported outcomes, leaving open the question of whether the benefits of systems to reveal self-reports outweigh their added cost. There are several tools for assessment of symptoms in oncology. In cancer treatment clinical trials, the standard source of adverse symptom data is clinician reporting by use of items from PRO-CTCAE, developed by NCI. To address these questions, we conducted a single-center prospective trial to test whether systematic tablet computer-based collection of patient-reported symptoms during chemotherapy treatment, with automated alerts to clinicians for severe adverse events (grade 3-4) will change in questionnaire score at 6 months compared with baseline. Secondary endpoints will include difference in unscheduled clinic visits frequency, and survival. Methods: Patients initiating chemotherapy at General Hospital Pula Oncology Clinic for advanced or metastatic gastrointestinal, lung, breast, genitourinary, or gynecologic cancers will be enrolled in a nonblinded, prospective trial of self-reporting of symptoms, compare with usual care. Patients receiving chemotherapy and their clinicians will be independently asked on the same day to complete 10 symptoms (including fatigue, pain, nausea, vomiting, diarrhea, dysgeusia, appetite, sleep disturbance, fever and hair loss). Participants will remain on study until discontinuation of cancer treatment, withdrawal, or death. All participants will provide written informed consent and followed for up to 28 months or until death. To compare how patient’s vs clinician’s reports relate to clinical events, a time-dependent Cox regression model adjusted for covariates including cancer type, age, sex, and education level will be used to measure associations between reaching particular grade severity thresholds with the risk of death and unscheduled clinic visits. Clinical trial information: 2019-000855-15.

Incidence and Risk Factors for Hospital Readmission or Unexpected Visits in Women Undergoing Unscheduled Cesarean Delivery.

Hospital readmissions are increasingly tracked and assessed for value-based compensation. Our objective was to determine the incidence and risk factors associated with post-cesarean delivery (CD) readmissions or unexpected visits, defined as unexpected office or emergency room visits. This is a secondary analysis of a multicenter randomized controlled trial of adjunctive azithromycin prophylaxis for CD performed in laboring patients with viable pregnancies. Patients were followed up to 6 weeks postpartum. Our primary outcome was a composite of hospital readmission or unexpected visit, defined as unscheduled clinic or emergency department visits. Data of hospital readmissions, unexpected visits, and their reasons were collected. Demographics, antepartum, intrapartum, and postpartum risk factors were evaluated in bivariate analyses and multivariable logistic regression modeling. A total of 1,019 women were randomized to azithromycin and 994 to placebo. The prevalence of readmission or unexpected visit was 10.2% (95% confidence interval [CI]: 8.9-11.6), with rates of 3.8% (95% CI: 3.0-4.7%) hospital readmissions, 6.9% (95% CI: 5.8-8.0%) emergency room visits, and 4.2% (95% CI: 3.4-5.2%) unexpected clinic visits. The most common causes were infectious disease and hypertensive disorder. Women with readmissions or unexpected visits were more likely to be obese and diabetic, as well as experience longer length of ruptured membranes, intrauterine pressure catheter placement, and postpartum fevers. On multivariable analysis, diabetes (adjusted odds ratio [aOR]: 1.6, 95% CI: 1.1-2.4), prolonged ruptured membranes (aOR: 1.9, 95% CI: 1.3-2.8), and postpartum fevers (aOR: 4.6, 95% CI: 3.0-7.0) were significantly positively associated with readmission or unscheduled visit, while azithromycin was a protective (aOR: 0.6, 95% CI: 0.5-0.9). Women who had postpartum fever were at especially high risk for readmission or unexpected visits. Diabetes, prolonged ruptured membranes, and postpartum fevers were significantly associated with the adverse outcome, and azithromycin was associated with lower rates of readmission and unexpected visits.

A Pilot Randomized Controlled Trial of a Preoperative Patient Education Intervention to Improve Satisfaction and Reduce Resource Utilization in Gynecologic Surgery

