Medico-Legal Implications of Video Recordings of Clinic Visits in Malpractice Claims Against Medical Providers.

OBJECTIVE: Although audio-video recordings of clinic visits improve patient satisfaction and recall, the associated presumed risk of increased malpractice claims limits their use. In this study, we identified whether video recording clinic visits was associated with increases in professional liability claims. METHODS: From 2015 to 2017, the institution's loss run was analyzed, and the rates of medical malpractice claims per physician-year were compared between physicians who used video recordings of clinic visits (V-RoCs) and those who did not. The term "users" was applied to all physicians whose mean percentage of patient visits with video recording was greater than the mean percentage for the practice overall. RESULTS: Over three years, 15,254 patients used V-RoCs. The use of video recordings for clinic visits increased at a rate of 23% per year. No association was found between video recordings and increased malpractice claims. The rate of all claims between users and nonusers did not differ significantly (P=0.66). Of seven paid claims or lawsuits from 2000 to 2017, none were against physicians who used video recordings. CONCLUSION: Video recording of patient-physician encounters was not associated with an increase in malpractice lawsuits. According to federal law, a patient can legally record a clinic encounter without physician consent, which has many ethical implications. Formalizing the recording process is beneficial for both parties and allows the resource to be used to its maximum potential.

Generalized and COVID related anxiety as risk factors for health outcomes among adolescents with HIV during COVID-19 in Tanzania.

The COVID-19 pandemic and associated prevention strategies caused widespread interruptions to care and treatment for people living with HIV. Adolescents living with HIV (AWHIV) were particularly vulnerable to poor mental and physical health during COVID-19. We assessed the burden of generalized and COVID-19-related anxiety and associations with adherence to HIV care and treatment and viral load suppression (VLS) among AWHIV during the peak of the COVID-19 pandemic in Tanzania. Methods: This cross-sectional study was conducted among AWHIV aged 15-19 years attending 10 clinics in Dar es Salaam from April 2022-February 2023. Study participants completed a self-administered questionnaire including Generalized Anxiety Disorder (GAD), COVID-19-related anxiety, and other psychosocial and physical health and support measures. HIV visit adherence, viral load and sociodemographic data were abstracted from patient health records.Analysis:: Multivariable (MV) quasibinomial and logistic regression models examined associations of Generalized and COVID-19-related anxiety with visit adherence and HIV virologic suppression (HIV VL < 50 copies/mL). Data were analyzed using R software. Results: 658 AWHIV (52% male) were included in this analysis. Most (86%) had been on antiretroviral treatment (ART) for at least four years, 55% attended at least 75% of their scheduled clinic visits, and 78% were HIV virologically suppressed. The median GAD and COVID-19-related anxiety scores were 2 (IQR: 0-5, and 26 (IQR: 13-43; respectively. Only 2% scored moderate-severe generalized anxiety (score 10-21). We found no significant associations between COVID-19-related anxiety or GAD and visit adherence. Higher GAD was inversely associated with VLS (adjusted odds ratio (AOR): 0.89 (95% CI 0.81, 0.98)). Female gender and higher quality of physical life were significantly associated with VLS. Conclusion: Low levels of generalized and COVID-19 related anxiety were reported among Tanzanian AWHIV. Integrating screening and management of generalized anxiety screening into HIV care for AWHIV could improve VLS among this population.

Adherence to PKU guidelines among patients with phenylketonuria: A cross-sectional national multicenter survey-based study in Argentina, Brazil, and Mexico.

Objective: To characterize adherence to Phenylketonuria (PKU) management practices among PKU patients treated at reference sites around Argentina, Brazil, and Mexico. Methods: This is a retrospective, observational, multicenter, and multinational survey-based study using aggregate data. From an initial list of 40 sites, 22 clinicians expressed interest in completing the survey, with 20 clinicians from 20 unique sites fulfilling all the study criteria. The Survey contained 28 questions, including respondent's clinic characteristics, clinic PKU treatment recommendations, and patient adherence to clinic recommendations. Survey was available in local languages, and the respondents were asked to consult their clinic records to complete their responses. Adherence was assessed by target blood phenylalanine (Phe), target blood testing frequency, and clinic visits. Results: A total of 1077 (out of 1377) actively managed PKU patients (seen in the clinic in the last 3 years) from 13 clinics in Brazil, six in Argentina, and one in Mexico were analyzed. Upper blood Phe target was set over 360 µMol/L in 70% of the clinics for adult patients. Around 40% of the patients >30 years old had Phe blood tests done twice a year or less, with 60% of the clinics recommending semestral visits for adults <30 years old. Twice a month was the most common frequency of visits for <1 year old. The COVID-19 pandemic was a disruptor for frequency of visits and exams. Conclusions: These results show that there is still room for improvement in terms of adherence, namely in adults and older children. More efforts must be made to educate patients and healthcare professionals about the importance of treatment adherence, accompanied by public policies that expand access to pharmacological and dietary treatment with diversity and quality to improve adherence to adequate blood Phe levels.

