Use In Patient Care Research Articles

Health care coach support in reducing acute care use in patients with cancer.

4 Background: Lay health workers (LHWs) who are trained to proactively discuss goals of care and assess patient symptoms have improved value-based cancer care among Veterans and a Medicare Advantage population. Little data exists regarding the effect of integrating LHWs into community oncology care among commercially insured populations. In this study, we implemented an LHW intervention to assist with goals of care and symptom management in collaboration with a private community oncology practice among patients with advanced cancer. This randomized controlled trial evaluates the effect of the intervention on acute care use and secondarily on goals of care documentation and patient satisfaction. Methods: Newly diagnosed patients with advanced stages of solid and hematologic malignancies were randomized from 8/11/2016 through 6/5/2019 into the intervention and control groups. All patients were followed for 12 months or death, whichever was first. Patients reported satisfaction with care using the Consumer Assessment of Healthcare Providers and Systems survey at time of enrollment and 9 months follow-up. We compared risk of death using Cox Models and compared rates of acute care, palliative care and hospice use using generalized models adjusted for length of follow-up. Results: A total of 104 patients were randomized with 52 in the intervention and 52 in the control. In both groups, the mean age was 67 years; 70% were non-Hispanic white, 25% Asian Pacific Islander, 1% Native Hawaiian, 1% American Indian/Alaskan Native, 3% multiple races/ethnicities. There were no differences in cancer diagnoses or stages. There were no differences in rates of survival between the two groups. Intervention patients as compared to the control had lower mean emergency department visits (0.80 +/- 0.17 versus 1.9 +/- 0.46, p = 0.02) and hospitalizations (0.67 +/- 0.19 versus 1.49 +/- 0.37, p = 0.04), greater rates of goals of care documentation (92% versus 33% p = 0.002) and no differences in palliative care (88% versus 77% p = 0.16) or hospice use (27% versus 21% p = 0.45). At 9 months follow-up as compared to baseline, patients in the intervention experienced greater improvements in satisfaction with their care (difference-in-difference: 0.41, 95% CI 0.22-0.60, p < 0.001). Conclusions: An LHW intervention significantly reduced acute care use and improved patient experiences with cancer care as compared to a control group. This intervention may be a solution to improve care delivery and experiences for patients after a diagnosis of cancer in community oncology settings. Clinical trial information: NCT03154190 .

Optimizing hepcidin measurement with a proficiency test framework and standardization improvement.

Hepcidin measurement advances insights in pathophysiology, diagnosis, and treatment of iron disorders, but requires analytically sound and standardized measurement procedures (MPs). Recent development of a two-level secondary reference material (sRM) for hepcidin assays allows worldwide standardization. However, no proficiency testing (PT) schemes to ensure external quality assurance (EQA) exist and the absence of a high calibrator in the sRM set precludes optimal standardization. We developed a pilot PT together with the DutchEQA organization Stichting Kwaliteitsbewaking Medische Laboratoriumdiagnostiek (SKML) that included 16 international hepcidin MPs. The design included 12 human serum samples that allowed us to evaluate accuracy, linearity, precision and standardization potential. We manufactured, value-assigned, and validated a high-level calibrator in a similar manner to the existing low- and middle-level sRM. The pilot PT confirmed logistical feasibility of an annual scheme. Most MPs demonstrated linearity (R2>0.99) and precision (duplicate CV>12.2%), although the need for EQA was shown by large variability in accuracy. The high-level calibrator proved effective, reducing the inter-assay CV from 42.0% (unstandardized) to 14.0%, compared to 17.6% with the two-leveled set. The calibrator passed international homogeneity criteria and was assigned a value of 9.07±0.24nmol/L. We established a framework for future PT toenable laboratory accreditation, which is essential to ensure quality of hepcidin measurement and its use in patient care. Additionally, we showed optimized standardization is possible by extending the current sRM with a third high calibrator, although international implementation of the sRM is a prerequisite for its success.

Costs of surgical ablation of atrial fibrillation in Ontario, Canada from 2006 to 2017.

