Nonprofit Health System Research Articles

From margins to mainstream: Incorporating internationally educated health professionals' skills into primary care.

This case study explores the collaborative integration of Internationally Educated Healthcare Professionals (IEHPs) into comprehensive primary care through partnerships between non-profit organizations and health systems actors. It addresses the critical need for such collaboration amidst challenges of limited access to primary care and underutilization of IEHPs' skills in the Canadian healthcare workforce. Through the examination of ACCES Employment's integration into the Team Primary Care initiative, this article demonstrates the importance of coordinated efforts in overcoming longstanding barriers faced by IEHPs. Data collection involved a review of program activities, program reports, policy documents, and interviews with key collaborators to highlight strategies, partnerships, and outcomes. Data were analyzed to identify recurring patterns in collaborative integration efforts. The initiative reveals promising outcomes in facilitating IEHPs' transition into various healthcare roles through increasing collaboration between non-profit workforce development organizations and health systems actors.

Implementation of CYP2C19 and CYP2D6 genotyping to guide antidepressant use in a large rural health system.

We describe the implementation and ongoing maintenance of CYP2C19 and CYP2D6 focused pharmacogenetic (PGx) testing to guide antidepressant and antianxiety medication prescriptions in a large rural, nonprofit health system. Depression and anxiety are common psychiatric conditions. Sanford Health implemented PGx testing for metabolism of cytochrome P450 (CYP) isozymes 2C19 and 2D6 in 2014 to inform prescribing for multiple medications, including antidepressant and antianxiety therapies. As guidelines, genotype to phenotype translation, panel offerings, and other resources are updated, we adapt our approach. We make educational and informational materials available to providers and patients. Pharmacogenomic clinical pharmacists review PGx results with discrete values and provide guidance documentation in the electronic medical record. A robust clinical decision support system is in place to provide interruptive alerts, noninterruptive alerts, and genomic indicators. A referral-based interdisciplinary clinic is also available to provide in-depth education to patients regarding PGx results and implications. Additionally, partnering with our health plan has expanded access to PGx testing for patients with anxiety or depression. The implementation and maintenance of Sanford Health's PGx program to guide antidepressant and antianxiety medication use continues to evolve and requires a multipronged approach relying on both human and informatics-based resources.

Spiritual Support Staff Influence Stress Among Hospital-Based Health Care Personnel: A Cross-Sectional Study.

Stress negatively affects well-being, relating to poor physical, emotional, and occupational outcomes for health care personnel. Health care professionals faced extreme stressors in the context of the COVID-19 pandemic, making occupational stress relief a top priority for hospital administrators. Many health systems employ specially trained spiritual support staff as one strategy to alleviate work-related stressors. It is unclear whether health care personnels' perceptions of the availability of spiritual care staff influence self-reported stress. The purpose of this study was to explore relationships between perceived stress and perceptions of availability of spiritual support among acute care health care personnel. This study analyzed cross-sectional, survey-based data collected between February and April 2022 from 1352 interdisciplinary health care staff working in a large, nonprofit Catholic health system in the Western United States. Bivariate tests and multivariate linear regression models were conducted to test for factors influencing perceived stress. Results support that high stress was prevalent in the sample. Perceived availability of spiritual support staff in the hospital and seeking coworker and professional support for work-related stress all independently influence stress in this population when controlling for confounders. Stress of health care personnel may be influenced by the perceived availability of specially trained spiritual support staff. Hospital administrators should advocate for spiritual support staff availability in all health care settings as one strategy to mitigate occupational stress that health care professionals may experience through providing high-stakes patient care. Further research is warranted to uncover targeted spirituality-related strategies to reduce stress and preserve well-being of health care personnel.

An Investigation of Teledermatology Trends in the State of Texas: A Multicenter, Retrospective Cohort Review of an eConsult Service Line.

