Safety Net Healthcare Setting Research Articles

Abstract C132: Building capacity for equitable cervical cancer care in safety-net settings through an FQHC-NCI comprehensive cancer center partnership in Los Angeles

Abstract Introduction: Multilevel barriers to screening and follow-up contribute to persistent disparities in cervical cancer burden, particularly in marginalized communities receiving care in safety-net healthcare settings. While evidence-based interventions (EBIs) exist for improving cancer screening and follow-up, building capacity to identify effective strategies for implementation and alignment of EBIs to the context of safety-net settings and the diverse communities they serve is critical. Methods: Supported by the HRSA Accelerating Cancer Screening Program, Chinatown Service Center, a multi-site Federally Qualified Health Center (FQHC) serving Chinese and Latino/a populations in Los Angeles, and USC Norris Comprehensive Cancer Center established a new partnership to identify multilevel factors that impact cervical cancer screening, follow-up and referral and inform the implementation of EBIs to improve care. We conducted a mixed methods assessment June-December 2023 to understand care processes through surveys and qualitative interviews (20-30 minutes, guided by the Consolidated Framework for Implementation Research) with providers and clinic staff and medical chart reviews of patients with ≥ 1 cervical cancer screening order January 2020-March 2023. Results: Surveys (n=23) showed higher knowledge of screening guidelines (p<0.05) and more confidence discussing cervical cancer with patients (p<0.05) among providers compared to clinic staff, indicating opportunities for staff training. Qualitative interviews (n=23) identified inner setting barriers such as limited system-level implementation of cervical cancer screening guidelines and limited technology supports to track patients requiring follow-up. At the individual level, older patients and those not sexually active often declined testing and requested gender concordant (female) providers. Motivation for building cervical cancer care capacity within the FQHC were noted, with clinic members highlighting FQHC strengths in addressing cultural barriers, social needs, and community outreach. Several outer setting barriers emerged for referral and follow-up care, including long wait times for referrals, trouble finding language concordant specialists, transportation barriers, and difficulty accessing specialists through their managed care network. Medical chart abstractions (n=1,428) identified opportunities to improve closed-loop communication with specialists and limited ease for clinic staff identify high and low risk screening results for further treatment. Discussion: By establishing a new FQHC-NCI cancer center partnership, we advanced our combined capacity to address cervical cancer care equity in marginalized communities. We identified patient-level (cultural, logistic, social determinants), provider/clinic staff-level (training needs, patient tracking), and system-level (access to and communication with specialists) barriers that will require selection of EBIs and implementation strategies via a partnered approach with local specialists, health systems, payers, and policymakers. Citation Format: Jennifer Tsui, Samantha Garcia, Emily Dang, Alejandra Ramos, Allison Oh, Kathy Lui, Angela Ching, Eugene Hui, Chanita Hughes Halbert, Lourdes Baezconde-Garbanati, Jack Cheng. Building capacity for equitable cervical cancer care in safety-net settings through an FQHC-NCI comprehensive cancer center partnership in Los Angeles [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C132.

Current Practices and Attitudes of Community Health Centers Toward the Use of Algorithmic Logic to Identify Patients with Undiagnosed Hypertension.

Treating patients with uncontrolled hypertension is a powerful intervention for reducing the risk of heart attack and stroke. Leveraging health information technology to identify patients with undiagnosed hypertension using algorithmic logic can be an effective approach for reaching hypertensive patients who may otherwise be overlooked. Despite evidence that this strategy can support favorable cardiovascular health outcomes in the safety-net healthcare setting, little is known about its implementation outside of targeted practice and research environments. In 2021-2022, Community Clinic Association of Los Angeles County and the Los Angeles County Department of Public Health collaborated on a mixed methods, organizational assessment of community health centers to better understand their practices and attitudes toward the use of algorithmic logic to identify patients with undiagnosed hypertension. Results from the assessment suggest that awareness and use of this approach are limited; numerous challenges are associated with its adoption and implementation.

