Large Healthcare System Research Articles

Opioid Prescribing Rate for Nonoperative Distal Radius Fractures and Clinician Response to a Clinical Decision Support Alert

BackgroundOpioids are commonly prescribed for the management of acute orthopedic trauma pain, including nonoperative distal radius fractures. ObjectivesThis prospective study aimed to determine if a clinical decision support intervention influenced prescribing decisions for patients with known risk factors. We sought to quantify frequency of opioid prescriptions for acute nonoperative distal radius fractures treated. MethodsWe performed a prospective study at one large health care system. Utilizing umbrella code S52.5, we identified all distal radius fractures treated nonoperatively, and the encounters were merged with the Prescription Reporting with Immediate Medication Mapping (PRIMUM) database to identify encounters with opioid prescriptions and patients with risk factors for opioid use disorder. We used multivariable logistic regression to determine patient characteristics associated with the prescription of an opioid. Among encounters that triggered the PRIMUM alert, we calculated the percentage of encounters where the PRIMUM alert influenced the prescribing decision. ResultsOf 2984 encounters, 1244 (41.7%) included an opioid prescription. Age increment is a significant factor to more likely receive opioid prescriptions (p < 0.0001) after adjusting for other factors. Among encounters where the physician received an alert, those that triggered the alert for early refill were more likely to influence physicians’ opioid prescribing when compared with other risk factors (p = 0.0088). ConclusionOver 90% of patients (106/118) continued to receive an opioid medication despite having a known risk factor for abuse. Additionally, we found older patients were more likely to be prescribed opioids for nonoperatively managed distal radius fractures.

PARTNERING TO ADDRESS ADULT MALTREATMENT: HARD-EARNED LESSONS AND WISDOM GAINED BY APPLIED RESEARCHERS

Abstract We focus on three projects in which applied researchers collaborated with community-based and government partners to address adult maltreatment. In our first study with Texas, we partnered with a large healthcare system and Adult Protective Services (APS). Two APS workers served as consultants to clinicians and 529 patients were reported to APS. Researchers struggled with quantifying case notes on the consultations, pointing to the importance of creating a systematic method to document case notes for future studies. In the second grant, the same partners evaluated a case management intervention to prevent self-neglect among at-risk, adult primary care patients. A total of 477 randomly selected participants completed a baseline interview. Lessons learned included revising language in how to discuss self-neglect, particularly in consent forms and becoming more flexible in where to conduct interviews. Other challenges encountered included the time and effort it took to develop data use agreements that allowed us to access APS administrative data. Our third study with Oklahoma APS was conducted in the midst of a pandemic, requiring us to change study protocols from home to telephone-based interviews. Despite these challenges, we interviewed 188 clients over the phone. Drawing on the experiences across all three projects, we will discuss challenges – from contracting to IT issues, to recruitment and data collection – and how each one has presented an opportunity for growth and wisdom that can be applied to future research activities.

INSIGHTS ON THE CLINICAL NURSE ROLE IN IMPLEMENTING WHAT MATTERS FOR OLDER ADULTS IN ACUTE CARE

Abstract The Age-Friendly Health System (AFHS) evidence-based 4Ms framework (What Matters, Medication, Mentation, &amp; Mobility) is designed to be implemented in clinical settings to reliably provide high-quality age-friendly care to older adults and reduce harm and hospital-associated complications. The 4M concept of ‘What Matters to You’ (WMTY) refers to assessing and aligning an individual’s specific health outcome goals and care preferences to ensure patient-centered care with a measurable impact on patient experience. While published toolkits support the implementation of WMTY for all disciplines, there is limited guidance and empirical evidence about the implementation and impact of this concept when used by clinical nurses in acute care. Some researchers have identified issues with implementing WMTY with patients who are not able to articulate their wishes or when the question is posed in a granular way. A large healthcare system in the Midwest supported five hospitals to implement the AFHS 4Ms including the WMTY concept but did not observe an improvement in nurse-sensitive patient experience measures. A qualitative study is in progress aimed at gaining an in-depth understanding of the knowledge, perceptions, and experiences of leaders and clinical nurses who have implemented the WMTY concept for older adults in their hospital to evaluate the implementation and impact on patient care. The results gathered by this study will lay the foundation for designing clinical nurse-targeted interventions to successfully implement WMTY and identifying supportive strategies for partnering with patients and their caregivers to ensure that their goals/preferences are fully integrated into care.

