Enhancing existing medical school curricula with an innovative healthcare disparities curriculum

Background Effective healthcare disparities curricula seek to train physicians who are well equipped to address the health needs of an increasingly diverse society. Current literature on healthcare disparities curricula and implementation focuses on courses created independent of existing educational materials. Our aim was to develop and implement a novel resource-conserving healthcare disparities curriculum to enhance existing medical school lectures without the need for additional lectures. Methods This non-randomized intervention was conducted at the University of California Los Angeles. The curriculum was offered to all first-year medical students in the class of 2021 (n=188). With institutional approval, a new healthcare disparities curriculum was created based on the Society of General Internal Medicine’s core learning objectives for effective healthcare disparities curricula (J General Internal Med 25:S160–163, 2010). Implementation of the curriculum made use of “teachable moments” within existing medical school lectures. Teachable moments were broad lecture topics identified by the research team as suitable for introducing relevant healthcare disparities content. The new lecture-enhancing healthcare disparities curriculum was delivered with the related lecture via integrated PDF documents uploaded to an online learning management system. Students were encouraged to complete pre- and post- course assessments to examine changes in disparities knowledge and self-rated confidence in addressing disparities. Matched χ2 tests were used for statistical analysis. Results Participating students (n=92) completed both pre- and post-course assessments and were retrospectively stratified, based on self-reported use of the new lecture enhancing curriculum, into the “high utilizer” group (use of materials “sometimes” or “very often,” n=52) and the comparison “low utilizer” group (use of the materials “rarely” or “very rarely,” n=40). Students who self-identified as underrepresented racial and ethnic minorities in medicine were more likely to utilize the material (41% of the high utilizers vs. 17% of the low utilizer group, p<.01). Post-course knowledge assessment scores and self-reported confidence in addressing healthcare disparities improved only in the high utilizer group. Conclusions Integrating new guideline based curricula content simultaneously into pre-existing lectures by identifying and harnessing teachable moments may be an effective and resource-conserving strategy for enhancing healthcare disparities education among first year medical students.

Evaluation of Provider Acceptance of Pharmacist Recommendations in a High User Patient Population

OBJECTIVE: To compare the acceptance rate of pharmacist recommendations in an interdisciplinary team for patients interviewed by the pharmacist versus those assessed by chart review. DESIGN: Retrospective chart review. SETTING: Interdisciplinary consultative team in an outpatient setting as part of a large academic health system provided care for "high utilizer" patients. PARTICIPANTS: Sixty-five patients at moderate to high risk of hospitalization who completed their first appointment with the team between March 1, 2019, and December 30, 2019. Most patients were 65 years of age or older and all had Medicare insurance. INTERVENTIONS: A pharmacist completed a chart review for all patients. A cohort of patients were also interviewed. Recommendations were recorded in the electronic medical record, discussed with the team, and forwarded to the patient's primary care provider. RESULTS: A total of 253 recommendations were made by pharmacists, with a significantly higher acceptance rate for patients who completed an interview with the pharmacist (40.7% vs. 28.4%; P = 0.046). Patientspecific factors resulting in higher acceptance rates in the interview group included age younger than 65 years (P = 0.013), 10 to 19 medications (P = 0.004), and mental health diagnosis (P = 0.02). CONCLUSION: The addition of an interview to chart review allowed pharmacists to make recommendations that were more likely to be accepted and therefore more clinically impactful.

Characteristics of sickle cell patients with frequent emergency department visits and hospitalizations

Vaso-occlusive episodes (VOEs) are a hallmark of sickle cell disease (SCD), and account for >90% of health care encounters for this patient population. The Cooperative Study of Sickle Cell Disease, a large study enrolling >3000 patients, showed that the majority of SCD patients (80%) experienced 0–3 major pain crises/year. Only a small minority (~5%) experienced ≥6 VOEs/year. Our study sought to further understand this difference in VOE frequency between SCD patients. We analyzed 25 patients (13M/12F, mean age of 28.8) with ≥6 ED visits or hospitalizations/year (high utilizers), and compared these with 9 patients (6M/3F, mean age of 37.6) who had ≤2 ED visits or hospitalizations/year (low utilizers). All subjects were given a demographic survey along with questionnaires for depression, anxiety, and Health Locus of Control. Each subject then underwent quantitative sensory testing (QST) with three different modalities: pressure pain sensitivity, heat and cold sensitivity, and Von Frey monofilament testing. Laboratory and clinical data were collected through subjects’ medical records. CBC and chemistry analysis showed high utilizers had higher WBC (p<0.01), ANC (p<0.01), total bilirubin (p = 0.02), and lower MCV (p = 0.03). Opioid use (morphine equivalents) over the past 6 months was significantly higher in the high utilizer group (12125.7 mg vs 2423.1 mg, p = 0.005). QST results showed lower pressure pain threshold at the ulna (224.4 KPa vs 338.9 KPa, p = 0.04) in the high utilizer group. High utilizers also had higher anxiety (9.0 vs 4.6, p = 0.04) and depression scores (10.0 vs 6.0, p = 0.051). While the low utilizer group had higher education levels with more associate and bachelor degrees (p = 0.009), there was no difference in income or employment. These data show that many biological and psychosocial factors contribute to high health care utilization in SCD. A multi-disciplinary and multi-faceted approach will be required to address this complex problem.

