Vitamin D Level Testing in an Urban Midwest Clinic: To Test or Not to Test?

Vitamin D deficiency (VDD) is significantly higher among urban populations in the U.S. Midwest, with African Americans being disproportionately affected. There is ongoing debate surrounding who and how often individuals should be screened for VDD. This study aimed to understand the prevalence of VDD, associated risk factors, and discrepancies in testing at an urban-based internal medicine residency clinic. Data were retrospectively collected on all adult patients seen by the clinic during 2018 and descriptive statistical analysis performed. Among 3976 total patients (mean age: 53 years), 18% (n=698) had vitamin D levels analyzed, with deficiency found in 71% of those tested. Mean age of the tested cohort was 59 years, and women (68%) and African Americans (72%) were found more likely to be tested. Women and patients with certain medical conditions were more likely to be tested (P<0.02 for all) but were not more likely to have VDD. Individuals with a diagnosis of chronic kidney disease were less likely to have VDD (P=0.002). Vitamin D levels typically showed improvement after retesting. A low testing rate could contribute to missed diagnoses. Overall, this study revealed that differences in rate of testing do not necessarily correlate to patients' demographical risk of VDD. Clinicians may benefit from a standardized vitamin D testing protocol.

Prevalence of high-risk medications in patients enrolled in the Hospital Elder Life Program.

OBJECTIVE: The study aimed to assess the prevalence of newly prescribed antipsychotic/benzodiazepine medication, as well as 30-day readmissions, among Hospital Elder Life Program (HELP)-enrolled patients. DESIGN: Retrospective case-control study. SETTING: HELP intervention took place in eight hospital units. The standard care group was selected from eight additional hospital units. PARTICIPANTS: Hospitalized patients, aged 65 years and older, enrolled in HELP during between January 1, 2017 to December 31, 2018 were included in the HELP cohort. Patients hospitalized in eight additional units during the same time frame were part of the standard care group. MEASUREMENTS: Antipsychotic/benzodiazepine medications were pulled from the electronic health record. History of chronic mental illnesses were classified by ICD10 codes. Basic descriptive statistics were used to analyze patient characteristics and comorbidities. Chi-squared and t-tests were performed to detect statistical differences as appropriate. RESULTS: There were 1411 patients in the HELP group and 10,807 patients in the standard care group. The HELP group was likely to be older, female and to have a shorten length of stay (all p ≤ 0.02). Our study demonstrated that approximately 8.9% (n = 125) of patients enrolled in HELP received an order for antipsychotics during their hospital admission, while 31.5% (n = 3400) from the standard care group (p < 0.001). The difference in benzodiazepine prescription in patients enrolled in HELP was also less when comparing the two groups (22.8% HELP vs 25.6% standard care; p = 0.02). CONCLUSIONS: Patients enrolled in the HELP group were less likely to receive a prescription for antipsychotics or benzodiazepines. The majority of patients enrolled in HELP were discharged to a more independent environment (home or assisted living) and there was a relatively low 30-day readmission rate among HELP patients.

Evaluation of opioid disposal process for home hospice patients.

Context: Considering the national opioid epidemic and its impact on thousands of lives, the importance of appropriate management of controlled substances in the home hospice setting is paramount. Family members tend to be the primary caregivers for home hospice patients, and hospice nurses are the front line for providing education on opioid disposal. As such, the importance of effective and consistent education is essential in minimizing the risks of misuse and diversion. Objectives: To evaluate the use of a standardized opioid disposal policy through the implementation of three steps: (1) opioid education at enrollment in hospice program; (2) the use of the Medication Diversion or Misuse checklist; and (3) a review of the standards for safe opioid disposal. We also evaluated the current knowledge and understanding of the standard processes of opioid education and disposal among home hospice nurses. Study Design: Mixed methods. Setting or Dataset: Retrospective data and survey data, Milwaukee, WI; 07-12/2019. Population Study: Home hospice patients, home hospice registered nurses. Outcome Measures: The fidelity of our institution's opioid medication disposal policy and knowledge of the policy. Basic descriptive statistics were used to describe the patients and survey responses. Results: A total of 160 patients met inclusion criteria. We found that 108 (67.9%) patients/families received education on admission, 11 (6.9%) families received education on opioid disposal at the time of death, and 152 (95.6%) of families had an opioid disposal discussion at the death certification visit. Of the 16 nursing survey respondents, only 3 (18.8%) consistently provided all of the necessary education to new patients. However, when education is provided, 14 (87.5%) respondents did provide all the appropriate instructions regarding dosing, administration, side effects, and storage. On death calls/visits, 13 (81.2%) reported consistently providing the appropriate education regarding opioid disposal. Conclusion: Our results suggests that nursing staff do provide the appropriate education regarding the use and administration of opioids, as well as appropriate disposal practices, but do not do so consistently. The project highlighted the importance of continued nursing education regarding safe opioid use, disposal, and awareness of drug diversions.

