Consequences of the COVID-19 pandemic on lung cancer care and patient health in a German lung cancer center: results from a cross-sectional questionnaire.

BACKGROUND: The novel coronavirus SARS-CoV-2 has caused a global COVID-19 pandemic, leading to worldwide changes in public health measures. In addition to changes in the public sector (lockdowns, contact restrictions), hospitals modified care to minimize risk of infection and to mobilize resources for COVID-19 patients. Our study aimed to assess the impact of these measures on access to care and behaviour of patients with thoracic malignancies. METHODS: Thoracic oncology patients were surveyed in October 2020 using paper-based questionnaires to assess access to ambulatory care services and tumor-directed therapy during the COVID-19 pandemic. Additionally, behaviour regarding social distancing and wearing of face masks were assessed, as well as COVID-19 exposure, testing and vaccination. Results are presented as absolute and relative frequencies for categorical variables and means with standard deviation for numerical variables. We used t-test, and ANOVA to compare differences in metric variables and Chi2-test to compare proportions between groups. RESULTS: 93 of 245 (38%) patients surveyed completed the questionnaire. Respiration therapy and physical therapy were unavailable for 57% to 70% of patients during March/April. Appointments for tumor-directed therapy, tumor imaging, and follow-up care were postponed or cancelled for 18.9%, 13.6%, and 14.8% of patients, respectively. Patients reported their general health as mostly unaffected. The majority of patients surveyed did not report reducing their contacts with family. The majority reduced contact with friends. Most patients wore community masks, although a significant proportion reported respiratory difficulties during prolonged mask-wearing. 74 patients (80%) reported willingness to be vaccinated against SARS-CoV-2. CONCLUSIONS: This survey provides insights into the patient experience during the second wave of the COVID-19 pandemic in Munich, Germany. Most patients reported no negative changes to cancer treatments or general health; however, allied health services were greatly impacted. Patients reported gaps in social distancing, but were prepared to wear community masks. The willingness to get vaccinated against SARS-CoV-2 was high. This information is not only of high relevance to policy makers, but also to health care providers.

Impact of COVID-19 on cancer care in India: a cohort study.

BACKGROUND: The COVID-19 pandemic has disrupted health-care systems, leading to concerns about its subsequent impact on non-COVID disease conditions. The diagnosis and management of cancer is time sensitive and is likely to be substantially affected by these disruptions. We aimed to assess the impact of the COVID-19 pandemic on cancer care in India. METHODS: We did an ambidirectional cohort study at 41 cancer centres across India that were members of the National Cancer Grid of India to compare provision of oncology services between March 1 and May 31, 2020, with the same time period in 2019. We collected data on new patient registrations, number of patients visiting outpatient clinics, hospital admissions, day care admissions for chemotherapy, minor and major surgeries, patients accessing radiotherapy, diagnostic tests done (pathology reports, CT scans, MRI scans), and palliative care referrals. We also obtained estimates from participating centres on cancer screening, research, and educational activities (teaching of postgraduate students and trainees). We calculated proportional reductions in the provision of oncology services in 2020, compared with 2019. FINDINGS: Between March 1 and May 31, 2020, the number of new patients registered decreased from 112 270 to 51 760 (54% reduction), patients who had follow-up visits decreased from 634 745 to 340 984 (46% reduction), hospital admissions decreased from 88 801 to 56 885 (36% reduction), outpatient chemotherapy decreased from 173634 to 109 107 (37% reduction), the number of major surgeries decreased from 17 120 to 8677 (49% reduction), minor surgeries from 18 004 to 8630 (52% reduction), patients accessing radiotherapy from 51 142 to 39 365 (23% reduction), pathological diagnostic tests from 398 373 to 246 616 (38% reduction), number of radiological diagnostic tests from 93 449 to 53 560 (43% reduction), and palliative care referrals from 19 474 to 13 890 (29% reduction). These reductions were even more marked between April and May, 2020. Cancer screening was stopped completely or was functioning at less than 25% of usual capacity at more than 70% of centres during these months. Reductions in the provision of oncology services were higher for centres in tier 1 cities (larger cities) than tier 2 and 3 cities (smaller cities). INTERPRETATION: The COVID-19 pandemic has had considerable impact on the delivery of oncology services in India. The long-term impact of cessation of cancer screening and delayed hospital visits on cancer stage migration and outcomes are likely to be substantial. FUNDING: None. TRANSLATION: For the Hindi translation of the abstract see Supplementary Materials section.

