Showing papers on "Referral published in 2018"

Clinical Oncology Society of Australia position statement on exercise in cancer care

Abstract: Introduction: Clinical research has established exercise as a safe and effective intervention to counteract the adverse physical and psychological effects of cancer and its treatment. This article summarises the position of the Clinical Oncology Society of Australia (COSA) on the role of exercise in cancer care, taking into account the strengths and limitations of the evidence base. It provides guidance for all health professionals involved in the care of people with cancer about integrating exercise into routine cancer care. Main recommendations: COSA calls for: • exercise to be embedded as part of standard practice in cancer care and to be viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment; • all members of the multidisciplinary cancer team to promote physical activity and recommend that people with cancer adhere to exercise guidelines; and • best practice cancer care to include referral to an accredited exercise physiologist or physiotherapist with experience in cancer care. Changes in management as a result of the guideline: COSA encourages all health professionals involved in the care of people with cancer to: • discuss the role of exercise in cancer recovery; • recommend their patients adhere to exercise guidelines (avoid inactivity and progress towards at least 150 minutes of moderate intensity aerobic exercise and two to three moderate intensity resistance exercise sessions each week); and • refer their patients to a health professional who specialises in the prescription and delivery of exercise (ie, accredited exercise physiologist or physiotherapist with experience in cancer care).

Improving patient and caregiver outcomes in oncology: Team-based, timely, and targeted palliative care.

Abstract: Over the past decade, a large body of evidence has accumulated supporting the integration of palliative care into oncology practice for patients with advanced cancer. The question is no longer whether palliative care should be offered, but what is the optimal model of delivery, when is the ideal time to refer, who is in greatest need of a referral, and how much palliative care should oncologists themselves be providing. These questions are particularly relevant given the scarcity of palliative care resources internationally. In this state-of-the-science review directed at the practicing cancer clinician, the authors first discuss the contemporary literature examining the impact of specialist palliative care on various health outcomes. Then, conceptual models are provided to support team-based, timely, and targeted palliative care. Team-based palliative care allows the interdisciplinary members to address comprehensively the multidimensional care needs of patients and their caregivers. Timely palliative care, at its best, is preventive care to minimize crises at the end of life. Targeted palliative care involves identifying the patients most likely to benefit from specialist palliative care interventions, akin to the concept of targeted cancer therapies. Finally, the strengths and weaknesses of innovative care models, such as outpatient clinics, embedded clinics, nurse-led palliative care, primary palliative care provided by oncology teams, and automatic referral, are summarized. Moving forward, more research is needed to determine how different health systems can best personalize palliative care to provide the right level of intervention, for the right patient, in the right setting, at the right time. CA Cancer J Clin. 2018;680:00-00. 2018 American Cancer Society, Inc.

Effect of Offering Same-Day ART vs Usual Health Facility Referral During Home-Based HIV Testing on Linkage to Care and Viral Suppression Among Adults With HIV in Lesotho: The CASCADE Randomized Clinical Trial.

Abstract: Importance Home-based HIV testing is a frequently used strategy to increase awareness of HIV status in sub-Saharan Africa. However, with referral to health facilities, less than half of those who test HIV positive link to care and initiate antiretroviral therapy (ART). Objective To determine whether offering same-day home-based ART to patients with HIV improves linkage to care and viral suppression in a rural, high-prevalence setting in sub-Saharan Africa. Design, Setting, and Participants Open-label, 2-group, randomized clinical trial (February 22, 2016-September 17, 2017), involving 6 health care facilities in northern Lesotho. During home-based HIV testing in 6655 households from 60 rural villages and 17 urban areas, 278 individuals aged 18 years or older who tested HIV positive and were ART naive from 268 households consented and enrolled. Individuals from the same household were randomized into the same group. Interventions Participants were randomly assigned to be offered same-day home-based ART initiation (n = 138) and subsequent follow-up intervals of 1.5, 3, 6, 9, and 12 months after treatment initiation at the health facility or to receive usual care (n = 140) with referral to the nearest health facility for preparatory counseling followed by ART initiation and monthly follow-up visits thereafter. Main Outcomes and Measures Primary end points were rates of linkage to care within 3 months (presenting at the health facility within 90 days after the home visit) and viral suppression at 12 months, defined as a viral load of less than 100 copies/mL from 11 through 14 months after enrollment. Results Among 278 randomized individuals (median age, 39 years [interquartile range, 28.0-52.0]; 180 women [65.7%]), 274 (98.6%) were included in the analysis (137 in the same-day group and 137 in the usual care group). In the same-day group, 134 (97.8%) indicated readiness to start ART that day and 2 (1.5%) within the next few days and were given a 1-month supply of ART. At 3 months, 68.6% (94) in same-day group vs 43.1% (59) in usual care group had linked to care (absolute difference, 25.6%; 95% CI, 13.8% to 36.3%; P P = .007). Two deaths (1.5%) were reported in the same-day group, none in usual care group. Conclusions and Relevance Among adults in rural Lesotho, a setting of high HIV prevalence, offering same-day home-based ART initiation to individuals who tested positive during home-based HIV testing, compared with usual care and standard clinic referral, significantly increased linkage to care at 3 months and HIV viral suppression at 12 months. These findings support the practice of offering same-day ART initiation during home-based HIV testing. Trial Registration clinicaltrials.gov Identifier:NCT02692027

