Community-based Medical Center Research Articles

Risk factors for readmission of patients with amputation to acute care from inpatient rehabilitation: A retrospective cohort study.

Amputation is a major condition that requires inpatient rehabilitation. Some research has been conducted to explore the risk factors for readmission of patients from inpatient rehabilitation facilities to acute care hospitals. However, few studies have included patients with amputation in the study population. To identify the risk factors for readmission of patients with amputation to acute care hospitals from an inpatient rehabilitation facility. Retrospective cohort study. An acute rehabilitation hospital associated with a community-based tertiary medical center. A retrospective review of 156 independent admissions of 145 patients from June 2019 to July 2022. The study outcome measure was readmission to acute care from an acute rehabilitation unit. Of the 156 independent admissions, the readmission rate was 19% (29/156). The most common cause of transfer was incision-site complications (9/29, 31%), including wound infection and wound dehiscence. Patients with amputation readmitted to acute care are more likely to be receivingdialysis (p < .001), have a longer length of stay in acute care before admission to the rehabilitation facility (p = .039), and have a lower Section GG score on admission (p < .001). Age, sex, ethnicity, amputation level, and history of diabetes mellitus were not associated with acute care hospital readmission. The logistic regression model revealed that patients being on dialysis was the only significant risk factor predictive of readmission to acute care (odds ratio [OR] 4.82, p = .006). This study showed that incision-site complications were the most common cause of disruption in inpatient rehabilitation via acute hospital readmission in patients with amputation. Being on dialysis was associated with a higher risk of readmission to acute care hospitals. Based on the results of this study, specific rehabilitation plans might be required for patients with amputation who carry certain risk factors to reduce rehospitalization to the acute care unit.

2187. Validation of Local Risk Factors for Antibiotic-resistant Pathogens in Community-acquired Pneumonia at an Urban Community-based Medical Center

Abstract Background The 2019 ATS/IDSA community-acquired pneumonia (CAP) guidelines recommend to abandon the term healthcare-associated pneumonia (HCAP) and to base the use of broad-spectrum antibiotics on local epidemiology and risk factors. Jamaica, NY represents a unique population of ethnically diverse, largely immigrant patients. Several nursing homes, an international airport, along with a low socioeconomic status population feed into the hospital. The purpose of this study is to determine prevalent risk factors for drug-resistant pathogens (DRP) in CAP within an urban population. The secondary objective is to validate the Drug Resistance in Pneumonia (DRIP) score in this population. Methods A retrospective study was conducted on adults admitted from August 2018-December 2019 with a diagnosis of CAP, including aspiration pneumonia. Patients with a DRP respiratory culture (collected within 48 hours of admission) were selected, the next consecutively admitted patient with a non-resistant culture was included as a control. Results A total of 227 patients were included (114 in the DRP group and 113 in the control group). The DRP group had more patients with tracheostomies (30% vs 3%, p &amp;lt; .001) and chronic pulmonary disease (37% vs 16%, p &amp;lt; .001) (Table 1). Approximately 40% of the DRP patients were admitted from a long term care (LTC) facility compared to 8.8% in the control group (p &amp;lt; .001). Isolation of P. aeruginosa was not associated with LTC residence (Odds Ratio: 0.75) in our population (Table 2). All DRIP score components were associated with the isolation of DRP in our patient population, except for methicillin-resistant S. aureus (MRSA) colonization (Table 3). In our population 50% of the DRP had a DRIP score &amp;lt; 3. DRIP scores &amp;gt; 2, &amp;gt; 3 and &amp;gt; 4 had low negative predictive values (NPV) for the isolation of DRP in CAP (71.9%, 67.4% and 64.2%, respectively). Conclusion Demographic risk factors may exist for DRP in CAP, e.g. tracheostomy, pulmonary disease. Using a DRIP score cut off of &amp;gt; 4 missed 50% of the DRP in our study population. Despite a DRIP score &amp;gt; 4 having a specificity of 90.3%, with a NPV of 64.2% this scoring tool may underestimate the prevalence of DRP in our patient population. Based on our findings, institutions should consider local validation of the DRIP score prior to implementing use at their site. Disclosures All Authors: No reported disclosures.

