Time Of Clinic Visit Research Articles

A large-scale retrospective study in China explores risk factors for disease severity in plaque psoriasis

Severe psoriasis has a long course and poor outcome, and it has long been a problem for patients. Understanding the independent risk factors that contribute to patients with severe psoriasis is critical for the development of effective treatment strategies. This large, multicenter study recruited 2,109 plaque psoriasis patients from 12 hospitals across China (October 31, 2019 – May 31, 2022). The logistic regression model underwent internal validation and external validation using two independent cohorts over future time periods (June 1, 2022 – January 31, 2023). The discriminative power of our model was substantiated by a C-index of 0.863 (95% CI: 0.848–0.879) in internal validation, further affirmed through 1,000 bootstrap validation (C-index: 0.860, 95% CI: 0.836–0.885) and external validation cohorts, where the C-index reached up to 0.910 (95% CI: 0.868–0.953) and 0.951 (95% CI: 0.924–0.977) in 2 external validation cohorts. To enhance accessibility for clinicians, the model has been made available as a dynamic nomogram and QR code. Our study identified 10 risk factors (the “DELPHI” consensus dichotomy, the DLQI index, the extent of skin involvement as measured by body surface area, the age of the patient at the time of clinical visit, sex, body weight in kilograms, career, the presence of scalp involvement, facial involvement, and arthropathy) for the overall severity of psoriasis (PASI ≥ 10). “Nomogram-10” provides clinicians with a practical tool to develop personalized intervention strategies based on an individual’s risk profile.Trial registration: Chinese Clinical Trial Registry: ChiCTR1900024852.

Physician-reported barriers and facilitators to thyroid hormone deprescribing in older adults.

Thyroid hormone is one of the most commonly prescribed medications in the United States. Misuse of and overtreatment with thyroid hormone is common in older adults and can lead to cardiovascular and skeletal adverse events. Even though deprescribing can reduce inappropriate care, no studies have yet explored specific barriers and facilitators to guide thyroid hormone deprescribing in older adults (defined as discontinuation of thyroid hormone when initiated without an appropriate indication or dose reduction in those overtreated). We conducted semi-structured interviews with 19 endocrinologists, geriatricians, and primary care physicians who prescribe thyroid hormone. Interviews were completed between July 2020 and December 2021 via two-way video conferencing. We used both an inductive and deductive content analysis guided by the Theoretical Domains Framework to evaluate transcribed and coded participant responses. Thematic analysis characterized themes related to barriers and facilitators to thyroid hormone deprescribing practices in older adults. The most commonly reported barriers to thyroid hormone deprescribing were related to patient-level factors, followed by physician- and system-level factors. Patient factors included patients' perceived need for thyroid hormone use and patient anxiety/concerns about potential side effects related to thyroid hormone dose reduction, patient lack of knowledge, and misinformation regarding deprescribing. Physician- and system-level barriers included clinic visit time constraints, physician inertia, physician lack of knowledge about deprescribing, perceived lack of sufficient patient follow-up, and electronic health record limitations. The most prominent physician-reported facilitators to thyroid hormone deprescribing were effective physician-to-patient communication, and positive physician-patient relationship, including patients' trust in their treating physician. Barriers and facilitators to thyroid hormone deprescribing in older adults were reported at multiple levels including patient-, physician-, and system-level factors. Interventions to improve thyroid hormone deprescribing in older adults should aim to improve patient education and expectations, increase multidisciplinary physician awareness, and overcome physician inertia.

Responsive Neurostimulation in Pediatric and Young Adult Patients With Drug-Resistant Focal, Multifocal, and Generalized Epilepsy: A Single-Center Experience

BackgroundResponsive neurostimulation (RNS) is used off-label in pediatric patients with drug-resistant epilepsy (DRE). Our study aims to assess the safety and efficacy of RNS in pediatric and young adult patients with focal, multifocal, and generalized DRE. MethodsAll patients who underwent RNS implantation at Primary Children's Hospital in Salt Lake City, UT, between December 2017 and 2022. ResultsA total of 47 patients were retrospectively identified, of which 32 patients were included in the final analysis. Patients ranged in age from five to 21 years (pediatric n = 22, young adult n = 10) at the time of RNS implantation with focal (20 [63%]), multifocal (8 [25%]), and generalized (4 [12%]) DRE. Operative complications (3 [9%]) and negative side effects (6 [19%]) were minor. At the time of most recent clinic visit (mean 18.6 months, S.D. 13.9), 19 of 32 patients (59%) were responders with ≥50% reduction in seizure frequency (pediatric n = 14, young adult n = 5). The rate of responders increased with prolonged activation of RNS stimulation, reaching 71% (five of seven patients) after 24 months. Antiseizure medication was reduced in five (16%) patients, and seizure rescue medication usage was reduced in 10 (31%) patients. Quality of life improved in 15 (47%) patients. ConclusionsRNS implantation resulted in a sustained reduction in seizure frequency with minimal side effects in a majority of patients. Taken together, our data suggest that RNS is an effective and safe treatment option for focal, multifocal, and potentially generalized DRE in the pediatric and young adult population.

Cerebrospinal fluid characteristics of patients presenting for evaluation of pediatric acute-neuropsychiatric syndrome.

