General Internal Medicine Clinic Research Articles

Exploring Characteristics of Patients Using Telehealth vs In-Person Visits in General Internal Medicine Clinic

Exploring Characteristics of Patients Using Telehealth vs In-Person Visits in General Internal Medicine Clinic

Assessing Factors That Determine High Inpatient Utilization in the University of Kansas General Internal Medicine Clinic – A Quality Improvement Needs Assessment

Assessing Factors That Determine High Inpatient Utilization in the University of Kansas General Internal Medicine Clinic – A Quality Improvement Needs Assessment

Factors Predicting Caregiver Contributions to Self-care in Patients with Heart Failure

Introduction Caregivers play an important role in contributing to self-care in patients with heart failure (HF). To date, knowledge regarding factors associated with caregiver contributions to self-care remains limited, particularly in Thai patients with HF. Objective This study aimed to 1) describe caregiver contributions to self-care, and 2) examine factors predicting caregiver contributions (self-care maintenance, symptom perception, self-care management) of patients with HF. Design This correlational predictive study was guided by a situation-specific theory of caregiver contributions to heart failure self-care. Methodology The study included 128 caregivers of patients with heart failure, who were purposively selected based on the following inclusion criteria: aged at least 18 years, unpaid for their caregiving tasks, and living with the patients who attended the heart failure clinic and general internal medicine clinic at an outpatient department of a super-tertiary hospital from April to August 2023. Data collection was conducted using questionnaires and record forms, and the data were analyzed using descriptive statistics, simple linear regression, and multiple linear regression. Results The majority of the participants were female (75.78%), with an average age of 46.10 years (SD = 13.74). Caregiver contributions (CC) to symptom perception and self-care maintenance were found to be adequate, with means of 73.38 (SD = 14.83) and 72.72 (SD = 13.75), respectively. In contrast, self-care management was deemed inadequate, with a mean of 68.83 (SD = 16.56). Multiple linear regression analysis revealed that health perception and self-efficacy together predicted CC for symptom perception, explaining 35.20% of the variance. Health perception, self-efficacy, and positive aspects of caregiving together predicted CC to self-care maintenance, explaining 31.50% of variance. Self-efficacy and comorbidities in patients together predicted CC to self-care management, explaining 21.20% of variance. While the status of caregivers to patients was not a statistically significant predictor of all three dimensions of CC to self-care in the patients with HF in this study. Recommendation The results of this study can be utilized to develop specific programs aimed at enhancing caregiver contributions to the self-care of patients with HF, particularly in promoting self-efficacy, positive aspects of caregiving, caregivers’ health perception, and managing the comorbidities of the patients.

Implementation of a "Health Equity Rounds" Curriculum in a Military Internal Medicine Residency Program: A Pilot Study.

Health disparities in the Military Health System (MHS) have been consistently documented despite the system ensuring equal access to care for its beneficiaries. Research has shown that social, economic, and political factors (i.e., Social Determinants of Health) and health care-specific factors like provider bias and systemic discrimination are key drivers of health disparities in the general population. Medical education focused on introducing these concepts using case-based learning has led to effective learning of health equity terminology. However, a significant gap exists in identifying optimal teaching approaches to develop skills to recognize these factors in actual clinical cases. This begs the million-dollar question: can case-based learning help trainees acquire the skills needed to identify the main factors contributing to health disparities in the MHS? A longitudinal case-based curriculum was developed in which clinical cases from the Internal Medicine Wards, Medical Intensive Care Unit, or General Internal Medicine Clinic at the National Capital Consortium were solicited from trainees and analyzed for evidence of health care provider bias and systemic forms of discrimination using small groups. The National Capital Consortium Internal Medicine Residency Program implemented this pilot study in November 2021. A retrospective pretest-posttest survey assessing trainee reactions to the curriculum and changes in self-reported confidence in skills was used for curriculum assessment. Survey data were analyzed using a paired samples t-test. The survey was administered during the last session of the 2022-2023 academic year, with 14 of the 23 available trainees completing it: a 60.8% response rate. Overall, 93% reported that the cases selected that academic year were engaging; the skills they were taught were practice-changing, and the educational value of the curriculum was good, very good, or excellent. Confidence ratings, assessed via a 5-point Likert Scale, demonstrated a statistically significant increase in self-reported confidence in the following skill domains with large effect sizes: identification of bias and systemic discrimination in clinical cases-change in mean: 1.07 (Pre: 3.29, Post: 4.36), P < .001, g = 1.38; recognizing and mitigating personal biases-change in mean: 0.71 (Pre: 3.50, Post: 4.21), P <.001, g = 1.10; participating in a discussion about health care provider bias and systemic discrimination-change in mean: 0.79 (Pre: 3.57, Post: 4.36), P = .001, g = 1.06; and leading a discussion about bias and systemic discrimination-change in mean: 1.00 (Pre: 2.93, Post: 3.93), P = .002, g = 0.98. As the need to address health disparities in the United States becomes more pressing, so does the need for military physicians to recognize the drivers of these disparities within the MHS. Results from this pilot study of Health Equity Rounds suggest that case-based learning may be an optimal teaching approach to improve the skills of military Internal Medicine trainees in identifying and recognizing the impact of health care provider bias and systemic discrimination on clinical cases from the MHS.

