Discontinuity of psychiatric care among patients with bipolar disorder in the Netherlands.

BACKGROUND: Patients with bipolar disorder benefit from guidelines recommended continuous community-oriented psychiatric and somatic healthcare, but often discontinue psychiatric care. AIMS: The first objective was to identify predictive factors of discontinuity of psychiatric care among patients who had received psychiatric care. The second objective was to examine if practice variation in discontinuity of psychiatric care existed between providers of psychiatric care. METHOD: Registry healthcare data were used in a retrospective cohort study design using logistic regression models to examine potential predictive factors of discontinuity of care. Patient-related predictive factors were: age, sex, urbanization, and previous treatment (type and amount of psychiatric care, alcohol, and opioid treatment). Patients already diagnosed with bipolar disorder were selected if they received psychiatric care in December 2014 to January 2015. Discontinuity of psychiatric care was measured over 2016. RESULTS: A total of 2,355 patients with bipolar disorder were included. In 12.1% discontinuity of care occurred in 2016. Discontinuity was associated with younger age and less outpatient care over 2013 to 2014. Discontinuity of patients who received all eight quarters outpatient care including BD medication was very low at 4%. The final model contained: age, type of psychiatric care, and amount of outpatient care in 2013 to 2014. Practice variation among providers appeared negligible. CONCLUSIONS: The (mental) health service in the Netherlands has few financial or other barriers toward continuity of care for patients with severe mental disorders, such as bipolar disorder. An active network of providers, aim to standardize care. This seems successful. However, 12% discontinuity per year remains problematic and more detailed data on those most at risk to drop out of treatment are necessary.

The continuity psychiatric nursing care model to enhance medication adherence in schizophrenia patients in Indonesia: Participatory action research.

OBJECTIVE: To develop a continuity of psychiatric nursing care model to enhance medication adherence in schizophrenia patients. METHODS: The Participatory Action Research study was conducted from 2017 to 2018 in Pekanbaru, Riau, Indonesia, after approval form the ethics review committee of the Faculty of Nursing, Prince of Songkla University, Thailand. The sample included schizophrenia inpatients at a mental hospital, their family members and nursing staff. Qualitative data were gathered through in-depth interviews, observations, field notes, and photo records. Data was subjected to content analysis, while trustworthiness of the model was also determined. RESULTS: Of the 57 subjects, 22(38.6%) were schizophrenia patients, 22(38.6%) were family members, and 13(22.8%) were nurses. The continuity of psychiatric nursing care model consisted of three components: preparing for readiness to live a normal way of life; creating a supportive environment; and, sustaining the continuity of care until the community level care. CONCLUSIONS: The continuity of psychiatric nursing care model facilitated holistic nursing care aspects.

Working in smaller teams in community midwifery practices to foster continuity of carer: Midwives' experiences - A qualitative study in the Netherlands.

BACKGROUND: Midwife-led continuity of carer (MLCC) improves health outcomes and increases pregnant women's satisfaction. Working in smaller teams in community midwifery practices is one of the ways to promote continuity of carer. AIM: To gain insight into the experiences of Dutch community midwives regarding working in smaller teams, by identifying motivators and barriers. METHODS: A qualitative study was conducted using individual, semi-structured interviews (n=9). The sample was purposively selected. The interviews were analysed using the Abbreviated Grounded Theory. FINDINGS: Four themes were identified: 1) Ideal implementation of working in smaller teams, 2) Best care for pregnant women, 3) Conflicts with the current maternity care system, 4) Personal interests of the midwife. The core concept connecting all themes was midwives' experiences of an 'inner conflict' regarding working in smaller teams. CONCLUSION: A strong motivation for working in smaller teams is the wish to provide the best care for pregnant women through offering more continuity of carer. The structure of maternity care, financially and organisationally, acts as a barrier in the transition to working in smaller teams. How community midwives manage these motivators and barriers depends on their personal interests, vision, and personal life. The balance between the motivators and barriers can create an inner conflict among the midwives. This inner conflict encompasses an ethical issue: what is the best care and what is it worth? A discussion within the professional group concerning the practical and ethical aspects of working in smaller teams is needed to find ways to reduce the inner conflict of community midwives who wish to work in smaller teams, thereby promoting the implementation of MLCC.

Continuity and coordination of care for childhood cancer survivors with multiple chronic conditions: Results from the Childhood Cancer Survivor Study.

