Large County Health Research Articles

Abstract 11889: Ischemic Evaluation in Patients Presenting With Advanced Atrioventricular Block - Experience From a Large County Health System

Introduction: Coronary artery disease (CAD) is a risk factor for advanced (2 nd degree Mobitz II and 3 rd degree) atrioventricular (AV) block. Research Question: While AV block in the setting of acute myocardial infarction (AMI) is often reversible, data is limited on utility of ischemic evaluation in advanced AV block without AMI. Aim: We assessed whether ischemic evaluation and revascularization was associated with reversibility of advanced AV block not in the setting of AMI. Methods: We queried the electronic medical records of a large county health system that serves the Houston metropolitan area for patients with diagnosis of advanced AV block between 1/1/2018 and 1/1/2022. Demographic, medical history, ischemic evaluation (by coronary catheterization or stress test) data and pacemaker interrogation reports were abstracted from the medical records. Patients with AV block from AMI were excluded. Results: Over a period of 4 years, there were 116 patients who presented with advanced AV block, of which 73 (62.9%) underwent ischemic evaluation either by coronary angiography or non-invasive imaging. Patients who underwent ischemic evaluation were associated with lower pacing burden on device interrogation compared to those with no ischemic evaluation (Table 1). In multivariable regression, ischemic evaluation was associated with lower odds of pacing burden >40% on device interrogation (OR -1.53, 95% CI -3.02, -0.03) but not AV block resolution (OR 0.41, 95% CI -1.76, 2.58). Of those who underwent ischemic evaluation, 26.0% had obstructive CAD, of which 78.9% underwent revascularization. AV block resolved in 13.3% who underwent revascularization. Conclusion: Among patients presenting with advanced AV block not in the setting of AMI, ischemic evaluation was associated with decreased pacing burden but not AV block resolution. In patients found to have obstructive CAD, a minority had resolution of AV block after revascularization.

Disproportionate Burden of COVID-19 Infection Among Hispanic Patients During the First COVID-19 Surge in South Texas.

Introduction:The morbidity and mortality of the COVID-19 pandemic have disproportionately burdened Hispanic populations in the United States. While health equity research is typically conducted in populations where Hispanics are the minority, this project analyzes COVID-19 racioethnic transmission trends over the first 6 months of the pandemic within a large majority-minority city in South Texas.Methods:Patients diagnosed with COVID-19 across inpatient, emergency department, and outpatient settings of a large county health system were included in a clinical registry. For 4644 COVID-19-positive patients between March 16 and August 31, 2020, demographic and clinical data were abstracted from the registry. Race/ethnicity trends over time were compared for patients with and without COVID-19 diagnoses. Logistic regressions identified predictors of inpatient diagnosis by age, race/ethnicity, and testing delay.Results:The proportion of patients with COVID-19 identifying as Hispanic increased rapidly during the pandemic's first months: from 55.6% in March to 85.7% in June. A significantly greater proportion of patients identified as Hispanic within the COVID-19 cohort compared to other diagnoses cohort. Testing delay was 11.6% longer for Hispanic patients, with each day of testing delay associated with 7% increased odds of inpatient COVID-19 diagnosis.Conclusion:These findings highlight the disproportionate impact of COVID-19 on Hispanic populations even within a majority-minority community. In the United States, Hispanic persons are more likely to work frontline jobs, live in multigenerational homes in poverty, and be uninsured. The burden of COVID-19 cases within Bexar County's largest hospital system reflects this systemic inequity. Identifying racioethnic health disparities supports efforts toward mitigating structural factors that predispose minority groups to illness and death.

Training of Registered Dietitian Nutritionists to Improve Culinary Skills and Food Literacy

ObjectiveTo understand if a culinary medicine training program increases food literacy, culinary skills, and knowledge among practicing registered dietitian nutritionists (RDN). MethodsPrepost study design evaluating pilot test of RDN train-the-trainer curriculum from September, 2019 to January, 2020. ResultsOn average, results indicate an increase in culinary nutrition skills (mean difference, 6.7 ± 4.4; P < 0.001; range, 10–30) and a significant increase in 5 of the 8 food literacy factors. Through process evaluation, RDNs rated the training as extremely useful to their practice (mean, 4.4 ± 0.3). Conclusions and ImplicationsRegistered dietitian nutritionist participants increased culinary nutrition skills with statistically significant scores across all individual measures. This study describes an RDN training curriculum in culinary medicine across a diverse group of practicing RDNs from a large county health care system. Culinary medicine shows a promising impact on promoting nutrition skills and confidence; however, it warrants further assessment.

