Care In California Research Articles

Atrial flutter and sick sinus syndrome

BackgroundSick sinus syndrome (SSS) is a common condition resulting in reduced quality of life, syncope, and permanent pacemaker (PPM) implantation, but predictors have not been elucidated. Whereas atrial arrhythmias are frequently associated with SSS, we hypothesized that atrial flutter (AFL) would strongly predict SSS, given shared relationships with right atrial and particularly crista terminalis fibrosis. ObjectiveThe study aimed to assess the impact of AFL on the occurrence of SSS and associated syncope and PPM implantation. MethodsHealth care databases were used to identify adults aged ≥18 years receiving hospital-based care in California in 2005–2019. International Classification of Diseases codes were used to identify diagnoses and procedures. Patients were classified on the basis of the presence of AFL and atrial fibrillation (AF). Cox proportional hazards models adjusting for demographics and comorbidities were employed. ResultsWe included 29,357,609 individuals (54% female; mean age, 46 years), 101,243 with AFL alone, 1,674,680 with AF alone, and 284,547 with AF and AFL. After adjustment for age, sex, race and ethnicity, and comorbidities, AF, AFL, and both arrhythmias were each associated with increased risk of SSS and associated syncope and PPM implantation (all P < .001). In the population with AF, an additional AFL diagnosis conferred a higher risk for development of SSS (hazard ratio [HR],1.62; 95% confidence interval, 1.59–1.64), syncope (HR, 1.63; 1.54–1.72), and PPM implantation (HR, 1.74; 1.70–1.79). ConclusionAFL is associated with an increased risk of incident SSS and its adverse consequences, especially in patients with coexisting AF. AFL may be useful for risk stratification strategies to predict, to prevent, and to treat SSS.

Minimum National Prevalence of Diagnosed Atrial Fibrillation Inferred From California Acute Care Facilities

BackgroundPrevalence estimates of atrial fibrillation (AF) from large populations have not been updated for >2 decades. Using data from 1996 to 1997, a previous study projected that there would be 3.3 million adults with AF in the United States in 2020. ObjectivesThe purpose of this study was to determine the contemporary age-, sex-, and race-standardized prevalence and the number of adults with diagnosed AF in the United States. MethodsWe merged California’s state-wide health care databases to assemble a cohort of adults aged ≥20 years who received hospital-based care in California from 2005 to 2019. International Classification of Diseases codes were used to identify AF and other comorbidities. After accounting for deaths, we utilized the U.S. Census to calculate the national age-, sex-, and race-standardized estimates of diagnosed AF. ResultsOf 29,250,310 patients (mean age 50.6 ± 19.8 years, 53.8% women, 50.1% White), 2,003,867 (6.8%) had an AF diagnosis. The proportion of patients with diagnosed AF increased from 4.49% in 2005 to 2009 to 6.82% in 2015 to 2019. Over time, AF patients became relatively younger, were less likely to be female or White, and were more likely to have hypertension and diabetes. Standardizing based on age-, sex-, race-, and ethnicity-based proportions to the U.S. population, we estimate that the current national prevalence of diagnosed AF is at least 10.55 million (95% CI: 10.48-10.62 million), comprising 4.48% (95% CI: 4.47%-4.49%) of the adult population. ConclusionsThe prevalence of diagnosed AF in the United States is higher than previously estimated. More efficient prevention and treatment strategies are needed to curb the burden of AF in the United States.

Contemporary trends in incident ischemic stroke, intracranial hemorrhage, and mortality in individuals with atrial fibrillation.

