Valery, Jose R.

Introduction: Advance care planning (ACP) supports goal-concordant care but remains underused nationally. In resident clinics, limited continuity, short visits, and lack of standardized workflows create barriers to ACP integration. In our Community Internal Medicine resident clinic, ACP discussion was documented in 2.5% of annual physicals, and 19.6% of paneled patients had an advance directive (AD) on file. We aimed to increase ACP documentation from 2.5% to 12.5% within 1 year without increasing perceived resident workflow burden. Methods: We conducted a resident-led quality improvement project using Lean Six Sigma methodology. Three interventions were implemented sequentially: nursing distribution of ACP brochures, an electronic medical record DotPhrase to prompt and document ACP discussions, and targeted patient portal outreach to patients without an AD before annual visits. The primary outcome was documented ACP discussion during annual physicals. Secondary outcomes included AD uploads and ACP consult referrals. The balancing measure was resident-perceived workflow burden. Charts were reviewed over 5-week periods at baseline (n = 118) and after each implementation phase (n = 132, 158, 129). Results: ACP documentation increased from 2.5% at baseline to 12.2%, 17.1%, and 24.0% across sequential phases (χ 2 (3) = 24.74, P < 0.0001). Pairwise comparisons versus baseline were significant (all P ≤ 0.005). AD upload rate increased from 1.7 to 6.0 per month, and ACP consult referrals increased from 0.0% to 10.9%. Mean perceived workflow burden decreased from 4.9 to 3.0. Conclusion: Workflow-embedded interventions improved ACP documentation, AD uploads, and ACP referrals without increasing perceived resident burden.

Abstract Pharmacogenomic (PGx) biomarkers integrated using machine learning can be embedded within the electronic health record (EHR) to provide clinicians with individualized predictions of drug treatment outcomes. Currently, however, drug alerts in the EHR are largely generic (not patient‐specific) and contribute to increased clinician stress and burnout. Improving the usability of PGx alerts is an urgent need. Therefore, this work aimed to identify principles for optimal PGx alert design through a health‐system‐wide, mixed‐methods study. Clinicians representing multiple practices and care settings ( N = 1062) in urban, rural, and underserved regions were invited to complete an electronic survey comparing the usability of three drug alerts for citalopram, as a case study. Alert 1 contained a generic warning of pharmacogenomic effects on citalopram metabolism. Alerts 2 and 3 provided patient‐specific predictions of citalopram efficacy with varying depth of information. Primary outcomes included the System's Usability Scale score (0–100 points) of each alert, the perceived impact of each alert on stress and decision‐making, and clinicians' suggestions for alert improvement. Secondary outcomes included the assessment of alert preference by clinician age, practice type, and geographic setting. Qualitative information was captured to provide context to quantitative information. The final cohort comprised 305 geographically and clinically diverse clinicians. A simplified, individualized alert (Alert 2) was perceived as beneficial for decision‐making and stress compared with a more detailed version (Alert 3) and the generic alert (Alert 1) regardless of age, practice type, or geographic setting. Findings emphasize the need for clinician‐guided design of PGx alerts in the era of digital medicine.

Background: Survey studies have found an increased prevalence of migraine in patients with inflammatory bowel disease (IBD). However, the clinical characteristics of migraines in this population are unknown. We conducted a retrospective medical record review study to characterize migraines in the IBD population. Methods: Six hundred seventy-five migraine patients (280 with IBD, 395 without IBD) who were evaluated at Mayo Clinic Rochester, Mayo Clinic Arizona, or Mayo Clinic Florida between July 2009 and March 2021 were included. Patients with ICD codes for migraine and either Crohn’s disease (CD) or ulcerative colitis (UC) were selected. Electronic health care records were reviewed. Patients confirmed to have IBD and migraine were included. Demographic, IBD, and migraine characteristics were collected. Statistical analysis was completed using SAS. Results: Patients with IBD were less often male (8.6% vs 21.3%, P < .001) and had a higher Charlson Comorbidity Index (>2: 24.6% vs 15.7%, P = .003); 54.6% had CD and 39.3% had UC. Patients with IBD had migraine with aura and without aura more frequently ( OR 2.20, P < .001 and OR 2.79, P < .001, respectively) than non-IBD patients. Additionally, those with IBD less commonly had chronic migraine (OR 0.23, P < .001) and less commonly had chronic migraine or treatment for migraine (ORs 0.23-0.55, P ≤ .002). Conclusions: Migraine with and without aura have increased prevalence in IBD patients. Further study of this topic will be helpful to clarify the prevalence of migraine, establish this population’s response to treatment, and better understand the reason(s) for a low rate of treatment.

Objective We sought to determine the prevalence and possible features associated with symptoms in adult patients diagnosed with an aberrant right subclavian artery (ARSA). Methods In this single-center retrospective study, 386 adult patients were diagnosed with ARSA on chest CT scans performed between June 2016 and April 2021. Patients were grouped by the presence of symptoms, which included dysphagia, shortness of breath, cough, and upper airway wheezing. Four cardiothoracic radiologists reviewed the chest CT scans to assess features of ARSA. Agreement and multivariable logistic regression analyses were performed to determine interobserver variability and features associated with the presence of symptoms, respectively. Results The prevalence of ARSA was 1.02% and 81.3% of patients were asymptomatic. Shortness of breath (74.6%) was the most common symptom. Interobserver agreement was acceptable with most variables having an interclass correlation coefficient or κ >0.80. A patient's height > 158 cm (OR: 2.50, P = 0.03), cross-sectional area > 60 mm2 of ARSA at the level of the esophagus (OR: 2.39, P = 0.046), and angle >108 degrees formed with the aortic arch (OR: 1.99, P = 0.03) were associated with the presence of symptoms on multivariable logistic regression. A distance increase per 1 mm between ARSA and trachea (OR: 0.85, P = 0.02) was associated with decreased odds of symptoms. Conclusions Aberrant right subclavian artery is an incidental finding in most adult patients. The cross-sectional area at the level of the esophagus, angle formed with the medial wall of the aortic arch, distance between the ARSA and the trachea, and a patient's height were features associated with the presence of symptoms.

