Resident Primary Care Clinic Research Articles

Abstract 4131737: Atherosclerotic Cardiovascular Disease Risk Management in a Primary Care Residency Clinic

The 2018 AHA/ACC Multisociety Guideline on the Management of Blood Cholesterol recommends to target an LDL-C <70mg/dL in very high risk ASCVD patients. If the patient is on maximally tolerated statin therapy and LDL-C remained >70mg/dL, addition of ezetimibe was recommended. If LDL continued to be elevated, the addition of PCSK9 inhibitor was discussed. In 2019, the European Atherosclerosis Society recommended lowering the target LDL-C goal to <55mg/dL in patients with very high ASCVD risk. This is based on prior studies demonstrating dose-dependent reduction in ASCVD with LDL-C reduction. The purpose of this study is to identify individuals at very high ASCVD risk and determine if they are on optimal medical therapy to achieve LDL <55mg/dL with the intention to improve atheroscloertic cardiovascular risk management in primary care residency clinics. A review of electronic medical records from a primary care residency clinic was performed. Patients with hyperlipidemia and prior ASCVD event were identified. Additional data including lipid panel and current medical management were collected. Patients were stratified into very high risk and not very high risk groups according to AHA classification and analyzed. A total of 1,727 patients were found to have hyperlipidemia and a prior ASCVD event. The not very high risk group had an average age of 51 years with 54% (n=40) females and 45.9% (n=34) males. The very high risk group contained 95.7% (n=1,653) patients. The average age in the very high risk group was 68 years with 53.2% (n=879) of patients being female and 46.8% (n=774) being males. Of those patients, 73.6% (n=1,216) had an LDL ≥ 55 mg/dL. In these patients, 563 were on high intensity statin, 163 on moderate intensity statin and 15 on low intensity statin. There were 475 patients not on any statin. Of those on statin therapy, 66 were on ezetimibe alone and 10 were on both ezetimibe and PCSK9 inhibitors. Over 95% of patients with a prior ASCVD event were identified as being very high risk. Our data demonstrates that 3 in 4 patients were not on optimal medical therapy based on a stricter LDL goal. There was poor escalation of medical therapy as not all patients were on high intensity statin and only 10% of patients were on ezetimibe while even fewer patients were on additional PCSK9 inhibitor therapy. This study highlights the importance of risk stratification and vigilance in optimizing medical therapy.

"Life with Diabetes": A Pilot Study on an Experiential Continuous Glucose Monitoring Curriculum for Resident Physicians.

The use of technology in diabetes mellitus (DM) management has been growing. The indications and coverage for continuous glucose monitoring (CGM) have increased. Primary care (PC) clinics, including resident continuity clinics, are the frontline for DM management; however, they struggle to adopt CGM. To implement a CGM curriculum to resident physicians to improve knowledge and confidence. An internal medicine (IM) resident PC clinic in an urban academic medical institution. Twenty-four IM residents. We designed a curriculum that included a lecture about CGM indications, interpretation, ordering, and insurance consideration; and a voluntary, experiential learning module in which the residents wore a CGM. We conducted a retrospective pre-post survey with a 4-point Likert scale. Average self-reported scores in knowledge increased for CGM (1) indications from 1.85 to 3.45, (2) ordering from 1.35 to 3.05, (3) functioning from 2.20 to 3.50, and (4) data interpretation from 1.85 to 3.25 (all p < 0.0001). Confidence for "describing CGM monitoring" and "fielding questions about CGM" increased from 2.25 to 3.65 (p < 0.0001) and 1.90 to 3.30 (p < 0.0001). Given the demand for DM management in the PC setting, this targeted CGM curriculum has promise to help residents adopt CGM into their practice.

Enhancing point-of-care ultrasound (POCUS) utilization in primary care: A thyroid POCUS training course for internal medicine residents.

