Internal Medicine Resident Clinic Research Articles

"Life with Diabetes": A Pilot Study on an Experiential Continuous Glucose Monitoring Curriculum for Resident Physicians.

The use of technology in diabetes mellitus (DM) management has been growing. The indications and coverage for continuous glucose monitoring (CGM) have increased. Primary care (PC) clinics, including resident continuity clinics, are the frontline for DM management; however, they struggle to adopt CGM. To implement a CGM curriculum to resident physicians to improve knowledge and confidence. An internal medicine (IM) resident PC clinic in an urban academic medical institution. Twenty-four IM residents. We designed a curriculum that included a lecture about CGM indications, interpretation, ordering, and insurance consideration; and a voluntary, experiential learning module in which the residents wore a CGM. We conducted a retrospective pre-post survey with a 4-point Likert scale. Average self-reported scores in knowledge increased for CGM (1) indications from 1.85 to 3.45, (2) ordering from 1.35 to 3.05, (3) functioning from 2.20 to 3.50, and (4) data interpretation from 1.85 to 3.25 (all p < 0.0001). Confidence for "describing CGM monitoring" and "fielding questions about CGM" increased from 2.25 to 3.65 (p < 0.0001) and 1.90 to 3.30 (p < 0.0001). Given the demand for DM management in the PC setting, this targeted CGM curriculum has promise to help residents adopt CGM into their practice.

The Discrepancy Between Hemoglobin A1c and Glucose Management Indicators in 26 Patients Treated With Continuous Glucose Monitoring in an Internal Medicine Residency Clinic.

We conducted a retrospective observational cohort study between 2020 and 2023 in 26 patients with type 1 and type 2 diabetes mellitus (DM) who were using 3-4 injections per day of insulin and were monitored by continuous glucose monitoring (CGM). The goal of this retrospective observational cohort study is to compare these two metrics in an internal medicine community primary care residency clinic. We used CGM devices, Dexcom G6 and G7, and Freestyle Libre 3. The goal was to compare the patient's hemoglobin A1c (HbA1c) taken during their clinic visit by phlebotomy as a marker for diabetic control with an estimated HbA1c glucose management indicator (GMI) derived from the 30-day CGM readings. HbA1c is derived from the blood, while the GMI value is derived from the interstitial fluid. Both parameters were taken within 30 days of each other. GMI was taken in the last 30 days. We excluded patients with known anemia, chronic kidney disease, polycythemia, cirrhosis of the liver, or metabolic dysfunction associated with steatohepatitis (MASH) because disease states can affect the measured HbA1c. Also, pregnantand African American patients were excluded. We concluded the measured HbA1c was 0.34% (4 mmol/mol) higher than the CGM-derived GMI. The relationship between factors that affect glycemic control was discussed in the article, as well as the future utilization of them in improving diabetic control and management. As the use of CGM continues to grow, addressing differences between laboratory-measured HbA1c and CGM-derived GMI is critical.

Case Series on Implementation of Continuous Glucose Monitoring for Better Glycemic Control without Long-acting Insulin

In our case series, we are describing 6 patients with uncontrolled, complicated type 2 Diabetes Mellitus (Type 2-DM). Although they were self-monitoring their blood glucose (SMBG) at least 4 times a day, they continued to have suboptimal glucose control. Continuous glucose monitoring (CGM) was started at our Internal medicine residency primary care clinic. The patients were educated on diet, lifestyle changes, and how to adjust their insulin regimen according to their blood glucose results from the CGM as the standard of care. They were called every two weeks by the representative of our CGM team to monitor and answer any queries regarding insulin adjustment, blood glucose monitoring, diet, physical activity, or lifestyle. The CGM team included Internal medicine and transitional year medical residents and a board-certified endocrinologist who was a member of our clinic. Moreover, the patients were seen at the clinic once every month by a member of the CGM team. Long and rapid-acting Insulins were started to achieve optimal glucose control initially. Eventually, Insulin dosage was gradually reduced, and the patients we described were started on alternate agents like oral antidiabetic agents with or without injectable glucagon-like peptide GLP-1 receptor agonists. The five-hour postprandial C-peptide was checked after discontinuation of insulin in all of our patients and was normal. Within a few months of CGM initiation, there was a significant improvement in the patients’ glucose control which was maintained after stopping the Insulin. Some patients were also able to lose weight. We concluded that CGM could be initiated safely in an internal medicine residency clinic not only at specialized endocrine clinics in a project that was managed primarily by internal medicine and transitional year residents under the supervision of a member of the clinic who was board certified in endocrinologists. We also demonstrated the introduction of CGM instead of SMBG in patients with Type 2-DM helped them to achieve better glycemic control with insulin, overcome glucose toxicity, and eventually stop the insulin and maintain excellent glucose control only with oral antidiabetic agents with or without injectable GLP 1 receptor agonist.