International guidelines currently recommend concomitant surgical ablation of atrial fibrillation (AF) in patients with AF undergoing cardiac surgery. However, a systematic review and meta-analysis of 23 randomized controlled trials (RCTs) showed no significant difference in mortality or stroke in patients who underwent surgical AF ablation compared with those who did not (moderate-quality evidence). We estimated the Ontario-wide costs of surgical AF ablation between 2006 and 2017 using data from a systematic review and meta-analysis of RCTs, estimates of case volumes from Ontario Health Insurance Plan fee codes, the ongoing left atrial appendage occlusion study III trial (NCT01561651), institutional costs from large academic centers in Ontario, as well as professional fees based on the Ontario fee schedule. Device costs were obtained from Canadian industry data with expert input. We estimated the average extra cost of surgical AF ablation at $4,287 CAD (95% CI $4,113-4,619) per patient. Procedural costs (equipment costs and physician remuneration) comprise 82.2% of this, while smaller portions relate to the increased need for pacemaker (3.9%) and additional hospital length of stay (13.9%). Approximately 2,391 patients underwent surgical AF ablation between 2006 and 2017, corresponding to an estimated $10.2 million in incremental cost during that time span. Ontario taxpayers spend significant financial resources on surgical ablation of AF, a procedure lacking high-quality evidence demonstrating benefit in reducing mortality or stroke. Further large prospective studies examining clinically important outcomes are needed to justify its routine use in patient care and to guide allocation of healthcare funds.

Handheld electronic device use in patient care: the emergency department patient perspective—a cross-sectional survey

BackgroundStaff use of smartphones and tablets in the healthcare setting is increasingly prevalent, but little is known about whether this use is acceptable to patients. Staff are concerned that the...

Accuracy of diagnostic tests for respiratory syncytial virus infection within a paediatric hospital population in Kilifi County, Kenya

Background: Respiratory syncytial virus (RSV)-induced lower respiratory tract disease is a prominent cause of hospitalisation among children aged <5 years in developing countries. Accurate and rapid diagnostic tests are central to informing effective patient management and surveillance efforts geared towards quantifying RSV disease burden. This study sought to estimate the sensitivity (Se), specificity (Sp) (along with the associated factors) and predictive values of a direct immunofluorescence test (IFAT), and two real-time reverse transcription polymerase chain reaction (rRT-PCR) assays for RSV infection within a paediatric hospital population: a multiplex rRT-PCR (MPX) and Fast-Track Diagnostics ® (FTD) Respiratory Pathogens 33 (Resp-33) rRT-PCR. Methods: The study enlisted 1458 paediatrics aged ≤59 months admitted with acute respiratory illness at the Kilifi County Hospital between August 2011 and December 2013. A Bayesian latent class modelling framework was employed to infer the tests’ estimates based on the patients’ diagnostic data from the three tests. Results: The tests posted statistically similar Se estimates: IFAT (93.7%, [90.7; 95.0]), FTD (97.8%, [94.6; 99.4]) and MPX (97.5%, [94.2; 99.3]). As for Sp, FTD registered a lower estimate (97.4%, [96.2; 98.2]) than MPX (99.7%, [99.0; 100.0]) but similar to IFAT (99.0%, [98.2; 99.6]). The negative and positive predictive values were strong (>91%) and closely mimicked the pattern given by the Se and Sp values respectively. None of the examined covariates (age, sex and pneumonia status) significantly influenced the accuracy of the tests. Conclusions: The evaluation found little to choose between the three diagnostic tests. Nonetheless, with its relative affordability, the conventional IFAT continues to hold promise for use in patient care and surveillance activities for RSV infection within settings where children are hospitalised with severe acute respiratory illness.

Abstract 2045: Characterization of inpatient opioid use among pediatric neuroblastoma patients during dinutuximab therapy