Change in Geographic Accessibility to Dental Clinics Affects Access to Care.

Access to dental clinics is a feature of the neighborhood service environment that may influence oral health care utilization. However, residential selection poses a challenge to causal inference. By studying the involuntary relocation of survivors of the 2011 Great East Japan Earthquake and Tsunami (GEJE), we examined the association between changes in geographic distance to dental clinics and dental visits. Longitudinal data from a cohort of older residents in Iwanuma City directly impacted by the GEJE were analyzed in this study. The baseline survey was conducted in 2010, 7 mo before the occurrence of GEJE, and a follow-up was conducted in 2016. Using Poisson regression models, we estimated the incidence rate ratios (IRR) and 95% confidence intervals (CIs) for the uptake of denture use (as a proxy for dental visits) according to changes in distance from the nearest dental clinic to their house. Age at baseline, housing damage by the disaster, deteriorating economic conditions, and worsened physical activity were used as confounders. Among the 1,098 participants who had not worn dentures before the GEJE, 495 were men (45.1%), with a mean ± SD age at baseline of 74.0 ± 6.9 y. During the 6-year follow-up, 372 (33.9%) participants initiated denture use. Compared to those who experienced a large increase in distance to dental clinics (>370.0-6,299.1 m), a large decrease in distance to dental clinics (>429.0-5,382.6 m) was associated with a marginally significantly higher initiation of denture use among disaster survivors (IRR = 1.28; 95% CI, 0.99-1.66). The experience of major housing damage was independently associated with higher initiation of denture use (IRR = 1.77; 95% CI, 1.47-2.14). Improved geographic access to dental clinics may increase dental visits of disaster survivors. Further studies in non-disaster-affected areas are needed to generalize these findings.

Impact of the Coronavirus Disease 2019 Pandemic on Dental Visits in Japan.

PURPOSE: This study aimed to clarify the impact of the coronavirus disease 2019 (COVID-19) pandemic on individual dental-visit behaviour and examine the difference between elderly and other individuals regarding the impact on dental visits. MATERIALS AND METHODS: An interrupted time-series analysis was performed to examine the change in data from the national database before and after the first declaration of a state of emergency. RESULTS: The number of patients visiting a dental clinic (NPVDC), number of dental treatment days (NDTD) and dental expenses (DE) during the first declaration of a state of emergency decreased by 22.1%, 17.9%, and 12.5% in the group under 64 years of age and 26.1%, 26.3%, and 20.1% in the group over 65 years of age, respectively, compared with those in the same month of the previous year. Between March and June 2020, the monthly NPVDC and NDTD were significantly reduced (p < 0.001, p = 0.013) in those over 65 years of age. The DE did not change statistically significantly in either the under 64 group or the over 65 group. There was no statistically significant change in the slope of the regression line in the NPVDC, NDTD, and DE before and after the first state-of-emergency declaration. CONCLUSION: The first state of emergency greatly reduced the NPVDC, NDTD, and DE compared to those in the previous year. In people aged over 65 years, it might still be unresolved 2 years after the postponement of dental treatment owing to the first declaration of a state of emergency.

Short-term environmental nitrogen dioxide exposure and neurology clinic visits for headaches, a time-series study in Wuhan, China.

