Safety Net Health Care System Research Articles

Improving Identification of Patients Experiencing Homelessness in the Electronic Health Record: A Curated Registry Approach.

Identification of persons experiencing homelessness (PEH) within healthcare systems is critical to facilitate patient and population-level interventions to address health inequities. We created an enhanced electronic health record (EHR) registry to improve identification of PEH within a safety net healthcare system. We compared patients identified as experiencing homelessness in 2021, stratified by method of identification (i.e., through registration data sources versus through new EHR registry criteria). Sociodemographic and clinical characteristics, healthcare utilization, engagement with homeless service providers, and mortality. In total, 10,896 patients met the registry definition of a PEH; 30% more than identified through standard registration processes; 78% were identified through only one data source. Compared with those identified only through registration data, PEH identified through new registry criteria were more likely to be female (42% vs. 25%, p < 0.001), Hispanic/Latinx or Black/African American (30% versus 25% and 25% vs. 18%, p < 0.0001), and Medicaid or Medicare beneficiaries (74% vs. 67% and 16% vs.10%, respectively, p < 0.0001). New data sources also identified a higher proportion of patients: at extremes of age (16% < 18years and 9% ≥ 65years vs. 2% and 5%, respectively, p < 0.0001), with increased clinical risk (31% with CRG 6-9 vs. 18%, p < 0.0001), and with a mental health diagnosis (56% vs. 42%, p < 0.0001), and a lower proportion of patients with a substance use diagnosis (39% vs. 54%, p < 0.0001) or criminaljustice involvement (8% vs. 15%, p < 0.0001). Newly identified patients were more likely to be engaged in primary care (OR 2.03, 95% CI 1.83-2.26) but less likely to be engaged with homeless service providers (OR 0.70, 95% CI 0.63-0.77). Commonly utilized methods of identifying PEH within healthcare systems may underestimate the population and introduce reporting biases. Recognizing alternate identification methods may more comprehensively and inclusively identify PEH for intervention.

Identification and Treatment of Lung Cancer Oncogenic Drivers in a Diverse Safety Net Setting

IntroductionAdvances in the testing and treatment of patients with non-small cell lung cancer (NSCLC) harboring oncogenic drivers have improved outcomes. Little is known about testing and treatment patterns in diverse patient populations. MethodsWe conducted a retrospective study in a diverse cohort of patients treated in the John Peter Smith safety net healthcare system. We determined patterns of blood- and tissue-based testing and treatment of patients with EGFR and ALK alterations. Cox proportional-hazards regression models were used to assess the impact of EGFR and ALK testing. ResultsA total of 220 patients were included, 97 (44%) were non-Hispanic White, 72 (33%) were Black, 28 (13%) were Hispanic, and 23 (10%) were Asian. EGFR and ALK testing increased over time from 55% and 52%, respectively, in 2017 to 87% and 82%, respectively, in 2021. Frequency of EGFR alterations were highest in Asian patients (45%) and comparable among other groups (6-13%). Frequency of ALK alterations were highest in Hispanic (13%), and Asian (11%) patients, and were 2% for both Black and non-Hispanic White patients. In a multivariate model, lack of testing was associated with worse survival (aHR 1.6; P = .003) and testing positive for EGFR (aHR 0.43; P = .01) or ALK (aHR 0.28; P = .04) was associated with improved survival. Race and ethnicity were not associated with survival differences. ConclusionAs molecular testing for oncogenic mutations in NSCLC increases, druggable alterations such as ALK and EGFR can be identified in all race-ethnicity groups and are associated with improved outcomes.

Implementation of universal screening for substance use in pregnancy in a public healthcare system

