Variation in multimorbidity by sociodemographics and social drivers of health among patients seen at community-based health centers.

Purpose: Understanding variation in multimorbidity across sociodemographics and social drivers of health is critical to reducing health inequities. Methods: From the multi-state OCHIN network of community-based health centers (CBHCs), we identified a cross-sectional cohort of adult (> 25 years old) patients who had a visit between 2019-2021. We used generalized linear models to examine the relationship between the Multimorbidity Weighted Index (MWI) and sociodemographics and social drivers of health (Area Deprivation Index [ADI] and social risks [e.g., food insecurity]). Each model included an interaction term between the primary predictor and age to examine if certain groups had a higher MWI at younger ages. Results: Among 642,730 patients, 28.2% were Hispanic/Latino, 42.8% were male, and the median age was 48. The median MWI was 2.05 (IQR: 0.34, 4.87) and was higher for adults over the age of 40 and American Indians and Alaska Natives. The regression model revealed a higher MWI at younger ages for patients living in areas of higher deprivation. Additionally, patients with social risks had a higher MWI (3.16; IQR: 1.33, 6.65) than those without (2.13; IQR: 0.34, 4.89) and the interaction between age and social risk suggested a higher MWI at younger ages. Conclusions: Greater multimorbidity at younger ages and among those with social risks and living in areas of deprivation shows possible mechanisms for the premature aging and disability often seen in community-based health centers and highlights the need for comprehensive approaches to improving the health of vulnerable populations.

Early Results of an Initiative to Assess Exposure to Firearm Violence in Ambulatory Care: Descriptive Analysis of Electronic Health Record Data.

BACKGROUND:  Current research on firearm violence is largely limited to patients who received care in emergency departments or inpatient acute care settings or who died. This is because standardized disease classification codes for firearm injury only represent bodily trauma. As a result, research on pathways and health impacts of firearm violence is largely limited to people who experienced acute bodily trauma and does not include the estimated millions of individuals who were exposed to firearm violence but did not sustain acute injury. Assessing and collecting data on exposure to firearm violence in ambulatory care settings can expand research and more fully frame the public health issue. OBJECTIVE: The aim of the study is to evaluate the demographic and clinical characteristics of patients who self-reported exposure to firearm violence during a behavioral health visit. METHODS: This study assessed early data from an initiative implemented in 2022 across a national network of ambulatory behavioral health centers to support trauma-informed care by integrating structured data fields on trauma exposure into an electronic health record behavioral health patient assessment form (SmartForm), as such variables are generally not included in standard outpatient medical records. We calculated descriptive statistics on clinic characteristics, patient demographics, and select clinical conditions among clinics that chose to implement the SmartForm and among patients who reported an exposure to firearm violence. Data on patient counts are limited to positive reports of exposure to firearm violence, and the representativeness of firearm exposure among all patients could not be calculated due to unknown variability in the implementation of the SmartForm. RESULTS: There were 323 of 629 (51%) clinics that implemented the SmartForm and reported at least 1 patient exposed to firearm violence. In the first 11 months of implementation, 3165 patients reported a recent or past exposure to firearm violence across the 323 clinics. Among patients reporting exposure, 52.7% (n=1669) were male, 38.8% (n=1229) were Black, 45.7% (n=1445) had posttraumatic stress disorder, 37.5% (n=1186) had a substance abuse disorder (other than nicotine), and 11.7% (n=371) had hypertension. CONCLUSIONS: Current research on firearm violence using standardized data is limited to acute care settings and death data. Early results from an initiative across a large network of behavioral health clinics demonstrate that a high number of clinics chose to implement the SmartForm, resulting in thousands of patients reporting exposure to firearm violence. This study demonstrates that collecting standardized data on firearm violence exposure in ambulatory care settings is feasible. This study further demonstrates that resultant data from ambulatory settings can be used for meaningful analysis in describing populations affected by firearm violence. The results of this study hold promise for further collection of structured data on exposure to firearm violence in ambulatory settings.

Pandemic-related practice changes and CVD risk management in community clinics.

