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1.
International Journal of Environmental Research and Public Health ; 19(9):4959, 2022.
Article in English | ProQuest Central | ID: covidwho-1837528

ABSTRACT

Australia is a federation of six states and two territories (the States). These eight governmental entities share responsibility for health and health services with the Australian Government. Mortality statistics, including causes of death, have been collected since the late 19th century, with national data produced by the (now) Australian Bureau of Statistics (ABS) from 1907. Each State introduced hospital in-patient statistics, assisted by State offices of the ABS. Beginning in the 1970s, the ABS conducts regular health surveys, including specific collections on Aboriginal and Torres Strait Islander peoples. Overall, Australia now has a comprehensive array of health statistics, published regularly without political or commercial interference. Privacy and confidentiality are guaranteed by legislation. Data linkage has grown and become widespread. However, there are gaps, as papers in this issue demonstrate. Most notably, data on primary care patients and encounters reveal stark gaps. This paper accompanies a range of papers from expert authors across the health statistics spectrum in Australia. It is hoped that the collection of papers will inform interested readers and stand as a comprehensive review of the strengths and weaknesses of Australian health statistics in the early 2020s.

2.
Radiation ; 1(4):261, 2021.
Article in English | ProQuest Central | ID: covidwho-1834875

ABSTRACT

Simple SummaryWe offer an overview of the state of regulation of AI in healthcare in the European Union, the United States of America, the China, and the Russian Federation and future strategies to make AI applications safe and useful.The COVID-19 crisis has exposed some of the most pressing challenges affecting healthcare and highlighted the benefits that robust integration of digital and AI technologies in the healthcare setting may bring. Although medical solutions based on AI are growing rapidly, regulatory issues and policy initiatives including ownership and control of data, data sharing, privacy protection, telemedicine, and accountability need to be carefully and continually addressed as AI research requires robust and ethical guidelines, demanding an update of the legal and regulatory framework all over the world. Several recently proposed regulatory frameworks provide a solid foundation but do not address a number of issues that may prevent algorithms from being fully trusted. A global effort is needed for an open, mature conversation about the best possible way to guard against and mitigate possible harms to realize the potential of AI across health systems in a respectful and ethical way. This conversation must include national and international policymakers, physicians, digital health and machine learning leaders from industry and academia. If this is done properly and in a timely fashion, the potential of AI in healthcare will be realized.

3.
Health Affairs ; 41(5):651-653, 2022.
Article in English | MEDLINE | ID: covidwho-1833673

ABSTRACT

The COVID-19 pandemic profoundly changed health care. Policy makers and health care leaders must evaluate the lessons learned from the pandemic and leverage telehealth innovations with an eye toward how such changes can advance health equity;drive high-quality, high-value, person-centered care;and promote affordability and sustainability.

4.
Health Affairs ; 41(5):635-642, 2022.
Article in English | MEDLINE | ID: covidwho-1833670

ABSTRACT

Anticipating a growing need for health care during the COVID-19 pandemic, the Centers for Medicare and Medicaid Services expanded telemedicine coverage in the United States on March 6, 2020. In this study we used roughly thirty million Medicare fee-for-service claims to quantify outpatient telemedicine use before and after the Medicare telemedicine coverage waiver and to examine the association of telemedicine use with the Area Deprivation Index, a comprehensive measure of neighborhood socioeconomic disadvantage. Before the waiver, 0.42 percent of patients had at least one outpatient telemedicine visit, with no significant differences between people residing in the most versus the least disadvantaged neighborhoods. With the waiver, 9.97 percent of patients had at least one outpatient telemedicine visit, with the highest odds of utilization seen for people residing in the most disadvantaged neighborhoods. After adjustment, our data suggest that the coverage waiver increased access to telemedicine for all Medicare populations, including people residing in the most disadvantaged neighborhoods, although the odds of use were persistently lower with increasing age. Overall, these findings are encouraging, but they illuminate a need for targeted interventions to improve telemedicine access further.

