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Objective To compare patients with DKA, hyperglycaemic hyperosmolar syndrome (HHS), or mixed DKA-HHS and COVID-19 [COVID (+)] to COVID-19-negative (−) [COVID (−)] patients with DKA/HHS from a low-income, racially/ethnically diverse catchment area. Methods A cross-sectional study was conducted with patients admitted to an urban academic medical center between 1 March and 30 July 2020. Eligible patients met lab criteria for either DKA or HHS. Mixed DKA-HHS was defined as meeting all criteria for either DKA or HHS with at least 1 criterion for the other diagnosis. Results A total of 82 participants were stratified by COVID-19 status and type of hyperglycaemic crisis [26 COVID (+) and 56 COVID (−)]. A majority were either Black or Hispanic. Compared with COVID (−) patients, COVID (+) patients were older, more Hispanic and more likely to have type 2 diabetes (T2D, 73% vs 48%, p

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.

Specialty care accounts for a significant and growing portion of year-over-year Medicaid cost increases. Some referrals to specialists may be avoided and managed more efficiently by using electronic consultations (eConsults). In this study a large, multisite safety-net health center linked its primary care providers with specialists in dermatology, endocrinology, gastroenterology, and orthopedics via an eConsult platform. Many consults were managed without need for a face-to-face visit. Patients who had an eConsult had average specialty-related episode-of-care costs of $82 per patient per month less than those sent directly for a face-to-face visit. Expanding the use of eConsults for Medicaid patients and reimbursing the service could result in substantial savings while improving access to and timeliness of specialty care and strengthening primary care.

Collaborative visit agenda setting between patient and doctor is recommended. We assessed the feasibility, acceptability, and utility of patients attending a large primary care safety-net clinic typing their agendas into the electronic visit note before seeing their clinicians. One hundred and one patients and their 28 clinicians completed post-visit surveys. Patients and clinicians agreed that the agendas improved patient-clinician communication (patients 79%, clinician 74%), and wanted to continue having patients type agendas in the future (73%, 82%). Enabling patients to type visit agendas may enhance care by engaging patients and giving clinicians an efficient way to prioritize patients' concerns.

This cross-sectional study uses electronic health record data to evaluate the association between COVID-19 and breast cancer screening at an urban integrated health system’s safety-net hospital between September 2019 and January 2021.

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: One of the potential benefits of insurance reform is greater stability of insurance and reduced coverage disparities by race and ethnicity. OBJECTIVES: We examined the temporal trends in insurance coverage by racial/ethnic group before and after Massachusetts Insurance Reform by abstracting records across two urban safety net hospital systems. RESEARCH DESIGN: We examined adjusted odds of being uninsured and incident rate ratios of gaining and losing insurance over time by race and ethnicity. We used billing records to capture the payer for each episode of care. SUBJECTS: We included data from January 2005 through December 2013 on patients with hypertension between the ages of 21 and 64 years. We compared four racial and ethnic groups: non-Hispanic White, non-Hispanic Black, non-Hispanic Asian and Hispanic. MEASURES: We examined individual patients’ insurance coverage status in 6 month intervals. We compared odds of being uninsured in the transition and post insurance reform period to the pre reform period, adjusting for age, sex, comorbidities practice location and education and income by Census tract. RESULTS: Among 48,291 patients with hypertension, reduction in rates of uninsurance with insurance reform was greater for Hispanic (29.7%), non-Hispanic Black (24.8%) and non-Hispanic Asian (26.8%) than non-Hispanic White (14.9%) patients. The odds of becoming uninsured were reduced in all racial and ethnic groups (OR 0.27–0.41). CONCLUSIONS: Massachusetts Insurance Reform resulted in stable insurance coverage and a reduction in disparities in insurance instability by race and ethnicity.

