Low-income Patient Population Research Articles

P-515. Enhancing Sexual Wellness: A Novel Approach to Screening and Prevention in an Urban Health Center

Abstract Background The Family Health Centers at NYU Langone (FHC) is a network of Federally Qualified Health Centers that serves a largely marginalized, diverse, and low-income patient population in Brooklyn, NY. In 2023, the FHC provided care for over 112,000 patients, with 52% being on Medicaid or Medicare and 28% being uninsured. We identified 44 HBSAG positive patients as well as 25 newly diagnosed HIV patients. Patients as well as providers are often reluctant to have conversations around sexual health. Identifying risk factors for HIV, infectious hepatitis, and other infections is an area critical for providing excellent primary care to end the epidemic and curb Hep and STI rates. Methods The FHC had no standardized approach to collecting HIV and Hep B risk history being followed by providers. Our approach aimed to standardize risk screening processes while raising provider awareness of the significance of Hepatitis screening and HIV prevention. A Sexual Wellness Screening Tool was developed and integrated into the EPIC My Chart system. The screening tool is answered by patients ahead of an initial/annual appointment through the patient portal and updated annually. Patients with high-risk responses trigger an EPIC Best Practice Alert (BPA). The BPA recommends elements of care and prepopulates a Hepatitis B lab orders and/or referrals to the HIV prevention team. For provider buy-in and education, learning sessions were held across the network. Results During Q1 of 2024, 866 patients completed the tool, 525 patients screening positive for risk factors. Of the 525 patients, 88% reported having sex without a condom in the past 12 months. 65% of patients had multiple risk factors. All patients at risk, were offered testing, however 26 HBV tests were actually ordered and 5 completed. For HIV prevention, 26 referrals were generated and contacted by Prevention Navigators, leading to 2 patients beginning PrEP. Risk Responses Conclusion Having patients fill out the tool ahead of appointments allows for a provider to review the tool with the patient and can help guide the conversations patients and providers have; maximizing the finite time providers have with patients and empowering patients to have their questions answered. Continued education and laboratory process refinement are necessary to streamline the work. Disclosures All Authors: No reported disclosures

Knowledge, attitudes, and referral practices for smokers to a state tobacco quitline in a federally qualified healthcare center: Healthcare provider perspectives.

Federally qualified healthcare centers (FQHC) treat a large population of low-income patients disproportionately burdened by tobacco use. This study investigated healthcare providers' knowledge, attitudes, and referral patterns of patients who smoke to a state tobacco quitline. The study used a descriptive-qualitative design. In-depth interviews were conducted in 2021 with a sample of healthcare providers recruited from a federally qualified healthcare center (FQHC) in a large city in the Midwest. The interviews were guided by a standardized moderator's guide and lasted 30-45 minutes. Written informed consent was obtained before each interview, and participants completed a brief self-administered survey. Among the 25 participants, 92% were female and 44% were Black. Participants included medical providers (52%), behavioral health providers (16%), and other types of providers (32%). Participants' age and work experience averaged 41.5 and 5.25 years, respectively. Only 32% of providers reported having specialty training in smoking cessation or addiction counseling. Over half (52%) of the participants never or rarely referred patients to the Illinois Tobacco Quitline (ITQL). Providers reported several barriers to referring patients to the ITQL, including limited knowledge about services offered, time constraints, difficulties with the referral process, and lack of feedback between providers and the ITQL. Further, providers described patient-related barriers, including low motivation to quit smoking, language barriers, and failure of patients to respond to calls from the quitline. Recommendations were described for improving patient and provider education, referral processes, and increasing bi-directional communication between providers and the quitline. Providers identified numerous barriers to referring patients for smoking cessation treatment. Addressing the identified barriers requires a multi-faceted approach involving education, streamlined processes, supportive infrastructure, and patient-centered interventions to strengthen provider use and satisfaction with the available resources.

Financial toxicity screening in an urban underserved patient population with cancer.