Differential Effect of Patient- and Provider-Level Factors on Patient Satisfaction Scores in Academic General Internal Medicine Clinics.

Determine whether patient-level or provider-level factors have greater influence on patient satisfaction scores in an academic general internal medicine clinic. Two years of data (2017-2019) from the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) surveys from ambulatory internal medicine clinic visits in an academic health center located in the Midwest United States were used. Patient satisfaction was measured using the overall provider satisfaction score (0-10), dichotomized with 9-10 defined as satisfactory and 0-8 as unsatisfactory. Provider-level independent variables included age, sex, race/ethnicity, provider type, service type, clinical effort, academic rank, and years since graduation. Patient-level factors included age, sex, race/ethnicity, education, and Epic Risk Score. Generalized mixed-effects logistic regression models were used to investigate associations between top-box satisfaction score and patient- and provider-level factors, accounting for the nesting of patients within providers. Thirty-three providers and 4597 patients were included in the analysis. Male providers (OR, 1.57; 95% CI, 1.00, 2.47), minority group 2 (OR, 3.54; 95% CI, 1.24, 10.07) and minority group 3 (OR, 6.04; 95% CI, 1.45, 25.12), faculty (OR, 3.83; 95% CI, 1.56, 9.36), and primary care providers (OR, 5.60; 95% CI, 1.62, 19.34) had increased odds of having a top-box rating compared with females, minority group 1, advanced practice providers, and perioperative providers respectively. Age was the only patient independent correlate of top-box rating with a 3% increased odds of top-box rating for every year increase in age (OR, 1.03; 95% CI 1.02, 1.03). In this academic general internal medicine clinic, top-box satisfaction scores were more strongly associated with provider-level factors, including provider race/ethnicity, provider type, and service type, as opposed to patient-level factors. Further research is needed to confirm these findings and identify potential system-level interventions.

Anxiety and depression symptoms among patients with long COVID: a retrospective cohort study.

Patients suffering from post-acute sequelae of COVID-19 (PASC) have a higher prevalence of anxiety and depression than the general population. The long-term trajectory of these sequelae is still unfolding. To assess the burden of anxiety and depression among patients presenting to the University of Iowa Hospitals and Clinics (UIHC) post-COVID-19 clinic, we analyzed how patient factors influenced Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) scores. In this retrospective cohort study, the GAD-7 and PHQ-9 questionnaire scores of patients presenting to the UIHC post-COVID clinic between March 2021-February 2022 (N = 455) were compared to the scores of a sample of patients presenting to the general internal medicine (GIM) clinic during the same period (N = 94). Our analysis showed that patients with an absent history of depression on their electronic medical record (EMR) problem list scored significantly higher on the GAD-7 (mean difference -1.62, 95% CI -3.12 to -0.12, p = 0.034) and PHQ-9 (mean difference -4.45, 95% CI -5.53 to -3.37, p < 0.001) questionnaires compared to their similar counterparts in the GIM clinic. On the other hand, patients with an absent history of anxiety on their EMR problem list scored significantly higher on the GAD-7 (mean difference -2.90, 95% CI -4.0 to -1.80, p < 0.001) but not on the PHQ-9 questionnaire (p = 0.196). Overall, patients with PASC may have experienced a heavier burden of newly manifest anxiety and depression symptoms compared to patients seen in the GIM clinic. This suggests that the mental health impacts of PASC may be more pronounced in patients with no prior history of anxiety or depression.

