Changes in Acute ED Visits by Race/Ethnicity During the Early COVID-19 Pandemic.

Emergency department (ED) visits for conditions unrelated to the Coronavirus Disease 2019 (COVID-19) pandemic decreased during the early pandemic, raising concerns about critically ill patients forgoing care and increasing their risk of adverse outcomes. It is unclear if Hispanic and Black adults, who have a high prevalence of chronic conditions, sought medical assistance for acute emergencies during this time. This study used 2018-2020 ED visit data from the largest safety net hospital in Los Angeles County to estimate ED visit differences for cardiac emergencies, diabetic complications, and strokes, during the first societal lockdown among Black and Hispanic patients using time series analyses. Emergency department visits were lower than the expected levels during the first societal lockdown. However, after the lockdown ended, Black patients experienced a rebound in ED visits while visits for Hispanics remained depressed. Future research could identify barriers Hispanics experienced that contributed to prolonged ED avoidance.

Shift in Prehospital Mode of Transportation for Trauma Patients During the COVID-19 Pandemic.

INTRODUCTION: Since the start of the COVID-19 pandemic, we experienced alterations to modes of transportation among trauma patients suffering penetrating injuries. Historically, a small percentage of our penetrating trauma patients use private means of prehospital transportation. Our hypothesis was that the use of private transportation among trauma patients increased during the COVID-19 pandemic and was associated with better outcomes. METHODS: We retrospectively reviewed all adult trauma patients (January 1, 2017 to March 19, 2021), using the date of the shelter-in-place ordinance (March 19, 2020) to separate trauma patients into prepandemic and pandemic patient groups. Patient demographics, mechanism of injury, mode of prehospital transportation, and variables such as initial Injury Severity Score, Intensive Care Unit (ICU) admission, ICU length of stay, mechanical ventilator days, and mortality were recorded. RESULTS: We identified 11,919 adult trauma patients, 9017 (75.7%) in the prepandemic group and 2902 (24.3%) in the pandemic group. The number of patients using private prehospital transportation also increased (from 2.4% to 6.7%, P < 0.001). Between the prepandemic and pandemic private transportation cohorts, there were reductions in mean Injury Severity Score (from 8.1 ± 10.4 to 5.3 ± 6.6: P = 0.02), ICU admission rates (from 15% to 2.4%: P < 0.001), and hospital length of stay (from 4.0 ± 5.3 to 2.3 ± 1.9: P = 0.02). However, there was no difference in mortality (4.1% and 2.0%, P = 0.221). CONCLUSIONS: We found that there was a significant shift in prehospital transportation among trauma patients toward private transportation after the shelter-in-place order. However, this did not coincide with a change in mortality despite a downward trend. This phenomenon could help direct future policy and protocols in trauma systems when battling major public health emergencies.

COVID-19 Mortality by Demographics in a Brooklyn Hospital

Previous publications have shown worse COVID-19 outcomes in African American and LatinX patients. We are sharing the experience of a 750-bed tertiary safety net hospital in Brooklyn, NY. Copyright © Wolters Kluwer Health, Inc. All rights reserved.

Addressing the unmet social needs of gynecologic oncology patients as identified by a universal screening tool in a safety net hospital

Objectives: To identify the unmet, actionable social needs of gynecologic oncology patients using a self-administered social needs assessment tool and quantify the interventions subsequently provided to our patients. Method(s): This is a study of data collected in an ongoing performance improvement initiative in a gynecologic oncology clinic at a safety net hospital and was determined to be exempt from review by the institutional IRB. Eligible patients completed the social needs screening tool from October 2021 to March 2022. The following social needs domains were assessed: food insecurity, utility insecurity, housing insecurity, transportation insecurity, need for childcare, exposure to violence, lack of companionship, difficulty reading, or difficulty accessing medical care due to fear of losing job. Patients were asked if they desired to speak with a social worker and if any needs were urgent. Data from the screening tool was collected and supplemented by data from the EMR. Univariate descriptive statistics were used to report the patient demographic information, prevalence of social needs, and referral rates for social needs identified. Result(s): There were 475 patients seen in the gynecologic oncology clinic since October 2021. 286 (60%) patients completed the screening tool. 139 (49%) screened positive for at least 1 social need;of those 98 (70%) were Hispanic with a median age of 56 years. 27 (6%) patients were receiving treatment for a gynecologic malignancy, of whom 19 (70%) had at least 1 social need. 25 (92%) patients were insured through Medi-Cal. 12 (44%) patients were being treated for endometrial cancer, followed by ovarian (7, 26%) and cervical (4, 15%). The social needs identified in all patients and in patients actively receiving cancer treatment are summarized in Fig. 1. Patients reporting lack of companionship were referred to mental health or cancer support groups through the American Cancer Society or the Los Angeles County Department of Public Health. Those needing transportation or utility services were linked with services available through their insurance or LA County, ride share vouchers, low-income energy assistance programs, COVID rent/mortgage relief programs. Patients with food and housing insecurity were assisted in applying for public housing or food stamps;local food banks were provided. Patients were assisted with applying for disability insurance as needed. To date, all actively treated patients reporting lack of companionship, need for transportation, avoiding medical care for fear of losing their job, and utility insecurity were provided resources;80% received resources for food insecurity. Conclusion(s): Universal screening for social needs in gynecologic cancer patients identifies a high rate of unmet needs within a safety net hospital. Cancer care navigators can successfully provide these patients community-based resources tailored to their individual social needs. Our next steps will be to determine if and how these resources impact our patients' experiences and treatment outcomes.[Formula presented]Copyright © 2022 Elsevier Inc.

