Care Enrollment Research Articles

The influence of center-based care on young children's gender development

Many U.S. children spend a significant amount of time in center-based care prior to entering preschool. Previous theory and research would suggest center-based care settings offer important opportunities for gender socialization as children here are surrounded by multiple sources of gender-typing information (e.g. peers, adults, toys and activities). The present longitudinal study examined whether center-based care enrollment status influences level and timing of children's gender-typed behaviors (same-gender friendships, play and appearance), and knowledge (self-categorization and stereotyping) between the ages of 2–5. Participants were children and their mothers of low-income, urban backgrounds (N = 232; African American, Mexican American, and Dominican American). Overall, children enrolled in center-based care at ages 2 and 3 showed higher gender-typing patterns than children enrolled later or not at all. Associations were strongest for same-gender-friendships and gender-typed play, domains that might affect children's subsequent engagement in and learning of certain tasks, skillsets, and activities.

Abstract C018: Racial disparities in health care utilization at the end of life among New Jersey Medicaid beneficiaries with advanced cancer

Abstract PURPOSE: Quality of cancer care experienced by Medicaid beneficiaries near the end-of-life (EOL) is not well understood. Measures endorsed by national organizations discourage aggressive EOL care and encourage timely referrals to hospice care. We sought to 1) assess the prevalence of aggressive EOL care and hospice enrollment for Medicaid beneficiaries with advanced cancer, and 2) determine whether racial/ethnic disparities exist in patterns of EOL care. METHODS: We used a New Jersey State Cancer Registry-Medicaid claims linked dataset to identify Medicaid beneficiaries (ages 21-64) diagnosed with stage IV breast and colorectal cancer from 2011-2015 and died by January 2016. We measured aggressive EOL care using the four measures: >1 hospitalization, >1 emergency department (ED), any intensive care unit (ICU) admission in the last 30 days before death; receipt of chemotherapy in the last 14 days before death; and a composite measure for “any aggressive care” using the four measures described. We measured hospice enrollment after diagnosis, and hospice enrollment in the last 3 days of life. We used descriptive statistics and multivariate logistic regression models to assess the relationship between race/ethnicity and outcome measures (i.e., rates of aggressive EOL care and hospice use). We adjusted for sex, age at diagnosis, year of diagnosis, length of survival, cancer type, comorbidities, and Medicaid managed care status. RESULTS: We identified 349 patients diagnosed with stage IV breast and colorectal cancer. More than half (56%) identified as a racial/ethnic minority, including 33% Non-Hispanic (NH) Blacks, 18% Hispanics, and 5% NH-Asian Pacific Islanders. Nearly two-thirds of patients (62%) received at least one measure of aggressive EOL care. Almost one-third had >1 hospitalization (27%), >1 ED visit (31%), or were admitted to the ICU (30%) in the last 30 days of life; or received chemotherapy (34%) in the last 14 days of life. Compared to NH-Whites, NH-Blacks had higher odds of receiving any aggressive EOL care (aOR 1.87, 95% CI: 1.08-3.26), >1 hospitalization (aOR 1.98, 95% CI: 1.13-3.47), and >1 ED visit (aOR 1.79, 95% CI: 1.05-3.06), after adjusting for other demographic and tumor characteristics. Among all patients, only 39% of patients enrolled in hospice, while 14% enrolled in hospice in the last 3 days of life. No significant differences in hospice enrollment were observed by race/ethnicity in the multivariate models. CONCLUSION: The majority of Medicaid patients with advanced cancer received aggressive EOL care and did not enroll in hospice. Although all patients in our study were Medicaid beneficiaries, NH-Blacks were twice as likely to receive aggressive EOL care compared to NH-Whites. These racial/ethnic disparities suggest further work is warranted, particularly in larger datasets with greater numbers of diverse cancer patients, to understand the multilevel processes beyond socioeconomic or health insurance status, that lead to suboptimal EOL care. Citation Format: Annie W Yang, David Goldin, Jose Nova, Jyoti Malhotra, Joel Cantor, Jennifer Tsui. Racial disparities in health care utilization at the end of life among New Jersey Medicaid beneficiaries with advanced cancer [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C018.

