Inner-city Safety Net Hospital Research Articles

Potential barriers to lung cancer screening in a minority population: Assessing attitudes, beliefs, and values towards screening with low-dose computed tomography amongst a high-risk minority population.

17 Background: While the National Lung Screening Trial (NLST) has shown a relative reduction in mortality from lung cancer with the application of the United States Preventative Services Task Force (USPSTF) guidelines for the use of Low-Dose Computed Tomography (LDCT) in a select high risk population, many studies have shown that the rate of screening has been below the national average in minority population. Furthermore, lung cancer mortality still appears to be disproportionately higher amongst minority populations. With this study, we aim to evaluate the attitudes, beliefs and values towards lung cancer screening with LDCT in a predominantly Black and Hispanic population in our outpatient clinic. Methods: A survey was conducted over a 3-month period in our outpatient department at an urban inner-city safety net hospital. We included high risk smokers, aged 50 to 80 years who reported no evidence of symptoms. The survey consisted of 20 questions; these included utilizing the Health Belief Model to assess beliefs on perceived susceptibility, severity, benefits and barriers to screening, questions exploring fears of cancer screening and questions assessing overall willingness to undergo lung cancer screening with LDCT. We also included a question on the willingness of participants to engage in educational sessions with regards to lung cancer screening and risk reduction. Results were collected and analyzed via univariate logistic regression model to compare patient populations. Results: 67 patients participated in our survey. 62% were Black, 34% were Hispanic and 4% were Asian/Pacific Islanders. The mean age of our population was 64.5 years and they had an average of 27.2 pack-years of smoking. Issues related to insurance coverage and co-pay were identified as the most significant concern with regards to the unwillingness to undergo screening (p < 0.05). Other concerns identified were the fear of a positive screening result, fear of radiation exposure and lack of understanding of the association with smoking history and lung cancer (p = 0.12). All participants responded yes to being open to be educated on reducing their risk of lung cancer (p < 0.05). Conclusions: While many factors still exist with regards to lung cancer screening in minority populations, the cost of medical care, fear of radiation exposure and anxiety were identified as potential barriers to willingness to screen. Structured educational programs were identified as a possible measure that can be implemented to address these factors, with the potential to increase the willingness to undergo screening in a high risk minority population.

Implementation and outcomes of monoclonal antibody infusion for COVID-19 in an inner-city safety net hospital: A South-Bronx experience

BackgroundMonoclonal antibody therapy (MAT) is recommended in mild to moderate Coronavirus disease 2019 (COVID-19) patients who are at risk of progressing to severe disease. Due to limited data on its outcomes and the logistic challenges in administering the drug, MAT has not been widely used in the United States (US) despite of emergency use authorization (EUA) approval by the Food and Drug Administration (FDA). AimWe aim to study the outcomes of MAT in patients predominantly from ethnic minority groups and the challenges we experienced in implementing the infusion therapy protocol in an inner-city safety-net-hospital in the South Bronx. Methods and resultsWe conducted a retrospective observational study of 49 patients who were offered MAT as per EUA protocol of FDA. Patient who met the criteria for MAT and received therapy were included in treatment group (n = 38) and the remaining (n = 11) who declined treatment were included in the control group. A majority of patients (76%) in the study group reported symptomatic improvement, the day after infusion. There was statistically significant reduction in COVID-19 related hospitalizations (7.8 vs 54.5%, P = < 0.001) mortality (0 vs 18.1%, P value = 0.008) in the treatment group. ConclusionMAT reduced both hospitalization and mortality in this predominantly Hispanic patient population with mild to moderate COVID-19 with high risk factors for disease progression.

Potential predictors of outcomes among hospitalized COVID-19 patients treated with convalescent plasma: a single-center study

ABSTRACT Background: The coronavirus disease 2019 pandemic is a major international public health crisis, which has led to over 3 million deaths as of April 2021. Several therapeutics have been tried for this deadly illness including antivirals, immunosuppressive agents and convalescent plasma (CP). In this study, we present our inner-city safety net hospital experience with CP therapy. Methods: This was a retrospective chart review of hospitalized patients with confirmed COVID-19 who were treated with CP. Results: A total of 60 patients received CP during the study period. The mean age for patients in this study was 58.95 years. The most common presenting symptoms were shortness of breath (85%) and cough (73%). Hypertension (65%) and diabetes mellitus (55%) were the most common comorbidities in our patients. In our multivariate regression analysis, male sex, nausea and loss of appetite at presentation were associated with improvement in oxygenation after CP. Total survival time, history of obstructive airway disease, home use of angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers were associated with decreased survival, whereas Hispanic ethnicity showed a trend towards lower survival after CP therapy. Conclusions: Our study highlights several important characteristics of inner-city safety net hospital patient population who might benefit from CP therapy.

