Uptake of the Post COVID-19 Condition ICD-10-CM Diagnosis Code By Social Factors

Objectives: Post-COVID conditions (PCC) are increasingly reported in people who had COVID. Certain racial or socioeconomic groups may be at greater risk for PCC and less likely to seek care. We examined the uptake of the new ICD-10-CM diagnosis code for PCC in routine clinical practice in the United States and how it varied by race and payer group. Method(s): Using the Optum de-identified Electronic Health Record (EHR) dataset, we identified patients with an ICD-10-CM code for PCC (U09.9) between October 1, 2021, through March 31, 2022, with 6 months of prior EHR activity. The earliest diagnosis defined the index date. All concurrent diagnoses were measured on the index date. Prior COVID diagnosis was assessed using all available data before the index date. Result(s): There were 23,647 patients: 9.9% were African American, 12.1% had Medicaid, and 2.4% were uninsured. There was an overrepresentation of white patients among those with PCC (78.6% compared with 69.6% of the overall EHR in 2021). More African American (24.1%), Medicaid (23.1%), and uninsured (27.5%) patients were diagnosed in the inpatient setting or emergency department than whites (14.0%) and commercially insured patients (10.0%). Among racial groups, African Americans had the highest percentage of documented prior COVID diagnosis at 63.6%. Of concurrent diagnoses, shortness of breath and acute respiratory failure with hypoxia were higher among African Americans (13.9% and 6.1%, respectively) than whites (11.5% and 4.3%, respectively). The same pattern was seen when comparing Medicaid and uninsured to commercial payors. Conclusion(s): The PCC code was used differently across racial groups and payor types and captures varying manifestations of PCC. The differences in diagnosis locations underscore the importance of using data capturing all care settings when conducting studies using this code. Subgroup analyses are important for future studies using U09.9 due to variability in code application.Copyright © 2023

Older Adults' Perspectives on Emergency Department Costs During COVID-19

OBJECTIVES: COVID-19 has strained the household finances of many Americans who are already experiencing increasing health care expenses. Concerns about the cost of care may deter patients from seeking even urgent care from the emergency department (ED). This study examines predictors of older Americans' concerns about ED visit costs and how cost concerns may have influenced their ED use in the early stages of the pandemic.STUDY DESIGN: This was a cross-sectional survey study using a nationally representative sample of US adults aged 50 to 80 years (N = 2074) in June 2020.METHODS: Multivariate logistic regressions assessed the relationships of sociodemographic, insurance, and health factors with cost concerns for ED care.RESULTS: Of the respondents, 80% were concerned (45% very, 35% somewhat) about costs of an ED visit and 18% were not confident in their ability to afford an ED visit. Of the entire sample, 7% had avoided ED care because of cost concerns in the past 2 years. Of those who may have needed ED care, 22% had avoided care. Predictors of cost-related ED avoidance included being aged 50 to 54 years (adjusted odds ratio [AOR], 4.57;95% CI, 1.44-14.54), being uninsured (AOR, 2.93;95% CI, 1.35-6.52), having poor or fair mental health (AOR, 2.82;95% CI, 1.62-4.89), and having an annual household income of less than $30,000 (AOR, 2.30;95% CI, 1.19-4.46).CONCLUSIONS: During the early COVID-19 pandemic, most older US adults expressed concerns about the financial impact of ED use. Further research should examine how insurance design could alleviate the perceived financial burden of ED use and prevent cost-related care avoidance, especially for those at higher risk in future pandemic surges.Am J Manag Care. 2023;29(4):204-208. doi:10.37765/ajmc.2023.89282

Assessing Factors Contributing to Disparities in Kidney Stone Management

INTRODUCTION AND OBJECTIVE: Studies suggest that there is a disproportionately increasing prevalence of kidney stone disease among African American and Hispanic patients in the United States. Furthermore, evidence indicates that disparities exist in the workup, management, and surgical interventions of different diseases based on race, ethnicity and socioeconomic status, among other variables. We sought to explore the potential non-clinical factors that could lead to disparities in the management of patients with symptomatic nephrolithiasis at a tertiary care center serving a mixed urban and non-urban population. METHOD(S): We retrospectively analyzed consecutive nonestablished adult patients presenting with symptomatic unilateral nephrolithiasis requiring definitive ureteroscopic stone extraction at a single institution between October 2019 and September 2021. The primary endpoint was time in days from the date of referral to the date of definitive treatment. Other variables included patient demographics, clinical characteristics, need for preoperative decompression, referral source, treatment date in relation to the COVID-19 pandemic, and Area Deprivation Index (ADI) ranking, a validated measure of neighborhood adversity related to education, employment, housing, and income. RESULT(S): Of 398 included patients, the mean age was 53 years, 55% female and 75% Caucasian. 47% had private insurance, 40% had government assistance and 13% were uninsured. The majority (73%) of referrals were from the emergency department. 10% of patients had a urinary tract infection on presentation. Renal obstruction was present in 77% of patients with 40% requiring preoperative decompression. The overall mean time from referral to surgery was 29 days (IQR 15-36). Factors associated with significantly longer time to surgery included Hispanic identity (40 days IQR 12-68, p=0.0098) compared to other ethnicities, Medicaid insurance (36 days IQR 17-55, p=0.012) compared to other payer groups and patients within the highest tertile ADI (most disadvantaged) ranking (+8 days, p=0.022) compared to those in the lowest tertile (most advantaged). CONCLUSION(S): In our cohort we demonstrated several nonclinical factors that resulted in a delay to definitive treatment in symptomatic kidney stone patients including Hispanic identity, Medicaid insurance, and most disadvantaged ADI ranking. Recognition of such disparities is the first step to help delineate and eliminate the barriers delaying the care of these vulnerable patients.

