Healthcare and Social Needs Assessment and Response Quality Among Black Men

To understand Black men's healthcare and social needs and determine if the resources that healthcare systems offer meet expectations. We surveyed men who had previously participated in at least one Minority Men's Health Fair in Cleveland, Ohio. In this descriptive study, we spoke with men up to three times (i.e., phases) between May and October 2020 by email and/or telephone. Phase 1 was a needs assessment survey. Phase 2 involved outreach to those who identified a need to provide a resource. Phase 3 determined whether the resource met individuals' needs. We described the demographic characteristics of the survey respondents, the percentage of men reporting a need and wanting a resource, and whether the resource resolved their need. Of the 768 men contacted, 275 completed the survey (36% response rate). The majority of respondents were 50-69 years old, identified as Black, and had at least a bachelor's degree. Eighty-five percent reported a need, of which wellness, financial, and healthcare access were among the top-reported needs. Among the men identifying a need, 35% were interested in a resource. Resources that were provided for employment, behavioral health, oral health, vision, or wellness needs were deemed insufficient. A few individuals reported that resources for food/personal hygiene, financial support, health care access, annual health screening, and medication met their needs. Among men with healthcare and social needs, only a fraction were interested in a resource, and fewer reported that the resource met their needs. These results warrant a greater understanding of what constitutes a resolution of healthcare and social needs from patients' perspectives.

Racial and ethnic differences in uncontrolled diabetes mellitus among adults taking antidiabetic medication

AIM

To examine whether racial and ethnic disparities in uncontrolled type 2 diabetes mellitus (T2DM) persist among those taking medication and after accounting for other demographic, socioeconomic, and health indicators.

METHODS

Adults aged ≥20 years with T2DM using prescription diabetes medication were among participants assessed in a retrospective cohort study of the National Health and Nutrition Examination Survey 2007-2018. We estimated weighted sequential multivariable logistic regression models to predict odds of uncontrolled T2DM (HbA1c ≥ 8%) from racial and ethnic identity, adjusting for demographic, socioeconomic, and health indicators.

RESULTS

Of 3649 individuals with T2DM who reported taking medication, 27.4% had uncontrolled T2DM (mean HgA1c 9.6%). Those with uncontrolled diabetes had a mean BMI of 33.8, age of 57.3, and most were non-Hispanic white (54%), followed by 17% non-Hispanic Black, and 20% Hispanic identity. In multivariable analyses, odds of uncontrolled T2DM among those with Black or Hispanic identities lessened, but persisted, after accounting for other indicators (Black OR 1.38, 97.5% CI: 1.04, 1.83; Hispanic OR 1.79, 97.5% CI 1.25, 2.57).

CONCLUSIONS

Racial and ethnic disparities in T2DM control persisted among individuals taking medication. Future research might focus on developmental and epigenetic pathways of disparate T2DM control across racially and ethnically minoritized populations.

Health-Related Social Needs: Which Patients Respond to Screening and Who Receives Resources?

BACKGROUND

Health systems are screening patients for health-related social needs (HRSN) but the optimal approach is unknown.

OBJECTIVE

To describe the variation in responding to an HRSN questionnaire delivered via patient portal, and whether referral to and resources provided by social workers differed by response status.

DESIGN

Retrospective observational study.

PARTICIPANTS

Primary care patients with a visit between June 2020 and January 2022.

INTERVENTION

HRSN questionnaire MAIN MEASURES: We identified each patient's index visit (e.g., date of their first questionnaire response for responders or their first visit within the study period for non-responders). Through the EHR, we identified patients' demographic characteristics. We linked the area deprivation index (ADI) to each patient and grouped patients into quintiles. We used multilevel logistic regressions to identify characteristics associated with responding to the questionnaire and, for responders, reporting a need. We also determined if responder status was associated with receiving a social worker referral or receiving a resource. We included patient demographics and ADI quintile as fixed variables and practice site as a random variable.

