1
|
Su DG, Rehman S, Wang K, Deng Y, Rose MG, Dosani T, Kunstman JW. Outcomes Following Implementation of an Electronic Model for Perioperative Hematologic Consultation. J Surg Res 2024; 301:10-17. [PMID: 38905768 DOI: 10.1016/j.jss.2024.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 04/06/2024] [Accepted: 04/21/2024] [Indexed: 06/23/2024]
Abstract
INTRODUCTION Electronic consultations (e-consults) for periprocedural hematologic questions were introduced at the VA Connecticut Healthcare System in 2011. We sought to explore the relationship between the availability of e-consults, referral patterns, and surgical outcomes. METHODS A single-center retrospective study of all perioperative hematologic consultations from 2006 to 2018 was conducted. Patient characteristics, indications, and outcomes were analyzed. Primary outcome measures were time from consult to surgery and operative morbidity via Clavien-Dindo classification. Secondary outcomes included consult volume and procedural outcomes of interest. RESULTS Of 357 consultations, 62% were conducted via e-consults. 68.3% had associated procedural data and constituted the study cohort. Annual consult volume increased from 7 in 2006 to 41 in 2018, a 5.8-fold increase. E-consults comprised 20% of consults in 2011 but had risen to 92.3% in 2018. Time to resolution of e-consults after 2011 improved compared to pre-face-to-face (FTF-pre, P = 0.001) and FTF-post (P = 0.002). Time from consult to surgery remained unchanged. 8.4% had major complications (Clavien-Dindo >2) with readmission or reoperation occurring in 4.0% and 3.7%, respectively. Intraoperative and postoperative transfusions were required in 15.2% and 13.1% of cases, respectively. Hematologic complications (i.e., deep vein thrombosis/pulmonary embolism) occurred in 3.5%. Comparison between FTF and e-consults revealed no significant differences in these outcomes (P > 0.05, all). CONCLUSIONS E-consults for perioperative hematologic issues were rapidly adopted and addressed more quickly than FTF consultation while time to surgery was unchanged despite increased consult volume. Adoption of the e-consult model was not associated with changes in the assessed operative outcomes.
Collapse
Affiliation(s)
- David G Su
- Department of General Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Shahyan Rehman
- Department of General Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Kaicheng Wang
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Michal G Rose
- Division of Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Talib Dosani
- Division of Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - John W Kunstman
- Department of General Surgery, Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut; Division of Surgical Oncology, Yale University School of Medicine, New Haven, Connecticut.
| |
Collapse
|
2
|
Kern-Goldberger AS, Bracy D, Szymczak JE, Gonzalez D, Rothberg MB, Gerber JS, Bonafide CP. Drivers of Inpatient Subspecialty Consultation Among Pediatric Hospitalists: A Qualitative Study. Hosp Pediatr 2024; 14:782-789. [PMID: 39188250 DOI: 10.1542/hpeds.2023-007589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 03/29/2024] [Accepted: 04/06/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND AND OBJECTIVE Inpatient subspecialty consultation is often medically necessary but in some cases may represent overuse. While pediatric consultation patterns have been described using observational data, qualitative methods may generate knowledge about contextual determinants of consultation behavior. Our objective was to understand how pediatric hospitalists make decisions about subspecialty consultation. METHODS This qualitative study took place at a large academic children's hospital as part of an explanatory sequential mixed-methods design (QUAN → qual). We conducted semistructured interviews with a purposive sample of previously identified high-consulting (top quartile) and low-consulting (bottom quartile) pediatric hospitalists. Interviews were conducted virtually, and audio recordings were transcribed. Two analysts coded transcripts using an integrated approach and established high interrater reliability (κ > 0.75). We organized findings using the Social Ecological Model. RESULTS Participants (n = 12) included high-(n = 6) and low-(n = 6) consulting hospitalists. Our respondents identified considerations including patient characteristics, confidence in their own competence and that of their team, and perceived helpfulness of consultants. Participants viewed consultation requests as being strongly influenced by a desire to maintain relationships with families. Specific to this context, the hospital's elite reputation was believed to influence families to expect consultations. Other considerations included medicolegal risk, clinical pathways, and availability of secure text messaging to facilitate informal "curbside" conversations with subspecialists. CONCLUSIONS Decision-making around pediatric subspecialty consultation is complex and influenced by factors unrelated to a patient's clinical need. Efforts to reduce low-value consultation must account for the social and organizational dynamics that promote consultation.
