The Utility of Dot Phrases and SmartPhrases in Improving Physician Documentation of Interpreter Use.

Background: Patients with limited English proficiency (LEP) experience significant healthcare disparities. Clinicians are responsible for using and documenting their use of certified interpreters for patient encounters when appropriate. However, the data on interpreter use documentation in the emergency department (ED) is limited and variable. We sought to assess the effects of dot phrase and SmartPhrase implementation in an adult ED on the rates of documentation of interpreter use. Methods: We conducted an anonymous survey asking emergency clinicians to self-report documentation of interpreter use. We also retrospectively reviewed documentation of interpreter- services use in ED charts at three time points: 1) pre-intervention baseline; 2) post-implementation of a clinician-driven dot phrase shortcut; and 3) post-implementation of a SmartPhrase. Results: Most emergency clinicians reported using an interpreter "almost always" or "often." Our manual audit revealed that at baseline, interpreter use was documented in 35% of the initial clinician note, 4% of reassessments, and 0% of procedure notes; 52% of discharge instructions were written in the patients' preferred languages. After implementation of the dot phrase and SmartPhrase, respectively, rates of interpreter-use documentation improved to 43% and 97% of initial clinician notes, 9% and 6% of reassessments, and 5% and 35% of procedure notes, with 62% and 64% of discharge instructions written in the patients' preferred languages. Conclusion: There was a discrepancy between reported rates of interpreter use and interpreter-use documentation rates. The latter increased with the implementation of a clinician-driven dot phrase and then a SmartPhrase built into the notes. Ensuring accurate documentation of interpreter use is an impactful step in language equity for LEP patients.

Comparing the health of refugee and asylee patients with that of non-refugee immigrant and US-born patients in a large Urban clinic.

OBJECTIVES: To compare disease burden in refugee/asylee, non-refugee immigrant, and US-born patients in the largest safety net clinic in San Francisco, California. METHODS: This is a retrospective chart review including 343 refugee/asylee, 450 immigrant, and 202 US-born patients in a San Francisco clinic from January 2014 to December 2017. Using electronic medical records, we compared prevalence of several diseases by immigration status. Using Poisson regression models with robust variance, we assessed association of diseases with immigration status, adjusting for sociodemographic characteristics. RESULTS: Diagnoses of non-communicable chronic diseases were less common in refugees/asylees, who had a greater risk of being diagnosed with mental health conditions. In Poisson regression models adjusted for sociodemographic characteristics, compared with refugees/asylees, US-born patients were more likely to have hypertension (IRR[CI] = 1.8 [1.0, 3.7]) and less likely to have depression (IRR[CI] = 0.5 [0.3, 0.8]). US-born (IRR[CI] = 0.06 [0.01, 0.2]) and immigrant patients (IRR[CI] = 0.1 [0.06, 0.2]) were less likely to have post-traumatic stress disorder. CONCLUSIONS: We uncover differences in burden of non-communicable chronic diseases and mental health by immigration status. These results highlight the importance of clinical screenings and research on disease burden in refugees.

Prevalence of otolaryngological disease in a refugee population compared to US-born patients.

Objective: Limited data exists regarding otolaryngological (ENT) disease in refugees and we aim to characterize its prevalence. Methods: This is a retrospective descriptive chart review of adult US-born, immigrant, and refugee patients receiving care at a primary care clinic between 2014 and 2017. We report the prevalence of ENT disease by immigration status. Bivariable and multivariable logistic regression models were conducted to assess differences in prevalence of ENT disease by immigration status. Results: Of 995 patients included, 202 US-born, 450 immigrants, and 343 were refugees. Immigrants were older (46 years vs. 34 years among refugees, 35.5 years among US-born, p < .001) and more likely to be women (64% vs. 52% among refugees and 56% among US-born, p = .003). Among refugees, 27% were Central American, 22% Chinese, and 9.3% Middle Eastern. Hearing loss and allergic rhinitis were the top two diagnoses among the three groups of immigration status. More refugees had at least 1 ENT diagnosis compared to the other groups (16% vs 14% among immigrants and 6% US-born, p < .001). Refugees were more likely to have at least 1 ENT diagnosis compared to US-born individuals (age and gender adjusted [aOR] 3.40, 95% CI [1.80-6.95], p < .001) and immigrants (aOR 1.62, [1.05-2.51], p = .03). Conclusion: ENT disease is prevalent among refugees, necessitating standardized evaluation during refugee health assessments and identifying barriers to referral and treatment. Level of evidence: 2b.