RACIAL DIFFERENCES IN HEARING LOSS AMONG MIDDLE-AGED AND OLDER ADULTS

Abstract Prior studies have documented how social and systemic factors contribute to racial differences in health; however, less is known about the life course and social determinants of racial differences in hearing loss (HL) among middle-aged and older adults. Evidence from U.S. population-based cohorts indicates that Black adults have better pure-tone thresholds and a 40-70% lower prevalence of HL compared to White adults. However, beyond documenting racial differences in general hearing sensitivity (i.e., degree of HL), it is unknown how the characteristics of HL (e.g., type, laterality, etc.) vary by race. Using ICD codes and the AMCLASS classification system, we will evaluate types of HL (e.g., sensorineural, conductive, and mixed HL); symmetry categories (e.g., symmetrical or asymmetrical HL); and severity categories (by classifying pure-tone average according to standard metrics: normal [-10-15 dB HL], slight [16–25 dB HL], mild [26–40 dB HL], moderate [41–55 dB HL], moderately severe [56–70 dB HL], severe [71–90 dB HL], and profound [&amp;gt;90 dB HL]). We will examine audiological data on 22,905 adults aged 50 and older (17.9% Black, 82.1% White) using electronic health records (EHR) and linked area-level data from a large healthcare system. We will also investigate how socioeconomic (e.g., education, income, health insurance), psychosocial (e.g., mental health), behavioral (e.g., smoking), and clinical factors (e.g., disease comorbidities) are associated with HL characteristics in White and Black adults. Findings will provide important and actionable insights into racial differences in HL.

FINDING COMMON GROUND: IMPROVING RESEARCHER-PRACTITIONER COLLABORATION IN ADULT MALTREATMENT RESEARCH

Abstract The work of adult protection is inherently multidisciplinary–involving health care professions, social services agencies, law enforcement, criminal and civil justice systems, and the broader aging services network. Researchers seeking to develop and evaluate screening tools and interventions for elder abuse and neglect must cultivate partnerships with state and local agencies that are responsible for adult protection. In this symposium, early career researchers will share the unique challenges they have faced when collaborating with adult protective services (APS), healthcare organizations, and other state agencies on research to improve adult maltreatment outcomes. First, Reynolds and colleagues will summarize three collaborative projects involving a large healthcare system in Texas and APS agencies in Oklahoma. They will share how the research team adapted protocols to pandemic-related disruptions to data collection, and how they created new systems to standardize documentation. Liu interviewed state agencies in Montana and analyzed transcripts using thematic analysis. She will share the challenges and strategies that surfaced and relate to improving state-level collaboration in addressing the needs of mistreatment victims and survivors. DeLiema will present on planning for and navigating administrative barriers to cross-sector collaborations, including contracts and legal agreements that are part and parcel to university-government research partnerships. Last, Burnes will introduce the RISE project and share how he and his colleagues managed expectations to co-create a new outcomes measurement tool with adult protection workers. Reaching consensus necessitated honesty, openness, humor, and patience, but ultimately strengthened the collaboration to yield a more valid outcomes measurement assessment.

