Care Discussions Research Articles

Cancer advance care planning: development of a screening tool

ObjectivesAdvance care discussions are a useful communication tools for medical preferences and beneficial for shared decision-making processes in hospital settings. The present study developed the first screening tool for need...

Team-based versus technology-based supportive cancer care (SCC): Implementation across 24 clinical settings.

86 Background: Advanced care planning and symptom management, otherwise known as Supportive Cancer Care (SCC), are fundamental services that patients should receive after a cancer diagnosis. Yet, barriers prevent such care delivery. In response, we launched a 24-clinic site cluster randomized trial in July 2022 comparing two SCC delivery approaches: a team-based intervention in which patients engage with a SCC-trained health educator via phone versus a technology-based intervention in which patients receive internet-based SCC education. The preliminary aim of this study is to evaluate clinic characteristics that may impact SCC implementation and effectiveness. Methods: Study staff at all 24 sites, including community oncology clinics, Kaiser Permanente clinics, Veterans Affairs facilities, safety-net hospitals, and academic centers, participated in a survey and semi-structured interview. We used Consolidated Framework for Implementation Research (CFIR) and Reach, Effectiveness, Adoption, and Implementation (RE-AIM) frameworks to assess organizational culture, facilitators, and barriers. Surveys were analyzed using descriptive statistics; interviews were qualitatively coded and thematically analyzed. Results: Among 31 interview participants, of which 24 completed surveys, 9 (29%) were principal investigators, 10 (32.3%) were research staff, and 12 (38.7%) were implementation staff. Survey respondents implementing team-based SCC were more confident that their approach accounted for patient care preferences (93.8%) and had strong evidence (87.5%) than respondents implementing technology-based SCC (62.5% and 25.0% respectively). More team-based SCC respondents expressed confidence in organization leadership (100%) and adequate resources for SCC (87.5%) than technology-based SCC respondents (87.5% and 75.0% respectively). Interviews revealed that team-based SCC was more likely to be effective, as it could 1) adapt delivery to patient needs, 2) improve patient support and outcomes, and 3) decrease clinician time burden, rather than tech-based SCC which could 1) worsen sociodemographic disparities in SCC delivery due to digital delivery and 2) result in EHR messaging overload for patients and clinicians. Participants were concerned about sustainability of both SCC approaches due to 1) competing organization priorities that limit staffing and funding, 2) barriers to technology access for patients, 3) information overload at time of diagnosis, and 4) patients’ hesitancy to engage in end-of-life care discussions. Conclusions: Supportive cancer care requires resources, organizational leadership, and assessment of patient needs. While the comparative effectiveness of team-based and technology-based approaches remains yet to be determined, many believe that team-based approaches may be more effective but remain concerned about sustainability.

Initiating advance care planning at admission: a brief intervention to increase goals of care discussions in geriatric trauma patients in an urban level I trauma center

ObjectivesThe burden of geriatric trauma continues to rise. Older trauma patients experience higher morbidity and mortality and thus benefit from early goals of care (GOC) discussions and advance care planning...

Improving serious illness conversations in oncology: A machine learning approach that integrates natural language processing for mortality prediction.

590 Background: ML-based mortality prediction tools in oncology can optimize clinical decisions and prompt end-of-life care discussions. Patients with advanced cancer who have engaged in Goals of Care (GoC) conversations report improved quality of life and better care alignment. However, oncologists often have overly optimistic prognoses and miss timely GoC discussions. Clinical notes are a valuable source of information, but processing and extracting data from them is time-consuming and labor-intensive. To address this issue, we have developed a machine learning application that ingests clinical notes and structured data from electronic health records (EHRs) to generate a 180-day mortality risk, prompting oncologists for GoC conversations. Methods: A predictive machine learning model was developed using data from cancer patients aged 21 and above, diagnosed between January 2016 and December 2021. Data was collected from various sources, including cancer and death registry and the EHR. By analyzing structured and unstructured data from ambulatory progress notes, a clinical profile was created for each patient. The model utilized Spark-NLP for preprocessing, applying word2vec embedding and pre-trained NER models to extract information on diseases, symptoms, procedures, treatments, and medications. Feature engineering techniques were used to select the best NLP features, combined with structured data. The model was trained using 894 patients, employing Random Forest Classifier with 10-fold cross-validation, and tested on a separate set of 43,274 patients. Performance evaluation included ROC AUC, PR AUC, and F1 Score metrics. Results: After the fine tuning, the best model showed an AUC-ROC of 0.88 on the train set and 0.75 on the test set. At a threshold of 0.44, the model achieved a balanced performance with a sensitivity of 0.70 and specificity of 0.71 on the testing set. Conclusions: Our team pioneered the development of an automated multi-modality pipeline that combines unstructured real-world data with structured data, allowing for training and testing of a fusion model. This automation opens doors for scaling and dissemination, to enhance mortality prediction. Future works will involve qualitative analysis of implementation and acceptance in clinical practice.