169 Background: Cancer-related financial hardship is associated with treatment delays, non-adherence and adverse survival outcomes. Racial/ethnic minorities and low-income households are disproportionately impacted by financial toxicity. The Comprehensive Score for Financial Toxicity (COST) measure is used to measure financial toxicity in research but has not been validated in low-income, racially diverse cancer patient populations. Methods: We conducted this study at a large urban medical center from January-August 2023. We included cancer patients on systemic therapy for at least 2 months with ECOG performance status 0-2. Participants completed the COST measure, the Functional Assessment of Cancer Therapy: General (FACT-G) and the European Organization for Research and Treatment of Cancer (EORTC) QOL to assess health-related quality of life (HRQOL). Cancer diagnosis/stage, demographic data, and social work/financial counseling interventions were abstracted. Factor analyses were conducted to determine the underlying factor structure of the COST measure responses and bivariate analyses were conducted to identify relationships between COST scores and other data. Results: 100 patients participated in the study; the average age was 65 and both sexes were equally represented. Most patients reported African American (67%) race/ethnicity. 72% of patients held less than a 4-year college degree, 22 % were unemployed and 55% reported a yearly household income of less than $35,000. Lung (46%) and gastrointestinal (38%) cancers were the most represented. 73% were enrolled in a government sponsored insurance program (Medicare, Medicaid). The average COST score among participants was 22 [range 0-44] and mean FACT-G and EORTC scores were 16.5 [range 0-28] and 59.6 [ range 0 – 100] respectively. Fifty-eight patients were referred to social work or financial counseling for financial interventions. Factor analysis revealed three predominant factors among the COST responses (Eigenvalues > 1) including Factor 1: items 3, 7, 8, 9, 10, 11; Factor 2: item 4; Factor 3: item 5. COST was weakly associated with FACT-G and EORTC (Pearson range 0.27 – 0.37). The most highly correlated value was between the COST and EORTC physical wellbeing subscale (Pearson 0.38). The COST score was significantly associated with income, with higher incomes reporting less financial toxicity (p = 0.004). No significant differences in COST scores were noted across gender, race, or level of education. Conclusions: Low levels of financial toxicity were detected using the COST measure in a diverse, low-income cancer patient population despite many patients being referred to social work/financial counseling. Compared to similar studies, we found a weaker correlation between the COST measure and HRQOL. These findings suggest that the COST measure may need to be further adapted for use in underserved populations and patients with government sponsored insurance.

Access to the internet and mobile applications in a mixed population emergency department: A repeated cross-sectional survey

ObjectiveThis study aimed to assess patients' interest in education content delivered through electronic modalities and identify trends in internet access and use among emergency department patients of various socioeconomic statuses. MethodsA prospective, cross-sectional survey with 50 questions was completed by 241 English and Spanish-speaking patients in 2014 and repeated with 253 participants in 2019 at the University of California, Irvine Medical Center's Emergency Department (UCIMCED). ResultsInternet access increased from 83.8 % in 2014 to 88.1 % in 2019. Most internet-using patients owned smartphones (80.1 % in 2014, 89.7 % in 2019). Patients used electronic devices, such as fit bits and activity trackers, to obtain health information. Email was the preferred method for receiving discharge instructions. ConclusionsAs of 2019, 88.1 % of UCIMCED patients have access to the internet or email, making electronic media a reasonable venue for patient education. Given that we have a predominantly low-income patient population—61 % and 32 % of respondents in 2014 and 2019, respectively, reporting an income of less than $25,000—these results are provide new avenues to reach patients of all socioeconomic statuses. InnovationThe implications of this study can be used to develop electronic resources tailored to educate emergency department patients about their healthcare beyond the confines of a hospital.

