Underinsured Patients Research Articles

742 Is There a Mortality Benefit of Being Well-Insured in Burns?

IntroductionThe purpose of the Affordable Care Act was to make affordable health insurance available to more people, to cover adults with fewer resources, and to facilitate delivering health care in a cost-effective way. Burn care is both financially and medically intense, expensive, and prolonged. We aimed to compare outcomes of patients treated at a tertiary care center with no insurance, those considered under-insured (Medicare/Medicaid), and those with private/commercial insurance.MethodsPatients were identified using our institutional Burn Center registry and linked to the clinical and administrative data. All adult patients admitted to the Burn Center between January 1, 2011 and December 31, 2020 were eligible for inclusion. Demographics, length of stay (LOS), co-morbid conditions and mortality were evaluated. Statistical analysis was performed with Students’ t-test and chi-squared.ResultsA total of 9,306 patients were admitted during the study period. Forty-one percent of patients had private/commercial insurance. Thirty-four percent were under-insured, while 25% of patients had no insurance. Total body surface area (TBSA) of the burn was significantly higher for the under-insured, p< 0.05. Mortality was significantly higher for the under-insured, p< 0.05. The average LOS for the under-insured was 14.7 days, which was significantly longer than that for the insured (9.2 days) and for those without insurance (7.4 days), p< 0.05.ConclusionsThere are outcome disparities secondary to insurance coverage in burns. Under-insured patients had poorer outcomes than those with private/commercial insurance and those without insurance.

Billing and Utilization Trends for Hand Surgery Indicate Worsening Barriers to Accessing Care.

Hospitals and providers may increase hand surgery charges to compensate for decreasing reimbursement. Higher charges, combined with increasing utilization of ambulatory surgical centers (ASCs), may threaten the accessibility of affordable hand surgery care for uninsured and underinsured patients. We queried the Physician/Supplier Procedure Summary to collect the number of procedures, charges, and reimbursements of hand procedures from 2010 to 2019. We adjusted procedural volume by Medicare enrollment and monetary values to the 2019 US dollar. We calculated weighted means of charges and reimbursement that were then used to calculate reimbursement-to-charge ratios (RCRs). We calculated overall change and r2 from 2010 to 2019 for all procedures and stratified by procedural type, service setting, and state where service was rendered. Weighted mean charges, reimbursement, and RCRs changed by + 21.0% (from $1,227 to $1,485; r2 = 0.93), +10.8% (from $321 to $356; r2 = 0.69), and -8.4% (from 0.26 to 0.24; r2 = 0.76), respectively. The Medicare enrollment-adjusted number of procedures performed in ASCs increased by 63.8% (r2 = 0.95). Trends in utilization and billing varied widely across different procedural types, service settings, and states. Charges for hand surgery procedures steadily increased, possibly reflecting an attempt to make up for reimbursements perceived to be inadequate. This trend places uninsured and underinsured patients at greater risk for financial catastrophe, as they are often responsible for full or partial charges. In addition, procedures shifted from inpatient to ASC setting. This may further limit access to affordable hand care for uninsured and underinsured patients.

The association of health insurance and race with treatment and survival in patients with metastatic colorectal cancer.

Black patients and underinsured patients with colorectal cancer (CRC) present with more advanced disease and experience worse outcomes. The study aim was to evaluate the interaction of health insurance status and race with treatment and survival in metastatic CRC. Patients diagnosed with metastatic CRC within NCDB from 2006-2016 were included. Primary outcomes included receipt of chemotherapy and 3-year all-cause mortality. Multivariable logistic regression and Cox-regression (MVR) including a two-way interaction term of race and insurance were performed to evaluate the differential association of race and insurance with receipt of chemotherapy and mortality, respectively. 128,031 patients were identified; 70.6% White, 14.4% Black, 5.7% Hispanic, and 9.3% Other race. Chemotherapy use was higher among White compared to Black patients. 3-year mortality rate was higher for Blacks and lower for Hispanics, in comparison with White patients. By MVR, Black patients were less likely to receive chemotherapy. When stratified by insurance status, Black patients with private and Medicare insurance were less likely to receive chemotherapy than White patients. All-cause mortality was higher in Black patients and lower in Hispanic patients, and these differences persisted after controlling for insurance and receipt of chemotherapy. Black patients and uninsured or under-insured patients with metastatic CRC are less likely to receive chemotherapy and have increased mortality. The effect of health insurance among Blacks and Whites differs, however, and improving insurance alone does not appear to fully mitigate racial disparities in treatment and outcomes.

