Safety-net Hospital Systems Research Articles

Hispanic/Latino Ethnicity is an Independent Predictor of Worse Survival for Gastric Cancer in a Multicenter Safety-Net Patient Population.

Various population-based studies have shown Hispanic/Latino ethnicity is a risk factor for worse survival in patients with gastric cancer linked to disparate access to care. We aimed to address whether Hispanic patients treated within safety-net hospital systems continue to experience this survival deficit compared to non-Hispanic patients. We performed a retrospective cohort study comparing survival between Hispanic and non-Hispanic patients diagnosed with gastric adenocarcinoma between January 1, 2016 to December 31, 2020 within Los Angeles County's safety-net hospital system. Gastric cancer-specific survival was compared between the two cohorts using the Kaplan-Meier estimate and Cox proportional-hazards regression model. 448 patients who received care from five medical centers were included. 348 (77.7%) patients self-identified as Hispanic and 100 (22.3%) as non-Hispanic. Mean follow-up time was 2.0 years (median 0.91 years, IQR, 0.34-2.5 years). Hispanic patients were found to be diagnosed at a younger age (55.6 vs 60.7 years, p <0.01), demonstrate higher state area deprivation index (6.4 vs 5.0, p <0.01), and present with metastatic disease (59.8% vs 45%, p =0.04). After adjusting social and oncologic variables, Hispanic ethnicity remained an independent risk factor for worse survival (HR 1.56, [95% CI 1.06-2.28], p = 0.02). Hispanic patients treated within a large, multi-center safety-net hospital system experience worse survival compared to non-Hispanic patients. This suggests ethnic disparities exist within safety-net hospital systems, independent of known clinicopathologic factors. Improving outcomes for Hispanic patients with gastric cancer requires future efforts aimed at defining and addressing these unidentified barriers to care.

Engaging primary care physicians is critical in the screening and diagnosis of colorectal cancer at safety-net hospital systems

BackgroundPrimary care physicians (PCP) play a key role in offering colorectal cancer (CRC) screenings, particularly amongst underserved populations. Given potential delays in or omission of CRC screening in the absence of a PCP, we aimed to determine stage of CRC at diagnosis in an underserved population. MethodsA retrospective chart review was conducted at two Los Angeles County safety-net hospitals. Inclusion criteria were a CRC diagnosis between 2018 and 2021 and age between 50 and 75 years at diagnosis time. The primary outcome was the cancer stage at diagnosis. ResultsA total of 373 patients were included, of those, 52.5 % had a PCP. Compared to others, PCP was similar in age, racial composition, and primary spoken language (Table 1). Of patients with a PCP, 52.0% were diagnosed by screening. After screening, the most common indication for colonoscopy were blood per rectum (24.9 %) and imaging findings (18.0 %). Patients with a PCP had a significantly lower rate of late stage CRC than those without a PCP (42.4 % vs. 68.0 %, p < 0.001). After adjustment, having a PCP was associated with significantly reduced odds of late stage CRC (Adjusted Odds Ratio 0.83, 95 % Confidence Interval [0.68–1.04]). Having a PCP was not associated with any adjusted increase in number of adenomas or tumor size. ConclusionsPatients with a PCP, irrespective of undergoing screening, were diagnosed at earlier CRC stages. This underlines the crucial role of PCPs in CRC and diagnosis, reinforcing the need for their active involvement in these processes.

Integrating Community Health Workers into Hospital Systems Through a Social Work Partnership: A Report from the Field.

While studies support the effectiveness of community health worker (CHW) services, best approaches for CHW integration in health systems are not well understood. We describe early outcomes from a partnership between a safety-net hospital systems' social work department and CHWs to address adverse social determinants of health of high-risk patients.

Warfarin Monitoring in Safety-Net Health Systems: Analysis by Race/Ethnicity and Language Preference.

