Death With Dignity: A Policy Analysis

Death with dignity is one of many titles attributed to the practice of providing a patient with terminal illness a means to die in light of extreme suffering as a result of a terminal illness. The purpose of the Oregon Death with Dignity Act is to provide individuals suffering from a terminal illness with the right to make a written request for life-ending medication to end their life in a “humane and dignified manner.” Deborah Stone’s policy goals of equity, efficiency, welfare, security, and liberty provides a framework to analyze whether a policy is doing what it says it wants to do. As such, the goal of this presentation is to apply the policy goals framework to determine if the Death with Dignity Act is accomplishing its stated goals. Applying a theory of the policy process, the Death with Dignity Act was analyzed using the most recently available data from the Oregon Health Authority. Results showed that since the Death with Dignity Act passed in 1997, 2,518 people have received prescriptions for life-ending medications, and of those, 1657 or 66% have used the medication to end their lives. Based on the data aggregated between 1997 and 2019, the Death with Dignity Act has mostly met its purpose of providing individuals with a terminal illness with the right to die on their own terms and with dignity. However, there are still several issues regarding equity, especially for low-income BIPOC populations. Implications for practice, policy and research are discussed.

Kristine M. Alpi, AHIP, FMLA, Medical Library Association President, 2021–2022

In this profile, Kristine M. Alpi, AHIP, FMLA, Medical Library Association (MLA) president, 2021–2022, is described as committed to public health, professional development, and the growth and evolution of MLA. She teaches and speaks on the shared health impact from interactions among animals, humans, and the environment, and she mentors graduate students and fellows in librarianship and informatics. Alpi earned her PhD in educational research and policy analysis in 2018 and directs the Oregon Health & Science University Library.

81. Reducing Unnecessary Blood Cultures Through Diagnostic Stewardship

Background At our institution, we learned the frequency of blood cultures was sometimes being changed from “Once” to “Daily” without a defined number of days. We hypothesized this led to unnecessary blood cultures being performed. Methods Over a 3 month period from 12/6/2019-3/6/2020, we retrospectively evaluated the charts of patients who had a blood culture frequency changed to “Daily”. We evaluated if there was an initial positive blood culture within 48 hours of the “Daily” order being placed and the number of positive, negative, or “contaminant” sets of cultures drawn with the order. Contaminant blood cultures were defined as a contaminant species, present only once in the repeat cultures, and not present in initial positive cultures. Results 95 unique orders were placed with 406 sets of cultures drawn from 89 adults. ~20% of the time (17 orders) the order was placed without an initial positive blood culture. This led to 62 sets of cultures being drawn, only 1 of which came back positive. 78/95 orders had an initial positive blood culture. The most common initial organisms were Staphylococcus aureus (SA) (38), Candida sp (10), Enterobacterales sp (10), and coagulase negative staphylococci (7). 43/78 (55%) orders with an initial positive set had positive repeat cultures. SA (26) and Candida sp (8) were most common to have positive repeats. Central line associated bloodstream infections (CLABSI) were found in 5 of the orders and contaminant species were found in 4 of the orders. 54% of the patients who had a “Daily” order placed did not have positive repeat cultures. The majority of the cultures were drawn from Surgical (40 orders) and Medical (35 orders) services. Assuming that SA and Candida sp require 48 hours of negative blood cultures to document clearance and other species require 24 hours, it was estimated that 51% of the cultures drawn using the "Daily" frequency were unnecessary. Cost savings over a year of removing the "Daily" frequency would be ~&14,000. Data from "Daily" blood culture orders drawn at Oregon Health & Science University from 12/6/2019-3/6/2020 Conclusion Unnecessary blood cultures are drawn when the frequency of blood cultures is changed to "Daily". Repeat blood cultures had the greatest utility in bloodstream infections due to SA or Candida sp, and with CLABSI where the line is still in place. These results led to a stewardship intervention to change blood culture ordering at our institution. Disclosures All Authors: No reported disclosures

Medicaid, Earnings, and Heterogeneous Treatment Effects: Evidence from the Oregon Health Insurance Experiment

