Clinical care advice for monitoring of islet autoantibody positive individuals with presymptomatic type 1 diabetes.

BACKGROUND/AIM: Type 1 diabetes is an autoimmune disease that involves the development of autoantibodies against pancreatic islet beta-cell antigens, preceding clinical diagnosis by a period of preclinical disease activity. As screening activity to identify autoantibody-positive individuals increases, a rise in presymptomatic type 1 diabetes individuals seeking medical attention is expected. Current guidance on how to monitor these individuals in a safe but minimally invasive way is limited. This article aims to provide clinical guidance for monitoring individuals with presymptomatic type 1 diabetes to reduce the risk of diabetic ketoacidosis (DKA) at diagnosis. METHODS: Expert consensus was obtained from members of the Fr1da, GPPAD, and INNODIA consortia, three European diabetes research groups. The guidance covers both specialist and primary care follow-up strategies. RESULTS: The guidance outlines recommended monitoring approaches based on age, disease stage and clinical setting. Individuals with presymptomatic type 1 diabetes are best followed up in specialist care. For stage 1, biannual assessments of random plasma glucose and HbA1c are suggested for children, while annual assessments are recommended for adolescents and adults. For stage 2, 3-monthly clinic visits with additional home monitoring are advised. The value of repeat OGTT in stage 1 and the use of continuous glucose monitoring in stage 2 are discussed. Primary care is encouraged to monitor individuals who decline specialist care, following the guidance presented. CONCLUSIONS: As type 1 diabetes screening programs become more prevalent, effective monitoring strategies are essential to mitigate the risk of complications such as DKA. This guidance serves as a valuable resource for clinicians, providing practical recommendations tailored to an individual's age and disease stage, both within specialist and primary care settings.

Telemedicine in specialist outpatient care during COVID-19: a qualitative study.

BACKGROUND: COVID-19 accelerated healthcare changes, introducing various telehealth services. Work is needed to determine the suitability of telemedicine in the post-pandemic era. AIMS: To explore perceptions and experiences of telemedicine among patients and providers (clinicians and health administrators) who were involved in telemedicine appointments in hospital outpatient clinics in 2020-2022. DESIGN, SETTING AND PARTICIPANTS: Qualitative study: semi-structured interviews were conducted with 37 participants (16 patients and 21 providers) in various hospital specialist outpatient clinics in a New South Wales local health district. RESULTS: Patients were generally satisfied with telemedicine consultations, especially during COVID restrictions, because of the convenience of accessing care from home and minimising the risk of COVID exposure. However, patients considered that the inability to receive a physical examination was a significant disadvantage of telemedicine. Providers had ambivalent perceptions and expressed concerns about mis- and under-diagnoses because of the inability to conduct physical examinations. They considered telemedicine suitable for review appointments but noted an associated increased workload and stressed the need for sustainable funding models (Medicare items). Both patients and providers recognised the need for education/training and better integration of telemedicine platforms into existing infrastructure to facilitate an optimal hybrid model of care. CONCLUSION: Despite expressing some concerns over its limitations, patients valued telemedicine for its convenience and for meeting their needs during the pandemic. While acknowledging that patients experienced some benefits from telemedicine, clinicians expressed concerns about potential missed diagnoses, uncertain clinical outcomes and lack of administrative and technological infrastructure. The ultimate test of telemedicine will be its impact on clinical outcomes versus longstanding models of in-person care.

Is complementary medicine and diagnosis associated among spinal patients in the secondary sector: a cross-sectional study.

PURPOSE: The services defined as complementary and alternative medicine/healthcare (CAM) are used to varying degrees according to the nature of the health problem, and musculoskeletal disorders, in particular, often lead to the use of CAM. Chronic pain is often cited as a reason for using CAM, and it is also the cardinal symptom of patients with back pain referred for specialist care. However, previous studies do not consider the heterogeneity of back pain when examining the use of CAM. Thus, this study aimed to explore the associations between CAM use and clinical findings incl. ICD-10 diagnostic codes in such a context. METHODS: In a cross-sectional study, a logistic regression analysis examined associations between CAM use and clinical findings at a public outpatient spine department. Chi-squared test examined the association between self-reported reasons for CAM use and the diagnostic groups. RESULTS: Of the 432 patients in the study population, 23.8% reported using CAM within 12 months prior to clinical assessment. CAM use was associated with being female and of younger age. Seeking CAM was not associated with clinical findings nor diagnosis, and no statistically significant association between the reasons for seeking CAM and the diagnostic groups was described. CONCLUSIONS: Among patients referred to specialist care for back pain, this study provides no evidence that the spinal condition should be expected to lead to the use of CAM. Only the individual demographic findings, specifically age and gender, were associated with CAM use.

