University-based Health System Research Articles

Effect of Minimally Invasive Gastrectomy on Return to Intended Oncologic Therapy for Gastric Cancer.

Adjuvant chemotherapy offers survival benefit to patients with gastric cancer. Only 50-65% of patients who undergo neoadjuvant chemotherapy and gastrectomy are able to receive adjuvant therapy. It is optimal to start adjuvant therapy within 8weeks after gastrectomy. We compared the rate of return to intended oncologic therapy (RIOT) between minimally invasive gastrectomy (MIG) and open gastrectomy (OG). Retrospectively, we analyzed patients who underwent gastrectomy within a multi-hospital university-based health system (2019-2022). Data on patient demographics, comorbid conditions, operative approach, and postoperative outcomes were assessed with univariate analysis and multivariable analysis (MVA) to determine the association with RIOT. Among 87 eligible patients, 33 underwent MIG and 54 underwent OG. There were no differences in demographics, performance status, comorbid conditions, or type of gastrectomy between the two groups. MIG patients were significantly more likely to RIOT compared with OG patients (87.9% vs. 63%, p=0.003), with 73.1% of MIG patients starting adjuvant therapy within 8weeks compared with 53.1% of OG patients. Factors associated with higher odds of RIOT included MIG and age <65years, while major postoperative complications (Clavien-Dindo grade ≥IIIa) was associated with lower odds of RIOT. On MVA, MIG was independently associated with higher odds of RIOT compared with OG (odds ratio 6.05, 95% confidence interval 1.47-24.78, p=0.008). The minimally invasive approach may benefit patients undergoing gastrectomy, irrespective of the extent of gastric resection for adenocarcinoma. MIG is associated with a higher likelihood of (1) RIOT and (2) starting adjuvant therapy within the optimal time period after gastrectomy.

Impact of the COVID-19 Pandemic on Foodborne Disease Healthcare-Seeking Behavior and Diagnoses at a Large Academic Medical System.

The objective of this study was to examine changes in healthcare-seeking behaviors and diagnostic practices around foodborne illness during the COVID-19 pandemic in a large university-based health system. A retrospective cohort study of individuals diagnosed with pathogens commonly transmitted through food between 2015 and 2020 was undertaken using electronic medical record data. Regression models were used to compare measured incidence rates of various foodborne pathogens as well as associated healthcare-seeking behaviors during the pandemic year of 2020 to previous years. Incidence of campylobacteriosis, cholera, and norovirus in 2020 significantly decreased, respectively, by 65.5% (p < 0.01), 90.1% (p = 0.02), and 73.0% (p = 0.03) compared with an average from 2017- to 019. Average annual visits for patients included in our sample significantly increased by 8.0% when comparing the average from 2017-2019 to 2020 (p < 0.01). These results suggest that the pandemic impacted healthcare use related to foodborne disease either due to reduced exposure to foodborne pathogens or reduced willingness to seek healthcare.

Cannabis Use Reported by Patients Receiving Primary Care in a Large Health System

