Better Nurse Practitioner Primary Care Practice Environments Reduce Hospitalization Disparities Among Dually-Enrolled Patients

BACKGROUND

Over 12 million Americans are dually enrolled in Medicare and Medicaid. These individuals experience over twice as many hospitalizations for chronic diseases such as coronary artery disease and diabetes compared with Medicare-only patients. Nurse practitioners (NPs) are well-positioned to address the care needs of dually-enrolled patients, yet NPs often work in unsupportive clinical practice environments. The purpose of this study was to examine the association between the NP primary care practice environment and hospitalization disparities between dually-enrolled and Medicare-only patients with chronic diseases.

METHODS

Using secondary cross-sectional data from the Nurse Practitioner Primary Care Organizational Climate Questionnaire and Medicare claims files, we examined 135,648 patients with coronary artery disease and/or diabetes (20.0% dually-eligible, 80.0% Medicare-only), cared for in 450 practices employing NPs across 4 states (PA, NJ, CA, FL) in 2015. We compared dually-enrolled patients' odds of being hospitalized when cared for in practice environments characterized as poor, mixed, and good based on practice-level Nurse Practitioner Primary Care Organizational Climate Questionnaire scores.

RESULTS

After adjusting for patient and practice characteristics, dually-enrolled patients in poor practice environments had the highest odds of being hospitalized compared with their Medicare-only counterparts [odds ratio (OR): 1.48, CI: 1.37, 1.60]. In mixed environments, dually-enrolled patients had 27% higher odds of a hospitalization (OR: 1.27, CI: 1.12, 1.45). However, in the best practice environments, hospitalization differences were nonsignificant (OR: 1.02, CI: 0.85, 1.23).

CONCLUSIONS

As policymakers look to improve outcomes for dually-enrolled patients, addressing a modifiable aspect of care delivery in NPs' clinical practice environment is a key opportunity to reduce hospitalization disparities.

Equity-Centered Postdischarge Support for Medicaid-Insured People: Protocol for a Type 1 Hybrid Effectiveness-Implementation Stepped Wedge Cluster Randomized Controlled Trial

BACKGROUND

Disparities in posthospitalization outcomes for people with chronic medical conditions and insured by Medicaid are well documented, yet interventions that mitigate them are lacking. Prevailing transitional care interventions narrowly target people aged 65 years and older, with specific disease processes, or limitedly focus on individual-level behavioral change such as self-care or symptom management, thus failing to adequately provide a holistic approach to ensure an optimal posthospital care continuum. This study evaluates the implementation of THRIVE-an evidence-based, equity-focused clinical pathway that supports Medicaid-insured individuals with multiple chronic conditions transitioning from hospital to home by focusing on the social determinants of health and systemic and structural barriers in health care delivery. THRIVE services include coordinating care, standardizing interdisciplinary communication, and addressing unmet clinical and social needs following hospital discharge.

OBJECTIVE

The study's objectives are to (1) examine referral patterns, 30-day readmission, and emergency department use for participants who receive THRIVE support services compared to those receiving usual care and (2) evaluate the implementation of the THRIVE clinical pathway, including fidelity, feasibility, appropriateness, and acceptability.

METHODS

We will perform a sequential randomized rollout of THRIVE to case managers at the study hospital in 3 steps (4 in the first group, 4 in the second, and 5 in the third), and data collection will occur over 18 months. Inclusion criteria for THRIVE participation include (1) being Medicaid insured, dually enrolled in Medicaid and Medicare, or Medicaid eligible; (2) residing in Philadelphia; (3) having experienced a hospitalization at the study hospital for more than 24 hours with a planned discharge to home; (4) agreeing to home care at partner home care settings; and (5) being aged 18 years or older. Qualitative data will include interviews with clinicians involved in THRIVE, and quantitative data on health service use (ie, 30-day readmission, emergency department use, and primary and specialty care) will be derived from the electronic health record.

RESULTS

This project was funded in January 2023 and approved by the institutional review board on March 10, 2023. Data collection will occur from March 2023 to July 2024. Results are expected to be published in 2025.

CONCLUSIONS

The THRIVE clinical pathway aims to reduce disparities and improve postdischarge care transitions for Medicaid-insured patients through a system-level intervention that is acceptable for THRIVE participants, clinicians, and their teams in hospitals and home care settings. By using our equity-focused case management services and leveraging the power of the electronic medical record, THRIVE creates efficiencies by identifying high-need patients, improving communication across acute and community-based sectors, and driving evidence-based care coordination. This study will add important findings about how the infusion of equity-focused principles in the design and evaluation of evidence-based interventions contributes to both implementation and effectiveness outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54211.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05714605; https://clinicaltrials.gov/ct2/show/NCT05714605.

Reporting of paediatric osteoporotic vertebral fractures in Duchenne muscular dystrophy and potential impact on clinical management: the need for standardised and structured reporting

BACKGROUND

In boys with Duchenne muscular dystrophy (DMD), initiation of bisphosphonate is recommended upon identification of moderate or severe vertebral fractures, even if asymptomatic. Clear radiological reporting is important for consistency of clinical interpretation and management.

OBJECTIVES

To audit radiology reports of spine imaging for vertebral fracture assessment in DMD, and assess potential impact on diagnosis and management.

MATERIALS AND METHODS

Lateral thoracolumbar spine imaging (71 lateral spine radiographs and 13 lateral dual energy absorptiometry spine image) in 84 boys with DMD performed across two centres. Anonymised radiology reports by paediatric radiologists were circulated to two neuromuscular clinicians and two endocrinologists. Clinicians determined if there was vertebral fracture, no vertebral fracture, or unclear interpretation. Endocrinologists also determined if bisphosphonate was indicated. A single observer (a clinician with expertise in vertebral fracture assessment) performed vertebral fracture assessment in 37 images and re-reported using a structured format. Structured reports were re-circulated to the four clinicians to re-evaluate the degree of concordance in clinical diagnosis of vertebral fracture and treatment decisions with bisphosphonate.

