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Item A STEP in the Right Direction: An Interdisciplinary Approach to Transitional Care (2017)(2017-03-14) Connally, Patrica; Allen, John G.Background: The Affordable Care Act, calls for more focus on finding innovative delivery systems that improve care, increase efficiency, and reduce costs. Purpose: Hospital readmissions, excessive falls, and poor quality of life are factors that unnecessarily increase healthcare costs. The Safe Transitions for the Elderly Patients (STEP) program is a hybrid transitional care model developed by the UNT Health Science Center (UNTHSC) as part of an 1115 Waiver to address these factors in a home care setting in Tarrant County. Objectives: The primary goals of STEP are to reduce all-cause 30 day hospital readmissions, improve quality of life, and decrease falls among Medicaid patients over 50 years through a collaborative and interdisciplinary approach to patient care. Methods: An interprofessional team that includes a physician/geriatrician, nurse practitioner, physician assistant, social workers, physical therapists and a dietician assess and treats the patient in the home for up to 90 days post hospital discharge based on the individual patient needs. Conclusions: Through this model, UNT Health Science Center has the opportunity to demonstrate a unique transitional care model that will improve health care delivery post-hospitalization.Item An Evaluation of Attitudes and Understanding of Vaccinations in Rural Populations(2017-03-14) Mamun, Md Abdullah; Handoyo, Anthony; Pulvino, John; Abraham, Stacy; Kaushal, DeepikaBackground: Recently in the media, there has been a movement to abstain from childhood immunizations. At the same time, a rise in the rate of preventable childhood diseases for which there are available immunizations has also been witnessed. It is known that the attitude towards vaccination of both the parents and providers and the knowledge about vaccines all influence vaccination compliance. Methods: My colleagues and I surveyed rural communities in Texas to assess parental knowledge and how that affected vaccination compliance. Clifton, Texas is located in Bosque County. As of the census of 2000, there were 3,542 people. Plainview, Texas is located in Hale County. The current census data reports a population of 22,194. Bilingual versions of surveys developed by Zingg et al were distributed to participants with children up to 10 years of age who live in or near the rural towns of Clifton or Plainview between the fall of 2015 and the spring of 2016. Results: When analyzing survey results, correct knowledge was estimated by summing over the number of correct answers for the 11 items in the survey. Using a multiple linear regression model our study revealed that here is statistically significant difference in knowledge on vaccination for parents who has a Bachelor degree or more in comparison to parents who are high school graduate or less after adjusting for the effects of race and number of children. However, there is no statistically significant difference in knowledge on vaccination for parents who has some college degree in comparison to parents who are high school graduate or less after adjusting for the effects of race and number of children. Conclusions: On an average, parent’s knowledge on vaccination increases as their number of children increases after adjusting for the effects of educational status and race. There is no statistical difference on vaccination knowledge in White versus Hispanic and White versus Other racial groups after adjusting for the effects of parent’s education and number of children.Item Assessment of a Faculty Mentoring Program Implemented at the UNT System College of Pharmacy(2017-03-14) Gibson, Caitlin; White, Annesha; Bullock, KaturaObjectives: As new pharmacy schools continue to be established, design and structure of faculty mentoring programs continues to receive increased attention. Effective mentoring can lead to increased faculty productivity and retention, and enhanced career satisfaction and achievement. Few studies have evaluated pharmacy faculty mentoring programs. The objective of this study was to (1) describe the nature and extent of mentoring relationships established at a new college of pharmacy and (2) compare those relationships based on whether the mentor involved was an on-site or off-site mentor. Methods: In 2016, a QualtricsTM survey was developed by members of the College Faculty Mentoring Study Group and the Assessment Committee and sent to faculty members with(1=strongly disagree, 5=strongly agree) and open ended questions. Descriptive statistics were used to summarize responses to both surveys. This study was approved by the IRB. Results: Of the 13 survey responses, the majority of mentees were female (69%), non tenure track (54%) and had one (38%) or two (54%) mentors. The preferred mentoring type was unstructured but in person (69%) and optimal duration for more than 1 year (54%). Time commitment to partnership was 1-2 hours per month (85%). General attitude towards mentoring was positive (85%). Respondents agreed or strongly agreed that their mentoring partnership increased their confidence in teaching (38%), research (69%) and service (69%). Mean scores were: My mentor was readily available (4.23), My mentor was a good match for me (4.00), I benefited from my mentoring partnership in terms of my personal growth (4.00), I am better prepared to advance my career (4.00) and overall satisfaction with the mentoring process (4.08). A comparison of on-site (77%) vs. off-site (23%) mentors showed a significant difference in responses to the items ‘I benefited from my mentoring partnership in terms of my personal growth’ (on-site mean 4.00 vs. off-site mean 5.00) and ‘My mentoring partnership has increased my work productivity’ (on-site mean 3.44 vs. off-site mean 5.00) (p Conclusions: Findings from the faculty mentoring program may assist other health disciplines in planning similar programs. Future research includes aims to compare views on mentoring by clinical vs. non clinical faculty.Item Benefits of a Pediatric Home Visitation Program Involving TCOM Students(2017-03-14) Raines-Milenkov, Amy; Bowman, Paul; Shah, Deep; Calder, BrittanyBackground: Home visitation programs increase child development, access to healthcare, and attendance at well child visits as well as decrease accidental injuries. By focusing on maternal and child health, there is the opportunity to prevent disease development, improve overall health, and decrease infant mortality. Including medical students in