Potential Gaps In Care Research Articles

Understanding Colorectal Cancer Patient Experiences with Family Practitioners in Canada.

Despite ongoing screening efforts, colorectal cancer (CRC) remains a leading cause of death in Canada. The aim of this study was to better understand the experiences of Canadian CRC patients with their family practitioners (FPs) during and after their CRC diagnosis. Patient-reported data were collected through an online questionnaire to understand their CRC diagnosis experiences and identify potential gaps in care. Various factors contributing to challenges throughout a patient's CRC diagnosis (e.g., delayed CRC diagnosis) were determined using descriptive, qualitative, and inferential analyses. These factors could be targeted to optimize CRC care. This study found that 40.6% of the 175 respondents were unaware of at least one of the following aspects of CRC prior to their diagnosis: early-age onset (EAO), symptoms, and screening procedures. While 84.6% had access to a family physician (FP) before their diagnosis, only 17.7% were diagnosed by FPs. Higher proportions of younger individuals experienced misdiagnoses and felt dismissed compared to older individuals. Only half felt fully informed about their diagnosis when it was explained to them by their FP, while 53.1% had their diagnosis explained in plain language. Transitioning towards patient-centred care would promote pre-diagnosis CRC awareness, address differences in management of CRC care (e.g., dismissal and support), and accommodate for age and health-literacy-related disparities, thereby improving CRC care pathways for patients. Future research should investigate FPs experiences in detecting CRC cases to develop educational resources and recommendations, enhancing early detection and improving patient outcomes (1).

Ophthalmology Encounters During the COVID-19 Pandemic in a Student Run Free Clinic

Background: Ophthalmology services at student run free clinics (SRFC) serve an important role for the socioeconomically underserved within a city. The coronavirus disease 2019 (COVID-19) pandemic has worsened gaps in care for ophthalmology tertiary clinics, but its effects on ophthalmology encounters at SRFCs are not known.
 Methods: This was a retrospective chart review from a single center that compared patient encounters in the ophthalmology SRFC six months prior to its closure (pre-COVID group) with patient encounters in the ophthalmology SRFC six months after its reopening (post-COVID closure group).
 Results: There was a decline (47.3%) in the number of encounters in the post-COVID closure group (n=20) when compared to the pre-COVID group (n=38). While the number of encounters for routine screening stayed about the same in both groups, there was a 90.5% decline in encounters with active disease (21 pre-COVID vs. 2 post-COVID closure). Sub-group analysis of the pre-COVID group showed that patients with active disease tended to have worse vision (-0.33 logMAR, p=0.034 OD; -0.27 logMAR, p=0.048 OS) than those undergoing routine screening.
 Conclusions: Patients in West Texas with active eye diseases are not presenting to SRFC after its reopening. Early recognition of this is critical to address the potential gap in care in a vulnerable population.

Disparities in Eye Care Utilization Among Refugee and Migrant Populations.

In this cross-sectional study, we examined refugee/migrant participants' health and eye care utilization compared to controls in San Diego County. Data were collected from electronic health records (EHRs) at UCSD Health-affiliated medical centers. Through a manual review of EHRs, eligibility criteria to identify a cohort were developed. A total of 64 refugee/migrant participants and 95 control participants matched based on country of origin, age, and sex were included in the analysis. Demographic characteristics, insurance type, and vision/eye care utilization were compared between the two groups. A greater proportion of refugee/migrant participants were more likely to be enrolled in government-sponsored insurance programs, predominantly Medicaid when compared to controls (55% vs. 24%, P = < 0.01). When adjusting for age, history of ophthalmic procedure, and surgery, refugee status was associated with fewer encounters with ophthalmologists in a multivariable linear regression model (coefficient = -1.66 [95% confidence interval [CI] = -2.89 to -0.44], P = 0.009). This study highlights disparities in eye care utilization for refugee/migrant populations. When compared to controls, a larger proportion of refugees/migrants had government-funded insurance, and refugee status was associated with fewer encounters with ophthalmologists. These findings underscore the need for further research on this population to better understand potential healthcare barriers these individuals may encounter. This analysis of EHR data illustrates disparities in eye care experienced by refugees/migrants, highlighting potential gaps in care in a vulnerable population.