Clinical outcomes and inflammatory marker levels in patients with Covid-19 and obesity at an inner-city safety net hospital.

Patients with Covid-19 and obesity have worse clinical outcomes which may be driven by increased inflammation. This study aimed to characterize the association between clinical outcomes in patients with obesity and inflammatory markers. We analyzed data for patients aged ≥18 years admitted with a positive SARS-CoV-2 PCR test. We used multivariate logistic regression to determine the association between BMI and intensive care unit (ICU) transfer and all-cause mortality. Inflammatory markers (C-reactive protein [CRP], lactate dehydrogenase [LDH], ferritin, and D-dimer) were compared between patients with and without obesity (body mass index [BMI] ≥30 kg/m2). Of 791 patients with Covid-19, 361 (45.6%) had obesity. In multivariate analyses, BMI ≥35 was associated with a higher odds of ICU transfer (adjusted odds ratio [aOR] 2.388 (95% confidence interval [CI]: 1.074-5.310) and hospital mortality (aOR = 4.3, 95% CI: 1.69-10.82). Compared to those with BMI<30, patients with obesity had lower ferritin (444 vs 637 ng/mL; p<0.001) and lower D-dimer (293 vs 350 mcg/mL; p = 0.009), non-significant differences in CRP (72.8 vs 84.1 mg/L, p = 0.099), and higher LDH (375 vs 340, p = 0.009) on the first hospital day. Patients with obesity were more likely to have poor outcomes even without increased inflammation.

Therapeutic Plasma Exchange (PLEX) in Thrombotic Microangiopathy (TMA): Experiences of an Inner-City Hospital over a Decade

Introduction: There are multiple mechanisms of occurrence of TMA. Some of the etiologies are associated with high morbidity and mortality, but there are very subtle differences in presentation. A high index of suspicion is recommended for thrombotic thrombocytopenic purpura (TTP) due to the time sensitive nature of treatment initiation and poor outcomes associated with delay in treatment. Due to this, treatment with PLEX is often initiated empirically before diagnostic test results are available. We aim to report the management and outcomes of TMA along with the predictive value of the PLASMIC score in our patient population, over a 10-year period in an inner-city safety net hospital. Methods: This is a single center observational study including patients who underwent PLEX for a diagnosis of TMA, due to concern for TTP between January 2009 and May 2019 at an inner-city safety net hospital. Patients were identified from blood bank records and data was collected by review of electronic medical record. We excluded patients &amp;lt;18 years old and who received PLEX for indications other than that described previously. Data was collected until death or last follow-up. Statistical analysis was done using STATA. Results: A total of 40 patients met the inclusion criteria. Of these, 57.5% (n=23) were male, 17.5% (n=7) had a known malignancy and 15% (n=6) had human immunodeficiency virus infection. Study population was predominantly African American and Hispanic- comprising 75% (n=30) and 17.5% respectively- which differentiates our study from other validation studies for the PLASMIC score. Symptoms at presentation to emergency department, time to initiation of PLEX from presentation, and lab parameters before and after PLEX are shown in the attached table. ADAMTS13 activity level is available in 65% (n=26) patients, 57.7% of which were sent before initiation of PLEX. Average number of PLEX sessions during the admission was 9.4 (range: 2-30). As part of treatment, 85% (n=34) received steroids and 17.5% (n=7) received hemodialysis. 5 patients received rituximab and 2 received eculizumab. Final diagnoses included TTP in 62.5% (n=25), complement mediated TMA in 5% (n=2), drug induced TMA in 10% (n=4), TMA from sepsis or rheumatological condition in 15% (n=6), bone marrow suppression due to chemotherapy in 5% (n=2) and unsure in 2.5% (n=1). Average length of stay was 22.2 days (range: 6-85 days). Of the total 40 patients, 7.5% (n=3) died on the same admission, 10% (n=4) died after discharge and 3 were readmitted for repeat PLEX. Duration of follow-up after discharge ranged from 9 to 3319 days (mean 1102.6 days). We retrospectively estimated the PLASMIC score at the time of presentation for all the patients. Amongst the patients eventually diagnosed with TTP, 50% had a PLASMIC score of &amp;gt;5 and 70.83% had a score ≥5 at the time of presentation. Among non-TTP TMA, 25% had a score of &amp;gt;5 and 62.5% had a score ≥5. The sensitivity, specificity and positive predictive value of PLASMIC score for prediction of final diagnosis of TTP was calculated for all patients who met inclusion criteria and is shown in the attached table. Of those who underwent PLEX in the setting of TMA for the concern of TTP, only about a third were started on PLEX within 24 hours. Conclusion:Among our study population, only about a third were started on PLEX within 24 hours which is concerning and highlights the need for quality improvement initiatives to increase provider awareness and decrease time to PLEX. Final diagnosis of TTP was made in 62.5% of the patients but notably, the performance of PLASMIC score in our patient population was inferior compared to prior validation studies. One possible explanation for this could be the difference in baseline patient demographics, with our patients belonging mostly to minority groups. There is a need for further studies with derivation and validation cohorts in this patient population to derive a scoring system that is more predictive. Table Disclosures No relevant conflicts of interest to declare.

