Provider-level Factors Research Articles

New recommendation and coverage of low-dose computed tomography for lung cancer screening: uptake has increased but is still low

BackgroundIn 2013, the US Preventive Services Task Force (USPSTF) issued recommendations for low-dose computed tomography for lung cancer screening (LDCT-LCS), but there continues to be a dearth of information on the adoption of LDCT-LCS in healthcare systems. Using a multilevel perspective, our study aims to assess referrals for LDCT-LCS and identify facilitators and barriers to adoption following recent policy changes.MethodsA retrospective analysis of electronic medical record data from patients aged 55–80 years with no history of lung cancer who visited a primary care provider in a large healthcare system in California during 2010–2016 (1,572,538 patient years). Trends in documentation of smoking history, number of eligible patients, and lung cancer screening orders were assessed. Using Hierarchical Generalized Linear Models, we also evaluated provider-level and patient-level factors associated with lung cancer screening orders among 970 primary care providers and 12,801 eligible patients according to USPSTF guidelines between January 1st, 2014 and December 31st, 2016.ResultsDocumentation of smoking history to determine eligibility (59.2% in 2010 to 77.8% in 2016) and LDCT-LCS orders (0% in 2010 to 7.3% in 2016) have increased since USPSTF guidelines. Patient factors associated with increased likelihood of lung cancer screening orders include: younger patient age (78–80 vs. 55–64 years old: OR, 0.4; 95% CI, 0.3–0.7), Asian race (vs. Non-Hispanic White: OR, 1.6; 95% CI, 1.1–2.4), reported current smoking (vs. former smoker: OR, 1.7; 95% CI, 1.4–2.0), no severe comorbidity (severe vs. no major comorbidity: OR = 0.2, 95% CI = 0.1–0.3; moderate vs. no major comorbidity: OR = 0.5; 95% CI = 0.4–0.7), and making a visit to own primary care provider (vs. other primary care providers: OR, 2.4; 95% CI, 1.7–3.4). Appropriate referral for lung cancer screening varies considerably across primary care providers. Provider factors include being a female physician (vs. male: OR, 1.6; 95% CI, 1.1–2.3) and receiving medical training in the US (foreign vs. US medical school graduates: OR = 0.4, 95% CI = 0.3–0.7).ConclusionsFuture interventions to improve lung cancer screening may be more effective if they focus on accurate documentation of smoking history and target former smokers who do not regularly see their own primary care providers.

Patterns and correlates of cervical cancer screening initiation in a large integrated health care system

The latest 2012 US Preventive Services Task Force cervical cancer screening guidelines recommended screening initiation at age 21 years. Little is known about the cervical cancer screening initiation practices in the community and whether there are critical gaps with respect to adherence to current clinical guidelines. Despite an overall decline in cervical cancer incidence across women of all ages, the incidence rate has not declined among 24-25 year olds between 2000 (2.79 per 100,000) and 2013 (2.93 per 100,000). Thus, it is important to understand cervical cancer screening initiation in young women and how woman- and provider-level factors affect the timing of screening initiation to identify areas for improving cervical cancer prevention. We examined patterns and correlates of cervical cancer screening initiation among women turning age 21 years in a large community-based practice. Female members of Kaiser Permanente Southern California who turned age 21 years (baseline) during 2013-2015 and had not previously received a Papanicolaou test were included. Cervical cancer screening initiation through October 2016 was captured using electronic health records. Incidence rate and cumulative incidence of screening initiation was calculated. Associations between patient and provider characteristics and screening initiation were evaluated using multivariable Cox models. A total of 38,257 women were included and the Papanicolaou screening initiation rate was 44 per 100 person-years during the study period. Approximately 40% initiated screening within 1 year after turning age 21 years. In multivariable analyses, Asian/Pacific Islanders (hazard ratio, 0.91; confidence interval, 0.86-0.96 compared with non-Hispanic whites); Medicaid enrollees (hazard ratio, 0.90; confidence interval, 0.83, 0.97); those whose primary language is not English (hazard ratio, 0.71; confidence interval, 0.67, 0.75); those who have a historical inpatient visit, primary care physician in pediatrics, internal medicine, or another specialty compared with family practice; and have a male rather than female primary care physician (hazard ratio, 0.46; confidence interval, 0.36, 0.57) less often initiated screening. On the other hand, those who used other preventive services such as getting a human papilloma virus and influenza vaccination and those with a history of pregnancy, contraception use, and sexually transmitted infections more often had timely screening initiation. Less than half of the women insured for preventative services initiated screening at age 21 years. Strategies to improve adherence to screening initiation guidelines should consider a tailored approach for at-risk subgroups and addressing initiation challenges associated with male physicians.

