Sources of Clinician Burnout in Providing Care for Underserved Patients in a Safety-Net Healthcare System.

BACKGROUND: Burnout among clinicians is common and can undermine quality of care, patient outcomes, and workforce preservation, but sources of burnout or protective factors unique to clinicians working in safety-net settings are less well understood. Understanding these clinician experiences may inform interventions to reduce burnout. OBJECTIVE: To describe clinician perspectives on sources of burnout in a safety-net healthcare system. DESIGN: Semi-structured interviews were conducted with clinicians from multiple disciplines who provided care at a safety-net healthcare system from October 2018 to January 2019. Transcripts were analyzed using thematic analysis. PARTICIPANTS: Forty clinicians (25 female and 15 male; mean [SD] age, 41 [9.1]) participated, including physicians, social workers, advanced practice providers, nurses, psychologists, physical and occupational therapists, and other healthcare professionals. MAIN OUTCOMES AND MEASURES: Themes and subthemes that reflected clinician experiences, burnout, and workload expectations. KEY RESULTS: Five themes emerged: limited resources (entrenched social injustices, brokenness of the US healthcare system, precarious discharge options, and "revolving door" readmissions), barriers to building trust with patients (chasm of communication, addressing fear and mistrust, and being exposed to threats), administrative requirements (criticism hampering meaningful care, assuming extra workloads, bureaucratic burden), compassion fatigue (confronting traumatic situations, persistent worry about patient safety and welfare, witnessing mistreatment and stigmatization, overextending and overinvesting, withdrawing and shutting down, blaming self and career crisis), and advocacy as a counterbalance to burnout (solidarity when helping underserved communities, fervent advocacy, and patient gratitude). CONCLUSIONS: Among clinicians who provide care in a safety-net healthcare system, sources of burnout included limited resources, barriers to building trust with patients, administrative requirements, and compassion fatigue, but clinicians remained driven by their desire to advocate for patients. Policy-level interventions which increase funding to safety-net healthcare systems to bolster existing resources and staffing, create peer-support and wellness programs, and support advocacy efforts may mitigate burnout.

Patient Navigation: Addressing Social Challenges in Dialysis Patients.

Members of racial and ethnic minority groups make up nearly 50% of US patients with end-stage kidney disease and face a disproportionate burden of socioeconomic challenges (ie, low income, job insecurity, low educational attainment, housing instability, and communication challenges) compared with non-Hispanic whites. Patients with end-stage kidney disease who face social challenges often have poor patient-centered and clinical outcomes. These challenges may have a negative impact on quality-of-care performance measures for dialysis facilities caring for primarily minority and low-income patients. One path toward improving outcomes for this group is to develop culturally tailored interventions that provide individualized support, potentially improving patient-centered, clinical, and health system outcomes by addressing social challenges. One such approach is using community-based culturally and linguistically concordant patient navigators, who can serve as a bridge between the patient and the health care system. Evidence points to the effectiveness of patient navigators in the provision of cancer care and, to a lesser extent, caring for people with chronic kidney disease and those who have undergone kidney transplantation. However, little is known about the effectiveness of patient navigators in the care of patients with kidney failure receiving dialysis, who experience a number of remediable social challenges.

The Experience of Primary Caregivers of Undocumented Immigrants with End-Stage Kidney Disease that Rely on Emergency-Only Hemodialysis.

BACKGROUND: Undocumented immigrants with end-stage kidney disease (ESKD) who rely on emergency-only hemodialysis (dialysis only after an emergency department evaluation) face psychosocial distress. Emergency-only hemodialysis (EOHD) is likely burdensome for primary caregivers as well. OBJECTIVE: To understand the experience of primary caregivers of undocumented immigrants with ESKD who rely on emergency-only hemodialysis. DESIGN, SETTING, AND PARTICIPANTS: A qualitative, semi-structured interview study to assess the experiences of primary caregivers of undocumented immigrants with ESKD at a safety-net hospital in Denver, Colorado from June 28 to November 15, 2018. Applied thematic analysis was used to analyze interviews. MAIN OUTCOMES AND MEASURES: Themes and subthemes. RESULTS: Twenty primary caregiver participants had a mean (SD) age of 46 (17), 13 (65%) were female, 7 (35%) were in an adult child caregiver role, and 13 (65%) were spouses. Five themes and 17 subthemes (in parentheses) were identified: (1) Caregiver role (providing emotional, physical, and economic support, advocacy and care navigation), (2) Caregiver burden (anxiety related to patient and personal death, emotional exhaustion and personal illness, struggle with finances, self-care and redefining relationship), (3) Unpredictable EOHD (acute episodes of illness that trigger emergency, stress when patient is denied dialysis, impact on work and sleep, and emotional relief after a session of EOHD), (4) Effect on children (dropping out or missing school, psychosocial distress, children assuming caregiver responsibilities, and juggling multi-generational caregiving of children), (5) Faith and appreciation (comfort in God and appreciation of healthcare). CONCLUSIONS AND RELEVANCE: Caregivers of undocumented immigrants with ESKD who rely upon EOHD experience caregiver burden and distress. The impact of EOHD on caregivers should be considered when assessing the consequences of excluding undocumented immigrants from public insurance programs.