Bridging the gap in access to filter paper monitoring in patients with phenylketonuria - a Medical Nutrition Therapy for Prevention (MNT4P) program initiative

Background: Filter paper (FP) or dried blood spot testing is the preferred method of monitoring blood levels of phenylalanine and tyrosine for patients diagnosed with phenylketonuria (PKU) in the state of Georgia. This cost effective and convenient at-home approach simplifies the nutritional assessment and management of patients with PKU and lessens the burden on patients and caretakers. Emory and a local specialty laboratory had a long-standing contract for FP testing, which included patient insurance and grant billing. When this laboratory abruptly ended FP testing in September 2020, an emergent alternative plan became essential to prevent potential disruptions in patient care while working on a sustainable solution for PKU monitoring, especially given the ongoing COVID-19 pandemic. Method(s): Emory's in-house laboratory was not contracted with outside laboratories to process FP testing and bill insurance. To mitigate any delays in FP testing, the MNT4P program conducted a vendor search and selected ARUP Laboratories to perform PKU FP testing. Eligible patients included those referred, enrolled, and consented to the MNT4P program. To streamline the FP submission process, customized FP cards and business reply envelopes were developed and distributed in collaboration with PerkinElmer, Emory Mail Services and the United States Postal Service. Patient outreach efforts were facilitated through email campaigns, MNT4P website updates, and in collaboration with Georgia PKU Connect. Result(s): 95 patients were referred to MNT4P program for FP paper monitoring. During the 4-month period, a total of 239 FPs were collected from patients with PKU and processed with corresponding results reported to Emory Clinic, allowing registered dietitians to continue nutrition management without disruption. Once the patient-centered business prototype was established, FP testing was successfully transferred from the MNT4P program to Emory's inhouse laboratory. FP testing is now a part of Emory's test catalog, and results are available to providers through electronic health records. Conclusion(s): The MNT4P program successfully worked with Emory's in-house laboratory to develop a sustainable solution for FP monitoring. It prevented interruption in long-term follow up of patients with PKU. MNT4P continues to be the payor of FP tests for uninsured and underinsured patients.Copyright © 2022 Elsevier Inc. All rights reserved.

Health Disparities in Children with Covid-19 Early in the Pandemic: Socioeconomic Disadvantages Contributing to Severe Disease

Purpose of Study: Ethnic disparities are associated with increased risk for severe disease in pediatric patients with COVID-19. Identifying the underlying social determinants of health are necessary to lead to improved health care utilization and mitigation strategies. Methods Used: This is an observational cohort study of children with COVID-19 in Colorado (the CCC study) from March 15 2020-October 31 2020. Pediatric patients between 2-20 years of age with positive SARS-CoV-2 PCR were included. Multivariable logistical regression models were fitted to identify demographic, socioeconomic, and comorbid health conditions as predictors of severe COVID-19 disease, as defined by hospital admission and need for respiratory support. Summary of Results: We identified 1572 pediatric patients with COVID-19 (45% Hispanic, 54% Medicaid or uninsured, 16% non-English language, and 20% obese). In univariable analyses, Hispanic ethnicity was associated with severe outcomes, including hospital admission (OR 2.4, CI: 1.57, 3.80, p<0.01) and respiratory support (OR 2.4, CI: 1.38, 4.14, p<0.01). Patients who identified as Hispanic or Latino had significantly increased rates of obesity (28% vs. 14%, p<0.01), preferred non-English language (31% vs. 3%, p<0.01), and had Medicaid or no insurance (79% vs. 33%, p<0.01) when compared to non-Hispanic or Latino children. After adjusting for covariables, ethnicity was no longer associated with hospital admission (OR 0.9, CI: 0.53, 1.63, p=0.79) or respiratory support (OR 0.6, CI: 0.29, 1.21, p=0.15). Obesity (OR 1.9, CI: 1.15, 3.08, p=0.01), non-English language (OR 2.4, CI: 1.35, 4.23, p<0.01), and Medicaid insurance (OR 2.0, CI: 1.10, 3.71, p=0.02) were identified as independent risk factors for severe disease. Conclusion(s): Severe COVID-19 disease observed in Hispanic or Latino patients early in the pandemic appears to be secondary to underlying comorbid conditions, such as obesity, and socioeconomic disadvantages that may have influenced access to care, such as language and insurance status. Pediatric healthcare providers and public health officials should use this knowledge to tailor resource allocation to better target this underserved patient population.

Emergency Department-based monoclonal antibody therapy for patients with mild to moderate COVID-19

Objectives: To describe the implementation of an ED-based program to offer monoclonal antibody therapy to patients with mild-moderate COVID-19 disease. Background(s): Monoclonal antibody therapy (MOAB) has recently emerged as a treatment for mild to moderate COVID-19, potentially preventing those with underlying conditions from progressing to severe illness and hospitalization. Further, as EDs are the primary point of health care access for many at-risk individuals, offering MOAB in the ED may increase availability of treatment options for patients from traditionally underserved communities. Method(s): A retrospective chart review was conducted of patients 12 years and above who received treatment in our urban, academic, community hospital. Patients 12 years and older were screened for eligibility during ED visits or during follow-up calls providing positive test results. Staff was trained on specific consent, infusion, monitoring, and documentation procedures adherent to MOAB administration under the Emergency Use Authorization. Patients were contacted following MOAB and queried regarding symptom resolution and healthcare utilization. Data regarding patient demographics, ED course, and 7-day unscheduled visits were collected. Result(s): In this ongoing quality improvement initiative, from December 2020 to March 2021, there were 26,229 patient encounters at the pilot ED site. 84 patients were provided MOAB, 87% Bamlanivimab and 13% Bamlanivimab/Etesevimab. Patients had a mean age of 52.3 years (SD 24.4);21% were 12-17 years of age and 37% were >65 years old. 52% were male. 33% self-reported as Caucasian, 19% Black, 18% Asian/Pacific Islander, 21% as other, and 9% were unknown. 17% identified as Latinx. 19% of patients were insured by Medicaid, 36% Medicare, 39% commercially insured, and 6% were uninsured. Patients had symptoms a median of 3 days prior to MOAB. After age (46%), the most commonly reported eligibility criteria was obesity (20%), followed by hypertension (11%) and immunocompromised state (11%). 74% of infusions were administered during nights and weekends. No infusion reactions occurred. 8% returned to an ED within 7 days of MOAB, 5% were hospitalized. No patients required ICU admission or died. Conclusion(s): ED-based MOAB has been safely implemented and may be an effective treatment for patients with mild to moderate COVID-19. Health-system wide expansion of this program may provide opportunities to offer this life-saving therapy to underserved populations with poor access to care.Copyright © 2023

