Ambulatory Encounters Research Articles

Trends in Outpatient Radical Prostatectomy and Same-Day Discharge for Prostate Cancer: Analysis of the National Inpatient Sample and Nationwide Ambulatory Surgery Sample.

Interest has grown in optimizing radical prostatectomy (RP) pathways for prostate cancer, and RP has been removed from the Centers for Medicare & Medicaid Services inpatient-only list. We aim to determine national trends in outpatient RP. The National Inpatient Survey and Nationwide Ambulatory Surgery Survey were queried to categorize RPs between 2016 and 2020 as inpatient RP and outpatient RPs, comprising same-day discharge (SDD) and ambulatory encounters. Trends in outpatient RP over time were analyzed. Multivariable logistic regression analysis identified factors associated with SDD. Multivariable generalized linear models were used to compare total hospital charges between SDD and inpatient RPs. In a cohort of 362,123 RPs from 2016 to 2020, outpatient RPs increased from 4.8% to 53.7% (P < .01) and SDD increased from 0.03% to 2.0% (P < .01). Minimally invasive surgery (OR, 1.59, P < .01), highest quartile annual hospital caseload (OR, 1.98, P = .01), and low hospital bed count (OR, 1.96, P = .03) were associated with SDD. Less than 20% of centers used SDD, although a select few hospitals discharged more than 50% of RPs the same day. Ambulatory ($63,060) and SDD ($63,332) RPs had lower total charges compared with inpatient RPs ($69,951). Multivariable analysis demonstrated that SDD was associated with a reduction in total charges (OR, 0.88, P < .01). Over 50% of RPs are now performed as ambulatory or SDD encounters. SDD RP is more common in high-volume facilities with lower bed counts. Although our data suggest lower hospital charges, further study is warranted to evaluate the impact of SDD on readmission rates and direct patient costs.

P-1142. Evaluating Ambulatory Antibiotic Prescribing for Respiratory Infections at a Pediatric Institution

Abstract Background Over 85% of antibiotic prescribing occurs in outpatient settings such as emergency departments (ED), urgent care centers (UCC), and primary care clinics (PCC); almost half of antibiotics are prescribed for respiratory infections (RI). Given the rise of telehealth visits (TH) in both UCC and PCC settings in the past several years, this study examines the effect of location sites on antibiotic prescribing for RI at our institution. Methods Single-center, retrospective cohort study in Portland, Oregon, USA. Patients &amp;lt; = 20 years of age seen in the ED, UCC, and PC settings between 1/1/2019-12/31/2024, were included. Electronic data included age, race, ethnicity, location and encounter type, payor status, visit ICD-10 codes, and antibiotic prescription details. Multivariate logistical regression determined the effect of patient factors on antimicrobial prescribing. Results A total of 157,499 ambulatory encounters were included of which 24,236 were respiratory ICD10 code-related visits. Respiratory visit rates were not significantly different between non-Hispanic White and Hispanic/non-White children or by age group. RI were categorized as viral (57.7%), possible bacterial (37.6%), or co-infection (4.7%); antibiotics were prescribed 5.3%, 60.4%, and 62.8% of visits respectively. The rate of antibiotic prescribing for viral and possible bacterial RI was not different between non-Hispanic White and Hispanic/non-White children or between payor status. For viral RI, PCC and UCC settings were more likely to prescribe antibiotics compared to the ED (OR 1.4 and OR 2.36, respectively). Furthermore, PCC and UCC were less likely to prescribe narrow-spectrum antibiotics for possible bacterial RI compared to the ED (OR 0.84 and OR 0.79, respectively), including TH PCC and TH UCC visits (OR 0.29 and OR 0.56, respectively). Conclusion Pediatric patients with RI can receive ambulatory care through multiple settings. PCC TH (although a small percentage of all RI visits) shows the highest use of antibiotics for viral RI and the least narrow spectrum antibiotic prescribing for presumed bacterial RI. Efforts to reduce antibiotic use in viral RI should focus on non-ED settings, including TH. Strategies to encourage use of narrow-spectrum activity agents for RI should be shared with all departments. Disclosures All Authors: No reported disclosures

P-51. Influenza Vaccine Effectiveness in Ambulatory Care Settings among Pregnant Persons in the 2023-2024 Influenza Season

