Browsing by Subject "Health Services Accessibility"
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Item Assessment of Dermatology Clinic Resources at Safety-Net Hospitals: Results from a National Survey(2017-03-24) Malviya, Neeta; Chong, Benjamin F.; Pandya, Amit; Jacobe, HeidiBACKGROUND: The extent of resources available to outpatient dermatology clinics at safety-net hospitals providing care to the underserved is not well characterized. Identification of resource gaps can direct strategies that improve dermatologic care to this population. OBJECTIVE: To determine the state of resources at safety-net dermatology clinics. We hypothesized that staffing and specialty services at safety-net hospital dermatology clinics were suboptimal, and that these clinics have long patient wait-times and high no-show rates. METHODS: A cross-sectional survey was conducted to assess resources at outpatient dermatology clinics in safety-net hospitals affiliated with US dermatology residency programs. Surveys consisting of 42 questions were sent via e-mail to the chiefs of outpatient dermatology clinics at 50 safety-net hospitals. The survey was administered between July and October 2016. RESULTS: 31 (62%) safety-net dermatology clinics participated in the survey. The median wait time for the third next available appointment for a new and follow-up patient was 45 (interquartile range: 30-90) days and 30 (16.5-55) days, respectively. The median no-show rate was 30% (24.5-35). Clinics reported median ratios of 3 providers to 1 nurse (1.75-4), and 2 providers to 1 medical assistant (2-4). 58.1% utilized non-paid dermatology attendings. 93.5% offered dermatopathology and pediatric dermatology services, while 41.9% had on-site Mohs surgery. CONCLUSION: Patients face long wait times and no-show rates are high, with suboptimal provider to support staff ratios. Most clinics had access to dermatology subspecialty care, such as pediatric dermatology, and dermatopathology. Expanding staffing, improving patient no-show rates, and use of teledermatology could improve access to dermatologic care in safety-net hospital systems.Item Decentralizing outpatient diabetes care: a collaborative approach(2020-09-18) Gunasekaran, UmaItem Decreased Emergency Department Utilization by Lower Socioeconomic Status Population as a Result of the COVID-19 Pandemic(2022-05) Plumber, Arifa; Chang, Mary; Marshall, Amanda L.; Idris, Ahamed H.BACKGROUND: The SARS-CoV-2 (virus which causes COVID-19) pandemic has resulted in lower emergency department (ED) volumes. It precipitated business and school closures along with the implementation of physical distancing measures, which culminated in a Shelter-in-Place Order (SIPO) issued for a major urban area county in March 2020. OBJECTIVE: The objective of this study was to determine the effect of the COVID-19 pandemic on access to health care by patients of different socioeconomic status by examining differences in ED volume by zip code stratified by the SocioNeeds Index, a measure of socioeconomic need correlated with poor health outcomes. Our hypothesis was that decrease in patient visits due to the SIPO was not uniform across Dallas County but was based on socioeconomic need and proximity to Parkland's ED. METHODS: This retrospective chart review examines whether there was a quantitative change in patient visits to an urban, tertiary county hospital (Parkland or PMH) ED from 2019-2020 by zip code. The inclusion criterion was any ED visit from a patient with a zip code within Dallas County, and the exclusion criterion was any blank, alphanumeric, or PO box zip codes including zip codes located outside of Dallas County. The SocioNeeds Index, which rates each zip code by demographic factors relative to others in the county, was used as a proxy for the socioeconomic status of residents of each zip code. We mapped daily patient visits by zip code for four phases: Phase 1 was the three months preceding the first COVID-19 case's announcement in Dallas, Phase 2 began with the first COVID case, Phase 3 encompassed when the SIPO was in effect for Dallas County, and Phase 4 comprised the three months following the expiration of the SIPO. We compared this data to records over the same time period from the previous year to control for seasonal variation in the absence of a pandemic. RESULTS: There were 275,756 ED patient visits included in this study. We identified a statistically significant decrease in ED visits among patients from all zip codes during the pandemic: 24% between Phase 1 and 4 (p<0.0001) in 2020. Additionally, there was a decrease in visits after the first case in Dallas: Phase 2 (-14%, p<0.0001), Phase 3 (-41%, p<0.0001) and Phase 4 (-25%, p<0.0001) when compared to 2019 but an increase in visits (36%, p< 0.0001) in 2020 once the SIPO expired. Zip codes with highest SNI ranks (highest needs communities) were found to have greater reductions in visits during the SIPO and more sluggish recoveries after the expiration of the SIPO in comparison to those zip codes with the lowest needs. An examination of the geographic distribution