Health Care Delivery Science Research Articles

2023 Inaugural Healthcare Delivery Science: Innovation and Partnerships for Health Equity Research (DESCIPHER) Symposium.

This article provides an overview of presentations and discussions from the inaugural Healthcare Delivery Science: Innovation and Partnerships for Health Equity Research (DESCIPHER) Symposium. The symposium brought together esteemed experts from various disciplines to explore models for translating evidence-based interventions into practice. The symposium highlighted the importance of disruptive innovation in healthcare, the need for multi-stakeholder engagement, and the significance of family and community involvement in healthcare interventions. The article concluded with a call to action for advancing healthcare delivery science to achieve health equity.

Patient care in complex Sociotechnological ecosystems and learning health systems.

The learning health system (LHS) model was proposed to provide real-time, bi-directional flow of learning using data captured in health information technology systems to deliver rapid learning in healthcare delivery. As highlighted by the landmark National Academy of Medicine report "Crossing the Quality Chasm," the U.S. healthcare delivery industry represents complex adaptive systems, and there is an urgent need to develop innovative methods to identify efficient team structures by harnessing real-world care delivery data found in the electronic health record (EHR). We offer a discussion surrounding the complexities of team communication and how solutions may be guided by theories such as the Multiteam System (MTS) framework and the Multitheoretical Multilevel Framework of Communication Networks. To advance healthcare delivery science and promote LHSs, our team has been building a new line of research using EHR data to study MTS in the complex real world of cancer care delivery. We are developing new network metrics to study MTSs and will be analyzing the impact of EHR communication network structures on patient outcomes. As this research leads to patient care delivery interventions/tools, healthcare leaders and healthcare professionals can effectively use health IT data to implement the most evidence-based collaboration approaches in order to achieve the optimal LHS and patient outcomes.

Pharmacotherapy and pulmonary fibrosis risk after SARS-CoV-2 infection: a prospective nationwide cohort study in the United States

Pulmonary fibrosis is characterized by lung parenchymal destruction and can increase morbidity and mortality. Pulmonary fibrosis commonly occurs following hospitalization for SARS-CoV-2 infection. As there are medications that modify pulmonary fibrosis risk, we investigated whether distinct pharmacotherapies (amiodarone, cancer chemotherapy, corticosteroids, and rituximab) are associated with differences in post-COVID-19 pulmonary fibrosis incidence. We used the National COVID-19 Cohort Collaboration (N3C) Data Enclave, which aggregates and harmonizes COVID-19 data across the United States, to assess pulmonary fibrosis incidence documented at least 60 days after COVID-19 diagnosis among adults hospitalized between January 1st, 2020 and July 6th, 2022 without pre-existing pulmonary fibrosis. We used propensity scores to match pre-COVID-19 drug-exposed and unexposed cohorts (1:1) based on covariates with known influence on pulmonary fibrosis incidence, and estimated the association of drug exposure with risk for post-COVID-19 pulmonary fibrosis. Sensitivity analyses considered pulmonary fibrosis incidence documented at least 30- or 90-days post-hospitalization and pulmonary fibrosis incidence in the COVID-19-negative N3C population. Among 5,923,394 patients with COVID-19, we analyzed 452,951 hospitalized adults, among whom pulmonary fibrosis incidence was 1.1 per 100-person-years. 277,984 hospitalized adults with COVID-19 were included in our primary analysis, among whom all drug exposed cohorts were well-matched to unexposed cohorts (standardized mean differences <0.1). The post-COVID-19 pulmonary fibrosis incidence rate ratio (IRR) was 2.5 (95% CI 1.2-5.1, P=0.01) for rituximab, 1.6 (95% CI 1.3-2.0, P<0.0001) for chemotherapy, and 1.2 (95% CI 1.0-1.3, P=0.02) for corticosteroids. Amiodarone exposure had no significant association with post-COVID-19 pulmonary fibrosis (IRR=0.8, 95% CI 0.6-1.1, P=0.24). In sensitivity analyses, pre-COVID-19 corticosteroid use was not consistently associated with post-COVID-19 pulmonary fibrosis. In the COVID-19 negative hospitalized population (n=1,240,461), pulmonary fibrosis incidence was lower overall (0.6 per 100-person-years) and for patients exposed to all four drugs. Recent rituximab or cancer chemotherapy before COVID-19 infection in hospitalized patients is associated with increased risk for post-COVID-19 pulmonary fibrosis. The analyses described in this publication were conducted with data or tools accessed through the NCATS N3C Data Enclave https://covid.cd2h.org and N3C Attribution & Publication Policy v1.2-2020-08-25b supported by NIHK23HL146942, NIHK08HL150291, NIHK23HL148387, NIHUL1TR002389, NCATSU24 TR002306, and a SECURED grant from the Walder Foundation/Center for Healthcare Delivery Science and Innovation, University of Chicago. WFP received a grant from the Greenwall Foundation. This research was possible because of the patients whose information is included within the data and the organizations (https://ncats.nih.gov/n3c/resources/data-contribution/data-transfer-agreement-signatories) and scientists who have contributed to the on-going development of this community resource (https://doi.org/10.1093/jamia/ocaa196).

