Academic Medical System Research Articles

409 The Impact of Level Loading in a Large Academic Medical System

409 The Impact of Level Loading in a Large Academic Medical System

Understanding the Scope of Acute Care Vascular Surgery at a Tertiary Academic Medical System

The restructuring of nonelective general surgery and nationwide implementation of the acute care surgery paradigm has improved patient outcomes and healthcare resource utilization. Although vascular surgery maintains one of the highest acuity rates among surgical specialties, the acute care vascular surgery (ACVS) practice model has not been widely accepted. In the present study, we investigate the scope and burden of ACVS at a tertiary academic medical system. All vascular surgical procedures performed at three hospitals comprising a large tertiary academic medical system were retrospectively queried through electronic medical records. Data were collected on procedure, acuity, timing of intervention, primary service, admission type, and total costs and charges. Patients were stratified by acuity of surgical intervention, with ACVS being defined as urgent or emergent operation. A total of 12,689 vascular surgeries were performed from 2018 to 2022. ACVS procedures comprised 22.1% of this total (n=2,803; 12.5% urgent, 9.6% emergent), with an annual burden ranging from 19.1% to 28.3%. Vascular surgeons served as primary surgeon in 91.3% of ACVS and cosurgeon in 8.7%. Fourteen separate surgical specialties requested acute vascular assistance, with the most frequently consulting specialties, including trauma or acute care surgery (ACS) (n=109, 3.9%) and cardiac surgery (n=74, 2.6%). ACVS cases were more frequently performed during after-hours (30.7% vs 11.6%) and on weekends (27.1% vs 2.0%) compared with elective vascular procedures (P<0.0001 each). The majority of ACVS cases originated from inpatient (n=2,353, 85.0%) and emergency department (n=379, 13.5%) consultations. Overall, ACVS generated $37.5 million in charges, accounting for 14% of total procedure-related charges over the study period. ACVS comprises a substantial portion of modern vascular practice and is associated with significant human and healthcare resource expenditure. These data support the development of practice models dedicated to acute vascular surgical care.

ANAL CANCER SCREENING PRACTICES AMONG HIGHER-RISK POPULATIONS IN AN ACADEMIC MEDICAL SYSTEM.

While some experts recommend anal cancer screening for disproportionally affected populations including people living with HIV (PWH), condyloma acuminata, human papillomavirus (HPV)-associated gynecologic dysplasia and cancers, and solid organ transplants, actual screening practices remain understudied. Our objective was to characterize anal cancer screening practices among higher-risk populations in an academic medical system with access to high-resolution anoscopy (HRA). We extracted outpatient clinical data for the above populations from 01/01/2015 - 08/01/2022 at three sites of an academic medical system. Data included patients' demographics, medical comorbidities, and anal cytology and HPV testing results. We used chi-squared tests and logistic regression to assess for associations between patient characteristics and anal cancer screening. Of 7654 patients, 6.3% received anal cytology screening at least once including 21.7% of PWH, 13.8% of people with condyloma acuminata, 1.1% of people with gynecologic cancers, and 0.5% of people with solid organ transplants. In multivariable analysis, Black patients were 46% less likely to receive screening than white patients (95% confidence interval [CI] 0.40-0.71), and cisgender women were 73% less likely to receive screening than cisgender men (95% CI 0.20-0.38). Of 485 individuals who received anal cytology screening, 37.5% were only screened once and 70.5% had abnormal cytology on one or more screenings. Only one-fifth of PWH received anal cancer screening and other higher-risk populations had even lower screening rates. Black patients and women were also less likely to be screened. Strategies to improve equitable screening practices for anal cancer are needed.

Impact of the COVID-19 Pandemic on Foodborne Disease Healthcare-Seeking Behavior and Diagnoses at a Large Academic Medical System.

The objective of this study was to examine changes in healthcare-seeking behaviors and diagnostic practices around foodborne illness during the COVID-19 pandemic in a large university-based health system. A retrospective cohort study of individuals diagnosed with pathogens commonly transmitted through food between 2015 and 2020 was undertaken using electronic medical record data. Regression models were used to compare measured incidence rates of various foodborne pathogens as well as associated healthcare-seeking behaviors during the pandemic year of 2020 to previous years. Incidence of campylobacteriosis, cholera, and norovirus in 2020 significantly decreased, respectively, by 65.5% (p < 0.01), 90.1% (p = 0.02), and 73.0% (p = 0.03) compared with an average from 2017- to 019. Average annual visits for patients included in our sample significantly increased by 8.0% when comparing the average from 2017-2019 to 2020 (p < 0.01). These results suggest that the pandemic impacted healthcare use related to foodborne disease either due to reduced exposure to foodborne pathogens or reduced willingness to seek healthcare.