Abstract Background: Dinutuximab is a chimeric anti-GD-2 (disialoganglioside) antibody approved for use in post-consolidation care of patients with high-risk neuroblastoma. GD-2 receptors are also expressed in cerebellar neurons, melanocytes, and peripheral sensory nerve fibers in normal human tissue. Given this pattern of expression, pain is a common and often infusion rate-limiting adverse effect, with greater than 50% of patients experiencing severe (Grade 3 or above) pain. Standard pain management for dinutuximab infusions at our center includes initiation of continuous infusion of opioid patient-controlled analgesia along with demand, loading, and boluses doses. Little to no data exist in the literature to describe opioid use in pediatric patients with acute, episodic pain. Therefore, this study aims to characterize opioid use in this setting. Methods: Data were collected retrospectively from the electronic medical record under a study protocol approved by the Institutional Review Board at the University of Michigan, C.S. Mott Children's Hospital. Patients were included in the study if they had a clinical diagnosis of metastatic or relapsed high-risk neuroblastoma, received at least one dinutuximab cycle, and were aged 2-14 at the time of admission. Daily amount of opioids, calculated as the oral morphine equivalent daily dose (MEDD), acetaminophen, and gabapentin administered were calculated. Repeated measures ANOVA was used to evaluate within-subjects changes. Results: The average age of patients was 5.7 years [range 2-14 years]. Four of eleven (36.4%) were female and 7/11 (63.6%) were male. All patients received four days of dinutuximab infusions for an average length of 11.8 hours (SD=2.0) per day. All patients received gabapentin prophylactic treatment and an average of 3387 mg (SD=1275.5). Average total MEDD across all patients was 184.7 mg (SD=137.6) during the inpatient hospitalization. Females (p=0.003) and older patients (p=0.04) had significantly increased daily MEDD as compared to their day 1 intake. All patients experienced a fever spike and received acetaminophen (2915 mg, SD=1737.8) Older patients received higher doses of acetaminophen (p=0.007) Only 1 patient met definition of a chronic opioid user and was discharged with an outpatient opioid prescription. The remaining opioid-naïve patients were discontinued on opioid treatment at the time of discharge. Conclusions: Pediatric patients on dinutuximab therapy received a high MEDD parenteral opioids dose alongside adjunctive analgesics. Future studies are needed to determine opioid requirement trends across gender, age, and cycles in a larger cohort of patients, as well as to determine the risk of chronic opioid use in this patient population. Citation Format: Jola Mehmeti, Jae Eun Choi, Ian Wolfe, Juan Cata, Rajen Mody. Characterization of inpatient opioid use among pediatric neuroblastoma patients during dinutuximab therapy [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2045.

Inpatient Palliative Care Use in Patients With Pulmonary Arterial Hypertension: Temporal Trends, Predictors, and Outcomes

Pulmonary arterial hypertension (PAH) is a progressive disease associated with significant morbidity and mortality. Despite the negative impact of PAH on quality of life and survival, data on use of specialty palliative care services (PCS) is scarce. We sought to evaluate the inpatient use of PCS in patients with PAH. Using the National (Nationwide) Inpatient Sample, 30,495 admissions with a primary diagnosis of PAH were identified from 2001 through 2017. The primary outcome of interest was temporal trends and predictors of inpatient PCS use in patients with PAH. The inpatient use of PCS was low (2.2%), but increased during the study period from 0.5%in 2001 to 7.6%in 2017, with a significant increase starting in 2009. White race, private insurance, higher socioeconomic status, hospital-specific factors, higher comorbidity burden (Charlson Comorbidity Index), cardiac and noncardiac organ failure, and use of extracorporeal membrane oxygenation and noninvasive mechanical ventilation were independent predictors of increased PCS use. PCS use was associated with a higher prevalence of do-not-resuscitate status, a longer length of stay, higher hospitalization costs, and increased in-hospital mortality with less frequent discharges to home, likely because these patients were also sicker (higher comorbidity index and illness acuity). The inpatient use of PCS in patients with PAH is low, but has been increasing over recent years. Despite increased PCS use over time, patient- and hospital-specific disparities in PCS use continue. Further studies evaluating these disparities and the role of PCS in the comprehensive care of PAH patients are warranted.

Accuracy of diagnostic tests for respiratory syncytial virus infection within a paediatric hospital population in Kilifi County, Kenya.

Background: Respiratory syncytial virus (RSV)-induced lower respiratory tract disease is a prominent cause of hospitalisation among children aged <5 years in developing countries. Accurate and rapid diagnostic tests are central to informing effective patient management and surveillance efforts geared towards quantifying RSV disease burden. This study sought to estimate the sensitivity (Se), specificity (Sp) (along with the associated factors) and predictive values of a direct immunofluorescence test (IFAT), and two real-time reverse transcription polymerase chain reaction (rRT-PCR) assays for RSV infection within a paediatric hospital population: a multiplex rRT-PCR (MPX) and Fast-Track Diagnostics ® (FTD) Respiratory Pathogens 33 (Resp-33) rRT-PCR. Methods: The study enlisted 1458 paediatrics aged ≤59 months admitted with acute respiratory illness at the Kilifi County Hospital between August 2011 and December 2013. A Bayesian latent class modelling framework was employed to infer the tests' estimates based on the patients' diagnostic data from the three tests. Results: The tests posted statistically similar Se estimates: IFAT (93.7%, [90.7; 95.0]), FTD (97.8%, [94.6; 99.4]) and MPX (97.5%, [94.2; 99.3]). As for Sp, FTD registered a lower estimate (97.4%, [96.2; 98.2]) than MPX (99.7%, [99.0; 100.0]) but similar to IFAT (99.0%, [98.2; 99.6]). The negative and positive predictive values were strong (>91%) and closely mimicked the pattern given by the Se and Sp values respectively. None of the examined covariates (age, sex and pneumonia status) significantly influenced the accuracy of the tests. Conclusions: The evaluation found little to choose between the three diagnostic tests. Nonetheless, with its relative affordability, the conventional IFAT continues to hold promise for use in patient care and surveillance activities for RSV infection within settings where children are hospitalised with severe acute respiratory illness.

