Provider Awareness Research Articles

A qualitative study of unpaid caregivers of persons living with dementia and their interactions with health and community-based services and providers

Unpaid caregivers frequently feel underprepared and without adequate training, support, or access to services and resources to care for persons living with dementia. Health and community-based services and providers are critical to support persons living with dementia and their unpaid caregivers. The objective of this research is to understand how unpaid caregivers of persons living with dementia interact with health and community-based services and providers. We used a qualitative descriptive approach to analyze data from one-on-one semi-structured interviews with unpaid caregivers of persons living with dementia (N = 25). We used framework analysis to organize themes and sub-themes within the systems approach to healthcare delivery. Participants described a need for additional guidance, information, and support from health and community-based services and providers. This need was described by participants at 4 levels: individual, care team, organization, and political and economic environment. Participants were active in proposing potential solutions to challenges at all 4 levels, including improving provider awareness and training in dementia, opportunities to provide resources and referrals upon dementia diagnosis, a central clearinghouse for information and resources for persons living with dementia and caregivers, and opportunities to close service gaps. Findings of this study highlight the need for increased involvement of caregivers of persons living with dementia as community stakeholders for improving care and services. Recommendations to promote high quality care and better support unpaid caregivers by developing interventions to address multiple aspects of healthcare delivery are consistent with recent legislation and are important areas of future research.

Professional practice and awareness of child abuse among radiologists and radiologic technologists: results from Saudi Arabia

BackgroundThe knowledge, awareness and professionalism of health care providers in the field of child protection are crucial in identifying and reporting suspected child abuse. Radiologic technologists and radiologists play a vital role in the diagnosis of suspected physical child abuse.ObjectiveTo assess current practice, knowledge and awareness of child abuse among radiologic technologists and radiologists in Saudi Arabia.Materials and methodsWe distributed an internet-based questionnaire to radiologic technologists and radiologists working in Saudi Arabia via national radiology societies and social media channels over a 6-week period (27 October to 8 December 2021). Survey questions covered knowledge regarding child abuse, professional practice in radiology departments in Saudi Arabia in cases of suspected physical abuse (SPA), and knowledge of the national legislation and reporting and acting procedures in child abuse.ResultsA total of 315 respondents (224 radiologic technologists and 91 radiologists) participated in this study. The median score for knowledge of abuse was higher amongst radiologists (4.8) than radiologic technologists (4.0); P < 0.001. In total, 210 (93.8%) radiologic technologists and 61 (67.0%) radiologists reported that there was no protocol (i.e. skeletal survey) at their hospital for imaging children with SPA. Most radiologic technologists had no training in paediatric radiology (165/224, 73.7%) and most radiologists had received no training in evaluating imaging performed for SPA (73/91, 80.2%). More than half of respondents — 131 (58.5%) radiologic technologists and 44 (48.4%) radiologists — were not familiar with the reporting and acting procedures at their hospitals in cases of child abuse.ConclusionAlthough radiologic technologists and radiologists in Saudi Arabia have good knowledge and awareness of child abuse in general, they lack specific knowledge of the reporting and acting procedures at their hospitals in cases of suspected child abuse. National imaging guidelines and training courses are needed to develop appropriate skills in the recognition, imaging and reporting of SPA in infants and young children in Saudi Arabia.

Healthcare provider awareness, attitudes, beliefs, and behaviors regarding the role of pharmacists as immunizers

ABSTRACT We explored perceptions of healthcare providers in Nova Scotia and New Brunswick about pharmacists as immunizers. Pharmacists’ scopes of practice are increasingly broadening to include immunization, and providers and policymakers may find meaning in the lessons we learned. Invitations to participate in our online survey were circulated by professional associations, health authorities, and in social media posts. A total of 204 healthcare providers completed our survey, of whom 59.3% were pharmacists, 17.6% were nurses, and 23.0% were physicians. Nurses (30.6%) and physicians (34.0%) experienced fewer logistical barriers to immunizing compared to pharmacists, 71.1% of whom identified practice logistics as a determinant in offering vaccines to patients (p < .001). Pharmacists were most supportive of the expansion of their own scope of practice to include the provision of vaccines to adults (95.9%) and children as young as five years (92.6%) compared to nurses (72.2% and 69.4%) and physicians (61.7% and 40.4%) (p < .001). Diversity of opinion was evident even among pharmacists about whether they should be permitted to vaccinate children younger than five years. Nurse and physician respondents had lower odds of thinking pharmacists have enough training to vaccinate (p < .001), that vaccines should be given in a pharmacy (p < .001), and of supporting the expansion of pharmacists’ scope of practice (p < .001) than pharmacists did in the multivariable analyses. Pharmacists are well-positioned and willing to vaccinate and generally have support from their nurse and physician peers, but logistical challenges and interprofessional complexities persist as barriers to optimizing immunization by pharmacists.

