Utilization Of Clinical Services Research Articles

Effects of Patient Empowerment Programme (PEP) on clinical outcomes and health service utilization in type 2 diabetes mellitus in primary care: an observational matched cohort study.

BackgroundTo evaluate the effects of a large population-based patient empowerment programme (PEP) on clinical outcomes and health service utilization rates in type 2 diabetes mellitus (T2DM) patients in the primary care setting.Research Design and SubjectsA stratified random sample of 1,141 patients with T2DM enrolled to PEP between March and September 2010 were selected from general outpatient clinics (GOPC) across Hong Kong and compared with an equal number of T2DM patients who had not participated in the PEP (non-PEP group) matched by age, sex and HbA1C level group.MeasuresClinical outcomes of HbA1c, SBP, DBP and LDL-C levels, and health service utilization rates including numbers of visits to GOPC, specialist outpatient clinics (SOPC), emergency department (ED) and inpatient admissions, were measured at baseline and at 12-month post-recruitment. The effects of PEP on clinical outcomes and health service utilization rates were assessed by the difference-in-difference estimation, using the generalized estimating equation models.ResultsCompared with non-PEP group, PEP group achieved additional improvements in clinical outcomes over the 12-month period. A significantly greater percentage of patients in the PEP group attained HbA1C≤7% or LDL-C≤2.6 mmol/L at 12-month follow-up compared with the non-PEP group. PEP group had a mean 0.813 fewer GOPC visits in comparison with the non-PEP group.ConclusionsPEP was effective in improving the clinical outcomes and reduced the general outpatient clinic utilization rate over a 12-month period. Empowering T2DM patients on self-management of their disease can enhance the quality of diabetes care in primary care.Trial RegistrationClinicalTrials.gov NCT01935349

Exploring the relationship between EQ-5D, DLQI and PASI, and mapping EQ-5D utilities: a cross-sectional study in psoriasis from Hungary.

There is a growing interest in policy making for using utility measures and identifying algorithms to convert disease-specific measures into utilities. To analyse the relationship between EQ-5D, Dermatology Life Quality Index (DLQI) and Psoriasis Area and Severity Index (PASI) in psoriasis. To transform DLQI scores, and key clinical, demographic and health service utilisation variables into utilities. A cross-sectional questionnaire survey of 200 consecutive adult patients with moderate to severe psoriasis was carried out in two Hungarian university clinics. The relationship between the outcome measures were analysed with correlations and with the known-groups method. Bivariate and multivariate regression algorithms on EQ-5D scores were formulated. The mean age of respondents was 51 years (SD = 12.9), 68.5% were male, and 51.5% received biological therapy. Median EQ-5D, DLQI, and PASI scores were 0.73, 3.0, and 3.45, respectively. EQ-5D showed a moderate correlation with the DLQI and with the PASI (r s = -0.48 and -0.43, p < 0.05). Strong correlation was found between DLQI and PASI (r s = 0.81, p < 0.05). DLQI and PASI discriminated better among groups categorised by the localisation of the lesions than EQ-5D. Presence of psoriasis on the neck and/or décolletage was associated with the greatest health related quality of life (HRQOL) impairment. Ten variables were incorporated in a multivariate algorithm that accounted for 48.8% of EQ-5D variance (ANOVA p < 0.001). This study provided the first evidence that patients with visible psoriatic lesions have significantly worse HRQOL compared to those with non-visible lesions, measured not only with DLQI but also with EQ-5D. In addition to demographic and clinical variables, our model included health service utilisation variables related to psoriasis, and explained higher proportion of EQ-5D variance than any previous findings in the literature.

The use of health services among elderly patients with stage IV prostate cancer in the initial period following diagnosis.

