REFERRAL BEHAVIOUR OF PRIMARY CARE DOCTORS TO RHEUMATOLOGY CLINIC IN MALAYSIA

BackgroundThe workload at rheumatology clinics have been growing relentlessly and an audit on new.referrals helps to identify referral behaviour of primary care doctors and improvement can be done by providing further training.ObjectivesTo audit on new referral cases to rheumatology clinic from 2020-2022 and to identify new cases with misdiagnosis for future training purpose.MethodsThis was a retrospective study. The medical records of all new referral to rheumatology clinic Hospital Sultan Ismail and Hospital Pakar Sultanah Fatimah from 1st January 2020 to 31th November 2022 were reviewed. The referral diagnosis and final diagnosis were identified and analysed.ResultsThere were total of 927 new cases referral throughout the 35 months during Covid-19pandemic. Majority of them were diagnosed to have rheumatoid arthritis (217/927)followed by systemic lupus erythematosus (190/927), psoriatic arthritis (147/927),gout (62/927), osteoarthritis (58/927), systemic sclerosis (25/927), ankylosing spondylitis (25/927), soft tissue rheumatism (24/927), Sjogren syndrome (24/927),mixed connective tissue disease (14/927), vasculitis (11/927), fibromyalgia (10/927),polymyositis (7/927) and miscellaneous (39/927).45 out of the new cases were diagnosed as unlikely rheumatic diseases. There were 29pending cases awaiting final diagnosis.212 of the referrals were identified as misdiagnosis with the highest as nodal osteoarthritis.(55/212) followed by unlikely rheumatic disease (43/212), soft tissue rheumatism (24/212),psoriatic arthritis (20/212), Sjogren syndrome (14/212), gout (8/212), rheumatoid arthritis (7/212), fibromyalgia (6/212), systemic lupus erythematosus (5/212), ankylosing spondylitis (4/212), mixed connective tissue disease (3/212), systemic sclerosis (2/212), polymyositis (2/212) and others (19/212): diffuse idiopathic skeletal hyperostosis, hypermobility syndrome, RS3PE syndrome, idiopathic uveitis, graft versus host disease, juvenile idiopathic arthritis, antiphospholipid syndrome, hypothyroidism, post streptococcal arthritis, prolapsed intervertebral disc, cerebrovascular disease, traumatic sternoclavicular joint subluxation, ledderhose disease, paraspinal muscle spasm and viral myalgia).ConclusionNodal osteoarthritis and soft tissue rheumatism can be great mimicker for inflammatory.arthritis and if wrongly diagnosed will lead to unnecessary anxiety or wrong treatment. More training is needed to improve clinical skills amongst primary care doctors.ReferencesNA.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