The prognosis for atrial fibrillation (AF) patients is based on data that is decades old. Given evolving standards of clinical practice, we sought to evaluate temporal trends in clinically important outcomes among patients with AF. California's Department of Health Care Access and Information databases were used to identify adults aged≥18 years with AF receiving hospital-based care in California. We compared 3 time-periods: 2005-2009, 2010-2014, and 2015-2019. ICD codes were used to identify chronic diseases and acute events. The outcomes were incident ischemic stroke, intracranial hemorrhage, and overall mortality. We included 2009832 patients with AF (52.7% males, 70.7% Whites, and mean age of 75.0 years), divided in 3 cohorts: 2005-2009 (n=738954), 2010-2014 (n=609447), and 2015-2019 (n=661431). Each outcome became substantially less common with time: compared to 2005-2009, AF patients diagnosed in 2015-2019 experienced a 34% (adjusted hazard ratio [HR] 0.66, 95% CI 0.64-0.69), 22% (HR 0.78, 0.75-0.82), and 24% (HR 0.76, 0.75-0.77) reduction in risk of incident ischemic stroke, intracranial hemorrhage, and mortality, respectively. Between 2005-2009 and 2015-2019, patients aged≥65 years experienced more reductions in each outcome compared to younger patients (p<0.001 for all), and declines in each outcome were significantly lower for Hispanics and Blacks compared to white patients. The risks of stroke, intracranial hemorrhage, and death have significantly declined among AF patients, although differences in the magnitude of improvement of these outcomes by demographic groups were observed. Commonly described estimates of the prognosis for AF patients should be updated to reflect contemporary care.

Examining prevalence and predictors of food insecurity for transition-age youth transitioning out of foster care

ABSTRACT Transition-age youth with foster care involvement (TAY) face significant risks for food insecurity and other hardships in early adulthood. Using representative survey data of youth transitioning out of foster care in California, we examine the prevalence and predictors of food insecurity. We find that about 30% of study participants were food insecure at ages 19, 21, and 23. We also identify multiple risk and protective factors associated with being food insecure, such as TAY’s sexual identity and receipt of public benefits. The results of our study offer life-stage-specific recommendations for policy and practice to address food insecurity among TAY.

Abstract MP24: Contemporary Trends in Incident Ischemic Stroke, Intracranial Hemorrhage, and Mortality in Individuals With Atrial Fibrillation

Background: The prognosis for atrial fibrillation (AF) patients is based on data that is decades old. Given evolving standards of clinical practice that may now include lifestyle factor modification, catheter ablation, and DOACs, we evaluated temporal trends in clinically important outcomes among patients with AF. Methods: California’s Department of Health Care Access and Information databases were used to identify adults aged ≥18 years with AF receiving hospital-based care in California. We compared 3 time-periods in this population-based cohort corresponding to 2005-2009, 2010-2014, and 2015-2019. The outcomes were incident ischemic stroke, intracranial hemorrhage, and mortality. Results: We included 1,859,901 patients with AF (52.7% males, 71.0% Whites, and mean age of 74.8 years), divided in 3 cohorts: 2005-2009 (n=680,872), 2010-2014 (n=558,365), and 2015-2019 (n=620,664). Each of these outcomes became substantially less common with time: compared to 2005-2009 ( Figure 1A ), AF patients diagnosed in 2015-2019 experienced a 42% (adjusted hazard ratio [HR] 0.58, 95% CI 0.57-0.60), 17% (HR 0.83, 95% CI 0.80-0.88), and 28% (HR 0.72, 95% CI 0.71-0.73) reduction in risk of incident ischemic stroke, intracranial hemorrhage, and mortality, respectively. Between 2005-2009 and 2015-2019, the decline in the incidence rate of adverse outcomes was greater in patients aged ≥65 years (p&lt;.001), females (p=.02), and Whites (p&lt;.001) for ischemic stroke; more pronounced in patients aged ≥65 years (p=.008), females (p=.02), and Whites and Asians (p=.005) for intracranial hemorrhage; and greater in patients aged ≥65 years (p&lt;.001), in males (p=.04), and in Whites (p&lt;.001) for mortality ( Figure 1B ). Conclusion: The risk of stroke, intracranial hemorrhage, and mortality have significantly declined among AF patients, although significant disparities in the magnitude of improvement of these outcomes by demographic groups were observed. Estimates of the prognosis for AF patients should be updated to reflect contemporary care.

