Increase Provider Awareness Research Articles

A Quality Improvement Project to Increase Adolescent Vaping Capture and Provider Awareness of Use

A Quality Improvement Project to Increase Adolescent Vaping Capture and Provider Awareness of Use

12591 Screening For Metabolic Dysfunction-Associated Steatotic Liver Disease In Diabetes Clinics

Abstract Disclosure: D. D'Annibale: None. M. Mimoto: None. R. Lis: None. A. Deioma: None. H. Patton: None. Screening for Metabolic Dysfunction-Associated Steatotic Liver Disease in Diabetes Clinics Background: The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) in patients with Type 1 (T1D) or Type 2 diabetes (T2D) is elevated, ranging from 22% in T1D to >55% in T2D. However, MASLD screening is not standard in diabetes clinics. The Fibrosis-4 (FIB-4) score and transient elastography (TE) are non-invasive tools to identify those at risk for MASLD and liver fibrosis. To identify at-risk individuals and determine the prevalence of undiagnosed MASLD in our Veterans with diabetes and elevated BMI, we developed a screening protocol using FIB-4 and TE. Methods: Veterans with T1D or T2D and elevated BMI seen in diabetes clinic were prospectively screened. Patients with prior TE or liver disease were excluded. In phase 1, patients were offered in-clinic TE during their visit. In phase 2, a FIB-4 determined referral to TE or hepatology. Results: 274 patients were screened over 8 months. Of 102 qualifying patients in phase 1, 28 had in-clinic TE; of these, 7 (25%) had a kPa of 8 or greater, indicating increased risk of fibrosis, and 16 (57.1%) had a CAP score >280, indicating severe steatosis.In phase 2, a FIB-4 was ordered in 157 qualifying patients. Of 110 completed tests, the FIB-4 was <1.3 (low risk), 1.3–2.6 (indeterminate risk) and >2.6 (high risk) in 61 (55.5%), 44 (40%) and 5 (4.5%), respectively. Patients were referred to TE (indeterminate) or hepatology (high risk). To date, 21 patients have undergone TE, 5 (23.8%) had a kPa of 8 or greater and 11 (52.4%) had a CAP score >280. Conclusions In Veterans with T1D or T2D and elevated BMI, both of our screening protocols identified those with severe steatosis (57.1% vs 52.4%) by TE at rates similar to those reported in the literature. Increased risk of fibrosis by TE was identified in ∼24-25% of our screened population. The high prevalence of undiagnosed MASLD in our Veteran population supports the need for screening in diabetes clinics. Increased provider awareness and point-of-care TE may increase access to screening and improve early diagnosis. Presentation: 6/2/2024

Exploring the use of tummy time guidelines to improve infant development in rural primary care

BackgroundTummy time enhances motor development, improves mobility, strength, and head clearance, reduces cranial asymmetry, and decreases the risk of childhood obesity. The American Academy of Pediatrics (AAP) advises all infants, beginning at birth, partake in supervised daily tummy time during awake periods. Since 1994, when the AAP initiated the “Back to Sleep” campaign, the number of infants participating in daily tummy time has significantly declined, leading to an increase in adverse outcomes. MethodsUsing a quasi-experimental design, tummy time guidelines were implemented in a rural family primary care practice to support infant development. This three-phase intervention included educating providers, developing a smart phrase, and posting visual reminders. A convenience sample of infants who presented for well-visits at a rural family practice in southwestern Washington were included in this project. The Survey of Wellbeing of Young Children measurement tool was used to collect infant developmental outcome data. FindingsFollowing the intervention, infant developmental outcomes improved. There was a 10% reduction at two months of age and a 7% reduction at four months of age in the number of infants with below average developmental scores. DiscussionThis project demonstrates that increased provider awareness and implementation of tummy time clinical practice guidelines can benefit infant development in primary care, especially in rural populations. Application to practiceViable strategies for incorporating clinical practice guidelines into primary care are presented.