Decreasing Chlamydial Reinfections in a Female Urban Population.

Chlamydia is the most reported bacterial sexually transmitted infection (STI). The rates of chlamydia rose by 19% between 2011 and 2018. The STI National Strategic Plan (2021-2025), encourages coordinated solutions to address STIs and reduce disparities in disadvantaged populations. We implemented institutional policy changes, clinical decision support, including a Best Practice Advisory, and defaulted SmartSet with provider and patient education for women's health clinics at a large county health system. The advisory prompted providers to follow best practices when treating Chlamydia trachomatis infections. New C. trachomatis diagnosis cohorts were compared preintervention and postintervention for 6-month reinfection rates and patient and expedited partner treatment (EPT) practices. Five hundred and nineteen women were included in the final analysis. Six-month chlamydia reinfection was lower in the postintervention cohort after adjusting for age (12.3% [26/211] vs 6.5% [20/308], P = 0.02). There was an increase in directly observed therapy of primary patients (17.5% [37/211] vs 77.3% [238/308], P < 0.001), an increase in EPT prescriptions written (4.3% [9/211] vs 79.5% [245/308], P < 0.0001), and a decrease of partners referred out for treatment (61.6% [130/211] vs 5.2% [16/308], P < 0.001) when compared with the control group. The majority of EPT was patient-delivered partner therapy postintervention (3.3% [7/211] vs 69.2% [213/308], P < 0.001). A multifaceted, streamlined approach was effective in changing provider practices in the treatment of C. trachomatis. Increased rates of directly observed therapy for primary patient treatment and increased rates of patient-delivered partner therapy were observed postimplementation in addition to lower 6-month reinfection rates in a public women's health clinic setting.

Capacity Prioritization Initiative Reduced the Wait Time for Port Placement and Facilitated Increased Volume of Port Placements at a Large County Health System

Description of the problemWait time from request to placement of ports in interventional radiology had increased from 14 to 27 days over a 4-month period. The goal of this project was to reduce the wait time by 15% within 4 months while accommodating additional volume. Instituional approach to address problemCapacity analysis revealed 2 bottlenecks: (1) inadequate provider capacity for preprocedural visits in interventional radiology clinic and (2) inadequate number of spots for port placement in the angiography schedule. The intervention consisted of: (1) 2 reserved slots in the attending physician's morning clinic schedule and (2) 3 daily guaranteed spots for port placement in the angiography suite. Both changes were integrated into the electronic medical record scheduling system. Description of outcomesAfter the intervention, per biweekly period, the number of port requests increased by 17% (Preintervention: 16.6 ± 3.1, Postintervention: 20.1 ± 4.1, P = 0.03), the number of completed clinic visits increased by 19% (Preintervention: 16.7 ± 5.1, Postintervention: 20.5 ± 3.6, P = 0.05), and the number of port placements increased by 19% (Preintervention: 16.9 ± 3.9, Postintervention: 21.0 ± 3.5, P = 0.02). The average wait time from request to placement decreased by 22% (Preintervention: 22.2 ± 4.4 days, Postintervention: 18.3 ± 3.4 days, P = 0.03), driven by a 49% decrease in wait time between request and clinic visit (Preintervention: 11.0 ± 2.3 days, Postintervention: 7.4 ± 1.0 days, P = 0.03). ConclusionsPrioritization of clinic and angiography suite capacity, integrated into the electronic scheduling system, significantly reduced the wait time for port placement, even with significant increases in the volume of port requests.

Facilitators and Barriers of a Health Department-based Mailed Fecal Testing Program.