Organizational and provider level factors in implementation of trauma-informed care after a city-wide training: an explanatory mixed methods assessment

BackgroundWhile there is increasing support for training youth-serving providers in trauma-informed care (TIC) as a means of addressing high prevalence of U.S. childhood trauma, we know little about the effects of TIC training on organizational culture and providers’ professional quality of life. This mixed-methods study evaluated changes in organizational- and provider-level factors following participation in a citywide TIC training.MethodsGovernment workers and nonprofit professionals (N = 90) who participated in a nine-month citywide TIC training completed a survey before and after the training to assess organizational culture and professional quality of life. Survey data were analyzed using multiple regression analyses. A subset of participants (n = 16) was interviewed using a semi-structured format, and themes related to organizational and provider factors were identified using qualitative methods.ResultsAnalysis of survey data indicated significant improvements in participants’ organizational culture and professional satisfaction at training completion. Participants’ perceptions of their own burnout and secondary traumatic stress also increased. Four themes emerged from analysis of the interview data, including “Implementation of more flexible, less-punitive policies towards clients,” “Adoption of trauma-informed workplace design,” “Heightened awareness of own traumatic stress and need for self-care,” and “Greater sense of camaraderie and empathy for colleagues.”ConclusionUse of a mixed-methods approach provided a nuanced understanding of the impact of TIC training and suggested potential benefits of the training on organizational and provider-level factors associated with implementation of trauma-informed policies and practices. Future trainings should explicitly address organizational factors such as safety climate and morale, managerial support, teamwork climate and collaboration, and individual factors including providers’ compassion satisfaction, burnout, and secondary traumatic stress, to better support TIC implementation.

Predictors of Use of Monitored Anesthesia Care for Outpatient Gastrointestinal Endoscopy in a Capitated Payment System

Use of monitored anesthesia care (MAC) for gastrointestinal endoscopy has increased in the Veterans Health Administration (VHA) as in fee-for-service environments, despite the absence of financial incentives. We investigated factors associated with use of MAC in an integrated health care delivery system with a capitated payment model. We performed a retrospective cohort study using multilevel logistic regression, with MAC use modeled as a function of procedure year, patient- and provider-level factors, and facility effects. We collected data from 2,091,590 veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy during fiscal years 2000-2013 at 133 facilities. The adjusted rate of MAC use in the VHA increased 17% per year (odds ratio for increase, 1.17; 95% confidence interval, 1.09-1.27) from fiscal year 2000 through 2013. The most rapid increase occurred starting in 2011. VHA use of MAC was associated with patient-level factors that included obesity, obstructive sleep apnea, higher comorbidity, and use of prescription opioids and/or benzodiazepines, although the magnitude of these effects was small. Provider-level and facility factors were also associated with use of MAC, although again the magnitude of these associations was small. Unmeasured facility-level effects had the greatest effect on the trend of MAC use. In a retrospective study of veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy from fiscal year 2000 through 2013, we found that even in a capitated system, patient factors are only weakly associated with use of MAC. Facility-level effects are the most prominent factor influencing increasing use of MAC. Future studies should focus on better defining the role of MAC and facility and organizational factors that affect choice of endoscopic sedation. It will also be important to align resources and incentives to promote appropriate allocation of MAC based on clinically meaningful patient factors.

Use of Regional Anesthesia Techniques: Analysis of Institutional Enhanced Recovery After Surgery Protocols for Colorectal Surgery.

