Outpatient Encounters Research Articles

Rural-Urban Disparities in Video Telehealth Use During Rapid Mental Health Care Virtualization Among American Indian/Alaska Native Veterans

American Indian/Alaska Native veterans experience a high risk for health inequities, including mental health (MH) care access. Rapid virtualization of MH care in response to the COVID-19 pandemic facilitated care continuity across the Veterans Health Administration (VHA), but the association between virtualization of care and health inequities among American Indian/Alaska Native veterans is unknown. To examine differences in video telehealth (VTH) use for MH care between American Indian/Alaska Native and non-American Indian/Alaska Native veterans by rurality and urbanicity. In this cohort study, VHA administrative data on VTH use among a veteran cohort that received MH care from October 1, 2019, to February 29, 2020 (prepandemic), and April 1 to December 31, 2020 (early pandemic), were examined. At least 1 outpatient MH encounter during the study period. The main outcome was use of VTH among all study groups (ie, American Indian/Alaska Native, non-American Indian/Alaska Native, rural, or urban) before and during the early pandemic. American Indian/Alaska Native veteran status and rurality were examined as factors associated with VTH utilization through mixed models. Of 1 754 311 veterans (mean [SD] age, 54.89 [16.23] years; 85.21% male), 0.48% were rural American Indian/Alaska Native; 29.04%, rural non-American Indian/Alaska Native; 0.77%, urban American Indian/Alaska Native; and 69.71%, urban non-American Indian/Alaska Native. Before the pandemic, a lower percentage of urban (b = -0.91; SE, 0.02; 95% CI, -0.95 to -0.87; P < .001) and non-American Indian/Alaska Native (b = -0.29; SE, 0.09; 95% CI, -0.47 to -0.11; P < .001) veterans used VTH. During the early pandemic period, a greater percentage of urban (b = 1.37; SE, 0.05; 95% CI, 1.27-1.47; P < .001) and non-American Indian/Alaska Native (b = 0.55; SE, 0.19; 95% CI, 0.18-0.92; P = .003) veterans used VTH. There was a significant interaction between rurality and American Indian/Alaska Native status during the early pandemic (b = -1.49; SE, 0.39; 95% CI, -2.25 to -0.73; P < .001). Urban veterans used VTH more than rural veterans, especially American Indian/Alaska Native veterans (non-American Indian/Alaska Native: rurality b = 1.35 [SE, 0.05; 95% CI, 1.25-1.45; P < .001]; American Indian/Alaska Native: rurality b = 2.91 [SE, 0.38; 95% CI, 2.17-3.65; P < .001]). The mean (SE) increase in VTH was 20.34 (0.38) and 15.35 (0.49) percentage points for American Indian/Alaska Native urban and rural veterans, respectively (difference in differences [DID], 4.99 percentage points; SE, 0.62; 95% CI, 3.77-6.21; t = -7.999; df, 11 000; P < .001), and 12.97 (0.24) and 11.31 (0.44) percentage points for non-American Indian/Alaska Native urban and rural veterans, respectively (DID, 1.66; SE, 0.50; 95% CI, 0.68-2.64; t = -3.32; df, 15 000; P < .001). In this cohort study, although rapid virtualization of MH care was associated with greater VTH use in all veteran groups studied, a significant difference in VTH use was seen between rural and urban populations, especially among American Indian/Alaska Native veterans. The findings suggest that American Indian/Alaska Native veterans in rural areas may be at risk for VTH access disparities.

Intentional Self-Harm Among US Veterans With Traumatic Brain Injury or Posttraumatic Stress Disorder: Retrospective Cohort Study From 2008 to 2017.

