Safety Net Clinics Research Articles

Lessons Learned from Offering Video Visits as an Alternative to Phone Visits: A Case Study from a Safety-Net Obstetrics Clinics.

Before the Covid-19 pandemic, human-centered design work in San Francisco found video visits promising for Medicaid-insured pregnant individuals. They were deemed likely better than phone at addressing concerns about remoteness. We describe our experience with introducing video visits within a safety net clinic that had rapidly adopted phone visits as the standard telemedicine option early in the pandemic. By utilizing Kotter's change framework, providing an equity-focused vision, and supporting the implementation with a skilled, on-the-ground project manager, temporary uptake of offering video visits was achieved. However, competing priorities, staffing structure, and institutional culture were barriers to creating sustained change once grant funding ended, even after improvement of digital infrastructure. Efforts to increase video visit uptake in systems where telephone visits are the norm-as is in many safety net systems-may have limited success without leadership-driven prioritization and culture change at all levels.

Males Have Lower Anal Pap Smear Screening in a Miami Safety-Net HIV Clinic.

Although people with HIV have a markedly higher risk of anal squamous cell carcinoma (ASCC), there are few evaluations of anal Pap screening determinants within safety-net HIV clinics. We conducted an evaluation of anal Pap screening correlates within a safety-net HIV clinic in Miami. Medical records were reviewed for 298 people ages 45 and older receiving HIV primary care. Demographic information and the prevalence of anal Pap screening over 1year (i.e., 2018-2019) were extracted. Between 2018 and 2019, approximately half (46%) of patients completed anal Pap screening although this varied by sex assigned at birth. More than three-fourths of females (77%) compared to one-fourth (23%) of males were screened between 2018 and 2019 (p < 0.0001). Findings underscore the need for multi-level intervention approaches to optimize anal Pap screening among maleswith HIV within the Miami-basedsafety-net clinic.

Bridging the Language Gap in Healthcare: Implementing a Qualified Medical Interpreter Program for Lesser-Spoken Languages

Linguistic inequity drives systemic disparities in healthcare for non-native English speakers. This study evaluates a project to train and provide qualified medical interpreters (QMI) to assist volunteer and safety-net clinics and community-based organizations in supporting healthcare for immigrants and refugees. We provided scholarships to bilingual community members to take a medical interpreter training course and developed a workforce for those who passed the training course. We focused on lesser-spoken foreign languages such as Arabic, Amharic, Pashto, Dari, and Burmese. Those who passed the course participated in a semi-structured interview to learn about their experiences in the training program, as well as barriers and facilitators to becoming a QMI. To date, 23 people have passed the training and are part of the QMI workforce program that has provided 94 h of interpreter services over four months, serving 66 individual patients. The evaluation showed that community members have interest in becoming QMIs and many have the required language proficiency to enroll and pass training. Finding full-time employment for less spoken languages has proven to be challenging.

Geographic Socioeconomic Influences on Disease Activity in Rheumatoid Arthritis in an Academic and Safety Net Hospital System.

The objective of this study was to analyze the impact of the Area Deprivation Index (ADI) on disease activity and cardiovascular comorbidity in rheumatoid arthritis (RA). A retrospective analysis of adult patients with RA was conducted to highlight differences in academic and safety net hospital clinics. Demographics, RA medication history, patient portal engagement, primary care presence, emergency or inpatient visits, RA disease activity and functional scores, Charlson Comorbidity Index (CCI), and cardiovascular disease (CVD) presence were captured. The ADI rank was assigned using nine-digit zip codes. Patients were stratified by the upper versus lower ADI decile group and matched by age, sex, race, ethnicity, insurance, and CCI using propensity score analysis. Patients with RA from the academic practice (n = 542) and the safety net hospital (n = 496) were assessed. In the academic cohort, those with high ADI scores (>8, more deprivation) had higher RA disease activity scores (Routine Assessment of Patient Index Data 3 mean ± SD: high 13.83 ± 6.94 vs low 11.17 ± 7.37, P < 0.0001; Clinical Disease Activity Index mean ± SD: high 11.97 ± 11.74 vs low 9.40 ± 7.97, P < 0.05), more functional impairment (Multidimensional Health Assessment Questionnaire mean ± SD: high 2.99 ± 2.29 vs low 2.34 ± 2.23, P < 0.01), lower MyChart use (P < 0.001), and different smoking history (P < 0.01) compared to those with low ADI scores (<3, less deprivation). In the safety net cohort, there was a statistically significant difference only in smoking status (P < 0.05). CVD was not significantly different in either cohort. The absence of differences in RA disease activity and functional impairment in patients suggests that the ADI may not be as effective at predicting RA disease activity specifically in a safety net health care context. Identifying the discrepancies between the two systems may elucidate areas of improvement for patient care.

