Community Health System Research Articles

Public Policy Analysis in Stunting Reduction: A Review of National Programs and Strategies

Stunting remains a severe problem in public health, including in Indonesia, and tackling it requires cross-sectoral efforts and integrated public policies. This study analyzes public policies on stunting reduction, especially national programs and strategies in Indonesia. The research method used is public policy analysis, including identifying, describing, and evaluating existing policies and factors influencing their implementation. The study collected data from various sources, including policy documents and academic literature. The results of the analysis show that the Indonesian government has implemented various national programs and strategies to reduce stunting. These programs include nutrition interventions, maternal and child health services, health education, and community empowerment. The national strategy adopted includes a cross-sectoral approach, active community participation, increased accessibility, and health system strengthening. Nevertheless, implementing public policies to stunt reduction is faced with various challenges. These challenges include budget constraints, suboptimal cross-sectoral coordination, public awareness, and environmental factors affecting child nutrition. In addition, evaluation of the impact and effectiveness of the program is also an essential focus in improving the success of stunting reduction efforts. The study suggests several policy recommendations to improve the effectiveness of stunting reduction in Indonesia. The recommendations include increasing budget allocations for nutrition programs, improving cross-sectoral coordination through establishing more effective coordination mechanisms, increasing community participation through a community-based approach, and strengthening regular program monitoring and evaluation.

Census tract–level social determinants of health and variability in stage at diagnosis of bladder, breast, and non-small cell lung cancers.

11170 Background: Social determinants of health (SDOH) can identify underserved populations, inform the patient journey, and identify opportunities to improve outcomes. In cancer, SDOH may influence stage at diagnosis through exposure to risk factors for aggressive cancer and decreased access to care. However, privacy restrictions can limit research with SDOH in real world datasets, which often only know a patient’s broad location. Methods: Geocoding was undertaken on addresses of patients diagnosed between 1/1/17 and 9/30/22 with bladder (n=6078), breast (n=28,958), and non-small cell lung cancer (NSCLC, n=14,957) in the Syapse Learning Health Network of U.S. community health systems. Location was linked to five indicators of SDOH at the census tract level: the Social Vulnerability Index (SVI); percent (%) of tract spending >30% of income on housing; % of tract with broadband internet; county designation as a primary care shortage area; and rural urban commuting area (RUCA). Nested multivariable ordinal logistic regression models estimated independent associations between demographic, clinical, and SDOH factors with stage at initial cancer diagnosis. The statistical significance of including SDOH variables was assessed using a likelihood ratio test (LRT) comparing the models before and after including SDOH. Results: After successful geocoding and linkage to census tracts, there were marginal differences in the distribution of the five SDOH across stages at diagnosis within the three tumor types. In multivariable models adjusted for year of diagnosis, age, sex, race, ethnicity, smoking, and primary payor, among the tested SDOH measures, county designated as primary care shortage (proportional odds ratios (OR): 1.31, 95% confidence interval (95% CI): 1.05-1.64), and non-metropolitan area (0.69, 0.50-0.94) were statistically significantly associated with stage at bladder cancer diagnosis. SVI (1.52, 1.31-1.76) was also statistically significantly associated and directly proportional with stage at breast cancer diagnosis. Among patients with NSCLC, broadband internet access (1.01, 1.00-1.01), primary care shortage (1.15, 1.03-1.27) and non-metropolitan area (0.85, 0.74-0.99) were statistically associated with stage at diagnosis. In all three tumors, LRTs found that models with SDOH were statistically significantly better at predicting stage at diagnosis than those without (p <0.001). Conclusions: Using granular, census-tract geospatial resolution for geocoding of SDOH, we find that patients who live in greater vulnerability are diagnosed at later stages than those who live in areas of less vulnerability, suggesting that consideration of SDOH variables is important in assessing stage at diagnosis and identify patients with an unmet need for outreach and screening.

CGP-based IO biomarker assessment and treatment utilization across a major US health system.