This study characterizes cerebral spinal fluid (CSF) indices including total protein, the albumin quotient, IgG index and oligoclonal bands in patients followed at a single center for pediatric acute-neuropsychiatric syndrome (PANS) and other psychiatric/behavioral deteriorations. In a retrospective chart review of 471 consecutive subjects evaluated for PANS at a single center, navigational keyword search of the electronic medical record was used to identify patients who underwent lumbar puncture (LP) as part of the evaluation of a severe or atypical psychiatric deterioration. Psychiatric symptom data was ascertained from parent questionnaires and clinical psychiatric evaluations. Inclusion criteria required that subjects presented with psychiatric deterioration at the time of first clinical visit and had a lumbar puncture completed as part of their evaluation. Subjects were categorized into three subgroups based on diagnosis: PANS (acute-onset of severe obsessive compulsive disorder (OCD) and/or eating restriction plus two other neuropsychiatric symptoms), autoimmune encephalitis (AE), and "other neuropsychiatric deterioration" (subacute onset of severe OCD, eating restriction, behavioral regression, psychosis, etc; not meeting criteria for PANS or AE). 71/471 (15.0 %) of patients underwent LP. At least one CSF abnormality was seen in 29% of patients with PANS, 45% of patients with "other neuropsychiatric deterioration", and 40% of patients who met criteria for autoimmune encephalitis. The most common findings included elevated CSF protein and/or albumin quotient. Elevated IgG index and IgG oligoclonal bands were rare in all three groups. Elevation of CSF protein and albumin quotient were found in pediatric patients undergoing LP for evaluation of severe psychiatric deteriorations (PANS, AE, and other neuropsychiatric deteriorations). Further studies are warranted to investigate blood brain barrier integrity at the onset of the neuropsychiatric deterioration and explore inflammatory mechanisms.

Health Disparities in Young Adults: A Direct Comparison of Distress and Unmet Needs Across Cancer Centers.

Information on concerns that young adults (YAs) with cancer face when receiving care outside of specialized treatment centers is needed to increase equitable care to YAs at greater risk of marginalization by the health care system. The current study compared distress and unmet needs at the time of clinic visit between YAs receiving care from three different cancer clinics: (1) a National Cancer Institute-designated center, (2) a community-based clinic, and (3) a county hospital outpatient clinic. The Adolescent and Young Adult Psycho-Oncology Screening Tool (AYA-POST) was administered to measure distress and cancer-related concerns of YAs in active treatment. A one-way analysis of variance (ANOVA) compared distress scores by treatment site. A Fisher's exact test compared the number of participants endorsing each item on the Needs Assessment Checklist from each site. A simple linear regression determined the association between distress and number of items endorsed on the Needs Assessment Checklist. Ninety-seven participants completed the AYA-POST, endorsing, on average, 11 concerns. Fisher's exact test showed significant differences between sites in the proportion of participants endorsing eight items: boredom (P < .001), eating/appetite (P < .001), nausea/vomiting (P < .001), financial concern (P = .002), hopelessness/helplessness (P = .03), confidentiality (P = .04), sibling concern (P = .04), and insurance (P = .05). The simple linear regression model was significant (F(1, 94) = 39.772, P < .001, R2 = 0.297), indicating the number of unmet needs accounted for almost 30% of the variance in distress. The one-way ANOVA was not significant (F(2, 93) = 1.34, P = .267). Social determinants of health can influence the number and type of unmet needs experienced, affecting distress and other outcomes and underscoring the importance of timely, effective, age-appropriate screening and intervention for distress and unmet needs in YAs with cancer.

Effect of differentiated direct-to-pharmacy PrEP refill visits supported with client HIV self-testing on clinic visit time and early PrEP continuation.

Delivery of oral pre-exposure prophylaxis (PrEP) is being scaled up in Africa, but clinic-level barriers including lengthy clinic visits may threaten client continuation on PrEP. Between January 2020 and January 2022, we conducted a quasi-experimental evaluation of differentiated direct-to-pharmacy PrEP refill visits at four public health HIV clinics in Kenya. Two clinics implemented the intervention package, which included direct-to-pharmacy for PrEP refill, client HIV self-testing (HIVST), client navigator, and pharmacist-led rapid risk assessment and dispensing. Two other clinics with comparable size and client volume served as contemporaneous controls with the usual clinic flow. PrEP continuation was evaluated by visit attendance and pharmacy refill records, and time and motion studies were conducted to determine time spent in the clinics. Dried blood spots were collected to test for tenofovir-diphosphate (TFV-DP) at random visits. We used logistic regression to assess the intervention effect on PrEP continuation and the Wilcoxon rank sum test to assess the effect on clinic time. Overall, 746 clients were enrolled, 366 at control clinics (76 during pre-implementation and 290 during implementation phase), and 380 at direct-to-pharmacy clinics (116 during pre-implementation and 264 during implementation phase). Prior to implementation, the intervention and control clinics were comparable on client characteristics (female: 51% vs. 47%; median age: 33 vs. 33 years) and PrEP continuation (35% vs. 37% at 1 month, and 37% vs. 39% at 3 months). The intervention reduced total time spent at the clinic by 35% (median of 51 minutes at control vs. 33 minutes at intervention clinics; p<0.001), while time spent on HIV testing (20 vs. 20 minutes; p = 0.50) and pharmacy (8 vs. 8 minutes; p = 0.8) was unchanged. PrEP continuation was higher at intervention versus the control clinics: 45% versus 33% at month 1, 34% versus 25% at month 3 and 23% versus 16% at month 6. TFV-DP was detected in 85% (61/72) of samples, similar by the study group (83% vs. 85%). A client-centred PrEP delivery approach with direct-to-pharmacy PrEP refill visits plus client HIVST significantly reduced clinic visit time by more than one-third and improved PrEP continuation in public health HIV clinics in Kenya.

