UMass Memorial Medical Center Research Articles

Exploring patients' experiences with telehealth in obstetrics care during the COVID-19 pandemic: A qualitative study.

The aim of this study was to evaluate patients' experiences with telehealth provision of obstetrics and gynecology care during the COVID-19 pandemic qualitatively. In this study, a qualitative research design, namely descriptive phenomenology, was employed. Participants were recruited from the OB department at UMass Memorial Medical center in Worcester, MA, between 6/2020 and 7/2020. Between June 2020 and July 2020, in-depth interviews were conducted with 18 women receiving care at the Obstetrics and Maternal and Fetal Medicine clinics. Data were analyzed using qualitative thematic analysis, as outlined by Braun and Clarke. Telehealth is a feasible and safe health-care tool that is available during these unprecedented times. This study provided qualitative evidence based on patients' perspectives and experiences. Participants' meanings in relation to their experiences of using telehealth services emerged from the data in four themes: the overall experience of using modern telehealth platforms, telehealth and its perceived benefits, telehealth and its perceived challenges, and telehealth and its potential future use. While this study highlights areas in telehealth implementation that require improvement, the overall positive experiences and consistent perceived benefits of most participants suggests that telehealth can be an important tool in healthcare delivery for appropriate patients and situations moving forward in a post-pandemic world. During the global pandemic, telehealth has been recognized to have the potential to play a critical role in healthcare delivery. Establishing qualitative evidence-based practices in the emerging field of telehealth for OB services is pivotal to mitigate potential safety, feasibility, and cost issues that could be associated with the rapid adoption of telehealth. Yet, this qualitative study However highlighted several challenges that are necessary to be addressed in order for telehealth to meet maximum effectiveness and functionality in the future.

TeamBirth to Enhance Communication and Inpatient Maternity Care Experiences in English and Non-English-Speaking Patients [ID: 1380450

INTRODUCTION: Communication affects obstetric experiences. Limited data exist on the effect of speaking a language other than English on birthing persons’ experiences. Few scalable solutions exist to improve communication and mitigate potential poor clinical care experiences. We aimed to understand UMass Memorial Medical Center’s TeamBirth initiative on experiences with health care teams between English and non-English-speaking obstetric patients. METHODS: The TeamBirth quality improvement initiative was implemented May 2021. TeamBirth includes structured communication approaches using storyboarding and “huddles” throughout inpatient maternity care. During postpartum stay (May 3, 2021 to May 31, 2022), patients were given an opportunity to complete surveys including validated tools. Data analyses compared experiences between English- and non-English-speaking patients. RESULTS: Of 886 respondents, 785 were English-speaking (89%), and 101 were non-English-speaking (11%). English as compared to non-English-speaking patients reported having greater than or equal to 1 huddle in labor (75.1% versus 65.7%, P=.052). Sharing preferences was perceived as making a difference (yes somewhat or definitely) in care (82.0% English- versus 80.9% non-English-speaking, P=.64). There were no statistically significant differences between English- and non-English-speaking patients regarding questions about clinical teams helping patients understand all information (P=.85), providers using words patients did not understand (P=.62), providers talking too fast (P=.29), and providers ignoring what was shared (P=.36). Overall, regardless of preferred language, patients felt their providers were trustworthy (P=.64). CONCLUSION: TeamBirth may play a role in improving disparities within clinical care experiences between English and non-English speakers through enhanced communication. Ultimately, this may result in improved health outcomes and a more equitable experience for marginalized obstetric patients.

Richard Hader Visionary Leader Award 2022 Visionary Leader Finalist Justin Precourt

The following manuscript, selected as a finalist for the 2022 Richard Hader Visionary Leader Award entry, was submitted to Nursing Management in recognition of Justin Precourt, DNP, RN, NEA-BC, chief nurse executive at UMass Memorial Health and CNO at UMass Memorial Medical Center in Worcester, Mass.

Changes in postpartum contraception utilization rates during the early stage of the COVID-19 pandemic.

