Patient-level Interventions Research Articles

Emerging Nurse Billing and Reimbursement Models.

To explore and make recommendations to implement direct billing and reimbursement models for nursing care in the United States. Nurses make up the largest group of healthcare professionals and within hospitals, nurses represent approximately a quarter of all resources and associated costs of patient care. This care is mostly hidden in daily room and board charges. The authors surveyed the recent and historical literature related to costing and billing for nursing care. These results were synthesized and led to the recommendation of several new models to cost, bill, and pay for nursing care provided by nurses who are not currently billing for their services. Two basic billing models are proposed: the 1st is to remove nursing care out of the current daily room or facility-based charges and allocate nursing care time provided to each patient during each day of stay. The 2nd is to expand existing Current Procedural Terminology codes to bill for specific activities and interventions by nurses in all settings where nursing care is delivered. It is feasible to implement the proposed methods to identify patient-level nursing intensity, cost, services, and interventions provided by individual nurses in all healthcare settings.

A pragmatic randomized trial of mailed fecal immunochemical testing to increase colorectal cancer screening among low-income and minoritized populations.

Colorectal cancer (CRC) screening is underused, particularly among low-income and minoritized populations, for whom the coronavirus disease 2019 (COVID-19) pandemic has challenged progress in achieving equity. A hub-and-spoke model was used. The hub was a nonacademic organization and the spokes were three community health center (CHC) systems overseeing numerous clinic sites. Via a cluster-randomized trial design, nine clinic sites were randomized to intervention and 16 clinic sites were randomized to usual care. Patient-level interventions included invitation letters, mailed fecal immunochemical tests (FITs), and call/text-based reminders. Year 1 intervention impact, which took place during the COVID-19 pandemic, was assessed as the proportion completing screening among individuals not up to date at baseline, which compared intervention and nonintervention clinics accounting for intraclinic cluster variation; confidence intervals (CIs) around differences not including 0 were interpreted as statistically significant. Among 26,736 patients who met eligibility criteria, approximately 58% were female, 55% were Hispanic individuals, and 44% were Spanish speaking. The proportion completing screening was 11.5 percentage points (ppts) (95% CI, 6.1-16.9 ppts) higher in intervention versus usual care clinics. Variation in differences between intervention and usual care clinics was observed by sex (12.6 ppts [95% CI, 7.2-18.0 ppts] for females; 8.8 ppts [95% CI, 4.7-13.9 ppts] for males) and by racial and ethnic group (13.8 ppts [95% CI, 7.0-20.6 ppts] for Hispanic individuals; 13.0 ppts [95% CI, 3.6-22.4 ppts] for Asian individuals; 11.3 ppts [95% CI, 5.8-16.8 ppts] for non-Hispanic White individuals; 6.1 ppts [95% CI, 0.8-10.4 ppts] for Black individuals). A regional mailed FIT intervention was effective for increasing CRC screening rates across CHC systems serving diverse, low-income populations.

Perinatal loss in Tanzania: Perspectives of maternal-child healthcare providers.

Over 98% of stillbirths and neonatal deaths occur in Low- and Middle-Income Countries, such as Tanzania. Despite the profound burden of perinatal loss in these regions, access to facility or community-based palliative and psychosocial care is poor and understudied. In this study we explore perinatal loss through the lens of front-line healthcare providers, to better understand the knowledge and beliefs that guide their engagement with bereaved families. A Knowledge Attitudes and Practices survey addressing perinatal loss in Tanzania was developed, translated into Swahili, and administered over a 4-month period to healthcare professionals working at the Kilimanjaro Christian Medical Center (KCMC). Results were entered into REDCap and analyzed in R Studio. 74 providers completed the survey. Pediatric providers saw a yearly average of 5 stillbirths and 32.7 neonatal deaths. Obstetric providers saw an average of 11.5 stillbirths and 13.12 neonatal deaths. Most providers would provide resuscitation beginning at 28 weeks gestational age. Respondents estimated that a 50% chance of survival for a newborn occurred at 28 weeks both nationally and at KCMC. Most providers felt that stillbirth and neonatal mortality were not the mother's fault (78.4% and 81.1%). However, nearly half (44.6%) felt that stillbirth reflects negatively on the woman and 62.2% agreed that women are at higher risk of abuse or abandonment after stillbirth. A majority perceived that women wanted hold their child after stillbirth (63.0%) or neonatal death (70.3%). Overall, this study found that providers at KCMC perceived that women are at greater risk of psychosocial or physical harm following perinatal loss. How women can best be supported by both the health system and their community remains unclear. More research on perinatal loss and bereavement in LMICs is needed to inform patient-level and health-systems interventions addressing care gaps unique to resource-limited or non-western settings.

