Faculty Bibliography
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department:Medicine. General Internal Medicine
recentyears:2
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Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study
BACKGROUND:The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. METHODS:This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. FINDINGS:This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28-2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65-3·22], p<0·0001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (2·35 [1·57-3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01-2·39], p=0·046), emergency versus elective surgery (1·67 [1·06-2·63], p=0·026), and major versus minor surgery (1·52 [1·01-2·31], p=0·047). INTERPRETATION:Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. FUNDING:National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
PMID: 32479829
ISSN: 1474-547x
CID: 4851402
Journal of family trauma, child custody & child development. 2020:17(4):344-354.DOI: 10.1080/26904586.2020.1851336
Mothers' reports of behavioral symptoms among children detained at family detention centers in the U.S
Few studies have empirically examined children's symptoms during immigration detention. This study investigated the behavioral problems of detained children through their mothers' reports by interviewing 42 female immigrants from Honduras, El Salvador, and Guatemala who had been in family detention centers in Texas, using the Strengths and Difficulties Questionnaire (SDQ). Results revealed that a majority of children (59.5%) displayed significant behavioral symptoms, with 78.6% exhibiting Emotional Problems, 50% exhibiting Conduct Problems, 45.2% exhibiting Hyperactivity, and 57.1% displaying Peer Problems. Significant correlations were observed between the child's Total Difficulties score and the mother's experience of fear for one's life during the journey to the U.S. (r = .32), and between the child's Conduct Problems and the mother's experience of violence during the same stage (r = .39). Also, the child's Emotional Problems were associated with the mother's PTSD symptoms (r = .42), and Peer Problems were associated with the mother's depression symptoms (r = .39). The high prevalence of behavioral problems in the children indicates the need for special attention in the detention process. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
PSYCH:2020-97908-001
ISSN: 2690-4594
CID: 4840292
Sialylation of Human Natural Killer (NK) Cells is Regulated by IL-2
Sialic acids are terminal sugars on the cell surface that are found on all cell types including immune cells like natural killer (NK) cells. The attachment of sialic acids to different glycan structures is catalyzed by sialyltransferases in the Golgi. However, the expression pattern of sialyltransferases in NK cells and their expression after activation has not yet been analyzed. Therefore, the present study determines which sialyltransferases are expressed in human NK cells and if activation with IL-2 changes the sialylation of NK cells. The expression of sialyltransferases was analyzed in the three human NK cell lines NK-92, NKL, KHYG-1 and primary NK cells. NK-92 cells were cultured in the absence or presence of IL-2, and changes in the sialyltransferase expression were measured by qPCR. Furthermore, specific sialylation was investigated by flow cytometry. In addition, polySia and NCAM were measured by Western blot analyses. IL-2 leads to a reduced expression of ST8SIA1, ST6GAL1 and ST3GAL1. α-2,3-Sialylation remained unchanged, while α-2,6-sialylation was increased after IL-2 stimulation. Moreover, an increase in the amount of NCAM and polySia was observed in IL-2-activated NK cells, whereas GD3 ganglioside was decreased. In this study, all sialyltransferases that were expressed in NK cells could be identified. IL-2 regulates the expression of some sialyltransferases and leads to changes in the sialylation of NK cells.
PMCID:7356531
PMID: 32545211
ISSN: 2077-0383
CID: 4837652
The FLEX real-world data platform explores new gene expression profiles and investigator-initiated protocols in early stage breast cancer. [Meeting Abstract]
ISI:000560368309213
ISSN: 0732-183x
CID: 4821052
MammaPrint and BluePrint Molecular Profiles and Clinical-Pathological Features of Asian Early-stage Breast Cancer Patients: A Meta-analysis of Six Prospective Clinical Trials [Meeting Abstract]
ISI:000538247800067
ISSN: 1068-9265
CID: 4821022
Heart failure disease management versus usual care in patients with a primary diagnosis of heart failure in skilled nursing facilities [Meeting Abstract]
BACKGROUND: Skilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). However, readmissions from SNFs and immediately after SNF discharge are common. In this study, we examined whether patients with a primary hospital discharge diagnosis of HF may benefit from a HF disease management program (HF-DMP) while undergoing post-acute rehabilitation in SNFs.
