Large Urban Health Care System Research Articles

A mobile application for STEMI care optimization: Pilot implementation project report

BackgroundClinical outcomes of patients presenting with STEMI are significantly improved by reducing time from vessel occlusion to coronary blood flow restoration. In an effort to improve outcomes, we developed a secure mobile application, STEMIcathAID, and designed a pilot project implementing the app into the workflow for STEMI patients transfer. The aim of the study is to assess the impact of the app on key metrics for STEMI transfer before (historic) and after app launch. MethodsThe pilot project included physicians, nurses and technicians from the Emergency Medicine and Nursing Departments at the referring center, the catheterization laboratory and transfer center. From July 2021 to February 2023, the referring center activated STEMIcathAID alarms in parallel with the previously established STEMI activation with traditional phone call to transfer center. ResultsOne hundred eleven suspected STEMI calls were activated through the app with 66 accepted and 45 rejected cases; thirty-one STEMI cases with available device time were compared with 42 STEMIs activated through the traditional pathway before the app implementation. Median door-to-device time for STEMIcathAID-assisted transfer decreased from 106 to 86 min (p < 0.001). The significant improvement, 20 min (19%), of the key metric for interhospital transfer resulted in all STEMI cases meeting the AHA goal of door-to-device time ≤ 120 min. In addition, median door-in-door-out time at the referral hospital decreased from 56 to 50 min (p = 0.01). ConclusionsImplementation of a mobile app into STEMI workflow of a large urban healthcare system significantly improved the quality of care for transfer of STEMI patients. Trial registrationAHA Get With The Guidelines-Coronary Artery Disease® (GWTG-CAD) registry is a national quality improvement program and is not subject to the institutional review board approval.

Suicidal ideation among non-physician hospital system staff: Prevalence and workplace correlates

BackgroundResearch suggests that healthcare workers are at greater risk for suicide than other occupations, but most published studies focus on physicians. This study examines the prevalence of suicidal ideation (SI) and associated occupational factors among a broad group of non-physician healthcare staff. MethodsAn anonymous online survey was sent to a random sample of 30 % of non-physician healthcare staff at a large urban healthcare system between September and November 2022. Weighted multivariable binary logistic regressions were conducted to determine the workplace and mental health factors associated with SI. ResultsThe 1084 respondents included nurses, administrative staff, research staff, medical assistants, nurse practitioners, physician assistants, and other roles. Of the sample, 8.8 % endorsed having SI over the prior two weeks. Results of the regression indicated that, after adjusting for demographic factors, greater odds of SI were associated with physical violence experienced from a patient or visitor (odds ratio [OR] = 2.15, 95 % confidence interval [CI] = 1.06–4.37), lower perceived leadership support (OR = 0.95, 95 % CI = 0.92–0.98), and positive screening for depression (OR = 4.66, 95 % CI = 2.45–8.86). Exploratory analysis suggests that depression may be a mediating factor between workplace stressors and SI. LimitationsLimitations include the response rate, the use of a single item to assess SI, and the cross-sectional design. ConclusionFindings suggest that workplace violence and leadership support are important occupational factors associated with SI among healthcare workers. Reducing and mitigating workplace violence, enhancing leadership support, and improving access to mental health care should be considered targets for interventions to decrease suicide risk in this population.

Power Dynamics Perpetuate DEI Inaction: A Qualitative Study of Community Health Clinic Teams.

Despite increased clinician awareness of systemic racism, lack of substantial action toward antiracism exists within health care. Clinical staff perspectives, particularly those of racial-ethnic minorities/persons of color (POC) who disproportionately occupy support staff roles with less power on the team, can yield insights into barriers to progress and can inform future efforts to advance diversity, equity, and inclusion (DEI, also referred to as EDI) within health care settings. This qualitative study explored the perspectives of staff members on race and role power dynamics within community health clinic teams. We conducted semistructured 45-minute interviews with staff members working in community health clinics in a large urban health care system from May to July 2021. We implemented purposeful recruitment to oversample POC and support staff and to achieve equal representation from the 13 community health clinics in the system. Interviews were audio recorded, transcribed, and analyzed over 6 months using a critical-ideological paradigm. Themes reflecting experiences related to race and role power dynamics were identified. Our cohort had 60 participants: 42 (70%) were support staff (medical assistants, front desk clerks, care navigators, nurses) and 18 (30%) were clinicians and clinic leaders. The large majority of participants were aged 26 to 40 years (60%), were female (83%), and were POC (68%). Five themes emerged: (1) POC face hidden challenges, (2) racial discrimination persists, (3) power dynamics perpetuate inaction, (4) interpersonal actions foster safety and equity, and (5) system-level change is needed for cultural shift. Understanding the race and role power dynamics within care teams, including experiences of staff members with less power, is critical to advancing DEI in health care.

