Care Metrics Research Articles

The status of person-centered contraceptive care in the United States: Results from a nationally representative sample.

The Person-Centered Contraceptive Care measure (PCCC) evaluates patient experience of contraceptive counseling, a construct not represented within United States surveillance metrics of contraceptive care. We explore use of PCCC in a national probability sample and examine predictors of person-centered contraceptive care. Among 2228 women from the 2017-2019 National Survey of Family Growth who reported receiving contraceptive care in the last year, we conducted univariate and multivariable linear regression to identify associations between individual characteristics and PCCC scores. PCCC scores were high ( : 17.84, CI: 17.59-18.08 on a 4-20 scale), yet varied across characteristics. In adjusted analyses, Hispanic identity with Spanish language primacy and non-Hispanic other or multiple racial identities were significantly associated with lower average PCCC scores compared to those of non-Hispanic white identity (B = -1.232 [-1.970, -0.493]; B = -0.792 [-1.411, -0.173]). Gay, lesbian, or bisexual identity was associated with lower average PCCC scores compared to heterosexual (B = -0.673 [-1.243, -0.103]). PCCC scores had a positive association with incomes of 150%-299% and ≥300% of the federal poverty level compared to those of income <150% (150%-299%: B = 0.669 [0.198, 1.141]; ≥300%: B = 0.892 [0.412, 1.372]). Cannabis use in the past year was associated with lower PCCC scores (B = -0.542 [-0.971, -0.113]). The PCCC can capture differential experiences of contraceptive care to monitor patient experience and to motivate and track care quality over time. Differences in reported quality of care have implications for informing national priorities for contraceptive care improvements.

A broadly applicable approach to enrich electronic-health-record cohorts by identifying patients with complete data: a multisite evaluation.

Patients who receive most care within a single healthcare system (colloquially called a "loyalty cohort" since they typically return to the same providers) have mostly complete data within that organization's electronic health record (EHR). Loyalty cohorts have low data missingness, which can unintentionally bias research results. Using proxies of routine care and healthcare utilization metrics, we compute a per-patient score that identifies a loyalty cohort. We implemented a computable program for the widely adopted i2b2 platform that identifies loyalty cohorts in EHRs based on a machine-learning model, which was previously validated using linked claims data. We developed a novel validation approach, which tests, using only EHR data, whether patients returned to the same healthcare system after the training period. We evaluated these tools at 3 institutions using data from 2017 to 2019. Loyalty cohort calculations to identify patients who returned during a 1-year follow-up yielded a mean area under the receiver operating characteristic curve of 0.77 using the original model and 0.80 after calibrating the model at individual sites. Factors such as multiple medications or visits contributed significantly at all sites. Screening tests' contributions (eg, colonoscopy) varied across sites, likely due to coding and population differences. This open-source implementation of a "loyalty score" algorithm had good predictive power. Enriching research cohorts by utilizing these low-missingness patients is a way to obtain the data completeness necessary for accurate causal analysis. i2b2 sites can use this approach to select cohorts with mostly complete EHR data.

Impact of Telemedicine Modality on Quality Metrics in Diverse Settings: Implementation Science-Informed Retrospective Cohort Study.

Video-based telemedicine (vs audio only) is less frequently used in diverse, low socioeconomic status settings. Few prior studies have evaluated the impact of telemedicine modality (ie, video vs audio-only visits) on clinical quality metrics. The aim of this study was to assess telemedicine uptake and impact of visit modality (in-person vs video and phone visits) on primary care quality metrics in diverse, low socioeconomic status settings through an implementation science lens. Informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, we evaluated telemedicine uptake, assessed targeted primary care quality metrics by visit modality, and described provider-level qualitative feedback on barriers and facilitators to telemedicine implementation. We found marginally better quality metrics (ie, blood pressure and depression screening) for in-person care versus video and phone visits; de-adoption of telemedicine was marked within 2 years in our population. Following the widespread implementation of telemedicine during the COVID-19 pandemic, the impact of visit modality on quality outcomes, provider and patient preferences, as well as technological barriers in historically marginalized settings should be considered.

