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Cené CW, Viswanathan M, Fichtenberg CM, Sathe NA, Kennedy SM, Gottlieb LM, Cartier Y, Peek ME. Racial Health Equity and Social Needs Interventions: A Review of a Scoping Review. JAMA Netw Open 2023; 6:e2250654. [PMID: 36656582 PMCID: PMC9857687 DOI: 10.1001/jamanetworkopen.2022.50654] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE Social needs interventions aim to improve health outcomes and mitigate inequities by addressing health-related social needs, such as lack of transportation or food insecurity. However, it is not clear whether these studies are reducing racial or ethnic inequities. OBJECTIVE To understand how studies of interventions addressing social needs among multiracial or multiethnic populations conceptualize and analyze differential intervention outcomes by race or ethnicity. EVIDENCE REVIEW Sources included a scoping review of systematic searches of PubMed and the Cochrane Library from January 1, 1995, through November 29, 2021, expert suggestions, and hand searches of key citations. Eligible studies evaluated interventions addressing social needs; reported behavioral, health, or utilization outcomes or harms; and were conducted in multiracial or multiethnic populations. Two reviewers independently assessed titles, abstracts, and full text for inclusion. The team developed a framework to assess whether the study was "conceptually thoughtful" for understanding root causes of racial health inequities (ie, noted that race or ethnicity are markers of exposure to racism) and whether analyses were "analytically informative" for advancing racial health equity research (ie, examined differential intervention impacts by race or ethnicity). FINDINGS Of 152 studies conducted in multiracial or multiethnic populations, 44 studies included race or ethnicity in their analyses; of these, only 4 (9%) were conceptually thoughtful. Twenty-one studies (14%) were analytically informative. Seven of 21 analytically informative studies reported differences in outcomes by race or ethnicity, whereas 14 found no differences. Among the 7 that found differential outcomes, 4 found the interventions were associated with improved outcomes for minoritized racial or ethnic populations or reduced inequities between minoritized and White populations. No studies were powered to detect differences. CONCLUSIONS AND RELEVANCE In this review of a scoping review, studies of social needs interventions in multiracial or multiethnic populations were rarely conceptually thoughtful for understanding root causes of racial health inequities and infrequently conducted informative analyses on intervention effectiveness by race or ethnicity. Future work should use a theoretically sound conceptualization of how race (as a proxy for racism) affects social drivers of health and use this understanding to ensure social needs interventions benefit minoritized racial and ethnic groups facing social and structural barriers to health.
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Affiliation(s)
- Crystal W. Cené
- Department of Medicine, University of California, San Diego Health, San Diego
- School of Medicine, University of California, San Diego
| | - Meera Viswanathan
- RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center, RTI International, Research Triangle Park
| | - Caroline M. Fichtenberg
- University of California, San Francisco Social Intervention Research and Evaluation Network, San Francisco
- School of Medicine, Department of Family and Community Medicine, Center for Health and Community, University of California, San Francisco
| | - Nila A. Sathe
- RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center, RTI International, Research Triangle Park
| | - Sara M. Kennedy
- RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center, RTI International, Research Triangle Park
| | - Laura M. Gottlieb
- School of Medicine, Department of Family and Community Medicine, Center for Health and Community, University of California, San Francisco
| | - Yuri Cartier
- University of California, San Francisco Social Intervention Research and Evaluation Network, San Francisco
| | - Monica E. Peek
- Section of General Internal Medicine, MacLean Center for Clinical Medical Ethics, Center for the Study of Race, Politics and Culture, The University of Chicago, Chicago, Illinois
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A Practice-Based Research Network (PBRN) Roadmap for Evaluating COVID-19 in Community Health Centers: A Report From the OCHIN PBRN. J Am Board Fam Med 2020; 33:774-778. [PMID: 32989072 PMCID: PMC7908821 DOI: 10.3122/jabfm.2020.05.200053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Primary care practice-based research networks (PBRNs) are critical laboratories for generating evidence from real-world settings, including studying natural experiments. Primary care's response to the novel coronavirus-19 (COVID-19) pandemic is arguably the most impactful natural experiment in our lifetime. EVALUATING THE IMPACT OF COVID-19: We briefly describe the OCHIN PBRN of community health centers (CHCs), its partnership with implementation scientists, and how we are leveraging this infrastructure and expertise to create a rapid research response evaluating how CHCs across the country responded to the COVID-19 pandemic. COVID-19 RESEARCH ROADMAP: Our research agenda focuses on asking: How has care delivery in CHCs changed due to COVID-19? What impact has COVID-19 had on the delivery of preventive services in CHCs? Which PBRN services (e.g., data surveillance, training, evidence synthesis) are most impactful to real-world practices? What decision-making strategies were used in the PBRN and its practices to make real-time changes in response to the pandemic? What critical factors in successfully and sustainably transforming primary care are illuminated by pandemic-driven changes? DISCUSSION AND CONCLUSIONS PBRNs enable real-world evaluation of practice change and natural experiments, and thus are ideal laboratories for implementation science research. We present a real-time example of how a PBRN Implementation Laboratory activated a response to study a historic natural experiment, to help other PBRNs charting a course through this pandemic.
