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Introducción: Las hospitalizaciones por Ambulatory Care Sensitive Conditions es un indicador que mide la utilización de los servicios hospitalarios por problemas de salud que podrían haber sido prevenidos en el primer nivel de atención. El concepto se refiere a los procesos en que la atención ambulatoria efectiva puede ayudar a disminuir los riesgos de hospitalización, en un segundo nivel de atención. El objetivo del estudio fue construir y validar una lista uruguaya de problemas de salud sensibles a cuidados ambulatorios (PSSCA) según CIE-10. Metodología: Para la construcción de la lista inicial de códigos de PSSCA se realizó una revisión de los listados existentes y se propuso un listado inicial que fue validado a través del Método Delphi. Se propone un listado de 99 códigos diagnósticos de PSSCA adaptado a nuestro entono sanitario. Los mismos permiten identificar y cuantificar problemas de salud que pueden producir hospitalizaciones potenciamente evitables mediante cuidados ambulatorios accesibes y oportunos en el primer nivel de atención. Resultados: Se conformó un panel de 12 expertos. A partir de los datos obtenidos, considerando los 99 diagnósticos clasificados por CIE-10, éstos se pueden subclasificar en función de si la patología es infecciosa o no, obteniendo un resultado general de 62 patologías en un total de 99 que pueden ser clasificadas como infecciosas, lo que se corresponde a un 62 %. Discusión: De la comparación de la lista uruguaya de PSSCA a la que hemos arribado y las listas validadas utilizadas para la construcción inicial del listado de patologías propuesto, podemos decir que la primera presenta un mayor porcentaje de coincidencia con la lista de patologías de Bello Horizonte. Podemos mencionar que la mayoría de los problemas de salud identificados con base en el listado de PSSCA, son sensibles de ser resueltos con la atención primaria oportuna y de calidad que podría evitar o disminuir de una manera significativa su hospitalización. Conclusiones: Este trabajo describe el proceso de construcción y validación de una lista de códigos de PSSCA adaptados al contexto uruguayo a través del método Delphi. Hemos arribado a un listado que comprende un total de 99 diagnósticos, agrupadas en un total de diecinueve categorías que considera la especificidad del contexto uruguayo del indicador.

Introduction: Hospitalizations for Ambulatory Care Sensitive Conditions is an indicator that measures the use of hospital services for health problems that could have been prevented at the first level of care. The concept refers to the processes in which effective outpatient care can help reduce the risks of hospitalization, at a second level of care. The objective of the study was to build and validate a Uruguayan list of health problems sensitive to outpatient care (PSS-CA) according to ICD-10. Methodology: To construct the initial list of PSSCA codes, a review of the existing lists was carried out and an initial list was proposed that was validated through the Delphi Method. A list of 99 PSSCA diagnostic codes adapted to our healthcare environment is proposed. They make it possible to identify and quantify health problems that can lead to potentially avoidable hospitalizations through accessible and timely outpatient care at the first level of care. Results: A panel of 12 experts was formed. From the data obtained, considering the 99 diagnoses classified by ICD-10, these can be subclassified depending on whether the pathology is infectious or not, obtaining a general result of 62 pathologies in a total of 99 that can be classified as infectious, which corresponds to 62%. Discussion: From the comparison of the Uruguayan list of PSSCA that we have arrived at and the validated lists used for the initial construction of the proposed list of pathologies, we can say that the first presents a higher percentage of coincidence with the list of pathologies of Bello Horizonte . We can mention that most of the health problems identified based on the PSSCA list are sensitive to being resolved with timely and quality primary care that could prevent or significantly reduce hospitalization. Conclusions: This work describes the process of construction and validation of a list of PSSCA codes adapted to the Uruguayan context through the Delphi method. We have arrived at a list that includes a total of 99 diagnoses, grouped into a total of nineteen categories that consider the specificity of the Uruguayan context of the indicator.

