NorthShore University HealthSystem Research Articles

Effectiveness of Antimicrobial Use and Diagnostic Testing in the Postoperative Setting for Colectomy, Craniectomy and Knee Arthroplasty

BackgroundPatients with postoperative fevers tend to receive empiric antibiotics and a diagnostic workup even though postoperative fevers are frequently physiologic. The yield of postoperative workups ranges from 2–24%. Studying the effectiveness of antibiotic use and diagnostic testing across surgeries may provide insight to improve value of care for the postoperative patient.MethodsWe evaluated all patients who had elective colectomy, craniectomy and knee arthroplasty (KA) at NorthShore University HealthSystem between October 2009 and December 2013. Inpatient clinical data were extracted from the electronic data warehouse. All complications were confirmed by chart review. Antimicrobial Effectiveness was defined as the use of antibiotics only when patient had a confirmed infectious complication (pneumonia, urinary tract infection, etc) during hospital course. Diagnostic Effectiveness was defined as the use of diagnostic test only when patient had a confirmed complication. Length-of-stay (LOS) and cost were compared using Student’s t-test.Results233 patients had a colectomy, 506 had a craniectomy and 4,693 had a knee arthroplasty. Antibiotic and Workup Effectiveness rates were 51% and 45.33% for colectomy, 18% and 22.53% for craniectomy, and 27%and 9.89% for KA, respectively. Effectiveness of antimicrobial use and diagnostic workups are shown in Figure 1. Patients without complications in all 3 surgeries who had a workup, as compared with those patients without a workup, were more likely to have a longer LOS (colectomy: 8.95 days vs. 5.08 days, P < 0.0001; craniectomy: 4.88 days vs. 2.62 days, P < 0.001; KA: 3.22 days vs. 2.95 days, P < 0.0001) and a higher cost of hospitalization (colectomy: $76,034 vs. $42,865, P < 0.001; craniectomy: $83,779 vs. $58,998, P < 0.001; KA: $53,451 vs. $52,159, P < 0.001).ConclusionA significant fraction of empiric antibiotics in the postoperative setting are unnecessary across multiple surgeries. Diagnostic testing effectiveness rates are low and have consequences in terms of healthcare utilization.Disclosures All authors: No reported disclosures.

Weighing in: Effect of BMI on Postoperative Fever and Complications in Patients Undergoing Three Distinct Surgeries

BackgroundCurrent trends estimate a 33% increase in obesity and 130% increase in severe obesity by the year 2030. It is unclear what the effect of obesity is on postoperative fevers, postoperative complications, and diagnostic workup rates.MethodsWe evaluated 5,330 patients undergoing knee arthroplasty, colectomy, or craniectomy from October 2009 to December 2014 at NorthShore University HealthSystem, in Illinois. Clinical data were extracted from the Enterprise Data Warehouse, including diagnostic testing and complications. Complications were also verified by physician chart review. Χ2 and Mann–Whitney U tests were used to analyze categorical and continuous variables.ResultsObesity (BMI ≥ 35) was present in 1081 (23.4%) of knee arthroplasty, 38 (16.9%) of colectomy and 55 (12.6%) of craniectomy patients. There was no increase in complications by BMI in each individual surgery except for increased 30-day readmissions in craniectomy patients with BMI ≥ 35 (P = 0.032). Collectively, there was no difference in the relationship between BMI and rate of post-op complications (Table 1). However, patients with BMI ≥ 35 experienced more fevers (P = 0.002), underwent additional workup (0.011), and had higher workup costs (P < 0.001).ConclusionPatients with BMI ≥ 35 had more fevers, more workups and higher cost, but not higher complication rates during the index hospitalization after surgery. Awareness of the predisposition towards post-op fever in obese patients in the absence of complication may prevent costly and unnecessary testing. More work is still needed to understand the effect of obesity on more distant complication rates.Table 1: Post-Surgical Characteristics, Stratified by BMIBMI < 35 kg/m2, N = 4,156BMI ≥ 35 kg/m2, N = 1,174 P-valueSurgery Knee arthroplasty3533 (85%)1081 (92.1%)<0.001 Colectomy187 (4.5%)38 (3.2%) Craniectomy436 (10.5%)55 (4.7%)Fever ≥100.4696 (16.7%)242 (20.6%)0.002Fever ≥ 101329 (7.9%)125 (10.6%)0.003Any Work-Up2409 (58%)729 (62.1%)0.011Any in-hospital complication341 (8.2%)86 (7.3%)0.327Median work-up costs, dollars (IQR)51,038 (46656–57436)52,697 (48644–58517)<0.001Median length of stay, days (IQR)3.0 (2.0–3.0)3 (2.0–3.0)0.52430 days Readmission184 (4.4%)53 (4.5%)0.898Death w/in 30 days12 (0.3%)3 (0.3%)0.754Disclosures All authors: No reported disclosures.