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Marino M, Angier H, Springer R, Valenzuela S, Hoopes M, O'Malley J, Suchocki A, Heintzman J, DeVoe J, Huguet N. The Affordable Care Act: Effects of Insurance on Diabetes Biomarkers. Diabetes Care 2020; 43:2074-2081. [PMID: 32611609 PMCID: PMC7440906 DOI: 10.2337/dc19-1571] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 05/14/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We sought to understand how Affordable Care Act (ACA) Medicaid expansion insurance coverage gains are associated with changes in diabetes-related biomarkers. RESEARCH DESIGN AND METHODS This was a retrospective observational cohort study using electronic health record data from 178 community health centers (CHCs) in the ADVANCE (Accelerating Data Value Across a National Community Health Center Network) network. We assessed changes in diabetes-related biomarkers among adult patients with diabetes in 10 Medicaid expansion states (n = 25,279), comparing newly insured with continuously insured, discontinuously insured, and continuously uninsured patients pre- to post-ACA expansion. Primary outcomes included changes from 24 months pre- to 24 months post-ACA in glycosylated hemoglobin (HbA1c), systolic (SBP) and diastolic (DBP) blood pressure, and LDL cholesterol levels. RESULTS Newly insured patients exhibited a reduction in adjusted mean HbA1c levels (8.24% [67 mmol/mol] to 8.17% [66 mmol/mol]), which was significantly different from continuously uninsured patients, whose HbA1c levels increased (8.12% [65 mmol/mol] to 8.29% [67 mmol/mol]; difference-in-differences [DID] -0.24%; P < 0.001). Newly insured patients showed greater reductions than continuously uninsured patients in adjusted mean SBP (DID -1.8 mmHg; P < 0.001), DBP (DID -1.0 mmHg; P < 0.001), and LDL (DID -3.3 mg/dL; P < 0.001). Among patients with elevated HbA1c in the 3 months prior to expansion, newly insured patients were more likely than continuously uninsured patients to have a controlled HbA1c measurement by 24 months post-ACA (hazard ratio 1.25; 95% CI 1.02-1.54]. CONCLUSIONS Post-ACA, newly insured patients had greater improvements in diabetes-related biomarkers than continuously uninsured, discontinuously insured, or continuously insured patients. Findings suggest that health insurance gain via ACA facilitates access to appropriate diabetes care, leading to improvements in diabetes-related biomarkers.
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Affiliation(s)
- Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR .,Biostatistics Group, Oregon Health & Science University-Portland State University School of Public Health, Portland, OR
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Rachel Springer
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Steele Valenzuela
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | | | - Jean O'Malley
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Portland, OR
| | | | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Portland, OR
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Portland, OR
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
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Hatch B, Tillotson C, Huguet N, Marino M, Baron A, Nelson J, Sumic A, Cohen D, E DeVoe J. Implementation and adoption of a health insurance support tool in the electronic health record: a mixed methods analysis within a randomized trial. BMC Health Serv Res 2020; 20:428. [PMID: 32414376 PMCID: PMC7227079 DOI: 10.1186/s12913-020-05317-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 05/11/2020] [Indexed: 11/10/2022] Open
Abstract
Background In addition to delivering vital health care to millions of patients in the United States, community health centers (CHCs) provide needed health insurance outreach and enrollment support to their communities. We developed a health insurance enrollment tracking tool integrated within the electronic health record (EHR) and conducted a hybrid implementation-effectiveness trial in a CHC-based research network to assess tool adoption using two implementation strategies. Methods CHCs were recruited from the OCHIN practice-based research network. Seven health center systems (23 CHC clinic sites) were recruited and randomized to receive basic educational materials alone (Arm 1), or these materials plus facilitation (Arm 2) during the 18-month study period, September 2016–April 2018. Facilitation consisted of monthly contacts with clinic staff and utilized audit and feedback and guided improvement cycles. We measured total and monthly tool utilization from the EHR. We conducted structured interviews of CHC staff to assess factors associated with tool utilization. Qualitative data were analyzed using an immersion-crystallization approach with barriers and facilitators identified using the Consolidated Framework for Implementation Research. Results The majority of CHCs in both study arms adopted the enrollment tool. The rate of tool utilization was, on average, higher in Arm 2 compared to Arm 1 (20.0% versus 4.7%, p < 0.01). However, by the end of the study period, the rate of tool utilization was similar in both arms; and observed between-arm differences in tool utilization were largely driven by a single, large health center in Arm 2. Perceived relative advantage of the tool was the key factor identified by clinic staff as driving tool utilization. Implementation climate and leadership engagement were also associated with tool utilization. Conclusions Using basic education materials and low-intensity facilitation, CHCs quickly adopted an EHR-based tool to support critical outreach and enrollment activities aimed at improving access to health insurance in their communities. Though facilitation carried some benefit, a CHC’s perceived relative advantage of the tool was the primary driver of decisions to implement the tool. Trial registration ClinicalTrials.gov: NCT02355262, Posted February 4, 2015.
