Comparison of Virtual Management of Vulvovaginal Candidiasis to Traditional In-Person Care.

Objective: Compare demographics, treatment, and follow-up rates for patients with complaints of vulvovaginitis suggestive of candida infection evaluated via e-visit, face-to-face (F2F) visits, or nurse-administered phone protocol. Methods: Manual review of 150 vaginitis visits of each visit type (e-visit, F2F, and phone protocol) completed between May 5, 2018 through January 31, 2020 by Mayo Clinic patients residing in Minnesota. Outcomes: Comparison between the three visit types of patient characteristics, treatment rates, type of treatment, follow-up rates, and types of follow-up. Results: Patients utilizing phone visits were significantly older than those seeking care via e-visit (p < 0.0001) or F2F (p = 0.001) and were more likely to be treated with oral fluconazole than those treated by e-visit (p < 0.0001) or F2F (p < 0.0001) encounters. Patients were significantly less likely to receive fungal directed treatment at a F2F visit than an e-visit (p < 0.0001) or phone encounter (p < 0.0001). There was no significant difference in follow-up rates between the three groups. Conclusion: Virtual visits (non-F2F) for suspected vulvovaginal candidiasis are unlikely to result in more follow-up visits than F2F encounters; however, prescriptions for antifungals are significantly higher with virtual visits.

Portal Message Language Use Prior to Suicide, Suicide Attempts, and Hospitalization for Depression.

Introduction: Previous research suggests patients may be willing to communicate serious psychiatric concerns through patient portals. Methods: Retrospective chart review of portal messages sent by patients who had an emergency department (ED) visit or hospitalization for depression, self-harm, or suicidality or had a completed suicide (cases) was reviewed for content that was suggestive of depression or self-harm and language indicating emotional distress. Comparison with a randomly selected group (controls) was performed. Results: During the study period 420 messages were sent by 149 patients within 30 days of death by suicide, ED visit, and/or hospitalization related to depression, suicidality, or suicide attempt. Thirteen patients died by suicide but only 23% (3 of 13) sent one or more portal messages within 30 days before their death. None mentioned thoughts of self-harm. There were 271 messages sent by patients who were hospitalized, 142 messages by those who presented to the ED, and 56 messages patients who attempted suicide. Patient messages from cases were more likely than messages from controls to convey a depressed mood (17.1% vs. 3.1%, odds ratio 6.5; 95% confidence interval 3.6-11.9, p < 0.0001), thoughts of suicide or self-harm (4.8% vs. 0% p < 0.0001), or have a distressed tone (24.0% vs. 1.7%, odds ratio 18.7; 95% confidence interval 8.6-41, p < 0.0001). Conclusions: Patient portal messages from patients with subsequent hospitalizations for depression and suicidality do report thoughts of depression, distress, and thoughts of self-harm. However, portal use before completed suicide was not helpful at identifying at-risk patients although total numbers were small.

Use of the McIsaac Score to Predict Group A Streptococcal Pharyngitis in Outpatient Nurse Phone Triage and Electronic Visits Compared With In-Person Visits: Retrospective Observational Study.

BACKGROUND: The McIsaac criteria are a validated scoring system used to determine the likelihood of an acute sore throat being caused by group A streptococcus (GAS) to stratify patients who need strep testing. OBJECTIVE: We aim to compare McIsaac criteria obtained during face-to-face (f2f) and non-f2f encounters. METHODS: This retrospective study compared the percentage of positive GAS tests by McIsaac score for scores calculated during nurse protocol phone encounters, e-visits (electronic visits), and in person f2f clinic visits. RESULTS: There was no difference in percentages of positive strep tests between encounter types for any of the McIsaac scores. There were significantly more phone and e-visit encounters with any missing score components compared with f2f visits. For individual score components, there were significantly fewer e-visits missing fever and cough information compared with phone encounters and f2f encounters. F2f encounters were significantly less likely to be missing descriptions of tonsils and lymphadenopathy compared with phone and e-visit encounters. McIsaac scores of 4 had positive GAS rates of 55% to 68% across encounter types. There were 4 encounters not missing any score components with a McIsaac score of 0. None of these 4 encounters had a positive GAS test. CONCLUSIONS: McIsaac scores of 4 collected during non-f2f care could be used to consider empiric treatment for GAS without testing if significant barriers to testing exist such as the COVID-19 pandemic or geographic barriers. Future studies should evaluate further whether non-f2f encounters with McIsaac scores of 0 can be safely excluded from GAS testing.

