Specialty Care Settings Research Articles

Change starts at home: summary of the 2023 inaugural Small Animal Antimicrobial Stewardship Workshop for US Veterinary Schools.

Small animal antimicrobial stewardship (AS) is emerging as a priority area in the global battle against antimicrobial resistance. Veterinary practices have limited support for implementation of AS programs, and even within veterinary schools, efforts are largely siloed and often limited in scope. Increased collaboration is needed to support and unify AS and infection prevention and control efforts, and to identify priorities for continued research. To address this, a 2-day in-person small animal AS workshop was held in August 2023. Delegates representing 23 US veterinary schools and 4 corporations/government agencies gathered for a series of lightning talks and focused group discussions in 3 domains: implementation of clinical AS programs, research opportunities and needs, and education. The workshop's goal was to identify and propose solutions for AS challenges. Meeting discussion identified a lack of resources and training as the greatest barriers to hospital AS program advancement and suggested creating standards for AS programs and a road map to support program development. Assessing antimicrobial treatment effects and performing studies to establish necessary treatment durations were considered the highest research priorities. Integrated educational practices were recommended to support unified messaging of AS concepts between preclinical and clinical training. The development of strategies to implement these suggestions was delegated to working groups with a goal to continue meeting biennially as a large group. Sharing news of these efforts is considered integral to heightening awareness and promoting implementation of AS practices moving forward in academic, specialty, and primary care settings.

Co-designing a blueprint for spreading person-centered, Whole Health care to HIV specialty care settings: a mixed methods protocol

BackgroundSince 2013, the Veterans Health Administration (VHA) has advanced a person-centered, Whole Health (WH) System of Care, a shift from a disease-oriented system to one that prioritizes “what matters most” to patients in their lives. Whole Health is predicated on patient-provider interactions marked by a multi-level understanding of health and trusted relationships that promote well-being. Presently, WH implementation has been focused largely in primary care settings, yet the goal is to effect a system-wide transformation of care so that Veterans receive WH across VHA clinical settings, including specialty care. This sort of system-wide cultural transformation is difficult to implement.MethodsThis three-aim mixed methods study will result in a co-designed implementation blueprint for spreading WH from primary to specialty care settings. Taking HIV specialty care as an illustrative case- because of its diverse models of relationships to primary care - to explore how to spread WH through specialty care settings. We will use the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to organize quantitative and qualitative data and identify key determinants of WH receipt among Veterans living with HIV. Through a co-design process, we develop an adaptable implementation blueprint that identifies and matches implementation strategies to different HIV specialty care configurations.DiscussionThis study will co-design a flexible implementation blueprint for spreading WH from VHA primary care throughout HIV specialty care settings. This protocol contributes to the science of end-user engagement while also answering calls for greater transparency in how implementation strategies are identified, tailored, and spread.

Task-shifting of prolonged exposure for primary care (PE-PC) for PTSD in a semirural setting in South Africa: A pilot implementation study.

Implementation science (IS) has received increased attention as it provides a means to bridge the know-do gap to implement evidence-based interventions in real-world settings. Against this backdrop, posttraumatic stress disorder (PTSD) is a global mental health concern (Koenen et al., 2017), especially in low- and middle-income countries characterized by limited trained health professionals, infrastructure, and limited access to evidence-based mental health care (Chen et al., 2017). Over the last 3 decades, effective trauma-focused psychotherapies (TFPs) for PTSD have been developed (Hamblen et al., 2019). Prolonged exposure therapy (PE) is a first-line TFP for PTSD (Hamblen et al., 2019), yet the dissemination and implementation of PE have been limited to specialty care settings in developed or industrialized countries (Booysen & Kagee, 2020). Implementation science provides an opportunity for disseminating and implementing TFPs like PE in low- and middle-income countries. This article describes mixed-method data from a pilot implementation study of an abbreviated version of PE, known as prolonged exposure for primary care (S. A. M. Rauch, Kim, et al., 2023), in a semirural city in the Eastern Cape of South Africa. Importantly, prolonged exposure for primary care shows a significant reduction in PTSD when provided by lay counselors and good feasibility and acceptability. In addition, we reflect on the barriers and facilitators related to implementation research within a low-resourced community, namely, (a) training lay counselors, (b) cultural diversity, and (c) mental health literacy. Mental health literacy is proposed as an essential component to consider in implementation science, especially in low-resourced communities. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Dementia Specialty Care Clinicians' Perspectives on Their Role in the Dementia Diagnostic Process and Diagnostic Disclosure.