Abstract C120: Evaluating potential disparities in lung cancer screening eligibility and uptake in a large urban healthcare system

Abstract Lung cancer screening (LCS) currently has a low reported uptake rate in eligible patients. Identifying the population eligible for screening is crucial to assessing uptake yet is more difficult than for other cancer screening tests as LCS requires documentation of smoking history. Because new screening recommendations may experience disparities in early implementation, it is crucial to evaluate the uptake of LCS in diverse populations. The goal of this study is to evaluate any potential disparities in the uptake of LCS at a large healthcare system in southeast Michigan using previously published eligibility assessment methods. We assessed patient LCS eligibility using Medicare criteria (ages 50-77, currently/formerly smoking within 15 years and at least 20 pack-years) and two methods: a cross-sectional method currently in place clinically and a published algorithm using longitudinal data, accounting for all smoking history entries in the patient’s record. We compared differences in eligibility across patient-reported race and sex groups (Black female, Black male, White female, and White male). Using electronic health record data, we determined how many patients had received an LCS low-dose chest CT (LDCT) or an LDCT for another reason in the previous twelve months. These patients are considered up to date with screening. For both eligibility and uptake, we used Chi-Square for pairwise comparisons with a multiple comparisons adjustment to evaluate differences across race-sex categories. In total, 143,740 patients between the ages of 50-77 with no history of lung cancer had a healthcare encounter between July and December 2022. Of those patients, 38,026 (26.5%) were determined to be eligible for LCS. There were observed differences across the race-sex groups; Black female patients had the lowest proportion of those eligible (20.3%) while White male patients had the highest proportion eligible (29.5%). Of eligible patients, 9,718 (25.6%) received a verified LCS LDCT in the preceding twelve months; 7,144 (18.8%) received a LDCT for another reason; resulting in 44.3% being up to date with screening. Black female patients were the race-sex category with the highest proportion screened in the previous 12 months, and White male patients had the lowest proportion of patients screened (34.0% Black female, 28.8% Black male, 24.5% White female, 24.3% White male; p&amp;lt;0.0001). Black male patients had the highest proportion receiving an LDCT for any reason, and White females had the lowest (51.9% Black female, 52.4% Black male, 41.4% White female, 44.4% White male; p&amp;lt;0.0001). Our estimates indicate that 44.3% of patients would be considered up to date with screening, and 18.8% received an LCS LDCT. These estimates are higher than other reported LCS rates but significantly less than other cancer screening rates. These data do not suggest disparities exist related to the uptake of LCS at our health system; however, uptake remains low and measures to increase uptake should include methods effective and acceptable in diverse patients. Citation Format: Elizabeth R. Alleman, Katie Latack, Jessica Dagenais, Michael Sheehan, Katherine R. Zarins, Vritti Gupta, Michael Simoff, Christine Neslund-Dudas. Evaluating potential disparities in lung cancer screening eligibility and uptake in a large urban healthcare system [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C120.

Surgeon idiosyncrasy is a key driver of cost in arthroscopic rotator cuff repair: a time-driven activity-based costing analysis.

Delivering high-value orthopedic care requires optimizing value, defined as health outcomes achieved per dollar spent. Published literature is stippled with inaccurate proxies for cost, including negotiated reimbursement rates, fees paid, or listed prices. Time-driven activity-based costing (TDABC) offers a more robust and accurate approach to calculating cost, including shoulder care. In the present study, we sought to determine the drivers of total cost in arthroscopic rotator cuff repair (aRCR) using TDABC. Consecutive patients undergoing aRCR at multiple sites associated with a large urban health care system between January 2019 and September 2021 were identified. Total cost was determined using TDABC methodology. The episode of care was defined by 3 phases: preoperative, intraoperative, and postoperative care. Patient, procedure, rotator cuff tear morphology, and surgeon characteristics were collected. Bivariate analysis was performed across all characteristics between high-cost (top decile) and all other aRCRs. Multivariable linear regression was used to identify the key cost drivers. In total, 625 aRCRs performed by 24 orthopedic surgeons and 572 aRCRs performed by 13 orthopedic surgeons were included in the bivariate and multivariable linear regression analyses, respectively. By TDABC analysis, total aRCR cost varied 6-fold (5.9×) from least to most costly. Intraoperative costs accounted for 91% of average total cost, followed by preoperative costs and postoperative costs (6% and 3%, respectively). Biologic adjuncts (regression coefficient [RC] 0.54, 95% confidence interval [CI] 0.49-0.58, P<.001) and surgeon idiosyncrasy (RC of highest-cost surgeon 0.50, 95% CI 0.26-0.73, P<.001) were the major cost drivers in aRCR. Patient age, comorbidities, number of rotator cuff tendons torn, and revision surgery were not significantly associated with total cost. The amount of tendon retraction (RC 0.0012, 95% CI 0.000020-0.0024, P=.046), average Goutallier grade (RC 0.029, 95% CI 0.0086-0.049, P=.005), and the number of anchors used (RC 0.039, 95% CI 0.032-0.046, P < .001) were also significantly associated with cost, but with far smaller effect sizes. Episode of care costs vary nearly 6-fold in aRCR and are almost exclusively dictated by the intraoperative phase. Tear morphology and repair technique contribute to cost, although the largest cost drivers of aRCR are the use of biologic adjuncts and surgeon idiosyncrasy, defined as something a surgeon does or does not do that impacts total cost and is not controlled for in the current analysis. Future work should seek to better delineate what these surgeon idiosyncrasies may represent.

