Care In Patient Population Research Articles

Use of Multiplex Molecular Panels to Diagnose Urinary Tract Infection in Older Adults

Multiplex molecular syndromic panels for diagnosis of urinary tract infection (UTI) lack clinical data supporting their use in routine clinical care. They also have the potential to exacerbate inappropriate antibiotic prescribing. To describe the frequency of unspecified multiplex testing in administrative claims with a primary diagnosis of UTI in the Medicare population over time, to assess costs, and to characterize the health care professionals (eg, clinicians, laboratories, physician assistants, and nurse practitioners) and patient populations using these tests. This cohort study used Centers for Medicare & Medicaid Services (CMS) claims data for Medicare beneficiaries. The study included older community-dwelling adults and nursing home residents with fee-for-service Medicare Part A and Part B benefits from January 1, 2016, to December 31, 2023. Multiplex syndromic panels were identified using carrier claims (ie, claims for clinician office or laboratory services). The annual rate of claims was measured for multiplex syndromic panels with a primary diagnosis of UTI per 10 000 eligible Medicare beneficiaries. The performing and referring specialties of health care professionals listed on claims of interest and the proportion of claims that occurred among beneficiaries residing in a nursing home were described. Between 31 110 656 and 36 175 559 Medicare beneficiaries with fee-for-service coverage annually (2016-2023) were included in this study. In this period, 1 679 328 claims for UTI multiplex testing were identified. The median age of beneficiaries was 77 (IQR, 70-84) years; 34% of claims were from male beneficiaries and 66% were from female beneficiaries. From 2016 to 2023, the observed rate of UTI multiplex testing increased from 2.4 to 148.1 claims per 10 000 fee-for-service beneficiaries annually, and the proportion of claims that occurred among beneficiaries residing in a nursing home ranged from 1% in 2016 to 12% in 2020. In addition to laboratories or pathologists, urology was the most common clinician specialty conducting this testing. The CMS-assigned referring clinician specialty was most frequently urology or advanced practice clinician for claims among community-dwelling beneficiaries compared with internal medicine or family medicine for claims among nursing home residents. In 2023, the median cost of a multiplex test in the US was $585 (IQR, $516-$695 for Q1-Q3), which was more than 70 times higher than the median cost of $8 for a urine culture (IQR, $8-$16 for Q1-Q3). This cohort study of Medicare beneficiaries with fee-for-service coverage from 2016 to 2023 found increasing use of emerging multiplex testing for UTI coupled with high costs to the Medicare program. Monitoring and research are needed to determine the effects of multiplex testing on antimicrobial use and whether there are clinical situations in which this testing may benefit patients.

Abstract B021: Quitxt research study: A mobile messaging intervention to promote smoking cessation among young adult smokers in South Texas

Abstract Background: Despite major advances in tobacco control and treatment, tobacco use remains the single largest preventable cause of morbidity and mortality in the US. Smoking prevalence is highest among Texas young adults (ages 18-29), especially those with lower education and income and those living in rural areas, like Latinos. About 19.2% of Latinos ages 18-29 in the study areas are current smokers, putting them at higher risk of cancer and other tobacco-related morbidity and mortality. Young adults are heavy users of smartphones, text messaging, social media chats, and other mobile social media, providing a remarkable opportunity for innovation in the delivery of health promotion interventions to reduce health disparities in this large and rapidly growing racial/ethnic population. This research study aims to assess the effectiveness of Quitxt, our culturally appropriate mobile smoking cessation program. Quitxt – launched by our interdisciplinary research team using proven social cognitive, motivational interviewing, and brief intervention methods for promoting behavior change – blends bilingual text and social media messaging for smoking cessation tailored to the language and culture of young adult smokers in our vulnerable region of South Texas. The team also adapted the program to the Primary Care and Mays Cancer Center patient population, and it is currently being implemented. Quitxt has not been tested in a research study, as its creation as an evidence-based cancer prevention service for young adult smokers was supported by the Cancer Prevention and Research Institute of Texas. Methods: The proposed 5-year study involves a 2-group parallel randomized controlled trial with 4 assessments (baseline, 1, 3, and 6 months) and will recruit 1,200 young adult Latino smokers: 1)The intervention group will receive Quitxt (text messaging or chat); and 2) the usual care group will receive abbreviated text messaging with health promotion-related content, including smoking cessation and referral to the Texas DSHS cessation program YesQuit. Smoking cessation will be validated via biological tests for those who report smoking cessation at the study follow-ups. We hypothesize that the group receiving the Quitxt intervention will achieve significantly higher smoking cessation rates than the group receiving usual care. Results: The proposed intervention will mark the first significant study to assess the effectiveness of an innovative, bilingual, culturally, and linguistically appropriate mobile cessation intervention tailored to young adult Latinos living in South Texas by enhancing their skills development, competence, and self-efficacy to initiate and maintain cessation. Conclusion: This study will advance public health by testing the effectiveness of a scalable, evidence-based, easily disseminated, and adaptable intervention with potentially broad national reach to help young adults stop smoking and reduce smoking-related cancer and chronic disease morbidity and mortality and their associated healthcare costs. Citation Format: Patricia Chalela, Vivian Cortez, Sandra Sivak, Armida Flores, Martha De La Mora, Zully Garcia, Byeongyeob Choi, Edgar Muñoz, Cliff Despres, Alfred L. McAlister, Qurathul Ahmed, Audrey Cordova, Maria I. Sung-Cuadrado, Luis F. Velez, Sahak Kaghyan, Rahul Mundlamuri, David Akopian, Amelie G. Ramirez. Quitxt research study: A mobile messaging intervention to promote smoking cessation among young adult smokers in South Texas [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B021.