KEY RESULTS

Our study included 386,997 patients, of which 51% completed at least one HRSN questionnaire question. Patients with Medicaid insurance (AOR: 0.62, 95%CI: 0.61, 0.64) and those who lived in higher ADI neighborhoods had lower adjusted odds of responding (AOR: 0.76, 95% CI: 0.75, 0.78 comparing quintile 5 to quintile 1). Of responders, having Medicaid insurance (versus private) increased the adjusted odds of reporting each of the HRSN needs by two- to eightfold (p < 0.01). Patients who completed a questionnaire (versus non-responders) had similar adjusted odds of receiving a referral (AOR: 0.91, 95% CI: 0.80, 1.02) and receiving a resource from a SW (AOR: AOR: 1.18, 95%CI: 0.79, 1.77).

CONCLUSION

HRSN questionnaire responses may not accurately represent the needs of patients, especially when delivered solely via patient portal.

Primary care referral patterns for patients with asthma: analysis of real-world data

OBJECTIVE

To identify features related to management of patients prior to referral from primary care physicians (PCPs) to pulmonologists and allergists.

METHODS

This is an analysis of patient claims data from Symphony Health (2013-2018). To characterize referrals, a longitudinal cohort included 12 months with no asthma claims prior to the index date, followed by 36 months of observation. We also assessed a cross-sectional cohort for 12 months at the end of the observational period to characterize disease control and treatment patterns. Referral was defined as the first appearance of a claim from an allergist or pulmonologist for a patient's initial visit for asthma. Descriptive statistics were used to analyze the data.

RESULTS

The majority of patients with asthma were managed by PCPs (60%), followed by pulmonologists (16%) and allergists (8%). Forty-three percent had uncontrolled asthma. Only 8% were referred to specialists within the first 24 months after initial diagnosis, of which 76% were seen by pulmonologists and 24% by allergists. Referrals resulted in treatment change in 55%-68% of the cases. Patients who received a referral were more likely to be on oral corticosteroids (OCS) and/or have more hospitalizations/ED visits.

CONCLUSIONS

About one-third of the patients managed by PCPs received intermittent and/or chronic OCS prior to referral, which may be an indication of uncontrolled disease. The referral patterns in this analysis illustrate underutilization of specialists in the consultation and management of patients with uncontrolled asthma.

A nutrition and lifestyle-focused shared medical appointment in a resource-challenged community setting: a mixed-methods study

BACKGROUND

In order to address disparities in preventable chronic diseases, we adapted a nutrition and lifestyle-focused shared medical appointment (SMA) program to be delivered in an underserved community setting. The objective was to evaluate a community-based nutrition and lifestyle-focused SMA as it relates to acceptability and health and behavior-related outcomes.

METHODS

A mixed-methods study was performed to evaluate pre-post changes in wellness indices, biometrics, self-efficacy, and trust in medical researchers as part of a community-based SMA. To understand program acceptability including barriers and facilitators for implementation and scalability, we conducted two participant focus groups and five stakeholder interviews and used content analysis to determine major themes.

RESULTS

Fifteen participants attended 10 weekly sessions. The majority were older adult, African American women. There were pre-post improvements in mean [SD] systolic (-10.5 [7.7] mmHg, p = 0.0001) and diastolic (-4.7 [6.7] mmHg, p = 0.17) blood pressures and weight (-5.7 [6.3] pounds, p = 0.003) at 3 months though these were not significant at 6 months. More individuals reported improvements in health status, daily fruit and vegetable intake, and sleep than at baseline. There were no significant pre-post changes in other wellness indices, self-efficacy, trust in medical researchers, hemoglobin A1c, insulin, or LDL cholesterol. Participants discussed positive health changes as a result of the SMA program, program preferences, and facilitators and barriers to continuing program recommendations in focus groups. SMA implementation was facilitated by clinical staff who adjusted content to a low health literacy group and partnership with a trusted community partner. Sustainability barriers include heavy personnel time and in-kind resources to deliver the program.