of self-reported zip codes indicated that most communities in Dallas County saw a reduction in patient visits over Phases 2 and 3 (especially zip codes further from the ED) and an increase in visits during Phase 4 although not to pre-pandemic values. These changes, however, were not uniform across the county and were tied to socioeconomic factors and proximity of residence to PMH. CONCLUSION: Our hypothesis was supported by the results obtained: a significant decrease in ED visits was observed during the pandemic relative to a non-pandemic year among patients in most zip codes except those with the highest socioeconomic status, suggesting that the threat of the virus and SIPO deterred patients disproportionately from the higher socioeconomic needs communities from accessing healthcare. These results could have implications for future pandemic public health messaging and targeted outreach to communities with barriers to healthcare access.Item E-consults: an approach to improve access to specialty care(2017-09-15) Mayorga, Christian A.Item Evaluating the Effectiveness of a Teledermatology on System Utilization in a Safety-Net Public Health and Hospital System(2020-05-01T05:00:00.000Z) Wu, Lawrence Wen; Dominguez, Arturo R.; Chong, Benjamin F.; Hynan, Linda S.BACKGROUND: Teledermatology is a potentially useful and cost-effective modality for triaging patients in a primary care setting. However, the effect of teledermatology on health system utilization in a safety net hospital system has not been studied. OBJECTIVE: To determine the effect teledermatology on dermatological-problem related healthcare system utilization. Our hypothesis was that teledermatology would be associated with decreased dermatological-problem related healthcare system utilization. METHODS: The design is a retrospective cohort study comparing patients referred by Parkland Community Outpatient Clinics (COPC) primary care providers for dermatology evaluation during Fiscal Year 2016 (October 1st, 2015 and September 30th, 2016): 1) Patients evaluated through SAF teledermatology, 2). Patients from COPCs that did not have teledermatology available to them and were referred for a face-to-face visit. 3.) Patients from the COPCs in cohort 1 that had teledermatology available but were referred for a face-to-face visit instead. Data from 6 months prior to originating encounter and 18 months post originating encounter were measured. Statistical analysis with binary categorical repeated measures for a saturated model analyzed for significant variations in utilization. Health system utilization was measured at primary care clinics, dermatology and other specialty care clinics, urgent care clinic, and Emergency Room visits at Parkland Memorial Hospital. We compared the demographic, diagnostic, and clinical management data of the 3 cohorts. We measured sex, age, race/ethnicity, health care coverage, and diagnostic category for all 3 cohorts. The patients were classified as either having an inflammatory or neoplastic skin condition. The primary outcome was the percentage of patients with at least 1 visit in a 6-month time interval. Secondary outcomes measured were referral treatment capture rate, time to definitive treatment, and teledermatology response time. RESULTS: There were 809 total participants comprising the 3 cohorts, which were 64% female and with a mean age of 50.4 years. Baseline characteristics among groups were similar except for a higher proportion of eczematous conditions in the teledermatology cohort. Over the 24 month study period, total health system utilization, defined as the percentage of patients with at least 1 visit in each 6-month time interval measured over 4 intervals, was significantly greater for patients with inflammatory conditions receiving a face-to-face referral from both teledermatology and non-teledermatology-utilizing clinics compared to patients receiving teledermatology consults. There are no significant differences all combined, dermatology, and PCP clinic utilization between the face-to-face referrals from teledermatology and non-teledermatology-utilizing groups. CONCLUSION: This study provides evidence for the potential effectiveness of teledermatology improving access to care and reducing system utilization for patients with an inflammatory skin condition in a large safety-net public hospital system. There was no significant difference in utilization in patients with a neoplastic condition. Our results suggest additional benefits of utilizing a teledermatology system in a safety net hospital system.Item Getting to 100% insurance coverage: lessons from Canada's single-payer health insurance system(2021-10-29) Cram, PeterItem High value health care: the role of palliative care(2021-01-22) Kutner, JeanItem How can a safety net be the catalyst for creating a healthier community?