Ambulatory Care Network Research Articles

Challenges of Conducting Point-Of-Care Testing Operations In The Municipal Public Health System Based Ambulatory Care Clinics In New York City

Abstract Introduction/Objective Our New York City Municipal Public Health System- based multisite ambulatory clinics that offer various waived POCT (point of care tests) and provider-performed microscopy (PPM) to our communities, ensure standardization and quality of POC testing across our health system. Our laboratory service conducts system-wide centralized implementation, monitoring and oversight of the POCT operations regarding regulatory compliance, test performance, quality control and training. With our day-to-day POCT operations, like all other clinical laboratories, our ambulatory care clinics encounter various hurdles and challenges. Here we elaborated on the issues we encounter and how we manage to overcome them. Methods/Case Report We identified and stratified the challenges that affect our managerial as well as field-level laboratory operations and devised ways to deal with those POCT operational issues. Results (if a Case Study enter NA) Among the staffing issues, rapid staff turnover causes significant delays or cessation of POCT operations in our ambulatory care clinics, due to orientation, re-education and ensuring competency to the staff, that conducts POCT in our clinics. Besides, supply shortages, staff shortages and absences due to illness and overwork are the issues, noted at the laboratory field operational level. Delays in the processing of paperwork and new staff recruitments and in the laboratory supply chains are notable management issues. Conclusion Even though the vastness and complexity of our multisite ambulatory care network sometimes affect our ambulatory care clinic POCT operation in various challenging way, our timely, planned and coordinated intervention, close monitoring and communication and rapid initiatives handle those issues very effectively to ensure the quality of POC testing for the patient safety and care across our health system, which is one of the largest municipal-based public health care, in the country.

WP7.14 - The change of a DGH emergency surgical service leads to marked improvements in timing of cholecystectomy for gallstone pancreatitis, in line with international guidance

Abstract Background International Association of Pancreatology (IAP) guidelines recommend that cholecystectomy should be performed on patients with mild biliary pancreatitis during their index admission. This retrospective study compares how a paradigm shift in the provision of emergency surgical services in one district general hospital (DGH) significantly improved ability to follow this guideline. With input from the surgical ambulatory emergency care network (SAEC), our team transformed care via an Emergency Surgery Unit (EmSU) system. This includes surgical assessment with ambulation, linked radiology slots, semi-emergency theatre lists twice weekly in addition to NCEPOD theatre and the emergency take divided in two according to sex of patient ensuring appropriate patient load for each of the surgeons of the week. Methods A retrospective study of patients with mild biliary pancreatitis for three years before (n = 107) and after (n=108) the EmSU system. Cholecystectomy on index admission was recorded, as was overall time to surgery (days). Data was analysed using GraphPad Prism Version 9.5.1. Data is expressed as Mean + SEM. Percentages underwent Arcsine transformation prior to inferential analysis. Groups of data were analysed using Students T-Tests. Results The percentage of patients operated on index admission increased 13.1-fold (4.8% to 62.9%; P < 0.01). Days to surgery saw a 10.1-fold reduction (332.5 + 41.1 to 32.9 + 6.3 days; P < 0.0001). Conclusions Adoption of our EmSU system has drastically improved care for patients with gallstone pancreatitis, now closer to best practice guidance. Further improvement is likely with increased buy-in from all members of staff.

A Formative Evaluation of Social Care Integration Across a Safety-Net Health System

Summary Recognizing that social determinants of health influence patient outcomes, health systems increasingly look to integrate social care into clinical spaces. Although ample research addresses screening for unmet social needs, how social care integration is operationalized in large health systems remains largely undescribed. In an effort to complete a formative evaluation of social care integration across a large urban safety-net health system, researchers performed qualitative semi-structured interviews to assess baseline levels of social care integration and barriers and facilitators to social care delivery in multiple clinical settings (primary care, ED, inpatient, and specialty care) across the Los Angeles County Department of Health Services. They used the Consolidated Framework for Implementation Research to categorize implementation across disparate settings and the National Academies of Sciences, Engineering, and Medicine model of health system activities to integrate social care as the social determinants framework. Data were analyzed by using both an inductive and deductive approach. The authors interviewed 175 stakeholders (112 frontline providers, 32 executives, and 31 patients) across 4 hospitals, health system administration, and the ambulatory care network. Frontline providers included physicians, registered nurses, social workers, medical assistants, community health workers, and registration workers. Participants described 30 unique social care initiatives across the system that address needs in the areas of housing, food insecurity, employment, legal needs, material needs, financial needs, violence, and immigration status. All stakeholder groups reported that they believe helping patients with unmet social needs is aligned with the mission of the health system. True integration, however, has not yet occurred because social care remains widely considered an add-on rather than a core function of health care delivery, study participants report. Respondents say that social care integration is not on the agenda of their organizations’ operational committees; thus, entry into the available social care programs remains uncoordinated and the care fragmented. The authors’ findings show that in this large safety-net health system — which has both a patient population with high levels of unmet social needs and a vast array of social care programming — social care delivery is hindered by lack of strategy and coordination. The health care delivery lens of right care, right place, right time must be applied to social care integration to improve coordination between programs and to maximize efficiency.

