Streamlining documentation in patient electronic medical records: An example of chlamydia consultation shortcuts.

BACKGROUND: Australian general practitioners encounter a vast array of health issues in their clinical practice. High-quality clinical record keeping is crucial to support continuity of care for patients and decision making for clinicians. Many clinical software programs used in general practice contain shortcut features that allow insertion of pre-stored, editable text into progress notes. These can be used to support documentation of specific health issues. OBJECTIVE: Drawing on our experience within a research project seeking to strengthen chlamydia management in general practice, this article describes the co-design, implementation and use of documentation shortcuts for chlamydia management. DISCUSSION: Shortcuts are useful as a memory prompt and timesaver for general practice clinicians. It is important that they do not replace clinical acumen and judgement. General practices using our chlamydia management shortcuts found them easy to set up, that they acted as a prompt for best practice chlamydia management and that they integrated well with the general practice workflow.

Time-efficient consultation hours in the department of gynecological endocrinology.

BACKGROUND: The aim was to conduct a benchmark pilot study to find the best practice for consultation hours in the field of gynecological endocrinology. Suitable benchmarking participants were found in China, Germany, Greece, and Switzerland. Specifically, the study aimed to find the most time-efficient and beneficial consultation type in gynecological endocrinology focused on menopause and whether a shorter face-to-face consultation correlates with lower patient satisfaction. METHODS: This was an observational study. To analyze the processes of all benchmarking participants three tools were used: a measurement of time needed for the different consultation types, a questionnaire for patients and one for physicians. The primary endpoint was the time measurement of first consultations. Secondary endpoints were the time measurements of follow-up consultations and phone consultations and patient satisfaction. RESULTS: The mean overall duration of a first consultation differed from 20.4 min to 39.7 min (p = 0.003), mainly based on differences of the mean time to acquire the patient history, 5.6 to 21.6 min (p < 0.001). The percentage of patients who felt they had enough time to discuss questions ranged from 70% to 100% (p < 0.001). The percentage of patients who felt fully understood by their physician ranged from 62.5% to 92% (p = 0.006). The duration of a first consultation did not correlate with patients feeling well consulted (r=-0.048, p = 0.557). CONCLUSIONS: A concise patient history that concentrates on the most relevant points can reduce the total consultation time. Reducing consultation time can be made without compromising how well patients feel consulted.

Adherence to Non-operative Clinical Quality Measures in Carpal Tunnel Syndrome.

Background: Clinical quality measures exist for non-operative management of carpal tunnel syndrome (CTS). Factors predicting adherence are unclear. Methods: A retrospective cohort study of patients with chronic CTS using MarketScan Research Database (2015-2020) was conducted. Six logistic regression models were designed to study adherence to quality measures within 1 year after diagnosis. Results: Of 782,717 patients identified, 514,073 (65.7%) were female with an average (SD) age of 51.4 (13.4) years. Only 88 patients (0.01%) met all quality measures. Greatest compliance observed with receipt of nerve conduction study (NCS; 283,959 [36.3%]), no prescription of medications (336,297 [43.0%]) and no laser therapy (772,979 [98.8%]); 294,305 patients (37.6%) received hand surgeon referral. Hand surgeon referral predicted higher likelihood of NCS and splinting (OR, 1.83; 95% CI: 1.81-1.84; OR, 2.53; 95% CI: 2.50-2.56) and medication over-prescription (OR, 1.05; 95% CI: 1.00-1.10). Females were more likely to be referred to a hand surgeon and be referred for splinting (OR 1.02; 95% CI: 1.01-1.03; OR 1.19; 95% CI: 1.18-1.21) but less likely to have no prescriptions or avoid laser therapy (OR 0.85, 95% CI: 0.84-0.85; OR 0.82, 95% CI: 0.79-0.86). Medicare recipients adhered less to quality measures compared to patients with fee-for-service insurance. As comorbidities increased, patients were less likely to receive hand surgeon referral and carpal tunnel release. Conclusions: Findings suggest that hand surgery referrals increased adherence to quality measures. Females, Medicare recipients and multimorbid patients should be targeted for improved care. Future quality care efforts should incentivise adherence for Medicare beneficiaries and improve guideline recognition amongst physicians. Level of Evidence: Level III (Therapeutic).

