Advanced Practice Providers Research Articles

"Who You Are and Where You Live Matters": Hospice Care in New York City During COVID-19 Perspectives on Hospice and Social Determinants: A Rapid Qualitative Analysis.

Context: Social determinants of health (SDOH) impacted the quality of home hospice care provided during the COVID-19 pandemic. Perspectives from professionals who provided care identify challenges and lessons learned from their experience. Objective: To examine hospice professionals' perspectives of how SDOH affected the delivery of high-quality home hospice care in New York City (NYC) during the COVID-19 pandemic. Methods: We conducted semistructured interviews with 30 hospice professionals who delivered care to home hospice patients during the COVID-19 pandemic in NYC using a qualitative descriptive design. Purposive sampling was used to recruit professionals from a range of disciplines including physicians, advanced practice providers, nurses, social workers, chaplains, and hospice administration and management. Participants worked for one of two large NYC metro hospices and one outpatient palliative care practice serving the five boroughs of NYC and the surrounding suburbs. Rapid qualitative analysis was used to identify themes. Results: Thirty hospice professionals were interviewed, spanning a variety of clinical and administrative roles. Most (21 out of 30) reported that social determinants affected access and/or delivery of equitable hospice care. Two key themes emerged from interviews: (1) SDOH exist and affect the delivery of high-quality care and (2) disparities were exacerbated during the COVID-19 pandemic resulting in barriers to care. Subthemes outline barriers described by hospice professionals: decreased hospice enrollment, telehealth challenges, resulting in deficient patient/family education, shortages of nursing assistants in some neighborhoods, and diminished overall quality of hospice care for some patients. SDOH created barriers to hospice care through neighborhood factors, resource barriers, and system challenges. Conclusion: SDOH provide a context to understand disparity in the provision of hospice care. COVID-19 exacerbated these conditions. Addressing multidimensional barriers created by SDOH is key in creating high-quality and equitable hospice care, particularly during a crisis.

Future Considerations and Areas for Innovation for Pulmonary Rehabilitation in Chronic Obstructive Lung Disease Patients.

Pulmonary rehabilitation is an effective therapy that improves day-to-day symptoms and quality of life in patients with chronic obstructive pulmonary disease. In this review, we look at the role of virtual programs, implementation of artificial intelligence, emerging areas of improvement within the educational components of programs, and the benefit of advanced practice providers in directorship roles.

A Case for Specific Education of Advanced Practice Providers in Allergy & Immunology: Results of a Gap Analysis and Targeted Needs Assessment

A Case for Specific Education of Advanced Practice Providers in Allergy & Immunology: Results of a Gap Analysis and Targeted Needs Assessment

Development and Implementation of a Family Presence Facilitator Curriculum for Interprofessional Use in Pediatric Medical Resuscitations.

Family presence during pediatric medical resuscitation has myriad benefits. However, there is significant heterogeneity in provider acceptance and implementation of the family support role. We designed this curriculum to teach all members of the health care team best practices in the Family Presence Facilitator (FPF) role during pediatric medical resuscitations. We applied Kern's six-step approach to develop an FPF curriculum comprising didactic and interactive elements, along with training for simulated participants. We implemented the curriculum through (a) live sessions (30-minute didactic or 90-minute workshop) for learners; (b) a 20-minute asynchronous version of the didactic curriculum for self-directed learning; and (c) a 1-hour, monthly, in situ simulation curriculum in a pediatric emergency department setting. Curriculum evaluation surveys queried self-reported engagement, satisfaction, relevance, confidence, commitment, knowledge, skills, and attitudes in a retrospective pre/post format. We collected data from 153 learners, including attendings, fellows, residents, advanced practice providers, medical students, and child life specialists, between October 2022 and September 2023. Only 22% of participants had received similar prior training. One hundred percent of learners found the curriculum enjoyable and engaging; learners also agreed the curriculum improved their knowledge and skills in providing empathetic and respectful communication (99%); nonspeculative, clear information (100%); and nonverbal support (99%). Of respondents, 100% believed the curriculum would improve the patient care experience. Facilitating family presence during pediatric medical resuscitations is a crucial skill. Our curriculum improves self-reported confidence, knowledge, and skills among interprofessional learners. Next steps include expanding this curriculum beyond the pediatric setting.