Peritoneal dialysis catheter function and survival are not adversely affected by obesity regardless of the operative technique used.

Obesity has been considered a relative contraindication to peritoneal dialysis (PD). Surprisingly, PD catheter dysfunction rates and longevity have not been studied in the growing obese ESRD population. The aim of this study was to determine the effect of patient weight on PD catheter survival in the three insertion technique categories of advanced laparoscopy (AL), basic laparoscopy (BL), and open. We examine retrospectively collected data on 231 consecutive PD catheter insertions at the NorthShore University HealthSystem between 2004 and 2014. Three cohorts were created based on the catheter insertion technique: open, BL using selective adhesiolysis, and AL using rectus sheath tunnel, selective omentopexy, and adhesiolysis. Primary outcomes included catheter dysfunction and catheter dysfunction-free survival for each cohort by BMI: normal weight (18.5-24.9), overweight (25-29.9), obese (≥30). Nominal variables were compared using Chi-square test, continuous variables using ANOVA or Kruskal-Wallis tests, and catheter survival was assessed using the Kaplan-Meier method with log-rank test. Statistical significance was established at 0.05. For the three BMI categories, there were no statistically significant differences in patient demographics. There were no statistically significant differences in catheter dysfunction or peri-operative complications by BMI category among all patients. This was also true in the AL cohort. Among all patients, similar 2-year dysfunction-free catheter survival was noted for normal weight, overweight, and obese patients (log-rank p=0.79). This was also true across all insertion techniques: open (log-rank p=0.87), BL (log-rank p=0.41), AL (log-rank p=0.43). In the obese cohort, the 2-year dysfunction-free catheter survival was 91.1% in AL, 83.5% in BL, and 65.7% in open (log-rank p=0.58). Obesity does not increase complications or shorten dysfunction-free PD catheter survival regardless of the operative technique used. Obesity should not be considered as a relative contraindication to PD catheter placement as it confers similar technique success to normal- and overweight individuals.

Influenza vaccine formulation and effectiveness

Send your immunization questions to the JAPhA Contributing Editors who coordinate the Vaccine Update column: ▪Mary S. Hayney, PharmD, MPH, BCPS, Professor of Pharmacy, School of Pharmacy, University of Wisconsin, Madison ([email protected]). Alexandra S. Ribaudo, PharmD, PGY-1, Department of Pharmacy, North Shore University Health System, Evanston, IL; at time of study: student pharmacist, University of Wisconsin–Madison School of Pharmacy, Madison, WI Mary S. Hayney, PharmD, MPH, Professor of Pharmacy, University of Wisconsin–Madison School of Pharmacy, Madison, WI

Risk of Second Seizure in Pediatric Patients With Idiopathic Autism.

Epilepsy is a comorbidity of idiopathic autism spectrum disorder. The aim was to characterize the risk and time of second seizure in children with idiopathic autism spectrum disorder. A retrospective review was performed at the University of Chicago and NorthShore University HealthSystem. Patients with idiopathic autism spectrum disorder, ≥1 seizure, and age 2 to 23 years were included. 153 patients were included; 141 (92%) had a second seizure. The average age at first seizure was 7.14 years (median: 5.08 years) and 8.12 years (median: 7.3 years) at second seizure. Average time between first and second seizure was 7.68 months. A high risk of seizure recurrence was found in this population. There was a short time to second seizure, with most having a recurrence within 1 year. These findings may be used to guide therapy in children with autism spectrum disorder and epilepsy.

