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Volerman A, Carlson B, Wan W, Murugesan M, Asfour N, Bolton J, Chin MH, Sripipatana A, Nocon RS. Utilization, quality, and spending for pediatric Medicaid enrollees with primary care in health centers vs non-health centers. BMC Pediatr 2024; 24:100. [PMID: 38331758 PMCID: PMC10851548 DOI: 10.1186/s12887-024-04547-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 01/09/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Limited research has explored the performance of health centers (HCs) compared to other primary care settings among children in the United States. We evaluated utilization, quality, and expenditures for pediatric Medicaid enrollees receiving care in HCs versus non-HCs. METHODS This national cross-sectional study utilized 2012 Medicaid Analytic eXtract (MAX) claims to examine children 0-17 years with a primary care visit, stratified by whether majority (> 50%) of primary care visits were at HCs or non-HCs. Outcome measures include utilization (primary care visits, non-primary care outpatient visits, prescription claims, Emergency Department (ED) visits, hospitalizations) and quality (well-child visits, avoidable ED visits, avoidable hospitalizations). For children enrolled in fee-for-service Medicaid, we also measured expenditures. Propensity score-based overlap weighting was used to balance covariates. RESULTS A total of 2,383,270 Medicaid-enrolled children received the majority of their primary care at HCs, while 18,540,743 did at non-HCs. In adjusted analyses, HC patients had 20% more primary care visits, 15% less non-primary care outpatient visits, and 21% less prescription claims than non-HC patients. ED visits were similar across the two groups, while HC patients had 7% lower chance of hospitalization than non-HC. Quality of care outcomes favored HC patients in main analyses, but results were less robust when excluding managed care beneficiaries. Total expenditures among the fee-for-service subpopulation were lower by $239 (8%) for HC patients. CONCLUSIONS In this study of nationwide claims data to evaluate healthcare utilization, quality, and spending among Medicaid-enrolled children who receive primary care at HCs versus non-HCs, findings suggest primary care delivery in HCs may be associated with a more cost-effective model of healthcare for children.
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Affiliation(s)
- Anna Volerman
- Departments of Medicine and Pediatrics, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA.
| | - Bradley Carlson
- University of Chicago Pritzker School of Medicine, 924 E 57th St, Chicago, IL, 60637, USA
| | - Wen Wan
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Manoradhan Murugesan
- Department of Public Health Sciences, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Nour Asfour
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Joshua Bolton
- Health Resources and Services Administration (Affiliation at Time Research Conducted), 5600 Fishers Lane, Rockville, MD, 20857, USA
| | - Marshall H Chin
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Alek Sripipatana
- Health Resources and Services Administration, 5600 Fishers Lane, Rockville, MD, 20857, USA
| | - Robert S Nocon
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, 98 S Los Robles Ave, Pasadena, CA, 91101, USA
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Modica C, Lewis JH, Bay RC. Advancing Virtual at-Home Care for Community Health Center Patients Using Patient Self-Care Tools, Technology, and Education. J Multidiscip Healthc 2024; 17:521-531. [PMID: 38328633 PMCID: PMC10849139 DOI: 10.2147/jmdh.s443973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/22/2024] [Indexed: 02/09/2024] Open
Abstract
Introduction Health centers are community-based, patient directed primary care providers that offer accessible, high-quality primary care within medically underserved communities. Screening for cancer and managing complex chronic conditions such as diabetes, hypertension, obesity, and depression are vital services for the vulnerable populations seen by community health centers. Delivering care for complex chronic conditions and preventive services using virtual models that integrate self-care tools and technology is an important approach to increasing access for hard-to-reach patients served by health centers. Objective This study aimed to explore the use of a virtual care model, applied using a systems approach and patient-driven tools and technology, on the performance of clinical and patient experience measures. Methods A virtual care model, applied using a systems approach offered by the Value Transformation Framework (VTF), was combined with self-care tools and technology in twenty health centers across 17 states to drive improvement efforts. Changes in clinical measures and patient experience were compared. Results A total of 385 patients were enrolled and 270 (70.1%) completed a baseline visit and at least four virtual visits during the six-month intervention period. Statistically significant improvements were seen in measures for HbA1c, systolic and diastolic blood pressure, and bodyweight. Among the 270 who completed the baseline and at least 4 virtual visits, the percentage up-to-date for colorectal cancer screening increased from 113/270 (41.9%) to 169/270 (62.6%) after six months, p<0.001, a 20.7% increase. Patients completing the baseline visit and at least 4 virtual visits reported a 10.7% decrease in depression and increased satisfaction with virtual care visits compared to in-person visits (p<0.001). Conclusion Health centers applying the Value Transformation Framework's organizing framework to the use of virtual care models together with patient self-care tools, technology, and education, had improvements in measures for chronic and preventive conditions and patient experience.
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Affiliation(s)
- Cheryl Modica
- National Association of Community Health Centers, Bethesda, MD, USA
| | - Joy H Lewis
- Department of Medicine and Public Health, A.T. Still University, School of Osteopathic Medicine, Mesa, AZ, USA
| | - R Curtis Bay
- Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa, AZ, USA
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Laily A, Duncan R, Gabhart KM, Nephew LD, Christy SM, Vadaparampil ST, Giuliano AR, Kasting ML. Differences in Provider Hepatitis C Virus Screening Recommendations by Patient Risk Status. Prev Med Rep 2024; 38:102602. [PMID: 38375175 PMCID: PMC10874862 DOI: 10.1016/j.pmedr.2024.102602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 01/05/2024] [Accepted: 01/06/2024] [Indexed: 02/21/2024] Open
Abstract
Providers' recommendation is among the strongest predictors to patients engaging in preventive care. Therefore, the aim of this study was to compare providers' Hepatitis C Virus (HCV) screening recommendation quality between high-risk and average-risk patients to determine if providers are universally recommending HCV screening, regardless of risk behaviors. This cross-sectional survey of 284 Indiana providers in 2020 assessed provider characteristics, HCV screening recommendation practices (strength, presentation, frequency, timeliness), self-efficacy, and barriers to recommending HCV screening. T-test and Chi-square compared recommendation practices for high-risk and average-risk patients. Prevalence ratios were calculated for variables associated with HCV recommendation strength comparing high-risk and average-risk patients. Logistic regression analyses examined factors associated with HCV recommendation strength for high- and average-risk patients, with odds ratios. Compared to average-risk patients, high-risk patients received higher proportion of HCV recommendations that were strong (70.4 % v. 42.4 %), routine (61.9 % v. 55.6 %), frequent (37.7 % v. 28 %), and timely (74.2 % v. 54.9 %) (P-values < 0.001). Compared to average-risk patients, providers with high-risk patients had a lower percentage of giving a strong recommendation if they were nurse practitioner (PR = 0.49). For high-risk patients, providers with higher self-efficacy (aOR = 2.16;95 %CI = 0.99-4.69) had higher odds, while those with higher perceived barriers (aOR = 0.19;95 %CI = 0.09-0.39) and those with an internal medicine specialty compared to family medicine (aOR = 0.22;95 %CI = 0.08-0.57) had lower odds of giving a strong recommendation. These data suggest providers are not universally recommending HCV screening for all adults regardless of reported risk. Future research should translate these findings into multilevel interventions to improve HCV screening recommendations regardless of patient risk status.
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Affiliation(s)
- Alfu Laily
- Department of Public Health, College of Health and Human Sciences, Purdue University, 820 Mitch Daniels Blvd, West Lafayette, IN 47907, USA
| | - Robert Duncan
- Department of Human Development and Family Studies, College of Health and Human Sciences, Purdue University, 1202 West State St., West Lafayette, IN 47907, USA
| | - Kaitlyn M. Gabhart
- Department of Psychology, Vanderbilt University, 230 Appleton Pl, Nashville, TN 37203, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 340 W 10th St., Indianapolis, IN 46202, USA
| | - Shannon M. Christy
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Department of Oncological Sciences, University of South Florida, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Susan T. Vadaparampil
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Department of Oncological Sciences, University of South Florida, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Anna R. Giuliano
- Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Department of Cancer Epidemiology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Monica L. Kasting
- Department of Public Health, College of Health and Human Sciences, Purdue University, 820 Mitch Daniels Blvd, West Lafayette, IN 47907, USA
- Cancer Prevention and Control Program, Indiana University Simon Comprehensive Cancer Center, 535 Barnhill Dr., Indianapolis, IN 46202, USA
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Tung EL, Asfour N, Bolton JD, Huang ES, Zhang C, Anselin L. Impact of 2009 American Recovery and Reinvestment Act (ARRA) health center investments on disadvantaged neighborhoods after recession. Health Econ Rev 2024; 14:9. [PMID: 38294643 PMCID: PMC10829270 DOI: 10.1186/s13561-024-00482-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/22/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Federally qualified health centers (FQHCs) are integral to the U.S. healthcare safety net and uniquely situated in disadvantaged neighborhoods. The 2009 American Recovery and Reinvestment Act (ARRA) invested $2 billion in FQHC stimulus during the Great Recession; but it remains unknown whether this investment was associated with extended benefits for disadvantaged neighborhoods. METHODS We used a propensity-score matched longitudinal design (2008-2012) to examine whether the 2009 ARRA FQHC investment was associated with local jobs and establishments recovery in FQHC neighborhoods. Job change data were obtained from the Longitudinal Employer-Household Dynamics (LEHD) survey and calculated as an annual rate per 1,000 population. Establishment change data were obtained from the National Neighborhood Data Archive (NaNDA) and calculated as an annual rate per 10,000 population. Establishment data included 4 establishment types: healthcare services, eating/drinking places, retail establishments, and grocery stores. Fixed effects were used to compare annual rates of jobs and establishments recovery between ARRA-funded FQHC census tracts and a matched control group. RESULTS Of 50,381 tracts, 2,223 contained ≥ 1 FQHC that received ARRA funding. A higher proportion of FQHC tracts had an extreme poverty designation (11.6% vs. 5.4%), high unemployment rate (45.4% vs. 30.3%), and > 50% minority racial/ethnic composition (48.1% vs. 36.3%). On average, jobs grew at an annual rate of 3.84 jobs per 1,000 population (95% CI: 3.62,4.06). In propensity-score weighted models, jobs in ARRA-funded tracts grew at a higher annual rate of 4.34 per 1,000 (95% CI: 2.56,6.12) relative to those with similar social vulnerability. We observed persistent decline in non-healthcare establishments (-1.35 per 10,000; 95% CI: -1.68,-1.02); but did not observe decline in healthcare establishments. CONCLUSIONS Direct funding to HCs may be an effective strategy to support healthcare establishments and some jobs recovery in disadvantaged neighborhoods during recession, reinforcing the important multidimensional roles HCs play in these communities. However, HCs may benefit from additional investments that target upstream determinants of health to mitigate uneven recovery and neighborhood decline.
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Affiliation(s)
- Elizabeth L Tung
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, USA.
- Center for Health and the Social Sciences, University of Chicago, Chicago, USA.
- Center for Spatial Data Science, University of Chicago, Chicago, IL, USA.
| | - Nour Asfour
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, USA
| | - Joshua D Bolton
- Bureau of Primary Health Care at the U.S. Department of Health and Human Services, Health Resources and Services Administration (at the time of authorship), Rockville, MD, USA
| | - Elbert S Huang
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, USA
- Center for Chronic Disease Research and Policy, University of Chicago, Chicago, IL, USA
| | - Calvin Zhang
- Center for Spatial Data Science, University of Chicago, Chicago, IL, USA
| | - Luc Anselin
- Center for Spatial Data Science, University of Chicago, Chicago, IL, USA
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Dang P, Chavez A, Pham C, Tipton M, Woodard LD, Adepoju OE. Proxy use of patient portals on behalf of children: Federally Qualified Health Centers as a case study. Digit Health 2024; 10:20552076231224073. [PMID: 38205036 PMCID: PMC10777763 DOI: 10.1177/20552076231224073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024] Open
Abstract
Objective This study examined the proxy use of patient portals for children in a large Federally Qualified Health Centers (FQHC) network in Texas. Methods We used de-identified individual-level data of patients, 0-18 years, who had 1+ visits between December 2018 and November 2020. Logistic regression was used to examine patient-, clinic-, and geographic-level factors associated with portal usage by an assumed proxy (i.e. parent or guardian). Results The proxy portal usage rate increased from 28% in the pre-pandemic months (November 2018-February 2020) to 34% in the pandemic months (March-Nov 2020). Compared to patients 0-5 years, patients aged 6 to 18 years had lower odds of portal usage (6-10 OR: 0.77, p < 0.001; 11-14 OR: 0.62, p < 0.001; 15-18 OR: 0.51, p < 0.001). Minoritized groups had significantly lower odds of portal usage when compared to their non-Hispanic White counterparts (non-Hispanic Black OR: 0.78, p < 0.001; Hispanic OR 0.63, p < 0.001; Asian OR: 0.69, p < 0.001). Having one chronic condition was associated with portal usage (OR: 1.57, p < 0.001); however, there were no significant differences in portal usage between those with none or multiple chronic conditions. Portal usage also varied by service lines, with obstetrics and gynecology (OR: 1.84, p < 0.001) and behavioral health (OR 1.82, p < 0.001) having the highest odds of usage when compared to pediatrics. Having a telemedicine visit was the strongest predictor of portal usage (OR: 2.30, p < 0.001), while residence in zip codes with poor broadband internet access was associated with lower odds of portal usage (OR: 0.97, p < 0.001). Conclusion While others have reported portal usage rates as high as 64% in pediatric settings, our analysis suggests proxy portal usage rates of 30% in pediatric FQHC settings, with race/ethnicity, age group, and chronic disease status being significant drivers of portal non-usage. These findings highlight the need for appropriate and responsive health information technology approaches for vulnerable populations receiving care in low-resource settings.
