North Carolina Health Research Articles

There’s no place like home: Home time among older adults with AML by therapy intensity.

376 Background: Older adults with acute myeloid leukemia (AML) have identified home time (HT) as a critical outcome influencing their treatment selection. However, few studies have characterized HT in this disease setting. Methods: We conducted a retrospective, observational study of adults age ≥60 diagnosed with AML from 2015 to 2020 at University of North Carolina Health. First-line therapy was classified by intensity: low (hypomethylating agent [HMA]), intermediate (HMA+Venetoclax), and high (anthracycline-based). The primary outcome was cumulative HT days from time of diagnosis. A day was defined as HT if an individual was not hospitalized and did not utilize emergency department services or ambulatory oncology clinics. Secondary outcomes were proportion of days at home (PDH) and overall survival (OS). Covariates included demographics and disease risk by ELN 2017 criteria. HT was evaluated via summary statistics with comparisons among treatment groups made via linear (for HT / PDH) or Cox proportional hazard (for OS) regression models adjusted for age & ELN risk. PDH was further adjusted for log of follow up time. Median OS was calculated via the Kaplan-Meier method. Results: 197 individuals were identified. Mean age was 71 (range 60-95), 79% were white, and 59% male. 38% received high-intensity therapy, 33% received low, and 29% intermediate. Mean age was lower in the high-intensity group (66 vs 74 in low, 75 in intermediate; Kruskal-Wallis p < 0.0001). Mean HT was 284 days, and median survival was 10.3 months (95% CI 8.4-12.7). Mean HT was greater in the high-intensity group at 409 days (CI 310-508) vs. 243 (158-328) in low and 169 (121-216) in the intermediate group (Table). The high-intensity group had greater median OS at 19.9 months vs. 8.8 (low) or 7.7 (intermediate) but a lower mean adjusted PDH (high: 0.60 vs. low: 0.73 vs. intermediate: 0.75; p < 0.0001). In adjusted models, these differences remained statistically significant. Mean HT, median OS, and mean adjusted PDH did not differ significantly between the low & intermediate groups. Conclusions: Older adults with AML spend a tremendous amount of time - roughly 40% of days - engaged in oncology care. Although receiving high-intensity therapy was associated with longer OS, increases in HT were more modest, indicating that much of the survival gains were spent engaged in care. Shared treatment decision-making should incorporate patient preferences for securing HT versus attempting to prolong survival.[Table: see text]

The Impact of the COVID-19 Pandemic on Disparities in Motor Vehicle Traffic Deaths and Injuries among North Carolina American Indians.

A Periodic Feature to Inform North Carolina Health Care Professionals About Current Topics in Health Statistics.

SARS-CoV-2 Testing and Positivity Among Persons With and Without HIV in 6 US Cohorts.

It is not definitively known if persons with HIV (PWH) are more likely to be SARS-CoV-2 tested or test positive than persons without HIV (PWoH). We describe SARS-CoV-2 testing and positivity in 6 large geographically and demographically diverse cohorts of PWH and PWoH in the United States. The Corona Infectious Virus Epidemiology Team comprises 5 clinical cohorts within a health system (Kaiser Permanente Northern California, Oakland, CA; Kaiser Permanente Mid-Atlantic States, Rockville, MD; University of North Carolina Health, Chapel Hill, NC; Vanderbilt University Medical Center, Nashville, TN; and Veterans Aging Cohort Study) and 1 interval cohort (Multicenter AIDS Cohort Study/Women's Interagency HIV Study Combined Cohort Study). We calculated the proportion of patients SARS-CoV-2 tested and the test positivity proportion by HIV status from March 1 to December 31, 2020. The cohorts ranged in size from 1675 to 31,304 PWH and 1430 to 3,742,604 PWoH. The proportion of PWH who were tested for SARS-CoV-2 (19.6%-40.5% across sites) was significantly higher than PWoH (14.8%-29.4%) in the clinical cohorts. However, among those tested, the proportion of patients with positive SARS-CoV-2 tests was comparable by HIV status; the difference in proportion of SARS-CoV-2 positivity ranged from 4.7% lower to 1.4% higher. Although PWH had higher testing proportions compared with PWoH, we did not find evidence of increased positivity in 6 large, diverse populations across the United States. Ongoing monitoring of testing, positivity, and COVID-19-related outcomes in PWH are needed, given availability, response, and durability of COVID-19 vaccines; emergence of SARS-CoV-2 variants; and latest therapeutic options.

