Urgent Care Research Articles

Building a performance measurement framework for telephone triage services in Finland: a consensus-making study based on nominal group technique

BackgroundThere has been a significant expansion in the measurement of healthcare system performance. However, there is a lack of a comprehensive performance measurement framework to assess the effects of telephone triage services on the urgent care system. The aim of our Delphi study was to construct and validate a performance measurement framework designed explicitly for telephone triage services.MethodsThis study was conducted in Finland with a group of eight experienced senior physicians from the country's 20 largest joint emergency departments, serving over 90% of the population for urgent care. The Nominal Group Technique (NGT) was utilised to achieve consensus on measuring telephone triage performance. Initially, performance indicators (PIs) were identified through Delphi method rounds from December 10th to December 27th, 2021, with eight experts participating, and from December 29th, 2021, to January 23rd, 2022, where five of these experts responded. NGT further deepened these themes and perspectives, aiding in the development of a comprehensive performance measurement framework. The final framework validation began with an initial round from February 13th to March 3rd, 2022, receiving five responses. Due to the limited number of responses, an additional validation round was conducted from October 29th to November 7th, 2023, resulting in two more responses, increasing the total number of respondents in the validation phase to seven.ResultsThe study identified a strong desire among professionals to implement a uniform framework for measuring telephone triage performance. The finalised framework evaluates telephone triage across five dimensions: service accessibility, patient experience, quality and safety, process outcome, and cost per case. Eight specific PIs were established, including call response metrics, service utility, follow-up care type and distribution, ICPC-2 classified encounter reasons, patient compliance with follow-up care, medical history review during assessment, and service cost per call.ConclusionsThis study validated a performance measurement framework for telephone triage services, utilising existing literature and the NGT method. The framework includes five key dimensions: patient experience, quality and safety, outcome of the telephone triage process, cost per case, and eight PIs. It offers a structured and comprehensive approach to measuring the overall performance of telephone triage services, enhancing our ability to evaluate these services effectively.

Electric Scooter-related Injuries Are Becoming More Frequent and Costly in Denver, CO.

Electric scooters (e-scooters) have become a widely adopted form of transportation. Information regarding the timing, conditions, and context associated with increased frequency of e-scooter-related injuries could inform policy that may potentially reduce associated injuries and healthcare costs. However, this information is lacking, as most research to date has focused on the injury patterns sustained while using e-scooters rather than context. We sought to evaluate these factors in an urban setting and describe how these are evolving over time, as such information may help guide future safety initiatives. (1) How has the epidemiology of e-scooter-related injuries in Denver, CO, USA, changed over time? (2) What are the associated hospital charges to treat patients with these injuries? (3) What circumstances are associated with an increased frequency of e-scooter-related injuries and higher accompanying hospital charges? A retrospective study at a Level 1 trauma center in Denver, CO, USA, examined trends in e-scooter-related injuries from January 1, 2020, to November 1, 2023. Patients were identified by the key terms "e-scooter crash" or "scooter" within their emergency department/urgent care visit notes. Patient demographic and injury characteristics and hospital data (admission and hospital charges) were analyzed. Patients who sustained injuries from devices other than stand-up e-scooters or who did not have complete records available for analysis were excluded. The epidemiologic data on e-scooter-related injuries were quantified for each year within the study period, and descriptive analyses were performed to assess patient and injury characteristics, including age, gender, and fracture characteristics. Hospital charges were calculated using the mean annual sum of hospital charges associated with the treatment for e-scooter-related injuries. Circumstances influencing the frequency of injury and magnitude of hospital charges were assessed based on the timing of presentation to the emergency department or urgent care. We recognize that charge may have little or no direct relationship to true cost, but we believe that within one hospital system it represents a reasonable metric for comparative resource utilization. Injury frequency by time of the day and day of the week were compared using chi-square goodness-of-fit analyses. The value of hospital charges associated with e-scooter-related injuries was compared between patients presenting with alcohol intoxication and those who were not intoxicated. In all, 2424 patients were identified as having e-scooter-related injuries (58% [1405] men, 42% [1019] women, median (IQR) age 30 years [25 to 37 years]). The number of annual e-scooter-related injuries during the years 2020 to 2023 were 273 in 2020, 736 in 2021, 758 in 2022, and 657 in 2023 (only 10 months). From 2020 to 2023, the mean annual sum of hospital charges for treatment of e-scooter-related injuries was USD 10.4 million; USD 6.4 million in 2020, USD 11.5 million in 2021, USD 11.9 million in 2022, and USD 10.9 million in 2023 (only 10 months). Hospital charges associated with orthopaedic e-scooter-related injuries amounted to a mean annual sum of USD 3.6 million over the 4-year study period; USD 1.5 million in 2020, USD 3.9 million in 2021, USD 4.5 million in 2022, and USD 4.1 million in 2023 (only 10 months). Forty-five percent (1098) of all e-scooter-related injuries occurred between 7 PM and 3 AM, and 44% (1064) of them occurred over the weekend. The treatment of e-scooter-related injuries incurred higher hospital charges if injuries occurred during night hours (median [IQR] USD 10,459 [4779 to 16,423]) compared with early morning (USD 4973 [1178 to 11,671]) or daytime hours (USD 4871 [1059 to 11,673]; p < 0.001), or while patients were intoxicated (USD 13,404 [10,346 to 22,525]) compared with those who were not intoxicated (USD 6132 [2612 to 13,620]; p < 0.001). E-scooter-related injuries are increasing in frequency and occur most commonly during nighttime and weekend hours. Total hospital charges to treat these injuries are also increasing annually, with the highest charges observed during evening hours and in patients presenting with alcohol intoxication. These results may help inform e-scooter awareness initiatives and policy reform to place restrictions on e-scooter use during periods of highest injury frequency and healthcare charges. Further research related to the efficacy of implementing e-scooter restrictions is needed. Future observational studies evaluating time of injury compared with presentation for treatment could help to provide a more precise understanding of the epidemiology of these injuries. Level IV, prognostic study.