CONCLUSIONS

Nutrition and lifestyle-focused SMAs in a resource-challenged community setting may be an acceptable intervention for underserved patients.

Addressing COVID-19 health disparities through a regional community health response

To combat racial/ethnic and socioeconomic health disparities associated with COVID-19 in our surrounding communities, the Cleveland Clinic Community Health & Partnership team developed a comprehensive program focused on connecting and communicating with local officials, faith-based organizations, and individual community members. Since March of 2020, our team has donated resources (e.g., personal protective equipment) to local organizations, referred thousands of community members to community or clinical resources, and partnered with federally-qualified health centers to support community COVID-19 testing. Future work will include the use of these networks to deploy the COVID-19 vaccine.

Cardiovascular Disease & Cancer Risk Among South Asians: Impact of Sociocultural Influences on Lifestyle and Behavior

A comprehensive literature review revealed cultural beliefs, societal obligations, and gender roles within the South Asian community to be indirect contributors to the health of South Asian immigrants (SAIs). Health professionals need to increase their work with SAI communities to change less beneficial cultural elements such as misconceptions about health and exercise, and lack of communication when using alternative medicines. Community engaged efforts and continuing medical education are both needed to improve the health of the South Asian immigrant population in a culturally appropriate manner.

Assessing the Role of State and Local Public Health in Outreach and Enrollment for Expanded Coverage: A Case Study on Tacoma-Pierce County, Washington

The Patient Protection and Affordable Care Act (ACA) laid the groundwork for a substantial increase in the number of people who have access to health insurance through Medicaid expansion or health insurance marketplaces. During the first open-enrollment season, states used a variety of strategies to reach out to and enroll newly eligible people. Typically, they used federal and state funding to develop navigator programs. Program design differed by location, and, although many stakeholders were involved in these efforts, state and local health departments (LHDs) were, and remain, a relatively untapped resource. This article is one in a series designed to highlight innovative models and best practices that leverage LHD involvement in ACA outreach and enrollment and to facilitate knowledge transfer to other geographic regions looking to leverage the full range of roles for LHDs in ACA outreach and enrollment. Each case study was designed to capture nuanced differences in how health departments support these efforts in their communities, identify facilitators and barriers to these approaches, and develop lessons learned from these activities. These studies identify compelling models for how state and local health departments can implement similar activities in their own communities. Further, they provide guidance and insight into the role LHDs can play now, and help redefine that role in the future, as states continue to enroll residents in health insurance coverage moving forward. This article focuses on a case study on Tacoma-Pierce County, Washington.

Assessing the Role of State and Local Public Health in Outreach and Enrollment for Expanded Coverage: A Case Study on Boston and Massachusetts

The Patient Protection and Affordable Care Act (ACA) laid the groundwork for a substantial increase in the number of people who have access to health insurance through Medicaid expansion or health insurance marketplaces. During the first open-enrollment season, states used a variety of strategies to reach out to and enroll newly eligible people. Typically, they used federal and state funding to develop navigator programs. Program design differed by location, and, although many stakeholders were involved in these efforts, state and local health departments (LHDs) were, and remain, a relatively untapped resource. This article is one in a series designed to highlight innovative models and best practices that leverage LHD involvement in ACA outreach and enrollment and to facilitate knowledge transfer to other geographic regions looking to leverage the full range of roles for LHDs in ACA outreach and enrollment. Each case study was designed to capture nuanced differences in how health departments support these efforts in their communities, identify facilitators and barriers to these approaches, and develop lessons learned from these activities. These studies identify compelling models for how state and local health departments can implement similar activities in their own communities. Further, they provide guidance and insight into the role LHDs can play now, and help redefine that role in the future, as states continue to enroll residents in health insurance coverage moving forward. This article focuses on a case study on Boston and Massachusetts.

