Greatest Barrier Research Articles

Change starts at home: summary of the 2023 inaugural Small Animal Antimicrobial Stewardship Workshop for US Veterinary Schools.

Small animal antimicrobial stewardship (AS) is emerging as a priority area in the global battle against antimicrobial resistance. Veterinary practices have limited support for implementation of AS programs, and even within veterinary schools, efforts are largely siloed and often limited in scope. Increased collaboration is needed to support and unify AS and infection prevention and control efforts, and to identify priorities for continued research. To address this, a 2-day in-person small animal AS workshop was held in August 2023. Delegates representing 23 US veterinary schools and 4 corporations/government agencies gathered for a series of lightning talks and focused group discussions in 3 domains: implementation of clinical AS programs, research opportunities and needs, and education. The workshop's goal was to identify and propose solutions for AS challenges. Meeting discussion identified a lack of resources and training as the greatest barriers to hospital AS program advancement and suggested creating standards for AS programs and a road map to support program development. Assessing antimicrobial treatment effects and performing studies to establish necessary treatment durations were considered the highest research priorities. Integrated educational practices were recommended to support unified messaging of AS concepts between preclinical and clinical training. The development of strategies to implement these suggestions was delegated to working groups with a goal to continue meeting biennially as a large group. Sharing news of these efforts is considered integral to heightening awareness and promoting implementation of AS practices moving forward in academic, specialty, and primary care settings.

Exploring the effects of a real-time cardiac telerehabilitation using wearable devices in people with coronary artery disease following a recent myocardial infarction: a randomised controlled trial

Abstract Background Exercise-based cardiac rehabilitation (CR) is a non-pharmacological multidisciplinary program for individuals after myocardial infarction (MI), that offers multiple health benefits. One of the greatest barriers to CR participation is the travelling distance to the rehabilitation centre. Remotely monitored CR appears to be at least as effective in improving cardiovascular risk factors and exercise capacity as traditional centre-based CR. Nevertheless, the efficacy of a remotely monitored CR in people with recent MI has yet to be examined. Purpose The aim of this randomised controlled trial was to assess the effects of a real-time cardiac telerehabilitation monitored by wearable devices in people with recent MI. Methods Thirty people (8 women, 22 men) with CAD following a recent (i.e., < 4 week) MI were randomly allocated into two groups (online home-based and gym-based groups). The groups underwent a 26-week CR, thrice per week. All patients performed the baseline and 24 weeks follow up measurements where peak oxygen uptake (VO2peak), mean daily steps, distance and calories were assessed. Results The online group showed improved in mean daily steps (P<0.05) and mean daily distance (P<0.05) at 24 weeks compared to the gym-based group. The paired sample t-test showed that all the assessed variables were statistically (P<0.001) improved for both groups at 24 weeks. Pearson’s r demonstrated positive correlations between VO2peak and mean daily distance (r= .375), and negative correlations between VO2peak and muscle (r= -.523) and fat masses (r= -.460). There was no exercise-induced adverse events during the study. Conclusion Our findings might indicate that a real-time online supervised CR exercise programme using wearable technology to monitor the hemodynamic responses in CAD post MI patients is equally effective to a gym-based exercise programme.Individualized scanwatch report

Finding Free OER Textbooks Online: Untangling the Web

Although Open Educational Resources (OERs) can help reduce costs and maximize access to instructional materials, academics face significant problems in identifying good OER textbooks. This can be traced, in part, to the low quality of many OER directories. This study evaluated more than 350 potentially relevant resources, identifying 95 multidisciplinary and 23 subject-limited OER directories that include a relatively high proportion of free textbooks rather than other OERs (syllabi, assessment materials, etc.). Comparative information is presented for each of the 118 directories, with special attention to those with high recall, high precision, explicit and meaningful selection criteria, and consistently good textbook quality. The results focus on the characteristics of the OER directories, the extent to which they support the discovery of textbooks, the particular directories that are likely to be most useful, and the ways in which the most useful directories are systematically different from the others. There are at least 24 high-quality OER directories, but three—the Open Textbook Library, the B.C. Open Collection, and LibreTexts Commons—are especially useful. By devoting more attention to directories such as these, we can overcome the greatest barrier to the adoption of OER textbooks—the difficulty of identifying titles that can replace conventional texts.