During the initial surgical consult patients may feel overwhelmed by the information they are given regarding their diagnosis and surgical plan. We looked to determine if a preoperative patient educational intervention would improve patient satisfaction and optimize use of medical services after discharge. Methods: We randomized women undergoing major gynecologic surgery by laparoscopy or laparotomy, to standard of care (Control) or a preoperative educational intervention. The pre-operative educational intervention consisted of: 1) a handout with information on inpatient and outpatient recovery and 2) a preoperative phone-call to review the handout and answer questions. At the post-operative visit, patients completed a Patient Satisfaction Questionnaire (PSQ-18), addressing satisfaction, interpersonal manner, communication, time spent with doctors and physician accessibility. The number of phone calls, emergency department visits and unscheduled post-operative clinic visits were quantified during the first 2 weeks after surgery. Descriptive statistics and t-tests were used for analysis.Results: 62 consecutive patients were randomized: 31 to intervention and 31 to the control group. Within the cohort 35 patients underwent laparoscopy and 21 laparotomy, 6 patients withdrew or cancelled their surgery. Forty postoperative patient satisfaction questionnaires were collected, 20 in the intervention group and 20 in the control group (response rate 71%). Intervention was associated to increased patient satisfaction. In the LSC group, the intervention improved patients’ perception of their physicians’ interpersonal manners, communication and time spent with the doctor (p &lt; 0.05). Only one patient (3.5%) in the intervention group visited the ER post-operatively (laparotomy, wound separation) compared to 5 (17.8%) control patients (4 laparoscopy, 1 laparotomy, p &lt; 0.05), all for minor complaints (pain, anxiety, incision).Conclusions: In our randomized trial this low-cost, feasible pre-operative educational intervention improves patients’ perception of their surgeons’ communication skills and decreased post-operative healthcare resource utilization. The effects are most pronounced in women undergoing minimally invasive surgery.

Repair Integrity in Patients Returning for an Unscheduled Visit After Arthroscopic Rotator Cuff Repair: Retorn or Not?

Background:After rotator cuff repair, some patients have ongoing problems significant enough to warrant presentation to a clinic for reassessment.Purpose/Hypothesis:The purpose of this study was to determine whether this cohort of patients was more likely to have a healed rotator cuff. We hypothesized that patients who had an unscheduled postoperative visit were more likely to have a healed rotator cuff than those who did not have an unscheduled postoperative visit.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 321 consecutive patients who underwent arthroscopic rotator cuff repair were evaluated; of these, 50 patients had an unscheduled return to clinic that included an ultrasound assessment of the cuff repair within 4 months postoperatively. Repair integrity was evaluated in all patients at 6 months postoperatively via ultrasonography.Results:The failure-to-heal rate was greater in patients who had an unscheduled assessment (8/50; 16%) than in those who did not (14/275; 5%) (P = .01). The patients most likely to have a repair failure were those who were assessed before 2 weeks and after 12 weeks (7/18; 39%) compared with those who were assessed between 3 and 12 weeks (1/32; 3%) (P = .001). The failure-to-heal rate was very low in patients who had an unscheduled assessment with a tear size smaller than 4 cm2 (0/34; 0%) compared with those with tear sizes greater than 4 cm2 (8/16; 50%) (P < .0001, Fisher exact text).Conclusion:Patients who had an unscheduled clinic visit after rotator cuff repair had a 16% chance of a failed healing response, whereas those who did not have an unscheduled visit had a 5% rate of failed healing. The risk of a failed healing response was greater if the tear was larger than 4 cm2, if patients presented within 2 weeks following surgery, or if they presented after 12 weeks postsurgery.

Risk of seizures after immunization in children with epilepsy: a risk interval analysis

BackgroundIn children with epilepsy, fever and infection can trigger seizures. Immunization can also induce inflammation and fever, which could theoretically trigger a seizure. The risk of seizure after immunization in children with pre-existing epilepsy is not known. The study objective was to determine the risk of medically attended seizure after immunization in children with epilepsy < 7 years of age.MethodsWe conducted a retrospective study of children < 7 years of age with epilepsy in Nova Scotia, Canada from 2010 to 2014. Hospitalizations, emergency visits, unscheduled clinic visits, and telephone calls for seizures were extracted from medical records. Immunization records were obtained from family physicians and Public Health with informed consent. We conducted a risk interval analysis to estimate the relative risk (RR) of seizure during risk periods 0–14, 0–2, and 5–14 days post-immunization versus a control period 21–83 days post-immunization.ResultsThere were 302 children with epilepsy who were eligible for the study. Immunization records were retrieved on 147 patients (49%), of whom 80 (54%) had one or more immunizations between the epilepsy diagnosis date and age 7 years. These 80 children had 161 immunization visits and 197 medically attended seizures. Children with immunizations had more seizures than either those with no immunizations or those with no records (mean 2.5 versus 0.7 versus 0.9, p < 0.001). The risk of medically attended seizure was not increased 0–14 days after any vaccine (RR = 1.1, 95% confidence interval (CI): 0.5–2.8) or 0–2 days after inactivated vaccines (RR = 0.9, 95% CI: 0.1–7.1) versus 21–83 days post-immunization. No seizure events occurred 5–14 days after live vaccines.ConclusionsChildren with epilepsy do not appear to be at increased risk of medically attended seizure following immunization. These findings suggest that immunization is safe in children with epilepsy, with benefits outweighing risks.

