Access to outpatient services in rural communities changes after hospital closure.

OBJECTIVE: Between January 2005 and July 2020, 171 rural hospitals closed across the United States. Little is known about the extent that other providers step in to fill the potential reduction in access from a rural hospital closure. The objective of this analysis is to evaluate the trends of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) in rural areas prior to and following hospital closure. DATA SOURCES/STUDY SETTING: We used publicly available data from Centers for Medicare and Medicaid Provider of Services files, Cecil G. Sheps Center rural hospital closures list, and Small Area Income and Poverty Estimates. STUDY DESIGN: We described the trends over time in the number of hospitals, hospital closures, FQHC sites, and RHCs in rural and urban ZIP codes, 2006-2018. We used two-way fixed effects and pooled generalized linear models with a logit link to estimate the probabilities of having any RHC and any FQHC within 10 straight-line miles. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Compared to hospitals that never closed, the predicted probability of having any FQHC within 10 miles increased post closure by 5.95 and 11.57 percentage points at 1 year and 5 years, respectively (p < 0.05). The predicted probability of having any RHC within 10 miles was not significantly different following rural hospital closure. A percentage point increase in poverty rate was associated with a 1.98 and a 1.29 percentage point increase in probabilities of having an FQHC or RHC, respectively (p < 0.001). CONCLUSIONS: In areas previously served by a rural hospital, there is a higher probability of new FQHC service-delivery sites post closure. This suggests that some of the potential reductions in access to essential preventive and diagnostic services may be filled by FQHCs. However, many rural communities may have a persistent unmet need for preventive and therapeutic care.

Association of Medicaid Expansion With Quality in Safety-Net Hospitals.

Importance: Safety-net hospitals (SNHs) operate under limited financial resources and have had challenges providing high-quality care. Medicaid expansion under the Affordable Care Act led to improvements in hospital finances, but whether this was associated with better hospital quality, particularly among SNHs given their baseline financial constraints, remains unknown. Objective: To compare changes in quality from 2012 to 2018 between SNHs in states that expanded Medicaid vs those in states that did not. Design, Setting, and Participants: Using a difference-in-differences analysis in a cohort study, performance on quality measures was compared between SNHs, defined as those in the highest quartile of uncompensated care in the pre-Medicaid expansion period, in expansion vs nonexpansion states, before and after the implementation of Medicaid expansion. A total of 811 SNHs were included in the analysis, with 316 in nonexpansion states and 495 in expansion states. The study was conducted from January to November 2020. Exposures: Time-varying indicators for Medicaid expansion status. Main Outcomes and Measures: The primary outcome was hospital quality measured by patient-reported experience (Hospital Consumer Assessment of Healthcare Providers and Systems Survey), health care-associated infections (central line-associated bloodstream infections, catheter-associated urinary tract infections, and surgical site infections following colon surgery) and patient outcomes (30-day mortality and readmission rates for acute myocardial infarction, heart failure, and pneumonia). Secondary outcomes included hospital financial measures (uncompensated care and operating margins), adoption of electronic health records, provision of safety-net services (enabling, linguistic/translation, and transportation services), or safety-net service lines (trauma, burn, obstetrics, neonatal intensive, and psychiatric care). Results: In this difference-in-differences analysis of a cohort of 811 SNHs, no differential changes in patient-reported experience, health care-associated infections, readmissions, or mortality were noted, regardless of Medicaid expansion status after the Affordable Care Act. There were modest differential increases between 2012 and 2016 in the adoption of electronic health records (mean [SD]: nonexpansion states, 99.4 [7.4] vs 99.9 [3.8]; expansion states, 94.6 [22.6] vs 100.0 [2.2]; 1.7 percentage points; P = .02) and between 2012 and 2018 in the number of inpatient psychiatric beds (mean [SD]: nonexpansion states, 24.7 [36.0] vs 23.6 [39.0]; expansion states: 29.3 [42.8] vs 31.4 [44.3]; 1.4 beds; P = .02) among SNHs in expansion states, although they were not statistically significant at a threshold adjusted for multiple comparisons. In subgroup analyses comparing SNHs with higher vs lower baseline operating margins, an isolated differential improvement was noted in heart failure readmissions among SNHs with lower baseline operating margins in expansion states (mean [SD], 22.8 [2.1]; -0.53 percentage points; P = .001). Conclusions and Relevance: This difference-in-differences cohort study found that despite reductions in uncompensated care and improvements in operating margins, there appears to be little evidence of quality improvement among SNHs in states that expanded Medicaid compared with those in states that did not.