Evaluation of patient health outcomes of a student-run free clinic in East Harlem

BackgroundMost United States medical schools have affiliated student-run free clinics, but the quality of services provided in such contexts compared to national metrics is unknown. This study determines whether a student-run, attending-supervised free clinic servicing a low-income and minority race patient population in New York City can meet national metrics of care.MethodsThrough chart review from January 1, 2020 to December 31, 2020, patient outcomes and service utilization in the Healthcare Effectiveness Data and Information Set were examined and compared to national rates of patients using Medicaid HMO or Medicare. Patients are ≥ 21 years of age, residents of East Harlem, and ineligible for health insurance because of legal residency requirements. The majority identify as Hispanic and speak Spanish as their primary language. All patients who were seen in the clinic during the 2020 calendar year were included. The primary study outcome is the number of Healthcare Effectiveness Data and Information Set measures in which patients, seen in a student-run free clinic, meet or exceed national comparisons.ResultsThe healthcare outcomes of 238 patients, mean age 47.8 years and 54.6% female, were examined in 18 Healthcare Effectiveness Data and Information Set measures. The student-run free clinic met or exceeded national metrics in 16 out of 18 categories.ConclusionsThe student-run free clinic met or exceeded the national standard of care according to national metrics. Evidence-based priorities have been clarified for future improvement. Other student-run free clinics should similarly evaluate the quality of their services.

Implementing point-of-care hemoglobin A1C testing in an obstetrics outpatient clinic.

A1C ≥6.0% is associated with increased risk of adverse outcomes in pregnant diabetic patients. A1C testing is recommended by the American Diabetes Association as a secondary measure of glycemic control in pregnant patients. To determine the utility of A1C point-of-care testing (POCT) during pregnancy to facilitate rapid counseling and diabetes care, particularly in relatively low-income transient patient populations. We performed a single-center, retrospective analysis of patients presenting to an outpatient obstetrics office with routine, in-laboratory A1C testing, before and after the implementation of POCT for A1C (n = 70 and n = 75, respectively). Demographics, results, physician referral to a nutritionist, counseling, and outcomes were retrieved from patient electronic medical records. In total, 9% and 23% of the in-laboratory and POCT groups, respectively, were referred for nutrition services (P = .02). Of these, 22% of the in-laboratory group and 42% of the POCT group received immediate counseling (P < .01). An inverse correlation was observed between A1C level at study entry and gestational weeks at delivery, with a Pearson r value of -0.39 (-0.58 to -0.16) for the in-laboratory group and -0.38 (-0.57 to -0.14) for the POCT group. No statistically significant difference in pregnancy outcomes was observed. Implementation of A1C POCT was associated with immediate counseling and management of the health of pregnant patients, but was not associated with improved outcomes, in a low-resource patient population.

Impact of Implementing Point of Care Hemoglobin A1C Testing in an Obstetrics Outpatient Clinic

Abstract Hemoglobin A1C ≥ 6.0% is associated with increased risk of adverse outcomes in pregnant, diabetic patients and is recommended as a secondary measure of glycemic control in pregnant patients by the American Diabetes Association. However, the utility of A1C point of care testing (POCT) during pregnancy to facilitate rapid counseling and diabetes care, particularly in relatively low-income transient patient populations is unknown. We performed a single center, retrospective analysis of patients presenting to an out-patient obstetrics office with routine, In-lab A1C (n= 70) testing and after the implementation of POCT for A1C (n=75). Demographics, results, physician referral to a nutritionist, counseling, and outcomes were retrieved from the electronic medical record. 9% and 23% of the In-lab group and POCT respectively were referred for nutrition services (p=0.02). 22% of the In-lab group and 42% of the POCT groups received immediate counseling (p&amp;lt;0.01). An inverse correlation was observed between entry A1C and the weeks at delivery with a Pearson r of -0.39 (-0.58-0.16) for the In-lab group and -0.38 (-0.57--0.14) for the POCT group. In conclusion, the implementation of POC A1C testing was associated with immediate counseling and management of pregnant patients.

Racial and Socioeconomic Characteristics Associated with the use of Telehealth Services Among Adults With Ambulatory Sensitive Conditions.

