Urban Safety Net Hospital Research Articles

A qualitative study of the experiences of patients with prostate cancer when receiving negative genetic results: "I still don't have a grasp of what it all means".

Germline genetic testing has been increasingly conducted for treatment implications in patients with prostate cancer due to the expansion of testing eligibility. Understanding patients' comprehension of genetic results is crucial for establishing effective result disclosure practices. This importance has grown due to the increasing prevalence of negative genetic results being conveyed via electronic communication and by providers without a genetics specialization. This study explores patients with prostate cancer's perceptions of genetic results communication. We analyzed 24 qualitative, semi-structured interviews with patients with prostate cancer at an urban safety-net hospital who had genetic results documented in their medical records. Interview questions focused on patient experiences with genetic referrals, genetic counseling, and genetic result disclosure. Audio recordings were professionally transcribed and analyzed by the study team utilizing an inductive thematic approach to generate themes from recurring codes. Of those who participated, 18 were interviewed in English, 5 in Spanish, and 1 in Haitian Creole. No participants reported having a pathogenic variant identified with genetic testing. Study participants identified a number of gaps in results communication which led to misconceptions regarding hereditary cancer risk. Three themes were generated: (1) Patients desired clear communication about the next steps after genetic testing, (2) Patients commonly experienced cognitive dissonance with negative genetic results given personal and family history of cancer, and (3) Patients felt reassurance from negative genetic results. This research suggests that maintaining conversations between patients and healthcare providers alongside the delivery of negative results assists in patient comprehension. Additionally, it is essential to evaluate the accessibility and appropriateness of notes and results sent to patients. Ultimately, understanding communication barriers in genetic results return is imperative in order to provide high-quality genetic care.

Embracing anti-racism: Co-creating recommendations with Black people for how addiction treatment needs to change

In the United States, Black people face harsher health and social consequences of addiction compared to people who are not Black. These differential consequences are largely attributable to systemic racism. While addiction treatment may mitigate health disparities related to substance use, Black people also experience structural barriers and direct interpersonal racism which contribute to inequitable access and treatment outcomes. Improvements in addiction treatment for Black people are urgently needed, but there is little guidance or consensus on how to achieve this. Our interdisciplinary work group is comprised of 16 researchers and clinicians from one urban safety-net hospital in the Northeast US, and 9 community members with lived experience of substance use disorder (SUD) who came together from 2022 to 2024 for a community-engaged initiative to identify how to make addiction treatment more appealing, effective, and equitable for Black people. This paper's objective is two-fold. First, we provide a broad overview of the project, which included 6 scoping literature reviews, 7 focus groups, and 4 day-long convenings which included an additional 30 experts on addiction treatment for Black patients, drawn primarily from the Northeast U.S. Altogether, we engaged more than 70 people with expertise in substance use and treatment, the majority of whom identify as Black. Second, we present major findings from the convenings, where we identified actions that can be taken now to improve the care of Black people and challenge the racist features of our addiction treatment system. Making addiction treatment more appealing, effective, and equitable will help to achieve health equity for Black people who use substances.

Self-Collection for Primary HPV Testing: Acceptability in a Large Urban Emergency Department

Overdue cervical cancer screening increases the risk of invasive cervical cancer. It is important to identify settings where self-collection for primary human papillomavirus (HPV) testing can be implemented to have high effect on cervical cancer screening among hard-to-reach women with overdue screening. Herein, we examined the acceptability of HPV self-collection, including completion rates, attitudes, and experiences among women seeking noncritical care at a high-volume urban safety-net hospital emergency department (ED) in Houston, Texas, United States. In this single-arm intervention pilot study, we recruited women overdue for cervical cancer screening in the waiting areas of a safety-net hospital ED, seeking noncritical care from November 2023 to April 2024. Participants completed a preintervention survey and were offered an HPV self-collection kit. A postintervention survey followed immediately after HPV self-collection. Nearly 30% (119 of 401) screened for eligibility were overdue for cervical cancer screening. Of these, 93% were enrolled and were predominantly Hispanic, non-US born, and uninsured, with a median age of 45 years (IQR: 37 to 53). HPV self-collection completion rate was 90% (95% CI 82.9% to 94.9%). More than a quarter (27%) of these women had never been screened, and 14% had a screening >10 years prior. Most women who completed the HPV self-collection had positive attitudes and experiences and reported that the kit was easy to use (97%) and would be very willing to use HPV self-collection for regular screening (88%). HPV self-collection for primary cervical cancer screening during noncritical ED visits is possible and highly acceptable among women overdue for cervical cancer screening.

