Primary care doctor and nurse consultations among people who live in slums: a retrospective, cross-sectional survey in four countries

ObjectivesTo survey on the availability and use of primary care services in slum populations.DesignRetrospective, cross-sectional, household, individual and healthcare provider surveys.SettingSeven slum sites in four countries (Nigeria, Kenya, Pakistan and Bangladesh).ParticipantsResidents of slums and informal settlements.Primary and secondary outcome measuresPrimary care consultation rates by type of provider and facility.ResultsWe completed 7692 household, 7451 individual adult and 2633 individual child surveys across seven sites. The majority of consultations were to doctors/nurses (in clinics or hospitals) and pharmacies rather than single-handed providers or traditional healers. Consultation rates with a doctor or nurse varied from 0.2 to 1.5 visits per person-year, which was higher than visit rates to any other type of provider in all sites except Bangladesh, where pharmacies predominated. Approximately half the doctor/nurse visits were in hospital outpatient departments and most of the remainder were to clinics. Over 90% of visits across all sites were for acute symptoms rather than chronic disease. Median travel times were between 15 and 45 min and the median cost per visit was between 2% and 10% of a household’s monthly total expenditure. Medicines comprised most of the cost. More respondents reported proximity (54%–78%) and service quality (31%–95%) being a reason for choosing a provider than fees (23%–43%). Demand was relatively inelastic with respect to both price of consultation and travel time.ConclusionsPeople in slums tend to live sufficiently close to formal doctor/nurse facilities for their health-seeking behaviour to be influenced by preference for provider type over distance and cost. However, costs, especially for medicines are high in relation to income and use rates remain significantly below those of high-income countries.

Public knowledge, attitudes and practices related to antibiotic use and resistance in Singapore: a cross-sectional population survey

ObjectivesThe WHO’s Global Action Plan on Antimicrobial Resistance (AMR) includes increasing overall public awareness of appropriate antibiotic use and resistance as a key priority area. We aimed to measure public knowledge, attitudes and practices of antibiotics and antibiotic resistance in Singapore, as well as their healthcare-seeking behaviours relating to respiratory illnesses, providing baseline data against which to measure the progress of future interventions.DesignA cross-sectional study.SettingThe general population in Singapore.ParticipantsBetween May and June 2019, we conducted a survey via an online panel in Singapore with 706 respondents.ResultsOur findings indicated common misconceptions surrounding antibiotic effectiveness and mechanisms of antibiotic resistance—most participants thought that resistance occurs when our bodies become resistant to antibiotics (62.5%) or when antibiotics become less powerful (48.5%). In multivariable analyses, better knowledge scores were associated with more favourable antibiotic attitudes (β=0.29; 95% CI 0.20 to 0.37). In addition, more favourable attitude scores were associated with lower odds of both expecting (OR: 0.84, 95% CI 0.72 to 0.99) and being prescribed antibiotics by a primary care doctor (OR: 0.76, 95% CI 0.63 to 0.90).ConclusionsThis study presents important information about population perceptions towards antibiotics and antibiotic resistance in Singapore. Results from this study emphasise the importance of effective public communication strategies to promote responsible antibiotic use locally and should be used to inform future implementation of programmes and activities as laid out in Singapore’s National Strategic Action Plan on AMR.

Characteristics of COVID-19-Related Free Telephone Consultations by Public Health Nurses in Japan: A Retrospective Study

This study aimed to (1) describe the characteristics of community residents who used coronavirus disease 2019 (COVID-19)-related telephone consultation systems by public health nurses (PHNs) and (2) analyze the concerns they had during the first wave of COVID-19 in Japan. Among 1126 telephone consultations, PHNs recorded telephone consultations between 25 March, and 30 April, 2020, in City A, Japan. We analyzed 1017 consultations involving 799 (79%) community residents (resident group) and 218 (21%) organizational representatives (organization group) located in City A. Half of the consultations were made during midmorning, and most of the consultations were regarding COVID-19 symptoms. Among the resident group, visiting a primary care doctor was the most common recommendation by the PHNs; there was no difference in provision of consultation by sex. Health- and welfare-related organizations mainly consulted PHNs about “having COVID-19-related symptoms” and “undergoing PCR testing,” and PHNs’ recommended them to visit a primary care doctor and coordinate PCR testing. The results suggest that public health centers should provide more helpful information on COVID-19 that accurately reflects the concerns of the population.

