Chronic pain and continuity of analgesic treatment during the COVID-19 pandemic

INTRODUCTION

Chronic pain can trigger both physical and mental health complications. During the COVID-19 pandemic, patients with chronic diseases have had reduced access to some medications.

OBJECTIVE

To determine the pharmacological management of patients with chronic pain and its continuity during the COVID-19 pandemic.

METHODS

This was a retrospective longitudinal study of the continuity of analgesic use in patients with chronic pain between September 1, 2019 and February 28, 2021 based on a drug dispensing database. Survival analysis was performed until the discontinuation of chronic analgesics.

RESULTS

A total of 12,701 patients who were being treated for chronic pain were identified. Their median age was 70.3 years, and 74.4% were women. The pain of rheumatological origin was the most frequent etiology (46.1%); the most used medications were nonopioid analgesics (78.9%), pain modulators (24.8%) and opioid analgesics (23.3%). A total of 76.1% of the patients experienced interruptions in their management during the study period. The median time to the first interruption of treatment was 5.0 months (95% CI: 4.8-5.2). Those who were treated for oncological pain experienced a greater number of interruptions in their management.

CONCLUSIONS

The pharmacological management of patients with chronic pain is heterogeneous, and this real-world study showed that a high proportion of patients experienced an interruption of pain management during the 12 months following the onset of the COVID-19 pandemic.

Implementing Clinic First Guiding Actions Across 4 Family Medicine Residency Clinics

PROBLEM

Family medicine faculty and residents have observed that continuity clinic is often unsatisfying, attributed to a lack of patient and team continuity and erratic clinic schedules pieced together after the prioritization of hospital service and rotation schedules.

APPROACH

In 2019, a 3-year Clinic First project, called Clinic as Curriculum (CaC), was launched across the 4 family medicine residencies of the Department of Family Medicine and Community Health, University of Minnesota Medical School. The department began publishing quarterly CaC dashboard data. Each clinic completed a baseline assessment of their performance on the 13 Building Blocks of High-Performing Primary Care. Using their baseline data, each clinic identified which block or blocks, in addition to the blocks on continuity of care and resident scheduling, to focus on. The plan is to collaboratively implement the overall and local goals using dashboard data and iterative process improvement over 3 years.

OUTCOMES

At baseline, clinics functioned quite well with respect to the 13 building blocks, but CaC dashboard data varied across the 4 clinics, with large variation between clinics on how frequently faculty were scheduled in the clinic and the proportion of total clinic visits seen by faculty. Resident continuity rates were low (range, 38%-47%). Level loading (consistent physician availability to meet patient demand) rates ranged from 1 to 11 days a month. Regarding resident schedules, 2 programs are moving from 4-week to 2-week inpatient blocks, and 2 programs are exploring longitudinal scheduling. One clinic will assign faculty and residents to specific clinic days. Two clinics are implementing microteams of 1 faculty and 3-4 residents.

NEXT STEPS

The authors plan to analyze the dashboard data longitudinally; explore microteams, team continuity, and team scheduling adherence; and develop and implement resident scheduling changes over the next 3 years.

Trends in HIV Care Outcomes Among Adults and Adolescents-33 Jurisdictions, United States, 2014-2018

BACKGROUND

With significant improvements in the diagnosis and treatment of HIV, the number of people with HIV in the United States steadily increases. Monitoring trends in HIV-related care outcomes is needed to inform programs aimed at reducing new HIV infections in the United States.

SETTING

The setting is 33 United States jurisdictions that had mandatory and complete reporting of all levels of CD4 and viral load test results for each year during 2014-2018.

METHODS

Estimated annual percentage change and 95% confidence intervals were calculated to assess trends in stage of disease at time of diagnosis, linkage to HIV medical care within 1 month of HIV diagnosis, and viral suppression within 6 months after HIV diagnosis. Differences in percentages were analyzed by sex, age, race/ethnicity, and transmission category for persons with HIV diagnosed from 2014 to 2018.

RESULTS

Among 133,477 persons with HIV diagnosed during 2014-2018, the percentage of persons who received a diagnosis classified as stage 0 increased 13.7%, stages 1-2 (early infections) increased 2.9%, stage 3 (AIDS) declined 1.5%, linkage to HIV medical care within 1 month of HIV diagnosis increased 2.3%, and viral suppression within 6 months after HIV diagnosis increased 6.5% per year, on average. Subpopulations and areas that showed the least progress were persons aged 45-54 years, American Indian/Alaska Native persons, Asian persons, Native Hawaiian/other Pacific Islander persons, and rural areas with substantial HIV prevalence, respectively.

CONCLUSIONS

New infections will continue to occur unless improvements are made in implementing the Ending the HIV Epidemic: A Plan for America strategies of diagnosing, treating, and preventing HIV infection.

Continuity of care in acute survivorship phase, and short and long-term outcomes in prostate cancer patients

Continuity of care is important for prostate cancer care due to multiple treatment options, and prolonged disease history. We examined the association between continuity of care and outcomes in Medicare beneficiaries with localized prostate cancer, and the moderating effect of race using Surveillance, Epidemiological, and End Results (SEER) - Medicare data between 2000 and 2016. Continuity of care was measured as visits dispersion (continuity of care index or COCI), and density (usual provider care index or UPCI) in acute survivorship phase. Outcomes were emergency room visits, hospitalizations, and cost during acute survivorship phase and mortality (all-cause and prostate cancer-specific) over follow-up phase. Higher continuity of care was associated with improved outcomes, and interaction between race and continuity of care was significant. Continuity of care during acute survivorship phase may lower the racial disparity in prostate cancer care. Future research can analyze the mechanism of the process.

COVID-19 pandemic: a new cause of unplanned interruption of radiotherapy in breast cancer patients

The purpose of this study was to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on patients undergoing radiotherapy by comparing the patterns of unplanned radiotherapy interruption before and after the COVID-19 pandemic. We enrolled patients who received their first dose of radiotherapy for breast cancer between January 28 and July 31, 2019 and between January 28, 2020, and July 31, 2020. We compared the radiotherapy interruption patterns in 2019 with those in 2020 to analyze the impact of the COVID-19 pandemic on treatment interruption. Between January 28 and July 31, 2019, 287 patients with breast cancer received radiotherapy. Among them, 19 patients (6.6%) experienced treatment interruption; the reasons for treatment interruption were radiotherapy-related side effects (10 patients, 52.6%), other medical reasons (three patients, 15.8%), and personal reasons (six patients, 31.6%). Between January 28 and July 31, 2020, 279 patients with breast cancer received radiotherapy. Among them, 23 patients (8.2%) experienced treatment interruption; the reasons for treatment interruption were radiotherapy-related side effects (eight patients, 35%) and COVID-19 screening clinic-related reasons (six patients, 26.1%). Among the six patients with screening clinic-related causes of radiotherapy interruption, five had asymptomatic fever and one had mild cold-like symptoms. The duration of treatment interruption was longer in patients with screening clinic-related interruptions than in those with interruptions because of other causes (p = 0.019). Multivariate analysis showed that cancer stage and radiotherapy volume did not significantly affect treatment interruption. The radiotherapy of certain patients was suspended despite the lack of a confirmed COVID-19 diagnosis. Precise and systematic criteria for the management of patients with suspected COVID-19 are needed, and the opinion of radiation oncologist in charge of the patient must also be considered.

COVID-19 Pandemic and Thalassemia Major Patients: Transfusion Practice and Treatment Assessment

BACKGROUND

When the COVID-19 epidemic occurred for the first time in December 2019, the governments worldwide took some restriction measures for slowing the spread of novel coronavirus. Eventually, there was a considerable decrease in volunteer blood donations. Regular transfusions and follow-up of patients with thalassemia major (TM) should be maintained during this period. It is possible that the treatment of the patients with TM may hinder due to the difficulty of reaching the treatment center and the difficulty of blood supply. Thus, in this study, we aimed to investigate whether there were any differences in the follow-up and treatment of the patients with TM during the outbreak.

MATERIALS AND METHODS

Sixty-one patients with TM who were followed up in our center without COVID-19 contact history and symptoms were included in this study. The demographic features and red blood cell volume per kilogram they received, pretransfusion hemoglobin, serum ferritin (SF) level, biochemical parameters, and transfusion interval were recorded. The difference between the arithmetic mean of the data before and during the pandemic was evaluated.

RESULTS

In this study, 61 patients with TM (32 males/29 females, mean age 13.9±6.8 y) were evaluated. The mean pretransfusion hemoglobin value was 9.14±0.77 g/dL and 8.87± 0.80 g/dL before and during the pandemic, respectively (P=0.023). There was no difference between before and during the pandemic concerning transfusion interval and transfusion volume. However, SF levels increased above 1000 ng/mL in 16.6% of patients.

CONCLUSION

Although blood donation decreased significantly during the pandemic, it was observed in this study that the blood needs of patients with TM could be provided. The results of the SF level showed that the management of chelation therapy should be more meticulous. However, we should be ready for the challenges in the transfusion practice of patients with TM due to fluctuations in the COVID-19 pandemic.

Disrupted Access to Therapies and Impact on Well-Being During the COVID-19 Pandemic for Children With Motor Impairment and Their Caregivers

OBJECTIVES

The aim of this study was to determine the impact of the COVID-19 pandemic on access to rehabilitation therapies and the impact of changes in therapy access on the physical and mental well-being of children with motor impairment and their caregivers.

DESIGN

Caregivers of children younger than 18 yrs with childhood-onset motor impairment (primarily cerebral palsy) completed an anonymous survey through the online platform REDCap between May 5 and July 13, 2020.

