Safety-net System Research Articles

Telehealth for management of chronic non-cancer pain and opioid use disorder in safety net primary care

BackgroundThe SARS-CoV-2 (COVID-19) pandemic increased use of telehealth for the management of opioid use disorder and chronic non-cancer pain in primary care safety net clinical systems. Significant barriers to telehealth exist, little is known about how these barriers impact urban safety net, primary care providers and their patients. The objective of this study was to qualitatively assess the benefits and challenges of telehealth for management of chronic non-cancer pain, opioid use disorder, and multi-morbidity in primary care, safety net clinical systems.MethodsWe interviewed patients with chronic non-cancer pain and history of substance use (n = 22) and their primary care clinicians (n = 7) in the San Francisco Bay Area, March-July 2020. We recorded, transcribed, coded, and content analyzed interviews.ResultsCOVID-19 shelter-in-place orders contributed to increases in substance use and uncontrolled pain, and posed challenges for monitoring opioid safety and misuse through telehealth. None of the clinics used video visits due to low digital literacy/access. Benefits of telehealth included decreased patient burden and missed appointments and increased convenience and control of some chronic conditions (e.g., diabetes, hypertension). Telehealth challenges included loss of contact, greater miscommunication, and less comprehensive care interactions.ConclusionsThis study is one of the first to examine telehealth use in urban safety net primary care patients with co-occurring chronic non-cancer pain and substance use. Decisions to continue or expand telehealth should consider patient burden, communication and technology challenges, pain control, opioid misuse, and medical complexity.

150 A Mixed Methods Pilot Study of Telemedicine Group Visits for Chronic Migraine in a Safety Net Health System

OBJECTIVES/GOALS: Limited specialty care within safety net health systems reduces availability of follow-up appointments for chronic conditions. We evaluated patient acceptability of a 6 month series of telemedicine group medical visits for chronic migraine at a county hospital-based clinic as a potential method to improve access to specialty care in this setting. METHODS/STUDY POPULATION: We developed and implemented a pilot program of monthly physician-led telemedicine group visits to provide routine follow-up care for adults with chronic migraine. Visits were conducted through the neurology clinic at LAC+USC medical center, a safety net hospital in Los Angeles and included an educational component, peer support, and the opportunity to address individual needs or refill medications. We assessed headache severity (HIT-6) and mood (PHQ-9) through telephone surveys before and 6 months after patients’ first telemedicine group visit and compared timepoints using paired t-tests. Patient acceptability of the group visits was elicited through focus groups and key themes identified using grounded field theory. RESULTS/ANTICIPATED RESULTS: Baseline data was available for 18/20 pilot participants. Patients were predominantly female (89%) with mean age of 46 (SD 8.6). Mean HIT-6 was 65/78 reflecting a very severe impact on daily life, and mean PHQ-9 was 8.7 reflecting mild depressive symptoms. There was no statistically significant change in either HIT-6 (mean difference 2.36, p=0.34) or PHQ-9 (mean difference 2.09, p=0.12) after group participation. Key themes from the focus groups included lack of prior exposure to other people with similar headache burden and logistical barriers to care, such as difficulty contacting a provider or extended clinic wait times. Primary patient-reported benefits included more frequent access to a provider and peer support. DISCUSSION/SIGNIFICANCE: Telemedicine group visits for chronic migraine are feasible in a safety net context and were well-received by patients. However, this pilot study did not show a benefit of telemedicine group visits for headache control or mood symptoms.

Disparities in presentation and management of chronic hepatitis B among Hispanics in a diverse safety net system.