Adherence to CDC Guidelines for mpox Evaluation: Practice Patterns Across an Academic Medical System During the 2022 Epidemic.

Patients with suspected mpox presented to different venues for evaluation during the 2022 outbreak. We hypothesized that practice patterns may differ across venue of care. We conducted an observational study of patients undergoing mpox testing between 1 June 2022 and 15 December 2022. We assessed concomitant sexually transmitted infection (STI) testing, sexual history, and anogenital examination and a composite outcome of all 3, stratified by site. Venue of care was defined as ED (emergency department or urgent care), ID (infectious disease clinic), or PCP (primary care or other outpatient clinic). Of 276 patients included, more than half (62.7%) were evaluated in the ED. Sexual history, anogenital examination, and STI testing were documented as performed at a higher rate in ID clinic compared to ED or PCP settings. STIs were diagnosed in 20.4% of patients diagnosed with mpox; syphilis was the most common STI among patients diagnosed with mpox (17.5%). Patients evaluated in an ID clinic had higher odds ratio of completing all 3 measures (adjusted odds ratio, 3.6 [95% confidence interval, 1.4-9.3]) compared to PCP setting adjusted for age, gender, and men who have sex with men status. Cisgender men who have sex with men, transgender males, and transgender females had higher odds ratio of completing all 3 measures compared to cisgender females (adjusted odds ratio, 4.0 [95% confidence interval, 1.9-8.4]) adjusted for age and venue of care. Care varied across clinical sites. ID clinics performed a more thorough evaluation than other venues. Rates of STI coinfection were high. Syphilis was the most common STI. Efforts to standardize care are important to ensure optimal outcomes for patients.

Change in suicidal ideation, depression, and anxiety following collaborative care in the community

BackgroundThe Collaborative Care Model (CoCM) increases access to mental health treatment and improves outcomes among patients with mild to moderate psychopathology; however, it is unclear how effective CoCM is for patients with elevated suicide risk.MethodsWe examined data from the Penn Integrated Care program, a CoCM program including an intake and referral management center plus traditional CoCM services implemented in primary care clinics within a large, diverse academic medical system. In this community setting, we examined: (1) characteristics of patients with and without suicidal ideation who initiated CoCM, (2) changes in suicidal ideation (Patient Health Questionnaire-9 [PHQ-9] item 9), depression (PHQ-9 total scores), and anxiety (Generalized Anxiety Disorder Scale-7 scores) from the first to last CoCM visit overall and across demographic subgroups, and (3) the relationship between amount of CoCM services provided and degree of symptom reduction.ResultsFrom 2018 to 2022, 3,487 patients were referred to CoCM, initiated treatment for at least 15 days, and had completed symptom measures at the first and last visit. Patients were 74% female, 45% Black/African American, and 45% White. The percentage of patients reporting suicidal ideation declined 11%-7% from the first to last visit. Suicidal ideation severity typically improved, and very rarely worsened, during CoCM. Depression and anxiety declined significantly among patients with and without suicidal ideation and across demographic subgroups; however, the magnitude of these declines differed across race, ethnicity, and age. Patients with suicidal ideation at the start of CoCM had higher depression scores than patients without suicidal ideation at the start and end of treatment. Longer CoCM episodes were associated with greater reductions in depression severity.ConclusionsSuicidal ideation, depression, and anxiety declined following CoCM among individuals with suicidal ideation in a community setting. Findings are consistent with emerging evidence from clinical trials suggesting CoCM’s potential for increasing access to mental healthcare and improving outcomes among patients at risk for suicide.

Diagnostic Yield of Patients Undergoing Evaluation of Possible Superior Canal Dehiscence.

