470. Changing Urgent Care Patterns of Diagnosing Coccidioidomycosis in a Highly Endemic Urban Population


 
 
 We found previously (Pu et al. Clin Infect Dis, 2021: PubMed 32511677) that only 0.2% of ICD10 codes for coccidioidomycosis (CM) in our health care system were associated with patients (pts) managed at an urgent care (UC) visit. Since 2020, during onboarding, at quarterly meetings, and in periodic emails, UC clinicians were encouraged to test for CM in patients with pneumonia (PNA).
 
 
 
 For 2018 through 2021, Banner Health UC System increased clinics from 41 to 48, clinicians from 89 to 193 (Nurse Practioners, 49.2% ± 2%, Physician Assistants, 39% ± 2%, MDs/DOs 13% ± 1%), and total visits from 787 to 1,290 thousand. Average visits were 1.6 per pt. All UCs used a common electronic medical record (Cerner) during the study period. Data were downloaded in January 2022 to analyze UC clinician patterns of coccidioidal serologic testing (CST, 98% were EIAs), CST results, and their relation to ICD10 codes.
 
 
 
 For the study period, CST orders increased from 8.0 to 19.0 per 10,000 UC visits (chi-squared p< 0.001). The percent of clinics testing >10 per year increased from 16% to 78%, and the percentage of clinicians testing increased from 37% to 67%. Percent positive CSTs were highest for August, November, and December (27.4%) and lowest from April through July (8.1%). PNA ICD10 codes (J18.9 or J18.1) were most frequently associated with positive CSTs (374 positive of 1,872 tested), and the ICD10 code for Erythema nodosum (EN, L52, 176 total pts) had the highest positivity rate (61.4%, 27 positive of 44 tested). Only 6 pts had both EN and PNA codes. As indicated in the table, testing of PNA pts over time increased on first visits, decreased on second visits, and increased on second visits when the first CST was negative. Testing also increased for EN pats. Despite these favorable changes, CST was still not done on over three quarters of pts where recommended.
 Coccidioidal serologic testing in urgent care clinics by month for 2018-2021. Open circles are percentage of total visits that involved a test; closed squares are percentage of tests that are positive.
 
 
 
 Routine quality improvement activities have significantly but only partially improved rates of testing pts with PNA or EN for CM in UC clinics located in an endemic area. Innovative strategies to change clinical practices may be needed to achieve greater success.
 
 
 
 All Authors: No reported disclosures.