Increased Australian outpatient private practice psychiatric care during the COVID-19 pandemic: usage of new MBS-telehealth item and face-to-face psychiatrist office-based services in Quarter 3, 2020.

OBJECTIVE: The Australian federal government introduced new COVID-19 psychiatrist Medicare Benefits Schedule (MBS) telehealth items to assist with providing private specialist care. We investigate private psychiatrists' uptake of video and telephone telehealth, as well as total (telehealth and face-to-face) consultations for Quarter 3 (July-September), 2020. We compare these to the same quarter in 2019. METHOD: MBS-item service data were extracted for COVID-19-psychiatrist video and telephone telehealth item numbers and compared with Quarter 3 (July-September), 2019, of face-to-face consultations for the whole of Australia. RESULTS: The number of psychiatry consultations (telehealth and face-to-face) rose during the first wave of the pandemic in Quarter 3, 2020, by 14% compared to Quarter 3, 2019, with telehealth 43% of this total. Face-to-face consultations in Quarter 3, 2020 were only 64% of the comparative number of Quarter 3, 2019 consultations. Most telehealth involved short telephone consultations of ⩽15-30 min. Video consultations comprised 42% of total telehealth provision: these were for new patient assessments and longer consultations. These figures represent increased face-to-face consultation compared to Quarter 2, 2020, with substantial maintenance of telehealth consultations. CONCLUSIONS: Private psychiatrists continued using the new COVID-19 MBS telehealth items for Quarter 3, 2020 to increase the number of patient care contacts in the context of decreased face-to-face consultations compared to 2019, but increased face-to-face consultations compared to Quarter 2, 2020.

Impact of oral anticoagulation choice on healthcare utilization for the primary treatment of venous thromboembolism.

Little is known about the impact of oral anticoagulation (OAC) choice on healthcare encounters during venous thromboembolism (VTE) primary treatment. Among anticoagulant-naïve patients with VTE, we tested the hypotheses that healthcare utilization would be lower among users of direct OACs (DOACs; rivaroxaban or apixaban) than among users of warfarin. MarketScan databases for years 2016 and 2017 were used; healthcare utilization was identified in the first 6 months after initial VTE diagnoses. The 23,864 patients with VTE had on average 0.2 ± 0.5 hospitalizations, spent 1.3 ± 5.2 days in the hospital, had 5.7 ± 5.1 outpatient encounters, and visited an emergency department 0.4 ± 1.1 times. As compared to warfarin, rivaroxaban and apixaban were associated with fewer hospitalizations, days hospitalized, outpatient office visits, and emergency department visits after accounting for age, sex, comorbidities, and medications. Hospitalization rates were 24% lower (incidence rate ratio (IRR): 0.76; 95% CI: 0.69, 0.83) with rivaroxaban and 22% lower (IRR: 0.78; 95% CI: 0.71, 0.87) with apixaban, as compared to warfarin (IRR: 1.00 (reference)). Healthcare utilization was similar between apixaban and rivaroxaban users. Patients with VTE prescribed rivaroxaban and apixaban had lower healthcare utilization than those prescribed warfarin, while there was no difference when comparing apixaban to rivaroxaban. These findings complement existing literature supporting the use of DOACs over warfarin.

Association of an Acute Myocardial Infarction Readmission-Reduction Program With Mortality and Readmission.