To characterize the diagnostic yield of patients undergoing evaluation for superior canal dehiscence syndrome (SCDS), and identify alternative conditions diagnosed in patients suspected of, but not ultimately diagnosed with, SCDS. Diagnostically undifferentiated adult patients suspected of having SCDS were identified between 2016 and 2021 at a tertiary academic medical system. Patients were categorized by diagnostic testing, radiographic superior semicircular canal (SSC) abnormality, symptoms, evaluating clinician specialty, operative intervention, and diagnosis. Differences among groups were assessed for statistical significance. Of 1242 candidate patients, 477 met inclusion criteria-evaluation by a clinician with SCDS on their differential diagnosis prior to diagnostic imaging. The mean (SD) age was 53.0 (15.0) years and 70.6% were female. A total of 364 patients underwent subsequent diagnostic imaging, and among these, 164 (45.1%) had a radiographic SSC abnormality with 99 (27.2%) receiving a diagnosis of SCDS (two cases of "near dehiscence syndrome"). One third (33.3%) of patients with SCDS underwent operative repair. Most clinicians with the initial suspicion for SCDS were otolaryngologists (90.6%), who had greater diagnostic yield than clinicians from other specialties (22.2% vs. 6.7%, p = 0.012). Patients not diagnosed with SCDS alternatively received 21 unique diagnoses and 52.1% (138/265) were not definitively diagnosed with any condition. This study characterizes the diagnostic incidence, or yield, of newly identified radiographic SSC abnormalities (45.1%) and SCDS (27.2%) among people suspected of having SCDS. Considerable overlap in presentation between SCDS and other conditions exists, and there is need for improvement in efficiently diagnosing patients with SCDS and audio-vestibular complaints in general. III Laryngoscope, 134:4095-4100, 2024.

Evaluating Prescriber Adherence to a Standardized Postoperative Opioid Prescription Protocol for Cubital Tunnel Surgery

Concerns regarding the ongoing opioid epidemic have led to the implementation of standardized postoperative opioid-prescribing protocols for many common hand surgical procedures. This study investigated patient- and procedure-specific factors affecting adherence to a standardized postoperative opioid-prescribing protocol after cubital tunnel surgery. A retrospective review of patients who underwent primary cubital tunnel surgery within one academic medical system between October 1, 2016 (after the implementation of a standardized postoperative opioid-prescribing protocol) and March 1, 2020 was performed. Patients aged <18 years or with a history of revision surgery, prior traumatic ulnar nerve injury, additional concurrent surgical procedures, or a surgeon not participating in the protocol were excluded. Patient demographics, comorbidities, prior opioid history, and surgical variables were recorded. The primary outcome was adherence to the standardized postoperative opioid-prescribing protocol. A bivariate statistical analysis was performed. Ninety-eight patients were included. The median initial postoperative prescription amount was 75 morphine equivalent units (100% of protocol target) for 78 patients (80% of cohort) who underwent in situ decompression and 75 morphine equivalent units (50% of protocol target) for 20 patients (20% of cohort) who underwent decompression with ulnar nerve transposition. Forty-nine percent of initial opioid prescriptions adhered to protocol, compared with 26% below target and 26% above target. In the bivariate analysis, recent opioid prescriptions within 3 months preoperatively were associated with improved prescriber protocol adherence; longer tourniquet time and anterior transposition were associated with prescriptions below target, and in situ decompression was associated with prescriptions above target. Variation in postoperative opioid-prescribing patterns persists despite the implementation of a standardized postoperative opioid-prescribing protocol. Recent opioid prescriptions were associated with protocol adherence, possibly reflecting increased provider vigilance in this patient population. Differing target prescription amounts for in situ decompression versus decompression with anterior transposition may be unnecessary. Therapeutic IV.

Access to Otolaryngologic Telemedicine Care Across the COVID-19 Pandemic at an Urban Tertiary Hospital System.

Objective: To describe associations between patients' demographic characteristics and access to telemedicine services in an urban tertiary academic medical system across the COVID-19 pandemic, and to identify potential barriers to access. Methods: This was a retrospective cohort study conducted at a single-center tertiary academic medical center. The study included adult patients undergoing outpatient otolaryngologic care in person or via telemedicine during 8 week timeframes: before the pandemic, at the onset of the pandemic, and during later parts of the pandemic. Patients were characterized by age, sex, race, insurance type, primary language, portal activation status, income estimate, and visit type. Where appropriate, chi-squared tests, Wilcoxon signed-rank tests, and logistic regression were used to compare demographic factors between the cohorts. Results: A total of 14,240 unique patients [median age, 58 years (range, 18-107 years); 56.5% were female] resulting in a total of 29,457 visits (94.8% in-person and 5.2% telemedicine) were analyzed. Patients seen in person were older than those using telemedicine. Telemedicine visits included a higher proportion of patients with private insurance, and fewer patients with government or no insurance compared to in-person visits. Race, income, and English as primary language were not found to have a significant effect on telemedicine use. Conclusion: In an urban tertiary medical center, we found significant differences in sociodemographic characteristics between patients who accessed otolaryngologic care in person versus via telemedicine through different phases of the COVID pandemic, reflecting possible barriers to care associated with telemedicine. Further studies are needed to develop interventions to improve access.