The Carolina hysterectomy cohort (CHC): a novel case series of reproductive-aged hysterectomy patients across 10 hospitals in the US south

BackgroundHysterectomy is a common surgery among reproductive-aged U.S. patients, with rates highest among Black patients in the South. There is limited insight on causes of these racial differences. In the U.S., electronic medical records (EMR) data can offer richer detail on factors driving surgical decision-making among reproductive-aged populations than insurance claims-based data. Our objective in this cohort profile paper is to describe the Carolina Hysterectomy Cohort (CHC), a large EMR-based case-series of premenopausal hysterectomy patients in the U.S. South, supplemented with census and surgeon licensing data. To demonstrate one strength of the data, we evaluate whether patient and surgeon characteristics differ by insurance payor type.MethodsWe used structured and abstracted EMR data to identify and characterize patients aged 18–44 years who received hysterectomies for non-cancerous conditions between 10/02/2014–12/31/2017 in a large health care system comprised of 10 hospitals in North Carolina. We used Chi-squared and Kruskal Wallis tests to compare whether patients’ socio-demographic and relevant clinical characteristics, and surgeon characteristics differed by patient insurance payor (public, private, uninsured).ResultsOf 1857 patients (including 55% non-Hispanic White, 30% non-Hispanic Black, 9% Hispanic), 75% were privately-insured, 17% were publicly-insured, and 7% were uninsured. Menorrhagia was more prevalent among the publicly-insured (74% vs 68% overall). Fibroids were more prevalent among the privately-insured (62%) and the uninsured (68%). Most privately insured patients were treated at non-academic hospitals (65%) whereas most publicly insured and uninsured patients were treated at academic centers (66 and 86%, respectively). Publicly insured and uninsured patients had higher median bleeding (public: 7.0, uninsured: 9.0, private: 5.0) and pain (public: 6.0, uninsured: 6.0, private: 3.0) symptom scores than the privately insured. There were no statistical differences in surgeon characteristics by payor groups.ConclusionThis novel study design, a large EMR-based case series of hysterectomies linked to physician licensing data and manually abstracted data from unstructured clinical notes, enabled identification and characterization of a diverse reproductive-aged patient population more comprehensively than claims data would allow. In subsequent phases of this research, the CHC will leverage these rich clinical data to investigate multilevel drivers of hysterectomy in an ethnoracially, economically, and clinically diverse series of hysterectomy patients.

Lessons Learned: Evaluation of Fracture Liaison Service Quality Improvement Efforts in a Large Academic Healthcare System.

The Fracture Liaison Service (FLS) care model, a care coordination program for patients experiencing a fragility fracture, is proven to improve management of patients with an osteoporotic fracture, but treatment initiation gaps persist. We describe the evolution of a centralized FLS within a university-based healthcare system, including impact of adding clinical pharmacist consultation, and describe circumstances surrounding continued care gaps. Cohort analysis of osteoporosis medication initiation before FLS, after initial implementation, and after addition of pharmacist consultation. Individuals aged 65 and older experiencing any fragility fracture between 7/1/16 and 3/31/22. A centralized team outreached eligible patients, ordered dual x-ray absorptiometry and laboratory tests as needed, and scheduled an osteoporosis-focused primary care appointment. Three years after FLS implementation, clinical pharmacist consultative review was added prior to the primary care visit. Initiation of osteoporosis pharmacologic therapy, completion of DXA, primary care follow-up rate, and description of circumstances where therapy was not initiated. Of 1204 new fractures between 7/1/16 and 3/31/22, 315 patients were enrolled in one of two FLS phases, and 89 eligible historical controls were identified. Medication initiation rates went from 22/89 (25%) pre-FLS to 201/428 (47%) after-FLS phase 1 [POST1] (p<0.001) and to 106/187 (57%) after FLS phase 2 (POST2), when clinical pharmacist consultation was added (p=0.03 versus POST1). DXA was completed in 56/89 (67%) of pre-FLS patients, 364/428 (85%) POST1 patients (p<0.001 versus pre), and 163/187 (87%) POST2 (p< 0.001 versus PRE, p=0.59 versus POST1).Of 375 patients who did not initiate osteoporosis medication, more in the combined post-FLS cohorts attended a follow-up primary care appointment (233/308, 76% attended, versus pre-FLS 41/67, 61%, p=0.016). An FLS including centralized outreach and care coordination significantly improved patient follow-up, DXA, and medication initiation. Addition of de-centralized pharmacist consultation further improved medication initiation rates.

