Abstracts from the 38th Annual Meeting of the Society of General Internal Medicine

SCIENTIFIC ABSTRACTS

“WE ALL HAVE DIFFERENT STORIES”: VETERANS’ EXPERIENCES AND PREFERENCES FOR PROACTIVE IN-BETWEEN VISIT CARE Ashley E. Jensen 1, 2; Nicole Skursky1; Erica Sedlander1; Katherine Barboza1; Katelyn Bennett1, 2; Scott Sherman2, 1; Mark D. Schwartz2, 1. 1NYU School of Medicine, New York, NY; 2VHA New York Harbor Healthcare System, New York, NY. (Tracking ID #2198048)

BACKGROUND: Medical home models, like VA’s Patient Aligned Care Team (PACT) seek to engage patients via proactive outreach for prevention and chronic disease management (panel management). We know little about patients’ perspectives, experiences and preferences in receiving this type of non-face-to-face care. To address this gap and inform future implementation efforts, we conducted a qualitative study of veterans at two VA campuses.

METHODS: We conducted a qualitative study of veterans with hypertension or current smoking, who had participated in a cluster-randomized trial of panel management support in which Panel Management Assistants provided outreach and coaching to veterans. We recruited eligible patients by mail and phone, who were invited to participate in focus groups stratified by hospital, gender (six male and four female groups), and age (under or over age 60). Participants completed brief questionnaires to ascertain their health status and supplemental demographic information. Discussion questions focused on facilitators and barriers to healthy behavior change, experience with proactive outreach, and preferences for receiving care in-between visits. Each focus group was audio recorded and transcribed, and supplemental field notes were taken. A subset of transcripts was reviewed independently by four researchers, who then created an initial consensus codebook. Two researchers independently coded each transcript, modified the codebook as new themes emerged, and met to reconcile coding. Nvivo software was used for analysis.

RESULTS: A total of 1179 patients were invited, 127 were scheduled to attend, and 77 participated. Participants had a mean age of 59 years, were predominantly African American (64 %), and completed at least some college (57 %) with 29 % reporting that they worked outside the home. Most participants had hypertension (78 %), and smoked at least 100 cigarettes in their lifetime (77 %). Participants generally appreciated existing efforts to provide care in between visits including post-discharge phone calls and reminder letters. As one veteran put it, “I don’t mind somebody calling and checking up on me because that’s letting me know that you care....” Participants were receptive to additional outreach for referral, reminders and motivational support in between visits. However, they felt that these outreach efforts should be tailored to their needs and preferences in terms of frequency, content and mode of contact and some had concerns about privacy. Although many participants were open to non-clinicians contacting them as long as they had strong communication skills, empathy, connection to PC teams and training, many felt that the individual should be a veteran or at least able to relate to their military experience. Avoiding medications was a consistent motivator for making lifestyle changes and female veterans in particular wanted access to more holistic health options either at the VA or within their communities.

CONCLUSIONS: Our findings indicate that veterans are receptive to proactive outreach for prevention and management of chronic conditions, especially when this outreach is personalized and flexible. This study has important limitations as it was restricted only to veterans and those agreeing to attend a focus group. However, the information gathered from this study will be useful to inform the design of future panel management efforts.

“I JUST WANT MY DOCTOR’S UNDIVIDED ATTENTION”: PATIENT PERCEPTIONS OF THE IMPACT OF EMR USE ON COMMUNICATION Obiama Ukabiala3; Wei Wei Lee 1; Lollita Alkureishi1; Laura Ruth Venable2; Samantha Ngooi2; Jeanne M. Farnan1; Vineet M. Arora1. 1University of Chicago, Chicago, IL; 2University of Chicago Medical Center, Chicago, IL; 3Pritzker School of Medicine, Chicago, IL. (Tracking ID #2196181)

BACKGROUND: The use of the Electronic Medical Record (EMR) in exam rooms can impede the doctor-patient relationship. Little research to date has explored patient perceptions of provider EMR use and the impact on communication. Despite widespread EMR use, few curricula teach providers how to use the EMR to enhance communication with patients. The aims of our study are to identify patients’ perceptions of EMR use and elicit their suggestions to inform development of a patient-centered EMR use curriculum.

METHODS: Patients seen by internal medicine attendings and residents at the University of Chicago’s primary care clinic were randomly selected for our study. One year after EMR implementation, trained research assistants conducted structured telephone interviews with patients using critical incident technique and appreciative inquiry to elicit their positive and negative perceptions of EMR use by physicians. Using constant comparative analysis, three investigators independently coded 10 % of the transcripts to develop the coding library. An additional 10 % of the transcripts were coded to establish inter-rater reliability. The coding library was applied to the remainder of the transcripts for analysis using ATLAS.ti software.

RESULTS: Of the 384 patients selected, 12 were excluded due to disability, language barriers, or death. Of the 372 eligible patients, 113 telephone interviews were completed. The interviews revealed two overarching themes: (1) Clinical Functions of EMR (2) Communication functions of EMR. Six subthemes were identified: (1) Documentation functions of the EMR (2) Clinical Workflow functions of EMR (3) EMR as educational resource (4) Information access, (5) Facilitate Engagement and (6) Physical focus. To date we have analyzed 58 % (56/113) of the transcripts. Overall, 84 % (576/687) of total codes reflected positive perceptions of EMR. The majority of the positive perceptions fell under the “Clinical Workflow Functions of EMR” subtheme (i.e. ‘increases clinical efficiency’ and ‘promotes teamwork and communication between doctors’). For example one patient said ‘they can see all the other doctors’ notes… they really work together as a team. I love it!’ Only 16 % (111/687) of the codes represented negative perceptions. Interestingly, 45 % (50/111) of negative codes fell under the “Physical Focus” subtheme (i.e. “poor eye contact” and “unbalanced focus”). For example one patient stated ‘how can you focus on the patient if you’re looking somewhere else… it gets in the way.’

CONCLUSIONS: Patients have both positive and negative perceptions of EMR use. Positive perceptions centered on improving clinical efficiency by promoting efficient note writing and teamwork between providers. Negative perceptions focused on communication skills related to EMR use. Patients with negative perceptions cited poor attentiveness (i.e. poor eye contact, unbalanced focus, etc.). Interestingly, many patients who identified the EMR as a barrier to communication also acknowledged that it was useful in increasing clinical efficiency. By interviewing patients, we gained unique insights into their perceptions of EMR use. We will use our findings to inform a patient-centered EMR use curriculum to teach providers how to use the EMR to enhance communication with patients.

“IT ENCOURAGES THEM TO COMPLAIN”: POTENTIAL UNINTENDED CONSEQUENCES OF ROUTINE PAIN SCREENING AND IMPLICATIONS FOR IMPROVEMENT Sangeeta Ahluwalia 3; Risa Cromer4; Karleen Giannitrapani5; Hannah Schreibeis-Baum5; Steven Dobscha2; Erin E. Krebs1; Karl Lorenz5. 1Minneapolis VA Health Care System, Minneapolis, MN; 2Portland VAMC, Portland, OR; 3RAND Corporation, Encino, CA; 4Veterans Health Administration, Portland, OR; 5Veterans Health Administration, Los Angeles, CA. (Tracking ID #2192233)

BACKGROUND: The Veterans Health Administration (VHA) implemented the “Pain as the 5th Vital Sign” (P5VS) initiative in 1999, requiring a pain intensity rating on a 0–10 scale at all clinical encounters. We sought to better understand the perceived impact of implementing a routine pain screening program on primary care clinicians and clinical processes in order to identify opportunities for improving pain screening and management.

METHODS: We conducted multidisciplinary focus groups with VHA primary care team members including physicians, nurses, social workers, pharmacists, and other clinical and administrative staff involved in pain screening and management at multiple VHA sites. We explored current screening practices and multidisciplinary roles in pain screening; perceptions of the value of pain screening; preferred approaches to pain screening; and critical information needs for improved screening and management. We audiotaped, transcribed, and qualitatively analyzed the focus groups and characterized themes using constant comparison.

RESULTS: Primary care team members participated in nine multidisciplinary focus groups, each comprised of six to nine respondents. We identified five themes and several subthemes characterizing potential unintended consequences of routine pain screening in primary care: (1) Screening for pain encourages an affirmative response, because a) it prompts patient recall of old and chronic pain (“They say, ‘oh yeah, last year I had this and that’, and just go on and on”); or because b) answering “0” on the 0–10 scale is perceived as non-response (“they’ll eventually think of something and say ‘well now that I think of it, I’ll put something down’”). (2) Screening highlights the presence of a problem rather than directing the patient towards a solution for their pain, hindering self-management efforts (“If we’re asking about pain every visit then over time [the patient] will just assume, ‘it’s a limiting factor for me, I can’t do these things’”). (3) Screening for pain sets an expectation of intervention (“We have to treat the number”); and (4) worsens reliance on drug treatment because visit brevity and limited access to non-pharmacologic approaches preclude exploration of other interventions (“I have a lot of things to do on this short visit, and then there’s this pain. I give him [drug], and I’m done, boom.”) (5) Screening can unnecessarily change the focus of the clinic encounter because a) addressing pain consumes extra time (“They can be there for something else but it seems like then the whole visit will turn to the pain issue. It’s time consuming”); and b) it re-directs the patient from other medical issues (“all [screening] does is refocuses them on the pain and it’s not productive when I need to discuss whether their blood pressure medication is effective”).

CONCLUSIONS: Systematic efforts to address undertreatment of pain through routine screening may heighten expectations for treatment and interfere with other primary care priorities. To maximize the benefits of pain screening, clinicians may need more agency in determining the appropriateness of screening for each patient and the approach to intervening, and both clinicians and patients require greater access to non-pharmacologic and self-management resources.

“THEY ARE INTERRELATED, ONE FEEDS OFF THE OTHER”: A TAXONOMY OF DISEASE INTERACTIONS DERIVED FROM PATIENTS WITH MULTIPLE CHRONIC CONDITIONS Donna M. Zulman 1, 2; Cindie A. Slightam2; Jonathan G. Shaw1, 2; Kirsten Brandt3; Eleanor T. Lewis2; Steven Asch1, 2. 1Stanford University, Stanford, CA; 2VA Palo Alto, Menlo Park, CA; 3Stanford University School of Medicine, Stanford, CA. (Tracking ID #2198546)

BACKGROUND: There is growing awareness that multiple chronic conditions (MCCs) generate challenges that exceed the sum of their parts. Little is known, however, about patients’ perceptions of, and experiences with, condition interactions, and the impact of these interactions on self-management and treatment.

METHODS: We analyzed qualitative data from a study of patients with MCCs to understand patients’ perceptions about how their conditions interact. The study included a survey (administered by mail, e-mail, and in clinic) of patients from an academic medical center and a Veterans Affairs facility. We analyzed survey responses from 383 individuals who had two or more conditions and responded to multiple choice and open-ended questions about how their conditions interact. Patients were asked to indicate their health conditions, circle the condition that bothers them the most, and then respond to the question: “How do your other health problems affect your ability to take care of the health problem that you circled above?” Standard content analysis methods were used to code textual data, with the goal of identifying: 1) patients’ perceptions about the extent to which their conditions interact, and 2) the nature of those interactions. Four investigators iteratively reviewed textual data to develop a taxonomy of mutually exclusive codes capturing types of condition interactions, and cross-cutting themes about the quality of interactions. After refining codes and themes with all collaborators, three investigators independently coded all responses and collectively chose representative quotes. Themes and representative quotes were validated through an online survey with a sample of study participants.

RESULTS: Among survey respondents, the mean (SD) number of chronic conditions was 4(2) with the most common including hypertension (60 %), chronic pain (49 %), arthritis (41 %), depression (32 %), diabetes (29 %), and PTSD (26 %). Patients described interrelated relationships among their MCCs and treatments. For example, patients described condition-condition interactions (“The constant worry about prostate cancer recurrence aggravates my anxiety and depression”), condition-treatment interactions (“My back pain keeps me from getting enough exercise which makes it difficult to manage my weight which ultimately is bad for my already damaged heart”), treatment-condition interactions (“The epidurals I had [for chronic pain] caused extremely high blood sugar levels causing anxiety”), and treatment-treatment interactions (“Cancer treatments have caused fatigue and interrupted spine care”). Some patients expressed uncertainty about, or denied the presence of, condition interactions, while others described cyclic/multi-dimensional interactions (“Chronic pain causes loss of sleep and restless leg syndrome, which keeps me awake, exacerbating my depression and anxiety”). Cross-cutting themes included the presence of positive interactions (“What I do for diabetes has a beneficial effect on my other conditions”) as well as negative interactions (above), discussions about causal relationships (“It is the cancer and its required medications that causes the other health problems”), and frequent comments describing interactions among physical and mental health conditions.

CONCLUSIONS: This qualitative study revealed a novel taxonomy of condition interactions from the perspective of patients with MCCs. In order to support self-management and strengthen shared decision-making, it is important to address patients’ perceived interrelated symptoms and condition-treatment interactions.

“WE FOLLOW-UP”: IMPROVING FOLLOW-UP, COMMUNICATION AND DOCUMENTATION OF OUTPATIENT TEST RESULTS BY DUKE RESIDENTS Aparna C. Swaminathan; Joel C. Boggan; Samantha Thomas; Jonathan Bae. Duke University Health System, Durham, NC. (Tracking ID #2191330)

BACKGROUND: Following up on outpatient test results is a time-consuming process that has important patient safety implications. Failure to inform patients of test results and document communication may lead to diagnostic and therapeutic delays and are common sources of malpractice claims. We sought to compare the rates of follow up, communication, and documentation of outpatient test results by Duke residents before and after an educational quality improvement effort.

METHODS: All three resident clinics—a community-based clinic (Clinic 1), a Veterans Affairs clinic (Clinic 2) and a private practice model (Clinic 3)—were included in this study. A follow-up standard was developed to include definitions of ‘significant’ test results and appropriate times to follow-up. A predetermined subset of test results with significant results were to be communicated to patients within 72 h, while other, ‘nonsignificant’ results were to be communicated with 14 days. An online interactive experience to guide the project was developed utilizing Microsoft SharepointTM. Residents were required to participate in this mandatory residency-wide project as part of their regularly scheduled ambulatory blocks during each half of the academic year 2013–14. We examined follow-up rates both before and after an intervention that provided resident physicians with education, feedback, and real-time comparison to their peers.

RESULTS: Seventy-six residents completed the online module prior to the intervention (reviewing 1713 patient charts), and 73 residents completed the online module subsequent to the intervention (reviewing 1509 patient charts). At baseline 78 % of test results were communicated to patients within 14 days (Table 1). After our educational intervention, this rate of communication significantly improved to 85 % (p < 0.001). This observation held true across all clinic sites (Clinic 1: 69.5 vs. 79 %, Clinic 2: 85 vs. 89 %, Clinic 3: 86 vs. 94 %, p < 0.02 for all). Of the test results reviewed, 32 % were significant. The rate of communication of significant test results within 72 h also improved, from 70 % before the intervention to 81.5 % afterwards (p < 0.01). Prior to the intervention, 50 % of all results were communicated through patient letters and 23 % via phone calls. Letters were used more commonly for non-significant results (56 vs. 39 %) while phone calls were used more often for significant results (43 vs. 13 %, p < 0.001). Following the intervention the use of patient letters increased from 50 to 56 % (p < .001), while ratios of other types of communication remained stable. There was no change in the types of test followed up on before or after the intervention.

CONCLUSIONS: This study demonstrates that lack of follow-up of outpatient test results is a common problem, and that our simple educational interventions and feedback resulted in significant improvement across a large internal medicine residency program. Such interventions should be routinely integrated into residency education and patient care. With the prevalence of the electronic medical record it has become even easier to communicate results through letters or online portals. However it remains imperative that communication of time sensitive results occur in a reliable fashion.

“WORLD VAPE DAY” 2014: LESSONS FROM THE TWITTERSPHERE Jason Colditz 2; Kevin Pang2; Alton Everette James2; Christine Stanley2; Ellen Beckjord3; Judith Brook1; Brian A. Primack2. 1New York University School of Medicine, New York, NY; 2University of Pittsburgh, Pittsburgh, PA; 3University of Pittsburgh Cancer Institute, Pittsburgh, PA. (Tracking ID #2198803)

BACKGROUND: “Vaping” with electronic nicotine delivery systems (ENDS) has been increasing since these products entered the US consumer market about a decade ago. ENDS devices, more commonly referred to as e-cigarettes, hookah pens, or vapor pens, present dilemmas for public health advocates and regulatory agencies. For example, while ENDS may be valuable for cigarette smoking cessation among established adult smokers, thousands of non-cigarette smoking individuals are now experimenting with ENDS, which may lead to subsequent sensitization to nicotine and transition to cigarette smoking. ENDS are available in flavorings and packaging which may be attractive to youth. Furthermore, there are limited data on the toxicant load associated with use of these devices. Assessing public sentiment surrounding these products may help guide interventions by discovering information such as apparent misconceptions. Open-ended qualitative assessment of publicly available discussion such as that on social media may help focus researchers on rich data to which millions of people are exposed. Therefore, the purpose of this study was to qualitatively analyze publicly available information on Twitter related to ENDS.

METHODS: We selected Twitter not only because of its extreme popularity (about 400 million “Tweets” consisting of no more than 140 characters each are exchanged each day) but also because of ease of data collection via a programming interface. We focused data collection on one particular day—Thursday, September 18, 2014—which was promoted as “World Vape Day” by multiple businesses, organizations, and individuals. By focusing on this particular day, we hoped to access a valuable perspective on public discourse and perceptions surrounding ENDS use. We retrieved all Tweets and meta-data from the Twitter live-stream using customized software that filtered by relevant keywords, including “e-cig”, “e-hookah,” “vape,” “vapes,” and “vaping.” Two independent coders coded a random sample of 1000 Tweets related to ENDS and developed a comprehensive codebook through an iterative process based on grounded theory. This approach allowed us to (1) better understand public discourse surrounding ENDS use and the nature of World Vape Day specifically, (2) develop a structured content analysis framework (i.e., codebook) that future research projects may utilize or adapt, and (3) provide an open source software tool for other researchers to more-easily utilize live Twitter data for similar projects.

RESULTS: The filtered Twitter stream resulted in 5205 tweets over a strategically selected 12 h span. Five random subsamples of 200 tweets were double-coded and discussed in order to develop and refine the coding framework. This resulted in broad coding categories including positive and negative sentiment, health- and policy-related, cigarette-related, and marketing. The coders then independently coded a randomized subsample of 1000 different ENDS-related tweets. Inter-rater agreement for each coded variable was good-to-perfect (Cohen’s kappa ranged from 0.56 to 1.00 depending on the variable). Marketing-related messages were highly prevalent (41 %), while only 8 % of Tweets were related to health and only 3 % were related to policy or law. Of non-marketing tweets, coders detected more positive than negative sentiment (24 vs. 13 %). Open-ended content analysis yielded additional nuance to each of the broad coding categories and revealed valuable insights into contextual associations with ENDS in public discourse. For example, marketing messages focused on diversity of ENDS devices and associated parts/accessories for modifying and refilling them (e.g., high-power batteries, unique shapes and colors, novel flavors of “vape juice” or “e-liquid”). Users frequently referred to flavorings, social settings and social approval, and modifications (i.e., “mods” such as building, modifying, or personalizing ENDS devices). Young adults and teenage users seemed to focus on general social approval (e.g., “coolness”) and use at school.

CONCLUSIONS: Examination of Tweets exchanged on “World Vape Day” provided a valuable window into discourse from ENDS marketers and end-users. After an appropriate iterative codebook development process, double-coding was internally consistent. Available data suggest that ENDS represents a highly active area ripe with technical innovation by marketers and consequent excitement and invigoration among users. While the medical and public health community are actively interested in potential health implications and legal loopholes potentially created by this phenomenon, these themes were not commonly manifested in our sample of Tweets. These are trends of which researchers and practitioners should be aware when engaging in dialogue related to ENDS usage. Continued research and effective translational approaches are needed to inform the medical community of these emerging trends in ENDS use, which is a growing medical and public health concern.

INAPPROPRIATE NONFORMULARY REQUESTS: FORMULARY COMPLIANCE THROUGH CLINICAL DECISION SUPPORT IN AN ACADEMIC MEDICAL CENTER Qoua L. Her 1, 2; Mary Amato1, 2; Diane L. Seger1, 3; James F. Gilmore1; John Fanikos1; Julie Fiskio3; David W. Bates1, 3. 1Brigham and Women’s Hospital, Boston, MA; 2Massachusetts College of Pharmacy and Health Services University, Boston, MA; 3Partners Healthcare, Wellesley, MA. (Tracking ID #2195247)

BACKGROUND: Formularies are widely accepted as a cost containment tool, and can also help enhance medication safety, quality of care, and improve care efficiency.(1) Medicare and The Joint Commission require a formulary for reimbursement and hospital accreditation, respectively. The Joint Commission expanded their requirement mandating hospitals to at least review their formulary annually base on emerging safety and efficacy information, standardizing and limiting available drug concentrations, and implementing a process to select, approve, and procure nonformulary medications (NFM).(2) Such mandate expansion has the potential to increase hospital cost beyond the cost-savings of formularies in the form of physician and pharmacist time complying with formulary policies.(1) Appropriate clinical decision support (CDS) for formulary management can help realize these cost-savings. We evaluated a NFM system at a large academic medical center, quantified the proportion of inappropriate NFM requests, and used the results to develop best practice guidance on the design of automated formulary management systems.

METHODS: All approved NFM requests from Brigham and Women’s Hospital from 2009 to 2012, were extracted and quantified according to the American Hospital Formulary System (AHFS) Classification. A random sample of 2000 approved NFM requests were selected for preliminary ‘reason of NFM request’ analysis. Reasons were categorized and presented to an interdisciplinary panel of physicians, nurses, and pharmacists, where NFM appropriateness criteria were developed. A random sample of 206 requests from 2012 of the 11 most expensive and most frequently approved NFMs were further reviewed for appropriateness using the interdisciplinary appropriateness criteria by two pharmacists. Agreement between the reviewers was assessed using a Cohen’s kappa. Best practice guidance for automated formulary management systems were developed from these findings.

RESULTS: A total of 223,266 original NFM requests were approved between 2009 and 2012. The top 50 % of these approvals were classified into six AHFS Tier 2 Classes. Psychotherapeutic agents accounted for one-fifth of all NFM approvals, where quetiapine and olanzapine accounted for 62.6 % of all psychotherapeutic agents approved. We found that 46.9 % of the reasons for NFM requests provided no or marginal value for nonformulary appropriateness evaluation and could be considered inappropriate at the point-of-care. Approximately one-third of all approved NFM requests were for chronic or pre-admission medications. Other reasons listed includes disease/conditions, specialist or pharmacist recommendation, failure or intolerant of formulary alternatives, allergy or contraindication, end-of-life care, and medication interactions. The interdisciplinary panel simplified the complex NFM request reasons into four NFM appropriateness criteria. The review of 206 inpatient charts estimated that approximately 18 % of all approved NFM request were truly inappropriate. We recommend the following features for any automated formulary management system; 1) require prescribers to provide a ‘valid’ reason for NFM request to enhance retrospective medication utilization review (MUE) and trending; 2) provide pharmacists with a ‘comment option’ at the point of computer order verification to address inappropriate requests or reasons that provide no or marginal value for retrospective MUE; 3) utilize drop-down menus for standard and common NFM request reasons to facilitate deployment of more complex CDS, such as automated interchange for specific indications; and 4) begin annual clinical decision support and formulary reviews with the most expensive and commonly requested NFM (psychotherapeutic agents).

CONCLUSIONS: We found that nearly one-fifth of all NFM requests at our institution were inappropriate. Optimization of the NFM computer system could decrease the proportion of inappropriate NFM requested and improve cost-savings. NFM request systems with better tracking and trending features will guide better CDS development for automated formulary management. This study was funded by grant #U19HS021094 from the Agency for Healthcare Research and Quality (AHRQ). 1. Helmons PJ, Kosterink JG, Daniels CE. Formulary compliance and pharmacy labor costs associated with systematic formulary management strategy. Am J Health Syst Pharm. 2014;71(5):407–15. doi:10.2146/ajhp130219 2. Rich DS. New JCAHO medication management standards for 2004. Am J Health Syst Pharm. 2004;61(13):1349–58.

SIMILARITIES AND DIFFERENCES IN COMMUNITY, ACADEMIC, AND HEALTHCARE STAKEHOLDERS’ PERSPECTIVES OF IMPORTANT CONTRIBUTORS TO TRUST IN RESEARCH PARTNERSHIPS Leah Frerichs 1; Crystal W. Cene2; Gaurav Dave2; Mimi Kim2; Tiffany L. Young2; Anne Cheney3; Jessica Burke4; Jennifer Jones4; Arlene Brown5; Linda Cottler6; Giselle M. Corbie-Smith1, 1. 1University of North Carolina, Chapel Hill, NC; 2University of North Carolina at Chapel Hill, Chapel Hill, NC; 3University of Arkansas, Fayetteville, AR; 4University of Pittsburgh, Pittsburgh, PA; 5University of California, Los Angeles, Los Angeles, CA; 6University of Florida, Gainesville, FL. (Tracking ID #2194545)

BACKGROUND: Community engagement is recognized as critical to furthering translation of evidence to practice and improving quality of care. Research partnerships among community, academic, and healthcare institutions have become a common avenue for community engagement, a recommended strategy to address health disparities. These partnerships have found that trust between the diverse stakeholders is foundational to their success; yet, there has been limited empirical research on determinants of trust. The objective of this study was to determine the similarities and differences among community member, academic researcher, and healthcare provider stakeholders’ perspectives on important contributors to creating and maintaining trust within research partnerships.

METHODS: Across four institutions (University of Arkansas, University of California Los Angeles, University of Florida, and University of North Carolina) with Clinical and Translational Science Awards, we conducted concept mapping sessions with participants from three stakeholder groups. A fifth site, University of Pittsburgh, served as the data coordinating center. Each site conducted brainstorming sessions with each stakeholder group to generate lists of statements viewed as contributing to trust in community-academic research partnerships. All participants rated each statement by level of importance for creating and maintaining trust using a 5-point Likert scale (1 = not important, 5 = very important). Data were analyzed using Concept Systems Global Max©. Multi-dimensional scaling and hierarchical cluster analysis were used to determine statements that clustered together based on sorting and rating data, and clusters were collaboratively labeled by each stakeholder group. We compared and contrasted average ratings of statement clusters and assessed correlation of all statement ratings across stakeholder groups.

RESULTS: Participants (n = 65 community members, n = 74 academic researchers, and n = 47 healthcare providers) generated 125 unique statements that clustered into the following five themes: mutually respectful relationships, authentic communication, committed partnerships, sustainability, and communication and methodology to anticipate changes. Community members overall average rating of statements was higher (4.20) than academic researchers (4.10) and healthcare providers (4.02). Ratings of importance for creating and maintaining trust were highly correlated (r = 0.96 and r = 0.93) between academic researchers and healthcare providers, and less correlated between healthcare provider and community members (r = 0.36 and r = 0.58) and academic research and community members (r = 0.31 and r = 0.81). Figures 1 and 2 provide ladder graphs of average importance ratings of statement clusters by stakeholder group. The ranked order of average importance (i.e., lowest to highest) of the five clusters differed for community members compared to academic researchers and healthcare providers.

CONCLUSIONS: While there were similarities, we also found important differences between the ratings of the three stakeholder groups. Healthcare providers and academic researchers often have overlapping roles and similar work cultures that likely contribute to greater correlation in their importance ratings. Without proper attention, there is a risk that these similarities will mutually reinforce perspectives that differ from community members and create power imbalances that undermine trust between community members and researchers; thereby, potentially reducing efficiency (e.g., recruitment of underserved research participants) and quality (e.g., completeness of self-reported data) of research. Our findings identified specific areas of convergence and divergence of perspectives, which may be leveraged to improve trust. For example, partnership sessions could use role-playing exercises to help stakeholders build upon common perspectives as well as understand differences. More research is merited to explore the mechanisms that create differences in stakeholders perspectives of trust.

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COMMUNITY HEALTH WORKERS ARE ASSOCIATED WITH PATIENT REPORTED ACCESS TO CARE WITHOUT AFFECT ON SERVICE UTILIZATION AMONG LATINOS WITH POORLY CONTROLLED DIABETES Aileen Chang 1; Victor Cueto1; Hua Li1; Bhavana Singh3; Sonjia Kenya2; Yisel Alonzo1; Olveen Carrasquillo1. 1University of Miami, Miami, FL; 2University of Miami Miller School of Medicine, Miami, FL; 3Duke University, Durham, NC. (Tracking ID #2190676)

BACKGROUND: Community health workers (CHWs) are one promising approach to improve diabetes care among vulnerable populations. However, few rigorous randomized studies have evaluated the impact of CHWs on service utilization. The Miami Health Heart Initiative (MHHI) was a clinical trial testing the impact of a CHW intervention on physiologic outcomes among low-income Hispanics with poorly controlled diabetes versus usual care (USC). Preliminary data from MHHI suggests that as compared to the USC group patients randomized to the CHW group had improvements in blood pressure and hemoglobin A1C. In this abstract we report the impact of the CHW intervention on access to care and service utilization.

METHODS: We analyzed data from 215 Hispanics with poorly controlled diabetes recruited via physician referral and electronic medical record (EMR) from Miami’s public hospital system. Self-reported access to care measures were similar to those used in the Medical Expenditure Panel Survey (MEPS) and included the ability to access care when needed, obtain needed medications, ability to contact physicians and communicate in language of choice. Self reported utilization measures were also collected using MEPS questions and included number of care encounters and percent with inpatient stay. We also abstracted utilization data on outpatient visits, emergency room (ER) visits and hospitalizations from the EMR at the public hospital. Statistical significance of continuous outcomes were examined using the t-test if normally distributed or the Kruskall-Wallis test when not normally distributed. Categorical variables were examined using chi-square comparisons or generalized estimating equation (GEE) modeling when needed. We also performed logistic regression adjusted for age, gender, education, depression, and comorbidities on access to needed health care and medications.

RESULTS: This was a vulnerable population with 42 % having less than 12 years of education and 72 % were depressed. At 1 year, we found statistically significant differences in 2 of 4 self-reported access to care measures. For example, 30 % of the participants in the CHW group reported inability to access care in the last year compared to 43 % in the USC group (p = 0.04). Additionally, 28 % of the participants in the CHW group reported inability to access medications in the last year compared to 41 % in the USC group (p = 0.03). The differences in access to needed care and needed medications persisted after adjustment for age, gender, education, depression, and comorbidities with (OR = 0.52, 95 % CI = 0.29, 0.93) and (OR = 0.45, 95 % CI = 0.24, 0.82) respectively. Self-reported measures of utilization were similar in both groups with a median of seven care encounters in the past year and about a third reporting an inpatient stay in the last year. Similarly, EMR review found similar rates of outpatient visits, ER utilization and percentage having as hospital stay in the last year between the CHW and USC groups.

CONCLUSIONS: Among patients with diabetes, a greater percentage of those having a CHW intervention reported access to care but we found no significant changes in service utilization.

A COMPARISON OF IHI OPEN SCHOOL TO A FACULTY-LED QUALITY IMPROVEMENT AND PATIENT SAFETY CURRICULUM FOR UNDERGRADUATE MEDICAL EDUCATION Jason Fish 1; Michael Burton1; Tammy Chung2; Deepa Bhat2; Meredith Mayo2. 1UT Southwestern, Dallas, TX; 2UT Southwestern Medical Center, Dallas, TX. (Tracking ID #2198367)

BACKGROUND: Education in the principles and practice of quality improvement (QI) and patient safety is now required in undergraduate medical education. Most QI curriculum studies involving medical students have utilized didactics and web-based learning, with the majority providing less than 10 h of contact hours. Student knowledge, attitudes, and beliefs have been the mainstay of assessments, with no literature found focusing on assessment of QI skills or self-efficacy. In addition, the lack of resources and faculty expertise in QI have led to many institutions turning to online curricula. While requiring less faculty participation, the relative effectiveness and acceptance of online learning modules in QI has not been determined. This study evaluates the comparative effectiveness of a well-established online QI curriculum (online) with a Faculty-led face-to-face curriculum (pilot) for undergraduate medical education.

METHODS: Third-year medical students rotating through the University of Texas Southwestern Medical School Internal Medicine and Family Medicine services from July 2012 to June 2013 were included in this study. Students were randomly assigned to either a series of four weekly live didactic sessions with an applied, simulation project or to complete a predetermined subset of the Institute for Healthcare Improvement’s Open School online modules. The objectives for both curricula included 1) understanding basic concepts of QI/PS, 2) developing specific aim statements and identifying key stakeholders; 3) understanding fundamental concepts of measurement; 4) learning QI tools; and 5) recognizing human factors associated with change. All participants were asked to complete a modified Quality Improvement Knowledge Assessment Tool (QIKAT) at the beginning and conclusion of the study period. The QIKAT assesses attitudes and beliefs as well as QI skills through the use of clinical scenarios to identify improvement strategies. At the end of each 4 week period, students were asked to complete an online survey on student satisfaction, perceived effectiveness, and self-efficacy on being able to participate in, teach, and lead QI projects.

RESULTS: One hundred seventy-four students participated in the study—86 in the pilot and 88 in the online. Completion rates for the monthly surveys were 64 % (pilot) and 75 % (online). Using a Likert scale 1 to 5 (1 being least satisfied/comfortable and 5 being most satisfied/comfortable) for the monthly survey, the mean scores for the pilot and online groups were as follows: effectiveness of course 3.47, 2.91 (p < 0.001); satisfaction with course delivery 3.48, 2.88 (p < 0.001); confidence in participating in QI project 3.10, 2.61 (p < 0.01); confidence in teaching QI principles 2.62, 2.38 (p = 0.08); and confidence with leading a QI project 2.50, 2.28 (p = 0.13). The modified QIKAT clinical scenario section was assessed with a 10 point score. The pilot group had 97 and 93 % completion rates for the pre- and post-surveys respectively; the online group had 83 and 82 % completion rates for the surveys respectively. The pre- and post-test average QIKAT scores for the pilot group were 2.77 and 3.12; the scores for the online group were 2.70 and 2.54. There was no difference between the pilot and online groups for the pre-test or post-test mean scores (p = 0.72; p = 0.08), nor between the paired pre- and post-test means (pilot p = 0.27; online p = 0.95). The components of the QIKAT score included assessment of skills involving specific aim statements, stakeholders, current knowledge and processes, measurement and intervention design, and continous process improvement strategies. The pilot group had statistically significant higher scores on specific aim statements (p < 0.01) and trended towards significance on identifying processes and stakeholders (p = 0.07). There were no statistical significant differences in the other skills.

CONCLUSIONS: Our research indicates students in the face-to-face pilot program reported the course as more effective and more satisfying than those students in the online program. Students in the pilot also reported greater self-efficacy for future participation in QI projects than the on-line group. Although the study did not demonstrate a difference in overall effectiveness by objective measures, our study did indicate that the combination of didactics with an applied, simulation project improved some QI skills. More research is needed to identify important strategies to achieving sustainable and significant gains in applying QI/PS knowledge and demonstrating skills.

A QUALITATIVE EXAMINATION OF ATTITUDES TOWARD SMOKE-FREE POLICIES AMONG HOMELESS ADULTS Maya Vijayaraghavan 1, 2; Samantha Hurst2; John Pierce1, 2. 1University of California, San Diego, San Diego, CA; 2Division of Health Policy, San Diego, CA. (Tracking ID #2192801)

BACKGROUND: Smoke-free policies in indoor and some outdoor public spaces and the workplace has become normative in many states across the United States. These policies are an integral component of current population-wide tobacco control efforts. While there is widespread support for these policies among the general public, attitudes toward these policies among populations where the majority are smokers, such as the homeless population (70–80 % smoking prevalence), is unknown. In this study, we examined attitudes toward smoke-free policies among sheltered homeless adults.

METHODS: Quantitative and qualitative data were collected from 65 current and former smokers residing in seven transitional, or long-term homeless shelters in San Diego County. All of the participating shelters had indoor smoking restrictions, and four facilities also had outdoor bans on smoking. We administered a questionnaire to participants on smoking behaviors and perceived norms around smoking, and conducted eight focus groups to discuss attitudes toward smoke-free policies. We examined the association of smoke-free policies and perceived norms around smoking. We used a directed qualitative content analysis approach to analyze the focus group transcripts.

RESULTS: The sample included 62 current smokers and 3 former smokers. The mean age was 43.1 years (SD 11.5), 44.6 % were male, and 49.2 % were white. Average daily cigarette consumption for current smokers was 8.9 cigarettes per day. Approximately half the current smokers reported making a quit attempt in the past year. Fewer than one-fourth reported using nicotine replacement therapy or medications in a prior quit attempt. The majority of participants who lived in facilities that had fewer restrictions on smoking reported that staff smoked with them during breaks compared to those living in facilities with more restrictions (p < 0.001). In focus group interviews six major themes emerged: attitudes toward smoke-free policies, support for smoke-free housing, the use of electronic cigarettes, addictive potential of cigarettes, vulnerability to tobacco industry marketing, and interest in smoking cessation. The majority of current smokers and all former smokers were supportive of smoke-free policies because they limited secondhand smoke exposure to non-smokers and children. However, some current smokers who felt that the policies thwarted their autonomy to smoke felt marginalized by neighborhood-wide and countywide smoke-free policies. All current smokers were supportive of and did not express concerns about transitioning to low-income smoke-free housing. Cigarette smokers had tried electronic cigarettes because of the perception that they were safe and could be smoked in areas where smoking was prohibited, and/or used as a cessation aid. Some of the current smokers described their vulnerability to tobacco industry marketing, and felt targeted in part due to their addiction to nicotine and challenges with smoking cessation. The majority of current smokers described interest in smoking cessation and highlighted potential strategies to aid in smoking cessation attempts.

CONCLUSIONS: The general acceptance of smoke-free policies may highlight a shift in social norms around smoking in the homeless population; such policies may present an important strategy to reduce social inequalities and health disparities related to tobacco use among vulnerable populations. Findings highlight potential opportunities to increase acceptance of such policies and to educate about the potential risks of electronic cigarettes among the homeless population.

A SILVER-LINING IN THE CLOUDS? A QUALITATIVE ANALYSIS OF PATIENT’S SENTIMENTS ON HOSPITALIST SERVICE CHANGES Charlie M. Wray 1; Jeanne M. Farnan1; Vineet M. Arora2; David Meltzer1. 1University of Chicago, Chicago, IL; 2University of Chicago Medical Center, Chicago, IL. (Tracking ID #2196253)

BACKGROUND: Inpatient service handoffs are a frequent source of discontinuity in inpatient care. Despite the large amount of research on handoffs, none has described the patient perspective when cared for by a hospitalist physician. We sought to qualitatively describe hospitalized patient’s experiences regarding service changes and develop a conceptual framework from which to understand the patient perspective for future research.

METHODS: We approached hospitalized patients on the non-teaching hospitalist service at an academic tertiary care medical center whose hospitalizations spanned a weekly service change. Consenting patients were administered a semi-structured interview developed to elicit their perspective regarding physician service change. Questions were informed by expert opinion and existing literature review. All responses were digitally recorded, deidentified and transcribed. Grounded theory was utilized, with an inductive approach with no a priori hypotheses. The constant comparative method was used to generate emerging and reoccurring themes. Units of analysis were sentences and phrases. MAXQDA 11 was used to ease analysis.

RESULTS: The overall response rate was 96 % (22/23). Respondents had a mean age of 53.6 years (±15.6), with 60 % being female, and 56 % African American. At the time of interview, respondents had a mean LOS of 6.8 days (±4.0) and averaged 2.3 (±0.6) hospitalists/patient. The analysis yielded 192 discrete mentions that were mapped into 20 themes representing patients’ thoughts on hospitalist changeovers. Predominant themes were: importance of communication (82 %, 18/22), a lack of concern about the transition (63 %, 14/22), a lack of awareness that the transition had occurred (50 %, 11/22), new opportunities with a fresh doctor (36 %, 8/22) (ie. “I really liked her… she looked at my ears, when the first doctor never did.”), bedside manner (36 %, 8/22) (i.e. “…he sat down with me and spent the time to talk to me. I liked that.”), and trust (32 %, 7/22). Like themes were assembled into larger domains of construct, which included: communication, doctor-patient relationship, and systems-based issues.

CONCLUSIONS: The cloudy nature of service changes is evident from the findings that although almost all patients mentioned the importance of communication, only half were aware that a transition had occurred. Interestingly, some viewed service changes as a positive opportunity to address their care needs with a new doctor, appreciated good bedside manner, and trusted their new physician. These sliver linings could represent an opportunity for hospitalists to rapidly form effective doctor-patient relationships with their patients. Better education of patients as to the occurrence and potential positive and negative effects of inpatient service changes is needed to both understand and improve care transitions from a patient-centered perspective.

APPROPRIATENESS OF ECHOCARDIOGRAPHY ORDERING IN AN AMBULATORY INTERNAL MEDICINE RESIDENT CLINIC. Abdulaziz R. Algethami1; Rajan S. Bhatia 1; brian Wong2; Tina Borschel1. 1Women’s College Hospital, Toronto, ON, Canada; 2Sunnybrook Health Science Centre, Toronto, ON, Canada. (Tracking ID #2194950)

BACKGROUND: The American college of echocardiography had published criteria for appropriate use of echocardiography (AUC) to ensure echocardiography services are utilized in ways that will most impact patient care. Previous studies have suggested increased rates of inappropriate ordering of echocardiography in the ambulatory environment, but to date there is little data about echocardiography appropriateness in a medical resident run clinic.

METHODS: We conducted a retrospective chart review to examine outpatient transthoracic echocardiogram ordering by internal medicine residents over a 12 month period. We classified echocardiograms ordered into three categories: Appropriate (A), Inappropriate (I) and Uncertain (U) as per the 2011 AUC criteria for transthoracic echocardiography.

RESULTS: A total of 61 echocardiograms were reviewed. The median patient age was 62 ± 18 years (65.5 % female). The proportion of studies classified as appropriate was 82 %. The proportion of inappropriate studies was 8 % and the proportion of uncertain studies was 10 %. The proportional percentage of appropriate studies between males and females was similar. Common inappropriate indications were LV assessment with a recent normal LV assessment (5 %), presyncope without symptoms or signs of cardiac disease (2 %) and for initial diagnosis of pulmonary embolism (2 %).

CONCLUSIONS: Overall, the proportion of inappropriate echocardiograms ordered in this resident run clinic was lower than has been previously reported in outpatient studies. It is possible that education and initiatives such as the Choosing Wisely campaign have improved appropriate ordering.

ASSOCIATION BETWEEN THYROID DYSFUNCTION AND ANEMIA: A LARGE POPULATION-BASED STUDY Khadija M’Rabet-Bensalah1; Christine Baumgartner 1; Michael Coslovsky5; Tinh-Hai Collet4; Wendy P. den Elzen3; Robert N. Luben2; Anne Angelillo-Scherrer1; Drahomir Aujesky1; Kay-Tee Khaw2; Nicolas Rodondi1. 1Inselspital, Bern University Hospital, Bern, Switzerland; 2University of Cambridge, Cambridge, United Kingdom; 3Leiden University Medical Center, Leiden, Netherlands; 4University Hospital of Lausanne, Lausanne, Switzerland; 5University of Bern, Bern, Switzerland. (Tracking ID #2191357)

BACKGROUND: Anemia and abnormal thyroid function are common disorders that often co-occur in the elderly. Most textbooks and guidelines mention that thyroid-stimulating hormone (TSH) should be measured in the work-up of anemia. However, data on the association between thyroid dysfunction and anemia are scarce.

METHODS: In the population-based European Prospective Investigation of Cancer (EPIC)-Norfolk cohort, we examined 12,972 men and women aged 39–79 years with measured thyroid function and hematological parameters. Thyroid dysfunction was defined as hypothyroidism when TSH was >4.49 mIU/L, either subclinical (SHypo) with normal free thyroxine (FT4) or overt (OHypo) with low FT4, and as hyperthyroidism when TSH was <0.45 mIU/l, either subclinical (SHyper) with normal FT4 or overt (OHyper) with elevated FT4. Anemia was defined as hemoglobin (Hb) <13 g/dL for men and <12 g/dL for women based on the WHO definition. We examined the association between thyroid function and anemia, as well as Hb levels, using linear regression models first with adjustment for age and gender, then for other potential confounding factors. After excluding common causes of anemia, we also compared the prevalence of anemia according to different thyroid functionality groups.

RESULTS: Among 12,972 participants, 55 % were women and the mean age was 58.9 ± 9.5 years. Prevalence of thyroid dysfunction was 1.7 % OHypo, 5.6 % SHypo, 0.6 % OHyper, and 2.8 % SHyper. Anemia was observed in 1058 participants (8.2 %) and was more prevalent among those with thyroid dysfunction (10.3 %) compared to those in euthyroid state (7.9 %). The risk of anemia was increased for OHypo with an age and gender adjusted risk ratio (RR) of 1.55 [95 % confidence interval (CI) 1.10, 2.18] and OHyper with RR 1.86 [CI 1.12, 3.10], but not for SHypo (RR 1.06 [CI 0.84, 1.35]) and SHyper (RR 1.07 [CI 0.77, 1.49]). Hb concentration was decreased in participants with both higher and lower TSH levels (p for quadratic pattern <0.001) in age and sex adjusted analyses, but this association was only significant for participants with OHypo (Hb 0.19 g/dl lower [CI [−0.34, −0.04]) and remained significant after additional adjustment for BMI, smoking, and diabetes. After excluding participants with common causes of anemia, such as iron deficiency, inflammatory disease, and kidney disease, 8.8 % of participants with OHypo (p= 0.048), 16.3 % with OHyper (p= 0.005), 5.6 % with SHypo (p= 0.49) and 3.78 % with SHyper (p= 0.60) had anemia compared to 4.9 % of the euthyroid participants.

CONCLUSIONS: Overt hypothyroidism and overt hyperthyroidism, but not subclinical thyroid dysfunction, are associated with a higher prevalence of anemia. Given these data from the largest population-based study on this issue, TSH measurement is likely indicated only after excluding other common causes of anaemia.

ASSOCIATIONS BETWEEN TEACHING EFFECTIVENESS SCORES AND CHARACTERISTICS OF PRESENTATIONS IN HOSPITAL MEDICINE CONTINUING EDUCATION

John T. Ratelle; Christopher M. Wittich; Roger Yu; James Newman; Sarah Jenkins; Thomas J. Beckman. Mayo Clinic, Rochester, MN. (Tracking ID #2193724)

BACKGROUND: Hospital medicine (HM) is the fastest growing medical specialty in the United States. As HM evolves, the need for successful continuing medical education (CME) will be increasingly important. The Society for Hospital Medicine (SHM) recently developed core competencies for CME. However, there is little research regarding characteristics of effective CME presentations in HM. Our objectives were to describe the traits of participants at a national HM CME course, and to identify associations between validated CME teaching effectiveness scores and characteristics of CME presentations in the field of HM.

METHODS: This was a cross-sectional study of 368 participants, and 30 presenters delivering 32 didactic presentations, at a Mayo Clinic HM CME course in 2014. Participants provided CME teaching effectiveness (CMETE) ratings, which were obtained from an instrument with known content, internal structure, and criterion validity evidence (Wittich et al. JGIM. 2011). The instrument has the following 8 items: 1) clear and organized, 2) relevant, 3) case-based, 4) effective slides, 5) audience interactivity, 6) supporting literature, 7) appropriate length and 8) summary slide. For statistical analysis, overall CMETE scores (5-point scale: 1 = strongly disagree; 5 = strongly agree) were averaged across items and participants for all presenters. We estimated that this study of > 200 participants would provide > 90 % power to detect a medium Cohen’s effect size of 0.25 for associations between CMETE scores and variables related to characteristics of presentations. Associations between the CMETE overall scores and presentation characteristics were determined using the Wilcoxon rank sum or Kruskal-Wallis test, as appropriate. The threshold for statistical significance was set at p < 0.05.

RESULTS: A total of 277 out of 368 participants (75.3 %) returned evaluations, yielding 7947 ratings for statistical analysis. Overall, course participants (number, %), described themselves as hospitalists (181, 70.4 %), ABIM certified with HM focus (48, 18.8 %), physicians with MD or MBBS degrees (181, 70.4 %), nurse practitioners or physician assistants (52; 20.2 %), and in practice > 20 years (73, 28 %). The majority of participants (148, 53.4 %) worked in private practice, while only 63 (24.8 %) worked in academic settings. CMETE scores (mean [SD]) were significantly associated with the use of audience response (4.64 [0.16]) versus no audience response (4.49 [0.16]; p= 0.01), longer presentations (>30 min: 4.67 [0.13] versus < 30 min: 4.51 [0.18]; p= 0.02), and larger number of slides (>50: 4.66 [0.16] versus < 50: 4.55 [0.17]; p= 0.04). There were no significant associations between CMETE scores and use of clinical cases, defined goals, or summary slides.

CONCLUSIONS: To our knowledge, this is the first study regarding associations between validated teaching effectiveness scores and characteristics of effective CME presentations in HM. Course participants were diverse in terms of types of providers and practice settings. Our findings, which support previous research in other fields, indicate that CME presentations may be improved by increasing interactivity through the use of audience response systems, in addition to allowing longer presentations. Future research should determine whether course content that reflects the SHM core competencies improves the quality of CME presentations.

BASELINE OPIOID USE AS A PREDICTOR OF TELECARE COLLABORATIVE PAIN MANAGEMENT OUTCOMES

Erin E. Krebs 2, 3; Kurt Kroenke4, 1; Jingwei Wu1; Matthew J. Bair4, 1; Zhangsheng Yu1. 1Indiana University, Indianapolis, IN; 2Minneapolis VA Health Care System, Minneapolis, MN; 3University of Minnesota, Minneapolis, MN; 4Roudebush VAMC, Indianapolis, IN. (Tracking ID #2192185)

BACKGROUND: Use of opioids for chronic pain is controversial. Among patients with chronic pain, receipt of opioid therapy is associated with worse pain, disability, and mental health. Furthermore, longitudinal observational studies have reported that patients treated with opioids have poorer functional outcomes than those not treated with opioids. These observations have led to concerns that patients receiving opioid therapy may be resistant to pain management or that opioids may interfere with treatment response. We conducted a secondary analysis of data from the Stepped Care to Optimize Pain Care Effectiveness (SCOPE) randomized trial, which compared a telephone-based collaborative analgesic optimization intervention to usual care over 12 months. Our objectives were to 1) characterize factors associated with baseline opioid use among SCOPE participants and 2) determine whether baseline opioid use predicted pain outcomes. We hypothesized that participants with baseline opioid use would have worse pain, disability, and mental health comorbidity at baseline and that baseline opioid use would predict worse pain outcomes over 12 months.

METHODS: SCOPE participants were 250 VA primary care patients with chronic musculoskeletal pain of at least moderate severity. Participants were randomized to either intervention or usual care. Those assigned to the intervention group received 12 months of automated symptom monitoring, telephone-based nurse care management, and algorithm-guided analgesic optimization. Analgesic optimization focused primarily on active adjustment of non-opioid medications. The intensity of opioid therapy remained stable over the course of the trial. The primary trial outcome was the total score (0 to 10) on the Brief Pain Inventory (BPI), which assesses pain intensity and functional interference. For this analysis, we used chi-square and t-tests to conduct unadjusted comparisons between opioid users and non-users at baseline. We used multivariable logistic regression to examine cross-sectional associations with baseline opioid use; the model included variables that were theoretically related to opioid use or associated at the p ≤ 0.2 level in unadjusted comparisons. Finally, we used mixed-effect models for repeated measures (MMRM) to examine baseline opioid use as a predictor of the primary pain outcome (i.e., BPI score).

RESULTS: At baseline, 84 (33.6 %) trial participants reported use of prescribed opioid analgesics. In unadjusted comparisons, opioid users had worse baseline BPI total scores (6.2 vs. 4.7), more painful sites (5.5 vs. 4.6), and more medical comorbidities (2.3 vs. 1.9) than non-users. They were also less likely to be employed (52.4 vs. 69.9 %), more likely to have depression (42.9 vs. 14.5 %), more likely to smoke (35.7 vs. 19.9 %), and more likely to have high disability days in the past month (53.6 vs. 21.1 %). In the multivariable model examining baseline associations, only baseline pain (p= 0.006) and disability days (p= 0.036) were independently associated with baseline opioid use. In the model examining predictors of outcomes over 12 months, which included baseline BPI, treatment group assignment, disability days, depression, and smoking, there was no statistically significant effect of baseline opioid use (p= 0.98) on BPI score. In contrast, treatment group assignment, baseline BPI, and time were all significant predictors of BPI over 12 months. A test for interaction between baseline opioid use and treatment group assignment was not statistically significant (p= 0.95).

CONCLUSIONS: In this analysis of data from a randomized controlled trial of telecare collaborative pain management, we found that baseline opioid use did not predict the primary pain outcome and did not modify the intervention’s beneficial effect on pain. Results of our cross-sectional analyses were consistent with prior studies, showing that patients receiving opioid therapy at baseline had worse baseline pain, disability, and mental health than patients not receiving opioid therapy; in the adjusted model, pain and disability were independently associated with opioid use. We are encouraged by our finding that response to the collaborative pain management intervention was not significantly affected by pre-existing opioid therapy. Although patients on opioids were more distressed at baseline, they benefited from a relatively low-intensity telephone-based intervention involving symptom monitoring and optimization of primarily non-opioid analgesics. Given growing concerns about harms of long-term and high-dose opioid therapy, future research should examine whether a modified collaborative management protocol could be an effective strategy to achieve dual goals of improving pain outcomes and reducing intensity of opioid therapy.

BRIEF COMMUNICATION CURRICULUM IMPROVES DISCHARGE SUMMARY QUALITY

Valerie Perel1; Adam Carrington2; Michael Janjigian4; Verity Schaye2; Rachel Shur2; Jessica Taff3; Ellen Wagner 2; David Wei2; Meng Yang5; Lisa Altshuler2. 1NYU Department of Internal Medicine, New York, NY; 2NYU School of Medicine, New York, NY; 3New York University, New York, NY; 4New York University School of Medicine, New York, NY; 5Columbia University Mailman School of Public Health, New York, NY. (Tracking ID #2198189)

BACKGROUND: Good written communication is essential to maintaining continuity of care across transitions and minimizing adverse outcomes. Written discharge summaries (DCS) are the main mechanism for communication between hospital providers and those caring for the patient after discharge. Short-cuts such as “cut and paste” that are often used to save time when writing notes can lead to poor quality documentation. Improvements in DCS have been shown to reduce patient medication errors and other adverse events. To improve the quality of written communication at our institution, we provide interns and residents on a specialized inpatient ward rotation (Bedside Skills Team (BST)) a session on both written and verbal communication skills. This study examined the impact of this rotation on the quality of DCS.

METHODS: This study assessed DCS written by 48 Internal Medicine interns at an urban safety-net hospital who were rotating on the BST or a general ward team when they wrote the DCS (21 intervention, 27 control). Four to five DCS per intern written during the rotation were selected for review (102 intervention, 111 control). The intervention group received a one-hour session on note writing reviewing standardized note formats and previous notes they had written. The interns continued to receive feedback on their notes throughout the 2 week rotation by their attending and resident. A rating scale to assess the quality of summaries was developed based on Joint Commission standards and expert consensus. The initial scale consisted of 15 items but was reduced to 11 in order to achieve suitable internal consistency. Four items were rated as present or not present and seven quality items were scored on a three-point Likert scale for a total possible summary score ranging from 4 to 24. Each item had specific descriptors for each anchor point. Coding was done by four experienced physicians blinded to group status. Inter-rater reliability was established by having the four raters rate two DCS that another rater had also rated (kappa .77).20 % of charts were scored by all four raters and reviewed as a group to standardize rating system and establish consensus. Two sample t-tests were computed on the summary score as well as on individual items to assess impact of the rotation.

RESULTS: Mean DCS score for the intervention group was 20.8 (SD 4.2) and for the control group was 17.5 (SD 4.2) with a significant mean difference of 3.3 (p= 0.0002), with a Cohen’s d of 0.78 (large effect size). Interns in the intervention group were less likely than control interns to inappropriately copy and paste information (39 vs 74 % respectively, p < 0.001). Intervention interns were more likely than control interns to chronologically document the History of Present Illness and to clearly list consults and procedures from the hospitalization.

CONCLUSIONS: Interns who engaged in a 2-week rotation with a focus on written and oral communication skills wrote higher quality DCSs compared to trainees who had not received the rotation. In particular, interns in the intervention group produced a more organized, concise and chronological history of present illness, and better described the consultations and procedures completed during the hospital stay. The control group was twice as likely to show evidence of inappropriate copying and pasting of information. Both groups had room for improvement in important patient safety areas (e.g., deficits in medication reconciliation) that need continued focus during resident training. Futures studies should focus on durability of communication skills following a brief intervention.

figurec

Results by item.

CARDIAC VALVE DISEASE IN ADULTS WITH DOWN SYNDROME

Kristin M. Jensen 1; Laura A. Seewald1; Molly Levitt1; Edward R. McCabe2; Francis J. Hickey3; Jeremy R. Nicolarsen3, 4; Joseph Kay4, 3; Amber Khanna4, 3. 1University of Colorado School of Medicine, Aurora, CO; 2March of Dimes Foundation, White Plains, NY; 3Children’s Hospital Colorado, Aurora, CO; 4University of Colorado Hospital, Aurora, CO. (Tracking ID #2192787)

BACKGROUND: The care of adults with Down syndrome (DS) is an emerging field, due to the fact that few persons with DS survived past adolescence until the 1980s. As such, evidence to guide providers of the adult DS population has lagged behind the pediatric population. Children with DS have high rates of congenital heart disease (CHD) with prevalence estimates of 40–60 %. However, case reports in the 1980s–1990s suggest additional risk for acquired valve disease in adults with DS, regardless of their congenital heart disease status. To date, routine echocardiographic screening of adults with DS has not been adopted by the field of Cardiology, likely due to the small size and lack of controls in those early reports. In this study, we sought to systematically evaluate the prevalence of valve disease in adults with DS compared to non-DS adults undergoing echocardiogram for purposes other than known valve disease.

METHODS: We conducted a retrospective chart review from 2006 to 2012 of all persons ages 16–65 years with DS who underwent an echocardiogram at our institution. Controls were randomly identified at ratios of 2.5 controls: 1 case from all persons ages 18–65 years old who underwent an echocardiogram for complaints of syncope or palpitations. Stress and pregnancy echocardiograms were excluded from our analysis. We defined valve disease as the presence of moderate or severe valve disease on echocardiogram. Comparisons were made using t-tests and Pearson’s chi-squared tests as appropriate.

RESULTS: From 2006 to 2012, 81 adults with DS underwent echocardiography at our institution. Compared to non-DS controls (n = 225), adults with DS were younger at the time of their echocardiogram (median age at echocardiogram: DS 30.0y, nonDS 46.0y, p < 0.001) with higher rates of congenital heart disease (DS 73 %, nonDS 19 %, p <0.001). Twenty-eight percent of adults with DS had echocardiographic findings of moderate to severe valve disease vs. 14 % of the non-DS population (p 0.003). In subgroup analysis, we observed valve disease in 14 % of persons with DS and 11 % of persons without DS who did not also have a history of CHD and thus would qualify as truly acquired valve disease (p= 0.452). No differences were found in rates or pathology of valve disease among persons with CHD history regardless of DS status. There were no differences in rates of congestive heart failure, oxygen use, or valve repair between our cohorts. Eisenmenger’s syndrome was seen exclusively in the DS cohort (DS 2.5 %, nonDS 0 %, p= 0.018).

CONCLUSIONS: In this single center retrospective cohort study, we observed valve disease in DS patients both with and without a history of CHD. This indicates that the cardiac history of persons with DS continues to evolve beyond their initial CHD status and suggests the need to adapt recommendations for adults with DS to include screening for acquired valve disease in addition to following for sequelae of their CHD.

CHANGES IN HOSPITALIZED ANEMIC PATIENTS’ FATIGUE WITH RED BLOOD CELL TRANSFUSIONS

Micah T. Prochaska; Richard Newcomb; Andrea Flores; Tamar Polonsky; Andrew Artz; Caitlin Phillips; Sarah Follman; David Meltzer. University of Chicago, Chicago, IL. (Tracking ID #2199099)

BACKGROUND: The current AABB guidelines recommend transfusing red blood cells in hospitalized patients at “restrictive” hemoglobin (Hb) concentrations and for symptoms of anemia. However, studies incorporating objective patient symptoms into transfusion decisions are lacking. Therefore, we sought to measure how anemia related fatigue changes from hospitalization to 30 days post-discharge and whether baseline (in-hospital) Hb and receipt of red blood cell transfusions are associated with changes in fatigue.

METHODS: From May-December 2014, all hospitalized general medicine patients at a single urban academic medical center with Hb < 9 g/dL, were approached for an in-person interview while in the hospital and a 30-day post-discharge phone interview. The Functional Assessment of Cancer Therapy Fatigue Subscale (FACIT) was used to measure fatigue at both times. FACIT scores range from 0 to 52, with lower scores reflecting greater symptoms of fatigue, and score differences of 3 reflect the minimum for a clinically important difference. A “change in fatigue” score was calculated by subtracting responses on the FACIT while hospitalized from responses on the FACIT at the interview 30-days post discharge. Positive change in fatigue scores represented decreased (or improved) fatigue from hospital to 30 days post-discharge. Patients with baseline FACIT scores <31 were considered to have “high” baseline fatigue. Patients’ Hb level and number of transfusions received while in the hospital were assessed by chart review. Linear regression was used to test associations between “change in fatigue” score, baseline Hb concentration, and receipt of a transfusion.

RESULTS: Two hundred seventy-four patients completed the inpatient and follow up interview. The median age of participants was 58, with 61 % female, and 69 % African American. There were no significant differences in these demographics between those who were transfused versus those who were not transfused [(median age 58 vs. 55; p= 0.33), (percent female 60 vs. 61 %; p= 0.84), (African American 69 vs. 69 %; p= 0.54). There were also no significant differences in comorbidities between those who were transfused versus those who were not transfused [(cancer 18 vs. 14 %; p= 0.69), (diabetes 28 vs. 39 %; p= 0.21), (heart failure 28 vs. 25 %; p= 0.87), (chronic kidney disease 22 vs. 35 %; p= 0.08)]. Baseline FACIT score was 27 in those transfused and was 27 in those not transfused (p= 0.87). Among patients with baseline high levels of fatigue and a Hb < 8 g/dL, those receiving a transfusion had a clinically significant improvement in fatigue compared to non-transfused patients (median change in fatigue, transfused 16 vs. non-transfused group 6.75; p= 0.007) (Fig 1). Among patients with high levels of fatigue and a Hb > 8 g/dL, those receiving a transfusion also had improved fatigue compared to patients not transfused, although the difference was not statistically significant (median change in fatigue, transfused 10.8 vs. non-transfused group 9.45; p= 0.66). Among patients with low levels of fatigue (FACIT score >31) irrespective of Hb level, no significant difference in change in fatigue was found between those transfused and those not transfused.

CONCLUSIONS: These findings are consistent with the hypothesis that blood transfusions may improve fatigue in hospitalized anemic patients, specifically those with high levels of pre-transfusion fatigue. This suggests that inpatient providers may be able to combine self-reported fatigue in patients and their Hb concentration to better target those most likely to benefit symptomatically from a transfusion, while avoiding transfusions and attendant complications in other patients. Prospective studies are warranted to identify the effects of a symptom-guided transfusion strategy on other symptoms of anemia, such as functional capacity, as well as to evaluate other outcomes of hospitalized patients with anemia.

CHANGING THE CULTURE OF BEDSIDE TEACHING: MASTER CLINICIAN AND JUNIOR FACULTY PARTNERSHIP

Lisa Altshuler 2; Douglas Bails1; Adam Carrington2; Patrick M. Cocks3; Danise Schiliro4; Verity Schaye2; Ellen Wagner2; Sondra Zabar2; Michael Janjigian2. 1Bellevue Hospital Center, New York, NY; 2NYU School of Medicine, New York, NY; 3NYU School of medicine, NEw York, NY; 4Yale-Waterbury Internal Medicine Residency Program, Waterbury, CT. (Tracking ID #2197740)

BACKGROUND: We developed a 2-week ward rotation at an urban safety net teaching hospital with a focus on bedside teaching to improve physical examination, communication, and clinical reasoning skills in both house staff and faculty. Highly regarded clinical teachers, deemed “master clinicians” by their peers, lead morning sessions with a focus on clinical reasoning and afternoon sessions on physical diagnosis skills at the bedside. The ward attending physician supervises patient care and participates in all educational activities. While bedside teaching is a powerful teaching strategy, barriers to implementation include time constraints, concerns about patient comfort, and lack of confidence on part of faculty. This qualitative study evaluates how attending faculty perceive the benefit of such a teaching service, and the impact of clinical reasoning and physical exam sessions on their own methods of teaching.

METHODS: We conducted focus groups or structured interviews with 12 of the 18 faculty who served as attendings on this rotation from July 2012-June 2013, including seven females and one male. One attending had 20 years experience, with the remainder ranging from 2 to 10 years experience. Faculty were asked about their perceptions of the rotation and how it differed from other inpatient ward rotations, their participation in the teaching sessions, and the impact of the rotation on their own teaching. The interview was transcribed and imported into qualitative analysis software (dedoose) for analysis. A grounded theory analysis was used to develop and link thematic cues describing the responses. All data was read and coded by three independent readers.

RESULTS: The focus group highlighted the value of bedside rounds as an effective teaching method. Bedside teaching reinforced key concepts in physical examination and clinical reasoning and provided opportunities for evaluation of trainee performance. With respect to their own professional development, faculty found it “very helpful” to observe master clinicians demonstrating physical exam techniques and explaining their clinical reasoning because as junior faculty they “don’t ever really get to do that”. Many faculty reported teaching the physical exam skills that they learned during these bedside sessions and increasing the frequency of bedside teaching. One attending reported “…only if I’m going to the bedside with some expert teachers did I realize how much value there is in going to the bedside.” Another noted, “it let me focus on the skills that I had deficits in. And then I would get to learn those deficits and then re teach what I learned back to the residents and the interns.” Faculty reported integrating teaching skills modeled from the master clinician sessions, including how to effectively engage learners in clinical reasoning and physical exam sessions and how to assess their clinical reasoning. They valued observing different teaching styles from “expert teachers”. As one faculty member noted, “I definitely learned… how to think on your feet and how to approach a case presentation. How to lead a team through a case.”

CONCLUSIONS: This 2-week inpatient rotation is an effective way to partner junior faculty and master clinicians in order to teach clinical reasoning and physical exam skills. This partnership has been effective in overcoming barriers to bedside teaching by improving confidence in physical exam skills and providing a framework for effective teaching. The range of master clinician teaching styles enables junior faculty to adopt teaching strategies that play to their strengths. We have created an effective faculty development program by enhancing a mandatory ward rotation with teaching of clinical reasoning and physical exam skills by master clinicians.

CONTINUITY OF CARE BETWEEN MENTAL HEALTH AND PRIMARY CARE PROVIDERS AFTER A MENTAL HEALTH CONSULTATION.

Ben Colaiaco3; Carol Roth4; David Ganz1, 5; Mark Hanson3; Patty Smith3; Neil Wenger 2, 3. 1RAND Corporation, Santa Monica, CA; 2University of California, Los Angeles, Los Angeles, CA; 3RAND Health, Santa Monica, CA; 4RAND, Santa Monica, CA; 5GLA VA, Los Angeles, CA. (Tracking ID #2198037)

BACKGROUND: Continuity between mental health providers (MHPs) and primary care providers (PCPs) is important to coordinate care for persons with mental illness. Lack of continuity can lead to therapeutic failure and dangerous drug interactions. Efforts have been undertaken to enhance communication, but the level of continuity in community practice has not been rigorously studied. We evaluated communication between MHPs seeing a patient for a new consult and PCPs, and compared continuity among providers sharing a mutual access electronic health record (EHR), and continuity among providers not sharing an EHR.

METHODS: Medicare Advantage enrollees with a new outpatient mental health consultation in 2012 were randomly selected within six geographically diverse health plans. Patients had no mental health visits in 2011 and an outpatient mental health consult, as well as at least 1 PCP visit, in 2012. Plans endeavored to retrieve medical records from MHPs and PCPs. Among patients for whom MHP and PCP records were obtained, charts were abstracted for information about the mental health consultation in the PCP record, evidence of documented continuity with the PCP about mental health hospital admissions and emergency department visits, and acknowledgement in the PCP record of psychotropic medications noted in the mental health record. These measures were compared between patients whose providers used and did not use a mutual access EHR.

RESULTS: For 141 (65 %) of 216 patients, plans were able to retrieve both MHP and PCP records. Records could not be retrieved from MHPs for 45 patients, from PCPs for 13 patients, and from neither MHPs nor PCPs for 17 patients. The 141 patients had a mean of 4.2 mental health visits (range 1–30) and a mean of 5.5 primary care visits (range 1–20) in 2012. Thirty (21 %) patients had PCP medical record documentation of communication from the MHP within 3 months of the consultation. Among these 30 patients, for 8 patients there was evidence of a telephone call, e-mail or other correspondence between MHP and PCP, for 4 there was an indication of a plan for, or attempt at, a telephone call, for 11 there was a mental health consultation note or report in the primary care record, and for 10 patients in systems with a mutual access EHR, the PCP reviewed the mental health note within the record. The PCP medical record revealed evidence of timely communication about 11 of 26 (42 %) mental health admissions and emergency department visits. Seventy-eight of the 141 patients were receiving 152 psychotropic medications according to the MHP record during the study interval. For 103 (68 %) of those medications, there was acknowledgement in the PCP record of the medication (or for cases with a mutual access EHR, the medication list that included psychotropic medications was accessed by the PCP at the follow up visit). Evaluating only the 126 medications of the 54 patients whose physicians did not use a mutual access EHR, half of the psychotropic medications were antidepressants, 27 % were benzodiazepines and hypnotics, and 10 % were antipsychotics. Information discontinuity between the MHP and PCP records was found for 7 of 15 antipsychotic medications and 13 of 34 hypnotic/benzodiazepine medications. PCPs who shared a mutual access EHR with MHPs more often had access to mental health consult information (46 % v 11 %, p < 0.001) and information about psychotropic medication use (100 % v 56 %, p < 0.001).

CONCLUSIONS: This small, but detailed, study of patients receiving new outpatient mental health consults shows poor care continuity between MHPs and PCPs. Furthermore, evaluation of continuity between MHPs and PCPs is difficult for Medicare Advantage plans because of lack of mental health record accessibility. A mutual access EHR might mitigate discontinuity between mental health and primary care.

COST-EFFECTIVENESS OF HERPES ZOSTER (SHINGLES) VACCINE FOR PEOPLE AGED 50 YEARS

Phuc H. Le; Michael B. Rothberg. Cleveland Clinic, Cleveland, OH. (Tracking ID #2192780)

BACKGROUND: Herpes zoster (HZ) affects approximately 30 % of the general population over their lifetime. Both the incidence and severity of HZ increase with age. The zoster vaccine can prevent HZ and postherpetic neuralgia (PHN), and is licensed for use among people aged ≥ 50 years. However, the Advisory Committee on Immunization Practices recommends the vaccine for people aged ≥ 60 years only. To inform the decision making process, this study aimed to analyze the cost-effectiveness of HZ vaccine versus no vaccine for immunocompetent adults aged 50 years.

METHODS: We employed a previously published Markov decision model and updated the inputs relevant for people aged 50–59 years. The entire cohort entered the model in the ‘Healthy’ state at age 50; then moved between health states with transition probabilities for a life-long time horizon. The model considered cases of HZ, PHN, and other complications of HZ including ophthalmic and otic complications, hospitalization and death. Compared to the unvaccinated group, the vaccinated group had reduced disease incidence and complications proportional to vaccine efficacy. Model inputs were derived primarily from US-based studies to reflect the epidemiology, utilities, and quality-adjusted life years (QALYs) of a general US population. Vaccine efficacy was based on the Zostavax Efficacy and Safety Trial, and duration of efficacy on the Long-Term Persistence Substudy, which reported 11 years of follow up from the Shingles Prevention Study. Costs were drawn from the medical literature. They included both direct medical costs and indirect costs due to lost productivity, expressed in 2014 US dollars ($) adjusted for inflation. Outcomes included costs and effectiveness (the number of HZ cases, PHN cases, and QALYs) for each strategy. Results were presented as incremental cost-effectiveness ratio (ICER) per QALY saved. The study was conducted from the societal perspective, with both costs and QALYs discounted at 3 % per year. In addition to deterministic sensitivity analysis, probabilistic sensitivity analysis was also conducted, in which all variables were varied simultaneously; 10,000 Monte Carlo iterations were performed.

RESULTS: In the base case, for every 1000 persons vaccinated, 25 HZ cases and one PHN case would be prevented, equivalent to 0.4 QALYs saved at a cost of $134,000 ($318,071/QALY saved). Because HZ incidences were higher in women, the ICER was half as much for women as for men. In deterministic sensitivity analysis, only changes in vaccine cost resulted in an ICER of < $100,000/QALY (at $82/dose) (Figure 1). In probabilistic sensitivity analysis, the mean ICER was $422,112/QALY (95 % CI $17,814–$1,438,991/ QALY). At a willingness-to-pay threshold of $100,000/QALY, the vaccine was cost-effective in 11 % of iterations.

CONCLUSIONS: Although HZ vaccine is efficacious in protecting people aged 50–59 years, it does not appear to represent good value for this group.

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DEPRESSION CARE MANAGEMENT AMONG U.S. MEDICAL GROUPS

Tara F. Bishop 2; Patricia Ramsay3; Lawrence P. Casalino2; Shortell Stephen1. 1UC Berkeley, Berkeley, CA; 2Weill Cornell Medical College, New York, NY; 3University of California Berkley, Berkley, CA. (Tracking ID #2197973)

BACKGROUND: The Centers for Disease Control and Prevention (CDC) estimates that 6.8 to 8.7 % of the U.S. adult population suffers from depression at any given time. Primary care physicians play an important role in the diagnosis and management of depression. It is unclear whether primary care practices are well-equipped to manage depression as a chronic illness. To assess whether primary care practices are well-equipped to manage depression as a chronic illness, we analyzed data from the largest national survey of physician practice to answer three research questions: 1) what care management processes (CMPs) do practices use for patients with depression, 2) are the rates of use of CMPs for depression lower than for other chronic illnesses and 3) what practice characteristics correlate with high depression CMP use.

METHODS: We used data from the largest national survey of physician practices in the U.S.—the National Survey of Physician Organizations 3. The survey was a 40-min telephone survey with medical directors, presidents, or chief executive officers of the medical groups in the U.S. and focused on the use of care management processes particularly for patients with depression, asthma, diabetes, and congestive heart failure. For this study, we selected practices that were all primary care (general internists, family practitioners, and general practitioners) or multi-specialty which we defined as practices with between 33 and 99 % primary care physicians yielding. Data were collected in 2012 and 2013. The primary outcome was a CMP index for depression, asthma, diabetes, and congestive heart failure which ranged from 0 to 5 based on a practice’s response to the individual components. We calculated the percentage of practices that used each CMP for patients with depression, asthma, diabetes, and congestive heart failure and the mean CMP score for each of these conditions. We used multivariable logistic regression to explore associations between practice characteristics and high depression CMP scores (> = 3).

RESULTS: A total of 1070 practices were included in the analysis. The mean practice size was 21 physicians and 81 % of the practices were all primary care physicians. Practices had been in existence a mean of 21 years. The mean CMP scores for depression (0.82, SE 0.02) were lower than the mean CMP scores for asthma (1.13, SE 0.07), congestive heart failure (1.13, SE 0.07), and diabetes (1.74, SE 0.13). In the multivariable model, practices with high depression CMP scores were more likely to be larger (adjusted odds ratio [aOR] 0.98, p= 0.008), in the South (aOR 4.15 compared with the Northeast, p < 0.001), have higher pay-for-performance indices (aOR 1.71, p= 0.02), have higher public reporting indices (aOR 1.36, p= 0.02), have higher use of CMPs for other conditions (aOR 2.45, p= 0.0002), and have higher health information technology indices (aOR 1.06, p= 0.01). Practices that were owned by hospitals were less likely to have high depression CMP scores (aOR 0.46, p= 0.06 compared with physician-owned practices) as were practices in the West (aOR 0.18, p < 0.001 compared with the Northeast) and the Midwest (aOR 0.53, p= 0.08).

CONCLUSIONS: In this national survey of physician groups, the use of CMPs for depression in primary care practices was less than the use of CMPs for other chronic medical conditions. Our analyis also revealed regional variation in the use of CMPs for depression. Practices that had more incentives in place to improve quality and used CMPs for other conditions were more likely to have higher depression CMP scores. Our findings highlight the underuse of evidence-based CMPs for depression in U.S. primary care practices which may limit both access to and quality of depression care in the U.S.

EDUCATIONAL LEVEL, ANTICOAGULATION QUALITY, AND CLINICAL OUTCOMES IN PATIENTS WITH ACUTE VENOUS THROMBOEMBOLISM

Eveline Hofmann 2; Andreas Limacher1; Marie Méan2, 3; Tobias Tritschler2; Nicolas Rodondi2; Drahomir Aujesky2. 1University of Bern, Bern, Switzerland; 2Bern University Hospital, Bern, Switzerland; 3Lausanne University Hospital, Lausanne, Switzerland. (Tracking ID #2197822)

BACKGROUND: Previous studies have demonstrated an association between a lower educational level and an increased risk for venous thromboembolism (VTE). However, whether the educational level is associated with anticoagulation quality and clinical outcomes in patients with acute VTE is unknown.

METHODS: We studied 817 patients aged ≥65 years with acute VTE from a Swiss prospective multicenter cohort study between September 2009 and December 2013. We defined three educational levels: 1) less than high school (≤9 years of education), 2) high school, or 3) post-secondary (diploma from a university or an equivalent institution). The primary outcome was the quality of anticoagulation, expressed as the percentage of time in therapeutic INR range (2.0–3.0). Secondary outcomes were the time to a first fatal or non-fatal recurrent VTE, and the time to a first fatal or non-fatal major bleeding. We examined the association between educational level and outcomes using linear and competing risk regression, adjusting for patient baseline characteristics and treatments, including periods of anticoagulation as a time-varying covariate.

RESULTS: Overall, 56 % of patients had a less than high school, 25 % a high school, and 19 % a post-secondary educational level. The median time spent in the therapeutic INR range was 64 % for patients with less than high school, 68 % for patients with high school, and 65 % for patients with a post-secondary educational level (P = 0.27). After adjustment, we found no association between educational level and time in the therapeutic INR range. Furthermore, there was no association between educational level and recurrent VTE or major bleeding (Table).

CONCLUSIONS: In our prospective multicenter cohort, we did not find an association between educational level and anticoagulation quality or medical outcomes in patients with acute VTE.

Association between educational level and medical outcomes

Educational level Adjusted sub-hazard ratio (95 % confidence interval)
Recurrent venous thromboembolism
 Less than high school
 High school 0.97 (0.58–1.65)
 Post-secondary 1.16 (0.69–1.96)
Major bleeding
 Less than high school
 High school 1.13 (0.70–1.82)
 Post-secondary 1.40 (0.82–2.38)

EFFECT OF A PHARMACIST COUNSELING INTERVENTION ON HEALTHCARE UTILIZATION AFTER HOSPITAL DISCHARGE: A RANDOMIZED CONTROLLED TRIAL

Susan P. Bell3; Jeffrey L. Schnipper1; Kathryn Goggins3; Aihua Bian3; Ayumi shintani3; Christianne Roumie 3; anuj dalal1; terry jacobson4; Kim Rask4; Viola Vaccarino4; tejal gandhi1; Stephanie Labonville1; Daniel Johnson2; Erin Neal2; Sunil Kripalani3. 1Brigham and Women, Boston, MA; 2Vanderbilt Univeristy Medical Center, Nashville, TN; 3Vanderbilt University, Nashville, TN; 4Emory, Atlanta, GA. (Tracking ID #2201028)

BACKGROUND: Reduction in 30 day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal. We sought to determine the effect of a tailored, pharmacistdelivered, health literacy intervention on time to first hospital readmission or Emergency Department (ED) visit following discharge.

