Advanced Practice Professionals Research Articles

The Case for Decentralizing Cancer Care: The Rural Oncology Home

Despite significant advances in cancer therapies over recent decades, the United States grapples with growing disparities in cancer-related outcomes between its rural populations and urban and suburban counterparts. These disparities can be attributed, in part, to the centralization of oncology services within urban centers, which concomitantly imposes heightened travel demands on rural patients, constricting their access to comprehensive cancer treatment and specialized care. Historically, strategies such as the visiting consultant outreach model have been deployed to improve service accessibility, yet they offer only fragmented solutions to the multifaceted challenge of equitable care distribution. In response to this challenge, the authors introduce the rural oncology home, an alternative model for rural oncology care delivery. This innovative approach is centered on a community-based, team-oriented framework that incorporates medical specialists and emphasizes supportive services. By leveraging advanced practice professionals and care coordination, the model aims to enhance the accessibility of specialized cancer care for rural patients. Such models for rural oncology care delivery are emerging, with a pronounced emphasis on leveraging telehealth technologies. The Lakewood Health System Rural Oncology Home model can potentially create a more equitable system of cancer care delivery that can bridge the rural cancer gap and improve outcomes for rural patients with cancer.

Practice as you Teach: Comparing Ordering Practices Between Shared and Physician-Only Visits in Academically Affiliated Community Emergency Departments

BackgroundConsiderable variability exists in emergency physicians’ (EPs) rates of resource utilization, which may cluster in distinct patterns. However, previous studies have focused on academic and tertiary care centers, and it is unclear whether similar patterns exist in community practice. ObjectiveOur aim was to examine whether EPs practicing in community emergency departments (EDs) have practice patterns similar to those of academic EDs. Secondarily, we sought to investigate the effects of shared visits with advanced practice professionals and residents. MethodsThis was a retrospective study of two community EDs affiliated with an academic network. There were 62,860 visits among 50 EPs analyzed from October 1, 2018 through January 31, 2020 for rates of advanced imaging, admission, and shared visits. To classify practice patterns, we used a Gaussian Mixture Model (GMM), with groups and covariance determined by Bayesian Information Criteria. ResultsOur GMM revealed three groups. The largest had homogeneous patterns of resource use (n = 28; 50% were female; years of experience: 7; interquartile range [IQR] 2–11; advanced imaging: 28%; admission: 19%; shared: 34%), a small group with lower resource use (n = 4; 0% were female; years of experience: 6; IQR 4–10; advanced imaging: 28%; admission: 16%; shared: 8%), and a modest high-resource group (n = 18; 28% female; years of experience: 5; IQR 2–16; advanced imaging: 34%; admission: 23%; shared: 43%). Rates of shared visits had little direct correlation with imaging (r2 = 0.045) or admission (r2 = 0.093), and rates of imaging and admission were weakly correlated (r2 = 0.242). ConclusionsOur data suggest that community EPs may have multiple patterns of resource use, similar to those in academic EDs.

CORR Insights®: What Is the Geographic Distribution and Density of Orthopaedic Advanced Practice Professionals in Rural Counties? A Large-database Study.

CORR Insights®: What Is the Geographic Distribution and Density of Orthopaedic Advanced Practice Professionals in Rural Counties? A Large-database Study.

Advancing individualized care in advanced gastroesophageal cancers (GEC): A quality improvement initiative.