Disproportionate Incidence of COVID-19 Infection, Hospitalizations, and Deaths Among Persons Identifying as Hispanic or Latino - Denver, Colorado March-October 2020.

Persons identifying as Hispanic or Latino (Hispanic) represent the second largest racial/ethnic group in the United States (1), yet understanding of the impact of coronavirus disease 2019 (COVID-19) in this population is limited. To evaluate COVID-19 health disparities in the community and inform public health, health system, and community-based interventions, local public health authorities analyzed the sociodemographic characteristics of persons who were diagnosed, hospitalized, and who died with COVID-19 in Denver, Colorado. During the first 7 months of the COVID-19 epidemic in Denver (March 6-October 6, 2020) the majority of adult COVID-19 cases (54.8%), hospitalizations (62.1%), and deaths (51.2%) were among persons identifying as Hispanic, more than double the proportion of Hispanic adults in the Denver community (24.9%) (1). Systemic drivers that influence how Hispanic persons live and work increase their exposure risks: compared with non-Hispanic persons, Hispanic persons with COVID-19 in Denver reported larger household sizes and were more likely to report known exposures to household and close contacts with COVID-19, working in an essential industry, and working while ill. Reducing the disproportionate incidence of COVID-19 morbidity and mortality among Hispanic persons will require implementation of strategies that address upstream social and environmental factors that contribute to an increased risk for both infection and transmission and that facilitate improved access to culturally congruent care.

Perceived Adequacy of Tangible Social Support and Associations with Health Outcomes Among Older Primary Care Patients.

BACKGROUND: The availability and adequacy of tangible social support may be critical to older adults managing multiple chronic conditions, yet few studies have evaluated the perceived adequacy of needed tangible support and its relation to health outcomes. OBJECTIVE: We investigated the association between unmet, tangible social support needs, health status, and urgent healthcare use among community-dwelling older adults. DESIGN: Cross-sectional analysis. PARTICIPANTS: English-speaking older adults (n = 469) who participated in the Health Literacy and Cognitive Function cohort study. MAIN MEASURES: Perceived adequacy of tangible social support was measured using a brief, validated scale that determined (1) if an individual needed assistance managing his or her health, and (2) if yes, whether this need was met. Health status was measured using physical function, depression, and anxiety PROMIS short-form instruments. Urgent healthcare utilization (emergency department and hospitalization) was self-reported for the past 12 months. KEY RESULTS: Participants' mean age was 69 years; 73% were women and 31% were African American, and 16% identified unmet support needs. Unmet support needs were associated with worse physical (ß - 6.32; 95% CI - 8.31, - 4.34) and mental health (anxiety: ß 3.84; 95% CI 1.51, 6.17; depression: ß 2.45; 95% CI 0.32, 4.59) and greater urgent healthcare utilization (ED: OR 2.86; 95% CI 1.51, 5.41; hospitalization: OR 3.75; 95% CI 1.88, 7.50). CONCLUSIONS: Perceived unmet support needs were associated with worse health status and greater urgent healthcare use. Primary care practices might consider screening older patients for unmet tangible support needs, although appropriate responses should first be established if unmet needs are identified.

Clinicians' Perspectives on Providing Emergency-Only Hemodialysis to Undocumented Immigrants: A Qualitative Study.