Inequities in Patient Access to Care Among Asian American, Native Hawaiian, and Pacific Islander Adults in Medicaid.

Despite decades of advocacy for disaggregated data collection and reporting for Asian American, Native Hawaiian, and Pacific Islander (AA and NHPI) people, significant gaps remain in our ability to understand AA and NHPI individuals' access to care. We assess inequities in access to care measures between non-Hispanic White and AA and NHPI adult Medicaid enrollees. We used the 2014-15 Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers and Systems, the first-and-only nationally representative sample of Medicaid enrollees. Our main outcomes were access to needed care, access to a personal doctor, timely access to a checkup, and timely access to specialty care. Using multivariable linear probability models, we assessed the relationship between racial/ethnic group and our outcomes, both in the aggregate and disaggregated into ten racial/ethnic groups, and adjusted for enrollee-level sociodemographic characteristics, health status, and state-level Medicaid expansion status. In aggregate, AA and NHPI enrollees reported worse access to care than White enrollees on all four metrics (p < 0.001). The magnitude of disparities varied across the ten AA and NHPI ethnic groups. Disparities relative to White enrollees were particularly large in magnitude, roughly 1.5 to 2 times greater, for Chinese, Korean, and Vietnamese enrollees than for the aggregated AA and NHPI group. Despite comparable insurance coverage, there were inequities in multiple access to care metrics between non-Hispanic White and AA and NHPI Medicaid enrollees. Collection of disaggregated health data on AA and NHPI patients reveals important variation in access to care by ethnic group.

Assessing trends in breast care surveillance metrics after implementing surgeon-specific tracking and performance reporting in a large, integrated cancer network.

There are few quality metrics and benchmarks specific to surgical oncology. Development of a surgeon-level performance metrics system based on peer comparisons is hypothesized to positively influence surgical decision-making. This study established a tracking and reporting system comprised of evidence and consensus-based metrics to assess breast care delivered by individual surgeons. Surgeons' performance is assessed by a surveillance tracking system of metrics pertaining to referrals and surgical elements. This retrospective analysis of prospectively collected breast care data reports on recurring 6-month and cumulative data from nine care locations from 2015 to 2021. Breast care was provided to 6659 patients by 41 surgeons. A total of 27 breast care metrics were evaluated over 7 years. Metrics with consistent, proficient results were retired after 18 months, including the rate of core biopsy, specimen orientation, and referrals to medical oncology, genetics, and fertility, among others. In clinically node-negative, hormone receptor-positive patients 70 years of age or older, the cumulative rate of sentinel lymph node (SLN) biopsy significantly decreased by 40% over 5.5 years (p<.001). The overall breast conservation rate for T0-T2 cancer increased 10% over 7 years. At the surgeon level, improvements were made in the median number of SLNs removed and in operative note documentation. Implementation of a surgeon-specific, peer comparison-based metric and tracking system has yielded substantive changes in breast care management. This process and governance structure can serve as a model for quantification of breast care at other institutions and for other disease sites.

Implementation of the South Australian Regional Telestroke service is associated with improved care quality and lower stroke mortality: A retrospective cohort study.