Lost in Transition? Market Failure in the Implementation of the Circular Economy. A Comparative Analysis of the Netherlands and Poland

It is necessary for economies to transition to a circular economy (CE). What particularly inhibits the implementation of the CE in linear economies is market failures, whose theoretical principles are embedded in modern welfare economics and neoclassical economics. Market failures shape the functioning of different areas of the markets, including the allocation of and access to resources, competition, and cooperation, among others. Due to their presence in the market, opportunities for industrial symbiosis based on intersectoral cooperation and the creation of resource-efficient production systems are limited. It is crucial because the functioning of local actors within an industrial symbiosis significantly favours the promotion and development of a CE. The aim of the paper is to identify market failures that limit the implementation of CEs in traditional linear economies. The article is based on focus group interviews (FGI) conducted with four groups of stakeholders in the Netherlands and Poland: academia, society, business and the government. The main findings show that one of the greatest barriers in Poland is stakeholders’ low awareness of the CE, which influences their possibilities of cooperating and networking. Existing laws additionally limit opportunities to develop the CE. In contrast, in the Netherlands, where awareness is deeply embedded in the culture, education system and upbringing, the level of market failure is lower.

Abstract B120: Understanding Barriers and Facilitators Affecting Participation in Cancer Clinical Research Studies for Racially and Ethnically Diverse Populations in Rural North Carolina

Abstract Increasing representation of minoritized racial and ethnic populations in cancer clinical research studies has been declared a priority in the US for many years. Additionally, it is widely recognized that people living in rural areas of the US have limited access to cancer clinical research studies, and solutions are needed to extend participation opportunities to rural cancer patients. Underrepresentation of minoritized racial and ethnic populations and rural communities perpetuates health inequities, and solutions are needed to remove barriers and implement facilitators for participation. However, a review of existing literature found a lack of attention on the intersection of race and rurality and the needs and values of these populations as it pertains to cancer research. To address this concern, we used a sequential mixed method, community-engaged approach to explore the barriers and facilitators affecting participation in cancer clinical research from the perspectives of cancer survivors and their caregivers, as well as cancer healthcare professionals in rural North Carolina (NC). We used existing publicly available data to identify and characterize four of the most rural, racially and ethnically diverse, and medically underserved counties in NC. The principal investigator collaborated with cancer centers, churches, and American Indian tribal leaders in NC to administer surveys to cancer survivors and caregivers to assess their beliefs and experiences regarding cancer clinical research. Eligible participants included persons who had been diagnosed with cancer or a caregiver of someone diagnosed with cancer. In addition, we conducted key informant interviews with cancer health care professionals providing cancer care in the selected rural NC counties. We analyzed surveys and interview responses with descriptive statistics. Forty-three cancer survivors/caregivers completed surveys and twenty-two cancer healthcare professionals completed semi-structured interviews. Cancer survivors and caregivers indicated that the lack of invitation to participate in cancer clinical research was their greatest barrier to participation, whereas cancer healthcare professionals cited the lack of transportation as the perceived greatest barrier for patients. Cancer survivors, caregivers and healthcare professionals agreed that having support from clinical research personnel would be amongst the most helpful facilitators, along with opportunities to participate in clinical research studies close to home. Cancer healthcare professionals suggested the lack of trust in clinical research was a barrier for their patients; however, cancer survivors and caregivers in this study indicated lack of trust was not a significant barrier to their participation. Recommendations to address barriers and promote facilitators to participation in cancer clinical research include the importance of engaging the community, addressing unconscious bias, decentralizing clinical trials, and providing recruitment materials in culturally responsive formats. Citation Format: Amy Garrett, Karine Dubé, Lisa Spees, Ronny Bell, Marjory Charlot, Sandra Greene. Understanding Barriers and Facilitators Affecting Participation in Cancer Clinical Research Studies for Racially and Ethnically Diverse Populations in Rural North Carolina [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B120.