Introdução: As Internações por Condições Sensíveis à Atenção Ambulatorial são um indicador que mede a utilização de serviços hospitalares para problemas de saúde que poderiam ter sido evitados no primeiro nível de atenção. O conceito refere-se aos processos em que um atendimento ambulatorial eficaz pode auxiliar na redução dos riscos de internação, em um segundo nível de atenção. O objetivo do estudo foi construir e validar uma lista uruguaia de problemas de saúde sensíveis à atenção ambulatorial (PSS-CA) segundo a CID-10. Metodologia: Para construir a lista inicial de códigos PSSCA foi realizada uma revisão das listas existentes e foi proposta uma lista inicial que foi validada através do Método Delphi. É proposta uma lista de 99 códigos de diagnóstico PSSCA adaptados ao nosso ambiente de saúde. Permitem identificar e quantificar problemas de saúde que podem levar a hospitalizações potencialmente evitáveis ​​através de cuidados ambulatórios acessíveis e oportunos no primeiro nível de cuidados. Resultados: Foi formado um painel de 12 especialistas. A partir dos dados obtidos, considerando os 99 diagnósticos classificados pela CID-10, estes podem ser subclassificados consoante a patologia seja infecciosa ou não, obtendo-se um resultado geral de 62 patologias num total de 99 que podem ser classificadas como infecciosas, o que corresponde para 62%. Discussão: A partir da comparação da lista uruguaia de PSSCA a que chegamos e das listas validadas utilizadas para a construção inicial da lista de patologias proposta, podemos dizer que a primeira apresenta um maior percentual de coincidência com a lista de patologias de Belo Horizonte. Podemos mencionar que a maioria dos problemas de saúde identificados com base na lista PSSCA são sensíveis para serem resolvidos com cuidados primários oportunos e de qualidade que possam prevenir ou reduzir significativamente a hospitalização. Conclusões: Este trabalho descreve o processo de construção e validação de uma lista de códigos PSSCA adaptados ao contexto uruguaio através do método Delphi. Chegamos a uma lista que inclui um total de 99 diagnósticos, agrupados em um total de dezenove categorias que consideram a especificidade do contexto uruguaio do indicador.

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Objective: In this study, we assessed the usefulness of a previsit questionnaire for children who were referred for an initial evaluation in a mitochondrial subspecialty clinic. We explored the themes regarding parent's questions, concerns, and goals. We aimed to add to existing knowledge about the usefulness of previsit questionnaires in a pediatric specialty setting from the perspective of parents, the specialist, and the clinical coordinator. Method: We enrolled 25 patients and their parent(s) over 25 months. Questionnaires were completed by the parent(s), the clinical coordinator, and the mitochondrial specialist. Descriptive statistics and thematic analysis were used to summarize results. Results: Parental responses suggested that they are most concerned about their child's clinical problems, communication, language and developmental delays, disease progression and prognosis, understanding mitochondrial disease, quality of life, and physical challenges including muscle and energy problems. Parents felt the previsit questionnaire was very helpful for both the doctor and for themselves to be prepared for their visit. The specialist and the clinical coordinator also found it to be helpful. Parental comments suggested that they felt that writing down the story of their child's life was helpful for the provider, allowed time for reflection, and improved the appointment experience. Some felt it was a difficult or redundant activity. Conclusion: Parents were often pleased to complete the previsit questionnaire. This allowed them to highlight concerns and share information that they wanted the care team to know about their child. We revised the tool based on feedback from parents and the specialist and will continue to use it in our clinic.

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BACKGROUND: Fragmentation of care (that is, the use of multiple ambulatory providers without a dominant provider) may increase the risk of gaps in communication among providers. However, it is unclear whether people with fragmented care (as measured in claims) perceive more gaps in communication among their providers. It is also unclear whether people who perceive gaps in communication experience them as clinically significant (that is, whether they experience adverse events that they attribute to poor coordination). METHODS: We conducted a longitudinal study using data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, including a survey on perceptions of healthcare (2017-2018) and linked fee-for-service Medicare claims (for the 12 months prior to the survey) (N = 4,296). We estimated correlation coefficients to determine associations between claims-based and self-reported numbers of ambulatory visits and ambulatory providers. We then used logistic regression to determine associations between claims-based fragmentation (measured with the reversed Bice-Boxerman Index [rBBI]) and self-reported gaps in care coordination and, separately, between claims-based fragmentation and self-reported adverse events that the respondent attributed to poor coordination. RESULTS: The correlation coefficient between claims-based and self-report was 0.37 for the number of visits and 0.38 for the number of providers (p < 0.0001 for each). Individuals with high fragmentation by claims (rBBI ≥ 0.85) had a 23% increased adjusted odds of reporting any gap in care coordination (95% CI 3%, 48%) and, separately, a 61% increased adjusted odds of reporting an adverse event that they attributed to poor coordination (95% CI 11%, 134%). CONCLUSIONS: Medicare beneficiaries with claims-based fragmentation also report gaps in communication among their providers. Moreover, these gaps appear to be clinically significant, with beneficiaries reporting adverse events that they attribute to poor coordination.