MELD-Na Is More Strongly Associated with Risk of Infection and Outcomes Than Other Characteristics of Patients with Cirrhosis.

BACKGROUND AND AIMS: The nature and outcomes of infection among patients with cirrhosis in safety-net hospitals are not well described. We aimed to characterize the rate of and risk factors for infection, both present on admission and nosocomial, in this unique population. We hypothesized that infections would be associated with adverse outcomes such as short-term mortality. METHODS: We used descriptive statistics to characterize infections within a retrospective cohort characterized previously. We used multivariable logistic regression models to assess potential risk factors for infection and associations with key outcomes such as short-term mortality and length of stay. RESULTS: The study cohort of 1112 patients included 33% women with a mean age of 56 ± 10 years. Infections were common (20%), with respiratory and urinary tract infections the most frequent. We did not observe a difference in the incidence of infection on admission based on patient demographic factors such as race/ethnicity or estimated household income. Infections on admission were associated with greater short-term mortality (12% vs 4% in-hospital and 14% vs 7% 30-day), longer length of stay (6 vs 3 days), intensive care unit admission (28% vs 18%), and acute-on-chronic liver failure (10% vs 2%) (p < 0.01 for all). Nosocomial infections were relatively uncommon (4%), but more frequent among patients admitted to the intensive care unit. Antibiotic resistance was common (38%), but not associated with negative outcomes. CONCLUSION: We did not identify demographic risk factors for infection, but did confirm its morbid effect among patients with cirrhosis in safety-net hospitals.

Gender-Specific Risk Factors for Reflux Esophagitis in a Predominantly Hispanic Population of a Large Safety-Net Hospital.

BACKGROUND: Defining factors associated with severe reflux esophagitis allows for identification of subgroups most at risk for complications of strictures and esophageal malignancy. We hypothesized there might be unique clinical features in patients with reflux esophagitis in a predominantly Hispanic population of a large, safety-net hospital. AIM: Define clinical and endoscopic features of reflux esophagitis in a predominantly Hispanic population of a large, safety-net hospital. METHODS: This is retrospective comparative study of outpatients and hospitalized patients identified with mild (Los Angeles Grade A/B) and severe (Los Angeles Grade C/D) esophagitis through an endoscopy database review. The electronic medical record was reviewed for demographic and clinical data. RESULTS: Reflux esophagitis was identified in 382/5925 individuals: 56.5% males and 79.8% Hispanic. Multivariable logistic regression model adjusted for age, gender, race, body mass index (BMI), tobacco and alcohol use, and hospitalization status with severity as the outcome showed an interaction between gender and BMI (p ≤ 0.01). Stratification by gender showed that obese females had decreased odds of severe esophagitis compared to normal BMI females (OR = 0.18, 95% CI = 0.07-0.47; p < 0.01). In males, the odds of esophagitis were higher in inpatient status (OR = 2.84, 95% CI = 1.52 - 5.28; p < 0.01) and as age increased (OR = 1.37, 95% CI = 1.03 - 1.83; p = 0.03). CONCLUSIONS: We identify gender-specific associations with severe esophagitis in a predominantly Hispanic cohort. In females, obese BMI appears to be protective against severe esophagitis compared to normal BMI, while in men inpatient status and increasing age were associated with increased odds of severe esophagitis.

Disparities in inpatient costs and outcomes after elective anterior cervical discectomy and fusion at safety-net hospitals.

