Periodic Visits Research Articles

Transition cow nutrition and management strategies of dairy herds in the northeastern United States: Part III—Associations of management and dietary factors with analytes, health, milk yield, and reproduction

The objective was to evaluate relationships between putative periparturient management and dietary factors at the pen and herd levels with metabolic- and inflammation-related analytes, health disorders, milk yield, and reproductive performance. Multiparous and primiparous cows from 72 farms in the northeastern United States were enrolled in a prospective cohort study. Farms were visited 3 times during the prepartum and postpartum periods: during the far-off dry, close-up dry, and fresh periods. Pen measurements were taken at each visit for the pens where cows sampled were housed, and particle size was determined for the total mixed ration for the pen. A survey was used to acquire data on herd-level management variables. Blood samples were collected from the same 11 to 24 cows per farm during the close-up and fresh period visits. Whole blood was analyzed for postpartum β-hydroxybutyrate (BHB) concentrations, and plasma was analyzed for prepartum and postpartum nonesterified fatty acids (NEFA) and postpartum haptoglobin (Hp) concentrations. Health event, milk yield, and reproductive records were acquired through the records management software program used on the farm. For the pen-level analysis, primiparous and multiparous cows were analyzed separately. For the pen- and herd-level analysis, a simple linear regression was conducted on all possible explanatory variables. Variables were included in the full multivariable general linear model if P < 0.20, and a manual backward stepwise elimination process ensued until all variables had P < 0.10. Our results indicate that pen- and herd-level management factors are associated with blood biomarkers, health, milk yield, and reproductive performance. For the prepartum period, our results support increasing the proportion of particles on the 19-mm sieve of the Penn State Particle Separator, optimizing bunk space, and not overfeeding metabolizable energy (ME), to decrease the prevalence of elevated postpartum NEFA, BHB, and Hp concentrations, decrease disorder incidence, maximize milk yield, and improve pregnancy risk to first service. For the fresh period, our results generally support optimizing bunk space, avoiding commingling, increasing feeding frequency, avoiding high physically effective undigested neutral detergent fiber (NDF) after 240 h of in vitro fermentation and high total fermentable carbohydrate diets while optimizing the inclusion of forage NDF, and ensuring adequate diet ME and metabolizable protein to reduce the prevalence of elevated postpartum NEFA, BHB, and Hp concentrations, minimize disorder incidence, maximize milk yield, and improve pregnancy risk to first service. At the herd level, our results generally support not vaccinating in the calving pen, minimizing the number of prepartum and postpartum pen moves, and avoiding long stays in the calving pen after parturition to reduce the prevalence of elevated biomarker concentrations, decrease disorder incidence, increase milk yield, and improve reproductive performance.

1077 THE ROLE OF MILITARY NURSE IN THE CARDIAC AMBULATORY OF MILITARY HOSPITAL IN MILAN

Abstract Military nurses have a fundamental role in taking care of all military personnel, both in preventive medicine and direct health care, to be effective and competent during his duty, both in national settings and in operations abroad. The military nursing, in a cardiac ambulatory setting, aim to guarantee, collaborating with the cardiologist medical officer, the fitness for military service, i.e. the possession of physical and psycho-attitudinal requirements needed to carry out military service that requires specific and dynamic efforts that could solicit determined organs or body systems. Among the different visits that the military personnel have to attend, the cardiac ambulatory is specialized in: Personnel selection for volunteers recruitment;Evaluation for those soldiers that suffered from cardiovascular diseases that has to be visited by Military Legal Medical Facilities;Medical periodic visits for military personnel on duty to check the maintenance of psycho-physical requirements;Medical visits for military personnel ready to be deployed in missions abroad or that are just coming from them;Definition of diagnostic protocol and evaluation of those soldiers that suffered from cardiovascular disease. In details, the main specific competences of the military nurse in a cardiology ambulatory are: assessment of cardiovascular health (cardiac anamnesis and physical evaluation), diagnostic exams procedures (ECG, supporting in sonography examination, positioning and management of Holter for blood pressure and ECG, cardiopulmonary test), evaluation of medication prescription per cardiovascular disease (antihypertensives, antiplatelet agents, antithrombotic, thrombolytics, antiarrhythmics, with focus on the initiation of therapy, mode of action and interactions). The military nurse in cardiovascular ambulatory, in addition to the many activities, typical of being a warrant officer deployable in national activities or in operations abroad, must acquire competences and knowledge specific for cardiac setting, through basic training courses, continuous medical education, ensuring a constant synergy with all the équipe members, even at international level, also acting independently in all those complex situations that may arise to meet patients’ needs.