Background: Non-vitamin K antagonist oral anticoagulants (NOAC) have replaced vitamin K antagonist (VKA) oral anticoagulants as the first-line treatment option for stroke prevention in high-risk patients with atrial fibrillation. With VKA therapy, disease and treatment-related knowledge is associated with improved adherence and outcomes. There is concern that due to the lack of need for ongoing visits for laboratory monitoring in patients on NOACs, there is less opportunity for education, leading to poor disease- and treatment-related knowledge in this patient group. Methods: One hundred ninety-nine (199) patients presenting to 2 primary care clinics on NOAC therapy were surveyed regarding atrial fibrillation and their knowledge regarding NOACs. Chart review was completed to determine patient characteristics and data obtained was compared with survey results to determine the accuracy of the survey responses. Results: Patients with a lower degree of NOAC knowledge tended to be older ( P < .001), have higher Charlson Comorbidity Index scores ( P = .001), use apixaban more often ( P = .008), and have been on NOACs for a shorter time period ( P = .007). Conclusions: There is an opportunity to improve NOAC-related knowledge in patients with atrial fibrillation. When developing educational interventions, patient characteristics associated with poor knowledge should be considered. Based on our results, these are patients who are older, more medically complex, are on apixaban, and have been on NOAC therapy for a shorter duration.

Abstract Background and study aim The clinical impact of eosinophilic esophagitis (EoE) limited to the distal esophagus (Lim-EE) vs. diffuse involvement (Dif-EE) is unknown. This study compared clinical characteristics and outcomes of Lim-EE vs. Dif-EE. Patients and methods This retrospective, single-center study of patients with EoE between December 2011 and December 2019 evaluated treatment response based on repeated pathology and/or clinical improvement using comparative statistics. Results 479 patients were identified (126 Lim-EE, 353 Dif-EE). Lim-EE patients had a higher incidence of endoscopically identified esophagitis (23.0 % vs. 14.7 %; P = 0.04), were older (50.8 [SD 16.2] vs. 46.4 [SD 15.3] years; P = 0.007), and were more likely to present with iron deficiency anemia (5.6 % vs. 1.7 %; P = 0.05), dyspepsia (15.1 % vs. 8.8 %; P = 0.06) or for Barrett’s surveillance (10.3 % vs. 3.7 %; P = 0.02). Patients with Dif-EE presented more frequently with dysphagia (57.2 % vs. 45.2 %; P = 0.02). Both groups had similar proton pump inhibitor (87.2 % vs. 83.3 %; P = 0.37) and steroid (12.8 % vs. 21.4 %; P = 0.14) use. Patients with Lim-EE had a better clinicopathologic response (61.5 % vs. 44.8 %; P = 0.009). On multivariate analysis, EoE extent predicted treatment response with an odds ratio of 1.89 (95 % confidence interval 1.13–3.20; P = 0.02). However, treatment response based only on repeat biopsy results showed no statistical difference between Lim-EE (52.5 %) and Dif-EE (39.7 %; P = 0.15). Conclusions Lim-EE may represent a distinct phenotype separate from Dif-EE, with more overlap with gastroesophageal reflux disease and better treatment response.

Abstract Clostridioides difficile infection (CDI) is an issue of great concern due to its rising incidence, recurrence, morbidity and impact on healthcare spending. Treatment guidelines have changed in the last few years, and new therapies are being considered. This is a practical review for the primary care practitioner of the latest guidelines for CDI diagnosis, treatment, and emerging therapies.

Introduction: Improving flu vaccination rates in the general population is an important and effective strategy toward reducing morbidity, mortality, and the cost of seasonal influenza. In order to optimize immunization strategies, factors associated with decreased vaccination rates need to be explored. The literature suggests that there is a gender difference in the rate of influenza vaccination but is limited to population-based survey studies and also is inconsistent as to which gender has a higher rate of vaccination. The purpose of this study was to evaluate for a gender-based difference in the rate of influenza vaccination among patients who presented for an annual physical examination during the 2018 to 2019 influenza season. Methods: In this multi-site, retrospective chart review, a total of 1193 patients (608 female and 585 male) who underwent an annual physical examination in April of 2019 were included. Baseline medical information was collected, as well as demographic characteristics and influenza vaccination status. The proportion of patients who underwent influenza vaccination was compared between males and females using multivariable logistic regression models; odds ratios (ORs) were estimated. Results: The likelihood of influenza vaccination was significantly higher in females (62.8%) compared to males (53.2%) in both unadjusted analysis (OR = 1.49, P < .001) and in multivariable analysis adjusting for the potential confounding influences of clinic location, BMI, insurance type, and occupation (OR = 1.42, P = .005). Interestingly, a higher influenza vaccination rate for females compared to males was observed in patients age<60 years (OR = 1.70, P = .025) and between ages 60 and 75 (OR = 1.66, P = .009), but not for patients older than 75 years (OR = 1.12, P = .66). Conclusion: Our findings indicate that the rate of influenza vaccination is higher for females than for males who presented for an annual preventive physical exam and who are younger than 75 years old.