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Melnic CM, Salimy MS, Minutillo GT, Paprosky WG, Sheth NP. Acetabular Distraction Technique: A Multicenter Study With a Minimum 2-Year Radiographic Follow-Up. J Arthroplasty 2024; 39:S398-S403. [PMID: 38401613 DOI: 10.1016/j.arth.2024.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Chronic pelvic discontinuity is a challenge during revision total hip arthroplasty due to the loss of structural continuity of the superior and inferior aspects of the acetabulum from severe acetabular bone loss. Acetabular distraction provides an alternative surgical treatment by stabilizing the acetabular component through elastic recoil of the pelvis, which may be supplemented with modular porous augments for addressing major acetabular defects. This study reports 2-year radiographic findings following acetabular distraction for the treatment of chronic pelvic discontinuity. METHODS Patients undergoing acetabular distraction performed by 5 surgeons from 2002 to 2021 were identified across 5 institutions. Demographic, surgical, and postoperative outcomes, including radiographic component stability, were recorded. There were 53 of 91 (58.2%) patients (5 deceased, 33 lost to follow-up) consisting of 4 Paprosky IIC (7.5%), 8 Paprosky IIIA (15.1%), and 41 Paprosky IIIB (77.4%) defects included, with a mean follow-up time of 4.8 years (range, 2 to 13.5). Modular porous augments were used in 33 (62.3%) cases. Failure was defined as a subsequent revision of the acetabular construct. RESULTS Among the 13 (24.5%) patients who returned to the operating room, 6 (46.2%) had a prior history of revision total hip arthroplasty before undergoing acetabular distraction. Only 5 (9.4%) patients underwent acetabular revision following acetabular distraction, leading to an overall cup survivorship of 90.6%. Of the remaining 48 patients, 46 (95.8%) had evidence of radiographic bridging callus of the chronic pelvic discontinuity at their last clinical follow-up. CONCLUSIONS To our knowledge, in the largest series to date, acetabular distraction has proven to be a viable treatment for acetabular bone loss with a chronic pelvic discontinuity, with excellent early survivorship and radiographic evidence of bridging callus. Future studies with longer follow-ups are needed to further monitor the efficacy of this technique. LEVEL OF EVIDENCE Level III, Retrospective Comparative Study.
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Affiliation(s)
- Christopher M Melnic
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Mehdi S Salimy
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory T Minutillo
- Department of Orthopaedic Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Wayne G Paprosky
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Neil P Sheth
- Department of Orthopaedic Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
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Kaufmann J, Marino M, Lucas JA, Rodriguez CJ, Boston D, Giebultowicz S, Heintzman J. Atherosclerotic Cardiovascular Disease Primary and Secondary Prevention in Latino Subgroups. J Gen Intern Med 2024; 39:2041-2050. [PMID: 38858341 PMCID: PMC11306857 DOI: 10.1007/s11606-024-08822-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/14/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Studies assessing equity in the prevention of atherosclerotic cardiovascular disease (ASCVD) for Latinos living in the USA collectively yield mixed results. Latino persons are diverse in many ways that may influence cardiovascular health. The intersection of Latino nativity and ASCVD prevention is understudied. OBJECTIVE To determine whether disparities in ASCVD screening, detection, and prescribing differ for US Latinos by country of birth. DESIGN A retrospective cohort design utilizing 2014-2020 electronic health record data from a network of 320 community health centers across 12 states. Analyses occurred October 1, 2022, to September 30, 2023. PARTICIPANTS Non-Hispanic White and Latino adults age 20-75 years, born in Cuba, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, and the USA. EXPOSURES Ethnicity and country of birth. MAIN MEASURES Outcome measures included prevalence of statin eligibility, of having insufficient data to establish eligibility, odds of having a documented statin prescription, and rates of statin prescriptions and refills. We used covariate-adjusted logistic and generalized estimating equations logistic and negative binomial regressions to generate absolute and relative measures. KEY RESULTS Among 108,672 adults, 23% (n = 25,422) were statin eligible for primary or secondary prevention of ASCVD using American College of Cardiology/American Heart Association guidelines. Latinos, born in and outside the USA were more likely eligible than Non-Hispanic White patients were (US-born Latino OR = 1.55 (95% CI = 1.37-1.75); non-US-born Latino OR = 1.63 (95% CI = 1.34-1.98)). The eligibility criteria that was met differed by ethnicity and nativity. Latinos overall were less likely missing data to establish eligibility and differences were again observed by specific non-US country of origin. Among those eligible, we observed no statistical difference in statin prescribing between US-born Latinos and non-Hispanic White persons; however, disparities varied by specific non-US country of origin. CONCLUSION Efforts to improve Latino health in the USA will require approaches for preventing and reversing cardiovascular risk factors, and statin initiation that are Latino subgroup specific.
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Affiliation(s)
- Jorge Kaufmann
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA.
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Biostatistics Group, School of Public Health, Oregon Health & Science University - Portland State University, Portland, OR, USA
| | - Jennifer A Lucas
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Carlos J Rodriguez
- Department of Medicine, Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | | | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
- OCHIN, Portland, OR, USA
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Sirota M, Kodama L, Woldemariam S, Tang A, Li Y, Kornak J, Allen IE, Raphael E, Oskotsky T. Sex-stratified analyses of comorbidities associated with an inpatient delirium diagnosis using real world data. RESEARCH SQUARE 2024:rs.3.rs-4765249. [PMID: 39108477 PMCID: PMC11302686 DOI: 10.21203/rs.3.rs-4765249/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
Delirium is a detrimental mental condition often seen in older, hospitalized patients and is currently hard to predict. In this study, we leverage electronic health records (EHR) to identify 7,492 UCSF patients and 19,417 UC health system patients with an inpatient delirium diagnosis and the same number of control patients without delirium. We found significant associations between comorbidities or laboratory values and an inpatient delirium diagnosis, including metabolic abnormalities and psychiatric diagnoses. Some associations were sex-specific, including dementia subtypes and infections. We further explored the associations with anemia and bipolar disorder by conducting longitudinal analyses from the time of first diagnosis to development of delirium, demonstrating a significant relationship across time. Finally, we show that an inpatient delirium diagnosis leads to increased risk of mortality. These results demonstrate the powerful application of the EHR to shed insights into prior diagnoses and laboratory values that could help predict development of inpatient delirium and the importance of sex when making these assessments.