POCUS is valuable in primary care, yet outpatient-specific point-of-care ultrasound (POCUS) curriculum integration into internal medicine (IM) residency is limited. We addressed this gap by developing a thyroid POCUS workshop for IM residents. Develop and implement an educational curriculum to integrate thyroid POCUS into an IM residency program and evaluate the impact on resident knowledge, perceived skills, and attitudes. The study was conducted in a resident primary care clinic at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Residency Program in Internal Medicine at North Shore University Hospital and Long Island Jewish Medical Center. All 108 IM residents (PGY1-3) in one program participated in the study during their ambulatory clinic block. Residents participated in a 1-hour workshop involving a didactic session and two breakout groups: one for hands-on practice and another for case-based discussions with image review. Residents completed pre- and post-session surveys assessing knowledge, perceived skills, and attitudes toward thyroid POCUS. These data showed statistically significant increases in all assessed areas. Integrating thyroid POCUS into an IM residency curriculum significantly improved resident knowledge, attitudes, and perceived skills related to these exams. Residents valued this learning experience and expressed intentions to incorporate it into their future practice.

Disparities in the Timeliness of Addressing Patient-Initiated Telephone Calls in a Primary Care Clinic: The Impact of Quality Improvement Interventions

ABSTRACT A timely response to patient-initiated telephone calls can affect many aspects of patient health, including quality of care and health equity. Historically, at a family medicine residency clinic, at least 1 out of 4 patient calls remained unresolved three days after the call was placed. We sought to explore whether there were differential delays in resolution of patient concerns for certain groups and how these were affected by quality improvement interventions to increase responsiveness to patient calls. A multidisciplinary team at a primary care residency clinic applied Lean education and tools to improve the timeliness of addressing telephone encounters. Telephone encounter data were obtained for one year before and nine months after the intervention. Data were stratified by race, ethnicity, preferred language, sex, online portal activation status, age category, zip code, patient risk category, and reason for call. Stratified data revealed consistently worse performance on telephone encounter closure by 72 hours for Black/African American patients compared to Hispanic and non-Hispanic White patients pre-intervention. Interventions resulted in statistically significant overall improvement, with an OR of 2.9 (95% CI: 2.62 to 3.21). Though interventions did not target a specific population, pre-intervention differences based on race and ethnicity resolved post-intervention. Telephone calls serve as an important means of patient communication with care teams. General interventions to improve the timeliness of addressing telephone encounters can lead to sustainable improvement in a primary care academic clinic and may also alleviate disparities.

The Discrepancy Between Hemoglobin A1c and Glucose Management Indicators in 26 Patients Treated With Continuous Glucose Monitoring in an Internal Medicine Residency Clinic.

We conducted a retrospective observational cohort study between 2020 and 2023 in 26 patients with type 1 and type 2 diabetes mellitus (DM) who were using 3-4 injections per day of insulin and were monitored by continuous glucose monitoring (CGM). The goal of this retrospective observational cohort study is to compare these two metrics in an internal medicine community primary care residency clinic. We used CGM devices, Dexcom G6 and G7, and Freestyle Libre 3. The goal was to compare the patient's hemoglobin A1c (HbA1c) taken during their clinic visit by phlebotomy as a marker for diabetic control with an estimated HbA1c glucose management indicator (GMI) derived from the 30-day CGM readings. HbA1c is derived from the blood, while the GMI value is derived from the interstitial fluid. Both parameters were taken within 30 days of each other. GMI was taken in the last 30 days. We excluded patients with known anemia, chronic kidney disease, polycythemia, cirrhosis of the liver, or metabolic dysfunction associated with steatohepatitis (MASH) because disease states can affect the measured HbA1c. Also, pregnantand African American patients were excluded. We concluded the measured HbA1c was 0.34% (4 mmol/mol) higher than the CGM-derived GMI. The relationship between factors that affect glycemic control was discussed in the article, as well as the future utilization of them in improving diabetic control and management. As the use of CGM continues to grow, addressing differences between laboratory-measured HbA1c and CGM-derived GMI is critical.

Preparing Physicians to Treat Addiction: Inclusion of Dedicated Addiction Training During Internal Medicine Residency.