P134 Mobile Apps for Hypertension Management: Cross-sectional Survey of Dietitian App Use in Patient Care

<h3>Background</h3> Mobile apps show promise for managing chronic diseases such as hypertension; however, more evidence is needed to understand how dietitians are using apps in hypertension care. <h3>Objective</h3> To classify dietitians' incorporation of apps into dietary education for patients with hypertension. <h3>Study Design, Setting, Participants</h3> An online cross-sectional survey of registered dietitian nutritionists who work with patients with cardiovascular disease. <h3>Measurable Outcome/Analysis</h3> App use in hypertension diet education classified with descriptive statistics and Friedman tests with Bonferroni corrections. Dietitian characteristics impacting app use measured through stepwise regression. <h3>Results</h3> A total of 190 completed the survey. The DASH diet was the most common dietary approach used in hypertension education (<i>P</i> < .001). The most commonly recommended app for hypertension education was MyFitnessPal (23%); however, only 36% recommend any apps to patients with hypertension. For comparison, 64% recommended apps for weight management. Few (2%) were extremely satisfied with apps for hypertension management and less than a third were somewhat satisfied (30%). In general, dietitians did use apps for diet tracking, with a third reporting using apps for diet tracking most of the time, and another third sometimes. Dietitians were more likely to recommend apps for diet tracking than pen and paper (<i>P</i> < .001), online programs or websites (<i>P</i> = .01), or computer-based word-processing (<i>P</i> < .001). Stepwise regression analysis showed that as dietitian education level increased, the number of patients that dietitians recommended apps to also increased (R-squared = .04, <i>P</i> = .01). Dietitian age and gender did not significantly predict app use. <h3>Conclusions</h3> Most dietitians are not specifically recommending apps for hypertension management. Those who do use an app are most likely to use MyFitnessPal. Future work should examine the effectiveness of using MyFitnessPal to reduce hypertension and barriers to dietitian satisfaction with apps.

Nurses' Perceptions of Implant Barcode Scanning in Surgical Services.

The US Food and Drug Administration's 2013 Unique Device Identification System Rule requires manufacturers to label devices with unique identifiers. Implantable devices are now shipped with unique identifiers, and many electronic health records have fields to incorporate them. Health policy changes have prompted hospital systems to assess implementation of implant barcode scanning systems to capture unique device identifiers. Project aims were to assess predictors of operating room nurses' acceptance of a new implant barcode scanning system, describe operating room nurses' perceptions of the system value, and identify operating room nurses' perceived gaps in system implementation. An online survey was disseminated to operating room nurses, and focus groups were conducted with orthopedic operating room nurses in an academic medical center that had recently implemented an implant barcode scanning system in surgical services. Predictors of barcode scanning acceptance included perceived usefulness for patient care, perceived ease of use, and perceived usefulness (self). Nurses perceived the system to be more accurate and valuable for patient safety. Perceived gaps in system implementation related to communication, completeness of the system, consistency in process, and training. Understanding nurse perceptions of new barcode scanning systems and engaging them in the implementation process are key areas for success and optimization of these systems.

