Quality improvement approach to reduce patient cycle time at a student-run free healthcare clinical network.

BACKGROUND: The University of Florida (UF) Equal Access Clinic Network (EACN) is the largest student-run free healthcare clinic network in Florida. The UF EACN serves those who are underinsured or uninsured in Alachua County and its surrounding area. Nationally, average total clinic time per medical visit has been established to be 84 min. PROBLEM: Before this project, average patient cycle time at the UF EACN was 125.3 min, and there was no established quality improvement (QI) team to implement changes to address inefficiencies. METHODS: This was a prospective QI study that recorded patient cycle times for patients who received healthcare at any of the four primary care free clinics across the UF EACN from 5 July 2022 to 6 April 2023. INTERVENTIONS: Eighteen Plan-Do-Study-Act cycles were tailored to each of the four primary care clinic's needs with a focus on reducing patient cycle time by addressing the following identified problems: prolonged intake process, translation services, limited numbers of volunteers, and other inefficiencies and bottlenecks in workflow. RESULTS: The median patient cycle time at the EACN shifted from 125.3 min to 112.7 min over a nine month period. This drop of 12.6 min meant patients saw a 10.1% reduction in patient cycle time across the EACN. CONCLUSION: Underserved patients at EACN are experiencing increased value by having shorter patient cycle times.

Reduction of Pediatric Gastrostomy Tube Healthcare Utilization and Socioeconomic Disparities: Longitudinal Benefits of Quality Improvement.

BACKGROUND: Disparities in emergency department (ED) utilization after gastrostomy (G-) tube placement were previously demonstrated at our children's hospital. We aimed to reduce postoperative G-tube dislodgements and ED visits with a particular focus on socially vulnerable children. METHODS: Our improvement team implemented a G-tube care bundle (6/2018-9/2019) targeting caregiver preparedness and standardizing care in the pre-, intra-, and post-operative periods. Patients who had G tubes placed between 1/2011-8/2022 were categorized to either pre- or post-intervention groups. Primary outcomes were tracked prospectively. National area deprivation index (ADI) was assigned retrospectively and employed to evaluate social risk. Univariate comparisons were made between pre- and post-intervention groups, and between High ADI (≥80) and Low ADI (<80) subgroups in both pre- and post- intervention periods. We used statistical process control methods to further analyze change over time. RESULTS: 396 children were included (188 pre-intervention, 208 post-intervention). The post-intervention cohort demonstrated a lower rate of outpatient dislodgement at 90 days following G-tube placement (21.3 % vs 10.1 %, p = 0.002) and fewer G-tube-related ED visits per G-tube placed within one year of placement (mean 0.8 visits vs 0.6 visits, p = 0.012). Pre-intervention, children from high ADI neighborhoods had significantly greater healthcare utilization compared to those from lower ADI neighborhoods. Post-intervention, previously statistically significant disparities were no longer present. Outpatient G-tube dislodgements within 90 days were particularly mitigated. CONCLUSIONS: A longstanding quality improvement initiative has led to sustained reductions in overall G-tube-related health care utilization. Care standardization and improvement may mitigate outcome disparities related to socioeconomic advantage. TYPE OF STUDY: Retrospective Comparative Study and Prospective Quality Improvement. LEVEL OF EVIDENCE: Level III.

Disparities in Health Outcomes in Surgical Oncology.

Cancer health disparities refer to the unequal burden, treatment, and outcomes of cancer care experienced by specific populations. These disparities are systemic and often preventable, impacting diverse populations, including racial and ethnic minorities, medically underserved populations, populations in rural areas, individuals from the LGBT communities, disabled persons, extremes of age, and those living in persistent poverty. Addressing this topic is essential and timely to ensure equitable oncologic outcomes for all populations. Experts in surgical oncology and health disparities have collaborated to produce this seminar issue on Disparities in Surgical Oncology.

Research protocol for bridging research, accurate information and dialogue (BRAID)-clinical trials: a mixed-methods study of a community-based intervention to improve trust and diversify participation in clinical trials.