Veterans with a history of traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) may be at increased risk of suicide attempts and other forms of intentional self-harm as compared to veterans without TBI or PTSD. Using administrative data from the US Veterans Health Administration (VHA), we studied associations between TBI and PTSD diagnoses, and subsequent diagnoses of intentional self-harm among US veterans who used VHA health care between 2008 and 2017. All veterans with encounters or hospitalizations for intentional self-harm were assigned "index dates" corresponding to the date of the first related visit; among those without intentional self-harm, we randomly selected a date from among the veteran's health care encounters to match the distribution of case index dates over the 10-year period. We then examined the prevalence of TBI and PTSD diagnoses within the 5-year period prior to veterans' index dates. TBI, PTSD, and intentional self-harm were identified using International Classification of Diseases diagnosis and external cause of injury codes from inpatient and outpatient VHA encounters. We stratified analyses by veterans' average yearly VHA utilization in the 5-year period before their index date (low, medium, or high). Variations in prevalence and odds of intentional self-harm diagnoses were compared by veterans' prior TBI and PTSD diagnosis status (TBI only, PTSD only, and comorbid TBI/PTSD) for each VHA utilization stratum. Multivariable models adjusted for age, sex, race, ethnicity, marital status, Department of Veterans Affairs service-connection status, and Charlson Comorbidity Index scores. About 6.7 million veterans with at least two VHA visits in the 5-year period before their index dates were included in the analyses; 86,644 had at least one intentional self-harm diagnosis during the study period. During the periods prior to veterans' index dates, 93,866 were diagnosed with TBI only; 892,420 with PTSD only; and 102,549 with comorbid TBI/PTSD. Across all three VHA utilization strata, the prevalence of intentional self-harm diagnoses was higher among veterans diagnosed with TBI, PTSD, or TBI/PTSD than among veterans with neither diagnosis. The observed difference was most pronounced among veterans in the high VHA utilization stratum. The prevalence of intentional self-harm was six times higher among those with comorbid TBI/PTSD (6778/58,295, 11.63%) than among veterans with neither TBI nor PTSD (21,979/1,144,991, 1.92%). Adjusted odds ratios suggested that, after accounting for potential confounders, veterans with TBI, PTSD, or comorbid TBI/PTSD had higher odds of self-harm compared to veterans without these diagnoses. Among veterans with high VHA utilization, those with comorbid TBI/PTSD were 4.26 (95% CI 4.15-4.38) times more likely to receive diagnoses for intentional self-harm than veterans with neither diagnosis. This pattern was similar for veterans with low and medium VHA utilization. Veterans with TBI and/or PTSD diagnoses, compared to those with neither diagnosis, were substantially more likely to be subsequently diagnosed with intentional self-harm between 2008 and 2017. These associations were most pronounced among veterans who used VHA health care most frequently. These findings suggest a need for suicide prevention efforts targeted at veterans with these diagnoses.

Use of Real Time Clinical Video Telehealth to Home by primary care providers within the Veterans Health Administration during the first wave of the COVID-19 pandemic: variability across VA stations and with time.

Determine the extent to which use of Clinical Video Telehealth to Home (VT2H) for primary care licensed independent practitioner visits (PCLIPVs) varied over time and across the Veterans Health Administration (VA) during the first 18 months of the COVID pandemic, and if there was an association between VT2H usage and VA station characteristics. All outpatient encounters (n = 12 143 456) for Veterans (n = 4 373 638) that had VA PCLIPVs during the period of observation were categorized as conducted by VT2H, in-person, or telephone. The change over time in the percentage of total PCLIPVs conducted by VT2H was plotted and associations between VA station characteristics and VT2H usage were analyzed using simple statistics and negative binomial regression. Between March 2020 and mid-August 2020, VT2H visits increased from <2% to 13% of all VA PCLIPVs. However, VT2H usage varied substantively by VA station and declined system-wide to <9% of PCLIPVs by July 2021. VA stations that serve a greater proportion of rural Veterans were found less likely to use VT2H. The VA was successful in increasing the use of VT2H for PCLIPVs during the first phase of the COVID pandemic. However, VT2H usage varied by VA station and over time. Beyond rurality, it is unknown what station characteristics may be responsible for the variance in VT2H use. Future investigation is warranted to identify the unique practices employed by VA stations that were most successful in using VT2H for PCLIPVs and whether they can be effectively disseminated to other stations.

Mixed methods evaluation of pediatric telehealth equity for patients/families who communicate in languages other than English.

Emerging research demonstrates telehealth disparities for patients who communicate in languages other than English. A better understanding of pediatric telehealth use with families who communicate in languages other than English is needed to inform interventions to promote telehealth equity. We conducted a mixed methods study of telehealth care in a children's hospital health system using electronic health record data for outpatient video telehealth encounters from April 2020 to July 2021 and qualitative interviews with clinical staff and Spanish-speaking parents of telehealth patients. The 16-month study period included 102,387 telehealth encounters; 5% of which were encounters in languages other than English. 83% of languages other than English encounters were with patients/families with a preferred healthcare language of Spanish. 11% of providers conducted ≥10 languages other than English telehealth encounters. This subset of providers conducted 71% of all languages other than English encounters. We conducted 25 interviews with clinical staff (n=13) and parents (n=12). Common themes identified across interviews were: (I) technology barriers affect access to and quality of telehealth; (II) clinical staff and parents are uncertain about the future role of telehealth for patients/families who communicate in languages other than English; (III) the well-known impact of language barriers on in-person healthcare access and quality for patients who communicate in languages other than English is also evident in telehealth. Patients who communicate in languages other than English were underrepresented among telehealth encounters and encounters were concentrated among few providers. Promoting equitable telehealth care requires investment to address technology barriers, increase the readiness of providers and clinics to provide telehealth care in languages other than English, and continued attention to reducing the healthcare impact of language barriers.