Understanding patient and health care provider perceptions of barriers and facilitators to diabetes care in immigrant and refugee populations

BackgroundThere is a lack of literature which assesses both patient and health care provider (HCP) perceptions of barriers and facilitators to diabetes health care in immigrant and refugee populations within the United States. This study uniquely incorporates both cohorts’ perceptions on the same topic to assess for congruency and discrepancies in perspectives.MethodsSurveys were deployed to patients with diabetes and HCPs to solicit perceptions of barriers and facilitators to diabetes care, with the intention to determine similarities and differences between cohorts. A literature review was conducted to explore barriers and facilitators to diabetes care in immigrant/refugee populations in the US to aid in development of the survey used in this study, as no validated survey existed. Broad recruitment strategies were used, including snowball sampling. Descriptive statistics were calculated and reported p-values were derived from a chi-squared or Fisher’s exact test and used for categorical data and a Wilcoxon rank sum or Kruskal–Wallis rank sum test was used for continuous data. Qualitive analysis was completed using the inductive analysis method.ResultsAmong 19 immigrant and refugee patients and 35 HCPs, almost all facilitators to diabetes care were endorsed by patients and HCPs as helpful. The highest ranked facilitator among patients and HCPs was having access to health insurance. Patients rated stress, while HCPs rated lack of health insurance as the biggest barriers to diabetes care for immigrants and refugees. Patients and HCPs differed in perspective on who held primary responsibility for diabetes management. Patients wanted more diabetes education and nutrition support, while HCPs thought understanding patients’ cultural context/sensitivity, providing more education, and having language/translation services were the most important things HCPs can do to care for patients’ diabetes.ConclusionsImmigrant/refugee patients and HCPs largely agree about what factors are most helpful in managing diabetes, with access to health insurance as the greatest facilitator. However, while HCPs identified lack of health insurance as the greatest barrier to care, immigrant and refugee patients cited the role of stress as the greatest challenge in managing their diabetes. There was a striking difference in perception of responsibility for diabetes management, with 89% of patient participants responding that the patient is responsible, while only 17% of HCPs responded that the patient was responsible. Future work should include surveys translated into languages other than English to further elicit the perspective of diabetes care in immigrant/refugee populations. Clinical recommendations based on this study include assessing and supporting patient stressors, assuring patients understand that diabetes management is a partnership, providing culturally tailored diabetes education, and increasing access to health insurance.

3-Methylthiophene: A Sustainable Solvent for High-Performance Organic Solar Cells.

The use of harmful halogenated or aromatic solvents such as chloroform (CF), chlorobenzene (CB), and o-xylene (o-XY) is one of the greatest barriers to the industrial-scale manufacturing of high-performance organic solar cells (OSCs). Therefore, it is necessary to eliminate the effects of these solvents to ensure practical feasibility of OSCs. We found that the anthracene-terminated polymer donor and small-molecule acceptor BO-4Cl had good solubility in 3-methylthiophene (3-MeT). There were no toxicity labels in the SDS and exposure control limits for 3-MeT. An overall power conversion efficiency of 16.87% was achieved by using 3-MeT as the solvent for solar cell fabrication, which was higher than that of the cells made from CF (16.18%) and o-XY (15.69%). The best OSC based on PM6:D18:L8-BO and fabricated with 3-MeT exhibited a high PCE of 18.13%, which is one of the highest values for cells fabricated from halogen-free solvents. These results indicate that 3-MeT is an eco-friendly and low-toxicity solvent for the sustainable fabrication of the OSC active layer.

Education Research: The Current Landscape of Clinician Educator Tracks in Adult Neurology Residency Programs: A National Survey of Program Directors.

As the concept of a clinician-educator (CE) evolves and the multiple competencies of the role become better defined, there seems to be a growing need for targeted training for clinicians pursuing a career in medical education. This study aims to describe the current state of CE tracks in adult neurology residency programs and to identify the barriers to implementation, potential solutions, and program goals and outcomes. We characterized CE tracks using 2 methods. First, we reviewed the websites of all US adult neurology residency programs to determine the availability of a CE track and its characteristics. Second, we administered a 20-item survey to program directors (PDs) of all US neurology residency programs, with questions focused on track availability, characteristics, perceived benefits of CE tracks on resident career development, barriers to implementation, and ideas for national initiatives that may facilitate track development or improvement. Fifty-eight of 177 (33%) PDs responded to the survey. Combining the results of the website reviews and surveys, we found that 34 of 179 (19%) programs have CE tracks. Seventy percent of PDs felt that CE tracks are very impactful or impactful for participating residents' careers, a perception more common among PDs of programs with tracks. The greatest perceived benefit was in preparing residents for educational leadership roles. The greatest barriers to implementation were a lack of teaching faculty, a lack of resources, and limited resident time. The highest ranked idea for a national initiative that can facilitate track development was live and recorded lectures on medical education topics. Although most PDs surveyed agreed that CE tracks are impactful for preparing residents as teachers and education leaders, such tracks are available in only 19% of adult neurology residency programs. PDs report that the benefits of CE tracks extend beyond the participants, with implications for the health of the residency program and the neurology department. While some programs have significant barriers to implementation, national initiatives may help reduce the resource burden on individual programs. Future areas of study include assessing the development and outcomes of national initiatives and analyzing the outcomes associated with CE tracks.

