Creating and Implementing a Community-Focused, Culturally Tailored Health Marketing Campaign to Address Menthol Cigarette Use in Los Angeles County.

Introduction: Menthol tobacco products have been marketed disproportionately to communities of color for decades. Methods: In Los Angeles County, California, a health marketing campaign, which used glossy visuals and attractive people in appealing poses, reminiscent of tobacco marketing tactics, was created and implemented to educate smokers on the health risks of using menthol cigarettes. The campaign encouraged smokers to make a quit attempt by offering access to free or low-cost resources through the Kick It California quitline and the LAQuits website (laquits.com). A survey tailored for public health professionals and community members from the approximately 382,000 people in the county who smoked menthol cigarettes and were exposed to their smoke (our primary audience) was administered to generate insights about this problem. Survey data were used to finesse the campaign creative materials prior to launch. Advertisement exposures, website visits, and quitline call volume were monitored and tabulated to assess the performance of the campaign. Results: At the conclusion of its initial run (February-April 2021), the "Done with Menthol" campaign had garnered more than 66 million impressions, received approximately 56,000 clicks on its various digital media platforms, and had click-through rates that surpassed industry benchmarks. The quitline call volume for African American and Latino subgroups were 1.9 and 1.8 times higher than the average inbound call volume for corresponding months during 2018 and 2019, respectively. In its second run (May-June 2023), the campaign garnered approximately 11 million additional impressions. Conclusions: Despite having a lower budget and fewer resources than the tobacco industry, the "Done with Menthol" campaign attained excellent reach and offered free, low-cost, and accessible resources to county residents interested in tobacco use cessation.

Understanding the implementation and sustainability needs of evidence-based programs for racial and ethnic minoritized older adults in under-resourced communities with limited aging services.

BACKGROUND: Evidence-based programs (EBPs) for older adults effectively improve health outcomes. However, there is a limited understanding of the unique needs of service providers as they consider adopting, implementing, and maintaining programs for older minority adults in low-income communities with limited aging services. METHODS: We conducted semi-structured interviews with key informants of community-based organizations (CBOs) to understand implementation and sustainability needs of CBOs within four racial and ethnically diverse Los Angeles County geographic areas. We performed thematic analysis of interview transcripts. RESULTS: Interviews were conducted with representatives from 25 senior-serving agencies providing aging-related EBPs. CBO representatives reported implementing EBPs in 8 domains: Falls Prevention (68%), Mental Health (64%), Caregiver Health (48%), Chronic Disease Management (48%), Diabetes Management (36%), Arthritis Management (28%), Physical Activity (24%), and Multiple Conditions Management (8%). Themes are presented using the six domains of the Bass and Judge framework for factors impacting successful and sustained EBP implementation. CBOs in low-income and diverse communities described unique challenges with tailoring interventions based on local community context (literacy, language), cultural context, and locally available resources (technology, safe community spaces, transportation) and faced resource-intensive administrative burdens through staff turnover, data collection, sustainable funding, and networking. CONCLUSIONS: Serving racial and ethnic communities has unique challenges that require tailored approaches and additional resources to ensure equitable access to EBPs for all communities. We describe suggestions for enhancing the effective adoption of EBPs among service agencies in under-resourced and diverse aging communities serving populations with aging-related health disparities.

Examination of community-level interventions addressing early childhood obesity in Los Angeles County.

Objective: To help inform decisions regarding the equitable implementation of obesity interventions, we examined whether interventions were equitably reaching the most vulnerable communities, identified communities that received fewer interventions than expected, and estimated the effect of 'dose' of interventions on obesity prevalence. Methods: We created a database to identify and characterize obesity-related interventions implemented in Los Angeles County from 2005 to 2015 linked to community-level sociodemographic and obesity prevalence data. We ran generalized linear models with a Gamma distribution and log link to determine if interventions were directed toward vulnerable communities and to identify communities that received fewer interventions than expected. We ran fixed-effects models to estimate the association between obesity prevalence and intervention strategy count among preschool-aged children enrolled in the Special Supplemental Nutrition Assistance Program for Women Infants and Children. Results: We found that interventions targeted vulnerable communities with high poverty rates and percentages of minority residents. The small cluster of communities that received fewer interventions than expected tended to have poor socioeconomic profiles. Communities which received more intervention strategies saw greater declines in obesity prevalence (ß = -0.023; 95 % CI: -0.031, -0.016). Conclusions: It is important to determine if interventions are equitably reaching vulnerable populations as resources to tackle childhood obesity become available. Evaluating the population impact of multiple interventions implemented simultaneously presents methodological challenges in measuring intervention dose and identifying cost-effective strategies. Addressing these challenges must be an important research priority as community-wide interventions involve multiple intervention strategies to reduce health disparities.

