Majority Of Providers Research Articles

Survey of Anesthesiologists on Topical Vasoconstrictors and Intravenous Tranexamic Acid for Endoscopic Sinus Surgery.

Topical vasoconstrictors and intravenous tranexamic acid (IV TXA) are safe and efficacious to decrease bleeding and improve the surgical field during endoscopic sinus surgery (ESS). The purpose of this study was to investigate practice patterns, awareness of clinical evidence, and comfort levels among anesthesia providers regarding these hemostatic agents for ESS. A total of 767 attending anesthesiologists, residents, and certified registered nurse anesthetists (CRNAs) at 5 United States academic centers were invited to participate in a survey regarding their experience with IV TXA and 3 topical vasoconstrictor medications (oxymetazoline, epinephrine, and cocaine) during ESS. 330 (47%) anesthesia providers responded to the electronic survey. 113 (97%) residents, 92 (83%) CRNAs, and 52 (68%) attendings managed 5 or fewer ESS cases per month. Two-thirds of providers had not reviewed efficacy or safety literature for these hemostatic agents. Oxymetazoline was perceived safest, followed by epinephrine, IV TXA, and cocaine. Respondents considered potential side effects over surgical field visibility when selecting agents. The majority of providers had no formal training on these agents for ESS, but indicated interest in educational opportunities. Many anesthesia providers are unfamiliar with safety and efficacy literature regarding agents used to improve hemostasis for ESS, highlighting a need for development of relevant educational resources. Rhinologic surgeons have an opportunity to communicate with anesthesia colleagues on the use of hemostatic agents to improve the surgical field during ESS.

Abstract SS2-09: Telemedicine usability for cancer care during the COVID-19 pandemic

Abstract Background Healthcare delivery via telemedicine has increased substantially amid COVID-19. The George Washington Cancer Center (GWCC) now provides cancer care services via tele-visits for patients at high risk of morbidity and mortality secondary to COVID-19. This study was performed to assess usability of virtual cancer care delivery for patients and providers across specialties. Methods Participants included patients and providers surveyed to assess baseline usability after initiating tele-visits. Surveys included demographics, Telehealth Usability Questionnaire (TUQ), and questions on perceived safety and preferences around telemedicine. Subjects also provided open-ended feedback for quality improvement. Results For patients (n=133), 93% of surveys sent were completed and analyzed. Most patients were between ages 60-69 (26%), 70-79 (24%), 50-59 (22%). Breast cancer (41%) was the most commonly reported cancer type. Mean patient TUQ scores based on a 5-point scale (1-strongly disagree, 5 - strongly agree) were: 4.4 for Interface Quality (IfQ), 4.3 for Ease of Use (EU), 4.2 for Usefulness (U) and Satisfaction (S), 4.1 for Interaction Quality (ItQ), 3.4 for Reliability (R). No association was found between mean TUQ scores and age groups (p=0.33), sex (p=0.79), timing of diagnosis in relation to telemedicine visit (p=0.67), stage of diagnosis (p=0.98), or treatment type (p=0.65). However, patients with more telemedicine visits did score significantly higher in Reliability (P=0.018) and Satisfaction (P=0.039), compared to those with fewer telemedicine visits. Compared to in-person visits, 77% of patients agreed/strongly agreed that telemedicine made them feel safer, 75% agreed/strongly agreed that it reduced stress, and 72% expressed interest in using it with other medical specialties. For providers (n=109), 84% of surveys sent were completed and analyzed. Most providers were between ages 30-39 (33%) or 40-49 (21%), and 41% had 50 or more experiences with telemedicine. The predominant specialty participating was Internal Medicine (27%). Mean provider TUQ scores were 4.3 for U, 4.1 for S, 3.8 for EU, 3.7 for ItQ, 3.6 for IfQ, and 2.7 for R. No association was found between mean TUQ scores and experience with telemedicine (p=0.31), age groups (p=0.06), or specialty (p=0.53). However, providers with more experiences with telemedicine scored significantly higher in Satisfaction (p=0.01) and Usefulness (p=0.02). The majority of providers (97%) agreed/strongly agreed that telemedicine improves access to care, yet 59% expressed concern about missing something they may have caught in person. Furthermore, older providers generally had lower reliability scores compared to younger providers (p=0.03), and also showed generally greater concern about losing personal interface with patients with the use of telemedicine than younger providers (p= 0.006). Conclusion The utility of telemedicine in cancer care during the COVID-19 pandemic was perceived favorably by both patients and providers. All patient groups scored highly on perceived safety, reduced stress and improved access, independently of subject characteristics. Older providers were more wary of the reliability of telemedicine and its effects on patient-provider relationships. These findings provide a useful benchmark for advancement of virtual care delivery in cancer care, beyond the COVID-19 pandemic. Citation Format: Andrea Leon, Rebecca Kaltman, Hannah Arem, Richard Amdur, Andrea Gesteira, Samuel Duffy, Christian Miller, Brooke Burgess, Christiane Morecock. Telemedicine usability for cancer care during the COVID-19 pandemic [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr SS2-09.