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Lucas JA, Marino M, Giebultowicz S, Dinh D, Datta R, Boston D, Heintzman J. Association of neighbourhood walkability and haemoglobin A1c levels among Latino and non-Hispanic White patients with diabetes. Fam Pract 2024:cmae018. [PMID: 38526967 DOI: 10.1093/fampra/cmae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Neighbourhood walkability can benefit cardiovascular health. Latino patients are more likely than non-Hispanic White patients to have diabetes, and evidence has shown better diabetes-related outcomes for patients living in neighbourhoods conducive to physical activity. Our objective was to determine whether neighbourhood walkability was associated with haemoglobin A1c (HbA1c) levels among English- and Spanish-preferring Latino patients compared to non-Hispanic White patients. METHODS We used electronic health record data from patients in the OCHIN, Inc. network of community health centres (CHC) linked to public walkability data. Patients included those age ≥ 18 with ≥ 1 address recorded, with a study clinic visit from 2012 to 2020, and a type 2 diabetes diagnosis (N = 159,289). Generalized estimating equations logistic regression, adjusted for relevant covariates, was used to model the primary binary outcome of always having HbA1c < 7 by language/ethnicity and walkability score. RESULTS For all groups, the walkability score was not associated with higher odds and prevalence of always having HbA1c < 7. Non-Hispanic White patients were most likely to have HbA1c always < 7 (prevalence ranged from 32.8% [95%CI = 31.2-34.1] in the least walkable neighbourhoods to 33.4% [95% CI 34.4-34.7] in the most walkable), followed by English-preferring Latinos (28.6% [95%CI = 25.4-31.8]-30.7% [95% CI 29.0-32.3]) and Spanish-preferring Latinos (28.3% [95% CI 26.1-30.4]-29.3% [95% CI 28.2-30.3]). CONCLUSIONS While walkability score was not significantly associated with glycaemic control, control appeared to increase with walkability, suggesting other built environment factors, and their interaction with walkability and clinical care, may play key roles. Latino patients had a lower likelihood of HbA1c always < 7, demonstrating an opportunity for equity improvements in diabetes care.
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Affiliation(s)
- Jennifer A Lucas
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
| | | | - Dang Dinh
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Roopradha Datta
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
| | | | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
- OCHIN, Inc. Portland, OR, United States
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Kasten-Arias C, Hodes T, Marino M, Kaufmann J, Lucas JA, Estela Vasquez Guzman C, Giebultowicz S, Chan B, Heintzman J. Healthcare utilization for asthma exacerbation among children of migrant and seasonal farmworkers. Prev Med Rep 2024; 38:102598. [PMID: 38283959 PMCID: PMC10821615 DOI: 10.1016/j.pmedr.2024.102598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/14/2023] [Accepted: 01/05/2024] [Indexed: 01/30/2024] Open
Abstract
Latino children of Migrant and Seasonal Farmworkers (MSFWs) with asthma are at risk for poor health outcomes due to medical access barriers. We compared differences in acute care utilization for asthma exacerbations among migrant and non-migrant Latino and non-Hispanic white (NHW) children at U.S. community health centers. A retrospective observational study utilizing electronic health record data from the ADVANCE Clinical Research Network of United States community health centers included 13,423 children ages 3-17 with a primary care visit between 2005 and 2017 from eight states. Emergency department (ED) and hospitalization data came from Oregon Medicaid claims. Outcomes included acute clinic visits, ED visits, and hospitalizations for asthma exacerbation. Regression analyses adjusted for patient-level covariates. Latino children had higher odds of acute clinic visits for asthma exacerbation compared to NHW children (MSFW odds ratio [OR] = 1.17, 95 % CI = 1.03-1.33; without migrant status OR = 1.13, 95 % CI = 1.03-1.23). MSFW children using Oregon Medicaid had fewer ED visits (rate ratio [RR] = 0.72, 95 % CI = 0.52-0.99) and hospitalizations (RR = 0.47, 95 % CI = 0.26-0.86) compared to NHW children. Increased community health center visits may help mitigate disparities in acute asthma care for MSFW children.
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Affiliation(s)
| | - Tahlia Hodes
- Oregon Health & Science University, Department of Family Medicine, Portland OR, USA
| | - Miguel Marino
- Oregon Health & Science University, Department of Family Medicine, Portland OR, USA
| | - Jorge Kaufmann
- Oregon Health & Science University, Department of Family Medicine, Portland OR, USA
| | - Jennifer A. Lucas
- Oregon Health & Science University, Department of Family Medicine, Portland OR, USA
| | | | | | - Brian Chan
- OCHIN, Inc. Portland, OR, USA
- Oregon Health & Science University, Department of Medicine, Division of General Internal Medicine & Geriatrics, Portland OR, USA
| | - John Heintzman
- Oregon Health & Science University, Department of Family Medicine, Portland OR, USA
- OCHIN, Inc. Portland, OR, USA
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Huguet N, Hodes T, Liu S, Marino M, Schmidt TD, Voss RW, Peak KD, Quiñones AR. Impact of Health Insurance Patterns on Chronic Health Conditions Among Older Patients. J Am Board Fam Med 2023; 36:839-850. [PMID: 37704394 PMCID: PMC10662026 DOI: 10.3122/jabfm.2023.230106r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/25/2023] [Accepted: 06/05/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Patients have varying levels of chronic conditions and health insurance patterns as they become Medicare age-eligible. Understanding these dynamics will inform policies and reforms that direct capacity and resources for primary care clinics to care for these aging patients. This study 1) determined changes in chronic condition rates following Medicare age eligibility among patients with different insurance patterns and 2) estimated the number of chronically ill patients who remain inadequately insured post-Medicare eligibility among patients receiving care in community health centers. METHOD We used retrospective electronic health record data from 45,527 patients aged 62 to 68 from 990 community health centers in 25 states in 2014 to 2019. Insurance patterns (continuously insured, continuously uninsured, uninsured/discontinuously insured who gained insurance after age 65, lost insurance after age 65, discontinuously insured) and diagnosis of chronic conditions were defined at each visit pre- and post-Medicare eligibility. Difference-in-differences Poisson GEE models estimated changes of chronic condition rates by insurance groups pre- to post-Medicare age eligibility. RESULTS Post-Medicare eligibility, 72% patients were continuously insured, 14% gained insurance; and 14% were uninsured or discontinuously insured. The prevalence of multimorbidity (≥2 chronic conditions) was 77%. Those who gained insurance had a significantly larger increase in the rate of documented chronic conditions from pre- to post-Medicare (DID: 1.06, 95%CI:1.05-1.07) compared with the continuously insured group. CONCLUSIONS Post-Medicare age eligibility, a significant proportion of patients were diagnosed with new conditions leading to high burden of disease. One in 4 older adults continue to have inadequate health care coverage in their older age.