Improvement of in-office Blood Pressure targets in an Academic primary care setting

Background &#x0D; Accurate blood pressure (BP) measurement in an office-based setting is essential for diagnosis and management of hypertension. Staff education on proper blood pressure measurement technique and recording is a focus of recent hypertension guidelines. (1) Compared with other methods, unattended Automated Office Blood Pressure (AOBP) devices reduce measurement errors and improve BP Management. (2,3,4) The addition of AOBP to staff education needs to be assessed objectively. &#x0D; &#x0D; Objectives &#x0D; To determine the effect of staff education on proper BP measurement and addition of AOBP devices on BP targets in an academic general internal medicine clinic. &#x0D; &#x0D; Methods &#x0D; Education was provided to the medical staff on how to appropriately check BP in general and on the proper use of the AOBP devices. Education was repeated in several intervals to ensure consistency in practice. Six AOBP Hillrom (Welch Allyn spot 4400) devices were deployed for the clinic. Devices allowed for three automated readings 1 minute apart eliminating the first reading and keeping the other 2 readings. Staff were instructed to document two blood pressure readings into the electronic medical record. The number of patients who completed two BP measurements documented in the EMR over time. &#x0D; &#x0D; Results &#x0D; Our results showed timely education with refreshers, increased BP measurement protocol and improvement in BP recordings. Adherence to 2 BP checks increased from 40% in Dec-21 to 99% Jun-23. The percentage of patients with improved BP increased from 40% to 76% after staff education and addition of AOBP. &#x0D; &#x0D; Conclusion &#x0D; Timely education of medical staff and the addition of AOBP could increase the accuracy of in-office BP measurement. &#x0D; &#x0D; Key word: Internal medicine &#x0D; Type of submission: Abstract

Haemoglobin thresholds for transfusion: how are we doing in the era of Choosing Wisely? A retrospective cohort study.

Clinical practice guidelines and the Choosing Wisely initiative launched in 2012 recommend a haemoglobin (Hb) threshold of 70-80 g/lfor red blood cell (RBC) transfusions in stable hospitalised patients. Data on transfusion practices and their trends in medical inpatients are limited. To address this gap, we investigated transfusion practices and their trends in general internal medicine and other clinics. This retrospective cohort study analysed data from all hospitalisations with RBC transfusions at a Swiss university hospital between 2012 and 2019. We included all first transfusion episodes if pretransfusion Hb was available. The primary endpoint was mean pretransfusion Hb; secondary endpoints included potentially inadequate transfusions (i.e., transfusions at Hb ≥80 g/l) and receipt of a single RBC unit. Trends in mean pretransfusion Hb over time were estimated using generalised estimating equations, and risk factors for potentially inadequate transfusions were identified using multivariable adjusted generalised estimating equations models. Of 14,598 hospitalisations with RBC transfusions, 1980 (13.6%) were discharged from general internal medicine. From 2012 to 2019, mean pretransfusion Hb decreased from 74.0 g/l to 68.8 g/l in general internal medicine (mean annual decrease -0.76 g/l, 95% confidence interval [CI] -0.51 to -1.02) and from 78.2 g/l to 72.7 g/l in other clinics (mean annual decrease -0.69, 95% CI -0.62 to -0.77; p for interaction 0.53). The overall proportion of potentially inadequate transfusions was 17.8% in general internal medicine and 24.1% in other clinics (p <0.001) and decreased over the study period from 26.9% to 5.5% in general internal medicine and from 37.0% to 15.2% in other clinics. In contrast, the proportion of cases receiving a single RBC unit increased (39.5% to 81.4% in general internal medicine, 42.7% to 66.1% in other clinics). Older age (adjusted odds ratio [aOR] 1.45, 95% CI 1.32-1.58 for ≥65 vs <65 years), having surgery (aOR 1.24, 95% CI 1.14-1.36), acute haemorrhage (aOR 1.16, 95% CI 1.02-1.33), chronic heart failure (aOR 1.17, 95% CI 1.04-1.32), ischaemic heart diseases (aOR 1.27, 95% CI 1.15-1.41), chronic pulmonary diseases (aOR 1.24, 95% CI 1.08-1.42), malignancy (aOR 1.11, 95% CI 1.01-1.21), and rheumatic disease (aOR 1.27, 95% CI 1.01-1.59) were risk factors for potentially inadequate transfusions. More restrictive transfusion practices were adopted in general internal medicine and other clinics over time, suggesting that guideline recommendations and the Choosing Wisely initiative may have been increasingly followed. Interventions to reduce potentially inadequate transfusions should target providers who care for older patients and those with surgery or chronic cardiac and pulmonary diseases.