A qualitative analysis of trust and distrust within patient-clinician interactions

ObjectivesTrust represents a key quality of strong clinician-patient relationships.1 Many have attempted to assess patient-reported trust. However, most trust measures suffer from ceiling effects, with no variability, making it not possible to examine predictors of trust and distrust. Rather than rely on patient reports, we created a codebook for instances of trust and distrust from actual patient-clinician encounters. MethodsThree coders conducted a qualitative analysis of audio recordings among patient-cardiologist outpatient encounters. ResultsWe identified trust and distrust based on vocal and verbal cues in the interactions. We found consistent patterns that indicated patient trust and distrust. ConclusionOverall, this work empirically validates a new more accurate measurement of trust for patient-doctor interactions. InnovationWe are the first to use audio recordings to identify verbal markers of trust and distrust in patient-clinician interactions. From this work, others can code trust and distrust in recorded encounters rather than rely on self-report measures.

BT26 Safe use of mobile photographic devices in dermatology: a multicentre quality-improvement project

Abstract Mobile devices are increasingly being used in dermatology to take clinical images, particularly in settings where medical photography services are not readily available. Healthcare professionals are expected to use mobile technology safely to improve patient care. Published UK guidance on the use of mobile photographic devices in dermatology details standards in three key areas: gaining patients’ informed consent, safe use of mobile devices to capture patient images, and safe transfer and storage of these images. A quality-improvement project was conducted across three UK centres. Baseline data were collected over a 2-week period in January 2023 using an anonymous staff survey and analysis of 50 outpatient encounters where mobile devices were used to take clinical images. Our survey achieved a response rate of 77% (n = 20) from consultants (60%), specialty doctors/fellows (30%) and nurses/advanced care practitioners (10%). All respondents sought patient consent prior to taking images on their personal devices, with only 10% using written consent forms (remainder using verbal consent). Thirty-five per cent reported always documenting consent in patient notes and only 20% discussed the risks and benefits of using mobile devices to take patient images. Eighty-five per cent used devices with strong passcodes (six or more characters), but only 50% confirmed that data encryption was enabled on the device. Thirty-five per cent disabled cloud-based back-up systems, 55% disabled Bluetooth and only 5% switched off global positioning system information before taking patient images. For image transfer, 80% used NHS.net email and 20% used a secure clinical image transfer application. Seventy per cent confirmed using a secure network server for image storage and that they always removed patient images from their device after transfer. Analysis of 50 patient encounters revealed that verbal consent was only documented in 8% of cases and a discussion around the risks and benefits of using mobile devices was not documented in any case. National guidance states that it is the healthcare professional’s responsibility to give patients clear information on the risks and benefits of using mobile devices to capture and transfer clinical images for storage, without which there is no informed consent. Our findings highlight a lack of awareness and adaptation of practice to these standards. We will ascertain reasons for this and implement interventions to meet guidance, including an educational meeting and introduction of a standardized written consent form to ensure patient safety and appropriate informed consent. We will present our findings on the impact of these interventions following subsequent rounds of data collection.

The Impact of Patient-Physician Racial and Gender Concordance on Patient Satisfaction with Outpatient Clinic Visits.

Patient and provider race and gender concordance (patient and physician identify as the same race/ethnicity or gender) may impact patient experience and satisfaction. We sought to examine how patient and physician racial and gender concordance effect patient satisfaction with outpatient clinical encounters. Furthermore, we examined factors that changed satisfaction among concordant and discordant dyads. Consumer Assessment of Healthcare Provider and Systems (CAHPS) Patient Satisfaction Survey Scores were collected from outpatient clinical encounters between January 2017 and January 2019 at the University of California, San Francisco. Patients who were seen in the eligible time period, who voluntarily provided physician satisfaction scores. Providers with fewer than 30 reviews and encounters with missing data were excluded. Primary outcome was rate of top satisfaction score. The provider score (1-10 scale) was dichotomized as "top score (9-10)" and "low scores (<9)." A total of 77,543 evaluations met inclusion criteria. Most patients identified as White (73.5%) and female (55.4%) with a median age of 60 (IQR 45, 70). Compared to White patients, Asian patients were less likely to give a top score even when controlling for racial concordance (OR: 0.67; CI 0.63-0.714). Telehealth was associated with increased odds of a top score relative to in-person visits (OR 1.25; CI 1.07-1.48). The odds of a top score decreased by 11% in racially discordant dyads. Racial concordance, particularly among older, White, male patients, is a nonmodifiable predictor of patient satisfaction. Physicians of color are at a disadvantage, as they receive lower patient satisfaction scores, even in race concordant pairs, with Asian physicians seeing Asian patients receiving the lowest scores. Patient satisfaction data is likely an inappropriate means of determining physician incentives as such may perpetuate racial and gender disadvantages.