Abstract A161: Racial and ethnic differences in receipt of guideline-recommended hepatocellular carcinoma surveillance in a high Risk, diverse primary care patient population: A study in two large integrated healthcare systems in California and Hawai‘i

Abstract Guideline-recommended ultrasounds for hepatocellular carcinoma (HCC) surveillance target patients with cirrhosis and certain liver conditions, yet uptake remains low, particularly among racial/ethnic minority groups. Underuse may be attributed to factors at the patient, provider, healthcare system, and neighborhood levels. However, in-depth analyses identifying contributory factors are lacking. We investigated the presence of racial/ethnic disparities in receipt of recommended surveillance among high-risk patients as a retrospective analysis of electronic health record (EHR) data from Kaiser Permanente Hawai‘i (KPHI) and Sutter Health in California, both of which serve numerous Asian American, Hispanic, Native Hawaiian (NH), other Pacific Islander (PI), and multiracial/ethnic patients. We included patients with ≥1 in-person encounter (2000-2017), no history of liver cancer, and a clinical indication of surveillance eligibility (cirrhosis, chronic hepatitis B or C, or a high FIB-4 score ≥2.67) with a minimum EHR follow-up of 18 months post-eligibility. Recommended surveillance is biannual abdominal imaging (ultrasound, CT, MRI) or alpha-1 fetoprotein tests. We categorized eligible patients as 'ever surveilled' if conducted at least once during follow-up and by the proportion of follow-up time they were up-to-date with surveillance (PTUDS). The cohort includes 54,597 patients (9,488 from KPHI; 45,109 from Sutter); current results are for the KPHI subset only. Among N=9,488 patients (median age: 52; 46% female; 26% NHW, 14% NH, 11% Filipino, 10% multiracial/ethnic) median follow-up was 91 months and 82% were surveilled at least once, with a mean PTUDS of 14% (SD=19%) overall and 19% (SD=21%) among the surveilled. We used sex- and age-adjusted log-risk regression for risk ratio (RR) of ‘ever surveilled’ vs. not and linear regression for PTUDS; NHW is the reference group in all models. We found that NH (RR=0.96, 95%CI 0.93-1.00), PI (RR=0.91, 95%CI 0.97-0.95) and multiracial/ethnic (RR=0.95, 95%CI 0.91-0.99) patients were significantly less likely to be ever surveilled, and that PI (beta=-0.02, 95% CI -0.04-0.01) race/ethnicity was significantly associated with lower PTUDS, while Chinese (beta=0.04, 95% CI 0.02-0.06), Korean (beta=0.04, 95%CI 0.01-0.07), Vietnamese (beta=0.05, 95%CI 0.02-0.09), and other Asian (beta=0.03, 95%CI 0.00-0.07) ethnicities were significantly associated with higher PTUDS. Although not statistically significant, surveillance rates were lower for American Indian/Alaska Native and Black groups, and higher for Japanese and Non-Hispanic Other race/ethnicity groups. Continued analyses will incorporate Sutter data, employ fully adjusted models with clustering by health system, and examine patient, provider, and neighborhood drivers of these disparities. Our findings indicate racial/ethnic disparities in HCC surveillance receipt, particularly noting the heterogeneity within Asian populations, and underscore the importance of analyzing disaggregated data for Asian American groups to fully understand and address these disparities. Citation Format: Enyao Y. Zhang, Mindy DeRouen, Alison J. Canchola, Aly M. Cortella, Pushkar Inamdar, Janet N. Chu, Sixiang Nie, Mai Vu, Ma Somsouk, Michele M. Tana, Anna D. Rubinsky, Iona Cheng, Mi-Ok Kim, Mark Segal, Chanda Ho, Yihe G. Daida, Su-Ying Liang, Hashem B. El-Serag, Scarlett L. Gomez, Salma Shariff-Marco, Caroline A. Thompson. Racial and ethnic differences in receipt of guideline-recommended hepatocellular carcinoma surveillance in a high Risk, diverse primary care patient population: A study in two large integrated healthcare systems in California and Hawai‘i [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A161.

