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1.
Journal of Clinical Oncology ; 40(16), 2022.
Article in English | EMBASE | ID: covidwho-2009625

ABSTRACT

Background: Treatment options for patients with HSPC have broadened, and data regarding patient preferences for therapies can aid in therapeutic decision-making. This study evaluated the impact of attributes associated with therapies for US patients with locally advanced prostate cancer (LAPC) or metastatic HSPC (mHSPC) from the perspective of patient preferences. Methods: An online discrete choice experiment (DCE) was developed for patients with LAPC or mHSPC. The DCE included 12 questions designed to systematically require tradeoffs between treatment attributes of efficacy (5-year overall survival [OS]), tolerability (fatigue, skin rash, neurotoxicity, and common chemotherapy-related toxicity), and convenience (administration factors [route, frequency, and setting], concomitant use of steroids, and monitoring requirements). Respondents could choose androgen deprivation therapy (ADT) alone or with hypothetical therapies that improved 5-year OS but had additional adverse events (AEs). Attribute-specific importance weights measuring their relative impact on treatment choices were estimated using a mixed-logit model, which also controlled for heterogeneity in preferences. Results: From September 3 to October 14, 2021, 82 respondents (mean age 61 years) completed the survey (LAPC, n = 40;mHSPC, n = 42), with 61 (74.4%) receiving ADT at the time of the survey. Respondents reported treatment efficacy (36% [95% confidence interval (CI) 22, 49]) as the most important aspect of treatment choice, followed by changes in chemotherapy-related toxicity (13% [95% CI 3, 22]) and the need for concomitant steroid use (12% [95% CI 5, 19]). Respondents considered monitoring requirements (8% [95% CI 5, 19]) to be more important than fatigue (5% [95% CI 2, 13]). Administration factors were comparable in importance to therapy AEs (Table). Respondents preferred, by at least 10 percentage points, adding therapies to ADT that could improve 5-year OS, at the detriment of additional AEs. Conclusions: After efficacy, convenience was considered to impact treatment choices at a rate comparable to tolerability issues, potentially influenced by perceived COVID-19 exposure risks. Patients with LAPC and mHSPC prioritize efficacy despite the detriment of additional AEs.

2.
Annals of the Rheumatic Diseases ; 81:1116, 2022.
Article in English | EMBASE | ID: covidwho-2009191

ABSTRACT

Background: With the beginning of the Covid-19 pandemic, many hospital departments worldwide, including rheumatology ones, were forced to implement telemedicine strategies. Telemedicine revealed to be an umbrella term, with various practical implementations and different degrees of pre-paredness1. Some practitioners were already familiar with telemedicine, as in the case of the Rheumatology Unit of ASST Niguarda Hospital in Milan (Italy), where telemedicine projects have been implemented for more than a decade with structured design and organized processes. Moreover, patients in Niguarda have experimented telemedicine with personalized mixes of channels, including e-mails and phone calls, Patient Reported Outcomes questionnaires, and home delivery of drugs. This represents a paradigmatic case study that enables us to deepen essential questions on the success of telemedicine. Objectives: Given that the last decision on joining telemedicine rests with patients2, we decided to adopt their perspective. We deepened three main aspects: i) the benefits perceived, ii) the willingness to enrol in future projects, iii) the preference on the service-mix, i.e., on-distance contacts rather than in-person visits. Most importantly, we investigated differences in the three areas among all patients based on the type of personalized experience had. Methods: We conducted a survey from November 2021 to January 2022, enrolling randomly outpatients who attended the rheumatology unit for any reason. The survey originated from well-known surveys, such as the Tele-Health Usability Questionnaire3 and the Intention to use telehealth services4. However, we decided to overcome the usual separation that makes surveys addressed either to users or no users of telemedicine. Our survey comprised an introductory set of questions related to personal, social, clinical and ICT skills information, followed by the central part on telemedicine, which explored the three areas mentioned: benefits, adherence, preferences on service-mix. For this part, questions were the same for all patients apart from the tense used, being conditional tense for no-users and past tense for users. All the answers were analysed with descriptive statistics and regression models. Results: A complete response was given by 400 patients: 71% were female, 59% were 40-64 years old, 53% of them declared to work, and the diseases most represented were Rheumatoid Arthritis (36%) and Osteoporosis/arthrosis (21%). The descriptive statistics revealed interesting differences between users and no users, e.g., the desire to participate in future projects was stated by 95% of users, 81% of no users. These results were confrmed by multivariate logistic regression models that controlled for the influencing patients' characteristics (such as being old or a frequent hospital attender). It emerged that no-users imagined wide-ranging benefits. As for the willingness to participate to future telehealth projects, even if personal characteristics showed an impact (e.g., being a worker increased the probability to adhere), other things being equal, having had a more intense experience of telemedicine increased the odds of accepting by 3.1 times (95% C.I. 1.04-9.25), compared to no users. Furthermore, the more telemedicine was experienced, the higher the willingness to substitute in-person with online contacts. Conclusion: Our study contributes to enlighten the crucial role played by the telemedicine experience in determining patients' preferences. On one side, users appeared more aware of the realistic benefts to be expected from telemedicine. On the other side, it seemed that the more telemedicine was experienced, the higher the willingness to adhere to future projects and to increase on-distance contacts.