Background: In the United States, nearly half of undocumented immigrants with end-stage kidney disease receive hemodialysis only when they are evaluated in an emergency department and are found to have life-threatening renal failure ("emergency-only hemodialysis" [EOHD]). These patients experience psychosocial distress and much higher mortality than patients receiving regularly scheduled hemodialysis, but little is known about how providing EOHD affects the clinicians involved. Objective: To understand clinicians' experiences providing EOHD. Design: Qualitative study using semistructured interviews. Setting: A safety-net hospital in Denver, Colorado, and a safety-net system in Houston, Texas. Participants: Fifty interdisciplinary clinicians experienced in providing EOHD. Measurements: Interviews were analyzed using thematic analysis. Outcomes included themes and subthemes. Results: Four themes and 13 subthemes (in parentheses) were identified: 1) drivers of professional burnout (emotional exhaustion from witnessing needless suffering and high mortality, jeopardizing patient trust, detaching from patients, perceived lack of control over EOHD criteria, and physical exhaustion from overextending to bridge care), 2) moral distress from propagating injustice (altered care based on nonmedical factors, focus on volume at the expense of quality, and need to game the system), 3) confusing and perverse financial incentives (wasting resources, confusing financial incentives, and concerns about sustainability), and 4) inspiration toward advocacy (deriving inspiration from patients and strengthened altruism). Limitation: Whether the findings apply to other settings is unknown, and social desirability response bias might have reduced reporting of negative perceptions and experiences. Conclusion: Clinicians in safety-net settings who provide EOHD to undocumented patients describe experiencing moral distress and being driven toward professional burnout. The burden of EOHD on clinicians should inform discussions of systemic approaches to support provision of adequate care based on medical need. Primary Funding Source: Robert Wood Johnson Foundation and Doris Duke Charitable Foundation.

Patients' preferences for labor analgesic counseling: A qualitative analysis.

BACKGROUND: The decision to use, or not use, neuraxial labor analgesia is complex, with both maternal and fetal considerations. Fears and concerns about neuraxial analgesia may influence analgesic decision-making. Little is known about patients' preferences for analgesic counseling. Therefore, the objectives of this qualitative study were to evaluate the sources of information used by patients, the timing and content of antepartum counseling about labor analgesia, and patients' preferences for such counseling. METHODS: A semi-structured interview guide was developed. Survey domains included the sources of information used by patients, the timing and content of antenatal counseling, patients' perceptions of intrapartum analgesic counseling, and their preferences for analgesic counseling. Interviews occured on postpartum day 1. Interview transcripts were analyzed using content analysis. RESULTS: The interviews of 45 women were analyzed. The Internet was the most frequently mentioned source of information (44%). The majority of women (78%) discussed analgesic options with their obstetric providers before delivery. All women were counseled intrapartum by an anesthesiologist, but several women commented on the difficulty of concentrating while laboring. Seventy-three percent of women stated that they would want counseling on analgesic options from their obstetric provider during the second or third trimester. CONCLUSIONS: Women prefer to be counseled about labor analgesia by their obstetric providers, as they have an established relationship. Patients would prefer the counseling to occur during pregnancy, before the onset of labor. However, given the frequent use of the Internet, the content and quality of online materials should also be evaluated.

Patient-centered outcomes research to improve asthma outcomes.

The Patient-Centered Outcomes Research Institute is funding 8 comparative effectiveness research projects to improve patient-centered outcomes for African American and Hispanic/Latino patients with uncontrolled asthma. These projects aim to compare multilevel interventions with known efficacy at the community, home, and health system levels to enhance patient and clinician uptake of the National Heart, Lung, and Blood Institute's National Asthma Education Prevention Program guidelines and improve outcomes. The National Asthma Education Prevention Program guidelines provide clinicians with a range of acceptable approaches for the diagnosis and management of asthma and define general practices that meet the needs of most patients. Yet disparities in asthma care and outcomes remain pervasive for African Americans and Hispanics/Latinos. The National Heart, Lung, and Blood Institute AsthmaNet consortium has identified several top research priorities for pediatric and adult populations, including a recommendation to examine tailored approaches based on race/ethnicity. In addition, the guidelines emphasize the need for studies that focus on multicomponent interventions recognizing that single interventions are generally ineffective. This article will describe the Patient-Centered Outcomes Research Institute-funded asthma projects and how they are individually and collectively addressing evidence gaps in asthma care by focusing on multicomponent and tailored approaches for improving outcomes and reducing disparities for African American and Hispanic/Latino patients.

Primary Spoken Language and Neuraxial Labor Analgesia Use Among Hispanic Medicaid Recipients.