Assessing the Role of State and Local Public Health in Outreach and Enrollment for Expanded Coverage: A Case Study on West Virginia

The Patient Protection and Affordable Care Act (ACA) laid the groundwork for a substantial increase in the number of people who have access to health insurance through Medicaid expansion or health insurance marketplaces. During the first open-enrollment season, states used a variety of strategies to reach out to and enroll newly eligible people. Typically, they used federal and state funding to develop navigator programs. Program design differed by location, and, although many stakeholders were involved in these efforts, state and local health departments (LHDs) were, and remain, a relatively untapped resource. This article is one in a series designed to highlight innovative models and best practices that leverage LHD involvement in ACA outreach and enrollment and to facilitate knowledge transfer to other geographic regions looking to leverage the full range of roles for LHDs in ACA outreach and enrollment. Each case study was designed to capture nuanced differences in how health departments support these efforts in their communities, identify facilitators and barriers to these approaches, and develop lessons learned from these activities. These studies identify compelling models for how state and local health departments can implement similar activities in their own communities. Further, they provide guidance and insight into the role LHDs can play now, and help redefine that role in the future, as states continue to enroll residents in health insurance coverage moving forward. This article focuses on a case study on West Virginia.

A Community Engagement Symposium to Prevent and Improve Stroke Outcomes in Diverse Communities

BACKGROUND

Racial/ethnic minorities have a higher burden of stroke, but lower awareness and understanding of stroke and its risk factors. Our community-academic collaborative hosted a symposium in South Los Angeles to increase awareness about stroke, provide information on the Los Angeles Stroke Intervention and Research Program (SPIRP), and facilitate bidirectional communication between researchers and community stakeholders.

OBJECTIVES

We discuss our partnered approach to increase stroke awareness, elicit community perspectives and perceptions about stroke prevention and research participation, and increase community involvement in research using a community engagement symposium (CES).

METHODS

We used a community-partnered participatory research (CPPR) conference framework to guide symposium planning, implementation and analysis. The morning session included clinical lectures, a panel of researchers describing LA SPIRP, and a panel presentation by stroke caregivers and survivors. In afternoon breakout sessions, attendees identified 1) community-based strategies to prevent stroke and 2) methods to increase recruitment of diverse populations in stroke research studies. Attendees were surveyed about stroke knowledge before and after the morning session. Data from breakout sessions were analyzed using content analysis and pile sorting to identify themes.

CONCLUSIONS

We found that the CES based on CPPR principles was effective method to increase short-term stroke awareness and stimulate discussion about stroke research among community members and community stakeholders who serve racial/ethnic minorities.

Older Ethnic Minority Women's Perceptions of Stroke Prevention and Walking

OBJECTIVE

To inform the development of a tailored behavioral stroke risk reduction intervention for ethnic minority seniors, we sought to explore gender differences in perceptions of stroke prevention and physical activity (walking).

METHODS

In collaboration with community-based organizations, we conducted 12 mixed-gender focus groups of African American, Latino, Chinese, and Korean seniors aged 60 years and older with a history of hypertension (89 women and 42 men). Transcripts were coded and recurring topics compared by gender.

RESULTS

Women expressed beliefs that differed from men in 4 topic areas: 1) stroke-related interest, 2) barriers to walking, 3) facilitators to walking, and 4) health behavior change attitudes. Compared with men, women were more interested in their role in response to a stroke and post-stroke care. Women described walking as an acceptable form of exercise, but cited neighborhood safety and pain as walking barriers. Fear of nursing home placement and weight loss were identified as walking facilitators. Women were more prone than men to express active/control attitudes toward health behavior change.

CONCLUSIONS

Older ethnic minority women, a high-risk population for stroke, may be more receptive to behavioral interventions that address the gender-specific themes identified by this study.

Innovative approach to patient-centered care coordination in primary care practices

OBJECTIVES

Although care coordination is an essential component of the patient-centered medical home structure, current case manager models have limited usefulness to population health because they typically serve a small group of patients defined based on disease or utilization. Our objective was to support our health system's population health by implementing and evaluating a program that embedded nonlicensed coordinators within our primary care practices to support physicians in executing care plans and communicating with patients.