INTRODUCTION: Characterizing disparities that exist at safety-net hospitals is crucial for crafting national healthcare reform policies. Healthcare disparities in performing elective neurosurgical procedures like anterior cervical discectomy and fusion (ACDF) at safety-net hospitals have not yet been examined. OBJECTIVE: We use the National Inpatient Sample (NIS), a national all-payer healthcare database of inpatient admissions, to determine whether safety-net hospitals can provide equitable care after elective ACDF. METHODS: The NIS from 2002 to 2011 was queried for patients who received ACDF in the context of degenerative spine disease. Hospital safety-net burden was designated as low (LBH), medium (MBH), or high (HBH) based on the proportion of inpatient admissions that were billed as Medicaid, self-pay, or charity care. Significance was set at p < 0.001. RESULTS: A total of 219,433 admissions were included in this analysis. HBHs were more likely than LBHs to treat patients who were Black, Hispanic, on Medicaid, or had myelopathy (p < 0.001). After adjusting for patient, hospital, and clinical factors, treatment at an HBH was associated with greater in-patient inflation-adjusted log cost (p < 0.001), but not with greater length of stay (LOS) (p = 0.04) or odds of an inpatient adverse event like death, incidental durotomy, surgical site infections, deep vein thromboses and others (OR 95 % CI = 0.86-1.42, p = 0.43) compared to LBHs. DISCUSSION: Safety net hospitals had greater inpatient costs, but no greater LOS or odds of inpatient adverse events after elective ACDF. These results demonstrate a need for policies that reduce the cost of performing ACDFs at SNHs.

Medicaid Expansion Slowed Rates Of Health Decline For Low-Income Adults In Southern States.

Of the fourteen states that have not expanded eligibility for Medicaid, nine are in the southern census region, and two others border that region. Ongoing debate over the merits of Medicaid expansion in these states has focused, in part, on whether the safety net provides sufficient access for uninsured low-income Americans. We analyzed longitudinal survey and vital status data from the twelve-state Southern Community Cohort Study (SCCS) for 15,356 nonelderly adult participants with low incomes, 86 percent of whom were enrolled at community health centers. In difference-in-differences analyses, we compared changes in self-reported health between participants in four expansion and eight nonexpansion states before (2008-13) and after (2015-17) Medicaid expansion. We found that a higher proportion of SCCS participants in expansion states reported increases in Medicaid coverage (a differential change of 7.6 percentage points), a lower proportion experienced a health status decline (-1.8 percentage points), and a higher proportion maintained their baseline health status (1.4 percentage points). The magnitude of estimated reductions in health declines would meaningfully affect a nonexpansion state's health ranking in our sample if that state elected to expand Medicaid. Our results suggest that for low-income adults in the South, Medicaid expansion yielded health benefits-even for those with established access to safety-net care.

Perspectives of English, Chinese, and Spanish-Speaking Safety-Net Patients on Clinician Computer Use: Qualitative Analysis.

BACKGROUND: Safety-net systems serve patients with limited health literacy and limited English proficiency (LEP) who face communication barriers. However, little is known about how diverse safety-net patients feel about increasing clinician electronic health record (EHR) use. OBJECTIVE: The aim of this study was to better understand how safety-net patients, including those with LEP, view clinician EHR use. METHODS: We conducted focus groups in English, Spanish, and Cantonese (N=37) to elicit patient perspectives on how clinicians use EHRs during clinic visits. Using a grounded theory approach, we coded transcripts to identify key themes. RESULTS: Across multiple language groups, participants accepted multitasking and silent clinician EHR use if focused on their care. However, participants desired more screen share and eye contact, especially when demonstrating physical concerns. All participants, including LEP participants, wanted clinicians to include them in EHR use. CONCLUSIONS: Linguistically diverse patients accept the value of EHR use during outpatient visits but desire more eye contact, verbal warnings before EHR use, and screen-sharing. Safety-net health systems should support clinicians in completing EHR-related tasks during the visit using patient-centered strategies for all patients.

Age differences in emergency department utilization and repeat visits among patients with opioid use disorder at an urban safety-net hospital: A focus on young adults.