RESULTS

The term "fracture" was used in 25/84 (30%) radiology reports and only in 8/43 (19%) with description of vertebral body abnormalities. Fracture grading was included in 7/43 (16%) radiology reports. Diagnostic concordance by the clinicians was noted in 36/84 (43%). Unclear interpretation was noted in 22% to 51% based on radiology reports. No unclear interpretation was noted with structured reports. Complete diagnostic (37/37, 100%) and treatment (37/37, 100%) concordance was noted with the structured reports, whereas complete diagnostic and treatment concordance was noted in only 16/37 (43%) and 17/37 (46%) of the radiology reports, respectively.

CONCLUSION

Only a third of radiology reports of spine imaging in DMD explicitly used the terminology "fracture". Grading was only noted in a small percentage. Variability in diagnostic interpretation by clinicians may lead to differing management plans. As identification of vertebral fracture is a trigger for treatment, developing reporting guidelines for paediatric vertebral fracture assessment will improve care. A structured template should be introduced for radiological reporting of paediatric vertebral fracture assessment.

"I had become fed up": A qualitative study of Black nurse practitioners' experiences fighting against health inequity, racism, and burnout

BACKGROUND

Increasing diversity in the nurse practitioner (NP) workforce is key to improving outcomes among patients who experience health inequities. However, few studies to date have examined the specific mechanisms by which NPs from diverse backgrounds address inequities in care delivery.

PURPOSE

To explore Black NPs' efforts in addressing inequities, and the facilitators and barriers they face in doing so.

METHODOLOGY

We conducted focus groups and interviews of Black NPs ( N = 16) in the greater Philadelphia area in early 2022, just following the height of the COVID-19 pandemic and the social unrest of the early 2020s. Data were analyzed using thematic analysis.

RESULTS

Emergent themes included: Strategies Utilized to Address Health Inequities ; Burnout & the Minority Tax ; Risks & Rewards of Taking a Stance ; and Uneven Promises of Organizational Engagement . Nurse practitioners prioritized patient-centered, culturally congruent care, taking additional time to explore community resources and learn about patients' lives to facilitate care planning. Participants advocated to administrators for resources to address inequities while simultaneously navigating organizational dynamics, microaggressions, and racism. Finally, NPs identified organizational-level barriers, leading to emotional exhaustion and several participants' intent to leave their roles.

CONCLUSIONS

Black NPs use a myriad of strategies to improve equity, yet frequently face substantial barriers and emotional exhaustion in doing so with little change to the inequities in care.

IMPLICATIONS

The NP workforce has a critical role to play in reducing health inequities. The strategies outlined by Black NPs in this study offer a roadmap for all clinicians and health care organizations to prioritize equity in care delivery.

BETTER NP PRACTICE ENVIRONMENTS REDUCE HOSPITALIZATION DISPARITIES AMONG DUALLY ENROLLED PATIENTS

Adults dually-enrolled in Medicare and Medicaid experience twice as many hospitalizations and higher rates of ambulatory care-sensitive conditions (ACSCs) – such as coronary artery disease [CAD] and diabetes, compared to Medicare-only patients. Nurse practitioners (NPs) are well-positioned to address care needs of dually-eligible patients, yet NPs often work in unsupportive clinical practice environments. The purpose of this study was to examine the association between the NP primary care practice environment and disparities in all-cause hospitalizations between dually-eligible and Medicare-only patients with ACSCs. Using linked secondary cross-sectional data from the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ) and Medicare claims files, we examined 189,420 patients with CAD and/or diabetes (19.1% dually-eligible, 80.9% Medicare-only), cared for in 470 practices employing NPs across four states (PA, NJ, CA, FL) in 2015. After adjusting for patient and practice characteristics, dually-eligible patients in poor practice environments had the highest odds of being hospitalized compared to their Medicare-only counterparts (OR 1.60, CI: 1.49-1.71). In mixed practice environments, dually-eligible patients had approximately 48% higher odds of a hospitalization (OR 1.48, CI 1.31-1.68), while in the best practice environments, dually-eligible patients had approximately 37% higher odds (OR 1.37, CI 1.21-1.57, p < .001). As policymakers look to improve outcomes and reduce costs among dually-eligible patients, addressing a modifiable aspect of care delivery in NPs’ clinical practice environment is a key opportunity to reduce hospitalization disparities. Yet further efforts are needed to address remaining disparities by meeting patients’ health-related social needs, such as poverty and access to care.

A208 ASSESSING FEASIBILITY AND ACCEPTABILITY OF AN ONLINE MIND-BODY WELLNESS PROGRAM FOR PRIMARY BILIARY CHOLANGITIS

Background

Persons with primary biliary cholangitis (PBC) experience significantly higher rates of fatigue, stress, anxiety, depression, and impaired health related quality of life (HRQOL) as compared to the general population. While online wellness programming has been shown to be effective in decreasing fatigue and improving mental wellness in a variety of chronic disease populations, limited data is available for PBC.

Aims

This pilot study aimed to assess the hypothesis that a 12-week, online, mind-body wellness program would be feasible (assessed through adherence and retention) and acceptable in people with PBC. We also aimed to explore indicators of impact on measures of wellbeing.

Methods

Persons with PBC were recruited across Alberta and British Columbia in January 2021. The program included a 20–30 minute video containing low intensity mindful movement, meditation, and breathwork (goal 2–3 times/week) as well as a weekly behaviour change tip, PBC tip from a physician, and PBC nutrition tip. The online programming was accompanied by brief (10-minute) once weekly phone check-ins from a member of the study team, and optional once monthly zoom group sessions hosted by the Canadian PBC Society. Satisfaction and adherence were assessed at the end of the study using a survey. The pre-post exploratory efficacy assessment included: fatigue (Modified Fatigue Impact Scale), perceived stress (Perceived Stress Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and HRQOL (PBC-40). Using a qualitative descriptive approach, we conducted semi-structured interviews at the end of the study to explore experiences with the intervention, and gather feedback for improvement.