Perinatal depression before and during the COVID-19 pandemic in New York City

Quarantining and isolation during previous pandemics have been associated with higher levels of depression symptomatology. Studies in other countries found elevated rates of anxiety and/or depression among pregnant people during the COVID-19 pandemic compared with prepandemic rates. New York City was the initial epicenter of the pandemic in the United States, and the effects of the pandemic on perinatal depression in this population are not well known. This study aimed to evaluate the rates of perinatal depression before and during the COVID-19 pandemic. This is a single-center retrospective cohort study of patients screened for perinatal depression with the Edinburgh Postnatal Depression Scale at 2 private academic practices in New York City. This screen is done in these practices at the time of the glucose challenge test and at the postpartum visit. Patients aged ≥18 years who completed a screen at a postpartum visit and/or glucose challenge test from February 1, 2019 to July 31, 2019 and from February 1, 2020 to July 31, 2020 were identified, and the 2019 and 2020 groups were compared. The primary outcome was a positive screen, defined as ≥13 and ≥15 for postnatal and prenatal screens, respectively. Secondary outcomes included monthly changes in rates of positive screens and factors associated with perinatal depression. Data were analyzed using Mann-Whitney U test, chi-square, or Fisher exact test, and univariate and multivariate analyses with P<.05 defined as significant. A total of 1366 records met the inclusion criteria; 75% of the prepandemic (2019) records were included, as opposed to 65% of pandemic (2020) records due to a lower screen completion rate in the pandemic cohort. The 2020 cohort had a higher proportion of Hispanic patients (P=.003) and higher rates of diabetes mellitus (P=.007), preterm labor (P=.03), and current or former drug use (P<.001). The 2019 cohort had higher rates of hypertension (P=.002) and breastfeeding (P=.03); 4.6% of the 2020 cohort had a suspected or confirmed COVID-19 infection. There was no difference in perinatal depression between the 2019 and 2020 cohorts (2.8% vs 2.6%; P>.99). This finding persisted after adjusting for baseline differences (adjusted odds ratio, 0.89; 95% confidence interval, 0.38-1.86; P=.76). There were no differences in rates of positive Edinburgh Postnatal Depression Scale by month. Several risk factors were associated with a positive screen, including being unmarried (P<.001), pulmonary disease (P=.02), depression (P<.001), anxiety (P=.01), bipolar disorder (P=.009), and use of anxiolytics (P=.04). There were no differences in the rates of perinatal depression between the periods before and during the COVID-19 pandemic. The rate of perinatal depression in this cohort was below the reported averages in the literature. Fewer women were screened for perinatal depression in 2020, which likely underestimated the prevalence of depression in our cohort. These findings highlight potential gaps in care in a pandemic setting.

Lipid Testing Trends Before and After Hospitalization for Myocardial Infarction Among Adults in the United States, 2008-2019.

BackgroundRoutine monitoring of low-density lipoprotein cholesterol (LDL-C) identifies patients who may benefit from modifying lipid-lowering therapies (LLT). However, the extent to which LDL-C testing is occurring in clinical practice is unclear, specifically among patients hospitalized for a myocardial infarction (MI).MethodsUsing US commercial claims data, we identified patients with an incident MI hospitalization between 01/01/2008-03/31/2019. LDL-C testing was assessed in the year before admission (pre-MI) and the year after discharge (post-MI). Changes in LDL-C testing were evaluated using a Poisson model fit to pre-MI rates and extrapolated to the post-MI period. We predicted LDL-C testing rates if no MI had occurred (ie, based on pre-MI trends) and estimated rate differences and ratios (contrasting observed vs predicted rates).ResultsOverall, 389,367 patients were hospitalized for their first MI during the study period. In the month following discharge, 9% received LDL-C testing, increasing to 27% at 3 months and 52% at 12 months. Mean rates (tests per 1000 patients per month) in the pre- and post-MI periods were 51.9 (95% CI: 51.7, 52.1) and 84.4 (95% CI: 84.1, 84.6), respectively. Over 12 months post-MI, observed rates were higher than predicted rates; the maximum rate difference was 66 tests per 1000 patients in month 2 (rate ratio 2.2), stabilizing at a difference of 15–20 (ratio 1.2–1.3) for months 6–12.ConclusionAlthough LDL-C testing increased following MI hospitalization, rates remained lower than recommended by clinical guidelines. This highlights a potential gap in care, where increased LDL-C testing after MI may provide opportunities for LLT modification and decrease risk of subsequent cardiovascular events.

