Hospital-based Practice Research Articles

Financial Toxicity Intervention Decreases Mortality in High Risk Hematologic Malignancy Patients

Background: Financial toxicity (FT) is defined as financial distress as a result of disease or treatment decisions. FT might be considered analogous to physical toxicity. Patients with high risk hematologic malignancies represent an especially vulnerable group for cost related issues due to heavy healthcare utilization, high costs associated with their treatment, and the potentially deadly consequences of treatment noncompliance. We hypothesized that comprehensive intervention on the financial aspects of care for these patients would lead to decreased mortality. Methods: All patients seen in Leukemia Clinic at the Levine Cancer Institute, a tertiary hospital-based specialty practice, were surveyed prior to their visit over a six-month period. All patients were aged ≥18 years and diagnosed with a high-risk hematologic malignancy (intermediate/high risk AML, high risk ALL, high or very high risk MDS, blast phase CML, or mixed phenotypic acute leukemia). The survey consisted of the PROMIS Global-10 measure and two questions from the COST measure. FT was defined as scoring 5 or less (maximum: 10) in agreement with the COST questions: "I know that I have enough money in savings, retirement, or assets to cover the costs of my treatment" and "I am satisfied with my current financial situation." Patients who met these criteria were entered into the interventional cohort and scheduled for comprehensive intervention based on availability of study staff. Scheduling was done anonymously and without prioritization of perceived need. The intervention consisted of a nurse navigator visit where patients completed a standardized worksheet to identify gaps in care and opportunities for grant funding/other assistance, a clinical pharmacist visit for medication copay review and discussion of assistance programs, and the services of a community pro-bono financial planner for assistance with budgeting, asset management, and general financial advice. Demographic/clinical data were abstracted from the medical record and patients were tracked longitudinally for clinical outcomes. Categorical factors were summarized with proportions and compared between groups with Fisher's exact tests, while continuous factors were summarized with medians and compared between groups with median two-sample tests. Overall survival (OS) was evaluated with Kaplan Meier methods and compared between groups with a log rank test. Cox proportional hazards models were utilized in model selection procedures for OS. Individual prognostics were identified with univariable models, then backward elimination and forward selection (entry/elimination criteria p = 0.10) were carried out to identify a final base model. This was utilized to estimate an adjusted HR for the intervention variable. Results: A total of 105 patients met criteria and were placed in the interventional cohort with the intention to receive the full intervention. Of these patients, 59 (56.2%) were able to be scheduled and receive the full intervention, while the remainder received standard care only. There were no significant differences between the groups when compared by gender, race, age, marital status, insurance type, FT screening score, therapy received, or disease type (Table 1). OS was significantly different between the two groups, with a mortality rate during the study period of only 27% for the patients that received the full FT intervention as opposed to 43% for the patients who received standard care. Adjusted OS at 6 months for the interventional cohort was 81.4% (95% CI 68.9%-89.2%) versus 73.9% (95% CI 58.7%-84.3%) for the non-intervention group; OS rates at 12 months were 73.0% (59.0%-82.9%) and 46.4% (28.9%-63.8%), respectively (Figure 1). On univariate analysis, intervention was significantly associated with survival (HR: 0.44, 95% CI: 0.22 - 0.86, p = 0.017). After adjusting for insurance, race, and age at survey, risk of death in those receiving the intervention was 0.47 times the risk of death in those without the intervention (95% CI: 0.23 - 0.98, p = 0.043). Conclusions: High risk hematologic malignancy patients are at high risk for increased complications due to financial concerns. Intervening on FT in a comprehensive way including navigators, pharmacists, and financial counselors is effective and leads to decreased mortality. Disclosures Knight: Foundation for Financial Planning: Research Funding. Ai:Incyte: Speakers Bureau; Celgene: Speakers Bureau. Chojecki:Incyte: Research Funding; Novartis: Other: Investigator Meeting Attendance. Copelan:Amgen: Membership on an entity's Board of Directors or advisory committees. Grunwald:Pfizer: Consultancy; Agios: Consultancy; Abbvie: Consultancy; Agios: Consultancy; Daiichi Sankyo: Consultancy; Agios: Consultancy; Cardinal Health: Consultancy; Incyte: Consultancy, Research Funding; Trovagene: Consultancy; Daiichi Sankyo: Consultancy; Astellas: Consultancy; Daiichi Sankyo: Consultancy; Trovagene: Consultancy; Abbvie: Consultancy; Celgene: Consultancy; Amgen: Consultancy; Merck: Consultancy; Abbvie: Consultancy; Celgene: Consultancy; Janssen: Research Funding; Trovagene: Consultancy; Premier: Consultancy; Astellas: Consultancy; Astellas: Consultancy; Genentech/Roche: Research Funding; Premier: Consultancy; Premier: Consultancy; Amgen: Consultancy; Cardinal Health: Consultancy; Incyte: Consultancy, Research Funding; Celgene: Consultancy; Genentech/Roche: Research Funding; Genentech/Roche: Research Funding; Forma Therapeutics: Research Funding; Incyte: Consultancy, Research Funding; Merck: Research Funding; Janssen: Research Funding; Forma Therapeutics: Research Funding; Forma Therapeutics: Research Funding; Pfizer: Consultancy; Pfizer: Consultancy; Merck: Consultancy; Amgen: Consultancy; Merck: Consultancy; Cardinal Health: Consultancy.