Physicians in internal medicine lack comfort and skills required to diagnose and treat substance use disorder (SUD). Formal training in substance use treatment within primary care training has traditionally been inconsistent and sparse. The purpose of this study is to assess the impact of a longitudinal experiential addiction curriculum on the attitudes and experiences of graduates from a primary care/internal medicine residency program that included formal addiction didactics, rotations in an outpatient addiction clinic embedded within the resident primary care clinic, and exposure to addiction medicine faculty across treatment settings. A survey was emailed to all graduates from a single academic primary care residency program who graduated between 2016 and 2018 (n = 53). The survey assessed pharmacotherapy for SUD prescribing patterns, comfort with SUD pharmacotherapy, overall comfort treating SUD, experience correcting stigmatizing language, and providing guidance to colleagues on the care of patients with SUD. A subset of respondents (n = 14) were interviewed regarding their experience with the residency program's addiction medicine curriculum and its impact on their current clinical practice. Sixty percent (n = 28) of graduates responded to the survey. All respondents felt comfortable using medications to treat SUD. Eighty-four percent perceived themselves as more comfortable using pharmacotherapy to treat SUD than their colleagues. Qualitative interviews revealed that this addiction medicine training shaped participants' attitudes toward patients with SUD and imparted them with the skills to address stigmatizing language. Participants described how they have become ambassadors of addiction medicine in their workplace and a resource to colleagues with less comfort in the management of SUD. Graduates of a primary care/internal medicine residency with a dedicated addiction medicine curriculum are comfortable prescribing pharmacotherapy for SUD, taking an active role in reducing SUD-related stigma, and serving as a resource for colleagues.

Low Rate of Completion of Recommended Tests and Referrals in an Academic Primary Care Practice with Resident Trainees

A frequent, preventable cause of diagnostic errors involves failure to follow up on diagnostic tests, referrals, and symptoms-termed "failure to close the diagnostic loop." This is particularly challenging in a resident practice where one third of physicians graduate annually, and rates of patient loss due to these transitions may lead to more opportunities for failure to close diagnostic loops. The aim of this study was to determine the prevalence of failure of loop closure in a resident primary care clinic compared to rates in the faculty practice and identify factors contributing to failure. This retrospective cohort study included all patient visits from January 1, 2018, to December 31, 2021, at two academic medical center-based primary care practices where residents and faculty practice in the same setting. The primary outcome was prevalence of failure to close the loop for (1) dermatology referrals, (2) colonoscopy, and (3) cardiac stress testing. The primary predictor was resident vs. faculty status of the ordering provider. The authors present an unadjusted analysis and the results of a multivariable logistic regression analysis incorporating all patient factors to determine their association with loop closure. Of 12,282 orders for referrals and tests for the three studied areas, 1,929 (15.7%) were ordered by a resident physician. Of resident orders for all three tests, 52.9% were completed within the designated time vs. 58.4% for orders placed by attending physicians (p < 0.01). In an unadjusted analysis by test type, a similar trend was seen for colonoscopy (51.4% completion rate for residents vs. 57.5% for attending physicians, p < 0.01) and for cardiac stress testing (55.7% completion rate for residents vs. 61.2% for attending physicians), though a difference was not seen for dermatology referrals (64.2% completion rate for residents vs. 63.7% for attending physicians). In an adjusted analysis, patients with resident orders were less likely than attendings to close the loop for all test types combined (odds ratio 0.88, 95% confidence interval 0.79-0.98), with low rates of test completion for both physician groups. Loop closure for three diagnostic interventions was low for patients in both faculty and resident primary care clinics, with lower loop closure rates in resident clinics. Failure to close diagnostic loops presents a safety challenge in primary care and is of particular concern for training programs.

FRI081 Quality Improvement Initiative To Improve Management Of Obesity In A Primary Care Resident Continuity Clinic