Cultural beliefs, personal experiences, and historic abuses within the healthcare system-rooted in structural racism-all contribute to community distrust in science and medicine. This lack of trust, particularly within underserved communities, contributes to decreased participation in clinical trials and a lack of representation in the data. Open dialogue about community concerns and experiences related to research participation and medical care processes can help build trust and change attitudes and behaviors that affect community health. This protocol outlines an approach to increase trust in science and clinical trials among communities in the Bronx, New York that are typically underrepresented in research data. Bridging Research, Accurate Information and Dialogue (BRAID) is a two-phased, evidence-based community engagement model that creates safe spaces for bilateral dialogues between trusted community messengers, and clinicians and scientists. The team will conduct a series of BRAID Conversation Circles on the topic of clinical trials with local trusted community messengers. Participants will be members of the community who are perceived as "trusted messengers" and can represent the community's voice because they have insight into "what matters" locally. Conversation Circles will be audiotaped, transcribed, and analyzed to identify emergent challenges and opportunities surrounding clinical trial participation. These key themes will subsequently inform the codesign and co-creation of tailored messages and outreach efforts that community participants can disseminate downstream to their social networks. Surveys will be administered to all participants before and after each Conversation Circle to understand participants experience and evaluate changes in knowledge and attitudes about clinical trials, including protections for research participants the advantages of having diverse representation. Changes in motivation and readiness to share accurate clinical trial information downstream will also be assessed. Lastly, we will measure participants dissemination of codesigned science messages through their social networks by tracking participant specific resource URLs of materials and videos posted on a BRAID website. This protocol will assess the effectiveness and adoptability of an innovative CBPR model that can be applied to a wide range of public health issues and has the potential to navigate the ever-changing needs of the communities that surround health systems.

Bridging the Telehealth Digital Divide With Collegiate Navigators: Mixed Methods Evaluation Study of a Service-Learning Health Disparities Course.

BACKGROUND: Limited digital literacy is a barrier for vulnerable patients accessing health care. OBJECTIVE: The Stanford Technology Access Resource Team (START), a service-learning course created to bridge the telehealth digital divide, trained undergraduate and graduate students to provide hands-on patient support to improve access to electronic medical records (EMRs) and video visits while learning about social determinants of health. METHODS: START students reached out to 1185 patients (n=711, 60% from primary care clinics of a large academic medical center and n=474, 40% from a federally qualified health center). Registries consisted of patients without an EMR account (at primary care clinics) or patients with a scheduled telehealth visit (at a federally qualified health center). Patient outcomes were evaluated by successful EMR enrollments and video visit setups. Student outcomes were assessed by reflections coded for thematic content. RESULTS: Over 6 academic quarters, 57 students reached out to 1185 registry patients. Of the 229 patients contacted, 141 desired technical support. START students successfully established EMR accounts and set up video visits for 78.7% (111/141) of patients. After program completion, we reached out to 13.5% (19/141) of patients to collect perspectives on program utility. The majority (18/19, 94.7%) reported that START students were helpful, and 73.7% (14/19) reported that they had successfully connected with their health care provider in a digital visit. Inability to establish access included a lack of Wi-Fi or device access, the absence of an interpreter, and a disability that precluded the use of video visits. Qualitative analysis of student reflections showed an impact on future career goals and improved awareness of health disparities of technology access. CONCLUSIONS: Of the patients who desired telehealth access, START improved access for 78.7% (111/141) of patients. Students found that START broadened their understanding of health disparities and social determinants of health and influenced their future career goals.

Sexual Orientation and Gender Identity Collection of Older Adults in the UCHealth Electronic Health Record: Assessing the First Three Years of Implementation.

OBJECTIVES: This study examines sexual orientation/gender identity (SOGI) data collection in older adults from the UCHealth systems electronic health record. METHODS: Data of older adults aged 55 and older were analyzed between January 2019 and December 2022. Prevalence of SOGI documentation based on four new SOGI-related questions were analyzed along with social history documentation. RESULTS: Data were missing in reports (93% for sexual orientation and 96% for gender identity). Of 459,544 older adults potentially identifiable as a sexual or gender minority (SGM), 8.24% could be identified through other social history, and 91.76% could not. Data often returned a response of "undisclosed" (1.04%) or "unspecified" (98.79%), leaving .005% to represent the identifiable population of SGM minority adults. CONCLUSIONS: SOGI data often was not documented through questions recommended since January 2019. It is unlikely that .005% accurately represents the SGM older patient population as national estimates are between 7%-11%. Lower reported percentages of SGM older adults may lead to less recognition of patient needs, and thus less equitable and personalized care. CLINICAL IMPLICATIONS: These findings exemplify the need for evaluation strategies to be designed to improve SOGI collection with the primary goal of promoting equity and inclusion for SGM older adults.

