BACKGROUND: Little is known about antibiotic prescribing for respiratory tract infections (RTIs) in virtual versus in-person urgent care within the same health system.
METHODS: This is a retrospective study using electronic health record data from Cleveland Clinic Health System. We identified RTI patients via ICD-10 codes and assessed whether the visit resulted in an antibiotic. We described differences in diagnoses and prescribing by type of urgent care (virtual versus in-person.) We used mixed effects logistic regression to model the odds of a patient receiving an antibiotic by urgent care setting. We applied the model first to all physicians and second only to those who saw patients in both settings.
RESULTS: There were 69,189 in-person and 19,003 virtual visits. Fifty-eight percent of virtual visits resulted in an antibiotic compared to 43% of in-person visits. Sinusitis diagnoses were more than twice as common in virtual versus in-person care (36% versus 14%) and were associated with high rates of prescribing in both settings (95% in person, 91% virtual). Compared to in-person care, virtual urgent care was positively associated with a prescription (OR:1.64, 95%CI:1.53-1.75). Among visits conducted by 39 physicians who saw patients in both settings, odds of antibiotic prescription in virtual care were 1.71 times higher than in in-person care (95%CI:1.53-1.90).
CONCLUSIONS: Antibiotic prescriptions were more common in virtual versus in-person urgent care settings, including among physicians who provided care in both platforms. This appears to be related to the high rate of sinusitis diagnosis in virtual urgent care.

Women seeking care during the perinatal period often face delays or long waits at healthcare facilities due to lack of providers and/or resources, leading to sub-optimal outcomes. We implemented a program whereby patients with concerns could receive same-day care virtually from a midwife rather than presenting to the clinic or hospital for care. Implementation strategies included virtual training, a staged increase in patient volume, and frequent communication between the midwives via text, email, and monthly meetings. Virtual visits included a variety of complaints, the five most common being to establish care, first-trimester bleeding, nausea and vomiting, mental health concerns, and postnatal breast problems. There was a threefold increase in virtual visits during the first 6 months with 92% of patients not requiring urgent face-to-face follow-up. Midwives were able to provide high-quality telehealth care that met the patients\' needs and decreased the demand on hospital-based services. With the growing ubiquity of mobile phones and internet access, this strategy may be effective in providing quality care while decreasing demands on physical infrastructure. More research is needed to assess acceptability in other contexts. Reproducibility in low-resource settings may be limited if women lack access to video conferencing on phones or laptops.

BACKGROUND: In 2020, the Ministry of Health (MoH) in Ontario, Canada, introduced a virtual urgent care (VUC) pilot program to provide alternative access to urgent care services and reduce the need for in-person emergency department (ED) visits for patients with low acuity health concerns.
OBJECTIVE: This study aims to compare the 30-day costs associated with VUC and in-person ED encounters from an MoH perspective.
METHODS: Using administrative data from Ontario (the most populous province of Canada), a population-based, matched cohort study of Ontarians who used VUC services from December 2020 to September 2021 was conducted. As it was expected that VUC and in-person ED users would be different, two cohorts of VUC users were defined: (1) those who were promptly referred to an ED by a VUC provider and subsequently presented to an ED within 72 hours (these patients were matched to in-person ED users with any discharge disposition) and (2) those seen by a VUC provider with no referral to an in-person ED (these patients were matched to patients who presented in-person to the ED and were discharged home by the ED physician). Bootstrap techniques were used to compare the 30-day mean costs of VUC (operational costs to set up the VUC program plus health care expenditures) versus in-person ED care (health care expenditures) from an MoH perspective. All costs are expressed in Canadian dollars (a currency exchange rate of CAD $1=US $0.76 is applicable).
RESULTS: We matched 2129 patients who presented to an ED within 72 hours of VUC referral and 14,179 patients seen by a VUC provider without a referral to an ED. Our matched populations represented 99% (2129/2150) of eligible VUC patients referred to the ED by their VUC provider and 98% (14,179/14,498) of eligible VUC patients not referred to the ED by their VUC provider. Compared to matched in-person ED patients, 30-day costs per patient were significantly higher for the cohort of VUC patients who presented to an ED within 72 hours of VUC referral ($2805 vs $2299; difference of $506, 95% CI $139-$885) and significantly lower for the VUC cohort of patients who did not require ED referral ($907 vs $1270; difference of $362, 95% CI 284-$446). Overall, the absolute 30-day costs associated with the 2 VUC cohorts were $18.9 million (ie, $6.0 million + $12.9 million) versus $22.9 million ($4.9 million + $18.0 million) for the 2 in-person ED cohorts.
CONCLUSIONS: This costing evaluation supports the use of VUC as most complaints were addressed without referral to ED. Future research should evaluate targeted applications of VUC (eg, VUC models led by nurse practitioners or physician assistants with support from ED physicians) to inform future resource allocation and policy decisions.

