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Although many primary care clinics screen for behavioral health (BH) conditions using validated tools, it is not clear whether adult BH screening leads to better patient outcomes. Our objective was to determine the evidence base by reviewing effectiveness research for multiple strategies of BH screening in adult primary care identified in the Practice Integration Profile.We conducted five rapid reviews of effectiveness research supporting BH screening strategies cited in the Practice Integration Profile. Each rapid review was conducted using an adapted REAL (Rapid Evidence Assessment of the Literature) methodology and a standardized search tailored for each screening strategy to identify evidence related to BH screening in primary care.The database search yielded 931 references. Following eligibility review and extraction, we evaluated data from 20 references examining five screening strategies. Results demonstrated limited support for all five strategies and high risk of bias within most studies. Outcomes associated with various BH screening strategies were rarely the focus of study.There is an absence of robust, well-structured evidence supporting many of the BH screening strategies advocated for in primary care. Stakeholders may wish to understand how to ensure value when developing a robust screening program that will improve patient health outcomes. Future research should advance the science of BH screen selection, timing, and implementation by answering new questions about screening strategies. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Case management is an ideal service for patients with health complexity. However, most case management models do not integrate medical and behavioral health training and interventions, and there are little data evaluating these models in privately insured populations. The purpose of this study was to evaluate impact of an integrated case management (ICM) service at the payor level.Health care insurance company.A multimethod observational study was conducted at a health care insurance company in the Pacific Northwest of the United States. We conducted focus groups of case managers, leaders, and administrators and statistical analyses of outcomes data. Measures included care quality data (discharge follow-up appointment, cost per case, depression and anxiety measures, customer experience and satisfaction, and audit scores) of members receiving ICM services and employee focus group data (acceptability, adoption, feasibility, appropriateness, fidelity, and sustainability) related to the practice of ICM.Care quality data suggest ICM reduces mental health symptoms and increases discharge follow-up appointments for members. Implementation challenges include new employee orientation to ICM model, traditional views of case management, performance evaluation, documentation, and information technology. Facilitators of implementation include training, autonomy, and leadership support.Organizations should be aware both of the benefits and challenges related to implementing ICM. Open communication between case managers and leadership and an improvement-focused culture appear to be important elements of implementation success. Future research should examine the perspective of members receiving ICM services and the implementation of ICM into health care delivery systems.

Background: Starting in November 2017, 3 liver transplant centers in a single health care system tested and implemented a new protocol to begin accepting livers from hepatitis C virus–seropositive donors for seronegative liver transplant recipients. Although reports show an increase in donors after protocol implementation, there are no details regarding protocol uptake at each transplant center. Literature is limited on protocol implementation that is developed and disseminated by the same protocol producers. The purpose of this study was to evaluate the implementation of a new liver transplant protocol adopted at 3 transplant centers in the same health care system. Methods: A multimethod implementation study using interview, survey, and transplant data was conducted to develop a conceptual model of protocol implementation, identify facilitators of and barriers to implementation, and detect differences in implementation between 3 centers. Results: The conceptual model included 4 domains: rationale, development, implementation, and sustainability. Facilitators included clear, science-based rationale, input from multiple hepatologists, leadership support, and funded pilot data. Barriers included insurance coverage of posttransplant medication and donor field availability. A total of 94 physicians and staff at the 3 transplant centers completed the survey. Implementation factors were all rated moderately high to high at all 3 centers. One-way analysis of variance showed significant differences in mean implementation scores between the centers (F(2, 84)=11.65; PP=.02); post hoc comparisons indicated that the scores for physicians differed only between the leading center and 1 participating center. Transplant numbers increased across all 3 centers from 2017 to 2021. Conclusions: Protocol implementation was successful across all 3 centers, especially at the leading transplant center where the protocol was developed. Future efforts should examine the appropriateness of the protocol for other organs (eg, heart, kidney) and additional medical outcome data (eg, mortality, morbidity, quality of life). Trial Registration: Not applicable