Impact of a multi-disciplinary team-based care model for patients living with diabetes on health outcomes: a mixed-methods study

BackgroundIndividuals facing socioeconomic hardship experience higher than average rates of chronic disease, such as diabetes, with less access to evidence-based treatment. One solution to address these inequities is a team-based care (TBC) model, defined as one in which at least two providers work collaboratively with a patient and their caregiver(s) to make healthcare decisions. This paper seeks to describe the implementation of a TBC model within a safety-net healthcare setting and determine the extent to which it can be an effective, patient-centered approach to treating individuals with diabetes.MethodsSemi-structured interviews were conducted with staff (n = 15) and patients (n = 18). Clinical data were extracted from the electronic medical record of patients (n = 1,599) seen at a safety-net health system in Chicago, Illinois, United States. The mixed methods study was guided by implementation science and participatory research principles. Staff interviews were 60 min and covered patient care activities, work flow, perceived patient experience, and facilitators/barriers to care coordination. Patient interviews were 60 min and covered satisfaction, attitudes about diabetes management, quality of life, and technology. Patient interviews were co-analyzed by research staff and members of a patient advisory committee. Clinical data were collected at an index visit, two years prior and at one-year follow up (n = 1,599).ResultsFour themes emerged from the interviews: (1) patients perceived the TBC model to be patient centered and of high quality; (2) technology can be an innovative tool, but barriers exist; (3) diabetes management is a complex process; and (4) staff communication enhances care coordination, but misinterpreting roles reduces care coordination. From pre-enrollment to the follow-up period, we found a statistically significant increase in missed visits, decrease in hemoglobin A1c (HbA1c), decrease in body mass index, and decrease in the percent of patients with high blood pressure. We found that each medical visit during the follow-up period was associated with an HbA1c decrease of 0.26 points.ConclusionsA TBC model is a patient-centered approach to providing care to patients with complex health needs, such as diabetes, patients were satisfied with the care they were receiving, and the model was associated with an improvement in clinical outcomes.

"If You Plant That Seed, It Will Grow": A Qualitative Study to Improve Linkage to Care Among Patients With Methamphetamine Use Disorder in Emergency Department Settings.

Methamphetamine addiction is a serious and difficult-to-treat disorder. Existing treatment options are limited, and patient perspectives on effective strategies are lacking. Emergency departments (EDs) may be a critical entry point for individuals with methamphetamine use disorder (MUD) to be identified and linked to treatment. We aimed to understand patients' perspectives regarding their methamphetamine use and related ED experiences and how to improve linkage to substance treatment. Between July and November 2022, semistructured qualitative interviews were conducted with adult patients with MUD in an urban safety-net healthcare setting in Denver, Colorado. Interviews were recorded, summarized, and analyzed using the Rapid Assessment Process. During the interviews, 18 patients shared their experiences. Participants described feeling stigmatized and experiencing a lack of communication from ED staff during their visit. Additionally, participants shared the perception that ED staff often did not take their health concerns seriously once substance use was identified. Participants were uncertain about overdose risk and felt that their psychiatric symptoms complicated treatment. Referrals to treatment were lacking, and participants supported a care navigation intervention that incorporates elements of contingency management. Participants also shared the importance of ED staff recognizing their social needs and being empathetic, trauma-informed, and flexible to meet patients where they are regardless of their readiness to seek treatment. Treatment options and entry points for individuals with MUD are currently limited. The patient perspectives described here are helpful in developing services to support, engage, and link individuals to MUD services after discharge from ED services.

Initial Stage of Disease Similar for White and Black Patients With Early-Onset Colorectal Cancer at a Safety-Net Hospital.

