Underinsured Population Research Articles

Saving the Health Care Safety Net: Progress and Opportunities.

The health care safety net provides essential clinical care and social services for low-income, uninsured, and underinsured populations in the United States. Despite these important functions, the health care safety net has experienced recurrent financial instability, growing market pressures, and workforce strain. Payment reform has also introduced unique challenges for safety net providers related to measuring and reaching quality benchmarks. A common theme among these challenges is that many of them result from applying standard health policy approaches to the safety net instead of using safety net-specific approaches. This review describes progress toward strengthening the safety net, key challenges, and opportunities moving forward.

Effect of oncology provider conversations on patients’ vaccination decision-making: Patient perspectives at a safety-net system.

266 Background: Low immunization rates among adults are associated with worse outcomes, particularly among immunocompromised individuals, such as those diagnosed with a cancer. To better understand vaccination communication and decision-making experiences among adult cancer patients treated at a safety-net system, we conducted structured interviews to: (1) explore patients’ perceptions of their oncology providers’ role in adult immunization, and (2) understand the potential factors that underlie patients’ hesitancy to receive vaccines. Methods: Parkland Health is the safety-net system for Dallas County, providing care for a primarily minority and un-/under-insured population. Cancer patients who had previously deferred or declined immunization participated in either in-person or telephone interviews in their preferred language (English/Spanish), using a structured 8-question interview guide. Questions centered on oncology providers’ role, vaccine hesitancy, and vaccine decision-making. Interviews averaged 12 minutes and were recorded for transcription. Aggregated interview responses were coded by question and interpreted through content analysis which noted frequency (i.e., times concept stated) and extensiveness (i.e., repetition across questions). Results: Thirteen patients were interviewed – 7 in English, 6 in Spanish. Patient’s perceived their oncology providers as highly important to their vaccination decision-making as they were: (1) more likely to get a vaccine if it is recommended by their provider (P2: Well, if the doctor hadn’t told me I wouldn’t have gotten vaccinated ; P3: If they didn’t recommend it, I would not get it ; P12: If they recommend it, it's worth looking into or thinking about ), and (2) identified their oncology provider as a preferred means for learning about vaccines (P8: Asking the doctor or the doctor communicating with us patients about a vaccine... in my personal opinion, I would say, go ahead and vaccinate me ). Patient-identified reasons for hesitancy included concerns about side effects (P2: “several people told me that is why we got cancer” ), fear of needles, previous negative experiences, and preference for alternative medicine approaches. Conclusions: Results from this preliminary study suggest that while patients may not initiate vaccination conversations with their oncology providers, they do identify their providers as influential in their decision-making. Oncology providers may not consider immunization as their primary responsibility but can be a primary source for effective vaccine communication in conjunction with the oncology care team. Findings from our patient interviews informed interventions in a quality improvement project to increase immunization uptake among cancer patients at our safety-net system.

An Outline of Integrating Vision Screening at a Student-Run Free Health Clinic

Visual impairment (VI) is a pervasive issue associated with a significant financial burden, diminished health outcomes, and an overall reduced quality of life. This condition disproportionately affects uninsured patients as they face limited access to affordable care. For this reason, FaithCare Clinic, a free, student-run clinic in Augusta, Georgia that serves uninsured and underinsured patients at least two standard deviations below the poverty line, implemented a vision screening and referral protocol to better serve its patients. Patients were approached after check-in for their appointment, but prior to seeing the physician, and were screened with a Snellen Eye Chart and Amsler Grid to assess for refractive error and other types of VI. If they screened positive, they were referred to low cost, local resources for further care. Data was collected over a period of 17 months with 47.8% of the patients seen in clinic offered vision screening. Of the patients offered screening, the majority accepted (79.1%). Half of patients screened were cleared while the other half were referred for further care. These results illustrate that patients of a free clinic are willing to undergo vision screening and can benefit from its offering due to the high rates of VI in this population. Visual disabilities are a heavy burden, especially on the uninsured and underinsured populations. Implementing vision screening in free clinics across the country can identify and facilitate additional care in an at-risk population with minimal training and few additional resources.