Non-clinical community interventions: a systematised review of social prescribing schemes

Abstract: Background: This review focused on evaluation of United Kingdom social prescribing schemes published in peer-reviewed journals and reports. Schemes, including arts, books, education, and exercise ‘on prescription’ refer patients to community sources of non-clinical intervention. Method: A systematised review protocol appraised primary research material evaluating social prescribing schemes published 2000-15. Searches were performed in electronic databases using keywords, and articles were screened for evaluation of patient data, referral process, assessment method and outcomes; non-evaluated articles were excluded. Results: Of 86 schemes located including pilots, 40 evaluated primary research material: 17 used quantitative methods including six randomised controlled trials; 16 qualitative methods, and seven mixed methods; 9 exclusively involved arts on prescription. Conclusions: Outcomes included increase in self-esteem and confidence; improvement in mental wellbeing and positive mood; and reduction in anxiety, depression and negative mood. Despite positive findings, the review identifies a number of gaps in the evidence base and makes recommendations for future evaluation and implementation of referral pathways.

Do Job Networks Disadvantage Women? Evidence from a Recruitment Experiment in Malawi

Abstract: Using a eld experiment in Malawi where men and women apply for future surveyor positions with a local rm, we nd that highly skilled women are systematically disadvantaged through the use of referrals. This happens both because most men recommend other men, and because women refer fewer candidates who qualify for the position. We document that segregated networks do not cause this behavior. We develop a theoretical model of referral choice and exploit random variation in referral contract terms to nd that that both men’s and women’s biases result from social incentives rather than expectations of performance. We also document that the screening potential of networks is maximized when men refer men. This paper suggests that the use of social networks in hiring is an additional channel through which women are disadvantaged in the labor market.

Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical Outcomes and Patient Experiences.

Abstract: Importance Hospital-at-home (HaH) care provides acute hospital-level care in a patient’s home as a substitute for traditional inpatient care. In September 2017, the Physician-Focused Payment Model Technical Advisory Committee recommended implementation of an alternative payment model for a new model of HaH that bundles the acute episode with 30 days of postacute transitional care. Objective To report outcomes of this new payment model for HaH care. Design, Setting, and Participants Case-control study of HaH care patients with a concurrent control group of hospital inpatients recruited from emergency departments (EDs) and residences in New York City from November 18, 2014, to August 31, 2017. HaH patients were 18 years or older with fee-for-service Medicare and acute medical illness requiring inpatient-level care. Control patients met HaH eligibility but refused participation or were seen in the ED when a HaH admission could not be initiated. Exposures HaH care or inpatient care. Main Outcomes and Measures Primary outcomes were acute period length of stay (LOS), all-cause 30-day hospital readmissions and ED visits, admissions to skilled nursing facilities (SNFs), referral to a certified home health care agency, and patient experiences with care. Analyses accounted for nonrandom selection using inverse probability weighting. Results Among the 507 patients enrolled (mean [SD] age, 74.6 [15.7] years; 68.6% women), data were available on all patients 30 days postdischarge. HaH patients (n = 295) were older than controls (n = 212) and more likely to have a preacute functional impairment. HaH patients had shorter LOS (3.2 days vs 5.5 days; difference, −2.3 days; 95% CI, −1.8 to −2.7 days; weightedP Conclusions and Relevance HaH care bundled with a 30-day postacute transitional care episode was associated with better patient outcomes and ratings of care compared with inpatient hospitalization. This model warrants consideration for addition to Medicare’s current portfolio of shared savings programs.

Reducing wait time from referral to first visit for community outpatient services may contribute to better health outcomes: a systematic review.