3.
Cancer medicine ; 2022.
Article in English | MEDLINE | ID: covidwho-2007092

ABSTRACT

Thousands of colonoscopies were canceled during the initial surge of the COVID-19 pandemic. As facilities resumed services, some patients were hesitant to reschedule. The purpose of this study was to determine whether a decision aid plus telephone coaching would increase colorectal cancer (CRC) screening and improve patient reports of shared decision making (SDM). A randomized controlled trial assigned adults aged 45-75 without prior history of CRC who had a colonoscopy canceled from March to May 2020 to intervention (n = 400) or usual care control (n = 400) arms. The intervention arm received three-page decision aid and call from decision coach from September 2020 through November 2020. Screening rates were collected at 6 months. A subset (n = 250) in each arm was surveyed 8 weeks after randomization to assess SDM (scores range 0-4, higher scores indicating more SDM), decisional conflict, and screening preference. The sample was on average, 60 years old, 53% female, 74% White, non-Hispanic, and 11% Spanish speaking. More intervention arm patients were screened within 6 months (35% intervention vs 23% control, p < 0.001). The intervention respondents reported higher SDM scores (mean difference 0.7 [0.4, 0.9], p < 0.001) and less decisional conflict than controls (-21% [-35%, -7%], p = 0.003). The majority in both arms preferred screening versus delaying (68% intervention vs. 65% control, p = 0.75). An SDM approach that offered alternatives and incorporated patients' preferences resulted in higher screening rates. Patients who are overdue for CRC screening may benefit from proactive outreach with SDM support.

4.
Journal of Clinical Oncology ; 40(16), 2022.
Article in English | EMBASE | ID: covidwho-2005681

ABSTRACT

Background: Relugolix was approved by the FDA in late 2020 as an oral gonadotropin-releasing hormone (GnRH) receptor antagonist for the treatment of adults with advanced PCa. The approval was based on a large randomized trial (Shore et al NEJM) of patients with evidence of biochemical or clinical relapse after local primary intervention with curative intent (50%), newly diagnosed mCSPCa (23%), and advanced localized disease not suitable for primary surgical intervention with curative intent (28%). Our study aims to observe the adoption of relugolix in a large community-based medical oncology practice with affiliated urologists. Methods: A retrospective study using our EMR identified 39 males with PCa for whom relugolix was initiated between January 2021 and December 2021. The charts were analyzed for demographics, indications for treatment, barriers encountered to initiation of treatment, duration of therapy, previous therapies, specialty, primary insurance, and cardiovascular history. Results: Thirty-nine (39) patients with either localized PCa (40%) or with metastases to lymph nodes or distant sites (51%) were recommended initiation of relugolix by either urology (26%) or oncology (74%). Of these, 77% actually started the medication. 9 patients did not start therapy, of which 3 were due to insurance denial, 1 due to death, 2 changed their mind, and 3 did not start for unclear reasons. Medicare covered 56% of the patients. Cardiovascular disease was notable in 87%. 28% switched from another ADT due to intolerance, 10% started relugolix due to progressive disease, and 33% started as initial ADT. 13% discontinued within 6 months. Of these, 1 completed planned therapy, 3 were intolerant, 1 was switched to alternate therapy due to progression, and 1 had complications due to COVID. In comparison, 689 patients initiated ADT with leuprolide over the same time. Conclusions: ADT using GnRH agonists or antagonists form the backbone of PCa treatment, typically given as injections. The HERO trial showed that relugolix, a newer oral therapy, is associated with lower rates of cardiovascular events compared to leuprolide. While having at least one cardiovascular risk factor is a consideration for patients to either start with or switch to relugolix, the large majority of our patients still received first-line therapy with leuprolide. This study demonstrates limitations to initiating relugolix including financial constraints (e.g., insurance coverage), patient preference, and medication intolerance. (Table Presented).

5.
Journal of Clinical Oncology ; 40(16), 2022.
Article in English | EMBASE | ID: covidwho-2005659

ABSTRACT

Background: Randomised comparative data is lacking for focal therapy in localised prostate cancer. Imperial Prostate 4 CHRONOS (IP4-CHRONOS) is an RCT designed to reflect patient and physician equipoise to maximise acceptance to randomisation. Methods: Patients and physicians could opt for CHRONOS-A or CHRONOS-B. CHRONOS-A randomised between focal therapy (HIFU/cryotherapy) and radical therapy (radiation/prostatectomy). Using a multi-arm-multistage design, CHRONOS-B randomised between focal and focal combined with neoadjuvant medication (3 months of either finasteride or bicalutamide). We report the pilot phase outcomes on feasibility of randomisation. IP4-CHRONOS had ethics committee approval and was registered (ISRCTN17796995). Results: Due to impact of COVID-19, the target for CHRONOS-A was modified from 60 to 36;36 patients were randomised over 24 months from 7 sites (Nov/2019-Nov/2021). CHRONOS-B randomised 64 patients over 14 months across 6 sites (Dec/2019-Feb/2021). Median (IQR) age and PSA (ng/ml) for CHRONOS-A were 69 (65-72) years and 6 (5-7) and for 66 (60.5-70) years and 6 (4-7) for CHRONOS-B, respectively. 34/36 (94%) and 60/64 (94%) had ISUP Grade Group > / = 2, respectively. 4/18 (22%) randomised to radical in CHRONOS-A withdrew consent;1/22 (5%) randomised to focal withdrew. In CHRONOS-B, only 1/21 (5%) randomised to focal alone, and another randomised to focal with neoadjuvant bicalutamide withdrew. A qualitative recruitment intervention partially improved accrual to CHRONOS-A. Conclusions: IP4-CHRONOS evaluated patient and physician equipoise regarding focal therapy. Randomising between focal and radical therapy is not feasible due to strong patient preferences. A multi-arm, multi-stage RCT investigating the role of neoadjuvant agents combined with focal therapy is feasible.

