Autism is a behavior disorder with genetic influences indicated from twin and family studies and from the co-occurrence of autism with known genetic disorders. Tuberous sclerosis complex (TSC) is a known genetic disorder with behavioral manifestations including autism. A literature review of these two disorders substantiates a significant association of autism and TSC with 17-58% of TSC subjects manifesting autism and 0.4-3% of autistic subjects having TSC. In initial data collected on 13 TSC probands and 14 autistic probands in our family study of autism and TSC, we identified 7 TSC subjects with autism. The seven TSC autistic probands are similar to non-TSC autistic probands on the Social and Communication domains of the Autism Diagnostic Inventory (ADI) (Le Couteur et al., 1989), but show fewer Repetitive Rituals. There are more male TSC probands with autism than female, despite an equal sex ratio among TSC probands. The TSC probands with autism have significantly more seizures and mental retardation than those without autism; however, the extent and etiology of associations require further study. Our preliminary findings suggest that a fruitful approach for delineating genetic influences in autism may come from further investigation of possible mechanisms underlying the association of autism and TSC.
Work organizational factors (eg, frequent part-time work, inadequate breaks, perception as a "second team" distinct from the dentist and dental-assistant team) impede the remediation of ergonomics and other problems. Job flexibility encourages hygienists to change work hours or location rather than deal with work conditions. Occupational health interventions should address social environment and work organization.
Objectives Driven by beneficial patient-centered outcomes associated with patient portal use and the Affordable Care Act, portal implementation has expanded into safety nets—health systems that offer access to care to a large share of uninsured, Medicaid, and other vulnerable populations. However, little attention has been paid to the factors that affect portal accessibility by the vulnerable patients served by these health systems—including those who are limited English proficient (LEP). Materials and Methods The Los Angeles County Department of Health Services (LAC DHS), the second-largest safety net system in the nation, launched its first patient portal, and one of the few bilingual English-Spanish interfaces in existence, in March of 2015. To explore portal awareness and perceptions, we conducted focus groups with LAC DHS patients, in English and Spanish (LEP). The Technology Acceptance Model was used to guide thematic analysis of focus group data. Results Of the 46 participants, 37 were patients and 9 were caretakers; 23 were English-speaking and 23 Spanish-speaking LEP. All patients had diabetes or hypertension. Over half had an annual household income <$10 000, yet 78% of English-speaking and 65% of Spanish-speaking LEP participants reported at-home Internet access. Participants’ discussion centered around 3 major thematic narratives: (1) participants’ awareness or attitudes about the LAC DHS portal; (2) role of culture, language, or community with regard to portal accessibility and utility; and (3) perceived needs for successful portal implementation. Conclusions Safety net participants identified concrete benefits to the portal and emphasized the need for portal engagement that offered accessible education, support, and resources in clinical and community settings. The portal offers an additional opportunity to engage the patient and family with trusted and validated health information, and should be further developed in this capacity. This study provides a better understanding of preferred improvements of patient portal engagement that guide broader health technology efforts to address electronic health disparities.
The frequency and clinical presentation of autism in 28 probands with tuberous sclerosis complex (TSC) are reported and risk factors that may influence the development of autism in TSC are examined. Eight probands meet ICD-10 and DSM-IV criteria for autism, an additional 4 meet criteria for pervasive developmental disorder (PDD). Twelve TSC probands with autism/PDD are compared to 16 TSC probands without these conditions for factors which may underlie the association of autism and TSC. A specific seizure type, infantile spasms, as well as mental retardation, are increased in the TSC, autistic/PDD group. Furthermore, rates of social phobia and substance abuse are elevated among first-degree relatives of TSC probands with autism compared to first-degree relatives of TSC probands without autism. Implications of these findings in understanding the association of autism and TSC are discussed.
