Home-based self-sampling vs clinician sampling for anal precancer screening: The Prevent Anal Cancer Self-Swab Study.

Sexual minority men are at increased risk for anal squamous cell carcinoma. Our objective was to compare screening engagement among individuals randomized to self-collect an anal canal specimen at home or to attend a clinic appointment. Specimen adequacy was then assessed for human papillomavirus (HPV) DNA genotyping. A randomized trial recruited cisgendered sexual minority men and transgender people in the community and assigned them to use a home-based self-collection swabbing kit or attend a clinic-based swabbing. Swabs were sent for HPV genotyping. The proportions of participants completing screening in each study arm and the adequacy of their specimens for HPV genotyping were assessed. Relative risks were estimated for factors associated with screening. A total of 240 individuals were randomized. Age (median, 46 years) and HIV status (27.1% living with HIV) did not differ by study arm. A total of 89.2% and 74.2% of home-arm and clinic-arm individuals returned the swab, respectively (P = .003), difference between groups, 15.0% (95% CI 5.4%-24.6%). Among black individuals, 96.2% and 63.2% in the home and clinic arms screened (P = .006). Among individuals with HIV, 89.5% and 51.9% in the home and clinic arms screened (P < .001). Self-collected swabs and clinician-collected swabs were comparable in adequacy for HPV genotyping (96.3% and 93.3%, respectively). People at highest risk for anal cancer may be more likely to screen if they are able to self-collect swabs at home rather than attend a clinic.

Ambulatory Intensive, Multidisciplinary Telehealth for High-Risk Discharges: Program Development, Implementation, and Early Impact.

INTRODUCTION: Creating and implementing programs aimed at reducing readmissions for high-risk patients is critical to demonstrate quality and avoid financial penalties. Intensive, multidisciplinary interventions providing care to high-risk patients utilizing telehealth have not been explored in the literature. This study seeks to explain the quality improvement process, structure, intervention, lessons learned, and early outcomes of such a program. METHODS: Patients were identified prior to discharge with a multicomponent risk score. The enrolled population was managed intensively for 30 days after discharge through a suite of services, including weekly video visits with an advanced practice provider, pharmacist, and home nurse; regular lab monitoring; telemonitoring of vital signs; and intensive home health visits. The process was iterative, including a successful pilot phase followed by an expanded health system-wide intervention analyzing multiple outcomes including satisfaction with video visits, self-rated improvement in health, and readmissions compared to matched populations. RESULTS: The expanded program resulted in improvements in self-reported health (68.9% reported health was some or greatly improved) and high satisfaction with video visits (89% rated satisfaction with video visits 8-10). Thirty-day readmissions were reduced compared to individuals with similar readmission risk scores discharged from the same hospital (18.3% vs 31.1%) and individuals who declined to participate in the program (18.3% vs 26.4%). CONCLUSIONS: This novel model using telehealth to provide intensive, multidisciplinary care to high-risk patients has been successfully developed and deployed. Key areas for growth and exploration include developing an intervention that captures a greater percentage of discharged high-risk patients, including non-homebound patients, improving the electronic interface with home health care, and reducing costs while serving more patients. Data show that the intervention results in high patient satisfaction, improvements in self-reported health, and preliminary data showing reductions in readmission rates.

COVID-19 Vaccination Telephone Outreach: A Primary Care Clinic Intervention Targeting Health Equity.

INTRODUCTION: Equitable COVID-19 vaccine access is essential to ending the COVID-19 pandemic. In many instances, COVID-19 vaccination notification and scheduling occurred through online patient portals, for which socially vulnerable populations have limited access. Our objective was to reduce disparities in COVID-19 vaccine access for the Black and socially vulnerable populations unintentionally excluded by our health system's patient portal-driven vaccine outreach through a telephone outreach initiative. METHODS: From February 1, 2021, through April 27, 2021, telephone outreach was directed towards patients aged 65 and older without patient portal access at a large urban academic general internal medicine clinic. Univariate and multivariate analyses between those who did and did not receive telephone outreach were completed to assess the odds of vaccination, accounting for outreach status, sex, age, race/ethnicity, payor status, social vulnerability index, and Elixhauser Comorbidity count. RESULTS: A total of 1466 patients aged 65 and older without active patient portals were eligible to receive the COVID-19 vaccine. Of these patients, 664 received outreach calls; 382 (57.5%) of them got vaccinated compared to 802 patients who did not receive outreach calls, of which 486 (60.6%) got vaccinated (P = 0.2341). Patients who received outreach calls versus those who did not were more likely to be female, younger, non-Hispanic Black, from high social vulnerability index census tracts, and have higher Elixhauser Comorbidity counts. Logistical analysis revealed an odds ratio (OR) with a nonstatistically significant trend favoring higher vaccination likelihood in the no outreach cohort with univariate analysis with no changes when adjustment was made for age, sex, race/ethnicity, payor, social vulnerability index, and Elixhauser Comorbidity count (univariate analysis: OR 0.88 [95% CI, 0.71-1.09]; model 1: OR 0.89 [95% CI, 0.72 - 1.10]; model 2 - 0.89 (0.72 - 1.11); model 3: OR 0.87 (95% CI, 0.70 -1.09)]. CONCLUSIONS: While our telephone outreach initiative was not successful in increasing vaccination rates, lessons learned can help clinicians and health systems as they work to improve health equity. Achieving health equity requires a multifaceted approach engaging not only health systems but also public health and community systems to directly address the pervasive effects of structural racism perpetuating health inequities.