Abstract Background Despite increased risk of influenza-associated complications in pregnant people, influenza vaccination coverage has decreased in recent seasons as vaccine confidence has declined. The purpose of this study was to evaluate influenza vaccine effectiveness (VE) against influenza-associated ambulatory encounters among pregnant persons during the 2023-2024 season, and to compare VE in pregnant versus non-pregnant persons. Methods During October 15, 2023 – April 10, 2024, a test-negative, case-control analysis was conducted among pregnant and non-pregnant persons aged 18-49 years with documented female sex. Persons with acute respiratory illness (ARI)-associated emergency department or urgent care visits and who underwent molecular assay testing for influenza at six health systems in the VISION Network were included. VE was estimated using logistic regression comparing the odds of influenza vaccination (≥14 days before the encounter) in influenza positive cases vs influenza negative controls, adjusting for site, age, race/ethnicity, calendar time, and gestational age at encounter (where applicable). Results Among 2,439 ARI encounters in pregnant people, 773 (32%) tested positive and 1,666 (68%) tested negative for influenza; 205 (27%) cases vs 608 (36%) controls were vaccinated. Median gestational age at encounter was 20 weeks (IQR: 11-29). Among 40,374 ARI encounters in non-pregnant people, 10,599 (26%) tested positive and 29,775 (74%) tested negative for influenza; 1,727 (16%) cases vs 8,117 (27%) controls were vaccinated. VE was 46% (95% CI: 33-56) in pregnant people and 53% (95% CI: 50-56) in non-pregnant persons. Conclusion Influenza vaccination during the 2023-2024 season was effective against influenza-associated ambulatory encounters in pregnant people. VE was similar in pregnant and non-pregnant persons of reproductive age. Vaccination was effective in reducing influenza-associated ambulatory encounters by approximately 50%, yet less than half of the population included in this analysis received the current influenza vaccine. Demonstrating that vaccines are effective can help increase vaccine confidence and may lead to increased uptake. Disclosures Sara Y. Tartof, PhD MPH, GSK: Grant/Research Support|Pfizer Inc: Grant/Research Support Lina S. Sy, MPH, Dynavax: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Moderna: Grant/Research Support Nicola P. Klein, MD, PhD, CSL Seqirus: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Merck: Grant/Research Support|Pfizer: Grant/Research Support|Sanofi Pasteur: Grant/Research Support Toan Ong, PhD, Patent Title: Systems and Methods For Record Linkage: PCT/US2018/047961 Patent Title: Systems and Methods For Record Linkage|PCORI: Travel support to attend the PCORI Annual meeting in Washington DC, 2023|Regenstrief Institute: Advisor/Consultant|Regenstrief Institute: Travel support to attend the OHIE 23 meeting in Malawi. Michelle Barron, MD, Innoviva Specialty Therapeutics: Speaker bureau participant Malini DaSilva, MD, MPH, CDC, Vaccine Safety Datalink, Center for Excellence in Newcomer Health: Grant/Research Support Gabriela Vazquez-Benitez, PhD, MSc, Abbvie: Grant/Research Support|Sanofi Pasteur: Grant/Research Support

P-1713. Impact of an Evidence-Based Order Panel on Antimicrobial Prescribing in Ambulatory Patients with Complicated and Uncomplicated Cystitis

Abstract Background Optimizing antimicrobial prescribing for urinary tract infections (UTI) represents an area of opportunity for ambulatory antimicrobial stewardship programs. A pre-populated, ambulatory antibiotic order panel for UTI was implemented in the Mayo Clinic Enterprise on 5/16/2022. The order panel provides antimicrobial regimens which align with both institutional and national treatment guidelines based on patient comorbidities, complicating factors, and beta-lactam allergy status. We aimed to assess the impact of panel use on antibiotic prescribing for complicated and uncomplicated cystitis in the ambulatory setting. Methods This retrospective review included ambulatory encounters from the Mayo Clinic Enterprise in 2022 and 2023. Eligible encounters were randomly selected and included those with a primary ICD-10 code of cystitis performed by primary care or urgent care clinicians. Encounters were excluded if patients had symptoms indicative of pyelonephritis, underwent urinary instrumentation within 30 days, or had a urinary pathogen isolated within 90 days. The primary outcome was concordance with institutional guidelines. Secondary outcomes included repeat healthcare contact and therapy duration. Outcomes were analyzed with Pearson's chi-squared and Wilcoxon rank sum tests (α level = 0.05). Results 793 encounters (397 panel vs. 396 non-panel) were included. Prescribing was guideline concordant in 79.3% and 64.9% (p&amp;lt; 0.001) of panel and non-panel encounters, respectively. Inappropriate duration was the most common reason for non-concordance in the panel use cohort. There was no difference between groups for repeat healthcare contact incidence. Antimicrobials prescribed differed between panel and no-panel groups (Table 1), with higher use of sulfamethoxazole/trimethoprim and lower use of cefdinir in the panel cohort. Numerically shorter durations were seen in the panel group, with more 3- and 5-day regimens than the no-panel group. Conclusion Use of a pre-populated antimicrobial order panel for outpatient cystitis encounters resulted in greater adherence to institutional guideline recommendations, particularly in terms of antimicrobial selection, without adversely impacting repeat healthcare contact. Disclosures Paschalis Vergidis, MD, MSc, AbbVie: Advisor/Consultant|Ansun Biopharma: Grant/Research Support|Cidara Therapeutics: Grant/Research Support|F2G: Grant/Research Support|Scynexis: Advisor/Consultant|Scynexis: Grant/Research Support