Financial Toxicity in the Spanish Speaking Population

Advances in therapy have significantly improved cancer survival outcomes but with a harmful patient consequence: financial toxicity. Financial toxicity consists of a patient's many economic burdens from cancer treatment, encompassing direct healthcare costs as well as additional devastating financial consequences, such as job loss and medical bankruptcy. With rising cancer treatment costs, financial toxicity has become a problem that is increasingly impactful in both cancer treatment and survivorship, amplifying disparities, negatively impacting quality of life, treatment adherence and survival. The long-term research goal that this study will contribute to is to develop culturally appropriate and effective patient navigation resources and psychosocial support resources for interventions to increase coping and resilience to financial toxicity in high-risk populations. This study will seek to generate the early data needed to help develop the content and method of delivering strategies, tailored for an underserved, Spanish-speaking Latino population. Eligibility Participant must be 18 years of age or older at the time of study participation, able to read and speak Spanish, have diagnosis of cancer within the past 2 years or be on active treatment for their cancer; all disease sites and all stages are eligible for enrollment. We will exclude patients unable to give consent. Methods This is a prospective observational study of cancer patients and survivors, with participants to be recruited from Scripps MD Anderson Cancer Center. Participating clinics will be screened in the electronic medical record for individuals who meet above eligibility criteria. At the time of clinic visits, eligible individuals will be approached. Individuals who express that they would like to participate in the survey study will receive the study packet with the consent statement and baseline survey questions. Study participants will also be invited to participate in the OPTIONAL patient navigation portion of the study. Participants who are not active on the MyScripps patient portal will be invited to join the patient navigation portion of the study. Those elect to participate will be provided a device if they do not have their own. Participants will be given a Greenphire Clincard on which they will receive a total of $75 in three installments. Research team members will enter the item responses into the REDCap database. They will undergo a follow-up survey during a range from 4 months to 9 months from the initial survey date. Those participating in the patient navigation portion of the study will be contacted by the navigator on a monthly basis through the electronic portal or telephone. Statistics We plan to enroll N= 80 Spanish-speaking patients in the survey study. For correlation testing, we hypothesize a moderate effect size (correlation = 0.32) for the association between the primary outcome measure, the baseline measure of self-efficacy (Hope State score) and the baseline financial toxicity score (Economic Strain and Resilience in Cancer). For feasibility testing of navigation participation, feasibility will be assessed through descriptive statistics. We hypothesize that it is feasible for 50% of invited patients to participate. When the sample size is 40, a two-sided 95% confidence interval for participant completion rate will extend 0.15 from the observed proportion for an expected proportion of 0.50. Analysis The primary outcome measure is financial toxicity, measured using the ENRICh instrument at baseline. The primary predictor is the baseline Hope State score. This modeled association is of primary interest in the analysis. We will conduct descriptive and univariate/multivariate analyses on this association of primary interest, including Chi-square test, t-test. Other univariate and multivariate analyses of associations between financial toxicity and other measures obtained from survey measures, as well as clinical, demographic, socioeconomic, and care delivery variables, considered descriptive and exploratory, will be performed. Accounting for multiple comparisons will be based on stepdown procedures and familywise error rate control; we plan to control this overall error rate using the Holm-Sidak adjustment, or procedure with equitable properties.

Racial disparities in ALS diagnostic delay: a single center's experience and review of potential contributing factors.

Outcomes for amyotrophic lateral sclerosis (ALS) patients are improved with prompt diagnosis, earlier initiation of disease-modifying treatments, and participation in a multidisciplinary clinic. We studied diagnostic delay and disease severity at time of clinic presentation between Black and non-Hispanic Caucasian ALS patients. We performed a retrospective analysis of non-Hispanic Caucasian and Black ALS patients seen in the Virginia Commonwealth University Health System multidisciplinary ALS clinic between 2017 and 2023. Diagnostic delay, ALS Functional Rating Scale-Revised (ALSFRS-R) and upright forced vital capacity (FVC) scores at baseline appointment were collected. Patient's distance from clinic and affluency of residential neighborhood were evaluated. We analyzed 172 non-Hispanic Caucasian and 33 Black ALS patients. Black patients had a 64% increase in diagnostic delay compared to non-Hispanic Caucasian patients. Black patients had a lower performance on ALSFRS-R (5.3 points, p < 0.001) and FVC (17.9 percentage points p < 0.001) at time of first clinic visit. Black patients lived closer to clinic, with higher proportion living in the city of Richmond, but in less affluent areas with lower median house income ($55,300 ± 22,600 vs $69,900 ± 23,700). Our findings demonstrate a large racial difference in ALS diagnostic delay, and greater disease severity and lower respiratory function at time of diagnosis for Black ALS patients. Delay in diagnosis prolongs access to disease-modifying therapies, multidisciplinary care, durable medical equipment, and respiratory and nutritional support. Potential sources of these racial disparities include providers' implicit bias and structural racism.