Results

Participants (N = 32) completed baseline surveys and 29 (91%) were retained to end-of-study. Twenty-five (86%) adhered to the program goal of carrying out the mind-body practice at least 2–3 days per week. Comparing baseline to end-of-study, significant reductions were observed in fatigue (13%, p=0.004), anxiety (30%, p=0.005), and depression (28%, p=0.022), and significant improvements were observed in the PBC-40 itch (22%, 0.043), fatigue (13%, 0.005), cognitive (17%, 0.006), and emotional (18%, 0.001) domains. Eleven individuals participated in qualitative interviews, reporting an increase in energy, a more positive outlook, and increased knowledge of PBC. Feedback supported acceptability (satisfaction score of 90%), with fatigue cited as the primary barrier to increased program participation.

Conclusions

These findings suggest that a 12-week online mind-body intervention is feasible and acceptable to persons with PBC and has promising impact on efficacy. Recognizing the limitations of a single-arm study with a small sample size, a future RCT will be designed using this feedback.

Funding Agencies

MITACS Accelerate, Canadian PBC Society

African immigrant child health: A scoping review

The health of migrant children is a pressing issue. While most African migration takes place within Africa, a significant number of African migrants travel to outside of the continent. This article reports findings from a scoping review on the health of African immigrant children from sub-Saharan Africa now living outside of Africa. A systematic search for studies published between 2000 and 2019 resulted in only 20 studies reporting on the health of children up to 18 years of age migrating from sub-Saharan Africa. Data from these articles were thematically analyzed, highlighting concerns related to the children's nutrition status (n = 8), mental health (n = 7), and physical health (n = 5). Study participants were primarily from Somali and Ethiopia, and most studies were conducted in Australia or Israel. The review highlights several gaps related to the scope, range, and nature of evidence on the health of African immigrant children living outside of Africa. In particular, most focus on children's nutritional and mental health, but pay little attention to other health concerns this specific population may encounter or to the benefits associated with effective responses.

AB0298 PREGNANCY IN RHEUMATIC DISEASE: A REGION WIDE SURVEY OF CURRENT PRACTICE AMONGST CLINICIANS IN THE WESSEX MULTI-DISCIPLINARY CONNECTIVE TISSUE DISEASE NETWORK

Background:

Rheumatic diseases frequently affect females of child-bearing age, with implications for foetal and maternal outcomes.

Two-thirds (66%) of the women who died in the 2016-18 MBRRACE report were known to have pre-existing medical problems1. The NHS long-term plan supports creation of Maternal Medicine Networks to facilitate access to specialist care and advice in pregnancy.

Guidelines exist for use of disease modifying anti-rheumatic drugs (DMARDs) during pregnancy but other aspects of pregnancy related care in rheumatic disease remain less well defined. The Wessex wide connective tissue disease (CTD) network provides a multi-disciplinary forum to discuss cases, to obtain approval for high cost drugs, to compare practice in multiple hospitals but does not specifically discuss pregnancy related uncertainties.

Objectives:

To survey variations in clinical practice relating to rheumatic disease in pregnancy

Methods:

Following careful project planning with the tertiary referral centre obstetric lead consultant for maternal medicine, several areas of care were identified which were prone to local and individual variation. An anonymous online survey relating to these specific areas of pregnancy related care was circulated amongst members of the CTD network, including rheumatology consultants, rheumatology practitioners and specialist trainees.

Results:

16 responses were obtained across 7 hospital sites; 56% were from rheumatology consultants. 12/16 (75%) reported routinely offering contraceptive advice when prescribing DMARDs. Only 4/16 (25%) were aware of a specific pre-natal obstetric clinic available in their hospital. There was major variation in planned frequency of clinical review. 10/16 would increase frequency of review during pregnancy if a patient’s disease became active or unstable; 6/16 would aim to review patients approximately 3 monthly; 3/16 would not routinely increase frequency of review during pregnancy. Planned post-natal care was equally varied. 3/16 would routinely prescribe aspirin to all lupus women during pregnancy despite this being recommended for all women with SLE for prevention of pre-eclampsia2. Prescription of low molecular weight heparin was variable, and several responses were at odds with the current RCOG guidance on the subject3. 8/16 (50%) would prescribe corticosteroids judiciously in case of an acute disease flare.

Conclusion:

This survey has revealed significant variation in practice relating to rheumatic disease in pregnancy. Integrated care with colleagues from the regional referral centre for maternal medicine is required, in keeping with the recently published NICE guidance on the subject4. Adopting a hub and spoke model, with local centres working closely alongside a tertiary centre, will help optimise peri-partum care and outcome for patients with long-term rheumatic conditions.

References:

[1]Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) Saving Lives, Improving Mothers’ Care Maternal Report (December 2020). Available at https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2020/MBRRACE-UK_Maternal_Report_Dec_2020_v10.pdf [Accessed 28 January 2021]

[2]National Institute for Health and Care Excellence (2019) Hypertension in pregnancy: diagnosis and management (NICE guideline 133) Available at https://www.nice.org.uk/guidance/ng133 [Accessed 28 January 2021]

[3]Royal College of Obstetricians and Gynaecologists (2015) Reducing the risk of venous thromboembolism during pregnancy and the puerperium (Green-top Guideline Number 37a) Available at https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf [Accessed 5 January 2021]

[4]National Institute for Health and Care Excellence (2019) Intrapartum care for women with existing medical conditions or obstetric complications and their babies (NICE guideline 121) Available at https://www.nice.org.uk/guidance/ng121 [Accessed 5 January 2021]

Disclosure of Interests:

None declared

AB0409 INTRAVENOUS ILOPROST: A REGION WIDE SURVEY OF CURRENT PRESCRIBING AMONGST HOSPITALS IN THE WESSEX MULTI-DISCIPLINARY CONNECTIVE TISSUE DISEASE NETWORK

Background:

Digital ulceration in systemic sclerosis is a severe and disabling aspect of this complex, multi-system disease. Traditionally, intravenous (IV) iloprost has been prescribed to treat the problem. Alternative oral medications including sildenafil and bosentan are now readily available, although NHS clinical commissioning policy is yet to be updated to reflect changes in drug costs. Use of IV iloprost across Wessex was audited to review current practice across the region.

