Community-based Health System Research Articles

Genomic testing and uptake of alteration-targeted therapies among patients with hormone-receptor positive (HR+) metastatic breast cancer (MBC).

e13084 Background: There is no recognized standard of care treatment after progression on first-line endocrine therapy plus CDK4/6 inhibitor in HR+ / HER2 negative MBC. Alteration-targeted therapies (ATT) have the potential to delay initiation of chemotherapy with more favorable toxicity, and perhaps improved efficacy. Next-generation sequencing (NGS) of tumor tissue or circulating tumor DNA (ctDNA) can identify actionable mutations for targeted therapy. In this study, we sought to assess the results of genomic testing and uptake of ATT among patients with HR+ / HER2-negative MBC. Methods: We studied a retrospective cohort of patients with MBC who received treatment in the Koontz Center for Advanced Breast Cancer (KABCC) at St. Luke’s Cancer Institute, a community-based health system in the Kansas City metro area. The analytic cohort included 125 patients with HR+ / HER2-negative MBC who received treatment after progression on first-line therapy. Genomic testing was performed as a standard of care from ctDNA or tumor-tissue using commercially available NGS assays. Targetable alterations were defined as those with FDA-approved or routinely used off-label treatment regimens in MBC ( PIK3CA, PTEN, AKT, ESR1, ERBB2, BRCA1, BRCA2, PALB2 mutations; TMB >10 or PDL1+). We identified patients who received any ATT and compared them with those who did not. Overall survival (OS) and time to initiation of chemotherapy (TTC) were compared between the two groups using Kaplan-Meier analyses and the log-rank test. Results: Ninety-nine patients (79.2%) had genomic testing and 49 (39.2%) were tested prior to second-line therapy. Of those tested, 84% had at least one targetable alteration. ESR1 mutations were most common, detected in 36% of patients, followed by PIK3CA (31.2%), PTEN (12%), BRCA1/2 (7.2%) and ERBB2 (5.6%). A total of 35 patients received ATT, and around half of those (17 patients) received ATT in the second line. Alpelisib was the most common ATT (62.9%), followed by elacestrant (20%) and neratinib (14.3%). There was no significant difference in OS or TTC between the two groups. Conclusions: Approximately 80% of patients with HR+ / HER2-negative MBC in our cohort underwent genomic testing after progression on first-line therapy, and the vast majority had at least one targetable alteration identified. However, only 35 patients received ATT with most receiving alpelisib. We observed no significant improvement in OS or TTC among those who received ATT, although the numbers were small. There have been two new targeted therapies approved in the past year and many novel agents are currently under investigation in clinical trials. Newer therapies with distinct targets, improved tolerability and efficacy have the potential to improve the uptake and clinical benefit of targeted therapy in MBC.

Monitoring Data Nilai Gizi Balita menggunakan Tableau Public (Studi Kasus : Posyandu Sedap Malam)

In Indonesia, there are still toddlers with poor nutritional status. Nutrition is food substances needed for the development, growth, and health of a person's body. Toddlers who experience nutritional problems will have an impact on their growth and development, be susceptible to disease, and can even result in death in children under five. Children's growth and development are monitored regularly to detect potential problems early. Utilizing a community-based health system such as Posyandu is the most important key to improving the quality of children's growth and development. Monitoring of children's growth and development in Indonesia is carried out by measuring body weight every month at Posyandu with the Healthy Way Card (KMS) as a supporting tool. Through KMS, growth and development disorders in children can be identified early and appropriate steps can be taken to correct these problems. The Berbabis Tablue Posyandu Service Analysis Information System can help monitor data and information on the nutritional status of each child. The results of this paper show that the use of Tableau in analyzing data on the nutritional status of toddlers can provide a comprehensive and in-depth picture. Interactive visualization allows users to explore data directly, identify patterns, and quickly retrieve important information. With visualization, posyandu cadres can make decisions regarding toddler nutrition programs

Being both a grandmother and a health worker: experiences of community-based health workers in addressing adolescents’ sexual and reproductive health needs in rural Zambia

