Referral Pathways for Children with Atopic Diseases in Denmark.

Atopic diseases such as atopic dermatitis, food allergy, allergic rhinoconjunctivitis, and/or asthma are common. In Denmark, however, there are multiple referral pathways for these diseases in the healthcare system and they are poorly understood. To describe how children with atopic diseases navigate their way through the Danish healthcare system, a questionnaire was distributed to children aged ≤ 17 years, who were being treated for atopic diseases between August 2020 and June 2021, either by a practising specialist or a hospital department, in the Capital Region of Denmark. A total of 279 children completed the questionnaire and most were referred to a specialist or to a hospital by their general practitioner. No "common track" to hospital existed for patients with ≥ 3 atopic diseases. These patients were more often referred to a hospital compared with children with 2 atopic diseases or fewer (odds ratio [OR] 3.79; 95% CI 2.07-7.24). The primary determinants for hospital treatment were food allergy (OR 4.69; 95% CI 2.07-10.61) and asthma (OR 2.58; 95% CI 1.18-5.63). In conclusion, children with multiple atopic diseases were more likely to be referred to hospital departments than to practising specialists, mainly due to food allergies.

Laboratory specimen rejection rate and associated factors among referred specimens at Debre Markos Referral Hospital, Ethiopia: prospective cross-sectional study.

Introduction: laboratory errors mostly emerge from the pre-analytical phase, mainly those related to collection, handling, transportation, and storage of diagnostic specimens. Specimen rejection due to improper sample collection, may lead to poor patient outcomes, such as incorrect diagnosis, inappropriate treatment, and death. This study aimed to assess the specimen rejection rate and associated factors among referred specimens at Debre Markos Referral Hospital. Methods: a prospective cross-sectional study design was applied from January 2020 to April 2020 to investigate specimen rejection rate and associated factors among referred specimens. The study population was all laboratory specimens referred for viral load, CD4 count, gene expert, and early infant diagnosis to the Debre Markos Referral Hospital laboratory. The statistical analysis was done with Statistical Package for Social Sciences version 20.0 software. Results: of the total of 2750 specimens submitted to the laboratory from January 2020 to April 2020, 37 (1.34%) specimens were rejected due to different reasons like insufficient volume, hemolysis, and an inappropriate specimen container. Specimen collector training status and experience had a significant association with the specimen rejection rate. Conclusion: the results of our study show that the specimen rejection rate among referred specimens was high, indicating that more interventions are required to decrease the specimen rejection rate.

Evaluation of a Transitional Patient Navigation Protocol for People Living With Hepatitis C Virus in the New York City Jail System.

We evaluated outcomes from a telephone-based transitional patient navigation (TPN) service for people living with hepatitis C virus (HCV) upon returning to the community after incarceration in New York City (NYC) jails. NYC Health + Hospitals/Correctional Health Services offered referrals for TPN services provided by the NYC local health department patient navigation staff. We compared rates of connection to care among people referred for TPN services with those who were not referred. People living with HIV had a higher connection to care rate at three months (65.0% vs 39.8%, p≤.05) and people with opioid use disorder had a higher connection rate at six months (55.1% vs 36.1%, p≤.05) compared with people without these conditions. However, there was not an improved connection to HCV care associated with referral to TPN services for the overall cohort. Further research, including qualitative studies, may inform improved strategies for connection to HCV care after incarceration.

Children and young people's consultation rates for psychosocial problems between 2016 and 2021 in the Netherlands.

BACKGROUND: Worldwide, there are concerns about declining mental health of children and young people (CYP). OBJECTIVES: To examine trends in GP consultation rates for psychosocial problems and the impact of the COVID-19 pandemic. METHODS: We performed a population-based cohort study using electronic GP records of CYP (0-24 years) living in the Rotterdam metropolitan area between 2016 and 2021. We calculated monthly consultation rates for psychosocial problems, stratified by age group and sex. We used negative binomial models to model the pre-COVID-19 trend, and estimate expected rates post-COVID-19 onset. We modelled the effect of COVID-19 infection rate and school closure on consultation rates per sex and age group. RESULTS: The cohort increased from 64801 to 92093 CYP between January 2016 and December 2021. Median age was 12.5 years and 49.3% was female. Monthly consultation rates increased from 2,443 to 4,542 consultations per 100,000 patient months over the six years. This trend (RR 1.009, 95%CI 1.008-1.011) started well before the COVID-19 pandemic. Consultation rates of adolescent girls and young women increased most strongly. Between March and May 2020, there was a temporary reduction in consultation rates, whereupon these returned to expected levels. COVID-19 infection rate and school closures showed small but significant associations with consultation rates for psychosocial problems but this did not affect the overall trend. Although consultation rates for psychosocial problems increased, this increment was stable over the entire study period. CONCLUSION: The COVID-19 pandemic did not significantly increase consultation rates for psychosocial problems in CYP. The consultation rates increased, especially in adolescent girls and young women.

