Rapid Response: To Scan or Not to Scan? The Utility of Noncontrast CT Head for Altered Mental Status.

OBJECTIVES: The aims of the study were the following: (1) to determine how often computed tomography (CT) scans of the head are obtained on rapid responses called for altered mental status (AMS), (2) to determine whether CT imaging of the head is required during all rapid responses called for AMS, (3) to determine which patients would benefit from CT scans of the head in this setting, (4) to note whether an adequate neurologic exam was documented, (5) to determine the cost of CT scans that did not change management, and (6) to examine the role of medications leading to AMS. METHODS: The study was a retrospective chart review at Abington Jefferson Hospital. Data collected included the age, sex, time of rapid response, clinical condition of the patient, whether an arterial blood gas and blood glucose were done, and whether a neurological exam was documented in the resident's rapid response team note. The patien's medications were also reviewed. Computed tomography scan findings as well as changes made in a patient's care as a result of the scan were recorded. Any findings that did not lead to a change in management were considered a "negative" scan. RESULTS: Overall, 610 rapid responses were activated from January to August 2016. One hundred four (17.04%) of the total rapid responses were for AMS and 83 (79.8%) of these patients underwent noncontrast CT scan of the head. The mean (SD) age of the patients was 74.7 (13.6) years. A total of 56.6% were female. The most frequent clinical conditions documented at the time of rapid responses were noted as confused (33.7%, 28/83), either lethargic or unconscious (32.5%, 27/83), and concern for stroke (21.7%, 18/83). A total of 96.4% (80/83) of the CT scans done were negative for any acute changes. The three patients with positive scans (3/83) had a change in management as a result of the scans. If patients with symptoms concerning for stroke and unconscious patients are excluded, the total number of remaining patients is 56. Of these, zero patients had a positive scan. A total of 64.7% of the rapid response teams were activated either in the afternoon (31.3%) or at night (33.7%). A total of 33.7% had a complete neurological exam documented. A total of 66.2% were either incomplete (34.9%) or absent (31.3%). Sixty percent of the patients who had a CT head for AMS also had a blood sugar checked at bedside. Thirty-eight percent had an arterial blood gas. More than half the patients were taking one or more sedating medications (45/83, 57.8%). Most patients were not on anticoagulants (79.5%). CONCLUSIONS: The findings of this study suggest that CT scan of the head is useful in older patients, patients with symptoms concerning for stroke, or cases of sudden onset of impaired consciousness. Noncontrast CT scans of the head are not useful for other presentations of AMS.

A practical approach to the clinical challenges in initiation of basal insulin therapy in people with type 2 diabetes.

Initiating insulin therapy with a basal insulin analogue has become a standard of care in the treatment of type 2 diabetes mellitus (T2DM). Despite increasing choices in pharmacological approaches, intensified glucose monitoring and improvements in quality of care, many patients do not achieve the desired level of glycaemic control. Although insulin therapy, when optimized, can help patients reach their glycaemic goals, there are barriers to treatment initiation on both the side of the patient and provider. Providers experience barriers based on their perceptions of patients' capabilities and concerns. They may lack the confidence to solve the practical problems of insulin therapy and avoid decisions they perceive as risky for their patients. In this study, we review recommendations for basal insulin initiation, focussing on glycaemic targets, titration, monitoring, and combination therapy with non-insulin anti-hyperglycaemic medications. We provide practical advice on how to address some of the key problems encountered in everyday clinical practice and give recommendations where there are gaps in knowledge or guidelines. We also discuss common challenges faced by people with T2DM, such as weight gain and hypoglycaemia, and how providers can address and overcome them.

The importance of patient-reported outcomes in type 2 diabetes: insight from the PIONEER program with oral semaglutide.