Ethnoracial Disparities in SARS-CoV-2 Seroprevalence in a Large Cohort of Individuals in Central North Carolina from April to December 2020.

ABSTRACTSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused millions of deaths around the world within the past 2 years. Transmission within the United States has been heterogeneously distributed by geography and social factors with little data from North Carolina. Here, we describe results from a weekly cross-sectional study of 12,471 unique hospital remnant samples from 19 April to 26 December 2020 collected by four clinical sites within the University of North Carolina Health system, with a majority of samples from urban, outpatient populations in central North Carolina. We employed a Bayesian inference model to calculate SARS-CoV-2 spike protein immunoglobulin prevalence estimates and conditional odds ratios for seropositivity. Furthermore, we analyzed a subset of these seropositive samples for neutralizing antibodies. We observed an increase in seroprevalence from 2.9 (95% confidence interval [CI], 1.8 to 4.5) to 12.8 (95% CI, 10.6 to 15.2) over the course of the study. Latinx individuals had the highest odds ratio of SARS-CoV-2 exposure at 6.56 (95% CI, 4.66 to 9.44). Our findings aid in quantifying the degree of asymmetric SARS-CoV-2 exposure by ethnoracial grouping. We also find that 49% of a subset of seropositive individuals had detectable neutralizing antibodies, which was skewed toward those with recent respiratory infection symptoms.IMPORTANCE PCR-confirmed SARS-CoV-2 cases underestimate true prevalence. Few robust community-level SARS-CoV-2 ethnoracial and overall prevalence estimates have been published for North Carolina in 2020. Mortality has been concentrated among ethnoracial minorities and may result from a high likelihood of SARS-CoV-2 exposure, which we observe was particularly high among Latinx individuals in North Carolina. Additionally, neutralizing antibody titers are a known correlate of protection. Our observation that development of SARS-CoV-2 neutralizing antibodies may be inconsistent and dependent on severity of symptoms makes vaccination a high priority despite prior exposure.

Running the Numbers: Measuring Food Hardship in North Carolina Communities.

A Periodic Feature to Inform North Carolina Health Care Professionals About Current Topics in Health Statistics Access to healthy food is a foundational social determinant of health with several recognized cascading effects for health outcomes. To assess food access, analysts often rely on United

COVID-19: A Vaccine Priority Index Mapping Tool for Rapidly Assessing Priority Populations in North Carolina.

The initial limited supply of COVID-19 vaccine in the U.S. presented significant allocation, distribution, and delivery challenges. Information that can assist health officials, hospital administrators and other decision makers with readily identifying who and where to target vaccine resources and efforts can improve public health response. The objective of this project was to develop a publicly available geographical information system (GIS) web mapping tool that would assist North Carolina health officials readily identify high-risk, high priority population groups and facilities in the immunization decision making process. Publicly available data were used to identify 14 key health and socio-demographic variables and 5 differing themes (social and economic status; minority status and language; housing situation; at risk population; and health status). Vaccine priority population index (VPI) scores were created by calculating a percentile rank for each variable over each N.C. Census tract. All Census tracts (N = 2,195) values were ranked from lowest to highest (0.0 to 1.0) with a non-zero population and mapped using ArcGIS. The VPI tool was made publicly available (https://enchealth.org/) during the pandemic to readily assist with identifying high risk population priority areas in N.C. for the planning, distribution, and delivery of COVID-19 vaccine. While health officials may have benefitted by using the VPI tool during the pandemic, a more formal evaluation process is needed to fully assess its usefulness, functionality, and limitations. When considering COVID-19 immunization efforts, the VPI tool can serve as an added component in the decision-making process.