e23109 Background: Immune checkpoint inhibitors (IO) have become a powerful precision therapy option to treat advanced stage cancer with biomarkers such as PD-L1, tumor mutational burden (TMB), and microsatellite instability (MSI) associated with improved patient response rates. Despite this, many patients do not receive genomic testing for all IO biomarkers. Providence, a large US community health system, developed a pathologist-directed testing protocol where comprehensive genomic profiling (CGP) was routinely used at time of diagnosis for advanced cancer patients. Methods: Advanced cancer patients who received CGP (ProvSeq 523) and IHC testing for PD-L1 between 2019-2023 were included in the study. Patients were required to be treated at Providence and were assessed for presence of IO biomarkers and subsequent therapy selection. Real world data were curated from patient charts and genomic laboratory data by employing a novel natural-language processing (NLP) approach to accelerate abstraction. Results: The study included 2,502 patients (53% female, median age 68y, 83% white). Top 3 tumor types tested were lung (40%), colorectal (9%), and breast (8%). Overall, 58% (N = 1,455) of patients had presence of ≥1 IO biomarker, with 46% (N = 1,155) being PD-L1 positive, and 27% (N = 682) being TMB-H. In PD-L1 negative patients (N = 1,347; 54%), 300 (22%) were TMB-H and 18 (1%) were MSI-H. 53% (N = 767) of patients who harbored an actionable IO biomarker received IO-based therapy. Fewer patients with an IO biomarker received chemotherapy compared to patients without an IO biomarker (23% vs 35%, p < 0.001). Patients who possessed ≥2 IO biomarkers received an IO precision therapy 68% of the time vs 47% in patients with 1 IO biomarker (p < 0.001). In PD-L1 negative patients, 26% (N = 78) of TMB-H patients received IO monotherapy compared to 5% (N = 49) of TMB-L patients. Conclusions: IO biomarker presence is associated with increased precision therapy use. CGP identified many TMB-H patients for IO monotherapy that would have been missed with PD-L1 testing alone. More than half of patients eligible for IO therapy don’t receive it; ongoing analyses will evaluate the impact of pathology-directed reflex testing on IO as well as targeted therapy approaches. [Table: see text]

Accelerating cancer research trial startup in the community setting: A quality-improvement study.

11066 Background: There is a large variation in activation times for cancer clinical trials, delaying the opportunity for patients to benefit from cutting edge treatments. Academic medical centers typically take longer to activate a clinical trial as compared to community settings. Some academic medical centers have adopted quality improvement processes to reduce clinical trial start-up time. Our center, TriHealth Cancer & Blood Institute (TCBI) in the SW Ohio community has also adopted quality improvement processes to further reduce startup time within our oncology research group. Methods: This study encompassed July 2022-June 2023, with baseline data drawn from January 2021 to December 2021 prior to the study period which revealed a mean clinical trial start-up time of 116 days. The research group used a swim-lane process to define the typical process & stakeholders for clinical activation time at our institution prior to the study time. Our group identified three major areas with significant lag-time - contracts, budgets, & IRB/ICF - with the overarching root cause for delays due to lack of organizational process & expertise in these major areas. Using Plan-Do-Study-Act (PDSA), we instituted interventions, which included utilizing a central IRB, identifying a responsible member with extensive research budgeting to review research study budgets, & identified a responsible member with extensive contracts review & negotiations working with Central Legal throughout the contracts negotiation process with sponsor(s). Results: During this 12-month study time, our center demonstrated a 44% reduction in trial start up time (141 days to 79 days), while at the same time doubling the number of active trials. This process change resulted in sustainability that carried into 2023, further reducing start-up time to 70 days. In 2021, we opened 6 studies and after adoption of these process improvements (2022) we doubled the number of studies by 117%, while opening 67% more in 2023 than in 2021. The ability to open more studies has allowed us to shift patient enrollment to more investigational trials while increasing treatment enrollment from 2022 to 2023 by 24%. Through process improvement, more treatment studies are open & available for our community. Conclusions: By implementing interventions to streamline clinical trial activation time, our center was able to significantly & sustainably reduce the time required to start a clinical trial in our community health system in a 12-month period, resulting in our ability to initiate more clinical trials. As a result, more treatment trial patients were able to be enrolled in these clinical trials at TCBI, with the hope of improved outcomes. We anticipate that further adoption of just-in-time studies may help to decrease this activation time further. [Table: see text]

TriHealth Cancer Institute’s collaboration with the Tempus AI TIME program impact on clinical trial operations and enrollment.