(2012-09-11) Anderson, Ron J.The Parkland Health & Hospital System is one of the Nation's largest and most complicated safety net institutions. It provides care for over 40,000 admissions, 12,000 deliveries and 1.3 million outpatient and ED visits per year. It is a Level 1 Trauma and Burn Center, a Level 3 Neonatal Unit (one of the largest in the US), and it is part of the UTSW campus NCI designation for Cancer Care. Parkland has achieved many firsts as an innovator of the safety net, but must now rise to the challenges of "moving upstream" to invest in prevention, health promotion, earlier interventions in primary care, and care management in a fashion that is lead by a spirit of servant leadership, evidence based practice (competency) and the ethical tenets of beneficience, nonmaleficience, promotion of autonomy, distributive and social justice. The next evolutionary steps for Parkland involve collaboration with our competitors (so-called Co-optician) through a 1115 Medicaid Waiver to find and address gaps in service delivery for our most vulnerable residents. It requires the discipline to study health disparities, population health outcomes and the impact of the socioeconomic determinants of health. We have and will continue to use appreciate inquiry, dialogue and "deep listening" to guide us so as to avoid paternalism or exploitation and get the community's buy-in and participation. Enormous strength, innovation and vitality can come from the community's partnership with the safety net to effect health delivery reform at the local and regional level. We can, and must, do better by being better stewards of scarce resources, by putting quality and safety in both process and outcome at the forefront of our efforts. These efforts must be patient and community centered, not just provider centered to achieve an accountable, sustainable and affordable future.Item How the health and rights framework evolved and how that affects clinical research(2020-01-14) Inrig, StephenWhile the World Health Organization's (WHO) constitution defined "the highest attainable standard of health" as "a fundamental right of every human being" as early as 1946, it was not until the late 1980s, amidst the AIDS pandemic, that WHO representatives developed the "Health and Human Rights Framework" as a lens through which to understand and address inequalities in the global burden of disease. While the concept itself met with broad and rapid approval, several factors made it difficult to operationalize in health delivery. Beginning in the early 2000s, however, practitioners have made important strides in operationalizing these concepts in ways that have positively influenced local and global health delivery. This talk explores the development of "health and human rights" concepts over time, giving particular attention to the implications they have on drug research, clinical research ethics, the pharmaceutical industry, and the right to access medicines.Item Identifying Barriers and Solutions to Psychotherapy in Adults with Depression(2019-07-12) Small, Hunter Boone; Greer, Tracy L.; McClintock, Shawn Michael; Fischer, Noelle M.; Carmody, Thomas; Trombello, Joseph M.Research has suggested that adults with depression face a variety of intrinsic and extrinsic barriers to psychotherapy, which results in low initiation rates for psychotherapy. These barriers have been characterized in some detail, but to our knowledge, there has been no previous examination of how adults with depression initiate psychotherapy after first encountering barriers. The primary goals of this study were to assess barriers to psychotherapy endorsed by adults with depression currently receiving psychotherapy and to design and implement a new questionnaire (Overcoming Barriers to Psychotherapy) to examine what solutions adults with depression perceive as helpful in overcoming barriers to initiating psychotherapy. This study also aimed to evaluate the respective impacts of 1) demographic variables (race, ethnicity, income), 2) depression symptom severity, and 3) psychosocial functioning on endorsement of intrinsic and extrinsic barriers. An online survey was administered to examine sociodemographic information, depression symptom severity, psychosocial functioning, barriers to psychotherapy, and solutions to barriers in 132 adults with depression currently receiving psychotherapy recruited from a variety of outpatient settings across the Dallas-Fort Worth metroplex. Results revealed that a higher percentage of extrinsic relative to intrinsic solutions were endorsed for intrinsic barriers, and a higher percentage of intrinsic relative to extrinsic solutions were endorsed for extrinsic barriers. Results indicated that barriers to psychotherapy are more frequently resolved by solutions of different types (e.g., intrinsic barriers resolved by extrinsic solutions). Resolution of barriers to psychotherapy may require adults with depression to rely on solutions that enable them to work around the core difficulty posed by barriers. Both depression symptom severity and psychosocial impairment were associated with overall higher endorsement of intrinsic and extrinsic barriers. A lack of racial and ethnic diversity in the recruited sample prevented examination of the impact of race and ethnicity on endorsement of extrinsic barriers. Future research