Quality Assurance in Telehealth: Adherence to Evidence-Based Indicators.

Background: Value enhancing telehealth (TH) lacks a robust body of formal clinically focused quality assessment studies. Innovations such as telehealth must always demonstrate that it preserves or hopefully advances quality. Introduction: We sought to determine whether adherence to the evidence-based Choosing Wisely (CW) recommendations (antibiotic stewardship) for acute sinusitis differs for encounters through direct-to-consumer (DTC) telemedicine verses in-person care in an emergency department (ED) or an urgent care (UC) center. Materials and Methods: Study design was a retrospective review. Patients with a symptom complex consistent with acute sinusitis treated through DTC were matched with ED and UC patients, based upon time of visit. Charts were reviewed to determine patient characteristics, chief complaint, final diagnosis, presence or absence of criteria within the CW guidelines, and whether or not antibiotics were prescribed. The main outcome was adherence to the CW campaign recommendations. Results: A total of 570 visits were studied: 190 DTC, 190 ED, and 190 UC visits. The predominant chief complaints were upper respiratory infection (36%), sore throat (25%), and sinusitis (18%). Overall, there was a 67% (95% CI 62.3-71.7) adherence rate with the CW guidelines for sinusitis: DTC visits (71%), ED visits (68%), and UC visits (61%). There was a nonsignificant difference (p = 0.29) in adherence to CW guidelines based upon type of visit (DTC, UC, and ED). Discussion: The challenge is to demonstrate whether or not DTC TH compromises quality. Conclusion: In this study, DTC visits were associated with at least as good an adherence to the CW campaign recommendations as emergency medicine (EM) and UC in-person visits. © Daniel Halpren-Ruder et al

Associations of Emergency Department Length of Stay With Publicly Reported Quality-of-care Measures.

OBJECTIVE: The Institute of Medicine identified emergency department (ED) crowding as a critical threat to patient safety. We assess the association between changes in publicly reported ED length of stay (LOS) and changes in quality-of-care measures in a national cohort of hospitals. METHODS: Longitudinal analysis of 2012 and 2013 data from the American Hospital Association (AHA) Survey, Center for Medicare and Medicaid Services (CMS) Cost Reports, and CMS Hospital Compare. We included hospitals reporting Hospital Compare timeliness measure of LOS for admitted patients. We used AHA and CMS data to incorporate hospital predictors of interest. We used the method of first differences to test for relationships in the change over time between timeliness measures and six hospital-level measures. RESULTS: The cohort consisted of 2,619 hospitals. Each additional hour of ED LOS was associated with a 0.7% decrease in proportion of patients giving a top satisfaction rating, a 0.7% decrease in proportion of patients who would definitely recommend the hospital, and a 6-minute increase in time to pain management for long bone fracture (p \u3c 0.01 for all). A 1-hour increase in ED LOS is associated with a 44% increase in the odds of having an increase in left without being seen (95% confidence interval = 25% to 68%). ED LOS was not associated with hospital readmissions (p = 0.14) or time to percutaneous coronary intervention (p = 0.14). CONCLUSION: In this longitudinal study of hospitals across the United States, improvements in ED timeliness measures are associated with improvements in the patient experience

Smart Rooms Devices as a Modality of Enhancing Patient Engagement

Introduction: Recent literature has demonstrated that increased patient engagement is linked to improved patient outcomes. As such, hospitals are currently attempting to increase patient engagement via use of digital tools. One potential digital tool is a Smart Rooms Device, a voiceassistant integrated into hospital rooms. The goal of this investigation is to identify modalities by which patients intend to engage with the Smart Rooms Device. Methods: This is a prospective interview study conducted between 11/20/2019 and 12/17/2019, whereby patients from the TJU Observation Unit were asked pre-determined interview questions in order to ascertain potential device usages. Results: 12 patients were approached and 7 were interviewed (4 male, 3 male), with a median age of 50 (age range: 18-59). When asked about potential uses, 7 patients (100%) identified that they would use the device to: (1) request an item or (2) adjust a room setting. 6 patients (86%) would use the device to: (1) ask questions pertaining to their diagnosis or (2) call for a medical professional. When given the choice, 5 patients (71%) would prefer to discuss their medical care with a medical professional rather than a Smart Rooms Device. When asked why they would want to use the device, 6 patients (86%) noted that a device is faster than conventional modalities, and 3 patients (43%) noted that it is less work for nurses. Discussion: Overall, the interviewed patients appear to prefer discussing specifics of their medical care with a professional rather than the device but would readily use the device if given the option for a variety of non-urgent tasks. Future research should continue interviewing patients in order to develop a larger database of patient responses to draw conclusions from and to identify additional modes of engagement with the Smart Rooms device

Integrating Telehealth Emergency Department Follow-up Visits into Residency Training.