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Affiliation(s)
- Patrick Dang
- Humana Integrated Health Systems Sciences Institute, University of Houston, Houston, USA
| | - Arlette Chavez
- Humana Integrated Health Systems Sciences Institute, University of Houston, Houston, USA
| | - Cecilia Pham
- Tilman J Fertitta Family College of Medicine, University of Houston, Houston, USA
| | - Mary Tipton
- Humana Integrated Health Systems Sciences Institute, University of Houston, Houston, USA
| | - LeChauncy D Woodard
- Tilman J Fertitta Family College of Medicine, University of Houston, Houston, USA
| | - Omolola E Adepoju
- Humana Integrated Health Systems Sciences Institute, University of Houston, Houston, USA
- Tilman J Fertitta Family College of Medicine, University of Houston, Houston, USA
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Pourat N, Chen X, Lu C, Zhou W, Yu-Lefler H, Benjamin T, Hoang H, Sripipatana A. Differences in Health Care Utilization of High-Need and High-Cost Patients of Federally Funded Health Centers Versus Other Primary Care Providers. Med Care 2024; 62:52-59. [PMID: 37962396 DOI: 10.1097/mlr.0000000000001947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Primary care providers (PCP) differ in their ability to address the needs and reduce use of costly services among complex Medicaid beneficiaries. Among PCPs, Health Resources and Services Administration (HRSA)-funded health centers (HCs) are shown to provide high-value care. OBJECTIVE We compared health care utilization of complex Medicaid managed care beneficiaries whose PCPs were HCs versus 3 other groups. RESEARCH DESIGN Cross-sectional study using propensity score matching comparing health care use by provider type, controlling for demographics, health status, and other covariates. SUBJECTS California Medicaid administrative data for complex adult managed care beneficiaries with at least 1 primary care visit in 2018. MEASURES Primary and specialty care evaluation & management visits and services; emergency department (ED) visits; and hospitalizations. PCPs included HCs, clinics not funded by HRSA, solo, and group practice providers. RESULTS HRSA-funded HCs had lower predicted rates of specialty evaluation & management and other services than all others; lower predicted probability of any ED visits than clinics not funded by HRSA [54% (95% CI: 53%-55%) vs. 56% (95% CI: 55%-57%)] and group practice providers [51% (95% CI: 51%-52%) vs. 52% (95% CI: 52%-53%)]; and lower PP of any hospitalizations than solo [20% (95% CI: 19%-20%) vs. 23% (95% CI: 22%-24%)] and group practice providers [21% (95% CI: 20%-21%) vs. 24% (95% CI: 23%-24%)]. CONCLUSIONS Differences in HC care delivery and practices were associated with lower use of specialty, ED, and hospitalization visits compared with other PCPs for complex Medicaid managed care beneficiaries. Understanding the underlying reasons for these utilization differences may promote better outcomes among these patients.
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Affiliation(s)
- Nadereh Pourat
- Center for Health Policy Research, University of California, Los Angeles, CA
- UCLA Fielding School of Public Health, Department of Health Policy and Management, Los Angeles, CA
| | - Xiao Chen
- Center for Health Policy Research, University of California, Los Angeles, CA
| | - Connie Lu
- Center for Health Policy Research, University of California, Los Angeles, CA
| | - Weihao Zhou
- Center for Health Policy Research, University of California, Los Angeles, CA
| | - Helen Yu-Lefler
- Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, MD
| | - Troyana Benjamin
- Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, MD
| | - Hank Hoang
- Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, MD
| | - Alek Sripipatana
- Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, MD
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Gagnon KW, Coulter RWS, Egan JE, Ho K, Hawk M. Patient and Clinician Sociodemographics and Sexual History Screening at a Multisite Federally Qualified Health Center: A Mixed Methods Study. Ann Fam Med 2023; 21:395-402. [PMID: 37748900 PMCID: PMC10519747 DOI: 10.1370/afm.3012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 09/27/2023] Open
Abstract
PURPOSE In 2018, there were 68 million sexually transmitted infections in the United States. Sexual history screening is an evidence-based practice endorsed by guidelines to identify risk of these infections and adverse sexual health outcomes. In this mixed methods study, we investigated patient- and clinician-level characteristics associated with receipt of sexual history screening, and contextualized these differences in more depth. METHODS We collected sociodemographics of patients from the electronic health record and sociodemographics of their primary care clinicians via a census survey. Semistructured interviews were conducted with key practice staff. We conducted multilevel crossed random effects logistic regression analysis and thematic analysis on quantitative and qualitative data, respectively. RESULTS A total of 53,246 patients and 56 clinicians from 13 clinical sites participated. Less than one-half (42.4%) of the patients had any sexual history screening documented in their health record. Patients had significantly higher odds of documented screening if they were gay or lesbian (OR = 1.23), were cisgender women (OR = 1.10), or had clinicians who were cisgender women (OR = 1.80). Conversely, patients' odds of documented screening fell significantly with age (OR per year = 0.99) and with the number of patients their clinicians had on their panels (OR per patient = 0.99), and their odds were significantly lower if their primary language was not English (OR = 0.91). In interviews, key staff expressed discomfort discussing sexual health and noted assumptions about patients who are older, in long-term relationships, or from other cultures. Discordance of patient-clinician gender and patients' sexual orientation were also noted as barriers. CONCLUSIONS Interventions are needed to address the interplay between the social and contextual factors identified in this study, especially those that elicited discomfort, and the implementation of sexual history screening.
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Affiliation(s)
- Kelly W Gagnon
- Division of Infectious Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert W S Coulter
- Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - James E Egan
- Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ken Ho
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary Hawk
- Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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Gagnon KW, Coulter RW, Egan JE, Ho K, Hawk M. Associations Between Sexual History Documentation in Electronic Health Records and Referral to Pre-Exposure Prophylaxis Navigator on Prescription of Pre-Exposure Prophylaxis at a Multi-Site Federally Qualified Health Center. AIDS Patient Care STDS 2023; 37:403-415. [PMID: 37566534 PMCID: PMC10457630 DOI: 10.1089/apc.2023.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023] Open
Abstract
This cross-sectional study examined the relationships between sexual history screening (SHS) and referrals to a pre-exposure prophylaxis (PrEP) navigator (non-clinical staff member who assists patients in overcoming structural barriers to PrEP) on the proportion of days covered by PrEP for adult patients at a federally qualified health center. Patients' sociodemographics, PrEP prescriptions, referral to a PrEP navigator, and SHS data were extracted from the electronic health record (EHR). The analytic sample was 214 adult patients who were human immunodeficiency virus (HIV) negative and taking PrEP to prevent infection from January 2016 to December 2019. Mixed-effects negative binomial models were conducted accounting for clustering by patients' primary care providers. Documentation of SHS was associated with a higher proportion of days covered by PrEP (incidence rate ratio = 1.44, 95% confidence interval: 1.17-1.77). There was no significant effect of having a referral to the PrEP navigator on the proportion of days covered by PrEP, nor did having a referral to the PrEP navigator moderate the relationship between having SHS documented in the EHR and the proportion of days covered by PrEP. This study is the first to investigate the relationship between having sexual history documented in the EHR, referrals to a PrEP navigator, and their combined effect on the proportion of days covered by PrEP. Results of this study provide foundational evidence for future studies examining SHS as an opportunity to improve PrEP access and adherence and indicate the need for additional research exploring the value of PrEP navigators as an implementation strategy to overcome social and structural barriers to care.
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Affiliation(s)
- Kelly W. Gagnon
- Division of Infectious Diseases, Department of Medicine, Heersink School of Medicine, The University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Robert W.S. Coulter
- Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James E. Egan
- Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ken Ho
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mary Hawk
- Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Parzuchowski A, Oronce C, Guo R, Tseng CH, Fendrick AM, Mafi JN. Evaluating the accessibility and value of U.S. ambulatory care among Medicaid expansion states and non-expansion states, 2012-2015. BMC Health Serv Res 2023; 23:723. [PMID: 37400793 PMCID: PMC10318663 DOI: 10.1186/s12913-023-09696-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 06/07/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND While the Affordable Care Act's Medicaid expansion improved healthcare coverage and access for millions of uninsured Americans, less is known about its effects on the overall accessibility and quality of care across all payers. Rapid volume increases of newly enrolled Medicaid patients might have unintentionally strained accessibility or quality of care. We assessed changes in physician office visits and high- and low-value care associated with Medicaid expansion across all payers. METHODS Prespecified, quasi-experimental, difference-in-differences analysis pre and post Medicaid expansion (2012-2015) in 8 states that did and 5 that did not choose to expand Medicaid. Physician office visits sampled from the National Ambulatory Medical Care Survey, standardized with U.S. Census population estimates. Outcomes included visit rates per state population and rates of high or low-value service composites of 10 high-value measures and 7 low-value care measures respectively, stratified by year and insurance. RESULTS We identified approximately 143 million adults utilizing 1.9 billion visits (mean age 56; 60% female) during 2012-2015. Medicaid visits increased in expansion states post-expansion compared to non-expansion states by 16.2 per 100 adults (p = 0.031 95% CI 1.5-31.0). New Medicaid visits increased by 3.1 per 100 adults (95% CI 0.9-5.3, p = 0.007). No changes were observed in Medicare or commercially-insured visit rates. High or low-value care did not change for any insurance type, except high-value care during new Medicaid visits, which increased by 4.3 services per 100 adults (95% CI 1.1-7.5, p = 0.009). CONCLUSIONS Following Medicaid expansion, the U.S. healthcare system increased access to care and use of high-value services for millions of Medicaid enrollees, without observable reductions in access or quality for those enrolled in other insurance types. Provision of low-value care continued at similar rates post-expansion, informing future federal policies designed to improve the value of care.
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Affiliation(s)
- Aaron Parzuchowski
- Department of Veteran Affairs, National Clinician Scholars Program, Ann Arbor, MI, USA
- Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Carlos Oronce
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Rong Guo
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - A Mark Fendrick
- Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
| | - John N Mafi
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA.
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Nikpour J, Carthon JMB. Characteristics, work environments, and rates of burnout and job dissatisfaction among registered nurses in primary care. Nurs Outlook 2023; 71:101988. [PMID: 37329590 PMCID: PMC10592661 DOI: 10.1016/j.outlook.2023.101988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/05/2023] [Accepted: 04/30/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Although more people than ever are seeking primary care, the ratio of primary care providers to the population continues to rapidly decline. As such, registered nurses (RNs) are taking on increasingly central roles in primary care delivery. Yet little is known about their characteristics, their work environments, and the extent to which they experience poor job outcomes such as nurse burnout. PURPOSE The purpose of this study was to examine the characteristics of the primary care RN workforce and analyze the association of the nurse work environment with job outcomes in primary care. METHODS Cross-sectional analysis of survey data representing N = 463 RNs who worked in 398 primary care practices, including primary care offices, community clinics, retail/urgent care clinics, and nurse-managed clinics. Survey questions included measures of the nurse work environment and levels of burnout, job dissatisfaction, and intent to leave. DISCUSSION Approximately one-third of primary care RNs were burnt out and dissatisfied with their jobs, with the highest risk of these outcomes among RNs in community clinics. Community clinic RNs were also significantly more likely to be Black or Hispanic/Latino, hold a Bachelor of Science in Nursing, and speak English as a second language (all p < .01). Across all settings, better nurse work environments were significantly associated with lower levels of burnout and job dissatisfaction (both p < .01). CONCLUSION Primary care practices must be equipped to support their RN workforce. Adequate nursing resources are especially needed in community clinics, as patients receiving primary care in these settings frequently face structural inequities.