The promise and limits of inclusive public policy: federal safety net clinics and immigrant access to health care in the U.S.

Abstract In the United States, exclusionary public policies generate inequalities within and across labor, financial, and legal status hierarchies, which together undermine immigrant well-being. But can inclusive public policies improve immigrant health? We examine whether and how an immigrant-inclusive federal program, Federally Qualified Health Centers (FQHCs), shaped health care access and use among farmworkers over nearly three decades, paying particular attention to disparities at the intersection of nativity and legal status. Linking historical administrative data on the location and funding of FQHCs with the National Agricultural Workers Survey from 1989–2017, we first document trends in farmworkers’ county-level proximity to FQHCs and identify a steady increase in FQHC access among undocumented farmworkers following the Affordable Care Act. Next, using time-series cross-sectional regressions with a battery of fixed effects, we find that living in a county where FQHCs are available and better resourced is associated with increased health care use among undocumented farmworkers, but not among U.S.-born or documented immigrant farmworkers. We also find that county-level access to FQHCs is associated with reduced reports of language barriers to care among both documented and undocumented foreign-born farmworkers. These findings suggest that FQHCs may improve access for immigrants who are typically excluded from U.S. health care institutions. Still, county-level FQHC infrastructure is not associated with cost-related barriers to care for any nativity or legal status groups. Taken together, our study highlights both the potential and constraints of inclusive public policies for promoting health equity in a welfare state context characterized by commodification and stratification.

Patient and clinic staff perspectives on the implementation of a long-acting injectable antiretroviral therapy program in an urban safety-net health system

BackgroundLong-acting injectable cabotegravir plus rilpivirine (LAI CAB/RPV) has several potential benefits over daily oral formulations for HIV treatment, including the potential to facilitate long-term adherence and reduce pill fatigue. We aimed to assess facilitators of and barriers to LAI CAB/RPV implementation and delivery through the perspectives of physicians and clinical staff, and the experiences of LAI CAB/RPV use among people living with HIV (PLWH) at a Ryan-White supported safety-net clinic in North Texas.MethodsWe conducted semi-structured interviews with recruited clinic staff (physicians, nurses, and support staff) involved with LAI CAB/RPV implementation and PLWH who switched to LAI CAB/RPV and consented to participate in individual interviews. Data were collected from July to October 2023. Our interview guide was informed by the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM), and Proctor Implementation Outcomes frameworks. Qualitative data were analyzed using a rapid qualitative analysis approach to summarize key themes.ResultsWe recruited and interviewed 15 PLWH who transitioned to LAI CAB/RPV and 11 clinic staff serving these patients. PLWH conveyed that emotional and informational support from family or a trusted clinician influenced their decision to switch to LAI CAB/RPV. PLWH also reported that injectable treatment was more effective, convenient, and acceptable than oral antiretroviral therapy. Clinic staff and physicians reported that staff training, pharmacist-led medication switches, flexible appointments, refrigeration space and designated room for injection delivery facilitated implementation. Clinic staff cited medication costs, understaffing, insurance prior authorization requirements, and lack of medication access through state drug assistance programs as critical barriers.ConclusionsOur study offers insights into real-world experiences with LAI usage from the patient perspective and identifies potential strategies to promote LAI CAB/RPV uptake. The barriers to and facilitators of LAI CAB/RPV program implementation reported by clinic staff in our study may be useful for informing strategies to optimize LAI CAB/RPV programs.

Evaluation of the impact of neurology electronic consults (e-consults): Experiences of a neurology resident clinic in a safety-net hospital.