What do primary care providers want to know when caring for patients living with frailty? An analysis of eConsult communications between primary care providers and specialists.

BACKGROUND: Frailty is a complex condition that primary care providers (PCPs) are managing in increasing numbers, yet there is no clear guidance or training for frailty care. OBJECTIVES: The present study examined eConsult questions PCPs asked specialists about patients with frailty, the specialists' responses, and the impact of eConsult on the care of these patients. DESIGN: Cross-sectional observational study. SETTING: ChamplainBASE™ eConsult located in Eastern Ontario, Canada. PARTICIPANTS: Sixty one eConsult cases closed by PCPs in 2019 that use the terms "frail" or "frailty" to describe patients 65 years of age or older. MEASUREMENTS: The Taxonomy of Generic Clinical Questions (TGCQ) was used to classify PCP questions and the International Classification for Primary Care 3 (ICPC-3) was used to classify the clinical content of each eConsult. The impact of eConsult on patient care was measured by PCP responses to a mandatory survey. RESULTS: PCPs most frequently directed their questions to cardiology (n = 7; 11%), gastroenterology (n = 7; 11%), and endocrinology (n = 6; 10%). Specialist answers most often pertained to medications (n = 63, 46%), recommendations for clinical investigation (n = 24, 17%), and diagnoses (n = 22, 16%). Specialist responses resulted in PCPs avoiding referral in 57% (n = 35) of cases whereas referrals were still required in 15% (n = 9) of cases. Specialists responded to eConsults in a median 1.11 days (IQR = 0.3-4.7), and 95% (n = 58) of cases received a response within 7 days. Specialists recorded a median of 15 min to respond (IQR = 10-20), with a median cost of $50.00 CAD (IQR = 33.33 - 66.66) per eConsult. CONCLUSIONS: Through the analysis of questions and responses submitted to eConsult, this study provides novel information on PCP knowledge gaps and approaches to care for patients living with frailty. Furthermore, these analyses provide evidence that eConsult is a feasible and valuable tool for improving care for patients with frailty in primary care settings.

Between delivering chronic care and answering patients' burdens: Understanding HIV specialist nurses' experiences in the age of treatment.

AIM(S): To understand the experiences of HIV nurses in the context of ambivalence between biomedical treatment advancements and the continuing burden for people living with HIV and negative representations of HIV. DESIGN: An interpretative phenomenological study was conducted using in-depth interviews. METHODS: Twenty-one interviews with nurses were conducted between November 2021 and March 2022. A thematic analysis was performed. RESULTS: Six themes related to the nurses' experiences emerged. Despite effective treatment for most people with HIV, nurses identify patient populations that require additional care. Nurses are flexible in making extra appointments to accommodate complex issues in these patients. Nurses develop a unique relationship with their patients based on trust and empathy, linked to patient's experiences with stigma and discrimination for people with HIV. Nurses perceive their tasks as becoming increasingly complex. There is explicit awareness about the changes in HIV care from acute to chronic care and how this affects nurses' tasks. Nurses continue to differentiate HIV from other chronic conditions. CONCLUSION: Biomedical advancements change the organization of HIV care while public health concerns remain and patient population has particular needs due to negative social representations of HIV. Nurses navigate these issues in their everyday care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: A potential re-evaluation of the role of nurses in providing chronic HIV care. IMPACT: Our study addresses the roles of HIV nurses as care is shifting towards chronic care models. The unique relationship between nurses and patients is key in understanding the importance of nurses in the care trajectory. These findings impact the institutional role of nurses in HIV treatment centres and the institutional organization of HIV care. REPORT METHOD: The COREQ guideline was used. PATIENT OR PUBLIC CONTRIBUTION: Amsterdam UMC (AMC) staff, the national organization of HIV Nurses and patient organizations contributed to the study design.

