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We investigated efficacy and compliance related to percutaneous tibial nerve stimulation in patients treated for overactive bladder at a large, urban safety net hospital.Consecutive patients who underwent percutaneous tibial nerve stimulation at Grady Memorial Hospital from May 2015 through January 2019 were included in our cohort and records were reviewed retrospectively. Primary outcomes of interest included self-reported urinary symptoms and episodes of urinary incontinence. Our secondary outcome of interest was patient compliance, defined as completion of 12 or more treatment sessions. Descriptive analysis and paired t-tests were performed.Of the 50 patients with a mean ± SD age of 59 ± 12 years 80% were black, 52% were male, 34% were uninsured and 54% subscribed to government insurance. Prior treatment included behavioral modification in 100% of cases, anticholinergics in 86% and mirabegron in 4%. Patients completed a mean of 10.7 ± 2.7 of the 12 planned weekly percutaneous tibial nerve stimulation treatments. Of the patients 70% completed all 12 weekly treatments and 77% of those who completed 12 treatments continued to maintenance treatment. After percutaneous tibial nerve stimulation treatment average symptoms improved across all metrics, including mean daytime frequency (from 11.0 to 6.6 episodes per day or -24.5%), nighttime frequency (from 4.8 to 2.5 episodes per night or -47.1%), urgency score (from 3.4 to 1.9 or -42.1%) and incontinence (from 1.6 to 0.4 episodes per day or -79.6%) (each p0.001). A total of 43 patients (86%) reported symptom improvement.Percutaneous tibial nerve stimulation had favorable efficacy and compliance in a traditionally underserved patient population. This should be considered as a feasible modality to manage overactive bladder symptoms in patients in a similar demographic.

BACKGROUND: Although most American patients with ESKD become eligible for Medicare by their fourth month of dialysis, some never do. Information about where patients with limited health insurance receive maintenance dialysis has been lacking. METHODS: We identified patients initiating maintenance dialysis (2008–2015) from the US Renal Data System, defining patients as “safety-net reliant” if they were uninsured or had only Medicaid coverage at dialysis onset and had not qualified for Medicare by the fourth dialysis month. We examined four dialysis facility ownership categories according to for-profit/nonprofit status and ownership (chain versus independent). We assessed whether patients who were safety-net reliant were more likely to initiate dialysis at certain facility types. We also examined hospital-based affiliation. RESULTS: The proportion of patients

US hospitals that care for vulnerable populations, "safety-net hospitals" (SNHs), are more likely to incur penalties under the Hospital Readmissions Reduction Program, which penalizes hospitals with higher-than-expected readmissions. Understanding whether SNHs face unique barriers to reducing readmissions or whether they underuse readmission-prevention strategies is important.We surveyed leadership at 1600 US acute care hospitals, of whom 980 participated, between June 2013 and January 2014. Responses on 28 questions on readmission-related barriers and strategies were compared between SNHs and non-SNHs, adjusting for nonresponse and sampling strategy. We further compared responses between high-performing SNHs and low-performing SNHs.We achieved a 62% response rate. SNHs were more likely to report patient-related barriers, including lack of transportation, homelessness, and language barriers compared with non-SNHs (P-values0.001). Despite reporting more barriers, SNHs were less likely to use e-tools to share discharge summaries (70.1% vs. 73.7%, P0.04) or verbally communicate (31.5% vs. 39.8%, P0.001) with outpatient providers, track readmissions by race/ethnicity (23.9% vs. 28.6%, P0.001), or enroll patients in postdischarge programs (13.3% vs. 17.2%, P0.001). SNHs were also less likely to use discharge coordinators, pharmacists, and postdischarge programs. When we examined the use of strategies within SNHs, we found trends to suggest that high-performing SNHs were more likely to use several readmission strategies.Despite reporting more barriers to reducing readmissions, SNHs were less likely to use readmission-reduction strategies. This combination of higher barriers and lower use of strategies may explain why SNHs have higher rates of readmissions and penalties under the Hospital Readmissions Reduction Program.

To improve breast cancer screening in a federally qualified health center, NPs developed a collaborative team of nurses to implement innovative strategies that improved mammography rates from 23% to 40% over a 12-month period. Through shared expertise, this team led the way in translating mammography guidelines into clinical practice.