Electronic consults (e-consults) are asynchronous, formalized requests by a provider to involve a specialist to assist with decision making. E-consults are an alternative to face-to-face consultation and are a promising strategy to efficiently address certain requests for advice. The objective of this project was to examine the utility and characteristics of electronic consults utilized in a safety-net hospital outpatient neurology clinic. We retrospectively reviewed e-consults to the neurology clinic from1 January 2021 to 31 September 2021. The reasons for requests and any diagnostic or treatment recommendations were collected. The time to completion of the e-consults and the percentage of e-consult referred for an in-person clinic evaluation were determined as outcome measures. Following each e-consult, the consulting provider completed a survey to gather their assessment on the appropriateness of the consult, time spent answering the consult, and if unnecessary testing or clinic visits were avoided. A total of 528 e-consults were completed during the study period. The most frequent e-consult referrals were for headache (22%), stroke/neurovascular (21%), neuropathy/neuritis/disturbance of skin sensation (11%), and seizures/spells (11%). The majority of e-consults (94%) were answered in one business day (defined as occurring within 24 h) with 67% of consults answered the same day (defined as occurring within the same calendar day). The consulting providers reported that more than 90% of e-consults took <15 min to answer, and 84% of e-consult requests were felt to be appropriate. A total 156 (41.4%) patients initially seen as an e-consult were referred for a face-to-face visit within 90 days of the e-consult. E-consults provided expedited input from neurologists, which is vital in health systems that provide care to vulnerable populations. The majority of e-consults were answered within 1 day of referral, offering rapid access to neurological expertise in comparison to wait times currently encountered for face-to-face visits. Accordingly, e-consults have the potential to expedite treatment for patients, empower primary care providers, and reduce demand for in-person consultations, particularly in large health systems caring for vulnerable populations.

A survey of patient practices regarding leftover antibiotics reveals a potential source of antibiotic overuse.

Taking leftover prescribed antibiotics without consulting a healthcare professional is problematic for the efficacy, safety, and antibiotic stewardship. We conducted a cross-sectional survey of adult patients in English and Spanish between January 2020 and June 2021 in six safety-net primary care clinics and two private emergency departments. We assessed the reasons for stopping prescribed antibiotics early and what was done with the leftover antibiotics. Additionally, we determined 1) prior leftover antibiotic use, 2) intention for future use of leftover antibiotics, and 3) sociodemographic factors. Of 564 survey respondents (median age of 51), 45% (251/564) reported a history of stopping antibiotics early, with 171/409 (42%) from safety net and 80/155 (52%) from the private clinics. The most common reason for stopping prescribed antibiotics early was "because you felt better" (194/251, 77%). Among survey participants, prior use of leftover antibiotics was reported by 149/564 (26%) and intention for future use of leftover antibiotics was reported by 284/564 (51%). In addition, higher education was associated with a higher likelihood of prior leftover use. Intention for future use of leftover antibiotics was more likely for those with transportation or language barriers to medical care and less likely for respondents with private insurance. Stopping prescribed antibiotics early was mostly ascribed to feeling better, and saving remaining antibiotics for future use was commonly reported. To curb nonprescription antibiotic use, all facets of the leftover antibiotic use continuum, from overprescribing to hoarding, need to be addressed.

A Real-world Study Evaluating the Clinical Factors Associated with the Initial SGLT2 Inhibitor Prescription

Abstract: The American Diabetes Association (ADA) guidelines prioritize Sodicum-glucose transporter-2-inhibitors (SGLT2i) given cardio-renal and glycemic benefits. This study was conducted to observe clinical factors associated with initial SGLT2i prescription in type 2 diabetes patients eligible for SGLT2i by the ADA. Methods. A retrospective case-control study was performed in a safety-net clinic and consisted of the initial SGLT2i prescriptions group and the group without. The data from the electronic medical records between July 2021 and December 2022 were analyzed in the regressional models. Results. There was a significant association between A1c ≥8% (OR 3.7, p=.01), heart failure (OR 19.3, p&lt;.0001), a history of hypotension (OR 11.9, p=.01), and sulfonylureas (OR 6.5, p=.003) with the SGLT2i prescription. Conclusion. Patients with high A1c levels, heart failure, a history of hypotension, and sulfonylureas were more likely than their counterparts to receive SGLT2i prescriptions. Future research should investigate adherence and provider prescribing behaviors related to SGLT2i to further assess optimal drug use.

Predictors of PrEP Retention and Attrition in an Urban Publicly Funded Safety-net Specialty Clinic.

