Ambulatory Sites Research Articles

1891. Assessing the Needs for Antimicrobial Stewardship Education and Acceptance Across a Spectrum of Prescribers, Nurses and Pharmacists at a Large Academic Medical Center

BackgroundRegulatory bodies and quality groups have adopted the Centers for Disease Control and Prevention (CDC) Core Elements for Antimicrobial Stewardship Programs (ASP) as a measure for accreditation and scoring healthcare institutions across the United States. Multiple elements are driven by educating and integrating staff across the provider network. The ideal method of providing education and addressing gaps is unknown. The objectives of this study were to evaluate the familiarity of Nursing, Pharmacy, and Prescribers regarding local ASP activities and services, as well as perceptions regarding patient care and value. Secondary objectives were to determine what educational tools are currently utilized and the desired method for future education.MethodsThree distinct surveys were written for each provider type for Nurses, Pharmacists and Prescribers across ambulatory and inpatient sites. Each contained basic demographic data such as years in practice and primary practice site. Questions were developed to assess familiarity, perceived value, and overall satisfaction with the ASP. Additional items included the use of online ASP resources and desire for more education. The survey was delivered electronically to 5,091 providers.ResultsIn total, 443 completed the survey, 267 Nurses, 160 Prescribers, and 16 Pharmacists. A majority of Nurses (67%) and Pharmacists (56%) worked on inpatient units. Prescribers were 48% from Medicine and 16% Hospitalists. Familiarity with the ASP was lowest among Nursing staff, 53% unaware, and highest among prescribers (55% very familiar, 8% not familiar) and pharmacists (56% very familiar and none unfamiliar) as seen in Figures 1 through 3. ASP-assisted harm prevention was identified by 43% and therapy optimization by 44%. Of the highly familiar prescribers and pharmacists, 90% rated ASP as a moderate to high value service. More than 80% of all disciplines expressed the desire for more education, primarily as didactic lectures (65%), intranet portal training (37%), or emails (36%). ConclusionNursing staff at our institution have the greatest need for orientation with the ASP. The ASP is highly valued across prescribers and pharmacists, but all disciplines desire further education. Resource allocation toward education is an important need.Disclosures C. McCoy, Merck Inc.: Scientific Advisor, Consulting fee. Allergan: Scientific Advisor, Consulting fee.

Establishing a New Ambulatory Care Practice Site as a Pharmacy Practice Faculty.

There is an imminent need to identify and develop new ambulatory care practice sites with the increase in the number of colleges of pharmacy across the nation. This manuscript provides recommendations to help clinical faculty determine whether a potential pharmacy practice site will be able to provide adequate resources and support to establish a successful practice. This may be challenging to pharmacy practice faculty in settings where clinical pharmacy services have never been utilized. Topics include the pre-work needed prior to approaching a new practice site, assessing the need for physical requirements, meeting key personnel, marketing clinical skills and services, implementing, and evaluating practice site. Preparation includes having a clear vision of the pharmacist services, ensuring that stakeholders have an understanding of the pharmacy services inquiring the site support and resources for the pharmacist, and regularly communicating.

User Testing an Information Foraging Tool for Ambulatory Surgical Site Infection Surveillance.

Surveillance for surgical site infections (SSIs) after ambulatory surgery in children requires a detailed manual chart review to assess criteria defined by the National Health and Safety Network (NHSN). Electronic health records (EHRs) impose an inefficient search process where infection preventionists must manually review every postsurgical encounter (< 30 days). Using text mining and business intelligence software, we developed an information foraging application, the SSI Workbench, to visually present which postsurgical encounters included SSI-related terms and synonyms, antibiotic, and culture orders. This article compares the Workbench and EHR on four dimensions: (1) effectiveness, (2) efficiency, (3) workload, and (4) usability. Comparative usability test of Workbench and EHR. Objective test metrics are time per case, encounters reviewed per case, time per encounter, and retrieval of information meeting NHSN definitions. Subjective measures are cognitive load using the National Aeronautics and Space Administration (NASA) Task Load Index (NASA TLX), and a questionnaire on system usability and utility. Eight infection preventionists participated in the test. There was no difference in effectiveness as subjects retrieved information from all cases, using both systems, to meet the NHSN criteria. There was no difference in efficiency in time per case between the Workbench and EHR (8.58 vs. 7.39 minutes, p = 0.36). However, with the Workbench subjects opened fewer encounters per case (3.0 vs. 7.5, p = 0.002), spent more time per encounter (2.23 vs. 0.92 minutes, p = 0.002), rated the Workbench lower in cognitive load (NASA TLX, 24 vs. 33, p = 0.02), and significantly higher in measures of usability. Compared with the EHR, the Workbench was more usable, short, and reduced cognitive load. In overall efficiency, the Workbench did not save time, but demonstrated a shift from between-encounter foraging to within-encounter foraging and was rated as significantly more efficient. Our results suggest that infection surveillance can be better supported by systems applying information foraging theory.