Chemotherapy predictors and a time-dependent chemotherapy effect in metastatic esophageal cancer.

BACKGROUNDChemotherapy has long been shown to confer a survival benefit in patients with metastatic esophageal cancer. However, not all patients with metastatic disease receive chemotherapy.AIMTo evaluate a large cancer database of metastatic esophageal cancer cases to identify predictors of receipt to chemotherapy and survival.METHODSWe interrogated the National Cancer Database (NCDB) between 2004-2015 and included patients with M1 disease who had received or did not receive chemotherapy. A logistic regression model was used to examine the associations between chemotherapy and potential confounders and a Cox proportional hazards model was employed to examine the effect of chemotherapy on overall survival (OS). Propensity score analyses were further performed to balance measurable confounders between patients treated with and without chemotherapy.RESULTSA total of 29182 patients met criteria for inclusion in this analysis, with 21911 (75%) receiving chemotherapy and 7271 (25%) not receiving chemotherapy. The median follow-up was 69.45 mo. The median OS for patients receiving chemotherapy was 9.53 mo (9.33-9.72) vs 2.43 mo (2.27-2.60) with no chemotherapy. Year of diagnosis 2010-2014 [odds ratio (OR): 1.29, 95% confidence interval (CI): 1.17-1.43, P value < 0.001], median income > $46000 (OR: 1.49, 95%CI: 1.27-1.75, P value < 0.001), and node-positivity (OR: 1.35, 95%CI: 1.20-1.52, P < 0.001) were independent predictors of receiving chemotherapy, while female gender (OR: 0.86, 95%CI: 0.76-0.98, P = 0.019), black race (OR: 0.76, 95%CI: 0.67-0.93, P = 0.005), uninsured status (OR: 0.41, 95%CI: 0.33-0.52, P < 0.001), and high Charlson Comorbidity Index (CCI) (OR for CCI ≥ 2: 0.61, 95%CI: 0.50-0.74, P < 0.001) predicted for lower odds of receiving chemotherapy. Modeling the effect of chemotherapy on OS using a time-dependent coefficient showed that chemotherapy was associated with improved OS up to 10 mo, after which there is no significant effect on OS. Moreover, uninsured status [hazard ratio (HR): 1.20, 95%CI: 1.09-1.31, P < 0.001], being from the geographic Midwest (HR: 1.07, 95%CI: 1.01-1.14, P = 0.032), high CCI (HR for CCI ≥ 2: 1.16, 95%CI: 1.07-1.26, P < 0.001), and higher tumor grade (HR for grade 3 vs grade 1: 1.28, 95%CI: 1.14-1.44, P < 0.001) and higher T stage (HR for T1 vs T4: 0.89, 95%CI: 0.84-0.95, P < 0.001) were independent predictors of worse OS on multivariable analyses.CONCLUSIONIn this large, retrospective NCDB analysis, we identified several socioeconomic and clinicopathologic predictors for receiving chemotherapy and OS in patients with metastatic esophageal cancer. The benefit of chemotherapy on OS is time-dependent and favors early initiation. Focused outreach in lower income and underinsured patients is critical as receipt of chemotherapy is associated with improved OS.

