The Impact of Patient Travel Distance on Outpatient Visit Satisfaction: Comparison of Telehealth and Traditional In-Person Visits

Introduction: Patient satisfaction has been shown to changes based on the distance a patient to see their physician. We sought to examine the effects of telehealth on patient satisfaction. Methods: We examined patient satisfaction survey scores from outpatient clinics at University of California, San Francisco. Patient home and clinic addresses were used to calculate distance in kilometers (km). Outcomes were "top scores (9-10)" and "low scores (<9)." Results: Of 103,124 evaluations that met inclusion criteria, those where patient traveled >100 km for in-person visits had more top scores (84%) than those traveled <10 km (80.2%). Relative to in-person visits, telehealth was associated with an increased odds (odds ratio [OR]: 1.48) of receiving a top score at all distances. Those traveling >100 km had the highest odds of top score for telehealth (OR: 1.86). Conclusions: Patients receiving care through telehealth, particularly those far from the outpatient clinic, are more likely to provide high patient satisfaction scores for the visit provider.

The Impact of Patient-Physician Racial and Gender Concordance on Patient Satisfaction with Outpatient Clinic Visits

BACKGROUND

Patient and provider race and gender concordance (patient and physician identify as the same race/ethnicity or gender) may impact patient experience and satisfaction.

OBJECTIVE

We sought to examine how patient and physician racial and gender concordance effect patient satisfaction with outpatient clinical encounters. Furthermore, we examined factors that changed satisfaction among concordant and discordant dyads.

DESIGN

Consumer Assessment of Healthcare Provider and Systems (CAHPS) Patient Satisfaction Survey Scores were collected from outpatient clinical encounters between January 2017 and January 2019 at the University of California, San Francisco.

PARTICIPANTS

Patients who were seen in the eligible time period, who voluntarily provided physician satisfaction scores. Providers with fewer than 30 reviews and encounters with missing data were excluded.

MAIN MEASURES

Primary outcome was rate of top satisfaction score. The provider score (1-10 scale) was dichotomized as "top score (9-10)" and "low scores (<9)."

KEY RESULTS

A total of 77,543 evaluations met inclusion criteria. Most patients identified as White (73.5%) and female (55.4%) with a median age of 60 (IQR 45, 70). Compared to White patients, Asian patients were less likely to give a top score even when controlling for racial concordance (OR: 0.67; CI 0.63-0.714). Telehealth was associated with increased odds of a top score relative to in-person visits (OR 1.25; CI 1.07-1.48). The odds of a top score decreased by 11% in racially discordant dyads.

CONCLUSIONS

Racial concordance, particularly among older, White, male patients, is a nonmodifiable predictor of patient satisfaction. Physicians of color are at a disadvantage, as they receive lower patient satisfaction scores, even in race concordant pairs, with Asian physicians seeing Asian patients receiving the lowest scores. Patient satisfaction data is likely an inappropriate means of determining physician incentives as such may perpetuate racial and gender disadvantages.

Radiation-induced Fistulas in Patients With Prior Pelvic Radiotherapy for Prostate Cancer: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically aggregate and summarize existing data on fistula prevalence among patients with a history of pelvic radiotherapy for prostate cancer.

MATERIALS AND METHODS

We queried PubMed, Embase, and Web of Science on October 7, 2020 for peer-reviewed publications pertaining to radiation-induced fistulas in the pelvis. For meta-analysis, we used the random-effects model. We used the I2 statistic to quantify heterogeneity and the Newcastle-Ottawa Scale to assess risk of bias.

RESULTS

Our final meta-analysis included 6 cohort studies with a total of 7665 patients exposed to pelvic radiotherapy between 1967 and 2013. Median follow-up time was 35.5 months (IQR 33.5-57.5). Pooled prevalence of radiation-induced fistula across all 6 cohort studies was 0.2% (95% CI: 0.1-0.4, I2 = 0.000%, P < .608). In subgroup analysis, we did not detect significant heterogeneity in fistula prevalence in patients who were re-irradiated (0.3%, 95% CI: 0.1-0.4; P = .762) or patients on concurrent chemotherapy (0.4%, 95% CI: -0.3 -1.2; P = .664) compared to those receiving their first course of radiotherapy alone. No randomized controlled trials met inclusion criteria due to ambiguous and inconsistent reporting language for fistula occurrence.

