Assessing and Augmenting Predictive Models for Hospital Readmissions With Novel Variables in an Urban Safety-net Population.

BACKGROUND: The performance of existing predictive models of readmissions, such as the LACE, LACE+, and Epic models, is not established in urban safety-net populations. We assessed previously validated predictive models of readmission performance in a socially complex, urban safety-net population, and if augmentation with additional variables such as the Area Deprivation Index, mental health diagnoses, and housing access improves prediction. Through the addition of new variables, we introduce the LACE-social determinants of health (SDH) model. METHODS: This retrospective cohort study included adult admissions from July 1, 2016, to June 30, 2018, at a single urban safety-net health system, assessing the performance of the LACE, LACE+, and Epic models in predicting 30-day, unplanned rehospitalization. The LACE-SDH development is presented through logistic regression. Predictive model performance was compared using C-statistics. RESULTS: A total of 16,540 patients met the inclusion criteria. Within the validation cohort (n=8314), the Epic model performed the best (C-statistic=0.71, P<0.05), compared with LACE-SDH (0.67), LACE (0.65), and LACE+ (0.61). The variables most associated with readmissions were (odds ratio, 95% confidence interval) against medical advice discharge (3.19, 2.28-4.45), mental health diagnosis (2.06, 1.72-2.47), and health care utilization (1.94, 1.47-2.55). CONCLUSIONS: The Epic model performed the best in our sample but requires the use of the Epic Electronic Health Record. The LACE-SDH performed significantly better than the LACE and LACE+ models when applied to a safety-net population, demonstrating the importance of accounting for socioeconomic stressors, mental health, and health care utilization in assessing readmission risk in urban safety-net patients.

Pediatrics adverse childhood experiences and related life events screener (PEARLS) and health in a safety-net practice.

BACKGROUND: Adverse Childhood Experiences (ACEs) are associated with behavioral, mental, and clinical outcomes in children. Tools that are easy to incorporate into pediatric practice, effectively screen for adversities, and identify children at high risk for poor outcomes are lacking. OBJECTIVE: To examine the relationship between caregiver-reported child ACEs and related life events with health outcomes. PARTICIPANTS AND SETTING: Participants (0-11 years) were recruited from the University of California San Francisco Benioff's Children Hospital Oakland Primary Care Clinic. There were 367 participants randomized. METHODS: Participants were randomized 1:1:1 to item-level (item response), aggregate-level (total number of exposures), or no screening for ACEs (control arm) with the PEdiatric ACEs and Related Life Event Screener (PEARLS). We assessed 10 ACE categories capturing abuse, neglect, and household challenges, as well as 7 additional categories. Multivariable regression models were conducted. RESULTS: Participants reported a median of 2 (IQR 1-5) adversities with 76 % (n = 279) reporting at least one adversity; participants in the aggregate-level screening arm, on average, disclosed 1 additional adversity compared to item-level screening (p = 0.01). Higher PEARLS scores were associated with poorer perceived child general health (adjusted B = -0.94, 95 %CI: -1.26, -0.62) and Global Executive Functioning (adjusted B = 1.99, 95 %CI: 1.51, 2.46), and greater odds of stomachaches (aOR 1.14; 95 %CI: 1.04-1.25) and asthma (aOR 1.08; 95 %CI 1.00, 1.17). Associations did not differ by screening arm. CONCLUSION: In a high-risk pediatric population, ACEs and other childhood adversities remain an independent predictor of poor health. Increased efforts to screen and address early-life adversity are necessary.

Obesity and metabolic outcomes in a safety-net health system.

In the United States, obesity has increased in prevalence over time and is strongly associated with subsequent outcomes such as diabetes mellitus (DM) and nonalcoholic fatty liver disease (NAFLD). It is unclear, however, as to how the magnitude of NAFLD risk from obesity and DM is increased in safety-net health system settings. Among the San Francisco Health Network (SFHN) patients (N = 47,211), we examined the association between Body Mass Index (BMI) and elevated liver enzyme levels, including interaction by DM status. Our findings revealed that 32.2 percent of SFHN patients were obese, and Pacific Islanders in the safety-net had the highest rates of obesity compared to other racial groups, even after using higher race-specific BMI cutoffs. In SFHN, obesity was associated with elevated liver enzymes, with the relationship stronger among those without DM. Our findings highlight how obesity is a stronger factor of NAFLD in the absence of DM, suggesting that practitioners consider screening for NAFLD among safety-net patients with obesity even if DM has not developed. These results highlight the importance of directing efforts to reduce obesity in safety-net health systems and encourage researchers to further examine effect modification between health outcomes in such populations.

