Case-based Conference Research Articles

P25 TB or not TB? An unusual case of inflammatory arthritis in an anti-CCP positive patient

P25 TB or not TB? An unusual case of inflammatory arthritis in an anti-CCP positive patient

Use of Standardized Inflammatory Bowel Disease Endoscopy Scores in Clinical Practice.

Inflammatory bowel disease (IBD) treatment targets include mucosal healing based on standardized endoscopic scoring systems. The rates and ease of use of these scoring systems in practice have not been well described. We aimed to assess the rates and factors associated with the use of IBD endoscopic scoring systems in practice from IBD LIVE attendees. IBD Live is an international case-based conference focusing on the management of patients with IBD. We created a web-based survey consisting of 38 questions on the frequency and ease of use of various IBD endoscopic scores. This survey was emailed to the IBD Live listserv in March 2022 with a second email sent 14 days later. We included only respondents who are currently performing endoscopy. Continuous variables were analyzed using an unpaired student's t-test. Categorical variables were analyzed using Pearson's chi-square test. There were 65 responses out of 170 (38.2% response rate) regular attendees. Eleven responses were excluded (4 with no response on the use of endoscopy scores, and 7 were not performing endoscopy). Of the respondents, 72.2% are from the United States, 70.4% are adult gastroenterologists, 53.9% in academic practice, and 40.7% in practice for ≥15 years. Of the endoscopy scores used ≥50% of the time, 74.1% were using the Mayo Endoscopic Subscore (MES), 72.3% using the Rutgeerts Score, 61.2% using the Simple Endoscopic Score for Crohn's Disease, and 28.6% using the Pouchitis Disease Activity Index. Attending IBD LIVE ≥ monthly (P = .028), attending an IBD conference at least every 2 years (P = .020), and having the scoring system incorporated into the endoscopy documentation software (P = .002) were associated with more consistent use of the MES. Attending IBD Live at least monthly (P = .026), having an IBD volume of ≥50% (P = .011), and attending an IBD conference at least every 2 years (P = .004) was associated with more frequent use of the Rutgeerts score. There were no factors that increased the use of other endoscopic scores. The MES and the Rutgeerts score are more commonly used with much lower rates of use of endoscopic scores for Crohn's disease and pouchitis. The use of these endoscopy scores is more common among those who regularly attend IBD conferences, have higher volume IBD practices, and have these scoring systems incorporated into endoscopy software. Further evaluation of barriers to use and ways to improve utilization of endoscopic scoring for Crohn's disease and pouchitis is needed.

Resident-Led Effort Improves Adoption of Advance Care Planning among Emergency General Surgery Patients

INTRODUCTION: Advanced Care Planning (ACP) is underused in surgery, especially among older adults undergoing high-risk operations. For patients who may permanently or temporarily lose their ability to communicate preferences, pre-operative ACP and identification of a surrogate decision-maker is often the only mechanism to guide medical decision-making. METHODS: A resident-led, collaborative (faculty, advanced practice providers [APP], medical student, and nurse) quality improvement project including education (grand rounds, case-based conferences, didactic sessions), performance measurement and financial incentives, conducted on the Emergency General Surgery (EGS) service aimed to increase use of a tailored surgical template in the ACP tab in the electronic health record (EHR). 566 patients in the baseline period (2020-2021) were compared to 423 patients in the project period (2021-2022). Residents were surveyed about barriers to adoption. RESULTS: ACP compliance increased by 8.1% (10.1% to 18.2%) with a greater increase noted in patients age 65+ (20.3% vs 34.3%). Residents and APPs completed ACP, usually by integrating into patient admission workflow (52.1% within the first 24 hours of admission). For major cases, ACP compliance rates increased by 19.7% (18.9% to 38.6%). Residents surveyed (n = 19), all of whom had an ACP conversation all recognized the importance of ACP, noted barriers, including competing clinical duties (50%), patient or family hesitancy (30%), and language barriers (15%), (Table 1). CONCLUSION: A resident-APP partnership was effective at increasing ACP adoption on an EGS service. Further study is needed to identify approaches to facilitate ACP conversations in EGS patients with limited English proficiency.Table 1