6482 Knowledge and comfort in addressing eating disorders in people living with Type 1 Diabetes in an academic Endocrinology center

Abstract Disclosure: N. Viera Felicino: None. D. Lam: None. Background: Eating disorders(ED) occur at twice the rate in people living with type 1 diabetes(PWT1D) compared to the general population. Early detection and prevention necessitate a high level of clinical suspicion, as the coexistence of ED and T1D is linked to compromised metabolic control, earlier onset of microvascular complications, elevated mortality rates and diminished quality of life. Despite this, healthcare providers often encounter multiple challenges, such as the tendency for ED/DEB to be well hidden and/or denied, as well as a general discomfort in broaching this sensitive topic. Compounding the issue is the scarcity of literature offering optimal methods for supporting and treating individuals suffering from this dual diagnosis. Here, we conducted a survey at an academic center to assess providers’ overall knowledge and comfort level regarding the intersection of ED/DEB in PWT1D. Methods: A 15 question anonymous survey was distributed to members of our Endocrinology division, including fellows, attendings, and advanced practice providers (APPs) across four practices within an academic center in New York City. The primary objectives of the survey were to gauge participants' understanding in three key areas: general knowledge regarding the prevalence of this dual diagnosis, awareness of associated morbidity, and their professional experiences in providing care to this population. Results: The survey was distributed to a total of 40 participants with 29 responses: 38% Endocrine fellows, 41% attending physicians, and 21% APPs. 97% acknowledged that ED are more prevalent in PWT1D compared to the general population and 25% could identify validated screening tools for ED. Regarding the association between ED in PWT1D and health outcomes, 67% accurately identified the increased risk of developing microvascular complications and 36% recognized the increase in the risk of all-cause mortality. 71% reported caring for a PWT1D who expressed concerns about insulin and weight gain. When asked to rate their comfort level in addressing these concerns, 13.8% and 3.4% reported feeling comfortable and very comfortable, respectively. 86% of respondents expressed unfamiliarity with available resources for providing support to individuals in this group. Discussion: The results of the survey show general acknowledgment of the heightened prevalence of ED among PWT1D and association with morbidity and mortality, but emphasizes gaps in knowledge, a general sense of discomfort, and a shortage of resources to effectively manage individuals within this patient demographic. Our survey highlights the need for enhanced education and resources to better equip healthcare professionals in managing the complex intersection of both disorders. Given that diabetes outcomes are heavily dependent on behavioral adherence, strategies for addressing ED are crucial for comprehensive patient care. Presentation: 6/2/2024

5040 Leveraging Continuous Glucose Monitoring Data as an Additional Source for Glucagon Prescription Behavior

Abstract Disclosure: J. Ambalavanan: None. J. Rusticelli: None. D. Isaacs: Consulting Fee; Self; Medtronic Diabetes, Lilly USA, LLC, Novo Nordisk, Insulet Corporation, Abbott Laboratories, Dexcom. H. Xiao: None. J. Bena: None. Z. Jin: None. C. Babiuch: None. M. Lansang: Consulting Fee; Self; Glooko. Research Investigator; Self; Abbott Laboratories, Dexcom, Xeris. Background: Hypoglycemia is a major source of anxiety in, and can be life-threatening for, patients with diabetes (DM). Even though the American Diabetes Association (ADA) recommends glucagon be made available to all individuals taking insulin or at high risk for hypoglycemia (level E evidence), few patients have access to this life-saving medication. Given the rapid adoption of continuous glucose monitoring (CGM) in the management of DM, we aimed to 1) evaluate glucagon prescription by identifying patients with hypoglycemia on CGM reports, and 2) deliver an educational letter to the providers. Methods: Our study had a retrospective chart review and a quality improvement (QI) component. From Mar-Oct 2023, we identified adult patients in the Cleveland Clinic Ohio health system with type 1 or type 2 DM on insulin (including insulin pumps), sulfonylurea, or meglitinide, and hypoglycemia defined as time below range (TBR) ≥4% on CGM reports. We evaluated the percentages of pre-existing and incident glucagon prescription among those patients. For the QI component, we contacted providers individually via letter if the patients did not have a glucagon prescription and shared with them the ADA Standards of Care on hypoglycemia along with information about various forms of glucagon. Whether to prescribe glucagon was left to the clinical judgement of the providers. Information was collected 4 weeks later to see whether there was any change in the prescription practice. Results: Patients numbered 1543, with170 patients having TBR ≥4%. Among patients with hypoglycemia, 37% had pre-existing prescription and 14% incident glucagon prescription, compared with patients without hypoglycemia (p<0.001). Significant (p<0.001) risk factors for hypoglycemia included type 1 DM, insulin-only therapy, use of conventional insulin pumps, and lower A1c. Among patients with TBR ≥4%, 66 (39%) had level 1 hypoglycemia (54 to <70 mg/dl), 88 (52%) had level 2, and 16 (9%) had level 3 (hospitalization or ER admission for hypoglycemia). Pre-existing or incident glucagon prescription was seen in 28% without hypoglycemia, 38% with level 1 hypoglycemia, 49% with level 2, and 63% with level 3 (p<0.001 level 1 vs level 3; level 2 vs no hypoglycemia; level 3 vs no hypoglycemia). Among 70 patients whose providers received education letters, 27 (39%) prescribed glucagon after education. Glucagon emergency kit, glucagon autoinjector, and inhaled glucagon were the top prescription choices. A greater proportion of advanced practice providers responded to our education than physicians (p=0.021). Conclusion: Glucagon prescription remains suboptimal though better than in other studies even among patients with documented hypoglycemia on CGM reports. Effective provider education and communication can increase glucagon prescription. Provider and patient factors should be studied next to determine steps for further improvement. Presentation: 6/1/2024

General versus disease-specific medical oncology consults and impact on inpatient quality of care.

