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Lack of timely access to specialty care is a significant problem among disadvantaged populations, such as those served by the Los Angeles County Department of Health Services. In 2012 the department implemented an electronic system for the provision of specialty care called the eConsult system, in which all requests from primary care providers for specialty assistance were reviewed by specialists. In many cases, the specialist can address the primary care provider's question via an electronic dialogue, thereby eliminating the need for the patient to see a specialist in person. We observed rapid growth in the use of eConsult: By 2015 the system was in use by over 3,000 primary care providers, and 12,082 consultations were taking place per month, compared to 86 in the third quarter of 2012. The median time to an electronic response from a specialist was one day, and 25 percent of eConsults were resolved without a specialist visit. Three to four years after implementation, the median time to a specialist appointment decreased significantly, while the volume of visits remained stable. eConsult systems are a promising and sustainable intervention that could improve access to specialist care for underserved patients.

In facing the challenge of taking better care of more patients at lower cost, health care organizations can learn from safety-net systems: one innovation prompted by clinical exigencies, eReferral, offers a new model for integrating primary and specialty care. Health care reform has generated new pressures for the U.S. health care system to take better care of more patients at lower cost. Whereas these challenges are relatively new in the fee-for-service private sector, safety-net systems have perennially had to “do more with less”; innovations in this arena have generally been prompted by clinical exigencies rather than the need to gain market share or maximize revenues. 1 We believe that one such innovation — eReferral — can serve as a new model for integrating primary and specialty care. In 2005, San Francisco General Hospital (SFGH) was grappling with a challenge familiar . . .

A growing body of research supports the efficacy of text messaging programs to help tobacco users quit, but texting as a strategy for recruiting tobacco users into other evidence-based cessation services, such as quitline coaching, is less well understood. Texting to offer treatment could increase use of cessation resources, an important consideration for health systems trying to improve their quality metric performance on tobacco assessment and counseling. The aim of this study is to compare the effects of text messages offering free quitline coaching or free nicotine patches on engagement with quitline services by patients identified in electronic health records as unassisted tobacco users. Participants (N=4171) were adult patients of Los Angeles County Department of Health Services who had had a clinical visit in the past 12 months, were willing to receive text messages, and were identified as unassisted tobacco users (ie, those with no documented advice or assistance to quit in the past 24 months). They included 3139 English speakers and 1032 Spanish speakers. Participants were stratified by language, then randomly assigned to one of two groups. Group 1 received a text offering free quitline coaching. Group 2 received a text offering free nicotine patches. The texts were sent in April and May 2022. Outcome measures were the proportions calling the quitline and receiving evidence-based cessation treatments. Data were analyzed in 2025. Overall, 1.5% (61/4171) of participants called the quitline, including 1.3% (28/2086) in Group 1 and 1.6% (33/2085) in Group 2, and 0.5% (21/4171) received treatment, including 0.4% (8/2086) in Group 1 and 0.6% (13/2085) in Group 2. There was no significant difference either in calls (P=.52) or receiving treatment (P=.29). However, Spanish speakers were significantly more likely to call than English speakers, 2.3% (24/1032) vs 1.2% (37/3139), respectively (P=.008), and engaged in treatment at approximately twice the rate of English speakers, 0.9% (9/1032) vs 0.4% (12/3139), although the latter difference was nonsignificant (P=.07). A single text was effective in connecting unassisted tobacco users with evidence-based quitline services for both English and Spanish speakers, but especially the latter. A population health approach of reaching out to tobacco-using patients outside clinical visits can meaningfully supplement provider referral. Research is needed on ways to increase the population health impact of this strategy.

Background Hepatitis C (HCV) knowledge is limited in injection drug users (IDU). Vulnerable populations including IDUs are disproportionally affected by HCV. Effective HCV education can potentially reduce disparity in HCV prevalence and its outcome in this population. Aim This study aimed to assess the impact of formal HCV education and factors associated with improved HCV knowledge in the vulnerable population. Methods Over 18 months, 201 HCV-infected patients underwent a 2-h standardized education and completed demographic and pre- and post-education questionnaires. Results Patient characteristics were: 69% male, mean age 49 ± 10, 49% White (26% AA, 10% Latino), 75% unemployed, 83% high school education and above, 64% were IDU, and 7% were HIV co-infected. On multivariate analysis, baseline knowledge scores were higher in patients with at least a high school education (coef 7.1, p = 0.045). Baseline knowledge scores were lower in African Americans (coef −12.3, p = 0.004) and older patients (coef −0.7, p = 0.03). Following HCV education, the overall test scores improved significantly by 14% (p = 0.0001) specifically in the areas of HCV transmission (p = 0.003), general knowledge (p = 0.02), and health care maintenance (p = 0.004). There was a high compliance with liver specialty clinic attendance following education. Conclusions Formal HCV education is effective in improving HCV knowledge. Although White race, younger age, and higher education were predictors of having more HCV knowledge prior to education, all patients independent of racial background had a significant improvement in their knowledge after education. Therefore, promoting effective HCV education among vulnerable populations may be an important factor in reducing the disparities in HCV disease.