IntroductionCommunity-based health workers (CBHWs) possess great potential to be the missing link between the community and the formal health system for improving adolescents’ access to sexual and reproductive health and rights (SRHR) information and services. Yet, their role in addressing adolescents’ SRHR within the context of the community-based health system has received very little attention. This paper analyses how CBHWs experience and perceive their role in addressing adolescents’ SRHR needs in rural Zambia, including the possible barriers, dilemmas, and opportunities that emerge as CBHWs work with adolescents.MethodsBetween July and September 2019, we conducted 14 in-depth interviews with 14 community-based health workers recruited across 14 different communities in the central province of Zambia. The interviews were focused on eliciting their experiences and perceptions of providing sexual and reproductive health services to adolescents. Charmaz’s grounded theory approach was used for the analysis.ResultsWe present the core category “being both a grandmother and a CBHW”, which builds upon four categories: being educators about sexual and reproductive health; being service providers and a link to SRHR services; being advocates for adolescents’ SRHR; and reporting sexual violence. These categories show that CBHWs adopt a dual role of being part of the community (as a grandmother) and part of the health system (as a professional CBHW), in order to create/maximise opportunities and navigate challenges.ConclusionCommunity-based health workers could be key actors providing context-specific comprehensive SRHR information and services that could span all the boundaries in the community-based health system. When addressing adolescents SRHR, playing dual roles of being both a grandmother and a professional CBHW were sometimes complimentary and at other times conflicting. Additional research is required to understand how to improve the role of CBHWs in addressing adolescents and young people’s sexual and reproductive health.

Ovarian cancer risk among older patients with stable adnexal masses

Few studies have evaluated the risk of cancer among older patients with stable adnexal masses in community-based settings to determine the duration of observation time needed. This study aimed to assess the ovarian cancer risk among older patients with stable adnexal masses on ultrasound. This was a retrospective cohort study of patients in a large community-based health system aged ≥50 years with an adnexal mass <10 cm on ultrasound between 2016 and 2020 who had at least 1 follow-up ultrasound performed ≥6 weeks after initial ultrasound. Masses were considered stable on follow-up examination if they did not exhibit an increase of >1 cm in the greatest dimension or a change in standardized reported ultrasound characteristics. Ovarian cancer risk was determined at increasing time intervals of stability after initial ultrasound. Among 4061 patients with stable masses, the average age was 61 years (range, 50-99), with an initial mass size of 3.8 cm (range, 0.2-9.9). With a median follow-up of 3.7 years, 11 cancers were detected, with an absolute risk of 0.27%. Ovarian cancer risk declined with longer duration of stability, from 0.73 (95% confidence interval, 0.30-1.17) per 1000 person-years at 6 to 12 weeks, 0.63 (95% confidence interval, 0.19-1.07) at 13 to 24 weeks, 0.44 (95% confidence interval, 0.01-0.87) at 25 to 52 weeks, and 0.00 (95% confidence interval, 0.00-0.00) at >52 weeks. Expressed as number needed to reimage, ongoing ultrasound imaging would be needed for 369 patients whose masses show stability at 6 to 12 weeks, 410 patients at 13 to 24 weeks, 583 patients at 25 to 52 weeks, and >1142 patients with stable masses at 53 to 104 weeks to detect 1 case of ovarian cancer. In a diverse community-based setting, among patients aged ≥50 years with an adnexal mass that was stable for at least 6 weeks after initial ultrasound, the risk of ovarian cancer was very low at 0.27%. Longer demonstrated duration of stability was associated with progressively lower risk, with no cancer cases observed after 52 weeks of stability. These findings suggest that the benefit of ultrasound monitoring of stable masses beyond 12 months is minimal and may be outweighed by potential risks of repeated imaging.

Prenatal detection rates for congenital heart disease using abnormal obstetrical screening ultrasound alone as indication for fetal echocardiography.

To determine the live born prenatal detection rate of significant congenital heart disease (CHD) in a large, integrated, multi-center community-based health system using a strategy of referral only of patients with significant cardiac abnormalities on obstetrical screening ultrasound for fetal echocardiography. Detection rates were assessed for screening in both radiology and maternal fetal medicine (MFM). The impact on fetal echocardiography utilization was also assessed. This was a retrospective cohort study using an electronic health record, outside claims databases and chart review to determine all live births between 2016 and 2020 with postnatally confirmed sCHD that were prenatally detectable and resulted in cardiac surgery, intervention, or death within 1year. There were 214,486 pregnancies resulting in live births. Prenatally detectable significant CHD was confirmed in 294 infants. Of those 183 were detected for an overall live-born detection rate of 62%. Detection rates in MFM were 75% and in radiology were 52%. The number of fetal echocardiograms needed to detect (NND) sCHD was 7. A focus on quality and standardization of obstetrical screening ultrasound with referral to fetal echocardiography for cardiac abnormalities alone achieves benchmark targets for live-born detection of significant CHD requiring fewer fetal echocardiograms.