Background: An eConsult is a growing teledermatology tool that has the potential to address health disparities. Trends in teledermatology usage are still being defined in the context of the pandemic, postpandemic recovery, and a growing nonphysician primary care provider population. Objective: The aim was to understand teledermatology utilization trends for asynchronous dermatology eConsults in the geographically expansive state of Texas. Methods: This multicenter retrospective study examined the eConsult tool within a large, nonprofit health system, comparing characteristics of 893 eConsult visits with 27,189 in-person dermatology encounters from January 2022 to March 2023. Results: When comparing the demographics of patients seen through eConsult versus traditional in-person visits, eConsults demonstrated a significantly higher prevalence of pediatric (22.5% vs. 7.6%, p < 0.001), Hispanic/Latino (20.5% vs. 10.4%, p < 0.001), African American (12.5% vs. 6.9%, p < 0.001), Asian (4.6% vs. 2.1%, p < 0.001), and American Indian (1.0% vs. 0.5%, p = 0.049) patients compared with in-person visits. eConsult users came from areas with a lower percentage of bachelor's degree holders, reduced average household income, and an increased proportion of Medicaid and Tricare users. Physicians (MD/DO) submitted more eConsult cases than nonphysician providers (NPPs), with comparable diagnostic agreement with teledermatologists and similar recommendation rates for in-person dermatology visits. Conclusions: While the limitation of this study was that it was a descriptive data analysis in a single health care system with limited generalizability, eConsults hold promise to broaden dermatologic access for underserved groups, especially children, individuals from underrepresented backgrounds, and Medicaid and Tricare members. While no significant diagnostic or referral differences were seen for eConsults initiated by primary care physician and NPPs, these changing trends should continue to be examined.

Leadership to Accelerate Healthcare's Digital Transformation: Evidence From 33 Health Systems.

The COVID-19 pandemic, healthcare market disruptors, and new digital healthcare technologies have made a substantial impact on the delivery of healthcare services, highlighting the critical roles of leaders in hospitals and health systems. This study sought to understand the evolving roles of CEOs, CIOs, and other executive leaders in the postpandemic era and highlight the adaptability and strategic vision of executives in shaping the future of healthcare delivery. Between October 2022 and May 2023, 51 interviews were conducted with CEOs, CIOs, and other executives responsible for delivering technology solutions for 33 nonprofit health systems in the United States. They were asked to describe their backgrounds; how information solutions and technologies were viewed within their organizations' strategy, operations, and governance; and the key characteristics of executive leaders. The study has found that effective CEOs have an authentic belief in technology's role in achieving their organization's mission and that contemporary CIOs are strategic executive partners who align strategy with culture to improve care. This study examines how healthcare systems are creating digitally savvy executive leadership teams that operate in a new, integrated model that unites previously siloed functions. Some healthcare CIOs are unprepared for current and future business challenges, and some CEOs are unsure how to leverage digital technologies and C-suite expertise to transform their organizations. This research provides insights into how the nation's health systems are building and sustaining leadership teams capable of adapting to the healthcare environment and accelerating organizational transformation.

ICU Utilization After Implementation of Minor Severe Pneumonia Criteria in Real-Time Electronic Clinical Decision Support.

To determine if the implementation of automated clinical decision support (CDS) with embedded minor severe community-acquired pneumonia (sCAP) criteria was associated with improved ICU utilization among emergency department (ED) patients with pneumonia who did not require vasopressors or positive pressure ventilation at admission. Planned secondary analysis of a stepped-wedge, cluster-controlled CDS implementation trial. Sixteen hospitals in six geographic clusters from Intermountain Health; a large, integrated, nonprofit health system in Utah and Idaho. Adults admitted to the hospital from the ED with pneumonia identified by: 1) discharge International Classification of Diseases , 10th Revision codes for pneumonia or sepsis/respiratory failure and 2) ED chest imaging consistent with pneumonia, who did not require vasopressors or positive pressure ventilation at admission. After implementation, patients were exposed to automated, open-loop, comprehensive CDS that aided disposition decision (ward vs. ICU), based on objective severity scores (sCAP). The analysis included 2747 patients, 1814 before and 933 after implementation. The median age was 71, median Elixhauser index was 17, 48% were female, and 95% were Caucasian. A mixed-effects regression model with cluster as the random effect estimated that implementation of CDS utilizing sCAP increased 30-day ICU-free days by 1.04 days (95% CI, 0.48-1.59; p < 0.001). Among secondary outcomes, the odds of being admitted to the ward, transferring to the ICU within 72 hours, and receiving a critical therapy decreased by 57% (odds ratio [OR], 0.43; 95% CI, 0.26-0.68; p < 0.001) post-implementation; mortality within 72 hours of admission was unchanged (OR, 1.08; 95% CI, 0.56-2.01; p = 0.82) while 30-day all-cause mortality was lower post-implementation (OR, 0.71; 95% CI, 0.52-0.96; p = 0.03). Implementation of electronic CDS using minor sCAP criteria to guide disposition of patients with pneumonia from the ED was associated with safe reduction in ICU utilization.