Abstract 11645: Use of an Electronic Health Record to Identify Implantable Cardiac Rhythm Device Lead Failure

Introduction: Electronic health records (EHR) offer the potential to facilitate research examining the real-world effectiveness and safety of medical interventions. However, few studies have used EHR data to evaluate medical devices. This study sought to devise a method using current procedural terminology (CPT) and international classification of disease (ICD) codes captured in EHR data to identify patients with implantable cardiac rhythm device lead failures. Hypothesis: CPT and ICD diagnosis codes within an EHR can be used to correctly identify implantable cardiac rhythm device lead failures. Methods: Study data were extracted from the EHR of a large North Carolina health system. Patients who had implantable cardiac rhythm devices implanted during January 2013 to December 2018 were identified using predetermined CPT codes. Patients were followed longitudinally to identify those undergoing subsequent lead insertions or removals through December 2019. Medical records were reviewed to determine reasons for the re-insertion or removal and identify true lead failures. Random forest modeling was used to develop an algorithm for predicting true lead failure using CPT and ICD codes for mechanical breakdown or cardiac device complication. Patients with potential lead failure were split into two cohorts: 60% for model training and 40% for testing. Results: A total of 4,148 encounters with billed CPT codes for implantable cardiac rhythm devices were initially identified. After applying study exclusion criteria, 2,390 patients met study inclusion criteria. Of those, 175 patients had a subsequent insertion indicating a potential lead failure. A total of 31 patients were found to have true lead failures. A random forest algorithm predicted true lead failures with good discrimination, achieving an AUROC (area under receiver operating curve) of 0.908. The model accurately detected 66% of true lead failure cases in the testing dataset. Conclusions: Applying a specific combination of CPT and diagnosis codes to a cohort of patients undergoing subsequent implantable cardiac rhythm device procedures following an index insertion can correctly identify patients with lead failure with strong accuracy and moderate sensitivity.

Distance to Treatment Center Is Associated with Health Outcomes in Older Adults with AML Receiving Azacitidine and Venetoclax Containing Regimens

Introduction:Recent analyses have demonstrated that race and geographic area are important factors for outcomes in acute myeloid leukemia (AML) patients under the age of 60. Older patients with AML often receive outpatient therapy aimed at prolonging survival while maintaining time at home, a critical patient-centered outcome. We aimed to describe whether overall survival and time at home were associated with race, geographic area, and other baseline factors for older AML patients in the modern era of combination outpatient therapy including hypomethylating agents and Venetoclax.Methods:We identified all older adults (≥ 60 years) diagnosed with AML from 2015 - 2020 who received first-line treatment with Azacitidine (AZA), Azacitidine + Venetoclax (AZA+VEN), or other Venetoclax-containing regimens (Other VEN) within the University of North Carolina (UNC) Health System. Clinical and sociodemographic factors were captured.The primary independent variables of interest were race, socioeconomic status (SES), rurality, and distance from UNC Cancer Center, an NCI Comprehensive Cancer Center (NCI-CCC). Race was self-reported. SES and rurality were estimated by ZIP code, as determined by Census tract information from the American Community Survey (2015-2019). Geocoding was used to estimate distance and travel time from patient's home address to the NCI-CCC.The primary outcomes were overall survival (OS) and proportion of days engaged in oncologic services (PDEOS), which was defined as the proportion of person-days admitted, in the ED, at an office visit, or in infusion/transfusion divided by the overall number of person-days survived.Linear and logistic regression analyses were performed to assess associations between independent variables and outcomes. Cox proportional hazards models were used to identify associations with OS. Multivariable analyses were performed using covariates of potential significance (p < 0.20).Results:Of 136 newly diagnosed AML patients aged ≥ 60 years identified in the study period, 113 patients had full capture of service records (83%). These patients were treated with AZA (n = 43), AZA+VEN (n = 58), or other VEN (n = 11). Baseline demographics are shown in the Table. The median distance from the NCI-CCC was 42.3 miles. The median OS for the entire cohort was 0.64 years (CI 0.32 - 0.91). Mean PDEOS was 0.42. 35% of patients achieved remission (AZA = 14%, AZA+VEN = 52%; Other VEN = 27%).Race, SES, and rurality were not significantly associated with survival, remission, PDEOS, or chemotherapy regimen received. Median OS was shorter for Black/AA patients (0.47 years, CI 0.23 - 1.25) than for White patients (0.64 years, CI 0.28 - 0.91), although this difference was not statistically significant (p = 0.80).After adjusting for log years of follow-up time, distance from the NCI-CCC was associated with increased PDEOS. Patients who lived ≥ 50 miles from the NCI-CCC spent 7% more days engaged in oncologic services, which amounts to 2.1 more days per month (p = 0.03). No significant association was observed between distance from the NCI-CCC and OS. There was also no association seen between distance from the NCI-CCC and chemotherapy regimen received. We examined the association between PDEOS and age, ELN risk, and median household income, and none of these variables were significant enough in the model to be considered for multivariable analyses.Conclusion:Overall survival in this population of older AML patients was not significantly associated with race, SES, distance to NCI-CCC or rurality. Distance to treatment center was associated with increased burden of healthcare services. Patients who lived the greatest distances from the NCI-CCC spent a greater proportion of their days engaged in oncologic services. These conclusions are limited by the relative racial and ethnic homogeneity, lack of representation from urbanized and rural areas, and limited geographic location. Given the dismal median overall survival of only 7.7 months, targeted interventions including telehealth visits or consolidation of multidisciplinary care would likely be valuable for decreasing healthcare burden among older AML patients, especially for those with long distances to travel. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Time Spent at Home Among Older Adults with AML Treated with Hypomethylating Agents and Venetoclax

