High-Dose Opioid Prescribing in Individuals with Acute Pain: Assessing the Effects of US State Opioid Policies.

BACKGROUND: How state opioid policy environments with multiple concurrent policies affect opioid prescribing to individuals with acute pain is unknown. OBJECTIVE: To examine how prescription drug monitoring programs (PDMPs), pain management clinic regulations, initial prescription duration limits, and mandatory continued medical education affected total and high-dose prescribing. DESIGN: A county-level multiple-policy difference-in-difference event study framework. SUBJECTS: A total of 2,425,643 individuals in a large national commercial insurance deidentified claims database (aged 12-64 years) with acute pain diagnoses and opioid prescriptions from 2007 to 2019. MAIN MEASURES: The total number of acute pain opioid treatment episodes and number of episodes containing high-dose (> 90 morphine equivalent daily dosage (MEDD)) prescriptions. KEY RESULTS: Approximately 7.5% of acute pain episodes were categorized as high-dose episodes. Prescription duration limits were associated with increases in the number of total episodes; no other policy was found to have a significant impact. Beginning five quarters after implementation, counties in states with pain management clinic regulations experienced a sustained 50% relative decline in the number of episodes containing > 90 MEDD prescriptions (95 CIs: (Q5: - 0.506, - 0.144; Q12: - 1.000, - 0.290)). Mandated continuing medical education regarding the treatment of pain was associated with a 50-75% relative increase in number of high-dose episodes following the first year-and-a-half of enactment (95 CIs: (Q7: 0.351, 0.869; Q12: 0.413, 1.107)). Initial prescription duration limits were associated with an initial relative reduction of 25% in high-dose prescribing, with the effect increasing over time (95 CI: (Q12: - 0.967, - 0.335). There was no evidence that PDMPs affected high-dose opioids dispensed to individuals with acute pain. Other high-risk prescribing indicators were explored as well; no consistent policy impacts were found. CONCLUSIONS: State opioid policies may have differential effects on high-dose opioid dispensing in individuals with acute pain. Policymakers should consider effectiveness of individual policies in the presence of other opioid policies to address the ongoing opioid crisis.

Testing an Intervention to Improve Health Care Worker Well-Being During the COVID-19 Pandemic: A Cluster Randomized Clinical Trial.

Importance: Stress First Aid is an evidence-informed peer-to-peer support intervention to mitigate the effect of the COVID-19 pandemic on the well-being of health care workers (HCWs). Objective: To evaluate the effectiveness of a tailored peer-to-peer support intervention compared with usual care to support HCWs' well-being at hospitals and federally qualified health centers (FQHCs) during the COVID-19 pandemic. Design, Setting, and Participants: This cluster randomized clinical trial comprised 3 cohorts of HCWs who were enrolled from March 2021 through July 2022 at 28 hospitals and FQHCs in the US. Participating sites were matched as pairs by type, size, and COVID-19 burden and then randomized to the intervention arm or usual care arm (any programs already in place to support HCW well-being). The HCWs were surveyed before and after peer-to-peer support intervention implementation. Intention-to-treat (ITT) analysis was used to evaluate the intervention's effect on outcomes, including general psychological distress and posttraumatic stress disorder (PTSD). Intervention: The peer-to-peer support intervention was delivered to HCWs by site champions who received training and subsequently trained the HCWs at their site. Recipients of the intervention were taught to respond to their own and their peers' stress reactions. Main Outcomes and Measures: Primary outcomes were general psychological distress and PTSD. General psychological distress was measured with the Kessler 6 instrument, and PTSD was measured with the PTSD Checklist. Results: A total of 28 hospitals and FQHCs with 2077 HCWs participated. Both preintervention and postintervention surveys were completed by 2077 HCWs, for an overall response rate of 28% (41% at FQHCs and 26% at hospitals). A total of 862 individuals (696 females [80.7%]) were from sites that were randomly assigned to the intervention arm; the baseline mean (SD) psychological distress score was 5.86 (5.70) and the baseline mean (SD) PTSD score was 16.11 (16.07). A total of 1215 individuals (947 females [78.2%]) were from sites assigned to the usual care arm; the baseline mean (SD) psychological distress score was 5.98 (5.62) and the baseline mean (SD) PTSD score was 16.40 (16.43). Adherence to the intervention was 70% for FQHCs and 32% for hospitals. The ITT analyses revealed no overall treatment effect for psychological distress score (0.238 [95% CI, -0.310 to 0.785] points) or PTSD symptom score (0.189 [95% CI, -1.068 to 1.446] points). Post hoc analyses examined the heterogeneity of treatment effect by age group with consistent age effects observed across primary outcomes (psychological distress and PTSD). Among HCWs in FQHCs, there were significant and clinically meaningful treatment effects for HCWs 30 years or younger: a more than 4-point reduction for psychological distress (-4.552 [95% CI, -8.067 to -1.037]) and a nearly 7-point reduction for PTSD symptom scores (-6.771 [95% CI, -13.224 to -0.318]). Conclusions and Relevance: This trial found that this peer-to-peer support intervention did not improve well-being outcomes for HCWs overall but had a protective effect against general psychological distress and PTSD in HCWs aged 30 years or younger in FQHCs, which had higher intervention adherence. Incorporating this peer-to-peer support intervention into medical training, with ongoing support over time, may yield beneficial results in both standard care and during public health crises. Trial Registration: ClinicalTrials.gov Identifier: NCT04723576.

