Associations Between Structural and Social Determinants of Health With COVID Infection Rates at a Safety Net Hospital.

Abstract Background: The reported disproportionate impact of COVID-19 infections on minority populations may be due to living in disinvested communities with high level of poverty, pollution, inadequate unsafe employment, and overcrowded housing.Objective: To determine the association of county, city, and individual risk factors with COVID-19 infection ratesMethods: Retrospective chart review on COVID-19 tests performed from March through July 2020 at Arrowhead Regional Medical Center, Colton, California. Results: A total of 7104 tests were performed with 69% in the drive-through testing center. The mean duration of test-to-results time was 2.36 (+0.02) days. COVID-19 positive tests occurred in 1095 (15.4%). At least one symptom occurred in 414 (33%) with sensitivity of 37.8, specificity of 86.02, positive predictive value of 33.01, and negative predictive value of 72.76. Individual factors significantly associated with testing positive for COVID-19 were diabetes, Hispanic ethnicity, and male gender. Younger age was significantly associated with testing COVID positive with the highest risk in children <10 years. COVID-19 positive persons significantly resided in cities with higher population density, household members, poverty, non-English speaking homes, disability, lower median household income, lack of health insurance and decreased access to a computer and WIFI services. County health rankings showed significant positive association between testing positive for COVID-19 with increased smoking, air pollution, violent crimes, physical inactivity, decreased education and access to exercise. Conclusion: Adverse county health rankings; socially and economically disadvantaged cities are associated with an increased risk of testing positive for COVD-19. This information can be used in strategic planning and invention mitigation.

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Identifying Actionable Causes of Potentially Avoidable Readmissions to an Oncology Service at a Safety Net Hospital

JCO Oncology Practice ◽

10.1200/op.20.00593 ◽

2020 ◽

pp. OP.20.00593

Author(s):

Vishal K. Gupta ◽

Michael Dennis ◽

Emily Mann ◽

Joseph O. Jacobson ◽

Naomi Y. Ko

Keyword(s):

Pleural Fluid ◽

Cancer Progression ◽

Medical Center ◽

Hospital Readmissions ◽

Retrospective Chart Review ◽

Safety Net ◽

Outpatient Setting ◽

Oncology Service ◽

Safety Net Hospital ◽

Avoidable Readmissions

PURPOSE: Hospital readmissions occur commonly in those receiving cancer care and result in impaired quality of life and increased costs. Causes of readmission in safety net hospitals that serve vulnerable populations are not well understood. The primary goal of this project was to identify potentially avoidable and intervenable causes of readmissions to an urban safety net hospital. METHODS: A retrospective chart review was performed on patients who were readmitted within 30 days of discharge from the hematology and oncology service at Boston Medical Center over the 6-month period between October 2018 and March 2019. Charts were reviewed by three internal medicine residents and discussed under the supervision of an attending oncologist. RESULTS: Two hundred ninety-one patient encounters involving 203 unique patients were identified in the 6-month study period. Of these 291 encounters, 80 encounters (27.5%) were followed by a readmission within 30 days and occurred in 61 (30.0%) unique patients. Nineteen (31.1%) of these 61 patients experienced two readmissions within 30 days of discharge. Twenty-five readmissions (31.3%) were classified as potentially avoidable, with the most common cause of potentially avoidable readmissions attributed to ascitic or pleural fluid reaccumulation (8, 32%). The majority of presumed nonpreventable readmissions were due to expected complications of cancer progression and treatment-related side effects. DISCUSSION: In conclusion, readmissions were common, and a modifiable reason for 30-day readmissions was identified. Addressing recurrent ascitic and pleural fluid reaccumulation in the outpatient setting could help to reduce inpatient hospital readmission on an inpatient oncology service.