Collapse
Affiliation(s)
- Andrew S Kern-Goldberger
- Division of Pediatric Hospital Medicine
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | - Danny Bracy
- Mixed-Methods Research Laboratory, Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia E Szymczak
- Clinical Futures, a Center of Emphasis within the CHOP Research Institute
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Denise Gonzalez
- Mixed-Methods Research Laboratory, Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael B Rothberg
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | - Jeffrey S Gerber
- Clinical Futures, a Center of Emphasis within the CHOP Research Institute
- Division of Infectious Diseases
- Department of Pediatrics, Perelman School of Medicine
| | - Christopher P Bonafide
- Clinical Futures, a Center of Emphasis within the CHOP Research Institute
- Section of Pediatric Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
3
|
Suárez-Dono FJ, Martínez-Rey C, Novo-Platas J, Fernández Peña C, Rodríguez Méndez ML, Pérez Iglesias A, Casariego-Vales E. E-consults between primary care and internal medicine: implementation, accessibility, benefits, and implications. Rev Clin Esp 2024; 224:421-427. [PMID: 38871291 DOI: 10.1016/j.rceng.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 05/20/2024] [Indexed: 06/15/2024]
Abstract
AIM This work aims to evaluate whether electronic consultations (e-consults) are a clinically useful, safe tool for assessing patients between primary care and internal medicine. METHODS This is a retrospective cohort study of all e-consults ordered by the Primary Care Department to the Internal Medicine Department between September 2019 and December 2023. The results of initial consultations, emergency department visits and subsequent admissions, and survival were assessed and complaints and claims filed were reviewed. RESULTS A total of 11,434 e-consults were recorded (55.4% women) with a mean age of 62.1 (SD19.4) years and a wide range (15-102 years). The mean response time was 2.55 (SD 1.6) days. As a result of the e-consults, 5645 patients (49.4%) were given an in-person appointment. For the remaining 5789 (50.6%), a written response was provided. Among those given appointments, the time between the response and in-person appointment was less than five days (95% of cases). Compared to those not given appointments, in-person appointments were older (p < 0.0001), visited the emergency department more times (one month: p = 0.04; three months: p = 0.001), were admitted to the hospital more times (one month: p = 0.0001; three months: p = 0.0001), and had higher mortality at one year (12.7% vs. 9.8% p = 0.0001). In the Cox analysis, only in-person appointments (RR = 1.11; p = 0.04)) and age (RR = 1.09; p < 0.01) were independent factors of mortality. No complaints or claims of any kind were registered. CONCLUSIONS These data suggest that e-consults are a clinically useful, safe tool for assessing patients referred from primary care to internal medicine departments.
Collapse
Affiliation(s)
- F J Suárez-Dono
- Servicio de Medicina Interna, Complexo Hospitalario Universitario de Santiago de Compostela, Av Choupana s/n, Santiago de Compostela, 15706, Spain
| | - C Martínez-Rey
- Servicio de Medicina Interna, Complexo Hospitalario Universitario de Santiago de Compostela, Av Choupana s/n, Santiago de Compostela, 15706, Spain
| | - J Novo-Platas
- Control de Gestión, Complexo Hospitalario Universitario de Santiago de Compostela, Av Choupana s/n, Santiago de Compostela, 15706, Spain
| | - C Fernández Peña
- Servicio de Medicina Interna, Complexo Hospitalario Universitario de Santiago de Compostela, Av Choupana s/n, Santiago de Compostela, 15706, Spain
| | - M L Rodríguez Méndez
- Servicio de Medicina Interna, Complexo Hospitalario Universitario de Santiago de Compostela, Av Choupana s/n, Santiago de Compostela, 15706, Spain
| | - A Pérez Iglesias
- Servicio de Medicina Interna, Complexo Hospitalario Universitario de Santiago de Compostela, Av Choupana s/n, Santiago de Compostela, 15706, Spain
| | - E Casariego-Vales
- Servicio de Medicina Interna, Complexo Hospitalario Universitario de Santiago de Compostela, Av Choupana s/n, Santiago de Compostela, 15706, Spain.
