Abstract 230: Internal Medicine Trainee Understanding and Reaction to Out of Pocket Costs

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Jeffrey P Chidester ◽  
Sandeep R Das ◽  
Rebecca Vigen
Keyword(s):  
Internal Medicine ◽  
Decision Making ◽  
Safety Net ◽  
Cost Of Care ◽  
Care Hospital ◽  
Care Clinic ◽  
Significant Difference ◽  
Safety Net Hospital ◽  
Out Of Pocket Costs ◽  
Clinic Visits

Introduction: Out-of-pocket costs (OOPC) are a significant barrier to care and drive suboptimal medical therapy in ASCVD. Despite this, there is minimal attention paid to these costs in post-graduate education. To define a potential knowledge gap, we surveyed trainee understanding of OOPC. Methods: We surveyed Internal Medicine residents at a large academic program comprised of a large county safety-net hospital, a VA, and a private tertiary care hospital, about knowledge and practices surrounding patient OOPC. Residents rotate on services at all sites and the vast majority have primary care clinic at the county or VA hospital. Participants answered questions considering their most recent inpatient panel and their clinic patient panel. Familiarity was ranked on a 5-point Likert scale, and for the purposes of presentation, was divided into “Poor” and “Moderate or Better”. Non-parametric analysis was used to test differences between outpatients v inpatients and by year of training. Results: Of 159 residents, 106 (67%) responded. Familiarity with patient insurance status was moderate or better in 135 of 159 (85%). Moderate or better understanding of costs associated with medications (52% [83 of 159]), testing (19% [30 of 159]) and clinic visits (30% [48 of 159]) was less common. Respondents had higher familiarity with OOPC for clinic patients compared with their most recent inpatient panel: clinic visits (39% v 21% [62 v 33 of 159 p < 0.005]), testing (25.7% v 12.4% [41 v 20 of 159 p = 0.002]), and medications (62% v 42% [99 v 67 of 159 p <0.005]) Knowledge of cost of care was not an often-considered factor in decision making (27% “Often” or “Always” [43 of 159]). There was no significant difference in response by year of training. Discussion: Our survey demonstrates that trainee familiarity with OOPC was low overall but modestly higher for established clinic patients, perhaps reflecting longitudinal experience with them or the heterogeneity of admitted patient funding status. Familiarity with patient OOPC was not an often-considered factor in decision making and did not significantly improve over years of training. This suggests an important gap in trainee education. Teaching greater familiarity with patient OOPC during residency can increase awareness of the financial realities of patients, enabling more patient-centered care.

scholarly journals Internal Medicine Trainee Understanding and Reaction to Out of Pocket Costs

2021 ◽  
Vol 8 ◽  
pp. 238212052199636
Author(s):  
Jeffrey Chidester ◽  
Rebecca Vigen ◽  
Sandeep R Das
Keyword(s):  
Internal Medicine ◽  
Graduate Education ◽  
Parametric Analysis ◽  
Cost Of Care ◽  
Patient Centered ◽  
Internal Medicine Residents ◽  
Significant Difference ◽  
Centered Care ◽  
Barrier To Care ◽  
Out Of Pocket Costs

Background: Out-of-pocket costs are a serious barrier to care and drive suboptimal medical therapy. Understanding of these costs can lead to care oriented around the limits they generate. Despite this, there is minimal attention paid to these costs in post-graduate education. Objective: To define a potential knowledge gap regarding costs experienced by patients by surveying Internal Medicine residents at our large academic institution. Methods: We surveyed Internal Medicine residents in spring 2019 about knowledge and practices surrounding patient out-of-pocket costs. Participants answered questions considering their most recent inpatient panel and their clinic patient panel. Familiarity was ranked on a 5-point Likert scale, and for the purposes of presentation, was divided into “Poor” and “Moderate or Better.” Non-parametric analysis was used to test differences between outpatients and inpatients and by year of training. Results: Of 159 residents, 109 (67%) responded. Familiarity with patient insurance status was moderate or better in 85%. Reported understanding of costs associated with medications, testing, and clinic visits was less common. Respondents had higher familiarity with out-of-pocket costs for clinic patients compared with inpatients. Knowledge of cost of care was not an often-considered factor in decision making. There was no significant difference in response by year of training. Conclusion: Patient out-of-pocket costs are an important dimension of patient care which Internal Medicine Trainees at our institution do not confidently understand or utilize. Improvements in education around this topic may enable more patient-centered care.