Retrospective Audit of Malignant Epidural Spinal Cord Compression (MESCC) in an Inner-City Safety Net Hospital

Retrospective Audit of Malignant Epidural Spinal Cord Compression (MESCC) in an Inner-City Safety Net Hospital

Outcomes in left versus right metastatic colorectal cancer (mCRC) in patients presenting to an inner-city safety net hospital.

e15542 Background: Studies have shown that patients with left sided colon cancer (L-CRC) have better survival than the right sided ones. However, only few studies focused on minority population. We aim to assess the difference between left versus right sided colon cancer in an inner-city safety net hospital which has a significant proportion of minorities Methods: This is a retrospective study of 105 patients with mCRC who presented to the Medical Oncology clinic of John H Stroger Jr. Hospital of Cook County, Chicago from 2012-2014. Only those who were tested for KRAS mutation were included. Right colon cancer (R-CRC) was defined as tumor located in ascending colon and hepatic flexure. L-CRC were those arising in splenic flexure, descending colon and rectum. Chi-Square was used for categorical variables. Progression free survival (PFS) and overall survival (OS) were analyzed by Kaplan-Meier method, log-rank test and Cox proportional hazards regression models Results: Of the total population, 60.9% were African American (AA), 51.4% males, 48.5% R-CRC, 42.8% L-CRC, 5.7% Transverse-CRC, 3.8% Multicentric-CRC and 68.6% (n = 72) had documented progression. R-CRC showed poorer PFS compared to the left (median PFS 9.1 mo versus 15.1 mo, P = 0.003) but similar OS. KRAS mutation was found in 50.4% of the patients and the rate was higher in AA compared to Caucasians (57.8% versus 22.2%, P = 0.007). It was associated with a better PFS (HR 0.60; 95% CI 0.37, 0.98; P = 0.04) and a higher rate of lung metastasis on presentation (34.6% versus 16.9%, P = 0.03). There was no difference of KRAS mutation prevalence between R-CRC and L-CRC. In addition, having metastases at sites other than liver or lung at presentation was associated with worse PFS (HR 1.90; 95% CI 1.15, 3.14; P = 0.012) and OS (HR, 3.15; 95% CI 1.28, 7.78; P = 0.013) Conclusions: In our inner-city patient population presenting with metastatic CRC, right-sided tumor location and having metastases at sites other than liver or lung at presentation were associated with worse PFS, whereas KRAS mutation was associated with better PFS. Also, AA were more likely to have mutated KRAS than Caucasians, half of whom were Polish in our population

Barriers to Hospice Referral in an Inner City Medical Center (S721)

