Labor and Delivery Unit Closures in Rural Georgia from 2012–2016 and the Impact on Black Women: A Mixed-Methods Investigation

Background. Obstetric provider coverage in rural Georgia has worsened, with nine rural labor and delivery units (LDUs) closing outside the Atlanta Metropolitan Statistical Area from 2012–2016. Georgia consistently has one of the highest maternal mortality rates in the nation and faces increased adverse health consequences from this decline in obstetric care.Objective. This study explores what factors may be associated with rural hospital LDU closures in Georgia from 2012–2016.Methods. This study describes differences between rural Georgia hospitals based on LDU closure status through a quantitative analysis of 2011 baseline regional, hospital, and patient data, and a qualitative analysis of newspaper articles addressing the closures.Results. LDUs that closed had higher proportions of Black female residents in their Primary Care Service Areas (PCSAs), of Black birthing patients, and of patients with Medicaid, self-pay or other government insurance; lower LDU birth volume; more women giving birth within their PCSA of residence; fewer obstetricians and obstetric provider equivalents per LDU; and fewer average annual births per obstetric provider. Qualitative results indicate financial distress primarily contributed to closures, but also suggest that low birth volume and obstetric provider shortage impacted closures.Conclusions for Practice. Rural LDU closure in Georgia has a disproportionate impact on Black and low-income women and may be prevented through funding maternity healthcare and addressing provider shortages.

Documenting Behavioral Health Needs in an Urban Setting

Most local communities lack the capacity to conduct behavioral health needs assessments. The purpose of this paper is to describe a mixed-methods approach to estimate the behavioral health needs in St. Louis, MO. Data were drawn from multiple sources including local and state government prevalence estimates, medical records, and key informant interviews. The most prevalent behavioral conditions were depression, alcohol, and drug abuse. Priority populations were residents with co-occurring disorders, youth transitioning into the adult behavioral system, and homeless individuals with behavioral health needs. Treatment rates for behavioral health conditions were low, relative to identified needs. There are significant provider shortages and high staff turnover, which extend wait times, diminish the quality of care, and contribute to the use of emergency departments for behavioral health care. The data and methods described in this paper could be helpful to other municipalities that are looking to conduct behavioral health needs assessments.

Associations of LGBTQ+ Identities with Acceptability and Response to Online Single-Session Youth Mental Health Interventions

Background: A majority of youth with depression and related difficulties never access treatment. Barriers such as stigma, financial costs, and provider shortages contribute to this problem. Single session interventions (SSIs) have been found to benefit youth and help reduce depression symptoms. Since many SSIs are brief and can be accessed online, they may circumvent traditional barriers to accessing treatment, thus supporting wellbeing in individuals otherwise unable to access care. SSIs may be particularly beneficial for LGBTQ+ youth, for whom barriers to treatment are often exacerbated. There is a need to determine whether LGBTQ+ youth respond as positively to SSIs as non-LGBTQ+ youth, or if adaptations are needed prior to widespread dissemination. Methods: We investigated whether changes in helplessness, agency, and self-hate from before to after completing online SSIs differed as a function of LGBTQ+ identity in a sample of 258 youths (N=258, 81.4% female assigned sex, 60.5% LGBTQ+, 47.3% BIPOC). We also quantitatively and qualitatively compared intervention acceptability ratings and feedback across LGBTQ+ and non-LGBTQ+ youths. Results: Analyses revealed no significant differences between cisgender LGBQ+, trans and gender diverse, and cisgender heterosexual youths for any intervention outcomes. Likewise, no group differences emerged in intervention acceptability ratings or written program feedback. Limitations: Self-selection bias and underrepresentation of certain populations, such as American Indian and Alaskan Native youths, may limit generalizability of results.Conclusions: Results suggest that online mental health SSIs are equally acceptable and useful to LGBTQ+ and non-LGBTQ+ youth alike, even without culturally specific tailoring.