Risk Factors for Developing Community-Acquired Hand Infections at a Large-Volume Urban Safety Net Hospital.

Hand infections represent a significant burden for both health care systems and their patients. Epidemiological understanding of community-acquired hand infections is limited. This study examined a cohort of hand infection patients at a large urban safety net hospital for characteristics that were associated with protective and/or risk factors for hand infections. We performed a retrospective chart review for all patients who required hand surgery consultation in the emergency department during a 1-year period (2021-2022). County-level population characteristics were obtained through the county-level data sources. We then performed a risk ratio (RR) analysis for demographic and socioeconomic characteristics. A total of 125 patients were included in the study cohort. Cisgender male (RR, 4.654; P < 0.001), Black (RR, 6.062; P < 0.001) and American Indian/Alaska Native (RR, 3.293; P = 0.041) patients were found to be overrepresented in our cohort when compared to county proportions, indicating an association with increased risk of hand infections. Patients between 35 and 49 years of age were also found to have an increased risk (RR, 1.679; P = 0.005). Age over 65 years, retirement, and employment were found to be protective factors (RR, 0.341 [ P = 0.001]; RR, 0.397 [ P = 0.043]; RR, 0.197 [ P < 0.001]). In contrast, unemployment and unstable housing (unhoused or shelter) were found to have strong harmful risk for necessitating hand infection consults (RR, 7.587 [ P < 0.001]; RR, 235.715 [ P < 0.001]; RR, 29.990 [ P < 0.001]). There are clear risk factors at play for hand infection incidence. We found that housing status, employment, race, gender, and age were some of the most important contributors for incidence. This information can assist clinicians and public officials in developing more specific screening algorithms and prevention tools to reduce systematic burden. Further studies are required to elucidate specific etiologies associated with hand infection risk.

9202 Characterizing The Physiological Side-Effects Of Over-The-Counter Arthritis Supplements

Abstract Disclosure: K.S. Wei: None. M.O. De La Torre: None. A. Flores: None. C.E. Chiu: None. T.E. Angell: None. Introduction: Over the counter (OTC) health supplements are commonly used by patients for a variety of ailments but may contain active ingredients that are not stated, such as glucocorticoids. Here, we present a case series of 12 patients seen by the Endocrinology Consult service at an urban safety net hospital during 2022-2023 and determined to have iatrogenic adrenal insufficiency (AI) from specific OTC supplements that surreptitiously contained glucocorticoids. Clinical Cases:12 patients using OTC arthritis supplements [Artri King (n=8), Ardosons (n=3), and Ajo Rey (n=1)] were identified. Median age was 52 years and 33.3% were female. All started using the supplements because of joint pain. Median length of use prior to cessation was 6 months. The most common presenting symptoms were nausea/vomiting (42%), fatigue (42%), abdominal pain (33%), and dizziness (17%). The most common physical exam findings of steroid excess included moon facies (66%), central adiposity (66%), abdominal striae (50%), dorsocervical fat pad (33%), and bruising (33%). 3/12 patients required ICU admission. Cortisol assessment was performed in 11/12 patients, which showed normal cortisol level in 1 patient (cortisol ≥16 mcg/dL), AI in 3 patients (cortisol ≤3 mcg/dL), and an equivocal level (cortisol 3-16 mcg/dL) in 7 patients. Cosyntropin stimulation testing in 6/7 patients with equivocal cortisol levels suggested AI in 4 (cortisol level &amp;lt;16 mcg/dL at 60 minutes after ACTH stimulation), whereas 2 showed lower but normal response (cortisol levels 18.2 mcg/dL and 18.4 mcg/dL). In total, 10/12 patients were prescribed glucocorticoid tapering replacements to avoid precipitating adrenal crisis. The most common regimens were hydrocortisone 20mg qAM/10mg qPM (33%) and hydrocortisone 5mg qAM/5mg qPM (17%). To date, 2/10 patients have successfully discontinued steroid replacement. Conclusion: These cases demonstrate possible Cushing’s syndrome and/or adrenal insufficiency after unintentional exposure to glucocorticoids in these OTC arthritis supplements, which has only previously been reported in a small number of case reports (1). This series collected over a 2-year period offers important clinical insights: Because patients may not identify or recall a supplement, possible use of OTC medications for arthritis or other anti-inflammatory purposes should be specifically assessed in patients presenting with adrenal insufficiency (especially with concomitant findings suggesting Cushing’s syndrome). For patients on such supplements, immediate discontinuation may not be possible without cortisol replacement and should be done with caution. 1)Boncompagni A.C. et al. A case of iatrogenic Cushing syndrome and subsequent adrenal insufficiency from a hidden ingredient in the supplement Artri Ajo King. J Am Coll Emerg Physicians Open. 2023;4(4):e13007. Presentation: 6/1/2024

