Risk of recurrent severe maternal morbidity in an urban safety net health system

Abstract Hypertensive disorders of pregnancy (HDP) are a leading cause of severe maternal morbidity (SMM), yet mediation by cesarean delivery is largely unexplored. We investigated the association between HDP and SMM in a cohort of deliveries at a safety-net institution in Atlanta, Georgia, during 2016–2018. Using multivariable generalized linear models, we estimated adjusted risk differences, adjusted risk ratios, and 95% confidence intervals for the association between HDP and SMM. We examined interactions with cesarean delivery and used mediation analysis with 4-way decomposition to estimate excess relative risks. Among 3,723 deliveries, the SMM rate for women with and without HDP was 124.4 per 1,000 and 52.0 per 1,000, respectively. The adjusted risk ratio for the total effect of HDP on SMM was 2.55 (95% confidence interval (CI): 2.15, 3.39). Approximately 55.2% (95% CI: 25.7, 68.5) of excess relative risk was due to neither interaction nor mediation, 24.9% (95% CI: 15.4, 50.0) was due to interaction between HDP and cesarean delivery, 9.6% (95% CI: 3.4, 15.2) was due to mediation, and 10.3% (95% CI: 5.4, 20.3) was due to mediation and interaction. HDP are a potentially modifiable risk factor for SMM; implementing evidence-based interventions for the prevention and treatment of HDP is critical for reducing SMM risk.

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Patient and provider perception of appropriateness, acceptability, and feasibility of behavioral health home (BHH) core components based on program implementation in an urban, safety-net health system

Implementation Research and Practice ◽

10.1177/26334895211043791 ◽

2021 ◽

Vol 2 ◽

pp. 263348952110437

Author(s):

Ana M Progovac ◽

Miriam C Tepper ◽

H. Stephen Leff ◽

Dharma E Cortés ◽

Alexander (Cohen) Colts ◽

...

Keyword(s):

Primary Care ◽

Health System ◽

Behavioral Health ◽

Program Implementation ◽

Health Management ◽

Safety Net ◽

Clinical Settings ◽

Urban Safety ◽

Core Components ◽

Health Home

Background This manuscript evaluates patient and provider perspectives on the core components of a Behavioral Health Home (BHH) implemented in an urban, safety-net health system. The BHH integrated primary care and wellness services (e.g., on-site Nurse Practitioner and Care Manager, wellness groups and tools, population health management) into an existing outpatient clinic for people with serious mental illness (SMI). Methods As the qualitative component of a Hybrid Type I effectiveness-implementation study, semi-structured interviews were conducted with providers and patients 6 months after program implementation, and responses were analyzed using thematic analysis. Valence coding (i.e., positive vs. negative acceptability) was also used to rate interviewees’ transcriptions with respect to their feedback of the appropriateness, acceptability, and feasibility/sustainability of 9 well-described and desirable Integrated Behavioral Health Core components (seven from prior literature and two additional components developed for this intervention). Themes from the thematic analysis were then mapped and organized by each of the 9 components and the degree to which these themes explain valence ratings by component. Results Responses about the team-based approach and universal screening for health conditions had the most positive valence across appropriateness, acceptability, and feasibility/sustainability by both providers and patients. Areas of especially high mismatch between perceived provider appropriateness and measures of acceptability and feasibility/sustainability included population health management and use of evidence-based clinical models to improve physical wellness where patient engagement in specific activities and tools varied. Social and peer support was highly valued by patients while incorporating patient voice was also found to be challenging. Conclusions Findings reveal component-specific challenges regarding the acceptability, feasibility, and sustainability of specific components. These findings may partly explain mixed results from BHH models studied thus far in the peer-reviewed literature and may help provide concrete data for providers to improve BHH program implementation in clinical settings. Plain language abstract Many people with serious mental illness also have medical problems, which are made worse by lack of access to primary care. The Behavioral Health Home (BHH) model seeks to address this by adding primary care access into existing interdisciplinary mental health clinics. As these models are implemented with increasing frequency nationwide and a growing body of research continues to assess their health impacts, it is crucial to examine patient and provider experiences of BHH implementation to understand how implementation factors may contribute to clinical effectiveness. This study examines provider and patient perspectives of acceptability, appropriateness, and feasibility/sustainability of BHH model components at 6–7 months after program implementation at an urban, safety-net health system. The team-based approach of the BHH was perceived to be highly acceptable and appropriate. Although providers found certain BHH components to be highly appropriate in theory (e.g., population-level health management), their acceptability of these approaches as implemented in practice was not as high, and their feedback provides suggestions for model improvements at this and other health systems. Similarly, social and peer support was found to be highly appropriate by both providers and patients, but in practice, at months 6–7, the BHH studied had not yet developed a process of engaging patients in ongoing program operations that was highly acceptable by providers and patients alike. We provide these data on each specific BHH model component, which will be useful to improving implementation in clinical settings of BHH programs that share some or all of these program components.

