Parkland Center For Clinical Innovation

PurposeDecreased access to care and social drivers of health have been implicated in COVID-19 disparities. The objective of this study was to test the association between county-funded charity coverage (CFCC) and mortality among uninsured patients hospitalized with COVID-19 in a highly uninsured county.MethodsThis retrospective cohort study compared electronic health record (EHR) data among uninsured patients hospitalized with COVID-19 in a high-volume safety-net health system in Dallas County, Texas between June 2020 and December 2021. Uninsured patients included CFCC recipients and self-pay patients. We compared mortality over 180 days of follow-up using Cox proportional hazards models, adjusting for gender, age, race/ethnicity, and co-morbidities. Additional outcomes included 90-day mortality, need for mechanical ventilation, and intubation within 24 hours of presentation.ResultsAmong 2,047 patients, 47.0% received CFCC and 53.0% were self-pay. Overall, CFCC patients were older, more likely Hispanic, and had more diagnosed co-morbidities. CFCC patients had decreased adjusted mortality compared to self-pay (aHR 0.61, 95% CI [0.45 to 0.82], p < 0.01), with an absolute risk reduction of 3.3% and a number needed to treat (NNT) with CFCC of 30.4 (95% CI 21.4–66.6). CFCC was associated with lower 90-day mortality compared to self-pay (OR = 0.64, 95% CI [0.45–0.92], p = 0.01), despite similar need for ventilation. Intubation within 24 hours of presentation was lower for CFCC compared to self-pay (OR = 0.46, 95% CI [0.22–0.93], p = 0.03).ConclusionsCFCC was associated with decreased mortality among the uninsured hospitalized with COVID-19. The NNT for CFCC to prevent 1 death among uninsured patients was similar to that for standard medications to treat COVID-19. These findings support expanding coverage to improve COVID-19 outcomes.

Effective clinical decision support (CDS) interventions improve adherence to care guidelines, reduce prescribing errors, and, in some settings, decrease patient mortality. However, misalignment with the "Five Rights" framework, particularly regarding CDS timing in clinical workflows, can lead to implementation failures, alert fatigue, and physician burnout.This case series aimed to evaluate and redesign three interruptive CDS alerts at a large safety net health system to better align with clinician workflows, reduce interruptions, and improve compliance with care guidelines.We analyzed three interruptive alerts using data from Epic's SlicerDicer tool, focusing on alert frequency, contributors to alert triggering, and user responses before and after intervention. Alerts were modified to improve their timing and relevance within the workflow.Modifications included retiming a human immunodeficiency virus screening alert to trigger during laboratory test orders, reducing alert firings by 87% while increasing monthly screening orders from 3,561 to 4,547 (p < 0.001). An administrative alert's firing frequency decreased by 86% through the introduction of a 4-hour lockout period, maintaining compliance rates. Finally, restricting a pediatric head circumference discrepancy alert to in-person visits only eliminated interruptions during telehealth encounters, addressing a major source of clinician frustration.Aligning CDS tools with clinical workflows through adherence to the "Five Rights" framework reduces interruptions and improves outcomes. Iterative review, user feedback, and proactive redesign are essential to ensure CDS effectiveness, particularly as health care evolves to include novel care delivery models like telehealth.

Pre-exposure prophylaxis (PrEP) is an effective approach for preventing HIV infection, but it is underutilized by populations who may benefit the most, including people living in the Southern United States and those involved in the criminal legal (CL) system. Improving the access and use of PrEP for these groups could decrease HIV-related health disparities. Beyond individual outcomes, HIV prevention for CL-involved people can have a significant public health impact on HIV incidence due to a high turnover between jails and the community. We will develop, implement, and evaluate a multicomponent PrEP implementation strategy for the Dallas County Jail (DCJ) to increase the initiation of this HIV-preventive intervention for CL-involved individuals. This is a type 3 hybrid implementation-effectiveness study that takes a combined approach by assessing the implementation of a strategy to identify candidates for PrEP at the DCJ and linking them to PrEP providers upon community re-entry while also gathering information about clinical outcomes. The approach is guided by the EPIS (exploration, preparation, implementation, sustainment) framework. Initial formative work (exploration) involves qualitative interviews of diverse key stakeholders to identify factors that may influence linkage to PrEP after jail release. These findings will undergo rapid qualitative analysis (preparation) to inform the adaptation of a multicomponent jail PrEP implementation strategy protocol. This approach, which will include an electronic health record (EHR) prediction model and integration of a PrEP patient navigator into the jail health team, will allow medical providers and the navigator at the DCJ to engage individuals most likely to benefit in shared decision-making about PrEP and navigate them to community PrEP care (implementation) in a process that begins before release from jail and ends with successful care linkage. Regular quantitative and qualitative evaluations of this approach will allow for ongoing stakeholder input, refinement of the implementation strategy, and maintenance of the program (sustainment). Findings from 26 qualitative interviews (9 formerly incarcerated individuals, 9 county jail staff, and 8 employees of community organizations) have been obtained, analyzed, and mapped to an implementation strategy formalized in a jail PrEP protocol. An HIV risk prediction model based on EHR data to identify individuals most likely to benefit from PrEP has been developed and internally validated and is ready to be deployed. We anticipate the availability of preliminary study findings in 2026. This study will provide key insights into the feasibility and effectiveness of a PrEP implementation strategy among people at increased risk of HIV acquisition in an urban jail in Southern United States. This practical and scalable strategy can be used as a model for other urban jails to address HIV-related inequities. DERR1-10.2196/64813.