"Access to these screenings have been a gift": A mixed methods assessment of a community navigation program for breast and cervical in the era of COVID-19

Background: The COVID-19 pandemic exacerbated health inequities among systematically marginalized populations. At the onset of the pandemic, routine cancer screenings were effectively halted;from March to May 2021, there was a deficit of 9.3 million screens. Early evidence suggests that non-White patients, compared to White, have experienced even greater declines in breast and cervical cancer screenings. Consequences of missed or late screenings include later stage diagnosis and poor outcomes. Community navigation programs have been used to promote engagement in cancer screenings in under-resourced communities, but these too were interrupted as restrictions were put in place to mitigate the spread of COVID-19. Objective(s): To use a mixed methods approach to describe the challenges, strengths, and lessons learned of implementing a community navigation program for breast and cervical cancer screening during the COVID-19 pandemic. Method(s): In 2019, The University of Illinois Cancer Screening, Access, Awareness, and Navigation (UI CAAN) intervention was established to address breast and cervical cancer disparities on Chicago's West side, an area with large Black and Latinx populations. The intervention included community navigators who worked in partnership with community-based safety net hospitals and organizations. Participants were recruited at community events and through clinical referrals and were eligible if they were overdue for a guideline concordant breast or cervical cancer screening. Quantitative navigation and screening data were collected by the navigators in a REDCap database. Qualitative data, four focus groups with participants and partners, were also collected to broaden our understanding of impact of COVID-19 on the community navigation intervention. For these analyses, we describe participants' navigation and screening outcomes and use content analysis methods for the focus groups. We then triangulate the findings to understand the challenges, strengths, and lessons learned of the UI CAAN. Result(s): From 2019-2022, a total of 366 individuals were navigated for breast and cervical cancer screenings. Of these, 68% (n = 248) received a breast and/or cervical cancer screening. Among those who were screened, 75% were Latinx and 23% were Black, 92% were uninsured, and 86% did not have a primary care provider. Concerning services received, 30% had a mammogram and a pap smear, 37% a pap smear only, and 33% a mammogram only. At the height of the pandemic, navigators coordinated with community and clinical partners to deliver 500 meals, held 9 PPE distribution events, distributed 3000 masks, and conducted 2 webinars about COVID-19. Conclusion(s): Despite the challenges of the COVID-19 pandemic, the UI CAAN community navigation program was able to shift its efforts at the height of the pandemic to assist its community and clinical partners. The continued collaboration allowed for a successful resumption of navigation and screening efforts once healthcare systems were able to re-engage patients in cancer screenings.

Sustaining PrEP Prescriptions at a Safety-Net Hospital in New York City During COVID-19: Lessons Learned.

To understand the impact of COVID-19-related disruptions on PrEP services, we reviewed PrEP prescriptions at NYC Health + Hospitals/Bellevue from July 2019 through July 2021. PrEP prescriptions were examined as PrEP person-equivalents (PrEP PE) in order to account for the variable time of refill duration (i.e., 1-3 months). To assess "PrEP coverage", we calculated PrEP medication possession ratios (MPR) while patients were under study observation. Pre-clinic closure, mean PrEP PE = 244.2 (IQR 189.2, 287.5; median = 252.5) were observed. Across levels of clinic closures, mean PrEP PE = 247.3, (IQR 215.5, 265.4; median = 219.9) during 100% clinic closure, 255.4 (IQR 224, 284.3; median = 249.0) during 80% closure, and 274.6 (IQR 273.0, 281.0; median = 277.2) during 50% closure were observed. Among patients continuously prescribed PrEP pre-COVID-19, the mean MPR mean declined from 83% (IQR 72-100%; median = 100%) to 63% (IQR 35-97%; median = 66%) after the onset of COVID-19. For patients newly initiated on PrEP after the onset of COVID-19, the mean MPR was 73% (IQR 41-100%; median = 100%). Our ability to sustain PrEP provisions, as measured by both PrEP PE and MPR, can likely be attributed to our pre-COVID-19 system for PrEP delivery, which emphasizes navigation, same-day initiation, and primary care integration. In the era of COVID-19 as well as future unforeseen healthcare disruptions, PrEP programs must be robust and flexible in order to sustain PrEP delivery.

RETROSPECTIVE ANALYSIS OF THE COVID-19 PANDEMIC IN AN URBAN SAFETY-NET HOSPITAL IN ATLANTA, GA

SESSION TITLE: COVID-19 Infections: Issues During and After Hospitalization SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: We present a retrospective study at one of the largest public, safety-net hospitals in the United States to highlight the importance of codifying the impact of COVID-19 disparities in marginalized populations. We used the following metrics to draw conclusions: patient demographics, vaccination status, comorbid conditions, length of stay (LOS), readmission rates, and clinical outcome. METHODS: For this retrospective study, we used Slicer Dicer software (Epic Verona, WI), an Epic self-service reporting tool, to query clinical data and identified a cohort of 9,040 patients ≥ 18 years old diagnosed with COVID-10 at Grady Memorial Hospital in Atlanta from 1/1/21 to 12/31/21. Statistical significance was defined as p<0.05. RESULTS: Of the 9,040 patients, 54.7% were female (4,942) and 45.3% were male (4,096). The cohort median age was 51 (range 18 – 100) and 80.5% were African American (7,278/9,040). Double-dose vaccination rate was only 24.5% (2,215/9,040). 38.3% of patients diagnosed with COVID-19 were admitted (3,467/9,040) and among these patients 3.0% were re-admitted (107/3,467). The most prevalent comorbidities were essential hypertension (45.2%), diabetes (21.7%), and asthma (13.2%). Patients with these comorbidities were more likely to be discharged as opposed to being admitted. Patients with the following comorbidities were more likely to be admitted: Pulmonary hypertension (70% admission rate), COPD (64.9%), heart failure (61.0%), cancer (60.8%), atrial fibrillation (57.1%). Median LOS from admission was 4 days and there was no statistical difference among different comorbidities. We found higher mortality in COVID-19 patients with cancer (12.9%), atrial fibrillation (12.6%), heart failure (11.1%), pulmonary hypertension (10.1%) and COPD (9.1%) compared to patients with diabetes (7.5%), hypertension (6.7%), HIV (4.8%), DVT/PE (4.6%), or asthma (2.7%). When examining overall mortality based on self- reported race, we found that African American patients had a statistically significant higher mortality compared to Caucasian patients (p-value= 0.00454). CONCLUSIONS: Current retrospective study, which included COVID-19 patients with different comorbidities showed that COVID-19 patients with pulmonary hypertension have worse clinical outcomes compared to other comorbid conditions. CLINICAL IMPLICATIONS: Our findings suggest the importance of investigating COVID-19 disparities in marginalized populations to better understand the impact in these communities. All individuals should be encouraged to get vaccinated against COVID-19, especially those found to be at high risk of severe illness such as pulmonary hypertension. In this retrospective study, we found higher hospital admission rate and worse outcomes in patients with cancer, atrial fibrillation, heart failure, and pulmonary hypertension, as well as higher mortality among the African American patient population. DISCLOSURES: No relevant relationships by nicolas bakinde No relevant relationships by Suvrat Chandra No relevant relationships by Michelle Lee no disclosure on file for Mario Ponce;