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Development and Evaluation of Record Linkage Rules in a Safety-Net Health System Serving Disadvantaged Communities

ACI Open ◽

10.1055/s-0039-1693129 ◽

2019 ◽

Vol 03 (02) ◽

pp. e63-e70

Author(s):

William E. Trick ◽

Kruti Doshi ◽

Michael J. Ray ◽

Francisco Angulo

Keyword(s):

Health System ◽

Census Tract ◽

Record Linkage ◽

Safety Net ◽

Local Algorithm ◽

Disadvantaged Communities ◽

Registration Data ◽

Urban Safety ◽

Sensitivity Specificity ◽

Enterprise Data Warehouse

Background There is a need for flexible, accurate record-linkage systems with transparent rules that work across diverse populations. Objectives We developed rules responsive to challenges in linking records for an urban safety-net health system; we calculated performance characteristics for our algorithm. Methods We evaluated encounters during January 1, 2012 through September 30, 2018. We compared our algorithm, using name (first-last), date-of-birth (DOB), and last four of social security number to our electronic health record (EHR) system's reconciliation process. We applied our algorithm to unreconciled real-time Admission-Discharge-Transfer registration data, and compared match results to reconciled identities from our enterprise data warehouse. We manually validated matches for randomly sampled discordant pairs; we calculated sensitivity/specificity. We evaluated predictors of discordance, including census tract information. Results Of 771,477 unique medical record numbers, most (95%) were concordant between systems; a substantial minority (5%) was discordant. Of 38,993 discordant pairs, most (n = 36,539; 94%) were detected by our local algorithm. The sensitivity of our algorithm was higher than the EHR process (99% vs. 81%), but with lower specificity (98.6% vs. 99.9%). Our highest-yield rules, beyond full first and last name plus complete DOB match, were first three initials of first name, transposed first-last names, and DOB offsets (+1 and +365 days). Factors associated with discordance were homelessness (adjusted odds ratio [aOR] = 2.4; 95% confidence interval [CI], 2.2–2.6) and living in a census tract with high levels of poverty (aOR = 1.4; 95% CI, 1.3–1.4). Conclusion Our algorithm had superior sensitivity compared to our EHR process. Homelessness and poverty were associated with unmatched records. Improved sensitivity was attributable to several critical input-variable processing steps useful for similar difficult-to-link populations.

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Routine Screening and Linkage to Care for Hepatitis C Virus in an Urban Safety-Net Health System, 2017-2019

Public Health Reports ◽

10.1177/0033354920969179 ◽

2020 ◽

pp. 003335492096917

Author(s):

Bijou R. Hunt ◽

Christopher Ahmed ◽

Kimberly Ramirez-Mercado ◽

Christopher Patron ◽

Nancy R. Glick

Keyword(s):