Management of Acute Sinusitis via e-Visit.

Background: Acute sinusitis is the most common diagnosis in online health care delivery and is the diagnosis most associated with antibiotic prescriptions in the outpatient setting. Few studies have evaluated the effectiveness of managing sinusitis through e-visit in terms of antibiotic prescribing and follow-up rates. Introduction: The purpose of this study was to investigate whether e-visits for the management of acute sinusitis have equivalent clinical outcomes for patients when compared with face-to-face (F2F) visits and nurse-administered phone protocols in terms of antibiotic prescriptions and follow-up rates. Materials and Methods: A retrospective chart review was conducted on empaneled primary care patients between the ages of 18 and 75 years who had a clinical encounter for acute sinusitis at Mayo Clinic Rochester through e-visit, retail health clinic, or phone protocol. Initial antibiotic prescribing rates and follow-up rates for each encounter type were compared. Results: Both e-visit and phone protocol sinusitis encounters were less likely to result in initial treatment with an antibiotic than an F2F visit (84/150 [56%] e-visit, 92/150 [61%] phone, 108/150 [72%]; p = 0.01). There was no significant difference in follow-up rate between e-visits and F2F (27/150 [18%] vs. 21/150 [14%]; p = 0.34), and e-visits had significantly fewer follow-up visits than phone protocol (27/150 [18%] vs. 53/150 [35%]; p < 0.001). Conclusions: e-Visits are an effective modality to care for patients with acute sinusitis, offering equivalent or lower treatment and follow-up rates than more traditional avenues such as F2F visit at a retail clinic and phone protocol.

Frequency of and Factors Associated with Care Partner Proxy Interaction with Health Care Teams Using Patient Portal Accounts.

Introduction: Proxies can communicate with health care teams through patient portals either by using proxy login credentials or a patient's login credentials. The frequency of proxies using patient login credentials is unknown. Methods: A random selection of 3,000 portal messages sent in through adult patients' own portal account was reviewed for indicators (referring to the patient in the third person) that someone other than the patient was using the patient portal account. Results: Of the reviewed 3,000 portal messages sent through patient portal accounts, 221 (7.4%) appeared to be sent in by a proxy, 2,512 (83.8%) appeared to have been sent in by the patient and for 266 (8.9%) portal messages reviewed it was unclear who sent in the message. There was no difference in mean age between patients who had proxy messages sent through patient portal accounts versus proxy portal accounts. Patients who had proxies send messages through patient accounts were more likely to be married and male. Out of 221 manually reviewed messages apparently sent by proxies through patient portal accounts there were 113 (51%) where the proxy included their name and 56 (25.3%) where they reported their relationship to the patient. During the study period, 0.7% of total messages on adult patients were sent through proxy accounts. Discussion: Proxies appear to use patient portal accounts much more frequently than proxy accounts to communicate with the health care team on adult patients; however, when using patient accounts they only identify themselves approximately half of the time.

Comparison of eVisit Management of Urinary Symptoms and Urinary Tract Infections with Standard Care.

Background: Urinary symptoms and urinary tract infections (UTIs) are common complaints for which women seek health care. Evolving modalities of care delivery have shifted management of these complaints from in-person face-to-face (F2F) visits, to nurse phone protocol management, and recently to online assessment via eVisit. While research has vetted the use of nurse phone protocol management, eVisit management outcomes have not been thoroughly studied. Purpose: To compare antibiotic prescribing, follow-up rates, and clinical outcomes between F2F visits at a retail clinic, nurse phone protocol encounters, and eVisits for the assessment and management of urinary symptoms and UTIs. Methods: A retrospective chart review of primary care empaneled patients at Mayo Clinic Rochester was conducted of females, 18 to 65 years old, who sought care for urinary symptoms via phone, eVisit, or F2F visit from August 1, 2016, through May 1, 2017. A total of 450 encounters, 150 from each of the 3 encounter types, were manually reviewed and compared for antibiotic prescribing rates, clinical outcomes, and 30-day follow-up rates. Results: Antibiotic prescribing rates for all three encounter types were similar. Referral for follow-up at initial encounter was more likely to be recommended from phone and eVisit encounters than F2F. No significant differences in follow-up rates or clinical outcomes were noted between the three encounter types. Conclusions: eVisits for urinary symptoms and UTI offer patients a convenient option for care without an increased use of antimicrobials, follow-up, or adverse clinical outcomes when compared with F2F visits or nurse-administered phone protocols.