Abstract 18895: Myocardial Injury After Non-Cardiac Surgery (MINS) in the High Sensitivity Troponin Era: Current Trends of Preoperative Risk Stratification in a Large Urban Healthcare System

Introduction: Myocardial Injury after Non-Cardiac Surgery (MINS) is a significant cause of perioperative morbidity and mortality. Recognizing and understanding the patient characteristics and potential predictors of MINS can contribute to more effective patient risk stratification and management. Hypothesis: Certain preoperative risk factors are associated with a higher risk of developing MINS among patients undergoing noncardiac surgery. Methods: We retrospectively reviewed the data on 2458 noncardiac surgeries performed within the MedStar System between 2022-2023 in which patients underwent routine pre- and postoperative high sensitivity troponin I (hsTnI) and EKG monitoring over 72 hours. MINS was defined as any elevation in hsTnI &gt;99 th percentile for gender (&gt;34 ng/L: females, &gt;53 ng/L :males). Multivariable logistic regression models were used to identify the factors associated with MINS which included demographics, surgical details, comorbidities, relevant preoperative labs and vitals. Results: Out of the 2,458 patients, 889 (36%) were diagnosed with MINS. Patients with MINS were older, nonsmokers, and females with prior congestive heart failure (CHF), coronary artery disease (CAD), chronic kidney disease (CKD), atrial fibrillation, and preoperatively lower blood pressure and higher creatinine compared to patients without MINS (Table 1). In multivariable adjusted models, CHF [aOR=1.6, 95%CI: (1.1, 2.3)], CAD [aOR=2.1(14, 2.9)], CKD [aOR=1.4(1.2, 1.8)] were associated with higher odds of developing MINS. RCRI score was not associated with postop MINS. Figure 1 shows rates of developing MINS among surgical specialties. Conclusions: Our study demonstrates that risk factors including age, gender, pre-existing cardiovascular and renal disease, preoperative blood pressure, and certain surgery types are associated with MINS. Research is needed to further define how to utilize this information to identify and minimize the risk of MINS.

THU092 Characterizing Immune Checkpoint Inhibitor Induced Hypophysitis In A Large Urban Health Care System

Abstract Disclosure: M. Gogerly-Moragoda: None. U. Sharif Khawaja: None. K.C. Cheesman: None. A. Leiter: None. E.J. Gallagher: Consulting Fee; Self; Novartis Pharmaceuticals, Flare Therapeutics, Seagen, SynDevRx. INTRODUCTION Over the past decade, immune checkpoint inhibitors (ICIs) have transformed cancer therapy in multiple tumor types and improved outcomes. Endocrine immune related adverse events are well recognized side effects of ICIs. ICI induced hypophysitis is potentially life-threatening if not identified and treated. The present study examines the incidence and presentation characteristics of hypophysitis in a real-world cohort including a multitude of ICIs and tumor types. METHODS We conducted a retrospective analysis of all patients treated with ICIs at a large health system from 2011-2020. Patient demographics, type of cancer, type of ICI, endocrine symptoms and laboratory values were collected to characterize hypophysitis within the cohort. RESULTS A total of 1703 patients were treated with ICIs from 2011-2020 of whom 32 (1.9%) developed clinically apparent hypophysitis. Of the 32 patients, 26 patients were confirmed to have secondary adrenal insufficiency (AI), with 6 possible secondary AI. A majority were diagnosed in the outpatient setting (n=21, 66%). For those with hypophysitis, the most common tumor type was melanoma (n=12, 38%), followed by lung cancer (n=9, 28%) and genitourinary cancers (n=8, 25%). Combination cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitor, ipilimumab and programmed cell death protein 1 (PD-1) inhibitor, nivolumab (n=9, 28%) was the most common regimen, followed by monotherapies ipilimumab (n=6, 19%), nivolumab (n=6, 19%), pembrolizumab (n=6, 19%), the programmed cell death ligand 1 (PD-L1) inhibitor atezolizumab (n=3, 9%), with the remainder on durvalumab or combination durvalumab and tremelimumab. The most common presenting symptom was fatigue (n=21, 66%) with headache (n=8, 25%) and vision changes (n=2, 6%) being less common. The median time to presentation was 5 months with most presenting within 12 months of starting ICI (n=24, 75%). However, a subset of patients presented after 18 months on treatment (n=6, 19%), none of whom received ipilimumab. Seven patients underwent cosyntropin stimulation tests and six had muted responses, despite having low or inappropriately normal ACTH levels. DISCUSSION In this real-world dataset, we found a low percentage of hypophysitis across multiple tumor and ICI types. Secondary AI was most commonly seen with ipilimumab treatment. Notably, the subset of patients who presented after 18 months were all on PD-1 / PD-L1 inhibitors, which potentially indicates a distinct mechanism of hypophysitis with these agents compared with CTLA-4 inhibitors, and the new need to monitor these patients with labs and symptom review beyond the initial few months from ICI start. The muted cortisol response to cosyntropin was surprising in the setting of acute hypophysitis and warrants further investigation in these patients. Presentation: Thursday, June 15, 2023

Estimating racial differences in risk for CLABSI in a large urban healthcare system