Medical Specialist Care Utilization Prior to the Explantation of Cosmetic Silicone Breast Implants: A Nationwide Retrospective Data Linkage Study.

BACKGROUND: Explantation is the proposed treatment for breast implant illness (BII). Little is known about which medical specialists are visited and what diagnoses are made before explantation is provided as the treatment. OBJECTIVES: This study investigated medical specialist care utilization in women with cosmetic breast implants who underwent explantation compared to women who chose breast implant replacement surgery and to women without breast implants. METHODS: Retrospective cohort study using data linkage with the Dutch Breast Implant Registry and the Dutch health insurance claims database. Visits to medical specialists were examined over the 3 years before explantation. A total of 832 explantation patients were matched and compared to 1463 breast implant replacement patients and 1664 women without breast implants. RESULTS: Explantation patients were more likely to have visited > 5 different medical specialties compared to both replacement patients (12.3% vs. 5.7%; p < 0.001) and women without breast implants (12.3% vs. 3.7%; p < 0.001). Among explantation patients, women who underwent explantation because of BII were more likely to have visited > 5 different medical specialties compared to women who underwent explantation because of other reasons (25.0% vs. 11.0%; p < 0.001). CONCLUSIONS: Women who underwent explantation of breast implants had higher utilization of medical specialist care in the years before explantation compared to women who underwent breast implant replacement surgery and women without breast implants. Medical specialist care use was especially high among women for whom BII was the registered reason for explantation. These findings suggest further research is needed into the link between BII and the use of medical specialist care. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Interdisciplinary centers for autoimmune diseases in Germany]. / Interdisziplinäre Zentren für Autoimmunerkrankungen in Deutschland.

BACKGROUND: Interdisciplinary medical treatment is required to care for patients with complex autoimmune diseases. Although there are an increasing number of interdisciplinary centers for autoimmune diseases in Germany, they are not yet available throughout the country and the focuses and interdisciplinary structures are not organized according to a generally agreed standard. Furthermore, they are not regularly reflected in the general care structure. THE AIM OF THE WORK: To analyze the care structure using as an example an established center and a clinical case to demonstrate the usefulness of in-house standardized procedures. MATERIAL AND METHODS: In order to determine the status quo regarding interdisciplinary centers for autoimmune diseases in Germany, a university hospital is exemplarily presented for a structural analysis and a case presentation from another center to demonstrate the importance of an interdisciplinary patient care. RESULTS: At the selected center for autoimmune diseases of the university hospital, patients with autoimmune diseases receive interdisciplinary care from experts from various disciplines. The structures are anchored in an organizational chart. The case report demonstrates a standardized diagnostic and therapeutic pathway (standardized operating procedures, SOP) in a patient with systemic sclerosis and lung involvement. DISCUSSION: The article discusses which measures are necessary across disciplines for comprehensive diagnostics and treatment of certain autoimmune diseases, which challenges arise during implementation and which advantages can arise compared to guidelines because, among other things, they can be immediately adapted. The establishment of a national consensus for the structure, necessary settings and implementation into patient care within an interdisciplinary center for autoimmune diseases is desirable.

[Patient-oriented optimization of the quality of care in a specialized outpatient clinic in a tertiary rheumatology center : A qualitative study]. / Patientenorientierte Optimierung der Versorgungsqualität in der ambulanten spezialfachärztlichen Versorgung (ASV) in einem tertiären rheumatologischen Zentrum : Eine qualitative Studie.

BACKGROUND: The adaptation of structures and processes in treatment procedures can contribute to increasing patient satisfaction and is the focus of patient-oriented quality assurance. OBJECTIVE: To identify patient satisfaction as well as needs, expectations and preferences with respect to care and, based on this, to formulate recommendations for action to optimize the quality of care at a large tertiary rheumatology center. MATERIAL AND METHODS: As part of a qualitative research approach, semi-structured patient interviews and a focus group interview consisting of physicians in rheumatology training in outpatient specialist care were conducted. The quality dimensions of Donabedian were recorded. The data material was evaluated and analyzed using the content-structuring qualitative content analysis according to Kuckartz with the MAXQDA evaluation software. RESULTS: Using 12 patient interviews and a focus group of 3 future rheumatologists, recommendations for action to optimize the quality of care were derived on the basis of the structural, process and outcome quality. There was a need for optimization in the areas of personnel management, internal practice processes, practice equipment and treatment processes in the outpatient clinic. CONCLUSION: The results from the patient interviews and the focus group revealed the aspects in need of optimization. The methodology and results of this study can serve as a reference point for analyses of other rheumatology clinics in order to improve the quality of care within the framework of patient-oriented quality management and continuous further development.