Will Protective Innovations Like the "Airway Box" Become Routine Practice After the Pandemic?: An Opinion Survey.

BackgroundTracheal intubation carries an elevated risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to the generation of aerosols containing high concentrations of the virus. An airway box was designed to mitigate the exposure of healthcare professionals performing intubations.AimWe evaluated usability and sustainability in the routine practice of the "airway box" as a protective device during high-risk airway procedures. Materials and methodsAfter institutional review board approval, clinicians were educated on using the device through simulation, intranet learning modules, and emailed resources. The airway box was made available in the emergency department, critical care units, perioperative area, and operating rooms. QR codes affixed to the box, emailed, and displayed in common areas provided easy access to complete a REDcap survey (Vanderbilt University Nashville, USA) eliciting providers’ experience. Data was collected and analyzed between April 1 and July 31, 2020, on REDcap, and the results were analyzed.Results687 emergent intubations took place. 232 were performed by anesthesiologists, 315 by emergency department providers, and 140 by critical care specialists. 39 surveys were completed, 29 from intubations in the operating room, three from the critical care units, five from interventional radiology suites, and two perioperatively. Providers found the device to be readily available, with a score of 4.51/5, and the majority of providers, 60%, found the device easy to use, rating it either a 4 or 5 out of 5. Providers acquired a mean Mallampati score of 1.75 and 1.40 mean laryngoscopic grade view.ConclusionIntubation boxes may effectively mitigate high-risk viral exposure during airway procedures. Survey responses show that devices were easy to use and did not significantly affect visualization of the airway. Similar to mask use, enclosure devices in clinical practice could become a vital part of medical protective equipment even after the SARS-CoV-2 pandemic if they are effectively implemented.

Smoking cessation and shared decision-making practices about lung cancer screening among primary care providers.

ObjectiveWe describe primary care providers’ current practice patterns related to smoking cessation counseling and lung cancer screening (LCS).MethodsFamily, internal medicine, and pulmonary medicine providers from two medical centers were asked to complete an electronic survey to report their practice patterns.ResultsOf 52 participating providers, most reported initiating three major components of a smoking cessation intervention often or very often: advise to quit (50, 96%), assess willingness to quit (47, 90%), and assist with counseling or pharmacotherapy (49, 94%). However, other components were less commonly initiated such as arranging follow‐ups (only 11 providers indicated recommending them often or very often, 21%) and less than half of providers reported that they often or very often recommend cessation counseling or pharmacotherapy of any type (except varenicline), though family medicine providers were more likely to recommend pharmacotherapy compared to the other specialists (p < 0.01). The majority of providers (47, 92%) reported that they engage in informed/shared decision‐making about LCS, although only about one‐third (17, 33%) indicated using a patient decision aid. Pulmonary medicine providers were more likely to use decision aids than providers from internal or family medicine (p < 0.04).ConclusionsWithin the context of LCS, primary care providers report often having conversations about smoking cessation with their patients who smoke, have no clear preference for type of treatment, and rarely use follow‐up calls or visits pertaining to quitting smoking. While many providers report engaging in shared decision‐making about LCS, few use a decision aid for this conversation.

A Checklist to Assess Childbearing Intentions and Promote Referral to Preconception Care or Contraception: A Multi-Site Study.

