Overtreatment Research Articles

Medication overuse headache is associated with elevated lipopolysaccharide binding protein and pro-inflammatory molecules in the bloodstream

ObjectiveMedication overuse headache (MOH) is a secondary headache that accompanies chronic migraine. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most frequently used analgesics worldwide and they are known to induce leaky gut. In this study, we aimed to investigate whether NSAID induced MOH is associated with altered circulating lipopolysaccharide binding protein (LBP) levels and inflammatory molecules.Materials and methodsPiroxicam (10 mg/kg/day, po) for 5 weeks was used to induce MOH in female Sprague Dawley rats. Pain behavior was evaluated by periorbital withdrawal thresholds, head-face grooming, freezing, and head shake behavior. Serum samples and brain tissues were collected to measure circulating LBP, tight junction protein occludin, adherens junction protein vascular endothelial (VE)-cadherin, calcitonin gene-related peptide (CGRP), IL-6 levels and brain high mobility group box-1 (HMGB1) and IL-17 levels.ResultsChronic piroxicam exposure resulted in decreased periorbital mechanical withdrawal thresholds, increased head-face grooming, freezing, and head shake behavior compared to vehicle administration. Serum LBP, CGRP, IL-6, IL-17, occludin, VE-cadherin levels and brain IL-17 and HMGB1 levels were significantly higher in piroxicam group compared to controls. Serum LBP was positively correlated with occludin (r = 0.611), VE-cadherin (r = 0.588), CGRP (r = 0.706), HMGB1 (r = 0.618) and head shakes (r = 0.921), and negatively correlated with periorbital mechanical withdrawal thresholds (r = -0.740).ConclusionElevated serum LBP, VE-cadherin and occludin levels indicating disrupted intestinal barrier function and leakage of LPS into the systemic circulation were shown in female rats with MOH. LPS induced low-grade inflammation and elevated nociceptive and/or pro-inflammatory molecules such as HMGB1, IL-6, IL-17 and CGRP may play a role in the development and maintenance of MOH. Interference with leaky gut and pro-inflammatory nociceptive molecules could also be a target for sustained management of MOH.

Abstract 18420: Appropriateness and Cost Analysis of Adult Inpatient Transthoracic Echocardiograms in a Community Hospital

Introduction: Although inpatient transthoracic echocardiograms (TTEs) are important for guiding patient management, their overuse could be a concern leading to delayed discharges, unnecessary burden on hospital staff, and increased hospital costs. We analyzed the appropriateness, benefits, cost expenditure and unnecessary burden of TTE testing. Methods: A retrospective cohort analysis of a subset of patients undergoing TTEs in 2022 from a community hospital was performed. Appropriateness of use criteria (AUC) in accordance with American Society of Echocardiography and alteration in medical management was evaluated by 3 independent reviewers. Hospital cost analysis was performed based on median TTE cost ($682), yearly total adult TTEs performed (n=4,636), AUC criteria, and alteration in management under Maryland all-payer insurance model. Results: In 234 TTEs matched by age, gender, and race, AUC was not met in 32.5% of patients. Most TTEs were indicated for LV function assessment and ACS (Figure). Change in management was significantly higher in patients who met vs. not meeting AUC (54 vs. 11%, p<0.001). In patients meeting AUC, men had a higher change in management compared to women (61 vs. 46%, p = 0.05). No significant differences were found in the percentage of patients who benefitted from inpatient TTE by subgroups based on indications, except for cardiac trauma. Inappropriate TTE testing led to a yearly loss of approximately $313,000 in hospital revenue and an additional loss of $150,000/year for every 5% of patients who meet AUC with no alteration in medical management. Conclusion: In this community hospital analysis, nearly one-third of adult inpatient TTEs were obtained outside the recommendations of established guidelines. Strategies to improve adherence to ASE guidelines and patient selection for TTE testing are warranted to reduce unnecessary resource utilization and healthcare costs.