Racial and Ethnic Disparities in Screening Mammography During COVID-19

Purpose: Studies conducted prior to COVID-19 suggested that racial/ethnic disparities in breast cancer screening percentages have substantially reduced over time. COVID-19 has had devastating effects on racial/ethnic minorities and resulted in delays in preventive breast cancer screening. Our purpose was to determine if racial/ethnic minorities were less likely to receive recommended breast cancer screening after the resumption of preventive care during the COVID19 pandemic. Method(s): HIPAA-compliant, institutional review board exempt retrospective cohort study was performed at a multi-location academic medical center located in the Midwest. Patients included women aged 50-74 years old between June 2021 and May 2022, derived from the electronic medical records. Primary outcomes variables included receipt of screening mammogram within the last two years. Primary exposure variables included race (American Indian/Alaska Native, Asian/Native Hawaiian/Other Pacific Islander, Black or African American, White) and ethnicity (Hispanic/Latino, and Not Hispanic/Latino). Binary outcomes were analyzed using logistic regression, adjusted for potential confounders (insurance, age, preferred language, employment status, rural status). Result(s): 37,509 female patients without histories of mastectomies were included (mean age 63.1). 73.8% of eligible patients received a mammogram within the last two years. By race, 74.7% of White patients, 57.6% of Black patients, 67.0% of Asian/Pacific Islander patients, and 60.1% of American Indian patients received a screening mammogram within the last two years. In our unadjusted analyses, Black (OR 0.46, 95% CI 0.41 to 0.52, p < 0.001), Asian (OR 0.69, 95% CI 0.60 to 0.79, p < 0.001), and American Indian patients (OR 0.51, 95% CI 0.39 to 0.66, p < 0.001) were less likely to receive recommended mammography screening. In our adjusted analyses, Black (OR 0.54, 95% CI 0.47 to 0.61, p < 0.001), Asian (OR 0.79, 95% CI 0.68 to 0.92, p = 0.003), and American Indian patients (OR 0.63, 95% CI 0.48 to 0.82, p = 0.001) were less likely to receive recommended mammography screening. By ethnicity, 74.1% of Non-Hispanic patients and 64.2% of Hispanic patients received a screening mammogram within the last two years. In our unadjusted analyses, Hispanic patients (OR 0.62, 95% CI 0.55 to 0.71, p < 0.001) were less likely to receive recommended mammography screening. In our adjusted analyses, Hispanic patients (OR 0.92, 95% CI 0.79 to 1.08, p = 0.338) were comparably likely to receive recommended mammography screening. Patients with non-English preferred languages, uninsured or Medicaid patients, and patients living in rural areas were less likely to receive recommended mammography screening (p < 0.001). Conclusion(s): Racial/ethnic minority patients were less likely to receive recommended cancer screening after the resumption of preventive breast cancer screening during the COVID-19 pandemic. Targeted outreach efforts are required to ensure equitable access to breast cancer screening for racial/ethnic minorities, patients with non-English preferred languages, uninsured, Medicaid, and rural patients.

Incidence of Acute Myocardial Infarction and Hurricane Katrina: Sixteen Years after the Storm

Background We aimed to evaluate the incidence of acute myocardial infarction (AMI) in New Orleans in the sixteen years after Hurricane Katrina. Methods This was a single-center, retrospective study performed at Tulane University Health Sciences Center of patients admitted for AMI during two years prior to Hurricane Katrina and sixteen years after Hurricane Katrina. The pre-Katrina and post-Katrina cohorts were compared according to pre-specified demographic and clinical data. Results In the sixteen-year post-Katrina period, there were 3696 admissions for AMI out of a total census of 128,276 (2.9%) compared to 150 admissions out of a census of 21,079 (0.7%) in the pre-Katrina group (p<0.0001). The post-Katrina group had a higher prevalence of known coronary artery disease (CAD) (43.8% vs. 30.7%, p<0.0001), diabetes mellitus (40.7% vs. 28.7%, p<0.002), hypertension (80.1% vs. 74.0%, p<0.05), hyperlipidemia (54.2% vs. 44.7%, p<0.0001), smoking (54.2% vs. 39.3%, p<0.0002), drug abuse (18.7% vs. 6.7%, p<0.0002), and psychiatric disease (15.3% vs. 6.7%, p<0.0004). The post-Katrina group was more often prescribed aspirin (49.6% vs. 31.3%, p<0.0001), beta-blocker (46.9% vs. 34.0%, p<0.004), ACE inhibitor or ARB (51.9% vs. 36.0%, p<0.0004), and statin (52.6% vs. 28.0%, p<0.0001) but with higher medication non-adherence (15.8% vs. 7.3%, p<0.0001). The post-Katrina patients were also more likely to be unemployed (75.6% vs 22.7%, p<0.0001) and non-married (56.3% vs. 52.7%, p<0.0001). Rates of STEMI were lower in the post-Katrina group (29.1% vs 42.0%, p<0.002). There was no significant difference in terms of sex, being uninsured, or prior coronary artery bypass grafting. Four patients were COVID positive in the post-Katrina cohort. Conclusion There was a 4-fold increase in the incidence of AMI sixteen years after Hurricane Katrina. Psychosocial, behavioral, and traditional CAD risk factors were significantly higher among the post-Katrina group. These findings add to the growth of literature demonstrating the adverse cardiovascular outcomes that occur after a natural disaster. Further research is needed to explain the underlying mechanisms to help diminish future cardiac morbidity.Copyright © 2023 American College of Cardiology Foundation

Assessing the impact of the COVID-19 pandemic on a statewide breast and cervical cancer safety net screening and diagnostic program: Are there differences by rural - urban geography?