Non-Hispanic Black (NHB) patients with early-onset colorectal cancer (EOCRC) are more likely to present with advanced-stage disease than their Non-Hispanic White (NHW) counterparts. To further elucidate whether differences in tumor biology or disparities in access to care may be responsible, we examined the association between race/ethnicity and initial stage of disease, time to diagnosis, and tumor characteristics among NHW and NHB patients with EOCRC cared for in a safety-net health care setting. We performed a retrospective cohort study of NHW and NHB patients diagnosed with primary EOCRC who received care at Boston Medical Center between January 2000 and May 2020. We compared demographics, risk factors, presenting signs/symptoms, time to diagnosis, health care utilization, and tumor characteristics (stage, grade, location, and mutational status). We identified 103 patients (mean age 41.5±7.2 y, 53.4% men), including 40 NHWs and 63 NHBs, with EOCRC. NHB and NHW patients were similar with respect to demographics, presenting signs/symptoms, and risk factor distribution. There were also no significant differences between NHWs and NHBs with respect to the advanced stage of disease at presentation (45.0% vs. 42.9%, P=0.83), the median time to diagnosis [152 d (IQR, 40 to 341) vs. 160 d (IQR, 61 to 312), P=0.79] or tumor characteristics, except for a predilection for proximal disease among NHBs (30.2% vs. 15.0%). NHB patients were no more likely than NHW patients to present with advanced-stage disease, aggressive tumor histology, or experience delays in diagnosis within a safety-net health care system.

Clinician Experiences With Integrative Group Medical Visits for Chronic Pain.

The well-being of healthcare teams is an important consideration when seeking to improve patient experience and quality of care. Prior studies have found that changes to working conditions are most effective in improving clinician well-being. Integrative Group Medical Visits (IGMVs) modify working conditions in ways that have potential to improve clinician experience. The objective of this study was to understand healthcare teams' experiences with IGMVs. In this qualitative study, interviews were conducted via Zoom and telephone with 21 clinicians, administrators, and staff from safety-net healthcare settings throughout the United States (U.S.) who have implemented IGMVs for patients with chronic pain. Interviews included questions about clinician experience, well-being, and satisfaction with the IGMV model. Interviews were recorded, transcribed, and coded using thematic content analysis by a team of trained qualitative researchers. The authors identified five themes describing how IGMV positively affected clinician well-being: organizational supports, human-centered engagement, collaboration with an interprofessional team, provision of guideline-concordant care, and enhanced meaning and purpose for the clinicians. The current study was the first to use interviews from healthcare teams who have implemented IGMV to assess their experience. The themes identified warrant further investigation into IGMVs as a strategy to promote clinician well-being and mitigate aspects of burnout.

Disruptions to and Innovations in HPV Vaccination Strategies within Safety-Net Healthcare Settings Resulting from the COVID-19 Pandemic.

The COVID-19 pandemic disrupted healthcare delivery within safety-net settings. Barriers to and facilitators of human papillomavirus (HPV) vaccination during the pandemic can inform future HPV vaccine strategies for underserved communities. Qualitative interviews (n = 52) between December 2020 and January 2022 in Los Angeles and New Jersey were conducted with providers, clinic leaders, clinic staff, advocates, payers, and policy-level representatives involved in the HPV vaccine process. Using the updated Consolidated Framework for Implementation Research we identified (1) outer setting barriers (i.e., vaccine hesitancy driven by social media, political views during the pandemic) and facilitators (e.g., partnerships); (2) inner setting clinic facilitators (i.e., motivation-driven clinic metrics, patient outreach, vaccine outreach events); (3) individual characteristics such as patient barriers (i.e., less likely to utilize clinic services during the pandemic and therefore, additional outreach to address missed vaccine doses are needed); (4) innovations in HPV vaccination strategies (i.e., clinic workflow changes to minimize exposure to COVID-19, leveraging new community partnerships (e.g., with local schools)); and (5) implementation strategies (i.e., multisectoral commitment to HPV goals). Pandemic setbacks forced safety-net settings to develop new vaccine approaches and partnerships that may translate to new implementation strategies for HPV vaccination within local contexts and communities.