Clinical Presentations and Treatment Outcomes of Mycoplasma genitalium Infections at a Large New York City Health Care System.

Mycoplasma genitalium (MG) is an emerging sexually transmitted infection. Treatment of MG is complicated by increasing resistance to primary treatment regimens, including macrolides and fluoroquinolones. Understanding the various clinical presentations and relative effectiveness of treatments for MG is crucial to optimizing care. Patients with a positive MG nucleic acid amplification test between July 1, 2019, and June 30, 2021, at a large health system in New York City were included in a retrospective cohort. Demographics, clinical presentations, coinfections, treatment, and follow-up microbiologic tests were obtained from the electronic medical record. Associations with microbiologic cure were evaluated in bivariate and multivariable logistic regression models. Five hundred two unique patients had a positive MG nucleic acid amplification test result during the study period. Male individuals presented predominantly with urethritis (117 of 187 [63%]) and female individuals with vaginal symptoms (142 of 315 [45%]). Among patients with follow-up testing who received a single antibiotic at the time of treatment, 43% (90 of 210) had persistent infection and 57% (120 of 210) had microbiologic cure. Eighty-two percent of patients treated with moxifloxacin had microbiologic cure compared with 41% of patients receiving azithromycin regimens ( P < 0.001). In multivariable analysis, treatment with moxifloxacin was associated with 4 times the odds of microbiologic cure relative to low-dose azithromycin (adjusted odds ratio [aOR], 4.18; 95% confidence interval, 1.73-10.13; P < 0.01). Clinical presentations of MG vary, with urethritis or vaginal symptoms in most cases. Among patients who received a single antibiotic, only treatment with moxifloxacin was significantly associated with microbiologic cure relative to low-dose azithromycin.

Uptake and outcomes of supervised exercise therapy for peripheral artery disease: The importance of vascular medicine specialists at a large midwestern health care system during the first 5 years of CMS reimbursement.

Supervised exercise therapy (SET) is the cornerstone of medical therapy for symptomatic peripheral artery disease (PAD). Despite the efficacy of SET, initial reports following the 2017 Centers for Medicare and Medicaid Services (CMS) reimbursement decision indicate low SET uptake, referral, and completion. Vascular medicine specialists are key to the success of such programs. We examined rates of SET referral, completion, and outcomes in a health system with a robust SET program during the first 5 years of CMS reimbursement. A retrospective chart review of patients with PAD referred to SET between October 1, 2017 and December 31, 2022 was conducted. Patient demographic and medical characteristics, SET indication, referring provider specialty, SET participation (e.g., exercise modality, number of sessions, treadmill prescription), and outcomes were abstracted. Descriptive statistics, t-tests, and multiple linear regression were used to examine the sample, evaluate outcomes, and explore outcomes by relevant covariates (i.e., age, sex, referring provider specialty). Of 5320 patients with PAD, N = 773 were referred to SET; N = 415 enrolled and were included in the present study. Vascular medicine and vascular surgery specialists were the two primary sources of referrals (30.6% and 51.6%, respectively). A total of 207 patients (49.9%) completed SET. Statistically significant and clinically meaningful improvements were observed in all outcomes. SET referral and completion rates are low in the 5 years following CMS reimbursement, despite the advocacy of vascular medicine specialists. SET is effective in improving patient functional capacity and quality of life. Additional efforts are needed to increase both SET availability and referrals as part of comprehensive treatment of PAD.