METHODS: The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILLCVD) study enrolled adults at two tertiary care academic centers between May 2008 and September 2009 with a diagnosis of ACS and/or ADHF. Participants were randomized to intervention or standard of care in a 1:1 ratio by concealed allocation, and outcomes were assessed by blinded researchers. The intervention group received pharmacistassisted medication reconciliation, inpatient pharmacist counseling, and low literacy adherence aids while hospitalized, and individualized telephone followup calls after discharge. A Cox proportional hazard model was constructed to assess the effect of the intervention on time to first ED visit or unplanned rehospitalization during the 30 days after discharge. The multivariable analysis controlled for age, sex, race, marital status, health literacy, cognition, prior hospitalizations, and length of stay. Prespecified secondary analyses were performed to assess the differential effects of the intervention by site, health literacy, and cognition.

RESULTS: Among the 851 participants enrolled at Vanderbilt University Hospital (VUH) and Brigham and Women’s Hospital (BWH), 10 % of patients had inadequate health literacy, and 12 % had impaired cognition. Overall, the intervention and control groups did not differ significantly in their 30 day rate of ED visits (21.8 vs. 20.2 %, respectively) or unplanned readmissions (15.0 vs. 15.8 %). In the primary, adjusted analysis, the intervention did not show a significant effect overall on time to first unplanned hospital readmission or ED visit (HR = 1.04, 95 % CI 0.78, 1.39). Stratified analysis by site demonstrated a more beneficial effect at VUH as compared to BWH (P = 0.039). Among patients with inadequate health literacy, the intervention significantly improved the primary outcome, with a longer time to first unplanned hospital readmission or ED visit compared to usual care (HR = 0.41, 95 % CI 0.17, 1.00). There was no differential effect of the intervention by cognition.

CONCLUSIONS: A tailored, pharmacistdelivered medication safety intervention did not demonstrate an overall beneficial effect on time to first unplanned health care utilization after hospital discharge. Individuals with inadequate health literacy, however, did appear to benefit, suggesting targeted practice of pharmacist intervention in this population may reduce 30 day unplanned health care utilization.

EFFECT OF FAMILY HISTORY AND GENETIC RISK COUNSELLING FOR TYPE 2 DIABETES ON PERCEPTIONS OF RISK AND CONTROL: SECONDARY ANALYSIS OF A RANDOMIZED CONTROLLED TRIAL

R. R. Wu 2, 1; Tiffany Himmel2; Rachel A. Myers2; Elizabeth Hauser2; Allison Vorderstrasse2; Geoffrey Ginsburg2; Lori A. Orlando2. 1VA Health System, Durham, NC; 2Duke University, Durham, NC. (Tracking ID #2198114)

BACKGROUND: Family health history (FHH) based risk assessment has been shown to increase perceived risk of disease and affect behavior change. Incorporating genetic testing as part of a risk assessment (either alone or in combination with FHH) has the potential to further refine patient and provider understanding of individual risk and improve collaborative efforts to manage that risk. To understand the additive impact of genetic risk assessment, we performed a secondary analysis to determine the effect of personalized risk counselling for Type 2 Diabetes (T2D), with incorporation of FHH and genetic risk counselling, on risk perception and perception of control, two cognitive precursors of behavior change.

METHODS: A convenience sample of non-diabetic patients from two primary care clinics was recruited while awaiting bloodwork. Subjects were randomized to receive traditional risk counselling including FHH with or without the incorporation of genetic test results of SNP-based testing of four genes (i.e. eight alleles) known to be associated with T2D. FHH risk was categorized based on published algorithms and explained to subjects as average, moderate, or high. Genetic results were provided as total positive alleles out of the maximum of 8. Surveys were completed at baseline and post-counselling at 3 and 12 months to assess perceptions of overall disease risk and genetic risk for T2D using questions derived from the Common Sense Model and control over disease development using questions from the Illness Perception Questionnaire. Primary outcomes have already been reported.

RESULTS: Participants who completed the study (invited = 1416, enrolled = 409, completed = 321) were 69 % female (64 % Caucasian, 24 % black, and 12 % other). The mean age was 52. There was a reasonable distribution of participants in each of the FHH risk categories (average = 143, moderate = 84, high = 94), and the mean number of high risk alleles for the study population was 4.99 (SD 1.22, range 2–7.) FHH risk category and number of high risk alleles were correlated. Subjects with average FHH had a mean of 4.76 alleles, moderate FHH had a mean of 4.79 alleles, and high FHH subjects had a mean of 5.18 alleles (p-value = 0.03). Higher FHH risk level was associated with higher perceptions of overall risk of disease development across all time points (all p-values < 0.001) and did not change over time as a result of risk counselling. In addition perception of genetic risk for disease was correlated with FHH risk category (all p-values < 0.001) across all time points and was not affected by the counselling session. In regards to genetic testing, number of positive alleles did not influence perception of overall disease development risk at any time point. However having an increased number of alleles did lead to a change in perception of genetic risk from pre- to post-counselling (more risk: 5.21 alleles, same risk: 5.06 alleles, less risk: 4.44 alleles, ANOVA p-value = 0.007). When stratified by FHH risk category, this effect was most strongly seen in those with FHH risk that was average (p-value = 0.04) or moderate (p-value = 0.005) with no effect in the high FHH risk category (p= value = 0.46). (Table) Perception of control over risk of disease development was high overall (mean 24.08, SD 3.43, possible range 0–25) and not affected by FHH or genetic risk.

CONCLUSIONS: Patients have a strong sense of personal control over diabetes development. There was a strong understanding of the relationship of FHH to their overall risk of disease and perceptions of their genetic risk. A higher number of genetic risk alleles did not correlate with perception of overall disease risk but did have an effect on perceptions of genetic risk. Strongest effects were seen among those with an average or moderate FHH risk level. As genetic testing for risk prediction becomes more main stream, further work should be done to understand who most benefits from testing and optimal methods for delivery of that information to optimize behavior change and risk reduction.

Mean genetic allele number stratified by FHH risk category effect on change in perception of genetic risk over time

  Increased Risk Same Risk Decreased Risk Overall
Mean (SD) N (%) Mean (SD) N (%) Mean (SD) N (%) Mean (SD) N (%)
Average FHH* 5.08 (1.18) 36 (55) 4.90 (1.37) 20 (31) 3.89 (1.17) 9 (14) 4.86 (1.29) 65 (100)
Moderate FHH** 5.44 (0.78) 18 (42) 5.69 (0.95) 13 (30) 4.50 (1.00) 12 (28) 5.26 (1.00) 43 (100)
High FHH*** 5.25 (1.18) 16 (33) 4.76 (1.03) 17 (35) 4.73 (1.67) 15 (31) 4.92 (1.30) 48 (100)

*ANOVA p-value = 0.04; **ANOVA p-value = 0.005; *** ANOVA p-value = 0.46

ELECTRONIC MEDICAL RECORD BASED INTERVENTION TO REDUCE LENGTH OF STAY FOR VETERANS HOSPITALIZED WITH PNEUMONIA

Eric Mortensen 1, 2; Mary Bollinger3; MIchael Fine4. 1VANTHCS, Dallas, TX; 2UT Southwestern Medical Center, Dallas, TX; 3STVHCS, San Antonio, TX; 4VA Pittsburgh Health Care System, Pittsburgh, PA. (Tracking ID #2194967)

BACKGROUND: There are more than 1.2 million hospitalizations for pneumonia each year in the United States. Although there has been considerable focus on improving pneumonia-related process of care measures, such as use of guideline concordant antibiotics, there has been much less attention paid to reducing length of hospital stay. Therefore we conducted a pre-post intervention trial of a electronic medial record (EMR) based clinical reminder to identify when patients with pneumonia were clinically stable and ready for conversion from IV to oral antibiotics.

METHODS: We conducted this study at a single Department of Veterans Affairs hospital. We developed an EMR-based inpatient clinical reminder to assist physicians with appropriate conversion from IV to oral antibiotics and that encouraged discharge on the same day unless there were other social problems or unstable comorbid conditions. We implemented this reminder with academic detailing on February 1, 2011. We then compared patients hospitalized in April/May 2010 (pre) to patients hospitalized in April/May 2011 (post).

RESULTS: There were 66 patients in the pre-intervention period and 63 patients in the post-intervention period. There were no statistically significant differences in characteristics between the pre- and post-intervention groups. Overall, mean age was 69.7 years, 96 % were male, and 29 % were in the ICU during part of their stay. Regarding pneumonia severity index, 28 % were classes I–III, 46 % were class IV, and 26 % were class V. Mortality within 30-days was 3.0 % in the pre-intervention and 3.2 % in the post-intervention groups (p= 0.96). Length of hospital stay pre-implementation was 7.3 days and post-implementation was 5.4 days (p= 0.05).

CONCLUSIONS: Implementing an EMR-based reminder was associated with a significantly reduced length of hospital stay without significantly increasing mortality at a single VA medical center. Appropriately reducing length of hospital stay for pneumonia has been previously demonstrated to be associated with reduced costs, and may potentially be associated with improved patient safety. Additional research is needed to determine if this reminder can be successfully implemented in other hospitals.

ELECTRONIC PHARMACOVIGILANCE OF PATIENTS NEWLY STARTED ON MEDICATIONS FOR HYPERTENSION, DIABETES, INSOMNIA, OR DEPRESSION

Elissa V. Klinger 3; Alejandra Salazar3; Jeffrey Medoff3, 3; Patricia C. Dykes3; Jennifer Haas1; Japneet Kwatra3; Endel J. Orav4; Lucas Marinacci3; Shimon Shaykevich3; David W. Bates2; Gordon D. Schiff3. 1BWH, Boston, MA; 2Brigham and Women, Boston, MA; 3Brigham and Women’s Hospital, Boston, MA; 4Northwestern University, Boston, MA. (Tracking ID #2200262)

BACKGROUND: The safe and effective use of prescription drugs in the outpatient setting requires monitoring of patients to track outcomes and ensure potential adverse effects are identified and addressed in a timely fashion. Automated approaches offer the promise that such monitoring could be performed easily, reliably, and efficiently. We developed a patient-centered, EHR-integrated interactive voice response system (IVRS) to actively monitor the safety and effectiveness of treatment for patients taking FDA-approved medications for one of four common chronic conditions (diabetes, hypertension, insomnia, depression), with integrated management support by a clinical pharmacist. We report on preliminary findings of Calling for Earlier Detection of Adverse Reactions (CEDAR), a cluster-randomized, controlled trial.

METHODS: Eighteen primary care clinics using an integrated EHR were identified and matched based on geographic and patient-population characteristics and then randomized to either an intervention or control arm. We developed an algorithm to identify any adult primary care patient at any of the clinics who had been newly started on a medication for one of these four conditions. Eligible patients in the intervention clinics were sent a letter with study information and an opportunity to decline participation. Using automated IVRS phone calls, patients were called 4–6 weeks and again at 6–8 months following their medication start date and prompted to confirm that they were taking the drug and it was prescribed for the condition of interest. The IVRS then asked a series of targeted questions querying both adherence and symptoms commonly associated with ADRs. Any patient with a positive symptom was transferred to a clinical pharmacist in real-time at the conclusion of call; these IVRS-collected data sent a real-time secure email message to the pharmacist, containing relevant clinical information captured during the call, including reported possible drug-related symptoms. Patients reporting no symptoms on the IVRS call could also opt to transfer to the pharmacist. All patients counseled by the pharmacist had a note filed in the EHR, with more urgent clinical concerns triaged accordingly. Eligible patients from control clinics were identified via the EHR using the same eligibility criteria but did not receive any component of the intervention. A manual chart review at 1 year from time of the target prescription was performed for the intervention group and for a set of controls generated by propensity score matching. This outcome chart review compared target drug discontinuation, action taken by clinician following patient-reported symptoms consistent with ADRs, and other clinically relevant information.

RESULTS: Between June 2013-September 2014, 11,945 eligible patients from nine intervention and nine control clinic sites were identified who were classified as a new start on one of 103 target medications. Of these, 4847 eligible intervention patients were called and 609 (12.6 %) participated in the IVRS interviews, 496 (10.2 %) actively declined participation, and the remaining patients (77.2 %) either answered but did not complete the call or did not answer any call attempt. Of the 609 participating patients, 306 (6.3 % of all patients called, 50.2 % of those completing the calls) reported symptoms consistent with ADRs. A total of 430 (8.9 % of all patients called) were transferred to the pharmacist (for reported symptoms or request to speak to pharmacist) and had notes filed in their charts and their PCPs alerted accordingly. Outcome chart reviews are on-going as the cohort of participants reaches 1 year of follow-up to compare the percent of patients with identified adverse effects, drug discontinuation, and physician awareness and action in the intervention vs. control cohorts.

CONCLUSIONS: We demonstrate that an EHR-integrated IVRS that leverages real-time data capture and live transfer to a pharmacist can be an effective tool to reach out in a proactive manner to patients starting new medications. Consistent with prior studies screening for ADRs, 1 in 3 participating patients reported a potential ADR, many of which had not been reported or documented previously by the PCP. Our specially designed system allows real time transfer of IVRS calls to a pharmacist who can simultaneously access patient-reported data and the patient’s chart, and thereby troubleshoot symptoms that may be consistent with ADRs that may necessitate a change in dosage or a drug discontinuation. For patients not experiencing symptoms, the platform also provides a service to individuals who have questions or concerns about their medications.

ENGAGING RESIDENTS IN VENOUS THROMBOEMBOLISM PREVENTION AND STROKE QUALITY MEASURES THROUGH AN INTERACTIVE CHECKLIST AND INCENTIVE PROGRAM

Syed A. Hussain 1; Wilhelmine Wiese-Rometsch1; Corinne Hamstra1; Camelia Arsene2; Suzanne White1. 1Detroit Medical Center/Wayne State University, Troy, MI; 2Sinai-Grace Hospital/Detroit Medical Center, Detroit, MI. (Tracking ID #2154842)

BACKGROUND: Venous thromboembolism (VTE) is the most common preventable cause of hospital death. Stroke is the third leading cause of death in the United States. Given that checklists have been demonstrated to improve patient safety, we developed a novel, interactive Electronic Medical Record (EMR) checklist to monitor real-time gaps in VTE prevention and stroke process measures. We hypothesized that the use of this platform, coupled with a pay-for-performance plan, would globally engage residents in quality improvement and optimize the clinical learning environment as specified in the Accreditation Council for Graduate Medical Education “CLER Pathways to Excellence”.

METHODS: The real-time, interactive checklist was launched 1/1/14 for all adult patients at four hospitals within a major academic center. Twenty resident quality directors from various residency programs across the system led daily monitoring of performance and provided feedback on care gaps to physicians, midlevel providers, and 800 resident colleagues. Data on VTE prevention and stroke process measures were sampled and abstracted as per The Joint Commission and CMS guidelines.

RESULTS: Compliance with VTE prevention measures in the 6 months prior to implementation of the checklist and resident engagement program was 88.46 % and in the 6 months post-intervention was 94.15 %, with analysis done using the Mann–Whitney U test with p < 0.006. Similarly, compliance with stroke process measures 6 months prior to intervention was 88 % compared to 96.56 % post-intervention (p < 0.024). Over 800 residents received their second incentive payment in November 2014.

CONCLUSIONS: Implementing a real-time, interactive decision support checklist and pay-for-performance program for residents improved compliance with VTE prevention and stroke process measures. Empowering residents through leadership roles has been an important step toward integrating them into the quality infrastructure of the health system. Our project is unique in complexity, magnitude and goals in engaging trainees from training programs across the spectrum for one unified vision and purpose—increasing compliance for evidence based quality measures.

FALLING THROUGH THE CRACKS: CAN A MEDICAL HOME IMPROVE ACCESS AND CARE COORDINATION FOR PEOPLE WITH MENTAL HEALTH ISSUES?

Chloe Anderson; Rose Kleiman; Dominique Hall; Susan L. Hayes. The Commonwealth Fund, New York, NY. (Tracking ID #2198275)

BACKGROUND: About a quarter of U.S. adults live with a diagnosable mental illness. These individuals are at higher risk for comorbid chronic conditions, and without accessible and coordinated care, they may not receive appropriate treatment. This analysis provides an overview of the access and coordination problems faced by insured people with mental health issues, as compared to the general insured population, and explores whether having a medical home may mitigate these disparities in care experiences

METHODS: Data come from the 2013 Commonwealth Fund International Health Policy Survey, a nationally representative telephone survey of adults conducted from February through June 2013. The full sample consisted of 1350 adults ages 18–64 in the United States, 453 of whom reported a mental health issue (defined as emotional distress in the past 2 years or a mental health problem diagnosed by a doctor). In this analysis, we assessed access to care and care coordination among adults who reported mental health problems, and examined the role of a medical home in improving care experiences, using bivariate analysis and logistic regression.

RESULTS: More than one-third of adults reported a mental health issue, including nearly half of all lower income adults; 41 % also reported a chronic condition. Even with insurance, adults with mental health problems had significantly (p < 0.05) higher rates of ER use (55 vs. 40 %), access problems because of cost (54 vs. 37 %), gaps in care coordination (63 vs. 44 %), and medical or medication errors (31 vs. 20 %), compared to the full sample. Insured adults with a chronic condition in addition to a mental health problem had significantly higher hospital and ER utilization rates than those with a mental health problem and no chronic condition. Medical homes make a difference for adults with mental health issues. Among adults with a mental health issue, the odds of having access problems, care coordination problems, or experiencing a medical or medication mistake were reduced by more than 50 % (p < 0.05) for adults with a medical home, even after controlling for insurance and other demographic characteristics.

CONCLUSIONS: Consistent with previous studies, our analysis found that having mental health issues may not only lead to high utilization, but also may leave individuals vulnerable to inadequate care coordination and cost-related access issues. Our research shows that the medical home is associated with improved access and care coordination. Mental health is often addressed outside of the health care delivery system despite its impact on physical health. Primary care providers are often unequipped to adequately address patients’ behavioral health needs. The Affordable Care Act aims to expand requirements for health insurers to cover mental health benefits. However, in order for this expansion to have an impact on care outcomes, delivery systems need to better integrate physical and behavioral health care. States and payers, likewise, will need to incorporate financing and payment models that support this level of integration. Care coordination, particularly in the form of a medical home, may be one such way to improve outcomes for those experiencing both mental health issues and chronic conditions.

FIFTY YEARS OF HEALTH SPENDING BY LOW, MIDDLE, AND HIGH-INCOME AMERICANS, 1963–2012

Samuel L. Dickman 4; Steffie Woolhandler3; Jacob Bor6; Danny McCormick5; David Bor2; David Himmelstein1. 1CUNY School of Public Health, New York, NY; 2Cambridge Health Alliance, Cambridge, MA; 3City University of New York School of Public Health, New York, NY; 4Harvard Medical School, Boston, MA; 5Harvard Medical School / Cambridge Health Alliance, Cambridge, MA; 6Boston University School of Public Health, Boston, MA. (Tracking ID #2196643)

BACKGROUND: Growth in U.S. medical spending has slowed since 2004. Increased patient cost-sharing, a likely contributor to the slowdown, would be expected to have the greatest impact on lower income households, which have seen little income growth during this period. Whether the health spending slowdown has affected all income groups uniformly is unknown.

METHODS: Data on annual health expenditures were compiled from 22 nationally representative surveys carried out since 1963: the 1963 and 1970 Surveys of Health Services Utilization and Expenditures (N = 7759 and 11,619, respectively); the 1977 and 1980 National Medical Care Utilization and Expenditure Surveys (N = 38,815 and 17,123, respectively); the 1987 National Medical Expenditure Survey (N = 23,652); and the 1996–2012 Medical Expenditure Panel Surveys (N = 21,571–37,418 per year). These expenditures data include all spending on health care services, including out-of-pocket and insurance payments. We assessed average expenditure trends for each income quintile according to payer (private insurers, out-of-pocket, Medicare, and Medicaid), type of service (inpatient, outpatient, prescription medications, and dental), and self-reported health status in linear regression models. We also examined trends in the distribution of health expenditures by income group using quantile regression.

RESULTS: Per capita inflation-adjusted health expenditures grew from $785 in 1963 to $4309 in 2012. In 1963, prior to the introduction of Medicare and Medicaid, respondents in the lowest income quintile had the lowest health expenditures, despite having the worst health status. By 1977 their expenditures were the highest of any quintile, exceeding those for other Americans by 23 %; this pattern persisted until 2004. Since 2004, expenditures have fallen 3 % for the poorest quintile, increased 9 % for the middle three quintiles and increased 15 % for the wealthiest quintile, which now has the highest expenditures (Figure 1). Since 2004, increases in both per-visit costs and the number of visits drove the rapid rise in health spending among respondents in the highest income quintile. Adjusting for age and health status, 2012 per capita expenditures for the wealthiest Americans exceeded those for the poorest quintile by $1743, or 43 %. The divergence in health spending by income group since 2004 was limited to the under-65 population, with spending growth among the elderly flat across all income groups. These divergent trends were not driven by a very small number of very high cost patients, but by the larger number of respondents who incurred moderate-to-high health expenditures in any given year.

CONCLUSIONS: The post-2004 slowdown in the growth of U.S. health expenditures was concentrated among lower income Americans, indicative of a reallocation of health care resources nationally towards persons with the highest incomes. The wealthy, who report to be the healthiest segment of the population, now make the most healthcare visits and have the highest healthcare expenditures, a pattern not observed since prior to the introduction of Medicare and Medicaid in the 1960s.

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Figure 1: Medical spending by income group, adjusted for inflation, 1996–2012

FINANCIAL BARRIERS TO ADULT VACCINE DELIVERY

Laura P. Hurley 4; Megan C. Lindley2; Mandy Allison8; Lori A. Crane5; Michaela Brtnikova3; Brenda Beaty9; Megan Snow6; Carolyn Bridges1; Allison Kempe7. 1CDC, Atlanta, GA; 2Centers for Disease Control and Prevention, Atlanta, GA; 3Children’s Outcomes Research Program, Aurora, CO; 4Denver Health, Denver, CO; 5University of Colorado Anschutz Medical Campus, Aurora, CO; 6University of Colorado Denver, Aurora, CO; 7University of Colorado and Children’s Hospital Colorado, Aurora, CO; 8University of Colorado, Anschutz Medical Campus, Aurora, CO; 9Unviersity of Colorado, Aurora, CO. (Tracking ID #2192476)

BACKGROUND: A prior national survey found many physicians were not knowledgeable about adult vaccine financing in their practice; little is known about specific financial barriers to adult vaccination. The Affordable Care Act (ACA) increased reimbursement for vaccine administration for Medicaid patients to Medicare levels (~$25) for 2013 and 2014 and mandated that non-grandfathered health plans and plans for the newly eligible beneficiaries of the Medicaid expansion cover Advisory Committee on Immunization Practices recommended vaccines at no cost to patients while encouraging this practice for traditionally-eligible Medicaid beneficiaries. Our objectives were to assess attitudes about adequacy of reimbursement for adult vaccine purchase and administration, frequency of vaccine claim denial, estimated vaccination profit margin under different payers, and whether practices had considered stopping purchasing vaccines due to financial concerns.

METHODS: We administered a telephone survey 12/2013 to 4/2014 to staff that had been identified as knowledgeable about adult vaccine financing on a prior physician survey. Questions were developed jointly with the CDC and modified based on input from advisory committees and pilot testing. Respondents’ practices were stratified by size and financial decision-making capacity and quota sampling was conducted to make sure all practice types were represented. Multiple contacts to set up telephone interviews via mail or email were attempted to encourage non-responders to respond.

RESULTS: The response rate was 39 % (104/266). Most respondents were office managers/health administrators (52 %) or billing personnel (25 %). Respondents reported their practices included patients with the following types of insurance: Medicare Part B (100 %), Preferred Provider Organization (99 %), Private Fee for Service insurance (91 %), Managed Care (83 %), Medicare Part D (76 %), and Medicaid (72 %). Respondents reported perceived reimbursement. Medicaid was most often reported to reimburse less than purchase price for vaccines (58 %), followed by Medicare Part B (39 %). Fifty-four percent of respondents reported Medicaid pays less than $11 for vaccine administration and 79 % reported Medicaid pays less than $24 for vaccine administration. Sixty-four percent reported Medicare Part B and 48 % reported Medicare Part D pays less than $24 for vaccine administration. Thirty-seven percent reported Medicaid and Medicare Part B ‘frequently’ or ‘sometimes’ deny vaccine claims. Respondents most often reported losing money delivering vaccines to Medicaid patients (55 %). Regarding profit margin for vaccine delivery in recent years, 40 % reported it had stayed the same, 31 % reported it had decreased, 18 % reported it had increased and 11 % reported not knowing how profit margin had changed. Eight percent had stopped and 3 % had seriously considered stopping purchase of one or more vaccines for adults due to financial concerns. The top reasons for stopping or seriously considering stopping were the upfront cost of purchasing vaccines and the inconsistent coverage across insurance plans.

CONCLUSIONS: Practices may benefit from guidance about how to bill for vaccines including how to distinguish Medicare Part B from Medicare Part D vaccines and how to avoid errors that result in vaccine claim denials. Changes in vaccination reimbursement due to ACA may not yet be fully realized in practices, and may be contributing to a continuing financial burden to stock and administer adult vaccines.

GENDER REPRESENTATION IN THE JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE (JHUSOM) LEARNING ENVIRONMENT

Madeleine Manka 2; Megan S. Orlando2; David M. Levine1; April S. Fitzgerald1. 1Johns Hopkins University, Baltimore, MD; 2Johns Hopkins University School of Medicine, Baltimore, MD. (Tracking ID #2198808)

BACKGROUND: At JHUSOM, 50 % of students and over 35 % of faculty are female, yet study data found female student comfort negotiating for oneself, following on a team, and giving negative feedback decreased from matriculation to the end of the preclinical years, while male student comfort with the same skills increased. It is unclear if aspects of the learning environment contribute to this finding. We hypothesized that exposure to female vs. male leaders differs in the preclinical years and might lead to a disparity in gender-concordant role-modeling.

METHODS: We looked at exposure to academic leaders during the preclinical curriculum and examined the AY 2012–2013 1st and 2nd year courses for gender representation among both core and intersession course directors and lecturers. We used t-tests to evaluate the proportion of female faculty included as lecturers by female vs. male course directors.

RESULTS: Ten percent (3/31) of academic department heads, 0 % (0/4) of heads of learning colleges, 33 % (8/24) of salary-supported advisors, and 25 % (1/4) of deans in the Office of Student Affairs at JHUSOM are women. In core courses, 26 % (9/35) of course directors, 30 % (121/396) of course lecturers, and 23 % (184/789) of course hours were provided by female faculty. Intersessions had 55 % (6/11) female directors, 56 % (30/54) female lecturers, and 54 % (41/75) female lecture hours. Female course directors included higher proportions of female lecturers in their courses than did male course directors (48 % vs. 26 %; p < 0.0001).

CONCLUSIONS: Female faculty representation among preclinical leaders has not reached parity with the percentage of females on faculty. Interestingly, female course directors included a higher proportion of female lecturers in their courses. Medical students were not directly studied with regard to faculty gender role-modeling, and further investigation is needed to determine if increased exposure to female leader role-models affects female student comfort with leadership skills.

GUIDELINE-CONCORDANT TREATMENT OF HYPERTENSION AT COMMUNITY HEALTH CENTERS COMPARED TO PRIVATE PHYSICIANS’ OFFICES IN THE UNITED STATES

Valy Fontil 2, 4; Kirsten Bibbins-Domingo2, 4; Oanh K. Nguyen3; David Guzman1; Lauren Goldman2. 1UCSF, San Francisco, CA; 2University of California San Francisco, San Francisco, CA; 3University of Texas Southwestern Medical Center, Dallas, TX; 4University of California, San Francisco, CA. (Tracking ID #2191557)

BACKGROUND: Hypertension is the most important treatable risk factor for cardiovascular death, yet it is inadequately treated in nearly half of at-risk adults in the U.S. Community health centers (CHCs) provide care to a disproportionate share of vulnerable populations who are at highest risk for uncontrolled hypertension. Though guidelines recommend escalation of pharmacotherapy for those with uncontrolled hypertension and use of fixed-dose combination medications, thiazides, and aldosterone antagonists in resistant hypertension, it is unknown how hypertension treatment at CHCs reflects guideline-concordant therapy compared to private practice.

METHODS: This study is a cross-sectional analysis of all non-pregnant adults with hypertension receiving care at CHCs and private physicians’ offices in 2006–2010 National Ambulatory Medical Care Surveys, a probability sample of outpatient visits in the U.S. Our primary outcomes were prescription of new medication for uncontrolled hypertension (blood pressure above 140/90 mmHg); prescription of fixed-dose combination drugs for those on multiple antihypertensive medications; use of thiazide diuretics among patients with uncontrolled resistant hypertension; and use of aldosterone antagonist for resistant hypertension. Analyses were weighted to reflect national estimates. Odds ratios were estimated from logistic regression models adjusted for patient, visit, and practice characteristics. We also tested for interactions between clinic setting and payer in predicting use of fixed-dose combination drugs and prescribing of new medication for uncontrolled hypertension, hypothesizing that individuals with Medicaid would be less likely to receive either of these interventions due to concerns around affordability.

RESULTS: We identified an estimated 496 million patient visits for hypertension to primary care physicians in private practice and 25.4 million visits to CHCs. Patients at CHCs had higher odds of receiving a new medication for uncontrolled hypertension as compared to private physicians’ offices (AOR 1.5, 95 % CI 0.9–2.4). Among patients at CHCs, individuals with Medicaid were as likely as privately insured individuals to receive a new medication for uncontrolled hypertension (AOR 1.0, 95 % CI 0.6–1.9). However among patients at private physicians’ offices, those with Medicaid were less likely to receive a new medication compared to those with private insurance (AOR 0.4, 95 % CI 0.1–0.7). Patients at CHCs were less likely to be on fixed-dose combination drugs compared to those at private offices (AOR 0.6, 95 % CI 0.4–0.9). There was no difference in thiazide use (adjusted OR 0.7, 95 % CI 0.4–1.5). Aldosterone antagonist use in resistant hypertension was too low in both clinic settings (<3 %) to perform any reliable multivariable regression analysis.

CONCLUSIONS: Compared to private practices, CHCs are more likely to intensify hypertension treatment for patients with Medicaid but less likely to use fixed-dose combination drugs for patients taking multiple medications. Increasing physician use of fixed-dose combination drugs may be helpful in improving hypertension control, particularly in CHCs where there are higher rates of uncontrolled hypertension.

HIV TESTING AMONG PATIENTS WITH CANCER BEFORE INITIATION OF CHEMOTHERAPY

Jessica P. Hwang 1; Bruno Granwehr1; Harrys Torres1; Maria Suarez-Almazor1; Thomas Giordano2; Andrea Gabriela Barbo1; Heather Lin1; Michael Fisch1; Elizabeth Chiao2. 1MD Anderson Cancer Center, Houston, TX; 2Baylor College of Medicine, Houston, TX. (Tracking ID #2198882)

BACKGROUND: The Centers for Disease Control and Prevention (CDC) and the US Preventive Services Task Force recommend routine opt-out HIV testing for persons aged 13 to 65 years. In patients with cancer, routine HIV testing is warranted because it has the potential to improve patient outcomes; however, the rates of HIV testing and infection among patients with cancer at the initiation of systemic chemotherapy are unknown.

METHODS: Retrospective cohort study of adult patients with cancer who registered at a comprehensive cancer center from January 1, 2004, through April 30, 2011, and received systemic chemotherapy. We identified rates of HIV-1/2 and/or Western blot testing and HIV positivity at the initiation of cancer therapy. Multivariable logistic regression was used to determine the predictors of HIV testing among patients with AIDS-defining (non-Hodgkin lymphoma [NHL], cervical cancer) and non-AIDS-defining cancers.

RESULTS: A total of 18,874 patients with cancer received chemotherapy during the study period. Of these, 3514 patients (18.6 %) were tested for HIV at the initiation of chemotherapy. The rate of HIV testing was similar among patients 65 years of age or younger (19.5 %) and patients older than 65 years (15.8 %). The prevalence of positive HIV test results among tested patients was 1.2 % (41/3514). The rate of HIV testing was was lower in Black patients than in White patients (13.7 vs 19.2 %), but the prevalence of positive HIV test results was higher in Black patients (4.5 %) than in any other racial/ethnic group. Among patients with AIDS-defining cancers, history of NHL, history of sexually transmitted disease, and registration after publication of the 2006 CDC recommendations were significant predictors of HIV testing. Among patients with non-AIDS-defining cancers, the latter 2 factors also predicted HIV testing as did younger age, male sex, history of illicit drug use, and having a hematologic malignancy while Black patients had 30 % lower odds of HIV testing than White patients.

CONCLUSIONS: The prevalence of HIV infection was high among patients with cancer. Our study supports HIV testing in patients with cancer before initiation of chemotherapy. For patients with HIV and cancer, co-management of care by internists and oncologists would allow personalized HIV and cancer care planning and potentially improve clinical outcomes.

IDENTIFYING THE TRAINING AND SUPPORT NEEDS OF VOLUNTEER LAY HEALTH ADVOCATES: A FOCUS GROUP STUDY

Rebeca Rios 1; Margaret Haroth2; Joan Kub3. 1Johns Hopkins School of Medicine, Baltimore, MD; 2Johns Hopkins Medicine, Baltimore, MD; 3Johns Hopkins School of Nursing, Baltimore, MD. (Tracking ID #2199139)

BACKGROUND: The use of peer support has emerged as a promising strategy to improve disparities in chronic disease outcomes among racial minority and economically disadvantaged groups. These models train lay individuals (as lay health advisors, community health workers, etc.) to provide self-management support and linkage to community resources, and have demonstrated improvements in reducing health risks and improving chronic disease outcomes. Within faith institutions and other community institutions, individuals trained as lay health leaders are often volunteers. Given the efficacy and proliferation of peer support models, surprisingly little research has addressed the training and support needs of lay health leaders. As a valuable source of human capital and important partner to address community health needs, it is important to develop effective training and support models to meet the needs of lay health leaders. Using focus groups, this study sought to identify the perceived successes, challenges and training and support needs of trained, congregation-based lay health advocates.

METHODS: The LHA program is a 6-week training that covers learn principles and skills to provide self-management support to individuals with chronic diseases. Skills include guidance to effectively engage in health care, support for health behavior change and adherence to medical recommendations, and linkage to community resources. We recruited key stakeholders involved with our Lay Health Advocate (LHA) program, a training program offered through a medical-religious partnership with local faith institutions. We invited individuals to participate who were members of faith community partner organizations and who had trained as LHAs, or who were identified as key stakeholders involved with health advocacy activities within the partnering congregations. We recruited 18 individuals who participated in one of 3 focus groups, each lasting 1 h, 45 min. Mean age of participants was 54 years, and 78 % (n = 14) were female. The majority (78 %; n = 14) of participants had taken the LHA training and were African American (n = 10; 56 %); 8 were White (44 %). 8 (44 %) represented Protestant churches, 8 (44 %) represented Catholic churches, and 2 (11 %) represented other religious traditions. Participants represented 9 churches, the majority of which (67 %) were located in geographic areas designated as medically underserved. Trained study team members moderated the discussions and digitally audio-recorded the groups. Recordings were transcribed verbatim and independently coded by two investigators to identify and group comments into categories with discrete themes. A third investigator adjudicated discrepancies in theme assignments. In order to add confidence to the validity of the findings, we used a process for member checking by inviting commentary from participants on the accuracy of a draft of the thematic codes generated in the analysis.

RESULTS: Consistent themes related to perceived benefits of lay health advocate activities were (1a) the ability to address spiritual and physical health holistically, (1b) provision of social support, (1c) facilitating self-efficacy for health, and (1d) enhancing existing health ministries. Challenges were categorized as (2a) navigating relational and role boundaries, (2b) challenging church policies, and (2c) social stigma. Essential sources of support were categorized into (3a) church leadership support, and (3b), ongoing peer support.

CONCLUSIONS: LHAs have the strong potential to extend needed health information and self-management support to racial and ethnic minority and low income communities. Partnerships with faith institutions to train lay health leaders offer a promising strategy, yet adequate infrastructure and ongoing support for volunteer leaders should be given careful attention. Such support should include ongoing peer support and strategies to promote clergy leadership support for health advocacy. We will use results of this study to develop models for training and support of volunteer lay health leaders.

IMPACT OF CASE MANAGEMENT ON FREQUENT USERS’ QUALITY OF LIFE: A RANDOMIZED CONTROLLED TRIAL

Katia Iglesias 6, 2; Karine Moschetti1, 7; Stéphanie Baggio3; Venetia - Sofia Velonaki2; Ornella Ruggeri5; Olivier Hugli4; Bernard Burnand2; Jean-Blaise Wasserfallen2; Jean-Bernard Daeppen2; Patrick Bodenmann2. 1University of Lausanne, Lausanne, Switzerland; 2Lausanne University Hospital, Lausanne, Switzerland; 3Lausanne University, Lausanne, Switzerland; 4Lausanne university hospital, Lausanne, Switzerland; 5University Hospital of Lausanne (CHUV), Lausanne, Switzerland; 6University of Neuchâtel, Neuchâtel, Switzerland; 7Lausanne University Hospital,, Lausanne, Switzerland. (Tracking ID #2197194)

BACKGROUND: Frequent emergency department users represent a small number of patients but account for a large number of emergency department visits. They should be a focus because they are often vulnerable patients with many risk factors affecting their quality of life (QoL). Case management interventions have resulted in a significant decrease in emergency department visits, but association with QoL has not been assessed. One aim of our study was to examine to what extent an interdisciplinary case management intervention, compared to standard emergency care, improved frequent emergency department users’ QoL.

METHODS: Data are part of a randomized, controlled trial designed to improve frequent emergency department users’ QoL and use of health-care resources at the Lausanne University Hospital, Switzerland. In total, 250 frequent emergency department users (≥5 attendances during the previous 12 months; ≥ 18 years of age) were interviewed between May 2012 and July 2013. Following an assessment focused on social characteristics; social, mental, and somatic determinants of health; risk behaviors; health care use; and QoL, participants were randomly assigned to the control or the intervention group (n = 125 in each group). The final sample included 194 participants (20 deaths, 36 dropouts, n = 96 in the intervention group, n = 99 in the control group). Participants in the intervention group received a case management intervention by an interdisciplinary, mobile team in addition to standard emergency care. The case management intervention involved four nurses and a physician who provided counseling and assistance concerning social determinants of health, substance-use disorders, and access to the health-care system. The participants’ QoL was evaluated by a study nurse using the WHOQOL-BREF five times during the study (at baseline, and at 2, 5.5, 9, and 12 months). Four of the six WHOQOL dimensions of QoL were retained here: physical health, psychological health, social relationship, and environment, with scores ranging from 0 (low QoL) to 100 (high QoL). A linear, mixed-effects model with participants as a random effect was run to analyze the change in QoL over time. The effects of time, participants’ group, and the interaction between time and group were tested. These effects were controlled for socio-demographic characteristics and health-related variables (i.e., age, gender, education, citizenship, marital status, type of financial resources, proficiency in French, somatic and mental health problems, and behaviors at risk).

RESULTS: Participants were 45.5 (SD = 17.9) years old on average; 56 % were men; 50 % Swiss, 18 % European, and 32 % non-European; 43 % were beneficiaries of social welfare; 69 % suffered from somatic health problems and 50 % from mental health problems; and 32 % had at-risk behaviors. Levels of QoL were on average 54.1 (SD = 15.0) for physical health, 54.1 (SD = 17.3) for psychological health, 58.2 (SD = 24.8) for social relationship, and 58.9 (SD = 20.8) for environment (with no significant differences between control and intervention groups at baseline). Multivariate models showed an improvement in QoL for the 4 dimensions (physical health: b = 8.1, p < 0.001; psychological health: b = 9.5, p < 0.001; social relationship: b = 13.9, p < 0.001; environment: b = 10.1, p < 0.001) on both groups. Moreover, this improvement was significantly greater for the intervention group concerning the environment element (b = 6.2, p= 0.016). No other interactions were significant.

CONCLUSIONS: The case management intervention was accompanied by some improvement in frequent emergency department users’ QoL, with a significant positive effect on environment—a dimension composed of items such as physical safety and security, financial resources, and access to health-care. This result shows the success of case management in this context as the approach essentially aims to improve these aspects by providing assistance in obtaining income entitlements, health insurance coverage, stable housing, and schooling for children, and in preventing potential domestic violence and finding general practitioners or specialists. However, overall, QoL improved over time even without the intervention of the mobile team. One possible explanation could be that being a frequent emergency department user is a transient state associated with vulnerability and with a decrease in QoL, and that adaptation to this condition tends to return QoL to its initial level. A second, more plausible, explanation is that although the control group did not receive a “real” intervention per se, a study nurse contacted participants regularly to ask them about their QoL, which could have created social bonds and generally increased QoL. In terms of policy implications, this study shows that case management may improve environment QoL, and suggests that this dimension is most suitable for short-term interventions.

IMPACT OF HYPONATREMIA CORRECTION ON THE RISK OF 30-DAY READMISSION AND DEATH IN PATIENTS WITH CONGESTIVE HEART FAILURE

Jacques Donze 2, 1; Patrick E. Beeler1, 4; David W. Bates1, 3. 1Brigham and Women, Boston, MA; 2Bern University Hospital, Bern, Switzerland; 3Harvard Medical School, Boston, MA; 4University Hospital Zurich, Zurich, Switzerland. (Tracking ID #2190632)

BACKGROUND: Hyponatremia has been shown to be associated with worse outcomes in patients with heart failure. There are however conflicting findings regarding its prognostic value for readmission in patients with heart failure, and in particular whether or not correction of a low sodium level at admission affects the risk of readmission and death. We assessed whether correction of a low sodium level during a hospital stay impacted on the risk of 30-day unplanned readmission and death in patients with congestive heart failure, as compared to patients who did not have their sodium level corrected before discharge.

METHODS: We performed a retrospective study on adult patients admitted with a diagnosis of congestive heart failure between July 2003 and October 2009 at a tertiary-care hospital in Boston, MA. We restricted the analysis to those presenting with hyponatremia at admission. We captured the sodium level at admission and discharge to measure the difference between both. The exposure was categorized in 2 groups: 1) hyponatremia at admission without correction during the hospitalization, defined as a sodium level of less than 135 mmol/l both at admission and discharge; 2) hyponatremia at admission with correction during the hospitalization, defined as a sodium level at admission of less than 135 mmol/l, but 135 mmol/l or more at time of discharge. The primary outcome of interest was a composite of 30-day unplanned readmission or death. The secondary outcome was any 30-day unplanned readmission without death. We performed a multivariable logistic regression to evaluate the effect of hyponatremia correction on the outcome.

RESULTS: Among the 4295 eligible patients with hyponatremia at admission, 1799 (41.9 %) did not have their hyponatremia corrected before discharge, over a median length of stay of 6 (IQR 3–9). Overall, 1269 (29.6 %) patients had a 30-day unplanned readmission or died. In a multivariable logistic regression analysis, the absence of hyponatremia correction was associated with a 46 % increase in the odds of having a 30-day unplanned readmission or death (odds ratio 1.46 [95%CI 1.27–1.67]; Table). The odds ratio for specifically any 30-day unplanned readmission was 1.35 (95%CI 1.17–1.57).

CONCLUSIONS: The absence of correction of hyponatremia over the course of hospitalization is frequent and associated with an increase of nearly 50 % in the odds of having a 30-day unplanned readmission or death. This may or may not be causal as there is almost certainly confounding by severity of illness, but absence of correction is strongly correlated with a worse outcome.

Comparison of 30-day unplanned readmission and death between patients with and without hyponatremia correction

Variable Odds ratio 95 % Confidence Interval
Persistent hyponatremia 1.46 1.27–1.67
Age, per additional year 1.00 1.00–1.01
Female vs. male 1.13 0.98–1.30
Race
White reference  
Black 1.31 1.06–1.61
Hispanic 1.32 1.00–1.73
Other 1.24 0.79–1.94
Number of admissions in the last 6 months, per additional admission 1.30 1.24–1.36
Unplanned vs. elective index admission 1.86 1.44–2.39
Length of stay, per additional day 1.01 1.00–1.01
Atrial fibrillation 1.07 0.92–1.24
Ischemic heart disease 0.86 0.74–0.99
Cancer 1.85 1.56–2.20
COPD 1.02 0.85–1.22
Diabetes 1.12 0.96–1.30
Chronic kidney disease 1.03 0.87–1.24

IMPACT OF THE 2008 USPSTF RECOMMENDATIONS ON CLINICIANS’ PRACTICE FOLLOWING AN ELEVATED PSA TEST IN ELDERLY MEN

Sami Ibrahimi 5; Fadi Alkhatib5; Shin Yin Lee4; Jennifer Friderici1; Michael B. Rothberg3; Janice Fitzgerald2; Mihaela S. Stefan5. 1Baystate Health System, Springfield, MA; 2Baystate Medical Center, Springfield, MA; 3Cleveland Clinic, Cleveland, OH; 4Boston University, Boston, MA; 5Baystate Medical Center/Tufts Univ. School of Medicine, Springfield, MA. (Tracking ID #2195183)

BACKGROUND: Prostate specific antigen (PSA) for prostate cancer screening remains controversial. In 2008, the United States Preventive Services Task Force (USPSTF) published a statement recommending against screening for prostate cancer in men aged 75 years or older. Since then, 2 studies have shown a decrease in PSA testing frequency in this age group. It is unknown however, whether the 2008 recommendations had any impact on clinicians’ approach following an elevated PSA level in elderly men.

METHODS: We performed a retrospective cohort study and structured data abstraction of patients 65 years or older with an elevated PSA test (≥4 ng/μl), seen at one of 15 community-affiliated primary care practices in Western MA between 1/1/06 and 12/31/10. Patients with an abnormal PSA result in the prior year or with a prior diagnosis of prostate cancer were excluded. A stratified random sample was selected to yield the following study groups of equal sizes (n = 75 each or 300 total): age ≥75+ and 65 to 75, and into 2 time periods: before and after the USPSTF 2008 recommendations. The primary outcome was PSA retesting frequency within a 12 month follow up period after the first abnormal PSA. Secondary outcomes included (yes vs. no) prostate biopsy, urology referral, prostatectomy and other modalities of therapy including radiation therapy, chemotherapy and hormone treatment. Each outcome was analyzed using multiple logistic regression with an age-group by study period interaction term (criterion p-value for stratification ≤0.20). Two-sided p-values of 0.05 were used to determine statistical significance for remaining comparisons. All analyses were performed in Stata 13.1 (© 2014 StataCorp LP, Union Station, TX)

RESULTS: Three-hundred records were abstracted. The average age was 74.7 years (SD 7.0); most patients (82 %) were White; (7 %) were Black and (5 %) were Hispanic. Patient characteristics were similar between pre- and post study periods. The proportion of patients who underwent confirmatory testing decreased slightly in men aged ≥75 after the guidelines (53 % pre vs. 47 % post, p= 0.34), but increased slightly among men aged <75 (68 % vs. 76 %, p= 0.28). The difference in the intervention effect on this outcome achieved borderline significance (difference of 15 percentage points, p < 0.10). Among those with a confirmatory test, the proportion of patients referred to urologist increased dramatically in both age groups (age ≥75: 35 % pre vs. 74 % post, p= 0.001; age 65 to 75: 51 % pre vs. 86 % post, p < 0.001); this increase was similar between both groups (difference of 4 percentage points, p= 0.79). Similar large increase in biopsy rates were noted in both age groups (age 75+: 8 % pre vs. 42 % post, p= 0.005; age < 75: 23 % pre vs. 42 % post, p= 0.0.02). (Difference of 8 percentage points, p= 0.53). The number of patients receiving prostatectomy, chemotherapy or radiation therapy was small.

CONCLUSIONS: Among patients with an elevated PSA test, the guidelines had no impact on the frequency of repeat PSA testing to confirm result. More patients were referred to urology and underwent biopsy in both age groups after the guidelines.

IN-HOSPITAL COMMUNICATION PREFERENCES AMONG INTERNAL MEDICINE RESIDENTS: EASE OF USE VS. PRIVACY?

Micah T. Prochaska 2; Amber Bird2; Amar R. Chadaga3; Vineet M. Arora1. 1University of Chicago, Chicago IL, IL; 2University of Chicago, Chicago, IL; 3Advocate Christ Medical Center, Chicago, IL. (Tracking ID #2199026)

BACKGROUND: Mobile technology (smartphones and tablets) has been shown to improve physician efficiency and providers perceive it to improve inpatient communication. Short message service text messaging (texting) is one form of communication using mobile technology that is easy to use, accessible, and allows for the rapid and direct transfer of clinical information between providers. Therefore, texting has become pervasive in healthcare and is preferred for in-hospital communication between providers, compared to a traditional in-hospital paging system. Yet, texting is discouraged by the Joint Commission for security reasons, and there are concerns about its HIPAA compliance and ability to protect confidential patient health information when used on personal mobile devices. Currently, it is unclear if inpatient providers share these security concerns and how they may affect providers preferred method of communicating with other inpatient providers. Therefore, our study aimed to compare internal medicine residents’ preferences for texting versus other available in hospital communication modalities when considering efficiency, ease of use, and security. Additionally, we sought to determine residents’ experiences and perceptions of receiving confidential patient information through texting.

METHODS: A cross sectional survey of internal medicine residents at two academic medical centers during the 2013–2014 academic year. Residents at both institutions were provided iPads through their training programs, and were instructed to use only approved secured applications on the iPad for patient care activities. At both institutions the standard mode of communication between providers was the hospital paging system with a telephone call back. Residents were asked to rank on a four point Likert scale their preferred form of communication when considering efficiency, the ease of use, and the security of the communication modality. Responses were dichotomized to represent either “preferred” or “not preferred”. Communication options included telephone, email, alphanumeric text (hospital) paging system, and texting. Respondents were also asked to report whether they had received confidential patient identifiers (name, patient initials, or medical record numbers) through any of the above modalities. Descriptive statistics were used to summarize the results.

RESULTS: The overall response rate was 76 % (132/173). For overall efficiency 72 % (94/131) of respondents preferred texting, while 80 % (103/129) of respondents reported texting to be their preferred communication modality with respect to ease of use when communicating with other providers (Fig 1). In comparison, 36 % (46/129) of respondents preferred the current hospital paging system for ease of use when communicating with other providers. However, 83 % (104/126) of respondents rated the hospital paging system their preferred form of communication for security, while only 21 % (26/126) of respondents preferred texting for secure communication. Despite the security concerns of texting, 71 % (93/131) of respondents reported having received protected patient identifiers including a patient’s first and/or last name through text messages. Many [82 % (107/131)] reported receiving patient initials through text messages, and half [50 % (66/131)] reported receiving a patient’s medical record number through text messages. Responses did not vary by site.

CONCLUSIONS: Our data demonstrates that texting is preferred for in-hospital communication when considering efficiency and ease of use, but that providers are also aware of and concerned about its security. Interestingly, despite concerns about security, a large majority of residents reported receiving confidential patient information through text messaging. One possible explanation is that for providers the benefits of improved in-hospital communication with texting, and any presumed improvements in the coordination and delivery of care for patients, outweigh security concerns they may have. However, inpatient providers, patients, and even health systems may differ on what is an acceptable standard for texting or any new inpatient technology that improves communication or care, at some potential cost to security. As a two-institution study our results may not be generalizable, but they do highlight that there is an important role for the education and training of providers on how HIPAA applies to new mobile technology. Additionally, our findings suggest a tension providers face when communicating, in that texting is ubiquitous, efficient, and may improve care, but at some potential cost to securing patient data appropriately. In the future solutions should be sought that ensure the security and HIPAA compliance of mobile technology, without compromising efficiency and ease of use.

INCIDENCE OF CONVERSION TO ACTIVE WAITLIST STATUS AMONG TEMPORARILY INACTIVE TRANSPLANT CANDIDATES FROM LINGUISTICALLY ISOLATED COMMUNITIES

Efrain Talamantes; Keith Norris; Carol Mangione; Amy Waterman; John D. Peipert; Suphamai Bunnapradist; Edmund Huang. University of California, Los Angeles, CA. (Tracking ID #2199541)

BACKGROUND: One of the barriers to kidney transplantation occurs at the level of the waitlist, where temporarily inactive candidates cannot receive deceased donor organ offers. We hypothesized that candidates living in linguistically-isolated communities would be less likely to achieve active status.

METHODS: Using Organ Procurement and Transplantation Network/United Network for Organ Sharing data merged with five-digit zip code socioeconomic data from the 2000 U.S. Census, competing risks methods were performed to determine the cumulative incidence of conversion to active status (activation), death, and delisting before conversion among 84,783 adult kidney candidates designated temporarily inactive on the transplant waitling list from 2004 to 2012. Multivariate logistic regresson and Fine and Gray competing risks regression were performed to characterize the association between linguistic isolation, incomplete transplantation evaluation, and conversion to active status. The U.S. Census defines a linguistically isolated household as one in which all members 14 years of age and over speak a non-English language and also speak English less than “very well.”

RESULTS: At 8 years, the cumulative incidence of activation was 74.3 %, of death before conversion was 9.7 %, and of delisting was 13.4 %. The most commonly recorded initial reason for inactive status was “candidate work-up incomplete” (54.5 %). Compared to zip codes with <1 % linguistically-isolated households, candidates in zip codes with higher percentages had significantly higher odds of incomplete evaluation: 1 to 5 %, adjusted odds ratio [AOR] = 1.07, 95 % CI 1.00–1.14; 5 to 10 %, AOR = 1.16, 95 % CI 1.09–1.24; 10 to 20 %, AOR = 1.29, 95 % CI 1.20–1.39; ≥20 % AOR = 1.38; 95 % CI 1.27–1.50). After adjusting for demographic characteristics, co-morbid conditions, and socioeconomic variables candidates living in zip codes with increasing percentages of linguistically isolated households were strongly associated with decreasing subhazards of activation: 1 to 5 %, sHR 0.89 (0.87–0.92), 5 to 10 %, sHR: 0.84; 0.81–0.87, 10 to 20 %, sHR: 0.77; 0.74–0.79, ≥20 %, sHR: 0.73; 0.70–0.76, versus <1 % linguistically isolated households.

CONCLUSIONS: Our findings indicate that linguistic isolation is strongly associated with failure to complete candidate evaluations and negatively associated with achievement of active waitlist status. This study suggests that candidates living in linguistically-isolated communities may require improved levels of communication from providers to facilitate conversion to active waitlist status.

INCIDENCE OF GENITAL MYCOTIC INFECTIONS DECREASES OVER TIME IN OLDER PATIENTS WITH TYPE 2 DIABETES MELLITUS TREATED WITH CANAGLIFLOZIN

Michael Davies 1; Pamela Kushner2; Ujjwala Vijapurkar3; Gary Meininger3. 1Janssen Scientific Affairs, LLC, Raritan, NJ; 2University of California, Irvine, CA; 3Janssen Research & Development LLC, Raritan, NJ. (Tracking ID #2197721)

BACKGROUND: Patients with type 2 diabetes mellitus (T2DM) are at increased risk of genital mycotic infections (GMIs), and those with poorly controlled diabetes have higher risks. Sodium glucose co-transporter 2 inhibitors, such as canagliflozin (CANA), improve glycemic control by inhibiting renal glucose reabsorption and increasing urinary glucose excretion, a mechanism of action associated with an increased incidence of GMIs. This analysis evaluated the incidence of GMIs over time in older patients with T2DM treated with CANA.

METHODS: In a double-blind, Phase 3 clinical study, patients aged ≥ 55 to ≤ 80 years and inadequately controlled with their current treatment regimen (N = 714) were randomized to receive CANA 100 mg or 300 mg, or placebo (PBO). The incidence of GMIs was monitored over 2 years, and evaluated overall and at 3-monthly intervals in women and men.

RESULTS: The cumulative incidence of GMIs was higher with CANA 100 mg and 300 mg versus PBO in women (23.9 % and 18.7 % vs 4.3 %) and men (5.6 % and 10.9 % vs 1.4 %). The largest number of events occurred within 6 months of treatment initiation and declined with time (Figure). Between Months 0–3, the incidence of GMIs with CANA 100 mg and 300 mg was 12.8 and 9.3 %, respectively, in women; and 3.2 and 3.9 %, respectively, in men. Between Months >12–15, the incidence of GMIs decreased to 3.0 and 2.4 % with CANA 100 mg and 300 mg, respectively, in women; and 0.9 and 0 %, respectively, in men. GMIs were characterized by investigators as generally mild to moderate in intensity and responded to standard treatment. The most commonly reported female and male GMIs were vulvovaginal mycotic infection and balanoposthitis, respectively. Of the CANA-treated patients, 1.2 % of men and 1.3 % of women discontinued treatment for a GMI versus 0 % on PBO.

CONCLUSIONS: The results of this analysis indicate that, in older patients with T2DM treated with CANA, the risk of GMIs with CANA use is increased mostly early after treatment initiation. Most GMIs were mild to moderate in intensity and responded to standard treatment.

figuref

Incidence of GMIs in older female and male patients with T2DM treated with CANA 100 mg and 300 mg over 2 years.

INCORPORATION OF GUIDELINE DATA INTO ORDERING SYSTEMS REDUCES TRANSTHORACIC ECHOCARDIOGRAPHY ORDER FREQUENCY

Joel C. Boggan 1, 2; Ryan D. Schulteis1, 2; Mark Donahue1; David L. Simel1, 2. 1Durham Veterans Affairs Medical Center, Durham, NC; 2Duke University Health System, Durham, NC. (Tracking ID #2191290)

BACKGROUND: Guidance for appropriate utilization of transthoracic echocardiograms (TTEs) is available from several sources. At Durham Veterans Affairs Medical Center, approximately 50 % of ordered TTEs are ordered for the indications of dyspnea, edema, and/or valvular disease. We hypothesized that increasing the information available for these indications at the point of order would lead to a reduction in TTEs ordered.

METHODS: We incorporated data from the 2011 Appropriate Use Criteria for Echocardiography, the 2010 National Institute for Clinical Excellence Guideline on Chronic Heart Failure, and the American College of Cardiology Choosing Wisely® list on TTE use for dyspnea, edema, and valvular disease into our electronic ordering system as a quality improvement intervention beginning in September 2013. The primary outcome was the number of TTE orders per month from both the inpatient and outpatient settings modeled using Poisson regression. Secondary outcomes included rates of outpatient TTE ordering per 100 visits and frequency of brain natriuretic peptide (BNP) level ordering in the 30 days prior to TTE ordering. Outcomes were measured for 20 months before and 12 months after the intervention. Ordering rates for TTEs and BNP tests were obtained using the electronic health record.

RESULTS: The number of TTEs ordered across the medical center decreased significantly by 5.3 % after the intervention (338 +/− 32 TTEs/month prior vs. 320 +/− 33 afterward, p < 0.01). Rates of TTE ordering in the outpatient setting also decreased significantly post-intervention (2.28 per 100 primary care or cardiology visits prior vs. 1.99 afterward, p < 0.01). Over the same period, outpatient primary care and cardiology clinic visits at DVAMC increased by 10.7 % from fiscal year 2012 to fiscal year 2014. Thus, in fiscal year 2014, the reduced rate means that > 300 TTEs were avoided. The intervention significantly interacted with the time from the intervention (p < 0.01 for both TTE orders and outpatient TTE orders/visit), as the effect of the intervention partially waned over time. BNP measurement prior to ordering TTEs increased modestly after the intervention (21.8 % prior to intervention vs. 26.1 % after, p < 0.01). This was true for TTEs ordered from both the inpatient and outpatient settings (36.5 % prior vs. 42.2 % after in the inpatient setting, p= 0.01; 10.8 % prior vs. 14.5 % after in the outpatient setting, p < 0.01).

CONCLUSIONS: Incorporation of evidence-based guideline information into ordering prompts for TTEs throughout a VA hospital and its associated clinics led to improved adherence to guidelines with reduced ordering frequency and a significant increase in the frequency of TTEs linked to a prior BNP test. As the immediate effect of the intervention decayed with time, long-term educational strategies may be necessary to optimize utilization of TTEs.

figureg

UCL = Upper Control Limit, equal to +3 standard deviations from the mean

CL = Center Line, or mean

LCL = Lower Control Limit, equal to - 3 standard deviations from the mean

*Fiscal Year 2012 corresponds to October 2011 through September 2012, Fiscal Year 2013 corresponds to October 2012 through September 2013, and Fiscal Year 2014 corresponds to October 2013 through September 2014. The separating space in the graph indicates the time of the intervention.

INTEREST IN SMOKING CESSATION RELATED TO A SMOKE-FREE POLICY AMONG HOMELESS ADULTS

Maya Vijayaraghavan 1, 2; John Pierce1, 2. 1University of California, San Diego, San Diego, CA; 2Division of Health Policy, San Diego, CA. (Tracking ID #2192798)

BACKGROUND: The prevalence of smoking in the homeless population is 70 %, almost 5 times the general population. The high rates of tobacco use and its associated morbidity and mortality highlight an urgent need for specific tobacco control interventions in the homeless population. Smoke-free policies are an effective population-based strategy to reduce exposure to secondhand smoke among non-smokers and reduce smoking behaviors among smokers. Few studies have explored the potential of smoke-free policies as facilitators of smoking cessation or harm reduction among sheltered homeless adults.

METHODS: We focused on clients of a homeless shelter in San Diego, California. The facility prohibited smoking indoors and outdoors within 5 blocks of the building, and permitted smoking during 4 daily smoking breaks in designated smoking zones away from the building. Staff were not permitted to smoke with clients. Shortly after policy implementation, we interviewed current and former smokers on their smoking behaviors, perceived norms around smoking, and attitudes to smoke-free policies in the facility. Participants reported their level of agreement or disagreement to statements that described the facility’s norms around smoking and smoke-free policies.

RESULTS: Of the 170 ever smokers, 75.3 % were current smokers. The average daily cigarette consumption was 6.6 cigarettes per day (SD 4.3). More than half (57.8 %) attempted to quit smoking in the past year, with the average length of quit attempt being 45 days. One-third (33.6 %) of the current smokers reported having used nicotine replacement therapy and 12.5 % used medications in a prior quit attempt. Of the 128 current smokers, less than 15 % agreed that staff offered them cigarettes or smoked with them during smoking breaks. Two-thirds of the current smokers reported never smoking in an area where smoking was prohibited in the past month. Of the current smokers, three-fourths agreed that the facility policies were associated with their reduced consumption, and about half agreed that the policies were associated with either making a quit attempt or getting ready to quit completely. Less than 10 % reported that they would be unhappy to stay in the facility because of the policies. Sixty percent agreed that further restrictions on smoking, beyond the current policies, would be associated with increased interest in quitting smoking completely. Of the 42 former smokers, 30.9 % reported quitting after entering the facility, and of these, about half reported that the facility policies were part or the main reason for quitting smoking. Almost all current smokers (88.3 %) and former smokers (97.6 %) agreed that smoke-free policies were important because they offered a clean and safe living environment.

CONCLUSIONS: Findings suggest that smoke-free policies may not influence occupancy rates in shelters serving clientele with high rates of cigarette smoking. The facility’s policies on smoking were associated with reduced consumption and increased interest in smoking cessation among homeless adults. Thus, establishing a tobacco control program that includes smoke-free policies and resources for cessation may facilitate successful cessation among sheltered homeless adults.

INTERNATIONAL MULTICENTER VALIDATION OF THE “HOSPITAL” SCORE TO PREDICT 30-DAY POTENTIALLY AVOIDABLE READMISSIONS IN MEDICAL PATIENTS

Jacques Donze 6, 1; Mark Williams7; Edmondo Robinson2; Eyal Zimlichman8; Drahomir Aujesky6; Eduard E. Vasilevskis5; Sunil Kripalini5; Joshua Metlay3; Tamara Wallington9; Grant Fletcher10; Andrew D. Auerbach4; Jeffrey L. Schnipper1. 1Brigham and Women’s Hospital, Boston, MA; 2Christiana Care Health System, Wilmington, DE; 3Massachusetts General Hospital, Boston, MA; 4UCSF Division of Hospital Medicine, San Francisco, CA; 5Vanderbilt University, Nashville, TN; 6Bern University Hospital, Bern, Switzerland; 7University of Kentucky, Lexington, KY; 8Sheba Medical Centre, Tel HaShomer, Israel; 9William Osler Health System, Brampton, ON, Canada; 10Harborview Medical Center, Seattle, WA. (Tracking ID #2191115)

BACKGROUND: Efficiently improving transitions in care requires hospitals to target discharge interventions at those patients at high risk of potentially avoidable readmission. We previously derived the “HOSPITAL” score, an easy to use prediction model for medical patients (Table 1). This score had good discrimination for determining potentially avoidable readmissions in the hospital in which it was derived (C-statistic of 0.71). To assess its generalizability, we aimed to externally validate the “HOSPITAL” score in an international multicenter study.

METHODS: We applied the score to 124,212 adult patients consecutively discharged alive from the medical departments of 6 medical centers in the US, 1 in Israel, 1 in Canada, and 1 in Switzerland, between January and December, 2011. The outcome was any 30-day readmission that was classified as potentially avoidable using the previously validated SQLape algorithm. By comparing mainly ICD-9 codes from the two hospitalizations, SQLape excludes elective readmissions, foreseen readmissions such as chemotherapy, and readmissions for new diseases unknown during the preceding hospital stay unless a known complication of previously received treatment. The performance of the score was evaluated according to its discrimination (C-statistic, representing the area under the ROC curve) and its calibration (based on the Pearson goodness-of-fit statistic).

RESULTS: Among all patients in the cohort, the potentially avoidable readmission rate was 9.5 % (overall 30-day readmission rate was 14.5 %). The discriminatory power of the “HOSPITAL” score to predict potentially avoidable readmission was good with a C-statistic of 0.72 (95 % CI 0.71–0.72). As in the derivation study, patients were classified into 3 risk categories: low (63 %), intermediate (23 %), and high risk (14 %). The estimated proportions of potentially avoidable readmission for each risk category matched exactly the observed proportion, with a consequent excellent calibration (p= 0.97, with high p values indicating better fit; Table 2).

CONCLUSIONS: The “HOSPITAL” score identified patients at high risk of 30-day potentially avoidable readmission with high discrimination when applied to a large international multicenter cohort of medical patients. The “HOSPITAL” score is the first score to focus on potentially avoidable (as opposed to all-cause) readmissions, using readily available predictors at the time of discharge, and that is externally validated in a large cohort in 4 different countries. This score has the potential to easily identify patients in need of more intensive transitional care interventions to prevent avoidable hospital readmissions.

Table 1. ‘HOSPITAL’ Score for 30-day Potentially Avoidable Readmissions

Attribute Points
Low Hemoglobin level at discharge (<12 g/dL) 1
Discharge from an Oncology service 2
Low Sodium level at discharge (<135 mmol/L) 1
Procedure during hospital stay (any ICD-9 coded procedure) 1
Index admission Type: non-elective 1
Number of hospital Admission(s) during the previous year
  ≤ 1 0
 2–5 2
  > 5 5
Length of stay ≥5 days 2

Maximum = 13 points

Table 2. Observed vs. Predicted 30-day Potentially Avoidable Readmissions (PAR)

Points Risk category Patients in each category, n (%) Observed proportion of PAR in the derivation study, % Observed proportion of PAR in the validation study, % Estimated risk of PAR in the validation study, %
0–4 Low 77,896 (63 %) 5.4 5.8 5.8
5–6 Intermediate 29,239 (23 %) 9.0 11.8 11.8
≥7 High 17,077 (14 %) 18.7 22.4 22.4

PAR: potentially avoidable readmission

LOW RATES OF HIV PRE-EXPOSURE PROPHYLAXIS (PREP) AND NONOCCUPATIONAL POST-EXPOSURE PROPHYLAXIS (NPEP) IN A LARGE URBAN HEALTH CARE SYSTEM: IMPLICATIONS FOR IMPLEMENTING PREP AND NPEP

Monica Mercon 2; Uriel R. Felsen2; Viraj V. Patel1. 1Albert Einstein College of Medicine, Bronx, NY; 2Montefiore Medical Center, Rye Brook, NY. (Tracking ID #2199596)

BACKGROUND: The Bronx is an ongoing epicenter of the HIV epidemic in New York City with overall prevalence of 1.7 %, some Bronx neighborhoods the rate is as high as 2.6 %, while the general prevalence estimate for the United States is 0.4–0.9 %. The health care system studied provides health care service to more than 2 million people in the Bronx and Westchester, being one of most important health care system in that area. New tools are now available to help prevent HIV acquisition. Several recent trials have shown efficacy of daily oral antiretroviral for pre-exposure prophylaxis for HIV (PrEP) in reducing risk of HIV infection. Post-sexual exposure to HIV is also recommended by using 28 days course of daily highly active anti-retroviral therapy (nPEP). Both PreP and nPEP have been FDA approved and have been covered by NY Medicaid and most other commercial insurers. Little is known about to what extent these new tools are being used and who is accessing PrEP and nPEP. This study aims to describe socio-demographic characteristics and risk exposure among individuals prescribed nPEP or PrEP in a large urban health care system.

METHODS: We used a previously validated algorithm to identify all HIV negative individuals in the electronic medical records who attended outpatient visits and had also been prescribed one or more antiretrovirals from January 2011 through March 2014. A standardized chart abstraction tool was used to verify that the antiretrovirals had been prescribed for PrEP and nPEP and to collect sociodemographic and risk behavior data. We conducted descriptive statistics using SPSS 21 statistical software to calculate proportions and means as appropriate.

RESULTS: During the studied period, 51 individuals received nPEP and 10 individuals received PreP. Socio-demographic characteristics were similar between two groups. Individuals that received nPEP were mostly heterosexual women (33; 64.7 %), or men who have sex with men-MSM (15; 29.4 %), non-white (46; 90.1 %), age range 13–52 years old. The most frequent indication for nPEP was non-consensual sex (24; 47,1 %), and was frequently prescribed at the Emergency Department (30; 58.8 %). Poor adherence to follow up after nPEP was noted;14 (27 %) among individuals who received PEP had documented 28 days of use of antiretroviral medication. PreP was prescribed exclusively for heterosexual women (5; 50 %) and MSM (5; 50 %); 9 (90 %) individuals were non-white, and age rage range was 19–48 years old. PreP was mostly prescribed by primary care providers (6; 60 %), and almost exclusively for individuals in stable serodiscordant relationship (9; 90 %). There was no record of seroconversion.

CONCLUSIONS: In a large urban health care system with a high burden of HIV, located in a community with a high HIV prevalence, use of antiretroviral medications for nPEP and PrEP was extremely low. Better understanding of barriers to and facilitators of PrEP and nPEP are needed to inform implementation and increase uptake and improve the health of those at risk for HIV.

MEDICATION ADVISING AMONG LIMITED-ENGLISH PROFICIENT PATIENTS Eva Chang 1; Elizabeth Lin1; Gerardo Moreno2; Ron L. Johnson1; Heidi Berthoud1; Leo Morales3. 1Group Health Cooperative, Seattle, WA; 2UCLA, Los Angeles, CA; 3University of Washington, Seattle, WA. (Tracking ID #2198621)

BACKGROUND: Receipt of verbal and written medication advising for newly prescribed medication is key for medication safety, but little is known about how much information are given to patients with limited-English proficiency. This study described whether medication advising is associated with English language proficiency and immigration-related factors among insured patients with chronic conditions (hypertension, high cholesterol, and/or diabetes).

METHODS: We conducted a cross-sectional telephone survey of limited-English proficiency (LEP; n = 328) and English proficient (EP; n = 181) patients in an integrated healthcare system. The survey was administered in 6 languages/dialects (English, Spanish, Korean, Vietnamese, Chinese-Mandarin, and Chinese-Cantonese). Medication advising outcomes for the most recent prescription were verbal (explanation of medication purpose, medication directions, and possible side effects) and written (receipt of medication label in native language, receipt of medication information from pharmacy in native language). Univariate and bivariate analyses were conducted.

RESULTS: Among all patients, 98 % reported being told about the purpose of the medication, 97 % about how to take it, and 87 % about side effects; 85 % received all 3 pieces of verbal information. LEP patients reported similar percentages of receiving all verbal information as EP patients. Only 12 % of all LEP patients reported receiving a medication bottle in their native language and 63 % reported receiving medication information written in their native language. Ten percent of all LEP patients reported receiving both pieces of written information.

CONCLUSIONS: While the majority of patients received verbal medication advising, 10 % of LEP patients received all forms of written medication advising. The results suggest that the health care system can improve health care services to LEP patients. Requiring translated medication labels is an important next step to ensuring that LEP patients take their medications properly and avoid costly medication errors.

OPTIMIZING ACCESS TO OUTPATIENT SPECIALTY CARE IN THE SAFETY NET: A NATIONWIDE SURVEY Chelsea Bowman 4; Kevin Duan1; Nathan R. Handley2; Lena K. Makaroun3; Daniel Wheeler4; Alice Chen4, 5; Edgar Pierluissi4, 5. 1UCSF, San Francisco, CA; 2University of California - San Francisco, San Francisco, CA; 3University of California San Francisco, San Francisco, CA; 4University of California, San Francisco, San Francisco, CA; 5San Francisco General Hospital, San Francisco, CA. (Tracking ID #2190207)

BACKGROUND: Safety-net health care systems struggle to provide timely access to specialty care for uninsured, underinsured and Medicaid populations. While these challenges are longstanding, little is known about how safety-net health systems monitor specialty care access. We surveyed how specialty care is provided, assessed, and prospectively planned for in a national sample of safety-net health care systems. Based on our analysis, we propose a conceptual framework for how safety-net institutions can assess and plan for the provision of specialty care.

METHODS: We conducted a descriptive study of safety-net hospitals using a semi-structured interview with health systems’ leadership to address how systems planned for and measured specialty care access. Our sample included a member from each county in the California Association of Public Hospitals (CAPH) (N = 15) as well as members of America’s Essential Hospitals (AEH) in the 20 largest metropolitan areas according to the US 2010 census data (N = 16). Thirty-one health care systems were contacted between December 2013 and March 2014. Four authors independently reviewed the interviews and reached consensus on 5 major themes including 1) provider models for specialty care, 2) challenges in access to specialty care, 3) metrics for access, 4) metrics for productivity, and 5) strategies for improving access. The University of California, San Francisco committee on Human Research approved this study.

RESULTS: Eighteen of 31 (58 %) health care systems completed the interview. Of these, 10 were safety-net health care systems in California. A variety of models were used to provide specialty care including: academic affiliation with a School of Medicine, contracting with individual specialists, directly hiring specialists and a combination of these. The most commonly cited challenge to providing specialty care was the lack of available specialists. This was attributed to lower salaries compared to non-safety-net institutions, difficulty obtaining clinical space and inadequate funding for appropriate levels of support staff. The primary metric for measuring specialty care access was appointment wait times, although definition for this metric varied. Additional measures included the ratio of referrals to available clinic slots and patient satisfaction. Many systems collected subjective feedback from specialty leaders and had external consultation groups provide evaluation of specialty care access. Clinic productivity was measured using work relative value units, new to follow up visit ratios and full time equivalent providers to number of patients served. Strategies to improve access were categorized into three main approaches: 1) increasing specialist capacity, 2) expanding the role of the PCP, and 3) enhancing communication and coordination. (Table 1) No system employed a comprehensive framework to help guide provision and assessment of specialty care services.

CONCLUSIONS: Our study confirms that safety-net institutions face significant challenges in providing access to specialty care. Using the themes and metrics identified in our survey, we developed a conceptual framework to evaluate and plan for access to specialty care. (Figure 1) The framework may help health systems optimize existing services and plan for future provision of care.

Strategies for increasing specialty care access

Increasing Specialist Capacity Expanding Role of PCP Enhancing Communication and Coordination
Employ physician extenders (NPs,PAs) to help decrease specialist physician workload Create “mini-fellowships” for prolonged PCP immersion into specialty clinic, providing PCP with skills to bring back to primary care Create electronic referral system with screening template to ensure necessary labs and studies are completed before appointment with specialist
Place specialists physically within primary care clinic space to improve ease of access and consultation Develop system in which specialists develop management plans that are communicated to and carried out by PCPs Embed physician support tools and templates within electronic referral to improve specialty referral quality
Use tele-dermatology as means of remote access to dermatology consultative services Allow some Family Medicine physicians to accept referrals for basic dermatologic procedures Utilize a central referral office to coordinate all specialty referrals
Identify appropriate discharges from clinic to increase number of new patient appointments Create “mini-specialty” clinics (e.g. A1c, HTN, CHF, women’s health), all staffed by primary care providers Implement an electronic consult (“E-consult”) program to allow remote consultation for patients not requiring in-office visits
Increase number of total clinic half-days per week Place physician extenders and primary care physicians in specialty clinic for basic procedures Organize social events (e.g. informal dinners) to foster education and fraternization between specialists and PCPs
Adjust clinic schedule to include early morning and evening appointment time slots   Protocolize initial steps of treating certain medical conditions before initiating referral
Use digital retinal photography to improve access to ophthalmologic care   Encourage “curbside” consults by disseminating provider contact information
Reverse the model of primary and specialty care; bring PCPs into specialty care clinics for management of select patients   Standardize scheduling for all specialty clinics to improve efficiency of scheduling process and support staff
   Utilize electronic health record messaging tools to increase patient-provider communication
   Offer telephone visits as alternative to in-person specialty clinic appointments
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Figure 1: Conceptual framework to evaluate and plan for specialty care.

PERCEPTIONS OF ONLINE PORTAL USE AMONG PATIENTS WITH CHRONIC DISEASE IN A SAFETY NET HEALTHCARE SYSTEM Lina Tieu2; Urmimala Sarkar3; Dean Schillinger3, 2; James Ralston4; Neda Ratanawongsa1, 2; Courtney R. Lyles 2. 1UCSF, San Francisco, CA; 2University of California San Francisco, San Francisco, CA; 3University of California, San Francisco, San Francisco, CA; 4Group Health Research Institute, Seattle, WA. (Tracking ID #2192276)

BACKGROUND: Online portals, which provide patients access to electronic health record information, are becoming ubiquitous in the US, especially with the support of Meaningful Use financial incentives. While portals will be the first health technology to reach many diverse patient populations across the country, little is known about barriers to accessing these systems among vulnerable patients, especially among those with chronic illness for whom ongoing self-management is particularly important. This study examined patient and caregiver perspectives to the use of a patient portal before its implementation at San Francisco General Hospital (SFGH) in December 2014.

METHODS: We conducted 16 in-depth interviews with chronic disease patients receiving primary care at SFGH and caregivers providing instrumental chronic disease self-management support, from December 2013 to August 2014. We defined a caregiver as anyone giving formal or informal support in managing the health of a patient. Discussions focused on experiences with the healthcare system, technology use in everyday life, and interest in using an online portal to manage healthcare tasks. All participants were English-speaking (as the portal will only be initially available in English) and reported at least some interest in using a website to manage their healthcare (as we focused on those with existing Internet/computer access). We also assessed participant age, gender, years with diabetes, frequency of Internet use, and health literacy status. We used both deductive and inductive (open) coding to categorize barriers and facilitators to portal use. In an exploratory analysis, we also examined specific barriers among those categorized as having limited health literacy.