S2122 Longitudinal Weight Loss Outcomes Following Transoral Outlet Reduction (TORe) in a Minority Patient Population at an Urban Safety Net Hospital

S2122 Longitudinal Weight Loss Outcomes Following Transoral Outlet Reduction (TORe) in a Minority Patient Population at an Urban Safety Net Hospital

S355 Improving Post-Acute Diverticulitis Colonoscopy Adherence in an Urban Safety Net Hospital Using Computed Tomography Reports

S355 Improving Post-Acute Diverticulitis Colonoscopy Adherence in an Urban Safety Net Hospital Using Computed Tomography Reports

Assessing the Quality of Care of Pregnant Patients With Thyrotoxicosis at an Urban Safety Net Hospital

ObjectiveThyrotoxicosis can adversely affect pregnancy. The quality of care (QoC) for thyrotoxicosis in pregnancy at a tertiary care safety net hospital was evaluated based on current guidelines. MethodsPregnant patients with thyrotoxicosis or a history of Graves disease who delivered in 2015-2021 were divided into 3 groups: low thyroid stimulating hormone (TSH), active Graves disease, and past Graves disease. The QoC was assessed using thyroid hormone and thyroid stimulating immunoglobulin (TSI) levels, fetal ultrasound, and endocrine referrals. We assessed potential impacts of race/ethnicity and socioeconomic status (SES). ResultsWe included 147 subjects (mean age 31.5 years, 76% Black, 86% non-Hispanic). Of patients with low TSH (n = 95), 75% had repeat TSH measurements and 33% had TSI measured. Hispanic patients were more likely to have TSI and repeat TSH measured than non-Hispanics (58% vs 29%; P = .04, and 100% vs 71%; P = .03, respectively). In patients with active Graves disease (n = 23, 70% treated with thionamides), 35% had free thyroxine levels at goal and 90% had endocrine care or referral. In patients with past Graves disease (n = 27), 56% had TSI measured, 78% had first-trimester TSH measurements, and 58% had TSH at goal. Black patients were less likely to have TSH checked in the first trimester than other races (85% vs 100%, P = .048). ConclusionThe QoC of thyrotoxicosis in pregnancy at this tertiary care center can be improved. A larger study is needed to assess the potential impacts of race and SES on the care of pregnant patients with thyrotoxicosis.

S2044 Gap in Care: Follow-Up of Incidental Hepatic Steatosis on Imaging in a Urban Safety Net Hospital

S2044 Gap in Care: Follow-Up of Incidental Hepatic Steatosis on Imaging in a Urban Safety Net Hospital

Timely Hip Surgery Access in Children With Cerebral Palsy: Unaffected by Social Disadvantage at a Large Urban Safety Net Hospital.