Chronic hepatitis B (HBV) prevalence is highest in foreign-born Asian and African individuals in the US, though Hispanics make up the largest proportion of the immigrant population. Differences in the diagnosis and management of chronic HBV in Hispanics might exist due to the lower awareness of risk. We aim to examine racial/ethnic disparities in the diagnosis, presentation, and immediate management of chronic HBV in a diverse safety net system enriched for Hispanics. In a large urban safety-net hospital system, we retrospectively identified patients with chronic HBV by serological data and categorized them into mutually exclusive self-identified racial/ethnic groups: Hispanics, Asians, Blacks, and Whites. We then examined differences in screening, disease phenotype and severity, follow-up testing, and referral by race/ethnicity. Among 1063 patients, 302 (28%) were Hispanics, 569 (54%) Asians, 161 (15%) Blacks, and 31 (3%) Whites. More Hispanics (30%) were screened in the acute setting (defined as inpatient or emergency department encounters) than Asians (13%), Blacks (17%), or Whites (23%) (p<0.01). Hispanics also had lower rates of follow-up testing after HBV diagnosis than Asians including HBeAg status (43% vs. 60%, p<0.01) and HBV DNA levels (42% vs. 58%, p<0.01) and lower rates of linkage to specialty care (32% vs. 55%, p<0.01). Among those with available testing, however, the presence of immune-active chronic HBV was infrequent and similar across racial/ethnic groups. 25% of Hispanics had cirrhosis at initial presentation, proportionally higher than other groups (p<0.01). Our results underscore the importance of raising chronic HBV awareness and increasing both screening and linkage to care among Hispanic immigrants in addition to the existing risk groups, with the goal of mitigating downstream liver-related complications.

Impact of COVID-19 on healthcare utilization, cases, and deaths of citizens and displaced Venezuelans in Colombia: Complementary comprehensive and safety-net systems under Colombia's constitutional commitment.

Colombia hosts 1.8 million displaced Venezuelans, the second highest number of displaced persons globally. Colombia's constitution entitles all residents, including migrants, to life-saving health care, but actual performance data are rare. This study assessed Colombia's COVID-era achievements. We compared utilization of comprehensive (primarily consultations) and safety-net (primarily hospitalization) services, COVID-19 case rates, and mortality between Colombian citizens and Venezuelans in Colombia across 60 municipalities (local governments). We employed ratios, log transformations, correlations, and regressions using national databases for population, health services, disease surveillance, and deaths. We analyzed March through November 2020 (during COVID-19) and the corresponding months in 2019 (pre-COVID-19). Compared to Venezuelans, Colombians used vastly more comprehensive services than Venezuelans (608% more consultations), in part due to their 25-fold higher enrollment rates in contributory insurance. For safety-net services, however, the gap in utilization was smaller and narrowed. From 2019 to 2020, Colombians' hospitalization rate per person declined by 37% compared to Venezuelans' 24%. In 2020, Colombians had only moderately (55%) more hospitalizations per person than Venezuelans. In 2020, rates by municipality between Colombians and Venezuelans were positively correlated for consultations (r = 0.28, p = 0.04) but uncorrelated for hospitalizations (r = 0.10, p = 0.46). From 2019 to 2020, Colombians' age-adjusted mortality rate rose by 26% while Venezuelans' rate fell by 11%, strengthening Venezuelans' mortality advantage to 14.5-fold. The contrasting patterns between comprehensive and safety net services suggest that the complementary systems behaved independently. Venezuelans' lower 2019 mortality rate likely reflects the healthy migrant effect (selective migration) and Colombia's safety net healthcare system providing Venezuelans with reasonable access to life-saving treatment. However, in 2020, Venezuelans still faced large gaps in utilization of comprehensive services. Colombia's 2021 authorization of 10-year residence to most Venezuelans is encouraging, but additional policy changes are recommended to further integrate Venezuelans into the Colombian health care system.

Nudging to select single-lumen over multiple-lumen peripherally inserted central catheters (PICCs) in a large safety net system.

