A new look at low back complaints in primary care: a RAMBAM Israeli Family Practice Research Network study

BACKGROUND: Low back pain (LBP) is one of the most frequent reasons patients seek consultations in primary care, and it is a major cause of disability. Our research examines the natural history of LBP and the prediction of chronicity in the context of patients presenting to family medicine clinics. METHODS: We performed a prospective cohort study of new episodes of LBP within the framework of a national family practice research network. The setting was 28 primary care family practice clinics located throughout Israel. Of 238 eligible subjects, 219 (92%) completed the study. RESULTS: During the 2-month study period, 2 subjects were referred to the emergency department and discharged, and 2 others were hospitalized. Forty-five percent did not require bed rest, and 38% of the employed were not absent from work. Seventy-one percent showed improvement in functional status; however, only 37% noted complete pain relief. Clinical and demographic data usually did not predict LBP-episode outcomes. The strongest predictors of chronicity were depression, history of job change due to LBP in the past, history of back contusion, lack of social support, family delegitimization of patient's pain, dissatisfaction with first office visit, family history of LBP or other chronic pain, coping style, and unemployment. CONCLUSIONS: The cohort patients displayed a relatively benign natural history of LBP, matched by benign clinical behavior from their physicians. In Israeli primary health care, acute LBP is infrequently associated with hospitalization or prolonged work absenteeism. Although most patients have functional improvement, pain often lingers. Almost all predictors of chronicity are psychosocial.     

Risk of Rehospitalization or Emergency Department Visit is Significantly Higher for Patients who Receive Their First Home Health Care Nursing Visit Later than 2 Days After Hospital Discharge

ObjectivesThis study explored the association between the timing of the first home health care nursing visits (start-of-care visit) and 30-day rehospitalization or emergency department (ED) visits among patients discharged from hospitals.DesignOur cross-sectional study used data from 1 large, urban home health care agency in the northeastern United States.Setting/ParticipantsWe analyzed data for 49,141 home health care episodes pertaining to 45,390 unique patients who were admitted to the agency following hospital discharge during 2019.MethodsWe conducted multivariate logistic regression analyses to examine the association between start-of-care delays and 30-day hospitalizations and ED visits, adjusting for patients’ age, race/ethnicity, gender, insurance type, and clinical and functional status. We defined delays in start-of-care as a first nursing home health care visit that occurred more than 2 full days after the hospital discharge date.ResultsDuring the study period, we identified 16,251 start-of-care delays (34% of home health care episodes), with 14% of episodes resulting in 30-day rehospitalization and ED visits. Delayed episodes had 12% higher odds of rehospitalization or ED visit (OR 1.12; 95% CI: 1.06–1.18) compared with episodes with timely care.Conclusions and ImplicationsThe findings suggest that timely start-of-care home health care nursing visit is associated with reduced rehospitalization and ED use among patients discharged from hospitals. With more than 6 million patients who receive home health care services across the United States, there are significant opportunities to improve timely care delivery to patients and improve clinical outcomes.     

Annals Journal Club: Prognosis of Abdominal Pain in Children in Primary Care—A Prospective Cohort Study

PURPOSE

Abdominal pain is a common complaint in children. Because few data exist on its natural history, we wanted to investigate the prognosis of abdominal pain in children in general practice.

METHODS

In a prospective cohort study of children (aged 4 to 17 years) complaining of abdominal pain, follow-up was at 3, 6, 9, and 12 months using standardized questionnaires. The primary outcome measure was chronic abdominal pain: abdominal pain at least 1 time a month during at least 3 consecutive months that had an impact on daily activities. Prevalence, incidence, and duration of chronic abdominal pain were assessed.

RESULTS

Three hundred five children (116 boys, 189 girls), with a median age of 7.8 years (interquartile range [IQR] = 5.7–10.5 years) were included. Chronic abdominal pain was present in 142 (46.6%) children at an initial visit to the primary care physician for this complaint. During follow-up, 78.7% fulfilled the criteria for chronic abdominal pain at 1 or more follow-up points. Among 163 children at risk for developing chronic abdominal pain, the cumulative incidence of chronic abdominal pain was 60.1% (95% CI, 52.1%–67.7%) and was higher in girls than in boys (RR = 1.23; 95% CI, 0.94–1.61). Median duration of abdominal pain was 7.5 months (IQR = 4.5–12.0 months). Children aged 10 to 17 years had the longest duration of abdominal pain (median = 9.0 months; IQR = 7.5–12.4 months). Children with symptoms of irritable bowel syndrome seemed to have a less favorable prognosis compared with children with symptoms of functional dyspepsia or functional abdominal pain.