Food is Medicine National Summit: Transforming Health Care.

Food Is Medicine (FIM) interventions reflect the critical links between food security, nutrition security, health, and health equity, integrated into health care delivery. They comprise programs that provide nutritionally-tailored food, free of charge or at a discount, to support disease management, disease prevention, or optimal health, linked to the health care system as part of a patient's treatment plan. Such programs often prioritize health equity. On April 26-27, 2023, Tufts University's Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy and Food & Nutrition Innovation Institute held a two-day National Food is Medicine Summit with leaders, practitioners, and individuals with diverse lived experiences in health care, research, government, advocacy, philanthropy, and the private sector to identify challenges and opportunities to sustainably incorporate FIM services into the health care system and at scale. This report of a meeting describes key themes of the Summit, based on presentations and discussions on momentum around FIM, incorporating FIM in health care, tradeoffs and unintended consequences of various FIM models, scaling of programs, financing and payment mechanisms, educating and engaging the health care workforce, and federal and state government actions and opportunities on FIM. Speakers highlighted examples of recent public and private sector actions on FIM and innovative cross-sector partnerships, including state Medicaid waivers, academic and philanthropic research initiatives, health care system screenings and interventions, and collaborations including community-based organizations and/or entities outside of the food and health care sectors. Challenges and opportunities to broader implementation and scaling of FIM programs identified include incorporating FIM into health care business models, educating the health care workforce, and sustainably scaling FIM programs while leveraging the local connections of community-based organizations. This meeting report highlights recent advances, best practices, challenges, and opportunities discussed at the National Summit to inform future actions on FIM.

Association of rurality and health professional shortages with the clinicopathologic characteristics of melanoma in North Carolina.

PURPOSE: To assess rural-urban and health professional shortage area (HPSA)-related influences on the characteristics of melanoma in North Carolina. METHODS: We conducted a single-center retrospective cohort study of patients living in North Carolina with an available pathology report for invasive cutaneous melanoma seen in the Duke University Health System from 01/01/2014 to 12/31/2020. Multivariable logistic regression models were employed to compare patient and tumor characteristics between rural versus urban county residence as well between melanoma thicknesses dichotomized into thin (≤1.0 mm) and thicker (>1.0 mm) tumors. FINDINGS: The cohort included 807 patients, and rural patients accounted for 177 (21.9%) of invasive cutaneous melanomas. Rural patients had significantly higher odds of having thicker tumors than urban patients (odds ratio [OR] = 1.78, 95% confidence interval [CI]: 1.17-2.71; P = .008). Rural patients were significantly more likely to be female (OR = 1.59, 95% CI: 1.10-2.28; P = .013) and located in a population-based (OR = 2.66, 95% CI: 1.84-3.84; P<.001) or geographic-based (OR = 8.21, 95% CI: 3.33-20.22; P<.001) HPSA. Living in a medium- or high-shortage population-based HPSA was associated with higher odds of thicker tumors (OR = 2.65, 95% CI: 1.85-3.80; P<.001). CONCLUSIONS: Patients living in rural North Carolina counties were more likely than those in urban counties to be diagnosed with melanomas >1.0 mm in thickness, a clinically significant difference with important prognostic implications. Interventions at the county- and state-level to address this disparity may include improving access to skin cancer screening and teledermatology programs, increasing partnerships with primary care providers, and targeting interventions to counties with health professional shortages.

Applying the theoretical domains framework to identify determinants to mental healthcare use among older African Americans with type 2 diabetes: a qualitative study.