Examining the implementation of facility-based integrated management of childhood illness and insecticide treated nets in Bangladesh: lessons learned through implementation research

BackgroundBangladesh significantly reduced under-5 mortality (U5M) between 2000 and 2015, despite its low economic development and projected high mortality rates in children aged under 5 years. A portion of this success was due to implementation of health systems-delivered evidence-based interventions (EBIs) known to reduce U5M. This study aims to understand how Bangladesh was able to achieve this success between 2000 and 2015. Implementation science studies such as this one provide insights on the implementation process that are not sufficiently documented in existing literature.MethodsBetween 2017 and 2020, we conducted mixed methods implementation research case studies to examine how six countries including Bangladesh outperformed their regional and economic peers in reducing U5M. Using existing data and reports supplemented by key informant interviews, we studied key implementation strategies and associated implementation outcomes for selected EBIs and contextual factors which facilitated or hindered this work. We used facility-based integrated management of childhood illnesses and insecticide treated nets as examples of two EBIs that were implemented successfully and with wide reach across the country to understand the strategies put in place as well as the facilitating and challenging contextual factors.ResultsStrategies which contributed to the successful implementation and wide coverage of the selected EBIs included community engagement, data use, and small-scale testing, important to achieving implementation outcomes such as effectiveness, reach and fidelity, although gaps persisted including in quality of care. Key contextual factors including a strong community-based health system, accountable leadership, and female empowerment facilitated implementation of these EBIs. Challenges included human resources for health, dependence on donor funding and poor service quality in the private sector.ConclusionAs countries work to reduce U5M, they should build strong community health systems, follow global guidance, adapt their implementation using local evidence as well as build sustainability into their programs. Strategies need to leverage facilitating contextual factors while addressing challenging ones.

Predictors of Long-Acting Injectable Antipsychotic Medication Use in Patients with Schizophrenia Spectrum, Bipolar, and Other Psychotic Disorders in a US Community-based, Integrated Health System

Abstract Background and Hypothesis Long-acting injectable (LAI) antipsychotics improve patient outcomes and are recommended by treatment guidelines for patients with limited medication adherence in schizophrenia spectrum, bipolar, and other psychotic disorders. Reports of LAI antipsychotic use in these disorders and if use aligns with treatment guidelines are lacking. This study aimed to report patient characteristics associated with LAI antipsychotic use in these disorders. Study Design Retrospective observational study of patients ≥18-years-old with bipolar or psychotic disorders at a large, integrated, community-based health system. Patient demographic and clinical characteristics served as exposures for the main outcome of adjusted odds ratio (aOR) for LAI versus oral antipsychotic medication use from January 1, 2017 to December 31, 2023. Study Results There were N = 2685 LAI and N = 31 531 oral antipsychotic users. Being non-white (aOR = 1.3-2.0; P &amp;lt; .0001), non-female (aOR = 1.5; P &amp;lt; .0001), from a high deprivation neighborhood (NDI, aOR = 1.3; P &amp;lt; .0007), having a higher body mass index (BMI, aOR = 1.3-1.7; P &amp;lt; .0009), having a schizophrenia/schizoaffective (aOR = 5.8-6.8; P &amp;lt; .0001), psychotic (aOR = 1.6, P &amp;lt; .0001), or substance use disorder (aOR = 1.4; P &amp;lt; .0001), and outpatient psychiatry (aOR = 2.3-7.5; P &amp;lt; .0001) or inpatient hospitalization (aOR = 2.4; P &amp;lt; .0001) utilization in the prior year with higher odds and age ≥40 (aOR = 0.4-0.7; P &amp;lt; .0001) or bipolar disorder (aOR = 0.9; P &amp;lt; .05) were associated with lower odds of LAI use. Non-white, non-female, age 18-39, and high NDI patients had higher LAI use regardless of treatment adherence markers. Smoking and cardiometabolic markers were also associated with LAI use. Conclusions Demographic and clinical factors are associated with increased LAI use irrespective of treatment adherence. Research on utilization variation informing equitable formulation use aligned with treatment guideline recommendations is warranted.

Evaluation of gender-affirming care experiences of transgender and gender diverse patients within a LGBTQ+ community pharmacy

