Potential Gaps In Care Research Articles

Frequency of Opioid Prescription at Emergency Department Discharge in Patients with Inflammatory Bowel Disease: A Nationwide Analysis

Patients with inflammatory bowel disease (IBD) frequently experience chronic pain. Patients will often seek out care in the emergency department (ED) where short-term opioid use may be associated with potential treatment-related complications. We aimed to assess the rate and factors associated with opioid prescription in IBD patients discharged from the ED. We conducted a cross-sectional analysis of data collected in the US National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006-2017. We determined the proportion of adult patients (≥18 years) with IBD prescribed an opioid in ED or at ED discharge. Logistic regression was used to evaluate predictors of opioid prescription. Time-trend analysis was performed to evaluate temporal patterns in opioid use. All analyses were adjusted for complex survey design. We identified ∼965,000 weighted discharges from the ED for patients with IBD. In total, 51.9% [95% CI: 42.2% -61.6%] of visits resulted in opioid administration in ED and 35.3% [95% CI: 26.5% -45.2%] of IBD-related ED discharges were associated with an opioid prescription. IBDpatients with moderate/severe pain (adjusted odds ratio aOR 5.06 [95% CI: 1.72 -14.90], p< 0.01) were more likely to receive opioids whereas older age (aOR 0.73 per decade [95% CI: 0.55 -0.98], p = 0.04) were less likely. In temporal analysis, a trend towards decreasing opioid use in ED and opioid prescriptions at discharge was observed in 2015-2017. More than one third of IBD patients are prescribed an opioid at discharge from ED, highlighting a potential gap in care for accessing effective pain management solutions in this population.

A215 PATIENTS WITH INFLAMMATORY BOWEL DISEASE ARE FREQUENTLY PRESCRIBED OPIOID ANALGESICS WHEN DISCHARGED FROM THE EMERGENCY DEPARTMENT

Abstract Background Patients with inflammatory bowel disease (IBD) suffer a substantial burden of morbidity related to chronic abdominal pain and are susceptible to opioid dependence and abuse that is associated with increased rates of depression, hospitalization, and mortality. While opioid prescription and renewal by a single provider minimizes the long-term risk of misuse, many patients with IBD will seek out care in the emergency department (ED) where short-term, ‘to-go’ use of narcotic analgesia is associated with potential treatment-related complications. Aims To assess rates of opioid prescription in IBD patients presenting to the ED and to assess factors associated with opioid use. Methods This is a retrospective analysis of cross-sectional data collected in the United States National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006–2015. We compared a study population of adult IBD patients (International Classification of Diseases ICD-9 555.X, 556.X) ≥18 years discharged from the ED to a control group of patients presenting with non-specific abdominal pain (ICD-9 789.0, 564.1, 536.8). The proportion of patients given opioids in ED and at ED discharge were calculated with relative standard error (RSE), and national level estimates were produced using survey weights. Univariable and multivariable logistic regression was used to evaluate predictors of opioid prescription at discharge, expressed as odds ratios (OR) with 95% confidence intervals (CI). Results A total of 767,577 IBD patients were compared to 71,359,257 patients with non-specific abdominal pain. A total of 37.3% (RSE 4.7%) of IBD patients compared to 24.7% (RSE 0.8%) of controls (p&amp;lt;0.01) received an opioid prescription on ED discharge. 49.1% (RSE 5.6%) of IBD patients compared to 37.2% (RSE 0.8%) of patients with non-specific abdominal pain (p=0.02) received an opioid while in ED. Significant predictors of narcotic prescription at discharge in multivariable analysis included: age &amp;lt;50 (OR 6.83 [95% CI: 1.21, 38.48], p=0.03), non-white race (OR 4.73 [95% CI: 1.46, 15.39], p=0.01), and narcotic use in the ED (OR 5.27 [95% CI: 1.96, 14.21], p&amp;lt;0.01). Conclusions Nearly 40% of IBD patients were prescribed an opioid at discharge from the ED. This rate is significantly higher than for patients who present with non-specific abdominal pain and younger, non-white IBD patients were disproportionately more likely to receive an opioid prescription. Given the risks associated with on-demand narcotic use in IBD patients, our data highlight a potential gap in care for accessing comprehensive pain management solutions. Funding Agencies None

Dealing With Burn Patients in War Zones.