OBJECTIVE: To compare patient access to urgent care centers (UCCs) with a diagnosis of sudden hearing loss based on insurance.
METHODS: One hundred twenty-five random UCCs in states with Medicaid expansion and 125 random UCCs in states without Medicaid expansion were contacted by a research assistant posing as a family member seeking care on behalf of a patient with a one-week history of sudden, unilateral hearing loss. Each clinic was called once as a Medicaid patient and once as a private insurance (PI) patient for 500 total calls. Each phone encounter was evaluated for insurance acceptance and self-pay price. Secondary outcomes included other measures of timely/accessible care. Chi-square/McNemar\'s tests and independent/paired sample t-tests were performed to determine whether there were statistically significant differences between expansion status and insurance type. Calls ended before answering questions were not included in the analysis.
RESULTS: Medicaid acceptance rate was significantly lower than PI (68.1% vs. 98.4%, p < 0.001). UCCs in Medicaid expansion states were significantly more likely to accept Medicaid (76.8% vs. 59.2%, p = 0.003). The mean wage-adjusted self-pay price was significantly greater in states with Medicaid expansion at $169.84 than in states without at $145.34 when called as a Medicaid patient (mean difference: $24.50, 95% Confidence Interval: $0.45-$48.54, p = 0.046). The rates of referral to an emergency department and self-pay price nondisclosure rates were greater for Medicaid calls than for private insurance calls (8.2% vs. 0.4% and 17.4% vs. 5.8%; p < 0.001 for both).
CONCLUSIONS: Medicaid patients with otologic emergencies face reduced access to care at UCCs.
METHODS: NA Laryngoscope, 2024.

OBJECTIVE: To investigate the real-world experiences of nurses\' using smart glasses to triage patients in an urgent care centre.
METHODS: A parallel convergent mixed-method design.
METHODS: We collected data through twelve in-depth interviews with nurses using the device and a survey. Recruitment continued until no new themes emerged. We coded the data using a deductive-thematic approach. Qualitative and survey data were coded and then mapped to the most dominant dimension of the sociotechnical framework. Both the qualitative and quantitative findings were triangulated within each dimension of the framework to gain a comprehensive understanding of user experiences.
RESULTS: Overall, nurses were satisfied with using smart glasses in urgent care and would recommend them to others. Nurses rated the device highly on ease of use, facilitation of training and development, nursing empowerment and communication. Qualitatively, nurses generally felt the device improved workflows and saved staff time. Conversely, technological challenges limited its use, and users questioned its sustainability if inadequate staffing could not be resolved.
CONCLUSIONS: Smart glasses enhanced urgent care practices by improving workflows, fostering staff communication, and empowering healthcare professionals, notably providing development opportunities for nurses. While smart glasses offered transformative benefits in the urgent care setting, challenges, including technological constraints and insufficient organisational support, were barriers to sustained integration.
CONCLUSIONS: These real-world insights encompass both the benefits and challenges of smart glass utilisation in the context of urgent care. The findings will help inform greater workflow optimisation and future technological developments. Moreover, by sharing these experiences, other healthcare institutions looking to implement smart glass technology can learn from the successes and barriers encountered, facilitating smoother adoption, and maximising the potential benefits for patient care.
UNASSIGNED: COREQ checklist (consolidated criteria for reporting qualitative research).
UNASSIGNED: No patient or public contribution.