Abstract: Many people wait long periods for community outpatient services. However little is known about the impact of waiting from referral to first visit on patient outcomes. The aim of this systematic review is to investigate whether waiting for community outpatient services is associated with adverse effects on patient outcomes. Medline, Embase, Psych Info and CINAHL databases were searched, combining the key concepts of waiting for healthcare and patient outcomes. Studies were included if they reported data comparing health outcomes for patients with different waiting times for the same period. Three reviewers applied inclusion and exclusion criteria to identified studies and assessed quality using the McMaster Critical Review Forms. Levels of evidence were assessed using National Health and Medical Research Council guidelines. Included studies were analysed using a descriptive synthesis, and summarised according to levels of evidence and clinical significance for key outcomes. Fourteen studies that included 69,606 adult patients were selected. Selected studies included patients referred for treatment for musculoskeletal disorders (n = 28,722) or to cardiac rehabilitation (n = 40,884). There was low-level evidence that reduced wait time is associated with moderate improvement in workplace participation for patients seeking care for musculoskeletal conditions; and moderate improvement in exercise tolerance for patients referred to cardiac rehabilitation. There was inconsistent evidence that improvements in quality of life, patient satisfaction and psychological symptoms may be associated with shorter wait times. Pain, function and physical activity outcomes were not associated with wait time. This review found low-level evidence suggesting an association between early access to community outpatient services and improvement of some patient outcomes. Specifically, shorter wait times from referral to first visit for musculoskeletal pain services may improve patient work participation. Shorter wait times for cardiac rehabilitation may improve patient exercise capacity. The effects of a short wait time for other patient conditions and patient outcomes, including quality of life, psychological symptoms and patient experience, are inconclusive. The modest benefits in health outcomes observed in reducing wait time for community outpatient services suggest that other possible benefits such as increasing patient flow should be explored. PROSPERO registration no: CRD42016047003

Diagnosing cancer in primary care: results from the National Cancer Diagnosis Audit.

Abstract: Background Continual improvements in diagnostic processes are needed to minimise the proportion of patients with cancer who experience diagnostic delays. Clinical audit is a means of achieving this. Aim To characterise key aspects of the diagnostic process for cancer and to generate baseline measures for future re-audit. Design and setting Clinical audit of cancer diagnosis in general practices in England. Method Information on patient and tumour characteristics held in the English National Cancer Registry was supplemented by information from GPs in participating practices. Data items included diagnostic timepoints, patient characteristics, and clinical management. Results Data were collected on 17 042 patients with a new diagnosis of cancer during 2014 from 439 practices. Participating practices were similar to non-participating ones, particularly regarding population age, urban/rural location, and practice-based patient experience measures. The median diagnostic interval for all patients was 40 days (interquartile range [IQR] 15–86 days). Most patients were referred promptly (median primary care interval 5 days [IQR 0–27 days]). Where GPs deemed diagnostic delays to have occurred (22% of cases), patient, clinician, or system factors were responsible in 26%, 28%, and 34% of instances, respectively. Safety netting was recorded for 44% of patients. At least one primary care-led investigation was carried out for 45% of patients. Most patients (76%) had at least one existing comorbid condition; 21% had three or more. Conclusion The findings identify avenues for quality improvement activity and provide a baseline for future audit of the impact of 2015 National Institute for Health and Care Excellence guidance on management and referral of suspected cancer.

Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa: a systematic review of literature.

Abstract: Nearly 15% of pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labour and complications of abortion. Globally, an estimated 10.7 million women have died due to obstetric complications in the last two decades, and two thirds of these deaths occurred in sub-Saharan Africa. Though the majority of maternal mortalities can be prevented, different factors can hinder women’s access to emergency obstetric services. Therefore, this review is aimed at synthesizing current evidence on barriers to access and utilization of emergency obstetric care in sub-Saharan Africa. Articles were searched from MEDLINE, CINAHL, EMBASE, and Maternity and Infant Care databases using predefined search terms and strategies. Articles published in English, between 2010 and 2017, were included. Two reviewers (AG and AM) independently screened the articles, and data extraction was conducted using the Joanna Briggs Institute data extraction format. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. The identified barriers were qualitatively synthesized and reported using the Three Delays analytical framework. The PRISMA checklist was employed to present the findings. The search of the selected databases returned 3534 articles. After duplicates were removed and further screening undertaken, 37 studies fulfilled the inclusion criteria. The identified key barriers related to the first delay included younger age, illiteracy, lower income, unemployment, poor health service utilization, a lower level of assertiveness among women, poor knowledge about obstetric danger signs, and cultural beliefs. Poorly designed roads, lack of vehicles, transportation costs, and distance from facilities led to the second delay. Barriers related to the third delay included lack of emergency obstetric care services and supplies, shortage of trained staff, poor management of emergency obstetric care provision, cost of services, long waiting times, poor referral practices, and poor coordination among staff. A number of factors were found to hamper access to and utilization of emergency obstetric care among women in sub-Saharan Africa. These barriers are inter-dependent and occurred at multiple levels either at home, on the way to health facilities, or at the facilities. Therefore, country-specific holistic strategies including improvements to healthcare systems and the socio-economic status of women need to be strengthened. Further research should focus on the assessment of the third delay, as little is known about facility-readiness. PROSPERO CRD42017074102

