Healthcare Utilization and Chronic Disease Management for Non-Medicaid-Eligible Patients in a City-Wide Safety-Net Healthcare Access Program.

BACKGROUND: In 2019, New York City (NYC) launched NYC Care (NYCC), a healthcare access program through NYC Health + Hospitals (H + H) for individuals who are ineligible for federally funded health insurance programs or cannot purchase insurance through the State Marketplace, predominantly undocumented individuals. OBJECTIVE: To examine the sociodemographic characteristics, healthcare use patterns, and chronic disease quality measures for diabetes mellitus (DM) and hypertension among NYCC patients compared with Medicaid patients seen at NYC H + H. DESIGN: Observational study. PARTICIPANTS: Adults aged 18 years and older enrolled in NYCC (N = 83,003) or Medicaid (N = 512,012) as of January 1, 2022. Patients were included if they had at least one visit between January 1, 2021, and December 31, 2021. MAIN MEASURES: Sociodemographic characteristics, healthcare use patterns, and quality measures for DM and hypertension. KEY RESULTS: NYCC patients (n = 83,003) were, on average, older, more likely to be Hispanic with Spanish as their preferred language, had more comorbidities, and had more primary care (adjusted incidence rate ratio 2.75 [95% confidence interval 2.71, 2.80]) and specialty care (2.22 [2.17, 2.26]) visits compared to Medicaid patients (n = 512,012). Rates of emergency department visits were similar between the two groups (1.02 [1.00, 1.04]), but NYCC patients had relatively fewer hospitalizations (0.64 [0.62, 0.67]). NYCC patients with DM or hypertension had higher rates of having a documented hemoglobin A1c or blood pressure in 2022, respectively, and clinically similar rates of chronic disease control (mean difference in hemoglobin A1c - 0.05 [- 0.09, - 0.01] in patients with DM and mean difference in blood pressure - 0.38 [- 0.67, - 0.10]/ - 0.64 [- 0.82, - 0.46]) compared with Medicaid patients. CONCLUSIONS: NYCC effectively enrolled a large number of uninsured participants and provided them with healthcare access similar to that of Medicaid patients. Future studies should evaluate the impact of NYCC enrollment on healthcare utilization and disease outcomes.

Patient-Portal Compared with Supplemental In-Office Tablet Screening for Health-Related Social Needs in Primary Care.

BACKGROUND: Screening for health-related social needs (HRSN) has become more widespread but the best method of delivering the screening tool is not yet known. OBJECTIVE: Describe HRSN screening completion rate, specifically portal-based and in-person tablet-based screening. DESIGN: Cross-sectional retrospective observational study. PARTICIPANTS: Adults age 18 or older who had a non-acute primary care visit at one of three internal medicine primary care clinics at a large, urban, academic medical center between July 2022 and July 2023. MAIN MEASURES: We identified the proportion of individuals who were screened using the HRSN questionnaire, whether screening was completed by patient-portal or tablet, as well as the degree of burden of HRSN. Using the electronic health record, we explored associations between sociodemographic characteristics and HRSN attributes. KEY RESULTS: Our study included 24,597 patients, of whom 37% completed the HRSN questionnaire. A smaller proportion of Black/African American patients and those with Medicaid insurance completed the questionnaire, yet they comprised a greater percentage of those who screened positive for unmet HRSN (p ≤ 0.001). Most patients completed the questionnaire by patient-portal (86.1%) compared with in-office tablets (14.0%). A larger proportion of those who completed screening by tablet screened positive for HRSN. Of all patients screened, 21.8% were positive for an unmet HRSN and 11.5% had more than one unmet HRSN. CONCLUSIONS: A majority of patients are not being screened for HRSN and results illustrate disparities when screening patients for HRSN through portal-based compared with supplemental in-office tablet-based screening. Prevalence of unmet HRSN varied by demographics such as race and insurance status.

Leading a Healthcare Organization During a Period of Social Change: A Qualitative Study of Chief Executive Officers.

BACKGROUND: In recent years, organizational leaders have faced growing pressure to respond to social and political issues. Although previous research has examined the experiences of corporate CEOs engaging in these issues, less is known about the perspectives of healthcare leaders. OBJECTIVE: To explore the experiences of healthcare CEOs engaging in health-related social and political issues, with a specific focus on systemic racism and abortion policy. DESIGN: Qualitative study using semi-structured interviews from February to July 2023. PARTICIPANTS: CEOs of US-based hospitals or health systems. APPROACH: One-on-one interviews which were audio recorded, professionally transcribed, and analyzed using thematic analysis. KEY RESULTS: This study included 25 CEOs of US-based hospitals or health systems. Almost half were between ages 60 and 69 (12 [48%]), 19 identified as male (76%), and 20 identified as White (80%). Approximately half self-identified as Democrats (13 [55%]). Most hospitals and health systems were private non-profits (15 [60%]). The interviews organized around four domains: (1) Perspectives on their Role, (2) Factors Impacting Engagement, (3) Improving Engagement, and (4) Experiences Responding to Recent Polarizing Events. Within these four domains, nine themes emerged. CEOs described increasing pressure to engage and had mixed feelings about their role. They identified personal, organizational, and political factors that affect their engagement. CEOs identified strategies to measure the success of their engagement and also reflected on their experiences speaking out about systemic racism and abortion legislation. CONCLUSIONS: In this qualitative study, healthcare CEOs described mixed perspectives on their role engaging in social and political issues and identified several factors impacting engagement. CEOs cited few strategies to measure the success of their engagement. Given that healthcare leaders are increasingly asked to address policy debates, more work is needed to examine the role and impact of healthcare CEOs engaging in health-related social and political issues.

