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Objective: Rapid eye movement sleep behavior disorder (RBD) is often underdiagnosed among people living with mental disorders. The present study aimed to investigate the prevalence of probable RBD (pRBD) and its associated factors among middle-aged and older adults in a psychiatric outpatient clinic., Methods: We conducted a cross-sectional survey among 2907 people aged 45-80 years who visited the outpatient clinic between March 1 and August 31, 2022 in a psychiatric hospital. A cutoff score ≥5 on the RBD Screening Questionnaire (RBDSQ) was used to indicate the presence of probable RBD (pRBD). Potential factors associated with pRBD were also assessed with a structured checklist. The association between these factors and the presence of pRBD was examined with logistic regression., Results: The response rate was 64.3 %. Among 1868 respondents [age 58.5 ± 9.6 years, male n = 738 (39.5 %), female n = 1130 (60.5 %)], 15.9 % (95 % CI 14.2-17.6 %) screened positive for pRBD. Occupational exposure to chemicals; positive family history of psychotic disorders; a late start of mental health care; a medical history of autonomic dysfunction; mood problems; and use of antidepressants, hypnotics, and acetylcholinesterase inhibitors were associated with an increased likelihood of having pRBD (P < 0.05 for all)., Conclusion: pRBD is common among outpatients with mental disorders, especially in mental disorders due to neurological diseases and physical conditions, mood disorders and anxiety or somatoform disorders. The findings highlight the importance of identifying sleep behavior disorders among people living with mental disorders in clinical practice., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Huali Wang reports grant funding support was provided by Ministry of Science and Technology. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Study Design: This was a retrospective cohort study., Objective: To determine the proportion of referrals diverted by the spine virtual fracture clinic (SVFC) from traditional outpatient clinic management., Summary of Background Data: The consistent rise in demand for orthopedic outpatient clinic services is creating marked challenges to the provision of quality care. Virtual fracture clinics for upper and lower limb fractures have reduced the burden on outpatient clinics by providing an alternative telehealth management pathway. To date, no study describes the expansion of virtual care to the spine trauma population., Methods: A study of spine fractures referred to the RMH Department of Orthopaedic Surgery was conducted comparing outcomes before (January to December 2021) and following (July 2022 to November 2023) implementation of an SVFC. The primary aim of this study was to investigate the effect of a telephone-based SVFC on outpatient clinic activity, represented by the proportion of referrals discharged without requiring an outpatient clinic appointment. Secondary aims included appointment utilization, lost to follow-up rates, duration of care, missed or misdiagnoses, unplanned operations, and complications., Results: Of the 731 referrals managed by the SVFC, 91.1% were discharged without requiring in-person outpatient clinic attendance. Compared with the outpatient clinic historical cohort (150 referrals), SVFC management was associated with reductions in the average number of consultations per referral (1.8 vs . 2.4, P <0.001), appointments not attended (5% vs . 13%, P <0.001), referrals lost to follow-up (0% vs . 10.7%, P <0.001), and a shorter duration of care (median 48 vs . 58 d, P <0.001). A total of 65 patients (8.1%) were redirected to the outpatient clinic, of which three underwent surgical intervention. No diagnostic errors, complications or adverse events were identified., Conclusion: This study demonstrates that an SVFC is an effective and safe alternative pathway to traditional hospital-based outpatient clinics, ith low-risk for any adverse outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Social determinants of health (SDoH) influence overall health, although little is known about the SDoH for pediatric patients requiring surgical services. This study aims to describe SDoH for pediatric surgical patients attending out-patient, community, and outreach clinics, as well as demonstrate the feasibility of identifying and addressing SDoH and Adverse Childhood Experiences (ACEs) when appropriate., Methods: A cross-sectional study using surveys evaluating SDoH that were distributed to families attending pediatric surgical clinics over a two-year period. The pilot survey used validated questions and was later refined to a shorter version with questions on: Barriers to care, Economic factors, Adversity, Resiliency and Social capital (BEARS). Data was analyzed with descriptive and inferential statistics., Results: 851 families across 13 clinics participated. One third of families reported not having a primary health care provider or being unable to turn to them for additional support. One in four families were found to have a household income less than the Canadian after-tax low-income threshold (<$40,000 CAD). Two-thirds of families answered questions about ACEs, and those with more ACEs were more likely to report a low income. Forty percent of families rarely or only sometimes had adequate social support., Conclusion: This survey tool enabled discussions between families and care providers, which allowed clinicians to appropriately follow-up with families and refer them to social work for further support when indicated. Addressing concerns around SDoH within a busy surgical clinical is feasible and may positively affect long-term health outcomes and equitable resource allocation., Level of Evidence: IV., Competing Interests: Conflict of interest None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Conflicts of interest None disclosed.

Objectives: We examined differences between hospital-affiliated clinics and non-hospital-affiliated clinics (independent or Planned Parenthood clinics) regarding abortion service innovation and cash-pay availability in response to COVID-19., Study Design: We analyzed data from all three phases of a longitudinal nationwide survey of abortion providers conducted by the Society of Family Planning., Results: This study utilizes a convenience sample of 74 voluntarily participating clinics, representing about 5% of clinics nationwide. Compared to non-hospital-affiliated clinics, hospital-affiliated clinics were more likely to initiate care innovations but were less likely to offer cash-pay during the pandemic., Conclusions: Both hospital-affiliated and non-hospital-affiliated clinics enacted patient-centered care innovations during the pandemic. Hospital-affiliated clinics were more likely to initiate innovative services, particularly surrounding telemedicine. Hospital-affiliated clinics can improve cash-pay availability to expand access to abortion care in times of national emergencies., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Many existing healthcare ranking systems are notably intricate. The standards for peer review and evaluation often differ across specialties, leading to contradictory results among various ranking systems. There is a significant need for a comprehensible and consistent mode of specialty assessment., Methods: This quantitative study aimed to assess the influence of clinical specialties on the regional distribution of patient origins based on 10,097,795 outpatient records of a large comprehensive hospital in South China. We proposed the patient regional index (PRI), a novel metric to quantify the regional influence of hospital specialties, using the principle of representative points of a statistical distribution. Additionally, a two-dimensional measure was constructed to gauge the significance of hospital specialties by integrating the PRI and outpatient volume., Results: We calculated the PRI for each of the 16 specialties of interest over eight consecutive years. The longitudinal changes in the PRI accurately captured the impact of the 2017 Chinese healthcare reforms and the 2020 COVID-19 pandemic on hospital specialties. At last, the two-dimensional assessment model we devised effectively illustrates the distinct characteristics across hospital specialties., Conclusion: We propose a novel, straightforward, and interpretable index for quantifying the influence of hospital specialties. This index, built on outpatient data, requires only the patients' origin, thereby facilitating its widespread adoption and comparison across specialties of varying backgrounds. This data-driven method offers a patient-centric view of specialty influence, diverging from the traditional reliance on expert opinions. As such, it serves as a valuable augmentation to existing ranking systems., (© 2024. The Author(s).)

Competing Interests: Conflicts of interest The authors declare no conflicts of interest.

Background: Recent research highlighting a shortage of pediatric subspecialists in the United States has shown wide variations in the distance from children to the nearest subspecialists but has not accounted for subspecialty outreach clinics, in which specialists may improve access in rural areas by periodically staffing clinics there. This study aimed to determine the impact of pediatric subspecialty outreach clinics on the driving times to the nearest pediatric subspecialists for children in Maine., Methods: This cross-sectional study utilized administrative data on the schedule and location of pediatric subspecialty clinics in Maine in 2022 to estimate the driving time from each ZIP-code tabulation area to the nearest subspecialist, with and without the inclusion of outreach clinics. Using 2020 census data, we calculated the median and interquartile ranges of driving times for the state's overall child population, as well as for children living in urban and rural areas., Results: Of 207,409 individuals under 20 years old in Maine, 68% were located closer to an outreach location than to a clinical hub. Across the seven subspecialties offering outreach clinics, outreach clinics decreased median driving times to the nearest pediatric subspecialist by 5 to 26 minutes among all children, and by 16 to 46 minutes among rural children., Conclusions: Pediatric subspecialty outreach clinics can substantially reduce the driving time to the nearest pediatric subspecialist , especially for children living in rural areas. The use of outreach clinics should be accounted for in research describing the geographic access or barriers to care. Expanding the number of outreach clinics should be considered by policymakers hoping to improve access., (© 2024. The Author(s).)