1553 Background: TriHealth Cancer Institute has the largest personalized medicine program serving Cincinnati. TriHealth’s EMR integration with Tempus AI TIME allows for patient screening using an AI powered software TApp that matches to a broad clinical trial portfolio. Each patient is followed using LINK portal and trials can be activated rapidly via TIME’s operational model. The goal of this collaboration is to increase TriHealth’s patients' access for clinical trials. Methods: The TApp is software utilizing subject data, trial eligibility criteria, and NLP models for AI matching to TIME studies. Unique TApp searches occur whenever there is new patient data or changes to eligibility criteria. All TApp matches are reviewed by Tempus AI nurses followed by confirmatory screening by TriHealth’s staff. Trials were activated using the TIME program’s standardized operational methods including a pre-negotiated rate card, trials agreement, and a central IRB. Data included number of patients screened, unique TApp searches, trial activations, consents, operational metrics, and financial impact. Results: From January 2022 - March 2023, TApp performed 8,653,397 unique searches for 135 TIME trials on TriHealth’s population of 18,823 patients. During this period, 985 trial eligibility criteria were modified and 200,776 patient clinical updates occurred. There were 2,032 potential matches (1,944 interventional, 88 observational) for 45 different trials. Tempus AI nurses spent 389 hours reviewing all 1,944 interventional matches and of these sent 284 to TriHealth for evaluation. For TIME studies, 28 patients consented (18 interventional, 10 observational) and 7 trials were activated (4 interventional, 3 observational). Total trial billable revenue for TIME studies was approximately $241,500 ($34,500 average per trial). Regarding non-TIME trials, 3 patients consented on 3 interventional studies. Activation time for non-TIME trials compared to TIME trials was 186 days versus 37 days. Conclusions: TriHealth’s partnership with TIME evaluated 18,800+ patients for 135 trials. Over 8.6M unique TApp searches resulted in 2,000+ patients screened by nurses. Operationally, TIME trials resulted in a 2.3X increase in the number of trial activations, an 80% reduction in days to activation, and 9.3 fold increase in enrollment compared to non-TIME studies. The use of AI enabled patient screening, combined with a structured trial activation process, improved patient enrollment at a community health system. [Table: see text]

Updates to a pharmacy-technician driven centralized medication refill service in a large community health system

In 2020, we published a description of the newly implemented centralized refill service (CRS) led by pharmacy technicians in our large community health system. Since that time, the CRS has been refined, updated, and expanded. We have also received many inquiries with common questions about the process from those who seek to implement a similar process. The purpose of this commentary is to 1) provide updates to the process in the 5 years since its implementation, and 2) provide additional insights on specific topics from inquiries to the organization.

Utilizing disease transmission and response capacities to optimize covid-19 control in Malaysia

ObjectivesPublic Health Social Measures (PHSM) such as movement restriction movement needed to be adjusted accordingly during the COVID-19 pandemic to ensure low disease transmission alongside adequate health system capacities based on the COVID-19 situational matrix proposed by the World Health Organization (WHO). This paper aims to develop a mechanism to determine the COVID-19 situational matrix to adjust movement restriction intensity for the control of COVID-19 in Malaysia.MethodsSeveral epidemiological indicators were selected based on the WHO PHSM interim guidance report and validated individually and in several combinations to estimate the community transmission level (CT) and health system response capacity (RC) variables. Correlation analysis between CT and RC with COVID-19 cases was performed to determine the most appropriate CT and RC variables. Subsequently, the CT and RC variables were combined to form a composite COVID-19 situational matrix (SL). The SL matrix was validated using correlation analysis with COVID-19 case trends. Subsequently, an automated web-based system that generated daily CT, RC, and SL was developed.ResultsCT and RC variables were estimated using case incidence and hospitalization rate; Hospital bed capacity and COVID-19 ICU occupancy respectively. The estimated CT and RC were strongly correlated [ρ = 0.806 (95% CI 0.752, 0.848); and ρ = 0.814 (95% CI 0.778, 0.839), p < 0.001] with the COVID-19 cases. The estimated SL was strongly correlated with COVID-19 cases (ρ = 0.845, p < 0.001) and responded well to the various COVID-19 case trends during the pandemic. SL changes occurred earlier during the increase of cases but slower during the decrease, indicating a conservative response. The automated web-based system developed produced daily real-time CT, RC, and SL for the COVID-19 pandemic.ConclusionsThe indicators selected and combinations formed were able to generate validated daily CT and RC levels for Malaysia. Subsequently, the CT and RC levels were able to provide accurate and sensitive information for the estimation of SL which provided valuable evidence on the progression of the pandemic and movement restriction adjustment for the control of Malaysia.

A review of twenty-first century developments in paediatric surgery in Africa.