Stroke in Regional Australia may have worse outcomes due to difficulties accessing optimal care. The South Australian Regional Telestroke service aimed to improve telestroke neurologist access, supported by improved ambulance triage. To assess stroke care quality and patient mortality pre- and postimplementation of a vascular neurologist-led Telestroke service. Historically controlled mixed methods cohort study comparing key quality indicators and patient mortality (6 months pre- vs. 18 months postimplementation date [4 June 2018]) at the three major South Australian regional stroke centres. The primary outcome was 13 care quality indicators as a combined composite risk-adjusted score, and the secondary outcome was risk-adjusted mortality at 12-month postadmission. On an annualised basis, of 189 patients with stroke, more were admitted postintervention to the regional stroke centres than in the control period (158 [annualised rate 105.3, 95% CI 86.2-127.4] vs. 31 [annualised rate 62.0, 95% CI 47.5-79.5]) Baseline patient characteristics were similar in both periods. Post-implementation, median last-known-well time to presentation (3.5 h [IQR 1.6-17] vs. 2.0 [IQR 1-14]; p = 0.46) and door to needle times (121 min [IQR 97-144] vs. 90 [IQR 75-138]; p = 0.65) were not significantly lower but an improvement in the combined composite quality score was observed (0.069 [95% CI 0.004-0.134; p = 0.04]), reflecting individual improvements in some quality indicators. Mortality at 12-month postimplementation was substantially lower postimplementation (prechange 23% vs. postchange 13% [hazard ratio 0.58 (95% CI 0.44-0.76; p < 0.001)]). Implementation of a South Australian Regional Telestroke service was associated with improved care metrics and lower mortality.

Paradigm Shifts in Alloplastic Breast Reconstruction: A Nationwide Analysis of Direct-to-Implant Trends.

Direct-to-implant breast reconstruction is an attractive choice for appropriately selected patients, as a single-stage procedure can enhance global metrics of care. In an era of high-value health care, therefore, it is important to investigate use of such procedures. This study investigated direct-to-implant trends over the past decade on a nationwide basis. This was a retrospective investigation of direct-to-implant reconstruction between 2010 and 2018 in the United States, using the National Inpatient Sample database. All study analyses were undertaken using Stata version 15.0. The weighted sample included 287,093 women who underwent implant-based reconstruction between 2010 and 2018, of whom 43,064 (15%) underwent direct-to-implant reconstruction. Across the study period, the proportion of direct-to-implant procedures increased significantly ( P = 0.03), relative to staged and delayed implant-based procedures. Although direct-to-implant patients were younger and more likely to be White and privately insured, the proportion of non-White, publicly insured patients undergoing direct-to-implant reconstruction increased significantly by 2018 ( P < 0.05). Furthermore, direct-to-implant use among Medicaid patients was 2.2 times the rate in Medicaid expansion states compared with nonexpansion states. Direct-to-implant patients had significantly higher All Patient Refined Diagnosis Related Group risk scores in 2018 than in 2010 ( P = 0.02), indicating expanding clinical indications for this procedure. Direct-to-implant reconstruction had significantly lower inpatient charges than staged procedures ( P = 0.03), when considering expander placement and expander-to-implant exchange. Overall, use of direct-to-implant breast reconstruction has significantly increased over the past decade, facilitated by expanding clinical indications and improved insurance coverage. However, certain disparities continue to exist. Further work should investigate drivers of disparities to allow continued expansion of direct-to-implant reconstruction as clinically appropriate. Therapeutic, III.

Metrics of care and cardiovascular outcomes in patients with ST-elevation myocardial infarction treated with pharmacoinvasive strategy: a decade-long network in a populous city in Brazil

