Safety Net Health Care System Research Articles

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 Health Care 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 paper outlines a pilot study aimed to examine factors associated with COVID-19 patients within one of the nation's largest safety net health care systems. A cross-sectional survey design was conducted with adults over 18 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 health care 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 health care system. This study expands the literature on COVID-19 vaccine uptake, particularly in an under-resourced 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

Objective 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. Design Structured focus-group discussions and semistructured qualitative interviews. Background 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. Setting A large safety-net healthcare system. Participants/Methods 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. Results 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. Conclusions 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

No health without access: using a retrospective cohort to model a care continuum for people released from prison at an urban, safety net health system

BackgroundRelease from prison is characterized by discontinuity of healthcare services and results in poor health outcomes, including an increase in mortality. Institutions capable of addressing this gap in care seldom collaborate in comprehensive, data-driven transition of care planning. This study harnesses information from a data exchange between correctional facilities and community-based healthcare agencies in Colorado to model a care continuum after release from prison.MethodsWe merged records from Denver Health (DH), an urban safety-net healthcare system, and the Colorado Department of Corrections (CDOC), for people released from January 1 to June 30, 2021. The study population was either (a) released to the Denver metro area (Denver and its five neighboring counties), or (b) assigned to the DH Regional Accountable Entity, or (c) assigned to the DH medical home based on Colorado Department of Healthcare Policy and Financing attribution methods. Outcomes explored were outpatient, acute care, and inpatient utilization in the first 180 days after release. We used Pearson’s chi-squared tests or Fisher exact for univariate comparisons and logistic regression for multivariable analysis.ResultsThe care continuum describes the healthcare utilization at DH by people released from CDOC. From January 1, 2021, to June 30, 2021, 3242 people were released from CDOC and 2848 were included in the data exchange. 905 individuals of the 2848 were released to the Denver metro area or attributed to DH. In the study population of 905, 78.1% had a chronic medical or psychological condition. Within 180 days of release, 31.1% utilized any health service, 24.5% utilized at least one outpatient service, and 17.1% utilized outpatient services two or more times. 10.1% utilized outpatient services within the first 30 days of release.ConclusionsThis care continuum highlights drop offs in accessing healthcare. It can be used by governmental, correctional, community-based, and healthcare agencies to design and evaluate interventions aimed at improving the health of a population at considerable risk for poor health outcomes and death.

Abstract 15634: Primary Prevention Defibrillator Use in a Safety-Net Setting

Introduction: Disparities in use of implantable cardioverter-defibrillators (ICD) for primary prevention have been documented; however, whether ICDs may be underutilized within a safety-net healthcare system has not been studied. Methods: Using an electronic health record cohort of all patients with heart failure (HF) who received care within the public safety-net system in San Francisco from 2001-2018 linked to device implantation records from two health systems, we identified all patients with ICD implantation (adjudicated with manual chart review) and primary prevention ICD-eligible with no indication for secondary prevention ICD, EF&lt;35% on 2 echocardiograms at least 90 days apart, HF hospitalization (to increase specificity for symptomatic HF), and prescribed beta blocker and ACEi/ARB. For exploratory survival analysis, eligibility and follow up started at the second echocardiogram. Results: Out of 14,230 patients with HF, at least 384 patients were potentially eligible for primary prevention ICD, but only 9 (2.3%) had an ICD implanted (2 CRT-D, 7 ICD). Of these 6 were nonischemic, and 3 had revascularized ischemic cardiomyopathy. Those who received ICD were younger (47 years vs 55 years; p=0.05), with lower rates of substance use (Table). Among 4 patients who died after ICD, median survival after device placement was 2.8 years (range 0.73 to 7.3); among 5 still alive, median follow up is 6.2 years (range 5.5 to 7.0). In an exploratory analysis, survival did not greatly differ by ICD placement (logrank p=0.53; age-adjusted HR 1.55; 95%CI 0.57-4.24). Conclusion: Among individuals receiving care at a safety-net system in San Francisco, even acknowledging that not all barriers to ICD placement are measured, very few guideline-eligible patients received primary prevention ICD. Additional studies are needed to identify patient-level and systems-level barriers to referral and implantation specific to a diverse, publicly insured patient population.

Effect of modernized collaborative care for depression on brain-derived neurotrophic factor (BDNF) and depressive symptom clusters: Data from the eIMPACT trial

Brain-derived neurotrophic factor (BDNF) levels are lower in people with depression and are normalized following pharmacological treatment. However, it is unknown if psychological treatments for depression improve BDNF and if change in BDNF is a mediator of intervention effects on depressive symptoms. Therefore, using data from the eIMPACT trial, we sought to determine the effect of modernized collaborative care for depression on 12-month changes in BDNF and cognitive/affective and somatic depressive symptom clusters and to examine whether BDNF changes mediate intervention effects on depressive symptoms. 216 primary care patients with depression from a safety net healthcare system were randomized to 12 months of the eIMPACT intervention (internet cognitive-behavioral therapy [CBT], telephonic CBT, and select antidepressant medications) or usual primary care. Plasma BDNF was measured with commercially available kits, and depressive symptom clusters were assessed by the Patient Health Questionnaire-9. The intervention did not influence BDNF but did improve both the cognitive/affective and somatic clusters over 12 months. Changes in BDNF did not mediate the intervention effect on either cluster. Our findings suggest that modernized collaborative care is an effective treatment for both the cognitive/affective and somatic symptoms of depression and that the mechanism of action is not improvements in BDNF. Trial registrationClinicalTrials.gov Identifier: NCT02458690

Preliminary Workforce Outcomes of an Urban Longitudinal Integrated Clerkship.