Background: Socioeconomic barriers or divergent implementation of prevention measures may impact risk of healthcare-associated infections by racial groups. We utilized a previously studied cohort of patients to quantify disparities in central-line–associated bloodstream infection (CLABSI) risk by race accounting for inherent differences in risk related to device utilization. Methods: In a retrospective cohort of adult patients at 4 hospitals (range, 110–733 beds) from 2012 to 2017, we linked central-line data to patient encounter data: race, age, comorbidities, total parenteral nutrition (TPN), chemotherapy, CLABSI. Analysis was limited to patients with &gt;2 central-line days and &lt;3 concurrent central lines. Patient exposures were calculated for each central-line episode (defined by insertion and removal dates); analysis of central-line episode-specific risk of CLABSI among Black versus White patients adjusted for clinical factors, duration of central-line episode, and central-line risk category (ie, low: single port, dialysis or PICC; medium: single temporary or nontunneled; or high: any concurrent central-lines) in Cox proportional hazards regression of time to CLABSI. Results: In total, 526 CLABSIs occurred a median of 14 days after insertion among 57,642 central-line episodes in 32,925 patients. CLABSIs occurred in similar frequency across racial groups: 217 (1.7%) among Black patients, 256 (1.6%) among White patients, and 11 (1.6%) among Hispanic patients (also 42 among unknown or other race). Duration of central-line episode was similar between racial groups (median, 5 days). Black patients were less likely to have medium-risk central lines (34%) compared to white patients (RR, 0.82; 95% CI, 0.79–0.84), but they had a similar frequency of high-risk central lines (21%; RR, 1.0; 95% CI, 1.0–1.1). Compared with low-risk central lines, risk of CLABSI was increased among medium-risk central lines (RR, 1.3; 95% CI, 1.0–1.7) and high-risk central lines (RR, 2.2; 95% CI, 1.8–2.7). CLABSIs were more likely in TPN central lines (RR, 2.3; 95% CI, 1.9–2.7) than others, but they were not more likely among Black patients than White patients (RR, 0.9; 95% CI, 0.1–1.1). In survival analysis, there were 24,700 central-line episodes among Black patients compared to 26,648 episodes among White patients; adjusting for central-line risk and TPN, the risk of CLABSI was similar during the first 21 days of central-line use (adjusted hazard ratio, 1.08; 95% CI, 0.88–01.32) (Fig. 1). Conclusions: After accounting for central-line configuration, Black patients did not have a higher risk of CLABSI within 21 central-line days. Further evaluation is warranted to assess racial disparities in risks of other healthcare-associated infections and to determine whether a lack of CLABSI-specific racial disparities can be replicated in other regions and healthcare systems.Disclosures: None

Increasing Patient Tracking Compliance by Harnessing Frontline Clinician Engagement

Introduction:A large urban jurisdiction identified a lack of experience and knowledge in use of the established regional patient tracking system among frontline emergency department employees. Lack of nursing retention, shifted departmental priorities throughout the pandemic response, and decreased opportunities for exercising were notable causes of this identified knowledge gap. Effective patient tracking has a significant impact during response to any event with the capacity to strain the hospital and healthcare system. Mass casualty incidents pose a global threat to all jurisdictions. Recognition of this threat magnifies the importance of establishing a patient tracking system and empowering frontline staff, through education and training, to immediately implement the exercised patient tracking platform.Method:Bolstering hospital readiness through site visits and first-receiver clinician engagement during special event planning improved effective use of a citywide patient tracking system during planned events. “Just-in-time” training tools were developed and distributed during site visits. Notably, identification of key clinical staff at each institution was an important step in meaningful clinician engagement. Utilization of these systems during special events is an opportunity to exercise a high stakes procedure during a low stakes incident.Results:Site visits and training material distribution effectively enhanced first-receiver participation in patient tracking during a special event in comparison to previous special events. Users required less prompting throughout the response, and the post-intervention survey indicated an increase in user confidence levels. Increased utilization of the system improved visibility into the hospital's lived experience while engaged in the response.Conclusion:Targeted site visits and educational material tailored to first-receiver clinicians during special events improved patient tracking efforts throughout a large urban healthcare system. During real and planned events, person and patient tracking allows for patient load balancing across the healthcare system, assists with patient and family reunification, and directs future planning, funding, and first responder and receiver education.

Long-term functional independence after minimally invasive endoscopic intracerebral hemorrhage evacuation.