Implementation of 4T Score Documentation on PF4 Testing in Patients with Suspected Heparin-Induced Thrombocytopenia

Purpose: Heparin-induced thrombocytopenia (HIT) is a severe complication of heparin therapy. Diagnosis requires clinical evaluation and laboratory testing. The 4T score is a pretest clinical scoring tool used to determine the probability of HIT. A non-profit health system implemented mandatory documentation of 4T score calculation prior to ordering PF4 tests for suspected HIT patients. The purpose of this performance improvement project is to evaluate the implementation of 4T score documentation on PF4 testing and argatroban utilization. Methods: This was a retrospective, multi-site chart review of patients conducted to assess the impact of mandatory 4T score documentation prior to a PF4 order. The study included adult patients who were admitted to one of the practice sites between January 2020 and November 2022 with a suspicion of HIT and a PF4 order. The primary outcomes included the number of PF4 tests ordered and the percentage of positive PF4 results. Secondary outcomes included number of SRA orders and percentage of positive SRA results, turnaround time for SRA, and the utilization of argatroban. Data collection included baseline demographics, documentation of 4T score, PF4 results, SRA results, documentation of heparin allergy, initial anticoagulant prescribed, platelet trend, ordering provider, and duration of argatroban therapy in patients with a positive PF4 result. The analysis involved using χ2 test and Fisher's exact test for the primary outcomes. Results: Mandatory 4T score documentation significantly reduced PF4 orders by 68% over a two-year period (p&amp;lt;0.0001). It also improved the percentage of positive PF4 results from 12% to 24% (p=0.60) and positive SRA results from 19% to 44% (p=0.35). Notably, after documentation of the mandatory 4T score tool, only 21% of the patients had a PF4 order placed. A total of 42 patients with a positive PF4 test were included to assess argatroban utilization. The turnaround time for SRA in these patients was 3.6 days while duration of argatroban therapy was 6.8 days. Conclusion: Implementation of mandatory 4T score documentation significantly reduced PF4 orders and improved HIT diagnostic testing in a non-profit health system. Challenges remain with SRA turnaround time and corresponding duration of argatroban therapy. The results of this project have demonstrated that standardized documentation is essential for optimizing HIT diagnosis and management protocols. Future efforts will focus on optimizing confirmatory HIT testing and non-heparin anticoagulation therapy.

An action research partnership in an urban Texas county to explore barriers and opportunities for collaborative community health needs assessments.