A 15-year experience in pediatric palliative care: a retrospective hospital-based study.

BACKGROUND: The current Italian scenario of pediatric palliative care (PPC) services is characterized by inadequate coverage of the territory. Therefore, it is important to improve the referral of patients to the most appropriate setting (community care, general PPC, or specialized PPC) and to improve the delivery of PPC care. METHODS: Aiming at obtaining information about the referrals to the Padua Pediatric Hospice that could help estimate the investments needed to improve the provision of care, a retrospective analysis has been carried out. The rate of proper referral and discharge, the number of patients followed at the hospice, the mortality rate, and the length of follow-up were analyzed, and, when possible, data were stratified by oncological and non-oncological diseases. RESULTS: The analysis showed that of the 870 patients referred to the Padua Pediatric Hospice between 2008 and 2022, 76% were affected by non-oncological conditions. 82% of patients referred were taken in charge and most of the remaining patients have been inappropriately referred. The analysis showed a growing number of total referrals, which increased by 195% from 2008 to 2022. An increase in proper referrals and referrals of non-oncological patients was observed alongside a decrease in oncological patient referrals and a trend toward a decrease in discharge rates. A decreased mortality was observed in patients with non-oncological conditions, with only 6% of deceased patients in 2022. Moreover, a longer survival with a median follow-up length of 43 months was observed among patients with non-oncological conditions who were followed up at the Padua Pediatric Hospice for more than 12 months. Conversely, the short survival rate observed for oncological patients suggests that those patients should have been referred to PPC earlier to benefit from palliative care for longer periods. CONCLUSIONS: Considering these data, it is expected that the number of patients needing PPC services will steadily increase in the next years. Hence, there is a need to invest resources to provide the best care delivery model encompassing specific pathways for the transition into adulthood, the establishment of networks within all the Italian regions, and an efficient referral to the more suitable setting of care.

Virtual consultations for skin lesion assessment reduce carbon footprint compared to in-person reviews.

BACKGROUND AND OBJECTIVES: Climate change is one of the biggest threats to the healthcare sector. In addition, healthcare contributes significantly to greenhouse gas emissions. Virtual consultations are a growing tool to assess patients. The carbon emissions from virtual consultations have the potential to be much smaller than in-person consultations, predominantly through reduced transportation. This study assesses the carbon footprint of general practitioner referrals for skin lesions evaluated by a store-and-forward teledermatology service compared to an estimated equivalent in-person review. METHOD: The carbon footprint of virtual consultations for skin lesions was compared to estimated equivalent in-person reviews based on the average transportation modalities in New Zealand. RESULTS: Virtual consultations for 484 patients resulted in an average saving of 48 km and 11.17 kg carbon dioxide equivalent per consultation compared to equivalent in-person review. DISCUSSION: This study encourages the use of store-and-forward skin lesion assessment as a way of reducing carbon emissions in the healthcare sector.

Effect of cancer waiting time standards in the English National Health Service: a threshold analysis.

BACKGROUND: The English National Health Service has multiple waiting time standards relating to cancer diagnosis and treatment. Targets can have unintended effects, such as prioritisation based on targets instead of clinical need. In this case, a `threshold effect' will appear as a spike in hospitals just meeting the target. METHODS: We conducted a retrospective study of publicly available cancer waiting time data, including a 2-week wait for a specialist appointment, a 31-day decision to first treatment and a 62-day referral to treatment standard that attracted a financial penalty. We examined the performance of hospital trusts against these targets by financial year to look for threshold effects, using Cattaneo et al. manipulation density test. RESULTS: Trust performance against cancer waiting targets declined over time, and this trend accelerated since the start of the Covid-19 pandemic. Statistical evidence of a threshold effect for the 2-week and 31-day standard was only present in a few years. However, there was strong statistical evidence of a threshold effect for the 62-day standard across all financial years (p < 0.01). CONCLUSION: The data suggests that the effect of threshold targets alters hospital behaviour at target levels but does not do so equally for all standards. Evidence of threshold effects for the 62-day standard was particularly strong, possibly due to some combination of a smaller volume of eligible patients, a larger penalty, multiple waypoints where hospitals can intervene, baseline performance against the target and where the target is set (i.e. how much headroom is available). RCTs of the use of threshold targets and of different designs for such targets in the future would be extremely informative.