321 Background: Hospitalization is a time of crisis for patients and caregivers. Subspeciality oncologists may bring more timely, effective support compared to a general oncologists. Attendings, fellows and advance practice providers (APPs) may benefit from focused expertise for consultative care and education. Methods: Subspeciality oncology consults launched July 2023, with consults staffed by 4 oncologists from: 1) breast 2) head and neck/thoracic 3) gastrointestinal and 4) genitourinary/melanoma. Previously, 3 oncologists staffed all patients, regardless of primary malignancy. Throughout the study period, oncologists were supported by at least 1 fellow or 1 APP. Using Epic and Tableau, we collected LOS, time to consult (TTC), ICU rate, hospice referral rate, 30-day readmission, 30-day emergency department (ED) visit data. Using Qualtrics, we collected fellow, attending, and APP satisfaction feedback pre- and post-intervention. Data was analyzed using R-4.40. Oncologists, fellows, and APPs completed Qualtrics surveys pre- and post-intervention regarding their experience. Results: Subspeciality oncology consults were associated with a significant decrease in LOS, TTC, and ICU rate. Median LOS decreased by 2.0 days (P<0.001), with median TTC decreasing by 1.0 hour (P=0.003). ICU rate decreased from 27.5% to 16.4% (P<0.001). There was no difference in hospice referrals or 30-day ED visits. A significant increase in 30-day readmission during post-intervention was observed (Table). Oncologists reported a high level of satisfaction with the program. Oncologist, fellow, and APP overall experience and educational rankings increased after the introduction of subspeciality consults. Inpatient productivity measured by wRVU increased by 30% following the intervention, without associated changes to outpatient productivity. Conclusions: Transition to a subspeciality oncology consult model improved inpatient quality of care, as well as clinician experience. Additionally, inpatient productivity increased without decrease in outpatient metrics. Subspeciality medical oncology consultation can improve inpatient quality of care, education, clinician satisfaction and productivity. Subspeciality oncology consult outcomes. General Consults (Baseline)* Subspeciality Consults (Intervention) P-value Median TTC (Hours) 4.0 (1.5-6.0)** 3.0 (0-5.0)** P=0.003 Median LOS (Days) 7.0 (4.0-13.0)** 5.0 (3.0-10.0)** P<0.001 ICU Rate 148 (27.5%) 161 (16.4%) P<0.001 Hospice Referral Rate 56 (10.4%) 95 (9.7%) 0.655 30-Day Readmission Rate 136 (25.3%) 301 (30.7%) 0.028 30-Day ED Rate 157 (29.2%) 315 (32.1%) 0.247 *Baseline data reflects outcomes for general oncology consult staffing, prior to initiation of subspeciality consult model (pre-intervention). **Interquartile Range (IQR).

Perspectives of clinicians on the value of the Get to Know Me board in the Intensive Care Unit

BackgroundCritical illness can render patients at heightened risk of anonymity, loss of dignity and dehumanization. As dehumanization results in significant patient distress, it is imperative to find ways to humanize care in the ICU. A Get to Know Me Board (GTKMB) is a personal patient profile designed to bring the patient from anonymity, yet its widespread adoption has been challenging. Research QuestionIdentify perspectives of ICU clinicians on the value of the GTKMB in caring for ICU patients. Study Design and MethodsThis qualitative study used focus groups conducted via videoconference. We recruited stakeholders from multiprofessional teams across different ICU settings at a large U.S. quaternary care center. Thematic content analysis approach was performed to identify key themes and concepts. ResultsWe interviewed 38 participants in 6 focus groups including 10 nurses, 7 physicians, 6 advanced practice providers, 5 rehabilitation therapists, a respiratory therapist, and a social worker. Themes highlighted the role of the GTKMB in multiple domains including a) humanizing care of the critically ill, b) fostering communication, c) connecting with families and d) guiding and facilitating care processes. Several sub- themes were identified for each category. InterpretationThe GTKMB was considered important in fostering humanized caring in the ICU by diverse members of an interprofessional ICU team, helping to facilitate communication, establish family connection, and guide care.

Unlocking success: Multidisciplinary rounds for effective discharge planning.