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BACKGROUND: This study describes how New York City (NYC) Health + Hospitals implemented a large-scale Community Health Worker (CHW) program in adult primary care clinics between January 2022 and December 2023 and established metrics to monitor program implementation. This study is timely as healthcare systems consider how to scale high-quality CHW programs. METHODS: We collected metrics in the following areas: (1) Workforce demographics, team structure, and training; (2) Enrolled patient demographics; (3) Patient-centered metrics, such as patient counts (e.g. patients outreached and enrolled) and engagement (e.g. median time in program, caseloads per CHW), and goals (e.g. median number of goals identified and completed). Metrics are based on standard data elements captured through CHW documentation in the electronic health record collected during program implementation. Data cleaning is completed using SQL queries and R scripts. RESULTS: In June 2023, there were a total of 97 CHW and 22 CHW Supervisor staff lines in adult primary care across 17 healthcare sites. There were 4.6 CHWs to 1 CHW supervisor on average though this ranged by facility from 1:1 to 1:6. Compared to the population that receives primary care at NYC H + H, CHWs served more African American/Black patients (40% vs. 32%) and an older patient population (35% older than 65 vs. 21% older than 65). From January 2022 to December 2023, 13,812 patients were outreached by CHWs. Of these, 9,069 (66%) were referred by clinicians, 7,331 (53%) were enrolled, and 5,044 (37%) successfully graduated. The median number of goals identified by patients was four, and the median number of goals completed with a CHW per patient was three. The top three goals were primary care engagement (47%), specialty care engagement (46%), and food insecurity (45%). CONCLUSION: Establishing clear implementation and process metrics helps to ensure that CHWs embedded in health systems can meaningfully engage adult patients in health care, address patient-centered goals, and connect patients to community and government services.

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Risk stratification of patients with acute pulmonary embolism (PE) assists with the selection of appropriate initial therapy and treatment setting. Patients with acute symptomatic PE that present with arterial hypotension or shock have a high risk of death, and treatment guidelines recommend strong consideration of reperfusion in this setting. For haemodynamically stable patients with PE, the combination of a negative clinical prognostic score and the absence of computed tomography-assessed right ventricle enlargement may accurately identify those at low-risk of short-term complications after the diagnosis of PE, and such patients might benefit from an abbreviated hospital stay or outpatient therapy. Some evidence suggests that the accumulation of factors indicating worse outcomes from PE on standard anticoagulation identifies the more severe stable patients with acute PE who might benefit from intensive monitoring and recanalization procedures, particularly if haemodynamic deterioration occurs. Current risk classifications have several shortcomings that might adversely affect clinical and healthcare decisions. Ongoing initiatives aim to address many of those shortcomings, and will hopefully help optimize risk stratification algorithms and treatment strategies.

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Introduction: The COVID-19 pandemic necessitated a major expansion in telemedicine use. The continued use of telemedicine post-pandemic has the potential to enhance healthcare use for people at risk for sub-optimal healthcare access and utilization, such as patients with previous preventable hospitalization. This study analyzed the association between pre-pandemic preventable hospitalizations (PPHs) and telemedicine use during the pandemic. Methods: This retrospective cohort study uses Medicaid administrative claims data (01/2018-06/2022) for patients of a large Federally Qualified Health Center in Arizona that implemented telemedicine in March 2020. Bivariate and multivariable generalized estimating equations were used to analyze the relationship between the outcome and predictor variables. We also analyze racial/ethnic and primary language disparities in telemedicine use among those with PPH and report the average predicted probability. Results: There was a statistically significant relationship between telemedicine use and PPH even after adjusting for comorbidity severity (OR:1.85; CI: 1.74, 1.96). Analyses restricted to those who had PPHs showed an seven-percentage point difference in the predicted probability of telemedicine use between non-Hispanic White individuals and Asian/Pacific Islanders, the group with the lowest probability of telemedicine use among our study sample. Conclusion: Telemedicine is a unique tool that can be leveraged by interventions that aim to optimize healthcare use among those with a history of preventable hospitalizations. However, the lack of targeted interventions to identify and address barriers to telemedicine use among minoritized groups could limit the impact of such interventions and widen disparities.

