Pre-intervention Year Research Articles

Optimising the indications for biliary stent placement during endoscopic retrograde cholangiopancreatography: a quality improvement initiative to enhance patient care and reduce healthcare resource utilisation

BackgroundA retrospective chart audit was performed to review biliary stent utilisation from January 2020 to January 2021. Non-guideline-based stent insertion was identified in 16% of patients with common bile duct...

Partnerships with religious leaders to promote family planning in rural Tanzania: an open-label, cluster randomised trial

Family planning benefits maternal-child health, education, and economic wellbeing. Despite global efforts, an unsatisfied demand for family planning persists in sub-Saharan Africa. Based on previous successful partnerships, the aim of this study was to determine whether an educational intervention for religious leaders would increase community knowledge, demand for, and ultimately uptake of family planning. In this open-label, cluster randomised trial in Tanzania, 24 communities were randomised (1:1) to intervention or control arm. Communities, defined as the catchment area of a single public health facility, were eligible if they were at least 15 km from Mwanza City and had not previously participated in a health intervention for religious leaders. Random allocations were determined by coin toss and were not revealed to clinicians at health facilities in intervention and control communities, nor to the data entry team; however, due to the nature of the intervention, masking of religious leaders in the intervention communities was not possible. All Christian religious institutions were invited to send four leaders to an educational intervention that incorporated cultural, theological, and medical teaching about family planning. The primary outcome was contraceptive uptake at the community health facility during the year post intervention versus the year before the intervention. This trial was registered at clinicaltrials.gov, NCT03594305. 75 communities in three districts were assessed for eligibility. 19 communities were excluded and 56 were eligible for study inclusion and were placed in random order to be invited to participate. The first 24 communities that were invited agreed to participate and were randomly assigned to receive the educational intervention either during the trial or after trial completion. Between July 10, 2018 and Dec 11, 2021, we provided the intervention in 12 communities and compared contraceptive uptake with 12 control communities. All were followed up for 12 months. In intervention communities, contraceptive uptake increased by a factor of 1·47 (95% CI 1·41-1·53) in the post-intervention (prospective) versus pre-intervention (historical) year (geometric mean of contraceptive uptake, 466 in the prospective year vs 312 in the historical year), versus 1·24 (95% CI 1·20-1·29) in control communities (geometric mean, 521 in the prospective year vs 429 in the historical year). The rate of change in contraceptive uptake was greater in intervention communities (between-group ratio of geometric mean ratios over time, 1·19 [95% CI 1·12-1·25]; p<0·0001). The COVID-19 pandemic was associated with decreased contraceptive uptake (geometric mean, 365 during the pandemic in communities that had the majority of their prospective 12-month data collection periods occur after March 16, 2020, vs 494 before the pandemic; geometric mean ratio, 0·72 [95% CI 0·57-0·90]; p=0·0040). This intervention offers a scalable model, leveraging influence of trusted religious leaders to increase knowledge and uptake of family planning. New strategies such as this could help to overcome setbacks that occurred during the COVID-19 pandemic. John Templeton Foundation and Weill Cornell Medicine Dean's Diversity and Healthcare Disparity Award. For the Kiswahili translation of the abstract see Supplementary Materials section.

“To teach or not to teach- that is the question” The educational and clinical impact of introducing an outcome based, modular curriculum in Social Emergency Medicine (SEM) at a private tertiary care center in Karachi, Pakistan

IntroductionAn enhanced knowledge of Emergency Medicine (EM) personnel regarding negative Social Determinants of Health (SDH) can impact EM service provision in a resource limited country like Pakistan. Interventions to build capacity in identifying and addressing these SDH through education in Social Emergency Medicine (SEM) can be one of the ways in which EM key performance indicators (KPIs) can be improved.MethodA SEM based curriculum was administered to the EM residents at a tertiary care center in Karachi, Pakistan. Pre, post and delayed post-test was conducted for knowledge of EM residents and analyzed using Repeated Measures ANOVA (RMANOVA). Clinical impact of this intervention was assessed through the ability of the residents to identify the patients’ SDH and determining appropriate disposition. Comparison of the bounce-back of patients in the pre-intervention (2020) and post-intervention year (2021) year was appreciated to see the clinical impact of this intervention.ResultA significant improvement was seen in post intervention (p < 0.001) and follow up knowledge (p < 0.001) of residents regarding negative SDH. Bounce-back rate was higher in the pre-SEM curriculum (43%) as compared to the post-SEM curriculum year (27.7%). Post-intervention, the residents were able to identify the unique Pakistani SDH, however appropriate patient disposition needs further reinforcement.ConclusionThe study highlights the beneficial impact of an educational intervention in SEM upon the knowledge of EM residents and the bounce-back of patients in the emergency department (ED) of a low resource setup. This educational intervention can be scaled up to other EDs across Pakistan for potential improvement in knowledge, EM process flow and KPIs.

