Follow-up Phone Research Articles

Outcomes and reoperation rates after tibial tubercle transfer and medial patellofemoral ligament reconstruction: higher revision stabilization in patients with trochlear dysplasia and patella alta.

To determine the reoperation rate, risk factors for reoperation, and patient-reported outcomes after isolated or combined tibial tubercle transfer and medial patellofemoral ligament reconstruction, for patellofemoral instability surgery. Patient's records who underwent medial patellofemoral ligament reconstruction and/or tibial tubercle transfer for patellar instability by 35 surgeons from 2002 to 2018 at a single academic institution were retrospectively reviewed using CPT codes. Four-hundred-and-eighty-six patients were identified. Radiographic measurements, demographic parameters, and subsequent revision procedures and their indications were identified. A modified anterior knee pain survey was conducted by mail and with follow-up phone survey. The overall rate of reoperation was 120/486 (24.7%). The most common cause for reoperation was removal of hardware 42/486 (8.6%). The rate of reoperation for isolated medial patellofemoral ligament reconstruction 43/226 (19%) was lower than that of isolated tibial tubercle transfer 45/133 (33.8%) or a combined procedure 32/127 (25.2%) (P = 0.007). Woman had a higher rate of reoperation (29.4%) compared to men (15.9%) (P = 0.002). Patients at risk for a revision stabilization procedure included those with severe trochlear morphology (C or D) (6.1%) and those with Caton-Deschamps index > 1.3 (7.3%). Patients who underwent reoperation of any kind had poorer patient-reported outcomes. The overall reoperation rate after patellofemoral instability surgery remains high, and any reoperation portends worse patient-reported outcomes. Re-operations for instability are more likely in patients with trochlear dysplasia and patella alta and may benefit from more aggressive initial treatment, such as medial patellofemoral ligament reconstruction and tibial tubercle transfer in combination. Using the results of this study, surgeons will be able to engage in meaningful discussion with patients to counsel patients on expectations postoperatively. IV.

Hemophilia in Patients 50 Years or Older: Quality of Life, Health Maintenance, Cancer Screening and COVID19

INTRODUCTION: Major progress has been made in treatment of patients with hemophilia over the last 30 or 40 years. Factor replacement, eliminating HIV and hepatitis C transmission, and more recently, longer-acting coagulation factors and immune treatments play a role in allowing patients with hemophilia to experience a longer and healthier life. Previous studies show that invasive procedures like colonoscopies, bronchoscopies or biopsies can safely be performed in patients with hemophilia if an appropriate factor replacement is given. However, because of their risk of bleeding, patients with hemophilia may be reluctant to undergo such invasive procedures or get recommended health maintenance, and these fears may have been worsened by the outbreak of COVID19. Therefore, we wondered if older patients with hemophilia have been impacted by the COVID19 pandemic and have received the recommended vaccinations and cancer screenings.METHODS: The data for this study originates in the hemophilia clinics of two academic centers in Kentucky (University of Louisville and University of Kentucky). IRB approval was obtained in both institutions. Surveys were mailed or emailed to patients 50 years of age or older in our database. Follow-up phone calls were made to patients who did not respond. The surveys had 17 health related questions focusing on general well-being, pain, smoking, cancer screening, vaccinations and COVID19. The original survey was performed between 11/2020 and 3/2021 and COVID19 vaccination status was updated in 7/2021. Overall, 50 patients in our database met the study criteria (hemophilia and age 50 years or older) and 36 responded (72%). Some patients did not answer all questions.Patient details are given in Table 1. Median age was 61 years, most patients had mild to moderate hemophilia, three patients were positive for HIV (all with a negative viral load), and 12 had been infected with hepatitis C. Questions related to the impact of COVID19 explored anxiety of leaving the house, meeting with other people, availability of medical appointments, and getting necessary medications. Patients were asked if they received an influenza vaccination and, if older than 60 years, if they had received a pneumonia vaccination.RESULTS: Overall, most patients reported a good quality of life (Table 2). Nevertheless, most were often or always in pain. About half of the patients were on opioid pain medication. A minority took only over the counter pain medication or no pain medication. 57% of respondents had received both vaccinations for COVID19, two-thirds of the unvaccinated planned to get it. 55% of respondents had undergone a colonoscopy in the previous 5 years. Only 18% identified themselves as current smokers. Few men had undergone screening for prostate cancer. Finally, 5 of 32 patients reported a previous diagnosis of cancer (3 patients with localized skin cancer, 2 patients with head and neck cancers).CONCLUSIONS: Quality of life in patients with hemophilia is self-reported as good or excellent in most older patients. However, chronic pain problems persist and are not always sufficiently controlled. One reason may be that many of our patients did not have consistent factor replacements early in their life. Only a minority of patients reported a psychological or physical impact of the COVID19 lockdown. Most patients as of June or July 2021 have been vaccinated against COVID19, however this is probably lower than in an age-matched group. Mayo Clinic's vaccine tracker reported a vaccination rate of 92.3% for the 65 and older age group in Kentucky (as of July 31 st of 2021). The rate of influenza vaccination is probably comparable to rates in other rural communities. The same applies to cancer screening by colonoscopy and PSA screening. The rate of smoking of 18% is relatively low but may suffer from under-reporting. Overall, health maintenance in older patients with hemophilia appears acceptable but can certainly be improved. Limitations of our study are small sample size and that most patients have mild to moderate hemophilia. We plan to expand our study to other centers to get more insight into health issues in older patients with hemophilia. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Peripheral Blood Cytopenia and Risk of Cancer Mortality

