Internal Medicine Providers Research Articles

Contraception.

Contraception counseling and provision are vital components of comprehensive health care. Unplanned pregnancy can be devastating to any woman but is particularly dangerous for those with chronic illness. Internal medicine providers are in a unique position to provide contraception, as they often intersect with women at the moment of a new medical diagnosis or throughout care for a chronic problem. A shared decision-making approach can engage patients and ensure that they choose a contraceptive method that aligns with their reproductive plans and medical needs.

Palliative Medicine Education for Internal Medicine Residents (QI733)

1.Explain the improvement that a lecture series in palliative medicine can have in resident knowledge and skill in providing palliative care.2.Describe an educational program in palliative medicine that can be used to train internal medicine providers. Caring for patients with palliative needs is an essential part of internal medicine training, however this care is often not a focus of resident education. Less than half of accredited internal medicine programs have required palliative care lectures in their curriculum. Due to a shortage in palliative care specialists, internal medicine physicians need basic palliative training to help fill this need. The purpose of this quality improvement project was to create and maintain a curriculum to improve resident knowledge and skill in caring for patients with palliative care needs. Internal medicine residents at the University of Chicago were surveyed to determine their knowledge, attitudes, and skills regarding palliative care pre and post-curriculum. The curriculum utilized presentations, workshops, and simulation over a one-year period. Chi-squared analysis was used to compare pre and post-curriculum results. Response rate was 37% pre-curriculum (n=46/123) and 41% post-curriculum (n=51/123). Based on the pre and post-curriculum surveys, 61% self-reported baseline competence in providing symptom management for patients with chronic disease or life limiting illness, improving to 88% post-curriculum (p=0.002). On initial survey, a minority reported competence in providing patients with palliative resources (26%) which improved to 48% post-curriculum (p=0.027). Reported knowledge in the role of palliative care consultants increased from 78% to 90% post-curriculum (p=0.105) and knowledge in the educational training palliative care consultants receive increased from 35% to 57% (p=0.029). This study discovered that at baseline, many internal medicine residents report lack of competence in providing palliative care for patients. Following the one year curriculum, improvement in resident knowledge and skill was observed, however residents still report weaknesses in these areas. Based on these results, this curriculum has the potential to improve resident knowledge and skill in caring for patients with palliative needs.

185. Implementation of a Clinical Decision Support System (CDSS) for Ordering Antimicrobials in a Veterans Affairs Medical Center (VAMC): Results From a Pilot Quality Improvement (QI) Project

BackgroundWhen used as antimicrobial stewardship (AS) tool, CDSS built into electronic health record systems (EHRs) have been associated with more appropriate antimicrobial (AM) use. This QI project aimed to determine the perception toward, acceptance and utilization of an AM-CDSS by internal medicine providers at the Houston VAMC.MethodsFrom October 2017 to March 2018 (pilot period), ID pharmacists trained members of two to four general medicine inpatient teams/month in the use of the AM-CDSS and provided surveys to be completed during the first (pre) and last week (post) of a 1-month rotation. Surveys focused on the provider’s prescribing patterns, self-perception of infectious diseases knowledge, as well as provider’s awareness, perception of utility, ease of use of the AM-CDSS, and its impact on prescribing patterns. A retrospective chart review was conducted to compare the appropriateness, route and duration of AMs ordered and not ordered through the AM-CDSS. For this comparison, patients were randomly selected from patients with same discharge ID diagnosis matched 1:1 each month.ResultsThrough the pilot period, the AM-CDSS had a continual rate of increased usage of 4.4 AM orders/month. A total of 113 surveys were collected (63 pre-AM-CDSS and 50 post-AM-CDSS). Eighty percent of respondents reported having used the AM-CDSS, and 76% reported wanting to continue to use the AM-CDSS. The most common reasons cited for using it were to confirm their AM approach and to practice up-to-date evidence-based medicine. Thirty percent stated that it was hard to locate within the EHR. A total of 120 AM orders (AM-CDSS = 60 and non-AM-CDSS = 60) were reviewed for appropriateness. The most common indications for the orders were CAP (34.2%) and UTI (33.3%). AM-CDSS orders were more likely to be appropriate (83.3 vs. 50%, P = 0.0002) and to include oral AMs (58 vs. 13.6%, P < 0.0001) than non-AM-CDSS orders. There was a not significant shorter duration of therapy in the AM-CDSS group (8.7 vs. 9.4d, P = 0.46).ConclusionMost providers perceived the AM-CDSS as useful and easy to use. The use of the AM-CDSS was associated with more appropriate AM use and more frequent selection of appropriate oral AMs. When feasible, AS programs with trainees should consider including easily accessible AM-CDSS in their EHR.Disclosures All authors: No reported disclosures.