A81 OPTIMIZING THE INDICATIONS FOR BILIARY STENT PLACEMENT IN PATIENTS WITH CBD STONES: A QUALITY IMPROVEMENT INITIATIVE TO ENHANCE PATIENT CARE AND REDUCE HEALTHCARE RESOURCE UTILIZATION

Abstract Background A retrospective chart audit was performed to review biliary stent utilization from January 2020 to 2021 at the University of Alberta Hospital (UAH). Inappropriate stent usage was identified in 16% of patients with common bile duct (CBD) stones presenting for endoscopic retrograde cholangiopancreatography (ERCP). To improve this clinical practice, a quality improvement (QI) initiative was developed and completed. Purpose To reduce the number of inappropriately inserted biliary stents in patients with CBD stones. Method The results of the chart audit (pre-intervention) were shared with the ERCP group. The QI intervention was to align biliary stent insertion in accordance with published guidelines. A chart audit (post-intervention) was then performed on all ERCPs from July, 2021 to June, 2022. The indication for biliary stent insertion was assessed independently by two blinded reviewers. Result(s) A total of 661 patients (337 F) with mean age of 59±19 years (range 12-98 years) underwent 885 ERCPs during this post-intervention period. Of the 661 patients, 384 (58%) were referred for CBD stones. A total of 192 biliary stents (105 plastic, 85 metal) were placed during the first ERCP (192/661, 29%), as compared to the pre-intervention year (223/598, 37%, p=ns). However, only 13/192 stents (7%) were placed not in accordance with published guidelines (kappa=0.53), compared with 63/223 (28%) in the pre-intervention year (p&amp;lt;0.0001). This accounts for a 75% reduction in overall unnecessary stent placement. This reduction was mainly seen in the CBD stone subgroup, where there was an 88% reduction in inappropriate biliary stent placement compared to the pre-intervention year (8/384, 2% vs. 61/376, 16%, p&amp;lt;0.0001). Image Conclusion(s) Education to align practice in accordance with published guidelines has demonstrated a significant improvement in biliary stent insertion during ERCP in patients with CBD stones. This has resulted in significantly fewer inappropriate stent placements, a reduction in unnecessary follow-up ERCPs, and an overall saving of healthcare resources. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