Psychotic-Spectrum Disorders With Comorbid Anxiety are Predisposing Factors for Parkinson's Disease in a Case-Control Study.

Multiple studies have demonstrated associations between psychiatric conditions and Parkinson's disease (PD) development; fewer have examined psychotic-spectrum disorders and PD development. The objective was to assess the prevalence of psychotic-spectrum disorders with and without depression and anxiety preceding a PD diagnosis. In this retrospective, case-control study of adults > 60 years of age, cases were identified by PD diagnosis and controls were identified in a 3:1 ratio by ambulatory encounter from 2015 to 2020. Psychiatric conditions were identified by diagnosis code up to 5 years prior to the index date. Conditional logistic regression was conducted to assess associations. Among 13,998 patients, the odds of PD were 76% (95% confidence interval = 1.39-2.22) higher among those with psychotic-spectrum diagnoses. An additional anxiety diagnosis was associated with 166% (95% confidence interval = 1.35-5.25) higher odds of PD. Awareness of psychiatric conditions, including psychotic-spectrum disorders with comorbid anxiety, can stratify individuals at higher risk of developing PD.

Health Care Utilization Patterns Associated with eConsults for Headache: Insights from an Urban Academic Medical Center.

Introduction: Interprofessional electronic consultations (eConsults) can reduce health care utilization and improve access to specialty care. However, health care utilization and access impacts of eConsults for headache disorders remain incompletely characterized. Methods: We conducted a retrospective, 1:3-matched cohort study comparing patients referred for in-person headache evaluations to patients who had a headache-related eConsult. The cohorts were propensity score-matched by age, sex, race, preferred language, provider specialty, insurance status, and medical comorbidities. Our primary outcome was the presence of one or more headache-related ambulatory encounters in the 12 months following the index referral date. We used univariable and conditional logistic regression models to ascertain the associations between referral type and outcome. Results: We identified 74 and 222 patients with eConsult and in-person referrals, respectively. Over the follow-up period, the proportion of patients with the primary outcome was significantly greater in the eConsult cohort than the in-person cohort (46.0% vs. 43.2%, p < 0.0001). A greater proportion of the in-person cohort had one or more ambulatory headache encounters in the 12 months preceding their referral than the eConsult cohort (10.8% vs. 5.4%, p < 0.0001). In the adjusted analysis, eConsult usage was not associated with significantly increased odds of the primary outcome (adjusted odds ratio [aOR] 1.1, 95% confidence interval [CI] 0.6-2.0, p = 0.71), although patients with one or more ambulatory neurology encounters in the preceding 12 months had significantly increased odds of the primary outcome (aOR 3.1, 95% CI 1.2-7.9, p = 0.015). Conclusion: Compared to in-person referrals, eConsult use for headache was not associated with significantly increased odds of having subsequent ambulatory headache-related encounters.

Predictive Models for Sustained, Uncontrolled Hypertension and Hypertensive Crisis Based on Electronic Health Record Data: Algorithm Development and Validation.