Abstract 18597: Is Sleep Disordered Breathing Optimized in Patients With Bradycardic Rhythm Disorders Prior to Pacemaker Implantation? - A Retrospective Observational Study and a Quality Improvement Project

Introduction: Obstructive sleep apnea (OSA) is associated with cardiovascular (CV) morbidity and mortality ranging from asymptomatic bradycardia to sudden death. Studies have shown that sleep-related bradyarrhythmias, decrease with continuous positive airway pressure (CPAP) and are unlikely to develop symptomatic bradycardia in the long-term. AHA/ACC/HRS recommends to evaluate and treat suspected or documented conduction disorder during sleep including patients who have received or are being considered for permanent pacemaker (PPM). Objective We aim to examine the number of sleep studies and CPAP performed and address the barriers of under-diagnosis and treatment with post intervention quality improvement initiative. Methods: We performed retrospective analysis of patients >18 years admitted for elective PPM placement from 01/10/2021-01/01/2023. Categorical variables were reported as number and percent and numerical variable was reported as mean. Multiple logistic regression was used to identify predictors for compliance and sleep study prescription. All statistical analyses were performed with SAS software, version 9.4. Results Of 423 patients, mean age was 78.1 years, 56.50% were males, 96.9% were Caucasians and mean BMI was 30.1 kg/m 2 . Only 34.75 % (N= 147/423) received sleep study. 93.2% (N=137/147) were diagnosed with OSA and 82.9% (N=122/137) were treated with CPAP. Only 63.1% were compliant with CPAP. Males were more complaint with CPAP [OR 3.13 (95% CI 1.36-7.18, p=0.0072)]. Mean BMI at OSA diagnosis was 33.7 kg/m 2 and 30.1 kg/m 2 at PPM implantation. Weight loss was noted but most patients remained obese. Males, age ≥80 and obesity were significant predictors to get sleep study. After study outcomes, we adopted a standardized algorithm for risk assessment, incorporated EHR reminder and educated doctors. The intervention is currently ongoing. Conclusion Data on underutilization of sleep study helped us to work with administration to produce a protocol for screening high risk patients. Treating sleep apnea not only alleviates apnea-related symptoms but also improves CV outcome by avoiding unnecessary pacemaker implantation and minimizing unnecessary health care cost. If effective, this strategy can be a model for other hospitals.

Abstract 14386: High Sensitivity Troponin: Implementation Before Education

Introduction: Troponin T is strong indicator of Acute Myocardial Injury, however, concerns regarding its sensitivity have led to the inception of high sensitivity troponin (hscTn). The use of hscTn in clinical practice allows for an increased negative predictive value, which in turn can expedite triage and disposition of patients presenting with Acute Coronary Syndrome. The ACC/AHA have developed algorithms to provide a road map to aide in the interpretation of hscTn values and their indications. However, the understanding of the interpretation of test is integral hscTn in guiding management. Hypothesis: Evaluate if the implementation of hscTn within our hospital system decreased the amount of inappropriate diagnostic testing and admissions. Methods: A total of 602 patients consisting of two patient groups seen in our emergency department with the chief complaint of chest pain were studied. The troponin T group consisted of patient admitted between Jan 2021 to June 2021 (n=246) and the hscTn group between July 2021 - December 2021 (n=356). Baseline demographic and clinical comorbid characteristics were compared between both groups. Notable outcomes of interest were rates of admission as well as cardiac testing. Analysis was performed using T test for continuous variables and Chi squared test for categorical variables. Results: Admission rates were significantly increased in the hscTn group in comparison to the regular troponin group with proportions of 60.3% vs 39.7% respectively (p < 0.001). An 11 percent increase in inpatient cardiology consultation of the total visits occurred within the hscTn group vs the regular troponin group. When evaluating admitted patients, based on AHA guidelines for significant hscTn findings only 2% of those patients who were admitted met the criteria. Conclusions: The introduction of hscTn troponin within our hospital did not appear to decrease chest pain admissions regardless of its improved sensitivity and specificity. In contrast, rates were increased even when elevation was not significant, this may not be due to the test's efficacy but instead to the lack of education on its indications.

