Community-based Outpatient Clinics Research Articles

Postpartum Primary Care Engagement Using Default Scheduling and Tailored Messaging

More than 30% of pregnant people have at least 1 chronic medical condition, and nearly 20% develop gestational diabetes or pregnancy-related hypertension, increasing the risk of future chronic disease. While these individuals are often monitored closely during pregnancy, they face major barriers when transitioning to primary care following delivery, due in part to a lack of health care support for this transition. To evaluate the impact of an intervention designed to improve postpartum primary care engagement by reducing patient administrative burden and information gaps. An individual-level randomized clinical trial was conducted from November 3, 2022, to October 11, 2023, at 1 hospital-based and 5 community-based outpatient obstetric clinics affiliated with a large academic medical center. Participants included English- and Spanish-speaking pregnant or recently postpartum adults with obesity, anxiety, depression, diabetes, chronic hypertension, gestational diabetes, or pregnancy-related hypertension and a primary care practitioner (PCP) listed in their electronic health record. A behavioral economics-informed intervention bundle, including default scheduling of postpartum PCP appointments and tailored messages. Completion of a PCP visit for routine or chronic condition care within 4 months of delivery was the primary outcome, ascertained directly by reviewing the patient's electronic health record approximately 5 months after their estimated due date. Intention-to-treat analysis was conducted. A total of 360 patients were randomized (control, 176; intervention, 184). Individuals had a mean (SD) age of 34.1 (4.9) years and median gestational age of 36.3 (IQR, 34.0-38.6) weeks at enrollment. The distribution of self-reported race and ethnicity was 6.8% Asian, 7.4% Black, 68.6% White, and 15.0% multiple races or other. Most participants (75.4%) had anxiety or depression, 16.1% had a chronic or pregnancy-related hypertensive disorder, 19.5% had preexisting or gestational diabetes, and 40.8% had a prepregnancy body mass index of 30 or greater. Medicaid was the primary payer for 21.2% of patients. Primary care practitioner visit completion within 4 months occurred in 22.0% (95% CI, 6.4%-28.8%) of individuals in the control group and 40.0% (95% CI, 33.1%-47.4%) in the intervention group. In regression models accounting for randomization strata, the intervention increased PCP visit completion by 18.7 percentage points (95% CI, 9.1-28.2 percentage points). Intervention participants also had fewer postpartum readmissions (1.7% vs 5.8%) and increased receipt of the following services by a PCP: blood pressure screening (42.8% vs 28.3%), weight assessment (42.8% vs 27.7%), and depression screening (32.8% vs 16.8%). The findings of this randomized clinical trial suggest that the current lack of support for postpartum transitions to primary care is a missed opportunity to improve recently pregnant individual's short- and long-term health. Reducing patient administrative burdens may represent relatively low-resource, high-impact approaches to improving postpartum health and well-being. ClinicalTrials.gov Identifier: NCT05543265.

The role of symptom reduction in improving health-related quality of life through brief cognitive behavioral therapy

Objective Brief cognitive behavior therapy (bCBT) is effective in reducing symptoms of depression and anxiety disorders and improving health-related quality of life (HRQoL). However, the mechanisms through which cognitive behavior therapy impact HRQoL are not well understood. This study evaluated whether anxiety and depression symptom reduction is a mechanism of treatment for HRQoL outcomes. Method: Using secondary data from a multisite, pragmatic, randomized trial, this study evaluated bCBT vs enhanced usual care in 16 VA community-based outpatient clinics. Ordinary least-squares path analysis testing multiple mediators was used to evaluate the role of change in depression and anxiety symptoms in the relationship between treatment condition and HRQoL. Results: Receiving bCBT (vs. enhanced usual care) was significantly negatively associated with change (reduction) in depression and anxiety scores. The indirect effect of treatment on mental HRQoL was significant with change in depression scores as mediator. A similar pattern was observed for physical HRQoL and change in anxiety scores as mediator. Conclusion: Findings suggest reduction of depression and anxiety symptoms as a mechanism through which bCBT for depression promoted improvements in HRQoL, with important implications for understanding how CBT impacts functioning, as well as the utility of bCBT in nontraditional mental health settings. Trial registration: ClinicalTrials.gov identifier: NCT02466126.