Staff-Perceived Barriers to Patient Mobilization Vary by Hospital, Discipline, and Experience: A Multisite Cross-Sectional Survey

ObjectiveTo describe staff-perceived barriers to progressive patient mobilization. DesignCross-sectional staff survey. SettingTen internal medicine wards in 4 hospitals in a large health service. ParticipantsNursing, medical, and allied health staff (n=208). InterventionsNot applicable. Main Outcome MeasuresPatient Mobilization Attitudes and Beliefs Survey. An overall barriers score and subscale scores for knowledge, attitudes, and behaviors were calculated and compared between hospitals, discipline, and years of clinical experience. ResultsThe survey was completed by 208 participants (123 nurses, 27 medical, 58 allied health), of whom 104 (50%) had <5 years of experience. The greatest perceived barriers included nursing workload, medical orders not being in place, and patient and family resistance to mobilization. Overall barrier scores differed between hospitals, discipline (mean nursing score ± SD 50±7; mean medical score ± SD, 51±7; mean allied health score ± SD, 43±7), and years of clinical experience (<5y mean score ± SD, 50±7; 5-9y mean score ± SD, 47±7; ≥10y mean score ± SD, 46±8); significant differences by hospital and discipline persisted in multivariate analysis. The behavior subscale had the highest barriers score and knowledge the lowest across all subgroups. ConclusionsStaff-perceived nursing workload, lack of medical orders, and patient and family resistance to be the greatest barriers to patient mobilization. Barrier scores differed between disciplines, experience levels, and across hospitals within a single health service. Lower scores on the knowledge subscale highlight the need for multicomponent strategies beyond education that address culture and systems; education may particularly benefit medical staff.

Access to community-based eye services in Meru, Kenya: a cross-sectional equity analysis

BackgroundOver 80% of blindness in Kenya is due to curable or preventable causes and 7.5 m Kenyans currently need eye services. Embedding sociodemographic data collection into screening programmes could help identify the groups facing systematic barriers to care. We aimed to determine the sociodemographic characteristics that were associated with access among patients diagnosed with an eye problem and referred for treatment in the Vision Impact Programme, currently operating in Meru County.MethodWe used an embedded, pragmatic, cross-sectional design. A list of sociodemographic questions was developed with input from key stakeholders. The final question set included the following domains: age, gender, religion, marital status, disability, education, occupation, income, housing, assets, and health insurance. These were integrated into an app that is used to screen, refer, and check-in (register) participants within a major eye screening programme. We gathered data from 4,240 people who screened positive and were referred to their local outreach treatment clinic. We used logistic regression to identify which groups were facing the greatest barriers to accessing care.ResultsA quarter of those screened between April – July 2023 were found to have an eye problem and were referred, however only 46% of these people were able to access care. In our fully adjusted model, at the 0.05 level there were no statistically significant differences in the odds of attendance within the domains of disability, health insurance, housing, income, or religion. Strong evidence (p < 0.001) was found of an association between access and age, gender, and occupation; with males, younger adults, and those working in sales, services and manual jobs the least likely to receive care.ConclusionsAccess to essential eye services is low and unequal in Meru, with less than a third of those aged 18–44 receiving the care they need. Future work should explore the specific barriers faced by this group.