Nurses' Perceptions of Implant Barcode Scanning in Surgical Services

The US Food and Drug Administration's 2013 Unique Device Identification System Rule requires manufacturers to label devices with unique identifiers. Implantable devices are now shipped with unique identifiers, and many electronic health records have fields to incorporate them. Health policy changes have prompted hospital systems to assess implementation of implant barcode scanning systems to capture unique device identifiers. Project aims were to assess predictors of operating room nurses' acceptance of a new implant barcode scanning system, describe operating room nurses' perceptions of the system value, and identify operating room nurses' perceived gaps in system implementation. An online survey was disseminated to operating room nurses, and focus groups were conducted with orthopedic operating room nurses in an academic medical center that had recently implemented an implant barcode scanning system in surgical services. Predictors of barcode scanning acceptance included perceived usefulness for patient care, perceived ease of use, and perceived usefulness (self). Nurses perceived the system to be more accurate and valuable for patient safety. Perceived gaps in system implementation related to communication, completeness of the system, consistency in process, and training. Understanding nurse perceptions of new barcode scanning systems and engaging them in the implementation process are key areas for success and optimization of these systems.

Patient-Reported Outcome Measures in Sports Medicine: A Concise Resource for Clinicians and Researchers.

Despite the importance of assessing patient outcomes during patient care, current evidence suggests relatively limited use of patient-reported outcome measures (PROMs) by athletic trainers (ATs). Major barriers to PROM use include lack of knowledge, navigating the intricate process of assessing a wide variety of PROMs, and selecting the most appropriate PROM to use for care. A concise resource for ATs to consult when selecting and implementing PROMs may help facilitate the use of PROMs in athletic health care. To review the instrument essentials and clinical utility of PROMs used by ATs. We studied 11 lower extremity region-specific, 10 upper extremity region-specific, 6 generic, and 3 single-item PROMs based on the endorsement of at least 10% of ATs who use PROMs, as reported in a recent investigation of PROM use in athletic training. A literature search was conducted for each included PROM that focused on identifying and extracting components of the instrument essentials (ie, instrument development, reliability, validity, responsiveness and interpretability, and precision) and clinical utility (ie, acceptability, feasibility, and appropriateness). Through independent review and group consensus, we also classified each PROM question by International Classification of Functioning, Disability and Health domain and health-related quality-of-life dimensions. The PROMs contained in this report generally possessed appropriate instrument essentials and clinical utility. Moreover, the PROMs generally emphasized body structure and function as well as the physical functioning of the patient. Athletic trainers aiming to assess patients via a whole-person approach may benefit from combining different PROMs for use in patient care to ensure broader attention to disablement health domains and health-related quality-of-life dimensions.

Assessment of hospital emergency medication kit use at a large academic medical center with automated dispensing machine technology.

Hospital emergency medication kits (HEMKs) are used to provide certain critical medications in emergent situations, despite many technological advancements for patient safety and medication distribution. We sought to evaluate HEMK usage and analyze associated costs to identify and recommend process improvements. Mayo Clinic in Rochester, MN, is a large multisite academic medical center with 2 hospital campuses and many ambulatory clinics. All documentation of the approximately 250 HEMKs in circulation was analyzed from January to November 2017. The primary outcome was HEMK use. Secondary outcomes included individual medication usage and associated costs. These data were then used to recommend process improvements. Of 880 HEMKs evaluated, 675 (76.7%) were used, resulting in expiration 23.3% of the time. Atotal of 1,024 emergency medications were used, most commonly for hypoglycemia. Many of these medications are also available in automated dispensing machines for patient care use. Cost analysis revealed an average annual cost of nearly $200,000 associated with HEMKs. The results of our analysis indicated little added benefit of HEMKs in the setting of automated dispensing machine optimization. Steps for HEMK retirement are described. HEMKs offered little added benefit considering technological advancements that have been made in patient safety and medication distribution since their inception. Retirement of HEMKs is anticipated to increase pharmacy operational efficiency by using automated dispensing machine technology and appropriate emergency response protocols to ensure optimal patient care.

Associations Between Private Health Insurance and Medical Care Utilization for Musculoskeletal Disorders: Using the Korea Health Panel Survey Data for 2014 to 2015.

In South Korea, people may increase their medical coverage by purchasing private health insurance to augment low coverage provided by the National Health Insurance (NHI). Frequent and excessive use of medical care by those with private health insurance is an issue, especially for musculoskeletal disorders that require excessive care and contribute to moral hazard. In South Korea, since private health insurance is structurally linked to the scope of coverage with public health insurance, this increased use of medical care may adversely affect public health insurance finances. This study aimed to analyze the effects of private health insurance on medical care use for patients with musculoskeletal disorders. We used the Korea Health Panel 2014 to 2015 data that included 5622 participants who used medical care for musculoskeletal disorders in 2015. Two groups were created: those who purchased private health insurance (n = 3588) and those without private insurance (n = 2034). We compared their medical utilization using logistic regression, negative binomial regression, and multiple linear regression to determine the associations of private health insurance with medical care use. Medical expenditures by private health insurance purchasers were higher than those of non-purchasers for outpatient care (P < .001), but no differences were found for inpatient care. Our findings suggest that the expansion of private health insurance further burdened the NHI financially, ultimately increasing the burden of medical expenses for the population. Research should implement demonstration studies with different groups of diseases.