Objective Workforce development is essential for the dissemination of team-based integrated behavioral healthcare. There is limited literature on training family medicine residents to function within an integrated behavioral health (IBH) system. The purpose of this pilot study was to assess the feasibility and value of an IBH competency-based curriculum for family medicine residents across multiple programs. Methods Residency programs were recruited using professional listservs and networks to test a competency-based, multi-modal curriculum for preparing residents to practice IBH in primary care. Faculty instructors who led the workshop were invited to complete semi-structured interviews to examine the feasibility and appropriateness of the curriculum. Interview data were analyzed using thematic analysis to identify, analyze, and report patterns. Residents completed a survey of perceived IBH skill and knowledge before and after training. A paired-sample t-test was used to determine significant differences pre- and post-training. Results All five instructors completed interviews. Results suggest IBH training is valuable. Instructors gave specific feedback on online modules, implementation flexibility, and adjusting faculty development to differing levels of experience. Nineteen of forty residents (48%) completed anonymous pre-, post-, and retrospective-training surveys. Residents reported an increase in competence after training. Conclusion The results of this pilot suggest that IBH training implementation is feasible, desirable, timely, and may improve resident ability to work on an IBH team. Training should accommodate variations in program structure and faculty expertise.

Introduction The Affordable Care Act's Medicaid expansion has been found to increase healthcare access among low-income individuals in the general population. Fewer studies have explored the impact of Medicaid expansion on healthcare access among those living with chronic diseases. It is also unclear whether the impact of Medicaid expansion varies across levels of educational attainment or poverty among this subgroup. This study investigates the impact of Medicaid expansion on healthcare access among adults aged 18–64 years living with chronic diseases, as well as its variations across educational attainment and federal poverty levels. Methods The 2011–2017 Behavioral Risk Factor Surveillance System data were used. Difference-in-difference analyses explored the impact of Medicaid expansion on healthcare access (health insurance coverage, routine checkup, having a personal doctor, and cost-related delayed care within the past 1 year) among individuals living with chronic diseases. Analyses were also stratified by levels of educational attainment and quartiles of the federal poverty level. Data were analyzed between February and November 2019. Results Medicaid expansion was associated with increased health insurance coverage (β=0.27, 95% CI=0.16, 0.38), increased likelihood of having a routine checkup (β=0.12, 95% CI=0.04, 0.22) within the past 1 year, increased likelihood of having a personal doctor (β=0.08, 95% CI=0.01, 0.12), and decreased likelihood of reporting cost-related delayed care (β=−0.10, 95% CI=−0.19, −0.02). Medicaid expansion was associated with increased health insurance coverage across all levels of educational attainment and federal poverty level quartiles. Conclusions Medicaid expansion increased healthcare access for low-income individuals living with chronic diseases.

Background Elevated baseline neutrophil lymphocyte ratios (NLR) are now well established as a poor predictor of survival in renal cell carcinoma (RCC) and other cancers. Platelet Lymphocyte Ratios (PLR) have also recently shown similar effects. Despite these findings, the practical use of these ratios is still somewhat limited. We have previously shown that higher NLRs may be associated with increased concentrations of myeloid derived suppressor cells (MDSC). We hypothesized that increases in NLR or PLR (NLR/PLR failure) at 2 months while on immunotherapy could be a predictor of eventual treatment failure and overall survival. Methods We analyzed patients who received nivolumab therapy for RCC at our institution from 3/2016 to 6/2019. Patients with complete data on NLR and PLR at time = 0 and +2 months and those who had accurate response and overall survival information available were selected (n = 37). Information on comorbidities, previous therapy, demographics were collected for adjusted analysis. NLR failure was defined as an increase of 3 or more compared to baseline NLR. Cox proportional hazard models were used to analyze the risk of progression and death with NLR/PLR failure at 2 months (± 2 weeks). Kaplan Meier graphs were constructed to trace survival functions for PFS and OS by NLR Results NLR failure was associated with a statistically significant increase in the risk of progression on nivolumab therapy (HR 4.26, 95% CI [1.47–12.3], p = 0.007), in an adjusted cox regression model that included baseline NLR. In this adjusted model, the value of baseline NLR to predict treatment failure was non-significant (HR 1.01, p – 0.69). Similarly, NLR failure increased the risk of death (HR 3.83 95% CI [1.23–11.9], p = 0.02), with a similar non-significant contribution of baseline NLR (HR 1.06, p = 0.06). NLR failure predicted PFS less than 6 months with 90% positive predictive value (9/10) and a 48% (12/25) negative predictive value, and survival less than 1 year with a 56% negative predictive value and 100% positive predictive value (10/10). PLR changes failed to show any association with PFS (HR 0.99, p = 0.93) or OS (HR 1.00, p = 0.93). Conclusions An increase in NLR of 3 or more at 2 months of therapy with nivolumab appears to predict for impending treatment failure and increasing risk of death with a high positive predictive value. NLR failure if validated in larger studies could be useful in treatment management Ethics Approval The study was approved by UAB Comprehensive Cancer Centers Ethics Board