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BACKGROUND: Pharmacists provide increased access to care, vaccinations, and medication management for patients. Credentialing and privileging of pharmacists allows pharmacists to practice at the top of their licenses and elevate pharmacy practice. OBJECTIVE: The primary objective of this study was to assess the perception of healthcare team members of credentialed and privileged pharmacists working in a pediatric primary care network before and after implementation of pharmacist privileges. The secondary objective was to determine team members' perceptions on the amount of time spent refilling medications, resolving medication access issues, and ordering vaccines before and after implementation of pharmacist privileges. METHODS: This was a prospective pre-post study utilizing surveys to capture healthcare team members' perceptions of credentialed and privileged ambulatory care pharmacists. Surveyed participants included attending physicians, advanced practice nurses, registered nurses, licensed practical nurses, medical assistants, and patient care assistants. Summary statistics are reported as frequencies and percentages. Statistical analysis was conducted using SAS version 9.4. RESULTS: Fifty-eight pre-privileging and 56 post-privileging surveys were distributed. The return rate was 79.3% (n=46) for pre-privileging and 80.4% (n=45) for post-privileging surveys. More than 90% of respondents had a favorable perception of credentialed and privileged pharmacists in the clinic. There was a significant difference in the perception of the amount of time spent on medication access issues after pharmacist privileges were implemented (p = 0.0296). CONCLUSION: Credentialed and privileged pharmacists in a pediatric primary care network are viewed favorably by clinic team members and can have a positive impact on clinic workload.

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Background: Length of stay is one of the metrics of crowding in the emergency department. Identification of the factors associated with prolonged length of stay is vital for staffing and policy making to prevent overcrowding at the ambulatory care unit. Objective: This study aimed to determine the association of sociodemographic, clinical, and temporal factors with length of stay among patients seen at the ambulatory care unit of a tertiary government training hospital. Methods: A retrospective case-control study was conducted between January to December 2019 at the ambulatory care unit of a tertiary government hospital. Charts of patients who stayed for more than six (6) hours were classified as cases, while those who stayed for more than two (2) hours up to six (6) hours were classified as controls. Charts were reviewed to obtain the clinicodemographic profile of patients who satisfied the inclusion criteria. Results: The case group consisted of 86 patients, while the control group consisted of 172 patients. Eight factors had an effect on the probability of prolonged length of stay at the ambulatory care unit: age 40-59 years old (OR = 2.29, 95% CI: 1.16-4.49), ESI 3 at triage level (OR = 3.35, 95% CI: 1.50-8.38), psychiatric complaint (OR = 6.97, 95% CI: 2.53-19.21), medications given and diagnostics done (OR = 2.16, 95% CI: 1.16-3.99), medications given/diagnostics/referral to other services done (OR = 7.67, 95% CI: 2.70-21.80), psychiatric/substance-related case (OR = 6.97, 95% CI: 2.63-18.49), transferred to other services (OR = 3.25, 95% CI: 1.33-7.94), and endorsed to next shift (OR = 6.94, 95% CI = 3.90-12.35). Conclusion: The factors associated with prolonged length of stay were middle-aged adults, conditions with severe presentation, psychiatric/substance-use-related cases, need for more diagnostic test and treatment intervention, and decision to transfer care to other services.

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BACKGROUND: Diabetes is a multifactorial disease state that requires adequate patient monitoring for improved health outcomes. Diabetes knowledge and attitude, and associated factors such as medication adherence, medication discrepancy, health literacy, and glycemic control were evaluated in this study. The selected factors were also compared with diabetes knowledge and attitude. METHODS: A cross-sectional study was carried out among ambulatory diabetes patients in three tertiary healthcare facilities in Nigeria. An interviewer-administered semi-structured questionnaire was utilized for data collection. Data was analysed using descriptive and inferential statistics with the level of significance set at p < 0.05. RESULTS: A total of 188 diabetes patients participated in the study; 51 (27.1%) at the Federal Medical Center, Abeokuta, 69 (36.7%) at the University College Hospital, Ibadan, and 68 (36.2%) at the University of Ilorin Teaching Hospital, Ilorin. One hundred and twelve (59.6%) female patients participated in the study and patients' average age was 58.69 ± 13.68 years. Medication discrepancy was observed among 101 (53.7%) patients. One hundred and three (54.8%), 47 (25.0%) and 38 (20.2%) had high, medium, and low medication adherence, respectively. Ninety-one (48.4%) had high health literacy. Mean diabetes knowledge score was 14.64 ± 2.55 points out of a maximum obtainable score of 18 points. Mean diabetes attitude of patients was 62.50 ± 6.86 points out of a maximum obtainable score of 70 points. Significant positive association was observed between diabetes knowledge and health literacy (Beta = 0.021, p = 0.029). Diabetes knowledge was higher in patients with higher level of formal education (p = 0.046), higher diabetes attitude (p < 0.001) and high health literacy (p = 0.002). Patients' diabetes attitude was higher in individuals older than 60 years of age (p = 0.029), and those with high health literacy (p = 0.005). CONCLUSIONS: The diabetes patients displayed good disease knowledge, attitude and medication adherence. Average levels of health literacy and medication discrepancy was observed among the patients. Significant differences were observed between patients' diabetes knowledge and level of formal education, diabetes attitude, health literacy and age. Patients' health literacy was significantly associated with diabetes knowledge.