Linfoma di Burkitt in età pediatrica

Sporadic Burkitt lymphoma (BL) accounts for about 80% of non-Hodgkin lymphomas in childhood and adolescence, with an incidence of 3-5 cases per million in developed countries. The hallmark of LB is the deregulation of MYC oncogene, usually caused by the [t(8;14)(q24;q32)] translocation, involving the gene of immunoglobulin heavy chain. BL is a very aggressive neoplasm, with a doubling time of 12-24 hours and its diagnosis and therapy are a true haematologic emergency. Abdomen, head and neck are the most frequent sites of presentation and the involvement of ileo-caecal area can cause an intussusception as first manifestation of the disease. <br> BL and mature B-cell acute leukaemia (the leukaemic manifestation of BL) share the same therapeutic approach, intensive short courses with multiple alternating chemotherapy agents, the use of high dose-methotrexate and intrathecal CNS prophylaxis. The outcomes are satisfactory: in Italy during the period 1997-2014 the children with BL were treated according to the AIEOP LNH-97 protocol, achieving more than 90% of 5 year-survival. <br> In the last decades, the prognosis for children and adolescents with cancer has dramatically improved and the increasing number of long-term survivors has focused the attention of clinicians on the late effects of cancer and its therapy. A multidisciplinary follow up and a correct transition from the paediatrician to the primary care doctor plays a central role not only in the early detection and therapy of late effects of cancer but also in supporting the patient to realize their physical, mental and social well-being as much as possible.

Management of Pediatric Patients with Spina Bifida

Spina bifida is a neurodevelopmental disorder and belong to most common congenital malformations. It is a neural tube defect that originates within first 28 days after conception. Although survival rate of these patients had changed rapidly within last decades, neural tube defects are still cause of substantial part of children morbidity. Occult type of spina bifida is a simple nonunion of vertebral arch without causing any symptoms. Open defects according to degree of involvement of neural tissue cause symptoms such as paralysis of lower extremities, bladder and bowel morbidity, delay in development of cognitive functions of various severity and other possible complications affecting morbidity of these patients. Early diagnosis and treatment of open spina bifida and accompaying complications is crucial and largely affects the outome. Succesfull treatment requires lifelong cooperation of a whole range of specialists and guiding of treatment by primary care doctor. Survival and quality of life are associated with acces to proper medical and surgical treatment as well as community support systems. This chapter offers overview of this topic with emphasis on general management of patients suffering from this congenital malformation.

Flow redesign to improve prostate cancer access and care at the public healthcare system in Sao Jose dos Campos, Brazil.

