Safety-net Patients Research Articles

Conducting Internet-Based Visits for Onboarding Populations With Limited Digital Literacy to an mHealth Intervention: Development of a Patient-Centered Approach.

BackgroundThe COVID-19 pandemic has propelled patient-facing research to shift to digital and telehealth strategies. If these strategies are not adapted for minority patients of lower socioeconomic status, health inequality will further increase. Patient-centered models of care can successfully improve access and experience for minority patients.ObjectiveThis study aims to present the development process and preliminary acceptability of altering in-person onboarding procedures into internet-based, remote procedures for a mobile health (mHealth) intervention in a population with limited digital literacy.MethodsWe actively recruited safety-net patients (English- and Spanish-speaking adults with diabetes and depression who were receiving care at a public health care delivery system in San Francisco, United States) into a randomized controlled trial of text messaging support for physical activity. Because of the COVID-19 pandemic, we modified the in-person recruitment and onboarding procedures to internet-based, remote processes with human support. We conducted a preliminary evaluation of how the composition of the recruited cohort might have changed from the pre–COVID-19 period to the COVID-19 enrollment period. First, we analyzed the digital profiles of patients (n=32) who had participated in previous in-person onboarding sessions prior to the COVID-19 pandemic. Next, we documented all changes made to our onboarding processes to account for remote recruitment, especially those needed to support patients who were not very familiar with downloading apps onto their mobile phones on their own. Finally, we used the new study procedures to recruit patients (n=11) during the COVID-19 social distancing period. These patients were also asked about their experience enrolling into a fully digitized mHealth intervention.ResultsRecruitment across both pre–COVID-19 and COVID-19 periods (N=43) demonstrated relatively high rates of smartphone ownership but lower self-reported digital literacy, with 32.6% (14/43) of all patients reporting they needed help with using their smartphone and installing apps. Significant changes were made to the onboarding procedures, including facilitating app download via Zoom video call and/or a standard phone call and implementing brief, one-on-one staff-patient interactions to provide technical assistance personalized to each patient’s digital literacy skills. Comparing recruitment during pre–COVID-19 and COVID-19 periods, the proportion of patients with digital literacy barriers reduced from 34.4% (11/32) in the pre–COVID-19 cohort to 27.3% (3/11) in the COVID-19 cohort. Differences in digital literacy scores between both cohorts were not significant (P=.49).ConclusionsPatients of lower socioeconomic status have high interest in using digital platforms to manage their health, but they may require additional upfront human support to gain access. One-on-one staff-patient partnerships allowed us to provide unique technical assistance personalized to each patient’s digital literacy skills, with simple strategies to troubleshoot patient barriers upfront. These additional remote onboarding strategies can mitigate but not eliminate digital barriers for patients without extensive technology experience.Trial RegistrationClinicaltrials.gov NCT0349025, https://clinicaltrials.gov/ct2/show/NCT03490253

Using ICD-10-CM codes to detect illicit substance use: A comparison with retrospective self-report

BackgroundUnderstanding whether International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) codes can be used to accurately detect substance use can inform their use in future surveillance and research efforts. MethodsUsing 2015–2018 data from a retrospective cohort study of 602 safety-net patients prescribed opioids for chronic non-cancer pain, we calculated the sensitivity and specificity of using ICD-10-CM codes to detect illicit substance use compared to retrospective self-report by substance (methamphetamine, cocaine, opioids [heroin or non-prescribed opioid analgesics]), self-reported use frequency, and type of healthcare encounter. ResultsSensitivity of ICD-10-CM codes for detecting self-reported substance use was highest for methamphetamine (49.5 % [95 % confidence interval: 39.6–59.5 %]), followed by cocaine (44.4 % [35.8–53.2 %]) and opioids (36.3 % [28.8–44.2 %]); higher for participants who reported more frequent methamphetamine (intermittent use: 27.7 % [14.6–42.6 %]; ≥weekly use: 67.2 % [53.7–79.0 %]) and opioid use (intermittent use: 21.4 % [13.2–31.7 %]; ≥weekly use: 52.6 % [40.8–64.2 %]); highest for outpatient visits (methamphetamine: 43.8 % [34.1–53.8 %]; cocaine: 36.8 % [28.6−45.6 %]; opioids: 33.1 % [25.9–41.0 %]) and lowest for emergency department visits (methamphetamine: 8.6 % [4.0−15.6 %]; cocaine: 5.3 % [2.1−10.5 %]; opioids: 6.3 % [3.0−11.2 %]). Specificity was highest for methamphetamine (96.4 % [94.3–97.8 %]), followed by cocaine (94.0 % [91.5–96.0 %]) and opioids (85.0 % [81.3–88.2 %]). ConclusionsICD-10-CM codes had high specificity and low sensitivity for detecting self-reported substance use but were substantially more sensitive in detecting frequent use. ICD-10-CM codes to detect substance use, particularly those from emergency department visits, should be used with caution, but may be useful as a lower-bound population measure of substance use or for capturing frequent use among certain patient populations.

