Internal Medicine Research Articles

Frontline assessors’ opinions about grading committees in a medicine clerkship

BackgroundCollective decision-making by grading committees has been proposed as a strategy to improve the fairness and consistency of grading and summative assessment compared to individual evaluations. In the 2020–2021 academic year, Washington University School of Medicine in St. Louis (WUSM) instituted grading committees in the assessment of third-year medical students on core clerkships, including the Internal Medicine clerkship. We explored how frontline assessors perceive the role of grading committees in the Internal Medicine core clerkship at WUSM and sought to identify challenges that could be addressed in assessor development initiatives.MethodsWe conducted four semi-structured focus group interviews with resident (n = 6) and faculty (n = 17) volunteers from inpatient and outpatient Internal Medicine clerkship rotations. Transcripts were analyzed using thematic analysis.ResultsParticipants felt that the transition to a grading committee had benefits and drawbacks for both assessors and students. Grading committees were thought to improve grading fairness and reduce pressure on assessors. However, some participants perceived a loss of responsibility in students’ grading. Furthermore, assessors recognized persistent challenges in communicating students’ performance via assessment forms and misunderstandings about the new grading process. Interviewees identified a need for more training in formal assessment; however, there was no universally preferred training modality.ConclusionsFrontline assessors view the switch from individual graders to a grading committee as beneficial due to a perceived reduction of bias and improvement in grading fairness; however, they report ongoing challenges in the utilization of assessment tools and incomplete understanding of the grading and assessment process.

Patterns of kidney function and risk assessment in a nationwide laboratory database: the Brazilian CHECK-CKD study

BackgroundChronic kidney disease (CKD) is a global health problem with rising prevalence, morbidity, mortality, and associated costs. Early identification and risk stratification are key to preventing progression to kidney failure. However, there is a paucity of data on practice patterns of kidney function assessment to guide the development of improvement strategies, particularly in lower-income countries.MethodsA retrospective observational analysis was conducted in a nationwide laboratory database in Brazil. We included all adult patients with at least one serum creatinine assessment between June 2018 and May 2021. Our primary objective was to determine the proportion of patients with estimated glomerular filtration rate (eGFR) evaluations accompanied by predicted levels of urinary albumin-to-creatinine ratio (pACR) assessments within 12 months.ResultsOut of 4,5323,332 serum creatinine measurements, 42% lacked pACR measurements within 12 months. Approximately 10.8% of tests suggested CKD, mostly at stage 3a. The proportion of serum creatinine exams paired with pACR assessment varied according to the CKD stage. Internal Medicine, Cardiology, and Obstetrics/Gynecology were the specialties requesting most of the creatinine tests. Nephrology contributed with only 1.1% of serum creatinine requests for testing.ConclusionOur findings reveal that a significant proportion of individuals with a creatinine test lack an accompanying urinary albuminuria measurement in Brazil, contrary to the recommendations of the international guidelines. Non-Nephrologists perform most kidney function evaluations, even among patients with presumable advanced CKD. This highlights the urge to incorporate in clinical practice the early detection of CKD and to encourage more collaborative multidisciplinary care to improve CKD management.

Rural generalist medicine: a developing approach to health care in rural and island Japan.