Objective To operationalize constructs from each of the Consolidated Framework for Implementation Research domains and to present psychometric properties within the context of evidence-based approaches for promoting colorectal cancer screening in federally qualified health centers (FQHCs). Methods Data were collected from FQHC clinics across seven states. A web-based Staff Survey and a Clinic Characteristics Survey were completed by staff and leaders (n = 277) from 59 FQHCs. Results Internal reliability of scales was adequate ranging from 0.62 for compatibility to 0.88 for other personal attributes (openness). Intraclass correlations for the scales indicated that 2.4 percent to 20.9 percent of the variance in scale scores occurs within clinics. Discriminant validity was adequate at the clinic level, with all correlations less than 0.75. Convergent validity was more difficult to assess given lack of hypothesized associations between factors expected to predict implementation. Conclusions Our results move the field forward by describing initial psychometric properties of constructs across CFIR domains.

Screening with FIT or colonoscopy can reduce CRC mortality. In our pragmatic, randomized trial of screening outreach over three years, patients annually received mailed FITs or colonoscopy invitations. We examined screening initiation after each mailing and crossover from the invited to other modality. Eligible patients (50–64 years, ≥1 primary-care visit before randomization, and no history of CRC) received mailed FIT kits (n = 2400) or colonoscopy invitations (n = 2400) from March 2013 through July 2016. Among those invited for colonoscopy, we used multinomial logistic regression to identify factors associated with screening initiation with colonoscopy vs. FIT vs. no screening after the first mailing. Most patients were female (61.8%) and Hispanic (48.9%) or non-Hispanic black (24.0%). Among those invited for FIT, 56.6% (n = 1359) initiated with FIT, whereas 3.3% (n = 78) crossed over to colonoscopy; 151 (15.7%) and 61 (7.7%) initiated with FIT after second and third mailings. Among those invited for colonoscopy, 25.5% (n = 613) initiated with colonoscopy whereas 18.8% (n = 452) crossed over to FIT; 112 (8.4%) and 48 (4.2%) initiated with colonoscopy after second and third mailings. Three or more primary-care visits prior to randomization were associated with initiating with colonoscopy (OR 1.49, 95% CI 1.17–1.91) and crossing over to FIT (OR 1.63, 95% CI 1.19–2.23). Although nearly half of patients initiated screening after the first mailing, few non-responders in either outreach group initiated after a second or third mailing. More patients invited to colonoscopy crossed over to FIT than those assigned to FIT crossed over to colonoscopy.

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.

Introduction: Oral anticancer medications (OAMs) offer convenient administration but create new challenges with unique toxicity profiles, specific monitoring parameters and non-continuous dosing schedules. We evaluated provider compliance with US Food and Drug Administration (FDA) drug labeling-specified monitoring parameters for commonly dispensed OAMs at a public academic health system. Methods: A retrospective chart review of patients receiving OAMs was conducted at Grady Health System between July 2015 and June 2016. Patients included in the evaluation were dispensed one of the ten most common OAMs used in our cancer center. Laboratory data and provider documentation were collected and compared to FDA drug labeling-specified monitoring parameters, and the primary outcome was the percentage of fully-compliant cycles. Secondary outcomes included patient adherence assessed by provider documentation and fill history. Descriptive statistics were used to evaluate the data. Results: The initial report comprised 422 patients, of which 77 patients with a total of 349 treatment cycles were included for final analysis. One hundred twenty-six (36.1%) of the treatment cycles were fully compliant with the FDA drug labeling-specified monitoring parameters. Sixty-four of the 199 (32.2%) applicable clinic notes documented patient adherence, and 15 (39.5%) of 38 patients were adherent based on fill history. Conclusion: This study revealed low compliance with FDA-recommended monitoring parameters for commonly dispensed OAMs at our institution. In addition, this study confirmed national concerns about adherence to oral regimens. It also suggests that provider compliance with monitoring parameters is an area that needs to be addressed in order to improve the ambulatory OAM process.

