AL MDA 2019 Mid Winte r Confe re nc e Poste r Pre se nta tion - - PDF document

AL MDA 2019 Mid Winte r Confe re nc e Poste r Pre se nta tion

Abstra c t 19- 1- 01 T itle : T

ra nsfo rming De live ry o f Ca re a t the Ha rm Re duc tio n Clinic

Author: T

i Ho a ng , MS, OMS-I I I , Ala b a ma Co lle g e o f Oste o pa thic Me dic ine , Do tha n, AL

Summa ry: Opio ids we re histo ric a lly pre sc rib e d to tre a t c hro nic pa in a c ro ss the Unite d

Sta te s. Ho we ve r, it ha s tra nsc e nde d the b o unda rie s o f a ppro pria te me dic a l a pplic a tio n, a s pa tie nts b e c a me inc re a sing ly a ddic te d o r de pe nde nt. F

• r e xa mple ,

b e twe e n 2014 a nd 2015, Ma ssa c huse tts wa s o ne o f nine te e n sta te s to ha ve a sta tistic a lly sig nific a nt inc re a se in the ra te o f o pio id-re la te d de a ths.1 Be twe e n 2012 a nd 2016, the sta te sa w a 170% diffe re nc e .2 Ho we ve r, Bro c kto n, MA in pa rtic ula r e xpe rie nc e d a 367% diffe re nc e .3 By a na lyzing the c a use s o f re la pse in suc h a hig h-risk c o mmunity, da ta c a n b e e xtra po la te d to the sta te a nd/ o r na tio na l le ve l to ide ntify trig g e rs a nd sub se q ue ntly me tho ds o f pre ve ntio n o r c e ssa tio n. T we nty-thre e pa tie nts in the Bro c kto n Ne ig hb o rho o d He a lth Ce nte r (BNHC) Ha rm Re duc tio n Clinic (HRC) we re inte rvie we d o n-site b e fo re o r a fte r the ir a ppo intme nts. We a dministe re d a vo lunta ry surve y tha t c o nta ine d te n o pe n-e nde d q ue stio ns a b o ut b a rrie rs to so b rie ty, re la pse , mo tiva tio n a nd c o nfide nc e to a c hie ve g o a ls, a nd c linic impro ve me nt. Re po nse s we re a no nymo us a nd re c o rde d in a priva te se tting . Qua lita tive re sults we re c o nve rte d to q ua ntita tive re sults fo r a na lysis. Mo tiva tio n a nd c o nfide nc e to a c hie ve g o a ls we re ra nke d o n a sc a le o f 1-10. T he a ve ra g e fo r mo tiva tio n wa s 8.7 a nd c o nfide nc e 7.8. Appro xima te ly 60% o f pa tie nts re po rte d “me nta l he a lth” o r a so c ia l fa c to r a s a trig g e r fo r o pio id use o r re la pse . T he c o mmo n sug g e stio n fo r impro ving the HRC wa s to ha ve e ve ning o r we e ke nd a ppo intme nt time s a s we ll a s the a dditio n o f g ro up me e ting s. Ba se d o n o ur finding s, o ur re c o mme nda tio ns to impro ve de live ry o f c a re a t HRC we re e xpa nding a ppo intme nt a va ila b ility to the e ve ning s o r we e ke nds, the a dditio n o f e ve ning g ro up me e ting s, the hiring o f a ma le c o unse lo r, a nd inc luding a b e ha vio ra l o r me nta l he a lth spe c ia list in the sa me visit a s the physic ia n o r c o unse lo r. T he a b se nc e o f the se fe a ture s pa rtia lly e xpla ine d the disc re pa nc y b e twe e n the sc o re a ve ra g e s b e twe e n mo tiva tio n a nd c o nfide nc e in a c hie ving g o a ls. I de ntifying c a use s o f re la pse a nd se e king a re a s to impro ve tre a tme nt de live ry a re e sse ntia l in c urb ing the rise in

• pio id use .