Treating burn patients in the battlefield is one of the biggest challenges that military doctors and medical personnel can face. Wound patterns have been changed over time due to the introduction of new weapons, and many different aspects play a major role in the management of those burns nowadays. There is a potential gap in care of burn patients in war zones. A thorough literature search in PubMed, scientific journals, and Internet sites was conducted in regard to burn patients and trauma in war zones. It is crucial for military surgeons to be able to stabilize burn patients during wartime conflicts, especially those patients who suffer from extreme burn injuries, as specialized treatment should be given. Medical personnel should be aware of all medication types used, the ways to minimize the risk of bacterial infection, and the ways to keep the injured safe. Injured civilians with burn trauma in the field of battle are deserving care, and special recognition should be given to the non-governmental organizations (NGOs) that strive to ease human suffering in war zones. Proper management of burn patients in war zones is crucial, and military medical staff and NGOs can play a key role in that purpose.

Treatment patterns and sequences of pharmacotherapy for patients diagnosed with depression in the United States: 2014 through 2019

BackgroundUnderstanding how patients are treated in the real-world is vital to identifying potential gaps in care. We describe the current pharmacologic treatment patterns for the treatment of depression.MethodsPatients with depression were identified from four large national claims databases during 1/1/2014–1/31/2019. Patients had ≥2 diagnoses for depression or an inpatient hospitalization with a diagnosis of depression. Patients were required to have enrollment in the database ≥1 year prior to and 3 years following their first depression diagnosis. Treatment patterns were captured at the class level and included selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, other antidepressants, anxiolytics, hypnotics/sedatives, and antipsychotics. Treatment patterns were captured during all available follow-up.ResultsWe identified 269,668 patients diagnosed with depression. The proportion not receiving any pharmacological treatment during follow-up ranged from 29 to 52%. Of the treated, approximately half received ≥2 different classes of therapy, a quarter received ≥3 classes and more than 10% received 4 or more. SSRIs were the most common first-line treatment; however, many patients received an anxiolytic, hypnotic/sedative, or antipsychotic prior to any antidepressive treatment. Treatment with a combination of classes ranged from approximately 20% of first-line therapies to 40% of fourth-line.ConclusionsMany patients diagnosed with depression go untreated and many others receive a non-antidepressant medication class as their first treatment. More than half of patients received more than one type of treatment class during the study follow up, suggesting that the first treatment received may not be optimal for most patients.

Predictors of Care Gaps in Home Dialysis: The Home Dialysis Virtual Ward Study

Background: Home dialysis patients may be at an increased risk of adverse events after transitional states. The home dialysis virtual ward (HDVW) trial was conducted in Canadian dialysis centers and aimed to evaluate potential care gaps and patient satisfaction during the HDVW. Methods: The HDVW was a multicenter single-arm trial including peritoneal dialysis and home hemodialysis patients after 4 different events (hospital discharge, medical procedure, antibiotics, completion of training). Telephone-led interviews using a standardized assessment tool were performed over a 2-week period to assess a patient’s care and adjust treatment as required. Upon completion, patients were surveyed to evaluate their perceived impact on domains of care using a rating scale; 1 not satisfied to 10 completely satisfied. Results: The HDVW trial included 193 patients with a median number of potential care gaps/interventions of 1 (0–2) per patient. Patients admitted to the HDVW after hospital discharge were at a higher risk of potential gaps in care (OR 2.16, 95% CI 1.29–3.62), while longer dialysis vintage was ­associated with a lower number of gaps/interventions (OR 0.97 per year, 95% CI 0.95–0.98). A total of 105/193 (54%) patients completed satisfaction surveys. Patients were highly satisfied with the HDVW (median rating scale score 8, IQR 2) and felt it had a positive impact (rating scale score ≥7) on their overall health, understanding of treatment and access to a nephrologist. Conclusion: The HDVW was effective at identifying several potential care gaps, and patients were satisfied across several domains of care. This intervention may be valuable in supporting home dialysis patients during care transitions.