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Abstract 049: De Novo Postpartum Hypertension In A Safety-net Hospital: Incidence And Risk Factors

Circulation ◽

10.1161/circ.143.suppl_1.049 ◽

2021 ◽

Vol 143 (Suppl_1) ◽

Author(s):

Samantha E Parker ◽

Ayodele Ajayi ◽

Christina Yarrington

Keyword(s):

Risk Factors ◽

Blood Pressure ◽

Maternal Morbidity ◽

De Novo ◽

Medical Center ◽

Safety Net ◽

Chronic Hypertension ◽

Increased Risk ◽

Safety Net Hospital ◽

History Of

Introduction: Postpartum hypertension can be persistent, following a pregnancy complicated by hypertension, or new onset ( de novo ), following a normotensive pregnancy. The postpartum period is traditionally defined as six weeks after delivery, yet accruing evidence shows that hypertension underlies the majority of severe maternal morbidity events through a year postpartum. While guidelines for enhanced monitoring of women at risk of persistent postpartum hypertension exist, less is known about risk factors for de novo postpartum hypertension. The aim of this study is to estimate the incidence of and identify risk factors for de novo postpartum hypertension among a diverse safety-net hospital population through the entire year postpartum. Hypothesis: We assessed the hypothesis that women with de novo postpartum hypertension share similar demographic and reproductive characteristics to women at increased risk of cardiovascular related maternal morbidity. Methods: We conducted a cohort study of 8,531 deliveries at Boston Medical Center from 2016-2018. Data on demographics, reproductive history, and labor and delivery were obtained from medical records. All documented blood pressure measures from pregnancy through 12 months postpartum were extracted. Women with chronic hypertension or hypertensive disorders of pregnancy were excluded. De novo postpartum hypertension was defined as two separate blood pressure readings with systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥90 mmHg at least 48 hours after delivery. Severe de novo hypertension was defined using criteria of SBP ≥160 and/or DPB ≥110. We examined the distribution of demographic and pregnancy characteristics among women with and without de novo postpartum hypertension. Secondary analyses restricting to women with healthcare visits after six weeks postpartum were also conducted. Results: Among the 6,631 women without a history of hypertension, 10% (n=660) developed de novo postpartum hypertension; a third of whom had severe hypertension (n=225). Compared to women without de novo hypertension; cases were more likely to be non-Hispanic Black; delivered via cesearean section; have had a preterm delivery; and be multiparous. In analyses restricted to women with visits extending past six weeks postpartum (n=3,272), the incidence of de novo postpartum hypertension was 16.6%. Approximately 30% of these cases were diagnosed after the traditionally used six week period. Conclusion: In conclusion, 1 in 10 women with normotensive pregnancies experience de novo hypertension in the year after delivery, with a third of these cases developing after six weeks. Opportunities to monitor and manage women at the highest risk of de novo hypertension throughout the entire year postpartum could mitigate cardiovascular related maternal morbidity.

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Decreasing time to initiation of inpatient chemotherapy at LAC+USC medical center utilizing an admission checklist.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.27_suppl.262 ◽

2019 ◽

Vol 37 (27_suppl) ◽

pp. 262-262

Author(s):

Ronak Patel ◽

Victor Chiu ◽

Darcy V. Spicer

Keyword(s):