341 Background: Multidisciplinary rounds (MDR) streamline collaboration among healthcare professionals across various disciplines to devise patient progress and post-hospitalization transition plans. In our gynecology oncology inpatient unit, coordinating patient care involves multiple teams aiming for discharge objectives. While nurses oversee the care plan, physicians, advanced practice providers, case managers, and other key stakeholders possess essential insights to effective discharge planning. The aim of our study was to evaluate the impact of structured MDR implementation on discharge accuracy, effectiveness, and hospital throughput. Methods: In April 2022, our gynecologic oncology inpatient team implemented structured MDRs to enhance discharge processes, focusing on patient outcomes and hospital throughput. The initiative aimed to identify discharge barriers early, set goals, and address challenges collaboratively through: 1) Interdisciplinary Assessment: Using standardized tools to evaluate patient status and care needs; 2) Review of Clinical Data: Analyzing medical records via EHR systems; 3) Collaborative Decision-Making: Using decision-support tools to set the Estimated Discharge Date (EDD); 4) Patient Engagement: Involving patients and families in shared decision-making; 5) Documentation and Communication: Ensuring clear EDD documentation and effective communication through team huddles, bedside rounds, and discharge planning meetings. EDD reporting, discharge order timing, and patient discharge time were tracked using our Care Team Transformation Dashboard. Results: The implementation of structured MDR led to significant improvements in discharge processes. We observed enhanced accuracy in EDD, with a 2.9% increase, and a notable rise in the completion of discharge orders before 9 am, showing a 60.5% increase (Table). The percentage of patients leaving the hospital before noon increased by 20.4%, highlighting MDRs effectiveness in facilitating timely discharge, enhancing intradisciplinary collaboration, and streamlining discharge efficiency. Conclusions: MDRs play a pivotal role in improving teamwork, quality of care, and patient outcomes. Setting EDDs through structured MDR processes enhances proactive discharge planning, thereby reducing delays and optimizing patient flow, ultimately contributing to the delivery of high-quality, patient-centered healthcare. Measure Preintervention: 1/2023-1/2024 Postintervention02-05/2024 Percentage Increase EDD accuracy 1 day prior 46.9 48.3 2.9% Discharge orders before 9am 33.4 53.6 60.5% Discharges prior to noon 19.1 23.0 20.4%

Patient and care team experiences with an EHR-integrated symptom management program (eSyM) in routine oncology practice.

324 Background: Clinical trials have shown that collecting electronic patient-reported outcomes (ePROs) improves quality of life and survival in cancer patients. To bolster integration of ePROs into routine care, the SIMPRO Research Consortium developed an electronic symptom management (eSyM) program, deployed it at six cancer centers, and conducted a hybrid effectiveness-implementation study. eSyM, an ePRO toolkit integrated into the Epic EHR, enables patients to report and care teams to triage symptoms in real-time. To assess eSyM, we conducted structured qualitative interviews with patients and clinic staff, including doctors, nurses, advanced practice providers, and administrative staff. We sought to understand eSyM from the patient and staff perspectives. Methods: Using an iterative process, we developed semi-structured interview guides to query the experiences and perceptions of patients and staff exposed to eSyM. Questions were informed by the Consolidated Framework for Implementation Research. One year after eSyM was launched, sites identified and referred participants for interviews or focus groups. Participants must have either used eSyM to submit symptoms (patients) or had access to eSyM at their institution (staff). Patients provided written consent; a consent waiver was obtained for staff. Interviews were recorded and transcribed, and a common analytic codebook was developed. Transcripts were dual or triple-coded and underwent thematic analysis to identify key contexts and concepts within and across patient and staff groups. Results: From 9/28/20 to 4/14/23, 50 staff participated in individual interviews and 29 participated in focus groups (79 total). From 9/14/23 to 3/14/24, 14 patient interviews were conducted. Transcripts revealed that staff and patients held similar beliefs regarding eSyM compatibility, communication, and prioritization. 93% (13/14) of patients and 72% (57/79) of staff believed eSyM was easy to use and improved communication. Both cohorts (66% staff, 36% patients) noted that competing demands often needed to be prioritized over responding to symptom concerns. Discordance emerged in the domains of receptivity and technology; patients were more receptive and capable of using eSyM than staff perceived. Both groups believed eSyM was helpful but perceived that deeper engagement from patients and staff was necessary for sustainability. Conclusions: Most interviewees reported that eSyM added value and was easy to navigate. Competing clinical demands, however, frequently deprioritized use of eSyM. Staff tended to underestimate patients’ receptivity to use eSyM and were more likely to cite competing demands as a barrier to their own use of eSyM. Sites looking to adopt eSyM, or similar ePRO programs, will benefit from understanding the facilitators that need to be incorporated and the barriers that need to be surmounted to optimize success. Clinical trial information: NCT03850912 .

Closing the loop: Utilizing advanced practice providers for a 7-day post hospital discharge follow-up of GI oncology patients at an academic cancer center.