BACKGROUND Mailed at-home stool testing offers a promising strategy for overcoming barriers to colorectal cancer (CRC) screening in vulnerable populations. This paper evaluates the facilitators and barriers of successful implementation of a mailed fecal testing program among Medicaid populations within a health department setting.METHOD Interviews were conducted with key informants involved in intervention start-up and implementation tasks. The Consolidated Framework for Implementation Research (CFIR) was used to design the interview guide and structure the analysis. Axial coding was used to connect the themes to each other under the major categories of facilitators and barriers.RESULTS Overall, the process evaluation suggests that with strong partnerships, effective champions, and existing infrastructure, a large county health department can successfully implement a mailed fecal testing program targeted at Medicaid beneficiaries. The identified facilitators and challenges to implementation provide important information for similar emerging programs.LIMITATIONS The sample size of this evaluation is small. Additionally, we are unable to discern whether participating stakeholders' responses represent the feelings of non-interviewed staff, program implementers, or participants. We were not able to collect data on patient perspectives of the intervention. The nursing staff and interns were not able to be included in the process evaluation. Lastly, the information taken from this process evaluation may not be applicable to organizations and systems with different attributes.CONCLUSION The process evaluation suggests strong partnerships, effective champions, and elegant program designs were key contributors to successful implementation of a CRC screening program targeted at Medicaid beneficiaries in a large county health department.

Very Severe Hypertriglyceridemia in a Large US County Health Care System: Associated Conditions and Management.

ContextPatients with very severe hypertriglyceridemia (triglyceride levels ≥2000 mg/dL; 22.6 mmol/L) require aggressive treatment. However, little research exists on the underlying etiologies and management of very severe hypertriglyceridemia.ObjectiveWe hypothesized (i) very severe hypertriglyceridemia in adults is mostly associated with secondary causes and (ii) most patients with very severe hypertriglyceridemia lack appropriate follow-up and treatment.DesignWe queried electronic medical records at Parkland Health and Hospital Systems for lipid measurements in the year 2016 and identified patients with serum triglyceride levels ≥2000 mg/dL (22.6 mmol/L). We extracted data on demographics, underlying causes, lipid-lowering therapy, and follow-up.ResultsOne hundred sixty-four serum triglyceride measurements were ≥2000 mg/dL (22.6 mmol/L) in 103 unique patients. Of these, 60 patients were admitted to the hospital (39 for acute pancreatitis). Most were Hispanic (79%). The major conditions associated with very severe hypertriglyceridemia included uncontrolled diabetes mellitus (74%), heavy alcohol use (10%), medication use (7%), and hypothyroidism (2%). Two patients were known to have monogenic causes of hypertriglyceridemia. After the index measurement of triglycerides ≥2000 mg/dL (22.6 mmol/L), the use of triglyceride-lowering drugs increased, most prominently the use of fish oil supplements, which increased by 80%. However, in follow-up visits, hypertriglyceridemia was addressed in only 50% of encounters, and serum triglycerides were remeasured in only 18%.ConclusionIn summary, very severe hypertriglyceridemia was quite prevalent (∼0.1% of all lipid measurements) in our large county health care system, especially in Hispanic men. Most cases were related to uncontrolled diabetes mellitus, and follow-up monitoring was inadequate.

Comparative effectiveness of mailed reminders with and without fecal immunochemical tests for Medicaid beneficiaries at a large county health department: A randomized controlled trial.

Colorectal cancer (CRC) screening is effective but underused. Screening rates are lower among Medicaid beneficiaries versus other insured populations. No studies have examined mailed fecal immunochemical testing (FIT)-based outreach programs for Medicaid beneficiaries. In a patient-level randomized controlled trial, a mailed CRC screening reminder plus FIT, sent from an urban health department to Medicaid beneficiaries, was compared with the same reminder without FIT. The reminder group could request FIT. Completed FIT kits were processed by the health department laboratory. Respondents were notified of normal results by mail. Abnormal results were given via phone by a patient navigator who provided counselling and assistance with follow-up care. The primary outcome was FIT return. In all, 2144 beneficiaries at average CRC risk were identified, and there was no evidence of screening with Medicaid claims data. To the reminder+FIT group, 1071 were randomized, and 1073 were randomized to the reminder group; 307 (28.7%) in the reminder+FIT group and 347 (32.3%) in the reminder group were unreachable or ineligible (previous screening). The FIT return rate was significantly higher in the reminder+FIT group than the reminder group (21.1% vs 12.3%; difference, 8.8%; 95% confidence interval, 3.7%-13.9%; P < .01). Eighteen individuals (7.2%) who completed FIT tests had abnormal results, and 15 were eligible for follow-up colonoscopy; 66.7% (n = 10) completed follow-up colonoscopy. A health department-based, mailed FIT program targeting Medicaid beneficiaries was feasible. Including a FIT kit resulted in greater screening completion than a reminder letter alone. Further research is needed to understand the comparative cost-effectiveness of these interventions.