Pre-exposure prophylaxis (PrEP) is an effective tool for human immunodeficiency virus (HIV) prevention. The purpose of this study is to identify correlates of PrEP retention using patient data from an urban, publicly funded safety-net clinic in Washington, DC. Cox proportional hazards regression, logistical regression, and survival curves were used to assess the association of age, gender, race/ethnicity, insurance, number of partners, and sexually transmitted infection (STI) diagnosis at PrEP initiation with time on PrEP. From August 2016-December 2020, 1,126 people were prescribed PrEP - patients were mostly Black (44.8%) or Latinx (30.4%) and identified as cisgender men (84.6%). Half had no insurance (49.1%), with the remaining patients reporting private (28.9%) or public (21.5%) insurance. Age at PrEP prescription ranged from 15 to 66 with 80% being 20 to 39 years. For the 87.7% (n = 987) of patients who discontinued PrEP, mean PrEP time was 158 days and median was 28 days. The highest rates of discontinuation were observed within the first month with 44.3% discontinuing by day 30, 52.3% by 3 months, and 73.2% by 1 year. Cisgender women, transgender persons, and those younger than 30 years were more likely to discontinue PrEP. Latinx and patients with less than 3 male partners in the last 90 days were less likely to discontinue PrEP. We demonstrated a high level of PrEP uptake among populations disproportionally affected by HIV. Future analyses are needed to examine ways of reducing barriers to PrEP initiation and improving PrEP adherence.

COVID-19 Disruptions to Social Care Delivery: A Qualitative Study in Two Large, Safety-Net Primary Care Clinics

BackgroundSocial care integration refers to the incorporation of activities into health systems that assist patients with health-related social needs (HRSNs) that negatively impact the health outcomes of their patients, such as food insecurity or homelessness. Social care integration initiatives are becoming more common. The COVID-19 pandemic strained health systems while simultaneously increasing levels of unmet social needs.ObjectiveTo describe the effects of the COVID-19 pandemic on established social care delivery in a primary care setting.DesignWe used qualitative semi-structured interviews of stakeholders to assess barriers and facilitators to social care delivery in the primary care setting during the COVID-19 health emergency. Data was analyzed using a hybrid inductive/deductive thematic analysis approach with both the Consolidated Framework for Implementation Research (CFIR) and the Screen-Navigate-Connect-Address-Evaluate model of social care integration.SettingTwo safety-net, hospital-based primary care clinics with established screening for food insecurity, homelessness, and legal needs.ParticipantsSix physicians, six nurses, six members of the social work team (clinical social workers and medical case workers), six community health workers, and six patients (total N = 30) completed interviews.ResultsFour major themes were identified. (1) A strained workforce experienced challenges confronting increased levels of HRSNs. (2) Vulnerable populations experienced a disproportionate negative impact in coping with effects of the COVID-19 pandemic on HRSNs. (3) COVID-19 protections compounded social isolation but did not extinguish the sense of community. (4) Fluctuations in the social service landscape led to variable experiences.ConclusionsThe COVID-19 pandemic disrupted established social care delivery in a primary care setting. Many of the lessons learned about challenges to social care delivery when health systems are strained are important considerations that can inform efforts to expand social care delivery.

Strategic use of resources to enhance colorectal cancer screening for patients with diabetes (SURE: CRC4D) in federally qualified health centers: a protocol for hybrid type ii effectiveness-implementation trial

BackgroundPersons with diabetes have 27% elevated risk of developing colorectal cancer (CRC) and are disproportionately from priority health disparities populations. Federally qualified health centers (FQHCs) struggle to implement CRC screening programs for average risk patients. Strategies to effectively prioritize and optimize CRC screening for patients with diabetes in the primary care safety-net are needed.MethodsGuided by the Exploration, Preparation, Implementation and Sustainment Framework, we conducted a stakeholder-engaged process to identify multi-level change objectives for implementing optimized CRC screening for patients with diabetes in FQHCs. To identify change objectives, an implementation planning group of stakeholders from FQHCs, safety-net screening programs, and policy implementers were assembled and met over a 7-month period. Depth interviews (n = 18–20) with key implementation actors were conducted to identify and refine the materials, methods and strategies needed to support an implementation plan across different FQHC contexts. The planning group endorsed the following multi-component implementation strategies: identifying clinic champions, development/distribution of patient educational materials, developing and implementing quality monitoring systems, and convening clinical meetings. To support clinic champions during the initial implementation phase, two learning collaboratives and bi-weekly virtual facilitation will be provided. In single group, hybrid type 2 effectiveness-implementation trial, we will implement and evaluate these strategies in a in six safety net clinics (n = 30 patients with diabetes per site). The primary clinical outcomes are: (1) clinic-level colonoscopy uptake and (2) overall CRC screening rates for patients with diabetes assessed at baseline and 12-months post-implementation. Implementation outcomes include provider and staff fidelity to the implementation plan, patient acceptability, and feasibility will be assessed at baseline and 12-months post-implementation.DiscussionStudy findings are poised to inform development of evidence-based implementation strategies to be tested for scalability and sustainability in a future hybrid 2 effectiveness-implementation clinical trial. The research protocol can be adapted as a model to investigate the development of targeted cancer prevention strategies in additional chronically ill priority populations.Trial registrationThis study was registered in ClinicalTrials.gov (NCT05785780) on March 27, 2023 (last updated October 21, 2023).

