Advanced Practice Practitioners Research Articles

Therapeutic radiographer prescribing practices in the United Kingdom: Questionnaire survey

IntroductionNon-medical professionals in the United Kingdom (UK) have been granted prescribing rights to improve patient care quality and cost-effectiveness. There is limited evidence on how therapeutic radiographer prescribers have impacted medicine management or patient services. MethodsAn online survey was conducted amongst non-medical prescribing therapeutic radiographers in the UK between 2019 and 2022. The study teams initially analysed the individual data sets, subsequently combined, and secondary analysis was performed to provide a UK perspective, to understand the services provided and identify areas for improvement. Data was analysed using descriptive statistics from Microsoft Excel® and SPSS®. Results74 non-medical prescribing therapeutic radiographers who were predominantly over 40 years old and in full-time work participated. The main job categories were consultant radiographers (n = 23, 31.1%) and advanced practice practitioners (n = 18, 24.3%). Many use their prescribing qualifications (87.5%, n = 62), issuing a mean of 15 independent and seven items by supplementary and prescribing per week. Most received assessment and diagnostic skills training before prescribing courses (91.6%, n = 67). Respondents prescribed from a median of six areas, with the highest being in GI (82%), skin (68%), infections (58%), urinary tract disorders (55%) and ear, nose, and oropharynx conditions (54%). ConclusionThis study presents the first report on therapeutic radiographers prescribing in the UK, offering insights into current practices and highlighting the success of non-medical prescribing. Therapeutic radiographers’ roles continue to expand into advanced practice and medicine-prescribing responsibilities, contributing to holistic and patient-centred care. Implications for practiceThe results are relevant for nations grappling with oncology workforce shortages and contemplating similar roles for therapeutic radiographers. The study can be a valuable resource for policymakers and healthcare organisations worldwide.

Artificial Intelligence–Generated Draft Replies to Patient Inbox Messages

The emergence and promise of generative artificial intelligence (AI) represent a turning point for health care. Rigorous evaluation of generative AI deployment in clinical practice is needed to inform strategic decision-making. To evaluate the implementation of a large language model used to draft responses to patient messages in the electronic inbox. A 5-week, prospective, single-group quality improvement study was conducted from July 10 through August 13, 2023, at a single academic medical center (Stanford Health Care). All attending physicians, advanced practice practitioners, clinic nurses, and clinical pharmacists from the Divisions of Primary Care and Gastroenterology and Hepatology were enrolled in the pilot. Draft replies to patient portal messages generated by a Health Insurance Portability and Accountability Act-compliant electronic health record-integrated large language model. The primary outcome was AI-generated draft reply utilization as a percentage of total patient message replies. Secondary outcomes included changes in time measures and clinician experience as assessed by survey. A total of 197 clinicians were enrolled in the pilot; 35 clinicians who were prepilot beta users, out of office, or not tied to a specific ambulatory clinic were excluded, leaving 162 clinicians included in the analysis. The survey analysis cohort consisted of 73 participants (45.1%) who completed both the presurvey and postsurvey. In gastroenterology and hepatology, there were 58 physicians and APPs and 10 nurses. In primary care, there were 83 physicians and APPs, 4 nurses, and 8 clinical pharmacists. The mean AI-generated draft response utilization rate across clinicians was 20%. There was no change in reply action time, write time, or read time between the prepilot and pilot periods. There were statistically significant reductions in the 4-item physician task load score derivative (mean [SD], 61.31 [17.23] presurvey vs 47.26 [17.11] postsurvey; paired difference, -13.87; 95% CI, -17.38 to -9.50; P < .001) and work exhaustion scores (mean [SD], 1.95 [0.79] presurvey vs 1.62 [0.68] postsurvey; paired difference, -0.33; 95% CI, -0.50 to -0.17; P < .001). In this quality improvement study of an early implementation of generative AI, there was notable adoption, usability, and improvement in assessments of burden and burnout. There was no improvement in time. Further code-to-bedside testing is needed to guide future development and organizational strategy.