Evaluating diverse electronic consultation programs with a common framework.

BACKGROUND: Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion. METHODS: Using a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 early adopter healthcare delivery systems (San Francisco Health Network, Mayo Clinic, Veterans Administration, Champlain Local Health Integration Network) that represent varied organizational structures, care for different patient populations, and have well-established multi-specialty electronic consultation programs. Data sources include published and unpublished quantitative data from each electronic consultation database and qualitative data from systems' end-users. RESULTS: Organizational drivers of electronic consultation implementation were similar across the systems (challenges with timely and/or efficient access to specialty care), though unique system-level facilitators and barriers influenced reach, adoption and design. Effectiveness of implementation was consistent, with improved patient access to timely, perceived high-quality specialty expertise with few negative consequences, garnering high satisfaction among end-users. Data about patient-specific clinical outcomes are lacking, as are policies that provide guidance on the legal implications of electronic consultation and ideal remuneration strategies. CONCLUSION: A core set of effectiveness and implementation metrics rooted in the Quadruple Aim may promote data-driven improvements and further diffusion of successful electronic consultation programs.

Electronic Visits for Minor Acute Illnesses: Analysis of Patient Demographics, Prescription Rates, and Follow-Up Care Within an Asynchronous Text-Based Online Visit.

INTRODUCTION: Patients can obtain medical advice and treatment from a healthcare provider asynchronously through an electronic visit (eVisit) within a secure online portal. METHODS: We conducted a retrospective record review of Mayo Clinic Rochester primary care empaneled patients who had an eVisit for a minor acute illness and were reviewed for 30-day outcomes of follow-up. RESULTS: Of the 1,009 eVisits analyzed, a total of 340 (34%) had follow-up within 30 days, with a follow-up rate of 154 (20%) when those who were advised to follow-up were excluded. Factors significantly associated with any type of follow-up care included specific advice for follow-up given by the eVisit provider and lack of a prescription given at the eVisit. The majority of eVisits were requested by females (88%), although gender was not associated with likelihood of having follow-up care. Fourteen patients received follow-up care in the emergency department, one patient was hospitalized, and zero deaths occurred within 30 days of the eVisit. Most eVisits (70%) were requested during regular clinic hours. Four diagnoses (urinary tract infection, sinusitis, upper respiratory infection, and conjunctivitis) comprised 87% of all eVisits. CONCLUSION: Most eVisits for minor acute illnesses can be completed without any further interaction with the healthcare system.

Recommendation endpoints and safety of an online self-triage for depression symptoms.

INTRODUCTION: Online symptom checkers are a way to address patient concerns and potentially offload a burdened healthcare system. However, safety outcomes of self-triage are unknown, so we reviewed triage recommendations and outcomes of our institution's depression symptom checker. METHODS: We examined endpoint recommendations and follow-up encounters seven days afterward during 2 December 2021 to 13 December 2022. Patients with an emergency department visit or hospitalization within seven days of self-triaging had a manual review of the electronic health record to determine if the visit was related to depression, suicidal ideation, or suicide attempt. Charts were reviewed for deaths within seven days of self-triage. RESULTS: There were 287 unique encounters from 263 unique patients. In 86.1% (247/287), the endpoint was an instruction to call nurse triage; in 3.1% of encounters (9/287), instruction was to seek emergency care. Only 20.2% (58/287) followed the recommendations given. Of the 229 patients that did not follow the endpoint recommendations, 121 (52.8%) had some type of follow-up within seven days. Nearly 11% (31/287) were triaged to endpoints not requiring urgent contact and 9.1% (26/287) to an endpoint that would not need any healthcare team input. No patients died in the study period. CONCLUSIONS: Most patients did not follow the recommendations for follow-up care although ultimately most patients did receive care within seven days. Self-triage appears to appropriately sort patients with depressed mood to emergency care. On-line self-triaging tools for depression have the potential to safely offload some work from clinic personnel.