Neighborhood Deprivation and Crime on Asthma Exacerbations and Utilization in Mild Adult Asthma

Social determinants of health have a significant impact on asthma outcomes, and factors such as income level and neighborhood environment have crucial roles. This study aimed to assess the impact of the Neighborhood Deprivation Index (NDI) and Total Crime Index (TCI) on acute asthma exacerbation (AAE) and asthma-related emergency department and urgent care (ED/UC) visits in adults with mild asthma. This retrospective cohort study used administrative data from Kaiser Permanente Southern California among 198,873 adult patients with mild asthma between January 1, 2013 and December 31, 2018. We employed robust Poisson regression models, adjusted for age and sex, to investigate the associations of NDI and TCI with AAE and asthma-related ED/UC visits. Data analysis included subgroup assessments by race and ethnicity and body mass index categories to explore potential disparities in asthma outcomes. Among the cohort, 12,906 patients (6.5%) experienced AAE in 1 year, and Black patients had the highest AAE percentage (7.1%). Higher NDI quintiles were associated with increased AAE risk (adjusted risk ratio= 1.11-1.27), with similar trends across body mass index categories and race or ethnicity, except for Black patients. The TCI showed weaker associations with AAE. Regarding ED/UC visits, 5.0% had such visits within 1 year. Higher NDI quintiles were associated with higher ED/UC visit risk (adjusted risk ratio= 1.23-1.75) whereas TCI associations were weaker. Addressing socioeconomic disparities, as indicated by NDI, may be crucial in mitigating asthma exacerbations and reducing health care use, highlighting the importance of incorporating social determinants into asthma management strategies even in patients with mild asthma.

A Hybrid Markov-SPC Approach to Assess Cost Differences in Urgent Care Utilization Using Patient-Reported Data in Inflammatory Bowel Disease.

Cost is a key outcome in quality and value, but it is often difficult to estimate reliably and efficiently for use in real-time improvement efforts. We describe a method using patient-reported outcomes (PROs), Markov modeling, and statistical process control (SPC) analytics in a real-time cost-estimation prototype designed to assess cost differences between usual care and improvement conditions in a national multicenter improvement collaborative-the IBD Qorus Learning Health System (LHS). The IBD Qorus Learning Health System (LHS) collects PRO data, including emergency department utilization and hospitalizations from patients prior to their clinical visits. This data is aggregated monthly at center and collaborative levels, visualized using Statistical Process Control (SPC) analytics, and used to inform improvement efforts. A Markov model was developed by Almario et al to estimate annualized per patient cost differences between usual care (baseline) and improvement (intervention) time periods and then replicated at monthly intervals. We then applied moving average SPC analyses to visualize monthly iterative cost estimations and assess the variation and statistical reliability of these estimates over time. We have developed a real-time Markov-informed SPC visualization prototype which uses PRO data to analyze and monitor monthly annualized per patient cost savings estimations over time for the IBD Qorus LHS. Validation of this prototype using claims data is currently underway. This new approach using PRO data and hybrid Markov-SPC analysis can analyze and visualize near real-time estimates of cost differences over time. Pending successful validation against a claims data standard, this approach could more comprehensively inform improvement, advocacy, and strategic planning efforts.