Despite universal health coverage and high life expectancy, Japan faces challenges in health care that include providing care for the world's oldest population, increasing healthcare costs, physician maldistribution and an entrenched medical workforce and training system. Primary health care has typically been practised by specialists in other fields, and general medicine has only been certified as an accredited specialty since 2018. There are continued challenges to develop an awareness and acceptance of the primary health medical workforce in Japan. The impact of these challenges is highest in rural and island areas of Japan, with nearly 50% of rural and remote populations considered 'elderly'. Concurrently, these areas are experiencing physician shortages as medical graduates gravitate to urban areas and choose medical specialties more commonly practised in cities. This study aimed to understand the views on the role of rural generalist medicine (RGM) in contributing to solutions for rural and island health care in Japan. This was a descriptive qualitative study. Data were collected via semi-structured interviews with 16 participants, including Rural Generalist Program Japan (RGPJ) registrars and supervisors, the RGPJ director, government officials, rural health experts and academics. Interviews were of 35-50 minutes duration and conducted between May and July 2019. Some interviews were conducted in person at the WONCA Asia-Pacific Conference in Kyoto, some onsite in hospital settings and some were videoconferenced. Interviews were recorded and transcribed. All transcripts were analysed through an inductive thematic process based on the grouping of codes. From the interview analysis, six main themes were identified: (1) key issues facing rural and island health in Japan; (2) participant background; (3) local demography and population; (4) identity, perception and role of RGM; (5) RGPJ experience; and (6) suggested reforms and recommendations. The RGPJ was generally considered to be a positive step toward reshaping the medical workforce to address the geographic inequities in Japan. While improvements to the program were suggested by participants, it was also generally agreed that a more systematic, national approach to RGM was needed in Japan. Key findings from this study are relevant to this goal. This includes considering the drivers to participating in the RGPJ for future recruitment strategies and the need for an idiosyncratic Japanese model of RGM, with agreed advanced skills and supervision models. Also important are the issues raised by participants on the need to improve community acceptance and branding of rural generalist doctors to support primary care in rural and island areas. The RGPJ represents an effort to bolster the national rural medical workforce in Japan. Discussions from participants in this study indicate strong support to continue research, exploration and expansion of a national RGM model that is contextualised for Japanese conditions and that is branded and promoted to build community support for the role of the rural generalist.

Artificial Intelligence in the Provision of Health Care: An American College of Physicians Policy Position Paper.

Internal medicine physicians are increasingly interacting with systems that implement artificial intelligence (AI) and machine learning (ML) technologies. Some physicians and health care systems are even developing their own AI models, both within and outside of electronic health record (EHR) systems. These technologies have various applications throughout the provision of health care, such as clinical documentation, diagnostic image processing, and clinical decision support. With the growing availability of vast amounts of patient data and unprecedented levels of clinician burnout, the proliferation of these technologies is cautiously welcomed by some physicians. Others think it presents challenges to the patient-physician relationship and the professional integrity of physicians. These dispositions are understandable, given the "black box" nature of some AI models, for which specifications and development methods can be closely guarded or proprietary, along with the relative lagging or absence of appropriate regulatory scrutiny and validation. This American College of Physicians (ACP) position paper describes the College's foundational positions and recommendations regarding the use of AI- and ML-enabled tools and systems in the provision of health care. Many of the College's positions and recommendations, such as those related to patient-centeredness, privacy, and transparency, are founded on principles in the ACP Ethics Manual. They are also derived from considerations for the clinical safety and effectiveness of the tools as well as their potential consequences regarding health disparities. The College calls for more research on the clinical and ethical implications of these technologies and their effects on patient health and well-being.

Impact of pharmacist‐led discharge medication reconciliation on error and patient harm prevention at a large academic medical center

AbstractIntroductionMedication errors during hospital discharge can lead to adverse outcomes, medication‐related readmissions, and increased health care costs. Pharmacist‐led medication reconciliation at discharge is a potential solution to mitigate poor outcomes and optimize medication safety.ObjectivesThis study aimed to quantify medication errors identified at discharge and characterize the severity of patient harm prevented following pharmacist‐led discharge medication reconciliation. Cost avoidance analysis was conducted to determine its associated financial impact.MethodsPatients, who were discharged from an adult internal medicine service during October 2022, were included in this one‐month pilot prospective quality improvement study. The number of errors at discharge were documented, categorized by type, and adjudicated for severity of potential harm. Error severity was classified based on a modified National Coordinating Council for Medication Error Reporting and Prevention Medication Error Index. Cost avoidance was calculated based on whether each error would have resulted in additional medical encounters and length of stay.ResultsThirty‐one patients were included in the analysis. Forty errors were identified by pharmacist‐led medication reconciliation at discharge, with a mean of 1.3 ± 1.9 errors per patient and 68% of patients having at least one error. The most common errors were duplication of therapy (25%) and medication access barriers at discharge (25%). The severity of errors included low (22.5%), serious (75%), and life‐threatening harm (2.5%). Thirty‐five percent of errors could have led to emergency visits or hospital readmissions. The estimated total cost for errors was $25 600. Pharmacist labor cost for reconciliation was $816. Cost avoidance was $24 784 from the 14 errors at discharge that could have resulted in additional emergency or inpatient visits.ConclusionPharmacist‐led medication reconciliation at discharge may prevent harm from reaching patients, decrease cost from unnecessary health encounters, and stop the error from continuing across transitions of care.

