Disruptions to Abortion Care in Louisiana During Early Months of the COVID-19 Pandemic.

Objectives. To examine changes in abortions in Louisiana before and after the COVID-19 pandemic onset and assess whether variations in abortion service availability during this time might explain observed changes. Methods. We collected monthly service data from abortion clinics in Louisiana and neighboring states among Louisiana residents (January 2018‒May 2020) and assessed changes in abortions following pandemic onset. We conducted mystery client calls to 30 abortion clinics in Louisiana and neighboring states (April‒July 2020) and examined the percentage of open and scheduling clinics and median waits. Results. The number of abortions per month among Louisiana residents in Louisiana clinics decreased 31% (incidence rate ratio = 0.69; 95% confidence interval [CI] = 0.59, 0.79) from before to after pandemic onset, while the odds of having a second-trimester abortion increased (adjusted odds ratio [AOR] = 1.91; 95% CI = 1.10, 3.33). The decrease was not offset by an increase in out-of-state abortions. In Louisiana, only 1 or 2 (of 3) clinics were open (with a median wait > 2 weeks) through early May. Conclusions. The COVID-19 pandemic onset was associated with a significant decrease in the number of abortions and increase in the proportion of abortions provided in the second trimester among Louisiana residents. These changes followed service disruptions.

Ambulatory care for epilepsy via telemedicine during the COVID-19 pandemic.

OBJECTIVE: To assess feasibility, patient satisfaction, and financial advantages of telemedicine for epilepsy ambulatory care during the current COVID-19 pandemic. METHODS: The demographic and clinical characteristics of all consecutive patients evaluated via telemedicine at a level 4 epilepsy center between March 20 and April 20, 2020 were obtained retrospectively from electronic medical records. A telephone survey to assess patient satisfaction and preferences was conducted within one month following the initial visit. RESULTS: Among 223 telehealth patients, 85.7% used both synchronous audio and video technology. During the visits, 39% of patients had their anticonvulsants adjusted while 18.8% and 11.2% were referred to laboratory/diagnostic testing and specialty consults, respectively. In a post-visit survey, the highest degree of satisfaction with care was expressed by 76.9% of patients. The degree of satisfaction tended to increase the further a patient lived from the clinic (p = 0.05). Beyond the pandemic, 89% of patients reported a preference for continuing telemedicine if their epilepsy symptoms remained stable, while only 44.4% chose telemedicine should their symptoms worsen. Inclement weather and lack of transportation were factors favoring continued use of telemedicine. An estimated cost saving to patient attributed to telemedicine was $30.20 ±â€¯3.8 per visit. SIGNIFICANCE: Our findings suggest that epilepsy care via telemedicine provided high satisfaction and economic benefit, without compromising patients' quality of care, thereby supporting the use of virtual care during current and future epidemiological fallouts. Beyond the current pandemic, patients with stable seizure symptoms may prefer to use telemedicine for their epilepsy care.

Evaluation of the prescribing practice of guideline-directed medical therapy among ambulatory chronic heart failure patients.

BACKGROUND: Studies have demonstrated that heart failure (HF) patients who receive direct pharmacist input as part of multidisciplinary care have better clinical outcomes. This study evaluated/compared the difference in prescribing practices of guideline-directed medical therapy (GDMT) for chronic HF patients between two multidisciplinary clinics-with and without the direct involvement of a pharmacist. METHODS: A retrospective audit of chronic HF patients, presenting to two multidisciplinary outpatient clinics between March 2005 and January 2017, was performed; a Multidisciplinary Ambulatory Consulting Service (MACS) with an integrated pharmacist model of care and a General Cardiology Heart Failure Service (GCHFS) clinic, without the active involvement of a pharmacist. RESULTS: MACS clinic patients were significantly older (80 vs. 73 years, p < .001), more likely to be female (p < .001), and had significantly higher systolic (123 vs. 112 mmHg, p < .001) and diastolic (67 vs. 60 mmHg, p < .05) blood pressures compared to the GCHF clinic patients. Moreover, the MACS clinic patients showed more polypharmacy and higher prevalence of multiple comorbidities. Both clinics had similar prescribing rates of GDMT and achieved maximal tolerated doses of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in HFrEF. However, HFpEF patients in the MACS clinic were significantly more likely to be prescribed ACEIs/ARBs (70.5% vs. 56.2%, p = 0.0314) than the GCHFS patients. Patients with both HFrEF and HFpEF (MACS clinic) were significantly less likely to be prescribed ß-blockers and mineralocorticoid receptor antagonists. Use of digoxin in chronic atrial fibrillation (AF) in MACS clinic was significantly higher in HFrEF patients (82.5% vs. 58.5%, p = 0.004), but the number of people anticoagulated in presence of AF (27.1% vs. 48.0%, p = 0.002) and prescribed diuretics (84.0% vs. 94.5%, p = 0.022) were significantly lower in HFpEF patients attending the MACS clinic. Age, heart rate, systolic blood pressure (SBP), anemia, chronic renal failure, and other comorbidities were the main significant predictors of utilization of GDMT in a multivariate binary logistic regression. CONCLUSIONS: Lower prescription rates of some medications in the pharmacist-involved multidisciplinary team were found. Careful consideration of demographic and clinical characteristics, contraindications for use of medications, polypharmacy, and underlying comorbidities is necessary to achieve best practice.

