Trained Clinician's Documentation of Serious Illness Conversations and Use of Billing CPT 99497

2021 ◽  
pp. 082585972110491
Author(s):  
Jeanette M. Daly ◽  
Megan E. Schmidt ◽  
Kate DuChene Thoma ◽  
Barcey T. Levy
Keyword(s):  
Risk Score ◽  
Mortality Risk ◽  
Chart Review ◽  
Retrospective Chart Review ◽  
Care Program ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Chi Square ◽  
Serious Illness ◽  
Significant Difference

Background Advance care planning (ACP) involves patients and family members in discussions with clinicians about their values, goals, and preferences regarding future medical care. Objectives: To (1) assess whether an ACP conversation using the Serious Illness Conversation (SIC) was initiated and documented; (2) assess which components of SIC were documented; (3) determine how frequently clinicians trained to use the SIC guide used ACP billing codes during the study time period, (4) determine whether there was a significant difference in mortality risk score according to documentation of each component of the SIC. Methods; Thirteen clinicians at three family medicine offices were trained in the Serious Illness Care Program and asked to document SICs in the electronic medical record (EMR). A retrospective chart review of SIC components was conducted in the EMRs of patients who presumably had ACP conversations initiated by the trained clinicians. Patients were identified using the billing codes for ACP conversations and through referrals from another study that requires clinicians to have ACP conversations with their patients. Pearson chi-square test for categorical variables and t-tests for continuous variables were conducted. Results: A total of 157 patients were included in this study; 131 patients referred from another ACP study and an additional 26 patients using the billing codes of ACP conversations. Through retrospective chart review, the mean age of patients was 72 years and 54 were male. Sixty-two (40%) charts had one or more SIC components documented. “Explore key topics” was documented most frequently for 58 (38%) patients by the 13 participating clinicians. Mean mortality risk score was 10.7 and higher scores were significantly correlated with more SIC components documented ( rp = 0.217, P = 0.007). Conclusion: Little use of the SIC guide among trained physicians was found in the EMR. It was expected that provision of an EMR template for documenting the SIC would have facilitated documentation of SICs.

Comparative Morbidity Profile of Elective vs Therapeutic Neck Dissection

2021 ◽  
pp. 019459982110089
Author(s):  
Quinn Dunlap ◽  
James Reed Gardner ◽  
Amanda Ederle ◽  
Deanne King ◽  
Maya Merriweather ◽  
...  
Keyword(s):  
Neck Dissection ◽  
Surgical Complications ◽  
Chart Review ◽  
Care Center ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Neck Surgery ◽  
Continuous Variables ◽  
Significant Difference ◽  
History Of

Objective Neck dissection (ND) is one of the most commonly performed procedures in head and neck surgery. We sought to compare the morbidity of elective ND (END) versus therapeutic ND (TND). Study Design Retrospective chart review. Setting Academic tertiary care center. Methods Retrospective chart review of 373 NDs performed from January 2015 to December 2018. Patients with radical ND or inadequate chart documentation were excluded. Demographics, clinicopathologic data, complications, and sacrificed structures during ND were retrieved. Statistical analysis was performed with χ2 and analysis of variance for comparison of categorical and continuous variables, respectively, with statistical alpha set a 0.05. Results Patients examined consisted of 224 males (60%) with a mean age of 60 years. TND accounted for 79% (n = 296) as compared with 21% (n = 77) for END. Other than a significantly higher history of radiation (37% vs 7%, P < .001) and endocrine pathology (34% vs 2.6%, P < .001) in the TND group, no significant differences in demographics were found between the therapeutic and elective groups. A significantly higher rate of structure sacrifice and extranodal extension within the TND group was noted to hold in overall and subgroup comparisons. No significant difference in rate of surgical complications was appreciated between groups in overall or subgroup analysis. Conclusion While the significantly higher rate of structure sacrifice among the TND population represents an increased morbidity profile in these patients, no significant difference was found in the rate of surgical complications between groups. The significant difference seen between groups regarding history of radiation and endocrine pathology likely represents selection bias.

scholarly journals P047: Emergency department practice patterns of UTI investigation among the delirious elderly: a retrospective chart review

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S81-S81
Author(s):  
R. Pinnell ◽  
P. Joo
Keyword(s):  
Emergency Department ◽  
Elderly Patients ◽  
Chart Review ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Urinary Symptoms ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Indwelling Catheter ◽  
Exact Test