How Healthcare Providers Decide on a Referral Location in Telephone Triage: A Cross-sectional Study.

Approximately 25% of patients that present to the emergency department (ED) do so after contact with a healthcare professional. Many of these patients could be effectively managed in non-ED ambulatory settings. Aligning patients with safe and appropriate outpatient care has the potential to improve ED overcrowding, patient experience, outcomes, and costs. Little is understood about how healthcare providers approach triage decision-making and what factors influence their choices. To evaluate how providers think about patient triage, and what factors influence their decision-making when triaging patient calls. Cross-sectional survey-based study in which participants make triage decisions for hypothetical clinical scenarios. Healthcare providers in the specialties of internal medicine, family medicine, or emergency medicine within a large integrated healthcare system in the Southeast. Differences in individual training and practice characteristics were used to compare observed differences in triage outcomes. Free-response data were evaluated to identify themes and factors affecting triage decisions. Out of 72 total participants, substantial variability in triage decision-making was observed among all patient cases. Attending physicians triaged 1.4 fewer cases to ED care compared with resident physicians (p < 0.001, 95% CI 0.62-2.1). Academic attendings demonstrated a trend toward fewer cases to ED care compared with community attendings (0.61, p = 0.188, 95% CI - 0.31-1.5). Qualitative data highlighted the complex considerations in provider triage and led to the development of a novel conceptual model to describe the cognitive triage process and the main influencing factors. Triage decision-making for healthcare providers is influenced by many factors related to clinical resources, care coordination, patient factors, and clinician factors. The complex considerations involved yield variability in triage decisions that is largely unexplained by descriptive physician factors.

Factors influencing central nervous system medication deprescribing and behavior change in hospitalized older adults.

Central nervous system (CNS) medications are linked to higher morbidity and mortality in older adults. Hospitalization allows for deprescribing opportunities. This qualitative study investigates clinician and patient perspectives on CNS medication deprescribing during hospitalization using a behavioral change framework, aiming to inform interventions and identify recommendations to enhance hospital deprescribing processes. This qualitative study focused on hospitalists, primary care providers, pharmacists, and patients aged ≥60 years hospitalized on a general medicine service and prescribed ≥1 CNS medications. Using semi-structured interviews and focus groups, we aimed to evaluate patient medication knowledge, prior deprescribing experiences, and decision-making preferences, as well as provider processes and tools for medication evaluation and deprescribing. Rapid qualitative analysis applying the Capability, Opportunity, Motivation, and Behavior (COM-B) framework revealed themes influencing deprescribing behavior in patients and providers. A total of 52 participants (20 patients and 32 providers) identified facilitators and barriers across deprescribing steps and generated recommended strategies to address them. Clinicians and patients highlighted the opportunity for CNS medication deprescribing during hospitalizations, facilitated by multidisciplinary teams enhancing clinicians' capability to make medication changes. Both groups also stressed the importance of intensive patient engagement, education, and monitoring during hospitalizations, acknowledging challenges in timing and extent of deprescribing, with some patients preferring decisions deferred to outpatient clinicians. Hospitalist and pharmacist recommendations centered on early pharmacist involvement for medication reconciliation, expanding pharmacy consultation and clinician education on deprescribing, whereas patients recommended enhancing shared decision-making through patient education on medication adverse effects, tapering plans, and alternatives. Hospitalists and PCPs also emphasized standardized discharge instructions and transitional care calls to improve medication review and feedback during care transitions. Clinicians and patients highlighted the potential advantages of hospital interventions for CNS medication deprescribing, emphasizing the necessity of addressing communication, education, and coordination challenges between inpatient and outpatient settings.

Breast Cancer Management During the COVID Pandemic.