4051 Background: Biomarkers have become increasingly important in the treatment of metastatic gastroesophageal cancers (mGEC) with new targeted and immune-based therapies relying on biomarkers to identify patients who may benefit from these therapies. Here, we aimed to identify real-world challenges mGEC care teams face in implementing biomarker testing and evidence-based treatment choices. Methods: In July–September 2022, 74 health care professionals (HCPs) who treat mGEC at 3 US community oncology clinics completed surveys assessing practice patterns, challenges, and confidence related to treating mGEC. HCPs (N = 24) participated in interdisciplinary audit and feedback (AF) sessions to examine clinical evidence and develop clinic-specific action plans to address identified gaps. Results: Participating practices reported that ~22% of their practice is dedicated to GEC care. Participants represented the interprofessional GEC care team: medical oncologists (27%), radiation oncologists (1%), surgeons (1%), advanced practice professionals (32%), nurse/nurse navigators (32%), and other HCPs (5%). Providers reported testing for HER2, EGFR, FGFR, NTRK, microsatellite instability, tumor mutational burden, and PD-L1 in ~55-65% of advanced GEC patients. Most providers reported HER2 testing at time of diagnosis (91%) with 18% reporting testing at time of clinical or radiologic progression and 24% when new metastases are detected. Top reported barriers to use of predictive biomarker testing were long turnaround times for tests (32%) and keeping up to-date with current testing recommendations (23%). Top reported challenges in selecting therapies for GEC were keeping up with clinical evidence (35%) and delayed, pending, or unavailable biomarkers at the time of treatment selection (20%). Clinic action plans focused on specific gaps including (1) improved HCP education on guideline-concordant biomarker use (2) improving testing turnaround times, and (3) improving referrals to clinical trials based on biomarker results. The educational intervention increased correct identification of guideline concordant treatment for stage IV esophageal cancer (48% pre- and 72% post-AF) and confidence in use of biomarkers for treatment decision-making for patients with GEC (high/very high in 46% pre- and 72% post-AF). Conclusions: While molecular testing is becoming increasingly critical for mGEC care, HCPs report challenges with testing workflows and difficulty keeping up with developments in clinical data and guidelines. Clinic-specific interventions to improve biomarker workflows and ongoing educational initiatives to keep HCPs informed of the latest evidence-based best practices in biomarkers and associated therapies can address these gaps to improve outcomes for patients with GEC.

Examining molecular testing practices and targeted therapy use in advanced/metastatic non-small cell lung cancer (mNSCLC): A quality improvement initiative across ten community cancer centers.

e21191 Background: A growing number of targeted therapy approvals for mNSCLC have dramatically increased requirements for molecular testing. Identifying and addressing real-world challenges mNSCLC care teams face due to resulting workflow shifts is essential to optimize patient outcomes. Methods: In March–September 2022, 126 health care professionals (HCPs) who treat NSCLC at 10 US community oncology clinics completed surveys assessing practice patterns, challenges, and confidence related to biomarker testing and targeted therapy use. HCPs (N = 105) participated in interdisciplinary audit and feedback (AF) sessions to examine clinical evidence and develop clinic-specific action plans to address identified gaps. Results: Participants represented the interprofessional NSCLC care team: medical oncologists (32%), pathologists (1%), radiation oncologists (1%), pulmonologists (2%), PCP/other physicians (5%), advanced practice professionals (22%), nurses (19%), and other HCPs (e.g. patient navigator, practice manager; [19%]). At the time of the program there were 9 NCCN-recommended biomarkers for mNSCLC. Less than half of HCPs reported regular testing for 4 of these biomarkers (Table 1). The majority of HCPs were somewhat (52%) or very/extremely (23%) likely to start treatment prior to receiving molecular testing results. Top reported barriers to integrating molecular diagnostics into routine practice were biopsy tissue availability/quality (45%) and determining whether to begin treatment prior to receipt of molecular testing results (43%). Gap-oriented clinic action plans aimed to improve communication between oncologists, pulmonologists, and pathologists to increase quality and efficiency of testing. A targeted therapy toolkit was developed with a panel of oncology and pathology experts and distributed to participants to address gaps in knowledge of testing practices and guidelines. HCP confidence in biomarker testing increased from 72% to 92% following the intervention. More HCPs correctly answered knowledge (43% pre-AF vs 61% post-AF) and competence (29% pre-AF vs 54% post-AF) questions following participation in the AF sessions. Conclusions: While molecular testing is critical for mNSCLC care, HCPs report sub-optimal rates of conducting testing prior to treatment and incorporating results into treatment planning. Here, we highlight an unmet need for improved interdisciplinary communication and coordination in mNSCLC care teams and an educational intervention strategy that can be used to improve HCP biomarker and targeted therapy use in mNSCLC. [Table: see text]

A cross-sectional survey examining clinician characteristics, practices, and attitudes associated with adoption of the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines.