One stop vein clinic

Team involved are:Vascular surgery department in collaboration with the radiology department.Kent and Canterbury hospitalEast Kent University Foundation TrustIn the current practice under the vascular clinic, a patient with venous disease must pass through a journey of 3 steps.An outpatient appointment initially for clinical examination and evaluation of stage of his venous disease,Referral to radiographer for a duplex ultrasound scan (to rule out thrombosis and clarify the level of the disease)Further appointment with surgeon for receiving their final diagnosis and being listed for treatment.This unfortunately, has cause an unacceptable considerable delay in providing our service and treating those patients. The delay between referral to diagnosis exceeded more than 8 months. The main reasons were:Shortage of radiographersCOVID backlogTime consumed between these 3 appointmentsAssessment of issue and analysis of its causesWe analysed the factors of the cause of the delay in management of patients with venous diseases and it showed that the main reason for delay is delay in ultrasound scan, (the second step in the patient journey to gain the diagnosis).-We faced a period when our only radiographer resigned and we stayed without radiographers in the department for several months until the management were able to recruit a new radiographer. This of course has created a huge impact on our service.Of course the covid has impacted badly on our service. As we cancelled all the patient appointments with venous diseases and concentrated in life or limb threatening conditions only.-The inherited pathway has an element in delay as well as the time consumed between these 3 appointments may exceed several months.ImpactThe project is to merge all the three appointments in only one appointment where the patient will be examined and have the ultrasound in same setting. Thus, the patient will be able to have the outcome immediately in the same session without delay.The main problem , is that there's no enough radiographers to join the vascular surgeons in their clinic to carry on the scan simultaneously. Hence, the idea came to light, that the scan should be done by the vascular surgeons themselves.InterventionThis project helped me to act as a leader and express the ideas without fear and come out of my comfort zone.-We have been taught by the eclips team, To be a good leader , you have to start with your self.Thus, when I started this project, I had to learn the ultrasound skills and collaborate with the radiology department to ease the steps for the rest of the vascular team who would like to follow my steps and gain the ultrasound skill.Involvement of stakeholders, such as patients, carers or family members:The stakeholders areThe patientsFor the patient benefit, being assessed in one clinic, is believed to reduce the stress of awaiting diagnosis for such problem, in addition to some other merits like less time off work for patients, and less transportation cost.The vascular surgeons.The ultrasound is a cornerstone in the modern vascular era, and learning the skills for this tool will in fact benefit the surgeons in their daily work as they can scan the patient themselves particularly in case of emergency.The radiographers and radiology department.It is believed that scanning the patient by the vascular surgeons for the venous diseases will reduce the pressure on the radiology department for a huge list of patients awaiting scan .The management–Saving administration resources, by reducing the clinic cost and reducing the number of clinics.–Reduce the need for hiring locum radiographers or out of hours shifts to reduce the number of patients awaiting their venous scan.–To achieve the 18 months NHS timeframe between referral to diagnosis.–Cost effective measure to use the resources which is already present (portable ultrasounds) without need to buy a new machine or use another room for the scanning.Key MessagesThe main message is that there's a lot of brilliant ideas to improve the service in NHS. Giving us the chance to express these ideas is amazing. All appreciation to eclips team who helped us to start such projects.When I started describing my idea to my line manager, I was astonished that he was completing my words as if he was reading my mind. His support was outstanding and he eased the project steps to me.I hope my project will come to light and to be implemented in other sites as in my opinion, it will help plenty of patients who are struggling to manage their venous disease because of unaccepted delay , unfortunately a lot of them have no choice but to go the private sector which is extremely expensive.Lessons learntMy retrospective audit is still ongoing.There are 2 elements in my project.The first one is subjective, as I had to start with my self.I had a very limited ultrasound experience. So, I have done some search until I found a good centre for ultrasound course for vascular diseases. I applied and had my basic ultrasound skills.The challenge is how to apply this knowledge to the patients where I'm not yet confident to give a report. So, the collaboration with the radiology department was started and they were extremely helpful and supportive as they were kindly supported us with one of the best radiologist consultant to supervise me until I feel confident to do the scan independently. This step took around 2 months until is has been successful.-The second element is objective. As collecting the data during the working hours with busy rota is challenging.Measurement of improvementTo measure the effect of our improvement.We looked at the numbers of patients awaiting venous scan before starting the project (February 2022),. the number was around 230 patients.I managed to share my experience to my colleagues and one of them was interested and joined me. we as 2 speciality vascular surgeon in a half day once weekly clinic , were able to complete a venous scan of 105 patients (almost 50% of the number) in just 6 months.-Currently , we are running an audit to assess the time difference before and after the implementation of the project and hopefully, the data will come to light soon.Strategy for improvementThe timeline for the project is 6 month, which have been completed successfully as myself and the other vascular surgeon are able to perform the venous scan independently.The data is analysed at the moment and will soon be published.

Developing and Implementing a Depression Screening and Referral Protocol Among College Students

Depression is prevalent among college students but remains underrecognized and undertreated. Evidence supports universal depression screening among college students combined with follow-up systems to ensure appropriate diagnosis and management. Screening tools may include versions of the Patient Health Questionnaire, and follow-up systems may include following up with the current provider or referring the student to a mental health specialist. The purpose of this quality improvement project was to promote the identification of college students with depression and subsequent appropriate referrals.

The state of the faecal immunochemical test in symptomatic patients in the UK

In its 2015 NG12 guidance, NICE recommended the use of guaiac-based faecal occult blood test (gFOBT) and not FIT in primary care to triage patients with low-risk symptoms for cancer, due to paucity of evidence on FIT diagnostic accuracy at the time.1 But as evidence on FIT efficacy in symptomatic patients continued to emerge, gFOBT was replaced with FIT in NICE 2017 DG30 guidance.2 However, this recommendation was not extended to patients with high-risk symptoms for cancer or rectal bleeding.2 Since then, several pioneering centres in the UK, including centres in Nottingham, Oxfordshire and Tayside in Scotland, introduced FIT in patients with high and low risk symptoms using record linkage as part of service development projects, and reported promising results.3–5 At the same time, three large research studies were conducted in England, investigating the diagnostic accuracy of FIT in high and low risk symptomatic patients and reporting similar results.6–8 Two recent meta-analyses evaluated this and other evidence of the diagnostic accuracy of FIT.9,10 The key message from these studies remains remarkably consistent: The diagnostic accuracy of this test is, counter-intuitively, barely improved by the addition of other clinical characteristics into a risk-score.3,11Despite these encouraging results, there has been reluctance on the part of some groups in the UK, including NHS England, to recommend the use of FIT in the high-risk symptomatic patients because of concerns about missing cancer. Variation in post-colonoscopy colorectal cancer across colonoscopy providers in English National Health Service: population based cohort study.

