Designing a Checklist for Directly Observing Use of One-Minute Preceptor Steps on Inpatient Rounds: A Pilot Study.

BACKGROUND: "One-minute preceptor" (OMP) is a well-established educational technique; however, primary literature on OMP lacks a tool to assess behavioral change after delivery of curricula.Primary aim of this pilot study was to design a checklist for direct observation of teachers using OMP on general medicine rounds and obtain inter-rater reliability evidence for the checklist. METHODS: This study pilots an internally designed 6-item checklist to assess change in directly observed behavior. We describe the process of developing the checklist and training the observers. We calculated a percent agreement and Cohen's kappa to assess inter-rater reliability. RESULTS: Raters had a high percent agreement ranging from 0.8 to 0.9 for each step of OMP. Cohen's kappa ranged from 0.49 to 0.77 for the five OMP steps. The highest kappa obtained was for getting a commitment (κ = 0.77) step, whereas the lowest agreement was for correcting mistakes (κ = 0.49). CONCLUSION: We showed a percent agreement ≥0.8 and moderate agreement based on Cohen's kappa with most steps of OMP on our checklist. A reliable OMP checklist is an important step in further improving the assessment and feedback of resident teaching skills on general medicine wards.

Performance of peripheral catheters inserted with ultrasound guidance versus landmark technique after a simulation-based mastery learning intervention.

PROBLEM: Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is an effective method to gain vascular access in patients with difficult intravenous access (DIVA). While USGPIV success rates are reported to be high, some studies have reported a concerning incidence of USGPIV premature failures. AIMS: The purpose of this study was to compare differences in USGPIV and landmark peripheral intravenous catheter (PIV) utilization and failure following a hospital-wide USGPIV training program for nurses. METHODS: The authors performed a retrospective, electronic medical record review of all USGPIVs and PIVs inserted at a tertiary, urban, academic medical center from September 1, 2018, through September 30, 2019. The primary outcome was differences between USGPIV and PIV time to failure. RESULTS: A total of 43,470 short peripheral intravenous catheters (PIVCs) were inserted in 23,713 patients. Of these, 7972 (16.8%) were USGPIV. At 30 days of follow-up, for PIVCs with an indication for removal documented, USGPIVs had higher Kaplan-Meier survival probabilities than PIVs (p < 0.001). CONCLUSIONS: The use of simulation-based mastery associated with USGPIVs, demonstrated lower failure rates than standard PIVs after 2 days and USGPIVs exhibited improved survival rates in patients with DIVA. These findings suggest that rigorous simulation-based insertion training demonstrates improved USGPIV survival when compared to traditional PIVCs. SBML is an extremely useful tool to ensure appropriately trained clinicians acquire the necessary knowledge and skillset to improve USGPIV outcomes.

Trends in Suicidal Ideation-Related Emergency Department Visits for Youth in Illinois: 2016-2021.

BACKGROUND AND OBJECTIVES: Increasing suicide rates and emergency department (ED) mental health visits reflect deteriorating mental health among American youth. This population-based study analyzes trends in ED visits for suicidal ideation (SI) before and during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We analyzed Illinois hospital administrative data for ED visits coded for SI from January 2016 to June 2021 for youth aged 5 to 19 years. We characterized trends in patient sociodemographic and clinical characteristics, comparing three equal 22 month periods and analyzed patient and hospital characteristics associated with the likelihood of hospitalization. RESULTS: There were 81 051 ED visits coded for SI at 205 Illinois hospitals; 24.6% resulted in hospitalization. SI visits accounted for $785 million in charges and 145 160 hospital days over 66 months. ED SI visits increased 59% from 2016 through 2017 to 2019 through 2021, with a corresponding increase from 34.6% to 44.3% of SI principal diagnosis visits (both P < .001). Hospitalizations increased 57% between prepandemic fall 2019 and fall 2020 (P = .003). After controlling for demographic and clinical characteristics, youth were 84% less likely to be hospitalized if SI was their principal diagnosis and were more likely hospitalized if coded for severe mental illness, substance use, anxiety, or depression, or had ED visits to children's or behavioral health hospitals. CONCLUSIONS: This study documents child ED SI visits in Illinois spiked in 2019, with an additional surge in hospitalizations during the pandemic. Rapidly rising hospital use may reflect worsening mental illness and continued difficulty in accessing low cost, high-quality outpatient mental health services.

