ID: 212302 Prevalence of False Negative Results for Morphine in Oral Fluid Toxicology Compared With Urine Toxicology

Introduction: Urine drug testing has been the standard for monitoring opioid compliance in chronic pain patients. The COVID-19 pandemic created a dilemma for opioid monitoring by severely limiting in-person testing due to safety concerns. Oral fluid toxicology emerged as a feasible, alternative test due to its ability for remote sample collection under virtual supervision while minimizing infringements on patient privacy. However, the efficacy of these two tests for reliably detecting opioids should be explored prior to transitioning to testing only with oral fluids. Method(s): In this study, we compared morphine levels in oral fluid and urine toxicology studies from 5 randomly selected patients from a Chronic Pain Center who were regularly taking high doses (>=90 mEq) of extended-release morphine. Charts from the start of the COVID-19 pandemic until July 2022 were reviewed for urine and oral fluid testing results and medication regimens. All oral fluid and urine test results and collection methods were validated by a nationally recognized toxicology lab. Prescription Monitoring Program (PMP) reports were reviewed for each patient to observe pre-testing prescription trends. Result(s): We found that the overwhelming majority of patients had at least 1 false negative oral fluid test result. The remainder of the oral fluid results were below threshold (10 ng/mL) or ranged from 11.3 to 54 ng/mL of morphine. 80% of patients (n = 5) had at least one negative or positive-but-below-threshold (10 ng/mL) result in their oral fluid sample analyses. In contrast, none of the urine studies had negative results. Urine studies for all patients were positive for morphine and well-above primary cutoff values (100 ng/mL) with levels >6000 ng/mL. PMP reports did not reveal any aberrant drug taking behavior in any of the patients. No unprescribed medications or illicit substances were detected in any of the oral or urine samples. Conclusion(s): The prevalence of false negative results for the detection of morphine metabolites in oral fluid toxicology may be higher than clinicians are currently aware of. Physicians and other providers monitoring opioid compliance in chronic pain patients should keep this possibility in mind when selecting toxicology tests and making conclusions about aberrant drug-taking behavior. Larger scale studies are needed to compare oral fluid and urine levels of morphine with extension to other commonly prescribed opioids. Disclosure: Evan Chung, MD: None, Joseph Valenza, MD: NoneCopyright © 2023

Implementation and Outcomes of an Advanced Nurse Practitioner Telephone Chest Pain Clinic Developed in Response to the COVID-19 Pandemic.

Introduction: During the COVID-19 pandemic, a virtual telephone advanced nurse practitioner (ANP) led chest pain clinic was set up because face-to-face clinic visits had ceased. Methods: This retrospective cohort analysis compared the ANP virtual chest pain clinic to the face-to-face nurse specialist-led clinic. Results: Autonomous nursing management was significantly higher in the virtual clinic, and significantly fewer patients were referred for functional testing. Coronary arterial disease (CAD) diagnosis did not differ. Conclusion: ANP autonomy and experience enabled continued chest pain assessment and CAD diagnosis via a virtual telephone clinic.

Feasibility, diagnostic performance and clinical value of an abbreviated echocardiography protocol in an out-patient cardiovascular setting: a pilot study.

BACKGROUND: There has been a growing demand for echocardiography services over the last 5 years, with this supply-demand mismatch exacerbated by the COVID-19 pandemic. Prior studies have suggested a high proportion of normal findings among echocardiograms requested for patients without known cardiovascular disease, particularly in low-risk cohorts. This pilot study investigates the role of an abbreviated echocardiography protocol in improving access to echocardiography services in a low-risk outpatient setting within the rapid access chest pain (RACP) clinic. METHOD: A retrospective review of electronic medical records and transthoracic echocardiography (TTE) studies for 212 patients from RACP clinic in 2019 (cohort A), prior to the introduction of the abbreviated echocardiography protocol, and 175 patients seen in the RACP clinic in 2021 (cohort B) was performed. The outcomes measured include the echocardiography referral burden from RACP clinic, waiting time for a TTE and echocardiography findings. RESULTS: 33% and 45% of patients seen in the RACP clinic in 2019 and 2021, respectively, were referred for a TTE. The most common indications include chest pain (50%), dyspnoea (19%) and palpitations (11%). Abnormal findings were identified in 36% of TTEs performed in cohort A and 13% in cohort B. The median echocardiogram study time was significantly shorter in cohort B (7 min vs 13 min, p < 0.00001), with a lower number of images acquired (43 vs. 62, p < 0.00001). The median waiting time for an echocardiography in cohort B was significantly shorter (median: 14 days vs. 42 days in 2019, p < 0.00001). No major pathologies were missed on a retrospective review of these images. CONCLUSION: Our study demonstrates that an abbreviated echocardiography protocol has potential to improve access to echocardiography services through increasing scheduling capacity, without compromising diagnostic performance in a low-risk outpatient population.