| |
Collapse
|
4
|
Aledia AS, Dangodara AA, Amin AA, Amin AN. Implementation of Inpatient Electronic Consultations During the COVID-19 Crisis and Its Sustainability Beyond the Pandemic: Quality Improvement Study. J Med Internet Res 2024; 26:e55623. [PMID: 38754103 PMCID: PMC11140270 DOI: 10.2196/55623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/06/2024] [Accepted: 03/27/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Limiting in-person contact was a key strategy for controlling the spread of the highly infectious novel coronavirus (COVID-19). To protect patients and staff from the risk of infection while providing continued access to necessary health care services, we implemented a new electronic consultation (e-consult) service that allowed referring providers to receive subspecialty consultations for patients who are hospitalized and do not require in-person evaluation by the specialist. OBJECTIVE We aimed to assess the impact of implementing e-consults in the inpatient setting to reduce avoidable face-to-face referrals during the COVID-19 pandemic. METHODS This quality improvement study evaluated all inpatient e-consults ordered from July 2020 to December 2022 at the University of California Irvine Medical Center. The impact of e-consults was assessed by evaluating use (eg, number of e-consults ordered), e-consult response times, and outcome of the e-consult requests (eg, resolved electronically or converted to the in-person evaluation of patient). RESULTS There were 1543 inpatient e-consults ordered across 11 participating specialties. A total of 53.5% (n=826) of requests were addressed electronically, without the need for a formal in-person evaluation of the patient. The median time between ordering an e-consult and a specialist documenting recommendations in an e-consult note was 3.7 (IQR 1.3-8.2) hours across all specialties, contrasted with 7.3 (IQR 3.6-22.0) hours when converted to an in-person consult (P<.001). The monthly volume of e-consult requests increased, coinciding with surges of COVID-19 cases in California. After the peaks of the COVID-19 crisis subsided, the use of inpatient e-consults persisted at a rate well above the precrisis levels. CONCLUSIONS An inpatient e-consult service was successfully implemented, resulting in fewer unnecessary face-to-face consultations and significant reductions in the response times for consults requested on patients who are hospitalized and do not require an in-person evaluation. Thus, e-consults provided timely, efficient delivery of inpatient consultation services for appropriate problems while minimizing the risk of direct transmission of the COVID-19 virus between health care providers and patients. The service also demonstrated its value as a tool for effective inpatient care coordination beyond the peaks of the pandemic leading to the sustainability of service and value.
Collapse
Affiliation(s)
- Anna S Aledia
- Department of Medicine & Hospital Medicine, University of California, Irvine, Orange, CA, United States
| | - Amish A Dangodara
- Department of Medicine & Hospital Medicine, University of California, Irvine, Orange, CA, United States
| | - Aanya A Amin
- Department of Medicine & Hospital Medicine, University of California, Irvine, Orange, CA, United States
| | - Alpesh N Amin
- Department of Medicine & Hospital Medicine, University of California, Irvine, Orange, CA, United States
| |
Collapse
|
5
|
Du L, Cao Z, Han C, Wei J, Li M, Zhang C. Dermatology Consultation in the Geriatrics Department of a Tertiary Hospital in China: A Retrospective Study of 178 Patients. Clin Cosmet Investig Dermatol 2024; 17:925-930. [PMID: 38699408 PMCID: PMC11063470 DOI: 10.2147/ccid.s461156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/13/2024] [Indexed: 05/05/2024]
Abstract
Objective Dermatological consultation plays an important role in diagnosing and treating skin diseases in the Department of Geriatrics. The objective of this study is to provide an analysis of the factors leading geriatric inpatients to seek dermatological consultation, aiming to facilitate accurate diagnosis and effective treatment of skin diseases by healthcare professionals specializing in geriatrics and dermatology. Methods The electronic health records of hospitalized patients in the Department of Geriatrics who applied for dermatological consultation at the Second Hospital of Shandong University from June 1, 2022, to June 1, 2023, were retrieved. Sex, age, number of consultations, reason for dermatology consultation, and final diagnosis by