English-speaking Patients Research Articles

92 Validation of Coin-in-Hand Procedure in a Veteran Population

Objective:Performance validity tests (PVTs) provide a methodological approach to detecting credible neurocognitive performances. This proves invaluable to the diagnostic process, as it allows neuropsychologists to objectively determine if an evaluation reflects a patient’s true neurocognitive abilities or if external factors are impacting the results. However, their addition to a testing battery can increase an already lengthy evaluation. As such, there is a need for sensitive but less time intensive PVTs. The purpose of this study is to validate the Coin-in-Hand (CIH) procedure as a quick and effective PVT within a veteran population.Participants and Methods:68 English-speaking patients were identified from an outpatient neuropsychological assessment dataset. Performances were correlated to the well- validated Reliable Digit Span (RDS), and several other soft indicators of task engagement including expanded COWAT, BVMT-False Alarms (FA), WCST Failure to Maintain Set (FTM), TOMM, and the RBANS Effort Index (EI). All participants attempted CIH and RDS, testing was discontinued if 2 or more PVTs were invalid. An AUC analysis was conducted to determine how well the CIH discriminated between valid and invalid performance and determine the tests optimal cut-off score (sensitivity > 0.90 while maintaining the highest possible specificity). Logistic Regression was conducted to determine how well the CIH predicted performance validity.Results:Subject mean(SD) age and education were 55.25 (16.06) and 13.41 (2.55) years, respectively. 17% female, 60% Caucasian, and 32% Black. Descriptive statistics for each of the other performance validity tests were gathered. The CIH demonstrated low diagnostic accuracy (AUC = .66; p >.05; CI = .51 -.81); a cut score of <8 resulted in a sensitivity of .96 and a specificty of .64. Logistic Regression showed that CIH performance significantly predicted performance validity (X2 = -0.93; df = 1; N = 68; p < .05), accounting for 18-28% of the variance in performance classification (Cox & Snell R2 = .18; Nagelkerke R2 = .28). It correctly classified 96% of valid performers, but only correctly classified 35% of invalid performers, with an overall correct prediction rate of 83%. A predicted chase in log odds (B= -.93) and odd ratio [Exp (B) =.40] indicated that every unit increase in CIH score was associated with a decrease probability of performance invalidity. Logistic regression was also used to calculate the probability of performance invalidity at each possible CIH score (Table 1).Conclusions:Results suggests that poor performance on CIH does not necessarily equate to invalid performances, but instead, should act as a screener to cue neuropsychologists working with Veterans that additional PVTs should be considered. Overall, it was determined that CIH was able to correctly predict 35% of invalid performers and 96% of valid performers, with an overall correct prediction rate of 83%, suggesting the procedure may be too simple to be an effective standalone PVT for clinical use. These results also highlight that every correct response on the CIH was associated with a decreased probability of performance invalidity. Additionally, an AUC analysis determined the tests optimal cut off score to be <8, suggesting that shortening the procedure may be as effective as giving the full 10 trials.

Patient, Parent, and Provider Perceptions of Barriers to Pediatric Inflammatory Bowel Disease Care.

Children with inflammatory bowel disease (IBD) have a significant life-long burden as a result of disease, impacted by environmental and individual barriers. Successful health system interventions require a comprehensive approach, informed by various stakeholders. The main objective was to identify health system barriers and potential solutions from existing patients, families, and providers via focus groups. Participants for the focus groups were existing English-speaking patients (ages 9-18) with IBD, their caregiver(s), and providers including multiple professions (eg, physician, nurse, pediatrician, social worker, care coordinator, scheduler, and psychologist). Separate focus groups were led by experienced personnel for parents, children, and providers, using a standardized interview guide. Sessions were recorded, transcribed, and verified. Using content analysis, we systematically classified data through coding and identified themes. Focus groups comprised (a) 3 patient groups (n = 20, 50% female, including 2 younger; mean age = 11.4 ± 1.5 years) and 1 older group (mean age = 15.6 ± 1.3 years), (b) 3 parent groups (n = 24, 83% female), and (c) 2 multidisciplinary provider groups (n = 19). Families shared several common concerns with providers (eg, school, care delay, psychosocial, and financial) but varied on specifics. Some barriers may be addressable through family or staff education, improved communication (eg, care delay/ access, transition), or training (eg, labs and diet), while others may require change at an institutional or policy level (eg, insurance). This qualitative analysis identified several barriers to IBD care, some shared, some unique to patients, parents, and providers, highlighting the importance of obtaining multiple stakeholder perspectives when exploring barriers to care.

The lived experience of positive airway pressure therapy in patients with obstructive sleep apnea across the lifespan: a qualitative study.