The Status of Nutritional Management Guidelines for Head and Neck Cancer Patients.

IntroductionHead and neck cancer (HNC) is the seventh leading cause of cancer worldwide. Approximately 35%-60% patients with HNC are malnourished from the disease onset, malnutrition being associated with worsened health outcomes among these patients. This study aimed to review and synthesize existing guidelines regarding nutritional interventions in HNC patients and assess providers’ knowledge, opinions, and practice of guidelines for the nutritional management of HNC patients.MethodsThis is a multimethod study that includes a systematic review of guidelines for nutritional intervention in HNC patients and a providers’ survey regarding their knowledge and opinions regarding nutrition therapy guidelines for HNC patients.ResultsOur review yielded seven guidelines. Of the seven guidelines reviewed, all were specific to cancer patients, however, only three were specific for HNC patients. Three of the guidelines recommended using a nutritional screening tool, however, only two mentioned a specific screening tool. Out of 193 surveys included in our analysis, the highest percentage of respondents were physicians (52.4%), followed by registered nurses (33.5%). The majority of respondent (77.5%) worked in a hospital-based practice, while 18.8% worked in clinic-based practice. A large proportion (46.6%) of respondents were not aware of nutritional guidelines for HNC patients; with 23.6% not aware of any, and 23.0% aware of their existence but not aware of their content. The majority (81.5%) of respondents said that a more detailed guideline should be available for HNC patient with regards to nutrition.ConclusionNutritional deficiencies in HNC patients continue to cause significant complications in treatment and recovery. Existing practice guidelines are limited and lack specific recommendations. A universal standard of care with regard to addressing nutrition in HNC patients is needed to improve healthcare outcomes among NHC patients.

Evaluating the Impact of the Proposed Radiation Oncology Model: How Pressure to Lower Costs May Result in Reduced Access to Care

In 2019 the Center for Medicare & Medicaid Services (CMS) proposed a new payment model for radiation oncology (RO). This model introduced episode-based payments: a common, base payment for an episode of care, regardless of radiation technique or fractionation. This model may encourage providers to pursue shorter treatments as a means to reduce cost. The ability of individual facilities to reduce costs via this method has not been well characterized, and there are likely significant differences between a larger hospital-based radiation oncology facility (HF) and smaller community facility (CF). The goals of this study are to model how a HF and CF might adapt under pressure to shorten treatment courses, to compare their abilities to reduce costs, and to explore the impact of how these differences might affect access to care. Annual facility costs were determined based on our 2019 institutional financial reports as the sum of all relevant costs including personnel, space, utilities, equipment, materials, and service contracts. Per-unit salary, equipment purchase price, service contracts, and cost of utilities per square foot were assumed similar between the HF and CF. The shift toward hypofractionation was modeled as a 30% reduction in total fractions delivered per course. The HF was modeled as a 3 linear accelerator (LINAC) facility that could adapt as follows: 2 LINACs instead of 3, 2 physicists instead of 3, 6 therapists instead of 8, and a modest decrease in space required with one fewer LINAC vault. The CF was modeled as a 1 LINAC facility that could adapt by reducing therapists from 3 to 2.5 full time equivalents, with other staffing and equipment levels remaining constant. Annual estimated facility costs for the HF before and after adoption of hypofractionation were, respectively, $7,156,000 and $6,091,000, representing a cost savings of 15.1%. Annual estimated costs for the CF, before and after respectively, were $2,664,000 and $2,611,000, representing a cost savings of 2.0%. Larger departments are significantly better positioned to reduce costs as treatment courses shorten. In this study, the hospital-based facility was able to reduce costs by 15.1%, compared to just 2% for the community facility. This was primarily a result of greater flexibility in adjusting staffing and equipment. This difference may have a significant impact on access to care across the United States. Under the proposed RO model, a single base payment will be offered per episode of care, regardless of where care is furnished. Unless payment adjustments are made for smaller community-based practices, these facilities will have exceptional difficulty competing with larger hospital-based practices due to inability to reduce costs. As payment rates are adjusted to reduce nationwide healthcare expenditures, smaller community facilities are more likely to face financial pressures and ultimately close, which may disproportionately reduce access to care in rural communities.