Non-elective inpatient anti-cancer therapy for solid tumors: To treat or not to treat?

234 Background: Administration of anti-cancer therapy to hospitalized patients is associated with greater treatment-related complications and reduced quality of life. We designed and implemented a standardized process to review all non-elective systemic anti-cancer therapy in solid-tumor patients with the goal of reducing aggressive end of life care and improving quality. Methods: A multidisciplinary group of quality and safety, pharmacy, physician, and nursing leadership designed a workflow to standardize the review of all inpatient anti-cancer treatment requests for non-elective solid-tumor (NEST) patients. Our NEST process begins with a formal pharmacy and nursing review, which can flag a case for further physician review. The pharmacist reviews for adequate hematologic counts, hepatic function, creatinine clearance as well as any active infections requiring IV antibiotics. Then the nursing review assesses treatment plan parameters, patient’s performance status, recent vital signs, and other clinical concerns. If either review flags one or more criteria, the case then goes to physician review. The NEST escalation process includes two levels of physician review – a single reviewer and a committee. If the review determines that there are more potential benefits than risks associated with administering anti-cancer treatment, the treatment can be approved for inpatient administration. However, if the formal review estimates significantly greater risk than potential benefit, the treatment will not be approved for inpatient administration. Results: A total of 58 requests for inpatient anti-cancer therapy occurred between initial implementation (10/31/2022) through 3/31/2023. 82.8% (48/58) were reviewed by both pharmacy and nursing and 45.8% of those were approved without need to escalate. The remaining requests had baseline patient characteristics that triggered physician review - with 13 reviewed by a single physician and 3 requiring committee review. Of the cases requiring further review, 5 did not receive their requested therapy (either denied or the family decided to not pursue treatment). 36.2% (21/58) of NEST patients died within 60 days of process initiation, 22.4% (13/58) died within 30 days, and 13.8% (8/58) died within 10 days. These outcomes were more common in individuals where NEST was denied or inpatient treatment was not pursued (77.8% died within 60 days, 44.4% died within 10 days; note 2 patients discharged to hospice with no death date on record). Conclusions: We designed a formal review process for anti-cancer therapy to be administered in the inpatient setting to solid tumor patients. This multi-disciplinary review led to 15.5% of requests not being administered to patients. Ongoing continuous improvement work focuses on further developing review criteria, exploring options for hard stops prior to treatment administration and increasing earlier goals of care discussions.

Spiritual care support of goal concordant care in the oncologic emergency setting.

274 Background: Many patients admitted through emergency departments are near the end of life. Patients who have previously indicated that they do not wish for advanced resuscitation efforts are often admitted to the hospital with a presumption of full code status. Documentation of goals of care discussions (GOC) increases the likelihood of receiving goal concordant care during the ensuing hospitalization. In the fast-paced environment of emergency care, physicians often hesitate to introduce these critical conversations. Healthcare has evolved beyond the physician–patient dyad, it includes a variety of professions. A multi-disciplinary team including physicians, nursing, social work, and spiritual care providers (SCPs) was established to improve compliance of documenting goals of care. Methods: This quality improvement project was initiated in the institution's Acute Cancer Care Center. SCPs, a previously underutilized resource, were enlisted to assist in GOC discussions and advance care planning (ACP) documentation on patients who had previously elected do not resuscitate/do not intubate (DNR/DNI) status. The goal was to increase ACP documentation for these patients by 50% over baseline. The project employed a Plan-Do-Study-Act technique. Patients who had a history of DNR/DNI were automatically identified upon arrival to emergency care based on any of 4 criteria extracted from the electronic medical record: 1) History of DNR order within the past year; 2) advance care plan notes documenting the patient is not “full code”; 3) out of hospital DNR; and 4) previous discharge to hospice. Track boards were updated across multiple disciplines (attending physicians, SCPs, nursing and social work) to identify these patients. SCPs rounded on identified patients who were expected to be admitted based on discussions with nurses/attending physicians. They met with patients to provide support while confirming/updating their goals of care. This allowed attending providers to more easily confirm the patient’s wishes and place appropriate documentation/orders. The project took place during May 2023, using April 2023 as baseline data. Results: The goal of a 50% increase in ACP compliance was exceeded. In the month of April, 25 of 131 identified patients had ACP notes. In May 55 of 151 identified patients had ACP documentation. This represents a relative 89% increase in ACP documentation. An increase in DNR orders was also noted (table). Conclusions: SCPs can serve as a resource for establishing and documenting goals of care for patients in the emergency care setting. Collaborating with SCPs can increase compliance with local and national GOC initiatives.[Table: see text]

Impact of early palliative care on healthcare utilization in patients with advanced lung cancer in the final year of life.