scholarly journals Infertility knowledge and treatment beliefs among African American women in an urban community

2019 ◽  
Vol 4 (1) ◽  
Author(s):  
Ashley Wiltshire ◽  
Lynae M Brayboy ◽  
Kiwita Phillips ◽  
Roland Matthews ◽  
Fengxia Yan ◽  
...  
Keyword(s):  
Decision Making ◽  
African American ◽  
African American Women ◽  
Urban Community ◽  
Safety Net ◽  
Convenience Sample ◽  
American Women ◽  
Treatment Beliefs ◽  
Significant Difference ◽  
Safety Net Hospital

Abstract Background To assess infertility knowledge and treatment beliefs among African American women in an urban community in Atlanta, Georgia. Methods This was a cross sectional study at a safety net hospital. A convenience sample of a total of 158 women receiving outpatient obstetrical or gynecologic care from March–April 2017 were recruited. Infertility knowledge and treatment beliefs were assessed using a previously applied and field-tested survey from the International Fertility Decision Making Study. Results The mean infertility knowledge score was 38.15% for total subjects. Those with a higher level of education (p < 0.0001) and those with paid employment (p = 0.01) had a significantly higher level of infertility knowledge. Those who had a history of infertility therapy were significantly more likely to agree with negative treatment beliefs (p = 0.01). There was no significant difference in infertility knowledge or treatment beliefs based on age, sexuality, parity or being pregnant at the time of survey completion. Conclusions African American women in our urban clinic setting seem to have a limited level of knowledge pertaining to infertility. Further research is needed to understand how differences in knowledge and beliefs translate into infertility care decision-making and future childbearing.

Shared decision-making during surgical consultation for gallstones at a safety-net hospital

Surgery ◽  
2018 ◽  
Vol 163 (4) ◽  
pp. 680-686 ◽  
Author(s):  
Krislynn M. Mueck ◽  
Isabel M. Leal ◽  
Charlie C. Wan ◽  
Braden F. Goldberg ◽  
Tamara E. Saunders ◽  
...  
Keyword(s):  
Decision Making ◽  
Shared Decision Making ◽  
Safety Net ◽  
Shared Decision ◽  
Safety Net Hospital

Real-Time Risk Tool for Pharmacy Interventions

2020 ◽  
pp. 001857872097388
Author(s):  
Hanh L. Nguyen ◽  
Kristin S. Alvarez ◽  
Boryana Manz ◽  
Arun Nethi ◽  
Varun Sharma ◽  
...  
Keyword(s):  
High Risk ◽  
Prediction Models ◽  
Risk Model ◽  
Hospital Readmissions ◽  
Group Versus ◽  
Safety Net ◽  
Low Risk ◽  
Day Hospital ◽  
Significant Difference ◽  
Safety Net Hospital

Background: Adverse drug events (ADEs) result in excess hospitalizations. Thorough admission medication histories (AMHs) may prevent ADEs; however, the resources required oftentimes outweigh what is available in large hospital settings. Previous risk prediction models embedded into the Electronic Medical Record (EMR) have been used at hospitals to aid in targeting delivery of scarce resources. Objective: To determine if an AMH scoring tool used to allocate resources can decrease 30-day hospital readmissions. Design, Setting, and Participants: Propensity-matched cohort study, Medicine/Surgery patients in large academic safety-net hospital. Intervention or Exposure: Pharmacy-conducted AMHs identified by risk model versus standard of care AMH. Main Outcomes and Measures: A total of 30-day hospital readmissions and inpatient ADE prevention. Results: The model screened 87 240 hospitalizations between June 2017 and June 2019 and 4027 patients per group were included. There were significantly less 30 day readmissions among high-risk identified patients that received a pharmacy-conducted AMH compared to controls (11% vs 15%; P = 0.004) and no significant difference in readmission rates for low-risk patients. While there was significantly higher documentation of major ADE prevention in the pharmacy-led AMH group versus control (1656 vs 12; P < 0.001), there was no difference in electronically-detected inpatient ADEs between groups. Conclusions: A risk tool embedded into the EMR can be used to identify patients whom pharmacy teams can easily target for AMHs. This study showed significant reductions in readmissions for patients identified as high-risk. However, the same benefit in readmissions was not seen in those identified at low-risk, which supports allocating resources to those that will benefit the most.

