County Safety-net Hospital Research Articles

Abstract 230: Internal Medicine Trainee Understanding and Reaction to Out of Pocket Costs

Introduction: Out-of-pocket costs (OOPC) are a significant barrier to care and drive suboptimal medical therapy in ASCVD. Despite this, there is minimal attention paid to these costs in post-graduate education. To define a potential knowledge gap, we surveyed trainee understanding of OOPC. Methods: We surveyed Internal Medicine residents at a large academic program comprised of a large county safety-net hospital, a VA, and a private tertiary care hospital, about knowledge and practices surrounding patient OOPC. Residents rotate on services at all sites and the vast majority have primary care clinic at the county or VA hospital. Participants answered questions considering their most recent inpatient panel and their clinic patient panel. Familiarity was ranked on a 5-point Likert scale, and for the purposes of presentation, was divided into “Poor” and “Moderate or Better”. Non-parametric analysis was used to test differences between outpatients v inpatients and by year of training. Results: Of 159 residents, 106 (67%) responded. Familiarity with patient insurance status was moderate or better in 135 of 159 (85%). Moderate or better understanding of costs associated with medications (52% [83 of 159]), testing (19% [30 of 159]) and clinic visits (30% [48 of 159]) was less common. Respondents had higher familiarity with OOPC for clinic patients compared with their most recent inpatient panel: clinic visits (39% v 21% [62 v 33 of 159 p < 0.005]), testing (25.7% v 12.4% [41 v 20 of 159 p = 0.002]), and medications (62% v 42% [99 v 67 of 159 p <0.005]) Knowledge of cost of care was not an often-considered factor in decision making (27% “Often” or “Always” [43 of 159]). There was no significant difference in response by year of training. Discussion: Our survey demonstrates that trainee familiarity with OOPC was low overall but modestly higher for established clinic patients, perhaps reflecting longitudinal experience with them or the heterogeneity of admitted patient funding status. Familiarity with patient OOPC was not an often-considered factor in decision making and did not significantly improve over years of training. This suggests an important gap in trainee education. Teaching greater familiarity with patient OOPC during residency can increase awareness of the financial realities of patients, enabling more patient-centered care.

Abstract 18: Patient-administered Home Inotrope Therapy: A Proof of Concept

Background: Palliative use of continuous IV inotrope therapy has shown to improve quality of life and reduce hospital readmissions for patients with end-stage heart failure (HF) who are otherwise ineligible to receive advanced therapies. Administration of home inotrope therapy generally requires a hospice or home-health agency, placing this option out of reach for patients who lack funding. As such, underinsured patients are relegated to the difficult choice of either remaining in the hospital to receive IV inotropes, or going home without the therapy for as long as their symptoms allow. To address this issue at our large county safety-net hospital, we developed and implemented a patient self-administered home inotrope therapy program. Methods: A multidisciplinary team of physicians, pharmacists, nurses, and social workers was assembled to pilot the program. Eligible patients were provided with a peripherally inserted central venous catheter (PICC) and a portable infusion pump. They were then instructed on proper use of the pump, medication administration, medication bag changes, and IV line care using a nursing teach-back technique. After proper understanding was demonstrated, patients were discharged home with weekly follow up in heart failure clinic for PICC-care and medication exchanges. Results: During the initial 12 months of the program, 5 patients were deemed eligible for enrollment. Total hospitalized days for these patients was 277 (mean = 55.4 days) in the one year prior to enrollment and 12 (mean = 2.4 days) while enrolled for a cumulative period of 288 days (Figure 1). One patient was able to secure funding for advanced therapies, two patients died while enrolled, and two patients are currently enrolled and alive. Discussion: A self-administered home IV inotrope therapy program is a feasible alternative for palliation in unfunded patients with end-stage HF who are otherwise not candidates for advanced therapies, allowing for more days at home in the end of life. Thus far, the cost impact of the program has been mitigated by the cost savings for inpatient hospitalizations. Studies to assess patient-centered outcomes, and overall cost savings are ongoing.

Discrepancy in Neurologic Outcomes Following Aneurysmal Subarachnoid Hemorrhage as a Function of Socioeconomic Class

To investigate potential health care discrepancies in patients with ruptured cerebral aneurysms undergoing microsurgical intervention. We retrospectively reviewed patients with ruptured intracranial aneurysms treated at our tertiary referral university hospital (UH) and safety net county hospital (CH) from 2010 to 2015. We identified 73 UH patients and 58 CH patients. UH patients had shorter time duration between rupture and intervention (P < 0.001) and higher rates of intubation on admission (P= 0.01). Verapamil was more frequently used for clinical vasospasm in UH patients, at 0.13 (95% confidence interval [CI], 0.09-0.18) treatments per patient per day versus 0.077 (95% CI, 0.047-0.12) treatments per patient per day in CH patients, though there was no difference in delayed cerebral ischemia (P= 0.15). The majority of the CH cohort was uninsured (26.3%; UH 0%) or had Medicaid (59.7%; UH 35.2%) (P < 0.001). The UH had more dispositions to home or rehabilitation centers than the CH (82% vs. 67.3%; P= 0.04). After adjusting for disease severity, hospital stay, and insurance status, CH patients were 3.73 (95% CI, 1.25-12.14) times more likely to be discharged with a poor modified Rankin Scale score and 3.08 (95% CI, 1.04-9.61) times more likely to be discharged with a poor Glasgow Outcome Scale score compared with UH patients (P= 0.02 and P= 0.04, respectively). Limited resource availability in a safety net hospital system could be a major driving force behind the health care discrepancy identified in our ruptured cerebral aneurysm population. Reallocation of resources to supplement advanced inpatient acute care technologies and, more importantly, post-acute care environments can narrow the outcomes gap.