Objectives:

To compare use of IV iloprost across 7 different hospital rheumatology departments

Methods:

Data was collected across 7 different NHS hospital sites using rheumatology specific pharmacy records for high cost drug prescribing and a single uniform data collection proforma, which was then analysed by 1 person to ensure uniformity of results. Case notes were reviewed retrospectively to determine diagnosis, frequency and duration of iloprost treatment, if patients had been considered for sildenafil treatment (including if sildenafil was prescribed, any cautions or contra-indications to treatment, dose and any reason for discontinuation of treatment) and if patients had been considered for bosentan treatment and if it was prescribed.

Results:

45 patients were identified currently receiving IV iloprost. 32/45 (71%) had a diagnosis of systemic sclerosis, mixed connective tissue disease (CTD) or undifferentiated CTD (to be called scleroderma group). 13/45 had other miscellaneous diagnoses which had resulted in digital ulceration. These 13 patients were excluded from further analysis relating to sildenafil or bosentan prescribing as these medications were not indicated for other causes of digital ulceration. In the scleroderma group, 27/32 (84%) had been considered for sildenafil treatment. Of these, 8/27 started and discontinued due to intolerance and 17/27 remained on sildenafil. In the scleroderma group, 9/32 had been considered for bosentan treatment, and of these 7/9 remained on bosentan.

Conclusion:

The authors have identified that IV iloprost is still widely used for management of digital ulceration in rheumatology departments across seven different hospitals in Wessex. Most of this group of patients would likely be eligible for treatment with sildenafil or bosentan. Sildenafil intolerance is a challenge to management. Consideration of bosentan as a treatment option was limited in this group, and may be a cost-effective alternative to IV iloprost which would also eliminate the risk of infection associated with IV access in a potentially immunosuppressed group of patients.

Disclosure of Interests:

None declared

POS0295 NO CAUSAL EFFECTS OF GENETICALLY DETERMINED SERUM URATE LEVELS ON THE RISK OF ALL-CAUSE AND SITE-SPECIFIC CANCER: A MENDELIAN RANDOMIZATION STUDY

Background:

Positive associations between urate levels and gout and the risk of some cancer types (urogenital, prostate, gastrointestinal and lung) have been reported in a number of observational studies; however, whether the relationship is causal remains uncertain.

Objectives:

The study aim was to evaluate a causal effect of genetically determined serum urate (SU) concentrations on cancer risks (overall and major cancer types) in individuals with European ancestry using Mendelian randomization (MR) analyses design.

Methods:

We used the individual-level data from two population-based Swedish cohorts including middle-aged subjects (mean follow-up = 21.2 years), Malmö Diet Cancer and Malmö Preventive Project (MDC/MPP), for one-sample MR setting. Data from a total of 17,597 individuals (n = 17,597 for SU at baseline, diagnoses during follow-up: 5659 for all-cause, 516 for bladder, 545 for lung, 791 for bowel, 1521 for prostate and 729 for breast cancer) was included. For two-sample MR, summary-statistic data for SU was obtained from Global Urate Genetic Consortium (GUGC: n = 110,347), while UK-Biobank data was employed for several major cancer outcomes (n = 36,815 for all-cause, 2,245 for bladder, 2,590 for lung, 4,488 for bowel, 6,474 for prostate and 10,274 for breast cancer). The definitions for cancer endpoints were matched for ICD9 and 10 codes between MDC/MPP and UK-Biobank cohorts. For both MR settings, a set of 26 urate-associated single nucleotide variants was selected to build-up the SU instrument (SU-instr) to test for a causal effect of SU on cancer outcomes. Statistical analysis, adjusted for age and sex, was done using multiple conventional MR methodologies and MR package in R (v4.0.2). A p < 0.05 was designated as statistically significant.

Results:

We found no causal effect of our SU-instr on neither all-cause nor site-specific cancer across all MR analyses (all p > 0.05). In MDC/MPP, SU-instr did not show a causal effect on the risk of all-cause [OR = 1.06, p = 0.32], bladder [OR = 0.96, p = 0.84], lung [OR = 1.26, p = 0.17], bowel [OR = 0.96, p = 0.81], prostate [OR = 1.05, p = 0.62], and breast [OR = 0.99, p = 0.98] cancer. Similar findings were made in the two-sample settings. Detailed results are provided in Table 1.

Conclusion:

Our MR study, using a series of causal inference approaches, does not support a causal effect of genetically determined SU for major cancer outcomes. There is no evidence to support changing SU levels by lifestyle or pharmacological intervention to attenuate the risk of major cancer types.

Table 1.

Results from a range of MR analyses for causal effect of SU on cancer risk in MDC/MPP (one-sample MR) and GUGC and UK-Biobank (two-sample MR) cohorts

One-sample MRCancer typeIVW2SLSGRSOR(95% CI)p-causalp-HetOR(95% CI)p-causalOR(95% CI)p-causalBladder0.96(0.68; 1.36)0.840.550.99(0.70; 1.42)0.990.94(0.67; 1.34)0.76Lung1.26(0.90; 1.77)0.170.891.29(0.91; 1.82)0.141.26(0.90; 1.77)0.17Bowel0.96(0.72; 1.28)0.810.440.95(0.72; 1.27)0.770.97(0.73; 1.28)0.83Prostate1.05(0.84; 1.31)0.620.841.04(0.83; 1.30)0.721.04(0.83; 1.30)0.69Breast0.99(0.74; 1.33)0.980.110.98(0.73; 1.32)0.920.98(0.73; 1.32)0.94All-cause1.06(0.93; 1.21)0.320.61.07(0.94; 1.21)0.281.07(0.94; 1.21)0.29Two-sample MRCancer typeIVWWeighted medianMR-EggerOR(95% CI)p-causalp-HetOR(95% CI)p-causalOR(95% CI)p-causalBladder1.02(0.88; 2.16)0.770.361.03(0.86; 2.10)0.71.03(0.83; 2.13)0.75Lung0.86(0.73; 1.08)0.070.040.86(0.73; 1.09)0.090.84(0.66; 1.16)0.15Bowel0.82(0.69; 1.02)0.03< 0.00010.89(0.78; 1.06)0.060.92(0.72;1.67)0.52Prostate1.00(0.91; 2.64)0.970.720.98(0.88; 2.17)0.770.94(0.83; 1.45)0.37Breast0.97(0.88; 1.95)0.670.00021.00(0.91; 2.70)0.990.95(0.81; 1.59)0.46All-cause0.96(0.90; 1.20)0.18< 0.00010.97(0.92; 1.23)0.210.93(0.86; 1.12)0.11

OR; odds ratio, 95% CI; 95% confidence interval, IVW; Inverse variance weighted method, 2SLS; two-stage least square, GRS; genetic risk score, p-Het; p-value for heterogeneity.