Development of a Low-Resource Operating Room and a Wide-Awake Orthopedic Surgery Program During the COVID-19 Pandemic

Introduction. The COVID-19 pandemic resulted in significant medication, supply and equipment, and provider shortages, limiting the resources available for provision of surgical care. In response to mandates restricting surgery to high-acuity procedures during this period, our institution developed a multidisciplinary Low-Resource Operating Room (LROR) Taskforce in April 2020. This study describes our institutional experience developing an LROR to maintain access to urgent surgical procedures during the peak of the COVID-19 pandemic. Methods. A delineation of available resources and resource replacement strategies was conducted, and a final institution-wide plan for operationalizing the LROR was formed. Specialty-specific subgroups then convened to determine best practices and opportunities for LROR utilization. Orthopedic surgery performed in the LROR using wide-awake local anesthesia no tourniquet (WALANT) is presented as a use case. Results. Overall, 19 limited resources were identified, spanning across the domains of physical space, drugs, devices and equipment, and personnel. Based on the assessment, the decision to proceed with creation of an LROR was made. Sixteen urgent orthopedic surgeries were successfully performed using WALANT without conversion to general anesthesia. Conclusion. In response to the COVID-19 pandemic, a LROR was successfully designed and operationalized. The process for development of a LROR and recommended strategies for operating in a resource-constrained environment may serve as a model for other institutions and facilitate rapid implementation of this care model should the need arise in future pandemic or disaster situations.

“Palliative Pandemic Plan,” Triage and Symptoms Algorithm as a Strategy to Decrease Providers’ Exposure, While Trying to Increase Teams Availability and Guidance for Goals of Care (GOC) and Symptoms Control

As the spread of the novel coronavirus disease 2019 (COVID-19) continues worldwide, health care systems are facing increased demand with concurrent health care provider shortages. This increase in patient demand and potential for provider shortages is particularly apparent for palliative medicine, where there are already shortages in the provision of this care. In response to the developing pandemic, our Geriatrics and Palliative (GAP) Medicine team formulated a 2-team approach which includes triage algorithms for palliative consults as well as acute symptomatic management for both patients diagnosed with or under investigation (PUI) for COVID-19. These algorithms provided a delineated set of guidelines to triage patients in need of palliative services and included provisions for acute symptoms management and the protection of both the patient care team and the families of patients with COVID-19. These guidelines helped with streamlining care in times of crisis, providing care to those in need, supporting frontline staff with primary-level palliative care, and minimizing the GAP team’s risk of infection and burnout during the rapidly changing pandemic response.

New Strategies in Clinical Guideline Delivery: Randomized Trial of Online, Interactive Decision Support Versus Guidelines for Human Immunodeficiency Virus Treatment Selection by Trainees

Background Support for clinicians in human immunodeficiency virus (HIV) medicine is critical given national HIV-provider shortages. The US Department of Health and Human Services (DHHS) guidelines are comprehensive but complex to apply for antiretroviral therapy (ART) selection. Human immunodeficiency virus antiretroviral selection support and interactive search tool (HIV-ASSIST) (www.hivassist.com) is a free tool providing ART decision support that could augment implementation of clinical practice guidelines. Methods We conducted a randomized study of medical trainees at Johns Hopkins University, in which participants were asked to select an ART regimen for 10 HIV case scenarios through an electronic survey. Participants were randomized to receive either DHHS guidelines alone, or DHHS guidelines and HIV-ASSIST to support their decision making. ART selections were graded “appropriate” if consistent with DHHS guidelines, or concordant with regimens selected by HIV experts at 4 academic institutions. Results Among 118 trainees, participants randomized to receive HIV-ASSIST had a significantly higher percentage of appropriate ART selections compared to those receiving DHHS guidelines alone (percentage of appropriate responses in DHHS vs HIV-ASSIST arms: median [Q1, Q3], 40% [30%, 50%] vs 90% [80%, 100%]; P < .001). The effect was seen for all case types, but most pronounced for complex cases involving ART-experienced patients with ongoing viremia (DHHS vs HIV-ASSIST: median [Q1, Q3], 0% [0%, 33%] vs 100% [66%, 100%]). Conclusions Trainees using HIV-ASSIST were significantly more likely to choose appropriate ART regimens compared to those using guidelines alone. Interactive decision support tools may be important to ensure appropriate implementation of HIV guidelines. Clinical Trials Registration NCT04080765.