FRI122 Determinants Of Primary Aldosteronism Screening In The US: A Nationwide Physician Survey Study

Abstract Disclosure: A.F. Turcu: None. Z. Salman: None. S.M. Konzen: None. L. Zhang: None. H. Liu: None. L. Zhao: None. T. Suzer Gurtekin: None. M. Papaleontiou: None. Background: Primary aldosteronism (PA) is the most common cause of endocrine hypertension, affecting up to 25% of patients with treatment-resistant hypertension. PA contributes to cardiovascular and renal morbidity and mortality, via mechanisms additive to hypertension. Early detection and targeted therapy of PA mitigate the risk of such complications. Despite this, only a minute fraction of patients at risk are ever screened for PA. Objective: To ascertain triggers and barriers for PA screening across US practices. Methods: Physicians treating hypertension, including internists, family practitioners, cardiologists, nephrologists, and endocrinologists, were randomly selected from active members of the American Medical Association. Physicians were surveyed on their practice of PA screening. Multivariable logistic regression was performed to determine factors associated with PA screening. Results: Of 633 response-eligible physicians, 425 (67%) completed the survey, including 32.4% family practitioners, 26.9% internists, 13.2% cardiologists, 12.2% endocrinologists, and 11.8% Nephrologists. Of the respondents, 230 (55.2%) were men; 63% identified as White, 24% Asian, and 6% Black. Most participants reported that resistant hypertension (84.5%), and hypertension and spontaneous hypokalemia (81.4%) prompt them to screen for PA. Conversely, a minority reported diuretic-induced hypokalemia (26%), obstructive sleep apnea (10%), or atrial fibrillation (6.2%) as triggers for PA screening. Compared with internists, endocrinologists and nephrologists were more likely, and family practitioners were less likely to screen for PA in patients with hypertension and hypokalemia, early-onset hypertension, or adrenal nodules. Barriers to PA screening included clinic visit time constraints (37.4%), poor ancillary support (28.1%), testing logistic concerns (26.2%), ability to control hypertension with medications (20.5%), and belief that PA is rare (20.2%). Female physicians and family practitioners were more likely to report not being familiar with results’ interpretation and next steps, and not having time to keep abreast with expert guidelines; private practitioners were most likely to report reimbursement concerns. Conclusions: Heterogeneity in screening for PA exists among physicians at the frontline of hypertension care. Increasing awareness and developing tools to facilitate PA screening are crucial for the recognition and adequate care of millions of patients with hypertension. Presentation: Friday, June 16, 2023

Abstract P435: Barriers For Secondary Hypertension Screening In The Us: A National Physician Survey

Background: Although US and international expert guidelines recommend screening for secondary hypertension in patients with treatment-resistant hypertension (RHTN) and other high-risk groups, screening is conducted in &lt;3% of candidates. Objective: To determine barriers for secondary hypertension screening across US practices. Participants and Measurements: Internists, family practitioners, cardiologists, nephrologists, and endocrinologists, randomly selected from active members of the American Medical Association were surveyed on barriers for secondary hypertension screening. Results: Response rate was 67% (425 of 633 response-eligible physicians). The leading reported barriers preventing secondary hypertension screening included visit time constraints (43.5%), poor ancillary support (29.4%), and testing-related logistics (27.5%). Physicians practicing in large medical groups or staff-model HMO were more likely than physicians in private practice to not have access to specialists (adjusted OR, 95% CI: 4.01 [1.19-13.47]), and to be unfamiliar with screening results interpretation and next steps (2.11 [1.03-4.32]), but less likely to report poor ancillary support (0.47 [0.28-0.79]) or reimbursement concerns (0.29 [0.13-0.63]). Primary care physicians were more likely than endocrinologists (16.67 [2.04-100.00]) and nephrologists (10.00 [1.32-100.00] to lack familiarity with testing interpretation and subsequent steps. Physicians in practices covered primarily by Medicare were more likely to report poor ancillary support (2.02 [1.16-3.53]), and lack of access to specialists (4.96 [1.04-23.52]) as compared to physicians in practices covered primarily by private health insurance. Conclusions: Our findings suggest an urgent need to address major barriers to secondary hypertension screening, including ensuring adequate clinic visit time, ancillary support, and timely access to specialists.

A Mixed-Methods Study to Evaluate the Feasibility and Acceptability of Implementing an Electronic Health Record Social Determinants of Health Screening Instrument into Routine Clinical Oncology Practice.

Routine screening for social determinants of health (SDOH) in the outpatient oncology setting is uncommon. The primary goal of this study was to prospectively evaluate the feasibility and acceptability of implementing an electronic health record (EHR) SDOH screening instrument into routine, clinical, oncology practice. Adult patients with newly diagnosed gastrointestinal cancer presenting to a regional cancer center (November 2020 to July 2021) were eligible. Based on the consolidated framework for implementation research, feasibility measures included screening completion, median clinic visit time, and acceptability by the inter-professional care team and patients as measured by semistructured, qualitative interviews and surveys. Secondary outcomes included SDOH needs identified. Of 137 eligible patients, 112 (81.8%) were screened for SDOH. Demographics of the cohort included: 41.1% black (n = 46), 48.2% rural (n = 54), 4.5% uninsured (n = 5), and 6.3% Medicaid-insured (n = 7) patients. Median visit time was 97min (95% CI 70-107min) before and 100min after implementation (95% CI 75-119min; p = 0.95). In total, 95.5% (n = 107) reported at least one SDOH need. Clinicians (7/10) reported that SDOH screening was not disruptive and were supportive of ongoing use. Patients (10/10) found the screening acceptable. Screening staff (5/5) reported workflow barriers. Patients and staff also recommended revision of specific instrument questions. Routine collection of SDOH in an outpatient oncology setting using an EHR instrument is feasible and does not result in increased visit time for patients or clinicians. However, staff perceptions of clinic workflow disruption were reported. Further investigation to determine whether standardized SDOH assessment can improve cancer care delivery and outcomes is ongoing.