Validation of Quality Assessment Measures for Inpatient Gastroenterology Consults on Oncologic Patients in Non-teaching Services at a Cancer Center: A Cross-Sectional Study.

OBJECTIVE: To develop and validate tools for measuring inpatient gastroenterology (GI) consultation quality on oncologic patients. METHODS: A total of 145 inpatient GI consults were analyzed using electronic health records in this cross-sectional study. Essential Consult Elements on oncologic-hospitalized patients (EE-COH) and Hospitalized Oncologic Patients Enhanced Quality of Consult Assessment Tool (HOPE-QCAT) were used for grading. Interrater reliability was assessed. RESULTS: Both EE-COH and HOPE-QCAT showed near-perfect interrater reliability across most measures in the validation cohort. On application of these measures for quality assessment, basic evaluation by the requesting hospitalist was partially complete in 24.8%, the request for GI consultation was inappropriate in 18.6%, while the rationale for recommended studies from the GI consultant was provided in 55.7% of cases suggesting key areas for quality improvement. CONCLUSION: We developed highly reliable quality measures for inpatient GI consults on oncology patients. The EE-COH and HOPE-QCAT tools can be utilized in future studies of inpatient GI consult quality and to form the basis for interventions to improve communication between consultants and hospitalists. Such tools could be adapted for inpatient quality assessment across other specialties and settings.

Referral Efficiency for Veterans with Osteoarthritis: A Quality Improvement Project.

Management of osteoarthritis, a common disease among veterans, includes referrals to orthopedic specialists. This requires an effective referral system. The aim of this study was to evaluate a quality improvement project addressing inefficiencies in the osteoarthritis referral process between primary care providers and orthopedic specialists. A pre- and post-intervention evaluation using medical record review and provider surveys was conducted to measure the process improvement of a primary care to orthopedic referral template. There was a 3.5% increase in the referral acceptance rate following the intervention. In addition, primary care providers perceived that role clarity and perception on making referrals had significantly improved. The largest perceived improved change among orthopedic specialists was in communication. A simple process change, such as improving the referral template, can help with communication, data transfer, and referral acceptance rates between primary care providers and orthopedic specialists. This in turn will benefit the large population of veterans needing orthopedic referrals for management of osteoarthritis.

Oncologists' palliative care referral behaviour: testing utility of social exchange theory as an explanatory framework.

BACKGROUND: Adults and children with cancer are referred to palliative care infrequently or late. Oncologists often gatekeep these referrals. Social exchange theory is used to explain physician referral behaviour in various clinical settings. Its utility in a cancer palliative care setting is not known. METHODS: We used Karl Popper's hypothetico-deductive approach to test the hypothesis. The hypothesis was that social exchange theory is a helpful framework for explaining oncologists' palliative care referral behaviour in a cancer setting. The utility of the theoretical framework was tested against the empiric findings of a systematic review and original research. RESULTS: Most components of social exchange theory known to explain physician referral behaviour like beliefs about the provider or service, emotions triggered during the professional engagement, its symbolism and stigma, the complexity of the referral task, efforts needed to achieve it, its cost, benefit, and value were similar in a cancer setting. Empirical findings suggest that oncologists provided strategies and solutions to better palliative care integration instead of comparing their existing engagement with potential alternatives and choosing them. CONCLUSION: Social exchange theory was found to be helpful in explaining oncologists' palliative care referral behaviour. To further develop the social exchange theory based on the data used to test it, it is recommended to include feedback and solutions as a component of the theoretical framework alongside a comparison level for alternatives.