Synchronous Teledermoscopy in Military Treatment Facilities

Sustained demand for dermatologic care throughout military medicine, in conjunction with increasing dermatologic provider shortages, has led to increase use of teledermatology in military treatment facilities (MTFs). Initially used to aid in the differentiation of suspicious melanocytic lesions, dermoscopy has found increasing clinical utility in an expanding realm of general dermatologic conditions. We demonstrate the use of synchronous teledermoscopy within a remote MTF by repurposing webcam technology already available at most MTFs. Two patients were seen in clinic at a remote naval primary care clinic with limited subspecialties. Once written consent was retrieved, an on-site dermatologist evaluated each patient and performed a history and skin exam with dermoscopy. Synchronous consultations were conducted with the Global Med Cart (GlobalMed(R) Clinical Access Station with TotalExam(R) 3 HDUSB camera), and Cisco webcam video jabber (Cisco TelePresence PrecisionHD USB Camera part number TTC8-03). The patients then underwent individual synchronous teledermatology consultations with an off-site U.S. Navy dermatologist located in the continental United States. The methodology for the consultation involved the use of a standard dermatoscope and jabber webcam. Two synchronous teledermatology consultations were completed successfully on patients in MTFs with limited subspecialty capabilities. Both cases, with two lesions of concern per case, had 100% concordance between the on-site and teleconsulted dermatologist. Through observing inter-rater agreements between the on-site and remote dermatologists, this small study demonstrates a novel application of technology readily available at most MTFs.

Practical allocation system for the distribution of specialised care during cellular therapy access scarcity

Novel cellular therapy techniques promise to cure many haematology patients refractory to other treatment modalities. These therapies are intensive and require referral to and care from specialised providers. In the USA, this pool of providers is not expanding at a rate necessary to meet expected demand; therefore, access scarcity appears forthcoming and is likely to be widespread. To maintain fair access to these scarce and curative therapies, we must prospectively create a just and practical system to distribute care. In this article, we first review previously implemented medical product and personnel allocation systems, examining their applicability to cellular therapy provider shortages to demonstrate that this problem requires a novel approach. We then present an innovative system for allocating cellular therapy access, which accounts for the constraints of distribution during real-world oncology practice by using a combination of the following principles: (1) maximising life-years per personnel time, (2) youngest and robust first, (3) sickest first, (4) first come/first served and (5) instrumental value. We conclude with justifications for the incorporation of these principles and the omission of others, discuss how access can be distributed using this combination, consider cost and review fundamental factors necessary for the practical implementation and maintenance of this system.

Believe the H.I.P.E.: Hematology-Oncology Inter Professional Education to improve provider collaboration at an inpatient tertiary medical center.

10538 Background: With projected provider shortages and increasing pharmaceutical complexity, Advanced Practice Providers (APPs) and Pharmacists are becoming increasingly utilized members of hematology/oncology teams. Despite significant interdependence in practice, inter-professional training remains rare. Medical IPE has been shown to improve learning satisfaction and attitudes, however, IPE has seldom incorporated inter-professionalism into content development nor has it been evaluated in terms of sustainability. Methods: We developed a pilot IPE curriculum consisting of six, 1-hour long, case-based sessions. A preparation phase required a lead APP, Fellow, and Pharmacist to collectively build a case around three teaching points; 1) diagnosis, 2) treatment, and 3) coordination of care. The APP and Pharmacist presented the case while the Fellow moderated to ensure active participation among all groups. Surveys on collaboration, interaction, interest, and connection, as well as open-ended comments on strengths and areas for improvement were collected after each session ( > 80% completion rate). Results: With 3 of 6 sessions completed (02/19), attendance was stable, averaging 10 of 18 (Fellow), 5 of 8 (APP), and 3 of 6 (Pharmacist). Sessions were rated an average of 4.6/5 on collaboration, 4.5/5 interactive, 4.7/5 application, 4.3/5 communication, and 4.2/5 professionalism. 69% of attendees reported being more likely to attend future conferences. 65% reported feeling more connected to the care team. The most common suggestion for improvement was giving more teaching opportunities to the APPs. Session leaders were initially recruited but quickly transitioned to eager volunteers. Conclusions: Our IPE curriculum shows promising initial sustainability with perceived high marks in collaboration and applicability. Incorporating inter-professionalism into content development and longitudinal delivery to providers in practice provides a novel approach to educating IP teams. Future steps include ensuring continued sustainability, conducting qualitative and quantitative analysis, and dissemination to other units.