Large Academic Medical Center Research Articles

Emergency department imaging utilization post-transcatheter aortic valve replacement: single institution 7-year experience

PurposeThis study aims to highlight presentations, acute findings and imaging phenotypes of patients presenting to the emergency department (ED) within 30 days of a transcatheter aortic valve replacement (TAVR).MethodsA retrospective review of patients diagnosed with aortic valve disease who underwent a TAVR between Jan 2015 and Nov 2021 at a large academic medical center was completed. From an initial 1271 patients, 146 were included based on their presentation to the ED within 30 days post-TAVR procedure. Patient data, including ED presentation details and imaging results, were recorded and de-identified.ResultsOf the 146 post-TAVR patients, there were 168 ED visits within 30 days. The median time to ED after TAVR was 12 days. Respiratory symptoms were the most common complaint (27%). Neurological (23%) and cardiovascular symptoms (18%) followed. Cross-sectional imaging was conducted 250 times across visits, with an average of 1.7 scans per patient. CTs were most frequently used, followed by ultrasounds, especially echocardiograms and duplex extremity vasculature ultrasounds. 30.1% of patients had acute findings from imaging. Specific findings included heart failure (5.5%), access site complications (5.5%), pneumonia (5.5%), intracranial pathologies (3.4% for strokes and 0.7% for hematoma), and pleural effusion (3.4%). Echocardiograms and CTA chest were most associated with significant acute findings.ConclusionOur study highlights the vital role of early and accurate imaging in post-TAVR patients within 30 days post-procedure. As transcatheter approaches rise in popularity, emergency radiologists become instrumental in diagnosing common post-procedural presentations. Continued research is essential to devise post-discharge strategies to curtail readmissions and related costs. Proper imaging ensures prompt, effective care, enhancing overall patient outcomes.

Phenomewide Association Study of Health Outcomes Associated With the Genetic Correlates of 25 Hydroxyvitamin D Concentration and Vitamin D Binding Protein Concentration.

While it is known that vitamin D deficiency is associated with adverse bone outcomes, it remains unclear whether low vitamin D status may increase the risk of a wider range of health outcomes. We had the opportunity to explore the association between common genetic variants associated with both 25 hydroxyvitamin D (25OHD) and the vitamin D binding protein (DBP, encoded by the GC gene) with a comprehensive range of health disorders and laboratory tests in a large academic medical center. We used summary statistics for 25OHD and DBP to generate polygenic scores (PGS) for 66,482 participants with primarily European ancestry and 13,285 participants with primarily African ancestry from the Vanderbilt University Medical Center Biobank (BioVU). We examined the predictive properties of PGS25OHD, and two scores related to DBP concentration with respect to 1322 health-related phenotypes and 315 laboratory-measured phenotypes from electronic health records. In those with European ancestry: (a) the PGS25OHD and PGSDBP scores, and individual SNPs rs4588 and rs7041 were associated with both 25OHD concentration and 1,25 dihydroxyvitamin D concentrations; (b) higher PGS25OHD was associated with decreased concentrations of triglycerides and cholesterol, and reduced risks of vitamin D deficiency, disorders of lipid metabolism, and diabetes. In general, the findings for the African ancestry group were consistent with findings from the European ancestry analyses. Our study confirms the utility of PGS and two key variants within the GC gene (rs4588 and rs7041) to predict the risk of vitamin D deficiency in clinical settings and highlights the shared biology between vitamin D-related genetic pathways a range of health outcomes.

Ensuring safe and equitable discharge: a quality improvement initiative for individuals with hypertensive disorders of pregnancy

ObjectiveTo improve timely and equitable access to postpartum blood pressure (BP) monitoring in individuals with hypertensive disorders of pregnancy (HDP).MethodsA quality improvement initiative was implemented at a large academic medical...

Engagement in GI Behavioral Health Is Associated with Reduced Portal Messages, Phone Calls, and ED Visits.

