ABSTRACT
Background: Since COVID-19 pandemic started, there have been changes in clinical practice to limit transmission, such as switching from face-to-face to remote consultations. Our department switched to delivering remote consultations without suspending service. Patients were offered the preference of either video or telephone consultation. It is unclear what factors including clinician-related factors significantly influence remote consultations in Rheumatology. Objectives: We aimed to study the influence of senior (substantively employed) vs trainee status of clinicians on remote consultations in our experience during the pandemic. Methods: Between 15/10/2020 and 09/11/2020, 12 clinicians in our department completed data collection forms after each remote consultation, recording the technology used (video vs phone);technical problems encountered;discharge and subsequent appointment status;and technical aspects of the consultation itself using 11-point numerical rating scales (NRS) (Time Adequate;Relevant History;Physical Exam;Management Plan;and Communication Quality). Data were collated on an MS Access 2016 database, and transferred to SPSS version 25 for statistics. Results: Nine senior clinicians (3 consultant rheumatologists, 3 Specialist Nurses, 1 Advanced Rheumatology Practitioner and 2 Senior Rheumatology Pharmacists) and 3 trainee clinicians (2 Specialty Trainee Registrars and 1 Foundation Year 2 doctor) completed forms. 285 forms were validated for analysis. The majority of consultations were completed by senior clinicians (266, 93.3% vs 19, 6.7%). Senior and trainee clinicians had a similar proportion of new patients compared to follow-up patients (18%, n=48 vs 15.8%, n=3;p=0.80);of female patients (68%, n=181 vs 63.2%, n=12;p=0.66);and video consultations (17.3%, n=43 vs 10.5%, n=2;p=0.45);and similar mean age of their patients (59.5 vs 56.7years;p=0.72) respectively. Senior clinicians accounted for all the technical issues reported (20%, n=48 vs 0%, n=0;p=0.03). Senior clinicians had lower mean scores compared to the trainee clinicians on NRS for Relevant History (8.68 vs 9.68;p<0.001), Physical Exam (1.49 vs 2.95;p=0.045), and Communication Quality (8.02 vs 9.37, p=0.002);and had no signifcant differences in scores for Time Adequate (8.46 vs 9.00;p=0.10) and Management Plan (7.17 vs 7.84;p=0.16). Senior and trainee clinicians and a similar proportion requests for subsequent face-to-face appointments (21.9%, n=51 vs 25%, n=4;p=0.77). Conclusion: There were no signifcant differences between senior and trainee clinicians in distributions of patients and proportion of video consultations. While no technical issues were reported by the trainee clinicians, this may in part be a refection of their smaller proportion of overall consultations. Although senior clinicians rated their consultations somewhat lower in some of the NRS, there was no signifcant difference in management plan scores and subsequent face-to-face appointment status compared to trainee clinicians. While the lower scores may partly refect the technical issues reported by the senior clinicians, longer clinical experience and greater knowledge may also be an underlying factor for this. Further studies with larger numbers may clarify these issues.