Re fe re nc e s:

1 https:/ / www.c dc .g o v/ drug o ve rdo se / da ta / sta te de a ths.html 2 http:/ / www.ma ss.g o v/ e o hhs/ do c s/ dph/ sto p-a ddic tio n/ c urre nt-sta tistic s/ da ta -b rie f-

• ve rdo se -de a ths-ma y-2017.pdf

3 http:/ / www.ma ss.g o v/ e o hhs/ do c s/ dph/ sto p-a ddic tio n/ c urre nt-sta tistic s/ to wn-b y-

to wn-listing s-ma y-2017.pdf

Abstra c t 19- 1- 02 T itle : Mic ro sc o pic po lya ng iitis re la pse diffe rs fro m initia l pre se nta tio n Author: T

i Ho a ng , MS, OMS-I I I , Ala b a ma Co lle g e o f Oste o pa thic Me dic ine , Do tha n, AL

Summa ry: Mic ro sc o pic po lya ng iitis (MPA) is a ne c ro tizing va sc ulitis with fe w o r no

immune c o mple xe s a ffe c ting sma ll ve sse ls. Altho ug h it ha s dia g no stic o r sug g e stive fe a ture s, MPA do e s no t ha ve a sing le pre se nta tio n a nd c a n re la pse with diffe re nt sig ns a nd sympto ms. A 72-ye a r-o ld fe ma le pre se nte d to the e me rg e nc y ro o m with b la dde r pa in tha t b e g a n two we e ks prio r a nd dysuria a nd a b urning se nsa tio n upo n urina tio n tha t b e g a n o ne we e k prio r. She ha d so me he ma turia , a nd urine c ulture wa s po sitive fo r E nte ro c o c c us. He r c re a tinine wa s 2. Co nse q ue ntly, she wa s dia g no se d with a urina ry tra c t infe c tio n, urina ry re te ntio n, a nd a c ute kidne y injury. T he pa tie nt impro ve d with tre a tme nt a nd wa s disc ha rg e d with a c re a tinine o f 1.1. T wo mo nths la te r, she re turne d to the E R with we a kne ss a nd c o nfusio n fo r two we e ks. Afte r she finishe d he r c o urse o f a ntib io tic s a fte r disc ha rg e , the pa tie nt ha d two mo re e piso de s o f the sympto ms fro m the first E R visit, b ut the y we re wo rse this time . T he re wa s a n a dditio n o f a no re xia , we ig ht lo ss, fa tig ue , dizzine ss, sto ma c h pa in with b o we l mo ve me nts, dia rrhe a , vo miting , a nd le ft fla nk pa in. E rythro c yte se dime nta tio n ra te a nd C-re a c tive pro te in we re e le va te d. Urine a na lysis wa s do ne a nd wa s fo und to ha ve 4+ pro te in (4.1 g / dL ), 3+ b lo o d, hya line c a sts, a nd fe w e o sino phils. She ha d a c re a tinine (c r) o f 6, b lo o d ure a nitro g e n (BUN) o f 80, a nd g lo me rula r filtra tio n ra te (GF R) o f 7. Pro te inuria a b o ve 3 g ra ms pe r da y c o uld imply pre vio us ne c ro tizing g lo me rulo ne phritis, b ut a pre limina ry dia g no sis o f a c ute kidne y injury wa s ma de . T he pa tie nt b e g a n he mo dia lysis a nd tre a tme nt with do pa mine a nd pre dniso ne , re sulting in a n impro ve me nt in c re a tinine , BUN, a nd GF

• R. F

urthe r wo rkup with a n a b do mina l so no g ra m a nd e so pha g o g a stro duo de no sc o py yie lde d dia g no se s o f H. pylo ri-po sitive e ro sive g a stritis, a ntritis, a nd g a llsto ne s. He ma to lo g ic wo rkup re ve a le d po sitive p-ANCA, c -ANCA, a nd ANA. Re na l b io psy sho we d pa uc i-immune ra pidly pro g re ssive g lo me rulo ne phritis, whic h wa s sub se q ue ntly na rro we d to MPA. Ac c o rding ly, c yto xa n wa s a dde d to the me dic a tio n re g ime n. T he pa tie nt c o ntinue s to fo llo w-up with