DIAGNOSING IDIOPATHIC PULMONARY FIBROSIS IN COMMUNITY-BASED PULMONOLARY PRACTICES: FACTORS INFLUENCING APPROACH TO DIAGNOSIS

SESSION TITLE: Diffuse Lung Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Despite the increased awareness of Idiopathic Pulmonary Fibrosis (IPF) and refinement of the guidelines, there is still a significant delay in the diagnosis of IPF as many of these patients are cared for at non-Interstitial Lung Disease Centers of Excellence (ILD-CE). The purpose of this study is to gain further insight into the factors influencing the pulmonologists’ approach to diagnosing IPF at non-ILD-CE. METHODS: This study was approved by the Loma Linda University Institutional Review Board. An anonymous survey was emailed to pulmonologists throughout the United States using selected proprietary medical databases. Pulmonologists practicing at an ILD-CE were excluded. The survey evaluated the pulmonologist's approach related to referral to an ILD-CE, utilization of a Multi-Disciplinary Approach (MDA), and their attitude towards the importance of obtaining an early and accurate diagnosis. RESULTS: There were a total of 58 survey respondents: 35% in hospital-based practices and 65% in community-based practices. Only 55% of participants strongly agreed that obtaining an early and accurate diagnosis of IPF was important; no difference was noted between the practice settings. The median percentage of time the participants used an MDA was 45% (IQR: 10.75-90); 20% in hospital-based practice and 40% in community-based practice (p<0.05). In respondents with access to an ILD-CE, the median percentage of the time patients were referred to one was only 41%. CONCLUSIONS: Based on these preliminary results, the pulmonologist’s perspective on the importance of obtaining an early and accurate IPF diagnosis is low at non-ILD-CE. The utilization of an MDA was also very low despite this being the gold standard for diagnosis for all ILDs as recommended by the American Thoracic Society Task Force. Even with access to an ILD-CE, the referral rate was low. Further studies with higher sample sizes are needed to better understand the rationale behind low utilization rates of MDA and referrals to ILD-CE. CLINICAL IMPLICATIONS: This could reveal the reason behind the large number of patients with IPF that potentially go undiagnosed (or misdiagnosed) in the community-based practices. DISCLOSURES: Stock market shareholder relationship with ABT, ABBV, AZN, BMY, DOW,JNJ, LLY,PFE Please note: $1-$1000 Added 06/09/2020 by Abdullah Alismail, source=Web Response, value=only Quar.Div when applied No relevant relationships by Benjamin Becerra, source=Web Response No relevant relationships by Rodney Biehl, source=Web Response No relevant relationships by Niranjan Jeganathan, source=Web Response No relevant relationships by David Lopez, source=Web Response

Surgical Site Infections at a Level I Trauma Center in India: Data From an Indigenously Developed, e-SSI Surveillance System

Background: Globally, surgical site infections (SSIs) not only complicate the surgeries but also lead to $5–10 billion excess health expenditures, along with the increased length of hospital stay. SSI rates have become a universal measure of quality in hospital-based surgical practice because they are probably the most preventable of all healthcare-associated infections. Although, many national regulatory bodies have made it mandatory to report SSI rates, the burden of SSI is still likely to be significant underestimated due to truncated SSI surveillance as well as underestimated postdischarge SSIs. A WHO survey found that in low- to middle-income countries, the incidence of SSIs ranged from 1.2 to 23.6 per 100 surgical procedures. This contrasted with rates between 1.2% and 5.2% in high-income countries. Objectives: We aimed to leverage the existing surveillance capacities at our tertiary-care hospital to estimate the incidence of SSIs in a cohort of trauma patients and to develop and validate an indigenously developed, electronic SSI surveillance system. Methods: A prospective cohort study was conducted at a 248-bed apex trauma center for 18 months. This project was a part of an ongoing multicenter study. The demographic details were recorded, and all the patients who underwent surgery (n = 770) were followed up until 90 days after discharge. The associations of occurrence of SSI and various clinico-microbiological variables were studied. Results: In total, 32 (4.2%) patients developed SSI. S. aureus (28.6%) were the predominant pathogen causing SSI, followed by E. coli (14.3%) and K. pneumoniae (14.3%). Among the patients who had SSI, higher SSI rates were associated in patients who were referred from other facilities (P = .03), had wound class-CC (P &lt; .001), were on HBOT (P = .001), were not administered surgical antibiotics (P = .04), were not given antimicrobial coated sutures (P = .03) or advanced dressings (P = .02), had a resurgery (P &lt; .001), had a higher duration of stay in hospital from admission to discharge (P = .002), as well as from procedure to discharge (P = .002). SSI was cured in only 16 patients (50%) by 90 days. SSI data collection, validation, and analyses are essential in developing countries like India. Thus, it is very crucial to implement a surveillance system and a system for reporting SSI rates to surgeons and conduct a robust postdischarge surveillance using trained and committed personnel to generate, apply, and report accurate SSI data.Funding: NoneDisclosures: None