304 Background: Acute care visits for oncology patients may be preventable, especially for high-risk patients with a recent hospitalization. During our 2023 Fiscal Year, we observed an approximate 22% rate for 30 day readmissions for oncology patients, with our gastrointestinal (GI) oncology patients having the most readmissions, at Stanford Cancer Center. Readmission review through clinician surveys suggested that about 28% of unplanned admissions may have been preventable, with root cause analysis identifying timely access to ambulatory symptom management as a major driver. Methods: We established a cancer transitional care (CTC) clinic to provide consistent and timely post-discharge follow-up for oncology patients. We initiated a pilot program for GI oncology patients (chosen due to high acuity and readmission rate) who had an unplanned admission to Stanford Hospital. We aimed to schedule a visit with an advanced practice provider (APPs) within 7 days of discharge. The A3 problem solving process was implemented weekly by a multidisciplinary team. We created a referral in our electronic medical record. Inpatient oncology teams were instructed to place this referral within 3 days before discharge, allowing for adequate patient and family education regarding the goals of CTC visits and ample time for the post-discharge CTC visit to be scheduled prior to patient discharge. Prior to CTC visits, pharmacists performed outreach to reconcile medications to reduce medication errors. Eight oncology APPs were trained regarding the focused nature of a CTC visit, including symptom management, medication reconciliation, and goals of care discussions. Results: At baseline, from June 1 and November 30th, 2023, 61% of patients had follow-up within 7 days of discharge and 12% of patients with none. Between December 13, 2023 and April 19, 2024, CTC implementation resulted in a total of 220 referrals for GI oncology discharges, yielding 144 CTC clinic visits. Resulting in 66.1% of patients having follow up within 7 days of discharge and 9% of patients had no follow up scheduled. 79% of visits were within 7 days of discharge, representing a 29% increase in our goal scheduling timeline. The average time between discharge date and CTC visit was 6.2 days. Sixty six patients also received detailed pharmacy reviews with medication reconciliation and addressing medication access issues. Conclusions: Through our CTC clinic, we standardized post-discharge follow-up access for GI oncology patients, reducing variability in follow up. We plan to disseminate this model across medical oncology subspecialty clinics. Barriers included standardization of follow up with clinical team and expectations for the visit for both patients and clinicians. Future directions include integrating same day symptom management and urgent care access.

AI-enabled ACP on inpatient oncology: Feasibility, acceptability and impact on workflow.

403 Background: Advance care planning (ACP) can help patients understand and share their long-term health goals and values, and in turn facilitate the delivery of medical care consistent with those goals and values. However, in a survey of Californians about attitudes towards death and dying, while almost 80% of respondents indicated that they would like to talk to their doctor about end-of-life care, only 7% had ever had a doctor bring up the subject. To address this problem, the Stanford inpatient oncology service implemented an AI-enabled workflow to facilitate timely identification of patients for ACP conversations before discharge. While the workflow implementation has thus far been successful, less is known of the human factors from patients and providers that influence the feasibility and acceptability of this workflow. Methods: To gather perspectives on the AI-enabled tool, we used qualitative research methods to conduct semi-structured interviews with 15 patients and 15 providers. Patients were over the age of 18 and had been recently admitted to the Stanford Inpatient Oncology Service. Providers were over the age of 18 and worked within the Stanford Inpatient Oncology Service in one of four roles: attending oncologist, advanced practice provider, clinical dietician, occupational therapist. Interviews were conducted virtually via Zoom, recorded and transcribed for subsequent thematic analysis. Once transcribed, interviews were qualitatively coded using an inductive approach. Results: Patients and providers affirm the positive potential for AI implementation in healthcare settings, but emphasize the necessity of maintaining human-centered models of care which prioritize strong interpersonal relationships. Providers observe relatively minimal impacts of the AI-enabled tool on existing advance care planning workflows/practices, but express optimism surrounding the implementation of AI tools in inpatient oncology more generally. Patients exhibit similar levels of optimism and a general openness toward AI applications in healthcare settings, but highlight the need for transparency and informed consent throughout the processes of AI development and implementation. Conclusions: This study provides novel insights on the impacts of AI-enabled workflows in inpatient oncology care, as well as patient and provider perspectives concerning the implementation of AI technology in healthcare more broadly. As AI is increasingly developed with clinical care applications in mind, these insights provide valuable foundations for successful implementation.

Impact of a trainee-led initiative to address PCP prophylaxis barriers.