Background: Telehealth abortion has taken on a vital role in maintaining abortion access since the Dobbs v. Jackson Women's Health Organization Supreme Court decision. However, little remains known about the landscape of new telehealth-only virtual clinic abortion providers that have expanded since telehealth abortion first became widely available in the United States in 2021., Objective: This study aimed to (1) document the landscape of telehealth-only virtual clinic abortion care in the United States, (2) describe changes in the presence of virtual clinic abortion services between September 2022, following the Dobbs decision, and June 2023, and (3) identify structural factors that may perpetuate inequities in access to virtual clinic abortion care., Methods: We conducted a repeated cross-sectional study by reviewing web search results and abortion directories to identify virtual abortion clinics in September 2022 and June 2023 and described changes in the presence of virtual clinics between these 2 periods. In June 2023, we also described each virtual clinic's policies, including states served, costs, patient age limits, insurance acceptance, financial assistance available, and gestational limits., Results: We documented 11 virtual clinics providing telehealth abortion care in 26 states and Washington DC in September 2022. By June 2023, 20 virtual clinics were providing services in 27 states and Washington DC. Most (n=16) offered care to minors, 8 provided care until 10 weeks of pregnancy, and median costs were US $259. In addition, 2 accepted private insurance and 1 accepted Medicaid, within a limited number of states. Most (n=16) had some form of financial assistance available., Conclusions: Virtual clinic abortion providers have proliferated since the Dobbs decision. We documented inequities in the availability of telehealth abortion care from virtual clinics, including age restrictions that exclude minors, gestational limits for care, and limited insurance and Medicaid acceptance. Notably, virtual clinic abortion care was not permitted in 11 states where in-person abortion is available., (©Leah R Koenig, Jennifer Ko, Ushma D Upadhyay. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 05.08.2024.)

Musculoskeletal urgent care centers (MUCCs) are an increasingly common alternative to emergency departments for patients with orthopedic injuries. As there is a lack of longitudinal data regarding MUCCs' impact on the emergency health care system, our study seeks to understand recent trends in MUCC growth and their acceptance of Medicaid insurance. Over the last 6 years, at 2-year intervals (2019, 2021, and 2023), we performed a search to identify all MUCCs in the United States. We determined the affiliation and Medicaid acceptance status of all MUCCs, including those that closed/opened between 2019, 2021, and 2023, to analyze trends in MUCC availability and Medicaid acceptance. In 2019, there were 558 MUCCs, which increased to 596 MUCCs in 2021 and then decreased to 555 MUCCs in 2023, representing a growth and then decline of approximately 7%. Overall, since June 2019, 90 MUCCs have opened and 95 MUCCs have closed. Medicaid acceptance increased nationally between 2019 and 2023, from 58% to 71%. Medicaid acceptance increased for both nonaffiliated and privately affiliated MUCCs. Medicaid acceptance has increased nationally from 2019 to 2023, while MUCC availability has gone through a period of growth and then reversion to 2019 levels. As MUCCs have demonstrated limited Medicaid acceptance previously, it is promising that Medicaid acceptance has improved and MUCCs are providing patients with an additional avenue to access orthopedic care., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: The present study aimed to determine the prevalence of body dysmorphic disorder (BDD), its clinical features, and comorbidities in patients applying for plastic and reconstructive surgery., Method: Five-hundred and seventy nine participants who applied to the plastic and reconstructive surgery outpatient clinic completed a sociodemographic data form, and were subjected to the Body Perception Scale (seventy-nineBPS), Social Appearance Anxiety Scale (SAAS), TEMPS-A Temperament Scale, and Beck Depression Inventory (BDI). Participants who scored 135 or more on the BPS were included in a psychiatric interview. Next, the participants diagnosed with BDD were compared with participants with a high BPS scores but without a BDD diagnosis, along with a control group., Results: The prevalence of BDD among all patients attending the plastic surgery outpatient clinic was found to be 4.7%, whereas the prevalence was 8.6% among those specifically seeking cosmetic procedures. The mean SAAS, BDI, TEMPS-A depressive, and anxious scores were higher in the BDD group compared to the controls ( p  < 0.001). The difference in the mean SAAS, BDI, TEMPS-A depressive, and anxious scores of the patients with a high BPS scores and the control group was comparable to the difference observed between the BDD and control groups. A regression analysis revealed that the SAAS and depressive temperament scores have an effect on the BPS score., Conclusion: The significantly high comorbidity of BDD in patients seeking plastic and reconstructive surgery underscores the importance of identifying these patients to prevent unnecessary surgical procedures.

Purpose: Community Eye Clinics (CEC) increase accessibility of specialist ophthalmic services in the community, reducing demand for tertiary eye services. This paper aims to evaluate the impact of CEC on first-visit referrals from Hougang Polyclinic (HOU) to Tan Tock Seng Hospital Ophthalmology Specialist Outpatient Clinic (SOC)., Methods: A retrospective analysis was performed on first-visit referrals from Hougang Polyclinic (HOU) to Tan Tock Seng Hospital Ophthalmology Specialist Outpatient Clinic (SOC) over a similar 3-months period before and after the introduction of CEC in August 2018 (1 January to 31 March in 2018 and 2019, respectively). Data pertaining to patients' presenting complaints, referral reasons, final diagnoses, follow-up plans, and need for ophthalmic intervention were obtained., Results: We included 978 patients in our study. There was a 27.5% reduction in the number of first-visit referrals seen at SOC after the establishment of CEC. Patients were more likely to be referred on to sub-specialty eye clinics (10.8% vs. 12.9%, p = p  = .304) and receive more ophthalmic interventions (15% vs. 16.3%, p  = .066) than prior to CEC., Conclusion: The CEC provides greater accessibility to eye care within the community. Optometrists are upskilled to manage patients with stable eye conditions, whilst eye specialists can provide timely care to the SOC for patients with more severe eye conditions.

Introduction: Literature shows failure of the outpatient clinic (OC) pathway after emergency department (ED) ultrasound diagnosis of symptomatic cholelithiasis (SC). We hypothesized SC to be more prevalent on final surgical pathology (FSP) in patients who successfully completed OC pathway., Methods: This retrospective single-institution chart review compared OC and ED patients with right upper quadrant (RUQ) pain and cholelithiasis whom underwent cholecystectomy. Clinical evaluation was considered positive if RUQ pain >4 h, or + Murphy's sign. Ultrasound was positive if two of these three were present: sonographic Murphy's, wall thickness > 4 mm, or pericholecystic fluid. Results were compared with FSP., Results: Six hundred-seven patients underwent cholecystectomy, 299 OC and 308 ED. OC was more likely to SC (23% versus 4.6%) (P < 0.0001) and ED acute cholecystitis (39.3% versus 4.7%). Chronic cholecystitis was the most common FSP in both OC (72%) and ED (56%) populations, of these, 73% of OC denied pain >4 h versus only 10% of ED (P < 0.001). Median time from evaluation to cholecystectomy was 14 d versus 14 h in the OC and ED respectively (P < 0.0001)., Conclusions: While chronic cholecystitis was the most common FSP in both OC and ED, the majority of OC reported RUQ pain <4 h delineating these presentations. Duration of pain should be utilized as algorithm triage. We recommend patients with pain episode <4 h should complete OC algorithm with expedited cholecystectomy within 14 d., (Published by Elsevier Inc.)

Objectives: The Healthy Recovery after Childbirth Clinic (HRCC) in Nova Scotia provides postpartum care to patients who experience obstetric anal sphincter injuries (OASIS). The purpose of this study was to describe characteristics associated with HRCC attendance, characteristics associated with a trial of labour in a subsequent delivery, and OASIS recurrence by HRCC attendance status., Methods: A retrospective cohort study using the Atlee Perinatal Database and clinical record review included primiparous individuals who sustained an OASIS at IWK Health in Halifax between 2013 and 2020. The χ 2 and Fisher exact tests were performed to compare groups., Results: Of the 1041 individuals included, 67% attended HRCC. Attendance increased from 58% in 2013-2015 to 77% in 2019-2020. Younger age (<25 years) and smoking were associated with lower HRCC attendance (P = 0.07 and <0.01, respectively). Other characteristics, including area-level income and driving distance to HRCC, were not associated with attendance (P > 0.05). Of the 439 individuals who had a subsequent delivery, 92% had a trial of labour. Individuals with fourth-degree injury were less likely to attempt a trial of labour than those with third-degree injury (73% vs. 94%, P < 0.01). Of those who delivered vaginally, OASIS recurrence was similar in those who did and did not attend the HRCC (7.5% vs. 6.5%, P = 0.84)., Conclusions: HRCC attendance was high, but the disparity by age and smoking status suggests some barriers to access that should be explored. Although we found no difference in OASIS recurrence by HRCC attendance, more research with larger samples with adjustment for confounders is needed., (Copyright © 2024 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Background: Functional neurological symptom disorder (FND) is characterised by neurological symptoms that are incompatible with recognised neurological or medical conditions. The condition is common in neurology clinics and causes significant morbidity, though timely access to specialist care is difficult. We sought to characterise the availability and clinical practice of specialist FND clinics across Australia and New Zealand., Methods: Clinicians or coordinators involved in running specialist FND clinics were identified through clinical contacts with further recruitment by snowball sampling and contacting patient organisations. All clinics completed a survey about details of service delivery, including clinical model, referral sources, criteria, demand, staffing, interventions, clinical data collection, and funding., Results: We identified 16 clinics across Australia and New Zealand. Of these, 12 were in capital cities and four were in regional centres. Three of these focused on paediatric patients and 13 focused on adults. Clinics varied in their clinical model, referral sources, criteria, staffing, interventions, data collection, and funding. Most clinics reported challenges related to coping with demand and obtaining adequate funding., Conclusion: FND clinics in Australia and New Zealand appear to be concentrated predominantly in metropolitan areas and vary considerably in their referral sources, clinical data collection, and models of care. Reported challenges in meeting demand indicate a need for greater resources. The heterogeneity across clinics suggests a need to harmonise clinical standards to facilitate access to evidence-based care., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives: The goals of the study were to obtain a glimpse of the several types of organization of outpatient psychiatric clinics, as well as an overview of delays between a request for and the first appointment. We also look at geographical variability of appointment scheduling delays and assess the impact of the number of new applications on delays., Methods: We analyzed information collected from a phone survey conducted with the 103 adult outpatient psychiatric clinics of the French region Hauts-de-France. This survey had a one-week inclusion period in November 2022 and focused on the organization and delays before obtaining an appointment., Results: This study indicates that organizations seem to be homogeneous. Eighty-one outpatient psychiatric clinics (96.4%) receive with scheduled appointments. The initial evaluation by a nurse followed with a proposal for the organization of care seems to be the common practice. It also appears that primary psychiatric structures were capable of providing a response within a reasonable time frame in making a first appointment with a mental health professional. On the other hand, delays were much longer and heterogeneous for first appointments with psychiatrists and psychologists., Conclusions: The organizations of the outpatient psychiatric clinics of the French region Hauts-de-France seem homogeneous. The evaluation by a nurse followed with a care proposal is the common practice. Primary psychiatric structures are able to provide a response within a reasonable time, with half the centers proposing an appointment with a nurse within 10.0 days., (Copyright © 2023. Published by Elsevier Masson SAS.)