Chronic digestive disorders are associated with increased costs for healthcare systems and often require provision of both urgent care and non-face-to-face (non-F2F) care, such as responding to patient messages. Numerous benefits of integrated gastroenterology (GI) behavioral health have been identified; however, it is unclear if integrated care impacts healthcare utilization, including urgent care and non-F2F contact. We sought to investigate the association between patient engagement with GI behavioral health and healthcare utilization. We performed a retrospective chart review study of adult patients who were referred for and completed at least one behavioral health appointment between January 1, 2019 and December 21, 2021 in the Gastroenterology and Hepatology department of a large academic medical center. Data on electronic medical record (EMR) messages, phone calls, and Emergency Department utilization were collected 6months before and 9months after patient engagement with GI behavioral health. 466 adult patients completed at least one behavioral health visit from 2019 to 2021. Overall, messages, phone calls, and ED visits all decreased significantly from the 6months before behavioral health treatment to 6months after (all P values < 0.001). Engagement with integrated GI behavioral health is associated with reduced non-F2F care and emergency department utilization in patients with chronic digestive disorders. Increasing access to GI behavioral health may result in reduced provider workload and healthcare system costs.

Perceived stress from social isolation or loneliness among clinical and non-clinical healthcare workers during COVID-19

BackgroundWorkplace social isolation and loneliness have been found to result in a decline in job satisfaction and an increase in burnout among working individuals. The COVID-19 pandemic exacerbated feelings of loneliness and social isolation among healthcare workers. The majority of research on healthcare worker experiences is conducted in siloes which does not reflect the shared experiences of interprofessional teams. The purpose of this study is to understand stress from social isolation or loneliness across the entire clinical and non-clinical healthcare team over the course of the pandemic.MethodsData was acquired using a cross-sectional survey distributed to healthcare workers once a year at a large academic medical center in the Southeastern United States during the COVID-19 pandemic (2020–2022). Information pertaining to job role, work location, and demographic factors was collected. Participants were also asked to assess individual well-being and resilience, in addition to reporting stress derived from various sources including job demands and social isolation or loneliness. Descriptive statistics and bivariate analyses were conducted to assess the association between stress from social isolation or loneliness and individual characteristics.ResultsStress from social isolation or loneliness was found to decrease over the survey period across all measured variables. Trainees and physician-scientists were found to report the highest rates of this stressor compared to other job roles, while Hospital-Based ICU and Non-ICU work locations reported the highest rates of loneliness and social isolation stress. Younger workers and individuals from marginalized gender and racial groups were at greater risk for stress from social isolation or loneliness.ConclusionsGiven the importance of social connections for well-being and job performance, organizations have a responsibility to create conditions and mechanisms to foster social connections. This includes establishing and reinforcing norms of behavior, and developing connection mechanisms, particularly for groups at high risk of loneliness and social isolation.

The COVID-19 Tracheostomy Experience at a Large Academic Medical Center in New York during the First Year.

Background: New York City was the epicenter of the initial surge of the COVID-19 pandemic in the United States. Tracheostomy is a critical procedure in the care of patients with COVID-19. We hypothesized that early tracheostomy would decrease the length of time on sedation, time on mechanical ventilation, intensive care unit length of stay, and mortality. Methods: A retrospective analysis of outcomes for all patients with COVID-19 who underwent tracheostomy during the first year of the COVID-19 pandemic at the Mount Sinai Hospital in New York City, New York. All adult intensive care units at the Mount Sinai Hospital, New York. Patients/subjects: 888 patients admitted to intensive care with COVID-19. Results: All patients admitted to the intensive care unit with COVID-19 (888) from 1 March 2020 to 1 March 2021 were analyzed and separated further into those intubated (544) and those requiring tracheostomy (177). Of those receiving tracheostomy, outcomes were analyzed for early (≤12 days) or late (>12 days) tracheostomy. Demographics, medical history, laboratory values, type of oxygen and ventilatory support, and clinical outcomes were recorded and analyzed. Conclusions: Early tracheostomy resulted in reduced duration of mechanical ventilation, reduced hospital length of stay, and reduced intensive care unit length of stay in patients admitted to the intensive care unit with COVID-19. There was no effect on overall mortality.

Incidence and Outcomes of Posterior Circulation Involvement in Moyamoya Disease.