Sleepiness and fatigue associated with avoidance behavior in moderately severe PTSD patients presenting to a community-based sleep medical center

article: Sleepiness and fatigue associated with avoidance behavior in moderately severe PTSD patients presenting to a community-based sleep medical center - Minerva Psychiatry 2022 December;63(4):329-38 - Minerva Medica - Journals

New research infrastructure increases scholarly activity for orthopedic residency program

PurposeThis study investigated the impact of a PhD-led research infrastructure on scholarly output for an orthopedic residency program. We hypothesized that a research infrastructure leveraging non-surgeon faculty and medical students could increase research capacity and productivity in an orthopedic residency program.MethodsIn 2018, a PhD kinesiologist was hired by a community-based university-affiliated medical center to augment research in collaboration with volunteer clinical faculty orthopedic surgeons. Initiatives implemented included: (1) standardized patient reported outcome collection tools (2) creation of a seven-year retrospective joint registry for a high-volume (> 600/year) arthroplasty surgeon, with continued prospective collection (3) expansion of research staff with three data collection employees (4) creation of a monthly research lecture series for medical students conducted by the kinesiologist. Publications before and after implementation of the research infrastructure (2011–2021) were recorded through PubMed and annual faculty surveys.ResultsPeer-reviewed, indexed publications substantially increased by 491% and 305% for residents and faculty, respectively, since the inception of the kinesiologist-led research program. Over three years, 244 authorships on publications, presentations, and abstracts have been provided for medical students and residents through the lecture series. In subsequent years, a peer mentorship program was established, with senior medical students and residents serving as research mentors under faculty supervision.ConclusionA PhD-led orthopedic research program leveraging medical students resulted in a substantial increase in peer-reviewed publications. This model may be attractive to community medical centers with volunteer clinical faculty seeking to enhance their scholarly environment and provide additional research opportunities for residents and students.

Limitations to Health Care Quality Measurement: Assessing Hospital Variation in Risk of Cardiac Events After Noncardiac Surgery.

Limited sample size, incomplete measures, and inadequate risk adjustment adversely influence accurate health care quality measurements, surgical quality measurements, and accurate comparisons among hospitals. Since these measures are linked to resources for quality improvement and reimbursement, improving the accuracy of measurement has substantial implications for patients, clinicians, hospital administrators, insurers, and purchasers. The team examined risk-adjusted differences of postoperative cardiac events among 20 geographically dispersed, community-based medical centers within an integrated health care system and compared it with the National Surgical Quality Improvement Program (NSQIP) hospital-specific differences. The exposure included the hospital at which patients received noncardiac surgical care, with stratification of patients by the acuity of surgery (elective vs. urgent/emergent). Among 157,075 surgery patients, the unadjusted risk of cardiac event per 1000 ranged among hospitals from 2.1 to 6.9 for elective surgery and from 10.3 to 44.5 for urgent/emergent surgery. Across the 20 hospitals, hospital rankings estimated in the present analysis differed significantly from ranking reported by NSQIP (P for difference: elective, P = 0.0001; urgent/emergent, P < 0.0001) with significantly and substantially lower variation after risk adjustment. Current surgical quality measures may not adequately account for limitations of sample size, data capture, adequate risk adjustment, and surgical acuity in a given hospital, particularly for rare outcomes. These differences have implications for quality reporting and may introduce bias into hospital comparisons, particularly for hospitals with incomplete capture of their patients' baseline risk and acuity.

A Multicenter Analysis of the Early Impact of COVID-19 on Junior Resident Operative Case Volume

IntroductionInstitutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic. Materials and methodsA retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys. ResultsSenior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01). ConclusionsResidents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.

Characterizing patient flow after an academic hospital merger and acquisition.