935-P: Racial and Ethnic Disparities in the Application of Continuous Glucose Monitoring in Real-World Clinical Settings

Background: The use of continuous glucose monitoring (CGM) has improved glycemic control. Disparity in CGM use has been reported; however, the utilization of CGM across a health system in real-world clinical settings remains unknown. We aimed to characterize patients who use CGM and compare them to patients with diabetes who do not use CGM in a large health system. Methods: We retrospectively reviewed the electronic health record (EHR) of patients who received care at NYU Langone Health from 2015. CGM users were those whose EHR records had at least one uploaded CGM report, while CGM non-users were those who had at least one outpatient encounter in which a diabetes diagnosis was documented and who did not have any CGM files uploaded into Epic. Results: We identified 10,515 CGM users and 108,395 CGM non-users. CGM use significantly increased in patients with type 2 diabetes (T2D) after 2019, with higher use of CGM in patients with T2D than those with type 1 diabetes (T1D) (63.6% vs. 36.4%; p&amp;lt;.001). The rate of CGM use was significantly different across racial/ethnic groups: 9.9% of Whites, 7.8% Hispanics/Latinos, 7.5% African Americans, 7.2% Asian, and 7.1% Native Americans. When comparing CGM user among racial groups, CGM user was higher (than non-use) among Whites (60.4% vs 53.1%) and Filipinos (0.68% vs 0.55%), but less frequent among African Americans (13.0% vs 15.6%), Chinese (0.71% vs 1.7%), and Koreans (0.19% vs 0.45%) (p&amp;lt;.001). Regarding the ethnicity, more CGM users were Salvadoran (0.83% vs 0.45%), while less were Puerto Rican (3.3% vs 3.6%), Dominican (1.2% vs 1.4%), and Mexican (0.55 vs 1.4) (p&amp;lt;.001). Conclusions: Using a large real-world clinical setting dataset, our study identified disparity in the CGM use in patients with T1D compared to T2D. Further we noted racial/ethnic disparities in the CGM use and heterogeneity within Hispanics and Asian Americans. Researchers and clinicians should consider interventions to reduce disparities in CGM prescription patterns. Disclosure Y.Zheng: None. E.Iturrate: None. B.Wu: None. J.Fletcher: None. G.D.Melkus: None. S.B.Johnson: None. Funding National Institutes of Health (P30DK111022)

1066-P: Gaps in Guideline-Indicated Prescribing of GLP1RA/SGLT2i in Patients with T2DM and Cardiorenal Disease according to ADA Standards of Care

We evaluated the treatment gap in prescribing guideline-directed therapies in patients with T2DM and cardiorenal disease using EHR data from a large academic medical center. Eligible patients had T2DM and an outpatient encounter after January 1, 2019 in either endocrinology, cardiology, nephrology, or primary care. Eligibility subgroups were defined using ADA 2022 Standards of Care: ASCVD (N=1,962) - ‘SGLT2i or GLP1RA’; HFrEF or HFpEF or CKD stage 3 (N=5,537) - ‘SGLT2i Only’; ASCVD and HF or CKD stage 3 (N=1,773) - ‘SGLT2i primary’; CKD stage 4/5 (N=1,547) - ‘GLP1RA Only’. We extracted prescriptions for any GLP1RA or SGLT2i since 2006 to characterize ever prescribed and currently prescribed. The treatment gap for patients (N=10,819) ever prescribed ranged from 45.5% for those who should have been prescribed either an SGLT2i or GLP1RA to 71.9% for those eligible for GLP1RA only (Panel A). The treatment gap was &amp;gt;20% higher for currently prescribed across all subgroups, ranging from 73.5% to 92.1% across the subgroups (Panel B). Large treatment gaps in prescribing of guideline-directed cardiorenal protective agents in high-risk patients with type 2 diabetes exist. While all subgroups were sub-optimally treated, those with CKD stage 4/5 had the largest gap. These findings will inform multi-faceted interventions geared to improve the care of such high-risk patients. Disclosure I.Lingvay: Advisory Panel; Novo Nordisk A/S, Lilly Diabetes, Boehringer-Ingelheim, Sanofi, Consultant; Carmot Therapeutics, Inc., Merck Sharp &amp; Dohme Corp., Janssen Scientific Affairs, LLC, Pfizer Inc., Intercept, Intarcia, Valeritas, TargetRWE, Shionogi, Zealand Pharma, Structure, Bayer, Research Support; Novo Nordisk A/S, Boehringer-Ingelheim. M.E.Bowen: Research Support; Boehringer-Ingelheim. C.Mai: None. K.Marble: None. J.Pak: None. M.A.Basit: Research Support; Boehringer Ingelheim Inc., Verily Life Sciences. Funding Boehringer Ingelheim

Pediatric renal malignancy diagnosis is associated with significant burden of care for families.