Despite the changing legal status of cannabis and the potential impact on health, few health systems routinely screen for cannabis use, and data on the epidemiology of cannabis use, and especially medical cannabis use among primary care patients, are limited. To describe the prevalence of, factors associated with, and reasons for past-3 month cannabis use reported by primary care patients. This cross-sectional study used electronic health record data from patients aged 18 years and older who had an annual wellness visit between January 2021 and May 2023 from a primary care clinic within a university-based health system in Los Angeles, California. Factors of interest included age, race and ethnicity, sex, employment status, and neighborhood Area Deprivation Index (ADI). Cannabis use was assessed using the Alcohol Substance Involvement Screening Test (ASSIST). Patients were also asked about reasons for use, symptoms for which they used cannabis, and mode of use. Among the 175 734 patients screened, the median (range) age was 47 (18-102) years; 101 657 (58.0%) were female; 25 278 (15.7%) were Asian, 21 971 (13.7%) were Hispanic, and 51 063 (31.7%) were White. Cannabis use was reported by 29 898 (17.0%), with 10 360 (34.7%) having ASSIST scores indicative of moderate to high risk for cannabis use disorder (CUD). Prevalence of cannabis use was higher among male patients than female patients (14 939 [20.0%] vs 14 916 [14.7%]) and younger patients (18-29 years, 7592 [31.0%]; ≥60 years, 4200 [8.5%]), and lower among those who lived in the most disadvantaged neighborhoods (ADI decile 9-10, 189 [13.8%]; ADI decile 1-2, 12 431 [17.4%]). The most common modes of use included edibles (18 201 [61.6%]), smoking (15 256 [51.7%]), and vaporizing (8555 [29.0%]). While 4375 patients who reported using cannabis (15.6%) did so for medical reasons only, 21 986 patients (75.7%) reported using cannabis to manage symptoms including pain (9196 [31.7%]), stress (14 542 [50.2%]), and sleep (16 221 [56.0%]). The median (IQR) number of symptoms managed was 2 (1-4), which was higher among patients who were at moderate to high risk for CUD (4 [2-6] symptoms). In this study, cannabis use and risk of CUD were common, and more than three-quarters of patients who reported any cannabis use reported doing so to manage a health-related symptom. These findings suggest that integration of information regarding cannabis use for symptom management could help provide a crucial point-of-care opportunity for clinicians to understand their patients' risk for CUD.

Assessment of the utilization of real-time prescription benefits for patient cost savings within an outpatient setting

BackgroundThis study evaluates the impact of Real-Time Prescription Benefits (RTPB), a tool integrated into electronic health records (EHRs), on patient out-of-pocket costs in an academic institution. RTPB provides prescribers with alternative, less expensive medications based on insurance plans. The primary measure was cost-savings, defined as the difference between the out-of-pocket cost of the prescribed medication and its alternative. MethodsA retrospective analysis of prescriptions from outpatient clinics in a university-based health system was conducted between May 2020 and July 2021. Prescriptions were analyzed at the 2nd level of the Anatomical Therapeutic Chemical (ATC) classification system. Costs were standardized to a 30-day supply. Standardized cost and total cost per prescription, and overall savings for the top 20 medication classes at the 2nd ATC level were calculated. The overall impact of RTPB was estimated based on selecting the least expensive alternative suggested by RTPB. ResultsThe study found that RTPB information was provided for 22% of prescriptions, with suggested alternatives for 1.26%. Among prescriptions with an alternative selected, the standardized average cost saving was $38.83. The study realized $15,416 in patient total cost savings. If the least expensive RTPB-suggested alternative were chosen for all prescriptions, an estimated $276,386 could have been saved. Psychoanaleptic and psycholeptic medications were the most prescribed with an alternative, with most savings in specialty drugs like anthelmintic and immunostimulant medications. ConclusionThe study highlights the importance of RTPB in reducing patient costs. It reports patient cost-savings with RTPB in prescribing decisions. Future research could explore the impact of RTPB on medication adherence using pharmacy claims data.

The effects of osteopathic manipulative treatment on pain and disability in patients with chronic low back pain: a single-blinded randomized controlled trial.

