An Electronic Health Record-Integrated Application for Standardizing Care and Monitoring Patients With Autosomal Dominant Polycystic Kidney Disease Enrolled in a Tolvaptan Clinic: Design and Implementation Study.

Background: Tolvaptan is the only US Food and Drug Administration-approved drug to slow the progression of autosomal dominant polycystic kidney disease (ADPKD), but it requires strict clinical monitoring due to potential serious adverse events. Objective: We aimed to share our experience in developing and implementing an electronic health record (EHR)-based application to monitor patients with ADPKD who were initiated on tolvaptan. Methods: The application was developed in collaboration with clinical informatics professionals based on our clinical protocol with frequent laboratory test monitoring to detect early drug-related toxicity. The application streamlined the clinical workflow and enabled our nursing team to take appropriate actions in real time to prevent drug-related serious adverse events. We retrospectively analyzed the characteristics of the enrolled patients. Results: As of September 2022, a total of 214 patients were enrolled in the tolvaptan program across all Mayo Clinic sites. Of these, 126 were enrolled in the Tolvaptan Monitoring Registry application and 88 in the Past Tolvaptan Patients application. The mean age at enrollment was 43.1 (SD 9.9) years. A total of 20 (9.3%) patients developed liver toxicity, but only 5 (2.3%) had to discontinue the drug. The 2 EHR-based applications allowed consolidation of all necessary patient information and real-time data management at the individual or population level. This approach facilitated efficient staff workflow, monitoring of drug-related adverse events, and timely prescription renewal. Conclusions: Our study highlights the feasibility of integrating digital applications into the EHR workflow to facilitate efficient and safe care delivery for patients enrolled in a tolvaptan program. This workflow needs further validation but could be extended to other health care systems managing chronic diseases requiring drug monitoring.

Menopause in the workplace: Challenges, impact, and next steps.

INTRODUCTION: Menopause is a natural part of a woman's life that coincides with a time when many women play significant roles in the workforce. Menopause symptoms, such as hot flashes, fatigue, and difficulty with concentration and memory, can have a negative effect on work productivity and efficiency. OBJECTIVES: This paper summarizes the impact of menopause in the workplace, with an emphasis on the impact of symptoms on employed women and how the workplace influences their experiences. It highlights economic implications, promotes awareness, and suggests potential next steps. METHODS: A search for papers was conducted between August and November 2023 in the PubMed and Medline databases. Papers were selected based on personal experience and interpretation of the findings. Recommendations for managing menopause symptoms in the workplace and guidance on an optimal workplace intervention strategy were provided. RESULTS: Women experiencing severe menopause symptoms are more likely to report adverse work outcomes, including absenteeism and job-related decisions such as quitting, retiring early, or declining promotions than women experiencing few symptoms. Factors such as a lack of awareness about menopause, inflexible work conditions, and high-stress jobs can exacerbate the severity of these symptoms. Additionally, unaddressed menopause symptoms contribute to both direct and indirect economic costs, including medical resource utilization and lost work productivity, resulting in a substantial economic burden. CONCLUSION: Menopause symptoms impair women's work experiences and productivity. In addition to dismantling the stigma associated with menopause, it is critical to create and implement menopause workplace policies and interventions aimed at supporting women in this universal life stage.

Prospective assessment of entrance skin dose and targets for radiation reduction during abdominal plain films in pediatric urology patients.