CSA Partnerships for Health: outcome evaluation results from a subsidized community-supported agriculture program to connect safety-net clinic patients with farms to improve dietary behaviors, food security, and overall health.

Safety-net clinic patients are at risk for food insecurity, which is associated with poor diet quality and negative health outcomes. Research on the impact of interventions addressing food insecurity in health care settings is limited. The primary aim of this study was to determine the preliminary effectiveness of Community-Supported Agriculture (CSA) Partnerships for Health, a 23 week grant-subsidized CSA program, in improving dietary behaviors, self-efficacy to eat vegetables, food security, and overall health among safety-net clinic patients. This single-group pretest-posttest study used interviewer-administered surveys. Study participants were 48 safety-net clinic patients. Outcomes included fruit and vegetable intake, frequency of dark green and orange vegetable intake, self-efficacy to eat vegetables, eating habits, food security status and ability to afford to eat healthy meals, emotional health, social health, and general health status. Differences in values at postintervention versus preintervention were examined using two-sided paired t-tests, McNemar's tests, and generalized estimating equation models. The difference between postintervention versus preintervention values was statistically significant for a number of outcomes, including vegetable intake (p = .030), orange vegetable intake (p = .004), eating habits (p = .039), food security (p = .039), ability to afford to eat healthy meals (p = .003), and general health status (p = .039). Generalized estimating equation models showed similar associations. CSA Partnerships for Health may have the potential to improve dietary behaviors, reduce food insecurity, and improve overall health among safety-net clinic patients.

Abstract PO-012: Acceptance and refusal among multi-lingual safety net patients to participate in a trial comparing genetic counseling delivery modes

Abstract Introduction While still low, diversity among clinical trial participants has improved in recent years due to efforts to eliminate health disparities. Here we present and endeavor to explain participation rates in our multicenter partially randomized preference noninferiority trial comparing the effectiveness of phone, video, and in person genetic counseling among high-risk English-, Spanish-, and Chinese-speaking patients. Methods High-risk patients were identified using a family history screener in clinics and via physician referrals. After reviewing forms received, bilingual/bicultural clinical research coordinators (CRC) called patients considered eligible in their preferred language (English, Spanish or Cantonese, Mandarin or Toisanese). Patients were informed that their hospital was conducting the study in conjunction with an academic institution. The CRC went over each patient’s family history of cancer to confirm eligibility and to explain the study components, including free genetic counseling. Because previous research had significant refusals due to patients’ preferences for a single mode, our consented patients were asked if they would accept random assignment to phone, video, or in person counseling or if they had a strong preference. Patients who declined were asked their reasons. Results Out of 1,403 patients reached (70% English-, 26% Spanish-, and 3% Chinese- speaking), 86% agreed to participate. The highest acceptance rate was among Spanish-speakers (94%), followed by English-speakers (83%) and Chinese-speakers (67%). Among the 201 patients who declined, 49% did so upon contact, while 51% declined after eligibility was confirmed. Reasons for declining are available for 71% of decliners as follows: 22% not interested; 19% no time; 10% cited no benefit them or family members; 7% did not want to talk about cancer; 7% had too many other medical issues; and 6% provided a range of other reasons. Discussion and Conclusions We believe that our study’s high initial participation rate for patients contacted was due to the purpose which was particularly meaningful to those with a family history of cancer. Also, patients trusted their own hospitals which co- sponsored the study. It was helpful that providers in the 3 public hospitals strongly supported the research which provided much needed genetic counseling and pursued questions important to access to genetic services. Importantly, our study design addressed significant known barriers to minority and low SES participation in clinical trials through the use of bilingual/bicultural investigators, multi-language study materials, and strong, positive working relationships with gatekeeper medical and clinic support staff. Reasons given for declining may indicate the existence of a socio-economic structural ceiling for participation due to patient vulnerabilities and societal burdens, causes outside the investigative scope of our study that are likely to continue to hamper efforts to improve participation if not addressed. Citation Format: Robin Lee, Miya Frick, Celia Kaplan, Galen Joseph, Janice Tsoh, Selina Flores, Niharika Dixit, Heather Cedermaz, Lly Wang, Amal Khoury, Brittany Campbell, Rena Pasick, Claudia S. Guerra, Susan L. Stewart. Acceptance and refusal among multi-lingual safety net patients to participate in a trial comparing genetic counseling delivery modes [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-012.

Comparison of Demographics, Treatment Patterns and Outcomes Among Primary Central Nervous System Lymphoma (PCNSL) Patients Treated at a Safety-Net Hospital Versus a Tertiary Academic Institution within the Same Healthcare System