Racial/ethnic disparities in anticoagulation management are well established. Differences in warfarin monitoring can contribute to these disparities and should be measured. We assessed for differences in international normalized ratio (INR) monitoring by race/ethnicity and language preference across safety-net care systems serving predominantly low-income, ethnically diverse populations. Cross-sectional analysis of process and safety data shared from the Safety Promotion Action Research and Knowledge Network (SPARK-Net) initiative, a consortium of five California safety-net hospital systems. Eligible patients were at least 18 years old, received warfarin for at least 56 days during the measurement period from July 2015 to June 2017, and had INR testing in an ambulatory care setting at a participating healthcare system. We conducted a scaled Poisson regression for adjusted rate ratio of having at least one INR checked per 56-day time period for which a patient had a warfarin prescription. Adjusting for age, sex, healthcare system, and insurance status/type, we assessed for racial/ethnic and language disparities in INR monitoring. Of 8129 patients, 3615 (44%) were female; 1470 (18%), Black/African American; 3354 (41%), Hispanic/Latinx; 1210 (15%), Asian; 1643 (20%), White; and 452 (6%), other. Three thousand five hundred forty-nine (45%) were non-English preferring. We did not observe statistically significant disparities in the rate of appropriate INR monitoring by race/ethnicity or language; the primary source of variation was by healthcare network. Older age, female gender, and uninsured patients had a slightly higher rate of appropriate INR monitoring, but differences were not clinically significant. We did not find a race/ethnicity nor language disparity in INR monitoring; safety-net site was the main source of variation.

The Effect of IL-6 Inhibitors on Mortality Among Hospitalized COVID-19 Patients: A Multicenter Study.

BackgroundThe effectiveness of interleukin-6 inhibitors (IL-6i) in ameliorating coronavirus disease 2019 (COVID-19) remains uncertain.MethodsWe analyzed data for patients aged ≥18 years admitted with a positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test at 4 safety-net hospital systems with diverse populations and high rates of medical comorbidities in 3 US regions. We used inverse probability of treatment weighting via machine learning for confounding adjustment by demographics, comorbidities, and disease severity markers. We estimated the average treatment effect, the odds of IL-6i effect on in-hospital mortality from COVID-19, using a logistic marginal structural model.ResultsOf 516 patients, 104 (20.1%) received IL-6i. Estimate of the average treatment effect adjusted for confounders suggested a 37% reduction in odds of in-hospital mortality in those who received IL-6i compared with those who did not, although the confidence interval included the null value of 1 (odds ratio = 0.63; 95% confidence interval, .29–1.38). A sensitivity analysis suggested that potential unmeasured confounding would require a minimum odds ratio of 2.55 to nullify our estimated IL-6i effect size.ConclusionsDespite low precision, our findings suggested a relatively large effect size of IL-6i in reducing the odds of COVID-19–related in-hospital mortality.

Folate Deficiency in an Urban Safety Net Population

Introduction: Folate deficiency is a known cause of megaloblastic anemia. Serum folate level is therefore a common component of the workup for megaloblastic and other anemias. Following mandatory fortification of grain products with folic acid in the US in 1998, folate deficiency has become relatively rare in both the general population and in hospitalized patients. Some authors have suggested that serum folate levels should be tested rarely if at all in countries with mandatory folic acid fortification given low rates of deficiency, high cost per diagnosis of deficiency, and low rates of supplementation for those found to be deficient. However, given persistent racial, ethnic, and socioeconomic disparities in folate deficiency, these conclusions may not apply to all populations. In this study, we examine the rate at which serum folate testing detected folate deficiency in an urban safety net hospital and the characteristics of patients found to be folate deficient. Methods: All serum folate tests performed on inpatients and emergency department patients in 2018 at a large safety net hospital in Boston were reviewed. Serum folate levels under 4 ng/mL were considered deficient per WHO criteria. We reviewed the charts of all patients found to be folate deficient, collecting demographic data; data concerning social determinants of health; and clinical data such as hematologic lab data, stated reason for testing, and pertinent disease states such as malnutrition and substance use. We also noted whether the medical team acted upon the folate deficiency. Finally, we performed a cost analysis. Results: Out of 1368 patients whose serum folate was tested, 76 patients (5.5%) met criteria for folate deficiency. Of those patients, chart review found that hematologic abnormality was a documented cause of testing for 63%. Overall, 79% of folate deficient patients were anemic, but only 20% had a macrocytic anemia. 42% had a documented diagnosis of malnutrition. Common social determinants in patients found to be folate deficient include birth outside of the US (25%), homelessness (12%), and alcohol use disorder (29%). Of those found to be folate deficient, 93% were either started on folic acid supplementation or had already been prescribed supplementation prior to testing (5%). Given that our institution charges $71 per folate test, the expected charges per deficient test would total $1278. Discussion: While the decreased incidence of folate deficiency after fortification has led many to conclude that serum folate tests have limited utility, our data show that this conclusion may not apply to all populations. The 5.5% rate with which testing detects folate deficiency at our institution, with 46% of 2018 income from Medicaid, was markedly higher than the 0.4% rate reported in a similar study done at nearby hospital that derived 14% of 2018 income from Medicaid (Theisen-Toupal et al. J Hosp. Med. 2013). Comparisons to other studies are limited, as the cutoff for folate deficiency varies significantly between institutions. However, the markedly higher frequency with which folate deficiency was detected at our institution as compared to others suggests that folate testing may still have a role within safety net and many public hospital systems. In addition, serum folate testing may be more cost effective at such hospitals. At our hospital, the charge per deficient folate test was $1278, while previously published data from the nearby hospital described above showed a charge of over $35,000 per result under 4 ng/mL (Theisen-Toupal et al. J Hosp Med 2013). In addition, our results showed that deficient folate results usually prompted change in management. At our hospital, over 90% of folate deficient patients were prescribed a folic acid supplement at discharge, while prior studies reported rates of supplementation in the range of 0-65% (e.g. Ashraf et al. J Gen Intern Med 2008). This may reflect greater cognizance among our providers of nutritional deficiencies associated with social determinants of health common to our patient population. As our results indicated high rates of anemia, malnutrition, immigrant status, and substance use disorders among folate deficient patients, future research may include comparisons between patients found to have normal vs low folate levels. Identifying correlations between folate deficiency and other patient characteristics may help to target testing towards those most likely to benefit. Disclosures No relevant conflicts of interest to declare.