Socioeconomic disadvantage has been shown to limit timely access to pediatric orthopaedic care and can result in poor surgical outcomes. Insurance coverage has often served as a proxy for socioeconomic status; however, area deprivation index (ADI) and child opportunity index (COI) are more comprehensive measures of social determinants of health (SDOH). The treatment of hip displacement in children with cerebral palsy (CP) requires early radiographic identification and continuous surveillance, which may be impacted by SDOH. This study seeks to evaluate the influence of insurance, ADI, and COI on preoperative Reimer migration percentage and need for pelvic osteotomy during varus derotation osteotomy (VDRO) in children with CP. This retrospective cohort study examined 219 patients with CP who underwent VDRO surgery for hip subluxation or dislocation at a tertiary referral center (135 male, mean age 7.9y, SD: 2.9, range: 2.4 to 17.2; 17 GMFCS II, 21 GMFCS III, 89 GMFCS IV, 92 GMFCS V) from 2004 to 2022. Imaging and clinical documentation for patients with CP and hip displacement, age <18 years with ≥1 year of follow-up, treated with VDRO were reviewed. GMFCS level, preoperative Reimer migration percentages (MP), surgical details, and demographic and socioeconomic data were collected, and addresses were used to determine ADI (2018 version) and COI (2.0 database). The relationship of ADI, COI, and insurance type to preoperative Reimer MP of the more displaced hip and the need for pelvic osteotomy were analyzed with linear regressions and logistic regressions. The mean preoperative Reimer MP was 64.4% (SD: 25.0, range: 0 to 100). As expected, patients functioning at higher GMFCS levels presented with greater Reimer MPs. The average Reimer MP was 34.0 for GMFCS II, 44.2 for GMFCS III, 64.6 for GMFCS IV, and 74.5 for GMFCS V (P<0.01). The mean ADI state decile (1 to 10 scale) and COI (1 to 100 scale) for the cohort were 5.6 (SD: 2.2, range: 1 to 10) and 37.2 (SD: 28.1, range: 4 to 100), respectively. ADI (P=0.77), COI (P=0.30), and insurance type (P=0.78) were not related to preoperative Reimer MP. However, patients with lower ADIs (OR 0.83, 95% CI [0.70, 0.99], P=0.04) and higher COIs (OR 1.01, 95% CI [1.00, 1.03], P=0.03) underwent pelvic osteotomies at a higher rate. ADI, COI, and insurance type were not related to preoperative Reimer MP. Interestingly, greater social disadvantage was associated with a lower frequency of pelvic osteotomy at the time of VDRO. Our data demonstrate that at our institution, greater social disadvantage does not result in limited access to timely orthopaedic care for children with CP. This is likely due to adequate governmental insurance coverage for children with neuromuscular disorders in this state and the active involvement of pediatric orthopaedic surgeons in government-sponsored clinics, including ongoing hip screening programs for children with CP. These results provide hope that healthcare disparities can potentially be mitigated.

Impact of screening on mortality for patients diagnosed with hepatocellular carcinoma at a safety-net hospital: An opportunity for addressing disparities.

140 Background: Hepatocellular carcinoma (HCC) is a common and deadly cancer with a rising incidence in the US. HCC almost always develops on a background of chronic liver disease, which disproportionately affects individuals of lower socioeconomic status (SES), perpetuating existing disparities. Compounding these disparities, individuals of lower SES are less likely to participate in recommended cancer screening exams. Here, we describe the outcomes of patients diagnosed with HCC at a large urban safety-net hospital primarily serving the underserved. Methods: We identified patients diagnosed with HCC at John Peter Smith Hospital in Fort Worth, Texas from January 1, 2018, to March 31, 2021 to determine the impact of screening on survival. Patients were allocated to the screened cohort if they had undergone liver imaging within one year prior to HCC diagnosis. Kaplan-Meier methods and log-rank test were used to illustrate and compare 3-year survival curves from an index date of diagnosis until death. Cox proportional hazards model were used to calculate unadjusted and adjusted hazards ratios (HR) and 95% confidence intervals (CI). Lead time bias was adjusted in a sensitivity analysis using the Duffy adjustment and a sojourn time of 70 days and 140 days. Results: A total of 158 patients were included (n=53 screened, n=105 unscreened). The mean age was 62 years; 144 (91%) had cirrhosis, 78% were male, 34% were non-Hispanic white, and 8.2% had private insurance. Those in the unscreened cohort had more severe liver dysfunction (as measured by the ALBI grade) and produced higher levels of AFP, but were less likely to have cirrhosis than the screened cohort. The median overall survival (OS) for the screened cohort was 19.0 months (95% CI: 9.9-NA) and 5.4 months (95% CI: 3.7-8.5) in the unscreened cohort (HR death (unscreened v screened) = 2.4, 95% CI: 1.6-3.6; log rank P &lt;0.0001). After adjusting for ALBI grade, AFP, hepatitis C, insurance status and initial treatment, there was a statistical difference in hazard of death in the three years (HR: 2.3; 95% CI: 1.5-3.6), favoring the screened cohort. The benefit for screening remained after adjusting for lead-time bias. With a mean sojourn time of 70 days, the HR death was 2.19 (95% CI 1.4-3.3, P =0.0002) and was 2.09 (1.4-3.2, P =0.0005) with a 140-day sojourn time. Conclusions: In an urban safety-net population, screening for HCC was associated with improved outcomes compared to patients with incidentally-diagnosed HCC. Altogether, this implies that earlier diagnosis and institution of treatment can positively improve survival for patients with newly diagnosed HCC in a population of patients evaluated at a safety-net hospital. Development of screening programs in accordance with accepted guidelines with outreach to high-risk individuals represents an area of high value care for safety-net hospitals.