Intracerebral hemorrhage (ICH) is a devastating form of stroke with no proven treatment. However, minimally invasive endoscopic evacuation is a promising potential therapeutic option for ICH. Herein, the authors examine factors associated with long-term functional independence (modified Rankin Scale [mRS] score ≤ 2) in patients with spontaneous ICH who underwent minimally invasive endoscopic evacuation. Patients with spontaneous supratentorial ICH who had presented to a large urban healthcare system from December 2015 to October 2018 were triaged to a central hospital for minimally invasive endoscopic evacuation. Inclusion criteria for this study included age ≥ 18 years, hematoma volume ≥ 15 ml, National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, premorbid mRS score ≤ 3, and time from ictus ≤ 72 hours. Demographic, clinical, and radiographic factors previously shown to impact functional outcome in ICH were included in a retrospective univariate analysis with patients dichotomized into independent (mRS score ≤ 2) and dependent (mRS score ≥ 3) outcome groups, according to 6-month mRS scores. Factors that reached a threshold of p < 0.05 in a univariate analysis were included in a multivariate logistic regression. A total of 90 patients met the study inclusion criteria. The median preoperative hematoma volume was 41 (IQR 27-65) ml and the median postoperative volume was 1.2 (0.3-7.5) ml, resulting in a median evacuation percentage of 97% (85%-99%). The median hospital length of stay was 17 (IQR 9-25) days, and 8 (9%) patients died within 30 days of surgery. Twenty-four (27%) patients had attained functional independence by 6 months. Factors independently associated with long-term functional independence included lower NIHSS score at presentation (OR per point 0.78, 95% CI 0.67-0.91, p = 0.002), lack of intraventricular hemorrhage (IVH; OR 0.20, 95% CI 0.05-0.77, p = 0.02), and shorter time to evacuation (OR per hour 0.95, 95% CI 0.91-0.99, p = 0.007). Specifically, patients who had undergone evacuation within 24 hours of ictus demonstrated an mRS score ≤ 2 rate of 36% and were associated with an increased likelihood of long-term independence (OR 17.7, 95% CI 1.90-164, p = 0.01) as compared to those who had undergone evacuation after 48 hours. In a single-center minimally invasive endoscopic ICH evacuation cohort, NIHSS score on presentation, lack of IVH, and shorter time to evacuation were independently associated with functional independence at 6 months. Factors associated with functional independence may help to better predict populations suitable for minimally invasive endoscopic evacuation and guide protocols for future clinical trials.

A mobile application for STEMI care optimization: pilot implementation project report

Abstract Background In an effort to improve outcomes of STEMI patients, we developed a secure mobile application (app) to streamline real-time communication and coordination between multiple teams taking care of STEMI patients in a large health care system. The app includes multi-level alarm and notification systems, instant EKG transmission for quick interpretation, activation of the cardiac catheterization laboratory (CCL) after expert case review, secure video chat among team members facilitating clinical discussion, continuous updates on patients' clinical status and ambulance location tracking. Purpose One of the major shortcomings in STEMI system of care has been long delays in transfer of patients from non-PCI capable hospitals to a receiving center for primary PCI. To address the challenges of interhospital transfer, we designed a pilot project employing the app for STEMI transfer from a first contact hospital to our CCL. This report assesses the effect of the app on door-to-device time by comparing the key metric for STEMI transfer before (historic) and after app launch. Methods The pilot project involved key leadership stakeholders from Emergency Medicine and Nursing Departments at the referring hospital, CCL and our transfer center. During pilot period (July 2021 to January 2022) the referring center activated STEMI alarms using app activation in parallel with the previously established STEMI activation process via traditional phone calls to the transfer center. The built-in workflow redundancy was introduced to ensure the rapid and efficient, and at the same time, safe and reliable response to STEMI alert. In preparation for the pilot, more than 250 people were provisioned accounts, trained on their user-specific roles and scheduled in the app according to their schedules. Results A total of 40 suspected STEMIs were activated through the app during the pilot study; among them 30 cases were accepted for transfer and 10 rejected. After excluding patients who expired during transfer, were intubated, or had normal coronaries, final study population included 13 STEMI cases activated through the app. These cases were compared with 43 STEMIs activated through the traditional pathway from January 2019 to July 2021 before app launch. After implementing the app, the mean door-to-device time for STEMI transfer decreased from 120.3±48.3 to 91.8±15.4 min (P=0.002) (Figure 1). The significant improvement, 29 min (24%), of the key metric for interhospital transfer resulted in all STEMI cases meeting AHA goal of door-to-device time ≤120 minutes after the app launch. The respective percent of STEMI cases meeting the goal before app was 71% (Figure 2). Conclusions Implementation of a mobile app into STEMI workflow of a large urban healthcare system had a significant impact on the quality of care for transfer of STEMI patients, which has also helped bring our clinical practice closer to the AHA guidelines pertaining to the first door-to-device time. Funding Acknowledgement Type of funding sources: None.

S132 Disparity of Care Is Not Observed Across Racial and Ethnic Groups During Hospitalization for Inflammatory Bowel Disease