Integrating Healthy Nutrition Standards and Practices Into Food Service Contracting in a Large US County Government.

Purpose and Objectives: Although considered a promising model of practice, integrating healthy nutrition standards and practices into a large county government's contracting process with food vendors has not been widely described in empirical literature. We conducted an implementation evaluation project to address this gap. Intervention Approach: County of Los Angeles food vendors provide food or meals annually to more than 100,000 employees and millions of clients and visitors. In 2011, the County of Los Angeles Board of Supervisors adopted a policy to integrate healthy nutrition standards and practices into its requests for proposals (RFPs) and contracting process with food vendors. The policy required all contracts awarded to adhere to these new standards. Evaluation Methods: In 2011, the Los Angeles County Department of Public Health (DPH) began reviewing RFPs for food services for county departments that procured, served, or sold food. From 2011 through 2021, DPH applied a 4-pronged formative-evaluative approach to help county departments implement the Board of Supervisors policy and ensure that nutritional requirements were appropriately integrated into all RFPs for new and renewing contracts with food vendors. We focused our evaluation on understanding the process and tracking the progress of this policy intervention. Our evaluation included 13 key informant interviews, a 2-part survey, reviews of contract data, and synthesis of lessons learned. Results: Based on reviews and subsequent actions taken on more than 20 RFPs, DPH successfully assisted 7 county departments to incorporate healthy nutrition standards and practices into their food vendor contracts. Implementation of the food policy encountered several challenges, including staffing and training constraints and a limited infrastructure. An iterative approach to program improvement facilitated the process. Implications for Public Health: Although the model for integrating healthy nutrition standards and practices into a government contracting process is promising, more work is needed to make it less resource-intensive and to increase user buy-in.

Associations Between Patient Comfort with a Primary Care Provider and Three Measures of Behavioral Health Services Utilization.

BACKGROUND: Behavioral health services (BHS) can help improve and treat mental and emotional health problems. Yet, attitudinal and/or structural barriers often prevent individuals from accessing and benefiting from these services. Positive provider-patient interactions in healthcare, encompassing patient comfort with a primary care provider (PCP), which is often enhanced by shared decision-making, may mitigate the stigma associated with seeing a mental health professional; this may improve BHS utilization among patients who need these services. However, few studies have examined how patient comfort with a PCP, often through shared decision-making, may influence patients' BHS utilization in the real world. This study sought to address this gap in practice. METHOD: Multivariable regression analyses, using weighted data from an internet panel survey of Los Angeles County adults (n = 749), were carried out to examine the associations between patient comfort with a PCP and three measures of BHS utilization. Subsequent analyses were conducted to explore the extent to which shared decision-making moderated these associations. RESULTS: Participants who reported an intermediate or high comfort level with a provider had higher odds of reporting that they were likely to see (aOR = 2.10 and 3.84, respectively) and get advice (aOR = 2.75 and 4.76, respectively) from a mental health professional compared to participants who reported a low comfort level. Although shared decision-making influenced participants' likelihood of seeing and getting advice from a mental health professional, it was not a statistically significant moderator in these associations. CONCLUSION: Building stronger relationships with patients may improve BHS utilization, a provider practice that is likely underutilized.

Two-stage deep-learning-based colonoscopy polyp detection incorporating fisheye and reflection correction.