Moyamoya disease (MMD) is a progressive, occlusive disease of the internal carotid arteries and their proximal branches, with the subsequent development of an abnormal vascular network that is rupture-prone. Steno-occlusive changes in the posterior cerebral arteries (PCAs) may contribute to worsened outcomes in patients with MMD; however, there is little information on the incidence and natural history of posterior circulation MMD (PCMMD). We describe clinical PCMMD characteristics in a large cohort of patients with MMD. We retrospectively reviewed patients with MMD treated between 1991 and 2019 at a large academic medical center. Demographics, perioperative outcomes, and radiological phenotypes were recorded for 770 patients. PCA disease was graded as either 0 (no disease), 1 (mild), 2 (moderate), or 3 (severe or occluded) based on cerebral angiography. Patients with angiographically confirmed MMD diagnosis with at least 6 months follow-up and completion of revascularization surgery were included; patients with intracranial atherosclerosis, intracranial dissection, vasculitis, and undefined inflammatory processes were excluded. The presence of stenosis/occlusion was graded radiographically to assess for disease progression and the prevalence of risk factors related to reduced progression-free survival. In all, 686 patients met the inclusion criteria, with PCA disease identified in 282 (41.1%) patients. Of those 282 patients with PCMMD, disease severity ranged from 99 (35.1%) with mild, 72 (25.5%) with moderate, and 111 (39.4%) with severe. The total number of postoperative complications was significantly associated with PCMMD severity (P=0.0067). Additionally, PCMMD severity correlated with worse postoperative modified Rankin Scale scores (P<0.0001). At a mean follow-up of 6.0±3.9 (range, 0.1-25.0) years, a total of 60 (12.6%) patients showed new/worsening PCMMD. The overall postoperative, progression-free survival in patients with PCMMD was 95.4% at 1 year, 82.4% at 3 years, 68.8% at 5 years, and 28.3% at 10 years, with prognostic factors for progression including preoperative PCMMD status, history of tobacco use, and hypertension (P<0.0001, P<0.001, and P<0.0001, respectively). PCA disease involvement in MMD is associated with higher rates of ischemic perioperative complications and worsened functional outcomes, likely due to reduced collateral flow. Ten-year progression of PCA disease is highly likely and should be monitored throughout follow-up; future studies will assess the impact of PCA disease progression on long-term outcomes.

Analysis of patient safety event report categories at one large academic hospital.

Given the persistent safety incidents in operating rooms (ORs) nationwide (approx. 4,000 preventable harmful surgical errors per year), there is a need to better analyze and understand reported patient safety events. This study describes the results of applying the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) supported by the Teamwork Evaluation of Non-Technical Skills (TENTS) instrument to analyze patient safety event reports at one large academic medical center. Results suggest that suboptimal behaviors stemming from poor communication, lack of situation monitoring, and inappropriate task prioritization and execution were implicated in most reported events. Our proposed methodology offers an effective way of programmatically sorting and prioritizing patient safety improvement efforts.

130 Developing a Conceptual Data Model for Nursing Workload

OBJECTIVES/GOALS: Nurses are leaving the profession at an alarming rate due to increased workload and burnout.#_msocom_1 Computational models that are reliable and reproducible are needed to quantitatively examine nursing workload and estimate potential effect of interventions. This project developed a logical data model to represent nursing EHR interactions. METHODS/STUDY POPULATION: With nursing EHR interactions as a starting point, we expand upon literature that examined the EHR workload of physicians. We conducted an exploratory analysis of nursing EHR audit log data at a large academic medical center, and explored components of nursing workload that can be extracted from other health system data. Using concepts derived from the studying temporal biomedical data patterns, we formulated a data structure that describes nurse EHR interactions, nurse intrinsic and situational characteristics, and nurse outcomes of interest in a scalable and extensible manner. RESULTS/ANTICIPATED RESULTS: Temporal machine learning models are grounded in the concept of vectors. We developed a logical data model that describes tasks performed by nurses (NTask), nurse types (NType), and nursing outcomes (NOutcome). For each nurse (k), we define a function &lt;NTask (k, i)&gt;, i=1 to N as a vector of dimension N, where N is the number of time periods in the study. The i component corresponds to the activity that the nurse is doing. The model will allow the quantitative classification of activity patterns for any finite number of nurses for an arbitrary set of tasks and for time at any specified resolution. The expected outcome is a set of vectors that can then be utilized to quantitatively model nurse activity trajectories and other patterns of nurse EHR interactions. DISCUSSION/SIGNIFICANCE: By instantiating the logical data model, we will demonstrate how nurse EHR interactions can be studied using temporal unsupervised learning and state-of-the-art artificial intelligence methods. We plan to simulate the potential impact of workload interventions and predict risk for nurse burnout.

Critical Care Alarm Fatigue and Monitor Customization: Alarm Frequencies and Context Factors.