School Branding and Student Enrolment in Private Secondary Schools in Iganga Municipality, Uganda

The study examined the relationship between school branding and student enrolment in private secondary schools in Iganga Municipality guided by three specific objectives seeking to examine the relationship between 1) school image 2) school culture and 3) customer care, and student enrolment in private secondary schools in Iganga Municipality. The study adopted a cross-sectional survey design with both quantitative and qualitative approaches. A sample of 100 student leaders, 3 head teachers and 33 academic heads of department was selected using simple random sampling and census inquiry respectively. Data collection was by use of a closed-ended Likert type questionnaire, interview guide and focus group discussion guide. Quantitative data was analysed using correlation and multiple regression as well as thematic content analysis for qualitative data. Pearson product-moment correlation coefficients obtained for the study hypotheses were positive and statistically significant; school image and student enrolment (r= .290, p <003), school culture and student enrolment (r= .462, p <0.000) and customer care and student enrolment (r= .358, p <0.000). Overall, school branding indicates a positive weak effect on student enrolment (R2 = .247, p <.000). It was concluded that school branding has a weak relationship with student enrolment. The study recommends piloting of strategies beforehand, improved information flow, government intervention in support of inclusive education, instituting a culture of strategic planning, improved responsiveness and creation of conducive learning climate. Further research is proposed on the same topic at national level as well as considering other factors influencing student enrolment since school branding only contributes 24.7%.

Child care center quality and early child development

A unique dataset on applications and admissions to child care centers allow us to explore parental preferences for child care center characteristics. We proceed to study how staff qualifications, experience and sickness absence, as well as the proportion of male and immigrant staff, explain the cognitive development of children randomly allocated to child care centers contingent on observable characteristics. Children who receive their first offer of child care enrollment from a center with a high share of male staff, perform better on language tests in their early school years. If the sickness absence is high in the center, child test scores are lower in both language and mathematics.

Pediatric HIV Care Cascade in Southern Mozambique: Missed Opportunities for Early ART and Re-engagement in Care.

There are 170,000 children living with HIV in 2017 in Mozambique. Scaling-up HIV care requires effective retention along the cascade. We sought to evaluate the pediatric cascade in HIV care at the Manhiça District Hospital. A prospective cohort of children <15 years was followed from enrollment in HIV care (January 2013 to December 2015) until December 2016. Loss to follow-up (LTFU) was defined as not attending the HIV hospital visits for ≥90 days following last visit attended. From the 438 children included {median age at enrollment in care of 3,6 [interquartile range (IQR): 1.1-8.6] years}, 335 (76%) were antiretroviral therapy (ART) eligible and among those, 263 (78%) started ART at enrollment in HIV care. A total of 362 children initiated ART during the study period and the incidence rate of LTFU at 12, 24, and 36 months post-ART initiation was 41 [95% confidence interval (CI): 34-50], 34 (95% CI: 29-41), and 31 (95% CI: 27-37) per 100 children-years, respectively. Median time to LTFU was 5.8 (IQR: 1.4-12.7) months. Children 5-9 years of age had a lower risk of LTFU compared with children <1 year [adjusted subhazard ratio 0.36 (95% CI: 0.20-0.61)]. Re-engagement in care (RIC) was observed in 25% of the LTFU children. The high LTFU found in this study highlights the special attention that should be given to younger children during the first 6 months post-ART initiation to prevent LTFU. Once LTFU, only a quarter of those children return to the health unit. Elucidating factors associated with RIC could help to fine tune interventions which promote RIC.

Expansion and scale-up of HIV care and treatment services in four countries over ten years.