Information regarding variability in the type and extent of health services used by elderly patients with advanced prostate cancer (PCa) in the initial period following diagnosis is limited. We evaluated health services utilization among elderly men with stage IV PCa with (M1) and without (M0) distant metastasis during the year following diagnosis. We evaluated patients aged 66 and older with incident stage IV PCa during 2005-2007 using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Measures included skilled nursing facility (SNF) stay, hospice stay, and hospitalization. Multivariable logistic regression models were estimated to determine the association between M1 PCa and each health service. Poisson regression was used to assess hospital length of stay. The final sample included 3379 patients (20% M0; 80% M1). In the year following diagnosis, M1 patients had greater use of SNF (M0: 8%; M1: 22%), hospice (M0: 5%; M1: 20%), and hospitalization (M0: 43%; M1: 61%). Compared to M0 patients, M1 patients had statistically significantly higher adjusted odds of SNF use (OR=1.89; 95% CI=1.38-2.59), hospice use (OR=3.22; 95% CI=2.19-4.72), and hospitalization (OR=1.45; 95% CI=1.20-1.75). Among those hospitalized, M1 patients had 24% longer length of stay (p<0.01). There is 2- to 3-fold greater use of SNF and hospice, and higher hospitalization among M1 compared to M0 patients. Elderly patients with advanced PCa face significant clinical burden within the first year after their diagnosis. Greater understanding of the relationship between clinical disease burden and health services utilization can improve healthcare delivery in this population.

Motivations in seeking advanced pharmacy training

We appreciate the feedback and additional information provided by Dr. Rindfuss. We agree that pharmacists are being used differently today than almost 20 years ago but also recognize that the standardization and utilization of clinical pharmacy services vary nationally. As mentioned in our background discussion, there have been shifts in the supply and demand for pharmacists, increased formal recognition of the value of residency training, and an evolving utilization of pharmacists in health care teams. Since both studies reported on survey responses at particular points in time, we felt it prudent to hypothesize about rather than investigate how the changing landscape of pharmacy could have been a factor or a barrier in the pursuit of residency or fellowship training. In retrospect, it may have been effective to provide a historical perspective on progress of the profession between our survey and the earlier one, by Bucci et al.,1 specifically noting the proceedings of the March 1993 conference “Implementing Pharmaceutical Care” (conducted by ASHP and the ASHP Research and Education Foundation),2 held just six months before Bucci et al. conducted their survey. In 1993, the concept of pharmaceutical care was surfacing, and pharmacists were just beginning to assume responsibility for drug therapy outcomes. Interestingly, then-ASHP President Jannet M. Carmichael3 also shared her vision of the health care world as it would be in 2010, including how “the product focus of pharmacy has become a patient focus” and “nearly all drug information is available to all pharmacists at the touch of a few buttons.” Reflecting on our practice today, we agree that the recognized and respected value of pharmacists in the provision of patient-centered care may certainly play a role in the pursuit of residency and fellowship training.

A Program to Improve Detection of Undiagnosed Dementia in Primary Care and Its Association with Healthcare Utilization

Alzheimer's disease and related dementias are common and costly, with increased healthcare utilization for patients with these disorders. The current study describes a novel dementia detection program for veterans and examines whether program-eligible patients have higher healthcare utilization than age-matched comparison patients. Using a telephone-based case-finding approach, the detection program used risk factors available in the electronic medical record (EMR) and telephone-based brief cognitive screening. Holding illness severity constant, dementia detection and healthcare utilization were compared across age-matched groups with and without program risk factors. Five Veterans Affairs Healthcare Network Upstate New York primary care clinics. Veterans aged 70 years and older. EMR data and the Charlson comorbidity index. Program-eligible patients (n= 5,333) demonstrated significantly greater levels of medical comorbidity relative to comparison patients and were on average more than twice as likely to be admitted to the hospital. They also had nearly double the number of outpatient visits to several services. Similar patterns were seen in those who screened positive on a brief cognitive measure, compared with those who screened negative. A novel program using EMR data to assist in the detection of newly diagnosed dementia in a clinical setting was found to be useful in identifying older veterans with multiple comorbid medical conditions and increased utilization of hospital and clinic services. Results suggest undetected cognitive impairment and dementia may significantly contribute to healthcare utilization and costs of care in older veterans.

P3.058 Utilization of Municipal STD Clinic Services Among the Insured, San Francisco 2011–2: Implications For Health Care Reform in the United States

Limited data exist on the number of insured patients who receive care at publically funded STD clinics, despite having access to a primary care provider. In this analysis, we compare...