Alarm fatigue among nurses working in the intensive care unit has garnered considerable attention as a national patient safety priority. A viable solution for reducing the frequency of alarms and unnecessary noise is intensive care unit alarm monitor customization. A 24-bed cardiovascular and thoracic surgery intensive care unit in a large academic medical center identified a high rate of alarms and associated noise as a problem contributing to nurse alarm fatigue. An alarm monitor quality improvement project used both alarm frequency and nurse surveys before and after implementation to determine the effectiveness of interventions. Multimodal interventions included nurse training sessions, informational flyers, organizational policies, and an alarm monitor training video. Unexpected results inspired an extensive investigation and secondary analysis, which included examining the data-capturing capabilities of the alarm monitors and the impact of context factors. Alarm frequencies unexpectedly increased after the intervention. The software data-capturing features of the alarm monitors for determining frequency did not accurately measure nurse interactions with monitors. Measured increases in patient census, nurse staffing, and data input from medical devices from before to after the intervention substantially affected project results. Alarm frequencies proved an unreliable measure of nurse skills and practices in alarm customization. Documented changes in context factors provided strong anecdotal evidence of changed circumstances that clarified project results and underscored the critical importance of contemporaneous collection of context data. Designs and methods used in quality improvement projects must include reliable outcome measures to achieve meaningful results.

Food Insecurity Prevalence and Risk Factors at a Large Academic Medical Center in Michigan

Health care systems are increasingly adopting methods to screen for and integrate food insecurity and other social risk factors into electronic health records. However, there remain knowledge gaps regarding the cumulative burden of food insecurity in large clinical settings, which patients are most at risk, and the extent to which patients are interested in social assistance through their health care system. To evaluate the 5-year prevalence and associated risk factors of food insecurity among adult primary care patients, and to examine factors associated with patients' interest in social assistance among those with food insecurity. This cross-sectional analysis of a retrospective cohort study took place at a tertiary care academic medical center (encompassing 20 primary care clinics) in Michigan. Participants included adult patients who completed screening for social risk factors between August 1, 2017, and August 1, 2022. Data analysis was performed from November 2022 to June 2023. Food insecurity was assessed using the Hunger Vital Sign. The primary outcome was patients' interest in social assistance, and associated factors were examined using multivariate logistic regression models, adjusting for patients' demographic and health characteristics. Over the 5-year period, 106 087 adult primary care patients (mean [SD] age, 52.9 [17.9] years; 61 343 women [57.8%]) completed the standardized social risk factors questionnaire and were included in the analysis. The overall prevalence of food insecurity was 4.2% (4498 patients), with monthly trends ranging from 1.5% (70 positive screens) in August 2018 to 5.0% (193 positive screens) in June 2022. Food insecurity was significantly higher among patients who were younger, female, non-Hispanic Black or Hispanic, unmarried or unpartnered, and with public health insurance. Food insecurity was significantly associated with a higher cumulative burden of social needs, including social isolation, medical care insecurity, medication nonadherence, housing instability, and lack of transportation. Only 20.6% of patients with food insecurity (927 patients) expressed interest in social assistance. Factors associated with interest in social assistance including being non-Hispanic Black, unmarried or unpartnered, a current smoker, and having a higher burden of other social needs. In this retrospective cohort study, the overall prevalence of food insecurity was 4.2%, of whom approximately 1 in 5 patients with food insecurity expressed interest in assistance. This study highlights ongoing challenges in ensuring all patients complete routine social determinants of health screening and gaps in patients' interest in assistance for food insecurity and other social needs through their health care system.

Patient-perceived understanding of home-going medication with transitions of care services at a pediatric institution