Culture, church, and collective: a qualitative study about gambling harm prevention and reduction in Aotearoa/New Zealand—a Tongan male perspective

BackgroundIn New Zealand, Pacific people continue to be more at risk of gambling harm than the general population, despite increasing public health efforts and treatment service provisions introduced to address this social and health issue. In looking at why this is so, our first concern was to ask why the delivery of the prevailing gambling-focussed programmes was not influencing Pacific gambling behaviours. In seeking to answer this question, it was important to explore ethnic-Pacific-specific factors of gambling harm prevention and reduction.MethodsThe research design was interpretivist/constructivist and phenomenological, applied through the lens of a Tongan worldview. Participants comprised Tongan male elders and youth. Recruitment of participants was through snowball sampling from churches and kava-drinking circles. A total of 28 elders and 18 youth participated through focus group talanoa and individual talanoa. This study employed descriptive thematic analysis.ResultsParticipants were not aware of any policy document or problem-gambling preventative programmes. Four key themes were raised, which include raising the awareness of existing gambling harm treatment providers, the church influence in addressing gambling harm, community-based strategies, and cultural-based approaches.ConclusionsThis study proposes several recommendations such as more awareness of gambling harm providers in community, increasing cultural spaces and church engagements, and calls for further research in addressing the prevention and reduction of gambling harm amongst the Tongan community in New Zealand.

S95 Improving the Success Rates of Breastfeeding Amongst Newborns Born to Mothers With Inflammatory Bowel Disease (IBD)

Background: It has been shown that breastfeeding not only provides protection against Crohn’s and ulcerative colitis but is safe and protective for mothers and their newborns. It is a common misconception that mothers with inflammatory bowel disease (IBD) should not breastfeed due to medication safety in mothers breast milk and concern for increased risk of relapse while breastfeeding. When in fact, literature has shown that the vast majority of medications prescribed for IBD are either undetectable in breast milk or present in concentrations that would not be expected to harm the breastfeeding infant. The aim of this study was 2-fold; to investigate the awareness of providers education on the safety and benefits of breastfeeding in mothers with IBD. In addition, to determining whether mothers with IBD have concerns with breastfeeding and it’s impact on their disease. Methods: We conducted a survey on our pediatric providers; of which included physicians, residents, and lactation specialists. The survey specifically inquired on whether they felt comfortable recommending and supporting breastfeeding in patients with IBD. Our second assessment looked retrospectively at mothers who delivered in the past 6 months with IBD and whether they showed interest in breastfeeding following their delivery. Results: Thirty providers were randomly surveyed using a questionnaire on whether they felt comfortable recommending breastfeeding to mothers with IBD. Of the 30 that were surveyed, only 26% of providers felt confident in their ability to recommend breastfeeding to mothers with IBD.Of the 20 mothers born that were randomly surveyed within the past 6 months , 60% were interested in breastfeeding but were unsure of the medical benefits, 10% preferred bottle feeding due to fear of a flare or relapse of their disease while breastfeeding, and 30% preferred bottle feeding regardless of their disease status. Conclusion(s): It is important that we address this area of clinical fundamental knowledge to improve our breastfeeding success rates, specifically in mothers with IBD. It is well known that breastfeeding has many beneficial properties and some studies even suggest that it may have a protective effect against IBD. If we enhance our providers knowledge and awareness of the medical benefits of breastfeeding in patients with IBD, mothers can then be properly informed and educated. Mothers may feel motivated and more at ease in their decision to breastfeed knowing they have the support and encouragement of their medical team. Furthermore, with proper education during their hospitalization and following their delivery, mothers may have less fear and anxiety regarding misconceptions and concerns for relapse of their disease. Providing mothers with reassurance in regard to the safety of their medication and ability to breastfeed, we can ensure appropriate medication compliance. As we have seen in prior studies, optimal disease control and adherence to medical therapy will ensure good outcomes for women during their postpartum period.

Improving lung cancer screening rates among patients with head and neck cancer in a radiation oncology clinic.

The United States Preventive Services Task Force (USPSTF) recommends lung cancer screening via annual low dose computed tomography (LDCT) for high risk patients. Despite the strong evidence of a mortality benefit from several randomized clinical trials, rates of lung cancer screening remain low. We plan to assess how screening guidelines are implemented in a radiation oncology clinic for patients with head and neck cancer. A single institution, retrospective chart review was used to identify patients with head and neck cancer seen in a radiation oncology clinic who were potentially eligible for lung cancer screening under the current USPSTF guidelines. Patients who were potentially screening-eligible were enrolled in a phone survey to assess their knowledge about lung cancer screening and willingness to be screened. Of the 184 patients with head and neck cancer seen in the clinic, 8 (4%) patients were eligible for lung cancer screening under the previous USPSTF recommendations, including 1 (0.5%) patient already being screened. One patient (0.5%) became eligible under the expanded guidelines. All 184 patients had smoking history documented. Of the 87 current or former smokers, there were 24 (28%) who did not have pack-years documented; of the 82 former smokers, there were 8 (10%) who did not have quit date documented. Among the 16 phone survey participants (response rate: 70%) only 6 (38%) were aware there is a way to screen for lung cancer and 12 (75%) patients would be interested in screening if they are found to be eligible. These findings highlight a potential opportunity to increase rates of lung cancer screening among patients with head and neck cancer by both enhancing provider awareness as well as patient education at the community level.