Abstract Disclosure: M.G. Fernandez: None. M. Hillhouse: None. D. Ozimek: None. M. Salvo: None. Background: Obesity is a leading health concern in the US and a growing epidemic worldwide. Despite the substantial evidence on weight management interventions, it remains the least commonly addressed medical problem. Physicians also document obesity infrequently in medical records. It has been well established that increasing documentation of obesity improves its management as a chronic disease. Objective: The main aim of our project was to increase the percentage of patients with a body mass index (BMI) ≥30kg/m2 with documented obesity in the electronic medical record (EMR) from 42% to 70%. The second aim was to increase the percentage of patients with a BMI ≥30kg/m2 prescribed weight loss pharmacotherapy from 10% to 40%. The project was performed in an Internal Medicine residency program continuity clinic over six months. Methods: We used three cycles of the Plan-Do- Study-Act methodology; all included education in obesity medicine, distribution of a hard copy list of the patients who met inclusion criteria, and EMR message reminders to address obesity by the following medical appointment. The EMR was used to generate reports to track outcomes. The first report listed all the resident clinic patients with a documented BMI ≥30kg/m2. The following list the number of patients with BMI ≥30kg/m2 and a corresponding diagnosis of obesity in their chart. The last report listed the number of patients with BMI ≥30kg/m2 on weight loss pharmacotherapy. Reports were generated bi-monthly, and percentages were used to determine the efficacy of each cycle. Results: There were 25% of residents’ patients who met project inclusion criteria. Of this, 11% were prescribed pharmacotherapy at baseline. Of those receiving treatment, 98% had type 2 diabetes. After the interventions, the documentation of obesity in the EMR increased from 42% to 60%. As a result, the overall number of patients on weight loss pharmacotherapy increased from 10.53% to 12.68%. Conclusion: The overall goal of the interventions was successful. There was an increase in both EMR documentation of obesity and increased weight loss pharmacotherapy prescribing; however, both were lower than anticipated. It was also found that the resident physicians responded more to printed metrics of their population of patients. In addition, physicians were more susceptible to treating patients when obesity was documented as a chronic disease. However, this project emphasizes that more efforts should be made to engage residents in multidisciplinary training to improve the management of obesity and increase tools to navigate through barriers to obesity treatments. Presentation: Friday, June 16, 2023

Abstract P117: Improving Hypertension Control In A Veterans Affairs Resident Primary Care Clinic, A Mixed-Methods Study

Introduction: Hypertension (HTN) is a critical modifiable risk factor for cardiovascular disease (CVD). In 2017, ACC/AHA guidelines recommended a blood pressure (BP) target of ≤ 130/80 mmHg for patients with high CVD risk. Prior research in the primary care clinic showed poor adherence with up-to-date guidance for BP control. The current study targets resident physician prescribing barriers to improve HTN control. Method: The study was conducted in a large Midwest VA Patient Aligned Care Team (PACT) staffed by 49 Internal Medicine resident physicians and 10 supervising physicians. Physician prescribing barriers were identified via semi-structured interviews. Interventions included physician education on BP goals and treatment, guided self-audit exercise, and revised implementation of EMR HTN order menu. Therapeutic inertia (TI) data was collected weekly from October 2022 to May 2023. Results: Major themes of prescribing barriers identified by physician interviews were patient non-adherence, lack of guideline-integrated practices, and lack of knowledge of single-pill combination agents (Table 1). Therapeutic inertia was examined for patients with high CVD risk and uncontrolled BP at a PACT visit. Baseline TI from June to October 2022 was 88.2% (128 of 145 patients had no change in antihypertensive therapy). Post-intervention TI was 88.4% (107 of 121 patients had no change in antihypertensive therapy). Conclusion: This study highlights the ongoing need to engage resident physicians with interactive tools to increase awareness of updated HTN guidelines. Identifying barriers to resident prescribing behaviors can be used to target interventions.

PSUN172 Prescribing SGLT-2 Inhibitors and GLP-1 Agonists in Primary Care: Improving Rates of Guideline-Concordant Practice

Abstract Background In practice, prescribing of a GLP-1 agonist (GLP-1a) or SGLT-2 inhibitor (SGLT-2i) for patients with type 2 diabetes mellitus (T2DM) and multiple risk factors for atherosclerotic cardiovascular disease (ASCVD) may be lagging behind the guidelines that recommend it. We aim to increase the prescribing rates of GLP-1as and SGLT-2is in a primary care resident clinic. Methods Eligible patients included adults with T2DM in an internal medicine primary care resident practice at the University of Vermont who were not already taking a SGLT-2i or GLP-1a. These patients were offered a diabetes medication management (DMM) visit with their PCP. The residents participated in a 30-minute educational intervention on: prescribing guidelines, medication risks and side effects, counseling patients, dose titration, and current Medicaid and Medicare insurance coverage estimates. This information was summarized in two tables that were included in a templated progress note to be used for DMM visits. DMM visits took place over a six month period. Chart review was conducted to determine patient co-morbidities and outcomes of the initial and follow-up DMM visits. Additional data was gathered from a post-visit survey completed by resident PCPs. Data was analyzed using descriptive methods. Results One hundred sixteen patients with T2DM were eligible. Sixty-five patients either declined, could not be reached, or did not present for their scheduled appointment. Fifty-one patients (44% of those eligible) completed a DMM visit. Of these 51, 18 (35%) were started on a SGLT-2i, either at the initial visit or at a follow-up visit. A GLP-1a was started for 14 (27%) patients. Nearly all who completed a DMM visit had at least one risk factor for ASCVD, and most had multiple risk factors. Problem lists for these patients showed that 40 (78%) had hypertension, 33 (65%) had hyperlipidemia, 12 (24%) had coronary artery disease, and 5 (10%) were current smokers. Two (4%) had a diagnosis of CHF, and 12 (24%) had CKD. Forty (out of 46) (87%) survey respondents reported that they were "more likely" to prescribe SGLT-2is and GLP-1as after participating in the intervention. The two most common reasons that these medications were not prescribed were the presence of competing visit priorities and co-management of diabetes medications by an endocrinologist. Conclusions Most patients with T2DM also have risk factors for ASCVD and would benefit from a GLP-1a or SGLT-2i. Prescriber education is an effective way to expand prescribing of these medications. Primary care providers are well-positioned to consider patients’ cardiovascular co-morbidities when prescribing diabetes medications, but may also be burdened by other visit priorities taking precedence. This study highlights the importance of a team-based approach to diabetes management and demonstrates a role for enhanced communication between primary care and specialties such as endocrinology and cardiology. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Quality Improvement in CKD Management in a Resident Primary Care Clinic