• utpa tie nt ne phro lo g y. He r la te st BUN is 42, c r 3.3, a nd GF

R 15. T his c a se illustra te s the multisyste mic na ture o f MPA a nd ho w re la pse c a n po ssib ly ma nife st diffe re ntly fro m the initia l pre se nta tio n. T he re fo re , MPA c o uld b e c o nside re d in c a se s o f multisyste m dise a se in the c o nte xt o f re c urre nt ne phro sis. Re c o g nitio n o f this dise a se is c ritic a l to initia tio n o f a ppro pria te tre a tme nt a nd pre ve ntio n o f re na l de c line .

Abstra c t 19- 1- 03 T itle : Be tte r T

ra nsitio na l Ca re & Re imb urse me nt Outc o me s with I ntro duc tio n o f T OC T e mpla te in HE R

Authors: K

e lly Dia z, F a mily Me dic ine PGY3 – UAB Huntsville ; Shiva ni Ma lho tra , MD, UAB Huntsville

Introduc tion: I

n a n e ra o f va lue -b a se d c a re , tra nsitio ns o f c a re a re impo rta nt. T he Ce nte rs fo r Me dic a re a nd Me dic a id Se rvic e s (CMS) de fine s a “tra nsitio n o f c a re ” a s a tra nsfe r o f pa tie nt c a re fro m o ne se tting to a no the r (e .g . ho spita l, skille d nursing fa c ility, prima ry c a re o ffic e , e tc .) a nd imple me nte d CPT c o de s fo r tra nsitio na l c a re ma na g e me nt (T CM) in 2013. Ac c o rding to the Na tio na l T ra nsitio ns o f Ca re Co a litio n,

• ne in five U.S. pa tie nts disc ha rg e d fro m the ho spita l e xpe rie nc e d a n a vo ida b le

a dve rse e ve nt within thre e we e ks. Ho spita l re a dmissio ns a c c o unt fo r $15 b illio n do lla rs o f Me dic are spe nding a nd ~20% o f Me dic are be ne fic iarie s are re a dmitte d within 30 da ys.1 Prima ry c a re pro vide rs a nd the ir sta ff fa c e b a rrie rs in ide ntifying re c e ntly ho spita lize d pa tie nts, o b ta ining disc ha rg e summa rie s, a nd sc he duling fo llo w-up visits. T his tra nsla te s to po o r q ua lity o f c a re , pa tie nt dissa tisfa c tio n, inc re a se in pre ve nta b le re a dmissio ns, a nd lo st inc o me .

Hypothe sis: As a fa mily me dic ine re side nc y pro g ra m c o mpo se d o f 36 re side nts, we

hypo the size d tha t imple me nting a T ra nsitio n o f Ca re (T OC) no te te mpla te in o ur E HR wo uld a llo w fo r two ma jo r b e ne fits: (1) impro ve d ha ndo ffs b e twe e n inpa tie nt/

• utpa tie nt pro vide rs a nd (2) impro ve d c a pture o f tra nsitio na l c a re ma na g e me nt

c ha rg e s.

Me thods: On Ja nua ry 1, 2013, CMS e sta b lishe d tra nsitio na l c a re ma na g e me nt CPT