Delivering a diagnosis of Alzheimer's disease and related dementias (ADRD) can be challenging not just for patients and families, but also for clinicians. Our objective was to understand dementia specialty care clinicians' perspectives on their role in diagnosis and diagnostic disclosure in dementia. Qualitative interviews with clinicians from a specialty tertiary dementia care center focused on practices, challenges, and opportunities addressing patient and caregiver needs in dementia. Data was analyzed by an interdisciplinary team using thematic analysis. The 16 participants included behavioral neurologists, social workers, neuropsychologists, and nurses. Themes included the value of providing an accurate diagnosis, the timing and challenges of delivering a diagnosis, the central focus on diagnosis alongside the need for more education on care management, and the role of the interdisciplinary team. We identified areas for improvement and strengths that can be built upon or adapted to other settings, including providing clinicians in specialty and primary care settings more guidance and support when diagnostic challenges arise, strengthening interdisciplinary teamwork, and making dementia diagnosis and care more accessible.

Predictors of response in PROMIS-global in a chronic low back pain specialty clinic: STarTBack and chronic overlapping pain conditions.

Tools, such as the STarTBack Screening Tool (SBT), have been developed to identify risks of progressing to chronic disability in low back pain (LBP) patients in the primary care population. However, less is known about predictors of change in function after treatment in the specialty care population. We pursued a retrospective observational cohort study involving LBP patients seen in a multidisciplinary specialty clinic to assess which features can predict change in function at follow-up. The SBT was administered at initial visit, and a variety of patient characteristics were available in the chart including the presence of chronic overlapping pain conditions (COPCs). Patient Reported Outcomes Measurement Information System-10 (PROMIS-10) global physical health (PH) and global mental health (MH) were measured at baseline and at pragmatic time points during follow-up. Linear regression was used to estimate adjusted associations between available features and changes in PROMIS scores. 241patients were followed for a mean of 17.0 ± 7.5months. Mean baseline pain was 6.7 (SD 2.1), PROMIS-10 global MH score was 44.8 (SD 9.3), and PH score was 39.4 (SD 8.6). 29.7% were low-risk on the SBT, 41.8% were medium-risk, and 28.5% were high-risk. Mean change in MH and PH scores from baseline to the follow-up questionnaire were 0.86 (SD 8.11) and 2.39 (SD 7.52), respectively. Compared to low-risk patients, high-risk patients had a mean 4.35points greater improvement in their MH score (p= 0.004) and a mean 3.54points greater improvement in PH score (p= 0.006). Fewer COPCs also predicted greater improvement in MH and PH. SBT and the presence of COPC, which can be assessed at initial presentation to a specialty clinic, can predict change in PROMIS following treatment. Effort is needed to identify other factors that can help predict change in function after treatment in the specialty care setting.

Specialty Care Referral for Underrepresented Minorities Living with HIV in the United States: Experiences, Barriers, and Facilitators.

The increased incidence of chronic diseases among people with HIV (PWH) is poised to increase the need for specialty care outside of HIV treatment settings. To reduce outcome disparities for HIV-associated comorbidities in the United States, it is critical to optimize access to and the quality of specialty care for underrepresented racial and ethnic minority (URM) individuals with HIV. We explored the experiences of URM individuals with HIV and other comorbidities in the specialty care setting during their initial and follow-up appointments. We conducted qualitative interviews with participants at three large academic medical centers in the United States with comprehensive health care delivery systems between November 2019 and March 2020. The data were analyzed using applied thematic analysis. A total of 27 URM individuals with HIV were interviewed. The majority were Black or African American and were referred to cardiology specialty care. Most of the participants had positive experiences in the specialty care setting. Facilitators of the referral process included their motivation to stay healthy, referral assistance from HIV providers, access to reliable transportation, and proximity to the specialty care health center. Few participants faced individual, interpersonal, and structural barriers, including the perception of individual and facility stigma toward PWH, a lack of transportation, and a lack of rapport with providers. Future case studies are needed for those URM individuals with HIV who face barriers and negative experiences. Interventions that involve PWH and health care providers in specialty care settings with a focus on individual- and structural-level stigma can support the optimal use of specialty care.