1.Identify barriers for hospice referral from inner-city safety net hospitals.2.Identify a possible cohort in need of further palliative care interventions in order to align best practices (hospice) for patients at the end of life. Barriers exist to hospice referral for inner-city safety net hospitals. Palliative Care Teams (PCT) are effective at increasing hospice referrals. Despite these findings, a significant numbers of hospice eligible patients are not referred. We hypothesized that lack of referral is due to system challenges as opposed to patient and family preferences. A retrospective review ofprospectively collected data on patients admitted more than once and seen by the PCT at an urban, academic medical center from 3/2008-7/2011. Patients were deemed hospice eligible by the PCT. Information collected included hospice recommendation, discharge outcome, and reasons for declining hospice. Multiple admissions occurred in 409/4407 (9%) PCT patient visits. In 154/409 (38%) visits hospice was recommended by PCT. Of the 154 patients data was available for 121 patients: 86 (71%) patients had no hospice referral and 35 (29%) patients were readmitted after a hospice discharge. The reasons for hospice non-referral include 38/86 (44%) patient declined, 26/86 (30%) family declined, 17/86 (20%) lack of physician support, and 4/86 (5%) no insurance. Patients were predominately male, with a mean age of 54±15 and an average of 3±1 hospital admissions. Patients who declined hospice referal were predominately black (66%) with a mean age of 50±15 years and had common diagnoses of cancer (58%) and AIDS (8%). Ninety-five percent of patients participated in hospice discussion. In inner-city safety net hospital, when the PCT identified hospice-eligible patients but a hospice referral did not occur it was primarily due to patient or family preferences (74%) and less often due to a systems challenge (25%). Race, age, and gender data suggest these patients were younger minority males.

Non-insertive Acupuncture and Neonatal Abstinence Syndrome: a Case Series from an Inner-city Safety Net Hospital

Objective:We report on the safety of non-insertive acupuncture (NIA) in 54 newborns diagnosed with neonatal abstinence syndrome (NAS) in a busy inner-city hospital.Methods:For this case series, a retrospective chart review was conducted. Data on participant demographics, number of NIA treatments, provider referrals, and outcomes of interest (sleeping, feeding, and adverse events) were collected.Results:Of the 54 newborns receiving NIA, 86% were non-Hispanic white; 87% were on Medicaid, and gestational age ranged from 33.2 to 42.1 weeks. Out of 54 chart reviews, a total of 92 NIA sessions were documented ranging from 1 to 6 sessions per infant. Of the total number of treatments (n = 92), 73% were requested by a physician. Chart reviews reported that restless infants calmed down during NIA, babies slept through or fell asleep immediately following NIA, and better feeding was noted following NIA. There were no adverse events noted in the medical records.Conclusions:This retrospective chart review shows potential for the use of NIA as an adjunctive treatment in newborns with NAS symptoms during hospitalization. More research is necessary to study whether the incorporation of NIA can result in positive outcomes in newborns withdrawing from narcotics.

Accomplishing Much in a Short Time

The use of Lean tools for quality improvement and process refinement is gaining acceptance in many health care institutions. Traditionally, these tools are used to apply incremental changes to established processes in order to reduce waste and improve quality. In this article, the authors describe a novel Lean methodology, the Rapid Improvement Event (RIE), used in a unique way to develop a new treatment protocol for a specific medical condition: alcohol withdrawal. The RIE allowed for the collaboration of a multidisciplinary group of providers invested in the success of a new protocol for alcohol withdrawal that spans areas from the emergency department to the inpatient ward at an inner-city safety net hospital. It also allowed for the definition of measures for its success once it is implemented.

Prologed Use of Pegylated Liposomal Doxorubicin In An HIV-Infected Population with Kaposi's Sarcoma at An Inner-City Safety Net Hospital

AbstractAbstract 4873 Introduction:Kaposi's sarcoma (KS) is a low-grade HHV-8 associated vascular tumor that is particularly prevalent in patients infected with HIV. The mainstay of treatment is HAART, which has decreased the aggressiveness, and possibly the prevalence of this disease. Cytotoxic chemotherapy is generally added for moderate to severe symptomatic disease, with Pegylated Liposomal Doxorubicin (Doxil) being the treatment of choice. Studies have shown that unlike regular anthracyclines, Doxil can be safely administered over long periods at low doses without inducing cardio toxicity. The present study was done to evaluate cardiac toxicity associated with prolonged administration of Doxil in patients with KS. Methods:Seven-year retrospective chart review of 55 KS patients treated with 20mg/m2 of Doxil every 3 weeks until disappearance of lesions, withdrawal or change of treatment, or discovery of cardiac damage by annual MUGA scans. All patients received HAART concomitantly. In general, compliance was good. All presenting patients were male with one genetic male transsexual. Results:The median age of patients was 40 years; range between 25 – 56 years.Table 1:DemographicsEthnicityNumberPercentageBlack non-Hispanic3258.2White non-Hispanic1323.6Hispanic814.5Asian23.6Total55100Table 2:Grouping of patients by cumulative dose of Doxil receivedCumulative doseNumber of patients< 200mg/m221200-399mg/m211400-500mg/m27Over 500mg/m216Total555 patients died during the study; 3 due to infectious complications and 2 due to heart disease. 7 patients had to discontinue Doxil when LVEF decreased to < 50%. Of the 16 patients who received >500mg/m2 Doxil, 1 died of cancer and 3 were switched to other drugs due to low LVEF. 1 of these 3 patients with decreased LVEF had a severely abnormal MUGA which then led to the diagnosis of coronary artery disease. The other 12 in this subgroup remain alive with no evidence of heart disease. Conclusion:In concordance with prior studies, our study shows that patients can tolerate greater than 500mg/m2 of cumulative Doxil dose, while being monitored closely with physical examination and MUGA scans. Obtaining MUGA scans every 6 months, instead of annually as was done in our study, may lead to earlier recognition of cardiotoxicity. Disclosures:No relevant conflicts of interest to declare.