STUDY DESIGN

Matched case-control differences-in-differences.

METHODS

Comprehensive care coordinators (CCC) were introduced into 14 of the system's 28 practice sites in 2 waves. After a structured training program, CCCs identified, engaged, and intervened among patients within the practice in conjunction with practice primary care providers. We counted and broadly coded CCC activities that were documented in the intervention database. We examined the impact of CCC intervention on emergency department (ED) utilization at the practice level using a negative binomial multivariate regression model controlling for age, gender, and medical complexity.

RESULTS

CCCs touched 10,500 unique patients over a 1-year period. CCC interventions included execution of care (38%), coordination of transitions (32%), self-management support/link to community resources (15%), monitor and follow-up (10%), and patient assessment (1%). The CCC intervention group had a 20% greater reduction in its prepost ED visit rate compared with the control group (P < .0001).

CONCLUSIONS

Our CCC intervention demonstrated a significant reduction in ED visits by focusing on the centrality of the primary care provider and practice. Our model may serve as a cost-effective and scalable alternative for care coordination in primary care.

Study protocol of "Worth the Walk": a randomized controlled trial of a stroke risk reduction walking intervention among racial/ethnic minority older adults with hypertension in community senior centers

BACKGROUND

Stroke disproportionately kills and disables ethnic minority seniors. Up to 30 % of ischemic strokes in the U.S. can be attributed to physical inactivity, yet most Americans, especially older racial/ethnic minorities, fail to participate in regular physical activity. We are conducting a randomized controlled trial (RCT) to test a culturally-tailored community-based walking intervention designed to reduce stroke risk by increasing physical activity among African American, Latino, Chinese, and Korean seniors with hypertension. We hypothesize that the intervention will yield meaningful changes in seniors' walking levels and stroke risk with feasibility to sustain and scale up across the aging services network.

METHODS/DESIGN

In this randomized single-blind wait-list control study, high-risk ethnic minority seniors are enrolled at senior centers, complete baseline data collection, and are randomly assigned to receive the intervention "Worth the Walk" immediately (N = 120, intervention group) or in 90 days upon completion of follow-up data collection (N = 120, control group). Trained case managers employed by the senior centers implement hour-long intervention sessions twice weekly for four consecutive weeks to the intervention group. Research staff blinded to participants' group assignment collect outcome data from both intervention and wait-list control participants 1 and 3-months after baseline data collection. Primary outcome measures are mean steps/day over 7 days, stroke knowledge, and self-efficacy for reducing stroke risk. Secondary and exploratory outcome measures include selected biological markers of health, healthcare seeking, and health-related quality of life. Outcomes will be compared between the two groups using standard analytic methods for randomized trials. We will conduct a formal process evaluation to assess barriers and facilitators to successful integration of Worth the Walk into the aging services network and to calculate estimated costs to sustain and scale up the intervention. Data collection is scheduled to be completed in December 2016.

DISCUSSION

If this RCT demonstrates superior improvements in physical activity and stroke knowledge in the intervention group compared to the control group and is found to be sustainable and scalable, Worth the Walk could serve as a primary stroke prevention model for racial/ethnic communities across the nation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02181062 ; registered on June 30, 2014.

