Clinical Course of Children 1 to 24 Months Old With Positive Urine Cultures Without Pyuria.

OBJECTIVE: To describe the clinical course of children with positive urine cultures without pyuria who were not given antibiotics initially, identify predictors of subsequent antibiotic treatment, and evaluate the association between subsequent treatment and urinary tract infection (UTI) within 30 days. METHODS: We conducted a multicenter retrospective cohort study of children 1 to 24 months old who had positive urine cultures without pyuria and who were not started on antibiotics upon presentation to 3 health care systems from 2010 to 2021. Outcomes included clinical status at the time urine cultures resulted, escalation of care (emergency department visit or hospitalization) and subsequent antibiotic treatment within 7 days, and subsequent UTI within 30 days of presentation. RESULTS: Of 202 included children, 61% were female and median age was 9 months. Of 151 patients with clinical status information when cultures resulted, 107 (70.8%, 95% confidence interval [CI] 62.9-77.9%) were improved. Two of 202 children (1.0%, 95% CI 0.2-4.0%) experienced care escalation. Antibiotics were started in 142 (82.2%) children, and treatment was associated with prior UTI (risk ratio [RR] 1.20, 95% CI 1.15-1.26) and lack of improvement (RR 1.22, 95% CI 1.13-1.33). Subsequent UTI was diagnosed in 2 of 164 (1.2%, 95% CI 0.1-4.3%) treated and 0 of 36 (0%, 95% CI 0-9.7%) untreated children. CONCLUSIONS: Seventy percent of children with positive urine cultures without pyuria improved before starting antibiotics; however, >80% were ultimately treated. Future research should study the impact of diagnostic stewardship interventions and various urine testing strategies to optimize the management of children evaluated for UTI.retain-->.

Effects of Behavioral Economics-Based Messaging on Appointment Scheduling Through Patient Portals and Appointment Completion: Observational Study.

BACKGROUND: Behavioral economics-based techniques have been an increasingly utilized method in health care to influence behavior change by modifying language in patient communication (through choice architecture and the framing of words). Patient portals are a key tool for facilitating patient engagement in their health, and interventions deployed via patient portals have been effective in improving utilization of preventive health services. OBJECTIVE: We examined the impacts of behavioral economics-based nudge health maintenance reminders on appointment scheduling through a patient portal and appointment completion for 2 preventive services: Medicare wellness visits and Pap smear. METHODS: We conducted a retrospective observational study using electronic health record data from an integrated health care system in Northern California. Nudge health maintenance reminders with behavioral economics-based language were implemented for all sites in November 2017 for Medicare wellness visits and for selected sites in February 2018 for Pap smears. We analyzed 125,369 health maintenance reminders for Medicare wellness visits, and 585,358 health maintenance reminders for Pap smear sent between January 2017 and February 2020. The primary outcomes were rate of appointments scheduled through the patient portal and appointment completion rate. We compared the outcomes between those who received the new, behavioral economics-based health maintenance reminders (the nudge group) and those who received the original, standard health maintenance reminders (the control group). We used segmented regression with interrupted time series to assess the immediate and gradual effect of the nudge for Medicare wellness visits, and we used logistic regression to assess the association of nudge health maintenance reminders, adjusting for the propensity to receive a nudge health maintenance reminder, for Pap smear. RESULTS: The rates of appointments scheduled through the patient portal were higher for nudge health maintenance reminder recipients than those for control health maintenance reminder recipients (Medicare wellness visits-nudge: 12,537/96,839, 13.0%; control: 2,769/28,530, 9.7%, P<.001; Pap smear-nudge: 8,239/287,149, 2.9%; control: 1,868/120,047, 1.6%; P<.001). Rates of appointment completion were higher for nudge health maintenance reminders for Pap smear (nudge: 67,399/287,149, 23.5% control: 20,393/120,047, 17.0%; P<.001) but were comparable for Medicare wellness visits (nudge: 49,835/96,839, 51.5% control: 14,781/28,530, 51.8%; P=.30). There was a marginally gradual effect of nudge on number of appointments scheduled through the patient portal for the overall Medicare wellness visits sample (at a monthly rate of 0.26%, P=.09), and a significant gradual effect among scheduled appointments (at a monthly rate of 0.46%, P=.04). For Pap smear, nudge health maintenance reminders were positively associated with number of appointments scheduled through the patient portal (overall sample: propensity adjusted odds ratio [OR] 1.62; 95% CI 1.50-1.74; among scheduled appointments: propensity adjusted OR 1.61, 95% CI 1.47-1.76) and with appointment completion (propensity adjusted OR 1.07; 1.04-1.10). CONCLUSIONS: Nudges, a behavioral economics-based approach to providing health maintenance reminders, increased the number of appointments scheduled through the patient portal for Medicare wellness visits and Pap smear. Our study demonstrates that a simple approach-framing and modifying language in an electronic message-can have a significant and long-term impact on patient engagement and access to care.