CORR Insights®: Are There Differences in Pain Reduction and Functional Improvement Among Splint Alone, Steroid Alone, and Combination for the Treatment of Adults With Trigger Finger?

1Postdoctoral Fellow, Leni & Peter W. May Department of Orthopaedics / Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA B. Z. Stern, Icahn School of Medicine at Mount Sinai, Department of Population Health Science & Policy, 1 Gustave L. Levy Place, Box 1077, New York, NY 10029, USA, Email: [email protected] This CORR Insights® is a commentary on the article “Are There Differences in Pain Reduction and Functional Improvement Among Splint Alone, Steroid Alone, and Combination for the Treatment of Adults With Trigger Finger?” by Atthakomol and colleagues available at: DOI: 10.1097/CORR.0000000000002662. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Assessing Social Cognition Across Dementia Subtypes (P6-6.004)

<h3>Objective:</h3> In this study, we aim to determine the clinical utility of bedside social cognition assessments in the diagnosis of frontotemporal dementia (FTD). We hypothesized that patients with FTD would score lower compared to patients with other neuropsychiatric disorders and healthy controls. <h3>Background:</h3> Although social cognition is selectively impaired in FTD, it is not routinely assessed in clinical evaluations, leading to frequent misdiagnoses such as Alzheimer’s disease (AD) and primary psychiatric disorders (PPD). <h3>Design/Methods:</h3> We created a battery of social cognition assessments that provide a comprehensive measurement of each patient’s social cognition, including degree of empathy, ability to identify emotions in others, and capacity to interpret social cues. The battery includes the Interpersonal Reactivity Index (IRI), the Mini-Social Cognition and Emotional Assessment (mini-SEA), and The Awareness of Social Inference Test (TASIT-S). The battery was administered to 60 patients, including patients with FTD (n=11), AD (n=18), vascular dementia (VD) (n=9), Lewy Body Dementia (DLB) (n=3), PPD (n=9), and 10 healthy controls (HC). We then calculated the averages in assessment scores for comparison across subgroups (FTD, AD, VD, DLB, PPD, and HC). <h3>Results:</h3> Patients with FTD had lower scores across all assessments. On the IRI, the average score for FTD patients was 49.3 ±6.80 compared to AD (67.8), VD (57.2), DLB (58.7), PPD (62.1), and HC (69.6). The average score on the Mini-SEA was 25.2 ±2.98 for FTD patients compared to AD (30.3), VD (30.3), DLB (30.0), PPD (30.4), and HC (33.5). The average total score on the TASIT-S for FTD patients was 24.2 ±1.93 compared to AD (26.0), VD (24.2), DLB (24.2), PPD (26.8), and HC (29.5). <h3>Conclusions:</h3> The FTD subgroup consistently scored lower on all assessments in the social cognition battery, demonstrating the potential for bedside social cognition assessments for early diagnosis of FTD. <b>Disclosure:</b> Miss Lorino has received personal compensation for serving as an employee of Tulane University. The institution of Miss Lorino has received research support from National Institutes of Health. Ms. Yang has nothing to disclose. Ms. Covaciu has nothing to disclose. The institution of Dr. Seibert has received research support from Retirement Research Foundation. The institution of Dr. Seibert has received research support from Center for Healthcare Delivery Science and Innovation.

Ethnic Disparities in Clinical Presentation of Patients with Early-Onset Alzheimer’s Disease (P14-6.002)

