Order Diagnostic Tests Research Articles

Unnecessary diagnostic imaging requested by medical students during a first day of residency simulation: an explorative study

BackgroundPhysicians’ choice of appropriate tests in the diagnostic process is crucial for patient safety. The increased use of medical imaging has raised concerns about its potential overuse. How appropriately medical students order diagnostic tests is unknown. We explored their ordering behavior of diagnostic imaging during a simulated first day of residency.MethodsIn total, 492 undergraduate medical students participated in the simulation. After history taking with simulated patients, the students used an electronic system for requesting diagnostic tests. The analysis focused on 16 patient cases, each managed by at least 50 students. We calculated the total number of ordered images and unnecessary radiation exposure in millisievert per patient and performed one sample t-tests (one tailed) with an expected mean of zero on a Bonferroni-corrected alpha level of 0.003 for the independent variable of unnecessary radiation exposure.ResultsUnnecessary diagnostic imaging was ordered across all patient cases. Ultrasound, especially abdominal ultrasound, X-rays of the thorax, and abdominal CTs were notably overused in 90.9%, 80.0%, and 69.2% of all patient cases, respectively. Unnecessary requests of imaging related to radiation resulted in radiation over-exposure for nearly all patients, with 37.5% of all patients being exposed to a significant radiation overdose on average.ConclusionMedical students’ overuse of diagnostic imaging can be explained by patient-related factors like anxiety and medical factors like missing clinical information leading to cognitive biases in patient workup. This suggests the need for interventions to improve students’ clinical decision-making and reduce cognitive biases. Investigating student-specific factors being associated with overuse of diagnostic imaging would be of additional interest.

Recent Canadian Negligence Decisions Relating to Prenatal Care: Implications for Physicians’ Screening Practices

This article summarizes several Canadian court decisions from 2015 onward stemming from wrongful birth and wrongful life litigation. Plaintiff success often turns on whether causation is established, on a balance of probabilities, between a physician’s breach of standard of care and the harm to the parents and/or the child later born. Physicians’ failure to offer or order screening or diagnostic tests has been a source of wrongful birth liability, as too can be failure to ensure patient understanding of results. Physicians should ensure that they recommend diagnostic testing when presented with concerning clinical indications in accordance with professional practice guidance. Given non-invasive prenatal screening’s (NIPS) advantages and the threat of wrongful birth liability for failure to discuss this procedure, it is likely to be propelled into an ever more prominent position as a first-choice offering for aneuploidy screening. Appropriately cautious physician behaviour involves discussing and offering NIPS, and also involves ensuring that results are understood. This can reduce physician liability, improve patient reproductive autonomy, and sometimes benefit patient health by preventing or lessening trauma that informed women may opt to mitigate when granted the opportunity.

Neonatal Intensive Care Workflow Analysis Informing NEC-Zero Clinical Decision Support Design.

Decision support in neonatal ICUs is needed, especially for prevention and risk awareness of the devastating complication of necrotizing enterocolitis, a major cause of emergency surgery among fragile infants. The purpose of this study was to describe the current clinical workflow and sociotechnical processes among clinicians for necrotizing enterocolitis risk awareness, timely recognition of symptoms, and treatment to inform decision support design. A qualitative descriptive study was conducted. Focus groups were held in two neonatal ICUs (five groups in Unit A and six in Unit B). Transcripts were analyzed using content analysis and compared with field notes. Clinicians (N = 27) included nurses (37%), physicians (30%), neonatal nurse practitioners (19%), and other staff (16%). Workflow processes differed for nurses (who see necrotizing enterocolitis signs and notify providers to order diagnostic tests and treatments) and providers (who receive notification of necrotizing enterocolitis concern and then decide how to act). Clinicians desired (1) a necrotizing enterocolitis-relevant dashboard to support nutrition tracking and necrotizing enterocolitis recognition; (2) features to support decision-making (eg, necrotizing enterocolitis risk and adherence scoring); (3) breast milk tracking and feeding clinical decision support; (4) tools for necrotizing enterocolitis surveillance and quality reporting; and (5) general EHR optimizations to improve user experience.