BACKGROUND: Reducing hospital readmission after acute myocardial infarction (AMI) has the potential to both improve quality and reduce costs. As such, readmission after AMI has been a target of financial penalties through Medicare. However, substantial concern exists about potential adverse effects and efficacious readmission-reduction strategies are not well validated. METHODS AND RESULTS: We started an AMI readmissions reduction program in November 2017. Between July 2016 and February 2019, hospital billing data were queried to detect all inpatient hospitalizations at the Massachusetts General Hospital for AMI. Thirty-day readmission was identified through hospital billing data, and mortality was extracted from our electronic health record. The data set was merged with claims data for patients in accountable care organizations to detect readmission at other hospitals. We performed segmented linear regression, adjusting for secular trend and case mix, to assess the independent association of our program on both outcome variables. After inclusion and exclusion criteria were applied, the study population included 2020 patients. The overall 30-day readmission rate was higher before the intervention than after the intervention (15.5% versus 10.7%, P=0.002). The overall 30-day mortality rate was similar in both time periods (1.8% versus 1.4%, P=0.457). The program was associated with initial reduction in 30-day readmission (-9.8%, P=0.0002) and 30-day mortality (-2.6%, P=0.041). The program did not change trend in 30-day readmission (+0.19% readmissions/mo, P=0.554) and trend in 30-day mortality (-0.21% deaths/mo, P=0.119). CONCLUSIONS: An AMI readmissions reduction program that increases outpatient and emergency department (ED) access to cardiology care is associated with reduced 30-day readmission and 30-day mortality. Similar statistical techniques can be used to conduct a rigorous, mechanistic program evaluation of other quality improvement initiatives.

Inpatient and outpatient treatment patterns of cancer-associated thrombosis in the United States.

Low molecular weight heparins (LMWHs) and direct oral anticoagulants (DOACs) are among the recommended treatment options for cancer-associated thrombosis (CAT) in the 2019 National Comprehensive Care Network guidelines. Little is known about the current utilization of DOACs in CAT patients, particularly on the inpatient to outpatient therapy transition. This study assessed real-world treatment patterns of CAT in hospital/ED in adult cancer patients (≥ 18 years) diagnosed with CAT during a hospital visit in IQVIA's Hospital Charge Data Master database between July 1, 2015 and April 30, 2018, and followed their outpatient medical and pharmacy claims to evaluate the initial inpatient/ED and outpatient anticoagulants received within 3 months post-discharge. Results showed that LMWH and unfractionated heparin (UFH) were the most common initial inpatient/ED CAT treatments (35.2% and 27.4%, respectively), followed by DOACs (9.6%); 20.8% of patients received no anticoagulants. Most DOAC patients remained on DOACs from inpatient/ED to outpatient settings (71.4%), while 24.1%, 43.5%, and 0.1% of patients treated with LMWH, warfarin, or UFH respectively, remained on the same therapy after discharge. In addition, DOACs were the most common initial post-discharge outpatient therapy. Outpatient treatment persistence and adherence appeared higher in patients using DOACs or warfarin versus LMWH or UFH. This study shows that DOACs are used as an inpatient/ED treatment option for CAT, and are associated with less post-discharge treatment switching and higher persistence and adherence. Further research generating real-world evidence on the role of DOACs to help inform the complex CAT clinical treatment decisions is warranted.

Implementation research for public sector mental health care scale-up (SMART-DAPPER): a sequential multiple, assignment randomized trial (SMART) of non-specialist-delivered psychotherapy and/or medication for major depressive disorder and posttraumatic stress disorder (DAPPER) integrated with outpatient care clinics at a county hospital in Kenya.