Introduction: Given the rapid expansion of telehealth (TH), there is an emerging need for trained professionals who can effectively deliver TH services. As there is no formal TH training program for residents, the Department of Emergency Medicine (DEM) at Thomas Jefferson University (TJU) developed a pilot training program for senior post-graduate-year three (PGY-3) residents that exposed them to TH practices. The objective of the study was to determine the feasibility of developing a resident-led, post-Emergency-Department (ED) visit TH follow-up program as an educational opportunity to 1) address patient satisfaction; and 2) expose senior residents to TH delivery. Methods: During a one-month block in their third-year of training, EM residents were exposed to and educated on TH delivery and utility through on-the-job, just-in-time training. Residents spent four hours per week evaluating patients previously seen in the ED within the last 5-7 days in the form of TH follow-up visits. ED patients were screened to identify which patient chief complaints and presentations were appropriate for a follow-up visit, given a specific day and time for their TH encounter, facilitated by a resident, and supervised by a faculty member trained in TH. Demographic patient and visit data were collected. Residents then completed a brief survey at the end of the rotation to capture their educational experiences and recommendations for subsequent training improvement. Results: Over 12 months, 197 TH follow-up visits were performed by 12 residents. One hundred twenty-six patients (64%) were female. Top chief complaints included extremity pain (11.2%); abdominal pain (8.1%); upper respiratory infections (8.1%); lacerations (7.6%), and motor vehicle accidents (7.6%). The average number of days between the ED visit and the TH follow-up call was 5.1 days (IQR 3-6). 44.7% of patients were compliant with their discharge instructions and medications. On a Likert scale low (1) to high (10)], average patient helpfulness rating was 8.2 (IQR 7.8-10) and the average patient likelihood to recommend a TH follow-up visit was 8.5 (IQR 8-10). Ten residents completed the follow-up survey on the educational experience of the rotation (response rate 83%), of which seven described there is value to have a TH rotation in the curriculum. Thematic analysis of open-ended responses yielded constructive feedback for programmatic improvement. Conclusion: The authors propose a feasible TH training opportunity integrated into EM residency training to assist them with meeting a rapidly-growing demand for TH and prepare them for diverse job opportunities

Electrocardiogram and cardiac testing among patients in the emergency department with seizure versus syncope

Objective Cardiogenic syncope can present as a seizure. The distinction between seizure disorder and cardiogenic syncope can only be made if one considers the diagnosis. Our main objective was to identify whether patients presenting with a chief complaint (reason for visit) as seizure or syncope received an electrocardiogram in the emergency department across all age groups. Methods We conducted a secondary analysis of data collected in the 2010 to 2014 National Hospital Ambulatory Medical Care Survey comparing patients presenting with a chief complaint of syncope versus seizure to determine likelihood of getting an evaluation for possible life threatening cardiovascular disease. The primary endpoint was receiving an electrocardiogram in the emergency department; secondary endpoint was receiving cardiac biomarkers. Results There was a total of 144,094 patient encounters. Of these visits, 1,553 had syncope and 1,470 had seizure (60.3% vs. 44.2% female, 19.9% vs. 29.0% non-white). After adjusting for age, sex, mode of arrival and insurance, patients with syncope were more likely to receive an electrocardiogram compared to patients with seizure (odds ratio, 10.86; 95% confidence interval [CI], 8.52 to 13.84). This was true across all age groups (0 to 18 years, 56% vs. 7.5%; 18 to 44 years, 60% vs. 27%; 45 to 64 years, 82% vs. 41%; ≥65 years, 85% vs. 68%; P<0.01 for all). Car- diac biomarkers were also obtained more frequently in adult patients with syncope patients (18 to 44 years, 17.5% vs. 10.5%; 45 to 64 years, 33.8% vs. 21.4%; ≥65 years, 47.1% vs. 32.3%; P<0.01 for all). Conclusion Patients evaluated in the emergency department for syncope received an electrocar- diogram and cardiac biomarkers more frequently than those that had seizure

Electrocardiogram and cardiac testing among patients in the emergency department with seizure versus syncope.