BackgroundPharmacoinvasive strategy is an effective myocardial reperfusion therapy when primary percutaneous coronary intervention (p-PCI) cannot be performed in a timely manner.MethodsAuthors sought to evaluate metrics of care and cardiovascular outcomes in a decade-long registry of a pharmacoinvasive strategy network for the treatment of ST-elevation myocardial infarction (STEMI). Data from a local network including patients undergoing fibrinolysis in county hospitals and systematically transferred to the tertiary center were accessed from March 2010 to September 2020. Numerical variables were described as median and interquartile range. Area under the curve (AUC-ROC) was used to analyze the predictive value of TIMI and GRACE scores for in-hospital mortality.ResultsA total of 2,710 consecutive STEMI patients aged 59 [51–66] years, 815 women (30.1%) and 837 individuals with diabetes (30.9%) were analyzed. The time from symptom onset to first-medical-contact was 120 [60–210] minutes and the door-to-needle time was 70 [43–115] minutes. Rescue-PCI was required in 929 patients (34.3%), in whom the fibrinolytic-catheterization time was 7.2 [4.9–11.8] hours, compared to 15.7 [6.8–22,7] hours in those who had successful lytic reperfusion. All cause in-hospital mortality occurred in 151 (5.6%) patients, reinfarction in 47 (1.7%) and ischemic stroke in 33 (1.2%). Major bleeding occurred in 73 (2.7%) patients, including 19 (0.7%) cases of intracranial bleeding. C-statistic confirmed that both scores had high predictive values for in-hospital mortality, demonstrated by TIMI AUC-ROC of 0.80 [0,77–0.84] and GRACE AUC-ROC of 0.86 [0.83—0.89].ConclusionIn a real world registry of a decade-long network for the treatment of ST-elevation myocardial infarction based on the pharmacoinvasive strategy, low rates of in-hospital mortality and cardiovascular outcomes were observed, despite prolonged time metrics for both fibrinolytic therapy and rescue-PCI. Register Clinicaltrials.gov NCT02090712 date of first registration 18/03/2014.

Association of Historical Redlining and Present-Day Social Vulnerability with Cancer Screening.

The Healthy People 2030 initiative has set national cancer screening targets at 77.1%, 74.4%, and 84.3% for breast, colon, and cervical cancers, respectively. We sought to assess the association between historical redlining relative and present-day social vulnerability on screening targets for breast, colon, and cervical cancer. Data on national census-tract level cancer screening prevalence and social vulnerability index in 2020 was extracted from the CDC PLACES and CDC social vulnerability index databases, respectively. Census tracts were then assigned Home-Owners Loan Corporation grades (A: "Best", B: "Still Desirable", C: "Definitely Declining," and D: "Hazardous/Redlined"). Mixed-effects logistic regression and mediation analyses were conducted to evaluate the association between Home-Owners Loan Corporation grades and achievement of cancer screening targets. Among 11,831 census tracts, 3,712 were classified as redlined (A: n = 842, 7.1% vs B: n = 2,314, 19.6% vs C: n = 4,963, 42.0% vs D: n = 3,712, 31.4%). Notably, 62.8% (n = 7,427), 21.2% (n = 2,511), and 27.3% (n = 3,235) of tracts met screening targets for breast, colon, and cervical cancer, respectively. After adjusting for present-day social vulnerability index and access to care metrics (population to primary care physician ratio and distance to nearest healthcare facility), redlined tracts were markedly less likely to meet breast (odds ratio [OR] 0.76, 95% CI 0.64 to 0.91), colon (OR 0.34, 95% CI 0.28 to 0.41), and cervical (OR 0.21, 95% CI 0.16 to 0.27) cancer screening targets compared with the "Best" tracts. Notably, poverty, lack of education, and limited English proficiency, among others, mediated the adverse effect of historical redlining on cancer screening. Redlining as a surrogate for structural racism continues to adversely impact cancer screening. Policies that aim to make access to preventive cancer care more equitable for historically marginalized communities should be a public priority.

A nomadic multi-agent based privacy metrics for e-health care: a deep learning approach.