Situations Predisposing Primary Care Patients to Use Antibiotics Without a Prescription in the United States

Background: Using antibiotics without medical guidance (non-prescription use) is a potential safety threat to individual and public health. Patients' situations can impact their intentions to use non-prescription antibiotics in the future (intended use). This survey (1) explores the dimensionality of 13 predefined situations to identify ‘summary factor,’ which include conceptually similar situations that influence patients’ intended use of non-prescription antibiotics, and (2) identifies the sociodemographic predictors associated with these summary factors. Methods: A cross-sectional survey was conducted from January 2020–June 2021 in the waiting rooms of six safety-net primary care clinics and two private emergency departments. We used principal component analysis as a data reduction technique and confirmed the factor structure of the situations (identifying three situational summary factors). Multivariate linear regression identified the sociodemographic predictors (e.g., age, gender, race, education, insurance, healthcare system, language preference, birth country, and health literacy) associated with each summary factor. Results: Of the 564 patients surveyed, the majority were female (72%), Hispanic or Latinx (47%), college-educated (44%), and received public health insurance (e.g., Medicaid or County Financial Assistance) (56%). The largest proportion of patients endorsed intended non-prescription antibiotic use for situations involving high doctor visit costs (29.8%), having leftover prescription antibiotics (50.4%), and experiencing symptom relief with prior use of antibiotics (47.5%) (Figure 1). We identified three situational summary factors: (1) perceived barriers to a doctor visit and receiving a prescription (Cronbach’s alpha [α]=0.96), (2) convenience and accessibility of non-prescription antibiotics (α=0.81), and (3) previous symptom relief with antibiotics (α=0.95). After controlling for gender, race, education, insurance, language preference, birth country, and health literacy, our multivariate regression results revealed that younger patients (P &lt; 0 .04) and patients attending the safety-net health system (P &lt; 0 .001) had more intended use of non-prescription antibiotics for all three summary factors (Figure 2). Conclusions: Our study revealed that younger patients and individuals receiving care from the safety-net clinics had an increased risk of intended non-prescription antibiotic use across all summary factors. Future stewardship interventions should consider the types of situations that drive patients' decisions to use antibiotics without a prescription. Interventions aimed at reducing barriers to healthcare (e.g., high costs and long waits associated with doctor appointments) and educating individuals on the risks associated with inappropriate antibiotic use while providing alternative (non-antibiotic) treatment options may reduce antibiotic use and antimicrobial resistance. Acknowledgments: This work is supported by grant number R01HS026901 from AHRQ and NRSA T-32 (6T32HC10031).Disclosure: Barbara Trautner: Stock: Abbvie--sold in December 2023; Abbott Laboratories--sold in December 2023; -Bristol Myers Squibb--sold in December 2023; Pfizer--sold in December 2023; Consultant--Phiogen—consultant. Contracted research through NIAID for STRIVE trial, currently testing Shionogi product; Contracted research--Peptilogics; Contracted research--Genentech

Beyond the Prescription Pad—Finding a Window of Opportunity to Prevent Antibiotic Diversion and Non-Prescription Use