Fiscal and regulatory pressures on public hospitals and academic medical centers (AMC) will likely worsen in coming years, given looming changes to Medicaid and federal research funding. Recently, such pressures threatened to disrupt the 140-year affiliation between the Los Angeles General Medical Center (LA General) and the University of Southern California (USC). We sought to describe lessons learned during a two-year restructuring of this relationship, and to describe the impact of this transformation on patient care. Hospital-wide mortality metrics were extracted from the Vizient Clinical Database and Leapfrog hospital safety scores were retrieved from public releases. Citing increasing fiscal pressure, in March of 2023, USC noticed LA County that it was terminating the existing $170 million per year medical school affiliation agreement (MSAA) that funded >90% of the clinical staffing at LA General. In response, LA General began a national hiring campaign to ensure sufficient staffing irrespective of the outcome of ongoing negotiations. In 21 months, LA General hired 273 physicians, dentists, and allied health professionals across all 19 clinical departments. Meantime, LA General and USC evolved a shared understanding that a blended model of employment best served both organizations. Such a dramatic transformation of workforce in such a short period of time raised concerns about risks to patients. We therefore monitored hospital-wide mortality rate and Leapfrog patient safety scores during the hiring process. However, hospital-wide observed and observed/expected mortality rates significantly declined the quarter after hiring began, and Leapfrog safety scores rose during the hiring period. Public hospitals and AMCs can strengthen their relationships despite ongoing fiscal and regulatory pressures via intentional organization restructuring and cultural transformation. Such transformational efforts may be all the more important at a time of great flux and uncertainty in government funding for clinical care and academic research.

Background Inflammatory bowel disease (IBD) is increasingly common among non-Caucasian populations, but interracial differences in disease characteristics and management are not well-characterized. Aims We tested the hypothesis that disease characteristics and management vary by race among IBD patients in an ethnically diverse healthcare system. Methods A retrospective study of the safety net healthcare system of San Francisco, CA, from 1996 to 2009 was undertaken. Patient records with International Classification of Diseases, 9th Revision (ICD9) codes 555.xx, 556.xx, and 558.xx were reviewed. Adult patients with confirmed IBD diagnoses were included. Interracial variations in disease characteristics and management were assessed broadly; focused between-race comparisons identified specific differences. Results The 228 subjects included 77 (33.4%) with Crohn's disease (CD), 150 (65.8%) with ulcerative colitis, and 1 (0.4%) with IBD, type unclassified. The race distribution included 105 (46.1%) white, 34 (14.9%) black, 35 (15.4%) Hispanic, and 51 (22.4%) Asian subjects. Asians and Hispanics were diagnosed at older ages (41.0 and 37.1 years, respectively) and had shorter disease durations (5.4 and 5.2 years, respectively) than whites (30.5 years at diagnosis and 8.6 years duration, P < 0.05) and blacks (31.7 years at diagnosis and 12.1 years duration, P < 0.05). CD was more common among blacks (50% of subjects) than Asians (25.5% of subjects, P = 0.015). The Montreal classification of IBD was similar among races. Hispanics were less likely than others to be treated with 5-aminosalicylates (5-ASA), immunomodulators, and steroids. Medical and surgical management was otherwise similar among races. Conclusions Modest race-based differences in IBD characteristics exist in this racially diverse healthcare system, but the management of IBD is similar among race groups.

Background Electronic referrals can improve access to subspecialty care in safety net settings. In January 2007, San Francisco General Hospital (SFGH) launched an electronic referral portal that incorporated subspecialist triage, iterative communication with referring providers, and existing electronic health record data to improve access to subspecialty care. Objective We surveyed primary care providers (PCPs) to assess the impact of electronic referrals on workflow and clinical care. Design We administered an 18-item, web-based questionnaire to all 368 PCPs who had the option of referring to SFGH. Measurements We asked participants to rate time spent submitting a referral, guidance of workup, wait times, and change in overall clinical care compared to prior referral methods using 5-point Likert scales. We used multivariate logistic regression to identify variables associated with perceived improvement in overall clinical care. Results Two hundred ninety-eight PCPs (81.0%) from 24 clinics participated. Over half (55.4%) worked at hospital-based clinics, 27.9% at county-funded community clinics, and 17.1% at non-county-funded community clinics. Most (71.9%) reported that electronic referrals had improved overall clinical care. Providers from non-county-funded clinics (AOR 0.40, 95% CI 0.14-0.79) and those who spent ≥6 min submitting an electronic referral (AOR 0.33, 95%CI 0.18-0.61) were significantly less likely than other participants to report that electronic referrals had improved clinical care. Conclusions PCPs felt electronic referrals improved health-care access and quality; those who reported a negative impact on workflow were less likely to agree. While electronic referrals hold promise as a tool to improve clinical care, their impact on workflow should be considered.