Abstract P1-08-33: Disparities in the practice of precision medicine? Using multi-gene testing in early-stage, HR+/HER2- breast cancer

Abstract Background: Multi-gene testing (MGT) can be used to identify patients with early-stage, hormone receptor-positive (HR+), HER2-negative (HER2-) breast cancer that are likely to benefit from treatment regimens with chemotherapy and endocrine therapy, compared to endocrine therapy alone. Two examples of genomic panels include OncotypeDX (ODX) MammaPrint (MP). Tailoring practice to the unique profile of each patient, known as ‘precision medicine’, has significantly refined the treatment approach in breast cancer, while decreasing toxicity and cost. In this analysis, we explore disparities in the access to precision medicine among several socio-demographic groups. Methods: We conducted a retrospective analysis of the National Cancer Database, using the 2004-2017 breast cancer dataset. We included patients with HR+/HER2-, stage I-II breast cancer. We excluded patients with stage III disease as many would still receive chemotherapy with less use of MGT. Using chi-squared statistics, we identified socio-demographic, clinical and pathologic factors associated with the use MGT - either ODX or MP - in this group. We then included significant variables (p&amp;lt;0.05) in one multiple logistic regression model predicting the use of either genomic panel. Results: A total of n=841,716 patients who were candidates for MGT (early-stage, HR+/HER2- breast cancer) were included in this analysis. N=283,833 (n=33.7%) underwent MGT (32.2% used ODX while 1.5% used MP). Use of genomic assays has increased significantly over time (11.5% for patients diagnosed between 2007-2009, to 39.4% between 2016-2017). Variables significantly associated with the use of either ODX/MP at the multivariate level (p&amp;lt;0.05) included: age, race, insurance status, education level, facility type, year of diagnosis, geographic location, tumor grade, and tumor histology. Elderly patients (&amp;gt;70) were less likely than those &amp;lt;50 to undergo MGT (OR 0.32, 95% CI 0.32-0.33, p&amp;lt;0.001). Black patients were also less likely to receive a genomic assay compared to White patients (OR 0.80, 95% CI 0.78-0.82, p&amp;lt;0.001). Insurance status was another significant predictor, with uninsured patients being the least likely to receive ODX or MP (OR 0.69, 95% CI 0.66-0.72, p&amp;lt;0.001), compared to those with private insurance. Conversely, patients treated at academic/research cancer programs were more likely to undergo MGT than those treated at community cancer programs (OR 1.13, 95% CI 1.10-1.15, p&amp;lt;0.001). Geographic discordance in use of MGT was also identified: with highest rates of use (39.2%) in the Middle Atlantic (NJ, NY, PA), and lowest rates (23.5%) in West South-Central states (AR, LA, OK, TX). Conclusions: This large analysis of real world, national data identified several social determinants of health predictive of disparity in the implementation of precision medicine practices for early-stage, HR+/HER2- breast cancer. Improving access to innovative, diagnostic and prognostic tools, among black and underinsured patients, as well as those treated in community practices, is needed. Citation Format: Nadeem Bilani, Marita Yaghi, Diana Saravia, Iktej Jabbal, Maroun Bou Zerdan, Leah Elson, Liang Hong, Zeina Nahleh. Disparities in the practice of precision medicine? Using multi-gene testing in early-stage, HR+/HER2- breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-08-33.

Abstract P2-09-09: Genetic assessment of hereditary breast and ovarian cancer in the Smith Clinic: A 10-year, single center experience