Purpose: The Johns Hopkins Primary Care for Cancer Survivors (PCCS) Clinic was established in 2015 to improve care delivery for the growing cancer survivor population. We aim to describe areas of care addressed by PCCS and factors associated with clinic utilization., Methods: We conducted a retrospective chart review of the first 301 patients' clinic visits. We used negative binomial regression models to identify factors associated with the rate of PCCS clinic visits overall and for cancer surveillance and treatment-related effects., Results: There were 1702 clinic visits across 301 patients during the study period (77% female, median age 61). The most common areas of care addressed were chronic medical problems (80%), preventive health care (62%), cancer surveillance (59%), treatment-related effects (50%), and new/acute problems (46%). Multivariate analyses found that age > 60 years (IRR = 1.9, 95% CI = 1.2-3.0, p = 0.007) and higher number of comorbidities (IRR = 1.2, 95% CI = 1.1 - 1.2, p < 0.001) were associated with more overall PCCS visits, while female gender was associated with fewer visits (IRR = 0.6, CI = 0.4 - 0.8, p = 0.001). Gastrointestinal cancer type, shorter length of survivorship, male gender, and higher number of comorbidities were associated with a higher rate of visits addressing both surveillance and treatment-related effects (p < 0.05)., Conclusions: The PCCS clinic addressed cancer and non-cancer related needs. Older patients and survivors with more comorbidities had significantly increased clinic utilization., Implications for Cancer Survivors: As the cancer survivor population grows, increasing access to survivorship clinics based in primary care may help meet these patients' diverse oncologic and general health needs., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Somatic complaints are among the important complaints frequently seen in Generalized Anxiety Disorder (GAD) and Somatic Symptom Disorder (SSD). Death anxiety has also increased significantly with the Covid-19 pandemic, especially in the elderly population. In this study, we compared the difference of the death anxiety level among patients with GAD, SSD and healthy controls. This cross-sectional study which was carried out in Artvin State Hospital's Psychiatric Outpatient Clinic included 59 participants (GAD = 21, SSD = 18, HC = 20). Three groups were subjected to detailed psychiatric examination by the same psychiatrist. Subsequently, anxiety, somatic symptoms and death anxiety were assessed using standardized tools (GAD-7, Templer Death Anxiety Scale, Somatic Symptom Scale). The GAD-7 Scale mean of the GAD group was significantly higher than SSD (p = 0.001) and Healthy Control (HC) (p = 0.001) groups. Death anxiety and Somatic Symptom levels in GAD and SSD groups were significantly higher than in healthy controls. (GAD, p = 0.001; SSD, p = 0.001) with no significant difference between GAD and SSD groups (p = 1). Healthy controls exhibited significantly lower scores in the three scales mean scores compared to the SSD and GAD groups (p = 0.001). Irrespective of specific psychiatric diagnoses, these findings highlight elevated death anxiety in the elderly, underscoring the need for tailored mental health interventions., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Identify factors associated with presenting for abortion after 10 weeks' gestation in a large, geographically diverse sample., Study Design: From October 2019 to March 2020, we surveyed 1089 patients seeking abortion at seven U.S. facilities. We identified four domains of barriers: geographic, financial, logistical/personal, and legislative. Using multivariable logistic regression, we investigated the relationship between each domain and presenting for abortion after 10 weeks' gestation, overall and stratified by state policy landscape., Results: One-third of participants reported geographic (33.0%), financial (33.3%), and logistical/personal (31.4%) barriers; fewer (4.8%) reported legislative barriers. One-third (30.8%) traveled over 50 miles to the clinic. One-quarter (25.2%) presented after 10 weeks' gestation. In multivariable analyses, financial barriers (adjusted odds ratio [aOR] = 1.49, 95% confidence interval [CI] = 1.06-2.09), geographic barriers (aOR = 2.05, 95% CI = 1.44-2.90), and difficulty meeting basic expenses (aOR = 1.47, 95% CI = 1.15-1.89) were associated with presenting after 10 weeks' gestation across the seven clinics. Among participants accessing care at clinics in states with supportive abortion policies (n = 178), geographic barriers remained significantly associated with presenting after 10 weeks' gestation., Conclusions: In a large, geographically diverse sample, financial and geographic barriers were associated with presenting after the threshold for medication abortion. In supportive states, the association with geographic barriers persisted. Cost and geographic barriers are increasing as more states restrict abortion post-Dobbs, highlighting the urgent need to expand financial and travel support., Implications: People seeking abortion faced barriers before the Dobbs decision. Now, post-Dobbs, restrictions to abortion have only increased, making barriers to care even more threatening. Providing access to financial resources and transportation for people seeking abortion and expanding telehealth medication for abortion is now even more important., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: Although hepatitis A virus (HAV) and hepatitis B virus (HBV) immunisation is recommended in the UK for gay, bisexual and other men who have sex with men (GBMSM), data on immunisation coverage are limited. We aimed to determine the seroprevalence of HAV and HBV immunity among a sample of GBMSM attending sexual health services (SHS) in England., Methods: Residual serum samples from HIV/syphilis testing for adult GBMSM attending eight SHS in London and one in Leeds were tested for markers of HAV immunity (HAV IgG) and HBV immunity (anti-HBs) using an unlinked anonymous approach. We estimated seroprevalence of HAV and HBV immunity overall and stratified by individuals' characteristics, which we obtained from the Genitourinary Medicine Clinic Activity Dataset Sexually Transmitted Infection (STI) Surveillance System. We used logistic regression to calculate crude and adjusted ORs between seropositivity and demographic and clinical characteristics., Results: Seroprevalence of immunity to HAV (74.5% of 2577) and HBV (77.1% of 2551) was high. In adjusted analysis, HAV IgG seroprevalence varied by clinic and WHO region of birth (global p<0.001 for each), increased with older age (ORs of 1.50 (95% CI 1.18 to 1.86), 2.91 (2.17 to 3.90) and 3.40 (2.44 to 4.75) for ages 26-35, 36-45 and >46 vs 18-25 years (global p<0.001), was higher in those with an STI in the past year (1.58 (1.25 to 2.00); p<0.001) and those who were living with HIV (1.82 (1.25 to 2.64); p<0.001). Anti-HBs seroprevalence varied by clinic (global p<0.001), increased with older age (global p<0.001) and was higher in those with an STI in the past year (1.61 (1.27 to 2.05); p<0.001)., Conclusion: Our findings provide a baseline seroprevalence from which to monitor serial levels of immunity to HBV and HAV in GBMSM accessing SHS. Levels of immunity for both viruses are high, noting samples were taken after recent widespread outbreaks and vaccination campaigns. High vaccine coverage in all GBMSM should be maintained to prevent further outbreaks., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Social determinants of health (SDH) are nonbiologic influencers of disease and health care disparities. This study focused on understanding the association between SDH and urology clinic "no-show" visits within a diverse urban population., Methods: We retrospectively identified patients scheduled for urology clinic visits from October 2015 to June 2022 who completed a 10-question social needs screener. For each patient, demographic variables, and number of missed clinic appointments were abstracted. Multivariable logistic regression was performed to determine the association of unmet social needs and no-shows., Results: Of 5761 unique patients seen in clinic, 5293 completed a social needs screener. Respondents were most commonly male (62.8%), Hispanic (50.3%), English-speaking (75.5%), and insured by Medicare (46.0%). Overall, 8.2%, 4.6%, and 6.1% reported 1, 2, and 3+ unmet social needs, respectively. Most patients (61.7%) had 0 no-shows; 38.3% had 1+ no-shows. Between the 0 and 1+ no-show groups, we found significant differences with respect to gender ( P =.05), race/ethnicity ( P = .002), preferred language ( P = .006), insurance payer ( P < .001), SDH status ( P = .003), and total number of unmet social needs ( P = .006). On multivariable analysis, patients concerned about housing quality (odds ratio [OR] = 1.50, P = .002), legal help (OR = 1.53, P = .009), and with 3+ unmet social needs (OR = 1.39, P = .006) were more likely to have 1+ no-shows., Conclusions: Unmet social needs were associated with increased no-show urology clinic visits. Routine social needs screening could identify at-risk patients who would benefit from services. This may be particularly pertinent for patients with urgent diagnoses or those requiring frequent office visits where missing appointments could impact morbidity and mortality.