CYP' consultation rates for psychosocial problems within general practice almost doubled between 2016 and 2021 in the Rotterdam metropolitan area, the Netherlands.This increase was steady over time and was not affected by the COVID-19 pandemic.Consultation rates in general practice for psychosocial problems increased most strongly in adolescent girls and young women.

The first decade of the Danish Palliative Care Database: improvements and ongoing challenges in the quality and use of specialised palliative care.

BACKGROUND: Danish Palliative Care Database comprises five quality indicators: (1) Contact with specialised palliative care (SPC) among referred patients, (2) Waiting time of less than 10 days, (3) Proportion of patients who died from (A) cancer or (B) non-cancer diseases, and had contact with SPC, (4) Proportion of patients completing the patient-reported outcome measure at baseline (EORTC QLQ-C15-PAL), and (5) Proportion of patients discussed at a multidisciplinary conference. PURPOSE: To investigate changes in the quality indicators from 2010 until 2020 in cancer and non-cancer patients. Patients/material: Patients aged 18+ years who died from 2010 until 2020. METHOD: Register-based study with the Danish Palliative Care Database as the main data source. Indicator changes were reported as percentage fulfilment. RESULTS: From 2010 until 2020, the proportion of patients with non-cancer diseases in SPC increased slightly (2.5-7.2%). In 2019, fulfilment of the five indicators for cancer and non-cancer were: (1) 81% vs. 73%; (2) 73% vs. 68%; (3A) 50%; (3B) 2%; (4) 73% vs. 66%; (5) 73% vs. 65%. Whereas all other indicators improved, the proportion of patients waiting less than 10 days from referral to contact decreased. Differences between type of unit were found, mainly lower for hospice. INTERPRETATION: Most patients in SPC had cancer. All indicators except waiting time improved during the 10-year period. The establishment of the Danish Palliative Care Database may have contributed to the positive development; however, SPC in Denmark needs to be improved, especially regarding a reduction in waiting time and enhanced contact for non-cancer patients.

Predictors of MOUD referral among persons with involvement in the criminal legal system.

INTRODUCTION: Opioid use disorder (OUD) is a significant cause of opioid-related fatality, and while medications to treat OUD (MOUD) are effective, disparities remain in the access and uptake of such medications. This study investigated factors that may influence referral to and initiation of MOUD treatment. METHODS: Data from electronic medical records of 677 patients with a history of criminal legal system involvement in a recovery program were used to examine the flow of MOUD referral. RESULTS: Among patients identified as potentially eligible for MOUD treatment, about 38.0 percent were referred and 18.8 percent were confirmed to initiate MOUD treatment. Logistic regression analyses highlighted female gender and unemployment due to incarceration as positive and negative predictors of referral, respectively. The Chi-square test revealed that women and uninsured patients were more likely to initiate referred MOUD treatment. CONCLUSIONS: Data highlight the need for greater connection between referral agencies and MOUD treatment providers, considering factors that may influence referral.

Managing female stress urinary incontinence in a post mesh era: What to do and when to refer.

BACKGROUND: Urinary incontinence is a common presentation in general practice and can significantly affect a patient's quality of life. Stress urinary incontinence (SUI) is defined by the International Continence Society as 'the complaint of any involuntary loss of urine on effort or physical exertion (eg sporting activities), or on sneezing or coughing'. There is a key role for primary care providers in the assessment and management of female SUI. OBJECTIVE: To highlight the key diagnostic and management principles of female SUI in general practice and discuss management options. DISCUSSION: SUI can usually be diagnosed based upon clinical history and targeted physical examination. Pelvic floor physiotherapy and lifestyle interventions, including weight modification and management of co-morbidities, are important first-line therapies. Surgical options for both persistent or complex SUI include urethral bulking agents, Burch colposuspension and pubovaginal fascial slings. Synthetic (mesh) mid-urethral slings remain a viable surgical option for women suffering SUI.