Variability and trends over time and across centres in haemodialysis weekly duration in Australia and New Zealand.

AIM: Haemodialysis treatment prescription varies widely internationally. This study explored patient- and centre-level characteristics associated with weekly haemodialysis hours. METHODS: Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data were analysed. Characteristics associated with weekly duration were evaluated using mixed-effects linear regression models with patient- and centre-level covariates as fixed effects, and dialysis centre and state as random effects using the 2017 prevalent in-centre haemodialysis (ICHD) and home haemodialysis (HHD) cohorts. Evaluation of patterns of weekly duration over time analysed the 2000 to 2017 incident ICHD and HHD cohorts. RESULTS: Overall, 12 494 ICHD and 1493 HHD prevalent patients in 2017 were included. Median weekly treatment duration was 13.5 (interquartile range [IQR] 12-15) hours for ICHD and 16 (IQR 15-20) hours for HHD. Male sex, younger age, higher body mass index, arteriovenous fistula/graft use, Aboriginal and Torres Strait Islander ethnicity and longer dialysis vintage were associated with longer weekly duration for both ICHD and HHD. No centre characteristics were associated with duration. Variability in duration across centres was very limited in ICHD compared with HHD, with variation in HHD being associated with state. Duration did not vary significantly over time for ICHD, whereas longer weekly HHD treatments were reported between 2006 and 2012 compared with before and after this period. CONCLUSION: This study in the Australian and New Zealand haemodialysis population showed that weekly duration was primarily associated with patient characteristics. No centre effect was demonstrated. Practice patterns seemed to differ across states/countries, with more variability in HHD than ICHD.

Colocating Wound Care for Patients with Sickle Cell Ulcers in a Hematology Clinic.

OBJECTIVE: Leg ulcers affect 15% of people with sickle cell disease. However, wound centers typically treat few people with this condition, which makes it difficult to concentrate clinical expertise or support the scientific study of this orphan disease. This article describes an initiative to increase engagement in care through a partnership between wound healing and hematology leadership that led to colocating wound services within a sickle cell clinic. METHODS: Via a retrospective chart review, the authors collected records of all adult patients with sickle cell disease who received wound care in the last decade, including 7 years of wound center data and 3 years of data from the colocated services. Patient and visit characteristics were analyzed using descriptive analytics. RESULTS: The general wound center had previously treated 35 patients with sickle cell ulcers over 7 years. In contrast, colocated services engaged 56 patients within 3 years, including 20 who transferred care and 36 new patients. The majority of patients at the colocated site were women, unlike at the wound center (58% vs 47%, P = .07). Results indicated that 36% of patients healed initial wounds, and 45% had new wound occurrences. CONCLUSIONS: Colocation successfully increases the number of patients with sickle cell ulcers who will engage in wound care at a single site, laying the foundation for clinical studies to improve the evidence base for this difficult-to-treat condition.

Botulinum toxin therapy in the SARS-CoV-2 pandemic: patient perceptions from a German cohort.