The impact of the 4R Oncology model on OncotypeDx turnaround time.

531 Background: The OncotypeDx genomic assay has been widely used to predict recurrence in those with early-stage ER positive breast cancer to determine whether adjuvant chemotherapy is beneficial. Receiving OncotypeDx results in a timely manner prior to medical oncology appointment is critical to inform adjuvant therapy decisions. In this quality improvement project, we implemented a care delivery optimization for patients with breast cancer receiving OncotypeDx assays in an integrated healthcare system. The optimization was conducted as part of implementing the 4R Oncology model (Right Info / Right Care / Right Patient / Right Time), a novel care model that aims to optimize patient-centric care planning, team-based delivery and patient self-management. Herein, we assess the impact of implementing this model on improving OncotypeDx turnaround time. Methods: We examined two patient groups with newly diagnosed early-stage ER positive breast cancer who attended a multidisciplinary clinic and underwent surgery at a single medical center. The historical control (HC) group received care pre-4R implementation, from January 2019 through June 2020, while the 4R Intervention group received care from July 2020 to December 2021. The OncotypeDx-related care optimization was a team effort of 5 medical specialties that involved establishing an OncotypeDx reflex testing practice, updating workflows, working with a testing company to streamline the process and implementing a method to align result timing with scheduling medical oncology appointments. Bivariate analyses were used to compare the HC and 4R groups on demographic characteristics and OncotypeDx turnaround time. Results: Within the 4R group (N = 208), 72 (34.6%) patients received OncotypeDx and 89 (32.5%) patients from the HC cohort (N = 274) received OncotypeDx. The groups were balanced by median age at time of multidisciplinary clinic visit (HC: 59 years vs 4R: 60 years), female gender (HC: 99.6% vs 4R: 99.5%), race, combined race and ethnicity, language spoken, Charlson Comorbidity Index and tumor characteristics. The average turnaround time from surgery date to delivery of OncotypeDx results was significantly reduced in the 4R cohort (19.4 days) compared to that of the HC cohort (23.1 days), a difference of 3.8 days, p = 0.004. The availability of OncotypeDx results by the first medical oncology visit after surgery increased from 40% in the HC cohort to 69% in the 4R cohort, p = 0.0003, helping optimize the transition to adjuvant therapy for the appropriate population. Conclusions: The implementation of the 4R Oncology model within an integrated healthcare system significantly reduced turnaround time for patients with breast cancer awaiting OncotypeDx results, improving patient-centric care and enabling informed discussions at medical oncology visits. The 4R Oncology model is an effective method to optimize delivery of time-sensitive care.

The Best Method for CMV Prevention in High-risk Kidney Transplant Recipients? Either, per National Norwegian Transplant Database: Commentary on Blom et al, Cytomegalovirus High-risk Kidney Transplant Recipients Show No Difference in Long-term Outcomes Following Preemptive Versus Prophylactic Management.

The Best Method for CMV Prevention in High-risk Kidney Transplant Recipients? Either, per National Norwegian Transplant Database: Commentary on Blom et al, Cytomegalovirus High-risk Kidney Transplant Recipients Show No Difference in Long-term Outcomes Following Preemptive Versus Prophylactic Management.

Physician-Reported Barriers to Osteoporosis Screening: A Nationwide Survey

ObjectiveDespite increased awareness, osteoporosis screening rates remain low. The objective of this survey study was to identify physician-reported barriers to osteoporosis screening. MethodsWe conducted a survey of 600 physician members of the Endocrine Society, American Academy of Family Practice, and American Geriatrics Society. The respondents were asked to rate barriers to osteoporosis screening in their patients. We performed multivariable logistic regression analyses to determine correlates with the most commonly reported barriers. ResultsOf 566 response-eligible physicians, 359 completed the survey (response rate, 63%). The most commonly reported barriers to osteoporosis screening included patient nonadherence (63%), physician concern about cost (56%), clinic visit time constraints (51%), low on the priority list (45%), and patient concern about cost (43%). Patient nonadherence as a barrier was correlated with physicians in academic tertiary centers (odds ratio [OR], 2.34; 95% confidence interval [CI], 1.06-5.13), whereas clinic visit time constraints were correlated with physicians in both community-based academic affiliates and academic tertiary care ([OR, 1.96; 95% CI, 1.10-3.50] and [OR, 2.48; 95% CI, 1.22-5.07], respectively). Geriatricians (OR, 0.40; 95% CI, 0.21-0.76) and physicians with >10 years in practice were less likely to report clinic visit time constraints as a barrier (11-20 years: OR, 0.41; 95% CI, 0.20-0.85; >20 years: OR, 0.32; 95% CI, 0.16-0.65). Physicians with more patient-facing time (3-5 compared with 0.5-2 d/wk) were more likely to place screening low on the priority list (OR, 2.66; 95% CI, 1.34-5.29). ConclusionUnderstanding barriers to osteoporosis screening is vital in developing strategies to improve osteoporosis care.