Universal lipid screening in adolescents to identify familial hypercholesterolemia in a large healthcare system

Universal lipid screening in adolescents to identify familial hypercholesterolemia in a large healthcare system

Betrayal-Based Moral Injury and Mental Health Problems Among Healthcare and Hospital Workers Serving COVID-19 Patients

ABSTRACT One factor potentially driving healthcare and hospital worker (HHW)’s declining mental health during the COVID-19 pandemic is feeling betrayed by institutional leaders, coworkers, and/or others’ pandemic-related responses and behaviors. We investigated whether HHWs’ betrayal-based moral injury was associated with greater mental distress and post-traumatic stress disorder (PTSD) symptoms related to COVID-19. We also examined if these associations varied between clinical and non-clinical staff. From July 2020 to January 2021, cross-sectional online survey data were collected from 1,066 HHWs serving COVID-19 patients in a large urban US healthcare system. We measured betrayal-based moral injury in three groups: institutional leaders, coworkers/colleagues, and people outside of healthcare. Multivariate logistic regression analyses were performed to investigate whether betrayal-based moral injury was associated with mental distress and PTSD symptoms. Approximately one-third of HHWs reported feeling betrayed by institutional leaders, and/or people outside healthcare. Clinical staff were more likely to report feelings of betrayal than non-clinical staff. For all respondents, 49.5% reported mental distress and 38.2% reported PTSD symptoms. Having any feelings of betrayal increased the odds of mental distress and PTSD symptoms by 2.9 and 3.3 times, respectively. These associations were not significantly different between clinical and non-clinical staff. As health systems seek to enhance support of HHWs, they need to carefully examine institutional structures, accountability, communication, and decision-making patterns that can result in staff feelings of betrayal. Building trust and repairing ruptures with HHWs could prevent potential mental health problems, increase retention, and reduce burnout, while likely improving patient care.

Psychological Factors of Vaccination Intent among Healthcare Providers, Parents, and Laypeople.

The interrelatedness of social-structural aspects and psychological features with vaccination intention provides the context to explore personal psychological features related to vaccination. Specifically, we focused on general decision making and vaccine-related dispositions, and their contribution to the intention to vaccinate, within post-pandemic circumstances, after the imposed possibility of choosing a vaccine brand. Our study aimed to map the function (promotive, protective, risk, vulnerability) of a set of personal psychological aspects in the intention to vaccinate among people holding different social roles regarding the vaccination. We surveyed three samples of people: healthcare providers (HPs), parents, and laypeople, within the post-pandemic context. Negative vaccine attitudes lower intention to vaccinate in all regression models (all βs ranging from -0.128 to -0.983, all ps < 0.01). The main results indicate that, regardless of the sample/social role, there is a shared attitudinal core for positive vaccination intention. This core consists of [high] trust in large corporations, government, and healthcare systems, as well as perceived consensus on vaccine safety/efficacy and experience of freedom (protective factors), and [low] vaccination conspiracy beliefs, trust in social media, and choice overload (risk and vulnerability factors, respectively). There are no common promotive factors of intention to vaccinate: for parents, perceived consensus on vaccines, and trust in corporations and the healthcare system, play such roles; for HPs, the experience of freedom is obtained as a unique promotive factor. In contrast, for laypeople, no unique promotive factors were found. Our findings provide insights into the function of psychological factors of vaccination intention across different social roles, particularly healthcare providers, parents, and laypeople, and emphasize the need for tailored immunization interventions in the post-pandemic landscape.

Emergency department visits at Veterans Health Administration hospitals related to alcohol intoxication: A ten-year retrospective