The COVID-19 pandemic led to a major transition for patients from routine ambulatory-care-based in-person primary care visits to telehealth visits to manage chronic diseases. However, it remains unclear the extent to which individuals access telehealth services and whether such utilization varies along neighborhood characteristics, especially among racial minorities. This study aims to examine the association of outpatient telehealth utilization with sociodemographic, clinical, and neighborhood characteristics among adults with ambulatory care sensitive conditions (ACSCs) during the COVID-19 pandemic. We included adults treated for an ACSC between March 5, 2020, and December 31, 2020, at a single ambulatory-care-based healthcare system, which serves a large population of low-income patients in the South region of the United States (i.e., Memphis, TN, Metropolitan Statistical Area). Telehealth utilization was defined by outpatient procedural codes and providers' notes on the type of visits. Generalized linear mixed models were used to examine the association of sociodemographic, clinical, and neighborhood factors with telehealth utilization in the overall cohort and the racial subpopulations. Among the 13,962 adults with ACSCs, 8583 (62.5%) used outpatient telehealth services. Patients who were older, female, with mental disorders, and who had more comorbidities had higher rates of telehealth services (p < .05). Controlling for covariates, we observed 75.2% and 23.1% increased use of telehealth services among Hispanics and other race groups, respectively, compared to Whites. Patients who commuted more than 30 minutes to health facilities were slightly less likely to use telehealth services [OR: 0.994 (0.991,0.998)]. Racial minorities (Blacks and Hispanics) with mental disorders were more likely to use telehealth service when compared to Whites. We found that among patients being treated for ACSCs, the use of telehealth services was highly prevalent in Hispanic patients in general and were more pronounced among both Hispanics and Black patients who have mental disorders.

MEASURING SPECIALTY CARE UTILIZATION AMONG MEDICALLY FRAGILE, LOW-INCOME OLDER OR DISABLED ADULTS

Abstract The purpose of this research was to quantify the rates of specialty care referral completion and identify variables associated with successful completion among a population of low-income, elderly and/or disabled homebound patients with barriers to accessing office-based care. This was a cross-sectional study using descriptive and multivariate predictive analysis of specialty care referral completion, operationalized as attending an appointment of the same specialty care type within 6 months of being referred. Independent variables include patient age, sex, race, marital status, health insurance, blood pressure, and body mass index. Patient characteristics, referral information, and appointment information from July 1, 2014 to July 1, 2019 were extracted from electronic health record data of patients enrolled in the Just for Us primary care home visiting program in Durham, NC. Specialty care referrals were restricted to those for office-based consultations for chronic disease co-management originating from an outpatient primary care provider. Of 443 total referrals identified from 162 patients, 36% were successfully completed. Being married and female gender were found to be associated with successful referral completion. Of the 217 total patients in the study sample, 25% were identified as not having any referrals. No included patient characteristics were found to be significantly associated with being referred to specialty care. This study demonstrates that the specialty care needs of a medically and socially vulnerable population of homebound patients are not being adequately met.

Patient, provider, and nurse preferences of patient reported outcomes (PRO) and side effect management during cancer treatment of underrepresented racial and ethnic minority groups, rural and economically disadvantaged patients: a mixed methods study.

The purpose of this study was to evaluate patient, oncologist and nurse perspectives on side effects and patient reported outcomes (PROs) with the question of how to optimize side effect management and PRO tools in this unique population. This pilot study utilized a mixed method explanatory design. Patients receiving intravenous (IV) chemotherapy from June to August 2020 were surveyed about side effect burden and PRO system preferences. Providers and nurses (PN) completed complementary surveys. Semi-structured phone interviews were conducted among a subset of each group. Of 90 patient surveys collected; 51.1% minority, 35.6% rural, and 40.0% income < $30,000, 48% felt side effect management was a significant issue. All patients reported access to a communication device but 12.2% did not own a cell phone; 68% smart phone, 20% cell phone, 22% landline, 53% computer, and 39% tablet. Patients preferred a response to reported side effects within 0-3h (73%) while only 29% of the 55 PN surveyed did (p < 0.0001). Interviews reinforced that side effect burden was a significant issue, the varied communication devices, and a PRO system could improve side effect management. In a non-White, rural and low-income patient population, 87.8% of patients reported owning a cell phone. Although all agreed side effect management was a prominent issue, expectations between patients and PN differed substantially. Qualitative data echoed the above and providing concrete suggestions to inform development of a PRO program and side effect mitigation strategies among a diverse patient population.