c o de s 99495 a nd 99496. T he se c o de s e nc o mpa ss a 30-da y se rvic e pe rio d a nd ma y b e b ille d the 29th da y fo llo wing ho spita l/ fa c ility disc ha rg e . T he c o de ma y b e b ille d o nc e during tha t 30-da y pe rio d. T hre e c o mpo ne nts c o mprise T CM: inte ra c tive c o nta c t, pro visio n o f c e rta in no n-fa c e -to -fa c e se rvic e s, a nd a fa c e -to -fa c e visit within se ve n to fo urte e n da ys.2 Our re side nc y pro g ra m c re a te d a n E HR T OC no te te mpla te b a se d o n Me dic a re g uide line s inc luding de ta ils o f ho spita liza tio n, pro vide rs fa milia r with the pa tie nt, a nd me dic a tio n re c o nc ilia tio n o n the da te o f disc ha rg e fro m the ho spita l. E a c h no te wa s se nt to c linic a nc illa ry sta ff who c a lle d pa tie nts to e nsure tha t a c ute ne e ds a nd no n-fa c e -to -fa c e se rvic e s we re me t a nd to sc he dule the pa tie nt fo r a fo llo w-up visit in c linic . T he n, the no te wa s fo rwa rde d to the pa tie nt’ s a ssig ne d prima ry c a re physic ia n a nd a tte nding physic ia n fo r re vie w a nd fina l sig na ture . T he T OC no te s re ma ine d in the me dic a l re c o rd a s a visua l trig g e r, so urc e o f info rma tio n, a nd do c ume nta tio n o f re q uire me nts ne e de d fo r b illing . Our T OC no te te mpla te wa s re le a se d in la te 2016 a nd re side nts, fa c ulty, a nd c linic sta ff we re e duc a te d thro ug ho ut 2017 a s the T OC no te wa s pilo te d. A re c o rd o f CPT c o de s 99495 a nd 99496 b ille d fro m 2016-2018 wa s ke pt.

Re sults: T

he numb e r o f tra nsitio na l c a re ma na g e me nt c o de s tha t we re b ille d inc re a se d e a c h ye a r. I n 2016, prio r to the ne w no te te mpla te b e ing wide ly use d, o nly 50 T CM c o de s we re b ille d. I n 2017 during the pilo t ye a r o f the inte rve ntio n, 149 T CM c o de s we re b ille d. I n 2018, 216 T CM c o de s we re b ille d a t the time o f this inve stig a tio n (e xc lude s mo st o f the mo nth o f De c e mb e r). T his re pre se nts a 332% inc re a se in T CM c o de s b ille d

fro m 2016 to 2018. T his c o rre la te s to a 348% inc re a se in po te ntia l re ve nue g e ne ra te d fro m T CM c o de s.

Conc lusions: Utilizing a spe c ia lize d tra nsitio ns o f c a re no te te mpla te in the e le c tro nic

me dic a l re c o rd c a n b e b e ne fic ia l in se ve ra l wa ys: to se rve a s a visua l c ue o f re c e nt ho spita liza tio n; to pro mpt o ffic e sta ff to fo llo w up b y pho ne a nd sc he dule a n a ppo intme nt; to impro ve c o ntinuity o f c a re a nd pro vide use ful ha ndo ff info rma tio n; a nd fina lly, to impro ve c a pture o f CPT c o de s 99495 a nd 99496. T he se finding s a re like ly no t uniq ue to o ur re side nc y pro g ra m a nd simila r T OC/ T CM no te te mpla te s ma y b e imple me nte d wide ly in o the r prima ry c a re se tting s.

Author Disc losure s: K

. Dia z: No ne . S. Ma lho tra : No ne .

Re fe re nc e s:

1Na tio na l T

ra nsitio ns o f Ca re Co a litio n. “I mpro ving T ra nsitio ns o f Ca re ”. Se pte mb e r 2010. <http:/ / www.nto c c .o rg / po rta ls/ 0/ pdf/ re so urc e s/ nto c c issue b rie fs.pdf> Ac c e sse d 12/ 30/ 18.

2De pa rtme nt o f He a lth a nd Huma n Se rvic e s Ce nte rs fo r Me dic a re a nd Me dic a id

Se rvic e s. “T ra nsitio na l Ca re Ma na g e me nt Se rvic e s”. Me dic a re L e a rning Ne two rk. I CN

• 908628. De c e mb e r 2016.