Surgical Care Through a Community Free Clinic-Ambulatory Surgical Center Partnership.

Disparities secondary to underinsurance present throughout the surgical care continuum. Community free clinics are uniquely capable to provide health care services to the medically underserved, but surgery often falls outside their scope of care. Retrospective chart review was conducted on consecutive community free clinic patients receiving free surgical services via referral to a partnering ambulatory surgery center between March 2016 and September 2021. Those with documented contact information were recruited 1-3 years post-procedure for long-term quality-of-life (LTQOL) outcomes assessment via modified Veterans RAND 12-item health survey. Of 142 included patients, 95.7% identified as Hispanic/Latino and 75.6% were uninsured. Twelve patients had cancerous or precancerous lesions detected and/or removed through diagnostic or definitive procedures. 3.5% experienced postoperative complication including bacterial (n = 2) or fungal (n = 1) surgical site infection and wound dehiscence (n = 2). With a 48.9% response rate, no significant differences in sociodemographic or clinical characteristics were found between surveyed vs non-surveyed patients. Of surveyed patients, 59.7% and 52.2% reported pre-/post-operative improvement in physical health and emotional health, respectively. Free diagnostic screening procedures provided timely diagnoses while free definitive surgeries safely and positively impacted long-term patient-reported physical health. Longitudinal, multidisciplinary follow-up and social support may be warranted to concurrently improve emotional and mental health in similarly underinsured populations.

Emergency department communication with diverse caregivers and persons living with dementia: A qualitative study.

Research to date has detailed numerous challenges in emergency department (ED) communication with persons living with dementia (PLWD) and their caregivers. However, little is known about communication experiences of individuals belonging to minoritized racial and ethnic groups, who are disproportionately impacted by dementia and less likely to be included in dementia research. We conducted semi-structured interviews with 29 caregivers of PLWD from two urban academic hospital EDs with distinct patient populations. The first site is an ED in the Northeast serving a majority White, English-speaking, and insured population. The second site is an ED in the South serving a majority Black and/or Hispanic, Spanish-speaking, and underinsured population. Interviews lasted an average of 25 min and were digitally recorded and transcribed. We used an inductive approach to analyze interview transcripts for dominant themes and compared themes between sites. Our sample included caregivers of diverse racial and ethnic backgrounds. Caregivers cared for PLWD who spoke English, Spanish, Arabic, Chinese, and Vietnamese. We identified three themes. First, caregiver advocacy was central to experiences of ED communication, particularly when PLWD primarily spoke a non-English language. Second, routine care plans did not address what mattered most to participants and PLWD. Participants felt that care arose from protocols and did not address what mattered most to them. Third, White English-speaking caregivers in Site 1 more commonly expected ED staff to engage them in care decision-making than Black, Hispanic, Asian, and Middle Eastern caregivers in Site 2. Language barriers amplify the higher intensity care needed by PLWD in the ED. Strategies should be developed for communicating with PLWD and caregivers about what matters most in their ED care.

Real-world treatment outcomes from a retrospective cohort of patients with acute myeloid leukemia from an urban safety net hospital.

While continual advancements in acute myeloid leukemia have augmented response rates and survival, outcomes in clinical trials may not correlate with real-world practice as trials may underrepresent individuals with comorbidities, decreased performance status, and older age. Additionally, clinical trials may underrepresent certain ethnicities, and disparities based on ethnicity, socioeconomic status, and insurance have been demonstrated in acute myeloid leukemia. We performed a retrospective chart review of adult patients with acute myeloid leukemia who were treated at Harbor-UCLA from 2014 to 2022 to examine patient characteristics, management patterns, and outcomes in a safety net hospital setting. The median age was 56 years old (range 18-84). In regards to risk stratification, 22%, 33%, and 41% had favorable, intermediate, and adverse risk acute myeloid leukemia, respectively. The most common induction regimens included 7 + 3 (55%), azacitidine (10%), azacitidine + venetoclax (7%), and 7 + 3 + midostaurin (7%). The complete remission rate was 51%. Among patients who received intensive induction chemotherapy, 15% underwent re-induction with a second cycle, 51% received consolidation therapy, and 5% received maintenance therapy with a targeted agent. Overall, 12% of patients received allogeneic stem cell transplant. Median overall survival was 12.2 months, and 5-year overall survival was 18%. Suboptimal response rates and survival in this population may be related to low rates of re-induction and allogeneic transplant in addition to high rates of adverse cytogenetics, secondary acute myeloid leukemia, and supportive care only. Efforts to increase access to clinical trials, novel therapies, and transplants for diverse and underinsured populations are essential.