Quality Improvement in CKD Management in a Resident Primary Care Clinic

A Quality Improvement Approach to Enhance LGBTQ+ Inclusivity in Pediatric Primary Care.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) teens are at higher risk of illness as a result of bias but are less likely than peers to attend well visits. Medical organizations recommend improving care through staff education, visual cues, and routine inquiry of sexual orientation and gender identity (SO/GI) and pronouns. It is unknown how to do this confidentially in pediatrics. This quality improvement (QI) project aimed to confidentially collect and document SO/GI and pronouns early in at least 90% of teen acute care visits. A diverse, representative QI team in a resident primary care clinic conducted a series of staff and clinician trainings to improve knowledge, then displayed welcoming signage and offered staff pronoun and rainbow pins. Multiple Plan-Do-Study-Act cycles developed methods of routine and private collection of SO/GI and pronouns. Outcome measures included proportion of teen acute visits with such documentation collected via weekly chart reviews. Process measures included staff/clinician preparedness, assessed by surveys. SO/GI and pronouns were documented in 0% of teen acute visits at baseline, 70% after 6 months, and 90% during the 20-week sustainment measurement phase. The proportion of staff and clinicians who felt prepared to provide care for LGB and transgender patients increased (53% to 68% for LGB, P = .07; and 30% to 57% for transgender, P = .002). QI methods can create protocols for confidential, sustainable SO/GI and pronoun collection from teens early in acute visits. This allows clinicians and staff to address patients appropriately and for clinicians to better meet their needs.

Continuity and Health Outcomes in Resident Clinics: A Scoping Review of the Literature.

Continuity of care is an essential component of primary care, resulting in improved satisfaction, management of chronic conditions, and adherence to screening recommendations. The impact of continuity of care in teaching practices remains unclear.We performed a scoping review of the literature to understand the impact of continuity on patients and trainees in teaching practices. A systematic search was performed through PubMed to identify articles published prior to January 2020 addressing continuity of care and health outcomes in resident primary care clinic settings. A total of 543 abstracts were evaluated by paired independent reviewers.In total, 24 articles met the inclusion criteria and were abstracted by four authors. These articles included a total of 6,973 residents (median = 96, range = 9-5,000) and over 1,000,000 patients (median = 428, range = 70-1,000,000). Most publications demonstrated that higher continuity was associated with better diabetic care (71%, n = five of seven), receipt of preventive care per guidelines (60%, n = three of five), and lower costs or administrative burden of care (100%, n = three of three). A smaller proportion of publications reported a positive association between continuity and hypertension control (28%, n = two of seven). The majority of publications evaluating patient/resident satisfaction demonstrated that better continuity was associated with higher patient (67%, n = four of six) and resident (67%, n = six of nine) satisfaction.A review of the existing literature revealed that higher continuity of care in resident primary care clinics was associated with better patient health outcomes and patient/resident satisfaction. Interventions to improve continuity in training settings are needed.