Hospital mergers and acquisitions are increasingly used as a strategy to facilitate value-based care. However, no studies have assessed health care utilization (HCU) and patient flow across merged institutions. We aim to evaluate patient population distribution, HCU, and patient flow across a recent hospital merger of an academic medical center (AMC), a primary and specialty care alliance (PSC), and a community-based medical center (CMC). This was a retrospective observational study. The study used 2018 adult demographic and encounter data from electronic health records. Patients' parent health care institution was determined by the most frequently visited site of face-to-face visits. Differences in patient demographics and HCU (ie, emergency department [ED] visits, hospitalizations, primary care visits) were compared. Independent factors associated with utilization were identified using adjusted logistic regression models. A total of 406,303 adult patients were identified in the cohort. The PSC setting, compared with the AMC and the CMC, had significantly more female (62.7% vs 54.4% and 58.5%, respectively), older (mean [SD] age, 52.0 [18.1] vs 51.1 [17.8] and 49.2 [17.8] years), and privately insured (63.6% vs 51.3% and 56.0%) patients. A higher proportion of patients at the CMC (27.5%) visited the ED compared with patients at the AMC (10.8%). Approximately 1645 primary care patients (7%) at the CMC setting went to the AMC for specialized care such as oncology, surgery, and neurology. Hospital mergers are increasing across the United States, allowing AMCs to expand their reach. These findings suggest that patients mainly sought care at their parent health care institution, yet appropriately received specialized care at the AMC. These results provide insights for future mergers and guide resource allocation and opportunities for improving care delivery.

OBSTRUCTED HEMIVAGINA AND IPSILATERAL RENAL ANOMALY SYNDROME: A NONCLASSICAL PRESENTATION WITH AN INTERCERVICAL COMMUNICATION

To describe a nonclassical presentation and infertility management of Obstructed Hemivagina with Ipsilateral Renal Agenesis Syndrome (OHVIRA), also known as Herlyn-Werner-Wunderlich Syndrome (HWWS). This is a case report of a 31-year-old female with OHVIRA syndrome who presented to a community-based medical center and fertility office. A 31-year-old female presented to her obstetric provider with a missed abortion (MAB) and decision was made for surgical management. Intraoperatively, a uterine didelphys was incidentally found due to an inability to evacuate the correct cavity during suction dilation and curettage. Additionally, the right cervix was dilated three centimeters, likely due to chronic hematocolpos and hematometria. MRI imaging suggested OHVIRA syndrome with a patent cervical connection at the level of the internal cervical os. Subsequently, she underwent complete vaginal septum excision and marsupialization. A prophylactic robotic-assisted transabdominal cerclage was then placed for concern of an incompetent cervix from chronic obstruction and intercervical communication. Finally, in vitro fertilization was undertaken, leading to a successful pregnancy outcome. OHVIRA syndrome classically presents in adolescence with nonspecific complaints of dysmenorrhea or pelvic pain. We report a nonclassical presentation of OHVIRA syndrome and illustrate a stepwise management strategy for women with this heterogenic Mullerian anomaly to achieve and maintain a pregnancy to term.

Cancer inpatient malnutrition risk, documentation, and ICD-10 coding in an academic medical center.