The authors examined whether students participating in an urban longitudinal integrated clerkship (LIC) with a curriculum focused on care for underserved populations have a sustained commitment to urban underserved care through residency training and into practice. This mixed-methods study collected data from medical student application essays to the Denver Health LIC (DH-LIC), end-of-course surveys, residency match outcomes, and postgraduation surveys annually for academic years 2014 to 2022. The authors analyzed students' responses to the surveys on interest in working with underserved patients, understanding the rewards and challenges of working in safety net institutions, working in the community to improve health, and working at DH. The authors qualitatively coded the 70 application essays of all selected students using summative content analysis. Seventy DH-LIC students were compared with 1,450 medical students between 2014 and 2022. Qualitative analysis of LIC application essays revealed 3 themes: interest in working with underserved populations, work experience with underserved populations, and personal experience with medical vulnerability. Fifty-seven DH-LIC participants (81.4%) expressed high levels of career interest in working with underserved populations, 45 (64.3%) had high levels of work experience with underserved populations, and 18 (25.7%) expressed high levels of personal experience. Graduates of the DH-LIC program demonstrated a high degree of continuing interest in practicing in urban underserved settings throughout medical school and postgraduate training. Ten graduates (71.4%) in practice work in urban underserved settings. Participants reported a high or very high level of interest and commitment to working with underserved populations (96.7%-100%), understanding the safety net health care system (91.7%-98.6%), and working in communities (95.0%-100%) at all time points studied. Early data indicate high rates of graduates working in urban underserved settings. These preliminary outcomes suggest the LIC may support the development of a committed workforce for urban underserved communities.

Real-World Outcomes of Latinx Versus Non-Latinx Patients Treated With First-Line Immunotherapy for Metastatic Renal-Cell Carcinoma.

There are limited data regarding the impact of ethnicity among patients receiving immune checkpoint inhibitors. We evaluated real-world outcomes between Latinx and non-Latinx patients with metastatic renal-cell carcinoma (mRCC) treated with first-line nivolumab/ipilimumab within 2 different healthcare settings. We performed a retrospective analysis of patients with mRCC who received nivolumab/ipilimumab within the Los Angeles County Department of Health Services (LAC-DHS), a safety-net healthcare system, and the City of Hope Comprehensive Cancer Center (COH), a tertiary oncology center, between January 1, 2015 and December 31, 2021. Progression-free survival (PFS) and overall survival (OS) were determined using the Kaplan-Meier method and covariates were adjusted using multivariate Cox proportional hazards regression. Of 94 patients, 40 patients (43%) were Latinx while the remainder were non-Latinx (44 pts [46%] White, 7 pts [7%] Asian, and 3 pts [3%] Other). Fifty (53%) and 44 (47%) patients received their care at COH and LAC-DHS, respectively. Most Latinx patients (95%) were treated at LAC-DHS, and most non-Latinx patients (89%) were treated at COH. Pooled analysis by ethnicity demonstrated significantly shorter PFS in Latinx versus non-Latinx patients (10.1 vs. 25.2 months, hazard ratios [HR] 3.61, 95% CI 1.96-6.66, P ≤ .01). Multivariate analysis revealed a HR of 3.41 (95% CI 1.31-8.84; P = .01). At a median follow-up of 11.0 months, the median OS was not reached in either arm at the time of data cutoff. Latinx patients with mRCC had a shorter PFS treated with frontline nivolumab/ipilimumab compared to their non-Latinx counterparts. No difference was observed in OS although these data were immature. Larger studies are needed to further interrogate the social and economic determinants of ethnicity on clinical outcomes in mRCC.

Real-World Implementation of a COVID-19 Monoclonal Antibody Treatment Program in a Los Angeles County Safety Net Ambulatory Healthcare System - Barriers to Treatment and Lessons Learned.

Throughout the COVID-19 pandemic, low-income, minority, and otherwise vulnerable populations have repeatedly been shown to receive unequal access to novel therapies. Addressing this inequity requires specific awareness of the barriers experienced by vulnerable patients, and systemic efforts to address these barriers to provide equitable health care. We designed and implemented an ambulatory COVID-19 treatment program expressly aimed at increasing COVID-19 treatment uptake in a safety-net healthcare system. We describe systemic and human obstacles encountered as well as strategies used to increase use of COVID-19 treatments. Thanks to these strategies, we observed an increase in monoclonal antibody acceptance rate from 29 to 69% over the course of 10 months. We found that interventions such as engaging primary care providers, creating clear-language scripts for outreach calls, assisting with logistic barriers such as transportation, and addressing medical mistrust and hesitancy among both staff and patients were critical to increasing treatment uptake among our safety-net patient population.