New childhood cancer diagnoses require timely, complex care coordination and cause considerable logistic burden for families. We used renal tumors as a model to examine healthcare utilization and cost following new solid tumor diagnosis. Children (ages 0-21) with International Classification of Disease (ICD) codes for renal malignancy and subsequent nephrectomy were identified from North Carolina Medicaid claims data (2014-2020). We stratified patients by duration of follow-up, then quantified healthcare utilization and billing totals. Eighty-one children met study criteria. Median age at diagnosis was 3years (interquartile range [IQR]: 1-5). Median family monthly earned income was $0. One month following diagnosis, children cumulatively spent a median of 16days receiving medical care (IQR: 10-20), 28days at 3months (IQR: 21-43), and 50.5days at 1year (IQR: 35-94.5). Children cumulatively spent a median 12days as inpatients during the first 3months (IQR: 7-17) and 13.5days at 1year (IQR: 8.5-37). Children cumulatively completed a median 12 outpatient encounters at 3months (IQR: 7-17) and 26 at 1year (IQR: 12-36). At 1year, median Medicaid claim reimbursements for children with renal malignancy was $50,041 (IQR: $36,670-$80,734). In examining healthcare utilization in children with renal tumor diagnoses, the substantial number of days spent in medical facilities greatly impacts the burden of care on families, especially for those with limited financial resources. Awareness of this logistic strain on families and careful planning to consolidate patient visits may improve the navigability of pediatric cancer regimens for families, particularly those with limited resources.

Mental health care utilization among men with castration-resistant prostate cancer receiving abiraterone or enzalutamide.

Abiraterone and enzalutamide are castration-resistant prostate cancer (CRPC) therapies with potentially distinct associations with mental health symptoms given their differing antiandrogen targets. We used national Veterans Health Administration data to identify patients with CRPC who received first-line abiraterone or enzalutamide from 2010 to 2017. Using Poisson regression, we compared outpatient mental health encounters per 100 patient-months on drug between the abiraterone and enzalutamide cohorts adjusting for patient factors (e.g., age). We compared mental health encounters in the year before versus after starting therapy using the McNemar test. We identified 2902 CRPC patients who received abiraterone (n = 1992) or enzalutamide (n = 910). We found no difference in outpatient mental health encounters between the two groups (adjusted incident rate ratio [aIRR] 1.04, 95% confidence interval [CI] 0.95-1.15). However, men with preexisting mental health diagnoses received 81.3% of the outpatient mental health encounters and had higher rates of these encounters with enzalutamide (aIRR 1.21, 95% CI 1.09-1.34). Among patients with ≥1 year of enrollment before and after starting abiraterone (n = 1139) or enzalutamide (n = 446), there was no difference in mental health care utilization before versus after starting treatment (17.0% of patients vs. 17.6%, p = 0.60, abiraterone; 16.4% vs. 18.4%, p = 0.26, enzalutamide). We found no overall differences in mental health care utilization between CRPC patients who received first-line abiraterone versus enzalutamide. However, men with preexisting mental health diagnoses received the majority of mental health care and had more mental health visits with enzalutamide.

Financial Toxicity in the Clinical Encounter: A Paired Survey of Patient and Clinician Perceptions

ObjectiveTo compare the agreement between patient and clinician perceptions of care-related financial issues. Patients and MethodsWe surveyed patient-clinician dyads immediately after an outpatient medical encounter between September 2019 and May 2021. They were asked to separately rate (1-10) patient’s level of difficulty in paying medical bills and the importance of discussing cost issues with that patient during clinical encounters. We calculated agreement between patient-clinician ratings using the intraclass correlation coefficient and used random effects regression models to identify patient predictors of paired score differences in difficulty and importance of ratings. Results58 pairs of patients (n=58) and clinicians (n=40) completed the survey. Patient-clinician agreement was poor for both measures, but higher for difficulty in paying medical bills (intraclass correlation coefficient=0.375; 95% CI, 0.13-0.57) than for the importance of discussing cost (−0.051; 95% CI, −0.31 to 0.21). Agreement on difficulty in paying medical bills was not lower in encounters with conversations about the cost of care. In adjusted models, poor patient-clinician agreement on difficulty in paying medical bills was associated with lower patient socioeconomic status and education level, whereas poor agreement on patient-perceived importance of discussing cost was significant for patients who were White, married, reported 1 or more long-term conditions, and had higher education and income levels. ConclusionEven in encounters where cost conversations occurred, there was poor patient-clinician agreement on ratings of the patient’s difficulty in paying medical bills and perceived importance of discussing cost issues. Clinicians need more training and support in detecting the level of financial burden and tailoring cost conversations to the needs of individual patients.

Peer-to-Patient-Aligned Care Team (Peer-to-PACT; P2P), a Peer-Led Home Visit Intervention Program for Targeting and Improving Long-term Care Services and Support for Veterans With High Needs and High Risk: Protocol for a Mixed Methods Feasibility Study.