Patient-Reported Outcomes from a Pilot Plant-Based Lifestyle Medicine Program in a Safety-Net Setting.

Lifestyle medicine interventions that emphasize healthy behavior changes are growing in popularity in U.S. health systems. Safety-net healthcare settings that serve low-income and uninsured populations most at risk for lifestyle-related disease are ideal venues for lifestyle medicine interventions. Patient-reported outcomes are important indicators of the efficacy of lifestyle medicine interventions. Past research on patient-reported outcomes of lifestyle medicine interventions has occurred outside of traditional healthcare care settings. In this study, we aimed to assess patient-reported outcomes on nutrition knowledge, barriers to adopting a plant-based diet, food and beverage consumption, lifestyle behaviors, self-rated health, and quality-of-life of participants in a pilot plant-based lifestyle medicine program in an urban safety-net healthcare system. We surveyed participants at three time points (baseline, 3 months, 6 months) to measure change over time. After 6 months of participation in the program, nutrition knowledge increased by 7.2 percentage points, participants reported an average of 2.4 fewer barriers to adopting a plant-based diet, the score on a modified healthful plant-based diet index increased by 5.3 points, physical activity increased by 0.7 days per week while hours of media consumption declined by 0.7 h per day, and the percentage of participants who reported that their quality of sleep was "good" or "very good" increased by 12.2 percentage points. Our findings demonstrate that a lifestyle medicine intervention in a safety-net healthcare setting can achieve significant improvements in patient-reported outcomes. Key lessons for other lifestyle medicine interventions include using a multidisciplinary team; addressing all pillars of lifestyle medicine; and the ability for patients to improve knowledge, barriers, skills, and behaviors with adequate support.

Retrospective review of patients with lung cancer presenting emergently

BackgroundA significant proportion of lung cancer patients receive their diagnosis as part of an emergency presentation (EPs) to emergency departments (EDs). ObjectivesThis study aimed to describe EPs of lung cancer at a safety-net hospital system. MethodsWe conducted a retrospective analysis of patients with lung cancer at a safety-net ED. EP was defined as a diagnosis of lung cancer due to an acute presentation with symptoms of undiagnosed lung cancer (e.g., cough, hemoptysis, shortness of breath). Non-EPs were the result of either incidental findings (trauma pan-scan) or as part of lung cancer screening. ResultsA total of 333 patient charts were reviewed who had lung cancer. Of those, 248 (74.5%) were defined as having an EP. EPs were more likely stage IV than non-EPs (50.4% vs 32.9%). The percent mortality was higher for EP versus non-EP, 60.0% vs 49.4%. which is driven by a high mortality rate for stage IV EPs (77.5%). Most patients with an EP were seen in the ED (177, 71.4%) as the location of initial visit that had a workup concerning for lung cancer. Most of the EPs were admitted for completion of either their diagnostic work up and/or for symptom management (117, 66.5%). Logistic regression identified significant predictors for an EP including stage IV at diagnosis (OR 2.49, 95% CI 1.39–4.48) and lack of primary care (OR 0.07, 95% CI 0.009–0.53). ConclusionMost patients with lung cancer present acutely as an EP with advanced stage in a safety-net health care setting. The ED plays an important role in the initial diagnosis of lung cancer and coordinating subsequent cancer care.