Access to pain medicines and follow-up consultation after radiofrequency ablation for trigeminal neuralgia during the COVID-19 pandemic.

Background: In the recent coronavirus disease 2019 (COVID-19) pandemic, follow-up of patients with trigeminal neuralgia post radio-frequency ablation (RFA) of the Gasserian ganglion was restricted because of closure of pain clinic services (PCSs) at our institution, travel restrictions, and fear of contracting COVID-19 infection by hospital visit. Periodic follow-ups are a must in this group of patients. Because the access to pain medications and consultations remained restricted, we tried identifying the factors predisposing to these difficulties in patients. Methods: We had contacted patients telephonically, who underwent RFA at our institution in the past 5 years as the PCS had not re-started to follow up with in-person consultation. Demographics, socio-economic factors, clinical factors, literacy status, distance to the health care system, and current health status were noted. Collected data were analyzed descriptively, and correlations were calculated between the predictors for difficulty in follow-up to access the medications and consultations. Results: Out of 121 patients who underwent RFA in the past 5 years, 73 were accessible on phone. Of these, 42.46% (31/73) patients had difficulty in accessing either medications or consultation. The literacy status of the patient was the strongest predictor (0.044) with a negative correlation (-1.216). Difficulty in accessing PCS was associated with a poor health status (p-0.032) and higher pain scores (0.066). Conclusion: Along with the clinical factors, we have to overlook other factors in predicting difficulty to access PCS in trigeminal neuralgia patients post the RFA status. Difficulty in access to pain medicines and/or consultations was associated with a poor health status and higher pain scores.

Challenges of Conducting Osteoarthritis Quality Improvement Project in an Integrative Clinic During COVID-19

Methods: Patients with OA were identified through EPIC. Those that had a treatment scheduled in the Comprehensive Pain Center at Oregon Health & Science University were contacted and baseline patient reported outcomes (PRO) were obtained. The PRO tools included the Hip dysfunction and Osteoarthritis Outcome Score (HOOS), Knee dysfunction and Osteoarthritis Outcome Score (KOOS), Brief Pain Inventory (BPI) and PROMIS Global 10. The PRO were gathered at return visits for one year. Common treatment pathways were assessed using change scores. The OHSU IRB determined that the project did not need IRB oversite due to its QI nature. Results: Due to COVID-19 related changes in treatment patterns and safety precautions-virtual visits for MDs and psychologists, interruptions for acupuncture, chiropractic, massage and Rolfing -PROtools could not be handed to patients prior to visits. A multipronged approach to data gathering was implemented, including telephone and iPad accessed questionnaires. iPads required QR-code generation for participant identification. As of 10/15/2021, 51 patients provide 160 questionnaires. Average age of participants was 62.1 (8.85). Initial PROMIS GLOBAL physical score was 8.7 (SD 0.9) and mental was 10.0 (SD 0.33). Our original proposal estimated that we would have 125 individuals at this point in the project. We will discuss changes in methodology in response to COVID-19. Background: Implementation of a quality improvement (QI) project to understand treatment pathways of osteoarthritis patients (OA) in an integrativemedicine clinic. As the majority of visits shifted to virtual, we had to pivot our project. Conclusion: While COVID-19 created significant barriers to health care, it also created new patterns of utilization in patients with OA. Due to these changes, the methodology of conducting a QI project also had to change. While there were significant obstacles, our QI project was able to continue and new treatment patterns have emerged.

The impact of breast care nurse triage of referrals to one-stop clinic on detection of breast cancer

