Payer Coverage of Valley Fever Diagnostic Tests

Background The nonspecific symptoms of Valley fever, or coccidioidomycosis, hinders its proper diagnosis. This results in unnecessary health care costs and antibiotic usage. Thus, this study seeks to determine the coverage of the Valley fever diagnostic test as provided by Arizona insurance companies to increase early diagnosis rates. Methods Through scripted messaging and telephone communications, we contacted 40 health insurance companies in Arizona about their coverage of CPT 86635 (antibody diagnostic assay for Coccidioides) without prior authorization under all plan types provided in both primary and urgent care settings. If prior authorization was required, we discussed the coverage of ICD-10 codes J18.9 (pneumonia, unspecified organism), J18.1 (lobar pneumonia, unspecified organism), or L52 (erythema nodosum). Results Of the 40 health insurance companies contacted, 25 did not answer our inquiries, most requiring member-specific information to share coverage data. The remaining 15 companies covered Valley fever testing, of which 4 required prior authorization for the ICD-10 codes of interest. Of these 15 companies, 14 provided coverage in primary and urgent care settings, and 13 provided coverage for all available plans. Conclusion All payers that provided information covered Valley Fever testing. Most of the insurance companies that were unable to answer our inquiry likely cover Valley fever testing, but were unable to share information with third party inquiries. Obtaining general coverage information is difficult, which can potentially impact patient care.

Impact of Transitioning from In-Person to Virtual Heart Transplantation Selection Committee Meetings: An Observational Study (Preprint)

BACKGROUND Heart transplant selection committee meetings have transitioned from in-person to remote video meetings during the COVID-19 pandemic, but how this impacts committee members and patient outcomes is unknown. OBJECTIVE To determine perceived impact of remote video transplant selection meetings on usability and patient care and to measure patient selection outcomes during the transition period from in-person to virtual meetings. METHODS A 35-item anonymous survey was developed and distributed electronically to the heart transplant selection committee. We reviewed medical records to compare outcomes of patients presented at in-person meetings (January-March 2020) to those presented at video meetings (March-June 2020). RESULTS Among 83 committee members queried, 50 were regular attendees (48% physicians, 52% non-physicians), and 46 responses were received (50% physicians, 50% non-physicians) and included in the analysis. Overall, respondents were satisfied with the video conference format, felt that video meetings did not impact patient care and were an acceptable alternative to in-person meetings. However, 54% preferred in-person meetings, with 71% of non-physicians preferring in-person meetings compared to only 35% of physicians (P=.02). Of the 46 new patient evaluations presented, there was a statistically nonsignificant trend towards fewer patients initially declined at video meetings compared with in-person meetings (25% vs. 45%, P=.32). CONCLUSIONS The transition from in-person to video heart transplant selection committee meetings was well-received and did not appear to affect committee members’ perceived ability to deliver patient care. Patient selection outcomes were similar between meeting modalities.

812. The Impact of Post-Operative Cephalexin on Surgical Site (SSI) Infections During a Cefazolin Shortage

Background Drug shortages directly impact patient care. Rates of drug shortages have declined except for antimicrobials, where shortage rates remain similar each year.1 In November 2018, a national cefazolin shortage occurred driving health systems to implement a therapeutic interchange of cefazolin for cephalexin for post-operative antimicrobial prophylaxis. The objective of this study is to determine whether SSI-rates change when post-operative cephalexin is used in placed of cefazolin. Methods This was a retrospective, observational cohort study of patients receiving post-operative antimicrobial prophylaxis at a community-based health system in Oregon and Washington between May 2018 – August 2019. Participants were divided into 3 periods for SSI-rate trend analysis: pre-shortage (May 2018 – October 2018), shortage (November 2018 – February 2019), and post-shortage (March 2019 – August 2019). The primary outcome was SSI-rates between groups. Results There were 6,378 patients in total (5,840 cefazolin vs. 538 cephalexin). There were no significant differences in baseline characteristics of age, sex, body mass index (BMI), or hospital location. The rate of SSI between pre-shortage and post-shortage cefazolin groups was not statistically different (14 [0.5%] vs. 23 [0.8%]; p=0.16). The primary outcome of SSI in the shortage group who received cephalexin was not statistically different (37 [0.6%] vs. 0 [0%]; p=0.07). Conclusion National drug shortages significantly impact patient care, often leading to seeking evidence-poor alternative medications. These results suggest cephalexin may be an acceptable post-operative prophylaxis antimicrobial if cefazolin is unavailable. Disclosures All Authors: No reported disclosures