Self-scheduling Medical Visits in a Multispecialty, Multisite Medical Practice: Complexity, Challenges, and Successes.

Background: Self-scheduling of medical visits is becoming more common but the complexity of applying multiple requirements for self-scheduling has hampered implementation. Mayo Clinic implemented self-scheduling in 2019 and has been increasing its portfolio of self-schedulable visits since then. Our aim was to show measures quantifying the complexity associated with medical visit scheduling and to describe how opportunities and challenges of scheduling complexity apply in self-scheduling. Methods: We examined scheduled visits from January 1, 2022, through August 24, 2023. For seven visit categories, we counted all unique visit types that were scheduled, for both staff-scheduled and self-scheduled. We examined counts of self-scheduled visit types to identify those with highest uptake during the study period. Results: There were 9555 unique visit types associated with 20.8 M (million) completed visits. Self-scheduled visit types accounted for 4.0% (838,592/20,769,699) of the completed total visits. Of seven visit categories, self-scheduled established patient visits, testing visits, and procedure visits accounted for 93.5% (784,375/838,592) of all self-scheduled visits. Established patient visits in primary care (10 visit types) accounted for 273,007 (32.6%) of all self-scheduled visits. Testing visits (blood and urine testing, 2 visit types) accounted for 183,870 (21.9%) of all self-scheduled visits. Procedure visits for screening mammograms, bone mineral density, and immunizations (8 visit types) accounted for 147,358 (17.6%) of all self-scheduled visits. Conclusion: Large numbers of unique visit types comprise a major challenge for self-scheduling. Some visit types are more suitable for self-scheduling. Guideline-based procedure visits such as screening mammograms, bone mineral density exams, and immunizations are examples of visits that have high volumes and can be standardized for self-scheduling. Established patient visits and laboratory testing visits also can be standardized for self-scheduling. Despite the successes, there remain thousands of specific visit types that may need some staff-scheduler intervention to properly schedule.

Self-scheduling in a Large Multispecialty and Multisite Clinic: A Retrospective, Longitudinal Examination of Multiple Self-Scheduled Visit Types.

Background: Self-scheduling of medical visits is becoming available at many medical institutions. We aimed to examine the self-scheduled visit counts and rate of growth of self-scheduled visits in a multispecialty practice. Methods: For 85 weeks extending from January 1, 2022 through August 24, 2023, we examined self-scheduled visit counts for over 1500 self-scheduled visit types. We compared completed self-scheduled visit counts to all scheduled completed visit counts for the same visit types. We collected counts of the most frequently self-scheduled visit types for each week and examined the change over time. We also determined the proportion that each visit type was self-scheduled. Results: There were 20,769 699 completed visits during the course of the study that met the criteria for inclusion. Self-scheduled visits accounted for 4.0% of all completed visits (838 592/20,769 699). Over the 85-week span, self-scheduled visits rose from 3.0% to 5.3% of the total. There were 1887 unique visit types that were associated with completed visits. There were just 6 appointment visit types of the total 1887 self-scheduled visit types that accounted for 50.7% of the total 838 592 self-scheduled visits. Those 6 visit types were a lab blood test visit (19.5%, 163 K visits), two Family Medicine office visit types (13.0%, 109 K visits), a screening mammogram visit type (6.6%, 55 K visits), a scheduled express care visit type (6%, 50 K visits) and a COVID immunization visit type (5.7%, 48 K visits). Twenty-one visit types that were self-scheduled accounted for 75% of the total self-scheduled visits. Four seasonal visits, accounting for 10.6% of the total self-scheduled visits, were responsible for almost all the non-linear change in self-scheduling. Conclusion: Self-scheduling accounted for a small but growing percent of all outpatient scheduled visits in a multispecialty, multisite practice. A wide range of visit types can be successfully self-scheduled.

Impact of telemonitoring on older adults health-related quality of life: the Tele-ERA study.