BACKGROUND: Hispanic women are less likely than non-Hispanic Caucasian women to use neuraxial labor analgesia. It is unknown whether there is a disparity in anticipated or actual use of neuraxial labor analgesia among Hispanic women based on primary language (English versus Spanish). METHODS: In this 3-year retrospective, single-institution, cross-sectional study, we extracted electronic medical record data on Hispanic nulliparous with vaginal deliveries who were insured by Medicaid. On admission, patients self-identified their primary language and anticipated analgesic use for labor. Extracted data included age, marital status, labor type, delivery provider (obstetrician or midwife), and anticipated and actual analgesic use. Household income was estimated from census data geocoded by zip code. Multivariable logistic regression models were estimated for anticipated and actual neuraxial analgesia use. RESULTS: Among 932 Hispanic women, 182 were self-identified as primary Spanish speakers. Spanish-speaking Hispanic women were less likely to anticipate and use neuraxial anesthesia than English-speaking women. After controlling for confounders, there was an association between primary language and anticipated neuraxial analgesia use (adjusted relative risk: Spanish- versus English-speaking women, 0.70; 97.5% confidence interval, 0.53-0.92). Similarly, there was an association between language and neuraxial analgesia use (adjusted relative risk: Spanish- versus English-speaking women 0.88; 97.5% confidence interval, 0.78-0.99). The use of a midwife compared with an obstetrician also decreased the likelihood of both anticipating and using neuraxial analgesia. CONCLUSIONS: A language-based disparity was found in neuraxial labor analgesia use. It is possible that there are communication barriers in knowledge or understanding of analgesic options. Further research is necessary to determine the cause of this association.

Use of quality improvement interventions and the link to performance on percutaneous intervention for acute myocardial infarction.

BACKGROUND: Despite numerous calls for hospitals to employ quality improvement (QI) interventions to improve emergency department (ED) performance, their impact has not been explored in multi-site investigations. OBJECTIVE: We investigated the association between use of QI interventions (patient flow strategies, ED electronic dashboards, and five-level triage systems) and hospital performance on receipt of percutaneous intervention (PCI) within 90 min for acute myocardial infarction patients, a publicly available quality measure. METHODS: This was an exploratory, cross-sectional analysis of secondary data from 292 hospitals. Data were drawn from the Quality Improvement Activities Survey, the American Hospital Association's Annual Survey, and Hospital Compare. Linear regression models were used to detect differences in PCI performance scores based on whether hospitals employed one or more QI interventions. RESULTS: Fifty-three percent of hospitals reported widespread use of patient flow strategies, 62% reported using a dashboard, and 74% reported using a five-level triage system. Time to PCI performance scores were 3.5 percentage points higher (i.e., better) for hospitals that used patient flow strategies and 6.2 percentage points higher for hospitals that used a five-level triage system. Scores were 10.4 percentage points higher at hospitals that employed two quality improvement interventions and 12.8 percentage points higher at hospitals that employed three. CONCLUSION: Employing QI interventions was associated with better PCI scores. More research is needed to explore the direction of this relationship, but results suggest that hospitals should consider adopting patient flow strategies, electronic dashboards, and five-level triage systems to improve PCI scores.

Social Determinants of Health and Preoperative Care.

Preoperative care exists as part of perioperative continuum during which anesthesiologists and surgeons optimize patients for surgery. These multispecialty efforts are important, particularly for patients with complex medical histories and those requiring major surgery. Preoperative care improves planning and determines the clinical pathway and discharge disposition. The role of nonmedical social factors in the preoperative planning is not well described in anesthesiology. Research to improve outcomes based on social factors is not well described for anesthesiologists but could be instrumental in decreasing disparities and advancing health equity in surgical patients.

Leveraging Ethnic Backgrounds to Improve Collection of Race, Ethnicity, and Language Data.

INTRODUCTION: Healthcare disparities may be exacerbated by upstream incapacity to collect high-quality and accurate race, ethnicity, and language (REaL) data. There are opportunities to remedy these data barriers. We present the Denver Health (DH) REaL initiative, which was implemented in 2021. METHODS: Denver Health is a large safety net health system. After assessing the state of REaL data at DH, we developed a standard script, implemented training, and adapted our electronic health record to collect this information starting with an individual's ethnic background followed by questions on race, ethnicity, and preferred language. We analyzed the data for completeness after REaL implementation. RESULTS: A total of 207,490 patients who had at least one in-person registration encounter before and after the DH REaL implementation were included in our analysis. There was a significant decline in missing values for race (7.9%-0.5%, p < .001) and for ethnicity (7.6%-0.3%, p < .001) after implementation. Completely of language data also improved (3%-1.6%, p < .001). A year after our implementation, we knew over 99% of our cohort's self-identified race and ethnicity. CONCLUSIONS: Our initiative significantly reduced missing data by successfully leveraging ethnic background as the starting point of our REaL data collection.