Challenges for Management of Dilated Cardiomyopathy during COVID-19 Pandemic-A Telemedicine Application.

The 2019 coronavirus pandemic (COVID-19) represented a significant challenge for the medical community. The first aim of this study was to examine the COVID-19 impact on the follow-up of patients with dilated cardiomyopathy (DCM) and to establish the advantages of multiparametric home monitoring. Also, we tried to establish the main prognostic predictors at 2-years follow-up and the value of LV diastolic filling pattern (LVDFP) in increasing mortality and morbidity. We conducted a prospective study of 142 patients with DCM assessed by in-patient visit in the pre-pandemic period and hybrid (face-to-face, online consultation and telemedicine home monitoring with a dedicated application) during the pandemic period. The statistical analysis compared the strategy used in the pre-pandemic with management during the pandemic, in terms of clinical assessment, hospitalizations/emergency room visits due to HF exacerbation and total mortality. We did not observe significant changes in blood pressure (BP), heart rate (FC), weight and symptoms or an increased rate of adverse drug events between the two periods. We successfully titrated HF medications with close monitoring of HF decompensations, which were similar in number, but were mostly managed at home during the pandemic. There was also no statistically significant difference in emergency room visits due to severe decompensated HF. Mortality in the first and second year of follow-up was between 12.0 and 13%, similar in the pre-pandemic and pandemic periods, but significantly higher in patients with restrictive LVDFP. Clinical improvement or stability after 2 years was more frequent in patients with nonrestrictive LVDFP. The main prognostic predictors at 1 and 2-years follow-up were: the restrictive LVDFP, significantly dilated LV, comorbidities (DM, COPD), older age, associated severe mitral regurgitation and pulmonary hypertension. The pandemic restrictions determined a marked decrease of the healthcare use, but no significant change in the clinical status of DCM patients under multiparametric home monitoring. At 2-years follow-up, the presence of the restrictive LVDFP was associated with an increased risk of death and with a worse clinical status in DCM patients.

Telehealth for Assessing and Managing Tardive Dyskinesia: Expert Insights from a Cross-Disciplinary Virtual Treatment Panel.

Introduction: Publications on the integration of telehealth in the care of patients with movement disorders are increasing, but little has been presented regarding its use in tardive dyskinesia (TD), a drug-induced movement disorder associated with prolonged exposure to dopamine receptor blocking agents. This study was conducted to address that knowledge gap, based on insights from a panel of TD experts. Methods: In 2020, six neurologists, three psychiatrists, and three psychiatric nurse practitioners participated in individual semistructured interviews about in-person and virtual TD assessment and management in their practices. Two virtual roundtables were then conducted to consolidate findings from these interviews. Results: The panel agreed that despite the challenges of virtual TD assessment (e.g., technology issues, difficulty observing entire body, inability to conduct thorough neurological examinations), telehealth can offer benefits (e.g., fewer missed appointments, reduced time/cost, easier access to family/caregiver feedback). The panel also agreed that telehealth should be combined with periodic in-person visits, and they recommended an in-person TD assessment within 6 months before the first virtual visit and at least one in-person assessment every 6 months thereafter. Additional best practices for TD telehealth included implementing video, involving family/caregivers, and providing preappointment instructions to help patients prepare their technology and environment. Conclusions: Telehealth is not a substitute for in-person visits but can be a helpful complement to in-person clinical care. Clinicians can optimize virtual visits in patients at risk of TD by using targeted questions to identify TD and evaluate its impact and by providing education about approved TD treatments.