Although treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy is effective, adherence is often poor. Understanding the patient perspective is needed to inform adherence-promoting interventions. This qualitative study assessed the experiences, preferences, facilitators, and barriers surrounding PAP therapy for the management of OSA in patients from adolescence to older adulthood. Eligible participants ages 19 and older were identified from administrative health care claims; adolescent participants ages 12-18 and their parents/caregivers were identified via electronic health records of a tertiary sleep specialty clinic at a large children's hospital. Forty English-speaking patients and 10 parents of adolescents diagnosed with OSA and prescribed PAP therapy completed semistructured 60-minute telephone interviews conducted by a trained facilitator. Common themes and illustrative quotes were identified. Themes around OSA diagnosis, initiating OSA treatment, learning about OSA/PAP, decision to start PAP, PAP benefits and challenges, and reasons for nonadherence were identified. Participants suggested design and delivery changes to improve PAP devices. Issues unique to adolescents and their parents were discussed. The unique perspectives of patients regarding PAP therapy should be taken into consideration when developing interventions to increase PAP adherence and improve clinical care. Based on identified themes, opportunities for intervention may exist at all stages of care, from diagnosis to treatment initiation. Involving partners, parents, and other caregivers in PAP therapy may be beneficial for optimizing adherence. Simon SL, Stephenson JJ, Haynes K, etal. The lived experience of positive airway pressure therapy in patients with obstructive sleep apnea across the lifespan: a qualitative study. J Clin Sleep Med. 2024;20(3):407-416.

Association of language concordance and restraint use in adults receiving mechanical ventilation.

Clinician-patient language concordance improves patient outcomes in non-intensive care unit (ICU) settings. We sought to assess the association of ICU nurse-patient language concordance with delirium-related outcomes. We conducted a retrospective cohort study of adult English- or Spanish-speaking mechanically ventilated ICU patients admitted to ICUs at the University of Miami Hospital and Clinics (January 2021-September 2022). Our primary exposure was nurse-patient language concordance on each shift. We used mixed-effects multivariable regression to evaluate the association of language concordance with the primary outcome of restraint use, and secondary outcomes of agitation and identification of delirium, during each shift (with patient as a random effect). Our cohort included 4326 shifts (3380 [78.1%] with language concordance) from 548 patients and 157 nurses. Spanish language was preferred by 269 (49.1%) of patients. English-speaking patients tended to be younger (65 [53, 75] vs 73 [61, 83], p < 0.001) and of non-Hispanic ethnicity (55.5% vs 7.1%, p < 0.001). English-speakers had restraints ordered on fewer of their included shifts (0 [0, 3] vs 1 [0, 3], p = 0.005). After adjustment, the odds of restraint use on shifts with language concordance was significantly lower (odds ratio [OR, 95% confidence interval [CI]]: 0.50 [0.39-0.63], p < 0.001). Agitation (18.6% vs 25.2%; OR [95% CI]: 0.71 [0.55-0.92], p = 0.009) and delirium identification (34.5% vs 41.3%; OR [95% CI]: 0.54 [0.34-0.88], p = 0.014) were also less common. We identified a twofold reduction in the odds of restraint use among mechanically ventilated patients for language concordant nurse-patient dyads. Ensuring nurse-patient language concordance may improve ICU delirium, agitation, and restraint use.

The Effect of Language on the Decision to Image in the Evaluation of Atraumatic Headache

BackgroundPatients with limited English proficiency seen in the emergency department (ED) experience lower quality of care and higher diagnostic resource utilization unless they are evaluated in their own language. Despite a low rate of serious pathology identified and the availability of guidelines to direct its use, computed tomography (CT) is commonly used to evaluate atraumatic headache in the ED. ObjectiveOur aim was to determine whether Spanish-speaking patients with atraumatic headache were more likely than their English-speaking counterparts to undergo head CT, and whether evaluation by a clinician who passed a Spanish proficiency test mitigated this difference. MethodsThis retrospective observational study used electronic health record data of adult patients presenting with atraumatic headache to a level I trauma center during a 2-year period. Spanish-language testing of clinicians consisted of a brief, unvalidated, in-person, nonmedical verbal test administered by human resources staff. ResultsA total of 3030 patients with atraumatic headache were identified; 1437 were English speaking and 1593 were Spanish speaking. Spanish-speaking patients were older (48.3 vs. 41.9 years), more likely to be women (68.8% vs. 60.5%), and more likely to undergo head CT (31.8% vs. 26.4%). Evaluation by a clinician who passed the Spanish proficiency test had no significant influence on the likelihood of head CT for Spanish-speaking patients after controlling for confounding variables (adjusted odds ratio 0.95; 95% CI 0.75–1.20). ConclusionsSpanish-speaking patients are more likely to undergo head CT when evaluated for atraumatic headache than English-speaking patients. Evaluation by a clinician who passed a brief Spanish proficiency test did not mitigate this disparity.

