Care Enrollment Research Articles

Process Evaluation of Services for HIV-Infected Post-Partum Women and HIV-Exposed Infants in Primary Health Care Blantyre Malawi.

HIV testing among HIV-exposed infants (HEI) in Malawi is below global targets and, affected by low utilisation of health services after birth. We conducted a mixed methods evaluation of the implementation of services for early infant diagnosis (EID) of HIV against national guidelines in Blantyre, Malawi, to inform the development of strategies to improve EID services uptake. We estimated coverage of HEI enrolment in HIV care and HIV testing at 6 weeks through a retrospective data review. We qualitatively explored implementation gaps in EID services through process mapping of 8 mother-infant pairs (MIP); and investigated healthcare workers' (HCW) perspectives on the implementation gaps through group interviews with 16 HCWs. We analysed the quantitative data descriptively and conducted a thematic content analysis of qualitative data. Of 163 HEIs born at the study sites, 39 (24%) were enrolled in an HIV care clinic before post-natal discharge, and 85 (52%) received HIV testing by 6 weeks. The median time for MIP to receive EID services was 4 (1-8) hours. The implementation gaps observed during process mapping included: failure to identify and enrol HEI in HIV care clinic; lack of immunisation, counselling for HEI testing, HIV testing, drug refilling, and family planning; and different appointment dates for mother and infant. HCWs reported delays and gaps influencing optimal service provision including: lack of screening to identify MIP, limited supervision for student HCWs when providing services, inadequate capacity of point of care machines, challenges with integrating services, and role confusion. Use of unique identifiers for MIP and establishing a booking system to schedule appointments to suit point of care machine capacity were primary service improvement recommendations. This study identified suboptimal EID services in Malawi due to process, capacity, and system factors. Context-appropriate interventions accommodating systems thinking are needed to enhance service provision.

Pregnancy in girls under 14 years old: Spatial analysis in Brazil, 2011-2021.

The objective was to analyze the spatial distribution of pregnancy in children under 14 years and six months by Brazilian region and municipality and sociodemographic and health characteristics of pregnant women and live births. Ecological study analyzing the Live Birth Information System (SINASC) from 2011 to 2021 in three age groups (< 14 years and six months, 15-19 years, and 20 years and above) by demographic and birth variables. We applied the Global and Local Moran. A total of 127,022 live births to girls aged 10-14 years were identified during the period, most of whom were Black, 21.1% in common-law or married relationships, with a lower proportion of seven prenatal care appointments and enrollment in the first trimester, a higher proportion of low birth weight and low Apgar score, residing in the North and Northeast. The mean live birth rate for 10-to-14-year-old girls was significantly autocorrelated with space, especially in municipalities of the Midwest and North. Pregnancy from 10 to 14 years of age reveals several vulnerabilities suffered by these girls due to pregnancy at an early age, which is more common among Black women, with implications for morbimortality for them and their children and the presumed violence in these cases, including denied access to legal abortion.

Gravidez em meninas menores de 14 anos: análise espacial no Brasil, 2011 a 2021

Abstract The objective was to analyze the spatial distribution of pregnancy in children under 14 years and six months by Brazilian region and municipality and sociodemographic and health characteristics of pregnant women and live births. Ecological study analyzing the Live Birth Information System (SINASC) from 2011 to 2021 in three age groups (&lt; 14 years and six months, 15-19 years, and 20 years and above) by demographic and birth variables. We applied the Global and Local Moran. A total of 127,022 live births to girls aged 10-14 years were identified during the period, most of whom were Black, 21.1% in common-law or married relationships, with a lower proportion of seven prenatal care appointments and enrollment in the first trimester, a higher proportion of low birth weight and low Apgar score, residing in the North and Northeast. The mean live birth rate for 10-to-14-year-old girls was significantly autocorrelated with space, especially in municipalities of the Midwest and North. Pregnancy from 10 to 14 years of age reveals several vulnerabilities suffered by these girls due to pregnancy at an early age, which is more common among Black women, with implications for morbimortality for them and their children and the presumed violence in these cases, including denied access to legal abortion.