Integration of Automated Office Blood Pressure Measurement Into a General Internal Medicine Residency Clinic.

Integration of Automated Office Blood Pressure Measurement Into a General Internal Medicine Residency Clinic.

Cost effective quality improvement initiative in lung cancer screening: A single institutional pilot program.

458 Background: US Preventive Services Task Force (USPSTF) recommends lung cancer screening (LCS) with annual low-dose computed tomography (LDCT) screening for individuals aged 50-80 years with ≥20 pack-year smoking history. Nevertheless, only 4%-13% of eligible individuals are screened nationally. Lung cancer mortality is higher in the South where low socioeconomic status and racial minorities predominate and the screening rate in Alabama is between 4.7% - 7.7%. Thomas Hospital belongs to this catchment area and the goal of our study was to improve LCS with LDCT by embarking on a quality improvement initiative which was commenced as a pilot program for a larger healthcare system (&gt;5 large outpatient clinics with over 12,000 visits/month). Methods: Data were obtained retrospectively by reviewing the electronic medical records of eligible patients for LCS from 01/22 to 01/23 who visited the Thomas Hospital Internal Medicine Residency Clinic (pilot study site). A multidisciplinary team was created involving Thoracic oncologists, radiologists, Thoracic surgeons, resident physicians, and PCPs to identify barriers to LCS and discuss methods on how to improve LCS. We identified areas to be improved on and utilized performance improvement tools such as a Pareto chart and a PICK chart. Data was then collected prospectively. Results: In the initial 12-month period, only 6.95% (total n=185) of patients who qualified for LCS had LDCT done for LCS. The major barriers to screening were poor smoking history documentation, lack of proper identification of screening candidates, lack of awareness of screening guidelines, infrequent follow-up, discrepancies in smoking history within the EMR, and lack of a consistent system for LDCT referral. We identified 4 main initiatives which were introduced monthly, one at a time. The interventions include Educational services/Awareness campaigns on LCS, Distribution of current LCS guidelines in the clinic rooms/offices, Patient self-reported questionnaire on smoking history, and Implementation of an EPIC flag tool for LCS. We reviewed our performance after the interventions and the total LCS after 4 interventions included 48 (47%) patients compared to 102 patients who fit the screening criteria. 5 patients had LDCT ordered but yet to be completed and 6 patients had findings that needed immediate evaluation and received appropriate referrals. Conclusions: Lung cancer screening remains suboptimal in the United States, especially in the southern region. With our approach, the screening rates have increased exponentially only within a few months compared to the previous year and this model is to be adopted by other clinics affiliated with the umbrella health system. LDCT does carry certain risks including false positive results and unnecessary biopsies; hence shared decision-making is needed before ordering the test.

SAT113 Reducing The Frequency Of Ordering Hemoglobin A1c In Patients With Well-controlled Diabetes - A Quality Improvement Project