BACKGROUND AND AIM: Colonoscopy is a useful method for the diagnosis and management of colorectal diseases. Many computer-aided systems have been developed to assist clinicians in detecting colorectal lesions by analyzing colonoscopy images. However, fisheye-lens distortion and light reflection in colonoscopy images can substantially affect the clarity of these images and their utility in detecting polyps. This study proposed a two-stage deep-learning model to correct distortion and reflections in colonoscopy images and thus facilitate polyp detection. METHODS: Images were collected from the PolypSet dataset, the Kvasir-SEG dataset, and one medical center's patient archiving and communication system. The training, validation, and testing datasets comprised 808, 202, and 1100 images, respectively. The first stage involved the correction of fisheye-related distortion in colonoscopy images and polyp detection, which was performed using a convolutional neural network. The second stage involved the use of generative and adversarial networks for correcting reflective colonoscopy images before the convolutional neural network was used for polyp detection. RESULTS: The model had higher accuracy when it was validated using corrected images than when it was validated using uncorrected images (96.8% vs 90.8%, P < 0.001). The model's accuracy in detecting polyps in the Kvasir-SEG dataset reached 96%, and the area under the receiver operating characteristic curve was 0.94. CONCLUSION: The proposed model can facilitate the clinical diagnosis of colorectal polyps and improve the quality of colonoscopy.

Food recovery and produce distribution as a system strategy for increasing access to healthy food among populations experiencing food insecurity: lessons for post-pandemic planning.

Using data from an intercept survey of 428 adults who received free surplus produce at five distribution sites and qualitative data from 15 interviews with site personnel, we examined facilitators (e.g. community partnerships, coalition support) and challenges (e.g. limited refrigerated storage, lack of transportation infrastructure) to operating a food recovery and distribution program in Los Angeles County. Overall, this food system intervention appeared to fill an unmet need for recipients, nearly 80% of whom were food insecure and 60% visited a site several months/year or monthly. For many living in this county's underserved communities, this effort was instrumental in increasing access to healthy food before and during the COVID-19 pandemic. To sustain/expand this program's reach, local governments and food assistance programs should provide greater coordination and oversight, and invest more resources into this food recovery and distribution infrastructure.

Patterns of Health Care Access and Use in an Urban American Indian and Alaska Native Population.

Studies of health care access and use among historically resilient populations, while common, often field a limited sample size and rarely ask the groups most impacted by health inequities to weigh in. This is especially so for research and programs that focus on the American Indian and Alaska Native (AIAN) population. The present study addresses this gap by examining data from a cross-sectional survey of AIANs in Los Angeles County. To better interpret project findings and generate culturally relevant contexts, qualitative feedback was gathered at a community forum held in Spring 2018. Because recruitment of AIANs has historically been challenging, purposive sampling was employed to strategically identify a larger eligible pool. Among those who were eligible, 94% completed the survey (n = 496). AIANs who were enrolled in a tribe were 32% more likely to use the Indian Health Service (IHS), compared with those who were not enrolled (95% CI: 20.4%, 43.2%; p < .0001). In multivariable modeling, the strongest factors influencing IHS access and use were: tribal enrollment, preference for culturally-specific health care, proximity of the services to home or work, having Medicaid, and having less than a high school education. Feedback from the community forum indicated cost and trust (of a provider) were important considerations for most AIANs. Study findings reveal heterogeneous patterns of health care access and use in this population, suggesting a need to further improve the continuity, stability, and the image of AIANs' usual sources of care (e.g., IHS, community clinics).

Using Grand Rounds to Train and Prepare a Local Public Health Workforce To Manage COVID-19 Outbreaks During the 2020-2021 Pandemic Winter Upsurge.

In response to the coronavirus disease 2019 (COVID-19) pandemic, the Los Angeles County Department of Public Health (DPH) expanded its workforce by >250 staff during Fall 2020 to manage the expected volume of outbreaks, which ultimately peaked. The workforce included reorganized groups of physicians, nurses, outbreak investigators from several DPH programs, and a 100+ member data science team tasked with designing and operating a data system and information flow process that became the backbone infrastructure of support for field investigation and outbreak management in real-time. The accelerated workforce expansion was completed in 3 months. To prepare new and reassigned permanent staff for fieldwork, DPH and several faculty from the Emory University Rollins School of Public Health adopted a flexible, skills-based series of medical Grand Rounds. These 16 sessions were grounded in practice- and problem-based learning principles using case studies, interactive scenarios, and didactic presentations based on scientific and public health practice information to teach knowledge and skills that were needed to manage COVID-19 outbreaks in different sectors. The evaluation suggests positive experience with the training series as well as impact on job performance.

