UTILIZING INPATIENT ADMISSIONS TO INCREASE UNIVERSAL HIV SCREENING DURING THE COVID-19 PANDEMIC AND BEYOND

STATEMENT OF PROBLEM/QUESTION: Individuals at risk for HIV often face barriers to routine outpatient care which were exacerbated during the COVID-19 pandemic, creating a need and an opportunity to leverage hospital admissions for HIV screening. DESCRIPTION OF PROGRAM/INTERVENTION: This resident-led quality improvement project ran from 10/01/2020 to 6/30/2021 and aimed to increase rates of HIV screening among inpatients on the Medicine service at Zuckerberg San Francisco General Hospital (ZSFG), an urban safety net hospital. The QI intervention was informed by an initial gap analysis and consisted of three components: provider education, targeted outreach including biweekly performance metrics with peer comparisons, and electronic health record (EHR) optimizations. A pre-existing multidisciplinary care team was available to provide follow-up for positive test results, facilitating rapid linkage to HIV care. MEASURES OF SUCCESS: Given the high prevalence of HIV risk factors in this population, appropriate screening was defined as having an HIV test within the past 6 months. Our target for appropriate HIV screening was 55% of hospitalized patients on the Medicine service without a known HIV diagnosis, an increase of 10% from baseline. As a secondary goal, we sought to increase resident education about HIV as measured by pre- and post- intervention surveys. FINDINGS TO DATE: Among patients admitted during the intervention period (N = 1701), there was a 17.6% absolute increase in HIV screening rates compared to baseline (N = 885) (45.3% v. 62.9%, p < 0.001). To assess the impact of our intervention on previously identified differences in screening rates by gender, race, and language, we conducted post-intervention subgroup analyses. These results demonstrated persistently lower screening rates among females (59.6% v. 64.6%, p = 0.044), Asians (55.0% v. 64.5, p < 0.01), and patients speaking Chinese-based languages (53.5% v. 63.8, p = 0.01). Comparisons of pre- and post-intervention survey data showed an increase in provider comfort and knowledge across all domains assessed. KEY LESSONS FOR DISSEMINATION: Quality improvement interventions including education, targeted outreach, and EHR optimization can increase HIV screening rates of hospitalized patients. We found that despite improvement in overall screening rates, disparities persisted for women, Asians, and non-English speaking patients. Targeted interventions to address these disparities in HIV screening are needed. Inpatient providers are well-poised to help address HIV screening gaps, particularly for underserved patient populations who may face increased barriers to routine HIV prevention services.

Telemedicine acceptability and experience in a marginalized population at high-risk for hcv

Background: Telemedicine offers the opportunity to provide clinical services at a distance, thereby bridging geographic and other barriers to medical care. With the need to socially distance during the COVID-19 pandemic, clinical practices rapidly transitioned to telemedicine across the United States. Telemedicine will remain an important component of healthcare delivery but if not utilized in an equitable manner could exacerbate health disparities. To understand usage among medically underserved communities, we investigated acceptability and experiences with telemedicine among people undergoing community-based HCV screening as part of a larger ongoing point-of-diagnosis HCV treatment study (NOW Study). Methods: We performed descriptive and comparative analysis of self-report data about sociodemographic, clinical history, mobile device and internet access, and telemedicine experience and satisfaction information collected at the time of HCV screening between December 2020 and May 2021. Results: Among 92 participants (median age 42 years;75% men;50% non-White;73% with recent injection drug use);55% had reactive HCV antibody and 35% had active HCV. Most (86%) recently used a smartphone, tablet (44%), or laptop (37%) to access the internet (table 1). Many accessed the internet via their cellular network (70%) or relied on public or personal wireless (26%). The majority (74%) were somewhat or very interested in a telemedicine visit. Thirty (33%) had participated in a telemedicine visit (36% video, 33% telephone, 30% both);some (26%) participated prior to the COVID-19 pandemic and all had a visit during the pandemic. All but one participant (97%) described their telemedicine visit as somewhat or extremely helpful, easy (73%), and convenient (67%). Interest for future telemedicine care was higher among those with past experience compared to no experience (93% vs 65%, p=0.003;table 1). Despite general interest in telemedicine, 69% preferred in-person clinic visits when possible. No statistically significant differences emerged in age, race/ethnicity, gender, and HCV status when comparing 1) interested vs. not interested and 2) with vs. without a prior telemedicine visit. Conclusion: Within our population at high-risk for HCV, digital access was high, many had a previous telemedicine experience they found satisfying, and generally high interest in future telemedicine care. Nonetheless, when given the choice, the majority preferred in-person care.

Ensuring equitable access to hepatology telemedicine during the COVID-19 pandemic

Background: The COVID-19 pandemic has led to an unprecedented expansion in telemedicine but has also exposed the deep underlying healthcare disparities in the US Vulnerable patients, including those with limited English proficiency, underrepresented minority groups, older adults, and those with lower socioeconomic status, are more likely to experience digital barriers to engaging in telemedicine Although our academic hepatology practice adopted telemedicine several years before COVID-19, there was a concerted effort to assist patients and providers with video visits during the pandemic We aimed to evaluate shifting demographics of patients accessing telemedicine pre- and post-COVID-19 Methods: Patient demographics, appointment date, and visit type were obtained from the electronic health record reporting database for all patients seen by the UCSF Hepatology and Liver Transplant clinic 1/2/2019-5/29/2020. Visits were stratified into pre-COVID-19 (1/2/2019-3/15/2020) and post-COVID-19 (3/15/2020- 5/29/2020) periods We compared characteristics of clinic patients seen 1) in the pre- vs post-COVID-19 periods;2) via in-person vs video visits;and 3) via video visits pre- vs post- COVID-19 Chi-square or Kruskal-Wallis tests were used to compare categorical and continuous variables, respectively Telephone visits were not included in the analysis Results: Pre-COVID-19, a total of 12,017 patients were seen, including 1,509 via video (12 5%) Post-COVID-19, 1,894 patients were seen, including 1,504 via video (79%) Over the entire study period, compared to patients seen in-person (n=9,344), patients seen via video (n=3,013) were younger and more likely to be Caucasian, speak English as their primary language, and have commercial insurance (p < 0 001 across all comparisons) Among all patients who completed video visits, those seen post-COVID-19 were older, were more likely to be non-Caucasian, non-English speaking and utilizing an interpreter for the visit, and have public insurance compared to pre-COVID-19 (p < 0 001 across all comparisons) Conclusion: Prior to COVID-19, video visits were relatively common in our clinic, but disparities in video visit utilization existed. Post-COVID-19, with significant efforts to convert clinic visits to video, the characteristics of patients seen via video changed to include more vulnerable patients If telemedicine is the future of hepatology, we must work to ensure that all of our patients have equitable access. (Table Presented).