Abstract Disclosure: G. Umarji: None. K. Swedish: None. V. Tabatabaie: None. Introduction: “Let’s check an A1c” is a sentence heard often in primary care setting. Is it truly required each time? According to Standards of Care 2021 by American Diabetes Association, hemoglobin A1c should be tested every six months for patients with well-controlled diabetes. The cost of hemoglobin a1c test ranges $28 to $245, with an average of $85.20 without insurance. Unnecessary blood tests cause discomfort and anxiety to patients and increase healthcare costs. We conducted a quality improvement project whose aim was to decrease the frequency of unnecessary hemoglobin A1c testing by 50% from March 2022 to March 2023 at an internal medicine residency clinic. Methods: Our discovery phase included a survey of all providers in the residency clinic and a chart review. The goal of the survey was to understand how clinicians identified well-controlled diabetes. The survey was sent to 86 providers (attendings and residents) with a response rate of 43%. Results showed a shortcoming to define goal A1c for adults &amp;gt;65 years of age. Less than half knew that a patient with well-controlled diabetes should have A1c checked every 6 months. A chart review was conducted for all patients seen by attendings and residents as primary care providers in clinic with hemoglobin A1c between 6.5 and 8.5. Of the 462 total patients, a representative sample revealed that 38% of the patients with well-controlled diabetes (defined with goal A1c from standards of care 2021) had A1c ordered sooner than recommended. Three interventions have been planned to reduce this occurrence. The first intervention was an educational session with attendings, as they act as point regulators for every plan made for clinic patients. Results: Eight weeks after the first intervention, a similar chart review was conducted, which demonstrated a decrease in patients with well-controlled diabetes having A1c sent sooner than recommended from 38% to 33%. Discussion: The second intervention, an educational session with the residents, was performed and data is being gathered to determine the efficacy of that intervention. The third planned intervention will be to post information about A1c ordering in the precepting room at the clinic. We know that training is the least effective method to obtain change, an ideal intervention would be to introduce a hard stop in the electronic medical record (EMR) asking if the physician truly wanted to order another A1c since the last was ordered x months ago with the result of y%. However, despite being a more effective method of change, it is very expensive and difficult to introduce new measures into our EMR. Following our third intervention, we will reassess to determine if further interventions would benefit our goal of decreasing unnecessary A1c testing in patient with well-controlled diabetes. Presentation: Saturday, June 17, 2023

Improving colorectal cancer screening disparities among Somali-speaking patients in an Internal Medicine Residency Clinic

Colorectal cancer (CRC) is the third-most lethal cancer in the USA, and early detection through screening is crucial for improving outcomes. However, significant disparities in access and utilisation of CRC...

S1414 Removing Barriers to Treatment of Chronic Hepatitis C Using a Streamlined Algorithm and Partnership With a Specialty Pharmacy in an Internal Medicine Resident Clinic

S1414 Removing Barriers to Treatment of Chronic Hepatitis C Using a Streamlined Algorithm and Partnership With a Specialty Pharmacy in an Internal Medicine Resident Clinic

S1461 Utilization of the NAFLD Fibrosis Score for Screening Obese Patients in a Safety Net Internal Medicine Resident Clinic: A Quality Improvement Project

S1461 Utilization of the NAFLD Fibrosis Score for Screening Obese Patients in a Safety Net Internal Medicine Resident Clinic: A Quality Improvement Project

The Effectiveness of Continuous Glucose Monitoring Devices in Managing Uncontrolled Diabetes Mellitus: A Retrospective Study.

This retrospective study aimed to assess the effectiveness of continuous glucose monitoring (CGM) devices in managing uncontrolled diabetes mellitus (DM). The study cohort comprised 25 patients with uncontrolled diabetes who received treatment at an internal medicine resident clinic. The objective was to evaluate the impact of transitioning from self-monitoring of blood glucose (SMBG) to CGM devices on glycemic control, as measured by changes in hemoglobin A1c (HbA1c) levels, average blood glucose levels, hypoglycemic events, time spent within the target blood sugar range, and glucose variability. The findings indicated significant improvements in glycemic control with the adoption of CGM devices, highlighting their potential benefits for optimizing diabetes management. The study is particularly interesting because it was done in an internal medicine continuity clinic with the main participation of the internal medicine residents under the supervision of an endocrinologist. It was not done as the majority of the other studies used CGM in specialized endocrinology clinics.

Improvement of mild and more serious hypoglycemia in patients with DM type 1 and type 2 after introduction of Continuous Glucose monitoring in Internal Medicine Residency Clinic