Med-Match: An Interactive Game to Learn Medications for Clinical Practice.

Knowing medications and their use in patient care is a component of safe practice. The Med-Match game transforms learning medications from a solitary task to an interactive activity. Educational games create real-life scenarios in a safe, context-rich environment without real-world consequences. Gaming is a form of active learning; learning occurs as a result of student-to-student interaction, peer feedback, and faculty debriefing. Although this activity was initially developed for nursing students, it can also be used with new RNs being oriented to a clinical setting or as an annual review for experienced nurses.

The development and electronic delivery of case-based learning using a fast healthcare interoperability resource system

HL7 International’s Fast Healthcare Interoperability Resources (FHIR) standard provides a common format for sharing health data (eg, FHIR resources) and a RESTful Application Programming Interface (eg, FHIR API) for accessing those resources via a FHIR server connected to an electronic health record system or any other system storing clinical data. Substitutable Medical Applications and Reusable Technologies (SMART) leverages FHIR to create an electronic health record (EHR) agnostic app platform. It utilizes the OAuth standard to provide for authorization and authentication. This paper describes the development and informal evaluation of Case Based Learning on FHIR (CBL on FHIR), a prototype EHR-connected FHIR/SMART platform to provide interactive digital cases for use in medical education. The project goals were to provide a more interactive form of CBL than is possible on paper to more realistically simulate clinical decision making and to expose medical students to modern informatics systems and tools for use in patient care.

55 A Novel Approach to Establish and Enhance Event Reporting Systems Among Emergency Medicine Residents

Event reporting is an integral part of patient safety programs; however, often systems based barriers lead to few adverse events being reported. Mobile phone use in patient care is a growing facet of medical care. The ease of access and simplicity of use of mobile phones may be utilized to promote a culture of safety and increase adverse event reporting by residents in the emergency department (ED) and the hospital. We introduced a new method of adverse event reporting for residents in the ED and hospital by leveraging a widely used secure mobile messaging app to facilitate physician reporting of adverse events. The study was undertaken in 3 phases. The pre-intervention phase consisted of the evaluation of residents’ attitudes, satisfaction, time taken to report, the likelihood of future reporting, and the determination of a baseline of adverse event reporting in the prior year. The intervention phase consisted of implementation of the new secure text messaging-based system and the post-intervention phase entailed assessment of resident event reporting. The study population consisted of residents’ postgraduate year one through four. Residents submitted a total of 147 reports through the secure text messaging system. Rates of adverse reporting increased by 407% (147 vs. 29) during the first eight months of implementation of this system compared to the prior year as a whole. In addition, resident satisfaction with event reporting using the new text messaging system increased by 232% (7.3 vs. 2.2, P<0.0001) and there was a 104% (5.5 vs. 2.7, P<0.0001) increase in the comfort level of reporting an adverse event when compared to the pre-intervention methods. The minutes spent by residents submitting a report also decreased significantly when using the new mobile app (4 vs. 21, P<0.0001). Furthermore, the likelihood of event reporting by residents increased by 127% (6.8 vs. 3.0, P<0.0001) during the intervention period when compared to the pre-intervention phase. The use of a mobile messaging application to target the barriers associated with adverse event reporting significantly reduced the time to submission and increased adverse event reporting by residents in the ED and hospital, ultimately promoting a culture of safety.

A trainee-led quality improvement project to improve rates of palliative care utilization in patients with advanced cancer.