BackgroundTransgender and gender diverse (TGD) populations require personalized care. Lived experiences and needs TGD populations express, compounded by limited care access, negatively shape health care involvement. Manifestations from these barriers may present as health care avoidance, identity concealment, or preventive care hinderance. Community pharmacies remain engagement points for TGD patients, but gender diverse services remain limited. What remains unknown is how TGD pharmacy perceptions and behaviors are influenced with gender-affirming care (GAC) accessibility. ObjectivesThe primary objective is to assess how TGD patient perceptions and behaviors toward community pharmacy experiences are affected through a lesbian, gay, bisexual, transgender, queer/questioning, and others (LGBTQ+) community-based health system. MethodsA cross-sectional, multisite, reflective survey was conducted at 4 LGBTQ+ community pharmacies in central and southwest Ohio. Nine 5-point Likert-item questions and one ordinal question were used to analyze perception and behavior. Participants responded for LGBTQ+ and external pharmacy experiences respectively. Data were analyzed through descriptive methods, paired Student’s t test, and Fisher’s exact test or c2 test where appropriate. ResultsIn total, 267 surveys were completed with 96 TGD submissions qualifying for analysis. Perceptions toward pharmacy experience saw statistically significant differences among all evaluations of perception. Behavioral assessment demonstrated statistically significant improvements in pharmacy outreach except for seeking medications from outside sources. Respondents indicated more involvement with the LGBTQ+ pharmacies versus external pharmacies in discussing medications (96.9% vs. 60.4%), care plans (64.6% vs. 41.6%), disclosure of pronouns or gender (97.9% vs. 43.8%), and feeling needs were understood (96.8% vs. 51%). ConclusionInclusive community pharmacies may positively affect pharmacy perceptions and behaviors of TGD patients. These findings call attention to barriers in the provision of care for TGD patients while highlighting the change community pharmacies can have when providing these services. Community pharmacies should be encouraged to incorporate inclusive environments to improve TGD patient care involvement and access.

Evidence on community-based intervention for tackling childhood pneumonia Project in Bangladesh

Abstract In Bangladesh, pneumonia is a major cause of child mortality, killed 26,766 under 5 children, accounting for 24% of all under 5 child deaths in 2022. To address this issue, we implemented a community-based project in Barishal from June 2021 to December 2022. Project activities aimed to strengthen the health system for improved access and utilization of quality child health care and child immunization services, encouraged community practice and behavior for care-seeking and exclusive breastfeeding. During the project period, 22 medical doctors, 30 paramedics and 168 MoHFW employed service providers including community clinics, community-based health facility for six thousand population, received case management training, 38 health centers were equipped with necessary logistics and supplies for improved case management of sick children. We also conducted special vaccination campaigns in 13 hard-to-reach areas, deployed 11 vaccination aids for improving child vaccination coverage in remote areas and raised awareness of recommended health practices at the community level. A comparison of baseline and endline survey data showed significant improvements in children among 12-23 months of age who received all recommended basic vaccines by 12 months [77% in baseline (n = 239) vs. 92% in endline (n = 235); p &amp;lt; 0.01]; care-seeking from health facilities or trained health service providers for sick children with pneumonia [40% in baseline (n = 127) vs. 52% in endline (n = 225); p &amp;lt; 0.005]; and exclusive breastfeeding for children below 6 months [52% in baseline (n = 122) vs. 62% in endline (n = 120); p &amp;lt; 0.01]. These results revealed the project's success with simple but contextualized efforts to enhance the health system by developing the capacity and skills of service providers to provide high-quality child health care for sick children, improving access to equitable child immunization, and raising social awareness through partnerships with the MoHFW and community engagement initiatives. Key messages • Community-based intervention with minimum resources have potential to scale up with improving accessibility and utilization of health services, specially in hard to reach areas in Bangladesh. • Contextualized and simple intervention through collaboration with local government and community engagement is critical for success of community based health system strengthening project.

Unpacking the challenges of fragmentation in community-based maternal newborn and child health and health system in rural Ethiopia: A qualitative study.

In Ethiopia, country-wide community-based primary health programs have been in effect for about two decades. Despite the program's significant contribution to advancing Maternal Newborn and Child Health (MNCH), Ethiopia's maternal and child mortality is still one of the highest in the world. The aim of this manuscript is to critically examine the multifaceted fragmentation challenges of Ethiopia's Community Health Workers (CHWs) program to deliver optimum MNCH and build a resilient community health system. We conducted a qualitative case study in West Shewa Zone, rural Ethiopia. A purposive sampling technique was used to recruit participants. Data sources were two focus group discussions with sixteen CHWs, twelve key informant interviews with multilevel public health policy actors, and a policy document review related to the CHW program to triangulate the findings. Thematic analysis of the qualitative data was conducted. The World Health Organization's health systems framework and socio-ecological model guided the data collection, analysis, and interpretation. The CHWs program has been an extended arm of Ethiopia's primary health system and has contributed to improved health outcomes. However, the program has been facing unique systemic challenges that stem from the fragmentation of health finance; medical and equipment supply; working and living infrastructures; CHWs empowerment and motivation, monitoring, supervision, and information; coordination and governance; and community and stakeholder engagement. The ongoing COVID-19 and volatile political and security issues are exacerbating these fragmentation challenges. This study emphasized the gap between the macro (national) level policy and the challenge during implementation at the micro (district)level. Fragmentation is a blind spot for the community-based health system in rural Ethiopia. We argue that the fragmentation challenges of the community health program are exacerbating the fragility of the health system and fragmentation of MNCH health outcomes. This is a threat to sustain the MNCH outcome gains, the realization of national health goals, and the resilience of the primary health system in rural Ethiopia. We recommend that beyond the current business-as-usual approach, it is important to emphasize an evidence-based and systemic fragmentation monitoring and responsive approach and to better understand the complexity of the community-based health system fragmentation challenges to sustain and achieve better health outcomes. The challenges can be addressed through the adoption of transformative and innovative approaches including capitalizing on multi-stakeholder engagement and health in all policies in the framework of co-production.