The STAR-MAMA RCT: Bilingual Mobile Health Coaching for Postpartum Weight Loss

Gestational diabetes and overweight during pregnancy are associated with future type 2 diabetes. Postpartum weight loss can reduce diabetes risk. However, effective interventions for postpartum weight loss are lacking, in particular for Latina populations, despite their disproportionate burdens of gestational diabetes, overweight, and diabetes. This was a community-based RCT. Researchers recruited pregnant individuals with gestational diabetes or BMI>25 kg/m2 from safety-net health care settings and Women, Infants, and Children offices in Northern California in 2014-2018. Of 180 individuals randomized to intervention (n=89) or control (n=91), 78% identified as Latina, 61% were primarily Spanish speaking, and 76% perceived their diabetes risk to be low. The intervention consisted of a 5-month postpartum telephone-based health coaching intervention delivered in English or Spanish. Data were collected through surveys at enrollment and 9-12 months after delivery and chart review up to 12 months after delivery. The primary outcome, weight change from prepregnancy to 9-12 months after delivery, was compared between the groups, overall and within strata defined a priori according to language (Spanish or English) and diabetes risk perception (none/slight or moderate/high). The intent-to-treat estimated intervention effect was +0.7 kg (95% CI= -2.4 kg, +3.8 kg; p=0.67). In stratified analyses, intervention effects remained nonsignificant but varied in direction: effects were favorable among English speakers and those with higher perceived diabetes risk, and unfavorable among Spanish speakers and those with lower perceived risk. Analyses were conducted in 2021-2022. A postpartum health coaching intervention, designed for low-income Latina women at increased risk for diabetes, did not reduce postpartum weight gain. Intervention effects were nonsignificantly more favorable among English speakers versus Spanish speakers, and among those who perceived their diabetes risk to be high versus low. This study is registered at www. gov NCT02240420.

Assessing Alignment of Patient and Clinician Perspectives on Community Health Resources for Chronic Disease Management.

Addressing social determinants of health (SDoH) is associated with improved clinical outcomes for patients with chronic diseases in safety-net settings. This qualitative study supplemented by descriptive quantitative analysis investigates the degree of alignment between patient and clinicians’ perceptions of SDoH resources and referrals in clinics within the public healthcare delivery system in San Francisco. We conducted a qualitative analysis of in-depth interviews, patient-led neighborhood tours, and in-person clinic visit observations with 10 patients and 7 primary care clinicians. Using a convergent parallel mixed methodology, we also completed a descriptive quantitative analysis comparing the categories of neighborhood health resources mentioned by patients or community leaders to the resources integrated into the electronic health record. We found that patients held a wealth of knowledge about neighborhood resources relevant to SDoH that were highly localized and specific to their communities. In addition, multiple stakeholders were involved in conducting SDoH screenings and referrals, including clinicians, system navigators such as case workers, and community-based organizations. Yet, the information flow between these stakeholders and patients lacked systematization, and the prioritization of social needs by patients and clinicians was misaligned, as represented by qualitative themes as well as quantitative differences in resource category distribution analysis (p < 0.001). Our results shed light upon opportunities for strengthening social care delivery in safety-net healthcare settings by improving patient engagement, clinic workflow, EHR engagement, and resource dissemination.

Identifying the Needs of Primary Care Providers Caring for Breast and Colon Cancer Survivors in the Safety-Net: a Qualitative Study

As the number of cancer survivors continues to increase and given the shortage of oncology clinicians in safety net health care settings, primary care providers (PCPs) in these settings will increasingly provide cancer survivorship care. In order to ensure equitable care for low-income and underserved breast and colon cancer survivors, it is essential to understand the safety-net PCPs’ perspective. We conducted semi-structured, in-depth qualitative interviews with 11 PCPs working in a safety-net health care system to identify their needs in caring for cancer survivors. Interviews were audio-recorded and professionally transcribed. Two coders independently coded the interviews and conducted regular meetings until we reached consensus on the results. Analysis was based in grounded theory and performed using the constant comparative method. Thematic analysis identified six themes as follows: (1) Cancer survivorship care can be integrated with the whole person and chronic disease care management that occurs in primary care; (2) PCPs’ perceptions regarding patients’ survivorship care needs and their confidence in meeting those needs; (3) preference for a shared care model; (4) coordination of care; (5) PCPs’ need for survivorship care education and training; and (6) unique issues involved in the care of older cancer survivors. PCPs in the safety-net believe that providing comprehensive survivorship care requires coordination of care through the cancer continuum. Tools like checklists, electronic health records-based communication, and convenient electronic consultations with cancer specialists would enhance the quality of survivorship care. Respondents advocate the inclusion of survivorship care education in medical education. The continuity of care with PCPs means that they play a particularly important role in the care of older cancer survivors.

