Home visits detected previously undescribed types of outpatient errors which were common among children with sickle cell disease and seizure disorders. These should be targeted in future intervention development.

Acquired abdominal intercostal hernia (AAIH) is a rare disease phenomenon where intra-abdominal contents reach the intercostal space directly from the peritoneal cavity through an acquired defect in the abdominal wall musculature and fascia. We discuss a case of a 51-year-old obese female who arrived to the emergency room with a painful swelling between her left 10th rib and 11th rib. She gave a history of a stab wound to the area 15 years earlier. A CT scan revealed a fat containing intercostal hernia with no diaphragmatic defect. An open operative approach with a hernia patch was used to repair this hernia. These hernias are difficult to diagnose, so a high clinical suspicion and thorough history and physical exam are important. This review discusses pathogenesis, clinical presentation, complications, and appropriate treatment strategies of AAIH.

CM&R 2008 : 3/4 (December) 140 HMORN 2008 -Poster Presentations culture. Conclusions: Based on the results, our recommendations for increasing TRIP are: (1) ensure integrated development of a master data warehouse; (2) improve communication with special emphasis on involving researchers more directly with DS teams; (3) promote further research to identify what works/does not work in implementing TRIP; and (4) 'think globally, but translate locally.' Funded by NIH/AHRQ for the HMORN CCSN (Coordinated Clinical Studies Network). Abstract PS1-41 Background: In reviewing first quarter clinical quality metrics in 2006, the primary care department at the Merrill Center identified a statistically significant drop in glycemic control for their diabetic population that did not occur across the clinic system-wide. Quality improvement changes were implemented from mid 2006 through mid 2007. Aim: To increase glycemic control more than 50% over 12 months as evidenced by the percentage of patients with diabetes having most recent A1c test results <7%. Methods:The system-wide quality improvement initiative increased provider awareness and educated providers on the need to improve clinical outcomes for patients with diabetes. Providers partnering with nurse educators resulted in increased referrals to the Diabetes Self Management program. Diabetes educators intensified insulin dosing for patients with uncontrolled blood sugars through use of a standard protocol. In addition to expanding existing diabetes services and hours, telephonic care management was initiated for high risk patients. Implementation: An electronic medical record (EMR) and tablet computers improved the information that providers and other members of the care team could use to access at the point of service. An electronic reminder system helps identify patients not at goal requiring further testing, education, or medical intervention. A process for gathering outside A1c test results improved the coordination of diabetes care across health care facilities. Results: Glycemic control as evidenced by the percentage of patients with most recent A1c test results <7% rose from 41% in second quarter of 2006 to 68.2% in third quarter of 2007 for the more than 800 patients with diabetes. Conclusions: To improve quality of care, provider awareness and support are essential in developing a comprehensive diabetes program. Increased provider awareness, supported by an EMR has built a team approach to education, medical management, and care coordination resulting in improved glycemic control.Abstract PS1-42 Demonstrating the Effective Practice Background: For 160 years, government agencies, corporations, and nonprofit organizations have relied on demonstrations of radical innovations and interventions to stimulate interest in them and subsequent diffusion. Unfortunately, researchers and practitioners alike often fail to distinguish the functions that a demonstration project may serve and, thus, put into practice hybrid demonstration forms that typically under-achieve in all fu...

Background/Aims: Mastectomy and breast conserving surgery followed by radiotherapy are considered initial guideline therapies for early stage breast cancer with randomized trials demonstrating reduced risk of recurrence. However, older women and those with comorbidities frequently receive only breast conserving surgery. The interaction of age and comorbidity with breast cancer severity and their impact on receipt of guideline therapy have not been well studied. Methods: In the population-based BOW cohort of 1837 women age=65 years receiving initial treatment for early stage breast cancer in 6 integrated healthcare delivery systems in 1990-1994 and followed for 10 years, we examined predictors of receiving less than guideline therapy. We also assessed the impact of less than guideline therapy on breast cancer recurrence stratified by breast cancer severity (low, moderate, or high risk for recurrence using the 1992 St Gallen criteria). Results: Age and comorbidity were independently associated with receipt of less than guideline therapy after controlling for breast cancer severity and race. However, compared to those at lowest risk for recurrence, women at the highest risk were unlikely to receive less than guideline therapy (odds ratio (OR) 0.31, 95% confidence interval (CI) 0.21, 0.46) while women at moderate risk were about half as likely (OR 0.55, CI 0.36, 0.85). During follow-up, 295 women had a breast cancer recurrence. Using Cox regression modeling stratified by the 3 levels of risk for recurrence, non-receipt of guideline therapy was associated with recurrence among women at moderate (HR 5.10, CI 1.93, 13.49) and even low risk (HR 3.24, CI 1.15, 9.12). The elevated hazard rate ratio was not observed for the high risk level group (HR 1.29, CI 0.78, 2.15). Age and comorbidity were not associated with recurrence in any of the analyses. Conclusions: Among these older women with early stage breast cancer, decisions about guideline therapy appear to have partially balanced breast cancer severity against age and comorbidity. However, even among women at low risk of recurrence, omitting guideline therapy placed them at elevated risk of recurrence.