Making the case for outpatient palliative care for cancer patients at a safety-net hospital.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 310-310
Author(s):  
Heather A. Harris ◽  
Anne Kinderman ◽  
Kathleen Kerr
Keyword(s):  
Palliative Care ◽  
Cancer Patients ◽  
Average Length ◽  
Safety Net ◽  
Direct Costs ◽  
Cost Of Care ◽  
Initial Contact ◽  
Course Of Illness ◽  
Cancer Registry Data ◽  
Safety Net Hospital

310 Background: Prior research has shown that patients who receive earlier, outpatient palliative care (OP PC) have improved end-of-life care compared to patients who receive only inpatient palliative care (IP PC). We examined the need, expected impact and feasibility of providing OP PC to patients with cancer seen at our hospital, which offers IP PC but not OP PC. Methods: Retrospective cohort study of patients cared for at our urban, safety-net hospital who died of cancer between July 2010 and June 2013. We used cancer registry data to identify decedents and claims data to evaluate utilization patterns, contacts with our IP PC service, and cost of care in the final 6 months of life. Results: In the analysis period 403 patients died of cancer, 307 of whom were admitted to the hospital in the 6 months preceding death. On average patients were admitted 1.9 times, with 39% having multiple admissions. Average length of stay was 10.47 days. Nearly half of all patients were admitted to the hospital in the final month of life (181/403), and 21% of those (38/181) had multiple admissions. One third of patients died in the hospital and another 4% died within 3 days of hospital discharge. Direct costs per admission averaged $22,275. The IP PC service had contact with 178 patients; 44% of the entire decedent population and 58% of those who were hospitalized. In 60% of cases the initial contact with the PC team took place in the final month of life. We determined that 33% of patients had multiple inpatient and or outpatient encounters 90-180 days prior to death, pointing to an expected annual clinic volume of about 50 patients. Annual costs for staffing a clinic that could follow 50 patients for an average of 4 months were estimated at $88,290. We assumed that providing OP PC would reduce utilization of inpatient services by 40% (38 avoided admissions), with resulting avoided direct costs of $846,450. Conclusions: At our facility cancer patients often receive aggressive EOL care. Our IP PC team sees many of these patients, but most contacts occur days-weeks prior to death. Though many patients present very late in the course of illness, a substantial number have multiple health system contacts >3 months prior to death, and could be referred to an OP PC clinic.

scholarly journals Incidence of Neutropenic Fever at a Safety Net Hospital in Cancer Chemotherapy Patients Receiving Prophylactic Pegfilgrastim Manual Injection Compared to the on-Body Auto-Injector

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 4709-4709
Author(s):  
Atin Jindal ◽  
Jan Kover ◽  
Vanja Raduka ◽  
Timothy E. O'Brien
Keyword(s):  
High Risk ◽  
Febrile Neutropenia ◽  
Cancer Chemotherapy ◽  
Safety Net ◽  
Delivery Systems ◽  
Neutropenic Fever ◽  
Cancer Type ◽  
Injection Group ◽  
Safety Net Hospital ◽  
Clinic Visits