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BACKGROUND: The use of technologies has had a significant impact on patient safety and the quality of care and has increased globally. In the literature, it has been reported that people die annually due to adverse events (AEs), and various methods exist for investigating and measuring AEs. However, some methods have a limited scope, data extraction, and the need for data standardization. In Brazil, there are few studies on the application of trigger tools, and this study is the first to create automated triggers in ambulatory care. OBJECTIVE: This study aims to develop a machine learning (ML)-based automated trigger for outpatient health care settings in Brazil. METHODS: A mixed methods research will be conducted within a design thinking framework and the principles will be applied in creating the automated triggers, following the stages of (1) empathize and define the problem, involving observations and inquiries to comprehend both the user and the challenge at hand; (2) ideation, where various solutions to the problem are generated; (3) prototyping, involving the construction of a minimal representation of the best solutions; (4) testing, where user feedback is obtained to refine the solution; and (5) implementation, where the refined solution is tested, changes are assessed, and scaling is considered. Furthermore, ML methods will be adopted to develop automated triggers, tailored to the local context in collaboration with an expert in the field. RESULTS: This protocol describes a research study in its preliminary stages, prior to any data gathering and analysis. The study was approved by the members of the organizations within the institution in January 2024 and by the ethics board of the University of São Paulo and the institution where the study will take place. in May 2024. As of June 2024, stage 1 commenced with data gathering for qualitative research. A separate paper focused on explaining the method of ML will be considered after the outcomes of stages 1 and 2 in this study. CONCLUSIONS: After the development of automated triggers in the outpatient setting, it will be possible to prevent and identify potential risks of AEs more promptly, providing valuable information. This technological innovation not only promotes advances in clinical practice but also contributes to the dissemination of techniques and knowledge related to patient safety. Additionally, health care professionals can adopt evidence-based preventive measures, reducing costs associated with AEs and hospital readmissions, enhancing productivity in outpatient care, and contributing to the safety, quality, and effectiveness of care provided. Additionally, in the future, if the outcome is successful, there is the potential to apply it in all units, as planned by the institutional organization. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/55466.

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BACKGROUND: Up to 30% of patients with knee osteoarthritis (KOA) have evidence of sensitization, with a similar proportion experiencing severe pain during procedures. Most patients with KOA are elderly and often develop side effects from intravenous sedation. Our study investigated the effectiveness of a methoxyflurane inhaler combined with local anesthesia in reducing procedural pain from genicular nerve block compared with local anesthesia alone. METHODS: 42 adults with refractory KOA were randomized into two groups. Methoxyflurane group received a self-titrated methoxyflurane inhaler with local anesthesia whereas lidocaine group received local anesthesia only. The primary outcome was pain score on a 0-10 verbal numerical rating scale (VNRS) during the procedure. Secondary outcomes included changes in VNRS and behavioral pain scale (critical care pain observational tool) during the procedure, hemodynamic changes, anxiety level, sedation score, and adverse events. RESULTS: 42 patients with a mean age of 66±12 years participated in this study. There were no significant baseline differences. During the procedure, the methoxyflurane group experienced a significantly greater VNRS pain reduction from baseline (2 (1, 4) vs -1 (-2, 0); p<0.01) and greater VNRS reduction over time (p=0.01) compared with the lidocaine group, with a higher sedation score (p<0.01). Immediately postprocedure, anxiety levels were lower in the methoxyflurane group compared with the lidocaine group (median State-Trait Anxiety Inventory score 21 (IQR 20, 24) vs 27 (23, 29); p=0.02), but the median reduction in anxiety level was not significant (6 (1, 12) vs 5 (0, 14); p=0.61). There were no differences in behavioral pain scores, hemodynamic parameters, recovery or discharge times, and adverse effects between the two groups. CONCLUSION: A methoxyflurane inhaler combined with local anesthesia provided better procedural pain control than local anesthesia alone with no observable differences in adverse effects. Future studies evaluating the impact of a methoxyflurane inhaler on different types of painful procedures are warranted.