2330 Community frailty hotline service: an innovative hospital avoidance model for frailer older people in mid and South Essex health

Abstract Introduction Frailty Hotline Service (FHS) was set up initially in January 2021 to provide 24/7 advice and guidance to care home medical staff within the Mid &amp; South Essex Health and Care Partnership footprint as a part of covid response. This was expanded to support GPs, Urgent Care Response Team (UCRT), community hospitals, hospices etc and later established as Community Frailty Hotline Service (FHS) with an aim for hospital avoidance and provide support to frailer older patients in their own places. Later, a Frailty Virtual Ward (FVW) was established to complement FHS within the MSE HCP. Methods FHS was led by 5 secondary care consultant geriatricians with direct access to telephone, 7 days service operating from 9 am till 10 pm weekdays and 9 am till 10 pm weekends in 1:5 rota. Unified online portal ‘Netcalls’ was used to directly call consultants. Documentation completed on dedicated Frailty Consultant Hotline Tab on SystmOne to be visible to all care providers. Data-collection automated via Netcall and SystmOne from March 2023 till January 2024. Results Average number of call was 487/month, 2098 advices given over 11 months. Referral mostly done by UCRT 1511 (72%) followed by GP 193 (9.19%). Hospital admission avoided in 7 days and 30 days where the advice given in 82.9% and 73.6% cases, respectively. Total bed days saved was 13,920 Cost saving was over six million. Frailty score completed in 2982 cases. FVW referral done in 853 cases (40.6%). Feedback from FVW and UCRT, 95% found FHS was useful. Conclusion Our innovative model of FHS with direct access to geriatrician showed a safe and efficient model to support frailer older patients in the community with appropriate signposting to FVW and other community services as an alternative to acute hospital emergency admission and treat the right patient in the right place.

“YOU'RE NOT BLEEDING SO PHONE 111!”: HOW NHS 111 EXPERIENCES INFORM THE DECISION TO ATTEND THE EMERGENCY DEPARTMENT WITH LOW BACK PAIN

Purpose and backgroundLow back pain (LBP), a leading cause of chronic disability, is associated with high and disproportionate socioeconomic costs. Clinical assessment and triage via the NHS 111 service aims to reduce pressure on the urgent and emergency care system. Studies show that many attend the emergency department (ED) against advice, when they could be better managed elsewhere. The aim of this research was to explore how patients with LBP perceive and interact with NHS 111, and how this may have influenced their decision to attend ED.Methods and ResultsThis was a secondary analysis of a cross-sectional, qualitative dataset of 47 patients (26M:21F, aged 23–79 years) purposively sampled with LBP, who attended 1 of 4 EDs in the UK in 2021, (during the pandemic). The participants took part in online, semi-structured interviews, mean duration 45-minutes (range 23–156 minutes), within six weeks of their ED visit. The interviews were audio-recorded, transcribed verbatim and thematically analysed.Three key themes were identified: purpose, process and performance. The themes showed mixed understanding and low awareness of the purpose of NHS 111, despite its strong triage role. Long waits for call backs however, sometimes resulted in patients attending ED, along with previous negative perspectives and experiences.ConclusionThis research suggests enhanced visibility and knowledge of NHS 111 would increase its use by people with LBP. Further exploration comparing outcomes of callers to NHS 111 with those who seek care elsewhere, could help evaluate how NHS 111 can best help people with LBP and prevent unnecessary ED attendance.No conflicts of interest Sources of fundingFunding for primary data: Health Education England &amp; National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

A national survey of the impact of the COVID-19 pandemic on training and wellbeing of restorative and mono-speciality specialist trainees in the UK and Ireland.

Introduction COVID-19 emergency and associated measures across the UK and Ireland during the first and third waves of the pandemic disrupted mainstream dental services and training across all specialties.Aims Investigate the effect of COVID-19 pandemic on training, mental health and wellbeing of specialty trainees (STs) in restorative dentistry and associated mono-specialities across the United Kingdom and Ireland.Materials and methods A cross-sectional survey was conducted exploring experiences of STs in restorative dentistry, prosthodontics, endodontics and periodontics (n = 101) across the United Kingdom and Ireland during the first (March 2020) and third (July 2021) waves of the pandemic. Results were analysed quantitatively and qualitatively.Results In total, 28 postgraduate trainees responded, yielding a 28% response rate. STs reported perceived impact on their training in March 2020 and July 2021, with some redeployed to urgent dental care duties in this time period. STs reported reduction in speciality-level clinical activities and a negative impact on mental health and wellbeing in both March 2020 and July 2021. A total of 12 STs felt COVID-19 negatively impacted their future careers.Conclusion The COVID-19 pandemic negatively impacted clinical training and mental health of STs in restorative dentistry and associated mono-specialities across the United Kingdom and Ireland. Increased flexibility and accounting for lost clinical activities could have improved ST morale and wellbeing.