1562. Reduction in Healthcare Utilization and Overdose after Skin and Soft Tissue Infections for Injection Drug Users through Addiction Medicine Consultation

Background Healthcare encounters for skin and soft tissue infections (SSTIs) due to injection drug use (IDU) may provide opportunities for interventions to improve outcomes. We explored factors that may impact reduction of healthcare utilization and modify other complications of substance use disorder after an IDU-related SSTI. Methods We conducted a retrospective cohort chart review for 305 patients with IDU-related SSTIs between 10/1/2015 and 6/1/2019 to examine demographic, clinical and healthcare utilization data one year before and after the SSTI encounter. Patients were categorized as a low utilizer if they had &lt; 3 emergency department encounters and as a high utilizer if they had ≥3 encounters in the one-year period before or after the SSTI. For patients that changed utilization categories from the pre- to post-SSTI period, we analyzed demographic and clinical differences using Chi Square tests. We performed a secondary analysis using a Wilcoxon test to examine the relationship between receipt of an addiction consult and change in number of overdoses after SSTI. Results 131 patients were low utilizers at baseline and 174 were high utilizers. Patients who transitioned from low to high utilization (64 patients) were significantly less likely to have received an addiction consult, 16 (25%), than patients who transitioned from high to low utilization, 15 (48%), p=0.03. However, high utilizers were significantly more likely to remain a high utilizer (p&lt; 0.0001) with no variable predictive of transition to low utilization including addiction consultation, homelessness, insurance type, or treatment with medications for opioid use disorder. Patients who were low utilizers at baseline were more likely to remain low utilizers if they were not homeless, p=0.01. Of the entire sample, 96.2% (p&lt; 0.0001) of those admitted obtained an addiction consult, which significantly reduced rates of overdose in the following year (p=0.0014) for 223 patients for which we had overdose data. Conclusion Patients with IDU-related SSTIs who do not receive an addiction consult are more likely to cross from low to high utilization after the event. Preferentially targeting this population for addiction consultation can significantly improve outcomes. Disclosures All Authors: No reported disclosures

Characterization of the medication regimen complexity index in high-utilizer, adult psychiatric patients

Introduction Few studies have examined the role of medication-related factors in psychiatric readmissions. Our objective was to characterize the medication regimen complexity index (MRCI) and assess its association with psychiatric hospital readmission frequency and time to readmission in a high-utilizer psychiatric cohort. Methods Adult patients admitted between July 2012 and March 2014 were identified if discharged from an inpatient psychiatry service with greater than or equal to 5 psychiatric readmissions or at least one 30-day readmission. Complexity of the medication regimen was determined using a validated MRCI electronic capture tool. Results One hundred sixty-eight patients were included. Average MRCI for all readmissions was 7.09 for psychotropic medications, 5.90 for other prescription medications, 2.98 for over the counter, and 16.00 for total medications. Ages greater than 65 years old and female sex were associated with higher total MRCI scores. Average MRCI for psychotropic medications and average psychotropic medication count, along with depression diagnosis, were found to be significantly associated with average time between each readmission but not with readmission frequency. An average total MRCI score greater than 19.7, when broken down by percentiles, was associated with a shorter time to readmission. Discussion Psychotropic regimen complexity, psychotropic medication count, total MRCI greater than 19.7, and a diagnosis of depression may contribute to a shorter time to readmission in adult psychiatric patients with a history of frequent readmissions. Future studies are needed to confirm findings and evaluate clinical significance and impact.