Variation Between Hospitals in Outcomes and Costs of IBD Care: Results From the IBD Value Study.

Data on variation in outcomes and costs of the treatment of inflammatory bowel disease (IBD) can be used to identify areas for cost and quality improvement. It can also help healthcare providers learn from each other and strive for equity in care. We aimed to assess the variation in outcomes and costs of IBD care between hospitals. We conducted a 12-month cohort study in 8 hospitals in the Netherlands. Patients with IBD who were treated with biologics and new small molecules were included. The percentage of variation in outcomes (following the International Consortium for Health Outcomes Measurement standard set) and costs attributable to the treating hospital wereanalyzed with intraclass correlation coefficients (ICCs) from case mix-adjusted (generalized) linear mixed models. We included 1010 patients (median age 45 years, 55% female). Clinicians reported high remission rates (83%), while patient-reported rates were lower (40%). During the 12-month follow-up, 5.2% of patients used prednisolone for more than 3 months. Hospital costs (outpatient, inpatient, and medication costs) were substantial (median: €8323 per 6 months), mainly attributed to advanced therapies (€6611). Most of the variation in outcomes and costs among patients could not be attributed to the treating hospitals, with ICCs typically between 0% and 2%. Instead, patient-level characteristics, often with ICCs above 50%, accounted for these variations. Variation in outcomes and costs cannot be used to differentiate between hospitals for quality of care. Future quality improvement initiatives should look at differences in structure and process measures of care and implement patient-level interventions to improve quality of IBD care. NL8276.

Improving Medication Adherence Levels in Inflammatory Bowel Disease (IBD) Patients: A Narrative Evidence-Based Review.

Inflammatory bowel disease (IBD) management is typified by a long-term medication regimen which can comprise multiple medications prescribed in different combinations, doses, frequencies, and with various administration routes. This complexity can make medication adherence (MA) - patients taking their medications per the prescription - for patients with IBD a challenge. The research corpus contains diverse interventions aimed at improving MA in patients with IBD. Therefore, to condense the evidenced strategies for ease of reference, this narrative evidence-based review broadly outlines the patient-level interventions reported. The interventions are grouped as educational, behavioural, cognitive-behavioural, and multicomponent. They, however, present mixed results as to their efficacy at improving MA, with those employing combined approaches being the most promising. This reflects the reality that MA is impacted by multiple factors encompassing those pertaining to the patient, disease, therapy, patients' socioeconomic status, and health system. Hence, the most ideal interventions would likely be multifaceted patient-level interventions alongside policy/system-level strategies, to maximise the potential for successfully improving patients' MA. These findings might have been impacted by the heterogeneity of the studies in terms of the method of MA assessment, duration of interventions, and more besides.

Association of health information technology-driven multidisciplinary approaches with low-density lipoprotein cholesterol target achievement in patients with an acute coronary syndrome

ObjectiveControlling of low-density lipoprotein cholesterol (LDL-C) in patients with acute coronary syndrome (ACS) remains a challenge. Health information technology (HIT) is increasingly being applied to close quality gaps in chronic illness care. The aim of this study was to perform a qualitative review of the association of implementing HIT on lipid management processes of care and LDL-C goal attainment in patients with ACS. MethodEligible patients with a discharge diagnosis of ACS from January 2018 to December 2021 at a tertiary medical center were retrospectively reviewed. An HIT system with a multidisciplinary approach including initiating high-intensity statin therapy, periodic laboratory follow-up, titration of lipid-lowering agents, patient education, patient-level and system-level interventions involving database monitoring and outreach by centralized care teams was introduced in October 2018. Electronical medical records including data on medications and laboratory findings at discharge and within 1 year were compared before and after implementing the HIT system. ResultsA total of 2001 ACS patients (average age 63 ± 12.7 years, 79.66 % men) were analyzed. The LDL-C < 70 mg/dL goal attainment rates (36.52 %, 53.57 %, 59.22 %, 62.18 % in 2018–2021) and medium serum LDL-C levels (80.5 mg/dL, 68 mg/dL, 65 mg/dL, 64 mg/dL in 2018–2021) significantly improved within 6 months (2018 as the reference, all p<0.001). The LDL-C attainment rate at 12 months also steadily increased (53.80 %, 61.82 %, 64.21 % in 2019–2021, p = 0.019). Most of the patients switched to a high-intensity statins regimen at discharge (0.57 %, 63.67 %, 72.41 %, 84.44 %, in 2018–2021, p<0.001 with 2018 as the reference), with low adverse event rates. The maintenance rates of high-intensity statin regimens at 12 months continued to improve (41.36 %, 49.04 %, 61.39 % in 2019–2021, p<0.001). ConclusionsEfforts to control LDL-C should be increased in ACS patients by initiating and intensifying statin treatment earlier. Our results confirmed that a team-based strategy with HIT improved LDL-C target achievement for most patients with ACS.