Critical care innovations: navigating pain relief in intensive care: the role of regional anesthesia.

The purpose of this article is to provide an update of regional anesthesia and its applications in the critical care patient population. Regional anesthesia including blocks of the abdomen and thorax, head and neck, as well as upper and lower extremities can be used to alleviate pain and assist in managing life-threatening conditions such as cerebral vasospasm and ventricular storm in the ICU population. There have been many advances in these techniques including ultrasound-guidance with innovative approaches that allow for more superficial procedures that are safer for critically ill patients. Regional anesthesia can decrease hospital length of stay (LOS), prevent ICU admission, shorten ICU LOS, and increase ventilator free days and may have mortality benefits. Pain management in the ICU is an important and sometimes challenging aspect of patient care. Regional anesthetic techniques have more indications and are safe, versatile tools that should be incorporated into care of critically ill patients.

Impact of Clinician Subjectivity on the Assessment of Dry Eye Disease Prevalence in a UK Public Health Care Patient Population.

To understand the impact of subjectivity on diagnosis rates of dry eye disease (DED) in an unbiased population. A multicenter study enrolled 818 subjects with complete report forms (465 females, 67.1 ± 16.7 years, 353 males, 65.0 ± 15.9 years). Subjects were evaluated for staining, TBUT, tear osmolarity, meibomian gland disease, and OSDI. Physicians diagnosed 48.7% of subjects as having DED, ranging from 42.9% to 62.3% between sites. Positivity rates for staining (≥ grade 1) ranged from 41.3% to 84.1% (mean = 0.8 ± 0.9 grade), TBUT (<10s) ranged from 39.1% to 61.6% (mean = 10.4 ± 6.6 seconds), osmolarity (>308 mOsm/L) ranged from 63.7% to 72.4% (mean = 319.7 ± 20.8), MGD grading ranged from 28.9% to 51.3% (mean = 0.5 ± 0.7), and symptoms measured by OSDI ranged from 57.6% to 71.0% (mean = 23.5 ± 20.5) between sites. Tear osmolarity was the most consistent between sites (max/min positivity = 114%), followed by OSDI (123%), TBUT (158%), MGD (178%), and staining (204%). DED markers were uncorrelated (average r2 = 0.05 ± 0.07). A substantial number of subjects (N = 110) exhibited positive symptoms (OSDI = 32.4 ± 15.7) and hyperosmolarity (338.1 ± 20.1 mOsm/L) but no other obvious signs of DED (MGD grade = 0.2 ± 0.4, TBUT = 13.5 ± 7.0 seconds, staining grade = 0.4 ± 0.5). Subjective signs of DED varied considerably, whereas objective measurements of OSDI and osmolarity were the most consistent between sites. A large proportion of subjects exhibited high symptoms and hyperosmolarity but no other obvious signs of dry eye disease, most of whom were undiagnosed by clinical assessment without access to the osmolarity measurement.

Screening for Alcohol Use Disorder and Management of Alcohol Withdrawal Syndrome in Critical Care Patients.

Evidence-based research indicates that subjective questionnaires should be eliminated in screening for alcohol use disorder and management of alcohol withdrawal syndrome in critical care patients. However, transitioning clinicians away from these screening tools remains challenging. To improve screening for alcohol use disorder and management of alcohol withdrawal syndrome in the critical care setting by implementing an evidence-based alcohol use disorder screening tool and alcohol withdrawal syndrome protocol for critical care patients. The project site was a 17-bed adult medical intensive care unit in a large, southeastern US teaching hospital. Interventions consisted of the elimination of previously used tools such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised and implementation of the Prediction of Alcohol Withdrawal Severity Scale for alcohol use disorder screening and the Richmond Agitation-Sedation Scale and symptom-triggered benzodiazepine administration for alcohol withdrawal syndrome management. Alcohol use disorder screening among the critical care patient population increased by 49% from before to after the intervention. Of the patients at risk for withdrawal, 79% had an order for monitoring with the new intensive care unit alcohol withdrawal protocol in the postintervention group, compared with 35% who had an order for monitoring with the Clinical Institute Withdrawal Assessment for Alcohol-Revised in the preintervention group. The elimination of previously used tools and the implementation of the Prediction of Alcohol Withdrawal Severity Scale and the new intensive care unit alcohol withdrawal protocol improved alcohol use disorder screening and alcohol withdrawal syndrome management among critical care patients.