The effectiveness of intervention in hepatitis C patients and improvement in their referral rate.

BACKGROUND: To investigate the effectiveness of the intervention with critical value management and push short messaging service (SMS), and to determine improvement in the referral rate of patients with positive hepatitis C antibody (anti-HCV). METHODS: No intervention was done for patients with positive anti-HCV screening results from 1 January 2015 to 31 October 2021. Patients with positive anti-HCV results at our hospital from 1 November 2021 to 31 July 2022 were informed vide critical value management and push SMS. For inpatients, a competent physician was requested to liaise with the infectious disease physician for consultation, and patients seen in the OPD (outpatient department) were asked to visit the liver disease clinic. The Chi-square correlation test, one-sided two-ratio test and linear regression were used to test the relationship between intervention and referral rate. RESULTS: A total of 638,308 cases were tested for anti-hepatitis C virus (HCV) in our hospital and 5983 of them were positive. 51.8% of the referred patients were aged 18-59 years and 10.8% were aged ≥75 years. The result of Chi-square correlation test between intervention and referral was p = .0000, p < .05. One-sided two-ratio test was performed for statistics of pre-intervention referral rate (p1) and post-intervention referral rate (p2). Normal approximation and Fisher's exact test for the results obtained were 0.000, p < .05, and the alternative hypothesis p1 - p2 < 0 was accepted. The linear regression equation was referral = 0.1396 × intervention + 0.3743, and the result model p = 8.79e - 09, p < .05. The model was significant, and the coefficient of intervention was 0.1396. CONCLUSIONS: The interventions of critical value management and push SMS were correlated with the referral rate of patients with positive anti-HCV.

Understanding referral of patients with cancer in rural Ethiopia: a qualitative study.

BACKGROUND: Cancer incidence is increasing in Ethiopia mainly due to increased life expectancy, while oncological capacities remain limited. Strong referral linkages between different levels of the healthcare system are key to provide timely access to cancer care. In this qualitative study, we assessed limitations and potential of cancer patient referral in the rural Southwest of Ethiopia. METHODS: We held four focus group discussions (FGD) with health professionals at one primary and three secondary hospitals and conducted eight in-depth interviews (IDI) with the hospitals´ medical executives and local health bureau representatives. Data was analysed inductively using thematic analysis and emerging themes were categorized within the revised concept of access by Penchansky and Saurman. RESULTS: The inevitable referral of patients with cancer in the rural Southwest of Ethiopia is characterized by the absence of clear communication protocols and the lack of formal referral linkages. The newly implemented hub-system has improved emergency referrals and could be expanded to non-emergency referrals, sensitive to the needs of advanced oncological care. Liaison officers can pave the way but need to be trained and equipped adequately. Referred patients struggle with inadequate transportation systems, the lack of accommodation close to specialized facilities as well as the inability to navigate at those sites due to language barriers, illiteracy, and stigmatization. Few Non-Governmental Organizations (NGOs) help but cannot compensate the limited governmental support. The shortage of medications at public hospitals leads to patients being directed to costly private pharmacies. In the light of those challenges, cancer remains to be perceived as a "death sentence" within the rural communities. CONCLUSIONS: Standardized referral linkages and a multi-faceted support network throughout the cancer care continuum are necessary to make oncology care accessible to Ethiopia´s large rural population.

Understanding delays in chronic limb-threatening ischaemia care: Application of the theoretical domains framework to identify factors affecting primary care clinicians' referral behaviours.