This review explores the significant advancements in paediatric surgery in Africa during the twenty-first century, with a particular focus on capacity-building, education, infrastructural development, and research. Historically, paediatric surgery has been an overlooked sector, especially in low-and-middle-income countries in Africa. However, recent years have seen considerable progress. Collaborative efforts such as the Global Initiative for Children's Surgery, and the formation of the Pan African Paediatric Surgery Association, the College of Surgeons of East, Central and Southern Africa and the West African College of Surgeons have facilitated knowledge sharing, collaboration, and advocacy for enhancing surgical standards. Local training programmes, including Master of Medicine programmes and fellowships, have been instrumental in building a skilled workforce. These initiatives have been complemented by infrastructural developments through non-governmental organisations like Kids Operating Room, which have expanded access to paediatric surgical care. Technological advancements, particularly in telemedicine, have further enhanced accessibility. Task-sharing strategies, where non-specialist physicians are trained in paediatric surgical skills, have also been utilised to address the shortage of specialised surgeons. Research in paediatric surgery has experienced an upswing, with local health professionals taking the lead. Research has been crucial for understanding the epidemiology of paediatric surgical conditions, and developing prevention strategies, and is increasingly leading to the inclusion of paediatric surgery in national health plans. Despite the progress, challenges remain, including the need for sustainable funding, continued investment in infrastructure, and training and retention of healthcare professionals. The review emphasises the importance of ongoing efforts in community engagement, innovative technologies, and health systems strengthening for the sustainable development of paediatric surgical services in Africa.

Quality of care and emergency department throughput during the COVID-19 pandemic in a community health system Pandemic in a Community Health System

Objective: This retrospective study explores the strategic plan formulated by AHMC Health System in California, USA, to sustain and improve quality of care and emergency department (ED) efficiency during the COVID-19 pandemic. It also analyzes the plan’s outcomes.Background: The COVID-19 pandemic has posed challenges for both individuals and healthcare industries alike, impacting decision-making and access to care. AHMC faced staff and resource shortages, patient reluctance, and difficulties adapting to rapidly evolving public health guidelines. These challenges highlighted the critical need for effective plans to maintain or improve healthcare quality and ED performance.Methods: AHMC adopted a comprehensive three-layer strategic plan in 2020. The first layer, “Pandemic Response,” focused on leadership, staff training and education, infection control, new treatments, and employee vaccination rates. The second layer, “ED Throughput,” set objectives for metrics such as door-to-doctor (door-to-doc) time, ancillary turnaround time (TAT), ED length of stay (LOS), and the left-without-being-seen (LWBS) rates. Progress was monitored through monthly improvement meetings. The third layer, “Quality Excellence,” tracked improvements in COVID-adapted objectives on quality initiatives, based on CMS Quality Star Ratings, Leapfrog Hospital Safety Grades, and Yelp review scores.Results: By 2023, the three-layer strategic plan had led to many improvements in the quality of care and ED efficiency. AHMC identified 22,287 positive COVID-19 cases, expanded its ventilator inventory by 50%, and enhanced patient outcomes by applying updated treatments. Additionally, AHMC saw a 3% reduction in ED wait times and sustained its overall patient satisfaction rates, CMS Quality Star Rating, and Leapfrog Hospital Safety Grade scores.Conclusions: AHMC’s three-layer strategic plan showed effectiveness in maintaining quality of care and ED efficiency during the COVID-19 pandemic. By focusing on “Pandemic Response,” “ED Throughput,” and “Quality Excellence,” AHMC was able to adapt to the rapidly evolving public health guidelines, expand its capacity to treat COVID-19 patients and sustain its overall patient safety, satisfaction, and quality ratings. The implementation of this plan highlights the importance of proactive and comprehensive strategies in managing healthcare crises.

Real-World Impact of Comprehensive Genomic Profiling on Biomarker Detection, Receipt of Therapy, and Clinical Outcomes in Advanced Non-Small Cell Lung Cancer.

Therapeutic decision making for patients with advanced non-small cell lung cancer (aNSCLC) includes a growing number of options for genomic, biomarker-guided, targeted therapies. We compared actionable biomarker detection, targeted therapy receipt, and real-world overall survival (rwOS) in patients with aNSCLC tested with comprehensive genomic profiling (CGP) versus small panel testing (SP) in real-world community health systems. Patients older than 18 years diagnosed with aNSCLC between January 1, 2015, and December 31, 2020, who received biomarker testing were followed until death or study end (September 30, 2021), and categorized by most comprehensive testing during follow-up: SP (≤52 genes) or CGP (>52 genes). Among 3,884 patients (median age, 68 years; 50% female; 73% non-Hispanic White), 20% received CGP and 80% SP. The proportion of patients with ≥one actionable biomarker (actionability) was significantly higher in CGP than in SP (32% v 14%; P < .001). Of patients with actionability, 43% (CGP) and 38% (SP) received matched therapies (P = .20). Among treated patients, CGP before first-line treatment was associated with higher likelihood of matched therapy in any line (odds ratio, 3.2 [95% CI, 1.84 to 5.53]). CGP testing (hazard ratio [HR], 0.80 [95% CI, 0.72 to 0.89]) and actionability (HR, 0.84 [95% CI, 0.77 to 0.91]) were associated with reduced risk of mortality. Among treated patients with actionability, matched therapy receipt showed improved median rwOS in months in CGP (34 [95% CI, 21 to 49] matched v 14 [95% CI, 10 to 18] unmatched) and SP (27 [95% CI, 21 to 43] matched v 10 [95% CI, 8 to 14] unmatched). Patients who received CGP had improved detection of actionable biomarkers and greater use of matched therapies, both of which were associated with significant increases in survival.