Low persistence to rivaroxaban or warfarin among patients with new venous thromboembolism at a safety net academic medical center.

Recent guidelines recommend direct acting oral anticoagulants (DOAC) over vitamin-k antagonist (VKA) for acute venous thromboembolism (VTE). Non-adherence to anticoagulation has been associated with increased frequency of VTE or stroke. This study evaluated 90 day persistence among patients prescribed rivaroxaban or warfarin for the treatment of acute VTE at an academic safety net hospital. We conducted a single center, retrospective cohort study of 314 consecutive patients newly prescribed rivaroxaban or warfarin for acute VTE between January 2016 and July 2017. Primary outcome was 90 day persistence, and secondary outcomes included 90 day readmission and/or ED visit, time to 90 m day readmission and/or ED visits, and attendance of direct oral anticoagulant education class. Of 314 patients, 78 were prescribed warfarin and 236 rivaroxaban. Patients had a mean age of 52 years, 62% were men, and 96% were diagnosed with deep vein thrombosis and/or pulmonary embolism. Persistence at 90 days was 52.6% among patients prescribed warfarin compared to 45.3% for patients prescribed rivaroxaban (p = 0.2678). Persistencewas associated with decreased 90 day hospital or ED readmission. Among patients prescribed rivaroxaban, attending a pharmacist led educational class was associated with a 2.5 fold increase in persistence (p < 0.0001). Among patients with new onset venous thromboembolism, 90 day persistence with anticoagulation was similarly low with either rivaroxaban or warfarin therapy. Participation in a pharmacist led DOAC class was associated with a 2.5-fold increase in persistence on rivaroxaban.

Healthy Days at home: A novel population-based outcome measure.

BACKGROUND: Healthy Days at Home (HDAH) is a novel population-based outcome measure developed in conjunction with the Medicare Payment Advisory Commission. METHODS: We identified beneficiary age, sex, race, and Medicaid eligibility, death date, chronic conditions and healthcare utilization among a 20% sample of Medicare beneficiaries in 2016. For each beneficiary we calculated HDAH for the year by subtracting the following measure components from 365 days: mortality days, the total number of days spent in inpatient, observation, skilled nursing facilities (SNF), inpatient psychiatry, inpatient rehabilitation and long-term hospital settings as well as the number of outpatient emergency department and home health visits. We examined how HDAH and its components varied by beneficiary demographic characteristics and chronic condition burden as well as by healthcare market (Hospital Referral Region). We specified a patient-level linear regression adjustment model with HDAH as the outcome and incorporated market fixed effects as well as beneficiary age, sex, and Chronic Conditions Warehouse categories as covariates. We examined the impact of including home health visits in the measure, as well as the association between market demographics and health system characteristics and mean market HDAH. We examined how HDAH changed from 2013 to 2016. RESULTS: The 6,637,568 beneficiaries age 65 and older in our sample had a mean of 347.2 HDAH, those 80 and older had a mean of 325.3 while those with three or more chronic conditions had a mean of 333.7. The components that led to the largest reduction in HDAH were mortality (7.4 days), home health (2.7 visits), SNF utilization (2.4 days) and inpatient care (1.5 days). The worst performing market had 5.8 fewer adjusted HDAH on average compared to the national mean, while beneficiaries in the best-performing market had 5.0 more HDAH on average compared to the national mean, among all beneficiaries age 65 and older. CONCLUSIONS: HDAH is a population-based quality measure with substantial market-level variation. IMPLICATIONS: HDAH recognizes the multidimensional nature of healthcare and may afford providers greater flexibility to tailor quality-improvement initiatives to the unique needs of their patients. LEVEL OF EVIDENCE: Level II.

Homelessness Among Patients in a Southeastern Safety Net Emergency Department.