Oral health knowledge, attitudes and care practices of people with diabetes: a systematic review

Abstract: People with uncontrolled diabetes are at greater risk for several oral health problems, particularly periodontal (gum) disease. Periodontal disease also impacts diabetes control. Good oral hygiene and regular dental visits are recommended to prevent and manage oral health problems. Several studies have been conducted to assess the oral health knowledge, attitudes, and practices of people with diabetes yet a review of these findings has not yet been undertaken. The aim of this systematic review was to synthesize current evidence on the knowledge, attitudes and practices of people with diabetes in relation to their oral health care. A systematic search of all literature was carried out in five databases using key search terms. The inclusion criteria were: 1) published in the English language; 2) from 2000 to November, 2017; 3) conducted on persons with any type of diabetes and of all ages; 4) explored at least one study outcome (knowledge or attitude or practices toward oral health care); and 5) used quantitative methods of data collection. No restrictions were placed on the quality and setting of the study. A total of 28 studies met the inclusion criteria. The studies included a total of 27,894 people with diabetes and were conducted in 14 countries. The review found that people with diabetes have inadequate oral health knowledge, poor oral health attitudes, and fewer dental visits. They rarely receive oral health education and dental referrals from their care providers. Provision of oral health education by diabetes care providers and referral to dentists when required, was associated with improved oral health behaviours among patients. Overall, people with diabetes have limited oral health knowledge and poor oral health behaviours. It is therefore essential to educate patients about their increased risk for oral health problems, motivate them for good oral health behaviours and facilitate access to dental care.

Trends in Regionalization of Hospital Care for Common Pediatric Conditions.

Abstract: OBJECTIVES: We have previously observed that hospital care for children is concentrating significantly in Massachusetts. We now extend those observations to include 4 US states and give closer attention to the management patterns of specific clinical conditions. METHODS: We used inpatient and emergency department administrative data sets from California, Florida, Massachusetts, and New York to measure transfer frequency and identify the site of care completion for >252 million hospital encounters from 2006 through 2013. We compared the concentration of pediatric care to adult care by using the Hospital Capability Index for all acute-care hospitals and quantified the regionalization of clinical conditions by using the Regionalization Index. RESULTS: The availability of hospital care was significantly more limited for children than adults in all 4 states (median Hospital Capability Index: 0.19 vs 0.74 in CA, 0.08 vs 0.79 in FL, 0.18 vs 0.69 in MA, and 0.16 vs 0.75 in NY). Between 2006 and 2011, care was concentrated for both adults and children but much more so for children. Although pediatric admissions decreased by 9.3% (from 545 330 to 494 645), interhospital transfers increased by 24.6% (from 64 285 to 80 101). The largest change in transfer rate was among children with common conditions, such as abdominal pain and asthma. CONCLUSIONS: Definitive pediatric hospital care is less available than adult care and is increasingly dependent on referral centers. This should be accounted for in public health plans, disaster preparedness, and determinations of network adequacy.

Factors influencing non-participation in an exercise program and attitudes towards physical activity amongst cancer survivors

Abstract: The purposes of this study are to investigate factors influencing non-participation in a structured exercise program for cancer survivors and to explore survivors’ experiences and attitudes in relation to physical activity participation. Face-to-face or telephone interviews were conducted with individuals who had registered for, or engaged in, the ‘Life Now’ exercise program run by Cancer Council Western Australia. Participants were 20 cancer survivors (mean age 63.90 years, SD 15.29) who had either cancelled their registration or withdrawn from the exercise program during the preceding 2 years. Interview transcripts were analysed using thematic analysis. Seven main themes emerged: availability of the program; access, time and cost; lack of motivation or confidence; unwell or fatigued; physical activity preferences; knowledge of physical activity guidelines; and lack of referral or advice. The main barriers were contextual and included availability of, and access to, the program. Participants expressed a preference for home-based physical activity. Interventions aimed at promoting physical activity in cancer survivors should offer home-based programs and include referral and advice from oncologists. Increasing cancer survivors’ participation in, and compliance with, exercise programs may require home-based strategies and referrals from oncologists to allied health professionals to individualise care.

Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists.