Development of a novel clinical decision support tool for diabetes prevention and feasibility of its implementation in primary care.

Prediabetes impacts 88 million U.S. adults, yet uptake of evidence-based treatment with intensive lifestyle interventions and metformin remains exceedingly low. After incorporating feedback from 15 primary care providers collected during semi-structured interviews, we developed a novel Prediabetes Clinical Decision Support (PreDM CDS) from August 2019 to February 2020. This tool included order options enabling prediabetes management in a single location within the electronic health record. We conducted a retrospective observational study examining the feasibility of implementing this tool at Erie Family Health Centers, a large community health center, examining its use and related outcomes among patients for whom it was used vs not. Overall, 7,424 eligible patients were seen during the implementation period (February 2020 to August 2021), and the PreDM CDS was used for 108 (1.5 %). Using the PreDM CDS was associated with higher rates of hemoglobin A1c orders (70.4 % vs 22.2 %; p < 0.001), lifestyle counseling (38.0 % vs 7.8 %; p < 0.001), and metformin prescription orders (5.6 % vs 2.6 %; p = 0.06). Exploratory analyses revealed small, nonsignificant weight loss among patients for whom the PreDM CDS was used. This study demonstrates the feasibility of developing and implementing the PreDM CDS in primary care. Its low use was likely related to not imposing an interruptive 'pop-up' alert, as well as major changes in workflows and clinical priorities during the Covid-19 pandemic. Use of the tool was associated with improved process outcomes. Future efforts with the PreDM CDS should follow standard CDS implementation processes that were not possible due to the Covid-19 pandemic.

Simulation-Based Mastery Learning Improves Ultrasound-Guided Peripheral Intravenous Catheter Insertion Skills of Practicing Nurses.

INTRODUCTION: Difficult intravenous (IV) access (DIVA) is frequently encountered in the hospital setting. Ultrasound-guided peripheral IV catheter (USGPIV) insertion has emerged as an effective procedure to establish access in patients with DIVA. Despite the increased use of USGPIV, little is known about the optimal training paradigms for bedside nurses. Therefore, we developed and evaluated a novel, sustainable, USGPIV simulation-based mastery learning (SBML) curriculum for nurses. METHODS: This is a prospective cohort study of an USGPIV SBML training program for bedside nurses over a 12-month period. We evaluated skills and self-confidence before and after training and measured the proportion of the nurses achieving independent, proctor, and instructor status. Procedure logs and surveys were used to explore the nurse experience and utilization of USGPIV on real patients with DIVA 3 months after the intervention. RESULTS: Two hundred thirty-eight nurses enrolled in the study. The USGPIV skill checklist scores increased from median of 6.0 [interquartile range = 4.0-9.0 (pretest) to 29.0, interquartile range = 28-30 (posttest), P < 0.001]. The USGPIV confidence improved from before (mean = 2.32, SD = 1.17) to after (mean = 3.85, SD = 0.73, P < 0.001) training (5-point Likert scale). Sixty-two percent of the nurses enrolled achieved independent status, 47.5% became proctors, and 11.3% course trainers. At 3-month posttraining, the nurses had attempted a mean of 35.6 USGPIV insertions with an 89.5% success rate. CONCLUSIONS: This novel USGPIV SBML curriculum improves nurses' insertion skills, self-confidence, and progresses patient care through USGPIV insertions on hospitalized patients with DIVA.

Initial Assessment of the Effect of ProvenCare on Lung Cancer Surgical Quality.