Effects of a Fruit and Vegetable Prescription Program With Expanded Education for Low-Income Adults.

Fruit and Vegetable Prescription (FVRx) Programs combine produce prescriptions and nutrition education to reduce fruit and vegetable consumption barriers and promote health among low-income patient populations. This study examined whether a multi-level FVRx intervention model with intensive education improves dietary behaviors, food security, and health outcomes over single-level interventions alone. A 6-month nonrandomized, parallel, controlled trial was conducted with one intervention, FVRx (n = 31) and two comparison groups, Ad hoc Nutrition Education (n = 13) and Control (n = 16). The FVRx group received produce prescriptions (US$1/day/household member) redeemable at a farmer's market, two SNAP-Ed programs, one financial literacy program, and monthly health screenings. The Nutrition Education (NE) group participated in one SNAP-Ed program, and the Control group received safety-net clinic care only. Surveys assessed dietary intake, food security, food purchasing practices, and financial and food resource management. Pre-post clinical biomarkers (blood lipid and hemoglobin A1c) and monthly biometrics (anthropometrics and blood pressure) were measured. Descriptive analysis and one-way analysis of variance (ANOVA) were conducted. Compared with comparison groups, FVRx participants significantly increased the frequency of consuming dark green vegetables, FVRx (0.36 ± 0.72); NE (0.14 ± 0.33); Control (-0.09 ± 0.19) cups/day (p < .05). FVRx participants significantly improved multiple healthful food purchasing practices, and the ability to afford more utilities (FVRx (33%); NE (0%); Control (10%); p < .05). Limited changes were observed in food security and clinical biomarker outcomes between groups. Combining expanded nutrition and financial literacy education with produce prescriptions improves low-income adults' financial and food resources, preference, knowledge, purchase, and consumption of locally grown vegetables over single-level interventions.

Practice Transformation to Improve Cancer Screening Outcomes at an Academic Medical Center.

In 2011, Texas received federal approval of the 1115 Healthcare Transformation waiver, which went to support the Texas Delivery System Reform Incentive Payment Program (DSRIP) incentivizing the transformation of service delivery practices which included expanded coverage of preventive cancer screenings. There is limited evidence that quality improvement initiatives stemming from DSRIP improve cancer screening outcomes for the Medicaid, low-income, and uninsured (MLIU) patient population. The present the results of a quality initiative to improve breast, cervical, and colorectal cancer screening rates for MLIU patients receiving primary care at an academic medical center. The initiative included engaging multidisciplinary primary care teams, health information technology (IT), and quality departments to standardize workflows. We found significantly improved rates of cervical and colorectal cancer screening among patients eligible to receive one or more screenings. Aligning primary care, IT, and quality processes resulted in significant improvement in cancer screening.

Evaluation of mHealth Apps for Diverse, Low-Income Patient Populations: Framework Development and Application Study.

BackgroundThe use of mobile technology or smartphones has grown exponentially in the United States, allowing more individuals than ever internet access. This access has been especially critical to households earning less than US $30,000, the majority of whom indicate that smartphones are their main source of internet access. The increasing ubiquity of smartphones and virtual care promises to offset some of the health disparities that cut through the United States. However, disparities cannot be addressed if the medical information offered though smartphones is not accessible or reliable.ObjectiveThis study seeks to create a framework to review the strengths and weaknesses of mobile Health (mHealth) apps for diverse, low-income populations.MethodsFocusing on smoking cessation, diabetes management, and medication adherence as models of disease management, we describe the process for selecting, evaluating, and obtaining patient feedback on mHealth apps.ResultsThe top 2 scoring apps in each category were QuitNow! and Smoke Free-Quit Smoking Now for smoking cessation, Glucosio and MyNetDiary for diabetes management, and Medisafe and MyMeds for medication adherence.ConclusionsWe believe that this framework will prove useful for future mHealth app development, and clinicians and patient advisory groups in connecting culturally, educationally, and socioeconomically appropriate mHealth apps with low-income, diverse communities and thus work to bridge health disparities.