Abstract Background: Highly penetrant pathogenic variants causing hereditary breast and ovarian cancer syndrome occur among patients of racial/ethnic minorities at least as frequently as they do among non-Ashkenazi Jewish, non-Hispanic White patients. However, studies suggest that disparities persist in genetic counseling and testing in these populations. It is critical that we reduce the testing gap to better understand genetic susceptibility in minority patients and identify individuals who may benefit from preventive and therapeutic interventions. We explore genetic counseling and testing outcomes in a safety net system with significant support from financial assistance programs that minimizes typical financial and insurance barriers. Methods: This is a retrospective study of adult patients evaluated by a genetic counselor for hereditary breast/ovarian cancer syndrome between October 1, 2009 and September 30, 2019 in Smith Clinic, which is part of a large, county hospital system serving predominantly racial/ethnic minority and uninsured or under-insured patients, and affiliated with the Dan L Duncan Comprehensive Cancer Center. All patients between October 1, 2009 and February 28, 2013 underwent genetic testing, whereas all patients after March 1, 2013 were evaluated by a genetic counselor but may not have completed testing. Patient clinical data was summarized using descriptive statistics. Results: 1,682 patients (mean age at time of counseling/testing 48.2 years) were evaluated by a genetic counselor. Patient-reported race/ethnicity was 58.7% Hispanic, 25.2% non-Hispanic Black (NHB), 8.8% non-Hispanic White (NHW), 4.6% Asian, and 2.7% other with 2.6% having some Native American and 0.6% having any Ashkenazi Jewish genealogic ancestry. Among the 1,397 patients who completed genetic testing, 76.2% received financial assistance. The majority were tested with a multigene panel (70.4%) with the remaining primarily undergoing BRCA sequencing or BRCA large rearrangement test (multigene panels not available until April 2014). More than three-quarters of patients who did not complete testing (n=285, 20.6% of those evaluated after March 1, 2013) did not meet guideline-based criteria or had a relative who was a more appropriate candidate for testing. Only 10.2% declined testing with rates of decline highest among NHB patients. A pathogenic mutation was found in 15.4% of individuals tested: BRCA1 (n=108), BRCA2 (n=57), PALB2 (n=26), ATM (n=8), other (n=18). Rates of pathogenic mutations were higher among NHW and Hispanic patients (NHW 14.9%, Hispanic 17.4%, NHB 11.3%, Asian 9.0%, Other 17.1%). The relatively high percentages of identified pathogenic mutations was likely related to the fact that 84.1% of patients were referred for a personal history of breast and/or ovarian cancer with 6.1% of NHW and 5.7% of Hispanic patients referred for a relative with or personal history of a known pathogenic mutation. Among those with BRCA1/2 or PALB2 mutations, risk-reducing procedures were frequent among all races except those classified as other (mastectomies: NHW 50%, NHB 45.5%, Hispanic 51.9%, Asian 40%, other 16.7%; salpingo-oophorectomies or salpingectomies: NHW 35.7%, NHB 45.5%, Hispanic 56.4%, Asian 60%, other 16.7%). Conclusions: In a racially/ethnically diverse, low-income population, genetic testing uptake is high when supported by financial assistance programs and an on-site genetic counselor. Regardless, reasons for declining testing warrant further exploration, particularly among non-Hispanic Black patients, to further reduce disparities in testing. Prompt referral of patients who meet testing guidelines for genetic evaluation is also critical since pathogenic mutations were frequently identified in all racial/ethnic subgroups and nearly half underwent a risk-reducing procedure. Citation Format: Nicole Higashiyama, Shaun Bulsara, Susan Hilsenbeck, Tiffaney Tran, Ria Brown, Mary Fang, Cathy Sullivan, Georgiann Garza, Maryam Nemati Shafaee, C. Kent Osborne, Mothaffar Rimawi, Julie Nangia. Genetic assessment of hereditary breast and ovarian cancer in the Smith Clinic: A 10-year, single center experience [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-09-09.

The 2021 Joseph St Geme, Jr, Leadership Award Address: The Role of Structural Racism in Injuries to Children and Adolescents.

The 2021 Joseph St Geme, Jr, Leadership Award Address: The Role of Structural Racism in Injuries to Children and Adolescents.

124. Implementation of IV Push Antibiotics for Outpatients During a National Fluid Shortage Following Hurricane Maria

BackgroundPrior to the introduction of intravenous (IV) drip infusion, most IV drugs were delivered in a single bolus. However, with the advent of new agents, IV drip infusions became the standard for all medication delivery. In September 2017, Hurricane Maria made landfall in Puerto Rico and took a devastating toll. As Puerto Rico is the largest supplier of IV fluid bags, this lead to a worldwide fluid bag shortage. The outpatient antimicrobial therapy program (OPAT) was significantly impacted by the fluid shortage and this required effective stewardship at the Parkland Health and Hospital System in order to serve a largely uninsured and under-insured patient population. MethodsParkland pharmacists evaluated all self-administered antimicrobials for viability of administration as an IV single bolus push (IV-push) instead of a mini-bag infusion (IV-drip infusion). These medications were transitioned to IV-push for patient care. Data was gathered on patient demographics, 30-day readmission rates, mortality, discharge teaching satisfaction, patient satisfaction, and cost evaluation. Results113 treatment courses were self-administered using the IV-push method and were compared to 102 self-administered courses using the IV drip infusion method, over the same time course. Individuals using IV-push had a statistically significant decrease in hospital length of stay as compared to those using IV-drip infusion. The 30-day readmission rate, emergency department visits, and mortality were similar between groups. Patient satisfaction was greater with IV-push (96% preferring). The shift to IV-push via the S-OPAT program saved 504 liters of normal saline, which along with a reduction in supplies and drug costs, resulted in an additional savings of &43,652 over a 6-month period.ConclusionThe abrupt IV fluid shortage following a natural disaster challenged clinicians to think differently about standard practices. This led to implementation of a high value care model that is sustainable without affecting safety, efficacy, or efficiency. Given the cost savings, increased patient satisfaction, and equal clinical outcomes, the IV push model is not only a viable alternative initiated during a crisis; it is preferable in many standard situations. Disclosures All Authors: No reported disclosures