Prevalence of diagnosable depression in patients awaiting orthopaedic specialist consultation: a cross-sectional analysis.

BACKGROUND: Musculoskeletal conditions, including osteoarthritis (OA), are a leading cause of disability and chronic pain, and are associated with high rates of comorbid depression. However, signs of depression are often masked by pain. The aim of this study was to determine the prevalence and severity of depression and pain in individuals awaiting specialist orthopaedic consultation. A secondary objective was to determine the relationship between pain and depression, irrespective of demographic factors and clinical diagnosis. METHODS: Cross-sectional analysis of individuals awaiting orthopaedic consultation at a public hospital in Melbourne, Australia. Relevant data were extracted from medical records and questionnaires. Descriptive statistics were used to summarise participant characteristics. The patient health questionnaire (PHQ-9) was used to assess depression and a numerical rating scale (NRS) was used to assess pain severity. Multiple linear regression analyses were used to establish the relationship between pain and depression. RESULTS: Nine hundred and eighty-six adults (mean ± standard deviation, age = 54.1 ± 15.7 years, 53.2% women) participated in the study. OA was present in 56% of the population and 34% of the entire population had moderate depression or greater, 19% of which met the criteria for major depressive disorder. Moderate-to-severe pain was present in 79% of individuals with OA and 55% of individuals with other musculoskeletal complaints. Pain was significantly associated with depression scores (ß = 0.84, adjusted R2 = 0.13, P < 0.001), and this relationship remained significant after accounting for gender, age, education and employment status, OA status, number of joints affected and waiting time (ß = 0.91, adjusted R2 = 0.19, P < 0.001). CONCLUSIONS: Depression affects one-third of individuals on an orthopaedic waitlist. A strong link between pain and depression in patients awaiting specialist orthopaedic consultation exists, indicating a need for an integrated approach in addressing pain management and depression to manage this complex and comorbid presentation.

Allergic and hypersensitivity conditions in non-specialist care: Flow diagrams to support clinical practice.

Most patients presenting with allergies are first seen by primary care health professionals. The perceived knowledge gaps and educational needs were recently assessed in response to which the LOGOGRAM Task Force was established with the remit of constructing pragmatic flow diagrams for common allergic conditions in line with an earlier EAACI proposal to develop simplified pathways for the diagnosis and management of allergic diseases in primary care. To address the lack of accessible and pragmatic guidance, we designed flow diagrams for five major clinical allergy conditions: asthma, anaphylaxis, food allergy, drug allergy, and urticaria. Existing established allergy guidelines were collected and iteratively distilled to produce five pragmatic and accessible tools to aid diagnosis and management of these common allergic problems. Ultimately, they should now be validated prospectively in primary care settings.

Evaluation of an Electronic Consultation Service for COVID-19 Care.

PURPOSE: COVID-19 has increased the need for innovative virtual care solutions. Electronic consultation (eConsult) services allow primary care practitioners to pose clinical questions to specialists using a secure remote application. We examined eConsult cases submitted to a COVID-19 specialist group in order to assess usage patterns, impact on response times and referrals, and the content of clinical questions being asked. METHODS: This was a mixed-methods analysis of eConsult cases submitted between March and September 2020 in Ontario, Canada to 2 services. We performed a descriptive analysis of the average response time and the total time spent by the specialist for eConsults. Primary care practitioners completed a post-eConsult questionnaire that asked about the outcome of the eConsult. We performed an inductive and deductive content analysis of a subset of cases to identify common themes among the clinical questions asked. RESULTS: A total of 208 primary care practitioners submitted 289 eConsult cases. The median specialist response time was 0.6 days (range = 3 minutes to 15 days); the average time spent by specialists per case was 16 minutes (range = 5 to 59 minutes). In 69 cases (24%), the eConsult enabled avoidance of a face-to-face referral. Content analysis of 51 cases identified 5 major themes: precautions for high-risk and special populations, diagnostic clarification and/or need for COVID-19 testing, guidance on self-isolation and return to work, guidance on personal protective equipment, and management of chronic symptoms. CONCLUSIONS: This study demonstrates the considerable potential of eConsults during a pandemic as our service was quickly implemented across Ontario and resulted in primary care practitioners' rapid and low-barrier access to specialist input.