Association of Self-reported Primary Care Physician Tolerance for Uncertainty With Variations in Resource Use and Patient Experience

Inappropriate variations in clinical practice are a known cause of poor quality and safety, with variations often associated with nonclinical factors, such as individual differences in cognitive processing. The differential response of physicians to uncertainty may explain some of the variations in resource use and patient experience. To examine the association of physician tolerance for uncertainty with variations in resource use and patient experience. This survey study linked physician survey data (May to June 2019), patient experience survey data (January 2016 to December 2019), and billing data (January 2019 to December 2019) among primary care physicians (PCPs) at Massachusetts General Hospital with at least 10 visits in 2019. The statistical analysis was performed in 2021. The analysis examined associations of PCP tolerance for uncertainty with the tendency to order diagnostic tests, the frequency of outpatient visits, hospital admissions, emergency department visits, and patient experience data (focused on physician communication and overall rating). A 2-stage hierarchical framework was used to account for clustering of patients under PCPs. Binary outcomes were modeled using a hierarchical logistic model, and count outcomes were modeled using hierarchical Poisson or negative binomial models. The analysis was adjusted for patient demographic variables (age, sex, and race and ethnicity), socioeconomic factors (payer and neighborhood income), and clinical comorbidities. Of 217 included physicians, 137 (63.1%) were women, and 174 (80.2%) were adult PCPs. A total of 62 physicians (28.6%) reported low tolerance, 59 (27.2%) reported medium tolerance, and 96 (44.2%) reported high tolerance for uncertainty. Physicians with a low tolerance for uncertainty were less likely to order complete blood cell counts (odds ratio [OR], 0.66; 95% CI, 0.50-0.88), thyroid tests (OR, 0.67; 95% CI, 0.52-0.88), a basic metabolic profile (OR, 0.78; 95% CI, 0.60-1.00), and liver function tests (OR, 0.72; 95% CI, 0.53-0.99) than physicians with a high tolerance for uncertainty. Physicians who reported higher tolerance for uncertainty were more likely to receive higher patient experience scores for listening to patients carefully (OR, 0.65; 95% CI, 0.50-0.83) and higher overall ratings (OR, 0.80; 95% CI, 0.66-0.98) than physicians with medium tolerance. Conversely, no association was found between physician tolerance for uncertainty and patient outpatient visits, hospital admissions, or emergency department visits. In clinical practice, identifying and effectively managing inappropriate variations and improving patient experience have proven to be difficult, despite increased attention to these issues. This study supports the hypothesis that physicians' tolerance for uncertainty is associated with differences in resource use and patient experience. Whether enhancing physicians' tolerance for uncertainty could help reduce unwarranted practice variations, improve quality and patient safety, and improve patient's experience remains to be established.

Knowledge, attitudes and practices relating to antibiotic use and resistance among prescribers from public primary healthcare facilities in Harare, Zimbabwe.

Background Overuse of antibiotics is one of the main drivers for antimicrobial resistance (AMR). Globally, most antibiotics are prescribed in the outpatient setting. This survey aimed to explore attitudes and practices with regards to microbiology tests, AMR and antibiotic prescribing among healthcare providers at public primary health clinics in Harare, Zimbabwe. Methods This cross-sectional survey was conducted in nine primary health clinics located in low-income suburbs of Harare between October and December 2020. In Zimbabwe, primary health clinics provide nurse-led outpatient care for acute and chronic illnesses. Healthcare providers who independently prescribe antibiotics and order diagnostic tests were invited to participate. The survey used self-administered questionnaires. A five-point Likert scale was used to determine attitudes and beliefs. Results A total of 91 healthcare providers agreed to participate in the survey. The majority of participants (62/91, 68%) had more than 10 years of work experience. Most participants reported that they consider AMR as a global (75/91, 82%) and/or national (81/91, 89%) problem, while 52/91 (57%) considered AMR to be a problem in their healthcare facilities. A fifth of participants (20/91, 22%) were unsure if AMR was a problem in their clinics. Participants felt that availability of national guidelines (89/89, 100%), training sessions on antibiotic prescribing (89/89, 100%) and regular audit and feedback on prescribing (82/88, 93%) were helpful interventions to improve prescribing. Conclusions These findings support the need for increased availability of data on AMR and antibiotic use in primary care. Educational interventions, regular audit and feedback, and access to practice guidelines may be useful to limit overuse of antibiotics.

Zoonotic Disease Testing Practices in Pediatric Patients with Meningitis and Encephalitis in a Subtropical Region.