home visitation has the potential to build relationships and understanding that increases quality of care and learning. The purpose of this project was to assess the feasibility and benefits of incorporating Texas College of Osteopathic Medical (TCOM) students into an existing UNT Health Science Center home visitation program. Methods: To assess the feasibility of this type of model at UNTHSC, a literature review of home visitation programs that involve medical students was conducted. Additionally, an interview and review of similar UNTHSC programs were conducted. Results: The literature revealed several benefits for student learning. For example, medical students found that many of their misconceptions about their patients and their care were corrected by visiting the patient's home. Additionally, students felt they could provide better care after seeing the environments where their patients lived. The experience also helped the students view the patient as a person not just their disease and increased humanism in their care. Conclusions: The literature suggests incorporating medical students into home visitation programs has benefits for the medical students and their future practice. UNTHSC has existing assets that could foster this type of educational experience. For example, the Healthy Start Program is a home visitation program with the intention of improving maternal and infant health. This program would be the backbone for a program involving medical students. Additionally, TCOM has a geriatric home visitation program whose logistics and curriculum could be used as a layout for a similar pediatric based program. A logic model detailing a sample pilot project will be presented. By building from established programs, instituting a pediatric home visitation program involving TCOM students could improve the quality of the medical students’ education while embracing the osteopathic model and providing service to the community. However, more research is needed to understand the program participant’s perspectives and acceptability of receiving services from medical students.Item Comprehensive literature examination to derive terminology currently used to describe pharmacist provided services and to develop a checklist for research and journal editors(2017-03-14) Huang, James; Clay, Patrick; Abebe, BrightonBackground: Reporting of pharmacist interventions in research publications requires a detailed description of the intervention and language used to evaluate them. However, reviews and meta-analyses of publications of pharmacist interventions often reveal insufficient and incomplete information. Further practitioners and policy makers who rely on pharmacists publications to inform decision making, identified lack of cohesiveness in the manner in which pharmacist interventions are described in publications. Incomplete reporting of interventions hinders the optimal use of research, and fails to meet broader applications. Pharmacist researchers are aware of CONSORT but the median overall compliance is low and the checklists is not fully appropriate for pharmacist interventions. The purpose of this research was to develop a checklist, with key emphasis in intervention and standardized lexicon to potentially enhance the quality of pharmacy research. Methods: This is a 4-step study. First stage was to extract the actual services provided by pharmacists from the methodology section of publications and compile a services provided category. The search for publications focused on PubMed database and evaluated using the PRISMA checklist. Second stage was to assess existing checklists used by researchers and design a draft checklist. The remaining two stages will externally validate the checklist by collecting qualitative feedback from experts in research, policy, and practice. Stage three is to validate the content of the draft checklist to a collection of relevant manuscripts with the help of independent reviews. State four is to conduct large-scale iterative testing to demonstrate relevance to a wider range of stakeholders. Results: From a database search of nearly 4,581 publications 30 RCT publications were eligible for extracting actual services provided by pharmacists. The SNOMED CT was also used to extract services. The terminologies were then added to the checklist. The checklist included 7 main questions (constructs) titled Intervention, Provider, Delivery Mode, Demographic, Schedule, Setting, and Authorization. Stage three and four are proceeding this summer. Conclusions: A draft pharmacist intervention lexicon and checklist has been developed for use by pharmacist. A unique advantage of this proposed checklist is the incorporation of an evidence based lexicon within the checklist providing the pharmacy service nomenclature to use in publications.Item Concomitant Opioid and Benzodiazepine Use: A Systematic Review(2017-03-14) White, PharmD, MS, PhD, Annesha; Vernachio, Kimberly PharmD; Pfluger, KassieObjective: In opioid users, the concomitant use of a benzodiazepine medication is associated with an increased risk of adverse reactions and overdose due to the synergistic effects on sedation and respiratory depression. The degree to which adverse events and overdoses occur is unclear when assessing patient characteristics, dosage and formulation. The objective of this study was to review the literature on the incidence and prevalence of an adverse event or death after concomitantly taking an opioid and benzodiazepine prescription medication and to assess the impact on the formulation, dosing, or administration of the medication in overdose. Methods: A review of the literature was performed using the following databases: PubMed, PsycINFO, the Cochrane Library, and Scopus for peer-reviewed journal articles in English to identify studies regarding concomitant benzodiazepine and opioid medication overdose in adolescents and adults for non-cancer pain August 2006 through August 2016. Relevant publications and their reference lists were reviewed to assess for inclusion criteria based upon relevance and quality. Applicable publications were reviewed and included whether outcomes of patients were clearly documented by medication use. Information on the study design, sample characteristics, purpose of study, intervention components, primary outcome, key findings and risk of bias were abstracted for each article and presented in a table. Articles were excluded from the review if concomitant use of benzodiazepine and opioid analgesic was not clear or intentional suicide was indicated as the cause of mortality. Key search terms utilized were: ‘opioid analgesic’, ‘benzodiazepine’, ‘non-cancer pain’, ‘substance-related disorders’, ‘polypharmacy’, ‘co-prescribing’, ‘illicit use’, and ‘overdose’. Results: Findings revealed 11 articles in the literature. Results are presented in a summary of findings table. Relevant studies assessed morbidity and mortality associated with opioid and benzodiazepine use, incidence of non-prescribed medications or illicit drug use, and descriptive information on patient populations of greatest risk of overdose. Common reasons for not selecting a particular article were due to study design and incomplete information of medications within each class. Conclusions: The prevalence of opioid and benzodiazepine misuse and abuse has warranted international attention due to the increased overdose risk with concomitant use. More information is needed regarding dosing, formulation, and particular agent for opioids and benzodiazepines. Assessment of mortality risk is lacking when comparing acute versus chronic drug users and abusers. The incidence of overdose increases as potency increases or when an illicit agent is included due to the central nervous system (CNS) depressant effects.Item Decreasing Inefficiencies in the Community Pharmacy Setting: Addressing the Top Issues in Patient Centered Care(2017-03-14) White, Annesha; George, Emanuel; Butler, Michell; Tran, NganObjective: The objective of this study was to review the literature in the last decade regarding inefficiencies in the community setting with respect to patient centered care. A 2013 study showed that 46.3% of 162 indemnity claims paid to patients due to a medication error were attributed to independent community pharmacies, while 34.6% from chain pharmacies. Additionally, 43.8% of all claims paid were a result of the patients’ injuries due to dispensing error. Sources for dispensing errors included: patient misidentification, improper computer coding, and nonadherence. Nonadherence is estimated at $300 billion annually. In contrast to the institutional setting, there is lack of literature emphasizing the inefficiencies in the community setting. Methods: Articles identified from electronic databases, Google Scholar, PubMed, and Scopus, from January 2006 to December 2016, were summarized in a table. A diagram and a visual display were created to represent an ideal community pharmacy of the future. Key search terms were “community pharmacy and efficiencies”, “community pharmacy and inefficiencies”, “retail pharmacy and efficiencies”, “retail pharmacy and inefficiencies”, “retail pharmacy workflow”, “retail pharmacy medical error”, “retail pharmacy dispensing error”, “dispensing error cost”, “patient centered care”, and “nonadherence”. Results: Seventeen articles and reports identified were categorized into inefficiencies associated with workflow and patient nonadherence. Inefficient workflow leads to prescription errors, time loss, and decrease in patient care. Moreover, the generic layout of the pharmacy creates a barrier in pharmacist-patient interaction. Also, prescription abandonment added unnecessary labor and resulted in poor patient outcome. Conclusions: A more efficient, patient centered care layout of the pharmacy is proposed utilizing the six-sigma tools to drive process improvement in the pharmacy. Although studies shows tools and technologies are available to increase efficiency, utilization remains low. This study highlights the benefits of incorporating technology to improve pharmacy operations. Maximizing technology may give pharmacists more time for patient-centered care service.Item Description of Home-Based Medication Therapy Management Services in an Interprofessional Transitional Care Program Aimed at Reducing 30-Day Hospital Readmissions(2017-03-14) Elrod, Shara; Rhoads, David; Nguyen, Benjamin; Li, DianaPurpose: Since the establishment of the Hospital Readmission Reduction Program (HRRP) in 2012, preventing 30-day unplanned hospital readmissions is crucial for reimbursement by Centers for Medicare & Medicaid Services. Published reports have shown pharmacist interventions after hospital discharge are associated with a smaller incidence of medication errors 30 days after hospital discharge, but most of these reports include pharmacists making follow-up phone calls. No published reports have described home-based pharmacy services as a part of transitional care programs designed to reduce unplanned 30-day hospital readmissions. This project describes the inclusion of a pharmacist as a part of an interprofessional transitional care team. Methods: Safe Transitions for the Elderly Patient (STEP) is a transitional care program for Medicaid-eligible adults at least 50 years of age who have been recently discharged from the hospital in Tarrant County, TX. Enrolled patients receive an intake home visit from a medical provider within the first 72 hours after discharge which includes referral to other STEP providers (e.g. pharmacists, physical therapists and social workers). Patients on high-risk medications, who are believed to be non-adherent to medications or need short-term medication management were referred to the pharmacist (0.3FTE) for home-based medication therapy management (MTM) services. All patient encounters are documented in an electronic health record (EHR). Risk stratification scores were calculated by including the total sum of each the following parameters: problem meds, psychiatry, polypharmacy, health literacy, patient support, prior hospitalization, and palliative care. High risk stratification scores were defined as those with 5 having or more risk factors. Descriptive statistics were used to characterize the study population. Pearson’s chi-square was used to examine the association between categorical variables. Results with a p value less than .05 were considered statistically significant. Patients enrolled in the STEP program during the time pharmacists provided services were included in this analysis (August 2014 to January 2015 and October 2015 to July 2016). Results: A total of 366 patients were enrolled in STEP during the specified time frame with 79 being seen by the pharmacist. The mean ages in those who were and were not seen by the pharmacist were 63.4 years (range 50-92) and 66.5 years (range 50-98), respectively (p=0.02). The majority of the patients seen by the pharmacist were women (72%, n=57), which was not significantly different than those not seen by the pharmacist (p=0.44). The median number of medications in those who were and were not seen by the pharmacist were 15 (range 3-38) and 11 (range 1-32), respectively (p=0.0002). Of the patients seen