Disparities in Lung Cancer Clinical Trial Discussion and Enrollment at a Safety Net Hospital

Background In the United States, less than 5% of all adult cancer patients enroll in clinical trials. Few studies explore participation in cancer clinical trials at safety net hospitals, which disproportionately care for minoritized, low-income, uninsured, and underinsured populations. Our study aims to investigate disparities in clinical trial discussions and enrollment among lung cancer patients at Boston Medical Center, the largest safety net hospital in New England. Methods We included 1121 patients diagnosed with lung cancer between January 2015 and December 2020. Electronic Medical Records (EMR) were queried, and patients were categorized into three groups: (1) clinical trial discussed and the patient enrolled, (2) clinical trial discussed but the patient not enrolled, and (3) clinical trial not discussed. Sociodemographic variables such as age, gender, race, ethnicity, city, primary language, median household income, medical insurance type, and education level were also collected. Chi-squared, t test, and multivariate regression analysis was done using SPSS version 26.0. Results Of the 1121 patients, clinical trials were discussed in 141 patients (12.6%), of which 22 (15.6%) were enrolled. Clinical trial discussions were conducted more with younger patients (68.19 vs 71.37, p = .001), but on multivariate analysis there was no significant difference (OR = 1.023; 95% CI 0.998-1.048; p = .068). There was no significant difference in clinical trial discussion or enrollment between the other sociodemographic factors. Conclusion Additional study of barriers to cancer clinical trial discussion and enrollment at safety net institutions can serve as a prerequisite to ameliorating racial disparities observed on a national scale.

1527. Assessment of Human Immunodeficiency Virus Testing in Underinsured Persons

Abstract Background Among those living with HIV, nearly 13% are unaware of their diagnosis and approximately 40% of new HIV infections are transmitted from those lacking a formal diagnosis. Thus, determination of populations at high risk of not having HIV testing completed are essential to reduce transmissions. A barrier to obtaining an HIV test within low-income individuals that do not qualify for Medicaid, or underinsured persons, is the rising cost of healthcare in the US. Thus, it is essential to determine if further resources should be dedicated to underinsured populations with the aim of increasing access to HIV testing. Methods This is a retrospective cross-sectional study utilizing the 2021 Behavior Risk Factor Surveillance System conducted by the US CDC to determine if individuals that do not qualify for Medicaid yet live in a household with an income of >138% but ≤200% of the US federal poverty line (FPL) had increased odds of not having an HIV test when compared to individuals that live in a household with an income of ≤138% of the FPL, and thus qualify for Medicaid. A multivariable logistic regression model was created to determine the adjusted odds ratio for not having an HIV test in those who did not qualify for Medicaid. Results This study analyzed data from 33,431 respondents that were age 18 – 64, living in a Medicaid expansion state, and had a household income of ≤200% the FPL. Among these persons, 65.1% of respondents qualified for Medicaid. Univariate analysis revealed that non-Medicaid eligible persons were more likely to not have an HIV test when compared to Medicaid eligible persons with 54% and 48.6% not having an HIV test, respectively. After adjusting for the confounding variables, persons who were not eligible for Medicaid had 1.26 (95% CI:1.21 - 1.32) times the odds of not having an HIV test compared to those who were eligible for Medicaid.(Table) Conclusion After adjusting for confounding variables, the odds that a person did not have an HIV test were higher among individuals that lived in a household with an income that was >138% but ≤200% of the FPL. These data reveal that underinsured persons are a potential group that may benefit from further resource allocation to bolster HIV screening. Disclosures Andrew M. Skinner, MD, Academy for Continued Healthcare Learning: Honoraria|American Society of Healthcare Pharmacists: Honoraria|Ferring Pharmaceuticals: Honoraria|MJH Life Sciences: Honoraria

Advancing health equity: A qualitative study assessing barriers and facilitators of implementing hereditary breast and ovarian cancer risk screening tools in community-based organizations.