The SARS-CoV-2 virus pandemic has provoked drastic countermeasures including shutdowns of public services. We wanted to describe the effects of a 6 week shutdown of a large German botulinum toxin (BT) outpatient clinics on patients and their well-being. 45 patients (age 61.9 ± 9.8 years, 29 females, 16 males) receiving BT therapy (319.3 ± 201.9MU-equivalent, treatment duration 8.3 ± 5.5 years) were surveyed with a standardised questionnaire. The shutdown delayed BT therapy by 6.6 ± 2.3 weeks. 93% of the patients noticed increased muscle cramps and 82% increased pain reducing their quality of life by 40.2 ± 19.5%. For 23 patients with cervical dystonia this reduction was 41.1 ± 18.3%, for 3 patients with blepharospasm 33.3 ± 15.3%, for 9 patients with spasticity 37.8 ± 15.6%, for 4 patients with pain conditions 37.4 ± 35.7% and for 3 patients with hemifacial spasm 27.5 ± 17.1%. After the shutdown 66% of patients perceived BT therapy as more important than before, 32% perceived it as unchanged. For all patients long-term availability of BT therapy was very important or important. 98% of the patients perceived the shutdown as inadequate and felt their patient rights not respected. The shutdown confirmed the considerable burden of disease caused by dystonia, spasticity, hemifacial spasm and various pain conditions and the importance of BT therapy to treat them. Any shutdown severely affects these patients and needs to be avoided.

Improved Glycemic Control Outcomes Regardless of Mental Health Disorders in a Pharmacist-Endocrinologist Diabetes Intense Medical Management (DIMM) "Tune Up" Clinic.

Background: Previous studies show patients with type 2 diabetes (T2D) and a mental health (MH) disorder exhibit poorer glycemic control compared with those without. Objective: Compare mean change in glycosylated hemoglobin (A1C) after 6 months in the Diabetes Intense Medical Management (DIMM) "Tune Up" Clinic in patients with and without MH disorders. Methods: Retrospective cohort study in T2D patients, with A1C at baseline and 6 months, divided into subgroups of those with ≥1 MH diagnoses and without MH. Primary outcome was mean change in A1C from baseline to 6 months. Secondary outcomes were mean change in other metabolic parameters and proportion achieving A1C and related goals. Results: Of 155 patients meeting inclusion criteria, 66 (42.6%) had at least 1 MH disorder (MH group) and 89 (57.4%) did not (non-MH group). Mean A1C, fasting blood glucose (FBG), and triglycerides (TG) change (improvement) did not differ significantly between MH and non-MH groups at 6 months (eg, A1C reduction: -2.1% [SD = 2.0] vs -2.3% [SD = 2.1]; P = 0.61, respectively). Percentage at A1C goal did not differ significantly between groups, though a higher percentage of the non-MH group achieved FBG and TG goals than the MH group. Conclusion and Relevance: In 6 months, both groups in the DIMM clinic achieved a statistically significant mean A1C reduction (over 2%) with no statistical or clinical difference in the magnitude of change between groups. Patients with T2D benefitted from the DIMM model and personalized visits with a pharmacist regardless of having a MH disorder.

Evaluation of an ambulatory geriatric rehabilitation program - results of a matched cohort study based on claims data.

BACKGROUND: Ambulatory geriatric rehabilitation (AGR) is a multidisciplinary outpatient prevention program designed to decrease hospitalisation and dependence on nursing care in multimorbid patients ≥70 years of age. We evaluated the effectiveness of AGR compared to usual care on progression of nursing care levels, nursing home admissions, hospital admissions, incident fractures, mortality rate and total cost of care during a one-year follow-up period. METHODS: Analyses were based on claims data from the health insurance company AOK Nordost. Propensity Score matching was used to match 4 controls to each person receiving the AGR intervention. RESULTS: A total of 632 AGR participants and 2528 matched controls were included. The standardized mean difference of matching variables between cases and controls was small (mean: + 1.4%; range: - 4.4/3.9%). In AGR patients, the progression of nursing care levels (+ 2.2%, 95%CI: - 0.9 /5.3), nursing home admissions (+ 1.7%, 95%CI: - 0.1/3.5), hospital admissions (+ 1.1%, 95%CI: - 3.2/5.4), incident fractures (+ 11.1%, 95%CI: 7.3/15) and mortality rate (+ 1.2%, p = 0.20) showed a less favourable course compared to controls. The average total cost per AGR participant was lower than in the control group (- 353€, 95%CI: - 989€/282€), not including costs for AGR. CONCLUSIONS: Analysis based on claims data showed no clinical benefit from AGR intervention regarding the investigated outcomes. The slightly worse outcomes may reflect limitations in matching based on claims data, which may have insufficiently reflected morbidity and psychosocial factors. It is possible that the intervention group had poorer health status at baseline compared to the control group. TRIAL REGISTRATION: German Clinical Trials Register DRKS00008926, registered 29.07.2015.

