Health care utilization following “digi-physical” assessment compared to physical assessment for infectious symptoms in primary care

Background The use of chat-based digital visits (eVisits) to assess infectious symptoms in primary care is rapidly increasing. The “digi-physical” model of care uses eVisits as the first line of assessment while assuming a certain proportion of patients will inevitably need to be further assessed through urgent physical examination within 48 h. It is unclear to what extent this approach can mitigate physical visits compared to assessing patients directly using office visits. Methods This pre-COVID-19-pandemic observational study followed up “digi-physical” eVisit patients (n = 1188) compared to office visit patients (n = 599) with respiratory or urinary symptoms. Index visits occurred between March 30th 2016 and March 29th 2019. The primary outcome was subsequent physical visits to physicians within two weeks using registry data from Skåne county, Sweden (Region Skånes Vårddatabas, RSVD). Results No significant differences in subsequent physical visits within two weeks (excluding the first 48 h) were noted following “digi-physical” care compared to office visits (179 (18.0%) vs. 102 (17.6%), P = .854). As part of the “digital-physical” concept, a significantly larger proportion of eVisit patients had a physical visit within 48 h compared to corresponding office visit patients (191 (16.1%) vs. 19 (3.2%), P < .001), with 150 (78.5%) of these eVisit patients recommended some form of follow-up by the eVisit physician. Conclusions Most eVisit patients (68.9%) with respiratory and urinary symptoms have no subsequent physical visits. Beyond an unavoidable portion of patients requiring urgent physical examination within 48 h, “digi-physical” management of respiratory and urinary symptoms results in comparable subsequent health care utilization compared to office visits. eVisit providers may need to optimize use of resources to minimize the proportion of patients being assessed both digitally and physically within 48 h as part of the “digi-physical” concept. Trial registration Clinicaltrials.gov identifier: NCT03474887.

Effective Telehealth – Open Heart Readmissions

Background The purpose of this study is to compare open heart surgery (OHS) Telehealth patients (TP) and non-Telehealth patients (NTP) using outcomes data such as hospital readmission, emergency department (ED) presentations, observation hours, and office visits. Visits for atrial fibrillation (Afib), pleural effusions (PE), and sternal wound complications (SWC) are of particular interest for this study. Methods A retrospective chart review of 110 patients above 18 years old who had OHS at Parkview Heart Institute from 2020 were assessed using hospital readmissions, ED presentations, observation hours, and office visits outcomes. Separate forms for blinding, demographic data, and surgery information were completed for every patient. A Telehealth form was completed out for every Telehealth intervention had per TP. An outcomes form was completed for each outcome had by each patient. TP outcomes were compared with NTP outcomes. Fisher’s exact test and X2 was used for statistical analysis (p=0.05). Results Results display a sample size of the total patient population (110/436). There was no significant difference found between NTP and TP in terms of office visits (79.5% vs 93%, p=0.598), readmissions (3 vs 6, p=0.889), and observation visits (0 vs 3, p=0.558). Significance was found between NTP and TP in terms of ED visits (0 vs 9, p=0.025). Most frequent reason for NTP readmission “other” (7.7%) and TP “other” (4.2%), reason for ED visit for NTP (all 0%) and TP “other” (7.0%), reason for observation visit for NTP (all 0%) and TP “other” (1.4%), reason for office visit for NTP “other” (76.9%) and TP “other” (91.5%). Conclusion TP presented to the ED significantly more than NTP. The largest outcome category was “surgery follow up” office visits listed in the “other” section. Data collection and analysis are in progress. At the time of writing this abstract, final results are not yet available.