BackgroundScale-up and expansion of antiretroviral therapy (ART) for people living with HIV (PLHIV) have been a global priority for more than 15 years.MethodsWe describe PLHIV at enrollment in care and ART initiation in Ethiopia, Kenya, Mozambique and Tanzania from 2005–2014 and report on enrollment location, CD4 count and loss to follow-up (LTF), death, and combined attrition (LTF and death) pre- and post-ART initiation over time. Pre-ART outcomes were estimated using competing risk and post-ART using Kaplan-Meier estimators; LTF defined as no visit within six months pre-ART and 12 months after ART start.ResultsFrom 2005–2014, 884,328 PLHIV enrolled in care at 350 health facilities, median age was 32.0 years (interquartile range [IQR] 26.0–42.0), and majority were female (66.5%). The proportion of PLHIV enrolled at primary and rural facilities increased from 12.9% and 15.3% in 2005–2006 to 43.5% and 41.7% in 2013–2014 (p<0.0001). Median CD4+ cell count at enrollment increased from 171 cell/mm3 in 2005–2006 (IQR 71–339) to 289 cell/mm3 in 2013–2014 (IQR 133–485) (p<0.0001). A total of 460,758 (57.4%) PLHIV initiated treatment. Cumulative risk of LTF for PLHIV prior to ART initiation 12 months after enrollment was 33.5% (95%CI 33.36–33.58) and 21.98% (95%CI 21.9–22.1) after ART initiation. Pregnant women and the youngest PLHIV group had the highest attrition after ART initiation, at 24 months 40.8% (95%CI 40.1–41.6) of pregnant women and 47.4% (95%CI 46.4–48.4) of PLHIV 15–19 years were not retained. Attrition at 12 months after enrollment among PLHIV regardless of ART status was 38.5% (95%CI 38.4–38.6).ConclusionOver 10 years of HIV scale-up in four sub-Saharan African countries, close to a million PLHIV were enrolled in care increasingly at rural and primary facilities with increasing CD4 count. Loss to follow-up from HIV care remains alarmingly high, particularly among pregnant women and younger PLHIV.

Racial Disparities in Health Care Utilization at the End of Life Among New Jersey Medicaid Beneficiaries With Advanced Cancer.

Racial and ethnic disparities in cancer care near the end of life (EOL) have been recognized, but EOL care experienced by Medicaid beneficiaries is not well understood. We assessed the prevalence of aggressive EOL care and hospice enrollment for Medicaid beneficiaries and determined whether racial and ethnic disparities exist. We identified Medicaid beneficiaries (age 21-64 years) who were diagnosed from 2011 to 2015 with stage IV breast and colorectal cancer and who died by January 2016 through a New Jersey State Cancer Registry-Medicaid claims linked data set. We measured aggressive EOL care (> 1 hospitalization, > 1 emergency department [ED] visit, any intensive care unit [ICU] admission in the last 30 days of life, and receipt of chemotherapy in the last 14 days of life) and hospice enrollment. Multivariable logistic regression models were used to determine factors associated with aggressive EOL care and hospice enrollment. Of the 349 patients, 217 (62%) received at least one of the following measures of aggressive EOL care: > 1 hospitalization (27%), > 1 ED visit (31%), ICU admission (30%), and chemotherapy (34%). The adjusted odds of receiving any aggressive care were 1.87 times higher (95% CI, 1.08 to 3.26) for non-Hispanic (NH) Black patients compared with NH White patients. Only 39% of patients enrolled in hospice. No significant differences in hospice enrollment were observed by race or ethnicity. The majority of Medicaid patients with advanced cancer received aggressive EOL care and were not enrolled in hospice. NH Black patients were more likely to receive aggressive EOL care. Further work to understand processes leading to suboptimal EOL care within Medicaid populations and among racial and ethnic minority groups is warranted.

HIV programmatic outcomes following implementation of the 'Treat-All' policy in a public sector setting in Eswatini: a prospective cohort study.