7.
Anesthesia and Analgesia ; 134(4 SUPPL):12-14, 2022.
Article in English | EMBASE | ID: covidwho-1820600

ABSTRACT

Background/Introduction: Amidst the COVID-19 pandemic, the sudden demand for virtual medical visits drove the drastic expansion of telemedicine across all medical specialties. Current literature demonstrates limited knowledge on the impact of telehealth on appointment adherence particularly in preoperative anesthesia evaluations. We hypothesized that there would be increased completion of preoperative anesthesia appointments in patients who received telemedicine visits. Methods: We performed a retrospective cohort study of adult patients at UCLA who received preoperative anesthesia evaluations by telemedicine or in-person within the Department of Anesthesiology and Perioperative Medicine from January to September 2021 and assessed appointment adherence. The primary outcome was incidence of appointment completion. The secondary outcomes included appointment no show and cancellations. Patient demographic characteristics including sex, age, ASA physical status class, race, ethnicity, primary language, interpreter service requested, patient travel distance to clinic, and insurance payor were also evaluated. Demographic characteristics, notably race and ethnicity, are presented as captured in the electronic health record and we recognize its limitations and inaccuracies in illustrating how people identify. Patient reported reasons for cancellations were also reviewed and categorized into thematic groups by two physicians. Statistical comparison was performed using independent samples t test, Pearson's chi-square, and Fischer's exact test. Results: Of 1332 patients included in this study, 956 patients received telehealth visits while 376 patients received in-person preoperative anesthesia evaluations. Compared to the in-person group, the telemedicine group had more appointment completions (81.38% vs 76.60%, p = 0.0493). There were fewer cancellations (12.55% vs 19.41%, p = 0.0029) and no statistical difference in appointment no-shows (6.07% vs 3.99%, p = 0.1337) in the telemedicine group (Figure 1). Compared to the in-person group, patients who received telemedicine evaluations were younger (55.81 ± 18.38 vs 65.97 ± 15.19, p < 0.001), less likely American Indian and Alaska Native (0.31% vs 1.60%, p = 0.0102), more likely of Hispanic or Latino ethnicity (16.63% vs 12.23%, p = 0.0453), required less interpreter services (4.18% vs 9.31%, p = 0.0003), had more private insurance coverage (53.45% vs 37.50%, p < 0.0001) and less Medicare coverage (37.03% vs 50.53%, p < 0.0001). Main reasons for cancellation included patient request, surgery rescheduled/cancelled/already completed, and change in method of appointment. Conclusions: In 2021, preoperative anesthesia evaluation completion was greater in patients who received telemedicine appointments compared to those who received in-person evaluations at UCLA. We also demonstrate potential shortcomings of telemedicine in serving patients who are older, require interpreter services, or are non-privately insured. Knowledge of these factors can provide feedback to improve access and equity to telehealth for patients from all backgrounds, particularly during the COVID pandemic as virtual evaluations increase. (Table Presented).

9.
Journal of Parenteral and Enteral Nutrition ; 46(SUPPL 1):S127-S128, 2022.
Article in English | EMBASE | ID: covidwho-1813569

ABSTRACT

Background: The consequences of the COVID-19 pandemic in long-term care facilities could be severe for frail and immunocompromised older adults.1 These older adult patients are hypermetabolic due to pressure ulcers, infection, fever, and elevated inflammatory labs such as CRP.1 They experience decreased appetite due to taste and smell changes. The inadequate intake, fat, and muscle loss due to prolonged hospitalization and increased nutrition demands create a negative nutrient balance, leading to unintentional weight loss (UWL).1 According to the Center for Medicare and Medicaid Services (CMS), UWL is defined as a weight loss of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days.2 In this proposal, our focus was unintentional weight loss (UWL) in long-term skilled care patients and how collaborative nursing and dietitian intervention impacts the UWL in this specific population. Methods: The data were collected retrospectively for all patients admitted between May 2020 to March 2021. The patient's demographic data was collected from the chart review using the point click care program. The top five patient diagnoses were retrieved using MDS coding for the study period. Additionally, the most common chronic disease in the geriatric population was used. The red napkin program was initiated in Oct 2020. The red napkin program was initiated to alert the nursing staff for patients with UWL and who also have pressure ulcers. Results: The results indicated that the average census was 152 patients during the study period. The majority of the patients (84%) were long-term care, with more females than males (59 vs 40%). Most of the patients were African American and Caucasian ethnic group. Nearly 40-45% of patients had diabetes, hypertension;one-fourth of the patients had CHF, dialysis, and dementia. During this period, there was a total of 77 patients who had unintentional weight loss as defined by CMS criteria. There were 60 patients before the intervention, and the numbers declined significantly to 33 patients post-intervention. Out of these 33 post-intervention patients, only 17 patients were new, and 16 were from the previous months of the preintervention period. The number has also declined from 12 to 7 expected weight loss related to hospice and comfort care patients. Most patients received oral nutrition supplements to halt weight loss. Four patients received alternate routes of nutrition support (TPN/EN) in addition to an oral diet. Almost 40% of patients had COVID-19 infection, and 38% of patients had pressure ulcers, which may have affected unintentional weight loss. Conclusion: The results indicated that appropriate and timely collaborative dietitian and nursing efforts improve patient outcomes or quality of care to halt unintentional weight loss in long-term skilled care facilities.

