The American Academy of Pediatrics views retail-based clinics (RBCs) as an inappropriate source of primary care for pediatric patients, as they fragment medical care and are detrimental to the ...medical home concept of longitudinal and coordinated care. This statement updates the original 2006 American Academy of Pediatrics statement on RBCs, which flatly opposed these sites as appropriate for pediatric care, discussing the shift in RBC focus and comparing attributes of RBCs with those of the pediatric medical home.
Use of commercial direct-to-consumer (DTC) telemedicine outside of the pediatric medical home is increasing among children, and acute respiratory infections (ARIs) are the most commonly diagnosed ...condition at DTC telemedicine visits. Our objective was to compare the quality of antibiotic prescribing for ARIs among children across 3 settings: DTC telemedicine, urgent care, and the primary care provider (PCP) office.
In a retrospective cohort study using 2015-2016 claims data from a large national commercial health plan, we identified ARI visits by children (0-17 years old), excluding visits with comorbidities that could affect antibiotic decisions. Visits were matched on age, sex, chronic medical complexity, state, rurality, health plan type, and ARI diagnosis category. Within the matched sample, we compared the percentage of ARI visits with any antibiotic prescribing and the percentage of ARI visits with guideline-concordant antibiotic management.
There were 4604 DTC telemedicine, 38 408 urgent care, and 485 201 PCP visits for ARIs in the matched sample. Antibiotic prescribing was higher for DTC telemedicine visits than for other settings (52% of DTC telemedicine visits versus 42% urgent care and 31% PCP visits;
< .001 for both comparisons). Guideline-concordant antibiotic management was lower at DTC telemedicine visits than at other settings (59% of DTC telemedicine visits versus 67% urgent care and 78% PCP visits;
< .001 for both comparisons).
At DTC telemedicine visits, children with ARIs were more likely to receive antibiotics and less likely to receive guideline-concordant antibiotic management compared to children at PCP visits and urgent care visits.
Background
An international panel achieved consensus on 9 need-based and 2 time-based major referral criteria to identify patients appropriate for outpatient palliative care referral. To better ...understand the operational characteristics of these criteria, we examined the proportion and timing of patients who met these referral criteria at our Supportive Care Clinic.
Methods
We retrieved data on consecutive patients with advanced cancer who were referred to our Supportive Care Clinic between January 1, 2016, and February 18, 2016. We examined the proportion of patients who met each major criteria and its timing.
Results
Among 200 patients (mean age 60, 53% female), the median overall survival from outpatient palliative care referral was 14 (95% confidence interval 9.2, 17.5) months. A majority (
n
= 170, 85%) of patients met at least 1 major criteria; specifically, 28%, 30%, 20%, and 8% met 1, 2, 3, and ≥ 4 criteria, respectively. The most commonly met need-based criteria were severe physical symptoms (
n
= 140, 70%), emotional symptoms (
n
= 36, 18%), decision-making needs (
n
= 26, 13%), and brain/leptomeningeal metastases (
n
= 25, 13%). For time-based criteria, 54 (27%) were referred within 3 months of diagnosis of advanced cancer and 63 (32%) after progression from ≥ 2 lines of palliative systemic therapy. The median duration from patient first meeting any criterion to palliative care referral was 2.4 (interquartile range 0.1, 8.6) months.
Conclusions
Patients were referred early to our palliative care clinic and a vast majority (85%) of them met at least one major criteria. Standardized referral based on these criteria may facilitate even earlier referral.
Abstract
This study provides data on the feasibility and impact of video-enabled telemedicine use among patients and providers and its impact on urgent and nonurgent healthcare delivery from one ...large health system (NYU Langone Health) at the epicenter of the coronavirus disease 2019 (COVID-19) outbreak in the United States. Between March 2nd and April 14th 2020, telemedicine visits increased from 102.4 daily to 801.6 daily. (683% increase) in urgent care after the system-wide expansion of virtual urgent care staff in response to COVID-19. Of all virtual visits post expansion, 56.2% and 17.6% urgent and nonurgent visits, respectively, were COVID-19–related. Telemedicine usage was highest by patients 20 to 44 years of age, particularly for urgent care. The COVID-19 pandemic has driven rapid expansion of telemedicine use for urgent care and nonurgent care visits beyond baseline periods. This reflects an important change in telemedicine that other institutions facing the COVID-19 pandemic should anticipate.