Introduction: Delirium is a common emergency department (ED) presentation in elderly patients. Urinary tract infection (UTI) investigation and treatment are often initiated in delirious patients in the absence of specific urinary symptoms, despite a paucity of evidence to support this practice. The purpose of this study is to describe the prevalence of UTI investigation, diagnosis and treatment in delirious elderly patients in the ED. Methods: We performed a retrospective chart review of elderly patients presenting to the ED at The Ottawa Hospital between January 15-July 30, 2018 with a chief complaint of confusion or similar. Exclusion criteria were pre-existing and current UTI diagnosis, Glasgow Coma Scale <13, current indwelling catheter or nephrostomy tube, transfers between hospitals, and leaving without being seen. The primary outcome was the proportion of patients for whom urine tests (urinalysis or culture) or antibiotic treatment were ordered. Secondary outcomes were associations between patient characteristics, rates of UTI investigation, and patient outcomes. Descriptive values were reported as proportions with exact binomial confidence intervals for categorical variables and means with standard deviations for continuous variables. Comparisons were conducted with Fischer's exact test for categorical variables and t-tests for continuous variables. Results: After analysis of 1039 encounters with 961 distinct patients, 499 encounters were included. Urine tests were conducted in 324 patients (64.9% [60.6-69.1]) and antibiotics were prescribed to 176 (35.2% [31.1-39.6]). Overall 57 patients (11.4% [8.8-14.5]) were diagnosed with UTI, of which only 12 (21.1% [11.4-33.9]) had any specific urinary symptom. For those patients who had no urinary symptoms or other obvious indication for antibiotics (n = 342), 199 (58.2% [52.8-63.5]) received urine tests and 62 (18.1% [14.2-22.6]) received antibiotics. Patients who received urine tests were older (82.4 ± 8.8 vs. 78.3 ± 8.4 years, p < 0.001) but did not differ in sex distribution from those than those who did not. Additionally, patients who received antibiotics were more likely to be admitted (OR = 2.6 [1.48-4.73]) and had higher mortality at 30 days (OR = 4.2 [1.35-12.91]) and 6 months (OR = 3.2 [1.33-7.84]) than those who did not. Conclusion: Delirious patient without urinary symptoms in the ED were frequently investigated and treated for UTI despite a lack of evidence regarding whether this practice is beneficial.

scholarly journals Assessment of production objective and breeding practices of rural goat keepers and implications for a breeding programme in north central Nigeria

2021 ◽  
Vol 43 (2) ◽  
pp. 50-61
Author(s):  
A. Yakubu ◽  
M. M. Achapu
Keyword(s):  
Disease Resistance ◽  
Breeding Programme ◽  
Primary Data ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Chi Square ◽  
System Productivity ◽  
North Central ◽  
Significant Difference ◽  
Breeding Practices

Goat farming is a veritable source of livelihood of many rural families in Africa. This study aimed at determining prevailing production systems and breeding objectives of rural goat producers in north central Nigeria. A total of 180 rural goat keepers corresponding to 60 per State (Nasarawa, Benue and Plateau) were randomly sampled. Primary data (socioeconomics of respondents, reasons for keeping goats, flock structure, management system, productivity and breeding practices) were collected through individual structured questionnaire administration. Cross tabulations and Chi square (÷2) statistics were used to compare categorical variables, while rank means, arithmetic means and standard deviations were calculated for within- and between-state comparisons of the continuous variables. While more goat producers were involved in crop farming in Benue State (43.6%), only 34.5 and 21.8% engaged in farming in Plateau and Nasarawa State, respectively. Goats were kept for income generation, milk, meat and cultural/religious functions by about 61.1, 12.8, 15.0 and 6.1% of the producers while the relative importance given by respondents to the different objectives varied significantly (Chi-square=6.62; P< 0.05) across the States. The average flock sizes of goats for Nasarawa (9.68±5.63), Benue (8.25±4.73) and Plateau (8.80±3.98) were not significantly (P>0.05) different. Semi-intensive system predominated (P<0.01). Productivity indices showed that for age of parturition, number of kids of Sahel doe and lifespan of goats, there was no significant difference (P>0.05). Among all the breeding traits across the three States, only disease resistance varied (P<0.01). Disease resistance, survival, fertility, number of offspring and body size appeared similar (P>0.05) as preference for production traits. However, growth (83.52-97.68 mean ranks) (Plateau State) and cultural importance (75.28-104.70 mean ranks) (Benue State) varied across the States (P<0.05 and P<0.01, respectively). The present information will be useful in understanding the farmers' production objectives, management and breeding practices as a first step in designing a sustainable breeding programme for rural farmers in the study areas.

scholarly journals 2005. Successful Implementation of a Procalcitonin Algorithm Associated with Reduction in Antibiotic Days