METHOD(S): This is a sub-group analysis of a cluster-randomized controlled trial of HF-DMP vs usual care (UC) for patients in SNF (n=671) with a HF diagnosis, regardless of ejection fraction (EF), conducted in 47 SNFs in the Denver-metropolitan area. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by a HF nurse advocate (HFNA). The HFNA directed a 7- component intervention focused on optimizing HF disease management through the following: documentation of EF, symptom and activity assessment, weights 3 times a week with dietary surveillance, recommendations for medication titration, patient/caregiver education, discharge instructions, and 7-day post- SNF discharge follow-up. This sub-group analysis examined patients discharged from hospital to SNF with a primary hospital discharge diagnosis of HF (n=125). The primary outcome was a composite of all-cause hospitalization, emergency department visits, and mortality at 60 days post-SNF admission. The etiology (HF related, non-HF cardiovascular (CV) related, or "other") of the first event was adjudicated by a Clinical Endpoints committee that was blinded to treatment group. Secondary outcomes were the composite outcome at 30 days, and change in health status and self-management from baseline to 60 days measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Self-care of HF Index (SCHFI).
RESULT(S): Of the 125 patients with a primary hospital discharge diagnosis of HF, 50were in the HF-DMP and 75 in UC. Overallmean age was 79+/-10, 53% were women, mean EF was 46+/-15%. At 60 days, the rate of the composite outcome was lower in the HF-DMP group (30%) compared to UC (52%) (p=0.02). Adjudicated events in the HF-DMP group revealed one HF related event, one CV related event, and 12 events classified as "other" within 60 days. In contrast, the UC group had 12 HF related events, 5 CV related events, and 19 events classified as "other" within 60 days. The rate of the composite outcome at 30 days for the HFDMP group was 18% versus 31% in the UC group (p=0.11). Change in KCCQ and SCHFI measures were not significantly different between groups at 60 days.
CONCLUSION(S): Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while receiving rehabilitation in a SNF had lower rates of the composite outcome at 60 days and less HF related events. Standardized HF management during SNF stays may be particularly important for patients with a primary discharge diagnosis of HF
METHOD(S): This is a sub-group analysis of a cluster-randomized controlled trial of HF-DMP vs usual care (UC) for patients in SNF (n=671) with a HF diagnosis, regardless of ejection fraction (EF), conducted in 47 SNFs in the Denver-metropolitan area. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by a HF nurse advocate (HFNA). The HFNA directed a 7- component intervention focused on optimizing HF disease management through the following: documentation of EF, symptom and activity assessment, weights 3 times a week with dietary surveillance, recommendations for medication titration, patient/caregiver education, discharge instructions, and 7-day post- SNF discharge follow-up. This sub-group analysis examined patients discharged from hospital to SNF with a primary hospital discharge diagnosis of HF (n=125). The primary outcome was a composite of all-cause hospitalization, emergency department visits, and mortality at 60 days post-SNF admission. The etiology (HF related, non-HF cardiovascular (CV) related, or "other") of the first event was adjudicated by a Clinical Endpoints committee that was blinded to treatment group. Secondary outcomes were the composite outcome at 30 days, and change in health status and self-management from baseline to 60 days measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Self-care of HF Index (SCHFI).
RESULT(S): Of the 125 patients with a primary hospital discharge diagnosis of HF, 50were in the HF-DMP and 75 in UC. Overallmean age was 79+/-10, 53% were women, mean EF was 46+/-15%. At 60 days, the rate of the composite outcome was lower in the HF-DMP group (30%) compared to UC (52%) (p=0.02). Adjudicated events in the HF-DMP group revealed one HF related event, one CV related event, and 12 events classified as "other" within 60 days. In contrast, the UC group had 12 HF related events, 5 CV related events, and 19 events classified as "other" within 60 days. The rate of the composite outcome at 30 days for the HFDMP group was 18% versus 31% in the UC group (p=0.11). Change in KCCQ and SCHFI measures were not significantly different between groups at 60 days.