Introduction: Primary CNS lymphomas (PCNSL) are rare, aggressive, extra-nodal, non-Hodgkin lymphomas confined to the CNS. Other than high-dose methotrexate (MTX) based induction regimens, there are no established standards-of-care for managing PCNSL. Treatment practices across institutions vary regionally and globally. At safety-net hospitals, there are often access issues, delays in seeking medical care, and limited treatment options due to insurance barriers and other prohibitive costs. This study compares the demographics, treatment patterns, and survival outcomes among PCNSL patients treated at a safety-net hospital versus a tertiary academic institution within the same healthcare system. Methods: Medical records of 94 patients who were treated for PCNSL from 2007-2020, at either a public safety-net hospital (n=34) or an academic tertiary-care center (n=60), both serving the same metroplex, were analyzed. Demographics, Memorial Sloan-Kettering Cancer Center (MSKCC) prognostic class, International Extranodal Study Group (IELSG) score, induction and consolidation treatment modalities used, and survival outcomes were compared between the 2 groups. Categorical variables and response rates were compared using Fisher's exact test. Continuous variables were compared using Mann-Whitney U test. Survival functions for overall- and progression-free survival (OS and PFS) were estimated by the Kaplan-Meier method and compared using a log-rank test. Cox proportional hazards regression was used for multivariate analysis. Results: Baseline characteristics of the study population is shown in Table 1. Compared to the tertiary academic center, patients at the safety-net hospital were significantly younger, had better Karnofsky performance status (KPS) and MSKCC prognostic class, and were more commonly Black or Hispanic, male, and HIV positive. Median follow-up was 39.4 months for surviving patients and 13.1 months for all patients. Induction regimens used were either chemotherapy (n = 74) or palliative whole brain radiation therapy (WBRT) (n = 16). Chemotherapy regimens were predominantly MTX-based (71/74, 95.9%). Safety-net patients were significantly less likely to receive induction chemotherapy (67.6% vs 85%, p = 0.004). Overall response to chemo-based induction was 70.3%. There was no significant difference in response rate to chemo-based induction between safety-net and academic center patients (73.9% vs 68.6%, p = 0.786). Patients who had a good response to induction chemotherapy (n = 52) were either given consolidative WBRT (n =11), autologous stem cell transplant (ASCT) (n = 14), chemotherapy (n = 17), or no further treatment (n = 10). When comparing safety-net and academic center patients, hospital location did not significantly affect whether patients received consolidation therapy (82.4% vs. 80%, p = 0.735). Safety-net hospital patients were significantly less likely to receive ASCT (0% vs. 40%, p = 0.001) and had higher rates of consolidative WBRT (41.2% vs 11.4%, p = 0.03). OS (71.7% vs. 51.1%, p = 0.218) and PFS (54.9% vs. 57.4%, p = 0.967) were not significantly different between safety-net and tertiary academic hospitals when adjusted for age and KPS. In a subset analysis, excluding patients who only received palliative care, there also were no differences in OS (68.9% vs 55.2%, p = 0.309) and PFS (50.3% vs 57.4%, p = 0.719) between hospitals (Figure 1). Patients who received consolidation treatment had significantly higher OS (84.8% vs 34.0%) and PFS (77.0% vs 30.3%), after adjusting for age and KPS (p = 0.001 for both). There were no significant differences between type of consolidation strategy employed for OS (p = 0.801) or PFS (p = 0.899). Conclusions: Safety-net patients with PCNSL were less likely to receive induction chemotherapy and could not receive ASCT as consolidation due to insurance barriers. Despite these differences in patterns of treatment, they had similar outcomes in terms of OS and PFS, even after adjusting for age and performance status. Consolidation treatments improved outcomes and it is critical to ensure eligible patients receive them, though the optimal type of consolidation remains unknown. This study is limited by the small sample size and retrospective analysis. Research to unearth the biologic heterogeneity of PCNSL and develop predictive biomarkers will be critical to personalize and optimize management strategies for these patients. Disclosures Awan: Genentech: Consultancy; MEI Pharma: Consultancy; Janssen: Consultancy; Astrazeneca: Consultancy; Celgene: Consultancy; Blueprint medicines: Consultancy; Sunesis: Consultancy; Karyopharm: Consultancy; Pharmacyclics: Consultancy; Gilead Sciences: Consultancy; Kite Pharma: Consultancy; Dava Oncology: Consultancy; Abbvie: Consultancy. Desai:Boston Scientific: Consultancy, Other: Trial Finding.

Patient interest in and barriers to telemedicine video visits in a multilingual urban safety-net system.

To determine interest in and barriers to video visits in safety-net patients with diverse age, racial/ethnic, or linguistic background. We surveyed patients in an urban safety-net system to assess: interest in video visits; ability to successfully complete test video visits; and barriers to successful completion of test video visits. Among 202 participants, of which 177 (87.6%) were persons of color and 113 (55.9%) preferred non-English languages, 132 (65.3%) were interested in and 109 (54.0%) successfully completed a test video visit. Younger age, non-English preference, and prior smartphone application use were associated with interest. Over half (n = 112) reported barriers to video visits; Internet/data access was the most common barrier (n = 50, 24.8%). Safety-net patients are interested in video visits and able to successfully complete test visits. Internet or mobile data access is a common barrier in even urban safety-net settings and may impact equitable telemedicine access.