12107 Background: Malnutrition (MN) is common in hospitalized cancer patients but often underdiagnosed. We evaluated the prevalence of MN risk, dietitian documented MN (DDMN), and physician coded malnutrition (PCMN) in a consecutive cohort of cancer inpatients in an academic, community-based medical center. Methods: Electronic medical records (EMR) were reviewed for inpatients with a solid tumor diagnosis staged I-IV and admitted to Atrium Health Carolinas Medical Center at least once between 1/1/2016 to 5/21/2019. All data were collected from the first admission EMR encounter closest to the cancer diagnosis date. High MN risk was a score ≥2 on the Malnutrition Screening Tool (MST) completed by an RN at admission. Registered Dietitian (RD) assessments were reviewed for DDMN and grade (mild, moderate, severe). PCMN diagnosis was based on MN ICD-10 codes extracted from the medical coder’s discharge summary. Multivariate logistic regression models identified associations between clinic-demographic factors and the prevalence of DDMN and PCMN with stepwise selection. Results: N=5,143; 48% females. Median age 63 (range 18-102) years. 70% White; 24% Black, 3% Latino. Most common cancers: thoracic 19% and digestive system (14% other, 11% colorectal). 28% had known stage IV disease. The MST was completed in 79%. Among those with MST ≥2 (N=1,005; 25%), DDMN and PCMN prevalence was 30% and 22%, respectively. In the entire cohort, 8% had DDMN; 7% PCMN; 4% both. Prevalence of MN risk, DDMN, and PCMN by cancer site are in the Table. DDMN (N=420) was mild 2%, moderate 16%; severe 66%; unspecified 16%. On discharge, PCMN (N=360) was mild 10%; moderate 0%; severe 69%; unspecified 21%. Male gender (OR 1.27 [1.01, 1.59]), Black race (OR 1.57 [1.25, 1.98]), stage IV disease (v. I-III) (OR 3.08 [2.49, 3.82]), and primary site were all independent predictors of DDMN (all p&lt;0.05); Black race (OR 1.46 [1.14, 1.87]), stage IV disease (OR 2.70 [2.15, 3.39]), and primary site were independent predictors of PCMN (all p&lt;0.05). Conclusions: 25% of cancer inpatients were at high risk for MN. Primary site, disease stage, and race were independent predictors of a greater risk. MN appears to be under-diagnosed compared to population studies. This is the first study to report the prevalence of MN in a large cancer inpatient database with a representative population.[Table: see text]

Assessment of Parental Choice Predisposition for Tonsillectomy in Children

The decision to proceed with tonsillectomy to treat pediatric obstructive sleep-disordered breathing (OSDB) often falls on individual families. Despite emphasis on shared decision-making between parents and surgeons about tonsillectomy for OSDB, the extent to which parents have already decided about surgery prior to the child's consultation is not known. To identify predictors of parent choice predisposition for surgical treatment of OSDB with tonsillectomy and describe its association with parent-clinician communication. Observational cohort study conducted at 3 outpatient clinical sites (urban-based outpatient center, suburban off-site outpatient center, and community-based medical center) associated with a large academic center. A total of 149 parents of children undergoing their initial otolaryngology consultation for OSDB were identified through clinic scheduling records and deemed eligible for participation in this study. Of the 149 parents, a volunteer sample of 64 parents (42.9%) agreed to participate and have their consultation audiorecorded. Of these 64 participants, 12 parents were excluded because their child had previously been evaluated for OSDB by a specialist. The primary outcomes and measures were treatment choice predisposition scale (a measure of the strength of a patient's treatment decision prior to entering a medical consultation), parent communication behaviors coded in consultation audiorecordings (substantive questions asked, introduced medical jargon, expression of treatment preference, and scores on the OSDB and Adenotonsillectomy Knowledge Scale for parents). A total of 52 parent participants were included in the final analysis. Most parent participants were female (n = 48; 92%); 50% (n = 26) of parents were non-Hispanic White, 37% (n = 19) were Black, 10% (n = 5) were Hispanic/Latino, and 4% (n = 2) self-reported race/ethnicity as "Other." Mean (range) choice predisposition was 6.84 (2-10), with 22 parents (42%) more predisposed to choose tonsillectomy. Parents more predisposed to choose tonsillectomy used more medical jargon during the consultation (odds ratio [OR], 3.95; 95% CI, 1.16-15.15) and were less likely to ask questions (OR, 0.22; 95% CI, 0.05-0.87). Parental predictors of greater predisposition toward choosing surgery were White race (OR, 7.31; 95% CI, 1.77-39.33) and prior evaluation by a pediatrician for OSDB (OR, 6.10; 95% CI, 1.44-33.34). In this cohort study of parents of children with OSDB, many parents were predisposed to choose treatment with tonsillectomy prior to initial surgical consultation, which may lessen engagement and influence 2-way communication. In this cohort, greater predisposition for tonsillectomy was observed in non-Hispanic White parents and parents of patients who had been previously evaluated by a pediatrician for OSDB. Understanding parent choice predisposition for surgery may promote improved communication and parental engagement during surgical consultations. It may also help direct education about sleep and tonsillectomy to nonsurgical forums.