Abstract B171: Using a transdisciplinary collaboration process to create a plan to address prostate cancer disparities

Abstract WI ranks highest in the US for overall cancer incidence and mortality among Black/African American (Black) individuals. Prostate cancer (PC) is the most frequently diagnosed cancer among men in WI and the second leading cause of cancer death. This region has numerous challenges including segregation, poverty, educational achievement gaps, and high Black imprisonment rates which impact PC awareness, screening, and treatment. To effectively address a problem as complex as prostate cancer disparities, multiple perspectives are needed. We brought together a transdisciplinary team that integrated community and academic expertise to develop a shared understanding of prostate cancer disparities and potential causes and to create a community action and research agenda. The team met every other week for 16 months. During that time, This team engaged in a facilitated process developed through our Community and Cancer Science Network that included: 1) Incubation: co-learning about the multi-factorial causes of PC disparities by reviewing available data, engaging experts, and seeking input from researchers, health care providers and community members; 2) Innovation: using this information to consider potential solutions to create a draft plan; and 3) Integration: seeking feedback to ensure the draft plan met the needs of diverse audiences and then refined the solutions. During the Incubation phase. the team reviewed available literature and data; developed a root causes analysis of disparities, conducted surveys, interviews and discussion sessions with researchers, healthcare providers, and community members (n=98); invited presentations by relevant experts and survivors, and engaged in robust discussions. In the Innovation phase, the team analyzed the data and reflected on opportunities to address the issues outlined in the root cause analysis. Potential solutions were assessed for fit and feasibility. Finally, in the Integration Phase, the team conducted a series of town halls with community members and researchers (n=70) to review the draft plan and seek feedback. The team used the feedback to refine the plan and consider next steps. Final recommendations include: 1) Patient navigation to assist men with PC at diagnosis; 2) A trusted messenger campaign to increase PC awareness; 3) Increase provider and community awareness of genetic risk; 4) Patient-provider forums to build relationships and trust; 5) Expand survivor support offerings for Black men with PC; 6) Improve PC screening education; 7) Increase provider awareness of current screening guidelines; 8) Expand research into the role of stress in PC. Our transdisciplinary approach is effective in engaging and blending diverse perspectives to generate solutions to complex problems. Future work will sustain this approach in implementing solutions through collaborative efforts. Citation Format: Tobi Cawthra, Kevin Izard, Robert Allen, Darryl Davidson, Chris Nielson, Ambrose Wilson-Brown, Deepak Kilari, Marquayla Ellison, Dev Karan, Ericka Sinclari, Alvin Flowers, Kyle Ashley, Leonard Wilson, Marcus Hogans, Kenneth Jacobsohn, Melinda Stolley. Using a transdisciplinary collaboration process to create a plan to address prostate cancer disparities [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 B171.

Abstract PO3-09-10: Minority participation in breast cancer therapeutic trials at an NCI-CCC affiliated safety-net system: Advancing equity in clinical research

Abstract Authors: Nasir Qureshi, MBBS Fabian Robles, MS Mai Badran, MBBS Nisha Unni, MD Hsiao C Li, MD Samira Syed, MD Glenda Delgado-Ramos, MD Sangeetha Reddy, MD Heather McArthur, MD Navid Sadeghi, MD Title: Minority participation in breast cancer therapeutic trials at an NCI-CCC affiliated safety-net system: Advancing equity in clinical research. Introduction: Participation of under-represented minorities (URMs) in clinical trials enhances the generalizability of the findings and can also improve clinical outcomes. Multiple factors, such as access, language barrier, distrust, and misconceptions, negatively impact URM enrollments in cancer clinical trials. Here we describe our approach to increase participation of breast cancer URMs in therapeutic trials at an academic-affiliated safety-net system. Methods: Parkland Health (PH) is a large safety-net system in Dallas County, Texas, and is affiliated with the NCI-CCC designated Harold C. Simmons Comprehensive Cancer Center (SCCC) at UT Southwestern. A dedicated team of SCCC research coordinators support the clinical trial operations at PH. In 2020, several steps were taken to increase access and enrollment of URMs in breast cancer trials at PH including review and optimization of the trial portfolio (more trials in curative intent setting), proactive screening, increasing provider awareness, and addition of a bilingual (English/Spanish) patient navigator to the research team. Data for 2018-2019 (pre-intervention) and 2021-2022 (post-intervention) is presented here. Data for 2020 is excluded due to the impact of COVID-19 pandemic on trial operations. Results: Racial and ethnic minorities composed the majority of breast cancer patients at PH (52% Hispanics, 32% Blacks). Ten percent of new patients at PH presented with metastatic disease. In 2018-2019, PH's portfolio included 13 therapeutic trials, 5 of which (38%) were in metastatic setting and 3 required a biomarker. A total of 47 breast cancer patients were enrolled in 11 therapeutic trials at PH, accounting for an average annual accrual rate of 6.1% (7.6% in 2018 and 4.5% in 2019). Accrual to trials in the metastatic setting accounted for 11% (5/47) of enrollments. Two trials in the metastatic setting had zero accruals. In 2021-2022, 16 trials were open at PH, including 7 cooperative group, 4 industry-sponsored (ISTs), and 5 Investigator-Initiated trials (IITs). Five trials (31%) were in metastatic setting and 4 required a genomic biomarker. A total of 87 patients were enrolled in 2021-22, representing an 85% increase in the accruals over the baseline (2018-2019). The annual accrual rates for 2021 and 2022 were 10.5% (43/409) and 10.4% (44/423), respectively. In 2021-22, 63 were enrolled in cooperative group studies, 20 in IITs, and 4 in ISTs. Accrual to trials in the metastatic setting accounted for 6% (5/87) of enrollments. Two studies had zero accruals. The majority of the trial participants (77/87; 89%) belonged to URMs (64 Hispanic, 13 Black). Overall participation rate was 67% (87/129) and was significantly higher in Hispanics compared to Blacks (77% vs 41% - p < 0.001). Among Black patients who declined participation, 42% (8/19) cited lack of interest as the reason, which may reflect distrust or misperceptions regarding clinical trials. Conclusions: The collaboration between academic centers and safety-net systems provides a unique opportunity to promote equity in clinical trials by increasing access and enrollment of URMs. Developing a balanced portfolio that matches the patient population, enhanced screening, and incorporating clinical trial patient navigation at our institution resulted in a sustained increase in the number of URM trial participants. Given the lower participation rate among eligible Black patients, we aim to expand our clinical trial navigation program to better address the distrust and misperceptions regarding clinical trials, as a strategy to further improve trial participation at our institution. Citation Format: Nasir Qureshi, Fabian Robles. Minority participation in breast cancer therapeutic trials at an NCI-CCC affiliated safety-net system: Advancing equity in clinical research [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-09-10.