Principles of Enhanced Recovery After Surgery (ERAS®) protocols are well established, with the primary goal of optimizing perioperative care and recovery. The use of multimodal analgesia is a key component of these protocols, including regional analgesia techniques such as thoracic epidural analgesia (TEA), transversus abdominis plane (TAP), rectus sheath blocks or continuous wound infiltration (CWI)/catheters, and spinal anesthesia. We compare and contrast regional anesthesia approaches in different institutional colorectal surgery ERAS protocols. ERAS protocols for open and laparoscopic colorectal surgery were obtained from 15 different healthcare facilities mostly located in North American and one in New Zealand. A comparison was then made with respect to regional anesthesia recommendations. The most commonly used regional technique among protocols was TEA. TAP blocks were the next most common, with rectus sheath blocks and continuous wound catheters only mentioned in one protocol each. There are both similarities and differences in regional anesthesia techniques, which may be due to institution- and provider-level factors. Most protocols advocate for TEA use, which has been associated with a lower incidence of paralytic ileus, attenuation of the surgical stress response, improved intestinal blood flow, improved analgesia, and reduction of opioid use. Use of spinal anesthesia may lead to earlier mobilization compared to TEA, and lower doses of intrathecal morphine are recommended to reduce respiratory depression. TAP blocks were indicated for laparoscopic procedures. Rectus sheath blocks, which are listed in some protocols, may provide analgesia equivalent to epidural anesthesia, while avoiding complications of TEA. CWI has been effective in reducing postoperative pain, hastening recovery, and improving pulmonary function.

Racial Differences and Disparities in Osteoporosis-related Bone Health: Results From the PAADRN Randomized Controlled Trial.

Determining whether observed differences in health care can be called disparities requires persistence of differences after adjustment for relevant patient, provider, and health system factors. We examined whether providing dual-energy x-ray absorptiometry (DXA) test results directly to patients might reduce or eliminate racial differences in osteoporosis-related health care. We analyzed data from 3484 white and 1041 black women who underwent DXA testing at 2 health systems participating in the Patient Activation after DXA Result Notification (PAADRN) pragmatic clinical trial (ClinicalTrials.gov NCT-01507662) between February 2012 and August 2014. We examined 7 outcomes related to bone health at 12 weeks and 52 weeks post-DXA: (1) whether the patient correctly identified their DXA baseline results; (2) whether the patient was on guideline-concordant osteoporosis pharmacotherapy; (3) osteoporosis-related satisfaction; (4) osteoporosis knowledge; (5 and 6) osteoporosis self-efficacy for exercise and for diet; and (7) patient activation. We examined whether unadjusted differences in outcomes between whites and blacks persisted after adjusting for patient, provider, and health system factors. Mean age was 66.5 years and 29% were black. At baseline black women had less education, poorer health status, and were less likely to report a history of osteoporosis (P<0.001 for all). In unadjusted analyses black women were less likely to correctly identify their actual DXA results, more likely to be on guideline-concordant therapy, and had similar patient activation. After adjustment for patient demographics, baseline health status and other factors, black women were still less likely to know their actual DXA result and less likely to be on guideline-concordant therapy, but black women had greater patient activation. Adjustment for patient and provider level factors can change how racial differences are viewed, unmasking new disparities, and providing explanations for others.

Patient, Provider, and System Factors Contributing to Patient Safety Events During Medical and Surgical Hospitalizations for Persons With Serious Mental Illness.

This study aimed to explore patient-, provider-, and system-level factors that may contribute to elevated risk of patient safety events among persons with serious mental illness (SMI). We conducted a medical record review of medical/surgical admissions in Maryland hospitals from 1994 to 2004 for a community-based sample of adults with SMI (N = 790 hospitalizations). We estimated the prevalence of multiple patient, provider, and system factors that could influence patient safety among persons with SMI. We conducted a case crossover analysis to examine the relationship between these factors and adverse patient safety events. Patients' mental status, level of consciousness, disease severity, and providers' lack of patient monitoring, delay/failure to seek consultation, lack of trainee supervision, and delays in care were positively associated with adverse patient safety events (p < 0.05). Efforts to reduce SMI-related patient safety risks will need to be multifaceted and address both patient- and provider-level factors.