753. Outpatient Parenteral Antibiotic Therapy (OPAT) in a Large Urban Safety Net Hospital Setting: Therapy for Vulnerable Populations at Home

BackgroundAdoption of outpatient parenteral antibiotic therapy (OPAT) is accelerating due to proven safety and value, but experience in safety-net settings remains limited, especially in those with history of illicit drug use. Emerging reports from safety-net settings have featured OPAT delivered in nursing facilities, respite care centers, and infusion centers (including some persons who inject drugs [PWID]), but literature is sparse on home-based OPAT for vulnerable patients. In a new home antibiotics program at San Francisco General Hospital, we sought to describe early safety and efficacy outcomes among adults without active injection drug use but with high rates of substance use and comorbid illnesses.MethodsWe conducted a cohort study of patients discharged from a large urban county medical center and enrolled in an outpatient IV antibiotics program from September 2017 to January 2019. We collected demographic and clinical data and computed outcomes of safety (30- and 90-day readmission for infection, vascular access complications, and death) and efficacy (completion of antibiotic therapy).ResultsOverall, 47 courses of antibiotics were given to 45 patients. Of these, 39/47 (83%) of antibiotic courses were administered in a residential setting, and 8/47 (17%) via the hospital outpatient infusion center. Comorbid conditions were common, including 9/45 (20%) with hepatitis B/C and 8/45 (18%) with HIV (Table 1). Present or prior illicit drug use was seen in 17/45 patients (38%), including recent or active illicit drug use in 11/45 (24%) (Table 1). Most common indications for antibiotics were osteomyelitis and bacteremia (Table 2). Efficacy in the OPAT program was high: overall, 44/47 (94%) courses of outpatient IV antibiotics were completed, and the 30-day and 90-day readmission rates were 13% and 20% respectively, with zero 30-day readmissions related to OPAT (Table 3).ConclusionAn OPAT program embedded within a safety net hospital system delivering care in patients’ homes had high completion rate and low readmission rate, despite patients’ high prevalence of underlying comorbid conditions and noninjection illicit drug use. Home-based OPAT should be considered for broader adoption in safety-net hospital systems. Disclosures All authors: No reported disclosures.

Surgical Epilepsy Care in a Safety-Net and Private Healthcare System: A Comparative Analysis