INTRODUCTION: Patients in the community with suspected Chronic limb-threatening ischaemia (CLTI) should be urgently referred to vascular services for investigation and management. The Theoretical Domains Framework (TDF) allows identification of influences on health professional behaviour in order to inform future interventions. Here, the TDF is used to explore primary care clinicians' behaviours with regards to recognition and referral of CLTI. METHODS: Semi-structured interviews were conducted with 20 podiatrists, nurses and general practitioners in primary care. Directed content analysis was performed according to the framework method. Utterances were coded to TDF domains, and belief statements were defined by grouping similar utterances. Relevance of domains was confirmed according to belief frequency, presence of conflicting beliefs and the content of the beliefs indicating relevance. RESULTS: Nine TDF domains were identified as relevant to primary care clinicians: Knowledge, Environmental context and resources, Memory, Decision and attention processes, Beliefs about capabilities, Skills, Emotions, Reinforcement and Behavioural regulation. Relationships across domains were identified, including how primary care clinician confidence and working in a highly pressurized environment can affect behaviour. CONCLUSION: We have identified key barriers and enablers to timely recognition and referral behaviour. These beliefs identify targets for theory-driven behaviour change interventions to reduce delays in CLTI pathways.

Obstetric and haematological management and outcomes of women with placenta accreta spectrum by planned or urgent delivery: Secondary data analysis of a public referral hospital in Lebanon.

BACKGROUND: Lebanon has a high caesarean section use and consequently, placenta accreta spectrum (PAS) is becoming more common. OBJECTIVES: To compare maternal characteristics, management, and outcomes of women with PAS by planned or urgent delivery at a major public referral hospital in Lebanon. DESIGN: Secondary data analysis of prospectively collected data. SETTING: Rafik Hariri University Hospital (public referral hospital), Beirut, Lebanon. PARTICIPANTS: 159 pregnant and postpartum women with confirmed PAS between 2007-2020. MAIN OUTCOME MEASURES: Maternal characteristics, management, and maternal and neonatal outcomes. RESULTS: Out of the 159 women with PAS included, 107 (67.3%) underwent planned caesarean delivery and 52 (32.7%) had urgent delivery. Women who underwent urgent delivery for PAS management were more likely to experience antenatal vaginal bleeding compared to those in the planned group (55.8% vs 28.0%, p<0.001). Median gestational age at delivery was significantly lower for the urgent group compared to the planned (34 vs. 36 weeks, p<0.001). There were no significant differences in terms of blood transfusion rates and major maternal morbidity between the two groups; however, median estimated blood loss was significantly higher for women with urgent delivery (1500ml vs. 1200ml, p = 0.011). Furthermore, the urgent delivery group had a significantly lower birth weight (2177.5g vs. 2560g, p<0.001) with higher rates of neonatal intensive care unit (NICU) admission (53.7% vs 23.8%, p<0.001) and perinatal mortality (18.5% vs 3.8%, p = 0.005). CONCLUSION: Urgent delivery among women with PAS is associated with worse maternal and neonatal outcomes compared to the planned approach. Therefore, early referral of women with known or suspected PAS to specialized centres is highly desirable to maximise optimal outcomes for both women and infants.

The effect of local hospital waiting times on GP referrals for suspected cancer.

INTRODUCTION: Reducing waiting times is a major policy objective in publicly-funded healthcare systems. However, reductions in waiting times can produce a demand response, which may offset increases in capacity. Early detection and diagnosis of cancer is a policy focus in many OECD countries, but prolonged waiting periods for specialist confirmation of diagnosis could impede this goal. We examine whether urgent GP referrals for suspected cancer patients are responsive to local hospital waiting times. METHOD: We used annual counts of referrals from all 6,667 general practices to all 185 hospital Trusts in England between April 2012 and March 2018. Using a practice-level measure of local hospital waiting times based on breaches of the two-week maximum waiting time target, we examined the relationship between waiting times and urgent GP referrals for suspected cancer. To identify whether the relationship is driven by differences between practices or changes over time, we estimated three regression models: pooled linear regression, a between-practice estimator, and a within-practice estimator. RESULTS: Ten percent higher rates of patients breaching the two-week wait target in local hospitals were associated with higher volumes of referrals in the pooled linear model (4.4%; CI 2.4% to 6.4%) and the between-practice estimator (12.0%; CI 5.5% to 18.5%). The relationship was not statistically significant using the within-practice estimator (1.0%; CI -0.4% to 2.5%). CONCLUSION: The positive association between local hospital waiting times and GP demand for specialist diagnosis was caused by practices with higher levels of referrals facing longer local waiting times. Temporal changes in waiting times faced by individual practices were not related to changes in their referral volumes. GP referrals for diagnostic cancer services were not found to respond to waiting times in the short-term. In this setting, it may therefore be possible to reduce waiting times by increasing supply without consequently increasing demand.