ObjectiveScreening questionnaires are one option for identification of at-risk substance use and substance use disorder (SUD) during pregnancy. We report the experience of a single institution following universal implementation of a brief screening tool for self-reported substance use at the first prenatal encounter. Study DesignThis is a prospective implementation study evaluating screening for substance use in pregnancy in a large safety net healthcare system. Universal screening with the National Institute of Drug Abuse (NIDA) Quick Screen V1.0 was integrated into the electronic medical record (EMR) and administered at the first point of contact with the healthcare system. SUD was identified initially with diagnosis within the EMR by a healthcare provider and was confirmed with toxicology (maternal or neonatal) results corroborating a pattern of substance use and maternal and neonatal ICD-10 codes for SUD. Patients identified with SUD were then classified as moderate or severe SUD based on criteria established by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. We measured rates of NIDA implementation across different healthcare settings, evaluated NIDA concordance with ascertainment of SUD, and compared adverse pregnancy outcomes associated with moderate and severe SUD. ResultsFrom July 28, 2021, through June 25, 2022, 14,634 unique pregnant individuals accessed care at ambulatory and acute care sites. Universal implementation of the NIDA Quick Screen identified at-risk substance use in 2146 (14.7%) of those who accessed our system, or 17.1% of 12,550 screened across the system, with greater screen completion in ambulatory over acute care settings. SUD was identified in 256 (1.7%) of 14,634 individuals and moderate or severe SUD was identified in 184 (1.3%). Among those with moderate or severe SUD, 90 (48.9%) were NIDA positive, 22 (12.0%) NIDA negative, and 72 (39.1%) unscreened. Of 94 individuals with NIDA discordance or who were unscreened 76 (81%) accessed initial care through an acute care setting. Of 96 individuals with opioid use disorder, 68 (70.8%) were treated with medication-assisted therapy, and 56 (58.3%) were screened with the NIDA Quick Screen. Among delivered individuals with available outcomes, those with moderate or severe SUD were less likely to seek prenatal care (71 (76%) vs 9852 (98%), <0.001)) and more likely to deliver before 37 weeks, (18 (20%) vs 909 (9%), RR (95% CI) 2.13 (1.40, 3.24)) compared to individuals without SUD. Neonates exposed to moderate or severe SUD were more likely to have birth weight <10th centile for gestational age (20 (22%) vs 1147 (12%), RR (95% CI) 1.92 (1.29, 2.85)) and require admission to the neonatal intensive care unit (NICU) (19 (21%) vs 964 (10%), RR (95%) 1.95 (1.30, 2.93)). ConclusionUniversal screening was implemented across a large public healthcare system at a high rate, with higher rates of implementation in ambulatory settings. NIDA successfully identified at-risk substance use in 17% of the SUD cohort but failed to identify more than 50% of patients with moderate or severe SUD. Patients with moderate and severe SUD accessed care primarily through the emergency department and experienced higher rates of adverse obstetric and neonatal outcomes. Future efforts to identify, engage, and retain this highest-risk group are needed.

Using a Built-in Clinical Decision Support to Improve Phosphate Repletion Practice: A Quasi-Experimental Study

BackgroundInpatient serum phosphate replacement is common, but there is great variability in replacement practice, which leads to overuse. Electronic medical record (EMR) interventions with clinical decision support (CDS) can be effective tools to guide clinicians towards best clinical practices. Our objective was to utilize CDS tools to reduce overuse of hypophosphatemia corrections at a large safety-net healthcare system. MethodsOur first intervention involved enhancing an existing order set for phosphate repletion by incorporating CDS to guide appropriate repletion orders based on deficit severity and simplifying ordering. The second intervention was a best practice advisory (BPA) that triggered when an intravenous (IV) phosphate repletion was ordered for a patient with mild to moderate phosphate deficiency without an existing nil per os (NPO) order. The primary outcome measure was the number of patients with mild and moderate hypophosphatemia receiving IV replacement without NPO orders per 1000 patient days. ResultsAcross all hospitals, rate of IV replacement in patients with mild to moderate hypophosphatemia (1.0 to 1.9 mg/dL) without NPO orders decreased from 7.22 to 3.40 per 1000 patient days (53.0% reduction, p<0.001), while the oral replacements in this population increased from 6.39 to 8.87 (38.8% increase, p<0.001). For patients with phosphate levels ≥2.0, IV replacements decreased from 10.66 to 5.36 (49.8% reduction, p<0.001) and oral replacements decreased 19.78 to 16.69 (15.6% reduction, p<0.01). ConclusionsOur intervention successfully reduced inpatient IV phosphate replacements by 53% in patients with mild to moderate hypophosphatemia using a two-pronged electronic health record intervention across a large safety net setting.

The effect of mailed outreach on FIT completion among patients aged 45-50 in a safety net healthcare system.