Effectively navigating and executing change within a medical organization, particularly a large health care enterprise, such as a department of surgery within a major hospital system, can present a ...major challenge to both departmental and institutional leadership. In developing projects designed to bring about desired change, it is essential to be mindful of the strategic plan of the institution and department and to design change initiatives to create models that align with and serve to enhance both the institutional and departmental missions. Doing so requires careful definition of the mission and vision of the department and the key stakeholders within the institution; defining both short- and long-term goals; critical analysis of resources, needs, strengths, and weaknesses; and maintaining a clear understanding of the goals, expectations, and specific measures of success. A careful project design process should then follow before implementation. In the following paragraphs, some of the key considerations and challenges of this process are explored in the particular context of developing clinics and clinical services in such a manner that the departmental and institutional missions are well-supported and advanced.
Objective
To explore using the Patient Activation Measure (PAM) for identifying patients more likely to have ambulatory care–sensitive (ACS) utilization and future increases in chronic disease.
Data ...Sources
Secondary data are extracted from the electronic health record of a large accountable care organization.
Study Design
This is a retrospective cohort design. The key predictor variable, PAM score, is measured in 2011, and is used to predict outcomes in 2012–2014. Outcomes include ACS utilization and the likelihood of a new chronic disease.
Data
Our sample of 98,142 adult patients was drawn from primary care clinic users. To be included, patients had to have a PAM score in 2011 and at least one clinic visit in each of the three subsequent years.
Principal Findings
PAM level is a significant predictor of ACS utilization. Less activated patients had significantly higher odds of ACS utilization compared to those with high PAM scores. Similarly, patients with low PAM scores were more likely to have a new chronic disease diagnosis over each of the years of observation.
Conclusions
Assessing patient activation may help to identify patients who could benefit from greater support. Such an approach may help ACOs reach population health management goals.
•Patients, when asked if they would complete another telemedicine encounter again, 92.9% (278/299) of patients reported they would.•Physicians reported high satisfaction, and that 78.4% of the time a ...telemedicine encounter was successful in replacing an in-person visit.•During our study period, over 600 telemedicine encounters were performed with extremely favourable ratings from patients and physicians.
Telemedicine provides a safe and effective means for the delivery of care by physicians amongst many subspecialties. Historically, orthopaedic practices in the United States have not widely utilized telemedicine for the delivery of orthopaedic care. As technology improves the adoption and utilization of telemedicine will likely grow, especially in light of the novel coronavirus (COVID-19) pandemic. Our study aims to assess patient and surgeon satisfaction and efficacy of telemedicine during a rapid adoption due to the global pandemic.
All patients who completed a telemedicine encounter (telephone or video) with an orthopaedic surgeon were contacted. Patients were individually contacted after their visit, and a standardized validated post-visit satisfaction survey was completed. Orthopaedic surgeons completed a standardized post-encounter survey after each visit. Pre-COVID-19 patient satisfaction data was used for comparison.
Orthopaedic surgeons completed 612 telehealth encounters either via phone or video consultation between April 6, 2020 and May 22, 2020. 95% of patients rated both surgeon sensitivity to their needs and response to their concerns as ‘good’ or ‘very good.’ 93% of patients reported they would participate in a telemedicine encounter again. Surgeons reported high satisfaction with telemedicine encounters (80%, 86% phone and video respectively), and that 78.4% of the time a telemedicine encounter was successful in replacing an in-person visit.