Association between exposure to ambient air pollution, meteorological factors and atopic dermatitis consultations in Singapore-a stratified nationwide time-series analysis.

Atopic dermatitis (AD) is a chronic inflammatory skin disease affecting approximately 20% of children globally. While studies have been conducted elsewhere, air pollution and weather variability is not well studied in the tropics. This time-series study examines the association between air pollution and meteorological factors with the incidence of outpatient visits for AD obtained from the National Skin Centre (NSC) in Singapore. The total number of 1,440,844 consultation visits from the NSC from 2009 to 2019 was analysed. Using the distributed lag non-linear model and assuming a negative binomial distribution, the short-term temporal association between outpatient visits for AD and air quality and meteorological variability on a weekly time-scale were examined, while adjusting for long-term trends, seasonality and autocorrelation. The analysis was also stratified by gender and age to assess potential effect modification. The risk of AD consultation visits was 14% lower (RR10th percentile: 0.86, 95% CI 0.78-0.96) at the 10th percentile (11.9 µg/m3) of PM2.5 and 10% higher (RR90th percentile: 1.10, 95% CI 1.01-1.19) at the 90th percentile (24.4 µg/m3) compared to the median value (16.1 µg/m3). Similar results were observed for PM10 with lower risk at the 10th percentile and higher risk at the 90th percentile (RR10th percentile: 0.86, 95% CI 0.78-0.95, RR90th percentile: 1.10, 95% CI 1.01-1.19). For rainfall for values above the median, the risk of consultation visits was higher up to 7.4 mm in the PM2.5 model (RR74th percentile: 1.07, 95% CI 1.00-1.14) and up to 9 mm in the PM10 model (RR80th percentile: 1.12, 95% CI 1.00-1.25). This study found a close association between outpatient visits for AD with ambient particulate matter concentrations and rainfall. Seasonal variations in particulate matter and rainfall may be used to alert healthcare providers on the anticipated rise in AD cases and to time preventive measures to reduce the associated health burden.

Newborn care knowledge and practices among care givers of newborns and young infants attending a regional referral hospital in Southwestern Uganda.

A child born in developing countries has a 10 times higher mortality risk compared to one born in developed countries. Uganda still struggles with a high neonatal mortality rate at 27/1000 live births. Majority of these death occur in the community when children are under the sole care of their parents and guardian. Lack of knowledge in new born care, inappropriate new born care practices are some of the contributors to neonatal mortality in Uganda. Little is known about parent/caregivers' knowledge, practices and what influences these practices while caring for the newborns. We systematically studied and documented newborn care knowledge, practices and associated factors among parents and care givers. To assess new born care knowledge, practices and associated factors among parents and care givers attending MRRH. We carried out a quantitative cross section methods study among caregivers of children from birth to six weeks of life attending a regional referral hospital in south western Uganda. Using pretested structured questionnaires, data was collected about care givers' new born care knowledge, practices and the associated factors. Data analysis was done using Stata version 17.0. We interviewed 370 caregivers, majority of whom were the biological mothers at 86%. Mean age was 26 years, 14% were unemployed and 74% had monthly earning below the poverty line. Mothers had a high antenatal care attendance of 97.6% and 96.2% of the deliveries were at a health facility Care givers had variant knowledge of essential newborn care with associated incorrect practices. Majority (84.6%) of the respondents reported obliviousness to putting anything in the babies' eyes at birth, however, breastmilk, water and saliva were reportedly put in the babies' eyes at birth by some caregivers. Hand washing was not practiced at all in 16.2% of the caregivers before handling the newborn. About 7.4% of the new borns received a bath within 24 hours of delivery and 19% reported use of herbs. Caregivers practiced adequate thermal care 87%. Cord care practices were inappropriate in 36.5%. Only 21% of the respondents reported initiation of breast feeding within 1 hour of birth, Prelacteal feeds were given by 37.6% of the care givers, water being the commonest prelacteal feed followed by cow's milk at 40.4 and 18.4% respectively. Majority of the respondents had below average knowledge about danger signs in the newborn where 63% and mean score for knowledge about danger signs was 44%. Caretaker's age and relationship with the newborn were found to have a statistically significant associated to knowledge of danger signs in the newborn baby. There are variable incorrect practices in the essential new born care and low knowledge and awareness of danger signs among caregivers of newborn babies. There is high health center deliveries and antenatal care attendance among the respondents could be used as an opportunity to increase caregiver awareness about the inappropriate practices in essential newborn care and the danger signs in a newborn.