1240. Antibiotic Prescribing in US Nursing Homes Using National Pharmacy Transaction Data

BackgroundAntibiotics are frequently prescribed inappropriately in nursing homes (NHs); however, national estimates of NH antibiotic use are limited. We aimed to describe antibiotic prescribing in US NHs to identify potential targets for antibiotic stewardship.MethodsA descriptive analysis was conducted using the 2014 proprietary IQVIA long-term care (LTC) Xponent database, which captures oral and intravenous antibiotic prescription transactions from sampled LTC pharmacies representing 70–85% of the LTC market. The data are projected to 100% of the US LTC market. Denominators for rate calculations were captured from the 2014 Minimum Data Set as the number of residents with at least one resident day in an NH in 2014. Antibiotic transaction counts and rates were calculated by resident gender, age, US census region, route of administration, antibiotic class and agent, and total transaction counts were summarized by provider type. Prescribing patterns for antibiotic classes and agents stratified by resident age were also calculated.ResultsIn 2014, there were over 14 million antibiotic transactions in LTC pharmacies, for a rate of 3,302 per 1,000 residents. Female residents accounted for 62% of antibiotic transactions at a rate of 3,305 transactions per 1,000 residents compared with 3,240 per 1,000 male residents. Antibiotic prescribing was highest in the South at 3,752 transactions per 1,000 residents (vs. 2,601 per 1,000 residents in the West). Oral antibiotics accounted for 85% of transactions. Fluoroquinolones were the most frequently prescribed antibiotic class (22%; 723 transactions per 1,000 residents) and the most common agents were levofloxacin, ciprofloxacin, and sulfamethoxazole–trimethoprim. Stratified by age, the percent change in prescribing rates among residents aged <85 to residents aged ≥85 was largest for fluoroquinolones (645 vs. 883) and urinary anti-infectives (210 vs. 319). Internal medicine and family practice providers accounted for 37% and 32% of all antibiotic transactions, respectively.ConclusionA potential antibiotic stewardship target in NHs is fluoroquinolone prescribing. Targeting states in the South for interventions may have the largest impact. Figure. Antibiotic prescribing rates in long-term care by U.S. census regionsDisclosures All authors: No reported disclosures.

Test Result Management Practices of Canadian Internal Medicine Physicians and Trainees.

Missed test results are a cause of medical error. Few studies have explored test result management in the inpatient setting. To examine test result management practices of general internal medicine providers in the inpatient setting, examine satisfaction with practices, and quantify self-reported delays in result follow-up. Cross-sectional survey. General internal medicine attending physicians and trainees (residents and medical students) at three Canadian teaching hospitals. Methods used to track test results; satisfaction with these methods; personal encounters with results respondents "wish they had known about sooner." We received surveys from 33/51 attendings and 99/108 trainees (response rate 83%). Only 40.9% of respondents kept a record of all tests they order, and 50.0% had a system to ensure ordered tests were completed. Methods for tracking test results included typed team sign-out lists (40.7%), electronic health record (EHR) functionality (e.g., the electronic "inbox") (38.9%), and personal written or typed lists (14.8%). Almost all trainees (97.9%) and attendings (81.2%) reported encountering at least one test result they "wish they had known about sooner" in the past 2months (p = 0.001). A higher percentage of attendings kept a record of tests pending at hospital discharge compared to trainees (75.0% vs. 35.7%, p < 0.001), used EHR functionality to track tests (71.4% vs. 27.5%, p = 0.004), and reported higher satisfaction with result management (42.4% vs. 12.1% satisfied or very satisfied, p < 0.001). Canadian physicians report an array of problems managing test results in the inpatient setting. In the context of prior studies from the outpatient setting, our study suggests a need to develop interventions to prevent missed results and avoid potential patient harms.