Colorectal Cancer Screening Decisions From Student-Led Telemedicine Initiative During COVID-19.

With the onset of the COVID-19 pandemic, there has been a significant decrease in colorectal cancer (CRC) screening leading to delayed diagnoses and increased cancer deaths. To mitigate these burgeoning gaps in care, we developed a medical student-led service learning project aimed at improving rates of colorectal cancer screening at the Farrell Health Center (FHC), a primary care practice within the Ambulatory Care Network (ACN) at New York-Presbyterian Hospital. A cohort of 973 FHC patients aged 50-75 years were identified as possibly overdue for screening. Student volunteers reviewed patient charts to confirm screening eligibility and then contacted patients to offer colonoscopy or stool DNA test. Following the patient outreach intervention, medical student volunteers completed a questionnaire to assess the educational value for the service-learning experience. Fifty-three percent of identified patients were due for CRC screening; 67.8% of eligible patients were reached by volunteers. Among the patients reached, 47.0% were referred for CRC screening. No statistical significance was observed between likelihood of CRC screening acceptance and patient age or sex; 87% of medical student volunteers felt that the service-learning project was a valuable educational experience. The student-led patient telehealth outreach program is an effective model for identifying and referring patients overdue for CRC screening and an enriching educational experience for preclinical medical students. The structure provides a valuable framework to address gaps in health care maintenance.

An innovative model for improving access to care: Patients’ experience of a primary care network caring for underserved communities in France

BackgroundVulnerable people have complex health needs but face multiple barriers to accessing healthcare. In 2018, Médecins du Monde (MDM), a French non-governmental association which care for underserved people, initiated an ambulatory primary care network in Marseille, France: the “PASS De Ville” (PDV). It supports vulnerable populations in obtaining immediate access to common primary care in the city before their health insurance rights are established. We aimed to assess the experience and care expectations of the patients who used the PDV. MethodsWe conducted a qualitative study based on a grounded theory approach. Patients who met at least one of the general practitioners involved in the PDV were included. We conducted semi-structured interviews amongst 16 service users, between February and May 2021. Two researchers performed an inductive analysis using NVivo. ResultsThe patients had both medical and non-medical needs. Alongside health, access to health insurance was a subject often considered a key priority. Although patients seemed to have little understanding of how the PDV works, they nevertheless managed to benefit from it and access medical care more easily. PDV users reported feeling more socially integrated through consideration by healthcare givers. Most of them still identified the general practitioner encountered during the PDV as their referent doctor once their health insurance rights were established. ConclusionThe PDV seems to support better integration into the French primary care system for patients who encounter barriers seeking medical care. Other studies are needed to identify PDV's efficiency on care pathways and patients’ overall health.

Abstract P222: Effectiveness Of A Multicomponent Implementation Strategy On Increasing Uptake Of USPSTF Hypertension Screening Recommendations In A Primary Care Network: The Embrace Cluster Randomized Trial