How Do Professional Associations Influence Health System Transformation? Lessons from Ontario, Canada

Introduction: Internationally, there are increasing collaborative efforts to transform health care systems in ways that align with the principles of integrated care. Within the Canadian context, the current province-wide reorganization of health care into Ontario Health Teams (OHTs) is an example of a large-scale system transformation, requiring collaboration between system stakeholders at macro-, meso- and micro-levels. Literature on the topic inter-organizational collaboration does not fulsomely consider the role of local professional associations in health system transformations. There is value in examining the role of professional associations in influencing health system transformations, as they have significant expertise and influence, particularly in the domain of health policy. &#x0D; Methods: We used a qualitative descriptive approach to explore the research question: what strategies have local professional associations used to influence the development of Ontario Health Teams? We collected data from eight, 60-minute interviews with senior level leaders from eight professional associations. Interviews were transcribed and data were analyzed using content analysis to construct four descriptive themes. &#x0D; Results: During times of health system transformation, professional associations balance the functions of: (1) supporting members, (2) negotiating with government, (3) collaborating with stakeholders, and (4) reflecting on their role. In this presentation, we focus primarily on themes #2 and #3, given the specific relevance of governance, leadership, and collaboration. In both themes, participants emphasized the importance of findings areas of alignment with the government and other stakeholders; and using shared aims as way to amplify their influence. Characteristics of a “good” collaborator included consistent demonstration of mutual respect, clear communication, and interest in building trusting relationships. Participants also described barriers to collaboration, such as power imbalances and lack of role clarity. These challenges were heightened within the context of the “low rules” OHT rollout, in which OHTs had a high degree of control in adapting their team structures to ideally meet the needs of their local care partners and patient population(s),&#x0D; Conclusion and Implications: Professional associations are highly connected groups, deeply engaged with their members (often frontline clinicians) and regularly engaged with other key stakeholders and decision-makers (e.g., government). PAs play a critical role in influencing health system transformations, by bringing forward practical solutions to government that reflect the needs of their members, often frontline clinicians. Sharing insights from this work with an international audience could support global dialogues with health system leaders, policymakers, and researchers about leveraging the strengths of professional associations to enhance large-scale health system transformations via strategic collaboration.&#x0D; Next Steps: This research was conducted to fulfill the requirements of the Health System Impact Fellowship (doctoral level, funded by the Canadian Institutes of Health Research). We have continued to engage selected professional associations in building a collaborative framework, grounded in their experiences of participating the development of Ontario Health Teams.

A Cross-Sectional Study of the Prevalence and Determinants of Common Mental Health Problems in Primary Care in Switzerland.

Objective: This study investigated the prevalence of the most common mental health symptoms in a large primary care patient population and characterized their determinants. Methods: Data came from a 2015-16 cross-sectional study of a primary care population in Switzerland. An investigator presented the study to patients in waiting rooms, and 1,103 completed a tablet-based questionnaire measuring stress in daily life, sleep disorders and anxiety and depressive symptoms. Diagnoses and treatments were recorded. Results: Moderate-to-high anxiety and depressive symptoms concerned 7.7% of patients; 27.6% felt stressed at least once a week; 17.2% had severe sleep disorders. Sociodemographic determinants were associated with psychiatric symptoms: female sex, young age, and frequency of consultations with a GP. Participants taking psychotropics had high levels of mental distress. Conclusion: Even though most patients were regularly monitored by their GP, a significant number of mental health problems were found. GPs should be provided with concrete tools to manage these patients better. Collaboration with mental health specialists should be encouraged in primary care settings.

Abstract C115: Framework for a community-based multiple myeloma screening program

Abstract Purpose: We develop a framework for a community-based screening program for multiple myeloma (MM). MM is known to be twice as common in Black/African American (B/AA) persons compared to white persons and B/AA patients have a higher risk of delay in initial treatment compared to white patients. Therefore, we developed a community-wide screening program for B/AA persons 50 years and older. As the first of these programs, we reveal an organizational framework that prioritizes engagement with key community partners who address barriers to cancer screening. Experimental Procedures: We expand organizational development knowledge about how to implement community-based MM screening and address barriers. The study uses an iterative and qualitative continuous improvement process. The study draws on literature review and multi-disciplinary team collaboration among clinicians, researchers, administrators, and the Cleveland Clinic Community Outreach Program (Cleveland Outreach). Data Summary: Our framework includes three interrelated partners and each address barriers to MM screening: 1) Cleveland Clinic Cancer Center. The multi-disciplinary team designs an educational brochure, secures pilot grant funding, plans for insurance/financial assistance as needed, develops care algorithms, and evaluates the impact of the program. Cleveland Outreach, a department within the Cancer Center, uses the Harold Freeman model as its foundational approach, which includes patient navigators and community outreach managers who are culturally/linguistically matched to medically underserved communities. The Cancer Center addresses barriers including program implementation despite a lack of national screening guidelines, insurance/financial barriers, and patient navigation to address fears and health literacy. 2) Faith-based organizations. Church leaders committed to cancer prevention participate in Cleveland Outreach’s faith-based outreach model. Faith-based partners address barriers of trust and fear. Also, by providing space at churches for on-site screening blood draws, they address transportation barriers. 3) Clinicians at Federally Qualified Health Centers (FQHC’s). Providers and nurses at FQHC’s receive a Continuing Medical Education program about MM screening designed/funded by the Cancer Center. From within the community, providers notify medically underserved patients about the screening. With their primary care patient population, FQHC partners address barriers such as trust, health literacy, and fear of blood draws. They facilitate on-site screening at FQHC’s and health fairs, which addresses transportation barriers. Conclusions: Given that there are no universal guidelines for MM screening, we develop a novel approach to early disease detection in B/AA patients. Our framework is a partnership between the Cancer Center, faith-based organizations, and FQHC’s. Collaboratively, we address barriers to screening including fear, trust, insurance/financial, health literacy, transportation, and patient navigation if abnormal results suggest the need for further testing. Citation Format: Heather McKee Hurwitz, Kimberly Bell, Diana Basali, Raymond D. Jackson II, Jason Valent. Framework for a community-based multiple myeloma screening program [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C115.