Peripherally inserted central catheters (PICCs) are increasingly used for vascular access in inpatient settings. Compared to multilumen PICCs, single-lumen PICCs carry a lower rate of complications, including central-line-associated bloodstream infection and thrombosis. Despite this, multilumen PICCs are still overused. This quality improvement initiative was implemented across 11 hospitals at New York City Health + Hospitals safety net system. The electronic health record (EHR) interventional radiology or vascular access team consultation orders were modified to allow for lumen choice, with default selection to a single-lumen PICC. Average single-lumen PICC utilization increased by 25.5%, from 44.4% to 69.9% (P < .001). CLABSI rates had a nonsignificant reduction by 26.7% from 2.44 to 1.79 infections per month (P = .255). Among provider types in the postintervention period, single-lumen PICC utilization ranged from 67.7% for advanced practice providers to 82.4%-94.6% for physicians. Among provider specialties, utilization ranged from 31.8% for neurology to 97.7% for orthopedics. Additionally, there was large variation in pre- and postintervention differences in utilization by hospital. We successfully increased single-lumen PICC utilization across all 11 safety net hospitals. This expands on previous work on improving single-lumen PICC use and use of default nudges in large, resource-limited settings. Further study is needed to examine variation among provider types, specialties, and hospitals.

Reducing Maternal Obesity and Diabetes Risks Prior to Conception with the National Diabetes Prevention Program.

Intrauterine exposure to maternal obesity and hyperglycemia greatly increases offspring health risks. Scalable lifestyle interventions to lower weight and glycemia prior to conception are needed, but have been understudied, especially in diverse and low-income women with disproportionately high risks of negative maternal-child outcomes. The objective of this report is to provide initial evidence of the National Diabetes Prevention Program's (NDPP) effects on maternal-child outcomes in diverse, low-income women and their offspring. The yearlong NDPP was delivered in a safety net healthcare system to 1,569 participants from 2013 to 2019. Using medical records, we evaluated outcomes for women < 40 years who became pregnant and delivered after attending the NDPP for ≥ 1 month (n = 32), as compared to a usual care group of women < 40 years (n = 26) who were initially eligible for the NDPP but were excluded due to pregnancy at enrollment. Most women in either group were Latinx, had Medicaid or were uninsured, and had obesity at baseline. The mean difference in BMI change from baseline to conception was - 1.8 ± 0.6kg/m2 (p = 0.002) for NDPP versus usual care. Fewer NDPP participants had obesity at conception (56.7% vs. 88.0%, p = 0.011) and hyperglycemia in early pregnancy (4.0% vs. 25.0%; p = 0.020) than usual care. No other differences were statistically significant, yet nearly all outcomes favored the NDPP. Covariate-adjusted results were consistent, except the difference in frequency of obesity at conception was no longer significant (p = 0.132). Results provide preliminary evidence that the NDPP may support a reduction in peri-conceptional obesity/diabetes risks among diverse and low-income women.

Choosing wisely initiative for reducing urine cultures for asymptomatic bacteriuria and catheter-associated asymptomatic bacteriuria in an 11-hospital safety net system

BackgroundTreatment of asymptomatic bacteriuria (ASB) is common. Overtreatment of ASB leads to harm, including adverse effects from antibiotics, antibiotic resistance, and increased length of stay. MethodsThis quality improvement initiative targeted inappropriate urine cultures across 11 hospitals in a safety-net setting. A mandatory prompt for appropriate indications for urine culture orders and a best practice advisory (BPA) for urine culture on patients with urinary catheters were created. Urine culture ordering was compared pre-intervention (6/2020 to 10/2021) to post-intervention (12/2021 to 8/2022). Catheter associated urinary tract infections (CAUTI) was compared pre- and post-intervention. Variation in urine culture ordering and CAUTI rates in hospitals were assessed. ResultsInpatient urine cultures decreased by 20.9% (p<0.001). Inpatient urine cultures on patients with urinary catheters decreased by 21.6% (p<0.001). CAUTI rates remained unchanged post-intervention. High variation in urine culture ordering and CAUTI rates was seen among hospitals. ConclusionsThis initiative successfully decreased urine cultures in a large, safety-net system. Further study is needed in assessing variation among hospitals.