Assessing the Psychometric Validity of the Epistaxis Severity Score: Internal Consistency and Test-Retest Reliability.

The Epistaxis Severity Score (ESS) is the gold-standard patient-reported outcome measure for evaluating nosebleed severity in patients with hereditary hemorrhagic telangiectasia (HHT). To date, the ESS has been assessed only for content validity and concurrent validity. We evaluate the internal consistency and test-retest reliability of the ESS. After receiving institutional review board approval, we sent an online survey battery, including the ESS survey, to 305 (39% male) English-speaking HHT patients ≥18 years old at a single center. Of those, 140 (46%) patients completed the battery, and 110/140 (79%) reported epistaxis. Cronbach's alpha and correlation analyses were used to evaluate internal consistency. For the test-retest reliability evaluation, we recruited 69 HHT patients during HHT clinic to complete 2 self-administered ESS surveys 2 weeks apart. Participants also completed a modified Clinical Global Impression-Improvement scale with readministration of the ESS survey. We calculated the intraclass correlation coefficient in a 2-way mixed model with absolute agreement. The ESS survey demonstrated low internal consistency (Cronbach's alpha = 0.495), suggesting that it measured multiple unrelated concepts. Factor analysis revealed 3 latent factors with moderate intercorrelation, suggesting the presence of 3 related but distinct constructs underlying the ESS. However, the ESS demonstrated excellent test-retest reliability (intraclass correlation coefficient = 0.955; 95% CI, 0.91-0.98). Although the ESS demonstrates high test-retest reliability, it may not adequately assess different dimensions of nosebleed severity. Additional correlated survey questions and sub-scores may be needed to increase internal consistency to accurately measure each component of epistaxis severity. It is necessary to acknowledge epistaxis severity from different dimensions and to consider evaluating individual ESS items separately for a comprehensive understanding.

H - 47 Bilingual Auditory Naming Test Performance in an Epilepsy Sample.

The growing multilingual population in the United States calls for culturally adapted norms for neuropsychological tools. Language testing, for example, is paramount in pre-surgical assessment in patients with dominant temporal lobe epilepsy. The Boston Naming Test (BNT) and the Auditory Naming Test (ANT) are frequently used in pre-surgical epilepsy evaluations; yet, while bilingual norms exist for the BNT, these are lacking for the ANT. To parse out how much of a bilingual patient's language performance is accounted for by bilingualism versus language deficits, we studied whether there is a significant difference in ANT performance between bilingual and monolingual English-speaking epilepsy patients. Our sample of patients with localized epilepsy from the UCSF Epilepsy Center included 22 bilingual (English-dominant; non-dominant languages included Spanish, Arabic, Dutch, Taiwanese, and Japanese) and 61 monolingual English-speakers (39% female, M age = 36.3). All patients took anti-seizure medication and completed the ANT and BNT as part of a pre-surgical neuropsychological assessment. Compared to monolingual English-speaking patients, bilingual patients had significantly lower scores on the ANT (Bilingual M = -4.03 [SD = 5.6], Monolingual M = -0.7 [SD = 1.9]; t(81) = 3.89, p < 0.001) and BNT (t(77) = 2.76, p = 0.007). This performance difference was significantly greater for the ANT than BNT (F(1,77) = 7.71, p = 0.007). These results highlight the importance of considering multilingualism in neuropsychological assessments. This is especially needed for pre-surgical language mapping in epilepsy surgical candidates. Future research should establish bilingual normative standards for neuropsychological language-based tests such as the ANT.

SAT114 Global Social Determinants Of Health Needs And Response For Those New To Insulin At Discharge