S1013 Use of IBD Endoscopic Scoring Systems in Practice

Introduction: Inflammatory bowel disease (IBD) treatment targets include mucosal healing based on standardized endoscopic scoring systems. The rates and ease of use of these scoring systems in practice have not been well described. We aimed to assess the rates and potential barriers to using IBD endoscopic scoring systems in practice from IBD Live attendees. Methods: IBD LIVE is an international case-based conference focusing on the management of patients with IBD. We created a web-based survey consisting of 38 questions on the frequency and ease of use of various IBD endoscopic scores. This survey was emailed to the IBD LIVE listserv in March 2022 with a second email sent 14 days later. We included only respondents who are currently performing endoscopy. Continuous variables were analyzed using an unpaired student’s t-test. Categorical variables were analyzed using a Pearson’s chi-square test. Results: There were 65 responses out of 170 (38.2% response rate) regular attendees. Eleven responses were excluded (4 with no response on the use of endoscopy scores, 7 were not performing endoscopy). Of the respondents, 72.2% are from the US, 70.4% are adult gastroenterologists, 53.9% in academic practice, and 40.7% in practice for ≥ 15 years. Of the endoscopy scores used ≥ 50% of the time, 74.1% were using the Mayo Endoscopic Sub-score (MES), 72.3% using the Rutgeert's Score, 61.2% using the Simple Endoscopic Score for Crohn's Disease, and 28.6% using the Pouchitis Disease Activity Index. Attending IBD Live ≥ monthly (p=0.028), attending an IBD conference ≥ every 2 years (p=0.020), and having the scoring system incorporated into the endoscopy documentation software (p=0.002) were associated with more consistent use of the MES. Attending IBD Live ≥ monthly (p=0.026), having an IBD volume of ≥ 50% (p=0.011), and attending an IBD conference ≥ every 2 years (p=0.004) was associated with more frequent use of the Rutgeert’s score. There were no factors that increased the use of other endoscopic scores. (Table) Conclusion: The MES and the Rutgeert’s score are more commonly used with much lower rates of use of endoscopic scores for Crohn’s disease and pouchitis. The use of these endoscopy scores is more common among those who regularly attend IBD conferences, have higher volume IBD practices and have these scoring systems incorporated into endoscopy software. Further evaluation of ways to improve utilization of endoscopic scoring for Crohn’s disease and pouchitis are needed. Table 1. - Results Use of Mayo UC Endoscopic Subscore ≥50% of the time (n=40), n (%) < 50% of the time (n=14), n (%) p-value Endoscopic Score Built into Software 27 (67.5) 3 (21.4) 0.002 Attend IBD Conference ≥ every 2 Years 39 (97.5) 11 (78.6) 0.020 Attend IBD Live:At least monthlyLess than monthly 30 (75)10 (25) 6 (42.9)8 (57.1) 0.028 Number of years in GI Practice:< 10 years≥ 10 years 18 (45)22 (55) 5 (35.7)9 (64.3) 0.55 Specialty:Adult GIPediatric GIColorectal SurgeryOther 32(84.2)4 (80)4 (80)0 6(15.8)1(20)6(60)1(100) 0.012 Use of the Rutgeert's Score ≥50% of the time (n=34), n (%) < 50% of the time (n=13), n (%) p-value Endoscopic Score Built into Software 17 (50) 3 (23.1) 0.45 Attend IBD Conference ≥ Every 2 Years 34 (100) 10 (76.9) 0.004 IBD patient volume ≥50% 22 (64.7) 3 (23.1) 0.011 Attend IBD Live:At least monthlyLess than monthly 23(76.7)7(23.3) 6(46.2)7(53.8) 0.026 Number of years in GI Practice:< 10 years≥ 10 years 14(41.2)20(58.8) 4(30.8)9(69.2) 0.51 Specialty:Adult GIPediatric GIColorectal Surgery 27 (79.4)3(8.8)4(11.8) 7(53.9)2(15.4)4(30.8) 0.19 Use of Simple Endoscopic Score for Crohn's Disease ≥50% of the time (n=30), n (%) < 50% of the time (n=19), n (%) p-value Endoscopic Score Built into Software 18 (60) 6 (31.6) 0.09 Attend IBD Conference ≥ Every 2 Years 29 (96.7) 16 (84.2) 0.12 IBD patient volume ≥50% 17 (56.7) 8 (42.1) 0.32 Attend IBD Live:At least monthlyLess than monthly 23(76.7)7(23.3) 11(57.9)8(42.1) 0.16 Number of years in GI Practice:< 10 years≥ 10 years 15(50)15(50) 5(26.3)14(73.7) 0.10 Specialty:Adult GIPediatric GIColorectal Surgery 24(68.6)2(40)4(44.4) 11(31.4)3(60)5(55.6) 0.25