Suicide Screening, Risk Assessment, and Lethal Means Counseling During Zero Suicide Implementation.

The authors measured implementation of Zero Suicide (ZS) clinical practices that support identification of suicide risk and risk mitigation, including screening, risk assessment, and lethal means counseling, across mental health specialty and primary care settings. Six health care systems in California, Colorado, Michigan, Oregon, and Washington participated. The sample included members ages ≥13 years from 2010 to 2019 (N=7,820,524 patients). The proportions of patients with suicidal ideation screening, suicide risk assessment, and lethal means counseling were estimated. In 2019, patients were screened for suicidal ideation in 27.1% (range 5.0%-85.0%) of mental health visits and 2.5% (range 0.1%-35.0%) of primary care visits among a racially and ethnically diverse sample (44.9% White, 27.2% Hispanic, 13.4% Asian, and 7.7% Black). More patients screened positive for suicidal ideation in the mental health setting (10.2%) than in the primary care setting (3.8%). Of the patients screening positive for suicidal ideation in the mental health setting, 76.8% received a risk assessment, and 82.4% of those identified as being at high risk received lethal means counseling, compared with 43.2% and 82.4%, respectively, in primary care. Six health systems that implemented ZS showed a high level of variation in the proportions of patients receiving suicide screening and risk assessment and lethal means counseling. Two opportunities emerged for further study to increase frequency of these practices: expanding screening beyond patients with regular health care visits and implementing risk assessment with lethal means counseling in the primary care setting directly after a positive suicidal ideation screening.

Superusers’ Proactive Integrated Use of Virtual Healthcare Resources to Inform Best Practices in Rehabilitation Specialty Care Settings

Superusers’ Proactive Integrated Use of Virtual Healthcare Resources to Inform Best Practices in Rehabilitation Specialty Care Settings

Primary and Specialty Care Trainees' Perceptions About Proton Pump Inhibitor Use.

Proton pump inhibitors (PPIs) are widely prescribed with proven efficacy in many indications, yet longstanding controversy about potential adverse events persists. We aimed to acquire knowledge about perceptions of outpatient PPI long-term prescribing (≥8 wk) among primary and specialty care trainees at 2 Canadian Universities. Family medicine, internal medicine, and gastroenterology trainees completed a web-based survey that included 20 clinical scenarios assessing trainee knowledge about PPI efficacy. Contextual PPI prescribing decisions were also elicited, balancing possible PPI indications versus side effects. Management strategies were compared between junior and senior trainees, as well as across training programs. Over a 4-month period,163 trainees (age <26 y: 12%; age 26 to 45: 88%; 59% females) participated in the survey (family medicine: 51%, internal medicine: 44%, and gastroenterology: 5%); 83% were considered junior residents. Only 42% had received formal education on prescribing PPI long-term. Overall, 93% believed they would benefit from such teaching, with 98% stating they would follow related guidelines. No between-group differences were noted in knowledge of appropriate PPI indications nor possible side effects when comparing juniors to seniors, or among different specialties. Across different management scenarios, inappropriate PPI discontinuation was chosen by 14.3% to 67.2%, whereas inappropriate PPI continuation was reported in up to 57%. Trainee seniority and specialty did not differ in appropriate deprescribing rates. Training level and primary versus specialty care settings are associated with frequent inappropriate PPI prescribing and deprescribing. These findings highlight the need for and may inform future educational programs on PPI usage.

Development of a transition program for emerging adults with type 1 diabetes: A quality improvement initiative