The Affordable Care Act mandated triennial community health needs assessments (CHNAs) for greater nonprofit hospital accountability in responding to community health needs. Over 10 years later, hospital spending on community benefits remains largely unchanged. While greater collaboration in CHNA implementation can increase hospital investment in community-based initiatives, nonprofit hospitals in conservative states are subject to policy, political, and economic factors that inhibit public health partnerships and magnify existing disparities in health care access. This participatory action research study explores the decision-making environment of collaborative CHNA implementation within a group of nonprofit hospitals in a north Texas urban county. In 2017 faculty from an urban anchor institution initiated an academic-community partnership with a coalition of nonprofit hospitals, public health departments, and academic institutions. An interdisciplinary research team engaged in multi-method document review and qualitative data collection to describe historical barriers for local CHNA processes and develop practical strategies for joint CHNA initiatives. Local CHNA documents were first reviewed through team-based content analysis and results applied to develop a qualitative study protocol. Key informants were recruited from county-based nonprofit hospitals, community-based nonprofit organizations, and public health systems. Seventeen senior- and mid-level professionals participated in semi-structured research interviews to describe their perspectives relating to CHNA-related planning and implementation decisions. Through iterative data collection and analysis, the research team explored CHNA-related knowledge, experiences, and processes. A constructivist lens was subsequently applied to examine historical barriers and future opportunities for local collaboration. Findings reveal CHNA implementation is a multi-stage cyclical process in organizational environments with accountability to a wide range of public and private stakeholders. This promotes varied levels of inclusivity and conservatism in data collection and community benefit implementation. Decisions to collaborate are hindered by competing priorities, including compliance with existing guidelines, administrative simplicity, alignment with health care service delivery, and efficient resource use. Efforts to promote greater CHNA collaboration may be facilitated through intentional alignment with organizational priorities and clearly communicated benefits of participation for leaders in both public and private nonprofit health systems. We consider implications for policymakers and health systems in restrictive political environments and advance a conceptual framework for greater CHNA collaboration.

335-OR: Participant Engagement and Weight Loss in the National Diabetes Prevention Program before and during COVID

The CDC’s National Diabetes Prevention Program (NDPP) aims to prevent or delay type 2 diabetes (T2D) through lifestyle change and weight loss. Due to challenges implementing in-person programs during the COVID-19 pandemic, many CDC-recognized organizations transitioned to offer the NDPP virtually. This analysis used NDPP data collected as part of routine care at Scripps Health, a large, non-profit health system in San Diego, CA. There were 273 individuals who participated in the NDPP before COVID (in-person sessions; October 2016 - January 2020) and 73 during COVID (virtual sessions; August 2020 - June 2021). Participants who attended virtually and in-person were, on average, 59.59±12.71 and 59.90±13.93 years old, and the majority were women (69% and 83%), White (65% and 45%), married (81% and 62%), and college graduates (66% and 44%), respectively. Chi-square, Fisher’s exact, and unpaired t-tests examined differences between the in-person vs. virtual cohorts. Compared to in-person, virtual participants consisted of significantly more men (31% vs. 17%, p= .01), but fewer Hispanics (14% vs. 43%, p&amp;lt; .01), Spanish-speakers (1% vs. 17%, p &amp;lt; .05), individuals with less than high school education (0% vs. 18%, p &amp;lt; .05), and individuals with household income of less than $24,000 (1% vs. 17%, p &amp;lt; .05). While the number of core sessions attended was not significantly different (M=20.19 vs. M=18.82; p&amp;gt; .05), average percent weight loss was significantly lower for individuals in the virtual sessions than in the in-person sessions (M=3.35 vs. M=4.50; p= .05). Although the NDPP has continued to reach participants despite the pandemic’s challenges, participation by racial and ethnic minority and socioeconomically disadvantaged individuals declined when the program transitioned to virtual delivery. More research is needed to examine patient-centered approaches to improve outcomes and engage underserved communities that are disproportionately affected by prediabetes and T2D. Disclosure E.San diego: None. M.Chichmarenko: None. E.Soriano: None. S.R.Spierling bagsic: None. N.Orendain: None. A.L.Fortmann: Employee; Dexcom, Inc. M.Ruiz: None. A.Philis-tsimikas: Advisory Panel; Dexcom, Inc., Novo Nordisk A/S, Sanofi, Other Relationship; Medtronic, Research Support; Novo Nordisk A/S, Lilly, Viking Therapeutics, NIH - National Institutes of Health. Funding National Institutes of Health (UL1TR002550, KL2TR002552)

Evaluation of Spending Differences Between Beneficiaries in Medicare Advantage and the Medicare Shared Savings Program

