Large Integrated Health System Research Articles

Implementing Behavioral Health Social Workers' Increased Mental Health Care Among Older Adults

Depression is underdiagnosed and undertreated among older adults. Health systems can screen patients to identify depression, but systemic linkages to treatment are required to ensure care. We used a retrospective stepped-wedge study to identify the impact of implementing behavioral health social workers (BHSWs) on receipt of treatment after a new depression diagnosis. We included adults over 65 years of age with a primary care visit between 2016 and 2019 at a large integrated health system. We excluded patients who were diagnosed with or treated for depression in 2015. Patients were categorized into control (diagnosed before implementation) and intervention (diagnosed after implementation) groups. From our electronic health record, we collected prescriptions for pharmacotherapy and behavioral health visits. Patients were considered treated if they received pharmacotherapy or had a behavioral health visit within 30 days of diagnosis. We used multilevel logistic regression models to identify the association between implementation period (pre versus post) and treatment, adjusted for demographic variables and clustering within site. Our population included 4,475 people. The percent of patients that received treatment increased from 47% to 54% after implementation and the percent of patients with ≥1 behavioral health visit within 30 days increased from 3% to 8% (p<0.01, respectively). The adjusted odds ratio of receiving treatment (AOR: 4.13, 95%CI: 2.84-6.01) and having a behavioral health visit (AOR: 3.12, 95%CI: 2.31-4.24) was significantly higher in the post-implementation period. In conclusion, implementation of BHSWs was associated with increased treatment for older patients with depression.

The use of a pediatric appendicitis pathway in a large integrated health system reduced computed tomography imaging in the ED.

Appendicitis is the most common cause of an acute surgical abdomen in children. Diagnosis is often challenging as few pediatric patients present with classic symptoms. Clinicians are thus dependent on imaging to reach an accurate diagnosis. Although computerized tomography (CT) has high sensitivity and specificity, it has the disadvantage of imparting ionizing radiation. Ultrasound (US) is readily available and has comparable accuracy to CT when performed by experienced sonographers. We sought to examine the impact of a system-wide process improvement plan on CT use and other metrics in pediatric patients who presented to the Emergency Department (ED) with suspected appendicitis. This is a retrospective study of the impact of a Pediatric Appendicitis Pathway (PAP) within a large integrated hospital system with 12 EDs including 3 designated hub EDs. Patients were placed in an initial risk category utilizing the Pediatric Appendicitis Score (PAS), and received US of the appendix at a hub ED if indicated by the PAS. Patients presenting to community EDs who required US appendix were transferred to hub EDs for imaging. Patients presenting in the 6-month pre-implementation period were compared to patients presenting in a 14-month post-implementation period on CT and US utilization, negative and missed appendectomy rates, and ED length of stay (LOS). 1874 patients (401 pre-PAP and 1473 post-PAP) were included in the study. At the hub EDs the rate of CT imaging for suspected appendicitis was reduced from 31% to 17% with a resultant increase in US utilization from 83% (333/401) to 90% (1331/1473) (p < 0.001). At community general EDs (404 pre-PAP and 449 post-PAP), the rate of CT was decreased from 45% (181/404) to 32%(144/449) (p < 0.001)) There was no significant change in the negative appendectomy rate pre-PAP (1/59 = 1.7%) and post-PAP (4/168 = 2.4%) (p = 0.99) at the hub EDs. There were no missed appendicitis cases after PAP implementation compared to 1 case in the pre-PAP period. Overall LOS was similar pre and post-PAP, however LOS was longer in patients that required transfer from community general EDs to hub EDs (median 264 vs 342 min, p < 0.001). A PAP that stratified patients into risk groups using the PAS and encouraged the use of US as a first line imaging modality, reduced the number of CT performed in a large integrated health system without significant changes to clinical outcomes. Furthermore, transferring select patients for an US as opposed to obtaining an initial CT in community general EDs was feasible and reduced CT use in the pediatric population.

Spectrum of Advanced Colorectal Neoplasia and Anticipated Yield of Average-Risk Screening in Veterans Under Age 50

The incidence of early onset colorectal cancer, or colorectal cancer (CRC) diagnosed before age 50, is increasing.1 In response, multiple societal guidelines in the United States now recommend initiating CRC screening at age 45 in average-risk individuals (ie, those without high-risk clinical characteristics, such as bleeding, or iron deficiency anemia), inflammatory bowel disease, or family history of colorectal neoplasia.2 The Veterans Health Administration (VHA) is the largest integrated health system in the United States and is contending with how best to expand CRC screening access to this younger population in the setting of limited colonoscopy resources. Understanding the rate and anatomic location of colorectal neoplasia in Veterans younger than age 50 can inform the expected yield of different screening modalities. Prior work has shown that individuals undergoing colonoscopy for low-risk diagnostic indications have equivalent risk of colorectal neoplasia as those undergoing average-risk screening.3 This study and a recent meta-analysis4 reported that 3.6% (95% confidence interval, 1.9%-6.7%) to 3.7% (95% confidence interval, 3.0%-4.7%) of average-risk individuals age 45-49 have advanced colorectal neoplasia (ACN), defined as an advanced polyp or carcinoma; however, data specific to the VHA population are lacking.