Differences in Cesarean Rates for Nulliparous, Term, Singleton, Vertex Births Among Racial and Ethnic Groups and States Before and After Stay-at-Home Orders During the COVID-19 Pandemic, United States, 2017-2021.

Evidence is limited on differences in cesarean rates for nulliparous, term, singleton, vertex (NTSV) births across racial and ethnic groups at the national and state level during the COVID-19 pandemic. We assessed changes in levels and trends of NTSV cesarean rates before and after stay-at-home orders (SAHOs) were implemented in the United States (1) overall, (2) by racial and ethnic groups, and (3) by 50 US states from January 2017 through December 2021. We used birth certificate data from 2017 through 2021, restricted to hospital births, to calculate monthly NTSV cesarean rates for the United States and for racial and ethnic groups and to calculate quarterly NTSV cesarean rates for the 50 states. We used interrupted time-series analysis to measure changes in NTSV cesarean rates before and after implementation of SAHOs (March 1 through May 31, 2020). Of 6 022 552 NTSV hospital births, 1 579 645 (26.2%) were cesarean births. Before implementation of SAHOs, NTSV cesarean rates were declining in the United States overall; were declining among births to non-Hispanic Asian, non-Hispanic Black, Hispanic, and non-Hispanic White women; and were declining in 6 states. During the first month of implementation of SAHOs in May 2020, monthly NTSV rates increased in the United States by 0.55%. Monthly NTSV rates increased by 1.20% among non-Hispanic Black women, 0.90% among Hispanic women, and 0.28% among non-Hispanic White women; quarterly NTSV rates increased in 6 states. In addition to emergency preparedness planning, hospital monitoring, and reporting of NTSV cesarean rates to increase provider awareness, reallocation and prioritization of resources may help to identify potential strains on health care systems during public health emergencies such as the COVID-19 pandemic.

Addressing Pediatric Toxic Stress During Initial Attention-Deficit/Hyperactivity Disorder Evaluations

Assessing for adverse childhood experiences (ACEs)/toxic stress (TS) is vital to comprehensive care for pediatric patients; however, no current national guidelines for pediatric ACEs/TS screening exist. Because of the similarity in externalizing behaviors for attention-deficit/hyperactivity disorder (ADHD) and elevated ACEs/TS scores, ACEs and TS need to be addressed with patients and families when evaluating for ADHD. Implementation of a quality improvement program to standardize ACEs/TS screening during all initial ADHD evaluation visits in a private pediatric clinic resulted in increased provider awareness of ACEs/TS, with an overall screening rate of 71%.

Characteristics of patients utilizing general inpatient (GIP) hospice.