Background: COVID-19 disrupted the healthcare system and services across the cancer continuum. Early on, breast and cervical (B & C) screenings were effectively halted, and many diagnostic and treatment procedures delayed. Emerging evidence suggests that uninsured populations and patients of color were disproportionately affected, but less is known about ruralurban differences. The Illinois Breast and Cervical Cancer Screening Program (IBCCP), administered by agencies across 102 counties, provides screening and diagnostic services for lowincome, uninsured, and underinsured persons. This study assesses the impact of COVID-19 on agencies' administrative functions and clients' ability to receive services, and to examine rural-urban differences. Method(s): IBCCP coordinators were invited to complete an online survey that asked about COVID-19's effect on administrative functions and services at two different time periods, the height of the pandemic and in the past month (11/2021-12/2021). Chi-square and Fisher's exact tests were used to examine differences between rural and urban agencies (classified by using the 2013 NCHS Urban-Rural Classification Scheme). Result(s): In total, 32 agencies (50% urban, 50% rural), responded. Concerning administrative functions, in the past month compared to at the height of the pandemic, fewer agencies overall reported that COVID-19 had a moderate to great impact (compared to occasional or no impact) on staffing (47% vs. 74%) and client enrollment (34% vs. 90%). Although not significant, more rural than urban agencies reported effects on staffing (56% vs. 38%) and enrollment (50% vs. 19%) in the past month. Concerning clients' ability to receive services, in the past month compared to the height of the pandemic, fewer agencies overall reported COVID-19 effects on screening (31% vs. 75%), diagnostic (19% vs. 61%), and treatment (3% vs. 38%) services. Some rural-urban differences were noted;at the height of the pandemic, urban agencies were more likely to report effects on diagnostic (88% vs. 33%, p=.002) and treatment (56% vs. 19%, p=.028) services when compared to rural. Although not significant, in the past month, more urban (vs. rural) agencies reported COVID-19 related effects on screening (44% vs. 19%), diagnostic (31% vs. 6%), and treatment (7% vs. 0%) services. Conclusion(s): Overall, agencies implementing this safety net program are generally rebounding from the pandemic's effect on administrative functions and clients' ability to receive services. However, rural and urban agencies may be differentially affected by the pandemic. For example, in the past month, a greater proportion of rural agencies reported effects on administrative functions Interestingly, more urban agencies reported lingering effects on clients' ability to receive screening and diagnostic services. These trends suggest that rural and urban agencies may be differentially affected by the pandemic and geographically tailored responses may best support recovery.

"Access to these screenings have been a gift": A mixed methods assessment of a community navigation program for breast and cervical in the era of COVID-19

Background: The COVID-19 pandemic exacerbated health inequities among systematically marginalized populations. At the onset of the pandemic, routine cancer screenings were effectively halted;from March to May 2021, there was a deficit of 9.3 million screens. Early evidence suggests that non-White patients, compared to White, have experienced even greater declines in breast and cervical cancer screenings. Consequences of missed or late screenings include later stage diagnosis and poor outcomes. Community navigation programs have been used to promote engagement in cancer screenings in under-resourced communities, but these too were interrupted as restrictions were put in place to mitigate the spread of COVID-19. Objective(s): To use a mixed methods approach to describe the challenges, strengths, and lessons learned of implementing a community navigation program for breast and cervical cancer screening during the COVID-19 pandemic. Method(s): In 2019, The University of Illinois Cancer Screening, Access, Awareness, and Navigation (UI CAAN) intervention was established to address breast and cervical cancer disparities on Chicago's West side, an area with large Black and Latinx populations. The intervention included community navigators who worked in partnership with community-based safety net hospitals and organizations. Participants were recruited at community events and through clinical referrals and were eligible if they were overdue for a guideline concordant breast or cervical cancer screening. Quantitative navigation and screening data were collected by the navigators in a REDCap database. Qualitative data, four focus groups with participants and partners, were also collected to broaden our understanding of impact of COVID-19 on the community navigation intervention. For these analyses, we describe participants' navigation and screening outcomes and use content analysis methods for the focus groups. We then triangulate the findings to understand the challenges, strengths, and lessons learned of the UI CAAN. Result(s): From 2019-2022, a total of 366 individuals were navigated for breast and cervical cancer screenings. Of these, 68% (n = 248) received a breast and/or cervical cancer screening. Among those who were screened, 75% were Latinx and 23% were Black, 92% were uninsured, and 86% did not have a primary care provider. Concerning services received, 30% had a mammogram and a pap smear, 37% a pap smear only, and 33% a mammogram only. At the height of the pandemic, navigators coordinated with community and clinical partners to deliver 500 meals, held 9 PPE distribution events, distributed 3000 masks, and conducted 2 webinars about COVID-19. Conclusion(s): Despite the challenges of the COVID-19 pandemic, the UI CAAN community navigation program was able to shift its efforts at the height of the pandemic to assist its community and clinical partners. The continued collaboration allowed for a successful resumption of navigation and screening efforts once healthcare systems were able to re-engage patients in cancer screenings.