A Novel Model for a Free Clinic for Prenatal and Infant Care in Detroit.

PURPOSE: Detroit experiences the highest preterm birth rate and some of the worst birth outcomes in the country. Women and children have extremely high levels of poverty and face numerous barriers to care including lack of trust and racial disparities in care and concrete barriers such as limited transportation and childcare, work hour conflicts, and lack of insurance. DESCRIPTION: We report on a unique model of patient care focused on providing patient-centered care and building trusting relationships. This model is encompassed in a new free, volunteer-run, faith-based clinic which offers prenatal, postpartum, and infant care. ASSESSMENT: In the first 2 years of operation, demand for services rose rapidly and there were stellar clinical outcomes, despite the fact that Luke patients are among the medically and socially highest risk populations in the nation. CONCLUSION: While marginalized populations have worse birth outcomes and far more infant deaths, making care accessible and responsive to patient needs while focusing on building patient relationships is an important strategy to improve outcomes.

Check-in Kiosks in the Outpatient Clinical Setting: Fad or the Future?

OBJECTIVES: Check-in kiosks are increasingly used in health care. This project aims to assess the effects of kiosk use upon check-in duration, point of service (POS) financial returns, and patient satisfaction. METHODS: Six kiosks were implemented in a large academic orthopedic clinic, and check-in duration for 8.5 months following implementation and POS returns for 10.5 months before and after implementation were analyzed. Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey and self-devised surveys recorded patient satisfaction. RESULTS: Cumulatively, 28,636 kiosk-based patient encounters were analyzed. Compared with historical norms, check-in duration decreased 2 minutes, 47 seconds (P < 0.001). Daily gross and individual POS returns increased $532.13 and $1.89, respectively (P < 0.001). Satisfaction surveys were completed by 719 of 1376 consecutive patients (52% response rate), revealing 12% improvement (P < 0.001), but Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey responses demonstrated no change (P = 0.146, 0.928, and 0.336). CONCLUSIONS: Kiosks offer to reduce check-in duration and increase POS revenue without negatively affecting patient satisfaction.

Provision of STD Services in Community Settings After the Loss and Return of State Funding to Support Service Provision: Observations From Select Providers in Massachusetts, 2010 and 2013.

CONTEXT: In 2008, the $1.2 M sexually transmitted disease (STD) services line item supporting STD clinical services by the Massachusetts Department of Public Health was eliminated, forcing the cessation of all state-supported STD service delivery. OBJECTIVE: To determine the impact on community provision of STD services after the elimination of state funds supporting STD service provision. DESIGN AND SETTING: Rapid ethnographic assessments were conducted in May 2010 and September 2013 to better understand the impact of budget cuts on STD services in Massachusetts. The rapid ethnographic assessment teams identified key informants through Massachusetts's STD and human immunodeficiency virus programs. PARTICIPANTS: Fifty providers/clinic administrators in 19 sites (15 unique) participated in a semistructured interview (community health centers [n = 10; 53%], hospitals [n = 4; 21%], and other clinical settings [n = 5; 26%]). RESULTS: Results clustered under 3 themes: financial stability of agencies/clinics, the role insurance played in the provision of STD care, and perceived clinic capacity to offer appropriate STD services. Clinics faced hard choices about whether to provide care to patients or refer elsewhere patients who were unable or unwilling to use insurance. Clinics that decided to see patients regardless of ability to pay often found themselves absorbing costs that were then passed along to their parent agency; the difficulty and financial strain incurred by a clinic's parent agency by providing STD services without support by state grant dollars emerged as a primary concern. Meeting patient demand with staff with appropriate training and expertise remained a concern. CONCLUSIONS: Provision of public health by private health care providers may increase concern among some community provision sites about the sustainability of service provision absent external funds, either from the state or from the third-party billing. Resource constraints may be felt across clinic operations. Provision of public health in the for-profit health system involves close consideration of resources, including those: leveraged, used to provide uncompensated care, or available for collection through third-party billing.