CONCLUSION

There is limited published literature reporting fistula as an adverse event of prostate cancer radiotherapy, especially in the medium and long-term period. Patients undergoing pelvic radiotherapy for prostate cancer appear at low short-term risk for developing fistulas. Adverse event reporting in randomized controlled trials merits greater granularity where fistulas should be reported with specificity rather than aggregating into broad categories of genitourinary or gastrointestinal adverse events.

Ultrafast transition between exciton phases in van der Waals heterostructures

Heterostructures of atomically thin van der Waals bonded monolayers have opened a unique platform to engineer Coulomb correlations, shaping excitonic^1-3, Mott insulating⁴ or superconducting phases^5,6. In transition metal dichalcogenide heterostructures⁷, electrons and holes residing in different monolayers can bind into spatially indirect excitons^1,3,8-11 with a strong potential for optoelectronics^11,12, valleytronics^1,3,13, Bose condensation¹⁴, superfluidity^14,15 and moiré-induced nanodot lattices¹⁶. Yet these ideas require a microscopic understanding of the formation, dissociation and thermalization dynamics of correlations including ultrafast phase transitions. Here we introduce a direct ultrafast access to Coulomb correlations between monolayers, where phase-locked mid-infrared pulses allow us to measure the binding energy of interlayer excitons in WSe₂/WS₂ hetero-bilayers by revealing a novel 1s-2p resonance, explained by a fully quantum mechanical model. Furthermore, we trace, with subcycle time resolution, the transformation of an exciton gas photogenerated in the WSe₂ layer directly into interlayer excitons. Depending on the stacking angle, intra- and interlayer species coexist on picosecond scales and the 1s-2p resonance becomes renormalized. Our work provides a direct measurement of the binding energy of interlayer excitons and opens the possibility to trace and control correlations in novel artificial materials.

The impact of early surgical intervention in free intestinal perforation: a time-to-intervention pilot study

PURPOSES

An abdominal inflammatory focus is the second most often source of sepsis with a high risk of death in surgical intensive care units. By establishing evidence-based bundled strategies the surviving sepsis campaign provided an optimized rapid and continuous treatment of these emergency patients. Hereby the hospital mortality decreased from 35 to 30 %. Sepsis treatment is based on three major therapeutic elements: surgical treatment (source control), antiinfective treatment, and supportive care. The international guidelines of the surviving sepsis campaign were updated recently and recommend rapid diagnosis of the infection and source control within the first 12 h after the diagnosis (grade 1c). Interestingly this recommendation is mainly based on studies on soft tissue infections.

METHODS

In this retrospective analysis 76 septic patients with an intraabdominal inflammatory focus were included. All patients underwent surgery at different time-points after diagnosis.

RESULTS

With 80 % patients of the early intervention group had an improved overall survival (vs. 73 % in the late intervention group).

CONCLUSIONS

Literature on the time dependency of early source control is rare and in part contradicting. Results of this pilot study reveal that immediate surgical intervention might be of advantage for septic emergency patients. Further multi-center approaches will be necessary to evaluate, whether the TTI has any impact on the outcome of septic patients with intestinal perforation.

Public health assessment of hexachlorobenzene

Recently, hexachlorobenzene (HCB) was proposed for inclusion in the system of toxicity equivalency factors (TEFs) currently used for dioxin-like compounds. In this paper, we explore the practical implications of the proposition to the Agency for Toxic Substances and Disease Registry (ATSDR) programs by comparing respective health guidance values for 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) and HCB (expressed as total toxicity equivalents [TEQs]), reviewing possible interactions between HCB and dioxin-like chemicals, and by providing information on actual co-existence of HCB and dioxin-like chemicals at hazardous waste sites. We found a good correlation between the TEF-adjusted oral exposure guidance values for HCB and guidance values for TCDD. The combination of HCB and other dioxin-like compounds was not found in soil, air, or water media at hazardous waste sites. Based on this fact, it is not necessary to include HCB in the total TEQ count at hazardous waste sites at this time.

