Ambulatory Clinic Research Articles

Cancer is chronic but antimicrobial stewardship is iconic: A retrospective cohort of optimal antibiotic use in ambulatory oncology clinics.

To evaluate antibiotic prescribing in ambulatory oncology clinics and to identify opportunities to improve antibiotic use. Retrospective cohort of adult patients who received care at 4 ambulatory oncology clinics from May 2021 to December 2021. Patients were included if they actively followed with a hematologist-oncologist for a cancer diagnosis and received an antibiotic prescription for uncomplicated upper respiratory tract infection (URTI), lower respiratory tract infection (LRTI), urinary tract infection (UTI), or acute bacterial skin-skin structure infection (ABSSSI) at an oncology clinic. The primary outcome was receipt of optimal antibiotic therapy, defined as a composite of drug, dose, and duration according to local and national guidelines. Patient characteristics were described and compared; predictors of optimal antibiotic use were identified using multivariable logistic regression. In total, 200 patients were included in this study: 72 (36%) received optimal antibiotics and 128 (64%) received suboptimal antibiotics. The proportions of patients receiving optimal therapy by indication were ABSSSI (52%), UTI (35%), URTI (27%), and LRTI (15%). The most common suboptimal prescribing components were dose (54%), selection (53%) and duration (23%). After adjusting for female sex and LRTI, ABSSSI (adjusted odds ratio, 2.28; 95% confidence interval, 1.19-4.37) was associated with optimal antibiotic therapy. Antibiotic-associated adverse drug events occurred in 7 patients; 6 occurred patients who received prolonged durations and 1 occurred in a patient who received an optimal duration (P = .057). Suboptimal antibiotic prescribing in ambulatory oncology clinics is common and mostly driven by antibiotic selection and dosing. Duration of therapy may also be an area for improvement as national oncology guidelines have not adopted short-course therapy.

PS-P06-8: TEXT MESSAGING AND HOME BLOOD PRESSURE MONITORING FOR PATIENTS WITH UNCONTROLLED HYPERTENSION: A PILOT RANDOMIZED CONTROLLED TRIAL

Objective: Improving adherence to antihypertensive medications is the most significant modifiable patient related factor to achieving blood pressure (BP) control. Elevated BP remains the leading cause of death globally. BP trends show disparities in the burden of hypertension in black and low socioeconomic status (LSES) populations, accompanied by low levels of awareness, treatment and control rates. Telehealth systems using text messaging (SMS) and home blood pressure monitors (HBPM) represent attractive scalable tools to reduce BP in those with health disparities. Design and methods: In three ambulatory clinics that serve a large number of those with LSES affiliated with an academic institution, we conducted a randomized controlled pilot study for low medication adherent patients with poorly controlled hypertension (BP > 130/80). The pilot aimed to (1) evaluate the feasibility of recruiting LSES participants to an effectiveness trial of SMS plus HBPM vs HBPM only; (2) measure the acceptability of the SMS system and (3) estimate the effects of the SMS approach on lowering BP. Satisfaction was measured using the validated systems usability survey (SUS). The SMS system was designed with the input of LSES focus groups and used Twilio® as its bidirectional platform. From February 2021 to October 2021, 24 participants were randomized (1:1) to either SMS intervention plus HBPM with an Omron BP cuff or HBPM alone for 12 weeks. Results: During the study period, the study coordinator enrolled 24 participants, averaging 3 per month. Demographics: participants were male (N = 14/24), predominantly African American (AA); (n = 19/24); 13/24 had high school education or less; mean age 55.7 (SD 12); weight 97.4 kg (SD 14); Mean initial SBP 156 mmHg (SD 20), DPB 100 mmHg (SD 11). Acceptability: 8/12 participants responded via SMS with at least one BP measurement in the SMS arm. Two participants were lost to follow up in each arm. Mean SUS was 81.6 (scale of 0 to 100, > 68 is considered above average). Reduction in SBP at 12 weeks in the SMS group and control group was 15 mmHg and 13 mmHg respectively (p = 0.58). Conclusion: Recruiting and retaining LSES participants with uncontrolled HTN for a larger trial of telehealth with SMS and HBPM is feasible and well accepted. Similar BP reductions were achieved in both arms. Utilizing the SMS and HBPM shows promise in reducing BP in the LSES population. A larger efficacy trial is needed to determine best practice and reduce cardiovascular health disparities.