The 2019 American Society for Colposcopy and Cervical Pathology (ASCCP) risk-based management consensus guidelines are the most recent national guidelines for the management of abnormal cervical cancer screening tests. These guidelines benefit patients by concentrating testing and treatment in those at highest cervical cancer risk. Adoption of guidelines often occurs slowly, with few studies examining the factors associated with guideline-adherent management of abnormal results. To elucidate the factors associated with the use of the 2019 ASCCP guidelines among clinicians who perform cervical cancer screening, physicians and advanced practice professionals who perform cervical cancer screening were cross-sectionally surveyed. Clinicians responded to screening vignettes with differing recommendations for management between the 2019 and prior management guidelines. Screening vignette 1 involved reduction of invasive testing on a low-risk patient; screening vignette 2 involved increased surveillance testing on a high-risk patient. Binomial logistic regression models determined the factors associated with the use of the 2019 guidelines. A total of 1251 clinicians participated from across the United States. For screening vignettes 1 and 2, guideline-adherent responses were given by 28% and 36% of participants, respectively. Management recommendations differed by specialty and were incorrect in different situations: there was inappropriate invasive testing by obstetrics and gynecology physicians (vignette 1) and inappropriate discontinuation of screening by family and internal medicine physicians (vignette 2). Regardless of their chosen response, over half erroneously believed they were guideline adherent. Many clinicians who believe they are following appropriate guidelines may not realize their management strategy is inconsistent with the 2019 guidelines. Education initiatives tailored to clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms. The 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines are the most recent national guidelines for abnormal cervical cancer screening test management. We surveyed over 1200 obstetrics and gynecology (OB/GYN), family medicine, and internal medicine physicians and advanced practice providers about their screening and abnormal results follow-up practices in relation to guidelines. Few clinicians are following the 2019 guidelines. Management recommendations differed by clinician specialty and were incorrect in different situations: there was inappropriate invasive testing by OB/GYN physicians and inappropriate screening discontinuation by family and internal medicine physicians. Education tailored by clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms.

What Is the Geographic Distribution and Density of Orthopaedic Advanced Practice Professionals in Rural Counties? A Large-database Study.

Advanced practice professionals, including physician assistants (PAs) and nurse practitioners (NPs), play an important role in providing high-quality orthopaedic care. This role has been highlighted by projections of nationwide shortages in orthopaedic surgeons, with rural areas expected to be most affected. Given that approximately half of rural counties have no practicing orthopaedic surgeons and that advanced practice professionals have been shown to be more likely to practice in rural areas compared to physicians in other medical disciplines, orthopaedic advanced practice professionals may be poised to address orthopaedic care shortages in rural areas, but the degree to which this is true has not been well characterized. (1) What percentage of rural counties have no orthopaedic caregivers, including surgeons and advanced practice professionals? (2) Is the density of advanced practice professionals greater than that of orthopaedic surgeons in rural counties? (3) Do orthopaedic advanced practice professionals only practice in counties that also have practicing orthopaedic surgeons? (4) Are NPs in states with full practice authority more likely to practice in rural counties compared with NPs in restricted practice authority states? We identified orthopaedic surgeons and advanced practice professionals using the 2019 Medicare Provider Utilization and Payment Data, as this large dataset has been shown to be the most complete source of claims data nationwide. Each professional's ZIP Code was matched to counties per the US Postal Service ZIP Code Crosswalk Files. The total number and density of physician and advanced practice professionals per 100,000 residents were calculated per county nationwide. Counties were categorized as urban (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) or rural (micropolitan and noncore) using the National Center for Health Statistics Urban-Rural Classification Scheme. Comparisons between rural and urban county caregivers were conducted with the chi-square test and odds ratios. Population densities were compared with the Wilcoxon rank sum test. A bivariate density map was made to visualize the nationwide distribution of orthopaedic caregivers and determine the percentage of rural counties with no orthopaedic caregivers as well as whether orthopaedic advanced practice professionals practiced in counties not containing any surgeons. Additionally, to compare states with NP's full versus restricted practice authority, each NP was grouped based on their state to determine whether NPs in states with full practice authority were more likely to practice in rural counties. We identified a group of 31,091 orthopaedic caregivers, which was comprised of 23,728 physicians, 964 NPs, and 6399 PAs (7363 advanced practice professionals). A total of 88% (20,879 of 23,728) of physicians and 87% (6427 of 7363) of advanced practice professionals were in urban counties, which is comparable to nationwide population distributions. A total of 39% (1237 of 3139) of counties had no orthopaedic professionals (defined as orthopaedic surgeons or advanced practice professionals) in 2019. Among these counties, 82% (1015 of 1237) were rural and 18% (222 of 1237) were urban. The density of advanced practice professionals providing orthopaedic services compared with the density of orthopaedic surgeons was higher in rural counties (18 ± 70 versus 8 ± 40 per 100,000 residents; p = 0.001). Additionally, 3% (57 of 1974) of rural and 1% (13 of 1165) of urban counties had at least one orthopaedic advanced practice professional, but no orthopaedic surgeons concurrently practicing in the county. There was no difference between the percentage of rural counties with an NP in states with full versus restricted practice authority for NPs (19% [157 of 823] versus 26% [36 of 141], OR 1.45 [95% CI 0.99 to 2.2]; p = 0.08). As advanced practice professionals tended to only practice in counties which contain orthopaedic surgeons, our analysis suggests that plans to increase the number of advanced practice professionals alone in rural counties may not be sufficient to fully address the demand for orthopaedic care in rural areas that currently do not have orthopaedic surgeons in practice. Rather, interventions are needed to encourage more orthopaedic surgeons to practice in rural counties in collaborative partnerships with advanced practice professionals. In turn, rural orthopaedic advanced practice professionals may serve to further extend the accessibility of these surgeons, but it remains to be determined what the total number and ratio of advanced practice professionals and surgeons is needed to serve rural counties adequately. To increase rural orthopaedic outreach, state legislatures may consider providing financial incentives to hospitals who adopt traveling clinic models, incorporating advanced practice professionals in these models as physician-extenders to further increase the coverage of orthopaedic care. Furthermore, the creation of more widespread financial incentives and programs aimed at expanding the experience of trainees in serving rural populations are longer-term investments to foster interest and retention of orthopaedic caregivers in rural settings.