e13595 Background: Prostate cancer is the second most common cancer diagnosis in São José dos Campos (SJC) and the sixth cause of cancer mortality. Access to early diagnosis and treatment is one big challenge in the local public healthcare system (Sistema Único de Saude) due limited resources. Between 2018 and 2020 the healthcare public system of SJC redesigned the access flow for diagnosis and prostate cancer care in SJC is a mid-sized city (720,000 hab.) in Sao Paulo state, Brazil. Methods: The local SUS was designed to provide access to all patients with elevated PSA (>4.00µg) to a urologist for further evaluation and subsequent reevaluation if needed. This process created long queues and median time to access the few overburdened specialists available to over a year (410 days median), risking significant disease progression and stage upgrade. The flow redesign was done using lean and queue theory techniques and involved basically a new Fast Track to patients with PSA > 10.0µg with age between 50 and 79, considering the probability of 67% chance of prostate cancer (Catalona, et al. NEJM 1991; 324: 1156-61). Patients were referred from the primary care doctor straight forward to a biopsy and then to a medical oncologist, that would recommend further treatment, including a urologist evaluation. Patients with PSA between 4 and 10 would keep regular access to urology. The aim was to guarantee access to specialist up to 60 days from the first PSA > 4.0µg. Results: From April 2019 to September 2020, 277 patients (PSA > 10.0µg) were submitted to a biopsy through the Fast Track; 150 were positive (54,2%) for prostate cancer; and 72% with Gleason score 7 or higher. The diagnosis of prostate cancer from 2017 to 2020 increased over 300% (from 93 to 283), and access to treatment in less than 60 days increased from 15 to 140 patients in 2020. Patient with PSA > 4.0µg access to urology in less than 60 days also increased dramatically by eliminating several medical appointments and unneeded process steps (Table). Conclusions: The process redesign for patients with elevated PSA was able to provide access to care < 60 days for more than 80% of patients with elevated PSA or positive for prostate cancer by splitting high risk and low risk patients and using alternative flows to reduce urology overloaded agenda. Access to Urology for patients with PSA >4.00 < 10.00µg (not in Fast Track).[Table: see text]

Differential effects of the 2015 American Cancer Society guidelines on screening mammography exams based on socioeconomic status.

10539 Background: Guidelines for screening mammography have changed several times since initiation of regular screening mammography in the 1970’s. Most recently, in 2015, the American Cancer Society (ACS) revised their screening guidelines, recommending that a patient discuss screening mammography with her primary care doctor (PCP) between the ages of 40-44 and should begin yearly screening at age 45; after age 54, ACS recommended screening every other year. Prior to this, from 2003-2015, ACS had recommended screening mammography every year beginning at the age of 40. We hypothesized that these guidelines were adopted to varying degrees in different patient populations and may have disproportionately reduced screening mammography utilization in socioeconomically disadvantaged populations. Methods: Here, we analyzed monthly screening mammography rates over time in two large New York City hospitals, one in a socioeconomically advantaged area and the other in a socioeconomically disadvantaged area. Using our radiology records query system, we searched for monthly screening mammography numbers for women by decade from 2012 to 2018. We performed statistical analysis to evaluate changes in number of exams over time. Student’s t-tests were used to evaluate for significant differences. Results: In both groups of 40-49 year old patients, monthly mammograms increased from 2012-2016. In the socioeconomically advantaged group, this increase continued until 2018 resulting in an overall 400% increase in screening mammograms over time. The change in ACS screening guidelines had no effect on the rate of screening mammography in this group. Conversely, after the revision of the ACS guidelines in 2015, there was a marked decline in screening mammography in the 40-49 year old group in the socioeconomically disadvantaged population. By 2018, there was a statistically significant difference in women screened in all age groups (40-49, p<.0001; 50-59, p<.0001; 60-69, p<.01; 70-79, p<.0001; 80+, p<.0001) between these two patient populations. Conclusions: These data suggest that implementation of the 2015 ACS screening guidelines had a disproportionate effect on patients from socioeconomically disadvantaged areas and that these effects have led to significant disparities in screening mammography trends over time. We postulate that lower levels of health literacy may have contributed to misunderstanding of the screening guidelines. More research is needed to elucidate the underlying etiology of these disparities and ensure that women from all socioeconomic backgrounds receive appropriate screening mammography. Over time, this may result in disproportionate breast cancer morbidity and mortality in populations not receiving appropriate screening.