Optimizing Flu Vaccine Planning at NorthShore University HealthSystem

Stan Kent, vice president of pharmacy at NorthShore University HealthSystem, is faced with the challenge of seasonal planning for the influenza vaccine. The supply received by the multilocation healthcare system is unreliable in terms of timing and quantity. As part of improved planning, Kent is contemplating a new contract with NorthShore's major supplier of flu vaccines. The options under consideration include fixing either the date of delivery or the quantity delivered. The main decision involved in either option would be how much vaccine to order. The case also provides details about the seasonal influenza epidemic in the United States, illustrates operational complexities of the U.S. flu vaccine supply chain, and provides a brief description of the various channels used to distribute flu vaccine to end consumers.The main objective of the case is to illustrate supply chain decision making when there is an unreliable supply (in contrast to the usual case of uncertain demand). A secondary objective is to make students think about appropriate internal (within sector) and external (other sectors) benchmarks to evaluate the performance of a health commodity supply chain.

Implementation of a multidisciplinary pharmacogenomics clinic in a community health system.

The development and implementation of a multidisciplinary pharmacogenomics clinic within the framework of an established community-based medical genetics program are described. Pharmacogenomics is an important component of precision medicine that holds considerable promise for pharmacotherapy optimization. As part of the development of a health system-wide integrated pharmacogenomics program, in early 2015 Northshore University Health-System established a pharmacogenomics clinic run by a multidisciplinary team including a medical geneticist, a pharmacist, a nurse practitioner, and genetic counselors. The team identified five key program elements: (1) a billable-service provider, (2) a process for documentation of relevant medication and family histories, (3) personnel with the knowledge required to interpret pharmacogenomic results, (4) personnel to discuss risks, benefits, and limitations of pharmacogenomic testing, and (5) a mechanism for reporting results. The most important program component is expert interpretation of genetic test results to provide clinically useful information; pharmacists are well positioned to provide that expertise. At the Northshore University HealthSystem pharmacogenomics clinic, patient encounters typically entail two one-hour visits and follow a standardized workflow. At the first visit, pharmacogenomics-focused medication and family histories are obtained, risks and benefits of genetic testing are explained, and a test sample is collected; at the second visit, test results are provided along with evidence-based pharmacotherapy recommendations. A multidisciplinary clinic providing genotyping and related services can facilitate the integration of pharmacogenomics into clinical care and meet the needs of early adopters of precision medicine.

Personalized, Genomic-Based Care Could Mean a Paradigm Shift

Personalized, Genomic-Based Care Could Mean a Paradigm Shift

Increasing compliance with the World Health Organization Surgical Safety Checklist—A regional health system's experience

BackgroundIn 2009, NorthShore University HealthSystem adapted the World Health Organization Surgical Safety Checklist (SSC) at each of its 4 hospitals. Despite evidence that SSC reduces intraoperative mistakes and increase patient safety, compliance was found to be low with the paper form. In November 2013, NorthShore integrated the SSC into the electronic health record (EHR). The aim was to increase communication between operating room (OR) personnel and to encourage best practices during the natural workflow of surgeons, anesthesiologists, and nurses. The purpose of this study was to examine the impact of an electronic SSC on compliance and patient safety. MethodsAn anonymous OR observer selected cases at random and evaluated the compliance rate before the rollout of the electronic SSC. In June 2014, an electronic audit was performed to assess the compliance rate. Random OR observations were also performed throughout the summer in 2014. Perioperative risk events, such as consent issues, incorrect counts, wrong site, and wrong procedure were compared before and after the electronic SSC rollout. A perception survey was also administered to NorthShore OR personnel. ResultsCompliance increased from 48% (n = 167) to 92% (n = 1,037; P < .001) after the SSC was integrated into the electronic health record. Surgeons (91% vs 97%; P < .001), anesthesiologists (89% vs 100%; P < .001), and nurses (55% vs 93%; P < .001) demonstrated an increase in compliance. A comparison between risk events in the pre- and post-rollout period showed a 32% decrease (P < .01). Hospital-wide indicators including length of stay and 30-day readmissions were lower. In a survey to assess the OR personnel's perceptions of the new checklist, 76% of surgeons, 86% of anesthesiologists, and 88% of nurses believed the electronic SSC will have a positive impact on patient safety. ConclusionsThe World Health Organization SSC is a validated tool to increase patient safety and reduce intraoperative complications. The electronic SSC has demonstrated an increased compliance rate, a reduced number of risk events, and most OR personnel believe it will have a positive impact on patient safety.