Genetic counseling and testing (GCT) inform cancer management for persons at risk for hereditary breast and ovarian cancer (HBOC). Community-based organizations (CBOs) may play a role in identifying at-risk Latinx individuals to connect them to GCT but data are lacking. Two academic centers and their four CBO partners planned to implement a validated questionnaire for HBOC risk screening ("HBOC risk screening tool"). This study aimed to assess CBO's preferences for HBOC risk screening tools, as well as the barriers and facilitators anticipated for future implementation. Pre-implementation focus groups were conducted with CBO's staff. Discussions centered on current practices to identify and refer at-risk patients. During the discussion, staff were asked to select one out of five validated HBOC risk screening tools to implement and to discuss anticipated barriers/facilitators for implementation. The four focus groups were coded and qualitative analyzed following the Consolidated Framework for Implementation Research (CFIR) and Health Equity domains. All CBOs chose the Family History Screen 7 (FHS-7). Participants (N = 35) highlighted how the FHS-7 was easy to adapt to better fit the target population and changing guidelines. They had positive attitudes toward implementing the screening tool, stressed how the culture of the organization positioned them to reach the target population, and noted barriers in different CFIR domains (e.g., low knowledge about HBOC and GCT referrals; scarce available resources). Participants pointed to barriers related to health equity domains including limited access to GCT and follow-up care for uninsured and underinsured populations, challenges obtaining accurate family history, and immigration-related barriers. CBOs highlighted the importance of partnering with other stakeholders to overcome barriers. Findings emphasize the need to develop multi-level implementation strategies to overcome barriers and leverage facilitators. This study can inform the development of implementation toolkits for CBOs to implement HBOC screening tools to advance health equity.

Incidence and Risk Factors for Severe Outcomes in Pediatric Patients With COVID-19.

Throughout the pandemic, children with COVID-19 have experienced hospitalization, ICU admission, invasive respiratory support, and death. Using a multisite, national dataset, we investigate risk factors associated with these outcomes in children with COVID-19. Our data source (Optum deidentified COVID-19 Electronic Health Record Dataset) included children aged 0 to 18 years testing positive for COVID-19 between January 1, 2020, and January 20, 2022. Using ordinal logistic regression, we identified factors associated with an ordinal outcome scale: nonhospitalization, hospitalization, or a severe composite outcome (ICU, intensive respiratory support, death). To contrast hospitalization for COVID-19 and incidental positivity on hospitalization, we secondarily identified patient factors associated with hospitalizations with a primary diagnosis of COVID-19. In 165 437 children with COVID-19, 3087 (1.8%) were hospitalized without complication, 2954 (1.8%) experienced ICU admission and/or intensive respiratory support, and 31 (0.02%) died. We grouped patients by age: 0 to 4 years old (35 088), and 5 to 11 years old (75 574), 12 to 18 years old (54 775). Factors positively associated with worse outcomes were preexisting comorbidities and residency in the Southern United States. In 0- to 4-year-old children, there was a nonlinear association between age and worse outcomes, with worse outcomes in 0- to 2-year-old children. In 5- to 18-year-old patients, vaccination was protective. Findings were similar in our secondary analysis of hospitalizations with a primary diagnosis of COVID-19, though region effects were no longer observed. Among children with COVID-19, preexisting comorbidities and residency in the Southern United States were positively associated with worse outcomes, whereas vaccination was negatively associated. Our study population was highly insured; future studies should evaluate underinsured populations to confirm generalizability.