P.009 Canadian Survey of the neurological care provided to women living with epilepsy: preliminary results

Background: In Canada, approximately 300,000 women with epilepsy (WWE) are of childbearing potential. Given the unique aspects of providing care for WWE, our objective was to gather demographic and practice characteristics of health care professionals providing care for WWE to identify potential gaps. Methods: We developed a questionnaire to understand the demographic and practice characteristics of professionals providing care for WWE. We invited all French and English practitioners (physicians, physician assistants and nurse practitioners), recruited through the Canadian League Against Epilepsy (CLAE), Canadian Neurological Sciences Federation (CNSF) and Canadian Epilepsy nursing Group (CENG), to complete our online questionnaire. Results: Preliminary data show 43% were between 32-40 years of age and 76% were medical doctors. Sixty-three percent had been in practice for less than 20 years; 81% considered themselves epilepsy specialists and 66% devoted their practice entirely to epilepsy patients and 78% practiced exclusively in academic centers. Conclusions: Our data shows providers involved in the care of women with epilepsy in Canada are predominantly academic experts in epilepsy. Potential gaps in care include mid-late career physicians, non-specialized health care practitioners, and community-based practices, as less likely to provide care for WWE. This snapshot may provide future insights to the unmet needs of WWE Canada.

Prevalence, Treatment, and Control of Hypertension Among US Women of Reproductive Age by Race/Hispanic Origin.

To explore the prevalence, pharmacologic treatment, and control of hypertension among US nonpregnant women of reproductive age by race/Hispanic origin to identify potential gaps in care. We pooled data from the 2011 to March 2020 (prepandemic) National Health and Nutrition Examination Survey cycles. Our analytic sample included 4,590 nonpregnant women aged 20-44 years who had at least 1 examiner-measured blood pressure (BP) value. We estimated prevalences and 95% confidence intervals (CIs) of hypertension, pharmacologic treatment, and control based on the 2003 Joint Committee on High Blood Pressure (JNC 7) and the 2017 American College of Cardiology and the American Heart Association (ACC/AHA) guidelines. We evaluated differences by race/Hispanic origin using Rao-Scott chi-square tests. Applying ACC/AHA guidelines, hypertension prevalence ranged from 14.0% (95% CI: 12.0, 15.9) among Hispanic women to 30.9% (95% CI: 27.8, 34.0) among non-Hispanic Black women. Among women with hypertension, non-Hispanic Black women had the highest eligibility for pharmacological treatment (65.5%, 95% CI: 60.4, 70.5); current use was highest among White women (61.8%, 95% CI: 53.8, 69.9). BP control ranged from 5.2% (95% CI: 1.1, 9.3) among women of another or multiple non-Hispanic races to 18.6% (95% CI: 12.1, 25.0) among Hispanic women. These findings highlight the importance of monitoring hypertension, pharmacologic treatment, and control by race/Hispanic origin and addressing barriers to equitable hypertension care among women of reproductive age.

Predicting Receipt and Types of Occupational Therapy Services for Patients with Arousal Deficits in the Neuro Critical Care Unit

Occupational therapy has been identified as a required service in the neuro critical care unit (NCCU), however who receives occupational therapy services and what services they receive are not well understood. We sought to determine if arousal deficits impacted patients’ likelihood to receive an occupational therapy evaluation or specific types of occupational therapy interventions in the NCCU. When compared to patients without arousal deficits, patients who were experiencing agitation or light sedation, but not deep sedation, were more likely to receive occupational therapy interventions in the therapeutic activities category. Arousal deficits were not associated with receipt of occupational therapy services or occupational therapy interventions in the self-care or therapeutic exercise categories. Determining predictors of occupational therapy services will help ensure the timely delivery of services by improving the allocation of resources and identifying potential gaps in care.