Application Barriers and the Socioeconomic Gap in Child Care Enrollment

Application Barriers and the Socioeconomic Gap in Child Care Enrollment

Restructuring Healthcare Financing to Enable Effective Integrated Care and Population Health

Singapore faces an aging population and spiraling healthcare costs. To address these challenges, Healthier SG will launch in 2023 to shift towards a population health approach to care for Singaporeans, to keep them healthy, and prevent or slow down disease progression. Residents will be encouraged to enrol with a primary care physician and take on an upstream preventive approach to healthcare. Delivery systems must focus on integrated care. In addition, there is a need to bend the rate of growth of cost curve. NHG, as one of the three public healthcare clusters, will take on the role of a “Population Health Manager” responsible for the health outcomes of 1.5M population assigned.&#x0D; Who is it for? Policy makers, health sector decision makers, health managers, health authorities, health and social care professionals, researchers, academia, health experts, and the staff working on implementation of integrated care, healthcare finance professionals&#x0D; Who did you involve and engage with? Singapore Ministry of Health officials, Chief financial officers of hospitals, healthcare professionals, and clinicians (both specialist and primary care physicians) and community care partners.&#x0D; What did you do? NHG restructured itself organisationally to form an Accountable Care Organisation (ACO). The Health Ministry would be providing funding for subsidised care in the form of capitation funding per assigned resident per year (as opposed to the predominant fee for service funding currently) and additional funding for preventive care and health screening. NHG will aggregate the funds to design payment models that cut across different care setting to integrate care delivery. Incentive payments tied to performance outcomes and indicators will be established. Providers will also part-take in shared savings. NHG will also serve as a network of providers to join up care delivery, with focus on primary and preventive care.&#x0D; What results did you get? What impact did you have?We are in the stages of planning and design. The results we hope to achieve are for residents to enrol with a single primary care provider who will be partnering NHG to oversee the end to end care of the enrolled residents. Some of the indicators to be monitored measure resource allocation, resident enrolment rate, primary care physician enrolment rate with NHG, avoidable ED and hospitalisation rates and total subsidised healthcare cost per resident.&#x0D; What is the learning for the international audience? The learnings to share are the importance of engagement of leadership across the ecosystems, appropriate funding and resource allocation based on care needs of the population, setting up of enablers, including IT and data exchange, use of incentives to prompt behaviour changes, and the need for change management to get buy-in.&#x0D; What are the next steps? NHG will be rolling out key activities in the areas of primary care enrolment, designing the financing framework for payment and sharing of incentives with the providers, and is also in the midst of implementing key IT system enablers.

The enrolment gap and the COVID-19 pandemic: an exploration of routinely collected primary care enrolment data from 2016 to 2023 in Aotearoa New Zealand.

Introduction For many countries, primary health care (PHC) serves as the gateway for individuals to access healthcare services. It has been shown to not only improve health but also health equity. To maximise this benefit, a substantial proportion of the population needs to be connected with PHC. The aim here was to assess the degree and evolution of enrolment in light of the coronavirus disease 2019 (COVID-19) pandemic in Aotearoa New Zealand. Methods We examined data on the enrolment of people in PHC organisations between 2016 and 2023. This analysis included breakdowns by sex, age groups, ethnicity, and socioeconomic deprivation levels. Poisson regression models were used to explore whether enrolment changed because of the COVID-19 pandemic. Results In 2016, Māori, young people and the most deprived had lower enrolment rates relative to their peers. Although young people's enrolment rate increased over time, especially during the COVID-19 pandemic, the Māori enrolment rate declined, as did the rate for Pacific people, and those who were the most deprived. The groups who had increases in enrolment rates were those with the lowest levels of socioeconomic deprivation and those in the 'Other' ethnic category, predominantly made up of European New Zealanders. Conclusion Enrolment statistics reveal disparities across sociodemographic lines. The COVID-19 pandemic was associated with changed patterns of enrolment that appear to have consequences for population health.

