Associations of At-Risk Drinking, Current Smoking, and Their Co-Occurrence With Primary Care Service Utilization

Purpose Smoking and at-risk drinking are each associated with lower primary care utilization, but the influence of their co-occurrence is not known. The current study compared associations of endorsement of one behavior vs endorsement of both with primary care utilization. Design Cross-sectional telephone survey. Setting All United States and Territories. Subjects 246 801 adults aged 18–64. Measures The outcome was endorsement of attending a past-year primary care visit. Predictor variables included drinking and smoking status examined individually and combined. Analysis Multivariable logistic regressions, adjusted for socio-demographics and number of chronic health conditions. Results The odds of attending a past-year primary care visit were 24% lower for persons who drank at risk levels compared to the odds of persons who did not drink and 36% lower for persons who smoked vs those who did not smoke. Among persons who endorsed at least one risk behavior, the odds of attending a past-year primary care visit were 25–35% lower for those who engaged in multiple behaviors compared to the odds of persons who engaged in one behavior. Conclusion Substance use screening and intervention services in primary care may not be reaching individuals with the greatest need for services. Proactive outreach and identification of primary care utilization barriers are needed, with special consideration of those with co-occurring substance use.

Implementing Behavioral Health Social Workers' Increased Mental Health Care Among Older Adults

Depression is underdiagnosed and undertreated among older adults. Health systems can screen patients to identify depression, but systemic linkages to treatment are required to ensure care. We used a retrospective stepped-wedge study to identify the impact of implementing behavioral health social workers (BHSWs) on receipt of treatment after a new depression diagnosis. We included adults over 65 years of age with a primary care visit between 2016 and 2019 at a large integrated health system. We excluded patients who were diagnosed with or treated for depression in 2015. Patients were categorized into control (diagnosed before implementation) and intervention (diagnosed after implementation) groups. From our electronic health record, we collected prescriptions for pharmacotherapy and behavioral health visits. Patients were considered treated if they received pharmacotherapy or had a behavioral health visit within 30 days of diagnosis. We used multilevel logistic regression models to identify the association between implementation period (pre versus post) and treatment, adjusted for demographic variables and clustering within site. Our population included 4,475 people. The percent of patients that received treatment increased from 47% to 54% after implementation and the percent of patients with ≥1 behavioral health visit within 30 days increased from 3% to 8% (p<0.01, respectively). The adjusted odds ratio of receiving treatment (AOR: 4.13, 95%CI: 2.84-6.01) and having a behavioral health visit (AOR: 3.12, 95%CI: 2.31-4.24) was significantly higher in the post-implementation period. In conclusion, implementation of BHSWs was associated with increased treatment for older patients with depression.

Is early activity resumption after paediatric concussion safe and does it reduce symptom burden at 2 weeks post injury? The Pediatric Concussion Assessment of Rest and Exertion (PedCARE) multicentre randomised clinical trial

ObjectiveInvestigate whether resuming physical activity (PA) at 72 hours post concussion is safe and reduces symptoms at 2 weeks, compared with resting until asymptomatic.MethodsReal-life conditions, multicentre, single-blinded randomised clinical trial, conducted in three Canadian paediatric emergency departments (ED). Children/youth aged 10–<18 years with acute concussion were recruited between March 2017 and December 2019, and randomly assigned to a 4-week stepwise return-to-PA protocol at 72 hours post concussion even if symptomatic (experimental group (EG)) or to a return-to-PA once asymptomatic protocol (control group (CG)). The primary outcome was self-reported symptoms at 2 weeks using the Health and Behaviour Inventory. Adherence was measured using accelerometers worn 24 hours/day for 14 days post injury. Adverse events (AE) (worsening of symptoms requiring unscheduled ED or primary care visit) were monitored. Multivariable intention-to-treat (ITT) and per-protocol analyses adjusting for prognostically important covariates were examined. Missing data were imputed for the ITT analysis.Results456 randomised participants (EG: N=227; mean (SD) age=13.3 (2.1) years; 44.5% women; CG: N=229; mean (SD) age=13.3 (2.2) years; 43.7% women) were analysed. No AE were identified. ITT analysis showed no strong evidence of a group difference at 2 weeks (adjusted mean difference=−1.3 (95% CI:−3.6 to 1.1)). In adherent participants, initiating PA 72 hours post injury significantly reduced symptoms 2 weeks post injury, compared with rest (adjusted mean difference=−4.3 (95% CI:−8.4 to –0.2)).ConclusionSymptoms at 2 weeks did not differ significantly between children/youth randomised to initiate PA 72 hours post injury versus resting until asymptomatic; however, many were non-adherent to the intervention. Among adherent participants, early PA was associated with reduced symptoms at 2 weeks. Resumption of PA is safe and may be associated with milder symptoms at 2 weeks.Level of evidence1b.Trial registration numberNCT02893969.Registry namePediatric Concussion Assessment of Rest and Exertion (PedCARE).