The Overarching Themes From the CLER National Report of Findings 2018.

The Overarching Themes From the CLER National Report of Findings 2018.

EPOP-136 - Standardizing Infection Control Rounds in the Hospital Based Ambulatory Setting

Background: In the continuing journey to integrate our multiple acute care hospitals, outpatient services, medical practices and ambulatory sites into one cohesive health care system, it became apparent that infection prevention was lacking in some of the settings. As infection preventionists, we can identify that many ambulatory practices lack infection prevention and control expertise and often have limited resources. Our acute care hospital system aimed to create a standard practice of evaluating over 80 sites.

Instrumentation Failure after Partial Corpectomy with Instrumentation of a Metastatic Spine.

ObjectiveTo identify the perioperative factors associated with instrument failure in patients undergoing a partial corpectomy with instrumentation (PCI) for spinal metastasis.MethodsWe assessed the one hundred twenty-four patients with who underwent PCI for a metastatic spine from 1987 to 2011. Outcome measure was the risk factor related to implantation failure. The preoperative factors analyzed were age, sex, ambulation, American Spinal Injury Association grade, bone mineral density, use of steroid, primary tumor site, number of vertebrae with metastasis, extra-bone metastasis, preoperative adjuvant chemotherapy, and preoperative spinal radiotherapy. The intraoperative factors were the number of fixed vertebrae, fixation in osteolytic vertebrae, bone grafting, and type of surgical approach. The postoperative factors included postoperative adjuvant chemotherapy and spinal radiotherapy. This study was supported by the National Research Foundation grant funded by government. There were no study-specific biases related to conflicts of interest.ResultsThere were 15 instrumentation failures (15/124, 12.1%). Preoperative ambulatory status and primary tumor site were not significantly related to the development of implant failure. There were no significant associations between insertion of a bone graft into the partial corpectomy site and instrumentation failure. The preoperative and operative factors analyzed were not significantly related to instrumentation failure. In univariable and multivariable analyses, postoperative spinal radiotherapy was the only significant variable related to instrumentation failure (p=0.049 and 0.050, respectively).ConclusionWhen performing PCI in patients with spinal metastasis followed by postoperative spinal radiotherapy, the surgeon may consider the possibility of instrumentation failure and find other strategies for augmentation than the use of a bone graft for fusion.

A hypertension control quality improvement pilot program: Experiences and blood pressure outcomes from physician practices

Improving Health Outcomes: Blood Pressure (IHO: BP) was a Quality Improvement (QI) pilot program developed by the American Medical Association (AMA) and Johns Hopkins Medicine aimed at helping physicians and their care teams better manage patients with uncontrolled hypertension. The pilot study was conducted at 10 ambulatory practice sites between October 2013 and November 2014 in which the initiative was to devise a framework and intervention strategies for improving hypertension control. The program included evidence-based tools and materials to support the Measure Accurately, Act Rapidly, and Partner with Patients (M.A.P.) framework, interactive components with coaching support and peer-to-peer learning opportunities, and a measurement system supported by health technology, all intended to aid blood pressure management. This paper captures the learnings from the engagement, experiences, and satisfaction of care teams from the IHO: BP pilot that were used to adjust, reassess, and refine components of the QI program. Overall, participation in the IHO: BP pilot was associated with an increase in BP control rates from a mean of 69% to 75% (p &lt; .05) for 3 of the 10 practices. Mean systolic and diastolic blood pressure was reduced in 8 of 10 practices by a mean of 12.5 mmHg/6.5 mmHg (p &lt; .05). Furthermore, evaluation of participant experiences indicated that 75% of the respondents were satisfied or very satisfied with the initiative. The results from this study include components of the pilot that participants indicated were most helpful and were used to generate useful information for hypertension QI efforts that were later scaled and spread to subsequent initiatives.