The first wave of the COVID-19 pandemic was associated with restricted access to reproductive care including delayed abortion and female sterilization procedures, in addition to altered maternity care experiences. Given high rates of unintended and short-interval pregnancies in the United States in general and negative obstetric outcomes specifically associated with COVID-19, access to all effective pregnancy prevention methods during the pandemic was crucial. To investigate changes in contraception utilization rates prior to delivery discharge, at outpatient postpartum visits, and at 10 weeks' postpartum, at the largest healthcare system in Central Massachusetts, during the first wave of the COVID-19 pandemic (15 March to 15 May 2020), compared to the same period in 2019. Retrospective cohort review. Compared perinatal individuals (n = 495) who received prenatal care and delivered at UMass Memorial Medical Center from mid-March to mid-May in both 2019 (non-pandemic) and 2020 (COVID-19 pandemic). Receipt of contraception prior to delivery discharge and at outpatient postpartum visit was estimated and compared between the two time periods using the Chi-square test for categorical variables (or Fisher's exact test when cell counts were < 5) and Student's t-test for continuous variables. Multivariable logistic regression was performed to adjust for confounders. The proportion of individuals who used long-acting reversible contraception before delivery discharge was 4% in 2019 and 13% in 2020 (p = 0.01). Modes of outpatient postpartum visit contraception did not vary from 2019 to 2020, (p = 0.06). Overall, there were no differences in contraception utilization rates at 10 weeks' postpartum from 2019 to 2020, (p = 0.50). Compared to a year prior, immediate postpartum long-acting reversible contraception use increased during the first wave of the COVID-19 pandemic, while overall contraception use at 10 weeks' postpartum remained unchanged. The evaluation of contraceptive use during the most restrictive time of COVID-19 pandemic can help identify opportunities to increase access to effective contraception, such as the immediate postpartum period prior to hospital discharge.

Racial and Sociodemographic Disparities in Telehealth Access and Utilization during the COVID-19 Pandemic

BACKGROUND: Telehealth is not new, but licensing restrictions, HIPAA compliance issues, and lack of reimbursement were significant barriers that hindered its success in the past. Enabling practices to adopt telehealth so that in-person care could be limited to urgent patients and curbed use of finite clinical resources like personal protective equipment for which there was significant shortages. This expansion allowed services including, but not limited to, home visits, therapy services, emergency consults, and nursing facilities visits to be conducted remotely.&#x0D; AIMS: The study objectives are to describe telehealth utilization rates among OB/GYN patients during the first four months of the COVID-19 pandemic by race/ethnicity and insurance coverage and to investigate telehealth access disparities.&#x0D; METHODS: A cross-sectional analysis design was employed. Data abstraction was performed using the electronic medical records of UMass Memorial Medical Center (UMMMC). A convenience sample of 9370 Women who received their telehealth or in-person care at the UMass Memorial Medical Center (UMMMC).&#x0D; RESULTS: Between March 15, 2020, and July 30, 2020, in total, 15,362 encounters were completed. Throughout the timeframe included in this study, 81.34% of appointments were conducted in person, and 18.66% were completed using telehealth. The age of telehealth patients ranged from 17 to 97, with a mean age of 45. Most of the patients were white (n=1202, 63.4%) and held private health insurance (n= 975, 52.4%). Hispanic and Asian patients were less likely to attend their telehealth appointment than patients of other races (p &lt;0.001). Patients with private health insurance were more likely to attend their telehealth appointments than patients with public health insurance (p &lt;0.001).&#x0D; CONCLUSIONS: Telehealth services have been providing patients with access to OB/GYN care during this challenging time and have enhanced health care delivery opportunities. This study identifies a clear need to improve telehealth access and utilization rates among racial and ethnic minority groups and persons with public insurance.&#x0D; Keywords: Telehealth, Health disparity, Telemedicine, Obstetrics

Definitive Radiation Therapy for Medically Inoperable Endometrial Carcinoma

PurposeUpfront radiation therapy consisting of brachytherapy with or without external beam radiation therapy is considered standard of care for patients with endometrial carcinoma who are unable to undergo surgical intervention. This study evaluated the cancer-free survival (CFS), cancer-specific survival (CSS), and overall survival (OS) of patients with endometrial carcinoma managed with definitive-intent radiation therapy. Methods and MaterialsThis was a single-institution retrospective analysis of medically inoperable patients with biopsy-proven endometrial carcinoma managed with up-front, definitive radiation therapy at UMass Memorial Medical Center between May 2010 and October 2021. A total of 55 cases were included for analysis. Patients were stratified as having low-risk endometrial carcinoma (LREC; uterine-confined grade 1-2 endometrioid adenocarcinoma) or high-risk endometrial carcinoma (HREC; stage III/IV and/or grade 3 endometrioid carcinoma, or any stage serous or clear cell carcinoma or carcinosarcoma). The CFS, CSS, OS, and grade ≥3 toxic effects were reported for patients with LREC and HREC. ResultsThe median age was 66 years (range, 42-86 years), and the median follow-up was 44 months (range, 4-135 months). Twelve patients (22%) were diagnosed with HREC. Six patients (11%) were treated with high-dose-rate brachytherapy alone and 49 patients (89%) were treated with high-dose-rate brachytherapy and external beam radiation therapy. Twelve patients (22%) were treated with radiation and chemotherapy. The 2-year CFS was 82% for patients with LREC and 80% for patients with HREC (log rank P = .0654). The 2-year CSS was 100% for both LREC and HREC patients. The 2-year OS was 92% for LREC and 80% for HREC (log P = .0064). There were no acute grade ≥3 toxic effects. There were 3 late grade ≥3 toxic effects owing to endometrial bleeding and gastrointestinal adverse effects. ConclusionsFor medically inoperable patients with endometrial carcinoma, up-front radiation therapy provided excellent CFS, CSS, and OS. The CSS and OS were higher in patients with LREC than in those with HREC. Toxic effects were limited in both cohorts.