Brazilian Policies and Programs in Urgent and Emergency Care Services in the Context of Cardiovascular Diseases: A Scoping Review

Brazilian Policies and Programs in Urgent and Emergency Care Services in the Context of Cardiovascular Diseases: A Scoping Review

Variability in Antimicrobial Prescribing Across Five Ambulatory Settings Within a Large Integrated Health System.

Background: Lack of access to timely, detailed antibiotic use data has limited ambulatory antibiotic stewardship efforts. Antibiotic utilization is tracked across ambulatory care sites and emergency departments (ED) within a large integrated health system. Methods: This is a retrospective cohort analysis from June 1, 2019 to May 31, 2020 comparing antibiotic prescribing for all patients with ICD-10 diagnosis codes for cystitis, otitis media, pharyngitis, sinusitis, and upper respiratory tract infections (URTIs) among five ambulatory care departments across northeast Ohio and southeast Florida locations: ED, Urgent Care (UC), On-Demand Telehealth (TEL), Pediatrics (PED), and Primary Care (PC). Results: A total of 261,947 encounters were included (ED:56,766, UC:92,749, TEL:8,783, PED:29,151, PC:74,498) for the treatment of cystitis (30,932), otitis media (22,094), pharyngitis (59,964), sinusitis (53,693), or URTI (95,264). The population was 63% female with a median age of 34.2 years [12.8-56.3]. A total of 17% of patients had documented penicillin allergies and 18% of patients with pharyngitis received Group A Streptococcus (GAS) testing. Antibiotics were prescribed in 44% of encounters (ED:21,746 [38%], UC:45,652 [49%], TEL:4,622 [53%], PED:10,909 [37%], PC:33,547 [45%]; P < 0.001). Guideline concordant antibiotics were prescribed in 65% of encounters (ED:14,338 [66%], UC:31,532 [69%], TEL:3,869 [84%], PED:8,212 [75%], PC:17,263 [51%]; P < 0.001). Conclusions: Observed rates of antibiotic and guideline concordant antibiotic prescribing were similar to national published rates of antibiotic prescribing in the ambulatory setting. The variability in antibiotic prescribing demonstrates opportunities for targeted outpatient stewardship efforts. Timely antibiotic tracking tools can facilitate ambulatory antimicrobial stewardship activities.

Disparate Patient Advocacy When Facing Unaffordable and Problematic Medical Bills

People in the US face high out-of-pocket medical expenses, yielding financial strain and debt. To understand how households respond to medical bills they disagree with or cannot afford. A retrospective cohort study was carried out using a survey fielded between August 14 and October 14, 2023. The study included a random sample of adult (aged ≥18 years) survey respondents from the Understanding America Study (UAS). Participant responses were weighted to be nationally representative. The analysis took place from November 3, 2023, through January 8, 2024. Respondents reported if their household received a medical bill that they could not afford or did not agree with in the prior 12 months, and if anyone contacted the billing office regarding their concerns. Those who did reach out were asked about their experience and those who did not were asked why. The survey was sent to 1233 UAS panelists, of which 1135 completed the survey, a 92.1% cooperation rate. Overall, 1 in 5 of the 1135 respondents received a medical bill that they disagreed with or could not afford. Leading bill sources were physician offices (66 [34.6%]), emergency room or urgent care (22 [19.9%]), and hospitals (31 [15.3%]), and 136 respondents (61.5%) contacted the billing office to address their concern. A more extroverted and less agreeable personality increased likelihood of reaching out. Respondents without a college degree, lower financial literacy, and the uninsured were less likely to contact a billing office. Among those who did not reach out, 55 (86.1%) reported that they did not think it would make a difference. Of those who reached out, 37 (25.7%) achieved bill corrections, better understanding (16 [18.2%]), payment plans (18 [15.5%]), price drop (17 [15.2%]), financial assistance (10 [8.1%]), and/or bill cancellation (6 [7.3%]), while 32 (21.8%) said that the issue was unresolved and 23.8% reported no change. These outcomes aligned well with respondents' billing concerns with financial relief for 75.8% of respondents reaching out about an unaffordable bill, bill corrections for 73.7% of those who thought there was mistake, and a price drop for 61.8% of those who negotiated. This cross-sectional survey of a representative sample of patients in the US found that most respondents who self-advocated achieved bill corrections and payment relief. Differences in self-advocacy may be exacerbating socioeconomic inequalities in medical debt burden, as those with less education, lower financial literacy, and the uninsured were less likely to self-advocate. Policies that streamline the administrative burden or shift it from patients to the billing clinician may counter these disparities.