CAUSES OF DEATH AMONG MEDICAL ICU (MICU) PATIENTS WITH PNEUMONIA DUE TO COVID-19 IN A SAFETY NET HOSPITAL

SESSION TITLE: Studies on COVID-19 Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: COVID-19 infection has a wide spectrum of clinical presentation ranging from asymptomatic carriers to severe critical illness associated with high morbidity and mortality. Although severe COVID-19 disease is associated primarily with pulmonary dysfunction and hypoxemia, many patients with lung disease can be supported by invasive mechanical ventilation allowing for other causes or complications to be the primary factor leading to death. The contribution of pulmonary dysfunction to the primary cause of death is not well-described. METHODS: We performed a retrospective cohort study of adult patients (age ≥ 18 years) admitted to the MICU at Los Angeles County + University of Southern California (LAC + USC) hospital from April 2020 to December 2020 with a primary diagnosis of COVID-19 pneumonia associated with documented in-hospital death. Data including baseline patient characteristics, primary cause of death and/or circumstance prior to withdrawal of care, and disease course were collected. The primary organ system responsible for death was defined as the organ dysfunction that most directly resulted in the patient’s death or impacted the decision for withdrawal of life support with details adapted from Ketcham, et al (Crit Care, 2020). RESULTS: We identified 86 patients who were admitted to the ICU that met inclusion criteria for review, of which 75% were male and 93% were Latino/Hispanic. Mean age on admission was 64 years. Of the 86 patients, 47 (54%) died from a primary pulmonary cause, 28 (32%) died from sepsis, 5 (6%) died from neurologic causes, and 4 (5%) died from either renal or hemorrhagic causes. Of the 47 patients who died primarily from pulmonary causes, 34 (72%) died from hypoxemic respiratory failure, 8 (17%) died from hypercapnic respiratory failure, and 5 (11%) died from combined respiratory failure. Of the 28 patients who died primarily from sepsis, 13 (46%) died from pneumonia, 7 (25%) died from fungemia, and 3 (11%) died from bacteremia with an identified source. Overall, 58 (67%) patients had multi-organ failure at time of death. Mean time from symptom onset to death was 27 days. Of the 69 patients who were intubated, mean times from admission to intubation and intubation to death was 4 and 19 days respectively. Only 1 patient who died underwent tracheostomy. CONCLUSIONS: We found that pulmonary dysfunction was the primary cause of death in the first year of the pandemic in our patient population at our single center MICU. Future studies are needed to further evaluate the primary cause of death in COVID-19 infection throughout the pandemic as medical management evolved and virus variant changed with time. CLINICAL IMPLICATIONS: Our study confirmed that a majority of patients with severe COVID-19 pneumonia died from hypoxemic respiratory failure. Further studies regarding COVID-19 interventions should focus on therapies to improve oxygenation. DISCLOSURES: No relevant relationships by Christopher Do No relevant relationships by Luis Huerta No relevant relationships by Janice Liebler

Evaluating predictors of food insecurity among patients with cancer in the safety-net setting

Background: Patients with cancer, especially minority and low-income individuals, are at increased risk of financial toxicity and food insecurity. The COVID-19 pandemic has added dire economic challenges to vulnerable populations leading to a global increase in food insecurity. We sought to evaluate the severity and predictors of food insecurity among low-income patients with cancer. Methods: We conducted a cross-sectional multi-lingual survey (i.e., English, Spanish, and Chinese) on a convenience sample of patients with cancer who receive oncologic care at a safety-net hospital. Food insecurity and financial toxicity were measured using validated scales [i.e., US Department of Agriculture Household Food Security Survey and the Comprehensive Score for Financial Toxicity (COST)]. The primary outcome was food insecurity during COVID-19 and predictors of interest included sex, financial toxicity, insurance change, and degree of acculturation. Data was summarized using descriptive statistics and we explored associations between food insecurity and predictors of interest using bivariate regression. Results: A total of 140 patients participated in the study, of whom 56% were male and 47% were 50-64 years old. The most common cancer diagnoses were breast cancer (33%), followed by prostate (13%) and lung cancer (12%). The diverse study participants self-reported being 42% Hispanic/Latinx, 33% Asian, 18% Black or African American, and 14% White. Over half (52%) reported an annual household income ≤$24,999 and 50% experienced a decrease in income during the COVID-19 pandemic. The median COST score was 24 (IQR: 19-31) with 41% experiencing financial toxicity (COST < 26). Most participants experienced food insecurity, including 42% with low food security and an additional 19% with very low food security. In bivariate analysis, increasing financial toxicity (i.e., lower COST score) was associated with a 21% increased risk of very low or low food security (95% CI: 1.11-1.32) and 13% increased risk of low food security (95% CI: 1.05-1.21). Male sex was associated with 312% increased risk of very low food insecurity when compared to female sex (95% CI: 1.02-9.55). Acculturation and changes in insurance coverage were not associated with increased risk of food insecurity. Conclusions: Food insecurity was highly prevalent in this multi-ethnic cohort of low-income patients with cancer. Interestingly, male sex was significantly associated with increased risk of very low food insecurity. Further analyses should explore this potentially at-risk population, their access to nutrition-related support, and the impact of food insecurity in cancer outcomes.