CONCLUSION(S): Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while receiving rehabilitation in a SNF had lower rates of the composite outcome at 60 days and less HF related events. Standardized HF management during SNF stays may be particularly important for patients with a primary discharge diagnosis of HF
EMBASE:633955831
ISSN: 1525-1497
CID: 4818652
Gout and Serum Urate Levels Are Associated with Lumbar Spine Monosodium Urate Deposition and Chronic Low Back Pain: A Dual-Energy CT Study [Meeting Abstract]
Background/Purpose: Spinal gout is reported as a rare event, presenting as acute back pain, neuropathy, and spinal compression. Diagnosis is commonly based on identification of a mass, followed by tissue confirmation of monosodium urate (MSU) deposition. It is likely that many more cases of gout involve the spine asymptomatically or with non-specific or under-recognized symptoms.
Method(s): Using dual-energy CT (DECT), we are determining the prevalence/extent of MSU deposition in the lumbosacral spines of patients with gout vs without gout, and with tophaceous vs non-tophaceous gout. We are recruiting 25 controls, 25 non-tophaceous and 25 tophaceous gout patients, 50-80 years old. Exclusion criteria include known CPPD disease, RA, spondyloarthropathy or active spinal malignancy. All gout subjects meet ACR classification criteria and have entry serum urate (sU) of >6.8 mg/dL, or sU >6.0 mg/dL on ULT for < 6 months. Demographics, gout history, Aberdeen back pain scale, sU, ESR, and CRP are collected. Subjects undergo DECT of the lumbosacral spine to assess for MSU deposition and osteoarthritic changes.
Result(s): 61 subjects are enrolled to date (25 control, 24 non-tophaceous and 12 tophaceous gout). Control and gout (all pooled) subjects have similar mean age in years (controls, 61.8+/-3.8 vs gout, 64.1+/-7.32, p=0.15), but differ in BMI (controls, 28.3+/-6.5 kg/m 2 vs gout, 32.35+/-6.9 kg/m 2, p=0.02) and creatinine (controls, 1.0+/-0.2 mg/dL vs gout, 1.5+/-0.7 mg/dL, p< 0.05). Mean sU and ESR are higher in gout subjects (sU-controls, 5.3+/-1 mg/dL vs gout, 8.7+/-1.7 mg/dL, p< 0.05; ESR-controls, 13.7+/-13.8 mm/h vs gout, 25.3+/-18.3 mm/h, p< 0.05). Using default threshold settings for MSU visualization, greater MSU deposition is observed in the spine of gout patients (controls, 2.2+/-1.2 cm 3 vs gout, 10.8+/-32.2 cm 3, p=0.18; Fig 1). When a single gout outlier with excessively high sU and spinal MSU is excluded, spinal MSU deposition between controls and gout patients becomes significant (controls, 2.2+/-1.2 cm 3 vs gout, 5.6+/-7.8 cm 3, p=0.04). Reanalysis of several scans using narrower threshold settings to limit possible artifact confirms increased MSU signal among gout patients. Although many subjects in each group do not have excessive MSU deposition, deposition is more common in both gout groups (Fig 2). Thus far, MSU deposition is not different between non-tophaceous and tophaceous gout patients (non-tophaceous, 12.3+/-2.92 cm 3 vs tophaceous, 7.9+/-3.2 cm 3, p = 0.7). No subject demonstrated a frank spinal tophus. Gout patients report higher back pain scores (controls, 5.7+/-8.3, vs gout, 11.8+/-14.3, p=0.06). Across all groups deposition is greater in patients with higher sU.