Applying a socioecological framework to chronic disease management: implications for social informatics interventions in safety-net healthcare settings.

ObjectiveVulnerable populations face numerous barriers in managing chronic disease(s). As healthcare systems work toward integrating social risk factors into electronic health records and healthcare delivery, we need better understanding of the interrelated nature of social needs within patients’ everyday lives to inform effective informatics interventions to advance health equity.Materials and MethodsWe conducted in-depth interviews, participant-led neighborhood tours, and clinic visit observations involving 10 patients with diabetes in underserved San Francisco neighborhoods and 10 community leaders serving those neighborhoods. We coded health barriers and facilitators using a socioecological framework. We also linked these qualitative data with early persona development, focusing on patients’ experiences in these communities and within the healthcare system, as a starting place for our future informatics design.ResultsWe identified social risk and protective factors across almost every socioecological domain and level—from physical disability to household context to neighborhood environment. We then detailed the complex interplay across domains and levels within two critical aspects of patients’ lives: housing and food. Finally, from these data we generated 3 personas that capture the intersectional nature of these determinants.ConclusionDrawing from different disciplines, our study provides a socioecological approach to understanding health promotion for patients with chronic disease in a safety-net healthcare system, using multiple methodologies. Future digital health research should center the lived experiences of marginalized patients to effectively design and implement informatics solutions for this audience.

Not Speaking the Same Language-Lower Portal Use for Limited English Proficient Patients in the Los Angeles Safety Net.

With the expansion of online patient portals linked to electronic health records in safety-net health care settings, we need more data on the use of these websites by patients with limited English proficiency (LEP) in order to guide their continued design, implementation, and evaluation as portals for the underserved. Cross-sectional portal data for the Los Angeles County Department of Health Services, the second largest safety-net system in the nation. We examined differences in portal use across language (English vs. non-English/LEP), covering four years since implementation. Of 425,281 patients assigned to primary care as of March 2019, 55,190 (13%) unique portal enrollments were registered. Among 54,981 portal users, LEP users had lower adjusted odds of using an active portal function (e.g., medication refill) vs. English-speakers. Even among those registered to access portals, these websites are underused, particularly by LEP patients. All systems must facilitate use for these populations, especially for time-saving active functions, which can improve outcomes. Health systems must prioritize design/usability as a factor to counter LEP underuse.

Abstract IA02: Ensuring diversity in precision medicine initiatives: Where are we now and what are we doing?

Abstract Precision medicine uses information about a person's genes, proteins, and environment to prevent, diagnose, and treat disease. The Precision Medicine Initiative (PMI) was launched by President Obama, with the goal of accelerating cancer discoveries. Although this initiative promises to result in substantial scientific advances, questions remain as to how members from diverse communities in the United States will become involved and benefit from discoveries resulting from the PMI. Participation of racial/ethnic, low-income, and rural populations in biospecimen and data sharing is vital to the success of the PMI. As part of the PMI, in his final State of the Union address, President Obama asked Vice President Biden to lead a new national effort to end cancer as we know it, now called the Beau Biden Cancer Moonshot Initiative. Recommendations from the Cancer Moonshot's Blue Ribbon Panel (BRP) attempt to ensure that traditionally under-represented populations benefit from the substantial discoveries that will be made through this landmark initiative. In doing so, the BRP identified cancer disparities as a cross-cutting and important theme, highlighting that disparities go beyond race and ethnicity to include individuals from urban and rural areas who are poor and medically underserved. It is imperative that all precision medicine efforts, including the exciting All of Us Research Program, ensure representation of underserved communities. The continued demographic shift in the United States population is projected to result in a majority-minority distribution by 2043. However, to date, there is marked under-representation of racial/ethnic minority groups in clinical trials and biospecimen banks. To address this inequity, an understanding of how to best include and engage individuals from traditionally under-represented groups will be required. Partnerships between academic institutions and safety-net health care settings offer an important strategy for enhancing participation of diverse racial/ethnic groups and underserved individuals. These partnerships will ensure that medically underserved and rural populations benefit from the exciting discoveries that are yet to come from precision medicine and help prevent false discoveries that result from sampling from a homogeneous population. In this session, the All of Us Program's goals, recruitment status, and initiatives to build trust and engage with community partners to ensure diverse representation will be presented. A presentation from a federally qualified health center will provide insights on important contributions that are possible by engaging with safety-net clinic settings to ensure representation of medically underserved communities. The advocate's perspective will address building community trust and provide a blueprint for engaging communities in precision medicine efforts. Citation Format: Elena Martinez. Ensuring diversity in precision medicine initiatives: Where are we now and what are we doing? [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr IA02.