by the pharmacist who reported race/ethnicity, 35.4% identified as Black or African American (n=28). The proportion of all STEP patients with calculated risk stratification score was 93% (n=342). The proportion of patients with high risk stratification scores for those who were and were not seen by the pharmacist were 49% and 57%, respectively (p=0.22). The most common discharge diagnoses for patients seen by the pharmacist were heart failure and COPD exacerbations. Hospital readmission rates were not found to be significantly different in those who were seen by the pharmacist versus those who did not (10%, 14%, p=0.34). Conclusions: Hospital readmission rates were not found to be significantly different between those patients who were seen by a pharmacist as part of a home-based interprofessional transitional care team versus those who were not. Overall hospital readmission rates were low for both groups. In this program, patients who saw the pharmacist were more likely to be younger and be taking more medications than those who did not see the pharmacist. Patients who saw the pharmacist did not have significantly higher risk stratification scores than those patients who did not see the pharmacist. More research is needed to demonstrate the benefit of home-based pharmacy transitional care services.Item Effect of Screw Type and Pilot Hole on Screw Fixation in Osteoporotic Metaphyseal Bone(2017-03-14) Nana, Arvind; Kosmopoulos, Victor; Patel, Shiv; Smith, Morgan; Rowland, RyanIntroduction: Osteoporosis is a disease in which weakening of the bone occurs due to increased bone resorption and/or decreased bone deposition. Adequate screw fixation can be difficult to achieve in osteoporotic bone leading to hardware loosening or failure. With the steady increase in the number of geriatric fractures as well as the incidence of osteoporosis, it is important to investigate the relationship between screw type and pilot hole diameter in order to use the best combination when fixating screws in osteoporotic bone. Thus, this study aims to compare osteoporotic bone screw fixation using cortical and cancellous screws placed with two different pilot holes. Fixation success was mechanically evaluated using screw pullout strength and stiffness. Methods: Eighty osteoporotic metaphyseal sawbone model blocks (10# cellular foam 40 mm thick, laminated on 1 side with 20# solid foam 3 mm thick, finished dimension 40x40x43 mm, standard tolerances; Pacific Research Laboratories Inc., Vashon, WA) were equally divided into 2 separate groups. Forty blocks received 2.0 mm pilot holes and the other forty 2.5 mm pilot holes. Each of the two different pilot hole groups then had a total of twenty 3.5 mm cortical screws and twenty 3.5 mm cancellous screws placed by a junior resident and a staff orthopedic surgeon. This resulted in the following four, 20 sample, testing configurations: (A) 3.5 mm cortical, 2.5 mm pilot; (B) 3.5 mm cortical, 2.0 mm pilot; (C) 3.5 mm cancellous, 2.5 mm pilot; and (D) 3.5 mm cancellous, 2.0 mm pilot. Pullout strength and stiffness were studied using a material testing system (MTS 858 Mini Bionix, MTS Systems Corp., Eden Prairie, MN) following the American Society for Testing and Materials standard (ASTM F543-13). A two-way balanced ANOVA was used to compare and identify differences between the 4 different configurations. Results: Configuration (D) resulted in the highest mean pullout strength (481.4 N) and stiffness (557.8 N/mm) and was thus the best configuration for this bone type. The 2.0 mm pilot holes outperformed the 2.5 mm pilot holes for each screw type. Furthermore, the 2.0 mm pilot holes were more important in the success of fixation than the type of screw. These conclusions are evident when comparing the resulting 372.2 N and 433.4 N pullout strengths of configurations (A) and (B), respectively, and the 433.4 N and 413.2 N pullout strengths of configurations (B) and (C). Significant differences in pullout strength (p=1.17e-5) and stiffness (p=0.0087) were found between different pilot holes. Significant differences were also found in pullout strength (p=0.0018) but not stiffness (p=0.3022) between the different screw types. Conclusions: With the incidence of osteoporosis on the rise, there is a need for improved hardware fixation. The results from this study support the use of configuration (D) for this type of bone. This configuration, with the 3.5 mm cancellous screw and the 2.0 mm pilot hole, resulted in highest pullout strength and stiffness as compared to the others tested in this study. Furthermore, the results show that pilot hole size is more important in successful fixation than screw type.Item Efficacious Integration of Health and Wellness Coaching into Clinical Care for Weight Management: A Review and Proposal(2017-03-14) Lee, Jenny; Alpini, SarahObjective: We examined health and wellness coaching in a clinical setting to motivate patients to pursue healthy lifestyles towards effective and sustainable weight management, and proposed an efficacious approach to integrate coaching into clinical care weight management. Methods: We conducted a systematic review of literature for the past 10 years concerning coaching for weight loss in a primary care setting, which yielding 75 studies. Abstracts were reviewed and excluded if they concerned non-coaching interventions or coaching in the context of non-obesity. After exclusion and inclusion criteria, 11 coaching studies were considered for evaluation. Studies were considered efficacious if the coaching intervention resulted in clinically meaningful weight loss (> 5% initial body weight in six months) or statistically significant weight loss compared to standard care. Selected studies were analyzed according to the approach coaching was applied towards weight management including: who administered coaching, how patients coaching, dosage of coaching intervention, and the results of treatment. Results: Coaching resulted in clinically meaningful weight loss in nine studies and statistically significant weight loss in four. Coaching offered at least at a moderate dose (>1/month) with a trained coach was most efficacious in achieving clinically meaningful weight loss. Coaching interventions for longer time frames was more likely to foster sustained weight loss. Coaching was successful in a variety of settings and with electronic support. Coaching also significantly improved diabetes and cardiovascular risk factors, healthy behaviors, and self-sufficiency for maintaining these changes. Conclusions: The present study may contribute to the growing evidence of coaching as an efficacious