LBA2 THE USE OF TELEMEDICINE FOR THE POSTOPERATIVE UROLOGIC CARE OF CHILDREN: RESULTS OF A PILOT PROGRAM

You have accessJournal of UrologyPlenary: Next Frontier1 Apr 2018LBA2 THE USE OF TELEMEDICINE FOR THE POSTOPERATIVE UROLOGIC CARE OF CHILDREN: RESULTS OF A PILOT PROGRAM Julia B Finkelstein, Michael P Kurtz, Julie Campbell, Briony K Varda, Rosemary Grant, Caleb P Nelson, and Carlos R Estrada, Jr. Julia B FinkelsteinJulia B Finkelstein More articles by this author , Michael P KurtzMichael P Kurtz More articles by this author , Julie CampbellJulie Campbell More articles by this author , Briony K VardaBriony K Varda More articles by this author , Rosemary GrantRosemary Grant More articles by this author , Caleb P NelsonCaleb P Nelson More articles by this author , and Carlos R Estrada, Jr.Carlos R Estrada, Jr. More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.03.081AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES For postoperative visits, which are often brief interactions between family and clinician, the costs may be out of proportion to the perceived benefits of the visit. Our objective was to evaluate the feasibility of telemedicine for postoperative encounters in pediatric urology. METHODS This is a prospective telemedicine pilot study during a 12-week implementation period from 11/10/17 to 2/6/18. All postoperative patients deemed eligible by one of two urologists were offered enrollment in the telemedicine program. Enrollees underwent at least one virtual visit within six weeks of surgery. After each virtual evaluation, the guardian and clinician were prompted to complete a survey pertaining to perceptions of the telemedicine experience, including their overall satisfaction (rated 1 to 10) and how effective the virtual visit was in delivering care. The following variables of interest were tracked: appointment compliance, estimated travel expense and time saved per round-trip visit, virtual waiting room and visit time as well as number of unscheduled clinic or emergency department (ED) visits, complications, and readmissions. Any technical difficulties were also noted. RESULTS During the study period, 64 postoperative virtual visits were performed in 45 patients. There was 97% technical success with utilization of the telemedicine software. Surgeries included labioplasty (1), circumcision (12) and circumcision revision (5), lysis of penile adhesions (2), hypospadias repair (2), hydrocele/hernia repair (5), scrotal orchidopexy (5), ureteral reimplant (6), stoma revision (4) and stone procedures (3). The median age of children was 4.0 years (IQR 1.1 to 9.0 years) and 73% of patients were boys. Families saved a mean of $378 of travel cost and 3.9 hours of travel time per visit. Inspection of the postoperative incision was possible in all appropriate cases. Clinicians found that the virtual visit was “very effective” in 86% of cases, delivering the same care that they would have provided during an in-person visit. Mean guardian and provider satisfaction with the virtual visit experience overall was 9.9 and 9.0, respectively. No adverse postoperative outcomes were observed. There were no unscheduled clinic or ED visits. CONCLUSIONS This pilot study demonstrates that telemedicine can be successfully implemented in the postoperative care of pediatric urology patients. Use of this innovative technology was feasible and reduced unnecessary costs to the family, while maintaining high satisfaction for clinicians, patients and their families. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e577 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Julia B Finkelstein More articles by this author Michael P Kurtz More articles by this author Julie Campbell More articles by this author Briony K Varda More articles by this author Rosemary Grant More articles by this author Caleb P Nelson More articles by this author Carlos R Estrada, Jr. More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Characteristics of Unscheduled and Scheduled Outpatient Palliative Care Clinic Patients at a Comprehensive Cancer Center