Background: Non-prescription antibiotic use is defined as taking antibiotics without medical guidance, which includes using leftover antibiotics, obtaining antibiotics from friends or relatives, or purchasing antibiotics without a prescription. This study aimed to (1) determine the symptoms prompting individuals to use non-prescription antibiotics, identify their sources of acquisition, and document the types of antibiotics utilized, (2) identify any associated side effects, and (3) gain insights into antibiotic storage practices, including whether antibiotics were used beyond their expiration date. Methods: A cross-sectional quantitative survey was conducted from January 2020-June 2021 in waiting rooms of six safety-net primary care clinics and two private emergency departments in Houston, Texas. Participants were read survey questions in English or Spanish by a bilingual research coordinator, and their responses to five questions about antibiotic use were recorded. Descriptive analysis was performed. Results: Among the 564 patients surveyed, the median age was 51 (range 19-92). The majority identified as female (72%), Hispanic/Latinx (47%), Black/African American (33%), held a college education (44%), and received public health insurance, such as Medicaid or County Financial Assistance (56%). Of all patients surveyed, 44% (246) reported taking an antibiotic without a prescription and answered questions about associated symptoms. Of all symptoms/illnesses associated with non-prescription use, the most common were sore throat (18%), dental symptoms (16%), and cold/flu (13%). The most common sources for non-prescribed antibiotics were leftover antibiotics (50%), from friends or relatives (31%), and purchased abroad (13%), although 3% had purchased non-prescription antibiotics from a local store or market (Figure 1). The most common antibiotics used were amoxicillin (38%) and penicillin (7%). The reported side effects were stomach pain/upset (24%), nausea and vomiting (19%), allergic reaction (e.g., rash) (14%), and diarrhea (14%). Among 246 participants reporting antibiotic use, 63% reported that the antibiotic they took had been previously prescribed for the same symptom/illness, and 93% had acquired antibiotics in a container, of which 90% reported that the container had an expiration date. Conclusions: Our survey reveals that 63% of individuals who use non-prescription antibiotics were motivated by having received prescribed antibiotics for similar symptoms previously. Leftover antibiotics were the source for half of all non-prescription use. These observations suggest that outpatient antibiotic stewardship campaigns have a window of opportunity at the time of the initial prescription of antibiotics, to focus on providing the shortest course possible, and to deliver antibiotic safe use information at that time. Acknowledgments: Financial Support AHRQ R01HS026901Disclosure: Barbara Trautner: Stock: Abbvie--sold in December 2023; Abbott Laboratories--sold in December 2023; -Bristol Myers Squibb--sold in December 2023; Pfizer--sold in December 2023; Consultant--Phiogen—consultant. Contracted research through NIAID for STRIVE trial, currently testing Shionogi product; Contracted research--Peptilogics; Contracted research—Genentech

Use of concept mapping to inform a participatory engagement approach for implementation of evidence-based HPV vaccination strategies in safety-net clinics

BackgroundMultiple evidence-based strategies (EBS) for promoting HPV vaccination exist. However, adolescent HPV vaccination rates remain below target levels in communities at high risk for HPV-associated cancers and served by safety-net clinics. Participatory engaged approaches are needed to leverage the expertise of community and clinical partners in selecting EBS relevant to their local context. We engaged concept mapping as a method to inform the adoption and adaptation of EBS that seeks to empower implementation partners to prioritize, select, and ultimately implement context-relevant EBS for HPV vaccination.MethodsUsing 38 EBS statements generated from qualitative interviews and national HPV vaccine advocacy sources, we conducted a modified concept mapping activity with partners internal to safety-net clinics and external community members in two study sites of a larger implementation study (Greater Los Angeles and New Jersey), to sort EBS into clusters and rate each EBS by importance and feasibility for increasing HPV vaccination within safety-net clinics. Concept mapping findings (EBS statement ratings, ladder graphs and go-zones) were shared with leaders from a large federally qualified health center (FQHC) system (focusing on three clinic sites), to select and implement EBS over 12 months.ResultsConcept mapping participants (n=23) sorted and rated statements, resulting in an eight-cluster solution: 1) Community education and outreach; 2) Advocacy and policy; 3) Data access/quality improvement monitoring; 4) Provider tracking/audit and feedback; 5) Provider recommendation/communication; 6) Expanding vaccine access; 7) Reducing missed opportunities; and 8) Nurse/staff workflow and training. The FQHC partner then selected to intervene on eight of 17 EBS statements in the “go-zone” for action, with three from “reducing missed opportunities,” two from “nurse/staff workflow and training,” and one each from “provider tracking/audit and feedback,” “provider recommendation/communication,” and “expanding vaccine access,” which the research team addressed through the implementation of three multi-level intervention strategies (e.g., physician communication training, staff training and workflow assessment, audit and feedback of clinic processes).ConclusionsConcept mapping provided a powerful participatory approach to identify multilevel EBS for HPV vaccination relevant to the local safety-net clinic context, particularly when several strategies exist, and prioritization is necessary. This study demonstrates how a clinic system benefited directly from the ratings and prioritization of EBS by multilevel clinic and community partners within the broader safety-net clinic context to identify and adapt prioritized solutions needed to advance HPV vaccine equity.