The association of adherence to antiretroviral therapy with healthcare utilization and costs for medical care

The association between antiretroviral adherence, healthcare utilization and medical costs has not been well studied. To examine the relationship of adherence to antiretroviral medications to healthcare utilization and healthcare costs. A retrospective cohort study was conducted using data from 325 previously antiretroviral medication-naive HIV-infected individuals initiating first antiretroviral therapy from 1997 through 2003. The setting was an inner-city safety net hospital and HIV clinic in the US. Adherence was assessed using pharmacy refill data. The average wholesale price was used for prescription costs. Healthcare utilization data and medical costs were obtained from the hospital billing database, and differences according to quartile of adherence were compared using analysis of variance (ANOVA). Multivariate logistic regression was used to assess predictors of higher annual medical costs. Sensitivity analyses were used to examine alternative antiretroviral pricing schemes. The perspective was that of the healthcare provider, and costs were in year 2005 values. In 325 patients followed for a mean (+/- SD) 3.2 (1.9) years, better adherence was associated with lower healthcare utilization but higher total medical costs. Annual non-antiretroviral medical costs were $US 7,612 in the highest adherence quartile versus $US 10,190 in the lowest adherence quartile. However, antiretroviral costs were significantly higher in the highest adherence quartile ($US 17,513 vs $US 8,690), and therefore the total annual medical costs were also significantly higher in the highest versus lowest adherence quartile ($US 25,125 vs $US 18,880). In multivariate analysis, for every 10% increase in adherence, the odds of having annual medical costs in the highest versus lowest quartile increased by 87% (odds ratio 1.87; 95% CI 1.45, 2.40). In sensitivity analyses, very low antiretroviral prices (as seen in resource-limited settings) inverted this relationship - excellent adherence was cost saving. Better adherence to antiretroviral medication was associated with decreased healthcare utilization and associated costs; however, because of the high cost of antiretroviral therapy, total medical costs were increased. Combination antiretroviral therapy is known to be cost effective; lower antiretroviral costs may make it cost saving as well.

A qualitative report of patient problems and postoperative instructions

While surgery related stress may interfere with the patient's ability to concentrate on instructions, language difficulty or low health literacy may also impede appropriate doctor/patient communication. The purpose of this study is to understand from a sample of minority patients the types of problems encountered during healing and the level of information regarding elements of postoperative instructions they recalled receiving at an inner-city safety net hospital. We initiated a qualitative study to understand the care sequence process and provision of informed consent and postoperative instruction. African American or Latino patients, 18 years of age or older, who had third molars removed under general anesthesia or received treatment for a mandibular fracture were recruited to participate in a focus group to discuss their treatment. Patients described their problem and any informed consent given about treatment risks and benefits and postoperative information they recalled. A total of 137 former patients were approached, 57 agreed to participate (42%) and 34 of those (60%) completed the interview. Subjects included 14 females and 20 males. Five categories of patient problems were reported: physical, eating, treatment-related, psychosocial, and other problems. People reported 5 categories of coping strategies: medication use, physical treatments, dietary solutions, rest, and clinical assistance. Twenty people recalled being given informed consent, and 5 participants recalled no elements of informed consent. Overall, 14 participants recalled elements of postoperative instruction. Gaps in patient understanding of postoperative care suggest room for improvement in postoperative instructions. Additional research is necessary to design and test high-quality postoperative instructions for surgical treatment and recovery in populations with limited health related literacy.