National trends in musculoskeletal urgent care centers: Improved Medicaid access from 2019 to 2023.

Musculoskeletal urgent care centers (MUCCs) are an increasingly common alternative to emergency departments for patients with orthopedic injuries. As there is a lack of longitudinal data regarding MUCCs' impact on the emergency health care system, our study seeks to understand recent trends in MUCC growth and their acceptance of Medicaid insurance. Over the last 6 years, at 2-year intervals (2019, 2021, and 2023), we performed a search to identify all MUCCs in the United States. We determined the affiliation and Medicaid acceptance status of all MUCCs, including those that closed/opened between 2019, 2021, and 2023, to analyze trends in MUCC availability and Medicaid acceptance. In 2019, there were 558 MUCCs, which increased to 596 MUCCs in 2021 and then decreased to 555 MUCCs in 2023, representing a growth and then decline of approximately 7%. Overall, since June 2019, 90 MUCCs have opened and 95 MUCCs have closed. Medicaid acceptance increased nationally between 2019 and 2023, from 58% to 71%. Medicaid acceptance increased for both nonaffiliated and privately affiliated MUCCs. Medicaid acceptance has increased nationally from 2019 to 2023, while MUCC availability has gone through a period of growth and then reversion to 2019 levels. As MUCCs have demonstrated limited Medicaid acceptance previously, it is promising that Medicaid acceptance has improved and MUCCs are providing patients with an additional avenue to access orthopedic care.

Synergistic patient factors are driving recent increased pediatric urgent care demand.

We aimed to use the high fidelity urgent care patient data to model the factors that have led to the increased demand at our local pediatric urgent care centre. The dataset for this retrospective cohort study was obtained from our local healthcare centre's national reporting data for pediatric urgent care visits from 2006 to 2022. Variables analyzed included: basic patient demographics, chief complaint, triage urgency, date and time of registration/discharge, discharge diagnosis, and discharge destination. Statistical analysis of non-linear trends was summarized by locally estimated scatterplot smoothing splines. For machine learning, we used the tidymodels R package. Models were validated in training using k-fold cross validation with k = 5. We used univariate linear regression as a baseline model. After the data was standardized, correlation and homoscedasticity were evaluated between all parameter permutations. This dataset consisted of 164,660 unique visits to our academic centre's pediatric urgent care. Over the study period, there was an overall substantial increase in the number of urgent care visits per day, with a rapid increase beyond previous levels in 2021 and further in 2022. The increased length of stay trend was consistent across presenting complaint categories. The proportion of patients without primary care in 2022 was 2.5 times higher than in 2013. A random forest machine learning model revealed the relative importance of features to predicting a visit in 2022 were: longer stay, later registration in the day, diagnosis of an infectious illness, and younger age. This study identified a combination of declining primary care access, circulating viral infections, and shifting chief complaints as factors driving the recent increase in frequency and duration of visits to our urgent care service.

I Think, Therefore I Am: A Reflection of Family Nurse Practitioners

&lt;p&gt;隨著台灣人口老化和社區醫療照護需求增加，在原本的內外婦兒、精神和麻醉專科護理師外應運而生「家庭專科護理師」，從傳統的急性照護邁向基層照護，更多的在門診、社區、居家、長照、偏鄉離島等場域提供民眾專業健康照護服務。本文從簡介國人健康形態的轉變延伸到對家庭專科護理師的需求、發展與培育，以國立陽明交通大學為例，分享家庭專科護理師養成的核心能力架構，並佐以核心訓練理念，達到：全生命歷程轉銜（從新生兒到老人）、急慢性疾病無縫接軌（照護能力養成）、醫護進階合作、國際領航訓練和無邊界學習擴充（線上虛擬實境），同時配合學生過去的教育背景（有無專科護理師碩士學位）提供完整或是轉銜家庭專科護理師訓練，讓學習更有效率。期待家庭專科護理師不僅僅是第一線的民眾健康照護提供者，更是具有國際觀和科技識能的進階護理專家。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Taiwan is going to be a super-aged society and has increased needs of primary care providers. There-fore, the demand for family nurse practitioners (FNPs) is expected high and strong in addition to the roles in medical, surgical, women health, pediatric, psychological, and anesthetic areas that nurse practitioners have contributed in Taiwan. FNPs are specialized in providing preventative and primary care to individuals and families across the lifespan in various care settings, including primary care clinics, family medicine practice, urgent care centers, long-term care facilities, home health agencies or in the places where medical services needed. National Yang Ming Chiao Tung University&amp;rsquo;s FNP master program emphasizes hands-on, real-life care in meeting all core competence requirements across the lifespan from infants to the elderly, from acute illness to chronic diseases, physician-nurses advanced collaborations, international visits and virtual education. We expect that our FNP graduates have the competence and confidence in their clinical practices and leading the advanced nursing prac-tice with global vision and technology skills in the new era&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Developing feasible person-centred care alternatives to emergency department responses for adults with epilepsy: a discrete choice analysis mixed-methods study.