Multiple studies have confirmed a high prevalence of prognostic germline mutations in prostate cancer. In recognition, the NCCN guidelines and recommendations for genetic counselling (GC) in prostate cancer patients were expanded.Data on prostate cancer patients at a single tertiary cancer center from January 2019 - June 2019 were queried. The cohort of patients from the queried list were evaluated for their eligibility for genetic testing. From the patients that were eligible for testing, the rate of referrals was ascertained. A 10-item questionnaire was concurrently sent to providers to understand germline genetic testing patterns and potential barriers.Only 39% of the eligible prostate cancer patients were referred, with testing completed in 11% with indications. 30% of providers reported they would be comfortable completing genetic counseling themselves. The identified barriers to provide genetic testing themselves were lack of time and expertise (50%). Other barriers included: lack of genetic counselor workforce (70%), lack of knowledge of genetic testing and the inadequate co-ordination of referrals (60%).In this retrospective study, many patients met the criteria for GC, however, the referrals for this patient population are inconsistent, and only a handful of the eligible patients completed testing. Identified barriers were provider's knowledge and comfort with guidelines and testing, systemic bottlenecks such as limited capacity of genetic counsellors, and the creation of improved workflows.

344 Background: IROC is an expanding multi-institution collaborative database which includes socioeconomic, genomic, pathologic, clinical and laboratory data in metastatic RCC patients (pts), primarily in the modern setting. Elevated baseline NLR is now an established poor prognostic factor in renal cell carcinoma (RCC) but currently has limited practical use. We hypothesized that an increase in NLR of 3 or more (NLR Failure) at 2 months on therapy could be a predictor of eventual treatment failure and shorter overall survival and thus augment the utility of this marker. Methods: Patients with complete data on NLR at time = 0 and +2 months of therapy were analyzed. Information on comorbidities, previous therapy, demographics were collected for adjusted analysis. NLR failure was defined as an increase of 3 or more compared to baseline NLR. Cox proportional hazard models were used to analyze the risk of progression and death with NLR failure at 2 months (+/- 2 weeks). Kaplan Meier graphs were constructed to trace survival functions for PFS and OS by NLR. Results: Among 165 pts; 121 were eligible (Table). NLR failure at 2 months was associated with a highly statistically significant increase in the risk of death in < 1 year (HR 6.82, 95% CI [3.16-14.70], p

43 Background: Recent studies have recognized the high prevalence of germline mutations in genes affecting DNA repair in patients with prostate cancer. In recognition of their growing clinical significance, the NCCN guidelines recommend genetic counselling in prostate cancer pts with certain risk factors. The application of these guidelines in clinical practice were evaluated. Methods: All new clinic visits of prostate cancer pts at UAB from January 2019 – June 2019 were identified and analyzed. We constructed a flow diagram of the UAB two-step referral model, and performed a chart review and analyzed the new clinic visits. We then sent a 10-item questionnaire to providers at UAB to collect information on germline genetic testing patterns, general approach to testing, and the barriers of GC, and actions to overcome barriers. Results: From January to June 2019, 57 new prostate cancer patients were seen, of which 23 had metastatic disease, 20 had high or intermediate risk localized disease and remaining had biochemical recurrence. In total, 38 had an indication for GC. The most common indication was metastatic disease in 23 pts (40%) and localized high risk in 15 pts (26%). Significantly 33% of 24 patients with early onset prostate cancer < 60 yrs did not meet NCCN defined criteria for testing. Only 39% of the 38 eligible patients were referred, with testing completed in 11% of those with indications. The response rate to the survey was 91%. 30% of respondents reported that they would be comfortable completing genetic counseling themselves, and the most commonly reported barrier to providing the testing themselves was time, and lack of expertise/experience. 70% percent of providers cited that lack of genetics workforce was a barrier to genetic testing, and 60% cited lack of knowledge of genetic testing and genetics and the inadequate coordination of referrals were barriers. Conclusions: While a majority of prostate cancer patients seen in the oncology clinic meet criteria for GC, referrals are inconsistent, and only a handful of eligible patients complete testing. From the survey results, the areas that need to be improved from the provider’s side are education and comfort with genetic testing. From a systems perspective, the need for more genetics workforce, and better process workflows are required to improve the uptake of Genetic Testing Referral and Testing. The interventions of practice transformation and education need to be implemented, and tested at UAB to improve adherence to the NCCN guidelines for genetic testing of prostate cancer.