The status of patient portal use among Emergency Department patients experiencing houselessness: A large-scale single-center observational study

OBJECTIVE

Patient portal (PP) use has rapidly increased in recent years. However, the PP use status among houseless patients is largely unknown. We aim to determine 1) the PP use status among Emergency Department (ED) patients experiencing houselessness, and 2) whether PP use is linked to the increase in patient clinic visits.

METHODS

This is a single-center retrospective observational study. From March 1, 2019, to February 28, 2021, houseless patients who presented at ED were included. Their PP use status, including passive PP use (log-on only PP) and effective PP use (use PP of functions) was compared between houseless and non-houseless patients. The number of clinic visits was also compared between these two groups. Lastly, a multivariate logistic regression was analyzed to determine the association between houseless status and PP use.

RESULTS

We included a total of 236,684 patients, 13% of whom (30,956) were houseless at time of their encounter. Fewer houseless patients had effective PP use in comparison to non-houseless patients (7.3% versus 11.6%, p < 0.001). In addition, a higher number of clinic visits were found among houseless patients who had effective PP use than those without (18 versus 3, p < 0.001). The adjusted odds ratio of houseless status associated with PP use was 0.48 (95% CI 0.46-0.49, p < 0.001).

CONCLUSIONS

Houselessness is a potential risk factor preventing patient portal use. In addition, using patient portals could potentially increase clinic visits among the houseless patient population.

Routine HIV clinic visit adherence in the African Cohort Study

Background

Retention in clinical care is important for people living with HIV (PLWH). Evidence suggests that missed clinic visits are associated with interruptions in antiretroviral therapy (ART), lower CD4 counts, virologic failure, and overlooked coinfections. We identified factors associated with missed routine clinic visits in the African Cohort Study (AFRICOS).

Methods

In 2013, AFRICOS began enrolling people with and without HIV in Uganda, Kenya, Tanzania, and Nigeria. At enrollment and every 6 months thereafter, sociodemographic questionnaires are administered and clinical outcomes assessed. Missed clinic visits were measured as the self-reported number of clinic visits missed in the past 6 months and dichotomized into none or one or more visits missed. Logistic regression with generalized estimating equations was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between risk factors and missed visits.

Results

Between January 2013 and March 2020, 2937 PLWH were enrolled, of whom 2807 (95.6%) had initiated ART and 2771 had complete data available for analyses. Compared to PLWH 50+, missed clinic visits were more common among those 18–29 years (aOR 2.33, 95% CI 1.65–3.29), 30–39 years (aOR 1.59, 95% CI 1.19–2.13), and 40–49 years (aOR 1.42, 95% CI 1.07–1.89). As compared to PLWH on ART for < 2 years, those on ART for 4+ years were less likely to have missed clinic visits (aOR 0.72, 95% CI 0.55–0.95). Missed clinic visits were associated with alcohol use (aOR 1.34, 95% CI 1.05–1.70), a history of incarceration (aOR 1.42, 95% CI 1.07–1.88), depression (aOR 1.47, 95% CI 1.13–1.91), and viral non-suppression (aOR 2.50, 95% CI 2.00–3.12). As compared to PLWH who did not miss any ART in the past month, missed clinic visits were more common among those who missed 1–2 days (aOR 2.09, 95% CI 1.65–2.64) and 3+ days of ART (aOR 7.06, 95% CI 5.43–9.19).

Conclusions

Inconsistent clinic attendance is associated with worsened HIV-related outcomes. Strategies to improve visit adherence are especially needed for young PLWH and those with depression.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-021-00425-0.

Adolescent and caregiver attitudes towards telemedicine use in pediatric nephrology

Background

Telemedicine is increasingly utilized as an alternative to in person consultation. Current pandemic conditions are providing additional impetus to virtual care delivery. We compared both adolescent and caregiver (parent or guardian) attitudes towards telemedicine (here as tertiary center to remote health care location) as a crucial determinant of longer-term effectiveness.

Methods

This qualitative research study analyzed transcribed structured telephone interviews with both 11–18 year-old pediatric nephrology patients and their caregivers and performed a quantitative analysis of patient demographics, disease factors and distance to tertiary center vs. telemedicine center.

Results

The study was conducted in a medium-sized tertiary pediatric nephrology centre with a large catchment area of over 0.5 million square kilometers and 629,000 children and adolescents under 18 years of age. Eleven dyads of adolescents and caregivers were enrolled. Five adolescents were male. The mean age of the adolescents was 14.4 ± 2.5 years (range 11.2–18.0). The median distance to our tertiary center was 191 km (range 110–1378 km). Four adolescents lived more than 500 km from our tertiary center. The 11 adolescents had a total of 334 in person visits (mean 30 ± 25) and 86 telemedicine visits (mean 8 ± 7). A ratio of 2:1 telemedicine to in-person visits was favored; with caregivers more in favor of remote care than adolescents. Qualitative analysis found that experiences with telemedicine were distinguished by consultation-specific factors and contextual factors. Contextual factors (travel/cost savings) were valued for telemedicine by adolescents and caregivers. Consultation-specific factors, such as the ability to show the doctor physical symptoms, were more valued during in-person consultations, especially by adolescents. The overall visit type preference was related to the nature of the consultation. For regular check-ups, and for adolescents with less complex needs, participants felt that telemedicine offered a comparable experience to in-person visits. Adolescents with more complex conditions preferred in-person visits.