Institution of same-day total joint replacement at an urban safety net hospital during the COVID-19 pandemic.

Background: Increasingly, total hip and total knee replacements are being performed at outpatient ambulatory surgery centers. The purpose of this study was to investigate the feasibility and safety of instituting a same-day surgery program for hip and knee replacement at an urban, safety net hospital. Methods: Retrospective review of a prospectively collected registry for all patients scheduled for same-day total joint replacement at a safety net hospital was performed. Medical records were reviewed for patient demographics, same-day hospital admissions, and 30-day emergency room/hospital admissions. Results: 131 same-day total joint replacements were identified, including 76 knees and 55 hips. Median ASA was 3, and median Charlson comorbidity score was 2. Rate of same-day surgery for total joint replacements increased from 4.5% in September 2020 to 100% in September 2021. On major patient outcomes, 3.8% of patients (n = 5) required conversion to inpatient admission. Rate of 30-Day Emergency Department (ED) visits was 13.0% (n = 17). Most common complaints included postoperative pain (n = 10), incision drainage/edema/hematoma (n = 9), and cellulitis (n = 2). 30-Day Hospital Readmissions occurred in 1.5% of patients (n = 2). Conclusion: Same-day hip and knee replacement can be performed safely at a safety net hospital. Unlike dedicated high-volume orthopedic hospitals or outpatient surgery centers, urban safety net hospitals face a different set of challenges and must care for a wide variety of patients who do not plan for their illness and/or may not be able to pay for their care. Outpatient total joint replacement may extend total joint replacement to patients who might not have access otherwise.

COVID-19 infections among minority patients with gastrointestinal malignancies in urban safety net academic medical centers

Background: COVID 19 infection has worse outcomes and is more severe among frail patients and with co-morbidities. Additionally, it was suggested by Mehta et al that gastrointestinal malignancies may have worse outcomes. Based off these findings, we have evaluated outcomes and potential predictors of these outcomes in patients with gastrointestinal malignancies and COVID 19 infection. Methods: We conducted a retrospective evaluation of 69 cases of patients between February 2020 to February 2021, that had both COVID 19 infection and a gastrointestinal malignancy, including: gastric, colon, pancreatic, biliary, and hepatic. We studied population general characteristics, most common tumors, oxygen requirements, management and death frequencies, at two urban safety net hospitals. Results: The median age of patients with gastrointestinal malignancies and COVID-19 infection was 68 (33 to 87), it was more frequently seen among males (N = 46, 67%);patients had on average 1-7 other comorbidities (N = 55, 80%), hypertension being the most common (N = 43, 62%). All patients in this study were minorities, the majority being Hispanics (N = 32, 46%), followed by African Americans (N = 21, 30%), the rest of patients were minorities such as Asians, Native Americans, and others (N = 16, 23%). We noted that more than half of patients were obese (N = 24, 35%), or overweight (N = 19, 28%), with a mean BMI of 26.24. Most patients were non-smokers (N = 39, 57%). The performance status among these patients was excellent in the large majority (ECOG 0-2;N = 62, 90%). The majority of malignant tumors were adenocarcinomas (N = 63, 91%);others included neuroendocrine tumors (N = 4, 6%) and gastrointestinal tumors (N = 2, 3%), the majority were advanced stage disease between stage III to stage IV disease (N = 38, 55%). The most common malignancy was colon cancer (N = 44, 64%), and also was the most reported deaths were among patients those patients with colon cancer (N = 13, 57%). Among patients that needed to be hospitalized (N = 43, 62%), needed some sort of oxygen supplementation (N = 36, 84%), a small number of patients required ICU admission (N = 8, 19%). When hospitalized, patients were mostly treated with hydroxychloroquine (N = 30, 70%) and steroids (N = 7, 16%). Inflammatory markers such as D-dimer, ferritin, C-RP were not reported in the majority of cases. Overall, the case fatality rate across all gastrointestinal malignancies was noted to be substantial (N = 22, 32%), 35% in males and 26% among females (p = 0.46). Conclusions: During the first year of the COVID-19 pandemic, patients with gastrointestinal malignancies who were infected, seemed to have a high chance to be admitted to the hospital (62%), once hospitalized the majority required some sort of oxygen supplementation (84%) and had a high case fatality rate from the COVID-19 infection (32%).

Promoting Equity in Telehealth Among Racially and Ethnically Diverse Adolescents: A Quality Improvement Initiative