Risk Factors ◽

Hepatitis C ◽

Health System ◽

Patient Navigation ◽

Linkage To Care ◽

Safety Net ◽

Test Results ◽

Number Of Patients ◽

Urban Safety ◽

Hcv Screening

Objective Hepatitis C virus (HCV) is a major threat to public health in the United States. We describe and evaluate an HCV screening and linkage-to-care program, including emergency department, inpatient, and outpatient settings, in an urban safety-net health system in Chicago. Methods Sinai Health System implemented a universal HCV screening program in September 2016 that offered patient navigation services (ie, linkage to care) to patients with a positive result for HCV on an RNA test. We collected data from February 1, 2017, through January 31, 2019, on patient demographic characteristics, risk factors, and various outcomes (eg, number of patients screened, test results, proportions of new diagnoses, number of patients eligible for patient navigation services, and proportion of patients who attended their first medical appointment). We also examined outcomes by patients’ knowledge of infection. Results Of 21 018 people screened for HCV, 6% (1318/21 018) had positive test results for HCV antibody, 68% (878/1293) of whom had positive HCV RNA test results. Of these 878 patients, 68% were born during 1945-1965, 68% were male, 65% were Black, 19% were Latino, 55% were newly diagnosed, and 64% were eligible for patient navigation services. Risk factors included past or current drug use (53%), unemployment (30%), and ever incarcerated (21%). Of 562 patients eligible for navigation services, 281 (50%) were navigated to imaging services, and 203 (72%) patients who completed imaging attended their first medical appointment. Conclusion Patient navigation played a critical role in linkage success, but securing stable, long-term financial support for patient navigators is a challenge.

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Characteristics of Emergency Department Visits and Select Predictors of Hospitalization for Adults With Newly Diagnosed Cancer in a Safety-Net Health System

Journal of Oncology Practice ◽

10.1200/jop.18.00614 ◽

2019 ◽

Vol 15 (6) ◽

pp. e490-e500 ◽

Cited By ~ 2

Author(s):

Arthur S. Hong ◽

Navid Sadeghi ◽

Valorie Harvey ◽

Simon Craddock Lee ◽

Ethan A. Halm

Keyword(s):

Emergency Department ◽

Health System ◽

Safety Net ◽

Emergency Department Visits ◽

Urgent Care ◽

Newly Diagnosed ◽

Care Clinic ◽

Medication Refill ◽

Urban Safety ◽

Ed Visits

PURPOSE: There is little description of emergency department (ED) visits and subsequent hospitalizations among a safety-net cancer population. We characterized patterns of ED visits and explored nonclinical predictors of subsequent hospitalization, including time of ED arrival. PATIENTS AND METHODS: This was a retrospective cohort study of patients with cancer (excluding leukemia and nonmelanoma skin cancer) between 2012 and 2016 at a large county urban safety-net health system. We identified ED visits occurring within 180 days after a cancer diagnosis, along with subsequent hospitalizations (observation stay or inpatient admission). We used mixed-effects multivariable logistic regression to model hospitalization at ED disposition, accounting for variability across patients and emergency physicians. RESULTS: The 9,050 adults with cancer were 77.2% nonwhite and 55.0% female. Nearly one-quarter (24.7%) of patients had advanced-stage cancer at diagnosis, and 9.7% died within 180 days of diagnosis. These patients accrued 11,282 ED visits within 180 days of diagnosis. Most patients had at least one ED visit (57.7%); half (49.9%) occurred during business hours (Monday through Friday, 8:00 am to 4:59 pm), and half (50.4%) resulted in hospitalization. More than half (57.5%) of ED visits were for complaints that included: pain/headache, nausea/vomiting/dehydration, fever, swelling, shortness of breath/cough, and medication refill. Patients were most often discharged home when they arrived between 8:00 am and 11:59 am (adjusted odds ratio for hospitalization, 0.69; 95% CI, 0.56 to 0.84). CONCLUSION: ED visits are common among safety-net patients with newly diagnosed cancer, and hospitalizations may be influenced by nonclinical factors. The majority of ED visits made by adults with newly diagnosed cancer in a safety-net health system could potentially be routed to an alternate site of care, such as a cancer urgent care clinic.

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Volume as an Indicator for Outcomes for Severe Maternal Morbidity in the Military Health System

Military Medicine ◽

10.1093/milmed/usab442 ◽

2021 ◽

Author(s):

Aimee Hunter ◽

Amanda Banaag ◽

Monica A Lutgendorf ◽

Col Barton Staat ◽

Tracey P Koehlmoos

Keyword(s):