Abstra c t 19- 1- 04 T itle : L

a c o sa mide -Asso c ia te d Hype rna te mia

Authors:

Andre s Arc inie g a s, Unive rsity o f Ala b a ma a t Birming ha m Sc ho o l o f Me dic ine K a c i Shuma n, Aub urn Unive rsity Ha rriso n Sc ho o l o f Pha rma c y

• J. Grie r Ste wa rt, MD, CMD, FACP,

Unive rsity o f Ala b a ma Co lle g e o f Co mmunity He a lth Sc ie nc e s I nte rna l Me dic ine Cle rkship Dire c to r, De pa rtme nt o f F a mily, I nte rna l, a nd Rura l Me dic ine Ma rilyn Bullo c h, Pha rmD, BCPS, F CCM, Aub urn Unive rsity Ha rriso n Sc ho o l o f Pha rma c y Asso c ia te Clinic a l Pro fe sso r, De pa rtme nt o f Pha rma c y Pra c tic e

INT RODUCT ION: L

a c o sa mide , a ne we r-g e ne ra tio n AE D, is a ppro ve d a s a n a djunc tive a nd mo no the ra py a g e nt fo r pa rtia l o nse t se izure s. I ts e xa c t me c ha nism is unkno wn, b ut it ha s b e e n sho wn to se le c tive ly e nha nc e slo w ina c tiva tio n o f vo lta g e -g a te d so dium c ha nne ls, whic h is tho ug ht to c o ntrib ute to its a ntie pile ptic a c tivity. L a c o sa mide ha s b e e n no te d to ha ve fa vo ra b le pha rma c o kine tic a nd sa fe ty pro file s with ma jo rity o f its c o mmo n a dve rse drug re a c tio ns (ADRs) a ppe a ring to b e do se -re la te d a nd a ffe c ting the c e ntra l ne rvo us syste m (CNS) a nd g a stro inte stina l tra c t. T he drug ha s pre vio usly no t b e e n a sso c ia te d with c linic a lly sig nific a nt e ffe c ts o n la b o ra to ry va lue s o r vita l sig ns.1,2,3 As its use inc re a se s, it is impe ra tive tha t a c o mpre he nsive a nd a c c ura te side e ffe c t pro file is e sta b lishe d to e nsure its sa fe the ra pe utic use .

CASE DE SCRIPT ION: T

his c a se re po rt a na lyze s two e lde rly pa tie nts tre a te d within the sa me he a lth syste m a nd sub se q ue ntly disc ha rg e d to the sa me lo ng -te rm re ha b ilita tio n fa c ility who de ve lo pe d hype rna tre mia a fte r initia tio n o f la c o sa mide . Pa tie nt 1 wa s b ro ug ht to the e me rg e nc y de pa rtme nt (E D) with a c ute a lte re d me nta l sta tus (AMS) a nd ha d a witne sse d se izure in ro ute to the ho spita l. T he pa tie nt wa s initia te d o n la c o sa mide 100 mg intra ve no usly (I V) e ve ry e ig ht ho urs. While he re ma ine d inpa tie nt, the do se wa s a djuste d to 150 mg I V e ve ry twe lve ho urs a nd the n to 200 mg b y mo uth e ve ry twe lve ho urs, whic h wa s the do se re c o mme nde d a t disc ha rg e . On a dmissio n, the pa tie nt’ s so dium le ve l wa s 139 mmo l/ L , b ut o ve r the c o urse o f his c a re , his so dium ro se g ra dua lly with a pe a k va lue o f 161 mmo l/ L . He wa s disc ha rg e d to a re ha b ilita tio n fa c ility, whe re his so dium le ve ls re ma ine d e le va te d. His la c o sa mide do se wa s ta pe re d do wn to 100 mg BI D, a nd his so dium le ve l de c re a se d to 145 mmo l/ L . Pa tie nt 2 pre se nte d to the E D fo r e va lua tio n o f AMS se c o nda ry to a fa ll a nd he a d injury. T he pa tie nt wa s fo und to ha ve a la rg e le ft side d sub dura l he ma to ma a nd unde rwe nt a n e me rg e nt c ra nio to my, a fte r whic h he de ve lo pe d se izure s. T he pa tie nt wa s g ive n a