OBJECTIVES: Understanding how the COVID-19 pandemic affected cardiovascular disease (CVD) risk monitoring in primary care may inform new approaches for addressing modifiable CVD risks. This study examined how pandemic-driven changes in primary care delivery affected CVD risk management processes. STUDY DESIGN: This retrospective study used electronic health record data from patients at 70 primary care community clinics with scheduled appointments from September 1, 2018, to September 30, 2021. METHODS: Analyses examined associations between appointment type and select care process measures: appointment completion rates, time to appointment, and up-to-date documentation for blood pressure (BP) and hemoglobin A1c (HbA1c). RESULTS: Of 1,179,542 eligible scheduled primary care appointments, completion rates were higher for virtual care (VC) vs in-person appointments (10.7 percentage points [PP]; 95% CI, 10.5-11.0; P < .001). Time to appointment was shorter for VC vs in-person appointments (-3.9 days; 95% CI, -4.1 to -3.7; P < .001). BP documentation was higher for appointments completed pre- vs post pandemic onset (16.2 PP; 95% CI, 16.0-16.5; P < .001) and for appointments completed in person vs VC (54.9 PP; 95% CI, 54.6-55.2; P < .001). HbA1c documentation was higher for completed appointments after pandemic onset vs before (5.9 PP; 95% CI, 5.1-6.7; P < .001) and for completed VC appointments vs in-person appointments (3.9 PP; 95% CI, 3.0-4.7; P < .001). CONCLUSIONS: After pandemic onset, appointment completion rates were higher, time to appointment was shorter, HbA1c documentation increased, and BP documentation decreased. Future research should explore the advantages of using VC for CVD risk management while continuing to monitor for unintended consequences.

Cardiovascular disease risk management during COVID-19: in-person vs virtual visits.

OBJECTIVES: Limited research has assessed how virtual care (VC) affects cardiovascular disease (CVD) risk management, especially in community clinic settings. This study assessed change in community clinic patients' CVD risk management during the COVID-19 pandemic and CVD risk factor control among patients who had primarily in-person or primarily VC visits. STUDY DESIGN: Retrospective interrupted time-series analysis. METHODS: Data came from an electronic health record shared by 52 community clinics for index (March 1, 2019, to February 29, 2020) and follow-up (July 1, 2020, to February 28, 2022) periods. Analyses compared follow-up period changes in slope and level of population monthly means of 10-year reversible CVD risk score, blood pressure (BP), and hemoglobin A1c (HbA1c) among patients whose completed follow-up period visits were primarily in person vs primarily VC. Propensity score weighting minimized confounding. RESULTS: There were 10,028 in-person and 6593 VC patients in CVD risk analyses, 9874 in-person and 5390 VC patients in BP analyses, and 8221 in-person and 4937 VC patients in HbA1c analyses. The VC group was more commonly younger, female, White, and urban. Mean reversible CVD risk, mean systolic BP, and percentage of BP measurements that were 140/90 mm Hg or higher increased significantly from index to follow-up periods in both groups. Rate of change between these periods was the same for all outcomes in both groups, regardless of care modality. CONCLUSIONS: Among community clinic patients with CVD risk, receiving a majority of care in person vs a majority of care via VC was not significantly associated with longitudinal trends in reversible CVD risk score or key CVD risk factors.

Care Delivery in Community Health Centers Before, During, and After the COVID-19 Pandemic (2019-2022).

INTRODUCTION: Health centers provide primary and behavioral health care to the nation's safety net population. Many health centers served on the frontlines of the COVID-19 pandemic, which brought major changes to health center care delivery. OBJECTIVE: To elucidate primary care and behavioral health service delivery patterns in health centers before and during the COVID-19 public health emergency (PHE). METHODS: We compared annual and monthly patients from 2019 to 2022 for new and established patients by visit type (primary care, behavioral health) and encounter visits by modality (in-person, telehealth) across 218 health centers in 13 states. RESULTS: There were 1581,744 unique patients in the sample, most from health disparate populations. Review of primary care data over 4 years show that health centers served fewer pediatric patients over time, while retaining the capacity to provide to patients 65+. Monthly data on encounters highlights that the initial shift in March/April 2020 to telehealth was not sustained and that in-person visits rose steadily after November/December 2020 to return as the predominant care delivery mode. With regards to behavioral health, health centers continued to provide care to established patients throughout the PHE, while serving fewer new patients over time. In contrast to primary care, after initial uptake of telehealth in March/April 2020, telehealth encounters remained the predominant care delivery mode through 2022. CONCLUSION: Four years of data demonstrate how COVID-19 impacted delivery of primary care and behavioral health care for patients, highlighting gaps in pediatric care delivery and trends in telehealth over time.