Conclusion(s): Based on preliminary results, gout patients have higher inflammatory markers, more spinal MSU deposition, and increased back pain versus controls. Preliminary results with more stringent DECT threshold settings suggests these differences are not artifact, but analysis is ongoing. These data suggest that non-tophaceous MSU deposition in the spine occurs in a subset of gout patients, is associated with sU level, and may be associated with low back pain
Method(s): Using dual-energy CT (DECT), we are determining the prevalence/extent of MSU deposition in the lumbosacral spines of patients with gout vs without gout, and with tophaceous vs non-tophaceous gout. We are recruiting 25 controls, 25 non-tophaceous and 25 tophaceous gout patients, 50-80 years old. Exclusion criteria include known CPPD disease, RA, spondyloarthropathy or active spinal malignancy. All gout subjects meet ACR classification criteria and have entry serum urate (sU) of >6.8 mg/dL, or sU >6.0 mg/dL on ULT for < 6 months. Demographics, gout history, Aberdeen back pain scale, sU, ESR, and CRP are collected. Subjects undergo DECT of the lumbosacral spine to assess for MSU deposition and osteoarthritic changes.
Result(s): 61 subjects are enrolled to date (25 control, 24 non-tophaceous and 12 tophaceous gout). Control and gout (all pooled) subjects have similar mean age in years (controls, 61.8+/-3.8 vs gout, 64.1+/-7.32, p=0.15), but differ in BMI (controls, 28.3+/-6.5 kg/m 2 vs gout, 32.35+/-6.9 kg/m 2, p=0.02) and creatinine (controls, 1.0+/-0.2 mg/dL vs gout, 1.5+/-0.7 mg/dL, p< 0.05). Mean sU and ESR are higher in gout subjects (sU-controls, 5.3+/-1 mg/dL vs gout, 8.7+/-1.7 mg/dL, p< 0.05; ESR-controls, 13.7+/-13.8 mm/h vs gout, 25.3+/-18.3 mm/h, p< 0.05). Using default threshold settings for MSU visualization, greater MSU deposition is observed in the spine of gout patients (controls, 2.2+/-1.2 cm 3 vs gout, 10.8+/-32.2 cm 3, p=0.18; Fig 1). When a single gout outlier with excessively high sU and spinal MSU is excluded, spinal MSU deposition between controls and gout patients becomes significant (controls, 2.2+/-1.2 cm 3 vs gout, 5.6+/-7.8 cm 3, p=0.04). Reanalysis of several scans using narrower threshold settings to limit possible artifact confirms increased MSU signal among gout patients. Although many subjects in each group do not have excessive MSU deposition, deposition is more common in both gout groups (Fig 2). Thus far, MSU deposition is not different between non-tophaceous and tophaceous gout patients (non-tophaceous, 12.3+/-2.92 cm 3 vs tophaceous, 7.9+/-3.2 cm 3, p = 0.7). No subject demonstrated a frank spinal tophus. Gout patients report higher back pain scores (controls, 5.7+/-8.3, vs gout, 11.8+/-14.3, p=0.06). Across all groups deposition is greater in patients with higher sU.
Conclusion(s): Based on preliminary results, gout patients have higher inflammatory markers, more spinal MSU deposition, and increased back pain versus controls. Preliminary results with more stringent DECT threshold settings suggests these differences are not artifact, but analysis is ongoing. These data suggest that non-tophaceous MSU deposition in the spine occurs in a subset of gout patients, is associated with sU level, and may be associated with low back pain
EMBASE:634234584
ISSN: 2326-5205
CID: 4811772
A rare case of anemia from azathioprine-induced red blood cell aplasia [Meeting Abstract]
LEARNING OBJECTIVE #1: Recognize the presentation of pure red cell aplasia caused from Azathioprine LEARNING OBJECTIVE #2: Distinguish key parts of history and lab findings that help diagnose pure red cell aplasia CASE: A 42-year-old female with a medical history of Crohn's disease, mixed connective tissue disease (MCTD), hypertension, and stage 3 chronic kidney disease, presented to the hospital with a complaint of fatigue and weakness for the previous two weeks. She was taking azathioprine, vedolizumab, and prednisone 5 mg for her Crohn's disease and MCTD. In addition, allopurinol was added 1.5 months prior. Initial lab workup revealed a macrocytic anemia with a hemoglobin of 7.5 mg/dl and a mean corpuscular volume of 100.9 fl. Previous CBCs showed a hemoglobin around 14 