Validating fatty acid binding protein 3 as a diagnostic andprognostic biomarker for peripheral arterial disease: Athree-year prospective follow-up study.

Patients with peripheral arterial disease (PAD) often remain undiagnosed and therefore suboptimally managed. Here, we investigated the diagnostic and prognostic potential of fatty acid binding protein 3 (FABP3) in patients with PAD. In the discovery phase, 374 PAD and 184 non-PAD patients were recruited from vascular surgery ambulatory clinics at St. Michael's Hospital (Toronto, Ontario, Canada) between October 4, 2017 to October 29, 2018. The diagnostic ability of baseline FABP3 level was investigated through receiver operator characteristic (ROC) curves to determine two cutoff points: 1) an exclusionary "rule out" cutoff point, and 2) a confirmatory "rule in" cutoff point. Next, these cutoff points were confirmed in the external validation phase using a separate cohort of 312 patients (180 PAD and 132 non-PAD) recruited from ambulatory vascular surgery clinics at St.Michael's Hospital (Canada) between November 6, 2018-July 30, 2019. Cox regression analyses were used to explore the independent association between FABP3 and major adverse limb events (MALE - defined as need for arterial revascularization or major amputation) and decrease in ankle-brachial index (ABI -defined as drop ≥0.15) during 3 years of follow-up. In the discovery phase, FABP3 levels were significantly elevated in patients with PAD compared to non-PAD patients. ROC analysis demonstrated that FABP3 had an AUC of 0.83 (95% CI: 0.81-0.86, p-value < 0.001). FABP3 exclusionary cutoff was <1.55ng/ml (sensitivity=96%; specificity=40%), whereas FABP3 confirmatory cutoff was >3.55ng/ml (sensitivity=43%; specificity=95%) - values that were confirmed in the external validation phase. Cox regression analysis demonstrated FABP3 to be an independent predictor of increase in MALE [HR=1.14 (1.03-1.29); p-value=0.010] and worsening PAD status (drop in ABI >0.15 [HR=1.11 (1.02-1.19); p-value=0.009]). Our findings suggested that FABP3 levels can be used as both a diagnostic and prognostic biomarker for PAD, and may facilitate risk stratification in select individuals for purposes of vascular evaluation or intensive medical management. Funding for this study was provided by the Bill and Vicky Blair Foundation.

Online Self-Triage of Ear or Hearing Concerns in a Patient Portal: Comparison of Subsequent Diagnoses and Hospitalizations to National Emergency Department and National Ambulatory Ear or Hearing Visits.

Although online self-triage is easily accessible, little is known about the patients who use self-triage or their subsequent diagnoses. We compared ear/hearing self-triage subsequent diagnoses to ear/hearing visit diagnoses in emergency departments (ED) and ambulatory clinics across the United States. We compared International Classification of Diseases version 10 (ICD10) coded diagnoses following online self-triage for ear/hearing concerns with those from national ED and ambulatory clinic samples. We used data from the Centers for Disease Control (CDC) National Hospital Ambulatory Medical Care Survey (NHAMCS) and National Ambulatory Medical Care Survey (NAMCS) for comparison. Using matched ear/hearing diagnostic categories for those aged 1 and over, we compared self-triage diagnosis frequencies with national ED and ambulatory diagnosis frequencies. Following ear/hearing self-triage, there were 1092 subsequent office visits with a primary diagnosis code. For five frequently diagnosed ear/hearing conditions (i.e., suppurative and nonsuppurative otitis media [OM], otalgia, otitis externa, and cerumen impaction), there was a strong correlation between diagnosis counts made following self-triage and estimated counts of national ED visit diagnoses (r = 0.94; CI 95% [0.37 to 0.99]; p = .016, adjusted r2 = 0.85). Seven diagnoses were available to compare with the national ambulatory sample; correlation was r = 0.79; CI 95% [0.08 to 0.97]; p = .037, adjusted r2 = 0.54. For ages 1 and over, estimated hospital admissions from the national ED visits for ear/hearing were 0.76%, CI 95% [0.28-2.1%]; estimated total national ear/hearing ED visits were 7.5 million (for 4 years, 2016 through 2019). The strong correlation of ear-related self-triage diagnoses with national ED diagnoses and the low hospitalization risk for these diagnoses suggests that there is an opportunity for self-triage of ear/hearing concerns to decrease ED visits for these symptoms.