dermatologists were reviewed. Results A total of 216 consultations of 178 patients (n=178, 95 men and 83 women) were collected in this study, of whom 153 (86.0%) required only one consultation, 19 (10.7%) required two consultations, and 4 (2.2%) required three consultations. The reasons for dermatology consultations were divided into three categories: the first was for the definitive diagnosis of a new skin condition that developed during the patient's hospitalization (n=165, 76.4%), the second was for the follow-up of the condition and adjustment of medication (n=40, 18.5%), and the third was for the evaluation of the patient's disease that existed before admission to the hospital (n=11, 5.1%). In 165 consultations, most of these diseases (n=131, 79.4%) can be diagnosed by patients' conscious symptoms and clinical manifestations. Some of them need to be diagnosed or differentially diagnosed with the help of supplementary examinations, such as microscopic examination of scabies or fungi, and pathological examination. Conclusion This study summarized the reasons for dermatology consultations for geriatric inpatients and found that dermatitis/eczema and infectious diseases were the common types of diseases consulted. The findings of this study contribute to the enhanced comprehension and management of dermatological conditions in hospitalized patients by geriatricians, as well as facilitating more efficient diagnosis and treatment by dermatologists.
Collapse
Affiliation(s)
- Lingyun Du
- Department of Dermato-venereology, the Second Hospital of Shandong University, Jinan, 250033, People’s Republic of China
| | - Zhiqiang Cao
- Department of Dermatology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710004, People’s Republic of China
| | - Changyu Han
- Department of Dermato-venereology, the Second Hospital of Shandong University, Jinan, 250033, People’s Republic of China
| | - Jingjing Wei
- Department of Dermato-venereology, the Second Hospital of Shandong University, Jinan, 250033, People’s Republic of China
| | - Mingming Li
- Department of Dermato-venereology, the Second Hospital of Shandong University, Jinan, 250033, People’s Republic of China
| | - Chunhong Zhang
- Department of Dermato-venereology, the Second Hospital of Shandong University, Jinan, 250033, People’s Republic of China
| |
Collapse
|
6
|
Providencia R, Aali G, Zhu F, Leas BF, Orrell R, Ahmad M, Bray JJH, Pelone F, Nass P, Marijon E, Cassandra M, Celermajer DS, Shokraneh F. Penicillin Allergy Testing and Delabeling for Patients Who Are Prescribed Penicillin: A Systematic Review for a World Health Organization Guideline. Clin Rev Allergy Immunol 2024; 66:223-240. [PMID: 38696031 PMCID: PMC11193836 DOI: 10.1007/s12016-024-08988-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2024] [Indexed: 06/23/2024]
Abstract
Secondary prevention with penicillin aims to prevent further episodes of acute rheumatic fever and subsequent development of rheumatic heart disease (RHD). Penicillin allergy, self-reported by 10% of the population, can affect secondary prevention programs. We aimed to assess the role for (i) routine penicillin allergy testing and the (ii) safety of penicillin allergy delabeling approaches in this context. We searched MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, WHO ICTRP, ISRCTN, and CPCI-S to identify the relevant reports. We found 2419 records, but no studies addressed our initial question. Following advice from the WHO-Guideline committee and experts, we identified 6 manuscripts on allergy testing focusing on other populations showing that the prevalence of allergy confirmed by testing was low and the incidence of life-threatening reactions to BPG was very low (< 1-3/1000 individuals treated). A subsequent search addressed penicillin allergy delabeling. This found 516 records, and 5 studies addressing the safety of direct oral drug challenge vs. skin testing followed by drug administration in patients with suspected penicillin allergy. Immediate allergic reactions of minor severity were observed for a minority of patients and occurred less frequently in the direct drug challenge group: 2.3% vs. 11.5%; RR = 0.25, 95%CI 0.15-0.45, P < 0.00001, I2 = 0%. No anaphylaxis or deaths were observed. Severe allergic reactions to penicillin are extremely rare and can be recognized and dealt by trained healthcare workers. Confirmation of penicillin allergy diagnosis or delabeling using direct oral drug challenge or penicillin skin testing seems to be safe and is associated with a low rate of adverse reactions.