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Affiliation(s)
- Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Tahlia Hodes
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Shuling Liu
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR
| | | | | | - Katherine D. Peak
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Ana R. Quiñones
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR
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Lucas JA, Hsu A, Heintzman J, Bailey SR, Suglia SF, Bazemore A, Giebultowicz S, Marino M. The Association of Mobility, Social Deprivation, and Pediatric Primary Care Outcomes in Community Health Centers. J Pediatr 2023; 259:113465. [PMID: 37179014 PMCID: PMC10524636 DOI: 10.1016/j.jpeds.2023.113465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 04/06/2023] [Accepted: 05/08/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To examine how social deprivation and residential mobility are associated with primary care use in children seeking care at community health centers (CHCs) overall and stratified by race and ethnicity. STUDY DESIGN We used electronic health record open cohort data from 152 896 children receiving care from 15 U S CHCs belonging to the OCHIN network. Patients were aged 3-17 years, with ≥2 primary care visits during 2012-2017 and had geocoded address data. We used negative binomial regression to calculate adjusted rates of primary care encounters and influenza vaccinations relative to neighborhood-level social deprivation. RESULTS Higher rates of clinic utilization were observed for children who always lived in highly deprived neighborhoods (RR = 1.11, 95% CI = 1.05-1.17) and those who moved from low-to-high deprivation neighborhoods (RR = 1.05, 95% CI = 1.01-1.09) experienced higher rates of CHC encounters compared with children who always lived in the low-deprivation neighborhoods. This trend was similar for influenza vaccinations. When analyses were stratified by race and ethnicity, we found these relationships were similar for Latino children and non-Latino White children who always lived in highly deprived neighborhoods. Residential mobility was associated with lower rates of primary care. CONCLUSIONS These findings suggest that children living in or moving to neighborhoods with high levels of social deprivation used more primary care CHC services than children who lived in areas with low deprivation, but moving itself was associated with less care. Clinician and delivery system awareness of patient mobility and its impacts are important to addressing equity in primary care.
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Affiliation(s)
- Jennifer A Lucas
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.
| | - Audree Hsu
- California University of Science and Medicine, Colton, CA
| | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Shakira F Suglia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | | | | | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
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Chan BL, Ezekiel-Herrera D, Bailey SR, Marino M, Lucas JA, Giebultowicz S, Cottrell E, Carroll J, Heintzman J. Screening for Hepatitis C Among Community Health Center Patients by Ethnicity and Language Preference. AJPM FOCUS 2023; 2:100077. [PMID: 37790651 PMCID: PMC10546589 DOI: 10.1016/j.focus.2023.100077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction Hepatitis C virus is associated with high morbidity and mortality-chronic liver disease is a leading cause of death among Latinos in the U.S. Screening for hepatitis C virus in community health center settings, which serve a disproportionate percentage of Latinos, is essential to eradicating hepatitis C virus infection. We assessed hepatitis C virus screening disparities in adults served by community health centers by ethnicity and language preference. Methods This was an observational cohort study (spanning 2013-2017) of adults born in 1945-1965 in the Accelerating Data Value Across a National Community Health Center Network electronic health record data set. Our exposure of interest was race/ethnicity and language preference (non-Hispanic White, Latino English preferred, Latino Spanish preferred). Our primary outcome was the relative hazard of hepatitis C virus screening, estimated using multivariate Cox proportional hazards regression. Results A total of 182,002 patients met the study criteria and included 60% non-Hispanic Whites, 29% Latino Spanish preferred, and 11% Latino English preferred. In total, 9% received hepatitis C virus screening, and 2.4% were diagnosed with hepatitis C virus. Latino English-preferred patients had lower rates of screening than both non-Hispanic Whites and Latino Spanish preferred (5.5% vs 9.4% vs 9.6%, respectively). Latino English preferred had lower hazards of hepatitis C virus screening than non-Hispanic Whites (adjusted hazard ratio=0.56, 95% CI=0.44, 0.72), and Latino Spanish preferred had similar hazards of hepatitis C virus screening (adjusted hazard ratio=1.11, 95% CI=0.88, 1.41). Conclusions We found that in a large community health center network, adult Latinos who preferred English had lower hazards of hepatitis C virus screening than non-Hispanic Whites, whereas Latinos who preferred Spanish had hazards of screening similar to those of non-Hispanic Whites. The overall prevalence of hepatitis C virus screening was low. Further work on the role of language preference in hepatitis C virus screening is needed to better equip primary care providers to provide this recommended preventive service in culturally relevant ways.
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Affiliation(s)
- Brian L. Chan
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health & Science University, Portland, Oregon
- OCHIN, Inc., Portland, Oregon
- Central City Concern, Portland, Oregon
| | - David Ezekiel-Herrera
- Division of Biostatistics, School of Public Health, Oregon Health & Science University, Portland, Oregon
| | - Steffani R. Bailey
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Miguel Marino
- Division of Biostatistics, School of Public Health, Oregon Health & Science University, Portland, Oregon
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jennifer A. Lucas
- Division of Biostatistics, School of Public Health, Oregon Health & Science University, Portland, Oregon
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Erika Cottrell
- OCHIN, Inc., Portland, Oregon
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Joe Carroll
- Open Door Community Health Center, McKinleyville, California
| | - John Heintzman
- OCHIN, Inc., Portland, Oregon
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
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Quiñones AR, Valenzuela SH, Huguet N, Ukhanova M, Marino M, Lucas JA, O'Malley J, Schmidt TD, Voss R, Peak K, Warren NT, Heintzman J. Prevalent Multimorbidity Combinations Among Middle-Aged and Older Adults Seen in Community Health Centers. J Gen Intern Med 2022; 37:3545-3553. [PMID: 35088201 PMCID: PMC9585110 DOI: 10.1007/s11606-021-07198-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/01/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Multimorbidity (≥ 2 chronic diseases) is associated with greater disability and higher treatment burden, as well as difficulty coordinating self-management tasks for adults with complex multimorbidity patterns. Comparatively little work has focused on assessing multimorbidity patterns among patients seeking care in community health centers (CHCs). OBJECTIVE To identify and characterize prevalent multimorbidity patterns in a multi-state network of CHCs over a 5-year period. DESIGN A cohort study of the 2014-2019 ADVANCE multi-state CHC clinical data network. We identified the most prevalent multimorbidity combination patterns and assessed the frequency of patterns throughout a 5-year period as well as the demographic characteristics of patient panels by prevalent patterns. PARTICIPANTS The study included data from 838,642 patients aged ≥ 45 years who were seen in 337 CHCs across 22 states between 2014 and 2019. MAIN MEASURES Prevalent multimorbidity patterns of somatic, mental health, and mental-somatic combinations of 22 chronic diseases based on the U.S. Department of Health and Human Services Multiple Chronic Conditions framework: anxiety, arthritis, asthma, autism, cancer, cardiac arrhythmia, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), congestive heart failure, coronary artery disease, dementia, depression, diabetes, hepatitis, human immunodeficiency virus (HIV), hyperlipidemia, hypertension, osteoporosis, post-traumatic stress disorder (PTSD), schizophrenia, substance use disorder, and stroke. KEY RESULTS Multimorbidity is common among middle-aged and older patients seen in CHCs: 40% have somatic, 6% have mental health, and 24% have mental-somatic multimorbidity patterns. The most frequently occurring pattern across all years is hyperlipidemia-hypertension. The three most frequent patterns are various iterations of hyperlipidemia, hypertension, and diabetes and are consistent in rank of occurrence across all years. CKD-hyperlipidemia-hypertension and anxiety-depression are both more frequent in later study years. CONCLUSIONS CHCs are increasingly seeing more complex multimorbidity patterns over time; these most often involve mental health morbidity and advanced cardiometabolic-renal morbidity.
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Affiliation(s)
- Ana R Quiñones
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA.