Consultations for Poland Syndrome: The Essentials for a Thoracic Surgeon.

Poland syndrome (PS) is a rare congenital musculoskeletal entity occurring in approximately 1 in 30,000 newborns that manifests with variable symbrachydactyly, ipsilateral costochondral deformities, an absence of pectoral muscles, and breast underdevelopment. These have potential impacts on social, somatic, and psychological functionality, often leading affected individuals to seek expert opinions on corrective surgery. Due to phenotypic variability, strict management guidelines are lacking, with treatment decisions often based on the specialist's personal experience rather than published evidence. Comprehensive imaging with CT and MRI with 3D reconstruction is crucial for providing a descriptive assessment of musculoskeletal defects. Management is multidisciplinary, involving thoracic, plastic, and pediatric surgeons and hand surgery specialists, as well as psychologists and developmental growth specialists. Surgery should achieve both structural and cosmetic correction to reverse the psychological and social impact and achieve patient satisfaction. We aim to provide thoracic surgeons the essential answers for sharing with affected adult individuals during consultations focusing on chest surgical correction.

Codesigned standardised referral form: simplifying the complexity.

BACKGROUND: Referring providers are often critiqued for writing poor-quality referrals. This study characterised clinical referral guidelines and forms to understand which data consultant providers require. These data were then used to codesign an evidence-based, high-quality referral form. METHODS: This study used both observational and quality improvement approaches. Canadian referral guidelines were reviewed and summarised. Referral data fields from 150 randomly selected Ontario referral forms were categorised and counted. The referral guideline summary and referral data were then used by referring providers, consultant providers and administrators to codesign a referral form. RESULTS: Referral guidelines recommended 42 types of referral data be included in referrals. Referral data were categorised as patient demographics, provider demographics, reason for referral, clinical information and administrative information. The percentage of referral guidelines recommending inclusion of each type of referral data varied from 8% to 77%. Ontario referral forms requested 264 different types of referral data. Digital referral forms requested more referral data types than paper-based referral forms (55.0±10.6 vs 30.5±8.1; 95% CI p<0.01). A codesigned referral form was created across two sessions with 29 and 21 participants in each. DISCUSSION: Referral guidelines lack consistency and specificity, which makes writing high-quality referrals challenging. Digital referral forms tend to request more referral data than paper-based referrals, which creates administrative burdens for referring and consultant providers. We created the first codesigned referral form with referring providers, consultant providers and administrators. We recommend clinical adoption of this form to improve referral quality and minimise administrative burdens.

Second Opinions for Diagnoses of Psychotic Disorders: Delivering Stage-Specific Recommendations.

OBJECTIVE: The impact of obtaining second-opinion consultations on diagnoses of schizophrenia spectrum disorders was evaluated. METHODS: A retrospective chart review was conducted for 177 patients referred to a psychosis consultation service at an academic medical center from January 1, 2017, to October 1, 2023; these consultations aimed to clarify a diagnosis of psychosis. Diagnoses made before and after consultations were compared, and treatment recommendations resulting from the consultation visit were summarized. RESULTS: Among patients without a preconsultation diagnosis of schizophrenia, 28% (N=28 of 100) received a postconsultation diagnosis of schizophrenia. Among 62 patients with a postconsultation diagnosis of treatment-resistant schizophrenia (TRS), 56% (N=35) received this diagnosis only after consultation. Nearly all of these patients were advised to begin taking clozapine, and electroconvulsive therapy was less commonly recommended. CONCLUSIONS: Expert consultation facilitates timely identification and optimal treatment of schizophrenia and its more severe subtype, TRS.