Understanding Causes of Inferior Outcomes in Adolescents and Young Adults With Cancer.

Individuals diagnosed with cancer as adolescents and young adults (AYAs; ages 15-39 years) face unique vulnerabilities. Compared with individuals diagnosed when younger (≤14 years) or older (≥40 years), AYAs have not seen the same improvement in survival. Furthermore, they sit at a complex moment of social, emotional, and cognitive development, and have a unique interface with the healthcare system. With these observations, NCI prioritized addressing the unique vulnerabilities among AYAs with cancer, and NCCN developed guidelines regarding optimal AYA cancer care. Improvements in certain locales have been seen in the wake of this focus on AYAs, suggesting that continuing to consider AYA outcomes in the context of their specific needs is critical as we strive toward additional improvements. However, it is key to consider the drivers of these outcomes to continue this trajectory. This review presents a holistic conceptual model that includes factors that influence outcomes among AYAs with cancer, including domains in these levels that influence both clinical outcomes (such as relapse and survival) and health-related quality of life (HRQoL). These include domains at the patient level, such as social constructs (race/ethnicity, socioeconomic status), behavior (adherence, risk-taking), biologic characteristics (cancer biology, host genetics), medical treatment (treatment regimen, risk-based survivorship care), and treatment-related toxicities. The model also includes domains at the system level, which include treatment location (NCI designation, facility model, AYA program presence), clinical trial enrollment, transdisciplinary communication, fertility preservation, and psychosocial support. Recognizing these multiple factors at the level of the individual and the healthcare system influence AYA outcomes (from HRQoL to survival), it is key not only to consider patient-level interventions and development of novel cancer agents but also to develop systems-level interventions that can be executed in parallel. In this way, the impact can be expanded to a vast number of AYAs.

Machine learning to identify attributes that predict patients who leave without being seen in a pediatric emergency department.

To characterize patients who left without being seen (LWBS) from a Canadian pediatric Emergency Department (ED) and create predictive models using machine learning to identify key attributes associated with LWBS. We analyzed administrative ED data from April 1, 2017, to March 31, 2020, from IWK Health ED in Halifax, NS. Variables included: visit disposition; Canadian Triage Acuity Scale (CTAS); triage month, week, day, hour, minute, and day of the week; sex; age; postal code; access to primary care provider; visit payor; referral source; arrival by ambulance; main problem (ICD10); length of stay in minutes; driving distance in minutes; and ED patient load. The data were randomly divided into training (80%) and test datasets (20%). Five supervised machine learning binary classification algorithms were implemented to train models to predict LWBS patients. We balanced the dataset using Synthetic Minority Oversampling Technique (SMOTE) and used grid search for hyperparameter tuning of our models. Model evaluation was made using sensitivity and recall on the test dataset. The dataset included 101,266 ED visits where 2009 (2%) records were excluded and 5800 LWBS (5.7%). The highest-performing machine learning model with 16 patient attributes was XGBoost which was able to identify LWBS patients with 95% recall and 87% sensitivity. The most influential attributes in this model were ED patient load, triage hour, driving minutes from home address to ED, length of stay (minutes since triage), and age. Our analysis showed that machine learning models can be used on administrative data to predict patients who LWBS in a Canadian pediatric ED. From 16 variables, we identified the five most influential model attributes. System-level interventions to improve patient flow have shown promise for reducing LWBS in some centres. Predicting patients likely to LWBS raises the possibility of individual patient-level interventions to mitigate LWBS.