Access to care for workers’ compensation patients in dense and sparse population centers

Background: Workers’ compensation was originated to provide a no-fault, timely access to appropriate medical care. Unfortunately, we have found that the system fails the injured worker in certain environments. By implementing procedural roadblocks in the form of initial claim denial and delay methods, the injured worker finds himself/herself in a battle of attrition. By delaying treatment and compensation benefits, the injured workers are “starved out” of their access to care and often walk away from their claim or accept a payout without treatment. Methods: We performed a randomized, consecutive case-series where 300 hypothetical patients called medical offices to attempt to arrange a physician consultation. We analyzed the ability of a patient to gain access (an appointment) to a primary care (N=100), orthopedic (N=100) and neurology (N=100) physician after stating that they were injured at work. We analyzed two cohorts, one as an injured worker that was given a claim number (N=150) and the other that was injured at work but not yet given a claim number (N=150). Conclusion: This study demonstrates how difficult it is to gain access to care as an injured worker. An injured worker in a low densely populated area without a claim number was unable to gain access to a primary care doctor in our cohort (100% denial rate). Even a patient with an accepted claim number in densely populated Cook County, IL had a 52% chance of being denied access to care with an orthopedic surgeon while a patient without a claim number had an 84% chance of being denied access to orthopedic care.

Beginning

Through personal narrative, this chapter details the author’s experience of first becoming aware that something was not right with his body. This experience leads to visiting his primary care doctor who tells him that she is concerned about the possibility of his having Parkinson’s disease and then refers the author to a neurologist who is a movement disorder specialist. He is examined by this neurologist, who says, “What worries me is that I think you are in the early stages of Parkinson’s disease,” but who wants the author to have a brain scan that will confirm the clinical diagnosis given his young age and subtle symptoms. The author leaves his office, drives home, and informs his wife that this doctor thinks he have Parkinson’s disease. Here begins his new life as a person with Parkinson’s (PwP).

Rheumatic? - A Digital Diagnostic Decision Support Tool for Individuals Suspecting Rheumatic Diseases: A Multicenter Validation Study

BackgroundDigital diagnostic decision support tools promise to accelerate diagnosis and increase health care efficiency in rheumatology. Rheumatic? is an online tool developed by specialists in rheumatology and general medicine together with patients and patient organizations. It calculates a risk score for several rheumatic diseases. In the current pilot study, we retrospectively test Rheumatic? for its ability to differentiate symptoms from immune-mediated diseases from other rheumatic and musculoskeletal complaints and disorders in patients visiting rheumatology clinics. MethodsThe performance of Rheumatic? was tested using data from 175 patients from three university rheumatology centers covering two different settings:A. Risk-RA phase setting. Here, we tested whether Rheumatic? could predict the development of arthritis in 50 individuals with musculoskeletal complaints and anti-citrullinated protein antibody positivity from the KI (Karolinska Institutet)B. Early arthritis setting. Here, we tested whether Rheumatic? could predict the development of an immune-mediated rheumatic disease in i) EUMC (Erlangen) n=52 patients and ii) LUMC (Leiden) n=73 patients.In each setting, we examined the discriminative power of the total score with the Wilcoxon rank test and the area-under-the-receiver-operating-characteristic curve (AUC-ROC). Next, we calculated the test characteristics for these patients at a rheumatology setting passing the first or second threshold for at least one of the rheumatic diseases.ResultsThe total test score clearly differentiated between: A) individuals developing arthritis or not, median 245 versus 163, P < 0.0001, AUC-ROC = 75.3B) patients with an immune-mediated arthritic disease or not, in EUMC median 191 versus 107, P < 0.0001, AUC-ROC = 79.0, and LUMC median 262 versus 212, P < 0.0001, AUC-ROC = 53.6.Threshold-1 (advising on seeking primary care doctor) was highly specific in two centers (0.72, 0.87 and 0.23, respectively) and far more sensitive (0.67, 0.61 and 0.67) in KI, EUMC respectively LUMC.Threshold-2 was very specific in all three centers but not very sensitive: specificity of 1.0, 0.96 and 0.91, sensitivity 0.05, 0.07, 0.14 in KI, EUMC respectively LUMC. ConclusionsRheumatic? is a web-based patient-centered multilingual diagnostic tool capable of differentiating immune-mediated rheumatic conditions from other musculoskeletal problems. The scoring system might be further optimized, for which we will perform a prospective study.