We are describing our experience of introducing Continuous Glucose Monitoring (CGM) for the first time as far as we know not in specialized endocrine clinic, but in Internal Medicine Residency Clinic in USA. The 25- patients we included in the trial were with type 2 Diabetes Mellitus (DM 2) -85% and Type 1 DM (DM1)-15%. They were treated with multiple injections of Insulin per day and were self-Monitoring their blood glucose (SMBG) 4 times a day. Their HbA1c was in the beginning of the trial was 9.5-to 14%. Before the introduction of the CGM the patients were spending 1 hour and 14 minutes a day having mild hypoglycemia- between 69-54 mg/dl-4.75% and more significant hypoglycemia- less than 54 mg/dl 29 min a day-3.01%. The CGM was started in the Clinic by the CGM team. In the CGM team were actively participating a10- Internal medicine and Transitional Year Residents under the supervision of board-Certified Endocrinologist who was a member of the clinic also. The CGM used was Dexcom G6. The goal of the project was to show that not only in specialized centers, but in General Internal Medicine Residency clinic we can not only improve the control of DM type 1 and type 2 in those 25- patients but most importantly reduce the time they had hypoglycemia. The Internal Medicine and Transitional year Residents were actively involved in the project. They were educating the patients before starting the CGM on their die and how to adjust their Insulin at home based on written instruction materials and treat their low blood sugar. The patients were called at least once a week by Internal Medicine Clinic representative of the CGM team with instructions how to adjust their Insulin, treat their hypoglycemia and to counsel them about their diet and physical activity. The patients had scheduled appointment to the clinic once a month. After the glucotoxicity from the initial high blood sugar was overcomed by using the appropriate dose of Insulin the control of the diabetes was achieved with reduction of HbA1c to 7.04% mean from 11.21% before the introduction of the CGM. With the help of the CGM the time spent by the patients with BS less than 70 mg/dl decreased from 1 hour and 14 minutes per day-4.75% to 11 minutes per day-0.78% and the time spend with blood sugar less than 54 mg/dl per day decreased from 29 minutes-3.01% to 3 minute per day-0.25%. Both values after the introduction of CGM were within the American Diabetic Association (ADA) standards- mild hypoglycemia goal of less than 4 % and more significant hypoglycemia goal of less than 1 % per day. Four of the patients were able to have excellent control of their DM 2 without any low blood glucose only on per oral antidiabetic medications and or GLP1-RAG. Our experience showed that introduction of CGM instead of SMBG in General Internal Medicine residency Clinic can help a lot of patients with DM type 1 and type 2 on multiple injections of insulin per day to reduce mild and more serious hypoglycemia and improve their blood sugar control with Insulin. Also, we showed that this can be done safely in General Internal Residency clinic and not only in specialized endocrine clinics which can be adopted in other Internal Medicine residency Clinics in USA. This also significantly improves the education and experience with the CGM devise of our Internal Medicine and Transitional Year Medical Residents.

Improvement of time in range and glucose management indicator in Type 1 and Type 2 Diabetes Mellitus patients after introduction of continuous Glucose monitoring in internal medicine residency clinic

Continuous glucose monitoring (CGM)-derived time in range (TIR) correlates with Glucose management indicator(GMI) which correlates with hemoglobin A1c (HbA1c) among patients with type 1 and type 2 diabetes mellitus. Compare to HbA1c it has better correlation with glucose control, because HbA1c can be influenced by conditions like anemia, Chronic kidney disease, Cirrhosis of the liver etc. With our current project we wanted to introduce CGM not in specialized endocrine clinic, but in Internal medicine Residency clinic. The CGM team had 12 Internal Medicine and Transitional year Residents who were functioning under the supervision of Board Certified Endocrinologist who was a member of the clinic also. Twenty Five patients -85% with type 2 DM and 15% with type 1 DM on multiple injections of Insulin per day-3-4, self-monitored their blood Glucose(SMBG). They were given CGM- Dexcom G6 in the clinic. In the first 2- weeks after the switch the TIR of the blood glucose of the patients-70-180 mg/dl was 18%. Their average blood glucose was 286 mg/dl, GMI was 11.21%. During then first 2- weeks after initiation of CGM the patients were educated in length by our CGM team about their diet, physical activity, how to adjust their Insulin based on their blood glucose levels as well as how to treat the hypoglycemia. Members of the CGM team were contacting the patients twice a week to adjust patients treatment with Insulin and other per oral antidiabetic medications and or injectable – GLP1-RAG if needed after consultation with the Endocrinologist in the clinic based on the shared information between the clinic and the patients. Once a month the patients were seen in the clinic by member of the CGM team as well. The patients were followed for 2- years. After 3- months on CGM and followed for the 2 years thereafter the patients TIR improved from 18 % to 74%, GMI decreased from 11.21% to 7.04% and the average blood glucose decreased from 286 mg/dl to 158 mg/dl. There was also significant reduction of the hypoglycemia. Twenty percent of the patients were able to discontinue their Insulin and be treated only with oral antidiabetic medications plus/minus GLP1-RAG and have GMI less than 7%. We have showed that targeted TIR – above 70% which has been associated recently with diabetic micro and macrovascular complications in diabetic patients can be achieved not only in specialized endocrine clinics , but in Internal Medicine residency clinic and can be adopted by other Internal Medicine Residency programs in USA.