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA.
| | - Steele H Valenzuela
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
| | - Maria Ukhanova
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer A Lucas
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
| | - Jean O'Malley
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
- Research Department, OCHIN Inc., Portland, OR, USA
| | | | - Robert Voss
- Research Department, OCHIN Inc., Portland, OR, USA
| | - Katherine Peak
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
| | | | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
- Research Department, OCHIN Inc., Portland, OR, USA
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Kaufmann J, Marino M, Lucas JA, Rodriguez CJ, Bailey SR, April-Sanders AK, Boston D, Heintzman J. Racial, ethnic, and language differences in screening measures for statin therapy following a major guideline change. Prev Med 2022; 164:107338. [PMID: 36368341 PMCID: PMC9703970 DOI: 10.1016/j.ypmed.2022.107338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/07/2022] [Accepted: 11/05/2022] [Indexed: 11/10/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) disproportionally affects racial and ethnic minority populations. Statin prescribing guidelines changed in 2013 to improve ASCVD prevention. It is unknown whether risk screening for statin eligibility differed across race and ethnicity over this guideline change. We examine racial/ethnic/language differences in screening measure prevalence for period-specific statin consideration using a retrospective cohort design and linked electronic health records from 635 community health centers in 24 U.S. states. Adults 50+ years, without known ASCVD, and ≥ 1 visit in 2009-2013 and/or 2014-2018 were included, grouped as: Asian, Latino, Black, or White further distinguished by language preference. Outcomes included screening measure prevalence for statin consideration, 2009-2013: low-density lipoprotein (LDL), 2014-2018: pooled cohort equation (PCE) components age, sex, race, systolic blood pressure, total cholesterol, high-density lipoprotein, smoking status. Among patients seen both periods, change in period-specific measure prevalence was assessed. Adjusting for sociodemographic and clinical factors, compared to English-preferring White patients, all other groups were more likely to have LDL documented (2009-2013, n = 195,061) and all PCE components documented (2014-2018, n = 344,504). Among patients seen in both periods (n = 128,621), all groups had lower odds of PCE components versus LDL documented in the measures' respective period; English-preferring Black adults experienced a greater decline compared to English-preferring White adults (OR 0.81; 95% CI: 0.72-0.91). Racial/ethnic/language disparities in documented screening measures that guide statin therapy for ASCVD prevention were unaffected by a major guideline change advising this practice. It is important to understand whether the newer guidelines have altered disparate prescribing and morbidity/mortality for this disease.
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Affiliation(s)
- Jorge Kaufmann
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA; Biostatistics Group, School of Public Health, Oregon Health & Science University - Portland State University, Portland, OR, USA
| | - Jennifer A Lucas
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Carlos J Rodriguez
- Department of Medicine, Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Ayana K April-Sanders
- Department of Biostatistics & Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | | | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA; OCHIN, Portland, OR, USA
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11
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Angier H, Kaufmann J, Heintzman J, O'Malley J, Moreno L, Giebultowicz S, Marino M. Association of Parent Preventive Care with their Child's Recommended Well-Child Visits. Acad Pediatr 2022; 22:1422-1428. [PMID: 35378334 PMCID: PMC10284090 DOI: 10.1016/j.acap.2022.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 03/24/2022] [Accepted: 03/27/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Receipt of recommended well-child care is lowest for children without insurance, many of whom receive care in community health centers (CHCs). OBJECTIVE To understand if there is an association between parent preventive care and their children's well-child visits. METHODS We used electronic health record data to identify children and link them to parents both seen in an OCHIN network (CHC; n = 363 clinics from 17 states), randomly selected a child aged 3 to 17 with ≥1 ambulatory visit between 2015 and 2018. We employed a retrospective, cohort study design and used general estimating equations Poisson regression to estimate yearly rates of well-child visits based on parent preventive care adjusted for relevant covariates and stratified by child age for 3 linked samples: mother only, father only, and two parents. RESULTS We included 75,398 linked mother only pairs, 12,438 in our father only, and 4,156 in our 2-parent sample. Children in the mother only sample had a 6% greater rate of yearly well-child visits when their mother received preventive care (adjusted rate ratio [ARR] = 1.06; 95% CI = 1.03-1.08) compared to no preventive care. Children in the father only sample had a 7% greater rate of yearly well-child visits when their father received preventive care (ARR = 1.07; 95% CI = 1.04-1.11) versus no preventive care. Children in the two parent sample had an 11% greater rate of yearly well-child visits when both parents received preventive care (ARR = 1.11; 95% CI = 1.03-1.19) compared to neither receiving preventive care. CONCLUSIONS These findings suggest focusing on receipt of healthcare for the whole family may improve well-child visit rates.
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Affiliation(s)
- Heather Angier
- Oregon Health & Science University (H Angier, J Kaufmann, J Heintzman, L Moreno, and M Marino), Portland, Ore
| | - Jorge Kaufmann
- Oregon Health & Science University (H Angier, J Kaufmann, J Heintzman, L Moreno, and M Marino), Portland, Ore
| | - John Heintzman
- Oregon Health & Science University (H Angier, J Kaufmann, J Heintzman, L Moreno, and M Marino), Portland, Ore; OCHIN, Inc. (J Heintzman, J O'Malley, and S Giebultowicz), Portland, Ore
| | - Jean O'Malley
- OCHIN, Inc. (J Heintzman, J O'Malley, and S Giebultowicz), Portland, Ore
| | - Laura Moreno
- Oregon Health & Science University (H Angier, J Kaufmann, J Heintzman, L Moreno, and M Marino), Portland, Ore.
| | | | - Miguel Marino
- Oregon Health & Science University (H Angier, J Kaufmann, J Heintzman, L Moreno, and M Marino), Portland, Ore
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12
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Amat M, Duralde E, Masutani R, Glassman R, Shen C, Graham KL. "Patient Lost to Follow-up": Opportunities and Challenges in Delivering Primary Care in Academic Medical Centers. J Gen Intern Med 2022; 37:2678-2683. [PMID: 35091918 PMCID: PMC9411305 DOI: 10.1007/s11606-021-07216-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 10/13/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Academic health centers (AHCs) face unique challenges in providing continuity to a medically and socially complex patient population. Little is known about what drives patient loss in these settings. OBJECTIVE Determine physician- and patient-based factors associated with patient loss in AHCs. DESIGN Retrospective cohort study, embedded qualitative analysis. SETTING Academic health center. PARTICIPANTS All visits from 7/1/2014 to 6/30/2019; 89 physicians (51%) participated in a qualitative analysis. MEASURES Physician-based factors (gender, years of service, hours of practice per week, trainee status, and departure during the study period) and patient-based factors (age, gender, race, limited English proficiency, public health insurance, chronic illness burden, and severe psychiatric illness burden) and their association with patient loss to follow-up, defined as a lapse in provider visit greater than 3 years. RESULTS We identified 402,415 visits for 41,876 distinct patients. A total of 9332 (22.3%) patients were lost to follow-up. Patient factors associated with loss to follow-up included patient age < 40 (HR 3.12 (2.94-3.33)), identification as non-white (HR 1.07 (1.10-1.13)), limited English proficiency (HR 1.18 (1.04-1.33)), and use of public insurance (HR 1.12 (1.04-1.21)). Provider factors associated with patient loss included trainee status (HR 3.74 (2.43-5.75)) and having recently departed from the practice (HR 1.98, 1.66-2.35). Structured interviews with clinical providers revealed unfavorable relationships with providers and staff (35%), inconvenience accessing primary care (23%), unreliable health insurance (18%), difficulty accessing one's primary care provider (14%), and patient/provider transitions (10%) as reasons for patient loss. CONCLUSIONS Younger patient age, markers of social vulnerability, and physician transiency are associated with patient loss at AHCs, providing targets to improve continuity of care within these settings.