Optimising referral letters for the dental practitioner.

Referrals are defined as 'a process in which a health worker at one level of the health system, having insufficient resources (drugs, equipment, skills) to manage a clinical condition, seeks the help of a better or differently resourced facility at the same or higher level to assist in patient management'. Within the UK, the NHS dental service is divided into nationally defined levels of care, which provide treatment based upon complexity and patient modifying factors. Having a sound knowledge of these levels will help general dental practitioners (GDPs) make appropriate and efficient onward referrals to the correct service.This article aims to outline the key information required for all strong GDP referrals, as well as highlighting information that may be specific to each speciality. This is with the hope of creating a key list for GDPs to use on clinic when writing referrals to reduce the incidence of missed information and subsequent rejection. The article also aims to outline the levels of NHS dental care and what factors and treatments are suitable for each to aid GDPs during their referral decision-making process.

Clinico-epidemiological evaluation of pharmaceutical/non-pharmaceutical poisoning in a referral poisoning emergency in the Central part of Iran.

The pattern of poisoning varies in different societies. In this study, we investigated the clinical-epidemiological features and outcomes of poisoned patients based on the substances involved, whether pharmaceutical or non- pharmaceutical toxins. This cross-sectional study involved a retrospective chart review of all poisoned patients who presented to the poisoning emergency hospital in the center of Iran between January 2015 and December 2019. We collected data on socio-demographics, the nature of the poisoning, and the outcomes. Backward stepwise binary regression analysis was conducted to predict the mortality. Throughout the study period, 5777 patients with acute poisoning met the inclusion criteria. Of these, 3524 cases (61%) were attributed to pharmaceutical, and 2253 cases (39%) were due to non-pharmaceutical poisoning. The majority of pharmaceutical poisonings (82.9%) were intentional, whereas non-pharmaceutical poisonings accounted for 46.2% of intentional exposures (P < 0.001). Patients with non-pharmaceutical poisoning were predominantly men, older in age, and had a history of addiction compared to those with pharmaceutical poisoning (P < 0.001). In binary logistic regression analysis, patients poisoned by non-pharmaceutical substances had a significantly higher risk of mortality [Odds ratio, 3.14; (95% CI 1.39-7.10); P = 0.006] compared to those poisoned by pharmaceutical substances (P < 0.001). The pattern of poisoning differs in terms of age and gender when comparing pharmaceutical to non-pharmaceutical poisoning. Patients poisoned by non-pharmaceutical may have a worse outcome compared to those poisoned by pharmaceutical substances.

Saxon Epidemiological Study in General Practice-6 (SESAM-6): protocol of a cross-sectional study.

INTRODUCTION: General practitioners (GPs) are mostly the first point of contact for patients with health problems in Germany. There is only a limited epidemiological overview data that describe the GP consultation hours based on other than billing data. Therefore, the aim of Saxon Epidemiological Study in General Practice-6 (SESAM-6) is to examine the frequency of reasons for encounter, prevalence of long-term diagnosed diseases and diagnostic and therapeutic decisions in general practice. This knowledge is fundamental to identify the healthcare needs and to develop strategies to improve the GP care. The results of the study will be incorporated into the undergraduate, postgraduate and continuing medical education for GP. METHODS AND ANALYSIS: This cross-sectional study SESAM-6 is conducted in general practices in the state of Saxony, Germany. The study design is based on previous SESAM studies. Participating physicians are assigned to 1 week per quarter (over a survey period of 12 months) in which every fifth doctor-patient contact is recorded for one-half of the day (morning or afternoon). To facilitate valid statements, a minimum of 50 GP is required to document a total of at least 2500 doctor-patient contacts. Univariable, multivariable and subgroup analyses as well as comparisons to the previous SESAM data sets will be conducted. ETHICS AND DISSEMINATION: The study was approved by the Ethics Committee of the Technical University of Dresden in March 2023 (SR-EK-7502023). Participation in the study is voluntary and will not be remunerated. The study results will be published in peer-reviewed scientific journals, preferably with open access. They will also be disseminated at scientific and public symposia, congresses and conferences. A final report will be published to summarise the central results and provided to all study participants and the public.