6.
Gut ; 71:A94, 2022.
Article in English | EMBASE | ID: covidwho-2005364

ABSTRACT

Introduction During the COVID-19 pandemic gastroscopy was halted with large burden on recovery and risk of late diagnosis. We established an early diagnosis service using Cytosponge to triage patients to timely gastroscopy and management Methods 2 patient cohorts were used: 1. Barrett's oesophagus (BO) on endoscopic surveillance 2. Patients with symptoms of gastro-oesophageal reflux referred for routine gastroscopy. Exclusions were patients with dysplasia on last gastroscopy, fundoplication, pregnancy and patient preference. Triage of patients on the waiting list was from endoscopy referrals, Barrett's surveillance database and telephone triage. 2 research nurses and 2 clinical nurse specialists were trained in delivering Cytosponge. A patient satisfaction survey was completed. All cytology specimens were analysed by Cyted. Results were relayed to patients within 4 weeks by consultant led nurse-run teleclinic and letter. Clinical triage was according to the table below. TFF3+ was used as a marker for intestinal metaplasia (IM), P53+ve and atypia for potential dysplastic change. Results 470 patients agreed to Cytosponge over 14 months November 2020-January 2022. 22 cancelled-mostly COVID related. 34 failed to swallow (5.5% of Barrett's, 8.9% reflux). of those successfully swallowing the sponge 6% were inadequate samples in Barrett's and 9% reflux. No major adverse events occurred. Conclusion We report on the largest single site series of Cytosponge in non-specialist clinical practice in England and its pragmatic use in patients management and pandemic recovery. Significant benefits in the Barrett's cohort were timely identification of dysplasia and those longer requiring surveillance. Benefits in the reflux group include identification of new BO, avoiding unnecessary gastroscopy and early discharge. Overall reduced endoscopy resulted in reduced cost, lower carbon footprint and improved patient experience. Careful follow up and longer-term outcomes will provide confidence to continue this new technique in routine clinical practice.

7.
Gut ; 71:A16, 2022.
Article in English | EMBASE | ID: covidwho-2005340

ABSTRACT

Introduction The COVID-19 pandemic resulted in a forced shift to providing remote (telephone and online) consultations following disruptions to traditional in-person care. As the pandemic wanes and IBD services recover, there is a need to rebalance provision of care and align with patient preference rather than provider convenience. Better knowledge of preferences for remote versus in-person care among people with IBD, and of the factors associated with such preferences, will guide this realignment. We report the results of a large-scale, UK-wide follow-up survey of patients who had completed the COVID-19 IBD Risk Tool during the early pandemic.1 Methods Adult patients who consented for research (n=35,329) were invited by e-mail. The survey included sociodemographics, place of residence, self-reported diagnosis, drug treatments, PRO-2 symptoms, IBD-Control Questionnaire and items relating to experience of, and future preference for, mode of IBD consultations. We investigated factors associated with: 'In-person preference' for future consultations (response option: 'Never by telephone or video' versus all other options);and 'Remote preference' (response: 'Mainly by telephone or video' versus all others) in bivariate and multivariable binary logistic regression analyses, with results expressed as adjusted odds ratios (aOR) and 95% CI. Results 7,341 respondents of which 6,015 (82%) had experienced a remote IBD consultation since the first UK lockdown. Of these, 4,396 (73%) said their first experience of a remote consultation was during the pandemic. A significant minority (9.6%) would prefer to avoid future remote consultations entirely (in-person preference) whereas a quarter (24.5%) wished to have mainly remote consultations (remote preference). The following factors were associated with in-person preference (aOR [95% CI]): Older age (>50 years;1.40 [1.19-1.63]), male gender (1.31 [1.11-1.53]), less-well controlled disease (IBD-Control-8 score <13, 2.06 [1.74-2.45]), and residents of more deprived areas (Quintile 5 [most deprived];1.72 [1.31-2.25] vs Quintile 1 [least deprived]). Conversely, we found the following associations for remote preference: Younger age (<50 years;1.24 [1.12-1.39]), Ulcerative Colitis or IBD-U (1.23 [1.10-1.37]), well-controlled disease (IBD-Control-8 score 13+, 1.55 [1.38-1.73]), not having sought emergency care during the pandemic (1.21 [1.06- 1.37]) and living in least deprived areas (Quintile 1;1.29 [1.05-1.59] vs Quintile 5). Conclusions A number of sociodemographic and clinical variables predicted future consultation preference at the time of survey. These included relatively fixed characteristics (e.g. age, gender, diagnosis, and deprivation status) and more dynamic factors (e.g. current disease control). Better understanding of factors associated with patient preference can inform efforts to realign services to provide the right mix of in-person and remote provision.