IntroductionThe Treat‐All policy – antiretroviral therapy (ART) initiation irrespective of CD4 cell criteria – increases access to treatment. Many ART programmes, however, reported increasing attrition and viral failure during treatment expansion, questioning the programmatic feasibility of Treat‐All in resource‐limited settings. We aimed to describe and compare programmatic outcomes between Treat‐All and standard of care (SOC) in the public sectors of Eswatini.MethodsThis is a prospective cohort study of ≥16‐year‐old HIV‐positive patients initiated on first‐line ART under Treat‐All and SOC in 18 health facilities of the Shiselweni region, from October 2014 to March 2016. SOC followed the CD4 350 and 500 cells/mm3 treatment eligibility thresholds. Kaplan‐Meier estimates were used to describe crude programmatic outcomes. Multivariate flexible parametric survival models were built to assess associations of time from ART initiation with the composite unfavourable outcome of all‐cause attrition and viral failure.ResultsOf the 3170 patients, 1888 (59.6%) initiated ART under Treat‐All at a median CD4 cell count of 329 (IQR 168 to 488) cells/mm3 compared with 292 (IQR 161 to 430) (p < 0.001) under SOC. Although crude programme retention at 36 months tended to be lower under Treat‐All (71%) than SOC (75%) (p = 0.002), it was similar in covariate‐adjusted analysis (adjusted hazard ratio [aHR] 1.06, 95% CI 0.91 to 1.23). The hazard of viral suppression was higher for Treat‐All (aHR 1.12, 95% CI 1.01 to 1.23), while the hazard of viral failure was comparable (Treat‐All: aHR 0.89, 95% CI 0.53 to 1.49). Among patients with advanced HIV disease (n = 1080), those under Treat‐All (aHR 1.13, 95% CI 0.88 to 1.44) had a similar risk of an composite unfavourable outcome to SOC. Factors increasing the risk of the composite unfavourable outcome under both interventions were aged 16 to 24 years, being unmarried, anaemia, ART initiation on the same day as HIV care enrolment and CD4 ≤ 100 cells/mm3. Under Treat‐All only, the risk of the unfavourable outcome was higher for pregnant women, WHO III/IV clinical stage and elevated creatinine.ConclusionsCompared to SOC, Treat‐All resulted in comparable retention, improved viral suppression and comparable composite outcomes of retention without viral failure.

Access to Elective Orthopaedic Surgery After the Affordable Care Act Medicaid Expansion: The New York State Experience.

As part of the Patient Protection and Affordable Care Act, states were given the option of expanding Medicaid coverage to include adults younger than age 65 years with income at or below 138% of the federal poverty level. Although this expansion was intended to provide health care coverage to an estimated 20 million Americans, several studies have shown increased coverage does not equate to increased access to care by specialty providers. We queried the New York Statewide Planning and Research Cooperative System database and identified all patients who underwent the 10 most common elective orthopaedic surgeries from January 1, 2012, through March 31, 2016. Medicaid monthly enrollment for the 4-year study period was obtained from NY Department of Health Medicaid Managed Care Enrollment Reports. Our query identified 700,159 patients who underwent the investigated orthopaedic surgeries. Of these, 60,786 were Medicaid recipients. During the 4-year study period, Medicaid enrollment and the number of procedures reimbursed by Medicaid increased significantly (P < 0.001 for both). Affordable Care Act-supported Medicaid expansion was associated with an increase in Medicaid enrollment and a concomitant increase in the utilization of orthopaedic surgery by Medicaid beneficiaries in New York State.

HIV-free survival among breastfed infants born to HIV-positive women in northern Uganda: a facility-based retrospective study.

Introductionthe HIV-free survival rate is the gold-standard measure of the effectiveness of interventions towards prevention of mother-to-child transmission of HIV in any setting. However, data on HIV-free survival among the HIV-exposed infants followed up in most low-resource settings are lacking. We determined the HIV-free survival among breastfed infants in two tertiary facilities in a resource-poor setting in northern Uganda.Methodswe conducted a retrospective cohort study in May 2019 and retrospectively reviewed records of HIV-exposed infants registered in 2014 through 2016 at two tertiary facilities in northern Uganda. We analyzed data using SPSS v16 software package. The chi-square and Student t-tests were used to compare factors among infant groups. Multivariate logistic regression analysis was used to determine factors independently associated with HIV-free survival. P-value <0.05 was considered for statistical significance.Resultsmajority of the infants were males 55.6% (203/365) and 98.6% (360/365) received nevirapine prophylaxis. A total of 345 (94.5%) infants were exclusively breastfed, only 100/345 (29.0%) of whom were exclusively breastfed for at least 6 months, while the breastfeeding status of 44/345 (12.8 %) infants could not be ascertained. The overall HIV-free survival rate was 93.7% (342/365), while 2.7% (10/365) were HIV-infected and 3.6% (13/365) died. Infants´ age at enrolment in care (aOR 5.20, p=0.008) and treatment facility (aOR 3.76, p=0.027) were the independent determinants of HIV-free survival.Conclusionthe HIV-free survival rate among the breastfed infants in the study setting marginally falls short of the recommended standard, thus calling for more efforts to improve survival.

