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Author(s): Sorensen, Andrea; Grotts, Jonathan F; Tseng, Chi-Hong; Moreno, Gerardo; Maranon, Richard; Whitmire, Natalie; Viramontes, Omar; Atkins, Sandy; Sefilyan, Ester; Simmons, June W; Mangione, Carol M | Abstract: Background/objectivesMedication discrepancies and adverse drug events are common following hospital discharge. This study evaluates whether a collaboration between community-based health coaches and primary care-based pharmacists was associated with a reduction in inpatient utilization following hospitalization.DesignRetrospective cohort study using propensity score matching.SettingUrban academic medical center and surrounding community.ParticipantsIntervention patients (n = 494) were adults aged 65 and older admitted to the University of California, Los Angeles (UCLA) Ronald Reagan Medical Center during the study period and who met study inclusion criteria. A matched-control group was composed of patients with similar demographic and clinical characteristics who were admitted to the study site during the study period but who received usual care (n = 2,470). A greedy algorithm approach was used to conduct the propensity score match.InterventionFollowing acute hospitalization, a health coach conducted a home visit and transmitted all medication-related information to a pharmacist based in a primary care practice. The pharmacist compared this information with the patient's electronic medical record medication list and consulted with the patient's primary care provider to optimize medication management.MeasurementsThirty-day readmissions (primary outcome), 60- and 90-day readmissions, and 30-day emergency department (ED) visits (secondary outcomes) to UCLA Health.ResultsAmong 494 patients who received the intervention, 307 (62.1%) were female with a mean age of 83.0 years (interquartile range [IQR] = 76-90 years). Among 2,470 matched-control patients, 1,541 (62.4%) were female with a mean age of 82.7 years (IQR = 74.9-89.5 years). For the propensity score match, standardized mean differences were below .1 for 23 of 25 variables, indicating good balance. Patients who received this intervention had a significantly lower predicted probability of being readmitted within 30 days compared with matched-control patients (10.6%; 95% confidence interval [CI] = 7.9-13.2) vs 21.4%; 95% CI = 19.8-23.0; P value l .001).ConclusionA home visit conducted by a health coach combined with a medication review by a primary care-based pharmacist may prevent subsequent inpatient utilization.

IntroductionRobust randomised trial data have shown that routine preoperative (pre-op) testing for cataract surgery patients is inappropriate. While guidelines have discouraged testing since 2002, cataract pre-op testing rates have remained unchanged since the 1990s. Given the challenges of reducing low-value care despite strong consensus around the evidence, innovative approaches are needed to promote high-value care. This trial evaluates the impact of an interdisciplinary electronic health record (EHR) intervention that is informed by behavioural economic theory.Methods and analysisThis pragmatic randomised trial is being conducted at UCLA Health between June 2021 and June 2022 with a 12-month follow-up period. We are randomising all UCLA Health physicians who perform pre-op visits during the study period to one of the three nudge arms or usual care. These three nudge alerts address (1) patient harm, (2) increased out-of-pocket costs for patients and (3) psychological harm to the patients related to pre-op testing. The nudges are triggered when a physician starts to order a pre-op test. We hypothesise that receipt of a nudge will be associated with reduced pre-op testing. The primary outcome will be the change in the percentage of patients undergoing pre-op testing at 12 months. Secondary outcomes will include the percentage of patients undergoing specific categories of pre-op tests (labs, EKGs, chest X-rays (CXRs)), the efficacy of each nudge, same-day surgery cancellations and cost savings.Ethics and disseminationThe study protocol was approved by the institutional review board of the University of California, Los Angeles as well as a nominated Data Safety Monitoring Board. If successful, we will have created a tool that can be disseminated rapidly to EHR vendors across the nation to reduce inappropriate testing for the most common low-risk surgical procedures in the country.Trial registration numberClinicalTrials.gov identifier: NCT04104256.

The COVID-19 pandemic has led to the rapid adoption of telemedicine. Health systems nationwide moved quickly to scale their telemedicine capabilities, and the Centers for Medicare & Medicaid Services (CMS) and other payers expanded reimbursement for telehealth visits.1 While widely lauded as a means to improve value of care, telemedicine may exacerbate disparities in health care access.2 In this study, we describe the increased adoption of telemedicine at a large academic health system since the pandemic and examine our hypothesis that this increase is associated with widening racial, ethnic, and socioeconomic differences in access to care.