P001 CHARACTERIZING CURRENT TREATMENT AND GAPS IN THE INFLAMMATORY BOWEL DISEASE POPULATION IN A LARGE INTEGRATED HEALTHCARE SYSTEM IN NORTHERN CALIFORNIA

Crohn’s disease (CD) and ulcerative colitis (UC), two major types of inflammatory bowel disease (IBD), affect as many as 1.6 million Americans. IBD is a chronic relapsing illness, where effective and efficient care requires seamless coordination of primary care providers, gastroenterologists, and caretakers, coupled with engaged and activated patients. We sought to understand the IBD patient population, to identify gaps in care, and ultimately develop a foundation for personalized patient care by analyzing patient characteristics, symptoms, and medications over a 5-year period using Electronic Health Record (EHR) data from a large integrated healthcare system in Northern California. All adult primary care (PC) patients who had one or more diagnoses of CD (ICD-9 555/ICD-10 K50) or UC (ICD-9 556/ICD-10 K51) associated with outpatient office visit or hospitalization encounters were identified as possible IBD cases. We defined incident-IBD care as first IBD-coded encounter occurring at least 270 days after the first PC encounter. We categorized IBD medications into 4 groups: 5-Aminosalicyclic-Acid (5-ASA) (G1), Steroids (G2), immunomodulators (G3), and biologics (G4). We used descriptive statistics to describe how symptoms and IBD-specific medications varied among those incident cases during pre- and post-diagnosis periods. Among 1,444,711 adult PC patients, 4009 (0.3%) were coded as CD, 5873 (0.4%) as UC, and 479 (5%) of these were coded as both. We identified 728 and 1139 patients as incident CD and UC cases, respectively. Tables 1-2 display demographic characteristics for all IBD patients and incident IBD patients, respectively. 48% of incident IBD patients (CD/UC) had at least one of the 5 common IBD symptoms (diarrhea, abdominal pain/cramping, blood in stool, unintended weight loss, reduced appetite) indicated by ICD diagnosis codes in the EHR prior to the IBD diagnosis. However, among those who had at least 2 encounters with IBD diagnosis codes, only 5% of incident CD patients and 8% of incident UC patients still had at least one of the 5 symptoms recorded at their 2nd visit after IBD diagnosis. Approximately 1/4 of incident IBD patients had orders placed for IBD-specific medications on or after diagnosis over a mean 32-month period as follows: CD cases: G1-10%, G2-5%, G3-5%, G4-5%; UC cases: G1-21%, G2-4%, G3-4%, G4-2%. Similar to many published US estimates, we identified more UC than CD in our healthcare system. Nearly half of incident IBD patients had documented symptoms at diagnosis, but symptoms were not reported at follow-up in most cases. Only a quarter received orders for IBD-specific drugs, with 5-ASAs the most commonly prescribed medication for both conditions. Future work includes further understanding why medication orders are lower than expected and the reasons behind this potential gap in care.

Ambiguities in Washington State hospital policies, irrespective of Catholic affiliation, regarding abortion and contraception service provision

BackgroundIn 2014, the governor of Washington State mandated that all hospitals publically post a reproductive health policy amidst concerns about the lack of clarity among the public how hospitals handled various aspects of reproductive health care.MethodsThe objective of this study is to assess the clarity of abortion and contraception service provision in the hospital reproductive health policies for the public in Washington State. All Washington State hospital reproductive health policies (n = 88) were analyzed in 2016 using content analysis. Results were stratified by Catholic religious affiliation of the hospital.ResultsThere were more similarities than differences between the non-Catholic and Catholic hospital reproductive health policies; however, there were a few differences. Non-Catholic hospitals were more likely than Catholic hospitals to use legal language (except for emergency contraception), include conscientious clause for providers (44% vs. 0%), and were less likely to specify that emergency contraception use was available for sexual assault victims only (16% vs 54%). Most hospital reproductive health policies, regardless of Catholic affiliation, provided more confusion than clarity in terms of abortion and contraception service provision.ConclusionsThe impact of Catholic, and non-Catholic, affiliated hospital care on patients who need abortion and contraceptive services is concerning. Given the difficulties in meeting the goals of increased transparency for the public through hospital policy language, the government should instead mandate hospitals use a standardized checklist. Additionally, patients are in dire need of positive rights to information about and services to avoid the potential gap in care that the negative rights afforded to providers and facilities to opt-out of providing abortion and contraceptive services have created.

Using a common data platform to facilitate audit and feedback on the quality of hospital care provided to sick newborns in Kenya

Essential interventions to reduce neonatal deaths that can be effectively delivered in hospitals have been identified. Improving information systems may support routine monitoring of the delivery of these interventions and...