BACKGROUND: Previous studies showed the adverse impacts of air pollution on headache attacks in developed countries. However, evidence is limited to the impact of exposure to air pollutants on headache attacks. In this study, we aimed to explore the impact of nitrogen dioxide (NO2) exposure on neurology clinic visits (NCVs) for headache onsets. METHODS: Records of NCVs for headaches, concentrations of ambient NO2, and meteorological variables were collected in Wuhan, China, from January 1st, 2017, to November 30th, 2019. A time-series study was conducted to investigate the short-term effects of NO2 exposure on daily NCVs for headaches. Stratified analyses were also computed according to season, age, and sex, and the exposure-response (E-R) curve was then plotted. RESULTS: A total of 11,436 records of NCVs for headaches were enrolled in our study during the period. A 10-µg/m3 increase of ambient NO2 corresponded to a 3.64% elevation of daily NCVs for headaches (95%CI: 1.02%, 6.32%, P = 0.006). Moreover, females aged less than 50 years of age were more susceptible compared to males (4.10% vs. 2.97%, P = 0.007). The short-term effects of NO2 exposure on daily NCVs for headaches were stronger in cool seasons than in warm seasons (6.31% vs. 0.79%, P = 0.0009). CONCLUSION: Our findings highlight that short-term exposure to ambient NO2 positively correlated with NCVs for headaches in Wuhan, China, and the adverse effects varied by season, age, and sex.

Acute effects of ambient air pollution on daily neurology clinic visits for vertigo: a time-series study in Wuhan, China.

This study aimed to disclose the relationship between ambient air pollution and neurology clinic visits (NCVs) for vertigo. A time-series study was conducted to examine relationships between six different criteria air pollutants (SO2, NO2, PM2.5, PM10, CO, and O3) and daily NCVs for vertigo in Wuhan, China, from January 1st, 2017 to November 30th, 2019. Stratified analyses were computed according to gender, age, and season. A total of 14,749 records of NCVs for vertigo were enrolled in this study. Data showed that the increase in daily NCVs for vertigo corresponding to 10 µg/m3 increase of respective pollutants are: SO2 (- 7.60%; 95% CI: - 14.25 to - 0.44%), NO2 (3.14%; 95% CI: 0.23 to 6.13%), PM2.5 (0.53%; 95% CI: - 0.66 to 1.74%), PM10 (1.32%; 95% CI: - 0.36 to 3.06%), CO (0.00%; 95% CI: - 0.12 to 0.13%), and O3 (0.90%; 95% CI: - 0.01% to 1.83%). Males were more susceptible to acute exposure to SO2 and NO2, compared to females (SO2: - 11.91% vs. - 4.16%; NO2: 3.95% vs. 2.92%), whereas the acute effect of O3 exposure was more significantly obvious in females than males (0.94% vs. 0.87%). Moreover, correlations between daily NCVs for vertigo and acute exposure to SO2, NO2, and O3 were all stronger in individuals under 50 years old (SO2: - 12.75% vs. - 4.41%; NO2: 4.55% vs. 2.75%; O3: 1.27% vs. 0.70%). Short-term exposure to PM2.5 was more significantly associated with daily NCVs for vertigo in cool seasons (1.62% vs. - 0.68%), while the correlation between CO exposure and daily NCVs for vertigo was stronger in warm seasons (0.21% vs. - 0.03%). Our study demonstrated acute exposure to ambient NO2 and O3 positively associated with daily NCVs for vertigo. Acute effects of air pollution on daily NCVs for vertigo varied according to gender, age, and season.

Increasing Awareness of Hypertensive Patients About Their Blood Pressure Readings During Clinic Visits in a Tertiary Hospital in Riyadh.

Introduction Hypertension (HTN) is one of the most important cardiovascular risk factors. It is associated with significant complications, such as coronary artery disease, stroke, and chronic kidney disease. Awareness among hypertensive patients regarding their blood pressure (BP) is low in the Kingdom of Saudi Arabia. Aim This study aimed to evaluate the awareness of patients regarding their BP readings and to identify which aspects of HTN they needed to be informed about. Patients and methods A descriptive cross-sectional study was conducted among hypertensive patients attending outpatient clinics at King Fahad Medical City, Riyadh, Saudi Arabia. An electronic questionnaire was used by a trained physician to collect data from patients during telephone interviews. The information included socio-demographic data (i.e., age, gender, and education), family history, compliance with medications, and BP measurements. Patients were asked to answer questions to assess their awareness of their BP readings. Results Of the 475 hypertensive patients included in this study, 32.7% were aged between 56 and 65 years and 60.4% were female. The proportion of patients who had knowledge of their target BP (systolic: 120-129 mmHg; diastolic: 80-84 mmHg) was 74.4%. The significant independent predictors of increased knowledge about BP were a high level of education, regular measurement of BP, and having received education about a healthy lifestyle. The significant independent predictor of decreased knowledge about BP was having an acceptable or poor understanding of chronic BP. Conclusion Hypertensive patients visiting the outpatient clinic at King Fahad Hospital had a good understanding of their target BP readings. Educated patients who regularly measured their BP and who received education about a healthy lifestyle tended to exhibit a higher motivation to achieve their BP targets. More research is needed to gain more insights into the knowledge of hypertensive patients and into how they manage their BP to determine the factors that influence their knowledge.