CONCLUSIONS

The presence and development of chronic abdominal pain is common and of long duration among children consulting in primary care for abdominal pain. These poor outcome data warrant follow-up.     

Provider response and follow-up to parental declination of HPV vaccination

ObjectiveParents often decline HPV vaccination, but little is known about how healthcare providers should promote vaccination at a later visit for secondary acceptance. We examined the associations of two factors, providers’ response to declination during the visit and follow-up after the visit, with secondary acceptance.MethodsWe conducted a cross-sectional survey of US parents whose 9- to 17-year-old child had not yet completed the HPV vaccination series. Parents who declined HPV vaccination during an initial discussion with a provider (n = 447) reported whether their provider engaged in any active response during the visit (e.g., giving information, trying to change their mind) or any follow-up after the visit (e.g., scheduling another visit). We conducted multivariable logistic regression to determine whether an active response or follow-up was associated with secondary acceptance of HPV vaccination.ResultsOnly about one-third of parents reported an active response during the visit (35%) or follow-up after the visit (39%) following HPV vaccination declination. Parents had higher odds of secondary acceptance of HPV vaccine if they received any provider follow-up after the visit (43% vs. 20%, aOR:3.19; 95% CI:2.00:5.07). Receipt of an active provider response was not associated with secondary acceptance. More parents thought a provider should actively respond and follow-up (61% and 68% respectively), compared with those who received such a response (both p < .01).ConclusionsProviders’ follow-up after the visit may be important for promoting secondary acceptance of HPV vaccination. Parents who decline HPV vaccination often prefer to receive an active response or follow-up from a provider.     

Transitional Care Clinic for Uninsured and Medicaid-Covered Patients With Diabetes Mellitus Discharged From the Hospital: A Pilot Quality Improvement Study

Abstract

Transitioning from the inpatient to outpatient setting is often a problematic aspect of diabetes mellitus (DM) care. Different factors during hospitalization may adversely affect glycemic control in patients, who are frequently discharged on regimens that differ markedly from prehospitalization outpatient regimens. Moreover, the discharge recommendations may not have been tested adequately during a relatively short hospital length of stay and pose a significant threat to patient safety upon discharge. Our pilot study evaluated the effect on hospital utilization of the transitional care clinic (TCC), where patients with DM are seen within 2 to 5 days of hospital discharge. One hundred patients with DM, who were either medically indigent (no insurance or Medicaid and no primary care providers) or covered by Medicaid, and who did not have a primary care provider, were randomized into either a control or an intervention group upon discharge from the hospital. Subjects from the intervention group (n = 50) were seen in the TCC. All subjects were contacted 90 days after discharge to collect information about emergency department visits and readmissions. Thirteen subjects from the control group and 13 from the intervention group visited the emergency department within 90 days of discharge. Fourteen control subjects (28%) and 10 intervention patients (20%) were rehospitalized for various medical conditions during the follow-up period (P = not significant). Among patients originally admitted for DM-related issues, 6 of 14 in the control group (42.9%) and 2 out of 16 in the intervention group (12.5%) were readmitted during follow-up (P < 0.05). We conclude that the TCC may be effective for the prevention of rehospitalizations in indigent patients admitted for DM-related problems and who did not have primary care providers. The benefit of the TCC was not seen when patients with DM were admitted for other medical problems. Larger randomized controlled trials are needed to confirm this preliminary finding.     

Non-urgent care in the hospital medical emergency department in France: how much and which health needs does it reflect?