Teledermoscopy – An Emerging Technology for Skin Cancer Detection

Dermatology is facing a worsening scarcity of providers, especially since the onset of the COVID-19 pandemic. With lengthening waiting periods for skin cancer screening examinations, there is a distinct need for alternatives to in-person evaluation. Delayed diagnosis is associated with poorer outcomes, especially in melanoma. Teledermatology has the potential to prevent the increased morbidity and mortality associated with late-stage diagnosis, especially when utilized with dermoscopy. In the literature, this novel field of "teledermoscopy” has exhibited accuracy and reliability comparable to face-to-face visits and is a promising alternative intervention for those who require triaging or for patients who are unable to access in-person care (rural, underserved populations). Although the early data is promising, formal guidelines for acquisition and interpretation of dermatoscopic images need to be established before wider implementation is possible. With standardization, use at-home or in in primary care offices will with such standardization, may relieve some of the pressure on an overburdened dermatologic care system and help patients who require urgent care to be seen more expediently.

Journal club

Patients often did not understand the diagnostic approach taken, for example, feeling advanced imaging was required and not appreciating the blood tests and CXR were being used to exclude cancer. A retrospective cohort study by Wang et al (Respiration 2022;101:553) looked at the short-term and long-term effects of antibiotic prescribing on treatment failure (repeat steroid prescription within 30 days) and re-exacerbations (prescription of steroids and or antibiotics between 30 days and 1 year). Saab et al (Nature Prim Care Respir Med 2022;32:42) completed a systematic review of seven studies investigating strategies that help primary healthcare professionals (HCPs) recognise and refer suspected LC patients quickly.

Underused Physical Therapy Services in Primary Care Settings: An Overview

The combined effects of longer life, noncommunicable diseases, and injuries increase the need for rehabilitation services. Although physical therapists' unique skill set on movement-related dysfunction allows for broad contributions to health care, physical therapy (PT) remains underutilized. This article situates the problem within the broader primary care context, focusing on PT's ability to mitigate disability and dysfunction in complex syndromes including pelvic floor incontinence, vertigo, cancer, chronic neuromusculoskeletal pain, and long coronavirus disease (ie, lingering effects after acute coronavirus disease infection passes). The path from PT research to clinical implementation remains dependent on factors beyond research evidence. This overview underscores the need to address this evidence to practice gap.

Screening tool to improve patient referral to acute surgical care from accident and emergency

IntroductionThis study aimed, first, to audit the appropriateness of surgical referrals to an acute surgical unit for urgent assessment and, second, to devise a screening tool for use in the emergency department to categorise patients into those who need an urgent surgical review and those who can be seen in an ambulatory setting within the next few days.MethodsThe first phase of the study was an audit of surgical referrals between 1 and 18 February 2020 to check the appropriateness of the surgical referral. In the second phase, a tool was designed to screen patients who did not require urgent surgical review and could be seen in the ambulatory clinic. A prospective questionnaire study was conducted from 1 February to 24 March 2020 with patients who were admitted to an acute surgical ward. Based on responses to the screening tool, patients were given the outcome of whether they can be discharged and seen in an ambulatory clinic. The accuracy of the screening tool outcome was assessed and compared with actual patient discharge outcomes by the surgical team evaluating patients' electronic medical records.ResultsIn the first audit of referrals to the acute surgical ward, 206 patients were referred to the acute surgical unit and seen by the senior surgeon. Of these, 142 (68.9%) were discharged on the same day with or without follow-up in the ambulatory surgical clinic. In the prospective questionnaire phase of the study, 98 patients completed the questionnaire. The most common presentation was abdominal pain (n=60) followed by urological symptoms (n=11), symptoms of hernia complication (n=10), abscess (n=7), testicular pain (n=2) and trauma (n=2). Of the patients discharged on the same day, 50% were given ambulatory care appointments and 50% were discharged with no further follow-up. The sensitivity and specificity of the screening tool were 100% and 60.7%, respectively;the overall accuracy was 88.4%.ConclusionA large proportion of patients who are referred to the acute surgical unit can be deferred and seen in the ambulatory clinic. The screening tool used for acute surgical referral had reasonable sensitivity and high specificity to screen patients who can be seen in ambulatory clinics. At the same time, it identified patients who were unwell and required urgent surgical admission.