EXPLORATION OF DISTRICT-LEVEL INNOVATIONS TO ADDRESS MATERNAL AND NEONATAL MORTALITY IN INDONESIA

Background: The Indonesian maternal and neonatal mortality rates remain some of the highest in Southeast Asia. Aims: This study aims to assess and compare district-level innovations that address maternal and neonatal mortality. Methods: This was a qualitative study conducted via four focus group discussions in eight selected districts in November 2021. Data obtained were analyzed using the WHO health system building blocks framework. Results: The study found high variation in districts’ innovations ranging from expansion of service for maternity waiting homes to periodical obstetrician visits at Puskesmas. A majority of districts use a local approach as the basis for innovation. Some innovations are modifications of the national program or initiated purely by District Health Offices, Puskesmas, and the community. Many interventions are based on multisectoral commitment, community participation, and targeting to strengthen health service delivery. Leadership and health financing also have an influence on the implementation of these innovations. Conclusion: The multitude of innovations reflects a high variation in barriers to reducing maternal and neonatal mortality that need to be addressed at the district level. A routine forum to share districts’ best practices is warranted. Additionally, family-based surveillance for neonatal danger signs, monitoring for pregnant women and neonates via WhatsApp, and zoning systems for referrals to healthcare facilities in larger districts are innovations identified in this study that have potential to be replicated in other districts or expanded nationally.

Reducing 48-h emergency department revisits and subsequent admissions: a retrospective study of increased emergency medicine resident floor coverage

BackgroundEarly unexpected hospital admission after emergency department (ED) discharge is an important topic regarding effective preventive measures. Reducing avoidable return visits can improve ED effectiveness and emergency care. This study evaluated the effects of an increase in the number of physicians and the 24-h coverage of emergency physicians on 48-h ED revisits with subsequent hospital admission. The characteristics and risk factors of the patients were also investigated.ResultsThis was a retrospective analysis performed 2 years before and 2 years after the implementation of an intervention in a tertiary care hospital in Thailand. The medical records of adult patients who revisited the ED within 48 h for related complaints were reviewed. The effect of the intervention was analyzed, and a prediction model was developed based on logistic regression.After implementing the intervention, the hospital admission rate at the second ED visit decreased from 44.5 to 41.1%; no significant difference was found (95% confidence interval (CI) − 5.05 to 11.78). Patients who required hospital admission had a significantly higher comorbidity score, more ED visits, and more hospitalizations within the past 12 months. A significantly higher hospital admission rate was also observed among patients older than 60 years, those who had an initial infectious diagnosis, and those who had a higher triage severity level (ESI II) at their first visit. The odds ratio (OR) showed lower odds of hospital admission at the second visit in the postintervention period; this difference was not significant (OR 0.87; 95% CI 0.61 to 1.23).ConclusionOur intervention did not significantly decrease the incidence of admission at an ED revisit. However, some factors identified in this study seem to have some benefits and might be helpful for preventing errors and constructing a standard discharge care plan for patients with these risk factors.

Towards a telehealth infrastructure supported by machine learning on edge/fog for Parkinson's movement screening

Approximately 10 million people worldwide live with Parkinson's disease (PD), a progressive and incurable neurological movement disorder. Symptomatic treatment is available for PD but requires patients to make periodic clinic visits (2–3 times per year) for symptom assessment. Advanced telehealth technologies can enhance clinical care for PD but warrant an Internet-of-Things-based (IoT) infrastructure that can enable symptom monitoring in out-of-clinic settings, such as homes. In this paper, we present an edge and Fog device-based IoT framework and a machine learning-based telehealth infrastructure that can detect and classify hand movement tasks based on a clinical test (UPDRS) for remote symptom assessment. We used a pair of smart gloves integrated with finger flex sensors, an inertial measurement unit (IMU), and a wireless embedded system (i.e., an edge device) to record the hand movements. The edge device (ESP32) detected the activity on the edge node and transmitted the data to the Fog node for classification. The Fog node (Raspberry pi) hosted the Machine Learning (ML) based activity classification models to classify UPDRS-based hand movement tasks. In this paper, we present the development of edge-fog-supported ML infrastructure. To develop ML models, we utilized the data of 9 participants (five healthy and four people with PD) who performed hand movements tasks while wearing the smart gloves. We developed and tested different classification models such as K-nearest neighbors (KNN), Support Vector Machine (SVM), and Decision Tree (DT) to identify which one fits best for such an edge-fog infrastructure for remote symptom assessment. Results showed that the SVM model outperformed others by giving 94% training, 94% testing, and 93% validation accuracy with a mean inference time of 560 μs on the Fog node. Our preliminary results are promising to further our research in deploying the edge-fog-driven ML-based telehealth infrastructure in real-world settings. • Development of Edge-Fog-supported telehealth IoT infrastructure. • Development and assessment of Machine Learning classifiers for hand movement activity classification. • Deployment and evaluation of the ML classification models on the Fog infrastructure. • Demonstration of how an edge-fog computing architecture can be useful for telehealth applications, including movement assessment, symptom tracking, and symptom management.