PURPOSE: Telemonitoring is being increasingly used for chronic disease monitoring. While the primary aim of telemonitoring is to improve chronic disease management and decrease hospitalizations, the potential impact on patient's health-related quality of life may be an additional benefit. METHODS: Two hundred and five patients aged 60 years and older with multiple medical conditions were enrolled in a one-year randomized controlled trial of daily home telemonitoring. Health-related quality of life was measured with the 12-Item Short-Form at the beginning and at the completion of the study. Per protocol analysis of the 166 patients responding to the follow-up survey was performed. RESULTS: Among the 166 responders, there were no significant differences at baseline in the physical component summary (PCS) scores (p value = 0.32), nor the mental component summary (MCS) scores (p value = 0.12) between the telemonitored group and the usual care group. There was also no difference in the 12-month PCS scores (p value = 0.39) or MCS scores (p value = 0.10) between groups. There was no difference in the change from baseline to 12-month MCS scores between groups (p value = 0.89); however, there was a significant difference in the baseline to 12-month change of PCS scores between groups, with the telemonitored group having a greater decrease in PCS scores (-4.3 ± 9.3), compared to the usual care group (-1.2 ± 8.5) over the course of the study (p value = 0.03). CONCLUSION: Home telemonitoring in older adults with multiple comorbidities does not significantly improve self-perception of mental well-being (as measured by MCS scores) and may worsen self-perception of physical health (as measured by PCS scores).

Application of a case-control design to the analysis of drop-outs from integrated behavioural health care.

BACKGROUND: Case-control designs are rarely employed in quality improvement investigations. The reason for the study was two-fold: (1) to demonstrate the feasibility of the method in a practice setting, and (2) because drop-outs from this programme had not previously been investigated. METHODS: Drop-out was defined as termination due to non-contact after two consecutive months. Fifty drop-outs were randomly selected from all cases discharged from the programme during the period 1 March 2008 to 28 February 2012. Fifty controls were randomly selected from among those discharged patients who did not drop out due to non-contact. RESULTS: Dropping out was significantly associated with female sex (P = 0.015), younger age (P = 0.000) and treatment site (P = 0.004). Sites still in the shake-down period had higher drop-out rates. Depression diagnosis and severity were not significant. CONCLUSIONS: The case-control design is an efficient approach to retrospective analysis of discrete quality indicators.

Emerging technologies to support independent living of older adults at risk.

The aging of the population is expected to place an unprecedented strain on health care systems over the next two decades and beyond. Emerging electronic monitoring technologies provide opportunities to learn about the aging process, age-related diseases, and contribute to new, cost effective care models that preserve independence at home for older adults at risk. The goals of this article are to familiarize the reader with emerging technologies and potential applications to older adults' at-risk, review the current literature about the clinical and economic outcomes of emerging technologies, and to outline future directions and challenges.

Hospitalization Risk Associated With Emergency Department Reasons for Visit and Patient Age: A Retrospective Evaluation of National Emergency Department Survey Data to Help Identify Potentially Avoidable Emergency Department Visits.

Background: Patients often present to emergency departments (EDs) with concerns that do not require emergency care. Self-triage and other interventions may help some patients decide whether they should be seen in the ED. Symptoms associated with low risk of hospitalization can be identified in national ED data and can inform the design of interventions to reduce avoidable ED visits. Methods: We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from the United States National Health Care Statistics (NHCS) division of the Centers for Disease Control and Prevention (CDC). The ED datasets from 2011 through 2020 were combined. Primary reasons for ED visit and the binary field for hospital admission from the ED were used to estimate the proportion of ED patients admitted to the hospital for each reason for visit and age category. Results: There were 221,027 surveyed ED visits during the 10-year data collection with 736 different primary reasons for visit and 23,228 hospitalizations. There were 145 million estimated hospitalizations from 1.37 billion estimated ED visits (10.6%). Inclusion criteria for this study were reasons for visit which had at least 30 ED visits in the sample; there were 396 separate reasons for visit which met this criteria. Of these 396 reasons for visit, 97 had admission percentages less than 2% and another 52 had hospital admissions estimated between 2% and 4%. However, there was a significant increase in hospitalizations within many of the ED reasons for visit in older adults. Conclusion: Reasons for visit from national ED data can be ranked by hospitalization risk. Low-risk symptoms may help healthcare institutions identify potentially avoidable ED visits. Healthcare systems can use this information to help manage potentially avoidable ED visits with interventions designed to apply to their patient population and healthcare access.