Contingency management for substance use disorders in the U.S. Veterans Health Administration: 2018–2022

Introduction: Contingency management (CM) is one of the most effective interventions for substance use disorders (SUDs), including stimulant use disorder. In the United States, the Veterans Health Administration (VHA) led the largest-scale rollout of CM in the US to date, but little is known about characteristics of patients treated and CM clinical practices.Methods: In this retrospective cohort study, we used VHA electronic health records data to descriptively examine CM treatment course (e.g., number of visits, time between visits, duration of treatment episode) and characteristics of patients receiving CM for SUDs from 2018 to 2022.Results: From January 2018 to September 2022, 2844 patients received CM at 90 VA Health Systems (including 98 VA Medical Center, 7 community-based outpatient clinics, and 15 other sites). The median number of CM visits was 8 (mean = 10.17, SD = 8.12) visits over the course of 1.5 months (median = 45 days, mean = 57.46 days, SD = 62.65). The target substance was stimulants in 86.42 % of visits. Average age of patients was 52.29 years (SD = 12.10), with 55.06 % of patients experiencing homelessness or housing instability, and 97.50 % of patients diagnosed with more than one SUD. Compared to the year prior to the COVID-19 pandemic (03/2019–02/2020; mean = 957.33, SD = 157.71 visits/month), CM visits declined by 83.20 % in the year following the pandemic (03/2020–02/2021; mean = 160.83, SD = 164.14), and have yet to return to pre-pandemic levels.Conclusions: The CM rollout has been markedly successful in the VHA, with adoption across multiple VHA sites within a complex patient population, indicating the potential for effective, more widespread CM implementation. At the same time, there was a considerable reduction in CM care during the COVID-19 pandemic and CM has not yet returned to pre-pandemic levels. Moreover, only a small minority of VA patients with stimulant use disorder have received CM. Given increasing rates of overdose, including stimulant-involved overdose, it is important to increase CM provision in VHA and non-VHA settings.

Low back pain management in primary healthcare: findings from a scoping review on models of care

IntroductionModels of care (MoCs) describe evidence-informed healthcare that should be delivered to patients. Several MoCs have been implemented for low back pain (LBP) to reduce evidence-to-practice gaps and increase the...

Barriers and Facilitators to Teledermatology and Tele-Eye Care in Department of Veterans Affairs Provider Settings: Qualitative Content Analysis.

Veterans Affairs health care systems have been early adopters of asynchronous telemedicine to provide access to timely and high-quality specialty care services in primary care settings for veterans living in rural areas. Scant research has examined how to expand primary care team members' engagement in telespecialty care. This qualitative study aimed to explore implementation process barriers and facilitators to using asynchronous telespecialty care (teledermatology and tele-eye care services). In total, 30 participants including primary care providers, nurses, telehealth clinical technicians, medical and program support assistants, and administrators from 2 community-based outpatient clinics were interviewed. Semistructured interviews were conducted using an interview guide, digitally recorded, and transcribed. Interview transcripts were analyzed using a qualitative content analysis summative approach. Two coders reviewed transcripts independently. Discrepancies were resolved by consensus discussion. In total, 3 themes were identified from participants' experiences: positive perception of telespecialty care, concerns and challenges of implementation, and suggestions for service refinement. Participants voiced that the telemedicine visits saved commute and waiting times and provided veterans in rural areas more access to timely medical care. The mentioned concerns were technical challenges and equipment failure, staffing shortages to cover both in-person and telehealth visit needs, overbooked schedules leading to delayed referrals, the need for a more standardized operation protocol, and more hands-on training with formative feedback among supporting staff. Participants also faced challenges with appointment cancellations and struggled to find ways to efficiently manage both telehealth and in-person visits to streamline patient flow. Nonetheless, most participants feel motivated and confident in implementing telespecialty care going forward. This study provided important insights into the positive perceptions and ongoing challenges in telespecialty care implementation. Feedback from primary care teams is needed to improve telespecialty care service delivery for rural veterans.

