Health equity and quantifying the patient experience: A case study

The COVID-19 pandemic has invigorated efforts to address health inequities disproportionately burdened by racial/ethnic groups and individuals of low socioeconomic status. Measuring and monitoring patient experience is crucial to understanding why the gaps exist and identifying mechanisms necessary to close them. Electronic health records and digital health tools hold much promise in this regard and can lead to change. We present a case study describing the innovative efforts undertaken at Sutter Health, a large integrated health network in Northern California, to quantify gaps in health equity using electronic platforms and visualization modalities. More work is needed to identify and address barriers rooted in social context and structural inequities and ultimately impact health equity. Experience Framework This article is associated with the Policy & Measurement lens of The Beryl Institute Experience Framework. (https://www.theberylinstitute.org/ExperienceFramework). Access other PXJ articles related to this lens. Access other resources related to this lens

Clinical Study Baseline Obesity Status Modifies Effectiveness of Adapted Diabetes Prevention Program Lifestyle Interventions for Weight Management in Primary Care

Objective. To examine whether baseline obesity severity modifies the effects of two different, primary care-based, technologyenhanced lifestyle interventions among overweight or obese adults with prediabetes and/or metabolic syndrome. Patients and Methods. We compared mean differences in changes from baseline to 15 months in clinical measures of general and central obesity among participants randomized to usual care alone ( = 81) or usual care plus a coach-led group ( = 79) or self-directed individual ( = 81) intervention, stratified by baseline body mass index (BMI) category. Results. Participants with baseline BMI 35+ had greater reductions in mean BMI, body weight (as percentage change), and waist circumference in the coach-led group intervention, compared to usual care and the self-directed individual intervention ( < 0.05 for all). In contrast, the self-directed intervention was more effective than usual care only among participants with baseline BMIs between 25 ≤ 35. Mean weight loss exceeded 5% in the coach-led intervention regardless of baseline BMI category, but this was achieved only among self-directed intervention participants with baseline BMIs < 35. Conclusions. Baseline BMI may influence behavioral weight-loss treatment effectiveness. Researchers and clinicians should take an individual's baseline BMI into account when developing or recommending lifestyle focused treatment strategy. This trial is registered with ClinicalTrials.gov (NCT00842426)

Public Protests and the Risk of Novel Coronavirus Disease Hospitalizations: A County-Level Analysis from California

The objective of this study was to assess the relationship between public protests and county-level, novel coronavirus disease (COVID-19) hospitalization rates across California. Publicly available data were included in the analysis from 55 of 58 California state counties (29 March–14 October 2020). Mixed-effects negative binomial regression models were used to examine the relationship between daily county-level COVID-19 hospitalizations and two main exposure variables: any vs. no protests and 1 or \u3e1 protest vs. no protests on a given county-day. COVID-19 hospitalizations were used as a proxy for viral transmission since such rates are less sensitive to temporal changes in testing access/availability. Models included covariates for daily county mobility, county-level characteristics, and time trends. Models also included a county-population offset and a two-week lag for the association between exposure and outcome. No significant associations were observed between protest exposures and COVID-19 hospitalization rates among the 55 counties. We did not find evidence to suggest that public protests were associated with COVID-19 hospitalization within California counties. These findings support the notion that protesting during a pandemic may be safe, ostensibly, so long as evidence-based precautionary measures are taken

Evaluation of a social determinants of health screening questionnaire and workflow pilot within an adult ambulatory clinic