Perspectives on opportunities and challenges in a predominantly flipped classroom-based pharmacy curriculum: A qualitative study

IntroductionTo adapt to flipped classroom pedagogy in universities, factors such as the amount of the program that is flipped, students' pre-existing educational experiences, and cultural background may influence adjusting to the approach. We investigated students' perspectives across four years of a predominantly flipped classroom-based pharmacy curriculum in a low to middle income country. MethodsWe conducted five semi-structured focus groups with 18 pharmacy students from years one to four of the bachelor of pharmacy program at Monash University Malaysia where students came from different pre-university backgrounds. Focus group recordings were transcribed verbatim and thematically analysed. Interrater reliability was performed to ascertain reliability of themes. ResultsThree major themes were identified. Firstly, students cited issues moving past the initial barrier when starting flipped classrooms in terms of education background impacting adaptability and how/why they eventually adapted. Another theme was how flipped classrooms helped development of life skills such as adaptability, communication, teamwork, self-reflection, and time management. The final theme was on requiring a sufficient safety net and support system in flipped classrooms that included well designed pre-classroom materials and well-implemented feedback mechanisms. ConclusionsWe have identified students' perspectives on the benefits and challenges associated with a predominantly flipped classroom pharmacy curriculum in a low to middle income country setting. We suggest using scaffolding and effective feedback approaches to guide the implementation of flipped classrooms successfully. This work can aid future educational designers in preparation and supporting a more equitable learning experience regardless of student background.

Abstract P6-08-14: Breast Cancer Treatment Choices and Results in Hispanic Women Without Funding for Radiation

Abstract Background: Although the survival rates for breast cancer have improved, there is still a disparity gap between Hispanic women and non-Hispanic women. Hispanic women in the US are vulnerable to cancer inequalities due to a plethora of barriers including disproportionate poverty, lack of health insurance, and citizenship status. A Surveillance, Epidemiology, and End Results analysis found that Hispanic women had lower rates of both early-stage breast cancer and receipts of radiation therapy (RT) after breast-conserving surgery than White women. For patients without private or government health insurance, charity and county indigent programs have variable levels of coverage, and some patients cannot access radiation services. The aim of this study is to identify disparities in breast cancer treatment for patients referred to the Travis County indigent cancer treatment program. Methods: We analyzed new referrals to the Ascension Seton Breast Clinic from April 2020 to January 2022. Demographics, disease stage, funding and treatments were extracted from medical records. We compared funding status at the time of referral vs time of surgery. We also analyzed the type of surgery elected and if RT was indicated and received. Results: We found that out of 242 referrals, 116 were diagnosed with a new malignancy. Of the 116, a total of 76 underwent breast surgery and RT was considered in 64 of these patients. 61% received RT. Of the remaining 25 patients, 16 patients elected simple mastectomies and 9 did not have funding to cover radiation (income was not low enough to qualify for RT benefit under the health district). Of the 9 women who did not have funding about 78% identified as Hispanic or Latino. 4 opted for simple mastectomies thus no longer needing RT, 3 received modified radical mastectomies without RT, 1 accessed charity funding for RT and 1 had lumpectomy without radiation and had recurrence of her breast cancer. Overall, the rate of breast conserving surgery was 43%. Discussion: The safety net system for patients in the US without access to private or government funding for healthcare is inherently limited. Costs of radiation treatment for cancer can be prohibitive for charity and indigent programs, but patients are forced to choose between mastectomy or risk a higher rate of recurrence. This data will be used to advocate for health district funding for this patient population. Citation Format: Maria De Los Leon-Camarena, Neha Reddy, Kimberly Ellison, Boone Goodgame. Breast Cancer Treatment Choices and Results in Hispanic Women Without Funding for Radiation [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-08-14.