Special Considerations for Brazilian Transgender Patients in the United States: A Commentary

Abstract: Despite facing many social and structural challenges inside and outside of health systems, transgender and gender diverse (TGD) Brazilian immigrants in the U.S. are understudied, and their barriers to care are largely unnamed. In this commentary, we build on existing literature and our experiences at a safety-net community health system that sees a high volume of Brazilian patients to discuss challenges facing TGD Brazilian immigrant populations. We highlight that while Brazilian TGD populations face discrimination in Brazil, major challenges persist upon immigrating to the U.S., and include: difficulty updating identity documents and changing immigration status, barriers seeking general and specialized health care (including finding bilingual and bicultural providers), challenges navigating complex health and insurance systems, and a lack of community supports. We end by recommending more coordinated efforts between health care and community organizations to help ensure the health and wellness of TGD Brazilian immigrants in the United States.

Two randomized controlled trials of nudges to encourage referrals to centralized pharmacy services for evidence-based statin initiation in high-risk patients: Rationale and design of the SUPER LIPID program

In patients with or at risk for atherosclerotic vascular disease, statins reduce the incidence of major adverse cardiovascular events, but the majority of US adults with an indication for statin therapy are not prescribed statins at guideline-recommended intensity. Clinicians' limited time to address preventative care issues is cited as one factor contributing to gaps in statin prescribing. Centralized pharmacy services can fulfill a strategic role for population health management through outreach, education, and statin prescribing for patients at elevated ASCVD risk, but best practices for optimizing referrals of appropriate patients are unknown. SUPER LIPID (NCT05537064) is a program consisting of two pragmatic clinical trials testing the effect of nudges in increasing referrals of appropriate patients to a centralized pharmacy service for lipid management, conducted within 11 primary care practices in a large community health system. In both trials, patients were eligible for inclusion if they had an assigned primary care provider (PCP) in a participating practice and were not prescribed a high- or moderate-intensity statin despite an indication, identified via an electronic health record (EHR) algorithm. Trial #1 was a stepped wedge trial, conducted at a single practice with randomization at the PCP level, of an interruptive EHR message that appeared during eligible patients' visits and facilitated referral to the pharmacy service. For the first 3 months, no PCPs received the message; for the second 3 months, half were randomly selected to receive the message; and for the last 3 months, all PCPs received the message. Trial #2 was a cluster-randomized trial conducted at 10 practices, with randomization at the practice level. Practices were randomized to usual care or to have eligible patients automatically referred to centralized pharmacy services via a referral order placed in PCPs EHR inboxes for co-signature. In both trials, when a patient was referred to centralized pharmacy services, a pharmacist reviewed the patient's chart, contacted the patient, and initiated statin therapy if the patient agreed. The primary endpoint of both trials was the proportion of patients prescribed a statin; secondary endpoints include the proportion of patients prescribed a statin at guideline-recommended intensity, the proportion of patients filling a statin prescription, and serum low-density lipoprotein level. SUPER LIPID is a pair of pragmatic clinical trials assessing the effectiveness of two strategies to encourage referral of appropriate patients to a centralized pharmacy service for lipid management. The trial results will develop the evidence base for simple, scalable, EHR-based strategies to integrate clinical pharmacists into population health management and increase appropriate statin prescribing. clinicaltrials.gov; NCT05537064.

How Can Community Data Be Leveraged to Advance Primary Health Care? A Scoping Review of Community-Based Health Information Systems.