Diversity, Equity, and Inclusion Officer Position Available: Proceed With Caution.

Diversity, Equity, and Inclusion Officer Position Available: Proceed With Caution.

High Value Tibial Nail Utilization Improves Cost Without Compromising Outcomes: Experience at a Level II Trauma Center

Introduction In today’s opportunistic healthcare climate, value based care has moved to the forefront of cost containment. With respect to orthopaedic trauma, it has become increasingly important to factor cost into the treatment of an often underinsured patient population. As patents expire on many commonly used trauma implants, high value alternatives represent an excellent opportunity for trauma surgeons to provide value-based care so long as it does not compromise outcomes. The objective of this study was to appraise the clinical and economic impact of the use of high quality, low-cost tibial nails in the treatment of tibial shaft fractures. Methods Two hundred patients treated with high value tibial nail implants were compared to two hundred patients treated with conventional implants at a busy community level II trauma center between January 2011 and December 2019. Operative records were reviewed to identify intraoperative complications, operative time, and estimated blood loss. Cases of infection, malunion, nonunion, or need for repeat surgery were recorded. Hospital financial records were analyzed to determine implant cost. Results There was no appreciable difference in age, sex, diabetes, smoking, or American Society of Anesthesiologist (ASA) physical status score between the high value and conventional groups. A significant difference in operative time was observed. No differences were observed in intraoperative or postoperative complications. There was no significant difference found in return to the operating room or interlocking screw removal. Analysis found an average of $735 per case in implant savings. This represented a 38% reduction in implant cost with an overall realization of $147,000 in savings across the study period. Conclusion The use of high value tibial nails at our institution resulted in significantly reduced implant expenditures with equivalent radiographic and clinical outcomes. Based on this data, the use of high value tibial nail implants has potential to markedly reduce operative costs without compromising patient care as long as quality products are utilized.

Evaluation of an Expedited Trauma Transfer Protocol: Right Place, Right Time

Trauma patients may initially be evaluated at non-trauma centers. This may cause a delay in treatment, which could affect their outcome. Additionally, advanced imaging may be performed which may be suboptimal or unnecessary, increase time to transfer, or unable to be viewed when the patient reaches a trauma center increasing the delays to treatment or need for repeat imaging. Rapid identification and transfer to definitive trauma care, minimizing unnecessary delays should be the priority. The trauma registry at a regional Level 1 Adult/Pediatric Trauma center was queried for transferred trauma patients over a 3-y period. A retrospective review was performed. Transferred trauma patients were compared prior to an expedited transfer protocol to after implementation. Demographics, mechanism of injury, injury severity score, computerized tomography scans performed prior to transfer, mortality, hospital and intensive care unit length of stay were compared using bivariate and multivariable regression statistics where appropriate. Transferred trauma patients were identified, 683 in the pre-protocol group and 821 in the post-protocol group, an increase of 16.8%. There were no differences in age, sex, injury severity score, mechanism of injury, mortality, hospital, or intensive care unit length of stay (LOS) throughout the study period. There was a significant decrease in time to transfer (263 min ± 222 versus 227 ± 189, P < 0.001) and computerized tomography scans performed prior to transfer (Head 47% versus 32%, C-spine 36% versus 23%, Thorax 22% versus 16%, Abdomen/Pelvis 24% versus 14%, all P values <0.001 except CT Thorax). Interestingly, the rate of underinsured patients did not increase (21% versus 25%, P=0.05). Risk-adjusted mortality and hospital LOS also did not change during the study period. After implementation of an expedited trauma transfer protocol to a regional Level 1 trauma center there was an associated reduced time of arrival to definitive care and decreased advanced imaging done prior to transfer. However, there was noassociated decrease inmortality or LOS among transferred patients. Further studies examining prehospital transport or hospital choice decisions and subsequent care provided at non-trauma facilities regarding imaging obtained, care rendered, and transfer decisions can be explored.