Purpose/Objectives: The COVID-19 pandemic magnified the longstanding health disparities and unique health needs of adolescents from racially and ethnically diverse backgrounds. With the rapid expansion of telehealth nationally, it is essential that health systems consider how telehealth could influence health equity and be leveraged to meet the needs of diverse populations. We launched a quality improvement (QI) initiative at a large safety-net hospital to assess adolescent and parent perspectives on the use of telehealth, specifically exploring barriers and facilitators to implementation, and then develop recommendations for adapting telehealth practices to optimize care and promote equity for diverse populations of adolescents. Design/Methods: From January-May 2021, we conducted surveys with adolescents ages 12-21 who had a telehealth visit at a county safety-net hospital during the COVID-19 pandemic (n=70) and their parents (n=41). We purposively sampled for adolescents from populations known to be underutilizing telehealth within our system;in our final sample, 39% were Latinx and 33% were Black, with 30% of Black adolescents identifying as Somali. The electronic surveys, which were delivered in English, Spanish or Somali, included questions about respondents': experiences and satisfaction with telehealth;barriers and facilitators to telehealth;experiences of racism and discrimination in healthcare;indicators of high-quality adolescent care and demographics. We analyzed data using descriptive statistics for quantitative variables, and content analysis for qualitative (open-ended) responses. We then hosted four listening sessions with adolescents (n=9) and parents (n=4) to collectively review findings and develop recommendations to optimize care for diverse adolescents and their families. Results: Participants were generally satisfied with telehealth and rated visits highly on quality of care (Figure 1). Commonly reported barriers to telehealth included: difficulty connecting to the visit, a lack of private space, feeling the provider may not be able to evaluate them fully during the visit, and not being able to get labs or imaging. Seven percent of adolescents and 15% of parents reported experiencing discrimination in healthcare, with over one-third (36%) of these experiences occurring during telehealth visits. Nearly half of adolescents (44%) expressed concern that something private from the visit might be shared with their parents, and 10% of adolescents did not have a private space to talk to their providers. Drawing on findings from surveys and listening sessions, we developed recommendations for clinicians and health systems (Table 1) and disseminated them across our hospital system. Conclusion/Discussion: Our QI initiative engaged a diverse population of adolescents and parents in developing recommendations for clinician- and systems-level changes for improving equity in the delivery and, ultimately, access to telehealth care. Our findings have implications, not only for our large safety-net county medical center, but also for other clinics serving racially and ethnically diverse young people. (Table Presented).

IMPROVING COLORECTAL CANCER SCREENING IN A SAFETY NET CLINIC THROUGH A RETURN- BY-MAIL FECAL IMMUNOCHEMICAL TEST PROGRAM

STATEMENT OF PROBLEM/QUESTION: Can establishing a return-bymail fecal immunochemical test (FIT) program increase the colorectal cancer screening rate in a safety net primary care clinic? DESCRIPTION OF PROGRAM/INTERVENTION: Colorectal cancer (CRC) screening rates are typically lower in safety net health systems. This trend has been exacerbated by the COVID-19 pandemic, which has limited access to colonoscopy for screening. There is evidence that FITs are costeffective and mailed FIT programs can increase screening rates for vulnerable patients. We implemented a return-by-mail FIT program in the adult primary care clinic of New York City Health + Hospitals/Bellevue, a public safety net hospital. We evaluated adults aged 50-75 who were not up to date with CRC screening. All patients due for CRC screening were only offered FIT as a screening modality. We implemented a partial mailed FIT program, in which FIT tests picked up in clinic could be returned by mail directly to the lab. Prior to our intervention, patients were required to return FITs to the clinic in person. MEASURES OF SUCCESS: We evaluated FIT completion rates within our clinic 30 days before and after the introduction of return-by-mail FIT kits in July 2021. We also evaluated our clinic's pre- and post-intervention performance relative to other clinics within the New York City Health + Hospitals system using claims data. Additionally, we randomly surveyed patients who received a FIT and did not complete it in the period prior to our intervention to assess reasons for incompletion. FINDINGS TO DATE: A total of 5,153 and 5,180 patients aged 50-75 were seen in clinic 30 days before and 30 days after the implementation of a mailed FIT program. 571 patients were provided a return-in-person FIT kit 30 days prior to our intervention. Of these patients, 289 (50.6%) completed a FIT. By contrast, 781 patients were provided a return- by-mail FIT kit 30 days following our intervention. Of these patients, 464 (59.4%) completed a FIT (p < 0.01). Additionally, the proportion of patients who completed annual CRC screening prior to our intervention was lower in our clinic (48.2%) compared to the average across the New York City public hospital system (51.4%) according to managed care Medicaid claims data (MetroPlus, June 2021). Four months following our intervention, our clinic's year-to-date CRC screening rate exceeded the average system-wide rate (59.3% vs. 57.6%, November 2021). We also called 45 patients who were provided a FIT test prior to our intervention and did not complete it. 12 patients were reached, and 2 of these patients cited difficulty dropping off the test as the primary barrier to FIT completion (16.7%). KEY LESSONS FOR DISSEMINATION: By implementing a return-bymail FIT program, we were able to increase our clinic's CRC screening rate by 8.8%. Our data are similar to previous programs implementing mailed FIT programs in safety net patient populations. Future aims are to implement a mail-to-patient FIT program in addition to our initial return-by-mail program.

CREATION AND IMPLEMENTATION OF COVID VIDEO DISCHARGE INSTRUCTIONS FOR ADMITTED PATIENTS

STATEMENT OF PROBLEM/QUESTION: Written discharge instructions about safe COVID practices may not address patients' communication needs, particularly for those with language barriers, necessitating novel means for patient education. DESCRIPTION OF PROGRAM/INTERVENTION: We aimed to improve patient comprehension of safe COVID practices by creating patientcentered, language-congruent, and illustrated video discharge instructions (VDI) in English and Spanish. This effort took place in an urban, safety-net hospital, focusing on adult patients in a pilot Med-Surg unit. We assessed patient knowledge with pre- and post-intervention phone surveys. The VDI intervention was launched utilizing a pre-existing television-based patient experience platform. MEASURES OF SUCCESS: We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to evaluate our intervention's impact and sustainability: R (number of patients who viewed the VDI);E (changes in knowledge post-intervention);A (number of providers displaying the VDI);I/M (longitudinal tracking to assess continued implementation). We also collected patient feedback on the discharge process and VDI. FINDINGS TO DATE: Of 174 pre-intervention subjects, 107 (62%) were COVID-positive (“C+”), and 67 were COVID-negative (“C-”). Predominant preferred languages were English (44%;34 C+, 43 C-) and Spanish (47%;61 C+, 20 C-). 164 (94%) described correct masking technique, and 147 (85%) knew the CDC distancing guideline of 6 feet. Only 31 (18%) could define a close contact. There were no differences based on COVID status. Of the C+ group, 61 (57%) knew their isolation discontinuation date, and only 15 (14%) knew ≥2 of 3 CDC criteria for stopping isolation. There was no difference based on preferred language. Post-intervention surveys and patient feedback collection are ongoing. Early responses have been positive: “[I] found it informative, particularly the playby-play with what COVID is and how it is spread.” KEY LESSONS FOR DISSEMINATION: Our data reveal a critical knowledge gap in safe COVID practices, suggesting that standard patient discharge education is insufficient. Video, language-concordant education may address this gap. Any innovation adoption requires change management;we use Kotter's 8- Step Process for Leading Change to guide our reflections on this effort. Our project emerged due to the urgency of rising COVID infections (1). With this momentum, we identified collaborators, outlined goals, and rallied staff to execute our multi-phase initiative (2-4). The pandemic's unpredictability and variable day-to-day demands on staff volunteers led to implementation challenges (4). Moreover, fluctuating numbers of COVID cases led to a proportional fluctuation in the sense of urgency for change, impeding implementation. We addressed barriers by meeting with providers and leadership to identify avenues for easing VDI deployment (5). Initial positive responses serve as a motivating short-term win to accelerate implementation, and we solicit additional feedback to promote smooth and standardized implementation (5-7).