Treatment and Follow-up Care Associated With Patient-Scheduled Primary Care Telemedicine and In-Person Visits in a Large Integrated Health System

Telemedicine visits can offer patients convenient access to a clinician, but it is unclear whether treatment differs from that with in-person visits or how often patients require in-person follow-up. To examine whether physician prescribing and orders differ between telemedicine and office visits, whether physicians conducting telemedicine visits are more likely to require in-person follow-up, and whether telemedicine visits are associated with more health events. This cohort study included all patients who scheduled primary care appointments through the patient portal of a large integrated health care delivery system newly implementing patient-scheduled video telemedicine visits from January 2016 to May 2018. Adjusted rates of any medication prescribed or laboratory tests or imaging ordered and rates of follow-up health care utilization (in-person visits, emergency department visits, and hospitalizations) within 7 days after the index visit, stratified by index primary care visit type, were generated using multivariable adjustment for patient, access, and clinical characteristics. This study included 1 131 722 patients (611 821 [54%] female; mean [SD] age, 43 [22] years) with 2 178 440 total appointments (307 888 [14%] telemedicine), of which 13.5% were for patients younger than 18 years, 22.2% were for patients 65 years or older, and 54.9% were for female patients. After adjustment, 38.6% (95% CI, 38.0%-39.3%) of video visits, 34.7% (95% CI, 34.5%-34.9%) of telephone visits, and 51.9% (95% CI, 51.8%-52.0%) of office visits had any medication prescribed; laboratory tests or imaging were ordered for 29.2% (95% CI, 28.5%-29.8%) of video visits, 27.3% (95% CI, 27.1%-27.5%) of telephone visits, and 59.3% (95% CI, 59.3%-59.4%) of clinic visits. After adjustment, follow-up visits within 7 days occurred after 25.4% (95% CI, 24.7%-26.0%) of video visits, 26.0% (95% CI, 25.9%-26.2%) of telephone visits, and 24.5% (95% CI, 24.5%-24.6%) of office visits. Adjusted emergency department visits and rates of hospitalizations were not statistically significantly different by primary care index visit type. In this cohort study of patient self-scheduled primary care telemedicine visits within ongoing patient-physician relationships, prescribing and orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher follow-up office visits for telemedicine but no difference in health events (emergency department visits or hospitalizations). Video or telephone visits may be a convenient and efficient way to access primary care and address patient needs.

Association of Sleep-Related Hypoxia With Risk of COVID-19 Hospitalizations and Mortality in a Large Integrated Health System

The influence of sleep-disordered breathing (SDB) and sleep-related hypoxemia in SARS-CoV-2 viral infection and COVID-19 outcomes remains unknown. Controversy exists regarding whether to continue treatment for SDB with positive airway pressure given concern for aerosolization with limited data to inform professional society recommendations. To investigate the association of SDB (identified via polysomnogram) and sleep-related hypoxia with (1) SARS-CoV-2 positivity and (2) World Health Organization (WHO)-designated COVID-19 clinical outcomes while accounting for confounding including obesity, underlying cardiopulmonary disease, cancer, and smoking history. This case-control study was conducted within the Cleveland Clinic Health System (Ohio and Florida) and included all patients who were tested for COVID-19 between March 8 and November 30, 2020, and who had an available sleep study record. Sleep indices and SARS-CoV-2 positivity were assessed with overlap propensity score weighting, and COVID-19 clinical outcomes were assessed using the institutional registry. Sleep study-identified SDB (defined by frequency of apneas and hypopneas using the Apnea-Hypopnea Index [AHI]) and sleep-related hypoxemia (percentage of total sleep time at <90% oxygen saturation [TST <90]). Outcomes were SARS-CoV-2 infection and WHO-designated COVID-19 clinical outcomes (hospitalization, use of supplemental oxygen, noninvasive ventilation, mechanical ventilation or extracorporeal membrane oxygenation, and death). Of 350 710 individuals tested for SARS-CoV-2, 5402 (mean [SD] age, 56.4 [14.5] years; 3005 women [55.6%]) had a prior sleep study, of whom 1935 (35.8%) tested positive for SARS-CoV-2. Of the 5402 participants, 1696 were Black (31.4%), 3259 were White (60.3%), and 822 were of other race or ethnicity (15.2%). Patients who were positive vs negative for SARS-CoV-2 had a higher AHI score (median, 16.2 events/h [IQR, 6.1-39.5 events/h] vs 13.6 events/h [IQR, 5.5-33.6 events/h]; P < .001) and increased TST <90 (median, 1.8% sleep time [IQR, 0.10%-12.8% sleep time] vs 1.4% sleep time [IQR, 0.10%-10.8% sleep time]; P = .02). After overlap propensity score-weighted logistic regression, no SDB measures were associated with SARS-CoV-2 positivity. Median TST <90 was associated with the WHO-designated COVID-19 ordinal clinical outcome scale (adjusted odds ratio, 1.39; 95% CI, 1.10-1.74; P = .005). Time-to-event analyses showed sleep-related hypoxia associated with a 31% higher rate of hospitalization and mortality (adjusted hazard ratio, 1.31; 95% CI, 1.08-1.57; P = .005). In this case-control study, SDB and sleep-related hypoxia were not associated with increased SARS-CoV-2 positivity; however, once patients were infected with SARS-CoV-2, sleep-related hypoxia was an associated risk factor for detrimental COVID-19 outcomes.