ABSTRACT
Background: Denosumab treatment is licensed for prevention of osteoporo-tic fractures. It can cause hypocalcaemia, so bone profile blood tests must be checked prior to treatment. In our department, we have a Standard that patients have blood tests within 1 month before their denosumab injection, and that they receive the injection within 1 month from its due date. A customized MS Access database to record this information and generate a date for the next dose was established in 2015 after a quality improvement project (QIP)1. At the onset of the COVID-19 pandemic, UK national guidance recommended continued provision of denosumab as an essential service. Objectives: 1. To re-audit delay from due date to actual injection date after establishment of our database. To compare delay from due date to actual injection date before and after onset of COVID-19. To compare the time between blood tests and actual injection date, before and after onset of COVID-19. Methods: Data for 2 time-periods were extracted from the database: Time Period 1 (pre-COVID-19) 01-03-2019-29-02-2020;Time Period 2 (post-COVID-19 onset) 01-03-2020-28-02-2021. For each patient attendance, dates of blood test, due date and actual injection date were extracted. All patient details were anonymised, with a decryption key to identifers held on a secure server at the host Trust. It was manually determined whether blood tests and injections were within 1 month of when they were due. Statistical analyses were carried out in Stata v.14.0. The Kolmogorov-Smirnov test was used to compare distributions between Time Periods 1 and 2. Results: TIME PERIOD 1: 100 appointments were audited from 68 patients. 20% of blood tests were within 1 month of actual injection date. Median time between blood tests and actual injection was 45 days [IQR 35-59]. 52% of actual injections were given within 1 month from due date. (This compares favourably with our 2015 QIP, when 40% of actual injections were within 1 month from due date1). Median time between due date and actual injection was 29.5 days [IQR 13-50.5]. TIME PERIOD 2: 77 appointments were audited from 66 individual patients. 24.7% of blood tests were within 1 month of actual injection. Median time between blood tests and actual injection was 45 days [IQR 35-59]. 16.6% of actual injections were given within 1 month of due date. Median time between due date and actual injection was 82 days [IQR 40-141]. There were no signifcant differences in time between blood tests and actual injection between Time Periods 1 and 2. However, the time between due date and actual injection date was signifcantly longer in Time Period 2 (p<0.005). Conclusion: The introduction of our customized database promoted an improvement in time between due date and actual injection date of denosumab. However, this improvement signifcantly declined after the onset of the COVID-19 pandemic. Resources may need to be increased and processes adapted to minimise the impact of future emergencies on denosumab provision.
ABSTRACT
Background/Aims The COVID19 pandemic significantly altered healthcare provision. Our department switched immediately to remote consultations without suspending service, including telephone and video consultations. In this analysis we aimed to explore the role of patient-related factors in influencing the process and outcome of remote consultations with a view to improving the quality of service provision. Methods A data collection form was developed and offered to all clinicians to complete after each remote consultation. Information on age, gender, new or follow up status and interpreter use were collected. Clinicians were asked to rate the effectiveness of specific components of the consultation process (time adequate, relevant history, physical examination, management plan and communication quality) as compared to the usual face to face appointments on Numerical Rating Scales (NRS, 00). Data were collated in a Microsoft Access database. Statistical analysis was performed using SPSS version 25. Results In total, 285 valid forms were evaluated. 193 (67.7%) were women. Patients registered for new appointments (n=51, 18%) were significantly younger (mean±SD 52.9 ± 19.7 vs 60.6 ± 17.2 years, P=0.012). There were no significant correlations with age or any significant differences with gender in mean scores of NRS. New patients scored lower on NRS for relevant history (8.0 ± 1.1 vs 8.9 ± 1.2, P<0.001), management plan (4.8 ± 2.5 vs 7.8 ± 2.0, P<0.001) and communication quality (6.6 ± 2.0 vs 8.4 ± 1.6, P<0.001). Interpreter usage (n=9, 3.4%) had lower scores for relevant history (7.1 ± 2.4 vs 8.8 ± 1.1, P=0.012) and communication quality (5.4 ± 2.6 vs 8.1 ± 1.8, P=0.002). There was no significant association of age or gender with subsequent follow up appointment requested as face-to-face or remote. New patients were significantly more likely than follow-up patients to be offered a face-to-face follow up appointment (univariate regression, odds ratio (OR) 5.49, 95% CI 2.7-11.1, P<0.001). However, once adjusted for management plan in multivariate regression, new patients were no longer significantly associated with subsequent follow up face-to-face appointment (adjusted OR 1.19, 0.48-2.92, P=0.71). Conclusion Our study is one of the first in the UK to explore patient-specific factors influencing remote consultations in rheumatology. In our cohort, patient age or gender was not a limiting factor in utilising remote consultation. New consultations and interpreter use pose challenges for remote consultations, and further studies are needed to address these to see if any measures such as appropriate selection at triaging new appointments may be possible, to improve outcomes.