Treatment utilization and modality preference among veterans receiving outpatient substance use disorder treatment during a pandemic.

This study examines substance use disorder (SUD) treatment utilization patterns in response to a pandemic. Retrospective electronic medical record data were collected during three time periods (N = 390): "Pre-COVID-19" (12/02/2019-03/14/2020), "COVID-19" (03/15/2020-06/30/2020), and COVID-19 "Re-entry" (7/01/2020-10/01/2020). Number of visits in each time period, SUD diagnosis, treatment modality (video, telephone, none), demographic, and clinical variables were examined. One-way analyses of variance (ANOVA) and chi-square analyses tested the relationships between treatment modality, demographics, clinical variables, and psychiatric emergency room (PER) visits. Binary logistic regressions examined the effect of treatment modality on PER use during COVID-19 and Re-entry, controlling for alcohol, opioid, and cocaine use disorders, age, and past-year (pre-COVID-19) PER use. Treatment modality was associated with SUD (alcohol, cocaine, opioids), age, and PER visits. Veterans who primarily attended telephone appointments were more likely to require PER services compared to those attending video appointments. In the full model, alcohol use disorder (AUD), past-year PER visits, and treatment modality (telephone visits) continued to be significantly associated with COVID-19 PER use, while past-year PER visits correlated with Re-entry PER use. During COVID-19, veterans whose main treatment modality was telephone were more likely to require PER services than veterans who were seen by video, even after controlling for age, AUD, opioid use disorder, and past-year PER visits. This study is the first to have examined SUD treatment modality utilization patterns in response to COVID-19. Findings suggest that treatment modality during the initial phase of COVID-19 correlated with PER presentation.

How regularly do people visit service places?

It is often believed that regularities are embedded in mobile behaviors. Highly regular mobile behaviors, such as daily commutes between home and workplace, have been actively investigated in the context of health risks. Less regular mobile behaviors, such as visits to service places (e.g., supermarkets and healthcare facilities), have not received much attention. This study explores the regularity in service place visits using a deep learning method and the effect of place type on the stability of recurring visits using an entropy assessment.Results reveal both periodic and bursty visit behaviors to service places. The periodic visits are prominent on the weekly and bi-weekly scales, and the bursty visits dominate the multi-day scales. Service place type indeed affects the stability of recurring visits, and certain place types have the strongest effect. The research findings substantially expand the knowledge of mobile behaviors and are valuable in informing both visitor-based and place-based health risks.

Naloxone Prescribing Associated With Reduced Emergency Department Visits in the Military Health System.

The aim was to determine the association between the receipt of naloxone and emergency department (ED) visits within 60 days after the receipt of an opioid. A retrospective cohort of individuals 18 years of age or above, enrolled in TRICARE, and were dispensed an opioid at any time from January 1, 2019, through September 30, 2020 was identified within the United States Military Health System. Individuals receiving naloxone within 5 days of the opioid dispensing date were propensity score matched with individuals receiving opioids only. A logistic regression was used to estimate the odds of an ED visit in the 60-day follow-up period after the index opioid dispense event among those co-dispensed naloxone and those receiving opioids only. Of the 2,136,717 individuals who received an opioid prescription during the study period, 800,071 (10.1%) met study inclusion criteria. Overall, 5096 (0.24%) of individuals who received an opioid prescription were co-dispensed naloxone. Following propensity score matching, those who received naloxone had a significantly lower odds of ED utilization in the 60 days after receiving an opioid prescription (odds ratio: 0.74, 95% CI: 0.68-0.80, P&lt;0.001). This study highlights the importance of expanding access to naloxone in order to reduce ED utilization. Future research is needed to examine additional outcomes related to naloxone receipt and develop programs that make naloxone prescribing a routine practice.