236 Background: GIP hospice acute care is an inpatient designation for patients (pts) with terminal illness and clinical need to manage uncontrolled symptoms that cannot be managed in other settings. We recently revised hospital workflows to streamline GIP enrollment when appropriate. This study investigates the GIP utilization patterns and characteristics of pts with cancer on GIP. Methods: In December 2022, in collaboration with a consulting hospice program, we revised hospital workflows to improve access to and increase provider and pt awareness about GIP hospice for eligible pts at our academic cancer center. In this study, we review the use of GIP services in hospitalized pts with cancer since the revised workflow. We investigate pt demographics, care utilization (chemotherapy use, hospital readmission) and advanced care planning (ACP) documentation. All data presented are descriptive. Results: A total of 44 pts with cancer enrolled in GIP hospice between 12/2022 and 5/2023 after workflow optimization. This rose from 9 pts in the preceding 6 months prior to revised workflow. Median age was 67 years (range 29-90); 57% were male; 41% were White, 34% were Asian, 5% were Black, and 18% were Other Race; 18% had a hematologic malignancy, and all other pts (82%) had metastatic solid tumors (gastrointestinal, genitourinary, and thoracic diseases most prevalent). 82% listed English as the primary language, and 11% needed an interpreter. 48% had Medicare, 16% had Medicaid, and 36% had private insurance. 98% of the pts had uncontrolled pain as the predominant symptom necessitating inpatient hospice. Among enrolled pts, 98% died on GIP, with a median length of stay preceding GIP of 11.5 days and 2 days on GIP. 39% of pts transitioned to GIP during their first hospitalization within 90 days of death, while 52% had hospital readmissions with a median of 2 admissions in the 90 days prior to death. 18% (8/44) received chemotherapy within 30 days of death (38% [n=3] with curative intent). Notably, the median length of time pts had been followed by their outpatient oncologist was 22 months, and only 18% had fewer than 3 months history at our cancer center. 48% utilized outpatient palliative care prior to death. ACP documentation was completed for 61% of pts (45% with documented prognosis), though only 27% had any documentation by their primary oncologist. Conclusions: Our pilot to identify pts eligible for GIP who could benefit from this care at end of life was successful in increasing utilization of this service. Most pts dying in the hospital on GIP had metastatic solid tumors, with two hospitalizations in the months prior to death. Most pts also had a well-established relationship in the oncology clinic but still had no prior utilization of hospice and only benefitted from a median of 2 days on GIP hospice prior to death. Additional data is needed to understand perspectives and barriers to utilization of outpatient hospice and palliative care resources.

Improving rates of referrals for fertility preservation among adult patients with cancer.

462 Background: Urgent fertility preservation (FP) represents a critical unmet need for patients of child-bearing potential undergoing cancer-directed therapies. A retrospective review of electronic medical record (EMR) based FP referrals placed prior to initiation of systemic cancer-directed therapies in patients aged 18-50 years, identified only 26 referrals to urology and 2 referrals to reproductive endocrinology during 2020. To address this issue, we conducted a division-wide survey to identify barriers to FP and designed and implemented a new FP referral EMR order set to facilitate timely fertility evaluation in patients about to begin cancer-directed therapy. Methods: We conducted a division-wide survey of faculty and fellows to identify barriers to FP (PDSA cycle 1), which identified that 50% of respondents did not know how to make a referral and 85% did not know the correct pre-requisite labs. Based on these results, we gathered multi-stakeholder input from reproductive endocrinology, urology, and stakeholders from different hematology/oncology disease groups to develop and design a common FP referral EMR order set (PDSA 2). The FP order set was tested and refined based on stakeholder input. Once the order set was implemented, we gave educational presentations at division-wide and disease group-specific conferences, placed informational flyers throughout the Cancer Center, and Cancer Center-wide communications via email to increase provider awareness (PDSA 3). The primary objective of the study was to increase in number of referrals for FP evaluation in patients aged 18-50 years undergoing cancer-directed therapy. We tracked number of FP referrals pre and post-intervention using EMR data. Results: In PDSA Cycle 2 and 3, the number of referrals increased further to 62 for urology and 35 for reproductive endocrinology. Of those referred, 35/97 (36.1%) were female. Regarding race/ethnicity, the largest percentage of patients referred identified as White and Asian with the lowest percentage being of Southwest Asian/North African or Black/African American (see Table 1). Conclusions: The development and implementation of a FP order set greatly increased the number of patients who underwent fertility evaluation prior to starting cancer-directed therapy. We did identify differences in groups with regards to referral rates with fewer women being referred, and fewer number of racial/ethnic minorities being referred. Further analysis is needed to identify potential areas of intervention to increase referrals and access to FP, particularly in under-represented groups.[Table: see text]

Hepatocellular Carcinoma: Surveillance, Diagnosis, Evaluation and Management.