Radiotherapy in Medically Inoperable Patients with Endometrial Carcinoma

<h3>Purpose/Objective(s)</h3> Upfront radiotherapy with or without brachytherapy is considered standard of care for patients with endometrial carcinoma that are unable to undergo surgical intervention. Here, we compare the cancer-free (CFS), cancer-specific (CSS), and overall (OS) survival between patients with low-risk and high-risk endometrial carcinoma managed with definitive-intent radiation therapy. <h3>Materials/Methods</h3> This is a single-institutional retrospective analysis of medically-inoperable patients with biopsy-proven endometrial carcinoma managed with upfront, definitive radiotherapy at UMass Memorial Medical Center between May 2010 and October 2021. Fifty-five cases were included for analysis. Patients were stratified as low-risk endometrial carcinoma (LREC: Uterine-confined grade 1/2 endometrioid adenocarcinoma) or high-risk endometrial carcinoma (HREC: Stage III/IV and/or grade 3 endometrioid carcinoma, or any stage serous or clear cell carcinoma or carcinosarcoma). CFS, CSS, OS and grade ≥3 toxicities were reported for patients with LREC and HREC. <h3>Results</h3> Median age was 66 (range: 42-86) with median follow-up being 44 months (range: 4-135). Twelve patients (22%) were diagnosed with HREC. Six patients (11%) were treated with high dose rate (HDR) brachytherapy alone and forty-nine patients (89%) were treated with HDR brachytherapy and external beam radiation therapy (EBRT). Twelve patients (22%) were treated with radiation and chemotherapy. The 2-year CFS was 82% for LREC patients and 80% for HREC patients (log rank p = 0.0654). The 2-year CSS was 100% for both LREC and HREC patients. The 2-year OS was 92% for LREC and 80% for HREC patients (log p = 0.0064). There were no acute grade ≥3 toxicities. There were 3 late grade ≥3 toxicities due to endometrial bleeding and gastrointestinal side effects. <h3>Conclusion</h3> For medically inoperable patients with endometrial carcinoma, upfront radiotherapy provided excellent CFS, CSS and OS. CSS and OS were higher in patients with LREC than those with HREC. Toxicities were limited in both cohorts.

Mismatch Repair Status in the Endometrial Cancer Population: Prognostic Implications