Food Insecurity Screening in Safety-Net Clinics in Los Angeles County: Lessons for Post-Pandemic Planning.

INTRODUCTION: Food insecurity is a major public health problem in the United States which was exacerbated by the COVID-19 pandemic. We used a multi-method approach to understand barriers and facilitators to implementing food insecurity screening and referrals at safety net health care clinics in Los Angeles County before the pandemic. METHODS: In 2018, we surveyed 1013 adult patients across eleven safety-net clinic waiting rooms in Los Angeles County. Descriptive statistics were generated to characterize food insecurity status, attitudes toward receiving food assistance, and use of public assistance programs. Twelve interviews with clinic staff explored effective and sustainable approaches to food insecurity screening and referral. RESULTS: Patients welcomed the opportunity to access food assistance in the clinic setting; 45% preferred discussing food issues directly with the doctor. Missed opportunities to screen for food insecurity and refer patients to food assistance were identified at the clinic level. Barriers to these opportunities included: competing demands on staff and clinic resources, difficulty establishing referral pathways, and doubts surrounding data. DISCUSSION: Integrating food insecurity assessment in clinical settings requires infrastructure support, staff training, clinic buy-in, and more coordination and oversight from local government, health center entities, and public health agencies.

Delivery of Comprehensive Medication Management and Other Clinical Services via Telehealth by Pharmacy Type.

BACKGROUND: The recent coronavirus pandemic accelerated the need to deliver pharmacy-related services remotely. OBJECTIVE: To describe experiences with providing comprehensive medication management (CMM) and other clinical services via telehealth by pharmacy type, before and during the COVID-19 pandemic. METHODS: An online survey of pharmacists, representing 27 pharmacies, was conducted to capture telehealth usage in three pharmacy types: independently owned, integrated into a clinical setting, and retail chain. A sub-analysis was performed to assess if providing CMM services via telehealth helped, resulted in no change, or worsened the care of different patient groups (e.g., those with diabetes, were low-income, aged 65+ years). RESULTS: During the pandemic, telehealth usage among independently owned pharmacies and those integrated into a clinical setting increased, but no change occurred among retail chain pharmacies. This usage increase in the first two pharmacy types occurred despite limited investments in connectivity-related resources to support telehealth services. Pharmacists from both independently owned pharmacies (63%) and those integrated into a clinical setting (89%) reported CMM via telehealth reached patients they would not otherwise have been able to reach during the pandemic. Most pharmacists/pharmacies found telehealth to be a feasible and acceptable method of delivering CMM. CONCLUSION: Pharmacists and pharmacies are now experienced with and have interest in continuing CMM via telehealth, even as the pandemic recedes. However, investments in telecommunications resources, training support, technical assistance, and continued telehealth reimbursement from health plans are needed to sustain this service delivery model.

Modeling COVID-19 infection dynamics and mitigation strategies for in-person K-6 instruction.

Background: U.S. school closures due to the coronavirus disease 2019 (COVID-19) pandemic led to extended periods of remote learning and social and economic impact on families. Uncertainty about virus dynamics made it difficult for school districts to develop mitigation plans that all stakeholders consider to be safe. Methods: We developed an agent-based model of infection dynamics and preventive mitigation designed as a conceptual tool to give school districts basic insights into their options, and to provide optimal flexibility and computational ease as COVID-19 science rapidly evolved early in the pandemic. Elements included distancing, health behaviors, surveillance and symptomatic testing, daily symptom and exposure screening, quarantine policies, and vaccination. Model elements were designed to be updated as the pandemic and scientific knowledge evolve. An online interface enables school districts and their implementation partners to explore the effects of interventions on outcomes of interest to states and localities, under a variety of plausible epidemiological and policy assumptions. Results: The model shows infection dynamics that school districts should consider. For example, under default assumptions, secondary infection rates and school attendance are substantially affected by surveillance testing protocols, vaccination rates, class sizes, and effectiveness of safety education. Conclusions: Our model helps policymakers consider how mitigation options and the dynamics of school infection risks affect outcomes of interest. The model was designed in a period of considerable uncertainty and rapidly evolving science. It had practical use early in the pandemic to surface dynamics for school districts and to enable manipulation of parameters as well as rapid update in response to changes in epidemiological conditions and scientific information about COVID-19 transmission dynamics, testing and vaccination resources, and reliability of mitigation strategies.