Incidence of acute myocardial infarction and Hurricane Katrina: Sixteen years after the storm

Purpose of Study:We aimed to evaluate the incidence of acute myocardial infarction (AMI) in New Orleans in the sixteen years after Hurricane Katrina. Methods Used: This was a single-center, retrospective study performed at Tulane University Health Sciences Center of patients admitted for AMI during two years prior to Hurricane Katrina and sixteen years after Hurricane Katrina. The pre-Katrina and post-Katrina cohorts were compared according to pre-specified demographic and clinical data. Summary of Results: In the sixteen-year post-Katrina period, there were 3696 admissions for AMI out of a total census of 128 276 (2.9%) compared to 150 admissions out of a census of 21 079 (0.7%) in the pre-Katrina group (p < 0.0001). The post-Katrina group had a higher prevalence of known coronary artery disease (CAD) (43.8% vs. 30.7%, p < 0.0001), diabetes mellitus (40.7% vs. 28.7%, p < 0.002), hypertension (80.1% vs. 74.0%, p < 0.05), hyperlipidemia (54.2% vs. 44.7%, p < 0.0001), smoking (54.2% vs. 39.3%, p < 0.0002), drug abuse (18.7% vs. 6.7%, p < 0.0002), and psychiatric disease (15.3% vs. 6.7%, p < 0.0004). The post-Katrina group was more often prescribed aspirin (49.6% vs. 31.3%, p < 0.0001), betablocker (46.9% vs. 34.0%, p < 0.004), ACE inhibitor or ARB (51.9% vs. 36.0%, p < 0.0004), and statin (52.6% vs. 28.0%, p < 0.0001) but with higher medication nonadherence (15.8% vs. 7.3%, p < 0.0001). The post- Katrina patients were also more likely to be unemployed (75.6% vs 22.7%, p < 0.0001) and non-married (56.3% vs. 52.7%, p < 0.0001). Rates of STEMI were lower in the post-Katrina group (29.1% vs 42.0%, p < 0.002). There was no significant difference in terms of sex, being uninsured, or prior coronary artery bypass grafting. Four patients were COVID positive in the post-Katrina cohort. Conclusion(s): There was a fourfold increase in the incidence of AMI sixteen years after Hurricane Katrina. Prevalent psychosocial, behavioral, and traditional CAD risk factors were significantly higher among the post- Katrina group. These findings will continue to add to the growing body of literature demonstrating the adverse cardiovascular outcomes that occur after a natural disaster. Despite this, further research is required to explain the underlying mechanisms to help mitigate future cardiac morbidity. This study will help enable cardiovascular clinicians to further understand the needs and dynamic changes that can occur following natural disasters. Copyright © 2023 Southern Society for Clinical Investigation.

Planning and executing a health fair to bridge accessibility gaps and language barriers for the Hispanic community in Mobile County, Alabama

Purpose of Study: Community health fairs have been developed to address the unmet needs for disease prevention and health education among underserved communities. Hispanic communities experience significant non-financial barriers (e.g., cultural and linguistic) that also contribute to lower rates of access and utilization of health care services, including important preventive screening services. Around 3% of Mobile County's population is Hispanic. The aim of this event was: (1) To perform basic health screening, provide health education, and administer COVID-19 and Influenza vaccines to children under the age of 18 years. (2) To act as a bridge between the Hispanic families in the community and the available resources to help them overcome barriers to accessing quality care. Methods Used: We started by identifying and finalizing the location and the date for the health fair with help from the Guadalupe Center (a faith-based organization). We planned to divide the health fair into three specialized zones: Health Screening, Health Education, and Vaccination. The Health Screening zone would include anthropometry, developmental screening, and vision screening. The Health Education zone would educate the families on asthma care, breastfeeding, drowning prevention, road safety, safe sleep practices, oral hygiene, adverse childhood experiences, and healthy lifestyle. The Vaccination Zone would administer COVID-19 and Influenza vaccines. We designed and printed brochures for all health education topics in English and in Spanish. Age and gender appropriate 'Health Passports' with growth charts and other key parameters to record the child's health status were also created. Resident and medical student volunteers were trained regarding documentation, health screening, health education, and referrals to early intervention or specialist services that accepted uninsured or Medicaid patients. Summary of Results: A total of 49 children underwent health screening and health education. Each child's health status was documented in age and gender appropriate 'Health Passport'. In addition to this, these children and their parents were educated at the various health education stations and provided with brochures. Around 40% of the children that were screened had an abnormal vision screen, the parents of these children were given a list of available resources for further follow-up. Six children with developmental delay were identified and early intervention forms were filled out for two and more information regarding the Individualized Education Program (IEP) was given to the other four families. Eight children were vaccinated for COVID-19 and five were vaccinated for Influenza. Conclusion(s): The Hispanic community has persistently faced barriers to access healthcare due to literacy and socioeconomic status. Academic institutions and community- based organizations must work to develop and sustain culturally relevant health education and outreach events to reduce these disparities. Copyright © 2023 Southern Society for Clinical Investigation.

Patient-reported access to telehealth: An important and unmeasured social determinant of health

Background: The recent COVID-19 pandemic expanded opportunities for remote oncology telehealth visits. However, reliable internet connectivity, digital literacy, and patient comfort with virtual medical visits may differ among patients, especially socially disadvantaged groups. The primary aim of this study was to identify patient demographics and social determinants of health (SDOH) which might limit access to remote telehealth services. Method(s): First, a retrospective analysis was performed of composite administrative data of all patient visits to a large regional cancer center over the COVID-19 pandemic (3/2020-4/2022). Second, a prospective, crosssectional study was conducted of patients with known or suspected malignancy presenting to the same center over six-months (11/2021-5/2022). Participants were asked a standard set of survey questions regarding telehealth accessibility during an in-person clinic visit. Demographics and SDOH were ed from the electronic health record (EHR). Result(s): Although Black patients comprised 43% (n=9,021) of all patient visits (n=20,953), the proportion of telehealth visits conducted among Black patients (29%;n=889) was significantly lower compared to White patients (71%, n=2,142, p<0.0001). Within the cross-sectional study cohort (n=149), 51% (n=76) were Black, 39% (n=58) resided in a rural county, and 8.7% (n=13) were uninsured or Medicaid-insured. Black participants were more likely to self-report lack of internet access (73.7% vs. 90.4%, p<0.01) and were less likely to report having access to or actively using a patient portal in the EHR compared to White patients (47.4% and 79.5%, respectively;p<0.001). Rates of self-reported access to videocapable devices (82.9% vs. 90.4%) and confidence in conducting video visits without assistance (59.2% vs. 68.5%) were similar among Black and White patients (p>0.05). The most common selfidentified challenge to telehealth usage among both races was limited digital literacy. Conclusion(s): Black patients disproportionally under-participated in telehealth visits, suggesting underlying structural disparities in access to digital care. A greater proportion of Black participants self-reported lack of internet access and access to a patient portal to the EHR compared to White patients. Ensuring equal internet access and digital literacy will be critical to reduce further disparities in cancer care among racial minorities.