Abstract Disclosure: C.A. Bullock: None. K. Davis: None. K. Carthy: None. P. Wax: None. C. Smyrniotis: None. T. Pollack: None. C. Barnard: None. J. Holl: None. A. Wallia: Grant Recipient; Self; Novo Nordisk. Research Investigator; Self; UnitedHealth Group. Unmet social determinant of health (SDoH) needs of patients with diabetes who are discharged with newly prescribed insulin place these patients at high risk of poor outcomes. Yet, few system level initiatives exist to identify patients with these needs and address them. An SDoH screening and referral initiative, consisting of an integrated screening tool administered by nursing upon hospital admission, was launched at a Chicago academic health system that cares for a diverse patient population. The electronic health record (EHR) screener assesses six specific domains including medication affordability, transportation barriers, food insecurity, housing stability, usual source of care, and mental health needs and a follow-up question if the patient would like assistance (leading to social work consultation). Our goal was to review the identified SDOH needs of patients newly prescribed insulin at discharge, and for whom a certified diabetes care and education specialist consultation (CDCES) was placed. From 05/01/22- 09/30/22, 279 patients had a CDCES consultation at Northwestern Memorial Hospital (NMH) of which 3 expired during admission. Of the 131 patients (47%) discharged with a new prescription for insulin, 18 (14%) were non-English, of which 17 (95%) had a complete SDOH screener, and 113 were English-speaking (86%), of which 74% (N=84) had a complete SDoH screener. The 113 English speaking patients had an age range from 20-84 (mean 56, SD + 14), 37 (33%) identified as black, 58 (51%) were female, and a majority (N= 55 [49%]) had Medicaid, Medicare coverage or were uninsured. Of those who had a screener completed (N=84), 28 (33%) reported at least 1 need, while 8% (N=7) identified &amp;gt;=3 needs, and 11% (N=9) requested assistance. The most reported need was a usual source of care (N=14, 17%). Other identified SDoH needs included medication affordability (N=8), transportation need (N=8), food insecurity (N=7), and housing stability issue (N=6), but few (N=2) identified any mental health needs. Sixty-five patients in total had a Social Work consultation and of those patients who identified needs 58% had their SDoH needs addressed by a Social Worker. Of the 14 patients without a usual source of care, 5 (43%) were readmitted or seen in the emergency department within 90 days of discharge and 1 had &amp;gt; 8 visit, despite enrollment in a hospital transitional care program. Only one patient established a usual source of care. Overall, 2 patients (2%), both with no identified needs, died within 90 days. Our findings reveal that many hospitalized patients who had a CDCES consultation before discharge and were newly prescribed insulin, identified global (&amp;gt; 3 SDoH or requiring assistance) needs. The findings also suggest that CDCES, nurses, pharmacists, and/or social workers may need to facilitate and/or create new pathways to address the needs of hospitalized patients newly prescribed insulin. Presentation: Saturday, June 17, 2023

Radiation Therapy Knowledge and Health Literacy among Culturally Diverse Patients with Prostate Cancer Treated at a Safety-Net Hospital.

Shared decision making is integral to the physician-patient relationship for radiotherapy (RT) patients. It is implicit that patients both comprehend and retain information explained during consultation. However, quality and quantity of patient knowledge following this visit is unknown. The purpose of this study was to evaluate post-consultation RT knowledge and health literacy among a diverse group of patients. Participants were patients ≥18 years old who received consultation for definitive or salvage RT to the prostate gland/fossa between April 2021 and January 2023 at an urban safety-net hospital. Following consultation, patients completed the Radiation Oncology Knowledge Assessment Survey (ROKAS), designed to measure patient understanding of proposed RT treatment (e.g., treatment frequency, length, safety) and possible short- and long-term side effects (SE). Additional measures included patients' health literacy, health numeracy (numerical medical concepts), acculturation (assimilation to the dominant culture), and socioeconomic factors. ROKAS was administered in both English and Spanish with Spanish-speaking patients offered medical translation if desired. Bivariate Pearson correlations were conducted to examine the relationships between independent variables and post-consultation RT knowledge. Two-sided t-tests were conducted to examine differences in patients' knowledge by language. Overall, 39 ROKAS were completed by 24 English-speaking and 15 Spanish-speaking patients (mean age 64.4 [SD 6.8], range 52-79). The majority (93%) of patients 'agreed' or 'strongly agreed' that they understood all the RT information presented. However, only 70% of the RT questions were answered correctly with 26% of patients answering all RT questions correctly. Similarly, 95% of patients 'agreed' or 'strongly agreed' with knowing the side effects of their proposed treatment, but only 71% and 74% of short- and long-term SE questions, respectively, were answered correctly. Higher health literacy (p = 0.04) and health numeracy (p = 0.001) were significantly correlated with better understanding of short-term SE, but not with RT knowledge or long-term SE. Spanish-speaking patients had significantly lower scores of health literacy (p = 0.001) and understanding of long-term (p = 0.01), but not short-term SE. There is a significant gap between perceived and measured knowledge of RT treatment and SE in patients who receive consultation for RT to the prostate gland/fossa. Health literacy was significantly associated with improved knowledge of RT and short-term SE. Spanish-speaking patients had poorer understanding of long-term SE than English-speaking patients. Efforts to identify gaps in patient health literacy are needed to target those at risk and ensure that culturally diverse patient populations can engage in shared decision making with their providers.