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S672-S673
Author(s):  
John B McCoury ◽  
Randolph V Fugit ◽  
Mary T Bessesen
Keyword(s):  
Patient Characteristics ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Categorical Variables ◽  
Successful Implementation ◽  
Continuous Variables ◽  
Chi Square ◽  
Clinician Training ◽  
Significant Difference ◽  
Mortality Table

Abstract Background Randomized controlled trials of procalcitonin (PCT)-based algorithms for antibacterial therapy have been shown to reduce antimicrobial use and improve survival. Translation of PCT algorithms to clinical settings has often been unsuccessful. Methods We implemented a PCT algorithm, supported by focus groups prior to introduction of the PCT test in April 2016 and clinician training on the PCT algorithm for testing and antimicrobial management after test roll-out. The standard PCT algorithm period (SPAP) was defined as October 1, 2017 to March 31, 2018. The antimicrobial stewardship team (AST) initiated an AST-supported PCT algorithm (ASPA) in August 2018. The AST prospectively evaluated patients admitted to ICU for sepsis and ordered PCT per algorithm if the primary medical team had not ordered them. The ASPA period was defined as October 1, 2018–March 31, 2019. The AST conducted concurrent review and feedback for all antibiotic orders during both periods, using PCT result when available. We compared patient characteristics and outcomes between the two periods. The primary outcome was adherence to the PCT algorithm, with subcomponents of appropriate PCT orders and antimicrobial discontinuation. Secondary outcomes were total antibiotic days, excess antibiotic days avoided, ICU and hospital length of stay (LOS), 30-day readmission and mortality. Continuous variables were analyzed with Student t-test. Categorical variables were analyzed with chi-square or Mann–Whitney test, as appropriate. Results There were 35 cases in the SPAP cohort and 57 cases in the ASPA cohort. There were no differences in demographics or infection site (Table 1). Baseline PCT was ordered in 57% of the SPAP cohort and 90% of the ASPA cohort (P = 0.0006) (Table 2). Follow-up PCT was performed in 23% of SPAP and 76% of ASPA (P < 0.0001). Antibiotics were discontinued per algorithm in 2/35 (7%) in the SPAP cohort and 25/57 (44%) in the ASPA cohort (P < 0.0001). Total antibiotic days was 7 (IQR 4–10) in the SPAP cohort and 5 (IQR 2–7) in the ASPA cohort (P = 0.02). There was no significant difference in LOS, ICU LOS, 30-day readmission, or mortality (Table 4). Conclusion A PCT algorithm successfully implemented by an AST was associated with a significant decrease in total antibiotic days. There were no differences in mortality or LOS. Disclosures All authors: No reported disclosures.

Vanishing congenital lung malformations: What is the incidence of true regression?

2021 ◽  
pp. 1-7
Author(s):  
C. Griggs ◽  
M. Schmaedick ◽  
C. Gerall ◽  
W. Fan ◽  
C. Orlas ◽  
...  
Keyword(s):  
Neonatal Intensive Care ◽  
Statistical Significance ◽  
Multivariable Analysis ◽  
Retrospective Chart Review ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Chi Square ◽  
Exact Test ◽  
Congenital Lung Malformation ◽  
Nicu Admission

BACKGROUND: A congenital lung malformation (CLM) that is diagnosed on prenatal ultrasound exam may subsequently become undetectable on later scans, a “vanishing” CLM. OBJECTIVE: The purpose of our study is to characterize the prenatal natural history and postnatal outcomes of “vanishing” lesions treated at our institution. METHODS: We performed a retrospective chart review of 107 patients diagnosed prenatally with CLM at our institution. Comparisons were made using Kruskal-Wallis or t-test for continuous variables and Fisher’s exact test or Chi-Square test for categorical variables. Multivariable analysis using logistic regression was performed. RESULTS: Of the 104 patients, 59 (56.7%) had lesions that became sonographically undetectable on serial ultrasound scans. Patients with lesions that vanished prenatally tended to need less Neonatal Intensive Care Unit (NICU) admission at birth (persistent CLM: 54.8%vs vanished CLM: 28.8%), decreased need for supplemental O2 at birth (persistent CLM: 31.0%vs vanished CLM: 11.9%), and decreased delay in feeds (persistent CLM: 26.2%vs vanished CLM: 8.5%) compared to those with persistent CLM. After multivariate analysis controlling for maternal steroid administration and sex, admission to NICU maintained a slight statistical significance, with patients in the vanishing CLM group 2.5 times less likely to be admitted to the NICU. None of our patients whose lesions vanished prenatally required mechanical ventilation. Eighty-six patients underwent postnatal computed tomography (CT) chest. Only 2 patients had lesions that regressed on postnatal CT. CONCLUSION: Lesions that vanish on prenatal imaging may be associated with improved clinical outcomes. The rate of true regression at our institution was as low as 2.3%.