Six Month Outcomes of Heart Failure Patients Followed at a Newly Established Multidisciplinary Program in the Middle East

Background Patients with heart failure (HF) are best managed within specialized programs in order to improve clinical outcomes and quality of life. Such programs are very rare in the Middle East. The objective of this observational study is to describe the experience at our centre following the establishment of an advanced HF program in October 2015. Methods A retrospective chart review was conducted on patients first seen at our HF clinic between Oct 2015 and Nov 2016. Patients included were adults with HF and reduced ejection fraction (HFrEF) defined as LVEF ≤ 40%. Patients were excluded if no 6-month follow up data were available. Data collected included clinical characteristics, LVEF, and pharmacotherapy both at baseline and at 6 months. In addition, survival and hospital re-admission rates were captured. Chi-square and paired t-test comparisons were performed to compare changes from baseline to the 6-month follow up point. Results Out of a total of 174 patients screened, 95 met the inclusion/exclusion criteria. Six patients expired prior to the follow up (6-month survival rate of 93.7%). Most (69.5%) were males with an average age of 57.8 ± 14.5 years and 61.8% had an ischemic etiology. More than half (56.8%) had an improvement in their LVEF (mean increased from 26.5 ± 7.7% to 34.5 ± 13.1; p figure 1 ). 25.8% of patients had an HF-related admission during the 6-months, with a subsequent 30-day re-admission occurring in 17.4% of them ( Table 1 ). More patients were on target doses of beta blockers and ACEI/ARBs, although this did not reach statistical significance. A significant proportion of patients were switched to sacubitril/valsartan at 6-months follow up compared to baseline (36% vs. 11.6% p Conclusion Close follow up of patients with HFrEF was associated with symptomatic improvement, low 6-month HF hospitalizations, and higher doses of HF pharmacotherapy. These findings warrant more studies comparing patients followed in advanced HF programs to those followed by general cardiology and internal medicine providers, especially in developing countries.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P55. Recognition and management of emergent versus nonemergent spinal pathology amongst first-line providers

BACKGROUND CONTEXT Spinal pathology, particularly spinal emergencies, require prompt identification, management, and surgical referral (if needed) from first-line providers. As such, diagnostic delays from the failure to recognize emergency conditions lead to adverse patient outcomes. In addition, even with nonemergent pathologies, the failure to provide adequate care can result in suboptimal patient outcomes and unnecessary resource utilization. PURPOSE We sought to understand the proficiency with which different types of first-line providers can recognize and manage spinal conditions, particularly spinal emergencies. This may aid in tailoring education resources for first-line providers. STUDY DESIGN/SETTING Cross-sectional analysis of collected single-site data. PATIENT SAMPLE A total of 143 internal medicine, family medicine, emergency care, and neurology providers. OUTCOME MEASURES Inter-departmental differences in management of spinal pathology, familiarity, and preparedness for the diagnosis of spinal emergencies. METHODS A pilot survey was distributed to physicians, physician assistants, and nurse practitioners via the REDCap data collection tool. Chi square, Fisher's Exact, and Kruskal–Wallis tests were utilized, as appropriate. RESULTS Participants were predominantly physicians (88.1%, n=126), with a smaller percentage of midlevel providers (11.9%, n=17). Bivariate analyses revealed inter-departmental differences in clinical knowledge pertaining to the management of lumbar radiculopathy (p CONCLUSIONS Disparities exist between the first-line provider specialties with regard to clinical knowledge in managing and proficiently identifying emergent and nonemergent spinal conditions. As appropriate recognition and management of emergent spinal pathologies is essential to patient outcomes and optimal resource utilization, it is necessary that measures be taken educationally to ensure first-line providers are familiar and proficient with the established standard of care for the spinal conditions they will be treating.