Antibiotic Prescribing Patterns for Urinary Tract Infections and Pneumonia by Prescriber Type and Specialty in Nursing Home Care, 2016–2018

ObjectiveTo identify whether differences in antibiotic prescribing practices by prescriber type and specialization in nursing home (NH) care exist for urinary tract infection (UTI) and pneumonia. DesignRetrospective cohort. Setting and ParticipantsThis national study included antibiotic dispensings to traditional Medicare beneficiaries aged ≥65 years with UTI or pneumonia infections residing long-term (≥100 days) in US NHs between 2016 and 2018. MethodsMinimum Data Set assessment data were linked to Medicare data [Part D prescription drug, inpatient hospital (MedPAR), prescriber characteristics, and enrollment]. We compared antibiotic prescribing patterns by prescriber type [physician vs advanced practice practitioner (AP)] and NH specialization (≥90% vs <90% of all associated medication dispensings to NH residents). Antibiotic dispensing measures included the total number of dispensings and duration of therapy (median number of days supplied) by antibiotic class. ResultsThere were 264,735 antibiotic dispensings prescribed by 32,437 prescribers for 140,360 residents in 14,035 NHs. NH specialists were less likely to prescribe fluoroquinolones for UTI (22.9% NH specialist physician, 23.9% non-NH specialist physician, 21.3% NH specialist AP, 24.2% non-NH specialist AP), but more likely to prescribe fluoroquinolones for pneumonia (38.9%, 37.8%, 38.8%, 37.3%, respectively). Over time, NH specialists reduced fluoroquinolone prescribing for pneumonia to a greater extent than non-NH specialists. The duration of therapy was similar across prescriber groups for UTI, but longer among non-NH specialist APs for several antibiotic classes for pneumonia, including tetracyclines, glycopeptides and lipoglycopeptides, and metronidazole. Conclusions and ImplicationsThere were differences in antibiotic prescribing patterns by prescriber type and specialization in NH care between 2016 and 2018. Understanding how antibiotic prescribing differs based on prescriber characteristics is essential to inform antibiotic stewardship efforts. Tailoring antibiotic stewardship efforts to prescribers by NH specialization is rational given differences in antibiotic prescribing patterns based on NH specialization.

Challenges and Solutions to Support Oncology Professionals Serving Underserved Populations With Cancer in the United States: Results From the ASCO Serving the Underserved Task Force.

Little data exist regarding approaches to support oncology professionals who deliver cancer care for underserved populations. In response, ASCO developed the Serving the Underserved Task Force to learn from and support oncology professionals serving underserved populations. The Task Force developed a 28-question survey to assess oncology professionals' experiences and strategies to support their work caring for underserved populations. The survey was deployed via an online link to 600 oncology professionals and assessed respondent and patient demographic characteristics, clinic-based processes to coordinate health-related social services, and strategies for professional society support and engagement. We used chi-square tests to evaluate whether there were associations between percent full-time equivalent (FTE) effort serving underserved populations (<50% FTE v ≥50% FTE) with responses. Of 462 respondents who completed the survey (77% response rate), 79 (17.1%) were Asian; 30 (6.5%) Black; 43 (9.3%) Hispanic or Latino/Latina; and 277 (60%) White. The majority (n = 366, 79.2%) had a medical doctor degree (MD). A total of 174 (37.7%) had <25% FTE, 151 (32.7%) had 25%-50% FTE, and 121 (26.2%) had ≥50% FTE effort serving underserved populations. Most best guessed patients' sociodemographic characteristics (n = 388; 84%), while 42 (9.2%) used data collected by the clinic. Social workers coordinated most health-related social services. However, in clinical settings with high proportions of underserved patients, there was greater reliance on nonclinical personnel, such as navigators (odds ratio [OR], 2.15 [95% CI, 1.07 to 4.33]) or no individual (OR, 2.55 [95% CI, 1.14 to 5.72]) for addressing mental health needs and greater reliance on physicians or advance practice practitioners (OR, 2.54 [95% CI, 1.11 to 5.81]) or no individual (OR, 1.91 [95% CI, 1.09 to 3.35]) for addressing childcare or eldercare needs compared with social workers. Prioritization of solutions, which did not differ by FTE effort serving underserved populations, included a return-on-investment model to support personnel, integrated health-related social needs screening, and collaboration with the professional society on advocacy and policy. The findings highlight crucial strategies that professional societies can implement to support oncology clinicians serving underserved populations with cancer.

Patient symptoms, self-management, and unscheduled healthcare use during the first 6 months of targeted oral anticancer agent therapy: protocol for a mixed-methods US study

IntroductionTargeted oral anticancer agents (OAAs) are increasingly used to treat cancer, including haematological malignancies and ovarian cancer, but they can cause serious symptomatic side effects such as arrhythmias, hypertension, and...

Provider moral distress in caring for tracheostomy and ventilator dependent children: A single institution cross-sectional evaluation.