Patterns of testosterone prescription overuse.

There has been an increase in the prescribing of testosterone therapy in the past decade. There is concern that at least part of this increase is driven by advertising rather than sound medical practice. The purpose of this review is to summarize the recent trends in testosterone prescribing, and to examine whether testosterone is being appropriately prescribed as per guidelines. Both global and U.S. data reflect an overall increase in the use of testosterone in the last decade, although there are early signs of a decline in testosterone sales since 2014. This increased prescribing has been accompanied with an overall increase in testing for testosterone levels, prescription of testosterone without the appropriate diagnostic evaluation recommended by clinical practice guidelines, and apparent use of this therapy for unproven medical conditions. Research to date suggests that there is room to improve our prescribing of testosterone. Greater understanding of the potential provider-level and system-level factors that contribute to the current prescribing practices may help accomplish such improvement.

Impact of Provider Characteristics on Outcomes of Carotid Endarterectomy for Asymptomatic Carotid Stenosis in New York State

The purpose of this study is to explore the impact of surgeon characteristics (including annual volume, specialty, and years in practice) on outcomes of carotid endarterectomy (CEA) for asymptomatic carotid atherosclerosis in New York State. The New York Statewide Planning and Cooperation System database was utilized to identify patients undergoing CEA from 2004 to 2011. Provider characteristics were determined by linkage to the New York Office of Professions and National Provider Identification databases. Provider-level factors were characterized by defining 5 quintiles of equal size for each factor. Hierarchical logistic regression models were created to evaluate the impact of provider characteristics on outcome. In total, 36,495 patients underwent CEA for asymptomatic disease performed by vascular (75.7%), general (16.1%), cardiac (6%), and neuro (2.1%) surgeons. Outcomes of interest included in-hospital mortality (0.26%), stroke (0.45%), and the composite end point of mortality, stroke, or cardiac complication (2.2%). Unadjusted outcomes improved with increasing surgeon annual CEA volume. Mid-career surgeons had lower mortality and stroke rates than early or late-career surgeons. Odds of mortality were increased when surgery was performed by the lowest volume providers (quintile 1; 0-11 CEA/year) (odds ratio [OR] 2.62, 95% confidence interval [CI] 1.3-5.28) or a nonspecialty trained (general) surgeon (OR 1.64, 95% 1.01-2.67). After adjustment for all patient-level factors, provider volume remained an independent predictor of outcome, with significantly increased odds of mortality for volume quintile 1 (OR 2.57, 95% CI 1.27-5.23) and quintile 2 (12-22 CEA/year) (0.30%; OR 2.07, 95% CI 1-4.27) surgeons. Adverse events after CEA for asymptomatic disease are comparatively rare. However, surgeon characteristics impact outcome, with the best results offered by high-volume, mid-career, specialty-trained surgeons. Efforts to define the optimal treatment of asymptomatic carotid atherosclerosis must account for the impact of surgeon characteristics on patient outcomes.

Factors influencing practice variation in the management of nephrotic syndrome: a qualitative study of pediatric nephrology care providers.

Treatment protocols for childhood nephrotic syndrome are highly variable between providers and care centres. We conducted a qualitative study to understand the complex multilevel processes that lead to practice variation and influence provider management of nephrotic syndrome. Focus groups with multidisciplinary pediatric nephrology care providers (n = 67) from 10 Canadian pediatric nephrology centres that had more than 1 pediatric nephrologist were conducted between September 2013 and April 2015. Focus group discussions were guided by the Ottawa Model for Research Use. We used a semistructured interview guide to elicit participants' perspectives regarding 1) the work setting and context of the clinical environment, 2) reasons for variation at the provider level and 3) clinical practice guidelines for nephrotic syndrome. Focus group discussions were transcribed and analyzed concurrently with the use of qualitative content analysis. Emerging themes were grouped into 2 categories: centre-level factors and provider-level factors. At the centre level, the type of care model used, clinic structures and resources, and lack of communication and collaboration within and between Canadian centres influenced care variation. At the provider level, use of experiential knowledge versus empirical knowledge and interpretation of patient characteristics influenced provider management of nephrotic syndrome. Centre- and provider-level factors play an important role in shaping practice differences in the management of childhood nephrotic syndrome. Further research is needed to determine whether variation in care is associated with disparities in outcomes.