<h3>Objective:</h3> N/A <h3>Background:</h3> Early-onset Alzheimer’s Disease (EOAD) affects patients younger than age 65 and may present with non-amnestic features. Black patients are half as likely to be diagnosed despite twice as many risk factors. Ethnic disparities in EOAD have not been fully characterized. <h3>Design/Methods:</h3> We retrospectively identified EOAD patients February 2017–February 2022 and collected data on ethnicity, level of education, Montreal Cognitive Assessment (MoCA) scores and clinical presentation. <h3>Results:</h3> Of 88 total patients, 60 (68.8%) identified as Caucasian/White and 28 (31.8%) identified as African American/Black. Age at diagnosis (years) was (57.3 ± 5.24) in Black patients compared to (55.9 ± 5.69) in White patients. Time to diagnosis (years) was on average longer in Black patients (5 ± 9.21) compared with White patients (3.5 ± 6.44) and Black patients were on average more advanced (total MOCA scores) at presentation (12.17 ± 6.91) compared with White patients (15.15 ± 5.92) despite similar education level (in years) among Black patients (14.71 ± 2.30) and White patients (15.21±3.00). An amnestic profile was more common in Black patients (19 or 67.9%) than non-amnestic presentations (9 or 32.1%), although 2 patients (7.14%) presented with visual symptoms suggestive of posterior cortical atrophy (PCA), 5 (17.9%) patients had prominent language symptoms suggestive of logopenic primary progress aphasia (l-PPA) and 1 (3.6%) patient had an executive presentation, suggestive of frontal variant of AD (fAD). Comparatively, non-amnestic presentations were more commonly diagnosed in White patients, with 11 (18.3%) PCA diagnoses, 10 (16.7%) patients with fAD and 8 (13.3%) patients with l-PPA. <h3>Conclusions:</h3> In our cohort, Black patients with EOAD are on average older, more advanced and experience longer delays in diagnosis than their White counterparts. Non-amnestic presentations are more common in White patients. Further work is needed to further characterize the barriers to diagnosis accessibility of care for Black patients with EOAD. <b>Disclosure:</b> Ms. Yang has nothing to disclose. Dr. Yoon has nothing to disclose. Ms. Covaciu has nothing to disclose. The institution of Dr. Seibert has received research support from Retirement Research Foundation. The institution of Dr. Seibert has received research support from Center for Healthcare Delivery Science and Innovation.

MP39-12 IMPACT OF BPH SURGICAL MANAGEMENT ON PATIENT AND HEALTH PLAN COSTS

You have accessJournal of UrologyCME1 Apr 2023MP39-12 IMPACT OF BPH SURGICAL MANAGEMENT ON PATIENT AND HEALTH PLAN COSTS Kevin Wymer, Gopal Narang, Daniel Heidenberg, Viengneesee Thao, Bijan Borah, Scott Cheney, and Mitchell Humphreys Kevin WymerKevin Wymer More articles by this author , Gopal NarangGopal Narang More articles by this author , Daniel HeidenbergDaniel Heidenberg More articles by this author , Viengneesee ThaoViengneesee Thao More articles by this author , Bijan BorahBijan Borah More articles by this author , Scott CheneyScott Cheney More articles by this author , and Mitchell HumphreysMitchell Humphreys More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003277.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A multitude of surgical treatment options exist for BPH - with differences in the level of invasiveness, complications, and durability. Despite the high prevalence of BPH treatment and its significant economic impact, limited data are available comparing the financial burden of specific surgical interventions. METHODS: We identified all commercially insured patients with a diagnosis of BPH who underwent a procedure of interest (SP, TURP, HoLEP, PVP, PUL, or WVTT) between 2015-2020 with the OptumLabs Data Warehouse, which includes commercial insurance and Medicare Advantage data. Patients were matched to a non-BPH control group based on demographic and clinical characteristics. The primary outcomes were patient out-of-pocket (OOP) costs and health plan paid (HPP) costs for the index procedure and combined follow-up years 1-5. A generalized linear model was used to estimate adjusted costs controlling for baseline demographic and clinical characteristics. Patients undergoing WVTT and SP were dropped from follow-up cost analyses due to limited data. RESULTS: Among 21,844 patients with BPH, 10,387 (48%) underwent TURP, 5,300 (24%) underwent PVP, 3,751 (17%) underwent PUL, 1,331 (6%) underwent SP, 906 (4%) underwent HoLEP, and 169 (.7%) underwent WVTT. Average costs for index procedure varied significantly by procedure with WVTT being the least costly with an aggregate cost of $3,516 ($441 OOP; $3,075 HPP), and SP being the most costly with an aggregate cost of $17,155 ($1,293 OOP; $15,862 HPP) (Figure 1). When evaluating combined 5-year follow-up costs, HoLEP was the least costly with an aggregate cost of $11,579 ($2,161 OOP; $9,418 HPP), and PVP was the most costly with an aggregate cost of $16,015 ($2,298 OOP; $13,717 HPP) (Figure 2). CONCLUSIONS: BPH treatment modality has a significant impact on patient and system level costs. Minimally invasive options, such as WVTT, may offer initial cost reductions; however, with the inclusion of longer-term follow up, HoLEP was associated with the lowest patient and HPP costs. Source of Funding: Robert D and Patricia E Kern Center for the Science of Health Care Delivery. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e539 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kevin Wymer More articles by this author Gopal Narang More articles by this author Daniel Heidenberg More articles by this author Viengneesee Thao More articles by this author Bijan Borah More articles by this author Scott Cheney More articles by this author Mitchell Humphreys More articles by this author Expand All Advertisement PDF downloadLoading ...