OBJECTIVES: There is a paucity of research focused on enhancing access to mental healthcare for older African Americans with type 2 diabetes (T2D), who may be at risk for or living with comorbid depression. This study aims to identify barriers and facilitators to mental healthcare utilisation among this population, guided by the theoretical domains framework (TDF). DESIGN: This qualitative study involved 30 interviews with older African American adults diagnosed with T2D. The interview questions were aligned with TDF domains to capture participant perspectives on barriers and facilitators to mental healthcare use. SETTING: Interviews were conducted via telephone by a licensed clinician trained in social work. Each session lasted 60-90 min and was transcribed and analysed. PARTICIPANTS: The study included 30 African American adults (15 males and 15 females), aged 60 and above, living in an urban area in the Midwest. PRIMARY AND SECONDARY OUTCOMES: The primary outcome was the identification of themes from participant responses, analysed using thematic content techniques and categorised into TDF constructs. Demographic data served as the secondary outcome. RESULTS: Nine key themes were identified, categorised under major TDF domains and constructs. Significant barriers included (1) systemic racism ('knowledge'), (2) normalisation of depressive symptoms ('beliefs about consequences'), (3) perceived stigma ('beliefs about consequences') and 4) costs of medications and healthcare ('environmental context and resources'). Facilitators to seeking mental healthcare included (1) empowerment ('beliefs about capabilities'), (2) perceived benefits of mental health exams ('beliefs about consequences'), (3) positive provider experiences ('reinforcement'), (4) recognition of depressive symptoms as a motivator ('goals') and (5) support networks ('social influences'). CONCLUSION AND IMPLICATIONS: Key findings highlight that fostering positive patient-provider relationships and enhancing self-recognition of depressive symptoms can significantly encourage mental healthcare utilisation among older African Americans with T2D. These findings suggest that future interventions should focus on strengthening these relationships and improving self-awareness to better mental health outcomes.

Partnerships Between Faith Communities and the Mental Health Sector: A Scoping Review.

OBJECTIVE: Faith communities are increasingly providing services to address the mental health needs of their congregations and communities. However, many feel limited in their capacity to address serious illness and experience challenges to collaborating with the mental health sector. To inform the development of faith community-mental health sector partnerships, the authors conducted a scoping review to assess the characteristics and evidence base of partnership approaches to addressing mental health needs. METHODS: A search of four databases identified peer-reviewed articles published between 2010 and 2023 on faith community-mental health sector partnerships in the United States. RESULTS: In total, 37 articles representing 32 unique partnerships were reviewed. Most partnerships (N=19) used multicomponent approaches, particularly involving training the faith community (N=18), mental health education for the broader community (N=14), and direct counseling (N=11). Many partnerships (N=14) focused on African American communities. Partnerships that included an evaluation component (N=20) showed promising findings for improving mental health symptoms, mental health literacy, stigma, and referrals, among other outcomes. Several articles reported facilitators (e.g., support from faith leaders and reciprocal relationships and equal power) and barriers (e.g., limited time and funding and differing interests and attitudes) to developing partnerships. CONCLUSIONS: The findings highlight how faith communities can be a critical partner in providing services across the continuum of mental health care and reveal the need for more rigorous evaluations of the effectiveness, feasibility, and sustainability of these partnerships. The results also identify strategies that may facilitate the development and strengthening of future faith community-mental health partnerships.

Barriers to identifying and addressing health-related social needs in cancer care: Patient and patient navigator perspectives.

BACKGROUND: The study aimed to gain insight into the experiences of patients with cancer and survivors regarding the integration of social needs assessment into their care, while also gathering perspectives from patient navigators on the barriers to obtaining and utilizing social needs information during cancer care, which taken together may influence cancer care policies. By comparing the perspectives of patients and navigators, the study sought to inform best practices for integrating, identifying, and addressing social needs to improve patient experiences and outcomes. METHODS: We conducted qualitative interviews and self-report surveys involving patients with cancer, providers, and patient navigators or care coordinators, seeking their insights and firsthand experiences related to health-related social needs in cancer care. Interviews were transcribed, separated into memos of main themes based on deductive coding, and further analyzed for new emergent themes using inductive coding. RESULTS: The present analysis focuses solely on the perspectives of 20 patient navigators and 21 patients. Qualitative analyses revealed two overarching themes: Theme 1: Personal and health system-related factors may create barriers for patients to disclose health-related social needs information during cancer care; and Theme 2: When social needs are identified, it is best practice to acknowledge and address social needs through referrals, resources, timely follow-up, and continued care coordination. Key barriers include individual beliefs and attitudes, concerns regarding privacy and sensitivity of questions, uncertainties about the outcomes of disclosing information, and patient-provider relationships and trust. CONCLUSION: Drawing upon the perspectives of patients and patient navigators provided valuable insight into the challenges associated with acquiring information on social needs. Their viewpoints presented feasible solutions to overcome barriers through early acknowledgment of patient needs, timely resource provision, and maintaining consistent follow-up actions. Additionally, it enhanced understanding of the pivotal role patient navigators play in oncology, serving as crucial links between screening for health-related social needs and addressing individual patient requirements. POLICY SUMMARY: The policies and policy improvements our paper seeks to impact include: inequalities in cancer care and health-related social needs of cancer.