Background: In 2015, the US Preventive Services Task Force (USPSTF) updated its primary care screening guidelines to recommend out-of-office BP testing with ABPM or HBPM for confirming the diagnosis of hypertension (HTN) in adult patients with high office BP. Methods: We applied the Behavior Change Wheel framework to develop a theory-informed strategy for increasing the uptake of the USPSTF HTN screening guideline. We then conducted a 2-arm cluster randomized trial in which 8 primary care practices (154 clinicians) in an ambulatory care network serving vulnerable communities in New York City were randomized to receive the implementation strategy (4 practices) or a wait-list control (4 practices). The strategy was implemented from October 2017 to March 2018, and consisted of: 1) clinician education about HTN screening recommendations; 2) clinician information on how to order ABPM and HPBM; 3) patient information on ABPM and HBPM; 4) nurse training on how to teach patients to conduct HBPM; 5) access to an ABPM testing service; 6) clinician feedback on out-of-office BP test ordering; and 7) embedded tools in the EHR to facilitate ABPM and HBPM ordering. The primary outcome was change in the proportion of patients completing ABPM or HBPM in the year before versus year after implementation. Results: There were 1069 eligible patients (mean age 53±16 years, 67% women) with high office BP but no diagnosis or treatment for HTN. In implementation practices, the proportion of patients with out-of-office BP test ordering increased from 0.5% in the year before implementation to 4.0% in the year after implementation (p<.001) whereas test ordering did not change in control practices (3.1% to 2.8%, p=0.66); p<.001 for interaction. Similarly, out-of-office BP test completion increased from 0.5% to 3.0% (p<.001) in implementation practices whereas test completion did not change in control practices (2.2% to 2.0%, p=0.76); p<.001 for interaction. Conclusions: A theory-informed implementation strategy increased out-of-office BP testing in adult primary care patients being screened for HTN. Yet, out-of-office BP testing in the context of HTN screening remained low in both implementation and control practices, suggesting a need for more potent implementation strategies.

Perspectives from leadership and frontline staff on telehealth transitions in the Los Angeles safety net during the COVID-19 pandemic and beyond.

ObjectivesThe start of the COVID-19 pandemic led the Los Angeles safety net health system to dramatically reduce in-person visits and transition abruptly to telehealth/telemedicine services to deliver clinical care (remote telephone and video visits). However, safety net patients and the settings that serve them face a “digital divide” that could impact effective implementation of such digital care. The study objective was to examine attitudes and perspectives of leadership and frontline staff regarding telehealth integration in the Los Angeles safety net, with a focus on telemedicine video visits.MethodsThis qualitative study took place in the Los Angeles County Department of Health Services (LAC DHS), the second-largest safety net health system in the US. This system disproportionately serves the uninsured, Medicaid, racial/ethnic minority, low-income, and Limited English Proficient (LEP) patient populations of Los Angeles County. Staff and leadership personnel from each of the five major LAC DHS hospital center clinics, and community-based clinics from the LAC DHS Ambulatory Care Network (ACN) were individually interviewed (video or phone calls), and discussions were recorded. Interview guides were based on the Consolidated Framework for Implementation Research (CFIR), and included questions about the video visit technology platform and its usability, staff resources, clinic needs, and facilitators and barriers to general telehealth implementation and use. Interviews were analyzed for summary of major themes.ResultsTwenty semi-structured interviews were conducted in August to October 2020. Participants included LAC DHS physicians, nurses, medical assistants, and physical therapists with clinical and/or administrative roles. Narrative themes surrounding telehealth implementation, with video visits as the case study, were identified and then categorized at the patient, clinic (including provider), and health system levels.ConclusionsPatient, clinic, and health system level factors must be considered when disseminating telehealth services across the safety net. Participant discussions illustrated how multilevel facilitators and barriers influenced the feasibility of video visits and other telehealth encounters. Future research should explore proposed solutions from frontline stakeholders as testable interventions towards advancing equity in telehealth implementation: from patient training and support, to standardized workflows that leverage the expertise of multidisciplinary teams.

Challenges of Conducting Point-Of-Care Testing Operations During The COVID-19 Pandemic In The Municipal Public Health System Based Ambulatory Care And School Health Clinics In New York City

Introduction/ObjectiveOur New York City Municipal Public Health System based multisite ambulatory clinics and school-based clinics, offer various waived POCT (point of care tests) and provider performed microscopy (PPM). To ensure standardization and quality of POC testing across our health system, our laboratory service conducts system wide centralized implementation, monitoring and oversight of the POCT operations in regard to regulatory compliance, test performance, quality control and training. With the emergence of the COVID-19 infection in the New York City, like all other clinical laboratories, our ambulatory care clinics encountered numerous hurdles and challenges. Here we elaborated the issues that we encountered and how we managed to overcome during the COVID-19 Pandemic.Methods/Case ReportWe categorized the challenges that affected our managers as well as field level laboratory operations and have devised a plane to deal with COVID-19 related predicaments.Results (if a Case Study enter NA)Among the staffing issues, staff relocation to the acute care hospital laboratories during the peak of the pandemic caused massive delay or cessation of POCT operations in our ambulatory care clinics. Manual result entry, for COVID-19 testing, at the patient portals due to lack of interface with the reference testing labs, staff shortages and frequent absences due to illness and fatigue were primary issues noted at technical level. Furthermore, there were notable delays in the processing of paper works and new staff recruitments. The lack of and significant delays in the critical laboratory supplies was another major management issue.ConclusionGiven the vastness and complexity of our multisite ambulatory care network, the COVID -19 pandemic impacted our ambulatory care clinic POCT operation in a very challenging way. However, our timeliness, coordinated interventions, close communications and initiatives handled the obstacles that arose very effectively to the ensure quality of POC testing, patient safety and quality care across our health system.