Abstract TP35: Stroke Nurse Navigation-Evolving Care Delivery To Effectively Meet The Needs Of Stroke Patients And Families

Background: Research indicates the importance of life-style modification, risk factor management, and medication and physician follow-up compliance in the prevention of stroke. Nurse navigators are in a unique position to influence this care. The pandemic changed post-acute management of stroke by requiring increased virtual care as opposed to in-person care. A known disparity existed in the number of touch points between the patients utilizing the patient portal versus those reached only by phone. We aimed to evaluate how changes in navigator workflow influenced the frequency of touchpoints, operating under the assumption that increased touchpoints will improve post-hospital care. Methods: A retrospective analysis was completed for acute stroke patients discharged from January 2020 - March 2021 for 4 certified stroke centers. We implemented standardized time intervals for patient outreach, regardless of modality. Initial outreach was completed within 48 hours to avoid potential gaps in care. Motivational interview calls were focused on education that included life-style changes, compliance, risk factor control and follow-up, which mirrored the mobile application’s education. Branded individualized education materials were created and sent to patients using US Mail or via the patient portal. New flowsheets were developed in the EMR for future data collection and reporting. Hand written notes and cards of encouragement were also sent reinforcing the counseling received. Linear regression analysis evaluated our primary outcome: the relationship between monthly touchpoints over time. Results: A total of 1935 patients were diagnosed with acute stroke, discharged and managed post-hospitalization for 90 days. During the 90 day episode, navigators interacted with patients for M = 4.64 SD = 2.46. Regression analysis demonstrated a linear relationship between time and touchpoints ( p &lt;0.001). Navigators also reported intangible results from patient and family feedback related to support and care received. Conclusions: Stroke care is complex and requires ongoing patient and caregiver support. Increasing availability to stroke experts, such as nurse navigators, provides support and tools to improve post-hospital care.

Quality of Care for Patients With Systemic Lupus Erythematosus: Data From the American College of Rheumatology RISE Registry.

Although multiple national quality measures focus on the management and safety of rheumatoid arthritis, few measures address the care of patients with systemic lupus erythematosus (SLE). Our objective was to apply a group of quality measures relevant to the care of patients with SLE, and we used the American College of Rheumatology's Rheumatology Informatics System for Effectiveness (RISE) registry to assess nationwide variations in care. The data derived from RISE and included patients who had ≥2 visits with SLE codes ≥30 days apart in 2017-2018. We calculated performance on 5 quality measures: renal disease screening, blood pressure assessment and management, hydroxychloroquine (HCQ) prescribing, safe dosing for HCQ, and prolonged glucocorticoid use at doses of >7.5 mg/day. We reported performance on these measures at the practice level. We used logistic regression to assess independent predictors of performance after adjusting for sociodemographic and utilization factors. We included 27,567 unique patients from 186 practices; 91.7% were female and 48% White, with a mean age of 53.5 ± 15.2 years. Few patients had adequate screening for the development of renal manifestations (39.5%). Although blood pressure assessment was common (94.4%), a meaningful fraction of patients had untreated hypertension (17.7%). Many received HCQ (71.5%), but only 62% at doses of ≤5.0 mg/kg/day. Some received at least moderate-dose steroids for ≥90 days (18.5%). We observed significant practice variation on every measure. We found potential gaps in care for patients with SLE across the US. Although some performance variation may be explained by differences in disease severity, dramatic differences suggest that developing quality measures to address important health care processes in SLE may improve care.

Caregiver Challenges Seen From the Perspective of Certified Home Hospice Medical Directors.

Background: Hospice medical directors (HMDs) play an important role as part of the interdisciplinary hospice team. Family caregivers (CGs) play a critical role in caring for patients receiving home hospice care. Understanding the challenges HMDs face when working with CGs is important when addressing potential gaps in care and providing quality end of life (EoL) care for the patient/CG dyad. Objectives: To understand issues HMDs encounter when working with and caring for CGs and to determine how they manage these issues in the home hospice setting. Design: Twelve semistructured phone interviews with certified HMDs were conducted. Data were analyzed using standard qualitative methods. Subjects: Participants included certified HMDs obtained from a public website. Results: Participants' responses regarding the major issues HMDs faced when working with CGs were categorized into 6 themes: (1) assessing CG competency, (2) CG financial burden, (3) physical burden of caregiving, (4) managing CG expectations, (5) CGs denial of patient's terminal condition, and (6) CGs unwilling or unable to engage with providers about their needs or the patient's needs. Conclusions: HMDs confirmed the important role CGs play in providing care to home hospice patients. Challenges faced by HMDs vary from assessing CG competency in providing care to the patient, dealing with the physical and financial toll that CGs face, and addressing CGs' expectations of hospice care. Future studies are needed to explore solutions to these issues to better support CGs in the home setting.