To explore the impact of COVID-19 among both the newly diagnosed patients and patients under follow-up for breast cancer by focusing on patients' accessibility to management and comparing the distribution of them before and during pandemic. Single-centric retrospective study. Place and Duration of the Study: Departmentof General Surgery and Department of Physical Medicine and Rehabilitation, Atilim University, Medicana International Ankara Hospital, Ankara, Turkiye, from March 2018to 2022. The data were collected to analyse numbers and distributions of physician visits regarding breast cancer. The mean age of patients was 55.98 ± 12.60 years. The percentages of newly diagnosed cases showed similarity (7.37% vs. 9.79%) before and during the pandemic (p = 0.18).The number of imaging studies decreased by 53.33% in patients under follow-up (p = 0.006), despite screening tests showed a similar trend (p = 0.145). General surgery visits marked up (+44.6%), in contrast to plastic surgery visits (-42.04%, p <0.001). Patients' admissions decreased in many COVID-19 related clinics (pulmonology, emergency, internal medicine, and intensive care), but cardiology (+96.59%) and rehabilitation (+75%) admissions increased during the pandemic (p <0.001). The number of medical oncology and radiation oncology visits did not change (p >0.05). Total number of physician visits was similar before and during the pandemic despite the changing distribution. While COVID-19 led to markedly rising trends of surgical, cardiological, and rehabilitative management in patients with breast cancer, falling trends were seen in other specialities except oncology which showed a plateau during two years. The falling trends of visits to pulmonology, emergency, internal medicine, and intensive care clinics may be explained by crowded COVID-19 cases. Breast cancer, COVID-19, Surgery, Oncology, Rehabilitation.

Cross-sectional study of the association between burnout and work overload and work-life imbalance among medical personnel in Liaoning, China: role of specialty

ObjectivesBurnout is common among medical personnel in China and may be related to excessive and persistent work-related stressors by different specialties. The aims of this study were to assess the...

Assessing the landscape of integrative oncology at US comprehensive cancer centers (CCC).

e13565 Background: Interest in integrative oncology (IO) has grown among patients and its availability has expanded within CCCs. This study assesses the availability of IO programs in U.S. CCCs. Methods: In 2023, a cross-sectional survey was sent to CCCs including NCI-designated CCCs by email regarding IO programs. Participants were asked to describe the importance of IO within their cancer center, the programs and services offered, and how the programs are provided. Results: Of ninety-four survey invitations sent, fifty-eight completed surveys were returned (response rate 62%). Three-fourths of completed surveys (74%) came from NCI-designated CCCs. Over half of respondents (57%) rated IO services to be important (or very important) at their center with 53% stating that their center has a formal IO clinical program. Univariate analysis showed that non-NCI centers were more likely to perceive IO services as being important compared to NCI-designated centers (100% vs. 77%, p=0.04). Respondents stated that their IO program has been in existence for ≥10 years (40%), 5-9 years (26%), and 0-4 years (34%). Among the surveyed cancer centers, availability of IO program was 33% (adult and pediatric) vs. 49% (adult only). The IO programs are available to patients with active cancer (91%), patients in survivorship off-treatment (81%), and healthy patients without a history of cancer (22%). The IO services were offered in an outpatient clinic on the main campus (76%), community sites (29%), or inpatient settings (40%). The most common oncology specific services reported were nutrition (51%), exercise counseling (42%), mind-body medicine (38%), and acupuncture (33%). The clinicians who provided integrative medicine consultations were primarily in internal medicine (31%), family medicine (26%), and medical oncology (19%). In inpatient and outpatient settings, insurance was billed for physical therapy (50% vs. 67%) and diet/nutrition (36% vs. 50%) services, whereas acupuncture (47%) and massage (43%) services were charged by cash/card in an outpatient setting only. Music therapy (33% vs. 47%) and pet therapy (34% vs. 43%) services were offered for free most commonly in both inpatient and outpatient settings, respectively. The highest average out of pocket fee service was acupuncture ($42±27) followed by integrative medicine consultations ($34±29). Conclusions: Despite increasing patient interest and established benefits of integrative therapies as noted by recently published ASCO clinical guidelines, only half of CCCs reported having a formal IO program. More research is needed to understand the gap between patient interest, the growing evidence-base, and how to expand integrative oncology services within existing cancer centers.