Hospital-based epilepsy care in Uganda: A prospective study of three major public referral hospitals

ObjectiveThis study sets out to describe the current demographics of people with epilepsy (PWE) attending hospital-based care in Uganda and the epilepsy treatment practices within three of the largest Ugandan public referral hospitals. MethodsIn a six-month prospective cohort study, 626 children and adults attending epilepsy clinics at Mulago National Referral Hospital, Butabika National Referral Mental Hospital and Mbarara Regional Referral Hospital were enrolled. Using a study questionnaire, data were collected at baseline and at 3 weeks, 3 months, and 6 months following enrollment. Specific data surrounding individual patient demographics, clinical characteristics and severity of epilepsy, and treatment of epilepsy with antiepileptic drugs (AEDs) were collected. ResultsFemale patients totaled to 50.8%, with a nearly equal gender distribution at each hospital. There was no statistical difference in gender or age between sites. The majority of PWE had completed primary school, with less than 15% of patients completing more than a secondary education. Seizure severity was high, with most patients having multiple seizures per week at the initial onset of epilepsy, and greater than 90% of patients reporting a loss of consciousness with seizures. The majority of patients (54.95%) also reported a developmental or learning delay. Most patients were on 1 AED (46.01%) or 2 AEDs (36.90%), with carbamazepine being the most frequently prescribed AED. There was a trend towards improved seizure severity over the follow-up period, as assessed by the corresponding Personal Impact of Epilepsy Scale (PIES) subscale. ConclusionsPeople with epilepsy attending hospital-based care in Uganda tend to have severe forms of epilepsy requiring management with AEDs. Current hospital-based practices show a positive trend for seizure burden and quality of life of PWE in Uganda. Further interventions to improve overall access to biomedical care are required to continue to advance the management of PWE across all communities.This article is part of the Special Issue “The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda"

Are vascular surgeons paying the price for critical limb ischemia care?

The article by Voicu et al1 in this issue is troubling, but also not news to most vascular surgeons, whether in private or hospital-based practices. Professional reimbursement for surgical care of critical limb ischemia (CLI) is insufficient to cover the cost of care. For the most part, I agree with the authors' methods and conclusions, although there may be factors specific to individual situations that make the problem more or less severe such as institutional support for care by advanced practice providers or house staff.

The Implication of Children Hospitals’ Adoption of Hospitalists on Financial Performance

Hospitalists (physicians specializing in hospital-based practice), have grown significantly in the U.S. in the last two decades. Prior studies on hospitalists have focused on costs and length of stay mainly at the patient level. Using a national longitudinal sample of acute care children hospitals operating in the US between 2007 and 2014, this study explores the impact of hospitalists staffing intensity on children hospitals’ financial performance. Data from the American Hospital Association (AHA) Annual Survey, the Area Health Resource File (AHRF), and the Centers for Medicare and Medicaid Services’ (CMS) costs reports and Case Mix Index files were used for this study. A panel design with facility and year fixed effects regression were used for data analysis. Results showed that children hospitals that switched from not using hospitalists to using a medium and high hospitalist staffing intensity had both increased patient revenues and higher operating costs per adjusted patient day. The higher operating revenues were offset by increased patient costs, resulting no significant increase in operating profitability.

The Impact of the COVID-19 Pandemic on Surgical Practice in the Southeastern United States: Results of a Survey of the Membership of the Southeastern Surgical Congress.

The coronavirus disease 2019 (COVID-19) pandemic dramatically altered the delivery of surgical care. Members of the Southeastern Surgical Congress were surveyed regarding system adjustments, personal impact, and productivity losses. Subgroups were analyzed for disproportionate impact across practice models (academic/employed/private), practice communities (urban, suburban, rural), and practice case-mix categories (broad general surgery, narrow general surgery, specialty practice, hospital-based practice). 135 respondents reported that 98.5% of surgeons and 97% of hospitals canceled elective cases. Practices and hospitals reduced staffing dramatically. Telemedicine was utilized by most respondents. Hospitals variably implemented system changes, developed tests, and set up diagnostic centers. Most surgeons anticipated resumption of practice and hospital activity by July 1, 2020. More than one-quarter reported worsened financial status and personal well-being. Interestingly, family/personal relationships were improved in more than one-third. Most surgeons anticipate reduced year-end case volumes, clinical productivity, and salary. In subgroup analyses, academic surgeons were more likely than employed and private-practice surgeons to use telemedicine and to work in hospitals with in-house COVID-19 testing. Private-practice surgeons expected decreased financial status, case volumes, relative value units (RVUs), and salary. More rural surgeons anticipate reduced salary than urban and suburban surgeons. Surgeons in narrow general surgery practice reported more furlough of employees than specialty surgeons, hospital-based surgeons, and broad-based general surgeons. Narrow-practice surgeons and specialists were more likely to report RVU reductions and improved family/personal relationships. The COVID-19 slowdown affected surgeons throughout the southeastern United States. Variations between different practice models, communities, and case-mix categories may help inform surgeons in the future.