Abstract 12473: Majority of Technetium-99m Pyrophosphate Scans for the Evaluation of Transthyretin Cardiac Amyloidosis Are Ordered Without Appropriate Paraprotein Evaluation

Background: Guidelines recommend the use of technetium-99 m pyrophosphate (PYP) scanning after light chain amyloidosis has been ruled out via laboratory testing. Yet lack of execution of this condition significantly hinders the real-world value of PYP scanning to diagnose transthyretin amyloidosis. Objective: The aim of this study was to evaluate the prevalence and consequences of inappropriate PYP scanning at an academic, tertiary care center. Methods: We performed a retrospective study of all PYP scans ordered at our institution from January 2018 to March 2023. Categorical variables were determined as frequencies and percentages. Continuous variables were determined as means and standard deviations. Results: 269 PYP scan orders were identified from 228 distinct patients. Mean age was 67.04 years, 51.2% of patients were female, 66.5% were White, and 47.7% were Hispanic. 52 PYP scans (19.3%) should not have been ordered given positive paraprotein results. 145 PYP scans (53.9%) should not have been ordered given lack of any paraprotein results. Only 9 scans (3.3%) were ordered after negative serum free light chain, serum protein electrophoresis, and serum immunofixation results. Up to seven patients (3.1%) did not receive appropriate paraprotein evaluation prior to tafamidis initiation and thus may have been erroneously treated, representing potential unnecessary healthcare costs to not only the patient, but also the healthcare system. There were no temporal trends for scans performed with zero, three, or positive paraprotein results ( Figure ). Conclusions: Most patients did not undergo complete serum monoclonal protein testing prior to PYP scan ordering. Many patients underwent PYP scanning despite positive serum monoclonal protein test results. Increased awareness and education among physicians regarding paraprotein evaluation prior to PYP scanning is still needed to prevent misdiagnosis, delayed diagnosis, and unnecessary healthcare costs.

Potential Predictors of Response to CGRP Monoclonal Antibodies in Chronic Migraine: Real-World Data.

Real-world data (RWD) has identified potential predictors of response to anti-CGRP therapies in patients with chronic migraine (CM). This review aims to synthesize the most remarkable findings published to date regarding this topic. Migraine features such as unilateral pain and positive triptan response and chronic features such as daily headache or medication overuse (MO) emerge as predictors of positive outcomes, potentially linked to elevated baseline serum anti-calcitonin gene-related peptide (anti-CGRP) levels. Demographic and baseline characteristics, encompassing obesity, psychiatric comorbidities, and prior refractoriness to prophylactic treatments, are associated with poor responses in both treatment-naïve patients and after-switch scenarios. Nevertheless, the consistency of these predictors across diverse populations requires further investigation. Recent RWD literature highlights emerging predictors of response of different sources among patients with CM receiving anti-CGRP therapies. Comprehending these predictors and identifying novel biomarkers of response hold the potential to refine treatment strategies for CM patients, enhancing their management and therapeutic outcomes.

The rise of depression and the risk of suicide: Understanding dysphoria in modern society

Abstract Problem Depression is on the rise and can result in the intense despair that underlies suicide risk. Description of the Problem Modern society has changed in ways that disrupt personal life, reduce lasting values, and create a disconnect from close interpersonal relations. It is important to understand the prevalence of despair and the high rates of death by suicide. Results A comprehensive scoping review identified five relevant factors that play a role in the rise of distress and despair across society. First, many people rely on alcohol or drugs to temporarily suppress emotional reactions. Drug abuse has become commonplace. Further, the over-use of antidepressant medications may result in the social and emotional causes of depression remaining untreated. Second, prescription pills and guns are the most common methods used in a suicidal act and both are commonplace throughout the U.S. Third, many adults struggle with occupational stress and chronic financial worries. In addition, many adults feel their job is repetitive and mundane, providing a source of income but little benefit to person or society. Fourth, many people experience pervasive feelings of loneliness and social isolation, often feeling disconnected from family and friends. Some aspects of social isolation may be related to an excessive use of technology that has changed social interactions in ways that are not helpful. Fifth, many people have been losing hope or lack meaning in life. As society becomes filled with interpersonal conflict, political strife, and suppressed hatred, feelings of hopelessness can grow. Some people have reached a level of fatigue over the assorted crises facing the world today. Lessons The rising suicide rates are not a time-limited epidemic, but despair has become endemic to modern society, quietly undermining the emotional lives of many people. Societal changes can promote positive mental health by addressing each of these five factors. Key messages • Mental Health professionals can promote non-pharmacological means of managing stress and depression. • All fields can encourage supportive and compassionate bonds when confronted with people in distress.