Ensuring Standardization, Quality Management And Improvement Of Point-Of-Care Testing In The Municipal Public Health System Based Ambulatory Care And School Health Clinics In New York City

Introduction/ObjectiveOperated under different acute care hospital clinical laboratory limited-service laboratory (LSL) licenses, our New York City five borough spanning multisite ambulatory clinics and school-based clinics have been offering various waived point-of-care tests (POCTs) and provider-performed microscopy (PPM) to the local communities. A wide range of variability existed among the clinics concerning regulatory compliance, test performance, quality control and training. To ensure standardization and quality of POCT across the health system, our laboratory service adopted and implemented a plan for systemwide LSL transfer from the acute care hospitals to ambulatory care laboratory service for centralized implementation, monitoring, and oversight of the POCT operations.Methods/Case ReportHaving over 60 clinics, while transferring the LSLs, we chose multi-site license with ten or more sites on each license and by phase transfer from NYSDOH. Since the commencement of the transfer, system wide our qualified laboratory personnel have been updating and providing standard operating procedures (SOP), performing quality assurance and validation of new tests/devices, providing competency assessments and helping clinical staffs maintain compliance with state and other regulatory agencies.Results (if a Case Study enter NA)After the final phase of the transfer and POCT standardization implementation in 63 clinics, currently the clinical staffs performing POCT, get expeditious training and troubleshooting in more timely manner and the providers get the results of the ordered POCTs much faster and more efficiently and overall the quality metrics get improved markedly, indicated by internal audit team.ConclusionEven though Implementation of the planned POCT standardization was initially challenging due to the vastness and complexity of our multisite ambulatory care network and later confounded by the COVID -19 pandemic effect but eventually, it helped improve patient care delivery significantly and very effectively. Expectedly, our planned transfer implementation provided standardization and ensured improved quality of POC testing across our health system.

High-Level Disinfection in Ambulatory Care: Overcoming the Barriers of a Decentralized System through Auditing and Education

Background: High-level disinfection (HLD) of semicritical instruments in a multispecialty ambulatory care network has the potential for increased risk due to the decentralized instrument reprocessing and lack of a sterile processing department. Attention to HLD practices is an important part of device-borne outbreak prevention. Method: An HLD database was developed to identify specific departments and locations where HLD occurred across a 30-medical practice ambulatory care network in eastern Massachusetts, which included otolaryngology, urology, endoscopy, and obstetrics/gynecology departments. Based on qualitative feedback from managers and reprocessing staff, this database centralized information that included the supply inventory including manufacturer and model information, HLD methodology, standard work, and listing of competency evaluations. The infection control team then led audits to directly observe compliance with instrument reprocessing and a monthly-driven HLD calendar was developed to enforce annual competencies. Result: The results of the audits demonstrated variability across departments with gaps in precleaning, transportation of used instruments, the dilution of enzymatic cleaner, and maintenance of quality control logs. Given the uniqueness of shape and size of various ambulatory locations, proper storage and separation between clean and dirty spaces were common pitfalls. Auditing also revealed different levels of staff understanding of standard work and variable inventory management. Centralized education sessions held jointly by the infection control team and various manufacturers for the reprocessing staff helped to create and reinforce best practices. Conclusion: Decentralized HLD that occurs across multiple ambulatory care sites led to gaps in instrument reprocessing and unique challenges due to variable geography of sites, physical space constraints, and an independent approach to procuring medical supplies. Through the auditing and feedback of all areas that perform HLD, an effective and sustainable strategy was created to ensure practice improvement. Streamlining standard work, seeking direct input from frontline staff, and collective educational events were critical to our success in the ambulatory setting.Funding: NoDisclosures: None

Factors Associated With Longer Than Recommended Durations of Antibiotic Therapy for Uncomplicated Ambulatory Infections in an Integrated Healthcare System.