This study assesses HIV provider views on the value of a checklist designed to assess patients' preconception care (PCC) needs and guide implementation of PCC. Ninety-two HIV providers in seven U.S. cities provided perspectives via an in-depth phone interview regarding a checklist to facilitate communication and referrals for PCC. A sub-sample of 27 providers shared feedback on a checklist designed for this purpose. Interview audio files were transcribed and uploaded to a web-based program supporting coding and analysis of qualitative data. Content analysis was utilized to identify key themes within the larger, a priori themes of interest. Feedback regarding the checklist was analyzed using a grounded theory approach to examine patterns and emergent themes across transcripts. Providers averaged 11.5years of HIV treatment experience; over 80 percent were physicians (MD) or nurse practitioners (NP) and 76 percent were HIV/infectious disease specialists. The majority of providers were female (70%) and Caucasian (72%). Checklist benefits identified included standardization of care, assisting new/inexperienced providers, educational resource for patients, and aid in normalizing childbearing. Concerns included over-protocolizing care, interfering with patient-provider communication, or requiring providers address non-priority issues during visits. Providers suggested checklists be simple, incorporated into the electronic medical record, and accompanied with appropriate referral systems. Findings support a need for a checklist tool to assist in conversations about reproductive intentions/desires. Additional referral or innovative consultative services will be needed as more persons living with HIV/AIDS are engaged on the topic of childbearing.

Prescriber Acceptance of Pharmacist-Written Recommendations in a Home-Based Primary Care Setting at a Veterans Affairs Healthcare System

OBJECTIVE: To assess prescriber acceptance of pharmacist-written recommendations and to identify areas of improvement for implementing and tracking pharmacist-written reviews.DESIGN: Phase one was a retrospective study to evaluate prescriber acceptance of pharmacist-written recommendations. Phase two consisted of the distribution of a brief anonymous survey for prescribers to provide input on preferences for pharmacist-written recommendations.SETTING: Patients receiving Home-Based Primary Care (HBPC) services at VA Connecticut Healthcare System. PARTICIPANTS: Fifty veterans admitted to the HBPC program from January 2019 to April 2019 with at least 3 months of follow-up per patient.MAIN OUTCOME MEASURE: The primary outcome was the prescriber acceptance rate of HBPC pharmacistwritten recommendations.RESULTS: Out of 194 total pharmacist-written recommendations documented, 40.2% were accepted by providers. Specialty providers accepted a higher percentage of recommendations than primary care providers. Recommendations had a higher acceptance rate when both an attending provider and trainee were alerted (63.0%) versus an attending alone (36.1%). The anonymous survey concluded the majority of providers appreciate short, direct, clinically relevant summary recommendations.CONCLUSION: Overall, approximately 40% of the pharmacist-written recommendations were accepted and 66.7% were appropriately tracked, demonstrating there are opportunities for improvement. Formulating short, focused, and direct recommendations as well as ensuring to alert both attendings and trainees when indicated may optimize acceptance rates. Further research with a larger sample size is still needed to assess the barriers to prescriber acceptance of pharmacist-written recommendations.

Barriers and Facilitators to Promoting Oral Health Literacy and Patient Communication among Dental Providers in California.

Studies demonstrate that dental providers value effective provider-patient communication but use few recommended communication techniques. This study explored perspectives of California dental providers and oral health literacy experts in the United States on use of communication techniques. We conducted a qualitative key informant interview study with 50 participants between November 2019 and March 2020, including 44 dental providers (dentists, hygienists, and assistants) in public or private practice in California and 6 oral health literacy (OHL) experts. We undertook thematic analysis of interview transcripts and descriptive statistics about interviewees from pre-surveys. Dental providers reported frequently speaking slowly, and using simple language and models/radiographs to communicate with patients, while infrequently using interpretation/translation, illustrations, teach-back, or motivational interviewing. Providers reported using only 6 of the 18 American Medical Association’s (AMA) recommended communication techniques and only 3 of the 7 AMA’s basic communication techniques. A majority of providers indicated using one of five oral health assessment and educational strategies. Key barriers to effective communication included limited time, financial incentives promoting treatment over prevention, lack of OHL training, limited plain-language patient education materials, and patients with low OHL knowledge. Dental organizations should prioritize supporting dental providers in effective patient communication practices. Standardizing OHL continuing education, creating an evidence-based OHL toolkit for dental teams, ensuring accessible interpretation/translation services, and incentivizing dental providers to deliver education could improve oral health literacy and outcomes.