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OBJECTIVE: To describe presenting diagnoses and rates and causes of death by age category and sex among children with acute illness brought to a district headquarter hospital in Pakistan. DESIGN: Prospective cohort study. SETTING: Sanghar district headquarter hospital, Sindh, Pakistan between December 2019 and April 2020 and August 2020 and December 2020. PARTICIPANTS: 3850 children 0-14 years presenting with acute illness to the emergency and outpatient departments and 1286 children admitted to the inpatient department. OUTCOME MEASURES: The primary outcome was Global Burden of Disease diagnosis category. Secondary outcomes were 28-day mortality rate, cause of death and healthcare delays, defined as delay in care-seeking, delay in reaching the healthcare facility and delay in appropriate treatment. RESULTS: Communicable diseases were the most common presenting diagnoses among outpatients and among inpatients aged 1 month to 9 years. Non-communicable diseases and nutritional disorders were more common with increasing age. Few children presented with injuries. Newborn period (age <28 days) was associated with increased odds of death (OR 4.34 [95% CI 2.38 to 8.18], p<0.001, reference age 28 days-14 years) and there was no significant difference in odds of death between female vs male children (OR 1.12, 95% CI 0.6 to 2.04, p=0.72). 47 children died in the hospital (3.6%) and three (0.2%) died within 28 days of admission. Most children who died were <28 days old (n=32/50, 64%); leading diagnoses included neonatal sepsis/meningitis (n=13/50, 26%), neonatal encephalopathy (n=7/50, 14%) and lower respiratory tract infections (n=6/50, 12%). Delays in care-seeking (n=15) and in receiving appropriate treatment (n=12) were common. CONCLUSION: This study adds to sparse literature surrounding the epidemiology of disease and hospital outcomes for children with acute illness seeking healthcare in rural Pakistan and, in particular, among children aged 5-14 years. Further studies should include public and private hospitals within a single region to comprehensively describe patterns of care-seeking and interfacility transfer in district health systems.

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BACKGROUND: Tuberculosis (TB) infectiousness decreases significantly with only a few days of treatment, but delayed diagnosis often leads to late treatment initiation. We conducted a sequential explanatory mixed methods study to understand the barriers and facilitators to prompt diagnosis among people with TB. METHODS: We enrolled 100 adults who started TB treatment in the Carabayllo district of Lima, Peru, between November 2020 and February 2022 and administered a survey about their symptoms and healthcare encounters. We calculated total diagnostic delay as time from symptom onset to diagnosis. We conducted semi-structured interviews of 26 participants who had a range of delays investigating their experience navigating the health system. Interview transcripts were inductively coded for concepts related to diagnostic barriers and facilitators. RESULTS: Overall, 38% of participants sought care first from public facilities and 42% from the private sector. Only 14% reported being diagnosed with TB on their first visit, and participants visited a median of 3 (interquartile range [IQR] health facilities before diagnosis. The median total diagnostic delay was 9 weeks (interquartile range [IQR] 4-22), with a median of 4 weeks (IQR 0-9) before contact with the health system and of 3 weeks (IQR 0-9) after. Barriers to prompt diagnosis included participants attributing their symptoms to an alternative cause or having misconceptions about TB, and leading them to postpone seeking care. Once connected to care, variations in clinical management, health facility resource limitations, and lack of formal referral processes contributed to the need for multiple healthcare visits before obtaining a diagnosis. Facilitators to prompt diagnosis included knowing someone with TB, supportive friends and family, referral documents, and seeing a pulmonologist. CONCLUSIONS: Misinformation about TB among people with TB and providers, poor accessibility of health services, and the need for multiple encounters to obtain diagnostic tests were major factors leading to delays. Extending the hours of operation of public health facilities, improving community awareness and provider training, and creating a formal referral process between the public and private sectors should be priorities in the efforts to combat TB.