<h3>Purpose/Objective(s)</h3> Recent studies for endometrial cancer (EC) have demonstrated a divergence of outcomes based on mismatch repair (MMR) status, with MMR deficiency being an important predictor of recurrence and death. Further investigation is needed to validate these findings in additional patient populations to support the clinical significance of MMR status in EC. <h3>Materials/Methods</h3> We performed a single institution retrospective review at UMass Memorial Medical Center to identify EC patients with immunohistochemistry (IHC)-confirmed MMR status and to follow their clinical outcomes after definitive management (TAH/BSO with adjuvant chemotherapy and/or radiation therapy, as per NCCN guidelines). Querying the EPIC electronic medical record for all available years (2017-2021), we identified patients with ICD10 codes C54-C55. Of the total of 582 cases, 454 were endometrioid histology, 340 (75%) of which had MMR IHC results. Charts were reviewed longitudinally following completion of definitive management, and recurrences were assigned only if pathologically confirmed by tissue biopsy as malignancy of the same histological and/or IHC profile as tumor obtained at initial diagnosis. Initial stage, adjuvant treatment, recurrence patterns, and survival were compared between MMR-intact and MMR deficit cohorts. <h3>Results</h3> Of the 340 endometrioid patients with IHC confirmed MMR status, the majority were early-stage, node negative (92.6% Stage I, 2.9% Stage II, 4.4% Stage III), and all were eligible for upfront definitive management with TAH/BSO. Among the 340 patients, 86 (25%) were MMR-deficient, the majority of which were MLH1/PMS2 deficient. At a median follow up of 46 months, the recurrence rate in the MMR-deficient cohort (9.3%) was statistically significantly (p=0.005) higher than that of the MMR-intact cohort (4%), despite the higher proportion of MMR-deficient recurrent population receiving adjuvant radiation (75%) compared to the MMR-intact population (20%). None of the patients included in this study received adjuvant chemotherapy. The patterns of recurrence demonstrated a higher proportion of locoregional and distant disease within the MMR-deficient cohort (87.5%) compared to MMR-intact cohort (50%). There was a trend towards worse survival within recurrent MMR-deficient cohort compared to MMR-intact cohort (p=0.098). <h3>Conclusion</h3> Although the overall number of recurrence events was low, our endometrioid endometrial recurrent population demonstrates clear differences in rates of recurrence, patterns of recurrence and possibly even survival outcomes between MMR-intact and MMR-deficient cohorts, suggestive of worse prognosis for the MMR-deficient patient population. Future analyses will need to be completed to further describe the tumor characteristics at presentation, behavior of disease following recurrence and success of salvage treatment at the time of recurrence.

VP.11 Shoulder subluxations and dislocations in non-ambulatory patients with Duchenne muscular dystrophy (DMD)

Patients with DMD are living into their 3rd decade of life, which raises a concern for upper extremity (UE) dysfunction. Many young men are now going to college and entering the work force, adding new contexts for which UE joint integrity and function need to be managed. Currently, there are no research studies on the evaluation and treatment of shoulder subluxations and dislocations in non-ambulatory individuals with DMD. The objective of this case series is to investigate the need for the evaluation, prevention, and treatment of shoulder subluxations and dislocations in non-ambulatory patients with DMD. A retrospective chart review of non-ambulatory patients with DMD took place in an interdisciplinary DMD dedicated clinic at UMass Memorial Medical Center. Herein we report the clinical profiles of 7 non-ambulatory patients aged 20-28 years old who were found to have shoulder subluxations and/or dislocations. Clinical evaluations included PROM, seated alignment assessment, manual muscle testing, and a PUL 2.0 outcome measure assessment. Common findings included: wheelchair-bound for 6-13 years with 6/7 patients on steroids, 5/7 patients without initial complaint of shoulder pain, 6/7 patients with atraumatic mechanism of injury, limited shoulder flexion, abduction and/or extension PROM with or without pain, shoulder complex depression, postural asymmetries, and Brooke score of 5 which corresponds to severe weakness, the inability to raise their hand to mouth, and elevate their shoulder against gravity. Patients responded to the treatments of UE support and wheelchair armrest modifications. In conclusion, patients presenting with limited PROM with or without pain, loss of antigravity shoulder function, and asymmetric shoulder alignment may need further evaluation of shoulder stability. X-rays can confirm the diagnosis and severity. Education on positioning and shoulder support may be helpful in the prevention and treatment of shoulder subluxation/ dislocation.

Med Moth: A Storytelling Platform for Improving Wellness in Medical Education

Background: Burnout is a major issue amongst medical students and professionals that demands a solution. Mindfulness has been shown to decrease burnout. Storytelling, as a form of mindfulness, leads to reflection. Few publications have studied the effect of storytelling on student and clinician wellness. To address wellness within their medical community and utilize the underexplored method of narrative medicine as a curricular enhancement, the authors designed and implemented a novel storytelling platform, Med Moth, at the University of Massachusetts Medical School (UMMS) and associated hospital (UMass Memorial Medical Center). Methods: Members of the community were invited to storytelling events to listen to and share stories about formative medical experiences. Four events were held between 2017 and 2018. After each event, participants received a survey inquiring how attendance benefitted them personally and professionally. Results: Clinicians, students, and faculty comprised the 104 first-time attendees surveyed. Med Moth produced a strong perceived benefit to surrogate measures including emotional exhaustion and depersonalization, defining characteristics of burnout, and professional development. Among these three measures, 66% of participants rated 4-5 (out of 5). Nearly all attendees (96%) rated 4-5 for the overall experience. Lastly, medical students reported a higher benefit regarding professional development than clinicians (p=0.002). Conclusions: This pilot study of a novel storytelling platform demonstrates positive personal and professional development outcomes, both during and after medical school training. Medical schools, residency programs, and medical institutions should strongly consider the implementation of such a wellness platform to build resiliency and to mitigate burnout through reflection.