IntroductionThe prognosis for older adults with acute myeloid leukemia (AML) is poor. Of approximately 12,000 adults age ≥ 60 diagnosed with AML in the U.S. annually, less than 40% survive 1 year from diagnosis. Prior research has shown that adults with AML feel time at home is a critical consideration in treatment selection. However, to date, no study has adequately described the amount of time older adults can expect to spend at home following initiation of AML therapy. In this study, we aimed to (1) quantify this time and (2) assess the impact of venetoclax (VEN) combination therapy on time at home for older adults with AML.MethodsWe queried records from University of North Carolina Health to identify individuals age ≥ 60 newly diagnosed with AML from 2015 to 2020. First-line AML therapy was identified, and those receiving azacitidine (AZA) and/or VEN were included. Dates of diagnosis, first remission, death, last follow up, and all oncology clinic / emergency department (ED) / inpatient encounters were captured. Patients with incomplete records were excluded.The primary outcome was proportion of days at home (PDH). PDH was calculated for each patient by subtracting the number of care days (days hospitalized or seen in an ED / oncology clinic / infusion center) from the total days of follow up, divided by total days of follow up. Overall survival (OS) was calculated via the Kaplan-Meier method. Covariates including demographics and disease risk (per European Leukemia Net 2017) were captured.PDH was evaluated via summary statistics for the full cohort and stratified by each categorical variable, both for the full follow up period and on a month-by-month basis among survivors. Associations between PDH and covariates were further assessed via linear regression with adjustment for length of follow up, with significance assessed via Wald Chi-square test.ResultsFrom 2015-2020, 137 older adults receiving first-line AZA and/or VEN were identified. 24 were excluded due to incomplete records. Among the remaining 113, mean age was 76 (range 60-99), 80.4% were white, and 43.4% were female. Most received AZA+VEN (51.3%) followed by AZA monotherapy (39.0%) and other VEN-containing combinations (9.7%). The majority had adverse-risk AML (61.3%). Baseline covariates including age and ELN risk were similar across therapy groups.Over the full follow up period, mean PDH was 0.58 (95% confidence interval 0.54-0.63) with a median of 0.63. PDH was similar among those with adverse-risk (mean 0.55, CI 0.49-0.61) and intermediate-risk AML (0.64, CI 0.56-0.72). PDH did not differ among therapy groups: AZA+VEN (0.60, CI 0.54-0.66), AZA alone (0.57, CI 0.49-0.66), and other VEN-containing regimens (0.54, CI 0.40-0.69). When adjusted for length of follow up, no covariate had a significant association with PDH (all p > 0.05).When evaluated month-by-month, the proportion of days at home rose over time among survivors. For example, of patients who survived the full month, mean PDH was 0.51 (CI 0.47-54, n = 105) in month 1 following diagnosis and 0.77 (CI 0.72-0.82, n = 57) in month 6. Figure 1 summarizes person-days at home or engaged in care for 12 months following diagnosis (including contributions from those who did not survive the full month).34.5% of patients achieved composite complete remission, with higher rates among those receiving AZA+VEN (51.7%) than AZA alone (13.6%) (OR 6.8, p = 0.0002). Median OS was 0.64 years (CI 0.32 - 0.91) and was similar across therapy groups.ConclusionBurden of care for older adults with AML treated with first-line AZA or VEN is high. These individuals spend nearly half (cohort mean 42%) of days following diagnosis engaged in oncology care. In randomized studies, the addition of VEN to AZA improves OS and increases remission rates though results in higher rates of neutropenic fever. Although this study may be underpowered to detect small differences, the superior remission rates with AZA+VEN did not translate to more days at home, perhaps due to increased admissions for neutropenic fever and office/infusion visits.Given the importance of time at home to older adults with AML identified in prior research, these data provide new information to support shared decision making regarding treatment options. Future prospective trials should evaluate burden of care, including time at home, as an endpoint. While awaiting these data, larger analyses of the impact of treatment regimen on burden of care would be useful. [Display omitted] DisclosuresBryant: Carevive: Consultancy, Research Funding; Jazz Pharmaceuticals: Consultancy, Research Funding; Servier Pharmaceuticals: Honoraria, Speakers Bureau. Coombs: Alexion Pharmaceuticals: Research Funding; Machaon Diagnostics: Research Funding. Foster: Macrogenics: Research Funding; Rafael Pharmaceuticals: Research Funding; Macrogenics: Consultancy; Daiichi Sankyo: Consultancy; Agios: Consultancy; Bellicum Pharmaceuticals: Research Funding.