Colorectal cancer screening is recommended starting at age 45, but there has been little research on strategies to promote screening in patients younger than 50. An outreach program quasi-randomly assigned patients aged 45-50 without recent fecal immunochemical test (FIT), colonoscopy or contraindications to screening to two intervention arms: electronic outreach with email and text (electronic outreach only)versus electronic outreach plus mailed outreach with FIT, an instructional letter and a prepaid return envelope (mailed + electronic outreach). In response to known disparities in screening uptake, all Black patients were assigned to receive mailed + electronic outreach. Among patients quasi-randomly assigned to an intervention (non-Black patients), the 180-day FIT completion rate was 18.8% in the electronic outreach only group (n = 1,318) and 25.0% in the mailed + electronic outreach group (n = 1,364) (difference 6.2% [95% CI 3.0, 9.4]). FIT completion was 16.6% among Black patients (n = 469), 8.4% (95% CI 4.1, 12.6) lower than among non-Black patients also assigned to mailed + electronic outreach. Among patients aged 45-50, mailed + electronic outreach had a greater effect on FIT completion than electronic outreach alone. Crossover between intervention groups likely lead to an underestimation of the effect of mailed outreach.

Implementing team-based telemedicine workflows in safety-net primary care.

Challenges in implementing telemedicine disproportionately affect patients served in safety-net settings. Few studies have elucidated pragmatic, team-based strategies for successful telemedicine implementation in primary care, especially with a safety-net population. We conducted in-depth, semistructured qualitative interviews with primary care clinicians and staff in a large urban safety-net health care system on the facilitators, challenges, and impact of implementing team workflows for synchronous telemedicine video and audio-only visits. Interviews were analyzed using modified grounded theory with multistage coding. Common themes were identified and reviewed to describe within-group and between-group variations. We used the Practical, Robust Implementation Sustainability Model framework to organize the final themes with an implementation science lens. Four themes emerged from 11 interviews: (1) having a dedicated individual preparing patients for video visits is a prerequisite for the successful introduction of video visits to patients with limited digital literacy; (2) health care maintenance during video and audio-only visits benefits from standardized workflows and communication; (3) the increased flexibility and accessibility of telemedicine visits were perceived benefits to patient care, despite barriers for subsets of patients; and (4) telemedicine visits generally have a positive impact on work experience for clinicians and staff due to increased efficiency, despite audio-only visits feeling less engaging. Understanding how to strategically use team-based workflows to expand video visit access while ensuring care quality of all telemedicine visits will allow primary care practices to maximize telemedicine's benefits to patients in the safety-net setting.

Geographic Accessibility and Completion of Initial Low-Dose CT-Based Lung Cancer Screening in an Urban Safety-Net Population.

Recent modifications to low-dose CT (LDCT)-based lung cancer screening guidelines increase the number of eligible individuals, particularly among racial and ethnic minorities. Because these populations disproportionately live in metropolitan areas, we analyzed the association between travel time and initial LDCT completion within an integrated, urban safety-net health care system. Using Esri's StreetMap Premium, OpenStreetMap, and the r5r package in R, we determined projected private vehicle and public transportation travel times between patient residence and the screening facility for LDCT ordered in March 2017 through December 2022 at Parkland Memorial Hospital in Dallas, Texas. We characterized associations between travel time and LDCT completion in univariable and multivariable analyses. We tested these associations in a simulation of 10,000 permutations of private vehicle and public transportation distribution. A total of 2,287 patients were included in the analysis, of whom 1,553 (68%) completed the initial ordered LDCT. Mean age was 63 years, and 73% were underrepresented minorities. Median travel time from patient residence to the LDCT screening facility was 17 minutes by private vehicle and 67 minutes by public transportation. There was a small difference in travel time to the LDCT screening facility by public transportation for patients who completed LDCT versus those who did not (67 vs 66 min, respectively; P=.04) but no difference in travel time by private vehicle for these patients (17 min for both; P=.67). In multivariable analysis, LDCT completion was not associated with projected travel time to the LDCT facility by private vehicle (odds ratio, 1.01; 95% CI, 0.82-1.25) or public transportation (odds ratio, 1.14; 95% CI, 0.89-1.44). Similar results were noted across travel-type permutations. Black individuals were 29% less likely to complete LDCT screening compared with White individuals. In an urban population comprising predominantly underrepresented minorities, projected travel time is not associated with initial LDCT completion in an integrated health care system. Other reasons for differences in LDCT completion warrant investigation.