The 2 primary efforts of Medicare to advance value-based care are Medicare Advantage (MA) and the fee-for-service-based Medicare Shared Savings Program (MSSP). It is unknown how spending differs between the 2 programs after accounting for differences in patient clinical risk. To examine how spending and utilization differ between MA and MSSP beneficiaries after accounting for differences in clinical risk using data from administrative claims and electronic health records. This retrospective economic evaluation used data from 15 763 propensity score-matched beneficiaries who were continuously enrolled in MA or MSSP from January 1, 2014, to December 31, 2018, with diabetes, congestive heart failure (CHF), chronic kidney disease (CKD), or hypertension. Participants received care at a large nonprofit academic health system in the southern United States that bears risk for Medicare beneficiaries through both the MA and MSSP programs. Differences in beneficiary risk were mitigated by propensity score matching using validated clinical criteria based on data from administrative claims and electronic health records. Data were analyzed from January 2019 to May 2022. Enrollment in MA or attribution to an accountable care organization in the MSSP program. Per-beneficiary annual total spending and subcomponents, including inpatient hospital, outpatient hospital, skilled nursing facility, emergency department, primary care, and specialist spending. The sample of 15 763 participants included 12 720 (81%) MA and 3043 (19%) MSSP beneficiaries. MA beneficiaries, compared with MSSP beneficiaries, were more likely to be older (median [IQR] age, 75.0 [69.9-81.8] years vs 73.1 [68.3-79.8] years), male (5515 [43%] vs 1119 [37%]), and White (9644 [76%] vs 2046 [69%]) and less likely to live in low-income zip codes (2338 [19%] vs 750 [25%]). The mean unadjusted per-member per-year spending difference between MSSP and MA disease-specific subcohorts was $2159 in diabetes, $4074 in CHF, $2560 in CKD, and $2330 in hypertension. After matching on clinical risk and demographic factors, MSSP spending was higher for patients with diabetes (mean per-member per-year spending difference in 2015: $2454; 95% CI, $1431-$3574), CHF ($3699; 95% CI, $1235-$6523), CKD ($2478; 95% CI, $1172-$3920), and hypertension ($2258; 95% CI, $1616-2,939). Higher MSSP spending among matched beneficiaries was consistent over time. In the matched cohort in 2018, MSSP total spending ranged from 23% (CHF) to 30% (CKD) higher than MA. Adjusting for differential trends in coding intensity did not affect these results. Higher outpatient hospital spending among MSSP beneficiaries contributed most to spending differences between MSSP and MA, representing 49% to 62% of spending differences across disease cohorts. In this study, utilization and spending were consistently higher for MSSP than MA beneficiaries within the same health system even after adjusting for granular metrics of clinical risk. Nonclinical factors likely contribute to the large differences in MA vs MSSP spending, which may create challenges for health systems participating in MSSP relative to their participation in MA.

Targeted Management of Excess Specialty Spending: The Case of Biologics for Retinal Disease

Summary Injectable biologics used for the treatment of retinal disease offer a strong use case for ACOs, payers, and policy makers as they seek to manage total costs by reducing costly practice variation and avoidable Medicare Part B drug spending. Bevacizumab, which was originally approved by the U.S. FDA in 2004 for the systemic treatment of advanced colon cancer, has seen increased off-label utilization as a vascular endothelial growth factor (VEGF) inhibitor for retinal disease. Three anti-VEGF medications that are commonly used for retinal disease each have similar outcomes in clinical trials but have notably different average costs (in USD) per injection: bevacizumab, $90; ranibizumab, $1,883; and aflibercept, $2,098. Based on these and other factors, leaders at CommonSpirit Health, a large national nonprofit health system operating in 21 states, propose and model a reduction of clinical practice variation to a standard of care for this single indication to represent a $2.3 billion annual savings opportunity for Medicare.

Comparable Quality Performance of Acute Low-Back Pain Care in Telemedicine and Office-Based Cohorts.