The Patient Protection and Affordable Care Act is expected to reduce the number of uninsured people in the United States during the next eight years, but more than 10% are expected to remain uninsured. Uninsured people are one of the main populations using publicly funded safety net sexually transmitted disease (STD) prevention services. Estimating the proportion of the uninsured population expected to need STD services could help identify the potential demand for safety net STD services and improve program planning. In 2013, an estimated 8.27 million people met the criteria for being in need of STD services. In 2023, 4.70 million uninsured people are expected to meet the criteria for being in need of STD services. As an example, the cost in 2014 U.S. dollars of providing chlamydia screening to these people was an estimated $271.1 million in 2013 and is estimated to be $153.8 million in 2023. A substantial need will continue to exist for safety net STD prevention services in coming years.

This article examines whether chronic disease is associated with chemical dependency treatment in primary care patients with problem drug use. Chronic disease was common in 781 disadvantaged individuals who had problem drug use and were seen in primary care clinics affiliated with a public safety-net hospital. Individuals had, on average, 5.4 chronic medical conditions, and overall 57% had low severity chronic disease. In the year following enrollment, 14% had chemical dependency treatment. Severity of chronic disease was not associated with chemical dependency treatment (p = .26). In summary, chronic disease neither hindered chemical dependency treatment, nor did it facilitate such treatment.

© 2015, Society of General Internal Medicine.Background: Little is known about hospitalization-associated disability (HAD) in older adults who receive care in safety-net hospitals. Objectives: To describe HAD and to examine its association with age in adults aged 55 and older hospitalized in a safety-net hospital. Design: Secondary post hoc analysis of a prospective cohort from a discharge intervention trial, the Support from Hospital to Home for Elders. Setting: Medicine, cardiology, and neurology inpatient services of San Francisco General Hospital, a safety-net hospital. Participants: A total of 583 participants 55 and older who spoke English, Spanish, or Chinese. We determined the incidence of HAD 30 days post-hospitalization and ORs for HAD by age group. Measurements: The outcome measure was death or HAD at 30 days after hospital discharge. HAD is defined as a new or additional disability in one or more activities of daily living (ADL) that is present at hospital discharge compared to baseline. Participants’ functional status at baseline (2 weeks prior to admission) and 30 days post-discharge was ascertained by self-report of ADL function. Results: Many participants (75.3 %) were functionally independent at baseline. By age group, HAD occurred as follows: 27.4 % in ages 55–59, 22.2 % in ages 60–64, 17.4 % in ages 65–69, 30.3 % in ages 70–79, and 61.7 % in ages 80 or older. Compared to the youngest group, only the adjusted OR for HAD in adults over 80 was significant, at 2.45 (95 % CI 1.17, 5.15). Conclusions: In adults at a safety-net hospital, HAD occurred in similar proportions among adults aged 55–59 and those aged 70–79, and was highest in the oldest adults, aged ≥ 80. In safety-net hospitals, interventions to reduce HAD among patients 70 years and older should consider expanding age criteria to adults as young as 55.

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.

In an era of decreasing reimbursements, the incentive to decrease readmissions has never been greater. It has been suggested that trauma readmission is an indicator of poor hospital care or fragmented discharge. Even though trauma readmissions are relatively low, readmissions add significant cost, tie up already limited resources and lead to worse outcomes, including mortality. The literature on trauma readmissions is sparse, and the reasons and risk factors for readmission are inconsistent across studies. If readmissions are to serve as useful indicators of quality of care, we must elucidate factors that may predict readmissions.We performed a retrospective review of all admissions to our urban Level I trauma center from July 1, 2012, to June 30, 2015. All patients aged 16 years or older who were discharged alive were included. We identified all unplanned readmissions that occurred within 30 days of discharge and performed an extensive chart review to determine the reasons for readmission. We performed univariate and multivariable analyses.We identified 6,026 index trauma admissions, with 158 (2.6%) unplanned readmissions within 30 days of discharge. The most common reasons for readmission were disease/symptom progression (30.2%), wound complications (28.9%), and pain control (11.8%). On multivariate analysis, only Injury Severity Score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.05; p=0.016), penetrating injuries (OR, 1.9; 95% CI, 1.12-3.24; p=0.018), and smoking (OR, 1.73; 95% CI, 1.05-2.86; p=0.031) were found to be significant. Hospital length of stay, insurance status, and race were not significant.In a resource-limited environment, we expected a lack of access to care would lead to increased trauma readmissions; however, we were still able to achieve similar readmission rates, irrespective of insurance status and race. Our trauma readmission rate is low and consistent with previously published studies. Our results at our Level I trauma center support previously published studies that found Injury Severity Score and penetrating injury to be risk factors for readmission; however, more ubiquitous risk factors, such as hospital length of stay and discharge destination, were not significant. With no consensus on the risk factors for unplanned early trauma readmission, individual trauma centers should evaluate their specific risk factors for readmission to improve patient outcomes and decrease hospital costs.Care management, level IV; Epidemiologic, level IV.