OBJECTIVES: The goal was to describe the use of the medical emergency department as a source of non-urgent medical care in order to assess unmet health care needs among its users. The specific objectives were thus to assess the proportion of emergency department visits for non-urgent medical care and to describe those who used the department for this reason. DESIGN: A cross sectional study was performed at the emergency department in two hospitals (around 12,000 visits per year each). Subjects were interviewed before and after the visit using a standardised questionnaire. SETTING: The medical emergency department of two university hospitals, one in Paris and one in Besançon (France). SUBJECTS: Each patient aged 15 and more attending the emergency department for a visit during 40 randomly selected periods of 12 hours was included. MAIN OUTCOME MEASURES: A definition of urgent care was adopted before the beginning of the study. Four expert judgments were then used for each case to determine whether the reason for the visit was urgent or not. RESULTS: Altogether 594 patients in the Paris emergency department and 614 in the Besançon one were included. In Besançon, the patients were older, a general practitioner was more often cited as the regular source of care, and the percentage of subsequent hospital admission was higher than in Paris (71% versus 34%). The non-urgent visits were estimated to account for 35% and 29% of the visits in Paris and Besançon respectively. Patients using the emergency department for a non-urgent visit were younger than other patients. More of them were unemployed, homeless, born outside of France, and without health insurance. CONCLUSIONS: Non-urgent use of the emergency department was observed in about one third of the visits. Groups using the department for primary care and/or non-urgent care were mostly young and socially fragile, with no regular source of health care. Their poor health condition suggests that there is a need for a structure providing primary care both inside and outside 'normal' working hours.     

Payment Source and Emergency Management of Deliberate Self-Harm

Objectives. We investigated whether health insurance type (private vs Medicaid) influences the delivery of acute mental health care to patients with deliberate self-harm.Methods. Using National Medicaid Analytic Extract Files (2006) and MarketScan Research Databases (2005–2007), we analyzed claims focusing on emergency episodes of deliberate self-harm of Medicaid- (n = 8228) and privately (n = 2352) insured adults. We analyzed emergency department mental health assessments and outpatient mental health visits in the 30 days following the emergency visit for discharged patients.Results. Medicaid-insured patients were more likely to be discharged (62.7%), and among discharged patients they were less likely to receive a mental health assessment in the emergency department (47.8%) and more likely to receive follow-up outpatient mental health care (52.9%) than were privately insured patients (46.9%, 57.3%, and 41.2%, respectively).Conclusions. Acute emergency management of deliberate self-harm is less intensive for Medicaid- than for privately insured patients, although discharged Medicaid-insured patients are more likely to receive follow-up care. Programmatic reforms are needed to improve access to emergency mental health services, especially in hospitals that serve substantial numbers of Medicaid-insured patients.In several medical contexts, insurance status affects access and quality of care.1,2 In relation to privately insured patients, Medicaid-insured patients are generally less likely to receive care, and the care they receive less often meets guideline-based standards.3,4 At a time of intense pressure to rein in Medicaid costs, the risks of insurance-related disparities in access and quality of care are especially great. Despite keen interest among health care policymakers, however, little information exists in the peer-reviewed literature on the comparative access and quality of mental health care provided to Medicaid- and commercially insured patients.The emergency department is an important setting in which to evaluate mental health care of Medicaid-insured and privately insured adults. In the management of deliberate self-harm, emergency departments have an opportunity to provide potentially lifesaving services. A key goal involves improving the recognition and treatment of psychiatric disorders in high-risk patients.5 One particularly high-risk group includes patients who go to emergency departments pursuant to self-harm, which may or may not involve suicidal intent.6,7 During the first year following emergency treatment of deliberate self-harm, suicide risk increases 30- to 130-fold.8–10 Psychiatric disorders, though exceedingly prevalent among adults with deliberate self-harm,11,12 are not always recognized or treated. Because of strong connections between psychiatric disorder, self-harm, and suicide, the National Institute for Clinical Excellence recommends that all individuals attending emergency departments with deliberate self-harm receive a mental health evaluation before emergency department discharge.13 Mental health assessment provides opportunities to evaluate aggression, impulsivity, hopelessness, and other symptoms that bear on suicide risk.14The quality of mental health care in emergency departments varies. In 1 statewide survey, most emergency departments did not have a mental health professional to evaluate and treat patients with self-harm.15 Only about one half of emergency department patients in the Medicaid program who come in with deliberate self-harm and are discharged to the community receive a mental health assessment.16We compared the mental health care received by adult Medicaid and privately insured beneficiaries who came to emergency departments with deliberate self-harm. We first compared these 2 groups with respect to the likelihood of hospital admission. Among those who were discharged to the community, we assessed the probability of receiving a mental health assessment in the emergency department and of receiving outpatient mental health treatment within the following 30 days. We hypothesized that Medicaid-insured patients with self-harm would be less likely than would their privately insured counterparts to be admitted to the hospital and that Medicaid-insured patients who were discharged to the community would be less likely than would privately insured patients to receive an emergency mental health assessment and follow-up outpatient mental health care.     