Introduction: To minimise footfall during COVID pandemic, breast care nurse (BCN) led triage of the referral letters was used in our department. Based on the referral history, the nurse would triage patients to be seen in the one-stop clinic, consultant telephone consultation or telephone BCN-led pain clinic. The study aimed to assess the effect of BCN-led triage on detection of cancer and number of patients seen in the clinic. Methods: A retrospective observational analysis was conducted for all referrals to one-stop clinic at breast unit in Broomfield Hospital from 1st-30th July 2020. Results: Of the total number of patients (n=225) triaged by the BCN, majority were females (M:F 2:223) having a mean age of 55.1 years (14-90). Most patients presented with a breast lump (152/225). 12% (n=27/225) of the patients were diagnosed with cancer. The average number of cancers identified per week were 4.4 (3-6) with the BCN identifying 67.5% (n=27/40) of them. The mean time to referral to initial decision was 2.6 days (0-14) with BCN-led triage compared to routine referral route (10.7 days [1-23]). 27 patients (12%) were triaged to telephone breast pain clinic. 1 patient re-attended the clinic after being discharged from pain clinic with persistent pain but not diagnosed with cancer. Conclusion: BCN-led triage had a higher rate of breast cancer detection and less time taken from referral to decision for breast patients. The BCN-led pain clinic reduced the number of patients seen in the one-stop clinic without missing any cancer diagnosis.

A nurse led telephone clinic is a safe and effective service for assessment of patients with breast pain

Introduction: Breast pain as an isolated symptom, with a normal clinical examination, is rarely associated with sinister pathology. In our service we manage these patients out with the one stop clinic (OSC), as most do not require breast imaging and / or biopsy. COVID19 has forced reduction in face-to-face outpatient appointments. We developed an advanced nurse practitioner-led telephone clinic (TC) to manage patients referred with breast pain. Here we describe the outcomes of this service. Methods: Retrospective single centre review of breast pain TC January - October 2021. Electronic patient records for all appointments were reviewed. Attendance, referral information, previous breast history, re-referrals to service and clinic outcomes were recorded. Data was compared with the same clinic performed in person, prior to COVID19. Results: 208 patients were assessed. A proportion were previous breast cancer patients (28/208, 13.5%). 18/208 (8.7%) required assessment in OSC after TC, because of patient concern about a lump. None were diagnosed with cancer. This is a higher proportion of patients needing OSC assessment after an in person pain clinic assessment (2/210, 1%), but remains low. 11/208 (5.3%) patients were re-referred from primary care following discharge from TC, comparable to in person pain clinic (11/210, 5%). Conclusion: TC is a valid way to manage patients referred with breast pain as an isolated symptom. There is a low incidence of cancer in this cohort and no need for OSC assessment. Most patients are reassured and discharged following a normal clinical examination in primary care and TC assessment.

Exploring the digital divide in telehealth adoption among pediatric pain patients in a children's hospital

Introduction: Telehealth provides an opportunity to deliver health care by reducing physical barriers. Although the adoption of telehealth has increased, the COVID-19 pandemic expedited the expansion and support for telehealth due to a need for social distancing and changes to reimbursement. While telehealth can bridge gaps in care, the rapid adoption of telehealth technology may lead to an increased digital divide, whereby technology can exacerbate existing health disparities. Understanding the impact of telehealth on health disparities is an important component toward achieving health equity. The goal of our study was to describe telehealth utilization among a pediatric pain clinic population and understand if patient demographic factors were associated with differences in telehealth utilization. Methods: Following IRB approval, we conducted a retrospective study of all pediatric pain clinic patients seen by telehealth at the Children's Hospital Los Angeles from 4/2020 to 5/2021. Patient demographic details and telehealth utilization data were ed from electronic health records. The primary outcome was telehealth appointment no-show or cancellation within 24 hours. Statistical analysis was conducted using SAS. Results: Our study included 550 patients, with 241 (43.8%) patients seen as new patient visits and 309 (56.2%) having their follow-up visits during the study time period. The median age was 15-years old. The most frequent self-reported race was White (24.6%), followed by Black (6.4%), and Asian (2.8%), with reports of Other (51.8%) and Unknown (14.2%). Our cohort self-reported their ethnicity as Hispanic (38.3%), Non-Hispanic (29.3%), with a group of Unknown (32.4%). The most common self-reported language was English (85.8%), followed by Spanish (14.0%). Most patients had government insurance (61.6%) versus commercial (38.4%). For all appointments, 14.9% were cancelled <24 hours/no-show, whereas new appointments had 21.2% of patients cancelled/no-show and follow-up appointments were cancelled/no-show in 10.0% of appointments. Among new patient visits, ethnicity and government insurance status were statistically associated with being cancelled <24 hours from appointment, or no-shows (p<0.05). Among new patient visits, those who identified as “Other” were more than twice as likely to cancel/no-show than those who identify as White. Discussion: In our study of pediatric pain clinic patients, ethnicity and insurance status were significantly associated with patients who had cancellations and no-shows for telehealth appointments. These factors may represent barriers related to the utilization of telehealth and are opportunities to further study how to reduce the digital divide and work toward health equity. We also found there were a large number of patients who self-identified their race as “Other” or “Unknown.” Improving the accurate collection of demographic data remains an important foundation toward identifying and reducing disparities in health and health care.

