The association between geriatric treatment and 30-day readmission risk among medical inpatients aged ≥75 years with multimorbidity

Background Readmission to hospital is frequent among older patients and reported as a post-discharge adverse outcome. The effect of treatment in a geriatric ward for acutely admitted older patients on mortality and function is well established, but less is known about the possible influence of such treatment on the risk of readmission, particularly in the oldest and most vulnerable patients. Our aim was to assess the risk for early readmission for multimorbid patients > 75 years treated in a geriatric ward compared to medical wards and to identify risk factors for 30-day readmissions. Methods Prospective cohort study of patients acutely admitted to a medical department at a Norwegian regional hospital. Eligible patients were community-dwelling, multimorbid, receiving home care services, and aged 75+. Patients were consecutively included in the period from 1 April to 31 October 2012. Clinical data were retrieved from the referral letter and medical records. Results We included 227 patients with a mean (SD) age of 86.0 (5.7) years, 134 (59%) were female and 59 (26%) were readmitted within 30 days after discharge. We found no statistically significant difference in readmission rate between patients treated in a geriatric ward versus other medical wards. In adjusted Cox proportional hazards regression analyses, lower age (hazard ratio (95% confidence interval) 0.95 (0.91–0.99) per year), female gender (2.17 (1.15–4.00)) and higher MMSE score (1.03 (1.00–1.06) per point) were significant risk factors for readmission. Conclusions Lower age, female gender and higher cognitive function were the main risk factors for 30-day readmission to hospital among old patients with multimorbidity. We found no impact of geriatric care on the readmission rate.

Retrospective Analysis of Intra-Departmental Requests for Consultation To Hematology Department

Aim: To investigate how much information a specialist hematologist receives at the time of initial assessment of referred patients through a referral letter. Study design: Retrospective study Place and duration of study: Haematology department BVH, October 2020 to February 2021 (5 months) Methods & Results: Among the 96 referral letters received, Majority 45 (47%) was referred from medicine department. Most common reason for referring the patient was evaluation of Pancytopenia n=19 (19.8%), Request for bone marrow biopsy n=14 (14.6%), being the second most common. The reason for referral was not properly stated in n=9 (9.4%) of patients in our study. Majority of referred patients were above 46 years of age n=22 (22.9%). CBC was mentioned only in n=35 (36.5%). Conclusion: Our study concludes that quality of referral letter was well below the acceptable standards. A well-documented protocol for referral letter is the need of hour to improve the quality of a referral process. Keywords: referral letter, pancytopenia, bone marrow, hematology clinics

Redundant laboratory testing on referral from general practice to the outpatient clinic

BackgroundInappropriately repeated laboratory testing is a commonly occurring problem. However, this has not been studied extensively in the outpatient clinic after referral by general practitioners.AimThe aim of this study was to investigate how often laboratory tests ordered by the general practitioner were repeated on referral to the outpatient clinic, and how many of the normal test results remained normal on repetition.Design & settingThis is a post hoc analysis of a study on laboratory testing strategies in patients newly referred to the outpatient clinic.MethodAll patients who had a referral letter including laboratory test results ordered by the general practitioner were included. These results were compared to the laboratory test results ordered in the outpatient clinic.ResultsData were available for 295 patients, 191 of which had post-visit testing done. In this group, 56% of tests ordered by the general practitioner were repeated. Tests with abnormal results were repeated more frequently than tests with normal results (65% vs 53%; P<0.001). A longer test interval was associated with slightly smaller odds of tests being repeated (OR 0.97 [0.95–0.99]; P=0.003). Of the tests with normal test results that were repeated, 90% remained normal. This was independent of testing interval or testing strategy.ConclusionLaboratory tests ordered by the general practitioner are commonly repeated on referral to the outpatient clinic. The number of test results remaining normal on repetition suggests a high level of redundancy in laboratory test repetition.

EP.TH.81Contribution of Information on GP Referral Letters to Patient Management in a Rapid-diagnosis Breast Clinic

Aims GP referral letters to rapid-diagnosis breast clinics are often poorly scanned copies of standard 2 week-wait proforma that are difficult to read, lengthy, and contain a large amount of irrelevant information. We studied the contribution of information in referral letters in patient management and compared this with information provided by patients themselves. Methods Patients completed a standard questionnaire (one side of A4) on arrival at clinic. This included all information relevant to a breast clinic such as family history and comorbidities. A consultant surgeon then saw the patients with the questionnaire and performed clinical assessment and imaging as necessary, without referring to GP letters. The letters were read before patients left clinic. Any additional useful information was noted. Results 202 consecutive new patients, median age 44 (16-93) seen in 23 clinics by 2 consultants were studied. The median number of pages in referral letter was 5 (1-14). Patient questionnaire took less than 30 seconds to read. The presenting complaints were real or perceived lump (n = 105), pain (n = 44), both (n = 14) and others (n = 39). 21 patients had cancer. Additional useful information in the referral letter was noted in 20 patients (10%). However, in no case this affected the patient management adversely. Conclusions GP letters are lengthy but contribute relatively little to the initial assessment and management of patients in a busy rapid diagnosis breast clinic. A patient-completed targeted questionnaire is quicker and can potentially replace a GP referral letter in most patients.