In recent years, there has been a surge in the use of deep learning systems for e-healthcare applications. While these systems can provide significant benefits regarding improved diagnosis and treatment, they also pose substantial privacy risks to patients' sensitive data. Privacy is a crucial issue in e-healthcare, and it is essential to keep patient information secure. A new approach based on multi-agent-based privacy metrics for e-healthcare deep learning systems has been proposed to address this issue. This approach uses a combination of deep learning and multi-agent systems to provide a more robust and secure method for e-healthcare applications. The multi-agent system is designed to monitor and control the access to patients' data by different agents in the system. Each agent is assigned a specific role and has specific data access permissions. The system employs a set of privacy metrics to a substantial privacy level of the data accessed by each agent. These metrics include confidentiality, integrity, and availability, evaluated in real-time and used to identify potential privacy violations. In addition to the multi-agent system, the deep learning component is also integrated into the system to improve the accuracy of diagnoses and treatment plans. The deep learning model is trained on a large dataset of medical records and can accurately predict the diagnosis and treatment plan based on the patient's symptoms and medical history. The multi-agent-based privacy metrics for the e-healthcare deep learning system approach have several advantages. It provides a more secure system for e-healthcare applications by ensuring only authorized agents can access patients' data. Privacy metrics enable the system to identify potential privacy violations in real-time, thereby reducing the risk of data breaches. Finally, integrating deep learning improves the accuracy of diagnoses and treatment plans, leading to better patient outcomes.

The association between systemic anticancer therapy (SACT) at the end of life (EOL) and acute care use among patients treated at oncology practices participating in the Oncology Care Model (OCM).

6580 Background: Receipt of chemotherapy near EOL has been shown to harm patient and caregiver experience, increase hospitalizations, intensive care unit (ICU) and emergency department (ED) use and drive-up costs. As rates of chemotherapy at EOL have declined, we have seen increases in the rates of immunotherapy at EOL. It is unknown whether use of EOL immunotherapy is associated with the same pattern of higher downstream acute care use and cost. Using data from OCM, a Centers for Medicare and Medicaid Services (CMS) alternative payment model, we evaluated the relationship between SACT type and acute care utilization within 30 days of death. Methods: Using anonymized Integra Connect data for OCM episode claims attributed to 8 multi-site OCM practices between July 2016 and December 2021, we stratified patients by SACT type received within 30 days of death (immunotherapy (IO), chemotherapy (CT), or none) and used chi-square tests to compare the proportion of decedents who had inpatient admission, ICU stay, ED visits without inpatient admission, and hospice use within 30 days of death. Results: Among 14,169 OCM decedents, 2,227 (15.7%) received IO within 30 days of death, 6,627 (46.8%) received CT and 5,315 (37.5%) received no SACT (table). Patients who received no SACT at EOL were significantly more likely to start hospice within 30 days of death (76%) and to be in hospice for ≥3 days prior to death (61%) compared with IO (65% and 40%) and CT patients (59% and 37%) respectively (all p-values&lt;0.05). Patients who received IO or CT were significantly more likely to have an inpatient stay within 30 days of death (66% and 68% respectively) compared with patients who received no SACT at EOL (58%, p-values &lt;0.001). No difference in ED visits within 30 days of death between IO (18%), CT (20%), and no SACT (19%) p &lt; 0.270. Conclusions: Patients who received chemotherapy or IO therapy within 30 days of death had higher proportion of inpatient admissions, ICU stay and lower rates of hospice than patients who received no SACT at the EOL. Patients who did not have any SACT at EOL were more likely to utilize hospice services and for a longer time. Further research should explore whether these findings are generalizable to patients outside of OCM and the magnitude of costs associated with these acute care metrics. [Table: see text]

AB163. SOH23ABS_050. Digital delivery of pain assessment education in the hospital setting—breaking barriers to enhance skills

Background: Audit of nursing documentation found that standards on pain assessment were not being met when measured against national quality care metrics. Face-to-face supportive education was impacting on staff and clinical nurse specialist (CNS) workload. Further education was needed to support nursing staff of the 12 identified units. The aim of the study was to identify the effectiveness of the delivery of supportive pain assessment education utilizing a digital platform in the hospital setting.