Servant leadership and its association with an environment of empathic care: an empirical analysis of the perspectives of mid-level practitioners

PurposeAt the nexus of servant leadership and empathic care, this paper aims to explore the perceptions that mid-level practitioners express regarding the role that servant leadership plays in fostering an environment of empathic care.Design/methodology/approachThe authors surveyed mid-level practitioners across a large integrated health system (n = 167). Through exploratory factor analysis, we identify factors that serve as antecedents to an environment of empathic care. The factor analysis was complimented with partial least squares structural equation modeling to test a theoretical model of empathic care.FindingsThe model explains approximately 37% of the variance observed in an empathic care environment (R2 = 0.372). The authors identify key constructs within servant leadership that health-care leaders can focus their efforts on to promote an environment of empathic care.Originality/valueThis study answers multiple calls for more empirical research into servant leadership and is one of the few studies that explores servant leadership within an exogeneous context. This research focuses on the perceptions of mid-level providers, whereas most extant servant leadership and empathy research focuses on the perceptions of patients. The authors extend servant leadership theory in a health-care context and support prior findings that servant leadership is a multidimensional construct. The authors outline a sound methodological approach for investigating the linkage between specific principles of servant leadership that can serve as predictors for the creation of an environment of empathic care.

Real-Time Surveillance of New Anticancer Therapies in the National Veterans Affairs System

<h3>Purpose/Objective(s)</h3> The Veterans Affairs (VA) system is the largest integrated health system in the US, with one of the world's longest-running electronic medical record (EMR) systems. We describe the potential of VA EMR data for real-time surveillance of efficacy, toxicity, and uptake of new therapies in oncology. As a case study, we describe the implementation of durvalumab for adjuvant treatment of stage III non-small-cell lung cancer (NSCLC) treated with concurrent chemoradiation (CRT) after publication of the landmark PACIFIC trial in 2017. <h3>Materials/Methods</h3> We used the Veterans Affairs Informatics and Computing Infrastructure (VINCI) to identify all intravenous administrations of durvalumab from November 2017 to January 2021 among patients with at least one inpatient or outpatient lung cancer ICD-10 diagnosis code. Cancer stage and tumor histology were algorithmically extracted from physician notes and reviewed for accuracy. Radiation therapy dates and concurrent chemotherapy delivery were ascertained through outpatient CPT codes for radiation delivery and intravenous chemotherapy infusion records. Overall survival (OS) was obtained from the VA Vital Status File (updated on a quarterly basis) and from the VA Master Patient Index (updated on a daily basis). Date of radiographic progression were obtained through physician review of extracted CT and PET scan reports. Demographic, staging, and treatment information were supplemented with VA Central Cancer Registry information where available. Statistics were performed with statistical analysis software. <h3>Results</h3> We identified 1106 patients with stage III NSCLC (60% stage IIIA, 35% IIIB, and 3% IIIC) treated with upfront CRT who received at least one adjuvant durvalumab infusion, of whom only 135 (12%) were represented in cancer registry data. The median age was 69 years and 95% were male. Eighty-six percent reported current or former tobacco use, and the cohort was evenly split between adenocarcinoma (48%) and squamous cell histology (48%). Patients received a median of 6 durvalumab infusions (IQR 3 to 15) over a median of 154 days (IQR 35 to 308 days). Compared to patients enrolled in the PACIFIC trial, veterans received a lower number of durvalumab infusions (6 vs. 14) and had a higher rate of systemic steroid initiation for possible immune-related toxicity (43% vs 20%). Three-year progression-free survival was 32.5% (95% CI 25% to 40%). Three-year OS was 51% (95% CI 46% to 56%) compared to 57% in PACIFIC. <h3>Conclusion</h3> Veterans received fewer adjuvant durvalumab infusions than in the PACIFIC trial but maintained comparable survival. National VA administrative data, which are largely updated on a daily or weekly basis, are a unique resource to study real-time implementation of new therapies in large national cohorts. Improved case-finding algorithms are necessary to capture patients not included in the VA Central Cancer Registry.