Abstract P1-17-10: Breast pain is a common complaint after breast cancer treatment but not a sign of recurrence

Abstract Background: Mastalgia, breast pain without other signs or symptoms, is a very common complaint, yet occurs in only approximately 5% of patients with breast cancer. Most clinicians are aware of this lack of association with cancer. Mastalgia is also a common complaint after breast cancer treatment. This symptom is very worrisome to many women, and when seen in the office, clinicians tend to give in to the fear of patients and order various tests. In 2017, we presented an abstract at SABCS that showed that breast pain was not associated with breast cancer diagnosis. Many attendees were interested in the incidence of breast pain after breast cancer treatment. The current study was performed to evaluate the incidence and significance of mastalgia after breast cancer treatment. Methods: Maricopa Medical Center, the county safety net hospital in Phoenix, Arizona serves a patient base which is 34.5% non-English speaking. The majority of these patients are uninsured or underinsured. A total of 1635 breast cancer patients were seen at least once at the Breast Clinic from June 1, 2006 to December 31, 2018. Sociodemographic variables were collected on all patients. All patients who were treated for breast cancer and then presented with a complaint of breast pain during follow up were evaluated. Additionally, all patients who complained of a breast mass but were found to have pain with no mass were evaluated in a similar fashion. Results: A total of 1577 patients were seen during the time period. The mean age of the patients was age 52. Of the patients, 144 presented with or developed metastatic disease prior to their operation. 116 patients transferred their care to another facility. Of the remaining patients, 36% of patients (474 of 1317) presented with a complaint of breast pain during their follow up after breast cancer treatment. Of the patients with breast pain, 16 had an ipsilateral breast tumor recurrence or contralateral breast cancer diagnosis, however, none of the patients presented with breast pain. The breast pain occurred after treatment was completed. Nine patients presented with a palpable mass and seven patients presented with abnormal imaging. In contrast, 6.0% patients (51 of 843) without breast pain developed an ipsilateral breast tumor recurrence, chest wall recurrence, or contralateral breast cancer. 35 patients presented with a painless breast mass and the remaining 26 recurrences or contralateral breast cancer were found on routine imaging. Local recurrence or contralateral breast cancer were more common in patients without breast pain during follow up (p = 0.036). The two most common factors related to any breast cancer recurrence and death were noncompliance with recommended treatment and presentation with T4 (Stage 3B) breast cancer. Conclusions: Mastalgia is a very common complaint in patients seen for follow up after breast cancer treatment. Patients and providers may believe a complaint of breast pain warrants further workup and often results in additional, repeat, or interval imaging. With normal physical examination and routine imaging, however, breast pain alone does not appear to be an indication of breast cancer recurrence. Additional or repeat imaging as well as laboratory tests do not appear beneficial in patients with breast pain. Reassurance and patient education is necessary to avoid continued use of unnecessary medical resources. Citation Format: Ian Komenaka, Anushi Shah, Tina Wong, Daniela Cocco, Chiu-Hsieh Hsu, Jesse Nodora, Waqas Arslan, Maria Elena Martinez. Breast pain is a common complaint after breast cancer treatment but not a sign of recurrence [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-17-10.

Implementation of a Urology E-Consult Service at a Safety Net County Hospital.

We assess the implementation of an e-consult service at a urology clinic in a safety net county hospital. An e-consult system was introduced in 2018 at our institution. All e-consults for January to December 2018 were collected and data analyzed. Patient demographics were recorded. Total consults, clinic referrals, cystoscopy referrals, need to reschedule and need for followup were compared. Time from referral to in-person clinic visit was collected. Reason for e-consult and final visit diagnosis were placed into urological categories and subcategories. In 2018 472 e-consults were received for 454 patients. The majority were men (62.3%) with a median age of 55 years (IQR 44-63). The majority (52%) were Hispanic. Most patients (69.1%) were scheduled for an in-person clinic visit with 23.9% of these patients scheduled for a cystoscopy. Median time from referral to in-person clinic visit was 39.5 days (IQR 33-50). A quarter of the patients did not require further followup after initial in-person consultation. The majority of e-consults were for hematuria (24%), renal pathologies (20%), and benign prostatic hyperplasia and lower urinary tract symptoms (17%). Implementation of a urology e-consult service is feasible and decreases need for in-person clinic visits.