US Hospital Service Availability and New 340B Program Participation.

Importance: The US 340B Drug Pricing Program enables eligible hospitals to receive substantial discounts on outpatient drugs to improve hospitals' financial sustainability and maintain access to care for patients who have low income and/or are uninsured. However, it is unclear whether hospitals use program savings to subsidize access as intended. Objective: To evaluate whether the 340B program is associated with improvements in access to hospital-based services and to test whether the association varies by hospital ownership. Design, Setting, and Participants: Difference-in-differences and cohort analysis from 2010 to 2019. Never and newly participating 340B general, acute, nonfederal hospitals in the US using data from the American Hospital Association's Annual Survey of Hospitals merged with hospital and market characteristics. Data were analyzed from January 1, 2023, to January 31, 2024. Exposures: New enrollment in 340B between 2012 and 2018. Main Outcomes and Measures: Total number of unprofitable service lines, ie, substance use, psychiatric (inpatient and outpatient), burn clinic, and obstetrics services; and profitable services, ie, cardiac surgery and orthopedic, oncologic, neurologic, and neonatal intensive services. Results: The study sample comprised a total of 2152 hospitals, 1074 newly participating and 1078 not participating in the 340B program. Participating hospitals were more likely than nonparticipating hospitals to be critical access and teaching hospitals, have higher Medicaid shares, and be located in rural areas and in Medicaid expansion states. At public hospitals, participation in the 340B program was associated with a significant increase in total unprofitable services (0.21; 95% CI, 0.04 to 0.38; P = .02) and marginal increases in substance use (5.4 percentage points [pp]; 95% CI, -0.8 pp to 11.6 pp; P = .09) and inpatient psychiatric (6.5 pp; 95% CI, -0.7 pp to 13.7 pp; P = .09) services. Among nonprofit hospitals, there was no significant association between 340B and service offerings (profitable and unprofitable) except for an increase in oncologic services (2.5 pp; 95% CI, 0.0 pp to 5.0 pp; P = .05). Conclusions and Relevance: The finding of the cohort study indicate that participation in the 340B program was associated with an increase in unprofitable services among newly participating public hospitals. Nonprofit hospitals were largely unaffected. These findings suggest that public hospitals responded to 340B savings by improving patient access, whereas nonprofits did not. This heterogeneous response should be considered when evaluating the eligibility criteria for the 340B program and how it affects social welfare.

Hospital commitment to community orientation and its association with quality of care and patient experience.

We examine the association between hospital community orientation and quality-of-care measures, which include process measures for patients admitted for acute myocardial infarction, heart failure, and pneumonia as well as measures of patient experience. The community orientation measure is obtained from the 2009 American Hospital Association's Annual Survey Database. Information on hospital quality of care and patient experience comes from 2009 Hospital Quality Alliance data and results from the 2009 Hospital Consumer Assessment of Healthcare Providers and Systems (Medicare.gov, 2009). To evaluate the relationship between community orientation and measures of quality and patient experience, we used multivariate linear regressions. Organizational and market control variables included bed size, ownership, teaching status, safety net status, number of nurses per patient day, multihospital system status, network status, extent of reliance on managed care, market competition, and location within an Aligning Forces for Quality community (these communities have multistakeholder alliances and focus on improving quality of care at the community level). After controlling for organizational factors, we found that hospitals with a stronger commitment to community orientation perform better on process measures for all three conditions, and they report higher patient experience of care scores for one measure, than do those demonstrating weaker commitment. Hospital commitment to community orientation is significantly related to the provision of high-quality care and to one measure of patient experience of care.

Assessment of a Peer Support Group Intervention for Undocumented Latinx Immigrants With Kidney Failure.

