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Purpose: The growing geriatric population has unique and often complex oral health care needs. The purpose of this study was to explore the perceptions regarding direct access dental hygienists (DH) regarding the geriatric curriculum needed in dental hygiene education programs to prepare DHs to provide direct access care for geriatric populations. Methods: Purposive and network sampling strategies were used to recruit eligible direct access DHs from across the United States for this qualitative study. Semi-structured telephone interviews were conducted until was met. Demographic data were analyzed using descriptive statistics. Open coding techniques were used to identify themes. Results: Ten direct access DHs agreed to participate. Nine themes emerged from the data analysis: combining didactic and hands-on experience, how direct access differs from traditional practice, importance of a standardized course in entry-level programs, need for a specialty course in geriatrics, understanding the geriatric patient, understanding direct access settings, modifications to treatment modalities, process of care, and interprofessional knowledge. Participants indicated that entry-level dental hygiene students should be exposed to hands-on clinical rotations, have a standardized aging and geriatrics course, and potentially incorporate geriatrics as a specialty tract within dental hygiene programs. Conclusion: Geriatrics may not be covered in sufficient depth to prepare entry-level dental hygiene students for work with these populations in direct access settings. Findings from this study may be used to support improvements in geriatric curriculum for entry-level dental hygiene programs. Future research is needed to determine necessary focus and most effective way to disseminate this curricular content. Key Words: geriatric oral health, geriatrics, dental hygiene education, dental hygiene students, direct access dental hygienists, direct access oral care, dental hygiene workforce models

We report the case of a woman who pursued direct access genetic testing and then presented with concerns regarding a positive test result for Long-QT syndrome. Although the result ultimately proved to be a false positive, this case illustrates that costs associated with follow-up of direct access genetic testing results can be non-trivial for both the patient and for health care systems. Here we raise policy questions regarding the appropriate distribution of these costs. We also discuss the possibility that, when confronted by a direct access genetic test result that reports high risk for one or more actionable diseases, a family physician might feel compelled to act out of a desire to avoid liability, even when information regarding the accuracy and validity of the testing were not easily accessible. This case outlines lessons that can easily be translated into clinical practice, not only by genetic counselors, but also by family physicians, medical specialists and members of the public.

Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)Background and AimsGalway University Hospital has an established ambulatory patient pathway governed by a ‘Direct Access’ policy. This was designed to minimise in- hospital time, maximise patient safety and facilitate Trauma and Plastic Surgery procedures. We conducted a review of this service to quantify volume of use, determine adherence to policy guidance and establish the level of Regional Anaesthesia involvement. Our aims are to promote the policy as a safe sustainable model for ambulatory care that maximises patient safety while increasing local Block Bay throughput.MethodsOperating Theatre records were interrogated to derive the patients recorded as ‘Direct Access’. This was cross-referenced with our Block Bay log to establish patients who were administered a regional block. Electronic records and bed management systems were reviewed to establish adherence to policy in relation to sedation use, conversion to general anaesthesia and length-of-stay. Data was stored within the hospitals network, password protected with vetted select access. Windows Excel was used to process the data.ResultsOf the 261 cases recorded as ‘Direct Access’; 233 were confirmed and included for analysis. Full results are included in attached image of Tables 1-5. Direct Access Pathway Review Abstract: Results Tables Abstract #35885 Table 1DemographicsMean Age 39.6 years(±19) Median Age 34 years Gender 39% Female Abstract #35885 Table 2Total 261 direct access from theatre records Year Patients (Block Bay involvement %) 2019 77 2020 27 (55%) 2021 68 (43%) 2022 85 (46%) Abstract #35885 Table 3Surgical specialityOrthopaedic/Trauma 63% Plastics 29% Other 8% Abstract #35885 Table 4Policy adherence (n=233)Total Sedation 14.6% -Sedation at Block Bay 6.9% -Sedation in Theatre 7.7% Generai Anaesthesia 2.6% Admission & Discharge DOS 91.4% No ln patient Bed Allocated 66.5% Abstract #35885 Table 5Patients admitted overnight (n=20)Mean Age 39.7 (Range 18-80) Gender 30% Female Length of stay 1 night 80% 2 nights 15% 4 nights 5% Discharged DOS 60% Regional Anaesthesia Block 50% Sedation 15% General Anaesthesia 5% ConclusionsOur review reflects a pathway that minimises in-hospital time as 91% cases admitted and discharged on the same day. Policy adherence is high with very low sedation, GA and Overnight-Admission rates. The overall number of ‘Direct Access’ cases highlights the need for promotion of this pathway locally to increase traffic through our Block Bay which will benefit both patients and Anaesthesia trainees alike.Direct Access service review Results Tables 1-5