Abstract INTRODUCTION Access to and delivery of quality surgical epilepsy care remains a challenge in both safety-net and private hospital systems. Underserved populations are more likely to utilize safety-net hospital systems, but to date there have been no published reports on epilepsy surgery outcomes in this setting. This study aimed to prospectively analyze and compare surgical epilepsy care in a safety-net versus private hospital system. METHODS We prospectively collected evaluation and treatment data in patients undergoing resective surgery for refractory epilepsy at the multi-institutional Los Angeles County Department of Health Services Comprehensive Epilepsy Program between 2010 and 2017. Seizure characteristics, pre-surgical evaluation, perioperative complications, and postsurgery seizure outcomes as measured by the Engel classification were recorded. This cohort was compared to patients treated in a private hospital system with which it collaborated during the same time period. RESULTS Data from 102 patients in the safety-net and 145 patients in the private hospital system were analyzed. There was a higher proportion of African American (P = .02) and Hispanic patients (P = .03) in the safety-net hospital system. There was no difference in mean time from epilepsy onset to surgery between groups (P = .54). The presurgical evaluation was equivalent (P &gt; .18), except for more frequent use of magnetoencephalography in the private system (P = .02). Seizure freedom outcomes were excellent, and complication rates were low with no difference between groups (P = .95 and P &gt; .22, respectively). However, patients from safety-net hospital systems were more likely to be lost to follow up (P = .04). CONCLUSION Quality surgical epilepsy care can be delivered in a safety-net hospital system and intrinsic factors of safety-net hospital do not limit quality. Partnership of safety-net hospital systems with established comprehensive epilepsy centers is essential for the delivery of quality surgical epilepsy care. The expansion of these services is vital for providing modern epilepsy care for the underserved population.

Diagnostic colonoscopy following abnormal FIT results: A quality improvement analysis.

568 Background: Published rates of colorectal cancer (CRC) screening with diagnostic colonoscopy after abnormal fecal immunochemical test (FIT) findings have varied substantially from 42% to 83% and median days to follow up colonoscopy have ranged from 41 to 184 days. Although data for lack of follow up exists for urban safety-net hospital systems, Veteran’s Affairs systems, and healthcare systems not located in the southern US to our knowledge no data exists for the Baylor Scott &amp; White Health System (BSWH) which is the largest not-for-profit healthcare system in Texas. Methods: The initial retrospective chart review searched BSWH’s Central Texas division for whom a FIT was ordered during the following dates: June 1, 2014 to June 1, 2016. Eligible patients were between and including 50 and 75 years of age. The search results were manually screened by two resident Internal Medicine physicians. Results: The initial screen produced 232 patients with a positive FIT test. After excluding for testing reasons other than CRC screening, 94 patients were included in the final analysis. Most of those (70/94, 74.47%) received a gastroenterology clinic visit within one year, and most (62/94, 65.96%) received or were offered a colonoscopy. The most common reasons for not completing colonoscopy were patient no-show (14/32, 43.75%) and no documented reason (12/32, 37.5%). Of those receiving a colonoscopy at our institution, median time from positive FIT to colonoscopy was 64 days, a quarter (11/43, 25.58%) waited longer than 6 months, and 22/43 (51.16%) had an abnormal finding. The abnormal findings on colonoscopy included: 3/22 (13.64%) were dysplastic polyps, 13/22 (59.10%) were adenomatous polyps and 6/19 (31.58%) were hyperplastic polyps. Conclusions: Colonoscopy following an abnormal FIT is an important part of preventing and diagnosing CRC. Although fecal based screening tests are more convenient and affordable, it appears that poor follow up is not limited to government and indigent health systems. As one of the largest not-for-profit health systems in the nation, a 65.96% follow up colonoscopy rate after abnormal FIT testing leaves much room for improvement.

New Opportunities for Funding Dialysis-Dependent Undocumented Individuals.

The cost of dialysis for the estimated 6500 dialysis-dependent undocumented individuals with kidney failure in the United States is high, the quality of dialysis care they receive is poor, and their treatment varies regionally. Some regions use state and matched federal funds to cover regularly scheduled dialysis treatments, while others provide treatment only in emergent life-threatening conditions. Nephrologists caring for patients who receive emergent dialysis are tasked with the difficult moral dilemma of determining "who gets dialysis that day." Without a path to citizenship and by exclusion from the federal marketplace exchanges, undocumented individuals have limited options for their treatment. A novel opportunity to provide scheduled dialysis for this population is through the purchase of insurance off the exchange. Plans purchased off the exchange must still abide by the 2014 provision of the Patient Protection and Affordable Care Act, which prohibits insurance companies from denying coverage based on a preexisting health condition. In 2015 and 2016, >100 patients previously receiving only emergent dialysis at the two largest safety-net hospital systems in Texas obtained off-the-exchange commercial health insurance plans. These undocumented patients now receive scheduled dialysis treatments, which has improved their care and quality of life, as well as decompressed the overburdened hospital systems. The long-term sustainability of this option is not known. Socially responsive and visionary policymakers allowing the move into this bold, new direction deserve special appreciation.