The association between provider encouragement and sodium consumption behaviors.

OBJECTIVE: To explore and describe the associations between provider encouragement and four sodium consumption behaviors. METHODS: We analyzed a 2016 Internet panel survey dataset of 954 socio-demographically diverse adults (age ≥18 years) living in Los Angeles County. Behaviors analyzed were current status of watching one's salt/sodium intake, frequency of adding salt to food, frequency of using a food/Nutrition Facts label to decide what food to purchase, and frequency of changing one's mind about buying a food product due to its sodium content. Multivariable logistic regression analyses examined the relationship between doctor/health professional (provider) encouragement and these sodium-related behaviors, controlling for self-reported health status and sociodemographic characteristics. RESULTS: Provider encouragement was positively associated with three of the four sodium consumption behaviors examined: currently watching salt/sodium intake (AOR=7.27, 95% CI=3.97-13.34); frequently using a food/Nutrition Facts label (AOR=1.70, 95% CI=1.09-2.64); and frequently changing one's mind about buying a food product due to its sodium content (AOR=2.29, 95% CI=1.45-3.63). CONCLUSIONS: Provider encouragement appears to have a salutary impact on sodium consumption among residents. PRACTICE IMPLICATIONS: Provider encouragement may represent an underutilized strategy for counseling patients about cardiovascular health and about the benefits of reducing sodium consumption.

An Organizational Assessment of 34 Home Delivered Meals Programs that Engaged and Assisted Homebound Individuals With Obtaining the COVID-19 Vaccine During the Pandemic.

Vaccinating homebound individuals during the COVID-19 pandemic presented several challenges, including time and cost of engaging this group. In Los Angeles County, the departments of Public Health and Aging and Disabilities turned to home delivered meals programs (HDMs) for help with this public health priority. A mixed-method organizational assessment of 34 HDMs was conducted during March-April 2022 to describe these efforts. Most HDMs were nonprofit (67.6%) and had <25 staff (58.8%). Overall, they served a large catchment area before and during COVID-19, providing services to an estimated total of 24,995 clients/week and delivering 19,511 meals/day. A majority (82.4%) reported engaging their clients to facilitate COVID-19 vaccinations. As of early 2022, <6% of these HDMs' homebound clients were unvaccinated. These programs' efforts to assist older individuals who were homebound during the pandemic represent a potentially underutilized model of public-nonprofit/not-for-profit partnership for improving vaccine delivery and uptake in this hard-to-reach population.

Financial and Other Life Stressors, Psychological Distress, and Food and Beverage Consumption among Students Attending a Large California State University during the COVID-19 Pandemic.

The novel coronavirus disease 2019 (COVID-19) pandemic abruptly disrupted the daily lives and health of college students across the United States. This study investigated several stressors (e.g., financial strain/uncertainty), psychological distress, and dietary behaviors among college students attending a large state university during the pandemic. A cross-sectional online survey was administered to students from the California State University, Los Angeles between April and May 2021 (final analytic sample n = 736). Differences in gender and race/ethnicity were examined using chi-square, t-test, and one-way ANOVA tests. Paired t-tests were performed to compare variables before and during the pandemic. Negative binomial regression models examined the associations between various stressors, psychological distress, and three key dietary outcomes. Descriptive results showed that the consumption of fruits and vegetables, fast food, and sugary beverages, along with psychological distress, all increased during the pandemic. Significant differences in fruit and vegetable and fast food consumption by gender and race/ethnicity were also observed. In the regression models, several stressors, including financial strain and psychological distress, were associated with unfavorable food and beverage consumption, thereby suggesting that college students may need more support in mitigating these stressors so they do not manifest as poor dietary behaviors. Poor diet quality is associated with poor physical health outcomes such as premature development of type 2 diabetes or hypertension.

Intraprocedure Artificial Intelligence Alert System for Colonoscopy Examination.