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Affiliation(s)
- Maelys Amat
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA.
| | - Erin Duralde
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | | | | | - Changyu Shen
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kelly L Graham
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
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13
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Larson AE, Angier H, Suchocki A, Voss RW, Marino M, Warren N, Huguet N. Primary and mental health service use in community health center patients before and after cancer diagnosis. Cancer Med 2022; 11:2320-2328. [PMID: 35481624 PMCID: PMC9160808 DOI: 10.1002/cam4.4524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Cancer survivors face increased risk for chronic diseases resulting from cancer, preexisting conditions, and cancer treatment. Having an established primary care clinic or health insurance may influence patients' receipt of recommended preventive care necessary to manage, treat, or diagnose new conditions. This study sought to understand receipt of healthcare in community health centers (CHCs) before and after cancer diagnosis among cancer survivors. We also examined the type of care received and assessed whether being established with a CHC or the type of health insurance affected the use of services. METHODS Using electronic health record data and linked cancer registries from 5,649 CHC patients in three states from 2012 through 2018, we obtained monthly rates of primary care and mental health/behavioral health (MHBH) visits and the probability of receipt of care before and after a cancer diagnosis. RESULTS Seventy-five percent of CHC patients diagnosed with cancer returned to their primary CHC for care within 2-years of their diagnosis. Among those who returned, there was a sharp increase in primary and MHBH care shortly before their diagnosis. Significantly more primary care (pre: 19.6%, post: 21.9%, p < 0.001) and MHBH care (pre: 1.2%, post: 1.6%, p < 0.001) was received after diagnosis than before. However, uninsured patients had fewer visits after their diagnosis than before. CONCLUSION Use of preventive care for cancer survivors is particularly important. Having an established primary care clinic may help to ensure survivors receive recommended screening and care.
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Affiliation(s)
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Robert W Voss
- Research Department, OCHIN Inc., Portland, Oregon, USA
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA.,Biostatistics Group, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
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14
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Bailey SR, Voss R, Angier H, Huguet N, Marino M, Valenzuela SH, Chung-Bridges K, DeVoe JE. Affordable Care Act Medicaid expansion and access to primary-care based smoking cessation assistance among cancer survivors: an observational cohort study. BMC Health Serv Res 2022; 22:488. [PMID: 35414079 PMCID: PMC9004133 DOI: 10.1186/s12913-022-07860-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/29/2022] [Indexed: 12/05/2022] Open
Abstract
Background Smoking among cancer survivors can increase the risk of cancer reoccurrence, reduce treatment effectiveness and decrease quality of life. Cancer survivors without health insurance have higher rates of smoking and decreased probability of quitting smoking than cancer survivors with health insurance. This study examines the associations of the Affordable Care Act (ACA) Medicaid insurance expansion with smoking cessation assistance and quitting smoking among cancer survivors seen in community health centers (CHCs). Methods Using electronic health record data from 337 primary care community health centers in 12 states that expanded Medicaid eligibility and 273 CHCs in 8 states that did not expand, we identified adult cancer survivors with a smoking status indicating current smoking within 6 months prior to ACA expansion in 2014 and ≥ 1 visit with smoking status assessed within 24-months post-expansion. Using an observational cohort propensity score weighted approach and logistic generalized estimating equation regression, we compared odds of quitting smoking, having a cessation medication ordered, and having ≥6 visits within the post-expansion period among cancer survivors in Medicaid expansion versus non-expansion states. Results Cancer survivors in expansion states had higher odds of having a smoking cessation medication order (adjusted odds ratio [aOR] = 2.54, 95%CI = 1.61-4.03) and higher odds of having ≥6 office visits than those in non-expansion states (aOR = 1.82, 95%CI = 1.22-2.73). Odds of quitting smoking did not differ significantly between patients in Medicaid expansion versus non-expansion states. Conclusions The increased odds of having a smoking cessation medication order among cancer survivors seen in Medicaid expansion states compared with those seen in non-expansion states provides evidence of the importance of health insurance coverage in accessing evidence-based tobacco treatment within CHCs. Continued research is needed to understand why, despite increased odds of having a cessation medication prescribed, odds of quitting smoking were not significantly higher among cancer survivors in Medicaid expansion states compared to non-expansion states.
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Affiliation(s)
- Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, USA.
| | - Robert Voss
- OCHIN, Inc, 1881 SW Naito Parkway, Portland, OR, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, USA
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, USA
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, USA.,Division of Biostatistics, School of Public Health, Oregon Health & Science University - Portland State University, 3181 SW Sam Jackson Park Road, Portland, OR, USA
| | - Steele H Valenzuela
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, USA
| | | | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, USA
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15
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Anderson JK, Newlove-Delgado T, Ford TJ. Annual Research Review: A systematic review of mental health services for emerging adults - moulding a precipice into a smooth passage. J Child Psychol Psychiatry 2022; 63:447-462. [PMID: 34939668 DOI: 10.1111/jcpp.13561] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The transition between child and adult services should aim to support young people into the next stage of their life in a way that optimises their function. Yet financial, organisational and procedural barriers to continuity of care often hamper smooth transition between child and adult services. AIM AND METHOD We reviewed studies of transition from child to adult mental health services, focusing on: (a) rates of referrals and referral acceptance; (b) barriers and facilitators of successful transition; (c) continuity of care during and post-transition and (d) service users' experience of transition. Studies were identified through systematic searches of electronic databases: PsycINFO, Medline, Embase and Child Development and Adolescent Studies. FINDINGS Forty-seven papers describing 43 unique studies met inclusion criteria. Service provision is influenced by previous history and funding processes, and the presence or absence of strong primary care, specialist centres of excellence and coordination between specialist and primary care. Provision varies between and within countries, particularly whether services are restricted to 'core' mental health or broader needs. Unsupportive organisational culture, fragmentation of resources, skills and knowledge base undermine the collaborative working essential to optimise transition. Stigma and young people's concerns about peers' evaluation often prompt disengagement and discontinuation of care during transition, leading to worsening of symptoms and later, to service re-entry. Qualitative studies reveal that young people and families find the transition process frustrating and difficult, mainly because of lack of advanced planning and inadequate preparation. CONCLUSIONS Despite increasing research interest over the last decade, transition remains 'poorly planned, executed and experienced'. Closer collaboration between child and adult services is needed to improve the quality of provision for this vulnerable group at this sensitive period of development.