Medical Center ◽

Intervention Group ◽

Retrospective Chart Review ◽

Safety Net ◽

Outpatient Setting ◽

Post Intervention ◽

Safety Net Hospital ◽

The Mean ◽

Chemotherapy Initiation ◽

Mean Time

262 Background: Delays in the initiation of chemotherapy for scheduled inpatient admissions cause excess lengths of stay and shift infusion start times to the evenings when hospital staffing is decreased. We sought to characterize delays in our admission process and assess the feasibility of using an admission checklist to shorten start times in a large academic safety-net hospital. Baseline data for scheduled chemotherapy admissions in July and August of 2017 (n = 25) showed a mean time to chemotherapy initiation of 14.6 hours and mean excess LOS was 0.7 midnights. Significant delays were identified in the time between ordering and resulting of pre-chemotherapy labs (average 2.6 hours), and the time required to obtain imaging to confirm peripheral-inserted central catheter (PICC) position (1.6 hours). Methods: We created a checklist of a standardized admission workflow for physicians, which included moving all pre-chemotherapy labs, pharmacy verification of chemotherapy regimen, and PICC imaging to the outpatient setting. We organized multiple staff in-services to introduce the admission workflow prior to implementation on May 1, 2018. We then performed a retrospective chart review of all scheduled inpatient chemotherapy admissions from May to August of 2018. Results: In the first 2 months after intervention, the mean time to chemotherapy initiation was 8.5 hrs, representing a 42% reduction. In the subsequent 2 months, the mean time to chemotherapy initiation was 11.6 hours, representing a 21% reduction from baseline. Mean excess LOS was 0.4 midnights and 0.5 midnights for those time periods, respectively. For the entire post-intervention group, 7 out of 26 patients obtained pre-chemotherapy labs in the outpatient setting. Conclusions: We observed an initial mean reduction of 6.1 hours in the time to start chemotherapy, as well as a reduction in mean excess length of stay with the introduction of a new admission workflow and admission checklist. We observed incomplete adoption of the checklist, and an increase in time to chemotherapy initiation after the first two months of implementation, suggesting that physician non-adherence represents a significant barrier to maintaining these reductions.

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Fertility Drugs Associated with Thyroid Cancer Risk: A Systematic Review and Meta-Analysis

BioMed Research International ◽

10.1155/2018/7191704 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7 ◽

Cited By ~ 4

Author(s):

QingAn Yu ◽

XiaoYing Lv ◽

KunPeng Liu ◽

DaKun Ma ◽

YaoHua Wu ◽

...

Keyword(s):

Thyroid Cancer ◽

Cancer Risk ◽

Clomiphene Citrate ◽

Positive Association ◽

Female Infertility ◽

Cochrane Library ◽

Significant Positive Association ◽

Fertility Drugs ◽

Increased Risk ◽

Thyroid Cancer Risk

Associations have been demonstrated between fertility drugs and a variety of hormone-sensitive carcinomas. The purpose of this study was to determine the relationship between fertility drugs used in the treatment of female infertility and the risk of thyroid cancer. To investigate the clinical significance of fertility drugs used for the treatment of female infertility and the risk associated with thyroid cancer, we performed a literature search using PubMed, MEDLINE, the Cochrane Library, the Web of Science, and EBSCOHOST for comparative studies published any time prior to July 21, 2017. The studies included women who were treated for infertility with fertility drugs, such as clomiphene citrate, gonadotropins, or other unspecified fertility agents, which reported the incidence of thyroid cancer as the main outcome. Eight studies were included in the meta-analyses. Among women with infertility, there was a significant positive association between thyroid cancer risk and the use of fertility drugs (relative risk [RR] = 1.35; 95% confidence interval [CI] 1.12–1.64; P=0.002). Additionally, among women with infertility, the use of clomiphene citrate was associated with an increased risk of thyroid cancer compared to women who did not use fertility drugs (RR = 1.45; 95% CI 1.12–1.88; P=0.005). After pooling results, we found that the parity status of infertile women using fertility drugs was not associated with thyroid cancer risk (RR = 0.99; 95% CI 0.61–1.58, P=0.95). In summary, clomiphene citrate (the most commonly used fertility drug) and other fertility drugs are associated with an increased risk of thyroid cancer.

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Tobacco use, knowledge of harms, and cessation support among patients with non-tobacco related cancers.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e24029 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e24029-e24029

Author(s):

Laura Vater ◽

Anup Trikannad Ashwini Kumar ◽

Neha Sehgal ◽

Maria Khan ◽

Kelsey Bullens ◽

...