Promoting multidisciplinary care for patients with unresectable hepatocellular carcinoma (HCC): Findings from a quality improvement initiative across two community cancer centers.

528 Background: Evolving treatment paradigms in HCC are increasing the need for multidisciplinary coordination and a focus on patient-centered care. Identifying real-world challenges HCC care teams face in implementing these critical practices is necessary to inform educational interventions and optimize patient outcomes. Methods: In March–April 2021, 22 health care professionals (HCPs) who treat HCC at 2 US community oncology clinics completed surveys assessing practice patterns, challenges, and confidence related to multidisciplinary and patient-centered care in HCC and participated in interdisciplinary audit and feedback sessions. Patient charts evaluated pre- and post-intervention assessed changes in clinical practice. Inclusion criteria included confirmed HCC diagnosis, age ≥ 18 years, and ≥ 2 visits in the one-year chart abstraction period. Results: Participants represented the interprofessional HCC care team: medical oncologists (38%), gastroenterologists (8%), hepatologists (4%), internal medicine (17%), advanced practice professionals (4%), and nurses (29%). Baseline and follow-up patient charts included 50% and 47% Stage II-III HCC patients and 50% and 53% Stage IV HCC patients, respectively. Top reported barriers to multidisciplinary tumor board use were ineffective interdepartmental coordination/collaboration (43%) and low volume of referrals (38%). HCPs aimed to resolve these gaps through improved collaboration between multidisciplinary teams (33%) and earlier referrals to a medical oncologist (29%). Providing patient-centered supportive care was identified by 33% of HCPs as the top challenge in HCC patient care. Of HCPs surveyed, 77% estimated that ≤ 25% of patients are evaluated for/referred to distress/behavioral health services. Chart audits after educational intervention and action plan implementation showed improvements in supportive care utilization (see table). A critical component of patient-centered care, shared decision-making (SDM) was reported by 24% of HCPs. HCPs reported patient resistance to SDM (33%) and low patient health literacy (29%) as top barriers to SDM. Chart documentation of HCP participation in SDM increased post intervention (see table). Conclusions: In current real-world practice, HCC care teams report challenges in interdisciplinary collaboration and referrals, providing supportive care, and involving patients in SDM. These identified gaps represent key opportunities for future interventions to improve HCC care. [Table: see text]