Emerging vector-borne and zoonotic pathogens can cause neuroinvasive disease in children; utilization of appropriate diagnostic testing can be low, hindering diagnosis and clinical management of these cases. We must understand factors that influence healthcare providers’ decisions to order diagnostic testing. We reviewed medical charts for pediatric meningitis and encephalitis patients (90 days–18 years) between 2010 and 2017 and analyzed variables associated with testing for known neuroinvasive zoonotic pathogens in the southern United States: West Nile virus (WNV), Bartonella spp., and Rickettsia spp. Among 620 cases of meningitis and encephalitis, ~1/3 (n = 209, 34%) were tested for WNV. Fewer cases were tested for Bartonella (n = 77, 12%) and Rickettsia (n = 47, 8%). Among those tested, 14 (7%) WNV, 7 (9%) Bartonella, and 6 (13%) Rickettsia cases were identified. Factors predicting testing were similar between all agents: clinical presentation of encephalitis, focal neurologic symptoms, new onset seizure, and decreased Glasgow Coma Scale on admission. Cases with a history of arthropod contact were more likely to be tested; however, we did not see an increase in testing during the summer season, when vector exposure typically increases. While our test utilization was higher than that reported in other studies, improvement is needed to identify zoonotic causes of neuroinvasive diseases.

Evaluation of Diplopia by Emergency Medicine Physicians and Consulting Neurologists.

Appropriate evaluation of diplopia requires separating serious from benign causes. If providers are not adept in this task, diagnosis of critical conditions may be delayed and unnecessary testing may result. We studied the records of 100 consecutive patients who presented to an emergency department between 2010 and 2020 with diplopia as a prominent symptom. We rated the performance of emergency medicine physicians (EMPs) and consulting neurologists (CNs) in the examination, diagnosis, and ordering of diagnostic tests according to standards based on neuro-ophthalmologic consultation and the neuro-ophthalmologic literature. EMPs made no diagnosis or an incorrect diagnosis in 88 (88%) of 100 encounters. They ordered 14 unindicated and 12 incorrect studies, mostly noncontrast computed tomography scans. CNs made an incorrect diagnosis in 13 (31%) encounters. They ordered 6 unindicated and 2 incorrect studies. The total charge for unindicated and incorrect studies ordered by EMPs and CNs was $119,950. EMPs and CNs made frequent errors in the examination, diagnosis, and ordering of diagnostic studies, leading to inefficient care and unnecessary testing. EMPs largely delegated the evaluation of diplopia to their consultants. If such consultative support were not available, the care of diplopic patients would be delayed. CNs performed more complete examinations, but rarely enough to allow appreciation of the pattern of ocular misalignment, contributing to misdiagnoses and ordering errors. The identification of these provider errors allows for more targeted teaching in the evaluation of diplopia.

Usability barriers and facilitators of a human factors engineering-based clinical decision support technology for diagnosing pulmonary embolism

BackgroundHealth IT, such as clinical decision support (CDS), has the potential to improve patient safety. However, poor usability of health IT continues to be a major concern. Human factors engineering (HFE) approaches are recommended to improve the usability of health IT. Limited evidence exists on the actual impact of HFE methods and principles on the usability of health IT. ObjectiveTo identify and describe the usability barriers and facilitators of an HFE-based CDS prior to implementation in the emergency department (ED). MethodsWe conducted debrief interviews with 32 emergency medicine physicians as a part of a scenario-based simulation study evaluating the usability of the HFE-based CDS. We performed a deductive content analysis of the interviews using the usability criteria of Scapin and Bastien as a framework. ResultsWe identified 271 occurrences of usability barriers (94) and facilitators (177) of the HFE-based CDS. For instance, we found a facilitator relating to the usability criteria prompting as the PE Dx helps the physician order diagnostic tests following the risk assessment. We found the most facilitators relating to the criteria, minimal actions, e.g. as the PE Dx automatically populates vitals signs (e.g., heart rate) from the chart into the CDS. The majority of the usability barriers related to the usability criteria, compatibility (i.e., workflow integration), which was not explicitly considered in the HFE design of the CDS. For example, the CDS did not support resident and attending physician teamwork in the PE diagnostic process. ConclusionThe systematic use of HFE principles in the design of CDS improves the usability of these technologies. In order to further reduce usability barriers, workflow integration should be explicitly considered in the design of health IT.

Addressing Medications Definitively By Avoiding “Medication Management”

Addressing Medications Definitively By Avoiding “Medication Management”

Consideration of Vector-Borne and Zoonotic Diseases during Differential Diagnosis.

Recognition and reporting of vector-borne and zoonotic disease (VBZD) cases is largely dependent upon the consideration of such diseases by healthcare practitioners during the initial diagnosis and ordering of specific confirmative diagnostic tests. This study was conducted to assess the general knowledge and understanding of VBZD transmission and clinical presentation. Healthcare practitioners were surveyed to determine the extent of training and educational experiences they received relative to VBZDs, and their likelihood to consider such diseases during differential diagnoses. In addition, an assessment of their knowledge of arthropod species that may transmit VBZD pathogens was conducted. Having postprofessional school training relevant to VBZDs significantly influenced diagnostic accuracy for such disease cases based on the presented clinical signs and symptoms. The prevalence of VBZDs in the United States likely is significantly underestimated. The authors suggest the enhancement of VBZD-focused education as an important initiative that would significantly improve timely diagnosis, treatment, and, ultimately, prevention of these diseases.

