Does improving indoor air quality lessen symptoms associated with chemical intolerance?

Aim: To determine whether environmental house calls that improved indoor air quality (IAQ) is effective in reducing symptoms of chemical intolerance (CI). Background: Prevalence of CI is increasing worldwide. Those affected typically report symptoms such as headaches, fatigue, ‘brain fog’, and gastrointestinal problems – common primary care complaints. Substantial evidence suggests that improving IAQ may be helpful in reducing symptoms associated with CI. Methods: Primary care clinic patients were invited to participate in a series of structured environmental house calls (EHCs). To qualify, participants were assessed for CI with the Quick Environmental Exposure and Sensitivity Inventory. Those with CI volunteered to allow the EHC team to visit their homes to collect air samples for volatile organic compounds (VOCs). Initial and post-intervention IAQ sampling was analyzed by an independent lab to determine VOC levels (ng/L). The team discussed indoor air exposures, their health effects, and provided guidance for reducing exposures. Findings: Homes where recommendations were followed showed the greatest improvements in IAQ. The improvements were based upon decreased airborne VOCs associated with reduced use of cleaning chemicals, personal care products, and fragrances, and reduction in the index patients’ symptoms. Symptom improvement generally was not reported among those whose homes showed no VOC improvement. Conclusion: Improvements in both IAQ and patients’ symptoms occur when families implement an action plan developed and shared with them by a trained EHC team. Indoor air problems simply are not part of most doctors’ differential diagnoses, despite relatively high prevalence rates of CI in primary care clinics. Our three-question screening questionnaire – the BREESI – can help physicians identify which patients should complete the QEESI. After identifying patients with CI, the practitioner can help by counseling them regarding their home exposures to VOCs. The future of clinical medicine could include environmental house calls as standard of practice for susceptible patients.

Development and Validation of a Risk Score to Predict the Frequent use of Emergency House Calls among Older People who Receive Regular Home Visits

Background: Demand for home care services is increasing in Japan, and a 24-hour on-call system could be a burden for primary care physicians. Identifying high-risk patients who need frequent emergency house calls could help physicians prepare and allocate medical resources. The aim of the present study was to develop a risk score to predict the frequent use of emergency house calls in patients who receive regular home visits.Methods: We conducted a retrospective cohort study with linked medical and long-term care claims data from two Japanese cities. Participants were ≥65 years of age and had newly started regular home visits between July 2014 and March 2018 in Tsukuba city and between July 2012 and March 2017 in Kashiwa city. A total of 4,888 eligible patients were randomly divided into a derivation cohort (n=3,259) and a validation cohort (n=1,629). The primary outcome was the frequent use of emergency house calls, defined as the use once per month or more on average during each observation period. We considered pre-specified variables, such as age, gender, medical procedure performed in home health care, long-term care need level, and medical diagnosis at the start of the regular home visit. We used the least absolute shrinkage and selection operator (Lasso) method to select predictor variables. Results: The frequent use of emergency house calls was observed in 13.0% participants (424/3,259) in the derivation cohort and 12.9% participants (210/1,629) in the validation cohort. The risk score included three variables with the following point assignments: home oxygen therapy (4 points); care need level 4-5 (2 point); cancer (5 point). The area under the curve (AUC) in the derivation cohort was 0.708, whereas the AUC of a model that included all pre-specified variables was 0.729. The AUC in the derivation cohort was 0.708, showing moderate discrimination. Conclusions: This easy-to-use risk score would be useful for assessing high-risk patients and would allow the burden on primary care physicians to be reduced through measures such as clustering high-risk patients in well-equipped medical facilities.

Community Characteristics and Readmissions: Hospitals in Jeopardy

Objective: The purpose was to identify community characteristics that contribute to reductions in readmission rates and reimbursement penalties for hospital systems in upstate New York. Methods: Hospitals in upstate NY were selected (N = 94). Using an ex post facto design and the ecological model, community characteristics of hospital systems were analyzed and coded. Independent t-tests, ANOVA, and Pearson Correlation tests were conducted. Results: Characteristicscorrelated with reduced hospital readmission rates and reimbursement penalties included hospitals (1) with critical access status; (2) located in counties with a better county health rank; and (3) located in a primary care shortage area that utilized house calls. Discussion: Implications include supporting policies that increase access to services, improve formulas for reimbursement, and encourage innovation in care delivery models. Future research efforts should focus on house calls in primary care shortage areas. Keywords: readmission rates, ecological model, house calls, community health DOI: https://doi.org/10.14574/ojrnhc.v21i1.638

Physician requirements for adoption of telehealth following the SARS-CoV-2 pandemic

It took the advent of SARS-CoV-2, a “black swan event”, to widely introduce telehealth, remote care, and virtual house calls. Prior to the epidemic (2019), the American Medical Association (AMA) conducted a routine study to compare physicians’ adoption of emerging technologies to a similar survey in 2016. Most notable was a doubling in the adoption of telehealth/virtual technology to 28% and increases in the use of remote monitoring and management for improved care (13–22%). These results may now seem insignificant when compared to the unprecedented surge in telehealth visits because of SARS-CoV-2. Even as this surge levels off and begins to decline, many observers believe we will continue to see a persistent increase in the use of virtual visits compared to face-to-face care. The requirements for adoption communicated by physicians in both the 2016 and 2019 surveys are now more relevant than ever: Is remote care as effective as in-person care and how best to determine when to use these modalities? How do I safeguard my patients and my practice from liability and privacy concerns? How do I optimize using these technologies in my practice and, especially integration with my EHR and workflows to improve efficiency? And how will a mix of virtual and in-person visits affect practice revenue and sustainability? Consumers have also expressed concerns about payment for virtual visits as well as privacy and quality of care. If telehealth and remote care are here to stay, continuing to track their impact during the current public health emergency is critically important to address so that policymakers and insurers will take necessary steps to ensure that the “new normal” will reflect a health care delivery model that can provide comparable or improved results today and into the future.