Physician Attitudes and Confidence Toward Dementia Capability: Screening, Diagnoses, and Referrals

The MaineHealth Alzheimer’s Disease Partnership is working to improve integration between the healthcare system and community partners through training and a referral network. Primary care providers are often the first to assess cognitively impaired patients, so it is important to understand their attitudes and confidence in dealing with dementia. The objective of this study is to determine barriers to care and evaluate healthcare providers’ attitudes towards their dementia capability, which includes screening for cognitive impairment, disclosing diagnoses, and making referrals to community-based organizations or specialists. A 27-item survey was developed and sent to 474 providers from MaineHealth practices via email. Fifty-three providers responded to the survey. Five healthcare professionals also took part in a focus group; looking more specifically at challenges encountered throughout the dementia care system. This poster will present the findings from the survey and focus group. There was strong agreement that much can be done to improve the quality of life for patients with dementia (86% agreed/strongly agreed) and that screening all patients over age 65 is important (85% agreed/strongly agreed). Confidence levels in ability to diagnose dementia, provide memory loss information, and refer patients to specialists were significantly associated with training (p<.05). The majority of providers identified barriers to cognitive screening and referring patients to community-based organizations, showing that improvements are needed at the system level to remove these barriers. Overall, the results suggest that dementia specific training can improve confidence in care and allow physicians to provide more information about memory loss to patients.

A regional analysis of payer and provider views on cholesterol management: PCSK9 inhibitors as an illustrative alignment model.

A regional analysis of payer and provider views on cholesterol management: PCSK9 inhibitors as an illustrative alignment model.

Practice Patterns in Hospitalized Adult Patients with Hemophilia: A Survey Study of US Hemophilia Centers

Introduction:The care of patients with hemophilia (PwH) is rapidly evolving, with novel uses for existing clotting factor concentrates (CFC) and the introduction of non-CFC hemostatic agents (e.g. emicizumab) recently approved by the Food and Drug Administration. However, inpatient care of PwH hospitalized for elective surgery or major bleeds does not follow standardized protocols, and the manner and extent to which novel therapeutic strategies are applied is unknown. Objective:We performed a nationwide survey to obtain information on the practice patterns of adult hematology providers practicing at accredited U.S. hemophilia treatment centers (HTC) in the inpatient care of PwH in the perioperative setting. Methods:Using a publicly available list of accredited HTC adult providers, 59 providers were contacted by email with the option to participate in a phone call or online survey. We aimed to collect information regarding the perioperative management of patients on emicizumab, postoperative factor level monitoring, type of CFCs routinely utilized in the inpatient setting, hospital length of stay, and use of venous thromboembolism (VTE) prophylaxis in the postoperative setting. All non-categorizable responses were excluded. Results: Providers from 10 out of 59 hemophilia centers contacted across the U.S. participated in a phone survey (n=5) or online survey (n=5). Responses were collected from providers practicing in the Mountain States (n=2), Southeast (n=2), Mid-Atlantic (n=2), New England (n=2), Northern States (n=1), and undisclosed (n=1). Of the participating providers, 80% had experience managing patients on emicizumab who had undergone elective surgery or experienced major bleeding. Perioperative management of patients undergoing elective surgery on emicizumab by center was as follows: a single pre-operative bolus of FVIII (n=1), unmonitored weight-based CFC for the same duration as patients not on emicizumab (n=5), and monitored weight-based CFC using a bovine chromogenic assay for the same duration as patients not on emicizumab (n=2). One provider who had not yet cared for patient on emicizumab undergoing elective surgery anticipated that they would preemptively discontinue emicizumab and treat with CFC alone perioperatively. Ninety percent of providers monitored factor levels in hospitalized PwH after elective surgeries; length of monitoring varied between 1-2 days (n=3), 4-5 days (n=1), daily or every other day while inpatient (n=4), or through utilization of surgical site dependent monitoring (n=1). Of those who monitored factor levels, 67% measured both peaks and troughs, while 33% monitored troughs alone. For postoperative inpatient CFC infusion, 60% of providers used standard half-life products alone, while 30% used both standard and extended half-life (EHL) products for hospitalized PwH, generally with the EHL product given preoperatively. Forty percent of providers employed bolus CFC delivery alone while 60% used a combination of bolus and continuous infusions in their practice. Mean length of hospital stay after elective surgery varied between centers and ranged from 1-2 days up to 5-7 days depending on factor levels, pain management, and/or physical therapy needs. Length of stay was highly variable for major bleeds and non-elective surgeries depending on severity of illness and location of bleed. VTE prophylaxis was not given postoperatively by 70% of providers, another 20% of providers reported they may conditionally consider it, and the remaining 10% prescribed either enoxaparin or apixaban to all PwH on CFCs getting elective surgery while hospitalized. Conclusions:Practice patterns of medical providers caring for PwH hospitalized for elective surgery or major bleeding are highly variable across institutions. While the majority of participating providers reported monitoring factor levels in inpatients, the length of monitoring and measurements of peaks/troughs varied. EHL products are being used occasionally in hospitalized patients. The majority of providers do not prescribe VTE prophylaxis inpatient. Additional studies are required to clarify the optimal management strategy in this complex patient population. Disclosures Shatzel: Aronora, Inc.:Consultancy.