Point-Counterpoint: A Nucleic Acid Amplification Test for Streptococcus pyogenes Should Replace Antigen Detection and Culture for Detection of Bacterial Pharyngitis.

Nucleic acid amplification tests (NAATs) have frequently been the standard diagnostic approach when specific infectious agents are sought in a clinic specimen. They can be applied for specific agents such as S. pyogenes, or commercial multiplex NAATs for detection of a variety of pathogens in gastrointestinal, bloodstream, and respiratory infections may be used. NAATs are both rapid and sensitive. For many years, S. pyogenes testing algorithms used a rapid and specific group A streptococcal antigen test to screen throat specimens, followed, in some clinical settings, by a throat culture for S. pyogenes to increase the sensitivity of its detection. Now S. pyogenes NAATs are being used with increasing frequency. Given their accuracy, rapidity, and ease of use, should they replace antigen detection and culture for the detection of bacterial pharyngitis? Bobbi Pritt and Robin Patel of the Mayo Clinic, where S. pyogenes NAATs have been used for well over a decade with great success, will explain the advantages of this approach, while Richard (Tom) Thomson and Tom Kirn of the NorthShore University HealthSystem will discuss their concerns about this approach to diagnosing bacterial pharyngitis.

STRUCTURED CLINICAL DOCUMENTATION FOR PATIENT CARE AND PRACTICE-BASED RESEARCH IN MCI AND DEMENTIA

To improve quality of care of patients with mild cognitive impairment and dementia, we used the electronic medical record to develop structured clinical documentation support (SCDS) tools following quality guidelines for MCI and dementia. The tools also prompted enrollment in practice-based research, including in a DNA biobank beginning in September 2014. The toolkits assess cognitive, behavioral/psychological, and motor symptoms and also include the Barthel Index, Functional Activities Questionnaire (FAQ), Geriatric Depression Scale (GDS), and Montreal Cognitive Assessment (MoCA). The Functional Assessment Stage Test is used for disease staging. All patients referred to the NorthShore University Health System Department of Neurology for an evaluation of changes in cognition or behavior are evaluated with our SCDS toolkit at initial visit and annual follow-up visits. At the initial visit, a diagnosis of MCI or dementia electronically prompted the physician to enroll the patient in the DNA biobank. There were 251 patients (103 with MCI and 148 with dementia) enrolled in the biobank. Median age at enrollment was 76 (mean 74.6). Most patients were initially evaluated within 4 years of symptom onset, and a similar age at onset was noted in men and women. Executive symptoms and irritability appeared to occur more frequently in men compared to women but did not reach statistical significance. Overall, there was no significant gender difference in current symptoms at the initial evaluation. However, there was a statistically significant difference between men and women for the place of living (Fisher test, p-value=0.001), with more women living in assisted living and more men living at home, which may reflect women outliving their spouses. There was no gender difference in MoCA scores or in the distribution of MCI or dementia diagnoses. Pairwise correlations found inverse correlations between age at onset and disease duration and between FAQ and MoCA. The GDS and MoCA were directly correlated. Multidimensional comparisons using principal component analysis revealed that the FAQ accounted for most of the variance between the 6 continuous trait measures (age at onset, disease duration, Barthel Index, FAQ, MoCA, and GDS). Our SCDS toolkit efficiently measures and improves the quality of care in memory disorders and through data capture has the potential to support multicenter practice based research.