Assessing Depression and Anxiety Levels in English and Spanish-Speaking Patients throughout a Course of Radiation Therapy

An estimated 32.2% and 41.9% of breast cancer patients experience depression and anxiety, respectively. However, distress experienced by patients with breast cancer receiving radiation therapy may vary at different time points and differ in comparison to other patients with breast cancer, potentially due to differences in the understanding of radiotherapy and variability in the severity of side effects. This study sought to describe the changes in levels of depression and anxiety experienced by English and Spanish-speaking patients throughout a course of radiation therapy for breast cancer, along with the impact of different variables on these levels of distress to better understand and quantify potential gaps. Eligibility criteria included English and Spanish-speaking females, ages 18 or older, undergoing radiation therapy treatment for breast cancer at two institutions, including a safety-net hospital. Pre- and post-treatment surveys were completed before and after delivery of radiation therapy. Sociodemographic characteristics collected included: race, ethnicity, marital status, education level, longest residency location, housing, and food security. The survey ended with the standardized PHQ-4 questionnaire, which uses a maximum total score of 12 to assess anxiety and depression. Results were analyzed using the Analysis of Covariance procedure. A total of 160 participants completed pre- and post-treatment surveys. Half of the participants were non-white (50%), primarily married (42.5%), and had a high school or associate's level education (46.9%). The total baseline distress mean (BDM) was 2.96 (Standard deviation, SD = 3.11), and the final distress mean (FDM) was 2.78 (SD = 3.78). English-speaking patients comprised 82.5% (n = 132) of the sample and had a BDM of 2.91 with an adjusted change mean (ACM) decrease of 0.45. Spanish-speaking patients comprised 17.5% (n = 28) of the sample, with a BDM of 3.21 and an ACM increase of 1.03 (P = 0.002). Housing (P = 0.021) and food insecurity (P = 0.002) also showed increasing distress with increased insecurity at baseline. Our study shows that Spanish-speaking patients present with higher levels of distress than their English-speaking counterparts and their distress increased throughout treatment as opposed to English speakers. Other factors, such as housing and food insecurity, are also significantly associated with increased distress. As the number of Spanish speakers in the US continues to increase, it will be important to continue assessing potential differences in cancer care. In addition, understanding the distress changes throughout radiation treatment could help inform future interventions that address these disparities.

Limited health literacy results in lower health-related quality of life in spine patients

Background ContextSpinal conditions impact health-related quality of life (HRQoL). Patient education and counseling improve HRQoL, yet the effects may be limited for patients with inadequate health literacy (HL). Despite the established relationship between HRQoL and HL in other fields, research in the orthopedic spine population is lacking. PurposeTo investigate if limited HL results in lower HRQoL and to evaluate factors are associated with HRQoL in patients seen at an outpatient orthopedic spine center. Study Design/SettingProspective single-center cross-sectional study. Patient SamplePatients 18 years of age or older seen at a tertiary urban academic hospital- based multi-surgeon outpatient spine center. Outcome MeasuresEQ-5D-5L health-related quality of life (HRQoL) questionnaire, and the Newest Vital Sign (NVS) HL assessment tool. MethodsBetween October 2022 and February 2023, consecutive English-speaking patients over the age of 18 and new to the outpatient spine clinic were approached for participation in this cross-sectional survey study. Patients completed a sociodemographic survey, EQ-5D-5L HRQoL questionnaire, and Newest Vital Sign (NVS) HL assessment tool. The EQ-5D-5L yields two continuous outcomes: an index score ranging from below 0 to 1 and a visual analog scale (EQ-VAS) score ranging from 0 to 100. The NVS scores were divided into limited (0–3) and adequate (4–6) HL. Multivariate linear regression with purposeful selection of variables was performed to identify independent factors associated with HRQoL. ResultsOut of 397 eligible patients, 348 (88%) agreed to participate and were included in statistical analysis. Limited HL was independently associated with lower EQ-5D-5L index scores (B=1.07 [95% CI 1.00–1.15], p=.049. Other factors associated with lower EQ-5D-5L index scores were being obese (BMI≥30), having housing concerns, and being an active smoker. Factors associated with lower EQ-VAS scores were being underweight (BMI<18.5), obese, having housing concerns, and higher updated Charlson comorbidity index (uCCI) scores. Being married was associated with higher EQ-VAS scores. ConclusionsLimited HL is associated with lower EQ-5D-5L index scores in spine patients, indicating lower HRQoL. To effectively apply HL-related interventions in this population, a better understanding of the complex interactions between patient characteristics, social determinants of health, and HRQoL outcomes is required. Further research should focus on interventions to improve HRQoL in patients with limited HL and how to accurately identify these patients. Level of evidenceLevel II prognostic.