The Limited Effect of Screening for Depressive Symptoms With the PHQ-9 in Rural Family Practices

CONTEXT: Previous studies have found that routine screening for depression does not improve patient outcome unless it is combined with case management. However, these studies were conducted before the widespread use of SSRIs or in settings other than traditional primary care. PURPOSE: This study investigated whether screening for depressive symptoms improves outcomes for depressed patients seen in rural fee-for-service primary care offices. METHODS: Depression screening was conducted at 2 private rural clinics in Iowa using the PHQ-9. Patients with depressive symptoms were randomized to the control group or the intervention group, where providers were given completed PHQ-9 questionnaires at the baseline visit. The outcome PHQ-9 scores were assessed by telephone at 4, 10, and 24 weeks after the index visit. FINDINGS: A total of 861 patients were screened for depressive symptoms; 51 subjects enrolled in the trial. The intervention and control groups did not significantly differ with respect to changes in PHQ-9 scores at any of the 3 follow-up times. They also did not differ with respect to the proportion of subjects who were actively managed with medication or by referral to a mental health specialist: 46% vs 33% (P = .38) for all subjects and 50% vs 50% (P = .96) for subjects with major depression at baseline. CONCLUSIONS: Screening for depressive symptoms with the PHQ-9 in 2 rural medical clinics did not significantly increase physicians' active management of depression or lead to improved patient outcomes.     

The Health and Social Needs of Patients Discharged From the Emergency Department With Suspected COVID-19

Health-related social needs (HRSNs), such as food or housing insecurity, are important drivers of disparities in outcomes during public health emergencies. We describe the development of a telehealth follow-up program in Boston, Massachusetts, for patients discharged from the emergency department after coronavirus disease 2019 (COVID-19) testing to identify patients with worsening clinical symptoms, to screen for unmet HRSNs, and to deliver self-isolation counseling and risk-reduction strategies for socially vulnerable people. We prioritized telephone calls to patients with public health insurance and patients without primary care physicians. In the first 43 days of operation, March 30–May 12, 2020, our intervention reached 509 patients, with 209 (41.1%) patients reporting an HRSN, most commonly related to food, housing, or utilities. Thirty-one (6.1%) patients required assessment by a clinician for clinical worsening. This public health intervention may be useful for other institutions developing programs to address the social and health needs of patients discharged with suspected COVID-19.     

Paediatric utilization of an emergency department in Italy

BACKGROUND: The purpose of this study was to determine the frequency and characteristics of paediatric attendance as a source of medically non-urgent problems at an accident and emergency department (ED) of a public non-teaching hospital in Crotone (Italy). METHODS: For each patient aged 16 years or younger, there were collected information on demographics and socioeconomic characteristics, medical history, route of referral, clinical complaints that they presented at the moment of their presentation at the ED, duration of presenting problems prior to arrival, hour of arrival, day of the week of arrival, and reason for attending the ED. Data about the consultation process and the final decision made were also recorded. RESULTS: Of a total of 980 patients included in the study, 27.6% had conditions that were definitely non-urgent. Multiple logistic regression analysis showed that the visit was non-urgent in younger population, in females, and in those attending the ED on the weekend. The results of the second multivariable regression analysis model indicate that patients who did not receive medical or surgical examination at the ED, with problems of longer duration prior to arrival at the ED, with non-traumatic injuries, and who did not require inpatient hospital admission were more likely to use the ED as a source of non-urgent care. The most frequent presenting problems for patient visits to ED were injury, respiratory diseases, and digestive symptoms. CONCLUSION: A closer cooperation within the health care organization system to provide a service responsive to the real needs of patients is essential.     