Abstract Introduction Febrile neutropenia (FN) is a potentially life-threatening complication of chemotherapy, with increased incidence in pts receiving high risk chemotherapy regimens and/or over age 651. Prophylactic filgrastim given daily or once dosing/cycle pegfilgrastim have been shown to decrease the incidence, duration, and severity of neutropenia, fever and infection in patients receiving high risk cancer chemotherapy. Pegfilgrastim stimulates the production, maturation, and activation of neutrophils. Because of its stimulatory effects on neutrophil precursors, it should be given 24 hours after chemotherapy to reduce paradoxical neutropenia. For many pts, particularly those who are underinsured and who will not have home injection covered, this requires a return visit to the clinic. In 2015, a new device delivery of this medication was introduced called the Neulasta® On-Body Injector (OBI) Onpro®.This is a small, lightweight, waterproof device that is timed to deliver an injection 27 hours after application, resulting in less clinic visits. The on-body injector has been shown to be safe in healthy volunteers2 and have pharmacokinetics similar to manual pegfilgrastim3. However, there is limited clinical efficacy data comparing the 2 delivery systems, particularly in an indigent care setting where adherence to home delivery systems may be an issue. Methods Between May 1, 2016 and May 30, 2017 the use of pegfilgastrim delivery systems as prophylaxis was reviewed at a large, urban cancer center. There were 120 patients identified: 60 returned the next day for manual injection of pegfilgrastim and 60 were ordered the home on-body injector. Primary data collected included the incidence of neutropenic fever, absolute neutrophil count (ANC) on admission, length of hospital stay, and on-body device failures. Results All pts received high risk chemotherapy regimens. Within each group (injection and OBI, respectively): ave age was 55.6 vs 56.1 (p = 0.78); sex 65% vs 92% female (p = 0.02); race 60% vs 68% White, 27% vs 22% African American, 3.3% vs 6.7% Hispanic, 5% vs 3.7% Asian (p = 0.7); cancer type: 38.3% vs 11.7% (p < 0.001) NHLymphoma, 28.3% vs 55% breast (p = 0.003), 8.3% vs 6.7% lung (p = 0.73), 25% vs 26.7% other cancer (p = 0.83); 21.7% vs 33.3% had commercial insurance, 73.3% vs 56.7% had Medicare/Medicaid, 5% vs 10% had self-pay. Overall, 17/120 (14%) patients developed FN: 10/60 (16.7%) from the manual injection group vs 5/60 (8.3%) from the OBI group (p = 0.17). 100% of FN patients were admitted for inpatient care and were treated with intravenous antibiotics in both groups. Of those that developed FN, nadir ANC on average was 160 vs 432 (p = 0.22), length of stay 6.6 vs 4.4 days (p = 0.497), 67% vs 40% had advanced cancer (p = 0.003), 70% vs 0% of patients that developed FN had lymphoma; 16.7% vs 20% were >65 years of age (p = 0.64), 8.3% vs 20% had ECOG ≥2 (p = 0.067), and 25% vs 20% had evidence of kidney or liver dysfunction (p = 0.51). Three patients (5%) reported the on-body injector falling off after attachment. One patient did not pick up the on-body injector. These four patients received a manual injection in clinic the following day. None of these patients had FN within 30 days post chemotherapy. Conclusion Cancer pts at a safety net institution receiving post-chemotherapy prophylactic pegfilgrastim were not found retrospectively to have had an increased incidence of febrile neutropenia when using the OBI compared to the manual subcutaneous injection. There was a non-significant increase in FN in the manual injection group but this may have been due to a significant imbalance of more myelosuppressive NHL regimens. Overall, in pts exposed to high risk chemotherapy, OBI use resulted in a low incidence of FN (8.3%) and fewer return clinic visits but education on handling device failure is vital to the effectiveness of the pegfilgrastim OBI in this patient population. 1Myeloid Growth Factors. National Comprehensive Cancer Guidelines (NCCN), Version 1.2018. http://www.nccn.org/. 2Josh RS et al. Performance of the pegfilgrastim on-body as studied with placebo buffer in healthy volunteers. Curr Med Res Opin. 2017; 33(2): 379-384. 3Yang BB et al. Comparison of pharmacokinetics and safety of pegfigrastim administered by 2 delivery methods: on-body injector and manual injection in a prefilled syringe. Can Chemo Pharmacol. 2015; 75(6): 1199-1206. Disclosures No relevant conflicts of interest to declare.

scholarly journals Decision-making support for cancer patients and their families at a palliative care clinic in a designated regional cancer care hospital

2015 ◽  
Vol 10 (1) ◽  
pp. 324-328
Author(s):  
Hiroaki Watanabe ◽  
Miho Kojima ◽  
Yoshimi Okumura ◽  
Yuki Kato ◽  
Yuko Deguchi ◽  
...  
Keyword(s):  
Decision Making ◽  
Palliative Care ◽  
Cancer Patients ◽  
Cancer Care ◽  
Care Hospital ◽  
Care Clinic ◽  
Decision Making Support

Abstract 112: Statin Utilization in the Outpatient Clinic of a University Based Residency Training Program

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Eric Chang ◽  
Demilade Adedinsewo ◽  
Camille Calcano ◽  
Obiora Egbuche ◽  
Aneese Chaudhry ◽  
...  
Keyword(s):  
Internal Medicine ◽  
Outpatient Clinic ◽  
Patient Population ◽  
Private Insurance ◽  
Safety Net ◽  
Atherosclerotic Cardiovascular Disease ◽  
Specific Patient ◽  
Factors Affecting ◽  
Safety Net Hospital ◽  
National Estimates