Effects of Primary Care-Led, Integrated Palliative Care for Medicare Patients in a Value-Based Model

ContextFaced with a projected shortage of specialized palliative care physicians, scalable palliative solutions are required to better meet the aging population's needs. ObjectivesTo determine whether a multi-site, primary care-led, integrated palliative care model improves clinical, utilization, and economic outcomes. MethodsPropensity score-matched comparison group formed from participants who were Medicare beneficiaries, died January 1, 2021–January 31, 2023, were patients of eight primary care practices that partner with agilon health, and enrolled in palliative care for at least seven days. Each practice operates in a value-based model, where primary care providers (PCPs) take on full-risk for the cost and quality of patient outcomes. Each program includes symptom management, defining goals of care/advance directives, PCP care coordination, and assistance with care transitions if patients enroll in hospice. ResultsFinal sample included 1778 decedents, with 889 in both enrolled and matched cohorts, average age 83. Palliative care is associated with improved patient outcomes from palliative care enrollment until death, including 5.4 more days at home (p < 0.001), 0.4 fewer hospitalizations (p < 0.001), 17% fewer deaths in a hospital (p < 0.001), and $10,393 lower overall healthcare costs (p < 0.001). ConclusionA primary care-led, integrated approach of delivering palliative care within a full-risk model can be an effective care delivery mechanism to meet the healthcare needs of an aging population by impacting patient outcomes and reducing avoidable utilization and cost at the end of life. These findings demonstrate that PCPs in a scaled, full-risk model can simultaneously improve care for patients while reducing costs to the healthcare system.

Transforming cancer clinical trials: The integral role of artificial intelligence in electronic health records for efficient patient recruitment

Healthcare is one of the sectors where artificial intelligence (AI) is currently viewed as a crucial driving factor. Patient care, medical research, and clinical trial enrollment could all significantly improve due to AI's incorporation into electronic health records (EHRs). This short communication highlights how AI may improve the recruitment process regarding speed, accuracy, and overall cancer clinical trial efficiency. AI can automate this procedure by utilizing machine learning (ML) algorithms, identifying potential trial participants quickly and precisely. Many challenges could be addressed due to this integration, including data privacy and security that can be resolved through cutting-edge encryption techniques and differential privacy algorithms that ensure data anonymization. Another significant obstacle is the lack of common EHR formats and interoperability that can be addressed by creating a standardized structured layout. Automating and improving recruitment processes with AI may speed up research, increase the effectiveness of clinical trials, and open the door to more specialized cancer treatments.

Assessing oncology patient interest in using telehealth for routine cancer care and clinical trials.

525 Background: Since the onset of COVID-19, oncology practices across the U.S. have integrated telemedicine (TM) and remote patient monitoring (RPM) into cancer care. However, the future role of telehealth in oncology remains unknown. We conducted a survey among a diverse group of oncology patients to assess their access to technology and interest in using TM/RPM as part of routine cancer care and clinical trials. Methods: Between March 27 and June 21, 2023, we administered in person surveys to oncology patients receiving cancer treatment at an academic cancer center in New York City. We collected respondent demographic and clinical data, as well as information about their access to technology and interest in using TM/RPM as part of cancer care. Results: There were 50 respondents with a mean age of 60 (SD 16). 62% identified as female, 22% were Hispanic of any race, 16% were non-Hispanic Black, and 48% were non-Hispanic White. 52% had a yearly income below $70,000 and 40% had less education than a bachelor’s degree. 34% had Medicare, 24% had Medicaid only, and 42% had commercial insurance. Regarding travel, 28% of respondents lived over an hour from the cancer center, and 39% paid &gt;$20 for travel each visit. The majority owned an electronic communication device (93%) and had internet access at home (98%). 80% had internet fast enough for video visits and 86% identified as comfortable using the internet. Prior to the survey, 66% of respondents had participated in a video visit and 59% had participated in a telephone visit with their oncologist. Of these patients, more than 95% were somewhat or very satisfied with their remote visit. If provided with internet, more than half of respondents were willing to participate in video visits (57%) and telephone visits (61%) as part of regular care. Convenience and eliminating travel were the most commonly cited reasons for preferring remote care. Regarding trial participation, 52% had previously enrolled in a cancer clinical trial and 67% reported openness to trial participation. If the risks and benefits of a trial were explained over the phone or in a video visit as opposed to in person, 73% of respondents reported they would be equally or more likely to enroll. If the risks and benefits had already been explained in person, 77% would be willing to sign consent electronically. A large majority (91%) would be equally or more likely to enroll in a clinical trial that reduced travel time by providing the option of remote visits. Similarly, 78% would be willing to use wearable technology and 80% would be willing to use a health app as part of a clinical trial. Conclusions: In this diverse and underprivileged group, patients have access to technology and are willing to use it for both routine cancer care and clinical trial enrollment and participation. In the future, oncology practices should incorporate remote technology into cancer care, including trials, to reduce travel time and enhance convenience.