Objectives. We identified Minnesota’s initial dental therapy employers and surveyed dental safety net providers’ perceptions of dental therapy. Methods. In July 2011, we surveyed 32 Minnesota dental safety net providers to assess their prospective views on dental therapy employment options. In October 2013, we used an employment scan to reveal characteristics of the early adopters of dental therapy. Results. Before the availability of licensed dental therapists, safety net dental clinic directors overwhelmingly (77%) supported dental therapy. As dental therapists have become licensed over the past 2 years, the early employers of dental therapists are safety net clinics. Conclusions. Although the concept of dental therapy remains controversial in Minnesota, it now has a firm foundation in the state’s safety net clinics. Dental therapists are being used in innovative and diverse ways, so, as dental therapy continues to evolve, further research to identify best practices for incorporating dental therapists into the oral health care team is needed.

Objectives. To compare health care use and spending of Medicaid enrollees seen at federally qualified health centers versus non–health center settings in a context of significant growth. Methods. Using fee-for-service Medicaid claims from 13 states in 2009, we compared patients receiving the majority of their primary care in federally qualified health centers with propensity score–matched comparison groups receiving primary care in other settings. Results. We found that health center patients had lower use and spending than did non–health center patients across all services, with 22% fewer visits and 33% lower spending on specialty care and 25% fewer admissions and 27% lower spending on inpatient care. Total spending was 24% lower for health center patients. Conclusions. Our analysis of 2009 Medicaid claims, which includes the largest sample of states and more recent data than do previous multistate claims studies, demonstrates that the health center program has provided a cost-efficient setting for primary care for Medicaid enrollees.

To assess whether differences in readmission rates between safety-net hospitals (SNH) and non-SNHs are due to differences in hospital quality, and to compare the results of hospital profiling with and without SES adjustment.In response to concerns that quality measures unfairly penalizes SNH, NQF recently recommended that performance measures adjust for socioeconomic status (SES) when SES is a risk factor for poor patient outcomes.Multivariate regression was used to examine the association between SNH status and 30-day readmission after major surgery. The results of hospital profiling with and without SES adjustment were compared using the CMS Hospital Compare and the Hospital Readmissions Reduction Program (HRRP) methodologies.Adjusting for patient risk and SES, patients admitted to SNHs were not more likely to be readmitted compared with patients in in non-SNHs (AOR 1.08; 95% CI:0.95-1.23; P = 0.23). The results of hospital profiling based on Hospital Compare were nearly identical with and without SES adjustment (ICC 0.99, κ 0.96). Using the HRRP threshold approach, 61% of SNHs were assigned to the penalty group versus 50% of non-SNHs. After adjusting for SES, 51% of SNHs were assigned to the penalty group.Differences in surgery readmissions between SNHs and non-SNHs are due to differences in the patient case mix of low-SES patients, and not due to differences in quality. Adjusting readmission measures for SES leads to changes in hospital ranking using the HRRP threshold approach, but not using the CMS Hospital Compare methodology. CMS should consider either adjusting for the effects of SES when calculating readmission thresholds for HRRP, or replace it with the approach used in Hospital Compare.