Introduction: Back pain is among the most common presentations in primary care offices. National organizations have standardized the appropriate use of imaging for acute low-back pain (LBP). The objective of this study was to evaluate the use of imaging in LBP between telemedicine and in-person clinical encounters. Methods: This retrospective cohort compared secondary data from 20,624 telemedicine and office encounters in a large nonprofit health system from July 1, 2019, to June 30, 2021. The proportion of patients aged 18-50 years who did not receive imaging for acute LBP (X-ray, computed tomography, or magnetic resonance imaging) within 28 days of the provider encounter was measured according to Healthcare Effectiveness Data and Information Set specifications. Performance was compared across race, ethnicity, age, body mass index, overall risk score, and insurance type. Chi-squared tests determined significant differences between cohorts (p < 0.05). Results: Patients seen via telemedicine had significantly lower rates of imaging within 28 days of their physician encounter (office: 16.32%, telemedicine: 11.20%; difference: 5.12%; p < 0.01). This was consistent across racial, ethnic, and risk score subgroups. Discussion: For practices and health systems, telemedicine might be a higher value approach for initial evaluation of acute LBP in primary care. For policy makers, telemedicine can save on health care costs without negatively impacting quality performance measures. Conclusions: Telemedicine is unlikely to compromise quality of acute LBP care, supporting this virtual space as an alternative care venue. The most beneficial use of telemedicine might be triaging initial encounters of acute LBP in primary care. Stronger evidence could support its long-term potential for driving value through cost savings.

Real-world evidence of a successful biosimilar adoption program.

Biosimilars have introduced new opportunities to reduce the disproportionately high US healthcare spending on biologic medications. This article describes strategic utilization management program initiatives designed to promote biosimilar utilization, reduce biologic drug costsand increase sustainability in a USnonprofit health system. Key components of these biosimilar utilization management program initiatives included expedited procedures to evaluate and establish the formulary status of biosimilars, enhanced contracting negotiations, specially designed electronic medical record tools to guide physician prescribing, payer coverage analysis, evaluations of biologic-utilization trendsand financial performance analysis. Within 2years (2019-2020), this program has resulted in savings of USD$26.9million for Providence St Joseph Health and biosimilar adoption rates that greatly exceed the USnational average.

Hospital Ownership and Financial Stability: A Matched Case Comparison of a Nonprofit Health System and a Private Equity-Owned Health System.

The long-term financial stability of hospital systems represents a "grand challenge" in health care. New ownership forms, such as private equity (PE), promise to achieve better financial performance than nonprofit or for-profit systems. In this study, we compare two systems with many similarities, but radically different ownership structures, missions, governance, and merger and acquisition (M&A) strategies. Both were nonprofit, religious systems serving low-income communities - Montefiore Health System and Caritas Christi Health Care. Montefiore's M&A strategy was to invest in local hospitals and create an integrated regional system, increasing revenues by adding primary doctors and community hospitals as feeders into the system and achieving efficiencies through effective resource allocation across specialized units. Slow and steady timing of acquisitions allowed for organizational learning and balancing of debt and equity. By 2019, it owned 11 hospitals with 40,000 employees and had strong positive financials and low reliance on debt. By contrast, in 2010, PE firm Cerberus Capital bought out Caritas (renamed Steward Health Care System) and took control of the Board of Directors, who set the system's strategic direction. Cerberus used Steward as a platform for a massive debt-driven acquisition strategy. In 2016, it sold off most of its hospitals' property for $1.25 billion, leaving hospitals saddled with long-term inflated leases; paid itself almost $500 million in dividends; and used the rest for leveraged buyouts of 27 hospitals in 9 states in 3 years. The rapid, scattershot M&A strategy was designed to create a large corporation that could be sold off in five years for financial gain - not for health care integration. Its debt load exploded, and by 2019, its financials were deeply in the red. Its Massachusetts hospitals were the worst financial performers of any system in the state. Cerberus exited Steward in 2020 in a deal that left its physicians, the new owners, holding the debt.