10.
Pain Physician ; 25(2):97-124, 2022.
Article in English | ProQuest Central | ID: covidwho-1812860

ABSTRACT

BACKGROUND: In the midst of the COVID-19 pandemic, data has shown that age-adjusted overdose death rates involving synthetic opioids, psychostimulants, cocaine, and heroin have been increasing, including prescription opioid deaths, which were declining, but, recently, reversing the trends. Contrary to widely held perceptions, the problem of misuse, abuse, and diversion of prescription opioids has been the least of all the factors in recent years. Consequently, it is important to properly distinguish between the role of illicit and prescription opioids in the current opioid crisis. Multiple efforts have been based on consensus on administrative policies for certain harm reduction strategies for individuals actively using illicit drugs and reducing opioid prescriptions leading to curbing of medically needed opioids, which have been ineffective. While there is no denial that prescription opioids can be misused, abused, and diverted, the policies have oversimplified the issue by curbing prescription opioids and the pendulum has swung too far in the direction of severely limiting prescription opioids, without acknowledgement that opioids have legitimate uses for persons suffering from chronic pain. Similar to the opioid crisis, interventional pain management procedures have been affected by various policies being applied to reduce overuse, abuse, and finally utilization. Medical policies have been becoming more restrictive with reduction of access to certain procedures, with the pendulum swinging too far in the direction of limiting interventional techniques. Recent utilization assessments have shown a consistent decline for most interventional techniques, with a 18.7% decrease from 2019 to 2020. The causes for these dynamic changes are multifactorial likely including the misapplication of the 2016 Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain, the relative ease of access to illicit synthetic opioids and more recently issues related to the COVID-19 pandemic. In addition, recent publications have shown association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids. These findings are leading to the hypothesis that federal guidelines may inadvertently be contributing to an increase in overall opioid deaths and diminished access to interventional techniques. Together, these have resulted in a fourth wave of the opioid epidemic. METHODS: A narrative review. RESULTS: The fourth wave results from a confluence of multiple factors, including misapplication of CDC guidelines, the increased availability of illicit drugs, the COVID-19 pandemic, and policies reducing access to interventional procedures. The CDC guidelines and subsequent regulatory atmosphere have led to aggressive tapering up to and including, at times, the overall reduction or stoppage of opioid prescriptions. Forced tapering has been linked to an increase of 69% for overdoses and 130% for mental health crisis. The data thus suggests that the diminution in access to opioid prescriptions may be occurring simultaneously with an increase in illicit narcotic use. Combined with CDC guidelines, the curbing of opioid prescriptions to medically needed individuals, among non-opioid treatments, interventional techniques have been affected with declining utilization rates and medical policies reducing access to such modalities. CONCLUSION: The opioid overdose waves over the past three decades have resulted from different etiologies. Wave one was associated with prescription opioid overdose deaths and wave two with the rise in heroin and overdose deaths from 1999 to 2013. Wave three was associated with a rise in synthetic opioid overdose deaths. Sadly, wave four continues to escalate with increasing number of deaths as a confluence of factors including the CDC guidelines, the COVID pandemic, increased availability of illicit synthetic opioids and the reduction of access to interventional techniques, which leads patients to seek remedies on their own.