The Medicaid and labor supply empirical literature offers competing conclusions of zero effects and significant reductions in earnings. However, zero effects are only theoretically consistent with the earnings distribution’s extremes. Medicaid participants with positive pre-treatment labor supply should unequivocally decrease earnings. This paper clarifies the literature’s ambiguity by combining quantile regression with data from the Oregon Health Insurance Experiment. The distributional impacts imply that zero effects are not universally representative of Medicaid households. The annual earnings impact of Medicaid participation ranges between increases of $1400 to deceases of $3120 for single adults. Pre-existing mental illness or health constraints on work account for counterintuitive positive earnings impacts. By demonstrating that sample compositional differences determine whether Medicaid’s labor supply impact is zero or negative, this paper offers a reconciliation to the range of existing estimates in the empirical literature.

Visualizing diversity: the Oregon Health & Science University Educational Use Photo Diversity Repository

Background: Health science education needs images that represent both the diversity of patients served and the diversity of its students and clinicians. To begin to address this need, a nurse educator and librarian collaborated to launch the Oregon Health & Science University (OHSU) Educational Use Photo Diversity Repository. This online resource provides educators of health professional students with access to photos of pathophysiological conditions in skin of various colors so their students can increase their awareness of issues related to health and diversity and prepare themselves for more effective clinical work with their future patients.Case Presentation: The OHSU Educational Use Photo Diversity Repository became a university-wide project, leveraging the thoughts of an image advisory board, clinicians, faculty members, administrators, and students. Key considerations were given to the workflows used to submit photos as well as the controlled vocabulary for submitting images. The repository was started with photos already in existence, with future plans to have images taken specifically for the repository.Conclusions: This repository is playing an important role as OHSU and the health sciences in general reflect on the role of systemic racism in health care and clinical education. Negotiating issues of consent, patient health information, and privacy around using different technologies to take photos is a complex and ongoing process. The repository provides opportunities for closely examining these processes and creating improvements that result in more equitable education.

Reconciling Seemingly Contradictory Results from the Oregon Health Insurance Experiment and the Massachusetts Health Reform

A headline result from the Oregon Health Insurance Experiment is that emergency room (ER) utilization increased. A seemingly contradictory result from the Massachusetts health reform is that ER utilization decreased. I reconcile both results by identifying treatment effect heterogeneity within the Oregon experiment and extrapolating it to Massachusetts. Even though Oregon compliers increased their ER utilization, they were adversely selected relative to Oregon never takers, who would have decreased their ER utilization. Massachusetts expanded coverage from a higher level to healthier compliers. Therefore, Massachusetts compliers are comparable to a subset of Oregon never takers, which can reconcile the results.

Clinical features and complications of acromegaly at diagnosis are not all the same: data from two large referral centers

Purpose: The number of international acromegaly-related registries is increasing; however, heterogeneity of acromegaly symptoms and signs across countries is not well described. We compared clinical disease manifestations at diagnosis between two large University referral centers from two continents. Methods: Retrospective, comparative epidemiological study of acromegaly patients at two centers; 1) C. I. Parhon National Institute of Endocrinology, “Carol Davila” University of Medicine and Pharmacy Bucharest, Romania (Parhon), and 2) Pituitary Center, Oregon Health & Science University, Portland, Oregon, United States (OHSU) from approved registries was undertaken. Data were extracted from medical charts and questionnaires. Binary logistic regression analysis was undertaken for the most frequently noted symptoms and clinical signs. Results: Study included 216 patients (87 Parhon, 129 OHSU). Age, sex and median delay in diagnosis were similar between centers. IGF-1 index was higher in patients at Parhon (3.3 vs 2.1, p < 0.001). The top five symptoms at both centers were; enlarged hands/feet, headache, arthralgia, fatigue, and irregular menses in women. A significant difference was noted for multiple signs and symptoms frequency, often >20 percentage points between centers. Center was a predictor of many signs and symptoms, independent of acromegaly biochemical severity or disease duration. Conclusion: We show in the first comparative study that differences in medical practice, documentation, and likely cultural differences can influence patients’ symptom(s) reporting and screening patterns in geographically different populations. Pooling data into large multicenter international registries databases may lead to loss of regional characteristics and thus a mixed overall picture of combined cohorts.