Nurse and Social Worker Palliative Telecare Team and Quality of Life in Patients With COPD, Heart Failure, or Interstitial Lung Disease

Many patients with chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) endure poor quality of life despite conventional therapy. Palliative care approaches may benefit this population prior to end of life. Determine the effect of a nurse and social worker palliative telecare team on quality of life in outpatients with COPD, HF, or ILD compared with usual care. Single-blind, 2-group, multisite randomized clinical trial with accrual between October 27, 2016, and April 2, 2020, in 2 Veterans Administration health care systems (Colorado and Washington), and including community-based outpatient clinics. Outpatients with COPD, HF, or ILD at high risk of hospitalization or death who reported poor quality of life participated. The intervention involved 6 phone calls with a nurse to help with symptom management and 6 phone calls with a social worker to provide psychosocial care. The nurse and social worker met weekly with a study primary care and palliative care physician and as needed, a pulmonologist, and cardiologist. Usual care included an educational handout developed for the study that outlined self-care for COPD, ILD, or HF. Patients in both groups received care at the discretion of their clinicians, which could include care from nurses and social workers, and specialists in cardiology, pulmonology, palliative care, and mental health. The primary outcome was difference in change in quality of life from baseline to 6 months between the intervention and usual care groups (FACT-G score range, 0-100, with higher scores indicating better quality of life, clinically meaningful change ≥4 points). Secondary quality-of-life outcomes at 6 months included disease-specific health status (Clinical COPD Questionnaire; Kansas City Cardiomyopathy Questionnaire-12), depression (Patient Health Questionnaire-8) and anxiety (Generalized Anxiety Disorder-7) symptoms. Among 306 randomized patients (mean [SD] age, 68.9 [7.7] years; 276 male [90.2%], 30 female [9.8%]; 245 White [80.1%]), 177 (57.8%) had COPD, 67 (21.9%) HF, 49 (16%) both COPD and HF, and 13 (4.2%) ILD. Baseline FACT-G scores were similar (intervention, 52.9; usual care, 52.7). FACT-G completion was 76% (intervention, 117 of 154; usual care, 116 of 152) at 6 months for both groups. Mean (SD) length of intervention was 115.1 (33.4) days and included a mean of 10.4 (3.3) intervention calls per patient. In the intervention group, 112 of 154 (73%) patients received the intervention as randomized. At 6 months, mean FACT-G score improved 6.0 points in the intervention group and 1.4 points in the usual care group (difference, 4.6 points [95% CI, 1.8-7.4]; P = .001; standardized mean difference, 0.41). The intervention also improved COPD health status (standardized mean difference, 0.44; P = .04), HF health status (standardized mean difference, 0.41; P = .01), depression (standardized mean difference, -0.50; P < .001), and anxiety (standardized mean difference, -0.51; P < .001) at 6 months. For adults with COPD, HF, or ILD who were at high risk of death and had poor quality of life, a nurse and social worker palliative telecare team produced clinically meaningful improvements in quality of life at 6 months compared with usual care. ClinicalTrials.gov Identifier: NCT02713347.

The role of Department of Veterans Affairs community-based outpatient clinics in enhancing rural access to geriatrics telemedicine specialty care.