ImportanceElectronic health record (EHR) clinical decision support (CDS) tools can provide evidence-based feedback at the point of care to reduce low-value imaging. Success of these tools has been limited partly due to lack of engagement by busy clinicians.ObjectiveMeasure the impact of a time-saving quality improvement intervention to increase engagement with a CDS tool for low back pain imaging ordering.Design, setting and participantsWe conducted a quasi-experimental difference-in-differences analysis at (BLINDED), examining back pain imaging orders from 29 May 2015 to 07 January 2016. The intervention site was (BLINDED) Emergency Medicine/Urgent Care Center (n=5736) and control sites included all other (BLINDED) hospitals and clinics (n=1621). In May 2015, the Department of Health Services installed a CDS tool that triggered a survey when clinicians ordered an imaging test, generating an ‘appropriateness score’ based on the American College of Radiology guidelines. Clinicians often bypassed the tool, resulting in ‘unscored’ tests.InterventionTo increase clinician engagement with the tool and decrease the rate of unscored imaging tests, a new policy was implemented at the intervention site on 15 August 2015. If clinicians completed the CDS survey and scored an appropriateness score >3, they could forego a previously mandatory telephone call for pre-imaging utilisation review with the radiology department.Main outcomes and measuresWe used EHR data to measure pre–post-intervention differences in: (1) percentage of unscored tests and (2) percentage of tests with high appropriateness scores (>7).ResultsPercentage of unscored tests decreased from 69.4% to 10.4% at the intervention site and from 50.6% to 34.8% at the control sites (between-group difference: −23.3%, pConclusionWorkflow time-saving interventions may increase physician engagement with CDS tools and have potential to improve practice patterns.

IMPACT: This project demonstrates that addressing low-value care, which has the potential to cause patient harm, relies on novel data tools and collaboration between health system and research stakeholders. OBJECTIVES/GOALS: Reducing low-value care, or patient care that offers no net benefit in specific clinical scenarios, is an important approach to improving value as it can simultaneously lower health care spending and improve quality. We describe an initiative to identify such care in a large statewide employer. METHODS/STUDY POPULATION: Claims data for self-funded University of California (UC) Preferred Provider Organization (PPO) plan members during 2019 were abstracted from the University of California Health (UCH) Clinical Data Warehouse, a unique central database that includes electronic medical record data from >5 million patients across UC medical campuses and all claims from UC self-funded health plans. UCH spans six academic health systems across California. The Milliman MedInsight Health Waste Calculator, a proprietary algorithm-based software tool, was used to identify low-value care and estimate associated spending. The HWC measures 48 low-value services using recommendations from the Choosing Wisely Campaign, the US Preventive Services Task Force, and other clinical specialty guidelines. RESULTS/ANTICIPATED RESULTS: Of 43,882 members of the UC PPO, 11,174 (25.4%) received at least one low-value service. The HWC identified 50,103 eligible services and classified 35% as low-value. Total spending on low-value services ranged between $2,209,516 and $5,089,866, based on a more or less conservative estimate. Across the five sites, the proportion of low-value services ranged from 31% to 39%. Five services comprised 65% of costs from low-value care: annual EKGs, preoperative baseline labs for low-risk surgeries, vitamin D deficiency screening, imaging for eye disease, and headache imaging. The top five services by order frequency were annual EKGs, vitamin D tests, preoperative labs, antibiotics for upper respiratory infections, and imaging for eye disease. DISCUSSION/SIGNIFICANCE OF FINDINGS: Low-value care is prevalent and costly within a large statewide employer. Collaborative multidisciplinary partnerships between employers, health systems, informatics, and researchers can leverage existing data to identify opportunities for improving the value of care for covered populations.

IMPACT: These findings identify a new way in which the COVID-19 pandemic exacerbates racial/ethnic health disparities, and will thus direct future research to explore potentially avoidable hospitalizations, as well as direct health policy to improve the value of this specific aspect of care without further widening the disparity. OBJECTIVES/GOALS: Racial and ethnic disparities in potentially avoidable hospitalizations predate COVID-19. In order to identify and address healthcare disparities exacerbated by the pandemic, we examined whether and to what extent the pandemic affected numbers of potentially avoidable hospitalizations by race and ethnicity. METHODS/STUDY POPULATION: This single-center pre-post study of 904 patients at UCLA included all patients admitted to an internal medicine service for an ambulatory care sensitive condition (ACSC) between March-August of 2020 (post) and March-August of 2019 (pre). We measured the change in number of potentially avoidable hospitalizations (defined per the Agency for Healthcare Research and Quality guidelines) stratified by race and ethnicity. We calculated 95% CIs for the number of potentially avoidable hospitalizations using a cluster bootstrap procedure, clustering at the level of patients. We inverted the bootstrap CIs to calculate p-values for overall changes within racial/ethnic groups as well as differential changes between groups. Patients with missing or unspecified racial/ethnic data were excluded (n=1,003; 7.8%). RESULTS/ANTICIPATED RESULTS: Between March 1 and August 31, 2020, 347 out of 4,838 hospitalizations (7.2%) were potentially avoidable, compared to 557 out of 6,248 (8.9%) during the same 6-months of 2019. Reductions in potentially avoidable hospitalizations among Non-Hispanic White (-50.3%; 95% CI, -60.9 - -41.2; p

The Patient Protection and Affordable Care Act (ACA) expands access to health insurance in the United States, and, to date, an estimated 20 million previously uninsured individuals have gained coverage. Understanding the law's impact on coverage, access, utilization, and health outcomes, especially among low-income populations, is critical to informing ongoing debates about its effectiveness and implementation. Early findings indicate that there have been significant reductions in the rate of uninsurance among the poor and among those who live in Medicaid expansion states. In addition, the law has been associated with increased health care access, affordability, and use of preventive and outpatient services among low-income populations, though impacts on inpatient utilization and health outcomes have been less conclusive. Although these early findings are generally consistent with past coverage expansions, continued monitoring of these domains is essential to understand the long-term impact of the law for underserved populations.