8.
Journal of Hepatology ; 77:S551, 2022.
Article in English | EMBASE | ID: covidwho-1996642

ABSTRACT

Background and aims: Hepatitis C virus (HCV) infection is a major global health problem in adults & children. The recent efficacy of Direct Acting Anti-viral therapy (DAA) has cure rates of 99% in adults and adolescents. These drugs were licensed for children 3–12 yrs during the recent coronavirus pandemic. To ensure equitable access, safe & convenient supply during lockdown, we established a virtual national treatment pathway for children with HCV in England & evaluated its feasibility, efficacy & treatment outcomes. Method: A paediatric Multidisciplinary Team Operational Delivery Network (pMDT ODN), supported by NHS England (NHSE), was established with relevant paediatric specialists to provide a single point of contact for referrals & information. Referral & treatment protocolswere agreed for HCV therapy approved byMHRA& EMA. On referral the pMDT ODN agreed the most appropriate DAA therapy based on clinical presentation & patient preferences, including ability to swallow tablets. Treatment was prescribed in association with the local paediatrician & pharmacist, without the need for children & families to travel to national centres. All children were eligible for NHS funded therapy;referral centres were approved by the pMDT ODN to dispense medication;funding was reimbursed via a national NHSE agreement. Demographic & clinical data, treatment outcomes & SVR 12 were collected. Feedback on feasibility & satisfaction on the pathway was sought from referrers. Results: In the first 6 months, 34 childrenwere referred;30- England;4-Wales;median (range) age 10 (3.9–14.5) yrs;15M;19F: Most were genotype type 1 (17) & 3 (12);2 (1);4 (4). Co-morbidities included: obesity (2);cardiac anomaly (1);Cystic Fibrosis (1);Juvenile Arthritis (1). No child had cirrhosis. DAA therapy prescribed: Harvoni (21);Epclusa (11);Maviret (2). 27/34 could swallow tablets;3/7 received training to swallowtablets;4/7 are awaiting release of granules.11/27 have completed treatment and cleared virus;of these 7/11 to date achieved SVR 12. 30 children requiring DAA granule formulation are awaiting referral and treatment. Referrers found the virtual process easy to access, valuing opportunity to discuss their patient’s therapy with the MDT & many found it educational. There were difficulties in providing the medication through the local pharmacy. However there are manufacturing delays in providing granule formulations because suppliers focused on treatments for COVID, leading to delays in referring and treating children unable to swallow tablets. Conclusion: The National HCV pMDT ODN delivers high quality treatment & equity of access for children & young people, 3–18 yrs with HCV in England, ensuring they receive care close to home with 100% cure rates.

9.
Journal of General Internal Medicine ; 37:S342-S343, 2022.
Article in English | EMBASE | ID: covidwho-1995797

ABSTRACT

BACKGROUND: COVID-19 presents a barrier to high-quality treatment for patients with chronic pain receiving long-term opioid therapy (LTOT) as guideline-recommended approaches may be challenging to deliver. We implemented a novel virtual care model, Video-Telecare Collaborative Pain Management (VCPM) harnessing innovative clinical approaches: opioid reassessment and tapering, buprenorphine switch and maintenance, and behavioral pain self-management. The primary aim of this study was to assess the feasibility and acceptability of VCPM. METHODS: VCPM is a multi-component intervention led by clinical pharmacy practitioners (CPPs) supported by a collaborating physician and approved as a quality improvement project by the two participating VA IRBs. Participants were VA patients on LTOT for chronic pain at ≥50 mg morphine equivalent daily dose identified using a VA dashboard. We mailed eligible patients letters describing the program, then called to invite them to schedule a virtual appointment with a CPP. Following a standardized intake, an individualized plan was presented to patients. Interested patients continued virtual follow-up for up to 90 days via video or phone, based on patient preference. We assessed feasibility and acceptability based on 1) enrollment rate, defined as completion of baseline visit;2) retention rate, as indicated by engagement in longitudinal care;3) willingness to trial buprenorphine when recommended;and 4) treatment satisfaction measured at three months post intake. We assessed pain and other measures at 3-month follow up. RESULTS: Of 133 patients contacted, 44 completed an initial CPP visit (33%) and 19 engaged in longitudinal care with VCPM (14%). Of those who engaged in VPCM, 11 trialed buprenorphine (58%), 7 reduced their opioid dose (37%), and 1 was lost to follow up. 32/44 patients (73%) completed the 3-month survey. Patients endorsed high satisfaction with both video (M = 4.3/5) and phone visits (M = 4.0/5). Patients who engaged viewed VCPM as successful (M = 7.0/10) and would recommend (M = 7.6/10). Patients who attended multiple VCPM visits (n = 16), compared to one visit, generally reported lower pain intensity (6.1/10 vs. 7.1), pain interference with enjoyment of life (6.0/10 vs 8.3) and general activities (5.9/10 vs 7.3), reported higher quality of patient-provider interaction (70.2/75 vs 64.1), and were more likely to report that their pain severity had improved compared to 3 months ago (44% vs 19%). CONCLUSIONS: Results partially supported feasibility and acceptability of VCPM. Enrollment rates were low, perhaps due to recruitment strategies;we are exploring peer outreach. Enrolled patients were satisfied and showed potential improvements in pain-related functioning. Refining recruitment approaches and larger effectiveness trials are underway.