Background: Current guidelines released in 2013 recommend statins for five specific patient groups including persons with clinical atherosclerotic cardiovascular disease (ASCVD) and diabetes. National estimates of statin utilization in 2012 report statin use in persons with ASCVD at 58.8% and 63.5% among persons with diabetes. A recent review also showed suboptimal statin prescription rates prior to 2013, with only 23% being prescribed a statin at goal dose. Our goal was to assess statin prescriptions in a large resident run outpatient clinic and identify factors affecting statin prescriptions as potential targets for intervention to improve compliance with the guidelines. Methods: We obtained data from the medical record data warehouse of a primary care outpatient clinic within a large safety-net hospital from Jan–Dec 2015. The clinic is predominantly run by internal medicine residents and supervised by general internal medicine attending physicians. Patients with a diagnosis of ASCVD and diabetes were identified and electronic medical records abstraction was done to identify persons who were prescribed a statin (regardless of dose). Bivariate analyses were conducted to identify potential factors affecting statin prescriptions. Results: Our patient population was predominantly African American, representing more than 70% of our clinic patients. We found 87% of persons with ASCVD and 70% of persons with diabetes were on statin. We found no differences in statin prescriptions by demographic characteristics among persons with ASCVD. Among patients with diabetes, younger age (p<0.01), female sex (p<0.05), non-black race (p<0.05) and private insurance/lack of insurance (p<0.01) were associated with a lower likelihood of being prescribed a statin. Conclusion: Statin prescriptions among patients with ASCVD and diabetes appear to be higher in our patient population compared to prior national estimates, however statin prevalence remains suboptimal. Our next steps are to begin a targeted educational intervention for residents in the continuity clinic and ultimately demonstrate that resident driven intervention is an effective way to increase compliance with the guidelines.

Abstract 15128: Clinical Outcomes in Heart Failure Patients With Concurrent Cocaine Use

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Jonah D Garry ◽  
Anjali Thakkar ◽  
Yifei Ma ◽  
Rebecca Scherzer ◽  
Priscilla Hsue
Keyword(s):  
Heart Failure ◽  
San Francisco ◽  
Hospital Readmissions ◽  
Safety Net ◽  
Chronic Obstructive ◽  
Day Hospital ◽  
Cocaine Use ◽  
Significant Difference ◽  
Safety Net Hospital ◽  
The Impact

Background: While cocaine use is associated with heart failure (HF) with reduced ejection fraction, the impact of cocaine use on HF outcomes including 30-day hospital readmission and survival has not been well described. Accordingly, this study evaluated the impact of cocaine use on 30-day hospital readmissions (heart failure and all cause) and mortality. Methods: We performed a case control study of HF patients with an index HF hospitalization at an academic safety net hospital in San Francisco between 2001-2019. 746 HF patients with history of cocaine use were matched to 746 HF patients without cocaine use, based on age, gender, and date of index hospitalization. We compared clinical characteristics, readmission rates, and mortality between these two groups. Results: Average age was 53 years and 79% were male. HF patients with cocaine use were more likely to be African American (69.6% vs. 29.8%, p<0.01), have hypertension, liver disease and concurrent use of methamphetamines and opioids. Rates of coronary artery disease, diabetes, chronic kidney disease, HIV, and chronic obstructive pulmonary disease were similar between the groups. There was no significant difference in prescription of guideline directed medical therapies at discharge. Within 30 days of index HF hospitalization, HF patients with cocaine use were more likely to attend follow up (91.8% vs 86.9%, p<0.01), but were more likely to be readmitted for HF (12.1% vs 7.4%, OR 1.75, p<0.01) or other causes (22.4% vs 14.7%, OR 1.67, p<0.01). Over the study period, cocaine use was associated with greater likelihood of death (27.9% vs 20.1%, p<0.01). Conclusions: HF patients with comorbid cocaine use were found to have higher likelihood of readmission or death following index HF hospitalization compared to HF patients without cocaine use. As cocaine use continues to grow it is critical to understand the mechanisms underlying cocaine induced cardiovascular pathophysiology, and to identify factors affecting readmission and mortality in this high risk group.

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