The status of patient portal use among Emergency Department patients experiencing houselessness: A large-scale single-center observational study.

OBJECTIVE: Patient portal (PP) use has rapidly increased in recent years. However, the PP use status among houseless patients is largely unknown. We aim to determine 1) the PP use status among Emergency Department (ED) patients experiencing houselessness, and 2) whether PP use is linked to the increase in patient clinic visits. METHODS: This is a single-center retrospective observational study. From March 1, 2019, to February 28, 2021, houseless patients who presented at ED were included. Their PP use status, including passive PP use (log-on only PP) and effective PP use (use PP of functions) was compared between houseless and non-houseless patients. The number of clinic visits was also compared between these two groups. Lastly, a multivariate logistic regression was analyzed to determine the association between houseless status and PP use. RESULTS: We included a total of 236,684 patients, 13% of whom (30,956) were houseless at time of their encounter. Fewer houseless patients had effective PP use in comparison to non-houseless patients (7.3% versus 11.6%, p < 0.001). In addition, a higher number of clinic visits were found among houseless patients who had effective PP use than those without (18 versus 3, p < 0.001). The adjusted odds ratio of houseless status associated with PP use was 0.48 (95% CI 0.46-0.49, p < 0.001). CONCLUSIONS: Houselessness is a potential risk factor preventing patient portal use. In addition, using patient portals could potentially increase clinic visits among the houseless patient population.

Patient and provider perspectives to utilization of telemedicine in surgery.

Objectives: Determine patient and provider perspectives on widespread rapid telemedicine implementation, understand the key components of a surgical telemedicine visit and identify factors that affect future telemedicine use. Summary of background data: Compared to other specialties, the field of surgery heretofore has had limited adoption of telemedicine. During the COVID-19 pandemic Healthcare, including the surgical specialties, saw new widespread use of telemedicine. Methods: We conducted a prospective cohort study during the COVID-19 California stay-at-home and physical distancing executive orders. Utilization data were collected from clinics and compared to usage data during the same time 1 year later. All patients and providers who participated in a telemedicine visit during the study period were asked to complete a survey after each encounter and the surveys were analyzed for trends in opinions on future use by stakeholders. Results: Over the 10-week period, the median percentage of telemedicine visits per clinic was 33% (17%-51%) which peaked 3 weeks into implementation. One hundred and ninety-one patients (48% women) with a median age of 64 years (IQR 53-73) completed the patient survey. Patients were first-time participants in telemedicine in 41% (n = 79) of visits. Fifty-seven percent (n = 45) of first-time users preferred that future visits be in-person versus 31% of prior users (p = 0.007). The median travel time from home to the clinic was 40 min (IQR = 20-90). Patients with longer travel times were not more likely to use telemedicine in the future (61% with longer travel vs. 53% shorter, p = 0.11). From the 148 provider responses, 90% of the visits providers were able to create a definitive plan with the telemedicine visit. A physical exam was determined not to be needed in 45% of the visits. An attempt at any physical exam was not performed in 84% of routine follow-up or new-patient visits, compared to 53% of post-op visits (p = 0.001). Conclusion: Telemedicine is a viable ambulatory visit option for surgical specialists and their patients. During rapid telemedicine deployment, travel distance did not correlate with increased use of telemedicine, and in-person visits are still preferred. However, nearly half of all visits did not need a physical exam, which favors telemedicine use.

The Social, Behavioral, and Ethical Modalities of COVID-19 on HIV Care in South Africa: A Systematic Review.