10.
Journal of General Internal Medicine ; 37:S300-S301, 2022.
Article in English | EMBASE | ID: covidwho-1995741

ABSTRACT

BACKGROUND: States and health systems are investing in programs to address patients' unmet social needs, such as food and housing insecurity, but there has been limited evaluation of the implementation of these programs. In 2020, Massachusetts initiated the Flexible Services (Flex) program to provide funding to Medicaid accountable care organizations (ACOs) to address food and housing insecurity through community resources. The study objective was to examine initial implementation of Flex (March 2020-July 2021), using the Reach, Efficacy, Adoption, Implementation, Maintenance (RE-AIM) framework. METHODS: This mixed-methods evaluation was part of LiveWell, a longitudinal study assessing the impact of Flex on community health center patients aligned with two large hospitals within Mass General Brigham (MGB) in Boston, MA. ACO participants were screened annually for food and housing insecurity. To assess reach, we examined Flex enrollment using electronic health record data of enrollees ≥21 years old. Eligibility criteria for Flex included: 1) enrollment in MGB Medicaid ACO, 2) food or housing insecurity identified by screening or clinical encounter, and 3) a complex health condition (e.g., uncontrolled diabetes, depression). To assess implementation, adoption, and effectiveness, we conducted qualitative interviews with Flex enrollees (N=16) and health system staff (N=15). Interviews were analyzed using the Framework Method. RESULTS: Of 44,417 ACO enrollees, 693 (2%) were enrolled in Flex in the first 17 months. A total of 19,275 (43%) of ACO enrollees and 521 (75%) of Flex enrollees completed annual screening for food/housing insecurity. Mean ACO participant age was 40 years (SD: 14);62% were female;32% were Hispanic. Mean Flex enrollee age was 46 years (SD: 13);81% were female;54% were Hispanic. Implementation challenges included complex eligibility requirements, administrative burden (e.g., tracking, documentation), COVID- 19 factors (e.g., reduced clinic visits), and coordinating with community organizations. Facilitators included raising staff awareness to increase referrals, administrative funding for enrollment staff, adaptive strategies to identify eligible patients, and streamlined communication with community organizations. Flex enrollees reported improvements in healthy eating and food security. Patients who were able to select food or meals based on their preferences reported higher satisfaction. Patient-reported housing support included assistance with utility bills and affordable housing applications. CONCLUSIONS: To improve reach, adoption, and effectiveness in diverse populations, states and health systems implementing programs to address social needs should consider expanding screening for food and housing insecurity, minimizing administrative burden, providing funding for enrollment staff, and tailoring programs to patient preferences.

11.
Journal of General Internal Medicine ; 37:S153, 2022.
Article in English | EMBASE | ID: covidwho-1995672

ABSTRACT

BACKGROUND: The rapid shift to telehealth during COVID-19 amplified inequities in video-based healthcare. Reduced use of video visits among historically marginalized populations may exacerbate existing healthcare access disparities. We explored patient and provider insights with primary care video visits. Due to concerns that the promotion of video visits could worsen access to care among marginalized populations, we centered our work on rurald welling African Americans. METHODS: We conducted 4 video-based focus groups (n = 38) with rural VA primary care teams and 24 semi-structured telephone interviews with rural-dwelling African American Veterans purposively sampled by video-visit experience (14 with video visit experience and 12 without). Data collection occurred January -May 2021. Data collection guides were based on the domains from the Fortney et al. 2011 model of access to telehealth. We used a rapid analytic approach to identify themes relevant to access to video-based primary care. RESULTS: Findings clustered within three domains related to video-based care: perceived access to care, satisfaction with care, and attitudes towards care. Perceived access: Some patients noted differential treatment by personal characteristics (eg, race, health condition) within the health care setting though not specifically related to telehealth. Reported barriers to video visits included a lack of proper equipment and comfort with technology. Patients noted that scheduling video-based appointments was easy. Clinicians noted that video visits were inappropriate for new patient encounters or for certain conditions (eg, cognitive impairment, significant sensory impairment, new/non-specific symptoms). Satisfaction: Patients appreciated the lower cost and travel times associated with video visits and some felt video visits were less rushed. However, multiple patients expressed concerns about poor quality care via video. Specifically reported were the impersonal feel of video-based care, distracted providers, and inability to fully assess patient concerns. Providers reported frequently spending significant time managing technical malfunctions and diminished interpersonal connections via video. Attitudes: Despite the logistical convenience, many patients noted a preference for in-person care due to perceived higher quality and general appeal of the ritual of going in-person for care. Patients wanted the choice of in-person vs remote care rather than being told which they would receive. Clinical teams were open to video-based visits but emphasized the importance of considering clinical appropriateness and the need for adaptation of clinic workflow to the needs of virtual care (eg, a pre-visit online check-in). CONCLUSIONS: Optimal and equitable incorporation of virtual modalities into primary care requires an assessment of clinical appropriateness of videobased care as well as patient preference and technological readiness at each visit.