BackgroundEmerging adults with type 1 diabetes (T1D) struggle with glycemic management that can be exacerbated by a disorganized transition process. Substantial gaps in care have been noted during this transition period and have been shown to lead to suboptimal health care utilization, worsening glycemic management, increased incidence of serious complications, and mental health challenges. A formal transition program can help prevent gaps in care, improve disease self-management skills, decrease disease burden, and reduce diabetes complications. PurposeThere is an increased focus within the pediatric community to formally prepare young adults with T1D as they transition to the adult health care setting. The purpose of the quality improvement initiative was to develop a transition program for adolescents with T1D in a pediatric endocrinology clinic within an academic medical center. Methods/interventionsThe Institute for Healthcare Improvement Model for Improvement was used to guide this project. Got Transition's® Six Core Elements of Health Care Transition were adapted to the unique needs of the pediatric endocrinology setting by incorporating diabetes-specific transition guidelines recommended by the American Diabetes Association (ADA). A new program was designed to target patients between the ages of 16–18 offering structured transition visits focused on enhancing knowledge and skills related to the management of T1D and improving the transfer of care process between pediatric and adult providers. Key elements of the program were integrated into the electronic health record. A focus group with clinical partners was used to evaluate the acceptability and practicality of the program. ResultsTransition activity within the clinic increased from 12/32–28/32 on the Current Assessment of Healthcare Transition Activities tool. Four themes were identified from clinical partner feedback supporting the acceptability and practicality of program design. ConclusionsThe integration of the Got Transition® framework and the ADA recommendations supports clinicians in meeting the unique needs of adolescents with T1D. Incorporating the transition activities into the electronic health record facilitated integration into the workflow of the clinic providers. This initiative can serve as a model to expand transition activities across pediatric specialty care settings.

INTERPROFESSIONAL HEALTH CARE: INTEGRATING AUDIOLOGY AND GERIATRICS IN INTERNATIONAL SETTINGS

Abstract Hearing is fundamental to communication and important for quality of life and overall health of older adults. Despite a potentially large role in how patients engage in healthcare, its importance is underrecognized in healthcare settings. Decreased patient-provider communication and poor treatment understanding may drive decreased satisfaction with healthcare services and avoidance of routine medical care, resulting in poorer health outcomes for older adults with hearing loss. Additionally, despite a high prevalence of hearing loss, less than 20% of those who could potentially benefit from hearing healthcare use hearing aids, potentially exacerbating sequalae of hearing loss in healthcare settings. Amidst growing recognition of the need for inter-professional healthcare collaboration, this session will focus on how audiologists and hearing specialists may partner with other healthcare providers (pharmacists, nurses, physicians) to address hearing needs in primary care, specialty care and hospital settings. We will include perspectives from the United Kingdom, the United States and Canada. We will describe factors that facilitate and impede communication between pharmacists and patients with hearing loss in the community pharmacy. We will also present results of a mixed-methods study from an interdisciplinary team (gerontology, public health, audiology, and otolaryngology/ear nose throat (ENT)) to inform primary care/ENT physicians about preferences for hearing treatment among Black women in the United States. Within a hospital setting, we will present how audiologist-nurse partnerships impact delirium. We will conclude with a discussion of how policy for hearing aid coverage impacts primary care providers recommendations for hearing healthcare in the United States.

HSD98 Patient Characteristics and Treatment Patterns in Patients with Advanced Psoriasis in Specialty Care Settings in Finland

HSD98 Patient Characteristics and Treatment Patterns in Patients with Advanced Psoriasis in Specialty Care Settings in Finland

Bridging the Gap: The Global CEOi Collaborative Workgroup for Adoption of Alzheimer’s disease Blood‐Based Biomarkers in Clinical Practice

AbstractBackgroundThe United States healthcare system is not prepared for disease modifying therapies (DMTs) of Alzheimer’s disease (AD). Eligibility for DMTs will be contingent on confirmation of AD pathology using biomarkers. Major difficulties are expected in providing PET and CSF testing in the population. Blood‐based biomarkers (BBMs) could greatly reduce the burden of biomarker testing by triaging patients for subsequent confirmation of AD brain pathology in specialty and primary care. The Global CEO Initiative on Alzheimer’s Disease (CEOi) has convened a Workgroup (WG) to develop guidelines and recommendations for the widespread adoption of BBMs in clinical practice to support feasible, timely, and accurate AD dementia diagnosis among symptomatic patients.MethodOver 80 stakeholders spanning academia, healthcare, advocacy, industry, non‐profit, and venture capital have joined the Workgroup, ensuring a wide range of expertise. The Workgroup consists of three active workstreams. Workstream A has defined use cases for symptomatic patients and minimum viable test specifications; Workstream B will provide recommendations on implementing BBMs in clinical practice; and Workstream C serves to educate practicing clinicians on outputs garnered from Workstreams A and B. Jointly led by 2 CEOi‐nominated experts, each Workstream has a core team, consisting of 6‐8 experts, and meet on a weekly basis to drive the WG objectives. General Workstream meetings are held periodically for the core team to present plans and outputs for full group input and feedback.ResultWorkgroup members have conceptualized the clinical care pathway for operationalizing BBM across specialty and primary care settings; and will present a feasible framework for real‐world implementation of BBMs. We have defined appropriate‐use criteria for BBMs in clinical settings, including test specifications, and will provide actionable recommendations to accelerate adoption in clinical care, while critically considering implementation challenges such as test result interpretation, and value to existing diagnostic pathway. Strategies to facilitate optimal implementation including novel educational tools will be disseminated.ConclusionThe Workgroup seeks rapid, efficient and effective utility of BBMs in clinical practice that is scientifically valid, and patient focused. Successful adoption will facilitate effectual triaging of patients for comprehensive diagnostic evaluations, streamlining patient access to appropriate and integrated care.