Calls have been made for paramedics to have some form of care pathway that they could use to safely divert adults with epilepsy away from emergency departments and instigate ambulatory care improvements. Different configurations are possible. To know which to prioritise for implementation/evaluation, there is a need to determine which are acceptable to service users and likely National Health Service-feasible. (1) Identify configurations being considered, (2) understand service users' views of them and current provision, (3) identify what sort of care service users want and (4) determine which configuration(s) is considered to achieve optimal balance in meeting users' preference and being National Health Service-feasible. Service providers were surveyed to address objective 1. Interviews with service users addressed objective 2. Objective 3 was addressed by completing discrete choice experiments. These determined users' care preferences for different seizure scenarios. Objective 4 was addressed by completing 'knowledge exchange' workshops. At these, stakeholders considered the findings on users' stated preferences and judged different pathway configurations against Michie's 'acceptability, practicability, effectiveness, affordability, side-effects and equity' feasibility criteria. This project took place in England. The survey recruited representatives from neurology and neuroscience centres and from urgent and emergency care providers. For the interviews, recruitment occurred via third-sector support groups. Recruitment for discrete choice experiments occurred via the North West Ambulance Service NHS Trust and public advert. Workshop participants were recruited from neurology and neuroscience centres, urgent and emergency care providers, support groups and commissioning networks. Seventy-two services completed the survey. Interviews were conducted with 25 adults with epilepsy (and 5 relatives) who had emergency service contact in the prior 12 months. Discrete choice experiments were completed by 427 adults with epilepsy (and 167 relatives) who had ambulance service contact in the prior 12 months. Workshops were completed with 27 stakeholders. The survey identified a range of pathway configurations. They differed in where they would take the patient and their potential to instigate ambulatory care improvements. Users had been rarely consulted in designing them. The discrete choice experiments found that users want a configuration of care markedly different to that offered. Across the seizure scenarios, users wanted their paramedic to have access to their medical records; for an epilepsy specialist (e.g. an epilepsy nurse, neurologist) to be available to advise; for their general practitioner to receive a report; for the incident to generate an appointment with an epilepsy specialist; for the care episode to last < 6 hours; and there was a pattern of preference to avoid conveyance to emergency departments and stay where they were. Stakeholders judged this configuration to be National Health Service-feasible within 5-10 years, with some elements being immediately deployable. The discrete choice experiment sample was broadly representative, but those reporting recent contact with an epilepsy specialist were over-represented. Users state they want a configuration of care that is markedly different to current provision. The configuration they prefer was, with support and investment, judged to likely be National Health Service-feasible. The preferred configuration should now be developed and evaluated to determine its actual deliverability and efficacy. The study is registered as researchregistry4723. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/62) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 24. See the NIHR Funding and Awards website for further award information.

Postpartum Depression Screening in Pediatric Primary Care Clinics and Infant Receipt of Preventive or Acute Care