RESULTS

The survey was completed by 102 participants. Before the pandemic, 92 of 102 children (90%) were receiving one or more therapies; at the time surveyed, 55 children (54%) were receiving any therapies (P < 0.001). More than 40% of the sample reported increased child stress, decreased physical activity, and/or decline in mobility/movement. Participants who reported a decrease in number of therapies at the time surveyed more frequently reported lower satisfaction with treatment delivery (P < 0.001), a decline in child's mobility (P = 0.001), and increased caregiver stress (P = 0.004). Five qualitative themes were identified from open-ended question responses related to therapies and well-being.

CONCLUSIONS

Access to pediatric rehabilitation therapies was disrupted during COVID-19. Disrupted access may be related to impact on physical and mental health. With the expansion of telehealth, caregiver and child feedback should be incorporated to optimize benefit.

Association of Inpatient Continuity of Care With Complications and Length of Stay Among Hospitalized Medicare Enrollees

IMPORTANCE

Continuity in primary care is associated with improved outcomes, but less information is available on the association of continuity of care in the hospital with hospital complications.

OBJECTIVE

To assess whether the number of hospitalists providing care is associated with subsequent hospital complications and length of stay.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used multilevel logistic regression models to analyze Medicare claims for medical admissions from 2016 to 2018 with a length of stay longer than 4 days. Admissions with multiple charges on the same day from a hospitalist or an intensive care unit (ICU) stay during hospital days 1 to 3 were excluded. The data were accessed and analyzed from November 1, 2020, to April 30, 2021.

EXPOSURES

The number of different hospitalists who submitted charges during hospital days 1 to 3.

MAIN OUTCOMES AND MEASURES

Overall length of stay and transfer to ICU or a new diagnosis of drug toxic effects on hospital day 4 or later.

RESULTS

Among the 617 680 admissions, 362 376 (58.7%) were women, with a mean (SD) age of 80.2 (8.4) years. In 306 037 admissions (49.6%), the same hospitalist provided care on days 1 to 3, while 2 hospitalists provided care in 274 658 admissions (44.5%), and 3 hospitalists provided care in 36 985 admissions (6.0%). There was no significant association between the number of different hospitalists on days 1 to 3 and either length of stay or subsequent ICU transfers. Admissions seeing 2 or 3 hospitalists had a slightly greater adjusted odds of subsequent new diagnoses of drug toxic effects (2 hospitalists: odds ratio [OR], 1.04; 95% CI, 1.02-1.07; 3 hospitalists: OR, 1.07; 95% CI, 1.03-1.12).

CONCLUSIONS AND RELEVANCE

There was little evidence that receiving care from multiple hospitalists was associated with worse outcomes for patients receiving all their general medical care from hospitalists.

Effects of dynamic response to coronavirus disease outbreak in a regional emergency medical center: A retrospective study

Emergency departments (EDs) are on the frontline of the coronavirus disease (COVID-19) outbreak. To resolve the abrupt overloading of COVID-19-suspected patients in a community, each ED needs to respond in various ways. In our hospital, we increased the isolation beds through temporary remodeling and by performing in-hospital COVID-19 polymerase chain reaction testing rather than outsourcing them. The aim of this study was to verify the effects of our response to the newly developed viral outbreak.The medical records of patients who presented to an ED were analyzed retrospectively. We divided the study period into 3: pre-COVID-19, transition period of response (the period before fully implementing the response measures), and post-response (the period after complete response). We compared the parameters of the National Emergency Department Information System and information about isolation and COVID-19.The number of daily ED patients was 86.8 ± 15.4 in the pre-COVID-19, 36.3 ± 13.6 in the transition period, and 67.2 ± 10.0 in the post-response period (P < .001). The lengths of stay in the ED were significantly higher in transition period than in the other periods [pre-COVID-19 period, 219.0 (121.0-378.0) min; transition period, 301 (150.0-766.5) min; post-response period, 281.0 (114.0-575.0) min; P < .001]. The ratios of use of an isolation room and fever (≥37.5°C) were highest in the post-response period [use of isolation room: pre-COVID-19 period, 0.6 (0.7%); transition period, 1.2 (3.3%); post-response period, 16.1 (24.0%); P < .001; fever: pre-COVID-19 period, 14.8(17.3%); transition period, 6.8 (19.1%); post-response period, 14.5 (21.9%), P < .001].During an outbreak of a novel infectious disease, increasing the number of isolation rooms in the ED and applying a rapid confirmation test would enable the accommodation of more suspected patients, which could help reduce the risk posed to the community and thus prevent strain on the local emergency medical system.

Service utilization and HIV outcomes among transgender women receiving Ryan White Part A services in New York City

Background

Prior research has found evidence of gender disparities in U.S. HIV healthcare access and outcomes. In order to assess potential disparities in our client population, we compared demographics, service needs, service utilization, and HIV care continuum outcomes between transgender women, cisgender women, and cisgender men receiving New York City (NYC) Ryan White Part A (RWPA) services.

Methods

The analysis included HIV-positive clients with an intake assessment between January 2016 and December 2017 in an NYC RWPA services program. We examined four service need areas: food and nutrition, harm reduction, mental health, and housing. Among clients with the documented need, we ascertained whether they received RWPA services targeting that need. To compare HIV outcomes between groups, we applied five metrics: engagement in care, consistent engagement in care, antiretroviral therapy (ART) use, point-in-time viral suppression, and durable viral suppression.

Results

All four service needs were more prevalent among transgender women (N = 455) than among cisgender clients. Except in the area of food and nutrition services, timely (12-month) receipt of RWPA services to meet a specific assessed need was not significantly more or less common in any one of the three client groups examined. Compared to cisgender women and cisgender men, a lower proportion of transgender women were durably virally suppressed (39% versus 52% or 50%, respectively, p-value < 0.001).

Conclusions

Compared with cisgender women and cisgender men, transgender women more often presented with basic (food/housing) and behavioral-health service needs. In all three groups (with no consistent between-group differences), assessed needs were not typically met with the directly corresponding RWPA service category. Targeting those needs with RWPA outreach and services may support the National HIV/AIDS Strategy 2020 goal of reducing health disparities, and specifically the objective of increasing (to ≥90%) the percentage of transgender women in HIV medical care who are virally suppressed.

Phase-Specific and Lifetime Costs of Multiple Myeloma Among Older Adults in the US

IMPORTANCE

Health care costs associated with diagnosis and care among older adults with multiple myeloma (MM) are substantial, with cost of care and the factors involved differing across various phases of the disease care continuum, yet little is known about cost of care attributable to MM from a Medicare perspective.

OBJECTIVE

To estimate incremental phase-specific and lifetime costs and cost drivers among older adults with MM enrolled in fee-for-service Medicare.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted using population-based registry data from the 2007-2015 Surveillance, Epidemiology, and End Results database linked with 2006-2016 Medicare administrative claims data. Data analysis included 4533 patients with newly diagnosed MM and 4533 matched noncancer Medicare beneficiaries from a 5% sample of Medicare to assess incremental MM lifetime and phase-specific costs (prediagnosis, initial care, continuing care, and terminal care) and factors associated with phase-specific incremental MM costs. The study was conducted from June 1, 2019, to April 30, 2021.

MAIN OUTCOMES AND MEASURES

Incremental MM costs were calculated for the disease lifetime and the following 4 phases of care: prediagnosis, initial, continuing care, and terminal.

RESULTS

Of the 4533 patients with MM included in the study, 2374 were women (52.4%), 3418 (75.4%) were White, and mean (SD) age was 75.8 (6.8) years (2313 [51.0%] aged ≥75 years). The characteristics of the control group were similar; however, mean (SD) age was 74.2 (8.8) years (2839 [62.6%] aged ≤74 years). Mean adjusted incremental MM lifetime costs were $184 495 (95% CI, $183 099-$185 968). Mean per member per month phase-specific incremental MM costs were estimated to be $1244 (95% CI, $1216-$1272) for the prediagnosis phase, $11 181 (95% CI, $11 052-$11 309) for the initial phase, $5634 (95% CI, $5577-$5694) for the continuing care phase, and $6280 (95% CI, $6248-$6314) for the terminal phase. Although inpatient and outpatient costs were estimated as the major cost drivers for the prediagnosis (inpatient, 55.8%; outpatient, 40.2%), initial care (inpatient, 38.1%; outpatient, 35.5%), and terminal (inpatient, 33.0%; outpatient, 34.6%) care phases, prescription drugs (44.9%) were the largest cost drivers in the continuing care phase.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that there is substantial burden to Medicare associated with diagnosis and care among older adults with MM, and the cost of care and cost drivers vary across different phases of the cancer care continuum. The study findings might aid policy discussions regarding MM care and coverage and help further the development of alternative payment models for MM, accounting for differential costs across various phases of the disease continuum and their drivers.

Outcomes and costs of publicly funded patient navigation interventions to enhance HIV care continuum outcomes in the United States: A before-and-after study

BACKGROUND

In the United States, patients with HIV face significant barriers to linkage to and retention in care which impede the necessary steps toward achieving the desired clinical outcome of viral suppression. Individual-level interventions, such as patient navigation, are evidence based, effective strategies for improving care engagement. In addition, use of surveillance and clinical data to identify patients who are not fully engaged in care may improve the effectiveness and cost-effectiveness of these programs.