Keeping older veterans with high needs and high risk (HNHR) who are at risk of long-term institutional care safely in their homes for as long as possible is a Department of Veterans Affairs priority. Older veterans with HNHR face disproportionate barriers and disparities to engaging in their care, including accessing care and services. Veterans with HNHR often have poor ability to maintain health owing to complicated unmet health and social needs. The use of peer support specialists (peers) is a promising approach to improving patient engagement and addressing unmet needs. The Peer-to-Patient-Aligned Care Team (Peer-to-PACT; P2P) intervention is a multicomponential home visit intervention designed to support older veterans with HNHR to age in place. Participants receive a peer-led home visit to identify unmet needs and home safety risks aligned with the age-friendly health system model; care coordination, health care system navigation, and linking to needed services and resources in collaboration with their PACT; and patient empowerment and coaching using Department of Veterans Affairs whole health principles. The primary aim of this study is to evaluate the preliminary effect of the P2P intervention on patient health care engagement. The second aim is to identify the number and types of needs and unmet needs as well as needs addressed using the P2P needs identification tool. The third aim is to evaluate the feasibility and acceptability of the P2P intervention delivered over 6 months. We will use a quantitative-qualitative convergent mixed methods approach to evaluate the P2P intervention outcomes. For our primary outcome, we will conduct an independent, 2-tailed, 2-sample t test to compare the means of the 6-month pre-post differences in the number of outpatient PACT encounters between the intervention and matched comparison groups. Qualitative data analysis will follow a structured rapid approach using deductive coding as well as the Consolidated Framework for Implementation Research. Study enrollment began in July 2020 and was completed in March 2022. Our sample size consists of 114 veterans: 38 (33.3%) P2P intervention participants and 76 (66.7%) matched comparison group participants. Study findings are expected to be published in late 2023. Peers may help bridge the gap between PACT providers and veterans with HNHR by evaluating veterans' needs outside of the clinic, summarizing identified unmet needs, and developing team-based solutions in partnership with the PACT. The home visit component of the intervention provides eyes in the home and may be a promising and innovative tool to improve patient engagement. DERR1-10.2196/46156.

Inflammatory Bowel Disease in Appalachian Kentucky: An Investigation of Outcomes and Health Care Utilization.

Rural residence has been associated with a lower incidence of inflammatory bowel disease (IBD) but higher health care utilization and worse outcomes. Socioeconomic status is intrinsically tied to both IBD incidence and outcomes. Inflammatory bowel disease outcomes have not been investigated in Appalachia: a rural, economically distressed region rife with risk factors for both increased incidence and unfavorable outcomes. Hospital inpatient discharge and outpatient services databases were utilized to assess outcomes in patients diagnosed with either Crohn's disease (CD) or ulcerative colitis (UC) in Kentucky. Encounters were classified by patient residence in Appalachian or non-Appalachian counties. Data were reported as crude and age-adjusted rates of visits per 100,000 population per year collected in 2016 to 2019. National inpatient discharge data from 2019, stratified by rural and urban classification codes, were utilized to compare Kentucky to national trends. Crude and age-adjusted rates of inpatient, emergency department and outpatient encounters were higher in the Appalachian cohort for all 4 years observed. Appalachian inpatient encounters are more frequently associated with a surgical procedure (Appalachian, 676, 24.7% vs non-Appalachian, 1408, 22.2%; P = .0091). In 2019, the Kentucky Appalachian cohort had significantly higher crude and age-adjusted rates of inpatient discharges for all IBD diagnoses compared with national rural and nonrural populations (crude 55.2; 95% CI, 50.9-59.5; age-adjusted 56.7; 95% CI, 52.1-61.3). There is disproportionately higher IBD health care utilization in Appalachian Kentucky compared with all cohorts, including the national rural population. There is a need for aggressive investigation into root causes of these disparate outcomes and identification of barriers to appropriate IBD care.

Telemedicine Utilization in an Outpatient Pediatric Neurosurgical Clinic: A Prospective Survey of Patient and Family Preferences