INTRODUCTION: Abdominal radiographs are frequently used for evaluation of bowel and bladder dysfunction in pediatric urology. However, the dose of radiation delivered with each study is estimated from machine settings as opposed to measurement of the true entrance skin dose. In addition, the correlation of radiographic constipation with patient symptoms has been questioned. OBJECTIVE: To evaluate the practices for obtaining abdominal radiographs and the true entrance skin dose of radiation for each examination in order to identify targets for radiation reduction. STUDY DESIGN: Pediatric urology patients were prospectively enrolled from June 2022 through June 2023. Dosimeters were attached to the navel to collect entrance skin doses from single view abdominal x-ray. Estimated doses were compared to measured entrance skin dose as well as patient characteristics. Exam parameters were evaluated to identify targets for radiation reduction. RESULTS: A total of 75 patients were recruited for this study with a median age of 10.0 years (IQR 6-14). Most evaluations were done to assess for bowel and bladder dysfunction (68 exams, 91%). The protocol for exams was not standardized resulting in 27% of patients undergoing a medium or high dose strength and 55% undergoing 1 or more image. The median estimated dose was 0.63 mGy (IQR 0.3-1.2 mGy). The median measured dose was 0.77 mGy (IQR 0.31-2.01 mGy) which was significantly different than the estimations (p < 0.001). The estimated dose, measured dose and estimate error were all found to be positively correlated with patient characteristics including age and body mass index (See Figure). Increasing age and body mass index also showed a higher likelihood of increased dose strength and image acquisition. DISCUSSION: The measured entrance skin dose of radiation is significantly higher than prior estimates. The measured dose but also the estimate error increased with patient age and size which is likely related to higher settings used for image acquisition as patients age. Standardized protocols using low dose settings and limiting image acquisition to the pelvis may reduce radiation exposure in children with bowel and bladder dysfunction while providing adequate diagnostic data. CONCLUSION: Radiation dose for abdominal radiographs is higher than previously estimated. Older and larger children received higher doses which may be mediated by increased dose strength and image acquisition. Standardization of protocols could lower radiation exposure.

Feasibility of Enhanced Recovery After Surgery (ERAS) implementation in Pediatric Urology: Pilot-phase outcomes of a prospective, multi-center study.

INTRODUCTION/BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a fundamental shift in perioperative care that has consistently demonstrated an improved outcome for a wide variety of surgeries in adults but has only limited evidence in the pediatric population. OBJECTIVE: We aimed to assess the success with and barriers to implementation of ERAS in a prospective, multi-center study on patients undergoing complex lower urinary tract reconstruction. STUDY DESIGN: Centers were directed to implement an ERAS protocol using a multidisciplinary team and quality improvement methodologies. Providers completed pre- and post-pilot surveys. An audit committee met after enrolling the first 5 patients at each center. Pilot-phase outcomes included enrollment of ≥2 patients in the first 6 months of enrollment, completion of 90 days of follow-up, identification of barriers to implementation, and protocol adherence. RESULTS: A total of 40 patients were enrolled across 8 centers. The median age at surgery was 10.3 years (IQR 6.4-12.5). Sixty five percent had a diagnosis of myelomeningocele, and 33 % had a ventriculoperitoneal shunt. A bladder augmentation was performed in 70 %, Mitrofanoff appendicovesicostomy in 52 %, Monti ileovesicostomy in 15 %, and antegrade continence enema channel in 38 %. The most commonly perceived barriers to implementation on the pre-pilot survey were "difficulty initiating and maintaining compliance with care pathway" in 51 % followed by a "lack of time, money, or clinical resources" in 36 %. The pre-pilot study experience, implementation, and pilot-phase outcomes are provided in the Table. All primary and secondary outcomes were achieved. DISCUSSION: The findings of the present study were similar to several small comparative studies with regard to the importance of a multidisciplinary team, strong leadership, and continuous audit for successful implementation of ERAS. Similar barriers were also encountered to other studies, which primarily related to a lack of administrative support, leadership, and buy-in from other services. The limitations of the present study included a relatively small heterogeneous cohort and absence of a comparative group, which will be addressed in the larger exploratory phase of the trial. The findings may also not be generaziable due to the need for sustainable processes that were unique to each center as well as an absence of adequate volume or resources at smaller centers. CONCLUSIONS: ERAS was successfully implemented for complex lower urinary tract reconstruction across 8 centers through a multidisciplinary team, structured approach based on the local context, and focus on a continuous audit.

Amiodarone Pharmacovigilance Through an Intelligent Electronic Health Record Application.