MP08-06 OUTCOMES FOR HIGH-RISK BLADDER CANCER AFTER BCG THERAPY IN PATIENTS WITH PRIOR PROSTATE RADIOTHERAPY: A SEER-BASED STUDY

You have accessJournal of UrologyCME1 Apr 2023MP08-06 OUTCOMES FOR HIGH-RISK BLADDER CANCER AFTER BCG THERAPY IN PATIENTS WITH PRIOR PROSTATE RADIOTHERAPY: A SEER-BASED STUDY Adri Durant, Yeonsoo Lee, Lanyu Mi, Faraj Kassem, and Mark Tyson Adri DurantAdri Durant More articles by this author , Yeonsoo LeeYeonsoo Lee More articles by this author , Lanyu MiLanyu Mi More articles by this author , Faraj KassemFaraj Kassem More articles by this author , and Mark TysonMark Tyson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003223.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is evidence that patients with bladder cancer who have previously received radiation therapy (RT) are at increased risk for poorer oncological compared to non-radiated counterparts. Little is known about the impact of prior RT on the efficacy of Bacillus Calmette-Guerin (BCG) in patients with non-muscle invasive bladder cancer (NMIBC). In this context, we investigated the impact of previous prostate RT on 5-year disease progression for NMIBC patients after BCG. METHODS: Male patients with a history of high-risk NMIBC, classified as Ta, T1 and CIS disease with completion of adequate BCG (at least 5 plus 2 treatments), were identified in the Surveillance, Epidemiology, and End Results (SEER) – Medicare database. Patients were stratified into two cohorts based on their history of prior radiation use: RT for prostate cancer prior to bladder cancer diagnosis (NMIBC RT) and no history of prostate cancer radiation (NMIBC without prior RT). The primary endpoint was 5-year total progression defined as progression to systemic chemotherapy, checkpoint inhibitors, radical or partial cystectomy, metastasis or cancer-specific death. Results: In a total of 3442 patients with NMIBC, 3306 had no history of prior RT while 136 had a history of prior RT for prostate cancer. The NMIBC RT cohort varied significantly by age (77.5 v 75.0, p=0.0002) and stage (Ta 43.4%, Tis 19.1%, T1 37.5% v Ta 41.0%, Tis 10.8%, T1 48.2%, p=0.0033) at initial tumor diagnosis. There was no significant difference in risk of progression to chemotherapy (p=0.6469), checkpoint inhibitors (p=0.1096), radical cystectomy (p=0.2023), partial cystectomy (p=0.5613), cancer-specific death (p=0.0667) and 5-year total progression between the two cohorts. On multivariate analysis NMIBC RT patients did not have a significantly higher risk of 5-year total progression (HR 1.37, p=0.08). CONCLUSIONS: In patients with NMIBC who undergo adequate BCG treatment, prior history of pelvic radiation for prostate cancer is not associated with worse progression-free survival. Source of Funding: This study was supported by Grant Number P30 CA015083 from the National Cancer Institute (NCI) and from the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (M.D.T.), the Christian Haub Family Career Development Award for Cancer Research Honoring Dr. Richard Emslander (M.D.T.), and the Eric and Gail Blodgett Foundation (M.D.T.). Its contents are solely the authors' responsibility and do not necessarily represent the official view of the NIH. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e95 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Adri Durant More articles by this author Yeonsoo Lee More articles by this author Lanyu Mi More articles by this author Faraj Kassem More articles by this author Mark Tyson More articles by this author Expand All Advertisement PDF downloadLoading ...

Health Systems Science – A Primer for Radiologists

Health systems science (HSS) is an educational framework designed to promote improved care through enhanced citizenship and the training of systems-fluent individuals trained in the science of health care delivery. HSS education in residency builds upon foundations established during medical school, emphasizing practical skills development, and fostering a growth mindset among trainees. The HSS framework organizes elements of system-based practice for radiology trainees, promoting practice-readiness for providing safe, timely, effective, efficient, equitable and patient centered radiological care. This paper serves as a primer for radiologists to understand and apply the HSS framework. Additionally, we highlight radiology-specific curricular elements aligned with the HSS framework, and provide teaching resources both for classroom education and for resident self-study.

CORR Insights®: High-volume Arthroplasty Centers Are Associated With Lower Hospital Costs When Performing Primary THA and TKA: A Database Study of 288,909 Medicare Claims for Procedures Performed in 2019.

1Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai. New York, NY, USA J. Poeran, Leni and Peter W. May Department of Orthopedic Surgery, Institute for Healthcare Delivery Science; Department of Population Health Science and Policy, Department of Medicine, Icahn School of Medicine at Mount Sinai; 1450 Madison Avenue, Box 1077, New York, NY 10029, USA, Email: [email protected] This CORR Insights® is a commentary on the article “High-volume Arthroplasty Centers Are Associated With Lower Hospital Costs When Performing Primary THA and TKA: A Database Study of 288,909 Medicare Claims for Procedures Performed in 2019” Blackburn and colleagues available at: DOI: 10.1097/CORR.0000000000002470. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Artificial intelligence-guided screening for atrial fibrillation using electrocardiogram during sinus rhythm: a prospective non-randomised interventional trial

Previous atrial fibrillation screening trials have highlighted the need for more targeted approaches. We did a pragmatic study to evaluate the effectiveness of an artificial intelligence (AI) algorithm-guided targeted screening approach for identifying previously unrecognised atrial fibrillation. For this non-randomised interventional trial, we prospectively recruited patients with stroke risk factors but with no known atrial fibrillation who had an electrocardiogram (ECG) done in routine practice. Participants wore a continuous ambulatory heart rhythm monitor for up to 30 days, with the data transmitted in near real time through a cellular connection. The AI algorithm was applied to the ECGs to divide patients into high-risk or low-risk groups. The primary outcome was newly diagnosed atrial fibrillation. In a secondary analysis, trial participants were propensity-score matched (1:1) to individuals from the eligible but unenrolled population who served as real-world controls. This study is registered with ClinicalTrials.gov, NCT04208971. 1003 patients with a mean age of 74 years (SD 8·8) from 40 US states completed the study. Over a mean 22·3 days of continuous monitoring, atrial fibrillation was detected in six (1·6%) of 370 patients with low risk and 48 (7·6%) of 633 with high risk (odds ratio 4·98, 95% CI 2·11-11·75, p=0·0002). Compared with usual care, AI-guided screening was associated with increased detection of atrial fibrillation (high-risk group: 3·6% [95% CI 2·3-5·4] with usual care vs 10·6% [8·3-13·2] with AI-guided screening, p<0·0001; low-risk group: 0·9% vs 2·4%, p=0·12) over a median follow-up of 9·9 months (IQR 7·1-11·0). An AI-guided targeted screening approach that leverages existing clinical data increased the yield for atrial fibrillation detection and could improve the effectiveness of atrial fibrillation screening. Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery.

Changing the research paradigm for digital transformation in healthcare delivery.

The growing focus on healthcare transformation (i.e., new healthcare delivery models) raises interesting issues related to research design, methodology, and funding. More than 20 years have passed since the Institute of Medicine first called for the transition to digital health with a focus on system-wide change. Yet progress in healthcare delivery system change has been painfully slow. A knowledge gap exists; research has been inadequate and critical information is lacking. Despite calls by the National Academies of Science, Engineering, and Medicine for convergent, team-based transdisciplinary research with societal impact, the preponderance of healthcare research and funding continues to support more traditional siloed discipline research approaches. The lack of impact on healthcare delivery suggests that it is time to step back and consider differences between traditional science research methods and the realities of research in the domain of transformational change. The proposed new concepts in research design, methodologies, and funding are a needed step to advance the science. The Introduction looks at the growing gap in expectations for transdisciplinary convergent research and prevalent practices in research design, methodologies, and funding. The second section summarizes current expectations and drivers related to digital health transformation and the complex system problem of healthcare fragmentation. The third section then discusses strengths and weaknesses of current research and practice with the goal of identifying gaps. The fourth section introduces the emerging science of healthcare delivery and associated research methodologies with a focus on closing the gaps between research and translation at the frontlines. The final section concludes by proposing new transformational science research methodologies and offers evidence that suggests how and why they better align with the aims of digital transformation in healthcare delivery and could significantly accelerate progress in achieving them. It includes a discussion of challenges related to grant funding for non-traditional research design and methods. The findings have implications broadly beyond healthcare to any research that seeks to achieve high societal impact.

347.6: Racial-Ethnic and Sex Disparities in Access to Renal Transplant Waitlisting Vary by Age in the United States