Protocol for a randomized controlled trial of moderate intensity interval training in individuals with chronic obstructive pulmonary disease and obstructive sleep apnea overlap syndrome who have excessive daytime sleepiness

BackgroundThe term “Overlap Syndrome” (OS) describes the presence of both chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) in a single individual. Excessive daytime sleepiness (EDS) is a common symptom of OS shown to be associated with an increased risk of cardiovascular disease (CVD) that could be reduced through exercise. Thus, we propose to investigate a novel exercise intervention in individuals with the EDS-OS phenotype as they are at highest risk of CVD yet have the greatest barriers to exercise. MethodsWe will conduct a single-site, randomized, two-arm, parallel group-controlled exercise trial in individuals with EDS-OS. The Epworth Sleepiness Scale (ESS) will be assessed at baseline. Individuals with OS and the EDS-OS phenotype (ESS >10) (n = 46) will be randomized to a moderate intensity interval training (MIIT, i.e. intervals of 5 min at 50% VO2peak followed by 3 min of active recovery at 10% VO2peak) or a control group of standard of care. We will investigate if MIIT intervention decreases the risk of CVD in EDS-OS, which will be assessed by: 1) quality of life, measured by the 36-Item Short Form Health Survey; 2) physical activity, measured by daily step counts; and 3) cardiovascular health, assessed as VO2peak, flow-mediated dilation and serum high sensitivity C-reactive protein, lipids, and glucose. ConclusionOur findings will guide future development and implementation of exercise interventions that could reduce the risk of CVD in the understudied EDS-OS phenotype.

Increasing Influenza Vaccination Rates among Patients with Type 2 Diabetes Mellitus in Chongqing, China: A Cross-Sectional Analysis Using Behavioral and Social Drivers Tools.

Influenza vaccination is essential for type 2 diabetes mellitus (T2DM) patients due to their higher risks of severe complications and mortality from influenza. This study investigated the willingness of T2DM patients in Chongqing, China, to receive the influenza vaccination during the 2023/2024 season, using behavioral and social drivers (BeSD) tools to improve vaccination uptake in this high-risk group. A multi-stage sampling method was used to select participants, and face-to-face surveys were conducted in community health centers between March 1 and May 1, 2023. Binary logistic regression was used to analyze the factors influencing vaccination willingness, and standardized scores identified barriers and drivers. Among 1672 T2DM patients, 11.7% had been vaccinated during the 2022/2023 season, and 59.6% were willing to receive the vaccination in the 2023/2024 season. Higher willingness was associated with ethnic minorities (odds ratio [OR], 3.18, 95% confidence interval [CI]: 1.58-6.39), being unemployed individuals (OR 2.69, 95% CI: 1.60-4.52), higher monthly household income per capita (OR 2.72, 95% CI: 1.65-4.50), having diabetes complications (OR 1.76, 95% CI: 1.23-2.51), sufficient vaccine knowledge (OR 1.87, 95% CI: 1.48-2.37), and previous vaccination (OR 7.75, 95% CI: 4.83-12.44). Concerning BeSDs, fear of infecting friends or family members and trust in vaccine efficacy were the predominant drivers, while high vaccine costs were the greatest barrier. Future strategies should focus on improving vaccine knowledge, supporting healthcare workers and peer recommendations, and enhancing vaccination policies. Key interventions such as health education among high-risk groups, such as unemployed individuals, advocacy campaigns, pay-it-forward strategies, and policies for free vaccination could improve coverage in Chongqing.

The foremost and greatest barrier to end-stage heart failure treatment: the impact of caregiver shortage.

We examined the number of patients abandoning cardiac replacement therapy due to the inability to secure a designated caregiver. At Osaka University Hospital Heart Center, when we receive a consultation for a patient with severe heart failure from another hospital, a heart failure team makes a visit to the referring hospital as soon as possible. We retrospectively analyzed this hospital-visit database. We received 199 severe heart failure consultations from 2016-2023. Issues identified during hospital visits included age ≥ 65years (8%), inability to confirm the patient's intention (8.5%), and explicit refusal of therapy (2.5%). Medical problems included multiple organ failure (18.1%), obesity (13.1%), diabetes (9.5%), malignancy (5.5%), chronic dialysis (1.0%), and other systemic diseases (12.6%). Adherence problems included poor medication compliance (3.5%), history of heavy drinking (2.5%), and smoking (2.0%). Social problems included inadequate family support in 16.1% of patients. Of the 199 patients, 95 (48.0%) proceeded to a heart transplant and LVAD indication review meeting at Osaka University Hospital. The remaining 104 patients (52.0%) did not proceed to the meeting. Reasons included improvement of heart failure with conservative treatment in 37 cases (35.6%), death before discussion in 21 cases (20.2%), medical contraindications in 18 cases (18.3%), lack of caregivers in 18 cases (18.3%; 9.5% of 199 cases), and patient refusal in 5 cases (4.8%). Approximately 10% of patients consulted at Osaka University Hospital Heart Center for severe heart failure abandoned cardiac replacement therapy due to the lack of caregivers.