Insights Into Patients' Perceptions of Health-Related Social Needs and the Role of the Adult Primary Care Clinic.

INTRODUCTION/OBJECTIVES: While it is well established that unmet healthrelated social needs (HRSN) adversely affect health outcomes, there has been limited evaluation in adult primary care of patients' perceptions of how these needs impact their health and the role of the primary care provider (PCP). The objective of this study is to identify patients' perceptions of HRSN and how PCPs could help address them. Secondary objectives include exploring the impact of goal setting and a 1-time cash transfer (CT). METHODS: This qualitative study used semi-structured baseline and follow-up interviews with patients in internal medicine clinics. Adult primary care patients were included if they screened positive as having 1 of 3 HRSN: financial resource strain, transportation needs, or food insecurity. All participants completed an initial interview about their HRSN and health, and were asked to set a 6-month health goal. At enrollment, participants were randomized to receive a $500 CT or a $50 participation reward. At 6-months, patients were interviewed again to investigate progress toward meeting their health goals, [when applicable] how the CT helped, and their beliefs about the role of PCPs in addressing HRSN. RESULTS: We completed 30 initial and 25 follow-up interviews. Participants identified their HRSN, however most did not readily connect identified needs to health. Although participants were receptive to HRSN screening, they did not feel it was their PCP's responsibility to address these needs. Verbal goal-setting appeared to be a useful tool, and while the CTs were appreciated, patients often found them inadequate to address HRSN. CONCLUSIONS: Given the importance of identifying the social conditions that shape patients' health, providers, and health systems have an opportunity to re-evaluate their role in helping patients address these barriers. Future studies could examine the effect of more frequent disbursement of CTs over time.

Development of a Practice-based Community Outreach Intervention to Prevent Inequities in COVID-19 Vaccinations.

Despite disproportionately higher rates of morbidity and mortality from COVID-19 among Black and Hispanic adults in the United States, ethnoracial disparities in vaccination rates emerged rapidly. The objective of this quality improvement study was to rapidly develop and implement an equity-focused community outreach intervention that facilitated COVID-19 vaccine appointments. Using the Plan-Do-Study-Act model, this multipronged, primary care-based outreach intervention developed call/recall systems that addressed vaccine hesitancy and facilitated real-time vaccine scheduling. Through 5058 calls to 2794 patients, 1519 patients were successfully reached. Of the 750 patients eligible for vaccine scheduling, 129 (17.2%) had a vaccine appointment scheduled by the caller and 72 (9.6%) indicated a plan to self-schedule. Low confidence in the vaccine was the most cited reason for declining assistance with a vaccine appointment. Primary care practices may wish to consider introducing similar outreach interventions in the future to address ethnoracial inequities in vaccination distribution.

The Diagnostic Accuracy Of Procalcitonin for Urinary Tract Infection in Hospitalized Older Adults: a Prospective Study.

BACKGROUND: The diagnosis of urinary tract infection (UTI) is challenging among hospitalized older adults, particularly among those with altered mental status. OBJECTIVE: To determine the diagnostic accuracy of procalcitonin (PCT) for UTI in hospitalized older adults. DESIGN: We performed a prospective cohort study of older adults (≥65 years old) admitted to a single hospital with evidence of pyuria on urinalysis. PCT was tested on initial blood samples. The reference standard was a clinical definition that included the presence of a positive urine culture and any symptom or sign of infection referable to the genitourinary tract. We also surveyed the treating physicians for their clinical judgment and performed expert adjudication of cases for the determination of UTI. PARTICIPANTS: Two hundred twenty-nine study participants at a major academic medical center. MAIN MEASURES: We calculated the area under the receiver operating characteristic curve (AUC) of PCT for the diagnosis of UTI. KEY RESULTS: In this study cohort, 61 (27%) participants met clinical criteria for UTI. The median age of the overall cohort was 82.6 (IQR 74.9-89.7) years. The AUC of PCT for the diagnosis of UTI was 0.56 (95% CI, 0.46-0.65). A series of sensitivity analyses on UTI definition, which included using a decreased threshold for bacteriuria, the treating physicians' clinical judgment, and independent infectious disease specialist adjudication, confirmed the negative result. CONCLUSIONS: Our findings demonstrate that PCT has limited value in the diagnosis of UTI among hospitalized older adults. Clinicians should be cautious using PCT for the diagnosis of UTI in hospitalized older adults.