12.
Journal of General Internal Medicine ; 37:S585, 2022.
Article in English | EMBASE | ID: covidwho-1995650

ABSTRACT

STATEMENT OF PROBLEM/QUESTION: There is a need to understand patients' experiences of the unprecedented expansion in telehealth services during Covid-19 at the Veterans Health Administration (VHA) to maintain its sustainability. DESCRIPTION OF PROGRAM/INTERVENTION: To evaluate Veterans' experiences with clinical video telehealth visits (CVT) and its impact on preferences for future CVT utilization, we conducted a quality improvement self-administered mailed survey Veterans from New York harbor (NYH) and San Diego (SD) VHA sites, as well as interviews (N=20) with clinical providers and VHA leadership from both sites. MEASURES OF SUCCESS: Provider and system-related barriers and facilitators were evaluated using interviews. Patient satisfaction and preferences for receiving CVT in comparison to in-person visits were identified. We evaluated these measures, as well as contrasted the differences from the information gathered from the survey and interviews. FINDINGS TO DATE: Veterans who received at least one CVT were identified through EHR. Using standardized tools, we assessed barriers to and facilitators of use, satisfaction, and preferences for CVT utilization in comparison to in person visits in different scenarios among N=308 from NYH (53%) and SD (47%). Our sample was mostly males (83%), with half being non-Hispanic Whites (50.6%), with mean age of 62.5 years (SD = + 13.6, range= 26-88). Satisfaction CVT was high overall (8.4 on a scale from 0-10, SD= + 2.0). The proportion of Veterans reporting positive experiences with CVT was high (Range: 94-98%) overall (e.g., ability to ask all needed questions, provider spending enough time, ability to communicate all health concerns). However, less Veterans (35.4 %) reported CVT preference (i.e., preferred CVT or found no difference in contrast to in person visits) compared to in person visits (64.6%). Overall, use of video calls (e.g., FaceTime) (79.9%), and having a device to access internet (97.1%) were high with no difference between groups. Veterans endorsing CVT were more likely to report intention to have future CVT for managing chronic illness (62% vs 38 %, p <.001), meeting with a specialist such as a dermatologist (41% vs 25.3%, p=0.0067), having followup care from an in person visit (90% vs 66%;p <.001), less discouraged by provider's inability to perform physical examination (15.5% vs 63.1%;p=0.0006), and reported that CVT saved time (91.8% vs 66.2%;p=0.0019). Providers viewed CVT as a complement to in-person visits;easier to schedule with less missed appointments;and easier to assess patient environment and speak with family members. Barriers included too many steps for scheduling (e.g., clerk needs to schedule and then send out links);and technological trouble shooting is not immediately accessible, often leading to switch to phone. KEY LESSONS FOR DISSEMINATION: There is very high satisfaction with CVT. However, most veterans seem to prefer in person visits, which varied by reason for visit. Our mixed methods approach delineated a potential discrepancy between process of CVT and provider perceptions of CVT barriers.

13.
JMIR Public Health Surveill ; 8(8): e37422, 2022 Aug 16.
Article in English | MEDLINE | ID: covidwho-1993692

ABSTRACT

BACKGROUND: China and the United States play critical leading roles in the global effort to contain the COVID-19 virus. Therefore, their population's preferences for initial diagnosis were compared to provide policy and clinical insights. OBJECTIVE: We aim to quantify and compare the public's preferences for medical management of fever and the attributes of initial diagnosis in the case of presenting symptoms during the COVID-19 pandemic in China and the United States. METHODS: We conducted a cross-sectional study from January to March 2021 in China and the United States using an online discrete choice experiment (DCE) questionnaire distributed through Amazon Mechanical Turk (MTurk; in the United States) and recruited volunteers (in China). Propensity score matching (PSM) was used to match the 2 groups of respondents from China and the United States to minimize confounding effects. In addition, the respondents' preferences for different diagnosis options were evaluated using a mixed logit model (MXL) and latent class models (LCMs). Moreover, demographic data were collected and compared using the chi-square test, Fisher test, and Mann-Whitney U test. RESULTS: A total of 9112 respondents (5411, 59.4%, from China and 3701, 40.6%, from the United States) who completed our survey were included in our analysis. After PSM, 1240 (22.9%) respondents from China and 1240 (33.5%) from the United States were matched for sex, age, educational level, occupation, and annual salary levels. The segmented sizes of 3 classes of respondents from China were 870 (70.2%), 270 (21.8%), and 100 (8.0%), respectively. Meanwhile, the US respondents' segmented sizes were 269 (21.7%), 139 (11.2%), and 832 (67.1%), respectively. Respondents from China attached the greatest importance to the type of medical institution (weighted importance=40.0%), while those from the United States valued the waiting time (weighted importance=31.5%) the most. Respondents from China preferred the emergency department (coefficient=0.973, reference level: online consultation) and fever clinic (a special clinic for the treatment of fever patients for the prevention and control of acute infectious diseases in China; coefficient=0.974, reference level: online consultation), while those from the United States preferred private clinics (general practices; coefficient=0.543, reference level: online consultation). Additionally, shorter waiting times, COVID-19 nucleic acid testing arrangements, higher reimbursement rates, and lower costs were always preferred. CONCLUSIONS: Improvements in the availability of COVID-19 testing and medical professional skills and increased designated health care facilities may help boost potential health care seeking during COVID-19 and prevent unrecognized community spreading of SARS-CoV-2 in China and the United States. Moreover, to better prevent future waves of pandemics, identify undiagnosed patients, and encourage those undiagnosed to seek health care services to curb the pandemic, the hierarchical diagnosis and treatment system needs improvement in China, and the United States should focus on reducing diagnosis costs and raising the reimbursement rate of medical insurance.


Subject(s)
COVID-19 , Pandemics , COVID-19/epidemiology , COVID-19 Testing , China/epidemiology , Cross-Sectional Studies , Humans , Pandemics/prevention & control , Propensity Score , SARS-CoV-2 , United States/epidemiology
14.
Gastroenterology ; 162(7):S-1061, 2022.
Article in English | EMBASE | ID: covidwho-1967404