BACKGROUND: Mental disorders are a leading cause of global disability, driven primarily by depression and anxiety. Most of the disease burden is in Low and Middle Income Countries (LMICs), where 75% of adults with mental disorders have no service access. Our research team has worked in western Kenya for nearly ten years. Primary care populations in Kenya have high prevalence of Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). To address these treatment needs with a sustainable, scalable mental health care strategy, we are partnering with local and national mental health stakeholders in Kenya and Uganda to identify 1) evidence-based strategies for first-line and second-line treatment delivered by non-specialists integrated with primary care, 2) investigate presumed mediators of treatment outcome and 3) determine patient-level moderators of treatment effect to inform personalized, resource-efficient, non-specialist treatments and sequencing, with costing analyses. Our implementation approach is guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. METHODS/DESIGN: We will use a Sequential, Multiple Assignment Randomized Trial (SMART) to randomize 2710 patients from the outpatient clinics at Kisumu County Hospital (KCH) who have MDD, PTSD or both to either 12 weekly sessions of non-specialist-delivered Interpersonal Psychotherapy (IPT) or to 6 months of fluoxetine prescribed by a nurse or clinical officer. Participants who are not in remission at the conclusion of treatment will be re-randomized to receive the other treatment (IPT receives fluoxetine and vice versa) or to combination treatment (IPT and fluoxetine). The SMART-DAPPER Implementation Resource Team, (IRT) will drive the application of the EPIS model and adaptations during the course of the study to optimize the relevance of the data for generalizability and scale -up. DISCUSSION: The results of this research will be significant in three ways: 1) they will determine the effectiveness of non-specialist delivered first- and second-line treatment for MDD and/or PTSD, 2) they will investigate key mechanisms of action for each treatment and 3) they will produce tailored adaptive treatment strategies essential for optimal sequencing of treatment for MDD and/or PTSD in low resource settings with associated cost information - a critical gap for addressing a leading global cause of disability. TRIAL REGISTRATION: ClinicalTrials.gov NCT03466346, registered March 15, 2018.

Trends in Avoidable Hospitalizations for Diabetes: Experience of a Large Clinically Integrated Health Care System.

Prevention quality indicators (PQIs) are used in hospital discharge data sets to identify quality of care for ambulatory care-sensitive conditions, such as diabetes. We examined the impact of clinical integration efforts on diabetes-related PQIs in a large community-based health care organization. Inpatient and observation hospitalizations from nine acute care hospitals were trended over 5 years (2012-2016). Using established technical specifications, annual hospitalizations rates were calculated for four diabetes-related PQIs: uncontrolled diabetes, short-term complications, long-term complications, and lower extremity amputations. The mean (±standard error of the mean) annual hospitalization rate for uncontrolled diabetes and short-term complications gradually increased from 1.3 ± 1.1 and 3.2 ± 2.5 per 1,000 discharges to 2.4 ± 1.7 (p < .001) and 7.1 ± 3.2 (p < .001) per 1,000 discharges, respectively. Conversely, the annual hospitalization rate for long-term complications and lower extremity amputations gradually decreased from 12.6 ± 1.1 and 88.6 ± 1.0 per 1,000 discharges to 6.5 ± 1.0 (p = .004) and 82.2 ± 1.0 per 1,000 discharges (p < .001). Trends generally persisted across payers, age, sex, and race. There was an inverse correlation between county income-per-capita and hospitalization rate for short-term complications (p = .04), long-term complications (p = .03), and lower extremity amputations (p < .001). Study limitations included use of administrative data, evolving coding practices, and ecological fallacy. Ambulatory-based efforts to optimize diabetes care can prevent long-term complications and reduce avoidable hospitalizations.

Coordinating Outpatient Care for Pregnant and Postpartum Women with Opioid Use Disorder: Implications from the COACHH Program.