Abstract WP33: Bedside Insertion Of Implantable Loop Recorders Prior To Hospital Discharge Improves Detection Of Atrial Fibrillation After Cryptogenic Stroke And May Reduce Stroke Recurrence

Atrial fibrillation (AF) is responsible for 15-20% of ischemic strokes. AF can be asymptomatic and remain undetected following acute stroke, initially classifying the event as cryptogenic. Implantable loop recorders (ILRs) provide long-term cardiac monitoring and are superior to traditional methods for detecting AF in patients with cryptogenic stroke. ILR placement is often performed by a cardiologist in an outpatient setting. Our institution identified that some patients were missing or cancelling appointments for device implantation. Failure to detect AF is associated with a greater risk of stroke recurrence. An interdisciplinary inpatient process was developed to place ILRs at the bedside on the stroke unit, prior to discharge. The purpose of the program was to increase patient compliance with ILRs, improve detection of asymptomatic AF, and reduce incidence of stroke recurrence through timely initiation of oral anticoagulants. To evaluate the program and provide recommendations, measures of success included rates of patient compliance with ILR implantation using inpatient vs. outpatient procedure and the percentage of patients who received a diagnosis of AF after ILR placement. Using 18 months of pre-implementation data as a benchmark, the average implant rate increased in the first 12 months following implementation. Of 97 patients who received ILR placement, nine (9%) have received a diagnosis of AF. Since three-year ILR monitoring has shown significantly higher AF detection than 30-day cardiac monitoring after cryptogenic stroke, more patients with AF may yet be identified. This presentation will demonstrate an increase in ILR implant rates and AF detection and highlight positive results using advanced practice professionals to perform the procedure. The program produced financial benefit and mitigated access to care barriers, with no poor outcomes or compromise in quality, and no negative impact on inpatient length of stay. In conclusion, bedside insertion of ILRs prior to discharge after cryptogenic stroke is a safe, efficient, cost-effective process that increases patient compliance when compared to outpatient return visits, improving detection of AF and prompt initiation of oral anticoagulants, and may reduce stroke recurrence.

What Are the Trends in the Utilization of Orthopaedic Advanced Practice Professionals? A Large Database Medicare Study

Background: Advanced practice professionals (APPs), such as physician assistants (PAs) and nurse practitioners (NPs), are expected to have an increasing role in delivering high-quality orthopaedic care in the coming years. Our analysis aimed to determine the current proportion and geographic distribution of APPs in orthopaedics. In addition, we predicted future growth into 2025. Methods: Our analysis was a retrospective, large national database study evaluating services provided by APPs from 2014 to 2019 using the Medicare Provider Utilization and Payment Data prepared by the Centers for Medicare & Medicaid Services (CMS). NPs and PAs were recognized by provider type and aggregated to form the APP group for analysis. Mann-Kendall trend tests were used to evaluate changes in the number of each provider type. Poisson regression will be used to predict the expected number of APPs in the field up to the year 2025. Results: From 2014 to 2019, there was a 34.36% increase in the number of orthopaedic APPs (5,480-7,363), compared with a 5.37% increase in orthopaedic surgeons (22,518-23,728). APPs were located in predominately large metropolitan areas (96%), followed by small metropolitan (3.6%) and rural areas (0.4%). Using data from our study period, we projected that by 2025, there will be 10,484 APPs in orthopaedic surgery [95% Confidence Interval (CI): 9,004-11,964 providers]. This represents an 84% increase over the decade between 2015 and 2025. Conclusion: Our analysis demonstrated that the volume of established patient visits and various nonsurgical services provided by APPs in orthopaedic surgery continues to grow. The number of APPs and surgeons in orthopaedics is increasing, but the proportion of APPs choosing orthopaedics as a speciality is on the decline. Furthermore, we found a greater proportion of PAs in orthopaedics than NPs. Because the demand for services for orthopaedic surgery continues to grow, APPs may serve as one possible solution to increase access to orthopaedic care, and additional programs should be developed to improve the educational access for APPs to train in orthopaedics.