Supporting Vulnerable Older Adults With Telehealth Through Wellness Calls and Tablet Distribution During COVID-19: Quality Improvement Project.

BACKGROUND: Loneliness, social isolation, and lack of technical literacy are associated with poorer health outcomes. To help improve social connection during the COVID-19 pandemic, Nova Southeastern University's South Florida Geriatric Workforce Enhancement Program partnered with a community-based organization to provide educational resources to promote telehealth services. OBJECTIVE: This study aimed to provide educational resources to older adults with limited resources and promote the use of telehealth services in this population. METHODS: Through this pilot project, we contacted 66 vulnerable older adults who expressed interest in telehealth support through wellness calls, with 44 participants moving on to participate in tablet usage. All tablets were preloaded with educational information on using the device, COVID-19 resources, and accessing telehealth services for patients, caregivers, and families. RESULTS: Feedback from wellness assessments suggested a significant need for telehealth support. Participants used the tablets mainly for telehealth (n=6, 15%), to connect with friends and family (n=10, 26%), and to connect with faith communities (n=3, 8%). CONCLUSIONS: The findings from the pilot project suggest that wellness calls and telehealth education are beneficial to support telehealth usage among older adults.

Using Data Science and a Health Equity Lens to Identify Long-COVID Sequelae Among Medically Underserved Populations.

Understanding how post-acute COVID-19 syndrome (PACS or long COVID) manifests among underserved populations, who experienced a disproportionate burden of acute COVID-19, can help providers and policymakers better address this ongoing crisis. To identify clinical sequelae of long COVID among underserved populations treated in the primary care safety net, we conducted a causal impact analysis with electronic health records (EHR) to compare symptoms among community health center patients who tested positive (n=4,091) and negative (n=7,118) for acute COVID-19. We found 18 sequelae with statistical significance and causal dependence among patients who had a visit after 60 days or more following acute COVID-19. These sequelae encompass most organ systems and include breathing abnormalities, malaise and fatigue, and headache. This study adds to current knowledge about how long COVID manifests in a large, underserved population.

Integrating 4Ms Assessment through Medicare Annual Wellness Visits: Comparison of Quality Improvement Strategies in Primary Care Clinics.

The Medicare Annual Wellness Visit (AWV), which includes comprehensive preventative assessments and screenings, is associated with improved preventative services, including vaccination and cancer screenings. However, the AWV alone does not promote whole-person care. Integrating the AWV within an Age-Friendly Health System (AFHS) contextualizes AWV services within a comprehensive geriatric care framework that integrates the "4Ms" (mentation, medication, mobility, and what matters). This study describes and evaluates quality improvement initiatives to improve the completion of AWV within two different AFHS-recognized health systems (an academic university clinic and a Federally Qualified Health Center). The results from this evaluation present opportunities that other health systems can consider for leveraging electronic health records (EHRs) and enabling services to complete AWVs within a 4Ms framework. The implementation results also suggest an adaptation of the 4Ms assessment schedule for patients with complex chronic conditions who may suffer from multiple comorbidities and cognitive impairment.

Using the 4M framework of the Age-Friendly Health System to improve MIPS documentation in primary care clinics: A quality improvement study.

Age-Friendly Health Systems (AFHS) commit to providing evidence-based, low-risk, coordinated care centered on what matters most to older adults, their families, and caregivers. Nova Southeastern University's South Florida Geriatric Workforce Enhancement Program (NSU SFGWEP) has partnered with primary care clinics to provide AFHS training and support to promote AFHS transformation in Broward and Miami-Dade Counties. NSU SFGWEP provides face-to-face and virtual training for AFHS and Electronic Health Record (EHR) documentation as part of the initiative. This project focuses on a group of primary care clinics in Broward County, Florida. In this paper, we evaluate the progress of AFHS transformation through six e-clinical measures that collectively provide indicators of the 4 M framework of AFHS (What Matters, Medication, Mentation, and Mobility). We used provider feedback and e-clinical measures aligned with the Center for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) to measure clinic outcomes. From Jan 1- Dec 31, 2019, to Jan 1-Dec 31, 2020, the clinics improved high-risk medication management (0-3.71%), advanced care planning (6.79%-20.74%), and fall risk assessment (no data- 46.72%). Results demonstrate some success and ongoing opportunities to continue and expand AFHS interventions for sustainability.