Socio-ethical challenges and opportunities for advancing diversity, equity, and inclusion in digital medicine.

Digitalization in medicine offers a significant opportunity to transform healthcare systems by providing novel digital tools and services to guide personalized prevention, prediction, diagnosis, treatment and disease management. This transformation raises a number of novel socio-ethical considerations for individuals and society as a whole, which need to be appropriately addressed to ensure that digital medical devices (DMDs) are widely adopted and benefit all patients as well as healthcare service providers. In this narrative review, based on a broad literature search in PubMed, Web of Science, Google Scholar, we outline five core socio-ethical considerations in digital medicine that intersect with the notions of equity and digital inclusion: (i) access, use and engagement with DMDs, (ii) inclusiveness in DMD clinical trials, (iii) algorithm fairness, (iv) surveillance and datafication, and (v) data privacy and trust. By integrating literature from multidisciplinary fields, including social, medical, and computer sciences, we shed light on challenges and opportunities related to the development and adoption of DMDs. We begin with an overview of the different types of DMDs, followed by in-depth discussions of five socio-ethical implications associated with their deployment. Concluding our review, we provide evidence-based multilevel recommendations aimed at fostering a more inclusive digital landscape to ensure that the development and integration of DMDs in healthcare mitigate rather than cause, maintain or exacerbate health inequities.

Artificial Intelligence Echocardiography in Resource-Limited Regions: Applications and Challenges.

Artificial intelligence (AI) is revolutionizing cardiac imaging, including echocardiography. However, AI has scarce penetration in resource-limited regions. The implementation of AI-aided echocardiography (AIE) poses unique challenges and opportunities in resource-limited areas. Some obvious advantages of AIE include aiding image acquisition, interpretation, and triaging patients based on severity. The challenges AIE faces in resource-limited regions include a lack of data accessibility for model development, physician apprehension, and an outdated regulatory framework. Based on our early experience with AI, we believe AIE in resource-limited regions will enhance health equity, improve access to the technology, and lead to cost savings. However, significant efforts are needed to realize these objectives.

Correlation of Pediatric Surgical Infrastructure With Clinical and Economic Outcomes: A Cohort Study.

INTRODUCTION: A significant burden of unmet pediatric surgical disease exists in low- and middle-income countries. We sought to assess the associations between the installation of a pediatric operating room (OR) and clinical and economic outcomes for families with children in Ethiopia. METHODS: A retrospective cohort study was performed of children who underwent elective surgery in a tertiary-level Ethiopian public hospital, comparing patient outcomes before and after OR installation in August 2019. Clinical data were collected via chart review, and an inpatient economic survey was administered to patient caregivers. Interrupted time series analysis investigated trends in surgical volume over time. The relative economic benefit was determined by comparing the patients' household income to the monetary health benefit gained using the value of statistical life method. RESULTS: One thousand one hundred and ninety-six patients were included from August 2018 to July 2022. Surgery averted 20,541 disability-adjusted life years (DALYs) cumulatively or 17 DALYs per patient. Monthly case volume and DALYs averted significantly increased postinstallation. The median annual household income of the economic survey responders (n = 339) was $1337 (IQR 669-2592). 27.7% (n = 94/339) lived in extreme poverty, and 41.3% (n = 140/339) experienced catastrophic healthcare expenditure. Net monetary health benefit was $29.3 million or $26,646 per patient. The ratio of net monetary health benefit to household annual income was 60:1. CONCLUSIONS: Installing a pediatric OR in a public Ethiopian hospital ensures increased access to surgery for those most impoverished in Ethiopia and improves equitable access to surgical care. Greater investment in expanding pediatric surgical infrastructure can help address global inequities in child health.