RESULTS:The sample included 11 patients and 5 caregivers. The mean age was 55 years, 69 % of the sample had diabetes or cared for someone with diabetes >5 years, and 10 (63 %) had limited health literacy. Overall, 8 respondents (50 %) were African American, 3 were Latino (19 %), 3 were Asian/Pacific Islander (19 %), and 2 were white (13 %); 10 were male (63 %). Ninety-four percent of participants had computer access at home, and approximately 70 % of participants reported using the Internet daily. At the conclusion of the interview, 88 % of participants reported that they would use a portal for future healthcare management. Participants reported completing a range of Internet tasks, such as using search engines, reading news, emailing and using social media, and paying bills. The major barriers to portal use were: concerns about security of information online, lack of technical skills/interest, and preferences for in-person visits/communication. However, participants with limited health literacy more often discussed fundamental barriers to using an online portal, including: challenges with reading, writing, and typing (“I think that’s the reason why I don’t really use the computer a lot because it’s a lot of reading. Like I said, I’m not really a heavily educated guy.”); personal experiences with online security breaches/viruses; and a distrust of potential portal security measures (“Regardless of what a person says that this site is secured and all that, I just don’t believe it.”). Overall, participants were satisfied with the current healthcare system, but saw the value of a patient portal to increase the convenience of care coordination (“Instead of bugging the front desk…and they have to look everywhere for you…it’s convenient I think just looking at the calendar yourself.”); improve health monitoring; and support patient-driven communication (“I just hope that it’s just useful when you’re not at the doctor and you just want to know different information or contact your doctor.”).

CONCLUSIONS: Patients in a safety net system reported major barriers to using an online portal. Overall, there was a high level of concern about reading and understanding medical information and preserving existing in-person relationships with providers. However, participants were enthusiastic about using a portal to improve their ability to manage their chronic conditions. Patient portals have the potential to be a convenient and effective way for patients and caregivers receiving care from safety net settings to improve self-management, quality of care, and improvements in health. Our findings suggest a strong need for training and support to assist vulnerable patients with portal registration and use, perhaps most so for those with limited health literacy.

PHYSICIAN ATTITUDES AND PRACTICES REGARDING ADULT VACCINES AND OTHER PREVENTION PRACTICES IN A SHIFTING PRACTICE ENVIRONMENT Laura P. Hurley 3, 10; Carolyn Bridges1; Mandy Allison8; Lori A. Crane4; Michaela Brtnikova2; Sean O’Leary6; Brenda Beaty9; Megan Snow5; Rafael Harpaz1; Allison Kempe7. 1CDC, Atlanta, GA; 2Children’s Outcomes Research Program, Aurora, CO; 3Denver Health, Denver, CO; 4University of Colorado Anschutz Medical Campus, Aurora, CO; 5University of Colorado Denver, Aurora, CO; 6University of Colorado School of Medicine, Aurora, CO; 7University of Colorado and Children’s Hospital Colorado, Aurora, CO; 8University of Colorado, Anschutz Medical Campus, Aurora, CO; 9Unviersity of Colorado, Aurora, CO; 10The Children’s Hospital Colorado, Aurora, CO. (Tracking ID #2181305)

BACKGROUND: United States Preventive Services Task Force (USPSTF) and Advisory Committee on Immunization Practices (ACIP) recommendations are widely used to guide delivery of non-immunization and immunization related clinical preventive services, respectively. Rates of all recommended preventive services remain below national goals and vaccination rates often trail rates for other preventive services. The Affordable Care Act (ACA) promotes delivery of preventive services by requiring that USPSTF Grade A and B and ACIP recommendations be provided without cost to several groups of patients and by creating the ‘Annual Wellness’ visit for Medicare beneficiaries. The short amount of time allotted for primary care visits makes it challenging to deliver all recommended preventive services to adult patients. Little is known about how physicians prioritize vaccination versus other preventive services for adults. Our objectives were to describe among U.S. primary care physicians: the perceived importance of vaccines relative to other USPSTF or ACIP recommended preventive services and awareness and use of ‘Annual Wellness’ visits.

METHODS: We administered an Internet and mail survey from March to June 2012 to national networks of 443 general internal medicine (GIM) and 409 family medicine (FM) physicians representative of the American College of Physicians and American Academy of Family Physicians memberships, respectively. Questions were developed jointly with the CDC and modified based on input from advisory committees and pilot testing among primary care physicians. GIM and FM results were combined where similar with differences noted.

RESULTS: Response rates were 79 % (352/443) for GIM and 62 % (255/409) for FM. Physician perceived importance of ACIP recommended vaccines relative to each other and Grade A or B USPSTF recommended preventive services for hypothetical, gender neutral, non-smoking, healthy 67 and 30 year-old patients are presented in the figure. Eighty-five percent of physicians were aware of ‘Annual Wellness’ visits, but 30 % of the aware physicians reported having conducted none of these visits in the prior month and 36 % reported having conducted less than ten. Physicians with ≥ 25 % Medicare patients compared to those with <25 % Medicare were more aware of these types of visits (p= 0.03)), but did not report conducting more of these visits (p= 0.38). Sixty-nine percent of respondents reported it would be feasible, 28 % reported it would not be feasible and 3 % reported not knowing the feasibility of conducting ‘Annual Wellness’ visits for the majority of their Medicare patients.

CONCLUSIONS: Despite uniform recommendations by ACIP, physicians are prioritizing some vaccines over others, and, sometimes, are ranking them below other clinical preventive services. Whether these attitudes result in missed opportunities for vaccination is uncertain and should be explored. Promotion of use of the ‘Annual Wellness’ visit might improve delivery of preventive services including vaccine-based prevention for seniors.

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PHYSICIAN ATTITUDES REGARDING ADVANCE CARE PLANNING FOR PATIENTS UNDERGOING CANCER TREATMENT Ali John Zarrabi 1; Alexandra Rosenberg1; Julia P. Brockway2; Matthew J. Press3; Orit Saigh2; Jenny J. Lin1. 1Icahn School of Medicine at Mount Sinai, New York, NY; 2Mount Sinai Beth Israel, New York, NY; 3Weill Cornell Medical College, New York, NY. (Tracking ID #2195648)

BACKGROUND: Palliative care can help manage physical and emotional symptoms and improve quality of life during active cancer treatment. Yet many physicians still view palliative care only for terminal cases. We undertook this study to assess perceived roles and responsibilities of medical oncologists and primary care physicians (PCPs) regarding advance care planning for patients receiving active cancer treatment.

METHODS: PCPs and medical oncologists practicing at three academic hospitals in New York City were administered an anonymous survey that included a vignette of a 55 year-old woman with early-stage breast cancer who had comorbid hypertension, hyperlipidemia, and diabetes. Physicians were asked about their attitudes regarding cancer-related symptom management, goals of care discussions, and palliative care involvement. Descriptive and univariate analyses were used to assess differences between PCPs vs. oncologists.

RESULTS: Of a total of 203 surveys returned out of 232 distributed (response rate 87.5 %), 127 (62.5 %) were from PCPs and 32 (15.8 %) were from oncologists. One hundred fifteen (56.7 %) were attending-level physicians, and 75 (36.9 %) were male. Oncologists were far more likely than PCPs to believe that they had received adequate training in symptom management related to cancer treatment (91 % vs 24 %, p < 0.01), and more oncologists reported feeling comfortable managing treatment-related physical symptoms (97 % vs 40 %, p < 0.01). Both PCPs and oncologists felt equally comfortable managing emotional symptoms (80 % vs. 90 %, p= 0.19) but PCPs were more comfortable than oncologists managing patients’ practical needs (49 % vs. 25 %, p= 0.02). Compared to PCPs, oncologists were less likely to address goals of care with the vignette patient with early-stage cancer (91 % vs. 66 %, p < 0.01) or to involve specialty palliative care in patients with advanced cancer (92 % vs. 69 %, p < 0.01). While the majority of PCPs and oncologists felt that all cancer patients should have their goals of care addressed while undergoing active cancer treatment (89 and 71 %, respectively, p= 0.02) and reported feeling comfortable addressing goals of care (84 and 97 %, respectively, p= 0.08), PCPs were more likely to agree with the statement that all cancer patients undergoing active cancer treatment should have a palliative care consultation (62 % vs 13 %, p < 0.01).

CONCLUSIONS: While the majority of PCPs and oncologists believed that all patients undergoing active cancer treatment should have goals of care addressed, PCPs were more likely to request specialty palliative care for all their active cancer patients, and oncologists were less likely to address goals of care in patients with non-advanced disease. PCPs were half as likely as oncologists to feel comfortable managing symptoms related to cancer treatment. Further efforts should target improving PCPs’ confidence in managing cancer-related symptoms and increasing multi-disciplinary collaboration for advanced care planning in cancer patients.

PHYSICIAN VIEWS ON COMMUNICATION AND COORDINATION OF CARE DURING ACTIVE TREATMENT OF PATIENTS WITH CANCER AND COMORBIDITIES Julia P. Brockway 1; Alexandra Rosenberg2; Ali John Zarrabi2; Matthew J. Press3; Orit Saigh1; Jenny J. Lin2. 1Mount Sinai Beth Israel, New York, NY; 2Icahn School of Medicine at Mount Sinai, New York, NY; 3Weill Cornell Medical College, New York, NY. (Tracking ID #2193526)

BACKGROUND: Poorly controlled comorbidities, such as diabetes mellitus, may be associated with poor outcomes during and after cancer therapy. However, the management of chronic medical conditions may be overlooked in patients undergoing active cancer treatment. Part of the challenge lies in identifying the roles of primary care providers and medical oncologists in coordinating care. Few studies have explored medical providers’ perceptions and expectations regarding care practices for patients actively undergoing cancer treatment. Our study aims to identify providers’ knowledge, practices, and beliefs regarding coordination of care for these patients.

METHODS: We developed a questionnaire centered on a vignette about a 55-year-old woman with early stage breast cancer who had comorbid diabetes, hypertension, and hyperlipidemia. Primary care providers (PCPs) and medical oncologists practicing at three academic hospitals in New York City were surveyed anonymously about their knowledge, attitudes, and practices regarding care coordination during active cancer treatment. Descriptive and univariate analyses were used to assess differences in the responses between the PCPs and oncologists.

RESULTS: To date, a total of 203 surveys have been completed, with a response rate of 87.5 %. Of these, 127 (62 %) were PCPs, 32 (16 %) were medical oncologists, 11 (5 %) were palliative care physicians, and the remainder were nurse practitioners or physician assistants. More than half (57 %) were attending physicians, and 126 (62 %) worked primarily in a hospital-based setting. Compared to PCPs, oncologists were twice as likely to feel uncertain about which physician should be providing cancer patients’ general preventive care (16.5 % vs. 34.4 %, p= 0.02). Yet PCPs were more likely to feel concerned about duplicated care (23 % vs. 6 %, p= 0.03). Medical oncologists were more likely to agree with the statement that they can readily access medical specialists for consultation about treatment plans (91 % vs 61 %, p < 0.01) and most (66 %) felt they had adequate resources and technical support to facilitate communication with other providers, whereas only 44 % of PCPs reported they had adequate resources to facilitate communication (p= <0.01). Regarding management of diabetes during active cancer treatment, almost all PCPs and oncologists (99 % vs. 100 %) agreed that diabetes should be actively managed while undergoing cancer treatment. However, more PCPs agreed with the statement “it’s okay for diabetes control to be less strict during cancer treatment” (57 % vs. 38 %, p= 0.05). PCPs were also more likely to agree that patients would miss some diabetes-related visits while undergoing cancer treatment (81 % vs. 57 %, p= 0.01) and twice as many PCPs (60 % vs 29 %, p= <0.01) were able to identify the correct hemoglobin A1c goal of 6.5–7.5 % for the patient in the vignette case.

CONCLUSIONS: Primary care providers and medical oncologists differ in their knowledge, attitudes, and practices regarding the management of comorbid conditions in patients actively undergoing cancer treatment. There is a communication gap and uncertainty about physician roles in providing coordinated care. Further efforts should help providers clearly define their roles to enhance multi-disciplinary collaboration for optimal cancer care delivery.

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PHYSICIANS’, NURSES’, PHYSICAL THERAPISTS’ AND MIDWIVES’ ATTITUDES TOWARDS COMPLEMENTARY MEDICINES: A SURVEY AT AN ACADEMIC HOSPITAL Eléonore Aveni1; Brent Bauer2; Ramelet Anne-Sylvie 1; Decosterd Isabelle1; Pierluigi Ballabeni1; Pierre-Yves Rodondi1. 1Unil/CHUV, Epalinges, Switzerland; 2Mayo Clinic, Rochester, MN. (Tracking ID #2193889)

BACKGROUND: The use of complementary medicines (CM) has increased in Europe and in the United States during the last decades, although CM are not integrated in most healthcare systems and are not part of the academical’s tradition. Few data are available about academical healthcare professionals’ attitude towards CM. The objective of this study was to assess the attitude of physicians, nurses, physical therapists and midwives in an academic hospital towards CM.

METHODS: The cross-sectional survey took place from October to December 2013. An email sent to 4925 healthcare professionals (1969 physicians, 2372 nurses, 145 physical therapists, and 111 midwives) working at the University Hospital of Lausanne, Switzerland, invited them to answer a web-based questionnaire. The questionnaire was built according to other surveys among healthcare professionals.

RESULTS: One thousand two hundred forty-seven health professionals answered the questionnaire (response rate: 25.3 %). More female doctors then men answered the questionnaire according to the whole sample (p= 0.044), but the reprensentativity of the sample was good for other professions (nurses: p= 0.57; physical therapists:p= 0.49; midwives: p= 0.39). A quarter (24.1 %) of healthcare professionals never spoke with patients about the possible benefits of using CM and 43.6 % never spoke about the risks of CM. Although 80.4 % of respondents thought they should inform patients about CM, 44.2 % found it difficult or very difficult to find reliable information about CM at the academic hospital. Respondents admitted that they initiated discussion about CM less frequently (35 %) than patients, with women and professionals trained in practicing CM (16 % of the respondents) having a tendency to initiate more frequently the discussion (p= 0.011 and p= 0.004, respectively). The majority of respondents (82.5 %) thought they lacked knowledge about CM with nurses (86 %) and physicians (81.7 %) thinking they lacked more information compared to physical therapists (75 %) (p < 0.001 and p= 0.003, respectively). When asked about the impact of several factors on their opinion towards CM, personal experience with CM had a higher impact for nurses (77.6 %) and midwives (85.3 %) than for physicians (51.8 %) (p < 0.001). Prospective randomized controlled clinical trials published in medical journals had a higher impact on physicians’ opinion (75.9 %) compared to nurses (52.1 %) (p < 0.001). Published case reports had the lowest impact for all professions.

CONCLUSIONS: Our results showed that a quarter never spoke about the potential benefits of CM and 44 % never spoke about potential risks. With the documented reluctance of patients to disclose their use of CM and the risk of herb-drug interactions, healthcare professionnals must take a more active role in initiating discussions about CM and be able to inform patients about their use. There is a difference between the professions as to which factor impacts the most on their opinion towards CM: physicians are more influenced by published controlled trials compared to nurses and midwives, who are more affected by personnal experience. This could have an impact on the recommendations about CM given to patients. With the need to develop more interprofessional education, CM could be a good example for the introduction of interprofessional training. To our knowledge, it is the largest study about professionnals’ attitude towards CM at an academic hospital.

PREDICTING LOW TESTOSTERONE IN THE AGING MALE: A SYSTEMATIC REVIEW Adam C. Millar 1; Adrian Lau2; George A. Tomlinson2; Alan P. Kraguljac3; David Simel4; Allan S. Detsky1; Lorraine Lipscombe5. 1University of Toronto, Mount Sinai Hospital, Toronto, ON, Canada; 2University Health Network, Toronto, ON, Canada; 3Mount Sinai Hospital, Toronto, ON, Canada; 4Durham VAMC and Duke University, Durham, NC; 5University of Toronto, Women’s College Hospital, Toronto, ON, Canada. (Tracking ID #2191601)

BACKGROUND: Physicians diagnose and treat suspected hypogonadism in aging men based on low testosterone levels and/or symptoms, extrapolating from the defined clinical entity of hypogonadism found in younger men. The objective of this study is to systematically review the literature to estimate the accuracy of clinical symptoms and signs for predicting low testosterone among men over the age of 40 years.

METHODS: The MEDLINE and EMBASE databases (January 1966 to July 2014) were searched for English-language articles on patient history or physical examination characteristics for identifying low testosterone in males over the age of 40. Original studies on the association between signs or symptoms and low testosterone in men over the age of 40 years were included. Three authors independently reviewed 6053 articles for inclusion and quality review, as well as extracted data from each of the selected 37 papers. The definition of the reference standard (both the method of measuring testosterone and lower limit of normal) varied considerably across studies.

RESULTS: In high quality studies, prevalence rates of low testosterone varied between 14 and 67 %, with a median of 33 %. Threshold testosterone levels used for reference standards also varied substantially. The individual symptoms most commonly evaluated were decreased libido and erectile dysfunction. The summary likelihood ratio (LR) for low testosterone associated with decreased libido was 1.6 (95 % CI: 1.3–1.9), and the LR for absence of this finding was 0.72 (95 % CI: 0.58–0.85). Similarly, the LR associated with the presence of erectile dysfunction was 1.7 (95 % CI: 1.3–2.1) and LR in the absence of erectile dysfunction was 0.76 (95 % CI: 0.61–0.89). In terms of multiple item instruments, the Androtest appears to have both the most favorable LR+ (range 1.9–2.2) and LR- (range 0.37–0.49), but head-to-head comparisons between instruments have not been done.

CONCLUSIONS: Few of the individual signs or symptoms used to identify or exclude low testosterone in men over the age of 40 years had a LR+ ≥2.0, while only one symptom (normal vigor) had a LR- ≤0.5. This poor overall correlation between signs, symptoms and testosterone levels coupled with uncertainty about what threshold testosterone levels should be considered low for older men and the wide variation in estimated prevalence of the condition, makes it difficult to extrapolate the method of diagnosing hypogonadism in younger men to clinical decisions for aging males.

PREFERENCES FOR FAMILY INVOLVEMENT IN END-OF-LIFE DECISION-MAKING Alyssa Harlow 1; Michael Green3; Benjamin Levi5; Jane Schubart5; Renee R. Stewart3; Jorge A. Dorantes2; Lisa S. Lehmann2, 4. 1Brigham and Women’s Hospital, Cambridge, MA; 2Brigham and Women’s Hospital, Boston, MA; 3Penn State College of Medicine, Hershey, PA; 4Harvard Medical School, Boston, MA; 5Penn State Hershey Medical Center, Hershey, PA. (Tracking ID #2199218)

BACKGROUND: Of the nearly 2.5 million people who die each year in the United States, 70 % lack decision-making capacity at the end of life. In most cases, family members serve as surrogate decision makers for end-of-life decisions. Family surrogates are often unsure of loved one’s preferences for end-of-life decisions, resulting in stress and angst. Furthermore, patients’ preferences for level of involvement of family members’ in end-of-life decision-making are variable. Addressing these complexities, this study of patients with advanced illnesses aimed to determine their preferences for family involvement in end-of-life decision-making. We also sought to assess whether patients’ decision preferences differ by demographic characteristics such as age, gender, race, religion, education, or disease category.

METHODS: We recruited a convenience sample of 92 severely ill patients from Brigham and Women’s Hospital and Penn State Hershey Medical Center. Patients were included if they were likely to lose decisional capacity within 2 years and had one or more of the following diagnoses: advanced cancer, severe congestive heart failure (New York Heart Association Class III or Class IV), severe lung disease (Stage III or Stage IV COPD by modified GOLD Spirometric Classification), or End Stage Renal Disease. We measured patients’ preferences for family involvement in medical decision-making using the Decision Control Preferences scale. Patients were asked to articulate their preferences for family involvement under two scenarios: 1) when they are awake with decision-making capacity, and 2) when they lack the ability to participate in decision-making. Response options ranged from family-centered (family member wishes take priority) to shared roles (equally weigh family member wishes with their own) to patient-centered (patient wishes take priority). Patients were also asked to weigh family members’ versus doctor’s input on decision-making. Socio-demographic information was collected for all participants. Descriptive and multivariate analyses were conducted to assess patient control preferences, and predictors of patient control preferences.

RESULTS: The mean age of participants was 63 years (SD ± 14). Fifty-one percent (44) of participants had cancer, 24 % (21) had COPD, 21 % (18) had CHF, and 4 % (3) had ESRD. Seventy-four percent (66) of participants were white, 18 % (16) were black, and 8 % (7) identified as a race other than black or white. Sixty-eight percent (16) did not have a college degree, 71 % (65) reported having strong religious faith, and 29 % (27) reported having weak or no religious faith. Fifty-four percent (50) preferred a shared role in decision-making when awake with decision-making capacity, 38 % (70) preferred patient centered roles, and 8 % (14) preferred family centered roles. When lacking decision-making capacity, less than half preferred a shared role [46 % (42)], opting for either patient-centered [30 % (28)] or family-centered roles [24 % (22)]. Most patients preferred the input of family members and doctors to be weighed equally in both clinical situations (69 % n = 63 and 63 % n = 56, respectively). There was no significant association between disease category, age, gender, religion, race and patients’ decision control preferences. College education was significantly associated with preferring a patient-centered role in decision-making (OR 2.8, [95%CI 1.2,6.9] p= 0. 02), and with weighing a doctor’s input more heavily than family members’ (OR 2.8, [95 % CI 1.1,7.4] p= 0.04). Strong religious faith was significantly associated with preferring a family-centered role in decision-making (OR 0.3, [95 % CI 0.150,0.710] p= 0.005).

CONCLUSIONS: Only half of severely ill patients prefer a shared role with family members when the time comes to make a significant end-of-life medical decision. When patients lose decision-making capacity, a significant percentage state a preference for family members’ wishes taking priority over their own prior stated wishes. Individuals with a strong religious faith prefer greater family involvement in decision-making. Our findings challenge the commonly held understanding of health care agents being the voice of the patient. In some cases, patients want family members’ preferences to trump their own preferences. Patient preferences for family involvement in end-of-life decision making may be highly variable. Therefore, health care providers will need to encourage early communication between patients and family members in order for family surrogates to better understand how their loved ones want end-of-life decisions to be made.

PROGNOSTIC PERFORMANCE OF ECHOCARDIOGRAPHY IN HEMODYNAMICALLY STABLE ELDERLY PATIENTS WITH ACUTE PULMONARY EMBOLISM Eveline Hofmann 3; Andreas Limacher5; Marie Méan3, 1; Nils Kucher3; Marc Righini4; Beat Frauchiger10; Juerg-Hans Beer6; Joseph J. Osterwalder11; Markus Aschwanden2; Christian M. Matter7, 8; Martin Banyai9; Michael Egloff4; Olivier Hugli1; Daniel Staub2; Henri Bounameaux4; Nicolas Rodondi3; Drahomir Aujesky3. 1Lausanne University Hospital, Lausanne, Switzerland; 2Basel University Hospital, Basel, Switzerland; 3Bern University Hospital, Bern, Switzerland; 4Geneva University Hospital, Geneva, Switzerland; 5Clinical Trials Unit Bern, Bern, Switzerland; 6Cantonal Hospital of Baden, Baden, Switzerland; 7Zurich University Hospital, Zurich, Switzerland; 8University of Zurich, Zurich, Switzerland; 9Cantonal Hospital of Lucerne, Lucerne, Switzerland; 10Cantonal Hospital of Frauenfeld, Frauenfeld, Switzerland; 11Cantonal Hospital of St. Gallen, St. Gallen, Switzerland. (Tracking ID #2195765)

BACKGROUND: Evidence suggests that several echocardiographic signs of right ventricular (RV) dysfunction are associated with an increased short-term mortality in hemodynamically stable patients with acute pulmonary embolism (PE). Cardiology guidelines recommend performing transthoracic echocardiography to risk-stratify such patients. Although elderly patients with PE have a higher complication rate than younger patients, the prognostic performance of transthoracic echocardiography to predict adverse outcomes has not been specifically examined in the elderly.

METHODS: We studied 400 hemodynamically stable patients aged ≥65 years with acute PE in a Swiss prospective multicenter cohort study between September 2009 and June 2012. Transthoracic echocardiography was performed by blinded cardiologists within three days of PE diagnosis. We defined RV dysfunction as a RV/left ventricular ratio >0.9 or RV hypokinesis (primary definition) or the presence of either ≥1 or ≥2 of 6 predefined echocardiographic signs of RV dysfunction (secondary definitions). Outcomes were overall mortality, the combination of mortality/non-fatal recurrent venous thromboembolism (VTE) and health-related quality of life at 90 days, and length of hospital stay. We examined the association between RV dysfunction and outcomes, adjusting for patient baseline characteristics.

RESULTS: Overall, 36 % of patients had RV dysfunction based on our primary definition, and 81 and 53 % based on our secondary definitions, respectively. Using our primary definition, there was no association between RV dysfunction and mortality (adjusted HR 0.81, 95%CI 0.35–1.88), mortality/non-fatal VTE (adjusted HR 0.96, 95%CI 0.45–2.08), or quality of life. RV dysfunction was associated with an increased length of stay (adjusted time ratio 1.18, 95%CI 1.03–1.36). Using our secondary definitions, we found no association between RV dysfunction and clinical outcomes. However, RV dysfunction was associated with a poorer quality of life and a longer hospital stay.

CONCLUSIONS: The prevalence of echocardiographic RV dysfunction varied widely based on the criteria used to define RV dysfunction in elderly, hemodynamically stable patients with acute PE. We did not find an association between RV dysfunction and clinical outcomes but patients with RV dysfunction had a poorer health-related quality of life and a longer hospital stay. The assessment of echocardiographic RV dysfunction as a stand-alone risk stratification tool appears to be of uncertain usefulness in elderly, hemodynamically stable patients with acute PE.

READMISSION-FREE SURVIVAL: ACCOUNTING FOR THE EFFECT OF MORTALITY RATES ON CHF READMISSION RATES John Hughes 1; Richard Averill2; James Vertrees2; Norbert Goldfield2; Jean Xiang2; Elizabeth McCullough2. 1Yale University School of Medicine, New Haven, CT; 23 M Health Information Systems, Wallingford, CT. (Tracking ID #2198922)

BACKGROUND: The sickest among hospitalized patients are the most likely to be readmitted, but are also the most likely to die either in hospital or shortly after discharge. Patients who die cannot be readmitted, and therefore hospitals with excessive mortality rates may have lower readmission rates as a consequence. Support for this possibility comes from several reports of an inverse relationship between hospital morality rates and readmission rates for Congestive Heart Failure (CHF).

METHODS: We examined the relationship between CHF readmission and mortality rates using CMS data from 2010 to 2012 for 2352 hospitals with more than 100 CHF discharges in 2010. We ranked hospitals by their risk-adjusted mortality rates from the time of admission until 30 days post discharge, using the All-Patient Refined Diagnosis Related Groups (APR DRG) Risk of Mortality method. We used the published Excess Readmission Ratios (ERR) for CHF for each hospital, drawn from Medicare data from 2009 to 2012, as a measure of readmission rates at 30 days after discharge. Medicare uses ERR as part of its formula to determine which hospitals will be subject to payment penalties. Individual hospital ERRs ranged from 0.746 to 1.333, with scores greater than 1.0 indicating higher than expected readmission rates.

RESULTS: While hospitals that score high on one outcome measure might be expected to score high on others, we found a modest inverse correlation between risk-adjusted mortality rates and ERR overall (Pearson = −0.2259) for CHF. We sorted hospitals into quartiles based on the ERR, and calculated severity-adjusted 30-day post discharge mortality rates for each quartile. Average ERR ranged from 0.893 for quartile 1 (Q1) up to 1.116 for quartile 4 (Q4). By contrast, risk adjusted mortality was highest for Q1 (9.0 %), where the ERR was lowest, and conversely was lowest for Q4 (6.8 %), where ERR was highest. These findings are consistent with an inverse relation for mortality and readmission rates. We then calculated a Readmission-Free Survival Rate (RFSR), a measure of positive performance based on the number of patients admitted for CHF who had survived hospitalization and had neither died nor been readmitted by 30 days after discharge. By including both readmissions and mortality, this calculation minimizes any censoring effect of excessive mortality rates. RFSR overall was 73.9 %, ranging from 75.8 % in Q1 to 72.2 % in Q4. We then examined the relationship between the CMS ERR and the RFSR with a cross-tabulation of quartiles to see how assessments of hospital performance would differ between the two measures. There were substantial differences within ERR Q4 (worst performing), containing the hospitals with the highest ERR scores. Twenty-five percent of hospital in EER Q4 would have ranked in the top two quartiles of RFSR (best performing), and over half (52 %) would have ranked in the top 3 RFSR quartiles.

CONCLUSIONS: These results confirm that lower readmission rates can be associated with higher mortality rates for CHF. Some hospitals could therefore be subject to financial penalties for excess readmissions under current Medicare rules, even though they had better overall survival outcomes. These findings can be explained in two ways: either because high-readmission hospitals kept their patients alive longer, who therefore had more opportunity to be readmitted, or perhaps because more frequent hospitalizations actually helped to keep their CHF patients alive longer. The Readmission-Free Survival Rate is a useful measure to assess the impact of CHF mortality rates on hospital readmission performance.

RED CELL DISTRIBUTION WIDTH (RDW) AS A PREDICTOR OF CLINICAL OUTCOMES IN PATIENTS WITH HYPERTENSIVE CRISIS Sagger Mawri 2; Suraj Raheja1; Alexander Michaels1; Joseph Gibbs1; Niral M. Patel1; Bharat Rao1; Ruchir Patel1; James McCord1. 1Henry Ford Health System, Detroit, MI; 2Henry Ford Hospital, Detroit, MI. (Tracking ID #2196441)

BACKGROUND: Red cell distribution width (RDW) is a measure of the variability in size of erythrocytes. A high RDW value indicates greater variation in size between individual erythrocytes and has been shown to be an independent predictor of mortality in patients with coronary artery disease, heart failure and in patients undergoing percutaneous coronary intervention (PCI). The aim of this study was to evaluate the prognostic value of RDW in predicting clinical outcomes in patients with hypertensive crisis.

METHODS: We performed a retrospective study of 465 consecutive patients from January 2007 to March 2010 who presented with hypertensive crisis. Hypertensive crisis was defined as systolic BP >180 and/or diastolic BP >110 mmHg with impending or progressive end organ dysfunction requiring inpatient hospitalization. The study sample consisted of 465 patients (38.9 % men; mean age 59.6 ± 15.9). Baseline levels of RDW were measured at time of admission and analyzed as continuous and categorical variables (elevated RDW was defined as >14.5 %). Multivariable regression analysis was performed for development of all-cause mortality, myocardial infarction, new-onset heart failure (defined as first time hospital admission for heart failure), stroke and MACE (MI, new-onset heart failure and stroke) at 2 years.

RESULTS: RDW > 14.5 % was a strong independent predictor of all-cause mortality at 2 years (OR: 1.90, 95 % CI: 1.1–3.3, p < 0.05). Elevated RDW was also found to be an independent predictor of new-onset heart failure at 2 years (OR: 1.97, 95 % CI: 1.1–3.7, p < 0.05). Elevated RDW was not a predictor of MI, PCI or stroke at 2 years.

CONCLUSIONS: Elevated RDW level in patients with hypertensive crisis was an independent predictor of all-cause mortality and new-onset heart failure in patients with hypertensive crisis.

REFERRAL BY PRIMARY CARE PROVIDERS INTO THE POWER WEIGHT LOSS TRIAL WAS NOT ASSOCIATED WITH GREATER WEIGHT LOSS Eva Tseng 1; Nae-Yuh Wang3; Jeanne M. Clark3; Lawrence J. Appel2; Wendy L. Bennett2. 1Johns Hopkins, Baltimore, MD; 2Johns Hopkins School of Medicine, Baltimore, MD; 3Johns Hopkins University, Baltimore, MD. (Tracking ID #2193342)

BACKGROUND: Primary care providers (PCPs) play an important role in identifying and counseling obese patients to lose weight. However, PCPs report many barriers to weight loss counseling and many prefer to refer patients into effective weight loss programs. The Hopkins POWER behavioral weight loss trial provided an opportunity to evaluate the method of recruitment into the trial and to determine if PCP referral is associated with greater weight loss and participation rates. We hypothesized that participants referred to the POWER trial by their PCP achieved greater weight loss and had higher participation rates and satisfaction level compared to other non-PCP recruitment methods.

METHODS: The Hopkins POWER trial was a 3-arm randomized controlled trial of 415 obese patients with at least one cardiovascular risk factor from six primary care practices in the Baltimore, MD area. Participants were randomized to a control group or one of two behavioral weight-loss interventions (remote or in-person coaching). A screening survey assessed participants’ stated recruitment method, which was dichotomized into “PCP referral” or “non-PCP” recruitment (including brochures or posters in the practice, mailed letters) methods. Study participants assigned to the intervention arms had PCPs who reviewed their weight loss progress reports at routine office visits and encouraged their participation. The primary outcome was percent weight change from baseline to 24 months. The secondary outcomes were satisfaction with PCP-patient relationship and participation rates in the intervention, assessed as the percentage of recommended coach contacts and web logins. We conducted longitudinal mixed-effects model, adjusting for clinic, sex, age, and race or ethnic group.

RESULTS: Of the 415 participants, 171 (41 %) reported PCP referral compared to 244 (59 %) who reported other recruitment methods. Those referred by their PCP were younger (52.8 ± 0.8 vs. 54.9 ± 0.7 years, p= 0.04), had a higher BMI (37.6 ± 0.4 vs. 35.9 ± 0.3 kg/m2, p= 0.0006), were more likely to be female (71.4 % vs. 58.2 %, P = 0.0006), and African American (46.2 % vs. 37.3 %, p = 0.0006). Participants in both “PCP referral” and “non-PCP” recruitment groups lost similar percentages of weight from baseline to 24 months (between-group difference: −0.6 %, 95%CI −2.3–1.1 %; p = 0.49), after adjusting for age, race, gender, and clinic site. PCP referral was also not significantly associated with percentage of completed coach contacts and web logins. However, those referred by their PCP into the trial reported higher satisfaction with the relationship with their PCP at the end of trial (p = 0.003).

CONCLUSIONS: Our study represents the first of its kind to examine the role of PCP recruitment of patients into a weight loss trial. Although the POWER trial was not designed to evaluate the effect of PCP recruitment on weight loss outcomes, our study does highlight the need for additional research to develop strategies for PCPs to identify eligible patients and recommend weight loss programs to ultimately impact patients’ success.

REFORMING AMBULATORY RESIDENCY EDUCATION: LONG TERM IMPACTS ON LEARNING, SATISFACTION, AND CAREER DECISIONS Lauren Block; Jennifer Verbsky; Nancy A. LaVine; Joseph Conigliaro; Saima Chaudhry. North Shore-LIJ Health System, Lake Success, NY. (Tracking ID #2196735)

BACKGROUND: Restructuring of ambulatory residency education has been promoted by professional groups. A major goal of reform is to increase the number of trainees entering primary care careers. Between 2010 and 2014 our health system sought to improve ambulatory education and increase the number of residents entering primary care through an iterative reform. Changes at the institutional level included electronic health record implementation and improving compensation for residency graduates entering primary care. Departmental initiatives were patient centered medical home (PCMH) transformation and a Hospital Medical Home Demonstration Grant to support care coordination within the resident practice. Residency program changes included establishing a 4 + 1 residency schedule and implementing a resident mentoring program, a team based learning curriculum, and a community primary care rotation. We sought to assess whether teaching, learning, and satisfaction with ambulatory training improved over the 4-year period, and whether more residents entered primary care careers subsequent to the reform.

METHODS: We employed a pre- and post-intervention survey to study second and third year internal medicine residents at a large residency program in New York. Residents are assigned to one of two ambulatory sites; a hospital-based clinic and a freestanding faculty and resident practice. All 2nd and 3rd year residents in the program were surveyed in 2011 regarding the prior academic year (2009–10, baseline) compared with the 2010–11 academic year (first round of reform) using a retrospective pre/post assessment methodology. All 2nd and 3rd year residents were surveyed in April 2014 (post-all reform efforts) using the same items. Residents reported career plans from the years 2010–2014. The Table displays key features of each redesign effort. The primary outcomes were self reported teaching and learning, satisfaction with ambulatory training, and number of trainees entering primary care careers. Secondary outcomes were measures of continuity and workload. All measures were validated and used in prior educational research.

RESULTS: The overall response rate was 93 %. A total of 46 % of residents were PGY2, 53 % were male, and 71 % practiced at the PCMH site. Mean scores on self reported learning and faculty teaching scales improved significantly over the study period (mean 3.6 baseline vs. 4.1 post-reform on a 1–5 Likert scale, p < 0.01 and 3.3 baseline vs. 3.6 post-reform, p= 0.04, respectively). Resident enjoyment of clinic improved during the study period as did satisfaction with the overall ambulatory experience (3.1 vs. 3.8 on a 1–5 Likert scale, 2.9 vs. 4, p < 0.01 for each). Residents reported that the schedule supported continuity of care to a higher extent in 2014 than 2010 (2.3 vs. 3.6, p < 0.01). The number of patients seen per half day declined (5.9 vs. 4.3, p < 0.01). The number of residents entering careers in primary care was: 0 (2010), 2 (2011), 1 (2012), 1 (2013) and 8 (2014).

CONCLUSIONS: Four years after implementation of a large structural and educational reform effort, residents reported improvements in learning and teaching, continuity, and satisfaction with ambulatory training. This came at a cost of fewer patients seen per day. Our redesign efforts addressed several of the factors reported in the literature as important towards increasing the primary care workforce, and included institution, department, and program-level reforms. A greater number of residents planned to enter primary care careers in the final year of study. The strengths of this intervention included its comprehensive approach and buy-in at all levels of the health system. Strengths of the evaluation include using validated measures over four years and studying two ambulatory sites. Limitations of the evaluation include potential confounding by concurrent changes to residency education, and surveying different residents in 2010–11 and 2014. More follow-up data on resident career paths is needed.

Components of ambulatory reform

Level Date Component Description
Institution 2010 and 2012 EHR conversion Allscripts electronic health record implemented
  2010 Compensation enhancement Included loan forgiveness, base salary increase, and incentive program for primary care clinicians
Department Late 2009 PCMH certification National Committee for Quality Assurance level 3 certification
  2010 Hospital Medical Home Demonstration grant Grant funded hiring of a nurse practitioner, clinic secretary, and data analyst to improve continuity in resident clinic
Program 2010 4 + 1 schedule Block schedule where residents do not assume simultaneous inpatient and outpatient responsibilities
  2010 Residency mentoring One-on-one mentoring for residents in their clinical area of interest
  2012 Team-based learning curriculum Approach to ambulatory curriculum based on individual preparation, team problem solving, and skill application
  2012 Community primary care rotation Residents practice alongside seasoned primary care physicians

RESIDENT RESILIENCY - HOW RESILIENT ARE OUR MEDICAL TRAINEES AND HOW DOES IT RELATE TO STRESS AND BURNOUT? Amber Bird; Amber Pincavage. University of Chicago, Chicago, IL. (Tracking ID #2192709)

BACKGROUND: Burnout amongst medical professionals is a growing concern. Many studies have shown that burnout is pervasive amongst medical trainees and is associated with increased rates of depression, suicide, and poor clinical performance. Data exists showing the correlation between physician burnout and depression. However, there remains little data on how physician burnout relates to resilience.

METHODS: Our objectives were to characterize levels of resilience amongst Internal Medicine residents and examine how levels of resilience impact self-reported measures of stress, burnout, and clinical performance, looking specifically at experience with medical errors and medical error reporting. Cross-sectional surveys were provided to a convenience sample of Internal Medicine residents attending the 2014 Northern Illinois Regional American College of Physicians meeting. Baseline resilience scores were assessed using the validated Connor-Davidson Resilience scale (CD-25). Responses were then divided into resilience categories of low (CD-25 of <70), intermediate (CD-25 70–79), and high (CD-25 80–100). Residents were also surveyed on their experience with burnout, resilience training, and involvement in medical errors.

RESULTS: A total of 77 residents from six institutions completed surveys. 26.0 % of residents had high resilience, 43.9 % intermediate, and 31.2 % low (range 40–100). The majority of residents believe burnout is an important issue during residency (92.2 %). Trainees with high resilience were more likely to report never having stress interfere with their relationships outside of work as compared to trainees with low resilience (high-40.0 %, low-0.0 %, p < 0.001). High resilience residents were more likely to report having the skills to manage feelings of stress and burnout (high-80.0 %, low-45.8 %, p= 0.02) and less likely to report feeling inferior to peers (high-20.0 %, low-70.8 %, p < 0.001). There was a trend towards more trainees with high resilience reporting less burnout from work (rarely or never feeling burnout) compared to trainees with low resilience (high-40.0 %, intermed-27 %, low-16.7 %, p = 0.08). Medical errors and reporting were not associated with resilience level. The majority of respondents in all categories reported prior involvement in medical errors (high-70.0 %, intermediate-69.7 %, low-79.2 %), but most respondents stated they had never reported these errors (high-55.0 %, intermediate-60.6 %, low-83.3 %). Overall, only 50 % of residents report an outlet within their program to discuss feelings of stress and burnout.

CONCLUSIONS: There is a wide range of resilience scores amongst Internal Medicine residents with many residents without high levels of resilience. Low resilience is associated with more stress interfering with relationships, feeling inferior to peers and fewer skills to manage stress and burnout. Burnout from work is high among residents and there are not enough outlets in programs to discuss stress and burnout. In addition, although there was no association with resilience and medical errors, our results show that despite most respondents acknowledging direct involvement in medical errors, most residents never formally report these incidents. More curricula to increase resilience and address stress, burnout, and medical errors involving medical trainees are needed.

RESIDENTS’ PERCEPTIONS OF THEIR HEALTH LITERACY SKILLS AND TRAINING NEEDS ACROSS SPECIALTIES Tamasyn Nelson2; Lisa Altshuler1; Colleen Gillespie1; Mrudula Naidu1; Alison Squires3; Shonna Yin1; Sondra Zabar 1. 1NYU School of Medicine, New York, NY; 2Vanderbilt University School of Medicine, Nashville, TN; 3NYU School of Nursing, New York, NY. (Tracking ID #2198469)

BACKGROUND: Low health literacy (HL) is common, particularly in underserved communities. HL deficits have been associated with patient safety issues and poor health outcomes. Provider use of HL-informed communication strategies, including plain language verbal and written communication, and use of “teach back” to confirm patient understanding, has been linked to improved patient outcomes, therefore; a “universal precautions” approach is recommended. A recent survey of medical schools found that 72 % of the 133 U.S. allopathic medical schools included HL in their curriculum, with a only a median time spent of 3 h in total (Coleman & Appy, 2012). As part of a needs assessment of residents at our institution, we surveyed residents across 7 programs to determine their previous training in HL, current practices, comfort level with HL skills and desire for further training. This allowed us to assess overall need and to identify differences by specialty.

METHODS: Data was collected from residents via an online survey (Qualtrics) during the 2013–2014 academic year. Residency programs surveyed included Emergency Medicine (EM), Internal Medicine (IM), Obstetrics/Gynecology (OB), Orthopedics (OR), Pediatrics (PED), Primary Care (PC), and Surgery (SUR). Completed responses were received from 269 residents (of 394 total), for a response rate of 68 % overall. This ranged from a 100 % response rate from OR down to 57 % from EM. HL questions for the survey were adapted from Schwartzberg et al. (2007) and Turner et.al. (2009). The following domains were assessed: 1) prior HL training (1Q), 2) use of HL techniques (8Q), 3) perceived skill in key HL techniques (3Q), 4) desire for HL training (1Q). Prior HL training was assessed with a question about whether they had HL training, and if so, where they received it. Use of HL techniques was rated on a 5-point Likert scale from 1 (never) to 5 (always); techniques included teach-back, providing easy to read written materials, underlining key points on written materials. A Overall HL Use score was calculated by averaging responses (Cronbach’s alpha = .88). Perceived skill in key HL techniques was, rated on a 4-point scale from 1 (not at all skilled) to 4 (very skilled); skills assessed included teach-back, choosing appropriate written materials, and converting medical terms into plain language. A HL Skills score was calculated by averaging responses (Cronbach’s alpha = .70). Finally, participants were asked to respond to open-ended questions re: what HL training they would like.

RESULTS: Sixty-five percent of residents reported prior training related to HL, with the majority of this being in medical school; educational formats used included didactics and OSCEs. Across specialties, 84 % of OR residents reported having had previous training, while IM was the lowest at 47 %. Statistically significant differences in reported Overall HL Use across programs was determined by one way ANOVA (F (6, 268) = 8.77, p = .0.0001). Post hoc Tukey test revealed that SUR Overall HL Use score was significantly higher than the other specialties, (p = 0.05). No other significant differences were found. For the HL Skill score, one way ANOVA was significant (F(6265) = 3.48, p = 0.002). Tukey post-hoc analysis revealed that SUR was again the highest scorer, with scores significantly higher than both IM and OB (p = 0.05). When asked what future training residents wanted, there were consistent themes across the specialties. Many residents wanted to know where to find easily accessible printed material suitable for low-literacy patients, ways to match health education literature to patients’ HL levels, and pragmatic strategies for integrating HL approaches in a busy clinical setting with diverse patient populations.

CONCLUSIONS: Most residents across multiple specialties report at least some training in HL during medical school, although the extent of such training is not known. There are differences between specialties with respect to self-reported use of and comfort with HL approaches, with surgeons feeling the most prepared and internal medicine and obstetrics trainees less so. In spite of their reported skill level, all groups identified need for further HL training. Additionally, this study assessed self-report of HL skill and use. To better understand differences by specialty assessing actual HL skill and use from an observational study is planned.

RISK OF ATRIAL FIBRILLATION ACROSS THE FULL TSH RANGE: AN INDIVIDUAL PARTICIPANT POOLED ANALYSIS OF LARGE PROSPECTIVE INTERNATIONAL COHORT STUDIES Christine Baumgartner 1; Bruno R. da Costa2; Tinh-Hai Collet3; Anne R.Cappola11; Douglas Bauer4; Daniel Segna1; Anette van Dorland1; Carmen Floriani1; Peter Jüni2; Graziano Ceresini5; Jacobijn Gussekloo6; Wendy P. den Elzen6; Robin P. Peeters7; Henry Völzke12; Marcus Dörr12, 13; John P. Walsh8, 14; Alexandra P. Bremner8; Massimo Iacoviello9; Ian Ford10; Jan Heeringa7; Susan R. Heckbert15; David J. Stott10; Rudi G. Westendorp6; Drahomir Aujesky1; Nicolas Rodondi1. 1Inselspital Bern, Bern University Hospital, Bern, Switzerland; 2Institute of Social and Preventive Medicine and Clinical Trials Unit, University of Bern, Bern, Switzerland; 3University Hospital of Lausanne, Lausanne, Switzerland; 4University of California San Francisco, San Francisco, CA; 5University Hospital of Parma, Parma, Italy; 6Leiden University Medical Center, Leiden, Netherlands; 7Erasmus Medical Center, Rotterdam, Netherlands; 8University of Western Australia, Crawley, WA, Australia; 9University of Bari, Bari, Italy; 10University of Glasgow, Glasgow, United Kingdom; 11University of Pennsylvania School of Medicine, Philadelphia, PA; 12University of Greifswald, Greifswald, Germany; 13DZHK (German Center for Cardiovascular Research), partner site Greifswald, Greifswald, Germany; 14Sir Charles Gairdner Hospital, Nedlands, WA, Australia; 15University of Washington, Seattle, WA. (Tracking ID #2191361)

BACKGROUND: The lower and upper limits of the optimal reference range of thyroid stimulating hormone (TSH) and optimal TSH targets in clinical guidelines remain controversial, leading to variability in the clinical management of thyroid dysfunction. Some prospective studies have found subclinical hypothyroidism to be associated with a reduced risk of atrial fibrillation (AF), while others have found an increased AF risk within the lower normal TSH reference range. Identification of modifiable risk factors and potentially reversible causes of AF is important to optimize prevention and treatment, given its significant public health burden. We aimed to assess the risk of AF across the full TSH range in prospective cohort studies participating in the International Thyroid Studies Collaboration.

METHODS: Individual participant data from seven large prospective cohort studies with measurement of thyroid function at baseline and assessment of incident AF outcomes were pooled to assess the risk of incident AF according to TSH levels. Euthyroidism was defined as TSH level from 0.45 to 4.49 mIU/l and subdivided into five categories (0.45–0.99 mIU/l, 1.00–1.49 mIU/l, 1.50–2.49 mIU/l, 2.50–3.49 mIU/l and 3.50─4.49 mIU/l). We compared the incidence of AF of all TSH groups to the reference group 3.50─4.49 mIU/l. Subclinical hypothyroidism was defined as TSH level between 4.5 and 19.9 mIU/l and subclinical hyperthyroidism as TSH level <0.45 mIU/l, both with normal free thyroxine levels.

RESULTS: Among 11,387 adults, 1064 (9.3 %) had subclinical hyperthyroidism and 900 (7.9 %) had subclinical hypothyroidism. In total, 962 individuals developed AF during follow-up. In individuals with subclinical hyperthyroidism, the risk of AF increased with lower TSH levels: age- and sex-adjusted hazard ratio (HR) 1.64 (95 % confidence interval [CI] 1.07–2.53) for a TSH level of 0.10–0.44 mIU/l and 1.71 (95 % CI 0.69–4.26) for a TSH level <0.10 mIU/l, p value for trend 0.024. The risk of AF events was not increased in TSH categories within the euthyroid range, with an HR of 1.16 (95 % CI 0.86–1.56) for a TSH level of 0.45–0.99 mIU/l, HR 0.97 (95 % CI 0.73–1.28) for a TSH level of 1.00–1.49 mIU/l, HR 1.14 (95 % CI 0.89–1.46) for a TSH level of 1.50–2.49 mIU/l, and HR 1.07 (95 % CI 0.82–1.39) for a TSH of 2.50–3.49 mIU/l compared to a TSH level of 3.50–4.49 mIU/l. Subclinical hypothyroidism was not significantly associated with a lower risk of incident AF (HR 1.15 [95%CI 0.86–1.55] for TSH 4.5–6.9 mIU/l, HR 0.80 [95 % CI 0.50–1.28] for TSH 7.0–9.9 mIU/l and HR 1.29 [95%CI 0.75–2.20] for TSH 10.0–19.9 mIU/l). Excluding patients with thyroid hormone medication at baseline yielded similar results.

CONCLUSIONS: Euthyroid individuals, even those with TSH levels within the low-normal range, are not at increased risk of developing AF, whereas the risk of AF increases with lower TSH levels in patients with subclinical hyperthyroidism. Subclinical hypothyroidism is not associated with a protective effect for AF. These data do not support changing the lower or upper limit of TSH based upon the risk of AF.

SHARED SYSTEMS, PERSONAL DECISIONS: VARIATION IN MAMMOGRAPHY UTILIZATION AMONG A DIVERSE GROUP OF WOMEN AGED 40–49 YEARS. Hana Akselrod; Kathleen Fairfield. Maine Medical Center, Portland, ME. (Tracking ID #2199345)

BACKGROUND: Since 2009, the US Preventive Services Task Force (USPSTF) has recommended that physicians engage in individualized decision-making regarding starting screening mammography in women before age 50, taking into account clinical factors as well as patient values and beliefs regarding specific benefits and harms. Prior research and clinical experience suggest that such individualized decision-making can prove challenging when there are barriers of language, culture, or trust between the patient and her provider. In recent years, our area has become home to a large population of refugees and secondary migrants hailing from areas as diverse as East Africa, the Middle East, Central Asia, and Latin America. Consequent to this demographic transition, our health system now serves a diverse population of patients, with cultural and socioeconomic barriers to optimal preventive care and shared decision making (SDM). At the same time, the integration of a system-wide electronic health record (EHR) affords an unprecedented opportunity to examine screening practices and SDM across populations. We therefore designed a study aiming (1) to describe patterns of mammography utilization in women aged 40–49 receiving primary care through in our network; and (2) to assess whether SDM took place with equal frequency among English-speaking versus non-speaking patients.

METHODS: After human subjects review, we queried the EHR to identify a retrospective cohort of women aged 40–49 who were seen for primary care visits in 2013. The primary outcome was incidence of screening mammography (performed or ordered during the study period). Covariates of interest included demographic variables including ethnicity, primary language, insurance type, zip code, and clinical site; and pertinent history affecting risk of breast cancer (medical, family, and social). Descriptive and analytical statistics were obtained using SAS software to evaluate relationships between covariate and outcome variables, and to identify disparities between demographic groups. Next, a systematic chart review will be conducted on a randomly selected subsample using a scoring system to assess documentation of SDM before the ordering of mammography.

RESULTS: Of a total of 3343 patients meeting inclusion criteria, 1265 (38 %) of the women had a mammogram in 2013. Compared to patients identified as White Non-Hispanic, who accounted for 87 % of the population, mammography rates were significantly higher among patients who self-identified as Asian (52 % vs. 38 %; p = 0.006) and as Multiracial/Other (71 % vs. 38 %; p < 0.001). Among English-speaking patients, mammography screening rate was lower compared to patients whose primary language was not English (38 % vs. 47 %; p = 0.005). Never-smokers had lower screening rate (20 %) compared to either current (27 %) or former (45 %) smokers (p < 0.001). Among women with public insurance (Medicare/Medicaid), rates were lower compared to those with self-pay or private insurance (30 % vs. 40 %, p < 0.001). There was wide variation in mammography rates between the ten ambulatory sites, ranging from 29 to 50 %. Systematic chart reviews are being performed to determine whether SDM was documented.

CONCLUSIONS: Mammography screening continues to be performed quite commonly among women in their 40s in our patient population, at rates roughly comparable to the nationally reported figures (reported between 40 and 50 % in 2011 NHANES). On initial analysis, screening rates in our patients varied widely by racial/ethnic group, national origin, insurance type, smoking, and clinic location. We have found that specific racial/ethnic minority status and lack of English fluency in our patient population were associated with higher rates of mammography during the study period. Additional reviews are being conducted to explore the role of SDM in the clinical encounters preceding the screening, to assess whether the higher screening rates observed in some patient groups are the outcomes of engaging in SDM, or on the contrary may indicate a disproportionate lack of engagement.

SKILLS FOR IDENTIFYING A STRUGGLING COLLEAGUE: I CANNOT TAKE THIS ANY MORE! Sondra Zabar 1; Russell Burman1; Mark Hochberg1; Donna Phillips1; Amara Shaker-Brown1; Kathleen Hanley1; Adina Kalet2; Colleen Gillespie1. 1NYU School of Medicine, New York, NY; 2New York University School of Medicine, New York, NY. (Tracking ID #2198823)

BACKGROUND: House staff generally receive little training in recognizing a colleague at risk. Even if they do realize a colleague needs help, there is reluctance to recommend or seek care because of the stigma surrounding emotional distress and the fear of being labeled as “incompetent” or “weak”. Residency training has been documented to be a stressful time. There is a need to change the culture in training programs and make sure all residents have the skills to address these issues and understand resources that are available.

METHODS: We designed an OSCE station to assess a resident’s ability to recognize substance abuse and depression in a colleague, to assess the acuteness of the situation and to make a plan. Skills were assessed in a 10-min case by “Standardized Intern” as part of the annual multi-station OSCE for 2 surgical residency programs and one medicine program. The learner was tasked with “giving sign-out” to an intern (Standardized Healthcare Professional) coming on-service with a reputation for being disorganized and a loner. The SHP is scripted to makes clear comments about how difficult residency is and admits to being stressed. Case background includes being new to the city, stressed about residency and meeting criteria for major depression and risky alcohol use. A checklist was created to assess general communication and case specific skills. Domains included: depression and substance use screen, current life situation assessment, and follow-up. Item response options were: not done, partly done, and well done, each with descriptive behavioral anchors to enhance rating reliability.

RESULTS: Sixty residents performed the case: 37 surgical and 24 medical. Almost all residents checked in with the intern about their emotional state (49/60; 82 %). Eleven percent (1 surgical and 6 medical residents) fully screened for depression with 2 question screen but a third asked generally about depression (21/60). Almost half did not ask about depression (28/60). Ten percent (6 medical residents) asked about suicidal ideations, 8 surgical residents asked if he thought about hurting himself and 46/60 did not ask about suicide. Over half of the surgical residents asked about alcohol use (20/37) compared to only less than a third of medical residents (7/23). A quarter (15/60) of the residents attempted to identify a person for the intern to talk to, either outside or inside the program. For follow up, 75 % (45/60) personally included themself in the intern’s support system and 65 % (39/60) directed them toward specific resources (e.g. GME psychiatrist, program director, or outside resource).

CONCLUSIONS: We identified a wide range of performance across three programs but most importantly this case provided an opportunity for experiential learning and an open discussion of an important topic. This data will help us design a curriculum on resident wellness.

SOCIAL SUPPORT AND ITS RELATIONSHIP TO ADVANCE CARE PLANNING Phuong Luu 1; Lucy Meoni2; Marie Nolan3; Joseph J. Gallo2. 1Johns Hopkins University School of Medicine, Baltimore, MD; 2Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; 3Johns Hopkins University School of Nursing, Baltimore, MD. (Tracking ID #2193025)

BACKGROUND: The Institute of Medicine’s recent report on “Dying in America” highlights the urgent need to focus on advance care planning to improve end-of-life care. Social support is an important component in understanding how patients approach advance care planning, however, limited studies have focused on this association. Thus our study’s aim was to assess whether older adults were more likely to complete an advance directive or have end-of-life discussions with their family and/or friends if they had strong social support.

METHODS: We conducted a cross-sectional study using the 2012 Precursors Study questionnaire. The Precursors Study is a cohort study of medical students beginning in the 1960’s. Social support was defined using the Medical Outcomes Study (MOS) Social Support Survey, which is further divided into four subscales of emotional, tangible, affective and positive social support. The overall social support score and each of the four subscales total scores were averaged and generated into binary variables. Respondents who had an average score of 5 within each subscale or across the overall social support scale, were assigned a 1 for that subscale or total score. All others were assigned a zero. The outcomes assessed were self-reported completion of advance directive or reporting having had an end-of-life discussion with family and/or friends. Five multivariate logistic models were done for the overall support scale and each of the subscales, respectively. Each model was adjusted for age, marital status, retirement status, personal preferences for end-of-life care, and preferences regarding doctor’s input and loved ones’ input in end-of-life care.

RESULTS: Of those who answered the question regarding advance directive completion (N = 449), 85 % reported having an advance directive. Of those who answered the question regarding end-of-life discussion (N = 452), 94 % reported having had an end-of-life discussion with their family and/or friends. Tangible support (adjusted OR 2.00, 95 % CI 1.13–3.57) and positive social support (adjusted OR 2.49, 95 % CI 1.38–4.50) were significantly associated with advance directive completion. Affective support (adjusted OR 2.92, 95 % CI 1.18–7.22) was significantly associated with reported having had an end-of-life discussion with family and/or friends. Though the remainder of the associations were not statistically significant, they all showed trend towards greater social support, regardless of the type, being related to completing an advance directive or having an end-of-life discussion.

CONCLUSIONS: Our results indicate that specific types of social support are associated with advance care planning. Individuals reporting tangible, affective and positive social support had greater than two-fold odds of reporting advance care planning. To our knowledge, this is the first study to utilize the MOS social support survey to understand the role of social support in advance care planning. These findings indicate that approaches to advance care planning should incorporate discussions regarding the patient’s social support.

THE 5 PHENOTYPES OF HIGH COST PATIENT Sang Been N. Hong 2; Noah Whitman1; Nirav Vakharia1; Michael B. Rothberg1. 1Cleveland Clinic, Cleveland, OH; 2Cleveland Clinic, Cleveland Heights, OH. (Tracking ID #2190027)

BACKGROUND: In order to design cost reduction strategies, it is important to understand the resource utilization patterns of those patients who drive the majority of healthcare costs. High cost patients may use resources in diverse ways. We used cluster analysis to identify profiles of utilization among the high cost population.

METHODS: We utilized a retrospective observational design. Using the Quality Resource and Use Report distributed by the Centers for Medicare and Medicaid Services, we identified all Medicare patients who were hospitalized exclusively at Cleveland Clinic Health System (CCHS) hospitals and received ≥90 % of their primary care services at a CCHS facility in 2012. We defined high-cost patients as the 10 % of the population with the highest sum of direct and indirect costs at a CCHS facility, based on CCHS internal cost accounting data. Total admissions, inpatient days, ICU days, inpatient surgeries, ED visits, and outpatient visits were obtained from the electronic medical record. We used the Agency for Healthcare Research and Quality Clinical Conditions Software to group ICD-9 diagnosis and procedures codes. Based on data review and clinical judgment, we used the k-medoids, a clustering algorithm that robustly organizes a heterogeneous dataset into a pre-determined number of distinct groups, to create five clusters. For each cluster, odds ratios of 24 high cost conditions were calculated in comparison to the high-cost population mean prevalence. Statistical significance was calculated by logistic regression.

RESULTS: Our high-cost sample included 1486 patients; 55 % were male, and median age was 68 (IQR 15). The “ambulatory” cluster contained patients with few admissions or ED visits (Table). They were most likely to have cancer and chemotherapy. “Surgical” patients generally had one expensive surgical admission. They had the highest odds of osteoarthritis and procedure/device complications; 61 % of these patients with osteoarthritis received arthroplasty. “Critically Ill” patients required intensive care; they had the highest inpatient as well as overall costs. They had higher odds of heart failure and cardiac arrhythmia and arrest. The “Frequent Care” cluster had frequent admissions, ED visits, and outpatient visits. Psychiatric disorders and COPD/asthma were most characteristic. “Mixed Utilization” patients had a mixture of admissions, ED visits, primary care visits, and specialist visits. They were not characterized by specific diagnoses, but complications of medical care and procedures were less common in this cluster.

CONCLUSIONS: Using cluster analysis, we identified subgroups of high cost patients exhibiting distinct utilization patterns. Efforts to reduce cost may benefit from a targeted approach that addresses the diversity of high cost utilization.

figurek

Table. Patient characteristics, median utilization (with interquartile range), and odds-ratios of characteristic conditions.

THE EFFECT OF A PAYER-MANDATED DECREASE IN BUPRENORPHINE DOSE ON RELAPSE RATES OF PATIENTS WITH OPIOID DEPENDENCE, A NATURAL EXPERIMENT. Anthony Accurso. Johns Hopkins Bayview Medical Center, Baltimore, MD. (Tracking ID #2197277)

BACKGROUND: Although office-based buprenorphine therapy is now a decade old, the optimal buprenorphine maintenance dose is still not known. Under-dosing may lead to craving and use of illicit drugs, while providing higher than needed doses may contribute to pill-diversion. In January 2013, a major local Medicaid-insurance organization stopped covering buprenorphine doses greater than 16 mg/day without prior authorization. This policy led to a subset of patients on stable buprenorphine therapy of higher doses being forced to decrease their dose to 16 mg/day. This event created conditions for a natural experiment in which to study the effects of a mandated dose decrease. The objective of the study was to assess whether patients with prior stability on higher doses of buprenorphine had greater relapse rates after this payer-imposed dose decrease.

METHODS: This study was a retrospective cohort study of laboratory test results and charts from patients at an urban, primary-care clinic in Baltimore with academic affiliation. The study population was comprised of patients of adults with a diagnosis of opioid dependence who had been maintained on buprenorphine from September through December 2012. Urine drug testing results for the entire practice were obtained from the period of August 2012-April 2013. Charts were reviewed to determine each subject’s insurer, buprenorphine dose, and other prescribed medications. Cohorts were then created with an experimental group comprised of patients who had experienced a dose decrease, and control groups based on insurer and buprenorphine dose, as described in Table 1. Urine drug testing was aggregated by test date and defined as “pass” or “fail” with “pass” defined as the presence of buprenorphine and absence of cocaine, opiates, methadone or nonprescribed benzodiazepines. Pass rates were calculated for each patient in the pre and post period of the study, which were then compared for each patient with the Wilcoxon Signed Rank Test.

RESULTS: We identified 410 patients in our practice who had been prescribed buprenorphine during the study period, of whom 310 met study criteria. Of those, 98 patients experienced a payer-mandated buprenorphine dose decrease, and were assigned to group 1. Overall pre-decrease urine pass rate by patient was 75 %, and post-decrease urine pass rate was 66 %, (p = 0.030). This analysis was repeated among three other control groups, none of which showed a significant change in urine pass-rate.

CONCLUSIONS: Our study suggests that mandated limits on buprenorphine dose may lead to increases in other drug use, at least in the short term. This data can inform policy decisions about the proper maintenance dose of buprenorphine. Of note, while a mandated dose-decrease to 16 mg had a statistically significant negative effect on treatment success, the effect size was small. Many of the patients in the practice tolerated the switch and acclimated to the dose decrease. Further research is needed on the optimal dosing of buprenorphine.

Description of Group Attributes and Pre/Post-Period Urine Pass Rates

  High Dose to Low Dose Imposed by Insurer Low Dose, Same Insurer High Dose, Other Insurer Low Dose, Other Insurer
N 98 78 76 68
Mandated Dose Decrease Yes No No No
Insurance Priority Partners Priority Partners Other Insurance Other Insurance
Initial Daily Buprenorphine Dosage >16 mg <=16 mg >16 mg <=16 mg
Pre-Period Pass Rate (%) 74.5 68.5 78.5 67.9
Post-Period Pass Rate (%) 65.9 63.3 80.1 65.1
p-value 0.030 0.203 0.659 0.307

THE IMPACT OF A HEART FAILURE PATHWAY IMPLEMENTATION: AN INSTITUTIONAL REVIEW Charles Allderdice 2; Neal Mehta, MD2; William Burkhart2; Nicole Simmons, APN2; Laura Bullock, PharmD2; Eric Heidel, PhD2; Natalie Varner, PhD2; Mark Rasnake1. 1UT Medical Center Knoxville, Knoxville, TN; 2University of Tennessee Medical Center-Knoxville, Knoxville, TN. (Tracking ID #2195792)

BACKGROUND: Heart failure is a primary diagnosis on admission in over 1 million cases annually and its prevalence is expected to rise 46 % by 2030 as survival after diagnosis has increased. All-cause re-hospitalization can reach as high as 25 % within one month, with case fatality rates being as high as 10.4 %. Our facility created a multidisciplinary clinical pathway to facilitate the provision of evidenced based care for heart failure patients. To compare the efficacy of this pathway versus standard care, we examined the primary endpoints of length of stay, 30-day readmission rate, and all-cause mortality for patients admitted with a primary diagnosis of heart failure. Secondary endpoints include evidence based heart failure medications administered upon discharge.

METHODS: All adults admitted with a primary diagnosis of heart failure to our facility between January 1, 2014 and June 30, 2014 were eligible for the study. Subjects were identified using ICD-9-CM heart failure codes. Baseline characteristics according to admission history and physicals and echocardiogram reports were compared. Adverse events including acute kidney injury and hyperkalemia were reviewed. Those placed on hospice or admitted primarily for other interventions were excluded.

RESULTS: A total of 310 patients were admitted with heart failure between January and June 2014, with 308 being included in the study. 133 (43 %) patients were managed through use of a pathway versus 175 (57 %) who underwent standard care. Length of stay remained equivalent at 5.64 days for both sets of patients, with a p-value of 0.99. There was a trend toward lower 30-day readmission (26 versus 23) and all-cause mortality (12 versus 4) with use of a pathway, however, the results did not reach significance. (p-value 0.64 and 0.14 respectively). Adverse events during the hospitalization including acute kidney injury and hyperkalemia showed no statistical difference (p-value 0.65 and 0.81 respectively). Secondary outcomes regarding evidence based heart failure medications on discharge also showed no statistical difference.

CONCLUSIONS: Among patients admitted with a primary diagnosis of heart failure, 43 % were managed with use of a pathway. Baseline characteristics and adverse events were compared between both groups and showed no significant difference. Pathway implementation did not reduce 30-day readmission rate, all-cause mortality, and length of stay, with length of stay remaining unchanged between both groups. None of these findings reached significance among unadjusted comparisons. Secondary outcomes regarding medication use at discharge according to evidence based medication guidelines also showed no difference with use of a pathway versus standard care. Our institution’s compliance with heart failure core measures was 96.6 % prior to pathway implementation, potentially limiting the amount of benefit achievable through pathway use. It is also unclear of the impact of this pathway after discharge. Such entities as nursing patient education and appropriate outpatient follow up were not taken into account. This use of the pathway may have direct positive results and will need further review in future studies.

THE RELATIONSHIP AMONG OPIOID USE, HIV, AND ACCIDENTAL DEATH: IS IT IN THE EYE OF THE BEHOLDER? William Becker 2; Janet P. Tate6; Eva J. Edelman6; Julie Gaither3; Kathleen Akgun2; Declan Barry3; Stephen Crystal4; Adam Gordon1; Jessica S. Merlin5; Robert D. Kerns2; Amy C. Justice6; David A. Fiellin6. 1University of Pittsburgh and VA Pittsburgh Healthcare System, Pittsburgh, PA; 2VA Connecticut, West Haven, CT; 3Yale University, New Haven, CT; 4Rutgers University, New Brunswick, NJ; 5University of Alabama at Birmingham, Birmingham, AL; 6Internal Medicine, Yale University, New Haven, CT. (Tracking ID #2198782)

BACKGROUND: Opioid-related accidental deaths, including unintentional overdose, have increased markedly in the U.S. Several large observational studies have demonstrated increased risk of opioid-related accidental death among those with serious mental illness, substance use disorders and pain, conditions that are disproportionately prevalent among individuals with HIV. Furthermore, as individuals with HIV live longer, they may be more vulnerable to harm from opioid use. To understand the relationship among opioid use, HIV status and accidental death, exposures and outcomes need to be determined in an unbiased manner. Recognizing that assigning cause of death is challenging and may be subject to bias, we sought to examine whether the relationship between opioid use and accidental death, including unintentional overdose death, varied by HIV status.

METHODS: Our data source was the Veterans Aging Cohort Study (VACS), a cohort of HIV-infected and matched uninfected Veterans consented for prospective, recurrent surveys on alcohol and drug use (including heroin and non-medical use of prescription opioids), among other health behaviors, with survey data linked to the electronic medical record (e.g. pharmacy data). Our analytic sample consisted of VACS decedents from 2002–2009 who, prior to death, responded to at least one follow-up survey. We linked VACS records with the National Death Index cause of death file, which lists underlying and contributory causes of death as reported by the medical examiner or coroner. Based on ICD-10 codes, we categorized cause of death, either underlying or contributory, as accidental (e.g. motor vehicle crash), unintentional overdose, or other, and categorized decedents as having had opioid use or not based on VACS survey self-report. Stratified by decedent’s HIV status, we calculated the ratio--with and without opioid use--of the proportion of decedents coded as accidental death and, separately, calculated the ratio--with and without opioid use--of the proportion of decedents with unintentional overdose death. For comparison, we examined different measures of opioid use (i.e. self-reported heroin use and pharmacy record of opioid receipt).

RESULTS: The sample consisted of 738 HIV-infected and 321 uninfected decedents. Accidental death and unintentional overdose death were 9.5 and 2.6 % of total deaths, respectively, with HIV-infected decedents less likely to be coded as having an accidental death (8.1 % vs. 12.8 %, p = <.001) and equally likely to be coded as unintentional overdose death (2.5 % vs. 2.8 %, p = .322). Opioid use was equally likely in decedents with and without HIV (24 % vs 26 %; p = .587). As depicted in the Table, among HIV-infected decedents, the ratio of opioid use vs. non-use status was 1.0 (p = .821) for those coded as having an accidental death and 1.7 (p = .269) for unintentional overdose death. However, uninfected decedents with opioid use were 4 times as likely to be coded as having an accidental death than those without opioid use (p < .001) and were 6.4 times as likely to be coded as having an unintentional overdose death than those without opioid use (p = .003). Patterns were similar regardless of measure of opioid use.

CONCLUSIONS: While opioid use was equally likely among decedents with and without HIV, the non-differential coding of accidental and unintentional overdose death among HIV-infected respondents with and without opioid use suggests a potential misclassification bias away from coding cause of death as opioid-related. Caution should be used in interpreting accidental and unintentional overdose death data among patients with life-limiting, chronic conditions. Future efforts to improve the validity of cause of death classification may be warranted to promote better understanding of harms of opioid treatment in vulnerable populations.

Self-Reported Opioid Use and Cause of Death by HIV status

  HIV (+) n = 738 HIV (−) n = 321
Opioid use No opioid use Ratio (p value) Opioid use No opioid use Ratio (p value)
Decedents, n 191 547   78 243  
Accidental death; n, (proportion) 15 (7.9) 45 (8.2) 1.0 (.82) 23 (29.5) 18 (7.4) 4.0 (<.001)
Unintentional overdose death; n, (proportion) 7 (3.7) 12 (2.2) 1.7 (.27) 6 (7.7) 3 (1.2) 6.4 (.003)

THE RELATIONSHIP BETWEEN PRIMARY CARE ORGANIZATIONAL PROCESSES AND PATIENT-REPORTED CARE EXPERIENCES Jaya Aysola 1; Rachel M. Werner2. 1University of Pennsylvania, Philadelphia, PA; 2University of Pennsylvania and Philadelphia VA, Philadelphia, PA. (Tracking ID #2199159)

BACKGROUND: There is increasing emphasis on the use of patient-reported experience data in the evaluations of outpatient primary care practice and provider performance. Yet there remains an insufficient understanding of what aspects of primary care organizational processes relate to patient primary care experiences. Therefore, we evaluated the relationships between organizational processes and patient-reported experiences in the network of University of Pennsylvania primary care practices.

METHODS: We analyzed visit data from patients (n = 8356) collected between January 2012 through July 2014 at all University of Pennsylvania Health System affiliated adult primary care practices with three or more providers (n = 22). We first surveyed practice managers at these 22 sites using a previously validated scale from 0 to 100 to quantify practice adoption of organizational processes across six domains : access and communication; patient tracking and registry; care management; test referral tracking; quality improvement; and external coordination. This practice-level data was then linked to data on patient experience and demographics. Experience was measured using visit-triggered survey data generating a patient experience score (0 to 100). To investigate the relationship between practice structural processes and patient experience, we used generalized estimating equations (GEE) with an exchangeable correlation structure to account for patient clustering by practice. In our multivariate models we accounted for practice location, practice patient panel size, number and type of providers, as well as patient demographics and clinical comorbidities (Charlson Comorbidity Index (CCI)). To determine if relationships between practice processes and patient experiences varied by the degree of patient comorbidity, we performed the above models stratified by categorical CCI (0, 1, 2, >2).

RESULTS: The mean scores (SD) across the 22 practices for the six domains of organizational processes were as follows: 74.8 (10.2) for access and communication; 67.5 (11.6) for patient tracking and registry; 53.8 (11.3) for care management; 37.2 (10.5) for test referral tracking; 48.8 (9.6) for quality improvement; and 74.5 (12.7) for external coordination. Of the 8356 patients in the study, 64 % were female, 24 % were Black, 5.3 % had Medicaid, 6.3 % had multiple chronic conditions (CCI > 2) and the mean age (SD) was 57 (17.5). The patient experience mean score (SD) was 87.4 (13.6). Amongst the entire patient sample in multivariate models, there were no statistical significant associations between any practice adopted processes and patient experience. Amongst a subset of patients with comorbid conditions (CCI >2), there were statistically significant positive associations between specific practice processes and overall patient experience and key aspects of patient experience, even after adjusting for a robust set of patient, provider, and practice characteristics. For example, a 10-point higher practice score in patient tracking and registry was associated with a 1.8 percentage point higher score in overall patient experience (95 % CI, 0.3, 2.0; p = 0.007), as well as a 1.5 percentage point higher score in patient experiences with access (95 % CI, 0.2, 2.8; p = 0.02) In addition, a 10-point higher score care management was associated with a 2.4 percentage point higher score in patient experiences with access (95 % CI, 1.6, 3.2; p < 0.001).

CONCLUSIONS: Amongst all primary care patients in our sample, we found no significant associations between practice adoption of organizational processes and patient experience in multivariate models. Understanding what practice processes if any influence patient experiences of care is paramount to improving practice and provider performance in this area. Amongst the subset of patients with comorbidities (CCI > 2), we found that organizational processes across several domains were positively associated with patient care experiences. These findings suggest that extensive practice efforts to adopt well-promoted organizational processes do appear to be associated with better care experiences in a subset of patients with multiple chronic conditions and that practices may benefit from targeting current efforts in practice redesign towards those patients.

THE ROLE OF CONTINUITY IN HOSPITAL CARE FOR READMITTED COLON CANCER PATIENTS Phuong Luu 2; Tanvir Hussain2; Hsien-Yen Chang1; Elizabeth Pfoh2; Craig E. Pollack2. 1Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; 2Johns Hopkins University School of Medicine, Baltimore, MD. (Tracking ID #2193016)

BACKGROUND: Readmissions may reflect a failure to provide care and/or to coordinate care prior to discharge, resulting in increased cost and potentially poorer outcomes. Identifying how to best care for this high risk group during readmissions to contain further cost and prevent poor outcomes has received relatively little attention. Our study seeks to evaluate whether mortality and costs differ based on whether patients are readmitted to the hospital they were initially discharged from or to a different hospital. We chose colon cancer as an important example; colon cancer is a leading cause of cancer mortality, its treatment often requires patients to see multiple different types of specialists, and efforts have focused on improving continuity of care for patients with cancer.

METHODS: We conducted a retrospective analysis using SEER-Medicare linked data of patients with stage I-III colon cancer between 2000 and 2009 who had surgery within 3 months of diagnosis and were readmitted within 30-days of discharge from their surgical hospital. Our independent variable was whether a patient was readmitted to the same hospital as their initial discharge or a different hospital. Our primary outcome was all-cause mortality (censor date: 12/31/2011). Secondary outcomes included colon cancer specific mortality and costs of care in the 12-months following diagnosis. We used Cox proportional hazards to assess all-cause mortality and subhazards for colon cancer specific mortality; we employed hierarchal generalized linear models for 12-months costs. For each model, we used a propensity-score weighted doubly robust approach to adjust for patient, physician, and hospital characteristics.

RESULTS: Approximately 23 % (N = 769) of the 3399 patients were readmitted to a different hospital than where they were initially discharged. Those readmitted to a different hospital tended to be older and have higher comorbidity burden compared to those readmitted to their initial discharge hospital. After adjustment, there was no difference in either all-cause or colon cancer specific mortality for patients readmitted to a different hospital compared to those readmitted to the same hospital (adjusted Hazard Ratio [HR] 1.09, 95 % Confidence Interval [CI] 0.97–1.24 for all-cause mortality; adjusted HR 0.98, 95 % CI 0.56–1.73 for colon cancer specific mortality). However, costs of care were significantly higher among patients readmitted to a different hospital (the adjusted costs difference was $13,364, 95 % CI $742–$28,954) for 12-months after colon cancer diagnosis.

CONCLUSIONS: Almost a quarter of patients were readmitted to a hospital different from which they were discharged; this may pose a challenge to providing continuity in care as these patients are more likely to be older and have more comorbidities and may increase health care expenses. Creating continuity between episodes of hospital care may be a strategy for managing the complex care of cancer patients.

THE USE OF TABLET TECHNOLOGY BY ELDERLY IN HEALTH CARE SETTINGS—IS IT EFFECTIVE AND SATISFYING? A SYSTEMATIC REVIEW AND META ANALYSIS Chethan Ramprasad 2; Leonardo Tamariz1; Yanira Garcia-Barcena2; Ana Palacio2. 1University of Miami, Miami, FL; 2University of Miami Miller School of Medicine, Miami, FL. (Tracking ID #2198013)

BACKGROUND: Tablet technologies such as iPads have become ubiquitous in today’s society. The use of these technologies by the elderly in clinical settings has the potential to increase clinical effectiveness as well as satisfaction. Appropriate use may reduce health care costs, especially for chronic conditions. The objective of the current study is to systematically review, appraise, and summarize the evidence of the impact of tablet technology on clinical effectiveness and satisfaction in cross-sectional, pre/ post, and randomized controlled trials.