Value of Clinical Laboratory Services in Health Care

Introduction Clinical laboratory professionals and the services they provide contribute to maximizing the effective delivery of care in today's complex healthcare system. Appropriate utilization of clinical laboratory services enhances the ability of clinicians to make evidence-based diagnostic and therapeutic decisions for their patients using the optimal level of resources and minimizing overall healthcare expenditures. Clinical laboratory services are the most cost effective, least invasive source of objective health information in disease prevention and diagnosis, improving patient outcomes, assuring patient safety, and fulfilling essential public health surveillance functions. Thus, clinical laboratory professionals and the services they provide are essential in providing care that is safe, effective, patient-centered, timely, efficient, and equitable.

Evaluation of the quality of care of a multi-disciplinary risk factor assessment and management programme (RAMP) for diabetic patients.

BackgroundType 2 Diabetes Mellitus (DM) is a common chronic disease associated with multiple clinical complications. Management guidelines have been established which recommend a risk-stratified approach to managing these patients in primary care. This study aims to evaluate the quality of care (QOC) and effectiveness of a multi-disciplinary risk assessment and management programme (RAMP) for type 2 diabetic patients attending government-funded primary care clinics in Hong Kong. The evaluation will be conducted using a structured and comprehensive evidence-based evaluation framework.Method/designFor evaluation of the quality of care, a longitudinal study will be conducted using the Action Learning and Audit Spiral methodologies to measure whether the pre-set target standards for criteria related to the structure and process of care are achieved. Each participating clinic will be invited to complete a Structure of Care Questionnaire evaluating pre-defined indicators which reflect the setting in which care is delivered, while process of care will be evaluated against the pre-defined indicators in the evaluation framework.Effectiveness of the programme will be evaluated in terms of clinical outcomes, service utilization outcomes, and patient-reported outcomes. A cohort study will be conducted on all eligible diabetic patients who have enrolled into RAMP for more than one year to compare their clinical and public service utilization outcomes of RAMP participants and non-participants. Clinical outcome measures will include HbA1c, blood pressure (both systolic and diastolic), lipids (low-density lipoprotein cholesterol) and future cardiovascular diseases risk prediction; and public health service utilization rate will include general and specialist outpatient, emergency department attendances, and hospital admissions annually within 5 years. For patient-reported outcomes, a total of 550 participants and another 550 non-participants will be followed by telephone to monitor quality of life, patient enablement, global rating of change in health and private health service utilization at baseline, 6, 12, 36 and 60 months.DiscussionThe quality of care and effectiveness of the RAMP in enhancing the health for patients with type 2 diabetes will be determined. Possible areas for quality enhancement will be identified and standards of good practice can be established. The information will be useful in guiding service planning and policy decision making.

Correlates of Higher-Dose Opioid Medication Use for Low Back Pain in Primary Care

Factors associated with high-dose opioid therapy for noncancer pain are poorly understood. We documented the prevalence of high-dose opioid use as well as associated demographic, clinical, and health service utilization correlates among low back pain patients. Patients prescribed higher doses of opioids (≥100 mg/day morphine equivalent at last dispensing; n = 453) and receiving opioids for 90+ consecutive days were compared to 2 groups: lower-dose opioid group (1–99 mg/day; n = 4,815) or no-opioid group (n = 10,184). Higher-dose opioid use occurred in 2.9% of patients who received any opioids and in 8.6% of patients who received opioids long-term. The median dose in the higher-dose group was 180.0 mg/day. Compared to the no-opioid group, higher-dose users reported poorer health. Compared to either comparison group, patients in the higher-dose group had higher rates of mental health and substance use disorders, concurrent sedative-hypnotic use (60.5%; n = 274), and health service utilization. After adjusting for select covariates, male gender (odds ratio [OR] = 1.68, 95% confidence interval [CI] = 1.37–2.06), higher comorbidity, Medicare coverage (OR = 1.65, 95% CI = 1.22–2.23), any mental health or substance use diagnosis (OR = 1.58, 95% CI = 1.28–1.95), co-prescriptions of sedative-hypnotics (OR = 1.75, 95% CI = 1.42–2.16), and more emergency department and specialty pain clinic visits were associated with higher likelihood of high-dose prescriptions. PerspectiveHigher-dose opioid therapy is being prescribed to 8.6% of back pain patients who receive long-term opioids. These patients had higher mental health and medical comorbidities and co-prescriptions of sedative-hypnotics, raising potential safety concerns.