Keyword(s):

Prostate Cancer ◽

Cancer Treatment ◽

Medical Center ◽

Safety Net ◽

Cancer Center ◽

Prescribe Medication ◽

Patients With Cancer ◽

Quit Smoking ◽

Increased Risk ◽

Quit Attempts

e24029 Background: Continued cigarette smoking among patients with cancer leads to numerous adverse health outcomes, even among patients with non-tobacco-related cancers such as breast, colon, and prostate cancer. Continued smoking is associated with poorer response to cancer treatment, increased risk for treatment-related toxicities, and shorter overall survival. While some patients with a smoking-related cancer make efforts to quit smoking at the time of diagnosis, patients with other forms of cancer might not understand the negative effects of continued smoking. In this study, we assessed patient knowledge of the harms of continued smoking, previous cessation attempts, and cessation support. Methods: We surveyed 102 adults with breast, colon, and prostate cancer at three locations: an NCI-designated cancer center, an urban safety-net medical center, and a rural cancer center. Patients were asked about current smoking behaviors, beliefs about the harms of continued smoking, quit attempts and resources used, and cessation support. We also surveyed seven oncologists to assess beliefs about harms of continued smoking, cessation support provided to patients, training and confidence in cessation counseling, and barriers to providing cessation support. Results: Most patients (82%) agreed or strongly agreed that continued smoking may shorten life expectancy, and 70% agreed or strongly agreed that continued smoking increased the risk of getting a different type of cancer. Only 41% of patients agreed or strongly agreed that continued smoking may cause more side effects from cancer treatment, and only 40% agreed or strongly agreed that ongoing smoking may affect treatment response. The majority of patients (86%) had tried to quit smoking for good, with an average 4.1 quit attempts per patient. Patients reported that physicians advised them to quit the majority of the time (92%), prescribed medication 33% of the time, and followed up on cessation attempts 43% of the time. Overall, oncologists had higher knowledge of the harms of continued smoking on treatment outcomes and survival. Those in practice for 20 years or more had higher confidence in cessation counseling than those in practice less than 4 years. Oncologists described lack of time and lack of confidence in cessation counseling as barriers to providing more cessation support. Conclusions: Among 102 patients with breast, colon, and prostate cancer who currently smoke, there was incomplete knowledge of the harms of continued smoking. Oncologists believe that tobacco cessation is important and frequently advise patients to quit, however they less frequently prescribe medication or follow up on cessation efforts. Interventions are needed to educate patients with cancer about the harms of continued smoking and to provide further cessation support.

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Abstract 16520: Predictors of Thirty Day Readmission in a Vulnerable and Underserved Urban Heart Failure Population

Circulation ◽

10.1161/circ.142.suppl_3.16520 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Alexandra B Steverson ◽

Paul Marano ◽

Caren Chen ◽

Yifei Ma ◽

Rachel Stern ◽

...

Keyword(s):

Heart Failure ◽

Substance Use ◽

San Francisco ◽

Chart Review ◽

Safety Net ◽

Housing Status ◽

Medical Comorbidities ◽

Increased Risk ◽

Safety Net Hospital ◽

Icd 10

Introduction: Heart failure (HF) readmission quality metrics disproportionately impact reimbursement in safety net hospitals. Prior research has demonstrated the effect of medical comorbidities on readmission, however, there is a paucity of data on predictors of readmission in vulnerable and underserved HF patients. We sought to evaluate the effect of demographics, medical and social comorbidities on risk of 30 day readmission in an academic safety net hospital in San Francisco. Methods: We performed a retrospective chart review from 2018 to 2020. Patients were included if treated for HF while on inpatient cardiology or medicine services and were assigned an ICD-10 discharge code for HF. Patients less than 21 years old were excluded. Demographics and comorbidities were obtained through evaluation of ICD-10 discharge codes and chart review. Multivariate modeling was used to determine predictors of 30 day readmission. Results: The study population included 383 patients in which the mean age was 60±13 years and 73% (n=282) were male. 44% (170) were Black, 23% (88) were Latinx, 33% (127) were not housed, 97% (371) had public insurance, and 21% (81) had a diagnosis of mental illness. 46% (177) had CAD, 76% (291) hypertension, and 36% (177) DM. Substance use was common with 30% (114) using methamphetamines, 36% (138) cocaine, 18% (69) opioids, and 35% (135) alcohol. On multi-variate analysis, EF less than 40% (75%, 285) was the only medical comorbidity associated with an increased risk of readmission (OR 1.86, 1.1-3.1, p= 0.018). Social variables associated with increased risk of readmission included identifying as Black (OR 2.26, 1.03-5.0, p= 0.043) or Latinx (OR 3.43, 1.41-7.59, p= 0.006), homelessness (OR 3.02, 1.76-5.18, p=<0.001), and specific substance use: methamphetamine (OR 2.23, 1.39-3.57, p=0.001), cocaine (OR 1.63, 1.03-2.57, p= 0.037), opioids (OR 1.81, 1.05-3.13, p= 0.033), and alcohol (OR 2.26, 1.43-3.58, p= 0.001). Conclusion: Race, housing status and substance use were more strongly associated with readmission risk than medical comorbidities in a population of urban, vulnerable and underserved HF patients. Interventions to improve HF readmission metrics should consider addressing racial and social disparities in similar populations.