OBJECTIVES: Emergency departments (EDs) are important providers for homeless individuals, providing vital health care and meeting the subsistence needs of many homeless patients (eg, food, water, shelter). Studies that have examined the proportion of patients in the ED setting who experience homelessness have been conducted primarily in the northeastern United States. We hypothesized that findings from prior studies, conducted primarily in the Northeast, would not generalize to other regions of the United States. We conducted a direct patient survey to describe the proportion and demographics of ED patients who have experienced homelessness within the past 12 months in an urban safety net hospital in Atlanta, Georgia. METHODS: A cross-sectional survey of a convenience sample of patients presenting to the ED from September to December 2016. A team of trained research assistants administered a structured survey instrument to patients who were 18 years old, English speakers, not incarcerated, and able to provide informed consent. Questions were based on the US Department of Health and Human Services definition of homelessness. RESULTS: A total of 923 ED patients (55.1% male; median age 44 years) completed the survey. Of the ED patients surveyed, 51.5% reported some measure of homelessness in the past 12 months: lived with others but did not pay rent (n = 279, 30.2%), skipped mortgage or rent payment (n = 111, 12%), experienced eviction (n = 74, 8%), lived in a hotel or motel (n = 196, 21.2%), lived in a place not meant for human habitation (n = 76, 8.2%), slept in a shelter (n = 131, 14.2%), and slept on the street (n = 115, 12.5%). Men (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.17-2.09), patients who completed some school (OR 2.85, 95% CI 1.72-4.71), and patients who completed high school (OR 2.32, 95% CI 1.53-3.52) were more likely to have experienced homelessness in the 12 months preceding their ED visit. CONCLUSIONS: The rate of patients experiencing homelessness at our hospital is substantially greater than those reported in prior surveys of ED patients. More research is needed on homelessness and its implications for ED patients.

A Toolbox Approach to Obesity Treatment in Urban Safety-Net Primary Care Clinics: a Pragmatic Clinical Trial.

BACKGROUND: There is a need for new strategies to improve the success of obesity treatment within the primary care setting. OBJECTIVE: To determine if patients offered low out-of-pocket cost weight management tools achieved more weight loss compared to usual care. DESIGN: Twelve-month pragmatic clinical weight loss trial with a registry-based comparator group performed in primary care clinics of an urban safety-net hospital. PARTICIPANTS: From a large clinical registry, we randomly selected 428 patients to have the opportunity to receive the intervention. INTERVENTIONS: Medical weight management tools-partial meal replacements, recreation center vouchers, pharmacotherapy, commercial weight loss program vouchers, and a group behavioral weight loss program-for $5 or $10 monthly. Patients chose their tools, could switch tools, and could add a second tool at 6 months. MAIN MEASURES: The primary outcome was the proportion of intervention-eligible patients who achieved ≥ 5% weight loss. The main secondary outcome was the proportion of on-treatment patients who achieved ≥ 5% weight loss. KEY RESULTS: Overall, 71.3% (305 of 428) had available weight measurement data/PCP visit data to observe the primary outcome. At 12 months, 23.3% (71 of 305) of intervention-eligible participants and 15.7% (415 of 2640) of registry-based comparators had achieved 5% weight loss (p < 0.001). Of the on-treatment participants, 34.5% (39 of 113) achieved 5% weight loss. Mean percentage weight loss was - 3.15% ± 6.41% for on-treatment participants and - 0.30% ± 6.10% for comparators (p < 0.001). The initially preferred tools were meal replacements, pharmacotherapy, and recreation center passes. CONCLUSIONS: Access to a variety of low out-of-pocket cost weight management tools within primary care resulted in ≥ 5% body weight loss in approximately one quarter of low-income patients with obesity. TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT01922934.

Addressing Health Disparities Through Voter Engagement.

Although the public's essential capacity for self-rule in the United States lies in the power of the ballot, there exist many barriers to voting, particularly for marginalized communities. These barriers cultivate less representative government and less inclusive public policy. Nonprofit and private health organizations, and in particular community health centers and safety-net hospitals, can help marginalized voting-eligible individuals overcome barriers to the ballot. With augmented, unbiased voter participation, elections would yield government that is more representative and public policy that is more equitable, while reducing costly and preventable health disparities. Health organizations can promote comprehensive, nonpartisan voter engagement through registration, mobilization, education, and protection of all voters.

"You Guys Really Care About Me ": a Qualitative Exploration of a Produce Prescription Program in Safety Net Clinics.