Abstract TP236: Eval to Groin Puncture Times: Efficiencies and Deficiencies of Live Physician vs Telemedicine Triage

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
David Rosenbaum-Halevi ◽  
Sujan T Reddy ◽  
Alyssa D Trevino ◽  
Muhammad Bilal Tariq ◽  
Mahan Shahrivari ◽  
...  
Keyword(s):  
Primary Outcome ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Chi Square ◽  
Specific Level ◽  
Site Specific ◽  
Exact Test ◽  
Wilcoxon Rank Sum Test ◽  
Significant Difference ◽  
A Site

Introduction: Telemedicine (TM) is increasingly implemented in community hospitals acute ischemic stroke (AIS). The efficiency of TM to facilitate thrombectomy (IAT) is unknown. We addressed this question by studying our spoke hospitals which are staffed by both in-person (IP) consultation (Day: 8am-5pm) and TM (Night: 5pm-8am) to analyze differences between TM and IP and comparing to our university hub which has IP staffing day and night. Methods: We performed a retrospective analysis from 3/2016 to 3/2019 of all IAT cases directly admitted to 4 IAT capable centers (1 hub + 3 spokes) in our system. Demographic, clinical, and time metrics were analyzed. Primary outcome was door to groin (DTG) time. Continuous variables were analyzed with Wilcoxon rank sum test, and categorical variables with chi-square or Fischer’s exact test. Results: Table 1 summarizes the cohort. Eval to tPA (ETPA) time was faster at spokes vs hub (p < 0.0001), with no significant difference in DTG between spoke and hub (p= 0.444). At spokes, while DTPA times were no different between IP and TM at spokes, IP achieved faster DTG times (p<0.0001) (Fig.1A). DTG was equal during day vs. night at the hub. At the spokes, day (IP) DTG times were faster than night (TM) at some but not all spokes (Fig.1B). TPA administration did not delay DTG at either the hub or the spokes (Fig. 1C). At spokes, TM-TPA cases were associated with faster DTG than TM-noTPA (Fig. 1D). Conclusions: While no difference is noted between TM and IP in rapid TPA treatment, our data show delayed DTG at spokes during the TM day and night service. While DTG in TM was prolonged, differences in spoke metrics imply that availability of staff and resources play a significant role. Further analysis is needed to identify factors that prolong DTG at a site-specific level.

Abstract 3: Association of Video- vs. Text-Based Informed Consent With Multicenter Registry Enrollment

2018 ◽  
Vol 11 (suppl_1) ◽  
Author(s):  
Alexander C Fanaroff ◽  
Shuang Li ◽  
Vincent Miller ◽  
Laura Webb ◽  
Ann Marie Navar ◽  
...  
Keyword(s):  
Informed Consent ◽  
Management Practices ◽  
Categorical Variables ◽  
Rank Test ◽  
Continuous Variables ◽  
Chi Square ◽  
Lipid Management ◽  
Significant Difference ◽  
Activation Times ◽  
Multicenter Registry

Background: Low patient participation in clinical research undermines the generalizability of findings. Conducting informed consent by video rather than a traditional text format may enhance the appeal of research and break down barriers to participation. Methods: The Patient and Provider Assessment of Lipid Management (PALM) Registry enrolled patients at U.S. cardiology, endocrinology, and primary care clinics to evaluate cholesterol management practices. PALM investigators developed an iPad-based video informed consent tool that included video segments totaling 8 minutes which patients navigated though a “game-ified” interface. At sites whose IRB did not approve the video tool, participants read a 6-page text consent form on the iPad. Characteristics of sites and site activation times were compared between sites that did and did not use the video consent tool using Pearson’s chi-square test for categorical variables and Wilcoxon’s signed rank test for continuous variables. Results: Of 140 sites that enrolled 7904 patients in PALM, 60 (42.9%) used the video informed consent tool. Compared with sites using text consent, sites using the video consent tool were more often rural (16.7 vs. 3.8%, p = 0.01) and used a central IRB (91.7 vs. 80.0%, p = 0.06). Sites using video consent enrolled a greater proportion of patients who were ≥ 75 years old (27.5 vs. 23.6%, p < 0.001) or non-white (17.7 vs. 14.2%, p < 0.001). Sites using video consent had shorter times from site approach to first patient enrollment ( Figure ). Median (IQR) enrollment was 33 (12, 98) patients at sites using video consent versus 24 (12, 86) at sites using text consent only (p = 0.54); there was also no significant difference in median weekly enrollment rate (2.9 [1.1, 7.5] vs. 2.8 [1.3, 6.6], p = 0.73). Conclusions: In this early experience with video consent in a multicenter registry, availability of video informed consent was associated with greater enrollment of older and non-white patients, faster speed to first patient enrolled, and numerically but not significantly more rapid enrollment compared with text informed consent.