Women in safety-net institutions are less likely to receive cervical cancer screening. Human papilloma virus (HPV) self-sampling is an alternative method of cervical cancer screening. We examine the acceptability and feasibility of HPV self-sampling among patients and clinic staff in two safety-net clinics in Miami.Haitian and Latina women aged 30-65 years with no Pap smear in the past 3 years were recruited. Women were offered HPV self-sampling or traditional Pap smear screening. The acceptability of HPV self-sampling among patients and clinic staff was assessed. If traditional screening was preferred the medical record was reviewed.A total of 180 women were recruited (134 Latinas and 46 Haitian). HPV self-sampling was selected by 67% women. Among those selecting traditional screening, 22% were not screened 5 months postrecruitment. Over 80% of women agreed HPV self-sampling was faster, more private, easy to use, and would prefer to use again. Among clinic staff, 80% agreed they would be willing to incorporate HPV self-sampling into practice.HPV self-sampling was both acceptable and feasible to participants and clinic staff and may help overcome barriers to screening.

Objective Although provider recommendation is a key predictor of HPV vaccination, how providers verbalize recommendations particularly strong ones is unknown. We developed a tool to describe strength and content of provider recommendations. Methods We used electronic health records to identify unvaccinated adolescents with appointments at six safety-net clinics in Dallas, Texas. Clinic visit audio-recordings were qualitatively analyzed to identify provider recommendation types (presumptive vs. participatory introduction; strong vs. weak), describe content communicated, and explore patterns between recommendation type and vaccination. Results We analyzed 43 audio-recorded discussions between parents and 12 providers. Most providers used a participatory introduction (42 discussions) and made weak recommendations (24 discussions) by using passive voice or adding a qualification (e.g., not school required). Few providers (11 discussions) gave strong recommendations (clear, personally-owned endorsement). HPV vaccination was lowest for those receiving only weak recommendations and highest when providers coupled the recommendation with an adjacent rationale. Conclusion Our new tool provides initial evidence of how providers undercut their recommendations through qualifications or support them with a rationale. Most providers gave weak HPV vaccine recommendations and used a participatory introduction. Practice implications Providers would benefit from communication skills training on how to make explicit recommendations with an evidence-based rationale.

Objective This study evaluates the actual or potential contribution of the chiropractic profession in meeting US healthcare workforce needs. Methods The authors performed a descriptive cross-sectional mail survey of US chiropractors in 2002 to 2003. Results The amount of charity care provided by chiropractors closely approximates that of medical physicians; on a weekly basis, approximately 2 weekly hours of chiropractic care are provided for free, and 4 weekly hours are provided at a reduced fee. Conclusion Chiropractors serve a vital, though often overlooked, role in the US health care safety net.

Delays in syphilis treatment may contribute to transmission. We evaluated time to treatment for symptomatic patients with syphilis by clinical testing site in 2 Arizona counties. Fewer patients were tested and treated at publicly funded sexually transmitted disease clinics, but received the timeliest treatment; these clinics remain crucial to syphilis disease control.