BACKGROUND: Although research shows produce prescription (PRx) programs increase fruit and vegetable (FV) consumption, little is known about how participants experience them. OBJECTIVE: To better understand how participants experience a PRx program for hypertensive adults at 3 safety net clinics partnered with 20 farmers' markets (FMs) in Cleveland, OH. DESIGN: We conducted semi-structured interviews with 5 program providers, 23 patient participants, and 2 FM managers. PARTICIPANTS: Patients interviewed were mainly middle-aged (mean age 62 years), African American (100%), and women (78%). Providers were mainly middle-aged men and women of diverse races/ethnicities. INTERVENTION: Healthcare providers enrolled adult patients who were food insecure and diagnosed with hypertension. Participating patients attended monthly clinic visits for 3 months. Each visit included a blood pressure (BP) check, dietary counseling for BP control, a produce prescription, and produce vouchers redeemable at local FMs. APPROACH: Patient interviews focused on (1) beliefs about food, healthy eating, and FMs; (2) clinic-based program experiences; and (3) FM experiences. Provider and market manager interviews focused on program provision. All interviews were audio-taped, transcribed, and analyzed thematically. KEY RESULTS: We identified four central themes. First, providers and patients reported positive interactions during program activities, but providers struggled to integrate the program into their workflow. Second, patients reported greater FV intake and FM shopping during the program. Third, social interactions enhanced program experience. Fourth, economic hardships influenced patient shopping and eating patterns, yet these hardships were minimized in some participants' views of patient deservingness for program inclusion. CONCLUSIONS: Our findings highlight promises and challenges of PRx programs for economically disadvantaged patients with a chronic condition. Patient participants reported improved interactions with providers, increased FV consumption, and incorporation of healthy eating into their social networks due to the program. Future efforts should focus on efficiently integrating PRx into clinic workflows, leveraging patient social networks, and including economic supports for maintenance of behavior change.

Follow-up of incidental pulmonary nodules and association with mortality in a safety-net cohort.

Background Though incidental pulmonary nodules are common, rates of guideline-recommended surveillance and associations between surveillance and mortality are unclear. In this study, we describe adherence (categorized as complete, partial, late and none) to guideline-recommended surveillance among patients with incidental 5-8 mm pulmonary nodules and assess associations between adherence and mortality. Methods This was a retrospective cohort study of 551 patients (≥35 years) with incidental pulmonary nodules conducted from September 1, 2008 to December 31, 2016, in an integrated safety-net health network. Results Of the 551 patients, 156 (28%) had complete, 87 (16%) had partial, 93 (17%) had late and 215 (39%) had no documented surveillance. Patients were followed for a median of 5.2 years [interquartile range (IQR), 3.6-6.7 years] and 82 (15%) died during follow-up. Adjusted all-cause mortality rates ranged from 2.24 [95% confidence interval (CI), 1.24-3.25] deaths per 100 person-years for complete follow-up to 3.30 (95% CI, 2.36-4.23) for no follow-up. In multivariable models, there were no statistically significant associations between the levels of surveillance and mortality (p > 0.16 for each comparison with complete surveillance). Compared with complete surveillance, adjusted mortality rates were non-significantly increased by 0.45 deaths per 100 person-years (95% CI, -1.10 to 2.01) for partial, 0.55 (95% CI, -1.08 to 2.17) for late and 1.05 (95% CI, -0.35 to 2.45) for no surveillance. Conclusions Although guideline-recommended surveillance of small incidental pulmonary nodules was incomplete or absent in most patients, gaps in surveillance were not associated with statistically significant increases in mortality in a safety-net population.

Unplanned Readmissions After Acute Myocardial Infarction: 1-Year Trajectory Following Discharge From a Safety Net Hospital.