Use of selected ambulatory dental services in Taiwan before and after global budgeting: a longitudinal study to identify trends in hospital and clinic-based services

BackgroundThe Taiwan government adopted National Health Insurance (NHI) in 1995, providing universal health care to all citizens. It was financed by mandatory premium contributions made by employers, employees, and the government. Since then, the government has faced increasing challenges to control NHI expenditures. The aim of this study was to determine trends in the provision of dental services in Taiwan after the implementation of global budgeting in 1998 and to identify areas of possible concern.MethodsThis longitudinal before/after study was based on data from the National Health Insurance Research Database from 1996 to 2001. These data were subjected to logistic regression analysis. Linear regression analysis was used to examine changes in delivery of specific services after global budgeting implementation. Utilization of hospital and clinic services was compared.ResultsReimbursement for dental services increased significantly while the number of visits per patient remained steady in both hospitals and clinics. In hospitals, visits for root canal procedures, ionomer restoration, tooth extraction and tooth scaling increased significantly. In dental clinics, visits for amalgam restoration decreased significantly while those for ionomer restoration, tooth extraction, and tooth scaling increased significantly. After the adoption of global budgeting, expenditures for dental services increased dramatically while the number of visits per patient did not, indicating a possible shift in patients to hospital facilities that received additional National Health Insurance funding.ConclusionsThe identified trends indicate increased utilization of dental services and uneven distribution of care and dentists. These trends may be compromising the quality of dental care delivered in Taiwan.

Limited physical therapy utilization protocol does not affect impairment and disability in Workers' Compensation patients after rotator cuff repair: a short-term follow-up study

Treatment of rotator cuff tears in injured workers is associated with poorer outcomes and abnormally high utilization of clinical services. This study evaluates the effect on impairment and disability rates after the implementation of an accelerated independent rehabilitation protocol on injured workers undergoing mini-open rotator cuff repair. Seventy-one primary rotator cuff repairs in injured workers were reviewed at least 1 year after claim closure. Outcomes based on permanent partial disability and impairment were compared among 28 patients using traditional outpatient physical therapy (group A) and 43 patients using an accelerated protocol-driven independent exercise program (group B). The number of physical therapy visits attended, disability, and impairment rates were compared between the 2 groups. Group B used a median of 16 physical therapy visits, which were 9 fewer visits per patient than group A (P < .001). This constituted a 36% reduction in the median number of physical therapy visits without negatively affecting disability and impairment rates. The difference between the 2 groups in time to release to work or time to claim closure was not significant. The implementation of an accelerated, independent, exercise protocol reduced physical therapy utilization to levels below national best-practices benchmarks without negatively affecting impairment or disability rates in Workers' Compensation patients undergoing mini-open rotator cuff repair. Level IV, Retrospective Case Series, Prognostic Study.

Clinical needs of patients referred early to supportive and palliative care.

9065 Background: Palliative care is evolving from delivering care to patients at the end-of-life to those earlier in the disease trajectory. We evaluated the differences in clinical characteristics, symptoms burdens, and service utilization between traditional palliative care patients (late referrals, LR) and the new patients group who are in earlier in their course of disease (early referrals, ER). Methods: We reviewed consecutive cancer patients referred to the Supportive Care Clinic with follow up visit within 30 days between August 2008 and October 2010. Patients were divided into two groups: ER (defined as patients with expected survival ≥ 2 years or receiving treatment for curative intent) and LR (all others). We compared clinical characteristics, symptoms and service utilization between both groups using chi-square test and Wilcoxon rank sum test. Results: 58% (695/1208) patients had a 2nd visit within 30 days. Among them, 100 patients were classified as ER (14.4%) and 100/595 LR were randomly selected as the comparison group. ER patients were younger (median age 54 years vs 60 years, p=0.009), more likely to have head and neck cancer (67% vs 6%, p&lt;0.001) and to have a shorter interval between cancer diagnosis and palliative care consultation (3.8 m vs 16.2 m, &lt;0.001). ER patients were also more likely to be CAGE positive (15% vs 4%, p=.014), referred from radiation oncology (49% vs 3%, p&lt;0.001), referred for treatment related side effects (70% vs 9%, p&lt;0.001), and receiving active anti-cancer treatment at the time of consultation (74% vs 48%, p=0.0002). Baseline symptoms (Edmonton Symptom Assessment Scale) were similar between ER and LR except for insomnia (1.8 vs 2, p=0.004). LR patients experienced greater improvement in the symptom distress score (-5.5 vs -3, p=0.007). Overall median number of medical visits was 24 for ER vs 10.5 for LR (p&lt;0.001); however, median visit per month was 4.3 for LR and 2.1 for ER (p&lt;0.001). Conclusions: ER was associated with different patient characteristics; patients have similar distress but different needs and outcomes as compared to traditional LR patients.