Cost comparison of a rapid results initiative against standard clinic-based model to scale-up voluntary medical male circumcision in Kenya.

Voluntary male medical circumcision (VMMC) reduces HIV acquisition by up to 60%. Kenya has successfully scaled up VMMC to an estimated 91% of eligible men and boys in certain regions in combination due to VMMC and cultural circumcisions. VMMC as a program is implemented regionally in traditionally non-circumcising counties where the prevalence is still below 91%, ranging from 56.4% to 66.7%. Given that funding toward VMMC is expected to decline in the coming years, it is important to identify what models of service delivery are most appropriate and efficient to sustainably meet the VMMC needs of new cohorts' eligible men. To this end, we compared the costs of facility-based VMMC and one within a rapid results initiative (RRI), a public health service scheduled during school holidays to perform many procedures over a short period. We employed activity-based micro-costing to estimate the costs, from the implementer perspective, of facility-based VMMC and RRI-based VMMC conducted between October 2017 and September 2018 at 41 sites in Kisumu County, Kenya supported by the Family AIDS care & Education Services (FACES). We conducted site visits and reviewed financial ledger and programmatic data to identify and quantify resources consumed and the number of VMMC procedures performed during routine care and RRIs. Ledger data were used to estimate fixed costs, recurring costs, and cost per circumcision (CPC) in United States dollar (USD). A sensitivity analysis was done to estimate CPC where we allocated 6 months of the ledger to facility-based and 6 months to RRI. Overall, FACES spent $3,092,891 toward VMMC services and performed 42,139 procedures during the funding year. This included $2,644,910 in stable programmatic costs, $139,786 procedure costs, and $308,195 for RRI-specific activities. Over the year, 49% (n = 20,625) of procedures were performed as part of routine care and 51% (n = 21,514) were performed during the RRIs. Procedures conducted during facility-based cost $99.35 per circumcision, those conducted during the RRIs cost $48.51 per circumcision, and according to our sensitivity analysis, CPC for facility-based ranges from $99.35 to $287.24 and for RRI costs ranged from $29.81 to $48.51. The cost of VMMC during the RRI was substantially lower than unit costs reported in previous costing studies. We conclude that circumcision campaigns, such as the RRI, offer an efficient and sustainable approach to VMMC.

Understanding Barriers to Timely Diagnosis and Intervention Among Immigrant Children With Hearing Loss.

OBJECTIVE: Identify the age at diagnosis and intervention of immigrant and/or non-English-speaking children with hearing loss (HL) and risk factors associated with delays. Identify barriers for non-English-speaking caregivers of deaf/hard-of-hearing children. STUDY DESIGN: Sequential mixed methods. SETTING: Tertiary care center in an urban city. METHODS: The analysis includes descriptive statistics, and 1-way and 2-way analysis of variance of the retrospective chart review. The quantitative study demonstrated foreign-born experienced disparities, so we conducted semistructured interviews on a subset of non-English-speaking families in the cohort that was then thematically analyzed using a human-centered design strategy. RESULTS: We divided 532 children into 3 groups: US-born with English as the preferred language (N = 294), US-born and non-English language preferred (N = 173), and foreign-born (N = 67). The laterality of HL and pure-tone averages were similar among the groups (p = .972 and .071, respectively). Age at diagnosis and time to the intervention were significantly different (39.7, 31.5, 75.8 months, p < .001 and 24.6, 29.2, 48.9 months, p = .001, respectively). Ages at diagnosis and intervention were associated with birthplace (p = .005, p = .0005, respectively) but not preferred language (p = .667, p = .343, respectively). Included in the qualitative interviews were Mandarin- (n = 5), Arabic- (n = 4), and Spanish-speaking families (n = 3). Insights revealed participants' quest for anticipatory guidance and social support, the consequences of cultural stigma, and the complexity of caring for a child with HL in an immigrant family. CONCLUSION: Foreign-born children with HL have significant delays in diagnosis and intervention compared to US-born children. For non-English-speaking parents, the diagnosis of HL presents challenges beyond that of the immigrant experience.

Implementing a Trauma-Informed Approach at a Student-Run Clinic for Individuals Seeking Asylum.