ABSTRACT

Background-During the COVID-19 pandemic all routine and surveillance gastroscopy was halted or delayed in the UK with considerable burden on recovery and risk of late diagnosis of significant pathology. We established an early diagnosis service using CytospongeR minimally invasive cell sampling device to help triage patients to timely gastroscopy and identify patients who could be managed without endoscopy. Methods-2 patient cohorts were identified: 1. Known Barrett's oesophagus on endoscopic surveillance 2. Patients with symptoms of gastrooesophageal reflux referred for routine gastroscopy. Exclusions were previous dysplasia of any grade on last gastroscopy, previous fundoplication, pregnancy and patient preference. Triage of patients on the waiting list was done initially from referrals to endoscopy and those on the Barrett's surveillance database, and then telephone clinic. 2 research nurses and 2 clinical nurse specialists were fully trained in delivering CytospongeR . All patients provided informed consent. All Cytology specimens were analysed by Cyted. Results were relayed to patients within 4 weeks of the procedure by consultant led nurse-run teleclinic or by letter for the Barrett's surveillance cohort. Clinical triage was according to the table below. TFF3+ was used as a marker for intestinal metaplasia, P53+ve and atypia for potential dysplastic change. Results-408 patients agreed to CytospongeR over 12 months November 2020-2021. 157 for Barrett's surveillance. 251 for Investigation of reflux. 28 failed to swallow (5% of Barrett's, 7.5% reflux). In the Barrett's Cohort 148 patients successfully swallowed, 139 for analysis 8 inadequate (5.4%) first samples. In the reflux cohort 232 successfully swallowed, 200 for analysis 32 inadequate first samples (13.8%) Discussion-Overall 205 (60.5%) of patients had low risk CytospongeR findings (no Barretts/short segment not requiring surveillance under BSG guidance) were managed symptomatically without initial gastroscopy, 114 (33.6%) had evidence of non dysplastic Barrett's and could be managed on a routine pathway. 20 (5.9%) had high risk findings suggesting dysplasia and had urgent gastroscopy. Conclusion-We report the largest single site series of CytospongeR in clinical practice in England and its pragmatic use in patients management and service recovery during the Pandemic. Notable benefits in the Barrett's cohort were timely identification of high numbers of potential dysplasia and also of those no longer requiring surveillance. Identification of new potential Barrett's for surveillance and the avoidance of unnecessary gastroscopy and early discharge were notable benefits in the Reflux cohort. Careful follow up and long-term outcomes of these patients will provide more data and safety netting for adoption of this new technique into routine clinical practice and help avoid unnecessary gastroscopy. (Table Presented)Table 1. CytospongeR findings and triage pathways in Barrett's oesophagus and gastrooesophageal reflux

15.
New Zealand Medical Journal ; 135(1556), 2022.
Article in English | EMBASE | ID: covidwho-1965253

ABSTRACT

The proceedings contain 17 papers. The topics discussed include: HIV patient preferences for care: resetting for a new normal;who accesses emergency hormonal contraception through an online sexual health service?;menstrual, sexual, and reproductive health interventions in out-of-school girls: a systematic review;three cycle QIP: improving testing and management of mycoplasma genitalium in a tertiary sexual health center 2019 - 2021;the weekend effect in GUM: a preliminary audit into genital herpes management across the week;comparing trichomonas vaginalis clinical care before and after the COVID-19 pandemic;time to start testing for latent tb infection(LTBI) - a quality improvement project;who, what, when, where, how and why? addressing the challenges of patient and public involvement and engagement (PPIE) within STI research and co-producing and applying a PPIE strategy within the SEQUENCE digital research program;an analysis of service users accessing a routine contraception service via an online platform during the COVID-19 pandemic;and effect of the COVID-19 pandemic on chlamydia testing and diagnosis within Scotland's largest sexual health service.

16.
Sexually Transmitted Infections ; 98, 2022.
Article in English | EMBASE | ID: covidwho-1955686

ABSTRACT

The proceedings contain 159 papers. The topics discussed include: HIV patient preferences for care: resetting for a new normal;who accesses emergency hormonal contraception through an online sexual health service?;menstrual, sexual, and reproductive health interventions in out-of-school girls: a systematic review;three cycle QIP: improving testing and management of mycoplasma genitalium in a tertiary sexual health center 2019 - 2021;the weekend effect in gum: a preliminary audit into genital herpes management across the week;comparing trichomonas vaginalis clinical care before and after the COVID-19 pandemic;and time to start testing for latent tb infection(LTBI)- a quality improvement project.

17.
J Community Genet ; 13(4): 449-458, 2022 Aug.
Article in English | MEDLINE | ID: covidwho-1920178

ABSTRACT

The COVID-19 pandemic required genetic counseling services, like most outpatient healthcare, to rapidly adopt a telemedicine model. Understanding the trends in patients' preferences for telemedicine relative to in-person service delivery both before and after the advent of the COVID-19 pandemic may aid in navigating how best to integrate telemedicine in a post-COVID-19 era. Our study explored how respondents' willingness to use, and preference for, telemedicine differed from before to after the onset of the COVID-19 pandemic. Respondents included patients, or their parent/guardian, seen in a general medical genetics clinic in 2018, prior to the COVID-19 pandemic, and in 2021, during the COVID-19 pandemic. Respondents were surveyed regarding their willingness to use telemedicine, preference for telemedicine relative to in-person care, and the influence of various factors. Among 69 pre-COVID-19 and 40 current-COVID-19 respondents, there was no shift in willingness to use, or preference for, telemedicine across these time periods. About half of respondents (50.6%) preferred telemedicine visits for the future. Of the 49.4% who preferred in-person visits, 79.1% were still willing to have visits via telemedicine. Predictors of these preferences included comfort with technology and prioritization of convenience of location. This study suggests that a hybrid care model, utilizing telemedicine and in-person service delivery, may be most appropriate to meet the needs of the diverse patients served. Concern for COVID-19 was not found to predict willingness or preference, suggesting that our findings may be generalizable in post-pandemic contexts.