Incidence of interruptive penicillin allergy alerts in patients with previously documented beta-lactam exposure: Potential for leveraging the electronic health record to identify erroneous allergies.

Approximately 10% of patients report allergies to penicillin, yet >90% of these allergies are not clinically significant. Patients reporting penicillin allergies are often treated with second-line, non-β-lactam antibiotics that are typically broader spectrum and more toxic. Orders for β-lactam antibiotics for these patients trigger interruptive alerts, even when there is electronic health record (EHR) data indicating prior β-lactam exposure. To describe the rate that interruptive penicillin allergy alerts display for patients who have previously had a β-lactam exposure. Retrospective EHR review from January 2013 through June 2018. A nonprofit health system including 1 large tertiary-care medical center, a smaller associated hospital, 2 emergency departments, and ˜250 outpatient clinics. All patients with EHR-documented of penicillin allergies. We examined interruptive penicillin allergy alerts and identified the number and percentage of alerts that display for patients with a prior administration of a penicillin class or other β-lactam antibiotic. Of 115,081 allergy alerts that displayed during the study period, 8% were displayed for patients who had an inpatient administration of a penicillin antibiotic after the allergy was noted, and 49% were displayed for patients with a prior inpatient administration of any β-lactam. Many interruptive penicillin allergy alerts display for patients who would likely tolerate a penicillin, and half of all alerts display for patients who would likely tolerate another β-lactam.

Terminal Delirium in Hospice: The Experiences and Perspectives of Caregivers Providing Care to Terminally Ill Patients in Home Settings.

Little is known about the experiences of caregivers who provide care to persons with terminal delirium (TD) in home settings. This scarcity of information is suggestive that further research is needed about care for hospice patients with delirium in the home and community. To elicit views, feelings, and end-of-life care experiences of primary caregivers assisting dying persons with TD in hospice at home. Qualitative, exploratory, cross-sectional study design was chosen. In-depth semistructured interviews explored caregiver experiences in caring for persons with TD. Qualitative thematic framework analysis was used. Fifteen bereaved adult primary caregivers who received services from a hospice care program affiliated with a large nonprofit health system in the US Midwest. Caregiver experiences were broad and reflected 4 major themes: symptomology, coping, effective and noneffective interventions, and support. The most distressing factors for caregivers were behaviors and symptomology of TD. They did not know what to say, how to respond, and how best to behave with someone who had delirium. Many caregivers had the impression that medication does not lessen delirium symptoms and that nonpharmacologic interventions are effective and beneficial only when they were important and meaningful to patients before delirium onset. This study added new knowledge from direct and personal perspectives of caregivers providing end-of-life care to patients at home. Understanding developed about provision of care to someone with TD in home hospice. Improved comprehension of caregiver experiences can help professional hospice and palliative care staff better prepare caregivers for when patients have TD.

Health system documents steep increase in alcohol withdrawal during pandemic

Early on in the COVID‐19 pandemic, reports of soaring alcohol sales generated concern over what kinds of impacts might surface later. A nonprofit health system has now been able to leverage data on its hospitalized patients to demonstrate that for many, drinking to cope with stress likely led to a full‐blown substance use disorder.