Community-based health information systems (CBISs) can provide critical insights into how community health systems function, and digitized CBISs may improve the quality of community-level data and facilitate integration and use of CBISs within the broader health system. This scoping review aims to understand how CBISs have been implemented, integrated, and used to support community health outcomes in low- and middle-income countries (LMICs). Both peer-reviewed and gray literature were included; relevant articles were identified using key terms and controlled vocabulary related to community/primary health care, health information systems, digital health, and LMICs. A total of 11,611 total records were identified from 5 databases and the gray literature. After deduplication, 6,985 peer-reviewed/gray literature were screened, and 95 articles/reports were included, reporting on 105 CBIS implementations across 38 countries. Findings show that 55% of CBISs included some level of digitization, with just 28% being fully digitized (for data collection and reporting). Data flow from the community level into the health system varied, with digitized CBISs more likely to reach national-level integration. National-level integration was primarily seen among vertical CBISs. Data quality challenges were present in both paper-based and digitized CBISs, exacerbated by fragmentation of the community health landscape with often parallel reporting systems. CBIS data use was constrained to mostly vertical and digitized (partially or fully) CBISs at national/subnational levels. Digitization can play a pivotal role in strengthening CBIS use, but findings demonstrate that CBISs are only as effective as the community health systems they are embedded within. Community-level data are often not being integrated into national/subnational health information systems, undermining the ability to understand what the community health needs are. Furthermore, stronger investments within community health systems need to be in place broadly to reduce fragmentation and provide stronger infrastructural and systemic support to the community health workforce.

Building consensus on common features and interoperability use cases for community health information systems: a Delphi study

IntroductionInformation systems for community health have become increasingly sophisticated and evidence-based in the last decade and they are now the most widely used health information systems in many low-income and...

521 Bringing UCSF Research Resources to Community Health Systems: CTSI Research Infrastructure Network (RIN)

OBJECTIVES/GOALS: The CTSI Research Infrastructure Network (RIN) expands CTSI’s reach into the regional health systems to provide our services to a broad and diverse translational science community. We create and support research collaborations that span multiple geographies and patient populations and serve as a bridge between the affiliate sites and CTSI programs. METHODS/STUDY POPULATION: We conducted needs assessments at each site (n=6) via in-depth, semi-structured interviews with key stakeholders. Informants (n=40) included investigators, study personnel, and research administrators. Investigators were selected across a variety of departments and career stages. Interview transcripts and notes were analyzed using matrix-based qualitative methods to identify both the common and unique research infrastructure needs of each site. Individualized support plans were shared with each site and a comprehensive summary report was presented to CTSI leadership. RIN met with UCSF’s Comprehensive Cancer Center, which conducts clinical trials at 2 sites, to coordinator our effort and services. When possible, RIN addressed service requests in real time that arose during interviews. RESULTS/ANTICIPATED RESULTS: We identified heterogeneous needs across multiple sites. However, among the community health systems with non-academic clinicians, there were common needs for research training, consultations in biostatistics/study design, and finding academic collaborators. The needs of sites with UCSF academic faculty differed from those of community sites and mainly included improved awareness and access to CTSI programs, ease of use of data extraction services, training programs, and assistance with regulatory approvals. Site needs are best addressed with individual plans created with CTSI Program leaders. A developing governance structure will include representation on a CTSI advisory committee and an annual conference to facilitate the sharing of best practices and foster collaboration across member sites. DISCUSSION/SIGNIFICANCE: Providing an individualized, site-specific approach to expanding CTSI services to regional health systems, will increase research collaborations across Northern California through building relationships, addressing unique infrastructure needs and sharing best practices throughout the network.

Effect of community-based newborn care implementation strategies on access to and effective coverage of possible serious bacterial infection (PSBI) treatment for sick young infants during COVID-19 pandemic.

In Ethiopia, neonatal mortality is persistently high. The country has been implementing community-based treatment of possible serious bacterial infection (PSBI) in young infants when referral to a hospital is not feasible since 2012. However, access to and quality of PSBI services remained low and were worsened by COVID-19. From November 2020 to June 2022, we conducted implementation research to mitigate the impact of COVID-19 and improve PSBI management implementation uptake and delivery in two woredas in Ethiopia. In April-May 2021, guided by implementation research frameworks, we conducted formative research to understand the PSBI management implementation challenges, including those due to the COVID-19 pandemic. Through a participatory process engaging stakeholders, we designed adaptive implementation strategies to bridge identified gaps using mechanism mapping to achieve implementation outcomes. Strategies included training and coaching, supportive supervision and mentorship, technical support units, improved supply of essential commodities, and community awareness creation about PSBI and COVID-19. We conducted cross-sectional household surveys in the two woredas before (April 2021) and after the implementation of strategies (June 2022) to measure changes in targeted outcomes. We interviewed 4,262 and 4,082 women who gave live birth 2-14 months before data collection and identified 374 and 264 PSBI cases in April 2021 and June 2022, respectively. The prevalence of PSBI significantly decreased (p-value = 0.018) from 8.7% in April 2021 to 6.4% while the mothers' care-seeking behavior from medical care for their sick newborns increased significantly from 56% to 91% (p-value <0.01). Effective coverage of severely ill young infants that took appropriate antibiotics significantly improved from 33% [95% CI: 25.5-40.7] to 62% [95% CI: 51.0-71.6]. Despite improvements in the uptake of PSBI treatment, persisting challenges at the facility and systems levels impeded optimal PSBI service delivery and uptake, including perceived low quality of service, lack of community trust, and shortage of supplies. The participatory design and implementation of adaptive COVID-19 strategies effectively improved the uptake and delivery of PSBI treatment. Support systems were critical for frontline health workers to deliver PSBI services and create a resilient community health system to provide quality PSBI care during the pandemic. Additional strategies are needed to address persistent gaps, including improvement in client-provider interactions, supply of essential drugs, and increased social mobilization strategies targeting families and communities to further increase uptake.