Electronic health record (EHR)-based PROMIS measures among neurology clinic decedents and survivors: a retrospective cohort analysis.

BACKGROUND: In addition to their standard use to assess real-time symptom burden, patient-reported outcomes (PROs), such as the Patient-Reported Outcomes Measurement Information System (PROMIS), measures offer a potential opportunity to understand when patients are experiencing meaningful clinical decline. If PROs can be used to assess decline, such information can be used for informing medical decision making and determining patient-centered treatment pathways. We sought to use clinically implemented PROMIS measures to retrospectively characterize the final PROMIS report among all patients who completed at least one PROMIS assessment from December 2017-March 2020 in one large health system, stratified by decedents vs. survivors. We conducted a retrospective cohort analysis of decedents (N = 1,499) who received care from outpatient neurology clinical practice within a single, large health system as part of usual care. We also compared decedents to survivors (360 + days before death; N = 49,602) on PROMIS domains and PROMIS-Preference (PROPr) score, along with demographics and clinical characteristics. We used electronic health record (EHR) data with built-in PROMIS measures. Linear regressions assessed differences in PROMIS domains and aggregate PROPr score by days before death of the final PROMIS completion for each patient. RESULTS: Among decedents in our sample, in multivariable regression, only fatigue (range 54.48-59.38, p < 0.0029) and physical function (range 33.22-38.38, p < 0.0001) demonstrated clinically meaningful differences across time before death. The overall PROPr score also demonstrated statistically significant difference comparing survivors (0.19) to PROPr scores obtained 0-29 days before death (0.29, p < 0.0001). CONCLUSIONS: Although clinic completion of PROMIS measures was near universal, very few patients had more than one instance of PROMIS measures reported, limiting longitudinal analyses. Therefore, patient-reported outcomes in clinical practice may not yet be robust enough for incorporation in prediction models and assessment of trajectories of decline, as evidenced in these specialty clinics in one health system. PROMIS measures can be used to effectively identify symptoms and needs in real time, and robust incorporation into EHRs can improve patient-level outcomes, but further work is needed for them to offer meaningful inputs for defining patient trajectories near the end of life. Assessing symptom burden provides an opportunity to understand clinical decline, particularly as people approach the end of life. We sought to understand whether symptoms reported by patients can be used to assess decline in health. Such information can inform decision-making about care and treatments. Of eight symptoms that we assessed, patient reports of fatigue and physical function were associated with clinical decline, as was an overall score of symptom burden. Because few symptoms were associated with decline, patient-reported outcomes in clinical practice may not yet be robust enough for incorporation in prediction models and assessment of trajectories of decline.

Key Factors in Designing the Health System-Community Pathways Program for African American/Black Children and Young Adults.