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Association between air travel and importation of chikungunya into the USA

Journal of Travel Medicine ◽

10.1093/jtm/taz028 ◽

2019 ◽

Vol 26 (5) ◽

Cited By ~ 3

Author(s):

Tahmina Nasserie ◽

Shannon E Brent ◽

Ashleigh R Tuite ◽

Rahim Moineddin ◽

Jean H E Yong ◽

...

Keyword(s):

Negative Binomial ◽

State Level ◽

Positive Association ◽

Air Travel ◽

The State ◽

Significant Positive Association ◽

Increased Risk ◽

Epidemic Period ◽

Imported Cases ◽

The Usa

Abstract Background: During infectious disease outbreaks with pandemic potential, the number of air passengers travelling from the outbreak source to international destinations has been used as a proxy for disease importation risk to new locations. However, evaluations of the validity of this approach are limited. We sought to quantify the association between international air travel and disease importation using the 2014–2016 chikungunya outbreak in the Americas as a case study. Methods: We used country-level chikungunya case data to define a time period of epidemic activity for each of the 45 countries and territories in the Americas reporting outbreaks between 2014 and 2016. For each country, we identified airports within or proximate to areas considered suitable for chikungunya transmission and summed the number of commercial air passengers departing from these airports during the epidemic period to each US state. We used negative binomial models to quantify the association between the number of incoming air passengers from countries experiencing chikungunya epidemics and the annual rate of chikungunya importation into the USA at the state level. Results: We found a statistically significant positive association between passenger flows via airline travel from countries experiencing chikungunya epidemics and the number of imported cases in the USA at the state level (P < 0.0001). Additionally, we found that as the number of arriving airline passengers increased by 10%, the estimated number of imported cases increased by 5.2% (95% CI: 3.0–7.6). Conclusion: This validation study demonstrated that air travel was strongly associated with observed importation of chikungunya cases in the USA and can be a useful proxy for identifying areas at increased risk for disease importation. This approach may be useful for understanding exportation risk of other arboviruses.

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1239. Efficacy of Preoperative Chlorhexidine Gluconate and Mupirocin in the Prevention of Orthopedic Surgical Site Infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1102 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S446-S446

Author(s):

Gabrielle Kahler ◽

Michael Ing

Keyword(s):