Hospitalization and Critical Illness in Chronic Kidney Disease

Background: Patients with chronic kidney disease (CKD) who are hospitalized with a critical illness are at increased risk for adverse outcomes. We studied the predictors of hospitalization with critical illness among patients with non-dialysis-dependent CKD stages 3 and 4 in a safety-net healthcare setting. Methods: A retrospective cohort study was conducted among patients ≥18 years of age with CKD stages 3 and 4 using a CKD registry from a safety-net healthcare system. Hospitalizations with critical illness were identified among patients requiring nonelective admission or transfer to the intermediate or intensive care unit during a 3-year period after the diagnosis of CKD. Poisson regression was used to determine associations between baseline characteristics and hospitalization requiring intermediate or intensive care among all CKD patients and in those with different stages of CKD. Outcomes of these hospitalizations were also tabulated. Results: Among 8,302 patients with CKD stages 3 and 4, 1,298 were hospitalized and 495 required intermediate or intensive care during a 3-year follow-up period. In the adjusted analysis, advanced CKD, Hispanics (incident rate ratio [IRR]: 1.88), non-Hispanic Blacks (IRR: 1.48), presence of congestive heart failure (IRR: 2.09), cardiovascular disease (IRR: 1.57), chronic pulmonary disease (IRR: 1.60), liver disease, malignancy, and anemia were associated with higher risk of hospitalization requiring intermediate or intensive care. The association of age, gender, race/ethnicity, congestive heart failure, anemia, and body mass index with hospitalization requiring intermediate or intensive care differed significantly by CKD stage (p value for interaction term <0.05). Congestive heart failure and severity of anemia were associated with a higher risk of hospitalization requiring intermediate or intensive care among patients with mild CKD, and the magnitude of association attenuated among patients with advanced CKD. Conclusions: The burden of hospitalization with critical illness among patients with non-dialysis-dependent CKD stages 3 and 4 remains high and was associated with demographic factors and comorbid medical conditions, especially among those with congestive heart failure and cardiovascular disease. Targeted, effective interventions to reduce the burden of hospitalization and critical illness in CKD patients within safety-net healthcare systems are needed.

Patients' self-reported barriers to colon cancer screening in federally qualified health center settings.

Colorectal cancer (CRC) is a leading cause of cancer-related death in the United States. Despite evidence that screening reduces CRC incidence and mortality, only about 60% of age-eligible adults are up-to-date on CRC screening. This analysis aims to identify self-reported barriers to CRC screening among patients in a safety-net healthcare setting.Participants were recruited from safety-net primary care sites that were participating in a trial to increase CRC screening. At baseline, patients (n = 483) completed self-report surveys that assessed demographics, healthcare and CRC screening. Barriers to CRC screening were assessed through an open-ended question. Using a basic text analysis, data were coded and organized into key topics.Overall, 65.2% ever had CRC screening; 46.4% were up-to-date. Of those who described barriers (n = 198), 22.9% said they were not due for screening or their provider had not recommended it. Other common barriers included fear or worry about the procedure or outcome, financial challenges such as lack of insurance or cost of testing, and logistic challenges such as transportation and time. Fewer said that screening was of low importance or mentioned discomfort with the procedure or colonoscopy preparation.In this safety-net setting, CRC screening rates were lower than national rates. These qualitative results are similar to quantitative findings reported in the literature but the qualitative data add to our understanding of patient-reported concerns and challenges faced by safety-net patients. These results may be applied to developing targeting communication or intervention strategies to improve CRC screening rates within safety-net health centers.