Patient-level interventions to increase guideline concordant treatment among Black breast cancer patients: Can they close the racial gap in survival after diagnosis?

6549 Background: While we have seen impressive improvements in breast cancer (BC) survival over the last few decades, substantial racial disparities persist. Inequities in the receipt of guideline-concordant treatment contribute to worse survival in Black BC patients. Previous studies have shown that patient-level disparity reduction interventions (e.g., patient navigation) can significantly increase guideline-concordant treatment receipt among Black patients, with positive spillover effects in nonBlack patients. The aim of this study was to estimate the potential impact of disparity reduction interventions on racial inequities in survival after BC diagnosis in North Carolina. Methods: We used data from the Cancer Information and Population Health Resource, which links multipayer claims to North Carolina’s cancer registry for biological women diagnosed with BC in 2004-2017. We calculated Black/nonBlack disparities in the receipt of chemotherapy (CTx) within 4 months of diagnosis for patients ages &lt;70 with hormone-receptor negative stage Ib-III BC (CTx cohort; N=2223) and the receipt of endocrine therapy (ET) within 12 months of diagnosis for stage I-III hormone receptor-positive BC (ET cohort=16220). We then simulated the potential increase in the proportion of patients receiving CTx and ET if proven patient-level disparity-reduction interventions were implemented across the state. Based on the literature, we assumed that the effects of these interventions in increasing treatment receipt would be same in the CTx and ET cohorts. We estimated the effect of this potential increase in CTx and ET receipt on 10-year overall survival using cohort-, race-, and treatment receipt-stratified Markov models. We report confidence bounds representing 95% of simulation results. Results: Over the 2004-2017 period, 72.9% and 70.8% of Black patients in our cohorts received CTx and ET, respectively. This was significantly lower than among nonBlack patients (p&lt;.05). State-wide implementation of disparity reduction interventions could increase CTx and ET receipt among Black patients to 86.7% (80.9-92.5%) and 84.2% (78.5-89.9%), respectively. As a result, the racial 10-year survival gap would decrease from 9.4 to 8.1 (5.7-10.5) percentage points in the CTx cohort, and from 6.2 to 5.4 (4.0-6.7) percentage points in the ET cohort. Conclusions: Patient-level interventions can reduce disparities in guideline-concordant-treatment receipt. However, increases in treatment receipt alone would not be enough to close the racial survival gap, suggesting that, in isolation, patient-level interventions are unable to eliminate disparities. Action on the structural factors that disadvantage Black BC patients is needed. Our team is conducting community-engaged work to share and interpret these findings.

A multi-level system quality improvement project to reduce disparities in lung cancer screening: The Sylvester Lung Screening Project.

6518 Background: Racial disparities in lung cancer mortality and screening have been well documented in the USA. Annual screening with low dose Computed Tomography (CT) scans is completed in fewer than 6% of the eligible population. Research suggests that many factors contribute to low screening uptake, including barriers to care at patient, clinician, healthcare system, and community levels. In collaboration with the American Cancer Society, the University of Miami/ Sylvester Cancer Center underwent a multi-level system quality improvement (QI) project with the goal to decrease lung cancer screening disparities and improve guideline concordant lung cancer screening across the health care system. Methods: During the one-year multi-level QI project, interventions were put into place to increase lung cancer screening exams via improvements in EMR- identification of eligible patients, patient navigation and expanded provider education services in primary care clinics. Patient level interventions included a marketing campaign, patient navigation, and interpreters to address language barriers. The Patient-interface of the EMR ‘Health Maintenance Gap’ was optimized to alert eligible patients about screening. In addition, a full-time lung cancer screening navigator provided culturally competent, patient-centered counseling, while allowing for an increased capability to manage a higher volume of patients. Provider level interventions included teaching sessions about lung cancer screening and motivational communication skills, and BPA alerts. The primary outcome was the change in the number of screened patients. Results: With the implementation of these multi-level interventions, there was a twenty five percent improvement in the number of lung cancer screening exams completed during the project period January 2022- December 2022 compared to 2021 baseline, from 20 to 25%. The screening rate was highest among Hispanics (12%), followed by Blacks (8%), and Non- Hispanic Whites (NHW) (6%). The majority of LDCT results were Lung RADS Category 1 or 2 (93%). Conclusions: Multi-level interventions that target patients, clinicians, and the health care system can improve lung cancer screening rates in a short-term period. Developing patient-centered, culturally competent interventions is key to reducing disparities in lung cancer screening. This QI intervention was strengthened by tailoring intervention components to the educational primary care physicians and simplifying the referral process. [Table: see text]

Association between patient, clinic, and geographical-level factors and 1-year surveillance colonoscopy adherence.