A systematic approach to quantifying infection prevention staffing and coverage needs

This article describes a large nonprofit health care system's approach at quantifying the actual number of infection preventionist (IP) and relative support staff required to build and sustain effective infection prevention programs. A list of all physical locations within the organization requiring infection prevention coverage were identified via survey, including department-level detail for 34 hospitals, 583 ambulatory sites, and 26 in-home and long-term care programs across 5 states. Required IP activities for each physical location were also tallied by task. Type of activity, frequency (times per year), hours per activity, and total number of locations in which each activity should occur were determined. From this, the number of hours per week of infection prevention labor resources needed was calculated. Quantitative needs assessment revealed actual labor need to be 31%-66% above current benchmarks of 0.5-1.0 IP per 100 occupied beds. When aggregated across the organization, the comprehensive review results yielded a new benchmark of 1.0 infection prevention full-time equivalent per 69 beds if ambulatory, long-term care, or home care are included. Size, scope, services offered, populations cared for, and type of care settings all impact the actual need for IP coverage, making the survey benchmarks available in the literature invalid. A comprehensive assessment of health care organization composition and structure is necessary prior to determining the IP staffing needs for that organization.

Landscape of antimicrobial stewardship programs in Ontario: a survey of hospitals.

Antimicrobial resistance is an important public health issue globally and in Canada. To understand the current state of antimicrobial stewardship programs in Ontario health care facilities, Public Health Ontario conducted a voluntary survey of hospitals in the province. The Ontario Antimicrobial Stewardship Program Landscape Survey was distributed online to hospitals, targeting front-line antimicrobial stewardship clinicians. The survey was open for 5 weeks in fall 2016. We used email and telephone reminders to encourage response. We performed descriptive and inferential statistical analyses at an aggregate level and by hospital type. Mental health and ambulatory sites were excluded. The response rate was 74.0% (97/131 organizations). Of the 97, 90 (93%) reported having a formal antimicrobial stewardship program or were in the process of implementing a formal program. Just over half (50 [56%]) identified appropriate antibiotic use as part of the organization's quality-improvement plan, strategic goal or priority. Half (45 [50%]) of programs did not have designated resources; those that did are underresourced with respect to physician and pharmacist staffing. The scope of implementation of program strategies was variable. Fifty hospitals (56%) reported tracking antimicrobial expenditures, 47 (52%) reported tracking defined daily dose, and 35 (39%) reported tracking days of therapy. Most Ontario hospitals have a formal antimicrobial stewardship program, but there are opportunities for improvement. Future efforts should increase the priority of and improve resource allocation for antimicrobial stewardship programs so that programs can continue to grow in scope and impact.

The Atrial Fibrillation Health Literacy Information Technology System: Pilot Assessment.