The profound public health impact of the novel outbreak of the SARS-CoV-2 virus in 2019 has been unparalleled in the last century. Rapid spread of the disease and a high death toll fueled the development and global rollout of effective vaccines regardless of the massive inequitable access. However, some public health measures intended to control COVID-19 have had collateral effects on the control of other infectious diseases. In this systematic review, we analyze the impact of the COVID-19 pandemic on efforts to control HIV in South Africa, emphasizing the social, ethical, and behavioral ramifications. The SCOPUS, PubMed, Ovid, PsychINFO, and Cochrane Library databases were searched for publications between March 2020 and January 2022. Of the 854 articles identified, 245 were found duplicated, and 609 were screened, 241 of which were potentially eligible, and 15 of which were ultimately included. Although no studies on the ethical implications were eligible for our study criteria due to insufficient primary data to perform an analysis on, we explored this topic in the Discussion section of this paper. We confirm declines in ART, PrEP, and HIV testing during the initial lockdown period, with slight variations across the South African provinces. Protecting routine services and reducing the disease burden on high-risk nations such as South Africa is imperative moving forward with the pandemic.

Disproportionate reduction in respiratory vs. non-respiratory outpatient clinic visits and antibiotic use in children during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic led to improved hygiene and reduced social encounters. Near elimination of the activity of respiratory syncytial virus and influenza viruses were observed, worldwide. Therefore, we assessed the rates of pediatric outpatient clinic visits and medications prescribed at those visits during the coronavirus disease 2019 (COVID-19) pandemic and pre-COVID-19 period (2016-2019). METHODS: Monthly and annual incidence rates for respiratory and non-respiratory diagnoses and dispensed prescription rates were calculated. Acute gastroenteritis (AGE) visits were analyzed separately since the mode of transmission is influenced by hygiene and social distancing. RESULTS: Overall, 5,588,702 visits were recorded. Respiratory and AGE visits declined by 49.9% and 47.3% comparing the COVID-19 and pre-COVID-19 periods. The respective rate reductions for urinary tract infections, trauma, and skin and soft tissue infections were 18.2%, 19.9%, and 21.8%. Epilepsy visits increased by 8.2%. Overall visits rates declined by 21.6%. Dispensed prescription rates of antibiotics and non-antibiotics respiratory medications declined by 49.3% and 44.4%, respectively. The respective declines for non-respiratory antibiotics and non-antibiotics were 15.1% and 0.2%. Clinic visits and prescription rates reductions were highest in April-May, following the first lockdown in Israel. CONCLUSIONS: COVID-19 pandemic resulted in a substantial reduction in respiratory outpatient clinic visits and dispensed respiratory drugs, with only a mild reduction seen for non-respiratory visits. These trends were probably driven by COVID-19 mitigation measures and by the profound disruption to non-SARS COV-2 respiratory virus activity.

Routine HIV clinic visit adherence in the African Cohort Study.

BACKGROUND: Retention in clinical care is important for people living with HIV (PLWH). Evidence suggests that missed clinic visits are associated with interruptions in antiretroviral therapy (ART), lower CD4 counts, virologic failure, and overlooked coinfections. We identified factors associated with missed routine clinic visits in the African Cohort Study (AFRICOS). METHODS: In 2013, AFRICOS began enrolling people with and without HIV in Uganda, Kenya, Tanzania, and Nigeria. At enrollment and every 6 months thereafter, sociodemographic questionnaires are administered and clinical outcomes assessed. Missed clinic visits were measured as the self-reported number of clinic visits missed in the past 6 months and dichotomized into none or one or more visits missed. Logistic regression with generalized estimating equations was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between risk factors and missed visits. RESULTS: Between January 2013 and March 2020, 2937 PLWH were enrolled, of whom 2807 (95.6%) had initiated ART and 2771 had complete data available for analyses. Compared to PLWH 50+, missed clinic visits were more common among those 18-29 years (aOR 2.33, 95% CI 1.65-3.29), 30-39 years (aOR 1.59, 95% CI 1.19-2.13), and 40-49 years (aOR 1.42, 95% CI 1.07-1.89). As compared to PLWH on ART for < 2 years, those on ART for 4+ years were less likely to have missed clinic visits (aOR 0.72, 95% CI 0.55-0.95). Missed clinic visits were associated with alcohol use (aOR 1.34, 95% CI 1.05-1.70), a history of incarceration (aOR 1.42, 95% CI 1.07-1.88), depression (aOR 1.47, 95% CI 1.13-1.91), and viral non-suppression (aOR 2.50, 95% CI 2.00-3.12). As compared to PLWH who did not miss any ART in the past month, missed clinic visits were more common among those who missed 1-2 days (aOR 2.09, 95% CI 1.65-2.64) and 3+ days of ART (aOR 7.06, 95% CI 5.43-9.19). CONCLUSIONS: Inconsistent clinic attendance is associated with worsened HIV-related outcomes. Strategies to improve visit adherence are especially needed for young PLWH and those with depression.