Reducing uncertainty in the derivation and application of health guidance values in public health practice. Dioxin as a case study

We were requested by the U.S. Environmental Protection Agency (EPA) to clarify the relationships among the minimal risk level (MRL), action level, and environmental media evaluation guide (EMEG) for dioxin established by the Agency for Toxic Substances and Disease Registry (ATSDR). In response we developed a document entitled "Dioxin and Dioxin-Like Compounds in Soil, Part I: ATSDR Interim Policy Guideline"; and a supporting document entitled "Dioxin and Dioxin-Like Compounds in Soil, Part II: Technical Support Document". In these documents, we evaluated the key assumptions underlying the development and use of the ATSDR action level, MRL, and EMEG for dioxin. We described the chronology of events outlining these different health guidance values for dioxin and identified the areas of uncertainty surrounding these values. Four scientific assumptions were found to have had a great impact on this process; these were: (1) the specific uncertainty factors used, (2) the toxicity equivalent (TEQ) approach, (3) the fractional exposure from different pathways, and (4) the use of body burdens in the absence of exposure data. This information was subsequently used to develop a framework for reducing the uncertainties in public health risk assessment associated with exposure to other chemical contaminants in the environment. Within this framework are a number of future directions for reducing uncertainty, including physiologically based pharmacokinetic modeling (PBPK), benchmark dose modeling (BMD), functional toxicology, and the assessment of chemical mixture interactions.

Expression of the death gene Bik/Nbk promotes sensitivity to drug-induced apoptosis in corticosteroid-resistant T-cell lymphoma and prevents tumor growth in severe combined immunodeficient mice

Members of the Bcl-2 gene family have been implicated in the regulation of cell death induced by cytostatic drugs. In some malignancies such as B-cell lymphoma, there is evidence that high expression of Bcl-2 is an independent negative prognostic marker and the overexpression of Bcl-2 has been shown to confer resistance to cytotoxic drugs by preventing drug-induced apoptosis. This function of Bcl-2 can be antagonized by apoptosis-promoting members of the Bcl-2 family. We previously showed that overexpression of Bax restores the chemosensitivity of Bax-deficient breast cancer cell lines. Therefore, we investigated whether the death-promoting Bcl-2 homologue Bik/Nbk can enhance cytostatic drug-induced apoptosis. As a model, we used the T-cell leukemia H9 (CD3(+) and CD4(+)CD8(-)), which is resistant to corticosteroid-induced cell death and does not express endogenous Bik/Nbk. Sensitivity for drug-induced apoptosis was increased 10- to 39-fold in cells transfected with the full-length coding sequence of Bik/Nbk. In addition, apoptosis induced via CD95/Fas or heat shock was increased to a similar extent. These data show that Bik/Nbk, which, unlike Bax, carries only a BH3 but no BH1 or BH2 domain may be a target to enhance chemosensitivity. The complete suppression of tumor growth in a severe combined immunodeficient mouse xenotransplant model suggests that, in analogy to Bax, Bik/Nbk may function as a tumor suppressor gene.

Site-specific consultation for a chemical mixture

The Agency for Toxic Substances and Disease Registry (ATSDR) uses the weight of evidence methodology to evaluate interactions of chemical mixtures. In the process, toxicity, toxicokinetics, and toxicodynamics of chemical components of the mixture are carefully examined. Based on the evaluation, predictions are made that can be used in real-life situations at hazardous waste sites. In this paper, health outcomes were evaluated for a mixture of eight compounds that were found at a specific site. These eight chemicals were identified and possibly associated with human exposure. The health assessors could consider similar thought processes when evaluating chemical mixtures at hazardous waste sites.

Public health assessment for dioxins exposure from soil

Dioxins are among the most toxic anthropogenic chemicals in the environment. Their toxicity has been extensively studied in both humans and animals. Dioxin-contaminated soil may result in dioxins occurring in a food chain. This is especially important for the general population. It has been estimated that about 98% of exposure to dioxins is through the oral route. In the 1980s, a concentration level of 1 ppb 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) in soil was specified as "a level of concern," based on cancer effects. However, recent studies indicate that end points other than cancer are also of concern. A health risk analysis scenario based on health effects of TCDD other than cancer is discussed and compared with the projected intake from 1 ppb TCDD in soil.