Randomized trial protocol for remote monitoring for equity in advancing the control of hypertension in safety net systems (REACH-SNS) study

BackgroundSelf-measured blood pressure monitoring (SMBP) is essential to effective management of hypertension. This study aims to evaluate effectiveness and implementation of SMBP that leverages: cellular-enabled home BP monitors without a need for Wi-Fi or Bluetooth; simple communication modalities such as text messaging to support patient engagement; and integration into existing team-based workflows in safety-net clinics. MethodsThis study will be conducted with patients in San Francisco who are treated within a network of safety-net clinics. English and Spanish-speaking patients with diagnosed hypertension will be eligible for the trial if they have recent BP readings ≥140/90 mmHg and do not have co-morbid conditions that make home BP monitoring more complex to manage. This study will implement a three-arm randomized controlled trial to compare varying levels of implementation support: 1) cellular-enabled BP monitors (with minimal implementation support), 2) cellular-enabled BP monitors with protocol-based implementation support (text reminders for patients; aggregated BP summaries sent to primary care providers), and 3) cellular-enabled BP monitors and pharmacist-led support (pharmacist coaching and independent medication adjustments). ResultsFor the main analysis, we will use mixed effects linear regression to compare the change in primary outcome of systolic BP. Secondary outcomes include BP control (<140/90 mmHg), medication intensification, patient-reported outcomes, and implementation processes (i.e., engagement with the intervention). DiscussionThis study will design and test a digital health intervention for use in marginalized populations treated within safety net settings, evaluating both effectiveness and implementation to advance more equitable health outcomes.

Skin and soft tissue infection incidence before and during the COVID-19 pandemic.

Skin and Soft Tissue Infections (SSTIs) are common bacterial infections. We hypothesized that due to the COVID-19 pandemic, SSTI rates would significantly decrease due to directives to avoid unneeded care and attenuated SSTIs risk behaviours. We retrospectively examined all patients with an ICD-10 diagnosis code in the Los Angeles County Department of Health Services, the second largest U.S. safety net healthcare system between 16 March 2017 and 15 March 2022. We then compared pre-pandemic with intra-pandemic SSTI rates using an interrupted time series analysis. We found 72,118 SSTIs, 46,206 during the pre-pandemic period and 25,912 during the intra-pandemic period. Pre-pandemic SSTI rate was significantly higher than the intra-pandemic rate (3.27 vs. 2.31 cases per 1,000 empanelled patient-months, P<0.0001). The monthly SSTI cases decreased by 1.19 SSTIs/1,000 empanelled patient-months between the pre- and intra-pandemic periods (P=0.0003). SSTI subgroups (inpatient, observation unit, emergency department, and outpatient clinics), all had significant SSTI decreases between the two time periods (P<0.05) except for observation unit (P=0.50). Compared to the pre-COVID-19 pandemic period, medically attended SSTI rates in our large U.S. safety net healthcare system significantly decreased by nearly 30%. Whether findings reflect true SSTI decreases or decreased health system utilization for SSTIs requires further examination.

What Should Antiracist Payment Reform Look Like?

Racism reduces eligibility for health insurance and access to high-quality care for people of color in the United States, and current payment structures exacerbate the resultant de facto racial segregation. Payers and health plans do not adequately support and incentivize clinicians and health care delivery organizations to meet the health needs of minoritized communities. This article describes foundational work needed to create an antiracist culture of equity; the Roadmap to Advance Health Equity; and specific, actionable antiracist payment reform strategies, including increasing access to and the scope of health insurance coverage, antiracism accountability in managed-care contracts, support for the safety-net system, strengthened nonprofit hospital tax status requirements, and payment incentives to advance health equity. Antiracist payment reforms have great potential to desegregate health care systems and to ensure that everyone has a fair opportunity to receive good health services and optimize their health.

Tell-a provider about tele: Reducing overuse of telemetry across 10 hospitals in a safety net system.

Telemetry is often a scarce resource at hospitals and is important for arrhythmia and myocardial ischemia detection. Overuse of telemetry monitoring leads to alarm fatigue resulting in failure to respond to arrhythmias, patient harm, and possible unnecessary testing. This quality improvement initiative was implemented across NYC Health and Hospitals, an 11-hospital urban safety net system. The electronic health record intervention involved the addition of a mandatory indication in the telemetry order and a best practice advisory (BPA)that would fire after the recommended time period for reassessment had passed. The average telemetry hours per patient encounter went from 60.1 preintervention to 48.4 postintervention, a 19.5% reduction (p < .001). When stratified by the 11 hospitals, decreases ranged from 9% to 30%. The BPA had a 53% accept rate and fired 52,682 times, with 27,938 "discontinue telemetry" orders placed. The true accept rate was 50.4%, as there was a 2.6% 24-hreorder rate. There was variation based on clinician specialty and clinician type (attending, fellow, resident, physician associate, nurse practitioner). We successfully reduced telemetry monitoring across a multisite safety net system using solely an electronic health record (EHR) intervention. This expands on previous telemetry monitoring reduction initiatives using EHR interventions at single academic sites. Further study is needed to investigate variation across clinician type, specialty, and post-acute sites.