McIsaac score for group A streptococcal infection: Comparison of electronic visits versus face-to-face visits.

INTRODUCTION: Acute sore throat is a common complaint traditionally completed with an in-person visit. However, non-face-to-face telemedicine visits offer greater access at reduced cost. We evaluated patient/caregiver asynchronous text-based electronic visits (eVisits) for acute sore throat and whether there was concordance for individual components and total McIsaac score compared to a clinician's assessment. eVisits were completed by patients and/or their caregivers via a secure patient portal. METHODS: In this retrospective study, we manually reviewed charts between February 2017 and July 2019 of patients who had an eVisit, in-person visit and group A streptococcal (GAS) test performed on the same day for an acute sore throat. We calculated a McIsaac score for eVisits and in-person visits, and compared each component and total score using Cohen's kappa agreement statistic. RESULTS: There were 320 instances of patients who had an eVisit, in-person visit and GAS testing done on the same day. Approximately a third of eVisits were missing at least one McIsaac component, with the physical examination elements missing most commonly. Individual score congruence was moderate for cough (0.41), fair for fever (0.34) and slight for tonsillar swelling/exudate and lymphadenopathy (0.17 and 0.08, respectively), with total congruence being slight to fair (0.09-0.37). A McIsaac score of ≤1 showed moderate agreement (0.44). Visits with complete individual score components demonstrated improved congruence: substantial for cough (0.64), moderate for fever (0.57), fair for tonsillar swelling (0.3) and slight for lymphadenopathy (0.13). DISCUSSION: Overall agreement for individual score components was better for symptoms than it was for examination components, and was improved when data were complete. A McIsaac score of 1 or 0 had moderate agreement and thus could reasonably be safely used to exclude patients from GAS testing.

Self-Triage Use, Subsequent Healthcare Utilization, and Diagnoses: A Retrospective Study of Process and Clinical Outcomes Following Self-Triage and Self-Scheduling for Ear or Hearing Symptoms.

Background: Self-triage is becoming more widespread, but little is known about the people who are using online self-triage tools and their outcomes. For self-triage researchers, there are significant barriers to capturing subsequent healthcare outcomes. Our integrated healthcare system was able to capture subsequent healthcare utilization of individuals who used self-triage integrated with self-scheduling of provider visits. Methods: We retrospectively examined healthcare utilization and diagnoses after patients had used self-triage and self-scheduling for ear or hearing symptoms. Outcomes and counts of office visits, telemedicine interactions, emergency department visits, and hospitalizations were captured. Diagnosis codes associated with subsequent provider visits were dichotomously categorized as being associated with ear or hearing concerns or not. Nonvisit care encounters of patient-initiated messages, nurse triage calls, and clinical communications were also captured. Results: For 2168 self-triage uses, we were able to capture subsequent healthcare encounters within 7 days of the self-triage for 80.5% (1745/2168). In subsequent 1092 office visits with diagnoses, 83.1% (891/1092) of the uses were associated with relevant ear, nose and throat diagnoses. Only 0.24% (4/1662) of patients with captured outcomes were associated with a hospitalization within 7 days. Self-triage resulted in a self-scheduled office visit in 7.2% (126/1745). Office visits resulting from a self-scheduled visit had significantly fewer combined non-visit care encounters per office visit (fewer combined nurse triage calls, patient messages, and clinical communication messages) than office visits that were not self-scheduled (-0.51; 95% CI, -0.72 to -0.29; P < .0001). Conclusion: In an appropriate healthcare setting, self-triage outcomes can be captured in a high percentage of uses to examine for safety, patient adherence to recommendations, and efficiency of self-triage. With the ear or hearing self-triage, most uses had subsequent visit diagnoses relevant to ear or hearing, so most patients appeared to be selecting the appropriate self-triage pathway for their symptoms.

Online Self-Triage of Ear or Hearing Concerns in a Patient Portal: Comparison of Subsequent Diagnoses and Hospitalizations to National Emergency Department and National Ambulatory Ear or Hearing Visits.