Identification of trauma exposure and PTSD in adolescent psychiatric inpatients: An exploratory study

Trauma exposure and posttraumatic stress disorder (PTSD), though prevalent among adolescent psychiatric inpatients, are underidentified in standard clinical practice. In a retrospective chart review of 140 adolescents admitted to a psychiatric inpatient unit, we examined associations between probable PTSD identified through the Child PTSD Symptom Scale and adolescents' service use and clinical characteristics. Results suggest a large discrepancy between rates of probable PTSD identified through standardized assessment and during the emergency room psychiatric evaluation (28.6% vs. 2.2%). Adolescents with probable PTSD had greater clinical severity and service utilization, an increased likelihood of being diagnosed with bipolar disorder (27.5% vs. 9.2%) and being prescribed antipsychotic medications (47.5% vs. 27.6%), and were prescribed more psychotropic medications. Upon discharge, those with probable PTSD were more than those without to be assigned a diagnosis of PTSD (45% vs. 7.1%), a comorbid diagnosis of major depressive disorder (30% vs. 14.3%), to be prescribed an antidepressant medication (52.5% vs. 33.7%), and to be prescribed more medications. The underidentification of trauma exposure and PTSD has important implications for the care of adolescents given that accurate diagnosis is a prerequisite for providing effective care. Improved methods for identifying trauma-related problems in standard clinical practice are needed.

Disability, Impairment, and Physical Therapy Utilization After Arthroscopic Partial Meniscectomy in Patients Receiving Workers’ Compensation

The treatment of meniscal tears in injured workers is associated with less favorable outcomes and higher utilization of clinical services. It was hypothesized that patients receiving Workers' Compensation who undergo arthroscopic meniscectomy can have excellent outcomes with physical therapy utilization below the national best-practices benchmarks. The records of 155 injured workers who had undergone 164 primary arthroscopic meniscectomies were reviewed at least one year following claim closure. The time to release to unrestricted full work duty and the number of postoperative physical therapy visits were compared between the study group (managed with a protocol-driven, independent exercise program) and the control group (managed with traditional outpatient physical therapy). The traditional therapy regimen was implemented by means of a written referral stating general goals (knee range of motion, strength, and function) and recommending a range or a maximum number of visits to be attended. Patients in the study group received a written referral specifying the exact number of visits that were approved, a kit containing exercise equipment with a booklet illustrating twenty-five exercises, and a prescribed rehabilitation protocol outlining the philosophy, expected subjective and functional outcomes, and specific objective weekly goals. The median number of physical therapy visits per patient was 40% lower in the study group than in the control group (six compared with ten; p < 0.001). There was no difference between the study group and the control group with regard to the permanent partial disability rate (0% compared with 4.3%; p = 0.076). Following arthroscopic meniscectomy, there was no significant difference between the study group and the control group in terms of the time to release to light duty, the time to release to full duty, the time to claim closure, or the rate of impairment. The implementation of a structured, independent exercise protocol appears promising as a method to reduce physical therapy utilization to levels below the national best-practices benchmarks without negatively impacting impairment and disability rates for patients receiving Workers' Compensation who undergo arthroscopic meniscectomy.