The POSITIONED Study: Prone Positioning in Nonventilated Coronavirus Disease 2019 Patients-A Retrospective Analysis.

Retrospective analysis of prospectively collected clinical data. Single-center rural community-based medical center in Grand Island, NE. One hundred five nonintubated, coronavirus disease-infected patients. None. After patients were educated on the benefits of awake self-proning, compliance was voluntary. The primary outcome was need for intubation during the hospital stay; secondary outcomes included serial peripheral capillary oxygen saturation measured by pulse oximetry to the Fio2 ratios, in-hospital mortality, and discharge disposition. Of 105 nonintubated, coronavirus disease-infected patients, 40 tolerated awake self-proning. Patients who were able to prone were younger and had lower disease severity. The risk of intubation was lower in proned patients after adjusting for disease severity using Sequential Organ Failure Assessment scores (adjusted hazard ratio, 0.30; 95% CI, 0.09-0.96; p = 0.043) or Acute Physiology and Chronic Health Evaluation II scores (adjusted hazard ratio, 0.30; 95% CI, 0.10-0.91; p = 0.034). No prone patient died compared with 24.6% of patients who were not prone (p < 0.001; number needed to treat = 5; 95% CI, 3-8). The probability of being discharged alive and peripheral capillary oxygen saturation measured by pulse oximetry to the Fio2 ratios were statistically similar for both groups. Awake self-proning was associated with lower mortality and intubation rates in coronavirus disease 2019-infected patients. Prone positioning appears to be a safe and inexpensive strategy to improve outcomes and spare limited resources. Prospective efforts are needed to better delineate the effect of awake proning on oxygenation and to improve patients' ability to tolerate this intervention.

East Tennessee State University James H. Quillen College of Medicine.

East Tennessee State University James H. Quillen College of Medicine.

Translational Nursing Science: Implementation of a Patient Fall Reduction Strategy in the Emergency Department at a Community-Based Medical Center

Translational Nursing Science: Implementation of a Patient Fall Reduction Strategy in the Emergency Department at a Community-Based Medical Center

1712. Candida auris: A Case Series at a Large Tertiary Care Medical System

Background Candida Auris has become one of the most feared pathogens globally in a relatively short period of time and, despite increased awareness, its incidence continues to rise. Recently there has been growing concern regarding drug resistance, difficulty in identification, as well as problems with eradication.MethodsLoyola Medicine includes Loyola University Medical Center, a large tertiary care transplant center, and Gottlieb Memorial Hospital, a community-based medical center. Both hospitals have reported cases of Candida auris infection. We reviewed the microbiology laboratory data and clinical information of all positively identified cases over a 17-month period.Results Candida auris was isolated from 14 patients in cultures from blood, urine, wounds, and respiratory secretions. Matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS; Burker, Biotyper RUO) was used for identification in all of the cases and susceptibility testing was performed using microbroth dilution (Sensititre, YeastOne) for all isolates. 7/14 isolates (50%) were considered resistant to fluconazole; however, none were multi-drug resistant. All 14 isolates (100%) were considered susceptible to echinocandins. In addition, all patients were critically ill and had multiple comorbidities.Conclusion Candida auris is an emerging global health threat with increasing incidence of infection. Awareness of the pathogen, appropriate contact precautions, and laboratory methods of identification are necessary. Given increasing drug resistance, we recommend susceptibility testing on all isolates. Disclosures All authors: No reported disclosures.