BACKGROUND: Amiodarone is the most effective and commonly used antiarrhythmic medication. Given its risk of toxicity, routine monitoring is recommended but is challenging to ensure in clinical practice. METHODS: We created an intelligent application, built within our electronic health record, that identified every living patient with an active outpatient prescription by a clinician in our health system. The application was designed to identify patients with lapses in recommended monitoring and facilitate scheduling of overdue testing. RESULTS: The percentage of patients with overdue monitoring tests decreased with use of the application, with greatest improvement in pulmonary function testing. DISCUSSION: Implementing a program to monitor and mitigate adverse reactions to amiodarone by using programable features of an electronic health record is feasible.

Neurogenic Lower Urinary Tract Dysfunction.

Neurogenic lower urinary tract dysfunction (NLUTD) remains a formidable challenge to pediatric urologists to achieve the goals of renal preservation and the reduction of urinary tract infections as well as the attainment of continence and independence as children grow toward adulthood. Tremendous progress has occurred over the past 50 years which have witnessed an evolution in focus from mere survival to optimal quality of life. This review presents four separate guidelines for the medical and surgical care of pediatric NLUTD, most commonly related to spina bifida, to highlight the change in approach from expectant to more proactive management.

Impact of Menopause Symptoms on Women in the Workplace.

OBJECTIVE: To evaluate the impact of menopause symptoms on work outcomes and to assess the estimated economic impact. PATIENTS AND METHODS: Women aged 45 to 60 years receiving primary care at 1 of the 4 Mayo Clinic sites were invited to participate in a survey study (Hormones and ExpeRiences of Aging) from March 1 through June 30, 2021. A total of 32,469 surveys were sent, with 5219 responses (16.1% response rate). Of the 5219 respondents, 4440 (85.1%) reported current employment information and were included in the study. The primary outcome was self-reported adverse work outcomes related to menopause symptoms assessed by the Menopause Rating Scale (MRS). RESULTS: The mean age of the 4440 participants was 53.9±4.5 years, with the majority being White (4127 [93.0%]), married (3398 [76.5%]), and educated (2632 [59.3%] college graduate or higher); the mean total MRS score was 12.1, signifying moderate menopause symptom burden. Overall, 597 women (13.4%) reported at least one adverse work outcome due to menopause symptoms; 480 women (10.8%) reported missing work in the preceding 12 months (median, 3 days missed). The odds of reporting an adverse work outcome increased with increasing menopause symptom severity; women in the highest quartile of total MRS scores were 15.6 (95% CI, 10.7 to 22.7; P<.001) times more likely to have an adverse work outcome vs those in the first quartile. Based on workdays missed due to menopause symptoms, we estimate an annual loss of $1.8 billion in the United States. CONCLUSION: This large cross-sectional study identified a major negative impact of menopause symptoms on work outcomes and the need to improve medical treatment for these women and make the workplace environment more supportive. Additional studies are needed to confirm these findings in larger and more diverse groups of women.

Automated electronic health record-based application for sedation triage in routine colonoscopy.

BACKGROUND AND AIMS: Nearly all routine endoscopy procedures are performed using moderate sedation (MS) or monitored anesthesia care (MAC). In this article, we describe how we improved decision-making and decreased practitioners' cognitive burden for choosing between MAC and MS by using patient data in an automated application within the electronic health record (EHR). METHODS: In our practice, we choose between MS or MAC for routine GI procedures according to written anesthesia-use guidelines and practitioner preferences. To expedite our decision-making for MS versus MAC, we developed an Excel (Microsoft Corp, Redmond, Wash, USA)-based tool from patient demographic characteristics, comorbid conditions, and medication use extracted from the EHR. The data points from Excel were then implemented in the automated application in the EHR to predict the type of sedation for GI procedures. RESULTS: Before use of the new application, nurses spent an average of 4 minutes and gastroenterology practitioners spent 5 minutes reviewing the EHR to determine the appropriate sedation (MS or MAC). After the application was implemented, the use of MS substantially increased. Time spent reviewing the EHR was reduced to 2 minutes. The rate of adverse events for MS (.5%) versus MAC (.6%) was comparable and low overall. CONCLUSIONS: The EHR-based application, which automates and standardizes determination of sedation type, is a highly beneficial tool that eliminates subjectivity in decision-making, thus allowing for appropriate use of MAC. Adverse event rates and sedation failure did not increase with use of the application. With the increased use of MS over MAC, healthcare costs for the more-expensive MAC sedation should also decrease.