Across the ambulatory care network of an integrated health care system, durations of antibiotic therapy prescribed for uncomplicated infections were longer than recommended in 39% of cases. By logistic regression, site of care, prescriber characteristics, and type of infection were independently associated with longer than recommended durations of therapy.

Intermittent Education and Audit and Feedback Reduce Inappropriate Prescribing of Oral Third-Generation Cephalosporins for Pediatric Upper Respiratory Tract Infections

In June 2017, leaders within a pediatric ambulatory care network in Houston approached the antimicrobial stewardship team at Texas Children's Hospital with concerns for high oral third-generation cephalosporin (oTGC) use in their clinics. An outpatient quality improvement (QI) team was formed. The specific aim was to reduce inappropriate oTGC prescribing at one clinic ("Clinic A") by 15% in one year. Following a benchmark analysis of oTGC use at Clinic A, Plan-Do-Study-Act (PDSA) cycles were designed and conducted over one year: one educational session, three individual audit and feedback sessions, and one group feedback session. The primary outcome was the percentage of oTGCs not aligning with American Academy of Pediatrics (AAP) guidelines for bacterial upper respiratory tract infections. Monthly oTGC prescribing at Clinic A was also compared to four control clinics. In June 2017, 72% (231/322) of oTGCs prescriptions at Clinic A did not align with AAP guidelines. The most common diagnosis was primary/nonrecurrent acute otitis media. Following interventions, the mean percentage inappropriate oTGCs decreased from 72% to 45% (absolute reduction 27%, p < 0.001), which was sustained the year following the last PDSA cycle (absolute reduction 26%, p < 0.001). Total monthly oTGC prescribing at Clinic A decreased over time, but not in four control clinics. Provider active participation in stewardship activities decreased over time. Intermittent education and audit and feedback were associated with reduced oTGC misuse at Clinic A but not at four control clinics. Improvements were maintained despite decreased participation in stewardship activities, suggesting that perceptions of ongoing antibiotic audits can help sustain prescribing improvements.

Implementation of patient-centered prescription labeling in a safety-net ambulatory care network.

An initiative to implement patient-centered medication labeling at 4 pharmacies within a publicly funded safety-net healthcare system is described. Medication nonadherence negatively affects patient outcomes and safety. Nonadherence has been attributed to poor understanding of instructions on medication labels. Research has demonstrated that patient-centered labeling (PCL) can improve adherence and produce safer medication-taking practices. As part of a mixed-methods study by a safety-net health system, audits of nearly 9,000 prescription labels generated at 4 pharmacy sites, as well as interviews with 6 stakeholder informants, were conducted to determine PCL adoption rates and factors contributing to success. Descriptive statistics were used to analyze audit data; constructs of the Consolidated Framework for Implementation Research were used to analyze interview data. Among the 4 sites, 3 pharmacies successfully converted more than 85% of audited prescriptions to a PCL format; 1 pharmacy converted less than 25% of prescriptions. Barriers to implementation included pharmacists' reluctance to modify prescriber instructions and inadequate real-time data on conversion rates. Interviewees perceived that leadership and policy directives promoted PCL conversion efforts. Successful pharmacies used adaptable software, had closer communication networks with prescribers, and/or used automation to facilitate PCL conversion. Three pharmacies successfully converted more than 85% of labels for audited prescriptions to a PCL format; 1 pharmacy converted less than 25% of prescriptions. Barriers to implementation included pharmacists' reluctance to modify prescriber instructions, inadequate real-time data on conversation rates, and lack of customizable software to automate changes.

Evaluation of Multimedia Medication Reconciliation Software: A Randomized Controlled, Single-Blind Trial to Measure Diagnostic Accuracy for Discrepancy Detection.