P32 Therapeutic dilemma due to gut complications with spondyloarthritis

Introduction/BackgroundTumor necrosis factor (TNF) inhibitor therapy is one of the primary modalities of treating spondyloarthritis. However, infections secondary to biologic use is a common complication. Clostridium difficile is a gut colonizer which may become pathogenic in the presence of dysbiosis and antibiotic use. Symptomatic clostridium difficile infection(CDI) due to adalimumab(ADA) use causing lymphocytic colitis(LC) is rarely reported. We present a case of axial plus peripheral spondyloarthritis on adalimumab who developed CDI and presented a therapy related dilemma.Description/MethodWe present a case of a 52-year-old lady who was diagnosed as HLAB27 positive axial spondyloarthritis with bilateral sacroiliitis on MRI bilateral sacroiliac joint in 2016. She failed two non-steroidal antinflammatory drugs (NSAID) with high disease activity scores(BASDAI 8.6, BASFI 6.2, Spinal VAS 9). She was eventually initiated on injection adalimumab in 2017. There was clinical improvement after 6 months of initiating ADA. Repeat MRI spine and SI joint showed resolution of inflammatory changes with adalimumab. Sulfasalazine was added in the treatment protocol due to peripheral arthralgia, however she developed a drug rash to it and it was stopped. In September 2021, she developed recurrent non-bloody watery diarrhoeal episodes. Adalimumab was stopped and she tested positive for Clostridium difficile on three occasions. She received multiple courses of vancomycin, fidoxamycin and metronidazole with partial resolution of diarrhoea. Adalimumab was rechallended in January 2022 since her disease activity was worsening in the absence of NSAID and biologic use. However, it was paused again due to worsening of diarrhoea. Gastroenterology conducted a Colonoscopy and biopsy of colonic polyps which showed increased number of intraepithelial lymphocytes with no thickening of subepithelial collagen plate suggestive of lymphocytic colitis (LC). It was postulated that CDI may have been the trigger for her LC. She has been started on local corticosteroid therapy(budesonide) for her LC. At this junction, we were faced with the decision of restarting adalimumab for her which may have been the original cause of her CDI.Discussion/ResultsWe present this case in view of a dilemma regarding which problem occurred first Did immunosuppression due to adalimumab lead to CDI? Literature is not suggestive of increased risk of CDI with adalimumab, especially in a non-inflammatory bowel disease (IBD) background. Was the lymphocytic colitis triggered by the CDI or was clostridium difficile just incidentally detected on a background of LC? There is a well documented associated of LC with autoimmune conditions and use of NSAIDs along with proton pump inhibitor is another trigger for it. TNF alpha inhibitor is one of the treatment modalities of refractory LC. Would it be appropriate to restart ADA for her since she responded well despite there being a risk of recurrence of a CDI? Finally, what is the role of gut dysbiosis in the role of CDI and LC in this situation. Presently, she is planned to be treated with local steroid therapy for her LC. ADA will be rechallenged once her gut has responded to the steroid course. In the event of her gut worsening on a rechallenge, she will be given a trial of Infliximab.Key learning points/ConclusionThe case highlights the crucial point of thinking of causes of diarrhea apart from well documented conditions of ulcerative colitis/Crohn’s disease in an immunosuppressed spondyloarthritis patient. A detailed stool examination including bacterial and parasitic examination is crucial in recurrent diarrhea. The threshold for colonoscopy should be low when episodes are refractory to treatment. The case-based conference gives us an opportunity to receive feedback regarding further management approaches in this case.