Real-world integration of the protocol for responding to and assessing patients' assets, risks, and experiences tool to assess social determinants of health in the electronic medical record at an academic medical center.

To describe the real-world deployment of a tool, the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), to assess social determinants of health (SDoH) in an electronic medical record (EMR). We employed the collection of the PRAPARE tool in the EMR of a large academic health system in the ambulatory clinic and emergency department setting. After integration, we evaluated SDoH prevalence, levels of missingness, and data anomalies to inform ongoing collection. We summarized responses using descriptive statistics and hand-reviewed data text fields and patterns in the data. Data on patients who were administered with the PRAPARE from February to December 2020 were extracted from the EMR. Patients missing ≥ 12 PRAPARE questions were excluded. Social risks were screened using the PRAPARE. Information on demographics, admittance status, and health coverage were extracted from the EMR. Assessments with N = 6531 were completed (mean age 54 years, female (58.6%), 43.8% Black). Missingness ranged from 0.4% (race) to 20.8% (income). Approximately 6% of patients were homeless; 8% reported housing insecurity; 1.4% reported food needs; 14.6% had healthcare needs; 8.4% needed utility assistance; and 5% lacked transportation related to medical care. Emergency department patients reported significantly higher proportions of suboptimal SDoH. Integrating the PRAPARE assessment in the EMR provides valuable information on SDoH amenable to intervention, and strategies are needed to increase accurate data collection and to improve the use of data in the clinical encounter.

Differences in Diabetes Control in Telemedicine vs. In-Person Only Visits in Ambulatory Care Setting.

Importance: The COVID-19 pandemic has led to increased utilization of telemedicine. Patients with diabetes are a vulnerable population that require regular treatment and monitoring. Little is known about the impact visit modality on diabetes outcomes in an ambulatory setting. Objective: Compare proportions of patients with diabetes with uncontrolled diabetes among those with telemedicine versus in-person only ambulatory visits and examine differences by age, race, gender, ethnicity, and insurance. Design: A retrospective cohort study. Setting: The largest academic healthcare system in the state of Georgia with ambulatory clinics in urban, suburban and rural settings. Participants: Adults with diabetes scheduled for an ambulatory primary or specialty clinic visit between May 2020 and May 2021 were included. Patients were compared among three visit groups: those with all in-person visits, those with one telemedicine visit, and those with 2+ telemedicine visits. Demographics including age, race, ethnicity, gender, insurance status, and comorbidities were extracted from the electronic medical record. Main Outcomes and Measures: The primary clinical outcome was uncontrolled diabetes, defined as HbAlc ≥ 9.0%. Chi-square test was used to determine crude differences in uncontrolled diabetes between visit groups. Multivariable logistic regression was used to assess differences in uncontrolled diabetes between visit groups following risk adjustment. Results: A total of 18,148 ambulatory clinic visits for patients with diabetes were scheduled during the study period, and 11.6% had uncontrolled diabetes. There was no difference in proportion of patients with uncontrolled diabetes between all in-person visits (834 (11.6%)), one telemedicine visit (558 (11.8%)), or 2+ telemedicine visits (709 (11.4%)) (p = 0.80). Patients with 2+ telemedicine visits had significantly lower odds of uncontrolled diabetes compared to all in-person visits after adjusting for age, gender, race, ethnicity, insurance status, and comorbidities (OR: 0.88; 95% CI: 0.79 - 0.99, p = 0.03). Conclusions and Relevance: Telemedicine visits were associated with a lower odds of uncontrolled diabetes. Further work is warranted to explore the relationship between telemedicine visits, equitable access to care, and diabetes outcomes.