is warranted to establish psychometrics of the novel study measure to assess solutions to barriers to psychotherapy, and to administer the measure in a more racially and ethnically diverse sample. The solutions to barriers to psychotherapy discussed in this study may help adults with depression to overcome barriers and initiate psychotherapy.Item Integrated Model for Hepatitis C Screening and Linkage to Care in Homeless Population(2019-01-22) Xia, Amy; Balakrishnan, Naveen; Tran, Minh; Pagels, PattiBACKGROUND: Hepatitis C is a major cause of morbidity and mortality as up to 46% of people infected with Hepatitis C develop cirrhosis and up to 20% develop hepatocellular carcinoma. Over the past year, a new initiative through the DFW Hep B Free organization at the University of Texas Southwestern (UTSW) was formed to target Hepatitis C among the homeless population, starting with screening at the Union Gospel Mission's Calvert Place homeless shelter. This underserved population is vulnerable because of inadequate healthcare access and resources, in addition to other risk factors such as former incarceration and injection drug usage. The main barriers to care for a transient, homeless population are 1) their lack of access to regular healthcare and screenings, 2) their inability to receive screening results via phone or mail, and 3) the difficulty of linking patients to affordable, accessible healthcare and treatment. METHODS: Our model integrates a student-run screening program, an on-site clinic at the shelter, and specialized hepatology services at Parkland Health Hospital System (PHHS), a local safety-net provider, to maximize the strengths that each component offers. Using OraQuick Rapid Hepatitis C Virus (HCV) tests, which screen for HCV antibodies and produce results in 20 minutes, we can deliver test results and provide counseling on the screening day. Under an IRB through a faculty hepatologist, patients that test positive are registered into Parkland Hospital's hepatitis surveillance program. The program then provides patient navigation, financial support, and treatment. RESULTS: On average, the HCV antibody positive rate from screenings at Calvert Place is 12.7% (N=126). 100% of positive patients were contacted with their result. For patients who tested positive (n=16), 2 (12.5%) did not need care (resolved HCV). From the 14 of 16 that had active HCV infections, 50% were lost to follow up and 50% were linked to care at Parkland hepatology clinic. CONCLUSION: Through our integrated model, we have created the foundations for a sustainable system to break down barriers to care while ultimately connecting HCV-positive homeless patients to treatment.Item It's just not the same: the crisis of sickle cell disease(2021-07-23) Nero, AleciaItem Palliative Care for Refugees and Asylees: A Systematic Review and Single-Institution Analysis of Healthcare Utilization(2021-05-01T05:00:00.000Z) Tao, Zoe Renee; Gimpel, Nora; McGregor, Tamara; Dussel, Veronica; Wang, WinnieBACKGROUND: Palliative care addresses physical, psychosocial, and spiritual dimensions of suffering. Palliative care may have significant impact for populations such as refugees and asylees, who flee conflict and persecution and may have a high burden of chronic and life-limiting illness. OBJECTIVES: The goal of this systematic review was to synthesize existing observational studies on palliative care for refugees and asylees. Additionally, the goal of the accompanying single-institution review was to analyze healthcare access and utilization in a safety net refugee outreach clinic. METHODS: A systematic review was undertaken using PRISMA guidelines. Six full-length articles were selected for review. National Consensus Project palliative care domains were utilized for thematic analysis. A retrospective chart review was undertaken for refugee patients establishing care between 2014-2016. Data was extracted on demographics, insurance status, and outpatient clinic and emergency department (ED) visits. RESULTS: Articles selected for systematic review covered heterogeneous research methodology and refugee populations, with all investigators originating from high-income nations. Identified Challenges and Practices to palliative care encompassed all NCP domains, and Recommendations for palliative care for refugees and asylees encompassed all but the Ethical and Legal aspects of care. In our single-institution review, we found that most refugee patients were able to maintain healthcare insurance and attended follow-up primary care visits, with few relying on the ED for primary care. CONCLUSIONS: Greater attention and funding should be allocated to lower-income nations for addressing refugee palliative care needs. Increased focus should be given to studying ethical, legal, and systemic barriers to care. Outpatient care in safety net hospitals may be an important means of addressing refugee and asylee palliative care in well-resourced settings.Item Resource-Poor Resuscitation: Approach to Cardiac Arrest in a Developing Country(2017-03-24) Hoerster, Valerie