METHODS AND FINDINGS

We employed a pre-post design to estimate the outcomes and costs, from the program perspective, of 5 state-level demonstration programs funded under the Health Resources and Services Administration's Special Projects of National Significance Program (HRSA/SPNS) Systems Linkages Initiative that employed existing surveillance and/or clinical data to identify individuals who had never entered HIV care, had fallen out of care, or were at risk of falling out of care and navigation strategies to engage patients in HIV care. Outcomes and costs were measured relative to standard of care during the first year of implementation of the interventions (2013 to 2014). We followed patients to estimate the number and proportion of additional patients linked, reengaged, retained, and virally suppressed by 12 months after enrollment in the interventions. We employed inverse probability weighting to adjust for differences in patient characteristics across programs, missing data, and loss to follow-up. We estimated the additional costs expended during the first year of each intervention and the cost per outcome of each intervention as the additional cost per HIV additional care continuum target achieved (cost per patient linked, reengaged, retained, and virally suppressed) 12 months after enrollment in each intervention. In this study, 3,443 patients were enrolled in Louisiana (LA), Massachusetts (MA), North Carolina (NC), Virginia (VA), and Wisconsin (WI) (147, 151, 2,491, 321, and 333, respectively). Patients were a mean of 40 years old, 75% male, and African American (69%) or Caucasian (22%). At baseline, 24% were newly diagnosed, 2% had never been in HIV care, 45% had fallen out of care, and 29% were at risk of falling out of care. All 5 interventions were associated with increases in the number and proportion of patients with viral suppression [percent increase: LA = 90.9%, 95% confidence interval (CI) = 88.4 to 93.4; MA = 78.1%, 95% CI = 72.4 to 83.8; NC = 47.5%, 95% CI = 45.2 to 49.8; VA = 54.6, 95% CI = 49.4 to 59.9; WI = 58.4, 95% CI = 53.4 to 63.4]. Overall, interventions cost an additional $4,415 (range = $3,746 to $5,619), $2,009 (range = $1,516 to $2,274), $920 (range = $627 to $941), $2,212 (range = $1,789 to $2,683), and $3,700 ($2,734 to $4,101), respectively per additional patient virally suppressed. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess patients against themselves at baseline and not against standard of care during the same time period.

CONCLUSIONS

Patient navigation programs were associated with improvements in engagement of patients in HIV care and viral suppression. Cost per outcome was minimized in states that utilized surveillance data to identify individuals who were out of care and/or those that were able to identify a larger number of patients in need of improvement at baseline. These results have the potential to inform the targeting and design of future navigation-type interventions.

Continuity of care and receipt of aggressive end of life care among women dying of ovarian cancer

OBJECTIVE

To evaluate the association between post-diagnosis continuity of care and receipt of aggressive end of life care among women dying of ovarian cancer.

METHODS

This retrospective claims analysis included 6680 Medicare beneficiaries over age 66 with ovarian cancer who survived at least one year after diagnosis, had at least 4 outpatient evaluation and management visits and died between 2000 and 2016. We calculated the Bice-Boxerman Continuity of Care Index (COC) for each woman, and split COC into tertiles (high, medium, low). We compared late or no hospice use, >1 emergency department (ED) visit, intensive care unit (ICU) admission, >1 hospitalization, terminal hospitalization, chemotherapy, and invasive and/or life extending procedures among women with high or medium vs. low COC using multivariable adjusted logistic regression.

RESULTS

In this sample, 49.8% of women received aggressive care in the last month of life. Compared to women with low COC, women with high COC had 66% higher odds of chemotherapy (adjusted OR 1.66 CI 1.23-2.24) in the last two weeks of life. Women with high COC also had 16% greater odds of not enrolling in hospice compared to women with low COC (adjusted OR 1.16 CI 1.01-1.33). COC was not associated with late enrollment in hospice, hospital utilization, or aggressive procedures.

CONCLUSIONS

COC at the end of life is complicated and may pose unique challenges in providing quality end of life care. Future work exploring the specific facets of continuity associated with quality end of life care is needed.

Experiences of maternity care among women at increased risk of preterm birth receiving midwifery continuity of care compared to women receiving standard care: Results from the POPPIE pilot trial

BACKGROUND

Midwifery continuity of care models for women at low and mixed risk of complications have been shown to improve women's experiences of care. However, there is limited research on care experiences among women at increased risk of preterm birth. We aimed to explore the experiences of care among women with risk factors for preterm birth participating in a pilot trial (POPPIE) of a midwifery continuity of care model which included a specialist obstetric clinic.

METHODS

A total of 334 pregnant women identified at increased risk of preterm birth were randomly allocated to either midwifery continuity of care (POPPIE group) or standard maternity care. Women in both groups were followed up at six-to-eight weeks postpartum and were invited to complete a postnatal survey either online or by post. An equal status exploratory sequential mixed method design was chosen to collect and analyse the quantitative postnatal survey data and qualitative interviews data. The postnatal survey included measures of social support, trust, perceptions of safety, quality of care, control during childbirth, bonding and quality of life. Categorical data were analysed with chi-squared tests and continuous data were analysed with t-tests and/or Mann-Whitney U test to measure differences in measures scores among groups. The qualitative interview data were subjected to a thematic framework analysis. Data triangulation brought quantitative and qualitative data together at the interpretation stage.

FINDINGS

A total of 166 women completed the survey and 30 women were interviewed (90 and 16 in POPPIE group; 76 and 14 in standard group). We found survey respondents in the POPPIE group, compared to respondents in the standard group, were significantly more likely to report greater trust in midwives (Mann-Whitney U, p<0.0001), greater perceptions of safety during the antenatal care (t-test, p = 0.0138), have a particular midwife to contact when they needed during their pregnancy (t-test, p<0.0001) and the postnatal period (chi-squared, p<0.0001). They reported increased involvement in decisions regarding antenatal, intrapartum and postnatal care (t-test, p = 0.002; p = 0.008; p = 0.006 respectively); and greater postnatal support and advice about: feeding the baby (chi-squared, p<0.0001), handling, settling and looking after the baby (chi-squared, p<0.0001), baby's health and progress (chi-squared, p = 0.039), their own health and recovery (chi-squared, p = 0.006) and who to contact about any emotional changes (chi-squared, p = 0.005). There were no significant differences between groups in the reporting of perceptions of safety during birth and the postnatal period, concerns raised during labour and birth taken seriously, being left alone during childbirth at a time of worries, control during labour, bonding, social support, and physical and mental health related quality of life after birth. Results from qualitative interviews provided insight and depth into many of these findings, with women in the POPPIE group reporting more positive experiences of bonding towards their babies and more positive physical health postnatally.

CONCLUSIONS

Compared with standard maternity care, women at increased risk of PTB who received midwifery continuity of care were more likely to report increased perceptions of trust, safety and quality of care.

TRIAL REGISTRATION

ISRCTN (Number: 37733900); UK CRN (ID: 31951).

Ambulatory Care Fragmentation and Subsequent Hospitalization: Evidence From the REGARDS Study

BACKGROUND

Previous studies have suggested that highly fragmented ambulatory care increases the risk of subsequent hospitalization, but those studies used claims only and were not able to adjust for many clinical potential confounders.

OBJECTIVE

The objective of this study was to determine the association between fragmented ambulatory care and subsequent hospitalization, adjusting for demographics, medical conditions, medications, health behaviors, psychosocial variables, and physiological variables.

DESIGN

Longitudinal analysis of data (2003-2016) from the nationwide REasons for Geographic And Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims.

SUBJECTS

A total of 12,693 Medicare beneficiaries 65 years and older from the REGARDS study who had at least 4 ambulatory visits in the first year of observation and did not have a hospitalization in the prior year.

MEASURES

We defined high fragmentation as a reversed Bice-Boxerman score above the 75th percentile. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and incident hospitalization in the 3 months following each exposure period.

RESULTS

The mean age was 70.4 years; 54% were women, and 33% were African American. During the first year of observation, participants with high fragmentation had a median of 8 ambulatory visits with 6 providers, whereas participants with low fragmentation had a median of 7 visits with 3 providers. Over 11.8 years of follow-up, 6947 participants (55%) had a hospitalization. High fragmentation was associated with an increased hazard of hospitalization (adjusted hazard ratio=1.18; 95% confidence interval: 1.12, 1.24).

CONCLUSION

Highly fragmented ambulatory care is an independent risk factor for hospitalization.

Patterns of clinic switching and continuity of medication for opioid use disorder in a Medicaid-enrolled population

BACKGROUND

Many persons with opioid use disorder (OUD) initiate medication for opioid use disorder (MOUD) with one clinic and switch to another clinic during their course of treatment. These switches may occur for referrals or for unplanned reasons. It is unknown, however, what effect switching MOUD clinics has on continuity of MOUD treatment or on overdoses.

OBJECTIVE

To examine patterns of switching MOUD clinics and its association with the proportion of days covered (PDC) by MOUD, and opioid-related overdose.

DESIGN

Cross-sectional retrospective analysis of Pennsylvania Medicaid claims data.

MAIN MEASURES

MOUD clinic switches (i.e., filling a MOUD prescription from a prescriber located in a different clinic than the previous prescriber), PDC, and opioid-related overdose.

RESULTS

Among 14,107 enrollees, 43.2 % switched clinics for MOUD at least once during the 270 day period. In multivariate regression results, enrollees who were Non-Hispanic black (IRR = 1.43; 95 % CI = 1.24-1.65; p < 0.001), had previous methadone use (IRR = 1.32; 95 % CI = 1.13-1.55; p < 0.001), and a higher total number of office visits (IRR = 1.01; CI = 1.01-1.01; p < 0.001) had more switches. The number of clinic switches was positively associated with PDC (OR = 1.12; 95 % CI = 1.10-1.13). In secondary analyses, we found that switches for only one MOUD fill were associated with lower PDC (OR = 0.97; 95 % CI = 0.95-0.99), while switches for more than one MOUD fill were associated with higher PDC (OR = 1.40; 95 % CI = 1.36-1.44). We did not observe a relationship between opioid-related overdose and clinic switches.

CONCLUSIONS

Lack of prescriber continuity for receiving MOUD may not be problematic as it is for other conditions, insofar as it is related to overdose and PDC.

The direct and indirect impact of the COVID-19 pandemic on the care of patients with pituitary disease: a cross sectional study

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic is widely believed to have had a major impact on the care of patients with pituitary disease. The virus itself may directly result in death, and patients with adrenal insufficiency, often a part of hypopituitarism, are thought to represent a particularly susceptible subgroup. Moreover, even in patients that do not contract the virus, the diversion of resources by healthcare institutions to manage the virus may indirectly result in delays in their management. To this end, the aim of this study was to determine the direct and indirect impact of the COVID-19 pandemic on patients with pituitary disease.