1273. Implementation of a Mobile Phone Intervention Method to Improve Clinical Outcomes in Patients with HIV

Abstract Background Antiretroviral therapy (ART) adherence decreases morbidity and mortality; however, this is often complicated by various external factors. Strategies implementing cellular technology have demonstrated improved medication adherence. The objective of this pilot study was to assess the effectiveness of utilizing weekly mobile phone calls or text messages to improve clinical outcomes among patients with HIV. Methods This study was conducted at an infectious disease clinic at an academic medical center 2019-21. Twenty-two patients were selected based on a history of poor ART adherence. For a period of 6 months, patients were contacted weekly by text message or phone call to determine medication adherence and to encourage continued adherence. Outcomes during the 12-month intervention period (6m intervention and subsequent 6m) were compared to the 12-month pre-intervention period and included viral load, CD4 count, clinic visits, emergency department (ED) visits, hospitalizations, and new-onset opportunistic infections (OI). Wilcoxon signed rank test and McNemar’s test were performed, though study is not powered for true analysis. Results Twenty-two patients were selected for inclusion and 13 (55%) maintained persistent communication throughout the intervention. For all 22 enrolled participants, this intervention resulted in increased mean yearly clinic visits (2.6 vs 3.8), decreased median viral load (32,979 vs 852 copies/mL, p=0.017), and increased median CD4 (142.5 vs 249 cells/uL). This also led to a decrease in patients with &amp;gt; 1 ED visit (54.6% vs 36.4%), &amp;gt; 1 inpatient hospitalization (36.4% vs 13.6%), and diagnosis of an OI (18.2% vs 13.6%). These outcomes were most remarkable in the 13 patients who maintained scheduled communication [mean yearly clinic visits (2.9 vs 5.2), median viral load (27,633 vs 118 copies/mL, p=0.0248), median CD4 cells/uL (76 vs 253), &amp;gt; 1 ED visit (61.5% vs 30.8%), &amp;gt; 1 inpatient hospitalization (38.5% vs 23.1%), and new OI (23.1% vs 7.7%)]. Impact of Intensifying Outpatient HIV Management Clinical outcomes for the pre-intervention year (routine communication) and the intervention year (enhanced communication) for all 22 patients initially selected for the study are compared to outcomes for the 13 patients who maintained persistent communication throughout the intervention period. Conclusion Enhanced communication through weekly mobile phone reminders may serve as a useful tool in the outpatient setting to improve ART adherence and reduce morbidity among adults with HIV. The findings of this small pilot study provide support for the need of a larger study to prove the benefit of this care model. Disclosures All Authors: No reported disclosures.

1664. Impact of a Midline Catheter Prioritization Project on Central Venous Access and Central Line Associated Bloodstream Infections at an Urban Safety-net Community Hospital

Abstract Background The use of peripherally inserted central catheters (PICCs) has increased in the past decade. PICCs are central lines (CLs) commonly used for venous access. Midline catheters (MLs) can provide access when the need for a CL, such as vasopressors, is no longer present. MLs have a lower rate of BSI compared to PICCs and CLs, while providing dwell times comparable to PICCs. We established a project prioritizing ML use. Methods This is a quasi-experimental study in a 151-bed safety net community hospital. The pre-intervention period was January-December 2018 and post period was January 2019-December 2021. MLs were prioritized when new PICCs are requested without CL indications, such as total parenteral nutrition, hyperosmolar solutions and vasopressors. PICCs and CLs are transitioned to a ML once indications are no longer met and peripheral IVs are not feasible. Data on utilization and complications, such as deep venous thrombus (DVT) and BSIs, were reviewed and compared. Results A total of 63 peripherally inserted lines occurred prior to the intervention, of which 55 (87%) were PICC and 8 (13%) were ML (Figure 1). Post-intervention, 76 lines were placed the first year, of which 48 were ML (63%). This upward trend was sustained throughout the pandemic, with 116 lines in 2020 (80% ML) and 96 in 2021 (88% ML). No BSIs occurred during the pre-intervention and first post-intervention year. During the pandemic, 8 BSIs in MLs and 3 in PICCs occurred. The most common organism was Candida (Figure 2). The majority had COVID-19 (72%) and all (100%) BSIs were in the setting of shock. Case review demonstrated suspected secondary sources other than central venous catheters (CVCs). All BSIs with ML would have met NHSN criteria if CL present. No upper extremity DVTs were found. Conclusion A midline prioritization project was successfully implemented and sustained during the COVID-19 pandemic. The decline of PICC use from 87% to 12% suggests use for access without CL needs. High acuity during the pandemic led to BSIs that were likely secondary to shock and complications of COVID-19. All cases would have met NHSN criteria for CLABSI. The cost of a CLABSI is estimated at $48,108. Thus, this midline prioritization project may have led to CLABSI avoidance and an estimated cost savings of $384,864. Disclosures All Authors: No reported disclosures.

Cost-Effectiveness of a New Outpatient Pulmonology Care Model Based on Physician-to-Physician Electronic Consultation.