Background: Transplantation provides numerous benefits, but racial/ethnic and gender disparities in access to renal transplantation exist globally. However, in the United States, the interaction between race/ethnicity and gender in transplant access has not been well explored. Further, it is unclear how age at diagnosis modifies these disparities. Methods: We used the United States Renal Data System to identify a retrospective cohort of incident adult dialysis patients from January 1, 2005 – December 31, 2017 and followed through 2018. We used multivariable Cox regression to model the association between combined race/ethnicity and sex (race x gender) group and time to renal transplant waitlisting. We adjusted for clinical and sociodemographic factors and included a time-dependent covariate reflecting a 2014 change in the national kidney allocation policy (KAS) aimed to improve equity. We incorporated a race x gender x age group interaction term to test for effect modification by age group. We also conducted stratified analyses per age group. Results: After excluding prior renal transplant recipients (n=5,227) and pre-emptive transplants (n=3,486), we identified 1,337,386 US incident dialysis patients of whom 19.4% were waitlisted (median time to waitlisting (interquartile range): 350 days (184, 651)). Most patients were over 50; 50-59 (n=215,028, 19.8%), 60-69 (24.8%), or 70 or greater (37.2%). Waitlisting was highest among Asian women aged 18-39 (n=6,260, 69.7%) and lowest among Hispanic women aged 70 or greater (n=2,315, 1.9%). We found significant effect modification by age in the association of demographic group and time to waitlisting (p-value: <0.0001). Across all age groups, Black women experienced reduced access to transplant waitlisting compared to age-matched white men; this disparity was worst among the oldest (aged 70 or greater) (adjusted hazard ratio (aHR): 0.60, 95% confidence interval (CI): 0.56, 0.64) and youngest (aged 18-39) Black women (aHR: 0.77, 95% CI: 0.74, 0.79). Furthermore, older Hispanic and white women (60-69 and 70 or greater) exhibited reduced transplant access compared to aged-matched white men and men within their own race/ethnic group. Hispanic women aged 70 or greater experienced worst disparity with 42% reduced likelihood of waitlisting compared to white men (aHR: 0.58, 95% CI: 0.53, 0.64). Conclusions: The interaction between race/ethnicity and gender in access to renal transplant waitlisting in the United States varies significantly by age. Older Black and Hispanic women and younger Black women have significantly reduced access to transplantation compared to other groups, even after adjusting for clinical and sociodemographic factors. More work is needed to understand and ameliorate these intersections of gender, race/ethnicity, and age-related disparities to promote equity in access to renal transplantation. This research was supported by University of Chicago Medicine’s Center for Healthcare Delivery Science and Innovation (HDSI), the Bucksbaum Institute for Clinical Excellence at the University of Chicago, and the National Kidney Foundation of Illinois. We also acknowledge the University of Chicago Research Computing Center for computational support of this work. The data reported here have been supplied by the United States Renal Data System (USRDS) and the United States Census Bureau. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the U.S. Government.

Design thinking to improve healthcare delivery in the intensive care unit: Promise, pitfalls, and lessons learned.

Design thinking is a problem-solving approach characterized by the empathetic lens through which designers integrate perspectives of end-users and key stakeholders throughout the entire process of developing solutions. This approach is rooted in diverse fields including engineering, computer science, psychology, and business and is increasingly widespread in healthcare. Herein, we describe the promise of design thinking to help solve intractable problems in healthcare delivery, including those within the complex social and technical intensive care unit system. We highlight our team's experience using design thinking to address the complex problem of aligning the delivery of life-sustaining treatments with patients' individual goals, values, and preferences. However, given the high stakes of design failure in healthcare, we also discuss the limitations of this approach and the potential consequences of inadequate application. Finally, we suggest a pathway forward that combines the philosophy and tools of design thinking with existing methods within healthcare delivery science, such as qualitative research, quality improvement methods, and implementation science. Ultimately, we argue that design thinking is a valuable approach to guide designers, clinicians, researchers, and administrators towards a more genuine understanding of the healthcare experience, through the lens of patients, their families, and frontline clinicians.

MP03-17 PATIENT, PHYSICIAN, HOSPITAL FACTORS ASSOCIATED WITH READMISSION AFTER RADICAL CYSTECTOMY

You have accessJournal of UrologyCME1 May 2022MP03-17 PATIENT, PHYSICIAN, HOSPITAL FACTORS ASSOCIATED WITH READMISSION AFTER RADICAL CYSTECTOMY Kassem Faraj, Lanyu Mi, and Mark Tyson Kassem FarajKassem Faraj More articles by this author , Lanyu MiLanyu Mi More articles by this author , and Mark TysonMark Tyson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002515.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical Cystectomy (RC) is associated with significant morbidity and a result, high complication rates. Patient, or clinical factors, are the most commonly identified variables associated with hospital readmission. Other factors that may be important include hospital and physician characteristics, which have been suggested as contributing factors for readmission in other major surgeries. This study investigates the contribution of patient, physician and hospital factors on hospital readmission after RC. METHODS: This was a retrospective review of the Surveillance Epidemiology and End Results (SEER)-Medicare database focusing on bladder cancer patients who underwent RC between 2007-2016. These claims were identified using ICD-9/ICD-10 or HCPCS codes from MEDPAR or NCH claims, from which the annual hospital and physician volumes were calculated and classified as low, medium and high. Univariate and multivariable analyses were done for 90-day readmission as the outcome using a multilevel model to explore the association between readmission and characteristics of patient, hospital, and physician. Models with random intercepts were constructed to consider the variation from hospital and physician. The intraclass correlation coefficient (ICC) for hospital, physician and patient levels were also calculated. RESULTS: In 3530 patients, 1291 (36.6%) were readmitted within 90 days of the index surgery. On univariate analysis, continent urinary diversion (OR 1.533), greater NCI comorbidity score (OR 1.460 for NCI 2-4 vs <2; OR 1.754 for NCI >4 vs <2), robotic approach (OR 1.210), AJCC stage (stage III vs stage I, OR 0.777), hospital length of stay (OR 1.037), Northeast vs Western hospital location (OR 4.19), and any postoperative complication (OR 6.790) were significantly (p <0.05) associated with 90-day hospital readmission. On multilevel multivariable analysis, factors significantly (p <0.05) associated with 90-day readmission included continent urinary diversion (OR 1.462), robotic approach (OR 1.299), and any postoperative complication (OR 6.865). Neither hospital volume, physician volume, hospital region, teaching hospital status, nor NCI center designation were associated with hospital readmission. The main source of variation was determined to be at the patient (92.5%), followed by the physician (5.1%), and then hospital (2.4%) levels. CONCLUSIONS: Ninety-day hospital readmission at the time of RC is high, with around one-third of patients requiring a readmission. Patient-specific factors are the most important in impacting the odds of readmission, while hospital and physician factors contribute minimally to this outcome. Consequently, efforts to reduce readmission rates should focus on the patient level. Source of Funding: This study was supported by Grant Number P30 CA015083 from the National Cancer Institute (NCI) from the Robert D. and Patricia E. Kern Center for Health Care Delivery Science (M.D.T.), the Christian Haub Family Career Development Award for Cancer Research Honoring Dr Richard Emslander (M.D.T.), and the Eric and Gail Blodgett Foundation (M.D.T.). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the NIH © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e27 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kassem Faraj More articles by this author Lanyu Mi More articles by this author Mark Tyson More articles by this author Expand All Advertisement PDF DownloadLoading ...