Colonoscopy is a valuable tool for preventing and reducing the incidence and mortality of colorectal cancer. Although several computer-aided colorectal polyp detection and diagnosis systems have been proposed for clinical application, many remain susceptible to interference problems, including low image clarity, unevenness, and low accuracy for the analysis of dynamic images; these drawbacks affect the robustness and practicality of these systems. This study proposed an intraprocedure alert system for colonoscopy examination developed on the basis of deep learning. The proposed system features blurred image detection, foreign body detection, and polyp detection modules facilitated by convolutional neural networks. The training and validation datasets included high-quality images and low-quality images, including blurred images and those containing folds, fecal matter, and opaque water. For the detection of blurred images and images containing folds, fecal matter, and opaque water, the accuracy rate was 96.2%. Furthermore, the study results indicated a per-polyp detection accuracy of 100% when the system was applied to video images. The recall rates for high-quality image frames and polyp image frames were 95.7% and 92%, respectively. The overall alert accuracy rate and the false-positive rate of low quality for video images obtained through per-frame analysis were 95.3% and 0.18%, respectively. The proposed system can be used to alert colonoscopists to the need to slow their procedural speed or to perform flush or lumen inflation in cases where the colonoscope is being moved too rapidly, where fecal residue is present in the intestinal tract, or where the colon has been inadequately distended.

Multiple amino acid substitutions in penicillin-binding protein-1A confer amoxicillin resistance in refractory Helicobacter pylori infection.

BACKGROUND: Amoxicillin resistance in Helicobacter pylori is mainly associated with mutations in penicillin-binding protein-1A (PBP-1A). However, the specific amino acid substitutions in PBP-1A that confer amoxicillin resistance in H. pylori remain to be investigated. OBJECTIVE: This study aimed to investigate the molecular mechanism underlying amoxicillin resistance in patients with refractory H. pylori infection. METHODS: Esophagogastroduodenoscopy (EGD) was performed in patients with persistent H. pylori infection after at least two courses of H. pylori eradication therapy between January-2018 to March-2021. Refractory H. pylori was cultured from the gastric biopsy specimens. Antibiotic susceptibility testing was conducted to determine the minimum inhibitory concentrations (MICs). Sequence analysis of pbp-1A was performed for amoxicillin-resistant strains. RESULTS: Thirty-nine successfully cultured isolates were classified as refractory H. pylori isolates, and seventeen isolates were resistant to amoxicillin (MIC > 0.125 mg/L). Sequence analysis of resistant strains showed multiple mutations in the C-terminal region of PBP-1A that conferred amoxicillin resistance in H. pylori. However, the number of PBP-1A mutations did not correlate with the high MICs of amoxicillin-resistant isolates. Notably, some amino acid substitutions were identified in all Taiwanese isolates with history of eradication failure but not in published amoxicillin-susceptible strains, suggesting that the mutations may play a role in conferring antibiotic resistance to these strains. CONCLUSIONS: Our results show that amoxicillin resistance in refractory H. pylori is highly correlated with numerous PBP-1A mutations that are strain specific. Continuous improvements in diagnostic tools, particularly molecular analysis approaches, can help to optimize current antimicrobial regimens.

An organizational assessment of 101 Community-Based Adult Services centers to identify and address gaps in influenza vaccination among Medicare-Medicaid beneficiaries.