Assessing disease progression among patients with uncontrolled hypertension is important for identifying opportunities for intervention. We aim to develop and validate 2 models, one to predict sustained, uncontrolled hypertension (≥2 blood pressure [BP] readings ≥140/90 mm Hg or ≥1 BP reading ≥180/120 mm Hg) and one to predict hypertensive crisis (≥1 BP reading ≥180/120 mm Hg) within 1 year of an index visit (outpatient or ambulatory encounter in which an uncontrolled BP reading was recorded). Data from 142,897 patients with uncontrolled hypertension within Atrium Health Greater Charlotte in 2018 were used. Electronic health record-based predictors were based on the 1-year period before a patient's index visit. The dataset was randomly split (80:20) into a training set and a validation set. In total, 4 machine learning frameworks were considered: L2-regularized logistic regression, multilayer perceptron, gradient boosting machines, and random forest. Model selection was performed with 10-fold cross-validation. The final models were assessed on discrimination (C-statistic), calibration (eg, integrated calibration index), and net benefit (with decision curve analysis). Additionally, internal-external cross-validation was performed at the county level to assess performance with new populations and summarized using random-effect meta-analyses. In internal validation, the C-statistic and integrated calibration index were 0.72 (95% CI 0.71-0.72) and 0.015 (95% CI 0.012-0.020) for the sustained, uncontrolled hypertension model, and 0.81 (95% CI 0.79-0.82) and 0.009 (95% CI 0.007-0.011) for the hypertensive crisis model. The models had higher net benefit than the default policies (ie, treat-all and treat-none) across different decision thresholds. In internal-external cross-validation, the pooled performance was consistent with internal validation results; in particular, the pooled C-statistics were 0.70 (95% CI 0.69-0.71) and 0.79 (95% CI 0.78-0.81) for the sustained, uncontrolled hypertension model and hypertensive crisis model, respectively. An electronic health record-based model predicted hypertensive crisis reasonably well in internal and internal-external validations. The model can potentially be used to support population health surveillance and hypertension management. Further studies are needed to improve the ability to predict sustained, uncontrolled hypertension.

Urine Testing in Children with Respiratory or Other Viral Illness Symptoms: a National Analysis of Ambulatory Encounters

Urine Testing in Children with Respiratory or Other Viral Illness Symptoms: a National Analysis of Ambulatory Encounters

Impact of a pilot advanced provider-based comprehensive management program to support patients with immunotoxicity-related adverse events in a cancer care setting.

31 Background: Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of many types of cancers. Despite the clinical benefits of the targeted therapy, its use is associated with a spectrum of autoimmune side effects known as immune-related adverse events (irAEs). Toxicities are distinct from those associated with standard chemotherapy, and, if unrecognized and not managed aggressively, can become life-threatening. Early recognition and management of these toxicities, as well as approaches toward cautious retreatment following resolution is essential in clinical practice. Methods: As part of larger effort to provide efficient and proactive care to patients, advanced provider-based comprehensive management program was established in an academic hospital ambulatory setting to identify and manage the full spectrum of unique toxicities of patients receiving standard-of-care ICIs. The goal of the program was to manage patients with severe toxicity including seamless transitions of care between outpatient and inpatient settings to obviate the need for future acute care utilizations. The program provided real-time guidance to providers with clinical questions on use of ICIs, actively navigated patients with suspected immunotherapy toxicity and assessed ongoing education needs for both outpatient and inpatient services. A retrospective analysis of 2-year post implementation of the program was performed with inpatient to outpatient referrals as primary outcome and median length of stay and 30-day readmission rate as secondary outcomes. Results: A total of 388 inpatient admissions (222 Year-1 and 166 Year-2) were included. Preliminary analysis revealed a 25% decrease in immunotoxicity related inpatient admissions (admission rate decreased from 2.8 to 1.9) while patients treated with immunotherapy increased by 7%. The number of ambulatory encounters with the navigator increased by 40% (362 vs 509). The median length of stay for those on the dedicated program decreased by 27.3% (5.5 vs. 4 days) and the 30-day readmission rate decreased by 15.8% (24.3 vs. 20.5) from Year 1 to Year 2. Conclusions: Preliminary analysis suggests the program improved patient care, provided timelier follow-up and management, and reduced the delay to return to anti-cancer treatment. The ambulatory program provided proactive intervention, diagnosis, and management of immunotherapy related toxicities, preventing hospitalization and readmission to the hospital. Although initial findings suggest improved preliminary outcomes, further analysis is required to make any causal inference on the true and sustainable impact of the intervention.

"What Else Could It Be?" A Scoping Review of Questions for Patients to Ask Throughout the Diagnostic Process.