COVID-19 vaccination telephone outreach: an analysis of the medical student experience.

INTRODUCTION: The COVID-19 pandemic diminished opportunities for medical students to gain clinical confidence and the ability to contribute to patient care. Our study sought out to understand the value of telephone outreach to schedule COVID-19 vaccines on medical student education. MATERIALS AND METHODS: Forty students engaged in telephone outreach targeting patients aged 65+ without active patient portals to schedule COVID-19 vaccines. Data consisted of a single administration retrospective pre/post survey inquiring about what students learned, expectations, other health-care processes that would benefit from outreach, and interest in a population health elective. Likert items were analyzed and open response analysis involved inductive coding and generation of thematic summaries by condensing codes into broader themes. Demographic data of patients called and subsequently received the vaccine were also collected. RESULTS: There were 33 survery respondents. There was a statistically significant increase in net comfortability for pre-clerkship students for documenting in Epic, providing telehealth care, counseling on common health-care myths, having challenging conversations, cold-calling patients, and developing an initial trusting relationship with patients. The majority called and who received the vaccine were non-Hispanic Black, within the high SVI category, and had Medicare and/or Medicaid. Qualitative data showed that students emphasized communication, the role of trusted messengers, the need to be open minded, and meeting patients where they are. DISCUSSION: Engaging students in telephone outreach early in the COVID-19 pandemic provided students the opportunity to develop their skills as physicians-in-training, contribute to combating the ongoing pandemic, and add value to the primary care team. This experience allowed students to practice patience, empathy, and vulnerability to understand why patients had not received the COVID-19 vaccine; this was an invaluable experience that helped students develop the skills to become empathetic and caring physicians, and supports the continued role of telehealth in future medical school curriculum.

The relationship between adverse childhood experiences, the frequency and acuity of emergency department utilization and primary care engagement.

INTRODUCTION: A history of adverse child experiences (ACEs) is associated with increased high-risk adult behaviors, morbidity, mortality, and use of the emergency department. This study was designed to understand the relationship between ACEs and the characteristics of emergency department use and primary care engagement. METHODS: An in-person survey was conducted at an academic emergency department (ED) assessing ACE score, emergency department utilization and acuity, and primary care engagement. RESULTS: The prevalence of ACEs was 71.1% with 1+ ACE and 32.5% with 4+ ACE. ACE scores of four or more were associated with three or more ED visits in the past year compared those with an ACE score of zero (OR 3.22; p < 0.05) and when adjusted for sociodemographic factors (OR 3.22; p < 0.10). Higher ACE scores were associated with lower acuity presentations as indicated by the Emergency Severity Index before (ACE score 1 OR 3.91 p < 0.05; ACE score 2-3 OR 2.35 p < 0.05; ACE score 4+ OR 3.95 p < 0.05) and after adjustment (ACE score 1 OR 3.80 p < 0.10; ACE 2-3 OR 3.50 p < 0.10; ACE 4+ OR 4.36 p < 0.05). There was no association between ACE score and having a primary care provider (PCP), frequency of PCP visits, or PCP rating. CONCLUSION: Higher ACE scores were associated with higher emergency department utilization and lower acuity presentations but not associated with levels of primary care engagement. Additional investigations are needed to adequately characterize the discrete causal mechanisms behind these current findings.

Details of developing and implementing an intensive interdisciplinary care program for high need, high cost patients.

1. Developing and implementing an intensive interdisciplinary medical home within a large academic medical center was feasible. 2. Deploying a complex care management program that shared staff and resources with an intensive primary care program was not successful. 3. Barriers included traversing legal barriers to text messaging patients, making hospital consults feasible financially, managing challenging patients, team wellness, provider back up, managing homebound patients, and discharging patients. 4. Although expensive, this model may have hidden benefits including improved patient satisfaction, quality of care, and providing a solid care system for a health system's most challenging and vulnerable population.