Hereditary Cancer Clinics Improve Adherence to NCCN Germline Testing Guidelines for Pancreatic Cancer.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) has a poor prognosis, with a 5-year overall survival rate of 10%. In November 2018, NCCN recommended that all patients with PDAC receive genetic counseling (GC) and germline testing regardless of family history. We hypothesized that patients with PDAC were more likely to be referred for testing after this change to the guidelines, regardless of presumed predictive factors, and that compliance would be further improved following the implementation of a hereditary cancer clinic (HCC). METHODS: We conducted a single-institution retrospective analysis of patients diagnosed with PDAC from June 2017 through December 2021 at University of California, Irvine. We compared rates of genetics referral among patients in different diagnostic eras: the 18-month period before the NCCN Guideline change (pre-NCCN era: June 2017 through November 2018), 14 months following the change (post-NCCN era: December 2018 through January 2020), and 18 months after the creation of an HCC (HCC era: June 2020 through December 2021). Family and personal cancer history, genetics referral patterns, and results of GC were recorded. Data were compared using chi-square, Fisher exact, and multivariate analyses. RESULTS: A total of 335 patients were treated for PDAC (123 pre-NCCN, 109 post-NCCN, and 103 HCC) at University of California, Irvine. Demographics across groups were comparable. Prior to the guideline changes, 30% were referred to GC compared with 54.7% in the post-NCCN era. After the implementation of the HCC, 77.4% were referred to GC (P<.0001). The odds ratio (OR) for referral to GC among patients with a positive family history of cancer progressively decreased following the change (pre-NCCN era: OR, 11.90 [95% CI, 3.00-80.14]; post-NCCN era: OR, 3.39 [95% CI, 1.13-10.76]; HCC era: OR, 3.11 [95% CI, 0.95-10.16]). CONCLUSIONS: The 2018 updates to the NCCN Guidelines for PDAC recommending germline testing for all patients with PDAC significantly increased GC referral rates at our academic medical center. Implementation of an HCC further boosted compliance with guidelines.

Expert consensus on unmet needs, referral criteria and treatment goals for hidradenitis suppurativa in Saudi Arabia.

Purpose: There is limited information about the diagnosis and treatment of hidradenitis suppurativa (HS) in the Kingdom of Saudi Arabia (KSA). This Delphi consensus study was conducted to develop recommendations for the management of HS in the KSA.Methods: The expert panel including 12 dermatologists with extensive experience treating HS patients provided nine consensus statements and recommendations on diagnosis and assessment, management, comorbidities and multidisciplinary approach, and education. The experts also developed clinical questions pertaining to the management of HS and rolled out as a survey to 119 dermatologists practising in the KSA.Results: The topics covered included: referring physicians' awareness of HS; referral criteria for HS; definition of moderate-to-severe HS; treatment goals; definition of treatment success; treatment and biologic initiation; comorbidities and multidisciplinary approach; patient education and awareness of HS. Full consensus (100%) from the expert dermatologists was received on all the topics except referring physicians' awareness of HS, definition of treatment success, and treatment and biologic initiation. The survey results resonated with the expert opinion.Conclusion: As HS is a chronic disease with negative impact on quality-of-life, timely diagnosis and treatment, early identification of comorbid conditions and a multidisciplinary care approach are crucial for effective management of HS.

Developing an entrustable professional activity for providing health education and consultation in occupational therapy and examining its validity.