Use of Nerve Block in Addition to General Anesthesia Reduces Pain and Time in Post-Anesthesia Care Unit After Rotator Cuff Repair

Purpose To determine if use of nerve blocks during rotator cuff repairs will result in an overall improvement of post-operative pain and reduction of time spent in the post-anesthesia care unit (PACU) without any increases in avoidable emergency department (ED) or urgent care (UC) visits within 7 and 30 days. Methods A large integrated health system was queried for all rotator cuff repairs conducted between January 1, 2016 and December 31, 2017 and separated into two groups: general anesthesia only or general anesthesia with an additional nerve block. Maximal pain scores in the PACU, time spent in the PACU and avoidable visits to the ED/UC within 7 and 30 days were recorded and compared. Results A total of 3,128 patients undergoing rotator cuff repair were included (39.5% received general anesthesia with a nerve block). The use of an additional nerve block was associated with a 1.3 (p &lt; 0.001) point reduction in maximum reported pain scores and a 15.7 (11.9%, p &lt; 0.001) minute reduction in PACU time per patient. Furthermore, there was no statistically significant difference in avoidable ED/UC visits within 7 (p = 0.432) and 30 (p = 0.454) days between groups. Conclusion The use of a nerve block in addition to general anesthesia was associated with a significant reduction in maximum pain scores and time spent in the PACU with no increases in avoidable ED/UC visits within 7 or 30 days. Therefore, use of a nerve block in addition to general anesthesia could lead to longitudinally decreased costs in the rotator cuff repair surgical pathway. Level of Evidence III

Effectiveness of mRNA BNT162b2 COVID-19 vaccine up to 6 months in a large integrated health system in the USA: a retrospective cohort study

BackgroundVaccine effectiveness studies have not differentiated the effect of the delta (B.1.617.2) variant and potential waning immunity in observed reductions in effectiveness against SARS-CoV-2 infections. We aimed to evaluate overall and variant-specific effectiveness of BNT162b2 (tozinameran, Pfizer–BioNTech) against SARS-CoV-2 infections and COVID-19-related hospital admissions by time since vaccination among members of a large US health-care system.MethodsIn this retrospective cohort study, we analysed electronic health records of individuals (≥12 years) who were members of the health-care organisation Kaiser Permanente Southern California (CA, USA), to assess BNT162b2 vaccine effectiveness against SARS-CoV-2 infections and COVID-19-related hospital admissions for up to 6 months. Participants were required to have 1 year or more previous membership of the organisation. Outcomes comprised SARS-CoV-2 PCR-positive tests and COVID-19-related hospital admissions. Effectiveness calculations were based on hazard ratios from adjusted Cox models. This study was registered with ClinicalTrials.gov, NCT04848584.FindingsBetween Dec 14, 2020, and Aug 8, 2021, of 4 920 549 individuals assessed for eligibility, we included 3 436 957 (median age 45 years [IQR 29–61]; 1 799 395 [52·4%] female and 1 637 394 [47·6%] male). For fully vaccinated individuals, effectiveness against SARS-CoV-2 infections was 73% (95% CI 72–74) and against COVID-19-related hospital admissions was 90% (89–92). Effectiveness against infections declined from 88% (95% CI 86–89) during the first month after full vaccination to 47% (43–51) after 5 months. Among sequenced infections, vaccine effectiveness against infections of the delta variant was high during the first month after full vaccination (93% [95% CI 85–97]) but declined to 53% [39–65] after 4 months. Effectiveness against other (non-delta) variants the first month after full vaccination was also high at 97% (95% CI 95–99), but waned to 67% (45–80) at 4–5 months. Vaccine effectiveness against hospital admissions for infections with the delta variant for all ages was high overall (93% [95% CI 84–96]) up to 6 months.InterpretationOur results provide support for high effectiveness of BNT162b2 against hospital admissions up until around 6 months after being fully vaccinated, even in the face of widespread dissemination of the delta variant. Reduction in vaccine effectiveness against SARS-CoV-2 infections over time is probably primarily due to waning immunity with time rather than the delta variant escaping vaccine protection.FundingPfizer.

S264 Effect of the COVID-19 Pandemic on Colorectal Cancer Screening in a Large Integrated Health System

S264 Effect of the COVID-19 Pandemic on Colorectal Cancer Screening in a Large Integrated Health System

Associations of weight loss with obesity-related comorbidities in a large integrated health system.