Cost analysis review of a patient navigator and fecal immunochemical testing on colorectal cancer screening in an underserved population

BackgroundColorectal cancer screening is a critical preventative service and part of routine patient care, yet a substantial portion of the population fails to undergo recommended screening.AimsTo investigate the impact and cost-effectiveness of a patient navigator on colorectal cancer screening via fecal immunochemical testing.MethodsDesign: retrospective analysis investigating structured outreach via a dedicated patient navigator. Location: Center for Primary Care, Rhode Island Hospital’s primary safety-net clinic for adult patients in Providence, Rhode Island. Timing: the study ran between 01/2017 and 12/2021, with the intervention introduced 01/2021.ResultsThis study included 3542 patients. The intervention improved completion rates from 64.7 to 74.5% at 1 month (HR 1.12, 95%CI [1.003–1.243]), 73.7% to 90.1% at 3 months (1.28[1.156–1.410]), and 87.8 to 98.8% at 1 year (1.36 [1.239–1.498]). Overall, completion rates were improved by 38.5% (1.39[1.260–1.522]). Total cost of colorectal cancer screening per patient was decreased by $874.18 in the post-intervention group ($72.0 ± 383.3 vs. $946.1 ± 1873.5, p < 0.0001).ConclusionsIn this retrospective analysis, our targeted intervention improved fecal immunochemical testing kit return rates and significantly reduced screening costs. The addition of a dedicated patient navigator is critical to ensuring compliance with screening guidelines, particularly for deprived and/or medically underserved populations. Health care systems, insurance companies and payers, and state health departments should actively and consistently support this role, as it will allow fecal immunochemical testing to reach and risk-stratify more patients, increasing the yield of colonoscopy for detecting advanced neoplasia and cancer and subsequently reducing pressure on endoscopy centers.

Implementing a Staff-Led Smoking Cessation Intervention in a Diverse Safety-Net Rheumatology Clinic: A Pre-Post Scalability Study in a Low-Resource Setting.

Quit Connect (QC), our specialty clinic smoking cessation intervention, supports clinic staff to check, advise, and connect willing patients to a state quit line or class. QC improved tobacco screening and quit line referrals 26-fold in a predominantly White academic health care system population. Implementing QC includes education, electronic health record (EHR) reminders, and periodic audit feedback. This study tested QC's feasibility and impact in a safety-net rheumatology clinic with a predominantly Black population. In this pre-post study, adult rheumatology visits were analyzed 12 months before through 18 months after QC intervention (November 2019 through November 2021, omitting COVID-19 peak April through November 2020). EHR data compared process and clinical outcomes, including offers, referrals to resources, completed referrals, and documented cessation. Clinic staff engaged in pre-post focus groups and questionnaires regarding intervention feasibility and acceptability. Cost-effectiveness was also assessed. Visit-level patients who smoked were 89.8% Black and 69.5% women (n = 550). Before intervention, clinic staff rarely asked patients about readiness to cut back smoking (<10% assessment). After QC intervention, staff assessed quit readiness in 31.8% of visits with patients who smoked (vs 8.1% before); 58.9% of these patients endorsed readiness to cut back or quit. Of 102 accepting cessation services, 37% (n = 17) of those reached set a quit date. Staff found the intervention feasible and acceptable. Each quit attempt cost approximately $4 to $10. In a safety-net rheumatology clinic with a predominantly Black population, QC improved tobacco screening, readiness-to-quit assessment, and referrals and was also feasible and cost-effective.

Abstract PO4-09-08: Perceptions and Experiences of Black Women on Family History Sharing and Genetic Testing for Hereditary Breast and Ovarian Cancer