Innovative Leadership Model for Healthcare Teams

Background: Healthcare teams possess multiple clinical capabilities to meet the demands and challenges of individual patient-centered care. Teams in healthcare have been used for centuries, but the functionality of a team largely depends on the leader facilitating. With the complexities of healthcare, single leadership models often do not apply. This study aimed to complete a multi-method qualitative study looking at four healthcare settings to explore the applicable use of the Simen-Schreiber leadership model to best describe the needs of healthcare teams (ambulatory diabetes clinic; skilled nursing facility [SNF], acute inpatient geriatric-psychiatric unit, and outpatient high-risk geriatric clinic). Methods: The key constructs researched in this mixed-method qualitative study were: 1) skills needed for good healthcare team participation and 2) essential outcomes needed for successful patient-centered care (e.g. communication, interpersonal engagement, and shared decision-making). The qualitative portion of this study included three distinctive methods: 1) observation of each team functionality; 1,2 2) interview to obtain background information about each facility; and 3) Focus Group session composed of 10 questions and a duration of approximately 75 to 90 minutes. Additional methodology utilized for this study included two validated and reliable quantitative assessments: 1) a healthcare team observation tool1,2 and 2) emotional intelligence questionnaire.3 This multi-method, multi-case study design was selected to allow for triangulation of the data to support the seven constructs of the leadership model. The constructs include rotation of the leader; clinical expertise; emotional intelligence; and managerial skills, with the outcomes of communication; interpersonal engagement and share decision-making. Results: There appears to be a slight trend of higher-functioning teams demonstrated higher emotional intelligence scores, according to the TEI-Que questionnaire and the Team Observation Tool results. From the managerial skills perspective, the Focus Groups results suggests that these skills, particularly in time management, are a target area for improvement among all four teams. Furthermore, these findings support the need to improve training in managerial skills to prepare professionals adequately for healthcare teamwork. it is widely accepted that, good communication is vital within a healthcare team and is related to positive patient outcomes. Unfortunately, poor communication is seen daily in healthcare and can lead to serious health consequences for the patient and dissatisfaction with care by patients, family members, other caregivers, along with clinicians and other healthcare team members. Lastly, there appeared to be support from this study that involvement of the patient, family and interprofessional team in the shared decision-making process is helpful for successful patient outcomes. Conclusions: The findings of this study support the Simen-Schreiber leadership model as applicable to healthcare teams. Each healthcare professional should possess clinical expertise, high emotional intelligence and good managerial skills, to be able to best function on a healthcare team. The Simen-Schreiber leadership model may be useful in preparing healthcare professionals for participation in teamwork, leading to more efficient and effective patient-centered care.

Patient perception towards shifting oral antihyperglycemic agents to injectable insulin and associated factors in the diabetes clinic of Tikur Anbessa specialized hospital: Cross-sectional study

BackgroundWith the growing understanding of the importance of preserving adequate glycemic control for the prevention of long-term diabetes-related complications, insulin therapy has become increasingly recommended for type 2 diabetes. However, insulin use in various healthcare settings remains low due to patients' low levels of acceptability of insulin therapy, which necessitates evaluating patients' attitudes. ObjectiveTo assess patients' perception toward shifting oral antihyperglycemic agents to insulin and associated factors at the ambulatory diabetes clinics of Tikur Anbessa Specialized Hospital (TASH). MethodA cross-sectional study design was applied using a pre-tested interviewer-administered questionnaire on adult type 2 diabetes patients on follow-up at the diabetes clinic of TASH, Ethiopia from July to September 2021. The questionnaire tool was adapted from Insulin Treatment Appraisal Scale with modifications to fit the purpose of the study. Data was gathered, cleaned up, entered, and analyzed using Statistical Package for the Social Sciences (SPSS) version 23 for descriptive and logistic regression. For logistic regression data, a p-value of 0.05 was used to determine the statistical significance. ResultOf 293 patients, 65.9% were female. Study participants had a mean age of 53.9 ± 10.9 years. About 45% and 75% of the participants have complications and comorbidities, respectively with a mean disease duration of 19.16 ± 8.2 years. Almost 54% of patients on oral antihyperglycemic agents were unwilling to start insulin. A perception score below the median was observed in 56.3% of the respondents. Patients with primary and secondary education were 45% and 42% less likely to have a poor perception of shifting oral antihyperglycemic agents to insulin than those who couldn't read or write (P < 0.05), respectively. The study found that participants who were taking only oral antihyperglycemic agents had a 2.76 times poor perception than those who are on insulin treatment (P < 0.001). ConclusionPoor perception toward shifting oral antihyperglycemic agents to insulin was found to be high among study participants. It was substantially correlated with low educational attainment, financial constraints, exclusively using oral antihyperglycemic agents, duration of disease, and absence of disease complications.

Handgrip strength and risk of malnutrition are associated with an increased risk of hospitalizations in inflammatory bowel disease patients.