Acute Traumatic Spinal Cord Injury: Implementation of a Multidisciplinary Care Pathway.

BACKGROUND: Management of acute traumatic spinal cord injuries is complex, and patients are at risk for severe complications while inpatient. Performance review revealed opportunities for improvement in the care of patients with acute traumatic spinal cord injury at our institution. OBJECTIVE: To compare mortality, failure-to-rescue, and health care utilization of patients with acute traumatic spinal cord injury after implementation of a revised multidisciplinary care pathway. METHODS: Using a pre- and post-between-subjects study design, a retrospective cross-sectional analysis of consecutive patients admitted to our Level I trauma center with acute traumatic spinal cord injury was performed. An updated care pathway for all patients who presented with acute traumatic spinal cord injury was implemented in July 2020. This pathway includes a revised order set in the electronic medical record, distribution of a "best practice" guide to inpatient providers, a formal twice-daily respiratory evaluation, and weekly clinical nurse specialist-led patient rounds. RESULTS: One hundred and eight patients were included in analysis (prepathway: n = 52, postpathway: n = 56). Total mean hospital length of stay was 15.2 (14.0) and 21.5 (24.8) days for the pre- and postpathway groups. Eleven patients (21%) compared with six patients (11%) died, and failure-to-rescue occurred in six patients (60%) compared with zero patient in the pre- and postpathway groups, respectively. In addition, 10 (20%) postpathway patients were discharged to home compared with one (2%) in the prepathway group. DISCUSSION: Following implementation of the updated acute traumatic spinal cord injury pathway, overall inpatient mortality decreased, and fewer patients died after experiencing a complication. Results highlight the need for continued review of care practices and multidisciplinary review in quality improvement initiatives.

Virtual Lifelong Learning Among Older Adults: Usage and Impact During the COVID-19 Pandemic.

Social isolation and loneliness are major health concerns for older adults, with the current prevalence of social isolation among older adults estimated to be as high as 43%. In older adults, loneliness and social isolation have both been linked with poor health outcomes including falls, re-hospitalizations, dementia, and all-cause mortality. During the coronavirus disease 2019 (COVID-19) pandemic, older adults constituted one of the most at-risk groups and were faced with some of the strictest and earliest social distancing recommendations, which were associated with increased feelings of loneliness and increased rates of depression and anxiety, upwards of 12%. The objective of this study was to identify the impact of online social connection on feelings of isolation and companionship among older adults during the COVID-19 pandemic. Following the Centers for Disease Control and Prevention (CDC) guidelines in March 2020, two South Florida social and educational programs for older adults adopted online programming utilizing the Zoom platform. A research team worked collaboratively with senior stakeholders to develop and administer a survey to understand the impact of online social connections on feelings of social isolation. One year later in 2021, the survey was reviewed, modified, and re-administered. Respondents of the survey included 211 older adults (mean age 75.5 years old). Notable findings included a strong association between frequency of online class attendance and increased feelings of connectedness (p<0.001), improved spirits (p<0.001), and decreased feelings of social isolation (p<0.001). These results underscore the importance and contribution of online programming among older adults during times of social isolation. Overall, clinical practitioners should consider the importance of initiating discussions with older adults regarding returning to activities that they enjoyed prior to the COVID-19 pandemic.

Low initial in-hospital end-tidal carbon dioxide predicts poor patient outcomes and is a useful trauma bay adjunct.