Relation of Telemetry Use and Mortality Risk, Hospital Length of Stay, and Readmission Rates in Patients With Respiratory Illness

The 2004 American Heart Association expert opinion-based guidelines restrict telemetry use primarily to patients with current or high-risk cardiac conditions. Respiratory infections have emerged as a common source of hospitalization, and telemetry is frequently applied without indication in efforts to monitor patient decompensation. In this retrospective study, we aimed to determine whether telemetry impacts mortality risk, length of stay (LOS), or readmission rates in hospitalized patients with acute respiratory infection not meeting American Heart Association criteria. A total of 765 respiratory infection patient encounters with Diagnosis-Related Groups 193, 194, 195, 177, 178 and 179 admitted in 2013 to 2015 to 2 tertiary community-based medical centers (Mayo Clinic, Arizona, and Mayo Clinic, Florida) were evaluated, and outcomes between patients who underwent or did not undergo telemetry were compared. Overall, the median LOS was longer in patients who underwent telemetry (3.0 days vs 2.0 days, p <0.0001). No differences between cohorts were noted in 30-day readmission rates (0.6% vs 1.3%, p = 0.32), patient mortality while hospitalized (0.6% vs 1.3%, p = 0.44), mortality at 30 days (7.9% vs 7.7%, p = 0.94), or mortality at 90 days (13.5% vs 13.5%, p = 0.99). Telemetry predicted LOS for both univariate (estimate 1.18, 95% confidence interval 1.06 to 1.32, p = 0.003) and multivariate (estimate 1.17, 95% confidence interval 1.06 to 1.30, p = 0.003) analyses after controlling for severity of illness but did not predict patient mortality. In conclusion, this study identified that patients with respiratory infection who underwent telemetry without clear indications may face increased LOS without reducing their readmission risk or improving the overall mortality.

Prevalence of potential nonallergic rhinitis at a community-based sleep medical center.

Nonallergic rhinitis (NAR) is a common condition involving symptomatic nasal congestion, stuffiness, or rhinorrhea, which overlap with symptoms of allergic rhinitis. Scant research has examined NAR and sleep. The aim of this study was to assess the frequency of potential NAR symptoms in a large sample of sleep center patients. A retrospective chart review was conducted on 2658 adult patients at our sleep center from 2008 to 2012; 1703 reported clinically relevant nasal congestion. For this subset, potential NAR status (NAR+ vs NAR-) was determined using a brief survey. NAR groups were further divided into three sub-groups based on presenting chief complaints: insomnia (INS), nonrestorative sleep (NRS), and sleep-disordered breathing (SDB). Patients objectively diagnosed with SDB were also analyzed by NAR status. Validated scales for sleepiness, insomnia, anxiety, and depression were compared among the groups. Potential NAR+ comprised 70% (1194 of 1703) of patients with congestion and showed significantly higher congestion scores than NAR- status [11.97 (3.62) vs 10.47 (3.37); p=.001; g=0.42; 95% CI, 0.32-0.53]. The proportion of potential NAR+ cases for each presenting chief complaint was nearly identical (range 69.6 to 71.2%). However, the comparison of effects between NAR+ and NAR- cases within each presenting group (INS, NRS, SDB) was more consistently significant on the scales for insomnia, sleepiness, anxiety, and depression only in the SDB category. The same four symptoms, measured in those objectively diagnosed with SDB, were also significantly worse in NAR+ compared to NAR- patients. Regardless of presenting chief complaint and ultimate diagnosis of sleep-disordered breathing, potential nonallergic rhinitis was common in patients at a sleep medical center at a rate possibly greater than twice that reported in the general population. Potential NAR+ was associated with worse sleep and distress symptoms. In both prevalence and treatment studies, research must further evaluate the potential impact of NAR on specific sleep disorders.