Background: Although Inflammatory Bowel Disease (IBD) is more common in non-Hispanic White populations, rates are increasing among non-Whites. Despite some possible differences in disease phenotypes between racial groups, disease management guidelines are identical for different groups. However, multiple studies have demonstrated that social determinants of health (SDOH) play a critical role in disease management and outcomes for patients with IBD, as patients from minority populations often have delayed diagnosis, increased surgeries, and post-surgical complications. Several factors likely contribute to these healthcare disparities, with financial compensation and access to healthcare among them. Hospital admission ideally provides a setting that removes these barriers, and therefore should not be associated with healthcare disparities, though this has not been previously studied. We sought to identify if SDOH guide inpatient management of patients with IBD. Methods: We conducted a retrospective cohort study of adult patients with IBD-related inpatient admissions to any of Northwell Health’s 21 hospitals between 2010-2018. Patients were identified by a hospital admission primary diagnosis of ulcerative colitis (UC) or Crohns disease (CD), or a secondary diagnosis of UC or CD with a primary diagnosis of diarrhea, abdominal pain, or gastrointestinal bleeding. We analyzed data on patient demographics, medical history, and inpatient management features, including the use of imaging, medications, and procedures. Biological medication was defined as the use of infliximab, adalimumab, certolizumab. Race/ethnicity was characterized as Hispanic, Asian, Black, White, other, and unknown. Insurance status was characterized as private, Medicare, or Medicaid. Self-pay patients were excluded from analysis. Variables were tested using logistic regression for binary outcomes. To control the overall Type 1 error rate for the hypothesis that there were racial disparities in inpatient management of IBD, the Holm-Bonferroni method was used to adjust the P-value thresholds for statistical significance in each of the multiple tests performed to evaluate the hypothesis. Results: In total, 1,732 patients were identified and included in the analysis. Overall, 57% (n = 985) were White, 9% Hispanic, 5% Asian, 13% Black, 6% other, 9% unknown. 55% of patients were female, 45% had Crohn’s Disease, 14% were on steroids prior to admission. 47% of patients had private insurance, with the remaining having either Medicare or Medicaid. When assessing hospital interventions and outcomes based on racial/ethnic group, there was no difference in length of stay, use of medications (corticosteroids, aminosalicylic acid formulations, opioids, biological) during hospital admission and on discharge, stool testing performed as inpatient, imaging (CT, MRI) or endoscopies performed. Conclusion(s): SDOH play a critical role in the disease course and outcomes for patients with IBD. In this large retrospective study, we found that among patients hospitalized for IBD exacerbations there was no disparity of care across racial/ethnic groups. Our findings suggest that factors such as insurance status and access to healthcare are likely the main contributors to the healthcare disparities seen in the outpatient setting. Our results reflect the experience in a large urban health care system, and further studies are needed to replicate the data in other settings.

Long-term impact of fluoroquinolone-sparing strategies for empirical treatment of acute uncomplicated cystitis among ambulatory patients.

Background:Acute uncomplicated cystitis is common among outpatients and frequently leads to antibiotic prescriptions, making urinary tract infections (UTIs) an important area for antimicrobial stewardship initiatives. Infectious Disease Society of America (IDSA) guidelines promote alternative agents in place of fluoroquinolones for acute uncomplicated cystitis. Despite IDSA guidance, adherence to the guideline remains low in the United States (US). Several studies have described interventions to improve guideline-concordant prescribing for UTIs. However, the long-term sustainability and impact of fluoroquinolone (FLQ)-sparing strategies on community antimicrobial resistance and treatment outcomes are unknown. The objectives of this study were to characterize current antibiotic prescribing patterns, treatment failures and Escherichia coli resistance rates in a setting which instituted FLQ sparing strategies for UTIs in 2007.Methods:Retrospective cohort study of women aged ⩾ 18 diagnosed with acute uncomplicated cystitis based on International Classification of Diseases, 10th Revision (ICD-10) codes were included. Data were abstracted for ambulatory visits over a 6-month period, January 2018 to June 2018, at a large urban health care system. Treatment decisions were made by individual providers, and data were analyzed retrospectively. Nitrofurantoin (NFT) resistance was obtained from the institutional antibiogram and patient-level data. Treatment failure was defined as the need for a different antibiotic for UTI within 28 days of the original prescription.Results:NFT was the most frequently prescribed antibiotic (n = 386, 71.6%) of empiric antibiotic prescriptions for UTIs. FLQs comprised 4.6% of all antibiotic prescriptions (n = 25). Treatment failure rate was 2.3% in patients treated with NFT. Urine culture was ordered for only 26.8% of patients. Among the small group of patients with cultures ordered, E. coli remained 98.5% susceptible to NFT.Conclusions:This study is the first to report significantly low rates (4.6%) of FLQ prescribing for acute uncomplicated cystitis. Treatment failure rate was low with empiric NFT. Increased NFT resistance among E. coli was not observed at the institution or among the subset of patients with E. coli positive urine cultures. These findings support current IDSA treatment guidance for uncomplicated cystitis.

A mobile application for STEMI care optimization: pilot implementation project report