Patient- and provider-level predictors of mortality among patients with metastatic renal cell carcinoma receiving oral anticancer agents.

116 Background: It is important to understand how emerging new therapies, such as oral anti-cancer agents (OAAs), diffuse across and can improve outcomes within real-world populations, which include age groups and racial groups not well-represented in clinical trials, such as people older than age 65 and Black patients. Our objectives were to examine whether disparities in mortality persist among patients with metastatic renal cell carcinoma (mRCC) receiving OAAs and whether these disparities may be partially explained by patient’s clinical characteristics or provider-level factors. Methods: We used linked state cancer registry data and multi-payer claims data to identify patients with mRCC who were diagnosed in 2004 through 2015 and had initiated an OAA and survived ≥ 90 days after initiating. Provider data were obtained from North Carolina Health Professions Data System and the National Plan &amp; Provider Enumeration System. A patient’s modal provider was the provider most frequently on claims with a diagnosis code of RCC or metastatic cancer between 2 months prior to and 3 months following the index date. We estimated hazard ratios (HR) and corresponding 95% confidence limits (CL) using Cox proportional hazard models to evaluate which patient demographics, patient clinical characteristics, and provider-level factors were associated with 2-year all-cause mortality. Results: The cohort included 207 patients with mRCC. In unadjusted analyses, public insurance (Medicaid or Medicare), de novo metastatic diagnosis, frailty, polypharmacy, and a visit to a skilled nursing facility were associated with increased all-cause mortality. In multivariable models, clinical variables such as frailty (HR: 1.36, 95% CL: 1.11-1.67) and de novo metastatic diagnosis (HR: 2.63, 95%CL: 1.67-4.16) were associated with higher all-cause mortality. Additionally, Medicare-insured patients continued to have higher all-cause mortality compared to privately insured patients (HR: 2.35, 95% CL: 1.32-4.18). None of the provider-level covariates (i.e., specialization, experience, volume, or practice location) investigated were associated with all-cause mortality. Conclusions: Even when adjusting for age, frailty, and comorbidities, Medicare-insured patient had lower overall survival than privately-insured patients. Patient survival did not differ based on modal provider’s characteristics.

Provider- and patient-level predictors of oral anticancer agent initiation and adherence in patients with metastatic renal cell carcinoma.