BACKGROUND: Opioid use disorder (OUD) among young adults from ages 18 to 25 years is increasing in the United States. Emergency departments (EDs) are recognized as major sources of care for patients with OUD, but questions remain about ED utilization among this population. We examined the demographics and ED utilization patterns at an urban safety-net hospital with a focus on young adults to inform intervention development. METHODS: We extracted demographic and clinical data from electronic medical records of patients ages 18 to 64 years diagnosed with OUD between 2013 and 2017. Descriptive statistics were assessed, including race/ethnicity, sex, insurance, other substance use disorder and mental health diagnoses, and ED utilization patterns by age group. Univariable and multivariable logistic regressions were performed to analyze the associations between age and ED utilization patterns. RESULTS: Among 12,025 OUD patients in the sample, 30% had an ED visit with a primary diagnosis of OUD. Among those who had an ED visit, 48% had at least one additional ED visit within a year. The probability of ED visits (adjusted odds ratio [AOR]:5.04; 95% confidence interval [CI]:4.14-6.13) and repeat ED visits (AOR:3.28; CI:2.53-4.26) were significantly higher among young adults (18-25 years) compared to the oldest age group (56-64 years). CONCLUSIONS: Compared to older adults, young adults with OUD are more likely to use the ED and to have repeat ED visits. The identification of youth-tailored interventions in the ED within broader efforts to address the opioid epidemic should be an urgent priority.

Differential Safety Between Top-Ranked Cancer Hospitals and Their Affiliates for Complex Cancer Surgery.

Importance: Leading cancer hospitals have increasingly shared their brands with other hospitals through growing networks of affiliations. However, the brand of top-ranked cancer hospitals may evoke distinct reputations for safety and quality that do not extend to all hospitals within these networks. Objective: To assess perioperative mortality of Medicare beneficiaries after complex cancer surgery across hospitals participating in networks with top-ranked cancer hospitals. Design, Setting, and Participants: A cross-sectional study was performed of the Centers for Medicare & Medicaid Services 100% Medicare Provider and Analysis Review file from January 1, 2013, to December 31, 2016, for top-ranked cancer hospitals (as assessed by U.S. News and World Report) and affiliated hospitals that share their brand. Participants were 29 228 Medicare beneficiaries older than 65 years who underwent complex cancer surgery (lobectomy, esophagectomy, gastrectomy, colectomy, and pancreaticoduodenectomy [Whipple procedure]) between January 1, 2013, and October 1, 2016. Exposures: Undergoing complex cancer surgery at a top-ranked cancer hospital vs an affiliated hospital. Main Outcomes and Measures: Risk-adjusted 90-day mortality estimated using hierarchical logistic regression and comparison of the relative safety of hospitals within each cancer network estimated using standardized mortality ratios. Results: A total of 17 300 patients (59.2%; 8612 women and 8688 men; mean [SD] age, 74.7 [6.2] years) underwent complex cancer surgery at 59 top-ranked hospitals and 11 928 patients (40.8%; 6287 women and 5641 men; mean [SD] age, 76.2 [6.9] years) underwent complex cancer surgery at 343 affiliated hospitals. Overall, surgery performed at affiliated hospitals was associated with higher 90-day mortality (odds ratio, 1.40; 95% CI, 1.23-1.59; P < .001), with odds ratios that ranged from 1.32 (95% CI, 1.12-1.56; P = .001) for colectomy to 2.04 (95% CI, 1.41-2.95; P < .001) for gastrectomy. When the relative safety of each top-ranked cancer hospital was compared with its collective affiliates, the top-ranked hospital was safer than the affiliates in 41 of 49 studied networks (83.7%; 95% CI, 73.1%-93.3%). Conclusions and Relevance: The likelihood of surviving complex cancer surgery appears to be greater at top-ranked cancer hospitals compared with the affiliated hospitals that share their brand. Further investigation of performance across trusted cancer networks could enhance informed decision making for complex cancer care.

Trends in Emergency Department Use by Rural and Urban Populations in the United States.