Awakening and Breathing Coordination: A Mixed-Methods Analysis of Determinants of Implementation.

Rationale: Routine spontaneous awakening and breathing trial coordination (SAT/SBT) improves outcomes for mechanically ventilated patients, but adherence varies. Understanding barriers to and facilitators of consistent daily use of SAT/SBT (implementation determinants) can guide the development of implementation strategies to increase adherence to these evidence-based interventions. Objectives: We conducted an explanatory, sequential mixed-methods study to measure variation in the routine daily use of SAT/SBT and to identify implementation determinants that might explain variation in SAT/SBT use across 15 intensive care units (ICUs) in urban and rural locations within an integrated, community-based health system. Methods: We described the patient population and measured adherence to daily use of coordinated SAT/SBT from January to June 2021, selecting four sites with varied adherence levels for semistructured field interviews. We conducted key informant interviews with critical care nurses, respiratory therapists, and physicians/advanced practice clinicians (n = 55) from these four sites between October and December 2021 and performed content analysis to identify implementation determinants of SAT/SBT use. Results: The 15 sites had 1,901 ICU admissions receiving invasive mechanical ventilation (IMV) for ⩾24 hours during the measurement period. The mean IMV patient age was 58 years, and the median IMV duration was 5.3 days (interquartile range, 2.5-11.9). Coordinated SAT/SBT adherence (within 2 h) was estimated at 21% systemwide (site range, 9-68%). ICU clinicians were generally familiar with SAT/SBT but varied in their knowledge and beliefs about what constituted an evidence-based SAT/SBT. Clinicians reported that SAT/SBT coordination was difficult in the context of existing ICU workflows, and existing protocols did not explicitly define how coordination should be performed. The lack of an agreed-upon system-level measure for tracking daily use of SAT/SBT led to uncertainty regarding what constituted adherence. The effects of the COVID-19 pandemic increased clinician workloads, impacting performance. Conclusions: Coordinated SAT/SBT adherence varied substantially across 15 ICUs within an integrated, community-based health system. Implementation strategies that address barriers identified by this study, including knowledge deficits, challenges regarding workflow coordination, and the lack of performance measurement, should be tested in future hybrid implementation-effectiveness trials to increase adherence to daily use of coordinated SAT/SBT and minimize harm related to the prolonged use of mechanical ventilation and sedation.

532-P: Know Your Diabetes by Heart—DSME/S Collaboration with Project Dulce and Dulce Digital Improves Knowledge and HbA1c

Cardiovascular disease (CVD) and type 2 diabetes (T2D) are closely linked, yet many people with T2D are unaware of the risk. The ADA and AHA, supported the integration of Know Your Diabetes by Heart (KDBH) messaging into DSME/S programs to improve knowledge of CVD risk in T2D populations. Scripps Health, a large health system in San Diego, CA employed two distinct diabetes education methods to deliver enhanced KDBH messaging and determined change in knowledge and clinical outcomes after program delivery. Messages emphasizing the connection of CVD to T2D, and BP and cholesterol risk management were developed in English and Spanish and delivered via 1) Project Dulce (PD), an evidence-based culturally and linguistically modified 9-hour, 5-session traditional in-person and virtual telehealth DSME/S program, and 2) Dulce Digital (DD), an innovative 6-month diabetes education texting program within Scripps ambulatory clinics and partnering Federally Qualified Health Centers (FQHCs) serving diverse racial and ethnic low-income populations in California. Pre/post surveys assessed knowledge and self-management, and clinical metrics were evaluated via electronic health records. Of the N=333participants, 59% were Female, mean age 54 (SD 12.3) years and 42% were Spanish speakers, 70% were White, 54% Hispanic, 17% AA, Asian, NA, PI, and 18% other. Among those with baseline (BL, N=291) and Month 6 (M6, N=82), survey feedback demonstrated improved knowledge of the association of CVD toT2D (PD-94 -&amp;gt;98%, DD-65-&amp;gt;85%), the leading cause of death as CVD (PD-51-&amp;gt;60%, DD-34-&amp;gt;45%) and an increased willingness to discuss the link between heart disease and diabetes. Mean change in HbA1c (N=86 paired values) between BL and M6, was -0.98 [-1.35, -0.61] (-p&amp;lt;0.0001). KDBH campaign in English and Spanish improved CVD risk knowledge and A1c with two methods of DSME/S, PD group live and DD texting in a community-based health system and FQHCs, serving low income diverse racial and ethnic communities. Disclosure M.Ruiz: None. S.R.Spierling bagsic: None. H.Sandoval: None. M.Chichmarenko: None. A.L.Fortmann: Employee; Dexcom, Inc. C.Walker: None. A.Philis-tsimikas: Advisory Panel; Dexcom, Inc., Novo Nordisk A/S, Sanofi, Other Relationship; Medtronic, Research Support; Novo Nordisk A/S, Lilly, Viking Therapeutics, NIH - National Institutes of Health.