Trends in Antibody Titers after SARS-CoV-2 Vaccination—Insights from Self-Paid Tests at a General Internal Medicine Clinic

Background: The rise in antibody titers against the novel coronavirus (SARS-CoV-2) and its duration are considered an important indicator for confirming the effect of a COVID-19 vaccine, and self-paid tests of antibody titer are conducted in many facilities nationwide. Methods: The relationship between the number of days after the second and third dose of vaccines, age, and antibody titer was determined from the medical records of general internal medicine clinics that conducted self-paid testing of the SARS-CoV-2 antibody titer using Elecsys Anti-SARS-CoV-2 S (Roche Diagnostics); the relationship between the number of days after two or more doses of vaccines and antibody titer was also determined. We also examined the antibody titers in cases of spontaneous infection with SARS-CoV-2 after two or more doses of the vaccine. Results: Log-transformed SARS-CoV-2 antibody titers measured within 1 month from the second or third dose of vaccine showed a negative correlation with age (p < 0.05). In addition, the log-transformed antibody titers also showed a negative correlation trend with the number of days after the second dose of vaccine (p = 0.055); however, there were no significant correlations between the log-transformed antibody titers and the number of days after the third dose of vaccine. The median antibody titer after the third vaccination was 18,300 U/mL, more than 10 times the median antibody titer after the second dose of vaccine, of 1185 U/mL. There were also some cases of infection after the third or fourth dose of vaccine, with antibody titers in the tens of thousands of U/ml after infection, but the patients still received further booster vaccinations after the infection. Conclusions: The antibody titers after the third vaccination did not attenuate after a short follow-up period of one month, while they tended to attenuate after the second vaccination. It is considered that many people in Japan received further booster vaccinations after spontaneous infection, even though they already had antibody titers in the tens of thousands of U/mL due to "hybrid immunity" after spontaneous infection following two or more doses of vaccine. The clinical significance of the booster vaccination in this population still needs to be thoroughly investigated and should be prioritized for those with low SARS-CoV-2 antibody titers.

The Future of Community Outreach: Using Patient Portals to Provide Voter Resources during the Coronavirus Disease 2019 Pandemic.

During the coronavirus disease 2019 (COVID-19) pandemic, there was a concern for the 2020 general election becoming a superspreader event due to in-person voting. Our project addressed this concern by disseminating nonpartisan websites detailing safe voter options in the state of North Carolina to prevent community spread of the virus as much as possible. In this study, patient portals were used to disseminate a Research Electronic Data Capture survey containing embedded links to voter resources including nonpartisan websites discussing voting options. The survey also asked for demographic data and sentiments regarding the resources provided. Quick response (QR) codes with the survey link were also placed in the clinics during the study period. The survey was sent to 14,842 patients who had at least one patient encounter in the past 12 months at one of three General Internal Medicine clinics at Atrium Health Wake Forest Baptist. Survey participation through both the patient portals and QR codes was assessed. Patient sentiments toward the voter resources in regard to (1) interest and (2) perceived helpfulness were collected in the survey. In total, 738 (4.99%) patients filled out the survey. Eighty-seven percent of survey respondents reported that the voter resources were helpful. Significantly more black patients than white (29.3 vs. 18.2, p < 0.05) voiced interest in voter resources. There was no statistical significance across gender or reported comorbidities. Multicultural, underserved, and underinsured patients perceived the most benefit. During public health crises, patient portal messages can be used to bridge information gaps and promote better health outcomes in a timely and effective manner.

Separate But Not Equal? A Cross-Sectional Study of Segregation by Payor Mix in Academic Primary Care Clinics.