Travel-associated carbon emissions of patients receiving cancer treatment from an urban safety net hospital

BackgroundHealthcare transportation, particularly the transportation of patients to access healthcare services, is a significant source of carbon emissions. This study aims to estimate the carbon emissions of patient transportation among patients receiving cancer care at an urban community safety net hospital. Materials and MethodsWe conducted a retrospective study of patients seen at the oncology clinic of an urban community safety net hospital between 1 July 2022 and 30 June 2023. Patients with at least one in-person visit in 1 year, documented home addresses, and oncologic diagnoses were included in the study. The distance between each patient's home address and the hospital was calculated using the Google Map API key and a macro to calculate distance in metres. The total estimated carbon emissions were calculated using the EPA equivalencies calculator. The primary outcome was carbon emissions from patients' round-trip travel from home to hospital. ResultsFrom 1 July 2022 to 30 June 2023, 13,970 visits were made to the oncology clinic. Of these, 8,235 visits made by 1,080 patients met the criteria for inclusion in the final analysis. Of the 8,235 visits recorded, 5,095 (61.8%) were follow-up/laboratory visits. The 1,080 patients who attended the clinic had a mean age of 63.8 years; 700 (64.8%) were male, and 525 (48.6%) were Black or African-American. Breast cancer was the most common diagnosis, accounting for 423 (39.2%) of cancer diagnoses. Each patient travelled 4.8 (0.3–149.3) miles for a one-way trip and 9.6 (0.7–298.6) miles for a round trip to receive cancer care. Approximately 1,520 (280–119,440) g carbon were emitted per patient visit. A total of 79,582 round-trip miles was calculated for the 8,235 visits made by all patients within 1 year, which corresponds to 31,832 kg CO2 emissions equivalent to 35,658 pounds of coal burned, 1,462 propane cylinders used for a home, or 3,872,250 smartphones charged. ConclusionTravel to receive cancer care is associated with significant carbon emissions and poses a climate and public health risk. Efforts to decrease the overall carbon footprint of cancer treatment are needed to minimise the contributions of cancer treatment to climate change.

A critical view: Examining disparities regarding timely cholecystectomy

BackgroundImplicit bias may prevent patients with abdominal pain from receiving optimal workup and treatment. We hypothesized that patients from socially disadvantaged backgrounds would be more likely to experience delays in receiving operative treatment for cholecystitis. To study this question, we examined factors related to having a prior emergency department presentation for abdominal pain (prior emergency department visit) within 3 months of urgent cholecystectomy. MethodsWe performed a retrospective analysis of consecutive patients who received an urgent cholecystectomy at an urban safety net public hospital between July 2019 and December 2022. The main outcome of interest was prior emergency department visit within 3 months of index cholecystectomy. We examined patient age, sex, race, ethnicity, preferred language, insurance, and employment status. Bivariate comparisons and logistic regression were used to determine the relationship between patient factors and prior emergency department visit. ResultsOf 508 cholecystectomy patients, 138 (27.2%) had a prior emergency department visit in the 3 months preceding their surgery. In bivariate analysis, younger age, Black race, Hispanic ethnicity, non-English preferred language, and type of insurance (P < .05) were associated with prior emergency department visit. In regression, younger age, Black race, Hispanic ethnicity, and having Medicare or being uninsured were associated with higher odds of having a prior emergency department visit. ConclusionMore than 1 in 4 patients had an evaluation for abdominal pain within 3 months of having an urgent cholecystectomy, and these patients were more likely to be from socially disadvantaged backgrounds. Standardized evaluation pathways for abdominal pain are needed to reduce disparities from institutional or implicit bias.

Health Status and Healthcare Utilization Patterns of Emergency Department Patients Who Prefer a Language Other Than English.