BACKGROUND: ProvenCare is a joint initiative of the American College of Surgeons Commission on Cancer, Geisinger, and The Society of Thoracic Surgeons (STS) to standardize evidence-based practices in the delivery of surgical lung cancer care. This study compares outcomes of ProvenCare patients with the STS Database. METHODS: Best practice elements were agreed on through expert consensus meetings. ProvenCare elements were used to direct care. Compliance was monitored while clinical outcomes were collected within the STS General Thoracic Surgery Database (GTSD). ProvenCare patient outcomes were compared with outcomes in all other STS GTSD patients. Univariable and multivariable logistic regression models compared morbidity and mortality. RESULTS: A total of 2026 patients at 23 ProvenCare hospitals were compared with 71 565 control patients at 311 hospitals from 2010 to 2016. ProvenCare patients were more likely to receive guideline-recommended staging evaluations and more likely to have mediastinal staging performed during resection (63.4% vs 49.4%; P < .001). There was no difference in 30-day mortality (1.4% vs 1.3% lobectomy [P = .84]; 3.4% vs 2.0% all other resections [P = .054]) or STS indicator complications (10.8% vs 9.9% lobectomy [P = .21]; 9.2% vs 9.4% all other resections [P = .92]). When controlling for patient-level clinical and demographic risk factors, the likelihood of perioperative morbidity and mortality was not significantly different (odds ratio [OR], 1.07 [95% CI, 0.77-1.47] lobectomy; OR, 0.97 [95% CI, 0.62-1.50] all other resections). CONCLUSIONS: Variability in preoperative evaluation of patients with lung cancer represents an opportunity to improve quality of care. ProvenCare increased use of guideline-recommended preoperative processes, which may improve cancer outcomes and survival, without resulting in differences in short-term surgical outcomes.

Ultrasound-Guided Peripheral Intravenous Catheter Insertion Training Reduces Use of Midline Catheters in Hospitalized Patients With Difficult Intravenous Access.

OBJECTIVES: Difficult intravenous (IV) access (DIVA) is a prevalent condition in the hospital setting and increases utilization of midline catheters (MCs) and peripherally inserted central catheters (PICCs). Ultrasound-guided peripheral intravenous (USGPIV) insertion is effective at establishing intravenous access in DIVA but remains understudied in the inpatient setting. We evaluated the effect of an USGPIV simulation-based mastery learning (SBML) curriculum for nurses on MC and PICC utilization for hospitalized patients. METHODS: We performed a quasi-experimental observational study. We trained nurses across all inpatient units at a large tertiary care hospital. We queried the electronic medical record to compare PICC and MC utilization for patients with DIVA during 3 periods: before USGPIV SBML training (control), during pilot testing of the intervention, and during the SBML intervention. To account for variations in insertion practices over time, we performed an interrupted time series (ITS) analysis between 2 periods, the combined control and pilot periods and the intervention period. RESULTS: One hundred forty-eight nurses completed USGPIV SBML training. Midline catheters inserted monthly per 1000 patient-days for DIVA decreased significantly from 1.86 ± 0.51 (control) to 2.31 ± 0.28 (pilot) to 1.33 ± 0.51 (intervention; P = 0.001). The ITS analysis indicated a significant intervention effect (P < 0.001). Peripherally inserted central catheters inserted monthly per 1000 patient-days for DIVA also significantly decreased over the study periods; however, the ITS failed to show an intervention effect as PICC insertions were already decreasing during the control period. CONCLUSIONS: A hospital-wide USGPIV SBML curriculum for inpatient nurses was associated with a significant reduction in MCs inserted for DIVA.

Delivery Complications and Postpartum Hospital Use in California.