P26 Challenging Scenario: Scleroderma/Sjogren overlap with dysautonomia

Introduction/BackgroundScleroderma Overlap conditions are well defined and often behave differently than their limited or diffuse counterparts. The treatment for such patients is usually tailored around the organ system involvement and severity. We present a challenging case of Scleroderma/Sjogren overlap with refractory Raynaud's phenomenon who posed treatment challenges due to severe autonomic dysfunction.Description/Method76-year-old Caucasian lady, non-smoker, who presented in 1990’s with dry eyes, dry mouth and severe Raynaud's phenomenon with recurrent digital ulceration which became infected on multiple occasions. ANA was 1:400 with Extractable nuclear antigen Ro and La positive. Anti DsDNA was negative and C4 was low. Antiphospholipid antibodies and cryoglobulins are negative. She failed calcium channels blockers and phosphodiesterase 5 inhibitors and was intolerant to intravenous (IV) Iloprost which was tried on multiple occasions. IV latanoprost was tried as well. This treatment was complicated when she developed postural hypotension and multiple fall episodes during vasodilator use. This was attributed to autonomic dysfunction secondary to her Sjogren syndrome. She was initiated on Injection Fludrocortisone, however her hypotensive episodes continued. She received monthly intravenous immunoglobulins 20gm (over two days) infusion for a few months for autonomic dysfunction with some response. She eventually developed recurrent diarrhoea and abdominal pain and bloating which was attributed to small bowel overgrowth with rapid bowel transit on a gastric emptying scan. She had a blocked bile duct as well which was unblocked using Endoscopic Retrograde Cholangiopancreatography. Over the next 8 years, she continued struggling with refractory Raynaud’s, having failed IV regional guanethidine blocks and digital sympathectomy. Her postural hypotension decompensated on multiple occasions necessitating plasmapheresis which provided some benefit. In 2020, she was detected to have a PET avid slowly progressing left upper lobe lung lesion. She underwent left video assisted thoracoscopy surgery with upper lobectomy. Histology was suggestive of adenocarcinoma. In 2021, she had another fall episode due to an acute/subacute infarct of left pons. She continues having postural hypotension and requires regular plasmapheresis sessions to manage her symptoms. She is also presently on Bosentan for her raynaud’s phenomenon.Discussion/ResultsThis is a case of overlap of Sjogren syndrome with scleroderma features. Management of Refractory Raynaud’s as part of her scleroderma phenotype was challenging. This case gave us the opportunity to explore all the treatment options available for Raynaud’s phenomenon albeit with poor outcome. She also struggled with autonomic dysfunction leading to postural hypotension and gastrointestinal symptoms which can be seen in upto 50% of patients with Sjogren syndrome. Autonomic failure is often thought to be immune mediated in Sjogren syndrome. This makes way for the use of intravenous immunoglobulin and plasmapheresis to treat these conditions as was done in this case. Increased risk of lung carcinoma with scleroderma is well documented. Autonomic dysfunction can also present as paraneoplastic syndrome with lung carcinoma, however it is more common with small cell lung carcinoma and our patient was diagnosed with Adenocarcinoma. We would have to wait and see if the resection of the tumour has any demonstrable effect on her dysautonomia.Key learning points/ConclusionOverlap connective tissue diseases are often difficult to manage in view of extensive disease heterogeneity. Clinicians need to be aware of challenges in managing Difficult Raynaud’s with Autonomic dysfunction. Treating physicians need to be aware of the high risk of lung malignancy and regular close monitoring is required. This case-based conference gives us the opportunity to discuss further management approaches for her.

P19 A case of pyrexia of unknown origin - wrong way round!

P19 A case of pyrexia of unknown origin - wrong way round!