Changes in Physician Work Hours and Implications for Workforce Capacity and Work-Life Balance, 2001-2021

Physician work hours are an underexplored facet of the physician workforce that can inform policy for the rapidly changing health care labor market. To examine trends in individual physician work hours and their contribution to clinical workforce changes over a 20-year period. This cross-sectional study focused on active US physicians between January 2001 and December 2021 who were included in the Current Population Survey. Outcomes for physicians, advanced practice professionals (APPs), and nonphysician holders of doctoral degrees were compared, and generalized linear models were used to estimate differences in time trends for weekly work hours across subgroups. Physician and APP workforce size, defined as the number of active clinicians, 3-year moving averages of weekly work hours by individual physicians, and weekly hours contributed by the physician and APP workforce per 100 000 US residents. A total of 87 297 monthly surveys of physicians from 17 599 unique households were included in the analysis. The number of active physicians grew 32.9% from 2001 to 2021, peaking in 2019 at 989 684, then falling 6.7% to 923 419 by 2021, with disproportionate loss of physicians in rural areas. Average weekly work hours for individual physicians declined by 7.6% (95% CI, -9.1% to -6.1%), from 52.6 to 48.6 hours per week from 2001 to 2021. The downward trend was driven by decreasing hours among male physicians, particularly fathers (11.9% decline in work hours), rural physicians (-9.7%), and physicians aged 45 to 54 years (-9.8%). Physician mothers were the only examined subgroup to experience a statistically significant increase in work hours (3.0%). Total weekly hours contributed by the physician workforce per 10 000 US residents increased by 7.0%, from 13 006 hours in 2001 to 2003 to 13 920 hours in 2019 to 2021, compared with 16.6% growth in the US population over that time period. Weekly hours contributed by the APP workforce per 100 000 US residents grew 71.2% from 2010 through 2012 to 2019 through 2021. This cross-sectional study showed that physician work hours consistently declined in the past 20 years, such that physician workforce hours per capita lagged behind US population growth. This trend was offset by rapid growth in hours contributed by the APP workforce. The gap in physician work hours between men and women narrowed considerably, with diverging potential implications for gender equity. Increasing physician retirement combined with a drop in active physicians during the COVID-19 pandemic may further slow growth in physician workforce hours per capita in the US.

Performance Measurement for Opioid Use Disorder Medication Treatment and Care Retention.

Performance Measurement for Opioid Use Disorder Medication Treatment and Care Retention.

Assessment of Oncology Advanced Practice Professional Willingness to Participate in Medical Aid in Dying

In 2021, New Mexico passed legislation allowing nurse practitioners and physician assistants (referred to herein as advanced practice professionals [APPs]) to prescribe medications for medical aid in dying (MAID). Other US states with existing MAID laws (eg, Washington) are also considering expanding MAID prescribing authority to APPs. There is a lack of research exploring APP knowledge of, willingness to, and comfort with acting as a prescribing or consulting clinician for MAID. To assess perspectives of oncology APPs regarding MAID, including their willingness to prescribe and/or consult for MAID and factors associated with willingness. This cross-sectional, self-report survey study used data collected from APPs working at a comprehensive cancer center in Washington State in fall 2021. The primary survey question was whether APPs would be willing to participate in death with dignity, the term used for MAID in Washington. Survey questions evaluated how influential specific factors were on APP views on MAID as well as respondents' knowledge of and comfort with aspects of the MAID process. Of 167 eligible APPs, 77 (46.1%) responded to the survey. Most respondents (68 [88.3%]) reported their race and ethnicity as White; 72 (93.5%) identified as a woman. Medical oncology (28 [36.4%]) was the most common field of practice, and 21 respondents (27.3%) reported having practiced as an APP for 6 to 10 years. Of all respondents, 61 (79.2%) reported having at least 1 patient who inquired about MAID; depending on the question, less than a third of respondents (5.0%-27.0%) endorsed feeling knowledgeable or very knowledgeable about any aspect of the MAID process. In this study, 39 APPs (50.6%) endorsed being willing to participate in MAID either as a consulting or prescribing clinician, whereas 31 (40.3%) were uncertain of whether they would participate. Willingness to participate was associated with having had more patients pursue MAID (33 of the 39 willing participants [84.6%] vs 15 of the 31 unsure participants [48.4%] reported having 1 or more patients pursue MAID). Higher knowledge and comfort scores were both significantly associated with increased odds of being willing to participate (odds ratio, 1.14 per 1-point score increase [95% CI, 1.03-1.27]; P = .01) vs unsure (1.18 [95% CI, 1.07-1.30; P = .001). The results of this survey study suggest that oncology APPs may require preparation for the addition of MAID to their scope of practice. This study also raises questions for future research regarding support for APPs who may be considering participation in MAID but question their role or want physician involvement.