HIV Care Cascade among Prisoners of the Mandalay Central Prison in Myanmar: 2011-2018.

Prisoners have a higher HIV prevalence and higher rates of attrition from care as compared with the general population. There is no published evidence on this issue from Myanmar. We assessed (1) HIV test uptake, HIV positivity, and enrollment in care among newly admitted prisoners between 2017 and 18 (2) Treatment outcomes among HIV-positive prisoners enrolled in care between 2011 and 18. This was a cohort study involving secondary analysis of program data. Among 26,767 prisoners admitted to the Mandalay Central Prison between 2017 and 2018, 10,421 (39%) were HIV-tested, 547 (5%) were HIV-positive, and 376 (69%) were enrolled in care. Among the 1288 HIV-positive prisoners enrolled in care between 2011 and 2018, 1178 (92%) were started on antiretroviral therapy. A total of 883 (69%) were transferred out (post-release) to other health facilities, and among these, only 369 (42%) reached their destination health facilities. The final outcomes (censored on 30 June 2019) included the following: (i) Alive and in care 495 (38%), (ii) death 138 (11%), (iii) loss to follow-up 596 (46%), and (iv) transferred out after reaching the health facilities 59 (5%). We found major gaps at every step of the HIV care cascade among prisoners, both inside and outside the prison. Future research should focus on understanding the reasons for these gaps and designing appropriate interventions to fill these gaps.

Temporal changes in ART initiation in adults with high CD4 counts in Latin America: a cohort study.

IntroductionIn 2013, the World Health Organization (WHO) recommended initiating combination ART (cART) in all adults with HIV and CD4+ lymphocyte counts (CD4) <500 cells/mm3. In 2015, this was updated to recommend cART initiation in all patients with HIV, regardless of CD4 count. Implementation of these guidelines in real‐world settings has not been evaluated in Latin America. To assess changes in time to cART initiation during routine care, we estimated trends in time from enrolment in care to cART initiation in HIV‐positive adults with high CD4 counts in the Caribbean, Central and South America network for HIV Epidemiology (CCASAnet) during 2003 to 2017.MethodsAll cART‐naive individuals ≥18 years of age from 2003 to 2017 with CD4 ≥350 cells/mm3 and without AIDS at enrolment at five CCASAnet sites (Brazil, Chile, Honduras, Mexico and Peru) were included. Patients without information regarding AIDS‐defining events were excluded. We estimated unadjusted median time from enrolment to cART initiation by calendar year using Kaplan‐Meier methods and calculated adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) for trends in cART initiation using Cox models and restricted cubic splines for continuous variables, accounting for age, sex, CD4 at enrolment, route of HIV transmission and clinic site.ResultsOf the 3171 patients included, 1,650 (52%) had CD4 ≥500 cells/mm3 at enrolment. Median time to cART initiation after 2013 was 6.21 weeks (interquartile range (IQR): 1.89, 23.21), and 4.71 weeks (IQR: 1.43, 9.57) after 2015. Among 763 (24%) patients who never initiated cART, 33 (4.3%) were reported as deceased, 481 (63%) were lost to follow‐up, and 249 (33%) were administratively censored before initiation. Adjusted probability of cART initiation greatly increased in recent years, in particular after 2013 and 2015 (2013 vs. 2003: HR = 7.14; 95% CI: 5.84 to 8.73, and 2015 vs. 2003: HR = 12.60; 95% CI: 10.37 to 15.32).ConclusionsTime to cART initiation decreased substantially, roughly following changes in WHO guidelines in this real‐world setting in Latin America. However, a very high proportion of patients never started cART, compromising retention in care and survival, as shown by their higher proportion of LTFU and death, which reinforce the notion that earlier treatment implementation strategies are needed.

