Ambulatory antibiotic prescription rates for acute respiratory infection rebound two years after the start of the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, acute respiratory infection (ARI) antibiotic prescribing in ambulatory care markedly decreased. It is unclear if antibiotic prescription rates will remain lowered. METHODS: We used trend analyses of antibiotics prescribed during and after the first wave of COVID-19 to determine whether ARI antibiotic prescribing rates in ambulatory care have remained suppressed compared to pre-COVID-19 levels. Retrospective data was used from patients with ARI or UTI diagnosis code(s) for their encounter from 298 primary care and 66 urgent care practices within four academic health systems in New York, Wisconsin, and Utah between January 2017 and June 2022. The primary measures included antibiotic prescriptions per 100 non-COVID ARI encounters, encounter volume, prescribing trends, and change from expected trend. RESULTS: At baseline, during and after the first wave, the overall ARI antibiotic prescribing rates were 54.7, 38.5, and 54.7 prescriptions per 100 encounters, respectively. ARI antibiotic prescription rates saw a statistically significant decline after COVID-19 onset (step change -15.2, 95% CI: -19.6 to -4.8). During the first wave, encounter volume decreased 29.4% and, after the first wave, remained decreased by 188%. After the first wave, ARI antibiotic prescription rates were no longer significantly suppressed from baseline (step change 0.01, 95% CI: -6.3 to 6.2). There was no significant difference between UTI antibiotic prescription rates at baseline versus the end of the observation period. CONCLUSIONS: The decline in ARI antibiotic prescribing observed after the onset of COVID-19 was temporary, not mirrored in UTI antibiotic prescribing, and does not represent a long-term change in clinician prescribing behaviors. During a period of heightened awareness of a viral cause of ARI, a substantial and clinically meaningful decrease in clinician antibiotic prescribing was observed. Future efforts in antibiotic stewardship may benefit from continued study of factors leading to this reduction and rebound in prescribing rates.

Clinician and administrator perspectives on outpatient administration of ciltacabtagene autoleucel in relapsed or refractory multiple myeloma.

Introduction: Chimeric antigen receptor (CAR) T-cell therapy (CAR T therapy) is a treatment option for patients with relapsed or refractory multiple myeloma that has led to unprecedented treatment outcomes. Among CAR T therapies available, ciltacabtagene autoleucel (cilta-cel) is a good candidate for outpatient administration due to its generally predictable safety profile. There are multiple advantages of outpatient administration of cilta-cel, including reduced healthcare burden, expanded access, and patient autonomy. This mixed methods qualitative study aimed to identify key factors for outpatient administration of CAR T and best practice recommendations by combining a targeted literature review with expert interviews and panels. Methods: The targeted review (Phase 1) aimed to identify factors for outpatient CAR T administration in the US and determine key topics for the exploratory interviews (Phase 2) and expert panels (Phase 3), which aimed to inform on best practices and challenges of outpatient CAR T administration (focusing on cilta-cel). Participants in clinical and administrative positions based in treatment centers that had experience with real-world outpatient administration of cilta-cel were recruited. Results: Seventeen studies were identified in Phase 1. Key factors for outpatient administration included the development of protocols for CAR T complications, education for caregivers, outpatient specialists, hospital staff, and emergency services staff for identification and referral after possible adverse events, the creation of multidisciplinary teams for effective communication and management, straightforward patient intake processes encompassing financial eligibility review and provision of patient education materials, and close patient monitoring throughout the treatment journey. In Phase 2, 5 participants from 2 centers were interviewed. In Phase 3, 14 participants across 6 treatment centers were interviewed. Two 90-minute virtual panel discussions took place. All participants agreed that cilta-cel can be safely and effectively administered in an outpatient setting. Key recommendations included the creation of educational resources for patients and caregivers, the development of standard operating procedures, dedicated outpatient infrastructure and establishment of interdisciplinary teams, outpatient monitoring for toxicity management, and monitoring of the reimbursement landscape. Discussion: This study offers a comprehensive understanding of the feasibility of outpatient cilta-cel administration in participating CAR T centers and provides actionable recommendations while acknowledging existing challenges.

Outpatient dental procedures carried out by Pediatric Dentists within Brazil's public healthcare system.