Exploring functional abilities and competing risks among stroke patients: a longitudinal and survival analysis study at Felege Hiwot Referral Hospital, Ethiopia.

OBJECTIVES: This study aimed to evaluate competing risks and functional ability measures among patients who had a stroke. DESIGN: A joint model comprising two related submodels was applied: a cause-specific hazard submodel for competing drop-out and stroke-related death risks, and a partial proportional odd submodel for longitudinal functional ability. SETTING: Felege Hiwot Referral Hospital, Ethiopia. PARTICIPANTS: The study included 400 patients who had a stroke from the medical ward outpatient stroke unit at Felege Hiwot Referral Hospital, who were treated from September 2018 to August 2021. RESULTS: Among the 400 patients who had a stroke, 146 (36.5%) died and 88 (22%) dropped out. At baseline, 14% of patients had no symptoms and/or disability while 24% had slight disability, and 25% had severe disability. Most patients (37.04%) exhibited moderate functional ability. The presence of diabetes increased the cause-specific hazard of death by 3.95 times (95% CI 2.16 to 7.24) but decreased the cause-specific hazard of drop-out by 95% (aHR 0.05; 95% CI 0.01 to 0.46) compared with non-diabetic patients who had a stroke. CONCLUSION: A substantial proportion of patients who had a stroke experienced mortality and drop-out during the study period, highlighting the importance of considering competing risks in stroke research. Age, diabetes, white cell count and stroke complications were significant covariates affecting both longitudinal and survival submodels. Compared with stand-alone models, the joint competing risk modelling technique offers comprehensive insights into the disease's transition pattern.

Multidisciplinary proactive e-consults to improve guideline-directed medical therapies for patients with diabetes and chronic kidney disease: an implementation study.

INTRODUCTION: We hypothesized that multidisciplinary, proactive electronic consultation (MPE) could overcome barriers to prescribing guideline-directed medical therapies (GDMTs) for patients with type 2 diabetes (T2D) and chronic kidney disease (CKD). RESEARCH DESIGN AND METHODS: We conducted an efficacy-implementation pilot study of MPE for T2D and CKD for primary care provider (PCP)-patient dyads at an academic health system. MPE included (1) a dashboard to identify patients without a prescription for sodium-glucose cotransporter-2 inhibitors (SGLT2i) and without a maximum dose prescription for renin-angiotensin-aldosterone system inhibitors (RAASi), (2) a multidisciplinary team of specialists to provide recommendations using e-consult templates, and (3) a workflow to deliver timely e-consult recommendations to PCPs. In-depth interviews were conducted with PCPs and specialists to assess feasibility, acceptability, and appropriateness of MPE and were analyzed using an iterative qualitative analysis approach to identify major themes. Prescription data were extracted from the electronic health record to assess preliminary effectiveness to increase GDMT. RESULTS: 20 PCPs agreed to participate, 18 PCPs received MPEs for one of their patients with T2D and CKD, and 16 PCPs and 2 specialists were interviewed. Major themes were as follows: appropriateness of prioritization of GDMT for T2D and CKD, acceptability of the content of the recommendations, PCP characteristics impact experience with MPE, acceptability and appropriateness of multidisciplinary collaboration, feasibility of MPE to overcome patient-specific barriers to GDMT, and appropriateness of workflow. At 6 months postbaseline, 7/18 (39%) patients were newly prescribed an SGLT2i, and 7/18 (39%) patients were either newly prescribed or had increased dose of RAASi. CONCLUSIONS: MPE was an acceptable and appropriate health system strategy to identify and address gaps in GDMT among patients with T2D and CKD. Adopting MPE could enhance GDMT, though PCPs raised feasibility concerns which could be improved with program enhancements, including follow-up e-consults for reinforcement, and administrative support for navigating system-level barriers.