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Affiliation(s)
- Jacqueline Nikpour
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - J Margo Brooks Carthon
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
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Marsteller JA, Hsu YJ, Weeks K, Oduwole M, Boonyasai RT, Avornu GD, Dietz KB, Zhou Z, Brown D, Hines A, Chung S, Lubomski L, Carson KA, Ibe C, Cooper LA. Assessing Factors Influencing Commitment to a Disparities Reduction Intervention: Social Justice Attitudes and Organizational Mission. J Healthc Qual 2023; 45:209-219. [PMID: 37387405 PMCID: PMC10498376 DOI: 10.1097/jhq.0000000000000385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
ABSTRACT This mixed-methods study aims to understand what the perceptions of leaders and healthcare professionals are regarding causes of disparities, cultural competence, and motivation before launching a disparity reduction project in hypertension care, contrasting perceptions in Federally Qualified Health Centers (FQHCs), and in a non-FQHC system. We interviewed leaders of six participating primary care systems and surveyed providers and staff. FQHC respondents reported more positive cultural competence attitudes and behavior, higher motivation to implement the project, and less concern about barriers to caring for disadvantaged patients than those in the non-FQHC practices; however, egalitarian beliefs were similar among all. Qualitative analysis suggested that the organizational missions of the FQHCs reflect their critical role in serving vulnerable populations. All system leaders were aware of the challenges of provider care to underserved groups, but comprehensive initiatives to address social determinants of health and improve cultural competence were still needed in both system types. The study provides insights into the perceptions and motivations of primary care organizational leaders and providers who are interested in improving chronic care. It also offers an example for care disparity programs to understand commitment and values of the participants for tailoring interventions and setting baseline for progress.
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12
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Emmons KM, Mendez S, Lee RM, Erani D, Mascioli L, Abreu M, Adams S, Daly J, Bierer BE. Data sharing in the context of community-engaged research partnerships. Soc Sci Med 2023; 325:115895. [PMID: 37062144 PMCID: PMC10308954 DOI: 10.1016/j.socscimed.2023.115895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 03/04/2023] [Accepted: 04/06/2023] [Indexed: 04/18/2023]
Abstract
Over the past 20 years, the National Institutes for Health (NIH) has implemented several policies designed to improve sharing of research data, such as the NIH public access policy for publications, NIH genomic data sharing policy, and National Cancer Institute (NCI) Cancer Moonshot public access and data sharing policy. In January 2023, a new NIH data sharing policy has gone into effect, requiring researchers to submit a Data Management and Sharing Plan in proposals for NIH funding (NIH. Supplemental information to the, 2020b; NIH. Final policy for data, 2020a). These policies are based on the idea that sharing data is a key component of the scientific method, as it enables the creation of larger data repositories that can lead to research questions that may not be possible in individual studies (Alter and Gonzalez, 2018; Jwa and Poldrack, 2022), allows enhanced collaboration, and maximizes the federal investment in research. Important questions that we must consider as data sharing is expanded are to whom do benefits of data sharing accrue and to whom do benefits not accrue? In an era of growing efforts to engage diverse communities in research, we must consider the impact of data sharing for all research participants and the communities that they represent. We examine the issue of data sharing through a community-engaged research lens, informed by a long-standing partnership between community-engaged researchers and a key community health organization (Kruse et al., 2022). We contend that without effective community engagement and rich contextual knowledge, biases resulting from data sharing can remain unchecked. We provide several recommendations that would allow better community engagement related to data sharing to ensure both community and researcher understanding of the issues involved and move toward shared benefits. By identifying good models for evaluating the impact of data sharing on communities that contribute data, and then using those models systematically, we will advance the consideration of the community perspective and increase the likelihood of benefits for all.
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Affiliation(s)
- Karen M Emmons
- Department of Social and Behavioral Science, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA.
| | - Samuel Mendez
- Department of Social and Behavioral Science, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Rebekka M Lee
- Department of Social and Behavioral Science, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Diana Erani
- Massachusetts League of Community Health Centers, 40 Court Street, 10th Floor, Boston, MA, 02108, USA
| | - Lynette Mascioli
- Massachusetts League of Community Health Centers, 40 Court Street, 10th Floor, Boston, MA, 02108, USA
| | - Marlene Abreu
- Massachusetts League of Community Health Centers, 40 Court Street, 10th Floor, Boston, MA, 02108, USA
| | - Susan Adams
- Massachusetts League of Community Health Centers, 40 Court Street, 10th Floor, Boston, MA, 02108, USA
| | - James Daly
- Department of Social and Behavioral Science, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Barbara E Bierer
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA; Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA
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13
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Avegno KS, Roberson KB, Onsomu EO, Edwards MF, Dean EL, Bertoni AG. Evaluating a Telephone and Home Blood Pressure Monitoring Intervention to Improve Blood Pressure Control and Self-Care Behaviors in Adults with Low-Socioeconomic Status. Int J Environ Res Public Health 2023; 20:5287. [PMID: 37047903 PMCID: PMC10094475 DOI: 10.3390/ijerph20075287] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/20/2023] [Accepted: 03/24/2023] [Indexed: 06/19/2023]
Abstract
Hypertension (HTN) affects nearly 75 million in the United States, and percentages increase with low socioeconomic status (SES) due to poor access to, and quality of, care, and poor self-care behaviors. Federally Qualified Health Centers (FQHCs) employ evidence-based strategies, such as telehealth interventions, to improve blood pressure (BP) control in under-resourced communities, yet a southeastern FQHC could achieve a BP control rate of only 27.6%, well below the Health People 2020 goal of 61.2%. This pilot project used a pre/post, matched-cohort design to evaluate the effect of a telehealth intervention on BP control and self-care behaviors. Secondary outcomes included self-efficacy and perceived stress. Frequency and percentage, Wilcoxon signed-rank, and McNemar tests were used for statistical analysis of results from a convenience sample of 27 participants. Baseline HTN management guidance that incorporated home blood pressure monitoring (HBPM) was reinforced through telephone counseling every two weeks. Although BP control was not achieved, average scores for systolic and diastolic blood pressures decreased significantly: 13 mm Hg (p = 0.0136) and 5 mm Hg (p = 0.0095), respectively. Statistically significant differences were also seen in select self-care behaviors. Greater BP reduction aligned with higher self-efficacy scores and call engagement. Overall, telephone counseling and HBPM were feasible and effective in reducing BP and increasing self-care behaviors. The inability to control BP may be attributable to under-recognition of stress, lack of medication adherence/reconciliation, and underutilization of guideline-based prescribing recommendations. Findings elucidate the potential effectiveness of a sustainable telehealth intervention to improve BP in low-SES populations.
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Affiliation(s)
- Komlanvi S. Avegno
- Division of Nursing, School of Health Sciences, Winston-Salem State University, 601 S. Martin Luther King, Jr Dr., Winston-Salem, NC 27110, USA
| | - Kristina B. Roberson
- Division of Nursing, School of Health Sciences, Winston-Salem State University, 601 S. Martin Luther King, Jr Dr., Winston-Salem, NC 27110, USA
| | - Elijah O. Onsomu
- Division of Nursing, School of Health Sciences, Winston-Salem State University, 601 S. Martin Luther King, Jr Dr., Winston-Salem, NC 27110, USA
| | - Michelle F. Edwards
- Triad Adult and Pediatric Medicine, 1002 S. Eugene Street, Greensboro, NC 27406, USA
| | - Eric L. Dean
- Dean Internal Medicine, 1409 Yanceyville St., Ste C, Greensboro, NC 27405, USA
| | - Alain G. Bertoni
- School of Medicine, Wake Forest University, 1 Medical Center Blvd, Winston-Salem, NC 27157, USA
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14
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Ford MM, Allard A, Goldberg J, Summers C. Federally Qualified Health Center Penetration Associated With Reduced Community COVID-19 Mortality in Four United States Cities. J Prim Care Community Health 2022; 13:21501319221138422. [PMID: 36448474 PMCID: PMC9716186 DOI: 10.1177/21501319221138422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has had significant impacts on health care access and delivery, with disparate effects across social and racial lines. Federally Qualified Health Centers (FQHCs) provide critical primary care services to the nation's most underserved populations, including many communities hardest hit by COVID-19. METHODS We conducted an ecological analysis that aimed to examine FQHC penetration, COVID-19 mortality, and socio-demographic factors in 4 major United States cities: New York, New York; Chicago, Illinois; Detroit, Michigan; and Seattle, Washington. RESULTS We found the distribution of COVID-19 cases and mortality varied spatially and in magnitude by city. COVID-19 mortality was significantly higher in communities with higher percentages of low-income residents and higher percentages of racial/ethnic minority residents. FQHC penetration was protective against increased COVID-19 mortality, after model adjustment. CONCLUSIONS Our study underpins the critical role of safety-net health care and policymakers must ensure investment in long-term sustainability of FQHCs, through strategic deployment of capital, workforce development, and reimbursement reform.
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Affiliation(s)
- Mary M. Ford
- Primary Care Development Corporation, New York, NY, USA,Mary M. Ford, Primary Care Development Corporation, 45 Broadway, New York, NY 10006, USA.
| | - Angela Allard
- Primary Care Development Corporation, New York, NY, USA,Angela Allard, Primary Care Development Corporation, 45 Broadway, New York, NY 10006, USA.
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15
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Whelihan K, Modica C, Bay RC, Lewis JH. Patient and Staff Satisfaction and Experience While Transforming Health Center Systems. Healthc Policy 2022; 15:2115-2124. [DOI: 10.2147/rmhp.s375983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/31/2022] [Indexed: 11/12/2022] Open
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16
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Modica C, Lewis JH, Bay RC. The Value Transformation Framework: Applied to Diabetes Control in Federally Qualified Health Centers. J Multidiscip Healthc 2021; 14:3005-3014. [PMID: 34737572 PMCID: PMC8558033 DOI: 10.2147/jmdh.s284885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/12/2021] [Indexed: 01/22/2023] Open
Abstract
Introduction Diabetes and pre-diabetes impact more than 114 million Americans. Federally qualified health centers (FQHCs) provide care to some of the most high-risk and underinsured individuals throughout the US, twenty-one percent of whom report being told they have diabetes, compared to 11% of the general adult population. It is widely agreed our health care system requires a transformation to effectively address diabetes and its complications. Objective By applying the Value Transformation Framework (VTF) in health centers, the National Association of Community Health Centers (NACHC) aims to show improvements in diabetes control. This systematic strategy to transform the way health centers operate can lead to improvements in health outcomes, patient and staff experiences, costs, and equity (Quintuple Aim). Special attention is paid to the health centers’ infrastructure, people systems and care delivery systems. Methods Evidence-based diabetes interventions, the learning community model, and the VTF were used together to drive system improvements and activate proven diabetes control practices within eight health centers. Multidisciplinary teams at select health centers in Georgia and Iowa, with their partner primary care associations, participated in this NACHC-led quality improvement project. Results During the one-year intervention (January 2017–December 2017), the mean raw percentage of patients with HbA1c Poor Control decreased from 50.9% (range, 23.7–70.4%) in January to 27.5% (range, 13.6–37.4%) in December. This represents a relative improvement in diabetes control of 46%. The 1-year-intervention data also showed trends in the desired direction with statistically significant improvements related to the following interventions: a formal written clinical policy, standing orders, patient recall/outreach, performance data shared at the provider/team-level, and performance data shared at the site/organization level. Conclusion A conceptual model focused on transforming health center systems, organized by the NACHC Value Transformation Framework and supported by a strong learning community, can lead to better diabetes control outcomes among patients seen at health centers.
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Affiliation(s)
- Cheryl Modica
- National Association of Community Health Centers, Bethesda, MD, USA
| | - Joy H Lewis
- Medicine and Public Health, SOMA Department of Public Health, School of Osteopathic Medicine in Arizona, A.T. Still University, Meza, AZ, USA
| | - R Curtis Bay
- Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa, AZ, USA
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17
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Han X, Pittman P, Ku L. The Effect of National Health Service Corps Clinician Staffing on Medical and Behavioral Health Care Costs in Community Health Centers. Med Care 2021; 59:S428-S433. [PMID: 34524239 PMCID: PMC8428858 DOI: 10.1097/mlr.0000000000001610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Prior studies of community health centers (CHCs) have found that clinicians supported by the National Health Service Corps (NHSC) provide a comparable number of primary care visits per full-time clinician as non-NHSC clinicians and provide more behavioral health care visits per clinician than non-NHSC clinicians. This present study extends prior research by examining the contribution of NHSC and non-NHSC clinicians to medical and behavioral health costs per visit. METHODS Using 2013-2017 data from 1022 federally qualified health centers merged with the NHSC participant data, we constructed multivariate linear regression models with health center and year fixed effects to examine the marginal effect of each additional NHSC and non-NHSC staff full-time equivalent (FTE) on medical and behavioral health care costs per visit in CHCs. RESULTS On average, each additional NHSC behavioral health staff FTE was associated with a significant reduction of 3.55 dollars of behavioral health care costs per visit in CHCs and was associated with a larger reduction of 7.95 dollars in rural CHCs specifically. In contrast, each additional non-NHSC behavioral health staff FTE did not significantly affect changes in behavioral health care costs per visit. Each additional NHSC primary care staff FTE was not significantly associated with higher medical care costs per visit, while each additional non-NHSC clinician contributed to a slight increase of $0.66 in medical care costs per visit. CONCLUSIONS Combined with previous findings on productivity, the present findings suggest that the use of NHSC clinicians is an effective approach to improving the capacity of CHCs by increasing medical and behavioral health care visits without increasing costs of services in CHCs, including rural health centers.