Hepatitis A surveillance using commercial laboratory data

ObjectiveTo evaluate the use of commercial laboratory data for monitoring trends in HAV infections over time and identifying geographic and demographic characteristics of HAV case clusters for the purpose of targeting interventions.IntroductionHepatitis A virus (HAV) infections have persisted in the United States despite the availability of an effective vaccine. Recent outbreaks of HAV infections among unvaccinated adults attributed to consumption of HAV-contaminated food, or person-to-person contact in certain populations (e.g., men who have sex with men) or settings (e.g., homeless shelters) have emphasized the importance of targeted vaccination of at-risk adults.MethodsWe used commercial laboratory data from Quest Diagnostics (Quest) and Laboratory Corporation of America (LabCorp) to identify unique individuals within each database who tested positive for HAV IgM antibody (indicative of acute HAV infection) from January 2011 through June 2017. Though de-depulication across the two laboratories was not possible, comparison of case characteristics indicated limited possible overlap of cases (&lt;0.5%) and thus data from the two laboratories were combined. Demographic characteristics associated with the first positive test were used to classify cases by age, gender, state of residence, insurance type, and provider specialty. Persons co-infected with hepatitis B and/or hepatitis C were identified based on positive test results for hepatitis B surface antigen and hepatitis C RNA, respectively.ResultsA total of 6,702,256 HAV IgM test results from Quest and 7,043,555 HAV IgM test results from LabCorp were processed. Of those, 24,697 (0.4%) and 13,785 (0.2%) tests, respectively, had a ‘Reactive’, or positive result, indicating acute HAV infection. From these test results, we identified 15,415 unique individuals from Quest and 10,622 unique individuals from LabCorp with an acute HAV infection between January 2011 and June 2017. Among the 26,037 acute cases, the majority were female (14,056; 54.0%), were aged 50 or older (13,940; 53.5%), resided in large central or fringe metropolitan areas (17,842; 68.5%), and had tests ordered by family or internal medicine providers (12,358; 47.5%; Table). We identified 330 cases (1.3%) among incarcerated persons. Although data could not be de-duplicated across labs, we estimated a minimum of 630 persons (2.4%) were co-infected with hepatitis B and 852 persons (3.3%) were co-infected with hepatitis C. From 2011 to 2015, there were 7,370 cases of acute HAV reported to CDC, whereas Quest and LabCorp test results indicated 19,822 cases over the same time period. Trends in cases by month revealed seasonal increases in cases in late summer and early fall months (Figure 1). Mapping of acutely-infected individuals demonstrated a range of cases from 0 to 1,119 cases by county over the study period (Figure 2).ConclusionsHAV IgM test results over a 6-year period from two commercial laboratories serving the United States suggest continuing hepatitis A transmission. Most cases occur among older adults, and appear to cluster geographically in metropolitan areas. Commercial laboratory data is a useful tool for supplementing case-based surveillance and informing prevention efforts.

Transition to international classification of disease version 10, clinical modification: the impact on internal medicine and internal medicine subspecialties

BackgroundThe US health care system uses diagnostic codes for billing and reimbursement as well as quality assessment and measuring clinical outcomes. The US transitioned to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) on October, 2015. Little is known about the impact of ICD-10-CM on internal medicine and medicine subspecialists.MethodsWe used a state-wide data set from Illinois Medicaid specified for Internal Medicine providers and subspecialists. A total of 3191 ICD-9-CM codes were used for 51,078 patient encounters, for a total cost of US $26,022,022 for all internal medicine. We categorized all of the ICD-9-CM codes based on the complexity of mapping to ICD-10-CM as codes with complex mapping could result in billing or administrative errors during the transition. Codes found to have complex mapping and frequently used codes (n = 295) were analyzed for clinical accuracy of mapping to ICD-10-CM. Each subspecialty was analyzed for complexity of codes used and proportion of reimbursement associated with complex codes.ResultsTwenty-five percent of internal medicine codes have convoluted mapping to ICD-10-CM, which represent 22% of Illinois Medicaid patients, and 30% of reimbursements. Rheumatology and Endocrinology had the greatest proportion of visits and reimbursement associated with complex codes. We found 14.5% of ICD-9-CM codes used by internists, when mapped to ICD-10-CM, resulted in potential clinical inaccuracies.ConclusionsWe identified that 43% of diagnostic codes evaluated and used by internists and that account for 14% of internal medicine reimbursements are associated with codes which could result in administrative errors.