Cashew-Induced Oxalate Nephropathy: A Rare Cause of Acute Renal Failure

ABSTRACT We present a rare case of cashew-induced oxalate nephropathy in a 69 year old veteran male with history of type 2 diabetes mellitus, nephrolithiasis, and undiagnosed chronic kidney disease (CKD). Oxalate nephropathy is a rare cause of acute renal failure with poor prognosis. The various causes of oxalate nephropathy are categorized as primary or secondary hyperoxaluria. Primary hyperoxaluria is caused by genetic mutation in genes involved in the metabolism of glyoxylate. Secondary hyperoxaluria is caused by mal-absorptive state, excessive intake of oxalate-rich diet, inflammatory diseases, and medications such as orlistat and antibiotics. Diet-induced oxalate nephropathy is often identified after unexplained acute kidney injury in patients with underlying CKD. Definitive diagnosis requires renal biopsy as laboratory tests are non-specific. A simple dietary history in CKD patients during routine primary care visit may lead to early diagnosis and lead to prevention of acute renal failure and progression of renal disease.

A-160 Validating the Picture-Based Memory Impairment Screen as a Memory Screener in a Diverse Primary Care Setting

Objective Quick cognitive screeners which can be used for ethnically and educationally diverse patients are particularly useful within the primary care setting. The Picture-Based Memory Impairment Screen (PMIS) is a brief screening tool which has been validated in such a population. Here we compare the PMIS against a gold-standard memory task (Hopkins Verbal Learning Test-Revised [HVLT-R]) and evaluate its utility as a stand-alone memory screener. Method In this cross-sectional study, adults over 65 with cognitive concerns were recruited at their primary care visit to complete the PMIS as part of a larger randomized controlled trial aimed at improving detection of cognitive impairment. A subset of those participants also agreed to complete neuropsychological testing in English or Spanish (including the HVLT-R). Correlations were performed. Results 108 participants (Mean age = 73; 73% female; 39% Black/AA; 58% Hispanic; 52% evaluated in Spanish; Mean years education = 10.8) completed the PMIS and HVLT-R. The PMIS was correlated with the HVLT-R Immediate Raw Score (rs = 0.229, p = 0.17) and even more strongly correlated with the HVLT-R Delayed Raw Score (rs = 0.347, p &lt; 0.001). Conclusions Early results of this ongoing trial suggest that the PMIS is a useful memory screener which can be used to quickly identify individuals in a diverse primary care setting who are likely to have memory weakness.

Changes in the top 25 reasons for primary care visits during the COVID-19 pandemic in a high-COVID region of Canada

Purpose We aimed to determine the degree to which reasons for primary care visits changed during the COVID-19 pandemic. Methods We used data from the University of Toronto Practice Based Research Network (UTOPIAN) to compare the most common reasons for primary care visits before and after the onset of the COVID-19 pandemic, focusing on the number of visits and the number of patients seen for each of the 25 most common diagnostic codes. The proportion of visits involving virtual care was assessed as a secondary outcome. Results UTOPIAN family physicians (N = 379) conducted 702,093 visits, involving 264,942 patients between March 14 and December 31, 2019 (pre-pandemic period), and 667,612 visits, involving 218,335 patients between March 14 and December 31, 2020 (pandemic period). Anxiety was the most common reason for visit, accounting for 9.2% of the total visit volume during the pandemic compared to 6.5% the year before. Diabetes and hypertension remained among the top 5 reasons for visit during the pandemic, but there were 23.7% and 26.2% fewer visits and 19.5% and 28.8% fewer individual patients accessing care for diabetes and hypertension, respectively. Preventive care visits were substantially reduced, with 89.0% fewer periodic health exams and 16.2% fewer well-baby visits. During the pandemic, virtual care became the dominant care format (77.5% virtual visits). Visits for anxiety and depression were the most common reasons for a virtual visit (90.6% virtual visits). Conclusion The decrease in primary care visit volumes during the COVID-19 pandemic varied based on the reason for the visit, with increases in visits for anxiety and decreases for preventive care and visits for chronic diseases. Implications of increased demands for mental health services and gaps in preventive care and chronic disease management may require focused efforts in primary care.