Systemic infarcts among patients with atrial fibrillation

BackgroundThe epidemiology of atrial fibrillation (AF)–associated thromboembolic complications outside of ischemic strokes has not been thoroughly elucidated. ObjectiveThe aim of this study was to describe the epidemiology of AF-associated systemic infarcts and relevant interactions by sex and race/ethnicity. MethodsUsing the Office of Statewide Health Planning and Development, we performed a longitudinal analysis of patients aged ≥18 years who received ambulatory surgery, emergency, or inpatient medical care in California between 2005 and 2015. We determined the distribution of infarct locations and risks of systemic infarcts for patients with AF. Interaction analyses by sex and race/ethnicity were conducted. ResultsOf 1,321,694 patients with AF, the average annual rate of systemic infarct was 2.1% ± 0.18% compared with 0.56% ± 0.06% in the 22,944,488 patients without AF. The increased frequency of these infarcts was observed for every body area investigated. After adjustment for potential confounders and mediators, patients with AF experienced a 45% increased risk of a systemic infarct (hazard ratio, 1.45; 95% confidence interval, 1.44–1.47; P < .001). Women, Asians, Blacks, and Hispanics each exhibited a statistically significant heightened relative risk of systemic infarcts in the presence of AF. ConclusionAF increases the risk of infarcts throughout the body. Susceptibility to these systemic infarcts varies by sex and race/ethnicity in patterns similar to differential risks for stroke. The presence of a systemic infarct in the absence of a clear cause should raise suspicion for AF, and the potential benefits of AF prevention and anticoagulation should be considered beyond only infarcts to the brain.

Impact of Illness Severity Tools on Adolescent Psychiatric Managed Care in California.

Youth with mental illness struggle to receive essential behavioral health care. One obstacle is denial of coverage by insurance. In California, managed care consumers may apply for independent medical review (IMR) which potentially overturns an insurance denial through the California Department of Managed Healthcare (CDMHC). The authors aim to analyze IMR appeals for psychiatric treatment among adolescents and elucidate factors associated with obtaining coverage of care. We performed an analysis to identify factors that are associated with depression and substance use disorder (SUD) treatment claim denials in 11-20-year-olds from 2001 to 2022 using CDMHC data. Logistic regression modeling was used to identify specific factors related to claim characteristics and medical society instruments that are significantly associated with overturning a denial by IMR.Behavioral health IMRs are overturned at a higher rate than non-behavioral health claims. 54.5% of those with depression and 36.3% of those with SUD initially denied care coverage were overturned by IMR. For those seeking depression treatment, we found a significantly greater odds of overturn by IMR if there was a reference of CALOCUS [1.64, 95%CI (1.06-2.5)]. The odds of a SUD treatment denial being overturned was significantly greater if referencing CALOCUS [3.85 (1.54-9.62)] or ASAM [2.47, [4.3 (1.77-10.47)]. After the standardized implementation of illness severity tools in IMRs, the odds of a medically necessary claim being overturned was 2.5 times higher than before the standards.With a high percentage of claims being overturned after IMR, the findings suggest that health plans inappropriately deny medically necessary behavioral health treatment. The use of medical society instruments was associated with higher odds of overturning a denial. The recent decision of CDMHC to implement standard use of CALOCUS and similar illness severity criteria is supported by our findings and may facilitate more equitable care.

Abstract 090: Using Evidence-Based Resources And Unique Self-Measured Blood Pressure Program Designs To Improve Blood Pressure Control