Implementation of a palliative care service in a tertiary hospital in a developing country: Methods, strategies and results.

e24056 Background: In Rio de Janeiro, only 11 palliative care facilities exist, creating challenges in meeting the complex needs of patients with metastatic cancer. Our study aims to implement a palliative care service within an existing oncology practice. This approach holds promise as a model that could guide similar practices in low- and middle-income countries, offering a blueprint for the implementation of palliative care services on a broader scale. Methods: This descriptive study spans from February to December 2023, involving the monitoring of 176 patients. Eligible patients met criteria such as a FAST scale for dementia syndrome ≥ 7A, stage IV disease, ranking 5 stroke, terminal organic failure, uncontrolled symptoms, or requiring end-of-life care. The PC team, denoted as “Continued Care”, comprises a medical leader, 3 routine doctors, and 1 nurse. Activities undertaken by the team encompass consults requested by internal medicine and intensive care unit (ICU) teams, outpatient care, continuous education, and daily monitoring of patients with advance care plan (ACP). Results: Among 176 patients initially enrolled, outcomes were completed for 171 patients. Remarkably, 80% of those receiving PC assistance had an ACP in place, with 78% opting for exclusive non-invasive support. The overall death rate was 38%. Notably, among patients enrolled in the PC program, the ICU death rate was 31%. Conclusions: Institutional PC policies associated with the integration of a dedicated team into the hospital's routine, and investments in disseminating knowledge about irreversible illness processes and comfort strategies, emerge as a pivotal component in establishing a comprehensive and integrated model of PC services. This approach appears to surpass the effectiveness of traditional consult or sectorized model, emphasizing the importance of an institutionalized and holistic framework for delivering quality PC.

Prescribers of opioids for head and neck cancer (HNC) survivors.

12085 Background: Older HNC survivors often experience post-treatment pain, and they have concerningly high rates of unsafe opioid prescribing per CDC guidelines (e.g., high doses, concurrent benzodiazepines). Because interventions to improve opioid safety should target providers who prescribe opioids to HNC survivors, we aimed to identify post-treatment opioid prescriber specialty. Methods: Using the national linked Surveillance, Epidemiology, and End Results (SEER) registry and Medicare claims data, we identified adults age &gt;65 diagnosed 2014-2017 with stage I-III HNC and who had ≥6 months treatment-free follow-up prior to censoring at further treatment, new cancer, hospice, death, or end 2019. Each opioid fill was assigned to a prescriber specialty: oncology (medical, radiation), surgery, primary care (internal medicine, family practice, geriatrics), pain, or other. Prescriber patterns (number of fills, duration of fill, annual opioid receipt) were summarized across follow-up and stratified by year. Multinomial logistic regression models captured trends in prescribing, accounting for clinical and sociodemographic characteristics. Results: Among 5547 HNC survivors, 2951 (53%) had ≥1 opioid fill (median 2.1 years follow-up). Primary care providers (PCPs) prescribed 49% of all fills (46%-53% each year). PCPs prescribed opioids to 49% of survivors with ≥1 opioid fill, a greater share than other specialties. PCPs prescribed longer supplies of opioids (median 30 days/fill and median 45 days/year) than oncologists or surgeons. The likelihood of an opioid being prescribed by an oncologist or surgeon was ≥5 times lower than by a PCP. Over follow-up, rates of opioid prescribing by oncologists decreased relative to rates of prescribing by PCPs (Table). Conclusions: Primary care involvement in opioid prescribing remains high over post-treatment HNC survivorship. Interventions to address unsafe opioid prescribing for HNC survivors should target the primary care setting, as is typical for opioid-reduction efforts in the non-cancer population. [Table: see text]

Increasing Trainee Comfort with Nutrition.

Nutrition counseling is necessary for the prevention and treatment of many chronic diseases. US survey data demonstrate that 61% of Internal Medicine (IM) residents receive little to no nutrition training. The objective of our study was to develop a curriculum to increase IM resident comfort and ability in conducting a nutritional assessment. Categorical IM residents at a large academic medical center participated in a curriculum that included a lecture, a small-group discussion, and a skills exercise. Residents completed pre- and posttest surveys that evaluated their attitudes and comfort level with nutritional assessment. Eighty percent (84/105) of the residents participated in the curriculum and 48% (40/84) of them completed both pre- and postsession surveys. Residents who considered themselves moderately to extremely comfortable completing a nutritional assessment increased after the program (27.5% to 87.5%, P < 0.0001). The proportion of those who agreed or strongly agreed with the statement, "Nutritional counseling should be included in any routine appointment, just like diagnosis and treatment," increased from 62.50% to 80.00% (P = 0.012). The proportion of residents who considered lack of individual knowledge to be a barrier for nutrition counseling decreased from 65.79% to 42.11% (P = 0.0126). This curriculum was successful in increasing IM resident comfort with conducting a nutritional assessment.