The Veterans Affairs Portland Healthcare System developed a medication history collection software that displays prescription names and medication images. This article measures the frequency of medication discrepancy reporting using the medication history collection software and compares with the frequency of reporting using a paper-based process. This article also determines the accuracy of each method by comparing both strategies to a best possible medication history. Randomized, controlled, single-blind trial. Three community-based primary care clinics associated with the Veterans Affairs Portland Healthcare System: a 300-bed teaching facility and ambulatory care network serving Veteran soldiers in the Pacific Northwest United States. Of 212 patients with primary care appointments, 209 patients fulfilled the study requirements. Patients randomized to a software-directed medication history or a paper-based medication history. Randomization and allocation to treatment groups were performed using a computer-based random number generator. Assignments were placed in a sealed envelope and opened after participant consent. The research coordinator did not know or have access to the treatment assignment until the time of presentation. The primary analysis compared the discrepancy detection rates between groups with respect to the health record and a best possible medication history. Of 3,500 medications reviewed, we detected 1,435 discrepancies. Forty-six percent of those discrepancies were potentially high risk for causing an adverse drug event. There was no difference in detection rates between treatment arms. Software sensitivity was 83% and specificity was 91%; paper sensitivity was 81% and specificity was 94%. No participants were lost to follow-up. The medication history collection software is an efficient and scalable method for gathering a medication history and detecting high-risk discrepancies. Although it included medication images, the technology did not improve accuracy over a paper list when compared with a best possible medication history. ClinicalTrials.gov Identifier: NCT02135731.

Immunization Delivery and Policy as an Ongoing Model for Systems Improvement.

Immunization delivery has long served as a model of the interface between health care and public health. The article by Stockwell et al in this issue of Pediatrics 1 illustrates the power of this interface. The authors studied the impact of a bidirectional exchange of pediatric immunization information between an electronic health record in a large urban ambulatory care network and a citywide immunization information system. They found that immunization up-to-date status increased in all age groups by 81.6% after implementation of the exchange. Importantly, the percent of overimmunized children decreased from 8.8% to 4.7% and was especially pronounced in adolescents (16.4% overimmunized preimplementation to … Contact Information: Simon J. Hambidge, MD, PhD, Denver Health Mailcode 0278, 660 Bannock St, Denver, CO 80204. E-mail: simon.hambidge{at}dhha.org

Has Choosing Wisely® affected rates of dual-energy X-ray absorptiometry use?

Reducing overuse of tests such as dual-energy X-ray absorptiometry (DXA) scans in younger women is an important quality issue. We evaluated trends in DXA ordering before and after Choosing Wisely recommendations were released. We found no significant difference in ordering trends suggesting that other initiatives are needed to change behavior. Reducing overuse of tests such as dual-energy X-ray absorptiometry (DXA) scans in younger women is an important quality issue, but trends in care are difficult to change. We evaluated (1) trends in DXA ordering before and after the Choosing Wisely recommendation release and (2) patterns of key characteristics that indicate a potentially appropriate DXA scan order. We performed a retrospective longitudinal analysis of electronic health record data at a multi-specialty, ambulatory care network of 34 practices across Maryland and Washington, DC. Since the Choosing Wisely DXA recommendation was released April 2012, the study periods were April-December 2011 (pre-initiative) and April-December 2012 (post-initiative). Women between 50 and 64years with primary care encounters, and primary care providers who saw ten or more women in the study population in both pre and post periods were included. For 42,320 eligible patients, the mean provider ordering rate was 2.6 % pre-initiative and 2.0 % post-initiative; there was no significant difference in trend over time. Over 70 % of the population had no characteristics associated with potentially appropriate DXA ordering. Low body mass index, current smoker status, and osteopenia were the most common characteristics indicating potentially appropriate DXA orders. Patients with any of these three characteristics had DXA ordering rates between 3-20 %. The trend in provider ordering rates of DXA scans did not decrease after the release of the DXA Choosing Wisely recommendation. Targeted initiatives addressing providers with high ordering rates will be needed to change behavior.

Improving Depression Screening Using CDS and Patient Access to Information Using PHRs