Trends in Contralateral Prophylactic Mastectomy

Many breast cancer patients remove their contralateral breast unaffected by cancer, commonly referred to as contralateral prophylactic mastectomy (CPM). CPM has been extensively studied and does not improve survival in patients without deleterious genetic mutation or lobular histology. Despite these limited indications, CPM rates have increased recently. We observed CPM trends in our county safety-net hospital. We performed a retrospective review of women treated for breast cancer who underwent bilateral mastectomy in our institution. We analyzed 100 CPMs: 51% (n = 51) had bilateral breast MRI before CPM, 54% (n = 54) had genetic testing prior to CPM, and 56% (n = 30) had a deleterious genetic result. Another 12% (n = 12) had lobular histology as the primary determinant for CPM. Of patients without genetic mutation or lobular histology, 13% (n = 13) had suspicious MRI findings in the CPM side that drove the decision for CPM. Forty-seven percent (n = 47) had reconstructive surgery documented. Only 42% (n = 42) of patients who underwent CPM had a documented justifiable medical reason. In the future, physician and patient education may decrease unindicated CPM. We also found that 13% of women without a medical indication chose CPM based on suspicious MRI findings, while only 8% of these MRI findings were malignant. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

1643. Infectious Sequelae of Injection Drug Use at a County Safety-Net Hospital Decline Following Establishment of a Syringe Service Program

BackgroundInfectious sequelae of injection drug use (ISIDU) and overdose are frequent but preventable among people who inject drugs (PWID). Syringe service programs (SSP) are an evidence-based harm reduction strategy to reduce incidence of ISIDU among PWID. Additionally, SSPs are noted to produce significant cost-savings for healthcare systems. Under current state legislation, Miami houses the only SSP in Florida, the IDEA SSP. This study builds on previous work characterizing morbidity and cost of ISIDU. This study sought to evaluate differences in admission rates and associated ISIDU costs at Jackson Memorial Hospital (JMH) in Miami before and after implementation of the IDEA SSP.MethodsRetrospective data collected from a chart review of patients hospitalized for ISIDU and overdose was used to evaluate morbidity and cost of ISIDU at JMH from December 1, 2015 to December 1, 2017, stratified by December 1, 2016—the opening of the IDEA SSP—as an index date. An algorithm utilizing ICD-10 codes for drug use and sequelae was used to identify PWID population. Specific infections investigated were: endocarditis, osteomyelitis, bacteremia- and/or -sepsis (BOS), and skin-and-soft-tissue-infections (SSTIs). Pearson’s chi-square test for independence used to report P-values for associations between infections and total charges using a 2-tailed t-test.Results726 admissions were identified during the study period, 328 PWID in the pre-index cohort vs. 398 in the post-index cohort. The median age of total sample was 45.24. 95.12% of the pre-index cohort were uninsured or had publicly-funded insurance vs. 96.48% post-index. Most ISIDU did not change significantly between pre-post cohorts, although bacteremia and sepsis declined significantly among opioid injectors (P = 0.026). Overdoses decreased significantly among PWID generally (57% decline pre-post; P = 0.0006), as well as for patients who inject opioids specifically (70% decline pre-post; P = 0.0034). Median cost declined by 20.5% among PWID, and 29.1% among opioid injectors in particular.ConclusionISIDU continues to represent significant morbidity for PWID in Miami-Dade County and substantial cost to the health system. Severe infections, including bacteremia and sepsis, declined significantly among opioid injectors, the PWID subset most strongly associated with local SSP services. This change following the establishment of a local SSP suggests direct effects on the frequency of hospital admissions for ISIDU. Despite local increases in drug use, overall PWID frequency and ISIDU charges did not change significantly. OD and admission frequency amongst opioid users and cost-per-patient declined between groups, suggesting a potential decrease in ISIDU and attendant costs. While median charges per admission declined, they were statistically insignificant and may represent stagnation in ISIDU-associated costs following SSP establishment. Diminishment in opioid user admissions and OD suggest additional possible positive epidemiological effects of the SSP. Weaknesses included difficulty of associating outcomes, limited post-index time period, and potential misclassification when establishing a standardized algorithm for PWID identification. Disclosures All authors: No reported disclosures.

ChemoPalRx: Development and implementation of a chemotherapy mobile provider order entry system in a safety net hospital.

73 Background: Computerized provider order entry (CPOE) systems have been shown to enhance the safety and efficiency of prescribing chemotherapy over the handwritten ordering process. However, many institutions lack the financial ability, technological capability, or operational flexibility to invest in and implement such a system. In particular, Olive View-UCLA Medical Center (OVMC), a Los Angeles County safety net hospital, is among these institutions with unique restrictions that preclude the use of chemotherapy CPOE and mandate handwritten orders. Methods: In an effort to bridge the gap for safe chemotherapy prescribing, we aimed to develop and implement an effective, scalable, and sustainable chemotherapy provider order entry solution that was operationally sensitive to institutions without a chemotherapy CPOE. The solution was designed as a mobile application using Xcode, the integrative development environment of Apple Inc., with the Swift programing language. Results: On September 5th, 2018, we launched a free, chemotherapy provider order entry solution on the worldwide Apple App Store – ChemoPalRx. Using ChemoPalRx, providers can search, customize, and print common chemotherapy regimens in prescription format. Along with a reference library of over 120 order set and 450 medications, ChemoPalRx is equipped with the functions to automate dosage calculation, suggest pre-medications and safety parameters, and trigger alerts for missing prescribing information. As a quality improvement initiative, we implemented ChemoPalRx at OVMC. Implementation stages include obtaining administrative buy-in, consulting with multidisciplinary staffs, investing $100 USD for a prescription printer, and encouraging providers to download ChemoPalRx on their own mobile devices. An ongoing prospective cohort study is being conducted to determine ChemoPalRx effectiveness in reducing errors compared to handwritten orders. Conclusions: ChemoPalRx is developed to enhance the safety and efficiency of chemotherapy prescribing. Implementation of this mobile application is feasible in the safety-net hospital setting and has the potential to transform oncology practices globally.