We sought to quantify and describe the volume of emergency department visits related to alcohol intoxication at the Veterans Health Administration (VHA), the largest healthcare system in the United States. This is a retrospective cohort study of patients with VHA emergency department visits for alcohol intoxication from 2010 to 2019 as identified via ICD-9/10 code and/or serum ethanol concentration >50 mg/dL. Encounters were identified and demographic and clinical data were acquired by automated query of the VHA Corporate Data Warehouse. Descriptive statistics and univariate analysis were performed. We identified 95,123 patients with a total of 251,310 emergency department visits. The annual number of visits increased over the study period, reaching 32,333 in 2019. Men aged 40–60 were the most common demographic group in the cohort (48% of all patients), and men made up a higher proportion of patients in the database (94%) than the VHA population overall (90%). A disproportionate number of visits (32%) came from the top 4.4% of most frequent visitors. Most of the emergency department visits in the database (68%) were associated with medical or psychiatric admission, or interfacility transfer for admission elsewhere. Patients in the cohort accounted for 1.3% of all VHA emergency department visits during the study period, a proportion that is somewhat smaller than what has been reported at non-VHA facilities, despite the high prevalence of addiction disorders in the VHA patient population. We submit that this lower-than-expected proportion of alcohol-related emergency department visits may be due to the access to primary and mental care which is afforded by VHA patient benefits.

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.

Original Research: Exploring Medication Safety Practices from the Nurse's Perspective.

Medication preparation and administration are complex tasks that nurses must perform daily within today's complicated health care environment. Despite more than two decades of efforts to reduce medication errors, it's well known that such errors remain prevalent. Obtaining insight from direct care nurses may clarify where opportunities for improvement exist and guide future efforts to do so. The study purpose was to explore direct care nurses' perspectives on and experiences with medication safety practices and errors. A qualitative descriptive study was conducted among direct care nurses employed across a large health care system. Data were collected using semistructured interview questions with participants in focus groups and one-on-one meetings and were analyzed using qualitative direct content analysis. A total of 21 direct care nurses participated. Four major themes emerged that impact the medication safety practices of and errors by nurses: the care environment, nurse competency, system influences, and the error paradigm. These themes were often interrelated. Most participants depicted chaotic environments, heavy nursing workloads, and distractions and interruptions as increasing the risk of medication errors. Many seemed unsure about what an error was or could be. The complexity of medication safety practices makes it difficult to implement improvement strategies. Understanding the perspectives and experiences of direct care nurses is imperative to implementing such strategies effectively. Based on the study findings, potential solutions should include actively addressing environmental barriers to safe medication practices, ensuring more robust medication management education and training (including guidance regarding the definition of medication errors and the importance of reporting), and revising policies and procedures with input from direct care nurses.

Increasing Cognitive Evaluations in Primary Care: Implementing the GSA KAER Model at a Large Healthcare System

AbstractThere is widespread recognition that patients with Alzheimer’s disease and related dementias (ADRD) receive better care if they receive an earlier diagnosis. In 2022, the Alzheimer’s Association published a survey of primary care providers (PCPs) indicating that a large majority agree that making an early diagnosis of ADRD is important. However, more than half of PCPs said that they lack the knowledge and confidence to assist in making such a diagnosis.Starting in 2021, the University of Washington launched the Cognition in Primary Care Program to meet that need. Developed with funding from the Centers for Disease Control and Prevention, as an adaptation of the Gerontological Society of America’s KAER Toolkit, the primary goals of the Cognition in Primary Care Program are to increase cognitive evaluations by PCPs and to increase the number of patients diagnosed with ADRD and mild cognitive impairment (MCI).Using practical training modules for PCPs with concise, evidence‐based checklists embedded in the electronic health record (EHR), the program has now been widely adopted by PCPs in a wide variety of clinics serving diverse populations of patients. Evaluations by PCPs describe the program as being of high quality and relevant to their practice. Results on the General Practitioners’ Attitude and Confidence Scale for Dementia (GPACS‐D) six months after the intervention show confidence in evaluating cognition. In addition, the number of MoCA tests uploaded to the EHR increased from 2.7 per month to 5.8 per month, and there was high utilization of the EHR checklist tools. Preliminary data also show that the number of visits in which PCPs have billed a diagnosis of MCI increased from 7.5 per month to 14.4 per month.The strengths of the Cognition in Primary Care Program include its emphasis on actions that PCPs can take to promote brain health and the implementation of innovative EHR tools which PCPs can use in their clinical practice. The Cognition in Primary Care Program is an effective model, shown to be acceptable to PCPs, easy to integrate into a large health system, and successful at increasing cognitive evaluations in the primary care setting.