PROBLEM: Health care professionals complete forensic medical evaluations (FMEs) to corroborate evidence of persecution among individuals seeking asylum. Many FMEs are conducted at student-run clinics for individuals seeking asylum (or student-run asylum clinics; SRACs). Trauma-informed care (TIC) recognizes that trauma is pervasive and seeks to mitigate reexposure to trauma in health care interactions. Given that FMEs involve recalling trauma, TIC is an ideal model for supporting the individuals involved in an FME. APPROACH: The authors operationalized TIC principles in an SRAC model (the Human Rights Cooperative) at the University of California, San Francisco. Between April 2019 and April 2022, the SRAC provided 3 to 10 pro bono FMEs per month, as well as community referrals for individuals seeking asylum, clinician and medical student training on FMEs and TIC, and research on FMEs. This report describes the SRAC operations, organized by the 10 implementation domains of the Substance Abuse and Mental Health Services Administration guidance to organizations for implementing a trauma-informed approach. OUTCOMES: Between April 2019 and April 2022, the SRAC completed 160 FMEs. Sixty-nine clinicians performed FMEs, and 119 first-year medical students participated in the accompanying elective. Qualitative survey responses by clinicians, lawyers, students, and clients (individuals seeking asylum) highlighted the trauma-informed principles of safety; trustworthiness and transparency; empowerment, voice, and choice; peer support; collaboration and mutuality; and cultural, historical, and gender issues. All students who acted as leaders sustained their engagement with the SRAC over time. NEXT STEPS: Future research should use validated tools to assess secondary trauma and resilience within SRACs. The SRAC concept, which engages medical students and experienced clinicians in learning skills that can be used in the pursuit of health justice and equity, should be expanded and supported in U.S. medical schools across the country, which is facing unprecedented levels of migration.

Hearing Loss Screening, Diagnosis, and Treatment for Refugees and Asylees in an Urban Clinic, 2014-2017.

Objectives: First, to determine whether using a single-question subjective hearing screen vs gold standard audiometric evaluation is effective for hearing loss screening in refugees and asylees. Second, to understand the clinical pathways for hearing loss diagnosis and treatment. Study Design: This is a case series with chart review from January 2014 to December 2017. Setting: A large urban safety net primary care clinic in San Francisco, California. Methods: Patients were included who had a medical record and completed single-question subjective hearing screening and audiometric evaluation during refugee health examinations. An overall 349 patients met all inclusion criteria. Results: Out of 349 patients, 48% were male; the median age was 29.3 years (SD, 15.1). The majority came from Central or South America (n = 148, 42%) and China (n = 79, 23%). Among all patients, 10 (3%) failed the subjective hearing screen, and 18 (5%) failed audiometric evaluation. Of those who failed the subjective hearing screen, 4 (40%) passed audiometric evaluation. Of those who failed the audiometric evaluation, 12 (66%) passed subjective screening, and only 5 (28%) received a diagnostic audiogram, with 4 diagnosed with hearing loss and 1 receiving hearing aids. The sensitivity of the subjective screening question was 33% and the specificity 99% as compared with audiometric evaluation. Conclusion: Audiometric evaluation is relatively inexpensive and easily administered, while a single subjective question is a poor screening tool. Hearing loss is undertreated in this population. Ensuring appropriate hearing loss screening, diagnosis, and treatment in this population is paramount to improving quality of life.

Evaluation of a pilot forensic dermatology curriculum in the USA.

Physician participation in asylum medicine through forensic medical evaluations increases the likelihood that asylum seekers are granted legal status. Based on a review of existing literature and input from content experts, we designed and implemented a forensic dermatology curriculum for dermatology residents at University of California, San Francisco. Our pilot curriculum led to improvements in learners' attitudes regarding physician participation in asylum medicine and their confidence in describing skin findings of torture or abuse.

Childhood Hearing Health and Early Language Exposure: A Culturally Sensitive Approach.

Implementation of the universal newborn hearing screening has changed the landscape for children born deaf or hard of hearing, and with this, pediatricians must be knowledgeable about the screening and referral process, state protocols, and how to support patients and their families in their unique journeys. Early access to language-spoken, signed, both-forms the foundation for successful outcomes for the development of fluent language. For children using spoken language, early access to sound is critical and can often be achieved with the assistance of hearing devices, even in the newborn period. For all language modalities, state-funded Deaf mentor programs allow families to have meaningful exposure to the Deaf community. The authors come from different professions in the health care and education fields, including General Pediatrics, Otolaryngology Head and Neck Surgery, and the state Department of Education, and use different languages, including spoken and American Sign Language.

