Andrew Moran, MD and Christian Youssef, DO

Introduction:

Autonomous hypercortisolism is increasingly recognized as an underdiagnosed contributor to difficult-to-control type 2 diabetes mellitus. It is estimated that "38.9 to 76.9%" of type 2 diabetics are uncontrolled. Recent data suggest that up to 24% of patients with poorly controlled diabetes may have undiagnosed hypercortisolism. Identifying appropriate candidates for screening in primary care remains challenging due to competing clinical demands and unclear workflows. The objective of this quality initiative is to determine the number of patients eligible for hypercortisolism screening in a primary care clinic.

Methods:

We conducted a quality improvement initiative within a family medicine residency continuity clinic. All adult patients with type 2 diabetes seen over a four-month period were identified using an electronic medical record query based on most recent hemoglobin A1c ≥ 7.5. Patients were entered into a structured spreadsheet and individual charts were reviewed to determine eligibility for hypercortisolism screening using inclusion and exclusion criteria adapted from the CATALYST trial. Criteria included hemoglobin A1c thresholds, antihyperglycemic medication burden, diabetes complications, and relevant exclusion conditions. Patients were categorized based on eligibility for screening with the overnight dexamethasone suppression test (DST). The primary outcome was the proportion of patients with uncontrolled T2DM (A1c ≥ 7.5) meeting criteria for hypercortisolism screening. Secondary outcomes included characterization of common exclusion criteria and feasibility of implementing this screening workflow in a busy primary care clinic.

Results:

Data collection analysis is ongoing.

Discussion:

Systematic electronic medical record review can identify a meaningful subset of patients with difficult-to-control diabetes who may benefit from screening for hypercortisolism. Integrating structured identification tools into primary care workflows may improve recognition of secondary contributors to poor glycemic control and facilitate earlier diagnosis and management.

John Hammond, MD and William Johnson

INTRODUCTION:

Hypertension is one of the most prevalent chronic health problems in the United States, recently estimated to affect almost half of US adults, with adequate BP control in only one-fifth of those patients. This prevalence is correlated with age, male sex, weight, alcohol and tobacco use, family history, and race. Uncontrolled hypertension increases risk of significant complications, as well as increasing death from all-cause mortality. Ultimately, the problem of uncontrolled hypertension represents the potential for significant reduction in patient morbidity and mortality.

METHODS:

One resident clinic in Columbia, SC, reevaluated the quality of its hypertension management after adopting a hypertension management protocol based on several large, multicenter hypertension control studies such as the SPRINT trial. This protocol included a standardized blood pressure assessment in clinic and an algorithm for medication management. This algorithm recommended initiating treatment with a calcium channel blocker and ACE/ARB, before adding thiazide diuretics, followed by mineralocorticoid receptor antagonists. Further management of resistant hypertension was individualized to each patient.

RESULTS:

Protocol adherence was assessed via retrospective chart review. Review of clinical encounters with hypertensive patients prior to the protocol's adoption suggested a disparity in quality of management between Caucasian and African-American patients, who represent the two largest ethnic groups served by this clinic. Upon review of clinical encounters following the protocol's implementation, this disparity significantly decreased.

DISCUSSION:

Standardized protocols for hypertensive management may improve race-based disparities in management.

References:

Fryar CD, Kit B, Carroll MD, Afful J. Hypertension prevalence, awareness, treatment, and control among adults age 18 and older: United States, August 2021-August 2023. NCHS Data Brief, no 511. Hyattsville, MD: National Center for Health Statistics. 2024. DOI: https://dx.doi.org/10.15620/cdc/164016.

Coles, S, Fisher L, Lin K, Lyon C, Vosooney A, Bird MD. Blood Pressure Targets in Adults with Hypertension: A Clinical Practice Guideline from the American Academy of Family Physicians. American Family Physician. November 14, 2022. Accessed November 15, 2022. https://www.aafp.org/dam/AAFP/documents/journals/afp/AAFPHypertensionGuideline.pdf

David Cole Faircloth, DO

Introduction:

Colorectal cancer (CRC) remains a leading cause of cancer-related deaths in the US, despite the availability of preventive screening. Routine CRC screening, recommended for average-risk adults starting at age 45, remains underutilized in primary care settings. Barriers such as limited patient awareness, uncertainty about screening options, and inadequate patient education contribute to low screening rates.