Background: The AHA National Hypertension Control Initiative (NHCI) is a $32M, 3-year grant from the Health Resources and Services Administration (HRSA) and the Office of Minority Health (OMH) to provide training and technical assistance (T/TA) to 350 HRSA-funded community health centers (CHCs) with blood pressure (BP) control rates below 58.9% in 2019. Hypothesis: NHCI can improve BP control particularly among Black, Hispanic, American Indian/Alaskan Native (AI/AN) persons through systematic, culturally sensitive, and evidence-based interventions, including use of self-measured blood pressure (SMBP). Methods: AHA’s T/TA included a training curriculum, evidence-based tools from Target: BP™ and the AMA MAP™ framework, and new tools, including a BP Measurement Policy and a BP Treatment Algorithm. CHCs used these resources to change clinical care and to implement SMBP though multidisciplinary and culturally relevant approaches that reflect the organizational capacities and characteristics of their patients. For example, 3 CHCs successfully implemented SMBP programs using different designs and achieved notable improvements in BP control (defined by the performance measure &lt;140/90 mm Hg). SWLA in Louisiana established a team-based care model that emphasizes standardized processes, including an SMBP onboarding protocol and a BP treatment algorithm. Canyonlands in Arizona coupled systematic in-clinic practices with AI/AN community health workers (CHW) to reach patients from the Navajo Nation in a culturally relevant manor. Via Care in California developed a collaborative practice model with their clinical pharmacists and clinicians for systematic medication management, SMBP and lifestyle education, and team-based visits. Results: SWLA increased BP control from 44% to 69% in 2022, Canyonlands from 53% in 2021 to 70% in 2023 in AI/AN patients that partnered with a CHW, and Via Care from 55% in 2021 to 74% in 2022. So far, the highest BP control rate percentage change was for CHCs that participated with NHCI and had a 5.1% year-over-year increase compared to 3.8% at all HRSA centers from 2020 to 2021. Conclusion: Various SMBP program designs with systematic processes, team-based care models and culturally sensitive approaches can improve BP control.

Radical Housing Justice Within and Beyond Caring

AntipodeEarly View Introduction Radical Housing Justice Within and Beyond Caring Michele Lancione, Corresponding Author Michele Lancione [email protected] orcid.org/0000-0002-9018-3562 Interuniversity Department of Regional and Urban Studies and Planning (DIST), Polytechnic and University of Turin, Turin, Italy[email protected]Search for more papers by this author Michele Lancione, Corresponding Author Michele Lancione [email protected] orcid.org/0000-0002-9018-3562 Interuniversity Department of Regional and Urban Studies and Planning (DIST), Polytechnic and University of Turin, Turin, Italy[email protected]Search for more papers by this author First published: 15 June 2023 https://doi.org/10.1111/anti.12958Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. 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Characteristics of California Emergency Departments in Centers for Disease Control and Prevention-Designated HIV Priority Counties

BackgroundRefocused national HIV testing initiatives include a geographic focus. ObjectiveUsing a geographic focus, we sought to identify which emergency departments (EDs) might be the most efficient targets for future HIV testing efforts, using California as an example. MethodsRetrospective analysis of California EDs, emergency physicians, and patients served, along with county-level estimates of HIV prevalence and proportion of the population living in poverty. Emphasis was placed on characterizing EDs affiliated with teaching hospitals and those located in Centers for Disease Control (CDC) and Prevention HIV priority counties. ResultsOf the 320 EDs studied, 178 were in priority counties, 29 were affiliated with teaching hospitals, and 24 had both characteristics. Of the 12,869,889 ED visits included, 61.8% occurred in priority counties, 14.7% in EDs affiliated with teaching hospitals, and 12.0% in EDs with both characteristics. The subset of EDs in priority counties with teaching hospital affiliations (compared with priority and nonpriority county ED groups without a teaching hospital affiliation) had higher overall median visit volumes and higher proportions of visits by at-risk and CDC-targeted populations (e.g., individuals who were homeless, those who identified as Black or African American race, and those who identified as Hispanic or Latino ethnicity, all p < 0.01). ConclusionsEDs in priority counties affiliated with teaching hospitals are major sources of health care in California. These EDs more often serve populations disproportionately impacted by HIV. These departments are efficient targets to direct testing efforts. Increasing testing in these EDs could reduce the burden of undiagnosed HIV in California.

Factors associated with person-centered care during pregnancy and birth for Black women and birthing people in California.