Patient priorities for fulfilling the principle of respect in research: findings from a modified Delphi study

BackgroundStandard interpretations of the ethical principle of respect for persons have not incorporated the views and values of patients, especially patients from groups underrepresented in research. This limits the ability of research ethics scholarship, guidance, and oversight to support inclusive, patient-centered research. This study aimed to identify the practical approaches that patients in community-based settings value most for conveying respect in genomics research.MethodsWe conducted a 3-round, web-based survey using the modified Delphi technique to identify areas of agreement among English-speaking patients at primary care clinics in Washington State and Idaho who had a personal or family history of cancer. In Round 1, respondents rated the importance of 17 items, identified in prior qualitative work, for feeling respected. In Round 2, respondents re-rated each item after reviewing overall group ratings. In Round 3, respondents ranked a subset of the 8 most highly rated items. We calculated each item’s mean and median rankings in Round 3 to identify which approaches were most important for feeling respected in research.ResultsForty-one patients consented to the survey, 21 (51%) completed Round 1, and 18 (86% of Round 1) completed each of Rounds 2 and 3. Two sets of rankings were excluded from analysis as speed of response suggested they had not completed the Round 3 ranking task. Respondents prioritized provision of study information to support decision-making (mean ranking 2.6 out of 8; median ranking 1.5) and interactions with research staff characterized by kindness, patience, and a lack of judgment (mean ranking 2.8; median ranking 2) as the most important approaches for conveying respect.ConclusionsInformed consent and interpersonal interactions are key ways that research participants experience respect. These can be supported by other approaches to respecting participants, especially when consent and/or direct interactions are infeasible. Future work should continue to engage with patients in community-based settings to identify best practices for research without consent and examine unique perspectives across clinical and demographic groups in different types of research.

Are Social Deprivation and Low Traditional Health Literacy Associated With Higher PROMIS CAT Completion in Orthopaedic Surgery?

Are Social Deprivation and Low Traditional Health Literacy Associated With Higher PROMIS CAT Completion in Orthopaedic Surgery?

Racial, Ethnic, and Language-Based Inequities in Inpatient Opioid Prescribing by Diagnosis from Internal Medicine Services, a Retrospective Cohort Study.

Opioid administration is extremely common in the inpatient setting, yet we do not know how the administration of opioids varies across different medical conditions and patient characteristics on internal medicine services. Our goal was to assess racial, ethnic, and language-based inequities in opioid prescribing practices for patients admitted to internal medicine services. We conducted a retrospective cohort study of all adult patients admitted to internal medicine services from 2013 to 2021 and identified subcohorts of patients treated for the six most frequent primary hospital conditions (pneumonia, sepsis, cellulitis, gastrointestinal bleed, pyelonephritis/urinary tract infection, and respiratory disease) and three select conditions typically associated with pain (abdominal pain, acute back pain, and pancreatitis). We conducted a negative binomial regression analysis to determine how average administered daily opioids, measured as morphine milligram equivalents (MMEs), were associated with race, ethnicity, and language, while adjusting for additional patient demographics, hospitalization characteristics, medical comorbidities, prior opioid therapy, and substance use disorders. The study cohort included 61,831 patient hospitalizations. In adjusted models, we found that patients with limited English proficiency received significantly fewer opioids (66 MMEs, 95% CI: 52, 80) compared to English-speaking patients (101 MMEs, 95% CI: 91, 111). Asian (59 MMEs, 95% CI: 51, 66), Latinx (89 MMEs, 95% CI: 79, 100), and multi-race/ethnicity patients (81 MMEs, 95% CI: 65, 97) received significantly fewer opioids compared to white patients (103 MMEs, 95% CI: 94, 112). American Indian/Alaska Native (227 MMEs, 95% CI: 110, 344) patients received significantly more opioids. Significant inequities were also identified across race, ethnicity, and language groups when analyses were conducted within the subcohorts. Most notably, Asian and Latinx patients received significantly fewer MMEs and American Indian/Alaska Native patients received significantly more MMEs compared to white patients for the top six most frequent conditions. Most patients from minority groups also received fewer MMEs compared to white patients for three select pain conditions. Discussion. There are notable inequities in opioid prescribing based on patient race, ethnicity, and language status for those admitted to inpatient internal medicine services across all conditions and in the subcohorts of the six most frequent hospital conditions and three pain-associated conditions. This represents an institutional and societal opportunity for quality improvement initiatives to promote equitable pain management.

Visit and Between-Visit Interaction Frequency Before and After COVID-19 Telehealth Implementation