S0551 Variability in Endoscopic Tattoo Practices Among Colorectal Surgeons and Gastroenterologists: A Nationwide Survey

INTRODUCTION: Effective tattooing is pivotal in localizing suspected malignant colorectal lesions for subsequent resection which has shown to reduce operating room time with significant cost savings. Despite its utility and widespread use, there are no established guidelines regarding optimal location or technique of tattooing. This has created wide variability in provider practices in the gastroenterology (GI) and colorectal surgery (CRS) communities. Thus, we sought to elucidate current practices among these providers. METHODS: A national online survey was e-mailed to directors of adult GI and CRS programs in the US, with additional distribution to their fellows and colleagues. RESULTS: Majority of providers, 93 of 108 (86.1%), practice tattooing to mark suspected colorectal cancer lesions for removal- GI (68 of 78, 87.2%) and CRS (25 of 30, 83.3%). Most GI providers tattoo proximal and distal to the lesion (57.7%) compared to most CRS who tattoo 2-3cm distal to the lesion (76.7%), this was statistically significant( P < 0.001, OR = 9.52, CI = 3.6–25.5). This remained unchanged when correcting for variables such as practice setting, age, gender and training. For tattoo injection technique, providers in both specialties inject while withdrawing the needle (80.8% of GI and 73.3% of CRS, P = 0.227), rather than while advancing it; usually 2 to 3 marks are placed at the tattoo site (72.2% of providers). Most providers do not tattoo cecal lesions—76.9% of GI and 73.3% of CRS—but tattoo practices for lesions in the rectum are more inconsistent with only 39.7% of GI tattooing these compared to 73.3% of CRS. CONCLUSION: Although there is paucity of data in tattooing techniques, published literature reports appropriate location for tattooing of suspected lesions to be 2-3cm distal to the lesion and technique to be injection of dye upon advancement of needle into the submucosal space. A minority of GI (25.6%) but a majority of CRS (76.7%) tattooed in the correct location, which was statistically significant. Both specialties had few providers using correct technique: 16.7% of GI and 6.7% of CRS. Our survey confirms the great variability in practices between GI and CRS, as well as within these respective groups. Tattooing practices are oftentimes institution dependent given the lack of national guidelines. There is a dire need for nationwide standardization of practices for improvement in efficacy and cost of patient care, especially for those receiving interfacility care.Table 1

Engagement and Activities in Long-Term Care: Tapping Into “I Would Love to Do That!”

Engagement and Activities in Long-Term Care: Tapping Into “I Would Love to Do That!”

Orbital Compartment Syndrome Following Major Burn Resuscitation: A Case Series and Survey of Practice Patterns.