Objective: Even with treatment, approximately one-third of patients with bipolar disorder relapse into depression or mania within 1 year. Unfavorable clinical outcomes for patients with bipolar disorder include increased rates of psychiatric hospitalization and functional impairment. However, only a few studies have examined predictors of psychiatric hospital readmission in a sample of patients with bipolar disorder. The purpose of this study was to examine predictors of psychiatric readmission within 30 days, 90 days and 1 year of discharge among patients with bipolar disorder using a conceptual model adapted from Andersen’s Behavioral Model of Health Service Use. Methods: In this retrospective study, univariate and multivariate logistic regression analyses were conducted in a sample of 2443 adult patients with bipolar disorder who were consecutively admitted to a public psychiatric hospital in the United States from 1 January to 31 December 2013. Results: In the multivariate models, several enabling and need factors were significantly associated with an increased risk of readmission across all time periods examined, including being uninsured, having ⩾3 psychiatric hospitalizations and having a lower Global Assessment of Functioning score. Additional factors associated with psychiatric readmission within 30 and 90 days of discharge included patient homelessness. Patient race/ethnicity, bipolar disorder type or a current manic episode did not significantly predict readmission across all time periods examined; however, patients who were male were more likely to readmit within 1 year. The 30-day and 1-year multivariate models showed the best model fit. Conclusion: Our study found enabling and need factors to be the strongest predictors of psychiatric readmission, suggesting that the prevention of psychiatric readmission for patients with bipolar disorder at safety-net hospitals may be best achieved by developing and implementing innovative transitional care initiatives that address the issues of multiple psychiatric hospitalizations, housing instability, insurance coverage and functional impairment.

Mammography is the most effective method to detect breast cancer in its earliest stages, reducing the risk of breast cancer death. We investigated the relationship between accessibility of mammography services at Federally Qualified Health Centers (FQHCs) and mortality-to-incidence ratio (MIR) of breast cancer in each county in the United States.County-level breast cancer mortality and incidence rates in 2006-2010 were used to estimate MIRs. We compared breast cancer MIRs based on the density and availability of FQHC delivery sites with or without mammography services both in the county and in the neighboring counties.The relationship between breast cancer MIRs and access to mammography services at FQHCs differed by race and county of residence. Breast cancer MIRs were lower in counties with mammography facilities or FQHC delivery sites than in counties without a mammography facility or FQHC delivery site. This trend was stronger in urban counties (p=0.01) and among whites (p=0.008). Counties with a high density of mammography facilities had lower breast cancer MIRs than other counties, specifically in urban counties (p=0.01) and among whites (p=0.01). Breast cancer MIR for blacks was the lowest in counties having mammography facilities; and was highest in counties without a mammography facility within the county or the neighboring counties (p=0.03).Mammography services provided at FQHCs may have a positive impact on breast cancer MIRs. Expansion of services provided at the FQHCs and placement of FQHCs in additional underserved areas might help to reduce cancer disparities in the United States.

Disparities in early and adequate prenatal care and infant/maternal outcomes still exist between white and nonwhite populations. Although Medicaid expansions were intended to improve outcomes, eligible women often delay enrollment and access barriers remain. This study examines racial disparities among pregnant women in Florida, Georgia, New Jersey, and Texas. The disproportionate location of minorities enrolled in Medicaid in urban areas with greater physician supply was not found to increase office-based prenatal care among blacks. More local physicians, especially foreign medical graduates, sometimes increased access, largely for Hispanics. The presence and use of safety net providers did increase prenatal care use among minorities. This evidence lends support to policies to maintain safety net providers, which are perhaps better equipped than others to serve low-income populations. However, policies should encourage participation extending to all racial/ethnic groups by office-based physicians. The role of foreign medical graduates, who are more likely to participate in Medicaid, should be considered.

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.

Use of oncology-related services is increasingly scrutinized, yet precisely which services are actually rendered to patients, particularly at the end of life, is unknown. This study characterizes the end-of-life use of medical services by patients with gynecologic cancer at a safety-net hospital.Oncologic history and metrics of medical use (eg, hospitalizations, chemotherapy infusions, procedures) for patients with gynecologic oncology who died between December 2006 and February 2012 were evaluated. Mixed-effect regression models were used to test time effects and construct usage summaries.Among 116 subjects, cervical cancer accounted for the most deaths (42%). The median age at diagnosis was 55 years; 63% were Hispanic, and 65% had advanced disease. Only 34% died in hospice care. The median times from do not resuscitate/do not intubate documentation and from last therapeutic intervention to death were 9 days and 55 days, respectively. Significant time effects for all services (eg, hospitalizations, diagnostics, procedures, treatments, clinic appointments) were detected during the patient's final year (P.001), with the most dramatic changes occurring during the last 2 months. Patients with longer duration of continuity of care used significantly fewer resources toward the end of life.To our knowledge, this is the first report enumerating medical services obtained by patients with gynecologic cancer in a large, public hospital during the end of life. Marked changes in interventions in the patient's final 2 months highlight the need for cost-effective, evidence-based metrics for delivering cancer care. Our data emphasize continuity of care as a significant determinant of oncologic resource use during this critical period.