239 Background: The benefits of early palliative care (PC) in advanced lung cancer are well established, including both increased quality of life and decreased hospital costs at end-of-life. We performed a quantitative and preliminary qualitative analysis on end-of-life healthcare utilization of patients with advanced lung cancer in their final year of life to explore the impact of early vs. late PC. Methods: We retrospectively reviewed claims and clinical data of 54 patients with advanced lung cancer who died between 2021 and 2022 under Northwestern Medicine’s Accountable Care Organization. We classified patients as having received PC if a diagnosis code (Z51.5) appeared in claims data or if the patient’s treatment team included a PC specialist. We identified patients as having received “early” PC if their first PC visit was 90 or more days before death. Statistical analysis was performed with Fisher exact tests. Results: Forty-three (80%) patients had a PC code on claims data, while 38 (70%) had a PC team member identified within the electronic medical record. Patients receiving PC were less likely to visit the emergency department in their last 6 months of life (71% vs. 94%, p = 0.03) and more likely to utilize hospice (53% vs. 44%, p = 0.27) compared to patients without PC. Patients receiving early vs. late PC were more likely to have initiated PC as an outpatient (67% vs. 31%, p = 0.02), more likely to utilize hospice (57% vs. 44%, p = 0.21), more likely to have shorter intensive care unit stays in their last month of life (average of 10 vs. 25 days), and significantly less likely to undergo systemic treatment in their last 30 days of life (24% vs. 56%, p = 0.02) or die in the hospital (29% vs. 56%, p = 0.04). From a preliminary qualitative review, patients receiving early PC may have engaged in increased communication about clinical prognosis and goals of care, while their PC teams provided more detailed documentation of conversations about end-of-life wishes and advanced directives. Conclusions: Our data demonstrate a difference in end-of-life healthcare utilization between patients who received early vs. late PC. Limitations of this study include its small sample size and the nature of retrospective cohort studies. Qualitative evaluation is ongoing to investigate the impact of early oncologist-driven goals of care discussions on end-of-life healthcare utilization as well as moderators of early palliative care’s positive impact.

Engagement of patients with advanced cancer (EPAC) randomized clinical trial: Long-term effects on survival and healthcare use.

76 Background: The Engagement of Patients with Advanced Cancer (EPAC) randomized Veterans with newly diagnosed stage 3 or 4 cancer or recurrent disease to usual care (control) or usual care with 6-month community health worker (CHW) support (intervention) to engage Veterans in end-of-life (EOL) goals of care discussions. At 6- and 15-months follow-up, the intervention tripled goals of care documentation (primary), doubled hospice (secondary), and reduced end-of-life (EOL) acute care use (secondary) and total costs (secondary). This post-hoc analysis after 10 years from study initiation evaluates effects on overall survival (OS) and EOL healthcare use and costs. Methods: We abstracted dates of death, emergency department (ED), hospitalization, palliative care (PC), hospice use, and costs within and outside Veterans Affairs (VA) using electronic health record and claims before data cut-off on February 1, 2023 for all EPAC participants. We compared OS using Kaplan Meier and log-rank, risk of death using Cox-proportional hazard models, ED, hospitalization, PC, hospice use and costs in the last 30 days of life using Logistic Regression, and incidence rate ratios of ED and hospitalizations using Poisson regression. Results: Among 213 participants, there were no imbalances in demographic or clinical characteristics. 165 (77.4%) were White, 211 (99%) males, 80 (37.6%) had lung cancer, and 118 (55.3%) had stage 4 disease. Median follow-up was 298 days (range 12-3438). Intervention group participants had greater OS (log rank p=0.03), 25% reduction in risk of death, lower acute care use, greater PC and hospice, and lower total costs (p<0.001) than control group participants. Conclusions: The CHW-led intervention significantly improved OS and maintained robust effects on EOL healthcare use and costs. Results support integration of CHWs into care to improve clinical outcomes. Clinical trial information: NCT02966509 .[Table: see text]

Cost-of-care discussions for individuals with newly diagnosed advanced non-small cell lung cancer and melanoma: Findings from a population-based study.