BackgroundAtrial fibrillation (AF) is a highly prevalent heart rhythm condition that has significant associated morbidity and requires chronic treatment. Mobile health (mHealth) technologies have the potential to enhance multiple aspects of AF care, including education, monitoring of symptoms, and encouraging and tracking medication adherence. We have previously implemented and tested relational agents to improve outcomes in chronic disease and sought to develop a smartphone-based relational agent for improving patient-centered outcomes in AF.ObjectiveThe objective of this study was to pilot a smartphone-based relational agent as preparation for a randomized clinical trial, the Atrial Fibrillation Health Literacy Information Technology Trial (AF-LITT).MethodsWe developed the relational agent for use by a smartphone consistent with our prior approaches. We programmed the relational agent as a computer-animated agent to simulate a face-to-face conversation and to serve as a health counselor or coach specific to AF. Relational agent’s dialogue content, informed by a review of literature, focused on patient-centered domains and qualitative interviews with patients with AF, encompassed AF education, common symptoms, adherence challenges, and patient activation. We established that the content was accessible to individuals with limited health or computer literacy. Relational agent content coordinated with use of the smartphone AliveCor Kardia heart rate and rhythm monitor. Participants (N=31) were recruited as a convenience cohort from ambulatory clinical sites and instructed to use the relational agent and Kardia for 30 days. We collected demographic, social, and clinical characteristics and conducted baseline and 30-day assessments of health-related quality of life (HRQoL) with the Atrial Fibrillation Effect on Quality of life (AFEQT) measure; self-reported medication adherence with the Morisky 8-item Medication Adherence Scale (MMAS-8); and patient activation with the Patient Activation Measure (PAM).ResultsParticipants (mean age 68 [SD 11]; 39% [12/31] women) used the relational agent for an average 17.8 (SD 10.0) days. The mean number of independent log-ins was 19.6 (SD 10.7), with a median of 20 times over 30 days. The mean number of Kardia uses was 26.5 (SD 5.9), and participants using Kardia were in AF for 14.3 (SD 11.0) days. AFEQT scores improved significantly from 64.5 (SD 22.9) at baseline to 76.3 (SD 19.4) units at 30 days (P<.01). We observed marginal but statistically significant improvement in self-reported medication adherence (baseline: 7.3 [SD 0.9], 30 days: 7.7 [SD 0.5]; P=.01). Assessments of acceptability identified that most of the participants found the relational agent useful, informative, and trustworthy.ConclusionsWe piloted a 30-day smartphone-based intervention that combined a relational agent with dedicated content for AF alongside Kardia heart rate and rhythm monitoring. Pilot participants had favorable improvements in HRQoL and self-reported medication adherence, as well as positive responses to the intervention. These data will guide a larger, enhanced randomized trial implementing the smartphone relational agent and the Kardia monitor system.

Development of a telemedicine palliative care program in a cancer center.

99 Background: Inpatient palliative care (PC) teams have increased their presence over the past decade, with over 90% of hospitals having access to PC specialists. However, such growth has not been mirrored in the outpatient setting; this is relevant for patients living far from major medical centers. Memorial Sloan Kettering Cancer Center (MSK) has expanded its ambulatory care footprint beyond New York City (NYC) to sites where PC is not currently available. To address the need for PC delivery to a geographically dispersed patient population, we developed a clinical initiative utilizing telemedicine technology. Methods: The Telemedicine Palliative Care Program (TPCP) was initiated after planning with multiple stakeholders, including clinical, legal, billing, compliance, ambulatory care, information systems, and scheduling departments. The TPCP provides PC consultation and management of patients via a “hub-and-spoke” model, whereby PC specialists are located at the main campus in NYC and patients are scheduled to be seen at one of six regional ambulatory cancer sites within a 50-mile radius. Regional ambulatory sites have video teleconference rooms equipped with Cisco (San Jose, CA) TelePresence MX300 hardware and Jabber software allowing for secure, high fidelity, real-time video communication with clinicians at the main campus who use iPads installed with Jabber software during their consultation sessions. Results: The TPCP is currently active at two regional sites in New York and New Jersey. Patient satisfaction, perception of quality of care, and patient outcomes will be measured. Preliminary results indicate that both patients and providers find this clinical program to be an extremely valuable experience. Conclusions: The technologic infrastructure is now available to deliver telemedicine-enabled PC for cancer patients in a geographically distributed model. Our early experience suggests that our program will help enable the convenient delivery of concurrent PC to cancer patients across a wide geographic area. This innovative clinical initiative has the potential to enable all MSK patients to access high-quality palliative care in a geography-agnostic manner, and eventually deliver such care to patients in their homes.