INTRODUCTION: Research on maternal birth outcomes rarely includes postpartum complications with longitudinally linked patient data. We analyze characteristics associated with delivery complications and postpartum hospital use. METHODS: This population-based cohort study is based on administrative data from California. International Classification of Diseases, 10th Revision, codes were used to categorize the incidence of severe maternal morbidity and other route-specific delivery complications as well as preexisting and pregnancy-related conditions and principal diagnoses for postpartum hospital visits. Postpartum hospital use is a composite outcome defined as emergency department visit or hospital readmission within 90 days of birth admission discharge. Multivariable modified Poisson regression analyses were used to estimate the association of patient-level and hospital-level characteristics with the likelihood of postpartum hospital use. RESULTS: In 2017, 457,498 birth admissions occurred in California-licensed hospitals, of which 348,828 index births with linked data were analyzed. Among linked births, 34,825 (10.0%) had an inpatient admission (4,206 [1.2%]) or an emergency department visit (30,371 [9.2%]) within 90 days of birth admission discharge. Birth complications included a 1.7% severe maternal morbidity rate, 7.9% rate of vaginal birth complications, 10.0% rate of cesarean birth complications, and 2.9% frequency of long lengths of stay, all of which were significantly associated with postpartum hospital use. Other significant risk factors for postpartum hospital use were preexisting and pregnancy-related conditions, undergoing cesarean birth, being younger than 18 years old, being non-Hispanic Black, living in a high poverty ZIP code, and having Medicaid. CONCLUSION: One in 10 birthing persons had a hospital visit within 90 days postpartum. Improving postpartum care is an urgent public health priority.

Hospital Volume Predicts Guideline-Concordant Care in Stage III Esophageal Cancer.

BACKGROUND: Esophageal cancer is a deadly disease requiring multidisciplinary coordination of care and surgical proficiency for adequate treatment. We hypothesize that quality of care is varied nationally. METHODS: From published guidelines, we developed quality measures for management of stage III esophageal cancer: utilization of neoadjuvant therapy, surgical sampling of at least 15 lymph nodes, resection within 60 days of chemotherapy or radiation, and completeness of resection. Measure adherence was examined across 1345 hospitals participating in the National Cancer Database from 2004 to 2016. We examined the association of volume, program accreditation, safety net status, geographic region, and patient travel distance on adequate adherence (≥85% of patients are adherent) using logistic regression modeling. RESULTS: The rate of adequate adherence was worst in nodal staging (12.6%) and highest for utilization of neoadjuvant therapy (84.8%). Academic programs had the highest rate of adequate adherence for induction therapy (77.2%; P < .001), timing of surgery (56.6%; P < .001), and completeness of resection (78.5%; P < .001) but the lowest for nodal staging (4.4%; P = .018). For every additional esophagectomy performed per year, the odds of adequate adherence increased for induction therapy (odds ratio [OR]. 1.16; 95% confidence interval [CI], 1.06-1.27) and completeness of resection (OR, 1.15; 95% CI, 1.06-1.25) but decreased for nodal staging (OR, 0.76; 95% CI, 0.65-0.89). CONCLUSIONS: Care provided at higher volume and academic facilities was more likely to be guideline concordant in some areas but not in others. Understanding the processes that support the delivery of guideline concordant care may provide valuable opportunities for improvement.

Prevalence and Impact of Adverse Childhood Experiences on Chicago Public School Students in the Youth Risk Behavior Survey.

BACKGROUND: Adverse Childhood Experiences (ACEs) can impair health and other outcomes. To obtain district-level data about the prevalence and impact of ACEs in Chicago Public Schools (CPS), we advocated for CPS to add a short ACE screener to the 2017 Youth Risk Behavior Survey (YRBS) and analyzed the results. METHODS: Responses to the screener were scored zero, one, or two ACEs. Student scores for violence and victimization, substance use, sexual health risk, mental health, housing insecurity, physical health, grades, and multiple risk/high vulnerability (those students in the top 20% of affirmative responses) were correlated with ACE scores for categories and individual items. RESULTS: Among 1883 student respondents (response rate 73%), there were 17.8% affirmative responses for experiencing physical abuse and 19.8% for witnessing domestic violence; 20% reported at least one ACE and 8% both. A significant dose-response was found for behaviors, experiences, and sleep by ACE scores. CONCLUSIONS: ACEs were common among CPS high school students and associated with many negative behavior and health-related outcomes. Increased awareness of ACEs and their impact among all school personnel can inform and strengthen the development of safer, more supportive, and trauma-informed schools that help all students and families thrive.