Effects of initiating physician-performed germline testing in safety net clinic patients with epithelial ovarian cancer

Germline genetic mutations occur in approximately 25% of women with epithelial ovarian cancers (EOC). We sought to determine whether newly initiated in-office oncologist-led germline testing improved time to testing and dissemination of results compared with historical controls.Patients with epithelial ovarian cancer seen between 4/1/2018 and 12/31/2019 were identified. Patients treated before genetic testing kits were made available in the gynecologic oncology clinics were compared to those treated after. Categorical variables were compared using Chi Squared and Fisher’s Exact test. Cox proportional hazards model was used to compare elapsed time from testing to results.73 patients were identified, and 502 clinic visits were analyzed. 56 (76.7%) patients were White Hispanic, 15 (20.5%) were Black, and 2 (2.7%) were White non-Hispanic. 55 (75.7%) underwent germline testing. Median time to genetic testing in the intervention group was shorter than in the control group (5, vs 24.3 weeks, 95% CI = 0–10.8 vs 14.9–33.7, p < 0.001). Among the 51 patients with genetic tests completed; results were recorded in a clinic note at 14 weeks (95% CI = 0–28.1) from first visit in the intervention group compared with 47 weeks (95% CI = 30.7–63.3) in the control group (p < 0.001). The majority of patients tested had county charity care insurance or were uninsured.Genetic testing in a safety net gynecologic oncology clinic is feasible. By initiating in-office testing, time to testing and receipt of results were meaningfully shortened. This allowed for timely identification of patients who would most benefit from PARP inhibitor maintenance therapy.

Portals of Change: How Patient Portals Will Ultimately Work for Safety Net Populations.

Despite the implementation of internet patient portals into the safety net after the introduction of the Affordable Care Act in the United States, little attention has been paid to the process of engaging vulnerable patients into these portals. The portal is a health technology tool that was developed with a mainstream, English-speaking audience in mind. Thus, there are valid concerns that such technologies will actually exacerbate health care disparities, conferring further advantages to the already advantaged. In this paper, we describe a framework for portal engagement (awareness, registration, and use) among safety net patients. We incorporate the experiences in the Los Angeles County Department of Health Services to illustrate important contextual factors for portal outreach in our safety net. Finally, we discuss considerations for moving forward with health technology in the safety net as the next version of patient portals are being developed.

4R program results: What is the impact of 4R care delivery model on patient self-management and which patients benefited?

139 Background: We previously proposed a 4R model of teamwork and patient self-management (pSM) in cancer care (NCI ASCO Teams Project, Trosman JOP 2016). 4R (Right Info/Care/Patient/Time) enables patient and care team to manage complex care with an innovative 4R Care Sequence plan, including a novel visual feature describing timing and sequence of care. We report final results of a program which tested 4R at 5 safety net and 5 non safety net US centers from 2016 to 2019. Methods: Patients with stage 0-III breast cancer received 4R plans (4R Cohort). We surveyed 4R cohort and a historical control cohort of patients receiving care at same centers pre-4R. We assessed the usefulness of 4R to the 4R cohort and the impact on pSM in 4R cohort compared to historical cohort. Results: Survey response rates: 63%, 422/670 (4R cohort); 47%, 466/992 (control). 4R significantly increased the composite pSM score and 5 of 7 pSM metrics vs control (Table). The increase was not influenced by patient age, stage or whether treated at safety net site. pSM scores increased in 4R vs control cohort to a similar extent for patients &lt; 65 years old (74% vs 51%, p = .0001) as for patients ≥ 65 years old (78% vs 57%, p = .0002). pSM improved similarly for patients with stage 0 or I breast cancer (77% vs 56%, p = .0001) as for patients with stage II or III breast cancer (72% vs 54%, p = .0001). Safety net patients showed pSM increase (77% vs 51%, p = .0001) similar to non safety net patients (74% vs 58%, p = .0002). Within the 4R cohort, 80% found 4R useful for organizing care and 70% found the novel visual feature useful to manage care timing and sequence. Usefulness was similar for age groups and stages, but higher for safety net than non safety net patients (88% vs 74%, p = .0008). Conclusions: 4R markedly improved patient self-management in early breast cancer across age groups and cancer stages, but further enhancements are needed to benefit as many patients as possible. 4R benefits in safety net setting indicate that 4R may reduce disparities. [Table: see text]

Overcoming sociodemographic factors in the care of patients with testicular cancer at a safety net hospital.

The objective of this study was to determine whether standardized treatment of germ cell tumors (GCTs) could overcome sociodemographic factors limiting patient care. The records of all patients undergoing primary treatment for GCTs at both a public safety net hospital and an academic tertiary care center in the same metropolitan area were analyzed. Both institutions were managed by the same group of physicians in the context of multidisciplinary cancer care. Patients were grouped by care center; clinicopathologic features and outcomes were analyzed. Between 2006 and 2018, 106 and 95 patients underwent initial treatment for GCTs at the safety net hospital and the tertiary care center, respectively. Safety net patients were younger (29 vs 33years; P=.005) and were more likely to be Hispanic (79% vs 11%), to be uninsured (80% vs 12%; P<.001), to present via the emergency department (76% vs 8%; P<.001), and to have metastatic (stage II/III) disease (42% vs 26%; P=.025). In a multivariable analysis, an absence of lymphovascular invasion (odds ratio [OR], 0.30; P=.008) and an embryonal carcinoma component (OR, 0.36; P=.02) were associated with decreased use of adjuvant treatment for stage I patients; hospital setting was not (OR, 0.67; P=.55). For patients with stage II/III nonseminomatous GCTs, there was no difference in the performance of postchemotherapy retroperitoneal lymph node dissection between the safety net hospital and the tertiary care center (52% vs 64%; P=.53). No difference in recurrence rates was observed between the cohorts (5% vs 6%; P=.76). Sociodemographic factors are often associated with adverse clinical outcomes in the treatment of GCTs; they may be overcome with integrated, standardized management of testicular cancer.