At some US Academic Health Centers (AHCs), patients with predominantly Medicaid insurance are seen in one clinic and patients with other insurance are seen in another. The extent of this practice and implications are unknown. To estimate the proportion of AHCs that have at least two primary care internal medicine clinics that differ substantially in proportion of patients with Medicaid and to compare patient demographic, staffing, and operational features. General internal medicine chiefs and clinic directors at 40 randomly selected US AHCs plus the top 10 AHCs in terms of NIH funding. An AHC was classified as maintaining clinics that differed substantially in the proportion of patients with Medicaid if any two differed by ≥ 40% (absolute). Other criteria were used for pre-specified secondary analyses (e.g., ≥ 30%). Thirty-nine of 50 AHCs (78%) participated. Four of 39 (10%; 95% CI, 3 to 24%) had two clinics differing by ≥ 40% in the proportion of patients with Medicaid, eight (21%; 95% CI, 9 to 36%) had clinics differing by ≥ 30%, and 15 (38%; 95% CI, 23 to 55%) had clinics differing by ≥ 20%. Clinics with more patients with Medicaid by any of the three criteria were more likely to employ resident physicians as providers of longitudinal care (with faculty supervision) and more likely to have patients who were Black or Hispanic. Some US AHCs maintain separate clinics defined by the proportion of patients with Medicaid. Clinics with a higher proportion of patients insured by Medicaid are more likely to employ residents (with faculty oversight), feature residents as providers of longitudinal care, and serve patients who are Black and Hispanic. Further research is needed to understand why some AHCs have primary care clinics distinguishable by insurance mix with the goal of ensuring that racism and discrimination are not root causes.

Evaluation of the characteristics of the patients Hospitalized in the internal diseases clinic in a third-level hospital a single-center experience

Objective: General internal medicine clinics are units where patients are evaluated holistically and systematically by working together with other branches of specialization. In the present study, the purpose was to reveal the general internal medicine practice by examining the characteristics and reasons for the hospitalization of patients in the general internal medicine clinic of a third-level university hospital. Material and Methods: The data of patients who were hospitalized between 01.10.2020 and 01.10.2022 in Afyonkarahisar Health Sciences University, Faculty of Medicine, Internal Medicine Clinic, General Internal Medicine Ward were obtained. The demographic data, reasons for hospitalization, and hospitalization areas of the patients were examined. Results: A total of 714 patients were included in the present study. The mean age of the patients was 59.9. The most common reason for hospitalization was symptomatic anemia and malignancy screening. Although symptomatic anemia was the most common reason for hospitalization over 65 years of age, intoxications were observed in patients under 65 years of age and the most common reason for hospitalization from the emergency units was acute pancreatitis, the most common reason for hospitalization from clinics was malignancy examination. Conclusion: General internal medicine clinics have a wide spectrum in terms of hospitalization causes. The most common reasons for admission to these units are anemia, malignancy examination, and electrolyte disorders.

Patient Perspectives on the Drivers and Deterrents of Antibiotic Treatment of Acute Rhinosinusitis: a Qualitative Study.

Antibiotics are prescribed in >80% of outpatient acute rhinosinusitis (ARS) visits, despite the low incidence of bacterial infection. Previous studies have shown patient expectations are the most robust predictor of antibiotics prescription in ARS. However, patient perceptions are not well known or understood. To understand patient perceptions regarding what drives or deters them from wanting, seeking, and taking antibiotic treatment of ARS. Iterative thematic analysis of semi-structured interviews. Nineteen adults diagnosed with ARS within the prior 60 days at the Northwestern Medicine General Internal Medicine clinic in Chicago, IL. Perceptions of patients with ARS. We interviewed 19 patients, identifying the following drivers of antibiotic use: (1) symptoms, especially discolored rhinorrhea, and seeking relief, (2) belief that antibiotics are a convenient and/or effective way to relieve/cure sinusitis, and (3) desire for tangible outcomes of a clinic visit. For deterrents, the following themes emerged: (1) concern about antibiotic resistance, (2) preference for other treatments or preference to avoid medications, and (3) desire to avoid a healthcare visit. Patients identified that a trustworthy physician's recommendation for antibiotics was a driver, and a recommendation against antibiotics was a deterrent to taking antibiotics; a delayed antibiotic prescription also served as a deterrent. Antibiotic side effects were viewed neutrally by most participants, though they were a deterrent to some. Patients have misconceptions about the indications and effectiveness of antibiotics for ARS. Intimate knowledge of key antibiotic drivers and deterrents, from the perspective of patients with ARS, can be leveraged to engage and increase patients' knowledge, and set appropriate expectations for antibiotics for ARS.

Social Determinants of Health and Diabetes-Related Distress in Patients With Insulin-Dependent Type 2 Diabetes: Cross-sectional, Mixed Methods Approach.