Building a Community-Academic Partnership to Expand Workforce Development in Underserved, High-Need/High-Demand Areas.

This case study highlights the partnership development between a large, urban, public, community-based behavioral health system and an academic program. Using principles of partnership building and facilitators that enhance partnership building, we describe the process of initiating, building, and sustaining the partnership. The Health Resources and Services Administration (HRSA) workforce development initiative was the primary catalyst for the partnership development. The public, community-based behavioral health system is located in an urban, medically underserved area and health care professional shortage area. The academic partner is a master in social work (MSW) program in Michigan. We assessed partnership development by using process and outcome measures that captured changes in the partnerships and in implementation of the HRSA workforce development grant. The goals of this partnership were to develop the infrastructure to support the training of MSW students, expand workforce skills in integrated behavioral health, and increase the number of MSW graduates who work with medically underserved populations. During 2018-2020, the partnership trained 70 field instructors, engaged 114 MSW students in HRSA field placements, and developed 35 community-based field sites (including 4 federally qualified health centers). The partnership provided training for field supervisors and for HRSA MSW students and developed new courses/trainings focusing on integrated behavioral health assessment/intervention practices, trauma-informed care, cultural awareness, and telebehavioral health practices. Of 57 HRSA MSW graduates who responded to a postgraduation survey, 38 (66.7%) were employed in medically underserved, high-need/high-demand urban areas. Partnership sustainability was helped by formal agreements, regular communication, and a collaborative decision-making approach.

Mental health care delivery and quality of service provision in Brazil

Public mental health system in Brazil is structured through “The Psychosocial Care Network (Rede de Atenção Psicossocial, RAPS)". This coordinated system comprises primary care, specialized mental health care, crisis management services, inpatient units, deinstitutionalization initiatives, and psychosocial rehabilitation programs. In this narrative review, we aim to provide an overview of mental health care delivery in Brazil by assessing three aspects of the RAPS: structure, operationalization, and current state. For reviewing its structure, we start by overviewing the public health system, then examining the psychiatric reform, as well as the law and policy that established the components of the community-based mental health system in the country. Regarding the operationalization, we review recommendations for how the different components of the system should be coordinated, as well as directions for practices at the assistance level. Finally, we review the results of the mental health system, including official data and academic publications assessing coverage, funding, and quality of care. Drawing on the results from this review, we highlight fragilities that indicate three future directions for strengthening the mental health provision in Brazil: establishing appropriate mechanisms for systematic assessment of the mental health system, improving the recommendations regarding the coordination and integration of services, and promoting evidence-based practices across the different levels of care provision.

Abstract P4-07-56: Mayo Clinic Enterprise patterns of growth-factor utilization for sacituzumab govitecan (SG)-induced neutropenia among patients with metastatic triple negative breast cancer

Abstract Background: SG was approved in 2020 for the treatment of metastatic triple negative breast cancer (TNBC). The most common grade 3/4 adverse event in the ASCENT trial was neutropenia (51.2%) with a 6% incidence of febrile neutropenia. 1 Package insert recommendations do not endorse primary prophylactic growth factor support, rather only initiating if severe neutropenia occurs on treatment.2 Objective: This study retrospectively reviewed the utilization of growth factor support in patients (pts) with metastatic TNBC initiated on SG at each Mayo Clinic Enterprise site. Methods: We performed a multi-center, retrospective review of all pts with TNBC who received SG from January 2021 to December 2021 at Mayo Clinic sites in Minnesota, Florida, Arizona, and its community-based health system network. Data collected included history of neutropenia with previous cycles of SG resulting in a treatment delay, number of cycles, grade of neutropenia and cycle/day of treatment plan when growth factor added. Pts who received only one dose of SG were excluded. The Fisher’s exact test was utilized to compare the difference in the use of primary prophylaxis between sites. Results: 67 pts received at least two doses of SG. Within this cohort, 42 pts (63%) received growth factor support during treatment with SG. Growth factor support was most often added during the first two cycles (59.5%). A total of 12 patients initiated growth factor with no history of delays related to neutropenia and without neutropenia at the time of administration. Eleven of these pts had growth factor support added on Cycle 1 as primary prophylaxis. Primary prophylaxis was most common at Mayo Clinic – Rochester compared to the other sites (Table 1), however there was not a statistically significant difference (p=0.27). There were 26 pts (39%) with a treatment delay due to neutropenia while receiving SG, of which 21 (81%) were managed with the addition of growth factor (13 pegfilgrastim, 8 filgrastim). The median number of cycles for all pts was 5 (range: 1-25). Pts who received growth factor were treated with a median of 5 cycles (range: 1-25) and pts who did not receive growth factor were treated with a median of 4 cycles (range: 1-19) (p=0.10). Conclusions: We observed wide variability in the use of prophylactic growth factor between Mayo Clinic sites with SG. The optimal practice of growth factor use with SG warrants further exploration.