Half of the 4.7 M veterans who reside in rural communities and rely on U.S. Department of Veterans Affairs (VA) health care are older (≥65). Their rurality presents unique challenges, including a shortage of clinicians skilled in geriatric medicine. Community-based outpatient clinics (CBOCs) help extend VA's geographic reach but are typically located in under-resourced settings. Telemedicine may increase access to care, but little is known about CBOCs' capacity to leverage telemedicine to meet older patients' needs. We identified organizational barriers and facilitators to the use of geriatric telemedicine specialty care from the perspective of rural clinicians and staff. From February-April 2020, we interviewed CBOC clinicians and staff (N = 50) from 13 rural CBOCs affiliated with four VA Geriatric Research Education and Clinical Centers. Semi-structured interviews addressed patient population characteristics; CBOC location, staffing, and in-house resources; use of VA specialty care services; and telemedicine use. We developed a codebook using an iterative process and Gale's Framework Method thematically organize and analyze data. Respondents perceived that their CBOCs serve a predominantly older patient population. Four characteristics enabled CBOCs to offer geriatric telemedicine specialty care: partnerships with larger VA Medical Center teams; social worker/telehealth clinical technician knowledge of geriatrics and telehealth resources; periodic outreach/education from geriatric specialists; and routine use of other telehealth services. Barriers included: constraints on clinic space and unstable internet for telemedicine visits; staffing challenges leading to limited familiarity with telemedicine resources; and clinician and staff perceptions of older veterans' preference for in-person visits. Telemedicine is an important modality to enhance access to care for an increasingly older and medically complex patient population. Although rural CBOCs provide a large portion of care to VA's growing geriatric population, staff are insufficiently trained in geriatrics, work in resource-poor settings, and are largely unaware of VA telemedicine programs designed to support them.

13 Investigating the Influence of Educational Attainment and Crystalized Verbal Skills on Verbal Fluency Performance Among Patients from a Community-Based Outpatient Neurology Clinic

Objective:Neuropsychological measures of verbal fluency help detect cognitive decline and neuropathology. The discrepancy between semantic verbal fluency and phonemic verbal fluency is commonly utilized to differentiate between cortical and subcortical processes. Understanding how other factors influence a patient’s verbal fluency scores is vital in informing clinical interpretation of neuropsychological test data. This study aimed to investigate how educational attainment and crystalized verbal skills (i.e., word reading and vocabulary) influence verbal fluency performance among a clinical sample of patients seen for neuropsychological evaluation services at a community-based outpatient neurology clinic.Participants and Methods:We utilized data from N=26 patients [mean age = 50.5 (SD = 22.0), 31% female, mean education = 13.5 (SD = 2.3)] who completed neuropsychological evaluations as part of their clinical care at an outpatient neurology clinic. Participants were included in this study if they had complete data for all variables of interest. We used Pearson correlation analyses to investigate associations between each predictor variable of interest (years of education, WRAT-5 Reading, WASI-2 Vocabulary) and age-norm corrected D-KEFS Verbal Fluency scores. Prior to analysis, all variables were converted to z-scores.Results:We found that years of education (r = 0.49, p = 0.01) and vocabulary (r = 0.41, p = 0.04) were significantly positively correlated with category fluency performance. Reading was also positively correlated with category fluency at trend level, but this association was not statistically significant (r = 0.36, p = 0.07). We found that vocabulary (r = 0.47, p = 0.02) and reading (r = 0.51, p = 0.007) were significantly positively correlated with phonemic fluency performance, while the association between education and phonemic verbal fluency performance was not significant (r = 0.27, p = 0.18).Conclusions:Our results suggest that educational attainment and crystalized verbal skills are positively associated with verbal fluency performance, though the degree of influence of these individual factors may differ for category fluency vs phonemic fluency performance. Our results have implications for the clinical practice of neuropsychology. Namely, appreciating a patient’s educational attainment and crystalized verbal skills can help guide clinical interpretation of whether or not a patient’s verbal fluency test scores reflect a decline from their baseline. This may be particularly important to consider among patients with high educational attainment or high premorbid verbal skills, as a subtle decline in their verbal fluency abilities may not be appreciated if relying only on age-based norms for interpretation. This is clinically relevant including when assessing for the early stages of neurodegenerative disorders (e.g., Alzheimer’s disease, Primary Progressive Aphasia) or for subtle changes associated with stroke or brain injury.

Expanding access to evidence-based psychotherapy in VA settings: implementation of the brief cognitive behavioral therapy for depression program.