Outcomes from birth to 6months of publicly insured infants born to mothers with severe acute respiratory syndrome coronavirus 2 infection in the United States.

We evaluated inpatient management, transition to home, breastfeeding, growth, and clinical outcomes of infants born to mothers diagnosed with SARS-CoV-2 infection in pregnancy and followed in a Federally Qualified Health Center (FQHC), that serves a diverse and low-income patient population, from birth through 6months of life. Infants born between 4/3/20 and 7/26/20 at Prentice Women's Hospital with mothers who received prenatal care at Erie Family Health Center (Erie), the second largest FQHC in Illinois, and had confirmed SARS-CoV-2 during pregnancy were included. Data were abstracted from delivery hospital admission and outpatient follow-up appointments between 4/8/20 and 2/4/21. Thirty-three infants met inclusion criteria. Average gestational age was 38.9weeks (IQR 37.6-40.4), 3 (10%) were premature and 5 (15%) required NICU admission. Nearly all (97%) mothers expressed intent to breastfeed. Outpatient follow-up rates were similar to historical cohorts and 82% (23/28) of infants were vaccination compliant. Growth parameters showed normal distributions at all time points. At 6months, any and exclusive breast milk feeding rates were lower compared to historic cohorts (18 vs. 36%, p<0.05, 0 vs. 21%, p<0.01). Three infants (10%) received development-related referrals, one carried an underlying genetic diagnosis. Outpatient visits were predominantly face-to-face with telemedicine use comprising only 6% of visits (11/182). Longitudinal follow-up of 33 publicly insured infants born to mothers with SARS-CoV-2 infection in pregnancy followed in an FQHC showed high rates of follow-up and vaccination compliance, normal growth patterns and reassuring clinical status, and lower than expected rates of breastfeeding.

Effectiveness of an interprofessional ambulatory care model on diabetes: evaluating clinical markers in a low-income patient population

ABSTRACT The purpose of this study was to determine whether a new ambulatory care model, interprofessional collaborative care–coordinated team model (interprofessional model), based on the Wagner Care Model improved clinical indicators in a low-income population. This study was a retrospective 12-month pre-post (n = 204) and propensity matched (n = 171) comparative study of the interprofessional model in a primary clinic for patients with type 2 diabetes. Secondary data were collected from June 2014to February 2017 in an academic medical centre in a large Midwestern city. Findings demonstrated statistically and clinically significant improvement in A1C in both the pre/post arm of the study (↓ 0.8%) and the intervention/propensity matched arm (↓ 0.53%). Within the intervention group, there was a significant decrease in weight in the pre/post arm with 55% of cases losing weight, whereas 45% did not lose weight (p = .02). Diastolic blood pressure less than 90 also significantly improved in the pre/post arm of the study (10.1% n = 18, versus 3.9%, n = 7, p = .04). The interprofessional model showed that an ambulatory healthcare redesign incorporating an interprofessional team approach to optimise the health of this type 2 diabetes patient population can be effective. This study demonstrates the importance of using interprofessional collaborative practice teams to guide healthcare and improve patient outcomes.

454-P: Pharmacist-Led Diabetes Self-Management Education and Reduction of Readmission Rates at a County Hospital

