BACKGROUND
Disparities in healthcare access and delivery, caused by transportation and health workforce difficulties, negatively impact individuals living in rural areas. These challenges are ...especially prominent in older adults.
DESIGN
We systematically evaluated the feasibility, acceptability, and effectiveness in providing telemedicine (TMed), searching the English‐language literature for studies (January 2012 to July 2018) in the following databases: Medline (PubMed); Cochrane Library (Wiley); Web of Science; CINAHL; EMBASE (Ovid); and PsycINFO (EBSCO).
PARTICIPANTS
Older adults (mean age = 65 years or older, and none were younger than 60 years).
INTERVENTIONS
Interventions consisted of live, synchronous, two‐way videoconferencing communication in nonhospital settings. All medical interventions were included.
MEASUREMENTS
Quality assessment, using the Cochrane Collaboration's Risk‐of‐Bias Tool, was applied on all included articles, including a qualitative summary of all articles.
RESULTS
Of 6616 citations, we reviewed the full text of 1173 articles, excluding 1047 that did not meet criteria. Of the 17 randomized controlled trials, the United States was the country with the most trials (6 35%), with cohort sizes ranging from 3 to 844 (median = 35) participants. Risk of bias among included studies varied from low to high. Our qualitative analysis suggests that TMed can improve health outcomes in older adults and that it could be used in this population.
CONCLUSIONS
TMed is feasible and acceptable in delivering care to older adults. Research should focus on well‐designed randomized trials to overcome the high degree of bias observed in our synthesis. Clinicians should consider using TMed in routine practice to overcome barriers of distance and access to care. J Am Geriatr Soc 67:1737–1749, 2019
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.
Systemic corticosteroids are commonly used in treating severe COVID-19. However, the role of inhaled corticosteroids in the treatment of patients with mild to moderate disease is less clear.
To ...determine the efficacy of the inhaled steroid ciclesonide in reducing the time to alleviation of all COVID-19-related symptoms among nonhospitalized participants with symptomatic COVID-19 infection.
This phase 3, multicenter, double-blind, randomized clinical trial was conducted at 10 centers throughout the US and assessed the safety and efficacy of a ciclesonide metered-dose inhaler (MDI) for treating nonhospitalized participants with symptomatic COVID-19 infection who were screened from June 11, 2020, to November 3, 2020.
Participants were randomly assigned to receive ciclesonide MDI, 160 μg per actuation, for a total of 2 actuations twice a day (total daily dose, 640 μg) or placebo for 30 days.
The primary end point was time to alleviation of all COVID-19-related symptoms (cough, dyspnea, chills, feeling feverish, repeated shaking with chills, muscle pain, headache, sore throat, and new loss of taste or smell) by day 30. Secondary end points included subsequent emergency department visits or hospital admissions for reasons attributable to COVID-19.
A total of 413 participants were screened and 400 (96.9%) were enrolled and randomized (197 49.3% in the ciclesonide arm and 203 50.7% in the placebo arm; mean SD age, 43.3 16.9 years; 221 55.3% female; 2 0.5% Asian, 47 11.8% Black or African American, 3 0.8% Native Hawaiian or other Pacific Islander, 345 86.3% White, and 1 multiracial individuals 0.3%; 172 Hispanic or Latino individuals 43.0%). The median time to alleviation of all COVID-19-related symptoms was 19.0 days (95% CI, 14.0-21.0) in the ciclesonide arm and 19.0 days (95% CI, 16.0-23.0) in the placebo arm. There was no difference in resolution of all symptoms by day 30 (odds ratio, 1.28; 95% CI, 0.84-1.97). Participants who were treated with ciclesonide had fewer subsequent emergency department visits or hospital admissions for reasons related to COVID-19 (odds ratio, 0.18; 95% CI, 0.04-0.85). No participants died during the study.
The results of this randomized clinical trial demonstrated that ciclesonide did not achieve the primary efficacy end point of reduced time to alleviation of all COVID-19-related symptoms.
ClinicalTrials.gov Identifier: NCT04377711.
To determine if a structured transition program for young adults with type 1 diabetes improves clinic attendance, glycemic control, diabetes-related distress, quality of life, and satisfaction with ...care.