Objective: Substance use disorders (SUDs) commonly co-occur with posttraumatic stress disorder (PTSD). Understanding PTSD clinics that serve higher percentages of patients with PTSD/SUD is crucial for improving SUD care in clinics with lower percentages of such patients. This study examined the differences between Veterans Affairs (VA) PTSD treatment sites with higher percentages ("High%") and lower percentages ("Low%") of patients with PTSD/SUD as well as exploring the roles of the PTSD/SUD specialists., Methods: The study collected quantitative and qualitative data from 18 clinic directors and 21 specialists from 33 VA PTSD specialty outpatient clinics from 2014 to 2016. The clinics were chosen from the top and bottom quartiles based on two criteria: (1) the percentage of patients with PTSD/SUD and (2) the percentage of patients with PTSD/SUD who completed at least three SUD visits within the first month of their SUD treatment. The interviews sought to identify distinguishing characteristics between the High% and Low% clinics in terms of treatment access and practices for patients with PTSD/SUD., Results: More of the High% clinics reported providing evidence-based, patient-centered, and integrated/concurrent PTSD/SUD treatment and had staff members with more up-to-date knowledge and skills than the Low% clinics. We also found the roles of the PTSD/SUD specialists were demanding and confusing, leading to high turnover rates., Conclusions: The two groups of PTSD clinics differed in three key factors: Resources, knowledge and skills of staff members, and local policies. Future research should focus on addressing resource limitations, knowledge gaps, and local policy disparities in Low% clinics. By emulating the practices of High% clinics, VA PTSD clinics can improve SUD care for patients with PTSD/SUD.

Background: The purpose of this study was to evaluate potential predictors of no-shows and late cancellations in an outpatient clinic within a large healthcare system serving vulnerable communities., Methods: Demographic data and appointment status were recorded for 537 consecutive patients scheduled for neuropsychological evaluation in an outpatient psychiatry clinic. Patients include 220 males and 317 females with an average formal education of 11.01 years (SD = 3.87) and age of 55.64 years (SD = 16.20)., Results: The overall rate of no-shows or late cancellations was 20%. Of the 106 patients who no-showed/late cancelled, 41% rescheduled, and of those, 23% missed or late cancelled their second appointment. No-shows and late cancellations were associated with historical/prior no-show rate, while race/ethnicity and activation of MyChart had slight impacts., Conclusions: These data suggest that prior no-show rates and MyChart access may be targets for interventions to improve show rates. This is important for the patients' gaining access to care as well as minimizing financial strains for the system and increasing wait times/delays to care for other patients., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Vaccine prevention strategies play a crucial role in the management of people living with HIV (PLWH). The aim of this study was to assess vaccination coverage and identify barriers to vaccine uptake in PLWH in the Paris region. A cross-sectional survey was conducted in PLWH in 16 hospitals in the Paris region. The vaccination status, characteristics, opinions, and behaviors of participants were collected using a face-to-face questionnaire and from medical records. A total of 338 PLWH were included (response rate 99.7 %). The median age of participants was 51 years (IQR: 41-58). Vaccination coverage was 77.3 % for hepatitis B (95 % CI: 72.3-81.8 %), 62.7 % for hepatitis A (57.3-67.9 %), 61.2 % for pneumococcal vaccines (55.8-66.5 %), 56.5 % for diphtheria/tetanus/poliomyelitis (DTP) (51.0-61.9 %), 44.7 % for seasonal influenza (39.3-50.1 %), 31.4 % for measles/mumps/rubella (26.4-36.6 %) and 38.5 % for meningococcal vaccine (13.9-68.4 %). The main reason for vaccine reluctance was related to the lack of vaccination proposals/reminders. The overall willingness to get vaccinated was 71.0 % (65.9-75.8 %). In the multivariable analysis, several factors were associated with a higher vaccine uptake; for DTP vaccine: higher education level, having vaccination records, being registered with a general practitioner; for seasonal influenza vaccine: age > 60 years, higher education level, being employed. The overall vaccination coverage was suboptimal. Development of strategies reducing missed opportunity to offer vaccines is needed., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Claudine Duvivier: consultancies, speaker honoraria, and travel grants (Gilead Sciences, MSD, and ViiV Healthcare), outside the submitted work; Antoine Cheret: Grants for study of MSD, ViiV and Janssen Cilag. Travel grant of ViiV and Gilead; other authors declare no conflict of interest, (Copyright © 2024. Published by Elsevier Ltd.)

Background: Extracorporeal shockwave therapy (ESWT) has been shown to reduce wound dimensions and healing time in chronic wounds and should be considered a valuable tool in the healing of chronic complex lower extremity wounds., Purpose: The aim of this small case series was to evaluate the effect of ESWT on complex chronic wounds in patients with multiple comorbidities in a medically underserved outpatient wound care clinic setting., Methods: All patients had baseline wound measurements taken. Pictures of the wounds were also taken at the time of the initial visit. Patients selected for ESWT received weekly treatments for a maximum recorded duration of 12 weeks in the form of focused electro-hydraulic acoustic pulses. Wound beds were cleansed according to standard of care., Results: Thirteen patients were followed with a total of 18 wounds treated. After retrospectively analyzing the data, 3 subjects and a total of 5 wounds were excluded, leaving 10 total subjects and 13 wounds. Out of these wounds, 12 healed completely by or before week 12 of ESWT. All wounds demonstrated significant wound dimension reduction during the first 12 weeks of treatment., Conclusion: ESWT could offer accessible, fast, safe, and cost-effective management of some complex chronic wounds. Further research is needed to validate these findings.

Background: Population-based prevalence estimates of distal symmetric polyneuropathy (DPN) and diabetic autonomic neuropathy (DAN) are scares. Here we present neuropathy estimates and describe their overlap in a large cohort of people with type 1 and type 2 diabetes., Methods: In a large population of outpatient participants, DPN was assessed using vibration perception threshold, sural nerve function, touch, pain and thermal sensation. Definite DPN was defined by the Toronto Consensus Criteria. Painful DPN was defined by Douleur Neuropathique 4 Questions. DAN measures were: cardiovascular reflex tests, electrochemical skin conductance, and gastroparesis cardinal symptom index., Results: We included 822 individuals with type 1 (mean age (±SD) 54 ± 16 years, median [IQR] diabetes duration 26 [15-40] years) and 899 with type 2 diabetes (mean age 67 ± 11 years, median diabetes duration 16 [11-22] years). Definite DPN was prevalent in 54 % and 68 %, and painful DPN was in 5 % and 15 % of type 1 and type 2 participants, respectively. The prevalence of DAN varied between 6 and 39 % for type 1 and 9-49 % for type 2 diabetes. DPN without other neuropathy was present in 45 % with T1D and 50 % with T2D., Conclusion: The prevalence of DPN and DAN was high. DPN and DAN co-existed in only 50 % of cases., Competing Interests: Declaration of competing interest PR has received honoraria to his institution for consultancy and/or speaking fees from Astellas, Abbott, AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly, Gilead, MSD, Mundipharma, Novo Nordisk, and Sanofi Aventis and research grants from AstraZeneca and Novo Nordisk (to institution). The funders of the study had no role in study design, data collection, analysis, interpretation or writing of the report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Hawai'i experiences some of the highest rates of houselessness per capita in the country. COVID-19 has exacerbated these disparities and made it difficult for these individuals to seek medical care. Hawai'i's Houseless Outreach in Medical Education (HOME) clinic is the largest student run free clinic in the state, which provides medical services to this patient population. This article reports the demographics, medical needs, and services provided to patients of Hawai'i's HOME clinic during the era of COVID-19. From September 2020 to 2021, the HOME clinic saw 1198 unique visits with 526 distinct patients. The most common chief complaints included wound care (42.4%), pain (26.9%), and skin complaints (15.7%). A large portion of the population suffered from comorbidities including elevated blood pressure (66%), a formal reported history of hypertension (30.6%), diabetes (11.6%), and psychiatric concerns including schizophrenia (5.2%) and generalized anxiety (5.1%). Additionally, a large portion of patients (57.2%) were substance users including 17.8% of patients endorsing use of alcohol, 48.5% tobacco and 12.5% marijuana. The most common services provided were dispensation of medication (58.7%), wound cleaning/dressing changes (30.7%), and alcohol or other drug cessation counseling (25.2%). This study emphasizes that the houseless are a diverse population with complex, evolving medical needs and a high prevalence of chronic diseases and comorbidities., Competing Interests: None of the authors identify a conflict of interest., (©Copyright 2024 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Background: Outpatient waiting list figures have substantially increased over the last 3 years due to the effects of a global pandemic and cyber-hacking crisis. Multidisciplinary initiatives are essential to try to reduce the burden on overwhelmed medical and surgical specialties., Objective: The purpose of the study is as follows: (1) to demonstrate the potential for a problem-specific clinic to help ease the burden on an overwhelmed specialty and identify high-risk patients who may benefit from earlier surgical intervention and (2) to provide supervised clinical training to our clinical nurse specialist., Methods: A retrospective audit of outpatient referrals awaiting an appointment was conducted, and a new outpatient clinic was formed for patients referred with tonsil issues with or without additional complaints., Results: Two hundred ninety-five patients with an average waiting time of 14.4 months were offered an outpatient appointment over 5 months. Sixty-four percent (n = 189) attended their appointments, and 59.3% (n = 112) of these were listed for surgery. One hundred fifty-eight patients were able to be discharged back to the care of their general practitioners., Discussion/conclusion: This outpatient clinic identified a large number of patients waiting significant periods of time for an outpatient appointment and allowed a definitive clinical decision to be made with most patients being either discharged or listed for surgery. Initiatives such as this offer the possibility of reducing the burden of long waiting times on individual institutions., (© 2023. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.)