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Affiliation(s)
- Xinxin Han
- School of Medicine, Tsinghua University, Beijing, China
| | | | - Leighton Ku
- Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC
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18
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Lewis VA, Spivack S, Murray GF, Rodriguez HP. FQHC Designation and Safety Net Patient Revenue Associated with Primary Care Practice Capabilities for Access and Quality. J Gen Intern Med 2021; 36:2922-2928. [PMID: 34346005 PMCID: PMC8481458 DOI: 10.1007/s11606-021-06746-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Concerns exist about the ability of safety net health care organizations to participate in US health care reform. Primary care practices are key to several efforts, but little is known about how capabilities of primary care practices serving a high share of disadvantaged patients compare to other practices. OBJECTIVE To assess capabilities around access to and quality of care among primary care practices serving a high share of Medicaid and uninsured patients compared to practices serving a low share of these patients. DESIGN We analyzed data from the National Survey of Healthcare Organizations and Systems (response rate 46.8%), conducted 2017-2018. PARTICIPANTS A total of 2190 medical practices with at least three adult primary care physicians. MAIN MEASURES Our key exposures are payer mix and federally qualified health center (FQHC) designation. We classified practices as safety net if they reported a combined total of at least 25% of annual revenue from uninsured or Medicaid patients; we then further classified safety net practices into those that identified as an FQHC and those that did not. KEY RESULTS FQHCs were more likely than other safety net practices and non-safety net practices to offer early or late appointments (79%, 55%, 62%; p=0.001) and weekend appointments (56%, 39%, 42%; p=0.03). FQHCs more often provided medication-assisted treatment for opioid use disorders (43%, 27%, 25%; p=0.004) and behavioral health services (82%, 50%, 36%; p<0.001). FQHCs were more likely to screen patients for social and financial needs. However, FQHCs and other safety net providers had more limited electronic health record (EHR) capabilities (61%, 71%, 80%; p<0.001). CONCLUSION FQHCs were more likely than other types of primary care practices (both safety net practices and other practices) to possess capabilities related to access and quality. However, safety net practices were less likely than non-safety net practices to possess health information technology capabilities.
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Affiliation(s)
- Valerie A Lewis
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, USA.
| | - Steven Spivack
- Center for Outcomes and Evaluation, Yale School of Medicine, New Haven, USA
| | - Genevra F Murray
- Department of General Internal Medicine, Boston Medical Center, Boston, USA
| | - Hector P Rodriguez
- School of Public Health, University of California, Berkeley, Berkley, USA
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19
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Roman SB, Whitmire L, Reynolds L, Pasha S, Brockman A, Oldfield BJ. Demographic and Clinical Correlates of the Cost of Potentially Preventable Hospital Encounters in a Community Health Center Cohort. Popul Health Manag 2021; 25:625-631. [PMID: 34468228 DOI: 10.1089/pop.2021.0169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study sought to describe the cost of hospital care for ambulatory care-sensitive conditions (ACSCs) and to identify independent predictors of high-cost hospital encounters related to an ACSC among an urban community health center cohort. The authors conducted a retrospective cohort study of individuals engaged in care in a large, multisite community health center in New Haven, Connecticut, with any Medicaid claims between June 1, 2018 and March 31, 2020. Prevention Quality Indicators of the Agency for Healthcare Research and Quality were used to identify ACSCs. The primary outcome was a high-cost episode of care for an ACSC (in the top quartile within a 7-day period). Multivariable logistic regression was used to identify independent predictors of high-cost episodes by ACSCs among sociodemographic and clinical variables as covariates. Among 8019 included individuals, a total of 751 episodes of hospital care involving ACSCs were identified. The median episode cost was $793, with the highest median cost of care related to heart failure ($4992), followed by diabetes ($1162), and chronic obstructive pulmonary disease ($1141). In adjusted analyses, male gender (P < 0.01), increasing age (P = 0.02), and ACSC type (P < 0.01) were associated with higher costs of care; race/ethnicity was not. Community health centers in urban settings seeking to reduce the cost of care of potentially preventable hospitalizations may target disease-/condition-specific groups, particularly individuals of increasing age with congestive heart failure and diabetes mellitus. These findings may inform return-on-investment calculations for care coordination and other enabling services programming.
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Affiliation(s)
- Susan B Roman
- Fair Haven Community Health Care, New Haven, Connecticut, USA
| | - Lacey Whitmire
- Fair Haven Community Health Care, New Haven, Connecticut, USA
| | - Lori Reynolds
- Fair Haven Community Health Care, New Haven, Connecticut, USA
| | - Saamir Pasha
- Fair Haven Community Health Care, New Haven, Connecticut, USA.,Yale School of Public Health, New Haven, Connecticut, USA.,IQVIA, Inc., Stamford, Connecticut, USA
| | | | - Benjamin J Oldfield
- Fair Haven Community Health Care, New Haven, Connecticut, USA.,Departments of Medicine and Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
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Abstract
PURPOSE OF STUDY Explore the perceptions of primary care physicians (PCPs) from community health care centers (CHCs) in Franklin County, Ohio, regarding factors that contribute to their inability to consistently provide sustainable asthma management services to their uninsured patient population. PRIMARY PRACTICE SETTING Asthmatic patients are not consistently receiving sustainable asthma management in CHCs in Ohio. Primary care physicians in CHCs play a pivotal role in closing health care gaps for asthmatic patients. To minimize the barriers that impede the efforts of PCPs to control asthma for their uninsured patients, asthma disease management programs that include case management services in CHCs in Franklin County, Ohio, are needed. METHODOLOGY AND SAMPLE A convenience sample of 4 PCPs from 2 CHCs in Franklin County, Ohio, was interviewed face-to-face. Interviews, direct observation, and previously published research were the sources of data utilized for this study. RESULTS Results indicated that 75% of participants did not use standard guidelines while treating their patients. Physician time constraints and access to affordable medication were identified as some of the barriers to providing sustainable asthma management services. IMPLICATIONS FOR CASE MANAGEMENT Asthma is a complex chronic disease. Disease case managers not only are capable of coordinating health care services for a variety of patient populations but are also effective in managing complex diseases such as asthma for disadvantaged populations. Evidence-based case management models are needed to support PCPs in CHCs. Without the inclusion of asthma-specific case managers as part of the care delivery structure, CHCs may continue to provide subpar disease management services for uninsured asthmatic patients.
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Affiliation(s)
- Mary Bynum
- Mary Bynum, MA, BSN, RN, CCM, DHA, is the Department Chair for Healthcare Programs, Program Chair for the Healthcare Management Program, and Lead Faculty for the Public Administration Program at Franklin University. Dr. Bynum received her doctorate in Health Administration from the University of Phoenix. In addition, she holds a Master of Arts in Public Policy and Management and Bachelor of Science in Nursing from the Ohio State University. Dr. Bynum is a certified case manager and a registered nurse. She has an extensive background in operational excellence, project management, regulatory adherence, and health care policy. She has served more than 22 years in both the public and private sectors. Her research interests include vulnerable populations, health disparities, health policy, and social determinants of health. Dr. Bynum is a national speaker and wellness enthusiast. She is a member of Alpha Kappa Alpha Sorority, Incorporated, Franklin County Children Services Citizens Advisory Committee, Central Ohio Case Management Network, and Fort Hayes Metropolitan Education Center Health Science and Dental Hygiene Advisory Board and is the founder of the Legacy Group of Ohio. She is the recipient of the Stephan Shank award for Teaching Excellence. In addition, she is a marathon runner and fitness guru
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Patel E, Bandara S, Saloner B, Stuart EA, Goodman D, Terplan M, McCourt A, White S, McGinty EE. Heterogeneity in prenatal substance use screening despite universal screening recommendations: findings from the Pregnancy Risk Assessment Monitoring System, 2016-2018. Am J Obstet Gynecol MFM 2021; 3:100419. [PMID: 34116233 DOI: 10.1016/j.ajogmf.2021.100419] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/26/2021] [Accepted: 06/02/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The American College of Obstetricians and Gynecologists recommends universal screening for tobacco, alcohol, and drug use as a part of routine prenatal care. However, little is known about the prevalence of prenatal substance use screening or factors that may contribute to differential rates of screening during prenatal care. OBJECTIVE This study aimed to describe the prevalence of prenatal substance use screening by substance, year, state, and state-level prenatal substance use policies and to examine individual-level factors associated with receipt of screening. STUDY DESIGN We analyzed 2016 to 2018 data from 103,608 women participating in the Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births. The Pregnancy Risk Assessment Monitoring System survey sampling weights were applied to all analyses. We described the percentage of individuals asked by a healthcare worker about substance use during a prenatal care appointment by substance, year, and state. Using chi-squared tests, we examined differences in the prevalence of screening by state-level prenatal substance use policies, including policies regarding classification of prenatal substance use as child abuse or neglect, mandatory testing or reporting of prenatal substance use, and targeted treatment funding and access for pregnant individuals with substance use disorders. Finally, we estimated the association between individual-level characteristics and receipt of prenatal substance use screening using logistic regression, controlling for year and state fixed effects and accounting for missingness using multiple imputation. RESULTS In 2018, approximately 95% individuals reported being asked about cigarette or alcohol use during a prenatal care appointment, whereas only 80% reported being asked about drug use. The percentage of individuals who were asked about substance use during a prenatal care appointment increased overall between 2016 and 2018, with variability across states. For all substances, states with laws designating prenatal drug use as child abuse or neglect had lower prevalence of screening, whereas states with laws mandating providers to test for substance use in pregnancy had higher prevalence of screening. Several individual-level characteristics were associated with increased odds of reported prenatal substance use screening for one or more substances, including being younger, less educated, unmarried, Black (vs White), non-Hispanic, or publicly insured (vs privately insured), receiving adequate prenatal care, and having a history of prepregnancy cigarette use. CONCLUSION Our study finds that despite recommendations for universal prenatal substance use screening, there are differences in who is actually asked about substance use during prenatal care appointments. This may be influenced by state-level prenatal substance use policies and selective screening approaches in which certain individuals are more likely to be asked about substance use during their prenatal care appointment. A better understanding of the repercussions of selective screening approaches on outcomes and the roles that policies, systems, and provider biases play in perpetuating these approaches is needed to advance guideline implementation efforts in prenatal care settings.