2869 Retrospective Study of Patients With Esophageal Squamous Cell Carcinoma in an Urban Safety Net County Hospital

INTRODUCTION: Esophageal squamous cell carcinoma (ESCC) accounts for 90% of esophageal cancers worldwide but is less common in the developed world. Our aim was to report patient and tumor characteristics of individuals diagnosed with ESCC within the underserved Los Angeles County population. METHODS: Review of the hospital pathology database identified 65 cases of patients ages 18-80 with a pathologic diagnosis of ESCC from 2003-2015. A retrospective chart review of electronic health records was conducted excluding patients of unknown ethnicity leaving 61 patients. Patients were characterized by gender, age, alcohol and tobacco use, and family history. Endoscopy and pathology reports were reviewed to confirm tumor location, length, and pathological staging. Frequency counts and percentages were reported for categorical characteristics. A chi-square test or Fisher’s Exact test was performed to assess if characteristic variables differed by ethnicity. RESULTS: Patients identified with ESCC in our cohort were predominantly Hispanic (59%, n = 36) and 41% were non-Hispanic (n = 10 Asian, n = 10 African Americans, and n = 5 Caucasian). ESCC was more commonly diagnosed in males vs. females in Hispanics and non-Hispanics (83.3% and 80% vs 16.7% and 20%, P = 0.75). Age of diagnosis was between the ages of 18-60 years in nearly 56% and greater than 60 years in 44% of Hispanics and non-Hispanics (P = 0.97). Most Hispanics and non-Hispanics had exposure to alcohol (74.1% and 85%, P = 0.48) or tobacco (53.9% and 68.2%, P = .31). Most Hispanic and non-Hispanics did not have a family history of cancer (72% and 80%, P = 0.73). Tumor location was most often proximal in Hispanic and non-Hispanics (66.7% and 83.3%, P = 0.16) and of similar length (P = 0.29). Most tumors in both Hispanic and non-Hispanic patients were moderately/poorly differentiated (82.9% and 91.3%, P = 0.46). Hispanics were less likely to present with metastatic ESCC as compared to non-Hispanic patients (42.3% vs. 75%, P = 0.03). CONCLUSION: ESCC in both groups within the Los Angeles County population were diagnosed most often in the proximal esophagus of males with history of exposure to alcohol and/or tobacco. Despite similar patient and tumor characteristics, ESCC in Hispanics was less often metastatic at the time of diagnosis compared to non-Hispanics. Despite the small numbers, our study is one of the few to include a large cohort of Hispanics and support further investigation of factors in different ethnicities that may be protective against advanced disease.

315 Effect of Prescription Drug Monitoring Program Databases on Opiate Prescribing at a Large County Safety-Net Hospital Emergency Department

The CDC reported over 70,000 Americans died from a drug overdose in 2017, nearly doubling the number just 10 years earlier. This rise was dominated by opiate overdoses which accounted for 47,600 of these deaths. Opiate use disorder is a multifactorial problem involving many factors both inside and outside of the traditional health care domain. Contributing factors include frequency and duration of opioid prescriptions in the emergency department (ED). Increased rates of long-term opioid use are seen among patients treated by high-volume opioid prescribers in the ED.

ENRICH: Validating a multidimensional patient-reported financial toxicity measure.