Completeness and timeliness of notifiable disease reporting: a comparison of laboratory and provider reports submitted to a large county health department

BackgroundMost public health agencies expect reporting of diseases to be initiated by hospital, laboratory or clinic staff even though so-called passive approaches are known to be burdensome for reporters and produce incomplete as well as delayed reports, which can hinder assessment of disease and delay recognition of outbreaks. In this study, we analyze patterns of reporting as well as data completeness and timeliness for traditional, passive reporting of notifiable disease by two distinct sources of information: hospital and clinic staff versus clinical laboratory staff. Reports were submitted via fax machine as well as electronic health information exchange interfaces.MethodsData were extracted from all submitted notifiable disease reports for seven representative diseases. Reporting rates are the proportion of known cases having a corresponding case report from a provider, a faxed laboratory report or an electronic laboratory report. Reporting rates were stratified by disease and compared using McNemar’s test. For key data fields on the reports, completeness was calculated as the proportion of non-blank fields. Timeliness was measured as the difference between date of laboratory confirmed diagnosis and the date the report was received by the health department. Differences in completeness and timeliness by data source were evaluated using a generalized linear model with Pearson’s goodness of fit statistic.ResultsWe assessed 13,269 reports representing 9034 unique cases. Reporting rates varied by disease with overall rates of 19.1% for providers and 84.4% for laboratories (p < 0.001). All but three of 15 data fields in provider reports were more often complete than those fields within laboratory reports (p <0.001). Laboratory reports, whether faxed or electronically sent, were received, on average, 2.2 days after diagnosis versus a week for provider reports (p <0.001).ConclusionsDespite growth in the use of electronic methods to enhance notifiable disease reporting, there still exists much room for improvement.

Transitional care management in the outpatient setting

Patients who are high risk high cost (HRHC), those with severe or multiple medical issues, and the chronically ill elderly are major drivers of rising health care costs.1 The HRHC...

A practical approach for incorporating dependence among fields in probabilistic record linkage

BackgroundMethods for linking real-world healthcare data often use a latent class model, where the latent, or unknown, class is the true match status of candidate record-pairs. This commonly used model assumes that agreement patterns among multiple fields within a latent class are independent. When this assumption is violated, various approaches, including the most commonly proposed loglinear models, have been suggested to account for conditional dependence.MethodsWe present a step-by-step guide to identify important dependencies between fields through a correlation residual plot and demonstrate how they can be incorporated into loglinear models for record linkage. This method is applied to healthcare data from the patient registry for a large county health department.ResultsOur method could be readily implemented using standard software (with code supplied) to produce an overall better model fit as measured by BIC and deviance. Finding the most parsimonious model is known to reduce bias in parameter estimates.ConclusionsThis novel approach identifies and accommodates conditional dependence in the context of record linkage. The conditional dependence model is recommended for routine use due to its flexibility for incorporating conditional dependence and easy implementation using existing software.

Economic impact of ambulatory care formulary restrictions at a large county health system

Study results documenting substantial cost savings achieved by an outpatient indigent-care pharmacy program through formulary modifications and optimized purchasing practices are presented. Wholesale purchasing data were retrospectively evaluated to compare drug expenditures before and after a large Florida hospital's adoption of a tiered formulary system for three ambulatory care facilities serving mostly uninsured patients. The outcomes assessed included the average cost per prescription and total medication purchases before and after implementation of the tiered formulary, which was phased in over several months and accompanied by intensive educational programs targeting physicians and pharmacy staff. Other outcomes included cost avoidance resulting from an increased emphasis on patient assistance program (PAP) enrollment and the use of "bulk replacement" arrangements for prescription replenishment. During a designated nine-month postimplementation period, the average cost per prescription declined by 4.7% (from $19.86 to $18.92) relative to the baseline value. Six-month spending decreases of 36-58% from prior-year levels were achieved in 7 of the 10 most-purchased drug classes, with an overall 25% decline in medication purchases. Cost avoidance due to more aggressive use of PAPs and bulk replacement programs also yielded substantial program savings. Formulary streamlining and other cost-control initiatives at an outpatient pharmacy program were associated with a decrease in the average cost per prescription of $0.94 over a nine-month period. The primary endpoint showed a potential annualized savings of approximately $1 million.