553 SIG-1191: A novel hydrating Cosmetic Functional Ingredient (CFI) for suborbital hyperpigmentation (under eye dark circles)

548 Effects of a natural immune modulator on plaque psoriasis N Korman, E Baron, K Gordon, S Glazer, S Phillips and JE Bernstein 1 University Hospitals, Cleveland, OH, 2 Northwestern University, Chicago, IL, 3 Northshore University Health System, Evanston, IL and 4 Elorac, Inc., Vernon Hills, IL Background: Recognition that psoriasis (PS) is a chronic inflammatory disorder, rather than a local hyperproliferative disorder, has led to the understanding that proinflammatory cytokines contribute to the initiation and/or persistence of inflammation in PS. These cytokines and their transduction pathways, include tumor necrosis factor alpha (TNF-a), various interleukins (IL), the Janus kinases and phosphodiesterase 4. Objective: To evaluate oral administration of a natural immune modulator(NIM) to patients with plaque PS receiving concomitant treatment with biological drugs, and effects of NIM on inflammatory biomarkers in treatment-naive PS patients. Methods: Nineteen (19) adult PS patients receiving a biologic (ustekinumab (9), adalimumab (7), etanercept (3)) for at least 3mo received NIM capsules qd for 8wks. Clinical benefits were assessed by a Self-Administered Psoriasis Area Severity Index (SAPASI), a patient global, and an evaluation of body surface area (BSA). Nineteen (19) PS patients without therapy for 90 days, or biological for 1yr, received NIM for 28 days. Serum TNF-a, IL-6 and IL-12 biomarkers were measured at baseline and at 28 days. Adverse effects (AE) were solicited. Results: Baseline SAPASI scores ranged from 4-60 (mean of 16.5). These scores were reduced to a mean SAPASI of 6.7 at 8wk. Of 11 patients with a baseline SAPASI>10, 91% had an 8wk PASI 50 and 55% had an 8wk PASI 75. Patient globals demonstrated that 63% of patients were Much Better or Better. Ten (10) patients (53%) had a substantial BSA decrease in. Eleven (11) of 19 patients had a decrease in serum TNF-a levels with a mean decrease of 18.6% and 10 of the 19 patients (53%) had a 47.3% mean reduction in IL-6/IL-12 serum levels. No NIM related AE were reported. Conclusions: Addition of NIM to PS patients on biologicals can provide additional clinical benefit, and the actions of the NIM may be related to its ability to inhibit a variety of inflammatory pathways critical to PS. 549 Antioxidative Activity of CSL Extracts on normal human epidermis J Shim Department of Oriental Cosmetic Science, Semyung Univ, Jecheon, Korea (the Republic of) In this study, the antioxidative effects of CSL extracts were investigated. CSL extract has the similar antioxidant activity compared to ascorbic acid by DPPH assay. To confirm the antioxidnat effect on human epiermal keratinocyte, we treated CSL extract on UVA (5 J/cm2) treated human epidermal keratinocyte. CSL extract can enhance the expression of AQP3 and HAS2 genes. And CSL extract reduced the H2O2 production by UVA treatment. To determine the cause of antioxidnat activity on human epidermal keratinocyte, we performed realtime PCR related on antioxidnat enzymes such as SODs, catalase, and GPXs. Only GPX7 mRNA expression was enhanced by CSL extract treatment. These results mean that CSL extract have radical scaveging and inducing the expression of antioxidant enzyme especially GPX7. And component analysis of CSL extract and antioxidant activity could be applicable to new functional cosmetics.

Obesity increases the risk of failure of noninvasive prenatal screening regardless of gestational age

Noninvasive prenatal screening has become an increasingly prevalent choice for women who desire aneuploidy screening. Although the test characteristics are impressive, some women are at increased risk for noninvasive prenatal screen failure. The risk of test failure increases with maternal weight; thus, obese women may be at elevated risk for failure. This risk of failure may be mitigated by the addition of a paternal cheek swab and screening at a later gestational age. The purpose of this study was to evaluate the association among obesity, gestational age, and paternal cheek swab in the prevention of screening failure. A retrospective cohort study was performed for women who were ≥35 years old at delivery who underwent screening at NorthShore University HealthSystem, Evanston, IL. Maternal weight, body mass index, gestational age, and a paternal cheek swab were evaluated in univariate and multivariable logistic regression analyses to assess the association with failed screening. Five hundred sixty-five women met inclusion criteria for our study. The mean body mass index was 25.9 ± 5.1 kg/m(2); 111 women (20%) were obese (body mass index, ≥30 kg/m(2)). Forty-four women (7.8%) had a failed screen. Obese women had a failure rate of 24.3% compared with 3.8% in nonobese women (P < .01). Gestational age was not associated with failure rate (mean ± standard deviation, 13 ± 3 weeks for both screen failure and nonfailure; P = .76). The addition of a paternal cheek swab reduced the failure rate from 10.2% in women with no swab to 3.8% in women with a swab (P < .01). In multivariable analysis, obesity and lack of a paternal cheek swab were independent predictors of screen failure (odds ratio, 9.75; 95% confidence interval, 4.85-19.61; P < .01; and odds ratio, 3.61; 95% confidence interval, 1.56-8.33; P < .01, respectively). The addition of a paternal cheek swab significantly improved noninvasive prenatal screen success rates in obesewomen. However, delaying testing to a later gestational age did not.