Background There is increased recognition in clinical settings of the importance of documenting, understanding, and addressing patients’ social determinants of health (SDOH) to improve health and address health inequities. This study evaluated a pilot of a standardized SDOH screening questionnaire and workflow in an ambulatory clinic within a large integrated health network in Northern California. Methods The pilot screened for SDOH needs using an 11-question Epic-compatible paper questionnaire assessing eight SDOH and health behavior domains: financial resource, transportation, stress, depression, intimate partner violence, social connections, physical activity, and alcohol consumption. Eligible patients for the pilot receiving a Medicare wellness, adult annual, or new patient visits during a five-week period (February-March, 2020), and a comparison group from the same time period in 2019 were identified. Sociodemographic data (age, sex, race/ethnicity, and payment type), visit type, length of visit, and responses to SDOH questions were extracted from electronic health records, and a staff experience survey was administered. The evaluation was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Results Two-hundred eighty-nine patients were eligible for SDOH screening. Responsiveness by domain ranged from 55 to 67%, except for depression. Half of patients had at least one identified social need, the most common being stress (33%), physical activity (22%), alcohol (12%), and social connections (6%). Physical activity needs were identified more in females (81% vs. 19% in males, p \u3c .01) and at new patient/transfer visits (48% vs. 13% at Medicare wellness and 38% at adult wellness visits, p \u3c .05). Average length of visit was 39.8 min, which was 1.7 min longer than that in 2019. Visit lengths were longer among patients 65+ (43.4 min) and patients having public insurance (43.6 min). Most staff agreed that collecting SDOH data was relevant and accepted the SDOH questionnaire and workflow but highlighted opportunities for improvement in training and connecting patients to resources. Conclusion Use of evidence-based SDOH screening questions and associated workflow was effective in gathering patient SDOH information and identifying social needs in an ambulatory setting. Future studies should use qualitative data to understand patient and staff experiences with collecting SDOH information in healthcare settings

Combined optical coherence tomography and hyperspectral imaging using a double-clad fiber coupler

This work demonstrates the combination of optical coherence tomography (OCT) and hyperspectral imaging (HSI) using a double-clad optical fiber coupler. The single-mode core of the fiber is used for OCT imaging, while the inner cladding of the double-clad fiber provides an efficient way to capture the reflectance spectrum of the sample. The combination of both methods enables three-dimensional acquisition of the sample morphology with OCT, enhanced with complementary molecular information contained in the hyperspectral image. The HSI data can be used to highlight the presence of specific molecules with characteristic absorption peaks or to produce true color images overlaid on the OCT volume for improved tissue identification by the clinician. Such a system could be implemented in a number of clinical endoscopic applications and could improve the current practice in tissue characterization, diagnosis, and surgical guidance

Examining the Influence of Care Processes and Clinical Engagement on Disparities in Blood Pressure Control

Nearly half of all adults in the United States (U.S.) have high blood pressure (BP) and despite the availability of effective and affordable medications, it is often very challenging for people to achieve BP control this in turn raises the risk of stroke, myocardial infarction and heart failure. This dissertation examines the role that healthcare inequities can play for historically marginalized patient groups that experience persisting disparities in BP control. It is unclear how suboptimal care as it related to care processes involved in the treatment of hypertension (HTN), or healthcare inequities, may differentially impact observed disparities in BP control. Our goal for these analyses will be both descriptive and inferential. We will aim to conduct an in-depth examination of contributors to disparities in uncontrolled hypertension from the perspective of healthcare processes and clinical care management. We use electronic health record data from real-world health systems to examine, first, factors associated with high performing clinical sites for BP control among Black individuals. Next, we examine how different patients may engage with primary care and what that might mean for their BP control outcomes. Finally, we examine whether clinical engagement trajectories most closely resembling the established paradigm for sequential “diagnosis, treatment and control” more or less likely among historically marginalized patient groups, at 24-months post-diagnosis. While upstream societal and social inequities undoubtedly play a major role in healthcare inequities and health disparities, health care plays a crucial role in addressing disparities in BP control as it is a system that can be modified and optimized by leveraging existing quality improvement infrastructure within a healthcare system and the greater healthcare ecosystem

Learning health system, positive deviance analysis, and electronic health records: Synergy for a learning health system.

INTRODUCTION: Over the past decade, numerous efforts have encouraged the realization of the learning health system (LHS) in the United States. Despite these efforts, and promising aims of the LHS, the full potential and value of research conducted within LHSs have yet to be realized. New technology coupled with a catalyzing global pandemic have spurred momentum. In addition, the LHS has lacked a consistent framework within which best evidence can be identified. Positive deviance analysis, itself reinvigorated by recent advances in health information technology (IT) and ubiquitous adoption of electronic health records (EHRs), may finally provide a framework through which LHSs can be operationalized and optimized. METHODS: We describe the synergy between positive deviance and the LHS and how they may be integrated to achieve a continuous cycle of health system improvement. RESULTS: As we describe below, the positive deviance approach focuses on learning from high-performing teams and organizations. CONCLUSION: Such learning can be enabled by EHRs and health IT, providing a lens into how digital clinical interventions are successfully developed and deployed