▪Introduction:Unexplained peripheral blood cytopenia remains a challenge in clinical practice which requires sorting through an array of etiologies from transient abnormalities to premalignant conditions. Clonal hematopoiesis has established an association between cytopenia and hematologic cancer, likely caused by inflammatory responses leading to hematopoietic stress. Similar mechanisms may occur in other organ systems and lead to neoplasia as the link between inflammation and solid tumors is well known. Thus, cytopenia may represent an early marker of serious conditions, including malignancy. Using the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study, we studied the association between cytopenia and cancer mortality.Methods:REGARDS prospectively enrolled 30,239 US black and white adults from 2003 to 2007 (41% black). Sociodemographic and medical data were obtained by phone interview, physical exam, and laboratory studies at enrollment (baseline CBC drawn after 8,000 people were recruited). Cancer death was identified via semiannual phone follow-up through 2018 to ascertain health events and linkage with Social Security Death and National Death Indexes. Cytopenia was defined as presence of 2 or more of the following: 1) hemoglobin below age, sex, and race-specific lowest 5th percentile, 2) white cell count below race-specific lowest 5th percentile, 3) platelet count below lowest 5th percentile, and 4) macrocytosis (MCV >98fL). Participants with baseline cancer, missing CBC, or lost to follow-up were excluded. Cox proportional hazards models were used to calculate hazard of cancer mortality associated with cytopenia, adjusting for demographics (Model 1), Model 1 + risk factors for cancer/anemia (Model 2), and Model 1 + socioeconomics (Model 3). Differences in the association of cytopenia and cancer death by race was tested by cross-product interaction terms and Inverse Odds Ratio Weighting (IORW) mediation analysis was conducted to study the effect of cytopenia as mediator in the race-cancer death interaction.Results:The analysis population included 19,028 participants, 62% were female and 60% were white. Median follow up was 9 years. There were 1112 (5.8%) cancer deaths and 3725 (19.6%) deaths from other causes. Cytopenia was present in 383 (2%) participants, of which 250 (65%) were white and 113 (35%) were black. Cytopenia prevalence increased by age and was higher in males (56%). Cytopenia was associated with increased risk of cancer mortality in all multivariate models adjusting for demographics (HR=1.60, 95%CI 1.16-2.21), cancer risk factors (HR=1.67, 95%CI 1.2-2.32), and socioeconomics (HR=1.58, 95%CI 1.12-2.23). Anemia and macrocytosis, but not leukopenia and thrombocytopenia, were hematologic parameters individually associated with risk of cancer death (Table 1). The 10-year cumulative incidence of cancer death was 13% for participants with baseline cytopenia vs. 6.5% for those without cytopenia (p<0.01, Figure 1). The race by cytopenia interaction term was significant with higher HR for cancer mortality in blacks compared to whites in all models: 2.01 vs 1.41, p=0.016 in model 1 (demographics), 2.12 vs 1.45, p=0.009 in model 2 (cancer risk factors), 1.82 vs 1.44, p=0.04 in model 3 (socioeconomics). Anemia and macrocytosis were individual hematologic parameters with higher HR for cancer death in blacks compared to whites and significant race by cytopenia interaction terms across all models (Table 2). Mediation analysis by IORW method showed that cytopenia was not a significant mediator in the pathway between the race and cancer death association (not shown).Discussion:In a large biracial prospective cohort, cytopenia was associated with increased risk of cancer mortality after adjusting for demographics, socioeconomics, and cancer risk factors. Cytopenia was a race-specific risk factor for cancer death affecting blacks more than whites, but not a mediator of the race and cancer death association. We conclude that 1) cytopenia is a risk factor for cancer death, with stronger association in blacks than whites, and 2) race is an effect modifier for the association of cytopenia with cancer death, but cytopenia is not a mediator of the black to white difference in cancer mortality. These results can inform further studies aimed at clarifying racial disparities in cancer death through theorized mechanisms such as clonal hematopoiesis. [Display omitted] DisclosuresGangaraju: Alexion: Consultancy; Sanofi Genzyme: Consultancy.