Effects of the Time of Hospice and Palliative Care Enrollment before Death on Morphine, Length of Stay, and Healthcare Expense in Patients with Cancer in Taiwan.

We aimed to investigate the effects of the time from hospice and palliative care enrollment to death on the quality of care and the effectiveness and trend of healthcare utilization in patients with terminal cancer. Data on the cancer-related mortality rates between 2005 and 2018 reported in the National Health Insurance Research Database in Taiwan were obtained. The effect of hospice and palliative care enrollment at different timepoints before death on healthcare utilization was explored. This retrospective cohort study included 605,126 patients diagnosed with terminal cancer between 2005 and 2018; the percentage of patients receiving hospice and palliative care before death increased annually. Terminal cancer patients who enrolled in hospice and palliative care at different timepoints before death received higher total morphine doses; the difference in the total morphine doses between the two groups decreased as the time to death shortened. The difference in the total morphine doses between the groups gradually decreased from 2005 to 2018. The enrolled patients had longer hospital stays; the length of hospital stays for both groups increased as the time to death lengthened, but the difference was not significant. The enrolled patients incurred lower total medical expenses, but the difference between the two groups increased as the time to death shortened.

State-Level Variation in Medicaid Managed Care Enrollment and Specialty Care for Publicly Insured Children

Medicaid and Children's Health Insurance Program cover almost 50% of children with special health care needs (CSHCN). CSHCN often require specialty services and have been increasingly enrolled in Medicaid managed care (MMC) plans, but there is a dearth of recent national studies on specialty care access among publicly insured children and particularly CSHCN. To provide recent, nationwide evidence on the association of MMC penetration with specialty care access among publicly insured children, with a special focus on CSHCN. This cross-sectional study used nationally representative data from the 2016 to 2019 National Survey of Children's Health to identify publicly insured children in 41 states that administered comprehensive managed care organizations for Medicaid. Data analysis was performed from May 2022 to March 2023. Form CMS-416 data were used to measure state-year level share of Medicaid-enrolled children who were covered by MMC (ie, MMC penetration). Measures of specialty care access included whether, in the past year, the child had (1) any visit to non-mental health (MH) specialists, (2) any visit to MH professionals, and (3) any unmet health care needs and (4) whether the caregiver ever felt frustrated getting services for their child. Logistic regression models were used to examine the association of MMC penetration with specialty care access among all publicly insured children, and separately for CSHCN and non-CSHCN. Among 20 029 publicly insured children, 7164 (35.8%) were CSHCN, 9537 (48.2%) were female, 4110 (37.2%) were caregiver-reported Hispanic, and 2812 (21.4%) were caregiver-reported non-Hispanic Black (all percentages are weighted). MMC was not associated with significant changes in any visit to non-MH specialists and unmet health care needs. In addition, MMC penetration was positively associated with caregiver frustration among all children (adjusted odds ratio, 1.23; 95% CI, 1.03-1.48; P = .02) and was negatively associated with any visit to MH professionals among CSHCN (adjusted odds ratio, 0.75; 95% CI, 0.58-0.98; P = .04). In this cross-sectional study evaluating MMC and specialty care access for publicly insured children, increased MMC enrollment was not associated with improved specialty care access for publicly insured children, including CSHCN. MMC was associated with less access to specialties like MH and increased frustrations among caregivers seeking services for their children.