and sustainable lifestyle intervention strategy for clinical weight management. It is recommendable for primary care practitioners to integrate health and wellness coaching into their clinical encounters to promote behavioral changes in patients who are overweight or obese. We propose that coaching is most successful when integrated for a prolonged time frame, minimally at a moderate to high intensity frequency, via various modes of delivery, and with a coach who has completed coaching training. Coaching was also successful when personalized to suit patient needs, which will help providers optimize patient care and enable patients become advocates for their own health.Item Enhancing Healthcare Quality Research Efforts at UNTHSC: A Three-Phase Plan for Interprofessional, Student-Driven Projects(2017-03-14) Traylor, Kathleen; Sembajwe-Reeves, Catherine; Reynolds, ConnerBackground: According to recent epidemiological studies, medical error is the third leading cause of patient death in the United States. There are also many factors independent of delivery that prevent access to healthcare altogether, including lack of health insurance coverage, the financial burden of healthcare, and having a usual source of care. In order to fully optimize patient health, the practical implementation of care must be addressed. On May 17, 2016, in collaboration with Texas Christian University, John-Petersmith Health Network, and Cook Children’s Medical Center, the University of North Texas Health Science Center (UNTHSC) launched its Institute for Patient Safety (IPS). This institute aims to improve healthcare throughout the nation, by patient-centered, interprofessional initiatives that directly impact healthcare safety, delivery, and accessibility. Aim: The UNTHSC Institute for Healthcare Improvement (IHI) Chapter seeks to fortify IPS efforts by increasing student involvement in quality improvement projects. Methods: To achieve this aim we propose a three phase plan, utilizing students from a variety of academic and healthcare professional track backgrounds. In Phase 1, interprofessional teams will collaboratively generate a Needs Assessment Survey (NAS) to determine needs within a chosen target population. In Phase 2, subgroups will use NAS results to drive design and implementation of quality improvement measures from multiple healthcare professional levels. In Phase 3, all students will contribute to establishing a new NAS group, thus ensuring the stable growth and sustainability of new quality improvement at UNTHSC. Conclusions: We believe this plan is uniquely suited for UNTHSC, utilizing the breadth of healthcare specialties present on campus in a mission towards substantial improvement for target populations in North Texas.Item Evaluation of effect of adherence patterns on the sample size and power: A simulation study(2017-03-14) Fossler, Michael; Chaturvedula, Ayyappa; Mallayasamy, SurulivelrajanPurpose: Adherence to medication regimens is an important factor contributing to the success of a therapy both in clinical trials and practice. The objective of our study was to evaluate the effect of adherence patterns on the sample size and power of a clinical trial using population pharmacokinetic (PK)-pharmacodynamic (PD) model-based simulations linked to quantitative adherence models. Methods: Longitudinal plasma concentration (PK) and pharmacological effect (PD) data were simulated in n=200 individuals per each group of test and standard-of-care (SOC) in each dataset. The population PK model used was a two compartment model with oral absorption. The PD model used was an indirect response inhibitory model. Two scenarios of PK behavior, A-short half-life (~12 hours) and B-long-half life (~35 hours) were simulated by altering the clearance parameter. Two scenarios of PD behavior, C-slower onset of effect (~4 weeks) and D- faster onset (~2 weeks) were simulated by altering the fractional turnover rate. Commonly seen drug PK-PD characteristics were generated by a combination of AC, AD, BC and BD scenarios. Non-Adherence, in terms of dose omissions (0-50%), was simulated as binary variable (missing a dose-0, taking a dose-1) using a discrete time first order Markov model. Test and SOC groups varied in their potency parameter in the PD model (EC50) such that test showed superior effect. Simulations were conducted using NONMEM software. The standard deviation (SD) of the effect at the 5th week of treatment was calculated from the simulated data and used for power and sample size calculations assuming various effect sizes. Results: Increasing non-adherence increased the variability (SD) of outcome in the simulated trials. The drug feature of long-half life with faster onset (BD) was more tolerant to the effects of non-adherence on statistical power. The drug feature of short half-life with slower onset (AC) was the most affected type by non-adherence. The sample size requirements could double depending on the adherence level and effect size. For smaller effect sizes, non-adherence can cause a significant drop in power and require large sample sizes. Conclusions: The effect of non-adherence on sample size and power is a function of drug PK-PD characteristics and effect size. Careful consideration of adherence patterns in clinical trial simulations could provide a valuable tool for designing successful trials.Item Factors Influencing Selection and Retention of Primary Care Practice by Texas Physician Assistants: A Mixed Methods Approach(2017-03-14) Williams, Jeffrey; Orcutt, Venetia; Lemke, HenryPurpose: Identify and describe factors that influence Texas Physician Assistant (PA) graduates to initially select and/or remain in primary care practice. We sought to answer these questions: 1) What factors influence PA graduates to select and/or remain in primary care in Texas? 