Orbital compartment syndrome (OCS) is a rare but devastating complication of over-resuscitation in burn patients that may lead to permanent visual loss. The purpose of this study was to 1) present a series of burn patients with OCS and 2) survey practice patterns of monitoring intra-ocular pressure (IOP) during burn resuscitation. Cases of OCS at two American Burn Association (ABA)-verified burn centers were retrospectively reviewed. Patients were included if they 1) required lateral canthotomy/cantholysis for elevated IOPs or 2) developed blindness on admission unrelated to any other ocular pathology. Data were collected on demographics, burn characteristics, fluid administration, ophthalmologic findings, and complications. An eight-item electronic survey was distributed by email through the ABA to all physician members. Twelve patients with OCS were identified, with a mean age of 47.8 ± 12.4 years and TBSA of 63.7 ± 18.6%. Mean fluid resuscitation at 24 hours was 4.9 ± 1.6 ml/kg/%TBSA or 0.29 ± 0.06 liter/kg. Eight patients underwent canthotomy/cantholysis for OCS, whereas four were later found to have visual loss. A total of 83 (14%) ABA physicians responded to the survey. IOP was routinely measured by 23% of respondents during acute burn resuscitation. OCS appears to have developed despite a relatively low 24-hour ml/kg/% burn resuscitation volume, but with a relatively higher cumulative (liter/kg) fluid volume. Their survey found that monitoring of IOP during burn resuscitation is not routinely performed by the majority of providers. Taken together, the present study suggests clinical guidelines to recognize this complication of over-resuscitation.

Barriers to the early integration of palliative care in pediatric oncology in 11 Eurasian countries.

The early integration of palliative care significantly improves quality of life for children with cancer. However, cultural, structural, and socioeconomic barriers can delay the integration of palliative care into cancer care, particularly in low-income and middle-income countries. To date, little is known regarding the timing of and barriers to palliative care integration in Eurasia. The Assessing Doctors' Attitudes on Palliative Treatment (ADAPT) survey evaluates physician perceptions regarding palliative care integration into pediatric oncology in Eurasia. This evidence-based survey was adapted to the regional context; iteratively reviewed by US and regional panelists; and piloted in English, Russian, and Mongolian. After distribution to physicians caring for children with cancer, statistical analysis was complemented by qualitative analysis of open-ended responses. A total of 424 physician responses were received from 11 countries in the Eurasian region. Study findings demonstrated wide variability in access to palliative care experts across countries (18%-96%), with the majority of providers (64%) reporting that the initial palliative care consultation typically occurs when curative options are no longer available. Providers desired an earlier initial palliative care consultation than what currently occurs in their setting (P<.001). Primary barriers to timely consultation included limited access to palliative care services and specialists, lack of physician education, and perceived family resistance. The current study is the first to identify physician perceptions of the delayed timing of palliative care integration into childhood cancer care and associated barriers in Eurasia. These findings will inform the development of targeted interventions to mitigate local structural and cultural barriers to access and facilitate earlier palliative care integration in the region.

Mixed-Methods Evaluation of Multiple Perspectives on Breast Cancer Control to Guide Stakeholder Selection of Implementation Strategies: The Time to A.C.T. Study in Mwanza, Tanzania

PURPOSE Tanzania recently developed national guidelines for early diagnosis of breast cancer to combat increasing incidence and mortality. The aim of this multiphase, adaptive implementation science study was therefore to assess the local context, couple implementation strategies with identified barriers, and test these strategies to improve breast cancer control, creating an adaptive A.C.T. framework with broad applicability to other low- and middle-income country settings. METHODS The assessment phase was made up of a broad medical chart review of women seeking care for breast concerns (n = 664); a knowledge, attitudes, and practices survey of community women (n = 1,129); and a knowledge, attitudes, and practices survey of health care providers (n = 114), followed by in-depth interviews (n = 15). RESULTS Women presented to the Zonal Hospital with swelling (45%) or a palpable lump (31%), with an average symptom duration of 6 months. Most diagnoses were based on clinical exam only (54%) and included 16% breast cancer. Of these, 43% had no treatment recorded, 50% had surgery at a median of 2.5 months, and 7% had chemotherapy only. Knowledge surveys indicated that 59% of women had heard of breast cancer, but only 14% felt they knew any signs or symptoms. Encouragingly, 56% were fairly to very confident that they would notice breast changes, and 74% said they would be somewhat to very likely to seek care, with 96% noting the severity of symptoms as a motivator. Providers indicated that barriers to care included low community knowledge and repeated misdiagnosis at the primary level. The majority of providers (95%) believe clinical breast examination is feasible to implement for symptomatic patients, yet only 65% feel they have sufficient training. CONCLUSION In all, 8 larger barriers were synthesized and linked to evidence-based interventions as potential solutions. All barriers and solutions were ranked by key stakeholders on the basis of feasibility, importance, and sustainability. These were incorporated into a 3-component intervention to improve breast cancer care at the Zonal Hospital and rollout is underway.