Impact of the COVID-19 Pandemic on Radiation Oncology Consult Volumes Within a Multi-Site Academic Practice

Purpose/Objective(s)Cancer care has been significantly impacted by the COVID 19 pandemic; however, a comprehensive understanding of the downstream effects of the pandemic on radiation oncology practice in the United States has not been well quantified. We sought to quantify the differences in radiation consult volumes across varying disease sites and practice locations within our National Cancer Institute (NCI) designated Comprehensive Cancer Center, at time points preceding and during the COVID 19 pandemic. The purpose of this study is to identify potential gaps in care for specific disease sites that could addressed in the future.Materials/MethodsWe collected new patient referral data from three clinical radiation oncology sites for the 2019 calendar year and the 2020 calendar year. Overall new patient referrals for 2019 and 2020 were analyzed and compared as well as consult volume for each disease site.ResultsIn 2019, there was a total 4,284 overall consults and in 2020 there was a total of 3,442 consults. This is a 20% reduction in consults over a 12-month period. The month of April had the most significant decrease in consults with a total of 357 consults in April 2019 compared to a total of 179 consults in April 2020 (50% reduction). The month of February had the least reduction with 329 total consults in 2019 compared to a total of 313 consults in 2020 (5% reduction). There was a decrease in consult volumes for all tumor sites with the exception of following tumor sites which saw an increase in consult volumes: colon (55.6%), kidney &renal pelvis (15.8), larynx (32.7%), oral cavity (7%), Non-Hodgkin's Lymphoma (9.9%), other head & neck (13.9%), and thyroid cancer (36.4%). Breast and prostate cancer had the greatest absolute change in consult volume loss (32.6%, 29.3% respectively). Oral tongue cancer was the sole tumor site that had no change in consult volume across the study period.ConclusionThe ramifications of COVID-19 will be seen in the practices of clinicians, cancer centers, and the experiences of patients and their families for years to come. We found a 20% overall reduction in new patient referrals for 2020. The most significant absolute change in volume loss was seen in breast and prostate cancer. Head and neck cancer referrals were the most minimally impacted, with some increases in referrals during the study period which could possibly be related to limited surgical resources necessitating non-operative treatment. Further studies are needed to more comprehensively understand the impact of the COVID 19 pandemic on radiation oncology practice.

Lipid testing trends before and after hospitalization for myocardial infarction among adults in the U.S., 2008–2019