OBJECTIVE: Cardiogenic syncope can present as a seizure. The distinction between seizure disorder and cardiogenic syncope can only be made if one considers the diagnosis. Our main objective was to identify whether patients presenting with a chief complaint (reason for visit) as seizure or syncope received an electrocardiogram in the emergency department across all age groups. METHODS: We conducted a secondary analysis of data collected in the 2010 to 2014 National Hospital Ambulatory Medical Care Survey comparing patients presenting with a chief complaint of syncope versus seizure to determine likelihood of getting an evaluation for possible life threatening cardiovascular disease. The primary endpoint was receiving an electrocardiogram in the emergency department; secondary endpoint was receiving cardiac biomarkers. RESULTS: There was a total of 144,094 patient encounters. Of these visits, 1,553 had syncope and 1,470 had seizure (60.3% vs. 44.2% female, 19.9% vs. 29.0% non-white). After adjusting for age, sex, mode of arrival and insurance, patients with syncope were more likely to receive an electrocardiogram compared to patients with seizure (odds ratio, 10.86; 95% confidence interval [CI], 8.52 to 13.84). This was true across all age groups (0 to 18 years, 56% vs. 7.5%; 18 to 44 years, 60% vs. 27%; 45 to 64 years, 82% vs. 41%; ≥65 years, 85% vs. 68%; P\u3c0.01 for all). Car- diac biomarkers were also obtained more frequently in adult patients with syncope patients (18 to 44 years, 17.5% vs. 10.5%; 45 to 64 years, 33.8% vs. 21.4%; ≥65 years, 47.1% vs. 32.3%; P\u3c0.01 for all). CONCLUSION: Patients evaluated in the emergency department for syncope received an electrocar- diogram and cardiac biomarkers more frequently than those that had seizure

Health benefi ts, costs, and cost-eff ectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models

Background New WHO guidelines recommend initiation of antiretroviral therapy for HIV-positive adults with CD4 counts of 500 cells per μL or less, a higher threshold than was previously recommended. Country decision makers have to decide whether to further expand eligibility for antiretroviral therapy accordingly. We aimed to assess the potential health benefi ts, costs, and cost-eff ectiveness of various eligibility criteria for adult antiretroviral therapy and expanded treatment coverage. Methods We used several independent mathematical models in four settings—South Africa (generalised epidemic, moderate antiretroviral therapy coverage), Zambia (generalised epidemic, high antiretroviral therapy coverage), India (concentrated epidemic, moderate antiretroviral therapy coverage), and Vietnam (concentrated epidemic, low antiretroviral therapy coverage)—to assess the potential health benefi ts, costs, and cost-eff ectiveness of various eligibility criteria for adult antiretroviral therapy under scenarios of existing and expanded treatment coverage, with results projected over 20 years. Analyses assessed the extension of eligibility to include individuals with CD4 counts of 500 cells per μL or less, or all HIV-positive adults, compared with the previous (2010) recommendation of initiation with CD4 counts of 350 cells per μL or less. We assessed costs from a health-system perspective, and calculated the incremental cost (in US$) per disability-adjusted life-year (DALY) averted to compare competing strategies. Strategies were regarded very cost eff ective if the cost per DALY averted was less than the country’s 2012 per-head gross domestic product (GDP; South Africa:$8040; Zambia: $1425; India:$1489; Vietnam: $1407) and cost eff ective if the cost per DALY averted was less than three times the per-head GDP. Findings In South Africa, the cost per DALY averted of extending eligibility for antiretroviral therapy to adult patients with CD4 counts of 500 cells per μL or less ranged from$237 to $1691 per DALY averted compared with 2010 guidelines. In Zambia, expansion of eligibility to adults with a CD4 count threshold of 500 cells per μL ranged from improving health outcomes while reducing costs (ie, dominating the previous guidelines) to$749 per DALY averted. In both countries results were similar for expansion of eligibility to all HIV-positive adults, and when substantially expanded treatment coverage was assumed. Expansion of treatment coverage in the general population was also cost eff ective. In India, the cost for extending eligibility to all HIV-positive adults ranged from $131 to$241 per DALY averted, and in Vietnam extending eligibility to patients with CD4 counts of 500 cells per μL or less cost $290 per DALY averted. In concentrated epidemics, expanded access for key populations was also cost eff ective. Interpretation Our estimates suggest that earlier eligibility for antiretroviral therapy is very cost eff ective in lowincome and middle-income settings, although these estimates should be revisited when more data become available. Scaling up antiretroviral therapy through earlier eligibility and expanded coverage should be considered alongside other high-priority health interventions competing for health budgets

Evidence that breast cancer risk at the 2q35 locus is mediated through IGFBP5 regulation.

GWAS have identified a breast cancer susceptibility locus on 2q35. Here we report the fine mapping of this locus using data from 101,943 subjects from 50 case-control studies. We genotype 276 SNPs using the 'iCOGS' genotyping array and impute genotypes for a further 1,284 using 1000 Genomes Project data. All but two, strongly correlated SNPs (rs4442975 G/T and rs6721996 G/A) are excluded as candidate causal variants at odds against &gt;100:1. The best functional candidate, rs4442975, is associated with oestrogen receptor positive (ER+) disease with an odds ratio (OR) in Europeans of 0.85 (95% confidence interval=0.84-0.87; P=1.7 × 10(-43)) per t-allele. This SNP flanks a transcriptional enhancer that physically interacts with the promoter of IGFBP5 (encoding insulin-like growth factor-binding protein 5) and displays allele-specific gene expression, FOXA1 binding and chromatin looping. Evidence suggests that the g-allele confers increased breast cancer susceptibility through relative downregulation of IGFBP5, a gene with known roles in breast cell biology