319 Background: In a prior trainee-led QI initiative, we surveyed clinicians about Pneumocystis pneumonia (PCP) and assessed rates of appropriate prophylaxis. Through retrospective chart review, we found that 47% of eligible patients (n=140/297) received PCP prophylaxis between 5/2022 and 5/2023. Clinician-reported barriers included knowledge gaps, systems-related gaps, and unclear corticosteroid durations. In the current initiative, we built an order set to facilitate PCP prophylaxis prescription and created an automated approach to assess prophylaxis rates. We then re-evaluated perceived barriers to prescribing PCP prophylaxis. Methods: A multidisciplinary team of oncology fellows and QI staff was established at Johns Hopkins. A new PCP prophylaxis order set was implemented on 4/15/2023. An automated data query was developed to identify patients with solid malignancies who were eligible for PCP prophylaxis per ASCO/IDSA guidelines (≥20mg prednisone equivalents daily for ≥1 month). Patient data was collected between 4/15/2022 and 4/15/2024. Surveys were conducted in 5/2023 and 5/2024 to assess prescriber knowledge of, and attitudes toward, PCP prophylaxis. The survey was open to prescribers across oncology specialties. Results: 1,404 patients were eligible for PCP prophylaxis over the 2-year study period, with 19% (n=264) receiving prophylaxis. In the year before the order set, 21% (n=138) of eligible patients were prescribed prophylaxis. In the year after the order set, 17% (n=126) of eligible patients were prescribed prophylaxis. A survey conducted post order set implementation included 52 responses from 42% (n= 22) attending physicians, 35% (n=18) advanced practice providers, and 23% (n=12) residents/fellows. While 92% (n=48) of survey participants had prescribed PCP prophylaxis, 31% (n=16) knew the dose/duration of corticosteroids at which society guidelines recommend prophylaxis. Unclear corticosteroid duration, guideline knowledge, and concern about side-effects were the most commonly reported barriers to prescribing prophylaxis. Conclusions: Compared to the prior chart review approach, the automated query identified more than twice as many patients at risk for PCP. Strikingly, <25% of eligible patients were prescribed PCP prophylaxis. Prescription rates did not improve following implementation of the order set. However, the post order set survey found increased rates of guideline knowledge and identified unclear corticosteroid durations as the primary barrier to prophylaxis. Building on these findings, an additional PDSA cycle is ongoing including development of notification system alerting providers when PCP prophylaxis is recommended for their patients. Barriers to PCP prophylaxis. Barrier Number of Respondents (%) Pre Order Set Number of Respondents (%) Post Order Set Unclear Corticosteroid Duration 8 (11%) 10 (19%) Guideline Knowledge 11 (16%) 7 (13%) Lack of EMR Notification 6 (9%) 2 (4%)

A qualitative study identifying the navigation needs of patients with HCC.

263 Background: Hepatocellular carcinoma (HCC), the 2 nd leading cause of cancer mortality, disproportionately affects racial and ethnic minorities. Disparities in risk are compounded by profound differences in HCC treatment and survival. Black patients are consistently diagnosed at more advanced stages, least likely to receive treatment, and have the lowest survival. In other cancer types, navigation facilitates successful treatment and improves outcomes. To inform development of a longitudinal navigation program, we aimed to ascertain the needs of HCC patients, and identify obstacles limiting access to cancer treatment and supports needed for successful HCC treatment from the vantage point of patients and other stakeholders. Methods: In-depth, one-hour qualitative interviews were conducted with 40 individuals (14 patients, 7 caregivers, 8 advocates, and 11 providers) in English or Spanish. Providers included physicians, advanced practice providers, social workers, nurse navigators, and transplant coordinators involved in HCC care. We recruited patients, caregivers, and providers from the Sylvester Comprehensive Cancer Center and Jackson Health System; advocates were recruited through partnerships with Global Liver Institute and the Hepatitis B Foundation. Results: The interviews identified five overarching themes representing navigation needs of HCC patients: (1) Education/ Health Literacy, (2) Financial Resources, (3) Coordination of Care, (4) Emotional Management, and (5) Social Support. The table displays the themes and subthemes. Conclusions: This study provides valuable insight into the needs of HCC patients at the institutional and national levels. Successful navigation must include interventions that address these needs; study findings have informed our pilot navigation intervention. Navigation needs of HCC patients. Themes Subthemes Education Disease progression and prognosisTreatment optionsPreparation for various stages of disease and treatmentEducation and preparation for upcoming visitsImportance of follow-upNutrition and other health behaviors Financial Resources Insurance–treatment/medication coverage andcopaymentsTransportationHousing/ RentFoodConnection to other agencies/ community resources (Medicare/ Medicaid, funding programs, foundations/ non-profits targeting HCC, advocacy) Coordination of Care Scheduling multiple doctor/lab visitsFollow-up for attendance to visitsMedical records ordered and receivedImaging done correctly and receivedServices to manage symptoms (Nutrition, acupuncture, massage, etc.) Emotional Management Manage anxiety/ depression/ overwhelm/ confusion/ denial/ fatiguePsycho-oncology/psychiatrist referralAlcohol and substance abuse treatmentSupport groupsStress reduction/ coping strategiesMindfulness/ meditationYoga/ Movement Limited Social Support Mental healthTransportationTreatment adherence

Advanced Practice Providers in Cellular Therapy: Survey Results from the ASTCT APP Special Interest Group Exploring Clinical Roles, Compensation, and Job Satisfaction