In-House Cardiology Consultation Reduces Readmission Rates and Costs for Patients in Skilled Nursing Facilities: 2 Years’ Experience in the Heart Failure Bundle Payment Care Improvement Initiative

Background Heart failure (HF) patients admitted to skilled nursing facilities (SNFs) are vulnerable to poor outcomes. CMS developed the Bundled Payments for Care Improvement Initiative (BPCI) which provides participating providers shared savings based on costs for 90-day episodes of care with the purpose of improving quality and cost-effectiveness. Greater availability of clinical staff has shown promise in improving outcomes for SNF patients. The effect of cardiology consultation for SNF patients with HF has not been evaluated. This study evaluates the impact of a SNF-based cardiologist-led HF program on 90-day readmission rate and resource utilization. Methods We performed a retrospective analysis using Medicare claims data of BPCI-enrolled HF patients admitted to St. Joseph's Center (SJC), a Genesis Healthcare SNF with a cardiologist-led HF program. Data were collected from October 2015 to September 2017. Readmission rates and cost savings versus CMS-determined cost targets were compared between SJC and 31 other enrolled SNFs, 24 of which had no HF program, 7 of which had standard programs composed of a multidisciplinary team of dietary, rehabilitation, social work and clinical staff. The SJC program additionally instructed staff to request cardiac consultation for patients with unstable vital signs, refractory volume overload or symptoms, or cardiac limitations to rehabilitative therapy. Cardiology rounds were conducted weekly and management was provided in the context of achieving subacute rehabilitation goals, clinical stability, and preparing for community discharge. The cardiologist identified and alerted staff to patients deemed high risk for readmission, and multidisciplinary monitoring and management for those patients was intensified. Results There were 602 total HF episodes in the 24-month evaluation period. Seventeen patients were admitted to SJC; 218 patients to a facility with a HF program; and 367 patients to a facility without a HF program. The case mix complexity at SJC included a higher percentage of patients with major complications and comorbid conditions (71% vs 60% for all other SNFs and 64% for SNFs with HF programs). More than 50% of patients at SJC prompted specialty consultation. Compared to other facilities, the percentage of SJC patients readmitted in the 90-day post HF hospitalization period was significantly lower (23.5% vs 43.4% (p = .052) for all other SNFs; and 48.2% (p = .025) for SNFs with a non-cardiologist based HF program). SJC achieved a higher margin of cost savings compared to facilities that did not have a consulting cardiologist (39% vs 15%). Conclusion Patient-centered cardiology consultation for high risk HF patients may effectively reduce re-hospitalizations and resource utilization within SNFs. These results identify a potential gap in care for this vulnerable cohort of HF patients and suggest that incorporating a cardiologist into the management team may impact outcomes.

Trends in contraceptive use according to HIV status among privately insured women in the United States

There is limited information on the patterns and trends of contraceptive use among women living with HIV, compared with noninfected women in the United States. Further, little is known about whether antiretroviral therapy correlates with contraceptive use. Such information is needed to help identify potential gaps in care and to enhance unintended pregnancy prevention efforts. We sought to compare contraceptive method use among HIV-infected and noninfected privately insured women in the United States, and to evaluate the association between antiretroviral therapy use and contraceptive method use. We used a large US nationwide health care claims database to identify girls and women ages 15-44 years with prescription drug coverage. We used diagnosis, procedure, and National Drug Codes to assess female sterilization and reversible prescription contraception use in 2008 and 2014 among women continuously enrolled in the database during 2003 through 2008 or 2009 through 2014, respectively. Women with no codes were classified as using no method; these may have included women using nonprescription methods, such as condoms. We calculated prevalence of contraceptive use by HIV infection status, and by use of antiretroviral therapy among those with HIV. We used multivariable polytomous logistic regression to calculate unadjusted and adjusted odds ratios and 95% confidence intervals for female sterilization, long-acting reversible contraception, and short-acting hormonal contraception compared to no method. While contraceptive use increased among HIV-infected and noninfected women from 2008 through 2014, in both years, a lower proportion of HIV-infected women used prescription contraceptive methods (2008: 17.5%; 2014: 28.9%, compared with noninfected women (2008: 28.8%; 2014: 39.8%, P < .001 for both). Controlling for demographics, chronic medical conditions, pregnancy history, and cohort year, HIV-infected women compared to HIV-noninfected women had lower odds of using long-acting reversible contraception (adjusted odds ratio, 0.67; 95% confidence interval, 0.52-0.86 compared to no method) or short-acting hormonal contraception method (adjusted odds ratio, 0.59; 95% confidence interval, 0.50-0.70 compared to no method). In 2014, HIV-infected women using antiretroviral therapy were significantly more likely to use no method (76.8% vs 64.1%), and significantly less likely to use short-acting hormonal contraception (11.0% vs 22.7%) compared to HIV-infected women not using antiretroviral therapy. Those receiving antiretroviral therapy had lower odds of using short-acting hormonal contraception compared to no method (adjusted odds ratio, 0.45; 95% confidence interval, 0.32-0.63). There was no significant difference in female sterilization by HIV status or antiretroviral therapy use. Despite the safety of reversible contraceptives for women with HIV, use of prescription contraception continues to be lower among privately insured HIV-infected women compared to noninfected women, particularly among those receiving antiretroviral therapy.