Disclosure of Interests:

None declared

Feasibility of Dual Energy X-Ray Absorptiometry Based Images for Measurement of Height, Sitting Height, and Leg Length in Children

BACKGROUND

Interpretation of pediatric bone mineral density by dual energy absorptiometry (DXA) requires adjustment for height (Ht). This is often not easily obtainable in nonambulant subjects.

AIMS

To investigate the feasibility of using DXA images to evaluate measurements of Ht, sitting height (SH), and leg length (LL).

METHODOLOGY

A total of 2 observers performed measurements of Ht, SH, and LL on 3 separate occasion using DXA digital images in 125 children. Intraclass correlation and relative technical error of measurement (rTEM) were performed to assess reliability of repeated measurements. In 25 children, Ht and SH were measured in clinic on the same day and Bland-Altman analysis was performed to compare DXA measured Ht, SH, LL with clinic measurements for these 25 children.

RESULTS

Intraclass correlation for DXA based Ht, SH, and LL measurements ranged from 0.996 to 0.998 (p < 0.0001). rTEM of Ht, SH, and LL for observer 1 was 0.0016%, 0.002%, and 0.0034%, respectively. rTEM of Ht, SH, and LL between observer 1 and 2 was 0.0047%, 0.0049%, and 0.0087%, respectively. Mean difference between clinic and DXA measurements from Bland-Altman plots were +0.57 cm (95% confidence interval [CI] -0.54 to +1.68) for Ht, +1.33cm (-1.60 to +4.24) for SH, and -0.76cm (-3.88 to +2.37) for LL.

CONCLUSIONS

Our study demonstrated for the first time that Ht, SH, and LL in children can be measured very precisely using DXA images. Ht can be measured accurately. We believe this may be a convenient method to obtain Ht measurements to allow size adjustment of DXA bone mineral density in immobile children with chronic conditions.

A222 EPIDEMIOLOGICAL, PHENOTYPIC AND CLINICAL PATTERNS OF EXTRAINTESTINAL MANIFESTATIONS IN INFLAMMATORY BOWEL DISEASE

Background

Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), may affect multiple organ systems. The extraintestinal manifestations (EIMs) occur frequently, considerably increase morbidity and mortality, and strongly influence the quality of life in IBD patients.

Aims

To establish the all-time prevalence of EIMs in a large cohort of IBD patients and assess risk factors contributing to their development.

Methods

We conducted a retrospective cohort study of IBD patients followed at the Division of Gastroenterology, University of Alberta, diagnosed between 1954 and 2019. We recorded demographic, clinical, and biochemical data. The EIMs included dermatological, musculoskeletal, ophthalmological, hepatobiliary, urogenital, and pulmonary manifestations. The chi-square and Mann-Whitney tests (median, IQR) were used to evaluate differences. Univariate logistic regression was used to determine the association of EIMs with demographic and disease-specific variables across CD and UC, with predictors (p≤0.05) further incorporated into multivariate regression models.

Results

We analyzed data of 4493 IBD patients: 2354 with CD and 2139 – with UC, aged 18–96 years. Males were underrepresented in the CD cohort compared to the UC (47.8% vs 52.8%; p=0.001), with longer disease duration (16.3, IQR 16.1 vs 12.3, IQR 12.4 years; p≤0.001). The EIMs were slightly more prevalent in the CD group compared to UC (22.2% vs 20.4%; p=0.134), along with a significantly higher proportion of patients with over two EIMs (4.1% vs 1.7%; p≤0.001). The EIMs’ pattern varied substantially between the IBD subtypes (Figure). In the CD cohort, the most common EIM was peripheral arthropathy (4.1%), followed by ankylosing spondylitis (4.0%) and nephrolithiasis (3.6%). Among CD patients, disease duration ≥20 years (OR 1.70, 95% CI 1.17–2.48; p=0.006), iron (OR 1.54, 95%CI 1.13–2.09; p=0.006) and calcium (OR 2.28, 95% CI 1.21–4.27; p=0.010) deficiencies were identified as risk factors for EIMs. The UC patients most frequently had primary sclerosing cholangitis (9.6%) with peripheral arthropathy and nephrolithiasis each being present in 2.2% of patients. In the UC cohort, three variables demonstrated the most significant associations with EIMs: male sex (OR 1.75, 95% CI 1.32–2.32; p≤0.001), disease duration ≥20 years (OR 1.93, 95% CI 1.35–2.74; p≤0.001), and pan-colonic disease extent (OR 2.12, 95% CI 1.03–4.36; p=0.041) (Table).

Conclusions

Our data demonstrate that over one-fifth of IBD patients had at least one EIM over the course of the disease and the EIMs pattern varies substantially across CD and UC. Identification of risk factors allowing prediction of EIMs would increase awareness, assist in their early recognition, and tailor further management.

Funding Agencies

AbbVie

Evaluating latent tuberculosis testing and treatment programme for new migrants in South East England

Background

Tuberculosis (TB) cases in England often originate from high burden TB countries due to ’reactivation’ of the latent TB infection (LTBI), an asymptomatic and non-infectious phase lasting years. 5,137 TB cases were notified in England in 2017, and 71% of these patients were born outside the UK. This mixed-method study evaluated the implementation of the four LTBI testing and treatment programme for new migrants in South East (SE) England.