Near Real-time Natural Language Processing for the Extraction of Abdominal Aortic Aneurysm Diagnoses From Radiology Reports: Algorithm Development and Validation Study.

BACKGROUND: Management of abdominal aortic aneurysms (AAAs) requires serial imaging surveillance to evaluate the aneurysm dimension. Natural language processing (NLP) has been previously developed to retrospectively identify patients with AAA from electronic health records (EHRs). However, there are no reported studies that use NLP to identify patients with AAA in near real-time from radiology reports. OBJECTIVE: This study aims to develop and validate a rule-based NLP algorithm for near real-time automatic extraction of AAA diagnosis from radiology reports for case identification. METHODS: The AAA-NLP algorithm was developed and deployed to an EHR big data infrastructure for near real-time processing of radiology reports from May 1, 2019, to September 2020. NLP extracted named entities for AAA case identification and classified subjects as cases and controls. The reference standard to assess algorithm performance was a manual review of processed radiology reports by trained physicians following standardized criteria. Reviewers were blinded to the diagnosis of each subject. The AAA-NLP algorithm was refined in 3 successive iterations. For each iteration, the AAA-NLP algorithm was modified based on performance compared to the reference standard. RESULTS: A total of 360 reports were reviewed, of which 120 radiology reports were randomly selected for each iteration. At each iteration, the AAA-NLP algorithm performance improved. The algorithm identified AAA cases in near real-time with high positive predictive value (0.98), sensitivity (0.95), specificity (0.98), F1 score (0.97), and accuracy (0.97). CONCLUSIONS: Implementation of NLP for accurate identification of AAA cases from radiology reports with high performance in near real time is feasible. This NLP technique will support automated input for patient care and clinical decision support tools for the management of patients with AAA. .

Linear relationship between absorbed radiation dose and pulse rate during fluoroscopy.

PURPOSE: To identify the relationship between fluoroscopy pulse rate and absorbed radiation dose. We compared absorbed radiation dose with common proxy measurements such as fluoroscopy time and C-arm reported dose. METHODS: Using a simulated patient model, 60 s fluoroscopy exposures were performed using pulse rates of 30, 8, 4, 2, and 1 pulse(s) per second. Each experiment was performed with both standard and low-dose settings using a GE OEC 9800 plus C-arm. Landauer nanoDot™ OSL dosimeters were used to measure the absorbed radiation dose. RESULTS: Fluoroscopy pulse rate and absorbed radiation dose demonstrated a linear correlation for both standard (R2 = 0.995, p < 0.001) and low-dose (R2 = 0.998, p < 0.001) settings. For any given pulse rate, using the low-dose setting reduced absorbed radiation dose by 58 ± 2.8%. Fluoroscopy time demonstrated a linear relationship with absorbed radiation dose for both standard (R2 = 0.996, p < 0.001) and low-dose (R2 = 0.991, p < 0.001) settings, but did not change with use of the low-dose setting. C-arm reported radiation dose correlated linearly with absorbed dose (R2 = 0.999) but consistently under-estimated measured values by an average of 49 ± 3.5%. Using a combination of 1 pulse-per-second and low-dose fluoroscopy, absorbed dose was reduced by 97.7 ± 0.1% compared to standard dose and 30 pulse-per-second settings. CONCLUSION: Absorbed radiation dose decreases linearly with fluoroscopy pulse rate during equivalent exposure times. Adjusting fluoroscopy pulse rate and utilizing low-dose settings significantly reduces overall absorbed radiation exposure by up to 98%.

Evaluating the role for regional analgesia in children with spina bifida: a retrospective observational study comparing the efficacy of regional versus systemic analgesia protocols following major urological surgery.