Many of the ethnic and racial workforce inequities in the United States are present in health care systems. Low representation of African American/Black individuals in the health care system workforce can be traced to a history of exclusionary practices that leave such individuals less likely to pursue health careers. Past research found that low representation is driven by inequities in health, education, and employment that are a result of structural racism. Pathways programs have been identified as one of the methods to increase recruitment, retention, and promotion in health-related career fields for African American/Black individuals. As prior research has shown, these programs recruit and support the graduation of students from underrepresented communities at all educational stages to increase their representation in specific fields. This article describes the development of key factors in framework design for the Health System-Community Pathways Program (HCPP), which aims to increase representation of African American/Black communities in the health care system workforce and improve the quality of their experience in pursuing careers in these fields. The HCPP framework of key factors is informed by an environmental scan, interviews and focus groups, and an expert discussion panel session. The article's authors come from diverse backgrounds; the team included African American/Black physicians and members of other historically marginalized communities. The qualitative research drew insights from diverse African American/Black community stakeholders; the study was reviewed by many stakeholders to ensure that the design of the research and the end product maximally benefits the community on which it focuses.

The U.S. Equity-First Vaccination Initiative: Impacts and Lessons Learned.

The one-year U.S. Equity-First Vaccination Initiative (EVI), launched in April 2021, aimed to reduce racial inequities in coronavirus disease 2019 (COVID-19) vaccination across five demonstration cities (Baltimore, Chicago, Houston, Newark, and Oakland) and over the longer term strengthen the United States' public health system to achieve more-equitable outcomes. This initiative comprised nearly 100 community-based organizations (CBOs), who led hyper-local work to increase vaccination access and confidence in communities of individuals who identify as Black, Indigenous, and People of Color. In this study, the second of two on the initiative, the authors examine the results of the EVI. They look at the initiative's activities, effects, and challenges, and provide recommendations for how to support and sustain this hyper-local community-led approach and strengthen the public health system in the United States.

An Exploratory Analysis of Differential Prescribing of High-Risk Opioids by Insurance Type Among Patients Seen by the Same Clinician.

BACKGROUND: Insurance status may influence quality of opioid analgesic (OA) prescribing among patients seen by the same clinician. OBJECTIVE: To explore how high-risk OA prescribing varies by payer type among patients seeing the same prescriber and identify clinician characteristics associated with variable prescribing DESIGN: Retrospective cohort study using the 2016-2018 IQVIA Real World Data - Longitudinal Prescription PARTICIPANTS: New OA treatment episodes for individuals ≥ 12 years, categorized by payer and prescriber. We created three dyads: prescribers with ≥ 10 commercial insurance episodes and ≥ 10 Medicaid episodes; ≥ 10 commercial insurance episodes and ≥ 10 self-pay episodes; and ≥ 10 Medicaid episodes and ≥ 10 self-pay episodes. MAIN OUTCOME(S) AND MEASURE(S): Rates of high-risk episodes (initial opioid episodes with > 7-days' supply or prescriptions with a morphine milliequivalent daily dose >90) and odds of being an unbalanced prescriber (prescribers with significantly higher percentage of high-risk episodes paid by one payer vs. the other payer) KEY RESULTS: There were 88,352 prescribers in the Medicaid/self-pay dyad, 172,392 in the Medicaid/commercial dyad, and 122,748 in the self-pay/commercial dyad. In the Medicaid/self-pay and the commercial-self-pay dyads, self-pay episodes had higher high-risk episode rates than Medicaid (16.1% and 18.4%) or commercial (22.7% vs. 22.4%). In the Medicaid/commercial dyad, Medicaid had higher high-risk episode rates (21.1% vs. 20.4%). The proportion of unbalanced prescribers was 11-12% across dyads. In adjusted analyses, surgeons and pain specialists were more likely to be unbalanced prescribers than adult primary care physicians (PCPs) in the Medicaid/self-paydyad (aOR 1.2, 95% CI 1.16-1.34 and aOR 1.2, 95% CI 1.03-1.34). For Medicaid/commercial and self-pay/commercial dyads, surgeons had lower odds of being unbalanced compared to PCPs (aOR 0.6, 95% CI 0.57-0.66 and aOR 0.6, 95% CI 0.61-0.68). CONCLUSIONS: Clinicians prescribe high-risk OAs differently based on insurance type. The relationship between insurance and opioid prescribing quality goes beyond where patients receive care.