Bacterial vaginosis diagnosis and treatment in postmenopausal women: a survey of clinician practices

Some diagnostic features of the genitourinary syndrome of menopause (GSM) and bacterial vaginosis (BV) overlap, such as low levels of vaginal Lactobacillus and pH > 5. We sought to determine clinicians' diagnostic and treatment practices for postmenopausal women presenting with BV and GSM scenarios and how commercial molecular screening tests are utilized. Anonymous surveys were sent to practicing women's health clinicians to evaluate assessment and treatment strategies for postmenopausal women presenting with BV and GSM scenarios. When given a scenario of a postmenopausal woman with symptoms overtly positive for BV, a majority of providers (73%) would conduct a wet mount, though only 35% would evaluate full Amsel's criteria. A majority (89%) recommended treatment with antibiotics, 28.2% recommended vaginal estrogen in addition to antibiotics, and 11.8% recommended vaginal estrogen alone. Of providers who would use a molecular swab, 30% would wait for results before treating the patient's symptoms. When given a scenario of a postmenopausal woman presenting with GSM, a majority (80%) recommended vaginal estrogen, and only 4.6% recommended antibiotics. Few (16%) responders would evaluate with a molecular swab, half of whom would wait for results before prescribing treatment. Clinicians in practice for less than 10 years were more likely to rely on molecular swabs than those who had been practicing longer (P < 0.0003). Methods used to evaluate postmenopausal women with vaginal symptoms vary. Future studies of postmenopausal women that differentiate diagnostic criteria between BV and GSM, and validate commercial molecular testing for BV in women over age 50 are needed.

Lichen sclerosus among women in the United States.

BackgroundVulvar lichen sclerosus (LS) is a chronic dermatosis for which the true prevalence is not well established. LS remains an underrecognized and undertreated disease, and treatment patterns and differences among various specialties that care for patients with LS are largely unknown.ObjectiveThis study sought to determine the prevalence of diagnosed vulvar LS, demographic characteristics, and diagnostic and treatment patterns in the United States.MethodsA database comprising >21.7 million women with commercial insurance in the United States was analyzed, and the largest cohort of patients with LS in the United States to date was identified.ResultsWe found that obstetricians/gynecologists are diagnosing and managing approximately half of women with LS, and regardless of specialty, the majority of providers are appropriately prescribing high-potency topical steroids.ConclusionOur results suggest that LS may truly be underrecognized and underdiagnosed, especially in younger women.

Abstract 376: Adverse Pregnancy Outcomes and Cardiovascular Risks Multi-disciplinary Awareness Project

Background: Cardiovascular disease (CVD) remains the number one cause of death amongst women. There has been much effort put forth over the past decade in reducing both the incidence and prevalence of this disease burden through screening and treating the traditional risk factors. Recent guidelines have shown that adverse pregnancy outcomes (APOs), including pre-eclampsia (PEC), gestational diabetes mellitus (GDM) and pre-term birth (PTB) have been associated with future maternal CVD risk. Much of the current literature focuses almost exclusively on PEC. Our investigation is more comprehensive, covering not only these other APOs but assessing whether providers of multiple specialties in our community are aware of the APO to CVD risk association. The primary objective of this study was to investigate if there exist any knowledge gaps regarding the progression from APO to CVD and if this knowledge varies by specialty. Methods: An anonymous voluntary survey through REDCap© was sent to providers in the fields of Internal medicine (IM, 21%), Family medicine (FM, 26%), Obstetrics-Gynecology (Ob-Gyn, 23%) and Cardiology (30%) who have been in practice for greater than five years in our local Gainesville community. This project was registered as a QI project and descriptive analysis was used to examine the responses. Results: A total of 53 providers responded to the survey. Despite having the majority of patients being women, Ob-Gyn was the least likely amongst all specialties to routinely screen for CV risk factors. However, when addressed, they were the most likely to ask about APOs. Cardiologists, despite declaring to be aware of the association between APOs and CV risk, were least likely to ask about APOs. All specialties recognized PEC and GDM as APOs linked to long-term maternal CV risk but failed to associate PTB as an APO. The majority of providers amongst IM, FM, and Cardiology did not ask about APOs and lacked the knowledge of how often to appropriately screen for secondary risk factors associated with APOs. Additionally, these providers outright admitted that they are not familiar with the current AHA and/or ACOG guidelines for screening and follow-up. Conclusion: Descriptive statistical analysis of our data suggests that there exists a notable knowledge gap between all four specialties investigated in our survey. Education concerning the link between APOs and future maternal CV risk is needed amongst all specialties, especially amongst the providers in Cardiology, IM, and FM. Targeted efforts at our institution to improve awareness of all APOs, their associated secondary risk factors, and appropriate screening is required in all specialties to help reduce CVD morbidity and mortality.