Background: Nearly half of Americans with diagnosed hypertension have uncontrolled blood pressure (BP) while some integrated healthcare systems, such as Kaiser Permanente Northern California, have achieved control rates upwards 90%. Methods and Results: We adapted Kaiser Permanente’s evidence-based treatment protocols in a racially and ethnically diverse population at 12 safety-net clinics in the San Francisco Health Network. The intervention consisted of 4 elements: a hypertension registry, a simplified treatment intensification protocol that included fixed-dose combination medications containing diuretics, standardized BP measurement protocol, and BP check visits led by registered nurse and pharmacist staff. The study population comprised patients with hypertension who made ≥1 primary care visits within the past 24 months (n=15 917) and had a recorded BP measurement within the past 12 months. We conducted a postintervention time series analysis from August 2014 to August 2016 to assess the effect of the intervention on BP control for 24 months for the pilot site and for 15 months for 11 other San Francisco Health Network clinics combined. Secondary outcomes were changes in use of guideline-recommended medication prescribing. Rates of BP control increased at the pilot site (68%–74%; P P P P P Conclusions: Evidence-based system approaches to improving BP control can be implemented in safety-net settings and could play a pivotal role in achieving improved population BP control and reducing hypertension disparities.

BACKGROUND: For many individuals, the implementation of the US Affordable Care Act will involve a transition from public to private health care venues for sexually transmitted infection (STI) care and prevention. To anticipate challenges primary care providers may face and to inform the future role of publicly funded STI clinics, it is useful to consider their current functions. METHODS: Data collected by 40 STI clinics that are a part of the Sexually Transmitted Disease Surveillance Network were used to describe patient demographic and behavioral characteristics, STI diagnoses, and laboratory testing data in 2010 and 2011. RESULTS: A total of 608,536 clinic visits were made by 363,607 unique patients. Most patients (61.9%) were male; 21.9% of men reported sex with men (MSM). Roughly half of patients were 20 to 29 years old (47.1%) and non-Hispanic black (56.2%). There were 212,765 STI diagnoses (mostly nonreportable) that required clinical examinations. A high volume of chlamydia, gonorrhea, and HIV testing was performed (>350,000 tests); the prevalence was 11.5% for chlamydia, 5.8% for gonorrhea, 0.9% for HIV, and varied greatly by sex and MSM status. Among MSM with chlamydia or gonorrhea, 40.1% (1811/4448) of chlamydial and 46.2% (3370/7300) of gonococcal infections were detected at extragenital sites. CONCLUSIONS: Sexually Transmitted Disease Surveillance Network clinics served populations with high STI rates. Given experience with diagnoses of both nonreportable and reportable STIs and extragenital chlamydia and gonorrhea testing, STI clinics comprise a critical specialty network in STI diagnosis, treatment, and prevention.

To examine the relationship between training during residency in a federally qualified health center (FQHC), rural health clinic (RHC), or critical access hospital (CAH) and subsequent practice in these settings.The authors identified residents who trained in safety net settings from 2001 to 2005 and in 2009 using 100% Medicare Part B claims files for FQHCs, RHCs, and CAHs and 2011 American Medical Association Masterfile residency start and end date histories. They used 2009 Medicare claims data to determine the relationship between this training and subsequent practice in safety net settings.The authors identified 662 residents who had a Medicare claim filed in their name by an RHC, 975 by an FQHC, and 1,793 by a CAH from 2001 to 2005 and in 2009. By 2009, that number of residents per year had declined for RHCs and FQHCs but increased substantially for CAHs. The percentage of physicians practicing in a safety net setting in 2009 who had trained in a similar setting from 2001 to 2005 was 38.1% (205/538) for RHCs, 31.2% (219/703) for FQHCs, and 52.6% (72/137) for CAHs.Using Medicare claims data, the authors identified residents who trained in safety net settings and demonstrated that many went on to practice in these settings. They recommend that graduate medical education policy support or expand training in these settings to meet the surge in health care demand that will occur with the enactment of the Affordable Care Act insurance provision in 2014.