This study assesses the impact of an electronic physician-to-physician consultation program on the waiting list and the costs of a Pulmonology Unit. A prepost intervention study was conducted after a new ambulatory pulmonary care protocol was implemented and the capacity of the unit was adopted. In the new model, physicians at all levels of healthcare send electronic consultations to specialists. In the preintervention year (2019), the Unit of Pulmonology attended 7,055 consultations (466 e-consultations and 6,589 first face-to-face visits), which decreased to 6,157 (3,934 e-consultations and 2,223 first face-to-face visits; 12.7% reduction) in the postintervention year (all were e-consultations). The mean wait time for the first appointment was 25.7 days in 2019 versus 3.2 days in 2021 (p < 0.001). In total, 43.5% of cases were solved via physician-to-physiciane-consultation. A total of 2,223 patients needed a face-to-face visit, with a mean wait time of 7.5 days. The mean of patients in the waiting listing decreased from 450.8 in 2019 to 44.8 in 2021 (90% reduction). The annual time devoted to e-consultations and first face-to-face visits following an e-consultation diminished significantly after the intervention (1,724 hours versus 2,312.8; 25.4% reduction). Each query solved via e-consultation represented a saving of €652.8, resulting in a total annual saving of €827,062. Physician-to-physiciane-consultations reduce waiting times, improve access of complex patients to specialty care, and ensure that cases are managed at the appropriate level. E-consultation reduces costs, which benefits both, society and the healthcare system.

Engaging academic staff in the quality assurance system in higher education: A field experiment

A randomised field experiment was conducted at the University of Malaga in 2017 to examine personalised norm-based messages’ effects on response rates to the annual faculty satisfaction survey. This research had a factorial design that combined formal versus informal writing styles with four norm-based messages: no norm, moral suasion, moral duty and social norm. The results reveal that two treatments – informal-moral duty and informal-social norm – both had the strongest positive effect. The university's quality assurance unit applied the informal-moral duty approach the following academic year, thereby increasing the overall response rate to the annual faculty satisfaction survey by 20% over the pre-intervention year.

The Impact of Pop-Up Clinical Electronic Health Record Decision Tools on Ordering Pulmonary Embolism Studies in the Emergency Department.

Emergency physicians make time-sensitive care decisions for life threatening diagnoses and utilize evidence-based decision rules and testing with high sensitivity to ensure that critical diagnoses are not missed. Current literature suggests that there is over testing for pulmonary embolism in the emergency department. This study aimed to determine whether the addition of a pop-up notification of the Modified Wells Criteria into the workflow would impact the number of total orders for computed tomography pulmonary angiography (CTPA) or the diagnostic yield of those studies. This study was a retrospective observational study comparing CTPA utilization rates and diagnostic yield among physicians at a single academic emergency department in the 1 year prior and 1 year post implementation of an active electronic health recored (EHR) pop-up of Modified Well's scoring when ordering a CTPA. CTPA utilization rates were statistically equivalent, p <0.0001 within a 0.5% equivalence margin, during the pre and post intervention years. The observed difference was 0.1% (95% CI -0.02%, 0.21%). Despite proving equivalence in the rates of CTPA studies ordered, the diagnostic yield, however, was significantly different (p=0.001), 32.35% in the pre-intervention year compared to 41.60% in the post-intervention year. There are many barriers to the implementation of successful EHR alerts. These findings support and validate previous studies that have shown a higher diagnostic yield of CT angiography for pulmonary embolism after implementation of active alerts integrated into the EHR with ordering studies. These tools are effective quality improvement initiatives, and their use should be encouraged.

Diagnostic Stewardship of Endotracheal Aspirate Cultures in a PICU.

Clinicians commonly obtain endotracheal aspirate cultures (EACs) in the evaluation of suspected ventilator-associated infections. However, bacterial growth in EACs does not distinguish bacterial colonization from infection and may lead to overtreatment with antibiotics. We describe the development and impact of a clinical decision support algorithm to standardize the use of EACs from ventilated PICU patients. We monitored EAC use using a statistical process control chart. We compared the rate of EACs using Poisson regression and a quasi-experimental interrupted time series model and assessed clinical outcomes 1 year before and after introduction of the algorithm. In the preintervention year, there were 557 EACs over 5092 ventilator days; after introduction of the algorithm, there were 234 EACs over 3654 ventilator days (an incident rate of 10.9 vs 6.5 per 100 ventilator days). There was a 41% decrease in the monthly rate of EACs (incidence rate ratio [IRR]: 0.59; 95% confidence interval [CI] 0.51-0.67; P < .001). The interrupted time series model revealed a preexisting 2% decline in the monthly culture rate (IRR: 0.98; 95% CI 0.97-1.0; P = .01), immediate 44% drop (IRR: 0.56; 95% CI 0.45-0.70; P = .02), and stable rate in the postintervention year (IRR: 1.03; 95% CI 0.99-1.07; P = .09). In-hospital mortality, hospital length of stay, 7-day readmissions, and All Patients Refined Diagnosis Related Group severity and mortality scores were stable. The estimated direct cost savings was $26 000 per year. A clinical decision support algorithm standardizing EAC obtainment from ventilated PICU patients was associated with a sustained decline in the rate of EACs, without changes in mortality, readmissions, or length of stay.