Abstract 12053: Worsening Tricuspid Regurgitation After Leadless Pacemaker Implantation Leads to Higher Hospitalization for Heart Failure

Introduction: One of the many purported benefits of a leadless pacemaker (LP) is avoidance of interaction with the tricuspid valve, decreasing tricuspid valve dysfunction from chronic injury resulting from contact with transvenous leads. Data suggests that 31-38% of patients develop worsening tricuspid regurgitation (TR) after transvenous pacemaker implantation. However, some recent data suggest that LP therapy is also associated with a higher incidence of worsening TR, possibly similar to transvenous pacemakers. We present data from a large community-based health system on the incidence of worsening TR after LP implantation and its clinical implications. Methods: A total of 256 patients (mean age 80±10 years, 61% male) who received Micra leadless single chamber pacemaker devices at the NorthShore University HealthSystem between April 2017 and November 2021 were retrospectively reviewed. A total of 103 patients (40%) received both a transthoracic echocardiogram within 6 months pre-implantation and 6 months post-implantation. Characterization of TR and heart failure hospitalization were gathered through chart review. Results: Of the 103 patients, 39 (38%) were found to have worsening of their TR after LP implantation when compared to before. Of the patients with worsening TR, 18 (46%) required hospitalization for heart failure within 12 months, compared to 15 (23%) without worsening TR ( X 2 = 5.7, p = 0.02). Conclusions: LP implantation is associated with comparable levels of worsening TR (38%) when compared to transvenous pacemakers. Worsening TR is associated with increased heart failure hospitalization within 12 months. More data is required to establish the reasoning behind the comparable levels of worsening TR in LP given the lack of mechanical interaction with the tricuspid valve apparatus.

The contribution of community health systems to resilience: Case study of the response to the drought in Ethiopia.

BackgroundEthiopia’s exposure to the El Niño drought (2015-2016) resulted in high malnutrition, internally displaced people, and epidemics of communicable diseases, all of which strained the health system. The drought was especially challenging for mothers and children. We aimed to identify salient factors that can improve health system resilience by exploring the successes and challenges experienced by a community-based health system during the drought response.MethodsWe collected data via key informant interviews and focus group discussions to capture diverse perspectives across the health system (eg, international, national, district, facility, and community perspectives). Data were collected from communities in drought-affected regions of: 1) Somali, Sitti Zone, 2) Hawassa, Southern Nations, Nationalities, and Peoples’ Region (SNNPR), and 3) Tigray, Eastern Zone. Data were analysed using a deductive-inductive approach using thematic content analysis applied to a conceptual framework.ResultsA total of 94 participants were included (71 from the communities and 23 from other levels). Key themes included the importance of: 1) organized community groups linked to the health system, 2) an effective community health workforce within strong health systems, 3) adaptable human resource structures and service delivery models, 4) training and preparedness, and 5) strong government leadership with decentralized decision making.ConclusionsThe results of this study provide insights from across the health system into the successes and challenges of building resilience in community-based health systems in Ethiopia during the drought. As climate change exacerbates extreme weather events, further research is needed to understand the determinants of building resilience from a variety of shocks in multiple contexts, especially focusing on harnessing the power of communities as reservoirs of resilience.

Fostering a High-Functioning Team in Cancer Care Using the 4R Oncology Model: Assessment in a Large Health System and a Blueprint for Other Institutions.