A centralized, primary care medical home survivorship model at the GW Cancer Center.

45 Background: Models for survivorship care are often oncology-based. George Washington (GW) Adult Cancer Survivorship Clinic (ACS) has developed a unique, centralized model for survivorship care delivery staffed by internal medicine providers. The objective is to provide care to survivors that encompass the broad array of chronic issues they face, in addition to guidance on cancer surveillance and prevention. Methods: We implemented a centralized, primary care, consultative model of survivorship care, emphasizing care coordination. A personalized, evidence based survivorship care plan (SCP) is provided to each patient. Patients with complex needs may be seen for follow-up. A copy of the SCP is sent to the patient’s primary care provider (PCP). Referrals are made to our network of specialists within the GW system including: cardiology, neurology, weight management, genetic counseling, dermatology, physical therapy, integrative medicine, psycho-oncology, sexual health, and oncofertility. Referrals are tracked to specialty services using the electronic medical record (EMR). Results: Based on preliminary data, from January 2016 to October 2017, 261 cancer survivors were seen in the survivorship clinic. The majority were breast cancer survivors (166). Referral records were available for 225 patients. Most common were dermatology for baseline skin cancer screening (28%), physical therapy (16%), social work and psycho-oncology (15%), and weight management (15%). Conclusions: Our clinic is based on a primary care medical home model for each survivor, which includes care coordination and referral to specialty services. Limitations include inconsistent referral tracking methods with our EMR and incomplete data for all survivorship patients. Future research plans include assessing the impact of referrals on patient-reported outcomes and morbidity.

Development and implementation of a centralized comprehensive refill authorization program in an academic health system.

The development and implementation of a centralized, comprehensive, refill authorization (CCRA) program within an academic health system are described. In order to improve continuity of care for our medically complicated patients, ambulatory pharmacy services developed and implemented a highly coordinated CCRA program for multiple community clinics within the system. To implement the CCRA program, we centralized the refill-request intake process to the Pharmacy Ambulatory Clinical Care Center (PAC3). PAC3 technicians were incorporated into the refill authorization process, and the collaborative practice agreement was updated to standardize the pharmacist refill approval process at the PAC3. We successfully standardized and centralized the medication refill process from 10 community clinics with 95 family practice and internal medicine providers and 26 medical residents. We handled an average of 12,000 refill requests each month, and pharmacists documented any interventions performed with each refill request. The cost savings associated with the CCRA program were attributed to the increased efficiency of the staff reviewing refill requests. The CCRA program increased the refill approval up to 10% compared with the previous decentralized refill authorization model. With the increased approval rate, the CCRA program saved 510 hours of our providers' time annually, which created time for an additional 1,530 clinic visits. We demonstrated a faster average turnaround time for refill authorization, from an average of 72 hours before implementation to about 1 business day. Implementation of an integrated refill authorization service standardized the method by which patients' refill requests were addressed, increased refill efficiency, and improved refill authorization turnaround time.

Atrial Fibrillation in a Patient With an Accessory Pathway.

A 24-year-old man with history of unspecified arrhythmia presented with palpitations and chest pain. Initial electrocardiogram (ECG) revealed irregular tachycardia with varying QRS width: 150 to 200 beats per minute for narrow complexes and 300 beats per minute for wide complexes. Following cardioversion, ECG revealed sinus tachycardia with a preexcitation pattern of positive delta waves in the anterolateral leads and negative delta waves in inferior leads. The patient remained in sinus rhythm and underwent successful ablation of a right posteroseptal accessory pathway. Subsequent ECG showed upright T waves in the leads I, aVL, and V2-6, large inverted T waves in leads III and aVF, and no delta waves. This case serves as an important reminder that atrial fibrillation (AF) in the presence of an accessory pathway may present with confounding ECG features, potentially leading to incorrect diagnoses and treatments that may be life threatening. Despite 10% to 30% prevalence of AF in the presence of an accessory pathway and the relative awareness of Wolff-Parkinson-White syndrome among general internal medicine providers, the clinical recognition of Wolff-Parkinson-White syndrome may be hindered in the presence of preexcited AF.

Explaining Breast Density Recommendations: An Introductory Workshop for Breast Health Providers.