Waiting times in healthcare: equal treatment for equal need?

BACKGROUND: In many universal health systems, waiting times act as a non-monetary rationing mechanism, one that should be based on clinical need rather than the ability to pay. However, there is growing evidence that among patients with similar levels of need, waiting times often differ according to socioeconomic status. The mechanisms underlying inequality in access remain unclear. METHODS: Using data for Spain, we study whether waiting times for primary and specialist care depend on patients' socioeconomic status (SES). Additionally, we make use of the continuous nature of our data to explore whether the SES-related differences in waiting times found for specialist consultations vary among different points of the waiting time distribution. RESULTS: Our results reveal the presence of a SES gradient in waiting times for specialist services explained on the basis of education, employment status and income. In addition, for primary care, we found evidence of a slightly more moderate SES gradient mostly based on employment status. Furthermore, although quantile regression estimates indicated the presence of a SES gradient within the distribution of waiting times for specialist visits, the SES differences attenuated in the context of longer waiting times in the public sector but did not disappear. CONCLUSION: Our findings suggest the principle of equal treatment for equal need, assumed to be inherent to national health systems such as the Spanish system, is not applied in practice. Determining the mechanism(s) underlying this selective barrier to healthcare is of crucial importance for policymakers, especially in the current COVID-19 health and economic crises, which could exacerbate these inequalities as increasing numbers of treatments are having to be postponed.

At the junctures of healthcare: a qualitative study of primary and specialist service use by Polish migrants in England.

BACKGROUND: Polish people are the biggest migrant group in the UK and the scholarship shows that they are attentive to their healthcare needs and seek to fulfil them by using various services both within and outside the British public healthcare system. This article explores the role of junctures within healthcare systems in the connections migrants realize between healthcare systems and sectors. The article argues that in a transnational context, migrants enact these junctures by joining different levels of care within the same sector, between sectors and across national borders. In particular, the article explores how Polish migrants' healthcare seeking practices within and beyond national borders are enacted given the features, availability and relationship between primary and specialist care for how they are articulated between private and public sectors. METHODS: This article is based on the second phase of a mixed-methods study on how Polish people in the UK manage their health transnationally. The participants were purposefully sampled from survey respondents (first phase) who identified as having a long-term health condition or caring in a non-professional capacity for someone who is chronically ill. Thirty-two semi-structured audio-call interviews were conducted with Polish migrants living in England between June and August 2020. Transcripts were analysed by applying thematic coding. RESULTS: Key findings include a mix of dissatisfaction and satisfaction with primary care and general satisfaction with specialist care. Coping strategies consisting in reaching specialist private healthcare provided a way to access specialist care at all or additionally, or to partially complement primary care. When Polish private specialists are preferred, this is due to participants' availability of time and financial resources, and to the specialists' capacity to fulfil needs unmet within the public healthcare sector in the UK. CONCLUSION: Polish migrants join with their practices systems which are not integrated, and their access is limited by the constraints implied in accessing paid services in Poland. This shapes transnational healthcare practices as relating mostly to routine and ad-hoc access to healthcare. These practices impact not only the wellbeing of migrants and the development of the private market but also the public health provision of services.

Health care use in response to health shocks: Does socio-economic status matter?

We investigate how utilization of primary care, specialist care, and emergency department (ED) care (and the mix across the three) changes in response to a change in health need. We determine whether any changes in utilization are impacted by socio-economic status. The use of a unique Australian data set that consists of a large survey linked to multiple years of detailed administrative records enables us to better control for individual heterogeneity and allows us to exploit changes in health that are related to the onset of two health shocks: a new diagnosis of diabetes and heart disease. We extend the analysis by also examining changes to patient out-of-pocket costs. We find significant differences in the mix between primary and specialist care use according to income and type of health shock but no evidence of using ED as a substitute for other care. Our results indicate that low- and high-income patients navigate very different pathways for their care following the onset of diabetes and to a lesser extent heart disease. These pathways appear to be chosen on the basis of ability to pay, rather than the most effective or efficient bundle of care delivered through a combination of GP and specialist care.