The evidence for the efficacy of osteopathic manipulative treatment (OMT) in the management of low back pain (LBP) is considered weak by systematic reviews, because it is generally based on low-quality studies. Consequently, there is a need for more randomized controlled trials (RCTs) with a low risk of bias. The objective of this study is to evaluate the efficacy of an OMT intervention for reducing pain and disability in patients with chronic LBP. A single-blinded, crossover, RCT was conducted at a university-based health system. Participants were adults, 21-65 years old, with nonspecific LBP. Eligible participants (n=80) were randomized to two trial arms: an immediate OMT intervention group and a delayed OMT (waiting period) group. The intervention consisted of three to four OMT sessions over 4-6weeks, after which the participants switched (crossed-over) groups. The primary clinical outcomes were average pain, current pain, Patient-Reported Outcomes Measurement Information System (PROMIS)29 v1.0 pain interference and physical function, and modified Oswestry Disability Index (ODI). Secondary outcomes included the remaining PROMIS health domains and the Fear Avoidance Beliefs Questionnaire (FABQ). These measures were taken at baseline (T0), after one OMT session (T1), at the crossover point (T2), and at the end of the trial (T3). Due to the carryover effects of OMT intervention, only the outcomes obtained prior to T2 were evaluated utilizing mixed-effects models and after adjusting for baseline values. Totals of 35 and 36 participants with chronic LBP were available for the analysis at T1 in the immediate OMT and waiting period groups, respectively, whereas 31 and 33 participants were available for the analysis at T2 in the immediate OMT and waiting period groups, respectively. After one session of OMT (T1), the analysis showed a significant reduction in the secondary outcomes of sleep disturbance and anxiety compared to the waiting period group. Following the entire intervention period (T2), the immediate OMT group demonstrated a significantly better average pain outcome. The effect size was a 0.8 standard deviation (SD), rendering the reduction in pain clinically significant. Further, the improvement in anxiety remained statistically significant. No study-related serious adverse events (AEs) were reported. OMT intervention is safe and effective in reducing pain along with improving sleep and anxiety profiles in patients with chronic LBP.

Epidemiology and Clinical Outcomes of Community-Acquired Acute Kidney Injury in the Emergency Department: A Multisite Retrospective Cohort Study

The prevalence of community-acquired acute kidney injury (CA-AKI) in the United States and its clinical consequences are not well described. Our objective was to describe the epidemiology of CA-AKI and the associated clinical outcomes. Retrospective cohort study. 178,927 encounters by 139,632 adults at 5 US emergency departments (EDs) between July 1, 2017, and December 31,2022. CA-AKI identified using KDIGO (Kidney Disease: Improving Global Outcomes) serum creatinine (Scr)-based criteria. For encounters resulting in hospitalization, the in-hospital trajectory of AKI severity, dialysis initiation, intensive care unit (ICU) admission, and death. For all encounters, occurrence over 180 days of hospitalization, ICU admission, new or progressive chronic kidney disease, dialysis initiation, and death. Multivariable logistic regression analysis to test the association between CA-AKI and measured outcomes. For all encounters, 10.4% of patients met the criteria for any stage of AKI on arrival to the ED. 16.6% of patients admitted to the hospital from the ED had CA-AKI on arrival to the ED. The likelihood of AKI recovery was inversely related to CA-AKI stage on arrival to the ED. Among encounters for hospitalized patients, CA-AKI was associated with in-hospital dialysis initiation (OR, 6.2; 95% CI, 5.1-7.5), ICU admission (OR, 1.9; 95% CI, 1.7-2.0), and death (OR, 2.2; 95% CI, 2.0-2.5) compared with patients without CA-AKI. Among all encounters, CA-AKI was associated with new or progressive chronic kidney disease (OR, 6.0; 95% CI, 5.6-6.4), dialysis initiation (OR, 5.1; 95% CI, 4.5-5.7), subsequent hospitalization (OR, 1.1; 95% CI, 1.1-1.2) including ICU admission (OR, 1.2; 95% CI, 1.1-1.4), and death (OR, 1.6; 95% CI, 1.5-1.7) during the subsequent 180 days. Residual confounding. Study implemented at a single university-based health system. Potential selection bias related to exclusion of patients without an available baseline Scr measurement. Potential ascertainment bias related to limited repeat Scr data during follow-up after an ED visit. CA-AKI is a common and important entity that is associated with serious adverse clinical consequences during the 6-month period after diagnosis. Acute kidney injury (AKI) is a condition characterized by a rapid decline in kidney function. There are many causes of AKI, but few studies have examined how often AKI is already present when patients first arrive to an emergency department seeking medical attention for any reason. We analyzed approximately 175,000 visits to Johns Hopkins emergency departments and found that AKI is common on presentation to the emergency department and that patients with AKI have increased risks of hospitalization, intensive care unit admission, development of chronic kidney disease, requirement of dialysis, and death in the first 6 months after diagnosis. AKI is an important condition for health care professionals to recognize and is associated with serious adverse outcomes.