Abstract Background Routine monitoring of low-density lipoprotein cholesterol (LDL-C) identifies patients who are candidates for initiation of lipid-lowering therapies (LLT), assesses adherence and response, and measures clinical indications for modifications to treatment. This study investigated LDL-C testing trends among patients hospitalized for incident myocardial infarction (MI), a population at high risk of future atherosclerotic cardiovascular disease (ASCVD) events who may benefit from additional LLT. Purpose Our objective was to estimate rates of LDL-C testing before and after MI hospitalization, hypothesizing that testing rates would increase following MI. Methods Using claims data from a large population with Medicare supplemental or commercial insurance, we identified U.S. adults aged ≥20 years discharged from a MI hospitalization. Patients qualified for the study cohort if their first MI hospitalization occurred during 1/1/2008–3/31/2019, with one year of continuous enrolment in insurance leading up to the hospitalization. Patients were required to be discharged alive to the community (excluded if died or transferred to another facility). LDL-C testing was assessed in the year before admission (pre-MI) and for up to one year after discharge (post-MI), with censoring due to insurance plan disenrollment. To evaluate changes in LDL-C testing, we fit an overdispersed Poisson model to the time-series of pre-MI rates and extrapolated the model to the post-MI period, accounting for person-time and seasonality. We predicted the LDL-C testing rates if no MI occurred (i.e., based only on pre-MI testing trends) and estimated rate differences with 95% confidence intervals (contrasting observed vs. model-predicted rates). Results A total of 389,367 patients were hospitalized for their first MI during the study period with 60% aged &amp;lt;65 years, 64% were male, and 51% filled a statin prescription after discharge (half being high-intensity statins). In the year pre-MI, 25% had a history of diabetes mellitus, 35% used statins, and 4% used ezetimibe. In the year post-MI, only 52% had an LDL-C test. Mean observed rates (tests per 1,000 patients per month) in the pre- and post-MI periods were 51.9 (95% CI: 51.7, 52.1) and 84.4 (95% CI: 84.1, 84.6), respectively. Across the 12 months post-MI, observed rates were higher than model-predicted rates, with the magnitude of rate differences changing over time (Figure). The observed testing rate peaked two months post-MI (rate difference: 65.7, 95% CI: 64.6, 66.7). Conclusions Our findings indicate that LDL-C testing rates increased following a MI hospitalization and stayed elevated throughout the following year. Despite this increase, overall rates remained low, with only one in two patients receiving an LDL-C test in the year after MI. These results highlight a potential gap in care, particularly given the importance of LDL-C monitoring for this population to reduce risk of future ASCVD events. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): This study was funded by Amgen, Inc. Several authors are employees and own stock in Amgen.

Suicide Screening and Risk Assessment in the Emergency Department: Case Review of a Suicide Attempt Survivor

One in 10 of those who die by suicide are seen in an emergency department within the 2 months before their death. Despite national guidelines and resources (including from the Joint Commission and Emergency Nurses Association) for suicide screening, risk assessment, and follow-up care, suicidal ideation and behavior continue to go undetected in emergency departments, leading to gaps in care. This case review was conducted as part of a larger electronic medical record review of emergency department practices and aims to highlight potential gaps in care and identify missed opportunities for suicide screening and risk assessment. In addition to highlighting these missed opportunities, this case review provides recommendations for suicide screening and risk assessment resources with options for evidence-based follow-up care for suicidal patients.

Association of insurance status with timing of hemodialysis access placement

ObjectivePatients without adequate outpatient follow-up often present requiring emergency hemodialysis and then undergo permanent dialysis access placement at a later time. We sought to examine the relationship between type of insurance and whether a patient was already on dialysis at time of surgery. MethodsThe Vascular Quality Initiative Hemodialysis Access registry was queried for all adult patients undergoing first time permanent hemodialysis access between January 2015 and September 2019. Patient and procedural characteristics were examined in patients split by private insurance—Medicare more than 65 years of age, Medicare less than 65 years of age, and Medicaid. The primary outcome was whether patients were on dialysis at the time of surgery. ResultsThere were 19,307 adult patients that underwent first time placement of an arteriovenous fistula or graft. Of these patients, 9729 (50%) had Medicare, 7179 (37%) had private insurance, and 2399 (12%) had Medicaid. The patients with Medicare were subgrouped by age with 2968 (31%) being less than 65 years of age and 6761 (69%) being more than 65 years of age. Patients with Medicare and less than 65 were the most likely to be on dialysis at the time of surgical access placement at 67%, whereas 59% of Medicaid patients were on dialysis, and 53% each group of patients with Medicare and more than 65 years of age and private insurance were on dialysis. After adjustment for patient characteristics, patients with Medicare who were less than 65 and more than 65 years of age were both significantly more likely to be on dialysis at time of surgery compared with private insurance with odds ratio (OR) of 1.64 (95% confidence interval [CI], 1.49-1.80; P < .001) and an OR of 1.11 (95% CI, 1.03-1.20; P = .007), respectively. After adjustment, patients with Medicaid were no longer significantly more likely to be on dialysis. Secondary outcomes demonstrated, after adjustment, no difference in the association between a surgical fistula vs graft in any insurance groups; however, patients with Medicare and who were less than 65 years of age were more likely to have a nonradial artery used for anastomosis with an OR of 1.18 (95% CI, 1.04-1.34; P = .011). ConclusionsCertain types of insurance are correlated with being on dialysis at the time of access placement. Although associations were seen between insurance type and surgical access characteristics, these were associations predominantly insignificant when patient demographics and status of dialysis were controlled for. These potential gaps in care represent an area for improvement that deserves further exploration.

