Collaborating for COVID-19: Hospital Health Information Exchange and Public Health Partnership.

Background: The coronavirus disease (COVID-19) pandemic highlighted the need for effective communication and information sharing among health care organizations and public health systems (PHSs). Health information exchange (HIE) plays a vital role in improving quality control and efficiency in hospital settings, particularly in underserved areas. Objective: This study aimed to investigate the variation of HIE availability among hospitals based on their collaboration with the PHS and affiliation with Accountable Care Organizations (ACOs) in 2020, as well as variation by community social determinants of health. Methods: The primary data set used for this study comprised the linked data set of the 2020 American Hospital Association (AHA) Annual Survey and the AHA Information Technology Supplement. The measures used included the hospital's participation in HIE networks, availability of data exchange, and HIE measures during the COVID-19 pandemic, including whether hospitals effectively received electronically transmitted information from outside providers for COVID-19 treatment. Results: The sample size of hospitals ranged from 1,316 to 1,436, depending on different outcomes related to HIE questions. Of the hospitals surveyed, ∼67% reported public health collaboration and ACO affiliation, while 7% reported neither. Hospitals without public health collaboration or ACO affiliation were more likely to be located in underserved areas. Compared with hospitals without public health collaboration or ACO affiliation, hospitals with both were 9% more likely to report the availability of electronically transmitted clinical information from outside providers and to participate in local and national HIE networks. Furthermore, these hospitals were 30% (marginal effect [ME] = 0.30, p < 0.001) more likely to report effective receipt of information from outside providers for COVID-19 treatment and 12% (ME = 0.12, p = 0.02) more likely to always/often receive clinical information for COVID-19 treatment electronically. Conclusions: Hospital collaboration with the PHS and ACO affiliation are associated with greater availability of electronic health data, particularly during the COVID-19 pandemic.

Impact of Early Stages of the COVID-19 Pandemic on Sexually Transmitted Infection Screening Claims Among Adolescent Females in a Pediatric Accountable Care Organization in Ohio, United States.

Background Testing for sexually transmitted infections (STIs) decreased during the early months of the coronavirus disease 2019 (COVID-19) pandemic. Less is known about the extent to which screening of asymptomatic adolescents for STIs was specifically affected. Our aim was to describe the impacts of early stages of the COVID-19 pandemic on asymptomatic STI screening and overall STI testing among adolescent females aged 13 to 19. We hypothesized that screening would decrease more than overall testing. Methods We evaluated claims data from a pediatric accountable care organization responsible for approximately 40,000 adolescent females. We assessed rates of asymptomatic screening and overall testing for chlamydia and gonorrhea in this population, comparing the early pandemic to pre-pandemic levels. Results Both STI screening and overall STI testing were found to be significantly decreased during the early period of the COVID-19 pandemic compared to pre-pandemic levels. The proportion of tests billed as screening was 70% of tests for April to August 2020 (early pandemic), compared to 67% for October 2019 to February 2020 and 64% for April to August 2019, contrary to our hypothesis. Conclusion Asymptomatic screening represented a similar proportion of STI testing among this population of adolescent females during the early COVID-19 pandemic compared to pre-pandemic testing. More work is needed to understand how asymptomatic screening was proportionally maintained despite COVID-19 pandemic restrictions.

Secondary Effects ofthe COVID19 Pandemic - didDelayed Acute Appendicitis Diagnosis and TreatmentOccur?- An Accountable CareOrganization Pediatric Population Study