Potential cost of not vaccinating against COVID19 in the United States

Introduction: As of April 2022, the COVID19 global pandemic has resulted in over six million deaths globally, and over 81 million cases of COVID19 in the United States. Objective(s): The objective of the presentation is to share estimated direct and indirect costs due to COVID19 infection juxtaposed with the costs of COVID19 vaccine administration in the United States. Method(s): A literature review was conducted to identify potential cost savings from being immunized against COVID19. The costs of COVID19 vaccinations, direct costs related to healthcare and types of indirect costs were noted. Result(s): After reviewing over 40 resources, several costs were identified. The cost of COVID19 vaccine series, as defined by the Centers of Medicare and Medicaid Services (CMS), is currently USD40 for single-dose and USD40 per dose in a multiple-dose series. It is estimated that the average hospitalisation stay of an uninsured inpatient was ~USD7000-USD10,000 per day. The average cost of 12 major metropolitan cities in the United States were estimated for primary care facilities, urgent care facilities, and emergency room visits at USD195, USD239, USD1,425, respectively. As of April 2, 2022, 77% of the US have received at least one dose of COVID19 vaccine and 66% are considered to be fully vaccinated against COVID19 primary series. Conclusion(s): According to the data, the cost reduction in healthcare is consequential and cost-effective in vaccinating the population. This analysis contributes to the limited reports of a national cost-benefit analysis.

"TRANSFER FOR HIGHER LEVEL OF CARE": AN EXCUSE TO GET RID OF UNINSURED PATIENTS?

SESSION TITLE: Actionable Improvements in Safety and Quality SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: The overall mortality rate for patients ‘transfered’ to the medical intensive care units is thought to be significantly higher than the mortality rate amongst those admitted directly. (1) It has also been suggested that uninsured critically ill patients have a higher probability of being ‘transferred’ to other hospitals as well as a higher mortality rate. (2, 3) We aim to determine whether insurance coverage impacts the transfer of critically ill patients. METHODS: This study was conducted at a quaternary care hospital which is also a regional transfer center. We accessed the public data for the year 2020 through our institutions Transfer Center Dashboard, System Analytics. The two aspects of transferred patients we focused upon were: 1) Hospital service (subspecialty care required) and 2) Financial class. Major subspecialties included in the study were: Pulmonology, Internal Medicine, Neurosurgery, Cardiology, and Neurology. Our study was a patient safety project, hence it qualified for IRB exemption. We classified the percentage of transfers as ‘Accepted’, ‘Declined’, or ‘Canceled’;and determined the insurance status of the patient. RESULTS: We found a total of 3552 patients transfers were initiated. 31.9% (1136) transfer patients were accepted, 46.79% (1662) transfers were declined, and 21.23% (754) were canceled due to reasons including unsafe transfer, acceptance at other institutions, or death prior to transfer. Major categories for transfers were Pulmonology (16.1%), other Internal Medicine related diseases (15.3%), and Neurosurgery (11.8%) were the subspecialties with the highest rate of transfers. In terms of financial class, we determined that 44.81% (n=509) of the ICU transfers had no insurance, 27.81% (n=316) had Medicare support, and 17.81% (n=202) had managed care through a health maintenance organization (HMO);the remaining 9.59% had other insurance plans. We used a binomial test to determine the probability of a transfer under no insurance (p) with the formula p + q=1, across the total number of transfer requests (n). K was the number of actual transfers that occurred. Total transfer requests were n=3552, actual transfers were k=1136 and transfers without insurance were 509/44.8%, converted into p=0.45 with a resulting q of 0.55.For z-test, we used the formula z = ((K - np) +- 0.5) / √npq = 15.58. Our one-tailed probability of exactly, or fewer than, 1136(K) out of 3552(n) was p <.000001. Our study was limited because of the COVID-19 pandemic occurring in the same year. CONCLUSIONS: Based on our results, we conclude that the ‘uninsured’ patients are more susceptible to getting transferred to other institutions. CLINICAL IMPLICATIONS: Critically ill ‘uninsured’ patients are selctively subjected to be transfered to other hospitals for higher level of care. These transfers may have significant health implications thereby resulting in higher morbidity and mortality in unisured populations. DISCLOSURES: No relevant relationships by Joodi Akhtar No relevant relationships by Sahar Fatima Advisory Committee Member relationship with Astra Zeneca Please note: 24 months Added 03/16/2022 by FAISAL MASUD, value=Honoraria Advisory Committee Member relationship with Teleflex Please note: 12 months Added 03/16/2022 by FAISAL MASUD, value=Consulting fee Advisory Committee Member relationship with La Jolla Please note: 12 months Added 03/16/2022 by FAISAL MASUD, value=Consulting fee No relevant relationships by Iqbal Ratnani No relevant relationships by Salim Surani No relevant relationships by Anza Zahid

IMPROVING ACCESS TO ADVANCED CARDIORESPIRATORY THERAPIES FOR UNDERSERVED PATIENTS AND MINORITIES WITH A MULTIDISCIPLINARY EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) PROGRAM IN A LARGE PUBLIC HOSPITAL NETWORK