METHODS

A cross-sectional study design was adopted, with all adult patients seen by our pituitary service in the year prior to the nationwide lockdown on March 23rd 2020 invited to participate in a telephone survey.

RESULTS

In all, 412 patients (412/586; 70.3%) participated in the survey. 66 patients (66/412; 16.0%) reported having suspected COVID-19 infection. Of the 10 patients in this group tested for COVID-19 infection, three received a positive test result. No deaths due to COVID-19 were identified. 267 patients (267/412; 64.8%) experienced a delay or change in the planned care for their pituitary disease, with 100 patients (100/412; 24.3%) perceiving an impact to their care.

CONCLUSIONS

Whilst only a small percentage of patients had confirmed or suspected COVID-19 infection, over half were still indirectly impacted by the pandemic through a delay or change to their planned care.

Association between continuity of care and subsequent diagnosis of multimorbidity in Ontario, Canada from 2001-2015: A retrospective cohort study

BACKGROUND

Continuity of care is a well-recognized principle of the primary care discipline owing to its medical, interpersonal, and cost-saving benefits. Relationship continuity or the ongoing therapeutic relationship between a patient and their physician is a particularly desirable goal, but its role in preventing the accumulation of chronic conditions diagnoses in individuals is unknown. The objective of this study was to investigate the effect of continuity of care with physicians on the rate of incident multimorbidity diagnoses in patients with existing conditions.

METHODS

This was a population-based, retrospective cohort study from 2001 to 2015 that focused on patients aged 18 to 105 years with at least one chronic condition (n = 166,665). Our primary exposure was relationship continuity of care with general practitioners and specialists measured using the Bice-Boxerman Continuity of Care Index (COCI). COCI was specified as a time-dependent exposure prior to the observation period. Our outcomes of interest were the time to diagnosis of a second, third, and fourth chronic condition estimated using cause-specific hazard regressions accounting for death as a competing risk.

FINDINGS

We observed that patients with a single chronic condition and high continuity of care (>0.50) were diagnosed with a second chronic condition or multimorbidity at an 8% lower rate compared to individuals with low continuity (cause-specific hazard ratio (HR) 0.92 (95% Confidence Interval 0.90-0.93; p<0.0001) after adjusting for age, sex, income, place of residence, primary care enrolment, and the annual number of physician visits. Continuity remained protective as the degree of multimorbidity increased. Among patients with two conditions, the risk of diagnosis of a third chronic condition was also 8% lower for individuals with high continuity (HR 0.92; CI 0.90-0.94; p<0.0001). Patients with three conditions and high continuity had a 9% lower risk of diagnosis with a fourth condition (HR 0.91; CI 0.89-0.93; p<0.0001).

CONCLUSIONS

Continuity of care is a potentially modifiable health system factor that reduces the rate at which diagnoses of chronic conditions are made over time in patients with multimorbidity. Additional research is needed to explain the underlying mechanisms through which continuity is related to a protective effect and the clinical sequalae.

Effectiveness of Financial Incentives in Achieving UNAID Fast-Track 90-90-90 and 95-95-95 Target of HIV Care Continuum: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Financial incentives influence behavioural changes and the current review was done to assess the effectiveness of this intervention in improving HIV care continuum. We conducted systematic searches in MEDLINE, Cochrane library, ScienceDirect and Google Scholar from inception until July 2019. We carried out a meta-analysis with random-effects model quantifying inconsistency (I²) for heterogeneity and reported pooled Risk Ratios (RR) with 95% confidence intervals (CIs). A total of 22 studies with 38,119 participants were included. All the six outcomes showed better results in financial incentive arm compared to standard care with statistical significance in three outcomes-HIV testing uptake (pooled RR: 2.42; 95%CI 1.06-5.54; I² = 100%), antiretroviral therapy (ART) adherence (pooled RR: 1.30; 95%CI 1.13-1.50; I² = 44%), and continuity in care (pooled RR: 1.24; 95%CI 1.09-1.41; I² = 86%). To summarize, financial incentives can be helpful in improving the uptake of HIV testing, ART adherence and continuity of care while it was better for achieving viral load suppression among studies conducted in high-income countries.

Standardizing Multidisciplinary Discharge Planning Rounds to Improve Patient Perceptions of Care Transitions

Patients' satisfaction with care transitions is low, especially when it comes to understanding their care when discharged home from the hospital. Therefore, a quality improvement effort was initiated with the aim of improving patients' satisfaction with care transitions. Specific goals of the project were to improve communication between healthcare providers and patients, increase patient satisfaction, and enhance patient education by standardizing multidisciplinary discharge planning rounds.

Do post-operative phone calls enhance family satisfaction and outcomes after outpatient pediatric urological surgeries? A prospective study

INTRODUCTION

This study assesses whether post-operative check-in phone calls (POPC) performed within 48 h of outpatient pediatric urological surgeries by a non-medical professional (NMP) would increase patient/family satisfaction and minimize extraneous resource use by increasing email/telephone communication, while reducing emergency department (ED) visits within 30 days of that procedure.

METHODS

Families of patients undergoing ambulatory pediatric urology surgeries were enrolled over 8 weeks. Group 1 did not receive POPC. Group 2 received a POPC within 48 h of their operation by a NMP. Both groups received a phone-call survey 2 weeks after surgery to assess families' perioperative satisfaction.

RESULTS

In total, 74 families were enrolled (Group 1 = 44, Group 2 = 31). The response rates to phone surveys for Groups 1 and 2 were 59.1% and 77.4%, respectively. POPC did not improve perioperative satisfaction, nor did it significantly promote the use of nursing email/telephone communication (19.2% vs. 4.2%, p = 0.128) or reduce ED visits (15.4% vs. 0.0%, p = 0.111). However, all families in Group 2 thought POPC was timed appropriately and 79.1% perceived it to be helpful in reducing post-operative anxiety.

CONCLUSION

POPC by a NMP within 48 h of surgery may not affect perioperative satisfaction of families of patients undergoing same-day pediatric urology surgery but may have an impact in reducing post-operative anxiety.

Interprofessional collaboration associated with frequency of life-saving links to HIV continuum of care services in the urban environment of Newark, New Jersey

BACKGROUND

HIV continuum of care has been used as a strategy to reduce HIV transmission rates, with timely engagement in HIV testing being the first and most critical step. This study examines interprofessional-collaboration (IPC) after controlling for agency/ provider demographics, provider training and self-efficacy as a significant predictor of how frequently HIV service providers link their clients to HIV testing.

METHODS

Multilevel binary logistic regression analysis was conducted to examine the effects of IPC on links to HIV testing while controlling for demographic and agency information, provider training, and standardized measures of providers' feelings, attitudes, and opinions about IPC. Cross-sectional data from 142 providers in 13 agencies offering treatment and prevention services for HIV and substance-use disorders were collected via a survey.

RESULTS

Those who scored higher on the IPC scale reported significantly higher rates of linkages to HIV testing. Compared to the null model (i.e., no predictor model), the final multilevel binary logistic regression model showed a significantly improved likelihood of linkage to HIV testing by 11.4%, p. < .05. The final model correctly classified 90.2% of links to HIV testing. Providers in agencies with smaller budgets and in agencies offering substance use disorder services were more likely to link clients to HIV testing. Younger providers who received HIV training were also more likely to link clients to HIV testing.

CONCLUSIONS

Findings suggest IPC training as a potential strategy to improve linkages to HIV testing for clients at risk for HIV infection. Future research is recommended to identify specific areas of IPC that might have differential effects on links to HIV testing.

Patterns of Exposure to Socio-structural Stressors and HIV Care Engagement Among Transgender Women of Color

Transgender women are disproportionately affected by HIV and experiences of social adversity that may interfere with engagement in care and viral suppression. We used latent class analysis to examine patterns of social adversity and their impact on HIV care continuum outcomes in an urban sample of transgender women of color. Participants (n = 224) were median age 29 and 86% non-Hispanic Black. Lack of resources, unemployment, and housing instability were reported by over 50%, and 41% reported history of incarceration. Latent class analysis identified 2 distinct classes representing higher and lower levels of social adversity. In latent class regression, membership in the higher social adversity class was associated with statistically significantly lower odds of viral suppression and HIV care engagement in univariate analysis; when adjusted for age, race, and recruitment site the association remained statistically significant for viral suppression (aOR 0.38, 95% CI 0.18-0.79; chi-square = 6.681, d.f. = 1, p = 0.010), though not for HIV care engagement. Our findings highlight the impact of socio-structural barriers on engagement in the HIV care continuum among transgender women.

Highly frequent utilization of outpatient services in a national health insurance system - analysis of associated factors and underlying co-morbidity

OBJECTIVE

We aimed to identify associated factors of highly frequent use of outpatient services and explore how they were impacted to provide policy references for government and medical institutes in their efforts to seek provision of reasonable medical services, continuous care and integrated outpatient services.

METHODS

The Taiwanese national health insurance database was used and 661,125 patients were identified in 2009. The patients with ≥100 internal medicine outpatient (IMO) visits were defined as the highly frequent group and they were matched at a ratio of 1:4 with patients of 1-99 IMO visits based on demographic characteristics. Multivariate logistic regression was used to estimate adjusted odds ratios with 95% confidence intervals.