INTRODUCTION: Regional techniques are a key component of multimodal analgesia and help decrease opioid use perioperatively, but some techniques may not be suitable for all patients, such as those with spina bifida. We hypothesized peripheral regional catheters would reduce postoperative opioid use compared with no regional analgesia without increasing pain scores in pediatric patients with spina bifida undergoing major urological surgery. METHODS: A retrospective review of a multicenter database established for the study of enhanced recovery after surgery was performed of patients from 2009 to 2021 who underwent bladder augmentation or creation of catheterizable channels. Patients without spina bifida and those receiving epidural analgesia were excluded. Opioids were converted into morphine equivalents and normalized to patient weight. RESULTS: 158 patients with pediatric spina bifida from 7 centers were included, including 87 with and 71 without regional catheters. There were no differences in baseline patient factors. Anesthesia setup increased from median 40 min (IQR 34-51) for no regional to 64 min (IQR 40-97) for regional catheters (p<0.01). The regional catheter group had lower median intraoperative opioid usage (0.24 vs 0.80 mg/kg morphine equivalents, p<0.01) as well as lower in-hospital postoperative opioid usage (0.05 vs 0.23 mg/kg/day morphine equivalents, p<0.01). Pain scores were not higher in the regional catheters group. DISCUSSION: Continuous regional analgesia following major urological surgery in children with spina bifida was associated with a 70% intraoperative and 78% postoperative reduction in opioids without higher pain scores. This approach should be considered for similar surgical interventions in this population. TRIAL REGISTRATION NUMBER: NCT03245242.

Sociotechnical Intervention for Improved Delivery of Preventive Cardiovascular Care to Rural Communities: Participatory Design Approach.

BACKGROUND: Clinical practice guidelines recommend antiplatelet and statin therapies as well as blood pressure control and tobacco cessation for secondary prevention in patients with established atherosclerotic cardiovascular diseases (ASCVDs). However, these strategies for risk modification are underused, especially in rural communities. Moreover, resources to support the delivery of preventive care to rural patients are fewer than those for their urban counterparts. Transformative interventions for the delivery of tailored preventive cardiovascular care to rural patients are needed. OBJECTIVE: A multidisciplinary team developed a rural-specific, team-based model of care intervention assisted by clinical decision support (CDS) technology using participatory design in a sociotechnical conceptual framework. The model of care intervention included redesigned workflows and a novel CDS technology for the coordination and delivery of guideline recommendations by primary care teams in a rural clinic. METHODS: The design of the model of care intervention comprised 3 phases: problem identification, experimentation, and testing. Input from team members (n=35) required 150 hours, including observations of clinical encounters, provider workshops, and interviews with patients and health care professionals. The intervention was prototyped, iteratively refined, and tested with user feedback. In a 3-month pilot trial, 369 patients with ASCVDs were randomized into the control or intervention arm. RESULTS: New workflows and a novel CDS tool were created to identify patients with ASCVDs who had gaps in preventive care and assign the right care team member for delivery of tailored recommendations. During the pilot, the intervention prototype was iteratively refined and tested. The pilot demonstrated feasibility for successful implementation of the sociotechnical intervention as the proportion of patients who had encounters with advanced practice providers (nurse practitioners and physician assistants), pharmacists, or tobacco cessation coaches for the delivery of guideline recommendations in the intervention arm was greater than that in the control arm. CONCLUSIONS: Participatory design and a sociotechnical conceptual framework enabled the development of a rural-specific, team-based model of care intervention assisted by CDS technology for the transformation of preventive health care delivery for ASCVDs.

Salvage Surgery Rates for Pediatric Testicular Torsion: Comparison of the Pre- and Post-Quality Metric Eras.