Surveillance colonoscopy 1-year after surgical resection for patients with stages I-III colorectal cancer (CRC) is suboptimal and data on factors associated with lack of adherence are limited. Using surveillance colonoscopy data from Washington state, we aimed to determine the patient, clinic, and geographical factors associated with adherence. Using administrative insurance claims linked to Washington (WA) cancer registry data we conducted a retrospective cohort study of adult patients diagnosed with stage I-III CRC between 2011 and 2018 with continuous insurance for at least 18 months after diagnosis. We determined the adherence rate to 1-year surveillance colonoscopy and conducted logistic regression analysis to identify factors associated with completion. Of 4,481 stage I-III CRC patients identified, 55.8% completed a 1-year surveillance colonoscopy. The median time to colonoscopy completion was 370 days. On multivariate analysis, older age, higher stage CRC, Medicare insurance or multiple insurance carriers, higher Charlson Comorbidity Index score and living without a partner were significantly associated with decreased adherence to 1-year surveillance colonoscopy. Among 29 eligible clinics, 51% (n=15) reported lower than expected surveillance colonoscopy rates based on patient mix. Surveillance colonoscopy 1-year after surgical resection is sub-optimal in WA state. Patient and clinic factors, but not geographic factors (Area Deprivation Index), were significantly associated with surveillance colonoscopy completion. This data will inform the development of patient and clinic level interventions to address an important quality of care issue across Washington.

The design and rationale of a multicenter real-world trial: The Southeastern Collaboration to Improve Blood Pressure Control in the US Black Belt – Addressing the Triple Threat

BackgroundImpoverished African Americans (AA) with hypertension face poor health outcomes. PurposeTo conduct a cluster-randomized trial testing two interventions, alone and in combination, to improve blood pressure (BP) control in AA with persistently uncontrolled hypertension. MethodsWe engaged primary care practices serving rural Alabama and North Carolina residents, and in each practice we recruited approximately 25 AA adults with persistently uncontrolled hypertension (mean systolic BP >140 mmHg over the year prior to enrollment plus enrollment day BP assessed by research assistants ≥140/90 mmHg). Practices were randomized to peer coaching (PC), practice facilitation (PF), both PC and PF (PC + PF), or enhanced usual care (EUC). Coaches met with participants from PC and PC + PF practices weekly for 8 weeks then monthly over one year, discussing lifestyle changes, medication adherence, home monitoring, and communication with the healthcare team. Facilitators met with PF and PC + PF practices monthly to implement ≥1 quality improvement intervention in each of four domains. Data were collected at 0, 6, and 12 months. ResultsWe recruited 69 practices and 1596 participants; 18 practices (408 participants) were randomized to EUC, 16 (384 participants) to PF, 19 (424 participants) to PC, and 16 (380 participants) to PC + PF. Participants had mean age 57 years, 61% were women, and 56% reported annual income <$20,000. LimitationsThe PF intervention acts at the practice level, possibly missing intervention effects in trial participants. Neither PC nor PF currently has established clinical reimbursement mechanisms. ConclusionsThis trial will fill evidence gaps regarding practice-level vs. patient-level interventions for rural impoverished AA with uncontrolled hypertension.

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study

BackgroundThe second Multicenter Medication Reconciliation Quality Improvement Study demonstrated a marked reduction in medication discrepancies per patient. The aim of the current analysis was to determine the association of patient...

The Michigan Genetic Hereditary Testing (MiGHT) study’s innovative approaches to promote uptake of clinical genetic testing among cancer patients: a study protocol for a 3-arm randomized controlled trial