Predictors of Payer Mix and Financial Performance Among Safety Net Hospitals Prior to the Affordable Care Act.

The objective of this study was to use audited hospital financial statements to identify predictors of payer mix and financial performance in safety net hospitals prior to the Affordable Care Act. We analyzed the 2010 financial statements of 98 large, urban safety net hospital systems in 34 states, supplemented with data on population demographics, hospital features, and state policies. We used multivariate regression to identify independent predictors of three outcomes: 1) Medicaid-reliant payer mix (hospitals for which at least 25% of hospital days are paid for by Medicaid); 2) safety net revenue-to-cost ratio (Medicaid and Medicare Disproportionate Share Hospital payments and local government transfers, divided by charity care costs and Medicaid payment shortfall); and 3) operating margin. Medicaid-reliant payer mix was positively associated with more inclusive state Medicaid eligibility criteria and more minority patients. More inclusive Medicaid eligibility and higher Medicaid reimbursement rates positively predicted safety net revenue-to-cost ratio. University governance was the strongest positive predictor of operating margin. Safety net hospital financial performance varied considerably. Academic hospitals had higher operating margins, while more generous Medicaid eligibility and reimbursement policies improved hospitals' ability to recoup costs. Institutional and state policies may outweigh patient demographics in the financial health of safety net hospitals.

Partnering with health care systems to assess tobacco treatment practices and beliefs among clinicians: evaluating the process.

BackgroundTobacco is a major cause of preventable illness and death. However, clinician use of an evidence-based guideline for treatment of tobacco use is low. This case study describes the process for conducting a pre-intervention assessment of clinician practices and beliefs regarding treatment of tobacco use.Community ContextLouisiana State University Health System, one of the largest safety-net public hospital systems in the United States, consists of 10 facilities in population centers across the state of Louisiana. The system serves a large proportion of the state’s underinsured and uninsured, low-income, and racial/ethnic minority populations, groups that have high rates of tobacco use.MethodsActivities included 1) partnering with hospital administrators to generate support for conducting a clinician assessment, 2) identifying and adapting a survey tool to assess clinicians’ practices and beliefs regarding treatment of tobacco use, 3) developing a survey protocol and obtaining approval from the institutional review board, and 4) administering the survey electronically, using the hospital’s e-mail system.OutcomeExisting partnerships and system resources aided survey administration. Use of the hospital’s internal e-mail system and distribution of an online survey were effective means to engage clinicians. Following notification, 43.6% of 4,508 clinicians opened their e-mail containing the invitation letter with a Web link to the survey; of these, 83.1% (1,634) completed the survey.InterpretationPartnering with stakeholders and using existing resources within the health care system are essential to successful implementation of a system-wide survey of clinician practices and beliefs regarding treatment of tobacco use.

Transferred and Delayed Care of Patients with Colorectal Cancer in a Safety-Net Hospital System—Manifestations of a Distressed Healthcare System

Safety-net hospital systems provide care to a large proportion of United States' under- and uninsured population. We have witnessed delayed colorectal cancer (CRC) care in this population and sought to identify demographic and systemic differences in these patients compared to those in an insured health-care system. DESIGN, PATIENTS, AND APPROACH/MEASUREMENTS: We collected demographic, socioeconomic, and clinical data from 2005-2007 on all patients with CRC seen at Parkland Health and Hospital System (PHHS), a safety-net health system and at Presbyterian Hospital Dallas System (Presbyterian), a community health system, and compared characteristics among the two health-care systems. Variables associated with advanced stage were identified with multivariate logistic regression analysis and odds ratios were calculated. Three hundred and eighteen patients at PHHS and 397 patients at Presbyterian with CRC were identified. An overwhelming majority (75 %) of patients seen at the safety-net were diagnosed after being seen in the emergency department or at an outside facility. These patients had a higher percentage of stage 4 disease compared to the community. Patients within the safety-net with Medicare/private insurance had lower rates of advanced disease than uninsured patients (25 % vs. 68 %, p < 0.001). Insurance status and physician encounter resulting in diagnosis were independent predictors of disease stage at diagnosis. A large proportion of patients seen in the safety-net health system were transferred from outside systems after diagnosis, thus leading to delayed care. This delay in care drove advanced stage at diagnosis. The data point to a pervasive and systematic issue in patients with CRC and have fundamental health policy implications for population-based CRC screening.