Retaining interest in caring for underserved patients among future medicine subspecialists: Underserved Medicine and Public Health (UMPH) program

Background Accessing subspecialty care is hard for underserved patients in the U.S. Published curricula in underserved medicine for Internal Medicine residents target future-primary care physicians, with unknown impact on future medicine subspecialists. Methods The aim was to retain interest in caring for underserved patients among Internal Medicine residents who plan for subspecialist careers at an urban university hospital. The two-year Underserved Medicine and Public Health (UMPH) program features community-based clinics, evening seminars, reflection assignments and practicum projects for 3–7 Internal Medicine residents per year. All may apply regardless of anticipated career plans after residency. Seven years of graduates were surveyed. Data were analyzed using descriptive statistics. Results According to respondents, UMPH provided a meaningful forum to discuss important issues in underserved medicine, fostered interest in treating underserved populations and provided a sense of belonging to a community of providers committed to underserved medicine. After residency, 48% of UMPH graduates pursued subspecialty training and 34% practiced hospitalist medicine. 65% of respondents disagreed that “UMPH made me more likely to practice primary care” and 59% agreed “UMPH should target residents pursuing subpecialty careers.” Conclusions A curriculum in underserved medicine can retain interest in caring for underserved patients among future-medicine subspecialists. Lessons learned include [1] building relationships with local community health centers and community-practicing physicians was important for success and [2] thoughtful scheduling promoted high resident attendance at program events and avoided detracting from other activities required during residency for subspecialist career paths. We hope Internal Medicine residency programs consider training in underserved medicine for all trainees. Future work should investigate sustainability, whether training results in improved subspecialty access, and whether subspecialists face unique barriers caring for underserved patients. Future curricula should include advocacy skills to target systemic barriers.

Interprofessional Continuous Glucose Monitoring for Underserved Adults with Type 2 Diabetes on Insulin or Secretagogues

Background: Literature describing continuous glucose monitoring for underserved patients, including those with type 2 diabetes or at risk for hypoglycemia, is lacking. Methods: An interprofessional internal medicine residency team implemented a blinded CGM service for underserved adults with type 2 diabetes with at-goal glycated hemoglobin (A1C) taking insulin or secretagogues. Results: The 2-week blinded CGM service (N=44) significantly reduced time in hypoglycemia (<70 mg/dL) by 4.1% (P=0.0038). Time-in-target-range increased significantly (4.31%, P=0.025). Body weight, number of medications, and daily insulin dose decreased significantly. Overall, A1C remained stable, indicating no worsening of diabetes control associated with the service. Conclusions: The interprofessional blinded CGM service influenced improved glycemic control in this vulnerable population.

Identifying barriers to equitable biomarker testing in underserved patients with NSCLC: A mixed-methods study to inform quality improvement opportunities.

123 Background: Despite recent advances in cancer precision medicine, patients from underserved communities do not have equal access to biomarker testing and targeted therapies. This study used a mixed-methods approach to identify barriers to equitable precision medicine access among underserved patients with non-small cell lung cancer (NSCLC). Methods: Paired national surveys (one clinician-facing and one patient-facing) were developed respectively by the Association of Community Cancer Centers (ACCC) and LUNGevity Foundation. Administered online in spring/summer 2020, the surveys were designed to identify key attitudes/barriers related to biomarker testing, resource needs, and current practice patterns for pertinent stakeholders. Survey data was triangulated with data from focus groups (2 clinician and 6 patient) conducted in fall 2020. The study was approved by Advarra IRB. Results: A total of 99 clinicians responded, with 67% (66/99) representing oncologists from community cancer programs. 248 patients responded to the LUNGevity survey, with 161 coming from the general population and 87 from the LUNGevity network (patients with relatively high income and education levels). Most clinicians surveyed indicated they were “very” (34%) or “extremely” likely (44%) to discuss biomarker testing with NSCLC patients. Academic clinicians, however, were more likely than community-based clinicians to order testing at the time of initial biopsy (76% vs 52%, P =.02). Academic clinicians were also more likely to involve the patient’s family in biomarker testing discussions (85% vs 59%, P =.009). Patient survey results identified that medical oncologists are the primary source of biomarker testing information; 64% of LUNGevity-connected and 37% of underserved patients. Eighty-five percent of LUNGevity-connected patients receive biomarker testing versus 52% for general patients (p < 0.05). Notably, more than a quarter (27%) of underserved patients who have undergone biomarker testing do not know their results. Clinician focus group participants corroborated survey findings that most clinicians receive testing results in 7-14 days, but for 23% of community and 6% of academic clinicians the process can take over 2 weeks. They identified disparities in offering biomarker testing and results to patients with known or presumed low socioeconomic status (SES) and/or health literacy. This was supported by patient survey data, which showed biomarker testing was proactively offered to only 40% of low-SES patients. Conclusions: This study identifies key areas of ongoing need related to equitable biomarker testing. Quality-improvement opportunities exist to address both clinician and patient barriers to guideline-concordant biomarker testing for underserved patients with NSCLC.