ObjectiveTo evaluate the association between postpartum depression (PPD) screening results in pediatric primary care and subsequent infant preventive and acute care utilization. MethodsThis was a retrospective cohort analysis of 5341 infants born in 2021 whose mothers were screened for PPD at a well-child visit during the first 6 months. Logistic regression was used to examine that association between a positive PPD screen and 1) adherence to the 12-month well-child visit, and 2) any acute care visits (urgent care or emergency department visits) from 6–15 months. The association between PPD screen and number of acute care visits was examined with negative binomial logistic regression. ResultsThe incidence of positive PPD screens was 15.6% in the first 6 months. There was no significant difference in 12-month well-child visit adherence based on PPD screening (adjusted odds ratio (aOR): 0.91; 95% confidence interval (CI): 0.77–1.06; P-value: 0.206). The odds of having any acute care visit were higher among infants whose mothers screened positive for PPD (aOR: 1.2; 95% CI: 1.0–1.3; P-value: 0.009). There was a significant difference in the incidence rate of acute care visits based on PPD screening results (incidence rate ratio: 1.1; 95% CI: 1.0–1.2; P-value: 0.005). ConclusionsScreening positive for PPD was associated with subsequent acute care utilization but not 12-month preventive care. Primary care providers may need to proactively follow-up after acute care visits to ensure both infant health and maternal needs are met, connecting mothers to resources as needed.

Distinct Clinical Courses and Shortened Lifespans in Childhood-Onset DNA Polymerase Gamma Deficiency.

DNA polymerase subunit gamma (POLG) deficiency is likely the most frequent cause of nuclear-encoded mitochondrial disorders. POLG-related disorders reportedly constitute a spectrum of overlapping phenotypes from infancy to late adulthood. We retrospectively reviewed natural histories for 40 children carrying biallelic pathogenic POLG variants. The patients were identified by the French coordinating center for mitochondrial disorders (CARAMMEL), making this a large monocentric series on childhood-onset POLG deficiency. Three patterns of clinical course and survival were observed, distinguished by main category of symptoms: neurologic, hepatic, and gastrointestinal. A total of 24 patients needed urgent neurointensive care for tonic-clonic seizures, myoclonic epilepsy, and status epilepticus, occasionally precipitated by valproate administration. Other neurologic symptoms included dystonia, cerebellar ataxia, and peripheral neuropathy. We report 6 POLG-deficient patients with polyradiculoneuropathy mimicking subacute Guillain-Barré syndrome and provide postgadolinium MRI evidence of diffuse cranial nerve root and cauda equina enhancement, suggesting these disorders have an inflammatory component. Children presenting with enteral nervous system involvement had vomiting, gastroparesis, and chronic intestinal pseudo-obstruction. They had later ages of onset and lived much longer. Primarily, hepatic presentations had the earliest onset and shortest survivals. Secondary hepatic failure was frequently precipitated by valproate administration given before diagnosis to patients with focal impaired awareness seizures or absence of seizures. These POLG deficiencies were often fatal, with age at death ranging from 3 months to 10 years, with a significant difference in survival between the 3 clinical forms; 6 of the 40 children did survive. No genotype-phenotype correlations were found for the 3 clinical course types. The study demonstrates the prevalence of neurologic presentation and the extent of central, peripheral, and autonomous nervous system involvement in 60% of patients. Most of the patients with early onset and rapidly fatal hepatic failure did not live long enough to develop neurologic symptoms. The study revealed a new clinical form of POLG deficiency presenting with neurodigestive symptoms with longer lifespan. We also propose that POLG deficiency should be considered in children presenting with unexplained polyradiculoneuropathy, demyelinating neuropathy, and elevated CSF protein. Finally, valproate administration remains a notable cause of avoidable death in POLG-deficient patients.

Transportation As A Determinant Of Health: Evaluating The Veterans Affairs Rideshare Program For Homeless Patients.

From 2020 to 2023, the Department of Veterans Affairs (VA) conducted a national pilot of a rideshare program to support homeless patients' transportation needs to obtain critical resources and attend medical appointments. This study linked Lyft rideshare data in 2022 to VA administrative data to examine characteristics and changes in service use among VA homeless service users. The results showed that VA homeless service users who used the VA Rideshare program were more likely to have psychiatric diagnoses and urgent care visits than those who did not use the program. When we controlled for past VA service use, use of the VA Rideshare program was associated with greater use of VA outpatient and inpatient services and fewer no-show medical appointments six months after the veterans' index date. VA Rideshare users had three to eight more program visits over the course of six months than non-Rideshare users. These findings indicate benefits associated with providing transportation assistance to vulnerable patients in a nationwide health system.

Videolaryngoscopy during Urgent Cesarean Delivery: Association with Neonatal Intensive Care Unit Admission.