Neighborhood socioeconomic status and the effectiveness of colorectal cancer screening outreach with mailed fecal immunochemical tests within a safety net healthcare system in San Francisco, CA: A subgroup analysis of a randomized controlled trial

Neighborhood context shapes opportunities and barriers for residents to access healthcare and cancer screening. Neighborhood socioeconomic status (nSES) is associated with disparities in colorectal cancer (CRC) screening, but the extent to which the effectiveness of specific screening interventions vary by nSES has not been studied. The original trial conducted in San Francisco, CA from 2016 to 2017 randomly assigned patients eligible for CRC screening either to a multicomponent intervention including advanced notification, mailed fecal immunochemical test (FIT) kits and reminders or to a control group receiving usual care. For the nSES analysis addresses for 9699 patients were geocoded and stratified by city-wide nSES quintile (Q1 lowest, Q5 highest) using an established index at the census tract level. Compared to usual care, the outreach intervention improved FIT test completion at one year (58.7% vs 38.4%; OR 2.32 [2.14, 2.52]) but its effectiveness did not vary substantially by nSES quintile (adjusted OR Q1 2.64 [2.30, 3.04]; Q2 2.43 [2.04, 2.90]; Q3 2.31 [1.84, 2.89]; Q4 2.47 [1.86, 3.28]; Q5 2.64 [1.83, 3.81]; Wald test for interaction p = 0.87). The implementation of mailed FIT outreach has the potential to increase CRC screening completion without leading to disparities in screening related to nSES (ClinicalTrials.gov NCT02613260).

Developing a Model to Predict High Health Care Utilization Among Patients in a New York City Safety Net System.

Health care facilities use predictive models to identify patients at risk of high future health care utilization who may benefit from tailored interventions. Previous predictive models that have focused solely on inpatient readmission risk, relied on commercial insurance claims data, or failed to incorporate social determinants of health may not be generalizable to safety net hospital populations. To address these limitations, we developed a payer-agnostic risk model for patients receiving care at the largest US safety net hospital system. We transformed electronic health record and administrative data from 833,969 adult patients who received care during July 2016-July 2017 into demographic, utilization, diagnosis, medication, and social determinant variables (including homelessness and incarceration history) to predict health care utilization during the following year.We selected the final model by developing and validating multiple classification and regression models predicting 10+ acute days, 5+ acute days, or continuous acute days. We compared a portfolio of performance metrics while prioritizing positive predictive value for patients whose predicted utilization was among the top 1% to maximize clinical utility. The final model predicted continuous number of acute days and included 17 variables. For the top 1% of high acute care utilizers, the model had a positive predictive value of 47.6% and sensitivity of 17.3%. Previous health care utilization and psychosocial factors were the strongest predictors of future high acute care utilization. We demonstrated a feasible approach to predictive high acute care utilization in a safety net hospital using electronic health record data while incorporating social risk factors.

Suubi4StrongerFamilies: A study protocol for a clustered randomized clinical trial addressing child behavioral health by strengthening financial stability and parenting among families in Uganda.