153 Background: Financial toxicity is a patient-reported outcome reflecting burdens of cancer treatment costs. There is a need to assess financial toxicity in cancer care, as its unique domains—upstream factors like direct medical costs or downstream economic impact like bankruptcy—predict worse QOL, adherence, and mortality. Socioeconomically disadvantaged patients bear disparate financial toxicity burdens. We thus developed and report performance of a new measure, the Economic StraiN and Resilience in Cancer (ENRICh), to assess all financial toxicity domains in economically diverse patients. Methods: We studied 238 patients with Stage I-IV cancer from a tertiary academic comprehensive cancer center (MDA) and county safety-net hospital serving socioeconomically disadvantaged patients (LBJ). Financial toxicity domains and corresponding subscales were developed from qualitative/cognitive (n = 104) interviews. ENRICh and Comprehensive Score for Financial Toxicity (COST) questions were administered (n = 127; MDA = 71, LBJ = 56). To demonstrate known-group validity, we compared ENRICh scores between centers; for concurrent validity, we correlated ENRICh and COST; for reliability, we calculated Cronbach's coefficient α for ENRICh subscales (range 0, none, to 10, high burden). Results: There were 4 distinct, valid financial toxicity domains/subscales: 1) Burden of cost; 2) Disruption of financial stability; 3) Depletion of financial coping; 4) Depletion of instrumental coping. Patients from the 2 centers significantly differed in subscale and overall ENRICh scores. Socioeconomically disadvantaged patients had worse mean scores (4.9 vs 2.1, 95%CI -3.6,-2.1, effect size 1.4, P &lt; .001). ENRICh significantly correlated with COST (r = -0.82, 95%CI -0.87,-0.77, P &lt; .001). Subscales were reliable with excellent internal consistency (Cronbach α = 0.78 to 0.94). The 4 ENRICh domains collectively had synergistic impact on overall financial toxicity burden. Conclusions: ENRICh is valid, reliable, and identifies and 4 novel domains of financial toxicity. Future utility of this tool is to guide assessment/interventions targeting financial toxicity domains affecting diverse cancer patients, to mitigate disparities.

Socioeconomic Barriers Affecting Neurological Recovery Facing the Aneurysmal Subarachnoid Population

Abstract INTRODUCTION Socioeconomic status is a known contributor to healthcare discrepancies in the United States. Pathologies requiring significant amounts of resources, such as ruptured cerebral aneurysms, are most representative. We aim to investigate if a healthcare discrepancy exists in the ruptured cerebral aneurysm population undergoing microsurgical intervention at our institution, and identify variables unrelated to aneurysmal features contributing to differences in neurologic outcomes. METHODS We retrospectively reviewed medical records of the ruptured intracranial aneurysm patients treated with microsurgical intervention at our tertiary referral University Hospital (UH) and safety net County Hospital (CH) from 2010 to 2015. Demographic information, insurance status, Glasgow coma scale score (GCS), Hunt-Hess (HH) and Fisher grade, aneurysm characteristics, surgical data, modified Rankin scale score (mRS), complications, and disposition were recorded for statistical analysis. RESULTS A total of 73 patients from UH and 58 patients from CH were identified for analysis. There was no statistically significant difference in demographics, Fisher score, presenting GCS, hospital days, aneurysm location, or complications between the 2 cohorts. Patients at UH had a shorter time duration between rupture and intervention (P &lt; .001), and higher rates of intubation at the time of admission (P = .01). UH patients with clinical vasospasm were moderately more likely to receive verapamil infusions as compared to CH patients (P = .08), though there was no difference in delayed cerebral ischemia (DCI) (P = .15). The majority of CH cohort was either uninsured (19%; UH 0%) or Medicaid (67.2%; UH 35.6%) (P &lt; .001). Private insurance was more prevalent in the UH cohort (49.3%; CH 12.1%) (P &lt; .0001). UH patients had significantly more dispositions to home or rehabilitation centers (nonskilled nursing facilities) as compared to CH patients (82% versus 67.3% respectively; P = .04) despite similar neurological outcomes at the time of discharge. Neurological recovery from the time of discharge to clinical follow-up was statistically superior favoring UH over CH patients (P = .0004). CONCLUSION Limited resource availability in a safety net hospital system could be a major driving force behind the healthcare discrepancy identified in our ruptured cerebral aneurysm population. Reallocation of resources to supplement advanced in-patient acute care technologies, and, more importantly, post acute care environments can narrow the outcome gap.

Patient and provider perspectives on delivery of oral cancer therapies

ObjectiveThe introduction of oral cancer therapies presents new challenges to delivery of quality cancer care. Little is known about how patients and providers address and overcome these challenges. We conducted a qualitative study exploring the range of patient and provider perspectives on oral cancer therapies. MethodsWe conducted semi-structured interviews with patients and providers at a tertiary referral center and county safety-net hospital in Dallas, TX. Interviews probed perspectives on differences between parenteral chemotherapy and oral therapies, adherence, communication, and cost/insurance. Interview transcripts were analyzed thematically using a deductively-driven coding scheme corresponding to the interview guide. ResultsWe conducted 22 patient (13 at tertiary referral center, 9 at safety-net hospital) and 10 provider (7 oncologists, 2 nurses, 1 pharmacist) interviews. Key themes from interviews included: (1) differences in parenteral chemotherapy vs. oral therapy; (2) adherence and dosing; and (3) experiences related to cost and communication. ConclusionsNearly all providers described challenges engaging with and educating patients about oral cancer therapies. Despite our initial hypothesis, safety-net patients encountered few barriers accessing oral therapies compared to patients receiving care in the tertiary referral center. Practice implications: Our findings will guide future interventions to monitor and support cancer patients receiving oral therapies.