Abstract: Regardless of their area of specialization, adult psychiatrists are likely to encounter gender-variant patients; however, medical school curricula and psychiatric residency training programs devote little attention to their care. This article aims to assist adult psychiatrists who are not gender specialists in the delivery of respectful, clinically competent, and culturally attuned care to gender-variant patients, including those who identify as transgender or transsexual or meet criteria for the diagnosis of Gender Dysphoria (GD) as defined by The Diagnostic and Statistical Manual of Mental Disorders (5th edition). The article will also be helpful for other mental health professionals. The following areas are addressed: evolution of diagnostic nosology, epidemiology, gender development, and mental health assessment, differential diagnosis, treatment, and referral for gender-affirming somatic treatments of adults with GD.

The My Child Matters programme: effect of public–private partnerships on paediatric cancer care in low-income and middle-income countries

Abstract: Summary In low-income and middle-income countries, an excess in treatment failure for children with cancer usually results from misdiagnosis, inadequate access to treatment, death from toxicity, treatment abandonment, and relapse. The My Child Matters programme of the Sanofi Espoir Foundation has funded 55 paediatric cancer projects in low-income and middle-income countries over 10 years. We assessed the impact of the projects in these regions by using baseline assessments that were done in 2006. Based on these data, estimated 5-year survival in 2016 increased by a median of 5·1%, ranging from −1·5% in Venezuela to 17·5% in Ukraine. Of the 26 861 children per year who develop cancer in the ten index countries with My Child Matters projects that were evaluated in 2006, an estimated additional 1343 children can now expect an increase in survival outcome. For example, in Paraguay, a network of paediatric oncology satellite clinics was established and scaled up to a national level and has managed 884 patients since initiation in 2006. Additionally, the African Retinoblastoma Network was scaled up from a demonstration project in Mali to a network of retinoblastoma referral centres in five sub-Saharan African countries, and the African School of Paediatric Oncology has trained 42 physicians and 100 nurses from 16 countries. The My Child Matters programme has catalysed improvements in cancer care and has complemented the efforts of government, civil society, and the private sector to sustain and scale improvements in health care to a national level. Key elements of successful interventions include strong and sustained local leadership, community engagement, international engagement, and capacity building and support from government.

An Assessment of Primary Care and Pulmonary Provider Perspectives on Lung Cancer Screening

Abstract: Rationale: Lung cancer screening has a mortality benefit to high-risk smokers, but implementation remains suboptimal Providers represent the key entry point to screening, and an understanding of provider perspectives on lung cancer screening is necessary to improve referral and overall implementationObjectives: The objective of this study was to understand knowledge, beliefs, attitudes, barriers, and facilitators to screening in a diverse group of referring pulmonologists and primary care providersMethods: We conducted an electronic survey of primary care and pulmonary providers within a tertiary care medical center across different practice sites The survey covered the following domains: 1) beliefs and assessment of evidence, 2) knowledge of lung cancer screening and guidelines, 3) current screening practices, 4) barriers and facilitators, and 5) demographic and practice characteristicsResults: The 196 participants included 80% primary care clinicians and 19% pulmonologists (1% others) Forty-one pe

How customer referral programs turn social capital into economic capital

Abstract: Customers acquired through a referral program have been observed to exhibit higher margins and lower churn than customers acquired through other means. Theory suggests two likely mechanisms for this phenomenon: (1) better matching between referred customers and the firm and (2) social enrichment by the referrer. The present study is the first to provide evidence of these two mechanisms in a customer referral program. Consistent with the theory that better matching affects contribution margins, (1) referrer–referral dyads exhibit shared unobservables in customer contribution margins, (2) referrers with more extensive experience bring in higher-margin referrals, and (3) this association between the referrer’s experience and margin gap becomes smaller over the referral’s lifetime. Consistent with the theory that social enrichment affects retention, referrals exhibit lower churn only as long as their referrer has not churned. These findings indicate that better matching and social enrichment are two m...

Patient-Sharing Networks of Physicians and Health Care Utilization and Spending Among Medicare Beneficiaries