BackgroundSocial determinants of health (SDOH) refer to the social, economic, and psychosocial conditions that influence health. Lower levels of SDOH factors including income, education, and employment are associated with a higher prevalence of diabetes, poorer glycemic control, and increased diabetes-related mortality. Few studies have conducted a comprehensive evaluation of multiple SDOH factors in a population with type 2 diabetes mellitus (T2DM).ObjectiveThis study aimed to identify the range of SDOH challenges—including diabetes-related distress—that impact patients with insulin-dependent diabetes at an urban safety-net clinic using the 5-domain SDOH framework developed by the Healthy People 2020 initiative.MethodsThe pilot study used a cross-sectional, mixed methods approach. Participants were recruited from 3 programs within a general internal medicine clinic that provides ambulatory care for patients with uncontrolled T2DM. We administered an investigator-developed SDOH survey based on the Healthy People 2020 framework and the validated Diabetes Distress Scale (DDS), which assesses 4 domains of diabetes-related distress. One-on-one interviews were conducted to gain in-depth information about challenges.ResultsIn total, 57 participants had an average hemoglobin A1c level of 11.0% (SD 2.6%). Overall, 92% (52/57) of participants had a barrier in at least one SDOH domain. SDOH challenges were most commonly reported in the domain of Health and Health Care (84%, 48/57), followed by Economic Stability (54%, n=31), Neighborhood and Built Environment (53%, n=30), Education and Health Literacy (47%, n=27), and Social and Community context (37%, n=21). The mean overall DDS score was 2.09 (SD 0.84), where scores of ≥2 indicate distress. Further, 79% (45/57) of participants had at least moderate diabetes-related distress in one of the 4 DDS domains. General themes that emerged from participant interviews included job interference with healthy behaviors, concerns about burdening others, challenges communicating with providers, and difficulty getting appointments in a timely manner.ConclusionsWe found high levels of SDOH barriers across all 5 domains of the Center for Disease Control and Prevention’s Healthy People 2020 framework, including significant levels of diabetes-related distress. Future programs to address SDOH barriers in patients with uncontrolled insulin-dependent diabetes should consider screening for and focusing on a wide range of challenges.

Implementing a collaborative practice agreement for HIV pre-exposure prophylaxis in the primary care setting

BackgroundHuman immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) medications are highly effective at reducing HIV transmission despite their underutilization. Pharmacists can be involved in HIV PrEP management through collaborative practice agreements (CPAs). ObjectivesThis study aimed to (1) describe the development of a CPA for a pharmacist-led HIV PrEP service within an outpatient primary care clinic and (2) describe the growth of the HIV PrEP CPA service after implementation. Practice descriptionThe service was developed and implemented within a network of 7 outpatient general internal medicine (GIM) clinics associated with a large academic medical center. Pharmacists are embedded in the clinics and provide care alongside an interprofessional team. Practice innovationAn HIV PrEP CPA was developed and implemented by primary care pharmacists to increase access to HIV PrEP therapy through pharmacist-led visits. The pharmacist-led visits were piloted at one site before expanding to the other primary care clinics. Evaluation methodsData were analyzed using an electronic health record-generated report that included all patients prescribed HIV PrEP medications by a GIM primary care provider (PCP) within the last year. The report was generated before the start of the intervention in October 2021 and again in May 2022. Retrospective chart review was then used to identify prescribing patterns and referrals to the pharmacy HIV PrEP CPA. ResultsSeven months after the start of the HIV PrEP CPA, 122 patients were prescribed HIV PrEP by a GIM PCP. Thirty-four patients (27.9%) were newly started on HIV PrEP by a GIM PCP since the beginning of the initiative. A total of 53 patient referrals (43.4%) were placed to the pharmacy team. Five of the 7 GIM clinics have established pharmacist-led HIV PrEP services. ConclusionThis report describes the successful development and implementation of a pharmacist-led HIV PrEP CPA in Ohio.