INTRODUCTION: Continuity and coordination-of-care for childhood cancer survivors with multiple chronic conditions are understudied but critical for appropriate follow-up care. METHODS: From April through June 2022, 800 Childhood Cancer Survivor Study participants with two or more chronic conditions (one or more severe/life-threatening/disabling) were emailed the "Patient Perceived Continuity-of-Care from Multiple Clinicians" survey. The survey asked about survivors' main (takes care of most health care) and coordinating (ensures follow-up) provider, produced three care-coordination summary scores (main provider, across multiple providers, patient-provider partnership), and included six discontinuity indicators (e.g., having to organize own care). Discontinuity (yes/no) was defined as poor care on one or more discontinuity item. Chi-square tests assessed associations between discontinuity and sociodemographics. Modified Poisson regression models estimated prevalence ratios (PRs) for discontinuity risk associated with the specialty and number of years seeing the main and coordinating provider, and PRs associated with better scores on the three care-coordination summary measures. Inverse probability weights adjusted for survey non-participation. RESULTS: A total of 377 (47%) survivors responded (mean age 48 years, 68% female, 89% non-Hispanic White, 78% privately insured, 74% ≥college graduate); 147/373 (39%) reported discontinuity. Younger survivors were more likely to report discontinuity (chi-square p = .02). Seeing the main provider ≤3 years was associated with more prevalent discontinuity (PR; 95%CI) (1.17; 1.02-1.34 vs ≥ 10 years). Cancer specialist main providers were associated with less prevalent discontinuity (0.81; 0.66-0.99 vs. primary care). Better scores on all three care-coordination summary measures were associated with less prevalent discontinuity: main provider (0.73; 0.64-0.83), across multiple providers (0.81; 0.78-0.83), patient-provider partnership (0.85; 0.80-0.89). CONCLUSIONS: Care discontinuity among childhood cancer survivors is prevalent and requires intervention.

Transfer to community and prison mental health care from Ireland's main remand prison over three years: 2015-2017.

Background: The post-release period is associated with an increased risk of morbidity and mortality. Previous studies have identified deficits in pre-release planning for mentally ill people in prison, particularly in remand settings. Objectives: We aimed to determine the proportion of mentally ill people in Ireland's main remand prison who were referred for mental health follow up in community and prison settings, who achieved face to face contact with the receiving service. Method: This retrospective observational cohort study was based in Ireland's main male remand prison, Cloverhill. Participants included all those individuals on the caseload of the prison inreach mental health team who were referred for mental health follow up in community and prison settings at the time of discharge, prison transfer or release from custody over a three-year period, 2015 - 2017. Successful transfer of care (TOC) was defined as face-to-face contact with the receiving service, confirmed by written correspondence or by follow up telephone call. Clinical, demographic and offence related variables were recorded for all participants. Results: There were 911 discharges from the prison inreach mental health team within the three-year study period. Of these, 121 were admitted to hospital, 166 were transferred to other prison inreach mental health services and 237 were discharged to community based mental health follow up in psychiatric outpatient or primary care settings. One third (304/911) had an ICD-10 diagnosis of schizophreniform or bipolar disorder (F20-31) and 37.5% (161/911) were homeless. Over 90% (152/166) of those referred to mental health teams in other prisons achieved successful TOC, with a median of six days to first face-to face assessment. Overall, 59% (140/237) of those referred to community psychiatric outpatient or primary care services achieved TOC following referral on release from custody, with a median of nine days from release to assessment. Clinical and demographic variables did not differ between those achieving and not achieving successful TOC, other than having had input from the PICLS Housing Support Service. Conclusion: Successful transfer of care can be achieved in remand settings using a systematic approach with an emphasis on early and sustained interagency liaison and clear mapping of patient pathways. For incarcerated individuals experiencing homelessness and mental health disorders, provision of a housing support service was associated with increased likelihood of successful transfer of care to community mental health supports.

Veteran's Health Administration HIV Care Continuum: 2019 vs 2022.