Implementing PODS (Patient Oriented Discharge Summary) in an acute medical urban health setting in Vancouver, Canada

The transition from hospital to home or community is a vulnerable time for patients and families, who face risks associated with misunderstanding instructions about medications, self-monitoring and when to seek emergency care. The quality of the discharge process can have a significant impact on patient confidence, overall patient experience, ability to manage health at home, and hospital readmission rates. Patient Oriented Discharge Summary (PODS) is a standardized form and set of process changes, utilized to overcome communication barriers faced at discharge. We implemented PODS in two Acute Medicine units of a tertiary care hospital in western Canada and used a mixed-methods approach to evaluate the four process changes (PODS form, use of teach-back, engagement of caregivers in discharge teaching, follow-up phone calls). Evaluation showed that 60% of patients received PODS and 87% found the form helpful. There was a large increase in the percentage of patients who felt adequately prepared at the time of discharge, and a 10% increase in the number of patients who rated their overall hospital experience positively. Healthcare providers reported that using PODS they were more confident that patients were adequately prepared to return home. The update of PODS on the implementation units has been sustained at 60% for 18 months. Implementation of the PODS form and process can be accomplished with an interdisciplinary team, leadership support and by working closely with Patient Family Partners. PODS can improve the discharge process even in the complex urban acute medical environment in ways that offer wide-reaching benefits.

Skilled Nursing and Inpatient Rehabilitation Facility Use by Medicare Fee-for-Service Beneficiaries Discharged Home After a Stroke: Findings From the COMPASS Trial

ObjectivesTo examine the effect of a comprehensive transitional care model on the use of skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) care in the 12 months after acute care discharge home following stroke; and to identify predictors of experiencing a SNF or IRF admission following discharge home after stroke. DesignCluster randomized pragmatic trial SettingForty-one acute care hospitals in North Carolina. Participants2262 Medicare fee-for-service beneficiaries with transient ischemic attack or stroke discharged home. The sample was 80.3% White and 52.1% female, with a mean (SD) age of 74.9 (10.2) years and a mean ± SD National Institutes of Health stroke scale score of 2.3 (3.7). InterventionComprehensive transitional care model (COMPASS-TC), which consisted of a 2-day follow-up phone call from the postacute care coordinator and 14-day in-person visit with the postacute care coordinator and advanced practice provider. Main Outcome MeasuresTime to first SNF or IRF and SNF or IRF admission (yes/no) in the 12 months following discharge home. All analyses utilized multivariable mixed models including a hospital-specific random effect to account for the non-independence of measures within hospital. Intent to treat analyses using Cox proportional hazards regression assessed the effect of COMPASS-TC on time to SNF/IRF admission. Logistic regression was used to identify clinical and non-clinical predictors of SNF/IRF admission. ResultsOnly 34% of patients in the intervention arm received COMPASS-TC per protocol. COMPASS-TC was not associated with a reduced hazard of a SNF/ IRF admission in the 12 months post-discharge (hazard ratio, 1.20, with a range of 0.95-1.52) compared to usual care. This estimate was robust to additional covariate adjustment (hazard ratio, 1.23) (0.93-1.64). Both clinical and non-clinical factors (ie, insurance, geography) were predictors of SNF/IRF use. ConclusionsCOMPASS-TC was not consistently incorporated into real-world clinical practice. The use of a comprehensive transitional care model for patients discharged home after stroke was not associated with SNF or IRF admissions in a 12-month follow-up period. Non-clinical factors predictive of SNF/IRF use suggest potential issues with access to this type of care.

Moy.02Using aboutmyop.org as an alternative method for post-operative follow-up after elective laparoscopic cholecystectomy – a feasibility study

Abstract Introduction The majority of institutions no longer offer routine post-operative follow-up after elective laparoscopic cholecystectomy. National guidelines however recommend the use of post-operative hotlines or planned telephone follow-up for day-case procedures. At a time when NHS resources are limited, a digital solution may provide a safe alternative to telephone or physical follow-up. Our aim was to identify if digital follow-up with aboutmyop.org; a digital data-sharing platform, was equivalent to telephone follow-up. Method Study participants were invited to use aboutmyop.org before and after surgery. Patients were given free choice on whether they opted to use post-operative digital follow-up or routine post-operative care (no follow-up or telephone follow-up). In addition to follow-up compliance, the outcomes measured included 30-day post-operative complications, readmission, and re-operation. Results Of 597 laparoscopic cholecystectomy patients who were offered follow-up, 16.4% opted for digital follow-up, and 33.3% phone follow-up. Over 5 times as many patients who opted for telephone follow-up missed their appointment when compared to those who chose digital follow-up (5.6% vs. 30.9%, p &amp;lt; 0.001). Digital follow-up had a high sensitivity (68.2%-100%) and specificity (100%) for identifying complications at 30-days post-operatively and was completed significantly earlier than phone follow-up (median 6 days vs. 13.5 days, p = 0.001) with high patient acceptability. Conclusion This feasibility study demonstrates that digital follow-up utilising the aboutmyop.org platform is an acceptable alternative modality to telephone follow-up in elective laparoscopic cholecystectomy patients. Future work should aim to compare matched cohorts of patients undergoing digital follow-up, telephone follow-up, and no follow-up as a randomised controlled trial.