Incident Kaposi sarcoma during the expansion of antiretroviral therapy eligibility in Nigeria: a retrospective cohort study

IntroductionThe expansion of antiretroviral therapy (ART) eligibility could lead to earlier initiation of Human Immunodeficiency Virus (HIV) treatment and consequently reduce the risk of HIV-associated Kaposi Sarcoma (KS). We investigated the impact of changes in the Nigerian HIV treatment guidelines on KS incidence among adults enrolled in HIV care in Nigeria.MethodsWe analyzed data of adults who enrolled for HIV care from January 2006 to December 2016 at one of Nigeria’s largest HIV treatment centers. Based on changes in HIV treatment guidelines, we classified 2006–2009 as the pre-expansion period and 2010–2016 as the post-expansion period. We used Kaplan Meier curves to compare the incidence of KS in the pre-expansion to the post-expansion period. We used Cox regression models to assess the hazard for incident KS between the two periods after adjusting for potential confounders.ResultsAmong 14,479 patients with HIV, the overall KS incidence was 2.35; 95% CI 2.01–2.74/1,000 person-years. The incidence of KS decreased from 2.53 to 1.58 per 1,000 person-years from 2006 to 2009 to 2010–2016. In models adjusting for age, sex, CD4-T cell count, and ART use, the risk for KS remained lower in 2010–2016 compared to 2006–2009. In analyses restricted to time on ART, there was no significant difference in KS incidence between HIV patients who enrolled in 2006–2009 and 2010–2016 after adjusting for age, sex, and CD4 T-cell count.ConclusionThe expansion of ART eligibility was associated with a reduced incidence of HIV-associated KS among adults initiating HIV care in Jos, Nigeria. The reduction was likely driven by earlier enrollment for HIV care and ART initiation.

Home and preschool influences on early literacy and numeracy development in England, Estonia, and the United States

ABSTRACT This study considered the influences of socioeconomic status (SES), home learning environment, and age of enrollment in early childhood education and care (ECEC) on early literacy and numeracy development of 5-year-olds in England (N = 2,577), Estonia (N = 2,110), and the United States (N = 2,234) by leveraging data from the International Early Learning and Child Well-being Study (conducted by the Organization for Economic Cooperation and Development in 2018). Structural equation modeling indicated that, in all three countries, SES was positively associated with earlier ECEC enrollment, emergent literacy and numeracy. Earlier ECEC enrollment was positively related to emergent literacy and numeracy in England. The home learning environment was positively related to emergent literacy in the United States and emergent numeracy in England and the United States. Overall, SES had a positive indirect effect on emergent literacy and numeracy through ECEC enrollment age in England. Findings are interpreted against country-specific ECEC policies.

Transformation to a patient-centred medical home led and delivered by an urban Aboriginal and Torres Strait Islander community, and association with engagement and quality-of-care: quantitative findings from a pilot study