Utilizing left atrial strain to identify patients at risk for atrial fibrillation on ibrutinib.

BACKGROUND: Ibrutinib is associated with atrial fibrillation (AF), though echocardiographic predictors of AF have not been studied in this population. We sought to determine whether left atrial (LA) strain on transthoracic echocardiography could identify patients at risk for developing ibrutinib-related atrial fibrillation (IRAF). METHODS: We performed a retrospective review of 66 patients who had an echocardiogram prior to ibrutinib treatment. LA strain was measured with TOMTEC Imaging Systems, obtaining peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) on 4-chamber and 2-chamber views. Statistical analysis was performed with chi-square analysis, t test, or binomial regression analysis, with a P-value < .05 considered statistically significant. RESULTS: Twenty-two patients developed IRAF (33%). Age at initiation of ibrutinib was significantly associated with IRAF (65.1 years vs 74.1 years, P = .002). Mean ibrutinib dose was lower among patients who developed IRAF (388.2 ± 121.7 vs 448.6 ± 88.4, P = .025). E/e' was significantly higher among patients who developed IRAF (11.5 vs 9.3, P = .04). PALS was significantly lower in patients who developed AF (30.3% vs 36.3%, P = .01). On multivariate regression analysis, age, PALS, and PACS were significantly associated with IRAF. On multivariate regression analysis, only PACS remained significantly associated with IRAF while accounting for age. CONCLUSIONS: Age, ibrutinib dose, E/e', and PALS on pre-treatment echocardiogram were significantly associated with development of IRAF. On multivariate regression analyses, age, PALS, and PACS remained significantly associated with IRAF. Impaired LA mechanics add to the assessment of patients at risk for IRAF.

Relationship Between Confidence, Gender, and Career Choice in Internal Medicine.

BACKGROUND: Understanding factors in internal medicine (IM) resident career choice may reveal important needed interventions for recruitment and diversity in IM primary care and its subspecialties. Self-reported learner confidence is higher in men than in women in certain areas of practicing medicine, but has never been explored as a factor in career choice. OBJECTIVE: The purpose of this study is to elucidate associations between confidence, gender, and career choice. DESIGN: IM residents completed a 31-item survey rating confidence in procedural, clinical, and communication skills on a 9-point Likert scale. Residents also reported anticipated career choice and rated influence of factors. Associations between gender and confidence scale scores, gender and career choice, and confidence and career choice were analyzed using t tests, ANOVA, and multiple linear regression controlled for postgraduate year (PGY), institution, and specialty choice. PARTICIPANTS: 292 IM residents at Northwestern and University of Texas (UT) Southwestern MAIN MEASURES: Resident gender, self-reported confidence, career choice KEY RESULTS: Response rate was 79.6% (n = 292), of them 50.3% women. Overall self-reported confidence increased with training (PGY-1 4.9 (1.1); PGY-2 6.2 (1.0); PGY-3 7.4 (1.0); p < 0.001). Men had higher confidence than women (men 6.6 (1.5); women 6.3 (1.4), p = 0.06), with the greatest difference in procedures. High confidence in men was associated with choice of procedural careers, whereas there was no association between confidence and career in women. CONCLUSIONS: This is the first study demonstrating a gender difference in self-reported confidence and career choice. There is a positive correlation in men: higher self-reported confidence with procedural specialties, lower with general internal medicine. Women's self-reported confidence had no association. Further investigation is needed to elucidate causative factors for differences in self-reported confidence by gender, and whether alterations in level of self-reported confidence produce a downstream effect on career choice.

Difficult intravenous access in the emergency department: Performance and impact of ultrasound-guided IV insertion performed by nurses.