Perspectives of Health-Care Providers Toward Advance Care Planning in Patients With Advanced Cancer and Congestive Heart Failure.

Advance care planning (ACP) discussions afford patients and physicians a chance to better understand patients' values and wishes regarding end-of-life care; however, these conversations typically take place late in the course of a disease. The goal of this study was to clarify attitudes of oncologists, cardiologists, and primary care physicians (PCPs) toward ACP and to identify persistent barriers to timely ACP discussion following a quality improvement initiative at our health system geared at improvement in ACP implementation. A 20-question, cross-sectional online survey was created and distributed to cardiologists, oncologists, PCPs, and cardiology and oncology support staff at the NorthShore University HealthSystem (NorthShore) from February to March 2015. A total of 117 individuals (46% of distributed) completed the surveys. The results were compiled using an online survey analysis tool (SurveyMonkey, Inc., Palo Alto, California, USA). Only 15% of cardiologists felt it was their responsibility to conduct ACP discussions with their patients having congestive heart failure (CHF). In contrast, 68% of oncologists accepted this discussion as their responsibility in patients with terminal cancer ( P < .01). These views were mirrored by PCPs, as 68% of PCPs felt personally responsible for ACP discussion with patients having CHF, while only 34% felt the same about patients with cancer. Reported documentation of these discussions in the electronic health record was inconsistent between specialties. Among all surveyed specialties, lack of time was the major barrier limiting ACP discussion. Perceived patient discomfort and discomfort of the patient's family toward these discussions were also significant reported barriers. Attitudes toward ACP implementation vary considerably by medical specialty and medical condition, with oncologists in this study tending to feel more personal responsibility for these discussions with patients having cancer than cardiologists with their patients having heart failure. Robust implementation of ACP across the spectrum of medical diagnoses is likely to require a true collaboration between office-based PCPs and specialists in both the inpatient and the ambulatory settings.

Clinical significance of mesenteric panniculitis-like abnormalities on abdominal computerized tomography in patients with malignant neoplasms.

AIMTo clarify the association of malignancy with mesenteric panniculitis-like changes on computed tomography (CT).METHODSAll abdominal CT scans performed at NorthShore University HealthSystem showing mesenteric panniculitis from January 2005 to August 2010 were identified in the Radnet (RadNet Corporation, Los Angeles, CA) database. Patients with a new or known diagnosis of a malignancy were included for this analysis. Longitudinal clinical histories were obtained from electronic medical records.RESULTSIn total, 147794 abdominal CT scans were performed during the study period. Three hundred and fifty-nine patients had mesenteric panniculitis (MP)-like abnormalities on their abdominal CT. Of these patients, 81 patients (22.6%) had a known history of cancer at the time of their CT scan. Nineteen (5.3%) had a new diagnosis of cancer in concurrence with their CT, but the majority of these (14/19, 74%) were undergoing CT as part of a malignancy evaluation. Lymphomas were the most common cancers associated with MP-like findings on CT (36 cases, 36%), with follicular lymphoma being the most frequent subtype (17/36). A variety of solid tumors, most commonly prostate (7) and renal cell cancers (6) also were seen. CT follow up was obtained in 56 patients. Findings in the mesentery were unchanged in 45 (80%), worsened in 6 (11%), and improved in 5 patients (9%). Positron emission tomography (PET) scans performed in 44 patients only showed a positive uptake in the mesenteric mass in 2 patients (5%).CONCLUSIONA new diagnosis of cancer is uncommon in patients with CT findings suggestive of MP. MP-like mesenteric abnormalities on CT generally remain stable in patients with associated malignancies. PET scanning is not recommended in the evaluation of patients with mesenteric panniculitis-like findings on CT.