"Palliative Care Is the Only Medical Field That I Feel Like I'm Treated As a Person, Not As a Black Person": A Mixed-Methods Study of Minoritized Patient Experiences with Palliative Care.

Background: Racial and ethnic disparities are well-documented in health care but generally understudied in palliative care. Objective: The goal of this mixed-methods study was to examine differences in patient experiences by race/ethnicity in palliative care and to qualitatively explore minoritized patient experiences with care for a serious illness. The data for this study were collected as part of a larger national effort to develop quality measures for outpatient palliative care. Setting/Subjects: Patients receiving outpatient palliative care (n = 153 Black patients and 2215 White patients) from 44 palliative care programs across the United States completed the survey; 14 patients and family caregivers who identified as racial/ethnic minorities participated in an in-depth qualitative interview. Measurements: We measured patients' experiences of (1) feeling heard and understood by their palliative care provider and team and (2) receiving desired help for pain using items developed from the larger quality measures project. We also conducted in-depth interviews with 14 patients and family caregivers to understand their experiences of palliative or hospice care to provide additional insight and understand nuances around minoritized patient experiences with palliative care. Results: Survey responses demonstrated that a similar proportion of Black patients and White patients (62.9% vs. 69.3%, p = 0.104) responded "completely true" to feeling heard and understood by their provider and team. Fewer Black patients than White patients felt that their provider understood what was important to them (53.3% vs. 63.9%, p = 0.009). The majority of Black patients and White patients (78.7% vs. 79.1%, p = 0.33) felt that they had received as much help for their pain as they wanted. Interviews with patient and family caregivers revealed positive experiences with palliative care but demonstrated experiences of discrimination in health care before referral to palliative care. Conclusion: Future work is needed to understand nuances around minoritized patient experiences with palliative care and receiving pain and symptom management.

Perceptions of Pediatric Endocrinologists and Neurologists on the Drivers of Telehealth Use.

OBJECTIVE: To assess the extent and drivers of telehealth use variation across clinicians within the same pediatric subspecialties. METHODS: In this mixed methods study, 8 pediatric medical groups in California shared data for eleven subspecialties. We calculated the proportion of total visits delivered via telehealth by medical group for each subspecialty and identified the 8 most common International Classification of Diseases 10 diagnoses for telehealth and in-person visits in endocrinology and neurology. We conducted semi-structured interviews with 32 pediatric endocrinologists and neurologists and applied a positive deviance approach comparing high versus low utilizers to identify factors that influenced their level of telehealth use. RESULTS: In 2019, medical groups that submitted quantitative data conducted 1.8 million visits with 549,306 unique pediatric patients. For 3 subspecialties, there was relatively little variation in telehealth use across medical groups: urology (mean: 16.5%, range: 9%-23%), orthopedics (mean: 7.2%, range: 2%-14%), and cardiology (mean: 11.2%, range: 2%-24%). The remaining subspecialties, including neurology (mean: 58.6%, range: 8%-93%) and endocrinology (mean: 49.5%, range: 24%-92%), exhibited higher levels of variation. For both neurology and endocrinology, the top diagnoses treated in-person were similar to those treated via telehealth. There was limited consensus on which clinical conditions were appropriate for telehealth. High telehealth utilizers were more comfortable conducting telehealth visits for new patients and often worked in practices with innovations to support telehealth. CONCLUSIONS: Clinicians perceive that telehealth may be appropriate for a range of clinical conditions when the right supports are available.

Improving Pain Care for Service Members: Administrator, Provider, and Patient Perspectives on Treatment, Policies, and Opportunities for Change.