Global Health Resource Utilization and Cost-Effectiveness of Therapeutics and Diagnostics in Immune Thrombotic Thrombocytopenic Purpura (TTP).

In this review, we examine the current landscape of health resource utilization and cost-effectiveness data in the care of patient populations with immune thrombotic thrombocytopenic purpura. We focus on the therapeutic (therapeutic plasma exchange, glucocorticoids, rituximab, caplacizumab) and diagnostic (ADAMTS13 assay) health technologies employed in the care of patients with this rare disease. Health resource utilization and cost-effectiveness data are limited to the high-income country context. Measurement of TTP-specific utility weights in the high-income country context and collection of health resource utilization data in the low- and middle-income country settings would enable an evaluation of country-specific quality-adjusted life expectancy and cost-effectiveness of these therapeutic and diagnostic health technologies. This quantification of value is one way to mitigate cost concerns where they exist.

Initial Validation of a Patient-Reported Compassion Measure in a Mandarin-Speaking Long-Term Care Patient Population.

Background and Purpose: Compassion is increasingly considered essential to quality nursing care and is a concept that is strongly embedded across cultures, including Chinese culture. The Patient Compassion Model (PCM) depicts the unique yet overlapping domains of compassion. The Sinclair Compassion Questionnaire (SCQ) was directly developed and validated from this empirical model. In this study, we sought to establish initial validation of a translated SCQ among Mandarin-speaking patients by assessing the transferability of the PCM and the clinical sensibility of the SCQ. Methods: Forward and back-translation of the PCM and SCQ were performed in accordance with World Health Organization guidelines. Qualitative interviews were used to assess the transferability of the PCM with conceptualizations of compassion within a Chinese context. Cognitive interviews were conducted to assess the clarity, readability, wording, questions, and response scales of the Mandarin translation of the SCQ. Qualitative data were analyzed using constant comparative analysis, and cognitive interviews were analyzed using framework analysis. Results: The original categories of the PCM were verified in this Mandarin-speaking patient population. Specifically, participants' understandings of compassion is described as consisting of healthcare provider virtues, emphasizing the importance of a virtuous response that sought to understand the individual and their unique needs, to relationally communicate from a place of shared humanity and to ameliorate suffering. Participants were able to answer, comprehend, and endorse all 15 Mandarin SCQ items, resulting in no modifications to the Mandarin SCQ. Conclusions: This study provides initial validation of the Mandarin SCQ and PCM. Future studies should consider further establishing the validity and reliability of the Mandarin SCQ among a larger Chinese patient population.

The Nordic perioperative and intensive care registries-Collaboration and research possibilities.

The Nordic perioperative and intensive care registries have been built up during the last 25 years to improve quality in intensive and perioperative care. We aimed to describe the Nordic perioperative and intensive care registries and to highlight possibilities and challenges in future research collaboration between these registries. We present an overview of the following Nordic registries: Swedish Perioperative Registry (SPOR), the Danish Anesthesia Database (DAD), the Finnish Perioperative Database (FIN-AN), the Icelandic Anesthesia Database (IS-AN), the Danish Intensive Care Database (DID), the Swedish Intensive Care Registry (SIR), the Finnish Intensive Care Consortium, the Norwegian Intensive Care and Pandemic Registry (NIPaR), and the Icelandic Intensive Care Registry (IS-ICU). Health care systems and patient populations are similar in the Nordic countries. Despite certain differences in data structure and clinical variables, the perioperative and intensive care registries have enough in common to enable research collaboration. In the future, even a common Nordic registry could be possible. Collaboration between the Nordic perioperative and intensive care registries is both possible and likely to produce research of high quality. Research collaboration between registries may have several add-on effects and stimulate international standardization regarding definitions, scoring systems, and benchmarks, thereby improving overall quality of care.

Characterization of Inclination Analysis for Predicting Onset of Heart Failure from Primary Care Electronic Medical Records.