Hepatocellular carcinoma (HCC) ranks fourth in cancer-related deaths worldwide. Semiannual surveillance of the disease for patients with cirrhosis or hepatitis B virus allows for early detection with more favorable outcomes. The current underuse of surveillance programs demonstrates the need for intervention at both the patient and provider level. Mail outreach along with navigation provision has proven to increase surveillance follow-up in patients, while provider-targeted electronic medical record reminders and compliance reports have increased provider awareness of HCC surveillance. Imaging is the primary mode of diagnosis in HCC with The Liver Imaging Reporting and Data System (LI-RADS) being a widely accepted comprehensive system that standardizes the reporting and data collection for HCC. The management of HCC is complex and requires multidisciplinary team evaluation of each patient based on their preference, the state of the disease, and the available medical and surgical interventions. Staging systems are useful in determining the appropriate intervention for HCC. Early-stage HCC is best managed by curative treatment modalities, such as liver resection, transplant, or ablation. For intermediate stages of the disease, transarterial local regional therapies can be applied. Advanced stages of the disease are treated with systemic therapies, for which there have been recent advances with new drug combinations. Previously sorafenib was the mainstay systemic treatment, but the recent introduction of atezolizumab plus bevacizumab proves to have a greater impact on overall survival. Although there is a current lack of improved outcomes in Phase III trials, neoadjuvant therapies are a potential avenue for HCC management in the future.

Lyme Disease Knowledge, Practices, and Vaccine Acceptability Among Nurse Practitioners in Pediatric Practice

Lyme disease (LD) is a major public health problem in the United States. Given its incidence and geographic expansion, nurse practitioners (NPs) will likely encounter patients with this condition. NPs were invited to participate in an electronic survey via email, newsletter, and social media posts. The 31-question survey collected information on provider characteristics, clinical scenario decisions, resources used, and vaccine sentiment for LD. Survey participants (n=606) were primarily cisgender female (75%) and aged 30-49 years (62%). Responding to six hypothetical clinical scenarios, only 31% of participants answered most questions correctly. If an LD vaccine becomes available, 39% said they would incorporate it into practice; 48% would seek further information before deciding. Additional education on LD prevention, diagnosis, and treatment is needed for NPs. Increasing provider awareness of current guidelines and developing tailored resources for NPs may improve patient care.

Health Care Provider Knowledge and Attitudes Regarding Adult Pneumococcal Conjugate Vaccine Recommendations - United States, September 28-October 10, 2022.

Despite the availability of effective vaccines against pneumococcal disease, pneumococcus is a common bacterial cause of pneumonia, causing approximately 100,000 hospitalizations among U.S. adults per year. In addition, approximately 30,000 invasive pneumococcal disease (IPD) cases and 3,000 IPD deaths occur among U.S. adults each year. Previous health care provider surveys identified gaps in provider knowledge about and understanding of the adult pneumococcal vaccine recommendations, and pneumococcal vaccine coverage remains suboptimal. To assess the feasibility and acceptability domains of the Advisory Committee on Immunization Practices (ACIP) Evidence to Recommendations (EtR) framework, a health care provider knowledge and attitudes survey was conducted during September 28-October 10, 2022, by the Healthcare and Public Perceptions of Immunizations Survey Collaborative before the October 2022 ACIP meeting. Among 751 provider respondents, two thirds agreed or strongly agreed with the policy option under consideration to expand the recommendations for the new 20-valent pneumococcal conjugate vaccine (PCV20) to adults who had only received the previously recommended 13-valent pneumococcal conjugate vaccine (PCV13). Gaps in providers' knowledge and perceived challenges to implementing recommendations were identified and were included in ACIP's EtR framework discussions in late October 2022 when ACIP updated the recommendations for PCV20 use in adults. Currently, use of PCV20 is recommended for certain adults who have previously received PCV13, in addition to those who have never received a pneumococcal conjugate vaccine. The survey findings indicate a need to increase provider awareness and implementation of pneumococcal vaccination recommendations and to provide tools to assist with patient-specific vaccination guidance. Resources available to address the challenges to implementing pneumococcal vaccination recommendations include the PneumoRecs VaxAdvisor mobile app and other CDC-developed tools, including summary documents and overviews of vaccination schedules and CDC's strategic framework to increase confidence in vaccines and reduce vaccine-preventable diseases, Vaccinate with Confidence.