Effect of police action on low-barrier substance use disorder service utilization

BackgroundPolice action can increase risky substance use patterns by people who use drugs (PWUD), but it is not known how increased police presence affects utilization of low-barrier substance use disorder bridge clinics. Increased police presence may increase or decrease treatment-seeking behavior. We examined the association between Operation Clean Sweep (OCS), a 2-week police action in Boston, MA, and visit volume in BMC’s low-barrier buprenorphine bridge clinic.MethodsIn this retrospective cohort, we used segmented regression to investigate whether the increased police presence during OCS was associated with changes in bridge clinic visits. We used General Internal Medicine (GIM) clinic visit volume as a negative control. We examined visits during the 6 weeks prior, 2 weeks during, and 4 weeks after OCS (June 18–September 11, 2019).ResultsBridge clinic visits were 2.8 per provider session before, 2.0 during, and 3.0 after OCS. The mean number of GIM clinic visits per provider session before OCS was 7.0, 6.8 during, and 7.0 after OCS. In adjusted segmented regression models for bridge clinic visits per provider session, there was a nonsignificant level increase (0.643 P = 0.171) and significant decrease in slope (0.100, P = 0.045) during OCS. After OCS completed, there was a significant level increase (1.442, P = 0.003) and slope increase in visits per provider session (0.141, P = 0.007). There was no significant change in GIM clinic volume during the study period.ConclusionsThe increased policing during OCS was associated with a significant decrease in bridge clinic visits. Following the completion of OCS, there was a significant increase in clinic visits, suggesting pent-up demand for medications for opioid use disorder, a life-saving treatment.

Demographic Predictors of Telehealth Use for Integrated Psychological Services in Primary Care During the COVID-19 Pandemic.

Prior to the COVID-19 pandemic, growing mental health needs were well documented, particularly those of diverse patient populations. The current study aims to better understand racial and psychosocial factors associated with patient utilization of integrated psychological services via telehealth during the COVID-19 pandemic within a diverse primary care clinic. Retrospective chart reviews were completed for patients seen by an integrated psychology team within a general internal medicine clinic at a large urban health system during the year 2020. Demographics were extracted from the medical record. Multivariate logistic regression analyses were conducted to examine demographic predictors for (1) telehealth video visits vs. audio only telehealth visits and (2) in-person vs. telehealth visits (both video and audio). Older patients, Black patients, and those with Medicare and Medicaid were more likely to complete audio only telehealth visits vs. video visits. There were no significant demographic predictors when comparing in-person vs. telehealth (both video and audio). Some underserved and vulnerable patient populations are more likely to utilize audio-onlyintegrated psychological visits to video visits. The utilization of audio visits over video for certain demographics speaks to the need to better understand how this type of care may benefit psychological services in the future and continued advocacy to extend audio mental health visits beyond the public health emergency to address patient populations with significant mental health needs.

Prevalence of pelvic floor disorders in adult women being seen in a primary care setting and associated risk factors

Determine the prevalence of pelvic floor disorders (PFD) stratified by age, race, body mass index (BMI), and parity in adult women attending family medicine and general internal medicine clinics at an academic health system. The medical records of 25,425 adult women attending primary care clinics were queried using International Classification of Diseases-10th Revision codes (ICD-10 codes) for PFD [urinary incontinence (UI), pelvic organ prolapse (POP), and bowel dysfunction (anal incontinence (AI) and difficult defecation)]. Prevalence and odds ratios were calculated using univariate and multivariate analysis for age, race, BMI, and parity when available. Multivariate logistic regression models were used to assess the impact of age, race, BMI, and parity on the likelihood of being diagnosed with a PFD. A separate model was constructed for each of the three PFD categories (UI, POP, and bowel dysfunction) as well as a model assessing the likelihood of occurrence for any type of PFD. The percentage of women with at least one PFD was 32.0% with bowel dysfunction the most common (24.6%), followed by UI (11.1%) and POP (4.4%). 5.5% had exactly two PFD and 1.1% had all 3 categories of PFD. Older age and higher BMI were strongly and significantly associated with each of the three PFD categories, except for BMI and prolapse. Relative to White patients, Asian patients were at significantly lower risk for each category of PFD, while Black patients were at significantly lower risk for UI and POP, but at significantly greater risk for bowel dysfunction and the presence of any PFD. Higher parity was also significantly associated with pelvic organ prolapse. Using multivariate analyses, age, race, and BMI were all independently associated with PFD. PFD are highly prevalent in the primary care setting and should be screened for, especially in older and obese women. BMI may represent a modifiable risk factor.