Innovative Cancer Survivorship Services for Rural and Underserved Communities.

In 2006, the Institute of Medicine recognized that cancer survivors faced complex physical and emotional health problems, often overlooked or inadequately managed. In Texas, access to programs specifically designed to address unique needs of cancer survivors is almost nonexistent for low-income uninsured or underinsured patients. In response to the unmet care needs of underserved cancer centers, Moncrief Cancer Institute, an affiliate of the National Cancer Institute-designated UT Southwestern Harold C. Simmons Comprehensive Cancer Center, established a community-based program using a survivorship care model similar to those offered in academic medical centers. Understanding that a one-size-fits-all approach could not successfully meet the needs across the service area, the cancer survivorship service line was mobilized to provide flexibility in delivery without sacrificing quality of care. The program continues to evolve, extending the foremost scientific information and resources into the communities it serves.

Integrating behavioral health into two primary care clinics serving vulnerable populations

Behavioral health (BH) problems and chronic disease often co-occur. Patients with both physical and behavioral conditions use more medical services, require more hospitalizations and readmissions, and experience poorer quality of life. The purpose of this article is to describe an innovative model in which BH services are integrated into nurse-led primary care clinics for uninsured and underinsured patients. BH providers, including a psychiatric mental health nurse practitioner, psychiatrist, clinical social worker, and care coordinator, were integrated into the ongoing Providing Access to Healthcare (PATH) and Heart FailuRe Transitional Care Services for Adults (HRTSA) clinics. In addition, other providers received training in BH screening and motivational interviewing. All patients were screened for depression, anxiety, tobacco and substance use at every visit. Examination of appointments revealed information about patient engagement with BH. A total of 520 unique patients at both clinics qualified for BH services and 250 remained engaged in treatment for approximately five visits. Improvement on measures of depression and anxiety was observed for both engaged and non-engaged patients. Integrated BH and primary care within the same clinic space, along with training for all clinicians, allows for early diagnosis and intervention which are crucial to patients with few resources and high needs.

Impact of Insurance Status on Oncologic and Perioperative Outcomes After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy.

A growing body of research has shown that underinsured patients are at increased risk of worse health outcomes compared with insured patients. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is largely performed at highly specialized cancer centers and may pose challenges for the underinsured. This study investigates surgical outcomes following CRS-HIPEC for insured and underinsured patients with peritoneal carcinomatosis. We performed a retrospective cohort study of 125 patients undergoing CRS-HIPEC between 2013 and 2019. Patients were categorized into two groups. The insured group was comprised of patients with private insurance at the time of CRS-HIPEC or who obtained it during the follow-up period. The underinsured group consisted of patients with Medicaid, or self-pay. Perioperative and oncologic outcomes were compared between the two groups. A total of 102 (82.3%) patients were insured, and 22 (17.7%) patients were underinsured. There were no significant differences in age, medical morbidities, primary tumor characteristics, peritoneal carcinomatosis index, or completion of cytoreduction score between the two groups. The median overall survival (OS) for insured patients was 64.8 months and was 52.9 months for underinsured patients (p = 0.01). Additionally, insured patients had a significantly longer follow-up time. Underinsurance status also was associated with increased hospital and intensive care unit length of stay, and higher rate of Clavien-Dindo classification III-IV complications. In this retrospective study conducted at a large, urban, specialized cancer center, private insurance status was associated with increased overall survival and longer follow-up period. Furthermore, underinsurance status was associated with increased perioperative morbidity.