Obesity and metabolic outcomes in a safety-net health system

ABSTRACT In the United States, obesity has increased in prevalence over time and is strongly associated with subsequent outcomes such as diabetes mellitus (DM) and nonalcoholic fatty liver disease (NAFLD). It is unclear, however, as to how the magnitude of NAFLD risk from obesity and DM is increased in safety-net health system settings. Among the San Francisco Health Network (SFHN) patients (N = 47,211), we examined the association between Body Mass Index (BMI) and elevated liver enzyme levels, including interaction by DM status. Our findings revealed that 32.2 percent of SFHN patients were obese, and Pacific Islanders in the safety-net had the highest rates of obesity compared to other racial groups, even after using higher race-specific BMI cutoffs. In SFHN, obesity was associated with elevated liver enzymes, with the relationship stronger among those without DM. Our findings highlight how obesity is a stronger factor of NAFLD in the absence of DM, suggesting that practitioners consider screening for NAFLD among safety-net patients with obesity even if DM has not developed. These results highlight the importance of directing efforts to reduce obesity in safety-net health systems and encourage researchers to further examine effect modification between health outcomes in such populations.

The Impact of Social and Clinical Complexity on Diabetes Control Measures.

In an age of value-based payment, primary care providers are increasingly scrutinized on performance metrics that assess quality of care, including the outcomes of their patient population in key areas such as diabetes control. Although such measures often adjust for patient clinical risk factors or clinical complexity, most do not account for the social complexity of patient populations, despite research demonstrating the strong association between social factors and health. Using patient electronic health record data from 2 large community health center networks serving safety net patients, we assessed the effect of both clinical and social risk factors on poor glucose control among diabetics. Logistic regression results were used to estimate the impact of adjusting for both clinical and social complexity on provider performance metrics. Clinical complexity was measured at the patient-level using the Charlson Comorbidity Index. Social complexity was measured at the community-level using the Social Deprivation Index. Clinical complexity alone was not consistently associated with poor diabetes control (ie, HbA1c > 9%) in diabetic patients with HbA1c testing during the study period. However, increasing social complexity was significantly associated with higher rates of poor diabetic control in both cohorts. After adding adjustment for social complexity down to the national median score, our models suggest that approximately 25% of providers would have 1 to 2% improvement in the assessment of their diabetes control measures, with 45% showing a 2 to 5% improvement, and 5% showing more than a 5% improvement. Providers caring for patients with greater social risk factors may benefit from having their performance metrics adjusted for the social complexity of their patient populations.

Early Outcomes With the Liver-kidney Safety Net.

A safety net policy was implemented in August 2017 giving liver transplant alone (LTA) recipients with significant renal dysfunction posttransplant priority for subsequent kidney transplantation (KT). This study was undertaken to evaluate early outcomes under this policy. Adults undergoing LTA after implementation of the safety net policy and were subsequently listed for KT between 60 and 365 days after liver transplantation contained in United Network for Organ Sharing data were examined. Outcomes of interest were receipt of a kidney transplant and postliver transplant survival. Safety net patients were compared with LTA recipients not subsequently listed for KT as well as to patients listed for simultaneous liver-kidney (SLK) transplant yet underwent LTA and were not subsequently listed for KT. There were 100 patients listed for safety net KT versus 9458 patients undergoing LTA without subsequent KT listing. The cumulative incidence of KT following listing was 32.5% at 180 days. The safety net patients had similar 1-year unadjusted patient survival (96.4% versus 93.4%; P = 0.234) but superior adjusted survival (hazard ratio0.133, 0.3570.960; P = 0.041) versus LTA recipients not subsequently listed for KT. Safety net patients had superior 1-year unadjusted (96.4% versus 75.0%; P < 0.001) and adjusted (hazard ratio0.039, 0.1260.406; P < 0.001) survival versus SLK listed patients undergoing LTA without subsequent KT listing. The safety net appears to provide rapid access to KT with good early survival for those able to take advantage of it. Survival of patients unable to qualify for KT listing after LTA needs to be better understood before further limitation of SLK, however.