Direct access to physical therapy (DAPT) is the patient’s ability to self-refer to a physical therapist, without previous consultation from any other professional. This model of care has been implemented in many healthcare systems since it has demonstrated better outcomes than traditional models of care. The model of DAPT mainly focuses on the management of musculoskeletal disorders, with a huge epidemiological burden and worldwide healthcare systems workload. Among the healthcare professionals, physical therapists are one of the most accessed for managing pain and disability related to musculoskeletal disorders. Additionally, the most updated guidelines recommend DAPT as a first-line treatment because of its cost-effectiveness, safety, and patients’ satisfaction compared to other interventions. DAPT was also adopted to efficiently face the diffuse crisis of the declining number of general practitioners, reducing their caseload by directly managing patients’ musculoskeletal disorders traditionally seen by general practitioners. World Physiotherapy organization also advocates DAPT as a new approach, with physical therapy in a primary care pathway to better control healthcare expenses. Thus, it is unclear why the Italian institutions have decided to recognize new professions instead of focusing on the growth of physical therapy, a long-established and autonomous health profession. Furthermore, it is unclear why DAPT is still not fully recognized, considering the historical context and its evidence. The future is now: although still preliminary, the evidence supporting DAPT is promising. Hard skills, academic paths, scientific evidence, and the legislature argue that this paradigm shift should occur in Italy.

The present study explored the experiences of working individuals with low back pain regarding self-management, fear of movement and pain during a 12-month follow-up period after receiving either direct access (DA) or conventional physical therapy. Data were collected through electronic questionnaires containing open-ended questions on physical therapy, fear of movement and pain. These were administered at baseline (after the initial physical therapy visit) and at 3-, 6-, and 12- month follow-ups. Participants were clients from real-life clinical settings in primary care or emergency departments. Fifteen participants completed all follow-ups; ten from DA and five from conventional physical therapy. Two distinct client types emerged: the , who actively engaged in recovery with support from the physical therapist, and the , who adopted a more passive approach by avoiding pain-inducing activities. These types were reflected in two main categories: 1) \"Understanding my pain\", with three subcategories: Nature of my pain, Daily living with my pain, and Knowing the cause of my pain, and 2) \"Managing my pain\", with three subcategories: Ownership of my recovery, Courage to be active, and Relieving pain. The findings underscore the individualized nature of self-management, fear of movement and pain experiences over 12 months follow-up. While personal strategies varied, guidance from physical therapist appeared instrumental in supporting the adoption of an active pilot-like role in recovery.

The American Dental Hygienists Association (ADHA) defines direct access as the ability of a dental hygienist to initiate treatment based on their assessment of patients needs without the specific authorization of a dentist, treat the patient without the physical presence of a dentist, and maintain a provider-patient relationship. In 2000 there were nine direct access states; currently there are 42 states that have authorized some form of direct access. The ADHA has been instrumental in these legislative initiatives through strong advocacy efforts. While research and data support the benefits of direct preventive/therapeutic care provided by dental hygienists, many barriers remain. This paper chronicles key partnerships which have influenced and advocated for direct access and the recognition of dental hygienists as primary health care providers. The National Governors Association (NGA) released a report in 2014 suggesting that dental hygienists be deployed outside of dental offices as one strategy to increase access to oral health care along with reducing restrictive dental practice acts and increasing the scope of practice for dental hygienists. The December 2021 release of the National Institutes of Health report, Oral Health in America, further supports greater access to dental hygiene preventive/therapeutic care. This paper also reflects on opportunities and barriers as they relate to workforce policy, provides examples of effective state policies, and illustrates an educational curriculum specifically created to prepare dental hygienists to provide oral health services in settings outside of the dental office. Dental hygiene education must ensure that graduates are future-ready as essential health care providers, prepared to deliver direct access to dental hygiene care.

Background In the United States, more than a third of patients are referred to specialists each year; however, most of these referrals do not lead to completed appointments. At the Grady Health System (GHS), our large safety net hospital system, the initial gastroenterology (GI) referral process suffered from multiple inefficiencies, creating barriers to care. We aimed to improve GI referrals with both a triage and a direct-to-endoscopy program to relieve systemic barriers to GI care at GHS especially around colorectal cancer screening. Methods Given wait times for GI services and employee dissatisfaction with navigating patients through the referral process, a GI smart order set was built using the Epic electronic medical record. The process took 8 months and included automated anesthesia screening as well as periprocedural guidance on blood thinners. We measured time from placement of referral for screening colonoscopy to scheduling of the screening colonoscopy to assess improvement in wait times for GI services. Key results In our pre-implementation survey, 60% of providers placed at least one urgent referral a month, and 55% of providers were either somewhat or very dissatisfied with the referral process. This led to the creation of multiple unofficial and only partially successful bypasses to expedite GI care. With the new GI smart order set, there was a 93% reduction over 12 months in the time from providers screening colonoscopy referral request to procedure scheduling from an average of 422 to 28 days. In addition, overall rates of colorectal cancer screening increased approximately 6% from 43.5 to 49% since the order set was implemented. Conclusions This novel outpatient GI referral smart order set addressed multiple barriers to care and created a novel triage mechanism as well as a direct-to-endoscopy referral stream. This model can be used to improve triaging and increase access to GI and other specialist services.