Assessing the Immunization Information System and electronic health record interface accuracy for COVID-19 vaccinations.

Our objective is to assess the accuracy of the COVID-19 vaccination status within the electronic health record (EHR) for a panel of patients in a primary care practice when manual queries of the state immunization databases are required to access outside immunization records. This study evaluated COVID-19 vaccination status of adult primary care patients within a university-based health system EHR by manually querying the Kansas and Missouri Immunization Information Systems. A manual query of the local Immunization Information Systems for 4114 adult patients with "unknown" vaccination status showed 44% of the patients were previously vaccinated. Attempts to assess the comprehensiveness of the Immunization Information Systems were hampered by incomplete documentation in the chart and poor response to patient outreach. When the interface between the patient chart and the local Immunization Information System depends on a manual query for the transfer of data, the COVID-19 vaccination status for a panel of patients is often inaccurate.

Factors associated with appropriate administration of magnesium sulfate for neuroprotection prior to early preterm birth

To evaluate factors associated with appropriate administration of magnesium sulfate (MgSO4) for fetal neuroprotection prior to preterm birth (PTB) in a large United States university-based health system. Multicenter retrospective cohort of all PTBs between 23 0/7-31 6/7 weeks’ gestation from 1/1/2019 to 12/31/21. Exclusion criteria included patients with hypertensive disorders of pregnancy (to assure only indication for MgSO4 administration was fetal neuroprotection and not maternal seizure prophylaxis), stillbirths, higher-order multiple gestations, and extramural deliveries. Cases were stratified into two groups based on whether MgSO4 was administered prior to PTB or not. Maternal characteristics were compared between the two groups using Chi-squared or Mann-Whitney U test with statistical significance set at P < 0.05. A subgroup analysis evaluating reasons for lack of administration in those who did not receive MgSO4 prior to delivery was also performed. Of the 527 patients included, 438 (83.1%) received MgSO4 prior to delivery. Baseline characteristics and delivery outcomes compared between the two groups are displayed in Table 1. Patients who did not receive MgSO4 prior to delivery were more commonly admitted for fetal status abnormalities and non-obstetric complaints, and had a significant shorter median time interval from arrival to delivery (1.5 hours vs. 59.0 hours, P = < 0.001) (Table 1). Lack of adherence to health system protocol for MgSO4 administration occurred in 16.9% (15/89, 2.8% of overall study cohort) of patients who did not receive MgSO4 prior to delivery (Table 2). The overall adherence to a protocol of MgSO4 administration for fetal neuroprotection prior to early PTB was high. Admission for fetal status abnormalities and non-obstetric complaints were more common among patients who did not receive MgSO4 prior to delivery, with most patients who did not receive MgSO4 either arrived < 2 hours from delivery or had an acute change in maternal/fetal status requiring immediate delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Strategies to Sustain Quality Interventions: Case Examples of Chlorhexidine Gluconate Bathing.

Strategies to Sustain Quality Interventions: Case Examples of Chlorhexidine Gluconate Bathing.

Patterns of treatment and survival outcomes with use of neoadjuvant chemotherapy in ovarian cancer (481)

Patterns of treatment and survival outcomes with use of neoadjuvant chemotherapy in ovarian cancer (481)

A new expert system with diagnostic accuracy for pediatric upper respiratory conditions