Psychometric Validation of a Combined Assessment for Anxiety and Depression in Primary Care in Mozambique (CAD-MZ)

This study sought to validate a combined assessment for major depression and generalized anxiety, administered by health providers in a primary care setting in Mozambique. Patients attending a primary care visit ( N = 502) were enrolled in the study and completed the Patient Health Questionniare–9, the Generalized Anxiety Disorder–7, and six items identified in a global systematic qualitative review of depression that were not captured in existing measures (e.g., social isolation, “thinking too much,” and “heart problems”). A separate trained mental health provider conducted the Mini International Neuropsychiatric Interview 5.0, adapted for Mozambique, to establish clinical diagnoses. Item response theory, factor analysis, and receiver operating characteristics were all used to identify the best screening items. Eight items were identified for the final screener: four items from the Patient Health Questionniare–9, two from the Generalized Anxiety Disorder–7, and two from the global depression literature. A cut-score of 7 was found to consistently increase the diagnostic likelihood of having a particular disorder. Overall, findings indicate good clinical utility of the screener in primary care in Mozambique.

Natural language processing for automated annotation of medication mentions in primary care visit conversations

Objectives The objective of this study is to build and evaluate a natural language processing approach to identify medication mentions in primary care visit conversations between patients and physicians. Materials and Methods Eight clinicians contributed to a data set of 85 clinic visit transcripts, and 10 transcripts were randomly selected from this data set as a development set. Our approach utilizes Apache cTAKES and Unified Medical Language System controlled vocabulary to generate a list of medication candidates in the transcribed text and then performs multiple customized filters to exclude common false positives from this list while including some additional common mentions of the supplements and immunizations. Results Sixty-five transcripts with 1121 medication mentions were randomly selected as an evaluation set. Our proposed method achieved an F-score of 85.0% for identifying the medication mentions in the test set, significantly outperforming existing medication information extraction systems for medical records with F-scores ranging from 42.9% to 68.9% on the same test set. Discussion Our medication information extraction approach for primary care visit conversations showed promising results, extracting about 27% more medication mentions from our evaluation set while eliminating many false positives in comparison to existing baseline systems. We made our approach publicly available on the web as an open-source software. Conclusion Integration of our annotation system with clinical recording applications has the potential to improve patients’ understanding and recall of key information from their clinic visits, and, in turn, to positively impact health outcomes.

THE FUTURE OF TELEMEDICINE IN MODERN HEALTHCARE

ABSTRACT The COVID-19 has brought a tremulous shift in healthcare delivery. Since February 2020, telemedicine grew from 1% of the primary care visit to nearly 43.5% in April 2020. The report published in 2020 by Telemedicon, revealed that non-metro cities recorded a growth of 7X in online consultations as compared to last year and started adopting an online mode of consultations amid the pandemic in metro to non-metro is 60:40 in 2020, as compared to 75:25 in 2019. This rapid growth presents telemedicine as the next frontier in healthcare. Digital and communication technologies have revolutionized the delivery of healthcare services. Telehealth is set to change the future of healthcare and remove many of the obstacles and challenges the patients and the industry face. Patients are rapidly transitioning to telehealth, 76% responded to the survey that they want to use telehealth going forward. Benefits of Telemedicine include convenience, access to care, better patient outcomes, a more efficient healthcare system, fewer hospital admissions, and fewer hospital re-admissions. With telemedicine’s current trajectory and rapid adoption rate, it has the potential to disrupt and redefine the way health systems operate, deliver care, manage costs, setting the stage for a vastly different healthcare experience in the future. The widespread use of telemedicine helps to push the industry to make better platforms that can cooperate and communicate. Telemedicine is an effective way to alleviate the congestion of hospitals, improve the utilization of medical resources, and also a powerful tool that makes healthcare accessible, cost-effective, and significantly enhances patient engagement. Key Words: Telemedicine, Telemedicine, healthcare, patient engagement.