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Background: Respiratory syncytial virus (RSV) is the leading cause of lower-respiratory-tract infection in children. Nirsevimab, a monoclonal antibody against RSV, was implemented in a few countries in September 2023. However, its post-license effectiveness in ambulatory care settings is unknown. We aimed to assess the effectiveness of nirsevimab against RSV-bronchiolitis in outpatients aged <12 months. Methods: We conducted a test-negative case-control study based on a national ambulatory surveillance system. We included all infants aged <12 months who had bronchiolitis and results of an RSV rapid antigen test performed, visiting a network of 107 ambulatory paediatricians from September 15, 2023, to February 1, 2024. Case patients were infants with bronchiolitis and a rapid antigen test positive for RSV. Control patients were infants with bronchiolitis and a rapid antigen test negative for RSV. Effectiveness was assessed by a logistic regression model adjusted for potential confounders. A range of sensitivity analyses were conducted to assess the robustness of the findings. Findings: We included 883 outpatients who had bronchiolitis and results of an RSV rapid antigen test (453 were case patients, and 430 were control patients). Overall, 62/453 (13.7%) case patients and 177/430 (41.2%) control patients had been previously immunised for nirsevimab. The adjusted effectiveness of nirsevimab against RSV-bronchiolitis was 79.7% (95% CI 67.7-87.3). Sensitivity analyses gave similar results. Interpretation: This post-license study indicates that nirsevimab was effective in preventing RSV-bronchiolitis in ambulatory care settings. Funding: The study was supported by Association Clinique et Thérapeutique Infantile du Val de Marne (ACTIV), French Pediatrician Ambulatory Association (AFPA) and unrestricted grants from GSK, MSD, Pfizer and Sanofi.

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The association between depression and ambulatory care utilization is unclear. The authors sought to determine the association between untreated depression and ambulatory care utilization, including the extent to which care is fragmented, or spread across providers. The authors conducted a longitudinal study using data from the nationwide REasons for Geographic and Racial Differences in Stroke study linked to Medicare fee-for-service claims (N = 1412). They categorized participants into three study groups, based on self-reported depressive symptoms (Center for Epidemiological Studies Depression Scale score ≥ 4) and a medication inventory for antidepressants: Symptomatic Untreated (SU), Symptomatic Treated (ST), and Asymptomatic Treated (AT). The authors used descriptive statistics to characterize ambulatory care patterns by study group. They determined the association between the study group and fragmentation score (with high fragmentation defined as a reversed Bice-Boxerman Index ≥ 0.85) using multivariable logistic regression. All groups had similar numbers of primary care visits, but the SU group had the fewest specialist visits. The SU group had the lowest proportion of participants who received care from a psychiatrist (3.4% vs. 10.7% for ST and 11.9% for AT, pairwise P-values < 0.001). The SU group was the least likely to have highly fragmented care (adjusted odds ratio 0.68; 95% confidence interval 0.48, 0.95, compared with the ST group). These results suggest that older adults with untreated depression are not engaged in excess care-seeking behaviors. Rather, the results suggest undertreatment of depression in primary care and underutilization of psychiatric care.

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BACKGROUND: Healthcare in Germany is not always needs-based and has considerable potential for optimization. Internal medicine (IM) plays a special role in the German healthcare system due to its long tradition. Against this background, a look at the optimization potential to achieve better quality and higher efficiency care seems particularly relevant. OBJECTIVE: Based on an international comparison and taking ambulatory care-sensitive conditions (ACSC) into account, this study aims to identify the steering potential in IM and to discuss it in the context of current reform plans. MATERIAL AND METHODS: The descriptive analysis was carried out as part of a report commissioned by the German Society of Internal Medicine and is based on data from the Federal Statistical Office and Eurostat as well as the ACSC catalogue developed for Germany. RESULTS: The top 10 reasons for inpatient treatment in IM include 7 ACSCs. These diagnoses account for almost one quarter of cases and treatment days and mostly relate to cardiology. The international comparison including numerous other indications shows that other countries have both significantly fewer cases and shorter lengths of stay for most indications. CONCLUSION: The results show that IM in Germany has considerable potential for optimization of inpatient care. In light of the regional variation in service providers and utilization as well as the potential for avoiding inpatient treatment, the current reform plans represent an opportunity for the reorientation of IM. Not least because of its high relevance, also in terms of numbers, it is therefore right and important that it is given such strong consideration within the reform plans.

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Knowing the prevalence of potentially avoidable hospitalizations (PAHs) and the factors associated with them is essential if preventive action is to be taken. Studies on PAHs mainly concern adults, and very few have been carried out in South America. To the best of our knowledge, there has been no study on PAHs in French Guiana, particularly among older adults. This case-control study aimed to estimate the prevalence of PAHs in the Guianese population aged over 65 and to analyze their associated factors. We used the 2017-2019 data from the French National Health Service database (Système National des Données de Santé). The patients were age- and sex-matched 1 : 3 with controls without any PAH in 2019. Factors associated with PAHs were investigated through two conditional logistic regression models [one including the Charlson comorbidity index (CCI) and one including each comorbidity of the CCI], with calculation of the adjusted odds ratio (aOR) and 95% confidence interval (CI). The PAH incidence was 17.4 per 1000 inhabitants. PAHs represented 6.6% of all hospitalizations (45.6% related to congestive heart failure or hypertension). A higher CCI was associated with PAHs [aOR 2.2 (95% CI: 1.6, 3.0) and aOR 4.8 (95% CI: 2.4, 9.9) for 1-2 and ≥3 comorbidities, respectively, versus 0], as was immigrant health insurance status [aOR 2.3 (95% CI: 1.3, 4.2)]. Connective tissue disease, chronic pulmonary disease, congestive heart failure, diabetes, and peripheral vascular disease were comorbidities associated with an increased risk of PAHs. While the prevention of PAHs among immigrants is probably beyond the reach of the Guianese authorities, primary care and a public health policy geared toward prevention should be put in place for the French Guianese population suffering from cardiovascular disease in order to reduce PAHs.