The Positive Effects of Manual Pronation in a United States Community Based Hospital Intensive Care Unit During the COVID-19 Surge Crisis

Background&#x0D; Patients in acute respiratory distress syndrome suffer a high mortality rate; however, manual pronation has a survival advantage up to 17% (Gattinoni, 2013). March 2020 marked the initial COVID-19 surge in the US, characterized by government lock-downs, inundation of healthcare systems, and high patient fatality levels. Initially, COVID-19 patients who might benefit from manual pronation were transferred to other local facilities until our interdisciplinary team implemented a manual pronation policy within 27 days of receiving our first COVID-19 positive patient.&#x0D; Aim&#x0D; The aim of this study was to describe the impact of a community hospital partaking in manual pronation for the first time, quality care metrics—specifically Central Line-Associated Bloodstream Infections (CLABSIs), Catheter-Associated Urinary Tract Infections (CAUTIs), and Ventilator-Associated Pneumonia/Events (VAP/VAEs)—associated with the COVID-19 surge, and the barriers overcome during this process.&#x0D; Methods&#x0D; This retrospective data collection study included hypoxemia, intubation, discharge and quality safety data from March 13 to June 1, 2020 for patients who underwent manual pronation.&#x0D; Results/Findings &#x0D; Pronation occurred a total of twenty-seven times in 13 patients (seven (53.8%) survived and six (46.2%) died during hospital admission). Four (57.1%) of the patients who survived were discharged home, two (28.6%) went to a rehabilitation facility, and one (14.3%) was transferred to an outside hospital. Zero CAUTIs (458 catheter days), CLABSIs (371 central line days), and VAEs (384 ventilator days) occurred during the study.&#x0D; Conclusions&#x0D; With the newly acquired proning policy in place and creative COVID-19 care, data were consistent with an overall improvement in patient outcomes. Manual pronation was shown to improve P/F ratios. There were no upticks in hospital acquired infections, notably CAUTIs, CLABSIs, and VAP/VAEs at our facility.

Telehealth Utilization in a Comprehensive Multiple Sclerosis Clinic During the COVID-19 Pandemic: Single Center Experience (P3-3.005)

Telehealth Utilization in a Comprehensive Multiple Sclerosis Clinic During the COVID-19 Pandemic: Single Center Experience (P3-3.005)

Prognostic impact of increased lymph node yield in colorectal cancer patients with synchronous liver metastasis: a population-based retrospective study of the US database and a Chinese registry.

The National Quality Forum has endorsed at least 12 lymph node yield (LNY) as a surgical quality indicator in colorectal cancer (CRC), but the prognostic value of adequate lymphadenectomy has rarely been investigated for CRC patients with distant metastatic disease. A total of 4575 CRC patients with synchronous liver metastasis who underwent primary tumor resection were identified from a Chinese registry and the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2017. The Kaplan-Meier methods and Cox regression models were performed to assess the correlations between LNY and 3-year cancer-specific survival (CSS). Propensity score matching were used to confirmed the survival comparison between patients with less than 12 and of at least 12 LNY. The retrieval of at least 12 LNY was identified in most CRC patients (SEER database, 3380/3899, 86.7%; Chinese cohort, 565/676, 83.6%). In both the SEER database and the Chinese cohort, the patients with LNY ≥12 was significantly associated with better CSS compared with patients with LNY <12 before and after propensity score matching, with all P -value less than 0.05. After controlling for the confounders, multivariate analysis demonstrated that LNY was also an independent prognostic factor for patients with distant metastasis in both cohorts. In subgroup analysis, the CSS benefit for patients with LNY ≥12 was observed across most of the subgroups. Clinical feasibility of the 12-node threshold as a guideline quality metric of cancer care for CRC patients is necessary, and an oncologically adequate lymphadenectomy is still a critical component of high-quality surgical standard in CRC patients with distant metastases.