Objective: Characterizing access to sudden sensorineural hearing loss (SSNHL) care at private practice otolaryngology clinics of varying ownership models., Study Design: Cross-sectional prospective review., Setting: Private practice otolaryngology clinics., Methods: We employed a Secret Shopper study design with private equity (PE) owned and non-PE-owned clinics within 15 miles of one another. Using a standardized script, researchers randomly called 50% of each clinic type between October 2021 and January 2022 requesting an appointment on behalf of a family member enrolled in either Medicaid or private insurance (PI) experiencing SSNHL. Access to timely care was assessed between clinic ownership and insurance type., Results: Seventy-eight total PE-owned otolaryngology clinics were identified across the United States. Only 40 non-PE clinics could be matched to the PE clinics; 39 PE and 28 non-PE clinics were called as Medicaid patients; 39 PE and 25 non-PE clinics were called as PI patients; 48.7% of PE and 28.6% of non-PE clinics accepted Medicaid. The mean wait time to new appointment ranged between 9.55 and 13.21 days for all insurance and ownership types but did not vary significantly (P > .480). Telehealth was significantly more likely to be offered for new Medicaid patients at non-PE clinics compared to PE clinics (31.8% vs 0.0%, P = .001). The mean cost for an appointment was significantly greater at PE clinics than at non-PE clinics ($291.18 vs $203.75, P = .004)., Conclusions: Patients seeking SSNHL care at PE-owned otolaryngology clinics are likely to face long wait times prior to obtaining an initial appointment and reduced telehealth options., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objective: To evaluate the change in overall clinical encounter time and clinical capacity after transitioning to single-use cystoscopes (Ambu A/S, Ballerup, Denmark) in an outpatient urology setting., Methods: A single-institution prospective study in an outpatient urology procedure clinic was performed. Discrete categories for each portion of nursing care responsibilities were defined, and time spent during each category was recorded. Two separate clinic days were observed and analyzed: one where the clinic exclusively used reusable cystoscopes and the other after the transition to single-use cystoscopes occurred. Additionally, clinic schedules were reviewed from all procedure clinics in the 3-month periods before and after the transition to single-use cystoscopes. Outcomes included overall clinical encounter time and the number of procedures per clinic day., Results: There were 12 flexible cystoscopies performed during each of the observed clinic days. Preliminary cystoscope cleaning and transportation tasks by nursing staff were eliminated when utilizing single-use cystoscopes. Average total encounter time decreased from 66 to 44 minutes, resulting in a 34% reduction in clinical encounter time. The median number of flexible cystoscopy procedures increased after the transition from 9 (IQR 7-12) to 16 (IQR 11-17), representing a 78% increase (P = .003)., Conclusion: Transition to a completely single-use cystoscopy outpatient procedure clinic improved clinical efficiency and facilitated an increased number of procedures per clinic day., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Robert Medairos and Michael Lipkin paid consultant to Ambu., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Retail health clinics offer easy access and lower costs in seeking nonemergent and usually focused care. The objective of this observational study was to describe the use of retail clinic services by women at MinuteClinic at CVS, the largest network of retail clinics in the United States. Methods: The retail clinic's large database included complete national data for every in-person encounter as recorded on the same electronic health record. Virtual care and pharmacist-delivered services like COVID-19 testing were excluded from the analysis. The primary reason for the visit and the patient's age group (<15, 15-44, 45-64, ≥65 years) and self-reported sex were recorded at each encounter from the most recent 5 years (January 1, 2018, to December 31, 2022). Results: There were 17,969,483 encounters by women seeking care, and women ≥15 years old were more likely than men to attend the clinics. Half of all encounters (50.6%) were for non-gynecologic acute care, whereas one-third (33.6%) dealt with either an infection or the need for a vaccination. Gynecologic reasons involved 5.6% of all encounters in women ≥15 years of age. No obstetrical care was provided except for pregnancy testing with referral, acute non-obstetric needs, or guideline-recommended vaccinations. Conclusion: Women, especially of reproductive age, are more inclined than men to seek care at retail clinics. Acute care is the most common need, although requests for immunizations, infection screening and treatment, and reproductive health issues occurred often.

Clinical practice guidelines recommend screening for primary hyperaldosteronism (PH) in patients with resistant hypertension. However, screening rates are low in the outpatient setting. We sought to increase screening rates for PH in patients with resistant hypertension in our Veterans Affairs (VA) outpatient resident physician clinic, with the goal of improving blood pressure control. Patients with possible resistant hypertension were identified through a VA Primary Care Almanac Metric query, with subsequent chart review for resistant hypertension criteria. Three sequential patient-directed cycles were implemented using rapid cycle improvement methodology during a weekly dedicated resident quality improvement half-day. In the first cycle, patients with resistant hypertension had preclinic PH screening labs ordered and were scheduled in the clinic for hypertension follow-up. In the second cycle, patients without screening labs completed were called to confirm medication adherence and counselled to screen for PH. In the third cycle, patients with positive screening labs were called to discuss mineralocorticoid receptor antagonist (MRA) initiation and possible endocrinology referral. Of 97 patients initially identified, 58 (60%) were found to have resistant hypertension while 39 had pseudoresistant hypertension from medication non-adherence. Of the 58 with resistant hypertension, 44 had not previously been screened for PH while 14 (24%) had already been screened or were already taking an MRA. Our screening rate for PH in resistant hypertension patients increased from 24% at the start of the project to 84% (37/44) after two cycles. Of the 37 tested, 24% (9/37) screened positive for PH, and 5 patients were started on MRAs. This resident-led quality improvement project demonstrated that a focused intervention process can improve PH identification and treatment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Through a retrospective analysis of 1,203 cases of referral from primary healthcare units to a specialized quaternary vascular surgical service, the findings of this study revealed a high proportion of inappropriate referrals, which may represent a substantial subutilization of this highly complex service. Consequently, in this study, we aimed to evaluate 1,203 cases of referral to a quaternary vascular surgical service, in São Paulo, Brazil, over a 6-year period, to assess the appropriate need for referral; in addition to the prevalence of surgical indications., Methods: In this retrospective analysis, we reviewed the institutional records of participants referred from Basic Healthcare Units to a vascular surgical service inside the Brazilian Unified Health System, between May 2015 and December 2020. Demographic and clinical data were collected. The participants were stratified, as per the reason for referral to the vascular surgical service, previous imaging studies, and surgical treatment indications. Referral appropriateness and complementary examinations were evaluated for each disease cohort. Finally, the prevalence of cases requiring surgical treatment was defined as the outcome measure., Results: Of the 1,203 referrals evaluated, venous disease was the main reason for referral (53%), followed by peripheral arterial disease (19.4%). A considerable proportion of participants had been referred without complementary imaging or after a long duration of undergoing an examination. Referrals were regarded as inappropriate in 517 (43%) cases. Of these, 32 cases (6.2%) had been referred to the vascular surgical service, as the incorrect specialty. The percentage of referred participants who ultimately underwent surgical treatment was 39.92%. Carotid (18%) and peripheral arterial diseases (18.4%) were correlated with a lower prevalence of surgical treatments., Conclusion: The rate of referral appropriateness to specialized vascular care from primary care settings was low. This may represent a subutilization of quaternary surgical services, with low rates of surgical treatment.

Background: The risk factors for oropharyngeal gonorrhea have not been examined in sex workers despite the increasing prevalence of gonorrhea infection., Objective: This study aims to determine the risk factors for oropharyngeal gonorrhea in female and gender-diverse sex workers (including cisgender and transgender women, nonbinary and gender fluid sex workers, and those with a different identity) and examine kissing, oral sex, and mouthwash practices with clients., Methods: This mixed methods case-control study was conducted from 2018 to 2020 at 2 sexual health clinics in Melbourne, Victoria, and Sydney, New South Wales, Australia. We recruited 83 sex workers diagnosed with oropharyngeal gonorrhea (cases) and 581 sex workers without (controls). Semistructured interviews with 19 sex workers from Melbourne were conducted., Results: In the case-control study, the median age of 664 sex workers was 30 (IQR 25-36) years. Almost 30% of sex workers (192/664, 28.9%) reported performing condomless fellatio on clients. Performing condomless fellatio with clients was the only behavior associated with oropharyngeal gonorrhea (adjusted odds ratio 3.6, 95% CI 1.7-7.6; P=.001). Most participants (521/664, 78.5%) used mouthwash frequently. In the qualitative study, almost all sex workers reported kissing clients due to demand and generally reported following clients' lead with regard to kissing style and duration. However, they used condoms for fellatio because they considered it a risky practice for contracting sexually transmitted infections, unlike cunnilingus without a dental dam., Conclusions: Our study shows that condomless fellatio is a risk factor for oropharyngeal gonorrhea among sex workers despite most sex workers using condoms with their clients for fellatio. Novel interventions, particularly targeting the oropharynx, will be required for oropharyngeal gonorrhea prevention., (©Tiffany R Phillips, Christopher K Fairley, Kate Maddaford, Anna McNulty, Basil Donovan, Rebecca Guy, Ruthy McIver, Rebecca Wigan, Rick Varma, Jason J Ong, Denton Callander, Gabrielle Skelsey, Mish Pony, Dylan O'Hara, Jade E Bilardi, Eric PF Chow. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 20.05.2024.)