Abstract Background In an effort to improve outcomes of STEMI patients, we developed a secure mobile application (app) to streamline real-time communication and coordination between multiple teams taking care of STEMI patients in a large health care system. The app includes multi-level alarm and notification systems, instant EKG transmission for quick interpretation, activation of the cardiac catheterization laboratory (CCL) after expert case review, secure video chat among team members facilitating clinical discussion, continuous updates on patients' clinical status and ambulance location tracking. Purpose One of the major shortcomings in STEMI system of care has been long delays in transfer of patients from non-PCI capable hospitals to a receiving center for primary PCI. To address the challenges of interhospital transfer, we designed a pilot project employing the app for STEMI transfer from a first contact hospital to our CCL. This report assesses the effect of the app on door-to-device time by comparing the key metric for STEMI transfer before (historic) and after app launch. Methods The pilot project involved key leadership stakeholders from Emergency Medicine and Nursing Departments at the referring hospital, CCL and our transfer center. During pilot period (July 2021 to January 2022) the referring center activated STEMI alarms using app activation in parallel with the previously established STEMI activation process via traditional phone calls to the transfer center. The built-in workflow redundancy was introduced to ensure the rapid and efficient, and at the same time, safe and reliable response to STEMI alert. In preparation for the pilot, more than 250 people were provisioned accounts, trained on their user-specific roles and scheduled in the app according to their schedules. Results A total of 40 suspected STEMIs were activated through the app during the pilot study; among them 30 cases were accepted for transfer and 10 rejected. After excluding patients who expired during transfer, were intubated, or had normal coronaries, final study population included 13 STEMI cases activated through the app. These cases were compared with 43 STEMIs activated through the traditional pathway from January 2019 to July 2021 before app launch. After implementing the app, the mean door-to-device time for STEMI transfer decreased from 120.3±48.3 to 91.8±15.4 min (P=0.002) (Figure 1). The significant improvement, 29 min (24%), of the key metric for interhospital transfer resulted in all STEMI cases meeting AHA goal of door-to-device time ≤120 minutes after the app launch. The respective percent of STEMI cases meeting the goal before app was 71% (Figure 2). Conclusions Implementation of a mobile app into STEMI workflow of a large urban healthcare system had a significant impact on the quality of care for transfer of STEMI patients, which has also helped bring our clinical practice closer to the AHA guidelines pertaining to the first door-to-device time. Funding Acknowledgement Type of funding sources: None.

Planning for Implementation of a Universal Decolonization Process at a Large Healthcare System (Masters of Science in Biomedical Informatics Capstone)

<h3>Background</h3> There is a growing body of literature to promote the use and highlight the effectiveness of universal decolonization (UD) over targeted decolonization (TD) to reduce the burden of methicillin-resistant Staphylococcus aureus (MRSA) on acute care patients. Infection preventionist (IP) leaders and stakeholders at a large urban healthcare system have supported implementing UD in adult intensive care units (ICUs) but have not yet identified a future state electronic health record (EHR) workflow due to technical, legal, and human factor constraints. This project served as a Masters capstone for an IP. <h3>Methods</h3> An IP with biomedical informatics experience identified constraints and requirements associated with UD at the implementation site, collaborated with clinical informaticists, and outlined pathways in the EHR, including triggering events, alerts, and order sets, to accomplish the UD process effectively. The target patient population will include adult ICU patients in 14 acute care hospitals. The IP identified three potential future state workflows in the EHR for effective UD implementation with strengths and weaknesses. <h3>Results</h3> Future state workflows were evaluated based on reliability that all UD components will be carried out to completion in each patient, the workflow will reach the target population, and there will be high compliance. IPs and stakeholders elected to pursue a partial hard-stop alert within the EHR with few override options in order to achieve high compliance, despite possible physician resistance as seen with total hard-stop alerts. In the coming months, this workflow will be built into the System's EHR and implemented. <h3>Conclusions</h3> A viable solution was identified for a future state MRSA UD workflow. The future state workflow successfully satisfied requirements and addressed constraints identified by IPs and stakeholders. This will ultimately lead to higher compliance with the UD process and a decrease in the burden of MRSA within the System is expected following implementation of the workflow.

Outcomes of Transcatheter Aortic Valve Implantation in Patients With Chronic and End-Stage Kidney Disease

Patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) are at higher risk of aortic stenosis. Data regarding transcatheter aortic valve implantation (TAVI) in these patients are limited. Herein, we aim to investigate TAVI outcomes in patients with ESKD and CKD. We analyzed clinical data of patients with ESKD and CKD who underwent TAVI from 2008 to 2018 in a large urban healthcare system. Patients' demographics were compared, and significant morbidity and mortality outcomes were noted. Multivariable analyses were used to adjust for potential baseline variables. A total of 643 patients with CKD underwent TAVI with an overall in-hospital mortality of 5.1%, whereas 84 patients with ESKD underwent TAVI with an overall mortality rate of 11.9%. The most frequently observed comorbidities in patients with CKD were heart failure, atrial fibrillation (AF), mitral stenosis (MS), pulmonary hypertension, and chronic lung disease. After multivariable analysis, MS (adjusted odds ratio (OR) 3.92; 95% confidence interval (CI) 1.09 to 11.1, p <0.05) and AF (adjusted OR 2.42; 95% CI 1.3 to 4.4 p <0.05) were independently associated with mortality in patients with CKD. The most common comorbidities observed in patients with ESKD undergoing TAVI were heart failure, chronic lung disease, AF, MS, and pulmonary hypertension. An association between MS and increased mortality was observed (adjusted OR 2.01; 95 CI 0.93 to 2.02, p=0.09) in patients with ESKD, but was not statistically significant. In conclusion, in patients with CKD undergoing TAVI, AF and MS were independently associated with increased mortality.

METABOLIC DYSFUNCTION AS A PREDICTOR OF FIBROID RECURRENCE

A growing body of research suggests a relationship between metabolic syndrome and fibroid prevalence. The role of metabolic dysfunction on fibroid recurrence is less clear. The objective of this study was to investigate the association between metabolic dysfunction and fibroid recurrence risk after index myomectomy, with a secondary aim of assessing the impact of metabolic dysfunction on healthcare utilization after surgical fibroid management in a large urban healthcare system over 10 years.

