Comorbidities, Rather Than Older Age, Are Strongly Associated With Higher Utilization of Healthcare in Colorectal Cancer Survivors

Background: Colorectal cancer (CRC) survivors generally have a higher healthcare utilization (HCU) than the general population due to cancer burden. However, it is unclear which factors are associated with this increased uptake. Our study aimed to (1) compare CRC-related and non-CRC visits to general practitioners (GPs) and medical specialists (MSs) by comorbidities, and (2) assess whether HCU differs by demographic, clinical, and psychological factors. Methods: We used data from a German population-based cohort of 1,718 survivors of stage I–III CRC diagnosed in 2003 through 2010 who provided information on HCU at 5-year follow-up. Multivariable linear regression was used to calculate least-square means of CRC-related and non-CRC HCU according to the Charlson comorbidity index and comorbidity cluster, adjusting for relevant demographic, clinical, and psychological characteristics. Results: A higher comorbidity level was associated with more CRC-related MS visits and non-CRC GP visits. In addition to being strongly associated with non-CRC GP visits, comorbidity clusters were associated with CRC-related GP and MS visits, but their association varied by specific cardiometabolic comorbidities. HCU was less dependent on prognostic factors for CRC, such as age and tumor stage, but was strongly associated with disease recurrence, depression, and emotional functioning. Conclusions: Comorbidities, rather than age or tumor stage, were related to HCU, suggesting that CRC survivors use healthcare mainly for reasons other than cancer 5 years postdiagnosis. Improved communication between primary and tertiary healthcare providers could enhance the medical care of cancer survivors with complex health needs and thereby also reduce healthcare costs.

Assessing the use of antibiotics and the burden of varicella in Belgium using a retrospective GP database analysis

Background Varicella is a highly contagious infection that typically occurs in childhood. While most cases have a generally benign outcome, infection results in a considerable healthcare burden and serious complications may occur. Objectives The objective of this study was to characterize the burden of varicella in a real-world primary care setting in Belgium, including the rate of varicella-related complications, medication management and general practitioner (GP) visits. Methods The study was a retrospective observational study using data from a longitudinal patient database in a primary care setting in Belgium. Patients with a GP visit and a varicella diagnosis between January 2016 and June 2019 were eligible and data one month prior and three months after the diagnosis were included. Outcomes included varicella-related complications, antibiotic use, antiviral use, and GP follow-up visits. Antibiotic use could be specified by class of antibiotic and linked to a diagnosis. Complications were identified based on concomitant diagnosis with varicella during the study period. Results 3,847 patients with diagnosis of varicella were included, with a mean age of 8.4 years and a comparable distribution of gender. 12.6% of patients with varicella had a concomitant diagnosis of a varicella-related complication. During the follow-up period, 27.3% of patients with varicella were prescribed antibiotics, either systemic (19.8%) and/or topical (10.3%). The highest rate of antibiotic prescriptions was observed in patients with complications (63.5%) and in patients younger than 1 year (41.8%). Nevertheless, 5.3% of the patients were prescribed antibiotics without a concomitant diagnosis of another infection. The most commonly prescribed systemic antibiotics were amoxicillin alone or combined with beta-lactamase inhibitor, and thiamphenicol. Fusidic acid and tobramycin were the most prescribed topical antibiotics. Antivirals were prescribed for 2.7% of the study population. 4.7% of the patients needed a follow-up visit with their GP. Conclusions This study reports a substantial burden of varicella in a primary care setting in Belgium, with high rates of complications and antibiotic use.

An in Depth Analysis of Factors Contributing to Diagnostic Delay in Myeloma: A Retrospective UK Study of Patients Journey from Primary Care to Specialist Secondary Care

