Use of interactive messaging to reduce pre-diagnosis loss to follow-up for TB care

OBJECTIVE: To investigate the uptake and usage of a WhatsApp-based interactive communication strategy to avert pre-diagnosis loss to follow-up (LTFU) from TB care in a high-incidence setting.METHODS: We enrolled adults (≥18 years) who underwent routine sputum TB testing in two primary healthcare clinics in Khayelitsha, Cape Town, South Africa. The intervention consisted of structured WhatsApp-based reminders (prompts) sent prior to a routine clinic appointment scheduled 2–3 days after the diagnostic visit. Pre-diagnosis LTFU was defined as failure to return for the scheduled appointment and within 10 days.RESULTS: We approached 332 adults with presumptive TB, of whom 103 (31%) were successfully enrolled; 213 (64%) did not own a WhatsApp-compatible phone. Of 103 participants, 74 (72%) actively responded to WhatsApp prompts; 69 (67%) opted to include a close contact in group communication to co-receive reminders. Pre-diagnosis LTFU was low overall (n = 7, 6.8%) and was not associated with failure to respond to WhatsApp prompts.CONCLUSION: In this high-incidence setting, enrolment in a WhatsApp-based communication intervention among adults with presumptive TB was low, mainly due to low availability of WhatsApp-compatible phones. Among participants, we observed high message response rates and low LTFU, suggesting potential for interactive messaging services to support pre-diagnosis TB care.

Acceptability, Effect and Cost of Mobile-Health on Art Adherence and Assessment of Covid-19 Knowledge Among Youths: A Mixed Methods Sequential Study in Kiryandongo. A Study Protocol Youth Trial

Background: AIDS is the leading cause of death among young people in sub-Saharan Africa. Adherence to antiretroviral therapy is the principal determinant for achieving and sustaining viral suppression, which decreases progression to AIDS and reduces risk of mortality. Few studies have evaluated mHealth adherence tools among youths in resource-limited settings.We aim to evaluate whethermHealth tool improves ART adherence outcomes among youth receiving ART at a rural district in Western Uganda. The Corona virus disease outbreak was announced a Public Health Emergency of International concern on Jan 2020; and declared a global pandemic by World Health Organization on Mar, 2020.In rural areas, there is little data on knowledge and myths on COVID among youths.General objective:To assessacceptability, effect and cost of themHealth tool on ART adherence, knowledge and myths on COVID-19among youth initiating and on ART at KiryandongoDistrict.Methods: This is a mixed methodsequential exploratory study, with the qualitative study conducted first followed by a randomized control trial and healthcare cost evaluation.The qualitative study will assess barriers, enablers of adherence and acceptability of mHealth among youths receiving care at three health facilities inKiryandongo District.The randomized control trial of 206 youth initiatingARTto either Standard of Care or mHealth tool plus Standard of care to assesseffect of mHealth tool on ART adherence and retention in care. Through a basic cell phone, participants in the intervention arm will receive pill reminders, clinic appointment reminders, health voice messages and self-reported symptoms in addition to standard of care. Collection of data on knowledge and myths on COVID-19, HIV and sexual behavior. The health care evaluationnested within randomized trial, will assess the cost of interventionin comparison to Standard of care.Discussion: This project will determine acceptability, effectiveness of mHealth, knowledge & myths on COVID-19and cost of delivering pill and clinic appointment reminders, and voice messages to a population with suboptimal ART adherence in a resource-limited setting.Trial registration: Fully registered under clinicaltrials.gov by 20th Jan 2021. The study is ongoing. Recruitment started Aug 2020.Clinical Trial registration: NCT 04718974

A Quality Improvement Project to Implement Choking Prevention and First Aid Education in Prader–Willi Syndrome Caregivers