High breast density is an independent risk factor for breast cancer and can decrease the sensitivity of mammography. However, evidence surrounding recommendations for patient risk stratification and supplemental screening is evolving, and providers receive limited training on breast density counseling. We implemented an introductory, interactive workshop about breast density including current evidence behind supplemental screening and risk stratification. Designed for providers who counsel women on breast health, this workshop was evaluated with internal medicine providers, primary care residents, and radiology residents. We surveyed participants about knowledge and attitudes at baseline, postintervention (residents and providers), and 3-month follow-up (providers only). We compared baseline and postintervention scores and postintervention and 3-month follow-up scores using paired t tests and McNemar's tests. Internal medicine providers had significant gains in knowledge when comparing baseline to postintervention surveys (6.5-8.5 on a 10-point scale, p < .0001), with knowledge gains maintained when comparing postintervention to 3-month follow-up surveys (p = .06). Primary care and radiology residents also had significant gains in knowledge when comparing baseline to postintervention surveys (p < .004 for both). All learner groups reported increases in their confidence regarding counseling women about breast density and referring for supplemental screening. Through this breast density session, we showed trends for increased knowledge and change in attitudes for multiple learner groups. Because we aim to prepare providers with the best currently available recommendations, these materials will require frequent updating as breast density evidence and national consensus evolve.

Payer database and geospatial analysis to evaluate practice patterns in treating allergy in North Carolina

ObjectiveThe objective of this study was to characterize the delivery of allergy care in North Carolina using a large payer charge database and visualization techniques. Study designGeospatial database analysis. SettingNorth Carolina State claims database. Subjects & methodsMedical data from the 2013 FAIR Health National Private Insurance Claims (FH NPIC) database for North Carolina was mined for CPT codes and charges for allergy testing, and for the preparation and provision of allergen immunotherapy. Provider and patient variables were analyzed. Analyses were performed to compare differences in allergy care delivery. A visualization strategy complemented the analytic approach. Results162,037 CPT charge entries were analyzed. Allergy-immunology specialists were the most common provider specialty to perform allergy immunotherapy treatments (68.9%, p<0.05). Among other specialties, there were no significant differences between specialists performing immunotherapy when comparing otolaryngology, family practice, and internal medicine (16.3%; 4.6%; 2.6%; p>0.05). Providers with an M.D. degree were the most common provider type. The three most commonly treated diagnoses were allergic rhinitis variants. Females were more likely to receive allergy treatments versus males (55.9% vs. 51.5%; p<0.001), and were more likely to receive allergy testing (65.3% vs. 34.7%: p<0.005). Internal medicine providers charged higher than any other specialist type (p<0.05) for allergy immunotherapy. ConclusionsUsing a large payer database coupled with visualization techniques was an efficient approach to characterizing the state-wide provision patterns of allergy diagnostic and therapy services in North Carolina. This first tier approach to efficiently exploring questions and describing populations is valuable.

Knowledge and Preferences of Primary Care Providers in Delivering Head and Neck Cancer Survivorship Care.

Long-term care for head and neck cancer (HNC) survivors is complex and requires coordination among multiple providers. Clinical practice guidelines highlight the role of primary care providers (PCPs) in screening for secondary cancer/recurrence, assessment of late/long-term side effects, and referrals for appropriate specialty management of toxicity. However, these responsibilities may be difficult to meet within the scope of primary care practice. We conducted this study to explore preferences, comfort, and knowledge of PCPs in the care of HNC survivors. We piloted a 40-item web-based survey developed with oncologist and PCP input targeted for family medicine and internal medicine providers. Responses were collected within a single university health system over 2months. PCPs (n=28; RR=11.3%) were interested in learning about health promotion after cancer treatment (89%) and generally agree that their current practice patterns address healthy lifestyle behaviors (82%). However, only 32% of PCPs felt confident they could manage late/long-term side effects of chemotherapy, radiation, or surgery. Only 29% felt confident they could provide appropriate cancer screening. Looking at shared care responsibilities with oncology providers, PCPs perceived being responsible for 30% of care in the first year after treatment and 81% of care after 5years. Seventy-one percent of PCPs agreed that oncologists provided them necessary information, yet 32% of PCPs found it difficult to coordinate with cancer providers. While these PCPs perceive increased care responsibility for long-term survivors, most are uncomfortable screening for recurrence and managing late/long-term side effects. Education and mutual coordination between PCPs and oncology providers may improve survivor care.