Transitioning to Telehealth During the COVID-19 Pandemic: Patient Perspectives and Attendance at an HIV Clinic in San Francisco.

Approximately 1.2 million people are living with HIV in the United States, with 16,000 in San Francisco. Many HIV-positive individuals have difficulty maintaining follow-up clinic visits under normal circumstances, and this is complicated by the coronavirus disease 2019 (COVID-19) pandemic as many institutions transition to a telehealth-focused model of care to maintain patient and provider safety. However, it was unknown how telehealth would impact patient attendance and perceptions about their care, particularly in populations at high risk of appointment nonattendance. To quantify the impact of telehealth on retention in care for a vulnerable HIV-infected population and to identify patient perspectives of telehealth and its effect on appointment attendance, we studied patients at the University of California, San Francisco (UCSF) 360 Wellness Center, an HIV primary care clinic in urban San Francisco, California. Anonymous surveys were conducted to assess patient perceptions of telehealth, and 21% of patients sent surveys responded. Appointment attendance rates for all visits were analyzed before and after the shelter-in-place order in San Francisco on March 16, 2020. With the transition to telehealth, the overall nonattendance rate decreased by ∼3%. Most common perceived strengths of telehealth included convenience and safety, whereas disadvantages included technical barriers and unfamiliarity. Despite barriers and disadvantages listed by patients, a majority are willing to attend telehealth visits, as 80.5% of respondents reported being equally or more likely to attend telehealth visits. This is a critical finding during the COVID-19 pandemic and beyond; we believe that telehealth can improve appointment attendance for vulnerable populations who often face barriers to receiving health care.

Stories from COVID-19 Reveal Hospitalized Patients with Limited English Proficiency Have Always Been Uniquely Prone to Social Isolation.

Through experiences with hospital visitor restrictions during the COVID-19 pandemic, a group of frontline trainees at the University of California San Francisco (UCSF) uncovered patient stories highlighting the unique challenges that patients with limited English proficiency (LEP) face in the hospital, particularly their vulnerability to social isolation. Here, we recount patient stories illustrative of this isolation, generated by insufficient professional interpreter use, ad hoc interpretation, and scarcity of media in preferred languages. When confronted with the social isolation faced by all patients during COVID-19, we more clearly saw the healthcare disparities affecting patients with LEP. A trainee-led videoconferencing initiative facilitating social calls between patients at UCSF and their loved ones proved especially helpful in reducing the disconnection that patients with LEP experience in the hospital. Motivated by the findings of this project, we advocate for other institutions to take similar action, such as hiring inpatient telehealth navigators and providing tablets for ad lib use. Enacting these changes will keep patients with LEP connected to their families and communities while in the hospital, an essential step towards establishing an equitable experience for patients with LEP.

The lysosomal aminopeptidase tripeptidyl peptidase 1 displays increased activity in malignant pancreatic cysts.

Incidental detection of pancreatic cysts has increased dramatically over the last decade, but risk stratification and clinical management remain a challenge. Mucinous cysts are precursor lesions to pancreatic cancer, however, the majority are indolent. Current diagnostics cannot identify mucinous cysts that harbor cancer or reliably differentiate these lesions from nonmucinous cysts, which present minimal risk of malignant progression. We previously determined that activity of two aspartyl proteases was increased in mucinous cysts. Using a global protease activity profiling technology, termed multiplex substrate profiling by mass spectrometry (MSP-MS), we now show that aminopeptidase activity is also elevated in mucinous cysts. The serine aminopeptidase, tripeptidyl peptidase 1 (TPP1), was detected by proteomic analysis of cyst fluid samples and quantitation using targeted MS demonstrated that this protease was significantly more abundant in mucinous cysts. In a cohort of 110 cyst fluid samples, TPP1 activity was increased more than 3-fold in mucinous cysts relative to nonmucinous cysts. Moreover, TPP1 activity is primarily associated with mucinous cysts that harbor high-grade dysplasia or invasive carcinoma. Although only 59% accurate for differentiating these lesions, measurement of TPP1 activity may improve early detection and treatment of high-risk pancreatic cysts when used in conjunction with other promising biomarkers.

Surgical overtreatment of pancreatic intraductal papillary mucinous neoplasms: Do the 2017 International Consensus Guidelines improve clinical decision making?