2) How do these factors influence the PA’s choice to initially select and/or remain in primary care? and, 3) Based on factors explored, can strategies be developed to enhance placement of graduates in primary care settings? Methods: PA licensure data was extracted from the Texas Medical Board to determine graduate characteristics from 3 of 8 Texas PA programs, including age, gender, ethnicity, race, years since graduation and current practice type. A stratified purposeful sampling frame was used to identify subjects for participation in scripted telephone interviews. Transcripts were analyzed to identify, code, and sort emerging themes using NVivo 10 (QSR International, Australia). Results: 1556 licensed PAs were identified from 3 participating Texas PA programs, representing 21.5% of all licensed PAs (n=7253) in Texas as of January 2015. Of these, 35% (n=548) were practicing in primary care. Descriptive analyses revealed the majority of graduates working in primary care were female (70.6%) and white (57.5%), with a mean age of 40. A total of 24 PAs were interviewed. Factors impacting on participants’ decisions to select or remain in primary care fell into 4 general themes. These were relationships developed with patients, personal gratification from “making a difference” in the lives of patients, the intellectual challenge and/or variety of problems seen in the primary care setting and the influential role of educational experiences. Conclusions: While previous studies have examined factors influencing physician assistant career choice, this study contributes uniquely to the literature by qualitatively examining graduates perspectives on factors influencing their career decision. Our findings suggest that PAs decisions to work in primary care are motivated by similar factors as physicians. The decision to select or remain in primary care was influenced by the individual’s desire for meaningful patient relationships that provide a feeling of making a difference in an environment rich with variety and intellectual challenges. Results also suggest that educational experiences can be leveraged to improve the number of PA graduates selecting primary care as a career choice.Item 'Happiness is the Path:' An Overview of and Initial Data from a Resident Wellness Program at Weatherford Regional Medical Center(2017-03-14) Rheams, Christopher; Nash, Lisa; Cash, Kyle; Finn, Stephanie; Pavelek, TaraPurpose: Resident education programs are challenging-mentally, physically, and emotionally. As residents progress through the training program, the novice physicians often neglect their own wellness. Poor self-care is primarily because of poor diet, lack of exercise, lack of sleep-hygiene, and a failure to maintain healthy personal relationships. Physician burnout brings a host of collateral consequences, including an increase in mental illnesses such as mood disorders, addiction disorders, and increased rates of suicide. Methods: Weatherford Regional Medical Center’s Graduate Medical education department implemented a resident wellness program during its inaugural year. The program helps to prevent or mitigate the burnout that often accompanies residents during their training. The Resident Wellness Committee coordinates the program. The interdisciplinary team consists of Residency Coordinators, Internal Medicine faculty, and residents. The Wellness Program uses a multi-faceted approach to both prevent and screen for physician burnout that utilizes a reporting system, didactics, and events. The program has created an anonymous reporting system that is available to all hospital employees; this allows all hospital employees to voice concern regarding the well-being of our residents. Focused didactics address topics related to resident stress, burnout, and emotional exhaustion. The program holds quarterly “Wellness Events” and all residents are excused from clinical duty to attend. This fosters a supportive atmosphere and provides activities geared towards enhancing the individual’s well-being. These activities include physical activity, designated personal time, and social activity to deepen interpersonal connections. The wellness committee has developed tools to evaluate and track the resident’s well-being. The program uses anonymous surveys collected from the residents twice a year to evaluate for signs of burnout, depersonalization, emotional exhaustion, and a sense of personal accomplishment. Feedback from the initial surveys allows for an early assessment of the program’s effectiveness. Each medical learner was asked to answer a series of questions that address personal levels of depersonalization, emotional exhaustion, and personal accomplishment. Nineteen medical learners participated in the survey (7 Internal Medicine residents, 6 students, and 6 traditional rotating interns). The scaled questions were tabulated and used to quantify each category. Results/Conclusions: The initial study yielded promising results. The Wellness Committee looks forward to seeing the impact of these programs as they continue to gather data and responses from residents. As the program continues, the Committee will continue to assess and expand the Wellness program. Unseen and unexploited opportunities exist for improving the quality of resident professional experience and their personal lives. Wellness programs such as Weatherford Regional’s also have a positive implication for the patient’s quality of care. By addressing the mental wellness of the medical professional community, the pool of healthcare providers in Texas will increase both in quantity and quality.Item Identifying problem areas and providing solutions to coordination of care in Urgent Care to Emergency Department transfers within a pediatric health care system(2017-03-14) Severson, Samantha; Welch, JoAnn; Reed, AlexandraPurpose: Pediatric urgent care centers (UCCs) provide access to convenient, on demand medical care for patients who have non-emergent medical needs. Although, most patients who present to UCCs can be appropriately treated and discharged home, some patients present with medical needs outside the scope of practice for the UCC and are transferred to an emergency department (ED) for further evaluation. Currently, there are no established standards for such patients who need transfer of care from a pediatric UCC to an ED. This study examines the UCC to ED transfer process in an integrated pediatric health care system, identifies inefficiencies, and proposes a solution. Materials and Methods: The records of all patients transferred from a suburban UCC site to the urban, high volume ED between July 1, 2015 and May 16, 2016 were retrieved from the system’s transport department. Using retrospective chart review, UCC transfer diagnosis, ED discharge diagnosis, patient no shows, and those who left without being seen (LWBS). Results: Of the 245 transfers, 14 (6%) never arrived or LWBS and, 221 (96%) of these had non-missing values on the variables of interest. The ED provider noted in the ED record that the patient was a transfer from the system’s UCC in 167 (76%) cases. However, the review the UCC record was documented in only 58 (26%) cases. The patient was subsequently admitted to the ED in 51 (23%) cases. Using logistic regression, results showed that ED providers were more likely to review the UCC record when the chart stated that the patient was sent from the UCC (P