Patient-reported outcomes (PROs), including treatment satisfaction, patient well-being, and quality of life, are becoming increasingly important contributors to treatment decisions in clinical practice and the evaluation of health care services. PROs have been included in a number of clinical trials in patients with type 2 diabetes (T2D), including those investigating glucagon-like peptide-1 receptor agonists (GLP-1RAs). The first oral GLP-1RA, oral semaglutide, was approved in the United States in 2019. Four PROs were included in the PIONEER clinical study program that evaluated oral semaglutide in patients with T2D across the full diabetes disease spectrum. PRO findings in the PIONEER studies were generally similar for oral semaglutide and comparators, with some exceptions. Improvements in a number of the 36-item Short Form Survey domains were observed for oral semaglutide versus placebo, including general health, bodily pain, physical component summary, social functioning, and mental health. For general health and social functioning, differences significantly favored oral semaglutide versus empagliflozin, whereas role-physical and the physical component summary significantly favored empagliflozin compared with oral semaglutide. The Diabetes Treatment Satisfaction Questionnaire findings indicated that oral semaglutide improved feelings of unacceptably high blood sugars versus placebo (in PIONEER 4, 5, and 8) and sitagliptin (in PIONEER 7). Significant improvements in craving control and craving for savory were observed with oral semaglutide versus empagliflozin in the Control of Eating Questionnaire (in PIONEER 2). These data provide valuable information that can facilitate a patient-centered approach and guide decision-making in managed care to optimize each patient's treatment experience.

Characteristics and Outcomes of Patients with Partial Do Not Resuscitate Orders in a Large Community Hospital.

Background Formal writing of do not resuscitate (DNR) orders first appeared in the literature in the late 20th century. Recently, providers have also noticed the presence of partial DNR orders while caring for patients. We sought to determine the effect of these orders on the clinical outcomes of the patients. Methods The study was a retrospective chart review covering a period of approximately 30 months. Patients included in the study were over 18 years of age and had a partial DNR order (i.e., chemical code, do not defibrillate (DND), do not intubate (DNI), intubate only, no cardiopulmonary resuscitation (CPR)) entered during hospitalization. Primary medical problems were categorized by organ system and the outcome was stated in terms of their disposition and mortality. Results A total of 71,143 code orders were entered during the study period, with partial DNR orders accounting for 1.8% of these orders (chemical code 2%, DND 0.8%, DNI 48%, intubate only 38%, and no CPR 10%). About 38% of all patients were discharged to home, 32% were discharged to a facility, and 11% were discharged on hospice. More than half of the patients did not have a palliative care consult. Of all the patients having partial code orders, about 150 patients had a rapid response team called on them and five patients had a cardiac arrest with a code blue activated on them. The mortality of these patients was significantly higher than other patients possibly due to confusing code orders. Surprisingly, a higher percentage of patients (19%) with a mean age significantly lower (p < 0.001) than discharged patients had inpatient mortality.  Conclusion Our study demonstrates the first reported prevalence of partial DNR orders in the general inpatient population and its possible detrimental effects on the patient clinical course. This study offers several opportunities for quality improvement, such as developing prompts for the healthcare team to involve palliative care services more often for such patients.

Process improvement for follow-up radiology report recommendations of lung nodules.

In the modern healthcare system, there are still wide gaps of communication of imaging results to physician and patient stakeholders and tracking of whether follow-up has occurred. Patients are also unaware of the significance of findings in radiology reports. With the increase in use of cross-sectional imaging such as CT, patients are not only being diagnosed with primary urgent findings but also with incidental findings such as lung nodules; however, they are not being told of their imaging findings nor what actions to take to mitigate their risks. In addition, patients at high risk for developing lung cancer often obtain serial CT scans, but tracking these patients is challenging for the clinician. In order to advance quality improvement goals and improve patient outcomes, we developed a custom application and business process for radiology practitioners that mines available healthcare data, identifies patients with lung nodules in need of follow-up imaging, notifies the patient and the primary care physician via mail, and measures process efficacy via executed follow-up screenings and captured patient condition. This integrated analytics and communication process increased our average rate of patient follow-ups for lung nodules from 26.50 in 2015 to 59.72% in 2017. 17.18% of these patients had new lung nodules or worsening severity of lung findings detected at follow-up. This new process has added missing quality and care coordination to an at-risk patient population. Problem: Communication of imaging results and follow-up recommendations to patients and primary care providers (PCPs) is a challenge for healthcare systems. In addition, tracking whether a patient's follow-up has been completed is another significant gap in care coordination. Patients are often unaware of or cannot even understand the significance of radiology findings or follow-up recommendations reported after imaging procedures. In addition, patients may not have a primary physician listed at time of imaging if the first encounter is in the emergency room (ER) or if their primary care physician or specialist works in a different electronic health record platform. Communication of imaging results to different healthcare providers is challenging with the myriad of existing electronic health record systems that often lack interoperability with other clinical entities.Description of lung nodules in radiology reports can vary widely if a standardised lexicon is not used. Moreover, follow-up recommendations by radiologists can be varied for certain size lung nodules because an individual's risk factors to develop lung cancer may not be known at the time of dictation.Approximately 500 000 radiology imaging procedures are interpreted and performed annually by a single private group of 33 radiologists located at a 665-bed regional referral centre and at a 140-bed acute care community hospital, both located in the suburbs of a major metropolitan city. Management of this volume of patients in the health system can be overwhelming to nurse navigators, and there is usually no system in place for primary care physicians to follow-up lung nodules found unexpectedly on inpatient images. The goal of this project was to develop a better automated tracking method and communication tool to reduce the likelihood that needed follow-up studies are missed by patients and clinicians.

Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper.

In this position paper, the American College of Physicians (ACP) examines the rationale for patient and family partnership in care and reviews outcomes associated with this concept, including greater adherence to care plans, improved satisfaction, and lower costs. The paper also explores and acknowledges challenges associated with implementing patient- and family-centered models of care. On the basis of a comprehensive literature review and a multistakeholder vetting process, the ACP's Patient Partnership in Healthcare Committee developed a set of principles that form the foundation for authentic patient and family partnership in care. The principles position patients in their rightful place at the center of care while acknowledging the importance of partnership between the care team and patient in improving health care and reducing harm. The principles state that patients and families should be treated with dignity and respect, be active partners in all aspects of their care, contribute to the development and improvement of health care systems, and be partners in the education of health care professionals. This paper also recommends ways to implement these principles in daily practice.

Glycemic Efficacy, Weight Effects, and Safety of Once-Weekly Glucagon-Like Peptide-1 Receptor Agonists.

This article provides an overview of the efficacy and safety of once-weekly glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in the treatment of type 2 diabetes mellitus (T2DM). GLP-1 RAs stimulate pancreatic GLP-1 receptors, which increases insulin secretion, delays gastric emptying, and increases satiety. As a class, GLP-1 RAs lower A1c levels and have been associated with reductions in weight and blood pressure and reduced fluctuations in glucose levels, and they have a low risk of hypoglycemia. Exenatide extended release (ER) and dulaglutide monotherapy have shown similar or superior reductions in A1c and weight compared with various oral antidiabetic drugs (OADs). Semaglutide has been shown to reduce both A1c and body weight compared with placebo and, in head-to-head studies versus both exenatide ER and dulaglutide, showed greater reductions in A1c and body weight. Once-weekly GLP-1 RAs have also been evaluated as add-on therapy in the continuum of care for the treatment of T2DM in combination with a variety of background medications, including 1 or more OADs (metformin, sulfonylureas, and/or thiazolidinediones), basal insulin, and prandial insulin. Gastrointestinal adverse events (e.g., nausea, vomiting, and diarrhea) are the most common side effects with once-weekly GLP-1 RAs. Rates of hypoglycemia, and especially major/severe hypoglycemia, are low with once-weekly GLP-1 RAs but, as expected, are higher when used in combination with sulfonylureas or insulin. These once-weekly GLP-1 RAs provide a safe and effective treatment option for patients with T2DM and may offer improved convenience and possibly greater adherence compared with daily GLP-1 RAs. DISCLOSURES: This supplement was funded by Novo Nordisk. Handelsman reports research grants from Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Grifols, Janssen, Lexicon, Merck, Novo Nordisk, Regeneron, and Sanofi; speaker fees from Amarin, Amgen, AstraZeneca, Boehringer Ingelheim-Lilly, Janssen, Merck, Novo Nordisk, Regeneron, and Sanofi; and has served in advisory capacity to Amarin, Amgen, AstraZeneca, Boehringer Ingelheim, Eisai, Intarcia, Janssen, Lilly, Merck, Merck-Pfizer, Novo Nordisk, Regeneron, and Sanofi. Cannon reports speaker fees and owns stock in Novo Nordisk. Shannon reports consultant and speaker fees from Novo Nordisk and Boehringer Ingelheim-Lilly Alliance. Schneider reports advisory board fees from Intarcia, Lilly, and Novo Nordisk. Wyne has nothing to disclose.