Climate Change Adaptation (CCA) Interventions and Indicators in Nepal: Implications for Sustainable Adaptation

We reviewed 76 climate change adaptation projects that were operational between 2010 and 2020. The review was followed by office and field visits for verification. The office visit helped crosscheck the findings, and the field observations carried out between December 2020 and April 2021 asked 24 key informants and collected supplementary information appraisal and indicator development. Of the CCA projects studied, the most (n = 48, 32%) were community-based initiatives, while the least (n = 12, 8%) were ecosystem-based interventions. The main environment-centered projects were Ecosystem-based Adaptations and Ecosystems Protecting Infrastructure and Communities (EPIC) while Enhanced Action of Inclusive CSOs for Participation in Climate Resilient Economic Growth (UTHAN), Initiative for CCA (ICCA), Support to Rural Livelihoods and Climate Change Adaptation in the Himalayas (HIMALICA), etc., adaptation projects were community-based. Capacity building and awareness-raising were the major thrust of the CbA projects, while the abatement of climate vulnerabilities and risks through nature-based solutions were priorities of EbA. Payment for Ecosystem services is a nature-based solution that can play a role in enhancing adaptation to climate change at a local scale by adopting community-based and culturally appropriate methods and enhancing and incentivizing adaptation measures and capacities. A set of 11 criteria and 40 indicators comprised the institutional and behavioral responses and the use of technologies, and the design of climate-resilient plans and climate-smart practices were proposed as appraisal measures to evaluate the success of CCA interventions. The importance of criteria and indicators lies in the fact that such a comprehensive assessment would lead to effective and efficient adaptation projects, which could help benefit beyond the borders. It also furthers ongoing adaptation interventions and is set to be an integral part of associated studies and monitoring and review of new adaptation interventions.

Sunshine Act in the dark

Background This study assessed patient perceptions of the Physician Payments Sunshine Act and opinions toward physicians who receive gifts and/or payments from pharmaceutical or medical device companies. Methods During their office visit, patients attending different specialty clinics volunteered to complete our survey. The survey asks if the patient knows what the Sunshine Act is, then asks questions on 5-point response scales to assess the patient's opinions toward physicians who receive compensation from companies, their self-rated knowledge of physician compensation, and how they believe this compensation affects the cost of care. Results Over 13 months, 523 responses were collected: 8.6% of patients reported having knowledge of the Sunshine Act, 56.8% rated their knowledge of physician compensations as “poor,” and 67.1% agreed with the statement that patients should be aware of the compensation physicians receive. When asked how their opinion toward their physician would change if they learned the physician received free meals or gifts from companies, 58.9% replied “not at all,” and 36.11% of patients did not believe their cost of care would increase if their physician received compensation from companies. Conclusions Most patients were unfamiliar with the Sunshine Act, and believe their knowledge of physician compensation is poor. Over half of the respondents would not change their opinion of their physician based on knowledge of their physician receiving payments/gifts from companies, and over one-third of respondents did not believe such compensation increased the cost of care. The majority of respondents agreed that patients should be aware of payments/gifts to physicians.

Telehealth May Reduce Rural-Urban Disparities in Accessing Pediatric Psychiatry Services: A Case Study of Trends in Central Ohio from 2020 to 2021 (Preprint)

BACKGROUND The rural-urban disparities in access to child behavioral health services are well known and are further exacerbated by the COVID-19 pandemic related restrictions on travel and in person visits. Fortunately, regulatory flexibilities allowed rapid transition of telehealth to reduce contagion while maintaining continuity of care. However, there has been contradicting evidence on whether telehealth narrows the rural-urban gap. OBJECTIVE To examine the telehealth utilization trends and no-show rates between urban vs rural areas for pediatric psychiatry visits after the public health emergency was declared. METHODS Using 2020-2021 electronic health records (EHR) data from the psychiatry department at a large urban academic pediatric hospital, we calculated the telemedicine utilization rates by patient’s residence area (urban vs rural). We used two proportions z-tests to examine whether the observed differences in no-show rates among 4 types of visit (urban office visit, urban telemedicine visit, rural office visit, and rural telemedicine visit) were statistically significant. RESULTS Telemedicine utilization rates (~80%) are comparable in urban and rural areas. The average no-show rates for telemedicine visits were around 17% for both urban and rural patients, while the average no-show rates for office visits were around 20% for urban patients and fluctuated between 15% and 36% for rural patients. Two proportions z-tests indicated that, for rural patients, telemedicine visits had significantly lower no-show rates than office visits between Sept 2020 and Feb 2021, but such difference turned insignificant after March 2021. CONCLUSIONS Telehealth improved access to child psychiatric services for rural families when primary delivery of services was telehealth-based. Returning to in-person only options and limiting telehealth access would be detrimental to behavioral health outcomes of rural children that have been traditionally underserved. CLINICALTRIAL N/A