Abstract 12872: Adherence to Guidelines for Heart Rate in Stable Ischemic Heart Disease in the Primary Care Setting

Per 2012 ACC/AHA Guidelines, patients with stable ischemic heart disease (IHD) should be treated with beta-blockers (BB) to target a resting heart rate (HR) of 55-60 bpm due to associations of higher HR with all-cause mortality. We sought to determine adherence to this in the resident primary care (PC) clinic at our institution. Two hundred twenty-nine patients with a medication list in the electronic medical record (EMR) that includes metoprolol succinate or tartrate or carvedilol who were seen in PC clinic in January 2020 were identified. Of these, 100 had a diagnosis of IHD, and their EMR were reviewed for vital signs; medication changes; and contraindications (CI) to BB titration such as hypotension, bradycardia, and max dosing; during their PC and cardiology visits. We found that 10% (10 of 100) had HR within goal during their PC visit, whereas 6 and 84 had HR below and above goal, respectively. Of the 90 whose HR was not at goal, 24 had some perceivable CI to BB titration. Of those without CI to titration, 9% (6 of 66) had their BB increased, 4.5% (3 of 66) had their BB switched to a different medication, and 85% (56 of 66) did not have their BB changed. Of those whose BB was unchanged, 79% (44 of 56) had no other antihypertensive changed. Moreover, 88% (74 of 84) of those with HR above goal had a HR also above goal at their last two PC visits. Sixty-eight of the 100 patients with IHD were also managed by cardiology, and in contrast, 18% (8 of 45) of those with HR not at goal and without CI to titration had their BB dose adjusted at their last cardiology visit. A chi-square test was performed to examine the relation between BB titration and clinic setting with no statistical significance, X 2 (1, N = 106) = 1.18, p = 0.28. In sum, adherence to guidelines for HR in stable IHD were poor and not significantly different in the PC and cardiology settings. Lack of provider initiative, perhaps due to trainee unfamiliarity with guidelines, may be one of many factors and warrants more investigation to improve quality of care.

S1419 Resident Education Is an Effective Method to Decrease Proton Pump Inhibitor (PPI) Over-Prescription in a Resident Primary Care Clinic

S1419 Resident Education Is an Effective Method to Decrease Proton Pump Inhibitor (PPI) Over-Prescription in a Resident Primary Care Clinic

Joint Corticosteroid Injection Associated With Higher Physical Therapy Compliance in Knee Osteoarthritis.

BackgroundKnee corticosteroid injection (KCSI) and physical therapy (PT) are two efficacious treatments for knee osteoarthritis (KOA). However, poor adherence to PT in resource-limited communities might limit its effectiveness. KCSI prior to PT might improve adherence in this population.MethodologyThis was a retrospective cohort analysis of patients referred to PT for KOA from January 01, 2018 to December 31, 2019 from an adult primary care resident clinic in Hartford, Connecticut, USA. Patients were divided into two groups, namely, those who had a KCSI around the time of the referral versus those who did not. PT adherence was evaluated in both groups.ResultsA total of 143 patients referred to PT were selected, and 11 patients were excluded. In total, 38/132 patients had a KCSI within a four-month window of the PT referral. Patients were mostly Hispanic (no injection 79.8% vs. injection 78.9%) females (80.9% vs. 71.1%), the average age was in the 60s, and over 90% were insured by either Medicaid or Medicare. In the injection group, 18/38 patients completed at least one PT visit (47.4%) versus 21/94 patients (22.3%) in the noninjection group. The odds ratio of undergoing PT was 1.38 (95% confidence interval [CI] = 1.14-1.69; p = 0.002), and the rate ratio of PT visits was 2.50 (95% CI = 1.82-3.42; p = 1.36 × 10-8), both adjusted for age, sex, and severity. Among those who attended at least one session, the mean number of PT visits was 5.4 in both injection and noninjection groups (median 5 versus 4). ConclusionsIn a predominantly Hispanic patient population, those who underwent KCSI were more likely to undergo PT and, as a group, attend more sessions.