Culturally Sensitive Advance Care Planning for African American Advanced Cancer Patients: A Pilot Randomized Controlled Trial

ContextRacial disparities in advance care planning (ACP) have been consistently identified in the literature. Few interventions have been designed to address the disparities identified. ObjectivesTo assess the feasibility, acceptability, and preliminary efficacy of a culturally sensitive, pilot ACP intervention for African American patients diagnosed with cancer in a safety net healthcare system. MethodsEligible patients with stage II, III, or IV breast, lung, colorectal, or prostate cancer were identified from the electronic health record, recruited, and randomized to the intervention group or usual care control group. Intervention participants met with an African American lay health advisor who assisted them in watching a video that addressed completion of ACP and facilitated ACP discussion. Descriptive analyses were conducted to examine baseline sociodemographic and clinical characteristics, cancer health literacy, and religious coping among participants. Logistic regression analyses were conducted to evaluate predictors of positive change in stage of intent to discuss ACP at 1, 3, and 6-months post intervention. ResultsSeventy-six participants were recruited and randomized (38 intervention, 38 controls). The mean age for participants was 58.8 years (SD 10.8), 62.5% were female, and 90.2% had stage III or IV disease. The intervention proved feasible with 89.5% completion. Intervention participants were more likely to have a positive change in stage of intent to discuss a living will or advance directive than usual care controls at one-month (AOR: 4.57, 95%CI: 1.11, 18.82) and 3-months (AOR: 5.38, 95%CI: 1.05, 27.68) post-intervention. The majority (94.1%) of intervention participants would recommend the intervention to a friend or family member. ConclusionThis culturally sensitive ACP program proved to be feasible, acceptable to participants, and showed some promise in promoting discussion about ACP among participants and members of their healthcare team.

Social Determinants of Health and Satisfaction With Sources of Information About COVID-19 Related to Vaccine Uptake in a Safety Net Healthcare System.

Vaccination is a critical tool to combat the COVID-19 pandemic. Yet, vaccine uptake varies across communities and is often affected by sociodemographic factors and accessibility. This article outlines a pilot study aimed to examine factors associated with COVID-19 patients within one of the nation's largest safety net healthcare systems. A cross-sectional survey design was conducted with adults over 18 years of age eligible to receive the COVID-19 vaccine. Descriptive analysis of survey data collected in 2021-2022 was employed. Unconditional and multivariate logistic regression analyses were conducted to examine associations between sociodemographics, social factors, and COVID-19 vaccine uptake. Study participants ( N = 280) were a diverse patient population, primarily low-income and majority Hispanic/Latinx, with low education levels, but with a high level of COVID-19 vaccine uptake and a high rate of intent to vaccinate again. Approximately 22% report having unstable housing, and 46% experiencing food insecurity. Most trusted sources for COVID-19 data included mainstream media, including TV, radio, and newspapers, and friends, family, or other informal networks. We found that respondents who were satisfied or very satisfied with COVID-19 information received from healthcare providers or the government had higher odds of vaccine uptake rates. These findings highlight the critical role of access to the COVID-19 vaccine and sources of information as an independent factor in COVID-19 vaccine uptake among patients within a safety net healthcare system. This study expands the literature on COVID-19 vaccine uptake, particularly in an underresourced region of the South Los Angeles community. Future research is needed to better understand the mechanisms between social determinants of health, perceived discrimination, and vaccine uptake.

Uptake of a Multilingual Intervention to Promote Toothbrushing in a Safety-Net Health Care System.

Uptake of a Multilingual Intervention to Promote Toothbrushing in a Safety-Net Health Care System.