METHODS: A comprehensive literature search was conducted of Pubmed, Scopus, CINAHL through July 2014 using keywords such as ‘iPads’, ‘tablet technology’, ‘elderly’ and ‘health promotion.’ We included randomized control trials, cross sectional, and pre/post studies. We defined satisfaction to include direct ratings of satisfaction as well as indirect ratings of satisfaction such as helpfulness, completion rates, and usability. We defined effectiveness as any improved health outcome including memory scores, blood pressure control, medication error reduction, number of steps per day, and gait speed. To calculate the pooled prevalent satisfaction we used the inverse variance method. To calculate effectiveness we used DeSirmonian and Laird method. This reported the standardized mean difference (SMD) for both intervention and control groups between two measurements before and after the intervention in randomized studies.

RESULTS: Our search strategy yielded 265 abstracts. We excluded 250 on abstract level and selected 25 for full-text review. We included a total of 9 studies (3 randomized controlled trials, 3 cross-sectional, 3 pre/post) with a median methodological quality of 26 out of 31 for cross-sectional and pre/post studies and 34 out of 37 for randomized control trials. There were a total of 517 subjects. The 9 studies included interventions of medication self-management, post-surgery education, memory retention, speech rehabilitation, and exercise promotion. The mean age was 70.07 (2.83). Common conditions among patients included diabetes, dementia, aphasia, and COPD. The 9 studies took place in the United States with the exception of one each in Spain, Switzerland, Australia, and South Korea. The pooled prevalence of satisfaction was 76 %; 95 % CI 21–100. The SMD for the intervention group was −0.22; 95 % CI −0.49 to 0.04 p = 0.09 and the SMD for the control group was −0.014; 95 % CI −0.16 to 0.13 p = 0.85.

CONCLUSIONS: The use of tablet technology by the elderly is associated with high satisfaction. There was a trend towards the improvement of health behaviors such as medicine self-management, memory retention, and exercise promotion. Given high satisfaction, there is strong potential for increased effectiveness for tablet technology use in patient education and rehabilitation as well. More studies should be conducted for further evaluation of such technology interventions.

figurel

TIOTROPIUM RESPIMAT®: CONTROL IN SYMPTOMATIC ASTHMA Kevin Murphy 1; William Berger2; Michael Engel3; Hendrik Schmidt4; Petra Moroni-Zentgraf3; Huib A. Kerstjens5. 1BTNRH, Boys Town, NE; 2Southern California Research Center, Mission Viejo, CA; 3Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany; 4Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany; 5University of Groningen, Groningen, Netherlands. (Tracking ID #2194847)

BACKGROUND: The goal of asthma treatment is to achieve control and minimize future risk. Here we assess the efficacy of once-daily tiotropium Respimat® add-on to inhaled corticosteroid (ICS) ± long-acting β2-agonist (LABA) maintenance therapy in patients with symptomatic asthma: lung function, asthma control, and asthma worsening data are presented.

METHODS: Data were evaluated from four Phase III, randomized, double-blind, placebo-controlled, parallel-group trials. PrimoTinA-asthma® (NCT00776984/NCT00772538): once-daily tiotropium Respimat® 5 μg or placebo Respimat® add-on to high-dose ICS (≥800 μg budesonide or equivalent) plus a LABA in adults over 48 weeks; MezzoTinA-asthma® (NCT01172808/NCT01172821): once-daily tiotropium Respimat® 5 μg or 2.5 μg, twice-daily salmeterol hydrofluoroalkane metered-dose inhaler 50 μg, or placebo (identical devices in a double-dummy protocol) add-on to medium-dose ICS (400–800 μg budesonide or equivalent) in adults over 24 weeks. Lung function was assessed at 24 weeks as peak forced expiratory volume in 1 s (FEV1) within 3 h post-dose (peak FEV1(0-3h)) and trough FEV1. Asthma symptoms and control were assessed using the seven-question Asthma Control Questionnaire (ACQ-7) as responder rate (percentage of patients with minimally important change of ≥0.5). Time to first episode of asthma worsening (defined as a progressive increase in symptoms, or a ≥30 % decrease in best morning peak expiratory flow from the patient’s mean morning peak expiratory flow for ≥2 consecutive days) was also assessed.

RESULTS: Overall, 3012 patients were treated (PrimoTinA-asthma®, n = 912; MezzoTinA-asthma®, n = 2100). Tiotropium Respimat® provided statistically significant and sustained improvements in both peak FEV1(0-3h) (all p < 0.05) and trough FEV1 (all p < 0.01) responses compared with placebo. A higher proportion of patients achieved an ACQ-7 response with tiotropium Respimat® compared with placebo (Table). Risk of asthma worsening was reduced with tiotropium Respimat® compared with placebo: 31 % risk reduction [RR] with 5 μg (hazard ratio [HR] 0.69; 95 % confidence interval [CI] 0.58, 0.82; p < 0.001) in PrimoTinA-asthma® over 48 weeks; 13 % RR with 5 μg (HR 0.87; 95 % CI 0.69, 1.08; p = 0.211) and 34 % RR with 2.5 μg (HR 0.66; 95 % CI 0.52, 0.84; p < 0.001) in MezzoTinA-asthma® over 24 weeks. The incidence of adverse events (AEs) was balanced between the treatment groups in all trials: PrimoTinA-asthma®, 73.5 and 80.3 % for tiotropium Respimat® 5 μg and placebo Respimat®; MezzoTinA-asthma®, 57.3 %, 58.2 %, and 59.1 % for tiotropium Respimat® 5 μg, tiotropium Respimat® 2.5 μg, and placebo, respectively. The incidence of serious AEs and drug-related AEs was low in all treatment groups. No fatal adverse events were reported.

CONCLUSIONS: Once-daily tiotropium Respimat® add-on to at least medium-dose ICS ± LABA provided significant and sustained improvements in lung function, improved asthma control, and reduced risk of asthma worsening in adults with moderate or severe symptomatic asthma.

   ACQ-7 responder rate, n (%)
Tiotropium Respimat® 5 μg QD Tiotropium Respimat® 2.5 μg QD Salmeterol HFA-MDI 50 μg BID Placebo Respimat® QD a
PrimoTinA-asthma® Week 24b NCT00776984/NCT00772538 n 453 454
Responsec 244 (53.9) 213 (46.9)
No change 180 (39.7) 209 (46.0)
Worseningd 29 (6.4) 32 (7.0)
Odds ratio 1.32
95 % CI 1.01, 1.73
PrimoTinA-asthma® Week 48b NCT00776984/NCT00772538 n 453 454
Responsec 263 (58.1) 205 (45.2)
No change 155 (34.2) 209 (46.0)
Worseningd 35 (7.7) 40 (8.8)
Odds ratio 1.68
95 % CI 1.28, 2.21
MezzoTinA-asthma® Week 24 NCT01172808/NCT01172821 n 513 515 535 518
Responsec 330 (64.3) 332 (64.5) 356 (66.5) 299 (57.7)
No change 162 (31.6) 163 (31.7) 156 (29.2) 181 (34.9)
Worseningd 21 (4.1) 20 (3.9) 23 (4.3) 38 (7.3)
Odds ratio 1.32 1.33 1.46
95 % CI 1.02, 1.71 1.03, 1.72 1.13, 1.89

Full analysis set; all randomized patients who received at least one dose of trial medication with baseline data and at least one on-treatment efficacy measurement

aPlus placebo HFA-MDI BID in MezzoTinA-asthma®; b Post hoc analysis; c ≥ 0.5 reduction in ACQ-7 mean score; d ≥ 0.5 increase in ACQ-7 mean score

BID, twice-daily; HFA-MDI, hydrofluoroalkane metered-dose inhaler; QD, once-daily

TOWARD NATIONAL ESTIMATES OF INPATIENT QUALITY OF CARE AMONG HISPANICS: THE CASE OF ACUTE MYOCARDIAL INFARCTION MORTALITY RATES Meng-Yun Lin 1, 4; Nancy R. Kressin2, 3; Michael Paasche-Orlow2; Lenny Lopez5; Jennifer E. Rosen6; Amresh D. Hanchate2, 3. 1Boston Medical Center, Boston, MA; 2Boston University School of Medicine, Boston, MA; 3Dept of Veterans Affairs and Boston University, West Roxbury, MA; 4Boston University School of Public Health, Boston, MA; 5Harvard University, Boston, MA; 6MedStar Washington Hospital Center, Washington, DC. (Tracking ID #2195780)

BACKGROUND: Although Hispanics now form the largest US minority, national estimates of disparities in quality of inpatient care have largely focused on the differences between blacks and whites, partly due to data limitations, including misclassification of Hispanics. We pooled inpatient discharge data from 15 states that together contain over 85 % of the national Hispanic population, and with near-complete identification of Hispanic ethnicity. Applying the Agency for Healthcare Research & Quality (AHRQ) Inpatient Quality Indicators (IQI) protocol, we compared risk-adjusted inpatient mortality from acute myocardial infarction (AMI) among Hispanics, non-Hispanic blacks, and non-Hispanic whites.

METHODS: Using comprehensive inpatient discharge data from Arizona, California, Colorado, Florida, Massachusetts, Maryland, New Jersey, New Mexico, Nevada, New York, Oregon, Pennsylvania, Texas, Virginia, and Washington, we identified AMI discharges for patients 18 and older in 2010–2011. Following AHRQ IQI protocol, we excluded discharges relating to patients transferred between acute hospitals. Our primary estimate of interest was racial/ethnic differences in inpatient mortality rates (odds ratio [OR]) after adjusting for compositional differences in age, sex and comorbidities (Elixhauser indicators) using a logistic regression model with state-level fixed effects. To delineate confounding with socioeconomic status (SES) we further adjusted for county-level differences in zip-code household median income, poverty, uninsurance and provider availability. We estimated inpatient mortality differences among Hispanics by national origin (Mexican, Cuban, Puerto Rican and Other), using census data at county level. We also examined mortality disparities for ST-elevation and non-ST-elevation AMI (STEMI & NSTEMI). Statistical significance was assessed at 5 % level.

RESULTS: We identified 444,431 AMI discharges by patient race/ethnicity: Hispanics (12 %), blacks (9 %), whites (70 %), others (6 %) and missing (3 %). Observed inpatient mortality was 6.4 % with lower rates among Hispanics (6.1 %) and blacks (5.5 %). Adjusted for age, sex, comorbidities, and state, and compared to whites, inpatient mortality was higher among Hispanics (OR = 1.11, 95 % confidence interval (CI) [1.07, 1.16]) and similar among blacks (OR = 1.01, 95 % CI [0.96, 1.05]) (Table 1). This trend persisted after additional adjustment for income, poverty, uninsurance, and provider availability. The distribution of the Hispanic population by national origin was: Mexican (62 %), Puerto Rico (9 %), Cuban (4 %), and Others (25 %). Compared to Mexican Hispanics, adjusted mortality was higher among Cuban Hispanics (OR = 1.25, 95 % CI [1.12, 1.40]) and similar among Puerto Rican and Other Hispanics. For STEMI cases, adjusted mortality was higher among blacks (OR = 1.21, 95 % CI [1.12, 1.30]) and Hispanics (OR = 1.08, 95 % CI [1.01, 1.15]), and for NSTEMI cases, adjusted mortality was higher among Hispanics (OR = 1.18, 95 % CI [1.11, 1.27]) and similar among blacks (OR = 0.99, 95 % CI [0.93, 1.05]).

CONCLUSIONS: Nationally, Hispanics experienced worse inpatient mortality following AMI compared to whites and blacks, among both types of AMI, and after accounting for SES indicators. Further research is needed to extend comparisons to other indicators of hospital quality outcomes, and to explore the underlying factors. Keywords: disparity, race, ethnicity, quality, acute myocardial infarction, inpatient mortality

Table 1 Racial/Ethnic Differences in AMI Inpatient Mortality Rates

Race/Ethnicity (ref = NH white) Unadjusted OR [95 % CI] Model 1 OR [95 % CI] Model 2 OR [95 % CI]
Hispanics 0.94 [0.90, 0.97] 1.11 [1.07, 1.16] 1.08 [1.02, 1.14]
Black, NH 0.85 [0.81, 0.88] 1.01 [0.96, 1.05] 1.00 [0.94, 1.05]

Notes: 1. Estimates for Asian & Others not reported. 2. Model 1 adjusted for sex, age, comorbidity, and state; Model 2 adjusted additionally for zip-code level median income, poverty, uninsurance, and provider availability.

TRANSITIONS OF CARE FROM OUTPATIENT TO INPATIENT: A SYSTEMATIC REVIEW Phuong Luu 2; Samantha I. Pitts2; Brent Petty2; Melinda Sawyer1; Cheryl Himmelfarb-Dennison1; Romsai T. Boonyasai2; Nisa Maruthur2. 1Johns Hopkins University, Baltimore, MD; 2Johns Hopkins University School of Medicine, Baltimore, MD. (Tracking ID #2193027)

BACKGROUND: Optimizing delivery of care at times of transition has been a prominent focus of healthcare reform. However, most transitions of care research has focused on the transition from the acute care setting back to the outpatient setting. The transition from outpatient to acute care setting is also important, but little is known about the outpatient to acute care transition. We conducted a systematic review of the evidence on transitions of care from the outpatient to acute care setting, focusing on provider-to-provider communication and its impact on quality of care.

METHODS: We searched the MEDLINE, CINAHL, Scopus, EMBASE, and Cochrane electronic databases for English-language articles describing direct communication between an outpatient clinician (e.g., primary care provider, outpatient specialist, pharmacist, nursing home provider) and an acute care clinician (e.g., emergency department provider, hospitalist, pharmacist) around patients presenting to the emergency room or admitted to the hospital. Key questions were to describe communication and its impact on outcomes (e.g., 30-day readmission). Search terms were generated from database subject headings and keyword terms. We conducted double, independent review of titles, abstracts, and full text articles. All citations included by ≥1 reviewer were advanced to abstract review. Conflicts on abstract and full text article inclusions were resolved by consensus. Included articles were abstracted using standardized forms. Search results were maintained via Refworks (ProQuest, Bethesda, MD).

RESULTS: Of 4009 citations, twenty articles evaluated communication around the outpatient to acute care transition. Most studies were cross-sectional (12) with others being cohort studies (4), randomized controlled trials (3) and a pre-post study (1). Studies were conducted in the US (11), Australia (6) and the UK (3). Most transitions studied were from the outpatient clinic to admission to the hospital (12); others were clinic to the ED (4) and nursing home to ED (4). Modes of communication used were telephone (8), referral letters (5), fax (5), and in-person (2). None discussed communication via email. Primary care providers/general practitioners comprised the majority of outpatient providers (16), with the remainder being nursing home providers (4) and pharmacists (3). The majority of acute care providers were ED physicians (8), then hospitalists (4), pharmacists (2), residents (1), and unknown (3). Only 35 % of studies (7/20) evaluated outcomes related to provider-to-provider communication: Thirty-day readmissions (3 studies) and utilization of laboratory testing and imaging (2 studies) were lower when outpatient to acute care setting communication occurred. Patient satisfaction (1 study) and provider satisfaction (2 studies) were higher when communication was successful. There were no significant differences in length of hospital stay (2 studies) or mortality (2 studies) associated with provider-to-provider communication.

CONCLUSIONS: The literature on provider-to-provider communication at the transition from the outpatient to acute care setting is sparse and heterogeneous. The current evidence does suggest that successful communication at this transition can improve outcomes. Further research is needed on how to optimize communication to facilitate seamless transfer of information at this stage of care transitions.

TRENDS IN HOSPITAL-OWNERSHIP OF PHYSICIAN PRACTICES AND THE EFFECT ON PROCESSES TO IMPROVE QUALITY Tara F. Bishop 1, 1; Shortell Stephen2; Patricia Ramsay2; Kennon Copeland3; Lawrence P. Casalino1. 1Weill Cornell Medical College, New York, NY; 2University of California, Berkeley, CA; 3NORC at the University of Chicago, Bethesda, MD. (Tracking ID #2194686)

BACKGROUND: Recent reports suggest a trend for physician practices to change ownership from physicians to hospitals. It is unclear how a change to hospital-ownership affects quality of patient care. Given that hospitals generally have greater resources than physician practices, increased hospital ownership of practices may improve quality of care. The objective of this study was to report the change in prevalence of hospital ownership of physician practices owned and the effect on the use of care management processes (CMPs) and health information technology (HIT).

METHODS: We performed cross-sectional and trend analyses of the three largest national surveys of physician practices in the U.S. The sample consisted of a nationally-representative sample of leaders in primary care and select specialty practices in the U.S. treating patients with asthma, congestive heart failure, diabetes, and depression. Large practices (>19 physicians) were surveyed in 2005/2006 and 2012/2013. Small practices (≤19 physicians) were surveyed in 2008/2009 and 2012/2013. The main outcomes were the percentage of practices owned by hospitals in 2005/2006, 2008/2009, and 2012/2013 and the changes in CMP and HIT indices among practices that were acquired by hospitals.

RESULTS: There was a non-significant increase in the percentage of large practices that were owned by hospitals in 2005/2006 (26.6 %) and 2012/2013 (35.6 %, p = 0.37) and small/medium practices that were owned by hospitals in 2008/2009 (8.3 %) and 2012/2013 (11.3 %, p = 0.47). Large practices acquired by hospitals had larger increases in their CMP index than those that remained physician owned (11.0 point increase vs. 7.0 point decrease, adjusted p-value = 0.03). Small/medium practices acquired by hospitals had smaller but significantly higher increases in their CMP score (3.8 points vs. 2.6 points, adjusted p = 0.04) compared with practices that remained physician-owned. Among all practices, there were no significant differences in the change in the HIT index between practices that were acquired by hospitals versus those that remained physician-owned.

CONCLUSIONS: This survey of physician groups showed minimal increase in the percentage of practices that were owned by hospitals, which is contrary to some previous surveys and anecdotal reports that physician groups are rapidly being acquired by hospitals. It may be that practices are considering changes in ownership but have not made that change or that reports of this change are over-stating what is actually occurring. As the healthcare environment continues to change and evolve due to changes in public and private policies, it will be important to continue to monitor both the prevalence and the effects of hospital ownership of practices on patients and physicians.

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USE OF INTERNET AND TELEPHONE REFILLS AMONG LINGUISTICALLY DIVERSE PATIENTS WITH LIMITED-ENGLISH PROFICIENCY AND CHRONIC CONDITIONS Gerardo Moreno 2; Elizabeth Lin1; Eva Chang1; Do Peterson1; Ron Johnson1; Heidi Berthoud1; Leo Morales3. 1Group Health Research Institute, Seattle, WA; 2UCLA, Los Angeles, CA; 3University of Washington, Seattle, WA. (Tracking ID #2196338)

BACKGROUND: The availability of patient internet sites with shared medical records (SMR) may provide an effective system level approach to help mitigate language-based disparities in medication non-adherence. The use of online prescription medication refill systems is relatively new in many healthcare systems and its application has been limited and targeted mostly to populations receiving care in vertically integrated health systems. Research shows that blacks and Latinos are less likely to use an online SMR system that has options to request medication refills, and that low education, income, and internet access are associated with lower use of online SMR. Despite emerging research on internet SMR, more research is needed on the use of online medication refill systems among non-English speaking patients and different ethnic groups with limited-English proficiency. The objective of this study was to describe the use of internet and telephone medication refill systems among an ethnically diverse sample of limited-English proficient (LEP) and English proficient (EP) patients with chronic conditions in a population of insured patients.

METHODS: We conducted a cross-sectional telephone survey in 6 languages/dialects (English, Cantonese, Mandarin, Korean, Vietnamese, and Spanish). The telephone survey was conducted between September and December 2013. Participants were 509 adults in ambulatory care in an integrated group practice healthcare delivery system. The study inclusion criteria included: (1) 18 years of age or older, (2) enrolled in the health systems health plan, (3) Diagnosis of one of the following three chronic conditions hypertension, hyperlipidemia, and/or diabetes, (4) had at least one medical visit (not urgent care or emergency room) within the health system during the last 6 months, and (5) spoke English, Cantonese, Mandarin, Korean, Vietnamese, or Spanish. Primary outcomes were use of 1) internet refill system, 2) telephone refill system, and 3) either internet or telephone refill system. The primary predictor was LEP as measured by the use of an interpreter. Other measures included race-ethnicity, age, gender, education, income, years in the U.S., and health status. We performed bivariate and multiple logistic regression analyses. In all regression models we adjusted for age, gender, education, and self-reported health status.

RESULTS: We found that among all survey participants, both EP and LEP (n = 509), 38.4 % used the telephone and 31.4 % used the internet to refill medication. Patients that used a remote refill system were more educated, had higher incomes, and were younger compared to those didn’t use a refill system. Among LEP patients (n = 328), 21.2 % used the internet and 34.7 % used the telephone refill systems, compared to 50.8 and 37.6 % for English speaking patients (n = 181). Half (49.5 %) of LEP patients used either the telephone or internet refill systems compared to 82.3 % for English speaking patients. LEP status was independently associated with not using the internet refill system (adjusted odds ratio [AOR] = 0.30; 95 % Confidence Intervals [CI] 0.18, 0.49]; p <0.001) compared to English proficient patients. In adjusted analysis, LEP status was not significantly associated with use of the telephone refill system. The proportion of patients within each language group that used the internet refill system was: English (50.8 %), Cantonese/Mandarin (27.9 %), Vietnamese (24.7 %), Korean (17.4 %), and Spanish (12.0 %). The proportion of patients within each language group that used the telephone refill system was: English (37.6 %), Cantonese/Mandarin (19.5 %), Vietnamese (27.2 %), Korean (56.2 %), and Spanish (38.0 %).

CONCLUSIONS: In this study we found substantial variation in the use of remote medication refill systems among a linguistically diverse group of LEP adults with chronic conditions. We found that 50 % LEP patients do not use either internet or telephone remote medication refill systems compared to 20 % among EP patients. To reach all populations within a health system that may potentially benefit from this system level change, efforts will need to be made to open access to persons with limited English proficiency. The results may be of interest to health systems that serve a linguistically diverse patient population at high risk for medication non-adherence.

USING PHOTOVOICE TO PROMOTE DIABETES SELF-MANAGEMENT FOR LATINO ADULTS Arshiya A. Baig 1; Matthew Stutz4; Patricia Fernandez1; Amanda Benitez1; Cara A. Locklin3; Yue Gao1; Sang Mee Lee1; Michael T. Quinn1; Marla C. Solomon2; Lisa Sanchez-Johnsen3; Deborah L. Burnet1; Marshall Chin1. 1University of Chicago, Chicago, IL; 2University of Illinois, Chicago, IL; 3University of Illinois at Chicago, Chicago, IL; 4University of California, Los Angeles, Los Angeles, CA. (Tracking ID #2198802)

BACKGROUND: No studies have assessed the feasibility and acceptability of using photovoice to promote diabetes self-management. We assessed the themes that emerged from a photovoice exercise that was part of a diabetes self-management program for Latino adults and measured patient satisfaction.

METHODS: Fifty adults with self-reported diabetes were enrolled in an 8-week church-based, culturally tailored intervention that consisted of weekly diabetes self-management classes led by lay leaders trained in motivational interviewing. Intervention participants were given disposable cameras and asked to take photographs of their lives with diabetes. In the weekly classes, participants discussed their photos with the group and shared their challenges and successes in diabetes self-care. The class leaders guided the group photo discussions and took notes on why the photo was important to the person who took it and what others in the class discussed regarding the photo. Using a codebook derived from prevalent themes, two researchers coded the photos and the discussion notes. Participants evaluated the photovoice activities at 6-month follow-up. The evaluation questions were analyzed using descriptive statistics.

RESULTS: Participants’ mean age was 54 ± 12 years, 81 % were female, 98 % were Latino, 71 % only spoke Spanish at home, 82 % had a household income below $30,000, and 51 % were uninsured. Of the 50 participants enrolled in the intervention, 37 attended at least one class, 26 participants took photos and 23 participants shared their photos in class. Participants’ photos spurred group discussion around diabetes self-management. Participants gave advice, were empathetic, and motivated the participants who presented their photos to make or sustain healthy behaviors. For example, one participant showed the group a photo of a statue holding a pack of cigarettes. He stated the picture captured the moment he decided to quit smoking while at work. The group encouraged him to try to stop smoking and understood the challenges in trying to quit. Of all the photographs taken, 79 % were of family, friends, or social gatherings, 47 % were of nutrition and exercise, 39 % were of the local neighborhood, 33 % depicted diabetes medications and supplies, 25 % depicted the patient’s home, and 8 % were of religious images. At 6-month follow-up, 86 % of participants who attended the intervention learned about better managing their diabetes from others’ photos, 82 % said they gained more confidence in managing their diabetes from talking about the photos, 82 % noted the photo discussions helped them better manage their diabetes, and 93 % noted that sharing photos made them feel more connected to the people in the group.

CONCLUSIONS: In a diabetes self-management intervention for Latinos, participants were highly satisfied with the photovoice exercise and had high rates of participation. Photovoice provided an effective vehicle to receive and provide social support and promote behavior change. Future studies should consider using photovoice as a way to encourage healthy behavior change and facilitate social support in a group setting.

VALIDATION OF A BRIEF CLINICIAN SURVEY TO REDUCE CLINICIAN BURNOUT. Scott Shimotsu; Sara Poplau; Mark Linzer. Hennepin County Medical Center, Minneapolis, MN. (Tracking ID #2191173)

BACKGROUND: Clinician stress and burnout rates are high and rising in the US. We validated a brief (10 question) survey to determine areas for work life improvement within all clinical departments at an upper Midwestern safety net hospital. The survey was administered by a provider wellness committee charged with improving clinician wellness. A valid and reliable tool that captures the dimensions of clinician work life may be effective in improving the longevity of providers in health care systems. This paper evaluates the psychometric properties of the brief instrument.

METHODS: We developed a brief self-administered questionnaire that was distributed electronically via Survey Monkey to clinicians. The instrument was modified from prior work life measures of the MEMO study (Minimizing Error Maximizing Outcome), and is called the Mini Z (for Zero Burnout Program). It included 10 quantitative questions concerning stress, burnout and their predictors. The survey was sent to a total of 603 clinicians including dentists, psychologists, physicians and advanced practice providers (NPs and PAs). The survey used 5 point likert scales to query job satisfaction, stress, burnout, workload, time for documentation, work environment (chaotic, busy, calm), values alignment with leadership, teamwork, time spent at home using the electronic medical record (EMR), and EMR proficiency. Main global measures included satisfaction (n = 3 items), stress and burnout (n = 4 items) and EMR-related stress (n = 3 items). Returned surveys (n = 402) resulted in 366 usable responses, which were randomly separated into developmental (n = 178) and cross validation samples (n = 178). All analyses were conducted using PC SAS 9.2 (Cary, North Carolina). First, we conducted confirmatory factor analyses (CFA) to evaluate a priori global scales. Based on Nunnally’s convention, we used the Kaiser’s eigenvalue rule and scree plots to identify total number of factors. An oblique rotation was applied to the CFA. We computed Cronbach alpha coefficients to assess reliability of each global scale. Second, pearson correlations were used to evaluate convergent and discriminant validity. Further, we used latent class analyses to determine characteristics of satisfied and dissatisfied clinicians. The same analyses were performed on both the developmental and cross-validation samples.

RESULTS: Of the 603 providers, 402 (67 %) clicked on the survey and 366 (61 %) completed it. Factor analysis revealed two factors: 1) teamwork/values, and 2) EMR use and stress. Overall alpha for the 10 items was 0.80; individual factor alphas were 0.74 and 0.72 for the teamwork/values factor and EMR use/stress factors, respectively. Correlations demonstrated convergent validity across survey items, with modest to moderate r values (0.39–0.57, p < 0.0001) between burnout and most mini Z items (satisfaction, values, teamwork, stress, work control, chaos and documentation time). Latent class analysis confirmed two classes of clinicians: a high satisfaction group (with teamwork and aligned values), and a high stress group (with high burnout and low work control). All analyses were similar in the cross-validation sample.

CONCLUSIONS: Clinician burnout and work life can be feasibly and reliably captured using the Mini Z survey tool. Our a priori sub-scales were partly supported as we hypothesized a satisfaction factor as well as a stress factor. The brief instrument may allow health care systems to feasibly assess stress, burnout and satisfaction among clinician workforces. By addressing root causes of stress and burnout in clinicians, health care systems can better recruit and retain their talent. Future work includes validation of the instrument on a nationwide sample of clinicians.

VULNERABILITY FOR HEALTHCARE COMMUNICATION GAPS FOR USERS OF VA PURCHASED CARE: IMPLICATIONS FOR THE VETERANS CHOICE ACT Donna L. Washington 1, 2; Alison B. Hamilton1, 2; Kristina M. Cordasco1, 2. 1VA Greater Los Angeles Healthcare System, Los Angeles, CA; 2UCLA School of Medicine, Los Angeles, CA. (Tracking ID #2198688)

BACKGROUND: The recent Veterans Choice Act is designed to expand timely access to health care for Veterans Health Administration (VA) users through purchasing services from non-VA community providers. These care arrangements will potentially create coordination and communication gaps between patients’ VA and non-VA providers, and between patients and their providers. Some Veteran populations may be particularly vulnerable for experiencing these communication gaps, increasing their risk for poor health outcomes. Our objective was to identify patient characteristics associated with communication gaps among Veterans using VA-purchased care delivered by non-VA providers.

METHODS: We conducted a secondary data analysis of the National Survey of Women Veterans (NSWV), a 2008–09 population-based telephone survey of women Veterans (response rate 86 %). Our analytic sample was comprised of 604 NSWV participants who used any VA-purchased non-VA provider care in the 12 months prior to the survey. Health care coordination and communication was measured with five questions that each assessed patient perceptions of communication (table). All measures used five-point Likert response options (all of the time; most of the time; some of the time; rarely; never). Responses of never, rarely, or some of the time were classified as indicative of a communication gap. We assessed prevalences of having any communication gap, and gaps by measure, followed by chi square and logistic regression analyses for the association of patient characteristics with each of the five measures. All analyses applied weights to account for the study design and response rate.

RESULTS: Nearly half (46 %) of the respondents perceived a communication gap in one or more of the measures. In unadjusted analyses, characteristics associated with a greater likelihood of a perceived communication gap were age 18–44 years (65 %), being a college graduate (54 %), being a newer Veteran (military service during the first Gulf War, the following peacetime, or during Operations Enduring Freedom/Iraqi Freedom/New Dawn [OEF/OIF/OND]) (59 %), having a military service-connected disability (53 %), and screening positive for a mood disorder (depression, anxiety, or post-traumatic stress disorder) (54 %). The table shows prevalence of communication gaps by measure. For each measure, age 18–44 years (versus older) was associated with a greater likelihood of experiencing a communication gap. In each of the first four measures, newer Veterans were more likely than those who served in the post-Vietnam Era or earlier to experience a communication gap. For example, a communication gap was perceived for these measures by 28 %, 42 %, 40 %, and 28 %, respectively, of OEF/OIF/OND Veterans. Being a college graduate was associated with perceived communication gaps for measures 1 (26 %), 3 (29 %), and 5 (27 %). Employed Veterans, Veterans with a military service-connected disability, and those screening positive for a mood disorder were more likely than others to report a gap in being able to get a convenient appointment (all 26 %). Communication gaps did not appear to vary by respondents’ race/ethnicity, income, insurance, or having three or more diagnosed medical conditions. In adjusted analysis, only younger age remained independently associated with having a perceived communication gap in one or more of the measures.

CONCLUSIONS: A sizable proportion of women Veterans using VA purchased care reported communication gaps in their care. Several patient characteristics identified Veterans at increased risk. The finding that younger Veterans are more likely to experience communication gaps is especially salient given that this is a growing demographic within VA-users. VA has recently implemented a new infrastructure to coordinate purchased care, though its effect on patient experiences of care is unknown. As the national Veterans Choice Act is implemented, expanding use of VA-purchased non-VA provider care, the VA should continue to make efforts to ensure that care provided from multiple sources is coordinated and that communication between VA and non-VA providers is seamless.

Care Coordination and Communication Measures: Percent Reporting a Communication Gap (response: some of the time, rarely, or never)

1. How often do your medical providers at the VA know about test results or tests you have had at a contract facility? 19 %
2. How often do you know how to get the results of your tests or medical procedures that were done at a VA contract facility? 20 %
3. How often does there seem to be good communication about your healthcare between your providers at the VA and providers at the contract facility? 23 %
4. When you have problems with your health, how often do you know who to call among your VA and non-VA medical providers? 14 %
5. How often can you get an appointment at a time that is convenient for you for contract services? 21 %

WHAT CAN HOSPITALISTS TEACH THE TEACHING SERVICE? COMPARING PATIENT EXPERIENCES ON HOSPITALIST AND HOUSESTAFF SERVICES Charlie M. Wray 1; Micah Prochaska1; David Meltzer1; Vineet M. Arora2. 1University of Chicago, Chicago, IL; 2University of Chicago Medical Center, Chicago, IL. (Tracking ID #2196296)

BACKGROUND: It is recommended that hospitalized patients understand and know who is in charge of their care. Yet the complex system of physician teams in academic teaching hospitals may interfere with current recommendations that patients know and understand who is responsible for their care at all times. Given the inherent differences between housestaff and hospitalist services, we aimed to compare patient’s ability to identify and understand the roles of their physician(s) between these two services.

METHODS: We performed a retrospective cohort analysis using data from internal medicine teaching and non-teaching services from July 2007 to June 2013 at an academic medical center. Patients were allocated first to teaching services staffed by an attending, resident, and two interns until the team capped, and subsequently to the hospitalist service which includes a nurse practitioner. Self-reported responses to a 30-day follow-up questionnaire were used to assess patients’ ability to 1) identify their physician(s) 2) understand the role of their physician(s) 3) rate the coordination of care, and 4) overall care. Responses were dichotomized to reflect the top 2 categories (“Excellent & Very Good”) and chi-square analyses were used to assess any differences. A multivariate logistic regression which controlled for baseline differences in patient characteristics (age, gender, length of stay, Charlson Comorbidity Index, academic year, and prior hospitalizations) was performed to ascertain the association between service type and patient-reported outcomes.

RESULTS: Data from 5753 housestaff and 2252 hospitalist service patients demonstrated that those on the hospitalist service were more likely to report being able to identify their physician (49 % vs. 45 % p < 0.05), understand the role of their physician (55 % vs. 50 %, p < 0.05), report greater satisfaction with coordination and teamwork (68 vs. 65 %, p < 0.05), and with overall care (72 % vs. 67 %, p < 0.05). In multivariate logistic regression, patients on the hospitalist service were 13 % more likely to report being able to understand the role of their physician (OR 1.13; 95 % CI, 1.01–1.27) and rated their overall care higher (OR 1.15; 95 % CI, 1.02–1.30) than patients on the teaching service.

CONCLUSIONS: Compared with housestaff services, patients under the care of a hospitalist service report being better able to understand the role of their physician and rated their overall care better. These findings may reflect inherent structural differences between the two services such as fewer providers or process differences such as greater attention to team introductions. Understanding these mechanisms may provide insight into how best to enhance the patient experience on both teaching and hospitalist services in academic medical centers.

WHO WANTS TO KNOW? DESIRE FOR PREDICTIVE TESTING FOR ALZHEIMER’S DISEASE AND IMPACT ON ADVANCE CARE PLANNING Meera Sheffrin; Irena Stijacic Cenzer; Michael A. Steinman. UCSF/ San Francisco VA Medical Center, San Francisco, CA. (Tracking ID #2171144)

BACKGROUND: Currently, much research is devoted to developing a test that would predict future Alzheimer’s disease. However, it is unknown who in the United States would want such as test, and how it would change subsequent behavior. Using a large national sample, we explored who would take a free and definitive test predictive of Alzheimer’s disease, and examined how use of such a test may impact advance care planning.

METHODS: In this cross-sectional study, we identified 874 adults age 65 or older in the Health and Retirement Study in 2012 who were asked the question: “If you could receive a test from your doctor, free of charge, that would definitely determine whether or not you would develop Alzheimer’s disease sometime in the future would you want to be tested?” Subjects were then told to imagine they knew they would develop Alzheimer’s disease in the future, and with this knowledge to rate the chance of completing advance care planning activities on a scale of 0–100. We classified >50 as being likely to complete that activity. We evaluated characteristics associated with willingness to take a test for Alzheimer’s disease, and how such a test would impact completing an advanced directive and discussing health plans with loved ones.

RESULTS: Among the 874 individuals, 861 (99 %) answered the question. Mean age was 74 years and 56 % were female. Overall, 75 % (N = 648) would take a free and definitive test predictive of Alzheimer’s disease. Older adults willing to take the test had similar race and educational levels as those that would not, but were more likely to be < =75 years old (63 % vs 52 %, p < 0.01). There were no differences in willingness to take the test by level of self-perceived health or memory problems, self-perceived risk of Alzheimer’s disease, or number of comorbidities. After subjects were asked to assume they knew they would develop Alzheimer’s disease, 87 % reported they would be likely to discuss health plans with loved ones. Most (81 %) reported they would be likely to complete an advanced directive, though only 15 % reported having done so already.

CONCLUSIONS: In this nationally representative sample, 75 % of older adults would take a free and definitive test predictive of future Alzheimer’s disease. Many expressed intent to increase activities of advance care planning with this knowledge. The potential for high demand, widespread use, and the opportunity to engage patients in advance care planning should be considered as tests predictive of Alzheimer’s disease become available.

AN EVALUATION OF DRUG-ALLERGY INTERACTION ALERT OVERRIDES IN INPATIENTS Sarah P. Slight 1, 3; Patrick E. Beeler1; Diane L. Seger4; Olivia Dalleur1; Mary Amato2; Tewodros Eguale1; Karen C. Nanji1; Patricia C. Dykes1; Michael Swerdloff5; Julie Fiskio4; David W. Bates1. 1Brigham and Women’s Hospital, Boston, MA; 2Brigham and Womens Hosptial/MCPHS, Boston, MA; 3Durham University, Stockton on Tees, United Kingdom; 4Partners Healthcare System, Wellesley, MA; 5Partners Healthcare Systems Inc., Wellesley, MA. (Tracking ID #2198426)

BACKGROUND: Clinical Decision Support (CDS) systems are designed to provide real-time guidance and support to providers at the point of prescribing. Drug allergy interaction alerts (DAIs) are generated when a known adverse sensitivity inducing substance is prescribed. High DAI override rates have been reported in the outpatient setting.(1) We evaluated the DAI override rates in the inpatient setting and the reasons why providers chose to override these alerts.

METHODS: After obtaining IRB approval, all Level 2 DAI alerts from Jan 2009 to Dec 2011 were obtained from the Brigham and Women’s Hospital, Boston, MA. A total of 2783 prescribers received allergy alerts at this site. Level 2 alerts suggest an undesirable interaction likely to cause serious injury, and give the provider the option of ‘cancelling’ the order or ‘overriding’ the alert. The downloaded file included the coded reasons given by physicians at the time of overriding the alert.

RESULTS: Overall 83.9 % (110,414 /131,615) of the DAI alerts generated were overridden. Drug classes, which were more frequently associated with allergies, triggered 31,843 DAI alerts (24.2 %) and were broken down as follows: cephalosporins (13.7 %, n = 17,978), aspirin and NSAIDs (6.6 %, n = 8730), penicillins (1.8 %, n = 2379), sulfonamides (1.4 %, n = 1819), ACE inhibitors and angiotensin receptor blockers (0.55 %, n = 724), contrast media (0.12 %, n = 161), and monoclonal antibodies (0.04 %, n = 52). Opioids triggered more than half of the alerts (50.9 %, n = 66,949), although these drugs are usually associated with sensitivities rather than true allergies. Providers overrode 72.5 % (1721/2373) of alerts that indicated that the patient was at risk of developing anaphylaxis, and were more likely to override these alerts when prescribing penicillin (62.5 %, 50/80) than contrast media (15.4 %, 2/13). The most common coded reasons for overriding DAI alerts were ‘Patient has taken previously without allergic reaction/patient has tolerated previously’ (56.0 %, 61,858/110,414), ‘Physician aware’ (16.8 %, n = 18,583) and ‘Low risk cross sensitivity, will monitor’ (12.0 %, n = 13,202).

CONCLUSIONS: This study offers important insights into providers’ behavior and the specific DAI alerts that were commonly overridden. The override rate of DAI alerts in inpatients was found to be very high. The inclusion of inaccurate or incomplete allergy information in the patient’s electronic health record can lead to the production of clinically inappropriate alerts. Suppressing alerts that have been previously overridden for an individual patient may help to reduce the numbers of inappropriate DAI alerts. Further research is needed to ascertain how best to record drug-allergy information and present the user with useful drug-allergy alerts. References: Nanji KC, Slight SP, Seger DL, Cho I, Fiskio JM, Redden LM, et al. Overrides of medication-related clinical decision support alerts in outpatients. J Am Med Inform Assoc. 2014;21(3):487–91.

CAN’T WE JUST HAVE SOME SAZóN? EVALUATION OF A NEW SCHOOL FOOD PROGRAM IN DORCHESTER, MA Avik Chatterjee 2; Genevieve Daftary3; Meg Campbell4; Lenward Gatison4; Liam Day4; Kibret Ramsey3; Roberta E. Goldman5; Matthew W. Gillman1. 1HMS-HPHCI, Boston, MA; 2Harvard Pilgrim Health Care Institute/Department of Population Medicine at Harvard Medical School, Cambridge, MA; 3Codman Square Health Center, Boston, MA; 4Codman Academy Charter Public School, Boston, MA; 5Warren Alpert Medical School, Brown University, Providence, RI. (Tracking ID #2192631)

BACKGROUND: Child and adolescent obesity is a growing problem in the United States and leads to obesity and chronic disease in adulthood. Certain dietary patterns, such as eating fruits, vegetables and whole grains and avoiding red meat, are linked to healthier weight and lower incidence of chronic disease. With 31 million children receiving food through the National School Lunch Program, schools provide a unique opportunity to promote healthy eating in children. In September 2013, a Dorchester high school in a low-income neighborhood launched a pilot nutrition program, with school food meeting new 2013 United States Department of Agriculture (USDA) requirements. The program included additional nutrition education and a junk food free policy. Our objective was to understand the attitudes of students, parents and staff to the new school food program that aimed to improve eating behaviors.

METHODS: Investigators employed community-based participatory research methods to complete a qualitative evaluation of the new food program at the school. School staff, student and community investigators from a neighboring health center were full partners in study design, implementation, and analysis. The study site was a public charter high school in the Dorchester neighborhood of Boston, MA, with approximately 140 students, where 98 % of students are people of color and 86 % qualify for free or reduced lunch. All students, parents, and faculty/staff were eligible, but due to resource constraints, we excluded parents who could not speak English. We conducted 4 student focus groups (1 per grades 9–12, n = 32 participants), 2 parent focus groups (n = 10), 1 faculty/staff focus group (n = 14), and interviews with school leadership (n = 3). We used the immersion/crystallization technique to find themes from transcripts of recordings of focus groups and interviews.

RESULTS: Ten themes emerged from the focus groups and interviews, in three major categories—impressions of the food itself (insufficient portion size, dislike of the taste, appreciation of the freshness, and overall dissatisfaction leading to fast food consumption outside of school), impact on student learning (students now knowing what’s healthy, pride in the innovative nature of the program, the tension between external control vs. freedom to choose), and concerns about stakeholder engagement (need for more student and family engagement, and a lack of cultural appropriateness of the food). A representative statement from a parent was: “You need something to hold them from 9 to 5, because if they are hungry, McDonald’s is right there” (Table 1).

CONCLUSIONS: Students, parents, and school staff appreciated the educational value of the new school food program based on USDA guidelines, but dissatisfaction with taste, portion size, student/family engagement, cultural appropriateness and unhealthy eating behaviors outside of school pose important challenges. School leadership were particularly sensitive to the fact that overall dissatisfaction with the new school food program may paradoxically be leading to increased consumption of unhealthy foods, such as fast food, outside of school. School leadership is committed to changing the school food program in order to improve student satisfaction with school food, while continuing to adhere to USDA guidelines. Near-term action steps could include creating a sodium-free seasoning bar for students, educating students and families about the new USDA guidelines and working with families to incorporate culturally appropriate recipes to the school’s menu. Longer-term changes include finding resources to add an additional meal at the end of the school day, and working with local restaurants to promote healthy offerings for young people—a strategy that has been employed in another nearby community with success. Changing eating behaviors in children and adolescents will be vitally important to prevent obesity and chronic disease in adults. New USDA guidelines and other school-based solutions are important tools, but our study reveals some important challenges for schools that adopt the new guidelines. Schools and communities will need to address such challenges in order for school-based healthy eating interventions to be successful.

Table 1: Sample quotations from student, parent, and school staff focus group participants about a new school food program at a Dorchester, MA, high school

  Theme Quote
Category 1: The Food Itself Taste “Can’t we just have some sazón?”
Portion size “When I leave here, I leave hungry.”
Undesirable eating behaviors “You need something to hold them from 9 to 5, because if they are hungry, McDonald’s is right there.”
Freshness “Healthy food is fresh food.”
Category 2: Student Learning Impact on student education “Our students [now] know what is healthy and what isn’t healthy.”
Control vs. choice “At the end of the day, you can’t really force anyone to eat [healthy foods]”
Innovation “[The new school food program] helped me to think critically…kudos to the school.”
Category 3: Stakeholder Engagement Student engagement “I loved Saturday cooking class. I want to do more.”
Family engagement “There’s school breakfast?”
Cultural representation “All the vegetables together with meat, [we Haitians] call it ‘legume,’ and she loves that. That is a good food for them.”

IT’S SO COMPLICATED : A NEEDS ASSESSMENT TO INFORM CONTINUING MEDICAL EDUCATION FOR PRIMARY CARE PROVIDERS ON PROSTATE CANCER AND AFRICAN AMERICAN MEN Nynikka R. Palmer 1, 1; Justin Morgan2; Michael B. Potter1; Eunice Neeley3; Matthew R. Cooperberg1; June M. Chan1, 1; Peter R. Carroll1; Rena Pasick1, 1. 1University of California San Francisco, San Francisco, CA; 2John Hale Medical Society and John Hale Foundation, San Francisco, CA; 3Kaiser Permanente, Oakland, CA. (Tracking ID #2198141)

BACKGROUND: Advances in medical science can exacerbate existing disparities in prostate cancer (PCa) care if they are only adopted in settings that serve those who are affluent, insured, and/or highly educated. African American patients, bearing the greatest burden of PCa, are overrepresented in safety net settings, and the gap between best and actual practice in PCa care is wider for African American men than for other low-income patients. Primary care providers (PCPs) can play an important role across the PCa spectrum. While urologists are typically the first clinicians to discuss treatment options with newly diagnosed patients, screening and evaluation of symptoms usually takes place in primary care. PCPs often have established relationships with patients and are at times involved in PCa treatment decision-making. PCPs are also being called upon to assume more responsibility for cancer survivors’ post-treatment follow-up. One step toward reduction of African American PCa disparities could be better integration of PCPs in the PCa management team. However, awareness and adoption of the most advanced treatment usually requires intensive promotion and education. We sought to explore the gaps between actual and optimal practice, and to elucidate the needs, preferences, and priorities around PCa care among PCPs who serve the African American community. These data were collected to inform the development of a continuing medical education (CME) curriculum for PCPs on state-of-the-science PCa care for African American men.

METHODS: We conducted a qualitative study which included three focus groups to explore the perceptions and practices regarding PCa care among clinicians serving African American men. Both PCPs and urologists from a range of settings were invited to participate through a partnership between the UCSF Clinical and Translational Science Institute’s Clinical Research Network and the John Hale Medical Society. Each group included 6–9 participants, lasted approximately 90 min, and was led by PCP research team members (Drs. Morgan and Potter). Clinicians received a $100 incentive payment for their time and participation. Focus groups were audio recorded, transcribed verbatim, and analyzed by two researchers (Drs. Palmer and Pasick) using thematic content analysis.

RESULTS: Twenty-three health care providers participated in focus groups in November 2012 (n = 8), January 2013 (n = 9), and February 2013 (n = 6). The majority were PCPs (n = 21), 12 were female, and there was one nurse practitioner and one urologist. Providers were Caucasian (n = 13), African American (n = 8), Latino (n = 1) and Asian (n = 1). Three main topics were discussed: PCa screening and shared decision-making, PCP’s involvement in PCa care, and ideal components of a CME curriculum. PCa Screening and Shared Decision-Making : PCPs consistently expressed uncertainty about best screening practices in light of current controversies and shifting guidelines regarding efficacy of the prostate-specific antigen test and the lack of data specific to those at high risk, particularly African Americans. PCa screening practices varied by provider and certain patient characteristics (e.g., high risk, requested test, or symptomatic). PCPs clearly recognized the importance of discussing the risks and benefits of PCa screening and engaging patients in shared decision-making, but admitted that this conversation is complicated and severely limited by time constraints. PCP’s Involvement in PCa care : PCPs expressed the desire to participate in the treatment decision-making process; several noted that patients have sought their input and they want to remain part of the process. However, providers felt they lacked sufficient knowledge about PCa care, treatment options, side effects, and post-treatment care, to help their patients understand their options and receive the best care. Providers also mentioned the need for better communication between PCPs and urologists. Developing A CME Curriculum: Providers were amenable to attending a CME on PCa care, noting key topics: synthesis of the controversy in PCa screening and clarification of guidelines, treatment options, side effects, and any differences specific to African American men. They discussed the need to include both PCPs and urologists as presenters and participants. Providers preferred in-person CME that was interactive and focused on communication skill-building for a brief yet effective discussion with patients.

CONCLUSIONS: Many PCPs desire to play a more integral role in caring for their patients facing PCa. However, they are uncertain about best practices across the PCa continuum. Providers are amendable to a CME course addressing state-of-the-science PCa care from screening through survivorship.

WALKING IN FAITH : EXAMINING THE FEASIBILITY OF IMPLEMENTING A FAITH-BASED NUTRITION EDUCATION AND WALKING PROGRAM. Milele L. Bynum 1; Giselle M. Corbie-Smith2. 1University of North Carolina, Durham, NC; 2University of North Carolina, Chapel Hill, NC. (Tracking ID #2198779)

BACKGROUND: African Americans continue to be disproportionately affected by obesity and obesity-related health problems. Innovative methods that tap into the strengths and resources of the African American community are needed. The purpose of this study was to describe the feasibility of using a community-based participatory research (CBPR) approach to implement the Faithful Families: Eating Smart and Moving More curriculum coupled with a walking program in an African American church. The primary objectives of the study were to equip lay leaders to serve as program co-facilitators, increase physical activity, and improve knowledge and skills related to nutrition and healthy eating behaviors.

METHODS: Working with the partnering church, a 10-week nutrition education and walking program was piloted. Church lay leaders were trained to facilitate the Faithful Families curriculum. At baseline and 10-weeks, we collected quantitative outcome data on physical activity; fruit/vegetable intake; changes in blood pressure [BP], and weight) and post intervention process data through semi-structured interviews with participants and facilitators to assess acceptability, implementation fidelity, and limited efficacy testing.

RESULTS: Eight lay leaders were recruited and completed a two-day training. By the conclusion of the program, seven lay leaders each co-facilitated at least four nutrition education sessions, attended at least one walking session weekly and assisted with the collection of data from participants. Thirty-five church members attended an orientation session to hear about the program, with 31 consenting to participate in the study. Twenty-two of them completed the study and provided follow-up data. At baseline, the mean fruit and vegetable intake was 3.56 servings/day. Participants averaged 121.88 min/week of physical activity, with 23.81 % of the participants meeting physical activity recommendations of at least 150 min/week. At 10 weeks, participants realized a statistically insignificantly reduction in BMI from 30.72 to 30.68; systolic and diastolic blood pressure decreased by 8.31 and 6.05 points respectively; mean fruit and vegetable intake increased by 0.58 servings/day to 4.14 servings/day; and physical activity mean improved by 50.82 min/week to 172.70 min/week with 61.90 % of the participants meeting physical activity recommendations of 150 min/week. Participants and facilitators endorsed the content and structure of the intervention as acceptable. Participants expressed satisfaction with the program, stating that it helped them to change habits, exercise more, and become conscious of what they were eating and drinking. However, they did voice a desire to have more support through accountability partners, more information on physical activity and an expanded faith component.

CONCLUSIONS: This study demonstrated that it is feasible to use a CBPR approach to implement a faith-based nutrition education and physical activity program using trained lay leaders recruited from the partnering church. By utilizing individuals from within the church to develop and implement the program, Walking in Faith was able to engage members of the faith community, while promoting improved health outcomes and program sustainability.

18 F-FDG PET OR PET/CT AND 67 GA-CITRATE SCINTIGRAPHY IN THE DIAGNOSIS OF CLASSIC FEVER OF UNKNOWN ORIGIN: A SYSTEMATIC REVIEW AND META-ANALYSIS OF TEST PERFORMANCE AND DIAGNOSTIC YIELD Motoki Takeuchi 1; Takashi Nihashi2; Issa Dahabreh3; Teruhiko Terasawa1. 1Fujita Health University, Nagoya, Japan; 2Nagoya University Graduate School of Medicine, Nagoya, Japan; 3Brown University, Providence, RI. (Tracking ID #2189730)

BACKGROUND: Fever of unknown origin (FUO) is a common clinical dilemma encountered in general medical practice. Although advances in anatomical imaging tests such as ultrasound, contrast-enhanced CT (CECT), and MRI, and improved culture techniques have continuously modified the spectrum of FUO-causing diseases, identifying the cause of FUO still remains a challenge. 18 F-FDG PET or PET/CT (FDG-PET or -PET/CT) and 67Ga-citrate scintigraphy (Ga-scintigraphy) are expensive but established functional imaging tests in the clinical management of malignant diseases, and are promising imaging modalities that may assist detecting the cause of FUO when conventional modalities are not helpful. Although several studies on the use of these functional imaging tests for diagnosing FUO have been published, their clinical role and impact remain unclear.We therefore performed systematic review and meta-analysis to quantitatively synthesize the current evidence. In this presentation, we focus on their test performance (i.e., sensitivity and specificity), and impact on diagnosis (i.e., diagnostic yield: how often these functional imaging tests can contribute to diagnosis) and diagnostic or therapeutic management.

METHODS: We searched PubMed and Scopus (from inception until June 30, 2014) and no language restrictions were applied. We included studies of FDG-PET or -PET/CT, or Ga-scintigraphy that were performed for evaluating the cause of FUO in adult patients with classic FUO. Two independent reviewers screened abstracts, perused full-text publications for eligibility, and performed data extraction. Sensitivity and specificity were calculated from a 2 by 2 contingency table data according to whether patients were a functional imaging test positive or negative, and whether the cause of FUO was identified by any add-on tests performed after the imaging test and/or clinical follow-up as the reference standard. Study validity was assessed using the QUADAS-2. Meta-analysis was performed when 4 or more studies were available for each imaging test.

RESULTS: Of 4458 citations retrieved, 74 were selected for full-text review, 30 of which (11 for FDG-PET; 15 for FDG-PET/CT; 6 for Ga-scintigraphy) including 1436 patients with classic FUO were eligible. Only two studies assessed both Ga-scintigraphy and FDG-PET or FDG-PET/CT to compare these modalities. Most (23 studies, 77 %) had a retrospective design based on data derived from clinical practice, and reported non-uniform work-up strategies before undertaking functional imaging tests. Few adopted standardized work-up algorithms for classic FUO including CECT of the chest and abdomen in all patients. More invasive and accurate tests such as biopsy or surgery were preferentially performed as add-on tests for patients with a positive scan result, while clinical follow-up was typically performed for those with a negative result, suggesting a possibility of differential verification bias. Also, treating physicians often employed functional imaging test results as the reference standard to make a clinical diagnosis when the uptake pattern was suggestive of a non-infectious inflammatory disease (NIID) such as large vessel vasculitis, which could overestimate both test performance and diagnostic yield. Overall, a cause of FUO was identified in approximately two-thirds of patients. The summary sensitivity and specificity were respectively 0.84 (95 % confidence interval [CI], 0.78–0.89) and 0.64 (CI, 0.44–0.79) for FDG-PET/CT; 0.76 (CI, 0.65–0.84) and 0.60 (CI, 0.39–0.77) for FDG-PET; and 0.60 (CI, 0.45–0.73) and 0.63 (CI, 0.37–0.84) for Ga-scintigraphy. The summary diagnostic yield was 56 % (CI, 49 %–65 %) for FDG-PET /CT, 47 % (CI, 34 %–64 %) for FDG-PET, and 35 % (CI, 23 %–53 %) for Ga-scintigraphy. Only 3 studies reported how often the scan results altered diagnostic or therapeutic management, which precluded in-depth analysis. Comparative evidence regarding FDG-PET or -PET/CT versus Ga-scintigraphy was limited.

CONCLUSIONS: FDG-PET, FDG-PET /CT and Ga-scincigrahy can contribute to identifying the cause of classic FUO. However, their clinical role particularly in contrast to alternative imaging modalities in contemporary diagnostic pathways is uncertain and the calculated naïve test performance based on the imperfect reference standards may be overestimated. Regarding FDG-PET and FDG-PET/CT, despite their moderately high sensitivity, management decisions based solely on the scan results may lead to unnecessary interventions given the low specificity. Prospective studies in settings where work-up algorithms are standardized are needed to better clarify the clinical role and impact of these functional imaging tests in contemporary diagnostic strategies.

24-HOUR EFFICACY OF TIOTROPIUM RESPIMAT® IN ASTHMA Thomas B. Casale 1; David M. Halpin2; Michael Engel3; Petra Moroni-Zentgraf3; Achim Muller4; Kai-Michael Beeh5. 1University of South Florida, Tampa, FL; 2Royal Devon & Exeter Hospital, Exeter, United Kingdom; 3Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany; 4Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany; 5insaf Respiratory Research Institute GmbH, Wiesbaden, Germany. (Tracking ID #2194778)

BACKGROUND: The once-daily long-acting anticholinergic bronchodilator tiotropium Respimat® has demonstrated efficacy as add-on to at least inhaled corticosteroid (ICS) maintenance therapy across severities of symptomatic asthma. We assessed the efficacy of tiotropium Respimat® add-on therapy over 24 h in adult patients with moderate or severe symptomatic asthma.

METHODS: Four Phase III, randomized, double-blind, placebo-controlled, parallel-group trials. PrimoTinA-asthma® (NCT00772538/NCT00776984): once-daily (morning dosing) tiotropium Respimat® 5 μg or placebo Respimat® add-on to high-dose ICS (≥800 μg budesonide or equivalent) plus a long-acting β2-agonist in adults over 48 weeks; MezzoTinA-asthma® (NCT01172808/NCT01172821): once-daily (evening dosing) tiotropium Respimat® 5 μg or 2.5 μg, twice-daily (morning and evening dosing) salmeterol hydrofluoroalkane metered-dose inhaler 50 μg, or placebo (identical devices in a double-dummy protocol) add-on to medium-dose ICS (400–800 μg budesonide or equivalent) in adults over 24 weeks. We report 24-h lung function measurements, performed in a subset of patients.

RESULTS: Patients included in the 24-h full analysis set: PrimoTinA-asthma®, n = 349 (tiotropium Respimat® 5 μg, n = 172; placebo Respimat®, n = 177); MezzoTinA-asthma®, n = 583 (tiotropium Respimat® 5 μg, n = 141; tiotropium Respimat® 2.5 μg, n = 144; salmeterol, n = 150; placebo, n = 148). Tiotropium Respimat® significantly improved lung function over 24 h, compared with placebo, after 24 weeks, with significant improvements observed in peak forced expiratory volume in 1 s (FEV1) within 0–3 h, trough FEV1, and all measures (0–12, 12–24, and 0–24 h) of FEV1 area under the curve with the 5 μg dose in PrimoTinA-asthma® and both the 5 μg and 2.5 μg doses in MezzoTinA-asthma® (Table).

CONCLUSIONS: Once-daily tiotropium Respimat® add-on to at least ICS maintenance therapy improves lung function and provides sustained bronchodilation over 24 h in adults with moderate or severe symptomatic asthma.

Tiotropium Respimat® versus placebo, mL
Adjusted mean difference a (95 % CI)
p value
n
  PrimoTinA-asthma® b MezzoTinA-asthma® c
  Tiotropium Respimat® 5 μg QD Tiotropium Respimat® 5 μg QD Tiotropium Respimat® 2.5 μg QD
Peak FEV1(0-3h) 137 (58, 216) 150 (81, 219) 199 (130, 268)
<0.001 <0.001 <0.001
n = 161 n = 140 n = 144
Trough FEV1 108 (37, 180) 119 (46, 192) 159 (87, 232)
0.003 0.001 <0.001
n = 161 n = 140 n = 144
FEV1 AUC(0-12h) 152 (69, 235) 151 (76, 226) 200 (126, 275)
<0.001 <0.001 <0.001
n = 159 n = 140 n = 144
FEV1 AUC(12-24h) 138 (58, 217) 144 (67, 221) 203 (126, 279)
<0.001 <0.001 <0.001
n = 159 n = 140 n = 144
FEV1 AUC(0-24h) 145 (65, 225) 147 (73, 222) 202 (128, 276)
<0.001 <0.001 <0.001
n = 159 n = 140 n = 144

Full analysis set with 24-h lung function test measurements

aAdjusted for treatment, center, visit, visit-by-treatment, baseline, and baseline-by-visit; bPooled data; Week 24; add-on to high-dose ICS plus a long-acting β2-agonist; cPooled data; Week 24; add-on to medium-dose ICS

AUC, area under the curve; CI, confidence interval; QD, once-daily; SE, standard error

30-DAY POTENTIALLY AVOIDABLE READMISSIONS DUE TO ADVERSE DRUG EVENTS IN MEDICAL PATIENTS Olivia Dalleur1, 4; Patrick E. Beeler1, 3; Jeffrey L. Schnipper1; Jacques Donze 2, 1. 1Brigham and Women, Boston, MA; 2Bern University Hospital, Bern, Switzerland; 3Zurich University Hospital, Zurich, Switzerland; 4Universite Catholique de Louvain, Brussels, Belgium. (Tracking ID #2194243)

BACKGROUND: Adverse drug events occurring after hospital discharge are an important reason for readmissions within 30 days. However, these events need to be better characterized in order to find the most appropriate risk reduction interventions. The objective of this study was to describe instances of potentially avoidable readmissions due to adverse drug events in a medical population.

METHODS: In this nested case control study, we analyzed a random sample of 534 potentially avoidable 30-day readmissions from 10,275 consecutive discharges from the medical department of an academic medical center between July 1, 2009 and June 30, 2010. Potentially avoidable readmissions were determined using the previously validated SQLape algorithm. Medical records were independently reviewed by 9 trained physicians to identify those readmissions due to adverse drug events. Instances of over-prescribing (use of a drug without a valid indication), mis-prescribing (valid indication, but inappropriate duration, dose, choice of active agent, costs, interactions, or route of administration), under-prescribing (lack of a required drug given the previously known conditions of the patient), and other potential causes of adverse drug events were identified.

RESULTS: Among 534 cases of 30-day potentially avoidable readmissions reviewed, 80 (15 %) were partially or predominantly due to an adverse drug event. The drug classes that were the most frequently involved were: antineoplastic agents (n = 14, 18 %), loop diuretics (n = 13, 16 %), analgesics (n = 11, 14 %), antibacterials for systemic use (n = 8, 10 %) and antithrombotic agents (n = 7, 9 %). Over-prescribing of drugs occurred in 9 % (n = 7) of cases, mainly due to altered mental status on analgesics (n = 3) and dehydration on diuretics (n = 2). Mis-prescribing was identified in 24 % (n = 19) of cases, mainly due to hypotension and acute renal failure on diuretics and antihypertensives (n = 8), bleeding on overdosed or poorly monitored antithrombotics (n = 3) and hypoglycemia on insulin (n = 3). Under-prescribing involved 10 % (n = 8) of the cases, most notably readmissions due to uncontrolled pain (analgesics, n = 3) and volume overload and heart failure (lacking sufficient dosing of diuretics, n = 2). The other 45 % (n = 36) were cases where the adverse drug event was related to other factors, such as compliance issues (n = 6).

CONCLUSIONS: Common drugs, such as analgesics and diuretics, were frequently involved in over-, mis- or under-prescribing, leading to adverse drug events that contributed to readmissions. Those drugs could be targets for interventions to prevent readmissions.

A DIAGNOSTIC SCORE FOR INSULIN RESISTANCE IN NON-DIABETIC PATIENTS WITH ISCHEMIC STROKE OR TRANSIENT ISCHEMIC ATTACK Jin Xu; Catherine Viscoli; Walter N. Kernan. Yale School of Medicine, New Haven, CT. (Tracking ID #2184927)

BACKGROUND: Insulin resistance is associated with increased risk of progression from prediabetes to diabetes, cardiovascular disease, and ischemic stroke. Despite the known public health impact of insulin resistance, identification of non-diabetic patients with this condition remains challenging. Currently available methods are expensive, time consuming, or rely on fasting insulin measurements, which are not standardized across laboratory platforms. We sought to develop a simple, reliable instrument, not relying on fasting insulin, to screen for insulin resistance in patients with a recent ischemic stroke or transient ischemic attack (TIA).

METHODS: Subjects were non-diabetic men and women with ischemic strokes or TIA within the past six months, over age 40 years of age, and enrolled in the Insulin Resistance Intervention after Stroke (IRIS) trial. The 7262 subjects were randomly divided (60–40 %) into development and validation cohorts. In the development cohort, clinical features were analyzed in bivariate analysis for their association with insulin resistance as measured by the homeostasis model assessment for insulin resistance (HOMA-IR). Abdominal obesity was defined as waist circumference >88 cm in women and >102 cm in men. Body mass index (BMI = kg/m2) was classified as <25, 25–29, 30–35, and >35. Elevated waist-hip (WTH) ratio was classified as >0.9 in men and >0.85 in women. Elevated systolic blood pressure (SBP) was defined as > 130 mm Hg. Features that were significantly associated with HOMA-IR (p < 0.05) were entered into a multivariable analysis. We used the magnitude of regression coefficients from the multivariable model to assign point values for a diagnostic scoring instrument. The performance of the instrument was then tested in the validation set using receiver operator characteristic (ROC) analysis.

RESULTS: Four features were retained in the multivariable regression analysis: BMI (25–29 kg/m2, 1 point; 30–35 kg/m2, 2 points; >35 kg/m2, 4 points), abdominal obesity (1 point), fasting glucose >100 mg/dL (4 points), and triglyceride-HDL ratio (1.6–2.3, 1 point; 2.4–3.5, 2 points; >3.6, 4 points). Points for each feature were summed to yield a total score between 0 and 13, with increasing score predicting increasing degrees of insulin resistance. The area under the curve (aROC) for prediction of HOMA-IR >3 (our criterion for insulin resistance) was 0.77 in the development cohort and 0.78 in the validation cohort. A score of three had sensitivity and specificity of 85 and 50 %, respectively, in the development cohort, and 86 and 53 %, respectively, in the validation cohort, for the prediction of HOMA-IR >3. A score of seven had 91 % specificity but 44 % sensitivity for predicting HOMA-IR >3 in the development cohort, with similar performance in the validation cohort.

CONCLUSIONS: We have developed a simple, easy-to-use instrument for diagnosing insulin resistance in patients with a recent ischemic stroke or TIA. A score of three provided high sensitivity and moderate specificity. Use of a higher score as cutoff for insulin resistance would reduce unnecessary confirmatory testing but with lower sensitivity. Our instrument may assist clinicians in rapidly identifying candidates for further metabolic testing or direct referral for lifestyle counseling to prevent future adverse events including diabetes, coronary disease, and ischemic stroke.

A Health Literacy Assessment of Hospitalized Adult Patients and Written Discharge Instructions Marina Arvanitis 5; Alex Gertner2; Mona Xiao2; Eric Allman5; John Stephens1; Edmund A. Liles4; Arlene E. Chung6; Daniel Jonas3; Darren A. DeWalt2. 1UNC Hospitals, Chapel Hill, NC; 2University of North Carolina, Chapel Hill, NC; 3University of North Carolina Chapel Hill, Chapel Hill, NC; 4University of North Carolina School of Medicine, Chapel Hill, NC; 5University of North Carolina at Chapel Hill, Chapel Hill, NC; 6University of North Carolina at Chapel Hill School of Medicine, Durham, NC. (Tracking ID #2200361)

BACKGROUND: One in five Medicare recipients is readmitted to the hospital within 30-days of discharge and excess hospital readmissions also occur to varying degrees in patients of all ages, especially those with certain high-risk diagnoses3 or health disparities, such as low health literacy. Written discharge instructions (DCI) are documents that patients must receive at the time of hospital discharge, ideally to summarize, clarify, and reinforce the important health information that patients need to maintain their health and avoid readmission. DCI are typically standard templates from electronic health record companies, which are often missing key instructions and not in lay-language. Attempts to standardize DCI content have shown inconsistent effects on patient comprehension, health outcomes, and readmission rates. As an initial step to improving the DCI we utilize at UNC Hospital, we aimed to assess the health literacy and associated characteristics of patients admitted to our General Internal Medicine services, as well as the readability, understandability and use of the DCI they receive.

METHODS: In this cross-sectional study at University of North Carolina Memorial Hospital, we recruited patients who were discharged from General Internal Medicine hospital services between June 23 and August 15, 2014. All adult patients who were being discharged to home after an unplanned admission, were acting as their own medical decision maker, had adequate vision to complete paper questionnaires, and were willing to receive a telephone call from a researcher after discharge were eligible to participate. We approached patients in their hospital room within 24 h of discharge, at which time the patient completed questionnaires of basic demographic information, a Short-Test of Functional Health Literacy (S-TOFHLA), a clock-draw test, and questionnaires of patient-reported physical and mental health, instrumental support, subjective socioeconomic status, and self-efficacy. We then made three attempts to contact the patient by telephone 5 to 14 days after discharge to assess their use and understanding of DCI. Two independent reviewers then systematically assessed the DCI reading level by Flesch-Kincaid and SMOG formulas and understandability by the Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P). We used descriptive statistics and bivariate comparisons to assess patient and DCI characteristics.

RESULTS: Of 122 eligible patients, 55 participated in the study. The average participating patient age was 54, 48 % were female, 51 % reported their race as Caucasian and 40 % African-American. Nineteen percent of participants reported their highest level of educational completion as grade school, 28 % high school and 53 % some or more college. One-third of patients were Medicare recipients and 74 % reported having a primary care provider. Fifty one percent of patients reported having been admitted to a hospital on at least one other occasion within the last year, with a mean of 1.8 admissions and a range from one to 12. According to a health literacy assessment with the S-TOFHLA within 24 h of discharge, 61 % of patients had adequate, 11 % marginal and 28 % inadequate health literacy. According to a clock-draw test, which patients completed at the same time as the S-TOFHLA, 38 % of patients who were acting as their own medical decision maker, and therefore receiving their own discharge instructions, were cognitively impaired. Health literacy was correlated with cognition (p = 0.002) and education (p = 0.05), but not with patient-reported subjective socioeconomic status, self-efficacy, physical health, mental health or number of hospitalizations within the last year. The mean DCI length was 11 printed pages, with a range from 5 to 22. All DCI were found to be at a high school reading level with a mean grade level of 14 by Flesch-Kincaid and 15 by SMOG, with a range from approximately 10 to 17 by both formulas. Two independent reviewers systematically assessed DCI and found them all to be poorly understandable, with PEMAT-P understandability scores ranging from 0 to 46 % (scores less than 70 % suggest the written document is poorly understandable). Of the 55 participating patients, we were able to reach 29 (53 %) by telephone 5 to14 days after discharge. Of those, only 7 patients reported having their DCI available to reference at the time of the phone call, and only 6 patients reported reading their DCI after discharge.

CONCLUSIONS: The written DCI we provide to patients upon hospital discharge are long, written at a very high reading level, likely to be poorly understood, and are referenced by only a small percentage of patients after discharge. We should aim to create DCI templates that are better suited to the health literacy and cognitive status of patients at time of hospital discharge, and future research should focus on whether this will impact patient outcomes, including hospital readmission.

A HIGH NUMBER OF DAYS IN PAIN IS ASSOCIATED WITH MORE MISSED CLINIC VISITS AMONG HIV-POSITIVE WOMEN Stella Safo 3, 2; Chinazo Cunningham2, 3; Arthur E. Blank1, 3; E. Byrd Quinlivan6; Thomas Lincoln5; Oni J. Blackstock4, 3. 1Albert Einstein College of Medicine, Bronx, NY; 2Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, NY; 3Montefiore Medical Center, Bronx, NY; 4Montefiore Medical Center/AECOM, New York, NY; 5Baystate Medical Center and Tufts University School of Medicine, Springfield, MA; 6University of North Carolina at Chapel Hill, Chapel Hill, NC. (Tracking ID #2199321)

BACKGROUND: Pain is highly prevalent among HIV-positive persons due to HIV infection itself and to other co-morbid conditions. Missed clinic visits is a widely used measure of retention in HIV medical care; poor retention care is associated with a lower likelihood of receiving antitretrovirals, a higher rate of antiretroviral failure, and worse survival. However, little is known about the relationship between pain and missed clinic visits, particularly among women. Therefore, using a multi-site cohort of HIV-positive women, we examined the relationship between pain and missed clinic visits.

METHODS: HRSA’s Enhancing Access and Quality in HIV care for Women of Color Initiative was a longitudinal study of 921 HIV-positive women with varying levels of engagement in HIV medical care that took place at 9 community-based organizations and clinics in high HIV prevalence areas throughout the U.S. From 2010 to 2013, study staff conducted baseline interviews, which collected data on socio-demographic, risk behavior and clinical characteristics. Participants were followed for at least 12 months after the baseline interview. Pain was our independent variable of interest and was measured using the CDC’s Healthy Days Symptoms Module; the module asks about the number of days in pain (“pain days”) in the previous month. We categorized pain as: no pain days vs. low number of pain days (1–13 pain days) vs. high number of pain days (14–30 pain days), with 14 pain days being the median for those reporting ≥1 pain day. Our outcome variable was missed clinic visits during the 1-year period after the baseline interview. We assessed missed clinic visits by chart abstraction, and dichotomized our outcome as 0 or 1 missed visit vs. 2 or more missed visits. To examine the association between pain and missed clinic visits, we used multivariate logistic regression, adjusting for race, age, substance use, frequency of depressive symptoms, high-risk sexual behavior, insurance coverage, housing status, and antiretroviral use.

RESULTS: At baseline, median age was 42 years; 25.7 % were Hispanic and 68.6 % non-Hispanic black; 35.8 % reported high-risk sexual behavior and 13.1 % current high-risk substance use; 35.2 % reported frequent depressive symptoms; and 48.3 % reported taking antiretrovirals. In the previous month, 52 % of women reported no pain days, 23.7 % a low number of pain days, and 24.1 % a high number of pain days. Compared to women with no pain days, those with a high number of pain days were more likely to miss 2 or more clinic visits during the year (AOR = 1.57, 95 % CI: 1.05–2.35). There was no significant difference in missed visits between those with no pain days and those with a low number of pain days (AOR = 0.82, 95 % CI: 0.56–1.21).

CONCLUSIONS: Compared to HIV-positive women with no days in pain in the previous month, those with a high number of days in pain at baseline were more likely to miss visits during 1-year of follow-up. Women who experience more days of pain may represent an especially vulnerable group at risk for poor clinical outcomes. A better understanding of how pain may impact retention in care could guide efforts to improve retention in care of HIV-positive women.

A LONGITUDINAL ASSESSMENT OF DEPRESSIVE SYMPTOMS DURING INTERNAL MEDICINE RESIDENCY Mariah A. Quinn 1; Lingling Li4; Holly G. Prigerson3; Steven R. Simon2. 1University of Wisconsin, Middleton, WI; 2VA Boston Healthcare System, Boston, MA; 3Weill Cornell Medical College, New York City, NY; 4Harvard Pilgrim HealthCare Institute, Boston, MA. (Tracking ID #2196024)

BACKGROUND: Physicians experience considerable stress during residency training. Depressive symptoms, which are correlated with burnout and errors, occur frequently among housestaff. Relatively little is known about the frequency of depression among housestaff since the implementation of work-hour restrictions; there is a paucity of longitudinal data regarding mood disturbance during residency. We undertook this study to assess the period prevalence of probable depression among a single cohort of Internal Medicine residents at a large training program.

METHODS: In 2006, we invited all Internal Medicine interns (N = 73) at Brigham and Women’s Hospital, Massachusetts, to complete an anonymous questionnaire assessing symptoms of depression, help-seeking, and use of time off work. We administered follow-up surveys throughout the subsequent 2 years of their training (N = 55, after preliminary interns left the program prior to the second post-graduate year). The main outcome measure was the proportion of residents experiencing probable Major Depressive Disorder (MDD) during each year of training. Because of missing data, estimates of the cumulative incidence of probable depression were made based on complete cases, a conservative approach in which missing data was assumed to be a non-depressed, and Multiple Imputation.

RESULTS: Fifty-three individuals completed the survey during internship (response rate = 74 %), of whom 38 completed at least one survey during the second or third year of residency (response rate over 2 years = 69 %). Missing data did not vary by sex, age, prevalent depression, prior mental health care, or anti-depressant use at baseline (all p > 0.05): a history of mental health care was associated with response to all surveys (p = 0.008). Estimates of the period prevalence of probable MDD during internship were 35 % (95 % confidence interval [CI] [23, 49]) using a complete cases approach, 12 % (95 % CI [3, 20]) using a conservative estimation, and 21 % (95 % CI [0, 84]) using multiple imputation. When 3 years of longitudinal data were considered, the proportion of residents with at least one episode of probable MDD was 63 % (95 % CI [48, 79]) using the complete case approach, 36 % (95 % CI [22, 52]) by the conservative estimation approach, and 60 % (95 % CI [44, 73) by multiple imputation. Prior receipt of mental health services and past history of personal diagnoses predicted being depressed at baseline, but not later in residency. Sadness was commonly reported, declining from 64 % during internship to 55 % during the third year, while adhedonia was prevalent but less so, declining from 38 % of respondents at the first time point to 19 % at the final time point. Active suicidal thinking was reported rarely (1 respondent); while passive suicidal thinking was reported at all time points except one (range 4–11 %). Over the course of the 3 years of residency, a total of 28 % of respondents reported that they utilized mental health services, while 8 % reported taking time off work for emotional issues.

CONCLUSIONS: Probable depression is common during internal medicine residency. More than 25 % of housestaff sought help for mental health symptoms. Rates of depression among housestaff remain high since the initiation of work hour’s limitations. Given the possible consequences of depression among house officers, program directors and policy makers need to explore how programs for mental health screening and treatment can be effectively incorporated in residency training programs.

A LOOK INSIDE COMMUNITY HEALTH WORKERS’ VISITS: A QUALITATIVE STUDY Julie B. Silverman 2; Jim Krieger3; Karin M. Nelson1. 1University of Washington, VA Puget Sound, Seattle, WA; 2VA Puget Sound, Seattle, WA; 3Action for Healthy Food, Seattle, WA. (Tracking ID #2198635)

BACKGROUND: Utilization of community health workers (CHWs) shows promise in improving health outcomes and reducing disparities. However, incorporation of CHWs into the U.S. health care system has not been widely adopted. The reluctance to integrate CHWs into the health care team may be due in part to unfamiliarity with CHWs and their role within the medical team. While there is extensive literature on CHWs, these studies typically focus on the effectiveness of interventions and do not consider the skills and services of CHWs. CHWs are broadly described as educators, navigators, and promoters of healthy behaviors. However, the specifics of what they do remain unclear to the larger health care community. The purpose of this qualitative study is to describe the issues that CHWs confront and the actions they perform to help their clients.

METHODS: We performed a retrospective qualitative analysis of the open-text responses on encounter forms completed by CHWs in the Peer Support for Achieving Independence in Diabetes (Peer AID) study. This randomized controlled trial tested the effectiveness of a home-visit diabetes self-management support program for low-income individuals with poorly controlled diabetes. Participants were randomized to home visits by CHWs or to usual care. The CHWs were paid employees of Public Health - Seattle King County. After each home visit, the CHW filled out an encounter form documenting the health goal of the visit, the self-management strategies discussed and any participant concerns. Using ATLAS.ti, we performed inductive content analysis of the CHW encounter notes.