ChemoPalRx: Development and implementation of a chemotherapy mobile provider order entry system in a safety net hospital.

e18071 Background: Computerized provider order entry (CPOE) systems have been shown to enhance the safety and efficiency of prescribing chemotherapy over the handwritten ordering process. However, many institutions lack the financial ability, technological capability, or operational flexibility to invest in and implement such a system. In particular, Olive View-UCLA Medical Center (OVMC), a Los Angeles County safety net hospital, is among these institutions with unique restrictions that preclude the use of chemotherapy CPOE and mandate handwritten orders. Methods: In an effort to bridge the gap for safe chemotherapy prescribing, we aimed to develop and implement an effective, scalable, and sustainable chemotherapy provider order entry solution that was operationally sensitive to institutions without a chemotherapy CPOE. The solution was designed as a mobile application using Xcode, the integrative development environment of Apple Inc., with the Swift programing language. Results: On September 5th, 2018, we launched a free, chemotherapy provider order entry solution on the worldwide Apple App Store – ChemoPalRx. Using ChemoPalRx, providers can search, customize, and print common chemotherapy regimens in prescription format. Along with a reference library of over 120 order set and 450 medications, ChemoPalRx is equipped with the functions to automate dosage calculation, suggest pre-medications and safety parameters, and trigger alerts for missing prescribing information. As a quality improvement initiative, we implemented ChemoPalRx at OVMC. Implementation stages include obtaining administrative buy-in, consulting with multidisciplinary staffs, investing $100 USD for a prescription printer, and encouraging providers to download ChemoPalRx on their own mobile devices. An ongoing prospective cohort study is being conducted to determine ChemoPalRx effectiveness in reducing errors compared to handwritten orders. Conclusions: ChemoPalRx is developed to enhance the safety and efficiency of chemotherapy prescribing. Implementation of this mobile application is feasible in the safety-net hospital setting and has the potential to transform oncology practices globally.

Effect of health disparities on overall survival of patients with glioblastoma.

Examine the potential effects of health disparities in survival of glioblastoma (GB) patients. We conducted a retrospective chart review of newly diagnosed GB patients from 2000 to 2015 at a free standing dedicated cancer center (MD Anderson Cancer Center-MDACC) and a safety net county hospital (Ben Taub General Hospital-BT) located in Houston, Texas. We obtained demographics, insurance status, extent of resection, treatments, and other known prognostic variables (Karnofsky Score-KPS) to evaluate their role on overall GB survival (OS). We identified 1073GB patients consisting of 177 from BT and 896 from MDACC. We found significant differences by ethnicity, insurance status, KPS at diagnosis, extent of resection, and percentage of patients receiving standard of care (SOC) between the two centers. OS was 1.64years for MDACC patients and 1.24years for BT patients (p < 0.0176). Only 81 (45.8%) BT patients received SOC compared to 577 (64%) of MDACC patients (p < 0.0001). However, there was no significant difference in OS for patients who received SOC, 1.84years for MDACC patients and 1.99years for BT patients (p < 0.4787). Of the 96 BT patients who did not receive SOC, 29 (30%) had KPS less than 70 at time of diagnosis and 77 (80%) lacked insurance. GB patients treated at a safety net county hospital had similar OS compared to a free standing comprehensive cancer center when receiving SOC. County hospital patients had poorer KPS at diagnosis and were often lacking health insurance affecting their ability to receive SOC.

Moving Through and Moving Forward.

Moving Through and Moving Forward Suzanne Minor On the five hour drive home after my father–in–law, Mike's, initial hospitalization for renal failure resulting in a diagnosis of aggressive multiple myeloma, my head seemed too tight, the radio too loud, and the DJ's too rambunctious. The tension in my head built, hammering, getting more severe over the evening. I slept fitfully that night, my head pounding every time I rolled over. The headache continued into the next day, when I went into work as I was scheduled to teach a clinical reasoning small group. I was horribly irritable, and didn't understand the headache. Mike was suffering with an illness, and medical school and residency trained me to deal with illness, so why was I so tense? I could deal with any patients' [End Page E10] medical problems. Yet Mike was not just any patient to me, a tiny voice inside whispered. I confirmed with my supervisor that I was back and would cover the small group on clinical reasoning. I naively felt that if I could work, the headache would pass. The first sentence of the case stopped my breath: the chief complaint was a growing lump in the neck. I frantically flipped to the last page, searching for the diagnosis. My grief, packed away for the past week, erupted in chaotic, wracking sobs. I closed my office door so passing students wouldn't see me losing it and tried not to wail too loudly. I sat on the floor in one corner of my office because the walls felt solid to me and I didn't want those in the nursing building who could see into my office to witness my private sorrow. I called my supervisor back and, still crying, said "I just can't do it." I wanted to give him time to find faculty coverage so I called when I was still in tears, thinking that I wouldn't be composed for hours or days or ever. The tears seemed infinite. I pulled myself together as much as I could and made my way to my car, awkwardly accepting kind remarks and dodging faces full of pity. Everything—the air, my body, life, reality—felt too thick, too heavy. I went home, crying the whole way. Slowly, my headache eased and through it, I felt more real than I had since the ordeal began the week before. I understood my crackling irritability and massive headache—I had been suppressing my feelings. Why wasn't I ok with feeling sadness? I hadn't even realized that I had turned that part of me off for the last week. I had been in crisis mode, doing what needed doing, supporting my husband, filtering the medical–ese being spoken by my peers. Besides, I was just the daughter–in–law. What right did I have to be upset? Mike wasn't my father, though he was a principled influence in my life for two decades. I didn't even realize I was avoiding my sadness or trying to reason around it. Looking back, I had some serious issues with sadness. I learned to stuff sadness, as needed, to function, especially in residency at the county safety–net hospital. Working 36 hour shifts with very sick patients, emotions became superfluous; work and marriage and then sleep were the priorities. I didn't feel justified in feeling sad. Even though feeling feelings was actually self–care, it felt indulgent, though in retrospect was entirely necessary. I crave reason and order whereas sadness isn't orderly at all. Sadness can't be scheduled and seems to exist on its own terms. Expressing sadness, crying, is replete with messy secretions. It didn't feel acceptable to not work just for feeling sad. What? Was I going to call in sad? Yet, I couldn't work when I was bawling and incoherent. I also didn't want people to know that I was that sad, feeling defenseless and entirely helpless in my sadness at work. During my father–in–law's many hospitalizations, I acted as the trusted medical interpreter and liaison for the family. The physicians were intelligent, compassionate...