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Affiliation(s)
| | | | - Tamsin J Ford
- Department of Psychiatry, University of Cambridge, Cambridge, UK
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16
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Kaufmann J, Marino M, Lucas J, Bailey SR, Giebultowicz S, Puro J, Ezekiel-Herrera D, Suglia SF, Heintzman J. Racial and Ethnic Disparities in Acute Care Use for Pediatric Asthma. Ann Fam Med 2022; 20:116-122. [PMID: 35346926 PMCID: PMC8959738 DOI: 10.1370/afm.2771] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/30/2021] [Accepted: 08/16/2021] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Previous work has shown that asthma-related emergency department (ED) use is greatest among Black and Latine populations, but it is unknown whether health care use for exacerbations differs across settings (outpatient, ED, inpatient) and correlates with use of routine outpatient services. We aimed to measure disparities by race, ethnicity, and language in pediatric acute asthma care using data from US primary care community health centers. METHODS In an observational study using electronic health records from community health centers in 18 states, we compared non-Hispanic Black, English-preferring Latine, Spanish-preferring Latine, and non-Hispanic White children aged 3 to 17 years on visits for clinic-coded asthma exacerbations (2012-2018). We further evaluated asthma-related ED use and inpatient admissions in a subsample of Oregon-Medicaid recipients. Covariate-adjusted odds ratios (ORs) and rate ratios (RRs) were derived using logistic or negative binomial regression analysis with generalized estimating equations. RESULTS Among 41,276 children with asthma, Spanish-preferring Latine children had higher odds of clinic visits for asthma exacerbation than non-Hispanic White peers (OR = 1.10; 95% CI, 1.02-1.18). Among the subsample of 6,555 children insured under Oregon-Medicaid, non-Hispanic Black children had higher odds and rates of asthma-related ED use than non-Hispanic White peers (OR = 1.40; 95% CI, 1.04-1.89 and RR = 1.49; 95% CI, 1.09-2.04, respectively). We observed no differences between groups in asthma-related inpatient admissions. CONCLUSIONS This study is the first to show that patterns of clinic and ED acute-care use differ for non-Hispanic Black and Spanish-preferring Latine children when compared with non-Hispanic White peers. Non-Hispanic Black children had lower use of clinics, whereas Spanish-preferring Latine children had higher use, including for acute exacerbations. These patterns of clinic use were accompanied by higher ED use among Black children. Ensuring adequate care in clinics may be important in mitigating disparities in asthma outcomes.VISUAL ABSTRACT.
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Affiliation(s)
- Jorge Kaufmann
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.,Biostatistics Group, School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon
| | - Jennifer Lucas
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | | | | | | | - Shakira F Suglia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.,OCHIN, Portland, Oregon
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17
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Heintzman J, Hwang J, Quiñones AR, Guzman CEV, Bailey SR, Lucas J, Giebultowicz S, Chan B, Marino M. Influenza and pneumococcal vaccination delivery in older Hispanic populations in the United States. J Am Geriatr Soc 2022; 70:854-861. [PMID: 34854478 PMCID: PMC9904430 DOI: 10.1111/jgs.17589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/29/2021] [Accepted: 10/24/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION National reports suggest that Hispanic patients may underutilize influenza and pneumococcal vaccination, although studies sometimes conflict on this point. A clearer picture of adult immunization utilization in older Hispanic patients is necessary to ensure equity in adult vaccinations. METHODS Using electronic health records from 648 community health centers (CHCs) across 21 states, we compared English-preferring Hispanic patients, Spanish-preferring Hispanic patients, and Non-Hispanic White (NHW) adults aged ≥50 years across five outcomes between 2012-2017: (1) Odds of ever receiving pneumococcal vaccination after age 65, (2) Odds of ever receiving ≥2 pneumococcal vaccinations for those ≥65, (3) odds of vaccination between the ages of 50 and 64 for those with diabetes or heart disease, (4) odds of influenza vaccine, and (5) annual rate of influenza vaccination. RESULTS Of our total study sample (N = 143,869), 85,562 were age 50-64 during the entire study period, and 65,977 were ≥65 at some point during the study period. In patients aged 50-64, Spanish-preferring Hispanic patients were more likely to have ever had an influenza vaccination (covariate-adjusted odds ratio [aOR] = 1.33, 95% CI = 1.29-1.37), had higher rates of annual influenza vaccination (covariate-adjusted rate ratio [aRR] = 1.41, 95% CI = 1.38-1.44), and higher odds of pneumococcal vaccination (aOR = 1.87, 95% CI = 1.76-1.98) than NHW patients. These findings were similar in Spanish-preferring Hispanic patients ≥65. English-preferring Hispanics ≥65 were less likely than NHW patients to ever have an influenza vaccination (aOR = 0.91, 95% CI = 0.85-0.98) and to have ever received at least one (aOR = 0.92, 95% CI = 0.86-0.99) or two (aOR = 0.86, 95% CI = 0.77-0.95) pneumococcal vaccine doses. CONCLUSIONS In a multistate CHC network, Spanish-preferring Hispanic patients were more likely to receive influenza and pneumococcal vaccinations than NHW patients; older English-preferring Hispanic patients were often less likely than NHW patients to receive these vaccinations. In vaccine initiatives, English-preferring Hispanic patients may be at higher risk of vaccination inequity.
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Affiliation(s)
- John Heintzman
- Associate Professor, Department of Family Medicine, Oregon Health and Science University (OHSU), 3381 Sw Sam Jackson Park Road, Portland, OR 97239
| | - Jun Hwang
- Oregon Health & Science University, Department of Family Medicine, Portland OR
| | - Ana R. Quiñones
- Oregon Health & Science University, Department of Family Medicine, Portland OR
| | | | - Steffani R Bailey
- Oregon Health & Science University, Department of Family Medicine, Portland OR
| | - Jennifer Lucas
- Oregon Health & Science University, Department of Family Medicine, Portland OR
| | | | - Brian Chan
- Oregon Health & Science University, Department of General Internal Medicine
| | - Miguel Marino
- Oregon Health & Science University, Department of Family Medicine, Portland OR
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18
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Huguet N, Larson A, Angier H, Marino M, Green BB, Moreno L, DeVoe JE. Rates of Undiagnosed Hypertension and Diagnosed Hypertension Without Anti-hypertensive Medication Following the Affordable Care Act. Am J Hypertens 2021; 34:989-998. [PMID: 33929496 PMCID: PMC8457435 DOI: 10.1093/ajh/hpab069] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/07/2021] [Accepted: 04/28/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The Affordable Care Act (ACA) Medicaid expansion improved access to health insurance and health care services. This study assessed whether the rate of patients with undiagnosed hypertension and the rate of patients with hypertension without anti-hypertensive medication decreased post-ACA in community health center (CHC). METHODS We analyzed electronic health record data from 2012 to 2017 for 126,699 CHC patients aged 19-64 years with ≥1 visit pre-ACA and ≥1 post-ACA in 14 Medicaid expansion states. We estimated the prevalence of patients with undiagnosed hypertension (high blood pressure reading without a diagnosis for ≥1 day) and the prevalence of patients with hypertension without anti-hypertensive medication by year and health insurance type (continuously uninsured, continuously insured, gained insurance, and discontinuously insured). We compared the time to diagnosis or to anti-hypertensive medication pre- vs. post-ACA. RESULTS Overall, 37.3% of patients had undiagnosed hypertension and 27.0% of patients with diagnosed hypertension were without a prescribed anti-hypertensive medication for ≥1 day during the study period. The rate of undiagnosed hypertension decreased from 2012 through 2017. Those who gained insurance had the lowest rates of undiagnosed hypertension (2012: 14.8%; 2017: 6.1%). Patients with hypertension were also more likely to receive anti-hypertension medication during this period, especially uninsured patients who experienced the largest decline (from 47.0% to 8.1%). Post-ACA, among patients with undiagnosed hypertension, time to diagnosis was shorter for those who gained insurance than other insurance types. CONCLUSIONS Those who gained health insurance were appropriately diagnosed with hypertension faster and more frequently post-ACA than those with other insurance types. CLINICAL TRIALS REGISTRATION Trial Number NCT03545763.