Background: The diagnosis-based Human Immunodeficiency Virus (HIV) Care Continuum offers a well-established framework for measuring HIV care quality. It is used by the government agencies, community organizations, and health care institutions to "guide the nation's response to HIV" and assesses HIV care from the time of HIV diagnosis through viral suppression. Our objective is to present the Veteran Health Administration's (VHA) HIV Care Continuum, assess postpandemic versus prepandemic performance, and compare VHA performance to Centers for Disease Control and Prevention-published data. Methods: We conducted a nationwide retrospective cohort analysis examining the care continuum for people with HIV (PWH) in VHA care in 2019 versus 2022. Measurements included linkage to care, receipt of care, retention in care, and viral suppression. We used multivariable logistic regression of virological suppression to identify factors associated with viral suppression. Results: In VHA in 2019, 83% of individuals newly diagnosed with HIV were linked to care, 84% of PWH received care, 76% were retained in care, and viral suppression was 76% among those with HIV and 93% of those with viral load (VL) results. In 2022, 74% were linked to care, 79% received care, 67% were retained in care, and viral suppression was 70% among those with HIV and 94% of those with a VL result. Conclusions: VHA has achieved >90% viral suppression among those with a VL result. Among all PWH, viral suppression decreased an absolute 5.2% between 2019 and 2022. VHA's performance on the HIV Care Continuum exceeds the national HIV Care Continuum reported by the Centers for Disease Control and Prevention.

General practitioners' assessment and management of chronic kidney disease in older patients- a mixed methods study.

BACKGROUND: Chronic kidney disease (CKD) is commonly managed in general practice, with established guidelines for diagnosis and management. CKD is more prevalent in the older population, and is associated with lifestyle diseases as well as social deprivation. Older patients also commonly experience multimorbidity. Current CKD guidelines do not take age into account, with the same diagnostic and management recommendations for patients regardless of their age. We sought to investigate general practitioners' (GPs') approach to older patients with CKD, and whether their assessment and management differed from guideline recommendations. We explored the reasons for variation from guideline recommendations. METHODS: This was a mixed methods study of Australian GPs. An online anonymous survey about the use of CKD guidelines, and assessment and management of CKD was sent to 9500 GPs. Four hundred and sixty-nine (5%) of GPs responded, and the survey was completed by 399 GPs. Subsequently, 27 GPs were interviewed in detail about their diagnostic and management approach to older patients with declining kidney function. RESULTS: In the survey, 48% of GPs who responded found the CKD guidelines useful for diagnosis and management. Four themes arose from our interviews: age-related decline in kidney function; whole person care; patient-centred care; and process of care that highlighted the importance of continuity of care. GPs recognised that older patients have an inherently high risk of lower kidney function. The GPs reported management of that higher risk focused on managing the whole person (not just a single disease focus) and being patient-centred. Patient-centred care expressed the importance of quality of life, shared decision making and being symptom focused. There was also a recognition that there is a difference between a sudden decline in kidney function and a stable but low kidney function and GPs would manage these situations differently. CONCLUSIONS: GPs apply guidelines in the management of CKD in older patients using a patient-centred and whole person approach to care. Older patients have a high prevalence of multimorbidity, which GPs carefully considered when applying existing CKD-specific guidelines. Future iterations of CKD Guidelines need to give due consideration to multimorbidity in older patients that can adversely impact on kidney function in addition to the expected age-related functional decline.

'What if I get sick?' Healthcare (non)decisions of overseas Filipino workers in Taiwan.

The increasing presence of overseas Filipino workers (OFWs) in Taiwan, particularly in the electronics and technology (E&T) industry, has raised concerns about their health and health-seeking behaviours. Our study draws on a theoretical framework combining Brandenberger et al.'s 3C model, which considers challenges in communication, continuity of care, and confidence regarding healthcare delivery for migrant workers, with Scott's sociology of nothing. This framework enables us to interpret the decisions of OFWs on seeking care, not seeking care, or not making any decision. Although the National Health Insurance covers migrant workers and the New South Bound Policy commits to promoting migrant health, narrative accounts of individual workers, migrant rights advocates, and shelter organisers inform us of OFWs' ambivalence towards utilising the healthcare resources available. The decisions made by OFWs in the E&T industry may include seeking assistance, not seeking assistance, or not addressing health concerns due to legal, financial, or cultural reasons. The contextual nuances behind their decisions led us to look beyond the challenges they face and argue for interventions such as peer education on legal rights awareness and health literacy to enable OFWs to make informed decisions about their well-being.

Everyone should have their own midwife: Women's and staff experiences during the implementation of two midwifery continuity of care models in regional Australia.