Primary care provider perspectives on the value of opportunistic CT screening

BackgroundClinical adoption of AI applications requires stakeholders see value in their use. AI-enabled opportunistic-CT-screening (OS) capitalizes on incidentally-detected findings within CTs for potential health benefit. This study evaluates primary care providers' (PCP) perspectives on OS. MethodsA survey was distributed to US Internal and Family Medicine residencies. Assessed were familiarity with AI and OS, perspectives on potential value/costs, communication of results, and technology implementation. Results62 % of respondents (n = 71) were in Family Medicine, 64.8 % practiced in community hospitals. Although 74.6 % of respondents had heard of AI/machine learning, 95.8 % had little-to-no familiarity with OS. The majority reported little-to-no trust in AI. Reported concerns included AI accuracy (74.6 %) and unknown liability (73.2 %). 78.9 % of respondents reported that OS applications would require radiologist oversight. 53.5 % preferred OS results be included in a separate “screening” section within the Radiology report, accompanied by condition risks and management recommendations. The majority of respondents reported results would likely affect clinical management for all queried applications, and that atherosclerotic cardiovascular disease risk, abdominal aortic aneurysm, and liver fibrosis should be included within every CT report regardless of reason for examination. 70.5 % felt that PCP practices are unlikely to pay for OS. Added costs to the patient (91.5 %), the healthcare provider (77.5 %), and unknown liability (74.6 %) were the most frequently reported concerns. ConclusionPCP preferences and concerns around AI-enabled OS offer insights into clinical value and costs. As AI applications grow, feedback from end-users should be considered in the development of such technology to optimize implementation and adoption. Increasing stakeholder familiarity with AI may be a critical prerequisite first step before stakeholders consider implementation.

Pubertal Delay Secondary to Hashimoto's Disease in the Hypothyroid Phase: About a Case in the Internal Medicine Department of the Gabriel Touré University Hospital in Bamako, Mali

Introduction: Pubertal delay is defined by the absence of development of secondary sexual characteristics beyond the age of 13 in girls or 14 years in boys. In children of puberty age, delayed puberty is common in long-standing, untreated hypothyroidism. We report a case of delayed puberty revealed by Hashimoto's disease in the hypothyroid phase diagnosed in the Internal Medicine department of the Gabriel Touré University Hospital in Bamako, Mali. Observation: This was a female patient, aged 20 years old, without any particular medico-surgical ATCD or notion of taking medication, who had consulted at the end of 2021, in the Internal Medicine department of the University Hospital Gabriel Touré from Bamako for primary amenorrhea and delayed puberty. At the end of the clinical and paraclinical examination, a hypometabolism syndrome and pubertal delay were noted. On an evolutionary level, development of secondary sexual characteristics (From T1 to T3, and appearance of menstruation) after one year of treatment. Conclusion: Delayed puberty may be the consequence of hypothyroidism. Opotherapy with L Thyroxine helps restore normal pubertal development.

Irradiate the knowledge gap: Empowering residents for blood product selection at Albany Medical Center.

