Browsing by Subject "Safety-net Providers"
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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 Benchmarking Surgical Quality: Cholecystectomy at a Safety-Net Hospital(2017-04-03) Byrd, Jacqueline Noelle; Reed, W. Gary; Choti, Michael; AbdelFattah, KareemBACKGROUND: Rates of conversion from laparoscopic to open cholecystectomy in the U.S. have been reported to be 5 to 10%. This study aims to benchmark conversion rate and identify preoperative factors that are predictive of conversion at a large, safety-net hospital. OBJECTIVE: To identify preoperative factors predictive of conversion from laparoscopic to open cholecystectomy for improved risk-adjustment of conversion as a quality indicator METHODS: The data for all patients who underwent laparoscopic and converted cholecystectomies from 2007 to 2015 were retrospectively abstracted from the electronic medical records of a public, teaching hospital. Variability in conversion rate was assessed over the time period captured in the study cohort. Univariate and multivariate logistic regression were used to identify the factors that are significantly associated with conversion. RESULTS: We identified 9,008 patients: 84.0% were female, 77.8% were Hispanic, and 75.2% were uninsured, with a median age of 37 years old. American Society of Anesthesiologists (ASA) 3 and 4 constituted 10.5% of patients. The majority (81.8%) of cases were performed between 7 a.m. and 3 p.m. There were 451 converted cholecystectomies across all case types - a conversion rate of 5.0%. On multivariable analysis, predictors of conversion were male gender (odds ratio (OR)=2.68; 95% confidence interval (CI): 2.09-3.43), increased age (OR=1.02; 95% CI: 1.02-1.03), diabetes mellitus (OR=1.42; 95% CI: 1.04-1.95), increased BMI (OR=1.018; 95% CI: 1.001-1.03), increased WBC count (OR=1.034; 95% CI: 1.01-1.06), and increased alkaline phosphatase (OR=1.002; 95% CI: 1.001-1.003). CONCLUSION: This is the largest single institution study to present a risk predictor for cholecystectomy conversion. The proposed risk score includes gender, diabetes mellitus, age, case type, BMI and two lab values - white blood cell count and alkaline phosphatase. These variables are readily available to providers pre-operatively, enabling application of this risk score to patient education and surgical planning.Item Enhanced Recovery Pathway for Colorectal Surgery Improves Outcomes in Private and Safety-Net Settings(2018-03-26) Roberts, Taylor Jean; Reed, W. Gary; Rabaglia, Jennifer; Anandam, JoselinBACKGROUND: Although it is known that Enhanced Recovery Pathways (ERP) decrease length of stay (LOS) and improve outcomes in colorectal surgery, these studies predominantly represent the private health care setting. There is a paucity of information regarding the effectiveness of ERP in the public arena, comprised of the under and uninsured who may have different social determinants of health. This study aims to compare the effect of an ERP on LOS and readmission for colorectal surgery across the private and safety-net settings in a large urban academic medical center. METHODS: A multidisciplinary panel of experts utilized professionally recognized standards and evidence-based best practice to create a comprehensive ERP for elective colorectal surgery. The ERP included standardization of patient education, optimization of co-morbidities, multimodal analgesia, carbohydrate loading, intraoperative goal-directed fluid therapy, minimization of opioids, and early ambulation, removal of urinary catheter, and resumption of diet. There were no social interventions. The ERP was implemented in the safety-net hospital (SNH) in September 2014 and the private hospital (PH) in December 2014. Process and outcome metrics from 100 consecutive patients having surgery in the 18 months prior to ERP at each institution were compared to a similar group post ERP. Surgeons and discharge criteria remained constant. Primary endpoints were LOS and readmissions. RESULTS: Patients in the post-ERP cohorts at both facilities were significantly older than pre-ERP (p=0.047, 0.034), with no significant difference in gender and BMI. The rate of open versus minimally invasive was similar at SNH (p=0.067), while more post-ERP patients at PH underwent open surgery (p=0.002). 96% of PH patients were funded through private insurance or Medicare, verses only 6% at the SNH. ERP implementation reduced total LOS at both facilities, while readmission and reoperation remained constant. LOS at PH fell from 8.1 to 5.9 days (p=0.028), and at SNH from 7.0 to 5.1 days (p=0.004). 30-day all-cause readmission and return to surgery were stable (PH p=0.634; SNH p=1) and (PH p=0.610; SNH p=0.066) respectively. Surgical site infection rate was unchanged at PH (p=0.485) and significantly reduced at SNH (p=0.021, OR 0.39). Mean time to ambulation and mean time to first bowel movement were reduced at SNH (p=0.002, 0.001). Mean time to resumption of solids was reduced at both PH and SNH (p<0.001). CONCLUSIONS: Implementation of ERP is similarly effective across private and safety net settings, without interventions to address social determinants of health. Both cohorts experienced reduced LOS without increasing readmission or reoperation. The data suggest ERP may have a more dramatic impact on outcomes in the safety net setting, perhaps through standardization in a group with more varied baseline health status. Utilization of ERP appears to be advantageous for all populations regardless of funding.Item 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.