Methods

A retrospective database (May 2016-Feb 2018) review was undertaken to identify LTBI cases using multiple data sources; LTBI testing laboratories, LTBI programmes, and the national TB team at Public Health England. In addition, a survey questionnaire was emailed to 51 stakeholders (45% response rate) and five in-depth interviews were conducted with LTBI programme leads/TB nurses to explore the challenges of the programme. Quantitative data were analysed using descriptive summary statistics and qualitative interviews were analysed using thematic content analysis.

Results

Of the 5931 eligible patients, 40 % (n = 2391) accepted the LTBI test and 13.4% (n = 321) tested positive. 93.1% (n = 299) of the positive patients were referred for treatment and 63.8% (n = 191) of these accepted the treatment. The programme also picked up 18 active TB cases, an unexpected incidental finding. Results from the survey and the interviews identified laboratory arrangements, workforce, and data collection/management as the greatest challenges for the LTBI programme. Patient focused care, cultural understanding, success in testing/treating migrants, and raising awareness amongst professionals/communities were highlighted as achievements of the programme.

Conclusions

This study found that LTBI programmes in SE England are in line with national expectations and other LTBI programmes in England. The study recognises the achievements and good practice of the LTBI teams in SE England and identifies key barriers to improve the service for the future.

Key messages

Data collection and management is the biggest challenges of the LTBI programmes in SE England. The LTBI programmes in SE England are in line with national expectations.

UK Role 4 military infectious diseases and tropical medicine cases in 2005-2013

INTRODUCTION

Infectious diseases are a frequent cause of morbidity among British troops. The aim of this paper is to describe the spectrum of infectious diseases seen when UK service personnel are evacuated for definitive care to the Role 4 Medical Treatment Facility based at Birmingham Heartlands Hospital.

METHOD

A retrospective analysis of all military patients presenting with infectious diseases and treated at Birmingham Heartlands Hospital between 14 April 2005 and 31 December 2013 was undertaken.

RESULTS

During this period, 502 patients were identified. Infections originated in 49 countries, most commonly Afghanistan (46% cases), the UK (10% cases) and Belize (9% of cases). The most common presentations were dermatological conditions, gastroenterological illnesses and undifferentiated fevers.

CONCLUSION

UK service personnel in significant numbers continue to suffer a wide range of infectious diseases, acquired throughout the globe, which often require specialist tertiary infection services to diagnose and manage. Future prospective data collection is recommended to identify trends, which in turn will inform military training needs and future research priorities in the Defence Medical Services (DMS) and allows development of appropriate policies and clinical guidelines for management of DMS personnel with infectious diseases.

Noninvasive In-Situ Measurement of Blood Lactate Using Microwave Sensors

GOAL

This paper reports a novel electromagnetic sensor technique for real-time noninvasive monitoring of blood lactate in human subjects.

METHODS

The technique was demonstrated on 34 participants who undertook a cycling regime, with rest period before and after, to produce a rising and falling lactate response curve. Sensors attached to the arm and legs of participants gathered spectral data, blood samples were measured using a Lactate Pro V2; temperature and heart rate data was also collected.

RESULTS

Pointwise mutual information and neural networks are used to produce a predictive model. The model shows a good correlation between the standard invasive and novel noninvasive electromagnetic wave based blood lactate measurements, with an error of 13.4% in the range of 0-12 mmol/L.

CONCLUSION

The work demonstrates that electromagnetic wave sensors are capable of determining blood lactate level without the need for invasive blood sampling.

SIGNIFICANCE

Measurement of blood metabolites, such as blood lactate, in real-time and noninvasively in hospital environments will reduce the risk of infection, increase the frequency of measurement and ensure timely intervention only when necessary. In sports, such tools will enhance training of athletes, and enable more effecting training regimes to be prescribed.

Genetic and treatment-related risk factors associated with external apical root resorption (EARR) concurrent with orthodontia

OBJECTIVE

As genetic variation accounts for two-thirds of the variation in external apical root resorption (EARR) concurrent with orthodontic treatment, we analyzed the association of selected genetic and treatment-related factors with EARR concurrent with orthodontic treatment.

SETTING AND SAMPLE POPULATION

This case-control study of 134 unrelated, orthodontically treated Caucasian individuals was conducted in part at an Indiana Private Practice, Indiana University and the University of Kentucky.

METHODS

Utilizing a research data bank containing information from ~1450 orthodontically treated patients, pre- and post-treatment radiographs from 460 individuals were evaluated for EARR of the four permanent maxillary incisors. Sixty-seven unrelated Caucasians with moderate to severe EARR were identified and were age-/sex-matched with orthodontically treated Caucasian controls yielding 38 females and 29 males per group. Factors tested for an association with EARR included the following: 1) treatment duration, 2) extraction of maxillary premolars, 3) numerous cephalometric measurements, and 4) DNA polymorphisms within/near candidate genes in a pathway previously implicated in EARR such as the purinergic-receptor-P2X, ligand-gated ion channel 7 (P2RX7; rs208294, rs1718119, and rs2230912), caspase-1 (CASP1; rs530537, rs580253, and rs554344), interleukin-1 beta (IL1B; rs1143634), interleukin-1 alpha (IL1A; rs1800587), and interleukin-1 receptor antagonist (IL1RA; rs419598) genes. Stepwise logistic regression was utilized to identify the factors significantly associated (significance taken at or less than the layered Bonferroni correction alpha) with the occurrence of EARR.

RESULTS

A long length of treatment and the presence of specific genotypes for P2RX7 SNP rs208294 were significantly associated with EARR.

CONCLUSION

EARR occurrence was associated with both genetic and treatment-related variables, which together explained 25% of the total variation associated with EARR in the sample tested.

An audit of the management of childhood-onset growth hormone deficiency during young adulthood in Scotland

Background

Adolescents with childhood onset growth hormone deficiency (CO-GHD) require re-evaluation of their growth hormone (GH) axis on attainment of final height to determine eligibility for adult GH therapy (rhGH).

Aim

Retrospective multicentre review of management of young adults with CO-GHD in four paediatric centres in Scotland during transition.