Role of primary care enrolment in advanced cervical cancer diagnosis: a population-based case–control study

IntroductionThe elimination of cervical cancer will only be achievable through primary and secondary prevention. The aim of this study was to determine the effect of primary care enrolment on the...

Medicaid managed care enrollments and potentially preventable admissions: An analysis of adult Medicaid recipients in Florida

ABSTRACT This study examines the relationship between a managed care program and preventable hospitalization for Medicaid beneficiaries. Also, a theoretical framework of market competition is developed to examine the relationship between the Medicaid managed care market and preventable hospitalization for overall Medicaid patients across all Medicaid payer groups. The data of the study were 1,957,072 Medicaid patients aged 18–64 years who were discharged from a short-term general hospital in Florida from 2006 to 2012. We used two-level hierarchal models to predict the probability of preventable hospitalization. The results show that Medicaid managed care patients had a higher probability of preventable hospitalization than Medicaid fee-for-service patients. This study also found that market competition moderates the relationship between Medicaid insurance type and preventable hospitalization.

Evidence From a Multistate Cohort: Enrollment in Affordable Care Act Qualified Health Plans' Association With Viral Suppression.

BackgroundHealthcare delivery changes associated with viral suppression (VS) could contribute to the United States’ “Ending the HIV Epidemic” (EtHE) initiative. This study aims to determine whether Qualified Health Plans (QHPs) purchased by AIDS Drug Assistance Programs (ADAPs) are associated with VS for low-income people living with HIV (PLWH) across 3 states.MethodsA multistate cohort of ADAP clients eligible for ADAP-funded QHPs were studied (2014–2015). A log-binomial model was used to estimate the association of demographics and healthcare delivery factors with QHP enrollment prevalence and 1-year risk of VS. A number needed to treat/enroll (NNT) for 1 additional person to achieve viral suppression was calculated.ResultsOf the cohort (n = 7776), 52% enrolled in QHPs. QHP enrollment in 2015 was associated with QHP coverage in 2014 (adjusted PR [aPR], 3.28; 95% confidence intervals [CIs], 3.06–3.53) and engagement in care in 2014 (aPR, 1.16; 1.04–1.28). PLWH who were engaged in care (n = 4597) and had QHPs had a higher VS rate than those who received medications from Direct ADAP (86.0% vs 80.2%). QHPs’ NNT for an additional person to achieve VS is 20 (14.1–34.5). Starting undetectable (adjusted risk ratio [aRR], 1.39; 1.28–1.52) and enrolling in QHPs in 2015 (aRR, 1.06; 0.99–1.14) was associated with VS.ConclusionsOnce enrolled in ADAP-funded QHPs, ADAP clients stay enrolled. Enrollment is associated with VS across states/demographic groups. ADAPs, especially in the South and in Medicaid nonexpansion states, should consider investing in QHPs because increased enrollment could improve VS rates. This evidence-based intervention could be part of EtHE.

Exploring the Needs and Priorities of Black Patients with Lymphoma: A Qualitative Study