Medicaid insured persons with diabetes have increased proportion of missed appointments and high HbA1c.

Objective: This study was conducted to evaluate whether the type of insurance coverage is associated with missed appointments and to evaluate the effect of missed appointments on diabetes control. Methods: All patients with diabetes mellitus (DM) managed at a major academic medical center between Jan 2015 and Dec 2020 were included in analysis. Association between insurance coverage and the proportion of missed appointments was evaluated with adjustments for demographic variables and social determinants of health. The relationship between proportion of missed appointments and glycemic control was also evaluated. Results: The dataset included 30,633 patients, out of which 14,064 (46%) reported commercial insurance, 13,376 (44%) reported Medicare and 3,193 (10%) reported Medicaid coverage. Proportion of missed appointments was 18.1 ± 18.1% among Medicaid covered patients,12.1 ± 15.3% among commercially insured and 10.2 ± 14.1% among Medicare covered patients (p < 0.001). Type of insurance was found to be a significant predictor of proportion of missed appointments after adjusting for age, race, language, marital status, smoking, BMI, HbA1c and type of diabetes (p < 0.001) in series regression analysis. Proportion of missed appointments was associated with HbA1c with partial correlation coefficient +0.104 (p < 0.005) after adjusting for age, race, gender, type of insurance coverage, BMI and type of diabetes. Conclusions: Medicaid covered patients with diabetes have higher proportion of missed clinic appointments and higher HbA1c. More research is needed to evaluate the root causes of inability to keep appointments in this population so that strategies for improved healthcare delivery can be designed.

Unaccompanied Clinic Visits: Practical Consequences of a Stressor Imposed by the COVID-19 Pandemic.

One of the restrictive measures of COVID-19 (coronavirus disease 2019) pandemic control is the prohibition of accompanied clinic visits. The specific features of ophthalmological patients imply different degrees of dependency that directly affect their response to such measures. This study aims to assess the effects of unaccompanied medical appointments on outpatients' stress levels and their retention of medical advice. A questionnaire-based survey was conducted at a large ophthalmic clinic in northern Greece during September 2020. Suitable subjects were asked to self-administer a 7-item questionnaire addressing their subjective perception of stress and their ability to fully understand and remember their doctor's instructions, given the fact that they would be alone during the consultation. The analysis was based on 200 patients who completed the survey. Sixty-three patients (31.5%) reported that unaccompanied clinic visits increased their stress, with a median value of 7.5 (mean 6.77 ± .2.7) on a scale from 1 to 10. A large number of the patients (30%) claimed it was difficult to remember the doctor's comments or instructions, and 24.6% indicated that they would not fully understand them if they were to attend the clinic unaccompanied. A marked impact on women and on the elderly (up to threefold) over 70 years of age was identified. This is the first study specifically addressing practical repercussions of unaccompanied clinic visits during the COVID-19 pandemic. A negative effect on patients' emotional status and on counseling effectiveness was demonstrated. Female gender and advanced age were found to be determinants of the highest vulnerability.

Adolescent and caregiver attitudes towards telemedicine use in pediatric nephrology.