BACKGROUND: Entrustable Professional Activities (EPA)-based assessment is easily and intuitively used in evaluating the learning outcomes of competency-based medical education (CBME). This study aimed to develop an EPA for occupational therapy focused on providing health education and consultation (TP-EPA3) and examine its validity. METHODS: Nineteen occupational therapists who had completed online training on the EQual rubric evaluation participated in this study. An expert committee identified six core EPAs for pediatric occupational therapy. TP-EPA3 was developed following the EPA template and refined through consensus meetings. The EQual rubric, a 14-item, five-point criterion-based anchor system, encompassing discrete units of work (DU), entrustable, essential, and important tasks of the profession (EEIT), and curricular role (CR), was used to evaluate the quality of TP-EPA3. Overall scores below 4.07, or scores for DU, EEIT, and CR domains below 4.17. 4.00, and 4.00, respectively, indicate the need for modifications. RESULTS: The TP-EPA3 demonstrated good validity, surpassing the required cut-off score with an average overall EQual score of 4.21 (SD = 0.41). Specific domain scores for DU, EEIT, and CR were 3.90 (SD = 0.69), 4.46 (SD = 0.44), and 4.42 (SD = 0.45), respectively. Subsequent revisions clarified observation contexts, enhancing specificity and focus. Further validation of the revised TP-EPA3 and a thorough examination of its reliability and validity are needed. CONCLUSION: The successful validation of TP-EPA3 suggests its potential as a valid assessment tool in occupational therapy education, offering a structured approach for developing competency in providing health education and consultation. This process model for EPA development and validation can guide occupational therapists in creating tailored EPAs for diverse specialties and settings.

Early provision of clinical information with an 'opt in' approach improves patient experience in tonsillectomy referrals.

Patients referred by their general practitioner (GP) with a definite diagnosis, for example, recurrent sore throat for consideration of tonsillectomy in adults, may wait for months without receiving any further clinical information from the hospital until their outpatient consultation. Prompt provision of condition-specific information after referral has received little attention despite considerable potential to enhance patients' understanding, thereby relieving uncertainty and anxiety, and facilitating shared decision-making.This study aimed to report the experience of patients with recurrent tonsillitis who had been sent a booklet outlining the benefits and risks of tonsillectomy immediately after GP referral.Greater Glasgow and Clyde Health Board received 218 referrals of patients aged 16-40 to discuss tonsillectomy between January and August 2022. Every patient was sent a 16-page booklet by post and given the choice to opt in for a consultation.165 (76%) patients opted in, and 53 (24%) did not. Feedback was obtained from 143 patients (66%) from both groups. 99% found the information booklet easy to understand, 97% would recommend it to a friend with recurrent tonsillitis, 93% felt their questions had been answered and 92% believed it helped them to decide whether to proceed with tonsillectomy. Socioeconomic deprivation did not influence the outcome.In conclusion, most patients found provision of clinical information immediately after vetting of the referral to be beneficial, irrespective of whether they opted in for a consultation. This concept has broad applicability across all specialties, and the principles can be readily adopted and adapted by clinicians and managers in local units.

Indications and Outcomes for Adult Extracorporeal Membrane Oxygenation at a Military Referral Facility.

INTRODUCTION: Extracorporeal life support, including extracorporeal membrane oxygenation (ECMO), is a potentially life-saving adjunct to therapy in patients experiencing pulmonary and/or cardiac failure. The U.S. DoD has only one ECMO center, in San Antonio, Texas. In this study, we aimed to analyze outcomes at this center in order to determine whether they are on par with those reported elsewhere in the literature. MATERIALS AND METHODS: In this observational study, we analyzed data from patients treated with ECMO at the only DoD ECMO center between September 2012 and April 2020. The primary outcome was survival to discharge, and secondary outcomes were discharge disposition and incidence of complications. RESULTS: One hundred and forty-three patients were studied, with a 70.6% rate of survival to discharge. Of the patients who survived, 32.7% were discharged home; 32.7% were discharged to a rehabilitation facility; and 33.7% were transferred to another hospital, 29.4% of whom were transferred to lung transplant centers. One patient left against medical advice. Incidence of ECMO-related complications were as follows: 64 patients (44.7%) experienced hemorrhagic complications, 80 (55.9%) had renal complications, 61 (42.6%) experienced cardiac complications, 39 (27.3%) had pulmonary complications, and 5 patients (3.5%) experienced limb ischemia. We found that these outcomes were comparable to those reported in the literature. CONCLUSIONS: Extracorporeal membrane oxygenation can be an efficacious adjunct in management of critically ill patients who require pulmonary and/or cardiac support. This single-center observational study demonstrated that the DoD's only ECMO center has outcomes comparable with the reported data in Extracorporeal Life Support Organization's registry.