Abstract Black women experience significant disparities in morbidity and mortality related to hereditary breast and ovarian cancer (HBOC). Early identification of women with HBOC is essential for proactive screening and timely diagnosis. However, evidence suggests that Black women receive genetic testing for HBOC at lower rates than their White counterparts. We conducted in-depth qualitative interviews with 107 Black women with a personal or family history of breast or ovarian cancer, to understand their perceptions of their familial risk of HBOC and interest in genetic testing. In phase 1 of this study, participants were recruited from the networks of patient support organizations and historically Black sororities representing mostly highly educated and well insured patients. In phase 2, participants were recruited from a family medicine safety net clinic in Jacksonville, FL for socioeconomic diversity. Participants in both cohorts frequently expressed a lack of awareness about their family cancer history and identified many barriers to family disclosure of a cancer diagnosis. These include a culture of silence around medical issues and a belief that personal difficulties should be kept to oneself. Practical and cultural barriers to family history sharing were magnified among those with lower socioeconomic status. Many participants in both cohorts indicated a strong desire to understand their own risk of HBOC. They also expressed interested in genetic testing to proactively mitigate risk to themselves and future generations. Understanding of the potential relevance of HBOC testing to one’s personal health and post-test actionability was variable across both groups, although perceptions of genetic testing were generally favorable. These findings suggest that culturally tailored educational materials and alternative clinical modalities to collect family health history may be beneficial to improve timely identification of Black women who meet NCCN Guidelines for HBOC testing. Specifically, greater attention should be given to addressing barriers that led to underestimation of HBOC risk among patients experiencing disparities driven by adverse social determinants of health. Citation Format: Kirsten Riggan, Jane Yap, Ewan Cobran, Michele Halyard, Sarah James, Marion Kelly, Daphne Phillips, Megan Allyse. Perceptions and Experiences of Black Women on Family History Sharing and Genetic Testing for Hereditary Breast and Ovarian Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-09-08.

Patient Satisfaction With Over-the-Phone Interpretation in an Outpatient Gynecology Clinic [ID 2683580

INTRODUCTION: In Miami, Florida, the majority of households are bilingual or non-English speaking, often necessitating use of translation services in clinical settings. Culturally competent care includes using a language that patients understand, which can lead to improved clinical outcomes. Over-the-phone translation is the only method of interpretation available in our public safety net outpatient gynecology clinic. To our knowledge, no study has explored patient satisfaction and comfort with this mode of interpretation in a gynecology clinic. METHODS: An anonymous 33-item Spanish language survey, adapted from existing studies on medical translation, was used to assess the translation experience for adult patients. Surveys were collected verbally and in-person immediately after a clinic visit in which over-the-phone translation services were used. A Likert-type scale (1, very bad, to 4, very good) was used to assess satisfaction domains. RESULTS: Twenty-nine Spanish-speaking participants completed the survey. The median age was 47.5 years. Over 75% (n=22) were uninsured and close to 50% had not completed high school/GED (n=14). Mean satisfaction with interpretation (3.55) and medical care (4) were high. However, 14% (n=4) felt disrespect by their interpreter, 10% (n=3) expressed dissatisfaction with their understanding of treatment plans, and 10% (n=3) reported issues of privacy with the interpreter. In participants over age 40 (n=19) and with less than a high school education (n=14), there was more discomfort in discussing medical history using the interpreter compared to less than 40 and college-educated respondents. 65% (n=19) of all respondents indicated a preference for an in-person professional interpreter. CONCLUSION: Although further research is needed, this study highlights potential concerns, particularly in older and less-educated patients, with over-the-phone translation services in the outpatient gynecology clinical setting. In settings where patients are likely to be non-English speaking, providing optimal translation services is crucial to both patient satisfaction and culturally competent care.

Telemedicine Screening for Eye Disorders in Federally Qualified Health Centers: Relationship to Vision-Targeted Health-Related Quality of Life.

Introduction: Federally Qualified Health Centers (FQHCs) play a crucial role as safety-net primary health care clinics in the United States, serving medically underserved areas and populations. However, eye services are rarely offered at FQHCs. We examined how telemedicine-generated ocular diagnoses impacted vision-targeted health-related quality of life at FQHCs in rural Alabama. Methods: We focused on patients who are at risk for glaucoma. Both visual function and retinal imaging were assessed. The telemedicine vision screening protocol performed by a remote ophthalmologist evaluated eyes for glaucoma, diabetic retinopathy, cataract, age-related macular degeneration, and a measurement of habitual visual acuity. The National Eye Institute Visual Function Questionnaire-9 (VFQ-9) was administered. Results: Using stepwise regression, the best-fitting model for predicting VFQ-9 scores incorporated visual acuity 20/40 or worse, a diabetic retinopathy diagnosis, and sociodemographic variables (gender, transportation, insurance type/status, and employment status). Conclusion: Vision-targeted, health-related quality of life in our FQHC settings was related to the visual acuity impairment and the diagnosis of diabetic retinopathy but was also influenced by a variety of sociodemographic factors.