Carolinas Research Day 2021

COMMONLY LOGGED DIAGNOSES AND TREATMENTS IN GERIATRIC PATIENTS DURING AMBULATORY FAMILY MEDICINE ROTATIONS Miriam Brown, OMS IV; Kyle Burke, OMS IV; Emma Griffith, OMS IV; Hannah Coulson, D.O., FASCP, FCAP;

Jaime Foushee, PharmD, BCPS, BCCCP; Harold R. Garner, Ph.D. Edward Via College of Osteopathic Medicine, Spartanburg, SC.

EDUCAT-1

Abstract

Results

Conclusions

Table 1. Top logged primary diagnoses and corresponding interventions in geriatric patients

Context : Clinical clerkships provide osteopathic medical students the opportunity to diagnose and treat commonly encountered medical conditions. Appropriate management of these conditions may include pharmacotherapy and/or non-pharmacologic interventions, such as osteopathic manipulative treatment (OMT). Opportunities may exist to expand the utilization of OMT in the management of common conditions, particularly for geriatric patients, who are at increased risk for adverse outcomes from inappropriate medication use. Objective : To assess the most common diagnoses and corresponding treatments logged by osteopathic medical students within an ambulatory geriatric population. Methods : Patient encounters logged electronically by osteopathic medical students were retrospectively reviewed to determine the most commonly reported diagnostic codes and their treatments. Logged interventions were filtered to include patients over the age of 65 seen on family medicine rotations within an ambulatory setting. The top ten diagnoses were sorted and assessed to determine the associated treatments, including medications, procedures, and OMT. Results : Between January 2018 and June 2020, 11,185 primary diagnoses were logged pertaining to the defined patient population. The most frequently documented diagnoses were essential hypertension (n=1420; 12.7%), encounter for well exam (n=1144; 10.2%), type 2 diabetes mellitus (n=837; 7.5%), hyperlipidemia (n=346; 3.1%), chronic obstructive pulmonary disease (n=278; 2.5%), osteoarthritis (n=221; 2.0%), low back pain (n=202; 1.8%), pain in joint (n=187; 1.7%), hypothyroidism (n=164; 1.5%), and urinary tract infection (n=160; 1.4%). Three of the top ten logged diagnoses were musculoskeletal in nature. Pharmacotherapy was reported as the predominant treatment for musculoskeletal conditions, with OMT being logged as a treatment for 10.9% (n=50) of those cases. The most commonly logged medication class in the management of patients with those musculoskeletal conditions was non-steroidal anti-inflammatory agents (n=128; 27.9%), while opioids were the second most frequently documented class of medications (n=65; 14.2%). Conclusions : Musculoskeletal complaints were commonly logged by osteopathic medical students within the studied population. Opioids were documented as a treatment for musculoskeletal conditions more frequently than OMT. As such, opportunities exist to expand the utilization of OMT during clinical clerkships and decrease inappropriate medication-based pain management strategies. A retrospective study design was used to review logged patient encounters in Clinical Rotation Evaluation Documentation Organizer (CREDO), an online patient encounter reporting system. Using the CREDO analytical tools, an Excel document of primary diagnostic codes associated with at least one secondary code specifying treatment was extracted. Data was filtered for entries logged by students on family medicine rotations between January 2018 and June 2020. This data was further filtered to include encounters occurring within an ambulatory setting for patients over 65. Utilizing a pivot table, the data was analyzed in order to determine prevalence of primary diagnoses based on the total number of times the International Classification of Disease (ICD- 10) code was inputted. Data was then filtered to determine the prevalence of each treatment associated with each primary code. Descriptive statistics were used to categorize the most commonly logged diagnostic codes and corresponding treatments. Methods

For the selected patient population, most of the top diagnoses were linked with standard of care interventions. Three of the top diagnoses were musculoskeletal in nature. Pharmacotherapy, which may be associated with adverse effects in the geriatric population, was the predominant treatment method for musculoskeletal conditions. This study identified a gap in geriatric pain management, specifically for the treatment of common musculoskeletal conditions including low back pain, osteoarthritis, and joint pain. OMT should be integrated into treatment plans as an alternative to opioid therapy for musculoskeletal pain management in the geriatric population.

TOTAL LOGGED

TOP INTERVENTION LOGGED

DIAGNOSIS

Hypertension

1420

ACE inhibitors

Encounter for wellness exam

1144

Various medications

A major limitation of this study is the variability of medical student logging in CREDO; for instance, some students logged primary diagnostic codes without associated treatment data.

Type 2 diabetes mellitus

837

Biguanides (metformin) HMG-CoA reductase inhibitors (statins)

Hyperlipidemia

346

The current use of OMT, as outlined by this study, should be expanded upon in the future. In order to facilitate that change, students must be familiar with techniques that are indicated and appropriate for a given diagnosis. Utilizing a patient encounter logging system, medical schools can educate students on how to formulate treatment plans for the most commonly encountered medical conditions in specific clinical settings or age groups. In turn, this could increase the incorporation of OMT into treatment plans and improve patient care.

Chronic obstructive pulmonary disease

278

Inhaled beta-2 agonists

Joint injection (corticosteroids)

Osteoarthritis

221

Low back pain

202

NSAIDs

Pain in joint

187

NSAIDs

References

Hypothyroidism

164

Levothyroxine

Urinary tract infection

160

Fluoroquinolone antibiotics

1. Chila A, Carreiro J, Dowling D, et al. Foundations of Osteopathic Medicine, 3e . Third. Lippincott Williams & Wilkins; 2011. 2. Els C, Jackson TD, Kunyk D, et al. Adverse events associated with medium ‐ and long ‐ term use of opioids for chronic non ‐ cancer pain: an overview of Cochrane Reviews. Cochrane Database Syst Rev . 2017;2017(10). doi:10.1002/14651858.CD012509.pub2 3. Finley CR, Chan DS, Garrison S, et al. What are the most common conditions in primary care?: Systematic review. Can Fam Physician . 2018;64(11):832. 4. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother . 2007;5(4):345-351. doi:10.1016/j.amjopharm.2007.12.002 5. Planning for Rotations. American Osteopathic Association. Accessed February 6, 2021. https://osteopathic.org/students/rotations/planning-for-rotations/ 6. Rawlins F, Sumpter C, Sutphin D, Garner HR. Quantifying medical student clinical experiences via an ICD Code Logging App. Int J Med Inf . 2018;111:51-57. doi:10.1016/j.ijmedinf.2017.12.017 7. Seffinger M, Buser B, Licciardone JC, et al. American Osteopathic Association guidelines for osteopathic manipulative treatment (OMT) for patients with low back pain. J Am Osteopath Assoc . 2010;110(11):653-666.

Figure 1 . Treatments for common musculoskeletal conditions in geriatric patients: osteoarthritis, pain in joint, and low back pain

Other 13%

NSAIDs 28%

Acetaminophen 5%

Corticosteroids 9%

OMT 11%

Acknowledgements

Joint Injection 20%

Opioids 14%

We would like to thank Cameron Sumpter for his help in collecting and organizing the data.

37

2 0 2 1 R e s e a r c h R e c o g n i t i o n D a y