BackgroundTransitions of care (TOC) is the coordination and continuity of health care as a patient transfers between different settings. This can include a wide range of services, such as medication reconciliation, patient counseling, bedside delivery of medications, and others that meet individual patient needs. In the pediatric population, patients are at increased risk of potential medication errors and subsequent harm owing to reduced patient and caregiver health literacy, limited dosage form availability, and errors in medication administration. The use of TOC services at the time of hospital discharge in this population has the potential to make a positive impact on patient safety and the treatment of medical conditions. ObjectivesThe primary objective of this study was to determine whether patient-perceived understanding of home-going medications was greater in patients and/or caregivers who received medication bedside delivery and education from a pharmacy-led TOC service at a large pediatric academic medical center. The secondary objective was to determine whether the primary practice area of the pharmacist providing medication education led to changes in understanding of home-going medication(s). MethodsUsing institution-wide, patient satisfaction surveys from January 1, 2021, to December 31, 2021, patient and caregiver responses were queried for 2 questions about home-going medications, relating to the understanding of administration and the potential adverse effects. Patients were divided into 2 groups depending on TOC services received, as documented in the electronic medical record (EMR). Survey responses for each of the 2 questions were categorized as top-box percentage by study group. Hypothesis testing between study groups for the primary and secondary outcomes were conducted using chi-squared tests at an alpha of 0.05. Statistical analyses were conducted using SAS version 9.4. ResultsOf the 1159 patients included in the study, 441 received TOC services, deemed the intervention group, and 718 did not receive TOC services, deemed the control group. When the intervention and control group were asked about understanding of medication administration, 96.37% versus 93.18% of patients (P = 0.007) gave the most favorable response of “yes, definitely,” respectively. Furthermore, 78.51% versus 77.44% of patients (P = 0.053) gave the most favorable response when asked about understanding potential medication adverse effects, respectively. ConclusionPatients receiving TOC services by a member of the pharmacy team had a greater score for understanding of both medication administration and adverse effects. Furthermore, this greater score was consistent among the education provided by the inpatient and outpatient pharmacist.

Abstract 4797: Impact of COVID-19 pandemic on breast cancer screening and diagnosis stage in a large midwestern United States academic medical center

Abstract Background: Access to breast cancer screening mammogram services decreased in association with the COVID-19 pandemic. There is also evidence for increases in late-stage breast cancer diagnoses. Our objectives were to determine: 1) the COVID-19-affected period on mammogram screening, 2) the proportion of pandemic-associated missed or delayed mammogram screening visits overall and by race/ethnicity and age group, and 3) evidence for pandemic-associated shifts in diagnosis stage. Methods: Screening mammogram encounter data between 1-1-2019 and 12-31-2022 were extracted from EPIC for females ≥ 40 years old for the screening analysis. We used Bayesian state space models to describe weekly screening mammogram counts, modeling an interruption that phased in and out from 3-1-2020 to 9-1-2020. We used the posterior predictive distribution to simulate differences between a predicted, uninterrupted process and the observed screening mammogram counts. Breast cancer diagnoses at ≥ 21 years from the tumor registry between 12-1-2018 and 11-30-2021 were included in the stage analysis. We used logistic regression models to estimate late-stage diagnosis odds comparing matched three-month periods during the pandemic to before the pandemic. Results: A total of 319,492 encounters among 146,644 women were included. Model-estimated screening mammograms dropped by 98.8% (95% CI 95.1 to 100) between 3-15-2020 and 5-24-2020, returning to pre-pandemic levels or higher after this period. Drops in screening mammogram encounters did not vary significantly by race/ethnicity or age group (p &amp;gt; .75). Among 4,669 breast cancer diagnoses, we found no significant differences in the odds of late-stage diagnoses for any period vs. the same period before the pandemic (Table). Conclusions: These data suggest a short-term pandemic effect on screening mammograms. Evidence for increases in late-stage diagnoses is limited. These results may inform future pandemic planning. OR (95% CI) Period comparison 1.19 (0.74 to 1.91) 3/2020 to 5/2020 vs. 3/2019 to 5/2019 1.05 (0.69 to 1.60) 6/2020 to 8/2020 vs. 6/2019 to 8/2019 1.14 (0.73 to 1.78) 9/2020 to 11/2020 vs. 9/2019 to 11/2019 0.92 (0.60 to 1.41) 12/2020 to 2/2021 vs. 12/2019 to 2/2020 1.08 (0.71 to 1.65) 3/2021 to 5/2021 vs. 3/2019 to 5/2019 0.89 (0.59 to 1.33) 6/2021 to 8/2021 vs. 6/2019 to 8/2019 1.31 (0.84 to 2.04) 9/2021 to 11/2021 vs. 9/2019 to 11/2019 Citation Format: Kimberly J. Johnson, RJ Waken, Caitlin P. O'Connell, Derek Brown. Impact of COVID-19 pandemic on breast cancer screening and diagnosis stage in a large midwestern United States academic medical center [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4797.