3 Background: Growing costs of cancer care can result in patient financial hardship and many professional organizations, including the American Society for Clinical Oncology, recommend patient-physician discussions about expected treatment costs as part of high-quality care. Documentation of these discussions is critical as even privately insured patients may find care unaffordable without additional assistance. This study examined medical records of individuals diagnosed with advanced non-small cell lung cancer (NSCLC) and melanoma, cancers with recently approved expensive treatment options, for documentation of cost discussions. Methods: Individuals newly diagnosed 2017-2018 with stage III/IV NSCLC (n = 1767) and melanoma (n = 689) in participating SEER regions were randomly selected for the population-based National Cancer Institute Patterns of Care study. Medical records were reviewed for reported cost discussions; terms used and record location were abstracted. Patient-, treatment- and hospital- factors, including age, sex, race/ethnicity, comorbidities, and health insurance coverage, were examined for associations with cost discussions in multivariable logistic regression analyses. Results: Cost discussions were documented in the medical records of 24.6% of NSCLC and 25.5% of melanoma patients. “Out-of-pocket costs”, “patient assistance plan”, and “inability to pay” were most commonly used terms. Cost discussions were most frequently noted in physician or nursing progress notes and assessment plans. Documentation of cost discussions varied little by patient and hospital factors. In adjusted analyses, privately insured (vs. publicly insured) patients were less likely to have documented cost discussions (odds ratio (OR) = 0.54; 95% CI:0.37-0.80). Patients who did not receive systemic therapy or did not receive any cancer-directed treatment were less likely to have documented cost conversations than patients who received systemic therapy (OR = 0.39; 95% CI:0.19-0.81 and OR = 0.46; 95% CI:0.30-0.70, respectively). Conclusions: Cost discussions were infrequently documented in medical records of patient with newly diagnosed advanced NSCLC and melanoma; variability in documentation may hinder identifying this information and tracking referrals to address patients’ financial needs. The findings underscore the importance of systematic documentation of cost of care discussions to ensure high quality care for all patients.

A16‘Not being afraid of saying dying’: sharing key vocabulary for palliative care discussions through simulation debrief

Simulation as a learning platform is recognized internationally as beneficial in terms of education, training and assessment of doctors [1,2]. This study aimed to introduce and evaluate a novel Palliative Medicine simulation session as a tool for Foundation Year 2 (FY2) doctors to gain competency and confidence in the assessment and management of life-limiting illness. We designed the palliative care (PC) simulation session based on the FY2 curriculum. The three scenarios involved management of opioid toxicity, breaking bad news and shared decision-making with a role-play patient with a gastrointestinal bleed. Session faculty included a mix of healthcare professionals, but always included a PC specialist. We evaluated the session using a pre- and post-session questionnaire collecting data using 5-point Likert scales and free-text comments. We analysed qualitative data using content analysis. Researcher and methodological triangulation increased the credibility of the findings. The three prevalent themes noted from the pre-content analysis were Communication, Prognostication and the Process of complex decision-making. Comments such as ‘Senior colleagues hesitant to have escalation discussions’ and ‘I find it difficult when the patient has a very different idea of how poorly they are’ were examples of quotes given by candidates as pre-session challenges. 95.6% of our candidates felt that the session addressed these challenges, mainly through the debrief process. The main learning points articulated were in relation to prescribing and communication skills. Candidates expressed the importance of ‘picking up communication techniques and phrases’. The debrief was the most highly valued, and frequently mentioned positive element of the content analysis. ‘Open discussions’ was mentioned on numerous occasions, ‘I felt comfortable asking questions’ and ‘Discussion after SIM was very useful’, all support the importance of skilled debrief. FY2 doctors identified communication as their biggest concern when managing Palliative Care patients. Our session addressed this through open and frank debrief discussion. This allowed reflection on previous experience and peer-to-peer learning of key vocabulary when talking to patients with a limited prognosis. Further qualitative evaluation of the impact of this session on clinical practice and how peer learning could be incorporated into day-to-day skills development on the wards would be of value. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Practical Questions About Rescue Medications for Acute Treatment of Seizure Clusters in Children and Adolescents with Epilepsy in the USA: Expanding Treatment Options to Address Unmet Needs.

Epilepsy is a common pediatric neurological condition, affecting approximately 470,000 children in the USA and having a prevalence of 0.9% in the global population of approximately 2.6 billion children. Epilepsy is associated with disruptions in several areas of a child's life, including medical burden, quality of life, cognitive outcomes, and higher risk of mortality. Additionally, some pediatric patients may experience acute seizure emergencies such as seizure clusters (also called acute repetitive seizures), which are intermittent increases in seizure activity that differ from the patient's usual seizure pattern and may occur despite daily antiseizure drug administration. Seizure clusters increase a patient's risk for status epilepticus and emergency room visits. Benzodiazepines are the main category of drugs used as acute seizure therapies for seizure clusters. This narrative review provides a practical discussion of care for pediatric patients with epilepsy and seizure clusters exploring such topics as details about the US Food and Drug Administration-approved acute seizure therapies, safety and ease of use of these medications, benefits of seizure action plans to help ensure optimal treatment, and considerations for transitioning a pediatric patient with acute seizure therapy to adult healthcare management.