The journey to high-quality care has many hurdles yet to overcome. Healthcare disparities in particular account for uneven burden of illness, access, delivery of care and outcomes. This chapter examines both health and healthcare disparities and illustrates various extant health inequity scenarios with discussion of approaches to bridging the current socioeconomic and infrastructural gaps that fuel health and healthcare disparities. A model approach to addressing the social determinants of health in Dallas that combines processes and workflows across health and social agencies with enabling advanced technology for seamless referrals and coordination of care is described along with preliminary experiences and data to stimulate best practice advancement in the field.

Although fine-needle aspiration (FNA) practice by pathologists is now well established, it has been primarily performed by manual palpation. In recent years, pathologists have begun to venture into ultrasound-guided FNAs (UGFNAs). Reports on experiences with this relatively new technique for pathologists have shown promising results. However to date, there have been few studies in the literature comparing pathologist-performed UGFNA with the more traditional pathologist-performed palpation-guided FNA (PGFNA). To compare UGFNA to PGFNA by cytopathologists at an academic medical center. A retrospective study of FNAs performed by cytopathologists within the University of California, Los Angeles (UCLA) pathology departmental FNA clinic was performed. Data collected included performance technique (UGFNA versus PGFNA), lesion site and size, adequacy status (nondiagnostic rate), and number of passes per procedure. Corresponding surgical pathology/flow cytometric/cytogenetic result follow-up was compared to FNA results. Findings between UGFNA and PGFNA cases were compared. Of 1029 FNA cases during the study period, there were 449 UGFNA cases (43.6%) and 580 PGFNA cases (56.4%). Nondiagnostic rates with UGFNA and PGFNA were 6.7% (30 of 449 cases) and 20.7% (120 of 580 cases), respectively. Nondiagnostic rate was also significantly lower with UGFNA than with PGFNA for lesions within the thyroid (6.0% versus 33.3%), head and neck (6.6% versus 21.2%), and salivary gland (6.2% versus 17.1%), and across all nodule sizes. A total of 495 of 1029 FNA cases (48.1%) had follow-up. Discordance rate was significantly lower with UGFNA than with PGFNA (5.4% versus 12.8%). This study shows improved performance characteristics of cytopathologist-performed UGFNA versus PGFNA.

Our health care and social services delivery systems are not well-equipped to effectively manage patients with multiple chronic diseases and complex social needs such as food, housing, or substance abuse services. Community-level efforts have emerged across the nation to integrate the activities of disparate social service organizations with local health care delivery systems. Evidence on the experiences and outcomes of these programs is emerging, and there is much to learn about their approaches and challenges. Profile and classify burgeoning initiatives, understand common challenges, and surface solutions to address those challenges. Mixed-methods approach, including literature search, surveys, semistructured interviews with program leaders, and consultation with expert panels. We categorized cross-sector community partnerships in four dimensions. We also identified five common challenges: inadequate strategies to sustain cost-savings, improvement, and funding; lack of accurate and timely measurement of return on investment; lack of mechanisms to share potential savings between health care and social services providers; lack of expertise to integrate multiple data sources during health care or social services provision; and lack of a cross-sector workflow evidence base.

We describe the results of an open-label study designed to assess the effectiveness and tolerability of aripiprazole addition to an antidepressant in patients with major depressive disorder with postpartum onset who had not experienced significant clinical improvement following an adequate trial of an antidepressant. Eight of ten women completed the trial with augmentation of aripiprazole (2-10 mg) to their existing antidepressant treatment. Our results suggest a possible therapeutic role for aripiprazole when added to an antidepressant in non-breastfeeding women with postpartum depression. Aripiprazole addition appeared effective and safe with no serious adverse events reported.

BackgroundCulture shapes how people understand illness and death, but few studies examine whether acculturation influences patients’ end-of-life treatment preferences and medical care.Methods and FindingsIn this multi-site, prospective, longitudinal cohort study of terminally-ill cancer patients and their caregivers (n = 171 dyads), trained interviewers administered the United States Acculturation Scale (USAS). The USAS is a 19-item scale developed to assess the degree of “Americanization” in first generation or non-US born caregivers of terminally-ill cancer patients. We evaluated the internal consistency, concurrent, criterion, and content validity of the USAS. We also examined whether caregivers’ USAS scores predicted patients’ communication, treatment preferences, and end-of-life medical care in multivariable models that corrected for significant confounding influences (e.g. education, country of origin, English proficiency). The USAS measure was internally consistent (Cronbach α = 0.98); and significantly associated with US birthplace (r = 0.66, P<0.0001). USAS scores were predictive of patients’ preferences for prognostic information (AOR = 1.31, 95% CI:1.00–1.72), but not comfort asking physicians’ questions about care (AOR 1.23, 95% CI:0.87–1.73). They predicted patients’ preferences for feeding tubes (AOR = 0.68, 95% CI:0.49–0.99) and wish to avoid dying in an intensive care unit (AOR = 1.36, 95% CI:1.05–1.76). Scores indicating greater acculturation were also associated with increased odds of patient participation in clinical trials (AOR = 2.20, 95% CI:1.28–3.78), compared with lower USAS scores, and greater odds of patients receiving chemotherapy (AOR = 1.59, 95% CI:1.20–2.12).ConclusionThe USAS is a reliable and valid measure of “Americanization” associated with advanced cancer patients’ end-of-life preferences and care. USAS scores indicating greater caregiver acculturation were associated with increased odds of patient participation in cancer treatment (chemotherapy, clinical trials) compared with lower scores. Future studies should examine the effects of acculturation on end-of-life care to identify patient and provider factors that explain these effects and targets for future interventions to improve care (e.g., by designing more culturally-competent health education materials).