RESULTS: One hundred forty-five participants were randomized to the CHW intervention, resulting in a total of 634 encounter reports. CHW notes revealed large gaps in patient understanding of diabetes and diabetes self-management, including how to check sugar levels, what constitutes a healthy diet and the importance of taking medications as prescribed. To address these gaps, the CHWs taught participants how to read food labels, cooked and shared recipes, fixed glucose meters, explained the purpose and mechanism of each medication, and more. The encounter forms further revealed that despite appropriate education and the desire to manage their diabetes more effectively, participants faced significant obstacles—such as the unaffordability of test strips or receipt of unhealthy foods from the food bank—to achieving optimal glycemic control. CHWs connected participants to community gardens, accompanied them to the grocery store to teach them how to find affordable and healthy foods, and helped fill out applications for discounted prescriptions. Visits with participants often uncovered frustration with and/or miscommunication between participants and their primary care providers (PCPs). The CHWs helped clarify the misunderstandings and coached participants on effective communications skills. In addition to these services, CHWs frequently called participants to check in regarding progress on their goals and to address any new questions or concerns.

CONCLUSIONS: CHWs may be able to provide services that are generally outside the scope of a primary care practice, such as connecting them to food banks and conducting grocery store tours. They also have the time to provide more thorough education that may not be possible in a 15-min PCP visit. CHWs may provide a valuable link between low-income patients and their providers.

A MULTICENTER RANDOMIZED TRIAL OF PHYSICIAN, PATIENT, AND PHYSICIAN/PATIENT INCENTIVES TO IMPROVE LIPID MANAGEMENT David A. Asch 2, 4; Andrea B. Troxel3; Walter F. Stewart6; Thomas D. Sequist1; JB Jones6; Annemarie G. Hirsch7; Karen Hoffer2; Jingsan Zhu3; Wenli Wang2; Amanda T. Hodlofski3; Antonette B. Frasch2; Mark G. Weiner8; Darra D. Finnerty2; Meredith Rosenthal5; Kelsey Gangemi3; Kevin G. Volpp3, 4. 1Partners Healthcare System, Boston, MA; 2University of Pennsylvania, Philadelphila, PA; 3University of Pennsylvania, Philadelphia, PA; 4Philadelphia VA Medical Center, Philadelphia, PA; 5Harvard School of Public Health, Boston, MA; 6Sutter Health, San Francisco, CA; 7Geisinger Health System, Danville, PA; 8Temple University Health System, Philadelphia, PA. (Tracking ID #2200183)

BACKGROUND: Pay for Performance programs that provide financial incentives to physicians for improved patient outcomes are widespread and increasing, though their prospective evaluation has been limited. Programs that provide financial incentives to patients for improved patient outcomes are similarly increasing, and their prospective evaluation has also been limited. At the same time, a growing literature suggests that traditional financial incentives might be made more effective if insights from behavioral economics were incorporated. In this large multicenter trial, we tested behavioral economic designs for physician and patient pay for performance in the management of hyperlipidemia.

METHODS: We enrolled 1503 patients nested within 238 primary care physicians (PCPs) in a multicenter, cluster-randomized trial comparing four alternative approaches to reduce LDL cholesterol among patients with high cardiovascular risk or established cardiovascular disease. PCPs were randomly assigned to one of four study arms: physician incentives (PHYS), patient incentives (PAT), shared physician-patient incentives (SHARE), or control (CNTRL). PCPs in PHYS accrued quarterly payments of $256 for each enrolled patient meeting a quarterly LDL goal of a 10 point reduction from the prior quarter or being at guideline (maximum 12-month payment = $1024 per enrolled patient). Patients in PAT could accrue up to the same amount for meeting quarterly LDL goals, distributed through a daily ‘regret lottery.’ The lottery encouraged medication adherence but payouts were conditioned on reaching quarterly LDL goals as described. PCPs and patients in SHARE shared those possible financial incentives--each eligible for up to half of the yearly maximum of $1024. PCPs and patients in CNTRL received no financial incentives, but did receive the same electronic pill bottles as the other arms used for monitoring adherence. The primary outcome was mean change in LDL at 12 months.

RESULTS: Patients in SHARE achieved the largest reductions in LDL (36.8 mg/dl), followed by patients in PHYS (30.0), CNTRL (26.6), and PAT (26.4). The rankings of these arms persisted at each quarterly measurement, including 3 months following the cessation of the intervention. Only patients in SHARE achieved a reduction in LDL statistically different from those in CNTRL (9.8; 95 % CI: 4.3–15.3, P < 0.001). Patients in SHARE also achieved LDL reductions significantly different from PAT (10.1, CI: 4.7–15.5, p < 0.001) and PHYS (6.7, CI: 1.6–11.8, p = 0.010). No other pairwise comparisons were statistically significant. At 12 months, 49 % of patients in SHARE had achieved their LDL goal compared to 40 % in PHYS, 40 % in PAT, and 36 % in C (p = 0.027). At 15 months, 3 months after all incentives had stopped, reassessment of LDL values showed essentially no change from 12 months.

CONCLUSIONS: This study simultaneously represents one of the largest prospective trials of pay for performance for physicians and for patients, and the only trial to have tested a shared incentive between patients and physicians. While the control condition in this study itself reflected an enhancement over usual care, we found that neither substantial payments to physicians nor substantial payments to patients offer incremental benefits in LDL reduction compared to this control when used alone. However, the study demonstrates superior results when such payments are shared between physicians and patients.

A MULTIVARIABLE STATISTICAL MODEL OF RISK FACTORS FOR HYPOGLYCEMIA IN DIABETES MELLITUS Michael Weiner 1, 2; Zuoyi Zhang2; Larry Radican3; Jon Duke2, 1; Xiaochun Li1; Jarod Baker2; Kimberly Brodovicz3; Karen Kurtyka3; Jeff Stroup2; Ramachandra G. Naik3; Jeremy Leventhal2; Arnaub Chatterjee3; Samuel Engel3; Swapnil Rajpathak3; Paige DeChant2; Shengsheng Yu3. 1Indiana University, Indianapolis, IN; 2Regenstrief Institute, Inc., Indianapolis, IN; 3Merck & Co., Inc., Kenilworth, NJ. (Tracking ID #2199146)

BACKGROUND: Approximately 346 million people globally have diabetes mellitus. Although treatment improves outcomes, hypoglycemia (HG) from treatment or patient-related factors is dangerous and occurs in more than a third of patients with diabetes. Although risk factors for HG have been identified, no recent reports identified relative risks of multiple factors in comprehensive models. Our objective was to test multiple established risk factors in a multivariable statistical model, to determine the magnitude of independent association between the factors and HG. We hypothesized that older age, non-long-acting insulin, and sulfonylurea (SU) drugs would pose significant risk.

METHODS: We reviewed medical literature to identify studies that reported risk factors for HG in diabetes. We studied an urban population in a tax-supported medical institution on an academic medical campus. The study period was 2004 to 2013. Eligible patients were at least 21 years of age on 01 January 2004 and were prescribed or dispensed a drug for diabetes mellitus during the study period. An index date was defined as the first HG event for a patient during the study period. For patients who did not experience a HG event, their index date was a randomly selected visit date during the study period. The baseline period was defined as the 2 years prior to the index date. We excluded patients with a diagnosis of abnormal glucose tolerance complicating pregnancy or childbirth, and patients with fewer than two clinical encounters on separate dates during the baseline period. From a health information exchange in which the target institution participates, we extracted data about risk factors and demographics, from medical records of patients seen at the institution during the study period. Using this retrospective cohort, we conducted multivariable logistic regression analysis, with HG as the primary outcome. HG was defined as an outpatient plasma glucose value of less than 70 mg/dL (3.9 mmol/L), identified through laboratory reports, previously validated International Classification of Diseases diagnosis codes, or narrative text that underwent natural language processing (NLP). Significance was defined by a p-value of less than or equal to 0.05.

RESULTS: The cohort had 38,780 patients with the following characteristics: mean age of 56 years, 56 % female, 33 % white, 34 % African-American, 19 % with Medicaid, and 39 % uninsured. HG was identified in 7589 (20 %) of them. Of these, NLP identified HG in 5488, with 1566 identified only by NLP. In logistic regression, positive risk factors included the following: eating disorder (OR 30.5; 95 % CI 1.6, 582.9), infection within 30 days (2.5; 2.2, 2.8), insulin other than long-acting insulin (without SU drug, 2.3; 2.1, 2.6; with SU within 90 days, 1.6; 1.3, 1.9; vs. non-insulin and non-SU), previous hypoglycemia within 12 months (2.2; 1.8, 2.7), African-American (1.8; 1.6, 1.9; vs. white), diabetic neuropathy (1.6; 1.4, 1.8), Medicaid (1.5; 1.4, 1.6), alcohol (1.4; 1.2, 1.7), chronic heart failure (1.4; 1.2, 1.6), without antibiotics (1.3; 1.1, 1.5), antibiotics with SU (1.3; 1.0, 1.8), dementia or falls (1.3; 1.2, 1.5), and A1C 6.5 or less (1.1; 1.0, 1.3; vs. greater than 6.5 to less than 7.0). Negative risk factors included serum calcium mg/dL (OR 0.5; 95 % CI 0.5, 0.5), age 85 years or more (0.6; 0.5, 0.8; vs. 45 to 64), long-acting insulin plus a SU within 90 days (0.6; 0.5, 0.8), Hispanic (0.6; 0.5, 0.8), and age 75 to 84 years (0.9; 0.8, 1.0).

CONCLUSIONS: HG was common in this population. NLP was a useful tool, uniquely identifying 21 % (1566/7589) of the HG group. Many risk factors for HG were identified, including modifiable factors such as eating disorders, infections, and drugs. Insulin other than long-acting insulin, and SU drugs, were confirmed as important risks. Surprisingly, the oldest ages (age 75 years or more) posed less risk; this may reflect diminished awareness of hypoglycemia, greater attention to medical management, or other unmeasured factors in this population. Results suggest that tight diabetes control (A1C of 6.5 or less) poses greater risk of HG. These results can be used to develop decision support tools for primary care clinicians at the point of care.

A NARRATIVE REVIEW OF MEDICATION-RELATED CLINICAL DECISION SUPPORT Clare L. Brown1; Sarah P. Slight 2; Andrew K. Husband2; Neil W. Watson4; David W. Bates3. 1University of Durham, Sunderland, United Kingdom; 2Durham University, Stockton on Tees, United Kingdom; 3Brigham and Women, Boston, MA; 4Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom. (Tracking ID #2193237)

BACKGROUND: Medication errors cause substantial patient harm and can occur at any stage of the medication use process. Health information technology, such as Computerized Physician Order Entry (CPOE) and Clinical Decision Support (CDS), may be used to reduce the likelihood of these errors. Medication-related CDS provides automated guidance and support to clinicians at the point of prescribing. CDS can provide drug-drug interaction (DDI) checks, drug allergy checks, dosing guidance, duplicate therapy checks and formulary decision support. CDS has been associated with a range of benefits such as improved patient safety, improved standards of care and reduction in healthcare costs. We reviewed the recent literature around medication-related CDS functionality and reflected upon the issues pertinent to its future development.

METHODS: We searched for papers in Medline Ovid and Embase Ovid, using MeSH terms and key words including ‘clinical decision support’, ‘decision support systems’ and ‘computerized physician order entry’ with a date range of 2007 to 2014. Specific MeSH terms and keywords relevant to five basic CDS functionalities were also used. We included all publication types, all types of CPOE systems and all clinical settings. Only English language papers were selected for further review. Reference lists, papers from world leading experts and the ‘other citing articles’ function were also used to identify additional articles. Titles and abstracts were initially screened to identify relevant papers, followed by the full text by one reviewer. A total of 896 articles were identified across each of the five areas, of which 184 were included.

RESULTS: The success of CDS very much depends on users finding alerts valuable and acting on the information received. CDS functionality is continually evolving in response to users’ needs. Assigning a severity level to DDI alerts has been shown to improve alert acceptance. Additionally, improving alert specificity and severity was found to be an important factor for realising the benefits of DDI alerts. Maintenance of accurate records and ability to carry out cross-sensitivity checks are key to the production of appropriate drug-allergy checks. Patient specific parameters should be incorporated into the decision-making algorithms to improve the accuracy and appropriateness of drug-dosage alerts; furthermore, suggested doses should be appropriately rounded to facilitate administration and include order sentences sequenced to reflect those most commonly used. How the CDS system is configured is important for drug-duplication checks and to avoid potentially exposing the patient to toxic drug levels. The knowledge base(s) for drug-formulary alerts must be accurate and reviewed regularly in order to produce relevant alerts and encourage formulary adherence. Finally, consideration of human factors principles during the design and implementation of CDS is critical and has been shown to improve system effectiveness.

CONCLUSIONS: CDS is still undergoing development. The implementation of automation in healthcare has surged in recent years and this is likely to continue. Moving forward, integration of patient specific parameters into CDS decision-making checks and consideration of human-factors design principles will be central to obtaining the potential benefits of CDS. Such advancements in CDS should enable it to have a much greater impact for improving patient care.

A PALLIATIVE NURSE PRACTITIONER INTERVENTION TO IMPROVE ADVANCE CARE PLANNING AND SUPPORTIVE CARE IN PATIENTS WITH ADVANCED CANCER Anne Walling 2; Sarah F. D’Ambruoso2; Sara Hurvitz2; Robin Clarke1; Andrew Hackbarth1; Christopher Pietras2; Neil Wenger3. 1UCLA, Los Angeles, CA; 2UCLA, Studio City, CA; 3University of California, Los Angeles, Los Angeles, CA. (Tracking ID #2199225)

BACKGROUND: The simultaneous care model for palliative care provides high quality care for patients with serious illness. Unfortunately, the U.S. healthcare system falls short of this goal, even in patients with advanced cancer. As the first phase of a system-wide advance care planning program, we used implementation science methods to test if a nurse practitioner (NP) with structured palliative care training using evidence-based principles of communication and a model that cultivates prognostic awareness with palliative care physician oversight can improve the quality of advance care planning and supportive care provided to patients with advanced cancer in an academic health system.

METHODS: Patients with advanced cancer were identified from the electronic health record (EHR) based on oncology visits and treatments and using free text analysis of oncology notes and imaging. An NP was integrated into the clinic of two oncologists who treated primarily breast cancer with the goal of seeing patients with incurable disease soon after presentation and then following patients in continuity. The oncologist documented prognosis and provided a warm handoff in referring the patient to the NP. Based on standardized assessments administered by the NP, patients were linked into resources for psychosocial support and symptoms were addressed. The NP focused on goals of care and valued future health states in advance care planning, which was documented in a Goals of care note in the EHR. The intervention was evaluated using EHR data to compare rates of advance care planning documented in Goals of care notes and hospice referral among decedents for patients with advanced cancer seen by the two target oncologists compared to all other advance cancer patients in clinics without the NP intervention.

RESULTS: Of 10,228 patients with active cancer, 2535 patients had advanced cancer and were treated by 39 oncologists. Advance care planning as represented by EHR Goals of care notes increased for patients of the two intervention oncologists compared to patients of the other oncologists as seen in the run chart in the Figure. Hospice referral before death was not different between the two groups at baseline, but was significantly higher for patients of intervention oncologists compared to patients of control oncologists (50 % v. 19 %, p = 0.03) over the 9 months of follow up.

CONCLUSIONS: This embedded NP-based model of advance care planning and palliative care delivery within an oncology clinic improves advance care planning and early results suggest better end of life care as evidenced by hospice enrollment.

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A PATIENT-CENTERED APPROACH TO IMPROVING DISCHARGE INSTRUCTIONS David S. Pilkington 3; Jessica R. Howard-Anderson3; Rachel Brook3; Ashley Busuttil1; Nasim Afsarmanesh2. 1UCLA, Los Angeles, CA; 2UCLA Health, Pacific Palisades, CA; 3University of California, Los Angeles, Los Angeles, CA. (Tracking ID #2199487)

BACKGROUND: The transition from hospital to home is a crucial time in a patient’s hospitalization as the inpatient team aims to create a seamless transfer to the ambulatory providers. Patient comprehension of their post discharge care is critical for ensuring patient safety and wellness after a hospital discharge. With the advent of the electronic health record (EHR), more hospitals use templates and auto-populated discharge instructions. Studies have been done evaluating the EHR’s affect on resident documentation - including their tendency to promote automaticity instead of creative clinical thinking. However, interestingly, patient satisfaction with and comprehension of EHR derived discharge instructions has not been robustly evaluated. The goal of our study was to use a patient-centered approach to evaluate patients’ knowledge of and satisfaction with the new EHR generated discharge instructions.

METHODS: Over a 3-month period (07/02/2014–09/24/2014), we conducted structured phone interviews of all patients discharged within 3 weeks from the general internal medicine teams at a tertiary academic medical center. We excluded patients who were discharged to nursing facilities or hospice, or did not speak English. The interview script asked patients if they could clearly identify key pieces of information on their discharge paperwork including medications, follow-up appointments, expected symptoms, and contact phone numbers. Additionally patients were asked questions regarding comprehension of their medication regimen and details regarding follow-up appointments. Lastly, using a 1–10 numeric scale, patients were asked to rate their satisfaction with the discharge process.

RESULTS: Of the 235 eligible patients contacted, 47 patients were successfully interviewed (20 %); 135 patients (57 %) were unable to be reached, 46 patients refused (20 %) and 7 patients (3 %) did not read the discharge paperwork. Overall patients reported being able to identify their medication regimens, and understand changes in dosages and indications for specific treatments greater than 90 % of the time. One-hundred percent of patients reported that they could identify their scheduled follow-up appointments on the discharge paperwork. However only 76 % reported that they were aware of scheduled or to-be scheduled follow up appointments on discharge. Most notably, 13 % of patients could not identify warning symptoms to be aware of on discharge, and 33 % of patients were unaware of routine symptoms to expect after discharge. Lastly, 13 % of patients could not locate any emergency contact information for a physician on the discharge paperwork. Overall satisfaction with the discharge paperwork was 8.8 [SD 1.4] on a scale of 1–10.

CONCLUSIONS: While patient satisfaction was overall adequate with our discharge instructions, these interviews identified important gaps in our discharge practices that may hinder our patients’ ability to fully understand their post-discharge care. For example, our institution has infrastructures in place to schedule 100 % of patients with follow-up appointments. However only 76 % of patients interviewed stated that they were scheduled for follow up appointments, or knew follow-up appointments would be scheduled for them. This discrepancy existed despite patients reporting being able to identify the post-discharge appointment section of the discharge paperwork. We think this discrepancy occurred because in our discharge instructions, follow up appointments needing to be scheduled (i.e. not secured prior to patient discharge) are located in a different place than the already scheduled appointments, thereby causing significant confusing. While this problem is specific to our institution, it provides a nice example of an area for intervention that we would have never known about had we not interviewed patients themselves. In addition, there was a significant percentage of patients who expressed confusion over both warning symptoms and expected symptoms post-discharge. Lastly, patients also described difficulty finding information on who to call if they had concerns when at home, after discharge. Both being aware of routine recovery symptoms, as well as knowing how to proceed if a question arises at home, can reduce patient anxiety on discharge and possibly prevent readmissions. Future steps will involve revising our institution’s discharge instructions to more clearly elucidate when follow-up appointments are made, as well as clarifying expectations for post-discharge care and recovery. As the nation continues to strive to improve patient safety while adapting EHRs, it will be imperative that patient insights continue to be considered and implemented in the care delivery process.

A PILOT STUDY EXAMINING HEALTH LITERACY PROMOTION PRACTICES AMONG HEALTHCARE PROFESSIONALS Allison Squires 1; Shonna Yin2; Sherry A. Greenberg1; Maryanne M. Giuliante1; Margaret V. McDonald3; Lisa Altshuler2; Tara Cortes1. 1New York University, New York, NY; 2NYU School of Medicine, New York, NY; 3Visiting Nurse Service of New York, New York, NY. (Tracking ID #2198606)

BACKGROUND: As health services delivery becomes more interprofessional it is important to understand how different professionals address health literacy with their clients. Practice differences related to health literacy contribute to health disparities and patient outcomes. The purpose of this study was to pilot test a series of questions that assess health literacy promotion practices in a cohort of nurses, physicians, and social workers. It was hypothesized that health literacy-informed practices are an important way to promote interprofessional collaboration and avoid duplication of work and at the same time allow for reinforcement of important patient education content, enhancing patient self-management.

METHODS: The previously non-validated 17 questions were derived from Schwartzberg and Turner’s (2007) list of practices promoting health literacy. We first completed an interprofessional content validation of the potential questions. Through the use of expert raters, as a pre-data collection step content validation evaluates questions for their relevance individually and as a group when measuring a phenomenon. Item and scale level scores result. Expert raters from medicine (n = 10), nursing (n = 8), and social work (n = 2) participated in the content validation process. Social work and nurse raters were grouped to create an even comparison since more social workers were not available for the exercise. A cross-sectional pilot study was then conducted as part of a larger survey aimed at evaluating perspectives on interprofessional practice. Participants rated the frequency with which they used the practices from 1 = never to 5 = always. Content validity scores of the questions were calculated using a modified kappa score. Trends in reported practices are described.

RESULTS: The scale content validity rating among physicians was 0.74 and among the nurse-social work cohort was 0.89. Each group of expert raters scored 3 items as fair or poor health literacy practice assessment measures, with only one low scoring item in common between the two groups. While data limitations around normalized distributions do not allow us to compare the means for significant differences, it appears that the relevance of certain practices around promoting health literacy in patients differ between groups. For the pilot test, 42 out of 53 eligible participants completed the health literacy assessment practices. Participants reported being most likely to use what they perceived as simple language to explain information to patients (4.05/5) and the use of models or drawing pictures as the least frequent strategy (2.73/5 and 2.9/5 respectively). All other responses ranged in the “sometimes” range between 3.02 and 3.93/5. While the sample is too small for comparison at this time, there do appear to be trends in practice differences between the professions in terms of which strategies they report using most.

CONCLUSIONS: Our data suggest that these questions designed to assess health professional’s reported health literacy promotion practices have potential in the study of outcomes of interprofessional patient care. The content validation exercise revealed early differences in perceived relevance of different practices by experts. We plan to further examine these trends as we accumulate a larger dataset from these groups.

A PILOT STUDY OF A DIABETES PREVENTION PROGRAM IN AN URBAN RESIDENCY PRACTICE Rose Coady; Catherine D. Agricola; Robert J. Fortuna; Brett Robbins. University of Rochester, Rochester, NY. (Tracking ID #2193959)

BACKGROUND: There are an estimated 54 million Americans who have pre-diabetes, many of whom will progress to type 2 diabetes (T2D) without intervention or lifestyle modifications. The Diabetes Prevention Program (DPP) is an intensive 22 week intervention involving both group and individual sessions. It has been studied in controlled trials and proven to be clinically and cost effective, but the DPP model has not been studied in a real-world setting. We examined its effectiveness in an inner city, residency primary care clinic environment.

METHODS: We modeled the Rochester Diabetes Prevention Program (R-DPP) after national DPP standards and the core principles of self-determination theory. We included patients with pre-diabetes (HgA1c 5.7–6.4 %) and those with morbid obesity regardless of the HgA1c. The goal of the program was to reduce the progression and development of T2D. We measured body mass index (BMI), weight measured in pounds (lbs), low-density lipoprotein (LDL), hemoglobin A1c (HgA1c), and exercise activity time measured in minutes per week (min/wk) before and after the intervention.

RESULTS: To date, 22 participants have completed R-DPP. The mean age of the cohort was 48 years with 77 % female, 72 % African American, and 45 % with public health insurance, primarily Medicare or Medicaid. Participants experienced a mean weight loss of 7 lbs (232 lbs to 225 lbs, p < 0.0001) and a decrease in BMI of 1.7 (38.8 to 37.1, p = 0.012). Self-reported exercise time increased by 68.4 min/week (40.6 min/week to 109 min/week). Participants also experienced a decrease in HgA1c (7.4 to 7.0 %, p = 0.093), total cholesterol (173 mg/dL to 165 mg/dL, p = 0.003), and LDL (93 mg/dL to 88 mg/dL, p = 0.023).

CONCLUSIONS: The R-DPP was an effectiveness pilot trial that reached an at-risk urban population in a resident clinic. It promoted positive behavior change leading to an increase in participants’ weekly exercise with significant weight loss and improvements in HgA1c, total cholesterol and LDL.

Average Measures Before and After the R-DPP
BMI (kg/m 2 ) Before R-DPP After R-DPP p value
Weight (lbs) 38.8 37.2 0.012
HgA1C (%) 232 226 <0.001
Total Cholesterol (mg/dL) 7.4 7.0 0.09
LDL (mg/dL) 173 166 <0.001
Exercise Time (min/week) 93 88 0.02

A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL OF A PRIMARY CARE-COMMUNITY LINKAGE FOR PREVENTING TYPE 2 DIABETES Ronald T. Ackermann 1; David T. Liss1; Emily Finch1; Laura Hays2; David G. Marrero3; Chandan Saha4. 1Northwestern University, Chicago, IL; 2Indiana University School of Nursing, Indianapolis, IN; 3Indiana University School of Medicine, Indianapolis, IN; 4Indiana University, Indianapolis, IN. (Tracking ID #2200110)

BACKGROUND: The U.S. Diabetes Prevention Program (DPP) showed that resource-intensive lifestyle interventions supporting daily physical activity and modest weight loss can cut the rate of developing type 2 diabetes in half. This randomized comparative effectiveness trial evaluated the weight loss effectiveness of a referral-based, ‘YMCA Model’ for offering the Diabetes Prevention Program (DPP) lifestyle intervention to adult primary care patients at high risk for developing type 2 diabetes.

METHODS: Five hundred nine overweight/obese, low-income, non-diabetic, adult primary care patients with elevated blood glucose were identified in 9 urban primary care settings and individually randomized to receive (1) standard care plus brief lifestyle counseling (SC); or (2) being offered a group-based adaption of the DPP delivered free-of-charge by the YMCA (YDPP). The primary outcome was mean difference in weight loss at 12 months. Intention-to-treat (ITT) analyses used longitudinal linear or logistic regression, with missing observations multiply imputed. Instrumental variables (IV) regression estimated weight loss effectiveness among participants completing ≥9 intervention lessons - a commonly cited threshold for high engagement in the DPP. Secondary outcomes included attendance in the referral-based intervention and changes in intermediate cardiometabolic risk factors across treatment arms.

RESULTS: At enrollment, participants had a mean age of 51, BMI 36.8 kg/m2, and HbA1c 6.0 %; 57 % reported African American race and 61.3 % reported annual household incomes < $25,000. In the YDPP arm, 161 (62.6 %) participants attended ≥1 lesson and 103 (40.0 %) completed ≥9 lessons. In ITT analysis, mean 12-month weight loss was 2.3 kg (95 % CI 1.1 to 3.4 kg) more for YDPP arm participants, compared to SC. In IV analyses, persons attending ≥9 lessons had a 5.3 kg (95 % CI, 2.8 to 7.9 kg) greater weight loss than without the intervention.

CONCLUSIONS: A ‘YMCA model’ for DPP delivery achieves meaningful weight losses at 12 months among low income adults. For every 5 high-risk primary care patients who were offered the intervention, about 1 additional person achieved and maintained ≥5 % weight loss after 12 months. This is the largest randomized intervention trial to date evaluating the uptake and weight loss effectiveness of community delivery of the DPP. It demonstrates that a primary care-community linkage is one promising approach for helping to slow the growing burden of type 2 diabetes in the U.S.

A RANDOMIZED CONTROL TRIAL OF OPT-IN VERSUS OPT-OUT ENROLLMENT INTO A DIABETES MANAGEMENT INTERVENTION Jaya Aysola 2; Andrea B. Troxel2; David A. Asch1; Emin Tahirovic2; Kelsey Gangemi1; Amanda T. Hodlofski1; Jingsan Zhu1; Kevin G. Volpp1. 1University of Pennsylvania, Philadelphila, PA; 2University of Pennsylvania, Philadelphia, PA. (Tracking ID #2199278)

BACKGROUND: Improving enrollment rates into research trials is central to ongoing efforts to maximize the external validity of research findings. This is particularly important for behavioral interventions, in which self selection in enrollment may be relevant in terms of intervention effectiveness. Opt-out defaults have been shown to influence decisions without restricting choice, but have primarily been tested in contexts that require a one-time decision such as retirement savings allocations or the release of childhood vaccination records. To examine the impact of an opt-out enrollment strategy for behavioral interventions, we conducted a randomized controlled trial comparing an opt-out recruitment strategy versus a conventional opt-in strategy on participation rates and adherence to a 6-month intervention for patients with poorly controlled diabetes.

METHODS: We recruited participants between November 2013 and March 2014 from two internal medicine primary care sites at the University of Pennsylvania Health System who met the following eligibility criteria: 1) age 18–80 years; 2) confirmed diagnosis of diabetes; and 3) a measured hemoglobin A1c greater than 8 % in the past 12 months. Eligible patients were randomized into opt-in and opt-out arms, using a 5:1 then 9:1 randomization ratio (opt-in versus opt-out). Participants in the opt-in arm received a letter inviting them to contact the study team if interested in enrolling in the study. Participants in the opt-out arm received a letter stating that they have been enrolled into a diabetes program being conducted at their practice and would be contacted within ten days to set up the initial appointment, at which point they could decline participation. Participants in both arms who agreed to participate received free wireless glucometers and blood pressure cuffs, automated messages regarding their glycemic control, ongoing support from nurse practitioners, and a lottery-based incentive tied to daily device use for the first 12 weeks of the study followed by a 12 week period of observation without incentives. Our primary outcomes were participation rate, defined as the proportion of enrollees invited to join the study via opt-in or opt-out who attended the baseline visit, and adherence to daily glycemic monitoring. We were powered to detect a difference of 20 % between arms in adherence to daily glycemic monitoring. As a secondary outcome we assessed attrition rates at 3 and 6 months.

RESULTS: Of the 569 eligible participants who received a recruitment letter, 496 were randomized to the opt-in arm and 73 to the opt-out arm. There were no differences in baseline characteristics between these groups. Participation rates were 13 % in the opt-in arm compared to 38 % in the opt-out arm (p value < 0.001). Of those who participated, 6 months attrition rates were 13 and 32 % in the opt-in and opt-out arms respectively (p value = 0.04). Amongst those who attended their 3-month visit, attrition rates at 6 months were similar (13 % opt in, 17 % opt out, p-value 0.72) There were significant but small differences between arms in the mean decline in adherence rates to glucometer usage during the first 12 weeks (opt-in vs. opt-out: −0.01 vs. −0.03; p-value =0.02) and the last 12 weeks (opt-in vs. opt-out: −0.02 vs. −0.008: p-value = 0.02).

CONCLUSIONS: Participation rates were threefold higher amongst patients recruited through an opt out default compared to a conventional opt-in approach with no significant compromise in adherence to the intervention at 6 months. This suggests that opt-out defaults, where clinically appropriate, could be a useful approach for increasing the external validity of trials testing behavioral interventions in clinical settings.

A RANDOMIZED CONTROLLED TRIAL EVALUATING THE EFFECT OF COMPASS (COLLEAGUES MEETING TO PROMOTE AND SUSTAIN SATISFACTION) SMALL GROUP SESSIONS ON PHYSICIAN WELL-BEING, MEANING, AND JOB SATISFACTION Colin P. West; Liselotte Dyrbye; Daniel Satele; Tait Shanafelt. Mayo Clinic, Rochester, MN. (Tracking ID #2199380)

BACKGROUND: Burnout and low job satisfaction are all too common among physicians. However, studies evaluating interventions to address these issues have been limited. Application of validated instruments has been uncommon, and prior studies have been largely observational. A recent randomized study of facilitated physician meetings (West CP et al., JAMA Intern Med 2014;174(4)527-33) demonstrated improvement in meaning and reduced depersonalization in the intervention arm, but it is unknown whether less intensive and less structured forms of this intervention would also be beneficial for physician well-being.

METHODS: We conducted a randomized controlled trial of a 6-month intervention involving 12 biweekly one-hour meetings of self-formed groups of 6–8 academic internal medicine physicians, termed COMPASS Groups (COlleagues Meeting to Promote And Sustain Satisfaction). Each intervention session consisted of a brief 15-min group discussion of an assigned topic relevant to the physician experience and drawn from prior physician well-being literature, followed by 45 min for a shared lunch or other group activity as determined by each group itself. Each participant received $20 per session for meal expenses. Control participants were wait-listed to complete their own small groups after the initial 6 months to ensure equity in study reimbursement opportunities. The small group topics included work-life balance, medical mistakes, meaning in work, and resiliency, among other topics relating to the physician experience. Participants completed surveys at baseline and then quarterly. Surveys included linear analog self assessment of overall quality of life (QOL), the Maslach Burnout Inventory, the 2-item PRIME-MD depression screen, the Empowerment at Work Scale assessing meaning from work, the Social Isolation PROMIS instrument, and the Physician Job Satisfaction Scale. The trial groups were compared using generalized estimating equations for repeated measures.

RESULTS: Of 125 study volunteers, 64and 61 participants were randomized to the intervention and control arms of the study, respectively. At baseline, no statistically significant differences were observed between the study groups for any well-being variable. Results are shown in the Table (p < 0.05 designated with an asterisk in the Table for relevant outcome variables). Preliminary data also suggest sustained benefits up to 6 months after the end of the study intervention period for each outcome.

CONCLUSIONS: Study participants engaged in biweekly meetings with colleagues supported by modest study funds experienced statistically and clinically significant improvements in multiple domains of well-being and satisfaction, including overall QOL, the depersonalization and personal accomplishment domains of burnout, meaning from work, social isolation, and job satisfaction. These results suggest that a relatively non-intensive intervention involving self-selected physician small group meetings can be effective in promoting physician well-being, meaning from work, and job satisfaction.

Absolute Change in Outcomes from Baseline to 6 Months.

Outcome Intervention (n = 64) Control (n = 61)
Poor QOL* −13.0 % −6.2 %
Overall QOL Score (0–10)* +0.72 +0.20
High Emotional Exhaustion −10.0 % −7.3 %
High Depersonalization* −4.4 % +2.4 %
Low Personal Accomplishment* −10.2 % +8.8 %
Overall Burnout −6.1 % −7.1 %
Positive depression screen −7.5 % −8.7 %
High Meaning from Work* −0.8 % −8.7 %
Social Isolation PROMIS Score (1–5)* −0.15 +0.38
High Job Satisfaction* +15.7 % +7.8 %
Likelihood of Leaving in Next 2 Years* +0.7 % +5.8 %

A RANDOMIZED CONTROLLED TRIAL TO DECREASE JOB BURNOUT IN FIRST-YEAR INTERNAL MEDICINE RESIDENTS USING A FACILITATED DISCUSSION GROUP INTERVENTION Jonathan Ripp 1; Robert Fallar1; Deborah R. Korenstein2. 1Icahn School of Medicine at Mount Sinai, New York, NY; 2Memorial Sloan-Kettering Cancer Center, New York, NY. (Tracking ID #2191957)

BACKGROUND: Job burnout is common in internal medicine (IM) trainees and has been associated with limited peer and professional support, depression, unprofessional behavior and sub-optimal patient care. Facilitated group discussion has reduced burnout among self-selected practicing clinicians. We hypothesized that a similar group discussion-based intervention would reduce the development of burnout among first-year IM resident physicians.

METHODS: We conducted a single-center randomized trial between June 2013 and May 2014 in an academic IM residency program. We selected participants from a convenience sample of 51 eligible incoming IM residents and randomly assigned groups of 3 participating residents to intervention or control. Intervention arm groups aimed to hold twice monthly discussion sessions (18 total). Expert group discussion facilitators led the sessions which were each organized around a theme (e.g. death and dying, difficult patients, coping mechanisms, etc.). Participants received lunch and one hour away from clinical duties. Due to residency program requirements, we were unable to hold the sessions in place of existing educational meetings. Residents in the control arm were provided lunch vouchers. We administered surveys at study onset and completion. The primary outcome was job burnout using the validated Maslach Burnout Inventory. Secondary outcomes included attitudinal items related to professional behavior and sub-optimal patient care, and fatigue as measured by the validated Epworth Sleep Scale. All metrics were dichotomized and changes in pre-post values were compared using chi-squared analyses or Fisher’s Exact test when cell sizes were small (n < 5). When comparing changes in scores, the data were analyzed using analysis of variance techniques.

RESULTS: All 51 eligible residents consented to participate; 39 (76 %) completed both surveys. Neither burnout prevalence at the start of training (10/21(48 %) v. 7/17(41 %), P = 0.69) nor incident burnout (9/11(82 %) v. 5/10 (50 %), P = 0.18) over the course of the year differed between intervention and control arms, though more intervention residents had high depersonalization scores at study end (18/21 (86 %) v. 9/17 (53 %), P = 0.04). (Table) Secondary outcomes did not differ between groups. During informal feedback, many intervention residents revealed that sessions did not effectively free them from their clinical responsibilities or eliminate other daily requirements.

CONCLUSIONS: A facilitated group discussion intervention was ineffective in decreasing job burnout in resident physicians. The failure of this approach highlights the difficulty of decreasing burnout in trainees. Failure of the intervention may be attributable to the unique challenges of residency training or to the fact that the intervention was performed in a convenience sample and not in a self-selected group. Future discussion-based interventions designed to mitigate the development of burnout in IM residents should consider a voluntary integrated format free from clinical duties.

Incidence and Prevalence of Job Burnout, Depersonalization and Emotional Exhaustion in a Cohort of Internal Medicine Resident Physicians Participating in a Randomized Controlled Study Examining the Impact of Facilitated Discussion

Residents’ characteristic No. (%) Intervention Arm ( n= 21) No. (%) Control Arm ( n= 17) P value
Overall Burnout
 Burnout Prevalence at the Start of Training 10/21 (48 %) 7/17 (41 %) .70
 Burnout prevalence at the end of PGY-1 18/21 (86 %) 12/17 (71 %) .43
 Burnout incidence 9/11 (82 %) 5/10 (50 %) .18
Depersonalization
 High DP subscores at the start of training 6/21 (29 %) 4/17 (24 %) 1.00
 High DP subscores at the end of PGY-1 18/21 (86 %) 9/17 (53 %) .04
 High DP incidencea 12/15 (80 %) 6/13 (46 %) .11
Emotional exhaustion
 High EE subscores at the start of training 5/21 (24 %) 3/17 (18 %) .71
 High EE subscores at the end of PGY-1 13/21 (62 %) 12/17 (71 %) .73
 High EE incidenceb 10/16 (63 %) 9/14 (64 %) 1.00

Abbreviations: PGY-1 indicates postgraduate year 1; DP depersonalization; EE, emotional exhaustion.

a Percentage of residents who start training without burnout or high DP and develop burnout and high DP by the end of PGY-1.

b Percentage of residents who start training without burnout or high EE and develop burnout and high EE by the end of PGY-1.

A RANDOMIZED TRIAL OF SELF-SAMPLING FOR HUMAN PAPILLOMA VIRUS AMONG MINORITY IMMIGRANT WOMEN IN NEED OF CERVICAL CANCER SCREENING: FINDINGS FROM THE SOUTH FLORIDA CENTER FOR REDUCING CANCER DISPARITIES Olveen Carrasquillo; Erin N. Kobetz-Kerman; Yisel Alonzo. University of Miami, Miami, FL. (Tracking ID #2199041)

BACKGROUND: Latina immigrants and Haitian women are 15–30 percentage points less likely to be screened for cervical cancer than Non-Hispanics whites (NHWs). Testing for the Human Papilloma Virus (HPV) is gaining increased acceptance for cervical cancer screening. A major advantage of this approach is that with minimal instruction women can perform the sampling themselves.

METHODS: Our study was conducted using the Community Based Participatory Research framework in three ethnic communities in Miami-Dade County: Hispanic, Haitian and one mixed. Each of three trained Community Health Workers (CHWs) recruited 200 women aged 30–65 years from various community-based locations and scheduled a subsequent 30-min assessment. Women were randomized to one of three arms; 1) culturally tailored health education materials 2) an individualized 60 min CHW led health education session followed by CHW navigation to a particpating health center for a Pap Smear 3) Individualized health education and the option of having HPV home self-sampling or CHW navigation for a Pap smear at a health center. Our primary outcome was self-report of having cervical cancer screening assessed at 6 months after the initial evaluation done by a research assitant blinded to allocation status. Women lost to follow-up were considered as not screened. At study exit, all women not having had screening were offered HPV self-sampling.

RESULTS: We assessed 4608 women of whom 1156 were study eligible. Having had a Pap smear in the last 3 years (51 %) and age (15 %) were the primary reasons for study ineligibility. We were unable to schedule an initial baseline assessment with 38 % of study eligible women and 11 % declined to participate. Among the 601 women randomized, mean age was 47 + 9 years, 67 % had household incomes under $20,000, and 76 % lacked health insurance. These characteristics and loss to follow-up at 6 months (9–12 %) were similar across all three arms. Using intention to treat, at 6 months 29 % of women randomized to health education reported being screened for cervical cancer versus 38 % in the CHW navigation group and 73 % in the HPV sampling group (P < 0.05 for group 2 versus group 1, and <0.01 for group 3 versus group 2 or 1. In pre-planned subgroup analysis, in one community (mixed) where barriers to traditional pap smears screening were minimized, rates of screening were more attenuated in groups 2 versus 3, 58 and 73 %, respectively as compared to 27 % in group 1 (p < .0.01 for all three comparisons). Rates of HPV positivity were highest in the Haitian community 25 % versus 10 % and 13 % in the other two locations (p < .05). CHWs were able to confirm follow-up and treatment (when needed) in over 90 % women having an abnormal screen.

CONCLUSIONS: We found that among a sample of immigrant predominantly low income and uninsured women, HPV self sampling was considerably superior to health education and CHW navigation to achieve cervical cancer screening. Our findings lend strong support for this screening strategy among hard to reach minority populations.

A RANDOMIZED TRIAL OF SOCIAL NORMS FEEDBACK AND FINANCIAL INCENTIVES FOR PHYSICAL ACTIVITY USING A TEAM-BASED APPROACH Mitesh Patel 1, 2; Kevin G. Volpp1, 2; Roy Rosin1; Dylan Small1; Scarlett Bellamy1; Nancy Haff3; Samantha Lee1; Lisa Wesby1; Karen Hoffer1; David Shuttleworth1; Devon Taylor1; Victoria Ulrich1; Jingsan Zhu1; Lin Yang1; Xingmei Wang1; David A. Asch1, 2. 1University of Pennsylvania, New York, NY; 2Philadelphia VA Medical Center, Philadelphia, PA; 3Massachusetts General Hospital, Boston, MA. (Tracking ID #2196543)

BACKGROUND: More than half of adults in the United States do not achieve the minimum recommended level of physical activity to achieve health benefits. Social comparisons and incentives may provide potent new ways to increase engagement but the optimal type of feedback is unknown. Insights from behavioral economics may offer new strategies to frame feedback and design incentives to change behavior. The objective of this study was to evaluate the effectiveness of using social norms feedback and financial incentives for physical activity using a team-based approach.

METHODS: Two hundred eigthy-eight employees from a large corporation in Philadelphia formed 72 four-member teams randomized to 4 arms: 50th percentile feedback (weekly feedback compared to other teams in the same arm), 75th percentile feedback, 50th percentile feedback with incentives, 75th percentile feedback with incentives—with reward eligibility based on achieving at least 7000 steps per day, a level endorsed by the American College of Sports Medicine as meeting federal guidelines for the minimum level of physical activity to achieve health benefits. Financial incentives with a daily expected value of $1.40 were offered during the 13 week intervention period using a weekly regret lottery in which participants had an 18 % chance to win $35 and a 1 % chance to win $350. Social norms feedback on performance relative to other teams was delivered weekly for all 26 weeks. Step counts were tracked by smartphone accelerometers using an application that ran passively in the background. The primary outcome measure was the proportion of participant-days that the goal was achieved during the intervention. The intent-to-treat analysis used generalized linear and mixed-models to adjust for the repeated measures of participant step counts and clustering by team. All hypothesis tests were two-sided. To maintain the type I error rate while testing 3 pairwise comparisons, we used a Bonferroni correction to define an alpha of 0.0167 as our threshold for statistical significance. We estimated that a sample of at least 280 participants would ensure 80 % power to detect a 20 % difference between arms.

RESULTS: Participants in the study sample had a mean body mass index of 28.4 (standard deviation [SD]: 6.5), mean age of 41.3 (SD 12.0), and were 80.1 % female. During the intervention period, the 50th percentile framing with incentives had the greatest proportion achieving the goal and was significantly more effective than feedback compared to the 75th percentile without incentives (0.45 vs. 0.27, Difference: 0.18, 95 % confidence interval [CI]: 0.04–0.32, P = 0.012). Compared to the 75th percentile without incentives, there were no significant differences for 75th percentile with incentives (0.38 vs. 0.27, Difference: 0.11, 95 % CI: −0.05–0.27, P = 0.19) or the 50th percentile without incentives (0.30 vs. 0.27, Difference: 0.03, 95 % CI: −0.10–16.1, P = 0.67). The 50th percentile with incentives arm had the greatest level of daily steps during the intervention period but it was not significantly different than the 75th percentile without incentives arm (Difference: 1078, 95 % CI: −71–2188, P = 0.07). There were no significant differences between arms during the follow-up period.

CONCLUSIONS: A team-based approach was effective for increasing physical activity when framing team performance relative to the 50th percentile and using financial incentives. These findings highlight that the design of performance feedback has a significant impact on engagement levels.

A SECOND LOOK AT POST-INTERVIEW COMMUNICATION Jonah Feldman 1, 2; Eugene Medvedev1; Jamie Yedowitz-Freeman1; Stanislaw Klek1; Nicholas Berbari1; Shirley Hanna1; Mark Corapi1. 1Winthrop University Hospital, Mineola, NY; 2Stony Brook Univesity School of Medicine, Stony Brook, NY. (Tracking ID #2197567)

BACKGROUND: In response to concerns about the variability of and challenges with post-interview communications between applicants and programs, an APDIM task force was convened to establish guidelines for communications during the NRMP match. The recommendations proposed by the task force include a provision that programs should advise applicants that second looks are “neither required nor encouraged”, but there exists no previously published studies that inform on this specific guidance. The aim of this study was to evaluate applicants’ attitudes toward a Formal Second Visit (FSV) at a large Internal Medicine Residency Program.

METHODS: An anonymous, four-question survey was distributed online to applicants following their FSV at a 600 bed University Hospital. Responses were collected prior to the 2014 Match Day and reflected both multiple choice and free-text answers. Characteristics of the FSV at this institution include: a formal invitation sent to the residency program’s top candidates, a prescheduled experience with the medical floor teams, planned participation in two of the program’s daily didactic sessions, individual meetings scheduled with the Program Directors, and a dinner with the Department Chair.

RESULTS: The survey response rate was 62.3 % (33/53). Among respondents, 97 % reported being happy they spent the time to take a second visit to the program, and 59.3 % felt their opinion changed in a positive way because of new information about the program learned during the FSV. When asked whether they felt pressured to attend an FSV once offered, the majority of respondent (75.8 %) said “no”. Similarly, when asked whether a policy advocating for the discontinuation of second visits would benefit Internal Medicine applicants, the majority (71.9 %) of respondents stated “no”.

CONCLUSIONS: Previous studies have reported that post-interview communication was stressful for applicants and, in some cases, undermined the integrity and spirit of the match. These studies focus on email or phone contact with applicants after interview day. There have been no previous studies evaluating second look visits in general, or FSVs in particular, at an internal medicine residency program. Second visits are different from other forms of post-interview communication as there is an opportunity for applicants to experience residency programs in a more intimate way than that which would be afforded to them on interview day. Our single center study found that FSVs as a particular form of post-interview contact was overwhelmingly supported by participants, though a significant minority felt pressure to attend the second visit once invited. Further research is needed to determine the optimal way to offer applicants the option of a second visit without contributing to the overall stress of the application process.

A SMARTPHONE-BASED ONLINE SUPPORT GROUP FOR PEOPLE LIVING WITH HIV Tabor E. Flickinger 2; Claire DeBolt2; Erin Wispelwey3; Colleen Laurence4; Erin Plews-Ogan2; Ava Lena Waldman2; George Reynolds5; Wendy F. Cohn2; Mary Catherine Beach1; Karen Ingersoll2; Rebecca Dillingham2. 1Johns Hopkins University, Baltimore, MD; 2University of Virginia, Charlottesville, VA; 3University of London, London, United Kingdom; 4Wake Forest School of Medicine, Winston Salem, NC; 5Health Decision Technologies, Oakland, CA. (Tracking ID #2198786)

BACKGROUND: Although there is growing interest in mobile applications and online support groups (OSGs) to enhance chronic disease self-management, little is known about the potential impact of these tools for people living with HIV (PLWH). Our study analyzes an innovative OSG delivered through a community message board (CMB) within a clinic-affiliated Smartphone application (Positive Links, PL). Our objectives were to 1) compare characteristics of posters and non-posters to the CMB and 2) evaluate content posted to the CMB.

METHODS: For this pilot study, 38 HIV-infected patients were recruited through provider referrals at a university-based clinic and from area AIDS service organizations (ASOs) and HIV testing sites. Participants received cell phones with the PL application that included the opportunity to interact with other users on a CMB. Logistic regressions investigated associations between participant characteristics and posting on the CMB. CMB messages were downloaded and analyzed qualitatively by two independent coders using a Grounded Theory approach.

RESULTS: Mean age was 34.1 years (SD 11.5) and the majority of participants were male (74 %). Seventeen participants identified as black, non-Hispanic (45 %), and 13 as white, non-Hispanic (34 %). Sixty-one percent of participants were unemployed; 37 % had public insurance (such as Medicare or Medicaid) and 32 % had no insurance; and 45 % were below 100 % of the federal poverty level. Twenty-four participants posted to the CMB; 14 did not. Participants had lower odds of posting if they were white [OR 0.20 (0.05–0.84), p = 0.028] and had private insurance [OR 0.07 (0.01–0.41), p = 0.003]. Participants had higher odds of posting if they had unsuppressed viral loads [OR 5.13 (1.13–23.30), p = 0.034)]. In multivariable analyses, having private insurance remained the strongest association with not posting on the CMB [OR 0.09 (0.01–0.71), p = 0.023]. Of the 840 CMB messages over 8 months, 62 % had psychosocial content, followed by community chat (29 %), and biomedical content (10 %). Of psychosocial content, posts frequently described stressors (including relationships outside the CMB, disclosure, stigma, and both geographic and social isolation) and discussed coping strategies. Of community chat content, greetings were most common and included messages welcoming new members, greetings to individual users and greetings to the entire group. Of biomedical content, most posts discussed medications, followed by seeing a healthcare provider and laboratory results. Posts on medications were centered on the importance of adherence and support for others having difficulty.

CONCLUSIONS: The dominance of psychosocial over biomedical content may be unique to this CMB, in contrast to other studies identifying informational support as the primary content on online forums for chronic illness. Participants who posted on the CMB expressed support for each other, appreciation for the community, and a perception that the app played a positive role in their struggles with HIV. This CMB on a clinic-affiliated mobile app may reach vulnerable populations, including racial/ethnic minorities and those of lower socio-economic status, and potentially provide psychosocial support to PLWH. Further development of this app and CMB will include investigation of possible benefits in improving social support, linkage and retention in HIV care, and health outcomes for PLWH.

A STATISTICAL MODEL FOR PREDICTING NEUTROPENIC FEVER Ariel Nelson; Dan Eastwood; Tao Wang; Karen Carlson; Laura Michaelis; Marcelo Pasquini; Parameswaran Hari; Christopher Chitambar; Timothy Fenske; Mary Beth Graham; Mehdi Hamadani; Anita D’Souza; Ehab Atallah. Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #2191299)

BACKGROUND: Febrile neutropenia (FN) is a common occurrence associated with chemotherapy regimens used in patients with acute myelogenous leukemia (AML). Febrile neutropenia is presently defined as a single temperature of ≥38.3 °C (101 °F) or a temperature of ≥38.0 °C (100.4 °F) for >1 h in a patient with an absolute neutrophil count <500/mm3. Due to the potential for life threatening infections, fever in a patient with neutropenia is considered an oncologic emergency. Initiating appropriate antibiotic therapy as soon as possible in these patients leads to better outcomes. However, to our knowledge, there is no evidence that supports the current definition of neutropenic fever. The goal of this pilot study was to analyze patient fever data and utilizing statistical analyses, develop a prediction model which would predict febrile neutropenia.

METHODS: After obtaining IRB approval we retrospectively obtained demographic and temperature data from hospitalized patients with AML undergoing chemotherapy who were admitted to our institution between 12/8/2012 and 12/7/2013. Temperature data was recorded at intervals per physician order and nursing discretion during admission. We identified fever as a single temperature ≥38.3 °C (101 °F) or consecutive temperatures recorded 1 h apart ≥38.06 °C (100.5 °F). Data was obtained for 68 patients containing 137 fever events. Plots were created showing temperature over time leading up to a fever event. Our data consists of unequal interval time series data and does not lend itself to the usual methods of statistical ROC analysis. The data was simplified to perform an ROC-like analysis to estimate sensitivity and specificity of decision rules that predict oncoming episodes of FN. Statistics on each patient series were used as variables in predicting fever onset in logistic regression analysis. The variables included were maximum temperature within 24 h, minimum temperature within 24 h, average of positive increases between subsequent measurements, and largest 24 h increase. Statistical analysis consisted of a generalized linear model with logit link (logistic regression) predicting fever at least 4 h before onset, and used generalized estimating equations to adjust for correlated temperature measures within patient.

RESULTS: Of the 68 patients identified, 47 % were male, 53 % were female with a mean age of 56.3 ± 15.1 years. Our fever curve plots suggest that there is an increase in average temperature at least 24 h before the onset of fever in those patients that will go on to develop a fever by current definition (Figure 1). Significant identified predictors of fever included; maximum and minimum temperature within 24 h, and the average of positive increases in temperature between subsequent measurements. A prediction score including, maximum temperature within 24 h, minimum temperature within 24 h, average of positive increases between subsequent measurements, and largest 24 h increase was able to predict 86.1 % of oncoming FN events 4 to 28 h before onset and reject 67.4 % of non-FN events. This rule has a negative predictive value of 96.2 % and a positive predictive value of 33.7 %.

CONCLUSIONS: Our analysis demonstrates the feasibility of using temperature series data for early prediction of FN. A more comprehensive analysis is planned and is expected to result in higher sensitivities. If subsequent analysis proves to be significant this data may be used to develop future prospective clinical studies to evaluate new fever criteria and may alter our current definition and management of patients with FN.

figureo

Figure 1. Fever curve plot of 96 h of temperature series data preceding the onset of fever or end of series if no fever. The dark lines are LOESS smoothed average temperatures for series ending in fever (dash) or non-fever (solid).

A STUDY OF THE LOCATION OF RESEARCH FUNDING DISCLOSURE IN HIGH IMPACT SCIENTIFIC JOURNALS Jonah Feldman 1, 2; Christopher Garcia1; gary carpenter1; Brahmbhatt Saloni1. 1Winthrop University Hospital, Mineola, NY; 2Stony Brook School of Medicine, Stony Brook, NY. (Tracking ID #2199149)

BACKGROUND: Recently published reports have demonstrated that disclosure of industry sponsorship negatively influences physicians’ perception of the methodological quality of a study. Though there is consensus on the importance of sponsorship disclosure, and a growing understanding of the effect of disclosure on readership, the actual disclosure practices of leading scientific journals have not been well characterized. The purpose of our study is to evaluate funding disclosure practices in top scientific journals, specifically focusing on the location of funding disclosure within the journal article.

METHODS: We reviewed the 221 scientific journals with an impact factor equal to or greater than 6, as categorized by the Thomas Reuters Journal Citation Report. The location of financial disclosure was determined by direct examination of print or online copies of a 2013 dated volume of the journal. Journals were categorized as having disclosures at the end of the article, at the end of the abstract, or no disclosure at all. The primary outcome was the percentage of journals with disclosures in each of these three categories.

RESULTS: It was found that 9 of 221 journals did not list disclosures (4.12 %). One hundred seventy-six of 221 journals (80.73 %) listed financial disclosures at the end of the article, and 33 of 221 journals listed financial disclosures in the abstract (15.13 %).

CONCLUSIONS: In this cross sectional study we show that the great majority of top scientific journals practice disclosure of funding sources, but there is heterogeneity among these journals with regards to disclosure location. The majority of journals listed funding disclosures at the end of the article, while a small but significant minority listed funding within the abstract. This finding is important as studies of medical journal readership have shown that almost half the time readers will scan an abstract and skip the rest of the paper. If sponsorship disclosure is placed at the end of the paper the impact of these disclosures may be blunted. Our findings raise important ethical questions about appropriate sponsorship disclosure practices, and open up many avenues for further research and discussion.

A TALE OF TWO CONSTITUENCIES: PATIENT AND CLINICIAN ENGAGEMENT IN RESEARCH Crispin N. Goytia1; Donna Shelley2; Rainu Kaushal3; Isaac Kastenbaum4; Carol R. Horowitz 1. 1Mount Sinai School of Medicine, New York, NY; 2NYU School of Medicine, New York, NY; 3Weill Cornell Medical College, New York, NY; 4New York Presbyterian, New York, NY. (Tracking ID #2198586)

BACKGROUND: Patients and front-line clinicians are not adequately engaged in key aspects of research, including idea generation, recruitment and dissemination. An increasing focus on and funding for patient-centered research has uncovered gaps in our understanding of how patients and clinicians should be involved in the research enterprise. The NYC Clinical Data Research Network aims to create a large electronic data infrastructure for conducting patient-centered, clinical outcomes research. As part of this process, we explored patient, advocate, and clinician experiences with research, how they would like to be involved, recruitment challenges and suggestions, and study ideas.

METHODS: A team of researchers, patients, clinicians, and privacy and technology experts developed a question guide. We identified pre-existing patient, community and clinician groups that meet regularly throughout NYC hospitals and neighborhoods, and asked to speak with them at one of their meetings for 15 min. A facilitator and note-taker met with 20 such groups (11 clinician; 9 patient/community). The research team analyzed meeting notes to identify themes of discussions and compare results of patient and clinician groups.

RESULTS: Fully 272 individuals participated in these listening sessions (49 % generalist and specialist clinicians, 51 % patients/families/advocates). Most (67 %) were non-white (90 % of patients and 44 % of clinicians). Few had personally participated in research (34 % of patients; 0 % of clinicians), but most were interested in future involvement as participants or collaborators. Patients and clinicians shared most themes: 1) To improve research-related recruitment, perceptions, awareness and interest, there should be “warm handoffs” from clinicians to patients, and accessibility to general research and specific study information through community education campaigns and patient and clinician-friendly portals; 2) Both wanted training to translate their thoughts and concerns into concrete research questions; 3) They were most interested in studies comparing outcomes of interest between practices and between neighborhoods; and 4) Concerns included the potential for data inaccuracy, and research findings not being shared with them and their geographic or clinical communities. Clinicians expressed concerns about research recruitment taking time and disrupting workflow, and study findings contradicting clinical recommendations they provide. Finally, patients’ negative attitudes toward clinical care readily translated into negative attitudes toward research at sites of care, and they were worried that data could never be truly de-identified and that research to date has not had enough impact.

CONCLUSIONS: While 15 min discussions only opened small windows to explore patient and clinician-centered research involvement, they afforded an opportunity to learn from diverse groups who can be difficult to engage in such efforts. These stakeholder groups shared many hopes, ideas and concerns about research, including strong interest in expanding their research literacy, social marketing to bolster research interest, and learning how to transform their experiences into study questions or outcomes of interest. Concerns about data inaccuracies, maintaining privacy, and failures in receiving past study findings and enjoying tangible research benefits dampened enthusiasm for participation. These findings may assist research teams in identifying areas for further research and building engagement and recruitment strategies.

ABERRANT BEHAVIOR IN CHRONIC NON-CANCER PAIN PATIENTS PRESCRIBED SCHEDULE II NARCOTICS Mohamed Rezik; Alex Garbarino; Grace Choe; Sheetal Patel; Sam Tirgari; Joshua Collins. Henry Ford Hospital, Dearborn, MI. (Tracking ID #2191810)

BACKGROUND: An estimated 100 million US patients suffer from chronic pain, a condition that is now largely treated with narcotics. The availability of these drugs has led to an increase in their adverse effects, misuse and abuse. This, in turn, has led to various attempts to reduce the potential for aberrant behavior including the use of patient-provider agreements. In an effort to reduce aberrant behavior in an urban academic primary care clinic, patient-provider agreements were instituted as part of a larger policy to monitor patients being treated for chronic non-cancer pain with schedule II narcotics. The primary aim of this study was to determine the rate of aberrant behavior in patients receiving schedule II narcotics 1 year after the implementation of this chronic pain policy.

METHODS: This was a retrospective cohort study involving manual electronic medical record (EMR) and Michigan Automated Prescription Review (MAPS) review of 952 patients. The inclusion criteria were adult patients with active chronic prescription for a schedule II narcotic with either two or more clinic visits from January 2014 through August 2014 or with faculty physicians listed as primary care physician in the EMR. Aberrant behavior was defined as: MAPS revealing early refills or prescriptions from a non-clinic provider and urine toxicology (UTox) results with illicit or unprescribed substances or absence of prescribed opiates. The primary outcome was the rate of aberrant behavior.

RESULTS: Two hundred seven patients were included in the study after full manual review. One hundred five patients (51 %) met the definition of aberrant behavior with 47 patients having early refills (45 %), 44 with multiple prescribers (42 %), and 54 with unexpected urine toxicology results (51 %). Secondary analyses revealed that predictors of identifying aberrant behavior included: missed pain visit in the prior year (1.4 vs. 0.8, p = 0.03) and a UTox being performed within the last 1 year (86 % vs. 68 %, p = 0.002).

CONCLUSIONS: The rate of aberrant behavior identified in our study was higher than similar studies. However, the definition of aberrant behavior varies widely in the existing literature. The most common aberrant behavior identified was an unexpected UTox result. Semi-synthetic opioids, even when taken as prescribed, often show up negative on UTox and require a confirmatory test. This was not a common practice in this clinic prior to our study. Furthermore, the accepted (and legal in Michigan) use of marijuana for analgesic purposes is inconsistent among providers in the clinic. When removing these patients whose only aberrant behavior was testing negative for opiates or positive for marijuana, the rate of aberrant behavior fell to 37 %. This figure is more in line with previous literature. An interesting observation was that patients with aberrant behavior were more likely to have missed a pain visit, either by cancelling or not showing. The only significant predictor of aberrant behavior was an obtained UTox, which can be presumed to be ascertainment bias. Implications of this study include changes to the formal clinic policy to encourage providers to follow up unexpected UTox results, particularly an unexpected negative test for prescribed opiates. Further secondary outcomes have informed internal quality improvement initiatives to optimize patient care and management of patients treated for chronic non-cancer pain with opiates.

ACCEPTED WISDOM: NOT NECESSARILY CORRECT. Jolian M. Rios 2; Thomas Higgins2; Orlando L. Torres1. 1Baystate Health, Springfield, MA, MA; 2Baystate Medical Center, Springfield, MA. (Tracking ID #2198850)

BACKGROUND: Hispanics and non-English proficient patients have a lower rate of CRC screening at the national level. This is concerning, because colorectal cancer (CRC) is the second leading cause of cancer death, and the third most common cancer found in men and women. Screening has a potentially significant impact on preventing mortality and morbidity with up to 60 % of deaths from CRC prevented if appropriate screening was done regularly and findings treated appropriately. According to the CDC, the overall rate of CRC screening is 58.6 % in the general population, but it is only 46.5 % in Hispanics, indicating significant disparities in the delivery of care. Lower cancer screening rates have been associated with less education and non-English speaking status. The objective of this study is to determine if non-English proficient Hispanics adults, primarily Spanish speaking, are less likely to undergo CRC screening.

METHODS: Baystate High Street health Center-Adult Medicine (BHSHC-A) is an urban, academic, patient centered medical home practice serving a primarily Puerto Rican population (51.8 %). A large proportion of the patient population self-identified as Spanish speaking (23.9 %). We used BHSHC-A Preventive Health Registry in October 2014 to identify Spanish speaking adults ages 50 to 75 years who were overdue for CRC screening. We then performed a chart review to verify their actual CRC screening status. Each chart was checked for evidence of CRC screening, either by endoscopy or by fecal occult blood testing (FOBT) by looking at the procedure notes, outside hospital records scanned, and laboratory results from October 2004 to October 2014.

RESULTS: Of 9294 individuals in the registry, we identified 3296 between the ages of 50 to 75 years; of these, 1038 reported Spanish as their primary spoken language. Of these, 60 % were female, and 40 % male. The percentage of men who had had up-to-date CRC screening was 74.4 %, while the percent of women with up-to-date CRC screening was 76.6 %. In average 75.7 % of the Spanish-speaking population ages 50 to 75 years at BHSHC-A were current on their CRC screening.

CONCLUSIONS: At a single health center, more than 75 % of eligible non-English proficient Hispanics were found to be current on their CRC screening, which is above the Healthy People 2020 target of 70.5 % set by the Department of Health and Human Services. This demonstrates that National HEDIS Top 10 percentile CRC screening rates can be achieved despite serving a socioeconomically disadvantaged population that is primarily Hispanic and non-English proficient.

ACCOMMODATIONS FOR MEDICAL STUDENTS WITH DISABILITIES: EXPLORING U.S. MEDICAL SCHOOLS’ TECHNICAL STANDARDS. Christopher Moreland 1; Philip Zazove2; Benjamin Case2; Missy Plegue2; Anne Hoekstra2; Alicia Oulette3; Ananda Sen2; Michael Fetters2. 1The University of Texas HSC - San Antonio, San Antonio, TX; 2University of Michigan, Ann Arbor, MI; 3Albany School of Law, Albany, NY. (Tracking ID #2191968)

BACKGROUND: Medical education literature increasingly supports correlations between diverse medical professionals, including physicians with disabilities, and higher quality care for underserved populations. However, about 20 % of the general population has a disability, while only about 1 % of medical students do. Moreover, the Americans with Disabilities Act (ADA) requires medical schools to provide reasonable accommodations to learners with disabilities. Medical schools, per accrediting organizations, have enacted technical standards (TS) that vary in scope, requirement, and compliance with ADA spirit. Despite recent case law, some schools have refused to provide accommodations. We sought to examine U.S. medical schools’ TS to assess apparent willingness to comply with and factors that predict compliance with federal antidiscrimination laws, including the ADA.

METHODS: From 2012 to 2014, we conducted a web-based search of existing websites (along with follow-up to schools without posted information) of 138 MD-granting medical schools (as listed by the Association of American Medical Colleges) to identify required TS for medical students, focusing on hearing, visual, and mobility disabilities. Two authors iteratively coded each school’s TS for the themes below; disagreements were resolved by consensus or, if none was reached, further review with 2 other authors. Themes, studied included the willingness of medical schools to provide reasonable accommodations, locus of responsibility for accommodations, and acceptability of intermediaries or auxiliary aids for students with disabilities. The process was later repeated for DO-granting schools.

RESULTS: One hundred sixteen (84.1 %) of 138 schools made technical standards available on their websites, of which 84 (59.4 %) were easily accessible; 9 of the remaining schools provided the standards upon direct request. Forty (29.0 %) schools had technical standards supportive of providing reasonable accommodations as required by the ADA to students with at least 1 of the 3 disabilities listed above; sixty (43.5 %) schools did not, 6 (4.3 %) were equivocal, and 32 (23.2 %) were unclear. Most schools provided no information on the locus of responsibility for providing accommodations, although 1 school placed it solely on the student and 8 (5.8 %) had joint responsibility between the school and student. Only 35 % allowed the use of auxiliary aids by students with hearing, visual, or mobility disabilities, and less than 10 % of all schools allowed the use of intermediaries such as a sign language interpreter.

CONCLUSIONS: Medical schools often do not provide easy online access to TS; some did not provide TS despite direct requests. Both create barriers for potential applicants with disabilities. Most TS are at best equivocal when it comes to reasonable accommodations; <35 % are openly supportive, while some overtly restrict accommodations. Few openly allow intermediaries. Further research should explore actual experiences with accommodations from the school, learner, and faculty perspectives. Medical schools and administrative organizations should reevaluate and modernize technical standards in light of the legal landscape, particularly the ADA.

ACQUISITION OF CARDIOVASCULAR DISEASE RISK FACTORS AMONG REFUGEES AND IMMIGRANTS: A LONGITUDINAL STUDY Gabriel E. Fabreau 2, 4; Seth A. Berkowitz3; Wei He3; Chantal Kayitesi1; Sarah Oo1; Steven J. Atlas3; Sanja Percac-Lima3. 1Massachusetts General Hospital, Chelsea, MA; 2University of Calgary, Calgary, AB, Canada; 3Massachusetts General Hospital, Boston, MA; 4Brigham and Women’s Hospital, Boston, MA. (Tracking ID #2196070)

BACKGROUND: Acquisition of cardiovascular disease risk factors such as obesity, hypertension and hyperlipidemia among refugees and immigrants living in the same community as American-born patients may differ partly due to acclimating into a new culture. Understanding risk factor differences between these populations has important implications for implementing cardiovascular disease prevention programs for refugee and immigrant populations.

METHODS: We conducted a longitudinal cohort study of adult refugee patients ≥ 18 years old entering the US between 2004 and 2013. We matched these patients by age, sex and date of initiation of care in a 1:3 ratio to 1) Spanish speaking non-refugee immigrants and 2) English speaking US-born controls. The cohort was limited to primary care patients within the same community health center, a state designated refugee clinic, located in a low-income, culturally diverse community in Eastern Massachusetts. Electronic medical record data were used to follow patients longitudinally for the acquisition of obesity (body mass index [BMI] > 30 kg/m2), hypertension and hyperlipidemia using validated algorithms. Additionally, we collected information on age at cohort entry, sex, baseline BMI, education (< vs. high school diploma vs. any post-secondary), insurance type, and, to account for neighborhood differences, census tract level median household income. We used multivariable Cox regression to estimate the risk of acquiring obesity, hypertension and hyperlipidemia for refugees and immigrants compared with English-speaking controls. We excluded patients with risk factors at baseline from the risk factor acquisition analyses.

RESULTS: A total of 3174 patients were included in our analysis. Mean (SD) age at cohort entry was 34.6 (12.3) years, and 51.7 % (1642/3174) were female. Among refugees, the most common countries of origin were Somalia (17.8 %), Iraq (16.7 %) and Bhutan (8.8 %). At baseline, 14.6 % (88/604) of refugees, 15.3 % (200/1310) of immigrants and 12.4 % (156/1260) of controls (p = 0.09) were obese, and the prevalence of hypertension was similar: 9.1 % (55/604) of refugees, 9.7 % (127/1310) of immigrants, and 8.6 % (108/1260) of controls (p = 0.61). Baseline hyperlipidemia was less common in refugees: 2.5 % (15/604) of refugees compared with 6.0 % (79/1310) of immigrants and 6.8 % (85/1260) of control patients (p < 0.01). Median follow-up time was 3.7 years [IQR, 1.3-7.4] during which 21.1 %, 8.0 %, and 11 % of refugees, 32.8 %, 10.1 %, and 20 % of immigrants and 31.3 %, 11.6 %, and 15.1 % of controls developed obesity, hypertension and hyperlipidemia respectively. In unadjusted Cox regression models, immigrant patients had higher risks of acquiring obesity (HR 1.21, 95 % CI 1.04 - 1.40) and hyperlipidemia (HR 1.52, 95 % CI 1.25–1.84) compared to controls. In contrast, refugee patients had no increased unadjusted risks of acquiring any risk factor compared to controls. In Cox models adjusting for the aforementioned covariates, both refugee and immigrant statuses were associated with an increased risk of obesity compared with English-speaking controls (Table 1). Immigrant status alone was associated with an increased risk for hyperlipidemia compared to controls (Table 1), and additionally when compared to refugees (HR 1.46, 95 % CI 1.01–1.98). There were no other significant differences in risk factor acquisition between refugees and immigrants in the adjusted analyses.

CONCLUSIONS: The acquisition of cardiovascular risk factors was observed in all study cohorts during follow-up. In particular, refugee and immigrant patients were at increased risk of becoming obese and immigrants were at increased risk of developing hyperlipidemia compared with both age and gender matched controls and refugees in the same community. These risk factors developed over a relatively short time span in a cohort of young patients and have significant implications for long-term health. Targeted and culturally tailored education and lifestyle interventions early after arrival of refugee and immigrant patients may mitigate the acquisition of these cardiovascular risk factors.

Frequencies of and Risk of developing obesity, hypertension and hyperlipidemia among refugee and immigrant patients compared with English-speaking controls

Risk Factor Patient Group Risk Factor Frequency at Baseline (%) Risk Factor Frequency at Follow up (%) Adjusted Hazard Ratio* [95 % CI]
Obesity Refugees 14.6 32.6 1.33 [1.04–1.72]
Immigrants 15.3 43.1 1.22 [1.01–1.46]
Controls 12.4 39.9
Hypertension Refugees 9.1 16.4 0.97 [0.65–1.45]
Immigrants 9.7 18.8 0.96 [0.70–1.31]
Controls 8.0 19.2
Hyperlipidemia Refugees 2.5 13.2 1.00 [0.72–1.39]
Immigrants 6.0 24.9 1.46 [1.13–1.88]
Controls 6.8 20.9

*model adjusted for age at entry, gender, baseline BMI, education, insurance and median household income.

ADDRESSING A GROWING NEED FOR LANGUAGE SERVICES: HOW WELL ARE WE DOING? Alissa Detz 1; Julie Brown2; Mark Hanson2; Karin Liu2; Mary Slaughter3; Robert Weech-Maldonado4; Neil Wenger1, 2; David Ganz2, 1. 1University of California, Los Angeles, Los Angeles, CA; 2RAND Corporation, Santa Monica, CA; 3RAND Corporation, Pittsburgh, PA; 4University of Alabama, Birmingham, AL. (Tracking ID #2198047)

BACKGROUND: Approximately 9 % of individuals in the U.S. have limited English proficiency (LEP), defined as speaking English less than “very well” by self-report. Title VI of the Civil Rights Act requires agencies receiving federal funding to provide interpreters to individuals in need, and prior research indicates that providing professional interpreters for LEP patients improves satisfaction and health outcomes. Nonetheless, previous studies suggest that access to interpreters is low across many healthcare settings. Because patient perception of access to interpreters and unmet need has not been fully explored, we pilot tested a set of survey items to evaluate patient perception of language services among Spanish-speaking LEP individuals.

METHODS: We modified existing Consumer Assessment of Healthcare Providers and Systems (CAHPS) items from the Cultural Competence Item Set based on cognitive interviews with older Spanish-speaking persons. These items were then embedded in a CAHPS survey conducted for the purpose of pilot testing new items. To optimize Spanish survey responses, 6 Medicare Advantage plans in Florida and California were identified for pilot testing due to having 30 % or more survey responses in Spanish during prior CAHPS surveys. Individuals were included in this study if they were 18 years or older and had been enrolled in these selected Medicare Advantage health plans for 6 months continuously prior to survey administration. Individuals known to be institutionalized were excluded. Surveys were administered by mail, with telephone administration as the secondary or non-response mode. Our analysis focused on individuals who completed the survey in Spanish. First, we conducted descriptive analyses of responses to the survey items addressing interpreter services. Second, we determined if individual or geographic level variables could predict the need for an interpreter using bivariate analysis and logistic regression. Third, we performed bivariate analysis followed by exploratory linear regression to determine the association between needing an interpreter and validated CAHPS measures regarding communication and overall ratings of physician, specialists, health plan, and healthcare, as well as a survey item regarding physician sensitivity to beliefs.

RESULTS: Total survey response rate was 40 %. The 991 individuals who completed the survey items regarding interpreters were primarily female (58 %), had less than a college education (81 %), and 93 % were 65 years or older. Fourteen percent (N = 134) of the 991 individuals completing the Spanish version of the survey reported needing a medical interpreter. Within this group, 47 (37 %) reported not being informed of their right to free interpreter services and 30 (23 %) reported an encounter when they needed an interpreter but were unable to get one. Among individuals reporting a need for an interpreter, 72 (56 %) always used an interpreter provided by the doctor’s office and 42 (33 %) used a family member or friends to interpret at least sometimes. Younger age and lower education were individual level predictors of the need for an interpreter. Multivariate models that also included state and health plan-related variables suggested that membership in a Medicare Advantage special needs plan (SNP) and state of residency were also important predictors. Individuals not in a SNP had a relative risk of needing an interpreter of 2.01 (95 % CI 1.04–3.89) compared to individuals enrolled in a SNP. Individuals from California had a relative risk for needing an interpreter of 6.34 (95 % CI 4.13–9.73) compared to those in Florida. Individuals who needed an interpreter rated their personal physician more poorly and were less likely to feel that their physician valued their beliefs.

CONCLUSIONS: A relatively small proportion of respondents needed an interpreter, but many of these individuals were unaware of their right to medical interpreters and had difficulty accessing interpreters when needed. Those needing interpreters had lower ratings of their personal physician. Our data support the importance of measuring access to interpreter services. Patients should be better informed about their right to interpreters, and health systems should devise targeted interventions to ensure timely access to interpreters for all patients with language barriers.

ADDRESSING BASIC RESOURCE NEEDS IN PRIMARY CARE IMPROVES BLOOD PRESSURE AND CHOLESTEROL CONTROL: A PRAGMATIC INTERVENTION Seth A. Berkowitz 1; Carine Y. Traore2; Steven J. Atlas2. 1MGH, Boston, MA; 2Massachusetts General Hospital, Boston, MA. (Tracking ID #2191912)

BACKGROUND: Unmet basic resource needs, such as difficulty affording food, housing, or medications, are associated with poor health. However, it is unclear if helping patients meet those needs improves clinical outcomes.

METHODS: We conducted a pragmatic evaluation of the HealthLeads program in two academic primary care practices in Eastern Massachusetts, using data from October 1, 2012 (1 year prior to the program’s start on October 1, 2013) through October 1, 2014. HealthLeads (HL) uses trained ‘advocates’ to screen patients at visit check-in for healthcare, employment, financial, food, transportation, utilities, housing, or legal needs, and then connect patients to community resources to meet those needs. Data on systolic and diastolic blood pressure (SBP and DBP), low-density lipoprotein cholesterol (LDL-C), and hemoglobin A1c (HbA1c), along with sociodemographic and clinical characteristics, were collected from electronic sources. We used chi-squared and t-tests to compare baseline demographic and clinical characteristics. We used unadjusted and multivariable difference-in-differences linear mixed modeling to compare changes in SBP and DBP (in those with hypertension), LDL-C (in those with increased cardiovascular event risk, including diabetes, hypertension, coronary heart disease, and hyperlipidemia), and HbA1c (in those with diabetes) between HL patients and those seen in the same practices, but who were not enrolled in HL. All patients also received usual clinical care.