Characterizing Interprofessional Collaboration and Referral to Mindfulness-Based Stress Reduction Programs.

BackgroundIn 2017, the American College of Physicians (ACP) designated Mindfulness-Based Stress Reduction (MBSR), an eight-week group program, as first-line non-pharmacological treatment for chronic low back pain. However, interprofessional collaboration between mindfulness instructors and Primary Care Providers (PCP) remains largely unknown.ObjectiveWe developed a survey to assess communication between mindfulness instructors and PCPs, identify predictors of referral to MBSR, and determine areas where interventions could increase patient access to MBSR.MethodsThe 25-question survey was sent via email to PCPs at the Division of General Internal Medicine, University of Pittsburgh, PA, the Piedmont Health Services Family Medicine Section, Chapel Hill, NC, the Boston Medical Center General Internal Medicine and Family Medicine Sections, Boston, MA, and the UMass Memorial Medical Center Family Medicine Section, Worcester, MA. We used descriptive statistics and logistic regression to analyze the data.ResultsAmong 118 eligible respondents, 85 (72.0%) were female PCPs, mean age was approximately 41.5±10.1, and the majority (65.2%) had been in medical practice ≤10 years. Of these PCPs, 83 (70.1%) reported familiarity with MBSR (95% CI: 62.1, 78.5), and 49 (59.0%) of them referred patients at least yearly. Of those who referred, 8 (16.3%) reported collaboration with mindfulness instructors. PCPs who were quite a bit or very much familiar with MBSR had 5.10 (1.10, 22.50) times the odds (P=.03), and those who were 50 years or younger had 3.30 times the odds (P=.04) of referring patients to MBSR. Frequency of PCPs’ personal practice of mindfulness was not significantly associated with referrals (P=.30).ConclusionThis is the first study to assess interprofessional collaboration between mindfulness instructors and PCPs. Suggestions for a potential integrative health care model are included; further studies on methods to augment communication and education are warranted to improve the referral process and ultimately increase accessibility and utilization of mindfulness-based programs.

Factors associated with diagnosis of stages I and II lung cancer: a multivariate analysis.

ABSTRACTOBJECTIVE To present the overall survival rate for lung cancer and identify the factors associated with early diagnosis of stage I and II lung cancer.METHODS This is a retrospective cohort study including individuals diagnosed with lung cancer, from January 2009 to December 2017, according to the cancer registry at UMass Memorial Medical Center. Five-year overall survival and its associated factors were identified by Kaplan–Meier curves and Cox’s proportional hazards model. Factors associated with diagnosing clinical stage I and II lung cancer were identified by bivariate and multivariate backward stepwise logistic regression (Log-likelihood ratio (LR)) at 95% confidence interval (CI).RESULTS The study was conducted with data on 2730 individuals aged 67.9 years on average, 51.5% of whom female, 92.3% white, and 6.6% never smoked. Five-year overall survival was 21%. Individuals diagnosed with early-stage disease had a 43% five-year survival rate compared to 8% for those diagnosed at late stages. Stage at diagnosis was the main factor associated with overall survival [HR = 4.08 (95%CI: 3.62–4.59)]. Factors associated with early diagnosis included patients older than 68 years [OR = 1.23 (95%CI: 1.04–1.45)], of the female gender [OR = 1.47 (95%CI: 1.24–1.73)], white [OR = 1.63 (95%CI: 1.16–2.30)], and never-smokers [OR = 1.37 (95%CI: 1.01–1.86)]; as well as tumors affecting the upper lobe [OR = 1.46 (95%CI: 1.24–1.73)]; adenocarcinoma [OR = 1.43 (95%CI: 1.21–1.69)]; and diagnosis after 2014 [OR = 1.61 (95%CI: 1.37–1.90)].CONCLUSIONS Stage at diagnosis was the most decisive predictor for survival. Non-white and male individuals were more likely to be diagnosed at a late stage. Thus, promoting lung cancer early diagnosis by improving access to health care is vital to enhance overall survival for individuals with lung cancer.

Bringing Care to Underserved and Vulnerable Patient Populations: Meeting Patients Where They Are.