The high prevalence of pediatric upper respiratory conditions combined with poor availability of specialized care for the proper diagnosis of these diseases continues to be a significant cause of morbidity and mortality worldwide. Despite advances in computer-assisted diagnosis, there are no automated triage tools that can effectively provide a first step guide for the parents or cognitive assistance for the care providers to improve the efficacy and accuracy of diagnosis in these children. We propose a new approach to designing expert systems using an integration of logical criteria and variable evoking strength to improve these tools’ diagnostic accuracy. We conducted a retrospective chart review of the electronic health records of children evaluated for several upper respiratory conditions at a large university-based health system in the United States. The diagnoses recorded in the charts were compared to the output from the tool. The accuracy rate of the tool was based on the assumption that human physicians are the gold standard of diagnosis. A total of 138 cases, ranging in age between 6 months to 18 years, were reviewed. Forty-three percent of the participants self-identified as female. The average accuracy of the tool in matching the physician diagnosis of the eight types of upper respiratory conditions that were included in this study was 75% for the first diagnosis and 84% for matching one of the top two differential diagnoses. Integration of logical diagnostic criteria and variable evoking strength into the design of expert systems can significantly improve the diagnostic accuracy of these tools.

Behavioral Health for the Front Line: Lessons from the Covid-19 Pandemic

Summary A large, university-based health system reorganized and expanded its behavioral health services to respond to the special needs of health care workers, students, faculty, patients, and caregivers across the Covid-19 pandemic. While patient services did not require much structural change, mental health support for employees, specifically frontline health care workers, required significant development. The Department of Psychiatry and Human Behavior, along with HR, launched a wide variety of mental health offerings at different levels of engagement beginning in March 2020. They adopted a four-tiered “pyramid” approach, with self-care resources (Tier 1) at the base; Tier 2 programs to teach supervisors how to support their employees; Tier 3 programs for peer support; and professional therapy at Tier 4. Most of the program development efforts targeted Tiers 1 and 3. Tier 1 self-care resources were well used, but Tier 3 group and individual support programs struggled with scheduling issues. They relaunched several programs in summer 2020 by moving scheduling responsibility to team leaders and managers, who were better able to determine the needs of their employees and the best times for everyone to gather. They adapted the programs to large-group and workshop formats. They established behavioral health liaisons for larger teams and departments to coordinate requests for services. They created four specialty targeted partnerships with the cancer center, the student counseling center, a new assisted coping program for health care providers, and institutional leadership, which has adopted mental health and wellness as a top priority.

Assessment of Perceptions of Professionalism Among Faculty, Trainees, Staff, and Students in a Large University-Based Health System

With a renewed focus on medical professionalism, an opportunity exists to better define its standards and application to meet the needs of an increasingly diverse workforce given the important association between interprofessional behavior and patient care. To examine the context of how professionalism is operationalized and perceived in diverse health care work and learning environments. A qualitative mixed-methods analysis of survey data collected from February to April 2015, was conducted followed by analysis of narrative data collected in June 2017. The setting was 2 health systems and 4 health professional and graduate schools. Participants were faculty, trainees, staff, and students (3506 survey respondents and 52 narratives) affiliated with the University of Pennsylvania and the University of Pennsylvania Health System. Data analysis was conducted in 2018 and 2019. Independent variables included the following respondent characteristics: gender identity, sexual orientation, race/ethnicity, position, generational age group, length of employment at institution, disability status, belief system or religion, and primary site of work or study. Survey questions were used to assess participants' perception and experiences of professionalism in the workplace as measured by a 5-point Likert-type scale. For the survey, there were 3506 respondents from a pool of 18 550 potential respondents (18.9% response rate). Of 3506 survey respondents, 2082 of 3231 (64.4%) were women, 331 of 3164 (10.5%) identified as gender or sexual minority groups, and 360 of 3178 (11.3%) were non-Hispanic Black individuals. In adjusted analyses, women compared with men (adjusted odds ratio [aOR], 1.8; 95% CI, 1.4-2.3) and Asian individuals (aOR, 2.0; 95% CI, 1.7-2.3) and Hispanic individuals (aOR, 2.0; 95% CI, 1.4-2.7) compared with non-Hispanic White individuals were more likely to value institutional professionalism. In addition, gender identity and sexual minority groups compared with heterosexual respondents (aOR, 1.5; 95% CI, 1.2-1.8) and non-Hispanic Black individuals compared with non-Hispanic White individuals (aOR, 1.3; 95% CI, 1.2-1.4) were statistically significantly more likely to consider changing jobs because of unprofessional behavior at work. The qualitative analysis of narratives revealed that marginalized populations (including but not limited to women, gender and sexual minority groups, racial/ethnic minority groups, those who identify as having a disability, and religious minority groups) reported (1) greater infringements on their professional boundaries, as well as increased scrutiny over their professional actions, and (2) a tension between inclusion vs assimilation. The findings of this study highlight the need for health care organizations to revisit how they define and operationalize professionalism to improve inclusivity.