AimsTo determine the health outcomes associated with weight loss in individuals with obesity, and to better understand the relationship between disease burden (disease burden; ie, prior comorbidities, healthcare utilization) and weight loss in individuals with obesity by analysing electronic health records (EHRs).Materials and MethodsWe conducted a case‐control study using deidentified EHR‐derived information from 204 921 patients seen at the Cleveland Clinic between 2000 and 2018. Patients were aged ≥20 years with body mass index ≥30 kg/m2 and had ≥7 weight measurements, over ≥3 years. Thirty outcomes were investigated, including chronic and acute diseases, as well as psychological and metabolic disorders. Weight change was investigated 3, 5 and 10 years prior to an event.ResultsWeight loss was associated with reduced incidence of many outcomes (eg, type 2 diabetes, nonalcoholic steatohepatitis/nonalcoholic fatty liver disease, obstructive sleep apnoea, hypertension; P < 0.05). Weight loss >10% was associated with increased incidence of certain outcomes including stroke and substance abuse. However, many outcomes that increased with weight loss were attenuated by disease burden adjustments.ConclusionsThis study provides the most comprehensive real‐world evaluation of the health impacts of weight change to date. After comorbidity burden and healthcare utilization adjustments, weight loss was associated with an overall reduction in risk of many adverse outcomes.

Preterm birth among women with and without severe acute respiratory syndrome coronavirus 2 infection.

IntroductionStudies directly comparing preterm birth rates in women with and without severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection are limited. Our objective was to determine whether preterm birth was affected by SARS‐CoV‐2 infection within a large integrated health system in New York with a universal testing protocol.Material and methodsThis retrospective cohort study evaluated data from seven hospitals in New York City and Long Island between March 2020 and June 2021, incorporating both the first and second waves of the coronavirus disease 2019 (COVID‐19) pandemic in the USA. All patients with live singleton gestations who had SARS‐CoV‐2 polymerase chain reaction (PCR) testing at delivery were included. Deliveries before 20 weeks of gestation were excluded. The rate of preterm birth (before 37 weeks) was compared between patients with positive and negative SARS‐CoV‐2 test results. This analysis was performed separately for resolved prenatal infections and infections at delivery, with the latter group subdivided by symptom status. Multiple logistic regression analysis was used to examine the association between SARS‐CoV‐2 infection and preterm birth, adjusting for maternal age, race‐ethnicity, parity, history of preterm birth, body mass index, marital status, insurance type, medical co‐morbidities, month of delivery, and wave of pandemic.ResultsA total of 31 550 patients were included and 2473 (7.8%) had laboratory‐confirmed infection. Patients with symptomatic COVID‐19 at delivery were more likely to deliver preterm (19.0%; adjusted odds ratio 2.76, 95% CI 1.92–3.88) compared with women with asymptomatic infection (8.8%) or without infection (7.1%). Among preterm births associated with symptomatic infection, 72.5% were medically indicated compared with 44.1% among women without infection (p < 0.001). Risk of preterm birth in patients with resolved prenatal infection was unchanged when compared with women without infection. Among women with infection at delivery, preterm birth occurred more frequently during the second wave compared with the first wave (13.6% vs. 8.7%, respectively; p < 0.006). However, this was not significant on multiple regression analysis after adjusting for other explanatory variables.ConclusionsPregnant women with symptomatic COVID‐19 are more than twice as likely to have a preterm delivery than patients without infection. Asymptomatic infection and resolved prenatal infection are not associated with increased risk.

Effectiveness and Safety of Dabigatran in Atrial Fibrillation Patients with Severe Obesity: a Real-World Retrospective Cohort Study.

Direct oral anticoagulants such as dabigatran are the preferred anticoagulant in treating atrial fibrillation (AF) patients due to their effectiveness and safety. Whether this applies to severely obese patients needs to be determined. To compare the effectiveness and safety of dabigatran with warfarin among AF patients with severe obesity. Retrospective cohort study. AF patients with a BMI >40kg/m2 or a weight >120kg receiving dabigatran or warfarin between 10/01/2010 and 12/31/2019 in a large integrated health system and followed through 08/01/2020. Not applicable. Primary effectiveness outcome was composite thromboembolism including transient ischemic attack, ischemic stroke, or systemic embolism. Primary safety outcome was composite bleeding including gastrointestinal bleeding, intracranial bleeding, or other bleeding. Secondary outcomes included the individual outcomes and all-cause mortality. Propensity score matching (PSM) was performed to create a 1:1 matched cohort and Cox proportional hazards model was used to estimate the hazard ratio (HR) of each outcome for dabigatran users compared to warfarin users. A total of 6848 patients receiving either dabigatran or warfarin were identified. In a 1:1 matched cohort, dabigatran users had a HR of 0.71 (95% confidence interval (CI): 0.56-0.91) for composite thromboembolism, a HR of 1.24 (95%CI: 1.07-1.42) for composite bleeding, and a HR of 0.57 (95% CI: 0.45-0.71) for all-cause mortality when compared to warfarin users. Among AF patients with a BMI >40kg/m2 or a weight >120kg in a real-world clinical setting, dabigatran was effective in reducing the risk of thromboembolism and mortality but was associated with an increased risk of bleeding when compared to warfarin. Dabigatran may be a reasonable option for AF patients with severe obesity.