SP3.1.8 What happens to patients with acutely symptomatic hernia in the UK? Findings from the MASH study

Abstract Aims Acutely symptomatic abdominal wall and groin hernias (ASH) are a common reason for acute surgical admissions in the UK. There is limited data to guide the treatment of such presentations. This study aimed to assess outcomes of emergency hernia surgery, and identify common management strategies, to improve care for these high risk patients. Methods A 12 week, UK-based, multi-centre, collaborative, prospective cohort study (NCT04197271) recruited adults with ASH. Data on investigations, specific surgical intervention, in-hospital morbidity and mortality, and quality of life was measured. 30 and 90-day follow-up phone calls collected complications and quality of life. Descriptive analyses were performed to describe population and outcomes. Results Twenty-three acute Trusts recruited 264 patients. Inguinal (37.9%) and umbilical (37.1%) were the most common hernia locations. 17% were awaiting elective surgery and 17% had been previously declined intervention. CT was performed in 47%. 82% of patients had surgery within 48 hours, with 95% of procedures performed open and 93% under general anaesthesia. 3/11 laparoscopic procedures were converted to open. Mesh was used in 55%, this was typically synthetic non-absorbable (86%). Complications were infrequent; 2% developed pneumonia or delirium. Surgical site infection occurred in 3% and mortality was 1.2%. Quality of life improved between baseline and 30-days following repair. Conclusions There is variation in the management of ASH in the UK, particularly with repair techniques, use of mesh and laparoscopy. One in five patients was awaiting repair; this might indicate a need for expedited pathways and reprioritising of elective hernia repair.

Effectiveness among MSM of an HIV PrEP program developed in a Parisian sexual health center

Abstract Background HIV pre-exposure prophylaxis (PrEP) is highly effective but depends on patients' adherence and follow-up. To enhance follow-up quality and care engagement, the PrEP program developed in our Parisian sexual health center offers accompanying measures throughout the patients' course of care, relying notably on an identified and easily accessible referent. This trained paramedic counselor in sexual health provides support in organizing appointments, phone and email follow-up to answer daily questions, as well as one-on-one sessions of therapeutic support and counseling. This study aimed to assess the effectiveness of such a PrEP program among men who have sex with men (MSM). Methods This retrospective observational study included all MSM who initiated PrEP for the first time between 1 August 2018 and 30 June 2019 in the Fernand-Widal hospital sexual health center, Paris, France. Sociodemographic characteristics, sexual practices including very high risk situations (chemsex practice and/or sexually transmitted diseases at initiation and/or history of post-exposure prophylaxis [PEP]) and course of care during the first year were described. A novel metric developed by Hendrickson et al., the PrEP success ratio at 12 months, was used to assess effectiveness of PrEP. Results Among the 125 MSM included in this study, the median age was 33 and most had only male partners. At initiation, 58% were considered at very high risk of HIV infection, mainly due to a history of PEP. During the first year, patients attended a median of 3 visits (Q1-Q3, 2-4). At 12 months, 96% (95% CI, 92.6 to 99.4) of patients had a successful PrEP course, with no reported seroconversion. Conclusions This experiment highlights the possibility of achieving a high PrEP success ratio among MSM in a real-world setting. The accompanying measures set up in our sexual health center could explain the effectiveness of our PrEP program in comparison with previous studies. Key messages In a Parisian sexual health center that developed an HIV PrEP program with a trained paramedic counselor in sexual health, 96% of MSM achieved a successful PrEP course at 12 months. Accompanying measures for PrEP users could play a key role in achieving high PrEP success among MSM.

Cops, Clinicians, or Both? Collaborative Approaches to Responding to Behavioral Health Emergencies.

How a community responds to behavioral health emergencies is both a public health issue and social justice issue. Individuals experiencing a behavioral health crisis often receive inadequate care in emergency departments (EDs), boarding for hours or days while waiting for treatment. Such crises also account for a quarter of police shootings and >2 million jail bookings per year. Racism and implicit bias magnify these problems for people of color. Growing support for reform provides an unprecedented opportunity for meaningful change, but solutions to this complex issue will require comprehensive systemic approaches. As communities grapple with behavioral health emergencies, the question is not just whether law enforcement should respond to behavioral health emergencies but how to reduce unnecessary law enforcement contact and, if law enforcement is responding, when, how, and with what support. This policy article reviews best practices for law enforcement crisis responses, outlines the components of a comprehensive continuum-of-crisis care model that provides alternatives to law enforcement involvement and ED use, and offers strategies for collaboration and alignment between law enforcement and clinicians toward common goals. Finally, policy considerations regarding stakeholder engagement, financing, data management, legal statutes, and health equity are presented to assist communities interested in taking steps to build these needed solutions.