Assessing the Short-Term Global Health Experience: A Cross-Sectional Study of Demographics, Socioeconomic Factors, and Disease Prevalence.

Interest in short-term global health experiences to underserviced populations has grown rapidly in the last few decades. However, there remains very little research on what participants can expect to encounter. At the same time, it has been suggested that in order for physicians and workers to provide safe and effective care, volunteers should have a basic understanding of local culture, health systems, epidemiology, and socioeconomic needs of the community before arriving. Our objective was to add to the limited literature on what short-term global health trips can expect to encounter through a cross-sectional study of patient demographics, socioeconomic markers, and the prevalence of diseases encountered on a short-term medical service trip to Lima, Peru. Descriptive analysis was conducted on clinic data collected from patients living in Pamplona Alta and Pamplona Baja, Lima, Peru, in July 2015. We found that volunteers encountered mainly female patients (70.8%), and that there were significant socioeconomic barriers to care including poverty, poor housing, environmental exposures, and lack of continuity of health care. Analysis of the disease prevalence found a high proportion of acute and chronic musculoskeletal pain in the adult populations (18.8% and 11.4%, respectively), and a high presentation of upper respiratory tract infections (25.4%) and parasites (22.0%) in the pediatric group. These findings can be used by future short-term medical service trips to address potential gaps in care including the organization of weekend clinics to allow access to working men, and the use of patient education and nonpharmacological management of acute and chronic disease.

A mixed-methods needs assessment of adult diabetes mellitus (type II) and hypertension care in Toledo, Belize

BackgroundNon-communicable diseases, including diabetes mellitus and hypertension, continue to disproportionately burden low- and middle-income countries. However, little research has been done to establish current practices and management of chronic disease in these settings. The objective of this study was to examine current clinical management and identify potential gaps in care of patients with diabetes mellitus and hypertension in the district of Toledo, Belize.MethodsThe study used a mixed methodology to assess current practices and identify gaps in diabetes mellitus and hypertension care. One hundred and twenty charts of the general clinic population were reviewed to establish disease epidemiology. One hundred and seventy-eight diabetic and hypertensive charts were reviewed to assess current practices. Twenty providers completed questionnaires regarding diabetes mellitus and hypertension management. Twenty-five individuals with diabetes mellitus and/or hypertension answered a questionnaire and in-depth interview.ResultsThe prevalence of diabetes mellitus and hypertension was 12%. Approximately 51% (n = 43) of patients with hypertension were at blood pressure goal and 26% (n = 21) diabetic patients were at glycemic goal based on current guidelines. Of the patients with uncontrolled diabetes, 49% (n = 29) were on two oral agents and only 10% (n = 6) were on insulin. Providers stated that barriers to appropriate management include concerns prescribing insulin and patient health literacy. Patients demonstrated a general understanding of the concept of chronic illness, however lacked specific knowledge regarding disease processes and self-management strategies.ConclusionsThis study provides an initial overview of diabetes mellitus and hypertension management in a diverse patient population in rural Belize. Results indicate areas for future investigation and possible intervention, including barriers to insulin use and opportunities for lifestyle-specific disease education for patients.

Abstract P3-11-03: Use of real-time patient reported outcomes to improve performance in breast surgery

Abstract P3-11-03: Use of real-time patient reported outcomes to improve performance in breast surgery

A Systems Approach to Improving Care for All Bereaved Families.

Bereavement services for families are an established part of hospice and palliative care. However, patients also die in the acute care and long-term care environments. Often, hospice is not involved, creating a potential gap in care. This article recounts a journey to improve care for all families of deceased patients, despite the presence or absence of hospice. A palliative care clinical nurse specialist led a quality improvement team, which used a systems thinking approach to develop and implement a downloadable bereavement booklet for families. Expected and unexpected outcomes are discussed for this replicable project.