Improvement in Housestaff Knowledge of Novel Antihyperglycemic Agents Through a Cross-Specialty Beyond Diabetes“Educational Initiative”

Lead Author's Financial Disclosures Nothing to disclose. Study Funding AstraZeneca Pharmaceutical Industry Company. Background/Synopsis Novel antihyperglycemic agents, including sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like-peptide-1 receptor agonists (GLP1-RA), demonstrate significant benefits in select patients with and without diabetes (T2DM). These benefits include improvements in cardiovascular, kidney and metabolic outcomes. Despite these benefits, these medications remain underutilized, attributed in part to a lack of provider knowledge across specialties. Our "Beyond-Diabetes" initiative is a health system-wide, multidisciplinary collaboration to raise awareness and prescriber utilization of these medications through a variety of informatics and educational modalities. Objective/Purpose The goal of this component of our initiative was to assess whether lecture based (grand rounds) and case-based conferences delivered via a virtual platform could improve understanding of SGLT2i and GLP1-RA among residents and fellows as part of their core curriculum. Methods We administered a 6-question electronic survey to assess knowledge of SGLT2i and GLP1-RA before and after a 1-hour, virtual case-based education that highlighted clinical uses, contraindications, dosing, adverse effects, and prescribing barriers. The housestaff were previously offered a grand rounds on the topic. The lectures and pre/post surveys were provided to internal medicine residents, as well as cardiology, nephrology, and endocrinology fellows. Efficacy was measured by analyzing the percent correct between pre/post-test questionnaires by a paired, two-sided t-test. Results After evaluating the pre-test and post-test results of the trainees, we found that among all disciplines (n = 119 pre/63 post), the average increase was 15% correct between pre-test and post-test (p-value <0.01) using random pre-test sampling. Limitations of this data include a low response rate with 28% of trainees completing the pre-test (119/418) and 53% completing the post-test (63/119). Cardiology fellows showed the greatest improvement in their overall scores with a 17% change. Endocrinology fellows had the least improvement, with a difference of 6%, likely attributable to having the highest baseline pre-test questionnaire scores. Analysis of each question showed that there was an increase in the percentage answered correctly, with the exception of one question, which had no change after education. Conclusions Our intervention demonstrates that a 1-hour virtual lecture can improve the knowledge of trainees across four disciplines regarding novel antihyperglycemic medications. This data supports the use of virtual lecture and case-based didactics to enhance provider knowledge regarding SGLT2i and GLP1-RA medications. However, further research into the most effective educational initiatives is warranted. This knowledge is essential to increase the utilization of these effective medications, which have been demonstrated to improve clinical outcomes and reduce healthcare expenditures. Nothing to disclose.

Increasing Pediatric Morning Report Educational Value Through Quality Improvement.

Morning report (MR) is a common case-based conference in graduate medical education. Recent studies highlight participant dissatisfaction with the educational value of MR, but data are lacking on means for improvement. We aimed to increase MR quality and participant satisfaction at our academic pediatric residency program. Improvement science was used to develop and implement a new standardized pediatric MR process (intervention), with 5 core educational elements and structured resident-faculty mentorship. Educational elements were measured via feedback forms and tracked using a run chart. Residents and faculty were surveyed regarding MR quality and satisfaction at baseline and 6 months postintervention; responses were analyzed using mixed effects logistic regression. The median of educational elements increased from 3 to 5 (5 maximum) during the 6-month study period and 12-months poststudy. Baseline and postintervention survey response rates were 90% (18 of 20) for residents and 66% (51 of 77) for faculty. Residents reporting high quality MR changed from 50% to 72% (P = .20), and faculty from 29% to 85% (P <.001). Satisfaction with MR content increased for both residents (50%-89%, P = .03) and faculty (25%-67%, P <.001). Resident satisfaction with faculty mentorship before MR increased from 28% to 78% (P = .01); satisfaction with faculty feedback after MR increased from 11% to 56% (P = .02). Improvement science can be used to develop a new pediatric graduate medical education process. Requiring core educational elements and providing structured mentorship were associated with improvements in pediatric MR quality and participant satisfaction.

Effective Strategies for Planning and Facilitating Morning Report.

Effective Strategies for Planning and Facilitating Morning Report.