Success of a Community-Based Delivery at Recruiting Individuals from Underserved Communities for an Observational Cohort Study of an Advance Care Planning Intervention

BackgroundUnderserved and minority populations are often reluctant to engage in advance care planning and/or research often due to distrust in healthcare and/or research institutions. AimTo determine if use of a community-based delivery model can facilitate recruitment of individuals from underserved communities in research about advance care planning. DesignRecruitment data are presented from a prospective, mixed methods observational cohort study that examined the feasibility and preliminary efficacy of a community-based delivery model involving an end-of-life conversation game to motivate participants to complete advance care planning behaviors. Event attendance and research participation data are reported. Setting/ParticipantsGame events were held in community venues in 27 states across the US in 2018–2019. The model involved leveraging existing social networks to recruit attendees and research participants to community game day events. Attendees were eligible for research if they were adults who read/spoke English. ResultsA total of 1,122 individuals attended events at 53 sites. Participants generally reported low income (48% reported $30,000 annual income). At sites with research assistants, there was a 90% consent rate (92% were Black). At community outreach sites, 45% agreed to a follow-up research phone call (49% were Black). ConclusionsUse of the community-based delivery model successfully engaged undeserved communities in a research-based advance care planning related community outreach event. This model may be useful for overcoming underserved and minority populations’ skepticism and distrust of healthcare and research that is a common barrier to progress in health agendas, especially advance care planning.

Algorithm for predicting cardiovascular events in low/moderate risk patients using traditional and new factors: data from 10-year follow-up study

Aim. To create an advanced algorithm for predicting cardiovascular events (CVE) in low/moderate risk patients using a complex of traditional and new factors.Material and methods. The study included 700 patients with Systematic Coronary Risk Evaluation (SCORE) &lt;5%, examined in 20092010. In addition to standard investigations, blood biochemistry tests, including high-sensitivity C-reactive protein (hsCRP), and sphygmography were carried. In 2019, a follow-up phone call was made to participants to identify recent CVEs: cardiovascular death, myocardial infarction, unstable angina, stroke, revascularization. The response rate was 79,6% (n=557; men, 100; women, 457).Results. CVEs were observed in 48 (8,6%) patients. The risk of CVEs increases systolic blood pressure (SBP) &gt;130 mmHg (odds ratio (OR), 1,9 (95% confidence interval (CI), 1,0-3,6)), hsCRP &gt;2,3 mg/L (OR, cardio-ankle vascular index (CAVI) &gt;8,05 (OR, 1,25 (95% CI, 1,0-1,6)). In patients with a combination of ≥2 lipid profile abnormalities, SBP &gt;130 mm Hg, hsCRP &gt;2,3 mg/L and pulse wave velocity &gt;13 m/s, the probability of developing CVEs (including cardiovascular death) increases 3,55 times (95% CI, 1,32-7,67).Conclusion. Levels of pulse wave velocity, CAVI, urea and hsCRP should be considered as additional risk factors for CVE in patients with low/moderate risk, estimated using standard scales. Combinations of traditional and new risk factors demonstrate a cumulative effect.

Supportive care reinforces telemonitoring in heart failure patients: pilot results of the “SupportHeart”

Abstract Introduction Disease management programs for HF are characterized by heterogeneity and different levels of complexity, thus the results regarding of their effectiveness are controversial. The trajectory of HF makes supportive care (SC) mandatory. The main feature of this framework is continuing communication addressing patient's support needs. Aim To evaluate the effectiveness of an individualized SC management program. Study design This was a pilot study of a randomized control trial (RCT) [control group (CG) and intervention group (IG)], the “SupportHeart” to assess a SC management program for HF patients. Patients allocated in the IG received written material for HF self-management and the first brief educational session was conducted by a nurse in the bedside. The intervention was consisted by monthly meetings including educational sessions about the HF syndrome, pharmacological and non- pharmacological treatment, self-management and physical activity (PA). The evaluation of the intervention included health-related quality of life (HR-QoL), self-care management, adherence to PA, anxiety and depression and perceived support. Furthermore, acute events (readmissions and deaths) were measured. Monthly phone calls were also contacted by the research team and patients could call them whenever they needed to. Statistical comparisons were performed and Kaplan Meir curves and the log-rank test (LRT) were utilised to explore the time until the first acute event. Results Thirty-five patients with HF participated in the study and the intervention lasted for six months (mth). A better HR-QoL was found for both groups in the sixth mth period with a difference in the social dimension of the HR-QoL favoring the IG. IG: baseline = 4.8 (4.9)/1st mth = 3.3 (3.5)/6th mth=2.8 (3.1), CG: baseline = 2.3 (1,1)/1st mth = 3.4 (2,7)/6th mth = 2.7 (2.8)]. Also, a difference in the sub-scale of family/significant others was indicated where the IG followed an increased trend [IG baseline = 50.9 (5.4)/6th mth = 52.7 (3.4)] [CG baseline = 50.3 (8.9)/6th mth = 49.9 (4.2)]. No difference was found for self-care management, except of the sub-dimension of PA and recognition of deteriorating symptoms favoring IG. IG: baseline = 11.7 (3.4)/1st mth = 13.1 (2.0)/6th mth = 13.6 (1.7). The survival of the CG was lower than that of the IG in 30 days: (LRT, χ2(1)=5.7, p=0.02), 90 days: (LRT, χ2(1)=12.3, p&amp;lt;0.001) and 180 days: (LRT, χ2(1)=6.8, p=0.009). Conclusion This is the first RCT assessing the effectiveness of SC in HF and it seems to be a promising concept for HF management programs. There was a great effect in acute events as it was found a reduced risk by 87% for a patient receiving SC. Continuing communication which seems to be achievable through telehealth and phone follow-up incorporating patients' preferences, values, beliefs, illness understanding and information needs into the decision-making process and is shown to be a promising approach in the care of patients with HF. Funding Acknowledgement Type of funding sources: None.