Collapse
Affiliation(s)
- Rui Providencia
- University College London, London, UK.
- Barts Heart Centre, London, UK.
| | - Ghazaleh Aali
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Oxford, UK
| | - Fang Zhu
- Department of Biostatistics, Systematic Review Consultants LTD, Oxford, UK
| | - Brian F Leas
- Department of Biostatistics, Systematic Review Consultants LTD, Oxford, UK
| | - Rachel Orrell
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Oxford, UK
| | - Mahmood Ahmad
- University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | | | | | - Petra Nass
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Oxford, UK
| | - Eloi Marijon
- European Georges Pompidou Hospital, Paris, France
| | | | | | - Farhad Shokraneh
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Oxford, UK
| |
Collapse
|
7
|
Peeters KMM, Reichel LAM, Muris DMJ, Cals JWL. Family Physician-to-Hospital Specialist Electronic Consultation and Access to Hospital Care: A Systematic Review. JAMA Netw Open 2024; 7:e2351623. [PMID: 38214930 PMCID: PMC10787322 DOI: 10.1001/jamanetworkopen.2023.51623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/22/2023] [Indexed: 01/13/2024] Open
Abstract
Importance Globally, health care systems face challenges in managing health care costs while maintaining access to hospital care, quality of care, and a good work balance for caregivers. Electronic consultations (e-consultations)-defined as asynchronous, consultative communication between family physicians and hospital specialists-may offer advantages to face these challenges. Objective To provide a quantitative synthesis of the association of e-consultation with access to hospital care and the avoidance of hospital referrals. Evidence Review A systematic search through PubMed, MEDLINE, and Embase was conducted. Eligible studies included original research studies published from January 2010 to March 2023 in English, Dutch, or German that reported on outcomes associated with access to hospital care and the avoidance of hospital referrals. Reference lists of included articles were searched for additional studies. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) scores were assigned to assess quality of evidence. Findings The search strategy resulted in 583 records, of which 72 studies were eligible for data extraction after applying exclusion criteria. Most studies were observational, focused on multispecialty services, and were performed in either Canada or the US. Outcomes on access to hospital care and the avoidance of referrals indicated that e-consultation was associated with improved access to hospital care and an increase in avoided referrals to the hospital specialist, although outcomes greatly differed across studies. GRADE scores were low or very low across studies. Conclusions and Relevance In this systematic review of the association of e-consultation with access to hospital care and the avoidance of hospital referrals, results indicated that the use of e-consultation has greatly increased over the years. Although e-consultation was associated with improved access to hospital care and avoidance of hospital referrals, it was hard to draw a conclusion about these outcomes due to heterogeneity and lack of high-quality evidence (eg, from randomized clinical trials). Nevertheless, these results suggest that e-consultation seems to be a promising digital health care implementation, but more rigorous studies are needed; nonrandomized trial designs should be used, and appropriate outcomes should be chosen in future research on this topic.
Collapse
Affiliation(s)
- Ken M. M. Peeters
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
- Zuyderland Medical Centre, Sittard, the Netherlands
- Omnes Medical Coordinating Centre for Diagnostics and Innovation, Sittard, the Netherlands
| | - Loïs A. M. Reichel
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Dennis M. J. Muris
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
- Omnes Medical Coordinating Centre for Diagnostics and Innovation, Sittard, the Netherlands
- Public Health Service South Limburg, Heerlen, the Netherlands
| | - Jochen W. L. Cals
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
8
|
Ramsey A, Rozario C, Stern J. Direct challenges are the gold standard for most antibiotic allergy evaluations. Ann Allergy Asthma Immunol 2023; 131:427-433. [PMID: 37031773 DOI: 10.1016/j.anai.2023.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 04/11/2023]
Abstract
Antibiotic allergies are frequently encountered in clinical practice, and delabeling of these allergies has individual and public health benefits. This review focuses on the evidence supporting graded challenges without preceding skin testing in adult and pediatric patients to the major groups of antibiotics including penicillins, cephalosporins, sulfamethoxazole, fluoroquinolones, tetracyclines, macrolides, metronidazole, carbapenems, and aztreonam. The cost savings, time savings, and evidence for performing graded challenges outside of an allergy/immunology office are also reviewed for graded challenges to penicillins.