Brazil's public healthcare system (SUS) offers specialized oral health services to Brazilians, but the productivity of specialists, such as Pediatric Dentists, has not been characterized. Therefore, the objective of this study was to characterize the outpatient dental procedures (ODPs) carried out by Pediatric Dentists within the SUS. An epidemiological study with an ecological, longitudinal, retrospective, and quantitative approach was conducted. The ODPs carried out by Pediatric Dentists within the SUS were characterized based on type of procedure, complexity level, and circumstance (urgent or elective). Data were analyzed using a descriptive and analytical approach, considering a significance level of 5%, as well as the impact of the COVID-19 pandemic (the 2020-2022 years were not included in secondary analyses). In the last 15 years, 29,234,972 ODPs were carried out by Pediatric Dentists within the SUS. Clinical procedures were the majority (55.4%), significantly more frequent than all other types of procedures (all p <0.05). Among these, restorative and periodontal procedures were the most common (30.7% and 21.0%, respectively). From 2008 to 2019, excluding COVID-19 pandemic years, the trend over the last 15 years was constant for all types of procedures (all p >0.05). In addition, low complexity ODPs were the majority (90.1%), significantly more frequent than medium (9.7%) and high complexity procedures (0.1%) (both p <0.05). At last, most ODPs were not characterized by circumstance in the outpatient production reports (96.9%). Therefore, it was possible to conclude that Pediatric Dentists carried out diverse ODPs within the SUS over the past 15 years, although there was a dominant pattern of type and complexity.

Weighted Blanket: An Anxiety Reduction Tool in the Outpatient Oncology Infusion Setting.

BACKGROUND: Adults with cancer experience a significantly higher level of anxiety compared with the general population. Anxiety is reported at diagnosis and throughout the cancer trajectory, and it is particularly heightened at the initiation of infusion treatments. In 2020, the COVID-19 pandemic exacerbated anxiety levels in patients receiving cancer treatments. OBJECTIVES: This evidence-based practice project evaluated the feasibility and effectiveness of using medical-grade weighted blankets to reduce anxiety in patients with cancer receiving the first two infusion treatments in the ambulatory setting. METHODS: Patients completed a modified version of the Visual Analog Scale for Anxiety to self-report anxiety pre- and postimplementation. Patients and nurses completed feasibility surveys. FINDINGS: Patients reported reduced anxiety after using a weighted blanket and described weighted blankets as comforting and soothing. More than 90% of surveyed patients agreed or strongly agreed that the blanket was comfortable, not too heavy, and easy to put on, and did not interfere with nursing care or their own activities. Nurses valued the ease of use and adherence to infection control standards.

Bridging the Gap: Standardizing Orientation to Improve Vacancy and Turnover Rates of Ambulatory Oncology Nurses.

This article describes standardizing ambulatory oncology nursing orientation within an academic comprehensive cancer center to reduce turnover rates. The nursing professional development specialist created a standardized orie.

Improving the Care and Cost of Treating Community-Acquired Stage 3 and 4 Decubitus Ulcers.

INTRODUCTION: The healthcare costs for treatment of community-acquired decubitus ulcers accounts for $11.6 billion in the United States annually. Patients with stage 3 and 4 decubitus ulcers are often treated inefficiently prior to reconstructive surgery while physicians attempt to optimize their condition (debridement, fecal/urinary diversion, physical therapy, nutrition, and obtaining durable medical goods). We hypothesized that hospital costs for inpatient optimization of decubitus ulcers would significantly differ from outpatient optimization costs, resulting in significant financial losses to the hospital and that transitioning optimization to an outpatient setting could reduce both total and hospital expenditures. In this study, we analyzed and compared the financial expenditures of optimizing patients with decubitus ulcers in an inpatient setting versus maximizing outpatient utilization of resources prior to reconstruction. METHODS: Encounters of patients with stage 3 or 4 decubitus ulcers over a 5-year period were investigated. These encounters were divided into two groups: Group 1 included patients who were optimized totally inpatient prior to reconstructive surgery; group 2 included patients who were mostly optimized in an outpatient setting and this encounter was a planned admission for their reconstructive surgery. Demographics, comorbidities, paralysis status, and insurance carriers were collected for all patients. Financial charges and reimbursements were compared among the groups. RESULTS: Forty-five encounters met criteria for inclusion. Group 1's average hospital charges were $500,917, while group 2's charges were $134,419. The cost of outpatient therapeutic items for patient optimization prior to wound closure was estimated to be $10,202 monthly. When including an additional debridement admission for group 2 patients (average of $108,031), the maximal charges for total care was $252,652, and hospital reimbursements were similar between group 1 and group 2 ($65,401 vs $50,860 respectively). CONCLUSIONS: The data derived from this investigation strongly suggests that optimizing patients in an outpatient setting prior to decubitus wound closure versus managing the patients totally on an inpatient basis will significantly reduce hospital charges, and hence costs, while minimally affecting reimbursements to the hospital.