When silence is not golden: Crying and other responses to microaggressions and implicit bias in academic medicine.

Journal of Hospital MedicineEarly View PERSPECTIVES IN HOSPITAL MEDICINE When silence is not golden: Crying and other responses to microaggressions and implicit bias in academic medicine Himali Weerahandi MD, MPH, Corresponding Author Himali Weerahandi MD, MPH Himali.Weerahandi@nyulangone.org orcid.org/0000-0001-9614-345X Division of Hospitalist Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA Correspondence: Himali Weerahandi, MD, MPH, Department of Medicine, NYU Grossman School of Medicine, 227 E 30th St., New York, NY 10016, USA. Email: Himali.Weerahandi@nyulangone.orgSearch for more papers by this author Himali Weerahandi MD, MPH, Corresponding Author Himali Weerahandi MD, MPH Himali.Weerahandi@nyulangone.org orcid.org/0000-0001-9614-345X Division of Hospitalist Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA Correspondence: Himali Weerahandi, MD, MPH, Department of Medicine, NYU Grossman School of Medicine, 227 E 30th St., New York, NY 10016, USA. Email: Himali.Weerahandi@nyulangone.orgSearch for more papers by this author First published: 04 January 2022 https://doi.org/10.1002/jhm.2740Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

PD59-09 EXTENDED ANTICOAGULATION AFTER RADICAL CYSTECTOMY: A SINGLE-INSTITUTIONAL EXPERIENCE

You have accessJournal of UrologyBladder Cancer: Invasive V (PD59)1 Sep 2021PD59-09 EXTENDED ANTICOAGULATION AFTER RADICAL CYSTECTOMY: A SINGLE-INSTITUTIONAL EXPERIENCE Kassem Faraj, Derek Scott, Rohan Singh, and Mark Tyson Kassem FarajKassem Faraj More articles by this author , Derek ScottDerek Scott More articles by this author , Rohan SinghRohan Singh More articles by this author , and Mark TysonMark Tyson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002096.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Extended anticoagulation therapy has been found to be effective in reducing the risk of developing venous thromboembolism (VTE) in trials evaluating major oncological surgeries. This practice has not been universally adopted in the care of patients undergoing radical cystectomy. At our institution, we have modified our extended anticoagulation options to low-dose oral options. This study aims to report our experience with extended VTE prophylaxis and our experience with oral options at the time of RC. METHODS: This is a retrospective review that included all patients who underwent RC at our institution between 01/2007-06/2020. Exclusion criteria included the following: patients with a prior history of VTE, those on anticoagulation prior to surgery, thrombosis events after 90 days, RC for benign indication, and RC for non-bladder indication. Extended anticoagulation was continued for 30 days after surgery and included either daily 40 mg subcutaneous enoxaparin, daily 10 mg rivaroxaban, or 2.5 mg apixaban twice per day. Descriptive statistics were performed to evaluate characteristics of patients who developed a symptomatic VTE verses those with did not. We then performed a multivariable logistics regression analysis to identify factors associated with the development of a VTE. RESULTS: In 616 patients, the median age was 72 years, medium BMI 28. Seventy-four patients received some form of extended VTE prophylaxis. On descriptive analysis, a deep vein thrombosis (DVT) was less common in the extended prophylaxis cohort, though this was not statistically significant (1.4% vs 5.4%, p=0.132). The incidence of pulmonary embolism was similar in the cohorts (2.7% vs 3.2%, p=0.834). Of the 74 patients who received extended VTE prophylaxis, 15 (20.2%) and 9 (12.2%) patients received rivaroxaban and Eliquis, respectively. The incidence of gastrointestinal bleed was low in the entire cohort and no patients in the extended DVT group developed a gastrointestinal bleed, compared to 1.5 % in the control group (p=0.376). On multivariable analysis, extended VTE prophylaxis was associated with a reduced risk of developing VTE and this approached statistical significance (OR 0.32, p=0.08). CONCLUSIONS: Extended DVT prophylaxis is associated with a reduced risk of developing a symptomatic VT after RC. Oral anticoagulant options are just as safe and appear to be associated with low rates of VTE, though larger studies are needed to confirm these results. Source of Funding: This study was generously supported by funding from the Robert D. and Patricia E. Kern Center for Health Care Delivery Science, the Christian Haub Family Career Development Award for Cancer Research Honoring Dr Richard Emslander, and the Eric and Gail Blodgett Foundation. The sponsors were not involved in the study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1057-e1057 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kassem Faraj More articles by this author Derek Scott More articles by this author Rohan Singh More articles by this author Mark Tyson More articles by this author Expand All Advertisement Loading ...