Conclusions: This study revealed that in 1 out of 4 cases the ED providers were not aware that the patient was transferred from the UCC. Additionally, in 3 out of 4 known UCC transfers, the ED providers didn’t review the transfer records. These results demonstrate that the transfer of information from the UCC to ED during the transfer process has many opportunities for improvement. Based on these findings, a quality improvement initiative was implemented in November 2016: UCC providers now place bands on patients, who are to be transferred to the ED to signify to the ED staff that the patient was transferred. In summer 2017, transfer data based on this program will be compared to the results above to examine the efficacy of this initiative.Item Impact of Palliative Care on Healthcare Outcomes in Complex Chronic Pediatric Patients(2017-03-14) Farias, Kimberly; Dang, The; Lawrence, Katie; Hoeft, Alice; Hamby, Tyler; Price, RachaelPurpose: Palliative Care (PC) has been correlated with decreased length of stay and cost of care and with fewer ICU visits, administered medications, and medical interventions. Additionally, research has correlated PC with better quality of life, quality of care, continuity of care, and management of family needs. Through patient and family health care education, PC services are able to reduce hospitalizations and normalize the patients’ lives as permitted by their medical conditions. The purpose of this research was to determine whether PC has had a positive impact on the care received by pediatric patients with complex chronic conditions at a single institution. Methods: A retrospective investigation was conducted on all pediatric patients with complex chronic conditions who died at Cook Children’s Medical Center between January 2013 and December 2014. For each patient, demographics, diseases, number of hospitalizations, and age at death were abstracted. For each patient visit, data collected included PC involvement, number of medications, length of stay, and whether a MOST form (medical orders for scope of treatment) was completed. Results: There were 43 total patients in this study (49% male), and 12 patients had at least 1 PC visit. Patients who had at least 1 PC visit did not differ from patients with no PC visits in demographic variables, disease, age at death, or in the rate of MOST orders, but they had greater number of hospitalizations, longer lengths of stay, and less medications per day than non-PC patients. Conclusions: The finding that PC patients had a smaller average number of medications per day could be due to the healthcare team taking into account the total effect of polypharmacy on a patient, and then selecting only the most necessary medications. The finding that PC patients had longer and more frequent hospitalizations could be due to the late initiation of PC, instead of PC’s intended early application. Lack of knowledge of what PC services offers to patients, and a misconstrued view of PC services could be contributing factors to the delay in start. Frequently providers view PC as end of life care only, so its late initiation most likely biased the results. Increasing providers’ knowledge of the services that PC has to offer could increase its early initiation with patients and possibly decrease the length of stay and frequency of hospitalizations.Item Implementation of TeamSTEPPS For Patient Safety In Long Term Care Settings(2017-03-14) Severance, Jennifer; Ross, SarahPurpose: Patient safety is a recognized component to reducing hospital readmissions and preventable adverse events, although little is known about improving patient safety in skilled nursing settings that have an increasingly frailer and more dependent patient population due to shorter inpatient hospital stays. With a long term goal of improving the safety and quality of care provided to skilled nursing facilities (SNF), the University of North Texas Health Science Centers’ Center for Geriatrics will use a case study method to evaluate factors related to the implementation of a patient safety improvement intervention in SNF. Methods: The research team will review SNF data from secondary data sources reporting on CMS quality measures over a twelve month period to assess facility characteristics and facility performance and patient outcomes against national benchmarks. The research team will develop and implement the TeamSTEPPS Long Term Care program at the two SNF in Fort Worth, Texas, with each case defined as an individual facility. The research team will work with SNF leadership, including the Medical Director, Director of Nursing, and a licensed administrator. Implementation will occur in three phases outlined by the TeamSTEPPS program: Phase 1) conduct the patient safety culture assessment using the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Survey; Phase 2) develop performance goals and an action plan of delivering customized training on patient safety areas prioritized through the data review and patient safety culture assessment; and Phase 3) conduct patient safety training and monitor performance of action plan items. Research team members will conduct open-ended and structured interviews with facility staff to gather data on their opinions about processes and facts related to implementation. The research team will also document activities in each phase of implementation. This exploratory data will be combined with process measures established during the action plan phase to conduct a holistic investigation of the implementation processes. Results: Research will be conducted at Trinity Terrace and Brookdale Cityview skilled nursing facilities in Fort Worth, Texas. Quality improvement teams will be formed at each center to complete the TeamSTEPPS training and monitor the implementation of patient safety initiatives that increase the capacity of skilled nursing facilities to implement team approaches in quality improvement activities, and increase the ability of skilled nursing facilities to improve patient safety. Conclusions: This exploration of TeamSTEPPS implementation will develop a replicable model of implementation to improve patient safety in SNF that will improve the health status of skilled nursing facility patients.Item Inter-professional Team Communication to Improve Patient Safety: A Medication Safety Tip Sheet(2017-03-14) Daugherty, Caleb; Fix, JenniferObjective: Communication in healthcare teams is essential to decrease medical errors and improve patient health outcomes. With these themes in mind, the objectives of this study were to: (1) Enhance patient safety (2) Demonstrate effective collaboration