ContextThere is limited literature regarding outpatient palliative care and factors associated with unscheduled clinic visits. ObjectivesTo compare characteristics of patients with unscheduled vs. scheduled outpatient palliative care clinic visits. MethodsMedical records of 183 unscheduled cancer new outpatients and 104 unscheduled follow-up (FU) patients were compared with random samples of 361 and 314 scheduled new patients and FU patients, respectively. We gathered data on demographics, symptoms, daily opioid usage, and performance status. ResultsCompared with scheduled new patients, unscheduled new patients had worse Edmonton Symptom Assessment Scale subscores for pain (P < 0.001), fatigue (P = 0.002), nausea (P = 0.016), depression (P = 0.003), anxiety (P = 0.038), drowsiness (P = 0.002), sleep (P < 0.001), and overall feeling of well-being (P = 0.001); had a higher morphine equivalent daily dose of opioids (median of 45 mg for unscheduled vs. 30 mg for scheduled; P < 0.001); and were more likely to be from outside the greater Houston area (P < 0.001). Most unscheduled and scheduled new and FU visits were for uncontrolled physical symptoms. Unscheduled FU patients, compared with scheduled FU patients, had worse Edmonton Symptom Assessment Scale subscores for pain (P < 0.001), fatigue (P < 0.001), depression (P = 0.002), anxiety (P = 0.004), drowsiness (P = 0.010), appetite (P = 0.023), sleep (P = 0.022), overall feeling of well-being (P < 0.001), and higher morphine equivalent daily dose of opioid (median of 58 mg for unscheduled FU visits vs. 40 mg for scheduled FU visits; P = 0.054). ConclusionUnscheduled new FU patients have higher levels of physical and psychosocial distress and higher opioid intake. Outpatient palliative care centers should consider providing opportunities for walk-in visits for timely management and close monitoring of such patients.

Delineating the burden of chronic post-operative pain in patients undergoing open repair of complex ventral hernias

BackgroundAfter open complex ventral hernia repair (cVHR), chronic pain has a significant impact on quality of life and processes of care. MethodsRecords of 177 patients undergoing cVHR were reviewed in order to characterize the burden of managing postoperative pain in the first post-operative year following open cVHR. ResultsIn this cohort, 91 patients initiated at least one unsolicited complaint of pain, though phone call (37), unscheduled clinic visit (45) or evaluation in the emergency room (9); among these an actionable diagnosis was found in 38 (41.8%). Among 41 patients who initiated additional unsolicited complaints of pain, an actionable diagnosis was found in only 3 patients. Risk factors for such complaints included pre-operative pain and the use of synthetic mesh. ConclusionsEven in the absence of an actionable diagnosis, significant resources are utilized in evaluation and management of unsolicited complaints of pain in the first year after cVHR.

Increased Risk of Exacerbation in Asthma Predominant Asthma-Chronic Obstructive Pulmonary Disease Overlap Syndrome.

BackgroundObstructive airway disease patients with increased variability of airflow and incompletely reversible airflow obstruction are often categorized as having asthma–chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS). ACOS is heterogeneous with two sub-phenotypes: asthma-ACOS and COPD-ACOS. The objective of this study was to determine the difference in risk of exacerbation between the two sub-phenotypes of ACOS.MethodsA total of 223 patients exhibiting incompletely reversible airflow obstruction with increased variability (spirometrically defined ACOS) were enrolled. These patients were divided into asthma-ACOS and COPD-ACOS according to their physician's diagnosis and smoking history of 10 pack-years. Within-group comparisons were made for asthma-ACOS versus COPD-ACOS and light smokers versus heavy smokers.ResultsCompared to patients with COPD-ACOS, patients with asthma-ACOS experienced exacerbation more often despite their younger age, history of light smoking, and better lung function. While the light-smoking group showed better lung function, they made unscheduled outpatient clinic visits more frequently. On multivariate analysis, asthma-ACOS and poor inhaler compliance were significantly associated with more than two unscheduled clinic visits during the previous year.ConclusionSpirometrically defined ACOS includes heterogeneous subgroups with different clinical features. Phenotyping of ACOS by physician's diagnosis could be significant in predicting future risk of exacerbation.

Mobile Web-Based Follow-up for Postoperative ACL Reconstruction: A Single-Center Experience.