After-hours Access of Convenient Care Clinics and Cost Savings Associated With Avoidance of Higher-Cost Sites of Care

This study examines the utilization of convenient care clinic services outside of typical physician office hours and estimates the cost savings from potentially avoided visits to the emergency room, urgent care center, and primary care physician associated with convenient care clinic encounters. The results show that 44.6% of convenient care clinic visits occurred on weekdays, 5 pm or later, or on weekends. Savings from avoided encounters with the emergency room, urgent care, and primary care physician were estimated at $135.53 million.

The Effect of Imaging on the Clinical Management of Breast Pain

Breast pain is a common complaint to primary care and breast specialists. Literature recommends imaging to provide reassurance of benign etiology. The effect of imaging on reassurance and subsequent healthcare utilization has not been described. To determine if initial imaging for breast pain reduces subsequent utilization. Retrospective cohort study at a hospital-based breast health practice. Women referred for breast pain from 2006-2009. Imaging ordered at initial provider visit; clinical utilization, defined as the number of follow-up visits, diagnostic imaging studies, and biopsies completed within 12 months following initial visit. Sixty-percent of women were age 40 or younger, 87% were from racial/ethnic minority groups. Twenty-five percent had imaging ordered at initial visit. Of those who received initial imaging, 75% had normal radiographic findings, yet 98% returned for additional evaluation. In adjusted analyses, women with initial imaging had increased clinical services utilization (OR 25.4, 95% CI: 16.7, 38.6). Women with normal clinical breast exams who received initial imaging exhibited increased odds for subsequent clinical services utilization (OR 23.8, 95% CI: 12.9, 44.0). Six cancers were diagnosed; imaging in the absence of clinical breast exam abnormalities did not result in any cancer identification. Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase reassurance in ruling out malignancy.

Developing a Modified Directly Observed Therapy Intervention for Hepatitis C Treatment in a Methadone Maintenance Program: Implications for Program Replication

Background: Hepatitis C virus (HCV) is a prevalent chronic blood-borne infection among opioid-dependent patients on methadone maintenance treatment (MMT). Despite case reports and case–control studies, a randomized controlled trial (RCT) examining HCV treatment adherence in methadone-maintained patients is lacking and was the impetus for this ongoing RCT examining modified directly administered therapy for HCV treatment integrated within a MMT. Methods: Subjects were randomized 1:1 to receive HCV treatment as modified directly observed therapy (mDOT) into the MMT program or at a liver specialty clinic as self-administered therapy (SAT). Randomization was stratified based on HIV status and HCV genotype. Results: Twenty-one subjects to date have enrolled in this pilot study. The mDOT subjects have had greater success in starting treatment and 10 of the 12 mDOT subjects achieved early virologic response (EVR) at week 12 and 6 of those 10 achieved sustained virologic response (SVR). Of the nine SAT subjects, only three achieved EVR at week 12 and only one achieved SVR despite not completing the treatment. Conclusions: Hepatitis C treatment can be successfully integrated into a methadone maintenance clinic, and mDOT can be implemented with a methadone clinic’s existing nursing and medical staff. Patients struggling with concurrent substance use and mental illness comorbidity may be successfully addressed in such settings and facilitate access to and completion of treatment through the utilization of on-site clinical services for HCV treatment and adherence support with mDOT. The exact importance of site of services and adherence support remains a significant area for future investigation.

Initial assessment of scaled-up sexually transmitted infection intervention in Himachal Pradesh under National AIDS Control Program - III

To assess the impact of scaled-up sexually transmitted infection (STI) intervention under National AIDS Control Program (NACP) III and to examine the profile of STI/RTI clinic (now named Suraksha Clinic) attendees. A retrospective study by data analysis was done from April 2008 to March 2010. The scaled-up intervention comprised of (i) adopting enhanced syndromic approach, (ii) capacity building by appointing counselors and trainings of staff, (iii) strengthening STI/RTI clinics by provision of logistics and privacy by civil works, and (iv) supervisory support. The outcome which directly influenced service delivery was evaluated within this framework. Sixteen "Suraksha Clinics" have been remodeled, equipped with supplies and laboratory set up. A total of 64,554 clinic visits were reported of which 27,317 [42%] attended the clinics for index STI/RTI complaint(s). Majority of the clients (44%) were young, 25-44 years old. Male to female ratio was 1:1.8. In females, the commonest complaint was lower abdominal pain (25%) and vaginal discharge (33%), the commonest syndrome. Amongst laboratory-confirmed STIs, 305 (1.4%) attendees were positive for trichomoniasis, while bacterial vaginosis was corroborated in 230 (1.07%) patients with clue cells. Amongst antenatal women, 251 were reactive for syphilis (≥1:8 dilutions). 10,579 partners of index STI/RTI patients were notified and partner management was attained to the level of 99%. Preliminary results show increased utilization of STI clinical services, though laboratory services need further strengthening. Continued supportive supervision and capacity building will enable skill development and quality monitoring.