Near real-time prediction of urgent care hospital performance metrics using scalable random forest algorithm: A multi-site development

While previous studies have shown the potential value of predictive modelling for emergency care, few models have been implemented for producing near real-time predictions across various demand, utilisation and performance metrics. In this study, 33 independent Random Forest (RF) algorithms were developed to forecast 11 urgent care metrics over a 24-hour period across three hospital sites in an Integrated Care System (ICS) in South West England. Metrics included: ambulance handover delay; emergency department occupancy; and patients awaiting admission. Mean Absolute Error (MAE), Root Mean Squared Error (RMSE) and Symmetric Mean Absolute Percentage Error (SMAPE) were used to assess the performance of RF and compare it to two alternative models: naïve baseline (NB) and Auto-Regressive Integrated Moving Average (ARIMA). Using these measures, RF outperformed NB and ARIMA in 76% (N = 25/33) of urgent care metrics according to SMAPE, 88% (N = 29/33) according to MAE and 91% (N = 30/33) according to RMSE. The RFs developed in this study have been implemented within the local ICS, providing predictions on an hourly basis that can be accessed by local healthcare planners and managers.

169 COPD Care for Patients in Rural Clinics: A Mixed Methods Evaluation

OBJECTIVES/GOALS: To assess barriers and recommendations for improving delivery of care for chronic obstructive pulmonary disease (COPD) in rural clinics, we assessed COPD care metrics and obtained perspectives of primary care providers (PCPs) who practice in rural clinics. METHODS/STUDY POPULATION: Quantitative retrospective analysis of patients with COPD using VA data. We included patients whose primary care clinic is located in a rural VA Midwest Health Care Network (HCN) facility and quantified binary measures for receipt of: spirometry, pulmonary specialty care, and optimal inhaler therapy (regimen with LAMA or LABA monotherapy) Qualitative semi-structured individual interviews of PCPs (physicians, nurse practitioners, and physician assistants) whose clinics are located in a rural VA Midwest HCN facility. We elicited perceived barriers to and recommendations for receiving spirometry, pulmonary specialty care, and optimal inhaler therapy from PCPs. RESULTS/ANTICIPATED RESULTS: 6,350 rural patients had a new diagnosis of COPD in 2016-2019. 48.4% had spirometry, 14.4% had pulmonary encounters, and among patients who were prescribed long-acting inhaler therapy, 48.8% received optimal inhaler regimens. Rural PCPs (n=14) highlighted lack of access to spirometry, pulmonary specialty care, and clinic staff support in local clinics and suggested: 1) leveraging the expertise of pharmacists in COPD management and 2) improving access to resources, including use of telehealth technologies. DISCUSSION/SIGNIFICANCE: Less than 50% of rural COPD patients received recommended diagnostic testing and therapy. Resource limitations in rural clinics were the main barrier. The main recommendation was to leverage pharmacists’ expertise in COPD care. These findings provide a pathway forward to improving rural COPD care.

HOW DOES PROVISION OF ORTHOGERIATRICIAN TIME INFLUENCE MANAGEMENT OF PATIENTS WITH A HIP FRACTURE?