PRIMARY CARE AND TELEMEDICINE UTILIZATION IN PATIENTS WITH TYPE 2 DIABETES AT A SAFETY-NET HOSPITAL BEFORE AND AFTER ONSET OF THE COVID-19 PANDEMIC

BACKGROUND: During the COVID-19 pandemic, healthcare systems implemented telemedicine to ensure safe uninterrupted care for patients who require regular follow up such as those with type 2 diabetes (T2DM). While studies have documented disparities in access to telemedicine, few have compared overall changes in primary care utilization pre and post pandemic, and few have focused on disparities in utilization among patients with T2DM in safety-net settings. METHODS: We conducted a retrospective analysis of electronic health record data of all established adult primary care patients with T2DM at the largest safety-net hospital in New England. We defined a minimum of semiannual visits as standard of care (SOC). Logistic regression models analyzed primary care utilization during pre-pandemic (3/15/18-3/14/20) and postpandemic onset (3/15/20-3/15/21) time periods according to patient demographics, insurance, and visit type (in-person, telemedicine-all, phone, video), adjusting for comorbidity and A1c. RESULTS: Of 8155 patients with T2DM, 86% had at least one primary care visit after pandemic onset. Of those patients, 5.8% had exclusively in-person visits, 45.2%had exclusively telemedicine visits, and 49.0%had a mix of both. Of 30,094 post-pandemic visits, 78%were telemedicine (88.1% via phone, 7.3% via video, and 4.6% unknown type). Pre-pandemic, 87% of patients had SOC utilization, and patients who are non-white, female (vs. male), Spanish speaking (vs. English), age >44, and have Medicare or Medicaid (vs. commercial) had higher odds of SOC utilization. Post-pandemic onset, 71% of patients had SOC utilization, and patients who are Hispanic (vs. white), female (vs. male), age 45-65, and have Medicare had higher odds of SOC utilization. Females (vs. males) and 45-65 year-olds (vs 18-44) had higher odds of engaging in at least one telemedicine visit (OR [95%CI]: female 1.3 [1.1-1.5];45-65 1.5 [1.2-1.9]). Patients who are Black (vs. white), non-English speaking, age >44, and with Medicare had lower odds of completing at least one video visit (OR [95%CI]: Black 0.8 [0.6-0.99];Spanish 0.3 [0.2-0.5], Haitian-Creole 0.5 [0.4-0.7];45-65 0.6 [0.5-0.7], >65 0.5 [0.4-0.6];Medicare 0.7 [0.6-0.9]), while females (vs. males) had higher odds (OR [95%CI]: 1.7 [1.5-2.0]). CONCLUSIONS: Most patients with T2DM had primary care visits at least semiannually prior to the pandemic. Following the pandemic, this proportion decreased across all groups. Odds of having visits at least semiannually were different according to demographics, insurance, and pandemic time-period. Most post-pandemic visits were via telemedicine, few of which included video. Odds of engagement in telemedicine did not differ between patients of different race/ethnicity, language, and insurance status. However, Black patients, older patients, and thosewho do not speak English are less likely to use video. Future studies should examine whether differential use of primary care and telemedicine during the pandemic has affected T2DM outcomes.

AN INITIATIVE TO DECREASE 30-DAY HOSPITAL READMISSION RATES AT AN URBAN ACADEMIC SAFETY-NET HOSPITAL THROUGH A RESIDENT-LED TRANSITIONS-OF-CARE CLINIC

STATEMENT OF PROBLEM/QUESTION: The transition between hospital discharge and primary care follow-up is a vulnerable period for patients that can result in adverse health outcomes and preventable hospital readmissions. The COVID-19 pandemic has exacerbated this transitional period, as many patients have forgone their routine healthcare visits, lost touch with their primary care providers (PCPs), and lacked a point of contact for their health needs after leaving the hospital. DESCRIPTION OF PROGRAM/INTERVENTION: We launched a postdischarge Transitions in Care Management (TCM) clinic to serve patients discharged from NYU Langone Hospital Brooklyn, an urban safety net academic hospital that serves a racially diverse and socioeconomically vulnerable population in Southwest Brooklyn. From October 2020 to October 2021, TCM visits were offered to patients prior to discharge from the general medicine service at NYU Langone Brooklyn who did not have a primary care provider or who could not get an appointment with their PCP within 10 days of discharge. Patients were given the option of in-person visits or virtual visits. TCM visits were scheduled with residents within 2 weeks of patient discharge. Questions at the TCM visit focused on scheduled speciality appointments, any discrepancy in medications prescribed at discharge, or if the patient was connected to additional community resources. MEASURES OF SUCCESS: The primary outcome was the 30-day readmission rate for patients referred to TCM compared to all patients discharged from the general medicine unit. FINDINGS TO DATE: From October 2020 through October 2021, there were a total of 357 TCM visits out of a total 806 referrals placed (44% completion rate). There was a reduction in 30-day hospital readmission rate for patients who completed a TCM visit compared with those who were not referred (5% vs 15.9%;p < 0.001). There was also a reduction in readmission rate for those who were referred but did not complete their TCM visit compared to those who were not referred (8.4% vs. 15.9%;p < 0.001). Of the completed visits, 172 were in-person, 138 were virtual, and 47 were over the telephone. Patients were also more likely to show up to their virtual visits than their in-person visits (30% no-show rate for in-person vs. 12% no-show rate for virtual). KEY LESSONS FOR DISSEMINATION: Thirty-day hospital readmission rate was lower for patients seen as part of the resident-run TCM clinic at a safety net academic medical center. Interestingly, patients referred but who did not complete TCM visits still had a decreased readmission rate compared to those who were not referred, suggesting that there may be an inherent difference in these two patient groups. Future studies will examine the differences between these groups, and analyze the factors that influence TCM referral and visit completion. Future studies will also analyze how the medium of visit (virtual vs. in-person) and specific interventions during the TCM visits (medication reconciliation, specialty appointments, community resources) influenced patients' transition in care.