Telehealth implementation associated with the COVID-19 public health emergency (PHE) affected patient-clinical team interactions in numerous ways. Yet, studies have narrowly examined billed patient-clinician visits rather than including visits with other team members (eg, pharmacists) or between-visit interactions. To evaluate rates of change over time in visits (in-person, telehealth) and between-visit interactions (telephone calls, patient portal messages) overall and by key patient characteristics. This retrospective cohort study included adults with diabetes receiving primary care at urban academic (University of California San Francisco [UCSF]) and safety-net (San Francisco Health Network [SFHN]) health care systems. Encounters from April 2019 to March 2021 were analyzed. Telehealth implementation over 3 periods: pre-PHE (April 2019 to March 2020), strict shelter-in-place (April to June 2020), and hybrid-PHE (July 2020 to March 2021). The main outcomes were rates of change in monthly mean number of total encounters, visits with any health care team member, visits with billing clinicians, and between-visit interactions. Key patient-level characteristics were age, race and ethnicity, language, and neighborhood socioeconomic status (nSES). Of 15 148 patients (4976 UCSF; 8975 SFHN) included, 2464 (16%) were 75 years or older, 7734 (51%) were female patients, 9823 (65%) self-identified as racially or ethnically minoritized, 6223 (41%) had a non-English language preference, and 4618 (31%) lived in the lowest nSES quintile. After accounting for changes to care delivery through an interrupted time-series analysis, total encounters increased in the hybrid-PHE period (UCSF: 2.3% per patient/mo; 95% CI, 1.6%-2.9% per patient/mo; SFHN: 1.8% per patient/mo, 95% CI, 1.3%-2.2% per patient/mo), associated primarily with growth in between-visit interactions (UCSF: 3.1% per patient/mo, 95% CI, 2.3%-3.8% per patient/mo; SFHN: 2.9% per patient/mo, 95% CI, 2.3%-3.4% per patient/mo). In contrast, rates of visits were stable during the hybrid-PHE period. Although there were fewer differences in visit use by key patient-level characteristics during the hybrid-PHE period, pre-PHE differences in between-visit interactions persisted during the hybrid-PHE period at SFHN. Asian and Chinese-speaking patients at SFHN had fewer monthly mean between-visit interactions compared with White patients (0.46 [95% CI, 0.42-0.50] vs 0.59 [95% CI, 0.53-0.66] between-visit interactions/patient/mo; P < .001) and English-speaking patients (0.52 [95% CI, 0.47-0.58] vs 0.61 [95% CI, 0.56-0.66] between-visit interactions/patient/mo; P = .03). In this study, pre-PHE growth in overall patient-clinician encounters persisted after PHE-related telehealth implementation, driven in both periods by between-visit interactions. Differential utilization based on patient characteristics was observed, which may indicate disparities. The implications for health care team workload and patient outcomes are unknown, particularly regarding between-visit interactions. Therefore, to comprehensively understand care utilization for patients with chronic diseases, research should expand beyond billed visits.

Patient and family perceptions of a discharge bedside board

ObjectiveTo explore patient and family perspectives of a discharge bedside board for supporting engagement in patient care and discharge planning to inform tool revision. MethodsThis qualitative descriptive study included 45 semi-structured interviews with a purposeful sample of English-speaking patients (n = 44; mean age 58.5 years) and their family members (n = 5) across seven adult inpatient units at a tertiary acute care hospital in mid-western Canada. Thematic (interviews), content (board, organization procedure document), and framework-guided integrated (all data) analyses were performed. ResultsFour themes were generated from interview data: understanding the board, included essential information to guide care, balancing information on the board, and maintaining a sense of connection. Despite application inconsistencies, documented standard procedures aligned with recommended board (re)orientation, timely patient-friendly content, attention to privacy, and patient-provider engagement strategies. ConclusionFindings indicate the tool supported consultation and some involvement level engagement in patient care and discharge. Board information was usually valued, however, perceived procedural gaps in tool education, privacy, and the quality of tool-related communication offer opportunities to strengthen patients' and families' tool experience. InnovationNovel application of a continuum engagement framework in the exploration of multiple data sources generated significant insights to guide tool revision.

Frequency and nature of discussing social influences on health in urban safety-net clinics: A qualitative analysis

ObjectiveChronic social isolation is a risk factor for all-cause mortality and disease progression, but is not routinely screened for in clinical settings. This study analyzed provider-patient communication patterns about social influences during primary care encounters, to identify opportunities to screen for objective or perceived social isolation. MethodsContent analysis was conducted on transcripts of 97 audiotaped, English-speaking patient encounters with 27 primary care providers at 3 safety-net primary care centers in New York City. Conversations were first coded for specific social isolation screening, then more broadly to quantify and qualify how social influences were discussed in relation to health. ResultsTranscripts included no explicit examples of social isolation screening. Social influences on health were discussed meaningfully in only 28 % of transcripts, compared to medication adherence (93 %) and diet (64 %). Patients initiated conversations about social influences on health twice as often as providers, however providers did not acknowledge 67% of these prompts. ConclusionSocial influences on health, including social isolation, were uncommonly discussed in this sample of primary care visits. When social influences were discussed meaningfully, providers utilized relationship-centered communication strategies. Practice implicationsStrategic conversations about social influences, even when brief and informal, can effectively screen patients for social isolation.

Hidden Disparities: How Language Influences Patients' Access to Cancer Care.