Acute and chronic pain are common among service members, with musculoskeletal pain and injuries being the leading cause of nondeployability among active-duty service members. Given the significant implications for individual health and force readiness, providing high-quality pain care to service members is a priority of the Military Health System (MHS). Prior RAND research used administrative data to assess the quality and safety of pain care and opioid prescribing in the MHS, generated a set of quality measures that the MHS could adopt going forward, and identified strengths and opportunities for improvement in care provided to service members with pain conditions. In this study, authors document findings from interviews with MHS administrators, providers, and patients, providing valuable detail and context for those findings, along with on-the-ground perspectives on MHS pain care policies and guidance in practice. Staff and patients recommended prioritizing increases in treatment access and availability to improve pain care, and patients emphasized effective treatment and patient-centered care as the most important facilitators of high-quality pain care.

Patient, Family Caregiver, and Provider Perceptions on Self-Assessment Screening for Cognitive Impairment in Primary Care: Findings From a Qualitative Study.

The purpose of this study was to evaluate patient, family, and provider perspectives on routine cognitive screening of older adults in primary care using a novel self-assessment tool for detection of early cognitive impairment (CI). We conducted four virtual focus groups with patients aged 65 and older with no CI (n = 18) and family caregivers of patients with CI (n = 5) and interviews with primary care providers (n = 11). Patient and family caregiver participants felt that early detection of CI was important in primary care and may facilitate planning for the future including finances, living arrangements, and advance care planning. Providers reported that they do not use a standardized tool to routinely screen patients for CI yet endorsed the use of a self-assessment CI screening tool. These results suggest that routine screening of older adults using a brief, self-assessment screening tool for CI in primary care may be acceptable to patients, family caregivers, and providers. The findings from this study will inform the development of a brief self-assessment CI screening tool for use in primary care.

Identifying Strategies to Boost COVID-19 Vaccine Acceptance in the United States.

This study presents the results of an evaluation of the root causes of COVID-19 vaccine hesitancy to inform strategies to boost vaccine acceptance among vaccine-hesitant populations in the United States. The authors conducted a literature review of the causes of vaccine hesitancy and vaccine acceptance; focus groups with patients, pre-hospital first responders, and hospital-based health care providers; a social media platform sentiment analysis to review attitudes regarding the COVID-19 vaccine; and a roundtable discussion with experts on vaccine hesitancy. Drawing on this mixed-methods analysis, the authors recommend strategies to help boost COVID-19 vaccine acceptance in the United States, grouping them according to three overall goals: boosting confidence in the safety and effectiveness of the COVID-19 vaccines, combating complacency about the pandemic, and increasing the convenience of getting vaccinated. The authors emphasize that combating misinformation about the COVID-19 vaccine is key to achieving these goals. These recommendations can inform the development of a toolkit of strategies to reach herd immunity and end the pandemic.

MACRA Palliative Care Quality Measure Development-Testing Summary Report: Measure Name: Receiving Desired Help for Pain.

Palliative care has expanded rapidly in the past 20 years, especially in the ambulatory (office) setting, and there is growing consensus regarding the need to systematically measure and incentivize high-quality care. The Centers for Medicare & Medicaid Services entered a cooperative agreement with the American Academy of Hospice and Palliative Medicine (AAHPM) as part of the Medicare Access and CHIP Reauthorization Act of 2015 to develop two patient-reported measures of ambulatory palliative care experience: Feeling Heard and Understood and Receiving Desired Help for Pain. Under contract to AAHPM, RAND Health Care researchers developed and tested both measures over a three-year project period. Researcher efforts included identifying, developing, testing, and validating appropriate patient-reported data elements for each measure; developing and fielding a survey instrument to collect necessary data in a national beta field test with 44 ambulatory palliative care programs; and collecting and analyzing data about measure reliability and validity to establish measure performance and final specifications. Further, the authors elicited provider and program perspectives on the use and value of the performance measures and their implementation and elicited the perspectives of patients from racial and ethnic minorities to understand their experience of ambulatory palliative care and optimal approaches to measurement. In this study, the authors present results from their test of the Receiving Desired Help for Pain performance measure, which they demonstrate to be a reliable and valid measure that is ready for use in quality improvement and quality payment programs.

MACRA Palliative Care Quality Measure Development-Testing Summary Report: Measure Name: Feeling Heard and Understood.