S1250 Telemedicine Use Among Gastroenterologists During the COVID-19 Pandemic: Recent Experience and Projection for Future Utility

INTRODUCTION: Telemedicine has become an essential tool that allowed physicians to continue to provide care during the coronavirus disease 2019 (COVID-19) pandemic. The use of telemedicine among gastroenterologists has peaked recently but questions remain regarding the future implication of this technology within the field. We aimed to evaluate providers' experience with telemedicine in a large academic health system with a broad geographic reach and quantify variations and factors that influenced this experience. METHODS: We developed a 22-item survey instrument based on literature review, conceptual models of physician behavior, pilot testing by colleagues and discussions with academic and community gastroenterologists. The survey was emailed to practicing providers in the Division of Digestive Diseases at a major university-based health system. RESULTS: Thirty-five out of 83 (41%) gastroenterologists responded to the survey within the first week of distribution, of whom 32% were female, and 68% were ≤44 years old. Sixty-four percent practiced general gastroenterology, 59% have been in practice for ≥10 years, and 18% for ≥20 years. The majority reported positive (46%) and very positive (29%) experience, and only 6% reported a negative experience with telemedicine. 63% felt telemedicine was more efficient than traditional visits, and 58% consider adding telemedicine visits between endoscopic procedures. Lack of physical exam was felt to be critical in 27%, and 25% thought in-person visits would change management plan compared to telemedicine. Age or gender were not associated with having a positive providers’ experience {74% for age <45 vs. 73% for age >45, P = 0.940; 82% for female vs. 70% for male; P = 0.68}. Similarly, the importance of physical exam was not associated with age (22% vs. 36%, P = 0.4), gender (18% for female vs. 30% for male, P = 0.6), or years of experience (36% for < 10 years vs. 20% for ≥10 years; P = 0.1). 91% plan to integrate telemedicine into practice after the COVID-19 outbreak; however two-thirds stated they will use it only if appropriate insurance payment, equal to office visits, is provided. CONCLUSION: The emerging use of telemedicine among gastroenterologists is perceived as a positive experience. The vast majority of our survey participants plan to integrate telemedicine into routine practice following the COVID-19 pandemic. Future efforts should focus on improving the technology’s user interface, overcoming billing/payment hurdles, and techniques to compensate for the lack of physical examination.Table 1.: Participants main characteristics and practice patternsTable 2.: Survey items and respondents feedback on clinical aspects of telemedicine use during the COVID-19 pandemicFigure 1.: Providers' overall experience and perceived patients' overall experience with telemedicine use during the COVID-19 pandemic.

Popularity and worldwide reach of targeted, evidence-based internet streaming video interventions focused on men's health topics.