BackgroundAlthough most cancers are sporadic, germline genetic variants are implicated in 5–10% of cancer cases. Clinical genetic testing identifies pathogenic germline genetic variants for hereditary cancers. The Michigan Genetic Hereditary Testing (MiGHT) study is a three-arm randomized clinical trial that aims to test the efficacy of two patient-level behavioral interventions on uptake of cancer genetic testing.MethodsThe two interventions being tested are (1) a virtual genetics navigator and (2) motivational interviewing by genetic health coaches. Eligible participants are adults with a diagnosis of breast, prostate, endometrial, ovarian, colorectal, or pancreatic cancer who meet the National Comprehensive Cancer Network (NCCN) criteria for genetic testing. Participants are recruited through community oncology practices affiliated with the Michigan Oncology Quality Consortium (MOQC) and have used the Family Health History Tool (FHHT) to determine testing eligibility. The recruitment goal is 759 participants, who will be randomized to usual care or to either the virtual genetics navigator or the motivational interviewing intervention arms. The primary outcome will be the proportion of individuals who complete germline genetic testing within 6 months.DiscussionThis study addresses patient-level factors which are associated with the uptake of genetic testing. The study will test two different intervention approaches, both of which can help address the shortage of genetic counselors and improve access to care.Trial registrationThis study has been approved by the Institutional Review Board of the University of Michigan Medical School (HUM00192898) and registered in ClinicalTrials.gov (NCT05162846).

Telemedicine and health disparities: Association between the area deprivation index and primary care telemedicine utilization during the COVID-19 pandemic.

The rapid implementation of telemedicine during the COVID-19 pandemic may have exacerbated the existing health disparities. This study investigated the association between the area deprivation index (ADI), which serves as a measure of socioeconomic deprivation within a geographic area, and the utilization of telemedicine in primary care. The study data source was electronic health records. The study population consisted of patients with at least one primary care visit between March 2020 and December 2021. The primary outcome of interest was the visit modality (office, phone, and video). The exposure of interest was the ADI score grouped into quartiles (one to four, with one being the least deprived). The confounders included patient sociodemographic characteristics (e.g., age, gender, race, ethnicity, insurance coverage, marital status). We utilized generalized estimating equations to compare the utilization of telemedicine visits with office visits, as well as phone visits with video visits. The study population included 41,583 patients with 127,165 office visits, 39,484 phone visits, and 20,268 video visits. Compared to patients in less disadvantaged neighborhoods (ADI quartile = one), patients in more disadvantaged neighborhoods (ADI = two, three, or four) had higher odds of using phone visits vs office visits, lower odds of using video visits vs office visits, and higher odds of using phone visits vs video visits. Patients who resided in socioeconomically disadvantaged neighborhoods mainly relied on phone consultations for telemedicine visits with their primary care provider. Patient-level interventions are essential for achieving equitable access to digital healthcare, particularly for low-income individuals.

Mediterranean diet score is associated with greater allocentric processing in the EPAD LCS cohort: A comparative analysis by biogeographical region.

Background: Adherence to the Mediterranean diet (MedDiet), a primarily plant-based eating pattern, has been associated with lower dementia incidence. Much of the research has focused on Alzheimer's disease (AD) dementia and mild cognitive impairment (MCI), with less research looking at the preclinical symptomatically silent stages that pre-empt MCI and AD dementia. Although there is evidence from studies conducted globally, no studies have compared the effects of the MedDiet within and outside of the Mediterranean region in one cohort. Methods: Our study explored cross-sectional and longitudinal associations between MedDiet and cognition in the pan-European EPAD LCS, comparing those living within and outside of the Mediterranean region (as classified by European Union biogeographical definitions). After deriving MEDAS scores to quantify adherence to the MedDiet, we used linear regression and linear mixed effects models to test for associations between the MEDAS score and cognitive function measured by the Four Mountains Test (FMT) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). We additionally calculated MEDAS continuous and PYRAMID scores to provide alternative measures of MedDiet adherence. Results: We included 1826 participants, mean age 65.69 (±7.42) years, majority female (56.2%) with family history (65.8%) and minority APOEε4 carriers (38.9%). Higher MEDAS scores were associated with better performance on the FMT both cross-sectionally (n = 1,144, ß: -0.11, SE: 0.04, p = 0.007) and longitudinally (slope: 0.10, 95% CI: 0.04-0.17, p: 0.002). The effect was marginally greater in the Mediterranean region in the cross-sectional analysis, with a stronger effect emerging longitudinally. In exploratory analyses, the association between MEDAS and FMT scores was only seen in female participants. A sensitivity analysis excluding Toulouse and Perugia, as cities near, but not within, the biogeographical region, found significant associations between higher MEDAS and MEDAS continuous scores, and a number of RBANS total and index scores. Conclusion: MedDiet adherence is associated with better FMT scores, with effects seen most strongly in the Mediterranean region from longitudinal data. Our sensitivity analysis suggested a more global cognitive benefit of MedDiet adherence. This study highlights the need to further explore for whom and for what brain health outcomes the MedDiet confers benefit. This evidence would identify a window of opportunity in the life-course to maximise the benefit and better inform public health campaigns and patient-level interventions.