1271 The Management of Acutely Symptomatic Hernia (MASH): A UK Wide Prospective Cohort Study

Abstract Introduction Acutely symptomatic abdominal wall and groin hernias (ASH) are a common presentation, accounting for approximately 25% of acute surgical admissions in the UK. There is limited data to guide the treatment of such presentations. This study aimed to assess outcomes of emergency hernia surgery, and identify common management strategies, to improve care for these high-risk patients. Method A 12 week, UK-based, multi-centre, collaborative, prospective cohort study (NCT04197271) recruited adults with ASH. Data on inpatient management, specific surgical intervention, in-hospital morbidity and mortality and quality of life (EQ-5D-5L) was measured. 30 and 90-day follow-up phone calls collected complications and quality of life. Descriptive analyses were performed to describe population and outcomes. Results Twenty-three acute trusts recruited 264 patients. Inguinal (37.9%) and umbilical (37.1%) hernias were most common. 17% were awaiting elective surgery and 17% had been previously declined intervention. 46% were incarcerated at presentation, and 31% symptomatic (painful/irreducible). 82% of patients had operations within 48 hours, with 95% performed open. Mesh was used in 55%, the majority (86%) being synthetic non-absorbable. Sutures used for suture repair varied widely. Complications were infrequent; 2% developed pneumonia or delirium. Surgical site infection occurred in 3% and mortality was 1.2%. Quality of life improved between baseline and 30-days following repair. Conclusions There is variation in the management of ASH in the UK, particularly with repair techniques, use of mesh and laparoscopy. One in five patients was awaiting repair; this might indicate a need for expedited pathways and reprioritising elective hernia repair.

373 Cancer Screening Education in the Emergency Department: An Interventional Study

Many patients utilize the emergency department (ED) as their primary site for medical care. This raises the issue of whether simple preventative measures may be appropriately integrated into the flow of a busy ED. Here we sought to study whether a paper-based educational curriculum and referral program can improve secondary cancer prevention. We conducted a randomized, controled trial with a convenient sample of patients presenting to 2 tertiary care EDs from 11/2017 – 10/2018. Trained research associates administered a brief questionnaire to assess patient demographics, cancer screening history, and access to primary care to identify patients who were deficient in screening for breast, colorectal, cervical and lung cancers, as defined by the National Comprehensive Cancer Network. If deficient, the control group would receive verbal education on what screening was necessary, while the intervention group received both verbal education and a brief educational handout. Both groups received referral to a primary care physician as necessary. Following this intervention, a 30-day chart review and follow-up phone call was performed to ascertain whether a primary care visit was attended to obtain the appropriate cancer screening guidance or testing. We utilized the chi square test to compare follow-up frequency with an alpha of .05. We enrolled 170 patients over the course of our study. The sample was 48% female with a median age range from 55-64. The rates of compliance with screening for each cancer were: breast – 52.7%; cervical – 77.7%; colorectal – 63.9%; and lung – 20%. Approximately 41% of patients surveyed were out of screening compliance and were randomized to control vs intervention. In the control group, 20% of patients reported seeing a doctor to discuss screening vs 50% in the intervention group (p<.001). At the 30-day follow-up, 50% of the intervention group reported receiving the recommended screening. Our patient population demonstrated overall poor adherence to recommended cancer screening guidelines, especially with regard to lung cancer. With minimal education and an informational handout, however, we demonstrated a significant increase in cancer screening follow-up and testing.

Educational Priorities for Providing End-of-Life Care: Parent Perspectives.