RESULTS

Among 1 million patients in the outpatient department, 0.05% had at least 100 visits. These patients with highly frequent IMO visits had significantly higher rates of emergency department (ED) visits, hospitalization, psychiatric disorders and possession of a catastrophic illness card as well as a significantly lower level of continuity of care index (COCI). Multivariate analysis showed that ED visits (adjusted OR [AOR] = 1.63), psychiatric disorders (AOR = 7.13), low COCI (AOR = 1.69), and several comorbidities including peripheral vascular diseases (AOR = 4.33), dementia (AOR = 0.04), chronic pulmonary disease (AOR = 3.02), peptic ulcer diseases (AOR = 3.70), diabetes mellitus (AOR = 3.45) and renal disease (AOR = 2.43) were significant associated factors.

CONCLUSIONS

To rationalize use and distribution of medical resources, we suggest proper regular care and health education to those with mental disabilities and multiple chronic conditions, which may not only improve the situation of highly frequent hospital visits but also effectively control incidence of acute conditions and reduce their ED visits. In addition, improving the continuity of care is vital, and the best way to do this is to promote family medicine as the primary form of healthcare.

Neighborhood and Network Characteristics and the HIV Care Continuum among Gay, Bisexual, and Other Men Who Have Sex with Men

In order for treatment as prevention to work as a national strategy to contain the HIV/AIDS epidemic in the United States (US), the HIV care continuum must become more robust, retaining more individuals at each step. The majority of people living with HIV/AIDS (PLWHA) in the US are gay, bisexual, and other men who have sex with men (MSM). Within this population, there are distinct race- and ethnicity-based disparities in rates of HIV infection, engagement, and retention in HIV care, and viral suppression. Compared with White MSM, HIV-infected Black MSM are less likely to be on anti-retroviral therapy (ART), adhere to ART, and achieve viral suppression. Among MSM living in urban areas, falling off the continuum may be influenced by factors beyond the individual level, with new research identifying key roles for network- and neighborhood-level characteristics. To inform multi-level and multi-component interventions, particularly to support Black MSM living in urban areas, a clearer understanding of the pathways of influence among factors at various levels of the social ecology is required. Here, we review and apply the empirical literature and relevant theoretical perspectives to develop a series of potential pathways of influence that may be further evaluated. Results of research based on these pathways may provide insights into the design of interventions, urban planning efforts, and assessments of program implementation, resulting in increased retention in care, ART adherence, and viral suppression among urban-dwelling, HIV-infected MSM.

Trends in Diagnosis of HIV Infection, Linkage to Medical Care, and Viral Suppression Among Men Who Have Sex with Men, by Race/Ethnicity and Age - 33 Jurisdictions, United States, 2014-2018

During 2018, gay, bisexual, and other men who have sex with men (MSM) accounted for 69.4% of all diagnoses of human immunodeficiency virus (HIV) infection in the United States (1). Moreover, in all 42 jurisdictions with complete laboratory reporting of CD4 and viral load results,* percentages of MSM linked to care within 1 month (80.8%) and virally suppressed (viral load <200 copies of HIV RNA/mL or interpreted as undetected) within 6 months (68.3%) of diagnosis were below target during 2018 (2). African American/Black (Black), Hispanic/Latino (Hispanic), and younger MSM disproportionately experience HIV diagnosis, not being linked to care, and not being virally suppressed. To characterize trends in these outcomes, CDC analyzed National HIV Surveillance System† data from 2014 to 2018. The number of diagnoses of HIV infection among all MSM decreased 2.3% per year (95% confidence interval [CI] = 1.9-2.8). However, diagnoses did not significantly change among either Hispanic MSM or any MSM aged 13-19 years; increased 2.2% (95% CI = 1.0-3.4) and 2.0% (95% CI = 0.6-3.3) per year among Black and Hispanic MSM aged 25-34 years, respectively; and were highest in absolute count among Black MSM. Annual percentages of linkage to care within 1 month and viral suppression within 6 months of diagnosis among all MSM increased (2.9% [95% CI = 2.4-3.5] and 6.8% [95% CI = 6.2-7.4] per year, respectively). These findings, albeit promising, warrant intensified prevention efforts for Black, Hispanic, and younger MSM.

Practical and Ethical Concerns in Implementing Enhanced Surveillance Methods to Improve Continuity of HIV Care: Qualitative Expert Stakeholder Study

BACKGROUND

Retention in HIV care is critical to maintaining viral suppression and preventing further transmission, yet less than 50% of people living with HIV in the United States are engaged in care. All US states have a funding mandate to implement Data-to-Care (D2C) programs, which use surveillance data (eg, laboratory, Medicaid billing) to identify out-of-care HIV-positive persons and relink them to treatment.

OBJECTIVE

The purpose of this qualitative study was to identify and describe practical and ethical considerations that arise in planning for and implementing D2C.

METHODS

Via purposive sampling, we recruited 43 expert stakeholders-including ethicists, privacy experts, researchers, public health personnel, HIV medical providers, legal experts, and community advocates-to participate in audio-recorded semistructured interviews to share their perspectives on D2C. Interview transcripts were analyzed across a priori and inductively derived thematic categories.

RESULTS

Stakeholders reported practical and ethical concerns in seven key domains: permission and consent, government assistance versus overreach, privacy and confidentiality, stigma, HIV exceptionalism, criminalization, and data integrity and sharing.

CONCLUSIONS

Participants expressed a great deal of support for D2C, yet also stressed the role of public trust and transparency in addressing the practical and ethical concerns they identified.

'Either You Float or You Drown:' The Role of Social Ties and Stigma in Lived Experiences of the HIV Care Continuum in HPTN 065

HPTN 065 utilized financial incentives to promote viral suppression among HIV-positive participants. Exit interviews were conducted in a sub-study of participants in Washington, DC and Bronx, NY. The present analyses explored lived experiences of social ties and stigma as individuals navigated the HIV care continuum, including gender differences in lived experiences. Using viral load data and informed by stages-of-change theory, participants were categorized into "Low-Adherers (n = 13)", "Action (n = 29)" and "Maintenance (n = 31)" stages. Secondary analyses of qualitative data were informed by grounded theory, and instances of social ties and stigma discussed by participants were quantified with descriptive statistics. Participants (N = 73) were mostly male (64%), African American (58%), with yearly income under $10,000 (52%). Low-adherers identified fewer, and sometimes more combative social ties than those in other adherence stages. Maintainers identified supportive ties as motivation for medication adherence (68%) but relied less on them for motivation than individuals in other adherence stages. Low-adherers described current experiences of stigma related to being diagnosed with HIV more than other adherence stages (23%). Individuals in Action reported stigma related to disclosing their HIV status to others (52%), while individuals in Maintenance mostly stigmatized others engaging in "risky" behaviors (32%). Findings suggest that women may perceive greater HIV stigma than men, perceive less supportive social ties, and were the majority of Low-adherers. Gender-informed approaches can facilitate community de-stigmatization of HIV, as African American women may be at greater risk of negative HIV health outcomes.

Association of Continuity of Care With Outcomes in US Veterans With Inflammatory Bowel Disease

IMPORTANCE

Health care fragmentation is associated with inefficiency and worse outcomes. Continuity of care (COC) models were developed to address fragmentation.

OBJECTIVE

To examine COC and selected outcomes in US veterans with inflammatory bowel disease (IBD).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used the Veterans Health Administration (VHA) Corporate Data Warehouse to identify veterans with IBD who received care in the VHA health care system between January 1, 2002, and December 31, 2014. Included patients were veterans with IBD who had a primary care physician and at least 4 outpatient visits with key physicians (gastroenterologist, primary care physician, and surgeon) within the first year after an index IBD encounter. Data were analyzed from November 2018 to May 2020.

EXPOSURES

Care continuity was measured with the Bice-Boxerman COC index to define care density and dispersion within year 1 after the initial presentation.

MAIN OUTCOMES AND MEASURES

A Cox proportional hazards regression model was used to quantify the association between a low level of COC in year 1 (defined as ≤0.25 on a 0 to 1 scale) and subsequent IBD-related outcomes in years 2 and 3 (outpatient flare, hospitalization, and surgical intervention).

RESULTS

Among the 20 079 veterans with IBD who met the inclusion criteria, 18 632 were men (92.8%) and the median (interquartile range [IQR]) age was 59 (48-66) years. In the first year of follow-up, substantial variation in the dispersion of care was observed (median [IQR] COC, 0.24 [0.13-0.46]). In a Cox proportional hazards regression model, a low level of COC was associated with a higher likelihood of outpatient flares that required corticosteroids (adjusted hazard ratio [aHR], 1.11; 95% CI, 1.01-1.22), hospitalizations (aHR, 1.25; 95% CI, 1.06-1.47), and surgical interventions (aHR, 1.72; 95% CI, 1.43-2.07).

CONCLUSIONS AND RELEVANCE

Results of this cohort study showed a wide variation in dispersion of IBD care and an association between a lower level of COC and active IBD and worse outcomes. The findings suggest that investigating the barriers to COC in integrated systems that have invested in care coordination is key to not only better understanding COC but also identifying opportunities to improve care fragmentation.

Completion of maternity continuum of care among women in the post-partum period: Magnitude and associated factors in the northwest, Ethiopia

Background

Maternity continuum of care is a model of integrated components of maternal health service from pregnancy to the post-partum period to improve maternal, neonatal and child health. In Ethiopia, the magnitude of antenatal care, skilled delivery, and post-natal care have shown improvement. However, there is limited evidence of the woman who attends continuing from antenatal care to post-partum care.

Objective

To assess completion of maternity continuum of care and its associated factors among women, in Motta town and Hulet Eji Enese district, Northwest Ethiopia.

Methods

A community based cross-sectional study with a stratified cluster sampling technique was conducted among 819 women 6week-6month post-partum period in Motta town and Hulet Eji Enese district. The data were collected from March 12, 2019 to April1, 2019 by face to face interviews, using a pretested structured questionnaire. Binary logistic regression (bi-variable and multivariable) model was done. Adjusted odds ratio with respect to 95% confidence interval was employed in the strength and direction of the association between covariates and outcome variable. Besides, a P value<0.05 was used to declare statistical significance.