Abstract A032: Quitline treatment enrollment, dose, and cessation outcomes among safety net patients linked with treatment via Ask-Advise-Connect: Differential efficacy among Spanish- vs. English-speaking smokers

Abstract Most quitlines offer treatment in Spanish. However, little is known about the long-term efficacy of quitline-delivered treatment among Spanish-speaking smokers. This study is a secondary analysis of a 34-month implementation trial evaluating Ask-Advise-Connect (AAC)—an electronic health record (EHR)-based approach designed to facilitate enrollment in quitline-delivered treatment—in 13 community clinics serving low-income, racially/ethnically diverse patients in Houston, TX. Our goal was to compare treatment engagement, counseling dose received, and smoking abstinence among individuals who received treatment in Spanish versus English. Clinic staff were trained to Ask all patients about their smoking status, Advise all smokers to quit, and offer to immediately Connect smokers with treatment through a link within the EHR. Quitline treatment consisted of up to 5 proactive counseling calls. Outcomes included treatment engagement (i.e., enrollment in treatment), treatment dose (i.e., number of counseling calls completed), and biochemically confirmed, self-reported abstinence six months after enrollment. The smoking status of 218,915 unique patients was assessed and recorded in the EHR. The preferred language for 95.2% of patients assessed was Spanish (n=102,146) or English (n=106,312). Among Spanish speakers, smoking prevalence was 8.4% (8,602/102,146). Among English speakers, smoking prevalence was 29.4% (31,264/106,312). The proportion of Spanish-speaking smokers who enrolled in treatment was 10.7% (924/8,602), and 78.5% of these individuals (725/924) agreed to be contacted for the 6-month follow-up. The proportion of English-speaking smokers who enrolled in treatment was 12.1% (3,785/31,264), and 78.1% of these individuals (2,957/3,785) agreed to be contacted for follow-up. Outcomes were examined among the subset of individuals who agreed to be contacted for follow-up. Among those who received treatment in Spanish, the median number of counseling calls completed was 2.26. Among those who received treatment in English, the median number of counseling calls completed was 1.20. Among those who received treatment in Spanish, self-reported 7-day point prevalence abstinence was 25.1% (182/725), and biochemically confirmed abstinence was 7.6% (55/725). Among those who received treatment in English, self-reported abstinence was 14.5% (429/2,957) and biochemically confirmed abstinence was 3.7% (110/2,957). Those who received treatment in Spanish were twice as likely to be abstinent at 6 months (self-report: OR: 1.98; 95% CI: 1.62, 2.40; biochemically confirmed: OR: 2.13; 95% CI: 1.52, 2.97). Findings indicate that streamlined, automated approaches such as AAC have great potential to engage Spanish-speaking smokers in treatment. Once engaged, Spanish speakers completed more counseling calls and were twice as likely to be abstinent at 6 months. It is also notable that large discrepancies were observed between self-reported and biochemically confirmed abstinence. Citation Format: Bárbara Piñeiro, Damon J. Vidrine, David W. Wetter, Diana S. Hoover, Summer Frank-Pearce, Nga Nguyen, Susan M. Zbikowski, Jennifer I. Vidrine. Quitline treatment enrollment, dose, and cessation outcomes among safety net patients linked with treatment via Ask-Advise-Connect: Differential efficacy among Spanish- vs. English-speaking smokers [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A032.

Abstract IA07: Biobanking and genomic research: Understanding and acceptance of individuals unrepresented in clinical trials

Abstract Disparities exists in recruitment in clinical trials and biorepositories among minority groups, rural residents, and low-income individuals. The objective of this study to identify barriers and facilitators to awareness, understanding, and acceptance of clinical trials and biobanking among English- and Spanish-speaking safety-net patients and providers and African American (AA) and Hispanic social and church groups. We conducted 14 focus groups and 7 individual interviews January-May 2017 among English-speaking adults in urban and rural communities in Louisiana. In September 2018 we expanded the study to Hispanic adults. (This study is ongoing.) Sites included safety-net oncology and primary care clinics, social service agencies, Alzheimer support groups, and social and church groups. Themes were identified. The first study included 103 individuals: 78 patient and community participants and 25 providers; 24% lived in rural areas. Patients and community members' age ranged from 45-88; 85% were female, 78% AA. Participants were aware of clinical trials and personalized medicine due to ads on TV. Low-income and minority patients were open to participating in genomic trials and biobanking even if it would not benefit them directly. Cancer patients and Alzheimer family caregivers were highly interested in clinical trials that might benefit them or their family. Community participants were less trusting of clinical trials than patients. All said information about clinical trials would be most effective and actionable if it comes from a trusted physician. Terms such as clinical trials and biobanking were scary to some and not understood—medical studies and a bank to store blood and tissue were clearer. AA participants indicated that a recruitment message needs to be “ALL people are needed for studies to improve treatments” rather than “AA have been under-represented and most treatments based on whites,” which raises suspicion. Some participants were concerned with who would see data and if it would be a barrier to jobs or insurance, despite being told of protections in place for confidentiality. Community providers were interested in being more involved in clinical trials. They lacked time to identify trials and explain them to patients. They wanted brief, plain-language handouts with talking points and a card to give patients to call for more information. Transportation to academic centers is a barrier to patient participation in clinical trials. Very few patients, caregivers, or providers had looked for clinical trials on the Internet or social media. AA and lower-income white adults were interested in clinical trials but not clear how to learn about them. Most were willing to participate but had never been asked. Recommendation to participate in a clinical trial is most effective coming from a trusted physician; however, community physicians lack appropriate information to give patients. Strategies to create understandable and actionable information that can be shared with community providers and the public are urgently needed. Citation Format: Terry C. Davis, Connie Arnold, Glenn Mills, Lucio Miele. Biobanking and genomic research: Understanding and acceptance of individuals unrepresented in clinical trials [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr IA07.