Collapse
Affiliation(s)
- Allison Ramsey
- Rochester Regional Health, Rochester, New York; Department of Medicine, University of Rochester, Rochester, New York.
| | - Cheryl Rozario
- Department of Medicine, University of Rochester, Rochester, New York
| | - Jessica Stern
- Department of Medicine, University of Rochester, Rochester, New York; Department of Pediatrics, University of Rochester, Rochester, New York
| |
Collapse
|
9
|
Robbins E, Johal K, Keswani A. The Use and Teaching of Telemedicine in Allergy/Immunology Training Programs. Curr Allergy Asthma Rep 2023; 23:463-470. [PMID: 37418070 DOI: 10.1007/s11882-023-01096-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 07/08/2023]
Abstract
PURPOSE OF REVIEW The use of telemedicine has greatly increased since the onset of the coronavirus disease 2019 (COVID-19) pandemic. This review discusses the types of telemedicine, current telehealth curricula in medical education, and benefits and disadvantages of incorporation of telemedicine into Allergy/Immunology training programs. RECENT FINDINGS The majority of Allergists/Immunologists use telemedicine in their clinical practice with leaders in graduate medical education recommending inclusion of telemedicine in training. Fellows-in-training reported that use of telemedicine in Allergy/Immunology training during the pandemic mitigated some concerns for lack of adequate clinical experience. Still, no standardized curriculum for telemedicine training in Allergy/Immunology exists, although curricula from internal medicine and primary care residencies can provide a framework for incorporation of telemedicine training into fellowship. Benefits of telemedicine in Allergy/Immunology training include enhanced immunology training, home environment monitoring, and flexibility to reduce physician burnout while disadvantages include limited physical examination skill building and lack of a standardized curriculum. As telemedicine has been widely accepted in medicine with high patient satisfaction, it is necessary to incorporate a standardized telehealth curriculum in Allergy/Immunology fellowship training, both as a tool for patient care as well as trainee education.
Collapse
Affiliation(s)
- Emily Robbins
- National Institute of Allergy and Immunology, National Institute of Health, Bethesda, MD, USA
| | - Kirti Johal
- Division of Allergy/Immunology, George Washington University School of Medicine and Health Sciences, 2300 M St NW, Suite 200, Washington, DC, 20037, USA
| | - Anjeni Keswani
- Division of Allergy/Immunology, George Washington University School of Medicine and Health Sciences, 2300 M St NW, Suite 200, Washington, DC, 20037, USA.
| |
Collapse
|
10
|
Samarakoon U, Accarino J, Wurcel AG, Jaggers J, Judd A, Blumenthal KG. Penicillin allergy delabeling: Opportunities for implementation and dissemination. Ann Allergy Asthma Immunol 2023; 130:554-564. [PMID: 36563744 DOI: 10.1016/j.anai.2022.12.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/01/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Although existing as a safety measure to prevent iatrogenic harm, unconfirmed penicillin allergy labels have a negative impact on personal and public health. One downstream effect of unconfirmed penicillin allergy is the continued emergence and transmission of resistant bacteria and their associated health care costs. Recognizing the consequences of inaccurate penicillin allergy labels, professional and public health organizations have started promoting the adoption of proactive penicillin allergy evaluations, with the ultimate goal of removing the penicillin allergy label when the allergy is disproved, also known as penicillin allergy "delabeling." A penicillin allergy evaluation includes a comprehensive allergy history often followed by drug challenge, sometimes with preceding skin testing. Currently, penicillin allergy delabeling is largely carried out by allergy specialists in outpatient settings. Penicillin allergy delabeling is performed on inpatients, albeit rarely, often at the time of need, as a point-of-care procedure. Access to penicillin allergy evaluation services is limited. Recent studies demonstrate the feasibility of expanding penicillin allergy evaluations and delabeling to internists, pediatricians, emergency medicine physicians, infectious diseases specialists, and clinical pharmacists. However, reducing the impact of mislabeled penicillin allergy will require comprehensive efforts and new investments. In this review, we summarize the current practices of penicillin allergy delabeling and discuss expansion opportunities for penicillin allergy delabeling as quality improvement.