Diagnostic errors are a global patient safety challenge. Over 75% of diagnostic errors in ambulatory care result from breakdowns in patient-clinician communication. Encouraging patients to speak up and ask questions has been recommended as one strategy to mitigate these failures. The goal of the scoping review was to identify, summarize, and thematically map questions patients are recommended to ask during ambulatory encounters along the diagnostic process. This is the first step in a larger study to co-design a patient-facing question prompt list for patients to use throughout the diagnostic process. Medline and Google Scholar were searched to identify question lists in the peer-reviewed literature. Organizational websites and a search engine were searched to identify question lists in the gray literature. Articles and resources were screened for eligibility and data were abstracted. Interrater reliability (K = 0.875) was achieved. A total of 5509 questions from 235 resources met inclusion criteria. Most questions ( n = 4243, 77.02%) were found in the gray literature. Question lists included an average of 23.44 questions. Questions were most commonly coded along the diagnostic process categories of treatment (2434 questions from 250 resources), communication of the diagnosis (1160 questions, 204 resources), and outcomes (766 questions, 172 resources). Despite recommendations for patients to ask questions, most question prompt lists focus on later stages of the diagnostic process such as communication of the diagnosis, treatment, and outcomes. Further research is needed to identify and prioritize diagnostic-related questions from the patient perspective and to develop simple, usable guidance on question-asking to improve patient safety across the diagnostic continuum.

Ascertaining accurate exposure to aspirin and other antithrombotic medications using structured electronic health record data

BackgroundAscertaining accurately the exposure to antithrombotic medications for both research and quality initiatives has been challenging due to a multitude of reasons: aspirin, the most commonly used antithrombotic, is available over the counter in the United States. Additionally, antithrombotic medications are frequently interrupted for bleeding and procedures. ObjectivesWe aimed to develop and validate an algorithm to capture accurately the longitudinal exposure to antithrombotic medications including aspirin using the electronic health record. MethodsWe used the Medical Inpatient Thrombosis and Hemostasis cohort, which consists of primary care patients at a university medical center followed for a median of 6.2 years. Exposure to antithrombotic medications was captured using the medication reconciliation data linked to each ambulatory encounter. We developed an algorithm that used the taking “yes” or “no” tab as well as start and stop dates to define the duration of exposure for each medication. Eighty charts were reviewed and compared with results of the algorithm for validation. We estimated the sensitivity, specificity, and positive and negative predictive values. ResultsThe algorithm was 97% (95% CI, 94%-100%) sensitive and 95% (95% CI, 90%-100%) specific in identifying exposure to any antithrombotic medication. This translated to a 93% (95% CI, 85%-100%) positive predictive value and 98% (95% CI, 96%-100%) negative predictive value. When looking at aspirin alone, the sensitivity and the positive predictive value were 95% (95% CI, 88%-100%) and 87% (95% CI, 71%-100%). ConclusionThis current algorithm provides a new and easily adaptable strategy to capture accurately exposure to aspirin and other antithrombotic medications.

Institutional practices for charitable medication access for uninsured patients.

To identify the most frequently prescribed medications, the location where prescriptions were filled, and whether a voucher was utilized among patients enrolled in a charitable care program within an academic medicalcenter. This was a retrospective cohort study analyzing electronic health record and pharmacy dispensing information at a medical center's outpatient pharmacies. Patients included in this analysis were enrolled in a charitable care program and had at least 1 ambulatory encounter in a primary care clinic from March 1, 2019, to June 30, 2021. The study identified frequently prescribed medications, prescription payment methods, the overall cost of prescriptions if available, and the percentage of patients who filled their prescription at a medical center's outpatient pharmacies vs external outpatient pharmacies. Descriptive statistics were used to describe the results. This study included 511 patients, 87% of whom were Spanish speaking. A total of 8453 prescriptions were identified, and more than half of the prescriptions were sent to external outpatient pharmacies. The most common medications prescribed were for cardiovascular disease, diabetes, and pain treatment. Forty-seven percent of all prescriptions were sent to the medical center's outpatient pharmacies. The medical center's charitable care program covered the costs of 44% of the prescriptions sent to internal pharmacies, assisting 148 unique patients and incurring a cost of $111,052 for the medical center. Overall, this study was able to characterize patient demographics, historical costs related to charitable care coverage, and the utilization of health care services among this population. This information can be used to support the development and implementation of a charitable medication formulary, with the aims of improving quality of care for this population and reducing medical center costs.