A collaboration team to build social service partnerships within a safety-net health system

BackgroundTo facilitate safety-net healthcare system partnerships with community social service providers, the Los Angeles County Department of Health Services (LAC DHS) created a new collaboration team to spur cross-agency social and medical referral networks and engage communities affected by health disparities as part of a Sect. 1115 Medicaid waiver in Los Angeles County entitled Whole Person Care-Los Angeles (WPC-LA).MethodsThis observational research reviews three years of collaboration team implementation (2018–2020) through Medicaid-reportable engagement reports, a collaboration team qualitative survey on challenges, facilitators, and recommendations for community engagement. Member reflections for survey findings were conducted with the collaboration team and LAC DHS WPC-LA leadership.ResultsCollaboration team Medicaid engagement reports (n = 144) reported > 2,700 events, reaching > 70,000 individuals through cross-agency and community-partnered meetings. The collaboration team survey (n = 9) and member reflection sessions portrayed engagement processes through outreach, service assessments, and facilitation of service partnerships. The collaboration team facilitated community engagement processes through countywide workgroups on justice-system diversion and African American infant and maternal health. Recommendations for future safety net health system engagement processes included assessing health system readiness for community engagement and identifying strategies to build mutually beneficial social service partnerships.ConclusionsA dedicated collaboration team allowed for bi-directional knowledge exchange between county services, populations with lived experience, and social services, identifying service gaps and recommendations. Engagement with communities affected by health disparities resulted in health system policy recommendations and changes.

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.

The Impact of the COVID-19 Pandemic on Food Access: Insights from First-Person Accounts in a Safety-Net Health Care System

Abstract: The COVID-19 pandemic disproportionately affected populations that were already facing socioeconomic disadvantages and limited access to health care services. The livelihood of millions was further compromised when strict shelter-in-place measures forced them out of their jobs. The way that individuals accessed food during the early stages of the COVID-19 pandemic drastically changed as a result of declines in household income, food chain supply disruptions, and social distance measures. This qualitative study examined the food access experiences of participants enrolled in a safety-net health care system-based, free, monthly fruit and vegetable market in the Metro Boston area during the first six months of the COVID-19 pandemic. The findings offer rich qualitative information to understand the financial repercussions of the pandemic on food access.

Telehepatology Satisfaction Is Associated with Ethnicity: The Real-World Experience of a Vulnerable Population with Fatty Liver Disease.

Since the coronavirus disease 2019 (COVID-19) pandemic began, telemedicine use has transformed healthcare delivery. Yet there is concern that telemedicine may widen care disparities for vulnerable populations, and patient experience data are limited. We aimed to assess patient satisfaction with hepatology-related telemedicine (telehepatology) for delivery of fatty liver disease (FLD) care in a safety-net healthcare system. Adult patients with FLD were surveyed regarding satisfaction with telehepatology. Clinical, demographic, resources, and social determinants of health (SDoH) data were collected to identify factors associated with satisfaction through multivariable modeling. From June 2020 to March 2022, 220 participants were enrolled: the median age was 52years, 37% were men, and 68% were Hispanic. One hundred nineteen (54%) had prior telehepatology experience. Overall, satisfaction was high; 70% reported being somewhat or very satisfied. On univariate analysis, Hispanic ethnicity (versus non-Hispanic, OR 0.34, 95% CI 0.1-0.9, p = 0.03) and limited access to personal cellphone/internet (OR 0.16, 95% CI 0.04-0.6, p = 0.01) were associated with lower satisfaction. On multivariable logistic regression modeling adjusted for pandemic duration, age, sex, severity of liver disease, and coexisting liver disease, Hispanic ethnicity and lack of personal cellphone/internet remained independently associated with lower telehepatology satisfaction (OR 0.24, 95% CI 0.07-0.9, p = 0.03 and OR 0.2, 95% CI 0.04-0.9, p = 0.04, respectively). The association remained statistically significant after inclusion of various SDoH in the multivariable model. Satisfaction with telehepatology among FLD patients in a safety-net clinical setting was high overall. However, Hispanic ethnicity and lack of personal cellphone/internet were independently associated with lower telehepatology satisfaction. A better understanding of patients' experience with telehepatology is needed to identify reasons for dissatisfaction, and in-person visits should remain an option for patients to ensure equitable care.