Collapse
Affiliation(s)
- Upeka Samarakoon
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John Accarino
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Alysse G Wurcel
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts; Tufts University School of Medicine, Boston, Massachusetts
| | - Jordon Jaggers
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Allen Judd
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
11
|
McCulloch MR, Thomas JF, Thompson MA, Carel KD. Outpatient electronic consultations in pediatric allergy and immunology. Ann Allergy Asthma Immunol 2023; 130:115-117. [PMID: 36220538 DOI: 10.1016/j.anai.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/20/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Matthew R McCulloch
- Allergy & Immunology Section, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.
| | - John F Thomas
- General Academic Pediatrics, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado; Peer Mentored Care Collaborative, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Kirstin D Carel
- Allergy & Immunology Section, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
12
|
Gong X, Hou M, Guo R, Feng XL. Investigating the relationship between consultation length and quality of tele-dermatology E-consults in China: a cross-sectional standardized patient study. BMC Health Serv Res 2022; 22:1187. [PMID: 36138410 PMCID: PMC9493166 DOI: 10.1186/s12913-022-08566-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022] Open
Abstract
Background Consultation length, the time a health provider spend with the patient during a consultation, is a crucial aspect of patient-physician interaction. Prior studies that assessed the relationship between consultation length and quality of care were mainly based on offline visits. Research was lacking in E-consults settings, an emerging modality for primary health care. This study aims to examine the association between consultation length and the quality of E-consults services. Methods We defined as standardized patient script to present classic urticaria symptoms in asynchronous E-consults at tertiary public hospitals in Beijing and Hangzhou, China. We appraised consultation length using six indicators, time waiting for first response, time waiting for each response, time for consultation, total times of provider’s responses, total words of provider’s all responses, and average words of provider’s each response. We appraised E-consults services quality using five indicators building on China’s clinical guidelines (adherence to checklist; accurate diagnosis; appropriate prescription; providing lifestyle modification advice; and patient satisfaction). We performed ordinary least squares (OLS) regressions and logistic regressions to investigate the association between each indictor of consultation length and E-consults services quality. Results Providers who responded more quickly were more likely to provide lifestyle modification advice and achieve better patient satisfaction, without compromising process, diagnosis, and prescribing quality; Providers who spent more time with patients were likely to adhere to clinical checklists; Providers with more times and words of responses were significantly more likely to adhere to the clinical checklist, provide an accurate diagnosis, appropriate prescription, and lifestyle modification advice, which achieved better satisfaction rate from the patient as well. Conclusions The times and words that health providers provide in E-consult can serve as a proxy measure for quality of care. It is essential and urgent to establish rules to regulate the consultation length for Direct-to-consumer telemedicine to ensure adequate patient-provider interaction and improve service quality to promote digital health better. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08566-2.
Collapse
Affiliation(s)
- Xue Gong
- School of Public Health, Capital Medical University, Beijing, China
| | - Mengchi Hou
- China Aerospace Science & Industry Corporation 731 Hospital, Beijing, China
| | - Rui Guo
- School of Public Health, Capital Medical University, Beijing, China.
| | - Xing Lin Feng
- Department of Health Policy and Management, School of Public Health, Peking University, Beijing, China.