MP35-05 DIGITAL RECTAL EXAM AND PROSTATE SIZE FOR THE EVALUATION OF BENIGN PROSTATE PATHOLOGY: AN ANALYSIS OF 30,500 MEN PRESENTING FOR SCREENING EXAMS IN THE PLCO CANCER SCREENING TRIAL

INTRODUCTION AND OBJECTIVES: The American Urological Association Symptom Score (AUA-SS) is the gold standard instrument used to assess lower urinary tract symptoms (LUTS) commonly associatedwith benign prostatic hyperplasia (BPH). However, completion of the AUA-SS may be difficult, as it requires adequate literacy and numeracy skills. This study aims to determine community levels of literacy and numeracy and to pilot a novel method of assessing LUTS in men. METHODS: A trained researcher recruited 64 men from clinics at Nashville General Hospital, a safety-net county hospital in Nashville, TN. Exclusion criteria included age less than 40 years or greater than 75 years, blindness, non-English speaking, and untreated psychiatric disease. We obtained demographic data and assessed literacy and numeracy using validated tools including: the revised Rapid Estimate of Adult Literacy in Medicine (REALM-R), the Schwartz-Woloshin numeracy instrument and the Subjective Numeracy Scale (SNS). Patients were then administered a 4-item questionnaire to assess LUTS covering the following domains; Frequency, Incontinence (Leakage), Nocturia (Overnight voiding), and Weak stream (FLOW). Time to complete the FLOW questionnaire was measured. RESULTS: Thirty-seven men (57.8%) had a reading level below the 6th grade. Twenty-two men (34.4%) had low to no numeracy (SNS score <2). The median time to complete the FLOW questionnaire was 18.0 seconds (IQR 15.8-21.0). The mean number of positive responses to the FLOW instrument was 1.7. Sixteen men (25%) reported zero symptoms, while the number of men who reported one, two, three, and four positive responses was sixteen (25%), eleven (17%), twelve (19%), and nine (14%), respectively. A subset of 28 patients was readministered the FLOW questionnaire two weeks later and there was no significant difference in the mean number of positive responses (1.6). Test-retest reliability was 0.91. Cronbach’s alpha, a measure of internal consistency, for the FLOW was 0.67. CONCLUSIONS: The majority of men recruited from clinics at a safety-net hospital had low literacy and numeracy scores, yet were able to complete the FLOW instrument with no difficulty. Using the novel FLOW instrument in this pilot group to measure urinary function is rapid and consistent, and represents a promising avenue for further research in assessing LUTS, even in men with limited literacy.