BACKGROUND: Difficult intravenous access (DIVA) is a common problem in Emergency Departments (EDs), yet the prevalence and clinical impact of this condition is poorly understood. Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is a successful modality for obtaining intravenous (IV) access in patients with DIVA. OBJECTIVES: We aimed to describe the prevalence of DIVA, explore how DIVA affects delivery of care, and determine if nurse insertion of USGPIV improves care delays among patients with DIVA. METHODS: We retrospectively queried the electronic medical record for all ED patients who had a peripheral IV (PIV) inserted at a tertiary academic medical center from 2015 to 2017. We categorized patients as having DIVA if they required ≥3 PIV attempts or an USGPIV. We compared metrics for care delivery including time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED length of stay (LOS) between patients with and without DIVA. We also compared these metrics in patients with DIVA with a physician-inserted USGPIV versus those with a nurse-inserted USGPIV. RESULTS: A total of 147,260 patients were evaluated during the study period. Of these, 13,192 (8.9%) met criteria for DIVA. Patients with DIVA encountered statistically significant delays in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients without DIVA (all p < 0.001). Patients with nurse-inserted USGPIVs also had statistically significant improvements in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients with physician-inserted USGPIVs (all p < 0.001). CONCLUSION: DIVA affects many ED patients and leads to delays in PIV access-related care. Nurse insertion of USGPIVs improves care in patients with DIVA.

Mortality, critical illness, and mechanical ventilation among hospitalized patients with COVID-19 on therapeutic anticoagulants.

Background: COVID-19 is associated with hypercoagulability and increased incidence of thrombosis. We compared the clinical outcomes of adults hospitalized with COVID-19 who were on therapeutic anticoagulants to those on prophylactic anticoagulation. Materials and methods: We performed an observational study of adult inpatients' with COVID-19 from March 9 to June 26, 2020. We compared patients who were continued on their outpatient prescribed therapeutic anticoagulation and those who were newly started on therapeutic anticoagulation for COVID-19 (without other indication) to those who were on prophylactic doses. The primary outcome was overall death while secondary outcomes were critical illness (World Health Organization Ordinal Scale for Clinical Improvement score ≥5), mechanical ventilation, and death among patients who first had critical illness. We adjusted for age, sex, race, body mass index (BMI), Charlson score, glucose on admission, and use of antiplatelet agents. Results: Of 1716 inpatients with COVID-19, 171 patients were continued on their therapeutic anticoagulation and 78 were started on new therapeutic anticoagulation for COVID-19. In patients continued on home therapeutic anticoagulation, there were no differences in overall death, critical illness, mechanical ventilation, or death among patients with critical illness compared to patients on prophylactic anticoagulation. In patients receiving new therapeutic anticoagulation for COVID-19, there was increased death (OR 5.93; 95% CI 3.71-9.47), critical illness (OR 14.51; 95% CI 7.43-28.31), need mechanical ventilation (OR 11.22; 95% CI 6.67-18.86), and death after first having critical illness (OR 5.51; 95% CI 2.80-10.87). Conclusions: Therapeutic anticoagulation for inpatients with COVID-19 was not associated with improved outcomes.

Adherence to quality measures improves survival in esophageal cancer in a retrospective cohort study of the national cancer database from 2004 to 2016.