51 Background: ASCO guidelines recommend palliative care (PC) referral for patients with advanced or metastatic cancer. Despite this, implementation has considerable hurdles. 1st year oncology fellows at our institution identified low rates of palliative care in their longitudinal clinic as an avenue for improvement. Methods: A Fellow-led multidisciplinary team aimed to increase palliative care utilization for patients with advanced cancer followed in first-year fellows’ clinic from baseline 11.5% (5/43 patients, Jul-Dec, '18) to 30% over a 4-mo period. Utilization was defined as evaluation in the outpatient palliative care clinic hosted in the cancer center. The team identified several barriers to referral: orders difficult to find in EMR, multiple consulting mechanisms (EMR, by phone, in person), EMR request not activating formal consult, no centralized scheduler to contact/confirm appointment, and poor awareness of team structure. PDSA cycles were implemented based on identified opportunities. Data were obtained from the EMR. Results: The PDSA cycle included focus groups with stakeholders, standardizing referral process via single order set, identifying a single scheduler with bidirectional communication, and dissemination of process changes. The PDSA was implemented Jan-Apr '19. Rates of palliative care use increased from 11.5% pre-intervention to 43% (27/62 patients) post-intervention. In addition, median time to evaluation in palliative care clinic after placing a consult improved from 23 days (range, 10-60 days) to 12 days (range, 6-19 days). Conclusions: A multidisciplinary approach and classic QI methodology improved palliative care use for patients with advanced cancer. The pilot succeeded given the small number of fellows, buy-in from stakeholders, and institutional support of efforts. Straightforward EMR interventions and ancillary staff use are effective in addressing under referrals.

Technology-enabled assessments to enhance multiple sclerosis clinical care and research.

Comprehensive and efficient assessments are necessary for clinical care and research in chronic diseases. Our objective was to assess the implementation of a technology-enabled tool in MS practice. We analyzed prospectively collected longitudinal data from routine multiple sclerosis (MS) visits between September 2015 and May 2018. The MS Performance Test, comprising patient-reported outcome measures (PROMs) and neuroperformance tests (NPTs) self-administered using a tablet, was integrated into routine care. Descriptive statistics, Spearman correlations, and linear mixed-effect models were used to examine the implementation process and relationship between patient characteristics and completion of assessments. A total of 8022 follow-up visits from 4199 patients (median age 49.9 [40.2-58.8] years, 32.1% progressive course, and median disease duration 13.6 [5.9-22.3] years) were analyzed. By the end of integration, the tablet version of the Timed 25-Foot Walk was obtained in 89.0% of patients and the 9-Hole Peg Test in 94.8% compared with 74.2% and 64.3%, respectively before implementation. The greatest increase in data capture occurred in processing speed and low-contrast acuity assessments (0% prior vs 78.4% and 36.7%, respectively, following implementation). Four PROMs were administered in 41%-98% of patients compared with a single depression questionnaire with a previous capture rate of 70.6%. Completion rates and time required to complete each NPT improved with subsequent visits. Younger age and lower disability scores were associated with shorter completion time and higher completion rates. Integration of technology-enabled data capture in routine clinical practice allows acquisition of comprehensive standardized data for use in patient care and clinical research.

Effects of Osteoarthritis Pain and Concurrent Insomnia and Depression on Health Care Use in a Primary Care Population of Older Adults.

To examine independent and combined effects of pain with concurrent insomnia and depression symptoms on the use of health care services in older adults with osteoarthritis (OA). Patients were Group Health Cooperative (GHC) patients with a primary diagnosis of OA (n = 2,976). We used survey data on pain (Graded Chronic Pain Scale), insomnia (Insomnia Severity Index), and depression (Patient Health Questionnaire-8), and health care use extracted from GHC electronic health records (office visits, length of stay, outpatient and inpatient costs, and hip or knee replacement) for 3 years after the survey. Negative binomial, logistic, and generalized linear models were used to assess predictors of health care use. Approximately 34% and 29% of patients displayed at least subclinical insomnia and at least subclinical depression symptoms, respectively, in addition to moderate-to-severe pain. Pain had the greatest independent effects on increasing all types of health care use, followed by depression (moderate effects) on increased office visits, length of stay, outpatient and inpatient costs, and insomnia (mild effects) on decreased length of stay. No synergistic effects of the 3 symptoms on use of health care services were observed. The combined effects of pain plus insomnia and pain plus depression were significant for all types of health care use and increased greatly with increasing severity of insomnia and depression, except for hip/knee replacement. Pain is the main driver for health care use in patients with OA. In addition to pain, insomnia plus depression jointly increased diverse types of health care use, and these combined effects increased greatly with increasing severity of insomnia and depression. These findings indicate the important role that concurrent symptomatic conditions may play in increasing use of health care services.