After becoming widespread during the COVID-19 pandemic, telemedicine continues to play an important role in outpatient neurosurgical care. Nevertheless, the factors that influence individual decisions to choose telemedicine versus in-person appointments remain understudied. Here, we performed a prospective survey of pediatric neurosurgical patients and caregivers presenting for telemedicine or in-person outpatient visits, to identify factors associated with appointment choice. All patients and caregivers with an outpatient pediatric neurosurgical encounter at Connecticut Children's between January 31st and May 20th, 2022, were invited to participate in this survey. Data related to demographics, socioeconomics, technological access, COVID-19 vaccination status, and appointment preferences were collected. During the study period, there were 858 unique pediatric neurosurgical outpatient encounters (86.1% in-person and 13.9% telemedicine). A total of 212 (24.7%) respondents completed the survey. Those with a telemedicine appointment were more likely to be white (P= 0.005), not Hispanic or Latino (P= 0.020), have private insurance (P= 0.003), be established patients (P < 0.001), have a household income >$80,000 (P= 0.005), and have caregivers who completed a 4-year college degree (P < 0.001). Those who were seen in-person cited the patient's condition, quality of care, and communication as important factors, whereas those who were seen via telemedicine cited time, travel, and convenience. While convenience influences some to choose telemedicine, concerns regarding the quality of care persist among those who prefer in-person encounters. Recognizing these factors will minimize barriers to care, better define the appropriate populations/contexts for each encounter type, and improve the integration of telemedicine within an outpatient neurosurgical setting.

Developing machine learning algorithms incorporating patient reported outcome measures to predict acute care events among patients with cancer.

1516 Background: Clinical trials have shown that collecting patient-reported outcome measures (PROMs) can improve outcomes among oncology patients. However, there remains uncertainty about how to best collect and use PROMs in routine clinical care. Since 2016 we have collected PROMs for patients receiving cancer treatment within a large health system containing academic and community sites. We sought to examine whether combining PROMs with electronic health record (EHR) data improves the performance of machine learning algorithms predicting patients’ risk of 30-day acute care events. Methods: The sample included patients with solid tumors receiving curative- or palliative-intent systemic therapy between 9/1/20 and 7/31/22 who completed at least one PROMs survey. PROMs were collected via a 12-item questionnaire based on the Common Terminology Criteria for Adverse Events measurement system. Patients completed questionnaires via the EHR’s patient portal or on tablets in waiting rooms. EHR data included 176 variables describing demographics, laboratory values, vital signs, diagnoses, medications, and prior healthcare encounters. A binomial outcome was calculated for each patient encounter to indicate whether the patient had an acute care event (ED visit or hospitalization) in the subsequent 30 days. Data were randomly assigned to training (70%) and test (30%) sets and were used to train and test four models: EHR + PROMs, EHR alone, PROMs alone, and ‘PROMs plus,’ which included PROMs and minimal EHR data such as age, sex, and site of cancer treatment, which served as an accessible proxy for cancer type. For each model, we compared multiple architectures and selected the best-performing model for comparison. Results: Between September 2020 and June 2022, 4,193 patients completed 20,359 PROM surveys during outpatient encounters. There were 2,118 30-day acute care events within the cohort. The area under the receiver operating curves (AUCs) were 0.84 (95% CI 0.81 to 0.86) for the EHR + PROMs model, 0.82 (95% CI 0.80 to 0.84) for the EHR alone model, 0.67 (95% CI 0.65 to 0.69) for the PROMs alone model, and 0.79 (95% CI 0.77 to 0.82) for the PROMs plus model. In the EHR alone and EHR + PROMs models, the most important variables were last albumin, white blood cell count and hemoglobin. In the PROMs plus model, the most important variables were age, treatment site, patient-reported pain, and patient-reported fatigue. Conclusions: Incorporating PROMs into machine learning models to predict risk of acute care events can improve model performance. Notably, the model combining PROMs with a small number of easily accessible EHR variables performed nearly as well as models including all EHR data. These models demonstrate the predictive value of PROMs in oncology patients and they lay the foundation for future interventions aiming to reduce acute care events among high-risk patients.

Congruence between International Classification of Disease, Tenth Revision (ICD-10) code and written documentation for outpatient encounters with antibiotic prescriptions