1266. Effects of Rapid Initiation of Antiretroviral Therapy in an Urban Clinic Setting

Abstract Background Rapid initiation of antiretroviral therapy (ART), i.e. within 72 hours of diagnosis, in people living with HIV (PLWH) has shown improved viral suppression, medication adherence, and retention in care, compared to deferral until initial labs have resulted. More real-world experience with rapid ART programs is needed, however, particularly among clinics in resource-limited settings that serve a complex and largely uninsured or underinsured population, such as the HIV clinic at SUNY Downstate Medical Center. In 2017, the clinic implemented rapid ART in select PLWH. Methods This was a single-center retrospective chart review of patients seen at our HIV clinic between January 2015 and June 2021. Patients were included if they were ART-naïve or off ART for > 3 months. Exclusion criteria included baseline undetectable viral load (VL) and perinatal HIV infection. Patients were assigned to standard or rapid start groups based on time from intake to initiation of ART. The primary outcome was proportion of patients with VL < 50 copies/mL at week 52. Secondary outcomes were proportion of patients with VL < 200 copies/mL, retention in care, and mean weight change from baseline, all at week 52; time from intake to ART; and time to viral suppression. Results As shown in Table 1, of the 190 patients that were included, 133 were rapid start while 77 were standard start. 103 patients had baseline resistance data; only 1 had integrase stand inhibitor resistance. Median time to ART was 0 days and 2.5 weeks in the rapid and standard groups, respectively. The most common initial regimen was BIC/FTC/TAF in both groups (49.6%, 31.2%). As described in Tables 2 and 3, 62.1% and 73.7% of patients had VL < 50 and < 200 copies/mL at week 52, respectively. Nearly 73% of patients remained in care at week 52, with similar rates between groups. Time from ART to viral suppression was similar between groups. Conclusion Rapid ART was well-tolerated but resulted in similar viral suppression and retention in care at week 52 compared to standard ART. However, rapid ART resulted in quicker viral suppression, although further evaluation of the clinical impact of this finding is needed. This study highlights the need for a multifaceted approach to engaging patients with HIV throughout the care continuum to ensure retention in care. Disclosures All Authors: No reported disclosures.

Dermatological Needs in an Urban Free Health Care Setting.

Introduction A large proportion of the United States' underinsured population relies on free health clinics for their health care needs. With only a few free health clinics nationwide hosting specialty clinics, a small subset of which are dermatology clinics, there is a dearth of information in the literature on which dermatological pathologies and treatment modalities are most common in this setting. The purpose of this study was to establish the most common dermatological conditions and treatments in the free health care setting as well as understand which facets of care need improvement. Methods A total of 57 patients with dermatological findings were identified at an urban student-run free health clinic in the southern United States in the past two years (2019-2021). Information reviewed for each patient included general demographics, chief complaint, medical/surgical history, treatments/procedures required for each visit, treatments/procedures available for each visit, referrals, and follow-up rate. Qualitative analysis was performed. Results The median age of the patients that presented with dermatological findings was 40 while the most common ethnicities were white (26.2%), Hispanic/Latino (28.6%), and black (28.6%). The most common chief complaints were rashes and cysts with a majority (63.2%) of these patients presenting to this particular clinic for the first time. Seven patients (12.3%) were unable to receive treatment due to expense, procedure unavailability, or an unknown reason. The most common treatment prescribed included a topical steroid. A majority (71.9%) of the patients were unable to follow up as scheduled. A majority of patients (81.2%) that were able to follow up were adherent to their prescribed medication. Conclusion Although dermatological conditions are plentiful in the free health care setting, the literature currently contains no information regarding this topic. This may be due to low patient follow-up rates and inadequately charted outcomes on often outdated electronic health records. In order to best care for dermatology patients in this setting, it is necessary to understand the barriers to care and available treatment options.