BACKGROUND: Telemedicine is increasingly utilized as an alternative to in person consultation. Current pandemic conditions are providing additional impetus to virtual care delivery. We compared both adolescent and caregiver (parent or guardian) attitudes towards telemedicine (here as tertiary center to remote health care location) as a crucial determinant of longer-term effectiveness. METHODS: This qualitative research study analyzed transcribed structured telephone interviews with both 11-18 year-old pediatric nephrology patients and their caregivers and performed a quantitative analysis of patient demographics, disease factors and distance to tertiary center vs. telemedicine center. RESULTS: The study was conducted in a medium-sized tertiary pediatric nephrology centre with a large catchment area of over 0.5 million square kilometers and 629,000 children and adolescents under 18 years of age. Eleven dyads of adolescents and caregivers were enrolled. Five adolescents were male. The mean age of the adolescents was 14.4 ± 2.5 years (range 11.2-18.0). The median distance to our tertiary center was 191 km (range 110-1378 km). Four adolescents lived more than 500 km from our tertiary center. The 11 adolescents had a total of 334 in person visits (mean 30 ± 25) and 86 telemedicine visits (mean 8 ± 7). A ratio of 2:1 telemedicine to in-person visits was favored; with caregivers more in favor of remote care than adolescents. Qualitative analysis found that experiences with telemedicine were distinguished by consultation-specific factors and contextual factors. Contextual factors (travel/cost savings) were valued for telemedicine by adolescents and caregivers. Consultation-specific factors, such as the ability to show the doctor physical symptoms, were more valued during in-person consultations, especially by adolescents. The overall visit type preference was related to the nature of the consultation. For regular check-ups, and for adolescents with less complex needs, participants felt that telemedicine offered a comparable experience to in-person visits. Adolescents with more complex conditions preferred in-person visits. CONCLUSIONS: Indiscriminate transfer to chronic care predicated on mainly telemedicine approach is not compatible with user expressed attitudes (especially among adolescents). Accurately mapping models of care to these attitudes is an essential determinant of effective management and longer-term engagement with potentially life-long health challenges.

Exploring the lengthiest ambulatory breast surgery clinic appointments: is the patient the problem?

BACKGROUND: Prolonged outpatient clinic appointments can disrupt schedules, impacting patients and providers. We sought to define features of the longest ambulatory appointments in a breast surgery clinic, and to ascertain whether patients attending these appointments consistently have protracted appointments. METHODS: A single-institution retrospective cohort study was conducted of breast surgery clinic patients, January 2017 to May 2019, and the longest 1% of appointments identified using a real-time patient tracking system. A primary chart review was performed, and data abstracted. Other appointments attended by these patients were identified, and the ratio of appointments >75th percentile duration (protracted appointments) to the total appointments during the study period was calculated, enabling comparison for patients with consistently protracted (ratio >50%) vs. sporadically protracted appointments (≤50%). Descriptive analysis was performed, and results reported as medians with inter-quartile ranges. RESULTS: A total of 15,265 clinic appointments were identified, and the longest 148 (exceeding 244 minutes) analyzed. Median appointment length was 264 minutes (inter-quartile range: 253-290). 70% were new patient appointments, and 54% of patients underwent a test/investigation that day. A minority were obese (39%), smokers (41%), diagnosed with a psychiatric comorbidity (34%), had a genetic cancer syndrome (22%), or received unexpected news at their appointment (16%). Of 118 patients with multiple appointments, 26% had consistently protracted appointments and 74% sporadically protracted appointments. CONCLUSIONS: The lengthiest appointments are usually newly diagnosed cancer patients. Only a minority of patients have consistently protracted appointments, implying that a patient's previously prolonged appointment may not predict future long appointments.

The short-term association of ambient fine particulate air pollution with hypertension clinic visits: A multi-community study in Guangzhou, China.

BACKGROUND: The association of ambient fine particulate pollution with daily outpatient clinic visits (OCV) for hypertension in China remains to be investigated. OBJECTIVES: This study aimed to examine short-term impacts of exposure to fine particulate matter of aerodynamic diameter < 2.5µm (PM2.5) on daily OCV for hypertension, using a large-scale multi-center community database in Guangzhou, one of the most densely-populated cities in Southern China. METHODS: We collected a total of 28,548 individual records of OCV from 22 community healthcare facilities in Guangzhou from January 1st to May 7th 2020. Hourly data on air pollutants and daily information on meteorological factors were obtained. According to the World Health Organization air-quality guidelines, daily excessive concentration hours (DECH) was calculated. PM2.5 daily mean, hourly-peak concentration and DECH were used as the exposure variables. Based on a case-time-control design, the Cox regression model was applied to evaluate the short-term relative risks (RR) of daily OCV for hypertension. Sensitivity analyses were conducted, with nitrogen dioxide, sulfur dioxide, carbon monoxide, and ozone being adjusted. RESULTS: Daily mean and hourly-peak of PM2.5 were significantly associated with daily OCV for hypertension, while weaker associations were observed for DECH. The estimated RRs at lag day 0 were 1.039 (95% confidence interval [CI]: 1.037, 1.040), 1.851 (95%CI: 1.814, 1.888), and 1.287 (95%CI: 1.276, 1.298), respectively, in association with a 1-unit increase in DECH, daily mean, and hourly-peak concentration of PM2.5. For the lagged effect, lag4 models estimated the greatest RRs for PM2.5 DECH and hourly-peak, whereas a lag2 model produced the highest for PM2.5 daily mean. DISCUSSION: This study consolidates the evidence for a positive correlation between ambient PM2.5 exposure and risks of hypertensive OCV. It also provides profound insight regarding planning for health services needs and establishing early environmental responses to the worsening air pollution in the communities.