Evaluation of an electronic consultation service for transgender care.

BACKGROUND: Access to transgender care in Canada is poor. Although primary care providers are ideally positioned to initiate care, many feel uncomfortable providing transgender care. This study aimed to explore the impact of an electronic consultation (eConsult) service between primary care providers and transgender care specialists on access to care and to explore the content of clinical questions that were asked. METHODS: This was a retrospective mixed methods analysis of 62 eConsults submitted between January 2017 and December 2018 by primary care providers to specialists in transgender care in a health region in eastern Ontario, Canada. A descriptive analysis was conducted to assess the average response time and the total time spent by the specialist for the eConsults. An inductive and deductive content analysis was carried out to identify common themes of clinical questions being asked to transgender specialists. A post-eConsult survey completed by primary care providers was assessed to gain insight into avoided face-to-face referrals and overall provider satisfaction. RESULTS: The median specialist response time was 1.2 days (range: 1 h to 5 days) and the average time spent by specialists per eConsult was 18 min (range: 10 to 40 min). The qualitative analysis identified six major themes: 1) interpretation/management of abnormal bloodwork, 2) change in management due to lack of desired effect/hormone levels not a target, 3) initiation of hormone therapy/initial work up, 4) management of adverse effects of hormone therapy, 5) transition related surgery counseling and post-op complications, and 6) management of patients with comorbidities. Approximately one-third of eConsults resulted in an avoided face-to-face referral and 95% of primary care providers rated the value of their eConsult as a 5 (excellent value) or 4. CONCLUSIONS: This study demonstrated that a transgender eConsult service has potential to significantly improve access to care for transgender patients. Given the importance that timely access has on improving mental health and reducing suicide attempts, eConsult has the potential to make a substantial clinical impact on this population. Identified themes of eConsult questions provides insight into potential gaps in knowledge amongst primary care providers that could help inform future continuing education events.

CPP or Not, That Is the Question: Physicians' Work With Activating CPPs.

The Norwegian government has launched a policy titled cancer patient pathways (CPPs), which assigns maximum deadlines to the various phases of the diagnostic investigation. In this article, I examine the starting point of CPPs through the lens of institutional ethnography-that is, how physicians work with the referral of patients in the context of CPPs. Based on qualitative interviews with physicians in both primary and secondary care across Norway (N = 37), the findings reveal that the distinction between CPP or not is by no means clear-cut for either primary or specialist physicians. The starting point of CPPs is mediated by the interaction between physicians and patients and how the referral is composed, as well as how and by whom the referral is interpreted, in conjunction with overarching discourses, policies, and guidelines for practice. The findings challenge the notion that all potential cancer patients can and should be equally prioritized.

[Care atlas rheumatology : Approaches and concepts for improving care in outpatient rheumatology]. / Versorgungsatlas Rheumatologie : Ansätze und Konzepte zur Verbesserung der Versorgung in der ambulanten Rheumatologie.

Inflammatory rheumatic diseases affect 1.5 million adults and an estimated 20,000 children and adolescents throughout Germany. The successful treatment of these patients is largely based on the availability of high-quality medical care. To be able to provide sufficient care and prevent long waiting times even though the number of rheumatologists is below demand, efficient practice structures and approaches that go beyond standard care play an important role. The present study takes a look at the current state of rheumatological outpatient care as well as innovative care initiatives to support the service provision structures and to improve the care situation in rheumatology and points out: to ensure guideline-based care despite scarce resources, selective contracts, integrated outpatient specialist care (ASV), early or emergency consultation hours, disease management programs (DMP) and appropriate delegation of medical services play an important role. New care concepts increasingly focus on interdisciplinary cooperation (DMP and ASV), strengthened self-management through structured patient training (DMP) and targeted patient management through screening tools. To ensure an up to date and high-quality treatment in the long term, an increase in further training in rheumatology is necessary. This should be achieved by attracting more students and, if necessary, adjusting the training system.

Impact of cardiology follow-up care on treatment and outcomes of patients with new atrial fibrillation discharged from the emergency department.