Health-Related Quality of Life Assessments with Once-Weekly Glucagon-Like Peptide-1 Receptor Agonists in Type 2 Diabetes Mellitus.

Type 2 diabetes (T2DM) is associated with significant impairment in health-related quality of life (HRQoL). A patient-centered collaborative approach is recommended to optimize clinical outcomes, including HRQoL, in this patient population. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) provide effective glycemic control and have demonstrated beneficial effects on HRQoL and treatment satisfaction. Available once-weekly GLP-1 RAs may offer enhanced convenience compared with daily GLP-1 RAs and include exenatide extended-release (ER), dulaglutide, and semaglutide. This article reviews the impact of once-weekly GLP-1 RAs on HRQoL and treatment satisfaction in patients with T2DM. Compared with oral antihyperglycemic drugs, insulin, and daily GLP-1 RAs, once-weekly GLP-1 RAs offer benefits with regard to HRQoL and treatment satisfaction. These benefits appear to be largely mediated by relative drug effects on glycemic control, weight, and hypoglycemia. While there was not an overall class benefit of once-weekly GLP-1 RAs compared with daily GLP-1 RAs on HRQoL and treatment satisfaction, results suggested that once-weekly GLP-1 RAs may enhance certain elements of treatment satisfaction and increase willingness to continue treatment. In 2 studies comparing once-weekly GLP-1 RAs with each other, semaglutide produced significantly greater improvement in overall treatment satisfaction compared with exenatide ER but not dulaglutide. Once-weekly GLP-1 RAs represent an effective and convenient treatment option that may potentially increase treatment satisfaction and enhance adherence, contributing to improved health outcomes. DISCLOSURES: This supplement was funded by Novo Nordisk. Billings reports personal fees from Dexcom, Novo Nordisk, and Sanofi. Handelsman reports research grants from Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Grifols, Janssen, Lexicon, Merck, Novo Nordisk, Regeneron, and Sanofi; speaker fees from Amarin, Amgen, AstraZeneca, Boehringer Ingelheim-Lilly, Janssen, Merck, Novo Nordisk, Regeneron, and Sanofi; and has served in advisory capacity to Amarin, Amgen, AstraZeneca, Boehringer Ingelheim, Eisai, Intarcia, Janssen, Lilly, Merck, Merck-Pfizer, Novo Nordisk, Regeneron, and Sanofi. Heile reports speaker fees from and has served as advisor to Novo Nordisk. Schneider reports advisory board fees from Intarcia, Lilly, and Novo Nordisk. Wyne has nothing to disclose.

The burden of severe hypoglycemia in type 1 diabetes.

AIMS: Approximately 1.25 million people in the US have type 1 diabetes mellitus (T1DM), a chronic metabolic disease that develops from the body's inability to produce insulin, and requires life-long insulin therapy. Poor insulin adherence may cause severe hypoglycemia (SHO), leading to hospitalization and long-term complications; these, in turn, drive up costs of SHO and T1DM overall. This study's objective was to estimate the prevalence and costs of SHO-related hospitalizations and their additional longer-term impacts on patients with T1DM using basal-bolus insulin. METHODS: Using Truven MarketScan claims, we identified adult T1DM patients using basal-bolus insulin regimens who were hospitalized for SHO (inpatient SHO patients) during 2010-2015. Two comparison groups were defined: those with outpatient SHO-related encounters only, including emergency department (ED) visits without hospitalization (outpatient SHO patients), and those with no SHO- or acute hyperglycemia-related events (comparison patients). Lengths of stay and SHO-related hospitalization costs were estimated and propensity score and inverse probability weighting methods were used to adjust for baseline differences across the groups to evaluate longer-term impacts. RESULTS: We identified 8,734 patients, of which 4.2% experienced at least one SHO-related hospitalization. Among those who experienced SHO (i.e. of those in the inpatient and outpatient SHO groups), 31% experienced at least one SHO-related hospitalization, while 9% were treated in the ED without subsequent hospitalization. Approximately 79% of patients were admitted directly to the hospital; the remainder were first assessed or treated in the ED. The inpatient SHO patients stayed in the hospital, including time in the ED, for 1.7 days and incurred $3551 in costs. About one-third of patients were hospitalized again for SHO. Inpatient SHO patients incurred significantly higher monthly costs after their initial SHO-related hospitalization than patients in the two other groups ($2084 vs $1313 and $1372), corresponding to 59% or 52% higher monthly costs for inpatient SHO patients. LIMITATIONS: These analyses excluded patients who did not seek ED or hospital care when faced with SHO; events may have been miscoded; and we were not able to account for clinical characteristics associated with SHO, such as insulin dose and duration of diabetes, or unmeasured confounders. CONCLUSIONS: The burden associated with SHO is not negligible. About 4% of T1DM patients using basal-bolus insulin regimens are hospitalized at least once due to SHO. Not only did those patients incur the costs of their SHO hospitalization, but they also incur red at least $712 (52%) more in costs per month after their hospitalization than outpatient SHO or comparison patients. Reducing SHO events can help decrease the burden associated with SHO among patients with T1DM.