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BACKGROUND: Estimate the costs of inpatient and outpatient care for people with Cerebral Palsy (CP) in Brazil. RESEARCH DESIGN AND METHODS: Health records of people with CP in the Hospital and Outpatient Information Systems of Brazil between 2015 and 2019 were analyzed. Variables analyzed were gender, age, ICD, Intensive Care Unit (ICU) use, total cost, and ICU cost. Costs were adjusted for inflation and converted to dollars. Linear regression analysis was performed to investigate the association between social and clinical variables and direct costs. RESULTS: A total direct cost of approximately $166 million to the National Health System was identified, with $7.08 million/year and $26.1 million/year of inpatient and outpatient costs, respectively. The healthcare was primarily for children up to 14 years of age. The ICD 'spastic quadriplegic CP' received the most attendance. Rehabilitation was responsible for 75% of the outpatient care, with physiotherapy standing out. Increased age, use of ICU, and the types of CP are related to increased cost. CONCLUSIONS: Healthcare for people with CP produced expressive costs for the Brazilian public health system, mainly with outpatient procedures and rehabilitation, with children being the most attended. Estimating these costs assist in better resource allocation for more effective healthcare provision.

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BACKGROUND: Understanding the epidemiological patterns of febrile infants can offer valuable insights for optimising management strategies and developing quality improvement initiatives, aiming to improve healthcare delivery in high-volume, low-resource emergency departments (EDs). OBJECTIVES: To characterise the epidemiology of febrile infants presenting to the paediatric ED of a tertiary care hospital. METHODS: A retrospective chart review of medical records was performed for febrile infants ≤1 year old, at paediatric ED, Indus Hospital and Health Network (IHHN), Karachi, Pakistan (1 January 2020-31 December 2020). RESULTS: There were a total of 2311 patients in the study, with a male-to-female ratio of 1.4:1. The mean age of presentation was 4.9±2.7 months. Cough (n=1002, 43.2%) was the most frequent presenting symptom. The most common provisional ED diagnosis in ≤1 month of age was sepsis (n=98, 51%), bronchopneumonia (n=138, 28.6%) in 1.1-3 and 3.1-6 months (n=176, 36.45%); and upper respiratory tract illness (n=206, 47.4%) in 6.1-12 months of age. Age was significantly associated with provisional ED diagnosis and outcomes (p<0.001). Of 175 ED admissions (n=47, 26.8%), patients were discharged with a hospital diagnosis of bronchopneumonia and (n=27, 15.4) of sepsis. The infant mortality rate was 3/1000 live births. CONCLUSIONS: This study is the first of its kind to explore the epidemiology of febrile infants in Pakistan, highlighting the burden and severity of respiratory illnesses and sepsis. It underscores the challenges of resource-limited settings, failing to meet the need for admission of febrile infants presenting to ED, IHHN. Moreover, it has highlighted the necessity to optimise the existing triage systems to effectively allocate resources and manage high patient volumes in low-resource EDs.

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During the COVID-19 pandemic, the federal government and many state governments instituted expanded coverage for telehealth (TH) services and since have maintained it. Using data from the Minnesota All Payer Claims Database and publicly available data sources, we examined TH use among commercially insured and Medicare Advantage (MA) patients in Minnesota. In 2022, 30.4% of commercially insured patients and 24.4% of MA patients used TH services. Living in a metropolitan area, an area with a high proportion of Black, Indigenous, and People of Color residents, having greater disease burden, and being younger were associated with a greater likelihood of using TH. Living in an area with limited broadband access reduced the likelihood of TH use. Two patient subgroups more likely to use TH-younger patients in metropolitan areas and high-risk patients with depression-received a similar proportion of ambulatory visits via TH.