Palliative care has expanded rapidly in the past 20 years, especially in the ambulatory (office) setting, and there is growing consensus regarding the need to systematically measure and incentivize high-quality care. The Centers for Medicare & Medicaid Services entered a cooperative agreement with the American Academy of Hospice and Palliative Medicine (AAHPM) as part of the Medicare Access and CHIP Reauthorization Act of 2015 to develop two patient-reported measures of ambulatory palliative care experience: Feeling Heard and Understood and Receiving Desired Help for Pain. Under contract to AAHPM, RAND Health Care researchers developed and tested both measures over a three-year project period. Researcher efforts included identifying, developing, testing, and validating appropriate patient-reported data elements for each measure; developing and fielding a survey instrument to collect necessary data in a national beta field test with 44 ambulatory palliative care programs; and collecting and analyzing data about measure reliability and validity to establish measure performance and final specifications. Further, the authors elicited provider and program perspectives on the use and value of the performance measures and their implementation and elicited the perspectives of patients from racial and ethnic minorities to understand their experience of ambulatory palliative care and optimal approaches to measurement. In this study, the authors present results from their test of the Feeling Heard and Understood performance measure, which they demonstrate to be a reliable and valid measure that is ready for use in quality improvement and quality payment programs.

Use of Telehealth Across Pediatric Subspecialties Before and During the COVID-19 Pandemic.

Importance: The identification of variation in health care is important for quality improvement. Little is known about how different pediatric subspecialties are using telehealth and what is driving variation. Objective: To characterize trends in telehealth use before and during the COVID-19 pandemic across pediatric subspecialties and the association of delivery change with no-show rates and access disparities. Design, Setting, and Participants: In this cohort study, 8 large pediatric medical groups in California collaborated to share aggregate data on telehealth use for 11 pediatric subspecialties from January 1, 2019, to December 31, 2021. Main Outcomes and Measures: Monthly in-person and telehealth visits for 11 subspecialties, characteristics of patients participating in in-person and telehealth visits, and no-show rates. Monthly use rates per 1000 unique patients were calculated. To assess changes in no-show rates, a series of linear regression models that included fixed effects for medical groups and calendar month were used. The demographic characteristics of patients served in person during the prepandemic period were compared with those of patients who received in-person and telehealth care during the pandemic period. Results: In 2019, participating medical groups conducted 1.8 million visits with 549 306 unique patients younger than 18 years (228 120 [41.5%] White and 277 167 [50.5%] not Hispanic). A total of 72 928 patients (13.3%) preferred a language other than English, and 250 329 (45.6%) had Medicaid. In specialties with lower telehealth use (cardiology, orthopedics, urology, nephrology, and dermatology), telehealth visits ranged from 6% to 29% of total visits from May 1, 2020, to April 30, 2021. In specialties with higher telehealth use (genetics, behavioral health, pulmonology, endocrinology, gastroenterology, and neurology), telehealth constituted 38.8% to 73.0% of total visits. From the prepandemic to the pandemic periods, no-show rates slightly increased for lower-telehealth-use subspecialties (9.2% to 9.4%) and higher-telehealth-use subspecialties (13.0% to 15.3%), but adjusted differences (comparing lower-use and higher-use subspecialties) in changes were not statistically significant (difference, 2.5 percentage points; 95% CI, -1.2 to 6.3 percentage points; P = .15). Patients who preferred a language other than English constituted 6140 in-person visits (22.2%) vs 2707 telehealth visits (11.4%) in neurology (P < .001). Conclusions and Relevance: There was high variability in adoption of telehealth across subspecialties and in patterns of use over time. The documentation of variation in telehealth adoption can inform evolving telehealth policy for pediatric patients, including the appropriateness of telehealth for different patient needs and areas where additional tools are needed to promote appropriate use.

Social determinants of atrial fibrillation.