Immigrants, nearly half of whom prefer a language other than English (LOE), face structural barriers to healthcare. This subgroup is believed to be at increased risk for reduced access to quality healthcare, yet few studies have examined the health needs and utilization patterns of LOE-preferring patients who seek care in the Emergency Department (ED). Given that the ED is often an entry point to the health system, we sought to characterize the health patterns of this population in an urban ED setting. We conducted a retrospective chart review of the electronic medical records of 1,566 patients who utilized interpreter services in the ED or Urgent Care) at an urban safety net hospital. We found that LOE-preferring patients had high levels of chronic disease. We also found that the majority of these patients had not seen a primary care provider (PCP) within the study period. PCP visits were positively associated with ED utilization suggesting that those without a PCP are less likely to receive ED care. These findings point to a need for greater policy and community health solutions addressing the high burden of chronic disease and underutilization of healthcare for those with LOE preferences.

Implementation of an Opt-Out Outpatient HIV Screening Program.

Screening rates for Human Immunodeficiency Virus (HIV) remain low despite guidelines by both the CDC and USPSTF recommending that all adolescents and adults be screened at least once. The aim of this quality improvement study was to increase HIV screening among eligible patients. This quality improvement study assessed the impact of interventions to increase HIV screening in an outpatient population at a large urban safety-net hospital. Outcomes were compared from the preintervention (December 2020 to November 2021) to postintervention years (December 2021 to November 2022). Stepwise electronic alerts to prompt HIV screening paired with provider financial incentives were implemented. The proportion of eligible individuals screened for HIV were compared after intervention implementation. Average monthly HIV screening increased from 506 ± 97 to 2484 ± 663 between the pre- and postintervention periods, correlating to a 5.1-fold increase in screening (7.8% to 39.8%, P < .01). Increases were seen across all ages, and those aged 55 to 64 and 65+ had the highest relative increase in screening at 7.5 and 9.3-fold, respectively (P < .01). Screening rates increased for Hispanics (7.9% preintervention vs 43.6% postintervention, P < .01). In the pre- and postintervention periods, 41 patients with new HIV diagnoses were identified (13 preintervention and 28 postintervention) and 85.4% were linked to care within 30 days. Stepwise interventions targeted at primary care clinicians are an effective way to increase HIV screening rates, particularly in older demographics. Earlier HIV diagnosis coupled with linkage to care is an important strategy in ending the HIV epidemic.

Neutrophil to Lymphocyte Ratio Values in Late Preterm and Term Patients with Evidence of Chorioamnionitis on Placental Histopathology: A Retrospective Cohort Study