Meaningful Engagement in Depression and Anxiety Collaborative Care: Associations With Systematic Case Review

BackgroundCollaborative Care (CC) is an evidence-based model of care for treating behavioral health conditions in primary care settings. The Collaborative Care (CC) team consists of a primary care provider (PCP), behavioral health care manager (CM), and a consultant psychiatrist who collaborate to create treatment plans. To date, there is limited data on factors associated with meaningful engagement in CC programs. ObjectiveTo identify the proportion of patients who were meaningfully engaged and to investigate the factors associated with meaningful engagement in a CC program. MethodsData was collected from a CC program implemented across 27 adult primary care clinics in a Midwestern, U.S. academic medical system. Logistic regression (n=5218) was used to estimate the odds of receiving meaningful engagement. ResultsData was collected from 6,437 individuals with 68% being female and a mean age of 45 years old (SD 17.6). Overall, 57% of patients were meaningfully engaged, however, this proportion differed based on demographic and clinical factors. Among modifiable clinical factors, systematic case reviews between the CM and psychiatrist (OR: 10.2, 95% CI: 8.6-12.1) and warm handoffs (OR: 1.3, 95% CI: 1.1-1.5) were associated with higher likelihood of receiving meaningful engagement. ConclusionsThe presence of systematic case reviews between the behavioral health care manager and the consultant psychiatrist was highly associated with meaningful engagement. When implementing such programs, high fidelity to the core principles including regularly scheduled systematic case reviews should be pursued.

The implementation and impact of an advanced practice recognition program.

Meaningful job recognition is a pillar for sustaining healthy work environments and proven beneficial for job satisfaction and retention. However, few dedicated award recognition programs exist for advanced practice registered nurses (APRNs), and no available literature evaluates the impact on professional practice, sense of belonging, and job retention or satisfaction. The purpose of this study was to introduce a novel award recognition program for APRNs and physician associates (PAs) in a large academic medical system and evaluate it's impact on job satisfaction, retention, and sense of belonging. Five awards were created to recognize areas of achievement for clinically practicing APRNs or PAs within an academic health system. Nomination letters were collected, deidentified, and reviewed by an award committee. Winners were announced and received a plaque. A survey was sent to employed APRNs evaluating their response to the program. The survey was sent to both APRNs (83%) and PAs (17%). Survey end points included job satisfaction, willingness to stay in role for 1 and 5 years, sense of community, something to work toward, and increasing recognition of APRNs. Results showed statistical significance in three areas. Advanced practice registered nurses or PAs who were aware of award opportunities and/or nominated for an award showed higher job satisfaction, more likely to stay in job for 1 year, and felt a greater level of recognition. Dedicated APRN award programs may have a positive impact on job satisfaction and retention. This model may be extrapolated to provide greater opportunities for meaningful recognition among clinical APRNs.