BACKGROUND Poor communication between referring clinicians and specialists may lead to inefficient use of specialist services. San Francisco General Hospital implemented an electronic referral system (eReferral) that facilitates iterative pre-visit communication between referring and specialty clinicians to improve the referral process. OBJECTIVE The purpose of the study was to determine the impact of eReferral (compared with paper-based referrals) on specialty referrals. DESIGN The study was based on a visit-based questionnaire appended to new patient charts at randomly selected specialist clinic sessions before and after the implementation of eReferral. PARTICIPANTS Specialty clinicians. MAIN MEASURES The questionnaire focused on the self-reported difficulty in identifying referral question, referral appropriateness, need for and avoidability of follow-up visits. KEY RESULTS We collected 505 questionnaires from speciality clinicians. It was difficult to identify the reason for referral in 19.8% of medical and 38.0% of surgical visits using paper-based methods vs. 11.0% and 9.5% of those using eReferral (p-value 0.03 and <0.001). Of those using eReferral, 6.4% and 9.8% of medical and surgical referrals using paper methods vs. 2.6% and 2.1% were deemed not completely appropriate (p-value 0.21 and 0.03). Follow-up was requested for 82.4% and 76.2% of medical and surgical patients with paper-based referrals vs. 90.1% and 58.1% of eReferrals (p-value 0.06 and 0.01). Follow-up was considered avoidable for 32.4% and 44.7% of medical and surgical follow-ups with paper-based methods vs. 27.5% and 13.5% with eReferral (0.41 and <0.001). CONCLUSION Use of technology to promote standardized referral processes and iterative communication between referring clinicians and specialists has the potential to improve communication between primary care providers and specialists and to increase the effectiveness of specialty referrals.

Rates of inflammatory bowel disease (IBD) appear to be increasing among nonwhite populations outside the United States, but national data describing the incidence and prevalence of IBD are not available for minority patients. The aim of this study was to examine time trends of hospital discharge among minority patients with IBD.MethodsNationally representative data describing hospital discharges were obtained from the National Hospital Discharge Survey for the years 1994 to 2006. Race-specific annual proportions of hospitalizations including a discharge diagnosis of ulcerative colitis and Crohn's disease were calculated. Trends in proportions were assessed for statistical significance using the extended Mantel–Haenszel χ-square test for trend.ResultsThe proportion of hospitalizations including a discharge diagnosis of IBD increased significantly from 1994 to 2006 among the total population and among Asian, black, and white patients separately. Increases were statistically significant when analysis was performed for Crohn's disease and ulcerative colitis combined and separately. Marked increases were seen among Asians.ConclusionsThe proportion of hospitalizations including a discharge diagnosis of IBD increased significantly among minority and nonminority patients from 1994 through 2006. The causes underlying these changes are not certain and should be further investigated. Inflamm Bowel Dis 2009

There is scarce information about the link between specific single-nucleotide polymorphisms (SNPs) and risk of liver disease among Latinos, despite the disproportionate burden of disease among this population. Our aim was to investigate nine SNPs in or near the following genes: PNPLA3, LYPLAL1, PPP1R3B, GCKR, NCAN, IRS1, PPARG, and ADIPOR2 and examine their association with persistently elevated alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels in Mexican adults. Data and samples were collected from 741 participants in the Mexican Health Worker Cohort Study, in Cuernavaca, Mexico. We identified 207 cases who had persistently elevated levels of ALT or AST (≥40 U/L) and 534 controls with at least two consecutive normal ALT or AST results in a 6 month period, during 2004–2006 and 2011–2013. TaqMan assays were used to genotype the SNPs. The risk allele of PNPLA3 rs738409 was found to be associated with persistently elevated levels of ALT or AST, adjusting for age, sex, BMI, type 2 diabetes, and ancestry: (OR 2.28, 95 % CI 1.13, 4.58). A significant association was found between the LYPLAL1, PPP1R3B, and GCKR risk alleles and elevated ALT or AST levels among overweight/obese adults. These results suggest that among Mexicans, the PNPLA3 (rs738409), LYPLAL1 (rs12137855), PPP1R3B (rs4240624), and GCKR (rs780094) polymorphisms may be associated with a greater risk of chronic liver disease among overweight adults. This study is the first to examine these nine SNPs in a sample of adults in Mexico.