11.
The New England Journal of Medicine ; 386(16):1488-1490, 2022.
Article in English | ProQuest Central | ID: covidwho-1805746

ABSTRACT

Strengthening the Medicaid Reentry ActUnder the Reentry Act, Medicaid would be able to pay for health care for eligible people who are incarcerated starting up to 30 days before their release from jail or prison. Changes to this bill could bring care in these facilities in line with community standards.

12.
Caring for the Ages ; 23(3):16-16, 2022.
Article in English | CINAHL | ID: covidwho-1803637
13.
Physician Leadership Journal ; 8(4):20-22, 2021.
Article in English | ProQuest Central | ID: covidwho-1801270

ABSTRACT

Using its experience with the MSSP and its Medicare Advantage (MA) capitation contract, Ochsner is engaging community physicians and physician networks to expand its reach. Two patient groups are prioritized: those who are new to Ochsner and those with multiple chronic conditions that put them at high risk for health problems. In addition to a clinical assessment and medical reconciliation, the nurse practitioner can verify whether the patient has appropriate food, social support, and the durable medical equipment that will help him or her recover safely at home. A third at-home strategy is the use of a vendor, Ready, to reduce avoidable ED utility through on-demand at-home urgent care visits and short-term case management for ED frequent fliers.

14.
Cancer Research ; 82(4 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1779489

ABSTRACT

Purpose: In the state of Wisconsin, breast cancer patients from African American (AAs) communities have lower survival rates compared to their Caucasian counterparts. Multiple inequities related to sociodemographic factors, delays in diagnosis, advanced disease stage at presentation and presence of comorbidities including higher body mass index (BMI) contribute to these disparities, many of which have only widened during the COVID-19 pandemic. This study examined specific factors related to prolonged hospital length of stay (LOS) for breast cancer patients admitted to inpatient units during the pandemic. Methods: This analysis includes initial CY20 LOS medical record data for hospitalized patients 18 years and older with a diagnosis of breast cancer from 1/1/2020-12/31/2020. Supplemental data included disease registry and diagnostic data, and SES data determined by patient zip code. Poisson regression models with robust standard errors were used to compare the LOS index (LOSi) between groups of patients based on race, SES group, primary payer, and BMI. Results: A total of 272 patients with breast cancer that were admitted to inpatient oncology units were identified. Demographics included White (72.4%), Black (22.4%), and others (5.1%). Other characteristics included: low SES (8.8%), medium-low (9.5%), medium (15.4%), medium-high (11.0%), high SES (4.4%), and others (non-SMilwaukee county) (50.7%), Medicaid (8.8%), Medicare (61.3%), Managed care (29.0%), and others (0.73%). Body mass varied among the patients;underweight (0.36%), overweight (30.8%), obese (41.5%). There were significant differences in LOSi: Black (LOSi=1.24, p=0.01), medium-low SES (LOSi=1.46, p=0.02), Medicaid (LOSi=1.40, p=0.00), underweight (LOSi=1.66, p=0.00), and overweight (LOSi=1.23, p = 0.01) patients had slightly longer LOSi, with LOSi ratio above 1. Conclusion: This study shows how patient-specific factors such as race, SES, primary payer, and BMI contribute to inpatient LOS for breast cancer patients. Healthcare systems may benefit by addressing indicators and patients' factors to reduce hospital LOS, and ultimately healthcare costs.