• ne -time do se o f la c o sa mide 400 mg I

V a nd the n initia te d o n 200 mg I V e ve ry e ig ht ho urs. While he re ma ine d inpa tie nt, he wa s switc he d to 200 mg b y mo uth e ve ry e ig ht ho urs a nd the n to 200 mg b y mo uth twic e da ily. He wa s disc ha rg e d o n 200 mg b y mo uth twic e da ily to a re ha b ilita tio n fa c ility. His so dium le ve l a t ho spita l a dmissio n wa s 132 mmo l/ L . T he so dium le ve l inc re a se d thro ug ho ut his inpa tie nt sta y with a pe a k va lue

• f 151 mmo l/ L

. While a t the re ha b ilita tio n fa c ility, the pa tie nt c o ntinue d la c o sa mide 200 mg twic e da ily fo r o ne we e k b e fo re the do se wa s ta pe re d do wn. He wa s switc he d to la c o sa mide 200 mg b y mo uth o nc e da ily a t b e dtime fo r fo urte e n da ys a nd the n to la c o sa mide 100 mg b y mo uth o nc e da ily a t b e dtime fo r se ve n da ys. L a b o ra to ry va lue s

ta ke n o ne we e k fo llo wing initia tio n o f the la c o sa mide ta pe r sho we d his so dium ha d re turne d to 144 mmo l/ L . One we e k la te r, his so dium de c line d furthe r to 142 mmo l/ L .

DISCUSSION: While this a dve rse e ve nt ha s no t b e e n pre vio usly re po rte d in the lite ra ture ,

the se c a se re po rts sug g e st do se -re la te d inc ide nc e s o f hype rna tre mia with la c o sa mide . Bo th pa tie nts’ Na ra njo sc o re s we re 7, whic h indic a te pro b a b le c a usa lity, b ut the sc o re s we re limite d fro m a c e rta in c a usa lity sc o re due to e thic a l re a so ns a nd sta nda rds o f c a re c o nside ra tio ns. T

• o ur kno wle dg e , this is the first re po rt o f L

a c o sa mide -a sso c ia te d hype rna tre mia in the lite ra ture . F urthe r study is ne e de d to c o nfirm the a sso c ia tio n b e twe e n la c o sa mide a nd hype rna tre mia .

Re fe re nc e s:

 Birnb a um AK, L e ppik I E , Sve nsde n K , e t a l. Pre va le nc e o f e pile psy/ se izure s a s a c o mo rb idity o f ne uro lo g ic diso rde rs in nursing ho me s. Ne uro lo g y. 2017;88:750-757.  Bito n V, Gil-Na g e l A, I so ja rvi J, e t a l. Sa fe ty a nd to le ra b ility o f la c o sa mide a s a djunc tive the ra py fo r a dults with pa rtia l-o nse t se izure s: Ana lysis o f da ta po o le d fro m thre e ra ndo mize d, do ub le -b lind, pla c e b o -c o ntro lle d c linic a l tria ls. E pile psy & Be ha vio r. 2015;52:119-127.  Chung SS. Ne w tre a tme nt o ptio n fo r pa rtia l-o nse t se izure s: e ffic a c y a nd sa fe ty o f la c o sa mide . T he ra pe utic Adva nc e s in Ne uro lo g ic a l Diso rde rs. 2010;3(2):77-83.  F a ug ht E , Ric hma n J, Ma rtin R, e t a l. I nc ide nc e a nd Pre va le c e o f e pile psy a mo ng

• lde r U.S. Me dic a re b e ne fic ia rie s. Ne uro lo g y. 2012;78:448-453.

 Ho y SM. L a c o sa mide : a re vie w o f its use a s a djunc tive the ra py in the ma na g e me nt

• f pa rtia l-o nse t se izure s. CNS Drug s. 2013;27(12):1125-42.

 Sa rkis RA, Sc hre ttne r M. Se izure s a nd e pile psy in the e lde rly. Pra c tic a l Ne uro lo g y. Ma rc h/ April 2018; 36-39.