Variability of physician perspectives toward advance care planning for patients with incurable cancer and congestive heart failure.

12 Background: Advance Care Planning (ACP) discussions afford patients and physicians a chance to better understand patients’ values and wishes regarding end-of-life care; however these conversations typically take place late in the course of a disease, or not at all. The goal of this study was to understand attitudes of oncologists, cardiologists, and primary care physicians (PCPs) towards ACP. We also aimed to identify persistent barriers to timely ACP discussion following a quality improvement initiative at our health system aimed at improving ACP completion rate. Methods: A 23-question cross-sectional online survey was created and distributed to cardiologists, oncologists, primary care physicians and cardiology and oncology support staff at the NorthShore University Health System (NorthShore) from February-March 2015. A total of 117 individuals (46% of distributed) completed the surveys. The results were compiled using an online survey analysis tool. Results: Only 15% of cardiologists felt it was their responsibility to conduct ACP with their congestive heart failure (CHF) patients. In contrast, 68% of oncologists accepted responsibility for ACP in incurable cancer patients. Sixty-eight percent of PCPs felt personally responsible for conducting ACP discussions with CHF patients, while only 34% felt the same about cancer patients. Documentation of ACP in the electronic health record (EHR) was inconsistent among specialties. Among all surveyed specialties, lack of time was the major barrier limiting ACP discussion. Perceived patient discomfort and discomfort of the patient’s family towards these discussions were also significant reported barriers. Conclusions: Attitudes toward ACP implementation vary considerably by medical specialty and medical condition, with oncologists in this study feeling more personal responsibility for carrying out these discussions with cancer patients than cardiologists with their heart failure patients. Robust implementation of ACP across the spectrum of medical illnesses is likely to require a true collaboration between office-based PCPs and specialists in both the inpatient and ambulatory settings.

Molecular subtyping improves diagnostic stratification of patients with primary breast cancer into prognostically defined risk groups.

Combined use of MammaPrint and a molecular subtyping profile (BluePrint) identifies disease subgroups with marked differences in long-term outcome and response to neo-adjuvant therapy. The aim of this study was to evaluate the prognostic value of molecular subtyping using MammaPrint and BluePrint in women with early-stage breast cancer (BC) treated at US institutions following National Comprehensive Cancer Network standard guidelines. Tumor samples were collected from stage 1-2B consecutively diagnosed BC patients (n = 373) who underwent lumpectomy or mastectomy with an axillary staging procedure between 1992 and 2010 at two institutes (NorthShore University HealthSystem and Fox Chase Cancer Center) in the United States of America, with a median follow-up time of 9.5 years. MammaPrint low-risk patients had a 10-year DMFS of 96 % (95 %CI 92.8–99.4), while MammaPrint high-risk patients had a 10-year DMFS of 87 % (95 %CI 81.9–92.1) with a hazard ratio of 3.62 (95 %CI 1.38–9.50) (p = 0.005). Uni- and multivariate analyses included age, tumor size, grade, ER, and Her2; in multivariate analysis, MammaPrint reached near-significance (HR 3.01; p 0.08). When comparing BluePrint molecular subtyping with clinical stratification, the prognosis (10-year DMFS) was significantly different in 10-year DMFS between the different molecular subtypes (p < 0.001). This retrospective study with 10-year follow-up data provides valuable insight into prognosis of patients with primary BC comparing clinical with molecular subtyping. The BluePrint molecular stratification assay identifies patients with significantly different outcomes compared with standard clinical molecular stratification.

Physician Attitudes Toward Urinary Incontinence Identification.