Quantification of Opioid Prescription Practice Changes Due to Hydrocodone Combination Product Rescheduling in an Academic Pain Clinic.

PurposeTo determine the effect of rescheduling on prescription practices in a large academic hospital-based multidisciplinary practice comprising anesthesiologist-trained pain physicians.Patients and MethodsWe examined the number of HCP prescriptions written and quantity of tablets prescribed during a 6-month period prior to rescheduling and compared this with a 6-month period 1 year after rescheduling. We also examined the changes in prescription of tramadol and acetaminophen with codeine from one period to the next.ResultsOur pain clinic conducted 3,320 office visits during the 6-month period prior to HCP rescheduling and 6,003 office visits in the 6-month period 1 year after rescheduling. The charted data from each of these visits were used for our analysis. The mean number of tablets of HCPs prescribed per patient decreased from 318.48 in the pre-period to 242.27 tablets in the post-period, while the mean number of HCP prescriptions per patient decreased from 2.24 to 1.84. The mean number of acetaminophen with codeine tablets prescribed per patient increased from 3.46 to 15.27 in the pre- and post-period. Similarly, the mean number of tramadol tablets per patient increased from 47.33 to 61.97 in the pre- and post-period. The mean number of acetaminophen with codeine and tramadol prescriptions per patient increased from 0.02 to 0.15 and 0.38 to 0.51 in the pre- and post-period, respectively. In the 6-month post-period, fewer new patients were started on opioids compared to the 6-month pre-period, 16% and 27%, respectively.ConclusionOur study showed a significant decrease in the mean number of HCP prescriptions written per patient, as well as a decrease in the mean number of HCP tablets prescribed. Pain physicians in our clinic increased the number of prescriptions for the non-HCPs. The number of acetaminophen with codeine and tramadol tablets prescribed significantly increased. Therefore, the rescheduling of HCPs has profoundly impacted practices within this academic pain clinic.

This COVID-19 Practice: Academic Neurology and Hospital-based Practices Hit by Pay Cuts, Furloughs, and Loss of Job Benefits

This COVID-19 Practice: Academic Neurology and Hospital-based Practices Hit by Pay Cuts, Furloughs, and Loss of Job Benefits

Predictors of Sustained Breastfeeding at 2 Months Among Early Term/Late Preterm Infants

Abstract Objectives To conduct secondary analyses to identify the independent effect of predictors of sustained breastfeeding at 2 months among early term/late preterm infants, and to specifically evaluate the associations between hospital-based practices and breastfeeding outcomes in this population. Methods Breastfeeding mothers (N = 125) who delivered an early term/late preterm infant (35 to 38 6/7 weeks gestation) were interviewed during their postpartum (pp) hospitalization. Medical records were reviewed to collect data on demographics, delivery characteristics and biomedical variables. Participants were contacted at 2 months pp to assess breastfeeding status. Bivariate analyses were conducted, and the significant bivariate predictors of breastfeeding at 2 months were entered into a logistic regression model to identify predictors of sustained breastfeeding at 2 months pp. Results At 2 months pp, 104 women (83.2%) were followed up, with 71.2% still breastfeeding. In bivariate analyses, significant predictors of sustained breastfeeding at 2 months pp included: skin-to-skin contact beyond the first 24 hours pp, higher breastfeeding self-efficacy score, breastfeeding assessment score &amp;gt;80% on day 1, no breast pump use after the first 24 hours during the pp hospital stay, no nipple shield use, primiparity, increased birthweight, singleton status, and no supplemental feedings given in the hospital. In the logistic regression analyses, the only significant predictors of sustained breastfeeding at 2 months were continued use of skin-to-skin contact beyond the first 24 hours (OR: 20.8; 95% confidence interval (CI) (3.19–133.6) and increasing birth weight (OR: 1.001, 95% CI (1.000–1.003). None of the hospital-based practices (use of breast pump, nipple shields, or nipple vs non-nipple supplemental feeding method) were associated with continued breastfeeding at 2 months. Conclusions Our findings suggest that continued use of skin-to-skin contact beyond the first 24 hours of life may be associated with extended breastfeeding duration among late preterm/early term infants. Future research is needed to evaluate the impact of variations in the timing and dose of extended skin-to-skin contact on breastfeeding duration of late preterm/early term infants. Funding Sources None.

A Novel Approach to Depression Care: Efficacy of an Adapted Interpersonal Therapy in a Large, Urban Primary Care Setting.