Delayed diagnosis of a piriformis abscess due to hyposkillia and communication error

A 69-year-old man with dementia presented to our hospital with fever and left back pain. He was diagnosed with acute pyelonephritis based on microscopy and CT findings indicating bacteriuria and elevated fat density around the right kidney, respectively. Three days post admission, the diagnosis of a urinary tract infection was queried and the patient was re-examined. Marked tenderness was observed in the left buttock; contrast CT scan was subsequently performed and a left piriformis abscess was diagnosed. This diagnostic delay occurred due to a communication error—the referral letter to the radiologist stated ‘fever and back pain’—and the physician’s hyposkillia; hence, differential diagnoses were not considered. Physicians can reduce the frequency of related errors by conducting proper physical examinations and not relying on imaging findings alone. Furthermore, to ensure accurate diagnoses, the comments to the radiologist should be clear and detailed when requesting diagnostic imaging.

You're too young to have an eye problem: Reasons for nonadherence to referrals for follow-up eye care for schoolchildren in Nigeria -- a descriptive qualitative study

Study objectives: to identify reasons for non-adherence to referrals for follow-up eye care after children fail a school vision screening test. Methods: Ten focus groups were held with parents or guardians (parents) of children who had not adhered to the referral for further care in Cross River State, Nigeria, in 2019. Data from verbatim transcripts were analysed deductively using topics from the interview guide plus OTHER to capture unanticipated results. Analysts followed procedures for Qualitative Content Analysis plus a modified Framework Method to identify overarching themes and barriers that are both highly salient (most frequently mentioned) and relevant (discussed in at least half of all groups). Results: Three themes identified in the data are 1) modifiable barriers (key among them being parental beliefs and problems with the referral letter), 2) contextual factors (parental situation, attitudes towards children and beliefs about care) and 3) participant recommendations to improve the child eye care program (educate the general public and correct parental misconceptions). Many of the findings echoed those from previous studies conducted in both low-and-middle income countries (LMICs) and high-income countries (HICs). Conclusion: This study went beyond identifying modifiable barriers to also identify contextual factors and what parents recommend be done to improve vision care for children in Cross River State, Nigeria. If acted on, these findings may increase acceptance and uptake of eye care services that can promote sustainability and spread of the program to other parts of Nigeria and/or Africa.

Documenting Patients’ and Providers’ Preferences When Proposing a Randomized Controlled Trial: A Qualitative Exploration

Background With advances in cancer diagnosis and treatment, women with early-stage breast cancer (ESBC) are living longer, increasing the number of patients receiving post-treatment follow-up care. Best-practice survivorship models recommend transitioning ESBC patients from oncology-provider (OP) care to community-based care. While developing materials for a randomized controlled trial (RCT) to test the feasibility of a nurse-led Telephone Survivorship Clinic (TSC) for a smooth transition of ESBC survivors to follow-up care, we sought to explore patients’ and OPs’ reactions to our proposed recruitment methods. Methods We used a qualitative study design with content analysis, and a two-pronged approach. We interviewed OPs, seeking feedback on ways to recruit their ESBC patients for the trial, and ESBC patients, seeking input on a questionnaire package assessing outcomes and processes in the trial. Results OPs identified facilitators and barriers and offered suggestions for study design and recruitment process improvement. Facilitators included the novelty and utility of the study and simplicity of methods; barriers included lack of coordination between treating and discharging clinicians, time constraints, language barriers, motivation, and using a paper-based referral letter. OPs suggested using a combination of electronic and paper referral letters and supporting clinicians to help with recruitment. Patient advisors reported satisfaction with the content and length of the assessment package. However, they questioned the relevance of some questions (childhood trauma) while adding questions about trust in physicians and proximity to primary-care providers. Conclusion OPs and patient advisors rated our methods for the proposed trial highly for their simplicity and relevance then suggested changes. These findings document processes that could be effective for cancer-patient recruitment in survivorship clinical trials.

Transition of young people from CAMHS to AMH 2017-19

AimsTransition from CAMHS to AMH is recognised as a potential struggle for young people who suffer with poor mental health. In response to the 2017-19 NHS CQUIN project, LPT organised a monthly working group to establish the best transition process & deliver the CQUIN project.BackgroundIt is estimated that more than 25,000 young people transition each year. It is reported that this process is often handled poorly, which can result in repeat assessments and emergency admissions for this large cohort of service users at a critical stage in life. The result is that young may go on to develop more severe problems in the absence of an appropriate transition service.MethodCohort of service users eligible for transition (17yrs 6months) was identified. They were referred from CAMHS to AMH with a transition plan and referral letter. A face-to-face transition meeting was arranged which included the patient, carer & clinicians from sending & receiving services. A clinical audit was completed to ensure that care was transferred to AMH post-18th birthday of the patient. The process was followed up by pre- and post-transitions surveys.ResultFrom 110 identified service users 46% had joint-agency transition meeting and 79% had transition plan in place. 72% felt prepared to transition to AMH and 89% felt their transition goals were met. Positive comments have been received from service users.ConclusionLink workers were identified to facilitate the transition process. Flow chart was established and disseminated across LPT. Services that need an improvement will be targeted and monitored. LPT will host an event for patients and carers to involve them in enhancing the transition process.