The Changing Clinical Landscape in Acupuncture for Women’s Health: A Cross-Sectional Online Survey in New Zealand and Australia

Background Acupuncture is growing in popularity as a treatment option for women’s health worldwide with reported increasing usage in the last ten years. A significant number of clinical trials and meta-analysis are now published on aspects of women’s health treatment with acupuncture. The aim of this survey was to explore if, how and why, aspects of acupuncture practice has changed since our last survey in 2013. Method An online cross-sectional survey of registered acupuncturists and Chinese Medicine practitioners in Australia and New Zealand. Questions covered the practitioner demographics and training, women’s health conditions commonly treated, modalities used, sources of information and continuing education (CE) (e.g. webinars), changes in clinical practice, and referral networks. Results One hundred and seventy registered practitioners responded to this survey, with 93% reporting treating women’s health in the last 12 months. The majority of respondents were from Australia (60%), held a bachelors level qualification (60%), and used a traditional Chinese medicine framework (86%). Most practitioners incorporated other modalities in addition to acupuncture. Most practitioners’ referral networks were predominantly based on word of mouth for menstrual, fertility and pregnancy related conditions, with referrals from medical practitioners being much less common. More than half (57%) reported having changed their women’s health practice in the past 12 months; just over a quarter of those who changed treatment (27%) reported it was due to research findings. The most commonly used sources of information/CE used to inform treatment were webinars and conferences, while peer-reviewed journal articles were the least commonly used source. Conclusion Acupuncture practitioners in Australia and New Zealand commonly treat women’s health conditions, but this is usually the result of women seeking them out, rather than being referred from a medical practitioner. The majority of practitioners did report changing their women’s health practice, but peer reviewed academic articles alone are not an ideal medium to convey this information since practitioners favour knowledge obtained from webinars and conferences. Academics and other clinician researchers should consider alternative means of disseminating knowledge beyond traditional academic publications and conferences, special interest groups may assist in this and also help improve research literacy.

Team Relationships and Performance: Evidence from Healthcare Referral Networks

We examine the teams that emerge when a primary care physician (PCP) refers patients to specialists. When PCPs concentrate their specialist referrals—for instance, by sending their cardiology patients to fewer distinct cardiologists—repeat interactions between PCPs and specialists are encouraged. Repeated interactions provide more opportunities and incentives to develop productive team relationships. Using data from the Massachusetts All Payer Claims Database, we construct a new measure of PCP team referral concentration and document that it varies widely across PCPs, even among PCPs in the same organization. Chronically ill patients treated by PCPs with a one standard deviation higher team referral concentration have 4% lower healthcare utilization on average, with no discernible reduction in quality. We corroborate this finding using a national sample of Medicare claims and show that it holds under various identification strategies that account for observed and unobserved patient and physician characteristics. The results suggest that repeated PCP-specialist interactions improve team performance. This paper was accepted by Carri Chan, healthcare management.

Development and assessment of the usability of a web-based referral to treatment tool for persons with substance use disorders

Background Hospitalized people with unhealthy substance use should be referred to treatment. Although inpatient referral resources are often available, clinicians report that outpatient referral networks are not well-established. The purpose of this manuscript is to describe the development and usability testing of a web-based Referral to Treatment Tool (RTT © 2020 Trustees of Indiana University, all rights reserved) designed to identify treatment centers for people with unhealthy substance use. Results The RTT was conceptualized, developed, and then populated with public use and local survey data of treatment centers from 14 market ZIP codes of hospitals participating in an SBIRT implementation study. The tool underwent initial heuristic testing, followed by usability testing at three hospitals within a large healthcare system in the Midwest region of the United States. Administrative (n = 6) and provider (n = 12) users of the RTT completed a list of tasks and provided feedback through Think-Aloud Tests, the System Usability Scale, and in-person interviews. Patients (n = 4) assessed multiple versions of a take-home printout of referral sites that met their specifications and completed in-person interviews to provide feedback. Each administrative task was completed in less than 3 min, and providers took an average of 4 min and 3 s to identify appropriate referral sites for a patient and print a referral list for the patient. The mean System Usability Scale score (M = 77.22, SD = 15.57, p = 0.03) was significantly higher than the passable score of 70, indicating favorable perceptions of the usability of the RTT. Administrative and provider users felt that the RTT was useful and easy to use, but the settings and search features could be refined. Patients indicated that the printouts contained useful information and that it was helpful to include multiple referral sites on the printout. Conclusion The web-based referral tool has the potential to facilitate voluntary outpatient referral to treatment for patients with unhealthy substance use. The RTT can be customized for a variety of health care settings and patient needs. Additional revisions based on usability testing results are needed to prepare for a broader multi-site clinical evaluation. Trial Registration Not applicable.

Defining Integrated Care Systems Through Patient Data From Referral Networks in the English National Health Service: A Graph-Based Clustering Study.