Setting quality improvement priorities for women receiving systemic therapy (ST) for early stage breast cancer (EBC) using population level administrative data.

299 Background: Routine evaluation of evidence informed quality measures (QM) can drive improvement in cancer systems by highlighting potential gaps in care. Targeting quality improvement at QMs that demonstrate substantial variation has the potential to make the largest impact on quality at a population level. We aimed to use variation in performance to set priorities for improving the quality of ST for women with EBC. Methods: EBC cases diagnosed 2006 – 2010 in Ontario, Canada were identified in the Ontario Cancer Registry and linked deterministically to multiple health care databases. A panel of QMs, previously developed to be operationalized for administrative data, was applied to reflect the quality of ST. Each QM was evaluated in all patients who met the inclusion criteria for the individual measure. QMs were ranked based on institutional variation in performance using the mean absolute difference (MAD). Results: We identified 28,303 patients, treated at 84 institutions. The performance of each QM is listed in Table 1. Timely receipt of ST, febrile neutropenia (FN) secondary prophylaxis, emergency room visits or hospitalizations, receipt of hormonal therapy (HT) and the use of surveillance imaging represented the 5 QM that demonstrated the greatest variation. Conclusions: Considerable institutional-level variation highlights potentially actionable areas of improvement [Table: see text]

Use of Diabetes Registry Data for Comparing Indices of Diabetes Management: A Comparison of 2 Urban Sites in Canada and Colombia.

To demonstrate the use of a multinational diabetes registry for comparing indices of diabetes management among countries with differing levels of income, healthcare systems and ethnic backgrounds. A cross-sectional study was conducted among 1742 people with type 2 diabetes attending diabetes clinics in London, Ontario, Canada, and Bogota, Colombia. The data were extracted from the Global Registry and Surveillance System for Diabetes (GRAND). Canadian patients were diagnosed with diabetes at significantly younger ages than Colombian patients (49 years and 53 years, respectively) and were heavier (body mass indices of 33 and 28, respectively). The Colombian patient population had significantly higher mean glycated hemoglobin (A1C) levels (9.4% vs. 8.6%) and fewer patients (22% vs. 26%) at the glycemic target (A1C <7.0%) than Canadian patients. In Colombia, 1 or more diabetes-related complications were present in 51% of the study population compared with 37% in Canada. Newly diagnosed Colombians had higher mean A1C levels (9.1% vs. 8.7%) and low-density lipoprotein-C levels (3.3 mmol/L vs. 2.5 mmol/L) than did newly diagnosed Canadians. A multination diabetes registry collecting standardized data facilitates transnational comparison of diabetes clinical parameters for the purpose of identifying potential gaps in care.

Trends in the Occurrence of Type 2 Diabetes in Community-Dwelling Trinidadian Subjects, 1993-2014

Objective: The purpose of this study is to examine secular trends in the occurrence of type 2 diabetes in community-dwelling Trinidadian subjects. Methods and design: We selected two regions in Trinidad and identified communities where people both live and seek health care services. We used several definitions of type 2 diabetes to recruit participants. Data on age, gender, onset of illness and educational level as a marker of socioeconomic status was collected. Findings: 301 participants were entered into the study. There was ethnic disparity but a reversal from South East to Africans. A strong inverse linear relationship (Pearson’s coefficient r=-0.82, p ≤ 0.05) was found between BMI and age at diabetes onset. Between the 1990’s and 2004-2014 in two regions of Trinidad the number of patients with T2DM doubled, occurring more commonly among females, the obese and overweight, a tendency towards younger age groups and those of lower socioeconomic status (SES). Conclusion: We provide evidence that at the community level that the occurrence of T2DM is increasing, and shifting towards younger age groups. and quantifying the number of people affected, now and in the future, is important to allow for rational planning, allocation of resources and effective strategies for prevention and management [4]. In addition comprehensive and up-to-date survey data at the community level helps to identify potential gaps in care, and to monitor and evaluate the provision of treatment to patients in the most efficient manner. The purpose of this study is to examine secular trends in the occurrence of type 2 diabetes in community-dwelling Trinidadian subjects. Methods

Application and feasibility of systemic lupus erythematosus reproductive health care quality indicators at a public urban rheumatology clinic.