Streaming video has emerged as a dominant content-delivery medium for healthcare information, with over 30 million visitors daily to the YouTube platform alone. Videos related to men’s health have proliferated, but content produced by trained health care providers remains scarce. We evaluated educational YouTube streaming videos created in collaboration with a large, university-based health system focused on male factor infertility, men’s health, and Peyronie’s disease, uploaded during 2016–2018. All videos featured a board-certified urologist with fellowship training in andrology. Using YouTube’s native analytics tools, we extracted data on views, engagement, and geographic reach through 8/2019. We obtained data for streaming videos on male infertility (n=3), general men’s health (n=2), and Peyronie’s disease (n=1). Video length ranged from 29 to 51 min, with a mean video duration of 39 min 41 sec. Actual mean watch time by viewers ranged from 3:45 to 8:30. The total view count was 646,684, with a watch time of nearly 3 million mins, reaching viewers in 47 countries. Fifty-three percent of watch time was on a mobile device and 33% on a personal computer. As patients increasingly turn to the internet for health information, health systems and physicians may wish to leverage high impact social media platforms such as YouTube to share evidence-based content. This study highlights the impressive reach a health system-sponsored video intervention using YouTube can have in sharing accurate video content related to a diverse range of men’s health topics. This is the first health systems-based streaming-video intervention to leverage the video streaming and social media platform YouTube, to facilitate sharing reputable, high quality, and evidence-based men’s health content.

A How-to Guide to Building a Robust SARS-CoV-2 Testing Program at a University-Based Health System

When South Florida became a hot spot for COVID-19 disease in March 2020, we faced an urgent need to develop test capability to detect SARS-CoV-2 infection. We assembled a transdisciplinary team of knowledgeable and dedicated physicians, scientists, technologists, and administrators who rapidly built a multiplatform, polymerase chain reaction- and serology-based detection program, established drive-through facilities, and drafted and implemented guidelines that enabled efficient testing of our patients and employees. This process was extremely complex, due to the limited availability of needed reagents, but outreach to our research scientists and multiple diagnostic laboratory companies, and government officials enabled us to implement both Food and Drug Administration authorized and laboratory-developed testing–based testing protocols. We analyzed our workforce needs and created teams of appropriately skilled and certified workers to safely process patient samples and conduct SARS-CoV-2 testing and contact tracing. We initiated smart test ordering, interfaced all testing platforms with our electronic medical record, and went from zero testing capacity to testing hundreds of health care workers and patients daily, within 3 weeks. We believe our experience can inform the efforts of others when faced with a crisis situation.

886 Underwater Endoscopic Mucosal Resection May Only Be Superior to Conventional Endoscopic Mucosal Resection for the Treatment of Colorectal Polyps 4 CM or Larger

INTRODUCTION: Underwater endoscopic mucosal resection (UEMR) is an alternative to conventional submucosal-lift EMR (CEMR) for removal of large non-pedunculated colorectal polyps. Retrospective studies have suggested that UEMR may be more effective at reducing lesion recurrence than CEMR, when performed by experts in this technique. The aim of this study was to compare the generalized safety and effectiveness of UEMR to CEMR for removal of large colorectal polyps when performed by expert endoscopists at a tertiary referral center. METHODS: Patients who had UEMR or CEMR performed by one of 7 experienced endoscopists (&gt;50 large polyp resections/year) at a single university-based health system between 3/2015 and 7/2018 were included. Each of the 7 endoscopists regularly performed CEMR but adopted UEMR before or during this study. Patients were identified retrospectively using CPT codes and data was collected from our electronic medical record. RESULTS: 186 patients who underwent 142 UEMR and 98 CEMR procedures were included (Table 1). Mean size of polyps removed was 30.7 mm (range: 15-120 mm) for UEMR and 25.3 mm (range: 15- 50 mm) for CEMR (P = 0.001). There were a significantly greater number of tubulovillous adenomas in the UEMR group (22% vs. 37%, P = 0.02). For polyps ≥4 cm, the residual polyp rate on the first follow-up colonoscopy was 26% for UEMR and 60% for CEMR (OR 4.2, P = 0.05), as confirmed by biopsies. However, there was no statistically significant difference between UEMR vs. CEMR for lesion recurrence for polyps &lt; 4 cm in size. For all polyp sizes, there was no difference in rates of complete macroscopic resection, en bloc resection, number of colonoscopies to reach clearance, and need for adjunctive resection techniques (i.e., argon plasma coagulation, hot biopsy avulsion) between the groups (Table 2). There were no instances of perforation. No significant differences in rates of intra-procedural or delayed procedural bleeding were found between groups (Table 3). CONCLUSION: When generalized across multiple endoscopists at a university-based health system, there was no observed benefit of UEMR compared to CEMR for colorectal polyps under 4 cm in size. However, for lesions 4 cm and greater, UEMR was superior in terms of reduced rates of residual lesion at the first follow-up colonoscopy. Prospective trials are required to further delineate the comparative impact of UEMR vs. CEMR with respect to rates of residual neoplasia.