Pediatric Myasthenia Gravis

Abstract: &#x0D; Pediatric myasthenia gravis (MG) is a relatively rare, but very treatable condition. Prognosis in pediatric myasthenia gravis is favorable for minimal manifestation status (MMS) or remission when compared to adults. Ocular only presentations are more common, though severe refractory generalized MG presentations also occur. An observational examination is key to the diagnosis and follow-up of pediatric MG patients in the clinic setting. Treatment options are limited by side effect and growth considerations, as well as lack of approved MG medications in the pediatric population. Multidisciplinary care should be considered for pediatric MG, similar to other neuromuscular conditions seen in specialty care settings.

Home and Community-Based Service Use Varies by Health Care Team and Comorbidity Level of Veterans with Dementia

ABSTRACT Home and community-based services (HCBSs) such as home care and adult day centers are vital to supporting adults with dementia in community settings. We investigated whether HCBS use (use of both home care and adult day, use of one service, and use of neither service) varied between adults receiving care from three types of health-care teams with case management from social workers and nurses, and by comorbidity level, using 2019 data of 143,281 patients with dementia in the Veterans Health Administration. We compared HCBS use by patients’ type of case-managed team (Home-Based Primary Care, geriatrics-based primary care, and dementia-focused specialty care) to patients in none of these teams, stratified by patients’ non-dementia comorbidities (<4 or ≥4). Each type of health-care team was associated with both home care and adult day services, at each level of comorbidity. Home-Based Primary Care was most consistently associated with other forms of HCBS use, followed by Dementia Clinics and geriatrics-based primary care, for patients with ≥4 non-dementia comorbidities. Our findings suggest that case management in primary and specialty care settings is a contributor to the use of critical community supports by patients with the most complex needs.

One Step at a Time: Improving Gait Speed Measurement in a Geriatric Medicine Clinic.

(1) Background: Mobility assessment is a key component of the assessment of an older adult as a part of the Age-Friendly Health System (AFHS) "geriatric 4Ms" framework. Several validated tools for assessing mobility and estimating fall risk in older adults are available. However, they are often under-utilized in daily practice even in specialty geriatric medicine care settings. We aimed to increase formal mobility assessment with brief gait speed measurement in a geriatric medicine outpatient clinic using phased change interventions. (2) Methods: This quality improvement (QI) initiative was conducted in a single outpatient geriatric medicine clinic. All clinic attendees who could complete a gait speed measurement were eligible for inclusion. The outcome measure was the completion of a 4 m gait speed. Several change interventions were implemented on a phased basis using the Model for Improvement methodology during the period from December 2018 to March 2020. Statistical process control charts were used to record gait speed measurements and detect non-random shifts. (3) Results: During this QI initiative, 80 patients were seen, accounting for 142 clinic visits. In response to change interventions, gait speed measurement at clinic visits increased from a median of 25% of visits to 67% by March 2020. (4) Conclusions: Adopting an AFHS care model is an urgent and challenging task to improve the quality of care for older adults. This initiative details how to effectively incorporate a brief, validated assessment of mobility using gait speed measurement into every geriatric medicine outpatient visit and progresses implementation of the AFHS "geriatric 4Ms". Mobility assessment can aid in identifying older adults at increased fall risk.

Successful Integration of HIV PrEP in Primary Care and Women's Health Clinical Practice: A Model for Implementation.