BackgroundThe patient-centred medical home (PCMH) is a model of team-based primary care that is patient-centred, coordinated, accessible, and focused on quality and safety. In response to substantial population growth and increasing demand on existing primary care services, the Institute for Urban Indigenous Health (IUIH) developed the IUIH System of Care-2 (ISoC2), based on an international Indigenous-led PCMH. ISoC2 was piloted at an urban Aboriginal and Torres Strait Islander Community-Controlled Health Service in South-East Queensland between 2019–2020, with further adaptations made to ensure its cultural and clinical relevance to local Aboriginal and Torres Strait Islander people. Little is known on the implementation and impact of PCMH in the Australian Indigenous primary care setting. Changes in implementation process measures and outcomes relating to engagement and quality-of-care are described here.MethodsDe-identified routinely collected data extracted from electronic health records for clients regularly attending the service were examined to assess pre-post implementation changes relevant to the study. Process measures included enrolment in PCMH team-based care, and outcome measures included engagement with the health service, continuity-of-care and clinical outcomes.ResultsThe number of regular clients within the health service increased from 1,186 pre implementation to 1,606 post implementation; representing a small decrease as a proportion of the services’ catchment population (38.5 to 37.6%). In clients assigned to a care team (60% by end 2020), care was more evenly distributed between providers, with an increased proportion of services provided by the Aboriginal and Torres Strait Islander Health Worker (16–17% versus 10–11%). Post-implementation, 41% of clients had continuity-of-care with their assigned care team, while total, preventive and chronic disease services were comparable pre- and post-implementation. Screening for absolute cardiovascular disease risk improved, although there were no changes in clinical outcomes.ConclusionsThe increase in the number of regular clients assigned to a team and their even distribution of care among care team members provides empirical evidence that the service is transforming to a PCMH. Despite a complex transformation process compounded by the COVID-19 pandemic, levels of service delivery and quality remained relatively stable, with some improvements in risk factor screening.

Choosing Veterans Affairs: Determinants of post-9/11 Veterans' enrollment in Veterans Affairs health care.

Following recent policy changes, younger Veterans have particularly increased options for where to receive their health care. Although existing research provides some understanding of non-modifiable individual (e.g., age) and external community (e.g., non-VA provider supply) factors that influence VA enrollment, this study focused on modifiable facility access and quality factors that could influence Veterans' decisions to enroll in VA. In this cohort study, we examined enrollment in and use of VA services in the year following military separation as the binary outcome using mixed-effects logistic regressions, stratified by Active and Reserve Components. This study included 260,777 Active and 101,572 Reserve Component post-9/11 Veterans separated from the military in fiscal years 2016 to 2017. Independent variables included 4 access measures for timeliness of VA care and 3 VA quality measures, which are included in VA Medical Centers' performance plans. Eligible Veterans were more likely to enroll in VA when the closest VA had higher quality scores. After accounting for timeliness of VA care and non-modifiable characteristics, rating of primary care (PC) providers was associated with higher VA enrollment for Active Component (odds ratio [OR] = 1.014, 95% confidence interval [CI]: 1.007-1.020). Higher mental health (MH) continuity (OR = 1.039, 95% CI: 1.000-1.078) and rating of PC providers (OR = 1.009, 95% CI: 1.000-1.017) were associated with higher VA enrollment for Reserve Component. Improving facility-specific quality of care may be a way to increase VA enrollment. In a changing policy environment, study results will help VA leadership target changes they can make to manage enrollment of Veterans in VA and deliver needed foundational services.

Alcohol use and the longitudinal HIV care continuum for people with HIV who enrolled in care between 2011 and 2019

PurposeWe described the impact of alcohol use on longitudinal engagement in HIV care including loss to follow-up, durability of viral suppression, and death. MethodsWe followed a cohort of 1781 people with HIV from enrolled in care at one of seven US clinics, 2011–2019 through 102 months. We used a multistate, time-varying Markov process and restricted mean time to summarize engagement in HIV care over follow-up according to baseline self-reported alcohol use (none, moderate, or unhealthy). ResultsOur sample (86% male, 54% White) had median age of 35 years. Over 102 months, people with no, moderate, and unhealthy alcohol use averaged 62.3, 61.1, and 59.5 months virally suppressed, respectively. People who reported unhealthy or moderate alcohol use spent 5.1 (95% confidence intervals (CI): 0.8, 9.3) and 7.6 (95%CI: 3.1, 11.7) more months lost to care than nondrinkers. Compared to no use, unhealthy alcohol use was associated with 3.4 (95%CI: −5.6, −1.6) fewer months in care, not virally suppressed. There were no statistically significant differences after adjustment for demographic and clinical characteristics. ConclusionsModerate or unhealthy drinking at enrollment in HIV care was associated with poor retention in care. Alcohol use was not associated with time spent virally suppressed.