1655. Extrapulmonary Tuberculosis in a Large Healthcare System

BackgroundThe US has seen a rise in the proportion of patients with extrapulmonary tuberculosis (TB) even though the yearly incidence of new TB cases has been in decline. The purpose of this study was to analyze incidence of extrapulmonary TB at Atrium Health, a large non-profit health system in the Southeastern US.MethodsRetrospective chart review of 94 adult patients with culture confirmed extrapulmonary TB between 2008-2019. Individuals younger than 18 years were excluded from analysis. The primary objective was to examine incidence of extrapulmonary TB and compare it to that reported in the literature. Secondary objectives included determination of sites of extrapulmonary disease and associated patient characteristics including HIV status, race, ethnicity, and birthplace.Results237 patients were identified as having confirmed TB infection from 2008-2019 in a retrospective analysis within the Atrium Health System. 94 (40%) were found to have extrapulmonary disease; 42 (45%) with concomitant pulmonary disease. The patients were 55% male, 40% African American, 21% Hispanic or Latino, and 51% US-born. Median age was 44 years (range 20-62). The most common sites of extrapulmonary TB were lymphatic (35%), pleural (24%), GI/Peritoneal (12%), CNS (10%), and Bone/Joint (10%). Lymphatic involvement was 40% cervical, 19% intrathoracic, and 16% axillary. 66% of skeletal disease was vertebral. Other sites included GU, pericardial, skin, and disseminated disease (5%). 37% were HIV positive, 18% with unknown HIV status as they were never tested. Information regarding patient’s race, ethnicity, and birthplace were unknown for 2 patients. The percentage of extrapulmonary cases were 29% in 2008, 39% in 2012, 38% in 2016, and 49% in 2019.ConclusionLymphatic and pleural involvement were the most common extrapulmonary sites. Of those tested, 37% were HIV positive but there was a significant portion never tested showing a need for increased testing. The proportion of extrapulmonary TB cases since 2008 is higher at 40% compared to the 31% reported in the United States. There has been a rise in the proportion of extrapulmonary TB within our healthcare system and deserves further analysis.Disclosures All Authors: No reported disclosures

1657. Musculoskeletal Tuberculosis in a Large Healthcare System

BackgroundMusculoskeletal tuberculosis (TB) is an important and elusive manifestation of extrapulmonary TB. This purpose of this study was to examine incidence and associated co-morbidities of confirmed cases of musculoskeletal TB at Atrium Health, a large non-profit health system in the Southeastern United States.MethodsRetrospective case series of 12 adult patients with confirmed musculoskeletal TB between 2008-2019. Individuals younger than 18 years were excluded. The primary objective was to compare local incidence of musculoskeletal TB with that reported in the literature. Secondary objectives included analysis of patient co-morbidities for their correlation with the development of musculoskeletal manifestations of TB and requirement of surgical correction for underlying deformities from TB infection.Results237 patients were identified with confirmed TB infection from 2008-2019 in a retrospective cohort within the Atrium Health System. Of 237 patients, 94 (40%) had extrapulmonary disease and 12 (5%) had musculoskeletal manifestations defined as involvement of bone, joint space, or muscle and were included in this analysis. Six (50%) of the 12 patients were foreign born individuals who immigrated to the US. Three (33%) had concomitant pulmonary disease. Vertebral involvement (8, 66%) was most common and 1 (8%) patient noted to have infected total knee arthroplasty. Other sites included wrist, sternum, ribs and pelvis. Co-morbidities evaluated included HIV status 0%, diabetes (2, 17%), immunosuppressive medications (1, 8%), ESRD 0%, and rheumatologic disease 0%. Surgical intervention was necessary in 4 (33%) patients for both diagnostic and therapeutic interventions.ConclusionOf those tested for HIV 100% were negative but only 50% were tested showing a need for improved HIV testing. Very few had other co-morbid conditions including diabetes, use of immunosuppressive medications, ESRD status, or rheumatologic disease. Surgical intervention was needed in 33% of patients with musculoskeletal TB including several with a preoperative suspected diagnosis of malignancy. In this retrospective case series, the incidence of musculoskeletal TB was 5% in comparison to the 2-3% reported consistently in the US.Disclosures All Authors: No reported disclosures

16.2 IMPROVING ACCESS TO BEHAVIORAL HEALTH SERVICES IN IDAHO: A LARGE HEALTH SYSTEM APPROACH

St. Luke’s Health System (SLHS) is the largest nonprofit health system in Idaho that spans rural and frontier areas throughout the region. SLHS developed a multipronged behavioral health strategy that includes standardization of depression and suicide screening among adolescent and adult patients in emergency department and primary care settings, integration of behavioral health into primary care, and development of a behavioral health virtual care delivery strategy. The primary objective of this presentation is to describe lessons learned chronicled over the past 4 years of efforts to develop and implement a comprehensive behavioral health strategy in a large rural state with limited resources.