Access to care, nativity and disease management among Latinos with diabetes in a safety-net healthcare setting.

IntroductionLatinos in the U.S. are disproportionately affected by diabetes and its complications. The role of access to care and nativity in diabetes management are important areas of research, as these findings can help direct tailored interventions.MethodsWe examined associations between access to care, acculturation and glycemic control among Latino patients with diabetes seen in a safety net emergency department. We used regression models to estimate the individual predictors' associations with glycemic control and then estimated adjusted associations by controlling for all relevant predictors. We tested for a moderating role of nativity in the associations between access to care and glycemic control.ResultsIn unadjusted analysis, we found the most significant predictors of glycemic control to be access to primary care (β = −0.89, p = 0.011), capacity for self-monitoring glucose (β = −0.68, p = 0.022), mental health comorbidities (β = 0.95, p = 0.013), male gender (β = −0.49, p = 0.091) and nativity (β = −0.81, p = 0.034). In adjusted analysis, nativity was no longer a significant predictor of glycemic control (β = −0.32, p = 0.541). Nativity did not significantly moderate the association of access to care and glycemic control.ConclusionsOur findings show a direct association between access to care and glycemic control among low-income Latinos seeking care in the emergency department. This supports concerns that many researchers, clinicians and policy analysts have expressed regarding access to care for immigrants. The importance of primary care and access to supplies to perform self-management in achieving glycemic control and reducing risk of complications indicate that ensuring access to quality care is critical to the health of this vulnerable group.

Innovative Implementation Studies Conducted in US Safety Net Health Care Settings: A Systematic Review.

Little is known about dissemination and implementation in safety net settings. The authors conducted a literature review of innovation/implementation studies in US safety net health care settings between 2008 and 2017. Each article was coded for (1) intervention characteristics, (2) implementation stage, (3) internal versus external ownership, and (4) prespecified implementation outcomes (eg, acceptability and fidelity). Twenty studies were identified; the majority were implemented within community clinics or integrated safety net systems (15 articles), most involved care process improvements (13 articles), and most were internally developed (13 articles). The internally developed innovations reported fewer barriers to acceptability among staff/providers, higher leadership involvement and organizational alignment, greater amounts of customization to the local setting, and better sustainment. Future work should harness the high levels of alignment and acceptability in implementation research within safety net settings, with an eye toward maintaining fidelity to facilitate dissemination across sites.

Race analysis in an African American sample with serious mental illness and comorbid diabetes.

Targeted Training in Illness Management (TTIM) focuses on enhancing care engagement for people living with serious mental illness and diabetes. This secondary analysis from a 60-week, randomized controlled trial of TTIM versus treatment as usual evaluated racial subgroup outcomes. Demographics, clinical characteristics, and diabetes status were evaluated for those self-identifying as non-Hispanic White, African American, and Hispanic. Longitudinal response to TTIM was evaluated using a multiple domain risk index. Due to their small sample size; those identifying as Hispanic were excluded from this analysis. Non-Hispanic White participants had greater baseline socioeconomic advantages. Baseline risk scores, glycosylated hemoglobin (HbA1c) values, and HbA1c differences over time were similar for African American and non-Hispanic White participants. African American participants living with serious mental illness and diabetes receiving TTIM did as well as non-Hispanic White participants. Inclusive approaches that feature peer support and are situated in safety-net health care settings need to be further investigated with respect to potentially impacting health disparities. (PsycINFO Database Record