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Affiliation(s)
- Brigit Hatch
- Oregon Health & Science University, 3405 SW Perimeter Court, Portland, OR, 97239, USA. .,OCHIN, 1881 SW Naito Parkway, Portland, OR, 97201, USA.
| | | | - Nathalie Huguet
- Oregon Health & Science University, 3405 SW Perimeter Court, Portland, OR, 97239, USA
| | - Miguel Marino
- Oregon Health & Science University, 3405 SW Perimeter Court, Portland, OR, 97239, USA
| | - Andrea Baron
- Oregon Health & Science University, 3405 SW Perimeter Court, Portland, OR, 97239, USA
| | - Joan Nelson
- OCHIN, 1881 SW Naito Parkway, Portland, OR, 97201, USA
| | | | - Deborah Cohen
- Oregon Health & Science University, 3405 SW Perimeter Court, Portland, OR, 97239, USA
| | - Jennifer E DeVoe
- Oregon Health & Science University, 3405 SW Perimeter Court, Portland, OR, 97239, USA.,OCHIN, 1881 SW Naito Parkway, Portland, OR, 97201, USA
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Cottrell E, Darney BG, Marino M, Templeton AR, Jacob L, Hoopes M, Rodriguez M, Hatch B. Study protocol: a mixed-methods study of women's healthcare in the safety net after Affordable Care Act implementation - EVERYWOMAN. Health Res Policy Syst 2019; 17:58. [PMID: 31186028 PMCID: PMC6558747 DOI: 10.1186/s12961-019-0445-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 03/29/2019] [Indexed: 11/29/2022] Open
Abstract
Background Evidence-based reproductive care reduces morbidity and mortality for women and their children, decreases health disparities and saves money. Community health centres (CHCs) are a key point of access to reproductive and primary care services for women who are publicly insured, uninsured or unable to pay for care. Women of reproductive age (15–44 years) comprise just of a quarter (26%) of the total CHC patient population, with higher than average proportions of women of colour, women with lower income and educational status and social challenges (e.g. housing). Such factors are associated with poorer reproductive health outcomes across contraceptive, preventive and pregnancy-related services. The Affordable Care Act (ACA) prioritised reproductive health as an essential component of women’s preventive services to counter these barriers and increase women’s access to care. In 2012, the United States Supreme Court ruled ACA implementation through Medicaid expansion as optional, creating a natural experiment to measure the ACA’s impact on women’s reproductive care delivery and health outcomes. Methods This paper describes a 5-year, mixed-methods study comparing women’s contraceptive, preventive, prenatal and postpartum care before and after ACA implementation and between Medicaid expansion and non-expansion states. Quantitative assessment will leverage electronic health record data from the ADVANCE Clinical Research Network, a network of over 130 CHCs in 24 states, to describe care and identify patient, practice and state-level factors associated with provision of recommended evidence-based care. Qualitative assessment will include patient, provider and practice level interviews to understand perceptions and utilisation of reproductive healthcare in CHC settings. Discussion To our knowledge, this will be the first study using patient level electronic health record data from multiple states to assess the impact of ACA implementation in conjunction with other practice and policy level factors such as Title X funding or 1115 Medicaid waivers. Findings will be relevant to policy and practice, informing efforts to enhance the provision of timely, evidence-based reproductive care, improve health outcomes and reduce disparities among women. Patient, provider and practice-level interviews will serve to contextualise our findings and develop subsequent studies and interventions to support women’s healthcare provision in CHC settings.
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Affiliation(s)
- Erika Cottrell
- OCHIN, Inc, 1881 SW Naito Pkwy, Portland, OR, 97201, United States of America
| | - Blair G Darney
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, United States of America
| | - Miguel Marino
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, United States of America
| | - Anna Rose Templeton
- OCHIN, Inc, 1881 SW Naito Pkwy, Portland, OR, 97201, United States of America.
| | - Lorie Jacob
- OCHIN, Inc, 1881 SW Naito Pkwy, Portland, OR, 97201, United States of America
| | - Megan Hoopes
- OCHIN, Inc, 1881 SW Naito Pkwy, Portland, OR, 97201, United States of America
| | - Maria Rodriguez
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, United States of America
| | - Brigit Hatch
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, United States of America
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