Challenges in Deprescribing among Older Adults in Post-Acute Care Transitions to Home

ObjectivesMedications with a higher risk of harm or that are unlikely to be beneficial are used by nearly all older patients in home health care (HHC). The objective of this study was to understand stakeholders’ perspectives on challenges in deprescribing these medications for post-acute HHC patients. DesignQualitative individual interviews were conducted with stakeholders involved with post-acute deprescribing. Setting and ParticipantOlder HHC patients, HHC nurses, pharmacists, and primary/acute care/post-acute prescribers from 9 US states participated in individual qualitative interviews. MeasuresInterview questions were focused on the experience, processes, roles, training, workflow, and challenges of deprescribing in hospital-to-home transitions. We used the constant comparison approach to identify and compare findings among patient, prescriber, and pharmacist and HHC nurse stakeholders. ResultsWe interviewed 9 older patients, 11 HHC nurses, 5 primary care physicians (PCP), 3 pharmacists, 1 hospitalist, and 1 post-acute nurse practitioner. Four challenges were described in post-acute deprescribing for HHC patients. First, PCPs' time constraints, the timing of patient encounters after hospital discharge, and the lack of prioritization of deprescribing make it difficult for PCPs to initiate post-acute deprescribing. Second, patients are often confused about their medications, despite the care team's efforts in educating the patients. Third, communication is challenging between HHC nurses, PCPs, specialists, and hospitalists. Fourth, the roles of HHC nurses and pharmacists are limited in care team collaboration and discussion about post-acute deprescribing. Conclusions and ImplicationsPost-acute deprescribing relies on multiple parties in the care team yet it has challenges. Interventions to align the timing of deprescribing and that of post-acute care visits, prioritize deprescribing and allow clinicians more time to complete related tasks, improve medication education for patients, and ensure effective communication in the care team with synchronized electronic health record systems are needed to advance deprescribing during the transition from hospital to home.

Identifying Factors Associated With Code Status Changes After Emergency General Surgery

IntroductionSurgical emergencies are time sensitive. Identifying patients who may benefit from preoperative goals of care discussions is critical to ensuring that operative intervention aligns with the patient’s values. We sought to identify patient factors associated with acute changes in a patient’s goals using code status change (CSC) as proxy. MethodsA retrospective analysis of single-institution data for patients undergoing urgent laparotomy was performed. Patients were stratified based on whether a postoperative CSC occurred. Parametric, nonparametric, and regression analyses were used to identify variables associated with CSC. ResultsOf 484 patients, 13.8% (n = 67) had a postoperative CSC. Patients with postoperative CSC were older (65 versus 60 years, P < 0.001). Odds of CSC were significantly higher in patients who were transferred between facilities (odds ratio [OR] 2.1), had a higher Charlson Comorbidity Index (3-4: OR 3.9, 5+: OR 6.8), and had a higher quick sequential organ failure assessment score (2: OR 5.0; 3: OR 38.7). Patients with anemia (OR 1.9) and active cancer (OR 3.0) had higher odds of CSC. ConclusionsTimely intervention in emergency general surgery may result in high-risk interventions and subsequent complications that do not align with a patient’s goals and values. Our analysis identified a subset of patients who undergo surgery and have a postoperative CSC leading to transition to comfort-focused care. In these patients, a pause in clinical momentum may help ensure operative intervention remains goal concordant.

Using the Kipling method to explore the contextual factors of decision-making during advance care planning for older cancer patients, their family, and health-care professionals: A qualitative secondary analysis.

