United States

Abstract Title: Improving ACEs Implementation at Frayser Health Center ​

Authors: Christian Mark Agatep, Mai Nojima, Ashlynn Rae Torres 

Background 

The Adverse Childhood Experiences (ACEs) survey is an important pediatric screening tool that predicts physical and mental health outcomes across an individual’s lifespan1. While the value of ACEs surveys has been recognized within federally qualified health centers (FQHC), little is understood about its implementation in these resource-constrained settings. Through a partnership between a FQHC and medical students enrolled in a Health Systems Science (HSS) Service-Learning course, we analyzed how health systems can impact patient and community health. Our community-engaged aim was to identify common themes about experiences in implementing an ACEs survey at the FQHC and to address these themes to facilitate its successful adoption and sustainability. 

Methods 

We implemented a Plan-Do- Study-Act quality improvement cycle between January 2021 – May 2022 at a FQHC in Southern California. We interviewed and surveyed stakeholders, including FQHC leadership and staff members. Thematic analyses were performed on qualitative data to co-identify successful workflow processes and opportunities for improvement. 



Results 

We interviewed 17 staff members, inquiring about their understanding of ACEs, the importance of survey implementation, and their specific roles in the screening process. Common themes that emerged were that staff a) do not receive consistent ACEs training and b) do not receive training about the rationale for administering ACEs surveys. 



Conclusion 

We found that using a HSS approach helped identify specific workflow steps with patient screening processes, define which staff delivers each step, and understand the interprofessional collaboration for efficient and effective screening. Through this we brought together multiple stakeholders to appreciate the context and implementation of an ACEs survey at a FQHC serving a high needs community. To address the training gaps, we developed a consolidated ACEs training pamphlet in English and Spanish for staff members that provides an overview of ACEs screening and referral resources to complement their clinical knowledge of trauma-informed care. Our next step is to ensure clinic staff receive consistent training so they can screen eligible children at the FQHC in an equitable matter. By doing so, early interventions can be identified to connect patients and their families to appropriate community resources and trauma-informed care.

AMA Research Challenge 2022

Improving ACEs Implementation at Frayser Health Center ​

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Background: Annual well-child visits (AWCV) are important for evaluating children’s well-being. During AWCV, one’s health, development, and anticipatory guidance are discussed, along with any unmet medical/social needs. Many families have barriers to attending AWCV due to social factors including transportation, housing, and childcare. Addressing socioeconomic barriers may improve access to AWCVs. The CATCH program utilizes tele-outreach to schedule AWCVs for patients lost to follow-up and offers access to community-based resources to address families’ unmet social needs in Pittsburgh, PA. This study assessed the efficacy of the CATCH program in scheduling pediatric AWCV and providing access to community resources.
Methods: This was a retrospective analysis of pediatric patients lost to follow-up (not seen for AWCV for 12 months since last visit), from 1/2021-6/2022. Families were contacted through phone calls. Each call inquired about interest in scheduling AWCV, identified preferred clinics, assessed families’ unmet social needs, and provided access to local resources. Telephone encounters were made in EPIC to notify pediatric offices of scheduled AWCVs. Chart review was performed to determine attendance rates of scheduled appointments. 
Results: A total of 459 families were contacted, of which 266 (58%) were unreachable. Of the 193 families reached, 79 (17%) had already attended AWCV within a year, and 22 (5%) patients had reached adulthood and transitioned care, and were thus excluded from our sample. Among the remaining 92 families, 41 AWCVs (45%) were scheduled. Cited reasons for declining scheduling assistance included residence/pediatrician change, guardianship issues, and personal preference. 19 of 41 scheduled appointments (46%) were attended. Community resources were universally provided, with 32 families connected with over 71 resources. These spanned areas of health care/insurance, COVID-19, food, housing, transportation, legal services, childcare, and general community resource hubs. 
Conclusion: The tele-outreach of the CATCH program increased rates of AWCV scheduling, and connected families with local resources to address unmet social needs. This model offers support for phone call-based outreach to contact families of children lost to follow-up and suggests its role in addressing health care and socioeconomic barriers. CATCH may serve as a model for other tele-outreach programs in underserved communities.