P124 Rheumatoid Arthritis with Normal CRP: an Underappreciated, Persistent Phenotype: Equally at Risk of Severe Disease

Abstract Background/Aims A subset of seropositive rheumatoid arthritis (RA) with normal CRP levels during ultrasound-proven flairs was previously identified. They experienced worse outcomes, with delays in initiation of conventional DMARDs, more joint damage and higher disease activity scores, with an increased likelihood of needing biologic therapy. The aims were to longitudinally assess this group over 5 years - to determine the persistence of the phenotype and establish if differences in outcome were sustained; and to estimate the prevalence of this phenotype among the wider seropositive RA cohort at UCLH. Methods The initial study described two groups: those with high CRP during flare (hCRP) and those with normal CRP during flare (nCRP). The electronic health records of the initial cohort were interrogated. CRP measurements at 1-, 2- and 5-years post recruitment were collated. Clinical notes were examined to determine if episodes of raised CRP were due to RA activity, or alternative causes. Because of its CRP lowering properties, patients on Tocilizumab were excluded from this analysis. To screen for the nCRP phenotype in the larger population, DAS-28-CRP results were analysed from the 312 most recently reviewed patients in the UCLH seropositive RA database (data extracted 8th October 2019). The clinic letter from the time of the CRP value was examined, and patients were defined as having active disease if DAS-28 &amp;gt; 4.5. Results Patients classified as nCRP at initial recruitment continued to have lower CRP (nCRP group median 1.1, maximum 6.4, hCRP group median 4, maximum 55.2, P = 0.0117). 1 patient originally classified as nCRP had a result &amp;gt;5 at 5 years (6.4). Among the original cohort, at 5 years, patients originally defined as nCRP were more likely to require a biologic (76.67%) than hCRP (44.4%) (P = 0.0324). There was no significant difference in DAS-28 scores between groups at 5 years (hCRP median 3.2, nCRP median 2.9 P = 0.8775) . Patients with nCRP phenotype were as likely to have erosive disease as those in the hCRP cohort (hCRP 66.67%, nCRP 56.52%, P = 0.7356). Among the larger sample of 312 patients, 28 had CRP levels &amp;lt; 5 and DAS-28 &amp;gt;4.5. Of these, on longitudinal analysis of CRP at the time of clinic visits, 16/28 never mounted a CRP in response to active arthritis - likely the most representative of the nCRP patients from the original ultrasound cohort. These data suggest the nCRP phenotype represents at least 5% of the seropositive rheumatoid arthritis cohort at UCLH. Conclusion The subgroup of patients exhibiting normal CRP levels during disease flair maintain this phenotype over time. They remain more likely to require biologic treatment, while having equivalent DAS-28 scores and risk of damage to hCRP patients. Their presence as a significant minority of the wider population has implications for clinical care and resource use. Disclosure M. Hutchinson: None. B. Sethi: None. G. Sritharan: None. B. Greenaway: None. E. Jury: None. J. Manson: None.

MP48-09 LEVERAGING IMPLEMENTATION SCIENCE TO SUCCESSFULLY SCALE A SHARED DECISION MAKING PROGRAM FOR MEN WITH PROSTATE CANCER

You have accessJournal of UrologyCME1 Apr 2023MP48-09 LEVERAGING IMPLEMENTATION SCIENCE TO SUCCESSFULLY SCALE A SHARED DECISION MAKING PROGRAM FOR MEN WITH PROSTATE CANCER Jonathan Bergman, David Penson, David Ho, Lorna Kwan, Kristen Williams, Jefersson Villatoro, and Christopher Saigal Jonathan BergmanJonathan Bergman More articles by this author , David PensonDavid Penson More articles by this author , David HoDavid Ho More articles by this author , Lorna KwanLorna Kwan More articles by this author , Kristen WilliamsKristen Williams More articles by this author , Jefersson VillatoroJefersson Villatoro More articles by this author , and Christopher SaigalChristopher Saigal More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003294.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Shared decision making (SDM) is recommended for men with prostate cancer. Implementation of SDM has proved challenging. We aimed to use the tools of implementation science to identify factors key to implementation of a successful SDM program at one institution to two new institutions with differing patient populations, including in the safety net. We also measured comparative effectiveness of the decision aid across populations. METHODS: As part of the Consolidated Framework for Implementation, we used the MUSIQ tool to assess readiness for implementation at UCLA, Vanderbilt, and Olive View-UCLA (OVMC), a large safety-net institution. We used MUSIQ scores to guide pre-implementation changes at each site. We then implemented the SDM program at new sites. The program featured a decision aid (DA) which quantified individual preferences for competing treatment outcomes, and used decision analysis to provide patients and physicians with a rank ordered list of evidence-based treatments. Statistical Control Process charts were used to track implementation outcomes and guide the need for interventions to improve outcomes. Decision quality outcomes were collected using a post-consult survey. We evaluated implementation outcomes and differences in decision quality among men at the different sites. RESULTS: MUSIQ scores were high (144, 157, and 117 out of 168 at OVMC, UCLA, and Vanderbilt, respectively), and guided pre-implementation efforts at each site. Modifications were made at each site to facilitate implementation, such as delivery of the DA in the waiting room at OVMC. Implementation outcomes were strong and preserved from the original site. Adoption among physicians was 100%. Penetration (invitation rate) and Fidelity (completion rate) were similar in academic and safety net settings (66% vs 60%, p=0.4 and 77% vs 80%, p=0.7, respectively; N=1909). At OVMC, implementation led to lower median time spent with a physician (24 minutes after implementation vs 33 minutes before, p=0.01) and a decrease in the percentage of patients who needed more than one urology clinic visit to make a treatment decision (13% vs 46%, p<0.001). Decisional quality was excellent across all sites, with high scores for satisfaction and sense of shared decision-making; post visit decisional conflict was higher at the safety net site (Table). CONCLUSIONS: Scaling a SDM program is feasible using the tools of implementation science, leading to preserved effectiveness across a variety of patient populations. SDM programs can save clinic visit time. Source of Funding: PCORI © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e658 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jonathan Bergman More articles by this author David Penson More articles by this author David Ho More articles by this author Lorna Kwan More articles by this author Kristen Williams More articles by this author Jefersson Villatoro More articles by this author Christopher Saigal More articles by this author Expand All Advertisement PDF downloadLoading ...