Social Factors of Health Care: a Thematic Analysis of First and Second Year Medical Student Reflections.

Addressing health disparities is necessary to ensure appropriate care for patients. This study examined the impact of Clinical Week experiences on students' recognition of social determinants of health early in their medical education. A 5-day experience each of the first three semesters of medical school provided direct patient care experiences. Two Clinical Weeks were spent in outpatient clinics located primarily in rural areas. Students completed a reflective writing assignment about their experiences after each 5-day experience. Ninety-two reflections during AY 2018-2019 included discussions about social determinants of health. Two investigators analyzed these essays independently using narrative inquiry techniques. After inductive coding was complete, researchers discussed themes and their broader meaning. Themes emerged related to health disparities experienced by rural communities, minority populations, and both uninsured and underinsured patients. Reflections emphasized a lack of public accommodations in rural settings, such as public transportation and access to healthy food. Students noted how ethnic, cultural, and linguistic identity affect a patient's experience with healthcare. Other themes involved the challenges patients face affording treatment plans and conversely how health status can impact economic stability. Finally, students emphasized the importance of physician advocacy in overcoming such barriers to quality health care. Although not the emphasis of Clinical Week, students' reflections identified critical social issues impacting the health of patients they encountered. This experience could be adapted at other institutions.

Thematic Analysis of Challenges of Care Coordination for Underinsured and Uninsured Cancer Survivors With Chronic Conditions

Although a majority of underinsured and uninsured patients with cancer have multiple comorbidities, many lack consistent connections with a primary care team to manage chronic conditions during and after cancer treatment. This presents a major challenge to delivering high-quality comprehensive and coordinated care. To describe challenges and opportunities for coordinating care in an integrated safety-net system for patients with both cancer and other chronic conditions. This multimodal qualitative study was conducted from May 2016 to July 2019 at a county-funded, vertically integrated safety-net health system including ambulatory oncology, urgent care, primary care, and specialty care. Participants were 93 health system stakeholders (clinicians, leaders, clinical, and administrative staff) strategically and snowball sampled for semistructured interviews and observation during meetings and daily processes of care. Data collection and analysis were conducted iteratively using a grounded theory approach, followed by systematic thematic analysis to organize data, review, and interpret comprehensive findings. Data were analyzed from March 2019 to March 2020. Multilevel factors associated with experiences of coordinating care for patients with cancer and chronic conditions among oncology and primary care stakeholders. Among interviews and observation of 93 health system stakeholders, system-level factors identified as being associated with care coordination included challenges to accessing primary care, lack of communication between oncology and primary care clinicians, and leadership awareness of care coordination challenges. Clinician-level factors included unclear role delineation and lack of clinician knowledge and preparedness to manage the effects of cancer and chronic conditions. Primary care may play a critical role in delivering coordinated care for patients with cancer and chronic diseases. This study's findings suggest a need for care delivery strategies that bridge oncology and primary care by enhancing communication, better delineating roles and responsibilities across care teams, and improving clinician knowledge and preparedness to care for patients with cancer and chronic conditions. Expanding timely access to primary care is also key, albeit challenging in resource-limited safety-net settings.

Clinical and Financial Outcomes of Necrotizing Soft-Tissue Infections in Safety-Net Hospitals

Background Prior work has demonstrated inferior outcomes for a multitude of medical and surgical conditions at hospitals with high burdens of underinsured patients (safety-net). The present study aimed to evaluate trends in incidence, clinical outcomes and resource utilization in the surgical management of necrotizing soft-tissue infections (NSTI) at safety-net hospitals.Materials and methods Adults requiring surgical debridement/amputation following NSTI-related hospitalizations were identified in the 2005-2018 National Inpatient Sample. Safety-net status (SNH) was assigned to institutions in the top tertile for annual proportion of underinsured patients. Logistic multivariable regression was utilized to evaluate the association of SNH with mortality, hospitalization duration (LOS), costs and discharge disposition.Results Of an estimated 212,692 patients, 76,719 (36.1%) were managed at SNH. The annual incidence of NSTI admissions increased overall while associated mortality declined. After adjustment, SNH status was associated with greater odds of mortality (adjusted odds ratios: 1.14, 95% CI: 1.03-1.26), LOS (β: +1.8 d, 95% CI: 1.3-2.2) and costs (β: +$4,400, 95% CI: 2,900-5,800). SNH patients had similar rates of amputation but lower likelihood of care facility or home health discharge.Conclusion With a rising incidence and overall reduction in mortality, safety-net hospitals persistently exhibit greater mortality and resource use for surgical NSTI admissions. Variation in access, disease presentation and timeliness of operative intervention may explain the observed findings.