BACKGROUND: Financial penalties rendered by the Centers for Medicare and Medicaid Services have brought about new challenges for safety net hospitals that serve a vulnerable patient population with risk factors associated with high readmission rates. Our goal was to determine the 1-year trajectory of unplanned readmissions in post-myocardial infarction (MI) patients, and to identify factors associated with readmission. METHODS: A total of 261 acute MI patients admitted from April 2015 to April 2016 were evaluated in a multidisciplinary cardiology clinic within 10 days of hospital discharge and baseline characteristics and medical comorbidities were collected. Readmission and mortality data were obtained at 1 year through chart review and telephone follow-up. RESULTS: At 1 year, there were 90 (34%) unplanned readmissions of which half were for noncardiac diagnoses. Of these, 69 patients (77%) were readmitted once, 16 (18%) were readmitted twice, 2 (2%) were readmitted 3 times, and 3 (3%) were readmitted 4 times over the subsequent year. Cardiac causes of 1-year readmission included recurrent MI in 23 (9%) and decompensated heart failure in 18 (7%) patients. Depressed left ventricular systolic function (hazard ratio, 2.23; 95% confidence interval, 2.00-2.44; P = 0.0003) and diabetes mellitus (hazard ratio, 1.60; 95% confidence interval, 1.38-1.82; P = 0.029) were associated with a significantly higher risk of readmission at 1 year. CONCLUSION: Following acute MI, patients are readmitted for cardiac and noncardiac diagnoses well beyond the 30-day mark. This is likely a function of the vulnerability of the patient population rather than a reflection of the medical care provided. More frequent surveillance may attenuate this problem.

Age differences in emergency department utilization and repeat visits among patients with opioid use disorder at an urban safety-net hospital: A focus on young adults.

BACKGROUND: Opioid use disorder (OUD) among young adults from ages 18 to 25 years is increasing in the United States. Emergency departments (EDs) are recognized as major sources of care for patients with OUD, but questions remain about ED utilization among this population. We examined the demographics and ED utilization patterns at an urban safety-net hospital with a focus on young adults to inform intervention development. METHODS: We extracted demographic and clinical data from electronic medical records of patients ages 18 to 64 years diagnosed with OUD between 2013 and 2017. Descriptive statistics were assessed, including race/ethnicity, sex, insurance, other substance use disorder and mental health diagnoses, and ED utilization patterns by age group. Univariable and multivariable logistic regressions were performed to analyze the associations between age and ED utilization patterns. RESULTS: Among 12,025 OUD patients in the sample, 30% had an ED visit with a primary diagnosis of OUD. Among those who had an ED visit, 48% had at least one additional ED visit within a year. The probability of ED visits (adjusted odds ratio [AOR]:5.04; 95% confidence interval [CI]:4.14-6.13) and repeat ED visits (AOR:3.28; CI:2.53-4.26) were significantly higher among young adults (18-25 years) compared to the oldest age group (56-64 years). CONCLUSIONS: Compared to older adults, young adults with OUD are more likely to use the ED and to have repeat ED visits. The identification of youth-tailored interventions in the ED within broader efforts to address the opioid epidemic should be an urgent priority.

Facilitators and Barriers to Successful Engagement in a Complex Care Management Program: Patient and Care Manager Perspectives.

Complex care management (CCM) interventions have been developed across the United States to address the challenges of high-need, high-cost patients. Though their heterogeneity makes it challenging to determine their general effectiveness, there are calls in the literature to continue to implement and evaluate them. This article presents CCM patient and care manager perspectives on facilitators and barriers to success in such a program in a safety-net hospital. Our findings suggest that motivated patients, team-based care, and the ability to form trusting, supportive relationships are important contributors to success in a CCM program while patients' own mental health and socioeconomic challenges impede success. Given the relatively short-term nature of most CCM programs and the complicated challenges faced by many CCM patients, this work poses larger questions to consider around the general alignment of the program model to the patient population and the definition of success for CCM programs.

Provider and Staff Morale, Job Satisfaction, and Burnout over a 4-Year Medical Home Intervention.

BACKGROUND: The patient-centered medical home (PCMH) is a widely adopted primary care model. However, it is unclear whether changes in provider and staff perceptions of clinic PCMH capability are associated with changes in provider and staff morale, job satisfaction, and burnout in safety net clinics. OBJECTIVE: To determine how provider and staff PCMH ratings changed under a multi-year PCMH transformation initiative and assess whether changes in provider and staff PCMH ratings were associated with changes in morale, job satisfaction, and burnout. DESIGN: Comparison of baseline (2010) and post-intervention (2013-2014) surveys. SETTING: Sixty clinics in five states. PARTICIPANTS: Five hundred thirty-six (78.2%) providers and staff at baseline and 589 (78.3%) post-intervention. INTERVENTION: Collaborative learning sessions and on-site coaching to implement PCMH over 4 years. MEASUREMENTS: Provider and staff PCMH ratings on 0 (worst) to 100 (best) scales; percent of providers and staff reporting good or better morale, job satisfaction, and freedom from burnout. RESULTS: Almost half of safety net clinics improved PCMH capabilities from the perspective of providers (28 out of 59, 47%) and staff (25 out of 59, 42%). Over the same period, clinics saw a decrease in the percentage of providers reporting high job satisfaction (- 12.3% points, p = .009) and freedom from burnout (- 10.4% points, p = .006). Worsened satisfaction was concentrated among clinics that had decreased PCMH rating, with those clinics seeing far fewer providers report high job satisfaction (- 38.1% points, p < 0.001). LIMITATIONS: Control clinics were not used. Individual-level longitudinal survey administration was not feasible. CONCLUSION: If clinics pursue PCMH transformation and providers do not perceive improvement, they may risk significantly worsened job satisfaction. Clinics should be aware of this potential risk of PCMH transformation and ensure that providers are aware of PCMH improvements.