15.
Cancer Research ; 82(4 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1779464

ABSTRACT

Background Digital breast tomosynthesis (DBT), also called 3D mammography, was first approved by the Federal Drug Administration in 2011. The goal of 3D mammography is to improve accuracy compared to 2D digital mammography (DM), by increasing sensitivity and decreasing recall rates. To capture the broad utilization of DBT in populations receiving both screening and diagnostic imaging, this analysis investigates DBT usage over time in a longitudinal sample from 2016 through 2020 for adult women ranging from 18-74 years of age. Methods Retrospective analyses were conducted using de-identified administrative claims data from a large national U.S. health insurer. The study cohort consisted of women who were continuously enrolled in a commercial or Medicare Advantage plan from 1/2016 to 12/2020 and aged 18 to 74 years old as of 2016. All procedures were identified based on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes. For each study year, receipt of breast cancer screening with DM (S-DM) or including DBT (S-DBT) were captured. Receipt of DM and DBT not specified for screening based on CPT code descriptions were categorized as diagnostic, D-DM and D-DBT respectively. Women that received both DBT and DM in the same year were included in the DBT group. In addition, women who received MRI and ultrasound were also captured. Rates of each procedure by study year, insurance type, and age categories that align with recommended screening guidelines (<40 years old, 40-49 years old and 50-74 years old) were examined. Results Approximately 3.8 million women met study criteria;85% were commercially insured and 15% were Medicare Advantage. Table 1 shows rates of adult women who received mammography, MRI and ultrasound over the study period. About 74% of study subjects receiving screening were 50-74 years old at the start of the study period, 25% were 40-49 years and 1% were under 40 years old. In 2020, there were fewer women (3%-13%) receiving imaging procedures compared to counts in 2019. During the 5-year study period, there was a 3.5-fold increase in the number of women who received S-DBT. In 2016, 23% of women who received a screening mammogram received S-DBT and by 2020, this percent increased to 82%. The percent of women who received a diagnostic mammogram using D-DBT compared to D-DM also increased overtime;29% of women received a D-DBT in 2016 and this increased to 77% in 2020. The number of women with receipt of ultrasound and MRI were similar in each study year. The percent diagnostic/screening tests (including DBT and DM) were in the range of 18.5%-20.2% each year. Conclusion Among this cohort of women who were continuously enrolled in the health plan throughout the 5-year study period, this analysis shows that screening and diagnostic DBT utilization rates increased from 2016 to 2020 while DM screening and diagnostic imaging utilization concomitantly decreased. The percentages of women that received S-DBT and D-DBT were highest in 2020, even though 8%-13% fewer women had evidence of mammography than in 2019, which is largely due to COVID-19 related healthcare service disruptions. The rate of diagnostic tests as a percent of screening tests did not decrease with the adoption of DBT. Further analyses investigating rates of follow-up procedures and downstream costs are warranted.

16.
Pain Physician ; 25(2):193-207, 2022.
Article in English | Web of Science | ID: covidwho-1776968

ABSTRACT

Background: Regenerative medicine interventions are applied to assist in the repair, and to potentially replace or restore damaged tissue through the use of autologous/allogenic biologics and it continues to expand. The anti-inflammatory, immunomodulatory, and regenerative properties of bone marrow mesenchymal stem cells (BM-MSCs), and investigation into their therapeutic efficacy and safety in patients with severe chronic low back pain, have not been demonstrated in controlled studies. Multiple pain generators have been hypothesized to be responsible in severe spinal degeneration and it is difficult to identify a single pain generator;consequently, resulting in inadequate therapeutic results. Objectives: The study was undertaken to evaluate the effectiveness of autologous bone marrow MSCs in the treatment of chronic low back pain due to severe lumbar spinal degeneration with involvement of multiple structures. Study Design: Prospective, open-label, nonrandomized, parallel-controlled, 2-arm exploratory study. Setting: A private, specialized, interventional pain management and regenerative medicine clinic. Methods: The treatment group patients received a one-time bone marrow concentrate injection into spinal structures (i.e., discs, facets, spinal nerves, and sacroiliac joints), along with conventional treatment, whereas, the control group received conventional treatment with nonsteroid antiinflammatory drugs, over-the-counter drugs, structured exercise programs, physical therapy, spinal injections and opioids, etc., as indicated. Outcomes Assessment: Outcomes were assessed utilizing multiple instruments, including the Oswestry Disability Index (ODI), Numeric Rating Scale (NRS-11), EuroQOL 5-Dimensional Questionnaire (EQ-5D-3L), Global Mental Health (GMH), and Global Physical Health (GPH). Multiple outcomes were assessed with primary outcomes being minimal clinically important differences (MCID) in ODI scores between the groups and/or a 2-point reduction in pain scores. In the study group, total nucleated cells, colony forming units-fibroblast, CD34-positive cell numbers and platelets were also recorded, along with post-procedure magnetic resonance imaging changes. Outcomes were assessed at 1, 3, 6, and 12 months. Results: Significant improvement was achieved in functional status measured by ODI, pain relief measured by NRS-11, and other parameters measured by EQ-5D-3L, GMH, and GPH, in the study group relative to the control group at all time periods. The results showed significant improvements at 12-month follow-up with 67% of the patients in the study group achieving MCID utilizing ODI when compared to 8% in the control group. Greater than 2-point pain reduction was seen in 74% of the patients at 3 months, 66% of the patients at 6 months, and 56% of the patients at 12 months. Both MCID and pain relief of 2 points were significantly different compared to the control group. Opioid use decreased in the investigational group, whereas, there was a slight increase in the control group. Age, gender, opioid use, and body mass index did not affect the outcomes in the stem cell group. Limitations: Single center, nonrandomized study. Conclusions: The first available controlled study utilizing BM-MSCs in severe degenerative spinal disease with interventions into multiple structures simultaneously, including disc, facet joints, nerve roots, and sacroiliac joint based on symptomatology, showed promising results.