BACKGROUND: Many health care systems have used digital technologies to support care delivery, a trend amplified by the COVID-19 pandemic. \"Digital first\" may exacerbate health inequalities due to variations in eHealth literacy. The relationship between eHealth literacy and web-based urgent care service use is unknown.
OBJECTIVE: This study aims to measure the association between eHealth literacy and the use of NHS (National Health Service) 111 online urgent care service.
METHODS: A cross-sectional sequential convenience sample survey was conducted with 2754 adults (October 2020-July 2021) from primary, urgent, or emergency care; third sector organizations; and the NHS 111 online website. The survey included the eHealth Literacy Questionnaire (eHLQ), questions about use, preferences for using NHS 111 online, and sociodemographic characteristics.
RESULTS: Across almost all dimensions of the eHLQ, NHS 111 online users had higher mean digital literacy scores than nonusers (P<.001). Four eHLQ dimensions were significant predictors of use, and the most highly significant dimensions were eHLQ1 (using technology to process health information) and eHLQ3 (ability to actively engage with digital services), with odds ratios (ORs) of 1.86 (95% CI 1.46-2.38) and 1.51 (95% CI 1.22-1.88), respectively. Respondents reporting a long-term health condition had lower eHLQ scores. People younger than 25 years (OR 3.24, 95% CI 1.87-5.62) and those with formal qualifications (OR 0.74, 95% CI 0.55-0.99) were more likely to use NHS 111 online. Users and nonusers were likely to use NHS 111 online for a range of symptoms, including chest pain symptoms (n=1743, 70.4%) or for illness in children (n=1117, 79%). The users of NHS 111 online were more likely to have also used other health services, particularly the 111 telephone service (χ12=138.57; P<.001).
CONCLUSIONS: These differences in eHealth literacy scores amplify perennial concerns about digital exclusion and access to care for those impacted by intersecting forms of disadvantage, including long-term illness. Although many appear willing to use NHS 111 online for a range of health scenarios, indicating broad acceptability, not all are able or likely to do this. Despite a policy ambition for NHS 111 online to substitute for other services, it appears to be used alongside other urgent care services and thus may not reduce demand.

BACKGROUND: Up to 50% of antibiotic prescriptions for upper respiratory infections (URIs) are inappropriate. Clinical decision support (CDS) systems to mitigate unnecessary antibiotic prescriptions have been implemented into electronic health records, but their use by providers has been limited.
OBJECTIVE: As a delegation protocol, we adapted a validated electronic health record-integrated clinical prediction rule (iCPR) CDS-based intervention for registered nurses (RNs), consisting of triage to identify patients with low-acuity URI followed by CDS-guided RN visits. It was implemented in February 2022 as a randomized controlled stepped-wedge trial in 43 primary and urgent care practices within 4 academic health systems in New York, Wisconsin, and Utah. While issues were pragmatically addressed as they arose, a systematic assessment of the barriers to implementation is needed to better understand and address these barriers.
METHODS: We performed a retrospective case study, collecting quantitative and qualitative data regarding clinical workflows and triage-template use from expert interviews, study surveys, routine check-ins with practice personnel, and chart reviews over the first year of implementation of the iCPR intervention. Guided by the updated CFIR (Consolidated Framework for Implementation Research), we characterized the initial barriers to implementing a URI iCPR intervention for RNs in ambulatory care. CFIR constructs were coded as missing, neutral, weak, or strong implementation factors.
RESULTS: Barriers were identified within all implementation domains. The strongest barriers were found in the outer setting, with those factors trickling down to impact the inner setting. Local conditions driven by COVID-19 served as one of the strongest barriers, impacting attitudes among practice staff and ultimately contributing to a work infrastructure characterized by staff changes, RN shortages and turnover, and competing responsibilities. Policies and laws regarding scope of practice of RNs varied by state and institutional application of those laws, with some allowing more clinical autonomy for RNs. This necessitated different study procedures at each study site to meet practice requirements, increasing innovation complexity. Similarly, institutional policies led to varying levels of compatibility with existing triage, rooming, and documentation workflows. These workflow conflicts were compounded by limited available resources, as well as an implementation climate of optional participation, few participation incentives, and thus low relative priority compared to other clinical duties.
CONCLUSIONS: Both between and within health care systems, significant variability existed in workflows for patient intake and triage. Even in a relatively straightforward clinical workflow, workflow and cultural differences appreciably impacted intervention adoption. Takeaways from this study can be applied to other RN delegation protocol implementations of new and innovative CDS tools within existing workflows to support integration and improve uptake. When implementing a system-wide clinical care intervention, considerations must be made for variability in culture and workflows at the state, health system, practice, and individual levels.
BACKGROUND: ClinicalTrials.gov NCT04255303; https://clinicaltrials.gov/ct2/show/NCT04255303.