Importance: Most undocumented immigrants with kidney failure rely on emergency dialysis (defined as dialysis after a patient presents as critically ill) and experience significant depression and anxiety and high mortality. Culturally and language-concordant peer support group interventions may be associated with reduced depression and anxiety and may provide emotional support. Objective: To investigate the feasibility and acceptability of a single-group peer support group intervention. Design, setting, and participants: This qualitative and single-group prospective study for undocumented immigrants with kidney failure receiving emergency dialysis was conducted in Denver, Colorado, from December 2017 to July 2018. The 6-month intervention included peer support group meetings in the hospital while participants were hospitalized for emergency dialysis. Data were analyzed from March to June 2022. Main outcomes and measures: To assess feasibility, the recruitment, retention, implementation, and delivery for the intervention were tracked. To measure acceptability, interviews were conducted with participants using a structured format. To assess the value of the peer support group intervention, themes and subthemes were identified from interviews with participants and group meetings. Results: Of 27 undocumented immigrants with kidney failure receiving emergency dialysis, 23 participants (9 females [39.1%] and 14 males [60.9%]; mean [SD] age, 47 [8] years) agreed to participate (recruitment rate, 85.2%). Among them, 5 individuals withdrew and did not attend meetings and 18 participants (retention rate, 78.3%) attended a mean of 6 of 12 meetings (50.0%). From interviews and meetings, 3 themes, with associated subthemes, were identified: camaraderie and emotional support from peers (subthemes: peer support is vital for people newly diagnosed with kidney failure, safe space to build relationships and share hardship with peers, hospital setting for peer support is ideal, solidarity to survive and change policy, and sustainability of the peer support group), solutions to improve care and resilience (subthemes: self-advocacy, self-motivation and optimism, kidney disease education, emotional support from peers caregivers, and faith), and emotional and physical aspects of receiving emergency dialysis (subthemes: psychosocial and physical distress, mixed experiences with language-concordant care, emotional exhaustion from end-of-life conversations, and gratitude for clinicians). Conclusions and relevance: This study found that peer support group intervention achieved feasibility and acceptability. The findings suggest that a peer support group may be a patient-centered strategy to build camaraderie and provide emotional support in kidney failure, especially for socially marginalized uninsured populations who report limited English proficiency.

Changes in disparities following the implementation of a health information technology-supported quality improvement initiative.

BACKGROUND: Health information technology (HIT)-supported quality improvement initiatives have been shown to increase ambulatory care quality for several chronic conditions and preventive services, but it is not known whether these types of initiatives reduce disparities. OBJECTIVES: To examine the effects of a multifaceted, HIT-supported quality improvement initiative on disparities in ambulatory care. DESIGN: Time series models were used to assess changes in racial disparities in performance between white and black patients for 17 measures of chronic disease and preventive care from February 2008 through February 2010, the first 2 years after implementation of a HIT-supported, provider-directed quality improvement initiative. PATIENTS: Black and white adults receiving care in an academic general internal medicine practice in Chicago. INTERVENTIONS: The quality improvement initiative used provider-directed point-of-care clinical decision support tools and quality feedback to target improvement in process of care and intermediate outcome measures for coronary heart disease, heart failure, hypertension, and diabetes as well as receipt of several preventive services. MAIN MEASURES: Modeled rate of change in performance, stratified by race and modeled rate of change in disparities for 17 ambulatory care quality measures KEY RESULTS: Quality of care improved for 14 of 17 measures among white patients and 10 of 17 measures among black patients. Quality improved for both white and black patients for five of eight process of care measures, four of five preventive services, but none of the four intermediate outcome measures. Of the seven measures with racial disparities at baseline, disparities declined for two, remained stable for four, and increased for one measure after implementation of the quality improvement initiative. CONCLUSIONS: Generalized and provider-directed quality improvement initiatives can decrease racial disparities for some chronic disease and preventive care measures, but achieving equity in areas with persistent disparities will require more targeted, patient-directed, and systems-oriented strategies.

Racial and ethnic disparities in neuraxial labor analgesia.