Telemedicine Utilization at an Academic Medical Center During COVID-19 Pandemic: Are Some Patients Being Left Behind?

Introduction: The purpose of this study was to examine the use of telemedicine at one academic health care center during the COVID-19 pandemic to identify opportunities to improve access to this novel delivery method of care. Methods: All patients who underwent telemedicine visits at one urban academic medical center between March 2020 and June 2020 were included. All departments were included including surgical and nonsurgical. Demographic data, primary language, and visit type were collected. Primary zip code was used as surrogate for socioeconomic status through use of the zip code median household income. The demographics of the New York metropolitan area were obtained through the U.S. Census Bureau and used as a control cohort. Results: A total of 362,413 telemedicine visits met inclusion criteria with the majority of visits performed in April and May; 127,851 (35.3%) and 110,166 (30.4%), respectively. The highest performing department was Internal Medicine, which performed 72,796 visits or 20% of the total cohort. In our cohort of telemedicine patients, 59.6% identified as White, 11.4% as Black, and 5.7% as Asian. This is less diverse than the overall population of the metropolitan area, which is 17.5% Black and 11.5% Asian. There was also a large gender gap in the utilization of telemedicine services in general, where women (60.2%) were more likely than men (39.8%) to utilize the virtual visits. In addition, although over a third of patients in the Metropolitan area have median household incomes of <50,000, this population only represented 13.6% of our total cohort. Conclusions: This study highlights both the capability of telemedicine to provide care at a large urban academic medical center during a pandemic in addition to identifying potential gaps in care with telemedicine. The disparities highlighted in our cohort stress the importance of outreach to non-White older patients of lower socioeconomic status.

Changes in Test Volumes During Coronavirus Disease 2019 (COVID-19): A Laboratory Stewardship Opportunity.

Coronavirus disease 2019 (COVID-19) changed the dynamics of health care delivery, shifting patient priorities and deferring care perceived as less urgent. Delayed or eliminated care may place patients at risk for adverse outcomes. To identify opportunities for laboratory test stewardship to close potential gaps in care created by the COVID-19 pandemic. The study was a retrospective time series design examining laboratory services received before and during the COVID-19 pandemic at a large metropolitan health system serving women and children. Laboratory test volumes displayed 3 distinct patterns: (1) a decrease during state lockdown, followed by near-complete or complete recovery; (2) no change; and (3) a persistent decrease. Tests that diagnose or monitor chronic illness recovered only partially. For example, hemoglobin A1c initially declined 80% (from 2232 for April 2019 to 452 for April 2020), and there was a sustained 16% drop (28-day daily average 117 at August 30, 2019, to 98 at August 30, 2020) 4 months later. Blood lead dropped 39% (from 2158 for April 2019 to 1314 for April 2020) and remained 23% lower after 4 months. The pandemic has taken a toll on patients, practitioners, and health systems. Laboratory professionals have access to data that can provide insight into clinical practice and identify pandemic-related gaps in care. During the pandemic, the biggest patient threat is underuse, particularly among tests to manage chronic diseases and for traditionally underserved communities and people of color. A laboratory stewardship program, focused on peri-pandemic care, positions pathologists and other laboratory professionals as health care leaders with a commitment to appropriate, equitable, and efficient care.