To determine levels of moral distress in a pediatric unit caring for patients with tracheostomy/ventilator dependence. Moral distress will be significant in a dedicated pediatric trach/vent unit. The Moral Distress Survey-Revised (MDS-R) is a 21-question survey measuring moral distress in pediatrics. The MDS-R was anonymously distributed to medical degree/doctor of osteopathy(MD/DOs), advanced practice practitioners (APPs), registered nurses(RNs), and respiratory therapists (RTs) in a unit caring for tracheostomy/ventilator dependent patients. Descriptive statistics, bivariate and multivariate analysis were performed. Response rate was 48% (61/127). Mean MDS-R score was 83 (range 43-119), which is comparable to reported levels in the pediatric intensive care unit (ICU). APPs had the highest median rate of moral distress (112, interquartilerange[IQR], 72-138), while MD/DOs had the lowest median score (49, IQR, 43-77). RNs and RTs had MDS-R scores between these two groups (medians of 91 and 84, respectively). Moral distress levels in a unit caring for long term tracheostomy and ventilator dependent patients are high, comparable to levels in pediatric ICUs. APPs.APPs had higher levels of distress compared to other groups. This may be attributable to the constant stressors of being the primary provider for complex patients, especially in a high-volume inpatient setting.

Understanding the role of antibiotic-associated adverse events in influencing antibiotic decision-making.

To (1) understand the role of antibiotic-associated adverse events (ABX-AEs) on antibiotic decision-making, (2) understand clinician preferences for ABX-AE feedback, and (3) identify ABX-AEs of greatest clinical concern. Focus groups. Academic medical center. Medical and surgical house staff, attending physicians, and advanced practice practitioners. Focus groups were conducted from May 2022 to December 2022. Participants discussed the role of ABX-AEs in antibiotic decision-making and feedback preferences and evaluated the prespecified categorization of ABX-AEs based on degree of clinical concern. Thematic analysis was conducted using inductive coding. Four focus groups were conducted (n = 15). Six themes were identified. (1) ABX-AE risks during initial prescribing influence the antibiotic prescribed rather than the decision of whether to prescribe. (2) The occurrence of an ABX-AE leads to reassessment of the clinical indication for antibiotic therapy. (3) The impact of an ABX-AE on other management decisions is as important as the direct harm of the ABX-AE. (4) ABX-AEs may be overlooked because of limited feedback regarding the occurrence of ABX-AEs. (5) Clinicians are receptive to feedback regarding ABX-AEs but are concerned about it being punitive. (6) Feedback must be curated to prevent clinicians from being overwhelmed with data. Clinicians generally agreed with the prespecified categorizations of ABX-AEs by degree of clinical concern. The themes identified and assessment of ABX-AEs of greatest clinical concern may inform antibiotic stewardship initiatives that incorporate reporting of ABX-AEs as a strategy to reduce unnecessary antibiotic use.

An Orthopaedic perspective on developing a Patient Experience Survey tool

Introduction: Our program’s aim is to integrate patients' values and perceptions of quality care into clinical decision-making and integrated orthopaedic care models that are reflective of the community/population that is served. Our institution currently has limited patient experience data or standardized tools that would allow us to comprehensively understand patient perspective across our orthopaedic populations. To that end, we designed a survey to understand patients’ experiences and any gaps that would require actionable change in real-time.&#x0D; Objectives and Methodology: The goal was to develop a survey tool that can meaningfully capture patient needs and preferences that impact their experiences and help identify any gaps or areas of opportunity to address. An environmental scan was completed which identified two validated patient experience surveys used to inform our survey development: CIHI’s CPES-IC (Canadian Institue for Health Information Canadian Patient Experience Survey - Inpatient Care) and OHA (Ontario Hospital Association) Outpatient Experience Survey. The survey was tested across a multidisciplinary team via feedback surveys and focus groups: 6 Patient Partners, 1 Clinical Manager, 3 Advanced Practice Practitioners, 3 Orthopaedic Surgeons, 4 Researchers, and 2 Administrators. Findings were collated and used to iterate the survey content until consensus was reached on a final patient experience survey. &#x0D; Highlights or Results or Key Findings: The focus of the survey is on understanding the patient’s Outpatient experience with their care team in orthopaedic clinics from referral to assessment. The survey was designed to cover multiple orthopaedic populations including patients with Hip and Knee, Foot and Ankle, Shoulder, Elbow and Spine issues. It focuses on two key components of the patient journey: 1) Pre-appointment and 2) Post-appointment. The pre-appointment pathway was deemed to be important as patient experience is often captured once care is delivered and it was important to understand how patients perceive their pre-appointment experience defined as the time from referral through day of appointment up to the time patients are seen (arrival at hospital, checking in to clinic). Specifically, the pre-appointment survey has up to 42 questions that aim to capture the patients’ perspectives on the clinic’s communication practices, wait time to be contacted, wait time for an appointment, how prepared patients felt for their appointment, how they felt about access to the clinic, their experiences with care transitions, their thoughts on transportation and any education that they received, and their overall experience. The post-appointment survey has up to 41 questions focused on understanding the patients’ perspectives on care transitions, the clinic space; wait time to see the practitioner, expectations, engagement in decision making, communication practices, education they received, and any other factors impacting their experience (e.g. confidentiality, empathy, trust, dignity). &#x0D; Conclusion and Next Steps: The survey, reviewed with our patient partners and multidisciplinary team, was found to be comprehensive and have good face validity. The survey will be implemented and the data will be analyzed to understand themes around areas of success and areas of improvement to advance our integrated models of care in order to provide high quality patient-centered care.