Designated primary care clinics largely serve low-income and uninsured patients who present a disproportionate number of chronic illnesses and face great difficulty in obtaining the medical care they need, particularly the access to specialty physicians. With limited capacity for providing specialty care, these primary care clinics generally refer patients to safety net hospitals' specialty ambulatory care clinics. A large public safety net health system successfully improved the effectiveness and efficiency of the specialty clinic referral process through application of Lean Six Sigma, an advanced process-improvement methodology and set of tools driven by statistics and engineering concepts.

This study aims to identify strategies for safe medication use practices in ambulatory care settings, with a special focus on clinical pharmacy services.We conducted case studies on 34 organizations, more than half of which were safety net providers. Data included discussions with 186 key informants, 3 interim debriefings, and a technical expert panel. We analyzed qualitative data using inductive analysis techniques and grounded theory approach.Ambulatory care organizations practice a broad range of safe medication use strategies. The inclusion of clinical pharmacy services is a culture change that supports efforts to improve patient safety and patient-centered care. Organizations integrated clinical pharmacy services when they introduced such services in a purposefully paced and gradual manner. Organizations sustained such services when they collected and reported data demonstrating improvements in patient outcomes and cost savings. Clinical pharmacy services were generally accompanied by strategies that helped organizations to provide patient-centered care; collect and measure process, safety, and clinical outcomes; promote leadership commitment; and integrate care delivery processes. These strategies interacted within organizations in synergistic rather than hierarchical or linear way. Organizational ability to provide safe, patient-centered, and efficient care that is supported by measurable data largely depends on leadership commitment and ability to integrate care processes.Ambulatory care organizations use multiple strategies for safe medication use systems. Understanding processes that promote such strategies will provide a helpful road map for other organizations in implementation and sustainability of safe medication use systems.

This study examines the adaptability of standardized performance measurement tools in 3 community-based health centers. Although health centers have considerable experience in the area of performance reporting, they do not currently participate in a national reporting system that is transparent and standardized. The analysis of the data collected from health centers indicates that not only can these safety net providers readily integrate standardized measures, the quality of care being provided compare favorably to national benchmarks. With evidence of solid performance may come the types of financial adjustments essential to permitting health centers to move more decisively into the broader private health insurance markets that may exist in their service areas.

It is becoming increasingly apparent that some disparities in health outcomes for vulnerable populations relate to performance of providers. Based on analysis of Medicaid claims records, large differences in performance among primary care providers are documented for New York City patients, suggesting the need for better evidence in making management decisions.

The primary mission of community health centers (CHCs) is to provide primary and preventive healthcare for the underserved and vulnerable populations, including the uninsured, underinsured, and Medicaid beneficiaries. Economic and regulatory challenges have placed these safety net providers in a precarious position, forcing some to respond using cooperative strategies. This article focuses on seven CHC-led networks, delineating their integrative efforts in the core areas of managed care, clinical, administrative, information, and finance. Interviews with key representatives from each network highlight the networks' accomplishments and the critical success factors and outcomes of their integrative efforts. Several underlying themes emerged from this study that are consistent with findings of previous studies conducted in other organizational settings. Specifically participants in CHC-led networks cite the following factors as contributors to success: reciprocity, communication, trust, and long-standing relationships among key individuals. This is the first study to provide a rich depiction of CHC network activities.

Urban safety net providers are under pressure to improve primary care productivity. In a survey of ambulatory care facilities in New York City, productivity (measured as the number of primary care visits per provider hour) increases with exam rooms per physician but has no association with computerized information systems or tightly controlled reimbursement. Also, sample facilities rely heavily on residents, which makes these facilities sensitive to medical education policies and raises questions about quality of care for the poor. We conclude that urban safety net providers will have difficulty making the productivity improvements demanded by a more competitive health system.

Medicaid managed care is becoming prevalent throughout the United States, but some commercial HMOs are exiting from the Medicaid market. This phenomenon suggests that success in this relatively new market depends on the development of Medicaid HMOs around the key safety-net providers in the community. These essential providers offer the backbone of expertise and commitment needed to serve the Medicaid population while they are eligible for coverage as well as after their Medicaid eligibility ends.