Institutional Entrepreneurship in Health Management: A Survey Experiment on Appreciative Inquiry®

Abstract Employing the lens of institutional entrepreneurship to help understand the logic of organizational change management, we conduct an analysis of the impact of Appreciative Inquiry® in a multi-unit division of a large, university-based health system. Our results indicate that, although there may have been some marginal impact in temporarily reducing an observed decline in employee commitment indicators, the program failed to sustain positive impacts over the longer term. Implications for the study of organizational change as the action of institutional entrepreneurs are briefly discussed.

Abstract TMP69: Incidence of Intracranial Hemorrhage After Intravenous Thrombolysis in Telestroke

Background: Promoting intravenous tissue plasminogen activator (IV tPA) in treating eligible patients with acute ischemic stroke (AIS) is critical in reducing overall stroke burden. Effective telestroke networks are proven to facilitate higher rates of IV tPA use. Increasing data on stroke outcomes continues to emerge with expansion of telestroke services nationwide. Objective: To estimate the incidence of intracranial hemorrhage (ICH) in AIS patients treated with IV tPA via telestroke evaluation. Methods: In this study, data from a large telestroke network comprising 36 hospitals from 3 States and associated with a university-based health system and comprehensive stroke center was utilized. Data included total of 3198 acute telestroke evaluations performed within the network between January 2014 and June 2016. Distance of spoke hospitals from the hub ranged between 2.5 and 125 miles. All telestroke consultations were done using the remote presence robotic technology. 15% of all telestroke evaluations and 51% of post-IV tPA patients were transferred to the hub. CT imaging was used for identification and ICH as defined mainly in the NINDS trial was used for comparison. Results: Mean age of patients was 67 years (sd=16) and majority were women (n=1759, 55%). Average NIHSS score at presentation was 7. IV tPA was administered to 18% of all telestroke patients. Post IV tPA, any ICH (symptomatic or not) was noted in 8.7% of patients. Petechial hemorrhage was most frequently reported finding. Rate of any ICH in our telestroke population was relatively lower compared to the ECASS II (39%, p&lt;0.001), ECASS III (27%, p&lt;0.001), SITS-MOST (9.6%, p=0.63), ATLANTIS (11.4%, p=0.30), and higher than the NINDS (6.4%, p=0.29). Conclusions: Higher rate of IV tPA use and lower rate of hemorrhagic complication observed in this large study further supports and strengthens the role of telestroke technology and expertise in treatment of AIS.

Follow-up Analysis of Adolescents Partially Vaccinated Against Human Papillomavirus

To evaluate factors associated with human papillomavirus vaccination among a cohort of female adolescents previously identified as receiving only one or two doses of vaccine. This was a 15-month follow-up analysis of a previously identified cohort of 9-18-year-old female adolescents seen in primary clinics within a university-based health system. Vaccine receipt and associated factors were identified by review of administrative records. Among the 1,714 partially vaccinated female adolescents, 53% eventually completed the vaccination series. There was a wide range of dosing intervals ranging from 31 to 840 days between first and second doses and from 85 to 666 days between second and third doses. Race and insurance type were associated with lower rates of series completion, but not with receiving second doses. Approximately half of the partially vaccinated girls in our cohort eventually completed the series, albeit often over a longer than recommended interval. There were important disparities in human papillomavirus vaccination.