Introduction Patients with Multiple Myeloma (MM) often have a significant delay between onset of symptoms and diagnosis of disease. As a result, a significant number of patients present via emergency routes with severe co-morbidities which affect survival rates. Timely diagnosis relies on the early recognition of symptoms and blood test results which may indicate disease. Methods We examined the medical records of 142 newly diagnosed MM patients (121 intact immunoglobulin and 21 light chains) across 2 UK Hospitals. Patients included had not previously been diagnosed with a plasma cell dyscrasia, including Monoclonal Gammopathy of Undetermined Significance (MGUS). Clinical symptoms and blood test results were examined from the time of initial presentation to the healthcare system with symptoms indicative of MM, to the point of diagnosis in order to highlight patterns of symptoms and blood tests results which may give an early indication of disease. Blood tests results recorded included globulin, calcium, creatinine, erythroid sedimentation rate and haemoglobin. Time to diagnosis from presentation with symptoms indicative of MM was also measured as well as the patient pathway from the point of presentation to the point of diagnosis. Results The median time to diagnosis from initial presentation was 77 days (range 0 - 12,986). Initial presentation was most commonly via primary care (58.1%). Urgent secondary care presentation was documented in 28.5% which included acute medical unit (15.6%), the emergency department (7.1%), and other secondary care specialities (5.7%) respectively. Multiple GP visits were common prior to haematology referral with a median of 3 visits (range 1 - 40). Initial presenting symptoms varied, but of those with data recorded (n=107) back/bone pain was the most common (58.2%) followed by anaemia (18.7%), fracture (7.5%), recurrent infection (7.5%) and renal impairment (3.7%) respectively. Interestingly, analysis of evaluable blood test results revealed a raised globulin was most often evident prior to diagnosis with 58% of patients recording an abnormal globulin a median of 140 days (range 3 - 4297) prior to diagnosis of disease. Conclusions Multiple GP visits prior to establishing a diagnosis of myeloma is very common. Inclusion of abnormal globulin to reflex electrophoresis request and serum free light chain assay may serve as a useful trigger for investigation when interpreted alongside presenting symptoms and other blood test results. Increased awareness of myeloma warning signs in primary care may reduce diagnostic delay and avoid presentation with severe co-morbidities in emergency settings. Disclosures No relevant conflicts of interest to declare.

How is patient activation related to healthcare service utilisation? Evidence from electronic patient records in England

Background There is increasing awareness of the importance of patient activation (knowledge, skills, and confidence for managing one’s health and health care) among clinicians and policy makers, with emerging evidence showing higher levels of patient activation are associated with better health outcomes and experiences of health care. This study aimed to examine the association between patient activation and a wide range of specific types of healthcare service utilisation in England, including GP and non-GP primary care, elective and emergency hospital admissions, outpatient visits, and attendances at the Accident and Emergency department. Methods Data were derived from linked electronic patient records collected by primary and secondary healthcare providers in North West London between January 2016 and November 2019. Our analyses focused on adults (18+) with a valid Patient Activation Measure (PAM). After excluding patients with missing data, we had an analytical sample of 15,877 patients. Data were analysed using negative binomial regression and logistic regression models depending on the outcome variable. Results Patients had a mean activation score of 55.1 and a standard deviation (SD) of 17.7 (range: 0–100). They had an average of 5.4 GP visits (SD = 8.0), 26.8 non-GP visits (SD = 23.4) and 6.0 outpatient attendances (SD = 7.9) within a one-year follow-up. About 24.7% patients had at least one elective admission, 24.2% had one or more emergency admissions, and 42.3% had one or more A&E attendance within the follow-up. After accounting for a number of demographic and health factors, we found a linear (or proximately linear) association between patient activation and the number of GP visits, emergency admissions and A&E attendance, but a non-linear relationship between patient activation and the number of non-GP visits, the number of outpatient attendance and elective inpatient admission. Conclusions This study has provided strong empirical evidence from England linking patient activation with healthcare service utilisation. It suggests the value of supporting patient activation as a potential pathway to ease the burden of healthcare system.

Associations between regular GP contact, diabetes monitoring and glucose control: an observational study using general practice data

ObjectiveContinuity and regularity of general practitioner (GP) contacts are associated with reduced hospitalisation in type 2 diabetes (T2DM). We assessed associations of these GP contact patterns with intermediate outcomes reflecting patient monitoring and health.DesignObservational longitudinal cohort study using general practice data 2011–2017.Setting193 Australian general practices in Western Australia and New South Wales participating in the MedicineInsight programme run by NPS MedicineWise.Participants22 791 patients aged 18 and above with T2DM.InterventionsRegularity was assessed based on variation in the number of days between GP visits, with more regular contacts assumed to indicate planned, proactive care. Informational continuity (claims for care planning incentives) and relational continuity (usual provider of care index) were assessed separately.Outcome measuresProcess of care indicators were glycosylated haemoglobin (HbA1c) test underuse (8 months without test), estimated glomerular filtration rate (eGFR) underuse (14 months) and HbA1c overuse (two tests within 80 days). The clinical indicator was T2DM control (HbA1c 6.5% (47.5 mmol/mol)–7.5% (58.5 mmol/mol)).ResultsThe quintile with most regular contact had reduced odds of HbA1c and eGFR underuse (OR 0.74, 95% CI 0.67 to 0.81 and OR 0.78, 95% CI 0.70 to 0.86, respectively), but increased odds of HbA1c overuse (OR 1.20, 95% CI 1.05 to 1.38). Informational continuity was associated with reduced odds of HbA1c underuse (OR 0.53, 95% CI 0.49 to 0.56), reduced eGFR underuse (OR 0.62, 95% CI 0.58 to 0.67) and higher odds of HbA1c overuse (OR 1.48, 95% CI 1.34 to 1.64). Neither had significant associations with HbA1c level. Results for relational continuity differed.ConclusionsThis study provides evidence that regularity and continuity influence processes of care in the management of patients with diabetes, though this did not result in the recording of HbA1c within target range. Research should capture these intermediate outcomes to better understand how GP contact patterns may influence health rather than solely assessing associations with hospitalisation outcomes.