Importance: Patterns in emergency department (ED) use by rural populations may be an important indicator of the health care needs of individuals in the rural United States and may critically affect rural hospital finances. Objective: To describe urban and rural differences in ED use over a 12-year period by demographic characteristics, payers, and characteristics of care, including trends in ambulatory care-sensitive conditions and ED safety-net status. Design, Setting, and Participants: This cross-sectional study of ED visit data from the nationally representative National Hospital Ambulatory Medical Care Survey examined ED visit rates from January 2005 to December 2016. Visits were divided by urban and rural classification and stratified by age, sex, race/ethnicity, and payer. Emergency departments were categorized as urban or rural in accordance with the US Office of Management and Budget classification. Codes from the International Classification of Diseases, Ninth Revision (ICD-9), were used to extract visits related to ambulatory care-sensitive conditions. Safety-net status was determined by the Centers for Disease Control and Prevention definition. Visit rates were calculated using annual US Census Bureau estimates. National Hospital Ambulatory Medical Care Survey estimates were generated using provided survey weights and served as the numerator, yielding an annual, population-adjusted rate. Data were analyzed from June 2017 to November 2018. Main Outcomes and Measures: Emergency department visit rates for 2005 and 2016 with 95% confidence intervals, accompanying rate differences (RDs) comparing the 2 years, and annual rate change (RC) with accompanying trend tests using weighted linear regression models. Results: During the period examined, rural ED visit estimates increased from 16.7 million to 28.4 million, and urban visits increased from 98.6 million to 117.2 million. Rural ED visits increased for non-Hispanic white patients (13.5 million to 22.5 million), Medicaid beneficiaries (4.4 million to 9.7 million), those aged 18 to 64 years (9.6 million to 16.7 million), and patients without insurance (2.7 million to 3.4 million). Rural ED visit rates increased by more than 50%, from 36.5 to 64.5 visits per 100 persons (RD, 28.9; RC, 2.2; 95% CI, 1.2 to 3.3), outpacing urban ED visit rates, which increased from 40.2 to 42.8 visits per 100 persons (RD, 2.6; RC, 0.2; 95% CI, -0.1 to 0.6). By 2016, nearly one-fifth of all ED visits occurred in the rural setting. From 2005 to 2016, rural ED utilization rates increased for non-Hispanic white patients (RD, 26.1; RC, 1.6; 95% CI, 0.4 to 2.8), Medicaid beneficiaries (RD, 56.4; RC, 4.1; 95% CI, 2.1 to 6.1), those aged 18 to 44 years (46.9 to 81.6 visits per 100 persons; RD, 34.7; RC, 2.3; 95% CI, 1.1 to 3.5) as well as those aged 45 to 64 years (27.5 to 53.9 visits per 100 persons; RD, 26.5; RC, 1.6; 95% CI, 0.7 to 2.5), and patients without insurance (44.0 to 66.6 visits per 100 persons per year; RD, 22.6; RC, 2.7; 95% CI, 0.2 to 5.2), with a larger proportion of rural EDs categorized as safety-net status. Conclusions and Relevance: Rural EDs are experiencing important changes in utilization rates, increasingly serving a larger proportion of traditionally disadvantaged groups and with greater pressure as safety-net hospitals.

Provider and Staff Morale, Job Satisfaction, and Burnout over a 4-Year Medical Home Intervention.

BACKGROUND: The patient-centered medical home (PCMH) is a widely adopted primary care model. However, it is unclear whether changes in provider and staff perceptions of clinic PCMH capability are associated with changes in provider and staff morale, job satisfaction, and burnout in safety net clinics. OBJECTIVE: To determine how provider and staff PCMH ratings changed under a multi-year PCMH transformation initiative and assess whether changes in provider and staff PCMH ratings were associated with changes in morale, job satisfaction, and burnout. DESIGN: Comparison of baseline (2010) and post-intervention (2013-2014) surveys. SETTING: Sixty clinics in five states. PARTICIPANTS: Five hundred thirty-six (78.2%) providers and staff at baseline and 589 (78.3%) post-intervention. INTERVENTION: Collaborative learning sessions and on-site coaching to implement PCMH over 4 years. MEASUREMENTS: Provider and staff PCMH ratings on 0 (worst) to 100 (best) scales; percent of providers and staff reporting good or better morale, job satisfaction, and freedom from burnout. RESULTS: Almost half of safety net clinics improved PCMH capabilities from the perspective of providers (28 out of 59, 47%) and staff (25 out of 59, 42%). Over the same period, clinics saw a decrease in the percentage of providers reporting high job satisfaction (- 12.3% points, p = .009) and freedom from burnout (- 10.4% points, p = .006). Worsened satisfaction was concentrated among clinics that had decreased PCMH rating, with those clinics seeing far fewer providers report high job satisfaction (- 38.1% points, p < 0.001). LIMITATIONS: Control clinics were not used. Individual-level longitudinal survey administration was not feasible. CONCLUSION: If clinics pursue PCMH transformation and providers do not perceive improvement, they may risk significantly worsened job satisfaction. Clinics should be aware of this potential risk of PCMH transformation and ensure that providers are aware of PCMH improvements.

