Primary care clinicians’ opinions before and after implementation of cancer screening and prevention clinical decision support in a clinic cluster-randomized control trial: a survey research study

Background Electronic health record (EHR)-linked clinical decision support (CDS) may impact primary care clinicians’ (PCCs’) clinical care opinions. As part of a clinic cluster-randomized control trial (RCT) testing a cancer prevention and screening CDS system with patient and PCC printouts (with or without shared decision-making tools [SDMT]) for patients due for breast, cervical, colorectal, and lung cancer screening and/or human papillomavirus (HPV) vaccination compared to usual care (UC), we surveyed PCCs at study clinics pre- and post-CDS implementation. Our primary aim was to learn if PCCs' opinions changed over time within study arms. Secondary aims including examining whether PCCs' opinions in study arms differed both pre- and post-implementation, and gauging PCCs’ opinions on the CDS in the two intervention arms. Methods This study was conducted within a healthcare system serving an upper Midwestern population. We administered pre-implementation (11/2/2017–1/24/2018) and post-implementation (2/2/2020–4/9/2020) cross-sectional electronic surveys to PCCs practicing within a RCT arm: UC; CDS; or CDS + SDMT. Bivariate analyses compared responses between study arms at both time periods and longitudinally within study arms. Results Pre-implementation (53%, n = 166) and post-implementation (57%, n = 172) response rates were similar. No significant differences in PCC responses were seen between study arms on cancer prevention and screening questions pre-implementation, with few significant differences found between study arms post-implementation. However, significantly fewer intervention arm clinic PCCs reported being very comfortable with discussing breast cancer screening options with patients compared to UC post-implementation, as well as compared to the same intervention arms pre-implementation. Other significant differences were noted within arms longitudinally. For intervention arms, these differences related to CDS areas like EHR alerts, risk calculators, and ordering screening. Most intervention arm PCCs noted the CDS provided overdue screening alerts to which they were unaware. Few PCCs reported using the CDS, but most would recommend it to colleagues, expressed high CDS satisfaction rates, and thought patients liked the CDS’s information and utility. Conclusions While appreciated by PCCs with high satisfaction rates, the CDS may lower PCCs’ confidence regarding discussing patients’ breast cancer screening options and may be used irregularly. Future research will evaluate the impact of the CDS on cancer prevention and screening rates. Trial registration clinicaltrials.gov, NCT02986230, December 6, 2016.

Clinical Recommendations for Reducing the Risk of Cognitive Decline

As much as 40% of dementia cases can be attributed to modifiable risk factors (Livingston et al., 2020). Much of that risk-reduction can be accomplished by changing behavior in midlife. In light of the emerging evidence that dementia may be preventable, UsAgainstAlzheimer’s convened a workgroup of national experts to develop new recommendations that primary care clinicians and general neurologists can use to initiate primary prevention conversations with their patients about cognitive decline. Few resources address steps that clinicians can take in their routine care to help patients reduce risk. Some relevant resources provide excellent guidance but tend to be more focused on early detection or slowing disease progression rather than primary prevention. The Risk Reduction Workgroup (RRWG) was convened to help address the need for clinicians to know how to discuss cognitive decline with their patients. The workgroup aligned on 11 recommendations for primary care clinicians and general neurologists. In addition the RRWG provide considerations for implementing the recommendations in clinical practice. The recommendations are mindful of social determinants of health, account for cultural differences, and are designed for general accessibility. This effort is part of a broader initiative by UsAgainstAlzheimer’s to address risk-reduction for cognitive decline and early interventions. Under the guidance of a multidisciplinary Provider Leadership Group consisting of representatives from some of the nation's largest health provider serving organizations, three independent workgroups are developing guidance and tools to assist providers in their clinical practice and improve health outcomes for patients at-risk for Alzheimer's and related dementias.

Corneal Surgery in the Cat: Diseases, considerations and techniques

Practical relevance: The ability to recognize, diagnose and treat corneal disease is essential for maintaining vision and comfort in feline patients. Being able to correctly identify appropriate techniques for surgical cases is of particular importance for success when performing corneal surgery. Clinical challenges: Many different corneal diseases present with similar clinical signs, and it can be hard to determine the appropriate treatment for individual patients. It is essential for the clinician to understand the indications for corneal surgery, instrumentation needed and microsurgical principles prior to attempting these procedures. The prognosis following surgery and potential complications should be discussed with the client. Audience: This review article aims to assist in decision-making and to provide detailed guidance for primary care clinicians considering referral of cats for corneal surgery. The review outlines common feline corneal diseases and associated surgical therapies performed by veterinary ophthalmologists, highlighting appropriate instrumentation and case selection. Some surgeries are explained in depth for ophthalmologists and residents in training. Equipment: Although some procedures may be performed with common surgical equipment and supplies, most require specialized ophthalmic instrumentation and expertise, which entails significant microsurgical training and practice, as well as financial investment. Most of the procedures require an operating microscope for the best surgical outcomes; however, surgical loupes may be sufficient in some cases. Evidence base: This review article compiles information from many published references on feline corneal diseases and surgeries, complemented by the experience of the authors.