Self-identified prescriber tendencies in sodium-glucose cotransporter-2 inhibitor outpatient prescribing

BackgroundDespite expanded indications and demonstrated cardiovascular and renal benefits, prescribing rates of sodium-glucose cotransporter-2 (SGLT-2) inhibitors are low. ObjectivesThe study aimed to identify factors impacting prescriber decision-making when prescribing SGLT-2 inhibitors in the outpatient setting and identify differences across specialties in self-identified prescribing patterns. MethodsAn anonymous survey was administered electronically to prescribers in relevant specialties at a large community health system. Descriptive statistics were used to compile results, and subgroup comparisons were conducted utilizing Fisher’s exact test. ResultsFifty-one prescribers completed the survey, representing a 25.2% response rate. The highest reported prescribing rates were for type 2 diabetes (92%), and the lowest for HFpEF (20%) and ASCVD risk reduction (16%). Prescribers without clinic-embedded pharmacist were more likely to report cost and insurance had at least a moderate effect on prescribing compared to prescribers with clinic-embedded pharmacists (95.3% vs. 62.5%, P = 0.0228) and less likely to report hemoglobin A1c less than 6.5% to have at least a moderate effect on prescribing (20.9% vs. 62.5%, P = 0.0317). Compared to specialty providers, primary care prescribers were more likely to report hemoglobin A1c over 9% had at least a moderate effect on prescribing (92.0% vs. 42.9%, P = 0.0082) and less likely to note history of urinary tract infection (22.2% vs. 85.7%, P = 0.0028), history of mycotic infection (38.9% vs. 100%, P = 0.0036), and sex (male: 5.6% vs. 42.9%, P = 0.0242; female: 8.0% vs. 42.9%, P = 0.0447) had at least a moderate effect on prescribing. ConclusionPrescribing hesitancies vary across specialty and when clinic-embedded pharmacists are present. Pharmacists may help improve SGLT-2 inhibitor prescribing rates and use of guideline-directed therapies. Pharmacists can target identified hesitancies through medication-access consultations, education regarding adverse effects, and expanded benefits of the class. Future studies should examine the impact of pharmacist intervention on SGLT-2 inhibitor prescribing rates.

Evaluation of a novel approach to community health care delivery in Ifanadiana District, Madagascar.

Despite widespread adoption of community health (CH) systems, there are evidence gaps to support global best practice in remote settings where access to health care is limited and community health workers (CHWs) may be the only available providers. The nongovernmental health organization Pivot partnered with the Ministry of Public Health (MoPH) to pilot a new enhanced community health (ECH) model in rural Madagascar, where one CHW provided care at a stationary CH site while additional CHWs provided care via proactive household visits. The program included professionalization of the CHW workforce (i.e., targeted recruitment, extended training, financial compensation) and twice monthly supervision of CHWs. For the first eighteen months of implementation (October 2019-March 2021), we compared utilization and proxy measures of quality of care in the intervention commune (local administrative unit) and five comparison communes with strengthened community health programs under a different model. This allowed for a quasi-experimental study design of the impact of ECH on health outcomes using routinely collected programmatic data. Despite the substantial support provided to other CHWs, the results show statistically significant improvements in nearly every indicator. Sick child visits increased by more than 269.0% in the intervention following ECH implementation. Average per capita monthly under-five visits were 0.25 in the intervention commune and 0.19 in the comparison communes (p<0.01). In the intervention commune, 40.3% of visits were completed at the household via proactive care. CHWs completed all steps of the iCCM protocol in 85.4% of observed visits in the intervention commune (vs 57.7% in the comparison communes, p-value<0.01). This evaluation demonstrates that ECH can improve care access and the quality of service delivery in a rural health district. Further research is needed to assess the generalizability of results and the feasibility of national scale-up as the MoPH continues to define the national community health program.

Inverting the deficit model in global mental health: An examination of strengths and assets of community mental health care in Ghana, India, Occupied Palestinian territories, and South Africa.