Pediatric Tele-Outreach Program Increases Well Child Visit Scheduling and Addresses Unmet Social Needs 

Background
During the height of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic, also known as COVID-19, clinicians warned the public of a significant symptom of COVID-19 called "silent hypoxemia," where patients presented with low oxygen saturation levels and no dyspnea. Pulse oximetry is a critical component of evaluating the severity of arterial deoxygenation. However, studies have shown discrepancies in these readings amongst deep skin tone individuals or individuals with higher levels of active melanocytes. Data from ecent studies have shown that black patients had almost three times the frequency of occult hypoxemia that was not detected by pulse oximetry. It is hypothesized that the importance of pulse oximetry in medical decision-making has some implications that may play a significant role in adverse COVID-19 health outcomes in marginalized communities.

Methods
The design of this study is a systematic review and data extraction of relevant articles that discuss pulse oximetry and racial disparities associated with pulse oximetry technology. Data examining COVID-19 related data that analyzed the rate of infection, hospitalization, and mortality among minorities was also considered.4, 5, 6.

Results
Researchers identified 21,431 citations with relative pulse oximetry accuracy and data related to COVID-19 health outcomes. Compared to their white counterparts, inaccurate pulse oximetry readings in black patients are more than doubled. Some data extractions provided significant evidence that the inaccuracy of these pulse oximetry readings could result in late intubation and or unnecessary intubations, which may have played an essential role in the increased mortality rate for black patients.

Conclusion
Our aim is to show that inequalities in pulse oximetry readings could affect COVID-19 outcomes for African-Americans. Based on the literature, inaccurate pulse oximetry readings could lead to delayed medical treatment of patients in need of further respiratory assistance, thus supporting the hypothesis. This delay is costly as it can increase the frequency of African-Americans needing advanced respiratory intervention such as intubation or ventilators. It is vital that others research topics related to this to prevent additional injuries or deaths.

Racial Disparities among Pulse Oximetry readings and Possible effects on COVID -19 outcomes

LEND is a program designed to address marked disparities in identifying and treating Autism Spectrum Disorder (ASD) in marginalized communities. Studies show that black children are less likely than white children to be diagnosed with ASD. Early and accurate detection of ASD is critical for access to early intervention which optimizes the outcomes. We aimed our project to equip immigrant communities with ASD treatments and available services, to provide a safe platform to explore cultural barriers, and to provide practical solutions to increase access to services.
Methods: It’s a cross-sectional study, a flier distributed through email to parents and colleagues. Three workshops were held, two in English and one in Chinese, which included a zoom presentation and an open discussion at the end of the presentation, pre and post assessment surveys used to assess knowledge. Presentation included basic facts about ASD, assessment, available treatments and resources, and transition from childhood to adulthood.
Results: Seventeen subjects participated in our workshops. In the first English workshop, 7 participated, in the second English workshop, 5 participated, and in the third Chinese workshop, 5 participated, with 100% versus 40% versus 100% respectively response to surveys. The data indicate that the audience became more familiar with diagnosis and treatments based on a 7-question survey.
Conclusions: We observed significant uncertainty in impartial hearings, proper school placements, Medicaid waivers, and OPWDD. Limitations include low attendance and lack of audience participation. Future research should consider event promotions in advance and live presentations in community settings.



Raising Autism Awareness For Disadvantaged Communities as Part of Leadership in Education and Neurodevelopmental and Related Disabilities (LEND) Program

Background: Nearly 10% of Medicare beneficiaries aged ≥65 experience food insecurity. Among this demographic, a greater risk of health impacts exist since many have diet-related chronic conditions such as diabetes (affecting 33% of older adults). Food-insecure, diabetic older adults face increased risks of poor diabetes management and diabetes-related complications due to difficulty adhering to a diabetes-appropriate diet. We examined risk factors associated with food insecurity among Medicare beneficiaries with type 2 diabetes (T2D).

Methods: This population-based cross-sectional study analyzed the 2019 Medicare Current Beneficiary Survey Public Use File (MCBS PUF), with a multi-stage cluster sample design and an overall response rate of 65.7%. The study population included community-dwelling, Medicare beneficiaries with T2D aged ≥65 (n=1,343). The MCBS PUF included a 4-item version of the USDA’s food insecurity questionnaire relating to inability to eat balanced meals, skipping meals, eating less, or food running out because of insufficient money. A binary variable was created to represent food insecurity with ≥2 affirmative responses designated as food insecure based on a previously established algorithm. Descriptive statistics and survey-weighted multivariable logistic models were used to examine the risk factors of food insecurity based on socio-demographic information, health conditions, and insurance coverage.