17.
Journal of the American College of Cardiology ; 79(9):2049, 2022.
Article in English | EMBASE | ID: covidwho-1768636

ABSTRACT

Background: The CMS Hospital at Home (H@H) program during the COVID 19 pandemic was successfully applied as a suitable alternative to unnecessary admissions in lower risk patient populations. As the top 5% pts ($50,000/Year) account for 50% of the US healthcare expenditure over 15 years (5:50 Rule), we sought to investigate the long-term clinical and financial effectiveness and sustainability of new model of home hospital and critical care (H2C2) on the top 5% patients. Methods: 68 consecutive pts with top 5% annual cost profile (~4 admissions/pt with severe chronic dx [CHF, CAD, CODP, sepsis] +/-ventilator, PEG, dialysis, LifeVest) were enrolled in a multiple MSO program. On-site & On-line care started 3/2019 via patented processes and individualized protocols/devices (24/7 monitoring + ICU level Telemetry, 12-lead ECG). All Medicare Part A, B & D costs, admissions and LOS for pts were computed and normalized per phase (PRIOR, DURING, POST H2C2) to determine effectiveness and sustainability. Results: Of the 68 patients, 90% discharged to PCP, 6% admitted to hospice and 4% remained on the program for continuous care. There were no deaths at home. Compared to baseline, H2C2 had an over 70% sustained total cost reduction. Conclusion: This is 1st study to assess long-term clinical & financial impacts of H2C2 in top 5% of high-risk/cost pts. H2C2 was safe with a significantly sustained reduction of admissions and costs both during and 1.5 years post H2C2. Further studies are warranted for scalability. [Formula presented]