Causes of Death in Patients Asking for Polyclinic Care for Coronary Heart Disease.

AIM: Retrospective analysis of the underlying causes for death of patients who did and did not seek outpatient medical care (OPMC) for ischemic heart disease (IHD), and discussion of a possibility for using administrative anonymized but individualized databases for analysis. MATERIAL AND METHODS: The electronic database of the Central Administration of the Civil Registry Office of the Moscow Region (Unified State Register of the Civil Registry Office of the Moscow Region), including medical death certificates (MDC) for 2021, was used to select all cases of fatal outcomes with the disease codes of the International Classification of Diseases, Tenth Revision (ICD-10) (codes of external causes, injuries, poisonings excluded) that were indicated as the primary cause of death (PCD). Personalized data of the deceased were combined with data from electronic medical records of patients who sought OPMC at institutions of the Moscow Region within up to 2 years before death. In addition to IHD, the following PCD codes were taken into account: malignant tumors, COVID-19, diabetes mellitus, cerebrovascular diseases, hypertension, chronic obstructive pulmonary disease, alcohol-associated diseases, and, as examples of unspecified PCD, old age and unspecified encephalopathy.Results In total, among those who died from diseases, the proportion of those who died from IHD was 18.9%; for another 8.4%, IHD was indicated as a comorbid disease in Part II of the MDC. Among those who sought OPMC for IHD, the IHD proportion indicated as PCD was 27.5%, and among those who did not seek OPMC 17.4% (p <0.0001). Those who died from IHD and who had sought OPMC were older (mean age, 75.59 ± 10.94 years) than those who died from IHD and had not sought OMPM (mean age, 73.96 ± 10.94 years; p < 0.0001). The frequency of myocardial infarction as PCD among those who had and had not sought OPMC was the same (12%), chronic forms of IHD were 83.9% and 79.7%, the frequencies of "unspecified" acute forms of IHD (codes I24.8-9) were 4.1% and 8.3%, respectively. The proportion of deaths from COVID-19 was the highest (21.7% and 24.3%, respectively), from malignant neoplasms 11.6% and 12.7%, respectively, and from unspecified encephalopathy 10.6% and 10.7%, respectively. CONCLUSION: Only 25% of patients who had sought OPMC for IHD died from IHD, otherwise the causes of death were the same as for patients who had not sought OPMC for IHD. Analysis of administrative databases allows identifying disparities in the PCD structure and to direct the efforts of specialists to reconciling the criteria for death from various forms of IHD.

The role of recovery peer navigators in retention in outpatient buprenorphine treatment: a retrospective cohort study.

BACKGROUND: Racial and ethnic disparities are evident in the accessibility of treatment for opioid use disorder (OUD). Even when medications for OUD (MOUD) are accessible, racially and ethnically minoritized groups have higher attrition rates from treatment. Existing literature has primarily identified the specific racial and ethnic groups affected by these disparities, but has not thoroughly examined interventions to address this gap. Recovery peer navigators (RPNs) have been shown to improve access and overall retention on MOUD. PATIENTS AND METHODS: In this retrospective cohort study, we evaluate the role of RPNs on patient retention in clinical care at an outpatient program in a racially and ethnically diverse urban community. Charts were reviewed of new patients seen from January 1, 2019 through December 31, 2019. Sociodemographic and clinical visit data, including which providers and services were utilized, were collected, and the primary outcome of interest was continuous retention in care. Bivariate analysis was done to test for statistically significant associations between variables by racial/ethnic group and continuous retention in care using Student's t-test or Pearson's chi-square test. Variables with p value ≤0.10 were included in a multivariable regression model. RESULTS: A total of 131 new patients were included in the study. RPNs improved continuous retention in all-group analysis (27.6% pre-RPN compared to 80.2% post-RPN). Improvements in continuous retention were observed in all racial/ethnic subgroups but were statistically significant in the non-Hispanic Black (NHB) group (p < 0.001). Among NHB, increases in continuous retention were observed post-RPN in patients with male sex (p < 0.001), public health insurance (p < 0.001), additional substance use (p < 0.001), medical comorbidities (p < 0.001), psychiatric comorbidities (p = 0.001), and unstable housing (p = 0.005). Multivariate logistic regression demonstrated that patients who lacked insurance had lower odds of continuous retention compared to patients with public insurance (aOR = 0.17, 95% CI 0.039-0.70, p = 0.015). CONCLUSIONS: RPNs can improve clinical retention for patients with OUD, particularly for individuals experiencing several sociodemographic and clinical factors that are typically correlated with discontinuation of care.