THE PRACTICE AND PERCEPTION OF LOW RESIDUE DIETS IN ADULT PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Abstract BACKGROUND Low residue diets have been traditionally recommended during disease flares or post-operatively in patients with inflammatory bowel disease (IBD) for the purported benefits of reduced pain or lower risk of bowel obstruction. However, these diets may not be healthy if consumed long-term and can adversely impact quality of life. It remains controversial whether such diets are truly beneficial, and the scale of such dietary practice remains unknown. METHODS A survey was conducted to better understand the practice and the perception related to low residue diet recommendations among patients with IBD at a large academic medical system in the United States. Adult patients (age ≥18) with an established diagnosis of IBD were identified using ICD-10 codes in the electronic medical record system. The survey contained 23 questions and was disseminated electronically from August 2023 to October 2023. RESULTS 132 patients (Crohn’s disease: 59, ulcerative colitis: 68, IBD-unclassified: 5) completed the online survey. The median age was 54 years (IQR 41, 67), with a median disease duration of 15 years (IQR 8, 30). Sixty percent of respondents were female. The majority of respondents (57%) reported currently receiving a biologic therapy. 14 (11%) patients reported currently following a low residue diet, and 34 (25%) reported following the diet in the past. Subjects followed the diet for a median duration of 18 months (IQR 6, 72). Among the 48 patients who followed a low residue diet, 33 (69%) reported using the diet to help with disease flare, while 23 (48%) did so to improve IBD symptoms and an additional 9 patients (19%) reported using a low residue diet post-operatively. 32 (67%) were instructed by their healthcare providers to follow this diet; however, only 4 of them were told not to continue this diet indefinitely. Low residue diets were reported to be “very helpful” (n=14, 29%) or “helpful” (n=18, 38%) in improving IBD symptoms. This benefit consisted of reducing pain (65%), bloating (60%), bowel movement frequency (44%), or urgency (38%). However, respondents noted significant adverse impact on quality of life from a low residue diet: 96% reported that the diet at least moderately limited them from eating foods they enjoyed, and 90% reported that it prevented them from eating what they perceived to be a healthy diet. CONCLUSION Within this cohort of individuals with IBD, 36% of survey respondents either followed or had followed a low residue diet. While up to 65% of individuals felt that this may improve abdominal pain, bloating, or other symptoms, almost all individuals felt such a diet limited their intake of foods they enjoy and from eating a healthy diet. Further education is required for providers regarding screening for low residue diet use and its appropriate indications to reduce its negative impact on quality of life.

Transgender Patients Report Lower Satisfaction with Care Received than Cisgender Patients Receiving Care in an Academic Medical Care System.

Purpose: Transgender and gender diverse (TGD) patients experience challenges in health care settings, including stigma, lack of culturally competent providers, and suboptimal gender-affirming care. However, differences in patient satisfaction between TGD patients compared with cisgender patients have been inadequately studied. This study aimed to assess such differences in patient satisfaction with care received in a large academic medical care system in Boston, Massachusetts. Methods: Routine patient satisfaction surveys were fielded from January to December 2021 and were summarized. Logistic regression models compared low net promoter scores (NPS; ≤6) between gender identity groups (cisgender women, transmasculine and nonbinary/genderqueer people assigned female at birth [AFAB], transfeminine and nonbinary/genderqueer people assigned male at birth) relative to cisgender men, adjusting for age, race, ethnicity, education, inpatient/outpatient service delivery, and distance from medical center. Results: Of 94,810 patients, 246 (0.3%) were TGD and 94,549 (99.7%) were cisgender. The mean age was 58.3 years (standard deviation = 16.6). Of the total sample, 17.0% of patients were people of color, 6.6% were Hispanic/Latinx, 48.6% were college graduates, and 2.6% had received inpatient care. In general, patient satisfaction with health care received was lower for TGD patients than for cisgender patients (7.3% vs. 4.5% reporting low NPS; adjusted odds ratio [aOR] = 1.14; 95% confidence interval [CI] = 0.70-1.85). Transmasculine and nonbinary/genderqueer patients AFAB had elevated odds of low NPS compared with cisgender men (8.8% vs. 3.6%; aOR = 1.71; 95% CI = 1.02-2.89). Conclusion: Future research is warranted to better understand factors driving lower ratings among TGD patients. Health care quality improvement efforts are needed to address gender identity inequities in care.