18.
Osteoarthritis and Cartilage ; 30:S411, 2022.
Article in English | EMBASE | ID: covidwho-1768346

ABSTRACT

Purpose: Osteoarthritis (OA) is a chronic and disabling condition affecting morbidity and mortality. Despite its high prevalence and the availability of international management guidelines, nearly half of patients do not receive recommended treatments. OA Management Programs (OAMPs) are an alternative care model to reduce barriers and enhance the receipt of evidence-based care. This study was designed to evaluate the fidelity and feasibility of an OAMP in a United States academic medical center and understand its patients' baseline characteristics. Methods: The OAMP, which opened on July 1, 2017, is focused on knee and hip osteoarthritis. A multi-disciplinary group, including patients with OA, designed the clinic model and operations based on international OAMP implementation recommendations considering local factors. The intended treatment dose was 1-6 appointments over 4-12 months with no more than two months between visits. At each appointment, patients had the opportunity to meet with a care team comprised of a medical provider (physician or advanced practice provider), registered dietitian, physical therapist, and mental health counselor. All providers had completed OA clinical competency training. Telemedicine video visits were also available after June 2020 due to the COVID-19 pandemic. Patients are asked to complete the patient questionnaires before their visit through a patient portal in the electronic health record. They are also provided with a tablet computer to complete the VR-12 and the HOOS and/or KOOS while in the clinic waiting room. For this study, a database was created for all adult patients who had at least one clinic visit from July 1, 2017, to January 15, 2021. Data was collected by an electronic health record data pull and a manual audit of visit notes. Primary outcomes related to clinic feasibility and fidelity included clinic operations and expansion, treatment duration, and number and type of appointments attended. Secondary outcomes included patients' baseline characteristics. Results: The 938 eligible patients attended an average of 2.7 visits over a mean of 114.4 days (±5.9). Patients utilized the OAMP differently: 371 (39.5%) of patients attended 1 visit, 348 (37.1%) attended 2-3, and 232 (24.7%) attended 4 or more. A total of 175 (18.66%) completed at least one telemedicine visit. Patient referrals came predominantly from primary care (61%%) and orthopedics (20.3%);8.6% were self-referred. The average time between seeking care and the first appointment is just over six weeks. Due to patient demand, the program has expanded from seeing six patients per week to seeing more than 40 patients per week. The expansion has required hiring and training an increased number of clinicians, starting with four clinicians in different specialties to 11 clinicians. The average patient was 62.2 years (±10.2), and most were female (72%). Nearly all were Caucasian (91.3%). Medicare (51.4%) was the most common type of insurance, followed by commercial insurance (38.3%). Half of the patients were employed (49%), while 32% were retired. At the initial visit, the average BMI was 40.9 (±10). The average Charlson Comorbidity Index score (CCI) was 2.1 (±1.3), indicating moderate severity of comorbid conditions. The baseline pain rating was moderate at 4.44 (±2.37) on a 1-10 pain scale. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and Hip Injury and Osteoarthritis Outcome Score (HOOS) pain scores were 47.9 (±18) and 44.9 (±23.6), respectively showing moderate baseline levels of pain. Veterans-Rand 12 scores were low at the initial visit. The VR-12 physical and mental subscales were 25.66 (±7.35) and 48.15 (±10.76) lower than expected for an adult population. The average number of repetitions obtained from the 30-second chair rise test was 10.65 (±3.49), which is lower than age and gender norms. The completion rate of self-administered patient questionnaires was low, with less than half of patients completing all questionnaires at the initial visit. Conclusions: Baseline data reveals patie ts with high levels of pain, low function, and multiple comorbid conditions who are willing to attend multiple visits. The program has continued to expand to meet increased patient demand. Patient utilization of the clinic varied, with some patients attending only one appointment and others returning numerous times. Despite being invited back within two months, a subset of patients returned for a second appointment more than six months after their initial appointment. Completion rates of the self-questionnaires (HOOS/KOOS, VR-12) were low despite having options of how to complete these. The low completion rate indicates that instruments should be selected judiciously with careful consideration for which should be administered at every clinic visit. Clinic operations and growth are feasible with variable fidelity. The next steps will be an evaluation of patient utilization of the clinic and its impact on patients outcomes.