scholarly journals Evaluating the care provision of a community-based serious-illness care program via chart measures

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Christine E. Kistler ◽  
Matthew J. Van Dongen ◽  
Natalie C. Ernecoff ◽  
Timothy P. Daaleman ◽  
Laura C. Hanson
Keyword(s):  
Quality Of Care ◽  
Chart Review ◽  
Retrospective Chart Review ◽  
Care Program ◽  
Academic Community ◽  
Care Provision ◽  
Community Based ◽  
Serious Illness ◽  
Home Based

Abstract Background Although quality-of-care domains for home-based primary and palliative programs have been proposed, they have had limited testing in practice. Our aim was to evaluate the care provision in a community-based serious-illness care program, a combined home-based primary and palliative care model. Methods Retrospective chart review of patients in an academic community-based serious-illness care program in central North Carolina from August 2014 to March 2016 (n = 159). Chart review included demographics, health status, and operationalized measures of seven quality-of-care domains: medical assessment, care coordination, safety, quality of life, provider competency, goal attainment, and access. Results Patients were mostly women (56%) with an average age of 70 years. Patients were multi-morbid (53% ≥3 comorbidities), functionally impaired (45% had impairment in ≥2 activities of daily living) and 32% had dementia. During the study period, 31% of patients died. Chart review found high rates assessment of functional status (97%), falls (98%), and medication safety (96%). Rates of pain assessment (70%), advance directive discussions (65%), influenza vaccination (59%), and depression assessment (54% of those with a diagnosis of depression) were lower. Cognitive barriers, spiritual needs, and behavioral issues were assessed infrequently (35, 22, 21%, respectively). Conclusion This study is one of the first to operationalize and examine quality-of-care measures for a community-based serious-illness care program, an emerging model for vulnerable adults. Our operationalization should not constitute validation of these measures and revealed areas for improvement; however, the community-based serious-illness care program performed well in several key quality-of-care domains. Future work is needed to validate these measures.

scholarly journals A Retrospective Analysis of the Prevalence of Distribution of Oral Mucosal Lesions (OMLs) among the People Of Delhi NCR

2019 ◽  
Vol 3 (4) ◽  
pp. 154-158
Author(s):  
Simran Kaur ◽  
Aseem Singh ◽  
Rahul Singh
Keyword(s):  
Health Education ◽  
Descriptive Analysis ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Chi Square ◽  
The People ◽  
Significant Difference ◽  
Oral Mucosal Lesions ◽  
Study Population ◽  
Mucosal Lesions

INTRODUCTION: The presence of Oral Mucosal Lesions (OMLs) in one’s oral mucosa can lead to unwanted consequences and mostly are due to tobacco use. AIM: To  document the prevalence of OMLs among patients of Delhi NCR and provide health education counselling to those under the grip of this evil practice.  MATERIAL AND METHODS: We retrospectively analyzed the data of a total of 402 subjects visiting various screening camps in Delhi NCR and recalled a total of 174 patients, out of which 161 reported back to us for further diagnosis and screening of OMLs. The examination of patients in the camp were an ADA type III examination. All patients we given a health education while tobacco users were also given a specialized one-on-one health education regarding the tobacco and its ill effects as well as techniques for cessation. A descriptive analysis of the sample was first performed using means (±standard deviation (SD)) for continuous variables  and frequencies (proportions) for categorical variables. The chi-square test was used for statistical analysis and to find significant difference, if any. RESULTS: Among the 402 subjects screened, the mean age was 33.24±6.74 Years and most of the study population belonged to the age group of 25-60 Years [178(44.3%)]. 301(74.8%) of the study population were males. The main chief complaint was periodontal problem [187(46.5%)], while 15 patients (3.73%) came for regular check-up. The prevalence of leukoplakia was found to be 8.70% and OSMF was found to be 6.21%. A significant difference was seen among gingivitis with respect to age and gender (p<.05), leukoplakia and frictional keratosis was seen significant in relation to gender. In all significant cases, Males were more prone to get these OMLs as compared to females CONCLUSION: It is advised that regular Oral Health Drives and counselling sessions be arranged for the people of elhi NCR to reduce the burden of the OMLs.

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