by members of the healthcare team (3) Address polypharmacy through patient education and (4) Develop a patient education tool that is endorsed by the Institute for Patient Safety and UNT Health. Methods: This descriptive study examined the process of establishing a group and tool to enhance patient safety. A work group was convened with the following members: Nurse Practitioner, Susan Matthew, a care provider for Mighty Care clinics, Associate Professor of Pharmacotherapy and Family Medicine, Dr. Jennifer Fix, clinical pharmacist provider of services for the Division of Family Medicine’s Mighty Care Medical Clinics. and fourth year student pharmacist Caleb Daugherty on his advanced pharmacy practice experiential (APPE) rotation tasked by NP Matthew to develop a tip sheet to hand out to patients to help them with understanding the dangers of mixing medications. Mr. Daugherty submitted his assignment prior to completing his rotation. Dr. Fix forwarded the first draft submitted by Mr. Daugherty to all providers within the Mighty Care Team who had an opportunity to provide input and edits to the document thereby developing a second draft of the document. Provider designations of contributors to the project included medical doctor, osteopathic doctor, nurse practitioner, physician assistant, medical assistant, social worker, pharmacist, and student pharmacist. Results: Because of the importance of communicating printed materials to consumers at an appropriate reading level, the Medication Safety Tip Sheet was presented to the Institute for Patient Safety for their review and assistance in revising the handout. The Medication Safety Tip Sheet is ready for patient distribution. Sharing of the Tip Sheet with patients has begun and patient as well as provider feedback is noted. Based on the positive feedback received on the use of the tool, a pre and post assessment survey is planned to track the usefulness of the tool. The survey will be administered prior to handing the patient the education tool and at a future visit not later than 180 days. Various providers also encourage adoption of the patient education tool by all UNT Health Prescribers. Conclusions: It is anticipated that the conclusions derived from the survey data will show that patients benefited from the educational tool and that it proves to be useful for enhancing patient safety while meeting the stated objectives for the project.Item Interest and Attitudes Toward Global Health Training of Prospective Obstetrics and Gynecology Residents(2017-03-14) Nguyen, Nguyen; Felini, Martha J.; Hoang, ChristinePurpose: The benefits of global health training in residency clinical education have been well described in graduate medical education literature. Despite these benefits there is a lack of elective global health training opportunities offered by OBGYN residency programs nationally. The purpose of the study is to assess prospective OBGYN residents’ interests and attitudes toward global health training during their residency. Results of the survey can potentially help develop a global health educational curriculum and clinical training opportunity for the JPS OBGYN residency program. Methods: A survey was developed to assess the prospective residents’ views on global health training. Questions assessing interest and attitudes utilized a Likert scale response. Demographic information was collected and applicants self-reported whether they had prior global health experience. The survey was anonymous and voluntary and distributed to all JPS OBGYN residency applicants who interviewed during the 2016-2017 season. The responses were analyzed and summarized. Results: 50 applicants submitted survey responses. Of those applicants, 76% were likely or very likely to participate in a global health elective if offered by their residency program. 94% of applicants agreed that OBGYN residencies should offer voluntary electives in developing countries. 64% of applicants expressed an interest in incorporating global health involvement or international volunteer services into their future practice post-residency while 28% planned to focus their medical career on global health. Scheduling conflicts were perceived as the greatest barrier to participation. Learning about global public health systems and gaining procedural experience were the main interests expressed. Over half of the applicants had previously participated in a global health experience prior to applying for residency. There was a positive association between prior participation and future interest in incorporating global health into their post-residency practices. Conclusions: Information obtained from the survey demonstrated that applicants to the JPS OBGYN residency program believe that a global health elective opportunity should be offered in residency training, and a majority would participate if given the opportunity. With the strong interest and positive attitudes toward a global health elective, steps can be taken to develop a curriculum and training opportunity for the residents.Item Is Weight Status Related to Asthma In Adult Males 35-54 Years Old?(2017-03-14) Houck, Steven; Baca, Ryan; Hockaday, Josh; Hartos, Jessica; Howard, HarrisonIntroduction: Asthma is a prevalent health issue today but the relationship between weight status and asthma in adult men has yet to be thoroughly explored. The purpose of this study was to assess the relationship between weight status and asthma in adult males 35-54 years old. Methods: This cross sectional analysis used 2014 BRFSS data for males ages 35-54 from Hawaii, Massachusetts, Michigan, and Oregon. Multiple logistic regression analysis was used to assess the relationship between weight status and current asthma while controlling for ethnicity/race, exercise, tobacco use, education level, income level, and metropolitan status. Results: Few males 35-54 years-old reported having current asthma (6-9%) and most reported being overweight (73-80%). After controlling for lifestyle and demographic factors asthma was not significantly related to weight status in any of the four states (Oregon, Hawaii, Michigan, Massachusetts). Conclusion: Weight status was not related to asthma in general population samples of adult males 35-54 years old. A limitation of this study was, we collected info about current asthma not asthma symptoms or severity. The sample was population-based and, therefore, may be reflective of the primary care population. It is recommended that primary care practitioners not automatically screen overweight patients for asthma; however, this may be different in specialty settings.