UMass Memorial Health, Worcester, MA The authors declare no conflict of interest. Correspondence to: Andrew S. Karson, MD, MPH, Chancellor’s Suite, Room S1-362, UMass Memorial Medical Center, 55 Lake Avenue North, Worcester, MA 01655. E-mail: [email protected].

Enhancing palliative care consultation workflow on an inpatient oncology unit.

208 Background: The American Society of Clinical Oncology practice guidelines recommend early palliative care integration for all patients with cancer. At UMass Memorial Medical Center from Sept. to Nov. 2020, only 16% (29/184) of patients on the inpatient oncology unit received a palliative care consultation. Of these consultations, 55% (16/29) were placed within 72 hours of admission. Results from a pre-pilot survey of nurses (n = 20) and providers (n = 14) about attitudes toward palliative care, team communication, and perceptions of barriers to palliative care consultation highlighted a lack of multidisciplinary communication and consensus on criteria for palliative care consultation. Methods: An evidence-based palliative care screening tool and multidisciplinary communication process was piloted to support team collaboration and early identification of oncology patients who may benefit from specialty-level inpatient palliative care. The primary objective was to increase the percentage of palliative care consultations placed within 72 hours of admission from 55% to 65%. Nurses screened patients upon unit arrival for palliative care needs. Patients who screened positive were discussed during daily multidisciplinary rounds, attended by the resource nurse, primary team, case manager and social worker. Results: In March 2021, the percentage of palliative care consultations placed by providers within 72 hours of inpatient admission increased to 68% (13/19). The proportion of patients who received palliative care consultation also increased to 29%. All the patients who screened positive for palliative care needs received a consultation. In a post-pilot survey of providers (n = 9) and nurses (n = 14), most providers (78%) reported that discussions of patients’ palliative care needs occurred more frequently during multidisciplinary rounds. A majority of nurses (57%) agreed the screening tool led to enhanced multidisciplinary communication. 63% of providers agreed that criteria for palliative care consultation was clearer as a result of the pilot; both nurse and provider perceptions of “lack of provider agreement on palliative care consultation criteria” as a barrier decreased compared to the pre-pilot survey. Although a majority of nurses (71%) found the screening tool easy to use, only half were comfortable with all the questions or understood them completely. All providers and 93% of nurses preferred to continue using the screening tool and communication process, and supported electronic medical record integration. Conclusions: The palliative care screening tool and workflow process had a positive impact on earlier identification of oncology patients who could benefit from specialty palliative care, and increased the total number of palliative care consultations. This improved process also enhanced team communication and collaboration. Next steps include refining the screening tool and EMR integration.

95 Assessment of Social Determinants of Health and Linkage to Care Within the UMassMemorial Medical Center Emergency Department

The contribution of social determinants of health (SDOH) to poor health outcomes is well established, and the emergency department (ED) is the most common site of contact between socially vulnerable patients and the healthcare system. The ED is thus uniquely well positioned to screen patients for social determinants of health and connect those identified as having social needs with appropriate community resources. Before such programs are developed, more information regarding the needs and characteristics of the target patient population is required. Our objective was to characterize the prevalence of common social determinants of health among adult patients presenting to a high volume, urban ED at an academic medical center in New England. During April 2021, four research assistants (RAs) administered a SDOH survey based on Boston Medical Center’s THRIVE Social Determinants of Health Screening and Referral Program. Patients were screened during 8-hr shifts over 16 days, corresponding to 24-hr coverage over 7 days. Exclusion criteria included patients with age under 18 yr, medical or cognitive inability to participate, or currently in state or federal custody. Patients were verbally consented in their preferred language and survey responses were entered into a dedicated REDCap database; interpreter services were used for all low-English proficiency patients. All patients were offered referrals to local community resources via text or email through the CommunityHELP.org platform at the conclusion of the survey. Patients were considered to have a positive screen for social risk factors if they responded “Sometimes true” or “Often true” to Likert scale questions regarding the frequency of risk, or “Yes” to binary risk questions. A total of 650 patients were approached by RAs, of whom 343 were eligible to participate in the survey; 122 eligible patients (35.6%) were identified as screen positive for SDOH risk factors. Patients screening positive were significantly more likely to be of Hispanic ethnicity (23.0% v. 9.1%, p<0.001), nonwhite race (30.3% v. 16.9%, p=0.004), and income < $40, 000/yr (51.0% v. 23.7%, p<0.001). Among patients with positive screens, the most common risks identified were concerns regarding food insecurity (n=59, 48.4%), access to transportation for medical appointments (n=36, 29.5%), cost of medications (n=34, 27.9%), and heat or electricity bills (n=34, 27.9%). A significantly greater proportion of patients with positive SDOH screens reported an increase in their needs during the COVID-19 pandemic (55.9% v. 21.0%, p<0.001). This SDOH screening study indicates that our ED population has significant unmet social risks and needs. More research on ED-based solutions will be necessary address this growing need in our population, and thereby improve health outcomes.