Validation of an outpatient questionnaire for bronchopulmonary dysplasia control.

Despite bronchopulmonary dysplasia (BPD) being a common morbidity of preterm birth, there is no validated objective tool to assess outpatient respiratory symptom control for clinical and research purposes. Data were obtained from 1049 preterm infants and children seen in outpatient BPD clinics of 13 US tertiary care centers from 2018 to 2022. A new standardized instrument was modified from an asthma control test questionnaire and administered at the time of clinic visits. External measures of acute care use were also collected. The questionnaire for BPD control was validated in the entire population and selected subgroups using standard methodology for internal reliability, construct validity, and discriminative properties. Based on the scores from BPD control questionnaire, the majority of caregivers (86.2%) felt their child's symptoms were under control, which did not differ by BPD severity (p = 0.30) or a history of pulmonary hypertension (p = 0.42). Across the entire population and selected subgroups, the BPD control questionnaire was internally reliable, suggestive of construct validity (albeit correlation coefficients were -0.2 to -0.4.), and discriminated control well. Control categories (controlled, partially controlled, and uncontrolled) were also predictive of sick visits, emergency department visits, and hospital readmissions. Our study provides a tool for assessing respiratory control in children with BPD for clinical care and research studies. Further work is needed to identify modifiable predictors of disease control and link scores from the BPD control questionnaire to other measures of respiratory health such as lung function testing.

PS-C31-4: METABOLIC RISK FACTORS DIFFER IN OBESE CHILDREN AND ADOLESCENTS FROM RURAL VERSUS NON-RURAL REGIONS

Objective: The obesity rate in children is rising in the United States, and this is particularly true in children located in rural regions. Rural communities are at greater risk for health disparities, such as metabolic disease, due to socioeconomic factors and access to food and healthcare. Previous studies in rural youth have focused on lifestyle intervention and behavior modification to improve obesity rates. However, there are limited studies comparing clinical parameters of metabolic disease in rural versus non-rural regions in youth. The objective of this study was to examine blood markers of glucose and lipid status among rural vs non-rural adolescents to identify risk factors for metabolic disease. Design and method: This is a single timepoint pilot study of n = 82 children and adolescents ages 6–17 recruited from a Pediatric High BMI Clinic. Subjects were grouped according to region: rural (n = 12), micropolitan (n = 20), and metropolitan (n = 50). Weight, adiposity, clinical data, and blood samples were collected at the time of initial clinic visit. Data were analyzed via one-way ANOVA. Results: BMI and waist circumference (WC) was highest in rural subjects (BMI - rural: 38.5 ± 5.4 versus micropolitan: 37.7 ± 9.1 versus metropolitan: 33.5 ± 5.5 kg/m2; P &lt; 0.05. WC - rural: 116 ± 12.5 versus micropolitan: 115.1 ± 19.8 versus metropolitan: 105.2 ± 15.6 cm; P &lt; 0.05). In contrast, there was no difference in markers of glucose homeostasis or lipids between regions. Serum concentrations of 25(OH)D3 were different among groups, with the lowest in subjects from the metropolitan area, and highest in the rural area (rural: 34.9 ± 9.6; micropolitan: 30.2 ± 9.7; metropolitan: 23.0 ± 9.3 ng/mL; P &lt; 0.001). Conclusions: In agreement with literature, adiposity was greatest in subjects living in non-metropolitan areas. However, this was not associated with elevated markers of metabolic risk, and rural subjects had the greatest serum vitamin D3 concentrations. Further understanding of differences in lifestyle in rural versus non-rural areas may improve opportunities for targeted health interventions.