Health System ◽

Maternal Morbidity ◽

Healthcare Systems ◽

Severe Maternal Morbidity ◽

Military Health System ◽

Case Volume ◽

Military Health ◽

Treatment Facilities ◽

The Military ◽

Military Treatment Facilities

ABSTRACT Background Maternal obstetric morbidity is a growing concern in the USA, where rates of maternal morbidity exceed Europe and most developed countries. Prior studies have found that obstetric case volume affects maternal morbidity, with low-volume facilities having higher rates of morbidity. However, these studies were done in civilian healthcare systems that are different from the Military Health System (MHS). This study evaluates whether obstetric case volume impacts severe maternal morbidity (SMM) in military hospitals located in the continental United States. Methods This cross-sectional study included all military treatment facilities (MTFs) (n = 35) that performed obstetric deliveries (n = 102,959) from October 2015 to September 2018. Data were collected from the MHS Data Repository and identified all deliveries for the study time period. Severe maternal morbidity was defined by the Centers for Disease Control. The 30-day readmission rates were also included in analysis. Military treatment facilities were separated into volume quartiles for analysis. Univariate logistic regressions were performed to determine the impact of MTF delivery volume on the probability of SMM and 30-day maternal readmissions. Results The results for all regression models indicate that the MTF delivery volume had no significant impact on the probability of SMM. With regard to 30-day maternal readmissions, using the upper middle quartile as the comparison group due to the largest number of deliveries, MTFs in the lower middle quartile and in the highest quartile had a statistically significant higher likelihood of 30-day maternal readmissions. Conclusion This study shows no difference in SMM rates in the MHS based on obstetric case volume. This is consistent with previous studies showing differences in MHS patient outcomes compared to civilian healthcare systems. The MHS is unique in that it provides families with universal healthcare coverage and access and provides care for approximately 40,000 deliveries annually. There may be unique lessons on volume and outcomes in the MHS that can be shared with healthcare planners and decision makers to improve care in the civilian setting.

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Outcomes of a Pharmacist-Led Hepatitis C Virus Treatment Program in an Urban Safety-Net Health System, Chicago, 2017-2019

Public Health Reports ◽

10.1177/00333549211015664 ◽

2021 ◽

pp. 003335492110156

Author(s):

Bijou R. Hunt ◽

Hollyn Cetrone ◽

Sharon Sam ◽

Nancy R. Glick

Keyword(s):

Hepatitis C Virus ◽

Hepatitis C ◽

Health System ◽

Treatment Program ◽

Safety Net ◽

The United States ◽

Hcv Treatment ◽

Treatment Cascade ◽

Urban Safety

Objective A recommendation in March 2020 to expand hepatitis C virus (HCV) screening to all adults in the United States will likely increase the need for HCV treatment programs and guidance on how to provide this service for diverse populations. We evaluated a pharmacist-led HCV treatment program within a routine screening program in an urban safety-net health system in Chicago, Illinois. Methods We collected data on all patient treatment applications submitted from January 1, 2017, through June 30, 2019, and assessed outcomes of and patient retention in the treatment cascade. Results During the study period, 203 HCV treatment applications were submitted for 187 patients (>1 application could be submitted per patient): 49% (n = 91) were aged 55-64, 62% (n = 116) were male, 67% (n = 125) were Black, and 15% (n = 28) were Hispanic. Of the 203 HCV treatment applications, 87% (n = 176) of patients were approved for treatment, 91% (n = 161) of whom completed treatment. Of the 161 patients who completed treatment, 81% (n = 131) attended their sustained virologic response (SVR) follow-up visit, 98% (n = 129) of whom reached SVR. The largest drop in the treatment cascade was the 19% decline from receipt of treatment to SVR follow-up visit. Conclusion The pharmacist-led model for HCV treatment was effective in navigating patients through the treatment cascade and achieving SVR. Widespread implementation of pharmacist-led HCV treatment models may help to hasten progress toward 2030 HCV elimination goals.

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Hospital Safety-Net Burden and Risk for Readmissions and Severe Maternal Morbidity

American Journal of Perinatology ◽

10.1055/s-0040-1710544 ◽

2020 ◽

Author(s):

Lilian P. McKinley ◽

Timothy Wen ◽

Cynthia Gyamfi-Bannerman ◽

Jason D. Wright ◽

Dena Goffman ◽

...