Patients and orthopaedic surgeons documented high levels of satisfaction with telehealth encounters during the novel coronavirus (COVID-19) pandemic. Telemedicine does not appear to be a replacement for all in-person clinic encounters, however, when used in the appropriate context demonstrated favourable results.
Level 4 Study.
The study analyzes the relationship between the risk of a hospitalization for an ambulatory care sensitive condition (ACSC), and the primary care payment and the organizational model used by the ...patient (fee-for-service, enhanced fee-for-service, blended capitation, blended capitation with interdisciplinary teams). The study used linked patient-level health administrative databases and census data housed at the Institute for Clinical Evaluative Sciences in Ontario. Since the province provides universal health care, the data capture all patients in Ontario, Canada's most populous province, with about 13 million inhabitants. All Ontario patients diagnosed with an ACSC prior to April 1, 2012, who had at least one visit with a physician between April 1, 2012, and March 31, 2013, were included in the study (n = 1,710,310). Each patient was assigned to the primary care model of his/her physician. The different models were categorized as Fee-for-Service (FFS), enhanced-FFS, blended capitation, and interdisciplinary team. A logistic regression was used to model the risk of having an ACSC hospitalization during the one-year observation period. Adjustments were made for patient characteristics (age, sex, health status, and socio-economic status) and for the geographic location of the practice. Using patients belonging to FFS models as the reference group, the risk of an ACSC hospitalization was higher for patients belonging to the blended-capitation model using interdisciplinary teams (Adjusted Odds Ratio AOR = 1.06, 95% confidence interval CI = 1.00–1.12) and lower for enhanced-FFS (AOR = 0.78, CI = 0.74–0.82) and blended capitation patients (AOR = 0.91, CI = 0.86–0.96). Using patients with hypertension as the reference group, the odds of an ACSC hospitalization were much higher for patients with any other ACSC and increased with patients' morbidity. The risk was lower for patients of higher socio-economic status (AOR = 0.63, CI = 0.60–0.67) in the highest neighborhood income quintile.
•Risk of ACSC hospitalization varies by model of payment to primary care physician.•Blended capitation payment associated with lower risk of ACSC hospitalization.•Enhanced-fee-for-service payment associated with lower risk of ACSC hospitalization.•Higher risk of hospitalization for patients in interdisciplinary primary care teams.•Neighborhood income negatively associated with ACSC hospitalizations.
A treatment gap exists between heart failure (HF) guidelines and the clinical care of patients. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting ...(IMPROVE HF) prospectively tested a multidimensional practice-specific performance improvement intervention on the use of guideline-recommended therapies for HF in outpatient cardiology practices.
Performance data were collected in a random sample of HF patients from 167 US outpatient cardiology practices at baseline, longitudinally after intervention at 12 and 24 months, and in single-point-in-time patient cohorts at 6 and 18 months. Participants included 34 810 patients with reduced left ventricular ejection fraction (< or =35%) and chronic HF or previous myocardial infarction. To quantify guideline adherence, 7 quality measures were assessed. Interventions included clinical decision support tools, structured improvement strategies, and chart audits with feedback. The performance improvement intervention resulted in significant improvements in 5 of 7 quality measures at the 24-month assessment compared with baseline: beta-blocker (92.2% versus 86.0%, +6.2%), aldosterone antagonist (60.3% versus 34.5%, +25.1%), cardiac resynchronization therapy (66.3% versus 37.2%, +29.9%), implantable cardioverter-defibrillator (77.5% versus 50.1%, +27.4%), and HF education (72.1% versus 59.5%, +12.6%) (each P<0.001). There were no statistically significant improvements in angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use or anticoagulation for atrial fibrillation. Sensitivity analyses at the patient level and limited to patients with both baseline and 24-month quality measure data yielded similar results. Improvements in the single-point-in-time cohorts were smaller, and there were no concurrent control practices.
The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting, a defined and scalable practice-specific performance improvement intervention, was associated with substantial improvements in the use of guideline-recommended therapies in eligible patients with HF in outpatient cardiology practices.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00303979.
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