The Collaborative Care Model (CoCM), in which social workers, primary care physicians, and a consulting psychiatrist work as a team, is an established approach to the treatment of common mental health conditions in primary care settings. Following implementation of a CoCM depression care program at our hospital-based academic primary care practice, we observed a low rate of retention with the use of problem solving therapy/behavioral activation (PST/BA). Our aim in this study was to evaluate the effectiveness of interpersonal psychotherapy (IPT), an evidence-based, flexible strategy that focuses on the relationship between depression and interpersonal challenges, compared to PST/BA. In 2015, most patients enrolled in our CoCM received PST/BA. In 2016, most patients received IPT. Patients who were enrolled and discharged from our CoCM depression care program in the years 2015 and 2016 and received either PST/BA or IPT, were included. Our primary measure was the difference in change in PHQ-9 score between the PST/BA and the IPT groups. Secondary outcomes included the difference in the change in GAD-7 score and measures of glycemic and blood pressure control between the two groups. Two hundred thirty four patients were included in our analysis. One hundred sixty five received PST/BA and 69 received IPT. There was no difference between groups in baseline demographics or measures of depression, anxiety, presence of hypertension, or presence of prediabetes/diabetes. Our primary analysis demonstrated a greater decrease in PHQ-9 score in patients receiving IPT (9.93) compared to those receiving PST/BA (5.41) (p< 0.0001). The proportion of patients achieving a clinical response (PHQ-9 < 10) was also greater in the IPT group (71%) compared to the PST/BA group (44%). In a CoCM depression care program, IPT was a more effective strategy in improving depression symptoms as measured by PHQ-9 scores than PST/BA.

A Multimethod Improvement Project to Strengthen Intermittent Auscultation Practice Among Nurse-Midwives and Nurses.

Intermittent auscultation (IA) is an accepted standard of care for intrapartum fetal assessment for low-risk individuals and is the exclusive method used to monitor fetal status in birth centers. However, there are conflicting national guidelines for practice and skill training. As a result, IA technique and skills vary across the perinatal care workforce, with many health care providers receiving no or minimal formal training. This article describes the design, implementation, and evaluation of a quality improvement program aimed at strengthening the IA skills of nurse-midwives and nurses. The project was implemented in a multisite network of freestanding birth centers and involved clinical practice guideline development, simulation-based training, audit and feedback, in-person training, and electronic health record configuration. The training resulted in self-reported increases in knowledge in all areas assessed. The integrated quality improvement initiative resulted in substantial improvements in consistency of practice and documentation. Policy change was not sufficient to improve use of IA, a nuanced skill that many midwives and nurses have limited exposure to in basic education programs and hospital-based clinical practice. Clinical improvement was possible when the policy change was accompanied by a comprehensive training and implementation strategy including interactive, simulation-based learning, audit and feedback, and an electronic health record configuration that better reflected the documentation standards.

Surgical outcomes of Glaucoma associated with Axenfeld-Rieger syndrome

BackgroundThe surgical management of glaucoma associated with Axenfeld-Rieger Syndrome (ARS) is poorly described in the literature. The goal of this study is to compare the effectiveness of various glaucoma surgeries on intraocular pressure (IOP) management in ARS.MethodsRetrospective cohort study at a university hospital-based practice of patients diagnosed with ARS between 1973 and 2018. Exclusion criterion was follow-up less than 1 year. The number of eyes with glaucoma (IOP ≥ 21 mmHg with corneal edema, Haabs striae, optic nerve cupping or buphthalmos) requiring surgery was determined. The success and survival rates of goniotomy, trabeculotomy±trabeculectomy (no antifibrotics), cycloablation, trabeculectomy with anti-fibrotics, and glaucoma drainage device placement were assessed. Success was defined as IOP of 5-20 mmHg and no additional IOP-lowering surgery or visually devastating complications. Kaplan-Meier survival curves and the Wilcoxon test were used for statistical analysis.ResultsIn 32 patients identified with ARS (median age at presentation 6.9 years, 0–58.7 years; median follow-up 5.4 years, 1.1–43.7 years), 23 (71.9%) patients were diagnosed with glaucoma at median age 6.3 years (0–57.9 years). In glaucomatous eyes (46 eyes), mean IOP at presentation was 21.8 ± 9.3 mmHg (median 20 mmHg, 4-45 mmHg) on 1.0 ± 1.6 glaucoma medications. Thirty-one eyes of 18 patients required glaucoma surgery with 2.2 ± 1.2 IOP-lowering surgeries per eye. Goniotomy (6 eyes) showed 43% success with 4.3 ± 3.9 years of IOP control. Trabeculotomy±trabeculectomy (6 eyes) had 17% success rate with 14.8 ± 12.7 years of IOP control. Trabeculectomy with anti-fibrotics (14 eyes) showed 57% success with 16.5 ± 13.5 years of IOP control. Ahmed© (FP7 or FP8) valve placement (8 eyes) had 25% success rate with 1.7 ± 1.9 years of IOP control. Baerveldt© (250 or 350) device placement (8 eyes) showed 70% success with 1.9 ± 2.3 years of IOP control. Cycloablation (4 eyes) had 33% success rate with 2.7 ± 3.5 years of IOP control. At final follow-up, mean IOP (12.6 ± 3.8 mmHg, median 11.8 mmHg, 7-19 mmHg) in glaucomatous eyes was significantly decreased (p < 0.0001), but there was no difference in number of glaucoma medications (1.6 ± 1.5, p = 0.1).ConclusionsIn our series, greater than 70% of patients with ARS have secondary glaucoma that often requires multiple surgeries. Trabeculectomy with anti-fibrotics and Baerveldt glaucoma drainage devices showed the greatest success in obtaining IOP control.