| |
Collapse
|
13
|
Pandya A, Waller M, Portnoy JM. The Regulatory Environment of Telemedicine After COVID-19. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE 2022; 10:2500-2505. [PMID: 35842133 PMCID: PMC9277986 DOI: 10.1016/j.jaip.2022.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/31/2022] [Accepted: 07/06/2022] [Indexed: 11/19/2022]
Abstract
The COVID-19 pandemic has created many barriers to providing health care, yet it also has created new opportunities. Although telemedicine was a nascent means of health care delivery before COVID-19, it now is one of the principal means for doing so today, and it is likely to remain so. Whether this will happen may depend in part on continued relaxation of regulations that hampered it before the pandemic. Whereas enforcement of compliance with Health Information Portability and Accountability Act will most likely resume, platform operators and providers have had an opportunity to prepare for this. State licensure requirements may also resume; however, the regulations were in the process of becoming more liberal before COVID-19 so that process might continue. There is no reason to anticipate that payment for telemedicine services including check-ins, remote physiologic and therapeutic monitoring, and relaxation of location and service requirements will end. For these reasons, telemedicine therefore is likely to continue as an important part of medical practice.
Collapse
|
14
|
Telemedicine in Drug Hypersensitivity. Immunol Allergy Clin North Am 2022; 42:323-333. [DOI: 10.1016/j.iac.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
15
|
Rikin S, Epstein EJ, Gendlina I. Rapid implementation of Inpatient eConsult Programme addresses new challenges for patient care during COVID-19 pandemic. BMJ INNOVATIONS 2021; 7:271-277. [PMID: 34192016 PMCID: PMC7944413 DOI: 10.1136/bmjinnov-2020-000557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/17/2020] [Accepted: 02/24/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION At the early epicentre of the COVID-19 crisis in the USA, our institution saw a surge in the demand for inpatient consultations for areas impacted by COVID-19 (eg, infectious diseases, nephrology, palliative care) and shortages in personal protective equipment (PPE). We aimed to provide timely specialist input for consult requests during the COVID-19 pandemic by implementing an Inpatient eConsult Programme. METHODS We used the reach, effectiveness, adoption, implementation and maintenance implementation science framework and run chart analysis to evaluate the reach, adoption and maintenance of the Inpatient eConsult Programme compared with traditional in-person consults. We solicited qualitative feedback from frontline physicians and specialists for programme improvements. RESULTS During the study period, there were 46 available in-person consult orders and 21 new eConsult orders. At the peak of utilisation, 42% of all consult requests were eConsults, and by the end of the study period, utilisation fell to 20%. Qualitative feedback revealed subspecialties best suited for eConsults (infectious diseases, nephrology, haematology, endocrinology) and influenced improvements to the ordering workflow, documentation, billing and education regarding use. DISCUSSION When offered inpatient eConsult requests as an alternative to in-person consults in the context of a surge in patients with COVID-19, frontline physicians used eConsult requests and decreased use of in-person consults. As the demand for consults decreased and PPE shortages were no longer a major concern, eConsult utilisation decreased, revealing a preference for in-person consultations when possible. CONCLUSIONS Lessons learnt can be used to develop and implement inpatient eConsults to meet context-specific challenges at other institutions.
Collapse
Affiliation(s)
- Sharon Rikin
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Eric J Epstein
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Inessa Gendlina
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| |
Collapse
|
16
|
Drug Allergy Labels Lost in Translation: From Patient to Charts and Backwards. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3015-3020. [PMID: 33607342 DOI: 10.1016/j.jaip.2021.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 12/12/2022]
Abstract
The current method of defining, reporting, assessment, labeling, delabeling, and reconciliation of adverse drug reactions (ADRs), and specifically immunologically mediated drug hypersensitivity reactions (HSRs), in electronic health records (EHRs) is inadequate and compromises care quality and safety. It is critical to accurately and succinctly report the signs and symptoms associated with ADRs and suspected HSRs to enable clinicians to determine the plausible reaction type and help guide appropriate future management plans. Despite the current limitations of the EHR allergy module, we must encourage improved clinical documentation and demand technological improvements. Telehealth methods have been shown to be valuable in the assessment of ADRs and HSRs, particularly in the case of penicillin allergy evaluation and delabeling. The implementation, assessment, and refinement of advanced technologies, including clinical informatics and artificial intelligence, along with continued education of health care providers have potential to improve EHR documentation and communication, thereby advancing patient safety efforts.
Collapse
|