In patients with inflammatory bowel disease (IBD), frailty is independently associated with mortality and morbidity. This study aimed to extend this work to determine the association between the clinical frailty scale (CFS), handgrip strength (HGS), and malnutrition with IBD-related hospitalizations and surgeries. IBD patients ⩾18 years of age were prospectively enrolled from two ambulatory care clinics in Alberta, Canada. Frailty was defined as a CFS score ⩾4, dynapenia as HGS < 16 kg for females and <27 kg for males, malnutrition using the subjective global assessment (SGA), and the risk of malnutrition using either the abridged patient-generated SGA (abPG-SGA), or the Saskatchewan Inflammatory Bowel Disease Nutrition Risk Tool (SaskIBD-NRT). Logarithm relative hazard graphs and multivariable logistic regression models adjusting for relevant confounders were constructed. One hundred sixty-one patients (35% ulcerative colitis, 65% Crohn's disease) with a mean age of 42.2 (±15.9) years were followed over a mean period of 43.9 (±10.1) months. Twenty-seven patients were hospitalized, and 13 patients underwent IBD-related surgeries following baseline. While the CFS (aHR 1.34; p = 0.61) and SGA (aHR 0.81; p = 0.69) did not independently predict IBD-related hospitalizations, decreased HGS (aHR 3.96; p = 0.03), increased abPG-SGA score (aHR 1.07; p = 0.03) and a SaskIBD-NRT ⩾ 5 (aHR 4.49; p = 0.02) did. No variable was independently associated with IBD-related surgeries. HGS, the abPG-SGA, and the SaskIBD-NRT were independently associated with an increased risk of IBD-related hospitalizations. Future studies should aim to validate other frailty assessments in the IBD population in order to better tailor care for all IBD patients.

Ambulatory vascular clinics provide a safe and effective pathway for management of chronic limb threatening ischaemia

Introduction: The management of chronic limb threatening ischaemia (CLTI) has changed rapidly over recent years. The outcomes of lower limb revascularisation, despite improvements since centralisation, remain poor. Ambulatory emergency care has emerged in several surgical subspecialties as the optimal pathway to ensure timely access to specialist services whilst avoiding unnecessary urgent hospital admission and lengthy inpatient stays. This study aims to describe the outcomes of such a service for those with CLTI. Methods: This study includes all patients with suspected CLTI presenting to the Guy’s and St Thomas’ (GSTT) Emergency Vascular Clinic (EVC) between 31 July 2017 and 19 April 2021. Demographic, clinical and admission data were gathered from a prospectively maintained database. Operative details, in hospital and mid-term outcomes were gathered retrospectively from electronic hospital records. Frailty data were calculated using the Edmonton Frailty Scoring (EFS) System. Results: There were 799 encounters at the EVC for suspected CLTI. 375 (46.9%) of these encounters resulted in a confirmed diagnosis of CLTI and admission, either the same day as an emergency (187 (23.4%)) or as a planned urgent admission (188 (23.5%)). Time from referral to EVC review was a median of 1 day (interquartile range (IQR) 1–3 days) and median time from EVC review to revascularisation or amputation (in cases where this was the primary treatment strategy) was 8 days (IQR 4–16 days). Median time to admission was 1 day (IQR 0–13 days and length of stay was a median of 7 days (IQR 2–15 days). Amputation-free survival (AFS) from the first patient encounter (with presentations for each leg taken separately) was 95% at one month and 78% at one year. Overall survival was 98% at one month and 84% at one year. Frailty was significantly associated with mortality (p=0.03), but not AFS (p=0.085). Conclusion: These data suggest that an EVC pathway provides a safe method of treating CLTI with minimal delays to urgent planned admission, revascularisation and AFS, in keeping with nationally reported data.

Effectiveness of triage at primary care ambulatory clinics for early detection and segregation of COVID-19-infected patients.

Effectiveness of triage at primary care ambulatory clinics for early detection and segregation of COVID-19-infected patients.

Journey Mapping to Improve Patient-Family Experience and Teamwork: Applying a Systems Thinking Tool to a Pediatric Ambulatory Clinic.

Journey Mapping to Improve Patient-Family Experience and Teamwork: Applying a Systems Thinking Tool to a Pediatric Ambulatory Clinic.

Addressing Suicide Risk in Primary Care: Cost Savings Associated with Diverting Patients From Emergency Departments.