Recovery peer navigators improve continuous clinical retention following initiation of outpatient treatment for opioid use disorder.Recovery peer navigators may be especially beneficial for patients with factors and identifiers commonly associated with discontinuation of care.

[Current Outpatient Psychotherapeutic Care for People with Migration and Refugee Experience in Germany - An Overview]. / Die aktuelle ambulante psychotherapeutische Versorgung von Menschen mit Migrations- und Fluchterfahrung in Deutschland ­ Eine Übersicht.

Although mental health is a human right, even in a country with a well-developed healthcare system like Germany, it is not possible to ensure non-discriminatory access to mental health care for all people, regardless of their origin. For individuals with a history of flight or migration it is particularly difficult to gain access to adequate psychotherapeutic care. This review addresses key barriers contributing to the lack of outpatient care for people with a history of flight or migration. Lack of knowledge about the treatment system, fear of stigma, structural barriers, language barriers, lack of networking of healthcare providers, lack of knowledge of mental health practitioners, as well as stereotypes, discrimination, and racism towards people with a refugee or migration history were identified as the most important barriers with sufficient evidence. Innovative concepts such as peer support can enable non-discriminatory treatment access. In addition, there is an urgent need to train the profession of psychotherapists in racism- and discrimination-sensitive work and to integrate these aspects into psychotherapeutic education and training.

Trends in C reactive protein testing: a retrospective cohort study in paediatric ambulatory care settings.

OBJECTIVES: This study aims to investigate C reactive protein (CRP) testing practices in paediatric ambulatory care across British primary care and accident and emergency (A&E) departments. DESIGN, SETTING, PARTICIPANTS: This retrospective cohort study included children <18 years old having ≥1 CRP test at primary care or A&E departments in Oxfordshire between 2007 and 2021. OUTCOMES: We estimated the frequency and annual changes in CRP testing in both settings and evaluated referral and admission patterns based on CRP levels: low (<20 mg/L), intermediate or high (≥80 mg/L). RESULTS: Over 15 years, 91 540 CRP tests were requested in 63 226 children, with 33 882 (53.6%) in primary care and 29 344 (46.4%) in A&E. Both settings showed rising trends in test requests, with average annual percentage change of 3.0% (95% CI 1.2% to 4.7%) in primary care and 11.5% (95% CI 8.6% to 14.6%) in A&E. The proportion of intermediate/high-test results remained stable. In primary care, 50 709 (95.8%) of CRP tests were <20 mg/L, with 99.0% of these children managed at home. High and intermediate CRP values increased odds of referral versus low CRP (OR adjusted for age=21.80; 95% CI 16.49 to 28.81 and 4.77; 3.78 to 6.02, respectively). At A&E, 27 610 (71.5%) children had CRP<20 mg/L, of whom 42.5% were admitted while 3776 (9.8%) had CRP≥80 mg/L with 57.9% admission rate. High and intermediate CRP values increased odds of admission versus low CRP (OR adjusted for age=1.90; 95% CI 1.78 to 2.04 and 1.39; 1.32 to 1.46, respectively). CONCLUSION: There are rising trends of CRP test requests in paediatric ambulatory care settings, with no evidence of increases in proportion of intermediate/high-test results in primary care. Low CRP values at primary care were linked to children managed at home, while almost half of children with low CRP values at A&E were admitted to the hospital.

Health Insurance Type and Outpatient Specialist Care Among Children With Asthma.