The Diagnostic-Therapeutic Care Pathway in Psoriasis: Towards ISO 9001:2015 Certification.

Background and objectives: Psoriasis (Pso) is a common skin condition characterized by a strong psychosocial impact, and is nowadays accepted as a systemic immune-mediated inflammatory disease. Diagnostic-Therapeutic Care Pathways (DTCPs) represent a predefined sequence of diagnostic, therapeutic, and assistance activities that integrate the participation of several specialists to obtain, for each patient, the correct diagnosis and thus the most appropriate therapy. A DTCP was validated in our dermatology clinic (AOU Maggiore della Carità, Novara, Italy). The validation process included the detailed elaboration of a protocol of diagnosis, staging of care, therapies, and follow-up of the patient with Pso. The formalization and adaptation of our DTCP resulted in ISO 9001: 2015 certification in May 2019. Materials and methods: This process involved several stages, including analysis of context and the identification of (i) targets, (ii) indicators, and (iii) service providers. The evaluation was based on a cohort of over 200 patients affected by moderate to severe Pso, who were treated and followed-up at our institution from September 2017 to April 2019. Results: The ISO 9001:2015 quality certification process allowed us to identify our weaknesses, i.e., the long waiting times for the first visit and the reduced physician-patient ratio, but also our strengths, such as the commitment to clinical research, effective collaboration with other specialists, the efficient use of technological and human resources, and attention to ensuring patient follow-up. Conclusions: In qualifying for and achieving the ISO Quality Management System (QMS) certification we were heartened to realize that our basic methodology and approach were fit for purpose. The implementation of the ISO QMS helped us to reorganize our priorities by placing the patient at the center of the process and raising awareness that Pso is not just a skin disease.

Implementation of a Smoking Cessation e-Learning Education Program for Oncology Clinic Healthcare Providers: Evaluation With Implications for Evidence-Based Practice.

BACKGROUND: Continued smoking after a cancer diagnosis increases the risk for treatment complications, primary cancer recurrence, and secondary malignancy development, while also reducing treatment efficacy, survival, and overall health. The lack of formal evidence-based smoking cessation education programs for oncology healthcare providers is a barrier to smoking cessation practices. PURPOSE: To evaluate the use of an evidence-based, smoking cessation e-learning education program for oncology healthcare providers. METHODS: A single group, pre- and post-test, nonexperimental design was used in this evidence-based quality improvement project. To assess the provider's knowledge in smoking cessation, a baseline assessment, a post-test, and an online survey were completed by the providers. A telephone survey was conducted to assess the patients' perception of cessation services received. RESULTS: The healthcare providers' (N = 58) test scores on smoking cessation knowledge increased significantly (p < .0001) after completing the e-learning education program. A majority of the providers reported that the education program increased their confidence (86%) in successfully helping the patient to quit smoking and agreed to make smoking cessation a priority (89%) in their practice. A majority of the patients (85%) were satisfied or extremely satisfied with the smoking cessation services received. Many patients (71%) self-reported having tried to quit smoking. CONCLUSION: An evidence-based e-learning education program is effective in increasing oncology healthcare providers' knowledge and confidence in tobacco dependence treatment practices. The program also has a positive impact on oncology patients' perception of cessation services received. LINKING EVIDENCE TO ACTION: A self-paced e-learning program is a feasible and effective way to educate healthcare providers in smoking cessation treatment. Incorporating evidence-based tobacco dependence treatment into their daily oncology practice is warranted.

Cigarette Smoking and Quitting-Related Factors Among US Adult Health Center Patients with Serious Mental Illness.