BackgroundImproving oral anticancer agent (OAA) initiation and adherence is the important quality‐of‐care issues, particularly since one fourth of anticancer agents being developed will be administered orally. Our objective was to identify provider‐ and patient‐level characteristics associated with OAA initiation and adherence among individuals with metastatic renal cell carcinoma (mRCC).MethodsWe used state cancer registry data linked to multi‐payer claims data to identify patients with mRCC diagnosed in 2004–2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. We estimated risk ratios (RRs) and corresponding 95% confidence limits (CLs) using modified Poisson regression to evaluate factors associated with OAA initiation and adherence.ResultsAmong the 207 (out of 687) patients who initiated an OAA following mRCC diagnosis and survived 90 days, median proportion of days covered was 0.91. Patients with a modal provider specializing in hematology/medical oncology were much more likely to initiate OAAs than those seen by other specialties. Additionally, patients with a female provider were more likely to initiate OAAs than those with a male provider. Compared to patients treated by providers practicing in both urban and rural areas, patients with providers practicing solely in urban areas were more likely to initiate OAAs, after controlling for patient‐level factors (RR = 1.37; 95% CL: 1.09–1.73). Medicare patients were less likely to be adherent than those with private insurance (RR = 0.61; 95% CL: 0.42–0.87).ConclusionsOur results suggest that provider‐ and patient‐level factors influence OAA initiation in patients with mRCC but only insurance type was associated with adherence.

Association of Histamine-2 Blockers and Proton-Pump Inhibitors With Delirium Development in Critically Ill Adults: A Retrospective Cohort Study.

Retrospective observational study using a deidentified database sourced from the University of North Carolina Health Care system. Participants were identified as having delirium utilizing an International Classification of Diseases-based algorithm. Associations among histamine-2 receptor antagonist, proton-pump inhibitor, or no medication administration and delirium were identified using relative risk. Multiple logistic regression was used to control for potential confounders including mechanical ventilation and age. Academic tertiary care medical ICU in the United States. Adults admitted to the University of North Carolina medical ICU from January 2015 to December 2019, excluding those on concurrent histamine-2 receptor antagonists and proton-pump inhibitors in the same encounter. None. We identified 6,645 critically ill patients, of whom 29% (n = 1,899) received mechanical ventilation, 45% (n = 3,022) were 65 or older, and 22% (n = 1,487) died during their medical ICU encounter. Of the 6,645 patients, 31% (n = 2,057) received an histamine-2 receptor antagonist and no proton-pump inhibitors, 40% (n = 2,648) received a proton-pump inhibitor and no histamine-2 receptor antagonists, and 46% (n = 3,076) had delirium. The histamine-2 receptor antagonist group had a greater association with delirium than the proton-pump inhibitor group compared with controls receiving neither medication, after controlling for mechanical ventilation and age (risk ratio, 1.36; 1.25-1.47; p < 0.001) and (risk ratio, 1.15; 1.07-1.24; p < 0.001, respectively). Histamine-2 receptor antagonists are more strongly associated with increased delirium than proton-pump inhibitors. Prospective studies are necessary to further elucidate this association and to determine if replacement of histamine-2 receptor antagonists with proton-pump inhibitors in ICUs decreases the burden of delirium in critically ill patients.

‘Behavioral health emergency’: North Carolina organizations ask leaders for help

The COVID‐19 pandemic caused immeasurable stress and loss, resulting in more people needing mental health services. The demand increase has strained North Carolina's already fractured mental health system, North Carolina Health News reported June 25. People who struggle to access mental health services when they first experience symptoms frequently end up in crisis and find themselves in jail or the emergency room. During the pandemic, North Carolinians flooded ERs looking for help, particularly for children, according to the North Carolina Healthcare Association (NCHA). The rate of kids in the emergency room because of a behavioral health concern nearly doubled in 2020. By December, the rate of emergency room discharges for pediatric patients with a behavioral health condition had increased by 70% over the prior year, according to the NCHA's patient data system. The NCHA and 11 other leading health organizations outlined these concerns in a letter to state leaders calling on both public and private entities to work together and look at ways to improve access to mental health services in the state. Gov. Roy Cooper's office is working on a response, and Sen. Phil Berger's spokesperson said he is “open to meeting with the organizations to discuss the letter and their concerns.”

Deriving Analytic Insights During a Novel Pandemic.