Atrial fibrillation decision support tool: Population perspective

Appropriate thromboprophylaxis for patients with atrial fibrillation or atrial flutter (AF) remains a national challenge. The recent availability of direct oral anticoagulants (DOACs) with comparable efficacy and improved safety compared with warfarin alters the balance between risk factors for stroke and benefit of anticoagulation. Our objective was to examine the impact of DOACs as an alternative to warfarin on the net benefit of oral anticoagulant therapy (OAT) in a real-world population of AF patients. This is a retrospective cohort study of patients with paroxysmal or persistent nonvalvular AF. We updated an Atrial Fibrillation Decision Support Tool (AFDST) to include DOACs as treatment options. The tool generates patient-specific recommendations based upon individual patient risk factor profiles for stroke and major bleeding using quality-adjusted life-years (QALYs) calculated for each treatment strategy by a decision analytic model. The setting included inpatient and ambulatory sites in an academic health center in the midwestern United States. The study involved 5,121 adults with nonvalvular AF seen for any ambulatory visit or inpatient hospitalization over the 1-year period (January through December 2016). Outcome measure was net clinical benefit in QALYs. When DOACs are a therapeutic option, the AFDST recommends OAT for 4,134 (81%) patients and no antithrombotic therapy or aspirin for 489 (9%). A strong recommendation for OAT could not be made in 498 (10%) patients. When warfarin is the only option, OAT is recommended for 3,228 (63%) patients and no antithrombotic therapy or aspirin for 973 (19%). A strong recommendation for OAT could not be made in 920 (18%) patients. In total, 1,508 QALYs could be gained if treatment were changed to that recommended by the AFDST. Availability of DOACs increases the proportion of patients for whom oral anticoagulation therapy is recommended in a real-world cohort of AF patients and increased projected QALYs by more than 1,500 when all patients are receiving thromboprophylaxis as recommended by the AFDST compared with current treatment.

A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites.

To reduce the risk of wrong-patient errors, safety experts recommend limiting the number of patient records providers can open at once in electronic health records (EHRs). However, it is unknown whether health care organizations follow this recommendation or what rationales drive their decisions. To address this gap, we conducted an electronic survey via 2 national listservs. Among 167 inpatient and outpatient study facilities using EHR systems designed to open multiple records at once, 44.3% were configured to allow ≥3 records open at once (unrestricted), 38.3% allowed only 1 record open (restricted), and 17.4% allowed 2 records open (hedged). Decision-making centered on efforts to balance safety and efficiency, but there was disagreement among organizations about how to achieve that balance. Results demonstrate no consensus on the number of records to be allowed open at once in EHRs. Rigorous studies are needed to determine the optimal number of records that balances safety and efficiency.

Association of Risk of Viremia, Immunosuppression, Serious Clinical Events, and Mortality With Increasing Age in Perinatally Human Immunodeficiency Virus–Infected Youth

As perinatally human immunodeficiency virus-infected youth (PHIVY) in the United States grow older and more treatment experienced, clinicians need updated information about the association of age, CD4 cell count, viral load (VL), and antiretroviral (ARV) drug use with risk of opportunistic infections, key clinical events, and mortality to understand patient risks and improve care. To examine the incidence or first occurrence during follow-up of key clinical events (including Centers for Disease Control and Prevention stage B [CDC-B] and stage C [CDC-C] events) and mortality among PHIVY stratified by age, CD4 cell count, and VL and ARV status. Combining data from the Pediatric HIV/AIDS Cohort Study (PHACS) Adolescent Master Protocol and International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) P1074 multicenter cohort studies (March 2007 through April 2015), we estimated event rates during person-time spent in key strata of age (7-12, 13-17, and 18-30 years), CD4 cell count (<200, 200-499, and ≥500/μL), and a combined measure of VL and ARV status (VL <400 or ≥400 copies/mL; ARV therapy or no ARV therapy). A total of 1562 participants in the PHACS Adolescent Master Protocol and IMPAACT P1074 were eligible, and 1446 PHIVY from 41 ambulatory sites in the 12 US states, including Puerto Rico were enrolled. The dates of analysis were March 2015 through January 2017. Clinical event rates stratified by person-time in age, CD4 cell count, and VL and ARV categories. A total of 1446 PHIVY participated in the study (mean [SD] age, 14.6 [4.6] years; 759 female [52.5%]; 953 black [65.9%]). During a mean (SD) follow-up of 4.9 (1.3) years, higher incidences of CDC-B events, CDC-C events, and mortality were observed as participants aged. Older PHIVY (aged 13-17 and 18-30 years) spent more time with a VL of 400 copies/mL or more and with a CD4 cell count of less than 200/µL compared with 7- to 12-year-old participants (30% and 44% vs 22% of person-time with a VL≥400 copies/mL; 5% and 18% vs 2% of person-time with CD4 cell count <200/µL; P < .001 for each comparison). We observed higher rates of CDC-B events, CDC-C events, bacterial infections, and mortality at lower CD4 cell counts, as expected. The mortality rate among older PHIVY was 6 to 12 times that among the general US population. Higher rates of sexually transmitted infections were also observed at lower CD4 cell counts after adjusting for age. Older PHIVY were at increased risk of viremia, immunosuppression, CDC-B events, CDC-C events, and mortality. Interventions to improve ARV therapy adherence and optimize models of care for PHIVY as they age are urgently needed to improve long-term outcomes among PHIVY.