COVID-19 Is Associated With an Increase in Visits for Anxiety but Not Depression.

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has increased concerns about mental health. We conducted a time-series analysis to determine whether the percentage of primary care visits for anxiety and depression changed after COVID-19.MethodologyWe assessed the adjusted weekly change in the percentage of primary care visits for anxiety and depression between August 2019 and October 2020 at a large integrated health system. To account for changes in overall visit behavior during the pandemic, we created three periods: pre-period (August 1, 2019 to March 8, 2020), initial period (March 9, 2020 to June 31, 2020), and return period (July 1, 2020 to October 31, 2020). We used hierarchical linear regression models (clustered by month) to identify the association between the time period and the adjusted mean weekly percentage of visits for depression or anxiety. We conducted the analysis in 2020 and 2021.ResultsThere were 1,691,071 encounters among 605,105 unique adults. The median age was 55 years (interquartile range = 39-68), 57% were female, 78% were white, and 59% had private insurance. Most visits were office-based (versus virtual), of which 99% were in the pre-COVID-19 period and 75% in the return period. There was a significant increase in the percentage of visits associated with anxiety after July compared to before COVID-19 (10.4% versus 9.2%; p = 0.006), and there was no difference in the percentage of visits for depression (p > 0.05).ConclusionsOutreach to individuals with depression who have not sought care may be necessary.

MP34-20 INITIAL ASSESSMENT OF QUALITY OF NMIBC CARE ACROSS AN INTEGRATED ACADEMIC HEALTH SYSTEM

You have accessJournal of UrologyHealth Services Research: Quality Improvement & Patient Safety II (MP34)1 Sep 2021MP34-20 INITIAL ASSESSMENT OF QUALITY OF NMIBC CARE ACROSS AN INTEGRATED ACADEMIC HEALTH SYSTEM Oliver Ko, Minh Pham, Kyle Tsai, Amanda Vo, Anuj Desai, Jake Miller, Joshua Meeks, Joshua Halpern, and Gregory Auffenberg Oliver KoOliver Ko More articles by this author , Minh PhamMinh Pham More articles by this author , Kyle TsaiKyle Tsai More articles by this author , Amanda VoAmanda Vo More articles by this author , Anuj DesaiAnuj Desai More articles by this author , Jake MillerJake Miller More articles by this author , Joshua MeeksJoshua Meeks More articles by this author , Joshua HalpernJoshua Halpern More articles by this author , and Gregory AuffenbergGregory Auffenberg More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002043.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Non-muscle invasive (NMIBC) bladder cancer relies heavily upon high quality transurethral resection, re-resection when indicated, and appropriate use of intravesical therapy. We sought to characterize baseline performance across various bladder cancer quality measures and to evaluate predictors of variation in performance as a basis for future quality improvement interventions. METHODS: We identified all transurethral resection of bladder tumor procedures (TURBT) performed from 9/2018 – 9/2019 across our health system comprised of over 70 credentialed urologists and 9 acute care hospitals. Manual chart abstraction was used to create a clinicopathologic database of procedural findings and outcomes. We evaluated surgeon-specific performance across three NMIBC quality measures (detrusor sampling on TURBT, re-resection for high-grade (HG) Ta/T1 disease within 8 weeks, and post-operative intravesical chemotherapy use). Multivariable logistic regression models were fit to evaluate the relationship between detrusor sampling, clinicopathologic features, and surgeon. RESULTS: During the study period, 343 TURBTs were performed in 295 patients for urothelial carcinoma by 21 surgeons. Among these procedures, detrusor muscle was sampled in 71.1% (244/343). Figure 1a displays regression results evaluating the relationship between clinicopathologic parameters and detrusor muscle sampling. After adjusting for these factors significant variation in surgeon-specific rates of sampling detrusor muscle remained (Figure 1b). Of these TURBTs, the highest stage present was 7% (24/343) CIS only, 49.9% (171/343) Ta, 32.4% (111/343) T1, and 10.8% (37/343) T2 or higher with 32.4% being low grade and 67.6% high grade. Re-resection was performed for 44.8% (64/143) with HG Ta or T1 disease. By stage, re-resection occurred 30.3% (17/56) in HG Ta, and 54% (47/87) in HG T1. The surgeon-specific rate of re-resection for HG Ta/T1 patients varied from 0 to 100%, p=0.04. Post-operative intravesical chemotherapy was used for 19.5% (67/343) of resections. CONCLUSIONS: We demonstrate significant surgeon-specific variability in three TURBT quality measures across a large integrated health system. This presents an opportunity for quality improvement to reduce surgeon-specific variation and improve outcomes for patients with NMIBC. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e624-e625 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Oliver Ko More articles by this author Minh Pham More articles by this author Kyle Tsai More articles by this author Amanda Vo More articles by this author Anuj Desai More articles by this author Jake Miller More articles by this author Joshua Meeks More articles by this author Joshua Halpern More articles by this author Gregory Auffenberg More articles by this author Expand All Advertisement Loading ...