Keyword(s):

Maternal Morbidity ◽

Obstetric Care ◽

Safety Net ◽

Severe Maternal Morbidity ◽

Linear Regression Models ◽

Maternal Risk ◽

High Burden ◽

Hospital Safety ◽

Increased Risk ◽

Log Linear

Abstract Objective This study aimed to analyze whether hospital safety-net burden status is associated with increased risk for severe maternal morbidity (SMM) and postpartum readmissions. Study Design The 2010 to 2014 Nationwide Readmissions Database was utilized for this retrospective cohort study. Hospitals were categorized as high-burden hospitals (25% of hospitals with the highest safety-net burden), medium-burden hospitals (50% of hospitals with intermediate safety-net burden), and low-burden hospitals (25% of hospitals with the lowest safety-net burden) based on the proportions of Medicaid or uninsured patients. Risk for (1) SMM, (2) 60-day postpartum readmissions, and (3) SMM during postpartum readmissions was analyzed. Unadjusted and adjusted log-linear regression models were performed, respectively, for these outcomes with unadjusted risk ratio (RR) and adjusted RR (aRR) as measures of effect. Adjusted models included demographic, hospital, and clinical factors. Results High-burden safety-net status was associated with increased risk for SMM compared with low-burden safety-net status in both unadjusted (RR: 1.51, 95% confidence interval [CI]: 1.50–1.53) and adjusted analyses (aRR: 1.27, 95% CI: 1.25–1.30). High-burden status was also associated with increased risk for readmissions in unadjusted analyses (RR: 1.42, 95% CI: 1.40–1.44), although this risk was attenuated in adjusted analyses (aRR: 1.07, 95% CI: 1.06–1.08). High-burden status was associated with significantly increased risk for readmission for uterine infections, hypertensive diseases of pregnancy, and psychiatric diagnoses. High-burden status was not associated with severe morbidity during readmissions in adjusted or unadjusted analyses (RR: 1.02, 95% CI: 0.98–1.05; aRR: 0.95, 95% CI: 0.92–0.99). Conclusion This study found that high safety-net burden hospitals may be a higher risk setting for obstetric care. Improvement of outcomes in high-burden settings may be important in overall efforts to reduce maternal risk.

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Stakeholder engagement to initiate lung cancer screening in an urban safety-net health system

Healthcare ◽

10.1016/j.hjdsi.2019.100370 ◽

2020 ◽

Vol 8 (1) ◽

pp. 100370

Author(s):

Simon J.Craddock Lee ◽

Heidi A. Hamann ◽

Travis Browning ◽

Noel O. Santini ◽

Suhny Abbara ◽

...

Keyword(s):

Lung Cancer ◽

Cancer Screening ◽

Health System ◽

Stakeholder Engagement ◽

Lung Cancer Screening ◽

Safety Net ◽

Urban Safety

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Time to ACT: launching an Addiction Care Team (ACT) in an urban safety-net health system

BMJ Open Quality ◽

10.1136/bmjoq-2020-001111 ◽

2021 ◽

Vol 10 (1) ◽

pp. e001111

Author(s):

Marlene Martin ◽

Hannah R Snyder ◽

Diana Coffa ◽

Scott Steiger ◽

Joseph P Clement ◽

...

Keyword(s):

Substance Use ◽

Health System ◽

Systems Approach ◽

Hospital Medicine ◽

Safety Net ◽

Care Team ◽

Successful Implementation ◽

Addiction Medicine ◽

Urban Safety ◽

Addiction Care

Across the USA, morbidity and mortality from substance use are rising as reflected by increases in acute care hospitalisations for substance use complications and substance-related deaths. Patients with substance use disorders (SUD) have long and costly hospitalisations and higher readmission rates compared to those without SUD. Hospitalisation presents an opportunity to diagnose and treat individuals with SUD and connect them to ongoing care. However, SUD care often remains unaddressed by hospital providers due to lack of a systems approach and addiction medicine knowledge, and is compounded by stigma. We present a blueprint to launching an interprofessional inpatient addiction care team embedded in the hospital medicine division of an urban, safety-net integrated health system. We describe key factors for successful implementation including: (1) demonstrating the scope and impact of SUD in our health system via a needs assessment; (2) aligning improvement areas with health system leadership priorities; (3) involving executive leadership to create goal and initiative alignment; and (4) obtaining seed funding for a pilot programme from our Medicaid health plan partner. We also present challenges and lessons learnt.

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