Conclusions

Indiscriminate transfer to chronic care predicated on mainly telemedicine approach is not compatible with user expressed attitudes (especially among adolescents). Accurately mapping models of care to these attitudes is an essential determinant of effective management and longer-term engagement with potentially life-long health challenges.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06506-0.

Acute effects of ambient air pollution on clinic visits of college students for upper respiratory tract infection in Wuhan, China

Ambient air pollutants have been linked to adverse health outcomes, but evidence is still relatively rare in college students. Upper respiratory tract infection (URTI) is a common disease of respiratory system among college students. In this study, we assess the acute effect of air pollution on clinic visits of college students for URTI in Wuhan, China. Data on clinic visits due to URTI were collected from Wuhan University Hospital, meteorological factors (including daily temperature and relative humidity) provided by Wuhan Meteorological Bureau, and air pollutants by Wuhan Environmental Protection Bureau. In the present study, generalized additive model with a quasi-Poisson distribution link function was used to examine the association between ambient air pollutants (fine particulate matter (PM2.5), particulate matter (PM10), sulfur dioxide (SO2), nitrogen dioxide (NO2), and ozone (O3)) and the daily number of clinic visits of college students for URTI at Wuhan University Hospital in Wuhan, China. In the meantime, the model was adjusted for the confounding effects of long-term trends, seasonality, day of the week, public holidays, vacation, and meteorological factors. The best degrees of free in model were selected based on AIC (Akaike Information Criteria). The effect modification by gender was also examined. A total of 44,499 cases with principal diagnosis of URTI were included from January 1, 2016, to December 31, 2018. In single-pollutant models, the largest increment of URTI visits were found at lag 0 day in single-day lags, and the effect values in cumulative lags were greater than those in single-day lags. PM2.5 (0.74% (95%CI: 0.05, 1.44)) at lag 0 day, PM10 (0.61% (95%CI: 0.12, 1.11)) and O3 (1.01% (95%CI: 0.24, 1.79)) at lag 0-1 days, and SO2 (9.18% (95%CI: 3.27, 15.42)) and NO2 (3.40% (95% CI:1.64, 5.19)) at lag 0-3 days were observed to be strongly and significantly associated with clinic visits for URTI. PM10 and NO2 were almost still significantly associated with URTI after controlling for the other pollutants in our two-pollutant models, where the effect value of SO2 after inclusion of O3 appeared to be the largest and the effects of NO2 were also obvious compared with the other pollutants. Subgroups analysis demonstrated that males were more vulnerable to PM10 and O3, while females seemed more vulnerable to exposure to SO2 and NO2. This study implied that short-term exposure to ambient air pollution was associated with increased risk of URTI among college students at Wuhan University Hospital in Wuhan, China. And gaseous pollutants had more negative health impact than solid pollutants. SO2 and NO2 were the major air pollutants affecting the daily number of clinic visits on URTI, to which females seemed more vulnerable than males.

Are In-Person Post-operative Clinic Visits Necessary to Detect Complications Among Bariatric Surgery Patients?

Patients undergoing bariatric surgery are expected to have frequent post-surgical follow-up. With the increased utilization of telemedicine across different surgical specialties, we are considering replacing the in-person post-surgery visits with telemedicine video visits in our bariatric practice. However, the safety and efficacy of conducting these visits through telemedicine is still unknown. Due to the concern of missing complications by eliminating in-person assessments, we reviewed 30-day complications, their severity, and the context of their detection experienced by bariatric surgical patients at our institution. Our results suggest that the majority of complications are detected when patients seek medical care rather than during clinic visits. Therefore, telemedicine is likely safe for 30-day follow-up in bariatric patients. Further studies are needed to assess its effect on patient compliance and outcomes.

Cluster-randomized controlled trial for the early promotion of clinic visits for untreated hypertension

Despite clear evidence of the benefits of lowering blood pressure among patients with hypertension, the treatment rate remains <40% worldwide. In the present trial, we aimed to investigate the effects of the early promotion of clinic visits among patients with untreated hypertension detected during annual health checkups. This was a worksite-based, parallel group, cluster-randomized trial with blinded outcome assessment. Employees of 152 Japanese supermarket stores found to have untreated hypertension (blood pressure levels ≥ 160/100 mmHg) during health checkups were assigned to an early promotion group (encouraged to visit a clinic in face-to-face interviews and provided with a referral letter to a physician as well as a leaflet) or a control group (received usual care), according to random assignment. The primary outcome was the completion of a clinic visit within 6 months. Odds ratios with 95% confidence intervals for the early promotion group versus the control group were estimated using multilevel logistic regression with random effects of clusters. A total of 273 participants (mean age 50.3 years, 55% women) from 107 stores were assigned to the early promotion group (138 from 55 stores) or control group (135 from 52 stores). During the 6-month follow-up, 47 (34.1%) participants in the early promotion group visited a clinic, as did 26 (19.3%) in the control group (odds ratio 2.33, 95% confidence interval 1.12-4.84, P = 0.024). Early promotion using a referral letter during health checkups significantly increased the number of clinic visits within 6 months completed by participants with untreated hypertension (UMIN000025411).