Parturients are at increased risk for difficult airway management with subsequent fetal complications. Videolaryngoscopy was opined to be the new standard of airway care to facilitate orotracheal intubation under urgent care conditions. We examined in parturients requiring general anesthesia for urgent cesarean delivery the association of the type of laryngoscopy technique and time required to facilitate orotracheal intubation with the incidence of subsequent neonatal intensive care unit (NICU) admission. Following institutional review board approval, 431 parturients aged 18 years and older who underwent urgent cesarean section requiring general anesthesia were entered into this study. Patient characteristics, maternal comorbidities, and indications for urgent cesarean delivery were collected from the electronic medical records from January 2013 to November 2018. Orotracheal intubation times by type of laryngoscopy (video or direct) and NICU admission rates also were collected. A measure of effect size, risk differences with 95% confidence intervals (CIs), were calculated for the likelihood of NICU admission by difficult orotracheal intubation and by type of laryngoscopy used to secure the airway. Videolaryngoscopy as the primary type of laryngoscopy was used in 24.1% (95% CI 20.3%-28.3%) of general anesthetics. The incidence of difficult orotracheal intubation was 4.4% (95% CI 2.8%-6.7%), with a higher incidence observed with videolaryngoscopy (8.7%) than with direct laryngoscopy (3.1%) and a risk difference of 5.6% (95% CI 0.001%-11.3%). The incidence of NICU admission was 38.4% (95% CI 34.0%-43.1%). Times for successful orotracheal intubation were longer with videolaryngoscopy. Videolaryngoscopy had a higher association for NICU admission (47%) than for direct laryngoscopy (36%), with a risk difference of 11.4% (95% CI 0.01%-22.3%). Videolaryngoscopy did not decrease the incidence of difficult orotracheal intubation, and it did not decrease the time associated with orotracheal intubation. Videolaryngoscopy was associated with a higher association of NICU admission. These results suggest that videolaryngoscopy does not supplant direct laryngoscopy as the standard of care for orotracheal intubation under urgent care conditions of general anesthesia for cesarean section.

Impact of fine particulate pollution exposures on respiratory health in a megacity of Pakistan

Air pollution poses a substantial barrier to global environmental sustainability and citizen well-being. However, there is a lack of research that specifically examines the effects of short-term exposure to PM2.5 and its components on health outcomes in developing nations in Asia, regions often cited as having some of the most severe urban air quality issues globally. The present study evaluated the associations between PM2.5 components and hospital admissions (HA) and emergency room visits (ERV) for respiratory diseases in the megacity of Karachi, Pakistan. We measured PM2.5 constituents, including black carbon (BC) and ionic species (sulfate - SO42−; nitrate - NO3−; and ammonium - NH4+) at two sites (August 2008 to August 2009) in Karachi. The HA and ERV, respiratory disease outcome data, were collected from three local, large tertiary care hospitals. We assessed the lag structure of excess risk (ER) of the pollutants-outcomes association (0–6 single and cumulative lag days) using time-series quasi-Poisson models after adjusting for temperature, humidity, and day of the week. Among a total 13,827 patients, the highest ERs for all respiratory urgent care use (UCU) were observed for PM2.5 (10.3, 95% CI: 2.59%-18.59), NH4+ (9.58%, 95% CI: 1.50%–18.30%), air quality index (9.11%, 95%CI: 2.54%–16.09%) and SO42− (7.26%, 95% CI: 1.03%–13.87%) within 0–4 lag days. Additionally, patients with chronic obstructive pulmonary disease (COPD), tuberculosis (TB), or other pulmonary diseases and older or male patients were more vulnerable to these pollutants. This first study in Pakistan found that PM2.5 and its constituents were associated with respiratory HAs and ERVs for the inhabitants of the megacity of Karachi. These associations varied by different PM constituents, disease subtypes, age, and gender. Our results provide important information to policymakers for developing regulations for improving air quality and public health. Further studies are urgently needed in other developing countries to disentangle the air pollution health effects.

Health Status and Healthcare Utilization Patterns of Emergency Department Patients Who Prefer a Language Other Than English.

Immigrants, nearly half of whom prefer a language other than English (LOE), face structural barriers to healthcare. This subgroup is believed to be at increased risk for reduced access to quality healthcare, yet few studies have examined the health needs and utilization patterns of LOE-preferring patients who seek care in the Emergency Department (ED). Given that the ED is often an entry point to the health system, we sought to characterize the health patterns of this population in an urban ED setting. We conducted a retrospective chart review of the electronic medical records of 1,566 patients who utilized interpreter services in the ED or Urgent Care) at an urban safety net hospital. We found that LOE-preferring patients had high levels of chronic disease. We also found that the majority of these patients had not seen a primary care provider (PCP) within the study period. PCP visits were positively associated with ED utilization suggesting that those without a PCP are less likely to receive ED care. These findings point to a need for greater policy and community health solutions addressing the high burden of chronic disease and underutilization of healthcare for those with LOE preferences.