Background: Antimicrobial stewardship programs (ASPs) often rely on International Classification of Diseases, Tenth Revision (ICD-10) codes to assess antibiotic appropriateness for provider feedback. Concordance between encounter ICD-10 codes and documented indication for antibiotics based on manual chart review varies greatly (74%–95%) in the inpatient setting. Data on concordance between documented indication and ICD-10 code in the outpatient setting are scarce. Methods: We conducted a retrospective cohort study of 650 randomly selected outpatient encounters with antibiotic prescriptions from walk-in and retail clinics between July 15 and September 15, 2021, at Vanderbilt University Medical Center. We performed chart review to compare documented antibiotic indication to the 3 most frequent encounter-associated ICD-10 codes. Also, 12 encounters were excluded due to insufficient available written documentation. The 95% CI for proportion of encounters with concordant antibiotic indications was calculated using Stata version 15.1 software. Results: Of the 638 antibiotic prescriptions with written documentation available for chart review, 204 (32%) were for amoxicillin, 102 (16%) were for amoxicillin-clavulanate, 61 (10%) were for cefdinir, and 56 (9%) were for azithromycin. Overall, 540 (84.6%; 95% CI, 81.6%–87.4%) of 638 encounters had concordant antibiotic indication based on documentation in the note and associated ICD-10 for the encounter. Of the 540 encounters with concordant ICD-10 and documented indications, 348 (64%), 130 (24%), and 35 (6%) were listed as the first, second, and third ICD-10 codes, respectively. An additional 27 (5%) had a concordant ICD-10 code listed beyond the third position. In total, 125 (19.6%) of 638 encounters did not have the intended antibiotic indication as documented in the note in the 3 most frequent encounter-associated ICD-10 codes (whether a lower position or incongruent ICD-10 code with documentation). Of those 125 encounters, 42 (34%) had a documented diagnosis of strep pharyngitis, 16 (13%) had a documented diagnosis of skin or soft-tissue infection, 11 (9%) had a documented diagnosis of urinary tract infection, and 11 (9%) had a documented diagnosis of acute otitis media. Conclusions: Our data suggest that outpatient antimicrobial prescriptions correlate relatively well with encounter ICD-10 codes. However, most ASP prescribing goals aim to reduce inappropriate prescribing to 10% or fewer of prescriptions based on indication. Therefore, providers may not trust individual prescribing feedback that is based on data that is only correct 85% of the time. For ASPs to accurately assess prescribing and provide trusted, meaningful recommendations and specific feedback to individual prescribers, more reliable and valid data are needed. We intend to evaluate whether requiring outpatient antibiotic indications on prescriptions increases data reliability and validity.Disclosures: None

Disparities in accessing open notes at a comprehensive cancer center.

e18507 Background: Patient use of open access medical notes can promote understanding of and engagement in disease management, in turn improving patient satisfaction, trust, medication adherence and clinical outcomes. Previous studies have shown that racial minorities were less likely to utilize personal health records online, as were patients with lower incomes compared to those with higher incomes. The CURES Act, enacted as of April 5 2021, is a national policy that requires healthcare providers to give patients access to the information and notes available on their own electronic medical registry. Given the recency of this legislation, little is known about who is accessing this information or how we can help it to be more widely accessible. Methods: We extracted demographic data available for all patients with an outpatient oncology encounter at UCSD between 1/1/21-12/31/21. Data available included age, gender, ethnicity, preferred language, and type of insurance. Mann-Whitney U test and Fisher’s exact test were used to compare continuous and categorical variables between the two groups, respectively. This analysis was approved by the UCSD ACQUIRE committee and met criteria for IRB excusal. Results: There were 22,419 patients who met inclusion criteria, 21,892 (97.3%) of whom were registered on MyChart and 4,114 (18.4%) of whom had accessed an oncology note. There was no significant difference in age or gender between those who did or did not access notes. Patient race, ethnicity, preferred language, and insurance type were all significantly different between groups (p&lt;0.001), with those who were non-White, Hispanic, Spanish speaking, or on Medicaid less likely to access their notes through OpenNotes. Conclusions: There are significant differences in the demographics of patients who do and do not access notes. Targeted outreach efforts (e.g., translation efforts) may help in making access to open notes more equitable. [Table: see text]

Management of modifiable risk factors and comorbidities in atrial fibrillation: suggestions for improvement from a patient perspective.

In patients with atrial fibrillation (AF), improved management of modifiable risk factors and concomitant diseases is recommended by guidelines, yet many AF patients have sub-optimal risk factor management. Digital health solutions may offer support in this matter. This study aims to identify how patients with AF perceive they could be supported by a digital tool aimed to optimize management of comorbidities and modifiable risk factors associated with an unhealthy lifestyle. This was a qualitative, descriptive study based on four semi-structured focus-group interviews analysed by manifest content analysis. Sixteen AF patients with recent in- or outpatient encounters were included [age 68 (52-78) years; 43% female; BMI 29.5 (20.4-35.8) kg/m2; paroxysmal/persistent AF (50%/50%); AF duration 7 (0-22) years]. Relevant comorbidities were hypertension (88%), heart failure (25%), diabetes mellitus type 2 (19%), and ischaemic heart disease (13%). The patients' suggestions were summarized into three main categories. First, person-centred information is essential, meaning that information should be customized and conveyed in an appropriate manner and include practical tips. Second, patients desire help with managing lifestyle habits in a way that is applicable in everyday life, and patients desire help with creating habits. Third, regular communication is necessary including inspirational reminders and motivational feedback. Patients with AF request person-centred information, support in managing healthy lifestyle habits, and more regular communication with caregivers. This study provides a first foundation on how to better support AF patients, and using a digital tool in standard care may improve outcomes and reduce cost of care.

Mental health service use among Canadian veterans within the first 5 years following service: methodological considerations for comparisons with the general population

IntroductionPrevious research comparing veteran and civilian mental health (MH) outcomes often assumes stable rates of MH service use over time and relies on standardisation or restriction to adjust for differences...