Abstract: Importance Physicians are embedded in informal networks in which they share patients, information, and behaviors. Objective We examined the association between physician network properties and health care spending, utilization, and quality of care among Medicare beneficiaries. Design, Setting, and Participants In this cross-sectional study, we applied methods from social network analysis to Medicare administrative data from 2006 to 2010 for an average of 3 761 223 Medicare beneficiaries per year seen by 40 241 physicians practicing in 51 hospital referral regions (HRRs) to identify networks of physicians linked by shared patients. We improved on prior methods by restricting links to physicians who shared patients for distinct episodes of care, thereby excluding potentially spurious linkages between physicians treating common patients but for unrelated reasons. We also identified naturally occurring communities of more tightly linked physicians in each region. We examined the relationship between network properties measured in the prior year and outcomes in the subsequent year using regression models. Main Outcomes and Measures Spending on total medical services, hospital, physician, and other services, use of services, and quality of care. Results The mean patient age across the 5 years of study was 72.3 years and 58.5% of the participants were women. The mean age across communities of included physicians was 49 years and approximately 78% were men. Mean total annual spending per patient was $10 051. Total spending was higher for patients of physicians with more connections to other physicians ($1009 for a 1–standard deviation increase,P Conclusions and Relevance Characteristics of physicians’ networks and the position of physicians in the network were associated with overall spending and utilization of services for Medicare beneficiaries.

Knowledge, practice and associated factors of infection prevention among healthcare workers in Debre Markos referral hospital, Northwest Ethiopia.

Abstract: Healthcare-associated infections are a major global public health agenda. Health care workers are front line of protecting themselves and clients from infection. This study examined the knowledge and practice of healthcare workers on infection prevention and its associated factors among health professionals working at Debre Markos Referral Hospital. A Hospital-based cross-sectional study was conducted with a structured pre-tested questionnaire among 150 participants. The healthcare workers were selected through systematic random sampling technique. Multivariate logistic regressions were computed to identify associated factors of knowledge and practice of infection prevention and variables with a p-value < 0.05 were considered statistically significant. More than two thirds (84.7%) of healthcare workers were found to be knowledgeable but only 86 (57.3%) of respondents demonstrated a good practice on infection prevention. Older age, lengthy work experience and higher educational status were significantly associated with both knowledge and practice of infection prevention. In-service training, availability of infection prevention supplies and adherence to infection prevention guidelines was also associated with the practice of infection prevention. The finding of this study revealed a good knowledge of infection prevention on the majority of participants with relatively minimal practice rate. Sociodemographic factors and health facility factors were associated with knowledge and practice of infection prevention. Hospitals and other concerned stakeholders should ensure constant availability of guidelines and the provision of training to health providers. Moreover, developing professionals’ educational level, introducing infection prevention standard of practice and continuous mentorship was recommended.

Successes, Challenges, and Considerations for Integrating Referral into Food Insecurity Screening in Pediatric Settings.

Abstract: Food insecurity, lack of access to enough food for an active and healthy life, is associated with poor child health. Three pediatric clinics implemented a two-question food insecurity screening of 7,284 families with children younger than five years. Over one thousand (1,133, 15.6%) reported food insecurity and 630 (55.6%) were referred to a benefits access organization for connection to public benefits and community resources. This study evaluated the efficacy of screening and referral through process evaluation, key informant interviews, and focus groups with 19 caregivers and 11 clinic staff. Using grounded theory, transcript themes were coded into facilitators and barriers of screening and referral. Facilitators included trust between caregivers and staff, choice of screening methods, and assistance navigating benefits application. Barriers included complex administration of referral, privacy and stigma concerns, and caregivers' current benefit enrollment or ineligibility. Results demonstrate importance of integrated screening and referral consent processes, strong communication, and convenient outreach for families.

Increasing success and evolving barriers in the hepatitis C cascade of care during the direct acting antiviral era.

Abstract: Barriers remain in the hepatitis C virus (HCV) cascade of care (CoC), limiting the overall impact of direct acting antivirals. This study examines movement between the stages of the HCV CoC and identifies reasons why patients and specific patient populations fail to advance through care in a real world population. We performed a single-center, ambispective cohort study of patients receiving care in an outpatient infectious diseases clinic between October 2015 and September 2016. Patients were followed from treatment referral through sustained virologic response. Univariate and multivariate analyses were performed to identify factors related to completion of each step of the CoC. Of 187 patients meeting inclusion criteria, 120 (64%) completed an evaluation for HCV treatment, 119 (64%) were prescribed treatment, 114 (61%) were approved for treatment, 113 (60%) initiated treatment, 107 (57%) completed treatment, and 100 (53%) achieved a sustained virologic response. In univariate and multivariate analyses, patients with Medicaid insurance were less likely to complete an evaluation and were less likely to be approved for treatment. Treatment completion and SVR rates are much improved from historical CoC reports. However, linkage to care following referral continues to be a formidable challenge for the HCV CoC in the DAA era. Ongoing efforts should focus on linkage to care to capitalize on DAA treatment advances and improving access for patients with Medicaid insurance.

Sociodemographic and Clinical Characteristics of Transgender Adults in Australia.