PURPOSE: Pediatric testicular torsion is a urological emergency that requires timely intervention. In 2015, quality metrics for testicular torsion were implemented in the U.S. News & World Report "Best Children's Hospitals" rankings. Our study examines and compares testicular salvage surgery rates before and after the institution of national quality metrics from a multi-institutional database. MATERIALS AND METHODS: The Pediatric Health Information System® was surveyed for all testicular torsion encounters using ICD (International Classification of Diseases), Ninth and Tenth Revisions coding from 52 hospitals between January 2010 and December 2019. Patients <1 year and ≥18 years of age were excluded. Only hospitals that reported outcomes before and after quality scoring were included. Testicular salvage surgery was defined as patients having undergone orchiopexy without concomitant orchiectomy. Age, race, distance from hospital, household income and insurance status were compared. RESULTS: A total of 890 patients (551 pre-metric and 339 post-metric) from 38 hospitals were included. The testicular salvage surgery rate was 12.5% higher in the post-metric cohort (70.9% versus 58.4%). Hospital compliance to testicular torsion quality metrics increased from 62% in 2015 to 98% in 2019. Mean age, race, distance to hospital, household income, insurance status and use of ultrasound were not statistically different between pre- and post-metric cohorts. CONCLUSIONS: Since the implementation of quality metrics, salvage surgery rates for testicular torsion increased to 70.9%, an improvement of 12.5% when compared to pre-metric outcomes. Patient factors were similar between the 2 groups. Multi-institutional prospective data are needed to validate this database study and evaluate overall testicular salvage rate.

Risk Prediction Model for 6-Month Mortality for Patients Discharged to Skilled Nursing Facilities.

OBJECTIVE: Hospitalized patients discharged to skilled nursing facilities (SNFs) for post-acute care are at high risk for adverse outcomes. Yet, absence of effective prognostic tools hinders optimal care planning and decision making. Our objective was to develop and validate a risk prediction model for 6-month all-cause death among hospitalized patients discharged to SNFs. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Patients discharged from 1 of 2 hospitals to 1 of 10 SNFs for post-acute care in an integrated health care delivery system between January 1, 2009, and December 31, 2016. METHODS: Gradient-boosting machine modeling was used to predict all-cause death within 180 days of hospital discharge with use of patient demographic characteristics, comorbidities, pattern of prior health care use, and clinical parameters from the index hospitalization. Area under the receiver operating characteristic curve (AUC) was assessed for out-of-sample observations under 10-fold cross-validation. RESULTS: We identified 9803 unique patients with 11,647 hospital-to-SNF discharges [mean (SD) age, 80.72 (9.71) years; female sex, 61.4%]. These discharges involved 9803 patients alive at 180 days and 1844 patients who died between day 1 and day 180 of discharge. Age, comorbid burden, health care use in prior 6 months, abnormal laboratory parameters, and mobility status during hospital stay were the most important predictors of 6-month death (model AUC, 0.82). CONCLUSION AND IMPLICATIONS: We derived a robust prediction model with parameters available at discharge to SNFs to calculate risk of death within 6 months. This work may be useful to guide other clinicians wishing to develop mortality prediction instruments specific to their post-acute SNF populations.

Improving Patient Selection and Prioritization for Hospital at Home Through Predictive Modeling.

Hospital at home is designed to offer patients hospital level care in the comfort of their own home. The process by which clinicians select eligible patients that are clinically and socially appropriate for this model of care requires labor-intensive manual chart reviews. We addressed this problem by providing a predictive model, web application, and data pipeline that produces an eligibility score based on a set of clinical and social factors that influence patients' success in the program. Providers used this predictive model to prioritize the order in which they perform chart reviews and patient screenings. Training performance area under the curve (AUC) was 0.77. Testing 'in production' had an AUC of 0.75. Admission criteria in training rapidly changed over the course of the study due to the novelty of the clinical model. The current algorithm successfully identified many inconsistencies in enrollment and has streamlined the process of patient identification.

Prospective evaluation of radiation dose with conventional fluoroscopic voiding cystourethrogram in pediatric patients.