Challenges and opportunities for medical referrals at a mobile community health clinic serving sexual and gender minorities in rural South Carolina: a qualitative approach.

BACKGROUND: Sexual and gender minorities (SGM) in the Southern United States face challenges in accessing sexual and gender affirming health care. Alternative care models, like inclusive mobile clinics, help mitigate barriers to care for SGM. There is limited data in the literature on the experience of medical referral processes for SGM individuals accessing services from mobile health clinics. AIMS AND OBJECTIVES: The purpose of this study is to describe the medical referral experiences of SGM clients and their providers at a mobile health clinic in the Southern United States. METHODS: We recruited English-speaking individuals who provided care or received care from the mobile health clinic in South Carolina between June 2019 and August 2020. Participants completed a brief demographic survey and a virtual in-depth, semi-structured individual interview. Data analysis was conducted using an iterative process to generate codes, categories, and themes. Data collection and analysis were terminated once thematic saturation was achieved. RESULTS: The findings from this study indicated that the mobile health clinic had an inconsistent referral process that was largely dependent on providers' knowledge. Furthermore, clients and providers expressed individual barriers to the referral process, such as financial barriers, and opportunities to improve the referral process, such as an opt-in follow-up from the mobile clinic and increased mobile clinic resources. CONCLUSION: The findings in this study underscore the importance of having mobile clinics create a structured referral process that all medical providers are familiar with, and the value of hiring patient navigators that can support and refer clients to care that goes beyond the mobile health clinic setting.

Family Physicians Are Using Neighborhood Navigator to Address Social Determinants of Health

Social determinants of health are crucial drivers of health outcomes and inequities in the United States and account for approximately 80% of health outcomes, compared with only 20% for health care.1 Family physicians are increasingly asked to assess social needs and connect patients with appropriate resources. One commonly used resource referral platform is Aunt Bertha/findhelp, which was adopted by the American Academy of Family Physicians and branded as the Neighborhood Navigator tool in 2018. We analyzed more than 168,000 searches between November 2018 and April 2022 to identify patterns that may inform the direction of policy, funding, education, and resource allocation.

Good continence care: tips for nurses working in any setting: How to ask the right questions, assess symptoms and provide support before offering pads to patients with continence issues

The article offers tips for nurses on providing care for patients with continence issues. Topics discussed include the consequences of pressures on continence services, the lack of confidence among nurses in continence, tools used for initial assessment of bladder symptoms in adults, and the lack of services for younger patients with bladder and bowel issues in the Untied Kingdom.

Healthcare Process Improvement Initiative Catalyzes Unintended Positive Consequences: An Evaluation Case Study

An After-Action Review of Mobile Charge Capture (MCC) (an electronic health record management tool that addresses billing, scheduling, and coding practices) software, post implementation, was the foundation of this "evaluation case" study that focused on process improvement (PI) at a Midwest United States specialty medical practice ("the practice"). Outcomes, influenced by the SARS-CoV-2 pandemic (COVID-19), confirmed substantial operational improvement from MCC activation and generated unintended positive consequences. The MCC Improved Process facilitated billing and scheduling continuity that cultivated a readiness for the nimble pivot to virtual healthcare delivery. Culture emerged as a key factor in organizational change;with additional PI opportunities identified for further study and consideration.

The Effect of a Customized Advocacy Product on Downstream Medical Expenditures and Utilization