Exploring Primary Care Clinicians’ Views about How Best to Implement a Potential Trial around Point-of-Care Tests for Common Infections in South Africa

Optimisation of antibiotic prescribing is critical to combat antimicrobial resistance. Point-of-care tests (POCTs) for common infections could be a valuable tool to achieve this in primary care. Currently, their use has primarily been studied in high-income countries. Trials in low-and-middle-income countries face challenges unique to their setting. This study aims to explore the barriers and facilitators for a future trial of POCTs for common infections in South Africa. Twenty-three primary care clinicians in the Western Cape Metropole were interviewed. Interview transcripts were analysed using thematic analysis. We identified three key themes. These themes focused on clinicians’ views about proposed trial design and novel POCTs, clinicians’ perspectives about trial set-up, and specific trial procedures. Participants were overall positive about the proposed trial and POCTs. Potential issues centred around the limited space and technology available and participant retention to follow-up. Additionally, impact on clinic workload was an important consideration. These insights will be invaluable in informing the design of a feasibility trial of POCTs in this setting.

How opioid prescribing policies influence primary care clinicians’ treatment decisions and conversations with patients with chronic pain

Objective: The 2016 Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain aimed to assist primary care clinicians in safely and effectively prescribing opioids for chronic noncancer pain. Individual states, payers, and health systems issued similar policies imposing various regulations around opioid prescribing for patients with chronic pain. Experts argued that healthcare organizations and clinicians may be misapplying the federal guideline and subsequent opioid prescribing policies, leading to an inadequate pain management. The objective of this study was to understand how primary care clinicians involve opioid prescribing policies in their treatment decisions and in their conversations with patients with chronic pain.Design: We conducted a secondary qualitative analysis of data from 64 unique primary care visits and 87 post-visit interviews across 20 clinicians from three healthcare systems in the Midwestern United States. Using a multistep process and thematic analysis, we systematically analyzed data excerpts addressing opioid prescribing policies.Results: Opioid prescribing policies influenced clinicians’ treatment decisions to not initiate opioids, prescribe fewer opioids overall (theme #1), and begin tapering and discontinuation of opioids (theme #2) for most patients with chronic pain. Clinical precautions, described in the opioid prescribing policies to monitor use, were directly invoked during visits for patients with chronic pain (theme #3).Conclusions: Opioid prescribing policies have multidimensional influence on clinician treatment decisions for patients with chronic pain. Our findings may inform future studies to explore mechanisms for aligning pressures around opioid prescribing, stemming from various opioid prescribing policies, with the need to deliver individualized pain care.

955. Trends in Top COVID-19 Questions Among a National Audience of Primary Care Clinicians

Background As COVID-19 took the world by storm, primary care clinicians (PCCs) played a critical role in identification and management of this disease. Yet, knowledge around COVID-19 is constantly evolving, leaving clinicians with many unanswered questions. We sought to examine what questions PCCs had about COVID-19 and whether there were any trends over time. Methods We sought to examine what questions PCCs had about COVID-19 and whether there were any trends over time. We collected questions from PCCs during 4 live virtual 60-minute continuing medical education (CME) panel discussions on COVID-19 led by infectious disease experts from November 2020 to February 2021. Questions were independently sorted and analyzed by 2 MDs using constant-comparison and tie-break methodology. Results A total of 600 questions pertaining to COVID-19 were collected across 4 sessions. Top questions asked by PCCs ranked in descending order related to the following topics, with most common themes listed in parentheses: 1. Vaccines (efficacy, safety in pregnancy, indications/contraindications, timing of administration, side effects/adverse events) 2. Medication-Specific Treatment (monoclonal antibodies, ivermectin, steroids, convalescent plasma, supplements [vitamin D, zinc, vitamin c]) 3. Testing (false positive/false negatives, use in travel, quarantine, and gatherings) 4. Other Management (role of anticoagulation, use of chronic medications, guidelines) 5. Personal Protective Equipment (masks, eye protection, post-vaccination, use in travel). [Table 1] The percentage of questions around vaccination increased from 5% of total questions in October 2020 to 67% in February 2021. Questions related to Treatment declined from 20% to 6%, Testing declined from 21% to 3%, Other Management declined from 6% to 1% and PPE increased from 3% to 8% during this period. Table 1. Top 5 topics of questions listed in descending order of frequency across all 4 COVID-19 panel sessions. Table 2. Percentage of questions in the top 5 topics for each of the 4 COVID-19 panel sessions, with associated trendline. Conclusion PCCs nationally have gaps in knowledge around COVID-19 which can impact clinical decision-making. Based on our analysis of questions submitted by PCCs to infectious disease experts in a CME setting, the greatest gaps in knowledge were around vaccination, treatment, and testing with vaccination showing the greatest shift in interest over time. Disclosures All Authors: No reported disclosures