The aim of this study is to characterize the performance of an inclination analysis for predicting the onset of heart failure (HF) from routinely collected clinical biomarkers extracted from primary care electronic medical records. A balanced dataset of 698 patients (with/without HF), including a minimum of five longitudinal measures of nine biomarkers (body mass index, diastolic and systolic blood pressure, fasting glucose, glycated hemoglobin, low-density and high-density lipoproteins, total cholesterol, and triglycerides) is used. The proposed algorithm achieves an accuracy of 0.89 (sensitivity of 0.89, specificity of 0.90) to predict the inclination of biomarkers (i.e., their trend towards a 'survival' or 'collapse' as defined by an inclination analysis) on a labeled, balanced dataset of 40 patients. Decision trees trained on the predicted inclination of biomarkers have significantly higher recall (0.69 vs. 0.53) and significantly higher negative predictive value (0.60 vs. 0.55) than those trained on the average values computed from the measures of biomarkers available before the onset of the disease, suggesting that an inclination analysis can help identify the onset of HF in the primary care patient population from routinely available clinical data. This exploratory study provides the basis for further investigations of inclination analyses to identify at-risk patients and generate preventive measures (i.e., personalized recommendations to reverse the trend of biomarkers towards collapse).

Parent-reported Barriers and Parental Beliefs Associated with Intentions to Obtain HPV Vaccination for Children in a Primary care Patient Population in Minnesota, USA.

Human papillomavirus (HPV) vaccine uptake among adolescents remains suboptimal in the US. The COVID-19 pandemic posed new challenges to increase HPV vaccination rates. To characterize parent-reported barriers to obtain HPV vaccination for their children and to identify psychosocial factors associated with parents' intention to vaccinate their children for HPV, we administered parent surveys between April 2020 and January 2022 during a randomized pragmatic trial assessing the impact of evidence-based implementation strategies on HPV vaccination rates for adolescent patients at six Mayo Clinic primary care practices in Southeast Minnesota. A total of 342 surveys were completed (response rate 34.1%). Analyses were focused on parents of unvaccinated children (n = 133). The survey assessed the main reason the child did not receive the HPV vaccine, parental beliefs about the vaccine, and the parent's intention to vaccinate the child for HPV in the next 12 months. Frequently reported awareness and access barriers to HPV vaccination included not knowing the child was due (17.8%) and COVID-19 related delay (11.6%). Frequently reported attitudinal barriers include the belief that the child was too young for the vaccine (17.8%) and that the vaccine is not proven to be safe (16.3%). Injunctive social norm (Adjusted-OR = 3.15, 95%CI: 1.94, 5.41) and perceived harm beliefs (Adjusted-OR = 0.58, 95%CI: 0.35, 0.94) about the HPV vaccine were positively and negatively associated with HPV vaccination intention, respectively. Our findings suggest that continued efforts to overcome parental awareness, access, and attitudinal barriers to HPV vaccination are needed and underscore the importance of utilizing evidence-based health system-level interventions.

519: ENHANCING NEUROCRITICAL CARE EDUCATION THROUGH MULTIDISCIPLINARY SIMULATION TRAINING

Introduction: Early recognition and response are paramount in treatment of neurologic emergencies. Due to its complexity, neurocritical care continues to provoke unease for practitioners and trainees. A simulation environment can provider a realistic opportunity for learners to detect and make rapid-fire decisions for an acutely deteriorating neurologic patient. A multidisciplinary simulation-based learning environment may improve education and trainee confidence when caring for the neurocritical care patient population. Methods: Three 45-minute simulation lab sessions were performed with a multidisciplinary team including medical students, neurology residents, critical care medicine fellows, advanced practice providers, and a critical care pharmacist. High fidelity manikins capable of reproducing acute neurologic and physiologic emergencies were used. Prior to the simulation, participants received Emergency Neurological Life Support resources. The simulation session lasted 45 minutes with an additional 10-minute debriefing with a neurointensivist and neurocritical care APP. After the simulation, participants were asked to complete a survey utilizing Likert scale responses, containing questions regarding pre- and post-simulation comfort levels managing specific acute neurologic emergencies. Results: Three simulation lab sessions were conducted and thirteen surveys were completed. Mean learner comfort levels in managing patients improved from pre- to post-simulation in patients with coma [3.25 vs 4.25 (p=0.007)], status epilepticus [3.25 vs 4.25 (p=0.007)], and procedures such as central lines [2.2 vs 3.8, p=0.003], intubations [2 vs 3.2, p=0.004], and bronchoscopies [2 vs 3.2, p=0.004]. Consistently, learners strongly agreed that faculty were knowledgeable, and sessions were well informed and thorough. Learners commented that the simulation experiences were realistic and allowed them to identify areas for improvement. Conclusions: Simulation training can be an effective method to improve education of neurocritical care team members by increasing clinician comfort in managing neurologic emergencies and procedures as well as providing opportunities for multidisciplinary collaboration. Further evaluation of the effectiveness of simulation education in this patient care setting is warranted.

Comparative effectiveness of real-time ultrasound-guided tracheostomy and anatomic landmark percutaneous dilatational tracheostomy: a retrospective cohort study.