Ending the HIV Epidemic is contingent upon the increased utilization of pre-exposure prophylaxis (PrEP). The majority of PrEP in the United States is prescribed in specialty care settings; however, to achieve national implementation goals, it is necessary to expand PrEP services in primary care and women's health clinics. To this end, a prospective cohort study was conducted of health care providers participating in one of three rounds of a virtual program aimed at increasing the number of PrEP prescribers in primary care and women's health clinics within the NYC Health and Hospitals network, the public healthcare system of New York City. Provider prescribing behavior was compared at pre-intervention (August 2018-September 2019) and post-intervention (October 2019-February 2021). Among 104 providers, the number prescribing PrEP increased from 12 (11.5%) to 51 (49%) and the number of individual patients on PrEP increased from 19 to 128. The program utilized clinical integration models centering on existing STI management workflows and was associated with increased numbers of PrEP prescribers and volume of prescriptions in primary care and women's health clinics. The dissemination of similar programs could support national scale-up of PrEP.

Using Behavior Change Theory to Identify Drivers and Barriers for Antifungal Treatment Decisions: A CaseStudy in a Large Teaching Hospital in the East of England, UK.

Antifungal stewardship (AFS) programs are recognized to contribute to optimizing antifungal prescribing for treatment and prophylaxis. However, only a small number of such programs are implemented. Consequently, evidence on behavioral drivers and barriers of such programs and learnings from existing successful AFS programs is limited. This study aimed to leverage a large AFS program in the UK and derive learnings from it. The objective was to (a) investigate the impact of the AFS program on prescribing habits, (a) use a Theoretical Domains Framework (TDF) based on the COM-B (Capability, Opportunity, and Motivation for Behavior) to qualitatively identify drivers and barriers for antifungal prescribing behaviors across multiple specialties, and (c) semiquantitatively investigate trends in antifungal prescribing habits over the last 5years. Qualitative interviews and a semiquantitative online survey were conducted across hematology, intensive care, respiratory, and solid organ transplant clinicians at Cambridge University Hospital. The discussion guide and survey used were developed to identify drivers of prescribing behavior, based on the TDF. Responses were received from 21/25 clinicians. Qualitative outcomes demonstrated that the AFS program was effective in supporting optimal antifungal prescribing practices. We found seven TDF domains influencing antifungal prescribing decisions-five drivers and two barriers. The key driver was collective decision-making among the multidisciplinary team (MDT) while key barriers were lack of access to certain therapies and fungal diagnostic capabilities. Furthermore, over the last 5years and across specialties, we observed an increasing tendency for prescribing to focus on more targeted rather than broad-spectrum antifungals. Understanding the basis for linked clinicians' prescribing behaviors for identified drivers and barriers may inform interventions on AFS programs and contribute to consistently improving antifungal prescribing. Collective decision-making among the MDT may be leveraged to improve clinicians' antifungal prescribing. These findings may be generalized across specialty care settings.

VA's implementation of universal screening and evaluation for the suicide risk identification program in November 2020 -Implications for Veterans with prior mental health needs.

United States Veterans are at higher risk for suicide than non-Veterans. Veterans in rural areas are at higher risk than their urban counterparts. The coronavirus pandemic intensified risk factors for suicide, especially in rural areas. To examine associations between Veterans Health Administration's (VA's) universal suicide risk screening, implemented November 2020, and likelihood of Veterans being screened, and receiving follow-up evaluations, as well as post-screening suicidal behavior among patients who used VA mental health services in 2019. VA's Suicide Risk Identification Strategy (Risk ID), implemented October 2018, is a national, standardized process for suicide risk screening and evaluation. In November 2020, VA expanded Risk ID, requiring annual universal suicide screening. As such, we are evaluating outcomes of interest before and after the start of the policy among Veterans who had ≥1 VA mental health care visit in 2019 (n = 1,654,180; rural n = 485,592, urban n = 1,168,588). Regression-adjusted outcomes were compared 6 months pre-universal screening and 6, 12 and 13 months post-universal screening implementation. Item-9 on the Patient Health Questionnaire (I-9, VA's historic suicide screener), Columbia- Suicide Severity Risk Scale (C-SSRS) Screener, VA's Comprehensive Suicide Risk Evaluation (CSRE), and Suicide Behavior and Overdose Report (SBOR). 12 months post-universal screening implementation, 1.3 million Veterans (80% of the study cohort) were screened or evaluated for suicide risk, with 91% the sub-cohort who had at least one mental health visit in the 12 months post-universal screening implementation period were screened or evaluated. At least 20% of the study cohort was screened outside of mental health care settings. Among Veterans with positive screens, 80% received follow-up CSREs. Covariate-adjusted models indicated that an additional 89,160 Veterans were screened per month via the C-SSRS and an additional 30,106 Veterans/month screened via either C-SSRS or I-9 post-universal screening implementation. Compared to their urban counterparts, 7,720 additional rural Veterans/month were screened via the C-SSRS and 9,226 additional rural Veterans/month were screened via either the C-SSRS or I-9. VA's universal screening requirement via VA's Risk ID program increased screening for suicide risk among Veterans with mental health care needs. A universal approach to screening may be particularly advantageous for rural Veterans, who are typically at higher risk for suicide but have fewer interactions with the health care system, particularly within specialty care settings, due to higher barriers to accessing care. Insights from this program offer valuable insights for health systems nationwide.