BACKGROUND: We assessed adherence to four novel quality measures in patients with stage III esophageal cancer, a leading cause of death among GI malignancies. METHODS: We performed a retrospective cohort study of 22,871 stage III esophageal cancer patients identified from the National Cancer Database (NCDB) between 2004 and 2016. Four quality measures were defined from published guidelines: administration of induction therapy, >15 lymph nodes sampled, surgery within 60 days of neoadjuvant treatment, and R0 resection. The association of patient demographic and treatment variables with measure adherence was assessed using multiple logistic regression. Risk of all-cause mortality was assessed comparing adherent and non-adherent cases using Cox modeling. Kaplan-Meier survival estimates of groups that adhered to zero to four out of four quality measures were performed. RESULTS: Adherence was high for neoadjuvant treatment (93.7%), timing of surgery (85.7%) and completeness of resection (92.0%), but low for nodal evaluation (45.9%). Medicaid insurance status was associated with decreased odds of adherence for neoadjuvant treatment [odds ratio (OR) 0.73, 95% confidence interval (CI): 0.54-0.99], nodal evaluation (OR 0.81, 95% CI: 0.68-0.96), and completeness of resection (OR 0.71, 95% CI: 0.54-0.92). From 2010 to 2016, when compared to cases from 2004 to 2005, there was a progressive increase in the odds of adequate induction therapy, nodal staging, and completeness of resection, but a progressive decrease in odds of well-timed surgery. Adherence was associated with decreased all-cause mortality for induction therapy, nodal staging, and R0 resection, but not for timing of surgery. Survival improved as the number of quality measures an individual patient adhered to increased. CONCLUSIONS: Adherence to quality measures is associated with improved survival in patients with stage III esophageal cancer. Understanding variability in measure adherence may identify targets for quality improvement initiatives.

Improving Use of a Hospital Transitional Care Clinic.

BACKGROUND: In response to Medicare readmission penalties, some hospitals have introduced transitional care clinics (TCCs) to meet the care needs of patients recently discharged from the emergency room or inpatient setting. This study was undertaken to increase the proportion of low-income, medically complex patients using a TCC at a large academic medical center, Northwestern Medical Group Transitional Care Clinic (NMG-TC). METHODS: This quality improvement study combined interviews and quantitative data analysis to determine how to increase use of NMG-TC. Physicians and patients were interviewed and surveyed to identify opportunities to expand clinic use. Logistic regression analysis of electronic health record (EHR) data was used to identify sociodemographic and clinical conditions influencing the TCC appointment show rate. RESULTS: Provider surveys and interviews suggested that referrals would likely increase via automation of referral guidelines and enhanced transitional care education. Patient interviews indicated that better communication of NMG-TC purpose, emphasizing nonmedical offerings, and warm handoffs could increase engagement. EHR analyses revealed that patients least likely to attend appointments were male, uninsured, non-Hispanic black, or homeless; had documented substance use; or lived > 50 miles from the clinic. Conversely, patients with heart failure, anxiety, or malignancy were more likely to attend appointments. CONCLUSION: TCC show rates could be improved with better communication of NMG-TC benefits to both patients and referring providers, as well as warm appointment handoffs, particularly for patients least likely to attend scheduled visits.

Declining health risk exposure among Chicago public high school students: Trends from the Youth Risk Behavior Survey 1997-2017.

There have been improvements nationally in teenagers' self-reported health risk since the 1990s. This study provides an overview of trends in substance use, sexual health, violence and victimization, and suicide risk among Chicago Public High School (CPS) students over a 20-year period. We compared responses to 29 identically worded items from the 1997, 2007, and 2017 Chicago Youth Risk Behavior Survey (YRBS) in the four domains. We show changes in responses across individual items, mean changes across the four domains, and change in the proportion of students with highest risk exposure (≥10 affirmative responses). Analyses control for CPS students' grade, sex, and race/ethnicity. Reductions in substance use, sexual health risk, and violence and victimization (30, 40% and 40% in the mean number of affirmative responses, respectively) were observed. Suicide risk showed an initial improvement from 1997 to 2007, only to worsen by 2017 and show little difference from 1997. There was an approximate 70% decrease in the likelihood of being in the high multiple risk category (≥10 affirmative responses) in 2017 compared to 1997 (OR 0.33; CI 0.22-0.49). In alignment with national trends, our study documents significant improvement in Chicago public high school students' long-term health risk exposure over the 20-year study period, with the notable exception of suicide risk. This study emphasizes the need to invest in strategies both inside and outside of the classroom to mitigate the effect of adversity and promote protective factors, which are at the root of academic success and overall wellbeing.