The burden of severe hypoglycemia in type 2 diabetes.

AIMS: More than 29 million people in the US have type 2 diabetes mellitus (T2DM), a chronic metabolic disorder characterized by a progressive deterioration of glucose control, which eventually requires insulin. Abnormally low levels of blood glucose, a feared side-effect of insulin treatment, may cause severe hypoglycemia (SHO), leading to emergency department (ED) admission, hospitalization, and long-term complications; these, in turn, drive up the costs of T2DM. This study's objective was to estimate the prevalence and costs of SHO-related hospitalizations and their additional longer-term impacts on patients with T2DM using insulin. METHODS: Using Truven MarketScan claims, we identified adult T2DM patients using basal and basal-bolus insulin regimens who were hospitalized for SHO (inpatient SHO patients) during 2010-2015. Two comparison groups were defined: those with outpatient SHO-related encounters only, including ED visits without hospitalization (outpatient SHO patients), and those with no SHO- or acute hyperglycemia-related events (comparison patients). Lengths of stay and SHO-related hospitalization costs were estimated, and propensity score and inverse probability weighting methods were used to adjust for baseline differences across the groups to evaluate longer-term impacts. RESULTS: We identified 66,179 patients using basal and 81,876 patients using basal-bolus insulin, of which ∼1.1% (basal) to 3.2% (basal-bolus) experienced at least one SHO-related hospitalization. Among those who experienced SHO (i.e. those in the inpatient and outpatient SHO groups), 27% (basal) and 40% (basal-bolus) experienced at least one SHO-related hospitalization. One-third of basal and about one-quarter of basal-bolus patients were admitted directly to the hospital; the remainder were first assessed or treated in the ED. Inpatient SHO patients using basal insulin stayed in the hospital, including time in the ED, for 2.8 days and incurred $6896 in costs; patients using basal-bolus insulin stayed in the hospital for 2.6 days and incurred costs of $5802. Forty-to-fifty percent of inpatient SHO patients were hospitalized again for SHO. Inpatient SHO patients using basal insulin incurred significantly higher monthly costs after their initial SHO-related hospitalization than patients in the other two groups ($2935 vs $1819 and $1638), corresponding to 61% and 79% higher monthly costs; patients using basal-bolus insulin also incurred significantly higher monthly costs than patients in the other groups ($3606 vs $2731 and $2607), corresponding to 32% and 38% higher monthly costs. LIMITATIONS: These analyses excluded patients who did not seek ED or hospital care when faced with SHO; events may have been miscoded; and we were not able to account for clinical characteristics associated with SHO, such as insulin dose and duration of diabetes, or unmeasured confounders. CONCLUSIONS: The burden associated with SHO is not negligible. Nearly one in three patients using only basal insulin and one in four patients using basal-bolus regimens who experienced SHO were hospitalized at least once due to SHO. Not only did those patients incur the costs of their SHO hospitalization, but they also incurred at least $1,116 (62%) and $875 (70%) more per month than outpatient SHO or comparison patients. Reducing SHO events can help decrease the burden associated with SHO among patients with T2DM.

Call for Submissions: New Clinical Diabetes Department Focuses on Quality Improvement and Practice Transformation Initiatives.

EDITOR'S NOTE: Quality Improvement Success Stories, a new Clinical Diabetes department developed in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program, will feature articles and a searchable online collection of information about quality improvement and practice transformation initiatives in the area of diabetes care. This article provides the rationale and article submission process for this new offering.