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SESSION TITLE: Respiratory Infections: What have We Learned About COVID-19 and New Trial Data for Management of Aspergilloma SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: To describe clinical characteristics of U.S. patients with pulmonary Mycobacterium avium complex (PMAC) whose sputum cultures were identified by gene sequence as M. chimaera. To highlight importance of MAC species identification (ID) following clinically focused assessment of PMAC patients. METHODS: From 2013-2019, sputum samples from 89 patients seen at the University of Texas Health Science Center at Tyler (UTHSCT) underwent processing for smear and culture of mycobacteria with species ID using partial 16S rRNA gene and ITS sequencing at first visit and at a minimum every 6 months thereafter. Clinical information was extracted from medical records. Microbiological significance of M. chimaera was assessed based on semi-quantitative colony count, smear positivity, and presence of the organism in broth only, broth and solid culture, and number of positive cultures. Clinical significance was based on symptoms, lung function and radiographic features. PMAC was defined according to 2007 ATS/IDSA criteria. RESULTS: M. chimaera was grown in 146 cultures from 89 patients. The mean patient age was 70.4 +/-10.3 years and 69% were women. The mean FEV1 percent predicted was 64% (SD, 24%). Only 4 patients were current tobacco smokers, 39% (35/89) patients had a history of >10 pack years. M. chimaera was associated with cavitary disease in 22% (20/89) patients and nodular bronchiectasis disease in 78% (69/89) of patients. Of the patients with nodular bronchiectasis, 35% (24/69) had multiple samples yielding M. chimaera. A single positive culture of the species occurred in 63% (56/89) of patients. Only 14% (20/146) cultures of M. chimaera had positive AFB smears and only 65/146 (45%) of total cultures were positive on solid media while 79/146 (54%) were positive in broth only. Isolates that were AFB smear negative and associated with a single positive culture grown only in broth did not meet ATS/IDSA guidelines for PMAC disease and therefore did not require therapy. CONCLUSIONS: This is the first large study of pulmonary M. chimaera in the U.S. PMAC infection with M. chimaera manifests as a variable clinical picture in patients. Identification of MAC species level ID is essential to understand the significance and pathogenicity of M. chimaera. CLINICAL IMPLICATIONS: ATS/IDSA criteria for PMAC disease was written in the context of M. avium and M. intracellulare infection. These criteria may not be applicable for other MAC species. ID of MAC isolates to the species level is an integral step in appropriate management of patients with sputum that grows M. chimaera. DISCLOSURES: Laboratory Research Grant relationship with Insmed Please note: >$100000 Added 06/01/2020 by Barbara Brown-Elliott, source=Admin input, value=Grant/Research Support Advisory Committee Member relationship with Insmed Inc Please note: $1001 - $5000 Added 06/12/2020 by David Griffith, source=Web Response, value=Consulting fee Consultant relationship with Insmed Inc. Please note: >$100000 Added 06/12/2020 by David Griffith, source=Web Response, value=Grant/Research Support Consultant relationship with Insmed Inc. Please note: $5001 - $20000 Added 06/12/2020 by David Griffith, source=Web Response, value=Consulting fee No relevant relationships by ELENA IAKHIAEVA, source=Web Response No relevant relationships by Pamela McShane, source=Web Response Consultant relationship with INSMED Please note: $1-$1000 by Julie Philley, source=Web Response, value=Honoraria Advisory Committee Member relationship with Janseen Please note: $1-$1000 by Julie Philley, source=Web Response, value=Honoraria Advisory Committee Member relationship with INSMED Please note: $1001 - $5000 by Julie Philley, source=Web Response, value=Consulting fee No relevant relationships by Carly Sigler, source=Web Response No relevant relationships by Sruthi Vasireddy, source=Web Response grant for labor tory study of arikace relationship with Insmed Please note: >$100000 Added 06/02/2020 by Richard Wallace, source=Web Response, value=grant to support lab work