Abstract P061: Blood Pressure Control in the Outpatient Setting Among Patients with Diabetes: The Guideline Advantage

Introduction: Blood pressure (BP) screening and control is often suboptimal in patients with diabetes, a population in whom cardiovascular disease (CVD) is the leading cause of morbidity and mortality. Hypertension in the context of diabetes uniquely increases risk for CVD incidence and mortality. The aim of this study was to describe the burden of uncontrolled BP among patients with diabetes seen in the outpatient setting and factors associated with BP control using data from a large, electronic health record (EHR) data registry. Methods: Outpatient EHR data were analyzed from The Guideline Advantage™ (TGA), a joint quality improvement initiative of the American Heart Association, American Diabetes Association, and American Cancer Society. Data were compiled from patients aged ≥18 years seen at &gt;70 individual clinics across the U.S. “Uncontrolled BP” was defined as measured BP ≥140/90mmHg at the most recent outpatient visit with or without a clinical diagnosis of hypertension. Logistic regression was used to examine factors associated BP control status. Results: We observed 1,710,702 BP measurements among 216,947 unique patients. The population was 42% male (n= 91,062) with a mean age of 49 years; 19% (n=41,714) of patients had BP ≥140/90 mmHg at their most recent outpatient visit and 8% of the population had a history of diabetes (n= 18,242). Patients with diabetes had 1.15 times the odds of BP ≥140/90 mmHg at their most recent outpatient visit [aOR(95% CI): 1.15 (1.11-1.20)]. Among patients with a diabetes history, the following factors were associated with uncontrolled BP: race/ethnicity [(aOR: 2.81 (2.48-3.19) for non-Hispanic blacks compared to non-Hispanic whites, 1.44 (1.31-1.57) for multiracial patients versus non-Hispanic whites] , sex [aOR: 1.28 (1.25-1.31)] for males compared to females], age [aOR per 10-year increase in age: 1.22 (1.21-1.23)], and time since diabetes diagnosis [aOR per 1-year increase in time since diagnosis: 0.99(0.98-1.00)]. Conclusions: Uncontrolled BP disproportionately impacts diabetes patients in the outpatient setting. Among these patients, BP control status differed by race/ethnicity, sex, and age. Additionally, patients were more likely to have uncontrolled BP ≥140/90 mmHg closer to the time of their diabetes diagnoses (i.e. time since diagnosis was inversely associated with BP control status). Additional investigation to identify underlying patient- and provider-level factors contributing to these observed differences will be particularly important moving forward for accountable care organizations to meet metrics for equitable quality care delivery across patient subgroups.

Abstract 91: An Objective Screening Tool Predicts Surgical Feeding Tube Placement in Acute Ischemic Stroke Patients

Introduction: Dysphagia is a common post-stroke complication, yet there are no standard tools to guide recommendations for placement of percutaneous endoscopic gastrostomy (PEG) tube. Prior prediction models in acute ischemic stroke (AIS) have had inconsistent findings and have not included objective swallowing assessments. We hypothesized that inclusion of an aspiration-based score would simplify the prediction model and be a strong independent predictor of PEG placement among patients referred for instrumental assessment of swallowing (IAS) after failed bedside swallow. Methods: Consecutive cases of AIS were identified from our inpatient registry (6/14- 4/15). Patients transferred to hospice or dying within 3 days of hospitalization were excluded. NIHSS and sub-items, medical history, and demographic data were included in the full model and subgroup analysis which included patients undergoing IAS. Univariate and multiple logistic regression were used to assess predictors of PEG placement. Penetration-Aspiration (PEN-ASP) scores (1-2 normal; 3-5, penetration, 6-8, aspiration) calculated using Fiberoptic Endoscopic Evaluation of Swallowing and Modified Barium Swallow Studies were included in the model for subgroup analysis. Results: Among 731 AIS patients, 17.9% (131) of patients received a PEG and 200 patients received IAS (39.5 % PEG). In the full model, arrival GCS and NIHSS, NIHSS level of consciousness score, and prior Diabetes Mellitus and ICH (p &lt; 0.05). Among patients receiving IAS, arrival NIHSS, PEN-ASP score, and race (Hispanic v White) was associated with PEG placement. Conclusions: This study represents the largest cohort of AIS patients undergoing PEG placement and IAS. We demonstrated that the PEN-ASP score helps to predict PEG placement in AIS. Race also emerged as a predictor, and in future studies, we will examine patient and provider-level factors to explain this association.