Patient mobilization in the intensive care unit: Assessing practice behavior – A multi-center point prevalence study

ObjectivesTo describe intensive care unit mobility clinical practice behaviors and the factors associated with these behaviors that could explain the theory–practice gap. MethodologyA multi-center, descriptive, retrospective, one-day point prevalence study. Settingintensive care patients hospitalized for a minimum of 24 hours, in 20 Israeli Adult Intensive Care Units, from six medical centers. Main outcome measuresMaximum patient mobility level during the 24 hours prior to the prevalence study collection day and 48 hours from patient admission; mobility clinical practice behaviors and their inhibiting factors. ResultsThe study included 210 patients from a relatively even distribution of admission diagnoses. About half (46%) were intubated and 31% were hemodynamically unstable. Position change was most frequently reported as the maximum mobility level. The use of intubation, ventilation, tracheostomy, and inotropes was positively correlated with the level of mobility. Charlson Comorbidity Index and body mass index were not related to the level of mobility.A multiple regression model including these variables found that only intubation was a significant predictor of mobility level (R2 = 0.52, p < 0.001). ConclusionThere is a gap between clinical practice guidelines and actual intensive care mobility practice behaviors. The association between mobility level and common therapies suggests subjective norms or common practices that could serve as a barrier to guideline implementation and partially explain the gap between clinical practice guidelines and clinical practice behavior. Implications for clinical practiceBehaviors and their subjective norms can be barriers to the implementation of clinical practice guidelines. Promoting increased provider awareness and policies of proactive mobilization could potentially improve patient outcomes.

Access to Health Care for Transgender and Gender-Diverse Adults in Urban and Rural Areas in the United States.

The objective of this study is to examine access to care based on gender identity in urban and rural areas, focusing on transgender and gender diverse (TGD) populations. Data on TGD (n = 1,678) and cisgender adults (n = 403,414) from the 2019 to 2020 Behavioral Risk Factor Surveillance System were used. Outcome measures were four barriers to care. We conducted bivariate and multivariable logistic regressions to assess associations between access, rurality, and gender identity. Bivariate results show that TGD adults were significantly more likely to experience three barriers to care. In multivariable models, TGD adults were more likely to delay care due to cost in the full sample (adjusted odds ratio [AOR]: 2.00, p < .001), rural subsample (AOR: 2.14, p < .01), and urban subsample (AOR: 1.97, p < .01). This study revealed greater barriers to care for TGD adults, with the most frequent barriers found among rural TGD adults. Increased provider awareness and structural policy changes are needed to achieve health equity for rural TGD populations.

Effects of Opioid-Limiting Legislation and Increased Provider Awareness on Postoperative Opioid Use and Complications After Hip Arthroscopy.

On August 31, 2017, Ohio passed legislation that regulates how opioids can be prescribed postoperatively. Studies have shown that such legislation is successful in reducing the morphine milligram equivalents (MMEs) prescribed after certain orthopaedic procedures. (1) To determine if the opioid prescription-limiting legislation in Ohio reduced the cumulative MMEs prescribed after hip arthroscopy without significantly affecting the rates of emergency department (ED) visits, hospital readmissions, and reoperations within 90 days postoperatively, and (2) to assess risk factors associated with increased postoperative opioid dosing. Cohort study; Level of evidence, 3. This study included patients who underwent primary and revision hip arthroscopy at a single institution over a 4-year period. The prelegislation (PRE) and postlegislation (POST) groups were defined as patients who underwent surgery before August 31, 2017, and on/after this date, respectively. The Ohio Automated Rx Reporting System was queried for controlled-substance prescriptions from 30 days preoperatively to 90 days postoperatively, and patient medical records were reviewed to collect demographic, medical, surgical, and readmission data. Inverse probability weighting-adjusted mean treatment effect regression models were used to measure the difference in mean outcomes between the PRE and POST cohorts. A total of 546 patients (228 PRE, 318 POST) were identified. There was a 25% reduction in the cumulative MMEs prescribed to the POST group as compared with the PRE group during the first 90 days postoperatively (840 vs 1125 MME, respectively; P < .01). The legislation was associated with a significant decrease in the cumulative MMEs prescribed in the first 90 postoperative days (mean treatment effect = -280.6; P < .01), and there were no significant between-group differences in the frequency of ED encounters (8.8% PRE, 11.6% POST; P = .32), hospital readmissions (1.3% PRE, 0.9% POST; P = .70), or reoperations (0.9% PRE, 0.6% POST; P ≥ .99) during this period. Preoperative opioid use was a significant independent risk factor for increased cumulative MMEs in the first 90 days postoperatively (β = 275; P < .01). Opioid prescription-limiting legislation in Ohio was associated with significant reductions in opioid MMEs dosing in the 90-day period following hip arthroscopy. This legislation had no significant effect on ED utilization, hospital readmissions, or reoperations within the same period. Preoperative opioid use was a significant risk factor for increased MME dosing after hip arthroscopy.