e23236 Background: Transfusion-associated graft versus host disease (ta-GvHD) poses risks for immunocompromised patients. Indications for irradiated blood products include hematological malignancies and bone marrow transplant cases. In instances of severe acute pancytopenia, the initial contact at the emergency room (ER) is typically a nurse, followed by the ER physician. Patients referred from the local private practice, New York Oncology and Hematology (NYOH) office to our local hospital, Albany Medical Center (AMC), often bring comprehensive paper charts, but those coming directly from home frequently lack necessary documents, relying on the medical teams' expertise to ensure appropriate blood product selection. We aim to improve understanding of transfusion products and their indications. Methods: An initial pre-survey questionnaire was sent to internal medicine residents. Of the 33 responses received, 87.9% were aware of the need for irradiated blood products in hematological malignancies, 66.6% knew it was not required for solid tumors, and only 57.6% knew about the need for CAR-T patients. Additionally, only 15.2% knew where to find information on selecting irradiated blood products at AMC. The analysis highlighted a significant knowledge gap in transfusing irradiated blood products for hematological and oncological malignancies. In response, a user-friendly educational resource was created and displayed in residents' conference rooms during inpatient rotations, with plans for intermittent educational sessions over the next months. A comprehensive educational initiative addressed this aspect of patient care within the inpatient service, distributing detailed materials and discussions with the internal medicine residents at AMC. The focus was on emphasizing the critical requirement for irradiated blood products in specific clinical scenarios, particularly when managing patients with hematological malignancies and other conditions where irradiated blood is medically indicated. Results: A follow-up survey, conducted four months after distributing educational material on medicine floors, included responses from 27 internal medicine residents. Notably, 100% and 88.9% were knowledgeable about the necessity of irradiated blood products in hematological malignancies and bone marrow transplant recipients, respectively. Additionally, 24 out of 27 residents were aware that irradiated products are unnecessary for solid tumor malignancies in adult patients. All residents knew where to find information on blood product selection at AMC, and 92.6% found the education material helpful. Conclusions: Improved knowledge among residents underscores our commitment to patient care. We aim to extend education on irradiated blood product necessity beyond our residency program. Our long-term vision is to broaden this critical knowledge across the healthcare community at AMC.

QAPI 124 - Effect of Education and Performance Feedback to Eliminate Central Line Associated Blood Stream Infections on an Internal Medicine Unit

QAPI 124 - Effect of Education and Performance Feedback to Eliminate Central Line Associated Blood Stream Infections on an Internal Medicine Unit

Prevalence and Risk Factors of Distal Symmetric Polyneuropathy Among Predominantly Non-Hispanic Black, Low-Income Patients.

Distal symmetric polyneuropathy (DSP) is a disabling, often painful condition associated with falls and reduced quality of life. Non-Hispanic Black people and people with low income are underrepresented in existing DSP studies; therefore, it is unknown whether data accurately reflect the prevalence, risk factors, and burden of disease in these populations. Patients older than 40 years presenting to an outpatient internal medicine clinic predominantly serving Medicaid patients in Flint, Michigan, were enrolled in a cross-sectional study. Demographics, clinical characteristics, including medication use, anthropomorphic measurements, fasting lipids, and hemoglobin A1c were collected. DSP was defined using the modified Toronto Clinical Neuropathy Score (mTCNS). Multivariable logistic regression was performed to model DSP and undiagnosed DSP as a function of potential risk factors age, metabolic syndrome, and race. DSP burden was measured using Peripheral Neuropathy Quality of Life Instrument-97. Two hundred participants were enrolled, and 169 (85%) completed all data collection. The population was 55% female of mean age (SD) 58.2 years (10.4) and 69% non-Hispanic Black. Among the population, 50% had diabetes, 67% had metabolic syndrome, and 47% had a household income <$20,000. DSP was present in 73% of the population, of which 75% were previously undiagnosed. Neuropathic pain was documented in 57% of participants with DSP. DSP based on mTCNS criteria was associated with older age (odds ratio [OR] 1.1 [95% confidence interval (CI) 1.03-1.2]) and metabolic syndrome (OR 4.4 [1.1-18.1]). Non-Hispanic Black participants had lower odds of DSP (OR 0.1 [0.01-0.4]) than non-Hispanic White and Hispanic participants. DSP burden was high, including increased pain, health-related worry, and poorer quality of life (all p < 0.001). DSP is extremely common and often underrecognized in this predominantly non-Hispanic Black, low-income population and leads to substantial disease burden. Metabolic syndrome is a highly prevalent, modifiable risk factor in this population that should be managed to lower DSP prevalence.

Understanding the factors associated with nurse employment in clinics: Experiences in Taiwan.