[Early childhood intervention and children's health development : Exemplary findings and methodological challenges in the use of the school entry examination]. / Angebote Früher Hilfen und gesundheitliche Entwicklung von Kindern : Exemplarische Befunde und methodische Herausforderungen bei der Nutzung der Schuleingangsuntersuchung.

BACKGROUND: Early childhood intervention is intended to systematically network and customise support services, particularly for socio-economically disadvantaged families. The programmes are universal or selective, but the evidence on their effectiveness is limited. AIMS: The aims of this study were to exemplary analyse whether participants in early childhood intervention services had better development than non-participants using the school entry examination (SEE) as well as to discuss to what extent the SEE can be used to assess the impact of early childhood intervention services. METHODS: We analysed three typical offers of early childhood intervention services (family education; Zukunft für Kinder (ZfK); Kita-U) in relation to full vaccination coverage and age-appropriate development at U9. Data from 4579 Düsseldorf first graders were included. Propensity score matching was used to calculate percentage differences (average treatment effect on the treated; ATT) in terms of immunisation coverage and development between comparable intervention and control groups. RESULTS: All programmes are associated with a slightly increased probability of full vaccination protection (ATT 2.1 for family education; 2.5 for ZfK; 5.3 for Kita-U). Family education is also associated with a slightly higher probability of age-appropriate development (ATT 1.6), while the probability of age-appropriate development is lower for participants in ZfK (-10.1) and Kita­U (-4.5). DISCUSSION: The evaluation of early childhood intervention, especially selective services, is a methodological challenge due to confounding and suitable comparison groups. However, the SEE could be a framework for impact analyses under specific conditions.

Is naloxone where it needs to be? Using spatial analytics to examine equitable distribution of community-based naloxone sites.

BACKGROUND: One of the most effective harm reduction services for preventing opioid overdose deaths is naloxone. Given the ongoing opioid crisis, which has led to a surge in overdose deaths across the country, expanding access to naloxone is critical. Community-based naloxone distributions sites in Palm Beach County can increase access to naloxone. However, several rural and disadvantaged regions rarely have any type of access to naloxone. The purpose of this descriptive paper is to examine the spatial distribution of and evaluate equitable accessibility to community-based naloxone sites in Palm Beach County. METHODS: We examined health equity in the distribution of community-based naloxone sites using a mixed-methods approach with ArcGIS Pro version 3.0, which is a geographic information system (GIS) software used for mapping, spatial analysis, and data visualization. RESULTS: The Belle Glade region was identified as the location most adversely affected with health inequities and limited accessibility to naloxone distribution sites, as it ranked in the 100 % percentile for all social vulnerability index (SVI) themes. The 30-minute drive-time area calculated a county service area of 1885.3 km2 (km2), which covers about 34 % of the 478.0 km2 land area of census tracts. Drive-time areas did not account for periods of heavier traffic such as during rush hour. Maximum distances during heavier traffic may be smaller, thus decreasing accessibility to naloxone distribution sites. CONCLUSION: There is a need for effective policy-led strategies tailored to expanding our understanding of the challenges that are experienced by the individuals in need of naloxone and encountered by the distribution sites themselves, as accessible naloxone is crucial for preventing nonfatal and fatal overdoses and ensuring timely emergency responses in vulnerable communities.

Strategically communicating inclusion efforts at hospitals: Trust-signalling for community engagement.

Trust is a challenging and complex concept and takes on particular significance in the context of community engagement and communication in healthcare. For the purpose of making health services more inclusive and of tackling discrimination where it occurs, there is a need to articulate a vision for inclusion that communities of historically disadvantaged or stigmatised patients can trust. This article considers examples of diversity and inclusion 'signals' on the public websites of two large public hospitals in Melbourne, Australia. We suggest that there is value in public communications reaffirming respect for diversity and a commitment to inclusion in health services. We also make the case for interdisciplinary research into how trust-signalling strategies, that is, rhetorical strategies employed to reassure or convince, are developed by and for health services for the purposes of community engagement, and the specific effects that they may engender. Websites' framing of messages that affirm institutional commitments to fostering an inclusive environment and addressing barriers can serve as a means of explicitly encouraging patients and healthcare workers from marginalised communities to overcome potential obstacles to fuller healthcare engagement and workforce participation respectively.