BackgroundAdvanced practice providers (APPs), which include physician assistants/associates and advanced practice nurses, are critical members of the transplant and cellular therapy (TCT) care team. Despite broad utilization in transplant centers, there is little published literature on the clinical roles and responsibilities, staffing models, compensation structure, and job satisfaction of TCT APPs. This study represents the results of a national survey administered by the APP Special Interest Group to better characterize the TCT APP workforce. ObjectiveTo characterize the TCT APP workforce by investigating clinical roles and responsibilities, compensation and institutional support, and job satisfaction. MethodsA 25-item web-based survey addressing four domains (transplant center data, APP roles and responsibilities, compensation and institutional support, and job satisfaction). Surveys were sent to participants through a chain-referral sampling method. Data were analyzed using descriptive statistics and multinomial logistic regression. ResultsA total of 198 responses were analyzed, representing 64 transplant centers of varying size from 29 states. APPs report working in inpatient and outpatient settings and performing a broad array of TCT-associated procedures including bone marrow biopsy (78%), lumbar puncture (43.2%), intrathecal chemotherapy (47.0%), and cellular infusions (45.9%). Median salary of respondents was $110,000-$119,000 and was significantly associated with geographic location of transplant center and years of experience. A minority of respondents reported no funding (4.2%) or time (9.8%) supporting continuing education. A majority of APPs (55.1%) do not feel they are appropriately paid. A majority (54.3%) did not feel that their center supported a good work-life balance. Nearly 35.4% of respondents did not feel valued in their role. ConclusionsThis survey represents the first to characterize the TCT APP workforce in the United States. APPs are highly integrated into the TCT care team and can serve as means to improve patient access to TCT therapies given a worsening physician shortage. However, the lack of satisfaction with compensation and work-life balance could represent barriers to recruitment and retention of TCT APPs and warrant future studies to better characterize.

Outpatient management of pediatric epistaxis: A cost analysis and clinical model.

Pediatric epistaxis is a common, often non-operative condition encountered by Otolaryngologists. The present study seeks to (1) describe our outcomes of epistaxis management, (2) estimate the associated healthcare burden, and (3) propose a clinical model to optimize care coordination with primary care and advanced practice providers. Retrospective case series of pediatric patients treated outpatient for epistaxis by a single otolaryngologist from 2021 to 2022. The primary outcome after treatment with nasal lubricants was defined as (1) refractory epistaxis, (2) improvement, or (3) complete resolution. Cost data for office versus operative nasal cautery were analyzed. In total, 122 patients were included for analysis. Over a follow-up duration of 20.5 months (IQR 8-36), 24.6% of patients experienced refractory epistaxis, 41.8% of patients found improvement, and 33.6% had complete resolution (n = 122). Refractory epistaxis was associated with a family history of coagulopathy (p = .007), daily epistaxis episodes (p = .043), and anemia (p <.001). Average direct hospital costs associated with nasal cautery were $187 for in-office cauterization and $2179 for intraoperative cauterization. Estimated patient/third party payors savings were $1617 and $15,412 for in-office and intraoperative procedures, respectively, and $541.59 for specialty office visits alone. The average charge for laboratory work-up was $576. Approximately 75% of patients with epistaxis experienced improvement or resolution of symptoms with nasal lubrication alone. Refractory epistaxis was associated with a family history of coagulopathy, daily epistaxis episodes, and anemia. Otolaryngology visits for epistaxis were associated with a direct healthcare expense burden. Adaptation of our clinical model may mitigate these costs while improving patient care. Level of Evidence: 4.

Pilot Study: Behavioral and Medical Clinical Partnership for Optimization of PAP Therapy in Pediatric Patients

Study ObjectivesTo assess the effectiveness of a structured algorithm for pediatric positive airway pressure (PAP) initiation for the treatment of obstructive sleep apnea (OSA). MethodsAn algorithm was created to support pediatric PAP use and identify patients that could benefit from early behavioral consultation and education. Sleep providers implemented a unified introduction to PAP therapy with the PAP therapy toolkit. Through a collaborative approach with the medical equipment companies, pediatric patients were provided with PAP equipment prior to PAP titration studies and were allowed a gradual initiation of PAP therapy. PAP downloads were reviewed to determine improvements in compliance measured by percent of average days used and average minutes per night used. ResultsThirty-eight pediatric patients completed the PAP therapy algorithm. There was significant improvement in PAP compliance in percentage of days used (paired t-test p value = 0.04), as well as an improvement (though not statistically significant) in average nightly use. Patients benefitted from close follow-up visits with the sleep advanced practice providers. Patients seen for the consultation with the pediatric behavioral psychologist showed statistically significant improvement in both percentage of days and average nightly use. ConclusionsOur pilot study shows that a behavioral and medical partnership using a structured algorithm was feasible and resulted in improved PAP compliance for our pediatric patients.