INTRODUCTION: Medicare-Medicaid beneficiaries are at high risk of experiencing severe disease from influenza. Yet, immunization assessment followed by influenza vaccination (when needed) are not regularly performed at Community-Based Adult Services (CBAS) centers in/near medically underserved areas. To better understand this challenge, an organizational assessment was conducted in early 2020 to identify and examine modifiable factors that may impede or facilitate immunization assessment and influenza vaccination at CBAS centers in Los Angeles County (LAC), California. METHODS: All 158 CBAS centers in LAC were asked to complete a 17-question survey. The survey asked about immunization assessment, gaps in communication with primary care providers, knowledge and use of the California Immunization Registry (CAIR), and institutional policies for influenza vaccination. In addition, the survey asked each center about its vaccination policy for staff and clients, including whether or not increasing vaccinations was an interest/priority for the center. Best subsets algorithms (regression models) were performed to identify factors that may influence CBAS centers' practices on immunization assessment and vaccination. RESULTS: Of the 158 centers, 101 (66 %) completed the survey. A majority did not conduct immunization assessments for influenza (n = 59; 58 %); nearly-two-thirds (n = 70; 71 %) reported it would be feasible to do so if the practice is integrated as part of the individualized/nursing plan of care. Best subsets algorithms showed the strongest factors influencing whether CBAS centers assess for influenza vaccination were: center size, staff training on CAIR, presence of barriers to vaccination, and the belief that it is the center's responsibility to conduct immunization assessments and vaccinations. CONCLUSIONS: Findings suggest that practice gaps in immunization assessment and influenza vaccination are common at LAC's CBAS centers. Closing these gaps may help LAC (and California) improve influenza vaccine uptake and other vaccinations (e.g., pneumococcal, COVID-19) among the most vulnerable of the state's aging populations, Medicare-Medicaid beneficiaries.

Building bi-directional referral and communication pathways across the community-clinic divide: Experiences from a systems-informed innovation project in Los Angeles.

Bi-directional communication and referral pathways (BCRPs) between clinics and community-based organizations could promote well-being among vulnerable populations with complex and overlapping health and social needs. While BCRPs are promising, establishing them is complex, involving system and process changes across diverse organizational settings. To date, few models have been implemented or empirically tested. This article describes an innovation and planning project to build a BCRP, linking patients in safety net primary care clinics to a comprehensive suite of community-based health and wellness supports in Los Angeles. During a year-long process, a multi-sector team iteratively engaged data to facilitate learning and improvement. The project proceeded through three distinct, but overlapping, phases: (1) Discovery, (2) Systems Mapping, and (3) BCRP Re-design and Testing, which were coordinated through frequent collaborative meetings. By using a stepwise systems-informed approach to collect and examine data, the team was able to generate new change ideas, dispel assumptions, and make transparent and informed decisions. It was critical to have engagement from both internal partners with knowledge of "on-the-ground" practice realities, and external stakeholders with the fresh perspective needed to identify opportunities and define an improvement agenda. These efforts represent first steps towards implementing sustainable BCRPs and realizing their full potential to dynamically bridge the community-clinic divide and improve population health. Other jurisdictions can learn from and adapt the practical data-driven approach used in Los Angeles to build BCRPs that will be thoroughly operationalized, consistently implemented, and optimized within their own unique contexts.

Albumin-Bilirubin Grade as a Novel Predictor of the Development and Short-Term Survival of Post-Banding Ulcer Bleeding Following Endoscopic Variceal Ligation in Cirrhotic Patients.

Background and Objectives: Endoscopic variceal ligation (EVL) is the primary and secondary treatment for acute esophageal variceal bleeding. Post-banding ulcer bleeding (PBUB) may lead to bleeding episodes following EVL, increasing mortality. The aim of this study was to evaluate the risk factors for PBUB and predict the 6-week mortality risk after PBUB. Materials and Methods: We retrospectively analyzed the data collected from cirrhotic patients with EVL from 2015 to 2017. The incidence of PBUB and the 6-week mortality rate were evaluated. Risk factors for PBUB and predictive factors for mortality after PBUB were analyzed. Results: A total of 713 patients were enrolled in this study. Among the studied subjects, the incidence of PBUB was 5.8% (N = 41). The 6-week mortality rate was 63.4% (26/41). In multivariate analysis, MELD score ≥20 (OR: 3.77, 95% CI: 1.94−7.33, p < 0.001), ALBI score of 3 (OR: 2.67, 95% CI: 1.34−5.3, p = 0.005) and the presence of gastric varices (OR: 2.1, 95% CI: 1.06−4.16, p = 0.03) were associated with the development of PBUB. Patients with ALBI grade 3 (OR: 4.8, 95% CI: 1.18−19.6, p = 0.029) and Child-Pugh scores B and C (OR: 16.67, 95% CI: 1.75−158.1, p = 0.014) were associated with 6-week mortality after PBUB. Conclusions: PBUB is a complication with low incidence but increased mortality following EVL. The ALBI grade is a useful score to predict not only the development of PBUB but also the 6-week mortality after PBUB.