Patients with limited English proficiency, a vulnerable patient population, remain understudied in the literature addressing cancer disparities. Although it is well documented that language discordance between patients and physicians negatively impacts the quality of patient care, little is known about how patients' preferred spoken language impacts their access to cancer care. Between November 2021 and June 2022, we conducted an audit study of 144 hospitals located across 12 demographically diverse states. Using a standardized script, trained investigators assigned to the roles of English-speaking, Spanish-speaking, and Mandarin-speaking patients called the hospital general information telephone line seeking to access care for 3 cancer types that disproportionately impact Hispanic and Asian populations (colon, lung, and thyroid cancer). Primary outcome was whether the simulated patient caller was provided with the next steps to access cancer care, defined as clinic number or clinic transfer. We used chi-square tests and logistic regression analysis to test for associations between the primary outcome and language type, region type, hospital teaching status, and cancer care requested. We used multivariable logistic regression analysis to determine factors associated with simulated patient callers being provided the next steps. Of the 1,296 calls, 52.9% (n=686) resulted in simulated patient callers being provided next steps to access cancer care. Simulated non-English-speaking (vs English-speaking) patient callers were less likely to be provided with the next steps (Mandarin, 27.5%; Spanish, 37.7%; English, 93.5%; P<.001). Multivariable logistic regression found significant associations of the primary outcome with language spoken (Mandarin: odds ratio [OR], 0.02 [95% CI, 0.01-0.04] and Spanish: OR, 0.04 [95% CI, 0.02-0.06] vs English) and hospital teaching status (nonteaching: OR, 0.43 [95% CI, 0.32-0.56] vs teaching). Linguistic disparities exist in access to cancer care for non-English-speaking patients, emphasizing the need for focused interventions to mitigate systems-level communication barriers.

Integration of Palliative Care in Hematopoietic Cell Transplant: Pediatric Patient and Parent Needs and Attitudes.

Early integration of palliative care (PC) in hematopoietic cell transplantation (HCT) has demonstrated benefits, yet barriers remain, including perceived lack of patient/caregiver receptivity despite no data on attitudes toward PC and limited patient/caregiver reported outcomes in pediatric HCT. This study aimed to evaluate perceived symptom burden and patient/parent attitudes toward early PC integration in pediatric HCT. Following IRB approval, consent/assent, eligible participants were surveyed at St. Jude Children's Research Hospital including English-speaking patients aged 10-17, 1-month to 1-year from HCT, and their parents/primary-caregivers, as well as parent/primary-caregivers of living HCT recipients <age-10. Data were assessed for trends in response content frequencies, percentages, and associations. Eighty one participants, within one year of HCT, at St. Jude Children's Research Hospital were enrolled including: 36 parents of patients<age-10, 24 parents of patients ≥age-10, and 21 patients≥age-10. Most (65%) were 1-3 months from HCT. Analysis revealed high levels of perceived symptom suffering in the first month of HCT. 85.7% of patients and 73.4% of parents expressed that a-great-deal/a-lot of attention should be paid to quality-of-life from the start of HCT. Most respondents (patients-52.4/parents-50%) indicated they would likely have wanted early PC consult and very few (0%-patients/3.3%-parents) reported definite opposition to early PC involvement in HCT. Our findings suggest that patient/family receptivity should not be a barrier to early PC in pediatric HCT; obtaining patient reported outcomes is a priority in the setting of high symptom burden; and robust quality-of-life directed care with early PC integration is both indicated and acceptable to patients/caregivers.

Limited health literacy in shoulder and elbow patients

Background The aim of this study was to evaluate health literacy in orthopedic shoulder and elbow patients. Methods This retrospective cross-sectional study included all new English-speaking adult patients presenting to two fellowship-trained shoulder and elbow surgeons from October 2020–July 2021. Patients who did not complete the Brief Health Literacy Screen Tool (BRIEF) were excluded, leaving 594 patients. Patient demographics and patient-reported outcome scores were also collected. Results Average BRIEF score was 18.7 (range, 4–20), with limited health literacy (BRIEF &lt;17) in 84 patients (14.1%). Patients with limited health literacy were significantly older (58 ± 18 vs. 54 ± 15 years, p = 0.03), less likely to be employed (34 [40%] vs. 332 [65%], p &lt; 0.001), and less likely to have private insurance (35 [42%] vs. 330 [65%], p &lt; 0.001). Average area deprivation index percentile was significantly higher (more deprivation) with limited (38 ± 20) compared to adequate health literacy (32 ± 21; p = 0.027). PROMIS physical (40.5 ± 8.5 vs. 45.5 ± 7.6, p = 0.001) and mental health scores (46.9 ± 10.5 vs. 51.0 ± 8.6, p = 0.015) and pain visual analog scale scores (5.3 ± 2.9 vs. 4.6 ± 2.7, p = 0.017) were significantly worse with limited health literacy. Discussion Limited health literacy is present in shoulder and elbow patients and may affect patient-reported outcomes. Surgeons must recognize this in order to provide high-level equitable care. Level of evidence Level III, retrospective cohort.