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Hepatocellular carcinoma (HCC) incidence and mortality vary by race/ethnicity and both are higher in Black patients than in Whites. For HCC surveillance, all cirrhotic patients are advised to undergo lifelong twice-annual abdominal imaging. We investigated factors associated with surveillance and HCC incidence in a diverse HCC risk group, cirrhotic patients recently cured of hepatitis C virus (HCV) infection.In this observational cohort study, all participants (n = 357) had advanced fibrosis/cirrhosis and were cured of HCV with antiviral treatment. None had Liver Imaging Reporting and Data System (LI-RADS) 2-5 lesions prior to HCV cure. Ultrasound, computed tomography, and/or magnetic resonance imaging were used for surveillance.At a median follow-up of 40 months [interquartile range (IQR) = 28-48], the median percentage of time up-to-date with surveillance was 49% (IQR) = 30%-71%. The likelihood of receiving a first surveillance examination was not significantly associated with race/ethnicity, but was higher for patients with more advanced cirrhosis, for example, bilirubin [odds ratio (OR) = 3.8/mg/dL, p = 0.002], private insurance (OR = 3.4, p = 0.006), and women (OR = 2.3, p = 0.008). The likelihood of receiving two or three examinations was significantly lower for non-Hispanic Blacks and Hispanics versus non-Hispanic Whites (OR = 0.39, and OR = 0.40, respectively, p 0.005 for both) and for patients with higher platelet counts (OR = 0.99/10,000 cells/µl, p = 0.01), but higher for patients with private insurance (OR = 2.8, p 0.001). Incident HCC was associated with higher bilirubin (OR = 1.7, p = 0.02) and lower lymphocyte counts (OR = 0.16, p = 0.01).Contrary to best practices, HCC surveillance was associated with sociodemographic factors (insurance status and race/ethnicity) among patients cured of HCV. Guideline-concordant surveillance is needed to address healthcare disparities.

Background: Surgical feeding ostomies (SFO, e.g. gastrostomy) have replaced natural orifice feeding tubes (NOFT, e.g. nasogastric feeding tube) as the preferred route for long-term enteral nutrition. Reports of complication rates for SFO vary. Many hospitalized patients are required to accept SFO before hospital discharge due to skilled nursing facilities (SNFs) policy, and without supportive data. We compare adverse event rates between SFO and NOFT. Methods: A prospective cohort study of enterally fed inpatients using semiweekly focused physical exam, scripted survey, and chart review. Findings: Over the course of nine weeks, 226 unique patients were seen an average of 6.25 times each for a total of 1118 unique observations. Demographic data were comparable between subgroups. There were 148 subjects with NOFT and 113 subjects with SFO. 35 NOFT crossed over to SFO during the study. More NOFT than SFO observations took place in ICUs (p

Purpose: The act of precharting, or navigating the EMR to review a patient’s recent vitals, labs, notes, and other results, is something that is required of every clinician prior to effective rounding on patients. The purpose of this scoping review is to review the extant literature on precharting. Methods: Scholarly data through OVID on Medscape and grey literature were systematically searched with extensive inclusion criteria including the terms “Pre-round” “precharting” as well as “student” “education” or “teach” adjacent to “EMR” or “electronic medical record” or “electronic health record” or “documentation.” We collated this with “education, medical, undergraduate,” or “Students/medical.” Results: As of September 23, 2020, 241 scholarly articles were identified. No grey literature were identified. Inclusion criteria included full article access, English language, and covering the precharting topic. Seventeen articles met inclusion criteria and were included in the review. These articles included 1 direct observational study, 1 retrospective study, 2 qualitative studies, 5 EMR workshop trainings, 1 perspective piece, 1 curriculum analysis, and 6 articles based on survey measures. Of these articles, the majority were published recently, with 8 of the 17 published since 2018. Summary of the limited existing literature can be distilled into 3 findings: a need for timely EMR data extraction, the potential optimization of EMR workflow, and the benefit of time intensive EMR trainings. Conclusions: This scoping review explored the existing scholarly and grey literature to summarize the review of precharting and education surrounding navigating the EMR for medical students as a means of exploring the topic to determine current practices and identify areas of potential improvement.