Background: The complexity of today’s healthcare system has led to the growth of an emerging healthcare function known as healthcare advocacy. A telephonic healthcare advocate or advisor can play an essential role in care coordination, a better understanding of health benefits, and ease in navigating the healthcare system. A healthcare advocate’s role may be filled by clinical staff (i.e., registered nurses), non-clinical staff, or both, with varying levels of training depending on the intended scope of service. Objective: With a higher number of employers seeking customized health advocacy programing, this study serves to determine if more favorable healthcare outcomes offset the additional operating costs associated with a more dedicated delivery system. Therefore, this study’s primary objective was to evaluate the impact of patient access to a customized health advocacy program on downstream medical costs and healthcare utilization compared to a control (CON) group without access to this service. The secondary aim was to provide information to employers on whether a higher investment in a more complex customized delivery model provides significant value compared to a less customized program. Methods: The study treatment (TRT) group included 89,372 individuals with access to a customized advocacy program for employees, while the CON group of 115,465 had access to a non-customized program. Key outcomes included total healthcare expenditures, hospital admissions, emergency room visits, and physician office visits 12 months after the advocacy start date compared to 6 months before the start date. Researchers evaluated the impact the customized advocacy intervention had on expenditures by comparing differences in pre- and post-expenditures between customized health advisor and non-customized health advisor groups after controlling for various demographic, socioeconomic, and health status characteristics. Inverse propensity score weighting helped minimize differences in characteristics between the TRT and CON groups. Results: With the customized advocacy product, healthcare expenditures increased by only $2.03 per member per month (PMPM) compared with a $26.35 PMPM larger increase for controls with a non-customized product. Also, customized health advisor participants experienced reduced hospital admissions and ER visits compared with the CON group. Conclusions: Study participants with access to customized healthcare advocacy services experienced significant healthcare cost savings, along with fewer ER visits, and reduced inpatient admissions compared with the CON group. Thus, these findings suggest that healthcare advocacy programs justify the increased delivery cost and can lead to reduced healthcare costs and utilization, along with the potential to improve health outcomes and quality of life.

Telephonic consultation for cardiac outpatient referrals – how safe and effective?

AimsThe COVID-19 pandemic necessitated remote consultation for outpatient referrals in many hospitals in the UK and encouraging results have been recorded from adult studies. There is a limited evidence base for telephonic consultation in paediatric cardiology patients, which is even more complicated by the perceived need for echocardiography. This brief report evaluates patients assessed over the telephone in a single paediatric cardiology outpatient clinic over a 15-month period.MethodsData (demographics, clinical information, and outcomes) on new referrals to a single paediatric cardiology clinic between March 2020 and May 2021 was analysed retrospectively. These patients had been initially assessed telephonically and subsequently face-to-face. We excluded patients who already had a cardiac diagnosis or were seen face-to-face on an earlier occasion. In addition, a survey was sent to parents or carers of patients, and another was sent to young patients aged >12 years, to ascertain what they thought about the approach in the context of the pandemic.ResultsOut of 93 new patients assessed telephonically, 64 were subsequently assessed face-to-face and were included in the data analysis. 34 of these patients were male and 30 were female, ranging in age from four days to 15 years old. Reasons for referral included cardiac-related symptoms (17%), an asymptomatic finding (53%) such as a heart murmur, and a requirement for screening (30%). After the initial appointment, 18 patients (28%) assessed to have possible significant heart disease were scheduled for a face-to-face appointment within 3 months, 28 (44%) assessed to have possible minor heart disease were scheduled within 6 months, and 18 (28%) assessed to have probable normal hearts were scheduled within 1 year. Outcomes from face-to-face consultation were either: reassurance and discharge (51%), remaining within the clinic for long-term follow-up (44%), or referral for intervention on an elective timescale (5%).Results from the surveys are encouraging so far in terms of acceptability of telephone consultation in the context of a pandemic. All results have not yet been recorded;hence they cannot be fully analysed at this time.ConclusionThe data collected from this sample of patients supports the safety of telephone consultation for initial assessment in outpatient paediatric cardiology during a pandemic. It also supports the extrapolation of results to a period when normalcy is established.

Forty-seven years of referrals and outcomes in a UK Child Development Centre (CDC): ongoing demand