Patient Use and Clinical Practice Patterns of Remote Cardiology Clinic Visits in the Era of COVID-19

The COVID-19 pandemic has led to an unprecedented shift in ambulatory cardiovascular care from in-person to remote visits. To understand whether the transition to remote visits is associated with disparities in patient use of care, diagnostic test ordering, and medication prescribing. This cross-sectional study used electronic health records data for all ambulatory cardiology visits at an urban, multisite health system in Los Angeles County, California, during 2 periods: April 1, 2019, to December 31, 2019 (pre-COVID) and April 1 to December 31, 2020 (COVID-era). Statistical analysis was performed from January to February 2021. In-person or remote ambulatory cardiology clinic visit at one of 31 during the pre-COVID period or COVID-era period. Comparison of patient characteristics and frequencies of medication ordering and cardiology-specific testing across 4 visit types (pre-COVID in-person (reference), COVID-era in-person, COVID-era video, COVID-era telephone). This study analyzed data from 87 182 pre-COVID in-person, 74 498 COVID-era in-person, 4720 COVID-era video, and 10 381 COVID-era telephone visits. Across visits, 79 572 patients were female (45.0%), 127 080 patients were non-Hispanic White (71.9%), and the mean (SD) age was 68.1 (17.0) years. Patients accessing COVID-era remote visits were more likely to be Asian, Black, or Hispanic individuals (24 934 pre-COVID in-person visits [28.6%] vs 19 742 COVID-era in-person visits [26.5%] vs 3633 COVID-era video visits [30.4%] vs 1435 COVID-era telephone visits [35.0%]; P < .001 for all comparisons), have private insurance (34 063 pre-COVID in-person visits [39.1%] vs 25 474 COVID-era in-person visits [34.2%] vs 2562 COVID-era video visits [54.3%] vs 4264 COVID-era telephone visits [41.1%]; P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone), and have cardiovascular comorbidities (eg, hypertension: 37 166 pre-COVID in-person visits [42.6%] vs 31 359 COVID-era in-person visits [42.1%] vs 2006 COVID-era video visits [42.5%] vs 5181 COVID-era telephone visits [49.9%]; P < .001 for COVID-era in-person vs telephone; and heart failure: 14 319 pre-COVID in-person visits [16.4%] vs 10 488 COVID-era in-person visits [14.1%] vs 1172 COVID-era video visits [24.8%] vs 2674 COVID-era telephone visits [25.8%]; P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone). After adjusting for patient and visit characteristics and in comparison with pre-COVID in-person visits, during video and telephone visits, clinicians had lower odds of ordering any medication (COVID-era in-person: odds ratio [OR], 0.62 [95% CI, 0.60-0.64], COVID-era video: OR, 0.22 [95% CI, 0.20-0.24]; COVID-era telephone: OR, 0.14 [95% CI, 0.13-0.15]) or tests, such as electrocardiograms (COVID-era in-person: OR, 0.60 [95% CI, 0.58-0.62]; COVID-era video: OR, 0.03 [95% CI, 0.02-0.04]; COVID-era telephone: OR, 0.02 [95% CI, 0.01-0.03]) or echocardiograms (COVID-era in-person: OR, 1.21 [95% CI, 1.18-1.24]; COVID-era video: OR, 0.47 [95% CI, 0.42-0.52]; COVID-era telephone: OR, 0.28 [95% CI, 0.25-0.31]). Patients who were Asian, Black, or Hispanic, had private insurance, and had at least one of several cardiovascular comorbidities used remote cardiovascular care more frequently in the COVID-era period. Clinician ordering of diagnostic testing and medications consistently decreased when comparing pre-COVID vs COVID-era and in-person vs remote visits. Further studies are needed to clarify whether these decreases represent a reduction in the overuse of tests and medications vs an underuse of indicated testing and prescribing.