Evidence-based psychotherapies (EBPs) are effective for mental health conditions, but access to these services remains limited and rural Veterans are particularly underserved. Specialized implementation and dissemination programs are needed to improve access to known EBPs. The current project sought to improve access to a known EBP-brief Cognitive Behavioral Therapy for depression (Brief CBT). Diverse Veterans and those from rural settings were a focus of this work. Aligned with the RE-AIM framework, a multifaceted implementation program was used to train and support VHA providers in their use of Brief CBT in VHA mental health settings, with specific outreach efforts made to providers at VHA Community-Based Outpatient Clinics (CBOCs) where rural Veterans often receive care. Evaluation included all facets of RE-AIM with a particular focus on adoption, effectiveness, and maintenance. During the first two years, over 40 VHA facilities adopted the program across four regional networks. Eighty-three providers were approached, and 54 (65.1%) providers completed the training and are delivering the intervention. A total of 688 Veterans, 174 rural (25.7%), received 2,186 sessions (average of 3.5 sessions per Veteran). Veterans receiving Brief CBT with elevated depression scores who completed three or more sessions were found to have significant symptom reductions of 4.6 points (first to last available evaluations). Implementation efforts of Brief CBT resulted in rapid uptake and significant clinical impact on Veterans. Rural outreach efforts, including targeted training for CBOC providers and use of tele-mental health, enhanced availability of EBP services for rural Veterans.

Brief Cognitive-Behavioral Therapy for Depression in Community Clinics: A Hybrid Effectiveness-Implementation Trial.

The authors examined whether brief cognitive-behavioral therapy (bCBT) for depression, delivered by mental health providers in community-based outpatient clinics (CBOCs) of the Veterans Health Administration, improved depression outcomes and was feasible and acceptable in clinical settings. The authors used a type-2 hybrid effectiveness-implementation, patient-randomized trial to compare bCBT with enhanced usual care. Participants (N=189) with moderate symptoms of depression (Patient Health Questionnaire-9 [PHQ-9] score ≥10) were enrolled from CBOCs in the southern United States. bCBT (N=109) consisted of three to six sessions, delivered by mental health providers (N=17) as part of routine clinic practices. Providers received comprehensive training and support to facilitate bCBT delivery. Recipients of enhanced usual care (N=80) were given educational materials and encouraged to discuss treatment options with their primary care provider. The primary effectiveness outcome was PHQ-9-assessed depression symptoms posttreatment (4 months after baseline) and at 8- and 12-month follow-ups. Implementation outcomes focused on bCBT dose received, provider fidelity, and satisfaction with bCBT training and support. bCBT improved depression symptoms (Cohen's d=0.55, p<0.01) relative to enhanced usual care posttreatment, and the improvement was maintained at 8- and 12-month follow-ups (p=0.004). bCBT participants received a mean±SD of 3.7±2.7 sessions (range 0-9), and 64% completed treatment (≥3 sessions). Providers delivered bCBT with fidelity and reported that bCBT training and support were feasible and effective. bCBT had a modest treatment footprint of approximately four sessions, was acceptable to participants and providers, was feasible for delivery in CBOCs, and produced meaningful sustained improvements in depression.

43322 A 10-year population-based prevalence study of the burden of palmoplantar pustulosis in Canadian patients hospitalized or seen in emergency departments and hospital- or community-based outpatient clinics

43322 A 10-year population-based prevalence study of the burden of palmoplantar pustulosis in Canadian patients hospitalized or seen in emergency departments and hospital- or community-based outpatient clinics

44100 A 3-year population-based incidence study of the burden of generalized pustular psoriasis in Canadian patients hospitalized or seen in emergency departments and hospital- or community-based outpatient clinics

44100 A 3-year population-based incidence study of the burden of generalized pustular psoriasis in Canadian patients hospitalized or seen in emergency departments and hospital- or community-based outpatient clinics

43266 A 10-year population-based prevalence study of the burden of generalized pustular psoriasis in Canadian patients hospitalized or seen in emergency departments and hospital- or community-based outpatient clinics

43266 A 10-year population-based prevalence study of the burden of generalized pustular psoriasis in Canadian patients hospitalized or seen in emergency departments and hospital- or community-based outpatient clinics