Effect of the "universal test and treat" policy on the characteristics of persons registering for HIV care and initiating antiretroviral therapy in Uganda.

We examined the effect of the Universal Test and Treat (UTT) policy on the characteristics of people living with HIV (PLHIV) at enrolment in HIV care and initiation of antiretroviral therapy (ART) in Uganda using data from 11 nationally representative clinics of The AIDS Support Organisation (TASO). We created two retrospective PLHIV cohorts: pre-UTT (2004-2016), where ART initiation was conditional on CD4 cell count and UTT (2017-2022), where ART was initiated regardless of World Health Organisation (WHO) clinical stage or CD4 cell count. We used a two-sample test of proportions and Wilcoxon rank-sum test to compare proportions and medians, respectively, between the cohorts. A total of 244,693 PLHIV were enrolled at the clinics [pre-UTT, 210,251 (85.9%); UTT, 34,442 (14.1%)]. Compared to the pre-UTT cohort, the UTT cohort had higher proportions of PLHIV that were male (p < 0.001), aged 18-29 years (p < 0.001), aged >69 years, never married (p < 0.001), and educated to primary (p < 0.001) and post-primary (p < 0.001) school level at enrolment in HIV care and ART initiation. Overall, 97.9% of UTT PLHIV initiated ART compared to 45.2% under pre-UTT. The median time from enrolment in HIV care to ART initiation decreased from 301 [interquartile range (IQR): 58-878] pre-UTT to 0 (IQR: 0-0) under UTT. The median CD4 count at ART initiation increased from 254 cells/μL pre-UTT to 482 cells/μL under UTT (p < 0.001). Compared to the pre-UTT cohort, the UTT cohort had higher proportions of PLHIV with a CD4 count >500 cells/μL (47.3% vs. 13.2%, p < 0.001) and WHO stage 1 (31.7% vs. 4.5%, p < 0.001) at ART initiation. Adoption of the UTT policy in Uganda was successful in enrolling previously unreached individuals, such as men and younger and older adults, as well as those with less advanced HIV disease. Future research will investigate the effect of UTT on long-term outcomes such as retention in care, HIV viral suppression, morbidity, and mortality.

An area-based description of closed books in general practices in Aotearoa New Zealand.

Introduction In Aotearoa New Zealand, patients can enrol in a general practice for their primary health care. When a general practice no longer enrols new patients this is known as 'closed books'. We examined which District Health Board (DHB) districts were most affected and what characteristics of general practices and DHB districts were associated with closed books. Methods Maps were used to display the distribution of closed books general practices. Linear regression and logistic regression were used to look at the association between DHB or general practice characteristics and closed books. Results There were 347 (33%) general practices that had closed books in June 2022. Canterbury DHB (n = 45) and Southern DHB (n = 32) had the greatest number of closed books general practices, while Wairarapa DHB (86%), Midcentral DHB (81%) and Taranaki DHB (81%) had the greatest percentage. Consultation fees (P Conclusion The problem of closed books is felt across the country but has a larger impact in the middle-lower North Island. This influences access to primary health care enrolment for patients in terms of travel distance, time, and cost. Consultation fees were strongly associated with closed books. This suggests there may be an income threshold above which general practices can afford to close their books if they reach capacity.

Concurrent hospice healthcare utilization in the hematology/oncology patient population at veterans affairs.