Enhancing Immunization Rates in Two Urban Academic Primary Care Clinics: A Before and After Assessment.

PURPOSE: Immunization rates in many cities in the United States remain suboptimal compared to Healthy People 2020 Goals and are lower than national averages. This study aimed to determine whether a lecture-based educational intervention targeted at nurses and medical assistants would improve vaccination rates. METHODS: We conducted a quality improvement study in two urban academic family medicine clinics serving a predominantly Medicaid patient population as well as a sizable proportion of refugees. The intervention consisted of 3 lectures that were delivered to clinic nurses and medical assistants. Vaccinations in 1689 patients - 872 in the 3-month preintervention period, 817 in the 3-month postintervention period - were analyzed. RESULTS: Following the educational intervention, a statistically significant increase was seen only in human papillomavirus vaccine immunization rates for 13-18-year-olds (from 90.7% [n=54] to 100% [n=45]; P=0.036). When the results were stratified by clinic, only 1 site showed statistically significant increases in: pneumococcal polysaccharide vaccine (23-valent) for high-risk 19-to-64-year-olds (from 36.4% [n=154] to 47.8% [n=136]; P=0.049); Haemophilus influenzae type B vaccine for 2-month-to-5-year-olds (from 91.1% [n=112] to 97.3% [n=111]; P=0.048); and meningococcal conjugate vaccine (quadrivalent) for 13-18-year olds (from 85.2% [n=27] to 100% [n=26]; P=0.042). No increases were seen for our study's refugee patient population (n=171), and a significant decrease of the second-dose measles, mumps, and rubella vaccine (P=0.036) occurred in this subcohort. CONCLUSIONS: Ultimately, this quality improvement study demonstrated that educational interventions alone have a limited impact on increasing immunization rates.

Cryptococcal Antigen Testing in an Integrated Medical System: Eastern Wisconsin.

Cryptococcosis is a serious environmentally acquired endemic fungal infection commonly associated with immunocompromised hosts. Little is known regarding frequency or distribution in Wisconsin. We explored the geodemographic and clinical features of patients tested with cryptococcal antigen tests (CrAg) - previously shown to be >90% sensitive and >90% specific - within a large health care system located in eastern Wisconsin. To examine this, we retrospectively analyzed 1465 CrAg tests on 1211 unique patients (female: 50.2%; white race: 73.9%; mean age: 53.7 ± 16.5 years). At least one CrAg result was positive in 23 of 1211 patients (1.9%). From these, 21 of 23 were immunocompromised. Positive patients were disproportionately male (82.6%) and nonwhite (3.8% of those tested vs 1.2% of whites tested); P<0.01 for both. These associations remained in multivariable models. Positive patients were not significantly older (59.1 vs 53.6 years; P=0.07). Overall, 17 separate zip codes had at least one positive case. Positive patients were more prevalent in the zip codes that included the city of Milwaukee (11 of 377 [2.9% of those tested] vs 12 of 834 [1.4% of all those tested in the remaining area of the state]), but this difference was not statistically significant. No other case clustering or close proximity to waterways was observed (41% were <162 m from green space, similar to historical controls). Overall, male sex, nonwhite race/ethnicity, and immunocompromised status, not zip code, were statistically associated with positive CrAg.