Variable Impact of Medical Scribes on Physician Electronic Health Record Documentation Practices: A Quantitative Analysis Across a Large, Integrated Health-System.

Medical scribes have been utilized to reduce electronic health record (EHR) associated documentation burden. Although evidence suggests benefits to scribes, no large-scale studies have quantitatively evaluated scribe impact on physician documentation across clinical settings. This study aimed to evaluate the effect of scribes on physician EHR documentation behaviors and performance. This retrospective cohort study used EHR audit log data from a large academic health system to evaluate clinical documentation for all ambulatory encounters between January 2014 and December 2019 to evaluate the effect of scribes on physician documentation behaviors. Scribe services were provided on a first-come, first-served basis on physician request. Based on a physician's scribe use, encounters were grouped into 3 categories: never using a scribe, prescribe (before scribe use), or using a scribe. Outcomes included chart closure time, the proportion of delinquent charts, and charts closed after-hours. Three hundred ninety-five physicians (23% scribe users) across 29 medical subspecialties, encompassing 1,132,487 encounters, were included in the analysis. At baseline, scribe users had higher chart closure time, delinquent charts, and after-hours documentation than physicians who never used scribes. Among scribe users, the difference in outcome measures postscribe compared with baseline varied, and using a scribe rarely resulted in outcome measures approaching a range similar to the performance levels of nonusing physicians. In addition, there was variability in outcome measures across medical specialties and within similar subspecialties. Although scribes may improve documentation efficiency among some physicians, not all will improve EHR-related documentation practices. Different strategies may help to optimize documentation behaviors of physician-scribe dyads and maximize outcomes of scribe implementation.

Explaining Variability in Electronic Health Record Effort in Primary Care Ambulatory Encounters.

Electronic health record (EHR) user interface event logs are fast providing another perspective on the value and efficiency EHR technology brings to health care. Analysis of these detailed usage data has demonstrated their potential to identify EHR and clinical process design factors related to user efficiency, satisfaction, and burnout. This study aimed to analyze the event log data across 26 different health systems to determine the variability of use of a single vendor's EHR based on four event log metrics, at the individual, practice group, and health system levels. We obtained de-identified event log data recorded from June 1, 2018, to May 31, 2019, from 26 health systems' primary care physicians. We estimated the variability in total Active EHR Time, Documentation Time, Chart Review Time, and Ordering Time across health systems, practice groups, and individual physicians. In total, 5,444 physicians (Family Medicine: 3,042 and Internal Medicine: 2,422) provided care in a total of 2,285 different practices nested in 26 health systems. Health systems explain 1.29, 3.55, 3.45, and 3.30% of the total variability in Active Time, Documentation Time, Chart Review Time, and Ordering Time, respectively. Practice-level variability was estimated to be 7.96, 13.52, 8.39, and 5.57%, respectively, and individual physicians explained the largest proportion of the variability for those same outcomes 17.09, 27.49, 17.51, and 19.75%, respectively. The most variable physician EHR usage patterns occurs at the individual physician level and decreases as you move up to the practice and health system levels. This suggests that interventions to improve individual users' EHR usage efficiency may have the most potential impact compared with those directed at health system or practice levels.

Cumulated time to chart closure: a novel electronic health record-derived metric associated with clinician burnout

Abstract Objective We sought to determine whether average cumulated time to chart closure (CTCC), a novel construct to measure clinician workload burden, and electronic health record (EHR) measures were associated with a validated measure of burnout. Materials and methods Physicians at a large academic institution participated in a well-being survey that was linked to their EHR use data. CTCC was defined as the average time from the start of patient encounters to chart closure over a set of encounters. Established EHR use measures including daily total time in the EHR (EHR-Time8), time in the EHR outside scheduled hours, work outside of work (WOW8), and time spent on inbox (IB-Time8) were calculated. We examined the relationship between CTCC, EHR use metrics, and burnout using descriptive statistics and adjusted logistic regression models. Results We included data from 305 attendings, encompassing 242 432 ambulatory encounters (2021). Among them, 42% (128 physicians) experienced burnout. The median CTCC for all clinicians was 32.5 h. Unadjusted analyses revealed significant associations between CTCC, WOW8, IB-Time8, and burnout. In a final adjusted model, only CTCC remained statistically significant with an odds ratio estimate of 1.42 (95% CI, 1.00-2.01). Discussion These results suggest that CTCC is predictive of burnout and that purely measuring duration of interaction with the EHR itself is not sufficient to capture burnout. Conclusion Workload burden as manifested by average CTCC has the potential to be a practical, quantifiable measure that will allow for identification of clinicians at risk of burnout and to assess the success of interventions designed to address burnout.