Disparities in Utilization of Ambulatory Cholecystectomy: Results From Three States

BackgroundInpatient cholecystectomy is associated with higher cost and morbidity relative to ambulatory cholecystectomy, yet the latter may be underutilized by minority and underinsured patients. The purpose of this study was to examine the effects of race, income, and insurance status on receipt of and outcomes following ambulatory cholecystectomy. Materials and MethodsRetrospective observational cohort study of patients 18-89 undergoing cholecystectomy for benign indications in Florida, Iowa, and New York, 2011-2014 using administrative databases. The primary outcome of interest was odds of having ambulatory cholecystectomy; secondary outcomes included intraoperative and postoperative complications, and 30-day unplanned admissions following ambulatory cholecystectomy. ResultsAmong 321,335 cholecystectomies, 190,734 (59.4%) were ambulatory and 130,601 (40.6%) were inpatient. Adjusting for age, sex, insurance, income, residential location, and comorbidities, the odds of undergoing ambulatory versus inpatient cholecystectomy were significantly lower in black (aOR = 0.71, 95% CI [0.69, 0.73], P< 0.001) and Hispanic (aOR = 0.71, 95% CI [0.69, 0.72], P< 0.001) patients compared to white patients, and significantly lower in Medicare (aOR = 0.77, 95% CI [0.75, 0.80] P < 0.001), Medicaid (aOR = 0.56, 95% CI [0.54, 0.57], P< 0.001) and uninsured/self-pay (aOR = 0.28, 95% CI [0.27, 0.28], P< 0.001) patients relative to privately insured patients. Patients with Medicaid and those classified as self-pay/uninsured had higher odds of postoperative complications and unplanned admission as did patients with Medicare compared to privately insured individuals. ConclusionsRacial and ethnic minorities and the underinsured have a higher likelihood of receiving inpatient as compared to ambulatory cholecystectomy. The higher incidence of postoperative complications in these patients may be associated with unequal access to ambulatory surgery.

CORR Insights®: Is There an Association Between Bundled Payments and "Cherry Picking" and "Lemon Dropping" in Orthopaedic Surgery? A Systematic Review.

CORR Insights®: Is There an Association Between Bundled Payments and "Cherry Picking" and "Lemon Dropping" in Orthopaedic Surgery? A Systematic Review.

Opportunities for successful de-escalation of proton pump inhibitors at a federally qualified health center

BackgroundA Proton Pump Inhibitor (PPI) de-escalation initiative was piloted at a Family Medicine Federally Qualified Health Center (FQHC) after a needs assessment showed that PPIs were prescribed inappropriately. The objective was to evaluate implementation of a PPI de-escalation program for an urban, underinsured patient population at a (FQHC).MethodsPatients receiving PPI with an upcoming appointment with their primary care provider (PCP) were evaluated by a pharmacist for the appropriateness of therapy. The pharmacist administered a questionnaire to patients to assess PPI usage patterns and then evaluated for appropriate PPI therapy which included diagnoses, risk factors for gastrointestinal bleed, symptom control, and duration of PPI therapy. For consenting patients, de-escalation was implemented per pharmacist protocol.ResultsA total of 36 patients were evaluated for appropriate PPI use, among those, 21 (58%) were eligible for de-escalation, and 19 agreed to de-escalation. Fifteen patients (15/19) had successful PPI de-escalation after 4 weeks without discomfort or symptoms which disrupted daily activities.ConclusionsThis pharmacist led initiative in collaboration with PCPs resulted in successful de-escalation of PPIs in an underserved primary care setting.