Abstract 6467: Causal personalized treatment estimation framework using real-world electronic health record (EHR) data to inform cancer care decisions

Abstract Background: The average treatment effects (ATEs) from randomized controlled trials often do not generalize across populations, or they are not sufficiently personalized to capture the benefits and risks to individual patients. Real-world data aids in validating and extending trial results, but can introduce biases that invalidate the causal interpretation. Here, we propose a robust statistical framework, which uses real-world EHR data to evaluate the efficacy of cancer treatments at both population and individual levels. We demonstrate the ability of our framework to deliver personalized insights in metastatic prostate cancer treatments. Methods: We assembled a retrospective cohort of metastatic prostate cancer patients from a large academic medical center. We gathered demographic, comorbidity, cancer treatment, and outcome data from the EHR or natural language processing of clinician narratives, and social determinants of health from Census data. We used doubly robust machine learning with bootstrap standard errors to compute the ATE and personalized treatment estimates (PTEs), comparing the impact of ADT (androgen depravation therapy) + chemotherapy (ACT) and ADT + combination anti-androgen therapy (ACAT) on percentage reduction in PSA levels in metastatic prostate cancer. Results: The baseline characteristics of our cohort are summarized in Table 1a. Our approach found that ACAT reduces PSA levels significantly more than ACT, and captured the heterogeneity in treatment effects across individuals (Table 1b). Through simulation studies, we demonstrated that any reasonable bias from unobserved confounding or missing information was small compared to the estimated treatment effects and their standard errors. Conclusion: We presented a doubly robust framework and demonstrated its utility in analyzing real-world data, enabling us to uncover the diversity in treatment responses among individuals with metastatic prostate cancer. Results summary a. Baseline demographic characteristics. ADT + chemotherapy N = 302 ADT + combination therapy N = 114 Treatments Any ADT + Docetaxel or Cabazitaxel Any ADT + Abiraterone or apalutamide or Enzalutamide Age Mean (SD) 69.3 (8.76) 66.7 (8.17) Median [Min, Max] 69.0 [47.0, 94.0] 66.5 [46.0, 86.0] Race Asian 8 (2.6%) 2 (1.8%) Black or African American 48 (15.9%) 7 (6.1%) White or Caucasian 224 (74.2%) 99 (86.8%) Other 22 (7.3%) 6 (5.3%) Max PSA treatment start (ng/mL) Mean (SD) 34.9 (98.5) 83.3 (448) b. Treatment effects estimation ATE (95% CI) 32.0% [24.6%, 40.8%] PTEs: 25th and 75th percentiles 29.0%, 34.3% Citation Format: Sumana Srivatsa, David Walsh, Mayada Aljehani, Jason Weinreb, Nathan Becker, Benjamin H. Ellis, Renee George, Xingyao Chen, Naim Matasci, Reva Basho, Mitchell E. Gross, Christine L. Swisher. Causal personalized treatment estimation framework using real-world electronic health record (EHR) data to inform cancer care decisions [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6467.

Impact of pharmacist-driven referral to increase specialty pharmacy prescription capture.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. To assess the impact of a clinical pharmacy specialist (CPS) embedded within a rheumatology clinic at a large academic medical center on the prescription capture rate at the health-system specialty pharmacy. Initially low prescription capture rates for the health-system specialty pharmacy led to the integration of a CPS in the main campus rheumatology clinic. Benchmarking was completed by assessing the prior prescription capture rate using electronic medical record analytics and Loopback Analytics (a database of prescription capture for the health-system specialty pharmacy). The existing workflows for both the rheumatology clinic and specialty pharmacy were observed with regard to biologic medication ordering and processing. Strategies for an updated workflow for biologic ordering with the incorporation of an embedded CPS in the rheumatology clinic were designed. This new workflow was established with key stakeholders, including the CPS, rheumatology providers, clinic staff, and pharmacy technicians. Once the workflow was established, all parties were educated and updated, including rheumatology providers, nursing staff, and specialty pharmacy staff. Prescription capture rate was monitored on a monthly basis. Prescription capture increased from 13.16% before pharmacist implementation (October to December 2021) to 35.42% after pharmacist implementation (October to December 2022) (P = 0.019). During the same periods, the revenue generated increased from $43,222.89 to $135,198.70 (P = 0.224) and the proportion of prescriptions initially sent to the health-system specialty pharmacy compared to other specialty pharmacies increased from 37% to 79% (P < 0.001) with CPS implementation. Expansion and implementation of pharmacy services by integrating a CPS in a rheumatology ambulatory clinic increased prescription capture and pharmacy revenue while optimizing patient care. We hope to expand similar CPS services to other clinics within the health system.