Introduction/aims Depression as a co-morbidity alongside another chronic disease often complicates the patient's ability to adhere to medical treatment. Patients with diabetes are twice as likely to have depression. Inconsistent screening for depression can lead to missed diagnoses and adversely impact the patient's treatment course. The aim of this project was to increase the diabetic population's rate of screening for depression using Clinical Decision Support (CDS) tools and alerts. These tools prompt the clinical care team to use a standardized Patient Health Questionnaire (PHQ)-2 depression screening tool and PHQ-9 for depression symptom level assessment. Further aims included improving the patient's awareness about depression and access to resources regarding diagnosis and treatment. Methods/process/procedures The area of focus for this project includes New York-Presbyterian Hospital's Ambulatory Care Network (ACN), which has adopted the National Committee for Quality Assurance's patient-centered medical home (PCMH) model. Diabetes and depression were identified as two of four conditions to be targeted during the first stage of implementing the PCMH model. A clinical workgroup comprised of primary care and mental health physicians at NewYork-Presbyterian hospital developed a clinical standard of care to identify the conditions, intervals, and frequency in which depression screening and assessment should occur. Structured PHQ-2 and PHQ-9 forms were embedded within appropriate flowsheets and documents in the Electronic Health Record (EHR). The standard of care was used as a roadmap for the technical development of a Medical Logic Module (MLM) or programming code built within the EHR. The MLM triggered CDS alerts that were presented when depression screening process conditions were met. These conditions included: annual PHQ-2 screen; administration of a PHQ-9 with a positive PHQ-2 screen; provider notification for a PHQ-9 score ≥20, or for any patient response other than “not at all” to question #9 (“thoughts that you would be better off dead, or of hurting yourself in some way”). NewYork-Presbyterian Hospital's Personal Health Record (PHR), myNYP.org, was updated to include printable PHQ forms. Resources for treatment and education regarding depression screening, diagnosis, and treatment were also incorporated into myNYP.org. Results A data analytics tool was used to capture the diabetic PCMH population's depression screening rates six months pre-implementation (June 2012) then again six months post-implementation (June 2013). Post-implementation, these data indicated an 8% increase in the number of patients screened for depression using the PHQ-2 (from 16 to 24%) and a 7% increase in the number of patients with a positive PHQ-2 who received a follow-up PHQ-9 assessment within 4 weeks (from 53 to 60%). Discussion/outcomes CDS alerts have the potential to improve the rate of screening for depression. Offering the patient resources for depression in a PHR provides real-time tools that can be beneficial, outside of the hospital setting. There is potential to further automate PHQ data entered by the patient. Lessons learned in this project include challenges with consuming patient-entered data into the EHR. Other considerations include workflow issues and technical alerts for the care providers if patients enter PHQ data that should trigger an immediate response.

Cervical cytology screening among low-income, minority adolescents in New York City following the 2009 ACOG guidelines

ObjectivesIn December 2009, the American College of Obstetricians and Gynecologists recommended that cervical cancer screening begin at age 21 for young women. In this study, we examine receipt of first lifetime Papanicolaou (Pap) test and predictors of over-screening among adolescents within a large urban ambulatory care network. MethodsWe compared the proportion of first lifetime Pap test of adolescents aged 13–20years between June 2007 — November 2009 (n=7700) and December 2009–June 2012 (n=9637) using electronic health records. We employed multivariable regression models to identify demographic and health care factors associated with receiving a first lifetime Pap test at age <21years in the post-guideline period (over-screening). ResultsThe proportion of Pap tests declined from 19.3% to 4.2% (p<0.001) between the two periods. Multivariable logistic regression results showed receiving care from gynecologic/obstetric/family planning clinics compared to pediatric clinics, having more clinic encounters, and older age were associated with over-screening in the post-guideline period. ConclusionsWe found that guideline adherence differed by clinic type, insurance status, and health care encounters. In the quickly evolving field of cervical cancer control, it is important to monitor practice trends as they relate to shifts in population-based guidelines, especially in high-risk populations.

Abstract C27: Cervical cytology screening patterns among low-income, minority adolescents in New York City following the 2009 ACOG guidelines