Delivering cancer care by high-functioning multidisciplinary teams promises to address care fragmentation, which threatens care quality, affects patient outcomes, and strains the oncology workforce. We assessed whether the 4R Oncology model for team-based interdependent care delivery and patient self-management affected team functioning in a large community-based health system. 4R was deployed at four locations in breast and lung cancers and assessed along four characteristics of high-functioning teams: recognition as a team internally and externally; commitment to an explicit shared goal; enablement of interdependent work to achieve the goal; and engagement in regular reflection to adapt objectives and processes. We formed an internally and externally recognized team of 24 specialties committed to a shared goal of delivering multidisciplinary care at the optimal time and sequence from a patient-centric viewpoint. The team conducted 40 optimizations of interdependent care (22 for breast, seven for lung, and 11 for both cancers) at four points in the care continuum and established an ongoing teamwork adaptation process. Half of the optimizations entailed low effort, while 30% required high level of effort; 78% resulted in improved process efficiency. 4R facilitated development of a large high-functioning team and enabled 40 optimizations of interdependent care along the cancer care continuum in a feasible way. 4R may be an effective approach for fostering high-functioning teams, which could contribute to improving viability of the oncology workforce. Our intervention and taxonomy of results serve as a blueprint for other institutions motivated to strengthen teamwork to improve patient-centered care.

Interventions for Increasing Digital Equity and Access (IDEA) among rural patients who smoke: Study protocol for a pragmatic randomized pilot trial

BackgroundCigarette smoking prevalence is higher among rural compared with urban adults, yet access to cessation programming is reduced. The Increasing Digital Equity and Access (IDEA) study aims to evaluate three digital access and literacy interventions for promoting engagement with an online evidence-based smoking cessation treatment (EBCT) program among rural adults. MethodsThe pilot trial will use a pragmatic, three-arm, randomized, parallel-group design with participants recruited from a Midwest community-based health system in Minnesota, Wisconsin, and Iowa. All participants will receive an online, 12-week, EBCT program, and written materials on digital access resources. Participants will be stratified based on state of residence and randomly assigned with 1:1:1 allocation to one of three study groups: (1) Control Condition-no additional study intervention (n = 30); (2) Loaner Digital Device-Bluetooth enabled iPad with data plan coverage loaned for the study duration (n = 30); (3) Loaner Digital Device + Coaching Support–loaner device plus up to six, 15–20 min motivational interviewing-based coaching calls to enhance participants' digital access and literacy (n = 30). All participants will complete study assessments at baseline and 4- and 12-weeks post-randomization. Outcomes are cessation program and trial engagement, biochemically confirmed smoking abstinence, and patient experience. ResultsA rural community advisory committee was formed that fostered co-design of the study protocol for relevance to rural populations, including the trial design and interventions. ConclusionStudy findings, processes, and resources may have relevance to other health systems aiming to foster digital inclusion in smoking cessation and chronic disease management programs and clinical trials in rural communities.

Implementing proven methods in a community-based health system to improve breast cancer screening rates during the COVID-19 pandemic.

6565 Background: There are reduced screening rates across the United States secondary to the COVID-19 pandemic; the additional anticipated deaths from breast and colorectal cancer, secondary to reduced screening, is approximated at 10,000 people. A study of thirty-two health systems in Georgia noted an 8% decrease in screening mammography compared to pre-pandemic rates. To help reverse the decline, Northeast Georgia Medical Center (NGMC) participated in the "Return to Screening" initiative, in conjunction with the American Cancer Society (ACS). A quality improvement project was performed at the community-based hospital system to increase breast cancer screening rates, using a multidisciplinary approach with a focus on health care disparities. Methods: The initial goal was to increase screening mammograms by 10% (n = 14,364) from June 1st to December 1st 2021. Interventions were selected by a multidisciplinary team of NGMC researchers, clinical providers, and oncology administrators. Interventions varied in category, encompassing unique patient and provider-specific approaches. The evidence-based interventions were tailored to address health care disparities in the local population. This included identification and quantification of cultural groups in the community to ensure quality patient access. Integrative collaboration consisted of intermittent meetings to certify consistent communication, project reflection and identification of barriers. The selected interventions were executed monthly, with simultaneous data tracking of mammography rates. Results: From June 1st to December 1st 2021, a total of forty evidence-based interventions were successfully implemented. Analysis of screening rates demonstrated a 15% increase across the allotted time period, corresponding to an average of 1,302 mammograms monthly (n = 15,284). This exceeded the initial anticipated goal of increasing screening by 10% (n = 14,364). Analysis of mammography results identified 331 new cases of breast cancer diagnosed within the allotted period, a 7% mean diagnosis rate increase. Certain planned interventions were unable to be conducted and required modification due to limitation of the ongoing pandemic; however, this solidified the use of social media and virtual participation as effective methods of community outreach. Conclusions: We identified key methods to engage the local community and successfully increased rates of screening mammography. Interventions were tailored to the local population, ensuring patient-centered tools and a personalized approach to medicine. The multidisciplinary, consistent collaboration with stakeholders ensured quality of care for the local patient population. This project demonstrates the importance of local community engagement to impact national cancer screening rates, and thus, ensure earlier detection of breast cancer.