Personal and provider level factors influence participation to cervical cancer screening: A retrospective register-based study of 1.3 million women in Norway

High coverage is essential for an effective screening programme. Here we present screening barriers and facilitators among 1.3 million women aged 25–69years eligible for screening within the Norwegian Cervical Cancer Screening Program (NCCSP). We defined non-adherence as no screening test in 2008–2012. We divided adherent women into those screened spontaneously, and those who had a smear after receiving a reminder from the NCCSP. Explanatory variables were extracted from several nationwide registers, and modelled by modified Poisson regression. In total, 34% of women were non-adherent. 31% of native Norwegians were non-adherent, compared to 50% of immigrants. Immigrant status was a strong predictor of non-adherence, but the vast majority of non-adherent women were still native Norwegians. Higher non-adherence rates were associated with having a male general practitioner (GP), a foreign GP, a young GP, and distance to the screening site. Being unmarried, having no children, having lower socioeconomic position and region of residence predicted non-adherence and, to a smaller extent, reminded adherence to screening. In contrast, previous experience with cervical abnormalities substantially increased adherence to screening. The population-based screening programme promotes equity by recruiting women who are less likely to participate spontaneously. However, socioeconomic disparities were evident in a country with a nationwide programme and a policy of equal access to health care. Initiatives aimed at removing practical and financial barriers to equitable screening delivery and at reducing the effect of sociodemographic attributes on screening participation are needed.

Factors influencing implementation of a survivorship care plan\u2014a quantitative process evaluation of the ROGY Care trial

PurposeThe aim of this study is to investigate the factors that influence implementation of Survivorship Care Plans (SCPs) in the intervention arm of the ROGY Care trial by (1) assessing the level of SCP receipt in the ROGY Care trial and (2) identifying patient- and provider-level factors that influence SCP receipt.MethodsBetween 2011 and 2015, a pragmatic cluster randomized-controlled-trial was conducted on the effects of automatically generated SCPs. Endometrial (N = 117) and ovarian (N = 61) cancer patients were allocated to ‘SCP care’, as provided by their SCP care providers (N = 10). Associations between SCP receipt (self-reported SCP receipt and actually generated SCPs), patient-factors (socio-demographic-, clinical-, and personality factors), and care provider factors (profession and a-priori motivation regarding SCP provision) were tested in univariate analysis. The odds ratios of factors influencing self-reported SCP receipt were estimated with a multivariate regression model.ResultsOf all patients in the SCP care arm (N = 178), SCPs were generated by the care provider for 90 % of the patients and 70 % of the patients reported that they had received an SCP. Patients with older age, ovarian cancer, type D (distressed) personality, and patients that completed the questionnaire a longer period of time after the SCP consult were more likely to report no SCP receipt.ConclusionsSCP receipt was influenced by patient- but not care-provider factors.Implications for cancer survivorsCertain patient groups were less likely to report SCP receipt. Whether all patients are in need of an SCP, requires further investigation. If they do, more efforts need to be made towards the implementation of SCPs.

Provider-Level and Other Health Systems Factors Influencing Engagement in HIV Care: A Qualitative Study of a Vulnerable Population.