Advance care planning (ACP) interventions are supposed to affect patients' autonomy and family health-care outcomes positively. However, the clinical benefits of ACP actualization and associated contextual factors merit questioning. Therefore, this study explores the critical contextual and procedural factors related to ACP decision-making based on the actual situation of older patients with cancer encountering end-of-life care in Taiwan. This retrospective qualitative secondary analysis used the Kipling method (5W1H) to explore further the critical contextual and procedural factors related to ACP decision-making processes. We applied thematic analysis and dual coding for 35 narratives, including 10 patients with cancer, 10 family caregivers, and 15 health-care staff, derived from a preliminary qualitative study regarding palliative care decision-making among patients with advanced cancer, their families, and health-care staff. We identified 6 domains detailing the contextual factors for ACP decision-making: (1) WHO (decision makers); (2) WHAT (discussion content); (3) WHEN (care plan for which disease stage); (4) WHERE (patient's situational location); (5) WHY (reasons underpinning the decisions); and (6) HOW (the way to form the decisions). Using the Kipling method to elaborate the contextual factors for ACP decision-making among older patients with cancer strengthens the understanding of complicated end-of-life care decision-making procedure. This study also demonstrates the dynamic and cultural complexity and the various factors considered during end-of-life care and future ACP discussion.

The roles and experiences of medical interpreters in palliative care: A narrative review.

Skilled medical interpreters are essential to providing high-quality, culturally sensitive palliative care and addressing health-care disparities for patients with limited English proficiency (LEP). While the benefits of utilizing medical interpreters are well documented, interpreter roles and experiences in palliative care are unique and poorly defined. This narrative review examines the extant literature on medical interpreters in palliative care to define their unique roles and describe their experiences and recommendations. A narrative literature review was completed through systematically searching the following databases: Medline, Embase, Web of Science, and CINHAL. Title and abstract screening was completed, followed by full-text review. Ten articles met inclusion criteria and were included in the review. Medical interpreters play several roles in palliative care for patients with LEP including interpreting language and meaning, acting as a cultural broker, and advocating for patients and families. Medical interpreters report being comfortable interpreting palliative care discussions; however, they face challenges in navigating their complex roles and the emotional impact of palliative care encounters. Their recommendations to improved palliative care encounters involving medical interpreters are careful language choice, holding pre- and post-meetings, education for interpreters and health-care professionals, and further integrating the medical interpreter into the interprofessional team. Medical interpreters play several complex roles when participating in palliative care encounters for patients with LEP. Understanding these roles and the experiences allows medical interpreters to be better integrated into the interprofessional team and enhances the ability to provide quality, culturally sensitive palliative care for patients with LEP. Further research is required to understand how implementing the recommendations of medical interpreters impacts patient outcomes.

Mild traumatic brain injury: not always a mild injury.

In general, risk of mortality after trauma correlates with injury severity. Despite arriving in relatively stable clinical condition, however, some patients are at risk of death following mild traumatic brain injury (TBI). The study objective was delineation of patients who die in-hospital following mild isolated TBI in order to inform Emergency Department (ED) disposition and care discussions with patients and families. In this retrospective cohort study, patients from the National Trauma Data Bank (NTDB) (2007-2018) were included if they were injured by blunt trauma and sustained a mild TBI (defined as Head Abbreviated Injury Scale [AIS] score of 1 or 2 and arrival Glasgow Coma Scale [GCS] score of 13-15). Exclusions were severe associated injuries (extracranial AIS > 2); transfers; and missing data. Patients were defined by in-hospital mortality: Survivors vs. Mortalities. Demographics, clinical/injury data, and the outcomes were collected and compared with univariate analysis. Multivariate analysis established independent factors associated with in-hospital mortality following mild TBI. In total, 932,107 patients (10% of NTDB population) met study criteria: 928,542 (99.6%) Survivors and 3,565 (0.4%) Mortalities. In general, comorbidities (including home anticoagulation, cardiac disease, and diabetes mellitus) were significantly more common among patients who died (p < 0.001), although drug and alcohol intoxication on arrival were more common among Survivors (16% vs. 7%, p < 0.001; 13% vs. 10%, p < 0.001). In terms of insurance status, Private/Commercial insurance was more common among Survivors (39% vs. 20%, p < 0.001) while Governmental Insurance was more common among Mortalities (55% vs. 36%, p < 0.001). On multivariate analysis, age ≥ 65 was most strongly associated with death (OR 26.43, p < 0.001), followed by ED intubation (OR 10.08, p < 0.001), admission hypotension (OR 4.55, p < 0.001), and comorbidities, particularly end-stage renal disease (ESRD) (OR 3.03, p < 0.001) and immunosuppression (OR 2.18, p < 0.001). Survivors differed substantially from Mortalities after mild TBI in terms of comorbidities, intoxicants, and insurance status. Independent variables most strongly associated with in-hospital death following mild head injury included age ≥ 65, intubation in the ED, admission hypotension, and comorbidities (particularly ESRD and immunosuppression). Increased clinical vigilance, including a mandatory period of clinical observation, for patients with these risk factors should be considered to optimize outcomes and potentially mitigate death after mild TBI.