Case report about treatment of the patient with DM Type 2 on multiple injections of insulin who with the help of continuous glucose monitoring (CGM) improved and was controlled only on anti-diabetic pills and GLP1 - RAG

We would like to describe a patient who was treated for decompensated Diabetes Mellitus Type 2(DM type 2) with Multiple Injections of Insulin per day. His HbA1c while when he visited our clinic was above 14 %. He was self-monitoring his Blood sugar at home (SMBG) 4- times a day. He was treated only with Metformin ER in the past. The CGM was started in Internal Medicine Residency Clinic. The patient start sharing his CGM data with the clinic through Dexcom G6 CGM and compatible I phone. The patient was educated on diet, how to adjust his insulin at home based on written instruction material. Moreover, the patient was called at least once a week by the Medicine Clinic professional how to adjust his insulin and to counsel him about his diet and physical activity. The patient had scheduled appointment to the clinic at least once a month. After the glucotoxicity from the initial high blood sugar was managed by using the appropriate dose of insulin, the insulin dosages started to decrease in our patient. DM type 2 was well controlled with GMI less than 7% after starting the CGM. During the clinic visits, the morning fasting C- peptide of the patient was increased which we attribute due to his morbid obesity. These gave us the opportunity to start the patients on per oral antidiabetic medications and injectable GLP-1 receptor agonists (GLP-1-RAG). The patient’s DM type 2 control was maintained 3-6 months after stopping the insulin with Glucose management index (GMI) which approximates HbA1c less than 7%. Our experience with this patient showed that introduction of CGM instead of SMBG in the General Internal Medicine Residency Clinic can help patients with DM type 2 to improve their blood sugar control with Insulin and eventually stop the Insulin and start therapy with oral antidiabetic agents and or injectable GLP-1 -RAG. Also, we showed that this can be done safely in General Internal Medicine Residency clinic and not only in specialized clinics.

Abstract 14324: Improving Rates of Uncontrolled Atrial Fibrillation Through Obstructive Sleep Apnea Screening and Management: Preliminary Data From the OFIB Institutional Quality Initiative

Introduction: Untreated obstructive sleep apnea (OSA) is a major cause of uncontrolled atrial fibrillation (AF). It represents a high prevalence and incidence, as well as significant cause of mortality. Uncontrolled AF with recurrent emergency department (ED) visits and inpatient admissions poses a burden to patient quality of life and increased risk of cardiovascular events, in addition to healthcare costs. Hypothesis: We aim to reduce ED visits and hospitalizations for General Internal Medicine resident clinic patients with OSA and uncontrolled AF over the next year by 10%. Methods: We identified approximately 382 patients with inclusion criteria of age 18-70 years with a history of both AF and OSA without documented CPAP use. Interventions included a week long educational session to all residents starting March 2022, standardizing CPAP device ordering/monitoring, and patient education. A protocol for sleep study ordering and CPAP titration was implemented across clinics. The next phase is inpatient screening and referrals. Results: Prior to our intervention date, 14.7% of our study population presented with uncontrolled AF in the past year. Since our interventions, 2.4% have presented with uncontrolled AF. Conclusions: Our preliminary interventions have shown a numerical trend towards decreasing rates of uncontrolled AF in patients with OSA at our institution. Our interventions are ongoing with periodic evaluation of outcomes. Our findings support the need for a comprehensive approach targeting both providers and patients.