In this multicenter randomized controlled trial, young adults (17-20 years) with type 1 diabetes were randomly assigned to a transition program with a transition coordinator or to standard care. The intervention lasted 18 months (6 in pediatric and 12 in adult care). The primary outcome was the proportion of participants who failed to attend at least one adult diabetes clinic visit during the 12-month follow-up after completion of the intervention.
We randomized 205 participants, 104 to the transition program and 101 to standard care. Clinic attendance was improved in the transition program (mean SD number of visits 4.1 1.1 vs. 3.6 1.2,
= 0.002), and there was greater satisfaction with care (mean SD score 29.0 2.7 vs. 27.9 3.4,
= 0.032) and less diabetes-related distress (mean SD score 1.9 0.8 vs. 2.1 0.8,
= 0.049) reported than in standard care. There was a trend toward improvement in mean HbA
(8.33% 68 mmol/mol vs. 8.80% 73 mmol/mol,
= 0.057). During the 12-month follow-up, there was no difference in those failing to attend at least one clinic visit (
= 0.846), and the mean change in HbA
did not differ between the groups (
= 0.073). At completion of follow-up, the groups did not differ with respect to satisfaction with care or diabetes-related distress and quality of life.
Transition support during this 18-month intervention was associated with increased clinic attendance, improved satisfaction with care, and decreased diabetes-related distress, but these benefits were not sustained 12 months after completion of the intervention.
Children who are placed in out-of-home care may have poorer outcomes in adulthood, on average, compared with their peers, but the direction and magnitude of these associations need clarification.
To ...estimate associations between being placed in out-of-home care in childhood and adolescence and subsequent risks of experiencing a wide range of social and health outcomes in adulthood following comprehensive adjustments for preplacement factors.
This cohort and cosibling study of all children born in Finland between 1986 and 2000 (N = 855 622) monitored each person from their 15th birthday either until the end of the study period (December 2018) or until they migrated, died, or experienced the outcome of interest. Cox and Poisson regression models were used to estimate associations with adjustment for measured confounders (from linked population registers) and unmeasured familial confounders (using sibling comparisons). Data were analyzed from October 2020 to August 2021.
Placement in out-of-home care up to age 15 years.
Through national population, patient, prescription drug, cause of death, and crime registers, 16 specific outcomes were identified across the following categories: psychiatric disorders; low socioeconomic status; injuries and experiencing violence; and antisocial behaviors, suicidality, and premature mortality.
A total of 30 127 individuals (3.4%) were identified who had been placed in out-of-home care for a median (interquartile range) period of 1.3 (0.2-5.1) years and 2 (1-3) placement episodes before age 15 years. Compared with their siblings, individuals who had been placed in out-of-home care were 1.4 to 5 times more likely to experience adverse outcomes in adulthood (adjusted hazard ratio aHR for those with a fall-related injury, 1.40; 95% CI, 1.25-1.57 and aHR for those with an unintentional poisoning injury, 4.79; 95% CI, 3.56-6.43, respectively). The highest relative risks were observed for those with violent crime arrests (aHR, 4.16; 95% CI, 3.74-4.62; cumulative incidence, 24.6% in individuals who had been placed in out-of-home care vs 5.1% in those who had not), substance misuse (aHR, 4.75; 95% CI, 4.25-5.30; cumulative incidence, 23.2% vs 4.6%), and unintentional poisoning injury (aHR 4.79; 95% CI, 3.56-6.43; cumulative incidence, 3.1% vs 0.6%). Additional adjustments for perinatal factors, childhood behavioral problems, and traumatic injuries, including experiencing violence, did not materially change the findings.
Out-of-home care placement was associated with a wide range of adverse outcomes in adulthood, which persisted following adjustments for measured preplacement factors and unmeasured familial factors.
Art is integrated into the Mayo Clinic environment. Since the original Mayo Clinic Building was finished in 1914, many pieces have been donated or commissioned for patients and staff to enjoy. Each ...issue of Mayo Clinic Proceedings features a work of art (as interpreted by the author) that is displayed in a building or on the grounds of Mayo Clinic campuses.
The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were ...compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.
Diagnostic errors are an understudied aspect of ambulatory patient safety.
To determine the types of diseases missed and the diagnostic processes involved in cases of confirmed diagnostic errors in ...primary care settings and to determine whether record reviews could shed light on potential contributory factors to inform future interventions.