In the United States, adverse birth outcomes are most prevalent among Black women and birthing people, who are known to experience increased mistreatment and disrespect in care. The purpose of this paper is to describe findings from a study that used two validated scales to examine factors associated with experiences of person-centered care during pregnancy and birth among Black birthing people in California. We used data from 234 Black women and birthing people who were recruited between January and September 2020 as part of a validation study for the Person-Centered Prenatal Care (PCPC) and the Person-Centered Maternity Care (PCMC-US) scales. Bivariate and multivariate analyses were conducted to examine the associations between PCPC and PCMC-US scores and sociodemographic, health-related, and care-related factors. The factors associated with lower PCPC scores were having foreign-born parents, having public or no insurance, part-time employment, unstable housing, late start of prenatal care (in the second or third trimester), poorer self-rated health (less than very good), and lack of continuity of care with prenatal providers. Factors associated with lower PCMC-US scores were having public insurance, late start of prenatal care, longer length of stay in facility following birth, poorer self-rated health, lack of continuity of care between prenatal care and birth providers, and racial discordance with birth provider. Our analysis highlights the contributions of intersecting identities as well as health-related and care-related factors to Black birthing people's experiences of care in California. Continuity of care and provider racial concordance, in particular, were shown to improve pregnancy and birth experiences.

Ischemic Stroke Systems of Care in California: Evolution in the Organization During the Mechanical Thrombectomy Era

Background Optimized stroke systems of care enable access to timely care, including endovascular thrombectomy (EVT). Stroke systems have likely evolved after publication of EVT benefit (2015). Our objective was to map the stroke patient transfer network in California in terms of EVT access and patient transfer patterns, and to examine changes after 2015. Methods In this observational study, we identified all ischemic stroke encounters, transfers, alteplase use, and EVT procedures in California from 2010 to 2017. An established connection between any hospital pair was defined as the transfer of ≥2 patients between them. A 2‐level logistic regression model assessed whether encounters were more frequently transferred to EVT‐capable hospitals post‐2015, adjusting for patient‐ and hospital‐level factors. Linear regression examined trends in key network characteristics over time, and interrupted time series regressions examined for changes post‐2015. Results Among 336 247 encounters, 3.4% were transferred, 9.3% received alteplase, and 2.3% underwent EVT. From 2010 to 2017 the proportion that were EVT treated increased (1.0%–4.3%; P ‐for‐trend&lt;0.001) with a significant increase post‐2015 ( P =0.01). Odds of transfer to EVT‐capable hospital were greater post‐2015 (adjusted odds ratio, 6.54; [95% CI 5.52–7.74]), but were lower for patients who were older, Black, Hispanic, and presented to a rural hospital. Significant network changes from 2010 to 2017 included increased number of encounters transferred, increased number of transferring hospitals, decreasing number of receiving hospitals, and increased proportion of receiving hospitals performing EVT. However, none of these network changes demonstrated a significant inflection point after 2015. Conclusion The California stroke network has been dynamic over time. Although most changes have been incremental, after the release of EVT trial data in 2015 changes in transfer patterns did lead to increased access to EVT.

Reshaping the Medi-Cal Dental Program — Evolving Oral Health Care in California

Reshaping the Medi-Cal Dental Program — Evolving Oral Health Care in California

Birth Doula Care in California During COVID-19: The Impacts of Social Distancing on a High-Touch Helping Profession.

Birth doulas were deemed “non-essential” personnel during the COVID-19 pandemic and were generally excluded from attending hospital births in person. This study documents the impacts of pandemic-related contextual factors on birth doula care in the San Francisco Bay Area, examines how doulas adapted their services, and explores implications for policy and practice. We employed a contextually bound qualitative case study methodology driven by social action theory and conducted interviews with 15 birth doulas. The pandemic disrupted physical settings, the social environment, communication modalities, contractual arrangements, and organizational level factors. The historical context also amplified awareness of institutionalized racism in birth settings and highlighted birth doulas’ advocacy role. Striking deficits exist in birth doulas’ integration into US healthcare systems; this made their services uniquely vulnerable to the pandemic circumstances. Birth doulas’ value ought to be more formally recognized within health policy, health insurance, and hospital systems as complementary care to that provided by medical providers to improve access to high-quality perinatal care.