SP10.1.4 COVID as a driver of innovation: getting the right patient to the right place at the right time. A novel Registrar-led approach to minimising unnecessary footfall in the Surgical Assessment Unit of a District General Hospital

Aim To give shielding Registrars opportunities to innovate and lead service development through telephone triage of Surgical Assessment Unit (SAU) referrals from General Practitioners and Nurse Practitioners. Prior to the COVID pandemic, referrals were taken by Nurse Coordinators. Increasing call volumes put pressure on the department and disrupted clinical duties. Furthermore, referrers often expressed difficulties in contacting SAU staff. Methods During the study, referral calls were diverted for triage by the hospital switchboard. Three outcomes were offered: Clinical advice, ‘Hot Clinic’ (HC) appointment or urgent SAU review. Prospective referral data (15/6-31/7/2020) and retrospective non-triage data (15/6-1/7/2019) were gathered. Triage effects were measured by outcome comparison with non-triage data and the associated financial implications calculated. Stakeholder feedback questionnaires were distributed. Results Non-triage data showed 56% of patients reviewed in SAU were sent home and 44% admitted, compared to 23.6% and 28.1% of referrals during the 2020 study period. Furthermore, 28.4% of admissions were avoided by triage. Only 3.1% of triaged patients presented to Emergency Department within 7 days of the triage conversation. Almost half of these had been reviewed in SAU following triage and discharged the same day. HC availability was limited during the triage study. In view of reduced admissions and overall cost savings of £8330.62/week, expanding these clinics may prove cost neutral. Triage was universally popular with stakeholders. Data will inform future development of Urgent and Emergency Care at our hospital. Conclusions Traditional ways of working should be challenged. Novel approaches can be cost effective & positively impact patient care.

Survey of Nurses’ Experiences Applying The Joint Commission’s Medication Management Titration Standards

Background Critical care nurses titrate continuous infusions of medications to achieve clinical end points. In 2017, The Joint Commission (TJC) placed restrictions on titration practice, decreasing nurses’ autonomous decision-making. Objectives To describe the practice and perceptions of nurses regarding the 2017 TJC accreditation/regulatory standards for titration of continuous medication infusions. Methods A survey of nurses’ experiences titrating continuous medication infusions was developed, validated, and distributed electronically to members of the American Association of Critical-Care Nurses. Results The content validity index for the survey was 1.0 for relevance and 0.95 for clarity. A total of 781 nurses completed the survey; 625 (80%) perceived titration standards to cause delays in patient care, and 726 (93%) experienced moral distress (mean [SD], 4.97 [2.67]; scale, 0-10). Among respondents, 33% could not comply with titration orders, 68% reported suboptimal care resulting from pressure to comply with orders, 70% deviated from orders to meet patient needs, and 84% requested revised orders to ensure compliance. Suboptimal care and delays in care significantly and strongly (regression coefficients ≥0.69) predicted moral distress. Conclusions Critical care nurses perceive TJC medication titration standards to adversely impact patient care and contribute to moral distress. The improved 2020 updates to the standards do not address delays and inability to comply with orders, leading to moral distress. Advocacy is indicated in order to mitigate unintended consequences of TJC medication management titration standards.