Academic Detailing From Medical Students: Part of a Plan to Emphasize Feedback in One Clerkship.

Medical schools have an enduring need to provide ongoing faculty development and to foster educational alliances between teachers and learners, so that feedback provided to learners is both frequent and of high quality. We hypothesized that medical students trained as academic detailers with a mission to increase the emphasis on feedback could serve in this role during our clerkship, while still being evaluated as students in our clerkship rotation. The family medicine clerkship at Mayo Clinic School of Medicine launched a revised curriculum in 2016 in which students were taught how they might build an educational alliance with preceptors, were taught characteristics of high-quality feedback, and practiced requesting more useful feedback when initial quality was poor. After utilizing a clerkship-specific curriculum with small group sessions on receiving feedback, and training students and preceptors on the SNAPPs model, students were then directed to request feedback from their preceptors and model successful feedback conversations for preceptors. The study evaluated the medical students' summative evaluations to compare the rate from the preintervention year (2015-2016) and the intervention year (2016-2017) at which preceptors added comments on students' use of feedback. Preceptors' written comments about students seeking feedback increased at about a four-fold rate (74.4% vs 18.8%, P<.001) after implementing a suite of changes to our clerkship curriculum. Using medical students to change preceptor behaviors was an important part of our suite of interventions. This intervention directed preceptor attention toward our instructional goal of increased medical student feedback.

CN113 - The effect of the short-term and long-term compassion fatigue resiliency program on the quality of life, perceived stress and psychological resilience of oncology-haematology nurses

BackgroundThis study was carried out as randomized-controlled, longitudinal interventional to determine whether there was a difference between the mean scores of compassion fatigue (CF), burnout (BO), compassion satisfaction (CS), perceived stress (PS) and psychological resilience (PR) after applying the short-term and long-term ‘Compassion Fatigue Resiliency Program’ for nurses working in the field of oncology-hematology. MethodsThe sample of the study consisted of oncology-hematology nurses working in two private hospitals, one university hospital. Hospitals were randomly assigned to experiment I (n:34), experiment II (n: 49) and control groups (n: 42). Short-term (two days, five hours per day) program implemented to experiment I, long-term (five weeks, 2hours a week) program implemented to experiment II and no any intervention implemented to control group. Measurements were made pre-intervention, post-intervention, third month, sixth month and first year. The data were collected by personal information form, professional quality of life scale-IV, PS scale, and PR scale for adults. SPSS 24 package program was used to analyze the data of the study. Primary research hypotheses were tested with multilevel models (MLM). ResultsThere was no statistically significant difference between the mean scores of CF, BO, PS and PR of the nurses in the short-term, long-term and control groups. The mean compassion satisfaction score of the nurses in the short-term and long-term education group was statistically significantly higher than in the control group. The mean CS scores of the nurses in both the short and long-term education groups were statistically significantly higher in the sixth month and first year follow-up measurements than in the pre-intervention period. ConclusionsIn this study, considering the effects of long-term and short-term education on CF, BO, CS, perceived stress and PR of nurses, it can be said that these two educations have the same effect on CS. It is the first study with randomized-controlled method, including the follow-up of up to a year. Doing new studies that are revealing the effect of this education can be suggested. Legal entity responsible for the studyTuğba Pehlivan. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

A “Sense”-ational HPV Vaccination Quality Improvement Project in a Family Medicine Residency Practice