Ann; Mihalic, Angela; Chang, Mary; Idris, Ahamed H.BACKGROUND: As part of its Advanced Cardiac Life Support (ACLS) guidelines, the American Heart Association (AHA) recommends immediate cardiac monitoring for adults in cardiac arrest and, in cases of Ventricular Fibrillation (VF) or pulseless Ventricular Tachycardia (pVT), early administration of electric shocks with a cardiac defibrillator. In the United States, cardiac monitors and defibrillators are available in all hospitals for use during in-hospital cardiac arrest. Furthermore, the use Automated External Defibrillators (AEDs) is encouraged for out-of-hospital arrests. In geographically remote, resource-limited areas, cardiac defibrillators may not be readily available. OBJECTIVE: This paper aims to evaluate the availability and efficacy of in-hospital cardiac defibrillation and discuss the potential global health goal of improving defibrillator access in Peru. METHODS: An online literature search was performed looking for key words. Retrieved articles, their references, and past literature reviews on the subject were screened for relevance. RESULTS: In the United States, overall survival to discharge for cardiac arrest is low; however, there is well-established evidence that the use of ACLS guidelines improves outcomes for cardiac arrest. Patients who present in shockable rhythms are more likely to survive than those in non-shockable rhythms when a defibrillator is available. Identification of the precipitating acute medical illness is a moderate predictor of both initial rhythm and chance of survival. In Peru, etiologies of in- hospital cardiac arrest is somewhat different. Few scientific data are available for cardiac arrest outcomes or defibrillator availability in Peru. CONCLUSION: Physicians practicing international medicine must recognize and adapt to differences in patient demographics and resource availability. In Peru and similar lesser-developed countries, basic public health need such as potable water and vaccines remain a priority. Efforts to improve outcomes for in-hospital arrest should focus on teaching high-quality CPR. When sufficient infrastructure is in place, improving access to defibrillators would be an appropriate next step.Item The State of Anesthesia Practice in Sub-Saharan Africa: Statistics, Case Studies, and Ways Forward(2020-03-12) Choo, Vincent; Mihalic, Angela; Ambardekar, Aditee; Tao, WeikeBACKGROUND: There is substantial need for additional anesthesia resources in Sub-Saharan Africa. In this region of the world, maternal and surgical mortality are high. Non-coincidentally, the number of anesthesiologists and anesthesia providers is low and provision of medications and other basic supplies is lacking. This thesis aims to describe anesthesia practice in Sub-Saharan Africa using statistics and case studies, present current initiatives already in place to improve access to care, and suggest other strategies that may improve anesthesia capacity in the future. OBJECTIVE: Non-adherence to minimum guidelines from the World Federation of Societies of Anaesthesiologists (WFSA) for anesthesia practice in the areas of staffing and physical resources is associated with poor anesthesia and surgical outcomes, which could be improved by improving training programs and increasing available physical resources. METHODS: A Pubmed literature search was performed using key words. Relevant articles from these searches were retrieved and references from these articles were also examined. Websites for organizations mentioned in the articles were queried. Websites containing factual information about individual Sub-Saharan African countries were consulted. The information found was grouped by themes and presented. RESULTS: The numbers of anesthesiology providers in Sub-Saharan Africa are insufficient to provide safe anesthesia care. A lack of medications and supplies and inadequate technology, including monitoring equipment, contribute to the problem. The situation in Ghana, Mozambique, Liberia, and Rwanda helps to illustrate this problem. Initiatives such as the founding of the World Federation of Societies of Anaesthesiologists and Lifebox, as well as formalizing task-sharing, have attempted to improve the situation. Continuing to ensure that equipment adapted to the reality of the practice environment in the region and careful planning and coordinating of future humanitarian projects can help improve anesthesia care provided in the region. CONCLUSION: The current state of anesthesia in Sub-Saharan Africa is insufficient to meet population needs. The causes are multi-factorial and include issues providing adequate human and material resources. Establishing strong, coordinated humanitarian efforts on the ground is critical to addressing the problem. Reorganizing manpower to best utilize precious human resources is another way forward. Providing appropriate resources in the form of equipment and medications, as well as encouraging local research, can help provide innovative solutions for the region.Item Transgender medicine: from affirmation to advocacy(2021-05-07) Abramowitz, Jessica