Site of Prenatal Care Impacts Aspirin Prophylaxis for Preeclampsia Prevention [29C

INTRODUCTION: Low-dose aspirin prophylaxis is recommended for preeclampsia prevention among high-risk women, but not all eligible women receive it. We investigated whether site of prenatal care impacts rates of aspirin prophylaxis among a cohort of women with chronic hypertension (cHTN). METHODS: This is a single institution, retrospective cohort study of women with cHTN who delivered between 2016–2018. Women with no prenatal care or care outside the hospital system were excluded (n=196). Medical records were reviewed to determine prenatal care site and to assess counseling and prescription of aspirin. Demographic and obstetric outcomes were compared by prenatal care site in univariate analysis. Multivariable logistic regression analysis was performed with adjustment for race, blood pressure and gestational age at first prenatal visit. RESULTS: We included 870 women. 126 (14.5%) had prenatal care in a hospital-based academic practice, 280 (32.2%) in a resident clinic, 303 (34.8%) in private practice, 76 (8.7%) in Maternal-Fetal Medicine (MFM) practice and 85 (9.8%) in a midwife or family practice. There were no differences in blood pressure or gestational age at first prenatal visit. Overall 64.6% of women were counseled or prescribed aspirin. Rates differed by prenatal care site (P&lt;.001) ranging from 44.4% (academic practice) to 92.1% (MFM practice). Counseling rates were 70.4% in resident clinic, 58.1% in private practice, 72.9% in midwife/family practice. Differences in counseling persisted in multivariable models. CONCLUSION: In a cohort of women at high-risk for preeclampsia, aspirin counseling was not universal and rates varied by prenatal care site, which is an area for quality improvement.

Illinois Pharmacists and Over the Counter Cannabidiol Products: A Survey on Knowledge and Educational Needs.

To assess Illinois pharmacists' (1) baseline knowledge of CBD and self-rated competency of OTC-CBD product pharmacotherapy, (2) concerns about OTC-CBD product safety and level of preparedness with answering questions about the product, and (3) current and future interest in learning more about these types of products to target an area of need for continuing education in the pharmacy field. This observational cross-sectional study used a quantitative survey to obtain information about Illinois pharmacists' knowledge, concerns and educational needs about OTC-CBD products. Survey questions were based on prior research and pilot tested for clarity and completeness. Descriptive statistics were utilized to assess all data. The study researchers collaborated with two state-based pharmacy organizations to distribute the survey online with up to two reminders. A total of 181 participants completed the survey. Majority of the respondents were 31-60 years of age, had worked in pharmacy for less than 5 years, in a geographic location with a population of 50,000 or more. About 41% worked in hospital-based practice setting and 39.2% work in a community-based setting. Most pharmacists (64.1%) reported ever being asked about the safety or efficacy of cannabidiol containing products, and only 20.7% responded that they felt moderately/highly prepared to provide medication counseling to patients who use OTC-CBD products. Majority of respondents reported being concerned about safety, quality, and regulations related to OTC-CBD products. Almost all respondents indicated that information about state (90.5%) and federal (89.4%) laws related to CBD, and safety (99.5%) were preferred topics for future education. Consumers are seeking information about CBD containing products; however, many pharmacists do not feel prepared when it comes to being the drug expert for these products. Educational opportunities are necessary for pharmacists to become more comfortable and knowledgeable regarding safe and effective use of CBD-OTC containing products.

BI-RADS 3 (short-interval follow-up) assessment rate at diagnostic mammography: Correlation with recall rates and utilization as a performance benchmark.