Purpose With the rise of opioid use disorder (OUD) among women of childbearing age, effective care models must address the complex needs of pregnant and postpartum women with OUD. This paper describes promising practices and implementation challenges from the Collaborative Outreach and Adaptable Care at Hallmark Health (COACHH) program, which utilizes a collaborative care team to coordinate outpatient care for pregnant and postpartum women with OUD. Description Semi-structured interviews were conducted with members of the COACHH team to discuss program logistics and takeaways. Interviews were coded to analyze themes. Assessment The COACHH team identified the need for specialized, time-intensive care coordination to address the unique needs of pregnant and postpartum women with OUD. First, the team prioritizes forming trusting relationships with patients to holistically understand patients' needs, improve patient engagement, and connect patients with resources. Second, the wide range of patient needs necessitates a team with diverse professional skills, whose members share an understanding of addiction and pregnancy. Third, finding the right quantitative outcome measurements is difficult; instead, success is measured in qualitative terms, stressing relationships and engagement as signals of change. Finally, the team encounters challenges with low referral rates, lack of provider awareness, and fragmented services. Conclusion We identified care delivery and program design considerations that may inform others who wish to coordinate care for pregnant and postpartum women with OUD. The program continues to face challenges enrolling patients and measuring outcomes, reflecting the need for tailored approaches and metrics for this population.

Trends in Outpatient Antibiotic Use in 3 Health Plans.

OBJECTIVES: Previous analyses of data from 3 large health plans suggested that the substantial downward trend in antibiotic use among children appeared to have attenuated by 2010. Now, data through 2014 from these same plans allow us to assess whether antibiotic use has declined further or remained stable. METHODS: Population-based antibiotic-dispensing rates were calculated from the same health plans for each study year between 2000 and 2014. For each health plan and age group, we fit Poisson regression models allowing 2 inflection points. We calculated the change in dispensing rates (and 95% confidence intervals) in the periods before the first inflection point, between the first and second inflection points, and after the second inflection point. We also examined whether the relative contribution to overall dispensing rates of common diagnoses for which antibiotics were prescribed changed over the study period. RESULTS: We observed dramatic decreases in antibiotic dispensing over the 14 study years. Despite previous evidence of a plateau in rates, there were substantial additional decreases between 2010 and 2014. Whereas antibiotic use rates decreased overall, the fraction of prescribing associated with individual diagnoses was relatively stable. Prescribing for diagnoses for which antibiotics are clearly not indicated appears to have decreased. CONCLUSIONS: These data revealed another period of marked decline from 2010 to 2014 after a relative plateau for several years for most age groups. Efforts to decrease unnecessary prescribing continue to have an impact on antibiotic use in ambulatory practice.

The Family Health Strategy: expanding access and reducinghospitalizations due to ambulatory care sensitive conditions (ACSC). / Do Programa à Estratégia Saúde da Família: expansão do acesso e redução das internações por condições sensíveis à atenção básica (ICSAB).

Since its creation in 1994, the Family Health Program has become the main strategy for changing care models and increasing access to the first contact service of the Unified Health System (SUS). A little more than ten years later, in 2006 the program was transformed into the Family Health Strategy (FHS) within the National Policy on Primary Care (PNAB). This article evaluates the effects of the implementation of the FHS over the last two decades in Brazil, demonstrating the access provided and the trends in ambulatory care sensitive conditions (ACSC). This is an ecological, time series study with secondary data referring to the number of family health teams that were established and the number of hospital admissions due to ACSC in the SUS from 2001-2016. The results show a 45% reduction of the standardized ACSC rates per 10,000 inhabitants, from 120 to 66 in the period 2001-2016. Although it was not possible to isolate the specific effects of primary care, it is quite plausible that this reduction in ACSC rates is linked to the progress of FHS coverage in Brazil, especially in terms of improved follow-up of chronic conditions, improved diagnosis and easier access to medicines.

Criado em 1994, o Programa Saúde da Família gradualmente tornou-se a principal estratégia para a mudança do modelo assistencial e a ampliação do acesso de primeiro contato aos serviços de saúde no SUS. Pouco mais de dez anos depois foi enunciada como Estratégia de Saúde da Família (ESF) na Política Nacional de Atenção Básica (PNAB), em 2006. Este artigo avaliou os efeitos da implementação da ESF ao longo das duas últimas décadas no Brasil, demonstrando o acesso proporcionado e a tendência das internações por condições sensíveis à atenção básica (ICSAB). Trata-se de um estudo do tipo ecológico de séries temporais com dados secundários referentes ao número de equipes implantadas de saúde da família e às ICSAB no SUS de 2001 a 2016. Os resultados evidenciam a redução em 45% das taxas padronizadas de ICSAB por 10.000 hab, que passaram de 120 para 66 no período de 2001 a 2016. Apesar de não ser possível isolar os efeitos da atenção primária, é bastante plausível que o resultado da redução das ICSAB esteja vinculada ao avanço da cobertura da ESF no Brasil, em especial na melhoria do acompanhamento das condições crônicas, no aprimoramento do diagnóstico e na facilidade do acesso aos medicamentos.