44118 A 3-year population-based incidence study of the burden of palmoplantar pustolosis in Canadian patients hospitalized or seen in emergency departments and hospital- or community-based outpatient clinics

44118 A 3-year population-based incidence study of the burden of palmoplantar pustolosis in Canadian patients hospitalized or seen in emergency departments and hospital- or community-based outpatient clinics

1050-P: Implementation of Professional Continuous Glucose Monitoring in VA Primary Care Clinics

Background: Professional continuous glucose monitoring (proCGM) can be used sporadically for patients who do not meet criteria for Personal CGM. The interdisciplinary nature of primary care teams from Veterans Affairs Community Based Outpatient Clinics (CBOCs) represents a good opportunity for implementation of proCGM technology to improve glycemic control. Objectives: To assess treatment changes prompted by proCGM implementation. Methods: Veterans with suboptimal glycemic control (A1c &amp;gt;7.5% or hypoglycemia) who did not qualify for a personal CGM had a proCGM placed during office visit. Two weeks later, the proCGM was downloaded during a follow-up visit and changes were implemented as needed. Results: Thirty-eight sensors were placed in 36 patients (two patients repeat after sensor fell off) seen by clinical pharmacists from 5 CBOCs from North Florida/South Georgia VA Health System. Baseline A1c was 8.1% (SD 1.3), proCGM data was available in 91% of patients. Mean duration of sensors was 13 days (SD 3.3). In 36% of patients, there was insulin de-intensification, mainly because of hypoglycemic events. In 6% of patients, an oral agent was discontinued because their time in range was above 90% and side effect profile (weight gain). About 18% of veterans needed insulin intensification, either adding short acting insulin or increasing basal insulin. Overall, significant treatments changes were implemented in 60% of patients, thus, avoiding clinical inertia. High glucose variability (% coefficient of variation &amp;gt;33%) was present in 45% of veterans and two thirds of them required de-intensification of their insulin regimen due to hypoglycemia. Conclusions: Implementation of proCGM in primary care clinics led to treatment changes in 60% of patients. This improvement project demonstrated feasibility of deploying new diabetes technologies in primary care setting. Disclosure K.Saren: None. A.L.Raulerson: None. S.Finch: None. J.A.Leey: None. Funding U.S. Department of Veterans Affairs Office of Rural Health

Expanding veteran treatment access points through Close To Me (CTM) infusion service.

1519 Background: Diagnosing and treating more than 43,000 Veterans annually, the Veterans Affairs (VA) National Oncology Program (NOP) oversees the largest integrated providers of hematology/oncology services in the US. Within the VA, parenteral therapies are primarily offered at VA Medical Centers (VAMC) in urban areas, often inaccessible to rural patients. Travel distance, parking, time, and caregiver support can prevent patients from adhering to treatment regimens. To resolve these challenges, NOP launched the Close to Me (CTM) infusion service. The service seeks to reduce travel time for patients, improve VA care continuity, and increase access points to patient-centric care by administering treatments utilizing the network of VA Community Based Outpatient Clinics (CBOC). Methods: In the CTM CBOC infusion service select medications are compounded at the main VAMC, then transported via a registered nurse to the surrounding CBOCs for administration. Eligible patients must be established with a VA hematologist/oncologist and tolerated 1 cycle of treatment at the VAMC. Patients are assessed via telehealth prior to each treatment at the CBOC. Patient drive miles saved was calculated by subtracting the mileage between the patient’s home address and the CBOC from the patient’s home address and the VAMC, then multiplied by number of treatment visits at the CBOC. Medication cost avoidance was calculated by subtracting the VA purchase price from the 2023 published Centers for Medicare and Medicaid Services reimbursement rates, then multiplied by number of treatments received at the CBOC. The first CTM CBOC clinics were opened within the Minneapolis VA Health Care System in October 2021, followed by the VA Pittsburgh Healthcare System in June 2022. Results: From October 2021 through December 2022, 373 unique patients were treated within CTM CBOC clinics for a total of 532 patient visits. The CTM infusion service resulted in 43,249 patient drive miles saved and 813,352 in medication cost avoidance. No medical emergencies were reported during CTM CBOC treatments. One medication was discarded without use due to damage during shipping. One compounded product was not used due to change in patient status. One patient was non-adherent with treatment appointments on two occasions resulting in an overall 99.6 % treatment adherence. Conclusions: The CTM infusion service optimizes current VA infrastructure to increase access points to hematology/oncology treatment, reduce travel burden for patients, increase treatment appointment adherence and reduce medication cost expenditures. To facilitate expansion of this successful service, NOP has provided funding and support to 11 additional VAMCs to implement one of the CTM solutions including CBOC, mobile infusion unit or home infusion. A comprehensive implementation toolkit was developed to encourage the independent adoption of this service at appropriate locations across VA.