INTRODUCTION: US adults with serious mental illness (SMI), compared to those without SMI, have a higher prevalence of smoking, which contributes to a shorter life expectancy. This study compared current smoking and quitting-related characteristics of low-income US adults with and without SMI who received healthcare at federally funded health centers. METHODS: Using cross-sectional data from adults ≥ 18 years old in the nationally representative 2014 Health Center Patient Survey (n = 5592), we compared the prevalence of ever and current smoking among adults with and without SMI and calculated quit ratios as the percentage of ever smokers who have quit smoking. We examined the association between SMI and receiving advice to quit, making quit attempts, and having plans to quit in the next 30 days using multivariable logistic regression. RESULTS: A total of 1376 (23%) of participants had SMI. Ever smoking prevalence was 68% in adults with SMI and 41% in adults without SMI, and current smoking prevalence was 48% and 22%, respectively. The quit ratio was 30% and 46% among participants with and without SMI, respectively. Compared to smokers without SMI, more smokers with SMI reported receiving advice to quit in the past 12 months (aOR 2.47, 95% CI 1.20-5.07). Smokers with and without SMI did not differ significantly in their odds of having made a past-12-month quit attempt or plans to quit. CONCLUSIONS: Smokers with SMI seen in federally funded health centers were just as likely to have made a quit attempt and to have plans to quit as smokers without SMI. Despite a higher likelihood of receiving clinician advice to quit, the lower quit ratio in this population suggests that advice alone is unlikely to be sufficient. These results underscore the need for augmented strategies to promote smoking cessation and reduce the excess burden of tobacco-related disease in patients with SMI.

The National Network of Sexually Transmitted Disease Clinical Prevention Training Centers Turns 40-A Look Back, a Look Ahead.

Since 1979, the National Network of Sexually Transmitted Disease (STD) Clinical Prevention Training Centers (NNPTC) has provided state-of-the-art clinical and laboratory training for STD prevention across the United States. This article provides an overview of the history and activities of the NNPTC from its inception to present day, and emphasizes the important role the network continues to play in maintaining a high-quality STD clinical workforce. Over time, the NNPTC has responded to changing STD epidemiological patterns, technological advances, and increasing private-sector care-seeking for STDs. Its current structure of integrated regional and national training centers allows NNPTC members to provide dynamic, tailored responses to STD training needs across the country.

An integrated, collaborative healthcare model for the early diagnosis and management of dementia: Preliminary audit results from the first transdisciplinary service integrating family medicine and geriatric psychiatry services to the heart of patients' homes.

BACKGROUND: The number of dementia cases is expected to rise exponentially over the years in many parts of the world. Collaborative healthcare partnerships are envisaged as a solution to this problem. Primary care physicians form the vanguard of early detection of dementia and influence clinical care that these patients receive. However, evidence suggests that they will benefit from closer support from specialist services in dementia care. An interdisciplinary, collaborative memory clinic was established in 2012 as a collaborative effort between a large family medicine based service and a specialist geriatric psychiatry service in Singapore. It is the first service in the world that integrates a family medicine based service with geriatric psychiatry expertise in conjunction with community-based partnerships in an effort to provide holistic, integrated care right into the heart of patients' homes as well as training in dementia care for family medicine physicians. We describe our model of care and the preliminary findings of our audit on the results of this new model of care. METHODS: This was a retrospective audit done on the electronic medical records of all patients seen at the Memory Clinic in Choa Chu Kang Polyclinic from August 2013 to March 2016. The information collected included gender, referral source, patient trajectories, presence of behavioural and psychological symptoms of dementia and percentage of caregivers found to be in need of support. A detailed outline of the service workflow and processes were described. RESULTS: A majority (93.5%) of the patients had their memory problems managed at the memory clinic without escalation to other specialist services. 22.7% of patients presented with behavioural and psychological symptoms of dementia. When initially assessed, a majority (82.2%) of patients' caregivers were found to be in need of support with 99.5% of such caregivers' needs addressed with memory clinic services. CONCLUSION: Our model of care has the potential to shape future dementia care in Singapore and other countries with a similar healthcare setting. Redesigning and evolving healthcare services to promote close collaboration between primary care practitioners and specialist services for dementia care can facilitate seamless delivery of care for the benefit of patients.

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 Comprehensive Abortion Care (CAC) and characteristics of women receiving abortion care in a tertiary hospital in Nepal.