Background. Direct access in physiotherapy (DAPT) occurs when a patient has the ability to self-refer to physical therapy without physician referral. This model of care in musculoskeletal diseases (MSDs) has shown better outcomes than the traditional-based medical model of care that requires physician referral to access physiotherapist services. This traditional physician referral often results in a delay in care. Unfortunately, DAPT is still not permitted in many countries. Objectives. The primary objective of this systematic review was to compare the effectiveness, safety, and the accuracy of DAPT compared to the physician-led model of care for the management of patients with musculoskeletal disorders. The secondary objective of the present study is to define the physiotherapists’ characteristics or qualifications involved in DAPT. Materials and methods. Databases searched included: Medline, Scopus and Web of Science. Databases were searched from their inception to July 2022. Research strings were developed according to the PICO model of clinical questions (patient, intervention, comparison, and outcome). Free terms or synonyms (e.g., physical therapy; primary health care; direct access; musculoskeletal disease; cost-effectiveness) and when possible MeSH (Medical Subject Headings) terms were used and combined with Boolean operators (AND, OR, NOT). Risk of bias assessment was carried out through Version 2 of the Cochrane risk-of-bias tool (ROB-2) for randomized controlled trials (RCTs) and the Newcastle Ottawa Scale (NOS) for observational studies. Authors conducted a qualitative analysis of the results through narrative analysis and narrative synthesis. The narrative analysis was provided for an extraction of the key concepts and common meanings of the different studies, while the summary narrative provided a textual combination of data. In addition, a quantitative analysis was conducted comparing the analysis of the mean and differences between the means. Results. Twenty-eight articles met the inclusion criteria and were analyzed. Results show that DAPT had a high referral accuracy and a reduction in the rate of return visits. The medical model had a higher use of imaging, drugs, and referral to another specialist. DAPT was found to be more cost-effective than the medical model. DAPT resulted in better work-related outcomes and was superior when considering patient satisfaction. There were no adverse events noted in any of the studies. In regard to health outcomes, there was no difference between models. ROB-2 shows an intermediate risk of bias risk for the RCTs with an average of 6/9 points for the NOS scale for observational studies. Conclusion. DAPT is a safe, less expensive, reliable triage and management model of care that results in higher levels of satisfaction for patients compared to the traditional medical model. Prospero Registration Number: CRD42022349261.

Background Non-pharmacologic treatments such as physical therapy (PT) are advocated for musculoskeletal pain. Early access to PT through self-referral has been shown to decrease costs and improve outcomes. Although self-referral is permitted in most U.S. states and supported by some health insurance plans, patients’ utilization of self-referral remains low. Objective To identify factors, beyond legislative policies and health insurance, associated with patients’ decisions to access physical therapy through self-referral or provider-referral. Methods We recruited 26 females and 6 males whose employer-sponsored insurance benefits included financial incentives for self-referral to physical therapy. Between August 2017 and March 2018, participants completed semi-structured interviews about their beliefs about physical therapy and reasons for choosing self-referral (15 participants) or provider referral (17 participants) for accessing physical therapy. Grounded theory approach was employed to identify themes in the data. Results Patients selecting self-referral reported major thematic differences compared to the provider-referral patients including knowledge of the direct access program, attitudes and beliefs about physical therapy and pharmacologic treatment, and prior experiences with physical therapy. Self-referral patients were aware that their plan benefits included reduced cost for self-referral and felt confident in selecting that pathway. They also had negative beliefs about the effectiveness of pharmacological treatments and surgery, and previously had positive direct or indirect experiences with physical therapy. Conclusion Knowledge of the ability to self-refer, attitudes and beliefs about treatment, and prior experience with physical therapy were associated with self-referral to physical therapy. Interventions aimed at improving knowledge and changing attitudes toward self-referral to physical therapy to increase utilization appear warranted.

With the advancement of high-speed rail technology and the expansion of intercity railway networks in China, improving the service quality of train schedules has become crucial. Currently, some intercity railways have the conditions for periodic transportation, but relevant research is still incomplete. This paper establishes an optimization model for the formulation of periodic intercity train schedules based on the PESP model. The model investigates the rationality of passenger flow demand under different direct access rates, with the objective of minimizing the total operation time of trains. It solves the relationship between the total operation time and the direct access rate for periodic intercity trains. An example study of the Chengdu-Mianyang-Lezhi intercity railway is conducted to validate the rationality and effectiveness of the model. This study provides a method for addressing the relationship between train operation schedules and passenger flow demand under the periodic model.