MP35-04 THE FLOW QUESTIONNAIRE: DEVELOPING A NOVEL INSTRUMENT TO EVALUATE LOWER URINARY TRACT SYMPTOMS IN MEN

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Epidemiology & Evaluation1 Apr 2016MP35-04 THE FLOW QUESTIONNAIRE: DEVELOPING A NOVEL INSTRUMENT TO EVALUATE LOWER URINARY TRACT SYMPTOMS IN MEN Daniel Heslop, Lisa Sherden, Consuelo Wilkins, Ken Wallston, and Kelvin Moses Daniel HeslopDaniel Heslop More articles by this author , Lisa SherdenLisa Sherden More articles by this author , Consuelo WilkinsConsuelo Wilkins More articles by this author , Ken WallstonKen Wallston More articles by this author , and Kelvin MosesKelvin Moses More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1596AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The American Urological Association Symptom Score (AUA-SS) is the gold standard instrument used to assess lower urinary tract symptoms (LUTS) commonly associated with benign prostatic hyperplasia (BPH). However, completion of the AUA-SS may be difficult, as it requires adequate literacy and numeracy skills. This study aims to determine community levels of literacy and numeracy and to pilot a novel method of assessing LUTS in men. METHODS A trained researcher recruited 64 men from clinics at Nashville General Hospital, a safety-net county hospital in Nashville, TN. Exclusion criteria included age less than 40 years or greater than 75 years, blindness, non-English speaking, and untreated psychiatric disease. We obtained demographic data and assessed literacy and numeracy using validated tools including: the revised Rapid Estimate of Adult Literacy in Medicine (REALM-R), the Schwartz-Woloshin numeracy instrument and the Subjective Numeracy Scale (SNS). Patients were then administered a 4-item questionnaire to assess LUTS covering the following domains; Frequency, Incontinence (Leakage), Nocturia (Overnight voiding), and Weak stream (FLOW). Time to complete the FLOW questionnaire was measured. RESULTS Thirty-seven men (57.8%) had a reading level below the 6th grade. Twenty-two men (34.4%) had low to no numeracy (SNS score <2). The median time to complete the FLOW questionnaire was 18.0 seconds (IQR 15.8-21.0). The mean number of positive responses to the FLOW instrument was 1.7. Sixteen men (25%) reported zero symptoms, while the number of men who reported one, two, three, and four positive responses was sixteen (25%), eleven (17%), twelve (19%), and nine (14%), respectively. A subset of 28 patients was re-administered the FLOW questionnaire two weeks later and there was no significant difference in the mean number of positive responses (1.6). Test-retest reliability was 0.91. Cronbach's alpha, a measure of internal consistency, for the FLOW was 0.67. CONCLUSIONS The majority of men recruited from clinics at a safety-net hospital had low literacy and numeracy scores, yet were able to complete the FLOW instrument with no difficulty. Using the novel FLOW instrument in this pilot group to measure urinary function is rapid and consistent, and represents a promising avenue for further research in assessing LUTS, even in men with limited literacy. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e481 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Daniel Heslop More articles by this author Lisa Sherden More articles by this author Consuelo Wilkins More articles by this author Ken Wallston More articles by this author Kelvin Moses More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outcomes for Patients with Poor-Grade Subarachnoid Hemorrhage: To Treat or Not To Treat?

To investigate potential health care discrepancies in patients with ruptured cerebral aneurysms undergoing microsurgical intervention.We retrospectively reviewed patients with ruptured intracranial aneurysms treated at our tertiary referral university hospital (UH) and safety net county hospital (CH) from 2010 to 2015. We identified 73 UH patients and 58 CH patients.UH patients had shorter time duration between rupture and intervention (P < 0.001) and higher rates of intubation on admission (P = 0.01). Verapamil was more frequently used for clinical vasospasm in UH patients, at 0.13 (95% confidence interval [CI], 0.09–0.18) treatments per patient per day versus 0.077 (95% CI, 0.047–0.12) treatments per patient per day in CH patients, though there was no difference in delayed cerebral ischemia (P = 0.15). The majority of the CH cohort was uninsured (26.3%; UH 0%) or had Medicaid (59.7%; UH 35.2%) (P < 0.001). The UH had more dispositions to home or rehabilitation centers than the CH (82% vs. 67.3%; P = 0.04). After adjusting for disease severity, hospital stay, and insurance status, CH patients were 3.73 (95% CI, 1.25–12.14) times more likely to be discharged with a poor modified Rankin Scale score and 3.08 (95% CI, 1.04–9.61) times more likely to be discharged with a poor Glasgow Outcome Scale score compared with UH patients (P = 0.02 and P = 0.04, respectively).Limited resource availability in a safety net hospital system could be a major driving force behind the health care discrepancy identified in our ruptured cerebral aneurysm population. Reallocation of resources to supplement advanced inpatient acute care technologies and, more importantly, post–acute care environments can narrow the outcomes gap.

A Cost Analysis of Hospitalizations for Infections Related to Injection Drug Use at a County Safety-Net Hospital in Miami, Florida.

BackgroundInfections related to injection drug use are common. Harm reduction strategies such as syringe exchange programs and skin care clinics aim to prevent these infections in injection drug users (IDUs). Syringe exchange programs are currently prohibited by law in Florida. The goal of this study was to estimate the mortality and cost of injection drug use-related bacterial infections over a 12-month period to the county safety-net hospital in Miami, Florida. Additionally, the prevalence of HIV and hepatitis C virus among this cohort of hospitalized IDUs was estimated.Methods and FindingsIDUs discharged from Jackson Memorial Hospital were identified using the International Classification of Diseases, Ninth Revision, codes for illicit drug abuse and endocarditis, bacteremia or sepsis, osteomyelitis and skin and soft tissue infections (SSTIs). 349 IDUs were identified for chart abstraction and 92% were either uninsured or had publicly funded insurance. SSTIs, the most common infection, were reported in 64% of IDUs. HIV seroprevalence was 17%. Seventeen patients (4.9%) died during their hospitalization. The total cost for treatment for injection drug use-related infections to Jackson Memorial Hospital over the 12-month period was $11.4 million.ConclusionsInjection drug use-related bacterial infections represent a significant morbidity for IDUs in Miami-Dade County and a substantial financial cost to the county hospital. Strategies aimed at reducing risk of infections associated with injection drug use could decrease morbidity and the cost associated with these common, yet preventable infections.