OBJECTIVE: To compare distributions of human rights violations and disease risk; to juxtapose these patterns against demographic and structural environmental variables, and to formulate implications for structural interventions. METHODS: Female sex workers who inject drugs were surveyed in Tijuana and Ciudad Juarez, Mexico. Structured interviews and testing for sexually transmitted infections (STIs) were conducted (October 2008 to October 2009). Frequencies of individual and environmental factors, including police abuse, risk of HIV infection, and protective behaviors, were compared between sites using univariate logistic regression. RESULTS: Of 624 women, almost half reported police syringe confiscation despite syringes being legal; 55.6% reported extortion (past 6 months), with significantly higher proportions in Ciudad Juarez (P < 0.001). Reports of recent solicitation of sexual favors (28.5% in Tijuana, 36.5% in Ciudad Juarez, P = 0.04) and sexual abuse (15.7% in Tijuana, 18.3% in Ciudad Juarez) by police were commonplace. Prevalence of STIs was significantly lower in Tijuana than in Ciudad Juarez (64.2% and 83.4%, P < 0.001), paralleling the lower prevalence of sexual risk behaviors there. Ciudad Juarez respondents reported significantly higher median number of monthly clients (6.8 versus 1.5, P < 0.001) and lower median pay per sex act (US$ 10 versus US$ 20, P < 0.001) (in the past month). Relative to Tijuana, security deployment, especially the army's presence, was perceived to have increased more in Ciudad Juarez in the past year (72.1% versus 59.2%, P = 0.001). CONCLUSIONS: Collateral damage from police practices in the context of Mexico's drug conflict may affect public health in the Northern Border Region. Itinerant officers may facilitate disease spread beyond the region. The urgency for mounting structural interventions is discussed.

Background Immediate postabortal intrauterine device (IUD) insertion decreases rates of repeat abortions. However, only one third of high-volume, non-hospital abortion providers in the United States offer immediate postabortal IUD placement. Study Design We conducted a cost analysis from a public payer perspective to evaluate the potential cost savings associated with a policy of immediate postabortal IUD insertion, compared to planned IUD insertion at the time of abortion follow up. Sensitivity analyses and Monte Carlo simulation were performed. Results Considering only direct costs of contraception and pregnancy-related care over 1 year, immediate postabortal IUD provision decreases public program expenditures by US$111 per woman compared to planned IUD placement at follow up. Over 5 years, the savings increases to $4296 per woman, when public health and social program costs are also considered. Conclusion Immediate postabortal IUD insertion is cost saving from a public payer perspective, compared to planned insertion at the time of follow up. These savings are seen over a wide range of model inputs.

Introduction Potentially avoidable hospitalizations are disproportionately experienced by racial and ethnic minorities and expose these groups to unnecessary iatrogenic harm (including the risk of nosocomial COVID-19) and undue financial burden. In working toward an overarching goal of eliminating racial and ethnic health disparities, it is important to understand whether and to what extent potentially avoidable hospitalizations have changed by race and ethnicity during the COVID-19 pandemic. Methods This single-center pre–post study included patients admitted to any UCLA Health hospital for an ambulatory care–sensitive condition between March–August 2019 (prepandemic period) and March–August 2020 (postpandemic period). Investigators measured the change in the number of potentially avoidable hospitalizations (defined per the Agency for Healthcare Research and Quality guidelines) stratified by race and ethnicity and calculated the 95% CIs for these hospitalizations using a cluster bootstrap procedure. Results Between March 1, 2020 and August 31, 2020, 347 of 4,838 hospitalizations (7.2%) were potentially avoidable, compared with 557 of 6,248 (8.9%) during the same 6-month period in 2019. Potentially avoidable hospitalizations decreased by 50.3% (95% CI=41.2, 60.9) among non-Hispanic Whites but only by 8.0% (95% CI= −16.2, 39.9) among African Americans (50.3% vs 8.0%, p=0.015). Conclusions Racial disparities in potentially avoidable hospitalizations increased during the COVID-19 pandemic at a large urban health system. Given that the prepandemic rates of potentially avoidable hospitalizations were already higher among racial and ethnic minorities, especially among African Americans, this finding should cause alarm and lead to further exploration of the complex factors contributing to these disparities.