PROBLEM: Midwifery Continuity of Care (MCoC) remains inaccessible for most Australian women; this is especially true in rural and regional areas. BACKGROUND: Strong evidence demonstrates MCoC models improve experiences for women and their babies and are also shown to improve midwifery workforce wellbeing. However, implementation and upscale remains limited. AIM: To explore the views and experiences of implementing MCoC for both staff and women, understanding their experiences, concerns and solutions in a regional context. METHODS: Qualitative data was collected via focus groups with women and healthcare staff, at six and twelve month post implementation. Data was thematically analysed using Braun and Clarke six step process. FINDINGS: The findings support that 'women love it' and midwives working in the new MCoC model 'loved their job'. The major concern was that not all women could access the model and disconnected communication was problematic during implementation. 'Sharing stories' was a solution to overcoming these issues and promoting the positive impact of MCoC - in particular ways of working and adaption to an all-risk midwifery group practice. DISCUSSION: This study supports widespread evidence that MCoC is valued by both women and staff. In a regional context it is important to recognise challenges faced during implementation and identifying solutions that other maternity services could consider when implementing MCoC. CONCLUSION: The study offers strong recommendation for regional areas to consider MGP to maintain safe, quality local maternity services.

Continuity of care and mortality in patients with type 2 diabetes.

BACKGROUND: How continuity of general practitioner care (GP-CoC) affects mortality in patients with type 2 diabetes (T2D) is unclear. AIM: The aim of this study was to examine the effect of having no continuity of care (CoC) and GP-CoC on mortality in primary health care (PHC) patients with T2D. DESIGN & SETTING: Cohort study in patients aged 60 years or older with T2D within the public PHC of the city of Vantaa, Finland. METHOD: Inclusion period was between 2002-2011 and follow-up period between 2011-2018. Six groups were formed (no appointments, one appointment and Modified, Modified Continuity Index [MMCI] quartiles). Mortality was measured with standardized mortality ratio (SMR) and adjusted hazard ratio (aHR). GP-CoC was measured with MMCI. Comorbidity status was determined with Charlson comorbidity index (CCI). RESULTS: In total 11,020 patients were included. Mean follow-up time was 7.3 years. SMRs for the six groups (no appointments, one appointment, MMCI quartiles) were 2.46 (95%CI: 2.24-2.71), 3.55 (3.05-4.14), 1.15 (1.06-1.25), 0.97 (0.89-1.06), 0.92 (0.84-1.01) and 1.21 (1.11-1.31), respectively. With continuous MMCI, mortality formed a u-curve. The inflection point was at a MMCI value of 0.65 with corresponding SMR of 0.86. Age and CCI adjusted HR for death between men and women was 1.45 (1.35-1.58). CONCLUSIONS: Patients with no CoC had the highest mortality. In patients having care over time, the effect of GP-CoC on mortality was minor and mortality turned to rise with high GP-CoC.

'None of Them Know Me': A Qualitative Study of the Implications of Locum Doctor Working for Patient Experience.

INTRODUCTION: There have been some concerns about the impact of temporary doctors, otherwise known as locums, on patient safety and the quality of care. Despite these concerns, research has paid little attention to the implications of locum working on patient experience. METHODS: A qualitative semi-structured interview study was conducted with 130 participants including locums, people working with locums and patients with experience of being seen or treated by locums. Analysis was conducted using a reflexive thematic approach and abductive analysis to position themes against wider knowledge. RESULTS: Three main themes were constructed through analysis: (1) Awareness and disclosure; patients were not always aware if their doctor was a locum, and there was some debate about whether patients had a right to know, particularly if locum working presented quality and safety risks. (2) Continuity and accessibility of care; access was regarded as priority for acute conditions, but for long-term or serious conditions, patients preferred to see a permanent doctor who knew their history, although it was acknowledged that locums could provide fresh perspectives. (3) Communication and practice; locums and patients described how consultations were approached differently when doctors worked as locums. Patients evaluated their interactions based on how safe they felt with practitioners. CONCLUSION: Patients reported that they were unlikely to have continuity of care with any doctors delivering care, regardless of their contractual status. Locums sometimes provided new perspectives on care which could be beneficial for patient outcomes, but for patients with long-term, complex or serious conditions continuity of care was important, and these patients may avoid or delay seeking care when locums are the only available option. PATIENT OR PUBLIC CONTRIBUTION: Patients and carers were involved in our study from inception to dissemination. Our Patient and Public Involvement (PPI) forum was involved throughout project design and planning and gave us feedback and guidance on research materials and outputs (e.g., study protocol, participant information sheets, survey tools, interview schedules, emerging findings). Our PPI forum co-produced our patient interview schedule, two members of our PPI forum led the patient focus groups and all were involved in analysis of patient interviews. Our PPI Chair was involved in the preparation of this manuscript.