Promoting the Participation of Children and Adolescents With Disabilities in Sports, Recreation, and Physical Activity

The benefits of physical activity are likely universal for all children, including children and adolescents with disabilities (CWD). The participation of CWD in physical activity, including adaptive or therapeutic sports and recreation, promotes inclusion, minimizes deconditioning, optimizes physical functioning, improves mental health as well as academic achievement, and enhances overall well-being. Despite these benefits, CWD face barriers to participation and have lower levels of fitness, reduced rates of participation, and a higher prevalence of overweight and obesity compared with typically developing peers. Pediatricians and caregivers may overestimate the risks or overlook the benefits of physical activity in CWD, which further limits participation. Preparticipation evaluations often include assessment of health status, functional capacity, individual activity preferences, availability of appropriate programs, and safety precautions. Given the complexity, the preparticipation evaluation for CWD may not occur in the context of a single office visit but rather over a period of time with input from the child’s multidisciplinary team (physicians, coaches, physical education teachers, school nurses, adaptive recreation specialists, physical and occupational therapists, and others). Some CWD may desire to participate in organized sports to experience the challenge of competition, and others may prefer recreational activities for enjoyment. To reach the goal of inclusion in appropriate physical activities for all children with disabilities, child, family, financial, and societal barriers to participation need to be identified and addressed. Health care providers can facilitate participation by encouraging physical activity among CWD and their families during visits. Health care providers can create “physical activity prescriptions” for CWD on the basis of the child’s preferred activities, functional status, need for adaptation of the activity and the recreational opportunities available in the community. This clinical report discusses the importance of participation in sports, recreation, and physical activity for CWD and offers practical suggestions to health care providers.

765. The Burden of Illness Associated with Recurrent Clostridioides difficile Infection: A Claims-based Analysis

Background Clostridioides difficile infection (CDI) is a significant public health concern and the leading cause of infection related healthcare utilizations in adults in the United States. A considerable proportion of CDI patients suffer recurrent episodes of CDI (rCDI). The objective of this study was to describe the impact of CDI on healthcare resource utilization (HCRU) and patient burden. Methods A retrospective analysis of patients with a CDI diagnosis claim was conducted using the HealthVerity database. Continuous enrollment with medical and pharmacy benefits was required for 12 months before and after the first occurrence of CDI diagnosis (index date). Patients were stratified by total number of CDI episodes. rCDI episodes were defined as episodes that occurred within 12 weeks of the previous episode. Baseline demographics, treatment by episode, and HCRU data were captured. Results 5,964 patients with a CDI episode were identified. The average age was 56.6 years with 30.2% of the population being ≥ 65 years old. 65.7% of patients were female and 61.2% had a claim for ≥ 1 antibiotic in the 90 days leading up to the index date. Vancomycin was the predominant treatment used across all episodes (54-67%). Use of fecal microbiota transplant (FMT) increased with number of CDI episodes (12.6% for the 3rd episode; 20.7% for 5th episode). Fidaxomicin was used for initial CDI treatment in 7.5% of cases. Prior to the initial CDI episode, 24% of patients had ≥ 1 emergency department (ED) visit, 64% had an outpatient office visit and 49% had an inpatient admission due to any cause. In the post-index period, 73% of patients experienced ≥ 1 ED visits, 95% had an outpatient office visit and 72% were admitted to the hospital for any cause. As the number of CDI episodes increased, the number of ED visits, inpatient admissions and ICU admissions trended upwards. Conclusion Results from this observational analysis suggest that the presence of CDI seems to lead to a considerable increase in HCRU after the initial episode. Despite variation in treatment patterns by episode, some HCRU seems to increase with additional episodes. Disclosures Rachel M. Black, PharmD, Seres Therapeutics (Consultant) Richard Stanford, PharmD, MS, AbbVie (Consultant)Sanofi-Genzyme (Consultant)Seres Therapeutics (Consultant) Dan Gratie, PharmD, MS, Seres Therapeutics (Consultant)