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Affiliation(s)
- Nathalie Huguet
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Annie Larson
- Research Department, OCHIN Inc., Portland, Oregon, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Miguel Marino
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Biostatistics Group, Oregon Health and Science University—Portland State University School of Public Health, Portland, Oregon, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Laura Moreno
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA
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19
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Blackburn BE, Marino M, Schmidt T, Heintzman J, Hatch B, DeVoe J, Moreno L, Huguet N. Preventive service utilization among low-income cancer survivors. J Cancer Surviv 2021; 16:1047-1054. [PMID: 34409521 PMCID: PMC8857290 DOI: 10.1007/s11764-021-01095-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/05/2021] [Indexed: 11/28/2022]
Abstract
Purpose Adequate access to and utilization of preventive services are vital among cancer survivors. This study examined preventive service utilization of cancer survivors compared to matched patients with no history of cancer among patients seeking care at community health centers (CHCs). Methods We utilized electronic health record data from the OCHIN network between 2014 and 2017. Cancer survivors (N = 20,538) ages ≥ 18 years were propensity score matched to three individuals with no history of cancer (N = 61,617) by age, sex, region, urban/rural, ethnicity, race, BMI, and Charlson Comorbidity Index. Preventive screenings included cancer, mental health and substance abuse, cardiovascular, and infectious disease screenings, and vaccinations. Patient-level preventive service indices were calculated for each screening as the total person-time covered divided by the total person-time eligible. Preventive service rate ratios comparing cancer survivors to patients with no history of cancer were estimated using negative binomial regression. Results Cancer survivors had higher overall preventive service utilization (incidence rate ratio = 1.11, 95% confidence interval = 1.09–1.13) and higher rates of cancer screenings (IRR = 1.16, 95% CI = 1.12–1.20). There was no difference between the two groups in mental health screenings. Conclusions Cancer survivors were more likely to be up-to-date with preventive care than their matched counterparts. However, mental health and substance abuse screenings were low in both groups, despite reports of increased mental health conditions among cancer survivors. Implications for Cancer Survivors With the growing number of cancer survivors in the USA, efforts are needed to ensure their access to and utilization of preventive services, especially related to behavioral and mental healthcare. Supplementary Information The online version contains supplementary material available at 10.1007/s11764-021-01095-7.
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Affiliation(s)
- Brenna E Blackburn
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR, USA. .,Department of Family and Preventive Medicine, School of Medicine, University of Utah, 375 Chipeta Way, Salt Lake City, UT, 84108, USA.
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR, USA.,Division of Biostatistics, School of Public Health, Oregon Health & Science University - Portland State University, 3181 SW Sam Jackson Park Road, Portland, OR, USA
| | | | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR, USA.,OCHIN, Inc., 1881 SW Naito Pkwy, Portland, OR, USA
| | - Brigit Hatch
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR, USA.,OCHIN, Inc., 1881 SW Naito Pkwy, Portland, OR, USA
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR, USA.,OCHIN, Inc., 1881 SW Naito Pkwy, Portland, OR, USA
| | - Laura Moreno
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR, USA
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR, USA
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20
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Lucas JA, Marino M, Giebultowicz S, Fankhauser K, Suglia SF, Bailey SR, Bazemore A, Heintzman J. Mobility and social deprivation on primary care utilisation among paediatric patients with asthma. Fam Med Community Health 2021; 9:e001085. [PMID: 34244305 PMCID: PMC8278882 DOI: 10.1136/fmch-2021-001085] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Asthma care is negatively impacted by neighbourhood social and environmental factors, and moving is associated with undesirable asthma outcomes. However, little is known about how movement into and living in areas of high deprivation relate to primary care use. We examined associations between neighbourhood characteristics, mobility and primary care utilisation of children with asthma to explore the relevance of these social factors in a primary care setting. DESIGN In this cohort study, we conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient-level covariates. SETTING We used data from community health centres in 15 OCHIN states. PARTICIPANTS The sample included 23 773 children with asthma aged 3-17 across neighbourhoods with different levels of social deprivation from 2012 to 2017. We conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient-level covariates. RESULTS Clinic visit rates were higher among children living in or moving to areas with higher deprivation than those living in areas with low deprivation (rate ratio (RR) 1.09, 95% CI 1.02 to 1.17; RR 1.05, 95% CI 1.00 to 1.11). Children moving across neighbourhoods with similarly high levels of deprivation had increased RRs of influenza vaccination (RR 1.13, 95% CI 1.03 to 1.23) than those who moved but stayed in neighbourhoods of low deprivation. CONCLUSIONS Movement into and living within areas of high deprivation is associated with more primary care use, and presumably greater opportunity to reduce undesirable asthma outcomes. These results highlight the need to attend to patient movement in primary care visits, and increase neighbourhood-targeted population management to improve equity and care for children with asthma.
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Affiliation(s)
- Jennifer A Lucas
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Katie Fankhauser
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Shakira F Suglia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrew Bazemore
- American Board of Family Medicine, Lexington, Kentucky, USA
- Center for Professionalism & Value in Health Care, Washington, DC, USA
| | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
- OCHIN Inc, Portland, Oregon, USA
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Bhatraju EP, Fuller C, Grekin P, Rockman S, Peavy KM. Mortality in an Opioid Treatment Program. J Psychoactive Drugs 2021; 54:93-98. [PMID: 33840354 DOI: 10.1080/02791072.2021.1909189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This retrospective study examined mortality in an Opioid Treatment Program (OTP) with policies designed to admit and retain patients with as few barriers as possible. Methadone provided in the context of an OTP is known to decrease mortality and morbidity. Historically, patients have been discharged or turned away because of continued substance use. We examined patient deaths over three years in an OTP serving approximately 2400 patients daily. Demographics and causes of death were gathered from electronic health records and medical examiner reports. Pairwise comparisons were used to compare drug poisoning versus non-drug poisoning deaths. There were 155 deaths during the study period. The average age was 54, and half of the participants had positive results on their most recent drug screen. Forty one (26%) died from "drug poisoning." Drug poisoning deaths were more common among patients who: 1) had recent positive drug test results; 2) had documented alprazolam use; 3) were younger; 4) had shorter treatment durations; 5) were female. The majority of deaths were among long-term patients over 50 and were not caused by drug poisoning. These results support keeping patients in treatment despite ongoing drug use, and linking them to appropriate primary care.