Prader–Willi syndrome (PWS) is a complex neurodevelopmental genetic disorder characterized by hypotonia and hyperphagia. Consequently, individuals with PWS are at high risk of choking, and choking is a leading cause of morbidity and mortality. The aim of this quality improvement (QI) project is to provide choking prevention and first aid education from 0% to 80% of PWS caregivers seen in a multidisciplinary PWS clinic, and to assess the effectiveness of this education program. A QI initiative was developed to standardize and implement choking prevention and first aid education for PWS caregivers. Using a Likert scale, pre- and post-education assessments were conducted to measure caregiver (1) awareness of the PWS choking risk, (2) self-reported knowledge of choking prevention strategies, and (3) comfort in providing choking first aid. The American Heart Association Family and Friends® CPR (Dallas, TX, USA) curriculum was utilized. Education was provided during a regularly scheduled PWS clinic appointment. At project conclusion, 45/52 (87%) of PWS caregivers received education. A post-education assessment revealed an improvement in PWS caregivers’ awareness of choking risk, self-reported knowledge of choking prevention strategies, and comfort in providing choking first aid. This QI project supports a practice change to implement choking prevention and first aid education as standard process within our PWS clinic.

P071 Listening to Beyoncé: factors associated with non-attendance at an outpatient sleep clinic

Introduction Patient non-attendance at outpatient sleep clinics is common and costly. Little is known about the factors associated with sleep clinic non-attendance, especially in an Australian context. The goal of our audit was to identify the patient, referral, and appointment factors that may affect attendance at an outpatient sleep clinic. Methods A case-control study was performed in 171 patients (57 cases / non-attenders and 114 controls / attenders) who had a sleep clinic appointment between September 20th, 2020 and March 21st, 2021. Statistical analysis was performed using the two-sided chi-square test with a 5% significance level. Results The overall rate of non-attendance was 10.8%. The rates of non-attendance between new and review cases were similar. Being single (odds ratio [OR]: 2.49; p = 0.010), middle-aged (OR: 4.39; p < 0.001 vs. older-aged), or female (OR: 2.08; p = 0.026) was associated with a higher rate of non-attendance. English was the primary language for all non-attenders. A higher proportion of non-attenders than attenders were born in Australia. For new cases, the source of referral, reason for referral, and triage category did not affect attendance rates. Likewise, the patient’s primary sleep disorder and treatment status did not affect attendance for review cases. Conclusion Factors associated with non-attendance at an outpatient sleep clinic include being single, middle-aged, or female. By identifying patients at higher risk of clinic non-attendance, a more tailored approach can be developed to mitigate this issue.

Waitlist management in a pediatric weight management clinic: implementing an orientation session

Background This study evaluates implementation of an orientation session to address a waitlist of more than 2000 referrals to a pediatric weight management clinic in the Mid-South United States. Methods An hour-long group-based orientation to the pediatric weight management clinic was implemented to provide information about the structure and expectations of the clinic as well as education on healthy lifestyle recommendations. Families were contacted from the waitlist by telephone and invited to attend an orientation session prior to scheduling a clinic appointment. Results Of 2251 patients contacted from the waitlist, 768 scheduled an orientation session, of which 264 (34 %) attended. Of the 264 orientation participants, 246 (93 %) scheduled a clinic appointment. Of those, 193 (79 %) completed a clinic visit. Waitlist times decreased from 297.8 ± 219.4 days prior to implementation of orientation sessions to 104.1 ± 219.4 days after. Conclusions Orientation has been an effective and efficient way to triage patient referrals while maximizing attendance in limited clinic slots for patients and families demonstrating interest and motivation. Elements of this approach are likely generalizable to other pediatric clinical settings that must strategically manage a large volume of patient referrals.

Psychological burden of anaphylaxis and the fight for an EpiPen

A university student with a background of atopy presented to her general practitioner (GP) 2 weeks following an episode of throat tightening and dizziness occurring after touching cashew nut to her lip. She took antihistamine medication immediately and went to sleep, fearing for her life. On waking, she felt astounded to be alive. Her symptoms resolved gradually over the following week. She waited 2 weeks for an appointment with her GP, who referred her to allergy clinic. Eight months later, she was still waiting for her clinic appointment, and was left fearing a future fatal reaction, having been provided with no interim treatment. Not all patients who have severe allergic reactions present to the emergency department. Living with the constant fear of anaphylaxis can be overwhelming for patients and their families, and it can negatively impact mental health. Therefore, we advise early allergy counselling and early EpiPen prescription.