Disparities in Patient-Reported Interest in Web-Based Patient Portals: Survey at an Urban Academic Safety-Net Hospital.

BACKGROUND: Offering hospitalized patients' enrollment into a health system's patient portal may improve patient experience and engagement throughout the care continuum, especially across care transitions, but this process is less studied than portal engagement in the ambulatory setting. Patient portal disparities exist and may lead to differences in access or outcomes. As such, it is important to study upstream factors in a typical hospital workflow that could lead to those disparities in safety-net settings. OBJECTIVE: The objective of this study was to evaluate sociodemographic characteristics associated with interest in a health care system's portal among hospitalized patients and reasons for no interest. METHODS: Nurses assessed interest in a Web-based patient portal, expressed by the patient as "yes" or "no," as part of the admission nursing assessment among patients at an academic urban safety-net hospital and recorded responses in the electronic health record (EHR), including reasons for no interest. We extracted patient responses from the EHR. RESULTS: Among 23,994 hospitalizations over a 2-year period, 35.90% (8614/ 23,994) reported an interest in a Web-based portal. Reasons for no interest included the following: not interested/other reason 41.68% (6410/15,380), no ability to use/access computers/internet 29.59% (4551/15,380), doesn't speak English 11.15% (1715/15,380), physically or mentally unable 8.70% (1338/15,380), does not want to say 8.70% (1338/15,380), security concerns 0.03% (4/15,380), and not useful 0.16% (24/15,380). Among the 16,507 unique patients included in this sample, portal interest was lower in older, African American, non-English speaking, and homeless patient populations. CONCLUSIONS: In a safety-net system, patient interest at the time of hospitalization in a Web-based enterprise portal-a required step before enrollment-is low with significant disparities by sociodemographic characteristics. To avoid worsening the digital divide, new strategies are needed and should be embedded within routine workflows to engage vulnerable safety-net patients in the use of Web-based health technologies.

Monitoring and Developing a Volunteer Patient Navigation Intervention to Improve Mammography Compliance in a Safety Net Hospital.

PURPOSE: Although mammography screening is crucial for cancer detection, screening rates have been declining, particularly in patients of low socioeconomic status and minorities. We sought to evaluate and improve the compliance rates at our safety net hospital through a prospective randomized controlled trial of a volunteer-run patient navigation intervention. METHODS: Baseline 90-day institutional mammography compliance rates were evaluated for patients who received a physician order for screening mammograms over a 1-month period. This analysis aided in the creation of a prospective randomized controlled trial of a volunteer-run patient navigation intervention to improve compliance, with 49 total participants. The primary outcome was 14-day mammography compliance rates. Secondary analysis examined the efficacy of the intervention with respect to patient demographics, prior mammography compliance, family history of cancer, beliefs on mammography, and past medical history. RESULTS: Analysis of baseline institutional compliance revealed a 47.87% compliance rate, with the majority of compliance occurring within 14 days of order placement. The patient navigation intervention significantly improved compliance by 34% (42% in the control group, 76% in the intervention group). Additional findings included significantly improved compliance in patients who believed they had a low susceptibility to cancer, those who understood the benefits of mammography and early diagnosis, those who had a prior mammogram, those who were employed, and those with a family history of cancer. CONCLUSION: A system to monitor compliance and intervene using patient navigation significantly improved mammography compliance of patients in a safety net hospital. The relatively straightforward design of this volunteer-based intervention makes it affordable, easily replicable, and perhaps beneficial at other institutions.