Halogenated aromatic hydrocarbons and toxicity equivalency factors (TEFs) from the public health assessment perspective

The validity of the toxicity equivalency factors (TEFs) approach to predicting toxicity of mixtures was investigated on the basis of the public health risk assessment that had been posted for different groups of halogenated aromatic hydrocarbons. First, the minimal risk levels (MRLs) were derived based on the databases available for chlorinated dibenzo-p-dioxins (CDDs), chlorinated dibenzofurans (CDFs), and polychlorinated biphenyls (PCBs). The MRL values were then converted to 2,3,7,8-tetrachlorinated dibenzo-p-dioxin (TCDD) toxicity equivalents (TEQs) and compared with each other. There was a good correlation between intermediate duration oral MRLs for TCDD and 2,3,4,7,8-pentaCDF when expressed in TEQs (7 pg/kg/day and 15 pg/kg/day). Although the studies that served for derivation of these MRLs used different species (guinea pigs and rats, respectively), the toxicity endpoints (immunological and hepatic for TCDD and hepatic for 2,3,4,7,8-pentaCDF) were comparable. The hepatic effects were measured by the same techniques (blood chemistry and histopathology), ensuring similar sensitivity. However, there was a discrepancy between acute oral MRLs for TCDD and 2,3,4,7,8-pentaCDF when they were expressed in TEQs (20 pg/kg/day and 500 pg/kg/day, respectively). The studies used for MRL derivation involved not only different species (mice and guinea pigs, respectively), the immunotoxicity endpoints were measured by techniques with different sensitivity (serum complement activity versus histopathology), making comparison difficult. Further calculations showed that the TEFs approach may be feasible for individual coplanar congeners of PCBs, but not for a mixture of Aroclors. Correlations presented here support the concept that the TEFs are valid only if specific criteria for their derivation are met (e.g., a broad database of information, consistency across endpoints, additivity for the effects, a common mechanism of action, etc.). In environmental exposure, the total toxicity of halogenated aromatic hydrocarbons is not necessarily the sum of the total individual congener toxicities because individual congeners compete for the same receptor; therefore, nonadditive behavior may occur.

[Extra-urogenital detection of Chlamydia trachomatis--perinatal transmission]

Infections produced by Chlamydia trachomatis reach an epidemic scale worldwide. Examination of 1,333 women with suspected cervicitis and other clinical symptoms revealed positive findings in 355 (27.5%). Of 72 examined men 25 (34.7%) were positive. Perinatal infection is confirmed also by positive evidence of Ch. t. in 28.9% neonates with conjunctivitis and 19% positive smears from the nasopharynx. The authors used the direct immunofluorescent method, Chlamyset of Orion Co., Finland.

[Detection of Chlamydia trachomatis in clinical material 1989-1990]

Examination of 276 smears and scrapings from the uterine cervix of women before delivery and during the puerperium revealed in 28.0% positive findings. Perinatal infection was confirmed by the presence of Chlamydia trachomatis in 35.5% neonates with conjunctivitis and 27.3% positive smears from the nasopharynx. The authors used the direct immunofluorescence method. For immunofluorescent staining they used Chlamyset of Orion Co., Finland.

[Detection of Chlamydia trachomatis in clinical material 1985-1988]

Investigation of 529 smears from the uterine cervix of women before delivery, during the puerperium and before induced abortion revealed positive findings in 25.2% of women before delivery and in 19.3% of women before induced abortion. Perinatal infection was confirmed by a positive finding of Ch. t. in 12.8% neonates with conjunctivitis and 15.4% from the nasopharynx. The direct immunofluorescent method was used. In another group of women examined by the serological method ELISA, from a total of 182 sera in 41.7% the presence of IgG antibodies was detected. In cervical smears from 10 seropositive women in seven Ch. t. was positive.