BACKGROUND: Significant overtreatment of intraductal papillary mucinous neoplasms can be attributed to low specificity of the current International Consensus Guidelines as well as nonconformity with the guidelines. We compare the ability of the 2012 and revised 2017 intraductal papillary mucinous neoplasms International Consensus Guidelines to predict high-grade dysplasia/invasive cancer and to determine the preoperative variables that predict resection of benign or low-grade dysplasia in tertiary care centers. METHODS: Clinical, radiographic, and pathologic data for resected intraductal papillary mucinous neoplasms at 3 high-volume National Cancer Institute Cancer Centers were reviewed and the 2012 and 2017 consensus criteria were retrospectively applied. When International Consensus Guidelines were not met, clinical decision analysis was used to determine the primary indication for resection. Logistic regression identified variables associated with pathologic grade. RESULTS: Records for a total of 251 patients were reviewed, 129 of whom (52%) had low-grade dysplasia. The revised 2017 International Consensus Guidelines had high sensitivity (98.4%) and negative predicted value (96.1%), and all high-risk stigmata predicted high-grade dysplasia/invasive cancer; however, specificity remained low (14.8%). Nonconformity with International Consensus Guidelines was the most powerful predictor of low-grade dysplasia on final pathologic examination (9.5; 2.12-40.78). Independent predictors of low-grade dysplasia included age younger than 50 (2.46; 1.08-5.62), fine-needle aspiration without epithelial cells (2.6; 1.43-4.72), and normal duct diameter (3.07; 1.99-4.75). Diabetes developed in 30% of patients after resection. CONCLUSION: Management of intraductal papillary mucinous neoplasms remains clinically challenging. Low specificity of the International Consensus Guidelines and nonconformity with the guidelines continue to contribute to unnecessary pancreatic resections. Improved tools for disease classification as well as a better understanding of the natural history, biology, and rates of progression of intraductal papillary mucinous neoplasms are needed to avoid surgical overtreatment of low-grade intraductal papillary mucinous neoplasms.

A method to increase reproducibility in adult ventricular myocyte sizing and flow cytometry: Avoiding cell size bias in single cell preparations.

RATIONALE: Flow cytometry (FCM) of ventricular myocytes (VMs) is an emerging technology in adult cardiac research that is challenged by the wide variety of VM shapes and sizes. Cellular variability and cytometer flow cell size can affect cytometer performance. These two factors of variance limit assay validity and reproducibility across laboratories. Washing and filtering of ventricular cells in suspension are routinely done to prevent cell clumping and minimize data variability without the appropriate standardization. We hypothesize that washing and filtering arbitrarily biases towards sampling smaller VMs than what actually exist in the adult heart. OBJECTIVE: To determine the impact of washing and filtering on adult ventricular cells for cell sizing and FCM. METHODS AND RESULTS: Left ventricular cardiac cells in single-cell suspension were harvested from New Zealand White rabbits and fixed prior to analysis. Each ventricular sample was aliquoted before washing or filtering through a 40, 70, 100 or 200µm mesh. The outcomes of the study are VM volume by Coulter Multisizer and light-scatter signatures by FCM. Data are presented as mean±SD. Myocyte volumes without washing or filtering (NF) served as the "gold standard" within the sample and ranged from 11,017 to 46,926µm3. Filtering each animal sample through a 200µm mesh caused no variation in the post-filtration volume (1.01+0.01 fold vs. NF, n = 4 rabbits, p = 0.999) with an intra-assay coefficient of variation (%CV) of <5% for all 4 samples. Filtering each sample through a 40, 70 or 100µm mesh invariably reduced the post-filtration volume by 41±10%, 9.0±0.8% and 8.8±0.8% respectively (n = 4 rabbits, p<0.0001), and increased the %CV (18% to 1.3%). The high light-scatter signature by FCM, a simple parameter for the identification of ventricular myocytes, was measured after washing and filtering. Washing discarded VMs and filtering cells through a 40 or 100µm mesh reduced larger VM by 46% or 11% respectively (n = 6 from 2 rabbits, p<0.001). CONCLUSION: Washing and filtering VM suspensions through meshes 100µm or less biases myocyte volumes to smaller sizes, excludes larger cells, and increases VM variability. These findings indicate that validity and reproducibility across laboratories can be compromised unless cell preparation is standardized. We propose no wash prior to fixation and a 200µm mesh for filtrations to provide a reproducible standard for VM studies using FCM.