How Have 30-Day Readmission Penalties Affected Racial Disparities in Readmissions?: an Analysis from 2007 to 2014 in Five US States.

BACKGROUND: Thirty-day readmission penalties implemented with the Hospital Readmission Reduction Program (HRRP) place a larger burden on safety-net hospitals which treat a disproportionate share of racial minorities, leading to concerns that already large racial disparities in readmissions could widen. OBJECTIVE: To examine whether there were changes in Black-White disparities in 30-day readmissions for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia following the passage and implementation of HRRP, and to compare disparities across safety-net and non-safety-net hospitals. DESIGN: Repeated cross-sectional analysis, stratified by safety-net status. SUBJECTS: 1,745,686 Medicare patients over 65 discharged alive from hospitals in 5 US states: NY, FL, NE, WA, and AR. MAIN MEASURES: Odds ratios comparing 30-day readmission rates following an index admission for AMI, CHF, or pneumonia for Black and White patients between 2007 and 2014. KEY RESULTS: Prior to the passage of HRRP in 2010, Black and White readmission rates and disparities in readmissions were decreasing. These reductions were largest at safety-net hospitals. In 2007, Blacks had 13% higher odds of readmission if treated in safety-net hospitals, compared with 5% higher odds in 2010 (P < 0.05). These trends continued following the passage of HRRP. CONCLUSIONS: Prior to HRRP, there were large reductions in Black-White disparities in readmissions at safety-net hospitals. Although HRRP tends to assess higher penalties for safety-net hospitals, improvements in readmissions have not reversed following the implementation of HRRP. In contrast, disparities continue to persist at non-safety-net hospitals which face much lower penalties.

Ethnic differences in the diagnosis of schizophrenia and mood disorders during admission to an academic safety-net psychiatric hospital.

U.S. Hispanics, now the single largest minority group in the country, face unique mental health disparities. The current study utilizes Andersen's Behavioral Model of Health Service Use to examine ethnic disparities in receiving a schizophrenia or mood disorder diagnosis at psychiatric hospital admission. Our retrospective cohort study examined electronic health record data at an academic safety-net psychiatric hospital for adult patients (n = 5571) admitted between 2010 and 2013. Logistic regression with block-wise entry of predisposing, enabling and need variables was used to examine ethnic disparities in receiving a schizophrenia diagnosis at admission. The block of need factors was the strongest predictor of receiving a schizophrenia diagnosis compared to predisposing and enabling factors. Compared to non-Hispanic whites, Hispanics and African Americans had a greater likelihood of receiving a schizophrenia diagnosis at admission. Additionally, patients diagnosed with schizophrenia had elevated positive and negative symptoms and were more likely to be male, single/unmarried, homeless, high inpatient service utilizers, involuntarily hospitalized, and to exhibit functional impairment at psychiatric hospital admission. To address elevated positive and negative symptoms of schizophrenia, functional impairment, social withdrawal, and high inpatient service utilization, promising psychosocial interventions should be adapted for racial and ethnic minority populations and utilized as an adjuvant to antipsychotic medication.

Implementation of evidence-based practices for complex mood disorders in primary care safety net clinics.