A new corps of trained Grand-Aides has the potential to extend reach of primary care workforce and save money

Because the Affordable Care Act will expand health insurance to cover an estimated thirty-two million additional people, new approaches are needed to expand the primary care workforce. One possible solution is Grand-Aides?, who are health care professionals operating under the direct supervision of nurses, and who are trained and equipped to conduct telephone consultations or make primary care home visits to patients who might otherwise be seen in emergency departments and clinics. We conducted pilot tests with Grand-Aides in two pediatric Medicaid settings: an urban federally qualified health center in Houston, Texas, and a semi-rural emergency department in Harrisonburg, Virginia. We estimated that Grand-Aides and their supervisors averted 62 percent of drop-in visits at the Houston clinic and would have eliminated 74 percent of emergency department visits at the Virginia test site. We calculated the cost of the Grand-Aides program to be $16.88 per encounter. That compares with current Medicaid payments of $200 per clinic visit in Houston and $175 per emergency department visit in Harrisonburg. In addition to reducing health care costs, Grand-Aides have the potential to make a substantial impact in reducing congestion in primary care practices and emergency departments.     

Insurance or a regular physician: which is the most powerful predictor of health care?

OBJECTIVES: This study compared the relative effects on access to health care of relationship with a regular physician and insurance status. METHODS: The subjects were 1952 nonretired, non-Medicare patients aged 18 to 64 years who presented with 1 of 6 chief complaints to 5 academic hospital emergency departments in Boston and Cambridge, Mass, during a 1-month study period in 1995. Access to care was evaluated by 3 measures: delay in seeking care for the current complaint, no physician visit in the previous year, and no emergency department visit in the previous year. RESULTS: After clinical and socioeconomic characteristics were controlled, lacking a regular physician was a stronger, more consistent predictor than insurance status of delay in seeking care (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.2, 2.1), no physician visit [OR] = 4.5%, 95% CI = 3.3, 6.1), and no emergency department visit (OR = 1.8, 95% CI = 1.4, 2.4). For patients with a regular physician, access was no different between the uninsured and the privately insured. For privately insured patients, those with no regular physician had worse access than those with a regular physician. CONCLUSIONS: Among patients presenting to emergency departments, relationship with a regular physician is a stronger predictor than insurance status of access to care.     

Development and implementation of an emergency department telephone follow‐up system

Implementing a telephone follow‐up system after a patient's emergency department (ED) visit is challenging, but it may improve patient safety and care. This study's objective was to describe the development and implementation of a comprehensive ED telephone follow‐up system over a 9‐year period. Discharged patients who received a follow‐up telephone call within 48 hours of their ED visit included all pediatric patients, those who left without being seen by a provider, and any adult patient with a “high‐risk chief complaint,” which was defined as a headache, visual problem, chest pain, dyspnea, abdominal pain, syncope, trauma, and neurological‐related problems. There were 127 524 cases that met criteria to receive a follow‐up call, with 138 331 attempted calls being made and 46 114 (36.2%) cases successfully followed up. Forty‐two percent of pediatric cases and 16% of patients who left without being seen were successfully contacted with a follow‐up call; 1.6% of cases were referred to the CQI Committee. In the 9 years prior and after implementation of this follow‐up system, there were 3.5 (95% confidence interval [CI] = 2.1–5.9) and 2.5 (95% CI = 1.3–4.5) medical malpractice lawsuits per 100 000 ED patient visits, respectively; this represented a 28.6% reduction. A comprehensive telephone follow‐up program can be developed and implemented utilizing available resources.     

Unraveling the mystery of pain in chronic pancreatitis.

Over 95% of patients with chronic pancreatitis have intractable abdominal pain. The etiology of the pain remains unclear and is considered multifocal. Treating pain associated with chronic pancreatitis requires a comprehensive approach. This care model encompasses interventional, medical, and adjuvant therapies for both pain and symptom management. Maximizing pain and symptom management in patients with chronic pancreatitis results in timely discharges from the hospital, fewer readmissions, and overall decrease in emergency department visitations. Proper assessment and management of pain and symptoms in patients with chronic pancreatitis improves overall quality of life.     

Care management cuts ED use for pain

A pain care management program at Kootenai Medical Center has resulted in a 77% decrease in emergency department visits by patients whose primary complaint was pain. Case managers are alerted when patients with a history of repetitive visits present to the emergency department. They work with the emergency department physicians on a treatment plan and help them identify a primary care physician and make an appointment for follow-up care. Patients receive non-narcotic pain relief whenever possible and may be referred to a physical therapist if appropriate.     