Partnership with parents is a tenet of pediatric medicine; however, initiatives to include parents in education and research have been limited. Through focus groups, we included parents at the beginning of curriculum development by asking them to identify the priorities, existing supports, and opportunities for improvement in their child's end-of-life (EOL) care. English and Spanish-speaking bereaved parents whose child had been cared for by the palliative care team and had died >18 months before the study initiation were invited to participate. In-person focus groups and a follow-up phone call were used to elicit opinions and capture a diversity of viewpoints. Themes were identified and clustered through an iterative analytic process. Twenty-seven parents of 17 children participated, with the total sample size determined by thematic saturation. Four themes were identified as important to parents in their child's EOL care: (1) honoring the role of the parent, (2) having confidence in the care team, (3) receiving gestures of love and caring, and (4) navigating logistic challenges. We asked parents to be partners in guiding priorities for health care education and professional development to improve pediatric EOL care. In addition to strengthening skills in communication, confidence in the team, and compassion, parents in this study identified a need for hospital staff to anticipate financial and social stressors and provide supportive resources more readily. Additionally, parents described clinical and nonclinical staff as providing support, suggesting that a multidisciplinary and interdisciplinary curriculum be developed to improve pediatric EOL care.

S1024 The Effect of Unintended Pancreatic Duct Cannulation on Post-ERCP Pancreatitis

Introduction: Post-ERCP pancreatitis (PEP) is the most common adverse event of endoscopic retrograde cholangiopancreatography (ERCP). Numerous studies have identified multiple synergistic patient-based risk factors for PEP including suspected sphincter of Oddi dysfunction, prior PEP, female gender, younger age, normal serum bilirubin, and history of acute recurrent pancreatitis. However, unintended pancreatic duct (PD) cannulation is less well studied as a risk factor for PEP. Our study investigates the risk of PEP in unintended PD cannulation. Methods: We conducted a retrospective cohort study of all ERCPs by a single advanced endoscopist between December 2013 and January 2020 at a tertiary medical center. Patients with prior sphincterotomy were considered to have a non-native papilla and were excluded. Details of the ERCP, laboratory results, hospitalizations, clinic visits, and follow-up phone calls were identified via chart review. PEP was defined by the revised Atlanta classification. Multiple logistic regression analysis was used to model demographic and clinical features of those who did and did not develop PEP. Group differences for various factors were compared using odds ratios calculated via Fisher’s exact test. Results: 823 ERCPs were included in this analysis of which 3.77% were complicated by PEP. The incidence of PEP was 8.4% among unintended PD cannulation, 3.2% among intentional PD cannulation, and 1.5% among no PD cannulation (Fisher's exact p-value < 0.00005). Using multiple logistic regression, PEP positively correlated with unintended PD cannulation (p-value < 0.005) but not intended PD cannulation. When controlled for age and gender, needle knife sphincterotomy was also identified as a risk factor for PEP (p-value = 0.017). Additionally, age was negatively correlated with PEP in unintended PD cannulation (p-value = 0.027). In both unintended and intended PD cannulation, PEP rates were not affected by contrast injection into the PD compared with just guidewire cannulation without contrast injection. Conclusion: While unintended PD cannulation appears to increase the likelihood of PEP, intentional cannulation does not seem to have the same effect, suggesting that underlying pancreatic disease such as chronic pancreatitis or pancreatic trauma confers a lower risk of PEP. Further studies are needed to determine whether patients with unintended PD cannulation could benefit from more aggressive PEP prophylaxis or monitoring after ERCP.

Impact of pharmacist contact via telephone vs letter on rate of acquisition of naloxone rescue kits by patients with opioid use disorder

Background: Limited data describes the effectiveness of strategies to optimize naloxone rescue kit distribution. Mental health clinical pharmacy specialists (CPS) at VA St. Louis HCS aimed to increase distribution of naloxone rescue kits to patients with Opioid Use Disorder (OUD). An informational letter detailing the purpose of rescue kits and how to obtain one were sent to patients with OUD who had no active order for a naloxone rescue kit within the previous year. Roughly half of these patients were targeted for follow-up education via telephone. Methods: A retrospective study was conducted comparing the effectiveness of these contact methods. Study groups included those contacted by letter alone and those contacted by both letter and phone call. The primary outcome was order placement for a rescue kit within 90 days of contact. Post-hoc analysis included a multivariate regression, case-control evaluation of variables potentially associated with kit distribution. Results: In total, 335 patients were included. Of 185 patients targeted for phone follow-up, 81 were reached (43.8%), and 254 received the letter alone. The primary outcome was achieved by 13 (5.1%) and 52 (64.2%) participants in the letter alone and letter plus phone contact groups, respectively (p < 0.001). In multivariate analysis, phone contact (OR 38.6; 95% CI 17.5–85.0), nonwhite race (OR 3.4; 95% CI 1.5–7.6), prior participation in the substance abuse rehabilitation treatment program (OR 3.2; 95% CI 1.3–8.0), and current active opioid prescription (OR 3.7; 95% CI 1.3–10.2) were independently associated with an order for a naloxone rescue kit. Conclusions: In patients with OUD, those contacted by phone in addition to receiving a letter were significantly more likely to receive a naloxone kit than those contacted via letter alone. In addition to contact by phone, nonwhite race, prior participation in rehabilitation and active opioid prescription were associated with a higher rate of kit obtainment.