Background: Management of idiopathic intracranial hypertension (IIH) is complex requiring contributions from multiple specialized disciplines. In practice, this creates considerable organizational and communicational challenges. To meet those challenges, we established an interdisciplinary integrated outpatient clinic for IIH with a central coordination and a one-stop- concept. Here, we aimed to evaluate effects of this concept on sick leave, presenteeism, and health care utilization., Methods: In a retrospective cohort study, we compared the one-stop era with integrated care (IC, 1-JUL-2021 to 31-DEC-2022) to a reference group receiving standard care (SC, 1-JUL-2018 to 31-DEC-2019) regarding economic outcome parameters assessed over 6 months. Multivariate binary logistic regression models were used to adjust for confounders., Results: Baseline characteristics of the IC group (n = 85) and SC group (n = 81) were comparable (female: 90.6% vs. 90.1%; mean age: 33.6 vs. 32.8 years, educational level: ≥9 years of education 60.0% vs. 59.3%; located in Vienna 75.3% vs. 76.5%). Compared to SC, the IC group showed significantly fewer days with sick leave or presenteeism (-5 days/month), fewer unscheduled contacts for IIH-specific problems (-2.3/month), and fewer physician or hospital contacts in general (-4.1 contacts/month). Subgroup analyses of patients with migration background and language barrier consistently indicated stronger effects of the IC concept in these groups., Conclusions: Interdisciplinary integrated management significantly improves the burden of IIH in terms of sick leave, presenteeism and healthcare consultations - particularly in socioeconomically underprivileged patient groups., (© 2024. The Author(s).)

Radiation disasters pose distinctive medical challenges, requiring diverse care approaches. Beyond radiation exposure assessment, addressing health impacts due to lifestyle changes, especially among vulnerable populations, is vital. Evacuation orders issued in radiation-affected areas introduce unique healthcare dynamics, with their duration significantly influencing the recovery process. Understanding evolving patient demographics and medical needs after lifting evacuation orders is crucial for post-disaster care planning. Minamisoma Municipal Odaka Hospital, located 13 to 20 km from Fukushima Daiichi Nuclear power plant in a post-evacuation zone, was greatly affected by the Great East Japan Earthquake and subsequent radiation disaster. Data were retrospectively collected from patient records, including age, gender, visit date, diagnoses, and addresses. Patient records from April 2014 to March 2020 were analyzed, comparing data before and after the July 2016 evacuation order lift. Data was categorized into pre and post-evacuation order lifting periods, using International Classification of Diseases, Tenth Edition codes, to identify the top diseases. Statistical analyses, including χ-square tests, assessed changes in disease distributions. Population data for Odaka Ward and Minamisoma City fluctuated after lifting evacuation orders. As of March 11, 2011, Odaka Ward had 12,842 residents (27.8% aged 65+ years), dropping to 8406 registered residents and 2732 actual residents by April 30, 2018 (49.7%). Minamisoma City also saw declines, with registered residents decreasing from 71,561 (25.9%) to 61,049 (34.1%). The study analyzed 11,100 patients, mostly older patients (75.1%), between 2014 and 2020. Post-lifting, monthly patient numbers surged from an average of 55.2 to 213.5, with female patients increasing from 33.8% to 51.7%. Disease patterns shifted, with musculoskeletal cases declining from 23.8% to 13.0%, psychiatric disorders increasing from 9.3% to 15.4%, and trauma-related cases decreasing from 14.3% to 3.9%. Hypertension (57.1%) and dyslipidemia (29.2%) prevailed post-lifting. Urgent cases decreased from 1.3% to 0.1%. This study emphasizes the importance of primary care in post-evacuation zones, addressing diverse medical needs, including trauma, noncommunicable diseases, and psychiatric disorders. Changing patient demographics require adaptable healthcare strategies and resource allocation to meet growing demands. Establishing a comprehensive health maintenance system tailored to these areas' unique challenges is crucial for future disaster recovery efforts., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Direct primary care (DPC) critics are concerned that the periodic fee precludes participation from vulnerable populations. The purpose is to describe the demographics and appointments of a, now closed, academic DPC clinic and determine whether there are differences in vulnerability between census tracts with and without any clinic patients., Methods: We linked geocoded data from the DPC's electronic health record with the social vulnerability index (SVI). To characterize users, we described their age, sex, language, membership, diagnoses, and appointments. Descriptive statistics included frequencies, proportions or medians, and interquartile ranges. To determine differences in SVI, we calculated a localized SVI percentile within Harris County. A t test assuming equal variances and Mann-Whitney U Tests were used to assess differences in SVI and all other census variables, respectively, between those tracts with and without any clinic patients., Results: We included 322 patients and 772 appointments. Patients were seen an average of 2.4 times and were predominantly female (58.4%). More than a third (37.3%) spoke Spanish. There was a mean of 3.68 ICD-10 codes per patient. Census tracts in which DPC patients lived had significantly higher SVI scores (ie, more vulnerable) than tracts where no DPC clinic patients resided (median, 0.60 vs 0.47, p-value < 0.05)., Conclusion: This academic DPC clinic cared for individuals living in vulnerable census tracts relative to those tracts without any clinic patients. The clinic, unfortunately, closed due to multiple obstacles. Nevertheless, this finding counters the perception that DPC clinics primarily draw from affluent neighborhoods., Competing Interests: Conflict of interest: University of Houston contracted with Elation. Please note that the opinions of Dr. Olaisen do not reflect the opinion of his employer, the Agency for Healthcare Research and Quality., (© Copyright 2024 by the American Board of Family Medicine.)

Importance: The Supreme Court decision Dobbs v Jackson Women's Health Organization (Dobbs) overturned federal protections to abortion care and altered the reproductive health care landscape. Thus far, aggregated state-level data reveal increases in the number of abortions in states where abortion is still legal, but there is limited information on delays to care and changes in the characteristics of people accessing abortion in these states after Dobbs., Objective: To examine changes in abortion provision and delays to care after Dobbs., Design, Setting, and Participants: Retrospective cohort study of all abortions performed at an independent, high-volume reproductive health care clinic network in Washington state from January 1, 2017, to July 31, 2023. Using an interrupted time series, the study assessed changes in abortion care after Dobbs., Exposure: Abortion care obtained after (June 24, 2022, to July 31, 2023) vs before (January 1, 2017, to June 23, 2022) Dobbs., Main Outcome and Measure: Primary outcomes included weekly number of abortions and out-of-state patients and weekly average of gestational duration (days) and time to appointment (days)., Results: Among the 18 379 abortions during the study period, most were procedural (13 192 abortions [72%]) and funded by public insurance (11 412 abortions [62%]). The mean (SD) age of individuals receiving abortion care was 28.5 (6.44) years. Following Dobbs, the number of procedural abortions per week increased by 6.35 (95% CI, 2.83-9.86), but then trended back toward pre-Dobbs levels. The number of out-of-state patients per week increased by 2 (95% CI, 1.1-3.6) and trends remained stable. The average gestational duration per week increased by 6.9 (95% CI, 3.6-10.2) days following Dobbs, primarily due to increased gestations of procedural abortions. The average gestational duration among out-of-state patients did not change following Dobbs, but it did increase by 6 days for in-state patients (5.9; 95% CI, 3.2-8.6 days). There were no significant changes in time to appointment., Conclusions and Relevance: These findings provide a detailed picture of changes in abortion provision and delays to care after Dobbs in a state bordering a total ban state. In this study, more people traveled from out of state to receive care and in-state patients sought care a week later in gestation. These findings can inform interventions and policies to improve access for all seeking abortion care.