Current Landscape of Child and Adolescent Psychology Internship Programs and Implications for Workforce Development.

Doctoral psychology internships play a key role in the development of the competencies of the clinical child and adolescent psychologist workforce needed to serve the increasing behavioral and mental health needs of children. This study surveyed 50 internship training directors regarding workforce needs, the structure of experiential internship components, and the organizational infrastructure and funding of internship programs that provide focused care to children and adolescents within medical settings. Findings suggest that internships most commonly occur within academic medical settings and include clinical child psychology, integrated care, pediatric psychology, neuropsychology, and developmental disabilities tracks. On average, sites had 6 interns, 3 tracks, and 4 major rotations per track. Training directors identified program funding to be the greatest barrier to sustaining internship programs. Currently, internships are funded through clinical revenue, grants, and organizational funds covering an average intern salary of $31,020 plus benefits as well as 0.3 FTE of a training director's time to administrate the program. The number of internship tracks within a single program was associated with greater administrative time for the training director. Implications for advocacy at the federal, state, profession, and institutional level to increase funding and decrease barriers to training are discussed.

Pricing of medication abortion in the United States, 2021-2023.

Financial costs remain one of the greatest barriers to abortion, leading to delays in care and preventing some from getting a desired abortion. Medication abortion is available through in-person facilities and telehealth services. However, whether telehealth offers a more affordable option has not been well-documented. We used Advancing New Standards in Reproductive Health (ANSIRH)'s Abortion Facility Database, which includes data on all publicly advertising abortion facilities and is updated annually. We describe facility out-of-pocket prices for medication abortion in 2021, 2022, and 2023, comparing in-person and telehealth provided by brick-and-mortar and virtual clinics, and by whether states allowed Medicaid coverage for abortion. The national median price for medication abortion remained consistent at $568 in 2021 and $563 in 2023. However, medications provided by virtual clinics were notably lower in price than in-person care and this difference widened over time. The median cost of a medication abortion offered in-person increased from $580 in 2021 to $600 by 2023, while the median price of a medication abortion offered by virtual clinics decreased from $239 in 2021 to $150 in 2023. Among virtual clinics, few (7%) accepted Medicaid. Median prices in states that accept Medicaid were generally higher than in states that did not. Medication abortion is offered at substantially lower prices by virtual clinics. However, not being able to use Medicaid or other insurance may make telehealth cost-prohibitive for some people, even if prices are lower. Additionally, many states do not allow telehealth for abortion, deepening inequities in healthcare.

Barriers and facilitators to effective electronic health record-based sepsis screening in the pediatric intensive care unit.

The Pediatric Surviving Sepsis Campaign supports the implementation of automated tools for early sepsis recognition. In 2019 the C.S. Mott Children's Hospital Pediatric Intensive Care Unit deployed an electronic medical record (EMR)-based screening for early recognition and treatment of sepsis. We analyzed all automated primary sepsis alerts, secondary screens, and bedside huddles from November 2019 to January 2020 (Cohort 1) and from November 2020 to January 2021 (Cohort 2) to identify barriers and facilitators for the use of this tool. We distributed surveys to frontline providers to gather feedback on end-user experience. In Cohort 1, 895 primary alerts were triggered, yielding 503 completed secondary screens and 40 bedside huddles. In Cohort 2, 925 primary alerts were triggered, yielding 532 completed secondary screens and 12 bedside huddles. Surveys assessing end-user experience identified the following facilitators: (1) 73% of nurses endorsed the bedside huddle as value added; (2) 74% of medical providers agreed the bedside huddle increased the likelihood of interventions. The greatest barriers to successful implementation included the (1) overall large number of primary alerts from the automated tool and (2) rate of false alerts, many due to routine respiratory therapy interventions. Our data suggests that the successful implementation of EMR-based sepsis screening tools requires countermeasures focusing on 3 key drivers for change: education, technology, and patient safety. While both medical providers and bedside nurses found merit in our EMR-based sepsis early recognition system, continued refinement is necessary to avoid sepsis alert fatigue.