A patient-oriented research approach to assessing patients’ and primary care physicians’ opinions on trauma-informed care

Objective To gather patients’ and primary care physicians’ (PCP) opinions on trauma-informed Care (TIC) and to investigate the acceptability of recommendations developed by patient, family, and physician advisors. Design Cross-sectional research survey design and patient engagement. Setting Canada, 2017 to 2019. Participants English-speaking adults and licensed PCPs residing in Canada. Main outcome measures Participants were given a series of questionnaires including a list of physician actions and a list of recommendations consistent with TIC. Results Patients and PCPs viewed TIC as important. Both patients and PCPs rated the following recommendations as helpful and likely to positively impact patient care: physician training, online trauma resource centres, information pamphlets, the ability to extend appointment times, and clinical pathways for responding to trauma. PCPs’ responses were significantly more positive than patients’ responses. Conclusion TIC is important to patients and PCPs. Patients and PCPs believe changes to physician training, patient engagement, and systemic factors would be helpful and likely to positively impact patient care. Future research needs to be conducted to investigate whether these recommendations improve patient care.

Application of Machine Learning in Pulmonary Function Assessment Where Are We Now and Where Are We Going?

Analysis of pulmonary function tests (PFTs) is an area where machine learning (ML) may benefit clinicians, researchers, and the patients. PFT measures spirometry, lung volumes, and carbon monoxide diffusion capacity of the lung (DLCO). The results are usually interpreted by the clinicians using discrete numeric data according to published guidelines. PFT interpretations by clinicians, however, are known to have inter-rater variability and the inaccuracy can impact patient care. This variability may be caused by unfamiliarity of the guidelines, lack of training, inadequate understanding of lung physiology, or simply mental lapses. A rules-based automated interpretation system can recapitulate expert’s pattern recognition capability and decrease errors. ML can also be used to analyze continuous data or the graphics, including the flow-volume loop, the DLCO and the nitrogen washout curves. These analyses can discover novel physiological biomarkers. In the era of wearables and telehealth, particularly with the COVID-19 pandemic restricting PFTs to be done in the clinical laboratories, ML can also be used to combine mobile spirometry results with an individual’s clinical profile to deliver precision medicine. There are, however, hurdles in the development and commercialization of the ML-assisted PFT interpretation programs, including the need for high quality representative data, the existence of different formats for data acquisition and sharing in PFT software by different vendors, and the need for collaboration amongst clinicians, biomedical engineers, and information technologists. Hurdles notwithstanding, the new developments would represent significant advances that could be the future of PFT, the oldest test still in use in clinical medicine.

Does simulation training in final year make new graduates feel more prepared for the realities of professional practice?

IntroductionThe transition from medical student to doctor has long been a source of concern, with widespread reporting of new graduates’ lack of preparedness for medical practice. Simulation has been suggested as a way to improve preparedness, particularly due to the difficulties in allowing full autonomy for patient care for undergraduate medical students. Few studies look at simulation alone for this purpose, and no studies have compared different simulation formats to assess their impact on preparedness.MethodsThis mixed-method study looked at two different simulation courses in two UK universities. Data were collected in two phases: immediately after the simulation and 3–4 months into the same students’ postgraduate training. Questionnaires provided quantitative data measuring preparedness and interviews provided a more in-depth analysis of experiential learning across final year and how this contributed to preparedness.ResultsThere were no significant differences between the two courses for overall preparedness, stress or views on simulation, and no significant differences in opinions longitudinally. Although the study initially set out to look at simulation alone, emergent qualitative findings emphasised experiential learning as key in both clinical and simulated settings. This inter-relationship between simulation and the student assistantship prepared students for practice. Longitudinally, the emphasis on experiential learning in simulation was maintained and participants demonstrated using skills they had practised in simulation in their daily practice as doctors. Nevertheless, there was evidence that although students felt prepared, they were still scared about facing certain scenarios as foundation doctors.DiscussionThe results of this study suggest that simulation may positively affect students’ preparedness for practice as doctors. Simulation will never be a replacement for real clinical experience. However, when used prior to and alongside clinical experience, it may have positive effects on new doctors’ confidence and competence, and, therefore, positively impact patient care.