2665. Health Care Provider Characteristics Associated with Anal Cancer Screening in an Academic Medical System

Abstract Background Anal cancer disproportionally affects persons living with HIV (PWH), sexual and gender minorities, and those with gynecologic cancers, condyloma acuminata, and solid organ transplantation. While expert guidance on anal cancer screening exists for PWH, there are no national guidelines for screening any of these populations. We analyzed clinician characteristics associated with anal cancer screening among providers who care for high-risk populations at an academic medical center including infectious disease (ID) specialists, primary care providers (PCPs), and obstetrician/gynecologists (OBGYNs). Methods We retrospectively reviewed medical charts for patients with HIV, gynecologic cancers, condyloma acuminata, solid organ transplantation, and sexual or gender minority status at Beth Israel Deaconess Medical Center and two affiliated clinics from 01/01/2015 - 08/01/2022. We extracted provider specialties, clinic locations, patient panel demographics, and dates of anal cytology and human papillomavirus (HPV) screening tests. We used chi-squared tests to identify provider factors associated with screening. Results Of 1,093 providers, at least one anal cytology test was performed by 93.8% (75/80) of ID providers, 55.2% (376/681) of PCPs, 28.3% (41/145) of OBGYNs, and 24.1% (45/187) of other providers (p &amp;lt; 0.001); among screeners, anal HPV co-testing was performed equally across specialties (54.2%, p = 0.23). Providers were more likely to screen if they cared for PWH (91.8% with 10-49 PWH vs 3.7% for no PWH, p &amp;lt; 0.001), majority cis-men (55.2%, p=0.003), or majority publicly insured patients (51.8%, p &amp;lt; 0.001). Providers were less likely to screen if they cared for majority cis-women (40.9%, p&amp;lt; 0.001) or majority privately insured patients (24.0%, p&amp;lt; 0.001). Screening practices did not differ by the racial composition of providers’ patient panels (p=.21). Conclusion While many ID specialists performed anal cancer screenings, other providers were less likely to screen. Providers caring for many PWH, cis-men, or publicly insured patients were more likely to screen. Additional research is needed to clarify screening guidance and optimize screening practices for all higher-risk populations, especially non-PWH groups. Disclosures Douglas Krakower, MD, Gilead: Grant/Research Support|Merck: Grant/Research Support|U. North Texas Health Sciences Center: Funding for mentoring|UAB: Advisor/Consultant|UpToDate, Inc.: Royalties|Virology Education: Honoraria

Colchicine for cardiovacular risk reduction in lower extremity peripheral artery disease

Abstract Introduction Although recent evidence from randomized trials suggests colchicine can reduce major adverse cardiovascular events (MACE) in patients with coronary artery disease, its effect in lower extremity peripheral artery disease (PAD) is not known.1,2 To make inferences about the effects of colchicine in PAD, we leveraged the variable prescribing practice of adding colchicine versus a non-steroidal anti-inflammatory (NSAID) to urate lowering therapy in patients with gout and PAD. Purpose Estimate the effect of colchicine therapy initiation on adverse cardiovascular and limb events in a real-world sample of high-risk patients with PAD and gout. Methods A pragmatic open-label target trial comparing colchicine initiators (treatment group) to NSAID initiators (control group) was emulated in PAD patients taking either drug in conjunction with initiation of urate lowering therapy. Patients were enrolled between July 2007 and December 2019 using electronic health records from a multi-hospital academic medical system linked to Medicare claims data. Patients with contraindications to colchicine or NSAIDs (e.g., severe kidney disease, hepatic failure) were excluded. Inverse probability of treatment weighting was used to create a pseudopopulation balanced with respect to risk factors for the outcomes. The primary outcome was a 5-year composite of major adverse limb events (MALE), MACE, and all-cause mortality. Secondary outcomes included MALE and death, MACE and death, and individual components of the primary outcome accounting for the competing event of death. Risks were estimated with the Kaplan-Meier estimator for the composite outcomes and the Aalen-Johansen estimator for the competing event outcomes. Percentile based 95% confidence intervals were generated using nonparametric bootstrapping. Results A total of 1,786 patients were enrolled; mean age was 77 years (SD 7), 33% were female, and 9% were non-white race (Table). Maximum absolute standardized mean difference in relevant covariates was 23% prior to weighting and 0.8% after weighting, indicating covariate balance. The risk of the primary composite outcome of MALE, MACE, and death at 5 years was 58% (95% CI 55%, 61%) in the colchicine group and 60% (95% CI 56%, 64%) in the control group, with a risk difference of -2% (-8%, 4%) and risk ratio of 0.96 (0.89, 1.04; Figure). Similar findings were noted in the secondary composite outcomes (Figure). In the analysis accounting for the competing risk of death, the cause-specific risk of MALE (9% colchicine vs. 9% control) and MACE (24% colchicine vs. 26% control) alone were similar at 5 years. Conclusions In a real-world sample of high-risk patients with PAD and gout, colchicine did not appear to reduce the risk of adverse cardiovascular or limb events. The cardiovascular benefits of colchicine in older populations with PAD and advanced systematic atherosclerosis remain uncertain.Table.Patient characteristics.Figure.Weighted Kaplan-Meier estimates.