Implementation of Outpatient Automated Stewardship Information System (OASIS©) Audit and Feedback in Two Healthcare Systems

Background: Combating antibiotic resistance, exacerbated by widespread unnecessary outpatient antibiotic prescriptions, necessitates innovative stewardship solutions. Audit and feedback reports are effective but often resource heavy. We introduced a free, open-source system, Outpatient Automated Stewardship Information System (OASIS©), for automating the creation and distribution of recurring audit and feedback reports to clinicians to improve antibiotic prescribing. Methods: We used mixed methods to evaluate implementation of OASIS© across 11 clinics at Denver Health and Hospital Authority (DHHA) and Children’s Hospital Colorado (CHCO) from July 2022 to August 2023. Both sites host their own Epic® electronic healthcare and enterprise data warehouse systems. R statistical software was utilized to retrieve and process the data needed to create individual[HCM1] clinician audit and feedback reports with peer comparison. Reports were provided for 1) antibiotics prescribed for respiratory diagnoses, 2) antibiotics prescribed for respiratory diagnoses where antibiotics are never indicated, 3) first-line antibiotic prescribing for acute otitis media (AOM), and 4) five-day duration of antibiotics for children two years and older with AOM. Feedback reports for each metric were emailed to clinicians for three consecutive months. The primary outcome was adaptations needed to implement OASIS©. Secondary outcomes included fidelity (measured by email readership), time to set up and maintain the program, and barriers and facilitators to implementation (assessed by four qualitative interviews with OASIS© stakeholders). Results: The most significant adaptations made pertained to the automation of OASIS© reports for organizations not using R for data retrieval and reporting, setting up OASIS© specific email addresses, and validating clinician fidelity via read receipts. Fidelity was higher at DHHA (91-100%) compared to CHCO (10-30%). When interviewed, data analysts expressed that time for initial setup ranged from 1-6 hours. After reporting was automated, the estimated monthly time to send reports was 10 minutes. Views on setup complexity were split, but all recognized the readability of the reports and OASIS©’s value for improving prescribing behaviors. The greatest barriers to implementation included obtaining analytic resources for initial setup and the need to download additional R packages. No interviewee had prior experience creating audit and feedback reports. Conclusions: Implementing OASIS© requires addressing system diversity and knowledge gaps in outpatient informatics and antibiotic stewardship. Despite these challenges, the tool proved efficient and beneficial for monitoring and reporting antimicrobial prescribing. This free tool could likely be effectively disseminated to other health systems given the limited time and resources required for adaptations, setup, and monitoring. [HCM1]I

Understanding the challenges of identifying, supporting, and signposting patients with alcohol use disorder in secondary care hospitals, post COVID-19: a qualitative analysis from the North East and North Cumbria, England

BackgroundAlcohol-related mortality and morbidity increased during the COVID-19 pandemic in England, with people from lower-socioeconomic groups disproportionately affected. The North East and North Cumbria (NENC) region has high levels of deprivation and the highest rates of alcohol-related harm in England. Consequently, there is an urgent need for the implementation of evidence-based preventative approaches such as identifying people at risk of alcohol harm and providing them with appropriate support. Non-alcohol specialist secondary care clinicians could play a key role in delivering these interventions, but current implementation remains limited. In this study we aimed to explore current practices and challenges around identifying, supporting, and signposting patients with Alcohol Use Disorder (AUD) in secondary care hospitals in the NENC through the accounts of staff in the post COVID-19 context.MethodsSemi-structured qualitative interviews were conducted with 30 non-alcohol specialist staff (10 doctors, 20 nurses) in eight secondary care hospitals across the NENC between June and October 2021. Data were analysed inductively and deductively to identify key codes and themes, with Normalisation Process Theory (NPT) then used to structure the findings.ResultsFindings were grouped using the NPT domains ‘implementation contexts’ and ‘implementation mechanisms’. The following implementation contexts were identified as key factors limiting the implementation of alcohol prevention work: poverty which has been exacerbated by COVID-19 and the prioritisation of acute presentations (negotiating capacity); structural stigma (strategic intentions); and relational stigma (reframing organisational logics). Implementation mechanisms identified as barriers were: workforce knowledge and skills (cognitive participation); the perception that other departments and roles were better placed to deliver this preventative work than their own (collective action); and the perceived futility and negative feedback cycle (reflexive monitoring).ConclusionsCOVID-19, has generated additional challenges to identifying, supporting, and signposting patients with AUD in secondary care hospitals in the NENC. Our interpretation suggests that implementation contexts, in particular structural stigma and growing economic disparity, are the greatest barriers to implementation of evidence-based care in this area. Thus, while some implementation mechanisms can be addressed at a local policy and practice level via improved training and support, system-wide action is needed to enable sustained delivery of preventative alcohol work in these settings.