289 Impact of an Emergency Department Quality Improvement Initiative to Promote Safe Discharge of Low-Risk Chest Pain Patients

Through participation in the Michigan Emergency Department Improvement Collaborative (MEDIC), an interdisciplinary team of physicians, advanced practice professionals, and nurses aimed to increase the safe discharge rate of adult low-risk chest pain patients. The purpose of this quality improvement project was to implement a standardized clinical pathway, including the use of the HEART score to promote the safe discharge of low-risk emergency department (ED) patients with chest pain.

COVID-19 Seroprevalence in ED Health Care Professionals Study: A Cross-Sectional Study

IntroductionED health care professionals are at the frontline of evaluation and management of patients with acute, and often undifferentiated, illness. During the initial phase of the SARS-CoV-2 outbreak, there were concerns that ED health care professionals may have been at increased risk of exposure to SARS-CoV-2 due to difficulty in early identification of patients. This study assessed the seroprevalence of SARS-CoV-2 antibodies among ED health care professionals without confirmed history of COVID-19 infection at a quaternary academic medical center. MethodsThis study used a cross-sectional design. An ED health care professional was deemed eligible if they had worked at least 4 shifts in the adult emergency department from April 1, 2020, through May 31, 2020, were asymptomatic on the day of blood draw, and were not known to have had prior documented COVID-19 infection. The study period was December 17, 2020, to January 27, 2021. Eligible participants completed a questionnaire and had a blood sample drawn. Samples were run on the Roche Cobas Elecsys Anti-SARS-CoV-2 antibody assay. ResultsOf 103 health care professionals (16 attending physicians, 4 emergency residents, 16 advanced practice professionals, and 67 full-time emergency nurses), only 3 (2.9%; exact 95% CI, 0.6%-8.3%) were seropositive for SARS-CoV-2 antibodies. DiscussionAt this quaternary academic medical center, among those who volunteered to take an antibody test, there was a low seroprevalence of SARS-CoV-2 antibodies among ED clinicians who were asymptomatic at the time of blood draw and not known to have had prior COVID-19 infection.

399 Advanced Practice Provider Perspectives on Advanced Care Planning

OBJECTIVES/GOALS: Perioperative surgical care is team-based with close partnership between surgeons, residents, advanced practice professionals (APPs), and others. The objective is to develop an understanding of the current state and implementation needs required for APPs to engage surgical patients in advanced care planning (ACP) to promote goal concordant care. METHODS/STUDY POPULATION: We will conduct a mixed methods evaluation of ACP knowledge, attitudes, and beliefs amongst surgical APPs to identify barriers and facilitators of APPs engaging in a team-based approach to engaging surgical patients in ACP. We will conduct an online survey and qualitative interviews in the following 4 domains: 1) knowledge, skills, and attitudes about engaging in ACP with a patient or their surrogate decision maker during their perioperative care; 2) prior ACP-specific education; 3) experiences conducting ACP discussions with patients; and 4) perceived training needs to increase ACP uptake and documentation. The findings will provide the foundations to design team-based interventions focused on addressing the barriers and inform training and coaching needs to develop expertise and comfort in the ACP process. RESULTS/ANTICIPATED RESULTS: We expect variability in the knowledge, skills, attitudes, and experiences with the ACP process. We anticipate gaining a better understanding of the educational materials best suited to support APPs as they begin engaging patients in ACP. Possible barriers to APP-led ACP discussions include inconsistent role delineation, uncertainty about the value of pre-operative vs. post-operative ACP discussions, lack of experience engaging in ACP discussion, and lack of familiarity with electronic health records ACP tools. Possible facilitators of APP-led ACP discussions may be related to past work experience settings, exposure to ACP in educational preparation, hands-on observation of value of ACP in surgical patients and influences from attending and residents. DISCUSSION/SIGNIFICANCE: While current ACP research in surgery focuses on physician-led patient engagement in ACP discussions, there is a paucity of research focusing on how to develop a team-based approach to ACP discussions in surgery. This study will provide information necessary for the development of interventions that increase team-based ACP for surgical patients.