Background: Across lymphoma subtypes, disparities have been uncovered in age of onset, stage, treatment, and outcomes by socioeconomic status, insurance status, and race. For several lymphoma subtypes, Black patients present at a mean age approximately 10 years younger than White patients and have worse survival. Racial disparities in access to care and clinical trial enrollment have been described across cancers and contribute to these differences in survival. We sought to clarify patients' perceptions of the needs and priorities for care during diagnosis, treatment, and survivorship. Objective: We conducted qualitative research with Black lymphoma patients in order to determine their perceptions and understanding regarding treatment and research, barriers to care, and future research priorities. Methods: Semi-structured phone interviews were conducted with 12 Black patients with lymphoma who had received treatment in Georgia. Participants were recruited from patients who were previously agreed to be contacted about research when identified through the state cancer registry and a current research participant pool at a university research hospital in Atlanta, Georgia. Interviews were recorded and transcribed verbatim. MAXQDA software (version 18.0.8) was used for coding and identifying themes and grounded theory processes were used to generate codes. Thematic analysis will be used to generate further themes and create a constant-comparative coding process. Results: Emerging themes from this ongoing data collection include endurance, lack of information surrounding diagnosis, trust in medical staff, and willingness to participate in research. Several participants described their cancer journey as simply another hurdle to overcome. They did not consider the emotional toll of their diagnosis and instead focused on positivity, refusing to feel sorry for themselves. A lack of information during the process of care was the most significant barrier for patients. The majority of patients felt that they were not given enough information regarding their diagnosis, with some stating that they had never heard of lymphoma before they were diagnosed with it. Others felt that this lack of information continued into their treatment with some patients being unaware of their cancer status or not being informed about procedures before they occurred. This gap in information left participants feeling disconnected from their own treatment process and uninvolved in their care. Despite this, patients expressed great trust in medical staff. Nearly all participants stated that they trusted their doctor most in their clinical care team and were therefore more willing to proceed with treatments and procedures at their doctor's recommendation. Those with a weaker connection to their doctor and care team reported feeling less satisfied with their care experience. Patients were also very willing to participate in research. Most expressed interest to participate in order to help others that may be diagnosed in the future. Some stated specific factors that would deter them from enrolling in a study, with one participant referencing the Tuskegee Syphilis Study as her reason for avoiding drug trials. Participants expressed interest in a wide range of topics for future research, with several focused on the origins of lymphoma. These participants assumed that they may have been exposed to hazardous materials while serving in the military or through an environmental contaminant and wanted more knowledge in this area. Conclusions: These preliminary findings suggest that the Black population in Georgia has specific needs that are unaddressed by current scientific and medical communities. A lack of information leaves patients feeling uninvolved with their care and potentially disconnected from their care team. This study presents the opportunity for clinicians and research personnel to collaborate with patients to develop communication tools and strategies that keep this population informed during their treatment. Clinicians and medical providers can utilize these data to improve support for this population. Disclosures Flowers: TG Therapeutics: Research Funding; Karyopharm: Consultancy; Gilead: Consultancy, Research Funding; National Cancer Institute: Research Funding; BeiGene: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Denovo Biopharma: Consultancy; Genentech, Inc./F. Hoffmann-La Roche Ltd: Consultancy, Research Funding; Spectrum: Consultancy; Pharmacyclics/Janssen: Consultancy, Research Funding; AbbVie: Consultancy, Research Funding; Acerta: Research Funding; Bayer: Consultancy; V Foundation: Research Funding; AstraZeneca: Consultancy; Millenium/Takeda: Research Funding; Optimum Rx: Consultancy; Eastern Cooperative Oncology Group: Research Funding; Burroughs Wellcome Fund: Research Funding.

Adherence to Well-Child Care and Home Visiting Enrollment Associated with Increased Emergency Department Utilization.

Pediatric primary care and home visiting programs seek to reduce health disparities and promote coordinated health care use. It is unclear whether these services impact high-cost, emergency department (ED) utilization. We evaluated the association of well-child care (WCC) and home visiting with ED visit frequency for children < 1year with an established medical home. Retrospective cohort study using linked administrative data for infants ≥ 34weeks' gestation from 2010 to 2014, within a multisite, academic primary care system. Latent class analysis characterized longitudinal patterns of WCC. Multivariable negative binomial regression models tested the independent association between WCC patterns and home visiting enrollment with ED visits. Among 10,363 infants, three WCC latent classes were identified: "Adherent" (83.4% of the cohort), "Intermediate" (9.7%), and "Decreasing adherence" (7.0%). Sixty-one percent of the sample had ≥ 1 ED visit in the first 12months of life, and 73% of all ED visits were triaged as non-urgent. There was a significant interaction effect between WCC pattern and insurance status. Among Medicaid-insured infants, "Intermediate" and "Decreasing adherence" WCC patterns were associated with a lower incident rate of ED visits compared with the "Adherent" pattern (incident rate ratios (IRR) 0.88, p = 0.03 and 0.79, p < 0.001 respectively); this effect was not observed among privately-insured infants. Home visiting enrollment was independently associated with a higher rate of ED visits (IRR 1.24, p < 0.001). Among infants with an established medical home, adherence to recommended WCC and home visiting enrollment was associated with greater ED use for non-urgent conditions.