Enhanced recovery after brain tumor surgery: pilot protocol implementation in a large healthcare system.

Enhanced recovery after surgery (ERAS) protocols have been used in numerous specialties to improve the safety, efficiency, and cost of surgical interventions. Despite these successes, implementation of ERAS in cranial neurosurgery remains limited. In this study, a comprehensive ERAS protocol was implemented at two pilot sites within the Providence Health & Services system, and groundwork was laid for systemwide adoption. An enhanced recovery protocol was developed and implemented through an interdisciplinary team of clinicians, executive leadership, and clinical informatics professionals across preoperative, intraoperative, and postoperative domains. Outcomes including length of stay, discharge destination, and cost were collected through systemwide databases and compared with nonprotocolized sites. During the study period, both pilot sites became top performers across the regional system in all evaluated metrics. The median length of stay for elective craniotomy at site 1 was reduced to 1.25 days, with a home discharge rate of > 90%. The cost per case at the pilot sites was nearly $7000 less on average than that of the nonprotocolized sites. Implementation of enhanced recovery protocols for brain tumor surgery is feasible and effective, resulting in marked improvements in healthcare efficiency. Future studies, including implementation of the current protocol across the entire Providence system, are needed to maximize the potential benefits of enhanced recovery programs.

Developing Leaders and Fighting Burnout: An Interview With Sharon Pappas.

This year, Sharon Pappas, PhD, RN, NEA-BC, FAAN, Chief Nurse Executive (CNE) at Emory Healthcare (EHC), Atlanta, Georgia, received the American Organization for Nursing Leadership (AONL) prestigious Lifetime Achievement Award, which honors an AONL member recognized by the nursing community as a significant leader in the nursing profession and who has served AONL in an important leadership capacity. As CNE of Georgia's largest healthcare system, she leads and supports a Magnet® nursing culture across EHC, with the goal of achieving Magnet designation for the entire EHC system. Dr Pappas was commended for her leadership in leading the EHC incident command during COVID-19 where she focused on providing exceptional patient care and supporting clinical nurses caring for critically ill patients.

Identification of Persons Living with Dementia Using the Electronic Health Record

AbstractBackgroundAlzheimer’s disease and related dementias (ADRD) are underdiagnosed in the primary care setting. Proactive screening for cognitive impairment and subsequent evaluation and diagnosis of patients who screen positive are not routinely and reliably performed. As a result, identification of persons living with dementia (PLWD) for enrollment in clinical programs, clinical trials, and research studies can be challenging. The electronic health record (EHR) represents a potentially viable tool to efficiently and accurate identify PLWD.MethodsIn a large academic health care system in the U.S., we performed an EPIC EHR search for PLWD with the intent of enrolling them in an outpatient dementia care management program. The EHR algorithm used the following criteria for dementia: (1) an ICD‐10 dementia diagnosis in the problem list or past medical history or (2) an FDA‐approved drug on their active medication list. We performed chart review for patients who were identified to have potential dementia using this algorithm to confirm dementia diagnosis is documented in clinical notes.ResultsA total of 985 patients were identified by EHR criteria as potentially having dementia. After chart review, 747 (75.8%) were confirmed to have dementia documented in their clinical history and progress notes. One hundred thirty (13.2%) did not have a confirmed dementia diagnosis, 58 (5.9%) had an incomplete dementia evaluation, and 50 (5.0%) had only mild cognitive impairment. In addition, 55 (5.6%) were deceased.ConclusionWe found that an EHR algorithm can identify patients with dementia in a health plan population. This model may be a useful tool for a focused recruitment of potential participants in clinical trials, research studies, and clinical programs.

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.