BACKGROUND: One of the leading cause of maternal mortality and morbidity is unsafe abortion. Globally 55.7million of abortions occurred each year between 2010 and 2014. In lower resource countries 24.3 million abortions were unsafe which is significantly higher. Nepal is one of the lower resource countries among others. Comprehensive abortion care (CAC) service can reduce this burden among women. METHODS: A retrospective review of CAC service register at Tribhuvan University Teaching Hospital (TUTH) was conducted to collect data from 2006 to2015 with approval from the Nursing Department to identify the trends of CAC service delivery, client characteristics, category of service providers, and reason for seeking CAC services, its effectiveness and complications. The data was entered in SPSS software and descriptive analysis was performed. RESULTS: A total of 2367 women received CAC in ten years period showing similar trend as 272-275 cases per year. Women's mean age was 28.4 years, 34% attained secondary level education and 98.9% were married. 70% were house wives and 84% multi gravid. The gestational period varied from 5 to 12 weeks. 85.6% had Manual Vacuum Aspiration (MVA) and 14.4% had Medical Abortion (MA). Only 37.6% women used any method of post abortion contraception. Unwanted pregnancy was the commonest reason for CAC. A majority of service providers were doctors (62.4%). The nurses were equally competent to provide CAC service as doctors. CONCLUSIONS: The number of women receiving CAC was relatively constant over the ten-year period. Nurses should be promoted for providing CAC services to cover a larger population in need.

Provider Trends in Atherectomy Volume between Office-Based Laboratories and Traditional Facilities.

BACKGROUND: As patient care is being increasingly transitioned out of the hospital and into the outpatient setting, there is a growing interest in developing office-based angiography suites, that is, office-based laboratories. Office-based care has been associated with increased efficiency and greater patient satisfaction, with substantially higher reimbursement directly to the physicians providing care. Prior studies have demonstrated a shift of revascularization procedures to office-based laboratories with a concomitant increase in atherectomy use, a procedure with disproportionately high reimbursement in comparison to other peripheral revascularization techniques. We sought to determine provider trends in endovascular procedure volume, settings, and shifts in practice over time, specific to atherectomy. METHODS: Using Centers for Medicare & Medicaid Services Provider Utilization and Payment Data Public Use Files from 2013 to 2015, we identified providers who performed diagnostic angiography (DA), percutaneous transluminal angioplasty (PTA), stent placement (stent), and atherectomy, and procedures were aggregated at the provider level. Trends in procedures performed in office-based laboratory and facility-based settings were analyzed. Atherectomy was specifically analyzed using the total number and proportion of office-based laboratory procedures, and providers were stratified into quintiles by case volume. RESULTS: Between 2013 and 2015, 5,298 providers were identified. Over this time period, the number of providers performing atherectomy increased 25.7%, with the highest quintile of atherectomy providers performing an average of 263 cases (range 109-1,455). The proportion of physicians who performed atherectomy only in the office increased from 39.8% to 50.7% from 2013 to 2015, whereas only 20.8% of physicians who performed DA, PTA, or stent in 2015 did so only in an office-based laboratory. Of the physicians with the highest atherectomy volume, 77.8% operated only in the office in 2015, and these physicians increased their atherectomy volume to 114.1% during the study period. Of those physicians who transitioned to a solely office-based laboratory practice over the study period, atherectomy volume increased 63.4%, which was disproportionate compared with the growth of their DA, PTA, and stent volume. CONCLUSIONS: Over this short study period, a rapid shift into the office setting for peripheral intervention occurred, with a concomitant increase in atherectomy volume that was disproportionate to the increase in other peripheral interventions. This increase in office-based laboratory atherectomy occurred in the setting of increased reimbursement for the procedure and despite a lack of data supporting superiority over PTA/stent.

Establishing a multidisciplinary day-care surgery department: Challenges for nursing management.

AIM: To increase our understanding of challenges in implementing multidisciplinary organisational models in hospitals. BACKGROUND: Health-service policies internationally are pushing for multidisciplinary and patient-centred organising models but there are challenges involved in moving from profession- and discipline-based organising to the new solutions. METHOD: Qualitative case study, interview and document data collected in real time following the implementation process. RESULTS: It was possible to argue for and against the new department applying either a business-like logic or a professional logic. The respective logics gave different prescriptions for how a hospital department should be organised. CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT: The institutional logics perspective enables managers to understand resistance to new ways of organising work and may be useful in trying to foresee and handle challenges in implementing new organisation models. Managers need to analyse models carefully in terms of which parts may be seen as problematic in their own organisation, and invite all relevant stakeholders into participatory change processes. If the goal is to gather multiple professions and disciplines under one manager in order to increase patient centredness, arrangements must be made for professionals to stay connected to the wider community of practice centred around their specialized knowledge and skills.