Background: The effect of the COVID 19 pandemic and public shutdowns remains to be fully elucidated, particularly in the pediatric population. Clinically, and in the literature, urgent and emergent disease processes that typically have a stable yearly incidence, were thought to have declined during the height of the pandemic. One such disease, acute appendicitis, has been studied both in the US and abroad with varying results. There appears to be a trend toward higher rates of complicated appendicitis and overall decrease of acute appendicitis presentations to healthcare centers during the pandemic. We set out to determine if these trends hold true in a large pediatric population. Methods: The Partners For Kids database, an accountable care organization database that comprises approximately 325,000 unique children annually, was queried for cases of acute appendicitis, including complicated, uncomplicated, and unspecified from April 1st - August 31st 2017-2020. The overall monthly rate/100,000 covered lives in the PFK database from April-August was calculated each year and compared for overall acute appendicitis diagnosis. The rate of complicated and uncomplicated appendicitis/100 cases of appendicitis were calculated from April-August for each year and compared as well. P-values < 0.05 were considered significant. Results: The overall monthly rate of acute appendicitis/100,000 covered lives in the PFK database was significantly lower in 2020 compared to 2017 and 2018, but not compared to 2019 (2.0% in 2020 vs 3.2% 2017 and 2018, 2.8% 2019, p <0.01, Figure 1). The rate of complicated appendicitis cases showed a decline over the study time period, with both 2019 and 2020 significantly lower than 2018 and 2017 (55.8% 2017, 53.7% 2018, 23.9% 2019, 20.6% 2020, p <0.01). The rate of uncomplicated appendicitis was significantly higher in 2020 compared to 2017, but otherwise the rates between years were not significant (46.3% 2017 and 2018, 71.4% 2019, 79.4% 2020, p = 0.02). See Figure 2. Conclusion: The results of this study using an accountable care organization database indicate that 2020 was not an outlier with regard to overall presentation of acute appendicitis, nor delayed presentation as indicated by complicated appendicitis rates in the pediatric population. Looking beyond the immediately preceding year to the pandemic demonstrates that overall rates of appendicitis had been declining and reached significance in 2020 compared to two and three years prior to the pandemic but not 2019. Rates of complicated appendicitis underwent a large decline one year prior to 2020 and remained low during the pandemic. Uncomplicated rates of appendicitis have followed a reciprocal pattern. While many secondary effects of the COVID 19 pandemic remain to be seen, acute appendicitis appears to have maintained its prior trajectory, contrary to smaller studies and those comparing 2020 to only the immediately preceding 1 or 2 years. (Figure Presented).

MIXEDMETHODS EVALUATIONOF THE INITIAL IMPLEMENTATION OF A MEDICAID ACCOUNTABLE CARE ORGANIZATION PROGRAM TO ADDRESS FOOD AND HOUSING INSECURITY

BACKGROUND: States and health systems are investing in programs to address patients' unmet social needs, such as food and housing insecurity, but there has been limited evaluation of the implementation of these programs. In 2020, Massachusetts initiated the Flexible Services (Flex) program to provide funding to Medicaid accountable care organizations (ACOs) to address food and housing insecurity through community resources. The study objective was to examine initial implementation of Flex (March 2020-July 2021), using the Reach, Efficacy, Adoption, Implementation, Maintenance (RE-AIM) framework. METHODS: This mixed-methods evaluation was part of LiveWell, a longitudinal study assessing the impact of Flex on community health center patients aligned with two large hospitals within Mass General Brigham (MGB) in Boston, MA. ACO participants were screened annually for food and housing insecurity. To assess reach, we examined Flex enrollment using electronic health record data of enrollees ≥21 years old. Eligibility criteria for Flex included: 1) enrollment in MGB Medicaid ACO, 2) food or housing insecurity identified by screening or clinical encounter, and 3) a complex health condition (e.g., uncontrolled diabetes, depression). To assess implementation, adoption, and effectiveness, we conducted qualitative interviews with Flex enrollees (N=16) and health system staff (N=15). Interviews were analyzed using the Framework Method. RESULTS: Of 44,417 ACO enrollees, 693 (2%) were enrolled in Flex in the first 17 months. A total of 19,275 (43%) of ACO enrollees and 521 (75%) of Flex enrollees completed annual screening for food/housing insecurity. Mean ACO participant age was 40 years (SD: 14);62% were female;32% were Hispanic. Mean Flex enrollee age was 46 years (SD: 13);81% were female;54% were Hispanic. Implementation challenges included complex eligibility requirements, administrative burden (e.g., tracking, documentation), COVID- 19 factors (e.g., reduced clinic visits), and coordinating with community organizations. Facilitators included raising staff awareness to increase referrals, administrative funding for enrollment staff, adaptive strategies to identify eligible patients, and streamlined communication with community organizations. Flex enrollees reported improvements in healthy eating and food security. Patients who were able to select food or meals based on their preferences reported higher satisfaction. Patient-reported housing support included assistance with utility bills and affordable housing applications. CONCLUSIONS: To improve reach, adoption, and effectiveness in diverse populations, states and health systems implementing programs to address social needs should consider expanding screening for food and housing insecurity, minimizing administrative burden, providing funding for enrollment staff, and tailoring programs to patient preferences.