Tu1186 The Role of Integrated Relaxation Pressure Assessed by Using High Resolution Manometry in Achalasia Patients

Background: Esophageal symptoms are common in the general population, and include dysphagia, heartburn and chest pain. High-resolution manometry (HRM) is often utilized to characterize motility disorders as contributors to these symptoms. Studies using HRM have been largely performed at specialized tertiary medical centers, and thus could be influenced by referral bias. To date, there are no studies evaluating the type and frequency ofmotility abnormalities in patients presenting in a community setting.Methods: A retrospective review of 100 consecutive HRM studies for adult patients was performed at a single, community-based medical center in Rockford, IL from January 2012 through December 2013. The Chicago Classification was applied to characterize motility findings. EGD and esophagram studies performed within 2 months of HRM were reviewed. Results: In this community-based study, 59% of patients who underwent HRM met major manometric criteria for esophageal abnormalities. Achalasia (I,II,III) was the most common major manometric abnormality (n=17), followed by esophagogastric junction (EGJ) outflow obstruction (n=10), and hypercontractile esophagus, including jackhammer (n=7) and nutcracker (n= 1). Weak peristalsis with large defects (n=3) and small defects (n=8) accounted for the most common minor criteria. Patients who underwent HRM most commonly presented with dysphagia (54%), followed by heartburn (25%) and chest pain (16%).Manometric abnormalities were present in 42/58 (72%) presenting with dysphagia, 14/26 (54%) with heartburn, and 7/17 (41%) with chest pain. Dysphagia to liquids, when noted by clinicians, was associated withmanometric abnormalities 72% of the time. In those patients withmanometric abnormalities, findings of abnormal esophagram (radiologist observed tertiary contractions, presbyesophagus, spasm, or dysmotility) were seen in 28/35 (80%) patients (SEN 80%; SPEC 36%; ACC 67%). Abnormal EGD findings (gastroenterologist observed dysmotility and/or spasm, significant retained food, tight LES, or suspected achalasia) were seen in 33/ 54 (61%) patients (SEN 61%; SPEC 65%; ACC 63%). In those HRM(abnormal) patients that received both EGD and esophagram, the presence of concurrent abnormalities in these tests occurred in only 17/35 (49%) patients (SEN 49%; SPEC 71%; ACC 55%).Conclusions: To our knowledge, this is the first community-based study to characterize esophageal symptoms using high-resolution esophageal manometry. Manometric abnormalities were common, seen in nearly 60% of patients, and included achalasia (28% of all abnormalities),

Tu1185 Community-Based Characterization of Esophageal Motility Disorders Using High-Resolution Manometry (HRM) in Symptomatic Adults

Background: Esophageal symptoms are common in the general population, and include dysphagia, heartburn and chest pain. High-resolution manometry (HRM) is often utilized to characterize motility disorders as contributors to these symptoms. Studies using HRM have been largely performed at specialized tertiary medical centers, and thus could be influenced by referral bias. To date, there are no studies evaluating the type and frequency ofmotility abnormalities in patients presenting in a community setting.Methods: A retrospective review of 100 consecutive HRM studies for adult patients was performed at a single, community-based medical center in Rockford, IL from January 2012 through December 2013. The Chicago Classification was applied to characterize motility findings. EGD and esophagram studies performed within 2 months of HRM were reviewed. Results: In this community-based study, 59% of patients who underwent HRM met major manometric criteria for esophageal abnormalities. Achalasia (I,II,III) was the most common major manometric abnormality (n=17), followed by esophagogastric junction (EGJ) outflow obstruction (n=10), and hypercontractile esophagus, including jackhammer (n=7) and nutcracker (n= 1). Weak peristalsis with large defects (n=3) and small defects (n=8) accounted for the most common minor criteria. Patients who underwent HRM most commonly presented with dysphagia (54%), followed by heartburn (25%) and chest pain (16%).Manometric abnormalities were present in 42/58 (72%) presenting with dysphagia, 14/26 (54%) with heartburn, and 7/17 (41%) with chest pain. Dysphagia to liquids, when noted by clinicians, was associated withmanometric abnormalities 72% of the time. In those patients withmanometric abnormalities, findings of abnormal esophagram (radiologist observed tertiary contractions, presbyesophagus, spasm, or dysmotility) were seen in 28/35 (80%) patients (SEN 80%; SPEC 36%; ACC 67%). Abnormal EGD findings (gastroenterologist observed dysmotility and/or spasm, significant retained food, tight LES, or suspected achalasia) were seen in 33/ 54 (61%) patients (SEN 61%; SPEC 65%; ACC 63%). In those HRM(abnormal) patients that received both EGD and esophagram, the presence of concurrent abnormalities in these tests occurred in only 17/35 (49%) patients (SEN 49%; SPEC 71%; ACC 55%).Conclusions: To our knowledge, this is the first community-based study to characterize esophageal symptoms using high-resolution esophageal manometry. Manometric abnormalities were common, seen in nearly 60% of patients, and included achalasia (28% of all abnormalities),