Patient Safety and Leadership: Do You Walk the Walk?

How will I know when my hospital is safe? To that question, many hospital CEOs would likely answer, When I no longer have to call ahead to let staff know a family member is being admitted.Patient safety has been a strategic imperative in healthcare since our wake-up call- the Institute of Medicine (2000) report To Err Is Human: Building a Safer Health System, which suggested that as many as 98,000 people die each year as a result of medical errors. Yet medical errors today are still the third leading cause of death in the United States (Makary & Daniel, 2016). As key stakeholders, healthcare leaders have primary responsibility to solve this challenge.As with any problem, the first step toward a patient safety solution is admitting that there is a problem. Only then can it be defined and appropriate resources be committed to solve it. True success requires more than establishing a safety culture; the culture must also be sustainable beyond current leadership.Patient safety is a combination of people and processes, and both elements depend on leadership. In the aviation and nuclear industries, which are widely viewed as highly reliable and therefore safe, almost every analysis of accidents reveals a recurrent theme: the failure of leadership to promote a safety culture (Institute of Nuclear Power Operations, 2013).How can healthcare leaders avoid this pitfall? Simply budgeting dollars will not fix the issue; a thoughtful patient safety strategy requires leaders to engage on a personal level. Weekly patient safety rounds throughout a hospital, for example, not only give staff an opportunity to learn about safety concerns (with feedback to close the loop); they also allow senior leaders to leave the C-suite and be seen on the units. By rounding, leaders demonstrate to staff their commitment to the importance of patient safety. Similarly, daily 15-minute patient safety calls engage all leaders in a rapid situational safety review of the organization.Several elements contribute to a safety culture, including a commitment to safety, a nonpunitive approach to reporting errors and near misses, a common belief in the importance of a safety culture, teamwork, and a pervasive feeling of trust. Leadership plays a aacritical role in fostering each component.THE IMPORTANCE OF MEASUREMENTIn all performance improvement efforts, one must first measure the current status to be able to confirm that an intervention has resulted in improvement. In patient safety, this process often starts with a survey. At Northwell Health, a metropolitan New York health system with 21 acute care hospitals and more than 450 ambulatory sites, we administer the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture every 18 months.The following aspects of administering a safety culture survey are key:1. Key stakeholders must participate in the process. A multidisciplinary team must be involved in selecting the survey, rolling it out, reviewing the data, and formulating a strategy based on the results. At Northwell, all care team members are involved, and the marketing team publicizes the survey to increase participation.2. A validated tool, such as the AHRQ safety culture survey, is required (Jones, Skinner, Xu, Junfeng, & Mueller, 2009).3. The data must be analyzed all the way down to the individual unit level. Variation, the bane of quality and safety, can occur between departments in the same hospital as well as between hospitals. Analysis ofthe data on multiple levels is required where multiple cultures are in place.4. The results need to be shared with staff. At Northwell, managers are given the results for their areas of responsibility and then share them with frontline staff.5. Most important, a strategy based on the results must be implemented. A repeat survey 18 months later will not show improvement if team members feel leaders have not responded to their concerns. …

An Assessment of Rewards and Faculty Development Opportunities Provided to Pediatric Community Faculty

Objective: Many medical schools in the US are experiencing difficulty maintaining sufficient ambulatory pediatric training sites for their students. The goals of this study were to assess the incentives, rewards, and faculty development opportunities provided for pediatricians serving as community faculty teaching in pediatric clerkships in the US. Methods: A 10 question prospective survey of the membership of the Council on Medical Student Education in Pediatrics incorporated into the organization's 2014 annual survey. Results: Representatives from 92% % (111 /121) of U.S. medical schools responded to the study. Seventy-nine percent of medical schools utilize community faculty to teach pediatrics. Eighty-two percent of respondents were having difficulty recruiting and retaining pediatricians to teach students. Thirty-nine percent of medical schools provided monetary stipends for teaching. Sixty-eight percent of schools provided faculty development for their community faculty. Conclusion: The majority of schools rely on non-monetary incentives to recruit and retain their community faculty. As compared to previous studies, more medical schools are offering financial stipends. Most schools, but not all, offer some form of faculty development training for their community faculty. There is a wide variation in the scope of faculty development training provided to community physicians that teach medical students.