INTRODUCTION: Appropriate triage of the trauma patient is critical. Low end-tidal carbon dioxide (ETCO2) is associated with mortality and hemorrhagic shock in trauma, but the relationship between low ETCO2 and important clinical variables is not known. This study investigates the association of initial in-hospital ETCO2 and patient outcomes, as well as the utility of ETCO2 as a predictive aid for blood transfusion. METHODS: Adult patients who presented to a Level One trauma center from 2019 to 2020 were eligible. Trauma bay ETCO2 measured by side-stream capnography was prospectively obtained for all trauma activations at time of initial evaluation. Using the Liu method of cut point estimation, patients were stratified as having low (≤29.5 mmHg) or normal ETCO2 (>29.5 mmHg). Multivariable regression was used to estimate the association of low ETCO2 with patient outcomes. RESULTS: A total of 955 patients underwent initial in-hospital ETCO2 measurement. Median time from arrival to ETCO2 measurement was 4 min. Among admitted patients (N = 493), 48.9% had low ETCO2. Compared to patients with normal ETCO2, those with low ETCO2 were older (median age 53 vs 46, p = 0.01) and more likely to have the highest trauma activation (27.4% vs 19.8%, p = 0.048). There was no difference in head injury. After adjustment, patients with low ETCO2 had greater odds of blood transfusion (OR 4.65, 95%CI 2.0-10.7), mortality (OR 5.10, 95%CI 1.1-24.9), inferior disposition (OR 1.64, 95%CI 1.1-2.6), and complications (OR 3.35, 95%CI 1.5-7.4). ETCO2 was more predictive of early blood transfusion than Shock Index (area under ROC = 67.6% vs 58.2%). CONCLUSIONS: Low trauma bay ETCO2 remains significantly associated with inferior clinical outcomes after adjustment. In comparison to other triage tools, low ETCO2 values may be more predictive of the need for blood transfusion. Further studies are needed to evaluate the role of ETCO2 as a decision making tool for early trauma management.

"Low initial pre-hospital end-tidal carbon dioxide predicts inferior clinical outcomes in trauma patients".

INTRODUCTION: Current guidelines continue to lead to under- and over-triage of injured patients in the pre-hospital setting. End-tidal carbon dioxide (ETCO2) has been correlated with mortality and hemorrhagic shock in trauma patients. This study examines the correlation between ETCO2 and in-hospital outcomes among non-intubated patients in the pre-hospital setting. METHODS: We retrospectively studied a cohort of non-intubated adult trauma patients with initial pre-hospital side-stream capnography-obtained ETCO2 presenting via ground transport from a single North Carolina EMS agency to a level one trauma center from January 2018 to December 2018. Using the Liu method, the optimal threshold for low ETCO2 was ≤ 28.5 mmHg. RESULTS: Initial pre-hospital ETCO2 was recorded for 324 (22.0%) of 1473 patients with EMS data. Patients with low ETCO2 (N = 98, 30.3% of cohort) were older (median 58y vs 45y), but mechanisms of injury and scene vital signs were similar (p>0.05) between low and normal/high ETCO2 cohorts. Median injury severity score (ISS) did not differ significantly between the low and normal/high ETCO2 groups (5 vs 8, p=0.48). Compared to normal/high ETCO2, low ETCO2 correlated with increased unadjusted odds of mortality (OR 5.06), in-hospital complications (OR 2.06), and blood transfusion requirement (OR 3.05), p<0.05. Low ETCO2 was associated with 7.25 odds of mortality (95% CI 2.19,23.97, p=0.001) and 3.94 odds of blood transfusion (95% CI 1.32-11.78) after adjusting for age, ISS, and scene GCS. All but one of the massive transfusion patients (N = 8/9) had a low pre-hospital ETCO2. CONCLUSIONS: Low initial pre-hospital ETCO2 associates with poor clinical outcomes despite similar ISS and mechanisms of injury. ETCO2 is a potentially useful pre-hospital point-of-care tool to aid triage of trauma patients as it may identify hemorrhaging patients and predict mortality.

Recurrent Primary Cutaneous Anaplastic Large Cell Lymphoma With Systemic Involvement: A Case Report and Literature Review.

Primary cutaneous anaplastic large cell lymphoma (PC-ALCL) is a rare, aggressive neoplasm that frequently relapses and requires the use of multiple treatment modalities. PC-ALCL most commonly presents in patients around the age of 60 and clinically manifests as red, single or sometimes grouped nodular lesions in the skin that tend to ulcerate over time. Although cases are limited to the skin, the extracutaneous spread has been occasionally reported. The diagnosis of PC-ALCL is made through excisional biopsy and subsequent immunohistochemical confirmation. Management of PC-ALCL is dependent on the extent of disease, and most patients can be effectively managed with surgical excision and/or radiation. If relapse occurs, systemic therapy including combination chemotherapy is considered. We present the case of a 43-year-old female who presented to an outpatient clinic with multiple suspicious, red, nodular lesions to her left elbow and right upper back. The further evaluation led to the diagnosis of a stage 4E, ALK-negative, CD30-positive PC-ALCL with recurrence after resection. This case highlights the diagnosis and management of PC-ALCL with systemic involvement that did not respond to initial radiotherapy.