BackgroundHuman papillomavirus (HPV) vaccination uptake for adolescents and young adults in the United States remains far from national goals. Using a multi-component intervention aligned with community-wide efforts, we implemented a quality improvement project to increase HPV vaccinations among 9-26 year-old male and female patients in an urban, low income, minority population family medicine residency practice. MethodsThe pre-intervention year was November 2, 2014 to October 31, 2015 and the intervention year was November 1, 2015 to October 31, 2016. Based on community input and published literature, the interventions were creative, practice-specific provider-, patient-, and system-level strategies. To compare pre- and post-intervention vaccinations, HPV vaccination data were extracted from an electronic medical record request for age-eligible patients seen in the practice during the intervention year. Chi-square, McNemar’s and 2-tailed, 2-sample Z tests were used to test differences in vaccination initiation (≥1 dose) and completion (3 doses) across groups and over time. ResultsDespite high pre-intervention rates (58% and 75%), HPV vaccine initiation significantly increased 12.8 percentage points (PP) for males and 10.6 PP for females from pre- to post-intervention (P < 0.001). HPV vaccine completion also significantly increased 16 PP for males and 10.9 PP for females (P < 0.001). Young adult patients (18-26 years-old) had significant increases in completion rates (9.9 PP; P < 0.001), not observed among adolescents (20 PP; ns). ConclusionsConsistent and abundant positive HPV vaccination messaging, low-cost sensory rewards, process change, and community, clinician, and nonclinical staff engagement were associated with higher HPV vaccine initiation and completion, especially among young adults.

Abstract 211: Reduction in Laboratory Associated Cost Through Education Based Gatekeeping

Background: Laboratory testing is one the factors contributing to rising health care expenditures. Recent estimates show that laboratory and pathology testing accounts for 4% of all yearly healthcare costs. Depending on the country, clinical setting, method, and specific tests evaluated, studies have shown that a relatively large percentage (up to 42%) of laboratory testing may be wasteful. We proposed a study to evaluate the lab related costs in our institution. Objectives: To evaluate the effects of behavioral interventions that may result in lab-associated cost reduction. Methods: We identified the top 10 Diagnosis-related Groups (DRG) for our institution, along with most common requested laboratory investigations for the patients hospitalized during three fiscal years 2015-2017. Extensive review of data from fiscal year 2015 (identification period) was performed by a review committee comprising of physicians, lab leadership, billing &amp; coding team and Internal Medicine operations director. Two interventions were selected based on the institutional work flow design, and included removal of default duration from complete blood count and basic metabolic panel orders, and behavioral modification with structured education to create awareness for the cost associated with unnecessary lab tests. Interventions were implemented by the end of fiscal year 2016 and start of 2017. Comparison of each fiscal year cost data was performed. Results: A total of 1612 patients with selected DRGs were identified in pre-intervention fiscal year 2016 with total lab cost of $1,603,724 and average cost of $995/patient. During post-intervention fiscal year 2017, 1530 patients were identified with total lab cost of $1,174,557 with average cost of $768/patient. Post-intervention overall cost reduction was noted to be $429,167 which is 26.7% lower than pre-intervention fiscal year. Per patient cost was lowered by an amount of $227; a 22.8% decrease. Conclusion: In this single center study, implementing modification of default lab orders along with structured educational program showed a significant reduction in lab related cost without interfering with the clinical decision-making process of the providers.

Impact of Emergency Medicine Consultants and Clinical Advisors on a NHS 111 Clinical Assessment Service

ObjectiveTo compare outcome of clinical advice given by emergency physicians (EPs) versus non-physician clinical advisors (NPCAs) on a UK National Health Service 111 centre.MethodThis was a prospective study conducted between...

Outcomes of a Statewide Learning Collaborative to Implement Mental Health Services in Pediatric Primary Care.