Quantifying EHR and Policy Factors Associated with the Gender Productivity Gap in Ambulatory, General Internal Medicine

BackgroundThe gender gap in physician compensation has persisted for decades. Little is known about how differences in use of the electronic health record (EHR) may contribute.ObjectiveTo characterize how time on clinical activities, time on the EHR, and clinical productivity vary by physician gender and to identify factors associated with physician productivity.Design, Setting, and ParticipantsThis longitudinal study included general internal medicine physicians employed by a large ambulatory practice network in the Northeastern United States from August 2018 to June 2021.Main MeasuresMonthly data on physician work relative value units (wRVUs), physician and practice characteristics, metrics of EHR use and note content, and temporal trend variables.Key ResultsThe analysis included 3227 physician-months of data for 108 physicians (44% women). Compared with men physicians, women physicians generated 23.8% fewer wRVUs per month, completed 22.1% fewer visits per month, spent 4.0 more minutes/visit and 8.72 more minutes on the EHR per hour worked (all p < 0.001), and typed or dictated 36.4% more note characters per note (p = 0.006). With multivariable adjustment for physician age, practice characteristics, EHR use, and temporal trends, physician gender was no longer associated with productivity (men 4.20 vs. women 3.88 wRVUs/hour, p = 0.31). Typing/dictating fewer characters per note, relying on greater teamwork to manage orders, and spending less time on documentation were associated with higher wRVUs/hour. The 2021 E/M code change was associated with higher wRVUs/hour for all physicians: 10% higher for men physicians and 18% higher for women physicians (p < 0.001 and p = 0.009, respectively).ConclusionsIncreased team support, briefer documentation, and the 2021 E/M code change were associated with higher physician productivity. The E/M code change may have preferentially benefited women physicians by incentivizing time-intensive activities such as medical decision-making, preventive care discussion, and patient counseling that women physicians have historically spent more time performing.

Palliative Care in Survivors of Critical Illness: A Qualitative Study of Post-Intensive Care Unit Program Clinicians.

Background: Survivors of critical illness experience high rates of serious health-related suffering. The delivery of palliative care may assist in decreasing this burden for survivors and their families. Objectives: To understand beliefs, attitudes, and experiences of post-intensive care unit (ICU) program clinicians regarding palliative care and explore barriers and facilitators to incorporating palliative care into critical illness survivorship care. Design: Qualitative inquiry using semistructured interviews and framework analysis. Results were mapped using the Consolidated Framework for Implementation Research. Setting/Subjects: We interviewed 29 international members (United States, United Kingdom, Canada) of the Critical and Acute Illness Recovery Organization post-ICU clinic collaborative. Results: All interprofessional clinicians described components of palliative care as essential to post-ICU clinic practice, including symptom management, patient/family support, facilitation of goal-concordant care, expectation management and anticipatory guidance, spiritual support, and discussion of future health care wishes and advance care planning. Facilitators promoting palliative care strategies were clinician level, including first-hand experience, perceived value, and a positive attitude regarding palliative care. Clinician-level barriers were reciprocals and included insufficient palliative care knowledge, lack of self-efficacy, and a perceived need to protect ICU survivors from interventions the clinician felt may adversely affect recovery or change the care trajectory. System-level barriers included time constraints, cost, and lack of specialty palliative care services. Conclusion: Palliative care may be an essential element of post-ICU clinic care. Implementation efforts focused on tailoring strategies to improve post-ICU program clinicians' palliative care knowledge and self-efficacy could be a key to enhanced care delivery for survivors of critical illness.