Do Programa à Estratégia Saúde da Família: expansão do acesso e redução das internações por condições sensíveis à atenção básica (ICSAB) / The Family Health Strategy: expanding access and reducinghospitalizations due to ambulatory care sensitive conditions (ACSC)

Resumo Criado em 1994, o Programa Saúde da Família gradualmente tornou-se a principal estratégia para a mudança do modelo assistencial e a ampliação do acesso de primeiro contato aos serviços de saúde no SUS. Pouco mais de dez anos depois foi enunciada como Estratégia de Saúde da Família (ESF) na Política Nacional de Atenção Básica (PNAB), em 2006. Este artigo avaliou os efeitos da implementação da ESF ao longo das duas últimas décadas no Brasil, demonstrando o acesso proporcionado e a tendência das internações por condições sensíveis à atenção básica (ICSAB). Trata-se de um estudo do tipo ecológico de séries temporais com dados secundários referentes ao número de equipes implantadas de saúde da família e às ICSAB no SUS de 2001 a 2016. Os resultados evidenciam a redução em 45% das taxas padronizadas de ICSAB por 10.000 hab, que passaram de 120 para 66 no período de 2001 a 2016. Apesar de não ser possível isolar os efeitos da atenção primária, é bastante plausível que o resultado da redução das ICSAB esteja vinculada ao avanço da cobertura da ESF no Brasil, em especial na melhoria do acompanhamento das condições crônicas, no aprimoramento do diagnóstico e na facilidade do acesso aos medicamentos.

Abstract Since its creation in 1994, the Family Health Program has become the main strategy for changing care models and increasing access to the first contact service of the Unified Health System (SUS). A little more than ten years later, in 2006 the program was transformed into the Family Health Strategy (FHS) within the National Policy on Primary Care (PNAB). This article evaluates the effects of the implementation of the FHS over the last two decades in Brazil, demonstrating the access provided and the trends in ambulatory care sensitive conditions (ACSC). This is an ecological, time series study with secondary data referring to the number of family health teams that were established and the number of hospital admissions due to ACSC in the SUS from 2001-2016. The results show a 45% reduction of the standardized ACSC rates per 10,000 inhabitants, from 120 to 66 in the period 2001-2016. Although it was not possible to isolate the specific effects of primary care, it is quite plausible that this reduction in ACSC rates is linked to the progress of FHS coverage in Brazil, especially in terms of improved follow-up of chronic conditions, improved diagnosis and easier access to medicines.

Current healthcare pathways in the treatment of rhinosinusitis in Germany.

BACKGROUND: In the outpatient setting in Germany, patients with rhinosinusitis usually present at general practices (GP) or ear, nose, and throat practices (ENT) for initial diagnosis and treatment. OBJECTIVES: The aim of this study was to analyze the referral patterns of rhinosinusitis patients in GPs and ENT practices in Germany, with respect to existing recommendations. MATERIAL AND METHODS: The study sample included patients from 940 GP and 106 ENT practices from Disease Analyzer database (IQVIA) who received an acute sinusitis (AS) or chronic sinusitis (CS), or nasal polyp (NP) in 2015. RESULTS: The total numbers of patients in GP versus ENT practices were 24,648 versus 12,095 (AS), 26,768 versus 19,826 (CS), and 516 versus 1773 patients (NP). Referrals to ENT practices were made by GP in 12.3% (AS), 14.8% (CS), and 40.5% (NP). The percentages of patients in GP versus ENT practices with subsequent hospital admissions were 6.9 versus 3.3% (AS), 6.3 versus 6.5% (CS), and 9.5 versus 13.8% (NP), respectively. CONCLUSIONS: Although 40% of patients with NP who consult GPs are referred to ENT practices, it remains unclear how the other 60% are being treated. The hospital admission rates of patients with CS as well as of patients with NP were found to be surprisingly low.