Urinary incontinence (UI) is a prevalent condition. Urinary incontinence impacts health, quality of life, and financial resources. Most barriers research is evaluated from the patient perspective. Research from physician perspective is needed to determine how best to address UI barriers. This study aimed to elucidate physician barriers to UI identification and treatment. After institutional review board waiver, we surveyed 78 NorthShore University HealthSystem primary care physicians. The survey was designed to assess physician comfort, familiarity with UI, and current practice patterns. Fifty-five (71%) of the 78 physicians completed the survey. Most indicated that they clearly understood UI and that UI was a common problem in their practice. Fifty-six percent of the physicians were very comfortable inquiring about UI. Only 19% of the physicians were very comfortable diagnosing UI and 11% of the physicians were very comfortable treating UI. Fifty-nine percent of the physicians agreed that differentiating the different types of UI is difficult and 69% of the physicians believed that managing UI is difficult. However, only 26% of the physicians agreed that managing UI takes too much time. Overall, 65% of the physicians would like to diagnose and treat UI more in their practices. The most common barriers listed were (1) "not familiar with algorithm available for treatment," (2) "no good screening tool," and (3) "uncomfortable with diagnosis and treatment." We initially thought that time would be the biggest barrier to care for UI, but we identified discomfort with diagnosis and treatment as barriers. The most common barrier was the lack of an accessible algorithm. Attention to physician education implementation of a screening tool algorithm for treatment of UI could improve UI identification.

Promotion of self-management for post treatment cancer survivors: evaluation of a risk-adapted visit.

The LIFE Cancer Survivorship Program at NorthShore University HealthSystem provides risk-adapted visits (RAV) facilitated by an oncology nurse during which a survivorship care plan (SCP) is provided and discussed. In this report, we describe and evaluate RAV in promoting individualized health care and self-management during survivorship transition. Patients complete a post-RAV questionnaire at their RAV and another ≥1 year after their RAV. One thousand seven hundred thirteen (1713) RAVs, majority for breast cancer, occurred from January 2007 to March 2014. One thousand six hundred fifteen (1615) "day-of" post-RAV questionnaires were completed. Respondents scaled statements as strongly agree/agree/disagree/strongly disagree. Combined strongly agree/agree ratings are 94 % felt more confident in communicating information about their treatments to other health care providers, 90 % felt more comfortable recognizing signs/symptoms to report to providers, and 98 % had a better appreciation for community programs/services. Of 488 respondents (RAV January 2007 to December 2012 n = 1366) to a questionnaire at least 1 year after the RAV, nearly 100 % found SCP useful to summarize medical information, 97 % to reinforce follow-up, 85 % to recognize symptoms of recurrence, 93 % to identify healthy lifestyle practices, 91 % to assist in identifying resources for support, 72 % discussed their SCP with their healthcare provider, and 97 % made at least one positive lifestyle change. Participation in LIFE RAV following treatment helps survivors to guide future self-care behavior. Data suggest that benefits may persist 1 year after the visit and support the feasibility of a nurse-led RAV to establish a SCP in cancer survivors. Combined provision and discussion of SCPs help survivors construct a useful understanding of their cancer experience and may promote long-term self-management.

Incidence and characteristics of patients presenting with acute myocardial infarction and non-obstructive coronary artery disease.

This study aimed to characterize the etiologies of patients presenting with myocardial infarction (MI) and found to have non-obstructive coronary artery disease (NOCAD) and compare risk factors and in-hospital mortality to those with obstructive coronary artery disease (CAD). Patients presenting with an MI are often found to have NOCAD defined as less than 50% luminal diameter reduction by visual estimation on coronary angiography. This study is a retrospective analysis of a total of 2,038 patients that presented to NorthShore University HealthSystem with MI and underwent coronary angiography from 2010 to 2013. 1,822 patients (89%) had CAD and 216 (11%) had NOCAD. Of the NOCAD patients, the most common etiologies were Takotsubo cardiomyopathy (28%), no alternative explanation (26%), demand ischemia (21%), myopericarditis (7%), coronary artery vasospasm (5%), and coronary artery dissection (3%). NOCAD patients were more likely to be younger and female. There was no significant difference between NOCAD and CAD patients in terms of in-hospital mortality (3.7% vs. 4.0% respectively, OR = 1.1, 95% CI 0.5-2.3, P = 0.83 by univariate logistic regression, OR = 1.2, 95% CI 0.5-3.1, P = 0.74 by multivariable analysis). CAD patients were more likely to have traditional risk factors of diabetes, hypertension, hypercholesterolemia, previous MI, previous revascularization with percutaneous coronary intervention or coronary artery bypass graft surgery. Patients presenting with MI and NOCAD were found to have several different etiologies on coronary angiography with the most common being Takotsubo cardiomyopathy.