Atrial fibrillation affects almost 60 million adults worldwide. Atrial fibrillation is associated with a high risk of cardiovascular morbidity and death as well as with social, psychological and economic burdens on patients and their families. Social determinants - such as race and ethnicity, financial resources, social support, access to health care, rurality and residential environment, local language proficiency and health literacy - have prominent roles in the evaluation, treatment and management of atrial fibrillation. Addressing the social determinants of health provides a crucial opportunity to reduce the substantial clinical and non-clinical complications associated with atrial fibrillation. In this Review, we summarize the contributions of social determinants to the patient experience and outcomes associated with this common condition. We emphasize the relevance of social determinants and their important intersection with atrial fibrillation treatment and outcomes. In closing, we identify gaps in the literature and propose future directions for the investigation of social determinants and atrial fibrillation.

Limited English Proficient Patient Visits and Emergency Department Admission Rates for Ambulatory Care Sensitive Conditions in California: a Retrospective Cohort Study.

BACKGROUND: Little is known about the risk of admission for emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs) by limited English proficient (LEP) patients. OBJECTIVE: Estimate admission rates from ED for ACSCs comparing LEP and English proficient (EP) patients and examine how these rates vary at hospitals with a high versus low proportion of LEP patients. DESIGN: Retrospective cohort study of California's 2017 inpatient and ED administrative data PARTICIPANTS: Community-dwelling individuals ≥ 18 years without a primary diagnosis of pregnancy or childbirth. LEP patients had a principal language other than English. MAIN MEASURES: We used a series of linear probability models with incremental sets of covariates, including patient demographics, primary diagnosis, and Elixhauser comorbidities, to examine admission rate for visits of LEP versus EP patients. We then added an interaction covariate for high versus low LEP-serving hospital. We estimated models with and without hospital-level random effects. KEY RESULTS: These analyses included 9,641,689 ED visits; 14.7% were for LEP patients. . Observed rate of admission for all ACSC ED visits was higher for LEP than for EP patients (26.2% vs. 25.2; p value < .001). Adjusted rate of admission was not statistically significant (27.3% [95% CI 25.4-29.3%] vs. 26.2% [95% CI 24.3-28.1%]). For COPD, the difference was significant (36.8% [95% CI 35.0-38.6%] vs. 33.3% [95% CI 31.7-34.9%]). Difference in adjusted admission rate for LEP versus EP visits did not differ in high versus low LEP-serving hospitals. CONCLUSIONS: In adjusted analyses, LEP was not a risk factor for admission for most ACSCs. This finding was observed in both high and low LEP-serving hospitals.

Inpatient patient safety events in vulnerable populations: a retrospective cohort study.

BACKGROUND: Widespread attention to structural racism has heightened interest in disparities in the quality of care delivered to racial/ethnic minorities and other vulnerable populations. These groups may also be at increased risk of patient safety events. OBJECTIVE: To examine differences in inpatient patient safety events for vulnerable populations defined by race/ethnicity, insurance status and limited English proficiency (LEP). DESIGN: Retrospective cohort study. SETTING: Single tertiary care academic medical centre. PARTICIPANTS: Inpatient admissions of those aged ≥18 years from 1 October 2014 to 31 December 2018. MEASUREMENTS: Primary exposures of interest were self-identified race/ethnicity, Medicaid insurance/uninsured and LEP. The primary outcome of interest was the total number of patient safety events, defined as any event identified by a modified version of the Institute for Healthcare Improvement global trigger tool that automatically identifies patient safety events ('automated') from the electronic record or by the hospital-wide voluntary provider reporting system ('voluntary'). Negative binomial models were used to adjust for demographic and clinical factors. We also stratified results by automated and voluntary. RESULTS: We studied 141 877 hospitalisations, of which 13.6% had any patient safety event. In adjusted analyses, Asian race/ethnicity was associated with a lower event rate (incident rate ratio (IRR) 0.89, 95% CI 0.83 to 0.96); LEP patients had a lower risk of any patient safety event and voluntary events (IRR 0.91, 95% CI 0.87 to 0.96; IRR 0.89, 95% CI 0.85 to 0.94). Asian and Latino race/ethnicity were also associated with a lower rate of voluntary events but no difference in risk of automated events. Black race was associated with an increased risk of automated events (IRR 1.11, 95% CI 1.03 to 1.20). LIMITATIONS: This is a single centre study. CONCLUSIONS: A commonly used method for monitoring patient safety problems, namely voluntary incident reporting, may underdetect safety events in vulnerable populations.