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Affiliation(s)
- Elenore P Bhatraju
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA.,Evergreen Treatment Services, Seattle, WA, USA
| | - Caitlin Fuller
- Department of Clinical Psychology, Alliant International University, San Diego, CA, USA
| | - Paul Grekin
- Evergreen Treatment Services, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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Goldstein EV. Community Health Centers Maintained Initial Increases in Medicaid Covered Adult Patients at 5-Years Post-Medicaid-Expansion. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2021; 58:469580211022618. [PMID: 34088240 PMCID: PMC8182175 DOI: 10.1177/00469580211022618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/27/2021] [Accepted: 05/13/2021] [Indexed: 12/05/2022]
Abstract
The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) providing primary care in medically-underserved communities. However, beyond evidence of initial policy effects, little is understood in the scholarly literature about whether the ACA Medicaid expansion affected longer-lasting changes in CHC patient insurance mix. This study's objective was to examine whether the ACA Medicaid expansion was associated with lasting increases in the annual percentage of adult CHC patients covered by Medicaid and decreases in the annual percentage of uninsured adult CHC patients at expansion-state CHCs, compared to non-expansion-state CHCs. This observational study examined 5353 CHC-year observations from 2012 to 2018 using Uniform Data System data and other national data sources. Using a 2-way fixed-effects multivariable regression approach and marginal analysis, intermediate-term policy effects of the Medicaid expansion on annual CHC patient coverage outcomes were estimated. By 5-years post-expansion, the Medicaid expansion was associated with an overall average increase of 11.7 percentage points in the percentage of adult patients with Medicaid coverage at expansion-state CHCs, compared to non-expansion-state CHCs. Among expansion-state CHCs, 39.8% of adult patients were predicted to have Medicaid coverage 5-years post-expansion, compared to 19.0% of non-expansion-state adult CHC patients. A state's decision to expand Medicaid was similarly associated with decreases in the annual percentage of uninsured adult CHC patients. Primary care operations at CHCs critically depend on patient Medicaid revenue. These findings suggest the ACA Medicaid expansion may provide longer-term financial security for expansion-state CHCs, which maintain increases in Medicaid-covered adult patients even 5-years post-expansion. However, these financial securities may be jeopardized should the ACA be ruled unconstitutional in 2021, a year after CHCs experienced new uncertainties caused by COVID-19.
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Hatch B, Hoopes M, Darney BG, Marino M, Templeton AR, Schmidt T, Cottrell E. Impacts of the Affordable Care Act on Receipt of Women's Preventive Services in Community Health Centers in Medicaid Expansion and Nonexpansion States. Womens Health Issues 2021; 31:9-16. [PMID: 33023807 PMCID: PMC9206529 DOI: 10.1016/j.whi.2020.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 08/21/2020] [Accepted: 08/26/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND The Affordable Care Act (ACA) increased health insurance coverage throughout the United States and improved care delivery for some services. We assess whether ACA implementation and Medicaid expansion were followed by greater receipt of recommended preventive services among women and girls in a large network of community health centers. METHODS Using electronic health record data from 354 community health centers in 14 states (10 expansion, 4 nonexpansion), we used generalized estimating equations and difference-in-difference methods to compare receipt of six recommended preventive services (cervical cancer screening, human papilloma virus vaccination, chlamydia screening, influenza vaccination, human immunodeficiency virus screening, and blood pressure screening) among active female patients ages 11 to 65 (N = 711,121) before and after ACA implementation and between states that expanded versus did not expand Medicaid. RESULTS Except for blood pressure screening, receipt of all examined preventive services increased after ACA implementation in both Medicaid expansion and nonexpansion states. Influenza vaccination and blood pressure screening increased more in expansion states (adjusted absolute prevalence difference-in-difference, 1.55; 95% confidence interval, 0.51-2.60; and 1.98; 95% confidence interval, 0.91-3.05, respectively). Chlamydia screening increased more in nonexpansion states (adjusted absolute prevalence difference-in-difference: -4.21; 95% confidence interval, -6.98 to -1.45). Increases in cervical cancer screening, human immunodeficiency virus screening, and human papilloma virus vaccination did not differ significantly between expansion and nonexpansion states. CONCLUSIONS Among female patients at community health centers, receipt of recommended preventive care improved after ACA implementation in both Medicaid expansion and nonexpansion states, although the overall rates remained low. Continued support is needed to overcome barriers to preventive care in this population.
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Affiliation(s)
- Brigit Hatch
- School of Medicine, Family Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Blair G Darney
- School of Medicine, Family Medicine, Oregon Health & Science University, Portland, Oregon; School of Medicine, Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Miguel Marino
- School of Medicine, Family Medicine, Oregon Health & Science University, Portland, Oregon
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Private/marketplace insurance in community health centers 5 years post-affordable care act in medicaid expansion and non-expansion states. Prev Med 2020; 141:106271. [PMID: 33039451 PMCID: PMC7704912 DOI: 10.1016/j.ypmed.2020.106271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/23/2020] [Accepted: 09/27/2020] [Indexed: 11/23/2022]
Abstract
Community health centers (CHCs) play an important role in providing care for the safety net population. After implementation of the Affordable Care Act, many patients gained insurance through state and federal marketplaces. Using electronic health record data from 702,663 patients in 257 clinics across 20 states, we sought to explore the following differences between Medicaid expansion and non-expansion state CHCs: (1) trends in private/marketplace insurance post-expansion, and (2) whether CHC patients retain private/marketplace insurance. We found that patients in non-expansion state CHCs relied more heavily on private/marketplace insurance than patients in expansion states and had increases in private/marketplace-insured visits from 2014 through 2018. Additionally, there appeared to be seasonal variation in private/marketplace-insured visits that were more pronounced in non-expansion states. While a greater percentage of patients in non-expansion states retained private/marketplace insurance than in expansion states, a greater percentage of those who did not retain it became uninsured. In comparison, a greater percentage of patients in expansion states who lost private/marketplace insurance gained other types of health insurance. CHCs' ability to provide adequate care for vulnerable populations relies, in part, on federal grants as well as reimbursement from insurers: decreases in either could result in reduced capacity or quality of care for patients seen in CHCs.
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25
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Filling the Public Health Science Gaps for Diabetes With Natural Experiments. Med Care 2020; 58 Suppl 6 Suppl 1:S1-S3. [PMID: 32412947 DOI: 10.1097/mlr.0000000000001330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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