18.
Telemed Rep ; 2(1): 156-162, 2021.
Article in English | MEDLINE | ID: covidwho-1901067

ABSTRACT

Background: As the use of telemental health-mental health care delivered through video or phone-has increased in the era of COVID, it is important to understand patients' preferences and perspectives regarding the use of video for telehealth visits. A new web-based treatment program for veterans uses video visits with mental health experts to supplement its online cognitive behavioral therapy to treat clinically significant symptoms of depression and/or post-traumatic stress disorder. Objective: As part of the program evaluation, Veterans were asked, "How important was it for you to be able to physically see your provider through video telehealth?" to understand whether they thought using video was important and why it may or may not be important. Materials and Methods: The study uses data from the program's exit survey and exit interview. The surveys and interviews were conducted over a 19-month period. Surveys and interviews were conducted over the phone with note taking. Matrix and content analyses were used to analyze the qualitative data-predetermined themes and emergent themes were analyzed and inform findings. Results: Seventy-three veterans completed a survey. Of these, 64 completed an interview. The majority of veterans surveyed (75%) said that it was "very important" to physically see their provider through video telehealth, 23% said that it was at least "somewhat important" or "not at all important." This study highlights three main themes found in the qualitative data: patients discuss (1) advantages of using video, (2) why they dislike video, and (3) technological barriers to using video. Conclusions: Being able to visually see a provider, and be seen by a provider, has distinct benefits for care and relationship building that are difficult to achieve over the phone. This has important implications for the future delivery of telemental health care and deserves consideration as patients and providers decide whether to use phone or video for remotely delivered care.

19.
Telemed J E Health ; 2022 Jun 23.
Article in English | MEDLINE | ID: covidwho-1901055

ABSTRACT

Background: We examine how and why Americans have experienced interrupted health care during the COVID-19 pandemic and measure awareness and usage of expanded benefits offered by health insurers and employers. We use an expanded concept of health literacy to include knowledge of access conditions and consider if patients' knowledge of the health system may relate to utilization of care. Methods: We conducted an online survey of 451 U.S. adults in September 2020, asking respondents about their health care experiences since March 1, 2020. This survey measured usage of medical care and awareness of the efforts made by government, private insurers, and employers to increase access to benefits such as telehealth services, well-being and mental health programs, and new prescription options. Results: The most common reasons cited for postponing or skipping medical appointments included fears over COVID-19 exposure, following local restrictions, or wanting to preserve resources for those with COVID-19. Our survey also finds that many Americans are largely unaware of whether they have access to expanded benefits implemented during the pandemic. Critically, respondents who recalled telehealth and prescription medication benefits being promoted were more likely to report using such benefits. Conclusion: This research suggests that greater attention to health literacy can help promote participation in the system by patients and has the potential to lead to improved health outcomes and greater adherence to treatment plans. Telehealth may offer patients increased opportunities to consult with their physicians for ailments that they might otherwise have delayed seeking care.

20.
Libri Oncologici ; 50(SUPPL 1):148-149, 2022.
Article in English | EMBASE | ID: covidwho-1894114

ABSTRACT

Introduction: Nivolumab is a PD-1 checkpoint inhibitor that restores the pre-existing antitumor immune response by selectively blocking the interaction between PD-1 receptors on T-cells and PD-1 ligands, PD-L1 and PD-L2, on tumor cells and antigen presenting cells. Nivolumab prolongs survival in patients with metastatic kidney cancer with a good safety profile as demonstrated in the CheckMate 025 clinical trial. Material And Methods: This retrospective data involved prospectively monitored patients (named patient programm) treated with second-line nivolumab for mRCC at the University Hospital Centre Zagreb from 2016 to 2018 and the treatment continued to be funded by the Croatian Health Insurance. Patients with metastatic kidney cancer (mRCC) received tyrosine kinase inhibitors (TKI), (29/30), one patient received mTOR inhibitor as first line therapy, and subsequently they initially received nivolumab 3 mg kg NPP every 2 weeks. Later we applied a monthly dose 480 mg. Nivolumab treatment was continued in patients who did not have disease progression or grade 3 and 4 toxicity. Patients were monitored every three momths with CT of the chest, abdomen and pelvis and laboratory tests (hemathology, biochemistry, T4, TSH). We also respected patients' preference in regard to cycle dynamic by stopping nivolumab therapy or introducing SBRT during nivolumab therapy. Results: We treated a total of 30 patients (22 men and 8 women) with mRCC, who initially received TKI or mTOR therapy with median age 60.2 ± 9.79 years at diagnosis of kidney cancer. Most patients belonged to intermediate-risk groups. Majority of patients (23/30) were treated with sunitinib as the first line treatment after nephrectomy. Six patients had CR (20%) but two of them died in 2021, one of COVID- 19 and one of haed and neck cancer. Currently, 6 (20%) are alive, ECOG=0, 4 (13.3%) have CR without therapy, expressed in months-23, 33, 35 and 53 (treatment-free survival). Median OS first line with TKI therapy was 34 months while median OS second line with nivolumab was 17 months. Patients with sarcomatoid component in pathohistology report have longer survival. Patients with bone metastases have shorter survival to patients with other metastases. Conclusion: Nivolumab demonstrated clinical efficacy in the CheckMate 025 clinical trial and in clinical practice as second line treatment after patients had previously received TKI. Our results show that six years after first cycle of nivolumab as second line therapy 6 out of 30 patient (20%) are alive, ECOG=0. Further research should show which sequence therapy would be the best for each patient. Research about potential immunotherapy biomarkers which would indicate who responds to the therapy and who does not is ongoing.

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