Use Characteristics and Triage Acuity of a Digital Symptom Checker in a Large Integrated Health System: Population-Based Descriptive Study.

BACKGROUND: Pressure on the US health care system has been increasing due to a combination of aging populations, rising health care expenditures, and most recently, the COVID-19 pandemic. Responses to this pressure are hindered in part by reliance on a limited supply of highly trained health care professionals, creating a need for scalable technological solutions. Digital symptom checkers are artificial intelligence-supported software tools that use a conversational "chatbot" format to support rapid diagnosis and consistent triage. The COVID-19 pandemic has brought new attention to these tools due to the need to avoid face-to-face contact and preserve urgent care capacity. However, evidence-based deployment of these chatbots requires an understanding of user demographics and associated triage recommendations generated by a large general population. OBJECTIVE: In this study, we evaluate the user demographics and levels of triage acuity provided by a symptom checker chatbot deployed in partnership with a large integrated health system in the United States. METHODS: This population-based descriptive study included all web-based symptom assessments completed on the website and patient portal of the Sutter Health system (24 hospitals in Northern California) from April 24, 2019, to February 1, 2020. User demographics were compared to relevant US Census population data. RESULTS: A total of 26,646 symptom assessments were completed during the study period. Most assessments (17,816/26,646, 66.9%) were completed by female users. The mean user age was 34.3 years (SD 14.4 years), compared to a median age of 37.3 years of the general population. The most common initial symptom was abdominal pain (2060/26,646, 7.7%). A substantial number of assessments (12,357/26,646, 46.4%) were completed outside of typical physician office hours. Most users were advised to seek medical care on the same day (7299/26,646, 27.4%) or within 2-3 days (6301/26,646, 23.6%). Over a quarter of the assessments indicated a high degree of urgency (7723/26,646, 29.0%). CONCLUSIONS: Users of the symptom checker chatbot were broadly representative of our patient population, although they skewed toward younger and female users. The triage recommendations were comparable to those of nurse-staffed telephone triage lines. Although the emergence of COVID-19 has increased the interest in remote medical assessment tools, it is important to take an evidence-based approach to their deployment.

Patient-Centric Scheduling With the Implementation of Health Information Technology to Improve the Patient Experience and Access to Care: Retrospective Case-Control Analysis.

BACKGROUND: Cancellations and rescheduling of doctor's appointments are common. An automated rescheduling system has the potential to facilitate the rescheduling process so that newly opened slots are promptly filled by patients who need and can take the slot. Building on an existing online patient portal, a large health care system adopted an automated rescheduling system, Fast Pass, that sends out an earlier appointment offer to patients via email or SMS text messaging and allows patients to reschedule their appointment through the online portal. OBJECTIVE: We examined the uptake of Fast Pass at its early stage of implementation. We assessed program features and patient and visit characteristics associated with higher levels of Fast Pass utilization and the association between Fast Pass use and no-show and cancellation rates. METHODS: This study was a retrospective analysis of Fast Pass offers sent between July and December 2018. Multivariable logistic regression was used to assess the independent contribution of program, patient, and visit characteristics on the likelihood of accepting an offer. We then assessed the appointment outcome (completion, cancellation, or no-show) of Fast Pass offered appointments compared to appointments with the same patient and visit characteristics, but without an offer. RESULTS: Of 177,311 Fast Pass offers sent, 14,717 (8.3%) were accepted. Overall, there was a 1.3 percentage point (38%) reduction in no-show rates among Fast Pass accepted appointments compared to other appointments with matching characteristics (P<.001). The offers were more likely to be accepted if they were sent in the evening (versus early morning), the first (versus repeated) offer for the same appointment, for a slot 1-31 days ahead (versus same-day), for later in a day (versus before 10am), for a primary care (versus specialty) visit, sent via SMS text messaging (versus email only), for an appointment made through the online patient portal (versus via phone call or in-person), or for younger adults aged 18-49 years (versus those aged 65 years or older; all at P<.001). Factors negatively associated with offer acceptance were a higher number of comorbidities (P=.02) and visits scheduled for chronic conditions (versus acute conditions only; P=.002). CONCLUSIONS: An automated rescheduling system can improve patients' access by reducing wait times for an appointment, with an added benefit of reducing no-shows by serving as a reminder of an upcoming appointment. Future modifications, such as increasing the adoption of SMS text messaging offers and targeting older adults or patients with complex conditions, may make the system more patient-centered and help promote wider utilization.