Knowledge, attitudes and practices relating to antibiotic use and resistance among prescribers from public primary healthcare facilities in Harare, Zimbabwe

Background Overuse of antibiotics is one of the main drivers for antimicrobial resistance (AMR). Globally, most antibiotics are prescribed in the outpatient setting. This survey aimed to explore attitudes and practices with regards to microbiology tests, AMR and antibiotic prescribing among healthcare providers at public primary health clinics in Harare, Zimbabwe. Methods This cross-sectional survey was conducted in nine primary health clinics located in low-income suburbs of Harare between October and December 2020. In Zimbabwe, primary health clinics provide nurse-led outpatient care for acute and chronic illnesses. Healthcare providers who independently prescribe antibiotics and order diagnostic tests were invited to participate. The survey used self-administered questionnaires. A five-point Likert scale was used to determined attitudes and beliefs. Results A total of 91 healthcare providers agreed to participate in the survey. The majority of participants (62/91, 68%) had more than 10 years of work experience. Most participants reported that they consider AMR as a global (75/91, 82%) and/or national (81/91, 89%) problem, while 52/91 (57%) considered AMR to be a problem in their healthcare facilities. A fifth of participants (20/91, 22%) were unsure if AMR was a problem in their clinics. Participants felt that availability of national guidelines (89/89, 100%), training sessions on antibiotic prescribing (89/89, 100%) and regular audit and feedback on prescribing (82/88, 93%) were helpful interventions to improve prescribing. Conclusions These findings support the need for increased availability of data on AMR and antibiotic use in primary care. Educational interventions, regular audit and feedback, and access to practice guidelines may be useful to limit overuse of antibiotics.

Medical malpractice litigations involving aortic dissection.

Medical malpractice litigation arises when a discrepancy exists between a patient's expectation of acceptable medical care and the care the patient receives. Aortic dissection is a frequently misdiagnosed and often-fatal condition. The purpose of this study was to characterize trends of medical malpractice litigations arising from aortic dissection, investigate the etiology, and analyze predictive factors regarding the verdict. The Westlaw legal database was used to compile relevant litigations from 1994 to 2019 across the United States. Each litigation was screened individually for inclusion, and after inclusion, descriptive factors were compiled, including patient data, litigation data, verdict data, and clinical outcomes data. The Fisher exact test was used to evaluate the significance of association between parameters and verdict type. In total, 135 unique litigations met criteria for inclusion, with a defendant verdict in 57% (n=77), plaintiff verdict in 20% (n=27), and settlements in 23% (n=31). Plaintiffs most commonly cited a failure to diagnose as their reason for litigation in 64% (n=87). Patient mortality was associated with a lower average plaintiff award, $1,892,781 versus $5,944,983, and a lower average settlement, $1,230,923 versus $2,250,000, than their surviving counterparts. California, Illinois, and Pennsylvania had the most cases filed. An alleged failure to test, failure to refer, failure to consult, incidence of a stroke, and incidence of an autopsy diagnosis were significantly associated with defendant verdicts and a failure to diagnose was significantly associated with plaintiff verdicts (P<.05). Plaintiffs frequently cited a failure to timely diagnose, order diagnostic tests, and interpret diagnostic tests as reasons for litigations. Defendant verdicts were common, suggesting judicially acceptable standards of care are commonly satisfied.

S0468 Virtual Patient Simulation Improves IBS Diagnosis and Treatment: A CME Study

INTRODUCTION: Irritible bowel syndrome (IBS) is is a functional bowel disorder routiely encountered by gastroenterologists and primary care physicians (PCPs). This study examined whether online continuing medical education (CME) that incorporated a virtual patient simulation (VPS) can improve performance in the management of IBS. METHODS: An online CME case-based intervention in a VPS platform1 allowed learners to interact with patients via video, order lab tests, make diagnoses, and order treatments. Clinical decisions were analyzed, and learners received clinical guidance (CG) based on current evidence and expert recommendations. Learners were allowed to modify their decisions post-CG. Pre- (baseline) to post-CG decisions were compared using a McNemar's test. The intervention launched on August 27, 2019 and data were collected through December 2, 2019. RESULTS Significant improvements were observed as a result of participation in VPS: Case 1 (n = 168 gastroenterologists; n = 474 PCPs): • Communication with patients: 6% relative change among gastroenterologists (51% vs 54% pre/post CG; P < 0.05) and 6% relative change among PCPs (50% vs 53% pre/post CG; P < 0.001). • Order diagnostic tests: 8% relative change among gastroenterologists (84% vs 91% pre/post CG; P < 0.001) and 11% among PCPs (70% vs 81% pre/post CG; P < 0.001. • Tailoring treatment: 192% relative change among gastroenterologists (23% vs 68% pre/post CG; P < 0.001) and 300% relative change among PCPs (16% vs 63% pre/post CG; P < 0.001). Case 2 (n = 103 gastroentertologists; n = 294 PCPs): • Tailoring treatment: 85% relative change among gastroenterologists (32% vs 59% pre/post CG; P < 0.001) and 335% relative change among PCPs (13% vs 58% pre/post CG; P < 0.001). • Gastroenterologists and PCPs had significant increases in prescribing alosetron or eluxodoline following CG (Figure 1). • The top 2 rationales for selection of eluxadoline among both gastroenterologists and PCPs were efficacy in reducing symptoms and guideline recommended. CONCLISION: Participation in a VPS-based education initiative that immerses and engages learners in an authentic and practical learning experience significantly improves clinical decisions related to the diagnosis and selection of evidence-based pharmacologic treatments.Figure 1.: Prescribed treatments pre- and post- clinical guidance.