BACKGROUND: Despite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration.
METHODS: We conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process.
RESULTS: We conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal.
CONCLUSIONS: The diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.

OBJECTIVE: To assess the knowledge and confidence level regarding the basic first-aid for treating epistaxis among medical staff, including nurses and physicians across various medical disciplines. The study focused three aspects of first aid management: location of digital pressure, head position and duration of pressure.
METHODS: The study involved 597 participants, categorized into five groups according to their specialties: emergency medicine, internal medicine, surgery, pediatrics, and community-based healthcare. A paper-based multiple-choice questionnaire assessed knowledge of managing epistaxis. Correct answers were determined from literature review and expert consensus.
RESULTS: Most medical staff showed poor knowledge regarding the preferred site for applying digital pressure in epistaxis management. For head position, pediatricians and internal medicine physicians were most accurate (79.4% and 64.8%, respectively, p < 0.01), and nurses from the emergency department outperformed nurses from other disciplines; internal medicine, surgery, pediatrics, and community-based healthcare (61.1%, 41.5%, 43.5%, 60%, 45.6%, respectively, p < 0.05). While most medical staff were unfamiliar with the recommended duration for applying pressure on the nose, pediatricians and community clinic physicians were most accurate (47.1% and 46.0%, respectively, p < 0.01), while ER physicians were least accurate (14.9%, p < 0.01). Interestingly, a negative correlation was found between years of work experience and reported confidence level in managing epistaxis.
CONCLUSIONS: Our findings indicate a significant lack of knowledge concerning epistaxis first-aid among medical staff, particularly physicians in emergency departments. This finding highlights the pressing need for education and training to enhance healthcare workers\' knowledge in managing epistaxis.

Bayesian approaches have been utilized to address the challenge of variable selection and statistical inference in high-dimensional survival analysis. However, the discontinuity of the ℓ0-norm prior, including the useful spike-and-slab prior, may lead to computational and implementation challenges, potentially limiting the widespread use of Bayesian methods. The Gaussian and diffused-gamma (GD) prior has emerged as a promising alternative due to its continuous-and-differentiable ℓ0-norm approximation and computational efficiency in generalized linear models. In this paper, we extend the GD prior to semi-parametric Cox models by proposing a rank-based Bayesian inference procedure with the Cox partial likelihood. We develop a computationally efficient algorithm based on the iterative conditional mode (ICM) and Markov chain Monte Carlo methods for posterior inference. Our simulations demonstrate the effectiveness of the proposed method, and we apply it to an electronic health record dataset to identify risk factors associated with COVID-19 mortality in ICU patients at a regional medical center.