Adoption of Emergency Department–Initiated Buprenorphine for Patients With Opioid Use Disorder

Emergency department (ED) initiation of buprenorphine is safe and effective but underutilized in practice. Understanding the factors affecting adoption of this practice could inform more effective interventions. To quantify the factors, including social contagion, associated with the adoption of the practice of ED initiation of buprenorphine for patients with opioid use disorder. This is a secondary analysis of the EMBED (Emergency Department-Initiated Buprenorphine For Opioid Use Disorder) trial, a multicentered, cluster randomized trial of a clinical decision support intervention targeting ED initiation of buprenorphine. The trial occurred from November 2019 to May 2021. The study was conducted at ED clusters across health care systems from the northeast, southeast, and western regions of the US and included attending physicians, resident physicians, and advanced practice practitioners. Data analysis was performed from August 2022 to June 2023. This analysis included both the intervention and nonintervention groups of the EMBED trial. Graph methods were used to construct the network of clinicians who shared in the care of patients for whom buprenorphine was initiated during the trial before initiating the practice themselves, termed exposure. Cox proportional hazard modeling with time-dependent covariates was performed to assess the association of the number of these exposures with self-adoption of the practice of ED initiation of buprenorphine while adjusting for clinician role, health care system, and intervention site status. A total of 1026 unique clinicians in 18 ED clusters across 5 health care systems were included. Analysis showed associations of the cumulative number of exposures to others initiating buprenorphine with the self-practice of buprenorphine initiation. This increased in a dose-dependent manner (1 exposure: hazard ratio [HR], 1.31; 95% CI, 1.16-1.48; 5 exposures: HR, 2.85; 95% CI, 1.66-4.89; 10 exposures: HR, 3.55; 95% CI, 1.47-8.58). Intervention site status was associated with practice adoption (HR, 1.50; 95% CI, 1.04-2.18). Health care system and clinician role were also associated with practice adoption. In this secondary analysis of a multicenter, cluster randomized trial of a clinical decision support tool for buprenorphine initiation, the number of exposures to ED initiation of buprenorphine and the trial intervention were associated with uptake of ED initiation of buprenorphine. Although systems-level approaches are necessary to increase the rate of buprenorphine initiation, individual clinicians may change practice of those around them. ClinicalTrials.gov Identifier: NCT03658642.

Single-Visit Long-Acting Reversible Contraception Initiation Among Adolescents Before and During COVID-19

PurposeSingle-visit long-acting reversible contraception (LARC) is cost-effective and convenient. Our objective was to compare incidence of single-visit LARC placement and associated factors during the year before the COVID-19 pandemic (March 15, 2020) and the first year of the pandemic. MethodsThis retrospective cohort study analyzed electronic health records from a large healthcare system. Eligible adolescents were aged 10–19 years and received outpatient LARC from March 15, 2019 to March 14, 2021. Logistic regression models determined the relationship of patient and provider characteristics on single-visit LARC before and during COVID-19. ResultsOne thousand six adolescents initiated LARC during the study period. Fewer adolescents received single-visit LARC during COVID-19 (289/506, 57.1%) compared to before (315/500, 63.0%), although changes in odds of single-visit LARC were not statistically significant. Concordance between county of patient residence and the location of the LARC placement facility was associated with single-visit LARC before (adjusted odds ratio [aOR] = 2.75) and during (aOR = 1.74) the pandemic (both p < .05). During the pandemic, a few factors were associated with reduced odds of single-visit LARC: (1) public insurance (aOR = 0.49, p < .01), (2) nonobstetricians/nongynecologists providers (pediatrics [aOR = 0.35, p < .01], family medicine [aOR = 0.53, p < .01], or internal medicine [aOR = 0.14, p < .05]), and (3) advanced practice practitioners (aOR = 0.49, p < .01). DiscussionIncidence of single-visit LARC was similar before and during the pandemic. Certain factors were associated with lower odds of single-visit LARC insertion, suggesting differential access during the pandemic for subgroups of adolescents. Our findings may guide policy and programmatic interventions to improve access to single-visit LARC for all adolescent populations.