The purpose of this study was to identify a correlation between the screening BI-RADS 0 (recall) rates and diagnostic BI-RADS 3 (short-interval follow-up) rates of individual interpreting radiologists, with the goal of utilizing the BI-RADS 3 rate as an acceptable performance metric in the diagnostic population. A multicenter retrospective analysis of medical audit statistics was conducted on annual radiologist performance data collected over a 14-year period in a community hospital-based practice. Mixed regression models were used to estimate the association between screening BI-RADS 0 and diagnostic BI-RADS 3 examinations while adjusting for calendar year, annual radiologist screening volume, annual radiologist diagnostic volume, and diagnostic examination indication. A moderate statistically significant positive correlation was established between the screening BI-RADS 0 rates and Diagnostic BI-RADS 3 rates (Pearson correlation coefficient+0.349, P≤.001). Furthermore, when utilizing a national benchmark range of 8%-12% as an acceptable BI-RADS 0 rate within a screening population, the correlative BI-RADS 3 assessment rate was demonstrated to be approximately 16%. We propose that this BI-RADS category 3 rate may represent an additional acceptable performance metric in the diagnostic population. Routine inclusion of an interpreting mammographer's diagnostic BI-RADS 3 rate in the annual medical audit may help reduce inappropriate and/or excess use of the BI-RADS 3 category, which may lead to significant potential reductions in follow-up examinations with their associated healthcare-related costs, resource expenditure, and induced patient anxiety.

Development and evaluation of a matrix for assessing fatigue-related risk, derived from a national survey of nurses' work patterns

BackgroundMultiple aspects of nurses’ rosters interact to affect the quality of patient care they can provide and their own health, safety and wellbeing. Objectives(1) Develop and test a matrix incorporating multiple aspects of rosters and recovery sleep that are individually associated with three fatigue-related outcomes - fatigue-related clinical errors, excessive sleepiness and sleepy driving; and (2) evaluate whether the matrix also predicts nurses’ ratings of the effects of rosters on aspects of life outside work. DesignDevelop and test the matrix using data from a national survey of nurses’ fatigue and work patterns in six hospital-based practice areas with high fatigue risk. MethodsSurvey data included demographics, work patterns (previous 14 days), choice about shifts, and the extent to which work patterns cause problems with social life, home life, personal relationships, and other commitments (rated 1 = not at all to 5 = very much). Matrix variables were selected based on univariate associations with the fatigue-related outcomes, limits in the collective employment contract, and previous research. Each variable was categorised as lower (score 0), significant (score 1), or higher risk (score 2). Logistic multiple regression modelling tested the independent predictive power of matrix scores against models including all the (uncategorised) work pattern and recovery sleep variables with significant univariate associations with each outcome variable. Model fit was measured using Akaike and Bayesian Information Criterion statistics. ResultsData were included from 2358 nurses who averaged at least 30 h/week in the previous fortnight in one of the target practice areas. Final matrix variables were: total hours worked; number of shift extensions >30 min, night shifts; breaks < 9 h; breaks ≥ 24 h; nights with sleep 11pm to 7am; days waking fully rested; and roster change.After controlling for gender, ethnicity, years of nursing experience, and the extent of shift choice, the matrix score was a significant independent predictor of each of the three fatigue-related outcomes, and for all four aspects of life outside work. For all outcome variables, the model including the matrix score was a better fit to the data than the equivalent model including all the (uncategorised) work pattern variables. ConclusionsA matrix that predicts the likelihood of nurses reporting fatigue-related safety outcomes can be used to compare the impact of rosters both at work and outside work. It can be used for roster design and management, and to guide nurses’ choices about the shifts they work.

Wie erleben junge Allgemeinärzt*innen den Übergang in die hausärztliche Praxis? Eine qualitative Studie

BackgroundAlthough the role of general practice has been strengthened in recent years, undergraduate teaching at medical schools and the clinical phase of specialist training remain dominated by specialized care of seriously ill people in hospitals. It is to be assumed that young doctors’ views on medical care are strongly shaped by this clinical focus. ObjectiveTo investigate how young general practitioners (GPs) perceive transition from medical school and hospital work to general practice. MethodsIn a qualitative study, a total of 13 physicians in specialist training for general practice as well as general practitioners who had completed their specialist examination up to two years ago participated in problem-oriented interviews. The interviews were analyzed using content analysis. ResultsThe significant differences between hospital-based and primary care practice initially came as quite a shock to the study participants. Key differences and challenges compared to working in a hospital included: 1) the totally different type of patients or complaints they faced; 2) learning that in many situations one can and should bide one's time (“wait-and-see” approach); 3) ruling out avoidable dangerous developments in patients reliably and coping with the corresponding residual risk; 4) the discovery that sometimes it makes sense not to make a diagnosis; 5) that the doctor-patient relationship should be more cooperative in general practice; and 6) that GPs are often under pressure to act although there is no clear need for taking action or no clear treatment option from a medical and scientific point of view. ConclusionsOur findings confirm that young doctors’ initial views on medical care are strongly shaped by the clinical focus of medical schools and hospital work. Working in general practice is perceived as being very different from working in a hospital.