Methods:

This quality improvement project aimed to increase CRC screening rates by at least 5% over a five-month period in a family medicine clinic through the implementation of an educational flyer. The flyer introduced three CRC screening options (colonoscopy, Cologuard, and FIT testing) and provided a QR code linking to a digital handout with additional educational material and FAQs. Using a pre- and post-intervention design, this project targeted patients who were eligible for CRC screening during in-person visits between September 2025 and January 2026. The intervention involved distributing the educational flyer during routine patient encounters, integrated into the clinic's rooming process. Flyer distribution was tracked in a secure data log. Screening completion rates before and after the intervention were compared using EMR data.

Results:

Primary outcomes include the change in CRC screening completion rates before and after the intervention. Clinic-wide CRC screening completion rate as of 9/1/25 was 59.9%. Completion rate as of 2/1/26 had improved to 62.41%. Secondary outcomes include screening completion rates stratified by race, age, preferred language, and insurance status.

Discussion:

This QI project leverages a simple, scalable educational intervention to improve CRC screening rates in a family medicine setting. By integrating educational materials into routine care, the project aimed to enhance patient decision-making and increase screening adherence.

Alexander Ash DO, Miguel Caldera DO, and Charity Miles DO

Background

Advance Care Planning (ACP) is a critical component of high quality care for adults aged 65 years and older. Despite national guidelines and Medicare reimbursement for ACP discussions, documentation rates remain low in outpatient settings. Resident physician discomfort and logistical barriers often contribute to underutilization.

Objective

This Practice-Based Learning and Improvement (PBLI) project aimed to increase ACP documentation rates in patients aged ≥65 years within a resident continuity clinic electronic medical record (EMR) system. This project represents a continuation and refinement of a prior year’s intervention.

Methods

During Year 1 (July–September 2024), residents received ACP education and ACP document folders were placed in patient care rooms. Resident comfortability was assessed via pre- and post-intervention surveys. ACP documentation rates were extracted from the Epic EMR. In Year 2 (September–December 2024), a targeted intervention was implemented, including physician reeducation and a dedicated ACP Saturday clinic with legal oversight, witnesses, and notarization services.

Results

Year 1 demonstrated a 12.5% increase in ACP documentation (28 to 32 documents) and a modest improvement in resident comfortability scores (6.36 to 6.55).  Year 2 results showed an increase from 19 to 26 active ACP documents, representing a 29% increase after accounting for patient deaths. The ACP clinic intervention produced a substantially greater improvement than the prior year.  Conclusion: A structured ACP clinic with physician re-education and real-time document completion significantly improved ACP documentation rates compared to passive availability of forms alone. This PBLI initiative highlights the importance of system-level solutions and iterative quality improvement.

to direct patients to may help reinforce teaching done during clinic visits.

Deepa Nuthalapati, MD, Radhika Mohan, MD, & Sanket Patel, MD

Background:

Transitional Care Management (TCM) addresses the safe handoff of a patient from one setting of care to another. Most often this handoff involves a patient moving from an acute, inpatient or emergency setting to an outpatient care environment. Well-defined protocols and improved coordination between inpatient and outpatient settings can promote safe transitions and improved communication, but they take time and effort to implement. Recognizing this, Fetter Healthcare created a new TCM team to track and help improve clinic follow-up for patients after discharge from the emergency department, with the goal of scheduling patients within 14 days of leaving the hospital.

Methods:

Using the HCA retrospective data bank (EDW) provided by the hospital management team, we analyzed patients discharged from SMC and TMC ED and referred to Fetter Healthcare Network for primary care appointments.

Results:

This year, from Oct 2024-Jan 2025, out of a total of 58,035 patients seen in the ED, 6178 were without a PCP. 1431 patients without PCP were referred to Fetter Healthcare. In total, 10.9% of ED patients were referred to Fetter last year vs. 23.16% in a similar three-month period this year. Of the 1431 people referred to Fetter, only 5.9% (84) patients referred by the ED made an appointment within 14 days.

Discussion:

Upon analysis, we found numerous barriers in the discharge process including lack of point person at TMC/SMC to handle Fetter discharges, lack of coordination at Fetter in providing discharge summaries from the ED prior to clinic appointments, and lack of training at Fetter in properly coding/billing hospital/ED follow ups. These are areas we can target in the future to improve hospital follow-up rates.

Disclaimer:

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare-affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.