888 Figure 1New referrals resulting in CDC assessment from 1974 to 2020[Figure omitted. See PDF] 888 Figure 2a) Reasons for referral 1999-2004 and 2019-2020 at the Northampton CDC (NCDC);b) Outcome diagnosis following assessment at NCDC for 1999-2004 and 2019-2020[Figure omitted. See PDF]Results399 children were assessed from 1st January 2019 to 31st December 2020 making a combined total of 4956 children over the 47-year period. For the entire timeline there is a consistent male predominance (figure 1).The previous study showed median age for assessment to be 2-3 years in 1987, this remains unchanged even in 2019-2020 data.Different reasons for referrals were observed over the two data sets of 1999- 2004 and 2019-2020 (figure 2(a)). Referrals for ‘social interactions’ have increased 3 and half fold, an increase from 10.4% in 1999-2004 to 32.6% in 2019-2020. Referrals for behavioural issues have almost doubled (10.1%-18.7%). However, referral for developmental delay/concerns approximately halved over the time.Figure 2b shows recorded assessment diagnosis comparing 1999-2004 with 2019-2020 data. ASD diagnosis predominates – 54.5% in 2019-2020. The trend in diagnosis of ‘developmental delay’ has halved from 1999-2004 to 2019-2020 (figure 2(b)).ConclusionThe previous presumptive South Northamptonshire Autism Follow Up Study (SNAFU) showed between 1974-2014 a clear change in recorded assessment outcomes over this period, with from 2004 the fall of the term ‘Developmental delay’ and the relentless rise of ‘Autism/autistic spectrum disorder’ (ASD)(1). This trend for 2019/2020 has continued in the newly presented data for 2019-2020.Despite the global COVID-19 pandemic, the number of referrals and subsequent diagnosis rates here have not changed much on 2020 data when compared with 2019. It is far too soon to determine for this CDC, the overall impact of COVID-19 for children who will be awaiting assessments.The 47-year long term trend is one of a consistent rise of referrals for and diagnosis of ASD in the CDC. ASD is the dominant cause for referral and diagnosis given. Commissioners of preschool educational services must take into account these rising case numbers to ensure equitably fully funded, preschool diagnosis and service provision for CDCs, Child Development Teams or other local service formulations.ReferencesWilliams AN, Mold B, Kilbey L, Naganna P. Forty years of referrals and outcomes to a UK Child Development Centre (CDC): Has demand plateaued? Child Care Health Dev. 2018 May;44(3):364-369. doi: 10.1111/cch.12552.Williams, A.N. and Essex, C. (2004), Developmental delay or failure to arrive? Dev. Med Child Neurol, 46:502-502. https://doi.org/10.1111/j.1469-8749.2004.tb00515.x

Cruise ship patient presentation, admission, and intervention rates to the emergency department

AIMS: Patients presenting to emergency departments (EDs) from cruise ships are a unique cohort of patients with several management challenges. Little evidence details the effect this has on EDs in terms of resource use. Therefore, we aimed to review the frequency, characteristics, admission, and intervention rates of cruise ship patient presentations to ED. METHODS: This retrospective study reviewed patient presentations to Wellington ED from cruise ships between 2016 and 2019. Data regarding presenting features, intervention and disposition were extracted via chart review. RESULTS: There were 214 patient presentations included with a median age of 68 (IQR 43.0-76.0);97/214(45.3%) were female. Regarding referral, cruise ship doctors referred 79/214 (36.9%) patients;16/79 (24.1%) to in-patient specialties and 63/79 (79.7%) to emergency medicine (EM);and 135/214 (63%) self-referred to ED. Common presenting complaints were chest pain, abdominal pain and trauma. Advanced imaging was requested for 21.5% of patients and 9.9% required urgent intervention. Regarding disposition, 38% were admitted (22% to in-patient wards, 16% to ED observation unit [OU]) and 61% were discharged (30% by ED and 31% after specialty consultation). CONCLUSION: Overall, the number of cruise ship patients presenting to the ED was low and unlikely to be a significant resource burden. Referrals by cruise ship doctors were appropriate. Education for cruise ship patients and port services regarding non-emergent care options would be valuable to reduce self-referral rates.

Outreach effort increases stem cell transplant referrals, may reduce racial disparities

Academic center outreach to community practices considerably increased stem cell transplant referrals for patients with multiple myeloma, according to study results. Stem cell transplant confers a survival benefit to patients with multiple myeloma, but referral to transplant centers remains a barrier. The outreach program is expected to expand to include areas around Macon and Savannah, allowing for coverage in a large portion of western South Carolina and eastern Georgia, a region where health outcomes tend to vary widely based on race and socioeconomic status.

Assisting Adult Protective Services in Addressing Maltreatment in Older Adults

My 81-year-old patient, E.P., has a history of hypertension, hypothyroidism, and mild chronic obstructive pulmonary disease, but I have not seen them since the initial COVID-19 shutdown. The county Adult Protective Services agency has requested a medical assessment because of concerns for E.P.’s safety and possible self-neglect following reports of E.P. appearing confused and wandering in the neighborhood. As a family physician, what are my responsibilites to the patient and to Adult Protective Services in this situation? What is the best clinical approach to addressing the concerns for E.P.’s welfare?