Importance: Although children with asthma are often successfully treated by primary care clinicians, outpatient specialist care is recommended for those with poorly controlled disease. Little is known about differences in specialist use for asthma among children with Medicaid vs private insurance. Objective: To examine differences among children with asthma regarding receipt of asthma specialist care by insurance type. Design, Setting, and Participants: In this cross-sectional study using data from the Massachusetts All Payer Claims Database (APCD) between 2014 to 2020, children with asthma were identified and differences in receipt of outpatient specialist care by whether their insurance was public (Medicaid and the Children's Health Insurance Program) or private were examined. Eligible participants included children with asthma in 2015 to 2020 aged 2 to 17 years. Data analysis was conducted from January 2023 to April 2024. Exposure: Medicaid vs private insurance. Main Outcomes and Measures: The primary outcome was receipt of specialist care (any outpatient visit with a pulmonology, allergy and immunology, or otolaryngology physician). Multivariable logistic regression models estimated differences in receipt of specialist care by insurance type accounting for child and area characteristics including demographics, health status, persistent asthma, calendar year, and zip code characteristics. Additional analyses examined if the associations of specialist care with insurance type varied by asthma persistence and severity, and whether associations varied over time. Results: Among 198 101 unique children, there were 432 455 child-year observations (186 296 female [43.1%] and 246 159 male [56.9%]; 211 269 aged 5 to 11 years [48.9%]; 82 108 [19.0%] with persistent asthma) including 286 408 (66.2%) that were Medicaid insured and 146 047 (33.8%) that were privately insured. Although persistent asthma was more common among child-year observations with Medicaid vs private insurance (57 381 [20.0%] vs 24 727 [16.9%]), children with Medicaid were less likely to receive specialist care. Overall, 64 239 child-year observations (14.9%) received specialist care, with substantially lower rates for children with Medicaid vs private insurance (34 093 child-year observations [11.9%] vs 30 146 child-year observations [20.6%]). Regression-based estimates confirmed these disparities; children with Medicaid had 55% lower odds of receiving specialist care (adjusted odds ratio, 0.45; 95% CI, 0.43 to 0.47) and a regression-adjusted 9.7 percentage point (95% CI, -10.4 percentage points to -9.1 percentage points) lower rate of receipt of specialist care. Compared with children with private insurance, there was an additional 3.2 percentage point (95% CI, 2.0 percentage points to 4.4 percentage points) deficit for children with Medicaid with persistent asthma. Conclusions and Relevance: In this cross-sectional study, children with Medicaid were less likely to receive specialist care, with the largest gaps among those with persistent asthma. These findings suggest that closing this care gap may be one approach to addressing ongoing disparities in asthma outcomes.

eHealth Literacy and the Use of NHS 111 Online Urgent Care Service in England: Cross-Sectional Survey.

BACKGROUND: Many health care systems have used digital technologies to support care delivery, a trend amplified by the COVID-19 pandemic. "Digital first" may exacerbate health inequalities due to variations in eHealth literacy. The relationship between eHealth literacy and web-based urgent care service use is unknown. OBJECTIVE: This study aims to measure the association between eHealth literacy and the use of NHS (National Health Service) 111 online urgent care service. METHODS: A cross-sectional sequential convenience sample survey was conducted with 2754 adults (October 2020-July 2021) from primary, urgent, or emergency care; third sector organizations; and the NHS 111 online website. The survey included the eHealth Literacy Questionnaire (eHLQ), questions about use, preferences for using NHS 111 online, and sociodemographic characteristics. RESULTS: Across almost all dimensions of the eHLQ, NHS 111 online users had higher mean digital literacy scores than nonusers (P<.001). Four eHLQ dimensions were significant predictors of use, and the most highly significant dimensions were eHLQ1 (using technology to process health information) and eHLQ3 (ability to actively engage with digital services), with odds ratios (ORs) of 1.86 (95% CI 1.46-2.38) and 1.51 (95% CI 1.22-1.88), respectively. Respondents reporting a long-term health condition had lower eHLQ scores. People younger than 25 years (OR 3.24, 95% CI 1.87-5.62) and those with formal qualifications (OR 0.74, 95% CI 0.55-0.99) were more likely to use NHS 111 online. Users and nonusers were likely to use NHS 111 online for a range of symptoms, including chest pain symptoms (n=1743, 70.4%) or for illness in children (n=1117, 79%). The users of NHS 111 online were more likely to have also used other health services, particularly the 111 telephone service (χ12=138.57; P<.001). CONCLUSIONS: These differences in eHealth literacy scores amplify perennial concerns about digital exclusion and access to care for those impacted by intersecting forms of disadvantage, including long-term illness. Although many appear willing to use NHS 111 online for a range of health scenarios, indicating broad acceptability, not all are able or likely to do this. Despite a policy ambition for NHS 111 online to substitute for other services, it appears to be used alongside other urgent care services and thus may not reduce demand.