Risk stratification tools in primary care in Europe

Abstract Risk stratification is an intentional, planned and proactive process that predicts the probability of adverse events occurring and assigns an individual a risk status or score. Based on individual risk assessment, patients are typically classified into high-, medium- (rising-) and low-risk groups. Risk levels should correspond to the likelihood that patients experience negative health outcomes and/or higher rates of unnecessary or preventable health care utilization. This allows targeting effective interventions to prevent them and promotes resource utilization based on individual and population needs rather than demand. Risk stratification is essential for PHC practices to be proactive and reach out to individuals based on their risk profile even if they do not present to PHC facilities and to tailor PHC service delivery accordingly. Even if risk stratification (especially as it becomes more sophisticated) is not done at the PHC level, the results can be made available to PHC professionals, often through integrated electronic health record systems, so they can benefit from it in their daily practice. Risk stratification may be carried out in PHC settings with varying degrees of complexity depending on local resources and with different purposes depending on the context. This presentation will discuss the different risk stratification tools used in country across the European region, and provide practical examples on their uses in PHC. The presentation will discuss enabling factors for advanced risk stratification that accounts for multimorbidity and social complexity.

Presenting a Comprehensive Definition of Unnecessary Healthcare Services and Their Drivers: A Systematic Review and Meta-synthesis.

Providing unnecessary healthcare services is a major common problem in every health system. The scope and cause of healthcare services must be identified in order to be managed and controlled. Finding the most complete definition of the problem and its causes are the goals of this meta-synthesis. A comprehensive search strategy was performed using a wide range of keywords and databases. Based on the defined inclusion and exclusion criteria, 22 articles were selected for content analysis and meta-synthesis. The Graneheim and Lundman method was used for content analysis. The MAXQDA software Version 18.2.0 was used for the first round of content analysis. Content analysis and meta-synthesis were used to comprehensively define the term "unnecessary healthcare services" and find the etiologic factors driving healthcare providers to unnecessary healthcare services. The term "unnecessary healthcare services" is defined as "overproviding healthcare services that could be harmful, low-value, insufficient, and inappropriate." The etiologic pattern of unnecessary healthcare services shows intrinsic and extrinsic factors as a driving force for unnecessary healthcare services. A multilayer strategy for efficient management and prevention of unnecessary healthcare services is appropriate due to the multifaceted character of these services. This approach consists of the modification of the intrinsic factors and extrinsic drivers.

Orthopaedic patients' experiences of their sleep during hospitalisation and suggestions for improvements

PurposeTo describe orthopaedic patients' perspectives on their sleep quality and their suggestions for improvement initiatives to achieve better sleep quality during hospitalisation. MethodsIn a qualitative design, 265 (50%) of 533 patients from a questionnaire survey responded to two free-text questions. Data were analysed based on a phenomenological-hermeneutic approach inspired by Paul Ricoeur's theory of narrative and interpretation. ResultsThree themes emerged: 1) Sleeping environment and preferences tailored to the individual patient, 2) The link between orthopaedic surgery care and sleeping, and 3) Noise challenged a good night’s sleep. Good sleep was related to nurses' professional behaviour and the physical environment, such as quality beds and sleeping aids. Single and shared rooms, room lighting, and fresh air all influenced sleep quality. Unfamiliar and uncomfortable sleeping positions posed a challenge for orthopaedic patients but aids such as pillows, and duvets could provide more comfort at night. Offset circadian rhythms could affect sleep quality, as could nausea and vomiting. Pain and lack of pain relief were associated with poor sleep quality. Noise from both nurses and other patients affected sleep quality. Therefore, unnecessary care activities should be kept to a minimum, and a “night noise level” was suggested. ConclusionPatients' sleep disturbance following orthopaedic surgery needs to be addressed by both nurses and hospital management. Patients’ involvement is essential to create a sleep environment tailored to individual needs and to provide strategies patients use at home for addressing sleeping problems.