Investigation of Complaints Received from Affiliated Centres in the Treatment Supervision Department of the Iran University of Medical Sciences in 2020

Background: Complaints are expressions of dissatisfaction that need to be addressed and are a very effective tool for improving the quality of care and treatment services. This study was conducted to investigate the complaints received in 2020 in the treatment supervision department of the Iran University of Medical Sciences.&#x0D; Methods: The present study is a retrospective descriptive study. All registered complaints, including written, oral and telephone, were reviewed by the complaints officer of the treatment supervision office in 2020. The data obtained from the review of complaints provided by clients of affiliated centres, including personal information of the complainant, the complainant was classified in an Excel file and analyzed by using descriptive statisticsSuch as number and percentage.&#x0D; Results: Of the total number of complaints received in 2020 with 2121, the cases included complaints about the provision of care and medical services 809cases, tariff 301 cases, health and infection control 222 cases, the activity of unauthorized persons 194 cases, visit services 125 cases, defects, respectively, Technical equipment 76 cases, lack of licenses 76 cases, admission and clearance services 69 cases, induced demand 66 cases, drugs 64 cases, how to deal 63 cases, center closure and non-service 20 cases, forgery and misuse 18 cases, illegal advertising 10 cases, manpower shortage 8 cases.&#x0D; Conclusion: It seems that by identifying the effective factors in the occurrence of complaints and dissatisfaction and adopting solutions regarding Training in improving behavioural, communication and professional skills, periodic monitoring visits, reporting functional deficiencies to affiliated centres to correct and eliminate deficiencies, can be done to satisfy and prevent dissatisfaction so that the patient and with a pleasant memory of the process if necessary, refer others to the mentioned centre if necessary.

Vaccination process evaluation at COVID-19 vaccination centers in Lebanon: a national study

BackgroundUpon the authorization of COVID-19 vaccines worldwide, national and international standards were developed to help integrate mass COVID-19 immunization campaigns into the healthcare network. The primary objective is to evaluate the overall COVID-19 vaccination process through on-site visits to vaccination centers all over Lebanon to assess whether these are abiding by the national and international requirements for both Pfizer-BioNTech and AstraZeneca vaccines. The secondary objective is to explore whether the type of the facility, private versus governmental, and educational versus non-education, affects the vaccination process in these centers.MethodsA convenient sample of 33 vaccination centers was selected from a list of all COVID-19 vaccination centers operating in Lebanon. Data were collected using a structured checklist developed following an extensive literature review of the national and international standards for Pfizer-BioNTech and AstraZeneca COVID-19 vaccines. A scoring system for the overall vaccination process was developed.ResultsQuality deficiencies were identified in several steps of the immunization process; however, the international standards were followed in most vaccination centers visited despite their limited resources. It was noticed that there were no significant differences between private and governmental, between educational and non-educational, and between Pfizer and AstraZeneca vaccination centers; the 33 vaccination centers visited have scored above 75 on the entire process immunization against COVID-19 with P-values above 0.05 in all steps evaluated.ConclusionAn optimization of the immunization process should be performed to ensure that the practice is within international standards. This can be done by conducting periodic vaccination center visits, implementing clear guidelines, training staff involved in the vaccination process, and ensuring continuous support of the Lebanese Ministry of Public Health.

Occurrence of algal stem blotch in ber (Ziziphus mauritiana) under coastal Odisha conditions in India

The investigation was carried out during 2017-18 to identify and document the emerging diseases of Indian Jujube or ber (Ziziphus mauritiana Lamk.) in Odisha state located in Eastern part of India. Periodical visit and subsequent investigations revealed the occurrence of a new kind of stem blotch disease in ber caused by alga. Symptoms were observed on bark of the stem and branches as bright red velvety blotch colonies during July- September 2017. However dull grey blotches were visible throughout the year. Leaves and fruits were left unaffected. The algal stem blotch occurrence was assessed during the year 2018 and disease severity rangedfrom 9.4-14.8 per cent. The green alga was identified and confirmed as Trentepohlia arborum (Agardh) Hariot based on key morphological characters. The stem blotches lead to death of young twigs measured between 3 to 8 mm thickness on primary and secondary branches wherein thickness of branches was more than 10 mm, algal blotches caused cracking of bark. Present study highlights the causal agent of stem blotch of ber, its symptomatology, impact of disease and suggested management practices.

Exploring the Need for Mobile Application in Stroke Management by Informal Caregivers: A Qualitative Study.