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Affiliation(s)
- Esita Patel
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD (Drs Patel, Bandara, Saloner, Stuart, and McCourt, White, and McGinty); Geisel School of Medicine at Dartmouth, Lebanon, NH (Dr Goodman); Friends Research Institute, Baltimore, MD (Dr Terplan)Patel, McCourt, White - Department of Health Policy and Management.Bandara - Department of Mental Health.Saloner, Stuart, McGinty - Department of Health Policy and Managment; Department of Mental Health.Goodman - Department of Obstetrics and Gynecology; Department of Community and Family Medicine; The Dartmouth Institute.
| | - Sachini Bandara
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD (Drs Patel, Bandara, Saloner, Stuart, and McCourt, White, and McGinty); Geisel School of Medicine at Dartmouth, Lebanon, NH (Dr Goodman); Friends Research Institute, Baltimore, MD (Dr Terplan)Patel, McCourt, White - Department of Health Policy and Management.Bandara - Department of Mental Health.Saloner, Stuart, McGinty - Department of Health Policy and Managment; Department of Mental Health.Goodman - Department of Obstetrics and Gynecology; Department of Community and Family Medicine; The Dartmouth Institute
| | - Brendan Saloner
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD (Drs Patel, Bandara, Saloner, Stuart, and McCourt, White, and McGinty); Geisel School of Medicine at Dartmouth, Lebanon, NH (Dr Goodman); Friends Research Institute, Baltimore, MD (Dr Terplan)Patel, McCourt, White - Department of Health Policy and Management.Bandara - Department of Mental Health.Saloner, Stuart, McGinty - Department of Health Policy and Managment; Department of Mental Health.Goodman - Department of Obstetrics and Gynecology; Department of Community and Family Medicine; The Dartmouth Institute
| | - Elizabeth A Stuart
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD (Drs Patel, Bandara, Saloner, Stuart, and McCourt, White, and McGinty); Geisel School of Medicine at Dartmouth, Lebanon, NH (Dr Goodman); Friends Research Institute, Baltimore, MD (Dr Terplan)Patel, McCourt, White - Department of Health Policy and Management.Bandara - Department of Mental Health.Saloner, Stuart, McGinty - Department of Health Policy and Managment; Department of Mental Health.Goodman - Department of Obstetrics and Gynecology; Department of Community and Family Medicine; The Dartmouth Institute
| | - Daisy Goodman
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD (Drs Patel, Bandara, Saloner, Stuart, and McCourt, White, and McGinty); Geisel School of Medicine at Dartmouth, Lebanon, NH (Dr Goodman); Friends Research Institute, Baltimore, MD (Dr Terplan)Patel, McCourt, White - Department of Health Policy and Management.Bandara - Department of Mental Health.Saloner, Stuart, McGinty - Department of Health Policy and Managment; Department of Mental Health.Goodman - Department of Obstetrics and Gynecology; Department of Community and Family Medicine; The Dartmouth Institute
| | - Mishka Terplan
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD (Drs Patel, Bandara, Saloner, Stuart, and McCourt, White, and McGinty); Geisel School of Medicine at Dartmouth, Lebanon, NH (Dr Goodman); Friends Research Institute, Baltimore, MD (Dr Terplan)Patel, McCourt, White - Department of Health Policy and Management.Bandara - Department of Mental Health.Saloner, Stuart, McGinty - Department of Health Policy and Managment; Department of Mental Health.Goodman - Department of Obstetrics and Gynecology; Department of Community and Family Medicine; The Dartmouth Institute
| | - Alexander McCourt
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD (Drs Patel, Bandara, Saloner, Stuart, and McCourt, White, and McGinty); Geisel School of Medicine at Dartmouth, Lebanon, NH (Dr Goodman); Friends Research Institute, Baltimore, MD (Dr Terplan)Patel, McCourt, White - Department of Health Policy and Management.Bandara - Department of Mental Health.Saloner, Stuart, McGinty - Department of Health Policy and Managment; Department of Mental Health.Goodman - Department of Obstetrics and Gynecology; Department of Community and Family Medicine; The Dartmouth Institute
| | - Sarah White
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD (Drs Patel, Bandara, Saloner, Stuart, and McCourt, White, and McGinty); Geisel School of Medicine at Dartmouth, Lebanon, NH (Dr Goodman); Friends Research Institute, Baltimore, MD (Dr Terplan)Patel, McCourt, White - Department of Health Policy and Management.Bandara - Department of Mental Health.Saloner, Stuart, McGinty - Department of Health Policy and Managment; Department of Mental Health.Goodman - Department of Obstetrics and Gynecology; Department of Community and Family Medicine; The Dartmouth Institute
| | - Emma E McGinty
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD (Drs Patel, Bandara, Saloner, Stuart, and McCourt, White, and McGinty); Geisel School of Medicine at Dartmouth, Lebanon, NH (Dr Goodman); Friends Research Institute, Baltimore, MD (Dr Terplan)Patel, McCourt, White - Department of Health Policy and Management.Bandara - Department of Mental Health.Saloner, Stuart, McGinty - Department of Health Policy and Managment; Department of Mental Health.Goodman - Department of Obstetrics and Gynecology; Department of Community and Family Medicine; The Dartmouth Institute
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Abstract
BACKGROUND With the transition toward value-based care, health care organizations have a business imperative to simultaneously focus on improved health outcomes, improved patient and staff experience, and reduced costs (the Quadruple Aim). For federally qualified health centers-which provide care to some of nation's most vulnerable populations-balancing the complex task of systems change in the face of overwhelming volumes of information and best practices is challenging and can be supported through a guiding framework. PURPOSE This need for synthesis and translation of evidence in an actionable and practical way led to the design of a model for health center systems change. This article describes the development process and defines the resulting conceptual framework. METHODS Deployed a four-step process between 2016 and 2018 to develop and test a framework for value transformation in health centers. RESULTS NACHC's Quality Center developed the Value Transformation Framework to guide health center systems change toward high value care. The framework identifies 15 change areas across three Domains: infrastructure, care delivery, and people and summarizes evidence-based action steps within the change areas. CONCLUSIONS The framework shows promise in supporting health center efforts to adapt, transform, and balance competing demands as they advance value-based models of care.
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Oldfield BJ, Becker WC. Improving Guideline Adherence for Opioid Prescribing in Community Health Centers. Pain Med 2020; 21:1739-1741. [PMID: 32772102 DOI: 10.1093/pm/pnaa247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Benjamin J Oldfield
- Fair Haven Community Health Care, New Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - William C Becker
- Yale School of Medicine, New Haven, Connecticut.,Pain Research, Informatics, Multimorbidities & Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
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Muench J, Fankhauser K, Voss RW, Huguet N, Hartung DM, O’Malley J, Bailey SR, Cowburn S, Wright D, Barker G, Ukhanova M, Chamine I. Assessment of Opioid Prescribing Patterns in a Large Network of US Community Health Centers, 2009 to 2018. JAMA Netw Open 2020; 3:e2013431. [PMID: 32945874 PMCID: PMC7501536 DOI: 10.1001/jamanetworkopen.2020.13431] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Understanding opioid prescribing patterns in community health centers (CHCs) that disproportionately serve low-income patients may help to guide strategies to reduce opioid-related harms. OBJECTIVE To assess opioid prescribing patterns between January 1, 2009, and December 31, 2018, in a network of safety-net clinics serving high-risk patients. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of 3 227 459 opioid prescriptions abstracted from the electronic health records of 2 129 097 unique primary care patients treated from 2009 through 2018 at a network of CHCs that included 449 clinic sites in 17 states. All age groups were included in the analysis. MAIN OUTCOMES AND MEASURES The following measures were described at the population level for each study year: (1) percentage of patients with at least 1 prescription for an opioid by age and sex, (2) number of opioid prescriptions per 100 patients, (3) number of long-acting opioid prescriptions per 100 patients, (4) mean annual morphine milligram equivalents (MMEs) per patient, (5) mean MME per prescription, (6) number of chronic opioid users, and (7) mean of high-dose opioid users. RESULTS The study population included 2 129 097 patients (1 158 413 women [54.4%]) with a mean (SD) age of 32.2 (21.1) years and a total of 3 227 459 opioid prescriptions. The percentage of patients receiving at least 1 opioid prescription in a calendar year declined 67.4% from 15.9% in 2009 to 5.2% in 2018. Over the 10-year study period, a greater percentage of women received a prescription (13.1%) compared with men (10.9%), and a greater percentage of non-Hispanic White patients (18.1%) received an opioid prescription compared with non-Hispanic Black patients (9.5%), non-Hispanic patients who self-identified as other races (8.0%), and Hispanic patients (6.9%). The number of opioid prescriptions for every 100 patients decreased 73.7% from 110.8 in 2009 to 29.1 in 2018. The number of long-acting opioids for every 100 patients decreased 85.5% during the same period, from 22.0 to 3.2. The MMEs per patient decreased from 1682.7 in 2009 to 243.1 in 2018, a decline of 85.6%. CONCLUSIONS AND RELEVANCE In this cross-sectional study, the opioid prescribing rate in 2009 in the CHC network was higher than national population estimates but began to decline earlier and more precipitously. This finding likely reflects harm mitigation policies and efforts at federal, state, and clinic levels and strong clinical quality improvement strategies within the CHCs.
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Affiliation(s)
- John Muench
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - Katie Fankhauser
- Department of Family Medicine, Oregon Health & Science University, Portland
| | | | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - Daniel M. Hartung
- Department of Pharmacy Practice, Oregon State University, Portland
- Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland
| | - Jean O’Malley
- Department of Family Medicine, Oregon Health & Science University, Portland
- OCHIN Inc, Portland, Oregon
| | - Steffani R. Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland
| | | | | | | | - Maria Ukhanova
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - Irina Chamine
- Department of Family Medicine, Oregon Health & Science University, Portland
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Bruckner TA, Singh P, Snowden LR, Yoon J, Chakravarthy B. Rapid Growth of Mental Health Services at Community Health Centers. Adm Policy Ment Health 2019; 46:670-7. [PMID: 31273479 DOI: 10.1007/s10488-019-00947-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Community Health Centers (CHCs) target medically underserved communities and expanded by 70% in the last decade. We know little, however, about mental health services at CHCs. We analyzed data from 2006 to 2015 and determined county-level drivers of these services. Mental health patients at CHCs fall from 2006 to 2007 but then rise consistently from 2007 to 2015. Counties with fewer physicians, greater percent insured and greater percent white population show faster growth in mental health services. Increases in mental health services at CHCs outpace general CHC growth and reflect federal efforts to integrate behavioral health care into primary care.
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26
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Horowitz CR. Genetic testing and results disclosure in diverse populations: what does it take? Genet Med 2020; 22:1461-3. [PMID: 32565545 DOI: 10.1038/s41436-020-0874-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/09/2020] [Indexed: 11/08/2022] Open
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27
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White-Williams C, Rossi LP, Bittner VA, Driscoll A, Durant RW, Granger BB, Graven LJ, Kitko L, Newlin K, Shirey M. Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e841-e863. [DOI: 10.1161/cir.0000000000000767] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study (
Data Supplement
) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.
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Riordan F, McHugh SM, O'Donovan C, Mtshede MN, Kearney PM. The Role of Physician and Practice Characteristics in the Quality of Diabetes Management in Primary Care: Systematic Review and Meta-analysis. J Gen Intern Med 2020; 35:1836-1848. [PMID: 32016700 PMCID: PMC7280455 DOI: 10.1007/s11606-020-05676-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/03/2019] [Accepted: 01/19/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite evidence-based guidelines, high-quality diabetes care is not always achieved. Identifying factors associated with the quality of management in primary care may inform service improvements, facilitating the tailoring of quality improvement interventions to practice needs and resources. METHODS We searched MEDLINE, EMBASE, CINAHL and Web of Science from January 1990 to March 2019. Eligible studies were cohort studies, cross-sectional studies and randomised controlled trials (baseline data) conducted among adults with diabetes, which examined the relationship between any physician and/or practice factors and any objective measure(s) of quality. Studies which examined patient factors only were ineligible. Where possible, data were pooled using random-effects meta-analysis. RESULTS In total, 82 studies were included. The range of individual quality measures and the construction of composite measures varied considerably. Female physicians compared with males ((odds ratio (OR) = 1.07, 95% CI: 1.04, 1.10), 8 studies), physicians with higher diabetes volume compared with lower volume (OR = 1.24, 95% CI: 1.05-1.47, 4 studies) and practices with Electronic Health Records (EHR) versus practices without (OR = 1.43, 95% CI: 1.11-1.84, 4 studies) were associated with a higher quality of care. There was no association between physician experience, practice location and type of practice and quality. Based on the narrative synthesis, increasing physician age and higher practice socio-economic deprivation may be associated with lower quality of care. DISCUSSION Identification of physician- and practice-level factors associated with the quality of care (female gender, younger age, physician-level diabetes volume, practice deprivation and EHR use) may explain differences across practices and physicians, provide potential targets for quality improvement interventions and indicate which practices need specific supports to deliver improvements in diabetes care.
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Affiliation(s)
- F Riordan
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland.
| | - S M McHugh
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | | | - Mavis N Mtshede
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - P M Kearney
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
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29
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Kilany M, Wells R, Morrissey JP, Domino ME. Are There Performance Advantages Favoring Federally Qualified Health Centers in Medical Home Care for Persons with Severe Mental Illness? Adm Policy Ment Health 2020; 48:121-130. [PMID: 32424452 DOI: 10.1007/s10488-020-01050-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To identify whether medical homes in FQHCs have advantages over other group and individual medical practices in caring for people with severe mental illness. Models estimated the effect of the type of medical home on monthly service utilization, medication adherence, and total Medicaid spending over a 4-year period for adults aged 18 or older with a major depressive disorder (N = 65,755), bipolar disorder (N = 19,925), or schizophrenia (N = 8501) enrolled in North Carolina's Medicaid program. Inverse probability of treatment weights (IPTW) were used to adjust for nonrandom assignment of patients to practices. Generalized estimating equations for repeated measures were used with gamma distributions and log links for the continuous measures of medication adherence and spending, and binomial distributions with logit links for binary measures of any outpatient or any emergency department visits. Adults with major depression or bipolar disorders in FQHC medical homes had a lower probability of outpatient service use than their counterparts in individual and group practices. The probability of emergency department use, medication adherence, and total Medicaid spending were relatively similar across the three settings. This study suggests that no one type of medical practice setting-whether FQHC, other group, or individual-consistently outperforms the others in providing medical home services to people with severe mental illness.