Results

A total of 819 women with100% response rate participated and Completion of maternity continuum of care was found to be 47% (43.2%-50.2%) in the study. Educational attainment of Secondary school and above (adjusted odds ratio(AOR) = 3.5; 1.9–6.3), urban residence (AOR = 4.6; 95%CI 2.5–8.5), women reach to a health facility within 30minute(AOR = 2.1; 95%CI 1.2–3.7), a woman was the primary decision maker for attending maternity continuum of care(AOR = 3.5;95%CI 1.9–6.3), index pregnancy-related complication(AOR = 2.4;95%CI 1.1–5.3), starting antenatal care within second trimester (AOR = 3.4;95%CI 2.1–5.6) and antenatal care visit 3–4 times(AOR = 2.1;95%CI 1.2–3.8) were statistically significant with completion of maternity continuum of care.

Conclusions

The completion of maternity continuum of care is low in the study area. Improving the educational status of women, engaging the rural community, physical accessibility of health facility, woman empowerment for decision making, emphasis on giving care for pregnancy-related complication, and early gestational age antenatal care at least 3 or more visits suggested to increase completion of maternity continuum of care.

Impacts of doctor-shopping behavior on diabetic patients' health: A retrospective longitudinal study in Taiwan

The aim of this study was to clarify the relationship between doctor-shopping behavior and clinical conditions, and to clearly outline the effects of both the number of clinic visits and the number of doctor changes on patients' health conditions. Data from January 1, 2000 to December 31, 2004 was collected from the National Health Insurance Research Database in Taiwan. After randomly selecting one million people, we extracted 5-year longitudinal data, about the number of clinic visits, number of doctor changes, and changes in self-health status for each patient with diabetes over the age of 18. We developed a relationship among the variables by using the generalized estimating equation. The results revealed that the number of clinic visits on the change of health status is a U curve, suggesting that health condition could be optimal with an appropriate number of clinic visits. The effect of the number of doctor changes is linearly correlated with health deterioration. The results suggest that disease conditions can only be controlled with an adequate number of clinic visits. Excessively frequent clinic visits are not only unfavorable to patients' health status but are also wasteful of limited medical resources. For diabetic mellitus patients, the more they change doctors, the worse their health status. All of these results are important for patients to stay healthy and to save medical resources.

Fabry disease during the COVID-19 pandemic. Why and how treatment should be continued

Fabry disease is an X-linked disease due to a deficiency of the lysosomal enzyme alpha-galactosidase A. Clinical symptoms in classically affected males include acroparesthesia, anhydrosis and angiokeratoma, which may present during childhood followed by cardiac, cerebral and renal complications. Even though pulmonary involvement is not widely appreciated by clinicians, an obstructive lung disease is another recognized component of Fabry disease. Coronavirus Disease-19 (COVID-19), caused by the SARS-CoV-2 virus was labeled as a global pandemic and patients with Fabry disease can be considered at high risk of developing severe complications. The impact of COVID-19 on patients with Fabry disease receiving enzyme replacement therapy is still unknown. Many patients who receive treatment in the hospital experienced infusion disruptions due to fear of infection. Effects of temporary treatment interruption was described in more detail in other lysosomal storage diseases, but the recommencement of therapy does not fully reverse clinical decline due to the temporary discontinuation. When possible, home-therapy seems to be the most efficient way to maintain enzyme replacement therapy access during pandemic. Sentence take-home message: Home-therapy, when possible, seems to be the most efficient way to maintain enzyme replacement therapy access during pandemic in patients with Fabry disease.

Fragmentation of postpartum readmissions in the United States

BACKGROUND

Fragmentation of care, wherein a patient is readmitted to a hospital different from the initial point of care, has been shown to be associated with worse patient outcomes in other medical specialties. However, postpartum fragmentation of care has not been well characterized in obstetrics.

OBJECTIVE

To characterize risk for and outcomes associated with fragmentation of postpartum readmissions wherein the readmitting hospital is different than the delivery hospital.

METHODS

The 2010 to 2014 Nationwide Readmissions Database was used for this retrospective cohort study. Postpartum readmissions within 60 days of delivery hospitalization discharge for women aged 15-54 years were identified. The primary outcome, fragmentation, was defined as readmission to a different hospital than the delivery hospital. Hospital, demographic, medical, and obstetric factors associated with fragmented readmission were analyzed. Adjusted log-linear models were performed to analyze risk for readmission with adjusted risk ratios and 95% confidence intervals as the measures of effect. The associations between fragmentation and secondary outcomes including (1) length of stay >90th percentile, (2) hospitalization costs >90th percentile, and (3) severe maternal morbidity were determined. Whether specific indications for readmission such as hypertensive diseases of pregnancy, wound complications, and other conditions were associated with higher or lower risk for fragmentation was analyzed.

RESULTS

From 2010 to 2014, 141,276 60-day postpartum readmissions were identified, of which 15% of readmissions (n = 21,789) occurred at a hospital different from where the delivery occurred. Evaluating individual readmission indications, fragmentation was less likely for hypertension (11.1%), wound complications (10.7%), and uterine infections (11.0%), and more likely for heart failure (28.6%), thromboembolism (28.4%), and upper respiratory infections (33.9%) (P < .01 for all). In the adjusted analysis, factors associated with fragmentation included public insurance compared to private insurance (Medicare: adjusted risk ratio, 1.68; 95% confidence interval, 1.52, 1.86; Medicaid: adjusted risk ratio, 1.28; 95% confidence interval, 1.24, 1.32). Fragmentation was associated with increased risk for severe maternal morbidity during readmissions in both unadjusted (relative risk, 1.84; 95% confidence interval, 1.79, 1.89) and adjusted (adjusted risk ratio, 1.81; 95% confidence interval, 1.76, 1.86) analyses. In adjusted analyses, fragmentation was also associated with increased risk for length of stay >90th percentile (relative risk, 1.48; 95% confidence interval, 1.42-1.54) and hospitalization costs >90th percentile (adjusted risk ratio, 1.74; 95% confidence interval, 1.67, 1.81).

CONCLUSION

This study of nationwide estimates of postpartum fragmentation found discontinuity of postpartum care was associated with increased risk for severe morbidity, high costs, and long length of stay. Reduction of fragmentation may represent an important goal in overall efforts to improve postpartum care.

Diagnosing and providing initial management for patients with Gestational Diabetes: What is the General Practitioner's experience?

AIM

This study explores the General Practice (GP) experience of Gestational Diabetes Mellitus (GDM). Much has been written about patient perspectives, yet little is known about the GP perspective at initial diagnosis and management. GDM is increasingly managed in the secondary and tertiary sector, the confidence of GPs and their role in ongoing care has not been examined. Given GDM's poor follow up rates, all aspects of the patient journey warrant close examination.

METHODS

Through purposive and snowball sampling, we conducted semi-structured interviews with GPs in Brisbane, Australia between April and October 2018. Data collection, until saturation, and analysis were concurrent, and the Leximancer analysis tool assisted with content analysis and suggestion of themes.

RESULTS

Dominant themes include uncertainty/urgency and feeling under-utilised. GPs have a pragmatic approach in the face of uncertainty, and adopt one of several strategies to meet patient needs. A key issue that may impact on long term follow up and high quality GP-patient relationships is concern about the patient being 'taken away' by the hospital. Communication with the hospital is generally perceived as poor.

CONCLUSIONS

The experience of GPs in the initial diagnosis and management of GDM may assist in improving GDM follow up.

High dropout rate from maternity continuum of care after antenatal care booking and its associated factors among reproductive age women in Ethiopia, Evidence from Demographic and Health Survey 2016

Background

Maternal continuums of care were vital to reducing maternal and neonatal mortalities. While the dropout rate remains high and limited studies were found on risk factors associated with a high dropout rate of the maternal continuum of care.

Objective

This study aimed to assess the magnitude of dropout rate and its associated factors of maternity continuum of care in Ethiopia, 2016

Methods

An in-depth secondary data analysis was conducted from the Ethiopian Demographic and Health Survey 2016 data. A total of 4,693 women who were booked for antenatal care visit were included to the final analysis. A community-based cross-sectional study design and a pre-tested and standardized questionnaire were used to collect the survey data. Data were weighted using women data weighting variables. Chi-square and multicollinearity assumptions were checked for independent variables. Bi-variable and multivariable logistics regression used to identify associated factors with a cut of the p-value of 0.2 and 0.05 respectively. Adjusted Odds Ratio (AOR) with 95%CI was reported for the final model.

Results

Of the total 4,693 women who were booked for antenatal care visits, 2,092(44.58%), 2,183 (46.52%), and 4,086(87.07%) dropped from a recommended number of ANC, Institutional delivery and postnatal care visit respectively. Only 308 (6.56%, 95%CI: 5.89, 7.31) women used all the complete continuum of care. Not married, and poorest wealth index were significantly associated with dropout from ANC visit. Being a protestant religious follower was significantly associated with dropout from PNC after antenatal care booking. While not exposed to media, distance from health facility as a big problem, protestant affiliation, parity of 2 to 4 and above4, Wealth index of the poorest, poorer, middle, and richer significantly associated with dropout from institutional delivery. Not being informed about pregnancy complications during their ANC visit was significantly associated with dropout from ANC, PNC, and institutional delivery.

Conclusions

Dropout of women from the maternity continuum of care after antenatal care booking was a public health problem in Ethiopia. Socio-demographic, pregnancy, and health service-related factors were significant determinants of dropout from the maternity continuum of care. Improving the family wealth index, increasing access to health facilities, media exposure, and giving more information during the antenatal care visit is important to reduce the dropout rate from the maternity continuum of care.