Implementation of a Web-Based Outpatient Asynchronous Consultation Service: Mixed Methods Study.

BACKGROUND: Asynchronous outpatient patient-to-provider communication is expanding in UK health care, requiring evaluation. During the pandemic, Aberdeen Royal Infirmary in Scotland expanded its outpatient asynchronous consultation service from dermatology (deployed in May 2020) to gastroenterology and pain management clinics. OBJECTIVE: We conducted a mixed methods study using staff, patient, and public perspectives and National Health Service (NHS) numerical data to obtain a rounded picture of innovation as it happened. METHODS: Focus groups (3 web-based and 1 face-to-face; n=22) assessed public readiness for this service, and 14 interviews with staff focused on service design and delivery. The service's effects were examined using NHS Grampian service use data, a patient satisfaction survey (n=66), and 6 follow-up patient interviews. Survey responses were descriptively analyzed. Demographics, acceptability, nonattendance rates, and appointment outcomes of users were compared across levels of area deprivation in which they live and medical specialties. Interviews and focus groups underwent theory-informed thematic analysis. RESULTS: Staff anticipated a simple technical system transfer from dermatology to other receptive medical specialties, but despite a favorable setting and organizational assistance, it was complicated. Key implementation difficulties included pandemic-induced technical integration delays, misalignment with existing administrative processes, and discontinuity in project management. The pain management clinic began asynchronous consultations (digital appointments) in December 2021, followed by the gastroenterology clinic in February 2022. Staff quickly learned how to explain and use this service. It was thought to function better for pain management as it fitted preexisting practices. From May to September 2022, the dermatology (adult and pediatric), gastroenterology, and pain management clinics offered 1709 appointments to a range of patients (n=1417). Digital appointments reduced travel by an estimated 44,712 miles (~71,956.81 km) compared to the face-to-face mode. The deprivation profile of people who chose to use this service closely mirrored that of NHS Grampian's population overall. There was no evidence that deprivation impacted whether digital appointment users subsequently received treatment. Only 18% (12/66) of survey respondents were unhappy or very unhappy with being offered a digital appointment. The benefits mentioned included better access, convenience, decreased travel and waiting time, information sharing, and clinical flexibility. Overall, patients, the public, and staff recognized its potential as an NHS service but highlighted informed choice and flexibility. Better communication-including the use of the term assessment instead of appointment-may increase patient acceptance. CONCLUSIONS: Asynchronous pain management and gastroenterology consultations are viable and acceptable. Implementing this service is easiest when existing administrative processes face minimal disruption, although continuous support is needed. This study can inform practical strategies for supporting staff in adopting asynchronous consultations (eg, preparing for nonlinearity and addressing task issues). Patients need clear explanations and access to technical support, along with varied consultation options, to ensure digital inclusion.

A novel model of ambulatory teaching of residents in general practice in China: a cross-sectional study.

BACKGROUND: This study aims to determine the satisfaction and future training needs of general practice residents participating in a novel model of ambulatory teaching aligned with the specifications for standardized residency training in outpatient management issued by the Chinese Medical Doctor Association (CMDA). METHODS: A cross-sectional survey of the satisfaction and training needs was conducted among general practice residents at West China Hospital, Sichuan University. Patient characteristics and preceptors' feedback on the residents' performance were also analyzed. RESULTS: The study involved 109 residents (30.28% men) and 161 patients (34.78% men; age: 52.63 ± 15.87 years). Residents reported an overall satisfaction score of 4.28 ± 0.62 with the ambulatory teaching program. Notably, residents scored lower in the Subjective-Objective-Assessment-Plan (SOAP) evaluation when encountering patients with the greater the number of medical problems (P < 0.001). Residents encountering patients with a shorter duration of illness (< 3 months) achieved higher scores than those with longer illness durations (≥ 3 months, P = 0.044). Residency general practitioners (GPs) were most challenged by applying appropriate and effective patient referrals (43/109; 39.45%). GPs expressed a strong desire to learn how to make decisions when facing challenging patient situations (4.51 ± 0.63). CONCLUSION: This study suggests selecting patients with multiple comorbidities for ambulatory teaching and enhancing training on practical problem-solving abilities for GPs. The findings provide insights for the development of future ambulatory teaching programs.