Do No Harm: A Multifactorial Approach to Preventing Emergency Department Falls-A Quality Improvement Project.

INTRODUCTION: Patient falls in the emergency department are a unique patient safety issue because of the often challenging nature of the environment. As there are a variety of potential causative factors for patient falls in the emergency department, this project employed a multifactorial approach to prevent patient falls in a Level 1 trauma center emergency department (adult only) in an urban tertiary care teaching hospital. METHODS: This project was a single-unit quality improvement intervention that compared postintervention monthly unit-level data to historic monthly rates on the same unit. The intervention was multifaceted with patient-level, nurse-level, and unit-level interventions employed. A task force was convened to review and identify specific departmental gaps related to fall prevention, complete a retrospective review of departmental patient falls to determine causative factors, and implement interventions to reduce ED falls. A comprehensive program consisting of an ED-specific fall risk assessment tool, remote video monitoring (RVM), stretcher alarms, and a robust patient safety culture, among other interventions, was implemented. Patient falls and falls with injuries were tracked as an outcome measure. RESULTS: After data driven analysis of causation, selection of key interventions, staff education, and sustained focus for 2 years, the department experienced a 27% decrease in falls and a 66% decrease in falls with injuries. DISCUSSION: A multifactorial approach was an effective strategy to decrease patient falls in the emergency department.

Weaning Humidified High Flow Oxygen Therapy among Paediatric Patients: An Integrative Review of Literature.

PROBLEM: The paucity of up-to-date recommendations and evidence-based models, whether it is physician-initiated or initiated by other healthcare professionals, for humidified high flow oxygen therapy among children. ELIGIBILITY CRITERIA: The inclusion criteria included the following: 1) use of high flow oxygen therapy (≥15 L/min); 2) published studies from the year 2000 and onwards; 3) research article in a peer-reviewed journal; 4) studies conducted in a hospital setting involving paediatric patients <18 years old; 5) availability of full article online. SAMPLE: From March to April 2018, electronic databases such as PubMed, Cumulative Index of Nursing and Allied Health Literature, Excerpta Medica Database, Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews, SCOPUS, Ovid, Informit, and Google Scholar were accessed. The systematic search initially yielded 41 studies. RESULTS: Eventually, three eligible studies were reviewed and appraised. Overarching themes were identified: 1) the lack of weaning standards; 2) the limited focus on young population in intensive care settings; and 3) the paucity of weaning models. CONCLUSION: The lack of studies suggested that this is a fertile area for research. In this light, this paper challenged researchers, clinicians, and experts to develop evidence-based standards and models of weaning towards efficient and better quality of care. IMPLICATION: This review may lead to the development of nurse-led or nurse-initiated weaning protocols to enable timely weaning intervention for children and thus reduce the need for prolonged oxygen use. Furthermore, this may also instigate an economic evaluation of a nurse-lead weaning against current models of medically lead weaning.

Pilot test of a six-week group delivery caregiver training program to reduce sleep disturbances among older adults with dementia (Innovative practice).

The purpose of the pilot program was to examine the adaptability and feasibility of a modified group-delivery sleep education program (NITE-AD) designed to reduce nocturnal disturbances in community-dwelling older adults with dementia. We recruited seven caregivers of persons with dementia from two adult day care centers in South Florida into a six-week group program at adult day care centers. A trained sleep educator taught caregivers about the impact of aging and dementia on sleep and how non-pharmacological interventions such as increasing light, regular exercise, and sleep hygiene strategies can improve sleep in persons with dementia. The curriculum incorporated ongoing problem solving and goal setting. Results suggest improvement in caregiver depression and persons with dementia sleep problems. Caregivers reported that the program provided them support and valuable strategies that they will continue to apply. Educating caregivers in a group setting about non-pharmacologic strategies for managing sleep may reduce caregiver burden and improve sleep among persons with dementia.