Mental health concerns are common in pediatric primary care, but practitioners report low levels of comfort managing them. A primary care intervention addressing organizational and individual factors was developed to improve the management of common mental health conditions. Twenty-nine practices participated in a statewide learning collaborative over 18 months. On-site training was used to teach communication and brief intervention skills and develop an organizational context supportive of mental health. Clinician confidence was measured pre- and postintervention. Medicaid claims data were used to estimate the intervention's effects on identification of mental health conditions and prescribing practices. Mean clinician confidence scores increased by 20% (95% confidence interval [CI]=15% to 25%), from 2.92 at baseline to 3.55 postintervention. In the first month of the preintervention year, 6.65% of patients with an office visit had at least one visit for a mental health condition, rising to 9% postintervention; this trend was driven by detection and treatment of attention-deficit hyperactivity disorder (ADHD). Rates of prescribing ADHD medication to patients with visits for ADHD increased by 0.12 percentage points per month (CI=0.02 to 0.22, p=0.022). Rates of prescribing second-generation antipsychotics to all patients with office visits decreased by 0.014 percentage points per month (CI=-.03 to -.00, p=0.028), relative to preintervention trends. This study suggests that a multicomponent intervention addressing individual staff and organizational factors together can promote identification and treatment of child mental health conditions in primary care. Future research is required to better understand the core components, impact on health outcomes, and sustainability.

Development of the individualised Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial: a protocol summary of a national cluster-randomised trial of resident duty hour policies in internal medicine.

IntroductionMedical trainees’ duty hours have received attention globally; restrictions in Europe, New Zealand and some Canadian provinces are much lower than the 80 hours per week enforced in USA. In USA, resident duty hours have been implemented without evidence simultaneously reflecting competing concerns about patient safety and physician education. The objective is to prospectively evaluate the implications of alternative resident duty hour rules for patient safety, trainee education and intern sleep and alertness.Methods and analysis63 US internal medicine training programmes were randomly assigned 1:1 to the 2011 Accreditation Council for Graduate Medical Education resident duty hour rules or to rules more flexible in intern shift length and number of hours off between shifts for academic year 2015–2016. The primary outcome is calculated for each programme as the difference in 30-day mortality rate among Medicare beneficiaries with any of several prespecified principal diagnoses in the intervention year minus 30-day mortality in the preintervention year among Medicare beneficiaries with any of several prespecified principal diagnoses. Additional safety outcomes include readmission rates, prolonged length of stay and costs. Measures derived from trainees’ and faculty responses to surveys and from time-motion studies of interns compare the educational experiences of residents. Measures derived from wrist actigraphy, subjective ratings and psychomotor vigilance testing compare the sleep and alertness of interns. Differences between duty hour groups in outcomes will be assessed by intention-to-treat analyses.Ethics and disseminationThe University of Pennsylvania Institutional Review Board (IRB) approved the protocol and served as the IRB of record for 40 programmes that agreed to sign an Institutional Affiliation Agreement. Twenty-three programmes opted for a local review process.Trial registration numberNCT02274818; Pre-results.

Improving allergy office scheduling increases patient follow up and reduces asthma readmission after pediatric asthma hospitalization

BackgroundPediatric asthma is a major contributor to emergency room utilization and hospital readmission rates. ObjectiveTo develop an allergy department‒based intervention to improve follow-up appointment scheduling processes for pediatric asthma patients after discharge for asthma exacerbation. MethodsThis quality improvement study was conducted in the allergy clinic of an urban, tertiary children's hospital. Children receiving subspecialty allergy care for asthma were included into the intervention group during the intervention period. The quality improvement intervention consisted of 3 attempts by telephone to reach the family to schedule the follow-up appointment. If this was unsuccessful or if the appointment was not kept, then a reminder letter was sent to the family. The primary outcome of interest in this study was the percent of postdischarge follow-up appointments scheduled within 30 days of discharge. Secondary outcomes measured were the percent of allergy appointments attended within 30 days of discharge and the 30-day hospital readmission rate. ResultsDemographics did not differ significantly between the intervention and baseline preintervention year. The initial baseline scheduled allergy follow-up visit rate was 48.8 ± 13.3% of patients discharged per month. This increased to an overall rate of 75.7 ± 20.1% patients scheduling allergy follow-up within 30 days of discharge during the intervention year. We also observed a significant increase in attended allergy visits 30 days postdischarge from 35.5 ± 15.6% in year 1 to 53.9 ± 25.5% during the intervention year and a significant decrease in the 30-day readmission rate on the allergy service. ConclusionThese data suggests that minor changes in allergy practice organization can significantly affect posthospitalization follow-up rates and decrease asthma readmission rates.