Major Drug-Drug Interaction Exposure Among Medicaid-Insured Children in the Outpatient Setting.

Drug-drug interactions (DDIs) can cause adverse drug events, but little is known about DDI exposure in children in the outpatient setting. This study aimed to determine the prevalence of major DDI exposure and factors associated with higher DDI exposure rates among children in an outpatient setting. We performed a cross-sectional study of children aged 0 to 18 years with ≥1 ambulatory encounter, and ≥2 dispensed outpatient prescriptions study using the 2019 Marketscan Medicaid database. DDIs (exposure to a major DDI for ≥1 day) and the adverse physiologic effects of each DDI were identified using DrugBank's interaction database. Primary outcomes included the prevalence and rate of major DDI exposure. We used logistic regression to assess patient characteristics associated with DDI exposure. We examined the rate of DDI exposures per 100 children by adverse physiologic effects category, and organ-level effects (eg, heart rate-corrected QT interval prolongation). Of 781 019 children with ≥2 medication exposures, 21.4% experienced ≥1 major DDI exposure. The odds of DDI exposure increased with age and with medical and mental health complexity. Frequently implicated drugs included: Clonidine, psychiatric medications, and asthma medications. The highest adverse physiologic effect exposure rate per 100 children included: Increased drug concentrations (14.6), central nervous system depression (13.6), and heart rate-corrected QT interval prolongation (9.9). One in 5 Medicaid-insured children with ≥2 prescription medications were exposed to major DDIs annually, with higher exposures in those with medical or mental health complexity. DDI exposure places children at risk for negative health outcomes and adverse drug events, especially in the harder-to-monitor outpatient setting.

Improved recognition of lung function decline as signal of cystic fibrosis pulmonary exacerbation: a Cystic Fibrosis Learning Network Innovation Laboratory quality improvement initiative

IntroductionCystic fibrosis (CF) is a systemic autosomal recessive condition characterised by progressive lung disease. CF pulmonary exacerbations (PEx) are episodes of worsening respiratory status, and frequent PEx are a risk...

Buprenorphine Use in the United States, 2010-2019

BackgroundBuprenorphine is effective for the treatment of opioid use disorder and chronic pain, has a safer pharmacological profile than full mu-opioid agonists, and can now be prescribed by any US provider with a Drug Enforcement Administration license. This study aimed to examine a decade of buprenorphine prescribing patterns in the United States. MethodsWe abstracted opioid and buprenorphine prescribing patterns, including patient characteristics, from the 2010-2019 National Ambulatory Medical Care Survey, a national probability sample of non-federal, ambulatory encounters. DISCUSSIONAmong 248,164 ambulatory encounters, opioids were prescribed 2.6%-4.3% of the time with a rate that peaked in 2013 and has been steadily declining. Buprenorphine was infrequently prescribed. Patients receiving buprenorphine were predominantly male (59%), white (70%), younger in age, and had higher rates of substance use disorder (72%). ConclusionBuprenorphine is infrequently used, despite being effective for pain and safer than full mu-opioid agonists. The Drug Enforcement Administration recently ended the requirement for prescribers to obtain an X-waiver, which may increase the rate of buprenorphine use among US practitioners.

Abstract 16087: Contemporary Use of Guideline Directed Heart Failure Medications in Patients With Centrifugal Durable Left Ventricular Assist Device