Integrating behavioral health into primary care ambulatory clinics can improve management of patients presenting with suicidality in medical practices. To date, financial outcomes associated with managing suicidality in integrated care have not been documented. This study sought to evaluate both course of treatment (e.g., the patient is discharged home and referred to emergency departments [EDs]) and financial outcomes (e.g., cost to medical center) for patients presenting with suicidality in integrated pediatric primary care. Medical record review was conducted across a 6-month period. Demographics, course of treatment, and financial data were collected. Financial data were extracted using EPSi software using a cost accounting model. We documented the amount in dollars billed to the patient/insurance company and the amount reimbursed to the medical center and then calculated net margins associated with each course of treatment. Participants were 103 youth (aged 7-24 years). The results demonstrate that the integrated model of care diverted 93% of participants from the ED and that the highlighted model of care yielded cost savings for the medical center. After reimbursement, patients seen in the ED for suicide evaluations cost the medical center an average of 16 times more than patients who were managed in the primary care setting. The results document the magnitude of cost savings associated with an integrated care model for treating high-risk youth.

A comparison of the sociodemographic, medical, and psychosocial characteristics of adolescents and young adults diagnosed with cancer recruited in-person and online: A Canadian cross-sectional survey.

Adolescents and young adults diagnosed with cancer (AYAs) are under-represented in research. The Internet and social media could increase the reach of recruitment efforts but may impact sample characteristics. This study evaluated the characteristics of AYAs recruited in-person at an urban hospital versus the Internet in terms of their sociodemographic and medical characteristics, and psychosocial wellbeing, and offers recommendation for increasing the inclusivity and representativeness of research samples. Participant data from a cross-sectional survey of AYAs in Canada were evaluated. In-person hospital recruitment used a registry to identify patients attending ambulatory clinics. Internet recruitment included notices on hospital, team members', and community partners' social media channels, and email newsletters. Independent sample t-tests and Chi-squared tests were used to identify differences in participant sociodemographic, medical, and psychosocial characteristics based on recruitment source. Of 436 participants, 217 (49.8%) were recruited in-person and 219 (50.2%) online. Online participants were more likely: to be white (p < .001), women (p < .001), and Canadian-born (p < .001); to speak English at home (p < .001), live alone (p = .001) and live in rural settings (p = .014); and to be farther from diagnosis (p = .023), diagnosed with breast cancer (p < .001), and cancer free (p < .001) compared to the hospital sample. Online participants also reported higher anxiety, depression, and loneliness (p < .001), and lower social support (p < .001), self-efficacy for coping with cancer (p < .001), and life satisfaction (p = .006). Online recruitment yielded a more geographically diverse but less sociodemographically diverse sample of AYAs who were farther from diagnosis and had poorer psychosocial wellbeing than in-person recruitment at an urban hospital. Future research efforts should consider partnering with under-represented communities and using targeted and stratified online and in-person recruitment strategies to achieve an inclusive and representative sample of AYAs.

Pattern of anti-epileptic medications nonadherence and associated factors at ambulatory clinic of Jimma Medical Center, Southwestern Ethiopia: A prospective observational study.

This study is designed to assess the pattern of nonadherence, and associated factors among ambulatory patients with epilepsy at Jimma Medical Center, Southwestern Ethiopia, from November 2020 to April 2021. A hospital-based prospective observational study was employed. A consecutive sampling method was used to recruit study participants. Nonadherence was assessed by the Hill-Bone compliance to the high blood pressure therapy scale. A threshold of 18 scores was used to classify adherence status. Epi-Data manager version 4.6 was used for data entry and all statistical analysis was performed by Statistical Package for Social Science 25.0. Multivariable logistic regression was performed to explore associated factors. A survey included 334 patients with epilepsy. One hundred twenty-two (36.52%) of the study participants were found to be non-adherent. The factors associated with nonadherence were poor involvement of the patient in the therapeutic decision (adjusted odds ratio = 1.74; 95% confidence interval: 1.04-2.90; p = 0.034), per month income of lesser than1000 Ethiopian birr (adjusted odds ratio = 2.66; 95% confidence interval: 1.03-6.84; p = 0.042), recent seizure episodes (adjusted odds ratio = 1.97; 95% confidence interval: 1.20-3.23; p = 0.007), adverse drug reaction (AOR = 2.13; 95% confidence interval: 1.31-3.47; p = 0.002), and negative medication belief (adjusted odds ratio = 1.28; 95% confidence interval: 1.53-2.25; p = 0.043). In our setting, the magnitude of nonadherence was substantially high. Hence, providing regular health-related information about the disease and treatment, supplying free antiepileptic drugs, routine assessment of adverse drug reactions, and a multidisciplinary approach involving patients may improve adherence.