ObjectivesThe start of the COVID-19 pandemic led the Los Angeles safety net health system to dramatically reduce in-person visits and transition abruptly to telehealth/telemedicine services to deliver clinical care (remote telephone and video visits). However, safety net patients and the settings that serve them face a “digital divide” that could impact effective implementation of such digital care. The study objective was to examine attitudes and perspectives of leadership and frontline staff regarding telehealth integration in the Los Angeles safety net, with a focus on telemedicine video visits.MethodsThis qualitative study took place in the Los Angeles County Department of Health Services (LAC DHS), the second-largest safety net health system in the US. This system disproportionately serves the uninsured, Medicaid, racial/ethnic minority, low-income, and Limited English Proficient (LEP) patient populations of Los Angeles County. Staff and leadership personnel from each of the five major LAC DHS hospital center clinics, and community-based clinics from the LAC DHS Ambulatory Care Network (ACN) were individually interviewed (video or phone calls), and discussions were recorded. Interview guides were based on the Consolidated Framework for Implementation Research (CFIR), and included questions about the video visit technology platform and its usability, staff resources, clinic needs, and facilitators and barriers to general telehealth implementation and use. Interviews were analyzed for summary of major themes.ResultsTwenty semi-structured interviews were conducted in August to October 2020. Participants included LAC DHS physicians, nurses, medical assistants, and physical therapists with clinical and/or administrative roles. Narrative themes surrounding telehealth implementation, with video visits as the case study, were identified and then categorized at the patient, clinic (including provider), and health system levels.ConclusionsPatient, clinic, and health system level factors must be considered when disseminating telehealth services across the safety net. Participant discussions illustrated how multilevel facilitators and barriers influenced the feasibility of video visits and other telehealth encounters. Future research should explore proposed solutions from frontline stakeholders as testable interventions towards advancing equity in telehealth implementation: from patient training and support, to standardized workflows that leverage the expertise of multidisciplinary teams.
In surgical clinics, missed appointments may lead to delayed diagnosis and postponed surgical intervention. Automated reminder calls (robocalls) have replaced live staff phone calls in many systems as a cost-saving measure. This study aims to evaluate whether robocalls reduced the outpatient appointment no-show rate for surgical patients in a county hospital. Demographic and clinic data from two surgical clinics at a safety net hospital were collected over two time periods: 3-months immediately before robocalls went live and 3-months immediately after robocalls went live. No-show rates were compared between time periods. Multivariate analysis confirmed that robocalls were independently associated with reduced no-show rates (OR: 1.32; 95% CI: 1.0-1.7; P = .032). In addition, new appointments were independently predictive of higher no-show rates (OR: 1.32; 95% CI: 1.0-1.7; P = .048). Robocalls appear to be an effective tool for improving appointment attendance overall. Furthermore, robocalls may free limited staff to perform higher value work in the healthcare system.
e18627 Background: Timely radiographic studies are essential to oncology care. At our institution, a safety net hospital in a large metropolitan area, baseline assessment determined that the overwhelming majority of outpatient computed tomographic (CT) scans for oncology patients were overdue for scheduling. We applied the Lean Kaizen quality improvement model to improve on-time scheduling of CT scans in our hematology-oncology clinic. Lean Kaizen is centered around eliminating waste, improving productivity, and maintaining sustained improvement through collaborative efforts from multiple departments to analyze system workflow inefficiencies in a stepwise fashion. Methods: In collaboration with our Kaizen Promotion Office, we conducted a series of interdisciplinary meetings including staff from radiology, oncology, scheduling, and administration. All aspects of the scheduling workflow were critically reviewed and barriers to scheduling were identified using an Ishikawa root-cause diagram and the Kaizen principle of gemba (“go and see the work”). A new workflow was developed in which clinic staff scheduled patients for CT scans prior to clinic discharge. To implement the new workflow, we employed the principles of shojinka (“create flow”) and nagara (“eliminate waste”). We developed and distributed workflow guides, conducted simulation events, and provided one-on-one training to ensure a successful rollout. Three months after our initial meeting, the new workflow was launched. The workflow was refined based on feedback from daily pre-clinic team meetings. Results: Preliminary data were gathered approximately 3 weeks following implementation of our new workflow. Since our intervention, the percentage of CT scans overdue for scheduling decreased from 87% (65 of 75 CT scans) to 17% (9 of 53 CT scans). Conclusions: Our study showed that the Lean Kaizen QI model was successful in improving the rate of oncology patients scheduled for CT scans in a timely fashion. This study demonstrated the importance of interdepartmental collaboration and continuous monitoring for improvement. Given the success of this project, this workflow will be expanded to other services within our institution following the Kaizen principle of yokoten (“sharing knowledge”).
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