S1988 Knowledge, Skills, and Confidence Gaps in Diagnosis of Primary Biliary Cholangitis Among Gastroenterologists and Advance Practice Providers Practicing in Gastroenterology or Hepatology

S1988 Knowledge, Skills, and Confidence Gaps in Diagnosis of Primary Biliary Cholangitis Among Gastroenterologists and Advance Practice Providers Practicing in Gastroenterology or Hepatology

‘’It’s like I am always on a leash’’: A multi-stakeholder qualitative analysis of the time toxicity of cancer care.

209 Background: As the oncology community increasingly acknowledges the time burdens of cancer care, there is a critical need for foundational work to understand the sources, populations impacted, and consequences of time toxicity. We sought to evaluate these through qualitative interviews. Methods: We conducted semi-structured interviews with adults with advanced stage gastrointestinal cancer, informal care partners, and clinicians at an NCI-designated cancer center in MN, USA from Feb-Oct 2023. We explored aspects of cancer care that took up time and were perceived as burdensome, identified those most impacted, and the consequences. We recorded and transcribed interviews, and conducted inductive thematic analysis. Results: We interviewed 47 participants [16 patients (8 &lt;60 years; 12 women), 15 care partners (10 &lt;60 years; 9 women), and 16 clinicians (including advanced practice providers, nurses, physicians, schedulers, and social workers; 11 women)]. We identified 22 subthemes that we grouped into 5 themes (Table). Conclusions: This multi-stakeholder qualitative analysis provides a deeper understanding of time toxicity. These data will help the oncology community to map, measure, and ultimately address time toxicity. Theme Subthemes Illustrative quotes Source: Healthcare outside the home Travel, parking, and, waiting time, planned appointments, unplanned care, hospitalizations and facility-based care '’My wife and I made over 100 drives in two years, over an hour and a half in each direction.’’ (Patient) Source: Often invisible tasks performed at home Logistic and administrative tasks, learning about the disease and treatment, medical management, time spent managing symptoms and on recovery, home-based care ‘’A large burden was like the insurance paperwork.’’ (Care partner)‘’And that has happened before where I've just spent the whole day at home waiting for home care.’’ (Patient) Populations impacted: Care partners alongside patients Care partners are equally affected, taking over social responsibilities/ tasks of daily living ‘’Anything that takes time for me, is almost an equal burden on her. If not more sometimes.’’ (Patient) Consequences Care becomes all-consuming, short visits turn into ‘’all-day’’ affairs, missing important life events/work, emotional distress, demoralization, financial burdens ‘’ It’s like I am always on a leash. I really don't have any control.’’ (Patient)‘’Even for a 30-minute infusion, you'll be there, like half a day or a whole day.’’ (Patient) Positive interactions and hope for change Not all time spent is perceived as burdensome, clinicians are hopeful of decreasing time burdens, clinicians recognize their own time burdens as a barrier to addressing patients’ ‘’Patients having to walk through this incredibly long, circuitous way to check in, do labs as ritual—we are disdainful of a patient's time. We should demand change.’’ (Clinician)

Impact of a Nutrition and Diabetes Continuing Education Program on Primary Care Provider's Knowledge, Attitude, and Clinical Practice.

Diet/nutrition is the first-line non-pharmacological therapy in the treatment of diabetes. Diet/nutrition counseling is infrequently provided by primary care providers (PCPs), who have limited nutrition education in both medical and advanced practice provider curricula. This quality improvement project aimed to improve knowledge and attitude, and frequency of diet/nutrition counseling by PCPs among patients with uncontrolled diabetes (glycosylated hemoglobin A1c ≥8%), by providing an online continuing medical education (CME) program on diabetes diet/nutrition. At a community health center in New England, PCPs attended a live 50-minute online CME program that was developed internally, which taught PCPs current diet/nutrition guidelines and recommendations related to diabetes. Knowledge was assessed prior to and two weeks following the program, utilizing a 10-question tool, the Nutrition Management of Diabetes Assessment (NMDA). Similarly, attitude was evaluated using two subscales of the Nutrition in Patient Care Survey (NIPS): Nutrition in routine care and Physician efficacy. Chart audits of patients with uncontrolled diabetes were evaluated to assess PCPs documentation of diet/nutrition counseling four weeks prior to and six weeks following the CME program. In September 2023, PCPs (n = 29) completed the CME program. There was an improvement in knowledge in the NMDA amongst PCPs (36% difference, p < 0.001). Attitude scores from two subscales of the NIPS were evaluated and both showed improvement, however only physician efficacy was significant (15% difference, p < 0.01). There was a positive difference in the trend of diet/nutrition counseling after the education program (p < 0.05). An online CME program improved diabetes diet/nutrition knowledge and attitude of PCPs and improved counseling practices for patients living with uncontrolled diabetes. The education program provided PCPs current standards of care guidelines/recommendations, which they can utilize when counseling patients with diabetes. PCPs would benefit from dedicated continuing education programs regarding diet/nutrition therapy for chronic illnesses.