Implementing an Additional Weekly Treatment Visit with an Advance Practice Provider to Reduce Hospitalizations and Improve Quality of Care in Patients Undergoing Radiation Therapy

Patients undergoing chemotherapy and radiation therapy (RT) simultaneously are at an increased risk of developing complications and requiring hospitalization. To reduce acute hospital admissions, patients were seen in an additional weekly on treatment visit, named high risk on-treatment visits (HR OTVS) with a radiation oncology advanced practice provider to identify and manage treatment induced symptoms. With early identification and management of these symptoms, our goal was to improve patient's wellbeing and reduce the rate of hospitalizations while undergoing radiation therapy, limiting treatment breaks, and improving patient outcomes. Oneyear of radiation therapy patients and their hospitalization rate during active radiation treatment was studied 2017. In 2018, the new quality implementation of HR OTVs was added at the end of the week (in addition to on-treatment visit day with the physician) for patients deemed high-risk of complications during radiation therapy. In 2019, one full year after implementation of HR OTVs, hospitalization rates were examined in patients undergoing radiation therapy and directly compared to hospitalization rates of 2017 before the new visit implementation. In 2017,40 out of 417 patients undergoing RT in our department were admitted to the hospital versus 44 out of 668 patients in 2019. As a result of implementing APP lead HR OTVs, the inpatient hospitalization rate went from 9.6% down to 6.5%. Chi-square test confirmed this to be significant with p value 0.03 (p <0.5). Of the 40 patients hospitalized in 2017, 9 of those 40 were undergoing concurrent chemotherapy and radiation and 0% had additional high-risk visits. In 2019, 12 of the 44 admissions included patients receiving concurrent chemoradiation. Of these specific 12 patients, 4 saw APP weekly and 8 did not. If a patient was undergoing chemotherapy and radiation therapy and they saw the nurse practitioner weekly, they were less likely to be admitted to the hospital (33% versus 67%). Utilizing advanced practice practitioners with weekly high-risk visits in addition to the routine on treatment visit can help identify, monitor, and manage treatment induced side effects, and in turn reduce hospitalization rates of patients undergoing radiation therapy.

Safety and Pain Reduction in Emergency Practitioner Ultrasound-Guided Nerve Blocks: A One-Year Retrospective Study

Emergency practitioners use ultrasound-guided nerve blocks to alleviate pain. This study represents the largest registry of single-injection ultrasound-guided nerve blocks performed in an emergency department (ED) to date. We wished to assess the safety and pain score reductions associated with ED-performed ultrasound-guided nerve blocks. The main outcomes of interest were ultrasound-guided nerve block complication rates and change in patient-reported pain (0 to 10 on the VAS) pre and post ultrasound-guided nerve blocks. Other variables of interest were ultrasound-guided nerve block types and indications during the study period. This is a retrospective analysis of 420 emergency practitioner-performed ultrasound-guided nerve blocks through chart review over 1 year in the Highland ED. Four emergency physician abstractors reviewed all templated ultrasound-guided nerve block notes and nursing records over the study period. Inter-rater reliability was assessed using 10 randomly selected charts with 100% agreement for 70 key variables (Kappa=1, P<.001). Seventy-five unique emergency practitioners performed 420 ultrasound-guided nerve blocks. Ultrasound-guided nerve blockswere most often performed by emergency residents (61.9%), advanced practice practitioners (21.2%), ultrasound fellowship-trained faculty (8.3%), interns (3.6%), nonultrasound fellowship-trained faculty (3.3%), and not recorded (1.7%). One complication occurred during the study (arterial puncture recognized through syringe aspiration without further sequelae). Among the 261 ultrasound-guided nerve blocks with preblock and postblock pain scores, there was an improvement in postblock pain scores. The mean pain scores decreased from 7.4 to 2.8 after an ultrasound-guided nerve block (difference 4.6, 95% confidence interval 3.9 to 5.2). This 1-year retrospective study supports that emergency practitioner-performed ultrasound-guided nerve blocks have a low complication rate and are associated with reduced pain.