Results: Approximately 11.6% (representing 1.0 million) of study participants with T2D reported food insecurity, with higher proportions for underserved populations such as income <$25,000 (23.9%) and non-Hispanic Black beneficiaries (21.7%). Using multivariable analysis, non-Hispanic Black beneficiaries were more likely to report food insecurity than Non- Hispanic White (odds ratio [OR]=2.44; 95% CI, 1.39-4.29). Beneficiaries with an income <$25,000 were more likely to report food insecurity than for income ≥$25,000 (OR=2.76; 95% CI, 1.34-5.71). Enrollment in Medicare Advantage (vs Traditional Medicare; OR=1.62; 95% CI, 1.07-2.45), having Medicare-Medicaid dual eligibility (vs nondual eligible; OR=2.14; 95% CI, 1.18-3.90), and living with functional limitations (e.g., ADLs ≥1 vs no limitations; OR=2.74; 95% CI, 1.64-4.59) were positively associated with food insecurity.

Conclusion: We found socio-demographic disparities in food insecurity exist among Medicare beneficiaries with T2D. Implementation of screening protocols and interventions related to social determinants of health during Medicare wellness visits may help mitigate food insecurity among this demographic.

Socio-Demographic Factors Associated with Food Insecurity Among Medicare Beneficiaries with Type 2 Diabetes

Abstract Title: Impact of the COVID-19 Pandemic on Medical Students in the 2021-2022 NRMP Application Process

Background: The COVID-19 pandemic significantly changed the undergraduate medical education (UME) NRMP application process (NAP). This included virtual interviews, the suspension or elimination of away rotations, elimination of COMLEX 2 PE/USMLE STEP 2 CS licensing exams, and increased online rotations. Previous literature has reported on the impact the pandemic had on the 2020-2021 NAP; however, limited data exists on the impact of the pandemic on this past cycle, from 2021-2022.1 – 4

Objective: To survey medical students from two colleges of osteopathic medicine regarding the impact the pandemic had on their 2021-2022 NAP in order to better understand challenges faced by students.

Methods: An IRB-approved 20 question survey was developed and distributed after the 2022 match via email and social media. 86 students from the Liberty University College of Osteopathic Medicine and the Kansas City University College of Osteopathic Medicine participated in the study. Likert-scale questions with a range of 1-5 and a comment box were used to assess student experiences related to changes the pandemic had on their match process. Several areas were assessed, e.g., away rotations, virtual interviews, board requirement changes including the suspension of COMLEX Level 2 PE, advising, psychological well-being, etc. Statistical analysis was performed using Qualtrics software. 

Results: 97.59% matched in the 2021-2022 NAP. 94.81% matched in their first-choice specialty. The number of away rotations in matched specialties ranged from 1 to 9 (M=3.22, SD=1.82). Only 39.74% matched at an away rotation site. The average amount of money spent on the entire application process was (M=$3070, SD=$2274). On a scale of 1 to 10, overall impact felt by the pandemic on the 2021-2022 NAP was M=4.92, SD=1.92. 54.5% of students reported the suspension of the third board exam to have impacted their application process high to very highly. However, more students felt highly impacted by the availability of away rotations (61.2%) and the virtual interviewing format (71.6%). Approximately 45% of students rated both stress and anxiety as high impacts. 72.06% of participants sought feedback from students from the 2020-2021 NAP and 48.98% of participants found this feedback to be highly helpful. The impact of the availability of away rotations and stress were positively correlated (r=0.266, p<0.005). The suspension of PE/CS and sleep were negatively correlated (r=-0.054, p<0.006). 

Conclusion: Changes in the 2021-2022 NAP due to COVID-19 positively and negatively impacted students. Student comments indicated that virtual interviews opened up more opportunities to interview and save money. Students also commented that due to the strain of the pandemic, they had less time with their attending physicians and that this could have negatively impacted their letters of recommendation. Overall, cancellation of the PE and CS was viewed positively. And many students sought out feedback from applicants of the 2020-2021 NAP to be better prepared to face the challenges of the continued pandemic.