SP1.2.8Are screen detected rectal cancers truely asymptomatic?

Aims Patients with rectal cancers would be expected to be symptomatic and present to GP and be referred to tertiary care for investigations. Nevertheless nearly 15% of rectal cancers are screen detected. This study compared the presentation, demographics, staging of screen detected rectal cancer (SDRC) and symptomatic rectal cancer (SRC). Methods The national bowel cancer-screening database, the Somerset Cancer Register, the Great North Record, hospital electronic patient record and Sunquest ICE system was used to gather clinical information. All rectal cancers diagnosed between 2014 and 2019 were included. Results There were 379 SRC and 54 SDRC. The SRC had an average of 1.07 GP visits per patient (range 1-4) and SDRC had an average of 0.27 GP visits per patient (range 0-7) (p < 0.001). Screen detected patients presented to their GP with diarrhoea, change of bowel habit and bleeding whereas symptomatic patients presented with tenesmus, bleeding and change of bowel habit in that order respectively. Screening cancers were more likely to present as T1 or T2 compared to the symptomatic group (p = 0.023). Conclusion Screen detected rectal cancer patients presented less frequently to their GP. Those who presented had a different symptom profile to symptomatic cancers. This would explain these patients not seeking advice or the GP not referring them to hospital. Is it the morphological differences of the cancers or is it that the patients in screening group have a different personality trait that prevents them consulting their GP. These questions need investigating in future studies.

Impact of COVID-19 social distancing on viral infection in France: a delayed outbreak of RSV

COVID-19 pandemic and associated lockdown measures has deeply modified the natural course of seasonal viral infections, such as respiratory syncytial virus (RSV). Methods We analysed French national data from three networks: emergency departments (ED) of French hospitals, general practitioners (GP), and hospital laboratories. We compared the number of ED visits and GP visits for bronchiolitis in children <2 years of age, and the percentage of RSV positive tests in the 2020-2021 season with those of the two previous seasons (2018-2019 and 2019-2020). We used time series of the previous 5 years to calculate epidemic thresholds. Results During the 2020–2021 season, the epidemic begun in February (week 05) in the Ile de France (Paris and suburbs) region, 12 weeks later compared with the previous seasons and progressively spread across all the French metropolitan regions. The highest number of bronchiolitis cases in 2021 (week 12) occurred 10-12 weeks after the previous seasonal peaks of previous seasons, but the number of cases remained lower than in the previous seasonal peaks. Conclusion We identified a delayed RSV epidemic in the period that usually corresponds at the end of the epidemic season, raising concerns for the burden of RSV in the already strained healthcare systems during the COVID-19 pandemic

Cost-Effectiveness Analysis of Switching from Trivalent to Quadrivalent Seasonal Influenza Vaccine in Argentina

The burden of seasonal influenza disease in Argentina is considerable. The cost-effectiveness of trivalent (TIV) versus quadrivalent influenza vaccine (QIV) in Argentina was assessed. An age-stratified, static, decision-tree model compared the costs and benefits of vaccination for an average influenza season. Main outcomes included: numbers of influenza cases; general practitioner (GP) visits; complicated ambulatory cases; hospitalizations; deaths averted; and costs per quality-adjusted life years (QALYs) gained. Epidemiological data from Argentina for 2014–2019 were used to determine the proportion of A and B strain cases, and the frequency of mismatch between vaccine and circulating B strains. To manage uncertainty, one-way and probabilistic sensitivity analyses were performed. Switching from TIV to QIV would prevent 19,128 influenza cases, 16,164 GP visits, 2440 complicated ambulatory cases, 524 hospitalizations, and 82 deaths. Incremental cost–effectiveness ratios (ICERs) per QALY were 13,590 and 11,678 USD from the payer’s and societal perspectives, respectively. The greatest health benefits and direct medical cost savings would occur in ≥ 65-year-olds. One-way sensitivity analyses demonstrated the principal drivers of ICER to be vaccine acquisition costs, environmental B strain predominance, and B strain mismatch. Introducing QIV in Argentina would be beneficial and cost-effective relative to TIV, particularly in older adults.