Introduction: As societal guidelines have recently supported, our large-volume center has recently protocolized the use of guideline directed medical therapy &lt;GDMT&gt; in patients with left ventricular assist devices &lt;LVAD&gt; to promote ventricular recovery. Hypothesis: We sought to understand the use of, and opportunity to improve upon, GDMT use in the LVAD population.To describe contemporary utilization of comprehensive GDMT in the &lt;HM3&gt; LVAD population and to characterize patient factors associated with use of HF medical therapy utilizing a comprehensive GDMT score. Methods: We conducted retrospective of analysis of patients who had HM3 implanted at our center &lt;N = 270&gt; and had at least one ambulatory visit for HF in the prior 12 months. Baseline characteristics, laboratory test, acute care utilization and GDMT score data were extracted from the nearest date of the ambulatory encounter to the data extraction date that occurred on 9/23/22. GDMT score &lt;range from 0 to 8&gt; composition includes beta-blocker, ACEI/ARB [0 for none, 1 for &lt;50% and 2 for ≥50% of max dose], MRA, SGLT2i, ARNI [0 for none and 2 for any dose] and ISDN/Hydra [0 for none and 1 for any dose]. Linear regression analyses of clinical variables associated with GDMT score were performed. Results: We observed mean score of 3.23 ± 1.7 with median of 3.0. In this study, mean age was 60, &gt;70% were Caucasian male and mean eGFR was 62. 49% of total cohort [135] were on beta-blocker, 75% [202] on ARB/ACE/ARNI, 47% [127] on MRA, and only 15% [40] on SGLT2i and 20% [53] on ISDN/Hydralazine. Majority [~95%] do not have absolute contraindication to GDMT [based on MAP &lt;65, eGFR &lt;30, K&gt; 5.0]. Adjusted multivariable regression analysis showed GDMT score &lt;/= 3 was associated with higher age [adjusted risk score of - 0.25 per every 10 years, 95% CI : -0.43 to - 0.65], higher MAP [adjusted risk score of - 0.19 per every 10 mmHg, 95% CI : -0.34 to - 0.03], and all-cause hospitalizations [adjusted risk score of - 0.23, 95% CI : -0.40 to - 0.06]. There was no significant association with gender, race, heart rate, NT-proBNP, eGFR, potassium and comorbidities. Conclusions: We identified significant opportunity to improve use of GDMT in the post LVAD population, with older age and frequent hospitalization being associated with worse GDMT use.

Abstract 18569: Patient and Provider Factors Associated With the Initiation of Sodium-Glucose Cotransporter-2 Inhibitors (SGLT2i) in the Year Post FDA Approval for HFpEF and HFmrEF

Introduction: Despite robust evidence for, and Food and Drug Administration (FDA) approval of sodium-glucose cotransporter-2 inhibitors (SGLT2i) for heart failure with preserved and mildly reduced ejection fraction (HFpEF/HFmrEF), use of this therapy is suboptimal. Hypothesis: We aimed to determine 1) prescribing context (inpatient/outpatient) and prescriber type of SGLT2i; 2) patient and provider level predictors of SGLT2i prescription in the year following FDA approval. Methods: All patients in a diverse, multi-state (Ohio and Florida), multi practice/hospital integrated system who had least 1 ambulatory encounter for HF and documented EF &gt; 40% were included. Data come from the electronic health record. We compared patients who were prescribed SGLT2i in the year post FDA approval 2/24/22-2/24/23 against those who were not using multivariable logistic regression to assess independent predictors of SGLT2i prescription. Results: 20,255 patients with HFpEF/HFmrEF were included in the study. Mean age 73±9 yrs, female (49.8%), Black (17.4%), DM2 (34%), AFib (43%), CKD (35%), baseline medications: BB (52.4%), ACEi/ARB (41%), MRA (19.7%), ARNI (6.5%), SGLT2i (3.2%). There were 1118 (5.6%) patients were newly prescribed SGLT2i in the study period. SGLT2i were most commonly initiated by cardiology 54.2%, general medicine 25.3% and endocrinology 8.5%. Of prescriptions, 82.9% were outpatient, 17.1% inpatient. Independent patient level predictors of SGLT2i prescription were DM2 2.82 (2.09-3.82), p&lt;0.001; AFib 1.42 (1.07-1.92), p=0.018; higher eGFR 1.16 (1.09-1.25), p&lt;0.001 and increasing EF 0.88 (0.81-0.97), p&lt;0.001. Insurance type/median income were not significant. Provider level predictors were total HF visits with each specialty: HF cardiology, 1.21 (1.13-1.29), p&lt;0.001; general cardiology, 1.1 (1.04-1.15), p&lt;0.001; and primary care, 1.1 (1.08-1.17), p&lt;0.001. After excluding patients with DM2, predictors were total visits with HF specialists, and general cardiologists. Conclusions: In the year post FDA approval, there has been significant underutilization of SGLT2i. Diabetes status and provider factors were associated with SGLT2i use, the majority of which were initiated in the outpatient setting by cardiology providers.