Safety-Net Primary Care and Endocrinology Clinicians’ Knowledge and Perspectives on Screening for Nonalcoholic Fatty Liver Disease: A Mixed-Methods Evaluation

ObjectiveClinical guidelines have expanded the indications for nonalcoholic fatty liver disease (NAFLD) screening to type 2 diabetes mellitus and obesity, which are conditions common in populations who receive care in urban safety-net settings. This study aimed to evaluate safety-net primary care and endocrinology clinicians’ knowledge of NAFLD, determine barriers and facilitators to screening, and examine perspectives on the use of electronic health record tools for risk assessment. MethodsSequential explanatory mixed methods using survey and qualitative interviews with primary care, primary care subspecialty, and endocrinology clinicians in an urban safety-net health care system. ResultsA total of 109 participants completed the survey (36.5% response rate), and 13 participated in interviews. Most respondents underestimated or did not know the prevalence of NAFLD (68%), did not use the recommended noninvasive tests for risk stratification (65%), and few were comfortable with screening for (27%) or managing (17%) NAFLD. Endocrinologists had greater knowledge of risk factors but lower rates of comfort and more often felt that screening was not their responsibility. The qualitative themes included the following: (1) lack of knowledge about screening, (2) concern for underdiagnosing NAFLD, (3) perception of severity impacts beliefs about screening, (4) screening should occur in primary care but is not normative practice, (5) concerns exist about benefit, (6) competing demands with a complex population hinder screening, and (7) a need for easier ways to integrate screening into practice. ConclusionKnowledge gaps may hamper uptake of new guidelines for NAFLD screening in primary care and endocrinology clinics in an urban safety-net health care system. Implementation strategies focused on training and educating clinicians and informed by behavioral economics may increase screening.

A Roadmap to Integrating Dermatologic Care at a Student-Run Free Health Clinic

Student-run free health clinics (SRFCs) play an important role in providing a safety net healthcare system for uninsured patients by offering primary healthcare or preventative medical services. Patients at free clinics may have to be referred out for medical complaints better managed with specialty care. Integrating these services at SRFCs can address barriers to accessing specialty care. Free dermatologic care offers an opportunity to provide care to patients who may otherwise ignore symptoms, which can lead to reduced quality of life and a worse prognosis in some conditions. We detail a roadmap to integrate dermatologic services at an SRFC by providing operational considerations such as assessing needs, developing a clinical workflow, engaging dermatologists and the community, and sustaining student involvement. We also discuss the potential for a dermatology clinic to foster interest in the specialty among students underrepresented in medicine, given the current call to action to increase racial and ethnic diversity in the dermatologic workforce.

A virtual recruitment protocol promotes enrollment of underrepresented groups in a diabetes prevention trial.

Strategies are needed to ensure greater participation of underrepresented groups in diabetes research. We examined the impact of a remote study protocol on enrollment in diabetes research, specifically the Pre-NDPP clinical trial. Recruitment was conducted among 2807 diverse patients in a safety-net healthcare system. Results indicated three-fold greater odds of enrolling in remote versus in-person protocols (AOR 2.90; P < 0.001 [95% CI 2.29-3.67]). Priority populations with significantly higher enrollment included Latinx and Black individuals, Spanish speakers, and individuals who had Medicaid or were uninsured. A remote study design may promote overall recruitment into clinical trials, while effectively supporting enrollment of underrepresented groups.

Understanding Primary Care Physician Perspectives on the Diagnosis and Management of Non-Alcoholic Fatty Liver Disease: A Qualitative Study.

Primary care physicians (PCPs) are well suited to manage patients with non-alcoholic fatty liver disease (NAFLD), but the limited, existing research suggests inadequate knowledge about the natural history, diagnostic methods, and management of NAFLD. The purpose of this qualitative study is to further understand the knowledge and practices for the diagnosis and management of NAFLD among PCPs. We conducted in-depth interviews with PCPs in the Greater Houston area, addressing current clinical practices used for diagnosing and managing NAFLD, as well as the perceptions of the PCPs regarding the burden of NAFLD on patients. We recorded interviews, transcribed them, coded transcripts, and identified patterns and themes. The interviewed PCPs (n = 16) were from internal or family medicine, with a range of experience (1.5-30 years). We found variations in NAFLD diagnosis and management across practices and by insurance status. Patients with abnormal liver imaging who had insurance or were within a safety-net healthcare system were referred by PCPs to specialists. Uninsured patients with persistently elevated liver enzymes received lifestyle recommendations from PCPs without confirmatory imaging or specialist referral. The role of PCPs in NAFLD management varied, with some helping patients set dietary and physical activity goals while others provided only general recommendations and/or referred patients to a dietitian. The diagnosis and management of NAFLD vary widely among PCPs and may be impacted by patients' insurance status and clinic-specific practices. The increasing burden of NAFLD in the U.S. medical system highlights the need for more PCPs involvement in managing NAFLD.