Use of pharmacy services in community-dwelling middle-aged and older adults in Ireland

Introduction Pharmacy has a potentially significant role in meeting the escalating need for healthcare, particularly with population ageing and shifts to more community-based care under Ireland’s health reform policies. The role of community pharmacists has evolved in recent years with expansion in pharmacy services offered. This study aims to assess pharmacy services use among adults aged ≥50 years in Ireland, and determine the demographic and clinical factors associated with pharmacy services use. Methods This cross-sectional study included community-dwelling participants in wave 4 of The Irish Longitudinal Study on Ageing (TILDA), aged ≥50 years who were self-respondents (i.e. proxy respondents were omitted). TILDA is a nationally representative cohort study, and wave 4 data was collected during 2016. TILDA participants were asked if they availed of several named services when visiting the pharmacy in the last 12 months. These included: requesting advice about medication; vaccination; blood pressure (BP) or cholesterol checks; advice on smoking cessation or weight management; and diabetes, asthma, or allergy tests. We considered age, sex, educational attainment, GP utilization, medical card and private health insurance status, loneliness, polypharmacy, use of high risk medications (anticoagulants, NSAIDs, opioids, diuretics, antiplatelets, antimicrobials, insulin and hypoglycaemics) and comorbidities. Multivariate logistic regression was used to examine the association of these with reporting (i) any pharmacy service use and (ii) requesting medicines advice. Results This study included 5,782 participants, 55.5% were female with a mean age of 68 years. 96.6% of participants (5,587) reporting visiting a pharmacy in the previous 12 months, and almost one quarter of these (1,323) availed of at least one specified pharmacy service. The most common services reported were requesting advice about medications (786, 13.6%), blood pressure monitoring (184, 3.2%), and vaccination (166, 2.9%). Compared to those not using any services, service users were a similar age (mean 68 years), but were taking more medications (mean 3.6 versus 2.8), were more often female (64.1% versus 54.2%), had higher educational attainment, and had higher GP visit rates. Controlling for other factors, the following were associated with a high likelihood of availing of pharmacy services: female gender (odds ratio (OR) 1.32, 95%CI 1.14–1.52), third level education (OR 1.85, 95%CI 1.51–2.27), higher rates of GP visits, private health insurance (OR 1.29, 95%CI 1.07–1.56), higher number of medications, loneliness, and a diagnosed respiratory condition (OR 1.42, 95% CI 1.14–1.74). The relationship between these factors and requesting medicines advice were similar. Conclusion A high proportion of middle-aged and older adults visit community pharmacy and a quarter avail of specified pharmacy services. Despite advances in the services offered in pharmacies, medicines advice remains at the core of pharmacists’ practice. Those on multiple medications, who may derive greater benefit from such services, are more likely to avail of them. Number of GP visits was also associated with service use, suggesting patients may avail of pharmacy services as a complement, rather than a substitute, to visiting their GP. Services were more often used by people who are lonely, and pharmacists should consider interventions to support these people.

Early indicators of intensive care unit bed requirement during the COVID-19 epidemic: A retrospective study in Ile-de-France region, France

The aim of our retrospective study was to evaluate the earliest COVID19-related signal to anticipate requirements of intensive care unit (ICU) beds. Although the number of ICU beds is crucial during the COVID-19 epidemic, there is no recognized early indicator to anticipate it. In the Ile-de-France region, from February 20 to May 5, 2020, emergency medical service (EMS) calls and the response provided (ambulances) together the percentage of positive reverse transcriptase polymerase chain reaction (RT-PCR) tests, general practitioner (GP) and emergency department (ED) visits, and hospital admissions of COVID-19 patients were recorded daily and compared to the number of ICU patients. Correlation curve analysis was performed to determine the best correlation coefficient, depending on the number of days the indicator has been shifted. Primary endpoint was the number of ICU patients. EMS calls, percentage of positive RT-PCR tests, ambulances used, ED and GP visits of COVID-19 patients were strongly associated (R2 ranging between 0.79 to 0.99, all P<0.001) with COVID-19 ICU patients with an anticipation delay of 23, 15, 14, 13, and 12 days respectively. Hospitalization did not anticipate ICU bed requirement. A qualitative analysis of the onset of the second wave period of the epidemic (August 1 to September 15, 2020) in the same region provided similar results. The daily number of COVID19-related telephone calls received by the EMS and corresponding dispatch ambulances, and the proportion of positive RT-PCR tests were the earliest indicators of the number of COVID19 patients requiring ICU care during the epidemic crisis, rapidly followed by ED and GP visits. This information may help health authorities to anticipate a future epidemic, including a second wave of COVID19, or decide additional social measures.