Introduction: Neutrophil to lymphocyte ratio (NLR) is an inexpensive biomarker that may aid in the prediction of adverse pregnancy outcomes, though data remains sparse at this time. Previously published research regarding chorioamnionitis almost exclusively focuses on preterm labor and preterm prelabor rupture of membranes before 34 weeks of gestation and suggests an increase in NLR in those patients with chorioamnionitis identified on placental histopathologic examination. However, chorioamnionitis in the late preterm and term timeframe also represents a significant source of maternal and neonatal morbidity. Therefore, the primary aims of the study were to: 1) compare obstetric admission NLR values among those with and without evidence of histopathologic chorioamnionitis 2) evaluate the efficacy of NLR in identifying histopathologic chorioamnionitis and 3) compare NLR values pre- and postdelivery in the setting of a placental histopathologic chorioamnionitis diagnosis in patients beyond 34 weeks of gestation. Methods: A retrospective electronic chart review was performed at an American urban safety net hospital. Institutional review board approval was obtained (UMKC #2093657), and patient consent was waived due to the retrospective nature of the review. Obstetric encounters were included if a complete blood count (CBC) with differential was performed on admission and postpartum, the subject underwent a trial of labor, a placental histopathologic examination was performed, and delivery occurred beyond 34 0/7 weeks of gestation. Subjects were excluded if an extrauterine infection was present during the hospitalization or the subject received corticosteroids within two weeks of delivery. Postdelivery placentas were examined by the University’s pathology department. Statistical analyses were performed with receiver operator curves, Mann-Whitney U test, and Wilcoxon Signed-Rank Test where applicable, with a significance level p &lt; 0.05. Results: Three hundred seventy-nine patient encounters were reviewed, with only 30.1% of all encounters with placental histopathology available. A total of 58 subjects met the inclusion criteria and 14 additional subjects were excluded due to extrauterine infection (n=1), SARS-CoV-2 diagnosis (n=5), and late preterm steroids administration (n=8). There was no difference between those subjects with and without histopathologic chorioamnionitis in median gestational age at the time of delivery (39 0/7 versus 39 1/7 weeks of gestational, p=0.960), median time of admission CBC collection to delivery (0.98 versus 0.98 days, p=0.340), and timing of collection of postpartum CBC (1.0 versus 1.0 days postpartum, p=0.631). Predelivery neutrophil to lymphocyte ratio values were compared in subjects with and without histopathologic chorioamnionitis and there was no significant difference in median values (4.11 versus 4.52, p=0.683). The predelivery NLR predicted the presence of chorioamnionitis poorly (AUC 0.518, 95% CI [0.326, 0.711], p=0.843). The postdelivery NLR was a slightly better predictor of chorioamnionitis (AUC 0.634, 95% CI [0.454, 0.815], p=0.147), but did not reach statistical significance. Although there was no significant difference in postpartum NLR values in those with and without chorioamnionitis on final histopathology (6.73 versus 4.63, p=0.147), the value was notably higher in the former. When the antepartum and postpartum NLR were compared across individual subjects in a paired fashion, there was a significantly higher postpartum NLR in those subjects both with and without chorioamnionitis on final histopathology (with chorioamnionitis: antepartum median 4.52 versus postpartum 6.73, p=0.012, n=15; without chorioamnionitis: antepartum median 4.11 versus postpartum 4.63, p=0.043, n=29). Conclusion: Though predelivery NLR is a poor predictor of chorioamnionitis, significantly higher postpartum NLR values in the sample population suggest an increase in NLR for all laboring patients, but a more pronounced increase occurs in those with inflammatory placental findings. While the study is limited by a heterogeneous sample population, nonparametric evaluation, and small sample sizes, the data does add to the paucity of preexisting literature that seeks to utilize NLR in the prediction of chorioamnionitis during the labor course. Larger longitudinal studies may help better characterize the rising NLR values over the course of labor and delivery as seen in our study. Neutrophil to lymphocyte ratio values across the spectrum of disease states and gestational ages in pregnancy may help isolate other inflammatory processes that impact perinatal outcomes.

All of whom? Limitations encountered using All of Us Researcher Workbench in a Primary Care residents secondary data analysis research training block.

The goal of this case report is to detail experiences and challenges experienced in the training of Primary Care residents in secondary analysis using All of Us Researcher Workbench. At our large, urban safety net hospital, Primary Care/Internal Medicine residents in their third year undergo a research intensive block, the Research Practicum, where they work as a team to conduct secondary data analysis on a dataset with faculty facilitation. In 2023, this research block focused on use of the All of Us Researcher Workbench for secondary data analysis. Two groups of 5 residents underwent training to access the All of Us Researcher Workbench, and each group explored available data with a faculty facilitator and generated original research questions. Two blocks of residents successfully completed their research blocks and created original presentations on "social isolation and A1C" levels and "medical discrimination and diabetes management." Departmental faculty were satisfied with the depth of learning and data exploration. In focus groups, some residents noted that for those without interest in performing research, the activity felt extraneous to their career goals, while others were glad for the opportunity to publish. In both blocks, residents highlighted dissatisfaction with the degree to which the All of Us Researcher Workbench was representative of patients they encounter in a large safety net hospital. Using the All of Us Researcher Workbench provided residents with an opportunity to explore novel questions in a massive data source. Many residents however noted that because the population described in the All of Us Researcher Workbench appeared to be more highly educated and less racially diverse than patients they encounter in their practice, research may be hard to generalize in a community health context. Additionally, given that the data required knowledge of 1 of 2 code-based data analysis languages (R or Python) and work within an idiosyncratic coding environment, residents were heavily reliant on a faculty facilitator to assist with analysis. Using the All of Us Researcher Workbench for research training allowed residents to explore novel questions and gain first-hand exposure to opportunities and challenges in secondary data analysis.

Feasibility of a 2-Part Substance Use Screener Self-Administered by Patients on Paper: Observational Study.