Using co-design to improve the client waiting experience at an outpatient mental health clinic

Prolonged wait times in healthcare are a complex issue that can negatively impact both clients and staff. Longer wait times are often caused by a number of factors such as...

Telehealth Care in a Pediatric and Adolescent Gynecology Clinic During the COVID-19 Pandemic

Since the onset of the COVID-19 pandemic, healthcare systems have increased their telehealth services to meet the changing public health needs. Prior to the pandemic, telehealth was used primarily in surgical specialties for post-op visits and rural medicine. However, out of necessity, nearly all medical and surgical subspecialties incorporated this virtual technology to improve patient access in healthcare access limited time. Few studies have addressed telehealth in Pediatric and Adolescent Gynecology (PAG) to date. To describe the large-scale utilization of telehealth visits and assess patient experience and improve access to care in a large academic ambulatory gynecology PAG clinic. This retrospective, cross-sectional quality improvement study was performed by administering patient surveys and compiling aggregate data from the EPIC electronic health record (EHR) in the Division of Pediatric and Adolescent Gynecology (PAG) clinics at a single children's hospital between March 2020 and March 2021. Patient demographics, payer characteristics, visit type and purpose, and patient experience were reviewed. Wider expansion of telehealth in PAG clinics at a single institution RESULTS: : A total of 6,159 telehealth appointments were performed, involving 6 clinic sites and 9 providers. Telehealth visits comprised 50% of the total ambulatory volume (12,527). Most patients were located within the institution's state (99.5%), and the remaining called into their telehealth visits from a neighboring state. Most patients were 18 years of age or younger (73%). Video visits lasted 15-30 minutes and included routine follow-up (66.3%), new/consult (28.4%), post-op (1.6%), and urgent follow-up (0.2%). The patient population was ethnically diverse by self-identification: 61.4% White, 38.4% Hispanic, 16% Black, 4.4% Asian, 0.40% Native Hawaiian/American Indian/Alaska Native. Payor mix included self-pay (45.5%), private payer (32.2%), and Medicaid/CHIP (22.3%). Conditions seen ranged from menstrual management (71%) and routine preventative or acute gynecologic concerns (21%) to surgical evaluation for congenital anomalies, endometriosis, fertility preservation, genital concerns or pelvic masses (8%). Telehealth visits met patient expectations in 87.3% of respondents. Patient-reported opportunities for improvement included: improving set-up instructions and more consistent audio/video connections. Challenges identified by providers included: difficulty utilizing interpreters, technology limitations, and privacy constraints during HEADSS examination. This study demonstrates how a large, diverse volume of patients with PAG needs received appropriate care through a telehealth format during the COVID pandemic. Patients were satisfied with the services, but opportunities for improvement were elicited to allow for continued refining of this healthcare delivery tool in the future.

Implementation of Machine Learning Pipelines for Clinical Practice: Development and Validation Study

Artificial intelligence (AI) technologies, such as machine learning and natural language processing, have the potential to provide new insights into complex health data. Although powerful, these algorithms rarely move from experimental studies to direct clinical care implementation. We aimed to describe the key components for successful development and integration of two AI technology-based research pipelines for clinical practice. We summarized the approach, results, and key learnings from the implementation of the following two systems implemented at a large, tertiary care children's hospital: (1) epilepsy surgical candidate identification (or epilepsy ID) in an ambulatory neurology clinic; and (2) an automated clinical trial eligibility screener (ACTES) for the real-time identification of patients for research studies in a pediatric emergency department. The epilepsy ID system performed as well as board-certified neurologists in identifying surgical candidates (with a sensitivity of 71% and positive predictive value of 77%). The ACTES system decreased coordinator screening time by 12.9%. The success of each project was largely dependent upon the collaboration between machine learning experts, research and operational information technology professionals, longitudinal support from clinical providers, and institutional leadership. These projects showcase novel interactions between machine learning recommendations and providers during clinical care. Our deployment provides seamless, real-time integration of AI technology to provide decision support and improve patient care.