The Shoeshine Stand and the Renaissance of Primary Care.

Over the past century, family physicians have moved from small independently owned practices, many of them solo, to being employed by large hospital systems, corporate entities, or health systems. Today, almost three-quarters of all physicians are employed and the highest percentage of employed physicians are family physicians.This essay contrasts the elements of independent practice with employed practice as part of what has been lost in the past half century, but what might be regained if physicians demanded more autonomy and control over their practices.

Speech-language therapy services for children with cleft palate: A scoping review on continuity of care.

BACKGROUND: Children with a cleft palate (with or without a cleft of the lip) often require speech-language therapy (SLT) services to achieve age-appropriate speech. For many children, this involves attending SLT services delivered by both specialised cleft team speech-language therapists (SLTs) and a local, community or school-based SLT. Given that these two different SLTs are typically involved in the child's care, it is important to ensure that effective communication, coordination and collaboration occur between them. This is known as continuity of care. While continuity of care in speech therapy has not generally been evaluated, in medicine it has been shown to improve health outcomes. AIMS: To identify what is known from the existing literature about processes for continuity of care in cleft speech therapy services. METHODS & PROCEDURES: A scoping review was conducted using Arksey and O'Malley's methodological framework. Seven databases were searched including MEDLINE via OVID, EMBASE via OVID, CINAHL via EBSCO, PsychINFO, Scopus, Web of Science and SpeechBITE. Covidence was used to screen 733 initial articles and five studies met the inclusion criteria. Thematic analysis was conducted to identify global and subthemes. MAIN CONTRIBUTION: Five papers were included for analysis. These identified two salient characteristics of cleft speech therapy continuity of care: (1) it is a continuous cycle and (2) it is complex. Although parents are integral team members, cleft and community SLTs must be responsible for initiating communication and collaborating. Furthermore, cleft SLTs have a crucial role in disseminating information and resources, as well as offering guidance and support. CONCLUSIONS & IMPLICATIONS: Given that only five studies were included, there is a need to gather more information from parents, community SLTs, and cleft SLTs to understand their experiences and perspectives. From what is known, there are breakdowns in the processes needed for continuity of care, including confusion regarding roles and responsibilities, and community SLTs lacking confidence, knowledge and support. Recommendations are provided to facilitate improvements in continuity of care. WHAT THIS PAPER ADDS: What is already known on the subject Children with CP+L often require SLT from two different clinicians including a specialised cleft SLT and a community or school-based SLT. As such, it is important that effective communication and collaboration occur between them to ensure continuity of care. What this study adds to the existing knowledge This study identified a breakdown in the processes necessary for continuity of care. According to community SLTs, there is a discrepancy between their expectations and current practices. This scoping review has identified two critical characteristics of effective continuity of care: (1) it operates as an ongoing cycle; and (2) it is a complex, multifaceted endeavour. What are the practical and clinical implications of this work? This study highlights the importance of cleft and community SLTs taking the initiative in communication and collaboration, rather than solely relying on parents as intermediaries. By offering practical recommendations, this research aims to improve continuity of care, potentially fostering greater awareness and advancements in service delivery.

Valuing Outpatients' Perspective on Primary Health Care Services in Greece: A Cross-Sectional Survey on Satisfaction and Personal-Centered Care.