0835 Substance Abuse, An Important Factor in the Evaluation of Hypersomnia Disorders

Abstract Introduction A detailed history is essential in the diagnostic workup of hypersomnia, but can be limited by withheld information. A common piece of information hidden during a detailed history is the presence of substance abuse/use. AASM guidelines dictate an MSLT study must be conducted in patients free from certain psychoactive medications. The guidelines mention these therapies be stopped at least 2 weeks prior to the planned study date and recommend utilizing an urinary drug screen to evaluate patients who undergo the study. From review of the available literature, substance abuse has significant effects upon sleep architecture and the development of hypersomnia. Certain substances such as stimulants may normalize a disorder of hypersomnolence and the opposite holds true for sedatives and depressants. Report of Cases: Mr. RB, a 52-year-old Veteran with a medical history inclusive of hypertension, DM2, cocaine abuse and hypersomnia. Initial workup demonstrated presence of OSA (AHI 16.4, O2 nadir 87%). After diagnosing and treating OSA, Mr. RB returned to clinic with complaints of persistent hypersomnia. Mr. RB was then evaluated by MSLT study for further assessment. Patient reported absence of cocaine use at time of clinic visit and prior to study. The results of the MSLT demonstrate MSL of 0.5 minutes and 3/4 SOREMs. Unfortunately, UDS verified Mr. RB had recently used cocaine (581 ng/mL). Mr. RB was then followed up in clinic due to persistent symptoms, with new reports of cataplexy, hypnopompic hallucination and sleep paralysis. Mr. RB also reported abstaining from cocaine use. A repeat MSLT was performed with MSL of 1.2 minutes and 3/5 SOREMS. Unfortunately, Mr. RB was again found to have recently used cocaine (441 ng/mL) on UDS. Mr. RB was then lost to follow-up. Conclusion This case demonstrates the importance of obtaining a truthful history during the evaluation of a sleep disorder. This case also demonstrates the utility of verifying the history obtained with laboratory testing. During this case, the physicians working with Mr. RB demonstrated detailed note documentation regarding reports of cocaine abstinence which was later disproven during the drug screening during the sleep study and follow up clinic appointment. Support (If Any) 1. Angarita, G. A., Emadi, N., Hodges, S., &amp; Morgan, P. T. (2016). Sleep abnormalities associated with alcohol, cannabis, cocaine, and opiate use: A comprehensive review. Addiction Science &amp; Clinical Practice, 11(1). https://doi.org/10.1186/s13722-016-0056-72. Anniss, A. M., Young, A., &amp; O'Driscoll, D. M. (2016). Importance of urinary drug screening in the multiple sleep latency test and maintenance of wakefulness test. Journal of Clinical Sleep Medicine, 12(12), 1633–1640. https://doi.org/10.5664/jcsm.63483. Dzodzomenyo, S., Stolfi, A., Splaingard, D., Earley, E., Onadeko, O., &amp; Splaingard, M. (2015). Urine toxicology screen in multiple sleep latency test: The correlation of positive tetrahydrocannabinol, drug negative patients, and narcolepsy. Journal of Clinical Sleep Medicine, 11(02), 93–99. https://doi.org/10.5664/jcsm.44484. Krahn, L. E., Arand, D. L., Avidan, A. Y., Davila, D. G., DeBassio, W. A., Ruoff, C. M., &amp; Harrod, C. G. (2021). Recommended protocols for the multiple sleep latency test and maintenance of wakefulness test in adults: Guidance from the American Academy of Sleep Medicine. Journal of Clinical Sleep Medicine, 17(12), 2489–2498. https://doi.org/10.5664/jcsm.96205.Roehrs, T. A., &amp; Roth, T. (2015). Sleep disturbance in substance use disorders. Psychiatric Clinics of North America, 38(4), 793–803. https://doi.org/10.1016/j.psc.2015.07.0086. emasinghe Bandaralage, S., Sriram, B., Rafla, M., Sharma, N., &amp; McWhae, S. (2021). P130 an audit of urinary drug screening use in multiple sleep latency and maintenance of wakefulness testing in an australian tertiary centre. SLEEP Advances, 2(Supplement_1). https://doi.org/10.1093/sleepadvances/zpab014.171

Bioimpedance Spectroscopy Offers An Objective Measure Of Heart Failure Stability During A Viral Pandemic

Introduction: Given the ongoing Covid-19 pandemic, shortness of breath (SOB) has increased as the chief complaint reported by patients. Viral pneumonia, telehealth, and the rising incidence of heart failure (HF) have driven the need for objective measures for wellness and congestion. Misclassification of congestion and delay in diuretics have been a concern by cardiologists across a variety of health care settings. We report the likelihood of a bioimpedance spectroscopy (BIS) measurement, specifically the Heart Failure Index (HF-Dex), to match patient perceived change since previous clinic visit.Background: BIS provides an objective measure of fluid levels. A recent publication reported the median HF-Dex value for patients with HF was 48.8%, in comparison to a healthy population whose median HF-Dex was 44.8%. Further research showed that HF patients with a value >51% had an odds ratio (OR) of 4.25 for readmission within 45 days.Methods: Fifty-six (56) HF patients were enrolled, during the Covid-19 pandemic, at their routine HF clinic appointment. Perceived change in status since last visit was reported as either no change, improved, or worsening symptoms. We assessed medication changes at time of clinic visit. HF-Dex values were obtained but were not made available to the treating physician. Based on a healthy control value of 44.8%, we applied a 45% threshold below which patients were considered stable from an HF perspective. A cut-point of ≥51% was used to determine the likelihood of medication changes and diuretic up dosing in the current study.Results: Seven (7) of 56 patients had an HF-Dex of 45% or below; none of these patients had an intensification of diuretic dosing or reported worsening symptoms. Twenty-one (21) patients had a measure of 51% or more, of whom 6 reported worsening symptoms prior to their exam for an odds ratio (OR) of 6.6 (95%CI: 1.2-36, p=0.03). The OR for any medication change in the ≥51% group of HF patients was 4.5 (95%CI: 1.1-18, p=0.03). Looking strictly at diuretic change, there was an OR of 3.6 (95%CI: 1.1-12.0, p=0.03).Conclusions: BIS measures provide a unique objective data point to aid in pretest probability for congestion. Patients with a HF-Dex of ≥51% required higher rates of medication and diuretic changes. Subjectively, HF patients at ≥51% also felt worse which may help limit misclassification of congestion when SOB is the chief complaint. Conversely, patients at <45% had fewer diuretic dose changes and felt better overall. The ability to quantify congestion may assist in triage of patients presenting with SOB, as has increasingly been the case during the Covid-19 pandemic in clinic and acute care settings.