We reviewed medical records of diagnostic errors detected at 2 sites through electronic health record-based triggers. Triggers were based on patterns of patients' unexpected return visits after an initial primary care index visit.
A large urban Veterans Affairs facility and a large integrated private health care system.
Our study focused on 190 unique instances of diagnostic errors detected in primary care visits between October 1, 2006, and September 30, 2007.
Through medical record reviews, we collected data on presenting symptoms at the index visit, types of diagnoses missed, process breakdowns, potential contributory factors, and potential for harm from errors.
In 190 cases, a total of 68 unique diagnoses were missed. Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) being most common. Process breakdowns most frequently involved the patient-practitioner clinical encounter (78.9%) but were also related to referrals (19.5%), patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%). A total of 43.7% of cases involved more than one of these processes. Patient-practitioner encounter breakdowns were primarily related to problems with history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further workup (57.4%). Most errors were associated with potential for moderate to severe harm.
Diagnostic errors identified in our study involved a large variety of common diseases and had significant potential for harm. Most errors were related to process breakdowns in the patient-practitioner clinical encounter. Preventive interventions should target common contributory factors across diagnoses, especially those that involve data gathering and synthesis in the patient-practitioner encounter.
As the urgent care landscape evolves, specialized musculoskeletal urgent care centers (MUCCs) are becoming more prevalent. MUCCs have been offered as a convenient, cost-effective option for timely ...acute orthopaedic care. However, a recent "secret-shopper" study on patient access to MUCCs in Connecticut demonstrated that patients with Medicaid had limited access to these orthopaedic-specific urgent care centers. To investigate how generalizable these regional findings are to the United States, we conducted a nationwide secret-shopper study of MUCCs to identify determinants of patient access.
(1) What proportion of MUCCs in the United States provide access for patients with Medicaid insurance? (2) What factors are associated with MUCCs providing access for patients with Medicaid insurance? (3) What barriers exist for patients seeking care at MUCCs?
An online search of all MUCCs across the United States was conducted in this cross-sectional study. Three separate search modalities were used to gather a complete list. Of the 565 identified, 558 were contacted by phone with investigators posing over the telephone as simulated patients seeking treatment for a sprained ankle. Thirty-nine percent (216 of 558) of centers were located in the South, 13% (71 of 558) in the West, 25% (138 of 558) in the Midwest, and 24% (133 of 558) in New England. This study was given an exemption waiver by our institution's IRB. MUCCs were contacted using a standardized script to assess acceptance of Medicaid insurance and identify barriers to care. Question 1 was answered through determining the percentage of MUCCs that accepted Medicaid insurance. Question 2 considered whether there was an association between Medicaid acceptance and factors such as Medicaid physician reimbursements or MUCC center type. Question 3 sought to characterize the prevalence of any other means of limiting access for Medicaid patients, including requiring a referral for a visit and disallowing continuity of care at that MUCC.
Of the MUCCs contacted, 58% (323 of 558) accepted Medicaid insurance. In 16 states, the proportion of MUCCs that accepted Medicaid was equal to or less than 50%. In 22 states, all MUCCs surveyed accepted Medicaid insurance. Academic-affiliated MUCCs accepted Medicaid patients at a higher proportion than centers owned by private practices (odds ratio 14 95% CI 4.2 to 44; p < 0.001). States with higher Medicaid physician reimbursements saw proportional increases in the percentage of MUCCs that accepted Medicaid insurance under multivariable analysis (OR 36 95% CI 14 to 99; p < 0.001). Barriers to care for Medicaid patients characterized included location restriction and primary care physician referral requirements.
It is clear that musculoskeletal urgent care at these centers is inaccessible to a large segment of the Medicaid-insured population. This inaccessibility seems to be related to state Medicaid physician fee schedules and a center's affiliation with a private orthopaedic practice, indicating how underlying financial pressures influence private practice policies. Ultimately, the refusal of Medicaid by MUCCs may lead to disparities in which patients with private insurance are cared for at MUCCs, while those with Medicaid may experience delays in care. Going forward, there are three main options to tackle this issue: increasing Medicaid physician reimbursement to provide a financial incentive, establishing stricter standards for MUCCs to operate at the state level, or streamlining administration to reduce costs overall. Further research will be necessary to evaluate which policy intervention will be most effective.
Level II, prognostic study.
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