Analysis of Sinus Balloon Catheter Dilation Providers Based on Medicare Provider Utilization and Payment Data.

The use of balloon catheter dilation (BCD) to treat chronic rhinosinusitis has increased dramatically since its conception, necessitating further characterization of BCD providers and trends in its usage. Medicare data on BCD providers have made it possible to study recent demographic patterns. There has also been an increase in mid-level providers' scope of otolaryngologic practice that is not well defined. To better understand BCD adoption by studying volume of BCD procedures as well as training, geography, and practice socioeconomic characteristics of BCD providers for Medicare beneficiaries. We reviewed Medicare Provider Utilization and Payment Data Public Use Files for 2014 and 2015 for providers with claims for BCD of the sinuses. We extracted provider zip code, state, gender, and number of services per BCD code. We obtained median household income by zip code and geographic region based on US Census Bureau data. Providers were classified using an Internet search to determine practice setting and type of specialty training/certification. In 2014 and 2015, 428 providers performed 42 494 BCDs billed to Medicare beneficiaries. Among BCD providers, 5.1% were female, 98.1% had Doctor of Medicine/Doctor of Osteopathic Medicine credentials, and 1.9% had nurse practitioner/physician assistant credentials. Over the 2-year period, the median number of BCDs was 63 for physicians and 37 for mid-level providers. Fellowship-trained rhinologists performed a median of 38 BCDs over 2 years. The most common subspecialty certification/training was in facial plastics and reconstructive surgery. The majority of providers (63.8%) performed 1 to 99 BCDs over the 2 years. In the South, there were 21.9 BCD procedures performed per 100 000 people compared to 7.3 in the Northeast, 9.3 in the Midwest, and 8.5 in the West. There is a large range in total BCD procedures performed by individual providers, and this varies by certain provider characteristics. Mid-level providers have emerged as a significant population performing BCD.

Health Care Provider Barriers to HIV Pre-Exposure Prophylaxis in the United States: A Systematic Review.

Increasing prescription of pre-exposure prophylaxis (PrEP) is imperative to ending the HIV epidemic in the United States. The objective of this review was to identify health care provider barriers to PrEP implementation. A systematic review was conducted in February 2019 using PubMed to identify barriers to PrEP prescribing practices in the United States. Targeted search terms surrounding PrEP and providers resulted in 222 original studies, 28 of which were ultimately included in our review, with data collected between 2011 and 2018. Six themes were identified across reviewed studies: (i) a lack of PrEP knowledge, (ii) the presence of the Purview Paradox, which refers to discordance in beliefs between HIV specialists and primary care providers on who should prescribe PrEP, (iii) concerns about PrEP costs, (iv) concerns about behavioral and health consequences, (v) interpersonal stigma, and (vi) concerns about patient adherence. A majority of providers were lacking knowledge regarding PrEP, resulting in discomfort in prescribing PrEP, or limited awareness and understanding of PrEP clinical guidelines. Discrepant opinions were identified regarding whether PrEP was best managed within primary care or specialty clinics. Other barriers included concerns about cost, patient adherence, and follow-up maintenance care. Finally, concerns about risk compensation and discomfort discussing sexual activities with patients who would benefit most from PrEP were apparent. Additional work is needed to prepare providers to prescribe and manage patients on PrEP, optimize PrEP delivery, and reduce provider bias. Future research is needed to identify providers' attitudes and beliefs regarding innovations in PrEP dosing, task shifting, and novel strategies for PrEP care.