Treatment Protocol ◽

Retrospective Chart Review ◽

Surgical Site Infections ◽

The United States ◽

Chlorhexidine Gluconate ◽

Orthopedic Procedures ◽

Causative Organism ◽

Infection Rates ◽

Chi Square ◽

Increased Risk

Abstract Background Surgical site infections (SSIs) affect 1–5% of patients undergoing surgical procedures in the United States each year and have a mortality rate of up to 75%. We sought to assess the efficacy of a bundled preoperative decolonization treatment protocol to prevent SSIs in hip, knee, or spine procedures. Methods A retrospective chart review was conducted for 2224 adult patients undergoing spine, knee, or hip procedures performed at the JL Pettis Memorial VAMC from October 1, 2010 to December 31, 2018. NHSN/CDC criteria were utilized. The study included spine surgeries with or without new hardware, but only hip and knee surgeries with new hardware. Procedures with an infection present at the time of surgery (PATOS) were excluded. A pre-operative methicillin-resistant Staphylococcus aureus (MRSA) nares screen was performed. Patients treated were given mupirocin (MPN) to apply to their nares and 4% chlorhexidine gluconate (CHG) to wash all skin prior to the procedure. Patients undergoing emergent procedures received CHG without MPN. The intention to treat model and chi-square test were utilized. The primary endpoints were the infection rates in both the untreated and treated groups. Secondary endpoints included the MRSA screening result, SSI class, causative organism(s), and the surgical site. Results A total of 2,112 procedures were included in the study. Thirty-three (1.56%) procedures met NHSN/CDC criteria for SSI. Of the 1,754 (83.0%) procedures given decolonization treatment with MPN and/or CHG, 22 (1.25%) developed an SSI. Of the 358 procedures not receiving treatment, 11 (3.07%) developed an SSI. Conclusion Patients given decolonization treatment had a lower infection rate compared with those who were not treated (1.25% vs. 3.07%, P = 0.0115). Even though the decrease in infection rates were most significant for hip procedures, the overall trend favored the use of a preoperative decolonization treatment protocol for all of the orthopedic procedures studied (Table 1). Current barriers include patient compliance and correct use of decolonization agents, which may affect the actual efficacy of decolonization treatment. A possible confounder was the known increased risk of SSIs in emergent procedures. Disclosures All authors: No reported disclosures.

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Calcium and magnesium infusions for prevention of oxaliplatin-induced peripheral neuropathy.

Journal of Clinical Oncology ◽

10.1200/jco.2011.29.4_suppl.387 ◽

2011 ◽

Vol 29 (4_suppl) ◽

pp. 387-387

Author(s):

M. Bupathi ◽

G. Mahmud ◽

J. Kovar ◽

E. Wang ◽

T. E. O'Brien

Keyword(s):

Peripheral Neuropathy ◽

Cumulative Dose ◽

Medical Center ◽

Demographic Data ◽

Performance Status ◽

Safety Net ◽

Control Group ◽

Minority Population ◽

Tumor Type ◽

Safety Net Hospital

387 Background: Oxaliplatin plays an important role in chemotherapy regimens for colorectal and other GI malignancies. Debilitating peripheral neuropathy (PN) often develops with use of this drug. One study (Grothey A et al, ASCO 2009, abst #4025) has shown that pre- and post-oxaliplatin infusions with calcium (Ca) and magnesium (Mg) may reduce this toxicity. To confirm this in an unselected indigent minority population, a retrospective review was performed comparing development of PN in oxaliplatin exposed patients treated with or without Ca/Mg. Methods: Records of patients who received oxaliplatin from 1/2008 to 12/2009 at MetroHealth Medical Center, a large safety net hospital in Cleveland, OH, were reviewed. 47 patients received Ca/Mg + oxaliplatin and 46 oxaliplatin alone. Data collected included age, race, gender, insurance status, performance status, tumor type, stage, concomitant diseases (DM and EtOH), number of cycles and cumulative dose of oxaliplatin. PN was determined using the Common Terminology Criteria of Adverse Events (CTCAE) version 3.0. Patients were followed 6 months after completion of oxaliplatin. Results: Demographic data was similar between the two groups. Colorectal cancer compromised 77% of the treatment group and 85% of control group. Patients who received Ca/Mg had significantly less PN in all three grades (1-3) compared with the control group (grade 1 89.4% vs. 71.7%, grade II 10.6% vs. 19.6%, grade 3 0% vs. 8.7%, respectively). The cumulative dose of oxaliplatin did not differ between the two groups (Ca/Mg median 1,143 range 260-2,169; control median 1,425 range 137-2,635). The combined total grades 2 and 3 in both the treatment and control (10.6% vs. 28.3%, p = 0.038) favored use of Ca/Mg. Conclusions: This small, retrospective study confirms that Ca/Mg infusions reduce the incidence of clinically significant (grade 2/3) PN in pts receiving oxaliplatin. No significant financial relationships to disclose.

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