This study compared the preventive service utilization of uninsured patients receiving care at Oregon community health centers (CHCs) in 2008 through 2011 with that of continuously insured patients at the same CHCs in the same period, using electronic health record (EHR) data.We performed a retrospective cohort analysis, using logistic mixed effects regression modeling to calculate odds ratios and rates of preventive service utilization for patients without insurance, or with continuous insurance.CHCs provided many preventive services to uninsured patients. Uninsured patients were less likely than continuously insured patients to receive 5 of 11 preventive services, ranging from OR 0.52 (95% CI: 0.35-0.77) for mammogram orders to 0.75 (95% CI: 0.66-0.86) for lipid panels. This disparity persisted even in patients who visited the clinic regularly.Lack of insurance is a barrier to preventive service utilization, even in patients who can access care at a CHC. Policymakers in the United States should continue to address this significant prevention disparity.

OBJECTIVE: We aimed to determine factors related to avoidability of 30-day readmissions at our public, safety net hospital in the United States (US). METHODS: We prospectively reviewed medical records of adult internal medicine patients with scheduled and unscheduled 30-day readmissions. We also interviewed patients if they were available. An independent panel used pre-specified, objective criteria to adjudicate potential avoidability. RESULTS: Of 153 readmissions evaluated, 68% were unscheduled. Among these, 67% were unavoidable, primarily due to disease progression and development of new diagnoses. Scheduled readmissions accounted for 32% of readmissions and most (69%) were clinically appropriate and unavoidable. The scheduled but avoidable readmissions (31%) were attributed largely to limited resources in our healthcare system. CONCLUSIONS: Most readmissions at our public, safety net hospital were unavoidable, even among our unscheduled readmissions. Surprisingly, one-third of our overall readmissions were scheduled, the majority reflecting appropriate management strategies designed to reduce unnecessary hospital days. The scheduled but avoidable readmissions were due to constrained access to non-emergent, expensive procedures that are typically not reimbursed given our system's payor mix, a problem which likely plague other safety net systems. These findings suggest that readmissions do not necessarily reflect inadequate medical care, may reflect resource constraints that are unlikely to be addressable in systems caring for a large burden of uninsured patients, and merit individualized review.

Introduction Free clinics are a unique safety net provider in that they exclusively serve the uninsured. Because free clinic providers are often volunteers, it is unclear whether uninsured patients seeking care in these clinics receive evidence-based tobacco cessation support. Here we report baseline data on prevalence and correlates of tobacco use and provider cessation advice among a sample of uninsured patients at six free clinics. Methods Patient exit interviews were conducted after a healthcare provider visit. Logistic regression analysis was used to assess correlates of tobacco use. Results Of the 158 patients interviewed, 83 (53%) were tobacco users. Tobacco use was less likely among Hispanics (AOR 0.13 [95% CI 0.03–0.64]) and high school graduates (AOR = 0.20 [95% CI 0.08–0.55]). Among tobacco users, 62% made at least one quit attempt in the past year and the majority were in the Contemplation (33%) or Preparation (39%) stage of readiness. 70% of all patients were screened in the past 3 months, although screening was more likely among tobacco users than nonusers (AOR 3.56 [95% CI 1.47–8.61]). At the current visit, 18% of tobacco users were advised to quit and 16% were asked if they were willing to quit. Conclusions The prevalence of tobacco use among uninsured free clinic patients was more than twice the national average. There is substantial opportunity to increase tobacco screening among all patients and cessation advice among tobacco users. Free clinics present an untapped opportunity to reduce tobacco harm in a population at high risk for tobacco morbidity and mortality.