INTRODUCTION: Skin entrance doses for voiding cystourethrogram (VCUG) have not been well characterized in the literature. Radiation exposure is measured as either dose area product (DAP) or air kerma, which estimates the effective dose, but does not accurately reflect absorbed dose at skin level. OBJECTIVE: The objective of this study was to measure the skin entrance dose during fluoroscopic VCUG study in pediatric patients using single point dosimeters. STUDY DESIGN: Pediatric patients undergoing fluoroscopic VCUG were prospectively enrolled in our study. Landauer NanoDot™OSLD dosimeters were affixed to the skin overlying the sacrum to measure skin entrance dose. The fluoroscopic unit was set to the following parameters: low dose setting, skin-to-source distance of 54 cm, pulsed fluoroscopy at 3 frames/sec. RESULTS: Forty-four patients with a median age of 13.6 months (IQR 3.7-42.3) were enrolled. Median fluoroscopic time was 54 s (IQR 36-72). The median values absorbed dose by dosimeter and air kerma were 0.32 mGy (IQR 0.13-0.56, range 0.01-2.9) and 0.24 mGy (IQR 0.14-0.37), respectively. There was a positive correlation between the air kerma and absorbed dose (r = 0.69, p < 0.001) and fluoroscopy time and absorbed dose mGy (r = 0.60, p < 0.001). Absorbed dose was independent of age, body mass index and body surface area (p = 0.19, p = 0.57 and p = 0.16, respectively). Median whole body effective dose was 0.04 mSv (IQR 0.02-0.7). DISCUSSION: Overall, the absorbed dose received by the dosimeter remained low at a median of 0.32 mGy (range 0.01-2.91). These values are remarkably low and well within the accepted radiation exposure norms. Our radiologists follow a strict protocol to reduce the overall radiation emitted during a VCUG. These measures include setting the x-ray source at a low dose mode, collimating to the smallest area possible, and using pulsed fluoroscopy at 3 frames/sec. Limitations to this study include a slight variability in technique of VCUG between different technicians and providers, for which we cannot control. CONCLUSION: The radiation dose absorbed at the skin entrance and uniform whole body effective dose is low for a single VCUG when utilizing strict parameters. While newer non-ionizing technologies continue to emerge, our data is encouraging and will serve as a valuable tool when educating parents regarding radiation doses associated with a VCUG.

Hepatitis B Screening of At-Risk Immigrants Seen at Primary Care Clinics: A Quality Improvement Project.

OBJECTIVE: To test an intervention to increase screening for hepatitis B (HBV) in at-risk immigrants in the primary care setting. PATIENTS AND METHODS: From a Mayo Clinic primary care panel, we identified approximately 19,000 immigrant patients from 9 high-risk countries/ethnic groups with intermediate or high prevalences of chronic HBV. Eligible patients with no record of prior HBV testing scheduled for primary care visits within the study period spanning October 1, 2017, through October 31, 2018, were identified. During the intervention period, the primary health care professional was notified by email 1 week prior to each primary care visit and encouraged to discuss screening for HBV infection and order screening tests at the appointment. We assessed rates of HBV screening during control and intervention periods. RESULTS: We identified 597 patients in the control period and 212 patients in the intervention period who had not been screened previously for HBV. During the intervention period, 31.4% (58) of the 185 eligible patients were screened for HBV vs 7.2% (43) of the 597 eligible patients in the control period. Thus, the intervention resulted in a 4.3-fold increase in screening (P<.00001). Of the 101 patients screened in the at-risk population, 22 (21.8%) screened positive for prior exposure to HBV (hepatitis B core antibody-positive) and 6 (5.9%) for chronic HBV infection (hepatitis B surface antigen-positive). CONCLUSION: Notifying primary care physicians of the high-risk status of immigrant patients substantially increased screening for HBV. Identifying patients with HBV is important for monitoring disease prevalence, preventing transmission, and initiating treatment and cancer surveillance, allowing earlier recognition and prevention of chronic hepatitis, disease reactivation, cirrhosis, and hepatocellular carcinoma.

Usability of a Digital Registry to Promote Secondary Prevention for Peripheral Artery Disease Patients.