Objective: The study aimed to determine the etiological characteristics of patients with dizziness/vertigo attending a neurological clinic according to the criteria of the International Classification of Vestibular Disorders (ICVD), hoping to provide a valuable reference for clinicians to diagnose and treat dizziness/vertigo., Method: A total of 638 consecutive patients with a chief complaint of dizziness/vertigo who attended the vertigo clinic of our neurology department from January 2019 to January 2020 were included. Clinical data of patients, including baseline data, medical history, neurological, neuro-otological, and auxiliary examination results were collected. The etiologic distribution of dizziness/vertigo was determined by analyzing the diagnoses of patients., Results: Of the 638 patients with dizziness/vertigo, 38.8% were males, 61.2% were females, with a male: female ratio of 1:1.58 and a mean age of 52.9 ± 16.9 years. Benign paroxysmal positional vertigo (BPPV) was the most common cause of dizziness/vertigo in both female (38.9%) and male patients (25.5%). Subgroup analysis based on sex showed that vestibular migraine (VM) and probable autoimmune inner ear disease (p-AIED) were more prevalent in female patients (10.7% and 3.8%, respectively), while vascular vertigo/dizziness was more common in male patients (10.1%). Subgroup analysis based on age showed that the most common diseases were VM in patients aged 0-30 years (27.4%), BPPV in patients aged 31-60 years (27.1%) and 61-100 years (46.0%). Episodic vestibular syndrome (EVS) was the most commonly observed, accounting for up to 60.6% (389/638) of all patients, and the most common diagnoses were BPPV (55.3%, 215/389), VM (15.2%, 59/389), primary unilateral peripheral vestibular dysfunction (p-UPVD) of unknown etiology (11.8%, 46/389), p-AIED (4.4%, 17/389), and vascular vertigo/dizziness (2.8%, 11/389) in these patients. Chronic vestibular syndrome (CVS) was found in 14.0% (90/638) of the patients, and the most common diagnoses were persistent postural-perceptual dizziness (PPPD, 35.6%, 32/90), psychogenic dizziness (18.9%, 17/90), p-UPVD of unknown etiology (15.6%, 14/90), vascular vertigo/dizziness (15.6%, 14/90), and bilateral vestibulopathy (7.8%, 7/90). Acute vestibular syndrome (AVS) was observed in 8.4% (54/638) of the patients, and the most common diagnoses were p-UPVD of unknown etiology (31.5%, 17/54), vestibular neuritis (24.1%, 13/54), probable labyrinthine apoplexy (16.7%, 9/54), stroke (13.0%, 7/54), and psychogenic dizziness (11.1%, 6/54). 16.4% (105/638) of the patients were found to have other disorders, including 15.2% (16/105) of patients with internal diseases, and 84.8% (89/105) of patients with unknown causes. In terms of localization diagnosis, 56.1%, 17.0%, 10.0%, and 16.4% of the patients were diagnosed with peripheral vestibular disorder, central vestibular disorder, psychiatric and functional vestibular disorders, and other disorders, respectively., Conclusion: (1) Dizziness/vertigo was more common in females, which was frequently caused by damage to the vestibular system. Non-vestibular or unknown etiologies were also seen in some patients; (2) VM was more prevalent in women than in men, vascular vertigo/dizziness was more commonly observed in men; (3) EVS was more common in patients with dizziness/vertigo. The most common causes of dizziness/vertigo were peripheral vestibular disorders in patients with AVS and EVS, PPPD and psychogenic dizziness in patients with CVS. The most common causes were BPPV and p-UPVD of unknown etiology in patients with a peripheral vestibular disorder, VM and vascular vertigo/dizziness in patients with central vestibular disorder, PPPD and psychogenic dizziness in patients with psychiatric and functional vestibular disorders., (© 2024. The Author(s).)

Purpose: Continuity of care is broadly associated with better patient health outcomes. The relative contributions of continuity with an individual physician and with a practice, however, have not generally been distinguished. This retrospective observational study examined the impact of continuity of care for patients seen at their main clinic but by different family physicians., Methods: We analyzed linked health administrative data from 2015-2018 from Alberta, Canada to explore the association of physician and clinic continuity with rates of emergency department (ED) visits and hospitalizations across varying levels of patient complexity. Physician continuity was calculated using the known provider of care index and clinic continuity with an analogous measure. We developed zero-inflated negative binomial models to assess the association of each with all-cause ED visits and hospitalizations., Results: High physician continuity was associated with lower ED use across all levels of patient complexity and with fewer hospitalizations for highly complex patients. Broadly, no (0%) clinic continuity was associated with increased use and complete (100%) clinic continuity with decreased use, with the largest effect seen for the most complex patients. Levels of clinic continuity between 1% and 50% were generally associated with slightly higher use, and levels of 51% to 99% with slightly lower use., Conclusions: The best health care outcomes (measured by ED visits and hospitalizations) are associated with consistently seeing one's own primary family physician or seeing a clinic partner when that physician is unavailable. The effect of partial clinic continuity appears complex and requires additional research. These results provide some reassurance for part-time and shared practices, and guidance for primary care workforce policy makers., (© 2024 Annals of Family Medicine, Inc.)

Background: There are giant steps taken in the introduction of the novel malaria vaccine poised towards reducing mortality and morbidity associated with malaria., Objectives: This study aimed to determine the knowledge of malaria vaccine and factors militating against willingness to accept the vaccine among mothers presenting in nine hospitals in Enugu metropolis., Methods: This was a cross-sectional study carried out among 491 mothers who presented with their children in nine hospitals in Enugu metropolis, South-East Nigeria. A pre-tested and interviewer-administered questionnaire was used in this study., Results: A majority of the respondents, 72.1% were aware of malaria vaccine. A majority of the respondents, 83.1% were willing to receive malaria vaccine. Similarly, a majority of the mothers, 92.9%, were willing to vaccinate baby with the malaria vaccine, while 81.1% were willing to vaccinate self and baby with the malaria vaccine. The subjects who belong to the low socio-economic class were five times less likely to vaccinate self and baby with malaria vaccine when compared with those who were in the high socio-economic class (AOR = 0.2, 95% CI 0.1-0.5). Mothers who had good knowledge of malaria vaccination were 3.3 times more likely to vaccinate self and baby with malaria vaccine when compared with those who had poor knowledge of malaria vaccination (AOR = 3.3, 95% CI 1-6-6.8)., Conclusion: Although the study documented a high vaccine acceptance among the mothers, there exists a poor knowledge of the malaria vaccine among them., (© 2024. The Author(s).)

Objective: To compare health outcomes and costs given in the emergency department (ED) and walk-in clinics for ambulatory children presenting with acute respiratory diseases., Design: A retrospective cohort study., Setting: This study was conducted from April 2016 to March 2017 in one ED and one walk-in clinic. The ED is a paediatric tertiary care centre, and the clinic has access to lab tests and X-rays., Participants: Inclusion criteria were children: (1) aged from 2 to 17 years old and (2) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia or acute asthma., Main Outcome Measures: The primary outcome measure was the proportion of patients returning to any ED or clinic within 3 and 7 days of the index visit. The secondary outcome measures were the mean cost of care estimated using time-driven activity-based costing and the incidence of antibiotic prescription for URTI patients., Results: We included 532 children seen in the ED and 201 seen in the walk-in clinic. The incidence of return visits at 3 and 7 days was 20.7% and 27.3% in the ED vs 6.5% and 11.4% in the clinic (adjusted relative risk at 3 days (aRR) (95% CI) 3.17 (1.77 to 5.66) and aRR at 7 days 2.24 (1.46 to 3.44)). The mean cost (95% CI) of care (CAD) at the index visit was $C96.68 (92.62 to 100.74) in the ED vs $C48.82 (45.47 to 52.16) in the clinic (mean difference (95% CI): 46.15 (41.29 to 51.02)). Antibiotic prescription for URTI was less common in the ED than in the clinic (1.5% vs 16.4%; aRR 0.10 (95% CI 0.03 to 0.32))., Conclusions: The incidence of return visits and cost of care were significantly higher in the ED, while antibiotic use for URTI was more frequent in the walk-in clinic. These data may help determine which setting offers the highest value to ambulatory children with acute respiratory conditions., Competing Interests: Competing interests: SBerthelot, LM, DT, PA and JRG currently hold FRQS research scholarships., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There are known health disparities in adolescent substance treatment access and engagement. The purpose of this project is to compare outcomes from school- and clinic-based substance treatment and to evaluate if providing school-based substance treatment reduces disparities in treatment access and engagement., Method: This quality improvement retrospective chart review compares baseline and outcome data for adolescents accessing school-based (n = 531) and clinic-based (n = 523) substance treatment in a natural quasi-experimental study with nonequivalent control group design. Baseline demographic and clinical measures include age, sex, ethnicity, race, and clinical diagnoses. Outcome measures include the number of sessions completed, proportion reaching a week of self-reported abstinence, and proportion providing a negative urine drug screen., Results: Compared to the clinic-based sample, the school-based sample includes more female (47.65% vs 26.77%) and Hispanic/Latinx (59.89% vs 46.46%) adolescents. The school-based group has a similar proportion reaching a negative urine drug screen (31.84% vs 28.83%, p = .5259) or a week of abstinence (43.15% vs 41.03%, p = .6718) as the clinic-based sample. There are significant differences in total session completion over a period of 16 weeks between school-based and clinic-based adolescents. In multivariable analyses, there was a significant interaction effect of race/ethnicity by location on the number of sessions completed., Conclusion: Providing school-based substance treatment increases access to care and treatment engagement for female, African American, and Hispanic/Latinx adolescents without diminishing outcomes., (© 2023, American School Health Association.)