Barriers to family history collection among Spanish-speaking primary care patients: a BRIDGE qualitative study.

Family history is an important tool for assessing disease risk, and tailoring recommendations for screening and genetic services referral. This study explored barriers to family history collection with Spanish-speaking patients. This qualitative study was conducted in two US healthcare systems. We conducted semi-structured interviews with medical assistants, physicians, and interpreters with experience collecting family history for Spanish-speaking patients. The most common patient-level barrier was the perception that some Spanish-speaking patients had limited knowledge of family history. Interpersonal communication barriers related to dialectical differences and decisions about using formal interpreters vs. Spanish-speaking staff. Organizational barriers included time pressures related to using interpreters, and ad hoc workflow adaptations for Spanish-speaking patients that might leave gaps in family history collection. This study identified multi-level barriers to family history collection with Spanish-speaking patients in primary care. Findings suggest that a key priority to enhance communication would be to standardize processes for working with interpreters. To improve communication with and care provided to Spanish-speaking patients, there is a need to increase healthcare provider awareness about implicit bias, to address ad hoc workflow adjustments within practice settings, to evaluate the need for professional interpreter services, and to improve digital tools to facilitate family history collection.

Airway anomalies in patients with 22q11.2 deletion syndrome: A scoping review.

People with 22q11.2 deletion syndrome (22q11DS) can present with a wide variety of findings. Various airway anomalies have been described intermittently within this syndrome, but this feature has not been extensively investigated. Increased provider awareness of these findings may help guide clinical decision-making and improve overall patient outcomes. The objectives of this review are to identify the types of airway anomalies in 22q11DS and the prevalence of airway anomalies within symptomatic individuals. PubMed/MEDLINE, Cochrane Library, and EMBASE databases were searched in February 2022 for all available articles. Search terms included those that described 22q11DS or one of its synonymous conditions AND those that described airway anatomy and anomalies. The term airway anomaly was defined as any structural aberration in the conductive airway from the oral or nasal vestibule region to the mainstem bronchus. Studies were screened by two authors. A review of references was conducted. Eligible manuscripts underwent full-text review for quality appraisal and data extraction. From a total of 909 unique manuscripts, 58 studies were selected, describing 328 people. The prevalence of airway anomaly diagnosis within symptomatic individuals ranged from 14% to 74%. Twenty-two unique airway anomalies were described. Laryngeal web was the most frequently described anomaly, followed by airway malacia and subglottic stenosis. Laryngeal web was 40% sensitive for suggesting a diagnosis of 22q11DS. Among affected individuals, as many as 46% had multiple concomitant airway anomalies. Aside from respiratory symptoms, other features that prompted airway evaluation included difficult intubation or failed extubation. The findings within this review support the notion that a wide variety of airway anomalies may be seen in people with 22q11DS and that these findings have been discovered frequently in those with airway symptoms. Providers should maintain a low threshold to perform an airway examination in those with 22q11DS, especially when airway symptoms are present.

Benzonatate Exposure Trends and Adverse Events.

Adverse events (AE), including death, occur in children with benzonatate use. This study aims to understand recent trends in benzonatate exposure and clinical consequences in pediatric patients. This retrospective analysis of data from IQVIA pharmacy drug dispensing, National Poison Data System, National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance Project, FDA Adverse Event Reporting System, and the medical literature evaluated exposure trends and medication-related AEs with benzonatate. Trends for comparator narcotic and nonnarcotic antitussive medications were analyzed where possible for context. During the study period, pediatric benzonatate prescription utilization increased but remained low compared with pediatric utilization of dextromethorphan-containing prescription antitussive medications. Among the 4689 pediatric benzonatate exposure cases reported to US poison control centers from 2010 to 2018, 3727 cases (80%) were for single-substance exposures. Of these, 3590 cases (77%) were unintentional exposures and most involved children 0 to 5 years old (2718 cases, 83%). Cases involving intentional benzonatate exposure increased among children 10 to 16 years old with a more pronounced increase for multiple-substance exposures. Most benzonatate cases involving misuse or abuse were for children 10 to 16 years old (59 cases, 61%). The proportion of cases with serious adverse effects was low. There were few cases annually of serious AEs with benzonatate in children. There were rising patterns of unintentional ingestion of benzonatate in children 0 to 5 years old and intentional benzonatate ingestion in children 10 to 16 years old. Rational prescribing and improved provider and caregiver awareness of benzonatate toxic effects may reduce risks associated with benzonatate exposure.