Pediatric Residency Education and the Behavioral and Mental Health Crisis: A Call to Action

For at least 4 decades, the need for improved pediatric residency training in behavioral and mental health has been recognized. The prevalence of behavioral and mental health conditions in children, adolescents, and young adults has increased during that period. However, as recently as 2013, 65% of pediatricians surveyed by the American Academy of Pediatrics indicated that they lacked training in recognizing and treating mental health problems. Current pediatric residency training requirements do not stipulate curricular elements or assessment requirements in behavioral and mental health, and fewer than half of pediatric residents surveyed felt that their competence in dealing with mental health problems was good to excellent. It is time that pediatric residency programs develop the capacity to prepare their residents to meet the behavioral and mental health needs of their patients. Meeting this challenge will require a robust curriculum and effective assessment tools. Ideal training environments will include primary care ambulatory sites that encourage residents to work longitudinally in partnership with general pediatricians and behavioral and mental health trainees and providers; behavioral and mental health training must be integrated into both ambulatory and inpatient experiences. Faculty development will be needed, and in most programs it will be necessary to include nonpediatrician mental health providers to enhance pediatrician faculty expertise. The American Board of Pediatrics intends to partner with other organizations to ensure that pediatric trainees develop the competence needed to meet the behavioral and mental health needs of their patients.

What Is the Cost of Disease Progression Among Patients with Indolent or Aggressive Non-Hodgkin Lymphoma (NHL)?

Background: The natural histories of aggressive and indolent NHL vary in terms of the timing and pattern of disease progression. However, little is known about the impact of progression of disease (PD) on costs, and in particular how this differs between aggressive and indolent subtypes of NHL. This study examined patterns of care and outcomes for patients with aggressive and indolent NHL, and the impact of PD on health care costs.Methods: To identify cases of NHL, this retrospective studyused medical and pharmacy claims from a large national US health plan to identify commercially insured and Medicare Advantage (MA) patients age ≥18 years from 1/2007 - 8/2014 with ≥2 medical claims for NHL based on ICD-9-CM diagnosis codes. Patients were divided into cohorts of aggressive (AGG) NHL and indolent (IND) and based on diagnosis codes. Patients were required to have ≥1 claim for systemic anti-cancer therapy, with the index date being defined as the first observed claim for such therapy. Continuous enrollment in the health plan for 6 months prior to (baseline period), and ≥6 months after, the index date (variable follow-up period) was required; patients with <6 months of follow-up due to death were included. An algorithm to identify line of therapy (LOT) periods was implemented. PD was defined as: start of a second LOT, receipt of hospice care (based on procedure or revenue codes) or death (based on Social Security Administration death data). Health care costs were calculated over 6-month periods of follow-up (6, 12, 18, 24 months), with costs calculated for pharmacy, inpatient hospital, ambulatory, and other sites of service.Results: A total of 1,197 AGG and 2,454 IND patients met study criteria. Progression was experienced by 40.6% of AGG and 49.4% of IND patients respectively during the entire study period; 6-month progression was 18.9% (AGG) and 18.5% (IND). Compared to patients without PD during the study period, patients who progressed had higher average costs over each time period: in the first 6-months, costs were $138,957 PD vs. $108,607 for non-PD among AGG, and $114,644 PD vs. $80,873 for non-PD among IND (Figure, Table). Similarly, total costs for PD were higher than non-PD over 12, 18, and 24 months (Figure). Costs by site of service were higher for PD patients compared to non-PD patients among both the AGG and IND groups, particularly for inpatients costs; the table shows costs by site of service for the first 6 months, and results were similar over 12, 18, and 24 months. A higher proportion of AGG patients died compared with IND patients. Approximately one third of patients who died used hospice services among AGG and IND, and of these, 90.1% of AGG and 91.3% of IND used 3 or more days of hospice care.Conclusion: Among both aggressive and indolent NHL populations, costs were higher for patients with progressive versus without progressive disease, and increased over longer follow-up time. Patients with aggressive NHL had higher costs compared with patients with indolent NHL for both progressive and non-progressive disease. This study is the first to quantify systematically the cost of progression in NHL, both indolent and aggressive, and can inform efforts to improve value-based care, taking into account costs not just of therapy, but of subsequent progression. [Display omitted] [Display omitted] DisclosuresEngel-Nitz:Optum: Employment, Other: UnitedHealth Group stock. Dacosta Byfield:UnitedHealth Group: Equity Ownership; Optum: Employment. Bancroft:Optum: Employment, Other: UnitedHealth Group stock. Amy:Optum: Employment, Other: UnitedHealth Group stock. Reyes:Genentech: Employment; Roche: Equity Ownership.