1424 Enhanced Consent in Endocrine Surgery in The Era Of COVID-19

Aim Informed consent is the process by which surgeon and patient agree to undergo a procedure after the risk, benefits and alternative treatments have been discussed. The current COVID-19 pandemic provides unique challenges to the consent process such as the uncertain risk of acquiring the virus and the impact of a second peak on the health services. The aim of this audit was to use an enhanced consent tool to inform patients of specific risks associated with surgery during the pandemic. Method At the beginning of the pandemic, elective operating was postponed - these patients were added to a COVID-19 database. With the resumption of services, all patients had a telephone clinic appointment with a 2-fold aim: 1) to ensure they wanted to remain on the waiting list and 2) to discuss consent specifically with regard to COVID-19 using an enhanced consent tool. Results Over a 6-week period, 79 patients were contacted. All patients were awaiting thyroid, parathyroid and adrenal operations. Of the 79 patients contacted, 77 (97%) agreed to remain on the waiting list after discussing the risks using the enhanced consent tool. The remaining 2 patients asked for their operations to be delayed. To date, none of our patients have acquired COVID-19 upon the resumption of services. Conclusions Despite the uncertain risks of COVID-19, the majority of patients requiring endocrine surgery were happy to proceed. Ongoing review of available literature concerning preoperative risk and COVID-19 is essential for clinicians involved in the consent process. The use of an enhanced consent tool standardised the consent process and enabled patients to make an informed decision concerning their care.

Associations of Telemedicine vs. In-Person Ambulatory Care Visits on Cancellation Rates and 30-Day Follow-Up Hospitalizations and Emergency Department Visits

Importance: Studies have shown that telemedicine use in specific conditions can promote continuity of care, decreases healthcare costs, and can potentially improve clinical outcomes. The COVID-19 pandemic forced many healthcare systems to expand access for patients using telemedicine, but little is known about cancellation frequencies in telemedicine vs. in-person appointments and its impact on clinical outcomes. Objective: Compare ambulatory clinic cancellation rates, 30-day inpatient hospitalizations rates, and 30-day emergency department visit rates between in-person and video telemedicine appointments, and examine differences in cancellation rates by age, race/ethnicity, gender, and insurance. Design: A retrospective cohort study. Setting: The largest academic healthcare system in the state of Georgia with ambulatory clinics in urban, suburban and rural settings. Participants: Adults scheduled for an ambulatory clinic appointment from June 2020 to December 2020 were included. Each appointment was identified as either a video telemedicine or in-person clinic appointment. Demographics including age, race, ethnicity, gender, primary insurance, and comorbidities were extracted from the electronic medical record. Main Outcomes and Measures: The primary process outcome was ambulatory clinic cancellation rates. The primary clinical outcomes were 30-day hospitalization rates and 30-day emergency department visit rates. Multivariable logistic regression was used to assess differences in the clinical outcomes between appointment types.

The efficiency of the medical role within a Single Point of Access (SPA) Service in reducing the number of clinic appointments required