Pharmacist-led Diabetes Self-Management Education and Reduction of Readmission Rates at a County Hospital With 10.5% of the US population or 34.2 million people affected by diabetes, education is greatly needed. The American Diabetes Association (ADA) and the Association for Diabetes Care and Education Specialists (ADCES) state that Diabetes Self-Management Education or Training (DSME/T) improves diabetes management, which can avoid hospital admissions and readmissions. Although DSME/T has traditionally been provided by nurses and dieticians, pharmacists can play a part, given their expertise in medication management, non-pharmacological therapies, and monitoring. The ADA and ADCES recommend that people with diabetes receive DSME/T at diagnosis, annually, when factors influence self-management, and at transitions of care. Therefore, a pharmacist-led transitions of care program was developed to reduce readmissions for patients with diabetes at Zuckerberg San Francisco General Hospital and Trauma Center. This hospital serves a diverse, low-income, and unhoused patient population, increasing the challenges of diabetes management. Pharmacists and pharmacy trainees were given a refresher course on DSME/T. Low-health literacy handouts in several languages, as well as demonstration kits, glucometers, insulin and insulin supplies, were all utilized for patient education. The objective of the study was to determine whether using pharmacists as educators, could reduce hospital readmissions. In 2017, provision of DSME/T at this institution was less than 5% and increased to 74% by December 2019, with the implementation of this program. The rate of readmission for patients with diabetes who received DSME/T was 11.7% compared to 19.2% for those who did not; an absolute risk reduction in readmission of 7.5%. Pharmacists and pharmacy trainees should use DMSE/T to help reduce readmissions, improve outcomes, and increase the national levels of patients with diabetes receiving DSME/T. Disclosure L. Mulala: None. T. Lenhoff: None.

Patient, provider, and nurse preferences regarding patient-reported outcomes (PRO) and side effect management during cancer treatment of minority, rural and economically disadvantaged patients.

e18652 Background: Side effects from treatment significantly impact quality of life and patients ability to continue cancer therapy. Patient Reported Outcomes (PRO) tools have been shown to significantly improve multiple key cancer endpoints including overall survival. However, preferences for PRO tool components, such as contact modality, is not well studied in minority, rural and low-income patient populations. As the only National Cancer Institute (NCI) Designated Cancer Center within a 500-mile radius, we care for the urban/rural, multiethnic communities we serve with tremendous cancer health and socioeconomic disparities. This study evaluated patient, provider and nurse perspectives with the goal of optimizing PRO tools for our unique population. Methods: A survey was developed to assess preferred PRO contact modality. Additional survey domains included side effect burden, quality of life, financial hardship and nutritional services accessed. The survey was offered to all patients receiving IV chemotherapy in the center infusion suite from June to August 2020 using the REDCap platform. Providers and nurses (P/N) were surveyed via email. Survey responses were analyzed using SAS 9.4 and compared via chi-square test where appropriate. Results: Ninety patient surveys were collected; 51.1% were minorities (44.4% Hispanic), 35.6% were rural and 40.0% had income &lt; $30,000. All patients had access to a communication device but 12% did not have access to a cell phone of any kind. Device access included 68% smart phone, 20% cell phone, 22% landline, 53% computer, 39% tablet. Patients preferred a response to reported side effects within 0-3 hours (73%) while only 29% of 55 P/N surveyed shared this expectation (p &lt; 0.0001). Almost half (48%) of patients felt side effect management was a moderate or significant issue with 58% experiencing nausea and/or vomiting, 41% diarrhea, 34% weight change, 33% pain, and 22% mucositis. While 72% of patients experienced nutritional related side effects and 95% of P/N preferred to answer nutritional issues by referring to a dietitian, only 9% of patients reported being referred. The majority of patients reported side effect quality of life implications (60.3%) or missed work / were unemployed (82%). Conclusions: In a minority, rural and low-income patient population, 88% of patients had access to a cell phone communication device, with smart phone access in the majority. Patients and P/N reported significantly different expectations regarding side effect management. Our data suggests an underutilization of nutritional referrals by P/N, despite a recognition of value. This study informs the implementation of a PRO tool to address side effects and develop nutritionist referral strategies in minority, rural and low-income patient populations.

Implementation of insurance marketplaces and changes in diagnosis stage in low-income cancer patients.