Provision of Lifestyle Counseling and the Prescribing of Pharmacotherapy for Hyperlipidemia Among US Ambulatory Patients: A National Assessment of Office-Based Physician Visits.

BACKGROUND: An estimated 27.8% of the United States (US) population aged ≥20 years has hyperlipidemia, defined as total serum cholesterol of ≥240 mg/dL. A previous study of US physician office visits for hyperlipidemia in 2005 found both suboptimal compliance and racial/ethnic disparities in screening and treatment. OBJECTIVE: The aim was to estimate current rates of laboratory testing, lifestyle education, and pharmacotherapy for hyperlipidemia. METHODS: Data were derived from the US National Ambulatory Medical Care Survey (NAMCS), a nationally representative study of office-based physician visits, for 2013-2014. Patients aged ≥20 years with a primary or secondary diagnosis of hyperlipidemia were sampled. Study outcomes included receipt or ordering of total cholesterol testing, diet/nutrition counseling, exercise counseling, and pharmacotherapy prescription including statins, ezetimibe, omega-3 fatty acids, niacin, or combination therapies. RESULTS: Compared with previously reported results for 2005, rates of pharmacotherapy have remained static (52.2 vs. 54.6% for 2005 and 2013-2014, respectively), while rates of lifestyle education have markedly declined for diet/nutrition (from 39.7 to 22.4%) and exercise (from 32.1 to 16.0%). Lifestyle education did not vary appreciably by race/ethnicity in 2013-2014. However, rates of lipid testing were much higher for whites (41.6%) than for blacks (29.9%) or Hispanics (34.2%). Tobacco education was ordered/provided in only 4.0% of office visits. CONCLUSION: Compliance with guidelines for the screening and treatment of hyperlipidemia remains suboptimal, and rates of lifestyle education have declined since 2005. There exists an urgent need for enhanced levels of provider intervention to reduce the morbidity and mortality associated with hyperlipidemia.

Ambulatory Care Use among Patients with Spina Bifida: Change in Care from Childhood to Adulthood.

PURPOSE: We examined the ambulatory health care visit use of children with spina bifida, adults who transitioned to adult care and adults who continued to seek care in a pediatric setting. MATERIALS AND METHODS: We evaluated use during a 1-year period of patients with spina bifida who visited any outpatient medical clinic within an integrated health care system. Patients were categorized as pediatric (younger than 18 years) or adult (age 18 or older). Adults were divided into those who did not fully transition to adult care and patients who fully transitioned (adult). Frequency and type of health care use were compared. Subanalysis was performed for patients 18 to 25 years old to examine variables associated with successful complete transition to adult care. RESULTS: During 1 year 382 children, 88 patients who did not transition and 293 adult patients with spina bifida had 4,931 clinic visits. Children had greater ambulatory care use (7.25 visits per year) compared to fully transitioned adults (5.33 visits per year, p=0.046). Children more commonly visited surgical clinics (52.3% of visits) and adults more commonly visited medical clinics (48.9%) (p <0.005). Adult transitioned patients were more likely to be female (p=0.004). Of the patients 18 to 25 years old, those who did not transition to adult care had similar outpatient visit types but greater use of inpatient and emergency care than those who transitioned. CONCLUSIONS: Children with spina bifida used more ambulatory care than adults and were more likely to visit a surgical specialist. Adult patients with spina bifida who successfully transitioned to adult care were more likely to be female, and patients who failed to transition were more likely to receive more inpatient and emergency care.

Predictors of Use of Monitored Anesthesia Care for Outpatient Gastrointestinal Endoscopy in a Capitated Payment System.