Evaluation of a Pharmacist-Based Intervention to Reduce Readmissions in Geriatric High-Utilizer Patients: A Pilot Study

Purpose: The goal of this study was to determine if a pharmacist-led intervention to improve medication safety at hospital discharge reduced the number of hospital readmissions among geriatric high-utilizer patients. This study is the first to test a pharmacist-based intervention in a high-utilizer population. Methods: This was a quasi-experimental pilot study done at a safety-net hospital in the southeastern US. Fifty-seven patients 65 years old and older who were in the 95th percentile for number of hospital admissions in a year were included. On the day of discharge, one of the study pharmacists reviewed the discharge medication list and calculated the Medication Appropriateness Index (MAI) for each medication and reviewed for Beers Criteria. Any medication identified as potentially high-risk or inappropriate was flagged by the pharmacist and discussed with the team. The primary outcome was the number of admissions in the year following the intervention in the intervention group versus the control group. Results: There were no statistically significant differences in the number of admissions, the MAI scores, or the number of medications meeting Beers Criteria between the two groups. Conclusion: Although this study did not demonstrate a decrease in hospital admissions, it shows that pharmacist review of medications at discharge can identify potentially unnecessary medications that could lead to confusion or adverse events. Further research is necessary to identify interventions to prevent readmissions in this high-risk population. Article Type: Original Research

Reduction in Hospital Days Using a Multidisciplinary Approach for Pediatric Patients with Sickle Cell Disease

Background: Pain crisis is the most frequent reason for admission in children with sickle cell disease (SCD). Frequent hospitalizations are associated with school absenteeism, emotional distress, and financial hardships. There is limited literature on initiatives to decrease admissions and hospital days in SCD pain crises. Prior studies have shown that individualized pain plans in emergency rooms can decrease admission rates and that a multidisciplinary approach with provider and patient education and close follow up can decrease 30-day readmission rates. Our goal was to decrease hospital days for pain crisis admissions by 40% over a 5-year period using a multidisciplinary approach. Methods: From September 2011 to August 2016 a multidisciplinary quality improvement project was conducted. A Plan-Do-Study-Act methodology was used. Five key drivers were identified and nine interventions were implemented. Interventions for the entire cohort included individualized home pain plans, emergency room and inpatient order sets, inpatient daily schedules, and a psychoeducation and biofeedback program. High utilizers, defined as ≥ 4 admissions per year, had an individualized SCD plan and were assigned a mental health provider. The high utilizer group was expanded to include at risk patients (3 admissions per year). Data was analyzed for all patients age 0-21 years admitted for SCD pain crises. The primary measure was hospital days, with 30-day readmission rate as a balancing measure. Results: 216 SCD patients were followed in 2011, with a 14% increase over the five year study period. From this cohort, a total of 122 patients were admitted for pain crises during this time. 48% of admitted patients were male, with a mean age of 10.68±5.65 years, and 72% had hemoglobin SS disease (16% SC, 5% Sβ0, 7% Sβ+). As shown in Table 1, the number of patients admitted decreased from 55 patients (25.4% of total SCD patients) in the pre-intervention period to 33 patients (13.3% of total SCD patients) in the final year of the intervention (p = 0.0014). The number of admissions decreased from 148 admissions in the pre-intervention period to 86 admissions in the final year of the intervention (54.7% decrease). The number of hospital days decreased by 61% from 59.6 days per month in the pre-intervention period to 23.2 days per month in the final year of the intervention (p < 0.0001). Number of high utilizers decreased from 13 patients in the pre-intervention period to 7 patients in the final year of the intervention. There was a 66% reduction in the number of hospital days in the high utilizer group compared to a 47% reduction in the low utilizer group. The 30-day readmission rate decreased from 33.9% pre-intervention to 19.4% in the final year of intervention. Special cause variation was first achieved in April 2014, 18 months after the start of all interventions, with a shift of the centerline from 59.6 days/month to 38.3 days/month and again in February 2016 with a decrease to 23.2 days/month (Figure 1). There was special cause variation in 30-day readmissions in April 2014 with a centerline shift in the 30-day readmission rate from 33.9% to 19.4%. The baseline direct hospital cost for SCD admissions was $909,000 per year. In the final year of the project, the average cost was $353,880 per year, with an overall annual savings of $555,120 in direct hospital costs. Conclusion: In this single center study, the multidisciplinary approach of effective home, emergency room, and inpatient pain management combined with increased mental health services for higher risk individuals proved to be effective in decreasing SCD pain crisis admissions and hospital days. A dedicated team effort with simple interventions had a significant impact on the well-being of the entire SCD population, but especially those who were more frequent utilizers of the healthcare system, while decreasing hospital costs, and can serve as a model for other institutions. Disclosures No relevant conflicts of interest to declare.