Effect of Changing Electronic Health Record Opioid Analgesic Dispense Quantity Defaults on the Quantity Prescribed

Interventions to improve judicious prescribing of opioid analgesics for acute pain are needed owing to the risks of diversion, misuse, and overdose. To assess the effect of modifying opioid analgesic prescribing defaults in the electronic health record (EHR) on prescribing and health service use. A cluster randomized clinical trial with 2 parallel arms was conducted between June 13, 2016, and June 13, 2018, in a large urban health care system comprising 32 primary care and 4 emergency department (ED) sites in the Bronx, New York. Data were analyzed using a difference-in-differences method from 6 months before implementation through 18 months after implementation. Data were analyzed from January 2019 to February 2020. A default dispense quantity for new opioid analgesic prescriptions of 10 tablets (intervention) vs no change (control) in the EHR. The primary outcome was the quantity of opioid analgesics prescribed with the new default prescription. Secondary outcomes were opioid analgesic reorders and health service use within 30 days after the new prescription. Intention-to-treat analysis was conducted. Overall, 21 331 patients received a new opioid analgesic prescription from 490 prescribers. Comparing the intervention and control arms, site, prescriber, and patient characteristics were similar. For the new prescription, compared with the control arm, patients in the intervention arm had significantly more prescriptions for 10 tablets or fewer (7.6 percentage points; 95% CI, 6.1-9.2 percentage points), a lower number of tablets prescribed (-2.1 tablets; 95% CI, -3.3 to -0.9 tablets), and lower morphine milligram equivalents (MME) prescribed (-14.6 MME; 95% CI, -22.6 to -6.6 MME). Within 30 days after the new prescription, significant differences remained in the number of tablets prescribed (-2.7 tablets; 95% CI, -4.8 to -0.6 tablets), but not MME (-15.8 MME; 95% CI, -33.8 to 2.2 MME). Within this 30-day period, there were no significant differences between the arms in health service use. In this study, implementation of a uniform reduced default dispense quantity of 10 tablets for opioid analgesic prescriptions led to a modest reduction in the quantity prescribed initially, without significantly increasing health service use. However, during 30 days after implementation, the influence on prescribing was mixed. Reducing EHR default dispense quantities for opioid analgesics is a feasible strategy that can be widely disseminated and may modestly reduce prescribing. ClinicalTrials.gov Identifier: NCT03003832.

CAIR: Implementation of peer response support for frontline health care workers facing the COVID-19 pandemic

ABSTRACT Purpose: While global pandemics such as the COVID-19 public health crisis are known to increase the likelihood of frontline health care workers experiencing the negative effects of stress and trauma, many health care workers on the frontlines of the COVID-19 pandemic lack adequate support. This paper presents the findings of a social work led peer support model, COVID-19 Am I Resilient (cAIR), developed and deployed during the first wave of the COVID-19 pandemic. Methods: This quality improvement initiative was developed and piloted within the Clinical Education and Practice department at a large urban health care system. The pilot included provision of peer support through synchronous video presentations, one-on-one peer support, and resourcing and referral. Pilot outcomes of feasibility and staff engagement were evaluated using participant responses to an online survey as well as attendance records at project activities. Implications: Developed to help frontline health care workers thrive in the midst, and wake, of the COVID-19 pandemic, the pilot study of the cAIR peer support model has implications for further development and implementation of peer support for typically underrepresented health care disciplines working during the COVID-19 pandemic as well as future public health emergencies.

Will prior health insurance authorization for medications continue to hinder hepatitis C treatment delivery in the United States? Perspectives from hepatitis C treatment providers in a large urban healthcare system.

BackgroundThe recent introduction of direct acting antivirals for the treatment of hepatitis C virus (HCV) has dramatically improved treatment options for HCV infected patients. However, in the United States (US) treatment uptake has been low and time to initiation of therapy has been long. We sought to examine provider perspectives of facilitators and barriers to HCV treatment delivery.MethodsFrom June to August 2019, we conducted in-depth, semi-structured interviews with medical staff providing HCV care as part of a university medical center in Los Angeles, CA. In order to understand the HCV treatment process, we interviewed key staff members providing care to the majority of HCV patients seeking care at the university medical center, including hepatologists and infectious disease specialists as well as key nursing and pharmacy staff. The interviews focused on workload and activities required for HCV treatment initiation for non-cirrhotic, treatment naïve patients.ResultsProviders noted that successful HCV treatment delivery was reliant on a care model involving close collaboration between a team of providers, in particular requiring a highly coordinated effort between dedicated nursing and pharmacy staff. The HCV care team overwhelmingly reported that the process of insurance authorization was the greatest obstacle delaying treatment initiation and noted that very few patient level factors served as a barrier to treatment uptake.ConclusionsIn the US, prior authorization for HCV treatment is a requirement for most public and private insurance plans. In an era with access to therapies that allow for a cure—and until revocation of prior authorization for HCV treatment is a reality—implementing strategies that can expedite authorization to accelerate treatment access are critical. Not only will this benefit patients, but it has the potential to help expand treatment to settings that are otherwise too resource strained to successfully deliver HCV care.