Background: Mobile health (mHealth) has been considered as a prominent concept in digital health and is widely used and easily accessible. Periodic follow-up visits, previously planned procedures, and rehabilitation services for stroke survivors have been cut down during the recent COVID-19 pandemic. Therefore, in this qualitative study we aimed to explore the need for a mobile application in stroke management by informal caregivers. Methods: A phenomenological qualitative study was conducted from November 2020 to June 2021. Thirteen respondents were recruited from two public rehabilitation centers in Kota Bharu, Kelantan, Malaysia. In-depth interviews were conducted. A comprehensive representation of perspectives from the respondents was achieved through purposive sampling. The interviews were conducted in the Kelantanese dialect, recorded, transcribed, and analyzed by using thematic analysis. Results: Thirteen participants were involved in the interviews. All of them agreed with the need for a mobile application in stroke management. They believed the future stroke application will help them to seek information, continuous stroke home care, and help in the welfare of caregivers and stroke patients. Conclusions: The current study revealed two themes with respective subthemes that were identified, namely, self-seeking for information and reasons for using a stroke mobile application in the future. This application helps in reducing healthcare costs, enhancing the rehabilitation process, facilitating patient engagement in decision making, and the continuous monitoring of patient health.

Follow-up of first permanent molar restorative treatment with and without Molar Hypomineralization.

Hypomineralization (MH) are controversial. The aim of this study was to compare need for treatment and status of restorations performed on first permanent molars in patients with and without MH. Retrospective design based on the clinical records of 153 patients who had received comprehensive care in 2014 at the Clinic of the Children's Comprehensive Dentistry Department (FOUBA) by 3 pediatric dentists (Kappa MH 0.94), and who attended periodical follow-up visits for at least 24 months. Need for treatment in first molars, and type and longevity of treatment were recorded (modified Ryge criteria /USPHS, Kappa 0.78). Results were compared between patients with MH and without MH. The Kruskal Wallis test was used to compare follow-up time, the asymptotic test was performed to compare proportions, and relative risk (RR) was calculated to compare need for treatment. Mean follow-up times for the 595 teeth analyzed were 61.7±20.1 months for Group without MH, and 57.5±23.9 months for Group with MH (p=0.0504). The percentages of teeth requiring at least one treatment were 7.2% in Group without MH and 27.5% in Group with MH (RR = 3.80, p <0.001). Of the teeth treated in Group with MH 23.1% required retreatment, while none of the teeth in Group without MH did. The need for treatment was approximately 4 times higher in molars affected with MH, with greater probability of retreatment.

Does epilepsy always indicate worse outcomes? A longitudinal follow-up analysis of 485 glioma patients

BackgroundEpilepsy is one of the most common glioma complications, and the two may be connected in more ways than we understand. We aimed to investigate the clinical features of glioma-associated epilepsy and explore the risk factors associated with it.MethodsWe collected clinical information from 485 glioma patients in the Nanjing Brain Hospital and conducted 4 periodic follow-up visits. Based on the collected data, we analyzed the clinical characteristics of glioma patients with or without epilepsy and their relationship with survival.ResultsAmong glioma patients, younger people were more likely to have epilepsy. However, epilepsy incidence was independent of gender. Patients with grade II gliomas were most likely to develop epilepsy, while those with grade IV gliomas were least likely. There was no difference in Karnofsky Performance Status scores between patients with glioma-associated epilepsy and those without epilepsy. Additionally, epilepsy was independently associated with longer survival in the World Health Organization grade IV glioma patients. For grades II, III, and IV tumors, the 1-year survival rate of the epilepsy group was higher than that of the non-epilepsy group.ConclusionsEpilepsy did not lead to worse admission performance and correlated with a better prognosis for patients with grade IV glioma.

Receipt of Out-of-State Telemedicine Visits Among Medicare Beneficiaries During the COVID-19 Pandemic

Early in the COVID-19 pandemic, states implemented temporary changes allowing physicians without a license in their state to provide care to their residents. There is an ongoing debate at both the federal and state levels on whether to change licensure rules permanently to facilitate out-of-state telemedicine use. To describe out-of-state telemedicine use during the pandemic. This cross-sectional study of telemedicine visits included all patients with traditional Medicare from January through June 2021. Telemedicine visits from January through June 2021 where the patient's home address and the physician's practice address were in different states. In describing which patients and specialties were using out-of-state telemedicine, we focused on the period between January to June 2021. We chose this period because it was after the turmoil of the early pandemic, when vaccines became widely available and the health care system had stabilized, but before many of the temporary licensing regulations began to lapse by mid-2021. In the first half of 2021, there were 8 392 092 patients with a telemedicine visit and, of these, 422 547 (5.0%) had 1 or more out-of-state telemedicine visits. Those who lived in a county close to a state border (within 15 miles) accounted for 57.2% of all out-of-state telemedicine visits. Among the out-of-state visits in this time period, 64.3% were with a primary care or mental health clinician. For 62.6% of all out-of-state visits, a prior in-person visit occurred between the same patient and clinician between March 2019 and the visit. The demographics and conditions treated were similar for within-state and out-of-state telemedicine visits, with several notable exceptions. Among those with a telemedicine visit, people in rural communities were more likely to receive out-of-state telemedicine care (33.8% vs 21.0%), and there was high of out-of-state telemedicine use for cancer care (9.8% of all telemedicine visits for cancer care). The findings of this cross-sectional study suggest that licensure restrictions of out-of-state telemedicine would have had the largest effect on patients who lived near a state border, those in rural locales, and those who received primary care or mental health treatment.