Comparison of hospitalist service staffing models at Baylor University Medical Center

Background Baylor University Medical Center benefits from being a quaternary care center with 900+ licensed beds and multiple different models to staff patients on the hospitalist service. These models include hospitalist only, resident teaching teams, and two different advanced practice practitioner teams. The primary goal of this study was to assess these different staffing models and to ascertain which model, if any, has better outcomes related to length of stay, total hospital charges, 30-day readmission rates, patient satisfaction, hospital-acquired infections, mortality, and early discharges. Methods The study was an observational retrospective chart review of all discharges from the hospitalist service at Baylor University Medical Center from October 1, 2021, to February 28, 2022. Patients were included if the hospitalist team was the primary team of record at the time of discharge. A total of 7803 patients were included. Results There was no difference in patient satisfaction, hospital-acquired infections, and mortality between the groups. The teaching teams had a shorter length of stay before the removal of outliers. Independent advanced practice practitioners reliably had more patients discharged before 11:30 am. Results support the concept of continuity of care, as well as lower patient-to-provider ratios. Conclusions These results have actionable implications that support the use of different advanced practice practitioner teams for the safe care of hospitalized patients as well as the safe integration of residents into patient care.

Comparison of Work Patterns Between Physicians and Advanced Practice Practitioners in Primary Care and Specialty Practice Settings

ImportanceDespite the increasing involvement of advanced practice practitioners (APPs; ie, nurse practitioners and physician assistants) in care delivery across specialties, the work patterns of APPs compared with physicians and how they are integrated into care teams have not been well characterized.ObjectiveTo characterize differences between physicians and APPs across specialty types related to days with appointments, visit types seen, and time spent using the electronic health record (EHR).Design, Setting, and ParticipantsThis nationwide, cross-sectional study used EHR data from physicians and APPs (ie, nurse practitioners and physician assistants) at all US institutions that used Epic Systems’ EHR between January and May 2021. Data analysis was performed from March 2022 to April 2023.Main Outcomes and MeasuresAppointment scheduling patterns, percentage of new and established and level of evaluation and management (E/M) visits, and EHR use metrics per day and week.ResultsThe sample consisted of 217 924 clinicians across 389 organizations, including 174 939 physicians and 42 985 APPs. Although primary care physicians were more likely than APPs to have more than 3 days per week with appointments (50 921 physicians [79.5%] vs 17 095 APPs [77.9%]), this trend was reversed for medical (38 645 physicians [64.8%] vs 8124 APPs [74.0%]) and surgical (24 155 physicians [47.1%] vs 5198 APPs [51.7%]) specialties. Medical and surgical specialty physicians saw 6.7 and 7.4 percentage points, respectively, more new patient visits than did their APP counterparts, whereas primary care physicians saw 2.8 percentage points fewer new patient visits than did APPs. Physicians saw a greater percentage of level 4 or 5 visits across all specialties. Medical and surgical physicians spent 34.3 and 45.8 fewer minutes per day, respectively, using the EHR than did APPs in their specialties, whereas primary care physicians spent 17.7 minutes per day more. These differences translated to primary care physicians spending 96.3 minutes more per week using the EHR than APPs, whereas medical and surgical physicians spent 149.9 and 140.7 fewer minutes, respectively, than did their APP counterparts.Conclusions and RelevanceThis cross-sectional, national study of clinicians found significant differences in visit and EHR patterns for physicians compared with APPs across specialty types. By underscoring the different current usage of physicians vs APPs across specialty types, this study helps place into context the work and visit patterns of physicians compared with APPs and serves as a foundation for evaluations of clinical outcomes and quality.

Understanding clinician perspectives on antibiotic associated adverse events to inform feedback

Background: Feedback regarding antibiotic-associated adverse events (ABX-AEs) may assist clinicians with antibiotic decision making. We sought to understand how clinicians account for ABX-AEs when prescribing and their preferences for ABX-AE feedback. Methods: We conducted 1-hour virtual focus groups with 3–5 physicians or advance practice practitioners (APPs) per session at Johns Hopkins Hospital. Participants discussed the role of ABX-AEs in antibiotic decision making and feedback preferences. Participants evaluated prespecified categorization (mildly, moderately, or very concerning) of several ABX-AEs. Focus groups were recorded and transcribed. Transcripts were coded inductively by 2 independent reviewers; discrepancies were resolved by consensus. Codes were used to conduct thematic analysis. Results: Overall, 3 focus groups were conducted with 12 participants: 41.6% were house staff, 16.7% were attending physicians, and 41.6% were APPs. Most were female (91.6%) and were white (41.7%) or Asian (41.7%). Clinicians generally agreed with the prespecified categorizations of ABX-AEs based on degree of clinical concern (Table). We identified 5 themes: (1) The risk of ABX-AE is considered during initial prescribing but influences agent selection more than the decision to prescribe antibiotics. (2) The occurrence of an ABX-AE leads to assessment of need for continued antibiotic therapy. (3) The impact of an ABX-AE on other management decisions is as important as the direct harm of the ABX-AE when assessing severity. (4) Feedback must be curated to prevent clinicians from being overwhelmed with data. (5) Clinicians will be more receptive to feedback regarding ABX-AEs if feedback is contextualized (Fig.). Conclusions: The themes identified and assessment of ABX-AEs of greatest clinical concern may help inform the development of effective ABX-AE feedback methods to improve antibiotic safety.Disclosures: None