FRI226 Ectopic Cushing’s Syndrome Of Unknown Primary Origin With Etomidate Use

Abstract Disclosure: C. Ohammah: None. J. Lloyd: None. T. Abdulwahid: None. R. Tangri: None. C. Musgrove: None. K. Selk: None. Background: Ectopic Cushing's syndrome (ECS) is rare and requires adrenolytic agents to control hypercortisolism until a definitive plan can be made to treat the underlying cause. We present a case of ECS of unknown primary origin causing immunosuppression due to the hypercortisolism that responded with etomidate infusion. Case: A 61-year-old male who presented to the hospital after a few weeks of increasing weakness, dyspnea, and hemoptysis. In the months prior to his admission, he was found to have persistent hypokalemia, COVID pneumonia, and new onset diabetes mellitus. On admission, his examination was remarkable for proximal hip flexor weakness. Labs were significant for metabolic alkalosis, hyperglycemia (A1c 7.7%) and persistent hypokalemia requiring about 300 mEq of potassium daily. CT chest, abdomen and pelvis was remarkable for aspiration pneumonia, vertebral compression fracture, and bilateral adrenal enlargement. Blood cultures grew Staphylococcus Aureus (MSSA) (suspected lung source) and Candida albicans. Treatment with vancomycin and caspofungin was initiated and narrowed to cefazolin after speciation. His MSSA cleared rapidly however, fungemia was persistent after 1.5 weeks of treatment. MRI brain was unremarkable for causative lesion. Further testing revealed elevated morning cortisol (136.2ug/dL) confirmed on repeated testing and elevated ACTH (653pg/mL). Serum metanephrines were normal. A high-dose dexamethasone suppression was unremarkable. In the following days, he developed respiratory failure secondary to a spontaneous hemothorax requiring intubation and ICU admission. He was started on an etomidate infusion given abnormal liver enzymes and unavailability of metyrapone. The infusion was titrated every 6 hours based on cortisol levels. His liver enzymes improved and ketoconazole was added but later discontinued due to development of thrombocytopenia. His cortisol level decreased (21.5ug/dL) and fungemia cleared. Arrangement for bilateral adrenalectomy was made but the patient decompensated and developed shock requiring pressors. After a goals of care discussion, he was transitioned to comfort measures and eventually passed. Conclusion: ECS is rare, and the diagnosis is challenging and often delayed. Ectopic ACTH can result from various malignancies. Medical management with adrenolytic agents should be considered early in the management of ECS until a definitive plan is made. Etomidate, ketoconazole, metyrapone, and mitotane can be used to treat hypercortisolism to achieve medical adrenalectomy. Bilateral adrenalectomy should be considered in patients without adequate response to adrenolytic agents. This case describes the severity of hypercortisolism from an ectopic ACTH production causing refractory hypokalemia and immunosuppression resulting in fatal infections. We highlight the use of etomidate to control hypercortisolism. Presentation: Friday, June 16, 2023

FRI416 Primary Hyperaldosteronism in Pregnancy

Abstract Disclosure: S.M. Seav: None. M. Basina: None. Background: Primary hyperaldosteronism is extremely rare in pregnancy. Since 1962, only approximately 30 cases have been reported in the literature.1 Clinical Case: A 40-year-old female was referred for work-up of primary hyperaldosteronism (PHA). She was first diagnosed with hypertension (HTN) at age 29 during her first pregnancy. Laboratory work-up was consistent with PHA: serum aldosterone 22.6 ng/dL, renin activity 0.1 ng/mL/hr, aldosterone:renin ratio of 226. Post-saline infusion aldosterone level was 10.7 ng/dL. Adrenal CT scan showed a 6mm left-sided adenoma. Surgery was not recommended because adrenal vein sampling did not show lateralization. She was started on Spironolactone 25 mg/day. Despite the significant pregnancy risks, patient continued to desire conception and was switched to Labetolol. She was lost to follow-up and returned to the emergency room for dizziness at 26 weeks pregnant with twins with BP 180/109 mmHg. She had not been taking any anti-hypertensives and there was evidence of severe fetal growth restriction in both babies. After a goals of care discussion, patient deferred emergent C-section and suffered intrauterine fetal demise on hospital day 9. Conclusion: PHA in pregnancy is rare and difficult to diagnose and manage. Newer studies estimate that &amp;gt; 5-10% of patients with HTN have PHA.2 Hence, maintaining high vigilance of this disease in pregnant patients is even more imperative, including screening for PHA during pre-conception period in hypertensive women. A systematic review of 38 cases of PHA in pregnancy showed that 19% of cases were diagnosed with HTN prior to pregnancy without PHA screening.1 The average age of women in this study was 29.8 years. Additionally, there is a correlation in women with younger age at diagnosis and having unilateral PHA, in which case adrenalectomy should be performed prior to conception.3 In pregnancy, first line anti-hypertensive therapies include alpha methyl dopa, labetolol, and nifedipine. In PHA, diuretics such as amiloride and mineralocorticoid receptors should also be considered if BP is not at goal. Spironolactone and eplerenone have been safely used in pregnancy with both male and female fetuses.1,4 If surgery is not an option and medical therapy is ineffective, then physicians should have a low threshold to admit patients for close BP monitoring. 1Landau, et al. Primary Aldosteronism and Pregnancy. Annales d’Endocrinologie. 2016;77:148–160 2Funder, et al. Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(5):1889–1916 3Akasaka, et al. Sex Difference in the Association Between Subtype Distribution and Age at Diagnosis in Patients With Primary Aldosteronism. Hypertension. 2019;74(2):368-374 4Cabassi, et al. Eplerenone Use in Primary Aldosteronism in Pregnancy. Hypertension. 2012;59:e18-e19 Presentation: Friday, June 16, 2023