The National Cancer Institute's Role in Advancing Health-Care Delivery Research.

Improvements in cancer care delivery have the potential to reduce morbidity and mortality from cancer, however, challenges to delivery of recommended care limit progress. These challenges include growing demands for care, increasing treatment complexity, inadequate care coordination, dramatic increases in costs, persistent disparities in care, and insufficient use of evidence-based guidelines. Recognizing the important role of research in understanding and addressing these challenges, the National Cancer Institute created the Healthcare Delivery Research Program (HDRP) in 2015 as a catalyst for expanding work in this area. Health-care delivery research is a multidisciplinary effort which recognizes that care delivery occurs in a multilevel system encompassing individuals, health-care systems, and communities. HDRP staff use a range of activities to fulfill the program's mission of advancing innovative research to improve delivery of care across the cancer control continuum. In addition to developing funding opportunities, HDRP staff; support and facilitate the use of research infrastructure for conducting health-care delivery research; oversee publicly available data that can be used to evaluate patterns, costs, and patient experiences of care; contribute to development and dissemination of standardized health measurement tools for public use; and support professional development and training to build capacity within the field and grow the workforce. As HDRP enters its sixth year, we appreciate the opportunity to reflect on the program's progress in advancing the science of health-care delivery. At the same time, we recognize the need for the program to evolve and develop additional resources and opportunities to address new and emerging challenges.

25475 Healthcare Delivery Science in LA: Addressing patient and health system priorities with cross-sector research infrastructure

ABSTRACT IMPACT: Effective healthcare interventions improve access, quality of care, and health outcomes for underserved, high-disparity populations of Los Angeles county and beyond. OBJECTIVES/GOALS: We will expand our successful, Los Angeles-based public-academic partnership to develop and evaluate health system interventions aimed at improving healthcare for underserved communities, as well as develop workforce skilled in healthcare delivery science. METHODS/STUDY POPULATION: Together with the LA County Department of Health Services, the two LA-based CTSA hubs at USC and UCLA have established critical infrastructure for effective cross-sector translational research: (1) New funding mechanisms to evaluate health system interventions in county hospitals and clinics in areas of mutual interest; (2) Specialized research service cores (Safety-net Health Innovation core, Clinical Research Informatics core, and Healthcare Delivery Science core), and (3) Training and mentorship programs tailored for healthcare delivery scientists. RESULTS/ANTICIPATED RESULTS: Outcomes from the first four years of the partnership include: (1) Significant impact on health outcomes from eight funded projects, e.g., lowered A1c levels by 0.9%; (2) Successful, coordinated service to dozens of research projects, e.g., a teleretinal screening program decreased ophthalmology visit wait times from 158 to 17 days; (3) New virtual coursework in seven domains (healthcare delivery science, dissemination and implementation science, systems engineering, behavioral economics, informatics, team science, and community engagement); (4) A published ‘synergy paper’ w/ CTSA hubs in three other urban cities examining common themes of academic-public partnerships; and (5) Rapid and streamlined COVID-19 research policy setting with county leadership. DISCUSSION/SIGNIFICANCE OF FINDINGS: Our sustainable infrastructure is effectively bridging research-policy-practice gaps in Los Angeles and addressing patients’ and the health system’s priorities.

A Response to Viewpoints on Healthcare Delivery Science Education Among Practicing Physicians in a Rural State [Response to Letter

A Response to Viewpoints on Healthcare Delivery Science Education Among Practicing Physicians in a Rural State [Response to Letter