THE EXAMINATION OF DETERMINANTS AND BARRIERS TO END-OF-LIFE DECISION MAKING AND PLANNING

As individuals are living longer, in many cases with chronic diseases, there is an increased focus on end-of-life (EOL) planning and decision making. This includes a broad spectrum of choices including advance care planning (ACP) and turning to palliative care or hospice care. Although there has been an increase in palliative and hospice care enrollment and ACP engagement over the past decade, participation remains low for certain subgroups of the population. The purpose of this symposium is to offer insight into reasons for these varying rates of engagement by exploring determinants and barriers to EOL decision making and planning and by examining caregiver knowledge of EOL decision making and planning from the service provider perspective. The first three studies examine various types of influences in EOL decision making and planning. Inoue and colleagues explore factors associated with the length of hospice stay, and Gaines and colleagues examine the impact of environmental characteristics in ACP. Ornstein and colleagues use Denmark registry data to assess the role of kinlessness at the time of death in EOL decision making and healthcare utilization. The final presentation by Noh and colleagues examines how service providers in rural areas perceive community residents’ knowledge of ACP and palliative care. The discussion following these presentations will compare findings across different forms of EOL decision making and planning, consider the impact of the varying methodological approaches used, and highlight implications of these works for potential interventions and policies related to EOL decision making and planning.

Effectiveness of home hospice care: a nationwide prospective observational study.

Many assert the need for home hospice care. However, limited research has shown its effectiveness. The authors of this study thus evaluated the effectiveness of a home hospice care pilot project regarding (1) early enrollment in hospice care, (2) efficient use of inpatient hospice resources, and (3) enabling terminally ill patients to stay at their preferred place of care. The authors conducted a nationwide prospective observational study. Patients were divided into home hospice care users (ever-users, n = 902) and inpatient-only hospice care users (never-users, n = 8210). Information about hospice service utilization was collected from a web-based registry system. Patients were registered if they started to receive the hospice service after providing written informed consent during the pilot project from March 2016-July 2017. Most ever-users preferred to stay at home (84.0%), while never-users preferred hospital admission (66.9%). Most ever-users were enrolled in hospice by home care (78.9%) and used both home and inpatient care (72.4%). The overall duration of hospice care was significantly longer among ever-users than never-users (median 39 vs. 15 days, respectively; mean ± SD 59.6 ± 62.8 vs. 24.8 ± 32.1, respectively; p < .001). Participation in the pilot program improved bed utilization (p = .025) and turnover rate (p < .001) of inpatient hospice service. Home hospice care enabled early enrollment in hospice services and provided a valid option to patients who wished to stay at home. Policy efforts to facilitate home hospice care are needed.

Impact of Universal Antiretroviral Treatment Eligibility on Rapid Treatment Initiation Among Young Adolescents with Human Immunodeficiency Virus in Sub-Saharan Africa.

Young adolescents with perinatally acquired human immunodeficiency virus (HIV) are at risk for poor care outcomes. We examined whether universal antiretroviral treatment (ART) eligibility policies (Treat All) improved rapid ART initiation after care enrollment among 10-14-year-olds in 7 sub-Saharan African countries. Regression discontinuity analysis and data for 6912 patients aged 10-14-years were used to estimate changes in rapid ART initiation (within 30 days of care enrollment) after adoption of Treat All policies in 2 groups of countries: Uganda and Zambia (policy adopted in 2013) and Burundi, Democratic Republic of the Congo, Kenya, Malawi, and Rwanda (policy adopted in 2016). There were immediate increases in rapid ART initiation among young adolescents after national adoption of Treat All. Increases were greater in countries adopting the policy in 2016 than in those adopting it in 2013: 23.4 percentage points (pp) (95% confidence interval, 13.9-32.8) versus 11.2pp (2.5-19.9). However, the rate of increase in rapid ART initiation among 10-14-year-olds rose appreciably in countries with earlier treatment expansions, from 1.5pp per year before Treat All to 7.7pp per year afterward. Universal ART eligibility has increased rapid treatment initiation among young adolescents enrolling in HIV care. Further research should assess their retention in care and viral suppression under Treat All.