Abstract P2-05-01: Addressing barriers to adherence and quality of life among women recommended to receive chemoprevention for breast cancer prevention

Abstract Aims: While women with breast cancer may have increased survival when compared to other cancers, aggressive, multi-modal treatments are often required with significant impact on quality of life and economic cost, highlighting the importance of breast cancer prevention and screening. For the estimated 10 million women in the United States who meet high-risk criteria for breast cancer, evidence-based interventions may be implemented to reduce risk, including long-term chemoprevention. Engaging in preventative care requires a healthy woman to navigate a complicated decision-making process involving the woman’s perception of risk, access to information about risk and prevention strategies, access to care, social support, and the financial ability to manage cost of preventive care. Even with substantial evidence supporting chemoprevention for risk reduction, there is significant lack of uptake and adherence, especially among racial and ethnic minorities and underserved women. Given the missed opportunity for breast cancer prevention that this represents, it is critical to characterize the experience of women with chemoprevention to improve uptake and adherence to chemoprevention. Our aims were to explore the patient experience of women recommended to receive chemoprevention for breast cancer prevention. Methods: Sampling from a unique high-risk specialty care setting, we interviewed a diverse cohort of thirty women recommended to receive chemoprevention for breast cancer to learn about their experience in single semi-structured qualitative interviews. Content analysis was used to describe their experience and identify barriers to chemoprevention uptake and adherence. The MDASI-Breast was used to capture patient reported symptom burden at the time of interview. Results: Mean participant age was 54.6 years (range 34-87 years); 44.0% Hispanic; 20.0% Black; 81.0% receiving a selective estrogen receptor modulator, 19% receiving an aromatase inhibitor. Mean time since initiating chemoprevention was 14.0 months (range 1.1-49.3 months). At the time of the interview, women reported multiple symptoms, with the most severe reports of fatigue (mean severity 3.77, SD 2.91), sleep disturbance (mean severity 2.90, SD 2.47), problems with memory (mean severity 2.48, SD 2.07), drowsiness (mean severity 2.23, SD 2.14), and decrease in sexual interest or activity (mean severity 2.09, SD 2.38). In qualitative interviews, women reported barriers to preventive care related to symptom burden, access to care, access to accurate information, lack of understanding of breast cancer risk, and financial concerns. Content analysis found 20 symptoms related to both risk and preventive treatment, with 8 symptoms reported by ≥ 20% of women. All women described distress related to their risk, with 23.8% of women describing sadness related to their risk. In addition, 33.3% of women reported distress related to the impact of their own risk on their family, primarily on their children. Women (23.8%) described breast changes that were present when their risk was identified, such as a lump or pain. Treatment-related symptoms varied based on type of endocrine therapy received and history of surgery and included sleep disturbance (23.8% of women), pain (28.6%), hot flashes/night sweats (33.3%), fatigue (28.6%), and joint stiffness or soreness (23.8%). Women shared ways in which symptoms impacted daily functioning, work, relationships, and ability to enjoy life. Conclusions: Women at risk for breast cancer recommended to receive chemoprevention experience multiple barriers to adherence including symptoms related to their risk and preventive care, access to care and accurate information, and financial burden. Interventions are needed to improve access to care and symptom management. Citation Format: Jessica T. Jones, Meagan Whisenant, Kelly J. Brassil, Hannah G. Warlick, Emily Solis, Sharvari Kamat, Ann Maliackal, Amie Walters, Darcy Ponce, Anneliese Gonzalez, Denise Rios, Robinson Emily. Addressing barriers to adherence and quality of life among women recommended to receive chemoprevention for breast cancer prevention [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 P2-05-01.