Children in Sub-Saharan Africa are burdened by significant unmet mental health needs. Across the region, high rates of poverty, HIV/AIDS, food insecurity, stigma, and an inadequate health safety net system exacerbate serious child behavioral health needs and impede an effective response. Disruptive behavioral disorders are particularly concerning as they persist through adolescence and adulthood. Hence, addressing the context-specific social influences on child behavioral health is critical given that children in the region comprise more than half of the total regional population. Against this backdrop, this study protocol describes a randomized clinical trial that will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial, and context-specific drivers affect the mental health of children in Uganda. The study uses an experimental, longitudinal design across 30 cluster-randomized primary schools to compare single and combination intervention options; influences of economic empowerment and family strengthening on economic, perceptual, and functioning mediators; and context-specific moderators. The study will be conducted with 900 Ugandan children in mid-upper primary school (10-14 years). The three study conditions (n = 300 each) are: (1) economic empowerment only (EE only), (2) multiple family group-based family strengthening only (MFG-based FS only), and (3) combined EE + MFG-based FS. The interventions will be provided for 12 months; and assessments will occur at baseline, 12, 24, and 36 months. Children in Sub-Saharan Africa are burdened by significant unmet mental health needs, including disruptive behavior disorders that persist through adolescence and adulthood if left untreated. The proposed study will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial and context-specific drivers affect the mental health of children in mid-upper primary schools in Uganda. Findings from this study can inform group, community, and population approaches that are needed for scalable solutions to address the social drivers negatively impacting child behavioral health in low-resource settings, including in Sub-Saharan Africa. [https://clinicaltrials.gov/], identifier [NCT053 68714].

Worsened outcomes of newly diagnosed cancer in patients with recent emergency care visits: A retrospective cohort study of 3699 adults in a safety net health system.

Many patients receive a suspected diagnosis of cancer through an emergency department (ED) visit. Time to treatment for a new diagnosis of cancer is directly associated with improved outcomes with little no describing the ED utilization prior to the diagnosis of cancer. We hypothesize that patients that have an ED visit in proximity to a diagnosis of cancer will have worse outcomes, including mortality. This study is a retrospective cohort study of all patients with cancer diagnosed at Eskenazi Health (Indiana) between 2016 and 2019. Individual health characteristics, ED utilization, cancer types, and mortality were studied. We compared those patients seen in the ED within 6months prior to their diagnosis (cases) to patients not seen in the ED (controls). A total of 3699 patients with cancer were included, with 1239 cases (33.50%). Patients of black race had higher frequencies in the cases vs. controls (46.57% vs. 40.68%). Lung cancer was the most frequently observed cancer among cases vs. controls (11.70% vs. 5.57%). For the cases, 232 patients were deceased (18.72%) compared with 247 patients among the controls (10.04%, p< 0.0001, OR 2.06 95% confidence interval [CI] 1.70-2.51). An ED visit in past 6months (OR=1.73, 95% CI 1.38-2.18) and Medicaid insurance type (versus commercial, OR=4.16, 95% CI 2.45-7.07) were associated with of mortality. Female gender (OR=0.76, 95% CI 0.67-0.88), tobacco use (OR=1.62, 95% CI 138-1.90), and Medicaid insurance type (versus commercial, OR=2.56, 95% CI 2.07-3.47) were associated with prior ED use. Over one third of patients with cancer were seen in the ED within 6months prior to their cancer diagnosis. Higher mortality rates were observed for those seen in the ED. Future studies are needed to investigate the association and impact that the ED has on eventual cancer diagnoses and outcomes.

Creating a Safety Net Process to Improve Colon Cancer Diagnosis in Patients With Rectal Bleeding.

Background Failure to follow up on patients with rectal bleeding is common and may result in a delay in diagnosis of colorectal cancer or in missing high-risk adenomas. The authors' purpose was to create an electronic patient safety net for those diagnosed with rectal bleeding but who did not have colonoscopy to ensure proper detection of colonic abnormalities, including colon cancer. Methods In an integrated health delivery system serving < 4.6 million patients in Southern California, from 2014 to 2019, the authors electronically identified patients with rectal bleeding aged 45 to 80 years but with no recently documented colonoscopy. These cases were reviewed by a gastroenterologist to determine if colonoscopy was appropriate. The physician looked for known documentation as to the cause of rectal bleeding and verified no contraindications to the procedure; if indicated, testing was offered. Results Using the authors' safety net program, 1430 patients with rectal bleeding who needed and completed a colonoscopy were identified. Of those patients, 7.5% had an advanced adenoma or cancer, with a total of 20 cancers, and 34% had findings that warranted more frequent colonoscopy. Conclusions The authors designed a safety net system that was able to capture information on patients with rectal bleeding who had not had a colonoscopy and detected in 34% colonic pathology that would have otherwise gone undetected. The program did not require many resources to implement and had the ability to potentially prevent harm from reaching patients whose rectal bleeding did not get prompt workup. Other health systems and practices should consider implementing a similar system.