Interactive Health Communication Technologies in the Public Health Sector: Positive Perceptions Still Outpace Actual Utilization

ABSTRACT Effective population-based and patient-centered public health care is highly dependent on timely and reliable health-related information. The continuous growth and availability of health-related information brought about by the emergence of a new digital communications environment offers a range of opportunities that facilitate access to useful health information for the public health sector–for providers as well as patients. Such advancements, however, can only be realized if public health professionals are knowledgeable about existing sources of online health information, have the ability to successfully judge the reliability of online health information, and are able to acquire the information in a timely and efficient manner. This research follows on the heels of a survey of public health professionals in New York State that concluded that limited access and knowledge negatively impacted utilization of interactive health communication technologies. In this study, a survey was administered to providers at a large county health department located in central Michigan. Results indicate that perceptions regarding the advantages of online health information still far outweigh actual utilization. Barriers to actual utilization include lack of easy access to computers with high-speed connections, trusted and timely online information, training and staff development issues, and organizational policies concerning computer access and usage.

Depot medroxyprogesterone acetate pioneers: A retrospective study at a north carolina health department

This article examines the characteristics of the first group of depot medroxyprogesterone acetate (DMPA) acceptors after US Food and Drug Administration (FDA) approval of the method and evaluates their continuation rates and factors associated with discontinuation. This was a population based retrospective study based on 12 months of clinic data for 510 women who began using DMPA in 1993 at a large county health department. Cumulative 12 month life table rates were calculated for the entire group and were then stratified by selected characteristics. The 4, 8, and 12 month continuation rates were 67%, 46%, and 35%, respectively. More than half of these women discontinued because of bleeding and nonbleeding side effects (25% and 28%, respectively). Almost 20% of these women were considered discontinuers because they waited longer than 16 weeks to return for an injection. As measured in this study, continuation rates for this first group of DMPA acceptors were low. The next step is to determine if the characteristics and patterns of use of these “pioneer” acceptors are representative of more recent acceptors, and if lessons learned from this group will lead to higher continuation rates.

Development of an orthopaedic case manager role.

Creation of a case manager role was one institution's strategy to improve the coordination and delivery of care for orthopaedic trauma patients. This article describes the development and implementation of the innovative role within a large county health system and applies Neuman's Health Care Systems Model to the process.

Evaluation of a Follow-Up System in a County Health Department’s Immunization Clinic

We designed a pilot follow-up system using two mailed reminders and evaluated it for use in the immunization clinic of a relatively large county health department in Washington State. Compliance with the recommended interval for DTP immunizations increased by 33.9% in the group of children receiving two postcard reminders compared to the control group. Over half of the respondents (52%) in the control group and 28% in the intervention group reported that transportation barriers and clinic problems prevented their return.

The Postgraduate Education of Physicians in Preventive Medicine

The Graduate Medical Education National Advisory Committee report projected a serious shortage of preventive medicine specialists in 1990, and the recommendations of a recent report from the Association of American Medical Colleges called for increased training of medical students in health promotion and disease prevention and in adapting to changes in health and health care. To help meet the need for physician manpower in preventive medicine a new residency was established at the State University of New York at Stony Brook in July 1983. The program features a structured approach to the practicum year, incorporating an organized core curriculum and opportunities for a varied field experience. In addition to the School of Medicine and University Hospital, major training sites include two large county health departments on Long Island, three community hospital departments of community medicine, a health maintenance organization as well as several neighborhood health centers, and community-based programs operated by these hospitals and health departments. The curriculum includes both longitudinal experiences at the medical school involving teaching, research, and didactic conferences, and block field rotations within the above affiliated agencies, providing practice experience in preventive medicine and public health. The diversity in the organization and type of preventive medicine institutions used for training enriches the residency experience and is complemented by core educational activities.

Nursing activities of the Erie County Department of Health and their reporting.

nurses of the Erie County Department of Health vary little from those performed by public health nurses in any large county health unit. In the last few years there has been an increasing demand for bedside service for the care of the sick in their homes and in group activities for health education. Our nursing activities are classified according to type of service. The direct nursing service that is rendered to or in behalf of individuals falls into three broad categories-home visits, school visits, and clinic visits. The clinic visits