Initial assessment of scaled-up sexually transmitted infection intervention in Himachal Pradesh under National AIDS Control Program – III

Objectives:To assess the impact of scaled-up sexually transmitted infection (STI) intervention under National AIDS Control Program (NACP) III and to examine the profile of STI/RTI clinic (now named Suraksha Clinic) attendees.Materials and Methods:A retrospective study by data analysis was done from April 2008 to March 2010. The scaled-up intervention comprised of (i) adopting enhanced syndromic approach, (ii) capacity building by appointing counselors and trainings of staff, (iii) strengthening STI/RTI clinics by provision of logistics and privacy by civil works, and (iv) supervisory support. The outcome which directly influenced service delivery was evaluated within this framework.Results:Sixteen “Suraksha Clinics” have been remodeled, equipped with supplies and laboratory set up. A total of 64,554 clinic visits were reported of which 27,317 [42%] attended the clinics for index STI/RTI complaint(s). Majority of the clients (44%) were young, 25–44 years old. Male to female ratio was 1:1.8. In females, the commonest complaint was lower abdominal pain (25%) and vaginal discharge (33%), the commonest syndrome. Amongst laboratory-confirmed STIs, 305 (1.4%) attendees were positive for trichomoniasis, while bacterial vaginosis was corroborated in 230 (1.07%) patients with clue cells. Amongst antenatal women, 251 were reactive for syphilis (≥1:8 dilutions). 10,579 partners of index STI/RTI patients were notified and partner management was attained to the level of 99%.Conclusion:Preliminary results show increased utilization of STI clinical services, though laboratory services need further strengthening. Continued supportive supervision and capacity building will enable skill development and quality monitoring.

Abstract B87: The effect of imaging on clinical management of breast pain

Abstract Breast pain is a common complaint to both primary care and breast specialists. Current literature recommends imaging for women with breast pain to provide reassurance of benign etiology. The current study sought to determine if imaging is a valuable tool in providing reassurance for women with breast pain, through measuring the association between initial imaging in the evaluation of women with breast pain and subsequent clinical services utilization From 2006–2009, 916 women were referred to an urban, Safety Net, diagnostic breast health practice for breast pain. We compared the subsequent clinical utilization of women who had imaging ordered at their initial visit to women who did not have imaging ordered. Clinical utilization was defined as the number of follow-up visits, diagnostic imaging studies, and biopsies completed within the 12 months following the initial provider visit. The study population was stratified based on the presence or absence of clinical breast exam findings. Sixty-percent of women referred for breast pain were age 40 or younger, 87% were from racial/ethnic minority groups, 45% were non-English speaking, and 73% had public or no health insurance. Twenty five percent of women had imaging ordered at initial provider visit for breast pain. Minority and non-English speaking women were less likely to receive initial imaging. Of those who received initial imaging, 75% had radiographic findings which required no additional follow-up, yet 98% returned for additional evaluation. In adjusted analyses, women with imaging ordered at initial provider visit had increased clinical services utilization (OR 25.4, 95% CI: 16.7, 38.6). When the study population was stratified by clinical breast exam results, the risk-adjusted association between initial imaging and subsequent clinical services utilization remained. Women with normal clinical breast exams who received initial imaging exhibited increased odds for subsequent clinical services utilization (OR 23.8, 95% CI: 12.9, 44.0) than women who did not initial imaging. Six cancers were diagnosed in the study population; yet imaging in the absence of clinical breast exam abnormalities did not result in any cancer identification. Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase diagnostic certainty in ruling out malignancy. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B87.