Barriers to Enrollment in Health Coverage in Colorado

As part of the implementation of the Affordable Care Act, Colorado has expanded Medicaid and also now operates its own health insurance exchange for individuals (called Connect for Health Colorado). As of early 2014, more than 300,000 Coloradans have newly enrolled in Medicaid or health insurance through Connect for Health Colorado, but there also continues to be a diverse mix of individuals in Colorado who remain eligible for but not enrolled in either private insurance or Medicaid. The Colorado Health Foundation commissioned the RAND Corporation to conduct a study to better understand why these individuals are not enrolled in health insurance coverage and to develop recommendations for how Colorado can strengthen its outreach and enrollment efforts during the next open enrollment period, which starts in November 2014. RAND conducted focus groups with uninsured and newly insured individuals across the state and interviews with local stakeholders responsible for enrollment efforts in their regions. The authors identified 11 commonly cited barriers, as well as several that were specific to certain regions or populations (such as young adults and seasonal workers). Collectively, these barriers point to a set of four priority recommendations that stakeholders in Colorado may wish to consider: (1) Support and expand localized outreach and tailored messaging; (2) Strengthen marketing and messaging to be clear, focused on health benefits of insurance (rather than politics and mandates), and actionable; (3) Improve the clarity and transparency of insurance and health care costs and enrollment procedures; and (4) Revisit the two-stage enrollment process and improve Connect for Health Colorado website navigation and technical support.

A systematic review of the prevalence of herb usage among racial/ethnic minorities in the United States

Clinical studies display a wide range of herb use prevalence among racial/ethnic minorities in the United States. We searched databases indexing the literature including CINAHL, EMBASE, Global Health, CAB Abstracts, and Medline. We included studies that reported herbal medicine prevalence among ethnic minorities, African American, Hispanic, or Asian adults living in the United States. Data from 108 included studies found the prevalence of herb use by African Americans was 17 % (range 1-46 %); for Hispanics, 30 % (4-100 %); and for Asians, 30 % (2-73 %). Smaller studies were associated with higher reported herb use (p = 0.03). There was a significant difference (p = 0.01) between regional and national studies with regional studies reporting higher use. While herb usage surveys in racial/ethnic minorities show great variability, indications suggest high prevalence. More research is needed to understand herb use among ethnic/racial minorities, reasons for use, and barriers to disclosure of use to clinicians.

The association of religiosity with overweight/obese body mass index among Asian Indian immigrants in California

OBJECTIVE

The aim of this study was to examine the association between religiosity and overweight or obese body mass index among a multi-religious group of Asian Indian immigrants residing in California.

METHODS

We examined cross-sectional survey data obtained from in-language telephone interviews with 3228 mostly immigrant Asian Indians in the 2004 California Asian Indian Tobacco Survey using multivariate logistic regression.

RESULTS

High self-identified religiosity was significantly associated with higher BMI after adjusting for socio-demographic and acculturation measures. Highly religious Asian Indians had 1.53 greater odds (95% CI: 1.18, 2.00) of being overweight or obese than low religiosity immigrants, though this varied by religious affiliation. Religiosity was associated with greater odds of being overweight/obese for Hindus (OR 1.54; 95% CI: 1.08, 2.22) and Sikhs (OR 1.88; 95% CI: 1.07, 3.30), but not for Muslims (OR 0.69; 95% CI: 0.28, 1.70).

CONCLUSIONS

Religiosity in Hindus and Sikhs, but not immigrant Muslims, appears to be independently associated with greater body mass index among Asian Indians. If this finding is confirmed, future research should identify potentially mutable mechanisms by which religion-specific religiosity affects overweight/obesity risk.

State-level variations in racial disparities in life expectancy

OBJECTIVE

To explore state patterns in the racial life expectancy gap.

DATA SOURCES

The 1997-2004 Multiple Cause of Death PUF, 2000 U.S. Census.

STUDY DESIGN

We calculated life expectancy at birth for black and white men and women.

DATA EXTRACTION METHODS

Data were obtained by the NCHS and U.S. Census Bureau.

PRINCIPAL FINDINGS

States with small racial differences are due to higher-than-expected life expectancy for blacks or lower-than-expected for whites. States with large disparity are explained by higher-than-average life expectancy among whites or lower-than-average life expectancy among blacks.

CONCLUSIONS

Heterogeneous state patterns in racial disparity in life expectancy exist. Eliminating disparity in states with large black populations would make the greatest impact nationally.