Global mental health [GMH] scholarship and practice has typically focused on the unmet needs and barriers to mental health in communities, developing biomedical and psychosocial interventions for integration into formal health care platforms in response. In this article, we analyse four diverse settings to disrupt the emphasises on health system weaknesses, treatment gaps and barriers which can perpetuate harmful hierarchies and colonial and medical assumptions, or a 'deficit model'. We draw on the experiential knowledge of community mental health practitioners and researchers working in Ghana, India, the Occupied Palestinian Territory and South Africa to describe key assets existing in 'informal' community mental health care systems and how these are shaped by socio-political contexts. These qualitative case studies emerged from an online mutual learning process convened between 39 academic and community-based collaborators working in 24 countries who interrogated key tenets to inform a social paradigm for global mental health. Bringing together diverse expertise gained from professional practice and research, our sub-group explored the role of Community Mental Health Systems in GMH through comparative country case studies describing the features of community care beyond the health and social care system. We found that the socio-political health determinants of global economic structures in all four countries exert significant influence on local community health systems. We identified that key assets across sites included: family and community care, and support from non-profit organisations and religious and faith-based organisations. Strengthening community assets may promote reciprocal relationships between the formal and informal sectors, providing resources for support and training for communities while communities collaborate in the design and delivery of interventions rooted in localised expertise. This paper highlights the value of informal care, the unique social structures of each local context, and resources within local communities as key existing assets for mental health.

Abstract A056: Development and application of an epithelial ovarian cancer-specific line of therapy algorithm using real-world data

Abstract Introduction. Characterizing lines of therapy (LoTs) helps researchers describe the epithelial ovarian cancer (EOC) patient treatment journey, but they are not routinely captured in real-world data. Algorithms must therefore be developed to transform individual treatment data into summary LoTs. Special considerations must be made for EOC as maintenance (MTx) therapy, which includes poly ADP ribose polymerase inhibitors (PARPi) and/or bevacizumab, may be given following treatment (Tx) lines. We developed an EOC-specific LoT algorithm and evaluated its performance using real-world data. Methods. Patients were sampled from the Syapse Learning Health Network, a database of cancer patients treated in large community health systems across 25 states in the US and were eligible for inclusion if they were diagnosed with EOC between 01/01/2015 and 09/30/2022 (index date) and had manually curated systemic therapy data. All patients were followed through 12/31/2022. Assignment of Tx and MTx lines and regimens and allowable treatment gaps were based on national treatment guidelines and typical disease course. To distinguish between Tx and MTx lines, all eligible patients who received systemic therapy following the initial diagnosis of EOC were assigned first-line (1L) Tx, and each subsequent LoT was classified as a Tx or MTx line depending on the therapies in the present LoT and one immediately preceding it. Therapies could be added or switched within a LoT, and assigned regimens distinguished between therapies given in combination from switch therapies. A shorter treatment gap was used to identify later LoTs to account for more rapid disease progression. Unexpected regimens were flagged for further evaluation. A subset of patients with advanced stage, non-mucinous EOC who received 1L platinum-based chemotherapy were manually reviewed by a medical oncologist to identify patients who received 1L MTx. Results. There were 2,275 eligible EOC patients. 415 patients with missing, incomplete, or invalid therapy dates were excluded, leaving 1,860 patients in the LoT analysis. Median follow-up was 23 months (IQR, 13-41 months). Nearly half (48%) of the patients received only one LoT; 15% of patients received 3 or more LoTs. Out of all patients, 15% received 1L MTx without any subsequent treatment. The top 1L Tx regimens were platinum and taxane combination, platinum and taxane plus bevacizumab, and platinum alone (73%, 16%, and 2% of patients who received 1L Tx, respectively). The top 1L MTx regimen was PARPi alone, followed by bevacizumab alone and bevacizumab plus PARPi (57%, 35%, and 8% of patients who received 1L MTx, respectively). 1,355 (74%) patients were identified for expert review. Among these, concordance in 1L MTx determination between expert review and the algorithm was 98%. Conclusion. The EOC-specific LoT algorithm performed well: line and regimen distributions aligned with real-world practice and expert clinical review. Researchers may wish to utilize this algorithm for real-world studies of ovarian cancer. Citation Format: Connor Sweetnam, Tirza Areli Calderón Boyle, Sara Burns, Jessica Perhanidis, Matthew Rioth, Rayna K Matsuno. Development and application of an epithelial ovarian cancer-specific line of therapy algorithm using real-world data [abstract]. In: Proceedings of the AACR Special Conference on Ovarian Cancer; 2023 Oct 5-7; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(5 Suppl_2):Abstract nr A056.