A Quality Improvement Initiative to Improve Implementation of Guideline-Concordant Hereditary Myeloid Malignancy Syndrome Evaluation

Background: Myeloid malignancies such as acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) are traditionally thought of as sporadic disorders. Recently, there has been increasing awareness of hereditary myeloid malignancy syndromes (HMMS) and their impact on MDS/AML treatment decisions, other organ and cancer surveillance, and at-risk family member management. Detection of patients with an HMMS is challenging due to variable expressivity, lack of physical signs, incomplete family history information, and limited provider awareness. In 2021, the National Comprehensive Cancer Network (NCCN) guidelines added recommendations for genetic evaluation of patients with MDS/AML meeting certain clinical or molecular criteria to facilitate identification of patients with an HMMS. The impact of utilizing these criteria on the proportions of patients with MDS/AML needing germline genetic evaluation and their efficacy in detecting the subset with an HMMS have not been studied. We established a quality improvement (QI) committee to implement and test the utility and efficacy of NCCN MDS/AML referral criteria. Methods: A QI committee, including a cancer geneticist, a molecular pathologist, hematology faculty and fellows, clinical pharmacists, research coordinators, and a genetic counselor, was formed to implement NCCN recommendations and evaluate patients with MDS/AML for referral to the UW Hereditary Hematology Clinic. At each monthly meeting, clinical and family history and molecular data are reviewed for patients with MDS/AML who had a next-generation sequencing panel performed in the prior month. Patients meeting criteria for referral are identified, and an HMMS evaluation referral recommendation note is written in the electronic medical record and routed to the patient's primary hematologist. To assess the impact of implementing these guidelines on need for HMMS evaluations in routine MDS/AML care, we compared the proportion of patients meeting criteria and referral rates before (1/2019-8/2021) and after (9/2021-4/2022) our intervention. Results: From 9/1/21 through 4/31/22, 42 patients (20 AML, 22 MDS) were reviewed by the committee. 34 patients had a new diagnosis, whereas eight had an established diagnosis but had molecular data obtained for the first time after 9/1/2021. Overall, 23 patients (55%) met criteria for referral. Six patients met clinical criteria, seven patients met molecular criteria, and 10 patients met both clinical and molecular criteria. Eight patients were ultimately referred for HMMS evaluation, corresponding to a referral rate of 35%. Two patients were found to have a pathogenic variant in DDX41, two patients had at least one variant of unknown significance (VUS), one patient had negative testing, and three patients have pending results. For the 15 patients who were not referred, three were deceased at the time of committee meeting, two were pursuing hospice, one patient declined, and one patient was lost to follow-up; the remaining eight patients were not referred for unknown reasons. In the pre-intervention cohort, 71 of 114 patients met criteria for referral (63%), and 8 were ultimately referred for HMMS evaluation, corresponding to a referral rate of 11%. One patient had a pathogenic variant in ANKRD26, two patients had at least one VUS, four patients had negative testing, and one patient declined genetic evaluation. Conclusion: Implementation of current NCCN germline genetic testing criteria for MDS/AML resulted in ~60% of unselected MDS/AML patients meeting referral criteria for HMMS evaluation. Formalized referral recommendations in the form of a QI committee referral note in the medical record increased provider referrals from 11% to 35% in those meeting criteria. Clinical acuity and patient mortality were the largest barriers to referral for HMMS evaluation in this patient population. Among the small proportion actually referred, 5% of patients in the intervention cohort and 1% of patients in the pre-intervention cohort were found to have an HMMS. This experience demonstrates that implementing current NCCN guidelines via a QI committee will significantly increase the proportion of patients recommended to have HMMS evaluation and increases detection of patients with HMMS. Whether these criteria can be refined to maximize detection while minimizing burden on patient care and the healthcare system warrants further investigation. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Increasing COVID-19 Vaccination Rates Amongst Children with Sickle Cell Disease: A Quality Improvement Project