Patient and Parent Experience with Pediatric Care Providers During the COVID-19 Pandemic: A Comparison of Press Ganey Survey Scores for Telehealth and In-Person Encounters.

Background: Prior research suggests that pediatric patients and their parents/guardians are generally satisfied with care provided through telehealth. The objective of this study was to compare Press Ganey provider-oriented experience survey scores between telehealth and in-person patient encounters among a variety of pediatric clinical specialties at a large academic medical center. Methods: We analyzed Press Ganey survey data from pediatric patient encounters from UC Davis Health, collected between August 2020 and February 2022. Survey results analyzed respondents' satisfaction with care providers, including satisfaction with explanations given, discussions led, concern showed, and inclusion by providers; and the likelihood the survey respondent would recommend the provider to others. We used logistic regression models, which included case mix variables and clinical specialty to compare the odds of scoring the highest possible survey response ("top box" score). Results: Of the 6,093 survey responses that met inclusion criteria, 1,157 (19%) were associated with telehealth encounters and 4,936 (81%) were associated with in-person encounters. We found no significant difference in the odds of respondents giving a top box score to rate their satisfaction with their care provider between telehealth and in-person encounters. When respondents were asked whether they would recommend the care provider to others, the odds of giving a top box score following a telehealth encounter relative to an in-person encounter was 1.22 (95% confidence interval [0.97-1.52]; p-value = 0.09). Discussion: We found that survey respondents' experiences with their care provider are high and comparable for telehealth and in-person encounters in a pediatric population.

Assessment of risk factors for Neonatal Abstinence Syndrome (NAS) using a Standardized Surveillance Case Definition in Clark County, NV

Background: Neonatal Abstinence Syndrome (NAS) is a withdrawal syndrome in neonates that can occur due to drug exposure during pregnancy. This study had two objectives: (1) Assess the implementation of the Council of State and Territorial Epidemiologists (CSTE) Tier 2 case definition for NAS surveillance in Clark County, Nevada and (2) Identify risk factors for NAS. Subjects and Method: This study utilized hospital discharge data. Claim-based records from non-federal acute care hospitals located in Clark County during 2016-2022 were analyzed. All newborn inpatient discharge records from January 1, 2016 to September 30, 2022 in Clark County, Nevada were selected. ICD-10-CM codes were utilized based on the CSTE Tier 2 case definition. Any neonate record that met the case definition, including any record with the diagnosis code P96.1, was considered a NAS confirmed case. Codes for suspect cases, maternal history of substance use, unspecified maternal medication, and transmitted noxious-substances were also assessed. A multiple logistic regression model using backward stepwise selection was developed to find risk factors related to NAS-confirmed births. Results: In Clark County, Nevada, the NAS incidence rate from January 2016 to September 2022 was 7.4 per 1,000 births. In 2022 alone, the rate of NAS was 8.9 per 1,000 births. Estimated rates of NAS were highest among neonates who were White at 13 per 1,000 births. Hospital J, the largest academic medical center in Southern Nevada, had the highest NAS confirmed case rate at 11.3 per 1000 newborn hospitalizations. Results from the multiple logistic regression model showed the odds of being born with NAS among neonates who identified as White were 5.0 (OR=5.17; 95% CI= 4.29 to 6.24; p &lt;0.001) times more likely to have NAS compared to the Hispanic group. Conclusion: Given that 2022 had the highest rate of confirmed NAS cases there is a need to collect substance and diagnosis-specific data about prenatal substance use to identify unmet service care and disparities. Keywords: neonatal abstinence syndrome, opioids, substance dependence. Correspondence: Cassius Lockett. Southern Nevada Health District. 280 S Decatur Blvd, Las Vegas, NV 89107. lockett@snhd.org. 702-759-1691.