A case of acute focal bacterial nephritis]

We report a case of acute focal bacterial nephritis (AFBN). A 30-year-old female patient visited Kyushu Rosai hospital with complaints of right flank pain and a fever of 3 days duration. She was immediately admitted, but still suffered from flank pain after 3 days of antibiotic therapy. Abdominal CT scan detected a focal mass lesion in the mid portion of the right kidney. Her clinical symptoms improved after 7 days of chemotherapy, and she was discharged. The mass lesion in the kidney disappeared after one month, she remained free of symptoms, and renal function was normal when followed up nineteen months later.     

Does concordance with guideline triage recommendations affect clinical care of patients with possible acute coronary syndrome?

BACKGROUND: The Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline recommends outpatient management for patients at low risk and admission to a monitored bed for patients at intermediate-high risk of adverse short-term outcomes, but the clinical consequences of adhering to these recommendations are unclear. METHODS: This analysis included 7466 adults who presented to the emergency department (ED) with symptoms of possible acute coronary syndrome (ACS) and who participated in 3 prospective clinical effectiveness trials during the period 1993 to 2001. The authors used logistic regression to assess the impact of concordance with guideline triage recommendations on subsequent diagnostic testing, follow-up care, and 30-day mortality and applied propensity score methods to adjust for selection bias. RESULTS: Among low-risk patients (n = 1099), ED discharge was not associated with higher mortality and did not increase the need for emergency care or hospitalization during follow-up (adjusted odds ratio [OR] = 1.0, 95% confidence interval [CI] = 0.63-1.6 for ED revisits); however, 1.7% of discharged low-risk patients had confirmed ACS. Among intermediate- to high-risk patients (n = 6367), admission to a monitored bed was not associated with reduction in 30-day mortality but significantly reduced the need for follow-up ED care (adjusted OR = 0.81, 95% CI = 0.69-0.96). CONCLUSIONS: This analysis supports the practice of discharging low-risk ED patients with symptoms of possible ACS but highlights the need to arrange timely follow-up (or to perform additional risk stratification in the ED prior to discharge). It also confirms the benefit of admitting ED patients with intermediate- to high-risk characteristics to a monitored bed.     

Health Care Utilization of Refugee Children After Resettlement

Refugee children can have significant health problems. Our objective was to describe health status and health care utilization of refugee children after resettlement. A retrospective chart review of refugee children was performed. Initial laboratory data was extracted. Primary care visits, emergency room visits, and subspecialty referrals in the first 15 months from arrival were recorded. The sample included 198 refugees, many with positive initial screening tests. After arrival, 21% had an emergency department visit, 40% had a primary care sick visit, and 71% had a primary care follow-up. Mean number of visits ranged from 0.3 for emergency department to 1.9 for follow-up. Fifty-seven percent were referred to at least one subspecialist. Refugee children had substantial disease burden at arrival. Most had primary care follow-up visits and subspecialty referral after resettlement. These visits were largely for problems identified on initial screening and for general pediatric illnesses.     

Pathways to the diagnosis of colorectal cancer: an observational study in three UK cities

BACKGROUND: Colorectal cancer can present in a variety of ways, and with any of several symptoms. Different referral routes from primary to secondary care cater for these different presentations. The route that has received most investment in the UK National Health Service is the 2-week clinic, but the proportions of patients taking this and other routes to diagnosis are largely unknown. METHODS: We designed an observational audit in Exeter, Oxford and Sheffield, UK. Colorectal cancers diagnosed in 2002 from participating practices were identified and the presence and timing of seven important clinical features noted: diarrhoea, constipation, rectal bleeding, abdominal pain, the finding of an abdominal or rectal mass on examination, anaemia and positive faecal occult blood tests. The referral pathways to secondary care were identified. RESULTS: Of the 151 patients studied, 112 (74%) were referred with at least one clinical feature of colorectal cancer to a specialist. Only 43 of these (28% of the total) were referred to a 2-week clinic; 39 patients (26% of the total) had an emergency admission, of whom 10 (7%) had their emergency admission after referral to a specialist for investigation but before a diagnosis had been established. The time intervals between the first consultation with a symptom of cancer and referral were mostly short. CONCLUSION: Patients with colorectal cancer travel several different pathways to diagnosis. The pathway with the most resources-the 2-week clinic-is used by a minority of patients.