The role of ultrasound during various airway procedures has been in the spotlight in recent years. This study reconsiders the potential role and effectiveness of ultrasound use during percutaneous dilatational tracheostomy in intensive care patient population. This study aims to assess the impact of real-time ultrasound (US) use on complication rates and procedural success in percutaneous dilational tracheostomy (PDT) opened with forceps dilatation technique using anatomical landmarks. In this study, 59 patients who had undergone PDT in the intensive care unit (ICU) were reached. Written-electronic files and intensive care follow-up forms of the patients were reviewed retrospectively. The patients were divided into two groups: 44 patients in Group G (anatomical landmark PDT) and 15 patients in Group U (real-time US PDT). Demographic data, duration of intubation and ICU stay, discharge status, procedural characteristics and postoperative complications of the patients were determined. A total of 59 patients were analyzed. The mean age of the patients was 74.9±11.7 years, the mean tracheostomy duration was 33.3±20 days, and the mean duration of ICU stay was 60±45 days. Complications occurred in 62.7% of all patients. Minor bleeding was present in five (8.5%), moderate bleeding in 13 (22%), and major bleeding in 11 (18.6%) patients. In addition, pneumothorax was observed in one patient, misplacement of the tracheostomy cannula and emphysema in one patient, and esophageal injury in three patients. A total of 50 (84.7%) patients died, and nine (15.3%) patients continued to be treated in the ICU. Bleeding, hypoxemia, hypercapnia, tracheostomy opening time duration, and the number of attempts for the successful procedure were significantly higher in Group G than Group U (p<0.05). A negative correlation was found between the groups regarding the duration of tracheostomy (p = 0.001) and tracheostomy opening technique (p = 0.001). The use of real-time ultrasound in percutaneous tracheostomies opened under elective conditions in the ICU reduces the complications of hypoxemia, hypercapnia and bleeding by dwindling the duration of the procedure and the number of attempts than the conventional technique.

Antibiotic susceptibility of urine culture specimens in Ontario: a population-based cohort study.

Surveillance of antimicrobial resistance is essential to mitigate its impact on population health and inform local empiric treatment practices. Our aims were to evaluate urine culture specimen susceptibility from a range of diverse settings and describe antibiotic susceptibility across all organisms and compare susceptibilities to that of Escherichia coli alone. In this descriptive cohort study, we measured the prevalence of organisms in urine culture specimens using linked province-wide administrative databases. Using positive urine cultures collected in Ontario between Jan. 1, 2016, and Dec. 31, 2017, we measured susceptibility to 6 classes of antibiotics using a weighted antibiogram for all organisms compared with E. coli alone. We included 689 497 cultures derived from 569 399 patients and 879 778 test orders for specimens. For all organisms, the rates of susceptibility in the outpatient, inpatient and long-term care settings were 49.3%, 42.8% and 39.2%, respectively, for ampicillin; 83.1%, 72.7% and 69.7%, respectively, for nitrofurantoin; 80.3%, 64.8% and 73.1%, respectively, for trimethoprim-sulfamethoxazole; 87.2%, 74.1% and 66.2%, respectively, for ciprofloxacin; 90.6%, 73.6% and 85.1%, respectively, for aminoglycosides; and 82.6%, 57.5% and 73.5%, respectively, for cefazolin. We found resistance to 3 or more antibiotic classes in 20.6% of episodes for all organisms compared with 14.0% for E. coli alone. The average absolute difference in antibiotic susceptibility between all organisms and E. coli across all drugs was lowest in the outpatient setting (6.2%) and highest in the inpatient setting (14.6%). In this study, urinary organism prevalence and antimicrobial susceptibility varied across health care settings and patient populations, with implications for both antimicrobial resistance surveillance and clinical decision-making. Weighted antibiograms may be most useful for guiding empiric treatment of urinary infections in inpatient settings where the diversity of infectious organisms is higher than in the community.

S1329 Nonalcoholic Fatty Liver Disease in Overweight Primary Care Patients: Comparison of Clinical Diagnosis vs Fibrosis-4 and Hepatic Steatosis Index Scores