Hepatitis C Virus Screening: Factors Associated With Test Completion in a Large Academic Health Care System.

In 2012, onetime hepatitis C virus (HCV) screening was recommended for all baby boomers (people born during 1945-1965) in the United States, but only 4.0%-12.9% of baby boomers have ever had a screening ordered by a health care provider. This study examined the HCV screening prevalence among adult patients in a large academic health care system and assessed factors associated with the completion of screening when ordered for baby boomers. We defined HCV screening completion as the completion of an HCV antibody test when it was ordered. We used electronic health records to examine HCV screening completion rates among adults (N = 106 630) from August 1, 2015, through July 31, 2020, by birth cohort. Among baby boomers whose health care provider ordered HCV screening, we examined frequency and percentages of HCV screening completion by sociodemographic and clinical characteristics. We conducted univariate and multivariable logistic regression analyses to assess factors associated with HCV screening completion among baby boomers. During the study period, 73.0% of baby boomers completed HCV screening when it was ordered. HCV completion did not differ by sex or race and ethnicity among baby boomers. Baby boomers with Medicare supplemental health insurance compared with commercial health insurance (adjusted odds ratio [aOR] = 1.87) and those seeing only advanced practice professionals compared with specialty care physicians (aOR = 2.24) were more likely to complete HCV screening when it was ordered. Noncompletion of HCV screening is one of many barriers along the HCV treatment continuum. Our findings suggest a need for interventions targeting systems, health care providers, and patients to increase HCV screening rates in the United States.

Lean Six Sigma Methodology and the Future of Quality Improvement Education in Anesthesiology.

Lean Six Sigma Methodology and the Future of Quality Improvement Education in Anesthesiology.

Interprofessional care team practices and perspectives on immuno-oncology (IO) therapies for metastatic non-small cell lung cancer (mNSCLC): Insights from a nationwide survey.

e21147 Background: Appropriate molecular testing, biomarker-directed treatment selection, and management of immune-related adverse events (irAEs) are essential best practices for managing patients with mNSCLC who are eligible for IO therapies. Identifying real-world challenges among mNSCLC care teams is necessary to inform educational interventions that support optimal care. Methods: From 10/2020 to 01/2021, 75 health care professionals (HCPs) who treat mNSCLC completed surveys assessing practice patterns, challenges, and confidence related to the use of IO therapies. To reflect current real-world practice across treatment settings, surveys were administered at 10 clinics nationwide and through a large oncology practice network. Results: Participants represented the interprofessional mNSCLC care team: oncologists (50%), primary care physicians (23%), advanced practice professionals (13%), and nurses (13%). Nearly one-third reported that PD-L1+ mNSCLC presented greater management challenges than other mNSCLC sub-types. Regarding patients who are eligible for IO therapies, the most commonly reported challenges were applying pathology results to treatment decisions (29%), differentiating IO therapies (19%), and managing irAEs (19%). Case-based questions revealed gaps in care relative to guidelines: 65% incorrectly identified which patients should be tested for PD-L1; 49% failed to identify the most appropriate IO regimen based on case details; and 65% failed to identify an inappropriate strategy for managing mild irAEs (Table). Further, HCPs reported inappropriate reasons to exclude patients from IO therapy and suboptimal use of supportive care measures. Confidence gaps echoed these challenges; most HCPs reported less-than-high confidence in their ability to apply molecular test results to treatment decisions (80%), differentiate IO therapies based on PD-L1 expression (65%), or coordinate irAE care (85%). Conclusions: In current real-world practice, mNSCLC care teams report challenges in biomarker testing and interpretation; differentiation of IO therapies based on patient, disease, and treatment factors; and irAE management. These identified gaps represent key opportunities for future interventions to improve mNSCLC care. [Table: see text]

Assessment of dermatologist-patient race and ethnicity concordance in the Medicare population

Assessment of dermatologist-patient race and ethnicity concordance in the Medicare population