Improving Pediatric Clostridioides difficile Testing Practices: Implementation of a 2-Tier Diagnostic Pathway

Introduction: Clostridioides difficile (C. difficile) is a significant concern for children, especially for those who are hospitalized or who have underlying medical conditions. Diagnosis of C. difficile infection (CDI) in these patients can be challenging due to asymptomatic colonization. Inappropriate testing and non-adherence to laboratory testing guidelines can result in increased false-positive rates precipitating unnecessary isolation precautions and antibiotic treatment for these patients. 
 
 Methods: This retrospective cohort study aimed to evaluate the effectiveness of a new diagnostic pathway for C. difficile testing that was implemented in two pediatric hospitals. The study design collected data for two years, one year before and one year after pathway implementation. The study highlighted the importance of appropriate testing and the need for interventions to improve testing practices in pediatric patients. A 2-tier testing algorithm was implemented, consisting of polymerase chain reaction (PCR) for the presence or absence of the toxin B gene and an enzyme immunoassay for toxin A/B production. The best practice advisory was used to determine when C. difficile testing should not be performed. The chi-square test and Fisher's Exact Test analyzed the data using SPSS version 29.
 
 Results: The study found a significant association between the implementation of the C. difficile testing pathway and the test positivity rates for both inpatient and emergency department (ED) patients at both hospitals. Out of 159,434 Hospital A inpatients, 71 had positive C. difficile test results, and out of 11,109 Hospital B inpatients, nine had positive test results. Similarly, out of 121,951 Hospital A ED patients, eight had positive test results, and out of 67,999 Hospital B ED patients, 16 had positive test results. The study found a statistically significant association between the pre and post pathway implementation years for both hospitals (p<0.001 for Hospital B inpatient and ED, p=0.033 for Hospital A inpatient, and p=0.004 for Hospital A ED).
 
 Conclusion: Adherence to laboratory testing guidelines, appropriate testing based on factors such as the patient's age, underlying health conditions, recent antibiotic use, and the presence of other infections or illnesses can reduce unnecessary testing and false-positive rates. False-positive results can occur in pediatric patients due to the high rate of asymptomatic colonization, making it essential to use a combination of clinical symptoms, history, and appropriate diagnostic testing to minimize the risk of misdiagnosis.

Ethical Prescribing of Psychotropic Medications for People with Neurodevelopmental Disorders

ObjectivesPeople with neurodevelopmental disorders (NDDs) such as intellectual and developmental disabilities (IDD) and autism are subjected to restrictive practices like physical restraint and the overuse of psychotropic medications for challenging behaviour in the absence of a psychiatric disorder. This practice may lead to human rights violations. Rational and evidence-based shared decision-making for person-centred planning will help reduce this practice.MethodsWe have discussed in this paper the issue of the overmedication of people with NDD, explaining how this practice may violate the United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD).ResultsWe have discussed how the following UN CRPD Articles may be affected by overmedication, including Article 15 (degrading treatment or punishment), 16 (abuse), 17 (the integrity of the person), and 25 (health). The other Articles that may be indirectly affected by this practice are 5 (equality and non-discrimination), 9 (accessibility), 19 (independent living and community inclusion), 21 (access to information), 24 (education), 26 (rehabilitation), 27 (work and employment), 28 (adequate living standard), and 30 (participation in recreation and leisure).ConclusionsOvermedication of people with NDD, particularly the off-licence use of psychotropics for challenging behaviour, the side effects of these medications impacting the person’s quality of life are likely to violet several UN Articles on Rights of Persons with Disabilities. Following the right guidelines may help reduce these human rights violations.