Abstract #1407325: Acromegalic Arthropathy Masquerading as Rheumatoid Arthritis- A Diagnostic Challenge

Acromegaly is a disorder related to the excessive production of growth hormone after puberty. The estimated incidence of acromegaly is approximately 3/10,00,000 persons per year. Although figures in the literature vary, the diagnosis of acromegaly is often delayed by 7-10 years from the onset of symptoms. Increased provider recognition allows for early diagnosis and treatment, which may prevent long-term complications of acromegaly. This case highlights the importance of increased provider awareness of the condition, and its clinical features. A 50-year-old female presented to primary care with several years of progressive joint pain in the hands with associated swelling and morning stiffness. On examination, she had synovitis in her PIP and MCP joints. Ultrasound of her hands revealed diffuse synovial fluid complexes and tenosynovitis. She was referred to Rheumatology and was diagnosed with seronegative rheumatoid arthritis. She was trialed on MTX, HCQ, and SSZ, followed by several biologics (Adalimumab, Etanercept, Abatacept) without clinical improvement. This prompted re-evaluation of her diagnosis. The rheumatologist recognized clinical features suggestive of acromegaly- mild frontal bossing, enlarged hands and dactylitis. A serum IGF1 level was elevated, which was confirmed on repeat testing upon establishing care with Endocrinology. MRI brain revealed a 7 mm pituitary microadenoma. The patient has been referred to neurosurgery and is awaiting surgical intervention. The clinical manifestations of acromegaly include frontal bone bossing, jaw prognathism, acral overgrowth, osteoarthritis, diabetes mellitus, hypertension, respiratory and cardiac failure. With untreated, prolonged disease, concentric myocardial hypertrophy develops, and diastolic heart failure occurs, which are not reversible. Skeletal disorders cause significant functional disability and compromised quality of life in patients with acromegaly. 70% of such patients have large-joint and axial arthropathy that includes thickened articular cartilage, periarticular calcifications, osteophyte overgrowth, and synovitis. About 40% of cases are initially diagnosed by an internist, and the rest are diagnosed when patients are seen by ophthalmologists for visual disturbances, by dental surgeons for bite disorders, by gynecologists for menstrual dysfunction and infertility, by rheumatologists for osteoarthritis, or by sleep-disorder specialists for obstructive sleep apnea. In conclusion, high suspicion of the diagnosis, along with early diagnosis, is critical in possibly preventing the morbidity associated with acromegaly and improving long-term outcomes.

Management disparities in metastatic castrate-sensitive prostate cancer (mCSPC).

79 Background: Recent approvals in management of high-volume mCSPC offer major improvements in patient outcomes. Triplet therapy combining androgen deprivation therapy (ADT) with docetaxel (D) and novel hormonal therapy (NHT) is the new standard of care in this patient population. Patients ineligible for triplet therapy should receive doublet therapy with ADT plus D or NHT based on category 1 evidence. Multiple retrospective datasets examining the “real-world” mCSPC treatment landscape note significant underutilization of therapies beyond ADT and discordance with treatment guidelines. Methods: A 15-question survey to assess management patterns was electronically distributed to various mCSPC providers in California and Washington. Results: A total of 40 responses were received, with 62.5% identifying as medical oncologists (MO), 20.0% as urologists, 5.0% as radiation oncologists, and 12.5% as advanced practitioners/other. Out of physician responders, 48.6% were academic and 51.4% were community-based. When treating newly diagnosed fit mCSPC patients, 20.0% would prescribe triplet therapy, 42.5% ADT/NHT, 5.0% ADT/D, 5.0% ADT/bicalutamide, 0% ADT alone, 10.0% other therapies, and 17.5% would refer out for therapies beyond ADT. When comparing academic versus community oncologists, 66.7% versus 0% would prescribe triplet therapy, while 22.2% versus 68.8% would prescribe ADT/NHT. Some perceived barriers to following mCSPC treatment guidelines included difficulty keeping up with rapidly evolving data/too many treatment options in 27.5%, insurance coverage concerns in 22.5%, difficulty obtaining early referrals for these therapies in 12.5%, patient factors in 10.0%, and toxicity concerns in 2.5%. When making referrals to MO, 37.5% of non-MO responders would do so at development of mCSPC and 6.3% at mCRPC. Conversely, 24.2% of MO perceived receiving referrals at development of mCSPC and 33.3% at mCRPC. Patterns of ordering genomic testing are listed, with biggest perceived barriers being cost, inadequate access to sequencing platforms and genetic counselors, lack of confidence in counseling about results, and patient refusal. Upon progression from mCSPC to mCRPC, ordering of repeat tumor biopsies would occur “sometimes” by 40.0% of providers, “rarely” by 20.0%, and “never” by 20.0%. Conclusions: Multiple provider disparities when managing mCSPC patients still exist. Our survey demonstrated higher compliance with treatment guidelines than in previous retrospective datasets, possibly due to higher proportion of academic providers. Increased provider awareness of genomic testing recommendations is also needed. [Table: see text]