Electronic health records analytics to identify cancer patients with metabolic syndrome.

e18649 Background: Metabolic syndrome, defined as the presence of at least 3 of 5 clinical factors including hypertension, elevated triglyceride levels, low high-density lipoprotein level, insulin resistance, and central obesity, increases the risk of heart disease, fatty liver, and multiple cancers. Metabolic syndrome in cancer patients has been associated with poor cancer-specific and overall survival. Lifestyle modification in patients with metabolic syndrome may reduce the risk of poor outcomes. In this quality improvement project, we aimed to determine the prevalence of metabolic syndrome among cancer patients and survivors seen in an outpatient general internal medicine (GIM) clinic and to determine the feasibility of using electronic health records (EHR) analytics to systematically identify such patients and refer them to lifestyle interventions and liver imaging. Methods: Study period was January-December 2021. During this period, an EHR algorithm was used to identify patients with metabolic syndrome based on the presence of ICD-10 diagnoses of metabolic conditions (diabetes, hypertension, lipid disease, and obesity). This algorithm was used to direct data from patient visits into an interactive dashboard to track metabolic syndrome prevalence and continuously monitor referrals to interventions. In September 2021, a best practice alert based on the EHR algorithm was created to identify patients with metabolic syndrome and prompt providers to refer them to nutrition counseling, liver ultrasound with elastography, and/or a community-based active-living support group for cancer survivors. GIM clinic nurses also reviewed medications and utilized an EPIC SmartPhrase that incorporated laboratory values (e.g., glucose, A1c, and lipids), blood pressure, and body mass index to confirm whether patients actually met the criteria for metabolic syndrome, and if so, they notified medical providers who then ordered the interventions. Patients confirmed to have metabolic syndrome received educational materials about lifestyle modifications. Data extracted from the dashboard were analyzed using Minitab 17 statistical software. Results: Among 1133 patients seen in the GIM clinic during 2021, 609 (54%) had metabolic syndrome. A total of 1045 patients (92%) had hypertension, 802 (71%) had hyperlipidemia, 571 (50%) had obesity, and 483 (43%) had diabetes. Among the 609 patients with metabolic syndrome, 148 (24%) were referred to liver ultrasound with elastography, 124 (20%) to nutrition counseling, and 21 (3%) to the support group. Beginning September 1, the best practice alert was triggered for 1131 clinical encounters meeting criteria for metabolic syndrome. Conclusions: The prevalence of metabolic syndrome among cancer patients seen in a GIM clinic was high. EHR analytics can lead to systematic identification and referral of patients with metabolic syndrome to lifestyle interventions and liver imaging.

Multidrug Resistant E-Coli in Patients with Urinary Tract Infections Presenting to Internal Medicine Clinics of Two Tertiary Care Hospitals in Lahore, Tip of the Iceberg

Background: The commonly presenting infections in medical outpatients’ department are that of Urinary tract. If not treated properly these can lead to hospitalization and can increase the morbidity and mortality. Escherichia coli is found to be the most frequent bacterium causing these infections. The available literature may not under representing the prevalence of E. Coli which is multi drug resistant and is seen in general medical outdoor and internal medicine clinics of our local population, because urine sample is usually sent for culture only in complicated patients. Objective: To determine the prevalence of multi drug resistant E. Coli and its resistance to the most commonly used antimicrobial agents in Internal Medicine Clinics of Bahria International Hospital, and Farooq Hospital, West wood branch, Lahore. Study Design: This is an observational study done retrospectively carried out at Internal Medicine Clinics of Bahria International Hospital Lahore and Farooq Hospital, Lahore from 1st January 2019 to 31st December 2020. Methodology: One hundred and ninety adult patients with urinary symptoms and suspected UTI were enrolled. We analyzed the available urine culture reports and susceptibility against the pathogens. The testing was interpreted according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) standards. Results: The most common microorganism was E. Coli (70%) followed by klebsiella (17.9%), enterococcus (8.9%) and Acinetobacter (3.2%) in both complicated and uncomplicated urinary tract infections. 75 % females were E. coli positive as compared to the male (58.6%). Patients aged greater than 60 and less than 20 years were mostly affected with E. coli. Most of the isolated pathogens were highly resistant to ampicillin, cotrimoxazole, and cephalexin (70%–95.5%). Conclusion: E. coli is found highly resistant to antimicrobial agents used to treat UTI at family medicine practice. No difference could be appreciated in the apportioning of resistant E. coli in both complicated and uncomplicated UTIs. This study emphasizes that we should collect data at National level and prepares a proper guideline for choosing appropriate antibiotics in patients with UTI presenting to general medical clinics. Key words: E. coli, Multidrug resistance, Urinary tract infection, Antibiotics, Pyelonephritis