Patients

Medical records of 130 eligible CO-GHD adolescents (78 males), who attained final height between 2005 and 2013 were reviewed. Median (range) age at initial diagnosis of CO-GHD was 10.7 years (0.1–16.4) with a stimulated GH peak of 2.3 μg/l (0.1–6.5). Median age at initiation of rhGH was 10.8 years (0.4–17.0).

Results

Of the 130 CO-GHD adolescents, 74/130(57 %) had GH axis re-evaluation by stimulation tests /IGF-1 measurements. Of those, 61/74 (82 %) remained GHD with 51/74 (69 %) restarting adult rhGH. Predictors of persistent GHD included an organic hypothalamic-pituitary disorder and multiple pituitary hormone deficiencies (MPHD). Of the remaining 56/130 (43 %) patients who were not re-tested, 34/56 (61 %) were transferred to adult services on rhGH without biochemical retesting and 32/34 of these had MPHD. The proportion of adults who were offered rhGH without biochemical re-testing in the four centres ranged between 10 and 50 % of their total cohort.

Conclusions

A substantial proportion of adults with CO-GHD remain GHD, particularly those with MPHD and most opt for treatment with rhGH. Despite clinical guidelines, there is significant variation in the management of CO-GHD in young adulthood across Scotland.

Prioritizing investment in public health and health equity: what can commissioners do?

OBJECTIVES

To explore commissioners' views on prioritizing for investment in health. This study reviewed: methods for decision support; their relevance for prioritizing health and health equity in principle; and their adoption by decision makers in practice.

METHODS

Decision makers' views were sought through semi-structured interviews and an online survey, and prioritization tools were reviewed. Interviews were held in 2008-2009 with a subsample followed up in 2009-2010. In late 2009, a national online survey was sent to 508 individuals across 146 primary care trusts (PCTs). The two phases of the interviews comprised 52 and 17 participants, respectively. Responses to the national survey were received from 138 decision makers in 95 (65%) PCTs. Prioritization tools were identified through interviews and the survey as above, a rapid review of literature and in consultation with health economists. A grounded theory approach was adopted for the qualitative interview analysis.

RESULTS

Although most PCTs used a prioritization framework, few of the tools identified in this review were used by public health commissioners. This was partly a consequence of limitations of priority-setting tools in the context of public health investment, and partly a lack of relevant skills and data. Tensions in relation to developing strategies for disinvestment and in prioritizing a long-term public health agenda in a context of economic austerity were evident.

CONCLUSIONS

The context for decision making appears to be more important than the deployment of specific tools and techniques. Commissioners need to recognize the limitations of priority-setting tools, but also know how to apply them to help maximize health gain and health equity over the longer term. Decision-support tools should be developed in collaboration with public health commissioners to ensure relevance and practicality of use.

Impact of inflammatory bowel disease on pubertal growth

BACKGROUND

Puberty is thought to be commonly affected in adolescents with inflammatory bowel disease (IBD).

AIMS

To determine the impact of Crohn's disease (CD) and ulcerative colitis (UC) on the pubertal growth spurt.

METHODS

Retrospective study of 30 boys with CD (CD-M), 11 girls with CD (CD-F), 14 boys with UC (UC-M) and 12 girls with UC (UC-F). Pubertal growth was assessed by calculating peak height velocity SDS (PHV SDS), height SDS at diagnosis (Ht(Diag)) and height SDS at PHV (Ht(PHV)) and age at PHV (Age(PHV)). Systemic markers of disease activity were also collected.

RESULTS

Altered parameters of pubertal growth were observed in the CD groups compared to the normal population: in the CD-M group, median Ht(Diag) was -0.56 (p = 0.001) and median Age(PHV) was 14.45 years (p = 0.004), and in the CD-F group, median Ht(Diag) was -1.14 (p = 0.007) and Ht(PHV) was -0.79 (p = 0.039). Individually, 8/30 CD-M cases had one or more parameter affected: 2 boys had Ht(Diag )<-2, 3 boys had Ht(PHV) <-2, 2 boys had an Age(PHV) >2 years above population mean, and 2 boys had a PHV SDS <-2. In the whole group, Age(PHV) showed an association with erythrocyte sedimentation rate (r = 0.4; p = 0.005) and an inverse association with BMI (r = 0.4; p = 0.001).

CONCLUSION

Disorders of pubertal growth are more likely to occur in CD and, particularly, in boys.

Effect of testosterone therapy for delayed growth and puberty in boys with inflammatory bowel disease

BACKGROUND

pubertal delay and growth retardation are common in children with inflammatory bowel disease (IBD).

AIMS

To assess pubertal status and growth in a group of boys with IBD undergoing testosterone therapy for pubertal induction.

METHODS

retrospective study of height, weight and pubertal status in 8 boys with IBD before and after testosterone therapy. Height velocity (HV) over the 6 months before each assessment was converted to standard deviation score. Markers of disease activity and concomitant medication were recorded. Response was based on an advance in pubertal status and a greater than 50% increase in HV.

RESULTS

eight boys with IBD, median age 14.8 years, had pubertal induction using either monthly injections of 50 mg Sustanon or daily 2.5/5 mg Andropatch. Seven boys showed an advance of pubertal status. Six boys had a greater than 50% increase in HV; median HV at T0 was 1.6 cm/year (0, 5) compared with 6.9 cm/year (1, 11.7) at T6 (p = 0.005). C-reactive protein during testosterone therapy had a significant association with HV at T6 (r = -0.786; p = 0.021).

CONCLUSION

in most cases, testosterone therapy in boys with IBD and delayed growth and puberty is associated with an advance in pubertal status and an improvement in growth.

Oesophageal xanthalasma with Barrett's Oesophagus and Menetrier's Disease

This case report describes three conditions; oesophageal xanthalasma, Menetrier’s disease and Barrett’s oesophagus, none of which have ever been seen together, diagnosed in one patient. Further to the details of the case the endoscopic, radiological and histological findings are discussed. Any links between these three conditions are currently unclear.