The Impact of Telehealth Implementation on Underserved Populations and No-Show Rates by Medical Specialty During the COVID-19 Pandemic.

A unique and sudden need for virtual medical visits created by the coronavirus disease 2019 (COVID-19) pandemic has led to an unprecedented expansion of telemedicine across nearly all medical specialties in the United States. In addition to providing essential medical services during the pandemic, telemedicine has the potential to expand health care access to underserved populations by eliminating traditional barriers to care such as transportation needs, distance from specialty providers, and approved time off from work. However, the literature regarding telehealth accessibility for low-income, non-English-speaking, and minority patients remains limited. Through a cross-sectional analysis comparing 2019 clinic visits with 2020 telehealth visits at the UMass Memorial Medical Center, we demonstrate specialty-specific changes in patient demographics, including a younger population, fewer non-English-speaking patients, and a relative preservation of minority, Medicaid, and Medicare patients among telehealth visits in comparison to clinic visits. We also demonstrate that nonsurgical specialties had significantly lower no-show rates and the greatest number of telehealth visits. Overall, our findings highlight the potential shortcomings of telemedicine in servicing non-English-speaking patients, while maintaining that it is an important tool with the potential to improve access to health care, particularly in nonprocedural specialties.

Assessment of Video Capsule Endoscopy in the Management of Acute Gastrointestinal Bleeding During the COVID-19 Pandemic

Evaluation of acute gastrointestinal (GI) bleeding using invasive endoscopic procedures comprising the standard of care (SOC)-upper endoscopy and colonoscopy-can expose the endoscopy staff to SARS-CoV-2. Video capsule endoscopy (VCE) does not generate aerosols and only requires 1 person to manage the procedure. To examine the safety of VCE for the initial evaluation of GI bleeding at the peak of the COVID-19 pandemic to identify signs of active bleeding while minimizing patient and personnel exposure, saving personal protective equipment, and avoiding invasive or unnecessary procedures. A multicenter (UMass Memorial Medical Center and Louisiana State University Health Sciences Center) retrospective cohort study including 146 patients with COVID-19 who received VCE as the first-line diagnostic modality was conducted from March 15 to June 15, 2020, compared with SOC in January 2020 for evaluation of GI bleeding. The association between treatment and outcomes was estimated using multivariable regression adjusting for potential confounders. Propensity score matching was used to verify the results. The primary end point was detection of active bleeding or stigmata of recent bleeding. Secondary end points included the number of patients requiring any invasive procedures, number of additional procedures, rates of rebleeding and rehospitalization, transfusion requirements, and mortality. Among 146 patients, 92 (63.0%) were men; mean (SD) age was 64.93 (14.13) years in the COVID-19 group and 61.33 (13.39) years in the SOC group. Active bleeding or stigmata of recent bleeding was observed in 44 (59.5%) patients in the COVID-19 group compared with 18 (25.0%) in the SOC group (adjusted odds ratio, 5.23; 95% CI, 2.23 to 12.27). Only 36 patients (48.7%) in the COVID-19 group required any invasive procedure during the hospitalization compared with 70 (97.2%) in the SOC group (adjusted odds ratio, 0.01; 95% CI, 0.001 to 0.08). The mean (SD) number of invasive procedures was 0.59 (0.77) per patient in the COVID-19 group compared with 1.18 (0.48) per patient in the SOC group (adjusted difference, -0.54; 95% CI, -0.77 to -0.31). Both approaches appeared to be safe and there was no significant difference in transfusion requirements, rebleeding, rehospitalization, or in-hospital mortality. No mortality was attributed to GI bleeding in either group. In this cohort study, first-line diagnostic evaluation of acute GI bleeding using VCE appeared to be a safe and useful alternative to the traditional approach of upper endoscopy and colonoscopy. Use of VCE was associated with increased detection of active bleeding and a reduced number of invasive procedures and unnecessary exposure of personnel to SARS-CoV-2 and use of personal protective equipment.