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Affiliation(s)
- Mona Kilany
- American Institutes for Research, Washington, D.C., USA
| | - Rebecca Wells
- The University of Texas School of Public Health, Houston, USA
| | - Joseph P Morrissey
- Professor Emeritus, Department of Health Policy and Management, The Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Marisa Elena Domino
- Department of Health Policy and Management, The Gillings School of Global Public Health, Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, 1105B McGavran-Greenberg Hall, CB#7411, 135 Dauer Dr., Chapel Hill, NC, 27599-7411, USA.
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30
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Oronce CIA, Fortuna RJ. Differences in Rates of High-Value and Low-Value Care Between Community Health Centers and Private Practices. J Gen Intern Med 2020; 35:994-1000. [PMID: 31745849 PMCID: PMC7174534 DOI: 10.1007/s11606-019-05544-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 09/17/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Community health centers (CHCs) are an integral part of the health care safety net. As health systems seek to improve value, it is important to understand the quality of care provided by CHCs. OBJECTIVE To evaluate the performance of CHCs compared with private practices on a comprehensive set of high-value and low-value care measures. DESIGN This cross-sectional study used data from the National Ambulatory Medical Care Survey from 2010 through 2012. We compared CHCs with private practices using logistic regression models that adjusted for age, sex, race/ethnicity, insurance, number of chronic illnesses, rural versus urban location, region of country, and survey year. SETTING/PARTICIPANTS We included outpatient visits to generalist physicians at either CHCs or private practices by patients 18 years and older. MAIN MEASURES We examined 12 measures of high-value care and 7 measures of low-value care. RESULTS A total of 29,155 physician visits, representing 584,208,173 weighted visits, from 2010 through 2012 were included. CHCs were more likely to provide high-value care by ordering beta-blockers in CHF (46.9% vs. 36.5%; aOR 2.56; 95%CI 1.18-5.56), statins in diabetes (37.0% vs 35.5%; aOR 1.35; 95%CI 1.02-1.79), and providing treatment for osteoporosis (35.7% vs 23.2%; aOR 1.77; 95%CI 1.05-3.00) compared with private practices. CHCs were more likely to avoid low-value screening EKGs (98.7% vs. 88.0%; aOR 11.03; 95%CI 2.67-45.52), CBCs (75.9% vs. 65.7%; aOR 1.72; 95%CI 1.18-2.53), or urinalyses (86.0% vs. 80.5%; aOR 1.87; 95%CI 1.11-3.14) during a general medical exam. CHCs were also less likely to prescribe antibiotics for a URI (48.3% vs. 63.1%; aOR 0.59; 95%CI 0.40-0.88). CONCLUSIONS On a number of high-value and low-value measures of care, CHCs performed similar to or better than private practices. As healthcare delivery reforms continue to progress, CHCs are well positioned to provide high-value healthcare.
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Affiliation(s)
- Carlos Irwin A Oronce
- VA Greater Los Angeles Healthcare System, 1100 Glendon Ave. Ste. 900, Los Angeles, CA, 90034, USA. .,National Clinician Scholars Program and the Division of General Internal Medicine and Health Services Research, University of California, 1100 Glendon Ave. Ste. 900, Los Angeles, CA, 90034, USA.
| | - Robert J Fortuna
- Department of Medicine, University of Rochester Medical Center, 913 Culver Rd, Rochester, NY, 14609, USA. .,Department of Pediatrics, University of Rochester Medical Center, 913 Culver Rd, Rochester, NY, 14609, USA. .,Center for Primary Care, Culver Medical Group, University of Rochester Medical Center, 913 Culver Rd, Rochester, NY, 14609, USA.
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31
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Corallo B, Proser M, Nocon R. Comparing Rates of Multiple Chronic Conditions at Primary Care and Mental Health Visits to Community Health Centers Versus Private Practice Providers. J Ambul Care Manage 2020; 43:136-47. [PMID: 32011414 DOI: 10.1097/JAC.0000000000000324] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study identifies differences in rates of multiple chronic conditions at primary care and mental health visits to Community Health Centers and private practice providers using 2013 National Ambulatory Medical Care Survey data. Community health center visits had higher rates of 1 or more, 2 or more, and 3 or more chronic conditions for working-age patient visits (ages 18-64). There were no differences in other age groups. After controlling for age and other covariates using logistic regression, community health center visits had 35% higher odds of having any chronic condition and 31% higher odds of having 2 or more chronic conditions.
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Powell C, Nunery C, Hays S, Curry K. Moving Childhood Immunizations Out of the Public Health Setting: Effects on Immunization Rates. Policy Polit Nurs Pract 2019; 21:21-28. [PMID: 31791204 DOI: 10.1177/1527154419892961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
County health departments typically bear responsibility for implementing immunization programs. In 2011, the Florida state legislature made significant reductions in state health department funding, and responsibility for routine childhood immunizations in some counties was shifted to local federally qualified health centers. This study was conducted to assess the impact of these administrative changes on childhood immunization rates in one county. A secondary analysis of data in the state immunization registry was conducted to assess changes and patterns in childhood immunization rates within the local health department, federally qualified health centers, and private pediatric practices. These changes were compared in the 3-year period before, during, and after the change. Results revealed that there was no net negative change in the vaccination rates of 0- to 7-year-old children in the county. There was a shift in the proportion of vaccinations administered by each health care delivery setting. The majority of immunizations were administered in private pediatric practices. When state funding for the local public health department ceased, other delivery settings covered the immunizations previously provided in the public health sector.
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Affiliation(s)
| | | | - Stacia Hays
- The University of Florida College of Nursing, Gainesville, FL, USA
| | - Kim Curry
- The University of Florida College of Nursing, Gainesville, FL, USA
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Rosenthal M, Shortell S, Shah ND, Peiris D, Lewis VA, Barrera JA, Usadi B, Colla CH. Physician practices in Accountable Care Organizations are more likely to collect and use physician performance information, yet base only a small proportion of compensation on performance data. Health Serv Res 2019; 54:1214-1222. [PMID: 31742688 PMCID: PMC6863236 DOI: 10.1111/1475-6773.13238] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
IMPORTANCE It is critical to develop a better understanding of the strategies provider organizations use to improve the performance of frontline clinicians and whether ACO participation is associated with differential adoption of these tools. OBJECTIVES Characterize the strategies that physician practices use to improve clinician performance and determine their association with ACOs and other payment reforms. DATA SOURCES The National Survey of Healthcare Organizations and the National Survey of ACOs fielded 2017-2018 (response rates = 47 percent and 48 percent). STUDY DESIGN Descriptive analysis for practices participating and not participating in ACOs among 2190 physician practice respondents. Linear regressions to examine characteristics associated with counts of performance domains for which a practice used data for feedback, quality improvement, or physician compensation as dependent variables. Logistic and fractional regression to examine characteristics associated with use of peer comparison and shares of primary care and specialist compensation accounted for by performance bonuses, respectively. PRINCIPAL FINDINGS ACO-affiliated practices feed back clinician-level information and use it for quality improvement and compensation on more performance domains than non-ACO-affiliated practices. Performance measures contribute little to physician compensation irrespective of ACO participation. CONCLUSION ACO-affiliated practices are using more performance improvement strategies than other practices, but base only a small fraction of compensation on quality or cost.
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Affiliation(s)
- Meredith Rosenthal
- Health Policy and ManagementHarvard University T H Chan School of Public HealthBostonMassachusetts
| | | | - Nilay D. Shah
- Division of Health Care Policy & ResearchMayo ClinicRochesterMinnesota
| | - David Peiris
- Health Systems ScienceUniversity of New South Wales Faculty of MedicineSydneyNSWAustralia
| | - Valerie A. Lewis
- Health Policy and ManagementUniversity of North Carolina at Chapel Hill Gillings School of Global Public HealthChapel HillNorth Carolina
| | - Jacob A. Barrera
- Health Policy and ManagementHarvard University T H Chan School of Public HealthBostonMassachusetts
| | - Benjamin Usadi
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew Hampshire
| | - Carrie H. Colla
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew Hampshire
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Martinez GS, Chu J, Marachelian A, Gomez M. More Than Health Care: The Value of Addressing Health, Education, and Social Service Needs Together Through Community Health Centers. J Ambul Care Manage 2020; 43:41-54. [PMID: 31770185 DOI: 10.1097/JAC.0000000000000314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Research on social determinants of health shows that factors outside of medical care including environment, education, and income also affect health. Some community health centers seek to address these by providing additional nonmedical services. Community health centers can find it difficult to justify these costs when the benefit is unclear. This review highlights studies on services like those the community health center Mary's Center provides through its Social Change Model, offering health, education, and social services in the Washington, District of Columbia metropolitan area. The review finds that most studies report positive results, though more research is needed, especially in the area of social services.
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Modica C, Lewis JH, Bay C. Colorectal Cancer: Applying the Value Transformation Framework to increase the percent of patients receiving screening in Federally Qualified Health Centers. Prev Med Rep 2019; 15:100894. [PMID: 31198660 PMCID: PMC6556543 DOI: 10.1016/j.pmedr.2019.100894] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/07/2019] [Accepted: 05/12/2019] [Indexed: 11/29/2022] Open
Abstract
Background Colorectal cancer is the second leading cause of cancer death in the U.S. and third-most common cancer in both men and women. Colorectal cancer screening (CRCS) rates remain low, particularly among vulnerable patients receiving care at federally qualified health centers. Through its Value Transformation Framework, the National Association of Community Health Centers provides a systematic approach to improving CRCS by transforming health center infrastructure, care delivery, and people systems—to improve health outcomes, patient and staff experiences, and lower costs (Quadruple Aim). Methods We combined the Value Transformation Framework, evidence-based CRCS interventions, and the Learning Community Model to drive system improvements and implement evidence-based practices. Multi-disciplinary teams at 8 health centers in Georgia and Iowa participated for 1-year with Primary Care Association support. Results Pre−/post- 1-year-intervention data showed, within health centers, raw percentage of eligible patients screened for CRC increased from 33.2% (13.5%–61.7%) in January 2017 to 46.5% (14.2%–81.5%) in December 2017, with an overall 13.3 percentage point average increase. This translates into an average increase of 3.3 (95% CI: 1.7, 5.0) eligible patients screened per month per health center over the year or 317 additional patients meeting CRCS guidelines. Specific interventions associated with higher CRCS rates included standing orders, sharing performance data, and electronic health record alerts. Conclusion Findings support a three-pronged approach for improving CRCS: The Value Transformation Framework's evidence-based recommendations, with actionable CRC interventions, offered in a learning community. These results guide methodological approaches to improving CRCS in health centers through a multi-level, multi-modality quality improvement and transformation approach.
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Affiliation(s)
- Cheryl Modica
- National Association of Community Health Centers, 7501 Wisconsin Avenue, Suite 1100W, Bethesda, MD 20814, United States of America
| | - Joy H Lewis
- A.T. Still University, School of Osteopathic Medicine in Arizona, 5850 E. Still Circle, Mesa, AZ 85206, United States of America
| | - Curt Bay
- Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, 5850 E. Still Circle, Mesa, AZ 85206, Mesa, AZ 85206, United States of America
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Lindner S, Solberg LI, Miller WL, Balasubramanian BA, Marino M, McConnell KJ, Edwards ST, Stange KC, Springer RJ, Cohen DJ. Does Ownership Make a Difference in Primary Care Practice? J Am Board Fam Med 2019; 32:398-407. [PMID: 31068404 DOI: 10.3122/jabfm.2019.03.180271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 02/01/2019] [Accepted: 02/05/2019] [Indexed: 11/08/2022] Open
Abstract
PURPOSE We assessed differences in structural characteristics, quality improvement processes, and cardiovascular preventive care by ownership type among 989 small to medium primary care practices. METHODS This cross-sectional analysis used electronic health record and survey data collected between September 2015 and April 2017 as part of an evaluation of the EvidenceNOW: Advancing Heart Health in Primary Care Initiative by the Agency for Health Care Research and Quality. We compared physician-owned practices, health system or medical group practices, and Federally Qualified Health Centers (FQHC) by using 15 survey-based practice characteristic measures, 9 survey-based quality improvement process measures, and 4 electronic health record-based cardiovascular disease prevention quality measures, namely, aspirin prescription, blood pressure control, cholesterol management, and smoking cessation support (ABCS). RESULTS Physician-owned practices were more likely to be solo (45.0% compared with 8.1%, P < .001 for health system practices and 12.8%, P = .009 for FQHCs) and less likely to have experienced a major change (eg, moved to a new location) in the last year (43.1% vs 65.4%, P = .01 and 72.1%, P = .001, respectively). FQHCs reported the highest use of quality improvement processes, followed by health system practices. ABCS performance was similar across ownership type, with the exception of smoking cessation support (51.0% for physician-owned practices vs 67.3%, P = .004 for health system practices and 69.3%, P = .004 for FQHCs). CONCLUSIONS Primary care practice ownership was associated with differences in quality improvement process measures, with FQHCs reporting the highest use of such quality-improvement strategies. ABCS were mostly unrelated to ownership, suggesting a complex path between quality improvement strategies and outcomes.