12125 Background: The benefits of early hospice enrollment include improved quality of life and overall survival (Kumar, 2017). Yet, most oncology patients continue to receive aggressive treatments including chemotherapy, radiation therapy, and hospitalizations until close to death (Ersek, 2017). Veterans have the unique opportunity to receive concurrent hospice which allows patients enrolled in hospice to receive disease modifying treatments and other interventions not typically provided under the traditional Medicare hospice benefit. Methods: A single institution retrospective review of 72 hematology and oncology patients who enrolled in the concurrent care program at the Hines VA between 12/28/2018-4/3/2021 was conducted. Patients were eligible for the concurrent care program if they (1) had a life-limiting illness with a prognosis of less than six months (2) were willing to enroll in hospice (3) had an oncologist willing to administer cancer-directed therapy. Data were summarized with descriptive statistics including medians and percentages. Results: Patients in the concurrent care hospice program were predominantly White (69.4%) and older than 70 years of age (63.9%). Most patients were diagnosed with primary gastrointestinal (29.2%), thoracic (22.2%), or genitourinary (19.4%) malignancies. While enrolled in concurrent care hospice, 15.3% of patients visited the emergency department and 45.8% had at least one hospitalization. Few patients received cytotoxic chemotherapy (27.8%), immunotherapy (20.8%), palliative radiation (20.8%), or pain procedures (4.2%) while enrolled in concurrent care hospice. Of the 19 patients who received chemotherapy, only one patient received treatment within 7 days prior to death. The minority of patients (11.1%) received a blood product and of those patients that did, 8.3% required one to three transfusions and 2.8% required three or more transfusions. Most (91.7%) patients died while in concurrent care hospice; 21.2% died within 30 days of enrollment and 56.1% died within 31 to 180 days of enrollment. Patients were more likely to die at home (63.6%) or in inpatient hospice (13.6%) as opposed to the hospital (3%). Conclusions: Enrollment in concurrent hospice care prevents patients from having to choose between comfort care and cancer-directed treatments, which is often a barrier to early hospice enrollment (Salz, 2009). At Hines VA, most patients receiving concurrent hospice care rarely or never utilized cancer directed treatments, pain procedures, blood products, or emergency room visits/hospitalizations despite having access to these resources. Furthermore, the majority of patients died with hospice-style care at home or in inpatient hospice rather than in the hospital. This observational study demonstrates that when offered the choice to pursue cancer-directed treatments, most patients opt instead to focus on comfort care at end of life.

Toxicity profile, palliative care and hospice utilization of geriatric patients with hepatocellular carcinoma treated with atezolizumab plus bevacizumab in the veteran health administration.

e24022 Background: Over the last decade, the incidence of Hepatocellular carcinoma (HCC) has increased in the geriatric population. Atezolizumab plus Bevacizumab (A+B) has become an established systemic therapy for patients with HCC. Even with the aging population and elevated prevalence of HCC amongst Veterans, limited studies have explored the safety of A+B in geriatric patients. This study aims to investigate the toxicity profile of A+B in the geriatric population as well as Palliative Care and Hospice utilization within the Veteran Health Administration (VHA). Methods: Data were extracted from the electronic medical records (EMR) for adults (deceased and living) with ICD9 and ICD10 HCC codes that received 1st line systemic therapy with A+B within the VHA between December 1, 2019, and March 1, 2023. Descriptive statistics were used to summarize baseline characteristics, toxicity profile and Palliative Care and Hospice enrollment between 3 populations aged &lt; 65, 65-69, and &gt; 70 years. A significant p-value of ≤0.05 was used. Results: In total, 332 patients were included in the study; 206 were deceased. Approximately 70% of patients were &gt; 65 years. The majority in each age group were non-Hispanic white males, ECOG ≥1, CPS class A and BCLC score of C. Veterans &gt; 70, significantly had less cirrhosis caused by viral hepatitis(p &lt; 0.0001) and no prior local therapy (p = 0.002). There was no significant difference in either median A+B doses, cessation of therapy due to toxicities or median reported toxicities of any grade, as reported in Table 1. Most common toxicities in all age groups were fatigue, decreased appetite, proteinuria and transaminitis. There was a significant difference in Hospice enrollment in deceased patients (p = 0.027), with Veterans &gt; 70 years more likely to enroll in Hospice. Conclusions: This is the first known study that reports geriatric advanced HCC patients with A+Z toxicities in VHA patients. This study demonstrates that A+Z can be used safely in geriatric patients. Further quality improvements projects need to be implemented to improve number and timing Hospice utilization.[Table: see text]