Improved access to and continuity of primary care after attachment to a family physician: longitudinal cohort study on centralized waiting lists for unattached patients in Quebec, Canada

BackgroundHaving a regular family physician is associated with many benefits. Formal attachment – an administrative patient-family physician agreement – is a popular feature in primary care, intended to improve access to and continuity of care with a family physician. However, little evidence exists about its effectiveness. In Quebec, Canada, where over 20% of the population is unattached, centralized waiting lists help attach patients. This provides a unique opportunity to observe the influence of attachment in previously unattached patients. The aim was to evaluate changes in access to and continuity of primary care associated with attachment to a family physician through Quebec’s centralized waiting lists for unattached patients.MethodsWe conducted an observational longitudinal population cohort study, using medical services billing data from public health insurance in the province of Québec, Canada. We included patients attached through centralized waiting lists for unattached patients between 2012 and 2014 (n = 410,140). Our study was informed by Aday and Andersen’s framework for the study of access to health services. We compared outcomes during four 12-month periods: two periods before and two periods after attachment, with T0–2 years as the reference period. Outcome measures were number of primary care visits and Bice-Boxerman Concentration of Care Index at the physician and practice level (for patients with ≥2 visits in a given period). We included age, sex, region remoteness, medical vulnerability, and Charlson Comorbidity Index as covariates in regression models fitted with generalized estimating equations.ResultsThe number of primary care visits increased by 103% in the first post attachment year and 29% in the second year (p < 0.001). The odds of having all primary care visits concentrated with a single physician increased by 53% in the first year and 22% (p < 0.001) in the second year after attachment. At the practice level, the odds of perfect concentration of care increased by 19% (p < 0.001) and 15% (p < 0.001) respectively, in first and second year after attachment.ConclusionOur results show an increase in patients’ number of primary care visits and concentration of care at the family physician and practice level after attachment to a family physician. This suggests that attachment may help improve access to and continuity of primary care.

The Coronavirus Disease 2019 Pandemic and Mental Health-Related School-Nurse Visits in United States Schools.

ObjectivesNo studies have examined school-nurse visits related to mental health (MH) during the COVID-19 pandemic. We examined changes in the rate of MH-related school-nurse visits before and during the COVID-19 pandemic.MethodsWe analyzed school-nurse visit data (n=3,445,240) for subjects Grade K-12 in U.S. public schools using electronic health record software (SchoolCare, Ramsey, NJ). Data between January 1-December 31 in 2019 (pre-COVID-19 pandemic) vs. January 1-December 31 in 2020 (during COVID-19 pandemic) were compared. For each year, total visits to a school-nurse were calculated for general MH, anxiety, and self-harm. The exposure was number of school-nurse visits in each time period (2019 vs. 2020). The main outcome was change in the rate of general MH, anxiety, and self-harm visits in 2019 vs. 2020.ResultsThere were 2,302,239 total school-nurse visits in 2019 vs. 1,143,001 in 2020. During the COVID-19 pandemic, the rate of visits for general MH increased by 30% (4.7 to 6.1 per 10,000 visits, 95%CI [18%,43%]; p<0.001), and visits for anxiety increased by 25% (24.8 to 31 per 10,000 visits, 95%CI [20%,30%]; p<0.001). There was no significant difference in self-harm visits across all ages during the COVID-19 pandemic.ConclusionsOur study found a significant increase in the rate of school-nurse visits for MH and anxiety during the COVID-19 pandemic, suggesting the pediatric population is at-risk for increased negative MH-effects associated with the pandemic and highlights a critical role of school-nurses in identifying youth with potential MH-needs.

Sam Houston Ridgway 1936–2022

Sam Houston Ridgway 1936–2022