Introduction: More than two-thirds of US adults are overweight or have obesity, a risk factor for nonalcoholic fatty liver disease (NAFLD). NAFLD is asymptomatic until late in the disease. Therefore, the aim of this study was to assess whether early evidence of NAFLD is being appropriately diagnosed in a primary care patient population. Methods: A retrospective data analysis was performed of overweight (BMI ≥ 23 for Asians or ≥ 25 for other races) patients (age ≥ 18) who had established primary care (defined as ≥ 2 visits in primary care) in a large healthcare system in Minneapolis between 2010 to 2019. Patients with a diagnosis of alcoholic liver disease, and hepatitis B and C virus infections were excluded. The clinical diagnosis of NAFLD was based on ICD-9 and -10 codes (571.8, K75.81, K76.0). Fibrosis 4 (FIB-4) score ≥ 3.25 and hepatic steatosis index (HSI) score ≥ 36 were calculated as markers of hepatic fibrosis and fatty liver disease, respectively. ICD codes were compared to FIB-4 and HSI scores. Results: 373,917 patients met study criteria; 52% were female, 86% white, average BMI at first primary care visit was 31.1 (SD 6.0) and average age was 46.4 (SD 17.3). At the end of the follow-up period in 2019, 6.6% of patients met criteria for hepatic fibrosis by FIB-4 score and 90.4% met criteria for fatty liver disease by HSI score. Among patients who met criteria for hepatic fibrosis by FIB-4 score, only 10.7% had been diagnosed as having NAFLD/NASH by ICD code; among those who met criteria for fatty liver disease by HSI criteria, only 6% had been diagnosed by ICD code (Table). A formal diagnosis of NAFLD/fatty liver/NASH by ICD code had been made in 4.1% of patients. Out of these patients, 97.7% had fatty liver by HSI score and 11.9% had hepatic fibrosis by FIB-4 score. Limitations: For 110,994 patients, a FIB-4 or HSI score could not be calculated. Duration of follow up was maximally nine years. Treatment information was not analyzed. Conclusion: Hepatic fibrosis and fatty liver disease are underdiagnosed in this healthcare system based on abnormal FIB-4 and HSI scores. These results are likely generalizable to other healthcare systems in the US. Given the frequency and reversibility of early NAFLD, primary care providers should have a low threshold to screen using simple labs tests (AST, ALT, platelet count) for fatty liver disease and hepatic fibrosis. Those with abnormal results should pursue intensive lifestyle modification and weight loss treatment. Table 1. - *Data Missing: Data to calculate FIB-4 or HSI score not available Yes Percentage No Data Missing Total (N) FIB-4 score ≥ 3.25 15,696 6.6 221,093 137,128 373,917 Patients with abnormal FIB-4 score who are diagnosed by ICD code 1,686 10.7 14,010 0 15,696 HSI score ≥ 36 241,357 90.4 25,543 107,017 373,917 Patients with abnormal HSI score who are diagnosed by ICD code 14,470 6.0 226,887 0 241,357 NAFLD/Fatty Liver/NASH diagnosis by ICD code 15,324 4.1 358,593 0 373,917 FIB-4 score ≥ 3.25 among patients who are diagnosed with NAFLD/fatty liver/NASH by ICD code 1,686 11.9 12,468 1,170 15,324 HSI score ≥ 36 among patients who are diagnosed with NAFLD/fatty liver/NASH by ICD code 14,470 97.7 346 508 15,324

Novel Drugs Approved in 2021-2022

This article provides an abbreviated overview of the newly Federal Drug Administration (FDA)approved novel drugs of 2021-2022 with their respective approved indication(s). The FDA serves as the governing body that regularly evaluates and approves medications that will eventually be introduced to the market for routine use. These medications include both drugs that are the same or related to previously approved products (e.g., Extended indications of priorly approved medications) and novel drugs. By definition, a novel drug is an innovative product which serves to improve quality care in patient populations with unmet or advanced medical needs to overall advance patient care and public health. This article was employed to highlight medications that may be seen in practice and to heighten overall awareness of these new drugs. From January 1, 2021, through June 13, 2022, the FDA approved 66 drugs characterized as novel (Table 1). The four drugs highlighted in this article were selected based on potential inpatient and outpatient utility, disease-state prevalence, and overall innovative medicationbased treatment approaches. The four highlighted drugs are included in Table 2.

Advancing Curriculum Development and Design in Health Professions Education: A Health Equity and Inclusion Framework for Education Programs.

The COVID-19 pandemic has exacerbated pre-existing health inequities in vulnerable and marginalized patient populations. Continuing professional development (CPD) can be a critical driver of change to improve quality of care, health inequities, and system change. In order for CPD to address these disparities in care for patient populations most affected in the health care system, CPD programs must first address issues of equity and inclusion in their education development and delivery. Despite the need for equitable and inclusive CPD programs, there remains a paucity of tools and frameworks available in the literature to guide CPD and broader education providers on how best to develop and deliver equitable and inclusive education programs. In this article, we describe the development and application of a Health Equity and Inclusion (HEI) Framework for education and training grounded in the Analyze, Design, Develop, Implement, and Evaluate model for instructional design. Using a case example, specifically a hospital-wide trauma-informed de-escalation for safety program, we demonstrate how the HEI Framework can be applied practically to CPD programs to support equity and inclusion in the planning, development, implementation, and evaluation phases of education program delivery. The case example illustrates how the HEI Framework can be used by CPD providers to respect learner diversity, improve accessibility for all learners, foster inclusion, and address biases and stereotypes. We suggest that the HEI Framework can serve as an educational resource for CPD providers and health professions educators aiming to create equitable and inclusive CPD programs.