INTRODUCTION: The aims of the study were to identify and analyze the determinants associated with outpatient satisfaction in Greek primary care. This is because there is a general consensus that primary care is the linchpin of effective person-centered care delivery. METHODS: A cross-sectional survey was conducted with 1012 patients' exit interviews; sociodemographic variables were included in the questionnaire to obtain data on the satisfaction of primary care users with 20 public primary healthcare centers in Athens between June 2019 and April 2021. Statistical analysis was applied to 55 items and eight dimensions of patient satisfaction, namely, arrival and admission, waiting before the appointment, cleanliness of toilets, medical examination and behavior of physician, behavior of nursing staff, laboratories, departure, and contribution of the PHCs. Descriptive analyses and multiple linear regression were used to analyze the factors influencing patient satisfaction through coefficients (ß) with 95% confidence intervals and associated tests of statistical significance. RESULTS: Τwo-thirds (74.21%) of this survey's participants ranged from 45 to 74 years of age. More than half of the participants were women (62.15%). The most common reasons for visits were pathological (26.48%), followed by cardiological conditions (9.78%), orthopedics (9.49%), gynecologic conditions (8.70%), and ophthalmologic problems (7.31%). In the center of satisfaction with primary care was the medical care and the behavior of the physician (ß = 0.427; p < 0.01), followed by the time during appointment (ß = 0.390; p < 0.01). Dimensions like "accessibility and availability, 2.19/5"; "waiting times, 2.89/5"; "infrastructure of facilities (2.04/5) and cleanliness of them, (2/5)"; "laboratories, 2.99/5" and "bureaucracy in the departure, 2.29/5" were crucial for the trust and satisfaction of patients. Overall satisfaction was rated at a moderate level (2.62 ± 0.18) while person-centered care was rated as weak (2.49 ± 0.28). CONCLUSIONS: Greece is recommended to increase the sensitivity of the use of the primary health care system by patients as a first contact, continuous, comprehensive, and effective patient- and family-focused care.

Comparison of the Quality of Discharge Letters Written by Large Language Models and Junior Clinicians: Single-Blinded Study.

BACKGROUND: Discharge letters are a critical component in the continuity of care between specialists and primary care providers. However, these letters are time-consuming to write, underprioritized in comparison to direct clinical care, and are often tasked to junior doctors. Prior studies assessing the quality of discharge summaries written for inpatient hospital admissions show inadequacies in many domains. Large language models such as GPT have the ability to summarize large volumes of unstructured free text such as electronic medical records and have the potential to automate such tasks, providing time savings and consistency in quality. OBJECTIVE: The aim of this study was to assess the performance of GPT-4 in generating discharge letters written from urology specialist outpatient clinics to primary care providers and to compare their quality against letters written by junior clinicians. METHODS: Fictional electronic records were written by physicians simulating 5 common urology outpatient cases with long-term follow-up. Records comprised simulated consultation notes, referral letters and replies, and relevant discharge summaries from inpatient admissions. GPT-4 was tasked to write discharge letters for these cases with a specified target audience of primary care providers who would be continuing the patient's care. Prompts were written for safety, content, and style. Concurrently, junior clinicians were provided with the same case records and instructional prompts. GPT-4 output was assessed for instances of hallucination. A blinded panel of primary care physicians then evaluated the letters using a standardized questionnaire tool. RESULTS: GPT-4 outperformed human counterparts in information provision (mean 4.32, SD 0.95 vs 3.70, SD 1.27; P=.03) and had no instances of hallucination. There were no statistically significant differences in the mean clarity (4.16, SD 0.95 vs 3.68, SD 1.24; P=.12), collegiality (4.36, SD 1.00 vs 3.84, SD 1.22; P=.05), conciseness (3.60, SD 1.12 vs 3.64, SD 1.27; P=.71), follow-up recommendations (4.16, SD 1.03 vs 3.72, SD 1.13; P=.08), and overall satisfaction (3.96, SD 1.14 vs 3.62, SD 1.34; P=.36) between the letters generated by GPT-4 and humans, respectively. CONCLUSIONS: Discharge letters written by GPT-4 had equivalent quality to those written by junior clinicians, without any hallucinations. This study provides a proof of concept that large language models can be useful and safe tools in clinical documentation.

Personal, health system, and geosocial disparities in appointment nonadherence at family medicine clinics in southcentral Pennsylvania, United States.