Prevalence of advance care planning in a resident run clinic in an underserved community.

e24067 Background: Advance Care Planning (ACP) ensures that patients receive care that is in line with their values and preferences. ACP is best done in the outpatient setting. Despite recognizing the importance of ACP, the rates of ACP completion continue to be low. We conducted a retrospective study to determine the rates of ACP in a resident run primary care clinic in Hartford, Connecticut, which serves the underserved community. We looked at patient characteristics to find correlation with ACP completion. We also aimed to determine the reasons which could decrease the completion of ACP. Methods: This was a retrospective chart review. Patients who met any of the inclusion criteria [i) Age&gt;65 ii) End stage renal disease on dialysis iii) Metastatic/Recurrent cancer iv) End stage heart failure v) COPD Gold stage D] and were seen in the primary care clinic from September 1, 2019 to December 31, 2019 were selected. Their charts were reviewed to see if ACP was documented during primary care visits over the past two years. The demographics of the patients were noted. Subsequently, a survey was distributed to residents to determine the possible causes of low rates of ACP discussion. Results: The characteristics of the 373 patients included in the study are shown in Table 1. Only 14 (3.8%) of the 373 had documentation of ACP during their primary care visits. The characteristics of the 14 patients in whom ACP was done are as follows: Sex- Female 9/14 (64%); Ethnicity- Hispanic 10/14 (71%), African American 4/14 (29%); Religious Affiliation- Christian 13/14 (93%), None 1/14 (7%); Married/Partner 2/14 (14%). Patient demographics including sex (p 0.6), religious beliefs (p 0.8), and marital status (p 0.6) did not show any correlation with the likelihood of ACP completion. Of the 31 residents who answered the survey, the most commonly listed barriers to ACP completion were the following: lack of time to conduct these discussions (94%), forgetting to conduct ACP discussions (48%), and lack of training (19%). All the residents believed that ACP discussion was beneficial to patients and medical providers. Conclusions: The rates of ACP planning in our clinic are much lower than the national average. African American and Hispanics, who make up the majority of our clinic population, traditionally have had low rates of ACP completion. This is an important issue that needs to be addressed. Advance care planning training should be also be strengthened during residency. [Table: see text]

Implementation of a Hepatitis C Treatment Program Into a Primary Care Residency Clinic.

Hepatitis C (HCV) is a commonly diagnosed disease state in primary care. Regimen simplification has made eradication possible with improvements in treatment and improved access through primary care physician (PCP) education. Little has been published discussing the role of resident physicians in the treatment of HCV. We implemented an HCV treatment program to increase access to HCV care, identify effective training methods, and examine the efficacy of resident physician treatment. Objectives were to increase the number of patients treated, improve resident confidence in ability to treat HCV, and increase the likelihood that they will continue to treat patients after graduation. A curriculum to train physicians to treat HCV was developed and implemented in a large family medicine residency program. This was a single-center implementation, with a retrospective chart review of patient data and anonymous survey of clinicians for curriculum assessment. We analyzed data using descriptive statistics. The resident physician survey had a 92.3% response rate (n=36). Precurriculum, 94.4% of residents were not confident in their ability to treat HCV. After program implementation, 25% of residents were confident in treating HCV. The most effective educational interventions involved the multidisciplinary team. To date, 30 patients have started treatment since 2017. Of the patients who completed treatment, 23 patients achieved a virologic cure. Treating patients for HCV at a residency clinic increased physician confidence in evaluating and addressing this chronic disease and resulted in a cure of all patients treated.

964. Opt-Out HIV- Hepatitis C (HCV) Testing at a Primary Care Resident Clinic in Columbia, SC: Who Gets Tested and Who Opts Out of Testing?