PREVENTATIVE CARE IN HOSPITAL MEDICINE: THE EVIDENCE BEHIND THIS UNUSUAL PRACTICE

STATEMENT OF PROBLEM/QUESTION: Over the last two years, COVID-19 pandemic has brought cancer screening programs in the US ground to a halt with significant drop in screening mammography utilization causing potential delays in breast cancer diagnosis. DESCRIPTION OF PROGRAM/INTERVENTION: Disparities in screening mammography use persists among low-income women, even those who are insured, despite the proven mortality benefit. Prior to the start of pandemic, hospitalized women aged 50-75 years were more likely to be non-adherent (∼42%) to breast cancer screening guidelines and at high-risk (32%) for developing breast cancer (Gail 5-year-risk prediction score ≥ 1.7%). The commonly reported barriers to screening mammograms were failure to remember appointments and lack of transportation. Low income, current or exsmoker, and history of stroke were reported as major predictors associated with non-adherence. Even with inpatient breast cancer screening education, scheduled outpatient mammography appointments at patients' convenience prior to discharge and phone call reminders, 67% of non-adherent hospitalized women remained non-adherent after discharge from hospital. These statistics are now expected to much higher considering the pandemic. As screening for all cancers is traditionally offered exclusively in outpatient setting, numerous challenges remain for health care system to get back on track for cancers screening to pre-pandemic level. Collectively these results illustrate the need for innovative approach to counsel, educate, and offer screening test to these patients during hospitalization. The purpose of the study was to evaluate the feasibility of coordinating inpatient breast cancer screening mammograms for non-adherent hospitalized women prior to their hospital discharge. MEASURES OF SUCCESS: We hypothesized that study intervention would result in a 50% increase in breast cancer screening adherence without affecting hospital length of stay. FINDINGS TO DATE: A prospective feasibility study was conducted among 101 non-adherent women aged 50-75 years hospitalized to a general medicine service. Mean age for study population was 59.2 years (SD=6), and 29% were African American. 78% of the enrolled women (n=79) underwent in-patient screening mammography. All women who underwent screening mammography during inpatient stay were extremely satisfied. Neither the ordering hospitalists nor the nurses taking care of these women reported any concerns or misgiving. Convenience of having a screening mammography while inpatient stay was reported to be a facilitator of completing the screening test. KEY LESSONS FOR DISSEMINATION: Inpatient breast cancer screening education along with inpatient screening mammography was successful in achieving the goal of securing screening mammography for hospitalized women. As hospitals move toward assimilation into accountable care organizations, tests needed for preventive care should be made available to patients wherever and whenever they interact with healthcare system, especially for patients at the highest risk for illness and pathology.

Clinical genomic population health testing for 431 genes implemented through family medicine practices: the Vermont experience