Decision making about anti-TNF therapy: A pilot trial of a shared decision-making intervention

ObjectiveWe conducted a pre-post pilot trial to determine the feasibility and acceptability of a multi-component intervention (pre-clinic letter, shared decision making cards and follow-up phone call) designed to facilitate SDM in pediatric inflammatory bowel disease (IBD). MethodsWe recruited physicians (n = 11) caring for IBD patients and families (n = 36) expected to discuss anti-tumor necrosis treatment. We measured feasibility and acceptability of the intervention, observed SDM, perceived SDM, decision conflict, and regret. Medical records were used to assess clinical outcomes, time to decision and adherence. We compared all outcomes between the usual care and intervention study arms. ResultsTwo out of three intervention components were feasible. Visit length increased significantly in the intervention arm. Parents and patients rated the intervention as acceptable, as did most physicians. The intervention was associated with a higher-level of observed SDM. There was no difference perceived SDM, decision conflict, regret or quality of life outcomes between arms. Physician global assessment improved over time in the intervention arm. ConclusionsThis pilot trial provides important guidance for developing a larger scale trial of a modified intervention. Practice implicationsOverall, our intervention shows promise in supporting SDM and engaging both parents and patients in pediatric IBD decisions.

Facilitators and barriers to post-discharge pain assessment and triage: a qualitative study of nurses\u2019 and patients\u2019 perspectives

BackgroundAfter hospital discharge, patients can experience symptoms prompting them to seek acute medical attention. Early evaluation of patients’ post-discharge symptoms by healthcare providers may improve appropriate healthcare utilization and patient safety. Post-discharge follow-up phone calls, which are used for routine transitional care in U.S. hospitals, serve as an important channel for provider-patient communication about symptoms. This study aimed to assess the facilitators and barriers to evaluating and triaging pain symptoms in cardiovascular patients through follow-up phone calls after their discharge from a large healthcare system in Central Massachusetts. We also discuss strategies that may help address the identified barriers.MethodsGuided by the Practical, Robust, Implementation and Sustainability Model (PRISM), we completed semi-structured interviews with 7 nurses and 16 patients in 2020. Selected nurses conducted (or supervised) post-discharge follow-up calls on behalf of 5 clinical teams (2 primary care; 3 cardiology). We used thematic analysis to identify themes from interviews and mapped them to the domains of the PRISM model.ResultsParticipants described common facilitators and barriers related to the four domains of PRISM: Intervention (I), Recipients (R), Implementation and Sustainability Infrastructure (ISI), and External Environment (EE). Facilitators include: (1) patients being willing to receive provider follow-up (R); (2) nurses experienced in symptom assessment (R); (3) good care coordination within individual clinical teams (R); (4) electronic health record system and call templates to support follow-up calls (ISI); and (5) national and institutional policies to support post-discharge follow-up (EE). Barriers include: (1) limitations of conducting symptom assessment by provider-initiated follow-up calls (I); (2) difficulty connecting patients and providers in a timely manner (R); (3) suboptimal coordination for transitional care among primary care and cardiology providers (R); and (4) lack of emphasis on post-discharge follow-up call reimbursement among cardiology clinics (EE). Specific barriers for pain assessment include: (1) concerns with pain medication misuse (R); and (2) no standardized pain assessment and triage protocol (ISI).ConclusionsStrategies to empower patients, facilitate timely patient-provider communication, and support care coordination regarding pain evaluation and treatment may reduce the barriers and improve processes and outcomes of pain assessment and triage.

Implementation of a Constipation Action Plan for Patients Discharged From a Pediatric Hospitalist Service.

The objective of this study was to determine the effect of a pharmacist-led constipation action plan on the rate of health care utilization. We conducted a prospective research study of patients 2 to 18 years of age admitted to a pediatric hospitalist service for constipation. A study pharmacist developed a patient-specific constipation action plan for each enrolled patient. Data were collected from the electronic medical record, patient/caregiver interview, and follow-up phone calls completed by a pharmacist. The primary outcome was to determine the effect of a pharmacist-led constipation action plan on the rate of health care utilization. Twenty-seven patients were enrolled in the study. Median (range) age was 9 (2-18) years. Health care utilization of the entire study population decreased from approximately 8.7 encounters per month prior to implementation to approximately 3 encounters per month after implementation. Patients also reported an increase in daily bowel movements from approximately 1 per day prior to implementation to 2 per day post implementation. Health care utilization appeared to decrease after implementation of a patient-specific, pharmacist-led constipation action plan.