COVID-19 and Kawasaki Disease: Novel Virus and Novel Case.

In the midst of the coronavirus disease 2019 (COVID-19) pandemic, we are seeing widespread disease burden affecting patients of all ages across the globe. However, much remains to be understood as clinicians, epidemiologists, and researchers alike are working to describe and characterize the disease process while caring for patients at the frontlines. We describe the case of a 6-month-old infant admitted and diagnosed with classic Kawasaki disease, who also screened positive for COVID-19 in the setting of fever and minimal respiratory symptoms. The patient was treated per treatment guidelines, with intravenous immunoglobulin and high-dose aspirin, and subsequently defervesced with resolution of her clinical symptoms. The patient's initial echocardiogram was normal, and she was discharged within 48 hours of completion of her intravenous immunoglobulin infusion, with instruction to quarantine at home for 14 days from the date of her positive test results for COVID-19. Further study of the clinical presentation of pediatric COVID-19 and the potential association with Kawasaki disease is warranted, as are the indications for COVID-19 testing in the febrile infant.

Assessment of Accuracy and Usability of a Fee Estimator for Ambulatory Care in an Integrated Health Care Delivery Network.

Importance: Given increased enrollment in high-deductible health insurance plans and mandates from the Patient Protection and Affordable Care Act, individualized price transparency tools are needed. Objective: To assess accuracy and initial user experience of a cost estimation tool for ambulatory procedures delivered via an online patient portal and informed by real-time data feeds from third-party payers. Design, Setting, and Participants: This quality improvement study included patients aged 18 years and older at an integrated health care system in Northern California. Data from patients who used the cost estimator tool from August 21, 2018, to April 9, 2019, and who had matching explanation of benefits statements were used to assess accuracy of the tool. User experience was assessed with a brief survey completed online or via postal mail. Data were analyzed from April 15, 2019, to October 11, 2019. Main Outcomes and Measures: Tool accuracy and user experience and satisfaction. Results: As of April 30, 2019, 4610 estimates (3569 [77.4%] via internet; 1041 [22.6%] via telephone) were produced using the cost estimator tool. Among 342 individuals who had an estimate and a matching explanation of benefits statement, 287 estimates (83.9%) were accurate. All 342 individuals with an estimate and an explanation of benefits statement were invited to participate in a user survey, and 125 individuals completed the survey (36.5% response rate). Survey respondents included 92 (73.6%) women, 72 (57.6%) non-Hispanic white participants , 91 participants (72.8%) with a college degree or higher, and 55 participants (44.0%) with an income of $100 000 per year or higher. Mean (SD) age was 46.8 (13.1) years. Ninety-nine participants (79.2%) found the tool easy to use, 109 participants (87.2%) would use it again, and 100 participants (80.0%) would recommend it to others. Seven participants (5.6%) reported contacting a clinician about the estimate, and 12 participants (9.6%) changed their decision based on the estimate. Conclusions and Relevance: This quality improvement study is the first report of an online cost estimator in an integrated health care delivery network. The findings suggest that the tool, informed by real-time data feeds from third-party payers, was easy to use and provided accurate results. Increasing the number of searchable services and sharing best practices with other health care systems who share the same portal platform are the next steps for the tool.