Diagnostic testing for onychomycosis: A retrospective study over 17 years

To the Editor: Onychomycosis is the most common nail condition, with prevalence increasing with age. It may be associated with cellulitis, which is life threatening. History and physical examination are helpful, but laboratory confirmation is required for definitive diagnosis.1Lipner S.R. Scher R.K. Onychomycosis: clinical overview and diagnosis.J Am Acad Dermatol. 2019; 80: 835-851Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar On October 29, 2013, the American Academy of Dermatology, as part of the ABIM Foundation's Choosing Wisely campaign, stated that confirmatory testing of onychomycosis should be performed before initiation of oral therapy.2American Academy of DermatologyTen things physicians and patients should question.http://www.choosingwisely.org/societies/american -academy-of-dermatology/Date: 2001Date accessed: March 26, 2019Google Scholar Therefore, our objective was to assess the prevalence of diagnostic testing for onychomycosis before prescribing of antifungal medications. After Weill Cornell Medicine institutional review board approval, data from EPIC were extracted for patients with the diagnosis codes 110.1 (International Classification of Diseases, Ninth Revision [ICD-9]) and B35.1 (ICD-10). Testing with potassium hydroxide with microscopy, fungal culture, or clipping with dermatopathology (January 1, 2002, to December 31, 2018) was analyzed.3Geizhals S, Lipner S. Mendeley supplementary table 1, Mendeley data, v1. https://doi.org/10.17632/kb7ry8xsvs.1. Accessed January 27, 2020.Google Scholar Polymerase chain reaction testing was excluded because of limited data, although it may eventually supplant other methods.1Lipner S.R. Scher R.K. Onychomycosis: clinical overview and diagnosis.J Am Acad Dermatol. 2019; 80: 835-851Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar The analysis included 1774 patients (47.6% women and 52.4% men). Of these patients, 1175 were prescribed oral medication (66.2%) and 599 received topical medications (33.8%). Terbinafine (93.4%) and ciclopirox (51.3%) were the most commonly prescribed oral and topical medications. Physician prescribers studied included dermatology (62.1%), infectious disease (1.4%), internal medicine (22.7%), pediatrics (0.6%), and podiatry (13.2%). From the 1774 patients, only 39.3% underwent diagnostic testing (potassium hydroxide 7.3%, fungal culture 10.9%, and dermatopathology 27.5%; 6.1% had 2 or more tests). Because the number of patients receiving a diagnosis varied yearly, we calculated the percentage of patients who underwent diagnostic testing. The greatest percentage of testing occurred in 2007 (75%) and steadily decreased, except for an isolated spike in 2014 (48.3%) (Fig 1). There was a 14.7% increase from 2013 to 2014 after the Choosing Wisely campaign of late 2013. However, in a multiple logistic regression analysis, there was a 37% greater chance of a patient's being tested before the Choosing Wisely date, adjusting for sex, medication type, age, and race (odds ratio 1.37; 95% confidence interval 1.11-1.69; P = .004). Pediatricians tested most frequently (63.6%), followed by dermatologists (51.2%), internal medicine (21.1%), infectious disease (16.7%), and podiatry (15.8%). Percentage of patients tested decreased after the Choosing Wisely campaign for dermatology, pediatrics, and podiatry, and increased for infectious disease and internal medicine (Fig 2). Overall, internal medicine physicians and podiatrists were, respectively, 75% and 82% less likely to test than dermatologists (P < .001). Podiatrists were 1.88 times more likely to prescribe oral medication than dermatologists (P < .001). Limitations for this study were its retrospective design, that data could be obtained starting only in January 2002, and that it was not specifically designed to analyze Choosing Wisely. Our study shows that dermatologists are more likely to order diagnostic testing for onychomycosis compared with most other physicians; however, almost half of all dermatologists are not testing. Although empiric treatment with terbinafine may be cost-effective,4Mikailov A. Cohen J. Joyce C. Mostaghimi A. Cost-effectiveness of confirmatory testing before treatment of onychomycosis.JAMA Dermatol. 2016; 152: 276-281Crossref PubMed Scopus (37) Google Scholar confirmatory testing can militate against missed diagnoses, treatment failures, and potential adverse events, including liver toxicity (1 case per 50,000-120,000 treatments).5Lipner S.R. Scher R.K. Confirmatory testing for onychomycosis.JAMA Dermatol. 2016; 152: 847Crossref PubMed Scopus (12) Google Scholar Increased efforts are needed to educate a broad group of physicians about mycologic testing before treating for onychomycosis, especially for children.1Lipner S.R. Scher R.K. Onychomycosis: clinical overview and diagnosis.J Am Acad Dermatol. 2019; 80: 835-851Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar

Nurses are Key Members of the Abortion Care Team: Why aren’t Schools of Nursing Teaching Abortion Care?

Abortion is a common and safe procedure in Canada, with the Canadian Institute for Health Information reporting approximately 100,000 procedures per year. Yet access remains problematic. As abortion is unrestricted by criminal law in Canada, access is limited by geographic barriers and by a shortage of providers. We present a feminist critical lens to describe how the marginalization of nursing and nurses in abortion care contributes to social stigma and public misunderstanding about abortion access. The roles of registered nurses and nurse practitioners in abortion advocacy, service navigation, counselling, education, support, physiological care and follow up are underutilized and under-researched. In 2015, decades after its availability elsewhere in the world, Health Canada approved mifepristone (a pill for medical abortion). In 2017, provincial regulators began to authorize nurse practitioners to independently provide medical abortion care, as appropriate given the inclusion in nurse practitioner scope of practice to order diagnostic tests, make diagnoses, and treat health conditions. Ensuring nurse practitioners are able to practice medical abortion has the potential to significantly increase abortion access for rural, remote and other marginalized populations. There is also an opportunity to optimize the registered nurse role in abortion care. However, achieving these improvements is challenging as abortion is not routinely taught in Canadian Schools of Nursing. We argue that to destigmatize abortion and improve access, undergraduate nursing and nurse practitioner programs across the country must begin to include abortion and family planning competencies.

2071. A Survey of Antibiotic Prescribing Practices Among Adult Primary Care Physicians in Idaho

BackgroundPrescribing an antibiotic is a complex process involving an interplay of prescriber’s knowledge, diagnostic acumen and patient factors. Understanding the prescriber rationale is key to provide feedback which might improve appropriateness of antibiotic prescribing. Currently, there are limited data on prescribing and test ordering practices among primary care physicians.MethodsWe surveyed primary care physicians taking care of adults (age 18 years and above). Physicians were contacted through the Idaho State Medical Board by a one-time email containing the survey link. The survey consisted of 25 questions under 2 major themes of diagnostic and antimicrobial stewardship (AS). It assessed physicians’ practice setting, ordering of diagnostic tests and antibiotics for common infections, delivery of patient education regarding antibiotics, availability of antibiogram and antimicrobial stewardship services, and assessment of penicillin allergy. Two infectious diseases physicians independently reviewed the results for appropriateness of testing and antibiotic prescribing per IDSA guidelines.ResultsOf 929 physicians surveyed, 157 (17%) responded. Of the respondents, 95 (61%) were male, the mean age was 50 years, and 72% worked in outpatient settings and were family medicine specialists. Only 55% of physicians reported having an AS program at their healthcare facility. Test-of-cure for C. difficile infection (24%) and UTI (13%) and use of superficial culture data to guide the treatment of osteomyelitis (27%) were the most common reasons for inappropriate testing. Longer than recommended duration, antibiotic combinations with overlap of spectrum, and guideline-discordant indications for prescribing antibiotics were the main reasons for inappropriate antibiotic use. The main factors influencing the decision to prescribe an antibiotic were diagnostic uncertainty (42%), being unsure of patient follow-up (23%) and cost of testing (21%).ConclusionThe survey results highlight the need for prescriber education for decreasing inappropriate test ordering and antibiotic prescribing. Additional studies involving a review of patient records, lab and prescription data are needed to confirm these practices.Disclosures All authors: No reported disclosures.

Use of Rheumatologic Testing in Patients Who Eventually Receive a Diagnosis of Rheumatoid Arthritis.