Kinetics of Droplet Wetting Mode Transitions on Grooved Surfaces: Forward Flux Sampling

The wetting configuration of a liquid droplet on a rough or physically patterned surface is typically characterized by either the Cassie wetting mode, in which the droplet resides on top of the roughness, or the Wenzel mode, in which the droplet penetrates into the roughness. For a fixed surface topology and droplet size, one of these modes corresponds to the global free-energy minimum. However, the other state is often metastable and long-lived due to a free-energy barrier that hinders the transition between the two wetting states. Metastable wetting states have been observed experimentally, and we also observe them in molecular dynamics (MD) simulations of a droplet on a grooved surface. Using forward flux sampling, we study the kinetics of the Cassie to Wenzel and Wenzel to Cassie transitions for two-dimensional droplets on periodically grooved substrates. The global-minimum wetting states that emerge from our nanoscale MD approach are consistent with those predicted by a macroscopic model based on free energy minimization. We find that the free-energy barriers for these transitions depend on the droplet size and surface topology. A committor analysis indicates that the transition-state ensemble consists of droplets that are on the verge of initiating/breaking contact with the substrate at the bottom of the grooves

Learning health system, positive deviance analysis, and electronic health records: Synergy for a learning health system

Abstract Introduction Over the past decade, numerous efforts have encouraged the realization of the learning health system (LHS) in the United States. Despite these efforts, and promising aims of the LHS, the full potential and value of research conducted within LHSs have yet to be realized. New technology coupled with a catalyzing global pandemic have spurred momentum. In addition, the LHS has lacked a consistent framework within which “best evidence” can be identified. Positive deviance analysis, itself reinvigorated by recent advances in health information technology (IT) and ubiquitous adoption of electronic health records (EHRs), may finally provide a framework through which LHSs can be operationalized and optimized. Methods We describe the synergy between positive deviance and the LHS and how they may be integrated to achieve a continuous cycle of health system improvement. Results As we describe below, the positive deviance approach focuses on learning from high‐performing teams and organizations. Conclusion Such learning can be enabled by EHRs and health IT, providing a lens into how digital clinical interventions are successfully developed and deployed

PreManage ED™ Evaluation in Hospitals of Alameda County, California

Background: In medically underserved markets, frequent utilization of the emergency department for nonurgent reasons suggests inadequate access to ambulatory care and contributes to suboptimal patient outcomes. Hospital-based interventions are challenging to implement because any single hospital has a limited view of a patient’s health story. To address this issue, PreManage ED™ (PMED), a data-sharing platform, has been implemented in 6 hospitals in Alameda County in Northern California –– 4 Sutter facilities and 2 Alameda Health System facilities. In the initial stage of the evaluation, we characterized PMED use and assessed user acceptance. Methods: In this study, we defined the population to be anyone with at least one hospital visit to a PMED-participating Sutter facility in the past 30 days, and examined patient emergency department use from May 30, 2016, to August 28, 2016, at the 6 participating hospitals. Using PMED and electronic health record (EHR) data, we recorded application usage and measured volume of high utilizers (defined as 3+ encounters in 30 days at any of the participating facilities). Results: During the study period, based on EHR, 47,455 patients made 49,453 encounters at the 4 Sutter Health emergency departments. PMED identified all encounters plus an additional 690 (1.4%) not found in the EHR. From these patients, PMED flagged 4,633 (10%) as high utilizers and identified 528 (11%) of these as having a care guideline in place at 1 of the 6 facilities. Among the 3 physicians, 2 case managers, 1 nurse and 4 other staff members who completed the questionnaire, at least 80% responded favorably to all questions concerning usefulness, at least 70% responded favorably to questions of ease of use, and at least 70% had a favorable attitude towards PMED. Conclusion: Data indicate that PMED is successful at alerting providers to high utilizers in the emergency department, and there is no evidence that any were missed. Further, PMED was able to flag those with a care guideline in place at any facility, thus reducing the chance that extraneous care guidelines be created. Users had high rates of acceptance, which indicates a high chance of success for implementation of interventions relying on PMED