Does adherence to the Mediterranean diet have differential effects on brain health for those living within and outside of the Mediterranean region?

AbstractBackgroundThe Mediterranean diet (MedDiet) is a primarily plant‐based eating pattern. High adherence to a MedDiet has been associated with a 10‐40% lower incidence of dementia. There is limited evidence exploring associations between the MedDiet and Alzheimer’s disease (AD) pathology.MethodOur study explored cross‐sectional associations between MedDiet and AD outcomes in the European Prevention of Alzheimer’s Dementia Longitudinal Cohort Study (EPAD LCS), comparing effects between those living within and outside of the Mediterranean region. After deriving MEDAS scores, to quantify adherence to the MedDiet, we used linear regression analyses to test for associations between the MedDiet and hippocampal volume, white matter lesion volume (WMLV) cerebrospinal fluid Abeta 1‐42 and phosphorylated tau and cognition. Participants were categorised by Mediterranean or non‐Mediterranean region according to European Union classification.ResultWe included 1625 participants from the EPAD LCS baseline dataset, mean age 65.48 (±7.40) years, majority female (55.9%), majority with family history (66.3%) and minority APOEε4 carriers (39.0%). Mediterranean participants had higher MEDAS scores compared to non‐Mediterranean participants (7.44 (±1.60) vs 7.20 (±1.74), p = 0.007). Higher adherence to the MedDiet was associated with lower log WMLV in fully adjusted models (b: ‐0.06, standard error (SE): 0.02, p&lt;0.001), indicating better brain health. Geographical region analysis found this effect only in Mediterranean participants (fully adjusted: b: ‐0.10, SE: 0.03, p&lt;0.001). Exploratory analysis further showed this effect was only apparent in male, and not female, participants. For non‐Mediterranean participants, higher adherence to the MedDiet was associated with lower Four Mountains Test scores (fully adjusted: b: ‐0.25, SE: 0.08, p = 0.003), indicating poorer brain health. Analyses are corrected using the Benjamini‐Hochberg False Discovery Rate estimation.ConclusionOur findings suggest that adherence to the MedDiet is associated with better brain health in those living within, but not outside of, the Mediterranean region. One explanation may be a difference in the duration of exposure to this diet (i.e., life‐long versus later life adoption in Mediterranean vs. non‐Mediterranean regions). This study highlights the need to further explore who the MedDiet is particularly effective for with regard to brain health outcomes, to better inform public health campaigns and patient level interventions.

Abstract 15917: Burden of End Organ Damage Among Patients With Hypertension and Associated Patient- and Facility-Level Factors in Ghana

End-organ damage (EOD) are a serious complication of uncontrolled hypertension stroke, kidney disease, retinopathy, cardiovascular disease, and neuropathy are the most prevalent. The studies of EOD and associated factors are scarce in Sub-Saharan Africa. We explored the burden of EOD and the associated patient- and facility-level factors among patients with hypertension in Ghana. Methods: We recruited 14 health facilities and 15 patients with hypertension from each facility. Health facilities with hypertension services and patients on hypertension treatment were eligible for inclusion. The outcome of interest was the self-report of one or more of the most prevalent EOD. The patient-level independent variables were adherence to hypertension treatment, alcohol consumption, employment, and education. At the facility level, we included the facility type, size, ownership, and availability of hypertension guidelines as independent variables. The mixed-effect logistic regression model was used. Results: The study included two hundred and nine (209) patients. 172 (82%) were female, and the mean (±SD) age of participants was 61 (±12.7). 80 (38%) participants reported having suffered at least one EOD, the most prevalent being retinopathy, 38 (18%), followed by cardiovascular complications, 24 (11%). Employment was associated with lower odds (Odds Ratio: 0.42, 95% CI: 0.19, 0.90) of EOD than unemployment and tertiary or higher education was associated with lower odds (Odds Ratio: 0.32, 95% CI: 0.14, 0.74) of EOD than primary or lower educational level. Higher adherence to hypertension treatment was associated with lower odds (Odds Ratio: 0.88, 95% CI: 0.79, 0.97) of EOD. Conclusion: The prevalence of EOD is high. Patient-level interventions to improve hypertension care are needed with a focus on socio-determinants of health. Largescale studies are recommended to explore the facility-level factors that impact the development of EOD in Ghana.