Strategic Purchasing as an Evidence-Based Approach for Reducing Medical Overuse

Overuse of healthcare services is an increasingly reported issue in health systems worldwide. Given the breadth and importance of the subject, identifying strategies/tools that can prevent medical overuse is beneficial. The authors of this article believe that strategic purchasing, because of its high capabilities, is one of the tools that can help avoid medical overuse. Also, strategic purchasing and capable government stewardship can lead to the optimal use of resources and the promotion of the right services. In general, and by expressing some strategic purchasing features that contrast with the drivers of overuse, it can be concluded that strategic purchasing can be used as a synergistic tool, along with other tools, to prevent and even reduce the overuse of healthcare services. In addition, strategic purchasing and capable government stewardship can lead to the optimal use of resources and the promotion of the right services.

Medication-overuse headache-a review of different treatment strategies.

Medication-overuse headache (MOH) can develop from primary headaches. MOH is usually the result of overuse of symptomatic medications. It is a noteworthy personal and societal burden. The identification and treatment of patients at risk for MOH is an essential component of MOH management. Medication overuse can be modifiable and can advance from episodic to chronic migraine. Treatment for MOH is complex, and experts in the field have varied views on the most appropriate strategy for MOH treatment. The objective of this review is to give a comprehensive synopsis of the literature for the management of MOH. Treatment strategies, such as detoxification and prevention, are the debatable issues. Medication withdrawal is the foundation for management. The available literature suggested abrupt withdrawal with preventive approaches for early management. Bridging therapy could be useful to get relief from withdrawal symptoms. Multidisciplinary choices proved beneficial in supporting withdrawal and preventing relapse. Worldwide, the termination of overused medications has been observed as a standard treatment strategy; however, patient-specific approaches should be taken.

Universal Germline-Genetic Testing for Breast Cancer: Implementation in a Rural Practice and Impact on Shared Decision-Making

BackgroundWhereas the National Comprehensive Cancer Network (NCCN) criteria restrict germline-genetic testing (GGT) to a subset of breast cancer (BC) patients, the American Society of Breast Surgeons recommends universal GGT. Although the yield of pathogenic germline variants (PGV) in unselected BC patients has been studied, the practicality and utility of incorporating universal GGT into routine cancer care in community and rural settings is understudied. This study reports real-world implementation of universal GGT for patients with breast cancer and genetics-informed, treatment decision-making in a rural, community practice with limited resources.MethodsFrom 2019 to 2022, all patients with breast cancer at a small, rural hospital were offered GGT, using a genetics-extender model. Statistical analyses included Fisher’s exact test, t-tests, and calculation of odds ratios. Significance was set at p < 0.05.ResultsOf 210 patients with breast cancer who were offered GGT, 192 (91.4%) underwent testing with 104 (54.2%) in-criteria (IC) and 88 (45.8%) out-of-criteria (OOC) with NCCN guidelines. Pathogenic germline variants were identified in 25 patients (13.0%), with PGV frequencies of 15 of 104 (14.4%) in IC and ten of 88 (11.4%) in OOC patients (p = 0.495). GGT informed treatment for 129 of 185 (69.7%) patients.ConclusionsUniversal GGT was successfully implemented in a rural, community practice with > 90% uptake. Treatment was enhanced or de-escalated in those with and without clinically actionable PGVs, respectively. Universal GGT for patients with breast cancer is feasible within rural populations, enabling optimization of clinical care to patients’ genetic profile, and may reduce unnecessary healthcare, resource utilization.

Burden of episodic migraine, chronic migraine, and medication overuse headache in Alberta.

To describe demographic and clinical characteristics, healthcare resource use, costs, and treatment patterns in three migraine cohorts. This retrospective observational study using administrative data examined patients with episodic migraine (EM), chronic migraine (CM) (without medication overuse headache [MOH]), and medication overuse headache in Alberta, Canada. Migraine patients were identified between 2012 and 2018 based on ≥ 1 diagnostic codes or triptan prescription. Patients with CM were defined using parameter estimates of a logistic regression model, and MOH was defined as patients with an average of ≥ 15 supply days covered of acute medications. EM was defined as patients without CM or MOH. Study outcomes were summarized using descriptive statistics. Patients with EM (n = 144,574), CM (n = 27,283), and MOH (n = 11,485) were included. Higher rates of healthcare use and costs were observed for CM (mean [SD] all-cause cost: ($12,693 [40,664]) and MOH ($16,611.5 [$38,748]) versus episodic migraine ($4,251 [$40,637]). Across all cohorts, opioids were the most dispensed acute medication (range across cohorts: 31.7%-89.8%), while antidepressants and anticonvulsants were the most dispensed preventive medication. Preventative medication classes were used by a minority of patients in each cohort, except anticonvulsants, where 50% of medication overuse patients had a dispensation. Patients with CM and MOH have a greater burden of illness compared to patients with EM. The overutilization of acute medication, particularly opioids, and the underutilization of preventive medications highlight an unmet need to more effectively manage migraine.