This paper summarizes the impact health care analytics has had on the COVID-19 pandemic from the combined perspectives of three North Carolina health systems: Vidant Health in Greenville, Duke Health in Durham, and Cone Health in Greensboro. Although these systems serve a diverse set of communities

Commentary on "Experiential Learning in Pediatric Physical Therapist Education: Faculty and Student Perceptions".

“How could I apply this information?” In their research, the authors identify that experiential learning (EL) with children in physical therapist education varies by program. Despite this, students and faculty agree that EL with children positively contributes to students' learning. Further, students value quality more than the quantity of EL with children. Pediatric physical therapy faculty may enhance students' perceived value of EL by clearly describing the goals of the EL activity and focus on direct interaction between students, children, and their families. A common barrier to EL is access to children with participation restrictions and their families. Faculty and local pediatric physical therapists must be proactive in developing partnerships to expand opportunities for meaningful EL with children. Cocreating a process to identify and recruit EL participants may decrease the administrative burden of implementing EL activities on campus and in the community. As faculty and clinicians work to improve EL opportunities for students, they may feel more equipped for an entry-level pediatrics position at graduation. “What should I be mindful about when applying this information?” There was small number of study participants compared with the total number of accredited Doctor of Physical Therapy (DPT) programs, as only 109 faculty and 20 students from 263 currently accredited DPT programs were included. Readers must also consider the potential bias of participants when generalizing the identified themes. Topics that were not covered in the article were how often clinicians from the community were involved with EL opportunities and their impact on quantity and quality of EL. This limits the understanding of the role of the clinician in EL. Questions remain about how the quantity or quality of EL influences students' decisions about pursuing a career in pediatric physical therapy at graduation. Chelsea Lasky-McFarlin, PT, DPT The University of North Carolina Health Care System, Chapel Hill, North Carolina Tricia Catalino, PT, DSc Hawai'i Pacific University, Honolulu, Hawaii

North Carolina health plan to provide affordable housing to people with SMI

Cardinal Innovations Healthcare, a specialized health plan and care coordinator for Medicaid recipients and the under‐ and uninsured in North Carolina with complex behavioral and special needs, is funding an innovative project to provide permanent, affordable housing for people with serious mental illness (SMI), according to a news release. A public/private partnership between Cross Disability Services Inc. and the University of North Carolina at Chapel Hill School of Social Work will use a $100,000 grant from Cardinal Innovations to develop Tiny Homes Village, whose primary purpose is to offer “well‐designed, affordable, permanent homes to support the health and wellbeing of people with SMI.” According to the grant application, the project will comprise 15 tiny homes, each valued at $50,000 with approximately 350 square feet of living space. The homes will be built in a village with a communal clubhouse, green spaces and ready access to public transportation and a variety of community‐based services. “Tiny Homes Village is an exciting and pioneering effort in support of those with SMI,” said Trey Sutten, Cardinal Innovations CEO. “We are honored to be a partner in helping to realize such an important project with great potential to become a national model.”

Librarian Contributions to a Regional Response in the COVID-19 Pandemic in Western North Carolina

At the start of the COVID-19 pandemic, the Mountain Area Health Education Center formed a response team with the goal of building capacity across Western North Carolina health systems to collectively identify needs, coordinate resources to fill gaps, and strategically manage the regional threats of the pandemic. The library team collaborated on interprofessional projects by gathering information and using LibGuides to quickly and easily organize and share resources. The team met challenges, including moving to telecommuting, balancing a growing workload, and navigating a changing information landscape, and in doing so, strengthened relationships across the organization and the region.

Using State Licensure Data to Assess North Carolina's Health Workforce COVID-19 Response Capacity.