mg/dl with normal mean corpuscular volume. She reported no history concerning for bleed. She had normal ESR and CRP levels and an unremarkable CT abdomen. Folate and B12 levels were normal. She had a haptoglobin of 152 mg/dl, an LDH of 218 units/liter, and total bilirubin of .3 mg/dL, inconsistent with hemolysis. A peripheral smear did not reveal hypersegmented neutrophils. Her reticulocyte count was 0.58%, and absolute count of 0.013, which suggested bone marrow suppression. Her white blood cell count and platelets were both normal. A 6- thioguanine nucleotides RBC level was elevated at 559 pmol/8x10(8)RBC (normal 235-400). Her azathioprine was subsequently discontinued, and her symptoms improved. A CBC on follow up visit approximately 3.5 months after discharge showed a hemoglobin of 13 mg/dl. IMPACT/DISCUSSION: Azathioprine is a purine analogue that interferes with DNA synthesis and inhibits proliferation of rapidly growing cells. 6-mercaptopurine (6-MP) is a drug metabolite of azathioprine that is used in the treatment of autoimmune diseases such as Crohn's disease. This occurs in part by the active metabolite, 6-Thioguanine nucleotide (6- TGN). Bone marrow suppression has been documented as a possible adverse effect of azathioprine, which is thought to occur via 6-TGN. Rarely, the suppression can be specific for erythrocyte generation and lead to a pure red cell aplasia (PRCA). Of note, our patient recently began allopurinol treatment to attempt to increase efficacy of the azathioprine. This occurs in part due to the inhibition of one of the metabolic pathways of 6-MP via Xanthine oxidase which will lead to increased therapeutically active 6-TGN. This simultaneous use likely contributed to the elevated 6-TGN metabolites and myelosuppression. This occurs more commonly in patients with low levels of Thiopurine methyl transferase (TPMT), however, aplastic anemia secondary to azathioprine can occur in patients with normal TPMT activity.
CONCLUSION(S): Allopurinol is often added in combination with azathioprine in the treatment for Crohn's disease. If these patients present with fatigue and macrocytic anemia, drug induced pure red cell anemia must be considered
CONCLUSION(S): Allopurinol is often added in combination with azathioprine in the treatment for Crohn's disease. If these patients present with fatigue and macrocytic anemia, drug induced pure red cell anemia must be considered
EMBASE:633957554
ISSN: 1525-1497
CID: 4803242
Journal of general internal medicine. 2020:Conference:(Annual):S277-S278.DOI: 10.1007/s11606-020-05890-3
Standardizing quality of virtual urgent care: An experiential onboarding approach using standardized patients [Meeting Abstract]
BACKGROUND: Virtual Urgent Care (VUC) is a now a common modality for providing real-time assessment and treatment of common medical problems. However, most providers have not had formal telemedicine training or clinical experience. Faculty have little experience with this new modality of healthcare delivery. We created an experiential onboarding program in which standardized patients (SPs) are deployed into a VUC platform to assess and deliver feedback to physicians in an effort to provide individual- level quality assurance and identify programlevel areas for improvement.
METHOD(S): We simulated a synchronous urgent care evaluation of a 25- year-old man with lingering upper respiratory tract symptoms refractory to over-the-counter medications. The SP was trained to strongly request an antibiotic prescription. A mock entry in the electronic medical record, available to providers during the visit, provided demographic, prior medical, pharmacy and allergy information. The encounter was scheduled into a regular 30-minute appointment slot during a routine 8-hour shift. We developed a behaviorally- anchored assessment tool to evaluate core communication, case-specific, and telemedicine-specific skills. Response options comprised 'not done,' 'partly done,' and 'well done.' SPs provided post-encounter verbal feedback to urgent care providers (UCPs), who received a summary report and had an opportunity provide structured feedback regarding the case. A single SP performed 20 / 21 visits.