Dental Care in California During Pregnancy

Dental Care in California During Pregnancy

Third-party Compliance With State-Mandated Orthodontic Coverage for Cleft Palate and Craniofacial Care in California: An Insurance Claim Thematic Analysis.

California Senate Bill 630 (SB630) enacted statutorily mandated health plan coverage for orthodontic care of patients with cleft palate and craniofacial anomalies in 2009, which was effective from July 1, 2010. In this qualitative analysis, third-party compliance with SB630 in a university-based cleft and craniofacial orthodontic program is evaluated. Privately insured patients that experienced a coverage delay or denial of orthodontic treatment for cleft lip and palate in the University of California, San Francisco Cleft and Craniofacial Orthodontic Program between July 1, 2010 and October 28, 2020 were identified. A thematic analysis of reasons for delay or denial was conducted. Nearly three quarters of patients experienced coverage delay and/or denials. The most common reason given was that services were not covered. Despite state-mandated coverage, inappropriate denials of orthodontic care for patients with cleft lip and palate by private insurers persist in California.

The relationship between stroke system organization and disparities in access to stroke center care in California.

BackgroundThere are significant racial and ethnic disparities in receipt of reperfusion interventions for acute ischemic stroke. Our objective was to determine whether there are disparities in access to stroke center care by race or ethnicity that help explain differences in reperfusion therapy and to understand whether interhospital patient transfer plays a role in improving access.MethodsUsing statewide administrating data including all emergency department and hospital discharges in California from 2010 to 2017, we identified all acute ischemic stroke patients. Primary outcomes of interest included presentation to primary or comprehensive stroke center (PSC or CSC), interhospital transfer, discharge from PSC or CSC, and discharge from CSC alone. We used hierarchical logistic regression modeling to identify the relationship between patient‐ and hospital‐level characteristics and outcomes of interest.ResultsOf 336,247 ischemic stroke patients, 55.4% were non‐Hispanic White, 19.6% Hispanic, 10.6% non‐Hispanic Asian/Pacific Islander, and 10.3% non‐Hispanic Black. There was no difference in initial presentation to stroke center hospitals between groups. However, adjusted odds of reperfusion intervention, interhospital transfer and discharge from CSC did vary by race and ethnicity. Adjusted odds of interhospital transfer were lower among Hispanic (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.89 to 0.98) and non‐Hispanic Asian/Pacific Islander patients (OR 0.84, 95% CI 0.79 to 0.90) and odds of discharge from a CSC were lower for Hispanic (OR 0.91, 95% CI 0.85 to 0.97) and non‐Hispanic Black patients (OR 0.74, 95% CI 0.67 to 0.81).ConclusionsThere are racial and ethnic disparities in reperfusion intervention receipt among stroke patients in California. Stroke system of care design, hospital resources, and transfer patterns may contribute to this disparity.

Mental Health and Postpartum Care in California: Implications from California's Provisional Postpartum Care Extension.