Outpatient Prescribing of Antibiotics and Opioids by Veterans Health Administration Providers, 2015–2017

Antibiotics and opioids are targeted by public health and stewardship communities for reductions in prescribing across the country. This study evaluates trends and factors associated with outpatient prescribing by dental and medical providers in a large integrated health system. This was a cross-sectional study of national dental and medical outpatient visits from Department of Veterans Affairs facilities in 2015-2017; analyzed in 2019-2020. Antibiotic and opioid prescribing rates were assessed by provider and facility characteristics. Multivariable Poisson regression adjusted for repeated measures by the provider was used to assess the independent association between facility and provider characteristics and rate of prescribing. Over the study period, 4,625,840 antibiotic and 10,380,809 opioid prescriptions were identified for 115,625,890 visits. Physicians prescribed most antibiotics (67%). Dentists prescribed 6% of the antibiotics but had the highest per-visit antibiotic prescribing rate compared to medical providers (6.75 vs 3.90 prescriptions per 100 visits, p<0.0001), which was largely driven by dental specialists. By contrast, dentists had lower opioid prescribing than medical providers (3.02 vs 9.20 prescriptions per 100 visits, p<0.0001). Overall, antibiotic and opioid prescribing decreased over time, with opioids having the greatest decreases (-28.0%). In multivariable analyses, U.S. geographic region, rurality, and complexity were associated with prescribing for both drug classes. Opioid and antibiotic prescribing were positively correlated. Although antibiotic and opioid prescribing has decreased, there are still important target areas for improvement. Interventions need to be tailored to community characteristics such as rurality and provider type.

Respiratory Distress in Hospitalized Non-Mechanically Ventilated COVID-19 Adults: A Retrospective Multicenter Cohort Study.

Background:COVID-19 typically presents with respiratory symptoms which may progress with severe disease. There are standard guidelines for managing respiratory distress (e.g. opioids, anxiolytics) and palliative care teams are well versed in managing these symptoms.Aim:Determine the extent to which hospitalized COVID-19 patients with moderate respiratory distress received medications or palliative consultation for symptom management and if these interventions had any association with outcomes.Design:Retrospective chart review for hospitalized COVID-19+ patients from March 2-April 30, 2020.Setting:Large integrated health system in the New York Metropolitan area.Patients:312 adult patients hospitalized with COVID-19 with an order for a non-rebreather mask and meeting criteria for moderate respiratory distress on the Respiratory Distress Observation Scale: concurrent respiratory rate ≥30 and heart rate ≥110 at any point during hospitalization. Patients receiving mechanical ventilation or intensive care were excluded.Results:Most COVID-19 patients experiencing moderate respiratory distress did not receive medications or palliative consultation for symptom management. Patients who received medications were predominantly white, older, and had a Do-Not-Resuscitate order. Patients who received a palliative consultation were more likely to be older, female, and white, with a Do-Not-Resuscitate order. Mortality was similar between those receiving medication and those who did not.Conclusion:Medications and palliative expertise for symptom management were underused for patients with moderate respiratory distress due to COVID-19. Education and triggers may help providers to identify moderate respiratory distress and consider symptomatic treatment and palliative consultation when appropriate.

Impact of race on referral for genetics assessment for women with ovarian cancer in a large health care system