Exploring challenges in the patient’s discharge process from the internal medicine service: A qualitative study of patients’ and providers’ perceptions

ABSTRACTIn hospital-based medicine units, patients have a wide range of complex medical conditions, requiring timely and accurate communication between multiple interprofessional providers at the time of discharge. Limited work has investigated the challenges in interprofessional collaboration and communication during the patient discharge process. In this study, authors qualitatively assessed the experiences of internal medicine providers and patients about roles, challenges, and potential solutions in the discharge process, with a phenomenological focus on the process of collaboration. Authors conducted interviews with 87 providers and patients—41 providers in eight focus-groups, 39 providers in individual interviews, and seven individual patient interviews. Provider roles included physicians, nurses, therapists, pharmacists, care coordinators, and social workers. Interviews were audio-recorded and transcribed verbatim, followed by iterative review of transcripts using qualitative coding and content analysis. Participants identified several barriers related to interprofessional collaboration during the discharge process, including systems insufficiencies (e.g., medication reconciliation process, staffing challenges); lack of understanding others’ roles (e.g., unclear which provider should be completing the discharge summary); information-communication breakdowns (e.g., inaccurate information communicated to the primary medical team); patient issues (e.g., patient preferences misaligned with recommendations); and poor collaboration processes (e.g., lack of structured interprofessional rounds). These results provide context for targeting improvement in interprofessional collaboration in medicine units during patient discharges. Implementing changes in care delivery processes may increase potential for accurate and timely coordination, thereby improving the quality of care transitions.

Missed Opportunities to Identify Cardiovascular Disease in Women With Prior Preeclampsia [22OP

INTRODUCTION: Cardiovascular disease (CVD) is the number one killer of American women. Since 2011, the American Heart Association has recognized that women with prior preeclampsia have an increased risk for CVD equal to diabetics and smokers, and since 2013 the American College of Obstetricians and Gynecologists (the College) has recommended early screening for these patients. There are currently no guidelines in the internal medicine literature for CVD screening in women with prior preeclampsia, leading to a provider knowledge gap and missed opportunities to screen high risk women. METHODS: We performed a retrospective chart review of 89 women ages 18 to 48 with at least one prior delivery who presented for a well-woman visit after 2013, when the College guidelines were released. We assessed documentation of preeclampsia versus traditional risk factors for CVD (smoking, diabetes, and hypertension) and whether CVD screening was performed according to College guidelines. RESULTS: 21/89 women were asked about preeclampsia while 88/89 were asked about diabetes or smoking and 89/89 were asked about hypertension. Our data was analyzed using a test of two proportions to compare how often providers asked about preeclampsia compared to smoking, diabetes, and hypertension. The p value was statistically significant at 0.0002 in each individual comparison group. CONCLUSION: We identified a knowledge gap at our academic institution among internal medicine providers regarding preeclampsia as a major risk factor for CVD. We see this as an opportunity to improve provider education and ensure continuum of obstetrical to primary care, preventing CVD in high risk women.

Compliance With ASCCP Guidelines for Evaluation and Management of Abnormal Pap Smears [28E

INTRODUCTION: American Society for Colposcopy and Cervical Pathology (ASCCP) 2012 revised guidelines were developed to improve the detection and management of cervical dysplasia. A recent study revealed that not all health care providers are knowledgeable or aware of the 2012 national cervical cancer screening guidelines (Teoh et al., 2015). The goal of this study was to determine if primary care providers and Gynecologists manage abnormal PAP smears according to ASCCP current guidelines. METHODS: This was a retrospective study conducted at a Midwestern, regional medical center. An electronic search was conducted for abnormal PAP smears during a 12-month period performed by Gynecologists, Internal Medicine, and Family Medicine providers. The patients’ charts were reviewed and entered into an electronic database. The results of the PAP smear and its optimal management according to the 2012 ASCCP guidelines were compared to the providers’ next step in the treatment and management of the abnormal PAP smear. Proportions and 95% confidence intervals were determined for age of patient, type of provider and field of medicine. RESULTS: 284 charts were reviewed. The proportion of PAP smears that were managed appropriately was 0.658 (95% CI 0.603-0.714). The proportion of ASCCP guideline managed PAP smears were similar for age of patient, type of provider (physician or Advanced Practice Provider) and field of medicine. CONCLUSION: In this study, providers were not always managing abnormal PAP smears according to the current ASCCP guidelines. These results may reflect that providers are unaware of the recent guidelines or the guidelines are too complicated.