SESSION TITLE: Impact of Health Disparities and Differences SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Vulnerable patients, including minorities and underserved populations whose care relies on public hospitals, have limited access to advanced cardiac or respiratory care in shock centers or extracorporeal membrane oxygenation (ECMO)-capable hospitals, especially when socioeconomic or insurance barriers play a role in patient selection. Our aim is to describe the implementation of an ECMO program for cardiac and respiratory failure during the COVID-19 pandemic in the largest public health system in the country, as a strategy to mitigate healthcare disparities and improve access to care for minorities. METHODS: We collected clinical, demographic and socioeconomic data of all patients undergoing ECMO at Bellevue Hospital Center, the shock and ECMO center for New York City’s Health and Hospitals’ network. This public health system includes 11 Hospitals and provides care to 1 million New Yorkers. The decision to proceed with ECMO took place with a multidisciplinary team discussion, which was also in charge of providing longitudinal care during their hospitalization. RESULTS: A total of 49 patients were included [30 veno-venous (VV) ECMO, 19 venoarterial (VA) ECMO, including 9 extracorporeal cardiopulmonary resuscitation (ECPR)] from April 1st, 2020 to March 30th, 2022. The median age was 42.6 years, 57% were male, 38% were Hispanic, 35% African American, 14% white, 6% Asian and 8.2% had other ethnicities;33% were uninsured, 49% lived below the poverty level reported for New York City and 20% were undocumented. Level of education was 8th grade or less in 2.1%, high school in 24.5%, ≤ 2 years of college in 10.2%, >4 years of college in 12.2% and unknown in 51%. ECMO survival was 56% for VV ECMO, 44% for VA ECMO and 33% for ECPR. Survival to discharge was 56% for VV, 33% for VA and 33% for ECPR. One VV ECMO patient was bridged to lung transplant, there were no patients bridged to LVAD or heart transplant. Bleeding complications occurred in 3 patients (6%) and there were no procedural related complications. CONCLUSIONS: Our multidisciplinary ECMO program demonstrates feasibility to provide care to underserved and vulnerable populations with outcomes comparable to the national average, despite the challenges related to the potential limitations in bridging strategies for such patients. While socioeconomic and insurance status have a key role in bridging options for ECMO, they should not be a major determinant in denying patients advanced cardiopulmonary support if clinically indicated. CLINICAL IMPLICATIONS: Access to advance cardiorespiratory therapies including ECMO for vulnerable populations is a present need and is feasible with a multidisciplinary team DISCLOSURES: Speaker/Speaker's Bureau relationship with Zoll Please note: 3 years Added 04/04/2022 by Carlos Alviar, value=Honoraria No relevant relationships by Fariha Asef No relevant relationships by Sripal Bangalore No relevant relationships by Samuel Bernard No relevant relationships by Lauren Bianco No relevant relationships by Nishay Chitkara No relevant relationships by Jennifer Cruz No relevant relationships by Michael DiVita Research support relationship with Eurofins Viracor Please note: 12/1/2021 ongoing Added 12/23/2021 by Randal Goldberg, value=Grant/Research Support No relevant relationships by Kerry Hena No relevant relationships by William Howe No relevant relationships by Norma Keller no disclosure on file for Ma-Rosario Mertola;no disclosure on file for Thor Milland;No relevant relationships by vikramjit mukherjee No relevant relationships by Kayla Nunemacher No relevant relationships by Mansi Patel No relevant relationships by Radu Postelnicu No relevant relationships by Deepak Pradhan No relevant relationships by Vito Stasolla no disclosure on file for Amit Uppal;No relevant relationships by Susan Vlahakis No relevant relationships by Kah Loon Wan no disclosure on file for Victoria Yunaev;

Telemedicine Vision Threatening Diseases and Wellness Screenings in Uninsured Latino Community During COVID-19

Purpose : Limited access to eye-care among Latinos can lead to missed Vision Threatening Diseases (VTDs) defined as Age-related Macular Degeneration (AMD), cataracts, Diabetic Retinopathy (DR) and glaucoma. As 50% of the people with VTD's are unaware of their condition made worse during COVID-19, comprehensive eye screenings to assess ocular wellness was implemented using telemedicine, Artificial Intelligence (AI) and robotic consultations. Methods : State-sponsored screenings were conducted at a church in West New York, NJ (78% Latino, mostly from Colombia) over 3 weekends during the 2021 Pandemic. All participants had received two-dose vaccinations and wore a surgical mask during screenings. Nine first-year medical students and 6 community volunteers took part in the wellness evaluation including: medical history, blood pressure, visual acuity, automated refraction, puff tonometry, 45-degree non-mydriatic retinal photography AI. To confirm findings: 6-micron resolution ocular coherence tomography (OCT) B-scan was performed. Screened subjects had their data reviewed by an onsite ophthalmic grader using a Spanish-speaking interpreter. As 80% of screened subjects are lost to follow-up, remote robotic ophthalmology consultation via HIPAA compliant Wi-Fi was utilized in real-time to connect with an off-site ophthalmologist. Results : 153 subjects, (71 Female (46%), median age 55) had 127 ocular findings (Table 1) found in 85 (55%) subjects, of which 98% of findings were previously unknown and 40 (47%) classified as VTD. 23(15%) subjects had multiple findings. OCT confirmed 23 cases of AMD and glaucoma. AI referred 39 cases. 36 individuals took part in robotic virtual consults. Findings were: cataracts 70 (45%), glaucoma 32 (20%), and AMD 25(16%). Among those with findings, 82% were uninsured and 90% had >2 years since last eye exam. 32 (32/153) subjects had undertreated or untreated hypertension. 93% were un-familiar with telemedicine. Conclusions : Latinos without health insurance and ease of access to eyecare may have a higher burden of multi-VTDs. An exception was DR which could be a limitation of population bias. This pilot study supports comprehensive wellness eye screenings that may allow for early detection, confirmation, and referral of single or multiple VTD in high-risk low-income communities. Further studies are needed using larger sample populations. (Figure Presented).