Enhancing the Safe and Effective Management of Chronic Pain in Accountable Care Organization Primary Care Practices in Kentucky.

Chronic pain is a prevalent chronic condition with significant burden and economic impact in the United States. Chronic pain is particularly abundant in primary care, with an estimated 52% of chronic pain patients obtaining care from primary care physicians (PCPs). However, PCPs often lack adequate training and have limited time and resources to effectively manage chronic pain. Chronic pain management is complex in nature because of high co-occurrence of psychiatric disorders and other medical comorbidities in patients. This article describes a quality improvement initiative conducted by the American College of Physicians (ACP), in collaboration with the Kentucky ACP Chapter, and the Center for Health Services and Outcomes Research at the Johns Hopkins Bloomberg School of Public Health, to enhance chronic pain management in 8 primary care practices participating in Accountable Care Organizations in Kentucky, with a goal of enhancing the screening, diagnosis, and treatment of patients with chronic pain.

Evaluation of prediction strategy and care coordination for COPD readmissions.

OBJECTIVES: Factors that influence the likelihood of readmission for chronic obstructive pulmonary disease (COPD) patients and the impact of posthospital care coordination remain uncertain. LACE index (L = length of stay, A = Acuity of admission; C = Charlson comorbidity index; E = No. of emergency department (ED) visits in last 6 months) is a validated tool for predicting 30-days readmissions for general medicine patients. We aimed to identify variables predictive of COPD readmissions including LACE index and determine the impact of a novel care management process on 30-day all-cause readmission rate. METHODS: In a case-control design, potential readmission predictors including LACE index were analyzed using multivariable logistic regression for 461 COPD patients between January-October 2013. Patients with a high LACE index at discharge began receiving care coordination in July 2013. We tested for association between readmission and receipt of care coordination between July-October 2013. Care coordination consists of a telephone call from the care manager who: 1) reviews discharge instructions and medication reconciliation; 2) emphasizes importance of medication adherence; 3) makes a follow-up appointment with primary care physician within 1-2 weeks and; 4) makes an emergency back-up plan. RESULTS: COPD readmission rate was 16.5%. An adjusted LACE index of ≥ 13 was not associated with readmission (p = 0.186). Significant predictors included female gender (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.29-0.91, p = 0.021); discharge to skilled nursing facility (OR 3.03, 95% CI 1.36-6.75, p = 0.007); 4-6 comorbid illnesses (OR 9.21, 95% CI 1.17-76.62, p = 0.035) and ≥ 4 ED visits in previous 6 months (OR 6.40, 95% CI 1.25-32.87, p = 0.026). Out of 119 patients discharged between July-October 2013, 41% received the care coordination. The readmission rate in the intervention group was 14.3% compared to 18.6% in controls (p = 0.62). CONCLUSIONS: Factors influencing COPD readmissions are complex and poorly understood. LACE index did not predict 30-days all-cause COPD readmissions. Posthospital care coordination for transition of care from hospital to the community showed a 4.3% reduction in the 30-days all-cause readmission rate which did not reach statistical significance (p = 0.62).

The effect of water stress on super-high- density 'Koroneiki' olive oil quality.

BACKGROUND: Over the last two decades, the area of cultivated super-high-density olive orchards has increased rapidly. Water stress is an important tool in super-high-density orchards to reduce tree growth and promote suitability for overhead mechanical harvesters. Little is known regarding the effect of water stress in super-high-density orchards on oil quality parameters. In this study the effect of irrigation rate on oil quality parameters was evaluated in a six-year-old super-high-density 'Koreneiki' olive orchard for five consecutive seasons. Five water status levels, determined by irrigating in order to maintain various midday stem water potential threshold values (-1.5, -2, -2.5, -3 and -4 MPa), were applied during the oil accumulation stage. RESULTS: The MUFA/PUFA ratio and free fatty acid content generally decreased as a function of increasing tree water stress. In most seasons a reduction in polyphenols was found with decreasing irrigation level. Peroxide value was not affected by the water stress level. CONCLUSION: The present study demonstrates that limiting irrigation and exposure of olive trees to water stress in a super-high-density orchard lowers free fatty acid content and therefore benefits oil quality. However, the decreased MUFA/PUFA ratio and the reduction in polyphenol content that were also found under increased water stress negatively influence oil quality.