RESULT(S): Twenty-one UCPs, with 2 to 23 years of clinical experience, participated in an announced scheduled visit. UCPs performed 'well done' in Information Gathering (93%) and Relationship Development (99%) domains. All UCPs provided appropriate management plans and did not give antibiotics. In contrast, Education and Counseling skills were less strong (32% 'well done'). Within this domain, few received 'well done' for checking understanding (14%); conveying small bits of information and summarizing to ensure clarity (9%). Most (71% well done) collaborated with the SP in discussing next steps. Specific telemedicine skills were infrequently used: only 19% performed a virtual physical exam, 24% utilized the audio/video interface to augment information gathering, 14% optimized technical aspects by assessing sound, video or ensuring a backup plan should video fail. A subset of UCPs (n=9) provided structured feedback regarding the case. 100% 'somewhat or strongly agreed' that the encounter improved their confidence communicating via the video interface and helped improved telehealth skills.
CONCLUSION(S): This experiential virtual urgent care onboarding program utilizing standardized announced encounters uncovers several areas for improvement within telemedicine-specific and patient education domains. These findings form the basis for dedicated training for virtual urgent care providers to assure quality across the program
METHOD(S): We simulated a synchronous urgent care evaluation of a 25- year-old man with lingering upper respiratory tract symptoms refractory to over-the-counter medications. The SP was trained to strongly request an antibiotic prescription. A mock entry in the electronic medical record, available to providers during the visit, provided demographic, prior medical, pharmacy and allergy information. The encounter was scheduled into a regular 30-minute appointment slot during a routine 8-hour shift. We developed a behaviorally- anchored assessment tool to evaluate core communication, case-specific, and telemedicine-specific skills. Response options comprised 'not done,' 'partly done,' and 'well done.' SPs provided post-encounter verbal feedback to urgent care providers (UCPs), who received a summary report and had an opportunity provide structured feedback regarding the case. A single SP performed 20 / 21 visits.
RESULT(S): Twenty-one UCPs, with 2 to 23 years of clinical experience, participated in an announced scheduled visit. UCPs performed 'well done' in Information Gathering (93%) and Relationship Development (99%) domains. All UCPs provided appropriate management plans and did not give antibiotics. In contrast, Education and Counseling skills were less strong (32% 'well done'). Within this domain, few received 'well done' for checking understanding (14%); conveying small bits of information and summarizing to ensure clarity (9%). Most (71% well done) collaborated with the SP in discussing next steps. Specific telemedicine skills were infrequently used: only 19% performed a virtual physical exam, 24% utilized the audio/video interface to augment information gathering, 14% optimized technical aspects by assessing sound, video or ensuring a backup plan should video fail. A subset of UCPs (n=9) provided structured feedback regarding the case. 100% 'somewhat or strongly agreed' that the encounter improved their confidence communicating via the video interface and helped improved telehealth skills.
CONCLUSION(S): This experiential virtual urgent care onboarding program utilizing standardized announced encounters uncovers several areas for improvement within telemedicine-specific and patient education domains. These findings form the basis for dedicated training for virtual urgent care providers to assure quality across the program
EMBASE:633957469
ISSN: 1525-1497
CID: 4805262
Use of unannounced standardized patients and audit/feedback to improve physician response to social determinants of health [Meeting Abstract]
BACKGROUND: While much is known about the importance of addressing Social Determinants of Health (SDoH), less is known about how physicians elicit, respond to, and act upon their patients' SDoH information. We report on the results of a study that 1) sent Unannounced Standardized Patients (USPs) with programmed SDoH into clinics to assess whether providers uncovered, explored and acted upon the SDoH, 2) provided audit/feedback reports with educational components to clinical teams, and 3) tracked the impact of that intervention on provider response to SDoH.