SEE the DIFFerence: Reducing unnecessary C. difficile orders through clinical decision support in a large, urban safety-net system

Clostridioides difficile (C. difficile) is a hospital-acquired infection. Overtesting for C. difficile leads to false positive results due to a high rate of asymptomatic colonization, resulting in unnecessary and harmful treatment for patients. This was a quality improvement initiative to decrease the rate of inappropriate C. difficile testing across 11 hospitals in an urban, safety-net setting. Three best practice advisories were created, alerting providers of recent laxative administration within 48 hours, a recent positive test within 14 days, and a recent negative test within 7 days. The outcome measures were the number of C. difficile tests per 1,000 patient days, as well as the rate of hospital onset C. difficile infection was compared pre- and post-intervention. The process measures included the rate of removal of the C. difficile test from the best practice advisory, as well as the subsequent 24-hour re-order rate. The number of C. difficile tests decreased by 27.3% from 1.1 per 1,000 patient days preintervention (May 25, 2020-May 24, 2021) to 0.8 per 1,000 patient days postintervention, (May 25, 2021-March 25, 2022), P < .001. When stratified by hospital, changes in testing ranged from an increase of 12.5% to a decrease of 60%. Analysis among provider type showed higher behavior change among attendings than compared to trainees or advanced practice providers. There was a 12.1%, nonsignificant decrease in C. difficile rates from preintervention, 0.33 per 1,000 patient days compared to postintervention, 0.29 per 1,000 patient days, P=.32. Using only an electronic health record intervention, we successfully decreased C. difficile orders after 72 hours of admission in a large, safety-net system.Variation existed among hospitals and by provider type.

Abstract 14135: Neighborhood Socioeconomic Status and Heart Failure or All-Cause Readmission Within a Safety-Net System

Introduction: Neighborhood socioeconomic status (NSES) independently predicts higher rates of heart failure (HF) readmission, but whether this is true in a safety-net system is uncertain. Methods: We conducted a retrospective EHR-based cohort study of adults with HF between 2001-2019 at a municipal safety-net hospital in SF using Fine-Gray survival models. Most recent residential addresses were geocoded. NSES index is a composite measure including income, education, employment, and housing scaled to the SF Bay Area as quintiles (1=lowest, 5=highest). Results: Among 2,507 individuals with index HF hospitalization, 179 (7.1%) were readmitted within 30 days for HF and 374 (14.9%) for any cause. Within 1 year, 639 (25.5%) were readmitted for HF and 1,185 (47.3%) for any cause. In unadjusted analyses, NSES is associated with HF readmission at 30 days (p=0.013) or 1 year (p=0.021) and all-cause readmission at 30 days (p=0.0015) or 1 year (p=0.0049). Adjusted for demographics, substance use, and comorbidities, Quintile 1 has 58% higher risk of HF readmission (HR=1.58, 95% CI 1.07-2.33, p=0.021) and 56% higher risk of all-cause readmission (HR=1.56, 95% CI 1.19-2.05, p=0.001) over 1 year than Quintile 5. Similarly, compared to Quintile 5, all quintiles have higher risk of all-cause readmission over 1 year from Quintile 2 (HR=1.53, 95% CI 1.16-2.03, p=0.003) to Quintile 4 (HR=1.50, 95% CI 1.10-2.03, p=0.010). Including GDMT prescription does not change these results. Conclusion: NSES is associated with a higher risk of HF and all-cause readmissions over 1 year in a safety-net hospital. Further studies should investigate NSES domains to identify interventions and address disparities.