Measurement-based care in behavioral health uses patient-reported outcome measures (PROMs) to screen for mental health symptoms and substance use and to assess symptom change over time. While PROMs are increasingly being integrated into electronic health record systems and administered electronically, paper-based PROMs continue to be used. It is unclear if it is feasible to administer a PROM on paper when the PROM was initially developed for electronic administration. This study aimed to examine the feasibility of patient self-administration of a 2-part substance use screener-the Tobacco, Alcohol, Prescription medications, and other Substances (TAPS)-on paper. This screener was originally developed for electronic administration. It begins with a limited number of questions and branches to either skip or reflex to additional questions based on an individual's responses. In this study, the TAPS was adapted for paper use due to barriers to electronic administration within an urgent care behavioral health clinic at an urban health safety net hospital. From August 2021 to March 2022, research staff collected deidentified paper TAPS responses and tracked TAPS completion rates and adherence to questionnaire instructions. A retrospective chart review was subsequently conducted to obtain demographic information for the patients who presented to the clinic between August 2021 and March 2022. Since the initial information collected from TAPS responses was deidentified, demographic information was not linked to the individual TAPS screeners that were tracked by research staff. A total of 507 new patients were seen in the clinic with a mean age of 38.7 (SD 16.6) years. In all, 258 (50.9%) patients were male. They were predominantly Black (n=212, 41.8%), White (n=152, 30%), and non-Hispanic or non-Latino (n=403, 79.5%). Most of the patients were publicly insured (n=411, 81.1%). Among these 507 patients, 313 (61.7%) completed the TAPS screener. Of these 313 patients, 76 (24.3%) adhered to the instructions and 237 (75.7%) did not follow the instructions correctly. Of the 237 respondents who did not follow the instructions correctly, 166 (70%) answered more questions and 71 (30%) answered fewer questions than required in TAPS part 2. Among the 237 patients who did not adhere to questionnaire instructions, 44 (18.6%) responded in a way that contradicted their response in part 1 of the screener and ultimately affected their overall TAPS score. It was challenging for patients to adhere to questionnaire instructions when completing a substance use screener on paper that was originally developed for electronic use. When selecting PROMs for measurement-based care, it is important to consider the structure of the questionnaire and how the PROM will be administered to determine if additional support for PROM self-administration needs to be implemented.

Risk management or racial Bias? The disparate use of restraints in the Emergency Department of an Urban Safety-Net Hospital

ObjectivesLimited data exist on racial-ethnic differences in the application of restraints for patients visitng the emergency department (ED). This study examines whether there is an association between race and patient ED visit type with the application of four-point mechanical restraints in a high acuity safety-net urban academic hospital. MethodsThe study retrospectively reviewed 198,610 visits to the ED at Boston Medical Center made by patients between 18 and 89 years old between May 1, 2014 and May 1, 2019. ED visit type was categorized based on primary billing code for the visit as either medical or behavioral; behavioral visits were further categorized into 5 groups based on corresponding primary psychiatric billing code category. The relationships between race/ethnicity and four-point mechanical restraints were analyzed using binary logistic regression models in SPSS. Results1.4% of unique visits involved the use of four-point mechanical restraints. Patients with a behavioral visit were significantly over 16 times more likely to be restrained than those with a medical visit. Black patients were significantly more likely to be restrained than white patients for behavioral visits but less likely for medical visits. Black and Hispanic patients were also significantly more likely to be restrained for a behavioral visit regardless of psychiatric diagnosis. Asian patients were less likely to be restrained regardless of ED visit type. ConclusionsSignificant racial differences in restraints for White patients with medical visits and Black and Hispanic patients with behavioral visits prompts further investigation on the role of clinician bias when managing acute patients.

Primary Care After Pregnancy Survey: Patient Preferences, Health Concerns, and Anticipated Barriers.

Despite recommendations for ongoing care after pregnancy, many individuals do not see a primary care clinician within the first postpartum year, missing a critical window to engage reproductive-age individuals in primary care. We administered an anonymous, cross-sectional, trilingual survey at a large urban safety-net hospital to assess postpartum individuals' preferences, health concerns, and anticipated barriers to primary care during the year after pregnancy. While 90% of respondents preferred a visit within one year, most individuals - including those with complicated pregnancies - did not recall a primary care recommendation from their pregnancy care team. Respondents reported a variety of primary care-amenable health concerns, and many social and logistical barriers to care. Preference for virtual care increased if self-monitoring tools were hypothetically available, indicating virtual visits may improve primary care access.