Despite the existence of highly active antiretroviral therapy, HIV/AIDS morbidity and mortality continue to be public health burdens in the United States due to difficulties in engaging people living with HIV/AIDS (PLWHA) in continuous, effective care. In comparison to studies investigating patient-level characteristics associated with starting and remaining in care, there is relatively little research on how structural factors, such as those pertaining to healthcare providers and the infrastructure for delivery of health services, influence patients’ engagement in HIV care. Our study, based in the city of Baltimore, Maryland, uses qualitative research methods with a population of predominantly African American PLWHA who have a history of drug abuse, to examine facilitators and barriers regarding adherence to antiretroviral therapy (ART) and HIV care appointment attendance. Data collection involved conducting one-on-one, in-depth interviews with 31 study participants, and data analysis entailed thematic coding of interview transcripts and writing analytic memos to develop ideas and concepts. Among other findings, factors described as influential by our study participants related to appointment reminders and scheduling, the attitudes and communication styles of HIV clinicians, and the disposition and availability of other healthcare workers on the care “team.” Thus, improving quality of HIV care and means of delivering it may help mitigate the numerous points in the continuum of HIV care when a patient may disengage.

Impact of Low Procalcitonin Results on Antibiotic Administration in Hospitalized Patients at a Tertiary Care Center.

Procalcitonin is a sensitive and specific marker of bacterial infection; low results allow clinicians to safely de-escalate antibiotics. This retrospective cohort study aimed to determine the effect of low procalcitonin results on withholding, discontinuing, or de-escalating antibiotics in hospitalized patients at a tertiary care center. Antibiotics were initiated or continued without de-escalation in 55% of patients with low procalcitonin results. Among patients with low procalcitonin results, the primary service, but not measures of patient complexity, disease severity, or underlying disease process (lower respiratory tract infection evaluation versus systemic inflammatory response syndrome/possible sepsis) was associated with initiation or continued broad-spectrum antibiotic use. Provider-level factors may be an important variable in the initiation or continued use of broad-spectrum antibiotics for patients with low procalcitonin levels.

MP43-08 UTILIZATION OF MEDICAL EXPULSIVE THERAPY IN CHILDREN: AN ASSESSMENT OF NATIONWIDE PRACTICE PATTERNS AND OUTCOMES

You have accessJournal of UrologyPediatrics: Testis, Varicocele & Stones1 Apr 2016MP43-08 UTILIZATION OF MEDICAL EXPULSIVE THERAPY IN CHILDREN: AN ASSESSMENT OF NATIONWIDE PRACTICE PATTERNS AND OUTCOMES Jonathan Ellison, Benjamin Fu, Sarah Holt, Thomas Lendvay, John Gore, and Margarett Shnorhavorian Jonathan EllisonJonathan Ellison More articles by this author , Benjamin FuBenjamin Fu More articles by this author , Sarah HoltSarah Holt More articles by this author , Thomas LendvayThomas Lendvay More articles by this author , John GoreJohn Gore More articles by this author , and Margarett ShnorhavorianMargarett Shnorhavorian More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.217AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Medical expulsive therapy (MET) has been proposed to be an efficacious strategy for management of ureteral calculi in children. However, little is known regarding MET utilization within this patient population. We sought to evaluate to utilization and outcomes of MET in pediatric nephrolithiasis utilizing a nationally-representative administrative claims database. METHODS We interrogated the MarketScan Commercial Claims and Encounters database from 2007-2013 to identify children aged 1 to 18 years presenting to the emergency department (ED) with a diagnosis of nephrolithiasis. Patients not considered candidates for MET (i.e. coding for renal insufficiency, urinary tract infection, or surgical intervention at time of evaluation) were excluded. MET exposure was defined as having a prescription for an MET agent (alpha-adrenergic blocker or nifedipine) filled within 1 week of the ED encounter. Patient and provider characteristics were described and outcomes within 90 days of index encounter compared between patients with and without MET exposure. Sub-analysis was performed for patients with the specific diagnosis of ″calculus of the ureter″. RESULTS A total of 1356 patients were included in the study, of which 175 (15.1%) received MET. Of the 437 (32.2%) patients with the diagnosis ″calculus of the ureter″, 68 (16%) received MET. Tamsulosin was utilized in 166 (94.5%) of patients receiving MET. Male gender, any inpatient or outpatient encounter within 3-months of index encounter, and urologist or nephrologist involvement in care were positively associated with MET prescriptions. Rates of ED or inpatient encounters and surgical interventions did not differ by MET exposure (see Table). Only 62% of patients with ureteral calculi had follow-up imaging within 90 days. CONCLUSIONS MET is prescribed infrequently to children who are potential candidates for expulsive therapy. Prescribing patterns vary based on patient- and provider-level factors, and provider familiarity with nephrolithiasis may influence practice patterns. MET exposure was not associated with differences in unplanned medical encounters or need for subsequent surgery. Follow-up imaging is not obtained in 38% of patients with ureteral calculi. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e581 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Jonathan Ellison More articles by this author Benjamin Fu More articles by this author Sarah Holt More articles by this author Thomas Lendvay More articles by this author John Gore More articles by this author Margarett Shnorhavorian More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Development of an implementation plan for the 6-PACK falls prevention programme as part of a randomised controlled trial: protocol for a series of preimplementation studies