S1001 Pattern of Dermatological Screening for Patients With Inflammatory Bowel Disease in Primary Care Clinics: A Tertiary Care Center Experience

Introduction: Skin cancer is one of the most common forms of cancer in the United States of America. Incidence of melanoma in patients diagnosed with Inflammatory Bowel Disease (IBD) had a reported 37% increase in risk of melanoma when compared to the general population. It was seen that IBD was associated with an increased risk of melanoma, independent of biologic therapy. According to preventative care guidelines, patients with IBD should undergo screening for melanoma independent of the use of biologic therapy. Methods: A random sample of patients were collected from a database within a tertiary care center. Patients were selected by having a confirmed diagnosis of Ulcerative Colitis (UC) or Crohn’s Disease (CD) and having an established relationship with an internal medicine resident or non-teaching internist clinic. General demographics, referral to Dermatology and specific department from where the referral was placed were collected, along with relevant clinical information including current and previous therapies for IBD. Results: A total of 109 patients met inclusion criteria. Of the 60 patients who were cared for at the resident teaching clinic, 14 were referred to dermatology. Referrals were mostly made by a consulting gastroenterologist (11 out of 14 referrals). Only 8 out of the 14 patients that were referred successfully followed through with a dermatology clinic. Of the 49 patients who were cared for at the non-teaching internist clinic, 8 were referred to dermatology, all of whom were referred by the consulting gastroenterologist. Six out of the 8 patients followed up with dermatology. In general, CD patients were significantly more likely to be referred to dermatology compared to UC patients (p< 0.05). Patients who are currently or were previously on biologic therapy were significantly more likely to be referred to dermatology compared to those who have no history of biologic use (p< 0.05). Conclusion: Based on this descriptive study, overall screening for dermatological cancers in the IBD at-risk population is low despite their care being provided at a tertiary care center with access to consultants. This signifies gaps of care and low adherence to practice guidelines. The limitations need to be further studied as we speculate that the reason for low adherence could include deficiency in awareness of guidelines among primary care clinics, gastroenterologist reliance on primary care for general health maintenance, and insufficient patient education regarding the risks of skin cancer.

A Mixed-Methods Program Evaluation of a Self-directed Learning Panel Management Curriculum in an Internal Medicine Residency Clinic.

BackgroundPanel management (PM) curricula in internal medicine (IM) residency programs often assign performance measures which may not address the varied interests or needs of resident-learners.AimTo evaluate a self-directed learning (SDL)–based PM curriculum.SettingUniversity-based primary care practice in Burlington, Vermont.ParticipantsThirty-five internal medicine residents participated.Program DescriptionResidents completed a PM curriculum that integrated SDL, electronic health record (EHR)–driven performance feedback, mentorship, and autonomy to set learning and patient care goals.Program EvaluationPre/post-curricular surveys assessed EHR tool acceptability, weekly curricular surveys and post-curricular focus groups assessed resident perceptions and goals, and an interrupted time series analysis of care gap closure rates was used to compare the pre-intervention and intervention periods. Majority of residents (28–32 or 80–91%) completed the surveys and focus groups. Residents found the EHR tools acceptable and valued protected time, mentorship, and autonomy to set goals. A total of 13,313 patient visits were analyzed. There were no significant differences between rates between the pre-intervention period and the first intervention period (p=0.44).DiscussionA longitudinal PM curriculum that incorporated SDL and goal setting with EHR-driven performance feedback was well-received by residents, however did not significantly impact the rate of care gap closure.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-07507-3.

461-P: Prevalence and Patient Recognition of Distal Symmetric Neuropathy (DSP) in a Predominantly Low-Income U.S. Patient Population