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Khan NNS, Kelly-Blake K, Luo Z, Olomu A. Sex Differences in Statin Prescribing in Diabetic and Heart Disease Patients in FQHCs: A Comparison of the ATPIII and 2013 ACC/AHA Cholesterol Guidelines. Health Serv Res Manag Epidemiol 2019; 6:2333392818825414. [PMID: 30859113 PMCID: PMC6404057 DOI: 10.1177/2333392818825414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 12/21/2018] [Indexed: 12/05/2022] Open
Abstract
Purpose: The purpose of this study was to determine the difference in the rate of statin
prescribing based on the Adult Treatment Panel (ATP) III and 2013 American College of
Cardiology (ACC)/American Heart Association cholesterol guidelines across sex in
Federally Qualified Health Centers (FQHCs), and to determine the proportion of patients
on recommended statin dosage based on the 2013 cholesterol guideline. Methods: The Office Guidelines Applied to Practice (Office-GAP) study is a quasi-experimental, 2
FQHCs center study that enrolled patients with coronary heart disease and diabetes
mellitus (DM). We computed 10-year atherosclerotic cardiovascular disease (ASCVD) risks
scores based on ACC guidelines and determined the rate of statin prescribing across sex
in FQHCs using both guidelines. Main outcomes measures were (1) rate of statin
prescribing based on ATPIII and 2013 cholesterol guidelines across sex and (2)
proportion of patients on recommended statin dosage based on the 2013 cholesterol
guideline. Results: The 2013 cholesterol guideline did not increase the rate of eligibility of statin for
men and women compared to ATPIII guideline. No significant difference between men and
women in statin prescribing under ATPIII (67% vs 57%, P = .13) and 2013
cholesterol guidelines (66% vs 63%, P = .69) and in the recommended
dosage of statin per the 2013 cholesterol guidelines between men and women in FQHCs (12%
vs 22%, P = .22). Conclusions: We found statin underprescribing for both men and women with ASCVD and DM in FQHCs.
Utilizing both the ATPIII and the 2013 cholesterol guidelines, men with ASCVD and DM
were prescribed statin more than women. However, fewer men were found to be on the
recommended dosage of statin based on the 2013 cholesterol guideline. Our findings
suggest that Office-GAP may have improved the prescription/use of statin in both men and
women.
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Affiliation(s)
- Nazia Naz S Khan
- Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Karen Kelly-Blake
- Center for Ethics and Humanities in the Life Sciences and Department of Medicine, Michigan State University, East Lansing, MI, USA
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Adesuwa Olomu
- Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA
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Nath JB, Costigan S, Lin F, Vittinghoff E, Hsia RY. Access to Federally Qualified Health Centers and Emergency Department Use Among Uninsured and Medicaid-insured Adults: California, 2005 to 2013. Acad Emerg Med 2019; 26:129-139. [PMID: 30648780 DOI: 10.1111/acem.13494] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/29/2018] [Accepted: 06/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND While improved access to safety net primary care providers, like federally qualified health centers (FQHCs), is often cited as a route to alleviate potentially preventable emergency department (ED) visits, no studies have longitudinally established the impact of improving access to FQHCs on ED use among Medicaid-insured and uninsured adults. We aimed to determine whether improved access to FQHCs was associated with lower ED use by uninsured and Medicaid-insured adults. METHODS Using data from the Uniform Data System, U.S. Census Bureau, and California Office of Statewide Health Planning & Development, we conducted a longitudinal analysis of 58 California counties from 2005 to 2013. For each county-year observation, we employed three measures of FQHC access: geographic density of FQHCs (delivery sites per 100 square miles), FQHCs per county resident (delivery sites per 100,000 county residents), and the proportion of Medicaid-insured or uninsured residents ages 19 to 64 years that utilized FQHCs. We then used a fixed-effects model to examine the impact of changes in the measures of FQHC access on ED visit rates by Medicaid-insured or uninsured adults in each county. RESULTS Increasing geographic density of FQHCs was associated with a 26% to 35% decrease in ED use by uninsured but not Medicaid-insured patients. Increasing numbers of clinics per county resident and higher percentages of Medicaid-insured and uninsured adults seen at FQHCs were not associated with reduced rates of ED use among either uninsured or Medicaid-insured adults. CONCLUSIONS We were unable to detect a consistent association between our measures of FQHC access and ED use by Medicaid-insured and uninsured nonelderly California adults, underscoring the importance of investigating additional drivers to reduce ED use among these vulnerable patient populations.
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Affiliation(s)
- Julia B. Nath
- University of Chicago Internal Medicine Residency Program; Chicago IL
| | - Shaughnessy Costigan
- University of California San Francisco Fresno Emergency Medicine Residency Program; Fresno CA
| | - Feng Lin
- Department of Epidemiology and Biostatistics; University of California at San Francisco; San Francisco CA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics; University of California at San Francisco; San Francisco CA
| | - Renee Y. Hsia
- Department of Emergency Medicine; University of California at San Francisco; San Francisco CA
- Phillip R. Lee Institute for Health Policy Studies; University of California at San Francisco; San Francisco CA
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Saloner B, Hempstead K, Rhodes K, Polsky D, Pan C, Kenney GM. Most Primary Care Physicians Provide Appointments, But Affordability Remains A Barrier For The Uninsured. Health Aff (Millwood) 2019; 37:627-634. [PMID: 29608344 DOI: 10.1377/hlthaff.2017.0959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The US uninsurance rate has nearly been cut in half under the Affordable Care Act, and access to care has improved for the newly insured, but less is known about how the remaining uninsured have fared. In 2012-13 and again in 2016 we conducted an experiment in which trained auditors called primary care offices, including federally qualified health centers, in ten states. The auditors portrayed uninsured patients seeking appointments and information on the cost of care and payment arrangements. In both time periods, about 80 percent of uninsured callers received appointments, provided they could pay the full cash amount. However, fewer than one in seven callers in both time periods received appointments for which they could make a payment arrangement to bring less than the full amount to the visit. Visit prices in both time periods averaged about $160. Trends were largely similar across states, despite their varying changes in the uninsurance rate. Federally qualified health centers provided the highest rates of primary care appointment availability and discounts for uninsured low-income patients.
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Affiliation(s)
- Brendan Saloner
- Brendan Saloner ( ) is an assistant professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Katherine Hempstead
- Katherine Hempstead is a senior advisor at the Robert Wood Johnson Foundation, in Princeton, New Jersey
| | - Karin Rhodes
- Karin Rhodes is vice president for care management design and evaluation at Northwell Health, in Great Neck, New York
| | - Daniel Polsky
- Daniel Polsky is a professor of medicine, the Robert D. Eilers Professor in Health Care Management, and executive director of the Leonard Davis Institute of Health Economics, all at the University of Pennsylvania, in Philadelphia
| | - Clare Pan
- Clare Pan is a research associate at the Urban Institute, in Washington, D.C
| | - Genevieve M Kenney
- Genevieve M. Kenney is a senior fellow in and codirector of the Health Policy Center at the Urban Institute
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Casalino LP, Ramsay P, Baker LC, Pesko MF, Shortell SM. Medical Group Characteristics and the Cost and Quality of Care for Medicare Beneficiaries. Health Serv Res 2018; 53:4970-4996. [PMID: 29978481 PMCID: PMC6232442 DOI: 10.1111/1475-6773.13010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To estimate the relationship between outcomes of care and medical practices' structure and use of organized care improvement processes. DATA SOURCES/STUDY SETTING We linked Medicare claims data to our national survey of physician practices (2012-2013). Fifty percent response rate; 1,040 responding practices; 31,888 physicians; 868,213 attributed Medicare beneficiaries. STUDY DESIGN Cross-sectional observational analysis of the relationship between practice characteristics and total spending, readmissions, and ambulatory care-sensitive admissions (ACSAs), for all beneficiaries and five categories of beneficiary defined by predicted need for care. PRINCIPAL FINDINGS Practices with 100+ physicians and 50-99 physicians had, respectively, annual spending per high-need beneficiary that was $1,870 (12.5 percent) and $1,824 higher than practices with 1-2 physicians, and readmission rates 1.64 and 1.71 higher. ACSA rates did not vary significantly by practice size. Outcomes did not vary significantly by ownership or by practices' use of organized processes to improve care. CONCLUSIONS Large practices had higher spending and readmission rates than the smallest practices, especially for high-need beneficiaries. There were no significant performance differences between physician-owned and hospital-owned practices. Policy makers should consider the effects of specific policies on provider organization, pending further research to learn which types of practice provide better care.
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Affiliation(s)
- Lawrence P. Casalino
- Division of Health Policy and EconomicsDepartment of Healthcare Policy and ResearchWeill Cornell Medical CollegeNew YorkNY
| | - Patricia Ramsay
- Center for Healthcare Organizational and Innovation Research (CHOIR)School of Public HealthUniversity of California—BerkeleyBerkeleyCA
| | - Laurence C. Baker
- Department of Health Research and Policy and the Stanford
Institute for Economic Policy ResearchStanfordCA
| | - Michael F. Pesko
- Department of EconomicsAndrew Young School of Policy StudiesGeorgia State UniversityAtlantaGA
| | - Stephen M. Shortell
- Center for Healthcare Organizational and Innovation Research (CHOIR)School of Public Health, and the Haas School of BusinessUniversity of CaliforniaBerkeleyCA
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Abstract
Through the expansion of Medicaid eligibility and increases in core federal grant funding, the Affordable Care Act (ACA) sought to increase the capacity of community health centers to provide primary care to low-income populations. We examined the effects of the ACA Medicaid expansion and changes in federal grant levels on the centers' numbers of patients, percentages of patients by type of insurance, and numbers of visits from 2012 to 2015. In the period after expansion (2014-15), health centers in expansion states had a 5 percent higher total patient volume, larger shares of Medicaid patients, smaller shares of uninsured patients, and increases in overall visits and mental health visits, compared to centers in nonexpansion states. Increases in federal grant funding levels were associated with increases in numbers of patients and of overall, medical, and preventive service visits. If federal grant levels are not sustained after 2017, there could be marked reductions in health center capacity in both expansion and nonexpansion states.
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Affiliation(s)
- Xinxin Han
- Xinxin Han is a graduate research assistant in the Department of Health Policy and Management, Milken Institute School of Public Health, at George Washington University, in Washington, D.C
| | - Qian Luo
- Qian Luo is a research associate in the Department of Health Policy and Management, Milken Institute School of Public Health, at George Washington University
| | - Leighton Ku
- Leighton Ku is a professor in the Department of Health Policy and Management, Milken Institute School of Public Health, and director of the Center for Health Policy Research, both at George Washington University
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Abstract
Community health centers (CHC) provide quality care for vulnerable patients, and a potentially contributing factor to this quality is the integration of a patient-centered medical home (PCMH). PCMH relies on a team-based approach, a principle in which social workers are trained and research examines in primary care environments. Less is known about team-based care in CHCs. An exploratory qualitative study with 14 CHC staff was conducted to examine the current state of team-based care and secondarily, to examine the role of social workers. Content analysis revealed four themes central to team-based care. Implications for CHCs and social workers are discussed.
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Affiliation(s)
- Kristi L Law
- a Department of Social Work , University of Wisconsin-Whitewater, College of Letters and Science , USA
| | - Jeannine M Rowe
- a Department of Social Work , University of Wisconsin-Whitewater, College of Letters and Science , USA
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Shi L, Lee DC, Haile GP, Liang H, Chung M, Sripipatana A. Access to Care and Satisfaction Among Health Center Patients With Chronic Conditions. J Ambul Care Manage 2017; 40:69-76. [PMID: 27902554 DOI: 10.1097/JAC.0000000000000153] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study examined access to care and satisfaction among health center patients with chronic conditions. Data for this study were obtained from the 2009 Health Center Patient Survey. Dependent variables of interest included 5 measures of access to and satisfaction with care, whereas the main independent variable was number of chronic conditions. Results of bivariate analysis and multiple logistic regressions showed that patients with chronic conditions had significantly higher odds of reporting access barriers than those without chronic conditions. Our results suggested that additional efforts and resources are necessary to address the needs of health center patients with chronic conditions.
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Abstract
Preventive services have the potential to reduce health disparities; however, these services are underutilized, particularly among the underserved. Patients with low socioeconomic status and racial and ethnic minorities experience significant health disparities related to cancer and infectious and chronic diseases but face multilevel challenges accessing preventive care. The purpose of this article is to enhance understanding of preventive service utilization among underserved patients by providing an ecological framework that addresses factors at multiple levels that influence patient care. In addition to factors that directly impact the patient, the framework incorporates influences on the patient's experience of the health system.