Healthcare resource utilization following ECG sensor patch screening for atrial fibrillation

Background

Screening for asymptomatic, undiagnosed atrial fibrillation (AF) has the potential to allow earlier treatment, possibly resulting in prevention of strokes, but also to increase medical resource utilization.

Objective

To compare healthcare utilization rates during the year following initiation of screening among participants screened for AF by electrocardiogram (ECG) sensor patch compared with a matched observational control group.

Methods

A total of 1718 participants recruited from a health care plan based on age and comorbidities who were screened with an ECG patch (actively monitored group) as part of a prospective, pragmatic research trial were matched by age, sex, and CHA₂DS₂-VASc score with 3371 members from the same health plan (observational control group). Healthcare utilization, including visits, prescriptions, procedures, and diagnoses, during the 1 year following screening was compared between the groups using health plan claims data.

Results

Overall, the actively monitored group had significantly higher rates of cardiology visits (adjusted incidence rate ratio [aIRR] [95% confidence interval (CI)]: 1.43 [1.27, 1.60]), no difference in primary care provider visits (aIRR [95% CI]: 1.0 [0.95, 1.05]), but lower rates of emergency department (ED) visits and hospitalizations (aIRR [95% CI]: 0.80 [0.69, 0.92]) compared with controls. Among those with newly diagnosed AF, the reduction in ED visits and hospitalizations was even greater (aIRR [95% CI]: 0.27 [0.17, 0.43]).

Conclusion

AF screening in an asymptomatic, moderate-risk population with an ECG patch was associated with an increase in cardiology outpatient visits but also significantly lower rates of ED visits and hospitalizations over the 1 year following screening.

Face-to-face health professional contact for postpartum women: A systematic review

The postpartum period is a time when physical, psychological and social changes occur. Health professional contact in the first month following birth may contribute to a smoother transition, help prevent and manage infant and maternal complications and reduce health systems' expenditure. The aim of this systematic review was to assess the effect of face-to-face health professional contact with postpartum women within the first four weeks following hospital discharge on maternal and infant health outcomes. Fifteen controlled trial reports that included 8332 women were retrieved after searching databases and reference lists of relevant trials and reviews. Although the evidence was of moderate or low quality and the effect size was small, this review suggests that at least one health professional contact within the first 4 weeks postpartum has the potential to reduce the number of women who stop breastfeeding within the first 4-6 weeks postpartum (Risk Ratio 0.86 (95% Confidence Interval 0.75-0.99)) and the number of women who cease exclusive breastfeeding by 4-6 weeks (Risk Ratio 0.84 (95% Confidence Interval 0.71-0.99)) and 6 months (Risk Ratio 0.88 (95% Confidence Interval 0.81-0.96). There was no evidence that one form of health professional contact was superior to any other. There was insufficient evidence to show that health professional contact in the first month postpartum, at a routine or universal level, had an impact on other aspects of maternal and infant health, including non-urgent or urgent use of health services.

Comparison of two methods of collecting healthcare usage data in chiropractic clinics: patient-report versus documentation in patient files

Background

The use of patient-reported questionnaires to collect information on costs associated with routine healthcare services, such as chiropractic, represents a less labour intensive alternative to retrieving these data from patient files. The aim of this paper was to compare patient-report versus patient files for the collection of data describing healthcare usage in chiropractic clinics.

Methods

As part of a prospective single cohort multi-centre study, data on the number of visits made to chiropractic clinics determined using patient-reported questionnaires or as recorded in patient files were compared three months following the start of treatment. These data were analysed for agreement using the Intraclass Correlation Coefficient (ICC) and the 95% Limits of Agreement.

Results

Eighty-nine patients that had undergone chiropractic care were included in the present study. The two methods yielded an ICC of 0.83 (95% CI = 0.75 to 0.88). However, there was a significant difference between the data collection methods, with an average of 0.6 (95% CI = 0.25 to 1.01) additional visits reported in patient files. The 95% Limits of Agreement ranged from 3 fewer visits to 4 additional visits in patient files relative to the number of visits recalled by patients.

Conclusion

There was some discrepancy between the number of visits made to the clinic recalled by patients compared to the number recorded in patient files. This should be taken into account in future evaluations of costs of treatments.