HIV self-testing (HIVST) has the potential to reduce barriers associated with clinic-based preexposure prophylaxis (PrEP) delivery. We conducted a substudy nested in a prospective, pilot implementation study evaluating patient-centered differentiated care services. Clients chose either a blood-based or oral fluid HIVST kit at the first refill visit. Data were abstracted from program files and surveys were administered to clients. We purposively sampled a subset of PrEP clients and their providers to participate in in-depth interviews. We surveyed ( n  = 285). A majority (269/285, 94%) reported HIV risk. Blood-based HIVST was perceived as easy to use (76/140, 54%), and (41/140, 29%) perceived it to be more accurate. Oral fluid-based HIVST was perceived to be easy to use (95/107, 89%), but almost all (106/107, 99%) perceived it as less accurate. HIVST improved privacy, reduced workload, and saved time. HIVST demonstrates the potential to streamline facility-based PrEP care in busy African public health facilities., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Free clinics may present long wait times. A retrospective chart review was conducted at a free clinic to understand contributing factors. Three wait times (total visit time, lobby wait time, and triage time) were analyzed across 349 patients. Variables included in the models were the total number of patients, providers, and volunteers; interpreter services; social work involvement; medical complexity; new vs. returning patient; scheduled vs. walk-in appointment; transportation provision; medical volunteer training level; and on-site medications and labs. Data analysis with multiple regressions was conducted. Factors that significantly affected wait times included the level of medical complexity (p&lt;.001), medical volunteer training levels (p&lt;.001), in-house labs (p&lt;.001), in-house medications (p=.04), and new patients (p=.01). An intervention involving time benchmarks at the beginning of clinics reduced first-wave lobby wait times (p&lt;.001). Future interventions addressing these factors may reduce wait times at other clinics.

Importance: Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist., Objective: To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD., Design, Setting, and Participants: This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022., Exposure: Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services., Measures: Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods., Results: Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care., Conclusions and Relevance: The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.

Background: Chronic kidney disease (CKD) is a major public health issue worldwide and is an important contributor to the overall non-communicable disease burden. Chronic kidney disease is usually asymptomatic, and insidiously and silently progresses to advanced stages in resource limited settings., Methodology: A prospective longitudinal study was carried out on black patients with CKD attending the kidney outpatient clinic at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in South Africa, between September 2019 to March 2022. Demographic and clinical data were extracted from the ongoing continuous clinic records, as well as measurements of vital signs and interviews at baseline and at follow up. Patients provided urine and blood samples for laboratory investigations as standard of care at study entry (0) and at 24 months, and were followed up prospectively for two (2) years. Data were descriptively and inferentially entered into REDcap and analysed using STATA version 17, and multivariable logistic regression analysis was used to identify predictors of CKD progression., Results: A total of 312 patients were enrolled into the study, 297 (95.2%) patients completed the study, 10 (3.2%) patients were lost to follow and 5 (1.6%) patients died during the study period. The prevalence of CKD progression was 49.5%, while that of CKD remission was 33% and CKD regression was 17.5%. For patients with CKD progression the median age at baseline was 58 (46-67) years, the median eGFR was 37 (32-51) mL/min/1.73 m2, median urine protein creatinine ratio (uPCR) was 0.038 (0.016-0.82) g/mmol and the median haemoglobin (Hb) was 13.1 (11.7-14.4) g/dl; 95.2% had hypertension, 40.1% patients had diabetes mellitus and 39.5% had both hypertension and diabetes mellitus. Almost half (48.3%) of patients with CKD progression had severely increased proteinuria and 45.6% had anaemia. Variables associated with higher odds for CKD progression after multivariable logistic regression analysis were severely increased proteinuria (OR 32.3, 95% CI 2.8-368.6, P = 0.005), moderately increased proteinuria (OR 23.3, 95% CI 2.6-230.1, P = 0.007), hypocalcaemia (OR 3.8, 95% CI 1.0-14.8, P = 0.047), hyponatraemia (OR 4.5, 95% CI 0.8-23.6, P = 0.042), anaemia (OR 2.1, 95% CI 1.0-4.3, P = 0.048), diabetes mellitus (OR 1.8, 95% CI 0.9-3.6, P = 0.047), elevated HbA1c (OR 1.8, 95% CI 1.2-2.8, P = 0.007) and current smoking (OR 2.8, 95% CI 0.9-8.6, P = 0.049)., Conclusion: Our study identified a higher prevalence of CKD progression in a prospective longitudinal study of black patients with CKD compared with literature reports. CKD Progression was associated with proteinuria, diabetes mellitus, elevated HbA1c, anaemia, hypocalcaemia, hyponatraemia and current smoking in a cohort of black patients with CKD who had controlled hypertension and diabetes mellitus at baseline., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Meremo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Small dense low-density cholesterol (sdLDL) has been the focus of studies due to its potential as an independent risk factor for atherosclerotic cardiovascular diseases. We aimed to investigate the utilization of sdLDL testing by LDL particle size analysis and the prevalence of an sdLDL predominant phenotype in Korean adult patients by visiting local clinics and hospitals. Among 9222 Korean adults (4577 men and 4645 women) with a median age of 62.8 years (interquartile range, IQR 54.5 to 71.8 years) undergoing lipid profile testing using LDL particle size analysis, the prevalence of hypercholesterolemia (total cholesterol ≥ 240 mg/dL), hypo HDL cholesterolemia (<40 mg/dL), and hyper LDL cholesterolemia (≥160 mg/dL) was 7.8%, 12.9%, and 0.5%, respectively. The overall prevalence of the sdLDL predominant non-A phenotype of LDL was 46.8% of study subjects. Approximately 32.8% of the study subjects possessed lipid test results that did not exhibit increased risk except for sdLDL (only the sdLDL predominant non-A phenotype as a risk factor). In Korea, sdLDL testing was utilized in patients whose LDL cholesterol level was not increased. Future studies to clarify the clinical significance of this test in the Korean population are needed.

Importance: Care of adults at profit vs nonprofit dialysis facilities has been associated with lower access to transplant. Whether profit status is associated with transplant access for pediatric patients with end-stage kidney disease is unknown., Objective: To determine whether profit status of dialysis facilities is associated with placement on the kidney transplant waiting list or receipt of kidney transplant among pediatric patients receiving maintenance dialysis., Design, Setting, and Participants: This retrospective cohort study reviewed the US Renal Data System records of 13 333 patients younger than 18 years who started dialysis from 2000 through 2018 in US dialysis facilities (followed up through June 30, 2019)., Exposures: Time-updated profit status of dialysis facilities., Main Outcomes and Measures: Cox models, adjusted for clinical and demographic factors, were used to examine time to wait-listing and receipt of kidney transplant by profit status of dialysis facilities., Results: A total of 13 333 pediatric patients who started receiving maintenance dialysis were included in the analysis (median age, 12 years [IQR, 3-15 years]; 6054 females [45%]; 3321 non-Hispanic Black patients [25%]; 3695 Hispanic patients [28%]). During a median follow-up of 0.87 years (IQR, 0.39-1.85 years), the incidence of wait-listing was lower at profit facilities than at nonprofit facilities, 36.2 vs 49.8 per 100 person-years, respectively (absolute risk difference, -13.6 (95% CI, -15.4 to -11.8 per 100 person-years; adjusted hazard ratio [HR] for wait-listing at profit vs nonprofit facilities, 0.79; 95% CI, 0.75-0.83). During a median follow-up of 1.52 years (IQR, 0.75-2.87 years), the incidence of kidney transplant (living or deceased donor) was also lower at profit facilities than at nonprofit facilities, 21.5 vs 31.3 per 100 person-years, respectively; absolute risk difference, -9.8 (95% CI, -10.9 to -8.6 per 100 person-years) adjusted HR for kidney transplant at profit vs nonprofit facilities, 0.71 (95% CI, 0.67-0.74)., Conclusions and Relevance: Among a cohort of pediatric patients receiving dialysis in the US from 2000 through 2018, profit facility status was associated with longer time to wait-listing and longer time to kidney transplant.

Introduction: Many postoperative acute care visits (PACVs) are likely more appropriately addressed in lower acuity settings; however, the frequency and nature of PACVs are not currently tracked by the National Surgical Quality Improvement Program (NSQIP), and the overall burden to emergency departments and urgent care centers is unknown., Methods: NSQIP collaborative data were augmented to prospectively capture 30-d PACVs for 1 y starting October 2018 across all NSQIP specialties, including visit reason and disposition. Data were analyzed using binomial logistic regression., Results: A total of 9933 patients were identified; 12.0% (n = 1193) presented to an acute care setting over 1413 visits, most commonly for surgical pain (15.4%) in the absence of an identified complication. Visits most commonly resulted in discharge (n = 817, 68.5%) or admission (n = 343, 24.3%). Variables independently associated with visits resulting in discharge included age (odds ratio [OR] 0.99 per year, P < 0.001), increasing comorbidities (1-2 [OR 1.55, P < 0.001]; 3-4 [OR 2.51, P < 0.001]; 5+ [OR 2.79 P < 0.001]), operative duration (OR 1.08 per hour, P = 0.001), and nonelective (OR 1.20, P = 0.01) or urologic (OR 1.46, P = 0.01) procedures., Conclusions: PACVs are an overlooked burden on emergency medicine providers and healthcare systems; most do not require admission and could be potentially triaged outside of the acute care setting with improved perioperative care infrastructure. Younger patients, those with multiple comorbidities, and those undergoing nonelective procedures deserve special attention when designing initiatives to address postoperative acute care utilization. Data regarding PACVs can be routinely collected with minor modifications to current NSQIP workflows., (Copyright © 2022 Elsevier Inc. All rights reserved.)