BackgroundSouth Carolina (SC) remains one of the most heavily affected states for both HIV and HCV infections. Males account for the majority of cases. Implementation of universal opt-out testing has improved screening rates but not much has been published describing the characteristics of those who opt out of testing. This becomes important as 10-50% of patients have opted out in previous studies.MethodsBetween February and August 2019, we conducted a quality improvement (QI) project which implemented opt- out HIV-HCV testing at a single primary care resident clinic in SC with the primary aim of increasing screening rates for HIV-HCV by 50%. Secondary aims included describing the demographic characteristics of the opt-out population. Persons were considered eligible for testing if they were between the ages of 18-65 years for HIV and 18-74 years for HCV. This was prior to the USPSTF 2020 guidelines which recommend HCV screening for adults aged 18-79 years. A retrospective chart review was used to obtain screening rates, opt status and demographic data. Logistic regression and the firth model were used to determine linkages between categorical variables. We present 3-month data.Results1253 patients were seen between May 1, 2019- July 31, 2019 (See Table 1). 985 (78%) were eligible for HIV testing. 482 (49%) were tested for HIV as a result of our QI project and all tests were negative. 212 (22%) of eligible patients opted out of HIV testing. Males were 1.59 times more likely to opt out (p=0.008). (see Table 2,3)Regarding HCV, 1136 (90.7%) were deemed eligible for testing. 503 (44%) were tested for HCV as a result of our QI project. 12 (2.4%) were HCV antibody positive with viremia. 11 (90%) of antibody positive with viremia cases were in the 1945-1965 birth cohort (see Table 4). 244 (21%) opted out of HCV testing. Males and persons without a genitourinary chief complaint were more likely to opt out (p=0.02).Table 1: Demographic characteristics of the population seen at the internal medicine resident clinic between May- July 2019 Table 2: Relationship between demographic variables and the odds of being tested for HIV or HCV within the last 12 months. Logistic Model. Table 3: Relationship between demographic variables and the odds of opting out of testing for HIV or HCV. Firth Model. ConclusionAlthough implementation of routine HIV-HCV opt-out testing led to increased screening rates for both HIV and HCV, roughly 1 in 5 eligible patients chose to opt out of testing. Males were more likely to opt out despite accounting for the majority of newly diagnosed HCV cases. Future studies investigating drivers for opting-out in the male population could improve testing and assist with early diagnosis.Table 4: Characteristics of patients newly diagnosed with HCV positive with viremia. Disclosures All Authors: No reported disclosures

S1270 Inappropriate PPI Use in an Urban Resident Primary Care Clinic

INTRODUCTION: Proton pump inhibitors (PPIs) are an efficacious treatment for gastroesophageal reflux disease (GERD) and dyspepsia. The American College of Gastroenterology (ACG) guidelines recommend a time-limited 8 weeks of therapy with PPIs for GERD and dyspepsia. PPIs are frequently prescribed in the primary care setting but can be over-prescribed or prescribed for too long. This can result in polypharmacy and other adverse medication-associated side effects. We evaluated the appropriateness of PPI use in patients with GERD and dyspepsia at LAC + USC Medical Center's resident primary care clinic. METHODS: We retrospectively analyzed all the patients seen in one week at LAC + USC's resident primary care clinic. Provider documentation was used to determine reasons for PPI use, indications to continue, and plans to trial off. RESULTS: Patients prescribed a PPI tended to be older (mean age 57.3 [55.8–58.9] vs 53.3 [52.0–54.5], P < 0.01), had more medical issues (7.3 [6.8–7.8] vs 5.6 [5.4–5.8], P < 0.01), specifically rheumatologic conditions (14.2% vs 5.9%, P < 0.01), and were more frequently followed in Gastroenterology specialty clinic (9.7% vs 2.6%, P < 0.01). Among patients on PPIs, 47% were prescribed it for GERD or dyspepsia, while 32% had no reason documented (Figure 1). 49 of 73 (67%) patients on a PPI for GERD or dyspepsia had been on a PPI for greater than two months without an indication to continue PPI therapy, and only 2 of 49 (4%) had a trial off PPI. CONCLUSION: The majority of patients prescribed a PPI for GERD or dyspepsia at the LAC + USC Resident Primary Care Clinic were on the medication for longer than the 8 weeks recommended by the ACG. During the root cause analyses for the inappropriate use of PPIs, gaps in house staff knowledge around guideline directed therapy and PPI side effects, time constraints associated with caring for a patient population with multiple comorbidities, and poor provider documentation in the electronic medical records were identified as significant contributing factors. To address gaps in knowledge, we plan to implement succinct and high yield didactic sessions for residents on appropriate PPI use and monitor for improvements in both documentation and adherence to ACG recommendations.Table 1.: Patient demographics and PPI use in primary care clinic. PPI = proton pump inhibitor, IDDM = insulin-dependent diabetes mellitus, NIDDM = noninsulin dependent diabetes mellitus, CKD = chronic kidney disease, CHF = congestive heart failure, CAD = coronary artery disease, ESRD = end stage renal disease, GERD = gastrointestinal esophageal reflux disease, PUD = peptic ulcer diseaseFigure 1.: Analysis of PPI prescriptions in primary care clinic. PPI = proton pump inhibitor, GERD = gastroesophageal reflux disease.