Pharmacoeconomic effect of compliance with pharmacist's intervention based on cancer chemotherapy regimens: a cohort study.

BackgroundIt is important for pharmacists to manage cancer chemotherapy regimens in order to achieve safe treatment. We examined whether there was a useful pharmacoeconomic benefit of compliance the exclusion criteria of neutropenia, and the importance of a pharmacist's intervention was considered.MethodsA prospective observational cohort study was conducted at a community-based medical center. Among 374 patients who received chemotherapy between April 2010 and March 2011, 108 patients developed neutropenia and pharmacists recommended suspension of chemotherapy. These patients were divided into a group in whom chemotherapy was suspended (complying group) and a group in whom it was continued (non-complying group). Then the relative dose intensity (RDI) was compared between the two groups, and medical expenses related to the treatment of neutropenia (neutropenia-related costs: NRC) were compared. Analysis was carried out from the perspective of the health insurance provider, so only the direct medical costs were evaluated.ResultsThere was a significant difference of the RDI between a complying group (85.2 ± 10.0%) and a non-complying group (79.3 ± 15.0%) (P = 0.021). The average NRC per patient showed a significant difference between the two groups (complying group: 1,944 ± 412 dollars, non-complying group: 4,394 ± 837 dollars, P = 0.044). The economic effect over one year was 54,205 dollars.ConclusionThe present findings suggest that ensuring compliance with chemotherapy regimens (including the criteria for neutropenia) is effective from a pharmacoeconomic perspective. Accordingly, pharmacists should intervene as required to improve regimen compliance.

Effects of computerized physician order entry on medication turnaround time and orders requiring pharmacist intervention

Previous studies have demonstrated that computerized physician order entry (CPOE) of prescriptions reduces both turnaround time (TAT) and medication errors. However, these studies have been performed primarily in large academic centers with a relatively small number of medication orders. As such, many studies investigating the impact of CPOE on the level of pharmacist intervention have yielded conflicting results. The objective of this study was to examine the effects of CPOE on medication order TAT and the frequency of medication orders requiring pharmacist intervention in a community-based medical center. A prospective cohort study was conducted at a community-based medical center. A total of 24,767 prescriptions written for 940 patients over a six-month period were stratified into CPOE or non-CPOE (handwritten) cohorts. TAT between cohorts were tested using analysis of variance and Tukey's Honestly Significant Difference test. The number of orders requiring pharmacist intervention was compared between cohorts and tested using chi-square test or Fisher's exact test. Medication orders requiring pharmacist intervention were stratified by patient characteristics, therapeutic class, and types of medication error. Medication orders not using CPOE were approximately 8 times more likely to require pharmacist intervention (2.26% versus 0.29%; P < 0.001), with the majority of pharmacist interventions performed to prevent medication errors. The overall mean TAT for medication orders was significantly shorter in the CPOE group in comparison with the non-CPOE group (22.2 ± 86.5 min versus 81 ± 256.7 min; P < 0.001). CPOE orders nearly eliminated medication errors with wrong dosage forms and formulary issues. Medication orders entered via CPOE are associated with a significant reduction in medication TAT and less likely to require pharmacist intervention. Use of CPOE may improve quality of patient care and efficiency of health care delivery.