Abstract 17155: Lipoprotein (a) Testing in an Academic Medical System

Introduction: Lp(a) is a causal risk factor for ASCVD that is often elevated in patients with personal or family history (FHx) of ASCVD. The 2019 ESC guidelines recommend universal Lp(a) testing, while the 2019 AHA/ACC guidelines include Lp(a) as a ‘risk enhancer’. We used electronic health records (EHR) to assess utilization of Lp(a) testing in patients with ASCVD, premature ASCVD, and FHx of ASCVD at Mayo Clinic sites in Rochester MN, Phoenix AZ and Jacksonville FL and the Mayo Clinic Health System (MCHS) from 1999-2021. Methods: We ascertained Lp(a) testing using LOINC codes and ASCVD status using validated ICD/CPT-based algorithms. ASCVD included coronary heart disease (CHD), cerebrovascular disease (CVD) (ischemic stroke and/or carotid artery stenosis), peripheral artery disease, and abdominal aortic aneurysm. Premature ASCVD was defined as occurring in males &lt; 55 years and females &lt; 65 years. We ascertained FHx using EHR survey data from 2017-2021. We estimated the proportion of patients with ASCVD, premature ASCVD, or FHx of ASCVD who underwent Lp(a) testing. Results: Between 1999-2021, we identified 310,760 patients with at least 1 ASCVD subtype of whom 66,710 had premature disease. FHx data was available starting 2017. For the timeframe 2017-2021, we identified 267,177 patients with FHx of ASCVD and 90,269 ASCVD patients. As summarized in Table 1, Lp(a) was tested only in a small proportion of patients; 7% of ASCVD patients, 11% of premature ASCVD patients, and 6% of patients with FHx of ASCVD. Premature CHD patients had the highest testing proportion (17%). Conclusions: Our results demonstrate underutilization of Lp(a) testing in patients with personal or FHx of ASCVD. Lp(a) is one of the mediators of “ASCVD residual risk” in patients on statins, and with new Lp(a)-lowering medications in phase III clinical trials, patient and provider education will be needed to increase awareness of Lp(a) as a modulator of ASCVD risk.

Measurement of the Medial Clear Space: An Intra-Observer Comparison of Various Measurement Methods

Category: Ankle; Trauma Introduction/Purpose: The Medial Clear Space (MCS) is an anatomic space between the lateral cortex of the medial malleolus and the medial cortex of the talus. Measurement of the MCS is helpful in differentiating which ankle fractures are amenable to non- operative treatment, and which may require fixation. The MCS is often evaluated on radiographic views of the ankle, and several different methods of measuring the MCS have been described in the literature. There is little information on intra-observer reliability of MCS measurement, nor validation of the various medial clear space measurement techniques. As such, the aim of this study was to better understand intra-observer reliability of MCS via several of the most popularly described techniques. Methods: Patients with matched ankle X-rays and CT scans - either weight bearing or non-weight bearing imaging pairs - were identified via electronic medical record database review of a Level-1, academic medical system after IRB approval. Measurement of the MCS on CT scan was used as the gold standard against which radiographic measurements were compared given its superior osseous definition. Four independent reviewers measured the medial clear space on 20 weight bearing, and 20 non-weight bearing x-rays via the five most commonly described methods: 5mm inferior to the talar dome (MCS #1), half way down the medial articular surface of the talus (MCS #2), obliquely at the supero-medial corner of the talus (MCS #3), and at the level of the talar dome (MCS #4). Intraclass Correlation Coefficients (ICC) were then calculated for each of the four MCS measurements methods after compilation of all independent reviewer data. Results: The ICC varied between each of the four MCS measurement techniques. For measurements 5mm below the talar dome (MCS #1) the ICC was 0.041. Measured halfway down the medial talar articular surface, the ICC was 0.466. The superior oblique MCS measurement ICC was 0.725, and the MCS measured at the level of the talar dome had an ICC of 0.419. MCS measurement 5mm below the talar dome had poor intra-observer reliability, while measurement halfway down the medial articular surface and at the level of the talar dome had fair intra-observer correlation. Overall, measurement of the MCS at the superomedial talar dome had good intra-observer reliability, ranking as the most favorable measurement method. Conclusion: The commonality of ankle fractures demands accurate radiographic interpretation for the determination of need for surgical intervention. The medial clear space measurement is the most common metric used to determine the need for surgery. There is no consensus regarding the optimal method, nor reliability of the various MCS measurement techniques. The results of this study suggest that measurement of the medial clear space at the superomedial corner of the talar dome has the highest intra- observer reliability.

Addressing Structural Racism Using a Whole-Scale Planning Process in a Single Academic Center.