Background: Although online self-triage is easily accessible, little is known about the patients who use self-triage or their subsequent diagnoses. We compared ear/hearing self-triage subsequent diagnoses to ear/hearing visit diagnoses in emergency departments (ED) and ambulatory clinics across the United States. Methods: We compared International Classification of Diseases version 10 (ICD10) coded diagnoses following online self-triage for ear/hearing concerns with those from national ED and ambulatory clinic samples. We used data from the Centers for Disease Control (CDC) National Hospital Ambulatory Medical Care Survey (NHAMCS) and National Ambulatory Medical Care Survey (NAMCS) for comparison. Using matched ear/hearing diagnostic categories for those aged 1 and over, we compared self-triage diagnosis frequencies with national ED and ambulatory diagnosis frequencies. Results: Following ear/hearing self-triage, there were 1092 subsequent office visits with a primary diagnosis code. For five frequently diagnosed ear/hearing conditions (i.e., suppurative and nonsuppurative otitis media [OM], otalgia, otitis externa, and cerumen impaction), there was a strong correlation between diagnosis counts made following self-triage and estimated counts of national ED visit diagnoses (r = 0.94; CI 95% [0.37 to 0.99]; p = .016, adjusted r2 = 0.85). Seven diagnoses were available to compare with the national ambulatory sample; correlation was r = 0.79; CI 95% [0.08 to 0.97]; p = .037, adjusted r2 = 0.54. For ages 1 and over, estimated hospital admissions from the national ED visits for ear/hearing were 0.76%, CI 95% [0.28-2.1%]; estimated total national ear/hearing ED visits were 7.5 million (for 4 years, 2016 through 2019). Conclusion: The strong correlation of ear-related self-triage diagnoses with national ED diagnoses and the low hospitalization risk for these diagnoses suggests that there is an opportunity for self-triage of ear/hearing concerns to decrease ED visits for these symptoms.

Association of Early and Late Hospital Readmissions with a Novel Housing-Based Socioeconomic Measure.

Background: While socioeconomic status has been linked to hospital readmissions for several conditions, reliable measures of individual socioeconomic status are often not available. HOUSES, a new measure of individual socioeconomic status based upon objective public data about one's housing unit, is inversely associated with overall hospitalization rate but it has not been studied with respect to readmissions. Purpose: To determine if patients in the lowest HOUSES quartile are more likely to be readmitted within 30 days (short-term) and 180 days (long-term). Methods: A retrospective cohort study of 11 993 patients having 21 633 admissions was conducted using generalized linear mixed-effects models. Results: HOUSES quartile did not show any significant association with early readmission. However, when compared to the lowest HOUSES quartile, the second quartile (OR = 0.90, 95%CI 0.83-0.98) and the third quartile (OR = 0.91, 95%CI 0.83-0.99) were associated with lower odds of late readmission while the highest quartile (OR = 0.91, 95%CI 0.82-1.01) was not statistically different. Conclusion: HOUSES was associated with late readmission, but not early readmission. This may be because early readmissions are influenced by medical conditions and hospital care while late readmissions are influenced by ambulatory care and home-based factors. Since HOUSES relies on public county assessor data, it is generally available and may be used to focus interventions on those at highest risk for late readmission.

Telemonitoring increases patient awareness of health and prompts health-related action: initial evaluation of the TELE-ERA study.

INTRODUCTION: Telemonitoring is being increasingly used for chronic disease monitoring. Understanding elderly patients' feelings and perspectives toward telemonitoring is important to minimize any barriers to implementation in this population. METHODS: Twenty Tele-Era Trial participants completed qualitative interviews assessing opinions about their telemonitoring experience. Participants also rated telemonitoring on burden, communication with clinicians, impact on medical condition knowledge, and confidence in using the monitor. RESULTS: On an average, participants rated telemonitoring as minimally burdensome, rated themselves confident in using the monitor, and positively rated telemonitoring for clinical communication. Qualitative analysis revealed a predominant theme that telemonitoring increases patient awareness of their health and also that telemonitoring prompts action. CONCLUSION: Elderly patients find home telemonitoring to be an acceptable and satisfying experience that can increase their awareness of their health and provide a sense of safety in their home. Home telemonitoring can lead to earlier evaluation of decline in health status.