Anti-cyclic citrullinated peptide antibody (ACPA) has excellent specificity and prognostic value in patients with early rheumatoid arthritis (RA). The American College of Rheumatology included ACPA in their 2010 classification criteria for RA, but we hypothesize that primary care physicians (PCPs) underuse ACPA, even when clinical suspicion for RA is high. We aimed to describe their use of diagnostic testing in patients who were referred to a rheumatologist and eventually diagnosed as having RA. In this retrospective cohort study, a systematic abstraction tool was used to review the medical records of patients seen between January 1, 2010 and June 15, 2014 in two rheumatology clinics: one private practice and one community health center associated with an academic medical center. For purposes of hypothesis generation, we compared the characteristics of patients with and without testing using unpaired t tests or Fisher exact tests. We identified 173 patients with RA referred from 141 different PCPs: 82.7% were women with a mean ± standard deviation age of 55.5 ± 18.6 years. ACPA and rheumatoid factor were ordered in 28.9% (95% confidence interval 22.6-36.2) and 41.0% (95% confidence interval 33.9-48.6) of patients, respectively. Imaging was underused. Almost half (45.7%, or 37/81) of the patients with documented symptom duration had a delay of at least 1 year before referral; however, ACPA utilization was not associated with the delay to treatment initiation. Most PCPs failed to order diagnostic tests for RA before referring a patient with polyarthritis who eventually received a diagnosis of RA. We also observed delays in diagnosis, with half of the patients waiting >1 year from symptom onset to diagnosis. These findings suggest educational efforts for PCPs should focus on emphasizing earlier diagnostic workups, especially ACPA, in patients suspected to have RA.

Intervention to reduce vitamin testing in primary care: a randomized controlled trial

BackgroundAlthough vitamin tests are increasingly ordered by GPs, an evidence-based indication is often lacking.AimTo rationalise and reduce ordering of vitamin D and B12 tests by educating GPs and their patients about the merits and pitfalls of performing vitamin tests.MethodA two-armed cluster randomised study assessing the effectiveness of two separate interventions on the number of vitamin tests ordered. In total 26 health centres in the Netherlands participated (200 000 patients). De-implementation group 1 received education and a 3-monthly benchmarking of their own vitamin test ordering behaviour. De-implementation group 2 received the same intervention, but supplemented with educational material for patients. The primary study endpoint was the total reduction in vitamin D and B12 tests ordered at the end of the study as compared to a 1-year pre-intervention period. Secondary outcomes were the number of deficient test results, the number of (high dose) vitamin prescriptions, and the direct cost savings.ResultsThe number of vitamin D tests ordered at the end of the 1-year study period as compared to a 1-year pre-intervention period decreased with 23%. For vitamin B12 tests an overall reduction of 20% was found. Adding patient information had additional value over training and benchmarking of GPs, which was significant for vitamin D (−29% with and −19% without patient information), compared to respectively −22% and −18% for vitamin B12.ConclusionA structured intervention programme, including training of GPs and benchmarking their ordering of diagnostic tests, resulted in a significant reduction in ordered vitamin tests.

MP05: Diagnostic accuracy of point of care ultrasound in undifferentiated hypotension presenting to the emergency department: a systematic review

Introduction: Undifferentiated hypotension remains one of the most life-threatening presentations to emergency departments (ED) around the world. An accurate and rapid initial assessment is essential, as shock carries a high mortality with multiple unique etiologies and management plans. Point of care ultrasound (PoCUS) has emerged as a promising tool to improve these diagnostic and management challenges, yet its reliability in this setting remains unclear. Methods: We performed a systematic review of Medline, EMBASE, CINAHL, Cochrane, and clinicaltrials.gov databases from inception to June 8, 2018. Databases were reviewed by two independent researchers and all languages were included. The methodological quality of included studies were evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Our primary outcome was diagnostic accuracy of PoCUS in hypotension, with secondary outcomes including patient outcomes and changes to management. Results: Our literature search revealed 5345 articles after duplicates were removed, leaving 235 articles for full article review. Following full article review, 9 studies remained and were included in the systematic review. There were 2 randomized control trials, 6 prospective cohort trials, and 1 retrospective cohort trial. For our primary outcome of diagnostic accuracy, eight studies were included; we extracted Kappa values ranging from 0.70 to 0.971, pooled sensitivity ranging from 69% to 88%, and pooled specificity ranging from 88% to 96%. Four studies reported on management change including results reporting shorter time to disposition, change in diagnostic test ordering (18% to 31%), change in consultation (13.6%), change in admission location (12%) and change in management plan (25% to 40%). Only one study reported on patient outcomes, which revealed no survival or length of stay benefit. Conclusion: When assessing for the diagnostic accuracy of PoCUS in the setting of undifferentiated hypotension presenting to the emergency department, we found fair consistency between PoCUS and final diagnosis with high Kappa values, fair to good pooled sensitivities, and good to excellent specificities. There was no strong evidence indicating improved outcomes. However, the large amount of heterogeneity amongst studies has limited our ability to make a strong conclusion except that future research should focus on a uniform study design and patient focused outcomes.