Feasibility of a low-intensity intervention to improve antimicrobial use in outpatient settings

Background: Overall, ~12% of outpatient visits result in an antibiotic prescription, and 30% of those prescriptions are inappropriate. Behavioral nudges help influence practitioner behavior. We hypothesized that peer comparison combined with a behavioral nudge (a patient alert letter) would influence prescribers to reduce antibiotic prescriptions and improve antimicrobial stewardship in the outpatient setting. We pilot-tested this intervention in outpatient primary care clinics associated with a large Veterans Affairs (VA) medical center. Methods: We conducted a clustered randomized controlled trial of 12 community-based outpatient clinics. All practitioners in the intervention arm received quarterly comparative feedback reports and, when indicated, quarterly patient alert letters. Comparative feedback reports gave personalized feedback about antibiotic prescriptions for upper respiratory tract infections, comparing the recipient’s antibiotic prescriptions to the average for all practitioners at the primary care clinics included in our study. Patient alert letters notified practitioners to patients in their panel with recently detected Clostridioides difficile or resistant organism and their antibiotic exposures. We assessed outpatient visits during the preintervention period (April–September 2020), the intervention period (October 2020–September 2021), and the postintervention period (October 2021–September 2022). A mixed-effects logistic regression model predicting antibiotic prescriptions compared the arms across these periods. Results: The outpatient populations observed in the intervention and control arms were similar during each phase of the study. Prior to the intervention, the average proportion of visits with an antibiotic prescription was lower among clinics in the intervention arm (1.4% vs 1.8% in control arm; P = .45). This difference broadened slightly during the intervention period (1.4% vs 2.1%, respectively; P = .03) and the postintervention period (1.3% vs 2.1%, respectively; P = .01) (Fig. 1). Throughout the study, clinics in the intervention arm typically used more doxycycline and azithromycin and less amoxicillin-clavulanate and sulfamethoxazole-trimethoprim compared to clinics in the control arm. (Fig. 2). In the 6-month preintervention period, which coincided with the early phase of the COVID-19 pandemic, antibiotic prescriptions in the intervention compared to control clinics were similar. During the intervention and postintervention periods, the proportion of visits with an antibiotic prescription remained steady for clinics in the intervention arm and increased for those in the control arm. These results suggest that this pilot study using a low-intensity intervention consisting of comparative feedback reports and patient alert letters was successful in influencing the antibiotic prescribing behavior of primary care clinicians practicing in community-based outpatient clinics affiliated with a VA medical center.Financial support: This study was funded by Merck.Disclosures: None

The burden associated with generalized pustular psoriasis: A Canadian population-based study of inpatient care, emergency departments, and hospital- or community-based outpatient clinics