Integration of genomics into health practice depends on successful implementation in non-research settings. We describe a medical home-centered implementation at the intersection of genomic medicine and population health in the UVM Health Network. In this clinical implementation, the hospital laboratory orchestrates a collaboration involving primary care providers (PCPs), patient and family advisors, health system administrators, clinical genetics services, oncologists and cardiologists, Vermont’s accountable care organization, and a commercial CLIA genomic testing laboratory. Phenotypically unselected adult primary care patients are offered “The Genomic DNATest” at no cost as part of their regular care. Testing is introduced by primary care providers and their staff using a brief animated video and printed decision aids with graded detail. Question resolution and pre- and post-test genetic counseling is offered at no cost using telephone, video, or in-person visits, and is coordinated bya single phone and email contact point, the Genomic Medicine Resource Center. 431 genes are sequenced for germline health risk and recessive carrier variants;only pathogenic and likely-pathogenic variants are reported. New reports are issued when reported and unreported variants are later reclassified. Test reports are reviewed by a clinical geneticist and genetic counselor. Two brief "action plans" are developed with PCP and patient focus in a single messaging document. This is prepended to the lab reports before release to the PCP, who reviews and then conveys them to the patient. PCPs and their staff receive initial training on the test and process and are invited to participate in an online community with monthly video case discussions. Among the first 72 patients tested, 17% had a health risk identified. This included dominantly inherited disorders and bi-allelic or hemizygous variants for common recessive disorders. Care pathways created in advance using multi-disciplinary expertise were activated for those. Free testing for blood relatives was made available. 76% of tested patients had at least one heterozygous recessive disease variant identified, and low-cost partner testingwas made available. Frequency of positive test results was in line with population frequency predictions. Pre- and post-test genetic counseling uptakewas lower than expected. This raised the question of unmet informational needs. A 2-page anonymous process quality survey mailed twice to the first 61 tested patients had a 31% return rate. Key findings included (1) pre-test engagement methods and decision aids were helpful;(2) the testing decision was influenced equally by value for the individual’s health, for their family’s health, and for researchers;(3) emotions during the ∼4-week time to results were neutral or excited, with none experiencing anxious feelings, and none reported the wait time as too long;(4) 21% reported contacting the Genomic Medicine Resource Center;(5) 16% reported referral to a specialist due to their result;(6) about half reported sharing the results with family members, but none reported any family members getting tested;(7) none indicated they were dissatisfied with the testing and result process, and only one responded they would not recommend others get the test;and (8) all agreed or somewhat agreed that the PCPs officewas the right place to do this testing.While this implementation was designed with scalability and a low management profile in mind, several systems-level barriers were encountered that contributed to lower engagement efforts and slower expansion than planned. This included lack of institutional information technology resources to surmount paper-based systems for requisitions, sample-routing, and consent forms;dependency of the patient engagement process during PCP visits on rooming and nursing staff during times of staffing shortages;susceptibility to practice model disruptions and priorities caused by the Covid-19 pandemic;and PCP time distraction resulting from user interface and polic changes in our EHR during the pilot. These barriers are targets for study and continuous process improvement activities. In summary, an example of clinical genomic population health testing using a medical-home focus has been successfully implemented in a non-research setting, supported by multi-disciplinary collaboration. This implementation depends on minimal staff, avoids financial barriers to access and genetic counseling, and offers a short, defined, test turnaround time as compared to similar biobank-based research programs. Tested patients find the program satisfactory, and meaningful test results are at least as common as in existing population health risk screening archetypes.

Leveraging Accountable Care Organization infrastructure for rapid pandemic response in independent primary care practices.

BACKGROUND: Population risk segmentation and technology-enabled preventive care workflows are core competencies for Accountable Care Organizations (ACOs) that may also have relevance for public health emergencies. METHODS: During the early weeks of the COVID-19 pandemic, we aimed to leverage existing ACO capabilities to support 467 primary care practices across 27 states with pandemic response. We used Medicare claims and electronic health records to identify patients with increased COVID-19 vulnerability, for proactive outreach and guidance for "Staying Well at Home." RESULTS: 302,125 patients met intervention criteria; 45% were reached within the first 6 weeks. Engagement in the initiative was uneven among ACO-participating practices. ACO staff identified prior practice engagement in core ACO workflows as a major facilitator of success and staffing shortages as a major barrier. Small practice size, non-metropolitan location, penetration of value-based payment models in the practice, and pre-pandemic Annual Wellness Visit completion rates were independently associated with successful outreach to COVID-vulnerable patients. CONCLUSIONS: Rapid adaptation of ACO infrastructure assisted independent practices across the country to reach vulnerable patients with proactive guidance for staying well at home. The initiative was most successful in smaller, non-metropolitan practices and those with greater engagement in core ACO initiatives pre-pandemic. IMPLICATIONS: Our experience suggests that primary care participation in accountable care models can contribute to preparedness for future public health crises.