O24 Malignancy in antiphospholipid syndrome: a catastrophe

O24 Malignancy in antiphospholipid syndrome: a catastrophe

Point-of-care program in HIV, tuberculosis, and associated conditions: A virtual global technical assistance platform to strengthen HIV and tuberculosis workforce capacity

A global multi-disciplinary faculty was established to work collaboratively and provide virtual technical assistance, using a point-of-care continuing education model, to clinicians across the world engaged in the care of patients with either HIV infection or tuberculosis. Ancillary offerings included live or virtual lectures, case-based conferences, and courses. In spite of the considerable disruption of the program due to the COVID-19 pandemic, we engaged and assisted a substantial number of clinicians across the world and provided meaningful contributions to their continuous professional development and patient care. In light of the ongoing pandemic, virtual technical assistance models such as this should be scaled to continue essential high-quality HIV/TB services.

"MS4 Report": a Student-Led and Remote Model for Case-Based Learning in Preparation for Residency.

Case-based conference preparation is a valuable skill rarely covered in medical school training. We implemented an innovative program to teach fourth-year medical students to prepare and facilitate a virtual case presentation conference with faculty mentorship. Feedback survey results indicated improved confidence in case presentation and in establishing a broad differential.

Virtual Spine: A Novel, International Teleconferencing Program Developed to Increase the Accessibility of Spine Education During the COVID-19 Pandemic

BackgroundThe coronavirus identified in 2019 (COVID-19) pandemic effectively ended all major spine educational conferences in the first half of 2020. In response, the authors formed a “virtual” case-based conference series directed at delivering spine education to health care providers around the world. We herein share the technical logistics, early participant feedback, and future direction of this initiative.MethodsThe Virtual Global Spine Conference (VGSC) was created in April 2020 by a multiinstitutional team of spinal neurosurgeons and a neuroradiologist. Biweekly virtual meetings were established wherein invited national and international spine care providers would deliver case-based presentations on spine and spine surgery−related conditions via teleconferencing. Promotion was coordinated through social media platforms such as Twitter.ResultsVGSC recruited more than 1000 surgeons, trainees, and other specialists, with 50–100 new registrants per week thereafter. An early survey to the participants, with 168 responders, indicated that 92% viewed the content as highly valuable to their practice and 94% would continue participating post COVID-19. Participants from the United States (29%), Middle East (16%), and Europe (12%) comprised the majority of the audience. Approximately 52% were neurosurgeons, 18% orthopedic surgeons, and 6% neuroradiologists. A majority of participants were physicians (55%) and residents/fellows (21%).ConclusionsThe early success of the VGSC reflects a strong interest in spine education despite the COVID-19 pandemic and social distancing guidelines. There is widespread opinion, backed by our own survey results, that many clinicians and trainees want to see “virtual” education continue post COVID-19.

1270-P: Improving ABC Targets through a Quality Improvement Initiative in China

Strong scientific evidence supports the benefits of ABC control (A1c &amp;lt;7%, blood pressure &amp;lt;140/80 mmHg, and LDL cholesterol &amp;lt;100 mg/dL) in reducing complications. A recent national multicenter study in China showed that the percentage of Chinese patients with type 2 diabetes who met recommended targets for A1c, BP and LDL in 2010 was 5.4%. A diabetes clinic in a Chinese tertiary hospital conducted a pilot quality improvement project from January to November 2018 to enhance ABC outcomes. Doctors and nurses from the clinic participated in biweekly video case conferences with Joslin Diabetes Center clinicians (endocrinologist and a certified diabetes educator). They also received bi-monthly on-site training, each lasting 10 days, from visiting U.S. clinicians. A1c, blood pressure and cholesterol levels collected from patients receiving routine care in the diabetes clinic from the first half of 2018 were compared with those collected in the second half of 2018. There were 1,036 patients who had at least one visit at each of these periods, and 683 patients of them (65.9%) had A1c, BP and LDL measured during these two periods. Paired comparisons were done by paired t-test (continuous variables) or McNemar’s test (dichotomous variables) using SAS version 9.4. The mean age of the patients was 54.7±11.9 years, with 53.8% female, and 95.3% with T2DM. There was a significant increase in the patients who achieved composite A1c, BP and LDL goal from 6.8 to 10.0% (p=0.048). The percentage of patients attaining the BP goal increased from 54.6 to 63.5% (p=0.0016). The systolic pressure decreased from 137.8 ± 20.2 to 133.3 ± 19.4 mmHg (p&amp;lt;0.0001). The LDL cholesterol decreased from 107.5 ± 34.0 to 97.5 ± 34.4 mg/dL (p&amp;lt;0.0001), and resulted in an increase in the percentage of individuals meeting the LDL goal, from 24.5% to 32.9% (p=0.0012). Interventions through regular case-based video conferences, complemented by live coaching from diabetes specialists, have the potential to improve clinical outcomes for patients with diabetes in China. Disclosure K. Lau: None. L. Yunxia: None. L. Yi: None. C. Li: None. Y. Zhengguo: None. D.M. Pober: None. L. Zhang: None. R.A. Gabbay: Advisory Panel; Self; HealthReveal, Hygieia, Lark, Onduo LLC. Consultant; Self; Sanofi. W.C. Hsu: Consultant; Self; Onduo LLC.