IMPACT OF COVID-19 ON TRANSMISSIBLE INFECTION SCREENING AT AN URBAN SAFETY-NET HOSPITAL

BACKGROUND: Bacterial sexually transmitted infections (bSTI) and HIV outbreaks are on the rise nationally. Early diagnosis, which reduces individual and community morbidity, requires ready access to symptomatic and asymptomatic testing. The coronavirus 2019 (COVID-19) pandemic drove a shift towards telemedicine and the prioritization of symptomatic treatment over asymptomatic screening, raising concern about potential reductions in testing. The impact in safety-net settings, which faced disproportionate baseline bSTI/HIV rates rooted in structural inequities, and where many patients lacked telemedicine resources, is not yet known. This study describes the impact of COVID-19 on bSTI/HIV testing at an urban, safety-net hospital located in one of the federal Ending the HIV Epidemic priority counties. METHODS: The study took place at Boston Medical Center (BMC) in Suffolk County, MA. Medical center-wide chlamydia, gonorrhea, syphilis, and HIV testing volume and positivity rates were ed from July 1 2019-August 31 2021. On the basis of institutional modified COVID-19 operations, we defined the following study periods: pre-pandemic (July 1 2019 - February 29 2020), peak-pandemic (March 1 2020 -May 31 2020), and post-peak (June 1 2020 - August 31 2021). Descriptive statistics were used to characterize testing trends. RESULTS: Testing Volume Bacterial STI and HIV test volume dropped sharply beginning in March 2020. bSTI testing peak-pandemic (mean 1,145 tests/mo) was 42% of pre-pandemic baseline (mean 2,738 tests/mo) and nadired in April 2020 (766 tests). Similarly, peak-pandemic HIV testing (mean 711 tests/mo) was 43%of pre-pandemic baseline (mean 1635 tests/mo) and nadired in April 2020 with 438 tests concentrated in inpatient and ED settings. Post-peak bSTI (mean 2,551 tests/ mo) and HIV (mean 1585 tests/mo) testing did not return to baseline until March 2021. Positivity Rate Peak-pandemic bSTI tests were 10% more likely to be positive compared to the pre-pandemic period (4.64% vs 4.10%). Gonorrhea and chlamydia tests were 13% more likely to be positive (5.64% vs 4.98%), reaching peak positivity of 7.33% in April 2020. HIV tests were 35% more likely to be positive (1.76% vs 1.30%). CONCLUSIONS: Bacterial STI and HIV testing rates at an urban safety-net hospital declined precipitously at the onset of the pandemic and did not return to baseline levels until 1 year later. Increased positivity rate further supports the inadequacy of peak-pandemic testing. Facing another winter surge in COVID-19 cases, safety-net settings should develop low-barrier alternatives to traditional office-visit based testing, including walk-in and home testing pathways to mitigate testing gaps, high positivity rates, and associated morbidity.

CHAGAS SCREENING PROGRAM IN A PUBLIC SAFETY NET HOSPITAL IN QUEENS: CHALLENGES AND SUCCESSES

STATEMENT OF PROBLEM/QUESTION: Chagas disease (CD) is a lifelong protozoan parasitic infection that if left untreated can result in cardiomyopathy in a third of cases;a screening program can identify individuals with chronic asymptomatic disease. DESCRIPTION OF PROGRAM/INTERVENTION: Elmhurst Hospital is a public safety net hospital in Queens serving a diverse community with many immigrants from Mexico, Central and South America. An estimated 8 million people in Latin America and 300,000 in the US are living with CD. We implemented a Chagas screening program in the Elmhurst adult primary care clinic. Our electronic health record (EHR), Epic, captures patient diversity by including 200 ethnic background options;we used this field to identify at-risk patients. Patients waiting for their appointment were brought into a private area and educated about CD by a Spanish-speaking volunteer. They were asked their country of origin, their ability to recognize the Reduviid bug, and the type of house they grew up in. Written educational materials about CD in Spanish provided by CDC website were given to patients. Once a patient accepted screening the provider received a secure chat in the EHR instructing them to order the Chagas serology. All patients have been kept on a secure list, and all are called for follow-up regardless of their results. Patients who test positive receive a follow-up plan that includes cardiac testing and referral to the Infectious Diseases (ID) clinic. Education about immigrant health and CD was provided to faculty, nurses and residents by ID specialists. MEASURES OF SUCCESS: The number of patients accepted and screened for CD. FINDINGS TO DATE: From June to November 2021, 340 patients in the Elmhurst medicine clinic were approached about their risk for CD. Of these migrants 36% were from Mexico, 51% were from S. America and 13% were from Central America. 23% of these patients grew up in an adobe house and 26% recognized the reduviid bug from a picture. Of 324 at-risk individuals asked about previous Chagas knowledge, only 7% were familiar with CD. 203 patients were tested with final results, 18 refused testing, 37 tests are pending for the next visit, and 82 were not ordered. 2 were positive on the screening ELISA with confirmation pending;CDC has suspended testing during the COVID-19 pandemic. Family members will be screened if confirmatory testing is positive. KEY LESSONS FOR DISSEMINATION: For practices serving large atrisk populations, a Chagas screening program can help to address a healthcare disparity. Partnership with ID specialists is essential for this process to succeed. Having an EHR that captures diverse demographic information identifies atrisk patients and is critical to the success of such a program. Challenges include having to obtain confirmatory testing at CDC which involves a patient returning for a follow-up visit and another blood draw. PCP champions can be a useful resource to sustain CD screening in the future. Low awareness of CD in our patient population suggests that community outreach to at-risk individuals is needed to increase awareness.