Effective Intervention to Improve Viral Hepatitis Vaccination in Fellowsʼ Continuity Clinics

Introduction: In patients with chronic liver disease, superimposed viral hepatitis may result in higher morbidity and mortality. Vaccination against viral hepatitis appears to be underutilized in these patients. This study aimed to: 1) determine baseline Hepatitis A and B vaccination patterns in fellows' continuity clinics; and 2) implement and assess an intervention to improve these patterns. Methods: Each GI fellow reviewed Hepatitis A and B vaccination history for patients seen by one cofellow between April 1 and June 30, 2015, at one of two continuity clinics. All patients with cirrhosis were eligible for inclusion; patients with Hepatitis B cirrhosis were only included for Hepatitis A vaccine assessment. Only the earliest visit for each patient during this period was included, to assess baseline vaccination patterns. The intervention to improve vaccination was implemented prospectively starting on November 12, 2015, and data collection continued until February 25, 2016. The intervention consisted of designing and using a template to prompt immunization history, serology testing, and vaccine orders. We compared post-intervention patterns with baseline patterns. Results: 14 fellows participated in the study. Baseline period included 244 cirrhotic patients. HAV vaccination was addressed in 23% of patients in one clinic, and 67% in the other clinic; the rates were 29% and 64% respectively for HBV. In the intervention phase, 206 cirrhotic patients were included. Vaccination significantly improved with the intervention: HAV was addressed in 74% of patients (p < 0.001) and 93% (p < 0.001) in each clinic respectively, and HBV in 82% (p < 0.001) and 92% (p < 0.001) respectively. Conclusion: Hepatitis A and B vaccinations were underutilized in cirrhotic patients at fellows' ambulatory sites. Our intervention, using a dedicated clinic template, improved awareness and the rate at which vaccination status was addressed in fellows' continuity clinics. Vaccination rates in patients with chronic liver disease can be improved as part of their overall plan of care.

Prescribing pharmacists in the ambulatory care setting: Experience at the University of North Carolina Medical Center.

The prescribing authorities, clinical activities, and productivity documentation strategies of ambulatory care clinic-based pharmacists practicing within a large academic health system are described. North Carolina law encourages progressive pharmacy practice through acquisition of the clinical pharmacist practitioner (CPP) designation. Qualified CPPs are authorized to provide collaborative drug therapy management services, including medication prescribing and ordering of laboratory tests, according to defined protocols and under physician supervision. The University of North Carolina Medical Center has approximately 30 CPPs deployed across a wide range of ambulatory care clinical practice sites. This article describes (1) the pharmacy department's implementation of an ambulatory care practice model, (2) the credentialing and privileging process leading to granting of prescribing privileges, (3) metrics used to demonstrate the impact of CPP activities, (4) recommended general criteria for ambulatory care practice site identification, and (5) strategies for overcoming barriers to successful implementation of ambulatory care-focused clinical pharmacist services. Aggregated intervention-tracking data compiled by seven of the medical center's CPP ambulatory care practice sites indicate extensive CPP involvement in direct patient care encounters and patient or provider consultations, with large numbers of medication-related interventions to support institutional cost-avoidance and revenue goals. CPPs deployed at the medical center's ambulatory care clinics have had a positive impact on clinical and cost outcomes, improving patient care through interventions, contributing to readmission reduction efforts, generating indirect revenue through cost avoidance, and generating new revenue through billing for patient visits.