INTRODUCTION: Use quality improvement methods to implement evidence-based practices for bipolar depression and treatment-resistant depression in 6 Federally Qualified Health Centers. METHOD: Following qualitative needs assessments, implementation teams comprised of front-line providers, patients, and content experts identified, adapted, and adopted evidence-based practices. With external facilitation, onsite clinical champions led the deployment of the evidence-based practices. Evaluation data were collected from 104 patients with probable bipolar disorder or treatment-resistant depression via chart review and an interactive voice response telephone system. RESULTS: Five practices were implemented: (a) screening for bipolar disorder, (b) telepsychiatric consultation, (c) prescribing guidelines, (d) online cognitive-behavioral therapy, and (e) online peer support. Implementation outcomes were as follows: (a) 15% of eligible patients were screened for bipolar disorder (interclinic range = 3%-70%), (b) few engaged in online psychotherapy or peer support, (c) 38% received telepsychiatric consultation (interclinic range = 0%-83%), and (d) 64% of patients with a consult were prescribed the recommended medication. Clinical outcomes were as follows: Of those screening at high risk or very high risk, 67% and 69%, respectively, were diagnosed with bipolar disorder. A third (32%) of patients were prescribed a new mood stabilizer, and 28% were prescribed a new antidepressant. Clinical response (50% reduction in depression symptoms), was observed in 21% of patients at 3-month follow-up. DISCUSSION: Quality improvement processes resulted in the implementation and evaluation of 5 detection and treatment processes. Though varying by site, screening improved detection and a substantial number of patients received consultations and medication adjustments; however, symptom improvement was modest. (PsycINFO Database Record

Impact of a Primary Care CKD Registry in a US Public Safety-Net Health Care Delivery System: A Pragmatic Randomized Trial.

BACKGROUND: Many individuals with chronic kidney disease (CKD) do not receive guideline-concordant care. We examined the impact of a team-based primary care CKD registry on clinical measures and processes of care among patients with CKD cared for in a public safety-net health care delivery system. STUDY DESIGN: Pragmatic trial of a CKD registry versus a usual-care registry for 1 year. SETTING & PARTICIPANTS: Primary care providers (PCPs) and their patients with CKD in a safety-net primary care setting in San Francisco. INTERVENTION: The CKD registry identified at point of care all patients with CKD, those with blood pressure (BP)>140/90mmHg, those without angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) prescription, and those without albuminuria quantification in the past year. It also provided quarterly feedback pertinent to these metrics to promote "outreach" to patients with CKD. The usual-care registry provided point-of-care cancer screening and immunization data. OUTCOMES: Changes in systolic BP at 12 months (primary outcome), proportion of patients with BP control, prescription of ACE inhibitors/ARBs, quantification of albuminuria, severity of albuminuria, and estimated glomerular filtration rate. RESULTS: The patient population (n=746) had a mean age of 56.7±12.1 (standard deviation) years, was 53% women, and was diverse (8% non-Hispanic white, 35.7% black, 24.5% Hispanic, and 24.4% Asian). Randomization to the CKD registry (30 PCPs, 285 patients) versus the usual-care registry (49 PCPs, 461 patients) was associated with 2-fold greater odds of ACE inhibitor/ARB prescription (adjusted OR, 2.25; 95% CI, 1.45-3.49) and albuminuria quantification (adjusted OR, 2.44; 95% CI, 1.38-4.29) during the 1-year study period. Randomization to the CKD registry was not associated with changes in systolic BP, proportion of patients with uncontrolled BP, or degree of albuminuria or estimated glomerular filtration rate. LIMITATIONS: Potential misclassification of CKD; missing baseline medication data; limited to study of a public safety-net health care system. CONCLUSIONS: A team-based safety-net primary care CKD registry did not improve BP parameters, but led to greater albuminuria quantification and more ACE inhibitor/ARB prescriptions after 1 year. Adoption of team-based CKD registries may represent an important step in translating evidence into practice for CKD management.

Changes to Racial Disparities in Readmission Rates After Medicare's Hospital Readmissions Reduction Program Within Safety-Net and Non-Safety-Net Hospitals.