Abstract: Background: Over the last 10 years, increases in demand for transgender health care has occurred worldwide. There are few data on clinical characteristics of Australian adult transgender individuals. Understanding gender identity patterns, sociodemographic characteristics, gender-affirming treatments, as well as medical and psychiatric morbidities, including neurobehavioral conditions affecting transgender and gender-diverse adults will help to inform optimal health service provision. Purpose: In an Australian adult transgender cohort, we aimed to first, assess referral numbers and describe the sociodemographic and clinical characteristics, and second, to specifically assess the prevalence of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). Methods: We performed a retrospective audit of deidentified electronic medical records in a primary care and a secondary care gender clinic in Melbourne, Australia. Annual referral rates, sociodemographic data, and prevalence of medical and psychiatric conditions were obtained. Results: Data for 540 transgender individuals were available. Rapid rises were observed in referrals for transgender health services, more than 10 times the number in 2016 compared with 2011. Median age at initial presentation was 27 years (interquartile range (22, 36), range 16-74). Around 21.3% were unemployed and 23.8% had experienced homelessness despite high levels of education. Around 44.1% identified as trans male, 36.3% as trans female, and 18.3% as gender nonbinary. Medical morbidities were rare but mental illness was very common. The prevalence of depression was 55.7%, anxiety in 40.4%, ADHD in 4.3%, and ASD in 4.8%, all higher than reported age-matched general Australian population prevalence. Conclusions: Rising demand for transgender care, socioeconomic disadvantage, and high burden of mental health conditions warrants a comprehensive multidisciplinary approach to provide optimal care for transgender individuals. Given that ASD and ADHD are prevalent, in addition to gender-affirming treatments, psychosocial interventions may assist individuals in navigating health care needs and to support social aspects of gender transition. Further studies are required to understand links between ASD, ADHD, and gender identity and to evaluate optimal models of health service provision for transgender individuals.

“We Had to Keep Pushing”: Caregivers' Perspectives on Autism Screening and Referral Practices of Black Children in Primary Care

Abstract: Black children with autism spectrum disorder (ASD) are diagnosed later than their White peers, are more likely to be misdiagnosed, and are less likely to receive early intervention services or a developmental evaluation by three years old. Using a grounded theory approach, we solicited the perspectives of parents and other primary caregivers of Black children with ASD on barriers and facilitators to ASD screening and referrals in primary care. A socioeconomically diverse sample of 22 female caregivers participated. Four themes emerged. First, while some caregivers noted their child's primary healthcare providers facilitated a timely ASD diagnosis, other participants reported these providers ignored early concerns about child developmental delays. Second, many participants felt racial bias negatively impacted caregiver-primary healthcare provider interactions. Third, legal/custodial issues slowed caregivers' abilities to follow up on referrals from their primary healthcare providers. Finally, caregivers described denial, shame, and stigma relating to ASD in the Black community as possible factors for delayed follow up to referrals. Differences based on socioeconomic status are discussed. Efforts to improve family-centered, culturally relevant care for all Black caregivers raising children with or at-risk for ASD are needed, particularly for those families experiencing the multiple effects of poverty.

Supporting Parent Caregivers of Children with Life-Limiting Illness.

Abstract: The well-being of parents is essential to the well-being of children with life-limiting illness. Parents are vulnerable to a range of negative financial, physical, and psychosocial issues due to caregiving tasks and other stressors related to the illness of their child. Pediatric palliative care practitioners provide good care to children by supporting their parents in decision-making and difficult conversations, by managing pain and other symptoms in the ill child, and by addressing parent and family needs for care coordination, respite, bereavement, and social and emotional support. No matter the design or setting of a pediatric palliative care team, practitioners can seek to provide for parent needs by referral or intervention by the care team.

Association of Clinician Denial of Patient Requests With Patient Satisfaction.