SPATIAL ANALYSIS OF TELEHEALTH UTILIZATION IN A PEDIATRIC PAIN CLINIC

Introduction: Social determinants of health (SDOH) have a significant impact on access to health. Low socioeconomic status (SES) has been associated with delayed care and missed appointments. Telehealth services provides an opportunity to deliver health care by reducing physical barriers. During the COVID-19 pandemic, telehealth services were expanded by many health systems to continue providing socially distant care. While telehealth has the potential to bridge physical gaps in care, technology can be an additional barrier to accessing care and exacerbate existing health disparities. Understanding the impact of telehealth in the context of SDOH risk factors may be an important component toward studying and achieving health equity. Unfortunately, there is a limited amount of SES factors available to study in the electronic health record (EHR). The goal of our study was to use an innovative method to better understand the SES and location risk factors that are associated with the utilization of telehealth services in a pediatric pain clinic at an academic children's hospital. Methods: Following IRB approval, we conducted a retrospective study of all pediatric pain clinic patients seen by telehealth at a freestanding academic children's hospital from 4/2020 to 5/2021. Patient demographic details and telehealth utilization data were ed from the EHR and the enterprise data lake. Administrative outcomes of interest were telehealth appointment no-show or cancellations within 24 hours. Patient EHR addresses were geocoded and geospatial analytic techniques, including spatial linkage of EHR data with US Census-American Community Survey 2019 Data (5-Year) was conducted. Analysis was at the patient-level and neighborhood block-group level for SDOH measures. Specific neighborhood level measures used included the percent of households that have no computer. Analysis was conducted utilizing SAS, R, and ArcGIS Pro. Results: Our study included 550 pediatric pain patients, and all were successfully geocoded at the street level address. There were 309 patients (56.2%) who had their initial follow-up appointment using telehealth and 241 (43.8%) who were seen as a new patient visit. Most patients had government insurance (61.6%) as compared to commercial (38.4%). Overall, 14.9% of appointments were cancelled <24 hours or did not show up for their telehealth appointment. New appointments were more likely to be cancelled <24 hours or not show up (21.2%) as compared to follow-up appointments where 10% were cancelled/no show. A large percentage of patients self-reported their race as “Other” (51.8%) or were unknown (14.2%). Patient residential addresses came from a variety of locations in the state of California with a small number of patients from Nevada and Arizona. Patients who cancelled <24 hours or did not show up were more likely to come from neighborhoods (defined as Census Block Groups) of lower socioeconomic status. In addition, census block groups that had more “households with no computers” were more likely to cancel/no show for their telehealth appointment. Digital maps demonstrating geographic variation and disparities in access to telehealth utilization were created for exploration and descriptive purposes. Discussion: We successfully identified patient level and neighborhood level socioeconomic risk factors that are associated with cancelling (<24 hours) or not showing up for their telehealth appointment. Leveraging EHR data with geospatial analytics can augment our understanding of the SDOH that may impact the delivery of telehealth services in a pediatric population. Future steps include using these spatial risk factors to risk stratify and improve care delivery pathways to reduce disparities in telehealth utilization. (Figure Presented).

COVID 19: The New Normal in the Clinic: Overcoming Challenges in Palliative Care.

BACKGROUND AND AIM: In the wave of COVID-19 pandemic, the whole world has come to a standstill. This led to a major setback for cancer patients jeopardizing their treatment plans. This study analyzes the coping mechanisms of running outpatient and inpatient palliative care services in these COVID-19 times - the New Normal. MATERIALS AND METHODS: An observational study was conducted in the pain and palliative care unit at a tertiary care hospital, India. The data were collected from March 23, 2020, to May 22, 2020, of all patients coming to the clinic and inpatient referrals. Using manual and electronic records, demographic data was collected along with clinical data. Additional data were compiled with special attention to the patient's pain and its management. RESULTS: Despite complete lockdown and initial low patient load, we saw a progressive increase in the number of patients coming to the clinic. A total of 108 patients visited our clinic (65 male and 43 female), of which 78% of the patients were from Delhi. The median age was 43.94 years (range 6 years to 76 years). We had 33 new and 75 old registered cases coming. The main reason was new-onset pain because of noncompliance of drugs; the opioid stock finished with the patient. We saw a very high number of patients requiring strong and weak opioids. Proper personal protection and social distancing helped in preventing crossinfection. None of our staff or patients fell ill during this time. Communication skills were modified to convey feelings and empathize patients. Telemedicine using phone and video calls was used and found to be useful. CONCLUSION: We share our experience and challenges of providing palliative care in our clinic which can be modified as per the individual requirements in other setups.