Background: Individuals with sickle cell disease (SCD) are at an increased risk of complications from COVID-19. The COVID-19 vaccine safely protects children with SCD against serious COVID-19 disease. Objective: To increase the proportion of children with SCD receiving >2 doses of the COVID-19 vaccine to >70% by July 1st 2022. Methods: This quality improvement (QI) project was conducted at an academic pediatric hospital. The project team consisted of physicians, nurses, and advanced practice practitioners. We used the Model for Improvement as the improvement framework. We identified patients with SCD eligible for vaccine via our institution's data warehouse. Patients who received their primary hematology care at an alternative institution and those under 5 years of age were excluded. Baseline data was collected for five months prior to and then bi-weekly during the intervention period. Our SMART aim was to increase the proportion of eligible patients receiving the COVID-19 vaccine to >70% by July 1st 2022. We identified primary and secondary drivers of under-vaccination and then formulated change strategies. Three plan-do-study-act (PDSA) cycles were performed: 1) Information encouraging vaccination was sent to the families of children who were under-vaccinated via text message. Providers received a monthly report of their patients' vaccination statuses; 2) An automated weekly report of expected clinic patients' vaccination status was sent to the clinic team. Under-vaccinated patients were contacted prior to their appointment and offered a vaccination; 3) We sent patients and parents a video highlighting vaccine importance with a pediatric hematologist, a patient's mother, and a nurse via text message and posted a QR code linking to the video in our clinic (https://youtu.be/MY7C2Kt2tuI). The outcome measure was the proportion of patients who received >2 doses of the COVID-19 vaccine. The process measure was the number of patients who booked a vaccination. The balancing measure was the proportion of missed appointments. Statistical process control charts were used to track changes over time. Results: 243 patients were eligible for the COVID-19 vaccine. Changes in the vaccination rate during the pre-intervention (Sept 2021-January 2022) and intervention (February 2022-June 2022) periods are shown in Figure 1. COVID-19 vaccination rate increased from a baseline of 34% to 64% by June 2022. Based on the trend in vaccine uptake pre-intervention, the expected vaccination rate without any intervention was 51% in June 2022. There was no increase in missed clinic visits (9.0% of visits prior to the study vs. 9.6% during the study). When patients were contacted to schedule a vaccine appointment 10 (13.5%) booked a vaccine, 6 (8.1%) had received a vaccine that was not captured in our system, 19 (25.7%) articulated a barrier or concern to vaccination, 11 (14.8%) refused the vaccine, and 28 (37.8%) could not be reached. Conclusion: Via a QI initiative, we increased the vaccination rate for eligible patients with SCD without an increase in missed clinic visits. While our final vaccination rate of 64% did not reach our target of 70%, we did achieve a rate that exceeds the national average (44%), and a rate that is comparable to the highest level of vaccination in children nationwide (70%). Our final vaccination rate also exceeds the predicted vaccination rate our cohort based on the pre-intervention cadence of vaccination. We found that targeting misinformation regarding safety, mitigating logistical barriers, and increasing provider awareness of patients' vaccine status were effective ways to increase COVID-19 vaccination rates. Future work will focus on engaging with local community partners to offer individuals with SCD the COVID-19 vaccine at community-based events and on addressing the barriers and concerns articulated by patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

HOW ALLERGISTS ARE SAVING MARRIAGES: A REVIEW ON SEXUAL INTERCOURSE PRESENTING AS EXERCISE-INDUCED ASTHMA

<h3>Introduction</h3> Exercise has been long associated as a trigger for asthma. Exercise induced symptoms have been attributed to 40-90% of asthmatic patients. However, sexual intercourse is uncommonly associated as exercise. The purpose of this review is to investigate sexual intercourse as an underdiagnosed trigger for asthma exacerbations. <h3>Methods</h3> We collected in this review the available literature on this subject. The PUBMED database was searched by a combination of keywords and MESH terms: sexual intercourse OR honeymoon asthma OR sexual behavior AND allergy OR allergic reaction.The studies retrieved were independently evaluated by the authors and included in this review based on their clinical correlation and pertinence. No IRB was required. <h3>Results</h3> Several case studies have reported post-coital asthma exacerbations however more cases have been reported of allergic reactions to coital activity such as seminal fluid or latex. The few reported cases allude to underreporting of this condition given the intimate nature of this subject. Disclosure relies on the patient's comfortability with their provider and the provider's awareness of characterizing sexual activity as exercise. It is estimated the energy expenditure of sexual activity is approximately equivalent to walking up two flight of stairs. When sexually activity induced asthma is properly identified and treated, allergists are placed in a position where they can improve their patients' quality of life. <h3>Conclusion</h3> Properly investigating all causes of asthma exacerbations, including sexual intercourse, which shares its pathogenesis with exercise-induced asthma, can place allergists in a position of positively improving their patient's lives, including their marriages.

Seroprevalence of Rubella IgG in Women of Reproductive Age Group in a Tertiary Care Teaching Hospital

Rubella is a highly contagious infection caused by the rubella virus. Mothers who develop rubella early in pregnancy have a 90% chance of transmitting the infection to their unborn babies. Adverse effects on the fetus include stillbirth and congenital rubella syndrome. Pregnant women are not regularly screened for rubella antibodies in government hospitals in Kerala. Therefore, to raise awareness of healthcare providers, it is necessary to collect epidemiological data on the seroprevalence of rubella in this vulnerable group. Several sociodemographic variables as potential predictors of immunity to rubella were also analyzed. A cross-sectional descriptive study was conducted at Govt TD Medical College in Alappuzha, Kerala, of 604 women of childbearing potential who attended the Out patient department of the Obstetrics and gynecology division for the year from June 2016 to June 2017. Rubella-specific IgG (Quantitative) ELISA was done on patients after obtaining informed consent and filling out a questionnaire through direct interview. The test sera were considered seropositive (&gt;15 IU/ml), seronegative (&lt;13 IU/ml), or intermediate (13 -15 IU/ml) as per the manufacturer’s instructions. Rubella seroprevalence in the study group was found to be 73.3%. Around 26.65% were nonimmune to rubella infection. About 27.4% of antenatal cases in the present study were susceptible to rubella. The primigravidae had lower seroprevalence(28.5%) than multigravidae. The percentage of seropositivity was found to increase with age. Our observations show that women of childbearing age are highly susceptible to rubella. High seroprevalence without regular childhood vaccination indicates continued infection transmission of the rubella virus in the community. Hence there is a need for proper sero surveillance in this group who has not been vaccinated, before conception to eradicate CRS and Rubella.