Level of completion along continuum of care for maternal and newborn health services and factors associated with it among women in Arba Minch Zuria woreda, Gamo zone, Southern Ethiopia: A community based cross-sectional study

Background

Completion along continuum of care for maternal and newborn health (MNH) services like antenatal care, skilled birth attendance and postnatal care services is advantageous over each segment of services. It is one of the currently recommended strategies to reduce both maternal and neonatal mortality and achieve the global target of ending preventable maternal and under-five children’s mortality. Although studies on factors affecting each segment of MNH services have been well documented in Ethiopia, there is a dearth of evidence about the level of continuum of care and factors associated with it. This study was intended to fill this gap in evidence in the study area so that interventions could be taken to improve maternal and newborn health.

Methods

A community-basedcross-sectional study was conducted among 432 postnatal women who gave birth in the previous year in Arba Minch Health and Demographic Surveillance System (HDSS) site. Women were selected by computer generated random numbers from a list of women who stayed at least 6 weeks after birth. A pre-tested, structured, and interviewer-administered questionnaire was used for data collection. Data were entered and coded in Epi-data and analyzed using SPSS software version 23. Binary logistic regression model was fitted to identify factors associated with the dependent variable. Bivariate and multivariable analyses were fitted in steps to select candidate variables for multivariable analysis and to control for potential confounding effect respectively.

Results

The overall completion along the continuum of care was 42(9.7%). The factors significantly associated with completion of care along the continuumwere timely initiation of antenatalcare (before16weeks) [AOR: 10.7, CI (5.1, 22.7], birth preparedness and complication readiness [AOR: 2.9, CI (1.4, 6.1), pre-pregnancy contraception utilization [AOR: 3.9, CI: 1.4, 11.0], being employed [AOR: 2.6 CI:(1.3, 5.4)], and having a planned pregnancy [AOR:3.5 CI: (1.1, 11.4)].

Conclusion and recommendation

Completion along the continuum of care for MNH services was low in the study area. Thus, efforts to improve the completion of care should focus on interventions that enhance early initiation of antenatal care, planned pregnancy, and birth preparedness and complication readiness.

The cascade of care in managing hypertension in the Arab world: a systematic assessment of the evidence on awareness, treatment and control

BACKGROUND

Hypertension is a leading risk factor for mortality and morbidity globally and in the Arab world. We summarize the evidence on awareness, treatment, and control of hypertension, to assess the extent of gaps in the hypertension continuum of care. We also assess the influence of gender and other social determinants at each level of the cascade of care.

METHODS

We searched MEDLINE and SSCI databases for studies published between 2000 and 2017, reporting the rates of awareness, treatment or control of hypertension and/or their determinants in the Arab region. We included sources on both general populations and on clinical populations. The review process was based on the PRISMA guidelines. We present rates on the three stages of the care cascade corresponding to (1) awareness (2) treatment and (3) control of blood pressure, and estimated the losses that occur when moving from one stage to another. We also take stock of the evidence on social determinants and assess the statistical significance of gender differences in awareness, treatment and control.

RESULTS

Data from 73 articles were included. Substantial proportions of hypertensives were lost at each step of the hypertension care continuum, with more missed opportunities for care resulting from lack of awareness of hypertension and from uncontrolled blood pressure. More than 40% and 19% of all hypertensive individuals were found to be unaware and to have uncontrolled blood pressure, respectively, but among individuals diagnosed with hypertension, less than 21% were untreated. Awareness rates were higher among women than men but this advantage was not consistently translated into better blood pressure control rates among women.

CONCLUSIONS

This analysis of the cascade of care indicates that barriers to proper diagnosis and adequate control are greater than barriers to delivery of treatment, and discusses potential factors that may contribute to the gaps in delivery.

Patient Safety Initiative Using Peer Observations and Feedback Inspire Collegial Workplace Culture

Following Joint Commission recommendations for standardizing patient handoffs, direct peer observations and feedback were utilized in order to improve patient safety related to transitions of care in the Division of Pediatric Hospital Medicine at Kapi'olani Medical Center for Women & Children. All hospitalist attendings were trained in an evidence-based handoff bundle inclusive of team communication and feedback strategies. For the initial project, each hospitalist performed 12 peer observations and feedback sessions using validated tools for verbal and written handoffs over 6 months. For a subsequent "refresher" project, each hospitalist performed 6 handoff observations. Attendings were surveyed several times before, during, and after completion of the multiple iterations of the project. A qualitative interview was conducted 6 years after the initial handoff project. In total, 204 observations were completed by 17 hospitalists during the initial project. The perceived overall quality of the patient handoff improved significantly across shifts (P < .001 for the quality of each of two critical daily handoffs) as did pediatric hospitalists' confidence in providing peer feedback (P < .001). Downstream effects of this activity led to additional benefits towards the cohesive growth of the division. Themes from post-project qualitative interviews regarding the peer observation and feedback portion of the study included that it was "helpful," "collaborative," and inspired "camaraderie" that led to increased comfort and participation during future opportunities for observation and feedback. Performing direct peer observations with feedback strengthened the workplace culture, promoted growth through collaboration, and allowed acceptance and success of future projects involving peer observations and feedback.

Continuity of Care Is Associated with Medical Costs and Inpatient Days in Children with Cerebral Palsy

Background: Children with cerebral palsy (CP) place a considerable burden on medical costs and add to an increased number of inpatient days in Taiwan. Continuity of care (COC) has not been investigated in this population thus far. Materials and Methods: We designed a retrospective population-based cohort study using Taiwan’s National Health Insurance Research Database. Patients aged 0 to 18 years with CP catastrophic illness certificates were enrolled. We investigated the association of COC index (COCI) with medical costs and inpatient days. We also investigated the possible clinical characteristics affecting the outcome. Results: Over five years, children with CP with low COCI levels had higher medical costs and more inpatient days than did those with high COCI levels. Younger age at CP diagnosis, more inpatient visits one year before obtaining a catastrophic illness certificate, pneumonia, and nasogastric tube use increased medical expenses and length of hospital stay. Conclusions: Improving COC reduces medical costs and the number of inpatient days in children with CP. Certain characteristics also influence these outcomes.

Continuity and efficacy of real-world use of azacitidine

Long-term azacitidine (AZA) treatment is necessary for its maximal therapeutic effect. This study examined the continuity and efficacy of AZA treatment in real-world use. We conducted a retrospective study in 38 patients who had completed AZA treatment at the Ogaki Municipal Hospital between April 2011 and August 2019. The median number of AZA received cycles was 4. The number of AZA treatment cycles received was 1-3 cycles in 15 (39.5%), 4-6 cycles in 15 (39.5%), and ≥ 7 cycles in 8 (21.1%). The most common reason for discontinued AZA treatment was infection. Overall response rate was 33.3% in patients with discontinued AZA use (< 4 cycles) and 56.5% in patients with continued AZA (≥ 4). Median overall survival (OS) was 124 (15-529) days and 391 (132-2,825) days in the respective groups (p<0.01). The presence of peripheral blood blasts (PBs) was a prognostic factor for continuation of treatment (p =0.03). Discontinued AZA treatment due to infection (p <0.01), and PBs (p =0.03) were unfavourable prognostic factors for OS. Long-term AZA use is beneficial for improvement and survival. Infection control and presence of PBs were important factors for continuing AZA. These data support the idea of long-term continued treatment with AZA for optimal benefit to patients.

Observational study of continuity of HIV care following release from correctional facilities in South Africa

BACKGROUND

We sought to describe linkage to care, ART continuity, and factors associated with linkage to care among people with HIV following release from incarceration in South Africa.

METHODS

We conducted a study of South African correctional service community reentrants who were receiving ART at the time of release. The study was implemented in three of 46 correctional service management areas. Participants were enrolled prior to corrections release and followed up to 90 days post-release to obtain self-reported linkage to care status and number of days of ART provided at corrections release. Clinic electronic and paper charts were sought and abstracted to verify self-reported linkage to care. Log-binomial regression, adjusted for facility, was used to identify associations with post-release linkage to care (self-reported and verified). We sought to specifically assess for associations with HIV diagnosis during index incarceration, ART initiation during index incarceration, and duration of incarceration.

RESULTS

From May 2014 to December 2016, 554 inmates met eligibility and 516 (93%) consented to participate; 391 were released on ART, 40 of whom were excluded from analysis post-release. Of the remaining 351, 301 (86%) were men and the median age was 35 years (interquartile range 30, 40). Linkage to care was self-reported by 227 (64%) and linkage to care could be verified for 121 (34%). At most, 47% of participants had no lapse in ART supply. Initiating ART during the index incarceration showed a trend toward increased self-reported post-release linkage to care. Age > 35 years was associated with increased verified linkage to care while HIV diagnosis outside of a correctional setting and ART initiation during the index incarceration showed trends toward association with increased verified linkage to care.

DISCUSSION

The results of our study are the first description of retention in care following correctional facility release from an African setting and indicate high levels of attrition during the transition from correctional facility to community care. Initiating ART within a correctional facility did not impair post-release linkage to care.

Continuity With Patients, Preceptors, and Peers Improves Primary Care Training: A Randomized Medical Education Trial

PURPOSE

Infusing continuity of care into medical student clerkships may accelerate professional development, preserve patient-centered attitudes, and improve primary care training. However, prospective, randomized studies of longitudinal curricula are lacking.

METHOD

All entering Northwestern University Feinberg School of Medicine students in 2015 and 2016 were randomized to the Education Centered Medical Home (ECMH), a 4-year, team-based primary care clerkship; or a mentored individual preceptorship (IP) for 2 years followed by a traditional 4-week primary care clerkship. Students were surveyed 4 times (baseline, M1, M2, and M3 year [through 2018]); surveys included the Maslach Burnout Inventory (MBI); the Communication, Curriculum, and Culture (C3) survey assessing the hidden curriculum; and the Attitudes Toward Health Care Teams (ATHCT) scale. The authors analyzed results using an intent-to-treat approach.