SUPPORT-AF IV: Supporting use of AC through provider prompting about oral anticoagulation therapy for AF clinical trial study protocol

BackgroundSix million Americans suffer from atrial fibrillation (AF), a heart rhythm abnormality that significantly increases the risk of stroke. AF is responsible for 15% of ischemic strokes, which lead to permanent disability in 60% of cases and death in up to 20%. Anticoagulation (AC) is the mainstay for stroke prevention in patients with AF. Despite guidelines recommending AC for patients, up to half of eligible patients are not on AC. Clinical decision support tools in the electronic health record (EHR) can help bridge the disparity in AC prescription for patients with AF.ObjectiveTo enhance and assess the effectiveness of our previous rule-based alert on AC initiation and persistence in a diverse patient population from UMass-Memorial Medical Center and University of Florida at Jacksonville.Methods/ResultsUsing the EHR, we will track AC initiation and persistence. We will interview both patients and providers to determine a measure of satisfaction with AC management. We will track digital crumbs to better understand the alert’s mechanism of effect and further add enhancements. These enhancements will be used to refine the alert and aid in developing an implementation toolkit to facilitate use of the alert at other health systems.ConclusionIf the number of AC starts, the likelihood of persisting on AC, and the frequency alert use are found to be higher among intervention vs control providers, we believe such findings will confirm our hypothesis on the effectiveness of our alert.

Coronavirus Disease 2019 Capacity Response: Where's the Right Balance?

*UMass Memorial Medical Center †UMass Memorial Healthcare, Worcester, MA The authors declare no conflict of interest. Correspondence to: Kimiyoshi J. Kobayashi, MD, MBA, UMass Memorial Medical Center, 55 N Lake Avenue, Worcester, MA 01605. E-mail: [email protected].

Computed tomography angiography-derived area stenosis calculations overestimate degree of carotid stenosis compared with North American Symptomatic Carotid Endarterectomy Trial-derived diameter stenosis calculations

ObjectiveThe degree of carotid artery stenosis, calculated using catheter-based angiography and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method, has been shown to predict the stroke risk in several, large, randomized controlled trials. In the present era, patients have been increasingly evaluated using computed tomography (CT) angiography (CTA) before carotid artery revascularization, especially as the use of transcarotid artery revascularization has increased. Interpretation of CTA findings regarding the degree of carotid stenosis has not been standardized, with both NASCET methods and the area stenosis used. We performed a single-institution, blinded, retrospective analysis of CTA studies using both the NASCET method and the CT-derived area stenosis to assess the concordance and discordance between the two methods when evaluating ≥70% and ≥80% stenosis. MethodsThe UMass Memorial Medical Center vascular laboratory database was queried for all carotid duplex ultrasound scans performed from 2008 to 2017. The included patients were limited to those with duplex-defined ≥70% stenosis (defined as a peak systolic velocity of ≥125 cm/s and an internal carotid artery/common carotid artery ratio of ≥4), and a correlative CTA study performed within 1 year of the duplex ultrasound examination. A blinded review of all correlative CTA studies using centerline measurements on a three-dimensional workstation (Aquarius iNtuition Viewer; Terarecon, Durham, NC) was performed to characterize the degree of carotid stenosis using the NASCET method and the area stenosis method. Patients were excluded if revascularization had been performed between the two imaging studies. ResultsOf the 37,204 carotid duplex ultrasound scans reviewed (performed from 2008 to 2017), 3480 arteries met the criteria for duplex ultrasound-defined ≥70% stenosis. A correlative CTA study within 1 year of the duplex ultrasound examination was identified in 460 arteries, of which 320 were adequate quality for blinded review. The median interval between the duplex ultrasound and CTA examinations was 9.5 days. Concordance between the area stenosis and NASCET methods was poor for both ≥70% (κ = 0.32) and ≥80% (κ = 0.25) stenosis. Of the 247 arteries considered to have ≥70% area stenosis, 127 (51.4%) were considered to have ≥70% stenosis using the NASCET method. Of the 169 arteries considered to have ≥80% area stenosis, 44 (26.0%) were considered to have ≥80% stenosis using the NASCET method. ConclusionsThe area stenosis CTA calculations of carotid artery stenosis dramatically overestimated the degree of carotid stenosis compared with that calculated using the NASCET method. Given that stroke risk estimates have been determined from trials that used the NASCET method, the area stenosis method likely overestimates the risk of stroke. Therefore, area stenosis calculations could lead to unnecessary carotid revascularization procedures. This model highlights the need for standardized usage of the NASCET method when using CTA as the imaging modality to determine the threshold for carotid revascularization.