Collaborating with the Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program to Increase Receipt of Ovarian Cancer Care from a Gynecologic Oncologist.

Background: Treatment by a gynecologic oncologist is an important part of ovarian cancer care; however, implementation strategies are needed to increase care by these specialists. We partnered with National Comprehensive Cancer Control Programs in Iowa, Michigan, and Rhode Island in a demonstration project to deepen the evidence base for promising strategies that would facilitate care for ovarian cancer by gynecologic oncologists. Methods: Five main implementation strategies (increase knowledge/awareness; improve models of care; improve payment structures; increase insurance coverage; enhance workforce) were identified in the literature and used to develop initiatives. Specific activities were chosen by state programs according to feasibility and needs. Results: Activities included: (1) qualitative interviews with patients to determine barriers to receipt of specialized care; (2) development of patient/provider educational materials; (3) creation of patient/provider checklists to facilitate appropriate referrals; (4) expansion of a toll-free patient navigation hotline for ovarian cancer patients; (5) training of the health care workforce. The programs developed resources (educational handouts, toolkits, 2 webinars, 2 podcasts); trained 167 medical and nursing students during 8 Survivors Teaching Students® workshops; and conducted 3 provider education sessions reaching 362 providers in 45 states. Evaluations showed increases in providers' knowledge, awareness, abilities, and intentions to refer ovarian cancer patients to a gynecologic oncologist. Conclusion: The state program resources we discussed are available for other cancer control programs interested in initiating or expanding activities to improve access/referrals to gynecologic oncologists for ovarian cancer care. They serve as a valuable repository for public health professionals seeking to implement similar interventions.

ODP131 Zoledronic acid and red eye

Abstract Introduction Zoledronic acid, used for treatment of osteoporosis, Paget's disease of the bone, hypercalcemia of malignancy etc. is a bisphosphonate known for its anti-resorptive effect. A common adverse reaction with this medication is mild to moderate flu-like symptoms, which is transient and attributed to an acute phase reaction post zoledronic acid infusion. [1] A less common adverse reaction is ocular inflammation, including uveitis, iritis and episcleritis. [1] The incidence of ocular inflammation is 0.2 - 0.8%. [2] Development of ocular symptoms have been reported to occur between 1 to 7 days post zoledronic acid infusion. [2] We report a case of acute unilateral episcleritis following zoledronic acid infusion for treatment of osteoporosis. Clinical case: A 58-year-old female with a past medical history significant for glaucoma and gastroesophageal reflux (GERD) presented for management of osteoporosis. She could not tolerate oral bisphosphonates due to gastrointestinal side effects. She was therefore switched to intravenous zoledronic acid therapy. On day 1 post zoledronic acid infusion of 5mg dose, she developed diffuse joint and muscle pain as well as right eye pain, redness, photophobia, blurred vision and tearing. As her ocular symptoms progressed by day 5 post zoledronic acid infusion, she presented urgently to ophthalmology clinic when she was diagnosed with episcleritis of the right eye secondary to the zoledronic acid infusion. Patient was started on prednisolone acetate eyedrops twice a day. Three days after starting the eyedrops, patient reported complete resolution of her ocular symptoms. Further treatment for osteoporosis with zoledronic acid was discontinued. Conclusion We present a case of right eye episcleritis occurring 24 hours post zoledronic acid infusion leading to significant ocular discomfort and concern for the patient. Ocular inflammation is an uncommon occurrence post zoledronic acid infusion, hence is not often discussed during routine patient counseling in regards to risks and benefits of this particular treatment. We therefore stress the need for both provider and patient awareness regarding this uncommon ocular side effect related to zoledronic acid use. It is important to inform the patient and educate providers about the possibility of this acute phase reaction occurring post treatment with zoledronic acid to aid in prompt diagnosis and treatment. Our patient responded well to treatment with prednisolone acetate ophthalmologic drops. A rechallenge with zoledronic acid has not been pursued.

PSAT160 The Dangers of Long-term Aromatase Inhibitor use in an Elderly Hispanic Population