Residents as Key Effectors of Change in Improving Opioid Prescribing Behavior

There is a national imperative to curb the flow of opioids into our communities. In academic medical centers, the majority of discharge opioid prescriptions are written by residents who receive predominantly ad hoc, peer-to-peer education on perioperative analgesia. We aimed to reduce opioid overprescribing after common general surgical operations through a resident led quality improvement project that involved formal educational interventions and feedback on prescribing habits. A transdisciplinary team was formed to identify how current prescribing habits differed from best practices, and to identify the educational needs to bridge this gap. We then focused on multiple educational interventions, including department-wide grand rounds, case-based conferences with residents, and dedicated didactic sessions on opioid prescribing. Feedback reports of opioid prescribing habits of the residents were developed. Residents' attitudes toward opioid prescribing were assessed using an anonymous survey before and after our interventions. Actual opioid prescribing data were abstracted from the electronic health record. A single academic medical center. A surgical resident led a transdisciplinary team consisting of faculty, anesthesiologists, pharmacists, advanced practice providers, and health informaticians within the Department of Surgery. After our educational intervention, residents' impression of the appropriate number of opioid pills necessary after common general surgical operations decreased significantly, as measured by surveys pre- and postintervention. Electronic health record data regarding actual opioid prescribing behavior show significant discrepancy from the survey responses, but does show a significant decrease in the quantity of opioids prescribed for most evaluated operations following the educational intervention. Opioid prescribing is an ideal target for resident led education and quality improvement. Residents' attitudes toward appropriate opioid prescribing tend to differ from actual prescribing habits. Our results demonstrate that a well-scoped, resident-driven quality improvement program can lead to change in both attitudes and practice surrounding opioid prescribing.

A Faculty Development Workshop for High-Value Care Education Across Clinical Settings.

Despite rising health care costs, trainees frequently do not receive formal high-value care (HVC) training. As medical education often occurs through informal learning, it is imperative that medical educators be prepared to teach HVC concepts across clinical settings. This workshop was created to provide frameworks for teaching HVC across four pediatric educational settings: (1) case-based conferences, (2) inpatient rounding, (3) ambulatory visits, and (4) conversations with patients and families. Frameworks were developed based on literature review, content experts' knowledge, and internal assessment and feedback. The workshop was divided into two sections: a didactic overview of HVC education and interactive small-group sessions to practice application of the Toolkit for Teaching High-Value Care. At the end of the workshop, participants completed the Prescription for High-Value Care to create a personal action plan. This workshop has been presented at both national and local pediatric conferences. From over 89 evaluations (83% response rate), participants felt the workshop met objectives, served as a valuable use of their time, and provided useful resources. Evaluations elicited specific actions that participants gleaned from workshop content along with proposed behavior changes, such as creating HVC case-based conferences at their home institution and initiating more value-based discussions. This workshop has been successfully presented in both national and local settings and has been well received by participants. The workshop is targeted for clinical educators and aims to address the gap in faculty development for HVC education.

Promoting interdisciplinary shared mental models.