The Influence of W Filament Alloying on the Electronic Properties of Hwcvd Deposited a-Si:H Films

In depositing a-Si:H by HWCVD using W filaments, one issue common to this technique is that of filament lifetime. When using undiluted silane as the source gas, a buildup of silicon at the colder ends of the filament is routinely observed (thickening), and it is here that filament breakage usually occurs. Less well understood is the effect of filament alloy formation on a-Si:H electronic properties. In this work we combine ambipolar diffusion length (SSPG) measurements on consecutively deposited a-Si:H films with SEM surface topography and sputter (SP) Auger depth profiling of the filament Si/(W+Si) composition to track film electronic properties as a function of the Si buildup on short filaments entirely exposed to the growing film surface. We find that with increasing exposure time of the filament to silane, appreciable Si exists everywhere along the filament length, even in the non-thickened central regions. We discuss the effect of this alloying on the film deposition rate and electronic properties, and suggest that the nature of the filament surface must be carefully considered when optimizing a- Si:H film electronic properties. Finally, we discuss possible ways to minimize this alloying by post deposition treatments, which include different filament ‘run’ temperatures.

Factors affecting the uptake of new medicines in secondary care - a literature review

BACKGROUND AND OBJECTIVE

The rate of uptake of new medicines in the UK is slower than in many other OECD countries. The majority of new medicines are introduced initially in secondary care and prescribed by specialists. However, the reasons for relatively low precribing levels are poorly understood. This review explores the determinants of uptake of new medicines in secondary care.

METHODS

Nine electronic databases were searched covering the period 1992-2006. Once the searches had been run, records were downloaded and those which evaluated uptake of new medicines in secondary care were identified. UK studies were of primary interest, although research conducted in other countries was also reviewed if relevant. With the exception of 'think pieces', eligibility was not limited by study design. Studies published in languages other than English were excluded from the review. Determinants of uptake in secondary care were classified using Bonair and Persson's typology for determinants of the diffusion of innovation.

RESULTS

Almost 1400 records were screened for eligibility, and 29 studies were included in the review. Prescribing of new medicines in secondary care was found to be subject to a number of interacting influences. The support structures which exist within secondary care facilitate access to other colleagues and shape prescribing practices. Clinical trial investigators and physicians who sit on decision-making bodies such as Drug and Therapeutic Committees (DTCs) appear to have a special influence due to their proximity to their research and understanding of evidence base. Pharmaceutical representatives may also influence prescribing decisions through funding of meetings and academic detailing, but clinicians are wary of potential bias. Little evidence on the influence of patients upon prescribing decisions was identified. The impact of clinical guidelines has been variable. Some guidelines have significantly increased the uptake of new medicines, but others have had little discernible impact despite extensive dissemination. However given the increasing influence of the National Institute for Health and Clinical Excellence, guidelines may become more important. The impact of financial prescribing incentives on secondary care prescribing is unclear. Although cost and budget may influence hospital prescribing of new drugs, they are of secondary importance to the safety and effectiveness profile of the medicine. If a drug has a novel mechanism of action, or belongs to a class with few alternatives, clinicians are more likely to consider it favourably as a prescribing option.

CONCLUSIONS

Although price does not appear to be a primary factor behind prescribing decision-making, in secondary care there has long been a historical need for formal purchasing decisions through the DTC, which differentiates it from primary care. This, in addition to increasing pressures for cost-effectiveness within the NHS means that cost will appear more frequently on clinician consciousness. As a result, guidelines are more likely to be implemented using the strong professional networks in existence within secondary care, and although the influence of patients has not been addressed by the literature, they are likely to have an increasing input into the prescribing decision, given the importance of patient involvement in current UK policy.

A systematic review of the effectiveness and cost-effectiveness of different models of community-based respite care for frail older people and their carers

OBJECTIVES

To review the evidence for different models of community-based respite care for frail older people and their carers, where the participant group included older people with frailty, disability, cancer or dementia. Where data permitted, subgroups of carers and care recipients, for whom respite care is particularly effective or cost-effective, were to be identified.

DATA SOURCES

Major databases were searched from 1980 to March 2005. Ongoing and recently completed research databases were searched in July 2005.

REVIEW METHODS

Data from relevant studies were extracted and quality assessed. The possible effects of study quality on the effectiveness data and review findings were discussed. Where sufficient clinically and statistically similar data were available, data were pooled using appropriate statistical techniques.

RESULTS

Twenty-two primary studies were included. Most of the evidence came from North America, with a minority of effectiveness and economic studies based in the UK. Types of service studied included day care, host family, in-home, institutional and video respite. Effectiveness evidence suggests that the consequences of respite upon carers and care recipients are generally small, with better controlled studies finding modest benefits only for certain subgroups. However, many studies report high levels of carer satisfaction. No reliable evidence was found that respite can delay entry to residential care or that respite adversely affects care recipients. Randomisation validity in the included randomised studies was sometimes unclear. Studies reported many different outcome measures, and all of the quasi-experimental and uncontrolled studies had methodological weaknesses. The descriptions of the studies did not provide sufficient detail of the methods of data collection or analysis, and the studies failed to describe adequately the groups of study participants. In some studies, only evidence to support respite care services was presented, rather than a balanced view of the services. Only five economic evaluations of respite care services were found, all of which compared day care with usual care and only one study was undertaken in the UK. Day care tended to be associated with higher costs and either similar or a slight increase in benefits, relative to usual care. The economic evaluations were based on two randomised and three quasi-experimental studies, all of which were included in the effectiveness analysis. The majority of studies assessed health and social service use and cost, but inadequate reporting limits the potential for exploring applicability to the UK setting. No study included generic health-related quality of life measures, making cost-effectiveness comparisons with other healthcare programmes difficult. One study used sensitivity analysis to explore the robustness of the findings.

CONCLUSIONS

The literature review provides some evidence that respite for carers of frail elderly people may have a small positive effect upon carers in terms of burden and mental or physical health. Carers were generally very satisfied with respite. No reliable evidence was found that respite either benefits or adversely affects care recipients, or that it delays entry to residential care. Economic evidence suggests that day care is at least as costly as usual care. Pilot studies are needed to inform full-scale studies of respite in the UK.