Not much is known about the burden of generalized pustular psoriasis (GPP). To document the burden of GPP in Canada and to compare it with psoriasis vulgaris (PV). National data were used to identify Canadian adult patients with GPP or PV hospitalized or visiting an emergency department (ED) or hospital-/community-based clinic between April 1, 2007, and March 31, 2020. Analyses of 10-year prevalence and 3-year incidence were conducted. Costs were determined when the most responsible diagnosis (MRD) was GPP or PV (MRD costs) and for all reasons (all-cause costs). In the prevalence analysis, 10-year mean (SD) MRD costs were $2393 ($11,410) for patients with GPP and $222 ($1828) for those with PV (P<.01). In the incidence analysis, patients with GPP had higher 3-year mean (SD) MRD costs ($3477 [$14,979] vs $503 [$2267] for PV; P<.01). Higher all-cause costs were also associated with patients with GPP. Inpatient/ED mortality was higher in the GPP group in our 10-year prevalence (9.2% for patients with GPP vs 7.3% for those with PV; P=.01) and 3-year incidence (5.2% for patients with GPP and 2.1% for those with PV; P=.03) analyses. Physician and prescription drug data were not available. Patients with GPP incurred higher costs and mortality than patients with PV.

Women's Health Provider Perspectives on Reproductive Services Provision in the Veterans Health Administration.

Women veterans are a fast-growing population in the Veterans Health Administration (VHA), and ensuring reproductive service availability is a VHA priority. As such, we sought to explore barriers and facilitators to VHA reproductive service provision across a catchment area from women's health providers' perspectives. We performed a mixed-methods study, including semistructured, qualitative provider interviews with a quantitative survey on training, comfort, and knowledge of reproductive services. All women's health providers and their support staff from the Salt Lake City Veterans Affairs Medical Center and nine VHA community-based outpatient clinics were asked to participate. We conducted qualitative interviews and knowledge surveys with providers and staff to explore training, care processes, and improvement opportunities in reproductive service provision. We completed descriptive analyses of all of the quantitative data and used an open, iterative process to analyze provider interviews for emergent themes. We interviewed 15 providers (7 advanced practice nurses, 4 registered nurses, and 4 physicians) across nine sites (50% response rate). The commonly identified barriers included provider training and staffing, scheduling/referral processes, inconsistent services/supplies, and lack of veteran awareness of reproductive services. Facilitators included prior non-VHA reproductive health experience among providers, invested support staff, and the integrated VHA health system. Addressing barriers to VHA reproductive healthcare provision may overcome reproductive service variations related to clinic location and improve reproductive health outcomes for women veterans.

Impact of Clinical Pharmacist Practitioner Management of Chronic Obstructive Pulmonary Disease in the Ambulatory Care Setting

Objectives: To evaluate the impact of clinical pharmacist practitioner (CPP) management on potentially inappropriate use of inhaled corticosteroids (ICS) in the ambulatory care setting. Design: Multicenter, prospective quality assurance/improvement (QA/QI) project. Setting: Erie Veterans Affairs Medical Center (VAMC) and surrounding Ashtabula, Crawford, and Venango County Community-Based Outpatient Clinics (CBOCs). Participants: Thirty-five participants with chronic obstructive pulmonary disease (COPD) who met inclusion criteria were included in the project. Interventions: Participants were contacted to schedule an initial sixty-minute telephone visit with a CPP. Exacerbation history, rescue inhaler use, and symptom burden were assessed using the COPD Assessment Test (CAT) and Modified Medical Research Counsel Breathlessness Scale (mMRC) scales. Medication regimens were optimized based on guideline recommendations with an emphasis on appropriate use of ICS. Participants were scheduled for follow-up telephone visits with the CPP every 4 weeks. Main Outcome Measures: The primary project outcome was potentially inappropriate use of ICS without a long-acting muscarinic antagonist (LAMA)/long-acting beta agonist (LABA). Secondary project outcomes included ICS de-escalation, vaccinations, and smoking cessation. Results: The primary outcome of reducing use of ICS without a LAMA/LABA was achieved in thirty-one (88.6%) participants. ICS de-escalation was achieved in twenty-three (65.7%) participants. Rates of recommended vaccinations and smoking cessation with nicotine replacement therapy increased as a result of pharmacist intervention. Conclusion: Pharmacist management of COPD in the ambulatory care setting was associated with a decrease in potentially inappropriate use of ICS and an increase in preventative care measures.