RESULTS: Overall, 416 patients enrolled in HealthLeads and were compared with 2750 control patients. At baseline, HL patients were similar in age (mean age 56.3 vs. 54.9 years, p = .13), more likely to be women (51.9 % vs. 46.8 %, p = .048), be racial or ethnic minorities (24.7 and 18.4 % non-Hispanic black and Hispanic, respectively, vs. 16.4 and 11.2 %, p < .001), and have Medicaid (30.8 % vs. 20.0 %) or no insurance (9.2 % vs. 4.6 %), p < .001. HL patients most commonly reported difficulty affording healthcare and medications (46.5 %), food (40.0 %), and utilities (36.3 %). Hypertension (54.3 % vs. 46.3 %, p = .002) and diabetes (32.7 % vs. 20.4 %, p < .001) were more common in HL patients, but mean baseline SBP (135.3 vs. 135.2 mm/Hg in HL vs. non-HL patients, p = .96), DBP (79.2 vs. 78.0 mm/Hg, p = .19), LDL-C (111.0 vs. 106.3 mg/dL, p = .10), and HbA1c (7.7 % vs. 7.5 %, p = .39) were similar. In unadjusted models, HL participation was associated with greater reductions in SBP (3.8 mm/Hg lower in HL participants, 95%Confidence Interval [95%CI] 1.7–5.8 mm/Hg lower), DBP (2.0 mm/Hg lower in HL participants, 95%CI 0.8–3.1 mm/Hg lower), and LDL-C (10.5 mg/dL lower in HL participants, 95%CI 3.4–17.3 mg/dL lower), but not HbA1c (0.1 % higher in HL participants, 95%CI 0.2 % lower to 0.3 % higher). In models adjusted for age, gender, race/ethnicity, education, primary language, insurance, and Charlson comorbidity score, HL participation remained associated with significantly greater improvements in SBP (3.0 mm/Hg lower in HL participants, 95%CI 1.0–5.1 mm/Hg lower), DBP (1.8 mm/Hg lower in HL participants, 95%CI 0.6–3.0 mm/Hg lower), and LDL-C (11.5 mg/dL lower in HL participants, 95%CI 4.6–18.4 mg/dL lower). In adjusted models, improvement was not greater for HbA1c (0.1 % higher in HL participants, 95%CI 0.2 % lower to 0.3 % higher).

CONCLUSIONS: Addressing unmet basic resource needs as part of primary care was associated with clinically meaningful improvements in blood pressure and LDL-C, but not HbA1c. Future research should clarify which elements of the program were effective, make programatic modifications to improve HbA1c, and evaluate whether changes in blood pressure and LDL-C achieved by meeting basic resource needs are associated with fewer cardiovascular events.

ADDRESSING RACIAL DISPARITIES IN HOSPICE USE: RESULTS FROM AN EDUCATIONAL INITIATIVE FOR RELIGIOUS LEADERS IN BALTIMORE CITY, MARYLAND Kerry Schnell 1; Arnold Eppel2; G.I. Johnson3; Aruna Chandran4, 2. 1Johns Hopkins Bayview Medical Center, Baltimore, MD; 2Baltimore City Health Department, Baltimore, MD; 3Maryland State Department of Aging, Baltimore, MD; 4Johns Hopkins University School of Public Health, Baltimore, MD. (Tracking ID #2198748)

BACKGROUND: Hospice organizations provide comprehensive, compassionate, interdisciplinary care to dying patients and their loved ones, with the goal of helping patients achieve a dignified, pain-free death. Despite the fact than many public and private insurers pay for hospice care, there is a well-documented racial disparity in hospice use in the United States. In Baltimore City, Maryland, African American residents use hospice services at half the rate of white residents. Data suggest lack of knowledge about hospice is a barrier to hospice use. However, there is little published on evidence-based interventions to reduce hospice use disparities. Given this absence of data, our objective was to assess the feasibility, acceptability, and perceived efficacy of an educational seminar for religious leaders about hospice.

METHODS: Seminar planning was informed by the hospice use disparities literature and followed a previously described framework for health disparities research. Planning occurred with extensive input from local stakeholders and religious leaders. Following the seminar in November 2013, a survey was sent to all participants who registered for the event online with a valid email address. Results were analyzed by frequency of common responses and broader thematic categories.

RESULTS: Approximately 325 community and religious leaders attended the seminar; 15 % (38/247) of eligible participants completed a substantive portion of the survey. Following the seminar, 85 % were more likely to recommend a family member enroll in hospice, 79 % felt better prepared to counsel families about end-of-life care, and 91 % would participate in a similar event in the future. Two important themes emerged: (1) there is a need and desire in Baltimore communities for information about hospice and (2) respondents planned to share what they learned with their communities (table 1).

CONCLUSIONS: This novel, evidence-based educational seminar provides an example of a feasible, acceptable, and likely effective hospice outreach intervention, and suggests that religious leaders are important members of African American communities to engage in efforts to reduce hospice use disparities.

Summary of themes and select respondent answers

Theme Responses
There is a need and desire for information about hospice “The information shared was very informative and helpful. I felt empower by just being in the same room with so many members of the faith community who shared my experiences. Thank you for the investment in our ministries. It was much needed.”
“[The] information is vital.”
“I WOULD LOVE TO PARTICPATE in any similar event you may offer in the future to help me be informed with my ministry as a Missionary in my church.”
“I believe the more correct knowledge we have allows the community to utilize services that enhance a good quality of life even as that life takes a turn toward the end of life.”
“We need to know about this for our members.”
Respondents planned to share what they learned with their churches and communities “A lot of good information…that I can use in my practice.”
“I feel better able to address the issues with family members because of all that was shared.”
“I now feel more comfortable referring clients to hospice.”
“I feel more comfortable counseling families because I am more informed.”
I attended the seminar to learn “effective ways to impact end of life care in the
community”
I attended the seminar to learn “information on ways to help others and take that information back to my church.”

ADHERENCE TO DIABETES MEDICATION: A QUALITATIVE STUDY OF BARRIERS AND FACILITATORS AMONG URBAN, LOW INCOME MEXICAN-AMERICANS WITH TYPE 2 DIABETES Sara Baghikar 1, 2; Amanda Benitez1; Patty Fernandez Pineros1; Yue Gao1; Arshiya A. Baig1. 1University of Chicago, Chicago, IL; 2University of Illinois at Chicago, Chicago, IL. (Tracking ID #2198282)

BACKGROUND: Poor adherence to medication is an important barrier to metabolic control for Mexican-Americans with type 2 diabetes and contributes to adverse health outcomes in this population. Medication adherence is influenced by a complex interplay of different factors, including medication beliefs. The purpose of this study is to explore beliefs and perspectives on diabetes medications among urban, Mexican-Americans with type 2 diabetes in order to inform strategies to improve diabetes self-management.

METHODS: Face-to-face, in-depth interviews were conducted in Spanish with a sample of 27 individuals (25 Mexican-Americans and 2 Latinos of other origin) with type 2 diabetes as part of a church-based, randomized controlled trial for diabetes self-management in a low-income, Latino neighborhood of Chicago. Interviews were audio-recorded, transcribed verbatim and translated by bilingual staff. Systematic qualitative methods were used for analysis.

RESULTS: The sample included 5 males (19 %) and 22 females (81 %), the mean age was 57 ± 11 years and the mean duration of diabetes was 8.8 ± 7.5 years. 85 % of participants were on oral hypoglycemic medication and 30 % were on insulin therapy. Barriers to adherence were lack of knowledge and skills in managing medication, forgetfulness, social stressors, cost of medication and mental health problems. Furthermore, beliefs about harmfulness of medication, concerns with efficacy of medication and the perception that there is less need of medication when eating healthy and being physically active were present among many participants and emerged as important barriers to adherence. Family support emerged as the main facilitator to medication adherence.

CONCLUSIONS: Mexican-Americans with type 2 diabetes face multiple barriers to adherence, including lack of knowledge and skills to manage treatment and beliefs about harmfulness and lack of efficacy of medication. Healthcare providers need to assess and address patients’ perspectives and beliefs in order to improve medication adherence.

ADHERENCE TO SAFETY GUIDELINES FOR PRESCRIBING OPIOIDS FOR CHRONIC NONCANCER PAIN IN AN ACADEMIC PRIMARY CARE CLINIC Scott Steiger; Scott R. Bauer; John Gerstenberger; Hannah Harrison; Lily Hitchner. University of California, San Francisco, San Francisco, CA. (Tracking ID #2199490)

BACKGROUND: Several guidelines recommend dose limits and urine drug testing for patients prescribed opioids for chronic noncancer pain (CNCP). Higher prescribed doses inrease the risk of adverse effects, complications, and overdose. Drug testing appears to modestly decrease opioid misuse.

METHODS: To assess patient and provider characteristics associated with safer practices prior to implementation of quality improvement initiatives, we performed a retrospective cohort analysis of patients prescribed opioids for CNCP at two academic primary care clinics. We evaluated odds of high dose and urine drug testing using multivariate logistic models. Covariates included age, sex, race/ethnicity, marital status, city of residence, language, insurance, provider level, substance use disorders, smoking, and mental or physical comorbidities.

RESULTS: Among 842 patients prescribed opioids for CNCP (3.4 % of clinic population), 47 and 23 % were prescribed ≥50 and ≥180 mg morphine equivalents per day, respectively. Tables 1 shows adjusted odds ratio for each variable’s association with high dose. Associations were robust to sensitivity analysis using a 180 mg threshold. Thirty-five percent completed urine drug testing in the last 2 years. Table 2 shows adjusted odds ratio for each variable’s association with urine drug testing.

CONCLUSIONS: Patients managed by resident physicians were more likely to be treated in accordance with published guidelines, with lower doses of opioids for CNCP and greater odds of urine drug testing. High doses were less common in some groups and more common in nonlocal patients. Urine drug testing was uncommon and unequal utilization may have reflected biases and unsupported assumptions about risk of opioid misuse.

Odds of daily dose > 50 mg morphine equivalent

  Multivariate OR (95 % CI) P -value
Age (years)
  < 50 1.0 (Ref.)  
 50 to <60 0.74 (0.49–1.12) 0.15
 60 to <70 0.86 (0.56–1.32) 0.49
   ≥ 70 0.44 (0.26–0.74) 0.002
Female 0.68 (0.50–0.93) 0.02
Married 1.01 (0.72–1.43) 0.94
Non-San Francisco address 2.09 (1.52–2.89) <0.001
Non-English speaking 0.71 (0.33–1.53) 0.38
Medi-Cal insurance 1.24 (0.88–1.75) 0.22
Race/ethnicity
 Non-Hispanic White 1.0 (Ref.)  
 Black 0.97 (0.68–1.38) 0.87
Hispanic 0.53 (0.31–0.93) 0.03
Asian 0.33 (0.15–0.76) 0.008
Other/Mixed 0.80 (0.44–1.46) 0.47
Resident Physician Provider 0.66 (0.46–0.94) 0.02
Charlson Comorbidity Index
 0 1.0 (Ref.)  
 1 1.31 (0.91–1.88) 0.14
  ≥ 2 1.16 (0.81–1.68) 0.42
Other Comorbidities
 Alcohol use disorder (ever) 1.16 (0.58–2.32) 0.67
 Tobacco use (ever) 0.88 (0.55–1.39) 0.57
 Other substance use disorder 0.78 (0.42–1.46) 0.44
 Common mental health disorders 1.33 (1.00–1.80) 0.05
 Other mental health disorders 0.95 (0.60–1.50) 0.83
 Hypertension 0.87 (0.63–1.21) 0.41
 Obesity 1.01 (0.70–1.47) 0.81

Odds of urine drug testing in last 2 years

  Multivariate OR (95 % CI) P -value*
Morphine daily dose equivalent, mg/day
  < 50 1.0 (Ref.)  
50 to <180 3.11 (2.09–4.63) <0.001
   ≥ 180 3.92 (2.59–5.96) <0.001
Age (years)
  < 50 1.0 (Ref.)  
 50 to <60 1.22 (0.79–1.91) 0.37
 60 to <70 0.85 (0.53–1.37) 0.51
  ≥ 70 0.60 (0.33–1.10) 0.10
Female 1.08 (0.76–1.54) 0.66
Married 0.95 (0.65–1.41) 0.81
Non-San Francisco address 0.64 (0.44–0.92) 0.02
Non-English speaking 0.89 (0.35–2.26) 0.80
Medicaid insurance 1.92 (1.32–2.78) 0.001
Race/ethnicity
 Non-Hispanic White 1.0 (Ref.)  
Black 1.79 (1.21–2.65) 0.003
 Hispanic 0.98 (0.52–1.85) 0.95
 Asian 0.49 (0.18–1.32) 0.16
 Other/Mixed 0.73 (0.37–1.45) 0.45
Resident Physician Provider 3.52 (2.38–5.20) <0.001
Charlson Comorbidity Index
 0 1.0 (Ref.)  
 1 1.11 (0.75–1.65) 0.61
  ≥ 2 1.01 (0.67–1.53) 0.95
Comorbidities
 Alcohol use disorder (ever) 1.01 (0.46–2.22) 0.99
 Tobacco use (ever) 1.43 (0.87–2.34) 0.16
 Other substance use disorder 2.76 (1.40–5.42) 0.003
 Common mental health disorders 1.09 (0.78–1.52) 0.61
 Major mental health disorders 1.20 (0.74–1.99) 0.48
 Hypertension 0.73 (0.50–1.06) 0.09
 Obesity 0.65 (0.43–0.99) 0.05

ADVANCED FUNCTIONAL IMPAIRMENT IS ASSOCIATED WITH HIGHER POST-ACUTE COSTS OF CARE IN MEDICARE SENIORS S. Ryan R. Greysen 1; Irena S. Cenzer2; Ken Covinsky2. 1University of California, San Francisco, San Francisco, CA; 2University of California San Francisco, San Francisco, CA. (Tracking ID #2199473)

BACKGROUND: Background: Hospitalization identifies patients who are particularly costly to the Medicare system and current policy efforts to reduce costs focus on the 30 days after discharge; however, much less is known about which patients will have the greatest long-term Medicare costs. Given the prevalence of functional impairment in Medicare seniors and impact on clinical outcomes of hospitalization, we hypothesized that functional impairment would be significantly associated with higher costs of care up to a year after discharge.

METHODS: Methods: We studied 7854 Health and Retirement Study (HRS) subjects who were hospitalized at least once from 2000 to 2010 (18,598 hospitalizations). Our outcome was total post-acute costs for up to 365 days after hospital discharge, assessed by Medicare claims and adjusted for inflation. Main predictor was functional limitations as determined from the HRS interview immediately before the hospitalization and stratified into 5 levels: no functional impairments, difficulty with ≥1 instrumental activity of daily living (IADL), difficulty with ≥1 activity of daily living (ADL), dependency (need for help) in 1–2 ADLs, and dependency in ≥3 ADLs. Adjustment variables included age, race, gender, income, and net worth (obtained from HRS) and comorbid conditions (Elixhauser calculated from Medicare claims), and prior history of admission. We performed descriptive statistics and multivariable regression analysis adjusted for clustering at patient level to characterize the association of functional limitations and post-acute costs of care.

RESULTS: Results: Mean age was 78 (65–105), 44 % male, 77 % White, 90 % reported ≥3 comorbidities, 61 % with ≥1 hospitalization in previous year; 48 % had had some level of functional impairment prior to hospital admission. Unadjusted analyses show an increase in post-acute costs as the severity of impairment increases in a dose–response fashion; however, adjusted analyses suggest that this effect applies only to patients with more advanced impairments. While patients with IADL or ADL difficulty did not have significantly higher adjusted costs, those with any level of dependency in ADLs had much higher adjusted post-acute costs at 1 year: patients with 1–2 ADL dependencies cost $3235 more (95 % CI $857–5613) and those ≥3 ADL dependencies cost $8289 more ($4940–11,637) compared to patients with no impairments (Table 1).

CONCLUSIONS: Conclusions: Advanced functional impairment (ADL dependency) is associated with significantly higher post-acute costs in Medicare seniors; less severe impairments (ADL or IADL difficulty) are not. Our findings suggest the need for Medicare policy to expand beyond the traditional focus on chronic disease management and explore initiatives to manage advanced functional impairment in order to reduce overall costs of post-acute care for community-dwelling seniors.

Table 1: Association of Functional Impairments with Higher Post-Acute Costs

  Unadjusted Adjusted*
  N (%) Mean Total Cost ($) Mean Absolute Change ($) 95 % CI Mean Absolute Change ($) 95 % CI
Overall 18,598 32,395     
No Impairments 9765 (52 %) 28,773 reference   reference  
Difficulty with ≥1 IADL 2443 (13 %) 31,965 2103 (135,4073) −698 (−2513,1117)
Difficulty with ≥1 ADL 3274 (18 %) 32,997 3925 (2329,5522) 175 (−1277,1627)
Dependency in 1–2 ADL 1991 (11 %) 40,019 10,473 (7620–13,326) 3235 (857–5613)
Dependency in ≥3 ADL 1108 (6 %) 49,543 19,708 (15,895–23,522) 8289 (4940–11,637)

*Adjusted for comorbidities (30 Elixhauser conditions), age, race, gender, income, net worth, marital status, education, and hospitalizations in the prior year

AFTER HOSPITALIZATION, FOLLOW-UP WITH YOUR (AND ONLY YOUR) PRIMARY CARE PHYSICIAN IS ASSOCIATED WITH REDUCED READMISSIONS Ryan D. Schulteis 2, 1; David Simel2, 1. 1Duke University Medical Center, Durham, NC; 2Durham VA Medical Center, Durham, NC. (Tracking ID #2198618)

BACKGROUND: One intervention that is oft proposed to reduce hospital readmissions is arrangement of early follow-up visits. Studies examining the impact of post-hospital follow-up, however, have not shown an association with reduced readmissions. Furthermore, no studies, to our knowledge, have compared the effect of follow-up visits to Primary Care Physicians (PCPs) vs. non-Primary Care Physicians (non-PCPs). In this study, we measure the impact of the following follow-up visit types on a patient’s timing of readmission: 1) Follow-up with the patient’s own PCP; 2) Follow-up with another PCP that is not the patient’s own; and, 3) Follow-up with a non-PCP.

METHODS: We included patients discharged from the Durham VAMC Medicine service to the community over 43 months. For each, we recorded the time (in days) from discharge to readmission. To measure the associations of readmission with varying types of clinic visits, we recorded the times from discharge to the first follow-up visit with 1) a patient’s own PCP; 2) a PCP that was not the patient’s own; and, 3) a non-PCP physician. Using survival analysis with the Cox regression method, we measured the association of the various follow-up visits with time to readmission. We controlled for patients’ baseline predicted readmission risk. We generated time-dependent predictors to avoid producing artificially low, biased estimates of readmission risk otherwise generated when those patients at the highest risk of readmission are readmitted early and thus unable to arrive for a follow-up visit.

RESULTS: The predicted probability of readmission was positively associated with readmission risk. A visit with one’s own PCP was protective and associated with a reduced risk of readmission (HR 0.79, p < 0.001, Table 1, Figure 1). This effect was independent of the baseline predicted risk of readmission. The effect of a visit with a non-PCP was hazardous and associated with a significant and near 3-fold increase in risk (HR 2.63, Table 1, Figure 1). There was no apparent effect of follow-up with a PCP that was not the patient’s own on readmission (HR 1.00, p = 0.97).

CONCLUSIONS: These results are consistent with previous studies in demonstrating that follow-up with an unspecified PCP is not associated with any alteration in the risk of readmission. However, unlike previous studies, we were able to measure the effect of follow-up with one’s own PCP on readmission and found it to be protective (and associated with a readmission risk reduction of 25 %). Furthermore, we found that follow-up in the clinic of a non-PCP physician was associated with a near 3-fold increase in readmission risk. These results suggest that efforts to reduce readmissions through post-hospital follow-up should focus on improving access of patients to their own PCPs in the weeks following discharge. Futhermore, we have evidence that follow-up with unfamiliar PCPs are ineffective; worse, follow-up visits with non-PCPs following hospitalization are associated with, and may cause, increased readmissions.

Table 1: Effect of Type of Follow-Up Visit on Readmission: Adjusted Hazard Ratios (HR) from Multivariate Analysis

  HR 95 % CI p-value
Predicted Probability of Readmission 1.03 1.02–1.04 <0.001
Follow-up Visit with One’s Own PCP 0.79 0.69–0.91 <0.001
Follow-up Visit with Another PCP 1.00 0.88–1.14 0.97
Follow-up Visit with non-PCP 2.63 2.27–3.05 <0.001
figurep

Figure 1: Predicted survival to readmission for a cohort of patients each of whom has a clinic visit with their own PCP at day 7 (red curve) and a cohort of patients each of whom is seen by a non-PCP at day 21 (blue curve).

ALIGNING CLINICAL WITH EDUCATIONAL VALUE: A MULTI-SITE ASSESSMENT OF PATIENTS’ NEEDS AND POTENTIAL FOR STUDENT PATIENT NAVIGATORS Bobbie Johannes; Deanna Graaf; Barbara Blatt; Jed Gonzalo. Penn State College of Medicine, Hershey, PA. (Tracking ID #2200306)

BACKGROUND: Targeting patient needs beyond traditional clinic walls is becoming a primary focus of healthcare reform. New models of health care delivery, such as Accountable Care Organizations, Patient Centered Medical Homes and clinically integrated networks, are being used to address gaps in high-value care delivery. One healthcare delivery role, patient navigation (PN), has been used to improve patient outcomes, and has the potential to be used even more in evolving healthcare models. Although PN is well established in oncology, less is known about the value of PN in other patient populations, including medicine and surgery. Additionally, with the increasing need to provide medical students with authentic, value-added roles contextualized in systems sciences, we embarked on this project to develop a network of clinical sites within health systems in south-central Pennsylvania able to integrate medical students as PNs in a year-long educational experience. In this study, we explored the views of clinical site leadership regarding: (1) the key systems-related barriers encountered by their patients, and, (2) their perceptions regarding the potential to embed students as PNs to work with these patient populations in need.

METHODS: From January-November 2014, we performed an inductive content analysis of data obtained for the purpose of assessing clinical site willingness to collaborate in student PN. After identifying potential clinical sites within our region, we contacted site leaders, explained the student PN program, and requested a site visit to discuss opportunities. During site visits, we sought to understand the mission of each site, services provided, reported needs of site leaders as to care barriers encountered by patients, and potential for embedding students as PNs. Immediately following each visit, two investigators recorded a reflection on issues discussed and perceptions of receptivity of the program. Following each visit, a digitally-recorded key informant telephone interview with a site member was performed, exploring site demographics, current PN activities performed, and perceived value of student PNs. From these two data sources, the process of constant comparative analyses was used to identify initial themes and categories, and generate a preliminary codebook. Two investigators independently analyzed transcripts and compared codes for agreement. The research team had regular adjudication meetings to review codes, reconcile disagreements, and update the codebook.

RESULTS: To date, 20 site visits and follow-up informant interviews have been completed, with a wide variation in clinical site type, including primary care clinics, inpatient medicine discharge programs, a surgical-oncology transitions program, breast cancer survivorship program, and a state-run Tuberculosis clinic. Each site identified specific patient populations in need of PN, but notably the systems barriers encountered were variable and specific to each clinical site. In our preliminary analysis, several themes of systems barriers were identified, including un-/underinsured, poor access to medications and mental health services, and health literacy. Sites have processes in place to assist patients with specific barriers, including financial assistance programs, medical assistance education by attorneys, medical reconciliation programs, and transportation services; however, they report insufficient resources/staffing to fully realize the benefit of these strategies. Overall, sites had positive perceptions regarding the value-added role for student PNs, specifically with the anticipation of improved patient outcomes from performing tasks such as education about disease, medications, and follow-up appointments, coordinating appointments, linking patients to insurance exchanges, and performing home safety assessments.

CONCLUSIONS: Despite the popularity of PN for cancer populations, our results highlight the potential for expanding PN to a wide range of clinical sites, including outpatient and inpatient settings that care for both medical and surgical patients. Key systems barriers were not consistent across this range of clinical sites, suggesting each local setting must identify and address these factors in developing PN tasks to improve outcomes. Clinics are engaged in closing the gap between delivering care for all facets of patients’ needs and the lack of necessary resources needed to accomplish this goal. Despite our initial concerns regarding the receptivity for integrating students in PN roles, site leadership had a positive attitude and willingness to collaborate, specifically because of the perceived impact these roles could have on patient outcomes. With the increasing need to educate collaboratively effective systems physicians, student PN roles that optimize high-value care in our health systems may be an innovative and value-added experience for both students and the health system.

ALLOPURINOL FOR PRIMARY AND SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE Rakshita Chandrashekar 1; Karthik Kannegolla2; Louis Toledo1; Craig Beam1. 1Western Michigan school of medicine, Kalamazoo, MI; 2Western Michigan university, Kalamazoo, MI. (Tracking ID #2199405)

BACKGROUND: Allopurinol is a xanthine oxidase inhibitor with anti-inflammatory properties and hence its key effects would include reducing superoxide anions and other free radicals which exert oxidative stress (OS); to increase tissue oxygen, and to increase hypoxanthine. This paper investigates the effect of allopurinol on cardiovascular events in patients with gout and hyperuricemia.

METHODS: We conducted a retrospective, cross-sectional study of patients at Bronson Methodist Hospital in Kalamazoo, MI, who were diagnosed with gout according to International Classification of Diseases. The protocol was approved by the Institutional Review Board of the hospital. Test group were patients who have been on allopurinol (100–300 mg per day) for at least 5 years and the control group with patients not on allopurinol. Demographics and cardiovascular comorbidities were collected by electronic medical record review. The primary outcome was a composite of hospital admissions for unstable angina, Myocardial Infarction and Congestive heart failure.

RESULTS: To assess the association between allopurinol use and number of admissions for cardiovascular events, a Poisson regression model was fit using data from 124 patients who were diagnosed with gout. Of these, 73 patients had been using allopurinol to manage gout for at least 5 years, while 51 patients who did not use allopurinol in gout management served as the control group. Both groups were controlled for diabetes mellitus, statin use, hypertension, and smoking status. It was found that allopurinol reduced hospital admission for cardiovascular events by nearly 50 % (p = 0.0003). The mean incidence of cardiovascular admissions in the allopurinol group was estimated to be 0.55 per patient/year while that in the control group was 1.11 per patient/year. These findings provide statistically significant evidence that allopurinol use (p = 0.0003) related to the incidence of cardiovascular admissions at the alpha = 0.05 level when controlling for statin use (p = 0.0192), hypertension (p = 0.3642), smoking status (p = < 0.0001), and diabetes mellitus (p = 0.7150). The insignificance of hypertension and diabetes mellitus indicate these two factors do not add additional predictive ability to the model when allopurinol use, statin use, and smoking status are already present in the model. It is also important to note that the observed sample had only n = 7 non-hypertensive cases and n = 124 hypertensive cases. The small n for the non-hypertensive group may have played a role in the lack of significance for hypertension.

CONCLUSIONS: In this study, patients with gout who did not take allopurinol had twice the incidence (50 %) of hospital admissions for cardiovascular events and all-cause morbidity compared to those who took allopurinol. Allopurinol should be considered for primary and secondary prevention of cardiovascular events in patients who have been diagnosed with gout or hyperuricemia. The possible influence of confounding factors is being investigated.

Poisson regression model

Effect Num DF Den DF F value Pr > F
Allopurinol use 1 118 14.23 0.0003
Statin use 1 118 5.63 0.0192
Hypertension 1 118 0.83 0.3642
Smoking status 1 118 20.18 <0.0001
Diabetes Mellitus 1 118 0.13 0.7150

This table provides the results of fitting the Poisson model. In this model, the effect of allopurinol use is tested while controlling for the effect of statin use, hypertension, smoking status and diabetes mellitus.

AN ANALYSIS OF RECRUITMENT FOR AN ADVANCE CARE PLANNING STUDY IN ADVANCED CANCER PATIENTS Renee R. Stewart; Benjamin Levi; Jane Schubart; Lauren J. Van Scoy; Chengwu Yang; Elana Farace; Michael Green. Penn State College of Medicine, Hershey, PA. (Tracking ID #2198547)

BACKGROUND: Recruitment of participants is an essential component of any research study, yet is a particularly challenging when investigating patients with life-limiting illnesses. Recruiting for advance care planning (ACP) research presents additional challenges due to the inherent sensitivity of end-of-life issues, particularly in the context of terminal cancer. Minimal research exists on how to efficiently recruit individuals for ACP studies. We investigated specific barriers to enrollment for a non-treatment based intervention for end-stage cancer patients.

METHODS: We examined recruitment data from a randomized controlled study that compared efficacy of a novel, interactive online decision aid to a standard advance directive tool. Patients were referred by their oncologists based on the following inclusion criterion: 1) age >18 years 2) stage IV cancer, and/or 3) a life expectancy of less than 2 years. Basic demographics, referring provider, date of recruitment attempts, and recruitment outcomes were recorded. Referrals were categorized by season as follows: winter (Dec–Feb), spring (Mar–May), summer (June–Aug) and fall (Sept–Nov). Eligible referrals were mailed a personalized recruitment letter with self-addressed opt-out cards and subsequently contacted via the telephone 3 weeks later to explain the study, answer questions, and schedule a study visit if interested. We compared characteristics of enrolled patients to those of non-participants using chi-square tests and Mann–Whitney-Wilcoxon tests.

RESULTS: Referrals were provided from thirty oncologists over a 5-year period. Of the 1988 referrals, 90 % (n = 1788) of patients were classified as non-participants. Among these non-participants, 31 % (n = 545) returned the opt-out card, 30 % (n = 530) declined participation via phone, 12 % (n = 217) were unreachable, 10 % (n = 180) reported being too ill, 6 % (n = 107) died prior to contact, 6 % (n = 100) expressed interest but did not follow-up, 4 % did not attend their scheduled appointment, and 2 % were deemed ineligible after referral. Non-participants were slightly older than enrolled participants (mean 64.2 years (SD 13.1) and mean 62.0 (SD 13.5) respectively, p = 0.02). Compared to participants, a higher percentage of non-participants were of minority backgrounds (8 % versus 4 %, respectively, p = 0.03). On average, non-participants lived further away (50.5 miles, SD 151.6) from the study site than did participants (38.4 miles, SD 52.8, p = 0.01). Two-thirds of all enrolled participants were recruited after no more than one phone call, whereas only 5 % were enrolled after three follow-up calls. The number of referrals received was significantly lower in winter (13 %) than other seasons (28 % spring, 31 % summer, 28 % fall, p = <0.001), yet there were no differences in enrollment based on season of referral (p = 0.22). There were no significant differences between participants and non-participants based on gender (p = 0.881) or referring specialist (p = 0.07).

CONCLUSIONS: We found that patients who enrolled in an ACP study lived closer to the study site than non-participants. We identified a diminishing return on time investment with multiple recruitment calls since the majority of patients enrolled within the first phone call. Thus, recruiters with limited time should consider prioritizing efforts on patients who live closest to the study site and towards making initial contact with potential participants.

AN ETHNOGRAPHIC STUDY OF GENERAL MEDICINE INTERPROFESSIONAL ROUNDS: EXPLORING INTERPROFESSIONAL COMPETENCIES Heather A. Ward 1; Sylvia Abonyi1; Mitchell Anderson1; Christina Sparrow2; Petrina McGrath2; M. Suzanne Sheppard2. 1University of Saskatchewan, Saskatoon, SK, Canada; 2Saskatoon Health Region, Saskatoon, SK, Canada. (Tracking ID #2198540)

BACKGROUND: The changing landscape of healthcare service delivery is resulting in expansion of interprofessional collaborative care that adress a broad spectrum of medical and social issues. In the setting of a fast paced hospital environment, achieving team function is challenging. Interprofessional rounds are one process for facilitating care coordination in an acute care setting by multiple healthcare providers. Recommended competencies and processes to facilitate interprofessional collaboration, including rounds, are based on theoretical frameworks, such as the CIHC (Canadian Interprofessional Health Collaborative 2010) Interprofessional Competency Framework. This theoretical framework has not been fully validated. We undertook an ethnographic study of interprofessional rounds to identify components (processes or competencies) identified by participants as facilitating this interprofessional activity and compared the identified themes to the CIHC competency framework.

METHODS: This study took place in an academic acute care setting, a general medicine clinical teaching unit (CTU). Each CTU provides care for an average of 25 to 30 patients with multisystem chronic disease. Daily interprofessional ‘bullet’ rounds are 15 min in duration for each CTU. Participants include the RN coordinator, MD/senior internal medicine residents, RN/LPNs, physical therapy, occupational therapy, speech language pathology, social work, pharmacy, registered dietician, and home care coordinator. An experienced ethnographer observed 8 days of bullet rounds (3 per day) and completed 8 interviews with individual participants following rounds. Thematic analysis of both the rounds observations and interviews was completed.

RESULTS: This ethnographic study focused on themes identified by participants as supporting or hindering the effectiveness of the interprofessional rounds. These themes were then compared to recommended competencies from the CIHC framework. Two themes were clearly identified to facilitate the effectiveness of team function during bullet rounds, and one that limited effectiveness: Team processes that facilitated interprofessional rounds: 1. Strength in one’s own role: Knowledge of full scope of professional practice that meets individual patient care needs. Being familiar with what each professional brings to the care of an individual patient, rather than familiarity with the roles of other healthcare professionals, brings more depth to the patient care discussion at interprofessional rounds. 2. Cognitive conflict regarding roles for each patient: facilitates information sharing and discussion of care coordination. Cognitive conflict arises as each profession applies their expertise in providing care for an individual patient, sometimes with different perspective on care needs. Resolving this cognitive conflict adds to care coordination and increases job satisfaction during rounds. Team processes that hindered interprofessional rounds: 1. Differing objectives for the round by participants: Acute care care coordination vs rounds with the intent of discharge. These two different objectives resulted in different perspectives on information to be discussed and intended outcomes of the discussion. Focusing on discharge limited participation in discussion by several healthcare professionals who brought information to discuss regarding acute care coordination during the hospital stay. The key components of the CIHC framework are role clarification, interprofessional conflict resolution, collaborative leadership and team functioning. Role clarification is defined as “learners/practitioners understand their role and roles of others…” In our study, the emphasis was on being familiar with one’s own role and to bring this knowledge to rounds. Being familiar with the roles of others was not identified by any of the participants. Cognitive conflict supports role clarification of one’s own role and introduced a different aspect to interprofessional conflict resolution with positive outcomes to interprofessional discussion of care. Collaborative leadership needs to include shared objectives or intended outcomes of interprofessional activities such as bullet rounds.

CONCLUSIONS: Competency frameworks provide a guide for developing components of interprofessional healthcare delivery; however, further validation, both for establishing interprofessional practices in individual healthcare settings and for furthering interprofessional education, needs to occur through in depth qualitative research methods.

AN EVALUATION OF COMPUTERIZED MEDICATION ALERT OVERRIDE BEHAVIOR IN INPATIENT AND AMBULATORY CARE Michael Swerdloff 7, 6; Diane L. Seger5; Mary Amato3; Nivethietha Maniam4; Olivia Dalleur2; Julie Fiskio7; Qoua L. Her2; Sarah P. Slight1; Patrick E. Beeler2; Tewodros Eguale2; Karen C. Nanji7; Patricia C. Dykes6; David W. Bates1. 1Brigham and Women, Boston, MA; 2Brigham and Women’s Hospital, Boston, MA; 3Brigham and Womens Hosptial/MCPHS, Boston, MA; 4Partners HealthCare, Cambridge, MA; 5Partners Healthcare System, Wellesley, MA; 6The Center for Patient Safety and Practice, Boston, MA; 7Partners Healthcare, Wellesley, MA. (Tracking ID #2198007)

BACKGROUND: Evidence suggests that computerized decision support (CDS) improves care, but the amount of improvement achieved is typically a fraction of what is possible. Understanding how physicians respond to CDS alerts is a critical factor in improving care with the electronic health records (EHRs). Application of the CDS alert functionality has been variable between inpatient and outpatient providers and we continue to observe a high level of medication alert overrides for many prescription domains. While many overrides are justified clinically, some are not. It is important to reach out to those providers who are not prescribing optimally and understand their reasons for overriding alerts, and how they differ in inpatient and ambulatory care.

METHODS: We evaluated all Level 2 alert overrides that required a coded reason to be provided at the time of prescribing between January 2009 and December 2011. We limited our sample to providers who had received 20 or more alerts in any of the prescribing domains (drug-drug interaction alerts, drug-allergy interaction alerts, renal suggestion alerts, non-formulary alerts and age-based alerts) and the number of times each provider overrode these alerts was calculated. Of the 2495 providers eligible for the study, 1770 inpatient and 725 ambulatory, those with a high inappropriate override rate were targeted for academic detailing sessions. Research pharmacists trained in effective counter-detailing techniques conducted these sessions, each of which was tailored to the provider’s particular overrides. Graphical material including performance level data, a list of their inappropriate overrides and supporting evidence-based summaries, was presented to each provider and this was used as the prime basis for a two-way discussion. A robust and complete analysis of the data was carried out and prevalent concepts related to general views on alert functionality and specific prescribing behavior indentified.

RESULTS: We conducted 42 total academic detailing sessions, 34 with outpatient and 8 with inpatient providers. Overall, clinicians were generally favorable towards the alerts and felt that they were helpful in identifying possible adverse events. Providers were especially grateful for alerts informing them about the risk of drugs they infrequently use. However, many providers in the inpatient setting felt that alerts that reminded them to monitor the patient were extraneous. Providers ignored these warnings in the hospital because they were seeing their patients regularly independent of the alerts. They would like the option to disable alerts they consistently override and ignore. Regarding non-formulary alerts in the inpatient setting, physicians would like to see alternatives that are on formulary as well as the cost differential between the two options built into the alerts. Clinicians in the inpatient setting would rather override a drug allergy alert than make changes to a patient’s allergy record if it was incorrect They felt that responsibility should lie with the patient’s primary care provider. In the outpatient setting, providers found that the clinical relevance of the alerts could be improved by providing recent laboratory values, as well as the ability to order additional tests directly from the alert.

CONCLUSIONS: A number of insights were identified through academic detailing sessions including that alert fatigue existed for warnings deemed irrelevant, and frustration that repetitive alerts cannot be disabled. Providers in the inpatient setting were more frustrated than those in the ambulatory environment when prompted to monitor their patients. The alerts were appreciated when the provider first saw the patient, however subsequent alerting was seen as frustrating and time consuming. Clinicians would like to see repetitive inpatient alerts less frequently. By incorporating provider preferences, customizing alerts to the context of the visit and considering the increased attention patients receive in a hospital; providers felt that CDS alerts would be less likely to be overridden providing more effective, efficient care.

AN EVALUATION OF THE IMPACT OF CALIFORNIA’S TRANSITION TO MANAGED CARE ON HEALTH CARE UTILIZATION BY MEDICAID SENIORS AND PERSONS WITH DISABILITIES Lhasa Ray 3, 4; David Zingmond1, 4; Sitaram Vangala3; Jennifer N. Sayles5; Michael Tu6; Li-Hao Chu6; Bruce A. Pollack6; Demetria Malloy6; Debra Saliba2, 4. 1UCLA, Los Angeles, CA; 2UCLA Borun Center, VA GRECC, RAND, Los Angeles, CA; 3University of California, Los Angeles, Culver City, CA; 4Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; 5Los Angeles County, Los Angeles, CA; 6 L.A. Care Health Plan, Los Angeles, CA. (Tracking ID #2193338)

BACKGROUND: Moving high-cost, medically complex Medicaid enrollees into managed care is a strategy states have used to stabilize health care spending and improve access, service coordination, and care outcomes for vulnerable populations. Little data exist to ensure that such transitions are effective in achieving these goals. California’s recent transition of Medicaid seniors and persons with disabilities (SPDs) in 16 counties from traditional fee-for-service to managed care offers an opportunity to evaluate the impact of a managed care expansion on health-related outcomes for this important patient population.

METHODS: L.A. Care Health Plan in Los Angeles County, the nation’s largest not-for-profit provider of Medicaid managed care, was assigned over half of the SPDs transitioned in the state during the 12-month implementation between June, 2011 and May, 2012. We matched 12 months of pre-transition paid claims obtained from California’s Department of Health Care Services to 12 months of post-transition managed care encounter-level data provided the plan. Monthly rates of outpatient physician visits, emergency department visits, and hospital admissions were calculated based on the number of eligible individuals each month, yielding events per 1000 member months (PMM). Utilization rates are reported with respect to each individual’s transition month. We used negative binomial GEE regression models to compare rates between the four six-month pre- and post-transition intervals while accounting for repeated measurements. Differences in rates were evaluated using contrasts.

RESULTS: Of 148,923 individuals assigned to L.A. Care through the transition, we identified 103,656 (69.6 %) matched individuals with at least one month of post-transition plan enrollment. The final sample includes 94,772 individuals ≥ 18 years. The sample’s mean pre-transition Medicaid eligibility and post-transition plan enrollment was 11 months in both periods. Outpatient physician visits (Fig. 1) were stable for the 12 months preceding the transition at approximately 370 visits PMM (p = 0.64 for −12 to −6 months vs. −6 to 0 months contrast), then reached a new steady state of 250 visits PMM after the early post-transition period when visits dropped as low as 160 visits PMM (p < 0.001 for the contrast). Inpatient hospital admissions (Fig. 2) rose from 30 to 35 admissions PMM pre-transition (p < 0.001), then dropped post-transition to approximately 25 admissions PMM (p < 0.001). The drop in inpatient hospitalizations appears to be primarily due to fewer elective admissions. ED visit rates were variable, rising from approximately 67 PMM pre-transition to 79 PMM immediately prior to managed care enrollment (p < 0.001). Post-transition, ED visits fell to approximately 73 visits PMM after the second post-transition month, and were relatively stable thereafter (p = 0.02).

CONCLUSIONS: The transition of Medicaid SPDs in Los Angeles County to managed care was associated with overall reductions in ambulatory care visits and acute hospital admissions. Utilization patterns occurring around the transition period raises concerns that beneficiaries may have attempted to manage potential loss of access during the transition. Future analyses using these data will include examination of additional months of post-transition utilization data, types and appropriateness of care, and subgroup effects.

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Figure 1

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Figure 2

AN INTERVENTION TO IMPROVE HOSPITAL CARE DELIVERED ON WEEKENDS Saul Blecker 1, 2; Keith Goldfeld1; Hannah Park1; Martha J. Radford1, 2; Sarah Munson2; Fritz Francois1, 2; Jonathan Austrian1, 2; R. Scott Braithwaite1, 2; Katherine A. Hochman1, 2; Richard Donoghue2; Bernard Birnbaum2; Marc N. Gourevitch1, 2. 1New York University School of Medicine, New York, NY; 2NYU Langone Medical Center, New York, NY. (Tracking ID #2195188)

BACKGROUND: Hospital care on weekends has been associated with delays in care, reduced quality, and poor clinical outcomes. The “7-Day Hospital Initiative” was a hospital-based intervention designed to improve patient throughput and quality of care delivered on weekends. The purpose of this study was to evaluate the impact of the intervention on processes of care and clinical outcomes at an academic medical center.

METHODS: The multifaceted inpatient intervention consisted of the following components: 1) expanded access on weekends to diagnostic procedures (echocardiography, cardiac stress tests, radiological services including interventional radiology); 2) expanded hospitalist coverage on the Medicine service on weekends, with improved structure for patient handoffs from weekday to weekend providers; 3) increased care management staffing on weekends; 4) implementation of standard weekend interdisciplinary rounds; 5) increased elective weekend surgeries (primarily outpatient). To study the impact of the intervention, we performed an interrupted time series observational study of adult non-obstetrical patients between January 2011 and January 2014. The primary outcome was average length of stay. Secondary outcomes included percent of patients discharged on weekends, 30-day readmission rate, and in-hospital mortality rate. We used segmented regression analysis with adjustment for confounders to determine associations between the intervention and outcomes.

RESULTS: The study included 57,163 hospitalizations. Following implementation of the intervention in July 2012, average length of stay decreased by 13 % and continued to decrease by 1 %/month as compared to the underlying time trend (Figure). The reductions in length of stay were observed on the Medicine service but not on Surgery (p < 0.001 for difference; Figure). The percent of weekend discharges increased by 12 % at the time of the intervention and continued to increase by 2 %/month thereafter (Table). The intervention had no impact on readmissions or mortality (Table). During the post-implementation period, the hospital was evacuated and closed for 2 months due to damage from Hurricane Sandy and a new electronic health record was introduced in our medical center. We observed a lower inpatient census and found differences in patient characteristics, including higher rates of Medicaid insurance and comorbidities, in the post-Hurricane Sandy period as compared to the pre-Sandy period.

CONCLUSIONS: The 7-Day Hospital Initiative, a multi-component intervention to increase hospital services on weekends, was associated with a reduction in length of stay and an increase in weekend discharges. The study also illuminated the challenges of evaluating the effectiveness of a large scale intervention in a real world hospital setting.

Results of the interrupted time series analysis evaluating the effect of the 7-Day Hospital Initiative on outcomes. The Change in Level and Change in Rate indicate whether the intervention had an immediate or ongoing effect on the outcome of interest, respectively.

Outcome Rate of Change, pre-Intervention Change in Level, Introduction of Intervention Change in Rate, post-Intervention
Length of Stay 1.01 (1.01, 1.02) 0.87 (0.85, 0.90) 0.99 (0.98, 0.99)
% Weekend Discharges 0.99 (0.99, 1.00) 1.12 (1.02, 1.22) 1.02 (1.01, 1.03)
Readmission 0.99 (0.99, 1.00) 0.90 (0.81, 1.01) 1.01 (0.99, 1.02)
Mortality 0.99 (0.97, 1.00) 1.10 (0.84, 1.44) 1.02 (0.99, 1.05)
figures

Trends in adjusted length of stay, by month. July 2012 represents the beginning of the 7-Day Hospital Initiative. Data from November and December 2012 are missing due to hospital closure related to Hurricane Sandy.

ANALYSIS OF 510,713 ALCOHOL DEPENDENT PATIENTS LEAVING AGAINST MEDICAL ADVICE IN THE LAST 10 YEARS: BURDEN ON HEALTH ECONOMY Rakshita Chandrashekar 1; Karthik Kannegolla2. 1Western Michigan school of medicine, Kalamazoo, MI; 2Western Michigan university, Kalamazoo, MI. (Tracking ID #2199191)

BACKGROUND: Alcohol dependence is a condition resulting from prolonged and usually intense consumption of alcohol which has resulted in psychological and/or physiological dependence on alcohol consumption. This dependence results in significant problems in one or more areas of the person’s life. Millions of dollars are spent on these patients initially for their treatment but the patients decide to leave against medical advice (AMA) with incomplete treatment causing significant financial loses in the economy. Our aim is to assess the demographics of alcohol dependent patients that left AMA in 2012 and to also assess the trend of discharges from 2002–2012.

METHODS: Nationwide Inpatient Sample (NIS) database is developed through Agency of Healthcare and Research quality through federal-state funded partnership and represents 20 % of all the hospitalizations in USA. NIS data was used to extract demographics of alcoholic patients who left AMA for the year 2012 like the number of discharges, location and teaching status of hospitals, hospital regions, mean length of stays (LOS) in hospitals, mean hospital charges (in dollars), insurance payers and the trends of discharges from 2002 to 2012 using Diagnosis Related Group (DRG).

RESULTS: We extracted data for 43,440 alcohol dependent patients who left AMA in 2012. Their mean LOS was 2.4 days. Majority of patients (57.29 %) were between age group of 18–44 years, followed by patients between 45 and 64 years (40.07 %) with men leaving AMA thrice more often than women. Most patients were admitted in private, not for profit hospitals (77.04 %), in urban teaching hospitals (56.54 %), hospitals with large bed size (49.01 %) and were covered for by Medicaid (39.05 %) or private insurance (20.03 %). Most patients were from northeastern part of USA (50.06 %) followed by Western part (12.13 %). The cost of hospitalization in the West is more when compared to Hospitals from the Northeast ($16,000 vs $9825) though the former have far less cases reported. The mean hospitalization charge per patient was $10,415 and the total national aggregate charge was close to 453 million dollars. There were 510,700 patients who left AMA between 2002 and 2012. The maximum number of cases were in the year 2006 (53,073 cases), and minimum in 2003 with 41,041 cases. There has been no change in median LOS in hospitals in the last 10 years but the mean charges have increased from $6000 in 2002 to greater than $10,000 per patient.

CONCLUSIONS: Our study reports the demographic distribution that greater than 55 % of cases that left AMA are treated by urban teaching hospitals and close to 50 % cases are from the Northeast due to unknown factors. More than 452 million dollars are being spent annually on this subset of the population who leave before the completion of treatment is accomplished. By investing in programs dealing with social and psychological factors that lead to them leaving AMA, recurrent admissions for partially completed treatments could be limited, thereby reducing burden of millions of dollars on healthcare economy.

ARE RESEARCH ETHICS COMMITTEES PREPARED FOR COMMUNITY BASED PARTICIPATORY RESEARCH? Leonardo Tamariz; Ana M. Palacio; Olveen Carrasquillo. University of Miami, Miami, FL. (Tracking ID #2199123)

BACKGROUND: Community-based participatory research (CBPR) is a collaborative approach to research that involves all partners in the research process and recognizes the unique strengths that each brings. This new research methodology presents a variety of challenges for research ethics committees (RECs). The purpose of this study is to summarize the evidence supporting the level of preparedness that RECs have when reviewing CBPR projects.

METHODS: We performed a search of the MEDLINE database (1966 to December 2014) supplemented by manual searches of bibliographies of key relevant articles. We included studies that used surveys of researchers or REC members, evaluations of the forms and procedures of the REC and case studies reporting on experiences when submitting a CBPR project through a REC.

RESULTS: The search strategy yielded 42 studies, of which only 8 met our eligibility criteria. Five studies reported results of surveys of researchers and REC members and three studies reported on qualitative experiences of case studies when submitting a CBPR project through a REC. Three studies evaluated the REC’s submission/reviewer forms and found that the community involvement could be elicited in a median of 5 % (range 0–15 %) of all forms in 131 RECs from the US and Canada. One study surveyed community partners of CBPR projects who reported that common challenges when working with RECs were delays and lack of understanding of CBPR principles. One study surveyed REC members and found that they felt prepared to review CBPR projects. Facilitators of approval of CBPR projects were adequate communication between the REC and the community, use of community advisory boards, and having a large number of research projects. The case studies of researchers trying to submit CBPR projects to RECs, consistently reported frustration related to delays and refusal to approve, lack of understanding of community ethics, dealing with multiple RECs, risk determination, and research protection oversight.

CONCLUSIONS: RECs are not prepared to evaluate CBPR projects based on evaluation of the REC forms and process. This lack of preparedness leads to unnecessary delays in the approval process and is related to REC members not being familiar with the CBPR principles. CBPR training and better communication with the community are key to improving the process.

ASSESSING LEARNER ENGAGEMENT AND KNOWLEDGE: USE OF TEAM BASED LEARNING FOR INTERNAL MEDICINE AMBULATORY RESIDENT TEACHING Sandy Balwan 2; Alice Fornari1; Paola Dimarzio2; Jennifer Verbsky2; Renee Pekmezaris2; Saima Chaudhry3. 1Hofstra NSLIJ SOM, Hempstead, NY; 2North Shore LIJ Health System, Great Neck, NY; 3nslij, Manhasset, NY. (Tracking ID #2185058)

BACKGROUND: Traditional resident teaching is a passive process that does not model the “active learning” strategies currently promoted in medical education. Team Based Learning (TBL) is an active strategy commonly used in Undergraduate Medical Education (UME) to facilitate higher order content learning, promote high levels of learner engagement and collaboration, and foster positive learner attitudes. However, there is little data on the effect of TBL in Graduate Medical Education (GME) on medical resident and faculty engagement and satisfaction, and residents’ medical knowledge.

METHODS: In 2012, we replaced our didactic based ambulatory medicine curriculum with a TBL pedagogical approach to support our ambulatory curriculum. We are a large internal medicine residency program using two different ambulatory sites. The specific aims of this study was to determine whether TBL improves: 1) medical resident and faculty engagement and satisfaction, and 2) residents’ medical knowledge assessed by multiple readiness assurance tests. We assessed medical knowledge using individual (IRAT) and group readiness assurance (GRAT) tests. A prior validated survey was used to measure resident involvement, contribution, participation, and engagement. We used a modified Nominal Group Technique (NGT) to provide semi-quantitative, rank-ordered feedback on participant perceptions of medical education experiences. Residents and faculty who experienced both the traditional model and the TBL approach were asked the following:“Compared to the traditional didactic based ambulatory learning sessions used last academic year, please comment on the strengths and weaknesses of the TBL curriculum used this academic year.”

RESULTS: For all modules, the average GRAT score was significantly higher than the average IRAT score, with a range of improvement from 10 to 31 points (Wilcoxon signed rank tests for all matched pairs (p < 0.0001 for all seven modules). The survey response rate for residents and faculty was 61 and 85 %, respectively. The vast majority of faculty and residents agreed or strongly agreed that: 1) most residents were actively involved in TBL sessions, 2) contributed meaningfully to group discussions 3) talked with other residents about the material in each session, 4) contributed their fair share to the TBL session; 5) paid attention 6) participated in session discussions and 7) were perceived to be learners in the discussion Results from our NGT show that both residents and faculty thought the most important strength of the TBL curriculum was the interactive format with group work. Residents and faculty also reported that the competition between residents was a positive aspect of TBL. Interestingly, residents and faculty both ranked the format of TBL as both a strength and a weakness.

CONCLUSIONS: Both our survey and NGT results support our hypothesis that TBL promotes resident engagement. Positive feedback from the NGT data, from both residents and faculty, support the premise that learning in teams is favorable and creates a teaching environment where learners are engaged. In terms of knowledge, GRAT scores consistently increased for each clinical topic and overall composite knowledge scores increased by approximately 22 %. Survey results reported residents being actively involved in TBL sessions, contributing to group discussions and actively discussing the subject material with other residents. Faculty echoed similar responses and both residents and faculty reported that they would like more teaching session to be offered using the TBL pedagogy. In conclusion, TBL resulted in active resident engagement, improved group medical knowledge, and increased satisfaction by residents and faculty with learning specifically focused on the care of patients in the ambulatory setting.

Table 1: TBL Process

Session Activity
Pre TBL Session Residents emailed relevant articles and cases
Day 1 Administration of IRAT/GRAT with faculty facilitating the discussions of the questions. IRAT/GRAT collected.
Day 2 Clinical vignette with eight learning objectives distributed to residents. Faculty facilitates residents reading of case and choosing two additional learning objectives.
Day 3 Residents report out on all learning objectives.
Post TBL Session Residents complete peer evaluations and peer evaluations distributed to respective residents

ASSESSING SENIORS’ NORMATIVE BELIEFS AND SHARING OF HEALTH INFORMATION ABOUT THE PNEUMOCOCCAL VACCINATION Crystal T. Doan 1; Shira N. Goldman1; Tiffany Brown1; Stephen D. Persell1; Alpa Patel2; Kenzie A. Cameron1. 1Northwestern University Feinberg School of Medicine, Chicago, IL; 2Northwestern Medicine, Chicago, IL. (Tracking ID #2195864)

BACKGROUND: In 2012, only 59.9 % of seniors were vaccinated against invasive pneumococcal disease, despite the Healthy People 2020 goal of 90 % vaccination. Prior research has found that physician recommendations and patient attitudes may be more powerful predictors of pneumococcal vaccination (PnVx) than patient access to medical services. It remains unclear how patients’ normative beliefs about PnVx influence their vaccination decisions. Normative beliefs are perceptions of how the general population behaves and judgments toward these behaviors. They can be divided into: 1) injunctive norms, i.e., individuals’ perceptions of what should be done, based on what is socially acceptable; and 2) descriptive norms, i.e., individuals’ perceptions about the prevalence of a behavior. We assessed individuals’ normative beliefs, and explored differences by race and receipt of PnVx. We also assessed if patients discussed pneumonia and PnVx with anyone following a clinic visit.

METHODS: English-speaking patients age 65 and 66 from an academic general internal medicine clinic were recruited to participate in a telephone survey to assess their normative beliefs about pneumonia and PnVx approximately 1 week following their clinic visit. As part of a larger study, these patients had been shown a brief, 2-min educational video about PnVx at that visit. To assess normative beliefs, we created a 4-item injunctive norm scale (α = 0.69; e.g. “In general, most people think it is a good idea to get the pneumonia shot”) and a 3-item descriptive norm scale (α = 0.78; e.g. “I think that most people who are 65 or older get the pneumonia shot”). Patients responded on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree).

RESULTS: Participants (N = 72) had a mean age of 65.2, were 62.5 % female, 36.1 % identified their race as Black and 55.6 % as White, and 94.4 % had at least some college education. There was no variation by race on receipt of PnVx, with 52.8 % of patients reporting receipt at their recent clinic visit. Patients’ injunctive norms slightly supported receipt of PnVx (M = 3.70, sd = 0.84), but their descriptive norms toward receipt of PnVx were neutral (M = 3.13, sd = 1.20). Overall, neither injunctive nor descriptive norms differed between Black (injunctive norms: M = 3.44, sd = 0.93; descriptive norms: M = 2.84, sd = 1.47) and White patients (injunctive norms: M = 3.81, sd = 0.76; descriptive norms: M = 3.25, sd = 1.01). In addition, neither injunctive nor descriptive normative beliefs differed among participants based on self-reported PnVx vaccination status. Overall, participants had high agreement with the statement “My doctor thinks I should get the pneumonia shot” (M = 4.63, sd = 0.83). Compared to participants who did not receive the vaccine, those who received PnVx at their clinic visit were significantly more likely to discuss pneumonia and PnVx with others (Χ2 = 8.30, p = 0.016). Participants discussed pneumonia and PnVx after their clinic visit with friends and acquaintances (n = 22), family members (n = 19), partners or spouses (n = 17), and other medical professionals (n = 5). However, half (55.6 %) of patients reported being unaware that PnVx was covered by Medicare.

CONCLUSIONS: In our sample, we discovered no racial differences when exploring participants’ injunctive and descriptive norms toward receipt of PnVx. Not surprisingly, participants strongly agreed that their physicians supported receipt of PnVx. However, only half of those eligible received PnVx at their recent visit, and over half were unaware that Medicare covers the cost. These findings from our small sample at a single site could suggest that factors other than injunctive and normative beliefs are driving vaccination behavior. It is notable that those who received PnVx were likely to share information regarding pneumonia and PnVx with others after their visit, showing the proliferation of health communication beyond the medical encounter. Further research should explore both the content of this shared information as well as how best to utilize social networks to improve PnVx rates.

ASSESSMENT OF OPERATIONAL DEFINITIONS FOR MEDICATION ADHERENCE USING LONG-TERM OUTCOMES IN PATIENTS WITH HYPERTENSION Karen Tang; Hude Quan; Doreen Rabi. University of Calgary, Calgary, AB, Canada. (Tracking ID #2195940)

BACKGROUND: Medication adherence is defined as the extent to which a patient takes prescribed medications according to the dosage and frequency recommended by the provider. Research studies examining medication adherence tend to use pharmacy data, indirectly measuring adherence using the “medication possession ratio” [MPR] or the “proportion of days covered” [PDC]. Despite widespread use of these terms, there are in fact no standard operational definitions for adherence, nor is there a standard method of measuring adherence in patients using concurrent medications (termed “polytherapy”). In order to determine whether the use of different operational definitions results in different conclusions regarding adherence and outcomes, we aimed to compare and contrast adherence rates and association with mortality using MPR and PDC definitions of adherence, and using various methods of handling polytherapy.

METHODS: We conducted a cohort study of patients aged ≥65 years from Manitoba, Canada, with incident hypertension diagnosed in 2004, and followed up to 2009. Drug data were obtained from the Manitoba Pharmacare prescription database. We calculated and compared adherence rates to anti-hypertensive medications using the following operational definitions for medication adherence: MPR using a fixed observation interval of 1 year (“MPRi” = days supply/ 365 days), MPR using a prescription based interval (“MPRp” = days supply excluding last refill / (last refill date - first fill date)), and PDC (calculated as the number of days where at least one medication is available / 365 days). For patients on polytherapy, four different MPRi and MPRp’s were calculated: 1) MPR to any antihypertensive medication (“sum MPR”); 2) mean of the class-specific MPR’s for each anti-hypertensive medication prescribed (“mean MPR”); 3) the lowest of the class-specific MPR’s (“low MPR”); and 4) the highest of the class-specific MPR’s (“high MPR”). All adherence measures were dichotomized using the standard threshold of 0.80 such that patients with MPR’s or PDC’s greater than 0.80 were considered “adherent” to their medications. Logistic regression and Cox regression were performed to determine the association between medication adherence using these operational definitions and mortality.

RESULTS: Our final cohort consisted of 2199 patients. Mean age (SD) was 75.2 (7.0) years, 45.5 % were male, and 64.7 % were on monotherapy. For those on monotherapy, 71.8 % were considered adherent when using MPRi or PDC definitions, and 76.7 % were considered adherent when using the MPRp definition. For those on polytherapy, the proportion considered adherent ranged from 24.1 to 90.5 % using MPRi, depending on the method used to manage concurrent medications, compared to 71.2 to 92.7 % using MPRp measures. Using the “mean MPRi” and “mean MPRp” measures, the proportion considered adherent were 33.7 and 81.0 % respectively. Adjusted logistic regression showed a trend toward adherence being inversely associated with death for all definitions, with the association being strongest for MPRp measures (adjusted OR 0.71 to 0.78 [95 % confidence interval (CI) 0.53, 0.86 to 0.58, 1.03] for MPRp measures; aOR 0.80 to 0.90 [95 % CI 0.59, 1.09 to 0.68, 1.19] for MPRi measures). For patients on polytherapy, this association was significant only with mean MPRp [aOR 0.71, 95 % CI 0.53, 0.95] and sum MPRp [aOR 0.72, 95 % CI 0.51, 0.99] measures, but not with the highest or lowest class-specific MPRp’s, or with any MPRi or PDC measures.

CONCLUSIONS: The range of adherence estimates varies widely depending on the operational definition for adherence used, especially for patients taking more than one medication concurrently. The use of fixed observation intervals versus prescription based intervals as the denominator in MPR definitions also results in substantially different conclusions about medication adherence. These findings call for transparency in medication adherence research, such that the operational definition used is clearly defined, as well as for the development of a harmonized and accepted standard operational definition of adherence. Given less variation in adherence rates calculated by MPRp measures and its stronger association against mortality, MPRp (specifically mean or sum MPRp for those on polytherapy) are the recommended operational definitions for medication adherence.

ASSOCIATION BETWEEN DIABETES SELF-CARE AND PERCEIVED SUPPORT IN A SAMPLE OF LOW-INCOME AFRICAN AMERICANS Brittany D. Payne2; Robert Oster1; John P. Shelley1; April A. Agne1; Andrea Cherrington 1. 1University of Alabama Birmingham, Birmingham, AL; 2University of Alabama at Birmingham, Birmingham, AL. (Tracking ID #2199151)

BACKGROUND: Self-care behaviors are important to diabetes care and health outcomes. Studies suggest that social support is positively linked to self-care behaviors in patients with diabetes; however, the research examining social support and diabetes in minority communities is more limited. The purpose of this study was to investigate the multiple dimensions of social support and its relationship with diabetes self-care behaviors among African Americans. Specifically, we measured perceived support from health care professionals, as well as family and friends, and its relationship to medication adherence and an additional five diabetes self-care behaviors.

METHODS: We surveyed 119 low-income African American adults diagnosed with type II diabetes living in Birmingham, AL as part of the baseline assessment for a study examining the influence of community health workers on diabetes-related self-care, education, and outcomes. Participants were recruited from a local safety net health system and were included if they had diagnosed diabetes, poor glycemic control (HbA1c >7.5), and had been seen at the clinic within the last 2 years. Using previously validated measures, participants were queried regarding self-care activities (general diet, specific diet, exercise, blood glucose testing, and foot care), medication adherence, diabetes distress, depression, and social support. Support from the health care team was assessed using two items, one regarding perceived support and the other, satisfaction with support received. Perceived support from family and friends was assessed using a 5 item scale. Spearman (nonparametric) correlation analysis was used to determine bivariate associations. Statistical tests were two-tailed and were performed using a significance level of 5 %.

RESULTS: Our study population comprised 80 female and 39 male participants, age 31 and older (mean = 55, SD = 8), with about 1/2 having completed at least a high school level education. Participants had average HbA1c = 10 % and had been diagnosed with diabetes for about 9 years. While a majority of study participants (88 %) use cell phones, about 65 % never or rarely use text messaging or internet. Satisfaction with the support from the health care team was significantly associated with all 5 self-care behaviors (p = .001, .048, .001, .049. .042, respectively) as well as medication adherence. Perceived amount of social support from the health care team was significantly associated with general diet and exercise (p = .008 and .045, respectively). Both amount of support and satisfaction from the health care team were positively associated with age, education, and the extent to which the participant used text messaging and internet (p = .002 and .011 for amount of social support, and p = .001 and .001 for satisfaction with social support). Perceived social support from family and friends was positively associated with medication adherence (p = .001) but not the other self-care behaviors. Women were more likely to report support from family and friends (p = .041) and depression was inversely related to such support (p = .001). Higher levels of support from the health care team and from family and friends were associated with less diabetes distress (p = .004).

CONCLUSIONS: Findings in this study of low income African Americans with diabetes indicate that perceived support influences diabetes self-care. Satisfaction with the health care team was associated with the highest number of self-care behaviors, though perceived amount of support from the health care team and support from family and friends were both positively associated with some behaviors. While overall use of text messaging and internet was low, individuals engaging in these behaviors reported higher levels of social support. Diabetes specific distress was mitigated by support from both the health care team and family and friends.

ASSOCIATION BETWEEN FRAILTY AND 30-DAY OUTCOMES AFTER DISCHARGE FROM GENERAL INTERNAL MEDICINE WARDS: A MULTI-SITE PROSPECTIVE COHORT STUDY Sharry Kahlon; Sumit R. Majumdar; Jenelle Pedersen; Sara Belga; Darren Lau; Miriam Fradette; Debbie Boyko; Jeffery Bakal; Curt Johnson; Raj S. Padwal; Finlay A. McAlister. University of Alberta, Edmonton, AB, Canada. (Tracking ID #2198558)

BACKGROUND: Readmissions within 30-days of hospital discharge are common and costly but prediction models are poor at identifying those at high risk of being readmitted. Frailty is a multi-dimensional syndrome not routinely captured by administrative databases that may improve clinical prognostication.

METHODS: We prospectively enrolled 500 patients discharged from 7 GIM wards at 2 teaching hospitals in Edmonton, Alberta Canada. “Frailty” was defined as 5-points or more on the previously validated 9-point Clinical Frailty Score (CFS). The primary outcome was the composite of 30-day readmission or death. Multiple logistic regression analyses, adjusted for age and sex, were undertaken to compare 30 day outcomes between frail and non-frail patients.

RESULTS: Of the 500 patients we recruited, 164 (33 %) met the CFS definition of frailty: 93 (19 %) were mild (CSF score 5), 60 (12 %) were moderate (CFS score 6), and 11 (2 %) were severely frail (CFS score 7 and 8). Frail individuals were older, more likely to be female, had more comorbidities and lower EQ-5D scores, and higher LACE scores at discharge, but had similar mean serum albumins and mean scores on depression, cognitive, and anxiety scales as non-frail subjects. Overall, 96 patients were readmitted or died within 30 days of discharge, and frail patients exhibited higher event rates: 44 (27.2 %) vs. 52 (15.6 %), OR 2.02 (1.28–3.18). Even after adjusting for age and sex, frailty remained associated with 30 day outcomes (aOR 2.01, 95%CI 1.21–3.33 for frailty and aOR 2.12, 95%CI 1.18–3.81 for moderate-severe frailty).

CONCLUSIONS: In individuals discharged from general medical units, frailty was common, was associated with substantially increased risk of adverse events, and the CFS could potentially be used to identify those individuals in whom to target interventions to reduce hospital readmissions.

ASSOCIATION BETWEEN NEIGHBORHOOD SOCIAL SUPPORT AND QUALITY OF DIABETES CARE Roberto O. Diaz Del Carpio; Wudeneh Mulugeta; Scott Stewart. University at Buffalo, Buffalo, NY. (Tracking ID #2192948)

BACKGROUND: Diabetes is among the 10 leading causes of death in the U.S., with Type 2 diabetes representing almost ninety five percent of cases. Effective disease management comprised of medical care, self-management education, and ongoing diabetes support is key to improving quality of life and reducing acute and long-term complications. There is growing evidence that social support in the community is related to better long-term self-management and better health outcomes. We conducted this study to assess the relationship between neighborhood social support and diabetes management in our urban safety-net clinic, hypothesizing that higher perceived neighborhood support would be associated with improved diabetes management.

METHODS: The present report represents initial findings in an ongoing study examining the impact of social support and social resources in the treatment and outcomes of adult patients with type 2 diabetes who live in the city of Buffalo, New York. The Chronic Illness Resource Survey (CIRS) was used to measure support and resources for diabetes management across eight domains including neighborhood social support (NSS). This social support level includes 6 questions probed the amount of support received from patient’s neighborhood on a 5-point Likert scale (1: not at all- 5: a great deal). NSS index was created by computing the means of the subscale items. Patients were asked to complete the CIRS survey during their regular appointments to one of our teaching outpatient clinics. Diabetes process and outcomes measures were abstracted from the electronic medical record. Linear and logistic regression analyses were used to model the associations between the NSS and Physician Quality Reporting System outcome and process measures (A1c, microalbuminuria, and ophthalmology visits) adjusting for income, education and self-reported race/ethnicity.

RESULTS: Subject characteristics are shown in Table 1. The average NSS score was 2.6 (SD:0.6). We did not find any statistically significant associations between the NSS and outcome measures. As far as point estimates, there was a slight negative association between A1C and neighborhood social support (β :−0. 05, 95 % CI:−0. 13, 0.03, p: 0.21). The odds of having an ophthalmology visit (OR: 0.97, 95 % CI: 0.88, 1.05, p: 0.43), and the odds of having microalbuminuria (OR: 0.97, 95 % CI: 0.88, 1.07, p: 0.55) were not associated with NSS.

CONCLUSIONS: Our initial results suggest that there is no strong association between perceived NSS and the selected outcome measures. Future work will include confirming these findings following study completion, evaluating other aspects of social support, and evaluating more complex relationships between NSS and diabetes outcomes.

figuret

Sample Characteristics (n = 98)

ASSOCIATION BETWEEN SUBJECTIVE SOCIAL STATUS AND CARDIOVASCULAR DISEASE AND CARDIOVASCULAR RISK FACTORS: A SYSTEMATIC REVIEW AND META-ANALYSIS Karen Tang; Ruksana Rashid; William A. Ghali. University of Calgary, Calgary, AB, Canada. (Tracking ID #2197861)

BACKGROUND: Subjective social status (SSS) is an individual’s perception of his own position in the social hierarchy and has been shown to be associated with health outcomes, with lower SSS being associated with worse self-rated and mental health. These health associations may be due in part to its close correlation with objective socioeconomic measures (SES) such as income, education or occupation, though SSS may also exert effects independent of SES. Through internalization of perceptions of inferiority, resulting in activation of stress-related neuroendocrine mechanisms and increased unhealthy behaviors, low SSS may lead also to increased cardiovascular risk. Our objective was to determine the association between lower SSS and odds of coronary artery disease (CAD) and CAD risk factors, including hypertension, diabetes, obesity, and dyslipidemia.

METHODS: We performed a systematic review and meta-analysis. Our search strategy combined the themes “perception” and “social status”, searching PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO, SocINDEX, Web of Science, and reference lists of included studies up to October 2014. Inclusion criteria included: 1) original studies in adults aged 18 years and over; 2) odds, risk, or hazard ratios between “lower” SSS groups and “higher” SSS groups reported for at least one outcome of interest (CAD, hypertension, diabetes, obesity, or dyslipidemia); and 3) SSS is measured on a self-anchoring ladder. Only observational (case–control, cohort, and cross-sectional) study designs were considered. Two reviewers independently assessed studies identified by the search strategy for inclusion into the systematic review. One reviewer extracted data, with a second reviewer corroborating data extraction for 20 % of included studies. Both reviewers independently assessed study quality for all studies. For studies reporting only stratified estimates, a single weighted odds ratio (OR) for each outcome of interest was derived. All ORs were transformed to be expressed per rung decrease on the SSS ladder. Using random-effects models, odds ratios across studies were pooled for each outcome. Stratified analysis and meta-regression were completed for subgroups representing different patient characteristics and study quality criteria. We assessed publication bias through visual inspection of funnel plots, Begg’s test, and through the trim and fill procedure for outcomes where funnel plots suggested visual asymmetry.

RESULTS: Our search strategy identified 7842 citations, 45 of which underwent full-text review, of which ten were included in the systematic review and meta-analysis. Nine studies had a cross-sectional design while one was a prospective cohort study. In analyses adjusted for demographics but not adjusted for objective SES measures, the pooled OR per rung decrease in SSS was 1.06 [95 % confidence interval (CI) 1.01,1.12] for CAD, 1.06 [95 % CI 1.03, 1.10] for hypertension, 1.07 [95 % CI 1.02, 1.11] for diabetes, 1.14 [95 % CI 1.07, 1.21] for dyslipidemia, and 1.05 [95 % CI 0.99, 1.10] for obesity. The corresponding ORs comparing the bottom versus the top of the ten-rung SSS ladder for CAD, hypertension, diabetes, and dyslipidemia were 1.82 [95 % CI, 1.10, 2.99], 1.77 [95 % CI, 1.29, 2.44], 1.90 [95 % CI, 1.25, 2.87], and 3.68 [95 % CI, 2.03, 6.64] respectively. The associations were attenuated when adjusting for actual SES measures (income, education, and occupation), though all pooled ORs remained greater than 1.0; dyslipidemia was the only outcome to maintain statistical significance with an OR of 1.08 [95 % CI 1.01, 1.15] per rung decrease in SSS, or 2.10 [95 % CI 1.09, 4.06] when comparing the bottom to the top of the SSS ladder. Stratified meta-analysis revealed increased effect sizes for the outcomes of hypertension, diabetes, and obesity for studies with a predominantly Caucasian sample compared with studies without a predominantly Caucasian sample. Better quality studies, with adequate adjustment of non-SES confounders and lower risk of selection bias, reported greater effect sizes compared with lower quality studies. Meta-regression on the same variables did not however result in any significant p-values, likely due to being underpowered. There was no evidence of significant publication bias.

CONCLUSIONS: Lower SSS is associated with significantly increased odds of CAD, hypertension, diabetes, and dyslipidemia, and a trend toward increased odds of obesity. Though there is attenuation of these associations when adjusting for income, education, and occupation, the trend remains. Our findings provide further evidence that inequality in the socioeconomic hierarchy may have adverse health effects, not only through objective SES factors and material deprivation, but also through perceptions of social standing. Though there is likely substantial overlap between SES and SSS constructs, they appear to be distinct concepts; further understanding of this complicated relationship and their individual and combined effects on health are needed.

ASSOCIATION OF EATING HABITS WITH WEIGHT LOSS AND DIET SELF-MONITORING IN AN ONLINE WEIGHT LOSS TRIAL: RESULTS FROM THE OCELOT-PC STUDY Bethany Scanlan; Kathleen M. McTigue; Li Wang; Daniel Winger; Molly B. Conroy. University of Pittsburgh, Pittsburgh, PA. (Tracking ID #2198139)

BACKGROUND: Traditional, in-person weight loss interventions have emphasized rigorous self-monitoring of daily energy intake to help achieve weight loss. Additionally, studies have shown long-term weight loss and maintenance to be associated with decreased eating in restaurants and snacking, and decreased consumption of fried foods, desserts, sweetened beverages, and high-fat dairy products. With the growth of online resources and interventions, it is important to determine if similar associations are found in the setting of an online weight loss intervention done in coordination with primary care.

METHODS: The Online Counseling to Enable Lifestyle-focused Obesity Counseling in Primary Care (OCELOT-PC) study is an online adaptation of the Diabetes Prevention Program. We recruited 373 primary care patients. Two hundred fifty-seven were randomized to a 12-month structured, online intervention while the remaining patients had access to online group resources (OGR) alone. The online intervention included lessons, weight, diet, and physical activity self-monitoring, and feedback from a coach. Diet self-monitoring was done for both total daily calories and fat grams. Physical measures including weight and diet habits were measured at baseline, 6 months, and 1 year. Diet habits were assessed using a version of the previously validated Connor Diet Habit Survey. This survey provides scores for Meat, Dairy, Fats/Oils, Sweets/Snacks, Grains/Fruits/Vegetables, Beverages, Restaurants, and Seafood. Self-monitoring data was available from intervention participants only and was measured objectively by assessing participant entries into the online program. Changes in diet scores of all participants who achieved > = 5 % weight loss at 1 year were compared to those that did not achieve 5 % weight loss using Mann–Whitney U test. For intervention participants, diet score changes of those who were self-monitoring diet at 1 year were compared to those who were not self-monitoring using Mann–Whitney U test.

RESULTS: Two hundred fifty-four participants had 1 year weight and Connor Diet Habit Survey data available for analysis (mean age 50 years old, 76 % female, 78.1 % white, mean BMI of 37.8 kg/m2), including 166 intervention participants who also had self-monitoring data available. Connor Diet Habit Survey scores at baseline were corresponded to a diet of 30–37 % fat. At 1 year, participants that had > = 5 % weight loss (n = 78) had statistically significant greater improvements in their diet scores in Meat (2.8 vs. 1.2; p = 0.001), Dairy (3.9 vs. 1.9; p < 0.001), Fats/Oils (4.0 vs. 1.5; p < 0.001), Sweets/Snacks (1.8 vs. 0.7; p = 0.005), Beverages (1.0 vs. 0; p = 0.002), and Restaurants (3.0 vs. 1.0; p < 0.001), compared to those who lost less than 5 % or gained weight (n = 176). Intervention participants that did self-monitor diet at 1 year (n = 35) showed greater improvements in Meat (3.7 vs. 1.7; p = 0.005), Dairy (4.3 vs. 2.3; p = 0.04), and Fats/Oils scores (4.0 vs. 2.0; p = 0.02) at 1 year compared to those that did not self-monitor (n = 131).

CONCLUSIONS: Weight loss was associated with improvements in various dietary components, corresponding to a reduction in total calories consumed as well as healthier food choices. Additionally, diet self-monitoring was associated with improvements in eating habits, particularly in categories such as meat and dairy where foods tend to be higher in fat. While it is not possible to assess the self-monitoring component of the intervention apart from the other intervention components, our results suggest that online tools to monitor fat and calories may help primary care patients achieve weight loss goals.

ASSOCIATION OF MEDICAL STUDENT EMPATHY WITH CLINICAL COMPETENCE Rachel S. Casas; Lorraine Stanfield; Nanette Harvey; Angela Jackson; Daniel Chen. Boston University School of Medicine, Boston, MA. (Tracking ID #2180666)

BACKGROUND: Empathy is a crucial component of physician-patient interactions, and evaluating this skill is integral to medical education. Prior research has shown that empathy scores of medical students are associated with grades in core clerkships but not the Medical College Admissions Test (MCAT) or the United States Medical Licensing Examinations (USMLE) Step exams. Additionally, prior studies have shown conflicting associations between empathy scores and Objective Structured Clinical Examinations (OSCEs). No prior studies have evaluated all of these measures of clinical competence in the same cohort of students or evaluated if empathy scores early in medical school are predictive of later clinical performance. We hypothesized that empathy scores would be positively associated with OSCE and core clerkship performance but not standardized test scores.

METHODS: This longitudinal, cohort study compared clinical competence and empathy scores of 265 first year and 590 third year medical students enrolled at the Boston University School of Medicine from 2007 through 2010. Self-reported empathy scores were collected through the Jefferson Scale of Physician Empathy (JSPE) - Student Version, a validated, 20-item tool with higher scores corresponding to higher empathy (score range 20 to 140). Measures of clinical competence included grades from core third year clinical clerkships, third year OSCEs, and national standardized tests (MCAT and USMLE Step exams 1, 2 CS, and 2 CK). Data analysis was completed with JSPE score as a predictor for categorical outcomes using logistic regression and for continuous outcomes using linear regression. The associations between JSPE scores and grades were also evaluated with multiple regression analysis to control for demographic variables.

RESULTS: First year medical students were of median (IQR) age 23 (3) years, had a median (IQR) empathy score of 117 (15), and were 53 % percent female. Empathy scores of medical students in their third year were associated with higher performance in OSCEs and lower performance on Step 1, but were not associated with other standardized test or core clerkship grades. The relationship between third year empathy and OSCE score remained significant when controlling for age, gender, debt, and future career interest. Empathy scores in the first year of medical school were negatively associated with MCAT scores and not predictive of OSCE, Step 1, or Step 2 CK scores. The relationship between first year empathy and MCAT scores did not remain significant when controlling for demographic factors. Regression analysis for first year empathy scores and Step 2 CS or clinical clerkships could not be completed due to the limited number of students who failed these evaluations.