Background: To assess the relationship between patients' demographic, health system-related, and geosocial characteristics and the risk of missed appointments among patients in family medicine practice. Methods: The study was based on a retrospective cross-sectional design using electronic health records and neighborhood-level social determents of health metrics linked by geocoded patients' home address. The study population consisted of patients who had a primary care provider and at least one appointment at 14 family medicine clinics in rural and suburban areas in January-December 2022. Negative binomial regression was utilized to examine the impact of personal, health system, and geosocial effects on the risk of no-shows and same-day cancellations. Results: A total of 258,614 appointments were made from 75,182 patients during the study period, including 7.8% no-show appointments from 20,256 patients. The analysis revealed that individuals in the ethnic minority groups were 1.24-1.65 times more likely to miss their appointments than their White counterpart. Females and English speakers had 14% lower risk for no-show. A significant increase (32%-64%) in the odds of no-shows was found among individuals on Medicaid and uninsured. Persons with prior history of no-shows or same day cancellations were 6%-27% more likely to miss their appointments. The no-show risk was also higher among people living in areas experiencing socioeconomic disadvantage. Conclusion: The risk of missed appointments is affected by personal, health system, and geosocial contexts. Future efforts aiming to reduce no-shows could develop personalized interventions targeting the at-risk populations identified in the analysis.

Screening system for the detection of unknown or poorly controlled diabetes mellitus in a tertiary hospital: A retrospective study.

RATIONALE: Hospitalization may be a valuable chance for the detection of unknown and uncontrolled diabetes mellitus (DM). There is a screening tool at our hospital: in case of high inpatient plasma glucose level, an A1c value is added if no available from the last 3 months. AIMS AND OBJECTIVES: Our objective was to analyse the population with A1c ≥ 9% detected through this system from 2021 to 2023. MATERIALS AND METHODS: A retrospective study was performed. Three thousand five hundred seventy-two patients were screened. We studied 243 patients with A1c ≥ 9%. RESULTS: Fourty-eight patients (19.8%) had unknown DM. The Endocrinology department was consulted in 39 cases (16%). In most of the cases (51%), there was not a mention in the discharge report, nor changes in the usual treatment (65.4%). Ninety patients (37%) improved A1c. Most of the ones that improved (58.9%) had a correct follow-up, compared with those who did not (23.5%) (p < 0.01). CONCLUSIONS: Measurement of A1c during hospitalization can help us to diagnose unknown or poorly controlled DM. Therapeutic inertia and delayed diagnosis are two problems associated to DM that are confirmed by our data.

Impact of an Intervention Program on Clostridioides difficile Infections: Comparison of 2 Hospital Cohorts.

Background: Clostridioides difficile infection (CDI) occurs in various contexts and care settings and is managed by multiple specialists who are not experts in its management. While there are many initiatives to improve the diagnosis and avoid overdiagnosis, there is less focus on the overall management of the infection. Methods: We studied a cohort of patients with a positive test result for toxigenic C difficile in 2 hospitals. Hospital A has a program that provides advice from an infectious disease specialist (IDS) and promotes continuity of care by providing a phone number to contact the IDS. Hospital B does not have any specific CDI program. The evaluation assessed the proportion of patients not treated (carriers or self-limited disease), adherence to Infectious Diseases Society of America guidelines, access to novel therapies, recurrence and mortality rates, and readmission and emergency department visits due to CDI. We assessed the program's effectiveness through a logistic regression model adjusted for covariates chosen by clinical criteria. Results: Hospital A avoided more unnecessary treatments (19.3% vs 11.5%), provided access to novel therapies more frequently (35.3% vs 13%), and adhered more closely to current guidelines (95.8% vs 71.3%). Although the mortality and recurrence rates did not differ, the absence of an intervention program was associated with greater odds of admission due to recurrence (odds ratio, 4.19; P = .037) and more visits to the emergency department due to CDI (odds ratio, 8.74; P = .001). Conclusions: Implementation of a CDI intervention program based on recommendations from IDSs and improved access to specialized care during the follow-up is associated with enhanced quality of CDI management and potential reductions in hospital resource utilization.

FIGO good practice recommendations on optimizing models of care for the prevention and mitigation of preterm birth.

The global challenge of preterm birth persists with little or no progress being made to reduce its prevalence or mitigate its consequences, especially in low-resource settings where health systems are less well developed. Improved delivery of respectful person-centered care employing effective care models delivered by skilled healthcare professionals is essential for addressing these needs. These FIGO good practice recommendations provide an overview of the evidence regarding the effectiveness of the various care models for preventing and managing preterm birth across global contexts. We also highlight that continuity of care within existing, context-appropriate care models (such as midwifery-led care and group care), in primary as well as secondary care, is pivotal to delivering high quality care across the pregnancy continuum-prior to conception, through pregnancy and birth, and preparation for a subsequent pregnancy-to improve care to prevent and manage preterm birth.