The Impact of the COVID-19 Pandemic on Medical Students in the 2021-2022 NRMP Application Process

The Prevalence and Incidence of Sarcoidosis at the Phoenix VA Health Care System

Background
Sarcoidosis is a multisystem granulomatous disorder with different manifestations. It typically effects adults <50 years of age of African American or Scandinavian decent. In the United States the prevalence per 100,000 population is estimated to be 141.4, 49.8, 21.7, and 18.9 for African American, White, Hispanics, and Asians, respectively. The incidence of sarcoidosis is estimated to be of 2.3-17.8 per 100,000 per year.
The Phoenix VA Health Care System’s (PVAHCS) Pulmonary department has had multiple cases of sarcoidosis, leading to multiple educational conferences. The aim of the study was to assess burden of sarcoidosis within the PVAHCS.
Methods
A retrospective chart review of sarcoidosis cases from 2017 through 2021 were identified using ICD-10 (D86.0, D86.1, D86.2, D86.3, D86.82, D86.89, D86.9) codes. The prevalence and incidence sarcoidosis at the PVAHCS were calculated. Poisson regression was used to compare the prevalence between 2017 and 2021. 
Results
All rates are reported per 100,000 veterans enrolled in PVAHCS. Of the 345 sarcoidosis cases identified, majority were male (85.8%). From 2017 to 2021, the prevalence of sarcoidosis increased by 51% (100.4 vs 148.2 respectively, P=0.003). The incidence varied from 0 to 44.1 per year. On average, females had higher prevalence and incidence compared to men (788.6 and 30.04 vs 643.4 and 17.64, respectively). Group ages 45-54 and 55-65 have the highest prevalence (253 and 262.4, respectively). Patients ages 75-85 have the highest incidence (50.3). The cumulative incidence was significantly higher in African Americans as compared to other races/ethnicities (923.1 vs 178.73 (Hispanic or Latino), 149.6 (Whites), 71.9 (Native Hawaiians or other Pacific Islanders), and 62.6 (Native Americans, P<0.001).

Conclusion
This is the first study to report the incidence and prevalence of sarcoidosis at PVAHCS. The overall incidence and prevalence were similar to what has been reported and is increasing each year. In our review, PVAHSC African Americans have higher incidence and prevalence whereas females only have higher prevalence of sarcoidosis compared to the reported rates. Further studies should be conducted to determine associated risk factors. Additional efforts must be initiated to optimize care for this population.

The Prevalence and Incidence of Sarcoidosis at the Phoenix VA Healthcare System

Preoperative dealys of 90-120 days from tissue diagnosis of breast cancer to surgery can result in 3.1-4.6% absolute decline in overall survival. This has become the standard of care when assessing timeliness of Breast Programs across the United States. At Temple University Hospital in Philadelphia, we have the unique privilege of treating a primarily underserved population that is at risk for various obstacles to timely medical care. When assessing time to surgery in our patient population, we were able to see that delays in care occur at all stages of the evaluation protocol for possible breast cancer. Of importance, is the significant delay we found to be associated with obtaining initial imaging. Therefore, it is important to include time from abnormal imaging to tissue diagnosis in measurements of timeliness as there can be significant delays associated with imaging.

Timeliness of Care in a North Philadelphia Breast Program

Background:
Iron deficiency anemia (IDA) is an important contributor to the systemic disease process in heart failure (HF). Intravenous (IV) Iron repletion has been shown to be superior to oral iron repletion with respect to decreased side effect profile, improved quality of life, reduced mortality and rehospitalization in HF patients. No study has outlined a multidisciplinary hospital-based process in identifying and treating this specific cohort of patients with IV Iron repletion. 

Objectives: 
Our quality improvement (QI) initiative sought to identify patients with IDA and HF in real time and treat them with IV iron repletion instead of oral iron supplementation during their hospitalization using a multidisciplinary approach. 

Methods: 
Between May 2021 and February 2022, using a daily real time electronic medical record patient intake filter, we identified patients admitted for acute decompensated heart failure with a hemoglobin of less than or equal to 12g/dl. Patients were further analyzed for IDA via laboratory iron panel. In accordance with the European Society of Cardiology (ESC) guidelines, anemic patients with a ferritin <100 µg/L or ferritin of 100-299 µg/L with a transferrin saturation <20% qualified for IV Iron repletion. An IDA QI team was created consisting of internal medicine residents, advanced care practitioners, cardiology fellows, and pharmacists to educate providers, identify and treat qualified patients. Patients were treated with IV Iron Sucrose 300mg/day for three consecutive days.