Patient-reported disruptions to cancer care in the U.S. during the COVID-19 pandemic: A national cross-sectional study

Background: Disruptions to cancer care during the COVID-19 pandemic due to disease mitigation efforts, supply-chain issues, and fear of COVID-19 have all been reported, but study of their extent has been limited. The purpose of this study is to evaluate the extent and associations with patient reported disruptions to cancer treatment and other care during the COVID-19 pandemic using nationally representative data. Methods: This cross-sectional study uses data from the 2020 National Health Interview Survey (NHIS), an annual, cross-sectional survey of US adults. Adults who reported requiring current cancer treatment or other care related to their cancer in the second half of 2020 were included. Rates of patients with self-reported changes, delays, or cancellations to cancer treatment or other cancer-related care due to the COVID-19 pandemic were calculated and their associations with demographic and other variables were analyzed. All data were adjusted using sample weights and specific variables to account for stratification and other survey characteristics using the Stata svy command. Chi-square testing was used to compare proportions across variable groups. Univariable logistic regression analysis was utilized to assess variable associations with change, delay, or cancellations to cancer care during the COVID-19 pandemic. Multivariable logistic regression analysis was used to create a model adjusted for select demographic variables. Results: A sample-weighted 2,867,326 adults (n=574) reported requiring cancer treatment and/or other cancer care since the start of the COVID-19 pandemic. Of these, 189 (32.1%) reported any change, delay, or cancellation due to the pandemic. On univariable analysis, patients who were younger, female, had comorbidities, and uninsured were significantly more likely to report care disruptions. On adjusted analysis, younger age and female sex remained significant predictors. In a sample-weighted subset of 1,600,587 patients (n=331), 291 (87.9%) reported virtual appointment use. There was no association with disruptions across breast, prostate, lung, and colorectal cancer groups. Conclusions: Approximately 1/3 of patients experienced disruptions to cancer care during the COVID-19 pandemic. Patients with younger age or female sex were more likely to have disruptions in care, which may reflect risk stratification strategies in the early stages of the pandemic. The longitudinal impact of these disruptions on outcomes merits further study.

Racial and socioeconomic disparities in telemedicine use among US patients initiating cancer treatment during the COVID-19 pandemic

Background: The COVID-19 pandemic was associated with declines in in-person clinical visits. While telemedicine visits have increased, uptake has varied. Here we assess demographic and socioeconomic factors associated with telemedicine use among patients initiating treatment for 21 common cancers at community oncology clinics. Methods: This retrospective study uses the nationwide Flatiron Health electronic health record-derived de-identified database of patients with cancer. Patient characteristics were determined using structured and unstructured data curated via technology-enabled ion. We included patients (≥ 18 years) who initiated first-line cancer treatment between March 2020 and September 2021 (follow-up through December 2021). We focused on differences in telemedicine use (≥ 1 telemedicine visit within 90 days after treatment initiation) across race/ethnicity, insurance coverage, rurality (per Rural-Urban Commuting Areas), and socioeconomic status (SES). SES was defined using census block group data from the American Community Survey (2015-2019) (quintiles representing least to most affluent areas) based on patient addresses and measured using the Yost Index (incorporating income, home values, rental costs, poverty, blue-collar employment, unemployment, and education information). We used logistic regression models adjusted for clinical characteristics (i.e., age, sex, performance status, and stage) to examine differences in telemedicine use. Results: This study included 24,164 patients (48.1% women, median age: 69 [interquartile range: 61-77] years), of whom 15.9% used telemedicine services. Black patients were less likely to use telemedicine services than White patients (11.4% vs. 15.6%, odds ratio [OR] 0.69 [95% confidence interval [CI]: 0.59-0.79], p<0.01). Telemedicine use was also lower among patients without documented insurance than well-insured (commercial and Medicare payers) patients (10.7% vs. 15.9%, OR 0.62 [95% CI: 0.54-0.72], p<0.01). Those in rural (9.8%, OR 0.51 [95% CI: 0.45- 0.58], p<0.01) and suburban areas (13.1%, OR 0.71 [95%: 0.64-0.79], p<0.01) were less likely to use telemedicine services than patients in urban areas (17.6%). Finally, patients in the least affluent areas had lower telemedicine use than those in the most affluent areas (10.2% vs. 24.3%, OR 0.35 [95% CI: 0.31-0.40], p<0.01). Conclusions: During the COVID-19 pandemic, nearly one-fifth of patients initiating cancer treatment used telemedicine services. However, there were substantial disparities: Black, uninsured, non-urban, and less affluent patients are less likely to use telemedicine services. While telemedicine may expand access to specialty care, the proliferation of these services may widen cancer care disparities if vulnerable populations do not have equitable access.

Rapid evidence reviews to inform COVID-19 treatment guidelines in South Africa

Introduction/ Background: In March 2020, the South African National Essential Medicines List Committee established a multidisciplinary expert panel to review emerging evidence for COVID-19 medicines quickly and systematically. Recommendations inform National Department of Health COVID-19 guidelines. We describe implementation of this rapid review mechanism and the impact of recommendations on medicines utilisation. Methods: A protocol was developed for conducting rapid reviews, including the formulation of pre-specified review question, search of at least 2 databases, data extraction and synthesis, evidence appraisal, and summarising key findings and recommendations (PROSPERO registration: CRD42021286710). The COVID-nma initiative was engaged, using global evidence syntheses, adapted to local context. National Surveillance Centre medicines procurement data were analysed, monitoring the impact of the guidelines on medicine use. Pre-pandemic medicine use (2019) was compared to pandemic use (2020), as a ratio of utilisation per 1000 uninsured population for corticosteroids, azithromycin, colchicine, and vitamin C. Results: To date the committee have reviewed 26 medicines (for treatment and prevention of COVID-19) by conducting 52 rapid reviews (including updates and evidence summaries). Review of aggregate procurement data showed that utilisation of corticosteroids (that is recommended for hospitalised COVID-19 patients on oxygen), increased 1.6-fold across all 9 South African provinces. Colchicine and azithromycin (not recommended to treat COVID-19) use did not change. However, use of vitamin C (not recommended) increased 2.2-fold. Impact: A generic rapid review protocol using GRADE principles and an explicit evidence-to-decision framework promoted adaptation of global evidence to develop robust and transparent guidelines. Medicines utilisation data, though, suggests that investment is needed to strengthen guideline implementation. Conclusion: Through extensive collaboration, the Department of Health managed therapeutic uncertainty by developing and implementing a rapid, robust, and transparent evidence-informed approach. However, the impact on clinical practice is uncertain, highlighting the need for more intensive investigation of patient-level prescribing data and engagement with healthcare providers.