Abstract The most common endocrine therapies for breast cancer are Aromatase Inhibitors (AIs), which can help reduce the recurrence of the disease and its mortality rate. However, because aromatase inhibitors prevent the aromatization of androgens into estrogen, they can have serious effects on bone health. This can lead to accelerated bone loss and an increased risk for fractures, especially among postmenopausal women. In 2017, the Journal of Bone Oncology (JBO) released a joint position statement advising that all patients with breast cancer on endocrine treatment, such as AIs which are known to accelerate bone loss, be placed on bisphosphonate therapy should they present 2 or more risk factors for fracture (1). The purpose of this study was to evaluate patients on AIs at a 5-star Medicare Advantage plan facility and document any discrepancies with regards to whether appropriate treatment is being given to prevent fractures. We hypothesized that we may have a large percentage of patients on AI that have 2 or more risk factors and are not on treatment. An electronic chart review was conducted of 398 patients on AIs between 6/9/2020 and 8/25/2020. Patients were evaluated for the following risk factors: current smoking, personal history of hip/vertebral fracture, current use of glucocorticoids, age &amp;gt; 65, BMD T-score &amp;lt; -1.5, and BMI &amp;lt; 20. Surprisingly, 1 out of every 2 patients treated with an AI was not being treated in accordance with the JBO's recommendations. Of the 398 patients evaluated, 191 presented 2 or more risk factors and were not on antiresorptive treatment. There are a few steps that can be taken to better manage these at-risk patients. First is raising awareness to providers about the dangers of long-term AI use. Additional changes to the EMR system may help as well, such as prompting the ordering provider to consider bisphosphonate therapy if risk factors are present. Lastly, the addition of a fracture reduction clinic can help streamline the referral process to an endocrinologist upon the prescribing of AI therapy. This would allow patients to be fully evaluated for fracture risks and prescribed treatment should they qualify. With the low costs of generic bisphosphonate therapy, if a fracture is prevented, providers can hope to save a significant amount in indirect costs. Through improved awareness of providers of the risks, a more intuitive EMR system, and the creation of a new automatic referral process, we believe that we can vastly improve patient morbidity and quality of life by reducing the chances of fracture in patients on long-term AIs.Reference: (1) Hadji et al., J Bone Oncol. 2017 Mar 23;7: 1-12. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

A Comparison Study Quantifying Environmental Impact of All Surgical Modalities of Hysterectomies

<h3>Study Objective</h3> Compare carbon dioxide emissions generated from operating room waste from all types of hysterectomies. Improving provider awareness on the environmental impact of hysterectomies may facilitate interventions to minimize our carbon footprint. <h3>Design</h3> A prospective cohort study was conducted, including patients who had a hysterectomy for any indication. Surgical waste in pounds (lbs), procedure data, and patient demographics was collected for each case. The formula below was used to identify the emissions generated for each procedure: <i>CO2 emissions = Waste in pounds (lbs) x 1 short ton/2000 lbs x EPA emission factor (kg CO2 per short ton) x global warming potential</i> <h3>Setting</h3> A 305-bed Level II Trauma center and academic teaching hospital, 11/2021 – present. <h3>Patients or Participants</h3> A total of 81 women ≥ 18 years of age underwent a scheduled hysterectomy (robotic assisted, laparoscopic, vaginal, abdominal) for benign or malignant indications at one institution. We excluded women < 18 years of age and emergent hysterectomies (i.e., postpartum hysterectomy). Data collection is ongoing with the goal of reaching a sample size of 100. <h3>Interventions</h3> Waste that was generated for every hysterectomy was weighed by the Primary Investigator. <h3>Measurements and Main Results</h3> Among the 81 cases analyzed, there was no significant difference between groups in age, ethnicity, and BMI. The total waste generated by each type of hysterectomy ranges from lowest (vaginal, 3 lbs.) to highest (robotic, 46 lbs.). CO2 emissions was significantly higher for robotic hysterectomies (57%, <0.0001) when compared to the other types. 100% of robotic hysterectomy waste contributed more than the mean CO2 emission of our sample. There was no significant association between duration of surgical case and amount of waste generated. Additional analysis in progress. <h3>Conclusion</h3> Robotic hysterectomies were found to generate a statistically significant majority of CO2 emissions. Additional studies are needed to determine the environmental impact and strategies to reduce our carbon footprint.