Abstract P355: Identifying Barriers and Facilitators to Home Blood Pressure Monitoring Among Pregnant Women With Hypertension Disorders of Pregnancy-A Qualitative Approach

Background: Hypertensive disorders of pregnancy (HDP) are a major cause of maternal morbidity and mortality in the US, contributing to over 30% of maternal deaths. Improved diagnosis, treatment, and outcomes of HDP may be achieved through home blood pressure monitoring (HBPM). However, there are many challenges to effective HBPM during pregnancy. We conducted this qualitative study to explore barriers and facilitators to HBPM. Methods: Pregnant or postpartum (within 3 years) women, aged 18-50 years with either hypertension (HTN) or preeclampsia, were recruited from a large academic medical center to participate in virtual focus group meetings (N = 5 groups, 2-6 participants/group). The discussions centered on experiences with HDP, HTN management, and HBPM. Focus group meeting audio recordings were transcribed, and thematic analysis was performed (by MD and RR). Meetings (between MD, RR, and LK) resolved any discrepancies, focusing on responses discussing barriers and facilitators to HBPM. Results: Of the 20 participants, mean age was 33.8 (SD 5.9) years, 35% were Hispanic, and 35% were Black. Facilitators to HBPM shared by participants included external support (e.g., partner, healthcare), free access/decision support, comfort in knowing BP readings outside healthcare setting, and technology support. Barriers to HBPM shared by participants were lack of knowledge/uncertainty about the equipment and process (e.g., technique, monitors, and logging), cost/access, traditional pathways for monitoring, and declining motivation. Conclusion: In this study involving women with HDP from diverse backgrounds, we identified several facilitators and barriers to HBPM. Many of the barriers can be overcome through patient education, technology support, reinforcement, and better access to validated monitors. Given the importance of HBPM in improving outcomes for pregnant women with HDP, it is important for healthcare providers and policy makers to work to reduce barriers and amplify facilitators to HBPM for better adoption.

Leveraging large language models for generating responses to patient messages-a subjective analysis.

This study aimed to develop and assess the performance of fine-tuned large language models for generating responses to patient messages sent via an electronic health record patient portal. Utilizing a dataset of messages and responses extracted from the patient portal at a large academic medical center, we developed a model (CLAIR-Short) based on a pre-trained large language model (LLaMA-65B). In addition, we used the OpenAI API to update physician responses from an open-source dataset into a format with informative paragraphs that offered patient education while emphasizing empathy and professionalism. By combining with this dataset, we further fine-tuned our model (CLAIR-Long). To evaluate fine-tuned models, we used 10 representative patient portal questions in primary care to generate responses. We asked primary care physicians to review generated responses from our models and ChatGPT and rated them for empathy, responsiveness, accuracy, and usefulness. The dataset consisted of 499794 pairs of patient messages and corresponding responses from the patient portal, with 5000 patient messages and ChatGPT-updated responses from an online platform. Four primary care physicians participated in the survey. CLAIR-Short exhibited the ability to generate concise responses similar to provider's responses. CLAIR-Long responses provided increased patient educational content compared to CLAIR-Short and were rated similarly to ChatGPT's responses, receiving positive evaluations for responsiveness, empathy, and accuracy, while receiving a neutral rating for usefulness. This subjective analysis suggests that leveraging large language models to generate responses to patient messages demonstrates significant potential in facilitating communication between patients and healthcare providers.

Assessment of 2% vs 3% Peripheral Hypertonic Sodium Chloride Administration and Its Impact on Safe and Timely Treatment

Abstract Objectives Evaluate if peripheral administration of 3% hypertonic saline (HTS) provides timely treatment with a rate of infusion-related adverse events at or below what is reported in the literature. Methods This was a single-center, retrospective study conducted in a large academic medical center in New York City. Eligible patients were inpatients receiving either 2% or 3% HTS for severe hyponatremia, elevated intracranial pressure, or cerebral edema. The primary outcome was incidence of infusion-related adverse events. Secondary endpoints included achievement of appropriate sodium correction, incidence of over-correction, length of time from ordering to medication administration, and incidence of osmotic demyelination syndrome (ODS). Main Results A total of 199 patients were included in analysis (85 in the 3% HTS group and 114 in the 2% HTS group). No difference was found between groups for rate of infusion related adverse events or incidence of sodium overcorrection groups (0 vs 1 [0.9%]; p = 0.39). Significantly more patients in the 3% HTS group received intermittent administration (p &lt; 0.001), whereas more patients in the 2% HTS group received a continuous infusion (p &lt; 0.001). There were no reports of ODS in either group. No difference in length of time to administration was found between groups. Conclusion Our study, one of the largest to evaluate peripheral administration of 3% HTS, found that it is not associated with an increase in infusion related adverse events or sodium overcorrection versus 2% HTS. Peripheral administration should be recommended to provide timely treatment for patients requiring HTS.