BACKGROUND & AIMS: Use of monitored anesthesia care (MAC) for gastrointestinal endoscopy has increased in the Veterans Health Administration (VHA) as in fee-for-service environments, despite the absence of financial incentives. We investigated factors associated with use of MAC in an integrated health care delivery system with a capitated payment model. METHODS: We performed a retrospective cohort study using multilevel logistic regression, with MAC use modeled as a function of procedure year, patient- and provider-level factors, and facility effects. We collected data from 2,091,590 veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy during fiscal years 2000-2013 at 133 facilities. RESULTS: The adjusted rate of MAC use in the VHA increased 17% per year (odds ratio for increase, 1.17; 95% confidence interval, 1.09-1.27) from fiscal year 2000 through 2013. The most rapid increase occurred starting in 2011. VHA use of MAC was associated with patient-level factors that included obesity, obstructive sleep apnea, higher comorbidity, and use of prescription opioids and/or benzodiazepines, although the magnitude of these effects was small. Provider-level and facility factors were also associated with use of MAC, although again the magnitude of these associations was small. Unmeasured facility-level effects had the greatest effect on the trend of MAC use. CONCLUSIONS: In a retrospective study of veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy from fiscal year 2000 through 2013, we found that even in a capitated system, patient factors are only weakly associated with use of MAC. Facility-level effects are the most prominent factor influencing increasing use of MAC. Future studies should focus on better defining the role of MAC and facility and organizational factors that affect choice of endoscopic sedation. It will also be important to align resources and incentives to promote appropriate allocation of MAC based on clinically meaningful patient factors.

[2016 literature findings in internal general medicine]. / Acquisitions thérapeutiques en médecine ambulatoire en 2016.

Treatment with diclofenac appears to be more effective compared to other NSAIDs in the treatment of osteoarthritis of the large joints. Opioids do not diminish significantly the pain in chronic lower back pain. Degenerative tears of the meniscus, without signs of osteoarthritis, should be treated conservatively. Acute appendicitis without perforation signs should be treated conservatively if possible. Mindfulness meditation could prevent the recurrence of episodes in major depression. Oropharyngeal exercises could reduce the frequency and intensity of snoring. The choice of treatment in Helicobacter pylori infection must consider its effectiveness and tolerance. Concomitant use of statins and vitamin D could be an interesting alternative treatment in migraines.

Le traitement par diclofénac semble être le plus efficace comparé aux autres AINS dans le traitement de la gonarthrose et de la coxarthrose. Les opioïdes ne diminuent pas la douleur de manière significative lors de lombalgies chroniques. Les ruptures dégénératives du ménisque, sans signe d'arthrose, devraient être traitées conservativement. L'appendicite aiguë sans signe de perforation devrait l'être également. La méditation en pleine conscience permettrait de prévenir les récidives lors de dépression majeure. Les exercices oropharyngés pourraient réduire la fréquence et l'intensité des ronflements. Le choix du traitement éradicateur de l'Helicobacter pylori doit tenir compte de son effectivité et de sa tolérance. La prise de statines et de vitamine D constituerait une alternative lors de migraines.

[Regional Budgets in Psychiatry: An Alternative to Hospital per Diem Charges and the New Reimbursement System? - A Case Study from the District of Dithmarschen]. / Regionalbudgets in der Psychiatrie: Eine Alternative zu tagesgleichen Pflegesätzen und zum zukünftigen Finanzierungssystem?

Objective The study looked at the impact that the switch from a reimbursement system with hospital per diem charges to a regional budget had on treatment. Methods Routine data from two clinics over a period of ten years were evaluated. Results Treatment took place in day clinics and on an outpatient basis to an increased extent after the change. Conclusion The change in reimbursement system was the cause of the change in treatment. Since similar effects can also be expected when switching from the new reimbursement system for psychiatry and psychosomatic medicine to a regional budget system, regional budgets are a reasonable alternative.