California's Provisional Postpartum Care Extension (PPCE) extended Medicaid eligibility through 1year postpartum for women enrolled in Medi-Cal with annual household incomes of 138%-322% of the federal poverty level and maternal mental health diagnoses. For this cross-sectional descriptive study, we used the 2017 Listening to Mothers in California survey of postpartum women to identify those potentially eligible for PPCE. We then sought to describe their demographic characteristics, self-reported mental health, and utilization of postpartum care and mental health services compared with those with Medi-Cal during pregnancy who did not meet PPCE eligibility criteria. Overall, potentially PPCE-eligible women comprised 6.8% of respondents. Among those who did not qualify for PPCE, the primary reason was the absence of self-reported maternal mental health symptoms. Potentially PPCE-eligible women were approximately two-thirds Hispanic/Latina and more than one-third were ages 25 to 29. The most common self-reported mental health symptom was anxiety during pregnancy (78.9%). Among potentially PPCE-eligible women, 8.4% were taking medicine for anxiety/depression postpartum and 16.0% were receiving postpartum counseling/treatment for emotional or mental well-being. Our analyses suggest that PPCE could have extended postpartum coverage eligibility for approximately 30,360 women statewide. However, our findings demonstrate how narrowly defined PPCE eligibility criteria likely excluded many postpartum women in Medi-Cal who would have been left with limited benefits or more cost-sharing under alternative coverage options. This research could inform state and federal policymakers considering other proposals to extend postpartum Medicaid eligibility.

Economic Evaluation of Telemedicine Consultations to Reduce Unnecessary Neonatal Care Transfers

To perform an economic evaluation to estimate the return on investment (ROI) of making available telemedicine consultations from a healthcare payer perspective, and to estimate the economic impacts of telemedicine under a hypothetical scenario in which all rural hospitals providing level I neonatal care in California had access to telemedicine consultations from neonatologists at level III and level IV neonatal intensive care units (NICUs). We developed standard decision models with assumptions derived from primary data and the literature. Telemedicine costs included equipment installation and operation costs. Probabilistic analysis with Monte Carlo simulation was performed to address model uncertainties and to estimate 95% probabilistic confidence intervals (PCIs). All costs were adjusted to 2017 US dollars using the Consumer Price Index. Our probabilistic analysis estimated the ROI to have a mean value of 2.23 (95% PCI, -0.7 to 6.0). That is, a $1 investment in this telemedicine model would yield a net medical expenditure saving of $1.23. "Cost saving" was observed for 75% of the hypothetical 1000 Monte Carlo simulations. For the state of California, the estimated mean annual net savings was $661000. Providing telemedicine and making available consultations to rural hospitals providing level I neonatal care are likely to reduce medical expenditures by reducing potentially avoidable transfers of newborns to level III and IV NICUs, offsetting all telemedicine-related costs.

The Impact of Care Fragmentation on Pancreatic Cancer Care: More Complex Than It Seems

Introduction: Fragmentation of care (FC)—care at >1 facility—has been associated with increased cost, delayed treatment, and worse survival for gastrointestinal cancers. We assessed the impact of FC on pancreatic cancer care in California. Methods: Using the California Cancer Registry, linked with ambulatory surgery, emergency visits and discharge records from the Office of Statewide Health Planning Database, patients diagnosed with non-metastatic pancreatic ductal adenocarcinoma (PDAC) from 2007-2017 were identified. FC was determined by the number of unique facilities where patients received cancer care over the initial 12 months. We evaluated the association between FC and all-cause mortality using multivariable-adjusted Cox regression. Results: Among 9,464 PDAC patients, 4,545 patients received care at 1 facility (48.0%), 3,571 (37.7%) at 2, and 1,348 (14.2%) at >3. After adjusting for patient, tumor and hospital characteristics, female sex (HR=0.93 [0.89-0.97], p=0.001), high socioeconomic status (highest vs lowest quintile: HR=0.75 [0.70-0.82], p=<0.001) and cancer-hospital designations (all HR<1, p<0.001; see table) were associated with lower mortality. Mortality was lower for patients treated at 2 facilities compared to those treated at 1 facility (HR=0.95 [0.90-0.99], p=0.02), but was similar for patients treated at >3 vs 1 facility (HR=1.01 [0.94-1.07], p=0.87). Conclusions: Although prior data suggested that FC at >1 facility compromised cancer outcomes, in this large population-based cohort, PDAC patients treated at 2 facilities had better survival. FC is more complex than previously hypothesized. Our ongoing research is directed at better understanding “positive fragmentation” (e.g., seeking higher level of care) versus disjointed care (previously ascribed to fragmentation).