Recognize and Support Caregiving Youth in Your Care.

Recognize and Support Caregiving Youth in Your Care.

CAN YOU HEAR ME? A MEDICAL STUDENT-LED QUALITY IMPROVEMENT INITIATIVE FOR HOSPITALIZED PATIENTS WITH HEARING LOSS

Abstract In acute care settings hearing loss (HL) is associated with impaired patient-provider communication, increased length of stay, and increased mortality. COVID-19 has exacerbated this problem with the widespread use of masks and eye shields which muffle speech and prevent lip reading. Our 800-bed tertiary care medical center lacked a standardized approach to identify patients with HL and address communication barriers. Three first year medical students spearheaded the initiative as part of a health systems improvement curriculum with support from a faculty coach and a faculty researcher. From September 2020 to October 2021, the students met with stakeholders, leadership and champions and unit staff, identified the current state and completed a gap analysis through interviews, surveys, and direct observation. The pilot in May 2021 included two week-long PDSA cycles on one hospital unit to: 1) screen patients aged 65 and older using the validated 10-item HHIE-S questionnaire, 2) implement an education and awareness campaign with bedside signage, posters, and conferences and 3) provide a personal amplifier (purchased in bulk by the medical center) with verbal and written instructions. A total of 29 patients screened positive and were given personal amplifiers. Post-pilot interviews reported increased provider awareness and knowledge around best communication practices. Patients and staff reported limited amplifier use due to poor sound quality, small dials, poorly fitting ear buds and a short battery life. Based on these results the team recommended discontinuing the personal amplifiers and identifying other communication tools including higher quality personal amplifiers and speech to text applications.

Airway anomalies in patients with 22q11.2 deletion syndrome: A scoping review.

People with 22q11.2 deletion syndrome (22q11DS) can present with a wide variety of findings. Various airway anomalies have been described intermittently within this syndrome, but this feature has not been extensively investigated. Increased provider awareness of these findings may help guide clinical decision-making and improve overall patient outcomes. The objectives of this review are to identify the types of airway anomalies in 22q11DS and the prevalence of airway anomalies within symptomatic individuals. PubMed/MEDLINE, Cochrane Library, and EMBASE databases were searched in February 2022 for all available articles. Search terms included those that described 22q11DS or one of its synonymous conditions AND those that described airway anatomy and anomalies. The term airway anomaly was defined as any structural aberration in the conductive airway from the oral or nasal vestibule region to the mainstem bronchus. Studies were screened by two authors. A review of references was conducted. Eligible manuscripts underwent full-text review for quality appraisal and data extraction. From a total of 909 unique manuscripts, 58 studies were selected, describing 328 people. The prevalence of airway anomaly diagnosis within symptomatic individuals ranged from 14% to 74%. Twenty-two unique airway anomalies were described. Laryngeal web was the most frequently described anomaly, followed by airway malacia and subglottic stenosis. Laryngeal web was 40% sensitive for suggesting a diagnosis of 22q11DS. Among affected individuals, as many as 46% had multiple concomitant airway anomalies. Aside from respiratory symptoms, other features that prompted airway evaluation included difficult intubation or failed extubation. The findings within this review support the notion that a wide variety of airway anomalies may be seen in people with 22q11DS and that these findings have been discovered frequently in those with airway symptoms. Providers should maintain a low threshold to perform an airway examination in those with 22q11DS, especially when airway symptoms are present.