BACKGROUND AND AIMS Although chronic HCV infection increases mortality, thousands of patients remain diagnosed-but-untreated (DBU). We aimed to (1) develop a DBU phenotyping algorithm, (2) use it to facilitate case finding and linkage to care, and (3) identify barriers to successful treatment. APPROACH AND RESULTS We developed a phenotyping algorithm using Java and SQL and applied it to ~2.5 million EPIC electronic medical records (EMRs; data entered January 2003 to December 2017). Approximately 72,000 EMRs contained an HCV International Classification of Diseases code and/or diagnostic test. The algorithm classified 10,614 cases as DBU (HCV-RNA positive and alive). Its positive and negative predictive values were 88% and 97%, respectively, as determined by manual review of 500 EMRs randomly selected from the ~72,000. Navigators reviewed the charts of 6,187 algorithm-defined DBUs and they attempted to contact potential treatment candidates by phone. By June 2020, 30% (n = 1,862) had completed an HCV-related appointment. Outcomes analysis revealed that DBU patients enrolled in our care coordination program were more likely to complete treatment (72% [n = 219] vs. 54% [n = 256]; P

The telehealth policy changes enacted for short-term control of the coronavirus disease 2019 (COVID-19) pandemic present an opportunity to address the fundamental gap in health care underutilization.

Background: Over-ordering of daily labs affects patient safety through hospital-acquired anemia, patient discomfort, frontline staff burden, and unnecessary downstream testing resulting in the delivery of low-value care. Routine ordering of unnecessary tests occurs for many reasons and can additionally increase cost of care. At our center, previous interventions have targeted lab ordering, but have struggled to remain sustainable. Our student-run project, as part of a high value care curriculum, set out to understand current state practice and local culture to inform future high-value care and quality improvement interventions to target over-ordering of daily labs. Methods: We employed mixed methods to assess lab ordering behaviors and attitudes at an urban quaternary academic medical center. Electronic medical record (EMR) data was gathered to assess the number of daily labs (BMP, CMP, and CBC) ordered on a general medicine unit from June–October 2020. We surveyed internal medicine (IM) attendings, residents, physician assistants (PA), nurse practitioners (NP), registered nurses (RN), and patient care associates (PCA) to understand cross-professional beliefs and attitudes about daily lab testing. Results:An average of 2.2 labs were collected per patient day. This was an increase from the 1.3 labs per patient day found in a similar patient population from March 2016 to August 2017 after the last daily lab reduction intervention. A widely distributed survey yielded 127 frontline staff responses: 29 (22.8%) attending physicians, 43 (33.9%) resident physicians and fellows, 12 (9.4%) PAs, 10 (7.9%) NPs, 14 (11.0%) RNs, and 19 (15%) PCAs. Of the 94 ordering providers (MD, DO, PA, NP), 73% thought they were unnecessary. No attending physicians designated daily lab testing as necessary, in contrast to 10% of NPs, 33% of PAs and 25% of residents. Only 29% of ordering providers agreed that daily testing improved patient care and safety; moreover, 89% believe it has potential harms. Of the residents, NP, and PAs, 68% cited worry over attending reaction and 97% cited training/habit as a reason for ordering unnecessary labs. Conclusions: Analysis of prior interventions on unnecessary lab testing has demonstrated a strong need for sustainable interventions to improve patient care and reduce costs. Our multidisciplinary survey highlights a major discrepancy between attendings and other ordering providers on the necessity of daily tests. These results reveal the potential impact of planned PDSA (plan-do-study-act) cycle interventions including planned educational sessions, the initiation of monthly audit and feedback email, and attending-led rounding discussions on necessary labs. Learning Objective #1: To describe the current state of daily labs ordered per patient in the context of prior interventions to reduce lab burden as a means to identify areas of improvement for future quality initiatives. Learning Objective #2: To assess interdisciplinary attitudes on daily laboratory testing to develop a sustainable quality improvement intervention.

Our understanding of the risk of lymphoma in inflammatory bowel disease (IBD) is confounded by conflicting data, the impact of immunosuppressive medications on that risk, and the introduction of newer agents in the management of IBD. As we alter how we strategize, stratify, and combine therapies, this risk will also alter. Recent data is reassuring in downplaying the risk of lymphoma associated with anti-TNF therapies specifically and brings to the forefront legitimate concerns of thiopurine (6-MP, azathioprine) use, especially in young men. This chapter will discuss the impact of IBD and IBD therapies on overall lymphoma risk. We will also discuss the role of Epstein-Barr virus (EBV) in the development of lymphoma and our evolving understanding of the risk of hepatosplenic T-cell lymphoma (HSTCL) with IBD therapies.