Quality indicators (QIs) are evidence-based processes of care designed to represent the current standard of care. Reproductive health QIs for the care of patients with systemic lupus erythematosus (SLE) have recently been developed, and examine areas such as pregnancy screening for autoantibodies, treatment of pregnancy-associated antiphospholipid syndrome, and contraceptive counseling. This study was designed to investigate our performance on these QIs and to explore potential gaps in care and demographic predictors of adherence to the QIs in a safety-net hospital. We performed a record review of patients with a diagnosis of SLE at Denver Health Medical Center (DH) through an electronic query of existing medical records and via chart review. Data were limited to female patients between the ages of 18 and 50 who were seen between July 2006 and August 2011. A total of 137 female patients between the ages of 18 and 50 were identified by ICD-9 code and confirmed by chart review to have SLE. Of these, 122 patients met the updated 1997 American College of Rheumatology SLE criteria and had intact reproductive systems. Only 15 pregnancies were documented during this five-year period, and adherence to autoantibody screening was 100 percent. We did not have any patients who were pregnant and met criteria for pregnancy-associated antiphospholipid syndrome. Sixty-five patients (53%) received potentially teratogenic medications, and 30 (46%) had documented discussions about these medications' potential risk upon their initiation. Predictors of whether patients received appropriate counseling included younger age (OR 0.92, CI 0.87-0.98) and those who did not describe English as their primary language (OR 0.24, CI 0.07-0.87) in the multivariate analysis. We were able to detect an important gap in care regarding teratogenic medication education to SLE patients of childbearing potential in our public health academic clinic, as only one in two eligible patients had documented appropriate counseling at the initiation of a teratogenic medication.

Enhancing collaborative pharmaceutical care for patients with chronic kidney disease: survey of community pharmacists.

The Kidney Care Clinic at Sunnybrook Health Sciences Centre provides multidisciplinary care for patients with stage 4 or 5 chronic kidney disease. These patients are at high risk of drug therapy problems. Clinic pharmacists review medications and provide recommendations at each visit, but potential gaps in care exist between clinic visits. Community pharmacists are ideally situated to identify and resolve drug therapy problems between visits. To determine community pharmacists' confidence in managing care for patients with chronic kidney disease; to identify opportunities for improving collaboration between clinic and community pharmacists; and to determine the key clinical information that community pharmacists would use when caring for these patients. An anonymous survey was sent by mail and electronically to community pharmacies that were providing prescription medications for clinic patients. A total of 318 surveys were sent to 96 pharmacies. Data analysis was based on descriptive statistics, including frequencies, ranges, and measures of central tendency. Fifty-one completed surveys were returned (response rate 16%). Thirty-five (69%) of the responding pharmacists were not aware or were unsure that a patient from the Kidney Care Clinic was a client of their pharmacy. Forty-six (90%) were confident in providing counselling about medications used to manage chronic kidney disease, and 32 (63%) indicated confidence in recommending drug dosing changes based on kidney function. Forty-five (88%) of the pharmacists indicated a willingness to play a greater role in reviewing medications for patients with chronic kidney disease, and all agreed that they would benefit from education about the complications of this disease and their management. Clinical information ranked most useful included an updated medication list with indications and details regarding recent medication changes. Community pharmacists indicated willingness to have greater involvement in the care of patients with chronic kidney disease. The survey results revealed a need to increase awareness of clinic patients among community providers. Participants were receptive to continuing education, and initial efforts should focus on dosing adjustments of renal drugs and the complications of chronic kidney disease. Tools for transferring clinical information must be developed.

MRI of the Knee and Shoulder Performed Before Radiography

Available data are limited on the level of adherence to established guidelines for appropriate utilization of MR in musculoskeletal imaging. This study estimates the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography, which thus may fall outside the ACR Appropriateness Criteria for the Medicare and commercially insured populations. The percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography was estimated among patients in the Medicare 5% carrier claims limited data set and among commercially insured patients in the Truven Marketscan Treatment Pathways database in 2010. Approximately 28% of all knee MRIs, and 35%-37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee-for-service Medicare population was between $20 and $35 million. Between 20% and 23% of patients undergoing knee MRI, and 27%-32% undergoing shoulder MRI, did not have radiographic examination at any point before the MRI in the same calendar year. MRI performed without prior radiography represents a potential gap in care and should be considered as an area for establishment of performance measures.