RESULTS

Three hundred twenty-nine students were randomized; 316 (96%) participated in surveys. Seventy percent of all respondents would recommend the ECMH to incoming first-year students. ECMH students reported a more positive learning environment (overall quality, 4.4 ECMH vs 4.0 IP, P < .001), greater team-centered attitudes (ATHCT scale, 3.2 vs 3.0, P = .007), less exposure to negative aspects of the hidden curriculum (C3 scale, 4.6 vs 4.3, P < .001), and comparable medical knowledge acquisition. ECMH students established more continuity relationships with patients (2.2 vs 0.3, P < .001) and reported significantly higher professional efficacy (MBI-PE, 4.1 vs 3.9, P = .02).

CONCLUSIONS

In this randomized medical education trial, the ECMH provided superior primary care training across multiple outcomes compared with a traditional clerkship-based model, including improved professional efficacy.

Improving the validity, relevance and feasibility of the continuum of care framework for maternal health in South Africa: a thematic analysis of experts' perspectives

BACKGROUND

The continuum of care is a key strategy for ensuring comprehensive service delivery for maternal health, while acknowledging the role of the social determinants of health. However, there is little research on the operationalisation of the framework by decision-makers and implementers to address maternal health challenges. The framework should be measurable and feasible for implementation in low- and middle-income country contexts. In this study, we explore experts' perspective on monitoring indicators for continuum of care and key issues related to their use in the South African context.

METHODS

We conducted key informant interviews with a range of experts in decision-making and programme implementation roles in the health system and relevant sectors. Key informants provided their perspectives on systematically selected, nationally representative monitoring indicators in terms of validity, relevance and feasibility. We interviewed 13 key informants and conducted a thematic analysis of their responses using multi-stage coding techniques in Atlas.ti 8.4.

RESULTS

Experts believed that the continuum of care framework and monitoring indicators offer a multisectoral perspective for maternal health intervention missing in current programmes. To improve validity of monitoring indicators, experts suggested reflection on the use of proxy indicators and improvement of data to allow for equity analysis. In terms of relevance and feasibility, experts believe there was potential to foster co-accountability using continuum of care indicators. However, as experts stated, new indicators should be integrated that directly measure intersectoral collaboration for maternal health. In addition, experts recommended that the framework and indicators should evolve over time to reflect evolving policy priorities and public health challenges.

CONCLUSION

Experts, as decision-makers and implementers, helped identify key issues in the application of the continuum of care framework and its indicators. The use of local indicators can bring the continuum of care framework from an under-utilised strategy to a useful tool for action and decision-making in maternal health. Our findings point to measurement issues and systematic changes needed to improve comprehensive monitoring of maternal health interventions in South Africa. Our methods can be applied to other low- and middle-income countries using the continuum of care framework and locally available indicators.

Rethinking rehabilitation after percutaneous coronary intervention: a protocol of a multicentre cohort study on continuity of care, health literacy, adherence and costs at all care levels (the CONCARDPCI)

INTRODUCTION

Percutaneous coronary intervention (PCI) aims to provide instant relief of symptoms, and improve functional capacity and prognosis in patients with coronary artery disease. Although patients may experience a quick recovery, continuity of care from hospital to home can be challenging. Within a short time span, patients must adjust their lifestyle, incorporate medications and acquire new support. Thus, CONCARD^PCI will identify bottlenecks in the patient journey from a patient perspective to lay the groundwork for integrated, coherent pathways with innovative modes of healthcare delivery. The main objective of the CONCARD^PCI is to investigate (1) continuity of care, (2) health literacy and self-management, (3) adherence to treatment, and (4) healthcare utilisation and costs, and to determine associations with future short and long-term health outcomes in patients after PCI.

METHODS AND ANALYSIS

This prospective multicentre cohort study organised in four thematic projects plans to include 3000 patients. All patients undergoing PCI at seven large PCI centres based in two Nordic countries are prospectively screened for eligibility and included in a cohort with a 1-year follow-up period including data collection of patient-reported outcomes (PRO) and a further 10-year follow-up for adverse events. In addition to PROs, data are collected from patient medical records and national compulsory registries.

ETHICS AND DISSEMINATION

Approval has been granted by the Norwegian Regional Committee for Ethics in Medical Research in Western Norway (REK 2015/57), and the Data Protection Agency in the Zealand region (REG-145-2017). Findings will be disseminated widely through peer-reviewed publications and to patients through patient organisations.

TRIAL REGISTRATION NUMBER

NCT03810612.

Measuring follow-up time in routinely-collected health datasets: Challenges and solutions

A key requirement for longitudinal studies using routinely-collected health data is to be able to measure what individuals are present in the datasets used, and over what time period. Individuals can enter and leave the covered population of administrative datasets for a variety of reasons, including both life events and characteristics of the datasets themselves. An automated, customizable method of determining individuals' presence was developed for the primary care dataset in Swansea University's SAIL Databank. The primary care dataset covers only a portion of Wales, with 76% of practices participating. The start and end date of the data varies by practice. Additionally, individuals can change practices or leave Wales. To address these issues, a two step process was developed. First, the period for which each practice had data available was calculated by measuring changes in the rate of events recorded over time. Second, the registration records for each individual were simplified. Anomalies such as short gaps and overlaps were resolved by applying a set of rules. The result of these two analyses was a cleaned set of records indicating start and end dates of available primary care data for each individual. Analysis of GP records showed that 91.0% of events occurred within periods calculated as having available data by the algorithm. 98.4% of those events were observed at the same practice of registration as that computed by the algorithm. A standardized method for solving this common problem has enabled faster development of studies using this data set. Using a rigorous, tested, standardized method of verifying presence in the study population will also positively influence the quality of research.

A Technology-Enabled Concussion Care Pathway Reduces Costs and Enhances Care

BACKGROUND

The standardization of care along disease lines is recommended to improve outcomes and reduce health care costs. The multiple disciplines involved in concussion management often result in fragmented and disparate care. A fundamental gap exists in the effective utilization of rehabilitation services for individuals with concussion.

PURPOSE

The purpose of this project was to (1) characterize changes in health care utilization following implementation of a concussion carepath, and (2) present an economic evaluation of patient charges following carepath implementation.

DESIGN

This was a retrospective cohort study.

METHODS

A review of electronic medical and financial records was conducted of individuals (N = 3937), ages 18 to 45 years, with primary diagnosis of concussion who sought care in the outpatient or emergency department settings over a 7-year period (2010-2016). Outcomes including encounter length, resource utilization, and charges were compared for each year to determine changes from pre- to post-carepath implementation.

RESULTS

Concussion volumes increased by 385% from 2010 to 2015. Utilization of physical therapy increased from 9% to 20% while time to referral decreased from 72 to 23 days post-injury. Utilization of emergency medicine and imaging were significantly reduced. Efficient resource utilization led to a 20.7% decrease in median charges (estimated ratio of means [CI] 7.72 [0.53, 0.96]) associated with concussion care.

LIMITATIONS

Encounter lengths served as a proxy for recovery time.

CONCLUSIONS

The implementation of the concussion carepath was successful in optimizing clinical practice with respect to facilitating continuity of care, appropriate resource utilization, and effective handoffs to physical therapy. The utilization of enabling technology to facilitate the collection of common outcomes across providers was vital to the success of standardizing clinical care without compromising patient outcomes.

Universal coverage but unmet need: National and regional estimates of attrition across the diabetes care continuum in Thailand

Background

Diabetes is a growing challenge in Thailand. Data to assess health system response to diabetes is scarce. We assessed what factors influence diabetes care cascade retention, under universal health coverage.

Methods

We conducted a cross-sectional analysis of the 2014 Thai National Health Examination Survey. Diabetes was defined as fasting plasma glucose ≥126mg/dL or on treatment. National and regional care cascades were constructed across screening, diagnosis, treatment, and control. Unmet need was defined as the total loss across cascade levels. Logistic regression was used to examine the demographic and healthcare factors associated with cascade attrition.

Findings

We included 15,663 individuals. Among Thai adults aged 20+ with diabetes, 67.0% (95% CI 60.9% to 73.1%) were screened, 34.0% (95% CI 30.6% to 37.2%) were diagnosed, 33.3% (95% CI 29.9% to 36.7%) were treated, and 26.0% (95% CI 22.9% to 29.1%) were controlled. Total unmet need was 74.0% (95% CI 70.9% to 77.1%), with regional variation ranging from 58.4% (95% CI 45.0% to 71.8%) in South to 78.0% (95% CI 73.0% to 83.0%) in Northeast. Multivariable models indicated older age (OR 1.76), males (OR 0.65), and a higher density of medical staff (OR 2.40) and health centers (OR 1.58) were significantly associated with being diagnosed among people with diabetes. Older age (OR 1.80) and higher geographical density of medical staff (OR 1.82) and health centers (OR 1.56) were significantly associated with being controlled.

Conclusions

Substantial attrition in the diabetes care continuum was observed at diabetes screening and diagnosis, related to both individual and health system factors. Even with universal health insurance, Thailand still needs effective behavioral and structural interventions, especially in primary health care settings, to address unmet need in diabetes care for its population.

Patient-Physician Relational Continuity and Health System Utilization among Patients in Alberta

In Alberta, no standardized processes exist to identify patients with chronic diseases (CDs) who do not have a family physician. This study examined the association between relational continuity (continuity of care) and healthcare utilization patterns in this population. Relational continuity was assessed using health administrative data to calculate a Usual Provider Continuity (UPC) Index. The majority of patients with no or a low UPC Index were male, did not have CD and were healthy or non-users of healthcare. When grouped by UPC Index, regression modelling revealed that emergency department visits and unplanned hospitalization declined with increased continuity of care. Advanced state of disease(s) and location of residence increased the likelihood of utilization of these services in the low- and moderate-continuity groups.