22 Coping with Medicines After Hospital Discharge; the Invisible Work of Older Patients and Their Care-Givers

Abstract Introduction Older patients often experience medication-related problems following discharge from hospital. These can be categorised as issues with obtaining medication, taking medication, medication effects or problems with communication or care co-ordination (Nicosia et al., Journal of General Internal Medicine, 2019, https://doi.org/10.1007/s11606-019-05463-z). The aim of this study was to explore older adults’ experiences of post-discharge medicines management, including the strategies they use to safely manage their changed medicines. Methods Following ethical approval, patients aged 75 and above, with a change in their long term medicines, were recruited during admission to one of two hospitals in Yorkshire. Semi-structured interviews took place with the participants in their own homes, approximately two weeks after discharge. Interviews were audio recorded and transcribed. Data were analysed using the Framework method. Results Twenty-seven patients (mean age 85 years; 6 males) consented to be interviewed. They described multiple self-management and safety strategies used to support medicines management in the early post-discharge phase. The work done included adaptations (to routines, the home environment and action plans), scaffolding (where patients and their care-givers support the primary care system by providing additional documentation or prompts to ensure medicines were supplied on time and were correct) and error avoidance (seeking information, performing checks and balances). Conclusion Older patients experience gaps in their post-discharge medicines-related care which they had to bridge through implementing their own strategies or by enlisting support from others. This study shines a spotlight on to the invisible work that patients have to do in order to make post-discharge medicines management fit for purpose. Further work should consider those patients who are not able to carry out these tasks or who do not have any care-givers available for support and how this potential gap in care can be addressed.

Medical Student Patient Outreach to Ensure Continuity of Care During the COVID-19 Pandemic.

Background:In response to the COVID-19 pandemic, the Yale New Haven Health System began rescheduling nonurgent outpatient appointments as virtual visits in March 2020. While Yale New Haven Health expanded its telemedicine infrastructure to accommodate this shift, many appointments were delayed and patients faced considerable uncertainty.Objective:Medical students created the Medical Student Task Force (MSTF) to help ensure continuity of care by calling patients whose appointments were delayed during this transition to telemedicine.Methods:Eighty-five student volunteers called 3765 internal medicine patients with canceled appointments, completing screening for 2197 patients. Volunteers screened for health care needs, assessed preferences for future appointments, and offered emotional support and information about COVID-19. Urgent or emergent patient concerns were triaged and escalated to providers. In this analysis, we used a mixed-methods approach: call information and provider responses were analyzed quantitatively, and patient feedback was analyzed qualitatively via thematic analysis.Results:Ninety-one percent of patients screened found the MSTF calls helpful. Twenty-one percent of patients reported health concerns, with 1% reporting urgent concerns escalated to and addressed by providers. Themes of patient comments included gratitude for outreach and social contact, utility of calls, and well-wishes for health care workers.Conclusions:By calling patients whose appointments had been canceled during a rapid transition to telemedicine, the MSTF helped bridge a potential gap in care by offering patients communication with their care teams, information, and support. We propose that this model could be used in other care systems urgently transitioning to outpatient telemedicine, whether during ongoing outbreaks of COVID-19 or other public health emergencies.

Frequency of Opioid Prescription at Emergency Department Discharge in Patients with Inflammatory Bowel Disease: A Nationwide Analysis

Patients with inflammatory bowel disease (IBD) frequently experience chronic pain. Patients will often seek out care in the emergency department (ED) where short-term opioid use may be associated with potential treatment-related complications. We aimed to assess the rate and factors associated with opioid prescription in IBD patients discharged from the ED. We conducted a cross-sectional analysis of data collected in the US National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006-2017. We determined the proportion of adult patients (≥18 years) with IBD prescribed an opioid in ED or at ED discharge. Logistic regression was used to evaluate predictors of opioid prescription. Time-trend analysis was performed to evaluate temporal patterns in opioid use. All analyses were adjusted for complex survey design. We identified ∼965,000 weighted discharges from the ED for patients with IBD. In total, 51.9% [95% CI: 42.2% -61.6%] of visits resulted in opioid administration in ED and 35.3% [95% CI: 26.5% -45.2%] of IBD-related ED discharges were associated with an opioid prescription. IBDpatients with moderate/severe pain (adjusted odds ratio aOR 5.06 [95% CI: 1.72 -14.90], p< 0.01) were more likely to receive opioids whereas older age (aOR 0.73 per decade [95% CI: 0.55 -0.98], p = 0.04) were less likely. In temporal analysis, a trend towards decreasing opioid use in ED and opioid prescriptions at discharge was observed in 2015-2017. More than one third of IBD patients are prescribed an opioid at discharge from ED, highlighting a potential gap in care for accessing effective pain management solutions in this population.