Abstract: Importance Prior studies suggesting clinician fulfillment or denial of requests affects patient satisfaction included limited adjustment for patient confounders. The studies also did not examine distinct request types, yet patient expectations and clinician fulfillment or denial might vary among request types. Objective To examine how patient satisfaction with the clinician is associated with clinician denial of distinct types of patient requests, adjusting for patient characteristics. Design, Setting, and Participants Cross-sectional observational study of 1319 outpatient visits to family physicians (n = 56) by 1141 adults at one Northern California academic health center. Main Outcomes and Measures We used 6 Consumer Assessment of Healthcare Providers and Systems Clinician and Group Adult Visit Survey items to measure patient satisfaction with the visit physician. Standardized items were averaged to form the satisfaction score (Cronbach α = 0.80), which was then percentile-transformed. Seven separate linear mixed-effects models examined the adjusted mean differences in patient satisfaction percentile associated with denial of each of the following requests (if present)—referral, pain medication, antibiotic, other new medication, laboratory test, radiology test, or other test—compared with fulfillment of the respective requests. The models adjusted for patient sociodemographics, weight, health status, personality, worry over health, prior visit with clinician, and the other 6 request categories and their dispositions. Results The mean (SD) age of the 1141 patients was 45.6 (16.1) years, and 902 (68.4%) were female. Among 1319 visits, 897 (68.0%) included at least 1 request; 1441 (85.2%) were fulfilled. Requests by category were referral, 294 (21.1%); pain medication, 271 (20.5%); antibiotic, 107 (8.1%); other new medication, 271 (20.5%); laboratory test, 448 (34.0%); radiology test, 153 (11.6%); and other tests, 147 (11.1%). Compared with fulfillment of the respective request type, clinician denials of requests for referral, pain medication, other new medication, and laboratory test were associated with worse satisfaction (adjusted mean percentile differences, −19.75 [95% CI, −30.75 to −8.74], −10.72 [95% CI, −19.66 to −1.78], −20.36 [95% CI, −29.54 to −11.18], and −9.19 [95% CI, −17.50 to −0.87]), respectively. Conclusions and Relevance Clinician denial of some types of requests was associated with worse patient satisfaction with the clinician, but not for others, when compared with fulfillment of the requests. In an era of patient satisfaction-driven compensation, the findings suggest the need to train clinicians to deal effectively with requests, potentially enhancing patient and clinician experiences.

Sex and Racial Disparities in Cardiac Rehabilitation Referral at Hospital Discharge and Gaps in Long-Term Mortality.

Abstract: Background Cardiac rehabilitation (CR) referral is recommended for eligible patients, regardless of sex or race. It is unclear whether inequality in CR referral practices was associated with patients’ long‐term survival. Methods and Results We linked the American Heart Association Get With The Guidelines Coronary Artery Disease registry with Medicare claims data for 48 993 coronary artery disease patients from 365 hospitals across the United States between 2003 and 2009. We used generalized estimation equations to estimate the association between CR referral and mortality accounting for clustering within hospitals. Between 2003 and 2009, only 40% of eligible patients received CR referrals. Females were 12% less likely to receive CR referral compared with males. Black, Hispanic, and Asian patients were 20%, 36%, and 50% less likely, respectively, to receive CR referral than white patients. CR referral was associated with 40% lower 3‐year all‐cause mortality. Women and minorities who received CR referral at hospital discharge had significantly lower mortality compared with those who did not (odds ratios=0.61 [95% confidence interval, 0.56–0.66] for women, 0.75 [95% confidence interval, 0.63–0.88] for black, 0.62 [95% confidence interval, 0.50–0.79] for Hispanic, and 0.63 [95% confidence interval, 0.46–0.85] for Asian patients). Seven percent of the black versus white mortality gap could potentially be reduced by equitable CR referral. Conclusions CR referral rates at hospital discharge remained low. Gaps in receiving CR referral at hospital discharge were large for women and minorities, and the mortality gap could potentially be reduced through elimination of inequality in CR referral.

Peer Support and the HIV Continuum of Care: Results from a Multi-Site Randomized Clinical Trial in Three Urban Clinics in the United States

Abstract: Racial/ethnic minorities living with HIV and behavioral health co-morbidities are more likely to be disengaged from HIV primary care. Peer programs have been effective in HIV outreach and prevention but effectiveness of such programs for retention in care and viral suppression is understudied. Subjects (n = 348) were randomized in equal allocation to a peer navigation and education intervention versus standard clinical care at three urban clinics in the United States. The intervention group received seven structured interventions plus weekly contact to address medical and social needs. Primary outcomes included time-to-first 4-month gap in HIV care and viral suppression up to 12 months of follow-up. Intention-to-treat analysis showed no difference between groups on 4-month gap in HIV primary care, but subgroup analysis showed a suggestive effect of the peer intervention in reducing gaps in care among stably housed subjects. Fully compliant subjects in the peer intervention experienced significantly fewer 4-month gaps in HIV primary care (p < 0.0001). Those in the peer group who had more clinical face-to-face encounters in the first 3 months were also significantly more likely to have better retention in care (p = 0.04). There were no significant differences between any study subgroups in viral suppression at 12 months. Peer interventions may improve retention in primary care among subgroups of people living with HIV from racial/ethnic minority communities, although such improved retention may not increase viral load suppression. Attending and completing structured educational sessions along with early, intensive contact with peers could improve retention in HIV primary care for patients. Future peer programs should consider training on housing referral systems to help increase retention for patients who are not stably housed. clinicaltrials.gov registration number: NCT01616940.