Title: Association Between Clinician Computer Use and Communication with Patients in Safety- Net Clinics Neda Ratanawongsa, MD, MPH 1,2 neda.ratanawongsa@ucsf.edu Jennifer L. Barton, MD 3 bartoje@ohsu.edu Courtney R. Lyles, PhD 1,2 courtney.lyles@ucsf.edu Michael Wu, BS 4 MichaelWu0322@gmail.com Edward H. Yelin, PhD, MCP 5,6 ed.yelin@ucsf.edu Diana Martinez, MD 1,2 diana.martinez@ucsf.edu Dean Schillinger, MD 1,2 dean.schillinger@ucsf.edu Division of General Internal Medicine, the University of California, San Francisco (UCSF) UCSF Center for Vulnerable Populations at San Francisco General Hospital Department of Medicine at Oregon Health & Science University and VA Portland Health Care System John Burns School of Medicine, University of Hawaii Division of Rheumatology, University of California, San Francisco Institute for Health Policy Studies, University of California, San Francisco Word count: 600 References: 7 Tables: 2 Corresponding Author: Neda Ratanawongsa, MD, MPH Associate Professor of Medicine, Division of General Internal Medicine UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center 1001 Potrero Avenue, Box 1364 San Francisco CA 94110 Phone: 415-206-3188 Fax: 415-206-5586 neda.ratanawongsa@ucsf.edu Presentations: Preliminary data from this manuscript was presented at the International Conference on Communication in Healthcare, Montreal, Quebec, Canada, September 30, 2013 Acknowledgements: Author Contributions: Dr. Ratanawongsa had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Ratanawongsa, Yelin, Schillinger. Acquisition, analysis, or interpretation of data: Ratanawongsa, Barton, Lyles, Wu, Martinez. Drafting of the manuscript: Ratanawongsa, Yelin. Critical revision of the manuscript for important intellectual content: Barton, Lyles,Wu, Yelin, Martinez, Schillinger. Statistical analysis: Ratanawongsa, Yelin. Obtained funding: Ratanawongsa, Schillinger. Administrative, technical, or material support: Barton, Lyles,Wu, Martinez

Rural Latino populations continue to grow in part due to relocation of food processing industries to rural America along with other manufacturing and large retail stores. We use data from the Current Population Survey to examine the labor force participation of rural Latino population and the role rural employers play in providing health insurance coverage. We found that while rural Latinos are more likely to be uninsured, the meat packing industry has higher health insurance coverage rates than other rural employers such as construction and retail. Local communities recruiting new businesses to their rural communities need to explore the role that employers will play in providing health insurance coverage. Lack of adequate coverage will have an impact on the income, resources, and day-to-day activities of physicians, hospitals and traditional safety net providers.

To understand how proximity to safety net clinics and hospitals affects a variety of measures of access to care and service use by uninsured persons.The 1998-1999 Community Tracking Study household survey, administered primarily by telephone survey to households in 60 randomly selected communities, linked to data on community health centers, other free clinics, and safety net hospitals.Instrumental variable estimation of multivariate regression models of several measures of access to care (having a usual source of care, unmet or delayed medical care needs, ambulatory service use, and overnight hospital stays) against endogenous measures of distances to the nearest community health center and safety net hospital, controlling for characteristics of uninsured persons and other area characteristics that are related to access to care. The models are estimated with data from a nationally representative sample of uninsured people.Shorter distances to the nearest safety net providers increase access to care for uninsured persons. Failure to account for the endogeneity of distance to safety net providers on access to care generally leads to finding little or no safety net effects on access.Closer proximity to the safety net increases access to care for uninsured persons. However, the improvements in access to care are relatively small compared with similar measures of access to care for insured persons. Modest expansion of the safety net is unlikely to provide a full substitute for insurance coverage expansions.