1576 Background: Millions of low-income Americans gained insurance coverage through Medicaid expansion and the “Marketplaces” of the Affordable Care Act (ACA). How Marketplaces have specifically improved cancer outcomes among these individuals is unclear. Thus, we examined changes in insurance status and diagnosis stage following the ACA among low-income (139-250% of the Federal Poverty Level [FPL]), non-elderly patients (ages 30-64). Methods: In Ohio’s cancer registry, we identified patients diagnosed with one of the top 16 cancers before (2011-2013, “Pre-ACA”) and after (Q3 of 2014-2016, “Post-ACA”) the implementation of the ACA’s insurance Marketplaces and either had private insurance or no insurance. Low-income patients were isolated using a novel, geographically-driven approach called probability weighting. Results: The uninsured percentage dropped from 12.9% to 4.9% between the Pre- and Post-ACA periods in the study sample (N = 10,747). An estimated 11.1% of individuals had Marketplace insurance Post-ACA. A significant but modest Post-ACA (versus Pre-ACA) shift toward non-metastatic disease was identified (Adjusted Odds Ratio [AOR]: 0.95, 95%CI: 0.90-0.99). The largest site-specific shifts were observed for thyroid (AOR: 0.50, 95%CI: 0.30-0.83) and ovarian (AOR: 0.74, 95%CI: 0.58-0.93) cancers. In a control analysis of wealthier (400%+ FPL), privately insured individuals, no significant shifts were identified (AOR: 0.97, 95%CI: 0.92-1.02). Conclusions: This is the first study to show an effect in cancer stage at diagnosis from the Affordable Care Act’s Insurance Marketplaces. We found that the Marketplaces greatly reduced the number of low-income, uninsured cancer patients, translating to significant improvements in cancer stage at diagnosis. As policy makers contemplate modifications to the ACA, they should carefully consider the impact of those changes on the highly vulnerable population of low-income cancer patients.

Patient-Provider Communication and Adherence to Cholesterol Management Advice: Findings from a Cross-Sectional Survey.

High cholesterol is a preventable risk factor for heart disease. This study examines which aspects of patient-provider communication are associated with patient report of increased adherence to cholesterol management advice in a diverse, low-income patient population accessing the health care safety net, using the 2014 Health Center Patient Survey. Patient-provider communication measures included patient report of: how often a provider listened carefully, gave easy-to-understand information, knew important information about the patient's medical history, showed respect, and spent enough time with the patient. Outcome measures were patient report of following provider advice to eat fewer high fat or high cholesterol foods, manage weight, increase physical activity, or take prescribed medicine. In adjusted analyses, when patients perceived their provider always knew their medical history, patients were more likely to report taking prescribed medication (adjusted odds ratio [aOR]: 3.2; 95% confidence interval [CI]: 1.6, 6.6). Knowledge of medical history (aOR: 2.8, 95% CI: 1.4, 5.8), spending enough time (aOR: 2.3, 95% CI: 1.2, 4.4), and providing easily understandable information (aOR: 2.2, 95% CI: 1.0, 4.7) were significantly associated with report of following physical activity advice. Knowledge of medical history (aOR: 2.3, 95% CI: 1.0, 5.2) and providing easily understandable information (aOR: 3.3, 95% CI: 1.4, 7.9) were significantly associated with report of following weight management advice. This study indicates different components of patient-provider communication influence patient adherence to lifestyle modification advice and medication prescription. These results suggest a tailored approach to optimize the impact of patient-provider communication on cholesterol management advice adherence.

Of Being and Becoming: Psychoanalysis, Race and Class in an Urban ER

ABSTRACT Psychoanalysis in the United States has traditionally been a practice of long-term, individual therapy conducted within the safe and comfortable surroundings of a consulting room. Through my work as a white man with a largely African American, low-income patient population in a hospital emergency room, I learned it can also be used in that fast-paced, crisis environment. Doing so, I learned, required a full engagement with my biases, cultural history, memories and personal traumas. It required understanding how structural racism is embedded in the work, the role it plays in defining my patients’ reality coming into the ER, and their options once there. Although the first priority is to determine safety: Is the person in danger of harming themselves or another, if one broadens the scope of one’s attention, as an analyst does, to the full person, do one’s perspective, role and opportunities shift? I learned that I could do more than provide a descriptive diagnosis and disposition; I could actually begin the healing process. I learned I could better understand myself and my patients. The process was healing to both of us.