OBJECTIVE: To evaluate usability of a quality improvement tool that promotes guideline-based care for patients with peripheral arterial disease (PAD). PATIENTS AND METHODS: The study was conducted from July 19, 2018, to August 21, 2019. We compared the usability of a PAD cohort knowledge solution (CKS) with standard management supported by an electronic health record (EHR). Two scenarios were developed for usability evaluation; the first for the PAD-CKS while the second evaluated standard EHR workflow. Providers were asked to provide opinions about the PAD-CKS tool and to generate a System Usability Scale (SUS) score. Metrics analyzed included time required, number of mouse clicks, and number of keystrokes. RESULTS: Usability evaluations were completed by 11 providers. SUS for the PAD-CKS was excellent at 89.6. Time required to complete 21 tasks in the CKS was 4 minutes compared with 12 minutes for standard EHR workflow (median, P = .002). Completion of CKS tasks required 34 clicks compared with 148 clicks for the EHR (median, P = .002). Keystrokes for CKS task completion was 8 compared with 72 for EHR (median, P = .004). Providers indicated that overall they found the tool easy to use and the PAD mortality risk score useful. CONCLUSIONS: Usability evaluation of the PAD-CKS tool demonstrated time savings, a high SUS score, and a reduction of mouse clicks and keystrokes for task completion compared to standard workflow using the EHR. Provider feedback regarding the strengths and weaknesses also created opportunities for iterative improvement of the PAD-CKS tool.

Digital Health Surveillance Strategies for Management of Coronavirus Disease 2019.

OBJECTIVE: To describe the design, implementation, and utilization of electronic health record (EHR)-based digital health surveillance strategies used to manage the coronavirus disease 2019 (COVID-19) pandemic and to ensure delivery of high-quality clinical care, such as case identification, remote monitoring, telemedicine services, and recruitment to clinical trials at Mayo Clinic. METHODS: The design and implementation work described in this report was performed at Mayo Clinic, a large multistate integrated health care system with more than 1.5 million annual patient visits that uses the Epic EHR system. Rule-based live registries were designed in the EHR system to classify patients who currently test positive for COVID-19, patients who test positive but have recovered from COVID-19, patients who are thought to have COVID-19 but do not yet meet clinical diagnostic criteria, patients who test negative for COVID-19, and patients who exceed a risk score for serious complications from COVID-19. RESULTS: By use of registries, custom dashboards and operational reports were developed to provide a daily high-level summary for clinical practice use and up-to-date information to manage individual patients affected by COVID-19, including support of case identification, contact isolation, and other care management tasks. CONCLUSION: We developed and implemented a systematic approach to the use of EHR patient registries to manage the COVID-19 pandemic that proved feasible and useful in a large multistate group clinical practice. The key to harnessing the potential of digital surveillance tools to promote patient-centered care during the COVID-19 pandemic was to use the registry data, reports, and dashboards as informatics tools to inform decision-making.

A government mandated consent safely reduces opioid utilization for major pediatric genitourinary surgeries.

INTRODUCTION: We describe the effect of a state mandated opioid consent on opioid utilization and multimodal pain use for major pediatric genitourinary surgeries. METHODS: All patients who underwent an inpatient pediatric genitourinary surgery at the Children's Hospital of Pittsburgh between August 2015 and February 2020 were identified. Inpatient and outpatient multimodal pain control utilization were assessed. Delayed prescriptions or emergency department visits within 30 days were identified and when applicable referenced against National Surgical Quality Improvement Program data. RESULTS: After accounting for a 6-month transition period following policy implementation, 462 major pediatric genitourinary procedures were identified. The frequency of discharge opiate prescriptions decreased from 68.4% prior to the transition period to 10.7% afterward(p<0.001). Morphine milligram equivalents per prescription decreased from 75(IQR 45-150) to 45(IQR 22.5-75)(p<0.001). The rate of delayed non-opioid analgesic prescriptions (6.6% vs 7.4%), delayed opioid prescriptions (1.5% vs 0.3%), or emergency department visits (11.8% vs 12.6%)(p = 0.809) remained unchanged. Data agreed with National Surgical Quality Improvement Program data in 98.5% of cases. After excluding one surgeon who departed after the transition period, regional block utilization did not change from 61/115(53%) to 147/320(45.9%)(p = 0.425). CONCLUSIONS: A state mandated opioid consent safely reduced opioid utilization for most major pediatric genitourinary surgeries. LEVEL OF EVIDENCE: Level III.