CONCLUSIONS: Self-reported empathy scores in the third year of medical school are associated with higher performance on OSCEs but not standardized tests or clinical clerkship grades. Further research is needed to determine if tools like the JSPE are useful in identifying medical students needing early intervention to improve communication skills.

ASSOCIATION OF PHYSICIANS’ FINANCIAL RELATIONSHIPS WITH PHARMACEUTICAL COMPANIES AND THEIR LIPID-LOWERING MEDICATION PRESCRIBING PATTERNS James S. Yeh 1, 2; Jessica M. Franklin1, 2; Jerry Avorn1, 2; Joan Landon1, 2; Aaron Kesselheim1, 2. 1Brigham and Women’s Hospital, Boston, MA; 2Harvard Medical School, Boston, MA. (Tracking ID #2196307)

BACKGROUND: Physicians’ financial relationships with pharmaceutical companies have long been controversial. These relationships can consist of receipt of industry-sponsored meals, money for continuing medical education (CME) activities, reimbursements for consulting and participation on speaking bureaus, grants, and payments for education and training. Numerous small studies and surveys suggest that these financial relationships affect prescribing practices, but many physicians and policymakers remain unconvinced. Using a comprehensive Massachusetts medical conflicts of interest database and a prescription claims database, we sought to evaluate the association between physicians’ financial relationships and their prescribing of brand-name versus generic cholesterol-lowering medications.

METHODS: We manually linked Medicare prescription claims data prepared by the Centers for Medicare and Medicaid Services relating to Massachusetts physicians with the Massachusetts physician open-payment database from 2011. The exposure variable was the listing of physicians’ financial relationship and outcome measurement was physicians’ prescribing of any brand-name-only cholesterol-lowering medication. The analysis was limited to physicians who had at least 50 claims of a particular drug. We used chi-square and ANOVA tests to analyze the association between the intensity of physician-industry relationships (determined by monetary value of payments) and physicians’ prescribing practices. We used logistic regression model to determine the relationship between the types of physician-industry relationships and their brand-name prescribing behavior.

RESULTS: Our analysis included 2444 physicians. Approximately one-third (899, 37 %) had some sort of financial relationship with a pharmaceutical company, while 63 % (1546) had no industry payments in 2011. The most common payment type was for company-sponsored meals (639, 71 %), followed by grants (458, 51 %), consulting and speaking bureau (236, 26 %), and educational training grants (95, 11 %). Compared to physicians without pharmaceutical company payments, physicians in the top quartile of total value of payments (>$1188) had higher rates of brand-name cholesterol-lowering medication prescriptions (21 % versus 18 %, p < 0.01). When physicians were categorized by quartiles based on their rates of brand-name prescribing, there was a significant positive relationship between the average total monetary value of drug company payments ($3696, $1419, $701, and $542, p < 0.01) and brand-name prescribing percentage (39 %, 19 %, 10 %, and 4 %, p < 0.01), respectively. Among physicians who received pharmaceutical company payments, educational training payments were significantly associated with increased brand-name prescribing (18 % versus 22 %, p < 0.01), but the other payment types were not.

CONCLUSIONS: Physicians who have financial relationships with pharmaceutical companies have higher brand-name cholesterol-lowering medication prescribing than physicians who do not have such relationships. The rate of brand-name prescribing was associated with the intensity of physician-industry relationships measured by the total value of monetary payments. The receipt of educational training payments may be a significant predictor of brand-name prescribing. The study findings only apply to physicians prescribing substantial numbers of cholesterol-lowering medication each year and may be limited by the integrity of pharmaceutical companies’ self-reporting of physician payments.

ASSOCIATION OF THE BUILT ENVIRONMENT AND NEIGHBORHOOD RESOURCES WITH OBESITY-RELATED HEALTH BEHAVIOR Natalie N. Albanese 1; Jennifer P. Friedberg1, 3; Andrew Rundle4; James Quinn4; Kathryn Neckerman4; Stuart R. Lipsitz2; Sundar Natarajan3, 1. 1New York University Medical Center, New York, NY; 2Northwestern University, Boston, MA; 3VA New York Harbor Healthcare System, New York, NY; 4Columbia University, New York, NY. (Tracking ID #2199242)

BACKGROUND: The neighborhood may influence obesity-related health behaviors. In this project, we evaluated associations between neighborhood characteristics and physical activity, dietary intake, and body mass index (BMI) in high-risk patients with uncontrolled hypertension.

METHODS: Person-level data were collected at baseline from 533 veterans with uncontrolled hypertension participating in a randomized controlled trial. The two neighborhood measures were census tract level Walkability, measured using built environment features that promote walking (components were z-scored and summed to create tertiles), and healthy food proximity (HFP), a 0–100 score reflecting proximity of grocery stores and farmers’ markets. The exercise outcomes were: number of hours of exercise per week (continuous), assessed using the 7-day Physical Activity Recall (PAR); exercise adherence (dichotomous), designated as aerobic activity ≥ 3 days/week from PAR; and Stage of Change (SOC) for exercise (dichotomous), using valid measures. The diet outcomes were: adherence to saturated fat and total fat intake recommendations (continuous), measured by an adherence index (0–10) with 10 being maximal adherence using the Willett Food Frequency Questionnaire (FFQ); and Stage of Change (SOC) for DASH diet (dichotomous). The obesity measure was BMI. Robust or logistic regression (adjusting for age, race, education) clustered by provider were used to evaluate the association between the neighborhood measures (Walkability and HFP) and the exercise, diet, or BMI outcomes.

RESULTS: There was a positive association between Walkability and increased adherence to dietary recommendations for fat intake; for each tertile increase in Walkability, there was a 1.02-point increase in the saturated fat adherence index (95 % CI: 0.03, 2.02, p = .04) and a 0.84-point increase in the total fat adherence index (95 % CI: 0.23, 1.44, p = .007). Patients in the highest Walkability tertile were also 75 % more likely to be in the Action or Maintenance SOC for exercise than those in the lowest Walkability tertile (OR 1.75, 95 % CI: 1.14, 2.69, p = .01). Walkability was negatively associated with BMI, with each tertile increase in Walkability being associated with 1.13 decrease in BMI (95 % CI: −2.04, −0.23, p = .01). HFP was positively associated with increased exercise duration, with each point increase in HFP being associated with 0.63 additional hours of exercise (95 % CI: 0.047, 1.22, p = .03). Patients in the highest HFP tertile were also 66 % more likely to be adherent to exercise recommendations (OR 1.66, 95 % CI: 1.01, 2.75, p = .05), and 67 % more likely to be in Action or Maintenance SOC for exercise (OR 1.67, 95 % CI: 1.10, 2.52, p = .01) compared to those in the lowest HFP tertile. There was also a positive trend between HFP and increased dietary adherence to saturated fat, such that each point increase in HFP was associated with a 0.84 increase in saturated fat adherence index (95 % confidence interval [CI]: −0.11, 1.79, p = .08). There were no significant associations between neighborhood measures and SOC for DASH diet.

CONCLUSIONS: Neighborhood is associated with people’s eating and exercise habits. Environmentally-tailored health recommendations and interventions may lead to healthier lifestyles and potentially decrease obesity rates.

ASSOCIATIONS BETWEEN MENTAL HEALTH BURDEN, SMOKING AND CARDIOVASCULAR DISEASE IN WOMEN VETERANS OVER 45 Megan R. Gerber 1, 4; Matthew King3, 4; Suzanne Pineles3, 4; Katherine Iverson3, 4; Sally G. Haskell2. 1Boston University, Jamaica Plain, MA; 2Yale University, VA CT, and VA Central Office, Madison, CT; 3VA Boston Healthcare System, Jamaica Plain, MA; 4Boston University School of Medicine, Boston, MA. (Tracking ID #2198075)

BACKGROUND: Understanding the health and health care needs of aging Veterans is a key priority of the Veterans Health Administration (VHA). Currently, women Veterans (WV) aged 45–64 represent the highest proportion of female VHA users. WV experience significant mental health (MH) burden. MH and race are known risk factors for cardiovascular disease (CVD), but the impact of increasing MH burden on CVD for WV has not been described. Our study aims were to 1) determine which MH conditions have the strongest association with CV disease, and 2) quantify the impact of increasing MH burden on CV disease in WV over age 45. A secondary aim was to report smoking prevalence in this group.

METHODS: VHA National Patient Care Data (2009) were used to identify women Veterans over age 45. ICD-9-CM codes were used to categorize medical and psychiatric conditions. MH diagnoses examined were: alcohol and drug use, psychotic, bipolar, depressive, anxiety, somatization, eating disorders and PTSD. Smoking data was culled from clinical reminder data. We used stepwise logistic regression (LR) modeling to identify MH predictors of CVD, adjusting for age, race and smoking. Analyses were conducted using R statistical software.

RESULTS: One hundred fifty-seven thousand one hundred ninety-five WV were identified, their mean age was 59.4 years (SD 12.2, range 46–110). The majority (61 %) of the sample was white. Thirty-six percent reported current smoking and 19 % were past smokers. The majority of WV (69 %) had no mental health diagnosis, 18 % had one, and 12 % carried two or more. Logistic regression analyses (Table) demonstrated that depression, anxiety and psychotic disorder were the strongest mental health predictors of CVD.

CONCLUSIONS: Controlling for age, race and current smoking, each MH diagnosis increased CVD odds by 54 % in WV over age 45. Depression had the strongest association with CV disease, with higher odds than those for smoking. Tobacco use is prevalent among women Veterans over 45; a strength of this study was use of clinically-derived smoking data. The study findings are limited, however, by lack of information on psychiatric medication. In summary, interventions to reduce CVD among older WV must take into account MH comorbidity, and efforts at addressing smoking cessation in this population are critical. With its primary care-mental health integration model, VHA is well-positioned to improve medical outcomes for WV with MH comorbidity. To optimize the health of older WV with co-morbid MH conditions, future trials of multidisciplinary interventions to reduce CVD risk and smoking are warranted.

Adjusted stepwise logistic regression: diagnoses associated with CV disease

MODEL 1
 Control variables (% sample) OR [95 % CI]
 Age 1.06 [1.06, 1.06]
 Race Black (25 %) 1.02 [0.95, 1.10]
 Race Hispanic (6 %) 0.54 [0.45, 0.63]
 Current smoker (36 %) 1.61 [1.51, 1.71]
 Past smoker (19 %) 1.15 [1.08, 1.23]
MH Diagnoses
 Depression (21 %) 1.82 [1.71, 1.94]
 Anxiety (7 %) 1.30 [1.18, 1.42]
 Psychotic Disorder (5 %) 1.30 [1.18, 1.43]
MODEL 2 *
 MH diagnosis count (0–3) 1.54 [1.48, 1.60]

* Adjusted for age, race, smoking, substituted MH diagnosis count for individual diagnoses.

ASSOCIATIONS BETWEEN SOCIAL MEDIA USE AND DEPRESSIVE SYMPTOMS AMONG US YOUNG ADULTS Liu yi Lin 2; Ariel Shensa2; Jason Colditz2; Ana Radovic3; Elizabeth Miller1; Beth Hoffman2; Brian A. Primack2. 1Children’s Hospital of PIttsburgh of UPMC, Pittsburgh, PA; 2University of Pittsburgh, Pittsburgh, PA; 3Children’s Hospital of Pittsburgh, Pittsburgh, PA. (Tracking ID #2198215)

BACKGROUND: Over the last decade, use of social networking sites (SNSs) such as Facebook have and revolutionized the way people interact and communicate. Nearly all (90 %) of young adults use SNSs, and the majority of users visit these sites at least once daily. The association between social media use and depression is unclear. Some studies suggest that social media users may experience an increase in social connectedness and a related decrease in emotional health problems. Other studies, however, suggest that frequent use of social media may be associated with declines in subjective well-being, life satisfaction, and real-life social community. Prior studies have been limited by use of small, localized samples. In addition, they have tended to focus on one specific platform, Facebook, while real-life usage, especially among young adults, has broadened to include use of multiple other platforms such as Twitter, Google+, Instagram, Tumblr, Snapchat, and Vine. Therefore, the purpose of our study was to determine independent associations between social media use across multiple platforms and depressive symptoms in a large, nationally-representative sample of young adults.

METHODS: We surveyed a nationally-representative sample of the US population between the ages of 18 to 30 regarding social media use and depressive symptoms. We recruited participants via random-digit-dialing and address-based sampling frames representing over 97 % of the US population. Participants responded to online surveys over a 1-month period in October-November of 2014. We assessed our independent variable, social media use, in three different ways, including self-reported total time spent with online social networks per day, average number of social network site visits per week, and responses on a global frequency scale that was adopted from the Pew Internet Research Questionnaire. Each of these latter two scales prompted participants regarding the most commonly used 11 SNSs and combined response data. Our primary dependent variable was depressive symptoms as measured by the brief Patient-Reported Outcomes Measurement Information System (PROMIS) depression scale. The scale consisted of 4 items, each of which was assessed on a 5-point Likert scale. Based upon the distribution of data, scale values were collapsed into tertiles for primary analyses. We used ordered logistic regression with sample weights to assess multivariable associations between SNS use and depression and while controlling for relevant socio-demographic, personal and environmental factors. We developed separate models for each of the methods of assessing the independent variable (SNS use). All ordered logistic regression models satisfied the required proportional odds assumption.

RESULTS: Our sample of 1781 participants was 61.8 % female, 64.1 % Caucasian, 10.0 % African American, 16.6 % Hispanic and 9.3 % of mixed or other race. Our primary fully-adjusted multivariable models included all covariates, including age, sex, race and ethnicity, relationship status, living situation, household income, and education level. These analyses demonstrated that, compared to those in the lowest quartile for total time on SNS use per day, participants in the highest quartile had increased odds of having greater depressive symptoms (AOR = 1.66, 95 % CI = 1.14, 2.42). Results were also significant for each of the other independent variables. In particular, compared with those in the lowest quartiles, those in the highest quartiles of SNSs visits per week (AOR = 2.74, 95 % CI = 1.86, 4.04) and the global frequency scale (AOR = 3.05, 95 % CI = 2.03, 4.59) reported greater depressive symptoms. All associations between independent variables and depressive symptoms demonstrated strong, linear, dose–response trends (P < .001 for all). Results were robust to all sensitivity analyses.

CONCLUSIONS: Regardless of the particular method of operationalizing the variable of SNS use, we found a strong, linear, and significant association between SNS use and depressive symptoms, even after controlling for multiple relevant socio-demographic variables. Importantly, the cross-sectional design of this study inhibits our ability to infer directionality of this association. For example, while it could be that depressed individuals seek out social networking sites, it may also be that those who frequent social networking sites develop depressive symptoms. Other researchers have suggested that this latter explanation may result from frequent exposure to idealized, non-realistic images and messages from “friends” to which end-users may feel inferior. Longitudinal studies may help to tease out this directionality. Regardless of directionality, however, this study highlights an important association, especially given the increasing prevalence of SNS use and the substantial morbidity associated with depression. It also suggests that it may be valuable to use SNSs to identify individuals at risk for mood disorders.

ASSOCIATIONS BETWEEN SOCIAL MEDIA USE AND EATING DISORDER RISK AMONG US YOUNG ADULTS Jaime Sidani; Ariel Shensa; Mercy Baffour; Beth Hoffman; Brian A. Primack. University of Pittsburgh, Pittsburgh, PA. (Tracking ID #2198304)

BACKGROUND: Eating disorders represent a growing public health concern, especially among female young adults in developed nations. Prevalence estimates in the U.S. are approximately 0.8 % for anorexia nervosa (AN), 2.6 % for bulimia nervosa (BN), 3 % for binge eating disorder (BED), and 11.5 % for Feeding or Eating Disorder Not Elsewhere Classified (FEDNEC). Although the etiology of eating disorders is multi-factorial, exposure to media portrayals of idealized bodies is considered to be a significant contributor. While traditional media, such as television and magazines, have been examined extensively in relation to eating disorder risk, the influence of social media has received relatively less attention. Considering the proliferation of social media platforms and their popularity with the young adult population, investigation into their potential association with eating disorders should be examined. Therefore, we conducted a large scale, nationally representative study to assess associations between social media use and eating disorder risk among US young adults.

METHODS: We collected web-administered survey data from 1765 young adults who were part of a national probability-based online non-volunteer access panel randomly selected to participate in a study of health behaviors. For this study, we developed a composite 5-item eating disorder risk scale with items adapted for this population from two validated measures: the SCOFF Questionnaire and the Eating Disorder Screen for Primary Care (ESP). Each item was assessed on a 5-point Likert scale. We performed a factor analysis to assess the underlying structure of these items. The total scale ranged from 0 to 25 with higher numbers indicating greater eating disorder risk. Based on the distribution of this variable, eating disorder risk was subsequently collapsed into quartiles for analyses. Participants’ social media use was assessed in three ways. First, participants were asked to self-report total time per day using social media. Second, we estimated total average social media visits per week based on responses to self-report items. Finally, we used a global frequency scale based on a Pew Internet Research item which assessed use of each of the most commonly used 11 social media platforms. To assess independent associations between social media use and eating disorder risk, we used ordered logistic regression while controlling for socio-demographic variables including age, sex, race/ethnicity, relationship status, living situation, household income, and maternal education.

RESULTS: Our sample was 62 % female, 64 % Caucasian non-Hispanic, 10 % African-American non-Hispanic, 17 % Hispanic, and 9 % of mixed or other race. Factor analysis suggested that the 5 eating disorder risk items represented one underlying construct. These items were also internally consistent (Cronbach’s alpha = 0.81). Results from fully-adjusted multivariable ordered logistic regression models indicated that increased social media use was significantly associated with increased odds of greater eating disorder risk. This was true for each of the 3 different methods of measuring social media use. In particular, compared with those in the lowest quartile, those in the highest quartile for each social media use variable had significantly greater odds of having increased eating disorder symptoms, with AORs of 2.05 (95 % CI = 1.43, 2.94) for total minutes per day, 2.75 (95 % CI = 1.89, 4.02) for average visits per week, and 3.39 (95 % CI = 2.34, 4.91) for the global frequency scale. As required for ordered logistic regression, the proportional odds assumption was met for each model.

CONCLUSIONS: These findings suggest that individuals with greater use of social media are at greater odds of being at increased risk for eating disorders, even when controlling for multiple relevant socio-demographic variables. Second, these associations were consistent regardless of how social media use was measured, suggesting robustness of findings. However, it is noteworthy that these cross-sectional data cannot disentangle directionality. In particular, while it may be that individuals with eating problems seek out information on social media, it may also be that those exposed to social media subsequently develop eating concerns. Future longitudinal examinations will be helpful to determine directionality of these associations. In either case, however, it is useful to know that social media may be a particularly valuable medium to reach individuals at risk for eating disorders.

ASSOCIATIONS BETWEEN SOCIAL MEDIA USE AND PERCEIVED EMOTIONAL SUPPORT AMONG A NATIONALLY-REPRESENTATIVE COHORT OF YOUNG ADULTS Ariel Shensa 1; Jaime Sidani1; Jason Colditz1; Zhongying Xu1; Kaleab Abebe1; Liu yi Lin2; Brian A. Primack1. 1University of Pittsburgh, Pittsburgh, PA; 2University of Pittsburgh School of Medicine, Pittsburgh, PA. (Tracking ID #2198738)

BACKGROUND: Decreased emotional support has been associated with poor physical health, poor mental health, and increased mortality. With the explosion of Internet and social media use, opportunities for connectedness and support have become more complex. From 2005 to 2013, the percent of adults ages 18–29 who use social media increased from 9 to 90 %, with over 74 % of all online adults now reporting some social media use. Leveraging this ubiquitous medium may be helpful in increasing opportunities for emotional support related to health conditions. For example, social media platforms may help connect people with shared conditions, facilitating support groups and sharing of information. However, it is not known whether overall social media use is associated with increased emotional support for a general population of users. Therefore, the purpose of this study was to assess associations between social media use and perceived emotional support in a large, nationally-representative population.

METHODS: We collected survey data from a nationally-representative sample of 1796 young adults ages 18–30 recruited via random-digit-dialing and address-based sampling methods from October to November 2014. We assessed our independent variable, social media use, in three different ways, including self-reported total time spent with online social networks per day, average number of social network site visits per week, and responses on a global frequency scale adopted from the Pew Internet Research Questionnaire. Each of these latter two scales prompted participants regarding the most commonly used 11 social networking sites (e.g., Facebook, Twitter, Instagram, Tumblr, and Reddit) and combined response data. Our primary dependent variable was emotional support as measured by the brief Patient-Reported Outcomes Measurement Information System (PROMIS) emotional support scale. The scale consisted of 4 items, each of which was assessed on a 5-point Likert scale. Based upon the distribution of data, scale values were dichotomized into those with low vs. high emotional support. Subsequently, we used logistic regression with sampling weights to assess multivariable associations between social media use and emotional support. Our primary models controlled for all relevant socio-demographic variables, including age, sex, race and ethnicity, relationship status, living situation, household income, and education level.

RESULTS: Our sample of 1785 individuals was 62 % female, 64 % Caucasian and non-Hispanic, 10 % African-American and non-Hispanic, 17 % Hispanic, and 9 % of mixed or other race. Just over half (58 %) of respondents reported being in a committed relationship and 41 % reported that they lived with a significant other. A multivariable model including all measured covariates demonstrated that being in the highest quartile of total minutes per day of social media use was significantly associated with decreased odds of having high perceived emotional support (AOR = 0.62, 95 % CI = 0.40, 0.94). A second fully adjusted model demonstrated that being in the highest quartile of social media use on the global frequency scale was also significantly associated with decreased odds of having high perceived emotional support (AOR = 0.60, 95 % CI = 0.38, 0.94). However, being in the highest quartile for social media visits per day was not significantly associated with decreased odds of having high perceived emotional support (AOR = 0.70, 95 % CI = 0.45, 1.09), although the point estimate was below 1. Tests for trend demonstrated significant linear dose–response relationships for independent variables of total social media time (P = .019) and the global frequency scale (P = .011), but not for the number of visits per week (P = .17).

CONCLUSIONS: Participants in the highest quartiles of two different social media use frequency measures had significantly decreased odds of reporting higher levels of perceived emotional support. A third independent variable, which quantified social media visits per week, was associated with a lower point estimate for perceived emotional support but was non-significant. These results suggest that, while we might expect individuals who engage in frequent social media to feel more emotional support, it seems that heavy users may actually feel less emotional support. However, it should be emphasized that the cross-sectional nature of these data hinders our ability to infer directionality. In particular, while it may be that individuals with low emotional support tend to increase their social media use to compensate, it may also be that individuals who start to use increased social media ultimately feel less true emotional support and connection. Longitudinal analyses may help assess directionality of these findings. In either case, however, these findings are notable not only because of known associations between low emotional support and poor health outcomes but also because of the rapid rise in social media use among nearly all US adults.

AST: A SIMPLIFIED TOOL FOR MANAGING ALCOHOL WITHDRAWAL Samuel B. Holzman; Darius Rastegar. Johns Hopkins University, Baltimore, MD. (Tracking ID #2148096)

BACKGROUND: Alcohol withdrawal syndrome (AWS) is a common and potentially serious medical problem. The standard of care is symptom-triggered dosing of benzodiazepines. The “gold standard” for monitoring withdrawal is the Revised Clinical Institute Withdrawal Assessment Scale (CIWA-Ar), which is a 10-item scale that can take up to 5 min to complete. There have been efforts to develop simpler scales; a recent one is the Glasgow Modified Alcohol Withdrawal Scale (GMAWS), a 5-item scale reported to perform well in a previous report.

METHODS: This project took place in the Johns Hopkins Bayview Medical Center Chemical Dependence Unit in Baltimore, Maryland. Initially, the GMAWS was piloted and compared with CIWA-Ar. Based on initial evaluation of the GMAWS and nursing feedback, the “Anxiety Sweats Tremor” scale (AST) was developed by removing 2 of the 5 items that were rarely used and expanding the scoring range from 0–2 to 0–3. The AST was then piloted and compared with simultaneous CIWA- Ar scores. Internal consistency of each test was measured by Cronbach’s alpha and the adequacy of AST in predicting CIWA-Ar ≥ 8 (the cutoff for treatment) was assessed by Receiver Operator Characteristics (ROC) curve.

RESULTS: In the initial phase, the mean CIWA-Ar score was 5.3 and GMAWS 2.0. The internal consistency of CIWA-Ar and GMAWS were both poor, with Cronbach’s alpha scores of 0.46 (N = 156) and 0.41 (N = 156) respectively. The internal consistency of our modified AST scale was significantly better with a Cronbach’s alpha of 0.68 (N = 176) and good corrected item-total correlation (>0.4 for all components). AST was effective in identifying individuals with CIWA-Ar ≥ 8 with an area under the ROC curve (AUC) of 0.83 (95 % CI 0.77–0.89), compared to 0.8 (95 % CI 0.74–0.88) seen with GMAWS. An AST score of ≥3 (out of a possible 9) predicted CIWA-Ar ≥ 8 with a sensitivity of 93 % and specificity of 63 %, while the GMAWS operated with a sensitivity and specificity of 98 and 39 %, respectively, based on previously defined cutoffs.

CONCLUSIONS: Ou simplified scale, AST, easily remembered by the transaminase elevated in acute alcoholic hepatitis, measures withdrawal based on three domains: anxiety, sweat and tremor. Overall, the scale performed well, demonstrating good internal consistency and reliably identified individuals experiencing significant withdrawal based on CIWA-Ar scores. Its operating characteristics were at least as good as GMAWS, with an improved specificity, and benefited from a simpler and more streamlined design.

Table 1. Comparison of Alcohol Withdrawal Scales

  CIWA GMAWS AST
Number of observations 156 156 176
Number of items 10 5 3
Range for each item 0–7* 0–2 0–3
Maximum score 67 10 9
Score tiggering drug administration ≥8 ≥11 ≥32
Sensitivity 98 % 93 %
Specificity 39 % 63 %
Mean score (SD) 5.3 (2.6) 2.0 (1.0) 2.9 (1.7)
Range 0–13 0–5 0–7
Cronbach’s alpha 0.46 0.41 0.68

CIWA = Revised Clinical Institute Withdrawal Assessment Scale

GMAWS = Glasgow Modified Alcohol Withdrawal Scale

AST = Anxiety, Sweat, Tremor

*One item is scored 0–4.

1 As defined by Daeppen et al. 2002 and McPherson et al. 2012 2 Proposed based on study results

2 Proposed based on study results

ATTITUDES ABOUT LUNG CANCER SCREENING AMONG PRIMARY CARE PROVIDERS Dhvani Doshi; Alexandra Rosenberg; Juan P. Wisnivesky; Jenny Lin. Icahn School of Medicine at Mount Sinai, New York City, NY. (Tracking ID #2196761)

BACKGROUND: Lung cancer screening has been shown to reduce lung cancer mortality among high risk smokers but is also associated with many false positives results which may trigger lengthy and invasive evaluations. Primary care providers (PCPs) will be responsible for implementing current recommendations for screening. However, there is limited information regarding their attitudes about lung cancer screening.

METHODS: PCPs practicing at an academic hospital in New York City were surveyed anonymously about their knowledge of and attitudes toward lung cancer screening guidelines and the likelihood they would recommend lung cancer screening to their patients. The survey items were developed based on findings of a multidisciplinary focus group. Descriptive and univariate analyses were used to assess differences in attitudes about lung cancer screening between PCPs who reported they would be likely to order screening CT scans vs. those who would not be likely to screen.

RESULTS: A total of 69 surveys were completed. Of the respondents, 40 % were attendings, and 67 % were female. Almost all PCPs were familiar or very familiar with USPSTF guidelines for breast cancer (99 %), cervical cancer (94 %), or colon cancer (99 %) screening compared with only 53 % reporting familiarity with lung cancer screening guidelines. Most PCPs reported ordering breast, cervical, and colon cancer screening tests for >75 % of their eligible patients compared to ordering CT screening for <25 % of their eligible smokers. Three-quarters (81 %) of PCPs were concerned about not being able to order chest CTs due to insurance reasons, 48 % were concerned about the overall healthcare dollars associated with screening, but only 9 % felt that lung cancer screening was not cost effective. Only 28 % of PCPs believe that the recommended yearly screening interval is feasible and less than 15 % felt they have sufficient time to counsel patients about CT scan screening. An overwhelming majority (≥90 %) worried about incidental findings associated with CT screening or about the number of follow up procedures resulting from positive results, and all (100 %) believed that positive screening results can cause distress to patients. Most PCPs (64 %) were confused about how to apply lung cancer screening guidelines for patients with multiple comorbidities and only half (52 %) felt confident in their abilities to decide on the workup of patients with positive CT findings. PCPs who reported they would be very likely to order a screening CT scan in the next year for their high-risk smokers were more likely to be familiar or very familiar with screening guidelines (91 % vs. 46 %, p = 0.01), to be confident in their ability to decide on the workup of patients with positive CT findings (82 % vs. 47 %, p = 0.03), and to state that they were able to identify the appropriate patients for lung cancer screening (100 % vs. 56 %, p = 0.01).

CONCLUSIONS: While most PCPs agree that lung cancer screening with low-dose CT scans for high risk smokers is cost effective, many are still not familiar with the USPSTF lung cancer screening guidelines. Multiple barriers such as concerns about insurance coverage, frequency of recommended screening intervals, time needed for counseling patients and concerns about consequences of positive screening results may limit PCPs from ordering screening chest CTs. PCPs clearly need further education and support to improve lung cancer screening.

BARRIERS TO GREATER CIVIC ENGAGEMENT AMONG PHYSICIANS James M. Kuo; Tara F. Bishop. Weill Cornell Medical College, New York, NY. (Tracking ID #2194095)

BACKGROUND: Professional organizations, scholars, and leaders argue that it is a privilege and responsibility for physicians to be active members of their communities through civic engagement to influence the social determinants of health and increase public trust in the medical profession. However, a survey of US physicians found that 95 % rated community participation as important but only 54 % volunteered and 26 % participated in political involvement other than voting. Additionally, when controlling for socioeconomic factors, physicians are less likely to vote and volunteer than the general population. The objective of this study was to explore the types of civic activities physicians engage in and the barriers to and facilitators for physician participation.

METHODS: We performed a qualitative telephone interview study of physicians practicing in the community from a convenience sample through personal contacts. Our sample was limited to physicians who had completed training and provide at least 20 h per week of patient care. We used a semi-structured interview tool that focused on five topic areas: 1) definition and knowledge of civic engagement, 2) experience with civic engagement 3) reasons for not engaging in civic activities, 4) reasons for engagement in civic activities, and 5) views on civic engagement and professionalism. Transcripts were analyzed using the constant comparison method.

RESULTS: We interviewed 10 physicians and intend to interview 10 to 15 more. Participants to date were from 7 specialties and 6 states. Most viewed civic engagement as some combination of voting, volunteering, and advocacy. All viewed civic engagement favorably, but most saw it as something to be encouraged but not required. Interviewees participated in a variety of activities including advocating for healthcare issues, volunteering in the community, and donating money. Those who saw Medicaid or uninsured patients viewed these activities as a form of service. The most common barrier to greater participation was lack of time. Interviewees also stated that money was a factor and could not justify non-reimbursable activities. Some felt that they had inadequate training or expertise in advocacy or that their views were not valued by society. There was a significant group of interviewees who felt that seeing patients fulfilled any responsibility for civic engagement. One respondent felt that their compassion and empathy had already been consumed by her patients and that there was nothing left to give to their communities. A respondent cited liability fear while another cited fear of retaliation for advocating for reproductive rights. Facilitators of engagement included having a more established practice of patients and concomitantly working less hours.

CONCLUSIONS: In this qualitative study, we found that time and money were the most common reasons that physicians do not engage in civic activities. The nature of our study limits generalizability, but greater insight into physician views on civic engagement will allow the medical community to combat barriers to involvement to contribute to a more active and engaged populace of physicians that is better able to improve the health of their patients beyond the walls of the clinic.

BARRIERS TO PATIENT EMPOWERMENT AND SHARED DECISION-MAKING (SDM): HEALTHCARE PROVIDER (HCP) PERSPECTIVES Sarita Kundrod 2; Joseph Plaksin2; Andrew B. Wallach1; Sondra Zabar2; Lisa Altshuler2; Adina Kalet2. 1Bellevue Hospital, New York, NY; 2NYU School of Medicine, New York, NY. (Tracking ID #2198543)

BACKGROUND: Participation in shared decision-making (SDM) requires patients to ask questions, effectively communicate their values and preferences to healthcare providers (HCPs), and collaborate with HCPs to make medical decisions. Despite its benefits, many patients do not take a more active role in SDM because of desires to be a “good patient” and the difference in knowledge and power between patients and HCPs. We aim to develop a Patient Empowerment Program (PEP) that will address these barriers and allow patients to fully participate in SDM. However, the potential benefits of PEP could be limited by barriers to SDM from the HCP perspective, such as time constraints and misconceptions about patients’ ability or willingness to participate in SDM. To examine how to overcome these potential barriers, we conducted a qualitative study to explore HCP 1) experiences with patients who have varying levels of empowerment, 2) opinions on the role of patients and HCPs in SDM, and 3) approaches to treating patients who are highly empowered.

METHODS: Internal Medicine faculty at two NYC public hospitals, NYU Primary Care residents, and 3rd-4th year NYU medical students with at least 1 year of experience on clinical rotations were invited via email to attend focus groups. The same interview questions were asked at all levels of training and medical students were also asked about how their views had changed over the course of their core clinical rotations. All sessions were audio-recorded and transcribed by a professional company. Two independent coders reviewed one segmented transcript to develop a coding schema, then met to negotiate a finalized set of codes that were applied to the remaining transcripts. Dedoose software was used to assist with coding and thematic analysis.

RESULTS: A total of 38 participants attended the focus groups: 11 faculty, 16 residents, and 11 medical students. In order to protect the anonymity of participants, no demographic data was collected. Thematic analyses focus on characteristics of the ideal and difficult patient, the role of the HCP in SDM, and barriers to patient activation in the medical encounter. Across all levels of training, ideal patients were described as those who are prepared for their appointments and were knowledgeable about medical conditions, allowing the HCP to “focus on their medical issues…and also see progress” as well as those who “actually make efforts to participate in their care.” HCPs generally supported the idea of a PEP that helped patients achieve these goals. Difficult patients could be split into two broad categories. The first included patients who are non-English speaking or who HCPs perceive as not being empowered, such as those with poor social supports, serious psychological illnesses, or whose attitudes get in the way of their care, such as patients who perceive themselves as “victims: where everything bad that’s happening to them is because it’s somebody else’s fault.” The second category of difficult patients shares some characteristics with empowered patients; they believe they have a significant role in their care but they do not seem to value the knowledge and expertise of HCPs. Faculty and residents describe these patients as being entitled or “people who think they just walked into McDonald’s and they know what’s on the menu and they’re going to order it…they don’t really want to have any advice from [the HCP].” Medical students describe difficult patients who “have the information [about their labs or test results] but not what these values mean and then [they] make really incorrect assumptions” that are hard to dispel later. When discussing the role of the HCP in SDM, both faculty and residents believe that they “do many things that are not in their job description [in order to] get the patient’s health a little better.” Medical students echoed this sentiment, but were more surprised, saying “I didn’t think that physicians would even have to necessarily deal with all of this extra stuff,” which includes coordinating appointments and dealing with patients’ social issues. Systemic barriers to SDM included lack of time, difficulties navigating the system, and taking on additional roles due to limited support staff or limited trust in support staff.

CONCLUSIONS: HCPs across all levels of training considered more empowered patients ideal compared to less empowered patients. But they described patients who are “entitled” or have “too high of expectations” as difficult as well. These perspectives support the need for a PEP that helps equalize the power differential between HCPs and patients, while still valuing HCP expertise. HCPs also highlighted a number of systemic barriers that must be addressed, in addition to both HCP and patient barriers, in order to support opportunities for SDM.

BARRIERS TO PRIMARY ADHERENCE AT HOSPITAL DISCHARGE AMONG AN UNINSURED POPULATION IN NYC Alice Tang; Cassia Wells; Emily Milam; Michael Janjigian. New York University, New York, NY. (Tracking ID #2199177)

BACKGROUND: It is estimated that medication nonadherence increases healthcare costs by $170 billion annually. While there is literature illustrating causes of secondary adherence—defined as correct use of medications as prescribed—there have been limited studies on primary adherence, or the act of filling initial prescriptions. Our study attempted to identify predictors of primary nonadherence upon hospital discharge among a cohort of uninsured patients. We investigated whether patient characteristics (homelessness, psychiatric comorbidities, limited English language proficiency and age), prescription characteristics (number and whether medications were essential or new) and/or system characteristics (discharge time and whether medications were faxed prior to discharge) predicted poor rates of primary adherence at hospital discharge.

METHODS: We conducted an observational, prospective cohort study examining primary nonadherence rates among uninsured patients discharged from a large, high-volume, urban public hospital. The hospital has a pharmacy dedicated to providing free medications to the uninsured upon discharge. Our primary outcome of interest was whether the patients discharged with new prescriptions picked up their medication(s) from the discharge pharmacy within 24 h of discharge. We collected data on patients admitted to a medical service from April to June 2014 at Bellevue Hospital Center in New York City. Patients with insurance and those transferred to another facility were excluded. Patients who had medications delivered to the bedside were also excluded. Data was obtained through pharmacy records and chart review. Chi-squared and logistic regression analysis was used to determine significant predictors of nonadherence.

RESULTS: In total, 335 patients met inclusion criteria. Of this cohort, 66.6 % were male, 24.2 % had limited English language proficiency, 12.2 % were undomiciled, and 24.2 % had a psychiatric comorbidity. The average age was 48.7 (SD 14). Only 176 patients (52.5 %) picked up their discharge prescription(s) from the hospital pharmacy within 24 h, leaving 47.5 % with primary nonadherence. Of the prescriptions that were not picked up, 123 (77.4 %) were considered essential for the patient’s post discharge care, defined as necessary for ongoing treatment of medical conditions, the absence of which could predictably lead to poor clinical outcomes. Only 9 (5.6 %) of nonadherent patients had their prescriptions faxed to the pharmacy and only 32 (9.6 %) of all prescriptions were faxed within the optimal time frame for the pharmacy (prior to the day before discharge). The greatest predictor of primary adherence was whether the prescription was faxed in advance, with 91.5 % of patients picking up faxed prescriptions, compared to 34.5 % picking up those that had not been faxed (p < 0.0001). Other significant predictors of adherence were time of discharge (67.4 % of patients discharged in the morning, 53.7 % in the afternoon and 35 % in the evening, p = 0.004) and age group (46.5 % of those aged <39, 51.2 % aged 40–64 and 70.5 % in those aged >65, p = 0.029). Patient characteristics such as race, gender, English language proficiency, number of medical comorbidities, psychiatric comorbidities, homelessness, and distance from the hospital did not prove to be significant predictors of adherence. The number of prescriptions or whether the medication was essential or new also did not significantly predict adherence.

CONCLUSIONS: Primary adherence is enhanced by timely delivery of prescriptions to the pharmacy prior to discharge and a discharge time earlier in the day. Providing advanced notice to the pharmacy and discharging patients earlier in the day decreases wait times and increases likelihood of primary adherence. This illustrates the importance of early discharge planning for hospitalized patients and coordination across multiple disciplines responsible for facilitating this transition in care. Apart from increased age, patient characteristics were not predictive of primary adherence. This may be a consequence of selection bias by inpatient providers, who could opt to provide bedside delivery of medications to patients they predicted would have difficulties navigating the hospital. Additional studies evaluating outcomes, such as re-hospitalizations or mortality, amongst this cohort of nonadherent individuals are necessary to establish the clinical and financial significance of these findings.

BENEFITS AND RISKS OF WARFARIN WITH AND WITHOUT ASPIRIN FOR PREVENTION OF STROKE IN CORONARY ARTERY DISEASE OR CEREBROVASCULAR DISEASE: A META-ANALYSIS Abhishek Deshpande 2; Gaurav Alreja3; Krishna Patel2; Vinay Pasupuleti1; Michael B. Rothberg2. 1Case Western Reserve University, Cleveland, OH; 2Cleveland Clinic, Cleveland, OH; 3Baystate Medical Center, Springfield, MA. (Tracking ID #2199136)

BACKGROUND: Options for secondary prophylaxis of non-embolic stroke are limited. Randomized controlled trials (RCTs) evaluating warfarin with or without aspirin to prevent stroke have yielded mixed results. We conducted a meta-analysis of RCTs to evaluate the benefits and risks of warfarin (with and without aspirin) in patients with coronary artery disease (CAD) or cerebrovascular disease (CVD).

METHODS: We searched PubMed, Scopus, Cochrane Library, Embase and the Web of Science electronic databases for randomized trials published from January 1980 to December 2014. We did not include earlier trials, as they would not reflect the current standards of care for secondary prevention of acute coronary syndrome or cerebrovascular accident. RCTs reporting the benefits (reduced incidence of stroke) and risks (mortality, intracranial bleeds, major and minor bleeds) of warfarin (with and without aspirin) therapy were included. We excluded trials that studied the use of warfarin for atrial fibrillation, heart valves and peripheral vascular disease. Trials were stratified by the intensity of the therapeutic international normalized ratio (INR): low (INR < 2), moderate (INR 2–3) and high (INR > 3.0). Data were pooled across studies using the fixed and random-effects models. We expressed the associations as risk ratios (RRs) and their 95 % confidence intervals (CIs). We used the chi square test to evaluate heterogeneity among trial outcomes.

RESULTS: The initial search yielded 3572 articles of which 26 RCTs (34,983 patients) met our inclusion criteria. The duration of treatment varied from 10 weeks to 4.6 years. In 6 trials of 19,000 patients, low intensity warfarin, either alone or plus aspirin vs. aspirin alone did not reduce stroke in patients with CAD (RR 0.84, 95 % CI 0.62 to 1.13) or CVD (RR 1.21, 95 % CI 0.99 to 1.52). In 9 trials with 5869 CAD patients, moderate intensity warfarin plus aspirin vs. aspirin alone reduced stroke (RR 0.48, 95 % CI 0.29 to 0.80) but increased major bleeding (RR 2.54, 95 % CI 1.70–3.79). There were no trials of this regimen in CVD patients. In 4 studies with 4455 patients, high intensity warfarin vs. aspirin did not decrease stroke in either patients with CAD (RR 0.41, 95 % CI 0.12 to 1.36) or CVD (RR 1.02, 95 % CI 0.49–2.13), but did increase the risk of intracranial bleeds (RR 8.68, 95 % CI 1.99–37.87).

CONCLUSIONS: The effectiveness of warfarin in secondary prevention of stroke was dependent on the target INR, as well as whether aspirin was used in conjunction with warfarin. Use of moderate intensity warfarin with aspirin reduced the risk of stroke at the price of increased bleeding. Trials of moderate intensity warfarin (or other oral anticoagulant) plus aspirin for secondary prevention of stroke should be considered.

BETA BLOCKERS AND THE RISK OF SUICIDE IN THE ELDERLY Jonathan S. Zipursky 3, 4; Erin M. Macdonald5; Simon Hollands5; Tara Gomes1, 5; Muhammad Mamdani1, 5; Michael Paterson2; David N. Juurlink4, 5. 1St. Michael’s Hospital, Toronto, ON, Canada; 2Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; 3University of Toronto, Toronto, ON, Canada; 4Sunnybrook Health Sciences Centre, Toronto, ON, Canada; 5Institute of Clinical Evaluative Sciences, Toronto, ON, Canada. (Tracking ID #2160069)

BACKGROUND: Beta-adrenergic antagonists (β-blockers) are commonly used among the elderly but concerns have been raised about their potential association with suicide risk. Lipophilic β-blockers enter the central nervous system readily, and may increase the risk of depression and suicidality relative to hydrophilic β-blockers. We examined the relationship between β-blocker lipophilicity and the risk of suicide in the elderly.

METHODS: We conducted a population based case–control study of multiple healthcare databases in Ontario, Canada, from January 1, 1993 to December 31, 2011. Cases were Ontarians aged 66 years or older who died of suicide within 100 days of receipt of a prescription for a β-blocker. For each case, we identified up to 4 controls who also received a β-blocker prescription in the preceding 100 days, matching on age, sex, documented hypertension and a hospitalization for coronary artery disease in the preceding year. We identified all outpatient prescriptions for oral β-blockers, categorizing each as high, intermediate or low lipophilicity based on the partition coefficient for each. We used conditional logistic regression to estimate the odds ratio for the association between suicide and type of β-blocker prescribed, with hydrophilic β-blockers as the reference group. To test the specificity of our findings, we examined the association between β-blocker lipophilicity and death from lymphoma.

RESULTS: We identified 385 individuals who died of suicide within 100 days of receiving a prescription for a β-blocker and 1540 matched controls. Use of lipophilic β-blockers (propranolol or labetalol) was associated with a more than two-fold increase in the risk of suicide (adjusted odds ratio 2.42; 95 % confidence interval 1.40 to 4.19) relative to hydrophilic β-blockers (Table 1). No increased risk was observed with β-blockers of intermediate lipophilicity. In stratified analyses, the increased risk of suicide with lipophilic β-blockers persisted in men (adjusted odds ratio 3.04; 95 % confidence interval 1.58 to 5.84) and individuals greater than the age of 76 (adjusted odds ratio 2.41; 95 % confidence interval 1.16 to 5.02). As expected, we found no association between β-blocker lipophilicity and death from lymphoma.

CONCLUSIONS: The lipophilic β-blockers propranolol and labetalol are associated with an increased risk of suicide in the elderly. Clinicians should be aware of this association, particularly in elderly individuals with other risk factors for suicide.

β-blocker lipophilicity and risk of suicide

  No (%) of patients with exposure Odds Ratio (95 % Confidence Interval)
Lipophilicity Cases
( n = 385)
Controls
( n = 1540)
Unadjusted Adjusted
Hydrophilic* 136 (35.3) 569 (36.9) 1.0 (reference) 1.0 (reference)
Intermediate** 218 (56.6) 908 (59.0) 1.00 (0.78 to 1.28) 1.01 (0.76 to 1.33)
Lipophilic*** 31 (8.1) 63 (4.1) 2.13 (1.31 to 3.44) 2.42 (1.40 to 4.19)

†Adjusted for Charlson Score, alcohol abuse in preceding year, antidepressant use in the previous year, cardiologist visits in preceding year, psychiatrist visits in preceding year, number of prescription drugs in previous year.

* atenolol, sotalol, nadolol

** metoprolol, bisoprolol, carvedilol, acebutolol, timolol, pindolol

*** propranolol, labetalol

BEYOND “GREAT JOB”: CONTENT AND QUALITY OF FEEDBACK AMONG STUDENTS ON INTERPROFESSIONAL LEARNING TEAMS Jennifer Mandal 1; Maria A. Wamsley3; Sandrijn van Schaik2. 1UCSF, San Francisco, CA; 2University of California San Francisco, San Francisco, CA; 3University of California, San Francisco, San Francisco, CA. (Tracking ID #2199391)

BACKGROUND: The ability to exchange instructive feedback with team members is considered one of the core competencies of interprofessional collaboration. Yet little is known about how and when healthcare trainees develop the skills to give substantive, useful interprofessional feedback. The objective of this study is to analyze the content and quality of peer-to-peer feedback among health professional students working in interprofessional teams.

METHODS: Students from 7 health professional schools (Dentistry, Nursing, Nutrition, Medicine, Pharmacy, Physical Therapy, and Social Work) worked in teams during a 4-h Interprofessional Standardized Patient Exercise (ISPE) to interview and develop a care plan for a complex patient. After the exercise, students were asked to provide written feedback for each of their teammates on 1) their interviewing skills and 2) their teamwork skills. We developed a scoring grid to rate the quality of the de-identified feedback comments, based on whether the comments included specific statements to continue, initiate, or discontinue certain behaviors (referred to as “keep”, “start”, or “stop” statements, respectively) as well as an anchored global usefulness score. Two independent raters scored all comments and reconciled differences in ratings. In addition, we analyzed the length of feedback comments based on word count. We calculated descriptive statistics for quality scores and comment length and compared mean scores and length between comments on interviewing skills versus those on teamwork skills with paired t-tests.

RESULTS: We analyzed 1650 feedback comments from 353 students. Of all comments, 98.1 % included a “keep statement”, 29.6 % included a “start statement” and 4.7 % contained a “stop statement”. Global usefulness scores were higher for comments on interviewing skills than on teamwork skills (3.0 ± 0.8 vs 2.5 ± 0.8, 4-point scale; p < .0001) Students wrote longer comments about interviewing skills than about teamwork skills (45 ± 27 vs 30 ± 19 words per comment, P < .0001).

CONCLUSIONS: Students participating in the ISPE were able to provide each other with reasonable quality feedback, although overall they were far more likely to provide positive, reinforcing feedback (“keep statements”) than to provide suggestions for change (“start or stop statements”). Students provided longer, higher quality feedback on their colleagues’ interviewing skills, and were more vague and brief in feedback on teamwork skills. This may reflect that students have a better understanding of, and more experience with, interviewing skills than with teamwork skills. Our results indicate a need for explicit education about interprofessional teamwork as well as training in effective feedback provision.

BRIEF MEASURES FOR EVALUATING ENGAGEMENT AND PERCEIVED USEFULNESS OF HEALTH APPS FOR PATIENTS Joseph J. Sudano 1, 3; Adam T. Perzynski2; Misty Harris2. 1Case Western Reserve University, Cleveland, OH; 2Case Western Reserve University at MetroHealth, Cleveland, OH; 3The MetroHealth System, Cleveland, OH. (Tracking ID #2200039)

BACKGROUND: We evaluated the measurement properties of newly adapted self-report scales designed to evaluate the extent to which patients benefit from web-based, mobile and tablet health applications. While existing scales measure satisfaction with computer tools, we sought to evaluate brief measures that examine additional dimensions of user experience, notably patient engagement and patient ratings of the utility of the applications themselves.

METHODS: A sample of 105 patients, visitors and health professionals was recruited from a safety net hospital, two community organizations, and meetings of health professionals. Participants completed a health risk assessment (available at http://healthylifeHRA.org). Participants had the option of using a laptop or tablet for completing the HRA. Items measures Engagement (4 items; 1-not at all to 5-very), perceived usefulness (9 items; 1-disagree to 10-agree), and End User Computer Satisfaction (12 items; yes/no). A three item measure screened participants for poor/adequate numeracy.

RESULTS: Participants were 64 % female; 41 % white, 29 % black, 12 % other, 18 % did not report race; average age was 42 (range 18–86). Participants were highly satisfied with the software; 97 % responded “yes” on “easy to use,” and 100 % yes on “quick enough”, useful format and clear report. Factor analysis results supported a 3-factor model of usefulness and engagement. Cronbach’s alpha internal consistency was > 0.8 for all scales. Participants rated the software as engaging them in caring for their health Mean = 4.2, SD = 1.0 on the 1–5 scale. The majority of patients agreed that the software is useful (Mean = 7.1, SD = 2.0). Numeracy screening indicated that 66 % had adequate and 34 % poor numeracy. Participants with poor numeracy rated the software as more useful (8.1 vs 6.7, p = .007) than participants with adequate numeracy. Usefulness and Engagement had moderate associations with an existing measure of computer satisfaction.

CONCLUSIONS: Brief, easy to administer self-report questions can be used to evaluate the extent to which health applications are found to be useful and engaging by patients and other users. Variability on these adapted measures is sufficient to capture differences according to key variables (such as numeracy for understanding the potential unintended consequence for apps to increase inequality via the “digital divide”). Future work is necessary to examine these measures in larger samples and with other health apps.

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BRING IT TO THE BEDSIDE: TABLET COMPUTERS INCREASE TEAM-PATIENT INTERACTIONS Blake R. Barker; Brett Moran; James M. Wagner. UT Southwestern Medical Center at Dallas, Dallas, TX. (Tracking ID #2194116)

BACKGROUND: Once the primary form of care delivery and medical education in academic medical centers, rounding at the patient’s bedside has become an increasingly infrequent rounding style. Prior investigators have observed that bedside rounding occurred less than 25 % of the time. Concerned medical educators have advocated for curricula that increase the frequency of bedside rounding. The impact of technology, including electronic medical records (EHR), on rounding styles is unknown. However, medical educators have expressed concern that it may detract from patient interactions. In a prior observational study at our institution, two distinct rounding patterns of general internal medicine inpatient teaching teams were identified: “Room rounders”, which represented 27 % of the team rounding styles observed, stayed in a conference room for the majority of the patient presentations. This pattern was found to be associated with significantly greater use of the EHR and fewer distractions. Contrasting this were the “ward rounders” who primarily presented patients in the hallway or in the patient room. “Ward rounders” were found to access the EHR and use electronic technology much less but had significantly more patient interaction, including discussion the plan of care with the patient and attending examination of the patient in the presence of the team. The hypothesis that the provision of tablet computers and encouraging ward rounding would provide equivalent EHR access with an increase in team-patient bedside interactions was explored.

METHODS: Over two consecutive months in 2013, an intervention study was conducted on ten general medicine teaching teams at Parkland Memorial Hospital, a large county hospital and primary teaching site of UT Southwestern. Five of the ten teams were randomly selected to receive four tablet computers each. These teams were provided a brief introduction on tablet functionality and were asked to conduct rounds outside of the conference room. Behaviors of intervention and control teams were recorded by observers utilizing a standardized checklist codifying team rounding patterns, including patient interaction, EHR use, teaching time and team distractions. Data were analyzed using chi-square and Fisher’s Exact Tests with p-value < 0.05 as an indicator for statistical significance.

RESULTS: Intervention teams were observed using tablet computers and rounding outside of the conference room more frequently than control teams (50 % vs 18 %, p < 0.0001; 71 % vs. 34 %, p < 0.0001, respectively). Observed EHR access during patient encounters was similar between intervention and control groups (50 % for both groups). Intervention teams visited the bedside of a similar number of patients (75 % vs. 71 %, p = 0.33) and spent a similar amount of time with patients (222 s vs. 197 s, p = 0.64). Attendings of intervention teams were observed examining patients more often than control teams, but this did not reach statistical significance (57 % vs. 48 %, p = 0.05). Intervention teams were observed exchanging information with patients and discussing the plan of care with patients significantly more often than control teams (75 % vs 65 %, p = 0.03; 71 % vs 61 %, p = 0.03, respectively). Intervention teams spent a similar amount of time teaching but also encountered more distractions per patient encounter (2.6 vs 1.8, p = 0.005).

CONCLUSIONS: By simply providing handheld technology in the form of tablet computers and a recommendation to round outside of the conference room, internal medicine teaching teams at a large academic hospital were observed exchanging more information with and more often discussing plans of care with patients. There was also a trend towards increased examination of the patient by the attending during rounds. Access of EHR, visits to the bedside during rounds, time spent with patients and teaching time were all similar. We feel this study suggests that tablet computers can add value to patient care teams and particularly medical education through increased team-patient bedside interactions and role modeling while providing similar degree of EHR access. This may come at the cost of increased team distractions.

Comparison of Control and Intervention Groups Rounding Behaviors

Variable Control Intervention P value
Tablet used during rounds (y/n) 18.13 % 50.31 % < 0.0001
Rounds occurred outside conference room 34.38 % 71.17 % < 0.0001
Total time spent rounding (min) 742 637 0.0118
Percent of patients visited during rounds 70.63 % 75.46 % 0.3274
Time spent with each visited patient 197 s 222 s 0.6358
Examination of patient by the attending during rounds 47.94 % 56.98 % 0.0532
Exchange of information with the patient during rounds 65.40 % 74.86 % 0.0291
Discussion of plan with patients during rounds 60.95 % 70.95 0.0255
Access of EHR during rounds 49.54 % 50.46 % 0.2379
Patient-related teaching time (sec) 141 100 0.12
Non-patient related teaching time (sec) 260 408 0.9415
Distractions per patient encounter 1.84 2.60 0.0045

BUILDING INFRASTRUCTURE: LESSONS LEARNED FROM A PARTNERED COMMUNITY-ACADEMIC GRANT WRITING SERIES Keyonna M. King1; Yvette-Janine Pardo2; Keith Norris1; D’Ann Morris3; Arleen F. Brown 1. 1UCLA, Los Angeles, CA; 2Assist Management Consulting, LLC, Pasadena, CA; 3Los Angeles Urban League, Los Angeles, CA. (Tracking ID #2196498)

BACKGROUND: Many new funding opportunities to improve community/population health require substantial community and academic partnership. To strengthen community and academic infrastructure for sustainable partnered research, the UCLA CTSI Community Engagement and Research Program (CERP) developed a Partnered Community-Academic Grant Writing Series.

METHODS: We implemented a novel, no-cost, 13-week grant writing workshop focused on paired community-academic partners. The workshop was conducted between April and June 2013 and had three goals: 1) to identify teams of community stakeholders and academic investigators who were ready to write a partnered proposal, 2) to introduce these partnered grant writing teams to diverse sources of funding and standard grant writing language, and 3) to assist the teams in writing proposals that effectively demonstrate evidence of partnership. The series curriculum was modified from traditional grant writing workshops originally designed as separate courses for community organizations or for academic investigators. A half-day introduction session (Are you grant ready?) was held to promote the intensive grant writing workshop and introduce partnered grant writing to community and academic organizations interested in learning how to partner to write proposals. The modules of the intensive grant writing workshop were: 1) Community-based participatory research (CBPR) and collaborative community-academic grant writing; 2) writing corporate, community, and private foundation grant writing; and 3) NIH unsolicited grant writing. Eligible teams for the intensive grant writing sessions were required to have at least 2 representatives from the partnering community organization (to enhance capacity building) and an academic investigator. Teams were selected by the CERP leadership and staff. Teams were tracked to determine outcomes. At six- and 12-months teams were asked to complete an online post-workshop evaluation asking questions about partnered proposal submissions.

RESULTS: Of the 16 teams that submitted LOIs, 10 with varying levels of grant writing experience were invited to participate. Weekly feedback helped CERP staff iteratively review goals/needs and modify the program. On average, 22 people attended each week, and all teams were represented each week. At the end of the 13-week intensive grant writing series, the majority of attendees (93.3 %) indicated they understood the benefits of partnering, could identify appropriate grant funding opportunities (86.6 %), and understood foundation and NIH grant writing language (84.2 and 68.8 %, respectively). At 12 month follow up, 2 teams submitted one proposal, 1 team had submitted two proposals, and 1 team had submitted 3 proposals. Three of the teams were awarded funds totaling $1.87 million. One team is revising their proposal for a different funding agency.

CONCLUSIONS: We developed a novel and innovative approach to community-academic partnered grant writing with early evidence that participating in the workshop enhanced capacity for partnered research, building both team self-efficacy and success in applying for available research funding. We will continue to track the features of the partnerships and their products and will modify the series based on these early experiences and the recommendations of the participants.

BUILDING SUSTAINABLE SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT (SBIRT) WITHIN PRIMARY CARE IN AN INTEGRATED HOSPITAL SYSTEM IN NEW YORK, NYSBIRT-II: AN IMPLEMENTATION MODEL Jeanne Morley 5; Sandeep Kapoor5,1; Megan O’Grady2; Nancy Kwon3; Mark Auerbach4; Jon Morgenstern3; Charles Neighbors2; Joseph Conigliaro5. 1The Feinstein Institute for Medical Research,, Manhasset, NY; 2The National Center on Addiction and Substance Abuse at Columbia University (CASAColumbia), New York, NY; 3North Shore Long Island Jewish Health System, New Hyde Park, NY; 4North Shore Long Island Jewish Health System, Bay Shore, NY; 5North Shore Long Island Jewish Health System, Manhasset, NY. (Tracking ID #2196410)

BACKGROUND: Screening, Brief Intervention, and Referral to Treatment (SBIRT) for substance misuse has received a great deal of empirical support. Despite the strong evidence for effectiveness and a compelling rationale for its integration, the circumstances under which it is likely to be implemented and sustained remains elusive. In 2013, the North Shore LIJ Health System, the National Center on Addiction and Substance Abuse at Columbia University (CASAColumbia), and the Office of Alcoholism and Substance Abuse Services (OASAS) established a partnership funded by Substance Abuse and Mental Health Services Administration (SAMSHA), to build a sustainable SBIRT program within an integrated Hospital System in Hurricane Sandy affected areas of the New York metropolitan area, NYSBIRT-II. By the end of the 5-year funding, the model developed for Emergency Department and Primary Care sites will serve as the basis for subsequent dissemination of SBIRT services throughout New York State. Our objective is to describe the implementation process in NYSBIRT-II Primary Care sites during year one and to report our cumulative results.

METHODS: The SBIRT model was implemented as follows: 1) At every patient visit, Medical Office Assistants (MOA) administered a 5-question SBIRT Pre-Screen for alcohol, drug, and tobacco use while measuring vital signs prior to a Physician (MD) visit; 2) Completed screens were then reviewed in real time by the SBIRT Health Coach (HC); 3) Patients with positive pre-screens were approached by the HC either during or at the end of the MD portion of the visit to complete a full screen (AUDIT and/or DAST-10); 4) Brief interventions and referrals to treatment were performed by the HC as indicated based on the full screen score.

RESULTS: Implementation has occurred in three Primary Care Sites including one designated Level III Patient Centered Medical Home (PCMH), with the initial site providing SBIRT services since December 2013. Initial implementation was evaluated using Government Performance and Results Act (GPRA) data. In the first year, 24,068 patients were PreScreened with an 11.8 % positive rate. The patients were diverse, with more women than men prescreened (63 % female); Age: 18–24 (3.7 %), 25–34 (10.2 %), 35–49 (24.8 %), 50–59 (24.9 %), ≥60 (36.3 %); Ethnicity: Latino (24.7 %); Race: Caucasian (38.2 %), African American (18.5 %), Asian (7.4 %), Other (35.9 %). Nearly 1875 full screens were conducted with a 33 % positive rate, resulting in 537 brief interventions and 114 referrals to brief or formal addiction treatment. Abuse of multiple substances was an issue for many patients, with 14.7 % of patients positive on both the AUDIT and the DAST10, with marijuana, cocaine and hallucinogens as the most commonly used drugs.

CONCLUSIONS: SBIRT services in a large, integrated health system are needed, and can be successfully implemented. SBIRT allows the clinical team to efficiently identify and address substance misuse at the point of service. Further research will focus on how to make SBIRT universally sustainable in the Primary Care setting and play a role in the continued integration of Behavioral Health in Primary Care.

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BUPRENORPHINE INITIATION AND LINKAGE TO OUTPATIENT BUPRENORPHINE TREATMENT DOES NOT REDUCE FREQUENCY OF INJECTION DRUG USE FOR INPATIENT OPIOID-DEPENDENT INJECTION DRUG USERS: RESULTS OF A RANDOMIZED CLINICAL TRIAL Phoebe A. Cushman 1; Bradleey J. Anderson2, 3; Merredith Moreau4; Michael D. Stein2, 3; Jane M. Liebschutz1. 1Boston University, Boston, MA; 2Butler Hospital, Providence, RI; 3The Warren Alpert Medical School of Brown University, Providence, RI; 4The Fenway Institute, Boston, MA. (Tracking ID #2190822)

BACKGROUND: Buprenorphine opioid agonist treatment has established effectiveness for patients with opioid substance use disorders who seek treatment in the outpatient setting. Our STOP (Suboxone Transition to Opiate Program) study showed that initiation of buprenorphine for hospitalized patients with opioid substance use disorders (both injection drug users and non-injection drug users) resulted in 72 % entry into outpatient treatment and decreased odds (0.6 aOR) of illicit opioid use over 6 months. The objective of this planned subgroup analysis of the injection drug users was to determine if buprenorphine initiation during hospitalization and linkage to outpatient-based buprenorphine treatment after discharge reduces injection drug users’ number of injection drug days compared to an in-hospital buprenorphine detoxification.

METHODS: From August 1, 2009, through October 31, 2012, opioid-dependent inpatients at an urban safety-net hospital were enrolled in a randomized clinical trial (RCT) and randomized to either detoxification (5-day buprenorphine taper) or linkage (buprenorphine induction, bridge prescription, and facilitated referral to outpatient treatment within 1 week of discharge) conditions. The main outcome for this subgroup analysis of injection drug users was prior 30-day injection of opioids (self-report) at 1, 3, and 6 months, measured using a standard 30-day timeline follow-back (TLFB) method. Intervention effects were estimated using a fixed-effects panel regression model; this method compares within-subject change over time and controls for all time-invariant between-subject differences. The intervention effect was estimated as the treatment-by-time interaction. We also measured the effectiveness of the linkage in terms of the percent of patients in each group who presented to an initial visit at an outpatient buprenorphine program after hospital discharge. Finally, we conducted a person-day analysis by using a generalized estimating equation (GEE) to evaluate the association between prescription buprenorphine use and injection drug use during follow-up.

RESULTS: A total of 139 eligible patients were randomized; we limited our analysis to those participants in the detoxification (n = 62) and linkage groups (n = 51) who reported baseline injection drug use. There were no significant differences with respect to age (mean 39.5 years; t = −0.78, p = .440), gender (69.0 % male; X2 = 0.81, p = .368), ethnicity (48.7 % non-Latino Caucasian; 23.0 % African-American, 20.4 % Latino, 8.0 % other, X2 = 3.66, p = .301), or baseline frequency of injection drug use (mean 67.8 % of TLFB days; t = 0.10, p = .923) between the two groups. At follow-up, patients in the linkage group (70.6 %) were significantly (X2 = 44.46, p < .001) more likely to present to an initial visit at a buprenorphine program than those in detoxification group (9.7 %). However, there was no statistically significant difference in the proportion of days of injection drug use between the linkage and detoxification groups at follow-up. The treatment-by-time interaction was not statistically significant (LR2 = 2.85, df = 3, p = .415). Individual coefficients for treatment effects at 1- (b = 0.03, t = 0.48, p = .634), 3- (b = 0.09, t = 1.06, p = .288), and 6-months (b = −0.02, t = −0.27, p = .787) were not statistically significant. Using a person-day analysis, participants self-reported injection drug use on 5.8 % of follow-up days in which they also reported prescription buprenorphine use and 37.5 % of days in which they did not report prescription buprenorphine use. Using GEE, the odds of injection drug use was estimated to be 4.57 (z = −12.81, p < .001) times higher on days when prescription buprenorphine was not used.

CONCLUSIONS: Despite the robust effectiveness of the linkage protocol in facilitating entry of hospitalized, opioid-dependent injection drug users into initial outpatient buprenorphine treatment, the intervention did not decrease their frequency of injection drug use. Injection drug users may require a more intensive buprenorphine treatment protocol than do non-injection misusers of opioids. In particular, many hospitalized injection drug users are not actively seeking treatment for substance misuse and are likely to have especially complex medical and social needs. Further research is needed to determine how to engage these highly vulnerable patients in sustained addiction treatment beyond the initial linkage.

BURDEN OF BENZODIAZEPINE AND OPIOID OVERDOSE ON HOSPITALS IN USA: ANALYSIS OF NATIONWIDE EMERGENCY DEPARTMENT SAMPLE DATA Sourabh Aggarwal 2; Devin B. Malik2; Akshay Amaraneni2; Andrew Whipple1; Christopher M. Begley1. 1Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI; 2Western Michigan University School of Medicine, Kalamazoo, MI. (Tracking ID #2197613)

BACKGROUND: Opioid and Benzodiazepine drug abuse has been an emerging health care problem. It has significant implications on healthcare with associated morbidity and mortality. The trend and impact of the opioid and BZD overdose on USA hospitals has never been studied.

METHODS: We queried Nationwide Emergency Department (ED) Sample data for all the patient visits with first listed diagnosis of BZD overdose and opioid overdose using International Classification Code 9 codes of 969.4 and 965.09 respectively. Data was extracted for the years 2006 to 2011. Admission rate to hospitals during ED visits and in-hospital mortality for admitted patients was calculated.

RESULTS: We identified a total of 510,725 ED visits with first listed diagnosis of BZD overdose during 2006–2011 with rate of visits increasing from 25.7 per 100,000 total visits in 2006 to 28.7 per 100,000 total visits in 2011 with average admission rate of 46.94 % and in-hospital mortality rate of 0.78 %. We identified a total of 222,856 ED visits with first listed diagnosis of Opioid overdose during years 2006–2011 with rate of visits increasing from 9.9 per 100,000 total visits in 2006 to 13.8 per 100,000 total visits in 2011 with average admission rate of 48.54 % and in-hospital mortality of 1.77 %.

CONCLUSIONS: Our study reveals a significant burden of BZD and opioid overdose on hospitals in USA with increasing rate of hospitalizations. It indicates there is a large unmet need for interventions to regulate the use and prescription of controlled drugs.

BUT DOCTOR, I JUST ATE…THE RELATIONSHIP BETWEEN POSTPRANDIAL TIME AND RANDOM GLUCOSE VALUES Michael E. Bowen 1; Lei Xuan2; Ildiko Lingvay1; Ethan Halm1. 1UT Southwestern Medical Center, Dallas, TX; 2University of Texas Southwestern Medical Center at Dallas, Dallas, TX. (Tracking ID #2199277)

BACKGROUND: Non-fasting, random blood glucose (RBG) values are common and can identify patients at risk for dysglycemia (diabetes+prediabetes) in clinical practice. However, evidence guiding the interpretation of RBG values is limited. We sought to characterize the relationship between RBG values and prandial time and determine the postprandial time at which RBG values can best differentiate individuals with dysglycemia.

METHODS: We conducted a cross-sectional analysis of merged data from the 2007–20012 National Health and Nutrition Examination Survey (NHANES). The study sample included non-pregnant, non-fasting adults age ≥ 18 without diagnosed diabetes who had both a RBG and hemoglobin A1C (A1C) available. Participants consuming anything other than water in the 9 h before lab testing were considered non-fasting. Glycemic status was characterized using A1C as normal < 5.7 % or undiagnosed dysglycemia ≥5.7 %. Prandial time was modeled as a predictor of RBG using linear regression. We utilized unadjusted models to demonstrate the usefulness of this approach to identify undiagnosed dysglycemia in a real-world ambulatory clinic setting. We present the estimated prediction of RBG values at different prandial times using predictive margins. RBG values ≥ 100 mg/dL were considered clinically relevant glucose elevations.

RESULTS: A total of 7483 participants met inclusion criteria. Those with dysglycemia (n = 2406) were older (55.2 vs. 41.5; p < 0.001), had higher BMIs (30.3 vs. 27.3; p < 0.001), higher RBG values (103.6 vs. 89.2; p < 0.001), and were more likely to be non-white (35.9 % vs. 28.1 %; p < 0.001). Sex did not differ between groups. A statistically, but not clinically meaningful difference in prandial time of 12 min was observed between groups (2.9 vs. 2.7 h; p < 0.001). The predicted marginal RBG values ranged from 7.6 to 18.3 mg/dL higher in the dysglycemia group and were significantly higher in the dysglycemia group at all time points (p < 0.001; Figure). Predicted marginal RBG values in participants with normal glycemic status were always below 100 mg/dL in the first 9 h after intake. In the dysglycemia group, RBG values between 0 and 3 h after a meal were always significantly ≥100 mg/dL (Figure). If all individuals with a RBG ≥ 100 mg/dL between 0 and 5 h after a meal were screened with an A1C, 96.4 % of dysglycemia cases could be identified. Among those with dysglycemia, predicated RBG values at postprandial time ≥6 h were ≤100 mg/dL, which is below the fasting glucose cutpoint to diagnose dysglycemia.

CONCLUSIONS: RBG values ≥ 100 during 0–5 h after a meal are associated with dysglycemia and should prompt definitive diabetes testing. In routine clinical practice, RBG values could identify the majority of patients with dysglycemia, and fasting more than 6 h in clinical practice may not improve the detection of dysglycemia.

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Figure 1. The Relationship BetweenRandom Glucose Values and Postprandial Time Stratified by Glycemic Status

CALLING IT LIKE YOU SEE IT: THREE-HOUR WORKSHOP IMPROVES HOSPITALISTS OBSERVATION AND FEEDBACK SKILLS Margaret Horlick2; Louis H. Miller3; Patrick M. Cocks4; Lynn Bui 5; Mark D. Schwartz2; Anne Dembitzer1. 1NY Harbor VA, New York, NY; 2NY Harbor VA Healthcare Center, Brooklyn, NY; 3NYU School of Medicine, New York, NY; 4NYU School of medicine, NEw York, NY; 5New York University, New York, NY. (Tracking ID #2197982)

BACKGROUND: The implementation of the New Accreditation System (NAS) by the ACGME requires that residency programs focus their assessment of trainees on developmental milestones in part via direct observation as they care for patients. Clinician Educators (CE) are the primary evaluators of graduate trainees and yet they have had little to no education in this area. The ABIM advocates a model that uses performance dimension training and the development of shared mental models. Participation in a daylong ABIM workshop was associated with improved confidence and performance of direct observations and assessments. We sought to create a workshop that could be easily integrated into the professional lives of CEs and evaluate the impact on faculty’s confidence and skill in providing observation and feedback, and change in self-reported teaching behaviors.

METHODS: We recruited hospitalist physicians from three institutions to participate in a 3-h workshop. Participants were divided into small groups of 3–4 faculty. The workshop focused on interactive skill building using performance dimension training, shared mental models and role-plays. We evaluated the impact of this training on teaching confidence using pre and post surveys that asked faculty to rate their confidence on a 1–4 scale from “not confident” to “very confident.” Teaching performance was assessed using pre and post OSTEs. Standardized learners rated teaching performance using a checklist that that included 10 items specifically to assess observation and feedback; items were rated as “not done,” “partly done,” or “well done”. Teaching behavior change was assessed by 4 month follow-up on faculty’s commitment to change statements that were completed at the conclusion of the workshop.

RESULTS: Eighteen hospitalists completed the workshops and all assessments. Sixty-five percent were male with an average of 4 years in practice (range 1 to 8 years). Teaching confidence improved after participation in the workshop as the percentage of participants who reported themselves to be very confident in feedback and evaluation rose from 32 to 52 % (p = 0.006). Teaching performance also improved—the percentage of participants that received a score of “well done” for observation and feedback in the OSTE improved from 42 to 85 % (p = 0.00003). Participants improved their use of a shared mental model as the proportion of faculty rated “well done” on, “outlined to learner what you would be looking for during his/her exam” improved from 7 to 85 % (p = 0.00004). Participants also improved in providing behaviorally specific positive feedback from 50 to 92 % well done (p = 0.008). In addition, at four-month follow up, 81 % of participants reported they had partially or fully implemented the changes they had committed to in their teaching practice.

CONCLUSIONS: Focused, interactive faculty development can both improve faculty’s observation and feedback skills and impact their teaching practice. Pragmatic NAS aligned medical center wide faculty workshops have the potential to change the culture of assessment in a residency program.

CAN PATIENT-CENTERED CARE INNOVATION AFFECT PATIENTS’ EXPERIENCES OF CARE? Mark Meterko 2, 3; Errol Baker2; Corey Pilver2; Anna M. Barker1; A. Rani Elwy1, 3; Joel Reisman1; Kelly Dvorin1; Barbara G. Bokhour1. 1ENRM Veterans Affairs Medical Center, Bedford, MA; 2VA Boston Healthcare System, Boston, MA; 3Boston University School of Public Health, Boston, MA. (Tracking ID #2198142)

BACKGROUND: Providing patient-centered care (PCC) in an outpatient setting has become a priority for many medical centers, including the US Department of Veterans Affairs. A myriad of changes may lead to PCC, yet it is unclear as to the effectiveness of efforts to transform the culture of care. The VA Office of Patient-Centered Care and Cultural Transformation has designated certain medical centers as PCC Centers of Innovation (COI), noting them to be leaders in PCC transformation. Innovations have included changes in the physical environment, inclusion of complementary integrative medicine, education of staff to improve patient-centered communication, incorporation of health coaching, and a focus of care on patients’ whole health and well-being. We sought to evaluate the impact of ongoing programmatic changes at one outpatient clinic at a VA Center of Innovation for PCC.

METHODS: We conducted a cross-sectional survey of patient-centered care attitudes at two sites, one of which was the PCC Center of Innovation and the other was a matched comparison site. To assess the impact of the natural experiment in PCC innovation at the PCC innovation site, we purposively selected a comparison site that had not been engaged in PCC transformation and was similar to the innovation site with regard to overall complexity, urban location and geographic region. Samples of 300 recent ambulatory care patients were randomly selected at each site to receive a mail survey. Adjusting for potential respondents who could not be contacted, response rates of 44.4 % (n = 118) and 36.8 % (n = 106) were obtained at the innovation and comparison sites, respectively. The survey consisted of several standardized measures of the extent to which interactions with the primary care team were experienced as patient-centered including 1) shared decision making (CollaboRATE) and 2) patient-centered communication (Communication Assessment Tool). Additional standardized measures assessed perception of the physical environment (Perceived Environmental Quality Index - PEQI) and overall visit satisfaction. We measured more distal outcomes including 1) health and functional status (Patient Reported Outcomes Information System - 29); 2) self-care confidence (Self-Efficacy for Managing Chronic Disease); and 3) mindfulness (Mindful Attention Awareness Scale). Sites were compared using both simple bivariate analyses and multivariable models adjusted for observed site differences in patient health status, tenure with primary care provider, and ethnicity.

RESULTS: Scores for the innovation site were significantly more favorable than the comparison site on all measures of the perceived patient-centeredness of visit care processes. Scores on shared decision making (CollaboRATE) on a scale from 0 (no effort) to 10 (every effort), adjusted for demographic differences between the sites, were significantly higher among innovation site outpatients (9.2) compared to those at the comparison site (8.3; p < .03). Patients at the innovation site also significantly more frequently endorsed “Excellent” on CAT, relative to comparison site patients (59.3 % vs. 39.5 %, p < .001). Regarding overall visit satisfaction, when asked to think back on their most recent visit and rate it overall on a scale from 0 (worst possible) to 10 (best possible), about 73 % of innovation site outpatients rated their visit as a 9 or 10 compared to about 54 % of comparison site outpatients (p < .01). Adjustment for site differences in patient demographics and background using logistic regression confirmed these initial bivariate findings, indicating that intervention site outpatients were almost 2.5 times more likely than comparison site outpatients to rate their office visit as the best or almost best possible (odds ratio = 2.43, p < .01). Scores on the perception of the environment (PEQI) on a 7-point scale (1–7, from negative to positive), adjusted for demographic differences between sites, were significantly higher among PCC innovation site outpatients (6.4) relative to the comparison site (5.7; p < .01). No significant differences were found for the distal outcome measures.

CONCLUSIONS: Results suggest that innovations at the VA Center of Innovation have had a positive impact on the extent to which Veterans experience the communication processes and the physical environment as patient-centered and on overall visit satisfaction, an immediate outcome of the outpatient care process and environment. We did not see evidence yet of an impact on longer-term outcomes measured for this evaluation, including self-reported health, functional status, or health-related attitudes. These findings indicate that efforts to transform care to being more patient-centered can positively impact patients’ experience of the care they receive.

CAN WE IDENTIFY MINORITY PATIENTS AT RISK OF NON-ADHERENCE TO ANTIPLATELET MEDICATIONS AFTER CORONARY STENT PLACEMENT Leonardo Tamariz; Ana M. Palacio; Olveen Carrasquillo. University of Miami, Miami, FL. (Tracking ID #2199185)

BACKGROUND: Lack of medication adherence is associated with significant morbidity and mortality particularly among minority groups. Interventions shown to improve adherence are complex and difficult to sustain in real world settings. Learning how to identify and target subjects at risk of non-adherence is key to disseminate succesful strategies. The purpose of this study was to identify predictors of non-adherence to antiplatelet medications post coronary stent placement among Black and Hispanics enrolled into a randomized clinical trial that compared two interventions to improve adherence.