19.
Genetics in Medicine ; 24(3):S170-S171, 2022.
Article in English | EMBASE | ID: covidwho-1768092

ABSTRACT

Introduction: Chronic kidney disease (CKD) is a debilitating disorder associated with significant morbidity and mortality. CKD diagnoses can have overlapping, non-specific clinical symptoms and histology findings, and the underlying etiology can remain unknown. Recent studies have shown that 1 in 10 adults with CKD has a genetic component to their disease. However, genetic services are limited in this patient population and disproportionally impact those from medically underserved communities. Therefore, an adult kidney genetics clinic was developed within the Division of Nephrology at a large urban academic medical center to increase access to genetic services and testing in adults with kidney disease. Methods: In June 2019, the Division of Nephrology at Columbia University Irving Medical Center created a Kidney Genetics Clinic staffed by genetic counselors (GC) and nephrologists. Initially, appointments were held in-person but transitioned to telemedicine beginning in May 2020 due to the COVID-19 pandemic. The clinic utilized two appointment types: full genetic consults (staffed by a GC and nephrologist) and genetic counseling visits (staffed by a GC only). Genetic counselors implemented several genetic education initiatives to increase clinic referrals and increase provider interest. These included bi-monthly genetic case seminars, monthly genetic research sign-out rounds, a continuing education course focusing on clinical genetics, and genetic counseling student rotations. Results: Between June 2019 and June 2021, the clinic received 277 referrals, averaging 11 per month. Of those referred, 83% were scheduled, and 212 patients underwent genetic evaluation. The median wait time from referral to appointment was 37 days, and the no-show rate was 8%. The majority (89%) of appointments were via telehealth, either by phone or video, while the rest occurred in person. Genetic counseling visits accounted for 21% of patient appointments, and the remaining ones were full genetic consults. Most patients who attended their genetics appointment were in the NY tri-state area (87%), but 12% resided in nine additional states, three other countries, and one US territory. The primary insurance was Medicare in 10% of patients and Medicaid in 17%. Most patients described themselves as white (n=126), while 47 patients reported Hispanic or Latino ethnicity, 36 identified as Black, 15 Asian, and 4 Native Hawaiian or Pacific Islander. The average age of the patient population was 44 years old (ranging from 18 to 87). Patients seen in the genetics clinic were referred for a variety of indications and included several different kidney diagnoses, including: CAKUT (n=6), tubulointerstitial disease (n=26), suspected or clinical diagnosis of a collagenopathy (n=38), focal segmental glomerulosclerosis (FSGS) (n=28), tubulopathy or electrolyte disorder (n=16), cystic kidney disease (including PKD) (n=24), hematuria and/or proteinuria (n=31), complement dysregulation (n=8), tumor or cancer (n=4), and CKD of unknown etiology (n=23). Six patients had a known genetic diagnosis, and 23 were healthy relatives of individuals with a known genetic diagnosis or potential kidney donors. Of patients seen in the kidney genetics clinic, 42% reported a family history of CKD or a personal or family history of a genetic diagnosis. A total of 186 clinical genetic tests were ordered on 174 patients;nine tests still have results pending, and ten were canceled. Genetic tests that were ordered included: small (>50) and large gene panels (n=146), exome sequencing (n=6), microarrays (n=4), and single gene and targeted variant testing (n=20). In patients that did not undergo genetic testing, reasons included: not clinically indicated, testing already ordered, and financial concerns. A diagnostic or candidate diagnostic positive result was reported in 29% of patients, involving 18 different genes. Pathogenic or likely pathogenic variants were most common in COL4A4 (n=11), followed by PKD1 (n=8). Similarly, the highest diagnostic yield was in patients with a referral ndication of a suspected collagenopathy (diagnosis in 50%) or cystic disease (diagnosis in 50%). A non-diagnostic positive finding was identified in 9% of patients and included results such as secondary findings (n=1), carrier status (n=5), and risk factors, such as an APOL1 high-risk genotype (n=9). The identification of a genetic diagnosis in patients impacted several areas of clinical care, including referrals to specialists, kidney donor selection, clinical trial eligibility (for example, in patients with a genetic Alport diagnosis), and increased access to medications (such as tolvaptan in patients with PKD1 variants). In addition, those with non-diagnostic findings were referred to ongoing research studies at the medical center to elucidate the genetics of kidney disease. Conclusion: Here, we describe the successful creation and implementation of an adult kidney genetics clinic at a large medical center. By utilizing a combination of in-person appointments and telemedicine, the clinic was able to provide access to genomic services across a broad geographic region and to a diverse patient population of adults with kidney disease. Genetic education efforts were an integral component of the clinic's success, as it increased visibility and helped providers identify patients who would benefit from genetic services, as evidenced by the high percentage of referred patients scheduling appointments and high diagnostic yield in patients undergoing testing. Identifying genetic diagnoses in this patient population has several clinical implications, including changes in management, eligibility for genetically stratified clinical trials, and treatment decisions. Continued and ongoing access to genomic services is a fundamental component of patient care in adults with kidney disease.

20.
hfm (Healthcare Financial Management) ; 76(2):8-9, 2022.
Article in English | CINAHL | ID: covidwho-1762015
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