Insurance status is associated with urgent carotid endarterectomy and worse postoperative outcomes

ObjectiveUnderinsured patients can experience worse preoperative medical optimization. We aimed to determine whether insurance status was associated with carotid endarterectomy (CEA) urgency and postoperative outcomes. MethodsWe analyzed the Society for Vascular Surgery Vascular Quality Initiative Carotid Endarterectomy dataset from January 2012 to January 2021. Univariable and multivariable methods were used to analyze the differences across the insurance types for the primary outcome variable: CEA urgency. The analyses were limited to patients aged <65 years to minimize age confounding across insurers. We also examined differences in preoperative medical optimization and symptomatic disease and postoperative outcomes. A secondary analysis was performed to examine the effect of CEA urgency on the postoperative outcomes. ResultsA total of 27,331 patients had undergone first-time CEA. Of these patients, 4600 (17%) had Medicare, 3440 (13%) had Medicaid, 17,917 (65%) had commercial insurance, and 1374 (5%) were uninsured. The Medicaid and uninsured patients had higher rates of urgent operation compared with Medicare (20.0% and 34.7% vs 14.4%; P < .001), with no differences in the commercial group vs the Medicare group. Additionally, Medicaid and uninsured patients had lower rates of aspirin, statin, and/or antiplatelet use (93.6% and 93.5% vs 95.8%; P < .001) and higher rates of symptomatic disease (42.1% and 57.6% vs 36.2%; P < .001) compared with Medicare patients. The rate of perioperative stroke/death was higher for the Medicaid and uninsured patients than for the Medicare patients (1.63% and 1.89% vs 1.02%; P = .017 and P = .01, respectively), with no differences in the commercial group. Multivariable analysis demonstrated that compared with Medicare, Medicaid and uninsured status were associated with increased odds of an urgent operation (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.5; and OR, 2.3; 95% CI, 2.0-2.7, respectively), symptomatic disease (OR, 1.2; 95% CI, 1.1-1.4; and OR, 2.2; 95% CI, 1.9-2.5, respectively), and perioperative stroke/death (OR, 1.6; 95% CI, 1.1-2.4; and OR, 1.8; 95% CI, 1.1-3.0, respectively) and a decreased odds of aspirin, statin, and/or antiplatelet use (OR, 0.71; 95% CI, 0.6-0.9; and OR, 0.76; 95% CI, 0.6-0.99, respectively). Additionally, the rates of perioperative stroke/death were higher for patients who had required urgent surgery compared with elective surgery (2.8% vs 1.0%; P < .001). Multivariable analysis demonstrated increased odds of perioperative stroke/death for patients who had required urgent surgery (OR, 2.4; 95% CI, 1.9-3.1). ConclusionsMedicaid and uninsured patients were more likely to require urgent CEA, in part because of poor preoperative medical optimization. Additionally, urgent operation was independently associated with worse postoperative outcomes. These results highlight the need for improved preoperative follow-up for underinsured populations.

Providing Prenatal Care for Patients with Limited Medical Insurance Coverage.

Newer immigrants to the United States, whether undocumented, recent legal immigrants, those here on temporary visas, or migrant workers, are far less likely than native-born residents of the United States to have reliable health insurance. This entire group of patients is then at risk for delayed or absent medical care. Our study focused on what effects a free, quality prenatal care program had upon prenatal care and delivery outcomes for an underinsured population, primarily of immigrant women. With a recent change in Iowa's eligibility criteria for Presumptive Medicaid (referred to as Temporary Medicaid), pregnant patients who have less than a 5-year legal permanent residency status, undocumented status, or out-of-country resident status can receive up to two months of covered antepartum care, whereas previously eligible for coverage for the entirety of their pregnancy. With that reality, several faculty members from the Department of Family Medicine at the University of Iowa started a weekly prenatal care clinic in collaboration with the longstanding Iowa City Free Medical Clinic. This study sought to compare outcomes for patients who utilized only Temporary Medicaid to those who also had access to this prenatal free medical clinic (FMC), as well as to compare outcomes for the FMC program to typical Medicaid patients who had access to full prenatal care. Compared to the Temporary Medicaid-only group, our FMC patients had a significantly greater number of prenatal visits. This increased access of continuity prenatal care led to increased screening for gestational diabetes, receipt of recommended vaccinations, and screening for group B streptococcus. Our effort has shown that expanding prenatal healthcare coverage to this underinsured population can greatly increase the quality of maternity care and reduce the potential for high-risk pregnancies, bettering the care for these pregnant women and their newborns.