Background:The initial 6 weeks after surgery has been identified as an area for improvement in patient care. During this period, the persistence of symptoms that go unchecked can lead to unscheduled emergency room and clinic visits, calls to surgeons’ offices, and readmissions.Purpose:To analyze postoperative data from a previous study examining postoperative outcomes in 2 patient populations following breast reconstruction and anterior cruciate ligament (ACL) reconstruction with use of a patient-centered mobile application. Here, the authors establish whether this method of follow-up can provide useful insight specific to the orthopaedic patient population, and they determine whether the mobile platform has the potential to modify their postoperative treatment. In addition, the authors examine its utility for orthopaedic physicians and patients.Study Design:Case series; Level of evidence, 4.Methods:Eligible patients undergoing ACL reconstruction from 2 surgeons were consecutively recruited to use a mobile smartphone application that allowed physicians to monitor their recovery at home. Data from 32 patients were collected via the application and analyzed to evaluate recovery trends during the first 6 postoperative weeks. Following completion of the study, patients and physicians were interviewed on their experience.Results:Data collected from each question in the mobile application provided insightful trends on daily real-time indicators of postoperative recovery. The application identified 1 patient who required in-person reassessment to rule out a possible infection, following surgeon review of an uploaded image. It was estimated that the majority of patients could have avoided follow-up at 2 and 6 weeks, owing to the application’s efficacy. Participants described their satisfaction with the device as excellent (43%), good (40%), fair (10%), and poor (7%), and 94% (n = 30) of patients reported that they would respond to questions using a similar application in the future. Both physicians rated their experience as positive and identified useful traits in the web portal.Conclusion:This system can accurately assess patient recovery; it has the potential to change how postoperative orthopaedic patients are followed, and it is well received by patients and physicians. Recognition of the study’s limitations and employment of user feedback to improve the current application are essential before a formal randomized controlled trial is conducted.

Vascular Graft Infection: Incidence and Potential Risk Factors.

The purpose of this study was to identify factors that increase the risk of vascular graft infections (VGI) in patients following abdominal or lower extremity revascularization surgery. Retrospective, descriptive study. We reviewed the electronic health records of 223 patients who had undergone abdominal or lower extremity revascularization procedures from July 2012 to November 2014, looking for factors associated with VGI. We reviewed 28 preoperative, intraoperative, and post-operative factors. Descriptive statistics (mean, range, and standard deviation) were used to describe the sample; χ was used to determine correlations between the risk factors and subsequent VGIs. The level of significance was determined at P = .05, with a confidence level of 95%. We identified 33 cases of VGIs for the 223 charts reviewed, yielding an incidence rate of 15%. Seventeen of the 33 patients with VGI (51.5%) were male. The average age of patients who experienced VGI was 60.9 years (standard deviation, 12.2 years, range, 29-81 years). Preoperative factors that were shown to show statistical significance for the development of VGI were sequential procedures (P = .003), diabetes mellitus (P = .002), hemoglobin A1c more than 7.0 (P = .0002), blood glucose more than 180 mg/dL (P = .0006), and lack of mobility (0.0097). Intraoperative factors associated with VGI were hemostatic agents applied to the surgical field intraoperatively (P = .003) and perioperative hypoxemia (P = .027). Postoperative factors associated with VGI were discharge from the hospital to skilled nursing facility or acute rehabilitation facility (P = .005) and unscheduled clinic visits (P = .008). We measured a 15% incidence of VGI and identified multiple pre-, intra-, and postoperative associated factors. Vigilance is required to prevent VGI and knowledge of specific risk factors is important.

Description and Results of a Comprehensive Care Protocol for Overnight-Stay Spine Surgery in Adults.

This is a prospective cohort study. The aim of this study was to define the probability of successful morning-after discharge after adult spine surgery achieved with a standard care protocol as applied to patients with a large variety of common degenerative spine disorders. Qualifying criteria for ambulatory or overnight-stay adult spine surgery are not well defined in either the spine or anesthesia literature. Most reports simply go to American Society of Anesthesiology risk classification or surgical technique alternatives and do not present a clearly defined patient care and case management protocol. A standardized protocol of patient preparation, preoperative comorbidities optimization, and perioperative care was applied in a prospective cohort of 126 patients including 83 lumbar and 41 cervical procedures. Office and hospital chart records were reviewed for relevant outcomes. Fully 122 of 124 appropriately selected cases were able to successfully achieve uneventful same-day discharge without any need for readmission, unscheduled early emergency room or clinic visits, or other major complications. Both failures were for urinary retention in senior males and resolved after a single-day admission to the main hospital. A wide variety of common degenerative spinal pathology in adults can be routinely and safely managed on an overnight-stay basis without requirement for formal hospital inpatient admission in patients appropriately selected and pre-educated to the experience and whose major comorbidities are preoperatively optimized. N/A.