Acute effects of ambient air pollution on clinic visits of college students for upper respiratory tract infection in Wuhan, China.

Ambient air pollutants have been linked to adverse health outcomes, but evidence is still relatively rare in college students. Upper respiratory tract infection (URTI) is a common disease of respiratory system among college students. In this study, we assess the acute effect of air pollution on clinic visits of college students for URTI in Wuhan, China. Data on clinic visits due to URTI were collected from Wuhan University Hospital, meteorological factors (including daily temperature and relative humidity) provided by Wuhan Meteorological Bureau, and air pollutants by Wuhan Environmental Protection Bureau. In the present study, generalized additive model with a quasi-Poisson distribution link function was used to examine the association between ambient air pollutants (fine particulate matter (PM2.5), particulate matter (PM10), sulfur dioxide (SO2), nitrogen dioxide (NO2), and ozone (O3)) and the daily number of clinic visits of college students for URTI at Wuhan University Hospital in Wuhan, China. In the meantime, the model was adjusted for the confounding effects of long-term trends, seasonality, day of the week, public holidays, vacation, and meteorological factors. The best degrees of free in model were selected based on AIC (Akaike Information Criteria). The effect modification by gender was also examined. A total of 44,499 cases with principal diagnosis of URTI were included from January 1, 2016, to December 31, 2018. In single-pollutant models, the largest increment of URTI visits were found at lag 0 day in single-day lags, and the effect values in cumulative lags were greater than those in single-day lags. PM2.5 (0.74% (95%CI: 0.05, 1.44)) at lag 0 day, PM10 (0.61% (95%CI: 0.12, 1.11)) and O3 (1.01% (95%CI: 0.24, 1.79)) at lag 0-1 days, and SO2 (9.18% (95%CI: 3.27, 15.42)) and NO2 (3.40% (95% CI:1.64, 5.19)) at lag 0-3 days were observed to be strongly and significantly associated with clinic visits for URTI. PM10 and NO2 were almost still significantly associated with URTI after controlling for the other pollutants in our two-pollutant models, where the effect value of SO2 after inclusion of O3 appeared to be the largest and the effects of NO2 were also obvious compared with the other pollutants. Subgroups analysis demonstrated that males were more vulnerable to PM10 and O3, while females seemed more vulnerable to exposure to SO2 and NO2. This study implied that short-term exposure to ambient air pollution was associated with increased risk of URTI among college students at Wuhan University Hospital in Wuhan, China. And gaseous pollutants had more negative health impact than solid pollutants. SO2 and NO2 were the major air pollutants affecting the daily number of clinic visits on URTI, to which females seemed more vulnerable than males.

The Impact of Multidisciplinary Conferences on Healthcare Utilization in Chronic Pain Patients.

Approximately 100 million adults in the United States have chronic pain, though only a subset utilizes the vast majority of healthcare resources. Multidisciplinary care has been shown to improve outcomes in a variety of clinical conditions. There is concern that multidisciplinary care of chronic pain patients may overwhelm existing resources and increase healthcare utilization due to the volume of patients and the complexity of care. We report our findings on the use of multidisciplinary conferences (MDC) to facilitate care for the most complex patients seen at our tertiary center. Thirty-two of nearly 2,000 patients seen per year were discussed at the MDC, making up the top 2% of complex patients in our practice. We evaluated patients' numeric rating score (NRS) of pain, medication use, hospitalizations, emergency department visits, and visits to pain specialists prior to their enrollment in MDC and 1 year later. Matched samples were compared using Wilcoxon's signed rank test. Patients' NRS scores significantly decreased from 7.64 to 5.54 after inclusion in MDC (p < 0.001). A significant decrease in clinic visits (p < 0.001) and healthcare utilization (p < 0.05) was also observed. Opioid and non-opioid prescriptions did not change significantly (p = 0.43). 83% of providers agreed that MDC improved patient care. While previous studies have shown the effect of multi-disciplinary care, we show notable improvements with a team established around a once-a-month MDC.