BACKGROUND In the early months of the COVID-19 pandemic, health care decision-makers in North Carolina needed information about the available health workforce in order to conduct workforce surge planning and to anticipate concerns about professional or geographic workforce shortages.METHOD Descriptive and cartographic analyses were conducted using licensure data held by the North Carolina Health Professions Data System to assess the supply of respiratory therapists, nurses, and critical care physicians in North Carolina. Licensure data were merged with population data and numbers of intensive care unit (ICU) beds drawn from the Centers for Medicare and Medicaid Services (CMS) Healthcare Cost Report Information System (HCRIS).RESULTS The pandemic highlighted how critical data infrastructure is to public health infrastructure. Respiratory therapists and acute care, emergency, and critical care nurses were diffused broadly throughout the state, with higher concentrations in urban areas. Critical care physicians were primarily based in areas with academic health centers.LIMITATIONS Data were unavailable to capture the rapid changes in supply due to clinicians reentering or exiting the workforce. County-level analyses did not reflect individual, facility-level supply, which was needed to plan organizational responses.CONCLUSIONS Health care decision-makers in North Carolina were able to access information about the supply of clinicians critical to caring for COVID-19 patients due to the state's long-standing investments in health workforce data infrastructure. Ability to respond was made easier due to strong working relationships between the University of North Carolina at Chapel Hill Cecil G. Sheps Center for Health Services Research, the North Carolina Area Health Education Centers Program, the health professional licensure boards, and state government health care agencies.

Does XR injectable naltrexone prevent relapse as effectively as daily sublingual buprenorphine-naloxone?

YES. MONTHLY EXTENDED-RELEASE INJECTABLE NALTREXONE (XR-NTX) TREATS OPIOID USE DISORDER AS EFFECTIVELY AS DAILY SUBLINGUAL BUPRENORPHINE-NALOXONE (BUP-NX) WITHOUT CAUSING ANY INCREASE IN SERIOUS ADVERSE EVENTS OR FATAL OVERDOSES. (STRENGTH OF RECOMMENDATION: A, 2 GOOD-QUALITY RCTS).

Incidence of Vascular Thromboembolic Events in Outpatients with Mild COVID-19

IntroductionHypercoagulability is a hallmark of COVID-19, the disease caused by the severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2).1 While studies have investigated vascular thromboembolic events (VaTE) in critically ill and hospitalized patients with COVID-19, less is known about thrombotic complications in patients with mild symptoms.2 Our current institutional management protocol recommends prophylactic anticoagulation for COVID-19 patients admitted to the hospital but not for outpatients with less severe disease. We evaluated the incidence of VaTE in outpatients diagnosed with COVID-19 at our institution in order to assess the potential need for thromboprophylaxis in outpatient COVID-19 management.MethodsWe conducted a retrospective analysis of electronic medical record data of outpatients in the University of North Carolina Health System who tested positive for Sars-CoV-2 between March 15 and June 20, 2020. Patients were diagnosed at one of 17 ambulatory respiratory diagnostic centers (n=706), or diagnosed and subsequently discharged from one of 11 emergency departments (n=1967) in the UNC system. Diagnosis was made using reverse transcriptase polymerase chain reaction testing of nasopharyngeal or oropharyngeal swab samples. The study outcome was the diagnosis of a vascular thromboembolic event within 30 days of COVID-19 diagnosis. This included deep vein thrombosis, pulmonary embolism, superficial thrombophlebitis, myocardial infarction, ischemic stroke, and systemic arterial thromboembolism. VaTE was defined based on documentation of an associated ICD-10 code in the patient's electronic medical record within the specified time frame. Outcomes data were reported as incidence rates for the entire study population.Results2673 outpatients were diagnosed with COVID-19 in the study period. The mean age for this cohort was 37.9 ± 17.3 years and 54% were female. 20 unique individuals (0.7%) experienced a VaTE within 30 days of diagnosis. Of these, 3 (15%) experienced venous thromboembolic events, 16 (80%) experienced arterial events, and 1 patient experienced both. Mean time to VaTE was 12.8 ± 9.3 days. Within 30 days of diagnosis, 188 of these patients (7%) had an emergency department visit or experienced hospital observation or inpatient admission.ConclusionsWe found that the incidence of VaTE in outpatients with mild COVID-19 is low. Limitations of this study include that patients were not routinely screened for VaTE and may have sought treatment for thrombotic complications outside the hospital system. This may have led to an underestimate of the true incidence; however, the findings are in line with data showing that non-hospitalized COVID-19 patients tend to be younger and have fewer medical comorbidities than hospitalized patients.3 This argues against the routine use of thromboprophylaxis in outpatients with COVID-19.