AIMS: The first presentation of atrial fibrillation (AF) is often to an emergency department (ED). We evaluated the association of subsequent specialist care with morbidity and mortality. METHODS AND RESULTS: Retrospective cohort study of all adults in Alberta, Canada, with a new primary diagnosis of AF treated and released during an index ED visit between 2009 and 2015. Types of physician follow-up within 3 months of ED visit was analysed using Cox proportional hazards models with time-varying covariates. Outcomes were evaluated at 1 year. Of 7986 patients, 476 (6.0%) had no physician follow-up within 3 months, whereas 2730 (34.2%) attended a non-specialist only, 1277 (16.0%) an internal medicine specialist, and 3503 (43.9%) cardiology. An increasing gradient of cardiac investigations occurred across these groups. Cardiology compared with non-cardiologist care was associated with approximately two-fold greater electrophysiology interventions and revascularization, and increased use of beta-blockers (48.9% vs. 43.0%, P < 0.0001), statins (31.4% vs. 26.7%, P < 0.0001), and oral anticoagulation in patients with CHADS2 scores ≥1 (53.7% vs. 43.6%, P < 0.0001). In the subsequent year, cardiology care was associated with fewer deaths [adjusted hazard ratio (aHR) 0.72, 95% confidence interval (CI) 0.55-0.93], strokes (aHR 0.60, 95% CI 0.37-0.96), or major bleeds (aHR 0.69, 95% CI 0.53-0.89). No differences in the risk of hospitalization or ED visits were associated with cardiology care. CONCLUSION: Cardiology care after an ED visit for symptomatic new-onset AF is associated with better prognosis. The benefit may be mediated through more intensive investigation, identification, and treatment of cardiovascular risk factors and disease.

Poverty, insurance, and region as predictors of epilepsy treatment among US adults.

Disparities in epilepsy treatment have previously been reported. In the current study, we examine the role of socioeconomic status, health insurance, place of residence, and sociodemographic characteristics in past-year visit to a neurology or epilepsy provider and current use of antiseizure medications. Multiple years of data were compiled from the National Health Interview Surveys, Sample Adult Epilepsy Modules. The sample (n = 1655) included individuals 18 years and older who have been told by a doctor to have epilepsy or seizures. Independent variables included number of seizures in the past year, health insurance, poverty status, education, region, race/ethnicity, foreign-born status, age, and sex/gender. Two sets of weighted hierarchical logistic regression models were estimated predicting past-year epilepsy visit and current medication use. Accounting for recent seizure activity and other factors, uninsured and people residing outside of the Northeast were less likely to see an epilepsy provider, and people living in poverty were less likely to use medications, relative to their comparison groups. However, no racial/ethnic and nativity-based differences in specialty service or medication use were observed. Further research, including longitudinal studies of care trajectories and outcomes, are warranted to better understand healthcare needs of people with epilepsy, in particular treatment-resistant seizures, and to develop appropriate interventions at the policy, public health, and health system levels.

Delivery of care for functional gastrointestinal disorders: A systematic review.

BACKGROUND: A diverse range of treatments are available for the treatment of functional gastrointestinal disorders (FGIDs). Individual treatments, including drug therapies, behavioral therapy ("biofeedback"), psychological therapies, and dietary therapies, have been well validated in controlled, randomized trials and real-life case series. However, few studies have evaluated models of delivery of care for the whole population of referred patients with an FGID. This review evaluates models of specialist outpatient care for the management of FGIDs. METHODS: A systematic review was performed of full-text articles published until October 2018 in Pubmed/Medline and Embase. Studies were included if they evaluated a model of outpatient care in a specialist setting for the treatment of adult patients with an FGID and included patient-reported outcomes comprising symptoms, quality of life, or psychological well-being. RESULTS: Few studies have evaluated the delivery of care for the whole population of referred patients with an FGID, and there was one randomized comparison of different models of care. Two studies that evaluated the outcome of gastroenterologist-only clinics suggested poor long-term results. Two non-comparative case series reported the outcome of multidisciplinary care, including gastroenterologists and psychological therapists, suggesting improved patient quality of life and psychological well-being. CONCLUSIONS: Despite the high prevalence and cost of treating FGIDs, and the availability of effective treatments, there are few data and limited randomized comparisons reporting the outcome of different types of specialist care. The few data available suggest that multidisciplinary care is superior to gastroenterologist-only care, but this needs to be validated in prospective comparative studies.