PSUN128 Insurance Database Analysis of Healthcare Utilization by Women with PCOS

Abstract Polycystic ovary syndrome (PCOS) is among the most common disorders of premenopausal women, affecting up to 15% of this population. It has substantial reproductive and metabolic morbidities with healthcare costs of ∼$8 billion annually in the US alone. Despite its high prevalence and public health impact, PCOS diagnosis is frequently delayed and requires visits to multiple providers. Not surprisingly, patients are very dissatisfied with the care that they receive. Improving the diagnosis and management of PCOS will require an understanding of the patterns of healthcare utilization among affected women so that appropriate specialists can be targeted for educational initiatives. This information may also provide "real world" insight into the medical issues for which these patients seek care. We used an employer-sponsored commercial insurance database comprised of 26,146,275 subjects (ages 0-65 years, 48.3% female) representative of all United States regions to associate ICD-10-CM codes with specialists. Women were designated as having PCOS using a previously validated algorithm (positive predictive value 98%) of the ICD-10-CM diagnosis codes for PCOS or for hirsutism in combination with the codes for irregular menses. Women were designated as controls if they lacked ICD-10-CM codes for PCOS, ovarian hyperfunction, androgen excess, hirsutism, infertility, acne, menstrual disorders, or alopecia. The percentage of patients with ≥1 office visit to a given provider in the year 2017 was calculated. Between group comparisons were made using chi square where p&amp;lt;0. 01 was significant. Of 9,628,264 women ages 18-40 years, 101,380 (1.1%) fulfilled criteria for PCOS and 3,460,541 fulfilled criteria for controls (35.9%). Significantly greater percentages of PCOS cases compared to controls (all P&amp;lt;0. 001) had ≥1 visit to an endocrinologist (17. 0% vs 2.2%), an OB/GYN (66.4% vs 40.3%), a dermatologist (14.1% vs 7.8%), a psychiatrist (5.2% vs 3.7%), a cardiologist (7.4% vs 3.8%), a family medicine physician (50.5% vs 42.5%), or an internal medicine physician (29.6% vs 19. 0%). More PCOS cases (80.1%) saw family medicine and internal medicine physicians (PCPs) than controls (61.5%, PIt is not surprising, given the common symptoms of PCOS of irregular menses, hirsutism and acne, that more PCOS cases than controls had care provided by specialists in OB/GYN, endocrinology and dermatology. The higher percentage of care provided by psychiatrists is consistent with the reported increased prevalence of anxiety and depression among affected women. The increased percentage of care by cardiologists is surprising in this population of young women and supports the suggestion that PCOS is associated with premature cardiovascular disease. Our results suggest that efforts to improve provider awareness of PCOS should target PCPs. Specialist educational initiatives should include psychiatry and cardiology, in addition to the specialists providing care for the common reproductive manifestations of PCOS. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

A qualitative study evaluating the discharge process for vascular surgery patients to identify significant themes for organizational improvement.

Transition from the hospital to an outpatient setting is a multifaceted process requiring coordination among a variety of services and providers to ensure a high-quality discharge. Vascular surgery patients comprise a complex population that experiences high unplanned readmission rates. We performed a qualitative study to identify themes for process improvement for vascular surgery patients. A validated discharge process, RED (Re-Engineered Discharge), was used to identify additional actionable themes to create a more efficient discharge process tailored specifically to the vascular surgery population. A prospective, qualitative analysis at a tertiary center using a semi-structured focus group interview guide was performed to evaluate the current discharge process and identify opportunities for improvement. Focus groups were Zoom recorded, transcribed into electronic text files, and were loaded into Dedoose qualitative software for analysis using a directed content analysis approach. Two researchers independently thematically coded each transcript, starting with accepted discharge components to identify new thematic categories. Prior to analysis, all redundancy of codes was resolved, and all team members agreed on text categorization and coding. Eight focus groups with a total of 38 participants were conducted. Participants included physicians (n = 13), nursing/ancillary staff (n = 14), advanced nurse practitioners (n = 2), social worker/dietitian/pharmacist (n = 3), and patients (n = 6). Transcript analyses revealed facilitators and barriers to the discharge process. In addition to traditional RED components, unique concepts pertinent to vascular surgery patients included patient complexity, social determinants of health, technology literacy, complexity of ancillary services, discharge appropriateness, and use of advanced nurse practitioners for continuity. Specific themes were identified to target and enhance the future vRED (vascular Re-Engineered Discharge) bundle. Thematic targets for improvement include increased planning, organization, and communication prior to discharge to address vascular surgery patients' multiple comorbidities, extensive medication lists, and need for complex ancillary services at the time of discharge. Other thematic barriers discovered to improve include provider awareness of patient health literacy, patient understanding of complex discharge instructions, patient technology barriers, and intrinsic social determinants of health in this population. To address these discovered barriers, organizational targets to improve include enhanced social support, the use of advanced nurse practitioners for education reinforcement, and increased coordination. These results provide a framework for future quality improvement targeting the vascular surgery discharge process.

Passenger pathogens on physicians

BackgroundHospital acquired infections pose a significant risk for patients undergoing hematopoietic stem cell transplantation. Horizontal transfer of antimicrobial resistance genes contributes to prevalence of multidrug-resistant infections in this patient population. MethodsAt an academic bone marrow transplantation center, we performed whole genome DNA sequencing (WGS) on commonly used physician items, including badges, stethoscopes, soles of shoes, and smart phones from 6 physicians. Data were analyzed to determine antimicrobial resistance and virulence factor genes. ResultsA total of 1,126 unique bacterial species, 495 distinct bacteriophages, 91 unique DNA viruses, and 175 fungal species were observed. Every item contained bacteria with antibiotic and/or antiseptic resistance genes. Stethoscopes contained greatest frequency of antibiotic resistance and more plasmid-carriage of antibiotic resistance. Discussion and ConclusionsThese data indicate that physician examination tools and personal items possess potentially pathogenic microbes. Infection prevention policies must consider availability of resources to clean physical examination tools as well as provider awareness when enacting hospital policies. Additionally, the prevalence of antimicrobial resistance genes (eg, encoding resistance to aminoglycosides, β-lactams, and quinolones) reinforces need for antimicrobial stewardship, including for immunocompromised patients. Further research is needed to assess whether minute quantities of microbes on physician objects detectable by WGS represents clinically significant inoculums for immunocompromised patients.