Results:
54 patients were included in the study with three outliers removed, 16 patients were given oral iron sulfate therapy and 36 received IV iron sucrose therapy. Heart failure with reduced ejection fraction was the predominant HF phenotype with 38 patients. The average hemoglobin of our cohort was 8.6 with a mean corpuscular volume of 90.2, ferritin of 98, serum iron of 26, TIBC of 253, and transferrin of 200. A statistically significant decrease in average hospital length of stay was noted in the IV iron repletion arm of 5 days versus 10 days in the oral repletion group (p <0.01). There was no statistically significant difference in length of stay among HF patients with varying levels of ferritin. 

Conclusion: 
Our quality improvement project successfully created a real time multidisciplinary approach to identifying and treating patients with IDA and HF. A statistically significant decrease in length of stay was associated with IV iron repletion. We increased the utilization of IV iron compared to oral repletion by more than 100% during the same time. As a result of this project, IV iron repletion is now a part of our armamentarium in holistically treating heart failure.

Iron Deficiency Anemia and Treatment in ​Heart Failure: A Novel Multidisciplinary Quality Improvement Project

Background: Atopic dermatitis (AD) is a common relapsing inflammatory skin condition associated with a high economic burden due to its chronicity and multitude of direct and indirect treatment costs. AD disproportionately impacts children and minority populations, and treatment choices are cost-prohibitive for many patients.

Objective: To describe the treatment and management of AD from a cost-conscious perspective.

Methods: A review of the literature was conducted with PubMed using the following key words: atopic dermatitis, cost, medications, treatment, management, efficacy, adherence, education, and prophylactic.

Results: The use of moisturizers prophylactically in high-risk infants who have yet to develop AD may reduce incidence of disease and associated costs. Increasing patient medication adherence and moisturizing between flares also reduces costs in AD. The use of corticosteroids as a first-line treatment is efficacious and cost-effective for mild cases of AD, however in severe cases of AD corticosteroids alone are not sufficient. Systemic biologics are necessary in some patients with severe cases of AD; however, they are associated with high costs. Phototherapy, through portable home units, tanning beds, and natural sunlight are cost-effective alternatives. Effective management of AD improves with education programs for both the patient and their family, reducing long-term costs in the management of this disease.

Conclusion: Reducing AD treatment costs requires consideration of prophylactic therapies, patient education, and should differ based on the severity of disease. A multifaceted approach to AD treatment reduces costs and healthcare barriers. This article is protected by copyright. All rights reserved.


Reducing Costs in Atopic Dermatitis

Abstract Title
Factors Associated With Mortality and Prolonged Hospital Stay Among Skull Fracture Patients

Background
Skull fractures pose a high demand on hospital resources. The implication of skull fracture on patient length of hospitalization and mortality has not been elucidated. Identifying predictors of differential mortality risk and prolonged hospital stay in skull fracture patients present opportunities to improve patient outcomes and management of hospital resources. 

Methods
The 2019 National Emergency Department Sample database was used to outline the demographics of patients with a primary skull fracture. Multivariate logistic regression was used to determine factors that contributed to a long inpatient stay and death. Charlson Comorbidity Index (CCI) was calculated to correct for comorbidities relevant to mortality and hospital stay.

Results
In 2019, 1,769,709 patients presented to the emergency department with primary skull fractures.
Level I trauma center inpatients were at greater odds of long hospital stay (OR:2.40; 95% CI [1.72-3.35], p<0.001). Relative to other income groups, the highest income quartile had the lowest likelihood of a prolonged stay (OR:2.40; 95% CI [1.72-3.35], p<0.001). Inpatients presenting with multiple comorbid conditions (CCI: 3+) reported distinctly high likelihood of long hospital stay (OR:3.20; 95% CI [2.45-4.18], p<0.001) and death (OR: 2.18, CI [1.24-3.83], p=0.007). Medicaid beneficiaries reported lower odds of death due to skull fracture than Medicare inpatients (OR:0.63; 95% CI [0.40-0.98], p=0.04). Skull fractures sustained by fall (OR: 0.37 95% CI [0.23-0.58], p<0.001) or physical assault (OR: 0.34 95% CI [0.18-0.63], p<0.001) observed significantly lower odds of death than other-cause fractures. Vault fracture type was associated with both longest hospital stay (OR:3.49; 95% CI [2.54-4.80], p<0.001) and highest mortality rate (OR: 4357; 95% CI [589-32172], p<0.001). 

Conclusion
Distinct odds of prolonged hospitalization and mortality were realized across a motley of covariate-adjusted inpatient and hospital factors. Mindfulness of the associations reported here may serve well to mitigate bed management inefficiencies and improve skull fracture outcomes.

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