4R Program results: What is the impact of 4R care delivery model on patient self-management and which patients benefited?

e19211 Background: We previously proposed a 4R model of teamwork and patient self-management (pSM) in cancer care (NCI ASCO Teams Project, Trosman JOP 2016). 4R (Right Info / Care / Patient / Time) enables patient and care team to manage complex care with an innovative 4R Care Sequence plan, including a novel visual feature describing timing and sequence of care. We report final results of a program which tested 4R at 5 safety net and 5 non safety net US centers from 2016 to 2019. Methods: Patients with stage 0-III breast cancer received 4R plans (4R Cohort). We surveyed 4R cohort and a historical control cohort of patients receiving care at same centers pre-4R. We assessed the usefulness of 4R to the 4R cohort and the impact on pSM in 4R cohort compared to historical cohort. Results: Survey response rates: 63%, 422/670 (4R cohort); 47%, 466/992 (control). 4R significantly increased the composite pSM score and 5 of 7 pSM metrics vs control (Table). The increase was not influenced by patient age, stage or whether treated at safety net site. pSM scores increased in 4R vs control cohort to a similar extent for patients &lt; 65 years old (74% vs 51%, p = .0001) as for patients ≥ 65 years old (78% vs 57%, p = .0002). pSM improved similarly for patients with stage 0 or I breast cancer (77% vs 56%, p = .0001) as for patients with stage II or III breast cancer (72% vs 54%, p = .0001). Safety net patients showed pSM increase (77% vs 51%, p = .0001) similar to non safety net patients (74% vs 58%, p = .0002). Within the 4R cohort, 80% found 4R useful for organizing care and 70% found the novel visual feature useful to manage care timing and sequence. Usefulness was similar for age groups and stages, but higher for safety net than non safety net patients (88% vs 74%, p = .0008). Conclusions: 4R markedly improved patient self-management in early breast cancer across age groups and cancer stages, but further enhancements are needed to benefit as many patients as possible. 4R benefits in safety net setting indicate that 4R may reduce disparities. [Table: see text]

Assessing social determinants of health in a safety-net oncology population: Use of an EHR-based screening and referral system.

e19072 Background: Routine electronic health record (EHR)-based screening and resource referral to address social determinants of health (SDOH) have been established in adult primary care clinics and the emergency department of New England’s largest safety-net hospital. The burden of SDOH in safety-net oncology patients is less well-studied. This study aimed to understand the social needs of this vulnerable patient population and evaluate the need for implementation of SDOH screening in the oncology clinic. Methods: Patients with lung or head and neck cancer seen in consultation in the Department of Radiation Oncology at Boston Medical Center between 3/2019-1/2020 were identified. EHRs were reviewed for receipt of THRIVE, an EHR-based screening and referral model addressing SDOH. Associations between patient demographics and SDOH screening were evaluated. Results: A total of 104 head and neck (n = 53; 51%) and lung (n = 51; 49%) patients were identified. Median age was 65 years (interquartile range 57.5-72). The majority of patients were male (71.2%), and English-speaking (82%). Whites, Blacks, and Asians comprised 43%, 38%, and 3% of patients, respectively. Fifteen patients were Hispanic (14%). Patients were most likely to have private health insurance (n = 41; 39%), followed by joint Medicare-Medicaid plans including senior and community health plans for elderly (n = 27; 26%), Medicaid (n = 17; 16%), and Medicare (n = 17; 16%). 83 of 104 patients (79.8%) were screened for at least one SDOH domain, with 55 patients (66%) screened before presentation in radiation oncology clinic. Transportation to medical appointments (16%), food insecurity (14%), and inability affording medications (10%) were the most prevalent concerns among these oncology patients. Housing insecurity, utilities, caregiving, unemployment, and education were identified social concerns for 4-5% of patients. The majority of patients who had at least one social need requested resources to assist them (71%). Age, gender, race, language, and insurance status were not associated with receipt of the SDOH screener (p≥0.1). Conclusions: Safety-net oncology patients report significant social needs. Routine SDOH screening and resource referral should be considered in these vulnerable patients.

Effects of initiating in-office germline testing in safety net clinic patients with epithelial ovarian cancer.