Telemedicine in Primary Care for Patients With Chronic Conditions: The ValCrònic Quasi-Experimental Study.

BackgroundThe increase of chronic diseases prevalence has created the need to adapt care models and to provide greater home supervision.ObjectiveThe objective of our study was to evaluate the impact of telemonitoring on patients with long-term conditions at high risk for rehospitalization or an emergency department visit, in terms of target disease control (diabetes, hypertension, heart failure, and chronic obstructive pulmonary disease).MethodsWe conducted a quasi-experimental study with a before-and-after analysis to assess the effectiveness of the ValCrònic program after 1 year of primary care monitoring. The study included high-risk patients with 1 or more of the following conditions: diabetes, high blood pressure, heart failure, and chronic obstructive pulmonary disease. We assessed risk according to the Community Assessment Risk Screen. Participants used an electronic device (tablet) to self-report relevant health information, which was then automatically entered into their eHealth record for consultation.ResultsThe total sample size was 521 patients. Compared with the preintervention year, there were significant reductions in weight (82.3 kg before vs 80.1 kg after; P=.001) and in the proportion of people with high systolic (≥140 mmHg; 190, 36.5% vs 170, 32.6%; P=.001) and diastolic (≥90 mmHg; 72, 13.8% vs 40, 7.7%; P=.01) blood pressures, and hemoglobin A1c ≥8% (186, 35.7% vs 104, 20.0%; P=.001). There was also a decrease in the proportion of participants who used emergency services in primary care (68, 13.1% vs 33, 6.3%; P<.001) and in hospital (98, 18.8% vs 67, 12.8%; P<.001). Likewise, fewer participants required hospital admission due to an emergency (105, 20.2% vs 71, 13.6%; P<.001) or disease exacerbation (55, 10.5% vs 42, 8.1%; P<.001).ConclusionsThe ValCrònic telemonitoring program in patients at high risk for rehospitalization or an emergency department visit appears to be useful to improve target disease control and to reduce the use of resources.

Engaging schools in diagnosis and treatment of malaria: Evidence of sustained impact on morbidity and behavior

Background: In low and middle income countries (LMICs) teachers send home children found sick in class devolving subsequent care to parents; where malaria is endemic, morbidity is high as the most parents fail to access WHO-endorsed rapid diagnostic testing (RDT and prompt treatment with artemisinin combination therapy (ACT). Consequently malaria is the principal reason a child misses school; so, we trained teachers to use RDT to evaluate all sick pupils and give ACT promptly to those positive.Aims: Pre, intra and post intervention evaluation of impact of using the WHO Health Promoting School (HPS) model to empower teachers to provide RDT and ACT and engage and inform pupils about malaria in 4 schools in rural Uganda.Methods: Documenting duration of absence from school as a surrogate measure for morbidity and change in children’s knowledge and reported behaviors regarding malaria. Pre-intervention (year 1) baseline evaluation of days of absence and children’s malaria knowledge/behavior; Intervention (year 2) trained teachers administered RDT in all sick children and treated those positive with ADT; Post-intervention (end of year 3) after schools independently continued RDT/ACT and education on malaria.Results: Pre-intervention &lt;1:5 pupils had basic knowledge about malaria (caused by mosquitos; can be prevented; requires rapid diagnosis and prompt medication). In year 1: 953 of 1764 pupils were sent home due to illness. Mean duration of absence was 6.5 (SD 3.17) school days. In year 2: 1066 of 1774 pupils were sick, all had RDT, 765/1066 (68%) tested positive and received ACT; their duration of absence fell to 0.59 (SD 0.64) school days (p&lt;0.001). By year 2 all children knew the signs and symptoms of malaria and had essential epidemiological knowledge. Twelve months post intervention the universality of this knowledge had been sustained and the whole-school focus on malaria continued. Children reported better health, more consistent attendance and improved academic achievement, and had become proactive in prevention strategies; 6% fewer tested positive for malaria; and key health knowledge was being passed to new pupils.Conclusion: Teacher administered RDT/ACT reduced child morbidity from malaria significantly; essential knowledge was generated and new health practices acquired that changed behaviors. Our WHO HPS model is applicable to other LMICs where malaria is endemic and morbidity high.