Hiding in Plain Sight: Quantifying Salbutamol and Ipratropium Inhaler Wastage in Hospitals.

Previous studies have found significant inhaler wastage in the inpatient setting, which contributes to unnecessary health care expenditures. Wastage may involve inhalers available in automated dispensing cabinets (ADCs). To evaluate whether salbutamol and ipratropium inhalers were unnecessarily withdrawn from ADCs for hospital inpatients. This cross-sectional study included patients from 16 health care facilities in British Columbia. ADC reports were run for the period August 2021 to January 2022 to identify salbutamol and ipratropium inhalers removed from ADCs. Over the study period, 8.3% (2180/26 324) of salbutamol and ipratropium inhalers were withdrawn from ADCs unnecessarily for the same patient encounter within a 2-day timeframe, and another 1118 (4.2%) represented instances when multiple inhalers were withdrawn for the same patient at the same time. Overall, 12.5% (3298/26 324) of all salbutamol and ipratropium inhalers were withdrawn unnecessarily. The total cost of these inhalers was about $31 600 over the 6-month period. This evaluation revealed considerable wastage of inhalers, leading to wasted expenditures. Other health authorities should conduct similar analyses to determine whether similar problems exist in their settings.

Bipolar II Disorder: Understudied and Underdiagnosed.

Despite its inclusion as a distinct entity in APA's Diagnostic and Statistical Manual of Mental Disorders since 1994, bipolar II disorder remains a surprisingly neglected psychiatric condition. Understudied and underrecognized, bipolar II disorder is often misdiagnosed and misunderstood, even by experienced clinicians. As a result, patients typically experience symptoms for more than 10 years before receiving the correct diagnosis. Incorrect diagnosis leads to incorrect treatment, including overuse of monoaminergic antidepressant medications, with resultant declines in functioning and worse quality of life. Perhaps because of its underrecognition, treatment studies of bipolar II disorder are limited, and, too often, results of bipolar I disorder studies are applied to bipolar II disorder, with no direct evidence supporting this practice. Bipolar II disorder is an understudied and unmet treatment challenge in psychiatry. In this review, the authors provide a broad overview of bipolar II disorder, including differential diagnosis, course of illness, comorbid conditions, and suicide risk. The authors summarize treatment studies specific to bipolar II disorder, identifying gaps in the literature. This review reveals similarities between bipolar I and bipolar II disorders, including risks of suicide and predominance of depression over the course of illness, but also differences between the phenotypes in treatment response, for example, to antidepressant medications.

Precautionary planning at the end of life from the perspective of intensive care medicine

In recent years, the number of intensive care treatments has increased significantly. About every fourth patient who dies in hospital receives intensive care. Structured prevention planning is important in order to implement the patient's wishes in situations of serious illness in which patients cannot express their wishes themselves. However, the implementation in practice can be problematic since intensive care situations are complex and rarely correspond to the concrete pre-arranged situations. Communication of the prognosis and the prognostic uncertainty is therefore crucial in order to determine the presumed will of the patient, especially in the context of the process of weighing up the benefits and burdens of intensive care therapies. Hospital treatment can be the reason for targeted preventive planning and avoid unnecessary intensive care treatment during the same stay. Documentation templates can help to record the results of preventive care planning clearly and comprehensibly in the medical file.

S406 Reducing Inappropriate Fecal Immunochemistry Testing at a Veterans Affairs Healthcare System

S406 Reducing Inappropriate Fecal Immunochemistry Testing at a Veterans Affairs Healthcare System