Breast Cancer Screening Recommendations for Transgender and Gender Diverse Patients: A Knowledge and Familiarity Assessment of Primary Care Practitioners

Breast cancer screening recommendations for transgender and gender diverse (TGD) patients have only been recently developed and many primary care practitioners (PCPs) are unaware of these specific recommendations. The aim of this study is to assess the level of familiarity and knowledge PCPs have with breast cancer screening recommendations for TGD patients. An anonymous survey was distributed to primary care physicians, primary care advanced practice practitioners, and internal medicine and family medicine residents at three academic medical systems in the United States (Mayo Clinic, University of Michigan, University of Texas – Medical Branch). Survey questions assessed the familiarity and knowledge base of TGD breast cancer screening recommendations, training and experience with TGD patients, and basic demographics of the practitioners. Of the 95 survey respondents, only 35% of respondents were aware that breast cancer screening recommendations for TGD patients existed. PCPs who had increased transgender specific health care training and direct clinical exposure to TGD patients demonstrated significantly higher levels of screening recommendation awareness. Two-thirds of respondents received TGD specific medical education during training or medical career and those who had increased transgender specific medical education or direct clinical exposure to TGD patients demonstrated significantly higher levels of screening recommendation awareness. Awareness of breast cancer screening recommendations for TGD patients is low among PCPs and varied based on the practitioner’s prior TGD education and experience. Up-to-date breast cancer screening recommendations for TGD patients should be readily available across multiple platforms, target key audiences, and integrated into transgender health educational curriculums to maximize awareness of these important recommendations.

Change in opioid and buprenorphine prescribers and prescriptions by specialty, 2016–2021

BackgroundSafer opioid analgesic prescribing and increasing use of medications for opioid use disorder, including buprenorphine, are strategies prioritized to reduce opioid overdose deaths in the United States. Specialty-specific trends in the number of prescribers and prescriptions for opioid analgesics and buprenorphine are not well characterized. MethodsWe used data from the IQVIA Longitudinal Prescription database for January 1, 2016 through December 31, 2021. We identified opioid and buprenorphine prescriptions based on NDC codes. We classified prescribers into one of 14 mutually exclusive specialty groups. We calculated the number of prescribers and number of prescriptions for opioids and buprenorphine by specialty and year. ResultsFrom 2016 to 2021, the total number of opioid analgesic prescriptions dispensed decreased by 32% to 121,693,308 and the number of unique opioid analgesic prescribers decreased 7% to 966,369. Over the same time period, the number of buprenorphine prescriptions dispensed increased 36% to 13,909,724 and unique number of buprenorphine prescribers increased 86% to 59,090. Across most specialties we identified a contraction in the number of opioid prescriptions dispensed and opioid prescribers and an expansion in the number of buprenorphine prescriptions dispensed. Among high-volume opioid prescribing specialties, the largest decrease in opioid prescribers was 32% among Pain Medicine clinicians. By 2021, Advanced Practice Practitioners overtook Primary Care clinicians as the highest volume buprenorphine prescribers. ConclusionsMore work is needed to understand the impact of clinicians who stop prescribing opioids. While the trend in buprenorphine prescribing is encouraging, further expansion is warranted to meet the underlying need.

Perspectives of Health Care Personnel on the Benefits of Bronchiolitis Interventions.