BACKGROUND: Racial and ethnic disparities in the treatment of pain have been well documented, and there is evidence of such disparities in neuraxial analgesia use. Our objectives of this study were to analyze racial/ethnic disparities in neuraxial analgesia use, as well as anticipated use, among laboring Hispanic, African-American, and Caucasian women, and to evaluate sociodemographic, clinical, and decision-making predictors of actual and anticipated neuraxial analgesia use among these women. METHODS: Laboring women, in a large urban academic hospital, were interviewed using a face-to-face survey to determine individual factors that may influence choice of labor analgesia. After delivery, the type of labor analgesia used was recorded. The primary outcome was use of neuraxial analgesia. Multivariable logistic regression models were estimated to test the likelihood that race and ethnicity were significantly associated with neuraxial analgesia use, anticipated neuraxial analgesia use, and the intrapartum decision to use neuraxial analgesia. RESULTS: There was a univariate association between race/ethnicity and anticipated as well as actual use of neuraxial analgesia. However, there was no association between race/ethnicity and the intrapartum decision to use neuraxial analgesia. After controlling for confounders, the association between race/ethnicity and actual use of neuraxial analgesia no longer remained significant (adjusted odds ratio: Hispanic versus Caucasian women 0.66, 95% confidence interval [CI]: 0.24 to 1.80; African-American versus Caucasian women 0.93, 95% CI: 0.31 to 2.77). In contrast, Hispanic women were less likely than Caucasian women to anticipate using neuraxial analgesia even after controlling for confounders (adjusted odds ratio 0.40, 95% CI: 0.20 to 0.82). CONCLUSIONS: After controlling for confounding variables, Hispanic women anticipated using neuraxial analgesia at a lower rate than other racial/ethnic groups; however, actual use was similar among groups.

Reporting information on emergency department crowding to the hospital board and delivery of time-sensitive care.

BACKGROUND: Hospital governing boards influence the quality of care that hospitals provide by holding senior leaders and managers accountable. A study was conducted to determine whether reporting data on emergency department (ED) crowding to hospital boards was associated with better performance on a time-sensitive quality measure for patients with acute myocardial infarction (AMI): Primary PCI [percutaneous intervention] Within 90 Minutes of Hospital Arrival. METHODS: In a survey, hospital chief quality officers were asked whether the following data were reported to the hospital governing board: ED wait times, the percentage of ED patients who left without being seen (LWBS), and the percentage of admitted ED patients who are boarded in the ED. Responses were paired with Centers for Medicare & Medicaid Services (CMS) data on the percentage of eligible AMI patients who received PCI within 90 minutes of arrival, which served as the hospitals' PCI score. RESULTS: In the sample of 261 hospitals, 133 (51%) of hospital governing boards received data on wait times, 125 (48%) received data on LWBS, and 63 (24%) received data on ED boarding. After hospital characteristics were controlled for, hospitals that reported data on ED boarding to the governing board had PCI scores that were 5.5 percentage points higher (that is, better); p < .05. There was no association between reporting wait times or LWBS to the board and PCI scores. CONCLUSION: Reporting data on the incidence of ED boarding to hospital governing boards was associated with better performance for PCI. More research is needed to explore the direction of this relationship, but the results suggest that hospitals should consider reporting data on ED boarding to their boards as a low/no-cost quality improvement activity.

A process to deduplicate individuals for regional chronic disease prevalence estimates using a distributed data network of electronic health records.

Introduction: Learning health systems can help estimate chronic disease prevalence through distributed data networks (DDNs). Concerns remain about bias introduced to DDN prevalence estimates when individuals seeking care across systems are counted multiple times. This paper describes a process to deduplicate individuals for DDN prevalence estimates. Methods: We operationalized a two-step deduplication process, leveraging health information exchange (HIE)-assigned network identifiers, within the Colorado Health Observation Regional Data Service (CHORDS) DDN. We generated prevalence estimates for type 1 and type 2 diabetes among pediatric patients (0-17 years) with at least one 2017 encounter in one of two geographically-proximate DDN partners. We assessed the extent of cross-system duplication and its effect on prevalence estimates. Results: We identified 218 437 unique pediatric patients seen across systems during 2017, including 7628 (3.5%) seen in both. We found no measurable difference in prevalence after deduplication. The number of cases we identified differed slightly by data reconciliation strategy. Concordance of linked patients' demographic attributes varied by attribute. Conclusions: We implemented an HIE-dependent, extensible process that deduplicates individuals for less biased prevalence estimates in a DDN. Our null pilot findings have limited generalizability. Overlap was small and likely insufficient to influence prevalence estimates. Other factors, including the number and size of partners, the matching algorithm, and the electronic phenotype may influence the degree of deduplication bias. Additional use cases may help improve understanding of duplication bias and reveal other principles and insights. This study informed how DDNs could support learning health systems' response to public health challenges and improve regional health.