[Oral sedation in pediatric outpatient dentistry]. / Primenenie peroral'noi sedatsii pri ambulatornom stomatologicheskom vmeshatel'stve u detei.

THE AIM OF THE STUDY: Was to improve the quality of treatment in pediatric outpatient dentistry with the effective use of oral sedation. MATERIALS AND METHODS: The study comprised 60 children aged 3-12 years who were undergoing therapeutic/surgical dental treatment. All children's somatic state was assessed as ASAI-II. All children met a number of psychological, anamnestic and procedural criteria. Midazolam and chloropyramine in a dose calculated for the patient's body weight were used as components of oral sedation. The estimated sedation depth was Ramsay II-III. The study included an analysis of objective (the time of comfortable treatment, the amount of treated or removed teeth per visit, the possibility of treatment without anesthesia during further visits) and subjective (the possibility of contact with the child during treatment, behavioral reactions at home and on further visits) criteria. Negative behavioral reactions and dental effects were also assessed. RESULTS: The treatment features correlated with the age category and gender of the patient. In the older age group of 7-12 years, the amount of comfortable treatment time was higher, the possibility of contact with the child reached 100% (which is twice as much as in the younger one), and also a larger number of patients were treated during further visits without an anesthetic aid. At the same time, in the younger age group of 3-6 years, the volume of treatment per visit was higher, since it takes less time to treat a primary tooth than for a permanent one. Side effects (visual hallucinations, diplopia, hyperactivity, tearfulness and aggressiveness) were more often recorded in the younger age group, but emotional instability was equally manifested in both groups. CONCLUSION: In order to maximize the effectiveness of using oral sedation as a method, it is necessary to take into account the duration and traumatism of the proposed procedure, the peculiarities of age psychology and the peculiarities of the psychological development of boys and girls.

Morbidity profile and pharmaceutical management of adult outpatients between primary and tertiary care levels in Sri Lanka: a dual-centre, comparative study.

BACKGROUND: Outpatient care is central to both primary and tertiary levels in a health system. However, evidence is limited on outpatient differences between these levels, especially in South Asia. This study aimed to describe and compare the morbidity profile (presenting morbidities, comorbidities, multimorbidity) and pharmaceutical management (patterns, indicators) of adult outpatients between a primary and tertiary care outpatient department (OPD) in Sri Lanka. METHODS: A comparative study was conducted by recruiting 737 adult outpatients visiting a primary care and a tertiary care facility in the Kandy district. A self-administered questionnaire and a data sheet were used to collect outpatient and prescription data. Following standard categorisations, Chi-square tests and Mann‒Whitney U tests were employed for comparisons. RESULTS: Outpatient cohorts were predominated by females and middle-aged individuals. The median duration of presenting symptoms was higher in tertiary care OPD (10 days, interquartile range: 57) than in primary care (3 days, interquartile range: 12). The most common systemic complaint in primary care OPD was respiratory symptoms (32.4%), whereas it was dermatological symptoms (30.2%) in tertiary care. The self-reported prevalence of noncommunicable diseases (NCDs) was 37.9% (95% CI: 33.2-42.8) in tertiary care OPD and 33.2% (95% CI: 28.5-38.3) in primary care; individual disease differences were significant only for diabetes (19.7% vs. 12.8%). The multimorbidity in tertiary care OPD was 19.0% (95% CI: 15.3-23.1), while it was 15.9% (95% CI: 12.4-20.0) in primary care. Medicines per encounter at primary care OPD (3.86, 95% CI: 3.73-3.99) was higher than that at tertiary care (3.47, 95% CI: 3.31-3.63). Medicines per encounter were highest for constitutional and respiratory symptoms in both settings. Overall prescribing of corticosteroids (62.7%), vitamin supplements (45.8%), anti-allergic (55.3%) and anti-asthmatic (31.3%) drugs was higher in the primary care OPD, and the two former drugs did not match the morbidity profile. The proportion of antibiotics prescribed did not differ significantly between OPDs. Subgroup analyses of drug categories by morbidity largely followed these overall differences. CONCLUSIONS: The morbidities between primary and tertiary care OPDs differed in duration and type but not in terms of multimorbidity or most comorbidities. Pharmaceutical management also varied in terms of medicines per encounter and prescribed categories. This evidence supports planning in healthcare and provides directions for future research in primary care.