NEPHROLOGY E-CONSULTS: A NOVEL APPROACH TO KIDNEY CARE IN A SAFETY-NET HOSPITAL

STATEMENT OF PROBLEM/QUESTION: With Chronic Kidney Disease (CKD) on the rise, Grady Health System (GHS) implemented a novel Electronic-Consultation (E-Consult) Service for outpatient Nephrology and we sought to determine the characteristics and outcomes of these patients to better recognize the utility in our new approach to kidney care. DESCRIPTION OF PROGRAM/INTERVENTION: The Nephrology EConsult service was launched in September 2020 across all primary care clinics at GHS, which is located in downtown Atlanta, GA, and serves a population of mainly Medicare/Medicaid and uninsured patients. With this service, Primary Care Providers (PCPs) submit an E- Consult and a single Nephrologist reviews the chart to communicate closed-loop recommendations via the patient's Electronic Health Record (EHR). If high-complexity factors are discovered (including nephrotic-range proteinuria, acute kidney injury (AKI), or CKD 4/5), the patient is scheduled for an in-person clinic visit with Nephrology. MEASURES OF SUCCESS: We retrospectively analyzed the charts of 200 randomly-selected E-Consults placed 09/2020-12/2021 to determine disease complexity, A1c and albuminuria screening rates, DM2 control, common comorbidities, renoprotective medication use, as well as the percentage of PCPs who completed the consultation recommendations. We identified the number of in-person Nephrology clinic visits that were prevented with this virtual service and compared waitlist times against a traditional referral to outpatient Nephrology. FINDINGS TO DATE: The majority of patients (55%) have low-complexity kidney disease, and nearly half of all E- Consults are managed entirely virtually, avoiding an in-person visit to Nephrology. Fewer E-Consults have high- complexity disease (45%), most of which involve AKI (60%) and/or CKD4 (35%), warranting an in-person Nephrology evaluation, and with this service an in-person visit occurs in 1/3 the time of traditionally-placed referrals. The most common comorbidities are hypertension (80%) and DM2 (51%), and interestingly, the majority of patients with DM2 have relative control of their disease with an A1c <7% (63%). However, the rate of screening A1c differs from albuminuria: most patients have a recent A1c (70%) while less than half of patients have a recent urine albumin. Very few patients are prescribed an SGLT2-inhibitor (5%) and more than a quarter of eligible patients are not on any renoprotective medications. Nearly a quarter of PCPs do not complete the e-consult recommendations, representing an area where EMR automatization may be useful. KEY LESSONS FOR DISSEMINATION: Our Nephrology E-Consult Service improves access to kidney care for all patients, reduces clinic wait times for those with high-complexity disease, and may play an important role during the Covid-19 pandemic by reducing healthcare-associated exposures. By providing a closed-loop method of communication between PCP and Nephrologist, guideline-based recommendations for routine screening and renoprotective strategies can be exchanged for the patient's benefit.

DOES ACCESS TO TELEHEALTH IN PRIMARY CARE AFFECT PRIMARY CARE UTILIZATION IN A LARGE, PUBLIC HEALTHCARE SYSTEM?

BACKGROUND: Telehealth services may improve access to care by removing certain barriers to care. But, health systems and payors may be hesitant to provide or cover telehealth at the same rate as in-person services in part due to concerns around potential to increase overall healthcare utilization. During the coronavirus disease pandemic, many regulatory restrictions on telehealth were paused, allowing more widespread usage of telehealth. We sought to investigate whether patients engaged in telehealth had increased primary care (PC) utilization relative to those not engaged in telehealth. METHODS: We conducted an observational study of electronic health record data for patients with PC visits from July 1, 2020 to June 30, 2021 at 23 adult PC clinics at New York City Health + Hospitals, the nation's largest public healthcare system. This period represents when local COVID cases were past initial peak and telehealth visits were available to patients electively instead of preferentially. The primary outcome was the average number of annual completed PC visits per patient. We collected patient age, sex, race/ethnicity, language, insurance, and number of Elixhauser comorbidities and compared them between groups using χ2 tests. Then, we stratified patients by quintiles of comorbidity count and compared the average number of completed PC visits per patient between telehealth users and non-users using two-sided Welch's ttests. RESULTS: There were 569,724 visits by 225,147 patients. Of these patients, 133,830 (59.4%) were telehealth users. Compared to telehealth non-users, telehealth users were more likely to be older, female, Asian, Medicare beneficiaries, and have more comorbidities and less likely to be Black, commercially insured, or uninsured (p<0.001). The average (SD) number of PC visits were 2.9 (1.7) for telehealth users and 1.9 (1.3) for non-users. Compared to telehealth non-users, telehealth users had 1more PC visit per patient regardless of comorbidity count (Table;p<0.001). Among telehealth users, the average proportion of visits that were conducted via telehealth was 0.68 (0.28). CONCLUSIONS: Availability of telehealth may increase PC utilization in safety-net clinics. Differences in utilization may relate to decreases in barriers to care, lower efficacy of telehealth, or differences in propensity to engage in care not accounted for by comorbidity count. More research on outcomes, costs of care, patient and clinician experiences is essential to better inform policymakers' and payors' decisions around coverage of telehealth services.