<h3>Objectives:</h3> To identify racial and health factors associated with referral, assessment and genetic testing patterns for women with ovarian cancer. <h3>Methods:</h3> Women were identified with a new diagnosis of ovarian cancer in a large integrated health care system in Northern California between 8/1/2013 and 12/31/2018. Women were excluded if they had undergone genetic testing prior to the diagnosis of ovarian cancer. Standardized guidelines of the health system at the time of diagnosis were used for genetics referral criteria: from 8/2013 until 4/2015, the guidelines limited referral to ovarian cancer diagnosed under age ≤70 years and non-mucinous histology; from 4/2015-4/2017, ovarian cancer diagnoses of all ages became eligible; and starting in 4/2017, all ovarian cancer histologies were eligible for referral. Demographic variables including race, ethnicity, primary language and personal cancer history were retrieved from the electronic medical record. The primary outcome was referral to genetics for assessment within 12 months of ovarian cancer diagnosis. Secondary outcomes were completion of genetics contact and testing, as well as testing result. <h3>Results:</h3> We identified 1,414 women, newly diagnosed with ovarian cancer between 8/1/2013 and 12/31/2018, who were eligible for testing based on the health system criteria. Most of these women, 941 (66.5%) were referred to genetics in the first 12 months after diagnosis with a mean time from diagnosis to referral of 2.3 months. Referral rates varied by race and ethnicity: White 65.9%, Hispanic 69.7%, Black 58.2%, Asian 70.3%. Overall rates of referral to Genetics, seen by a genetic counselor, and tested for genetic mutations were lower for Black women compared to non-Black women although the difference was not significant (p-value = 0.07, 0.06, 0.07, respectively). Over the three time periods of genetics referral criteria, referrals for all races increased, the rate in Blacks increased from 45.8 % to 67.6% from the first period to the last (p-value = 0.09). Overall, 919/941 (65%) were seen by Genetics and 842 (59.5%) completed genetic testing, 796 had a multigene panel test, and the remainder had <i>BRCA</i> or single gene testing, with 161 (20%) with a positive test and 228 with variants of unknown significance. Only 6% (6/98) of Black women had a pathogenic mutation. <h3>Conclusions:</h3> In a large integrated health system with comprehensive health services, access to medical records for all tests and care, and a uniform cost structure for genetic services, Black women had lower referral and genetic testing rates than women of other races but the difference was not significant. While academic centers have shown significant differences in referral to genetic services of ovarian cancer patients by race, primary language and insurance types, these differences may be mitigated in systems with universal cost structures, integrated referrals and systemwide access for counseling, but more work still needs to be done to reach Black women.

Cost-Effectiveness of a Web-Based Program for Residual Depressive Symptoms: Mindful Mood Balance.

Mindful Mood Balance (MMB) is an effective Web-based program for residual depressive symptoms that prevents relapse among patients with partial recovery from major depressive episodes. This cost-effectiveness analysis was conducted from the health plan perspective alongside a pragmatic randomized controlled trial of MMB. Adults were recruited from behavioral health and primary care settings in a large integrated health system and randomly assigned to MMB plus usual depression care (MMB+UDC) or UDC. Patients had at least one prior major depressive episode; a current score of 5-9 on the Patient Health Questionnaire-9, indicating residual depressive symptoms; and Internet access. Program costs included recruitment, coaching, and MMB licensing. Center for Medicare and Medicaid fee schedules were applied to electronic health record utilization data for psychotropic medications and psychiatric and psychotherapy visits. Effectiveness was measured as depression-free days (DFDs), converted from PHQ-9 scores collected monthly for 1 year. Incremental cost-effectiveness ratios were calculated with various sets of cost inputs. A total of 389 patients (UDC, N=210; MMB+UDC, N=179) had adequate follow-up PHQ-9 measures for inclusion. MMB+UDC patients had 29 more DFDs during follow-up. Overall, the incremental cost of MMB+UDC was $431.54 over 12 months. Incremental costs per DFD gained ranged from $9.63 for program costs only to $15.04 when psychiatric visits, psychotherapy visits, and psychotropic medications were included. MMB offers a cost-effective Web-based program for reducing residual depressive symptoms and preventing relapse. Health systems should consider adopting MMB as adjunctive to traditional mental health care services.

Quality-of-Care Implications of Antimicrobial Prescription Patterns for Acute Respiratory Tract Infections.

The Centers for Disease Control and Prevention estimates that half of the antibiotic prescriptions for acute respiratory tract infections (ARTIs) in ambulatory care settings are unnecessary. To better understand the quality-of-care implications of prescription patterns for ARTIs, we conducted a retrospective chart review of outpatient ARTI visits, across a large integrated health system, and examined the association of patient characteristics with receiving antimicrobials, as well as the association between receiving antimicrobials and healthcare utilization (outpatient and emergency department visits). We found that 55.4% of all ARTI outpatients were treated with antimicrobials. There was no association between patient demographics and antimicrobial prescriptions on either the first (p < .0771) or follow-up (p < .6316) visits. A lower comorbidity score was significantly associated with receiving antimicrobials (p < .0022). Patients who received antimicrobials at the first visit had significantly higher number of follow-up visits (p < .005) and more follow-up antimicrobial prescriptions (p < .0066) as compared with patients who did not receive antimicrobials at the first visit. Our results highlight the potential for clinicians to improve quality of care in ARTI management.