Many interventions in bronchiolitis are low-value or poorly studied. Inpatient bronchiolitis management is multidisciplinary, with varying degrees of registered nurse (RN) and respiratory therapist (RT) autonomy. Understanding the perceived benefit of interventions for frontline health care personnel may facilitate deimplementation efforts. Our objective was to examine perceptions surrounding the benefit of common inpatient bronchiolitis interventions. We conducted a cross-sectional survey of inpatient pediatric RNs, RTs, and physicians/licensed practitioners (P/LPs) (eg, advanced-practice practitioners) from May to December of 2021 at 9 university-affiliated and 2 community hospitals. A clinical vignette preceded a series of inpatient bronchiolitis management questions. A total of 331 surveys were analyzed with a completion rate of 71.9%: 76.5% for RNs, 57.4% for RTs, and 71.2% for P/LPs. Approximately 54% of RNs and 45% of RTs compared with 2% of P/LPs believe albuterol would be "extremely or somewhat likely" to improve work of breathing (P < .001). Similarly, 52% of RNs, 32% of RTs, and 23% of P/LPs thought initiating or escalating oxygen in the absence of hypoxemia was likely to improve work of breathing (P < .001). Similar differences in perceived benefit were observed for steroids, nebulized hypertonic saline, and deep suctioning, but not superficial nasal suctioning. Hospital type (community versus university-affiliated) did not impact the magnitude of these differences. Variation exists in the perceived benefit of several low-value or poorly studied bronchiolitis interventions among health care personnel, with RNs/RTs generally perceiving higher benefit. Deimplementation, educational, and quality improvement efforts should be designed with an interprofessional framework.

Addressing Deficiencies in Knowledge and Skills Regarding the Management of Women with Multiple Sclerosis Throughout the Reproductive Years (P13-2.002)

<h3>Objective:</h3> To use continuing education (CE) to improve knowledge and skills related to specific issues and challenges regarding the management of women with multiple sclerosis (MS) throughout family planning, pregnancy/lactation, and menopause. <h3>Background:</h3> MS frequently impacts women of reproductive age, yet neurology physicians and advanced practice practitioners (APPs) lack knowledge and comfortability in the nuances of care required to manage women with MS throughout the reproductive years. Targeted CE can address knowledge and practice gaps, while also elucidating underlying drivers for these gaps to tailor future educational efforts. <h3>Design/Methods:</h3> In February 2021, Vindico Medical Education provided 5 CE activities designed to educate neurology physicians and APPs on the specific issues regarding the management of women with MS during family planning, pregnancy/lactation, and menopause. A series of pre-, intra-, and post-activity assessments were used to collect information regarding baseline knowledge, attitudes, and skills as well as how the education impacted these measures. <h3>Results:</h3> Complete datasets were available for 276 neurologists and 142 APPs, with baseline knowledge and competence higher among physicians compared to APPs on all topics. Overall, baseline knowledge was highest on topics related MS during menopause and lowest on topics related to MS before and during pregnancy. This knowledge deficit translated to low baseline competence regarding the management of women with MS at the pregnancy-planning stage. Post-learning, however, there was a 36% relative increase in knowledge; and completers were 20% more likely to always use evidence-based treatment for women with MS throughout family planning stages. <h3>Conclusions:</h3> Regarding the care of women with MS throughout the productive years, neurology HCPs most lacked knowledge regarding the management of patients prior to trying to conceive, which translates to suboptimal patient care. Targeted CE improved knowledge and skills on these topics, and these findings can be used to tailor future education. <b>Disclosure:</b> Dr. Robinson has nothing to disclose. Jennifer Frederick has received personal compensation for serving as an employee of Vindico Medical Education. Jenna Gentile has nothing to disclose. Robert Esgro has nothing to disclose. Mrs. Scully has nothing to disclose.

VALIDITY OF THE VIRTUAL SEVERITY SCORING SYSTEM IN PATIENTS WITH KNEE OSTEOARTHRITIS

The Severity Scoring System (SSS) is a guide to interpreting findings across clinical, functional, and radiological findings, used by qualified, specially trained physiotherapists in the advanced practice role in order to provide consistency in determining the severity of the patient's condition and need for surgical consultation. The system has been utilized for over 14 years as a part of standardized assessment and management care and was incorporated into virtual care in 2020 following the pandemic restrictions. The present study examined the validity of the modified SSS in virtual care.Patients who were referred to the Rapid Access Clinic (RAC), were contacted via phone by two experienced advanced practice practitioners (APPs) from May to July 2020, when in-person care was halted due to the pandemic. The virtual interview included taking history, completing self-reported measures for pain and functional ability and reviewing the radiological reports.A total of 63 patients were interviewed (mean age 68, SD=9), 34 (54%) females. Of 63 patients, 33 (52%) were considered a candidate for total knee arthroplasty (TKA). Men and women were comparable in age, P4 and LEFS scores. The TKA candidates had a significantly higher SSS (p&lt;0.0001) and pain scores (p=0.024). The variability of the total SSS score explained by the functional, clinical and radiological components of the tool were 55%, 48% and 4% respectively, highlighting the more important role of patient's clinical history and disability in the total SSS.The virtual SSS is a valid tool in directing patients for surgical management when used by highly trained advanced practice physiotherapists. A large component of the SSS is based on clinical data and patient disability and the APP's skillset rather than severity of pathology found on imaging.