Introduction: DSP is a disabling, painful condition among individuals with glucose intolerance. Patient awareness of DSP is essential to reduce the risk of infection and amputation. While DSP risk factors, such as glucose intolerance, are more common among Black people and those with low-income, these populations are underrepresented in DSP studies. The Flint Neuropathy Study is assessing glucose intolerance and DSP in a predominantly Black, low-income setting. Methods: Patients &amp;gt;40 years presenting to the Hurley Medical Center Outpatient Internal Medicine Residency Clinic in Flint, Michigan were enrolled. Demographics, clinical characteristics including medication use, anthropomorphic measurements, fasting lipids, fasting glucose, and Hemoglobin A1C were obtained. Glucose intolerance was defined using the 2021 ADA diagnosis and classification of diabetes mellitus criteria. DSP was defined using the Michigan Neuropathy Screening Instrument Questionnaire Index (MNSIQI) . Descriptive statistics were assessed using means and frequencies. Results: 81 participants (62% female, 57.5yrs (SD 8.7) . 67% Black, 53% Medicaid, 22% &amp;lt;high school education) have enrolled. 40 (49%) had a history of glucose intolerance, 4 (5%) denied a history of glucose intolerance despite a prior diagnosis, and 7 (9%) were diagnosed as glucose intolerant through study labs. (23%) reported a history of neuropathy. Mean MNSIQI score was 2.65 (SD 1.56) ; 46 (57%) had DSP. 28 (55%) participants with glucose intolerance had DSP. Among participants with a history of glucose intolerance and DSP, 16/21 (76%) were unaware they had DSP. 7/ (64%) participants who did not know they had glucose intolerance prior to participation had DSP. Conclusions: DSP is extremely common and underrecognized in this patient population with low incomes. Improving awareness of glucose intolerance and DSP is imperative to ensure appropriate foot care and reduce the risk of amputation. Disclosure A.Gagne: None. H.Marcus: None. T.Dawood: None. G.Bachuwa: None. M.Kvalsund: None. E.L.Feldman: None. L.Skolarus: None. B.C.Callaghan: None. M.Elafros: None. Funding NIH NINDS (5R25NS089450) ; NIH NCATS (UL1TR002240) ; NIH NIDDK (P30-DK-02926) ; NIH NIDDK (P30-DK089503)

Code status discussions in outpatient setting.

e13539 Background: In the face of the COVID 19 pandemic, goal-concordant care has been gaining further significance. Discussions about the care goals are best when they are exploratory, conversational, and longitudinal. Complex information processing is best done outside of a crisis. Ideally, these conversations should start with the primary care clinician who has a longitudinal clinical relationship with the patient. Methods: A quality initiative project was conducted at the Internal Medicine Residency Clinic located in Northwestern Medicine Woodstock Hospital. Review of order entry in electronic medical records and charts for code status was assessed for data gathering. Patients above the age of 65 years presenting for their annual physical visit were included in the study. Various interventions were done, including educating residents through didactic lectures, sending electronic reminders to the residents and formatting a template note including code status documentation. Pre and post-intervention data was gathered. Results: A total of 104 patients were in the pre-intervention group and 94 patients in the post-intervention group. Pre-intervention, code status was addressed in 33% of total patients interviewed during their annual physical visit. Post intervention, code status was addressed in 48% of the patients. Conclusions: This project was undertaken to increase awareness on a crucial aspect of the addressing code status in outpatient setting. Post intervention studies showed that addressing code status significantly increased. In order to fill the gap, we propose that addressing code status be a mandatory process or a reminder be generated in electronic health records.

Vitamin D Level Testing in an Urban Midwest Clinic: To Test or Not to Test?

Vitamin D deficiency (VDD) is significantly higher among urban populations in the U.S. Midwest, with African Americans being disproportionately affected. There is ongoing debate surrounding who and how often individuals should be screened for VDD. This study aimed to understand the prevalence of VDD, associated risk factors, and discrepancies in testing at an urban-based internal medicine residency clinic. Data were retrospectively collected on all adult patients seen by the clinic during 2018 and descriptive statistical analysis performed. Among 3976 total patients (mean age: 53 years), 18% (n=698) had vitamin D levels analyzed, with deficiency found in 71% of those tested. Mean age of the tested cohort was 59 years, and women (68%) and African Americans (72%) were found more likely to be tested. Women and patients with certain medical conditions were more likely to be tested (P<0.02 for all) but were not more likely to have VDD. Individuals with a diagnosis of chronic kidney disease were less likely to have VDD (P=0.002). Vitamin D levels typically showed improvement after retesting. A low testing rate could contribute to missed diagnoses. Overall, this study revealed that differences in rate of testing do not necessarily correlate to patients' demographical risk of VDD. Clinicians may benefit from a standardized vitamin D testing protocol.

QIM22-204: A Retrospective Analysis and Quality Improvement Project to Increase Breast Cancer Screening in Northwestern Medicine Hospital, Internal Medicine Residency Clinic

"QIM22-204: A Retrospective Analysis and Quality Improvement Project to Increase Breast Cancer Screening in Northwestern Medicine Hospital, Internal Medicine Residency Clinic" published on 31 Mar 2022 by National Comprehensive Cancer Network.