The correlation analysis of 21-gene assay use in uninsured and underrepresented minorities with estrogen receptor (ER) positive HER2 negative breast cancer.

e12531 Background: 21-gene breast cancer recurrence-score assay (Oncotype DX) have been used to predict recurrence risks and guide adjuvant chemotherapy. However, access to such tests is limited, especially in a population concentrated with uninsured and underserved patient populations. Previously equations such as the Magee equation has been proposed to predict correlation of the recurrence score and the estimated recurrence score with high concordance rate. This study examines the concordance of such an assay to predicted scores in uninsured and underrepresented minority heavy public hospital. Methods: We performed a retrospective chart review of 68 women with hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer seen at University Hospital (public safety net hospital in Newark, New Jersey with greater majority of the patient population consists of underrepresented minorities such as Black/African Americans and Latino/Hispanics). 6 patients did not have pathology records, 9 patients did not have the Oncotype information available, and 4 patients were waiting on the results. Of the pre-menopausal eligible patients, two did not have any treatment or follow up information available and were included as part of the correlation assay, however, no. Results: Of the 47 eligible patients with follow-up information, 13 had a low recurrence score of up to 10 if post-menopausal and up to 15 if pre-menopausal, 22 had an intermediate recurrence score of 11 to 25 if post-menopausal and 16 to 25 if pre-menopausal, and 12 had a high recurrence score of greater than 26 according to the national comprehensive cancer network guidelines. The Pearson correlation between the Magee predicted score and Oncotype recurrence score was 0.73 (p &lt; 0.001). All patients received hormone therapy and 5 patients total had recurred. 2 were pre-menopausal and had received adjuvant chemotherapy. 3 were post-menopausal in low and intermediate categories who had not received adjuvant chemotherapy. Conclusions: This study shows a high correlation between the predicted Magee score and Oncotype recurrence score. This reflects a possible use in the prediction scoring system as another resource for prognostication and guidance in treatment especially in the underinsured population.

Current Controversies in Radiology on Cost, Reimbursement, and Price Transparency: AJR Expert Panel Narrative Review.

Many believe that fundamental reform of the U.S. health care system is overdue and necessary given rising national health care expenditures, poor performance on key population health metrics, meaningful health disparities, concerns about potential financial toxicity of care, inadequate price transparency, pending insolvency of Medicare Part A, increasing commercial insurance premiums, and large uninsured and underinsured populations. The Medicare Payment Advisory Commission, an independent congressional agency, believes that part of this reform includes redistribution of reimbursements away from specialties such as radiology. Thus, despite an increase in the Medicare population and spending, Medicare payments for medical imaging have been decreasing for years. Further, the No Surprises Act, a federal law intended to curb the problem of surprise medical billing, was repurposed in federal rulemaking to reduce reimbursement from commercial payers to certain specialties, including radiology. In this article, we examine challenges facing the U.S. health care system, focusing on cost, reimbursement, and price transparency and the role of radiology in addressing such challenges. Medical imaging is a minor contributor to national health care expenditures but has an outsized impact on patient care. The radiology community should work together to reinforce the value of medical imaging and reduce inappropriate utilization of low-value care.

Integrating Population Health Strategies into Primary Care: Impact on Outcomes and Hospital Use for Low-Income Adults.