METHOD(S): Highly trained USPs (secret shoppers) portrayed six scenarios (fatigue, asthma, Hepatitis B concern, shoulder pain, back pain, well-visit), each with specific housing (overcrowding, late rent, and mold) and social isolation (shyness, recent break up, and anxiety) concerns that they shared if asked broadly about. USPs assessed team and provider SDoH practices (eliciting, acknowledging/exploring, and providing resources and/or referrals). 383 USP visits were made to residents in 5 primary care teams in 2 urban, safety- net clinics. 123 visits were fielded during baseline period (Feb 2017-Jan 2018); 185 visits during intervention period (Jan 2018-Mar 2019) throughout which quarterly audit/feedback reports of the teams' response to the USPs' SDoH and targeted education on SDoH were distributed; and 75 follow-up phase visits were fielded (Apr-Dec 2019). Analyses compared rates of eliciting and responding to SDoH across the 3 periods (chi- square, z-scores). One team, by design, did not receive the intervention and serves as a comparison group.
RESULT(S): Among the intervention teams, the rate of eliciting the housing SDoH increased from 46% at baseline to 59% during the intervention period (p=.045) and also increased, but not significantly, for the social issue (40% to 52%, p=.077). There was a significant increase from baseline to intervention in providing resources/referrals for housing (from 7% to 24%, p=.001) and for social isolation (from 13% to 24%, p=.042) (mostly resources, very few referrals were made). The comparison team's rates followed a different pattern: eliciting the housing issue and the social isolation issue decreased from baseline to the intervention period (housing: 61% to 45%; social isolation: 39% to 33% of visits) and the rate of providing resources/referrals stayed steady at 13% for both. In the cases where SDoH were most clinically relevant, baseline rates of identifying the SDoH were high (>70%) but rates of acting on the SDoH increased significantly from baseline to intervention. Increases seen in the intervention period were not sustained in the follow-up period.
CONCLUSION(S): Giving providers SDoH data along with targeted education was associated with increased but unsustained rates of eliciting and responding to housing and social issues. The USP methodology was an effective means of presenting controlled SDoH and providing audit/feedback data. Ongoing education and feedback may be needed
METHOD(S): Highly trained USPs (secret shoppers) portrayed six scenarios (fatigue, asthma, Hepatitis B concern, shoulder pain, back pain, well-visit), each with specific housing (overcrowding, late rent, and mold) and social isolation (shyness, recent break up, and anxiety) concerns that they shared if asked broadly about. USPs assessed team and provider SDoH practices (eliciting, acknowledging/exploring, and providing resources and/or referrals). 383 USP visits were made to residents in 5 primary care teams in 2 urban, safety- net clinics. 123 visits were fielded during baseline period (Feb 2017-Jan 2018); 185 visits during intervention period (Jan 2018-Mar 2019) throughout which quarterly audit/feedback reports of the teams' response to the USPs' SDoH and targeted education on SDoH were distributed; and 75 follow-up phase visits were fielded (Apr-Dec 2019). Analyses compared rates of eliciting and responding to SDoH across the 3 periods (chi- square, z-scores). One team, by design, did not receive the intervention and serves as a comparison group.
RESULT(S): Among the intervention teams, the rate of eliciting the housing SDoH increased from 46% at baseline to 59% during the intervention period (p=.045) and also increased, but not significantly, for the social issue (40% to 52%, p=.077). There was a significant increase from baseline to intervention in providing resources/referrals for housing (from 7% to 24%, p=.001) and for social isolation (from 13% to 24%, p=.042) (mostly resources, very few referrals were made). The comparison team's rates followed a different pattern: eliciting the housing issue and the social isolation issue decreased from baseline to the intervention period (housing: 61% to 45%; social isolation: 39% to 33% of visits) and the rate of providing resources/referrals stayed steady at 13% for both. In the cases where SDoH were most clinically relevant, baseline rates of identifying the SDoH were high (>70%) but rates of acting on the SDoH increased significantly from baseline to intervention. Increases seen in the intervention period were not sustained in the follow-up period.
CONCLUSION(S): Giving providers SDoH data along with targeted education was associated with increased but unsustained rates of eliciting and responding to housing and social issues. The USP methodology was an effective means of presenting controlled SDoH and providing audit/feedback data. Ongoing education and feedback may be needed
EMBASE:633958103
ISSN: 1525-1497
CID: 4803142