Community and Healthcare Perspectives on Implementing Hypertension Interventions for a Multiethnic Safety-Net Population.

To synthesize community and healthcare informants' perspectives on contextual considerations and tailoring recommendations for high-quality, sustainable implementation of evidence-based practices (EBPs) for managing hypertension (HTN) in a multiethnic safety-net population. Structured focus-group discussions and semistructured qualitative interviews. High-quality, sustainable implementation of HTN-related EBPs can promote equitable care. Implementation challenges extend beyond individual patients to span multiple levels of context. Few studies have systematically engaged community and healthcare perspectives to inform the design of HTN intervention trials. A large safety-net healthcare system. We conducted four structured discussions with each of five race- or ethnicity-specific community action boards (CABs) to understand community members' HTN-related norms, assets, needs, and experiences across local healthcare systems. We interviewed 41 personnel with diverse roles in our partnered healthcare system to understand the system's HTN-related strengths and needs. We solicited EBP tailoring recommendations from both groups. We summarized the findings using rapid content analysis. Participants identified contextual considerations spanning seven themes: social determinants, healthcare engagement, clinical interaction, system operations, standardization, patient education, and partnerships and funding. They offered tailoring recommendations spanning nine themes: addressing complex contexts, addressing social needs, system operations, healthcare system training and resources, linguistic and cultural tailoring, behavioral engagement, relational engagement, illness-course engagement, and community partnerships. Engaging community and healthcare informants can ground implementation in the policy, community, healthcare system, clinical, and interpersonal contexts surrounding diverse patients at risk for disparities. Such grounding can reframe inequitable implementation as a multilevel social problem facing communities and healthcare systems, rather than individuals.

1817. Skin and Soft Tissue Infection Incidence Before and During the COVID-19 Pandemic at A Large Safety Net Healthcare System

Abstract Background Skin and Soft Tissue Infections (SSTIs) are one of the most common bacterial infections that drive persons to seek medical care. We hypothesized that during the COVID-19 pandemic, SSTI rates would significantly decrease due to Public Health directives to avoid unneeded care and due to attenuated risk behaviors, such as skin injury and person to person contact, that drive SSTIs. Methods We performed a health system wide retrospective study using databases from the Los Angeles Department of Health Services, the second largest U.S. safety net healthcare system which is composed of 4 major medical centers and 20 clinics and ambulatory care centers. We examined all patients who had ≥1 medical encounter (inpatient, Emergency Department [ED], outpatient, or observation) for an SSTI. SSTIs were identified using ICD-10 diagnosis code between March 16, 2017 and March 15, 2022. Pre-pandemic and intra-pandemic SSTI rates were compared using a student’s t-test. Results During the study period there was a mean of 426,995 empaneled of patients per month. In total there were 72,218 SSTIs, 36,167 in the outpatient setting, 21,035 in the ED, 1143 in the observation unit, and 13,433 in the inpatient setting. Intra-pandemic SSTI rate was significantly lower than pre-pandemic (2.3 cases/1000 empaneled patient-months versus 3.3 cases/1000 empaneled patient-months, p&amp;lt; 0.0001). SSTI subgroups stratified by site of care all had significant SSTI decreases between the intra-pandemic and pre-pandemic time periods (inpatient (0.5 vs 0.6 empaneled patient-months), observation unit (0.05 vs 0.07), ED (0.6 vs 1.0), and outpatient clinics (1.2 vs 1.6), p&amp;lt; 0.0001 for all comparisons, see Figure). Skin and Soft Tissue Infection Rates Pre- and Intra- COVID-19 Pandemic Conclusion Compared to the pre-COVID-19 pandemic period, SSTI rates in our large U.S. safety net healthcare system significantly decreased by over 30% during the COVID-19 pandemic. Decreases occurred at all levels of care delivery. Whether the results of this study reflect a true reduction in SSTI incidence rates or a reduction in health system utilization for SSTIs requires further examination. Our data provide some insights as to expected changes in common bacterial infections during subsequent pandemics. Disclosures Loren G. Miller, MD MPH, ContraFect: Grant/Research Support|GSK: Grant/Research Support|Medline: Grant/Research Support|Merck: Grant/Research Support|Paratek: Grant/Research Support