Our objectives were two-fold: 1) To evaluate the benefits of population health strategies focused on social determinants of health and integrated into the primary care medical home (PCMH) and 2) to determine how these strategies impact diabetes and cardiovascular disease outcomes among a low-income, primarily minority community. We also investigated associations between these outcomes and emergency department (ED) and inpatient (IP) use and costs. Retrospective cohort. Community-based PCMH: Baylor Scott & White Health and Wellness Center (BSW HWC). All patients who attended at least two primary care visits at BSW HWC within a 12-month time span from 2011-2015. Outcomes for patients participating in PCMH only (PCMH) as compared to PCMH plus population health services (PCMH+PoPH) were compared using electronic health record data. Diastolic and systolic blood pressure, hemoglobin A1c, ED visits and costs, and IP hospitalizations and costs were examined. From 2011-2015, 445 patients (age=46±12 years, 63% African American, 61% female, 69.5% uninsured) were included. Adjusted regression analyses indicated PCMH+PoPH had greater improvement in diabetes outcomes (prediabetes HbA1c= -.65[SE=.32], P=.04; diabetes HbA1c= -.74 [SE=.37], P<.05) and 37% lower ED costs than the PCMH group (P=.01). Worsening chronic disease risk factors was associated with 39% higher expected ED visits (P<.01), whereas improved chronic disease risk was associated with 32% fewer ED visits (P=.04). Integrating population health services into the PCMH can improve chronic disease outcomes, and impact hospital utilization and cost in un- or under-insured populations.

Epidemiologic disparities in colon cancer screening and adherence during the COVID-19 pandemic: a retrospective cohort analysis.

BackgroundColorectal cancer (CRC) is the second-leading cause of death in the USA. CRC screening remains underutilized, especially in underinsured populations. Screening has been heavily disrupted during the COVID-19 pandemic.PurposeThe goal is to explore the impact of the pandemic on ethnic and gender disparities in CRC screening.MethodsPatients were identified 1 year before and after COVID-19 precautions began, using March 1, 2020, as the inflection point. The primary inclusion criterion was an ordered colonoscopy. The outcome of interest was a colonoscopy performed. Differences by year and race were assessed using chi-square analysis. A cohort of 1549 patients (899 in pre-COVID; 650 in post-COVID) between age 45 and 75 for whom a colonoscopy was ordered was selected from EHR at a large institution.ResultsThere was a 51% reduction in screening colonoscopies performed. White patients had a decrease of 49%, and African Americans had a 55% reduction. Stool testing increased from 47% prior to the pandemic to 94% during the pandemic representing a greater than 100% increase in stool testing uptake.ConclusionThe true impact of COVID-19 on colorectal cancer is yet to be uncovered as future mortality estimates from CRC are ongoing. Due to the widespread closure of endoscopy centers and delay in screening, we believe that the pandemic worsened the screening disparities most prevalent among minority populations. Our study points to the drastic reduction of screening for all races, especially for African Americans.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00384-022-04118-6.

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

COVID-19 Pandemic-Associated Changes in the Acuity of Brain MRI Findings: A Secondary Analysis of Reports Using Natural Language Processing

Rationale and ObjectivesWe aimed to assess early COVID-19 pandemic-associated changes in brain MRI examination frequency and acuity of imaging findings acuity.MethodsUsing a natural language processing model, we retrospectively categorized reported findings of 12,346 brain MRI examinations performed during 6-month pre-pandemic and early pandemic time periods across a large metropolitan health system into 3 acuity levels: (1) normal or near normal; (2) incidental or chronic findings not requiring a management change; and (3) new or progressive findings requiring a management change. Brain MRI frequency and imaging finding acuity level were compared over time.ResultsBetween March and August of 2019 (pre-pandemic) and 2020 (early pandemic), our health system brain MRI examination volumes decreased 17.0% (6745 vs 5601). Comparing calendar-matched 6-month periods, the proportion of higher acuity findings increased significantly (P< 0.001) from pre-pandemic (22.5%, 43.6% and 34.0% in acuity level 1, 2, and 3, respectively) to early pandemic periods (19.1%, 40.9%, and 40.1%). During the second 3 months of the early pandemic period, as MRI volumes recovered to near baseline, the proportion of higher acuity findings remained high (42.6% vs 34.1%) compared with a similar pre-pandemic period. In a multivariable analysis, Black (B coefficient, 0.16) and underinsured population (B coefficient, 0.33) presented with higher acuity findings (P< 0.05).ConclusionsAs the volume of brain MRI examinations decreased during the early COVID-19 pandemic, the relative proportion of examinations with higher acuity findings increased significantly. Pandemic-related changes in patient outcomes related to reduced imaging access merits further attention.