Abstract Objectives: In 2009, the American College of Obstetricians and Gynecologists (ACOG) issued new guidelines for cervical cancer screening to begin at age 21 based on the low incidence of cancer and the adverse effects associated with follow-up of abnormal screening results in young women. It is unclear whether low-income, minority adolescent girls, often presenting with higher risk for human papillomavirus (HPV) infection and cervical cancer, are screened according to current guidelines. In this study, we examine rates of first lifetime Papanicolaou (Pap) test and predictors of first screening at &amp;lt;21 years of age among adolescents within a large ambulatory care network serving an urban, low-income, minority population in New York City. Methods: We compared rates of first lifetime Pap test between June 2007-November 2009 (pre-guideline) and December 2009-June 2012 (post-guideline). Data were obtained from electronic health records of adolescent females (ages 13-20) who had at least one clinic visit within the ambulatory care network during each study period and no Pap tests before each study period (pre-guideline: n=7,700; post-guideline: n=9,637). Clinic sites included pediatric, family medicine, family planning, obstetrics, gynecology, or school-based health facilities. We examined screening rates in each study period by demographic characteristics, health care factors, sexually transmitted infection (STI) testing history, and HPV vaccination status. We employed multivariable regression models to identify demographic and health care factors associated with receiving a first lifetime Pap test at &amp;lt;21 years of age (over-screening) in the post-guideline period. Results: Rates of first lifetime Pap test declined from 19.3% to 5.7% (p &amp;lt;0.001) between the two study periods. Demographic, health care, and STI testing characteristics of adolescent girls were similar for the two study periods. The average age for each study period was 15 years. The majority of girls were Latina (pre-guideline: 75.8%, post-guideline: 76.8%) and most were covered by public insurance (pre-guideline: 69.1%, post-guideline: 72.7%). Only HPV vaccination history differed between the two periods, with higher initiation and completion rates among girls in the post-guideline period. Over-screening remained high in the post-guideline period for adolescent girls without insurance (9.9%), those who visited gynecologic, obstetrics, or family planning clinics (9.6%), had five or more clinic visits during the study period (11.3%) or were recently tested for a sexually transmitted infection (7.3%). Adjusted multivariable logistic regression results showed receiving care from gynecology, obstetrics, or family planning clinics (OR 3.87, 95% CI: 2.65-5.65) compared to pediatric clinics, having more clinic encounters (OR 6.72, 95% CI: 4.77, 9.45), and older age (OR 4.72, 95% CI: 2.97, 7.49) were associated with over-screening in the post-guideline period. HPV vaccination status, language spoken, and race/ethnicity were not associated with over-screening. Conclusions: While rates of first lifetime Pap tests declined substantially following the 2009 guidelines, we found that adherence to new recommendations differed by health care system factors, including site of care, insurance status, and number of clinic encounters. It is important to eliminate unnecessary medical tests, especially if disclosure and follow-up of abnormal screening results can lead to other adverse effects. In the quickly evolving field of cervical cancer control, it will be important to monitor practice trends as they relate to shifts in population-based guidelines, especially in relation to high-risk populations. Citation Format: Jennifer Tsui, Annika Hofstetter, Karen Soren. Cervical cytology screening patterns among low-income, minority adolescents in New York City following the 2009 ACOG guidelines. [abstract]. In: Proceedings of the Twelfth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2013 Oct 27-30; National Harbor, MD. Philadelphia (PA): AACR; Can Prev Res 2013;6(11 Suppl): Abstract nr C27.

Treatment and Management of Postmenopausal Osteoporosis within an Ambulatory Care Network

Background: Postmenopausal osteoporosis (PMO) is associated with substantial morbidity and mortality. Despite established guidelines for the care of PMO, the treatment and management of this disease remain suboptimal. Objective: To examine the treatment and management of PMO in a community-based ambulatory care setting. Methods: Women with a new diagnosis of PMO (International Classification of Diseases, 9th Revision, code 733.01) were identified through the electronic health records (EHR) of a community-based ambulatory care network in northern California between January 1, 2007, and December 31, 2008. Patients were included if they were 65 years of age or older and had EHR activity 26 months or more after diagnosis. They were excluded if they had a diagnosis of osteoporosis (ICD-9:733.xx) prior to the study period. A retrospective review of the EHR and medical charts was performed to identify patients who were prescribed FDA-approved pharmacotherapy, who received bone mineral density (BMD) testing via dual-energy X-ray absorptiometry (DXA), and who experienced a fracture. Results: One hundred thirty-one PMO patients were identified who met study eligibility criteria. Fifty-nine patients (45%) were prescribed FDA-approved pharmacotherapy at diagnosis. Ninety patients (69%) were prescribed pharmacotherapy at any point during follow-up. Sixty-four patients (49%) had a baseline DXA scan and 95 patients (73%) had 1 or more DXA scans during follow-up. Seventeen of 90 patients (19%) who received pharmacotherapy had 2 DXA scans within 2 years of follow-up. Nineteen fractures were reported among 16 patients during the study period. Conclusions: The proportion of patients with PMO who received pharmacologic treatment at diagnosis and had a baseline DXA scan was relatively low; however, the majority of these patients received treatment and had 1 or more DXA scans at some point during the 26-month follow-up period. Future studies should be conducted to assess the role of early BMD testing and pharmacologic intervention in optimizing outcomes among women with PMO.