1756. Prescriber Adherence to System-Wide Urinary Tract Infection Guidelines in Ambulatory Care Clinics

Abstract Background Antimicrobial stewardship (AMS) practices are well established in acute care, only recently expanding into ambulatory care settings. It has been estimated that 80-90% of antibiotic use occurs in the ambulatory setting with up to 52% of that use being unnecessary. Urinary tract infections (UTIs) are commonly treated in ambulatory settings, and drug selection and duration of therapy vary among different practices. Our study evaluated the impact of a system-wide guideline and prescriber education, two recommended AMS strategies, on antibiotic utilization for UTIs in the ambulatory setting. Methods This retrospective study evaluated female adult patients prescribed an antibiotic for acute uncomplicated cystitis by a primary care provider at a clinic within our organization between January and March 2021. System-wide UTI treatment guidelines were implemented in November 2020, with live education delivered to primary care prescribers in December 2020. The primary objective of this study was to assess prescriber adherence to system-wide guidelines. The secondary objective was to evaluate utilization of antibiotic regimens for treatment of acute uncomplicated cystitis. Results A total of 100 patients were evaluated. Guideline adherence was met in 49% of patients. The primary reason for guideline non-adherence was duration of therapy, which was inappropriate (too long) in 42% of patients. Nitrofurantoin, the first-line antibiotic recommendation on the system-wide guideline, was the antibiotic prescribed most frequently (48%), but was the antibiotic of choice in 90% of patients. Sulfamethoxazole/trimethoprim was prescribed in 35% of patients and was most often prescribed correctly with respect to appropriate dose and duration of therapy (60%), followed by nitrofurantoin (54%). Recurrent cystitis within 30 days occurred in 11% of patients. Conclusion Implementation of a system-wide guideline and prescriber education for treatment of UTIs in the ambulatory setting identified areas for future optimization of antibiotic use, namely first line antibiotic selection and duration of therapy. This data will be shared with our prescribers to continue to encourage guideline-adherent antibiotic use. Disclosures All Authors: No reported disclosures.

1796. Evaluation of Asymptomatic Bacteriuria in Critical Access Hospitals

Abstract Background The University of Washington Tele-Antimicrobial Stewardship Program (UW-TASP) provides antimicrobial stewardship education and training to rural and critical access hospitals (CAHs) in the United States through collaborative tele-mentoring. In 2021, UW-TASP implemented a pilot stewardship cohort to reduce antibiotic treatment of asymptomatic bacteriuria (ASB). We sought to quantify the overall prevalence of ASB and proportion treated in participating hospitals. Methods Patients undergoing urine testing were identified through local electronic medical records and microbiology data. CAHs adjudicated their own cases and reported demographics, symptoms of urinary tract infection, systemic inflammatory response symptoms (SIRS), location at the time of culture, laboratory results, and antibiotic treatment through a RedCap collection tool. The data form was created and analyzed by UW-TASP faculty. This study was waived by the University of Washington institutional review board. Results Nineteen CAHs in 5 states participated in this pilot. Eight submitted urine analysis and culture data for 417 patients. Seventy-seven percent of patients were female and the median age was 70. The emergency department was the most common culture collection location (274/417, 66%), followed by ambulatory care clinics (111/417, 27%), and nursing facilities (13/417, 3%). SIRS criteria and/or organ dysfunction were present in 149/417 patients (36%). Two hundred sixty patients (62%) had a positive culture with Escherichia coli being the most common implicated organism (167/260, 64%). ASB was identified in 69/260 patients (27%), and antibiotics were prescribed for 53/69 (77%) of those with ASB. Oral antibiotics were prescribed for 311 (75%) patients. Of those, 22% were prescribed a fluoroquinolone. Median treatment duration was 7 days (range, 1-14). Conclusion Although the prevalence of ASB was only 27% among 417 patients, treatment of ASB was high at 77%. High numbers of culture collections from the emergency department and ambulatory care settings identify these locations as future foci for stewardship interventions in CAHs. Low hanging fruit for intervention include reducing unnecessary fluoroquinolone use and reducing duration of antibiotic therapy. Disclosures Chloe Bryson-Cahn, MD, Alaska Airlines: Advisor/Consultant.