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Affiliation(s)
- Bettie Coplan
- School for the Science of Health Care Delivery, College of Health Solutions, Arizona State University, Phoenix
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Angier H, Hoopes M, Marino M, Huguet N, Jacobs EA, Heintzman J, Holderness H, Hood CM, DeVoe JE. Uninsured Primary Care Visit Disparities Under the Affordable Care Act. Ann Fam Med 2017; 15:434-442. [PMID: 28893813 PMCID: PMC5593726 DOI: 10.1370/afm.2125] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 05/24/2017] [Accepted: 07/03/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Health insurance coverage affects a patient's ability to access optimal care, the percentage of insured patients on a clinic's panel has an impact on the clinic's ability to provide needed health care services, and there are racial and ethnic disparities in coverage in the United States. Thus, we aimed to assess changes in insurance coverage at community health center (CHC) visits after the Patient Protection and Affordable Care Act (ACA) Medicaid expansion by race and ethnicity. METHODS We undertook a retrospective, observational study of visit payment type for CHC patients aged 19 to 64 years. We used electronic health record data from 10 states that expanded Medicaid and 6 states that did not, 359 CHCs, and 870,319 patients with more than 4 million visits. Our analyses included difference-in-difference (DD) and difference-in-difference-in-difference (DDD) estimates via generalized estimating equation models. The primary outcome was health insurance type at each visit (Medicaid-insured, uninsured, or privately insured). RESULTS After the ACA was implemented, uninsured visit rates decreased for all racial and ethnic groups. Hispanic patients experienced the greatest increases in Medicaid-insured visit rates after ACA implementation in expansion states (rate ratio [RR] = 1.77; 95% CI, 1.56-2.02) and the largest gains in privately insured visit rates in nonexpansion states (RR = 3.63; 95% CI, 2.73-4.83). In expansion states, non-Hispanic white patients had twice the magnitude of decrease in uninsured visits compared with Hispanic patients (DD = 2.03; 95% CI, 1.53-2.70), and this relative change was more than 2 times greater in expansion states compared with nonexpansion states (DDD = 2.06; 95% CI, 1.52-2.78). CONCLUSION The lower rates of uninsured visits for all racial and ethnic groups after ACA implementation suggest progress in expanding coverage to CHC patients; this progress, however, was not uniform when comparing expansion with nonexpansion states and among all racial and ethnic minority subgroups. These findings suggest the need for continued and more equitable insurance expansion efforts to eliminate health insurance disparities.
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Affiliation(s)
| | | | - Miguel Marino
- Oregon Health & Science University, Portland, Oregon
| | | | - Elizabeth A Jacobs
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Timbie JW, Hussey PS, Setodji CM, Kress A, Malsberger R, Lavelle TA, Friedberg MW, Wensky SG, Giuriceo KD, Kahn KL. Association Between Patient-Centered Medical Home Capabilities and Outcomes for Medicare Beneficiaries Seeking Care from Federally Qualified Health Centers. J Gen Intern Med 2017; 32:997-1004. [PMID: 28550610 DOI: 10.1007/s11606-017-4078-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 04/06/2017] [Accepted: 04/13/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patient-centered medical home (PCMH) models of primary care have the potential to expand access, improve population health, and lower costs. Federally qualified health centers (FQHCs) were early adopters of PCMH models. OBJECTIVE We measured PCMH capabilities in a diverse nationwide sample of FQHCs and assessed the relationship between PCMH capabilities and Medicare beneficiary outcomes. DESIGN Cross-sectional, propensity score-weighted, multivariable regression analysis. PARTICIPANTS A convenience sample of 804 FQHC sites that applied to a nationwide FQHC PCMH initiative and 231,163 Medicare fee-for-service beneficiaries who received a plurality of their primary care services from these sites. MAIN MEASURES PCMH capabilities were self-reported using the National Committee for Quality Assurance's (NCQA's) 2011 application for PCMH recognition. Measures of utilization, continuity of care, quality, and Medicare expenditures were derived from Medicare claims covering a 1-year period ending October 2011. KEY RESULTS Nearly 88% of sites were classified as having PCMH capabilities equivalent to NCQA Level 1, 2, or 3 PCMH recognition. These more advanced sites were associated with 228 additional FQHC visits per 1000 Medicare beneficiaries (95% CI: 176, 278), compared with less advanced sites; 0.02 points higher practice-level continuity of care (95% CI: 0.01, 0.03); and a greater likelihood of administering two of four recommended diabetes tests. However, more advanced sites were also associated with 181 additional visits to specialists per 1000 beneficiaries (95% CI: 124, 232) and 64 additional visits to emergency departments (95% CI: 35, 89)-but with no differences in inpatient utilization. More advanced sites had higher Part B expenditures ($111 per beneficiary [95% CI: $61, $158]) and total Medicare expenditures of $353 [95% CI: $65, $614]). CONCLUSIONS Implementation of PCMH models in FQHCs may be associated with improved primary care for Medicare beneficiaries. Expanded access to care, in combination with slower development of key PCMH capabilities, may explain higher Medicare expenditures and other types of utilization.
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Hatch B, Marino M, Killerby M, Angier H, Hoopes M, Bailey SR, Heintzman J, O'Malley JP, DeVoe JE. Medicaid's Impact on Chronic Disease Biomarkers: A Cohort Study of Community Health Center Patients. J Gen Intern Med 2017; 32:940-947. [PMID: 28374214 PMCID: PMC5515790 DOI: 10.1007/s11606-017-4051-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/05/2016] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Understanding the impact of health insurance is critical, particularly in the era of Affordable Care Act Medicaid expansion. The electronic health record (EHR) provides new opportunities to quantify health outcomes. OBJECTIVE To assess changes in biomarkers of chronic disease among community health center (CHC) patients who gained Medicaid coverage with the Oregon Medicaid expansion (2008-2011). DESIGN Prospective cohort. Patients were followed for 24 months, and rate of mean biomarker change was calculated. Time to a controlled follow-up measurement was compared using Cox regression models. SETTING/PATIENTS Using EHR data from OCHIN (a non-profit network of CHCs) linked to state Medicaid data, we identified three cohorts of patients with uncontrolled chronic conditions (diabetes, hypertension, and hyperlipidemia). Within these cohorts, we included patients who gained Medicaid coverage along with a propensity score-matched comparison group who remained uninsured (diabetes n = 608; hypertension n = 1244; hyperlipidemia n = 546). MAIN MEASURES Hemoglobin A1c (HbA1c) for the diabetes cohort, systolic and diastolic blood pressure (SBP and DBP, respectively) for the hypertension cohort, and low-density lipoprotein (LDL) for the hyperlipidemia cohort. KEY RESULTS All cohorts improved over time. Compared to matched uninsured patients, adults in the diabetes and hypertension cohorts who gained Medicaid coverage were significantly more likely to have a follow-up controlled measurement (hazard ratio [HR] =1.26, p = 0.020; HR = 1.35, p < 0.001, respectively). No significant difference was observed in the hyperlipidemia cohort (HR = 1.09, p = 0.392). CONCLUSIONS OCHIN patients with uncontrolled chronic conditions experienced objective health improvements over time. In two of three chronic disease cohorts, those who gained Medicaid coverage were more likely to achieve a controlled measurement than those who remained uninsured. These findings demonstrate the effective care provided by CHCs and the importance of health insurance coverage within a usual source of care setting. CLINICAL TRIALS REGISTRATION NCT02355132 [ https://clinicaltrials.gov/ct2/show/NCT02355132 ].
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Affiliation(s)
- Brigit Hatch
- Oregon Health & Science University, Portland, OR, USA.,OCHIN, Inc., Portland, OR, USA
| | - Miguel Marino
- Oregon Health & Science University, Portland, OR, USA
| | | | | | | | | | | | | | - Jennifer E DeVoe
- Oregon Health & Science University, Portland, OR, USA.,OCHIN, Inc., Portland, OR, USA
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Timbie JW, Setodji CM, Kress A, Lavelle TA, Friedberg MW, Mendel PJ, Chen EK, Weidmer BA, Buttorff C, Malsberger R, Kommareddi M, Rastegar A, Kofner A, Hiatt L, Mahmud A, Giuriceo K, Kahn KL. Implementation of Medical Homes in Federally Qualified Health Centers. N Engl J Med 2017. [PMID: 28636834 DOI: 10.1056/nejmsa1616041] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND From 2011 through 2014, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration provided care management fees and technical assistance to a nationwide sample of 503 federally qualified health centers to help them achieve the highest (level 3) medical-home recognition by the National Committee for Quality Assurance, a designation that requires the implementation of processes to improve access, continuity, and coordination. METHODS We examined the achievement of medical-home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients' experiences, and Medicare expenditures in demonstration sites versus comparison sites. Using difference-in-differences analyses, we compared changes in outcomes in the two groups of sites during a 3-year period. RESULTS Level 3 medical-home recognition was awarded to 70% of demonstration sites and to 11% of comparison sites. Although the number of visits to federally qualified health centers decreased in the two groups, smaller reductions among demonstration sites than among comparison sites led to a relative increase of 83 visits per 1000 beneficiaries per year at demonstration sites (P<0.001). Similar trends explained the higher performance of demonstration sites with respect to annual eye examinations and nephropathy tests (P<0.001 for both comparisons); there were no significant differences with respect to three other process measures. Demonstration sites had larger increases than comparison sites in emergency department visits (30.3 more per 1000 beneficiaries per year, P<0.001), inpatient admissions (5.7 more per 1000 beneficiaries per year, P=0.02), and Medicare Part B expenditures ($37 more per beneficiary per year, P=0.02). Demonstration-site participation was not associated with relative improvements in most measures of patients' experiences. CONCLUSIONS Demonstration sites had higher rates of medical-home recognition and smaller decreases in the number of patients' visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. Demonstration sites had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. (Funded by the Centers for Medicare and Medicaid Services.).
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Affiliation(s)
- Justin W Timbie
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Claude M Setodji
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Amii Kress
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Tara A Lavelle
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Mark W Friedberg
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Peter J Mendel
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Emily K Chen
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Beverly A Weidmer
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Christine Buttorff
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Rosalie Malsberger
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Mallika Kommareddi
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Afshin Rastegar
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Aaron Kofner
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Lisa Hiatt
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Ammarah Mahmud
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Katherine Giuriceo
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
| | - Katherine L Kahn
- From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.)
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Fam E, Ferrante JM. Lessons Learned Recruiting Minority Participants for Research in Urban Community Health Centers. J Natl Med Assoc 2017; 110:44-52. [PMID: 29510843 DOI: 10.1016/j.jnma.2017.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 02/28/2017] [Accepted: 06/21/2017] [Indexed: 11/20/2022]
Abstract
To help understand and mitigate health disparities, it is important to conduct research with underserved and underrepresented minority populations under real world settings. There is a gap in the literature detailing real-time research staff experience, particularly in their own words, while conducting in-person patient recruitment in urban community health centers. This paper describes challenges faced at the clinic, staff, and patient levels, our lessons learned, and strategies implemented by research staff while recruiting predominantly low-income African-American women for an interviewer-administered survey study in four urban Federally Qualified Health Centers in New Jersey. Using a series of immersion-crystallization cycles, fieldnotes and research reflections written by recruiters, along with notes from team meetings during the study, were qualitatively analyzed. Clinic level barriers included: physical layout of clinic, very low or high patient census, limited private space, and long wait times for patients. Staff level barriers included: unengaged staff, overburdened staff, and provider and staff turnover. Patient level barriers included: disinterested patients, patient mistrust and concerns over confidentiality, no-shows or lack of patient time, and language barrier. We describe strategies used to overcome these barriers and provide recommendations for in-person recruitment of underserved populations into research studies. To help mitigate health disparities, disseminating recruiters' experiences, challenges, and effective strategies used will allow other researchers to build upon these experience in order to increase recruitment success of underserved and underrepresented minority populations into research studies.
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Affiliation(s)
- Elizabeth Fam
- Preliminary Medicine, Rutgers- New Jersey Medical School, 185 South Orange Ave, Newark, NJ, 07103, USA
| | - Jeanne M Ferrante
- Department of Family Medicine and Community Health, Rutgers- Robert Wood Johnson Medical School, 112 Paterson St., New Brunswick, NJ, 08901, USA; The Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA; Rutgers Institute of Health, Health Care Policy, and Aging Research, New Brunswick, NJ, USA.
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50
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Kurtzman ET, Barnow BS. A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians’ Patterns of Practice and Quality of Care in Health Centers. Med Care 2017; 55:615-22. [DOI: 10.1097/mlr.0000000000000689] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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