DIPG-89. ENHANCEMENT OF BLOOD-BRAIN BARRIER PENETRATION AND TUMOR TARGETED DRUG DELIVERY FOR DMG USING A P-SELECTIN TARGETED NANOMEDICINE APPROACH

Abstract The blood-brain barrier (BBB) is one of the greatest barriers for the effective treatment of brain tumors, including H3K27-altered diffuse midline glioma (DMG), a near universally fatal childhood brain cancer. The BBB typically requires drugs to be given at maximally tolerated doses that are limited by systemic toxicities, particularly in settings of combination therapy. We have developed a clinically compatible fucoidan nanoparticle (Fi-NP) that homes to P-selectin on tumor vasculature after low-dose radiation (RT) to breach the BBB through an active caveolin-1-dependent mechanism and deliver several classes of targeted therapies. In non-CNS cancer xenograft models and a transgenic mouse model of SHH-driven medulloblastoma with an intact BBB, this approach improved survival while eliminating on-target systemic toxicities. We have now applied this approach to both brainstem and non-brainstem RCAS-TVA mouse models of DMG with an intact BBB. Specifically, we have found that DMG tumor vasculature expresses P-selectin, and that a single low-dose 2 Gy fraction of ionizing radiation further enhances it in a time-dependent manner up to 24 hours post-treatment. Importantly, we have also found that this P-selectin targeted drug delivery approach facilitates DMG tumor localization of Fi-NP encapsulated EZH2 inhibitor tazemetostat (EPZ-6438) as well as larger macromolecules including the PROTAC BET degrader dBET6, two promising targeted therapies for DMG limited by extremely poor BBB-penetration, while sparing drug delivery to non-tumor healthy brain regions. Work to measure PK, biodistribution, survival benefit, and drug target inhibition is ongoing. Our findings will provide the foundation for this P-selectin targeted Fi-NP approach to be evaluated in clinical trials for children with this lethal cancer.

Patterns of Use and Barriers to STI Point-of-care Tests for Military Obstetrician Gynecologists.

Sexually transmitted infections (STIs) are commonly reported in military populations. Point-of-care tests (POCTs) are commercially available, but their use is variable in the civilian sector. Their use among military providers has not been evaluated. We sought to identify the pattern of use and barriers to using STI POCTs for military obstetrician/gynecologists (OBGYNs). We adapted a survey of civilian OBGYNs on patterns of use and barriers to STI POCTs for military OBGYNs. We sent an online questionnaire to 479 military OBGYNs via Army, Air Force, and Navy specialty leaders in May 2023. The questionnaire included 14 demographic questions and up to 52 questions regarding availability, use, and barriers to STI POCTs. The USU Institutional Review Board deemed the study exempt from Institutional Review Board review. Of the 479 solicited, 117 participated in the survey (24.4%). Of respondents, 64.1% were women and 79.5% non-Hispanic white. Sexually transmitted infections were detected once to twice weekly by 13.0% of respondents and once or twice monthly by 52.8%. The most available STI-related POCTs were wet mount prep (68.7%), rapid HIV (43.3%), and urine dipstick (38.6%). Gram stain was available for 30.3%, the Affirm VPIII (Becton, Dickinson and Company, Franklin Lakes, NJ) for 24.5%, and stat RPR for 16.3%. Economic barriers to using POCTs included cost of the test from manufacturer/distributor (57.9%) and military funding/stocking decisions (10.3%). The greatest barriers to use were the purchasing of an instrument (60.8%) and the interruption to workflow in clinic (57.8%). Military OBGYNs rely on several STI-related POCTs. Economic factors and interruption to workflow were cited as the most significant barriers to using POCTs for military OBGYNs. Test cost and impact on workflow should be considered in future development and procurement of POCTs for the Military Health System.