AimsThe SPA service takes referrals from general practitioners (GPs), medical professionals, the London Ambulance service, the London Police, psychology and social services, and from patients themselves and their family members or support groups. Some of these referrals require input from secondary care, but others can be solved within primary care if given specialist advice, this minimizing the time spent by patients in the healthcare system and minimizing also the NHS costs.Our aim was to evaluate the implementation of the Advice from Medics Service in a 1-year period.MethodWe examined a random sample of 200 referrals between 1st of April 2019 and 31st of March 2020 out of all referrals that were considered, after the triage, to be appropriate for an advice on treatment provided by the medics as an alternative to a clinic appointment in secondary care. We collected information from the electronic patient records regarding the dates of referrals, the senders of referrals, the type of referrals, the age and gender of patients and the reasons to be referred, and finally we analysed the outcome of the referrals and compared it with the action requested.ResultOf the 200 referrals, 113 were for female patients and 87 for male patients. The age of patients was between 18 and 91 years old, with a median of 43 years old.The person/authority making the referral was the GP in 179 cases, and others in 21 cases.The referrers asked for review in 74 cases, urgent review in 2 cases, review and advice in 31 cases, only advice in 46 cases, and did not state the type of referral in 47 cases.The primary pathology implied was affective in most of the cases (122), followed by psychotic (31) and neurotic (22), organic (8), of personality (5), hyperkinetic disorders (5), due to substance misuse (4), of psychological development (2) and learning disability (1).The outcome of the referrals was as follows: 19 patients (9.5%) were seen by the Crisis Team, 11 (5.5%) were referred to other teams, 4 (2%) did not engage with SPA, and the rest of 166 (83%) referrals were solved with advice.ConclusionThe outcome was extremely favourable as the majority of referrals requested medical review but most of them (83%) were solved with specialist advice to GPs or other professionals, highlighting that the implementation of the Advice from Medics Service has been an improvement to the SPA.

AB0909-HPR COVID 19 CRISIS: RAPID DEVELOPMENT OF REMOTE RHEUMATOLOGY MEDICATION CLINICS

Background:We used to initiate DMARD(s) and Biologic therapies via nurse-led shared medical appointments (Group clinics) and could see up to 30 patients per week, with a maximum of 6 patients per group. We did this to start patients on their medications efficiently and safely and to manage the increase in workload.However, with the onset of the COVID 19 pandemic, we had to stop these clinics immediately, but, we did not have capacity to start everyone on their medications in a timely manner by telephone. Telephoning each individual took > 9 hours per week, whereas previously it took 3-4 haours.Objectives:We wanted to start patients on their all rheumatology medications safely and efficiently (within 10 days).Methods:By April 2202, we had organised the filming of 10 short healthcare videos to give patients all the information they required to start a range of DMARDs and biologics.We developed a new protocol (fig 1); patients are asked to view the relevant video, contact our department to confirm they understand the safety monitoring, risks, potential side effects, dose increases etc. As soon as they confirm by email they are happy to start treatment, a prescription is generated and emailed to the hospital outpatient pharmacy, where it is dispensed and delivered to the patient’s home. We send a follow up reminder letter about blood test monitoring etc (copy to GP) and a ‘shared care agreement’ to GP. They are given the option to have a telephone clinic appointment with a specialist nurse if required.Figure 1.Results:Of those requiring DMARDs, 62% reviewed the video, completed the checklist and confirmed by email they were happy to start treatment, within 24-hours. 88% had completed within 7 days.Over half the patients (56%) were starting DMARDs for the first time, of those 8% requested a telephone consultation to discuss treatment further with the Rheumatology nurses. Of the 44% of patients already taking a DMARD and due to start a second medication 24% required a telephone clinic appointment.As this is a new service, we asked for feedback, receiving replies from 34%, all scoring between 9/10 and 10/10.We have released > 7 hours of specialist nurse time for telephone/helpline clinics.Conclusion:The development of digital / remote medication clinics has been a success and we will continue with this approach. We have limited face-to-face appointments, started patients on rheumatology medications more quickly and efficiently than previously (but maintained safety), allowed the nursing staff time to spend more time working in our telephone clinics and have had excellent patient feedback. Although, we are aware, this is at a cost of no peer-to-peer interaction, which has been of value in the past.Disclosure of Interests:Rian Penford: None declared, Elaine Wren: None declared, Kirsten Mackay Speakers bureau: I have been paid as a speaker for Roche within the last 12 months, Consultant of: I have worked as a paid consultant for Novartis, Janssen and Lilly within the last 12 moths, Grant/research support from: Novartis have assisted in the development of our Rheumatology App - Connect Plus - developed for rheumatology patients attending our department.