A hip fracture represents the extreme end of osteoporosis, placing a significant burden on secondary care, society, and the individual patient. The National Hip Fracture Database (NHFD) reports each hospital's attainment of the BPT with other measures, along with reporting outcomes. There is clearly wide variability in provision of orthogerriatrician (OG) services across the dataset. Unfortunately, despite overwhelming evidence that provision of an OG service is of benefit, it is presently challenging to recruit to this important specialty within the UK.Publicly available reports from the NHFD were obtained for each of the 177 participating hospitals for 2017. This was matched with information held within the annual NHFD Facilities Audit for the same period, which include hours of OG support for each hospital. This information was combined with a Freedom of Information request made by email to each hospital for further details concerning OG support. The outcome measures used were Length of Stay (LoS), mortality, and return to usual residence. Comparison was made with provision of OG services by use of Pearson's correlation coefficient. In addition, differences in services were compared between the 25% (44) hospitals delivering outcomes at the extremes for each measure.Attainment of BPT correlated fairly with LoS (−0.48) and to less of a degree with mortality (−0.1) and return home (0.05). Perioperative medical assessment contributed very strongly with BPT attainment (0.75). In turn perioperative medical assessment correlated fairly with LoS (−0.40) and mortality (−0.23) but not return home (0.02). Provision of perioperative medical assessment attainment was correlated fairly with total OG minutes available per new patient (0.22), total OG minutes available per patient per day (0.29) and number of days per week of OG cover (0.34); with no link for number of patients per orthogeriatrician (0.01). Mortality for the best units were associated with 30% more consultant OG time available per patient per day, and 51% more OG time available per patient. Units returning the most patients to their usual residence had little association with OG time, although had 59% fewer patients per OG, the best units had a 19% longer LoS. For all three measures results for the best had on average 0.5 days per week better routine OG access.There is no doubt that good quality care gives better results for this challenging group of patients. However, the interaction of BPT, other care metrics, level of OG support and patient factors with outcomes is complex. We have found OG time available per patient per day appears to influence particularly LoS and mortality. Options to increase OG time per patient include reducing patient numbers (ensuring community osteoporosis/falls prevention in place, including reducing in-patient falls); increasing OG time across the week (employing greater numbers/spreading availability over 7 days per week); and reducing LoS. A reduction in LoS has the largest effect of increasing OG time, and although it is dependent on OG support, it is only fairly correlated with this and many other factors play a part, which could be addressed in units under pressure.

End-of-Life Care, Symptom Burden, and Quality of Life in Couples Facing Stage IV Lung Cancer: The Role of Patient and Spousal Psychospirituality and Discussions Around Fear of Death and Disease Progression.

Background: As patients live longer with stage IV nonsmall cell lung cancer, correlates of end-of-life (EOL) care and experience are increasingly relevant. Methods: We, therefore, prospectively examined associations among psychospirituality (Center for Epidemiologic Studies Depression Scale, Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being), discussions around fear of death and disease progression, and hospital-based EOL care in patients and caregivers. Patients additionally reported symptom burden (MD Anderson Symptom Inventory-Lung Cancer total) and quality of life (QOL) (quality-of-life at EOL). Results: Of the baseline patients (n = 75), 32% were alive at time of the analyses (mean = 4.6 years postbaseline). Deceased patients (n = 51) were middle aged (mean = 65.3 years) and non-Hispanic White (81%). Caregiver spiritual well-being (r = 0.34, p = 0.02) and depression (r = -0.31, p = 0.03) were associated with EOL care metrics. Patients who "held back" more of their fear of death or disease progression experienced greater symptom burden (r = 0.41, p < 0.001) and poorer QOL (r = -0.44, p < 0.001). Conclusion: For couples facing prolonged metastatic disease, psychospirituality is highly relevant to EOL care with potential sequelae of withholding one's fear regarding death or disease progression.

Geographical Disparities in Esophageal Cancer Incidence and Mortality in the United States.

Our previous research on neuroendocrine and gastric cancers has shown that patients living in rural areas have worse outcomes than urban patients. This study aimed to investigate the geographic and sociodemographic disparities in esophageal cancer patients. We conducted a retrospective study on esophageal cancer patients between 1975 and 2016 using the Surveillance, Epidemiology, and End Results database. Both univariate and multivariable analyses were performed to evaluate overall survival (OS) and disease-specific survival (DSS) between patients residing in rural (RA) and urban (MA) areas. Further, we used the National Cancer Database to understand differences in various quality of care metrics based on residence. N = 49,421 (RA [12%]; MA [88%]). The incidence and mortality rates were consistently higher during the study period in RA. Patients living in RA were more commonly males (p < 0.001), Caucasian (p < 0.001), and had adenocarcinoma (p < 0.001). Multivariable analysis showed that RA had worse OS (HR = 1.08; p < 0.01) and DSS (HR = 1.07; p < 0.01). Quality of care was similar, except RA patients were more likely to be treated at a community hospital (p < 0.001). Our study identified geographic disparities in esophageal cancer incidence and outcomes despite the similar quality of care. Future research is needed to understand and attenuate such disparities.