Background Integrated Care Systems (ICSs) are being introduced into the National Health Service (NHS) in England to replace Sustainability and Transformation Partnerships (STPs). They aim to improve care through place-based collaboration between primary, secondary and community providers. It is important that new organisational configurations adequately reflect existing patterns of patient care to minimise disruption resulting from patients crossing between ICSs. Methods All planned outpatient hospital clinic appointments from 1st April 2017 to 31st March 2018 for patients resident in England to NHS hospitals in England were identified from Hospital Episode Statistics. Markov Multiscale Community Detection (MMCD), an unsupervised network clustering technique, was used to identify natural communities of GP practices, hospitals and geographic regions according to patterns of GP practice registration and outpatient clinic referral. Two primary measures of care coverage were calculated; the proportion of patients registered to a GP practice in a different community than they reside, and the proportion of outpatient clinic appointments to hospitals in a different community to the referring GP practice. Results 109,830,647 outpatient clinic appointments were identified for 20,992,695 patients. A configuration of 42 ICSs was identified from MMCD to match the 42 STPs of the current configuration. In the current STP configuration, 534,946 patients (2.6%) were registered to a GP practice in a different STP than their residence, compared to 334,192 (1.6%) in the optimal MMCD configuration. 16,110,267 hospital clinic appointments (14.7%) occurred in a different STP to the referring GP practice, compared to 11,518,735 (10.5%) in the MMCD configuration. Conclusions Millions of hospital appointments annually occur in hospitals outside of the STP of the referring GP practice. Applying MMCD we derive spatially consistent partitions of NHS Trusts and GPs into ICSs that are more representative of existing patient flows while maintaining the intended population size and number of ICSs. The findings of this study should guide policymakers locally and nationally to determine where ICS boundaries may be redrawn and the extent to which such changes would better reflect the current needs of patients.

Proportion and reasons for loss to follow-up in a cohort study of people who inject drugs to measure HIV and HCV incidence in Kerman, Iran

Background Understanding the reasons for loss to follow-up (LTFU) in cohort studies, especially among marginalized groups such as people who inject drugs (PWID), is needed to strengthen the rigor of efficacy trials for prevention and treatment interventions. We assessed the proportion and reasons for loss to follow-up in a recent cohort of PWID enrolled in the southeast of Iran. Methods Using respondent-driven sampling, we recruited 98 PWID age 18 years or older who reported injecting drugs in the past 6 months, and were negative for HIV and HCV at initial screening. Participants were followed at 6 week intervals, alternating a short six-week visit and long 12-week or quarterly visit to measure incidence of HIV and HCV. Methods to enhance retention included incentives for completing each visit, tracking people who missed the scheduled visits through their peer referral networks, engaged outreach teams to explore hotspots and residences, and photos. LTFU was defined as participants who missed their quarterly visits for two or more weeks. Results Mean (SD) age of participants was 39.7 years (SD 9.6). Of 98 enrolled, 50 participants (51.0%) were LTFU by missed their scheduled quarterly visits for 2 weeks or more. For those whose reasons for LTFU could be defined (46.0%, 23 of 50), main reasons were: forgetting the date of visit (43.5%, 10 of 23), being incarcerated (39.1%, 9 of 23), and moving out of the city (17.4%, 4 of 23). Conclusion This study highlighted the difficulty in retaining PWID in longitudinal studies. Despite having several retention strategies in place, over half of PWID were LTFU. The LTFU might be reduced by setting up more effective reminder systems, working closely with security systems, and online means to reach those who move outside the study area.

Sexual Problems and Cancer

Cancer survivors face a unique set of treatment-related issues impacting sexual function and quality of life. While some treatment-related sexual adverse effects are temporary, many survivors face long-term effects such as treatment-induced menopause, altered gonadal function, and significant surgical disfigurement. Treatment modalities including surgery, chemotherapy, radiation therapy, and endocrine therapy present with persistent changes in tissue quality and sexual response. Common changes in sexual function for cancer survivors include decreased libido or sexual interest and pain with penetration in women and erectile dysfunction in men. As cancer survivorship improves, it is increasingly important for medical professionals to inquire about the sexual health of their patients. Health promotion strategies such as vulvovaginal moisturizers and dilator therapy for women or prescription medication for men can be recommended to counteract sexual side effects during and after treatment. Additionally, sexual counseling can enhance communication among distressed couples coping with cancer. While sexual side effects are prevalent, they often go unacknowledged in busy clinical settings. Screening tools can be utilized to identify treatment-related complications including lymphedema, fatigue, insomnia, and pain. Standardized measures validated in cancer populations are recommended to clinicians assessing sexual dysfunction in oncologic settings. Educational resources and sexual health referral networks can provide additional support to help patients manage distressing symptoms.