1588 Background: Germline genetic mutations occur in approximately 25% of women with epithelial ovarian cancers. Recent advances in frontline maintenance therapy for patients with hereditary breast and ovarian cancer syndrome make timely germline testing critical. Adherence to genetic testing remains low (approximately 30% nationally), including at our safety net hospital where germline testing by a genetic counselor was performed in only 38% of patients. After initiating in-office genetic testing, our aim was to compare current patients with historical controls to determine whether this intervention shortened the time to testing and results. Methods: IRB approval was obtained. Patients seen for a diagnosis of epithelial ovarian cancer between 4/1/2018 and 12/31/2019 were identified. Patients with only one visit or those who received testing elsewhere were excluded. Patient and visit data were abstracted for each visit during the study period. Comparison was made between patients treated before (control cohort) and after in-office testing was initiated (intervention cohort) on 5/21/2019. Categorical variables were compared using Chi Squared and Fisher’s Exact test. Mann Whitney U test was used to compare time from first clinic visit to the date of genetic testing and to the reporting of test results in the chart. All tests were two-sided and significance was set at p = 0.05. Results: 74 patients were identified and 504 clinic visits were analyzed. 57 (77%) patients were White Hispanic, 15 (20.3%) were Black, and 2 (2.7%) were White non-Hispanic. 56 (75.7%) underwent germline testing. Overall median time to testing from the first clinic visit was 21.2 weeks, and median time to reporting of results was 37 weeks. Though there was no significant difference in testing rate between the cohorts, the time to the date of genetic testing in the intervention group was approximately one-third as long as in the control group (9.6 vs 32.1 weeks, p &lt; 0.001). Among the 52 patients with reported genetic results, results were recorded in a clinic note at 4.1 weeks from first visit in the intervention group, compared with 28.8 weeks in the control group (p &lt; 0.001). In the intervention group, during clinic visits without genetics performed to date, testing was performed at that visit 25% of the time. Conclusions: By initiating in-office testing, time to testing and receipt of results were meaningfully shortened. Removing delays to test results will greatly improve the ability of our patients to receive potentially life-saving maintenance therapy following front line treatment.

Patient-reported physical and mental health of socioeconomically disadvantaged cancer patients.

e19041 Background: Patient-reported outcomes (PROs) are extensively described for cancer patients with access to care, but little information is available about PROs for socioeconomically disadvantaged cancer patients with barriers to care. Therefore, we aimed to compare patient-reported mental and physical health between newly diagnosed cancer patients at an urban safety-net cancer center and the general population. Methods: We used data collected during implementation of a quality improvement pilot initiative to integrate PROs into clinical care at the JPS Oncology and Infusion Center (Fort Worth, TX), which is a Comprehensive Community Cancer Program. The Patient-Reported Outcomes Measurement Information System (PROMIS) 10-item Global Health Survey was used to ascertain mental, physical, and social health for newly diagnosed cancer patients between August and December 2019. Our outcomes of interest were the mental and physical health subdomains. We computed T-scores, where a score of 50 represents the mean for the U.S. general population with a standard deviation (SD) of 10. We defined severely impaired health as subdomain scores ≥2 SDs below the mean. In addition, we estimated standardized morbidity ratios (SMR) and corresponding 95% confidence limits (CL) to compare the observed number of patients with severe impairment of mental or physical health with the expected number of patients with severe impairment. For example, an SMR = 1.0 implies that the observed number of severely impaired individuals in the study population is equal to the expected number in the general population. Results: Our study population comprised 59 patients, of whom 73% were aged &lt; 65 years, 51% were female, and 54% were racial/ethnic minorities. Breast (21%) and lung (21%) cancers were the most common diagnoses. The frequency of severely impaired physical health for our population was 4.4 times higher than the general population (SMR = 4.4, 95% CL: 1.6, 9.6), whereas no patients in our study population reported severely impaired mental health (SMR = 0, 95% CL: 0, 2.2). Conclusions: Our results suggest that socioeconomically disadvantaged cancer patients have substantially impaired physical health but not mental health at diagnosis. These findings may be useful for raising awareness about the importance of systematically ascertaining PROs and using the results to allocate resources for delivering care to safety-net cancer patients.

"It Gave Me Hope" Experiences of Diverse Safety Net Patients in a Group Acupuncture Intervention for Painful Diabetic Neuropathy.

Purpose: To explore the experiences of living with painful diabetic neuropathy (PDN) and with a group acupuncture intervention in a sample of low-income, diverse patients.Methods: We conducted a randomized clinical trial of a 12-week group acupuncture intervention for PDN. Data included validated measures of patient-reported outcomes, including pain and quality of life (QOL), as well as semistructured qualitative interviews about participants' experiences with PDN and the intervention. Interview transcripts were coded and analyzed using an inductive thematic framework.Results: We recruited 40 participants from diverse racial/ethnic backgrounds from a public hospital and conducted in-depth qualitative interviews with a subset of 17 participants. Participants randomized to acupuncture experienced greater decreases in pain compared with usual care as well as improved QOL. In interviews, they described a myriad of socioeconomic and personal life stressors that compounded the significant suffering and disability brought on by PDN. Those who received acupuncture were able to decrease reliance on pain medication, improve their sleep and daily function, reduce stress, and engage more with their own self-care. They noted that the acupuncture intervention also gave them hope in the face of their chronic disease.Conclusion: Acupuncture is a valuable adjunct treatment for low-income and marginalized populations with PDN. In addition to reducing pain and improving QOL, acupuncture may offer powerful benefits by increasing patient activation and hope.