The shortage and distribution of nurses affect healthcare access in aging societies. Limited research has explored the nursing workforce in clinics, which is vital for healthcare delivery. This study aimed to investigate the shortage and distribution of nurses in clinics in Taiwan, considering geographical, institutional, and specialty variations. We conducted a cross-sectional analysis of the national nursing workforce in Western medicine clinics in Taiwan using open government data. The nursing practice rate (NPR) was calculated. The ratio of clinics employing nurses (RCN) was determined by calculating the percentage of clinics with nurses in each category. A logistic regression model was fitted to examine the factors associated with nurse employment, including urbanization level and different specialty clinic. Adjusted odds ratios (OR) and 95% confidence intervals were calculated. The study revealed an overall NPR as low as 59.1%, and a decreasing trend with age. Among the 11706 clinics in the study, nearly a quarter did not employ nurses, with an overall RCN of 72.3%. Urbanization level and clinic specialty were associated with nurse employment (p<0.05). After adjusting for urbanization level, the fitted regression model identified the top three specialties as plastic surgery (OR=11.37, RCN=96.8%), internal medicine (OR=1.94, RCN=84.1%), and orthopedics (OR=1.89, RCN=83.6%), while the bottom three were otolaryngology (OR=0.59, RCN=61.5%), psychiatry (OR=0.49, RCN=57.1%), and rehabilitation medicine (OR=0.30, RCN=45.2%). Nurses were more likely to be employed in areas at urbanization level 1 (OR=1.17), 3 (OR=1.37), and 6 (OR=1.48), which represent highly urbanized areas within the urban, suburban, and rural categories, respectively, than in urbanization level 4. Clinics in Taiwan showed nursing shortages and maldistribution, with 72.3% RCN and variations based on urbanization and specialty. These factors may be considered in nursing research conducted in other countries to inform future workforce planning.

Evaluation and Comparison of Academic Impact and Disruptive Innovation Level of Medical Journals: Bibliometric Analysis and Disruptive Evaluation.

As an important platform for researchers to present their academic findings, medical journals have a close relationship between their evaluation orientation and the value orientation of their published research results. However, the differences between the academic impact and level of disruptive innovation of medical journals have not been examined by any study yet. This study aims to compare the relationships and differences between the academic impact, disruptive innovation levels, and peer review results of medical journals and published research papers. We also analyzed the similarities and differences in the impact evaluations, disruptive innovations, and peer reviews for different types of medical research papers and the underlying reasons. The general and internal medicine Science Citation Index Expanded (SCIE) journals in 2018 were chosen as the study object to explore the differences in the academic impact and level of disruptive innovation of medical journals based on the OpenCitations Index of PubMed open PMID-to-PMID citations (POCI) and H1Connect databases, respectively, and we compared them with the results of peer review. First, the correlation coefficients of the Journal Disruption Index (JDI) with the Journal Cumulative Citation for 5 years (JCC5), Journal Impact Factor (JIF), and Journal Citation Indicator (JCI) were 0.677, 0.585, and 0.621, respectively. The correlation coefficient of the absolute disruption index (Dz) with the Cumulative Citation for 5 years (CC5) was 0.635. However, the average difference in the disruptive innovation and academic influence rankings of journals reached 20 places (about 17.5%). The average difference in the disruptive innovation and influence rankings of research papers reached about 2700 places (about 17.7%). The differences reflect the essential difference between the two evaluation systems. Second, the top 7 journals selected based on JDI, JCC5, JIF, and JCI were the same, and all of them were H-journals. Although 8 (8/15, 53%), 96 (96/150, 64%), and 880 (880/1500, 58.67%) of the top 0.1%, top 1%, and top 10% papers selected based on Dz and CC5, respectively, were the same. Third, research papers with the "changes clinical practice" tag showed only moderate innovation (4.96) and impact (241.67) levels but had high levels of peer-reviewed recognition (6.00) and attention (2.83). The results of the study show that research evaluation based on innovative indicators is detached from the traditional impact evaluation system. The 3 evaluation systems (impact evaluation, disruptive innovation evaluation, and peer review) only have high consistency for authoritative journals and top papers. Neither a single impact indicator nor an innovative indicator can directly reflect the impact of medical research for clinical practice. How to establish an integrated, comprehensive, scientific, and reasonable journal evaluation system to improve the existing evaluation system of medical journals still needs further research.