METHODS: We used data collected for a randomized clinical trial that recruited 452 Black and Hispanic subjects with a coronary stent to compare a phone-based Motivational interviewing intervention to a mailed educational video. The primary outcome was 12- month adherence to antiplatelet medications measured by the claims based Medication Possession Ratio (MPR) and by the Medication Adherence Morisky Scale (MMAS-4). Adequate adherence was defined as MPR > =.80 and a Morisky score of 4. At enrollment which occurred within 90 days of stent placement, we collected demographic information including race, income, marital status, education as well as health literacy, the PHQ-9 to screen for depression, the MMAS-4, Charlson comorbidity score, acculturation and pill burden. We used univariate and multivariate logistic regression to identify predictors of non-adherence. We also calculated the area under the curve of multiple combinations of baseline variables.

RESULTS: We recruited 452 subjects with an average age of 69.52+/−8.8. Of those 57 % were male and 57 % were Hispanic. Seventy eight percent had a median income below or equal to $30,000 and 22 % completed high school or higher. Univariate analyses revealed that the MMAS-4 (p = 0.01), difficulty remembering to take medications (p = 0.03), not having a household partner (p < 0.01), PHQ2 (p = 0.01), PHQ9 (p < 0.01) were significantly associated with inadequate adherence. Low health literacy and speaking more Spanish than English had marginal significance (p = 0.06) The table reports the multivariate analyses. The combination of the Morisky Score score and the PHQ2 had the highest area under the curve 0.57(95 % CI 0.51–0.61) however it was not significantly better (p = 0.07) than only the Morisky score 0.56(95 % CI 0.48–0.57). Sixty three percent of those who had adequate adherence according to the baseline MMAS-4 and who screened negative for depression with the PHQ2 (less than 3 points) had adequate 12 month adherence compared to 48 % of those who had a MMAS-4 less than 4 and a PHQ2 of 3 points of more (p < 0.01)

CONCLUSIONS: Subjects with multiple comorbidities, particularly depression with suboptimal MMAS-4 at baseline are at higher risk of poor 12 month adherence after stent placement. The evaluation of the positive and negative predictive values of these variables in a non-intervened population could help in the development of a screening tool.

Multivariate evaluation of predictors

Variable Odds ratio (95 % CI) p-value
MMAS-4 1.7(1.0–2.6) 0.01
Difficulty remembering 0.2(0.1–0.4) <0.01
Health literacy 1.7(0.9–3.1) 0.08
PHQ-9 0.9(0.8–1.0) 0.09
Motivational interviewing 3.5(1.9–6.7) <0.01
Charlson score 0.8(0.8–0.9) 0.02

CAREGIVER BURDEN AND FAITH: SOCIO-DEMOGRAPHIC PREDICTORS OF STRAIN DURING END-OF-LIFE CARE. Jorge A. Dorantes 2; Michael Green3; Benjamin Levi3; Jane Schubart3; Renee R. Stewart3; Alyssa Harlow1; Lisa S. Lehmann2. 1Brigham and Women’s Hospital, Cambridge, MA; 2Brigham and Women’s Hospital, Boston, MA; 3Penn State College of Medicine, Hershey, PA. (Tracking ID #2200240)

BACKGROUND: Family caregiving for patients with end-stage medical conditions is a potentially transformative experience that can be both intensely burdensome and profoundly meaningful. The burden of caregiving may be related not only to the challenge of meeting medical demands, but also caregiver marital status, relationship with patient, and employment status. Despite an increasing awareness of the benefits in acknowledging a patient’s personal values during the advance care planning process, limited attention has been given to the associated stressors of family caregivers. Previous studies report inadequate stress management and role conflict as substantial contributors to family caregiver burden, but the extent to which religious strength serves as a coping mechanism in alleviating caregiver strain and anxiety remains unclear. We hypothesized that caregivers with stronger of faith would have lower levels of caregiver strain and lower levels of burden. We additionally aimed to evaluate whether caregiver strain was associated with socio-demographic characteristics, including education, gender, ethnicity, marital status, and age.

METHODS: We recruited 92 severely ill patients from Brigham and Women’s Hospital and Penn State Hershey Medical Center. Patients were included if they had a likely prognosis of less than 2 years with one of the following diagnoses: advanced cancer, severe congestive heart failure (New York Heart Association Class III or Class IV), severe lung disease (Stage III or Stage IV COPD by modified GOLD Spirometric Classification), or End Stage Renal Disease. We measured caregiver strain with a validated 12-item Zarit Burden Interview (ZBI) short form and a caregiver strain index form (FSI) comprised of 13 yes/no questions assessing the caregiver’s role and associated experiences. Both the ZBI and the FSI were administered to the caregiver during the first visit (ZBI + FSI pre-intervention) and subsequently administered 8–12 weeks after the second visit through a phone interview (PI + ZBI + FSI post-intervention). Socio-demographic information was collected for all subjects. Descriptive analyses and ANOVA was used to assess predictors of caregiver burden and strain.

RESULTS: The mean age of caregivers (CG’s) was 58 years (SD ± 14), while the mean age of patients was 63 years (SD ± 14). Fifty-one percent of patients had cancer, 24 % (n = 42) had COPD, 21 % (n = 36) had CHF, and 4 % (n = 6) had ESRD. Seventy-six percent of CG’s were white (n = 70) and 13 % of were Black (n = 12). Sixty-nine percent of CG’s (n = 64) reported having a strong religious faith, while 31 % (n = 29) reported having weak or no religious faith. ANOVA for pre and post intervention phone interviews showed that the mean change in family strain (FSI) (0–13, higher = more strain) was 2.88 (95 % CI 1.72–4.04) for unemployed caregivers (n = 45) as opposed to 1.00 (95 % CI .07–1.93) for employed caregivers (n = 47) (P = 0.01). ANOVA additionally revealed the following for pre and post intervention phone interviews: the mean change in family strain (FSI) between male CG’s (n = 27) and female CG’s (n = 66) was 2.83 and 1.37, respectively (P = 0.065). The mean change in family strain (FSI) between CG’s who were married (n = 66) was 1.69 (95 % CI .87, 2.51) and 2.43 (95 % CI 0.17, 4.68) for CG’s who were not married. The mean change in family strain (FSI) was 1.62 (95 % CI .90, 2.34) for CG’s who made no important medical decisions for their loved ones (n = 34) as opposed to a mean change in family strain of 4.33 (95 % CI 2.38, 6.29) for CG’s who did make an important medical decision for their loved one (n = 7) (P = 0.03). There was no significant association between change in family strain and strength of religious faith, age, education, and ethnicity.

CONCLUSIONS: Strength of faith, contrary to our hypothesis, was not has associated with change in CG strain in the pre and post-intervention phone interview. However, change in CG strain increased for CG’s who had been involved in making an important medical decision. Interestingly, change in CG strain was higher for men than women, and was lower for CG’s that are married and employed as opposed to CG’s that are not married and unemployed. Our findings suggest that CG strain is dynamic and not only correlative with a patient’s severity of illness or level of involvement in medical decisions. Caregiver gender, marital and employment status also contribute to differences in CG strain. Health care providers will be able to better support family caregivers if they are aware of the multiple factors contributing to CG strain while caring for patients at the end-of-life.

CENTOR SCORE PREDICTS COMMON BACTERIAL CAUSES OF SORE THROAT—NOT JUST GROUP A BETA HEMOLYTIC STREPTOCOCCUS. Robert M. Centor 1; Thomas P. Atkinson2; Ken Waites2; Carlos Estrada3, 2. 1University of Alabama at Birmingham, Huntsville, AL; 2University of Alabama at Birmingham, Birmingham, AL; 3Birmingham VAMC, Birmingham, AL. (Tracking ID #2168431)

BACKGROUND: Group A beta hemolytic streptococcus (GAS), Fusobacterium necrophorum, and group C/G beta hemolytic streptococcus cause pharyngitis. However, whether Centor score predicts all such bacterial infections is unknown. We sought to determine whether Centor score also stratifies risk of bacterial infection in young adults with sore throat and to explore whether revised weights increased discrimination.

METHODS: In a prospective, cross-sectional study, students aged 15–30 years presenting to a student health clinic with acute sore throat were tested with polymerase chain reaction from throat swabs to detect the three bacteria. We calculated the Centor score by assigning one point each of four indicators (fever history, lack of cough, anterior cervical adenopathy and tonsillar exudates) prospectively collected and computed the Area Under the Receiver Operating Curve (AUROC). We then revised the Centor score weights based on logistic regression odds ratios [OR].

RESULTS: The prevalence of bacterial infection was 34 % (106/312). Each of the four Centor criteria significantly correlated with bacterial pharyngitis: fever history (OR 1.7; 95 % confidence interval [CI], 1.0 to 2.8; p = 0.04), lack of cough (OR 2.1; 95 % CI, 1.3 to 3.4; p = 0.003), anterior cervical adenopathy (OR 1.7; 95 % CI, 1.0 to 2.8; p = 0.04), or tonsillar exudates (OR 3.1; CI, 1.7 to 5.7; p < 0.001). The AUROC was 0.66 (95 % CI; 0.60 to 0.73). The risk of bacterial infection increased as the Centor score increased (p < 0.001, Chi square for trend). For example, patients with scores 2–4 were twice as likely to have a bacterial pathogen (44 %, 74/169) as compared to patients with scores 0–1 (22 %, 32/143)(p < 0.001). A new logistic regression analysis yielded these weights: 1 for fever history, 2 for lack of cough, 2 for anterior cervical adenopathy, and 3 for tonsillar exudates. The risk of bacterial infection also increased as the revised Centor score increased (p < 0.001, Chi square for trend); scores 0–2 (22 %, 30/138), scores 3–5 (38 %, 51/133), and scores 6–8 (61 %, 25/41). However, the AUROC did not differ from the original criteria.

CONCLUSIONS: The Centor score stratifies the risk of any of 3 bacteria causing pharyngitis—(F. necrophorum, group A and group C/G beta hemolytic streptococci—among young adults patients with sore throat.

CHANGE IN CARDIOMETABOLIC RISK FACTORS WITH POSTPARTUM CHANGES IN WEIGHT AND WAIST CIRCUMFERENCE IN WOMEN WITH RECENT GESTATIONAL DIABETES Jacinda M. Nicklas 2; Chloe A. Zera1; Sue E. Levkoff3; Ellen W. Seely1. 1Brigham and Women’s Hospital, Boston, MA; 2University of Colorado School of Medicine, Aurora, CO; 3University of South Carolina, Columbia, SC. (Tracking ID #2194704)

BACKGROUND: Women with gestational diabetes (GDM) have increased risk for the development of type 2 diabetes (T2DM) and cardiovascular disease (CVD), as well as high risk for repeat GDM. Although studies in older women suggest that weight loss may improve cardiometabolic risk factors, little is known about how weight changes modify these risk factors in the postpartum period. Some cohort studies suggest that women with GDM, despite their increased risk, do not lose weight and may even gain weight in the postpartum period. Given that cardiovascular disease and diabetes are the second and eighth leading causes of death, respectively, among women 45–54, the first decade following the childbearing decades, earlier weight changes may be important.

METHODS: In the Balance after Baby (BAB) trial of 75 women with recent GDM, women randomly allocated to a web-based year-long lifestyle intervention program lost significantly more weight than the control group. There was no significant impact of the intervention to decrease cardiometabolic risk factors. However, there was a large range of weight change in both groups (−16 kg to +10 kg). For this analysis, we sought to determine if weight changes in the postpartum year were associated with changes in risk factors for T2DM and CVD, regardless of group assignment. In the BAB trial, we measured weight, height, waist circumference, blood pressure, fasting lipids, hsCRP, IL-6, fasting insulin, adiponectin, and conducted 75 g 2-h oral glucose tolerance tests at 6 weeks, 6 months, and 12 months postpartum. For this analysis, we include 59 women providing fasting blood samples at both 6 weeks and 12 months postpartum. We used JMP 11 Pro to conduct Spearman’s correlations to determine the relationship between weight change and change in markers of cardiometabolic risk.

RESULTS: Among 59 participants, the mean age was 33 ± 5 years; 6 week postpartum BMI was 31 ± 6 kg/m2; and 58 % were White, 31 % African-American, 12 % Asian; with 20 % Hispanic. Median weight change from 6 weeks to 12 months postpartum was +0.4 kg (IQR −4.8 kg, +2.7 kg) and median change in waist circumference was −1.4 cm (IQR −7 cm, +2 cm). Changes in weight from 6 weeks to 12 months postpartum significantly correlated with changes in several T2DM risk factors: HbA1c (Spearman’s r = 0.45, p < .001), fasting glucose (r = 0.41, p < .005), fasting insulin (r = 0.49, p < .001), homeostasis model assessment of insulin sensitivity (HOMA) (r = 0.5, p < .001), and adiponectin (r = −0.38, p < .005). Among CVD risk factors, weight changes were significantly correlated with changes in fasting triglycerides (Spearman’s r = 0.28, p < .05), but not with other CVD risk factors including blood pressure, LDL, or HDL, nor with the inflammatory markers hsCRP and IL-6. Changes in waist circumference significantly correlated with changes in HbA1c (r = 0.36, p < .01), fasting insulin (r = 0.38, p < .005), HOMA (r = 0.38, p < .005), HDL (r = −0.31, p < .05), and hsCRP (r = 0.28, p < .05).

CONCLUSIONS: Weight changes and changes in waist circumference in the postpartum period were significantly correlated with changes in certain cardiometabolic risk factors among women with recent GDM. Given the high risk for T2DM, CVD, and repeat GDM in this population, weight gain or loss, even in the first year postpartum, may have substantial impact on the development of future disease. Longer studies are needed to determine how postpartum weight changes affect the rate of development of T2DM, CVD, and repeat GDM. Supported by: CDC MM-1094-09/09; NIH BIRCWH 5K12HD057022-08; NIH NCAAM T32AT000051; NIH NHLBI K24HL096141

CHAOS AND CLINICAL COMPETENCE: ASSESSING THE INFLUENCE OF THE “BUSY-NESS” OF THE CLINIC ON RESIDENT PHYSICIANS’ CORE CLINICAL COMPETENCE: USING UNANNOUNCED STANDARDIZED PATIENTS Colleen Gillespie; Irina Nudelman; Kathleen Hanley; Amara Shaker-Brown; Ellen Wagner; Lisa Altshuler; Adina Kalet; Sondra Zabar. NYU School of Medicine, New York, NY. (Tracking ID #2198729)

BACKGROUND: Clinic functioning has been shown to influence quality of care. Less is known, however, about whether clinic functioning affects physicians’ core clinical skills such as communication. In addition, residency training may not focus sufficiently on preparing residents for maintaining their competence in challenging clinical settings. We explore association between the functioning of the primary care clinic and medicine residents’ core communication skills using Unannounced Standardized Patient (USP) visits as a method uniquely suited to capture both physician communication competence and in-the-moment “busy-ness” of the clinic.

METHODS: Three hundred three USP visits, focusing on 5 different common primary care clinical scenarios for new patients, were delivered to 120 medicine residents across two primary care clinics. Highly trained SPs showed up to the clinic as new patients, saw the resident physician, and completed a comprehensive assessment of both the functioning of the clinic, including clinic staff, and the competence of the resident physician in the core domains of communication, assessment, counseling, physical exam, treatment plan, and patient activation. Analyses focus on a single-item measure of how busy the clinic was ranging from 1-not busy at all to 5-hectic/chaotic with the midpoint of 3 anchored as busy but reasonable. Resident competence in communication was assessed using 14-items with behavioral anchors for not done, partly done and well done response options that included 3 sub-domains: information gathering, relationship development, and education/counseling. Summary scores were calculated as percent of items rated as well done and each domain and sub-domain score met minimum criteria (.80) for internal consistency.

RESULTS: Twenty-four percent of visits were rated as “calm”, 22 % as between “calm” and “busy but reasonable”, 41 % as “busy but reasonable”, 11 % as between “busy but reasonable” and “hectic/chaotic” and 2 % as “hectic/chaotic” (overall mean = 2.45, SD 1.03; 5-point scale). Mean overall communication scores differed significantly by chaos measure (F = 6.22, p = .013) with those scores assessed on days that were rated as more than “busy but reasonable” being significantly lower than those assessed on days when the clinic was less busy (means for each value of the chaos measure: 1 = 64 %; 2 = 60 %; 3 = 58 %; 4 = 51 %; 5 = 44 %). Scores for the sub-domains of communication showed similar trends (information gathering F = 6.22, p = .013); relationship development F = 7.26, p = .007; patient education F = 3.38, p = .067). Correlations supported these findings as a small but significant linear relationship was found between clinic chaos scores and overall communication performance Spearman’s (r = −.11, p < .05) and was slightly larger for relationship development (r = −.15, p < .05).

CONCLUSIONS: Resident physicians’ communication performance in primary care visits was found to be negatively associated with clinic chaos—the busier the clinic, the lower their communication scores. Both assessments were made by the USP and so one limitation of our data is that some of this association could be due to the chaos of the clinic affecting the USP’s rating. However, our results suggest that 1) preparing residents to communicate effectively even on more hectic, chaotic days may be one goal of training programs and 2) quality of communication at the individual provider level can be enhanced by improving the functioning of the clinic.

CHARACTERIZATING THE END OF LIFE CARE FOR THE UNINSURED AND UNDOCUMENTED IMMIGRANT PATIENTS IN A CITY HOSPITAL CENTER Janeen Marshall 1; Tita Castor2, 1; Sapna Shah2, 1; Nisha Viswanathan1; Ali-John Zarrabi1. 1The Mount Sinai Hospital, New York, NY; 2Elmhurst Hospital Center, Elmhurst, NY. (Tracking ID #2199239)

BACKGROUND: In 2014 the WHO mandated that access to palliative care and hospice be accessible for all. Here in the US care for the uninsured and undocumented (UAU) patients continues to be a struggle for many health systems yet limited data is available regarding the provision of service, clinical course and outcomes for these patients in need of palliative care and hospice services.

METHODS: Clinical and demographic data from UAU patients followed by the Palliative Care Consult Service (PCCS) at Elmhurst Hospital Center from 12/1/2013-11/30/2014 was obtained on intake to the service. Undocumented status was indicated on initial intake form and uninsured status was verified by chart review. The diagnoses, reason for consult, length of stay, PCCS interventions provided and discharge disposition were analyzed.

RESULTS: Four hundred twenty-eight total patients were referred to the PCCS. 40.2 % were 18–65 years old and 59.8 % were >65 years old. 49.8 % were Female. Approximately 11 % of these patients died within 2 days of completion of their PCCS consultation. Fourteen percent patients were identified as to be uninsured and undocumented. The most common reason for consult for these patients was discharge planning/placement and for 4 of these patients the ultimate determination was that they would remain in the city hospital until their death due to their lack of insurance and undocumented status. Mean number of days between admission and PCCS consultation for these patients was 7.4 days. Five percent of all PCCS patients remain hospitalized for more than 30 days after admission and 7 % remain after PCCS consultation.

CONCLUSIONS: To date very little data on the experience of undocumented and uninsured patients exists outside of anecdote and case report. Characterizing the end of life care in the uninsured and undocumented patients provides much needed data in assuring that hospital systems are able to provide palliation and discharge to appropriate care systems for this vulnerable population.

CHRONIC BENZODIAZEPINE PRESCRIBING IN AN ACADEMIC PRIMARY CARE CLINIC Maria Fan 2; Scott Steiger1. 1UCSF, San Francisco, CA; 2University of California, San Francisco, San Francisco, CA. (Tracking ID #2195005)

BACKGROUND: Chronic benzodiazepine use is geographically variable and associated with several harms, including dementia, falls, hip fractures, increased mortality, and possibly cancer. There is growing interest in reducing chronic benzodiazepine use, particularly in high-risk populations such as the elderly. In this study, our objective was to characterize chronic benzodiazepine prescribing patterns in an academic primary care clinic.

METHODS: We performed a cross-sectional study of patients receiving chronic benzodiazepines at the University of California, San Francisco, General Internal Medicine Practice. We queried the electronic health record (EHR) to identify all patients who received two or more outpatient prescriptions for any benzodiazepine between 7/1/2013 and 8/25/14. We reviewed the charts of identified patients to determine the indication for prescribing. Demographic information, prescribed benzodiazepine amounts, co-morbid diagnoses, concomitant hypnotic and anti-depressant prescription, and urine drug testing information was extracted through EHR query. Mean 10-mg diazepam daily dose equivalents were calculated based on total number of tablets prescribed in the specified time frame, including refills. Descriptive statistics were calculated for the group of patients receiving chronic benzodiazepines and compared to descriptive statistics for the practice as a whole.

RESULTS: There were a total of 634 patients identified as receiving chronic benzodiazepines out of a total practice population of 26,805 patients (2.4 %). The mean age of patients prescribed chronic benzodiazepines was 58 years, with a range of 24 to 95 years. Thirty four percent of patients prescribed chronic benzodiazepines were aged 65 years or older, compared to 27 % of the overall clinic population aged 65 or older. The most common indications for benzodiazepine prescriptions were anxiety (64 %) and insomnia (16 %) (Table 1). The mean 10-mg diazepam daily dose equivalent for the cohort was 1.47, with a range of 0.01 to 32.55. Forty-five percent of patients receiving chronic benzodiazepines were co-prescribed an anti-depressant. 23 % of patients receiving chronic benzodiazepines also received chronic opiates, compared to only 3 % of patients in the total practice population receiving chronic opiates. Fourteen percent of patients receiving chronic benzodiazepines had received urine drug testing at least once in the past year. Three percentof patients receiving chronic benzodiazepines had diagnoses of dementia or cognitive impairment.

CONCLUSIONS: Prevalence of chronic benzodiazepine prescribing in this academic primary care clinic was lower than recently reported national data, though our study was limited to prescriptions by primary care providers. Of patients receiving chronic benzodiazepines, a third were older than 65 years and a higher proportion of patients were simultaneously prescribed chronic opiates than compared to the general clinic population. This study characterizes prescribing patterns for chronic benzodiazepines in an academic primary care practice and identifies several potential areas for improving prescribing safety for chronic benzodiazepines.

Indications for benzodiazepine prescriptions

Indication* Number of patients (%)
Anxiety 409 (64 %)
Insomnia 104 (16 %)
Muscle spasms 22 (3.5 %)
Anxiety or insomnia 21 (3.3 %)
No indication provided 16 (2.5 %)
Pain 11 (1.7 %)
Panic symptoms 9 (1.4 %)
Depression 6 (0.95 %)
Seizures 6 (0.95 %)
Anxiety or pain 4 (0.63 %)
Anxiety or depression 4 (0.63 %)
Stress 3 (0.47 %)
Bipolar disorder 2 (0.32 %)
Nausea and vomiting 2 (0.32 %)
Agitation 2 (0.32 %)
Dizziness 2 (0.32 %)

* Additional indications for which only one patient received a prescription in each category: paranoia; PTSD; insomnia or stress; anxiety or PTSD; anxiety or seizures; anxiety, insomnia, or tinnitus; REM sleep disorder; tics; dystonia; restless leg syndrome; and abdominal cramping.

CLINICAL CHARACTERISTICS OF UNDOCUMENTED IMMIGRANTS WITH HIV IN BRONX, NY Jonathan Ross 2; David B. Hanna1; Uriel R. Felsen2; Viraj V. Patel1, 2. 1Albert Einstein College of Medicine, Bronx, NY; 2Montefiore Medical Center, Bronx, NY. (Tracking ID #2193701)

BACKGROUND: An estimated 11.7 million immigrants living in the United States are undocumented, yet there is almost no information about how this population is affected by the human immunodeficiency virus (HIV). We sought to describe demographic and clinical characteristics of HIV-positive undocumented immigrants and to determine whether immigration status is associated with certain HIV-related outcomes.

METHODS: We conducted a retrospective cohort study of HIV-positive patients receiving care in a large urban health care system in the Bronx, NY, a county with an extremely high HIV prevalence of 1.7 %. We included patients whose medical records were available in a database of HIV-positive adults receiving care in our system, and who entered care between January 1, 1997 and December 31, 2013. To identify undocumented immigrants we searched the database for individuals who had no social security number and whose only medical insurance was provided by programs who offer services to patients regardless of immigration status, with a subset of these patients undergoing chart review to validate documentation status. Undocumented immigrants were compared to controls matched by age, sex, race/ethnicity and date of entry to care. The chi-squared test was used to compare undocumented immigrants and matched controls for HIV transmission risk factor and achievement of virologic suppression, while the signed-rank test was used to compare CD4 count on entry to care.

RESULTS: Out of 15,134 HIV+ adults with available records in the database, 151 patients (1.0 %) were identified as undocumented. The majority were male (108, 71.5 %) and Hispanic (84, 55.6 %), with a median age at entry to care of 37 years (range 18–77). Among patients with available data on HIV risk factor, only 2.0 % of undocumented immigrants reported a history of injection drug use compared to 10.6 % of matched control patients (P = 0.01). Median CD4 count at entry to care was 325 cells/uL (interquartile range 143–434) for undocumented immigrants and 374 cells/uL (interquartile range 135–534) for matched controls (p < 0.01). Among patients with detectable viral loads at care entry who were followed for at least 90 days, 48.9 % of undocumented immigrants achieved virologic suppression by their last available viral load within one year compared to 47.4 % of matched controls (P = 0.84).

CONCLUSIONS: Undocumented immigrants represent a small but important population of HIV-positive patients. Compared to matched controls, undocumented patients presented with more advanced disease; however, rates of virologic suppression were similar in both groups. This study included only patients with health insurance, and the results may not be generalizable to undocumented immigrants who are uninsured. Our findings suggest that in a setting where health insurance is available to undocumented immigrants, similar HIV-related outcomes may be achieved regardless of immigration status.

CLINICAL DECISION-MAKING AROUND THE GENOME SEQUENCING RESULTS OF HEALTHY ADULTS: PRELIMINARY RESULTS FROM THE MEDSEQ PROJECT Jason L. Vassy 3, 2; Kurt D. Christensen2; Jill Oliver Robinson1; Michael F. Murray4; Amy L. McGuire1; Robert C. Green2. 1Baylor College of Medicine, Houston, TX; 2Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; 3VA Boston Healthcare System, Boston, MA; 4Geisinger Health System, Danville, PA. (Tracking ID #2184434)

BACKGROUND: Excitement and controversy surround the potential use of genome sequencing (GS) as a screening tool for preventive care among healthy, asymptomatic adults. Knowledge of one’s genetic makeup might guide personalized health screening and decision-making. However, the clinical significance of most of the 3–5 million variants that GS can identify remains unknown. Introducing GS to the clinical care of asymptomatic patients may thus increase healthcare costs but not value. Patient harm may also result if incidentally identified genetic variants with uncertain impact on human health precipitate unnecessary diagnostic and therapeutic procedures. To inform the research questions necessary to evaluate the role of GS in preventive medicine, we aimed to describe the clinical decision-making of primary care physicians (PCPs) around the GS results of their generally healthy patients.

METHODS: The MedSeq Project is an ongoing trial of integrating GS into primary care. We have enrolled PCPs from a network of practices at one academic center to participate in the study with their patients. Patients are eligible for enrollment if they are 40–65 years old, do not have cardiovascular disease (CVD), diabetes, or significant anxiety or depression, and are deemed generally healthy by their PCPs. Patients are randomized to receive either 1) a comprehensive family history report (FmHx arm) or 2) this FmHx report plus an interpreted GS report (FmHx + GS arm). The GS reports include any concerning variants found in genes associated with monogenic disease, carrier states for autosomal recessive disorders, pharmacogenetic associations for the efficacy or safety of certain medications, and polygenic risk estimates for certain common diseases such as coronary disease and type 2 diabetes. A clinic visit is scheduled for the PCP and patient to meet, discuss the results, and determine the next steps in clinical management. One week after this visit, the PCP completes a brief survey asking him or her to identify any laboratory tests, cardiology tests, imaging tests, and referrals ordered as a result of the patient’s FmHx and/or GS reports, in addition to the specific FmHx and/or GS result(s) prompting him or her to do so. Similarly, the PCP identifies any medication or health behavior changes recommended. For each FmHx + GS patient, the PCP reports on a 5-point Likert scale (from “Strongly disagree” to “Strongly agree”) whether he or she agrees with the statement “The genome report improved the overall clinical care of this patient beyond what the family history report alone could have achieved.”

RESULTS: Among 48 of 100 planned patients who have undergone results visits to date, the mean age was 54 years, 54 % were women, and 10 % were non-white or Hispanic. The table shows the clinical actions taken by these patients’ 7 PCPs. The PCPs reported that the FmHx +/− GS reports prompted no additional clinical actions for 69 % of the patients overall but did prompt actions in 24 and 39 % of the FmHx-only and FmHx + GS arms, respectively (p = 0.26). PCPs have ordered laboratory tests (2 vs. 2) and referrals (3 vs. 3) for as many patients in the FmHx-only arm as in the FmHx + GS arm. However, they tend to evaluate and manage potential CVD risk more aggressively in the FmHx + GS arm, as indicated by more recommendations for health behavior change and aspirin administration. PCPs disagreed that GS improved clinical care beyond FmHx alone for 10 patients (43 %) in the FmHx + GS arm, while they agreed for 9 (39 %).

CONCLUSIONS: Preliminary results from The MedSeq Project suggest that introducing GS to preventive medicine may impact clinical management compared to a FmHx assessment alone without increasing overall utilization of services. Future research should examine inter-provider variability and determine the appropriateness of such clinical actions, as measured by their impact on patient outcomes and cost to the healthcare system.

figurez

Counts of clinical actions made by PCPs in the care of their generally healthy adult patients randomized to receive a FmHx assessment only or a FmHx assessment plus genome sequencing. Parentheticals refer to result(s) identified by the PCP as prompting each clinical action.

CLINICAL IMPACT OF POST-DISCHARGE PHONE CALLS USING INTERACTIVE VOICE RESPONSE SYSTEM. Kelly A. Fung; Leah S. Karliner. UCSF, San Francisco, CA. (Tracking ID #2199500)

BACKGROUND: Post-discharge follow-up phone calls have been used to coordinate care in the transition period from hospital to home. These call programs have been limited because they are time and staff intensive. Interactive voice response systems (IVRS) enable a large number of patients to be called shortly after discharge with the potential of identifying and directing staff time to call those patients with post-discharge needs. We set out to determine how effective a post-discharge IVRS system is at reaching patients and identifying those with needs, and the impact reaching patients has on follow-up appointment attendance.

METHODS: We conducted a cohort study of established primary care patients at an urban academic medical center who were discharged to home from the Medicine service from December 2013 through September 2014 and had telephone contact information at the time of discharge. The IVRS was programmed to call patients and administer a simple survey 24 to 72 h after discharge. The survey’s objective was to identify all patients having new or worsening symptoms, problems filling prescriptions or starting medications, questions about medications, problems with follow-up appointments, questions on discharge instructions, or dissatisfaction with their hospital stay. All patients flagged by the IVRS as having any of these concerns were then telephoned by a nurse to clarify and address the problem(s). Patients were considered reached by the IVRS if they were able to identify themselves as the patient or caregiver and answer at least the first question of the survey. We used adjusted logistic regression models to examine the association between patient demographics (age, sex, payor, race/ethnicity, preferred language) and being reached by the IVRS. Additional models examined the association between IVRS reach and arrival to a scheduled primary care follow-up appointment within 14 days of discharge, adjusting for the same demographics.

RESULTS: Of 849 eligible discharges, 492 (58 %) were reached by the IVRS. Among those reached, 427 (87 %) answered all the survey questions, and 262 (53 %) triggered a call back from a nurse. The most common issue triggering a callback was need for help with follow-up (Figure). In multivariate analysis, the odds of being reached were higher for older patients (AOR Age 40–65 1.65, 95 % CI 1.05–2.69; Age > 64 1.87, 95 % CI 1.09–3.21), and lower for patients with Medicaid insurance (AOR 0.43, 95 % CI 0.29–0.65). Overall, 516 (61 %) attended a primary care follow-up appointment within 14-days of discharge; this significantly differed between those in the ‘reached’ and ‘not-reached’ group (65 % vs. 55 %; p = 0.004). Patients in the ‘reached’ group had higher odds of arriving to their 14-day follow-up appointment (AOR 1.48, 95 % CI 1.11–1.97).

CONCLUSIONS: Post-discharge IVRS phone calls are effective in identifying immediate follow-up and clinical needs of those patients who are reached and directing nurse phone call time to those patients with needs, as well as improving follow-up appointment attendance rates. However, a large proportion of patients are never reached, with a disproportionate number of Medicaid patients not being reached, and it is unknown how many of those patients have needs. Future efforts should examine risk stratification of patients with greatest socio-economic and clinical vulnerability post-discharge to a real-time nurse call if they are not reached by the IVRS.

figureaa

CLINICAL MANIFESTATION OF OSTEOARTICULAR TUBERCULOSIS AND ITS RELATIONSHIP TO COMPLICATION OF PULMONARY TUBERCULOSIS: A RETROSPECTIVE STUDY IN TWENTY-NINE CASES

Shigehisa Yanagi 1, 2; Toshihiko Ihi1, 2; Arisa Sano1, 2; Tsuyoshi Kodama1, 2; Yuumi Ideguchi1, 2; Hiroshi Kuroki1; Toshinobu Higa1; Masamitsu Nakazato2. 1National Hospital Organization Miyazaki Higashi Hospital, Miyazaki, Japan; 2University of Miyazaki, Miyazaki, Japan. (Tracking ID #2197300)

BACKGROUND: Osteoarticular tuberculosis, including spinal tuberculosis, is a rare clinical condition, but its incidence is increasing as a result of large proportion of the older patients with chronic debilitating disease, especially in Japan. With early diagnosis and prompt treatment, the prognosis of osteoarticular tuberculosis is generally good. However, delay in diagnosis may lead to spread of the infection from bone into adjacent neural structures, joints and surrounding soft tissue that leads to significant functional disability and joint deformity. Patients with osteoarticular tuberculosis are frequently unaccompanied by pulmonary lesion, and chronic back pain is often only symptoms in patients with spinal tuberculosis. In the early stages of the disease, radiological imaging studies and laboratory tests are inconclusive, and the determination of the diagnosis is extremely difficult. The purpose of this study is to investigate the clinical features and outcome of osteoarticular tuberculosis and to clarify its relationship to complication of pulmonary tuberculosis.

METHODS: This is a retrospective study including all patients who were diagnosed as osteoarticular tuberculosis in our institution between January 1999 and October 2013. The diagnosis of osteoarticular tuberculosis was based on (1) the radiological findings and (2) the detection of Mycobacterium tuberculosis from either sputum, or the bone lesion, or both.

RESULTS: Twenty-nine patients were included, including 13 male and 16 female (ratio 1: 1.2). The mean age of patients was 75.2 ± 14.8 years old (range, 26 to 91 yd). Location of the disease was cervical (1 case), dorsal (13 cases), lumbar (11 cases), knee joint (1 case), hip joint (1 case), hand joint (1 case) and metacarpal bone (1 case). The most common symptoms at presentation were back pain or joint swelling (69 % of all cases) followed by fever elevation (28 % of all cases). In 25 cases with spinal tuberculosis, 8 cases demonstrated paraplegia. The most frequent manifestations of pulmonary lesion were military tuberculosis (41 % of all cases), while 6 cases (21 % of all cases) demonstrated normal chest CT findings. The positive rate of sputum smears for acid-fast bacilli was lower in patients with osteoarticular tuberculosis than that of in all of tuberculosis patients treated in our institution (41 % vs 64 %). Patients who were smear-negative in the sputum for acid-fast bacilli had longer duration of doctor’s delay in the diagnosis of osteoarticular tuberculosis compared to the counterparts of patients who were smear-positive (99.8 ± 30.1 days vs 29.1 ± 26.7 days, P < 0.05). The positive rate of sputum smears for acid-fast bacilli was lower in patients with paraplegia than that of patients without paraplegia (12.5 % vs 64.7 %, P < 0.05).

CONCLUSIONS: Our results indicated that patients of osteoarticular tuberculosis without complication of pulmonary tuberculosis resulted in delayed diagnosis and subsequent functional disability. Osteoarticular tuberculosis is still an important public health issue, and it should be always considered as a differential diagnosis in patients with chronic back pain or chronic joint swelling, even if the findings on a chest X-ray are normal and sputum smears for acid-fast bacilli are negative. A high index of suspicion, accurate diagnostic approaches including imaging techniques such as MRI and the histological and microbiological examination after needle aspiration biopsy, and prompt treatment are key for the successful management of osteoarticular tuberculosis.

CLINICAL OUTCOMES OF INVASIVE BEDSIDE PROCEDURES Cynthia Kay 2, 1; Erica M. Wozniak1. 1Medical College of Wisconsin, Milwaukee, WI; 2Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI. (Tracking ID #2193261)

BACKGROUND: Bedside procedures, such as lumbar puncture, paracentesis and thoracentesis, are now generally referred for completion. Possible explanations for this include changes in residency procedure training, new duty hour rules, and the emergence of specialists equipped and trained to perform procedures. Our study’s aim was to assess the outcomes of bedside procedures at an academic medical center by referral status.

METHODS: A retrospective chart review was done on paracenteses, thoracenteses, and lumbar punctures performed on adults admitted to a resident or hospitalist service at an academic medical center over a 1 year period. Referred procedures were done by either radiology or the hospital procedure service. Non-referred procedures were those performed by the resident or hospitalist team. Immediate complications were defined as pneumothorax, hemothorax, pneumoperitoneum, hemoperitoneum, hypotension, uncontrolled bleeding and pain. Delayed complications included transfer to the ICU, infection at procedure site, and bleeding beyond 2 h post-procedure. Immediate and delayed complications were combined to create a binary indicator for occurrence of complications that served as the primary outcome of interest in this study. Procedure cost, length of hospitalization, and time from the decision to perform a procedure until its completion were secondary endpoints. Logistic regression was used to create a propensity score model that matched referred and non-referred patients according to demographic and clinical characteristics. The study was approved by our institution’s IRB.

RESULTS: There were 391 procedures reviewed, with a complication rate of 7 % (n = 23 referred and n = 4 not referred). For the primary outcome, logistic regression using propensity score matching found there was no difference in the risk of complications by referral status; however, the study was underpowered to detect such differences due to the low rate of complications. For the continuous secondary outcomes, linear regression with propensity score matching was used to control for observable confounders. We found that referral did not have a significant effect on length of hospitalization. Referral, however, significantly increased the time until a procedure was performed (p = 0.03) and the cost of the procedure (p < 0.001). To account for non-normality, length of hospitalization and time to procedure were log-transformed, and a square-root transformation was used for procedure cost.

CONCLUSIONS: The clinical outcome of complications was not different regardless of whether or not the procedure was referred. On the other hand, time until a procedure was performed and procedure cost were significantly more when referred to other services. These findings suggest that procedure performance remains an important skill to learn, despite changes in residency requirements. We also propose that the usual practice of referring procedures should be reconsidered both for patient care and for health care costs.

CLINICAL PROVIDER EXPERIENCES WITH MEDICATION DISCONTINUATION Amy Linsky 1, 2; Steven R. Simon1; Kelly Stolzmann1; Mark Meterko1. 1VA Boston Healthcare System, Boston, MA; 2Boston University School of Medicine, Boston, MA. (Tracking ID #2197763)

BACKGROUND: While medication adherence and medication reconciliation receive considerable attention, there has been less focus on improving intentional, proactive discontinuation of medications that may no longer be necessary or whose benefits no longer outweigh associated risks. Clinicians vary in their experience and attitudes related to medication management decisions; some are quite comfortable discontinuing medications that lack a clear indication, whereas others prefer to continue therapies that are not causing identifiable problems for the patient. Through the development and administration of a nationwide survey of Department of Veterans Affairs (VA) primary care providers, we assessed attitudes toward and experiences with discontinuing medications.

METHODS: We sampled 2475 VA primary care providers with prescribing privileges, including physicians, nurse practitioners (NPs), physicians’ assistants (PAs) and clinical pharmacists, for an online survey. Providers were asked about the prevalence of polypharmacy (i.e., 5 or more medications) in their patients, their experience and comfort level with deciding to recommend medication discontinuation to a patient and their opinions regarding various factors related to such decisions. We examined the range of responses on these questions and the bivariate associations between various provider demographic characteristics and their medication-relevant attitudes. We then used a backward elimination linear regression analysis to build a multivariable model identifying the provider factors associated with recommending medication discontinuation.

RESULTS: A total of 409 (17 %) of clinicians responded: 73 % were physicians, 17 % NP/PAs, and 10 % pharmacists. Study participants were mostly white (72 %), female (52 %), age ≥ 50 years (64 %), had 8 or more clinic sessions per week (52 %), had worked in VA for less than 10 years (53 %), and also had prior experience working outside of the VA (79 %). Non-responders were more likely to be physicians but were otherwise similar. Nearly all clinicians (92 %) indicated that at least 20 % of their patients take 5 or more medications regularly. Overall, 38 % of respondents reported that 40 % or more of their patients had a medication that could potentially be stopped, and 78 % indicated that at least 1 in 5 of their patients had a medication that might be discontinued. However, not all providers recommended discontinuation; among providers who identified patients taking a medication that could potentially be stopped, 11 % of providers recommended medication discontinuation to fewer than 20 % of candidate patients, while only 30 % recommended it for more than 80 % of candidates. In multivariable analyses, factors associated with recommending medication discontinuation included self-rated comfort level with medication discontinuation (p < 0.0001) and prior non-VA clinical experience (p = 0.048).

CONCLUSIONS: Nearly all clinicians identified patients who had medications that could potentially be stopped, yet whether they actually made a recommendation to do so varied among providers. When providers fail to act upon opportunities for discontinuation, patients may continue to take medications with low potential benefit-to-risk ratios. Given that self-rated comfort with discontinuation and practice experience were associated with taking action, it is essential to understand the factors that contribute to comfort level in order to develop education and interventions that lead to safer prescribing patterns.

CLINICIANS’ JUSTIFICATIONS FOR ANTIBIOTIC PRESCRIBING: A NEW TYPE OF QUALITY MEASURE Mark W. Friedberg 1, 2; Samuel Hirshman1; Jason N. Doctor3; Daniella Meeker3; Jeffrey A. Linder2. 1RAND, Boston, MA; 2Brigham and Women’s Hospital, Boston, MA; 3University of Southern California, Los Angeles, CA. (Tracking ID #2196370)

BACKGROUND: Nearly all measures of quality of care assess processes or outcomes of care that are not completely under individual clinicians’ control. Moreover, such measures may not accurately reflect the quality of clinical reasoning. By assessing clinicians’ justifications for prescribing antibiotics to patients with acute respiratory infections (ARIs), we sought to develop a new type of quality measure that directly assesses clinical reasoning--a construct that should be completely under individual clinicians’ control.

METHODS: From November 2011 to October 2013, we exposed 81 Boston-area primary care clinicians to an electronic health record (EHR)-based intervention that asked them to justify, in a free-text window, their decision each time they prescribed an antibiotic to treat a patient’s ARI. These justifications appeared as “Antibiotic Justification Notes” in the EHR, were viewable by other users, and contained default text stating “No justification was given” if prescribers did not enter a justification. Each time a justification was solicited, the EHR displayed guidelines from professional societies and the Centers for Disease Control and Prevention corresponding to the ARI for which the antibiotic was being prescribed (non-specific upper respiratory infection, acute sinusitis, acute pharyngitis, or acute bronchitis). Two physician reviewers independently coded each antibiotic prescribing justification as “good” (a guideline-concordant antibiotic prescribing rationale; or a reason why the guideline does not apply) or “bad” (a guideline does apply but does not support the prescriber’s antibiotic prescribing rationale), resolving all disagreements by consensus. Each antibiotic prescription could have one or more distinct justifications; each was coded separately. For each clinician, we calculated a justification quality score: the percentage of antibiotic prescriptions having at least one good justification. We excluded clinicians who wrote fewer than 10 antibiotic prescriptions, accounted for varying per-clinician sample sizes using empirical Bayes shrinkage estimators, computed the measurement reliability (i.e., the “signal-to-noise ratio”) and 95 % confidence bounds of each clinician’s justification score, and assessed associations between clinician characteristics and justification scores using bivariate regression model.

RESULTS: The full sample of 81 clinicians wrote 3435 antibiotic prescriptions for ARIs. Physician reviewers’ independent assessments were identical for 81 % of justifications, and the remaining 19 % were coded by consensus. Sixty-three clinicians (54 physicians, 7 NPs, and 2 PAs) wrote 10 or more antibiotic prescriptions. Among these clinicians, 28 % of prescriptions had good justifications and 72 % had bad justifications (including 4 % of prescriptions for which clinicians entered no justification). The range of individual clinicians’ justification quality scores was 16 to 58 %. The most frequent type of bad justification was to report a symptom irrelevant to guidelines (e.g., hoarseness, malaise; 19 % of all justifications). Relative to the mean, 2 clinicians had justification quality scores that were statistically significantly lower and 14 had justification quality scores that were statistically significantly higher. The reliability of justification quality scores was >0.7 for 36 clinicians (57 % of the sample). The mean justification quality score was 33 % among physicians and 25 % among NPs and PAs (P = 0.11 for difference). Justification quality scores were not statistically significantly associated with clinicians’ seniority (years since professional school graduation), full-time or part-time status, or rates of antibiotic prescribing for ARIs.

CONCLUSIONS: Using an EHR prompt to elicit justifications, it is possible to assess clinicians’ reasons for decision-making in patient care. For the decision to prescribe antibiotics for ARIs, justification quality scores had desirable measurement characteristics, including a wide range of scores, high reliability for a majority of primary care clinicians, and independence from underlying antibiotic prescribing rates—suggesting that justification scores may measure a distinct dimension of clinical performance.

CLOSING THE LOOP WITH AN ENHANCED REFERRAL MANAGEMENT SYSTEM Harley Ramelson 1, 3; Amanda V. Taube1; Pamela M. Neri2. 1Partners HealthCare, Wellesley, MA; 2Partners Healthcare Systems, Inc., Wellesley, MA; 3Brigham and Women’s Hospital, Boston, MA. (Tracking ID #2187686)

BACKGROUND: Outpatient referrals made by primary care physicians (PCPs) involve multiple sequential steps requiring provider-to-provider and provider-to-patient communication. Analysis of malpractice claims has shown that the referral process in the ambulatory setting is prone to incomplete follow-up and communication break-down. 1 An enhanced electronic referral management system (ERMS) was developed in an ambulatory EHR to meet a series of best practice steps for referral management.2 The objectives of this study were to assess PCP and staff satisfaction with the ERMS and to evaluate whether PCPs and their practice staff would find it easier to complete individual steps in the referral process and whether they would find it easier to identify when a problem has occurred in the process. 1 Gandhi TK, Keating NL, Ditmore M, et al. Improving referral communication using a referral tool within an electronic medical record. Advances in Patient Safety: New Directions and Alternative Approaches. 2008;3:1–12. 2 Hoffman J. Managing risk in the referral lifecycle. 2012; https://www.rmf.harvard.edu/Clinician-Resources/Article/2012/SPS-Managing-Risk-in-the-Referral-Lifecycle.Accessed January 5, 2015.

METHODS: The ERMS was launched in two separate releases in 2014. The first release focused on functionality to create, transmit and track referrals as well as the ability to indicate that a referral was complete (“close the loop”) and to identify when a referral was overdue. The second release primarily focused on a series of reports allowing retrospective analysis of referral patterns. This study enrolled nine ambulatory primary care practices affiliated with an integrated delivery system in the Northeast. Approximately 100 practice staff members, including physicians, medical assistants, nurses, and administrative staff involved in the referral process were recruited across these practices to participate in surveys and interviews conducted pre-and post-implementation of both releases. Data reported here reflect results of the surveys conducted at baseline and following the first release. Ease of use and usefulness of specific functions were evaluated on a five-point Likert scale while satisfaction was evaluated on a seven-point scale.

RESULTS: In the first 5 months following the release of the new ERMS module in the EHR, almost 3000 total referrals were generated. At baseline, 74 % reported that it was easy or fairly easy to create a referral. This increased to 91 % on the follow-up survey. At baseline, 33 % reported that it was easy/fairly easy to schedule an appointment with a specialist. This increased to 64 % on the follow-up survey. At baseline, the percent who reported that it was easy/fairly easy to identify when an appointment was not made with the specialist, when an appointment was missed or when an appointment was cancelled was 34, 22 and 12 % respectively. These increased on the follow-up survey to 54, 45 and 36 %, respectively. When asked about their overall satisfaction with the referral process, 36 % of respondents reported they were satisfied or very satisfied at baseline compared to 92 % at follow-up. The new functionality was also assessed in the follow-up survey to determine the usefulness of 15 major new functions in the referral module. Nine functions were found by 90 % or more of respondents to be useful or somewhat useful. These include the following: 1. Ability to refer to a practice in addition to an individual specialist 2. Search functionality for a specialist 3. Favorite list of specialists and practices to whom PCPs commonly refer their patients 4. Supporting the intra-practice workflow of a staff person creating the electronic referral and sending to the PCP to authorize 5. Ability of the system to automatically fill in the appointment date based on interfaces with scheduling systems 6. Ability of the system to automatically link the specialist’s consult note to the referral based on the linkage with the notes module in the EHR 7. Ability of the system to identify when a referral is overdue at various stages in the referral life cycle 8. Ability to acknowledge the consult note in the referral module 9. Ability to document the closing of the referral

CONCLUSIONS: The results from the surveys after the new release of the enhanced referral management module show there is enhanced user satisfaction with the referral process and that most of the functionality was considered to be useful by a majority of the respondents. Users of the module found that previously difficult tasks such as the ability to identify when an appointment with the specialist was not made or missed or cancelled became easier with the new module. The implications for quality of care and patient safety are clear: when practice staff are able to track referrals in a more effective and efficient way and be able to intervene when appropriate, fewer patients will experience delayed specialty care potentially leading to improved patient satisfaction and patient safety.

CODE STATUS DISCUSSION AND FREQUENCY OF INAPPROPRIATE CARDIOPULMONARY RESUSCITATION AMONG TERMINALLY ILL HOSPITALIZED PATIENTS IN JAPAN. Akinori Sasaki2; Eiji Hiraoka 1. 1Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan; 2Tokyobay UrayasuIchikawa Medical Center, Urayasu, Japan. (Tracking ID #2191504)

BACKGROUND: In the U.S.A, physician should discuss code status with all patients and officially order it when they are admitted to a hospital. On the other hand, it usually does not occur in Japan. Some doctors discuss it and others do not. We often observe inappropriate cardiopulmonary resuscitation (CPR) for terminally ill patients, including malignancy, dementia, and heart failure, etc. We also observe some physicians not perform CPR without discussion with patients if it appears to be futile or inappropriate. Because it has not been reported whether code status is discussed with patients on admission decreases the futile or inappropriate CPR for terminally ill patients.

METHODS: Objective: To explore the association between whether physicians discuss code status with patients on admission is associated with decrease futile CPR among patients with terminal illness. Design: retrospective cohort study Setting: One city hospital in Japan Patients: We included patients if they were admitted and died in Ito city hospital, Shizuoka, in Japan between April 1 and September 30 2014. Patients also should be terminally ill on admission. We use less than 70 points in Palliative Performance Scale (PPS) score as the definition of terminal cancer. And we use reference 1 for the definition of terminal stage of various diseases other than cancer. Main outcome: Whether cardiopulmonary resuscitation (chest compression for CPA), intubation with mechanical ventilation for pulmonary arrest, electrical cardioversion were performed was assessed as a main outcome. The incidence of these procedures were compared between in the presence and absence of discussion of code status on admission by chi square analysis. (1)Shelly R. Salpeter EJL, et al. Systematic Review of Noncancer Presentations with a Median Survival of 6 Months or Less. Am J Med 2012;125:e1-e16.

RESULTS: Eigthy-one patients met the inclusion criteria. Code status was discussed on admission for 43 patients. It was not discussed for the remaining 38. Table 1 presents the characteristics in two groups. Both groups are similar except the rate of cerebrovascular accident. As shown table 2, the rate of CPR was 1.9 % in the group with whom the code status was discussed on admission and 14.6 % in the group with whom it was not discussed. The odds ratio was 9.0 (95 % confidence interval, 1.10–76.9). Intubation and central venous catheter placement occurred more frequently among no discussion group. Discussion: Code status discussion is routine process on admission in the U.S.A.; however it is not the case in Japan. It was shown here that even among terminally ill patients, code status was not discussed with 38 patients (46 %). Not discussing code status on admission was associated with increase in incidence of CPR (OR 9.0). Code status discussion is likely to decrease unwanted CPR among terminally ill patients. One of the reasons is that probably most people would like to avoid futile aggressive care of CPR just to prolong life in Japan. Even if people would like full code on admission, the discussion of code status might give them a chance to rethink of the meaning of CPR and might change their code while hospitalization. To individualize the end of life care, we need to convey all information to the patients and discuss the end of life care, including code status in Japan. Limitation: this is small retrospective cohort study in one city hospital. Although it is definitely unethical to perform randomized controlled trial to investigate whether code status discussion decrease futile CPR, larger prospective observational study should be performed in Japan.

CONCLUSIONS: The code status discussion with terminally ill patients on admission is associated with decrease CPR before death. We need educate physicians about code status to improve end of life care.

Characteristics of study subjects

  Presence of code status discussion (43) Absence of code status discussion (38) P value
Age 81.8 ± 11.0a 77.8 ± 10.7 0.10
Gender    0.11
Male 23 27  
Female 20 11  
ADL a 2.9 ± 2.1b 2.8 ± 2.0b 0.73
Primary diagnosis    
Cancer 20 % 13 %  
Liver disease 4 % 2 %  
Heart disease 3 % 5 %  
Neuromuscular disease 3 % 8 %  
Respiratory illness 10 % 8 %  
Geriatric syndrome 3 % 2 %  

aADL: activity of daily life

b:number of ADLs patients can perform independently out of 5 ADLs; dressing, eating, ambulating, toileting, hygiene.

Result

  Presence of code status discussion (43) Presence of code status discussion (38) P value Odds ratio
CPR 1.9 % 14.6 % .025 9.0[1.10–76.9]
Intubation 3.7 % 20.8 % .012 6.8[1.40–33.3]
CVC 7.4 % 20.8 % .081 3.3[0.96–1.12]
Cardioversion 0 % 0 %

CPR: cardiopulmonary resuscitation

CVC: central venous catheter

COMBINATION WEIGHT MANAGEMENT PHARMACOTHERAPY WITH LORCASERIN AND IMMEDIATE RELEASE PHENTERMINE Steven R. Smith2, 3; W. Timothy Garvey1; Frank L. Greenway4; William Soliman5; Sharon Zhou5; Randi Fain 5; Ken Fujioka6; Louis Aronne7. 1University of Alabama at Birmingham, Birmingham, AL; 2Sanford/Burnham Medical Research Institute at Lake Nona, Orlando, FL; 3Florida Hospital, Orlando, FL; 4Pennington Biomedical Research Center, Baton Rouge, LA; 5Eisai Inc, Woodcliff Lake, NJ; 6Scripps Clinic, La Jolla, CA; 7Weill Cornell Medical College, New York, NY. (Tracking ID #2198196)

BACKGROUND: Pharmacotherapy for weight management may involve combining drugs targeting different signaling pathways. This pilot study was sized to assess the primary outcome of impact of lorcaserin (LOR), a specific 5-HT2C receptor agonist, and immediate release (IR) phentermine (phenIR) on pre-selected potentially serotonergic (5-HT) adverse events (AEs) compared to LOR alone.

METHODS: Two hundred thirty-eight patients with BMI >30 kg/m2, or >27 kg/m2 with a comorbidity, but without type 2 diabetes mellitus (T2DM), were randomized in a 12-week study comparing LOR 10 mg twice daily (BID) alone, LOR 10 mg BID with phenIR 15 mg QD (LOR/phenIR QD), or LOR 10 mg BID with phenIR 15 mg BID (LOR/phenIR BID). All received a standard diet and exercise program with adherence self-reported by study subjects. The primary endpoint evaluated whether short-term LOR/phenIR treatment is associated with exacerbation of potential 5-HT AEs compared to LOR alone. Secondary objectives included safety, tolerability, pharmacokinetics, and weight loss.

RESULTS: 37.2 % (LOR), 42.3 % (LOR/phenIR QD), and 40.5 % (LOR/phenIR BID) patients reported potential 5-HT AEs. 5.1 % (LOR), 2.6 % (LOR/phenIR QD), and 10.1 % (LOR/phenIR BID) patients discontinued due to AEs. At week 12, mean changes in blood pressure (systolic/diastolic) and pulse were −5.5/−2.5 mmHg and −1.9 bpm (LOR), −3.3/−1.4 mmHg and 1.1 bpm (LOR/phenIR QD), and −3.4/−1.7 mmHg and 3.1 bpm (LOR/phenIR BID). Mean change from baseline weight loss (kg/%) in 12-week completers was 4.0/3.8 (LOR), 7.6/7.3 (LOR/phenIR QD), and 8.9/8.7 (LOR/phenIR BID). 33.3 % (LOR), 68.2 % (LOR/phenIR QD), and 84.2 % (LOR/phenIR BID) patients achieved ≥5 % weight loss (12-week completers).

CONCLUSIONS: Treatment with LOR plus phenIR was not associated with exacerbation of potential 5-HT AEs compared to LOR alone. Common AEs during the trial were consistent with prior experience with these agents. The combination of LOR BID and phenIR BID more than doubled weight loss achieved compared to LOR alone.

COMBINED ANTIPLATELET AND ANTICOAGULANT THERAPY IN PATIENTS WITH ATRIAL FIBRILLATION—A DESCRIPTIVE STUDY Charlotte So; Mark H. Eckman. University of Cincinnati Medical Center, Cincinnati, OH. (Tracking ID #2194459)

BACKGROUND: As part of a system-wide performance improvement initiative focused on improving antithrombotic therapy decisions for patients with atrial fibrillation (AF), we discovered a large number of patients who were receiving dual therapy with both aspirin and warfarin. Our goal was to determine the indications for dual therapy and possibly identify patients who might reasonably be treated with oral anticoagulant therapy alone. We hypothesized that the majority of these patients likely had a prior indication for antiplatelet therapy, such as stable coronary artery disease or diabetes, subsequently developed AF and had warfarin added to their regimen without discontinuing aspirin. There have been multiple studies examining outcomes of dual therapy in patients with indications for both antiplatelet and anticoagulant therapy. All have demonstrated an increased risk of major bleeding compared with either treatment alone; and among patients with stable CAD, in particular, dual therapy has not been shown to reduce ischemic events. The 2012 AF guidelines from the American College of Chest Physicians (ACCP) recommends against the use of dual therapy for AF patients with stable CAD, indicating that warfarin alone within a therapeutic INR range of 2–3 is sufficient.

METHODS: We identified 348 patients (23 % of the total AF cohort) in the UC Health Primary Care Network who were receiving dual therapy with an antiplatelet as well as antithrombotic agent as of 1/7/2014. We randomly sampled 200 charts to evaluate and categorize the indication(s) for dual antithrombotic therapy and collected information describing the time course of events that led to the initiation this treatment.

RESULTS: Of the 200 patients reviewed, 77 (38.5 %) had stable CAD and 48 (24 %) had DM as co-morbidities resulting in dual therapy. Forty-one patients (20.5 %) were classified as unknown, meaning patients whose charts had insufficient information to determine the reason for dual therapy. Thirty-six patients (18 %) had diagnoses of both CAD and DM and were counted in both categories. Thus the total added up to more than 100 %.

CONCLUSIONS: Our data show that the majority of patients receiving dual antithrombotic therapy had a diagnosis of stable CAD or DM. Of interest, in a significant proportion of patients aspirin had been initiated due to a prior diagnosis of either stable CAD or DM and was not discontinued when warfarin was started for their AF (73 and 14.58 % respectively). The 2012 ACCP guidelines indicate that there is insufficient evidence to warrant dual therapy in AF patients with stable CAD. A number of recent studies have examined outcomes in AF patients with stable CAD receiving dual therapy, and have concluded that dual therapy increased bleeding risk without reducing the risk of ischemic events, defined as stroke or myocardial infarction. Withdrawing aspirin from the antithrombotic regimens of these patients may provide an opportunity to improve clinical outcomes.

figureab

COMMUNICATION ACCESS: WHY SOME PATIENTS CAN EMAIL THEIR DOCTORS AND OTHERS CAN’T Joy L. Lee 1; Mary Catherine Beach2; Albert W. Wu2. 1Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; 2Johns Hopkins University, Baltimore, MD. (Tracking ID #2192490)

BACKGROUND: Primary care physicians have different modes to choose from in communicating with patients outside of the clinic. In particular, cellphone, email, and secure-messaging portals are now widely available. Yet use of these technologies are used unevenly across physicians and physicians may not grant the same access to all their patients. This work seeks to understand the disparity in use of communication modalities between physicians and the disparity in use by each physician within a patient panel.

METHODS: Semi-structured key informant interviews were conducted with 25 primary care physicians at a large academic medical center, practicing at several clinic settings. We recruited faculty participants from the Division of General Internal Medicine via email, and performed thematic analysis on the transcribed interview data.

RESULTS: Cellphone numbers were most privileged and often only given to patients who needed close monitoring; whether patients could “handle” access without abuse was often considered. A few respondents were adamant about never providing cellphone numbers to patients. While respondents acknowledged the deficiencies of email use, email access was more prevalent and accepted. Granting patients email access was characterized by circumstance (e.g. patients traveling abroad), status/familiarity (e.g. patients employed within the same hospital system), and patient initiative (e.g. patients who asked for email access). Respondents encouraged patients toward the secure-message feature of the newly electronic health record system and away from email. Challenges with communicating with patients with mental illness and setting boundaries for such patients were also raised. For example, one respondent noted “I had a patient with pathologies who would write paragraph after paragraph after paragraph in emails. So I actively do not give out my email.”

CONCLUSIONS: Primary care physicians do not use communication technologies interchangeably. Factors such as patient health, patient relationship with physicians, and patient demand are all considered as physicians grant differential patient access to cellphone and email within their panel.

COMMUNITY HEALTH WORKERS UNDERSTANDING OF AND ATTITUDES REGARDING INTIMATE PARTNER VIOLENCE IN THE DOMINICAN REPUBLIC Nisha Viswanathan 1; Leo Carretero1; Omara Afzal1; Janeen Marshall2; Taraneh Shirazian1. 1The Mount Sinai Hospital, New York, NY; 2Mount Sinai Hospital, New York, NY. (Tracking ID #2199090)

BACKGROUND: Intimate partner violence (IPV) is prevalent in Latin America and is a leading cause of death for women. A population survey of Latin American and Caribbean countries reveals that 17–53 % of women in the region have experienced physical or sexual violence by an intimate partner, and many women do not seek help or report abuse. Health care providers may not have the knowledge or education regarding IPV to be a resource for affected women. Our objective is to explore the understanding and attitudes surrounding IPV among community health workers (cooperadoras) in the Dominican Republic, as well as determine the rates of the most common types of IPV in their respective communities.

METHODS: This project consisted of two components: focus groups and a survey component. Investigators planned to conduct five focus groups of cooperadoras representing various regions of the Dominican Republic. Participants were recruited randomly during a medical conference. A moderator script was developed using prior IPV-related research with community health workers. Participants were verbally consented for participation and to protect confidentiality, participants were asked to refrain from discussing responses outside of focus group. Nine open-ended questions were asked regarding domestic violence within their communities, including knowledge of and attitudes toward IPV in the community, understanding of causes and available resources, and the relationship between healthcare and affected women. Answers were audio recorded and transcribed. Data was analyzed using a grounded theory approach to coding, categorization and thematic generation/saturation. The cooperadoras were then trained to deliver existing validated surveys regarding types of IPV to women in their communities. Participants in the surveys were women in urban and rural communities and responses were anonymously recorded. Participants were recruited via door-to-door request creating a convenience sample of the community population. Results were analyzed as descriptive data to describe the prevalence of different types of IPV in various communities.

RESULTS: Five focus groups were conducted, for a total of thirty-five cooperadoras, representing 9 regions in the Dominican Republic and 110 distinct rural communities. Focus groups included both male and female adult participants (7 male and 28 female participants). Five common themes emerged from these focus groups. Cooperadoras 1. believed IPV is a social issue, not a medical one, 2. reported that women are at fault and felt that conflict between partners was due to poor communication, 3. stated that IPV is prevalent and that death was frequently an outcome, 4. felt they did not know the appropriate resources for affected women. 5. believed they did not know how to help affected women. Three hundred eighty-five IPV survey responses were collected. Analysis showed that urban and rural women were just as likely to suffer physical abuse (81 % urban and 85 % rural women), although urban women were more likely have suffered sexual abuse (81 % urban and 72 % rural; p = 0.04). Rural women were more likely to experience coercive control (77 % urban and 88 % rural; p = 0.01) versus urban women who were more likely to experience psychological abuse (88 % urban and 80 % rural; p = 0.03).

CONCLUSIONS: Community health workers in the Dominican Republic could be a potential resource for women affected by IPV, but currently do not view themselves as such because of limited knowledge and resources. Limitations of the study include selection bias, and the possibility for recall and/or cultural biases. Strengths are that this study offers insights into the beliefs of cooperadoras in an area where little research has been done. This study also established the high prevalence of IPV in Dominican communities serviced by cooperadoras. By recognizing the different types of IPV present in these communities, future interventions include education for community health care workers to identify and advocate for women, appropriate referral of women to resources, and discussions with community members regarding management and prevention of intimate partner violence.

COMPARING HOSPITALIZATION CHARGES OF TEACHING VS NON-TEACHING HOSPITALS: ANALYSIS OF THE LEADING 30 DIAGNOSES OF ADMISSION Andrew Whipple 1; Mark Loehrke2; Christopher M. Begley1; Akshay Amaraneni2. 1Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI; 2Western Michigan University School of Medicine, Kalamazoo, MI. (Tracking ID #2192576)

BACKGROUND: Teaching hospitals have classically been regarded as inefficient and financially burdensome, although to our knowledge no study has specifically addressed individual diagnoses in their assessment of hospitalization charges. Since teaching hospitals are reimbursed by the Inpatient Prospective Payment Services (IPPS) at a higher rate than non-teaching institutions, hospital-related expenses should more accurately be represented by hospital charges than cost. Hospitalization charges rely upon a variety of factors including admission diagnosis, extent of testing, length of stay, and treatment decisions. Therefore, this study aims to identify which admission related diagnoses are associated with differences between teaching versus non-teaching hospitalization charges.

METHODS: Using the Healthcare Cost and Utilization Project’s online query system, summary data was collected regarding mean total hospitalization charges for teaching vs. non-teaching urban hospitals in 2012 through the Nationwide Inpatient Sample (NIS). The NIS contains data on 5,557,703 discharge events among 4324 U.S. hospitals in 44 states. Data was collected for discharges that had a non-neonatal, non-maternal primary admission diagnosis of one of the top 30 most common hospital admission diagnoses. For each of these diagnoses, a z-test was used to compare average hospitalization charges at urban teaching hospitals and urban non-teachings hospitals. To control for multiple testing, a Bonferroni correction was applied and a significance level of alpha = 0.05/30 (0.0017) was used to determine statistical significance.

RESULTS: Of the 30 diagnoses tested, 12 resulted in statistical significance. Teaching hospitals, on average, had higher charges for: congestive heart failure (non-hypertensive) (p < .0001), mood disorders (p < .0001), cardiac dysrhythmias (p < .0001), complication of device/implant/graft (p = .0010), acute cerebrovascular disease (p < .0001), schizophrenia and other psychotic disorders (p < .0001), respiratory failure/insufficiency/arrest (adult) (p = .0002), and pancreatic disorders (not diabetes) (p = .0007). Non-teaching hospitals, on average, had higher charges for: skin and subcutaneous tissue infections (p = .0010), nonspecific chest pain (p < .0001), biliary tract disease (p = .0009), and asthma (p < .0001). Reliability and validity of these results are limited as the online query system provides only summary data which shows large differences between mean and median values and may indicate a skewing of the distribution of total charges.

CONCLUSIONS: There is statistically significant evidence that total charges differ for several of the most common diagnoses due to hospital teaching status. For 8 of the top 30 diagnoses, teaching hospitals had higher average charges while non-teaching hospitals had higher average charges on 4 of the top 30 diagnoses. There were no statistically significant differences in charges between teaching versus non-teaching hospitals for the remaining 18 diagnoses. This study is to serve as a pilot to open discussion regarding differences in charges due to teaching status. Subsequent analyses are needed to account for other various factors such as age, length of stay, gender, race, number of comorbidities, primary payer and primary procedure.

COMPARING USE OF LOW VALUE HEALTHCARE SERVICES AMONG U.S. ADVANCED PRACTICE CLINICIANS AND PHYSICIANS John N. Mafi 1; Christina C. Wee1; Roger B. Davis1; Bruce E. Landon2, 1. 1Beth Israel Deaconess Medical Center, Brookline, MA; 2Harvard Medical School, Boston, MA. (Tracking ID #2190292)

BACKGROUND: Evidence suggests that advanced practice clinicians (physician assistants and nurse practitioners, or APCs) provide similar quality of care when compared to physicians. Little is known, however, regarding differences in the use of potentially low value healthcare services.

METHODS: Using nationally representative data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey we examined ambulatory visits for four common chief complaint categories: upper respiratory (e.g., sore throat, sinusitis), orthopedic (e.g., back pain, knee pain), neurologic (e.g., headache, vertigo), and skin conditions (e.g., rash, dermatitis) from 1997–2010. Outcomes included use of antibiotics (upper respiratory and skin complaints), CT/MRI (neurologic and orthopedic complaints), referrals to other physicians (all complaints), x-rays (upper respiratory and orthopedic complaints), and laboratory testing (all except orthopedic complaints). We used logistic regression models focusing on APC provider as the exposure of interest, adjusting for patient and physician characteristics and year, and weighted results to reflect national estimates. We also stratified our results based on acute vs. non-acute presentations and primary care provider (PCP) vs. non-PCP visits.

RESULTS: We identified 9940 APC visits and 101,063 physician visits with the study complaints, representing an estimated 2.2 billion U.S. ambulatory visits during the study period. Patients seen by APCs were typically younger (mean age 49.6 vs. 51.8 years, p < 0.001), more frequently presented with acute symptoms (74.6 % vs. 70.4 % of visits, p = 0.005), and were less commonly located in urban settings (76.1 % vs. 84.6 %, p = 0.005) when compared to patients seen by physicians. APCs generally used more antibiotics than physicians for upper respiratory and dermatologic complaints (39.3 % vs. 33.3 % of visits, unadjusted p = 0.001) and referred to other physicians more frequently than physicians (10.5 % vs. 7.8 %, p = 0.001). Additionally, APCs ordered x-rays more often than physicians, particularly for orthopedic complaints (29.7 % vs. 23.8 %, p = 0.001). CT/MRI and laboratory use were similar between provider groups. After multivariable adjustment results remained largely unchanged (Table). Stratification revealed that differences in utilization were especially apparent during acute presentations and visits with non-PCPs (e.g., subspecialists), where the adjusted proportions of antibiotic use during non-PCP visits were 29.5 % of APC visits vs. 22.8 % of physician visits, aOR 1.41 [CI 1.08, 1.84]; referrals to other physicians, 9.1 % of APC visits vs. 6.5 % of physician visits, aOR 1.43 [1.08, 1.89]; x-ray use, 23.7 % of APC visits vs. 19.8 % of physician visits, aOR 1.26 [1.01, 1.58]; and laboratory testing, 11.3 % of APC visits vs. 7.9 % of physician visits, aOR 1.48 [1.01, 2.15].

CONCLUSIONS: In this nationally representative analysis comparing APCs and physicians in the management of common ambulatory conditions, APCs generally used potentially low value healthcare services and referred patients to other providers more frequently than physicians. Differences in utilization primarily occurred during acute presentations and were largely driven by subspecialists. As APCs continue to expand their role in ambulatory medicine these findings have important implications for containing costs and improving quality in the U.S. healthcare system.

Multivariable Adjusted* Frequencies of Use and Adjusted Odds Ratios of Use Comparing APC vs. Physician

  Adjusted Proportions of Use (%) Adjusted Odds Ratio [95 % CI]
  APC (n = 9940) Physician (n = 101,063)  
Antibiotics 35.7 32.1 1.17 [1.01, 1.36]
Upper Respiratory 42.5 39.2 1.14 [0.97, 1.35]
Skin 10.0 8.1 1.25 [0.79, 2.01]
CT/MRI 7.2 7.6 0.94 [0.73, 1.20]
Orthopedic 7.2 7.4 0.98 [0.74, 1.28]
Neurologic 6.5 8.0 0.80 [0.50, 1.29]
Refer to Other Physician 8.8 7.2 1.26 [1.04, 1.52]
Upper Respiratory 6.4 4.5 1.46 [1.05, 2.04]
Orthopedic 10.0 8.4 1.22 [0.97, 1.53]
Neurologic 12.4 8.7 1.49 [1.05, 2.10]
Skin 5.8 5.3 1.10 [0.65, 1.86]
X-ray 18.0 15.3 1.21 [1.02, 1.45]
Upper Respiratory 7.4 6.4 1.18 [0.85, 1.64]
Orthopedic 28.2 22.8 1.33 [1.12, 1.59]
Lab Testing 12.7 10.9 1.19 [0.91, 1.55]
Upper Respiratory 11.8 9.6 1.26 [0.90, 1.76]
Neurologic 20.1 15.6 1.36 [0.88, 2.10]
Skin 4.2 7.0 0.58 [0.31, 1.08]

*Models adjusted for age, sex, race/ethnicity, modified Charlson disease count, symptom acuity, insurance, whether the clinician was the PCP, region, urban location, and year.

CONCEPTS UNDERLYING EFFECTIVE USE OF THE ARTS IN MEDICAL EDUCATION: A QUALITATIVE SYNTHESIS OF THE LITERATURE Paul Haidet 1; Jodi Jarecke1; Nancy Adams1; Michael Green1; Heather Stuckey2; Daniel Shapiro1; Daniel R. Wolpaw1. 1Penn State College of Medicine, Hershey, PA; 2Penn State University College of Medicine, Hershey, PA. (Tracking ID #2199128)

BACKGROUND: Despite widespread use of the arts in medical education as a tool to promote diverse skills related to patient-centered care, educators often lack guidance for incorporating arts into educational designs. The purpose of this study was to systematically review and synthesize the literature in order to: 1) identify how the arts promote learning; 2) identify strategies used by educators to facilitate arts-based learning; 3) create a conceptual model that guides implementation and evaluation of the arts in medical education.

METHODS: Our project team includes both clinicians and researchers with expertise in medical humanities, library sciences and education. We performed searches of the PubMed and ERIC databases using various combinations of terms related to teaching, the arts, humanism, and theoretical models. We included articles that described the use of the arts to promote skills or knowledge acquisition, or that introduced models or theoretical frameworks incorporating arts-based approaches to facilitate humanism or individual change. The PubMed searches yielded 825 articles, and ERIC searches yielded 179 articles. Upon review of the abstracts of all identified articles, 143 were selected for further review. We read the entire text of these 143 articles, and identified 46 that met our inclusion criteria. We performed a qualitative analysis of the text and data of these selected articles. We used Atlas.ti 7.1 software to categorize, code, and review key passages and qualitative data presented in the articles. Two of the investigators independently coded the article texts and data. Weekly phone calls were conducted to discuss emergent themes and coding practices. We constructed a conceptual model to guide usage of the arts in education through repeated iterations of review and discussion of coded passages.

RESULTS: We identified three areas of focus related to using the arts in teaching: a) unique qualities of the arts that promote learning, b) intermediate or process outcomes that result from arts-based teaching, and c) downstream impacts of arts-based teaching. Unique qualities of the arts included activating and cultivating imagination, engaging emotions, providing new ways of seeing and processing everyday phenomena, and experiencing facets of the human condition that students would not normally recognize. Intermediate and process-based outcomes included the breakdown of hierarchies and fostering community among diverse groups of learners, increased emotional awareness and intelligence, high degrees of engagement, and personal awareness and surfacing of assumptions. Downstream impacts included increased empathy, narrative competence, better understanding of patients’ perspectives, and enhanced communication skills. Our emerging conceptual model suggests that particular design choices and teaching behaviors, such as creating activities explicitly aimed at helping students translate lessons learned from the arts to medical practice, are critical for unlocking the unique qualities of the arts and achieving important process-based outcomes and downstream impacts.

CONCLUSIONS: The arts provide a unique and powerful tool for fostering medical trainees’ knowledge, skills, and attitudes related to the human experience of illness. However, just incorporating the arts alone is unlikely to achieve such outcomes. Our conceptual model suggests that optimum incorporation of the arts in medical education requires an understanding of the aesthetic and observational processes inherent to the art being used, strategic use of the art to motivate engagement of students with the art and each other, and skillful translation of lessons learned from such engagement to students’ practice of medicine.

CONCEPTUAL MODEL OF HOUSE STAFF WORKLOAD IN THE INPATIENT SETTING Jennifer M. Schmidt 2; onur asan2; Laurie Simonds2; Kathlyn Fletcher1. 1Medical College of Wisconsin/Milwaukee VAMC, Milwaukee, WI; 2Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #2198319)

BACKGROUND: Workload is a complex concept that involves the cognitive, physical and emotional capacity to handle the tasks necessary to accomplish a goal. Medical education lacks a robust model for explaining the workload encountered by house staff. Our objective was to create a conceptual model of perceived contributors to house staff workload in the inpatient setting.

METHODS: We conducted focus groups with internal medicine interns and residents from a single program that includes 3 hospitals. The semi-structured focus group guide consisted of 19 open-ended questions with prompts. We audiotaped and transcribed the focus groups verbatim. We used the constant comparative method for data analysis. We started with open-coding to identify unique and unexpected codes. These were grouped into broader categories. We then applied a previously described model (the Systems Engineering Initiative for Patient Safety (SEIPS) model), for further categorization of the codes to one of the five SEIPS themes: Person, Environment, Technology, Organization, or Task. We used NVivo, a qualitative software package, for analysis. The line-by-line analysis was conducted by two members of the study team; one coded all of the transcripts; the other independently coded 2 of the transcripts. The entire study team met to discuss the emerging coding structure. Agreement between the two coders was calculated based on two of the transcripts.

RESULTS: We conducted five focus groups with a total of 19 internal medicine house staff. The coding scheme included 88 unique codes that encompassed traditional workload contributors (individual provider census) as well as more novel concepts (concern about physician physiologic needs—i.e., food). We sorted these codes into 18 categories, such as “Distractions,” “Patient Factors,” and “Electronic Health Record.” All of the codes fit into the SEIPS model (Table), although some encompassed more than one SEIPs factor. Agreement between the two reviewers was 79 %.

CONCLUSIONS: The emerging conceptual model derived from these focus groups confirms that workload is a complex construct, composed of much more than census. The SEIPs model is a good starting point, but there are many nuanced contributors to workload within each of the SEIPs factors. Exploring this model in other residency programs is the next step in this work. Practically speaking, this detailed conceptual model may help to identify potentially important and modifiable contributors so that interventions to mitigate them can be developed and tested.

Contributors to House Staff Workload: SEIPs Factors and Corresponding Categories

SEIPs factor Examples of Categories of Workload Contributors Examples of Individual Codes within Each Category
Person Ancillary Staff
Attending Physician
Medicine Team
Patient
Resident Characteristics
Knowledge of ancillary staff
Supervision style
Ability to work together
Acuity; family characteristics
Presence of physiologic needs
Environment Distractions
Location
Resources
Charting
Noise in team room
Geographic localization of pts
Wi-Fi
Locating a computer
Technology Charting
Health Record
Resources
Mobile charting on rounds Accessibility of EHR from home
Ability to use own devices (iPad)
Organization Clinic
Medicine Team
Rounds
Communication
Discharge
Clinical responsibilities
Team size
Type of rounds (bedside v. table)
Ability to give verbal orders
Administrative help with process
Task Charting
Communication
Coverage
Discharge
Education
Obtaining outside records