Importance: Although readmission rates are declining under Medicare's Hospital Readmissions Reduction Program (HRRP), concerns remain that the HRRP will harm quality at safety-net hospitals because they are penalized more often. Disparities between white and black patients might widen because more black patients receive care at safety-net hospitals. Disparities may be particularly worse for clinical conditions not targeted by the HRRP because hospitals might reallocate resources toward targeted conditions (acute myocardial infarction, pneumonia, and heart failure) at the expense of nontargeted conditions. Objective: To examine disparities in readmission rates between white and black patients discharged from safety-net or non-safety-net hospitals after the HRRP began, evaluating discharges for any clinical condition and the subsets of targeted and nontargeted conditions. Design, Setting, and Participants: Cohort study conducting quasi-experimental analyses of patient hospital discharges for any clinical condition among fee-for-service Medicare beneficiaries from 2007 to 2015 after controlling for patient and hospital characteristics. Changes in disparities were measured within safety-net and non-safety-net hospitals after the HRRP penalties were enforced and compared with prior trends. These analyses were then stratified by targeted and nontargeted conditions. Analyses were conducted from October 1, 2017, through August 31, 2018. Main Outcomes and Measures: Trends in 30-day readmission rates among white and black patients by quarter and differences in trends across periods. Results: The study sample included 58 237 056 patient discharges (black patients, 9.8%; female, 57.7%; mean age [SD] age, 78.8 [7.9] years; nontargeted conditions, 50 372 806 [86.5%]). Within safety-net hospitals, disparities in readmission rates for all clinical conditions widened between black and white patients by 0.04 percentage point per quarter in the HRRP penalty period (95% CI, 0.01 to 0.07; P = .01). This widening was driven by nontargeted conditions (0.05 percentage point per quarter [95% CI, 0.01 to 0.08]; P = .006), whereas disparities for the HRRP-targeted conditions did not change (with an increase of 0.01 percentage point per quarter [95% CI, -0.07 to 0.10]; P = .74). Within non-safety-net hospitals, racial disparities remained stable in the HRRP penalty period across all conditions, whether the conditions were HRRP-targeted or nontargeted. Conclusions and Relevance: Findings from this study suggest that disparities are widening within safety-net hospitals, specifically for non-HRRP-targeted conditions. Although increases in racial disparities for nontargeted conditions were modest, they represent 6 times more discharges in our cohort than targeted conditions.

A mixed-methods investigation of incident Hemodialysis access in a safety-net population.

BACKGROUND: Despite improved health outcomes associated with arteriovenous fistulas, 80% of Americans initiate hemodialysis using a catheter, influenced by low socioeconomic status among other factors. Risk factors for incident catheter use in safety-net populations are unknown. Our objective was to identify factors associated with incident catheter use among hemodialysis patients at one safety-net hospital, with a goal of informing fistula placement initiatives targeted at safety-net populations more generally. METHODS: We performed a retrospective review of all incident hemodialysis patients at a single urban safety-net hospital from January 1, 2010 - December 31, 2015 (n = 241), as well as semi-structured interviews with a multi-lingual convenience sample of patients (n = 10) from this cohort. The primary outcome was incident vascular access modality. Multivariable logistic regression was used to identify factors associated with incident catheter use. Interview transcripts were coded using a directed content analysis framework based on a model describing barriers to healthcare access. RESULTS: Subjects were 61.8% male, racially/ethnically diverse (19.5% white, 29.5% black, 28.6% Hispanic, 17.4% Asian), with a mean age of 52.4 years. Eighty-eight percent initiated hemodialysis using a catheter. In multivariable analysis, longer duration of nephrology care was associated with decreased catheter use (>12 months vs. 0-6 months: adjusted Odds Ratio [aOR] 0.07, 95% CI 0.02-0.23, p < 0.001), whereas uninsured status increased odds of catheter use (aOR 3.96, 1.23-12.76, p = 0.02). There was a decrease in catheter use after vascular surgery services became available in-hospital (OR 0.40, 95% CI 0.16-0.98, p = 0.04), however this association was not significant in multivariable analysis (aOR 0.48, 0.17-1.36, p = 0.17). During interviews, patients cited emotional responses to disease, lack of social and financial resources, and limited health knowledge as barriers to obtaining fistula surgery. CONCLUSIONS: The rate of catheter use in this urban safety-net population is above the national average. Access to health insurance, early referrals to nephrology, and provision of in-hospital vascular surgery should be prioritized in the safety-net. Additionally, services that support patients' emotional and learning needs may decrease delays in fistula placement.