Emergency Medicine (EM) and Hospital Medicine (HM) providers frequently interact when transitioning patients from the emergency department (ED) to the inpatient unit; however, there is infrequent collaboration between these subspecialties, and effective communication in EM-HM provider handover is an area for improvement. Shared mental models can enhance communication and safety. The purpose of this article is to describe the implementation of an interdisciplinary conference to allow providers to create shared mental models, and to assess the impact on attitudes and behaviours towards communication and collaboration outside the competing attentions of patient care environments. The authors instituted a quarterly interactive case-based conference at an academic tertiary care children's hospital in which EM and HM subspecialty trainees co-facilitate evidence-based interactive presentations of clinical, diagnostic or management dilemmas. The conferences were evaluated via repeated cross-sectional surveys of EM and HM providers, as well as session evaluations. Surveys included multiple-choice, Likert-scale and free-text responses to assess the degree of interaction and collaboration between the divisions and provider attitudes toward changes in clinical practice. Assessment of the EM-HM collaborative conferences demonstrated trends towards increased interaction between divisions and increased discussion about management decisions among colleagues. Two-thirds of individuals who attended at least one conference felt that having attended an interdisciplinary conference influenced future management decisions. Effective communication in EM-HM provider handover is anarea for improvement CONCLUSIONS: Interdisciplinary conferences provide a forum for cross-specialty communication to discuss management differences in a low-stress educational environment, and allow providers to develop shared mental models for effective, safe patient care.

Teaching High-Value Care in Pediatrics: A National Survey of Current Practices and Guide for Future Curriculum Development

Health care expenditures in the United States are increasing at an unsustainable pace. There have been calls to incorporate education on resource stewardship into medical training, yet the perceived need for and current use of high-value care (HVC) curricula in pediatrics residency programs is unknown. We described the current national landscape of HVC curricula in pediatrics residencies, including characterization of current programs, barriers to the practice of HVC, and clarification of preferred curricula types. Using a cross-sectional study design, we conducted a national, anonymous, web-based survey of pediatrics residency program directors and pediatrics chief residents in fall 2014. We received responses from 85 of 199 (43%) pediatrics program directors and 74 of 199 (37%) pediatrics chief residents. Only 10% (8 of 80) of program directors and 12% (8 of 65) of chief residents reported having a formal curriculum on HVC. Respondents identified the largest barriers to HVC as a lack of cost transparency (program directors) and attending physicians having the final say in treatment decisions (chief residents). The majority of respondents (83%, 121 of 146) agreed their program needs a HVC curriculum, and 90% (131 of 145) reported they would use a curriculum if it was available. Respondents significantly preferred a case-based conference discussion format over other approaches. Most pediatrics residency programs responding to a survey lacked formal HVC curricula. There is a desire nationally for HVC education in pediatrics, particularly in a case-based discussion format.

Finding Value in Surgical Didactics: Longitudinal Resident Feedback From Case-Based and Traditional Lectures in an Orthopaedic Residency

To evaluate orthopedic resident perceptions of a didactic curriculum presented in traditional and case-based formats. Prospective cohort study using anonymous web-based survey after each conference evaluating resident perceptions of faculty participation, didactic delivery, content, and overall conference value. Conferences were structured as primarily case-based or traditional lecture. Logistic analysis was performed to determine factors predictive of rating a conference as valuable time spent. Orthopedic residency training program at single institution over an academic year. Orthopedic residents in postgraduate training year 1 to 5 attending mandatory didactic conference. Cased-based conferences received higher Likert ratings on residents' perception of faculty participation, instructor delivery, and improvement in topic understanding when compared to traditional lecture-based conferences (p < 0.0001 for each factor). Residents also were more likely to rate case-based conferences as valuable time spent (p < 0.0001). In our logistic model, factors associated with a negative likelihood of rating a conference as valuable were lecture format (odds ratio [OR] = 0.155, 95% CI: 0.115-0.208), PGY-2 level presenter (OR = 0.288, 95% CI: 0.169-0.490), and PGY-3 level presenter (OR = 0.433, 95% CI: 0.269-0.696). Timing in the year, surgical subspeciality, and conference identity were not significant predictors of conference value rating. Longitudinal resident feedback demonstrates highly favorable resident perceptions toward case-based formats in didactic sessions. Junior levels residents are not perceived as effective as senior residents and faculty in presenting material in either format. These methods allow for a dynamic approach to identifying strengths and weaknesses in a resident curriculum as a well as a means for more focused and real-time improvements.