Implementation of a remote rapid access chest pain service during the COVID-19 pandemic

Background: Rapid Access Chest Pain Clinic (RACPC) is a vital service in many hospitals in the UK, providing early specialist input for patients with suspected coronary artery disease referred via the Emergency Department (ED) or primary care (1). When the COVID-19 pandemic forced hospitals to refine their outpatient systems (2), our Trust continued the RACPC service remotely via telephone consultations. Purpose: To examine the long-term viability of this service, we designed a study to compare the outcomes of patients seen remotely during the pandemic to patients seen face to face. Methods: We performed a retrospective cohort study. The remote group (n=217) were patients seen over 4 weeks in April 2020, all having telephone consultations. The control group (n=368) were patients assessed face to face in the same 4-week period in 2019. Outcomes being analysed included: mode of investigation;interventions performed;and a 12 month combined safety endpoint of ED attendance with chest pain, re-referral to cardiology and hospitalisation for cardiac issue. Subgroup analysis was performed based on typicality of symptoms defined by NICE (3). Results: Baseline characteristics were similar between groups. In both 2019 and 2020, the largest subgroup of patients were those with nonanginal chest pain (64%, 71%). There were significant differences in investigation and management between the two cohorts (Figure 1). In 2020, a higher proportion of patients were discharged with no investigation (57% vs 23%, p<0.0001). This was driven primarily by changes in management of patients with non-anginal chest pain. There were significantly higher rates of investigation of this subgroup in 2019 by either CT Coronary Angiography (25% versus 4.5%, p<0.001) or functional testing (25% versus 6.5%, p<0.001), with a much higher rate of reassurance and discharge in 2020 (81% versus 36%, p<0.0001). More patients received coronary intervention in 2019 than in 2020 (2.4% vs 0%, p=0.02). In 2020, higher proportions of patients were commenced on medical therapy without further investigation when presenting with atypical (28% versus 1%, p<0.0001) or typical angina (63% versus 11.4%, p<0.0001) (Figure 2). There was no significant difference in the 12 month combined safety endpoint (1.3% in 2019 versus 2.3% in 2020, p=0.39), and no reported cardiac deaths. Conclusions: During the pandemic, as expected, fewer patients were investigated for coronary artery disease, with the preference being to commence medical therapy initially. This did not have a significant effect on safety endpoints. Importantly, clinicians felt comfortable with assessing and discharging patients with non-anginal chest pain remotely in 2020. This is key to the viability of a remote RACPC model, as this subgroup forms the majority of the referrals. We suggest that RACPC is appropriate for a remote model in the long term, in view of the relatively low-risk population and clear management guidelines.

An Exploration of the help-seeking experiences of patients in an allied professions-led rapid access chest pain pathway: a qualitative study.

OBJECTIVE: A number of studies have explored delayed help-seeking practices for acute coronary syndrome (ACS) and have indentified multiple intersecting factors which may play a role, for example, attributing symptoms, age, gender, ethnicity and contextual influences. However, the pathway to diagnosis for suspected coronary heart disease (CHD) symptoms in a rapid access chest pain clinic (RACPC) context is underexplored. The objective of this study was to examine patients' help-seeking experiences of accessing RACPC services, from the point at which they notice and interpret symptoms, to their decision to seek help from their general practitioner. DESIGN: Qualitative study. SETTING: Interviews were conducted in the RACPC at Queen Mary's Roehampton Hospital, London, UK. PARTICIPANTS: Maximum variation sampling was used to recruit 30 participants (15 men and 15 women) referred to a RACPC, using sampling dimensions of age, ethnicity and occupation. METHODS: Semi-structured interviews focussed on the patient experience of their pathway to the RACPC. Thematic analysis was used to analyse the interview data. RESULTS: Participant interpretation of symptoms was shaped by multiple influences; reluctance to seek help contributed to delay; various factors acted as drivers as well as barriers to help-seeking; and GP referrals to RACPC were based on symptoms as well as patients' need for reassurance. CONCLUSION: We found complex issues shaped the patient's decision-making when accessing the RACPC, including making sense of symptoms and help-seeking practices. These findings can be used to develop health promotion literature to encourage early help-seeking and improve RACPC services.