The murder of George Floyd in 2020 prompted a national demand for cultural transformation to confront the systemic racism prevalent in the country. Academic medical centers were not exempt from this urgent call. This article evaluates the efficacy of a strategic process in fostering cultural transformation within an academic medical system. A whole-scale strategic planning process was implemented over 13 months, involving multiple working groups representing key stakeholders from each entity across the system, an anonymous survey, a communication plan, and a balanced scorecard to monitor progress. More than 5500 voices, 160 recommendations, 122 data gathering sessions, and town hall meetings contributed to the creation and implementation of vital action items and a strategic framework. The Diversity Engagement Survey (DES) was administered 18 months following the process launch. Of the 45,554 employees, students, faculty, and trainees, 96.5% completed unconscious bias education within the fiscal year and 76% of action items, termed "Just Do Its," were completed. Mission, vision, values, and strategic priorities were crafted to serve as a framework for intermediate and long-term actions. The DES revealed improvement in the "respect" attribute of an inclusive culture, and 64% of respondents confirmed that action for cultural transformation is addressing racism both within and outside of the institution. Implementing a shared purpose, engaging multiple working groups representing key stakeholders, and empowerment of stakeholders to implement changes, in conjunction with the development of a strategic framework addressing structural racism, resulted in the completion of vital action items to initiate cultural change.

Associations between delirium and SARS-CoV-2 pandemic visitor restrictions among hospitalized patients

ObjectivesDelirium is associated with increased morbidity and mortality, but environmental and behavioral factors may decrease the risk of developing delirium and thus must be considered. To investigate trends in delirium prevalence and examine associations of visitor restrictions with delirium diagnoses among all patients hospitalized during and prior to the novel coronavirus SARS-CoV-2 (COVID-19) pandemic. Study designRetrospective epidemiological assessment. MethodsThe medical records of all patients (n = 33,141) hospitalized within a three-hospital academic medical center system in a large Midwestern metropolitan area from March 20, 2019, through March 19, 2021, were analyzed. ResultsThe overall prevalence of delirium during COVID-19 was 11.26% (confidence interval [CI]: 10.79%, 11.73%) compared to 9.28% (CI: 8.82%, 9.73%) before COVID-19. From our adjusted logistic regression analyses, we observed that the odds of delirium among non-isolated patients were significantly higher during COVID-19 visitor restrictions (adjusted odds ratio [aOR]: 1.354; 95% CI: 1.233, 1.488; P < 0.0001) than before. The odds of delirium among isolated patients were not significantly higher during COVID-19 visitor restrictions (aOR: 1.145; 95% CI: 0.974, 1.346; P = 0.1006) than before. ConclusionsMedically isolated patients remained at high risk of developing delirium both prior to and during COVID-19 era visitor restrictions. However, non-medically isolated patients had a significantly increased risk of delirium during the social isolation of visitor restrictions compared to prior to visitor restrictions.

Phenobarbital versus benzodiazepines in alcohol withdrawal syndrome.

Phenobarbital, a long-acting barbiturate, presents an alternative to conventional benzodiazepine treatment for alcohol withdrawal syndrome (AWS). Currently, existing research offers only modest guidance on the safety and effectiveness of phenobarbital in managing AWS in hospital settings. The study objective was to assess if a phenobarbital protocol for the treatment of AWS reduces respiratory complications when compared to a more traditionally used benzodiazepine protocol. A retrospective cohort study analyzing adults who received either phenobarbital or benzodiazepine-based treatment for AWS over a 4-year period, 2015-2019, in a community teaching hospital in a large academic medical system. A total of 147 patient encounters were included (76 phenobarbital and 71 benzodiazepine). Phenobarbital was associated with a significantly decreased risk of respiratory complications, defined by the occurrence of intubation (15/76 phenobarbital [20%] vs. 36/71 benzodiazepine [51%]) and decreased incidence of the requirement of six or greater liters of oxygen when compared with benzodiazepines (10/76 [13%] vs. 28/71 [39%]). There was a significantly higher incidence of pneumonia in benzodiazepine patients (15/76 [20%] vs. 33/71 [47%]). Mode Richmond Agitation Sedation Scale (RASS) scores were more frequently at goal (0 to -1) between 9 and 48 h after the loading dose of study medication for phenobarbital patients. Median hospital and ICU length of stay were significantly shorter for phenobarbital patients when compared with benzodiazepine patients (5 vs. 10 days and 2 vs. 4 days, respectively). Parenteral phenobarbital loading doses with an oral phenobarbital tapered protocol for AWS resulted in decreased risk of respiratory complications when compared to standard treatment with benzodiazepines.