BackgroundInhospital falls cause morbidity, staff burden and increased healthcare costs. It is unclear if the persistent problem of inhospital falls is due to the use of ineffective interventions or their...

Medication Nonadherence and Effectiveness of Preventive Pharmacological Therapy for Kidney Stones

Among patients with kidney stones rates of adherence to thiazide diuretics, alkali citrate therapy and allopurinol, collectively referred to as preventive pharmacological therapy, are low. This lack of adherence may reduce the effectiveness of secondary prevention efforts, leading to poorer clinical health outcomes in patients with kidney stones. To examine the impact that medication nonadherence has on the secondary prevention of kidney stones, we compared clinical health outcomes between patients who adhered to their regimen and those who did not. Using medical and pharmacy claims data we identified adult patients with a physician coded diagnosis for kidney stones. Among the subset with a prescription fill for a preventive pharmacological therapy agent, we then measured adherence to therapy within the first 6 months of initiating treatment using the proportion of days covered formula. We defined adherence as a proportion of days covered value of 80% or greater. Finally, we fitted multivariable logistic regression models to examine the association between medication adherence and the occurrence of a stone related clinical health outcome (an emergency department visit, hospitalization or surgery for stone disease). Of the 8,950 patients who met the study eligibility criteria slightly more than half (51.1%) were adherent to preventive pharmacological therapy. The frequency of emergency department visits, hospitalization and surgery for stone disease was significantly lower among adherent patients. After controlling for sociodemographic factors and the level of comorbid illness, patients who were adherent to therapy had 27% lower odds of an emergency department visit (OR0.73, 95% CI 0.64-0.84), 41% lower odds of hospital admission (OR 0.59, 95% CI 0.49-0.71) and 23% lower odds of surgery for stone disease (OR 0.77, 95% CI 0.69-0.85) than nonadherent patients. Our data highlight the consequences of nonadherence to preventive pharmacological therapy among patients with kidney stones. To improve adherence further research is needed to understand patient and provider level factors that contribute to lower rates of adherence.

Improving breast cancer services for African-American women living in St. Louis.

A mixed methods, community-based research study was conducted to understand how provider-level factors contribute to the African-American and white disparity in breast cancer mortality in a lower socioeconomic status area of North St. Louis. This study used mixed methods including: (1) secondary analysis of Missouri Cancer Registry data on all 885 African-American women diagnosed with breast cancer from 2000 to 2008 while living in the geographic area of focus; (2) qualitative interviews with a subset of these women; (3) analysis of data from electronic medical records of the women interviewed; and (4) focus group interviews with community residents, patient navigators, and other health care professionals. 565 women diagnosed with breast cancer from 2000 to 2008 in the geographic area were alive at the time of secondary data analysis; we interviewed (n = 96; 17 %) of these women. Provider-level obstacles to completion of prescribed treatment included fragmented navigation (separate navigators at Federally Qualified Health Centers, surgical oncology, and medical oncology, and no navigation services in surgical oncology). Perhaps related to the latter, women described radiation as optional, often in the same words as they described breast reconstruction. Discontinuous and fragmented patient navigation leads to failure to associate radiation therapy with vital treatment recommendations. Better integrated navigation that continues throughout treatment will increase treatment completion with the potential to improve outcomes in African Americans and decrease the disparity in mortality.