A multidisciplinary approach to operationalizing financial toxicity interventions: The MSK Affordability Working Group.

2 Background: The financial toxicity (FT) of cancer is a concern for the healthcare system. Rising costs and increased cost-sharing result in high levels of financial burden, with negative implications for treatment adherence, quality of life, and financial well-being. As FT interventions must consider the interdependent systems of barriers patients face, this project highlights efforts toward developing and testing hospital-based FT interventions through the creation of the Memorial Sloan Kettering (MSK) Affordability Working Group. Methods: An interdisciplinary task force aimed to 1) characterize FT among patients receiving treatment at MSK; 2) identify areas for systemic change. Members included physicians, nurses, and social workers, and representatives from patient billing/financial services, health services research, and hospital administration and strategy. The team first conducted a review of medical records (2016 – 2018) to determine FT incidence and current practices for financial assistance uptake. Absent a formal FT screening, proxy measures defined FT as having bill payment issues, applying for financial assistance, or expressing financial concerns to Social Work, and we analyzed the percent of each category referred for assistance. Post-analysis program processes are also described. Results: Of 89,283 records reviewed, 22,187 (25%) patients experienced FT. Of 14,178 patients with payment issues, only 22% had been referred for financial assistance. As such, streamlining the assistance referral process became a priority, leading to the creation of an FT order set for providers to make direct referrals. From 3/2021-2/2022, 843 orders were placed, with $836,000 in co-pay assistance and $13,500 in essential needs assistance linked to the order set. The task force then met with hospital leadership to formally expand into an institutional working group, with organizational buy-in demonstrated through increased staffing and monetary support of patient-level pilot interventions. Stakeholders were engaged through presentations at departmental grand rounds and to individual disease teams. Operational and research efforts are now focused on systematic FT screening of patients, including validating a screening tool, developing nurse-led staff and patient education, assessing stakeholder feedback, and determining an appropriate screening cadence and workflow by disease type. Conclusions: With at least 25% of patients at MSK experiencing financial difficulties related to cancer treatment, it was, and remains, vital to develop systems-based interventions to proactively assess FT risk and refer to tangible resources. Planned future work includes implementation of universal FT screening with reflex referral to financial assistance, testing patient-level educational interventions, and developing policy/advocacy recommendations.

Identifying Modifiable System-Level Barriers to Living Donor Kidney Transplantation

Studying existing health systems with variable living donor kidney transplantation (LDKT) performance and understanding factors that drive these differences can inform comprehensive system-level approaches to improve LDKT. We aimed to quantify previously identified barriers and estimate their association with LDKT performance. We conducted a cross-sectional survey of health professionals (HPs). Statements, rated on a Likert scale of "strongly disagree" to "strongly agree", captured themes related to communication; role perception; HP's education, training and comfort; attitudes; referral process; patient; as well as resources and infrastructure. The percentage who agreed with these statements was analyzed and compared by LDKT performance (living donation rates higher or lower than the national average) and participant characteristics. We obtained 353 complete responses. Themes related to poor communication, poor role perception, and HPs education or training or comfort emerged as barriers to LDKT. When compared with HPs from high-performing provinces, those from low-performing provinces had lower odds of agreeing that their province promoted LDKT (adjusted odd ratio [aOR]= 0.27, 95% confidence interval [CI]: 0.16-0.48). They also had lower odds of initiating discussions about LDKT (aOR= 0.30, 95% CI: 0.17-0.55), and higher odds of agreeing that the transplant team is best suited to discuss LDKT (aOR= 2.64, 95% CI: 1.60-4.33) and that more resources would increase LDKT discussions (aOR= 2.06, 95% CI: 1.25-3.40). Nonphysician role and less than 10 years of experience were associated with the level of agreement across several themes. Creating guidelines, streamlining evaluations, and improving communication were ranked as priorities to increase LDKT. There are system-level barriers to LDKT and some were more prevalent in low-performing provinces. Interventions to eliminate them should be implemented in conjunction with patient-level interventions as part of a comprehensive system-level approach to increase LDKT.