P011: Discerning perceived barriers and facilitators to goals of care discussion in the emergency department: A survey of emergency physicians and residents

Introduction: Patients presenting to the Emergency Department (ED) may require clarification of their goals of care (GOC) to ensure they receive treatments aligned with their values. However, these discussions can be difficult to conduct for multiple reasons, including lack of time in a busy ED, competing priorities and a limited relationship with the patient. Few studies have examined the perceived challenges faced by Emergency Physicians in conducting GOC discussions. This study sought to contextualize and discern the barriers and facilitators to having these conversations as reported by Emergency physicians. Methods: An interdisciplinary team of Emergency Medicine, Palliative Care and Internal Medicine providers developed an online survey comprised of multiple choice, Likert-scale and open-ended questions to explore four domains of GOC discussions: training; communication; environment; and personal beliefs. Invitations and scheduled reminders were sent to 275 ED physicians at six academic sites in a Canadian urban centre, including 49 EM residents. Results: 105 (46%) staff physicians and 23 (47%) residents responded with similar representation from all sites. Differences were reported in the frequency of GOC discussions: 59% of staff physicians conduct several per month whereas 65% of residents conduct less than one per month. Most agreed that GOC discussions are within their scope of practice (92%), they feel comfortable (96%), and are adequately trained (73%) to have them; however, 66% reported difficulty initiating GOC discussions. 73% believed that admitting services should conduct GOC discussions, yet acuity was noted in the comments as a major determinant with initiating GOC discussions by ED physicians. Main barriers identified were lack of time, chaotic environment, lack of advanced directives and the inability to reach substitute decision makers. 54% of respondents indicated that the availability of 24-hour Palliative Care consults would facilitate GOC discussions in the ED. Conclusion: Emergency physicians are prepared to conduct goals of care discussions, but often believe they should instead be conducted by the patient’s admitting service. Multiple perceived barriers to goals of care discussion in the ED were identified, and a majority of respondents felt that the availability of Palliative Care in the ED may facilitate these discussions.

Abdominal imaging ordering patterns by referring provider specialty.

Prior work has demonstrated marked growth in the volume of abdominal imaging performed by radiologists. However, decisions to pursue imaging are largely driven by referring providers. In this study, we take the novel approach of investigating abdominal imaging utilization patterns by referring provider specialty. Data on imaging services were obtained from the 2014 DocGraph Medicare Referring Provider Utilization for Procedures (MrPUP) public use file. MrPUP contains aggregated transaction data for combinations of unique referring provider and service code. Imaging services were classified by modality and body region using the Neiman Institute Types of Service (NITOS). Each referring provider's specialty was determined using Medicare Physician Compare. Abdominal imaging ordering patterns were summarized by referring specialty. The final dataset included 5,824,754 abdominal imaging transactions. The most common ordering specialties of abdominal imaging were as follows: (1) internal medicine; (2) urology; (3) emergency medicine; (4) family practice; and (5) gastroenterology. The most common ordering specialties by abdominal imaging modality were emergency medicine for CT; gastroenterology for MRI and nuclear medicine; and internal medicine for ultrasound and radiography. While numerous specialties commonly ordered abdominal radiography and CT, urologists also commonly ordered retroperitoneal ultrasound and retrograde urography, and gastroenterologists also commonly ordered abdominal ultrasound, abdominal MRI, and esophagrams. Internal medicine, family practice, and emergency medicine providers ordered a much broader mix of imaging, including many non-abdominal imaging examinations. Referring specialty abdominal imaging ordering patterns are varied but distinct. Awareness of these patterns may facilitate focused educational and policy initiatives to improve abdominal imaging appropriateness and utilization.