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Owens-Jasey C, Chen J, Xu R, Angier H, Huebschmann AG, Ito Fukunaga M, Chaiyachati KH, Rendle KA, Robien K, DiMartino L, Amante DJ, Faro JM, Kepper MM, Ramsey AT, Bressman E, Gold R. Implementation of Health IT for Cancer Screening in US Primary Care: Scoping Review. JMIR Cancer 2024; 10:e49002. [PMID: 38687595 DOI: 10.2196/49002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/29/2023] [Accepted: 03/04/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND A substantial percentage of the US population is not up to date on guideline-recommended cancer screenings. Identifying interventions that effectively improve screening rates would enhance the delivery of such screening. Interventions involving health IT (HIT) show promise, but much remains unknown about how HIT is optimized to support cancer screening in primary care. OBJECTIVE This scoping review aims to identify (1) HIT-based interventions that effectively support guideline concordance in breast, cervical, and colorectal cancer screening provision and follow-up in the primary care setting and (2) barriers or facilitators to the implementation of effective HIT in this setting. METHODS Following scoping review guidelines, we searched MEDLINE, CINAHL Plus, Web of Science, and IEEE Xplore databases for US-based studies from 2015 to 2021 that featured HIT targeting breast, colorectal, and cervical cancer screening in primary care. Studies were dual screened using a review criteria checklist. Data extraction was guided by the following implementation science frameworks: the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework; the Expert Recommendations for Implementing Change taxonomy; and implementation strategy reporting domains. It was also guided by the Integrated Technology Implementation Model that incorporates theories of both implementation science and technology adoption. Reporting was guided by PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). RESULTS A total of 101 studies met the inclusion criteria. Most studies (85/101, 84.2%) involved electronic health record-based HIT interventions. The most common HIT function was clinical decision support, primarily used for panel management or at the point of care. Most studies related to HIT targeting colorectal cancer screening (83/101, 82.2%), followed by studies related to breast cancer screening (28/101, 27.7%), and cervical cancer screening (19/101, 18.8%). Improvements in cancer screening were associated with HIT-based interventions in most studies (36/54, 67% of colorectal cancer-relevant studies; 9/14, 64% of breast cancer-relevant studies; and 7/10, 70% of cervical cancer-relevant studies). Most studies (79/101, 78.2%) reported on the reach of certain interventions, while 17.8% (18/101) of the included studies reported on the adoption or maintenance. Reported barriers and facilitators to HIT adoption primarily related to inner context factors of primary care settings (eg, staffing and organizational policies that support or hinder HIT adoption). Implementation strategies for HIT adoption were reported in 23.8% (24/101) of the included studies. CONCLUSIONS There are substantial evidence gaps regarding the effectiveness of HIT-based interventions, especially those targeting guideline-concordant breast and colorectal cancer screening in primary care. Even less is known about how to enhance the adoption of technologies that have been proven effective in supporting breast, colorectal, or cervical cancer screening. Research is needed to ensure that the potential benefits of effective HIT-based interventions equitably reach diverse primary care populations.
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Affiliation(s)
- Constance Owens-Jasey
- BRIDGE-C2 Implementation Science Center in Cancer Control, Oregon Health & Science University, Portland, OR, United States
- Department of Health Administration and Policy, College of Public Health, George Mason University, Fairfax, VA, United States
- OCHIN, Inc, Portland, OR, United States
| | - Jinying Chen
- Department of Preventive Medicine and Epidemiology, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, United States
- Data Science Core, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, United States
- iDAPT Implementation Science Center for Cancer Control, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Ran Xu
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Amy G Huebschmann
- Adult and Child Center for Outcomes Research and Delivery Science, Ludeman Family Center for Women's Health Research, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Mayuko Ito Fukunaga
- Department of Medicine, UMass Chan Medical School, Worcester, MA, United States
| | - Krisda H Chaiyachati
- Penn Implementation Science Center in Cancer Control, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Verily Life Sciences, South San Francisco, CA, United States
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Katharine A Rendle
- Penn Implementation Science Center in Cancer Control, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Kim Robien
- Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | - Lisa DiMartino
- RTI International, Research Triangle Park, NC, United States
- UT Southwestern Medical Center, University of Texas, Dallas, TX, United States
| | - Daniel J Amante
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, United States
| | - Jamie M Faro
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, United States
| | - Maura M Kepper
- Brown School, Washington University, St. Louis, MO, United States
| | - Alex T Ramsey
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States
| | - Eric Bressman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Rachel Gold
- BRIDGE-C2 Implementation Science Center in Cancer Control, Oregon Health & Science University, Portland, OR, United States
- OCHIN, Inc, Portland, OR, United States
- Kaiser Permanente Center for Health Research, Portland, OR, United States
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Follmann D, Mateja A, Fay MP, Magaret CA, Huang Y, Fong Y, Angier H, Nason M, Gay CL, Kotloff K, Woo W, Cho I, Dunkle LM. Durability of Protection Against COVID-19 Through the Delta Surge for the NVX-CoV2373 Vaccine. Clin Infect Dis 2024:ciae081. [PMID: 38372392 DOI: 10.1093/cid/ciae081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/23/2024] [Accepted: 02/08/2024] [Indexed: 02/20/2024] Open
Abstract
BACKGROUND Protein-based vaccines for COVID-19 provide a traditional vaccine platform with long-lasting protection for non-SARS-CoV-2 pathogens and may complement messenger RNA vaccines as a booster dose. While NVX-CoV2373 showed substantial early efficacy, the durability of protection has not been delineated. METHODS The PREVENT-19 vaccine trial employed a blinded crossover design; the original placebo arm received NVX-CoV2373 after efficacy was established. Using novel statistical methods that integrate surveillance data of circulating strains with post-crossover cases, we estimated placebo-controlled vaccine efficacy and durability of NVX-CoV2373 against both pre-Delta and Delta strains of SARS-CoV-2. RESULTS Vaccine efficacy against pre-Delta strains of COVID-19 was 89% (95% CI: 75%, 95%) and 87% (72%, 94%) at 0 and 90 days after 2 doses of NVX-CoV2373, respectively, with no evidence of waning (p=0.93). Vaccine efficacy against the Delta strain was 88% (71%, 95%), 82% (56%, 92%), and 77% (44%, 90%) at 40, 120, and 180 days, respectively, with evidence of waning (p<0.01). In sensitivity analyses, the estimated Delta vaccine efficacy at 120 days ranged from 66% (15%, 86%) to 89% (74%, 95%) per various assumptions of the surveillance data. CONCLUSION NVX-CoV2373 has high initial efficacy against pre-Delta and Delta strains of COVID-19 with little evidence of waning for pre-Delta strains through 90 days and moderate waning against Delta strains over 180 days.
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Affiliation(s)
- Dean Follmann
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Allyson Mateja
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Michael P Fay
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Yunda Huang
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Youyi Fong
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | | | - Martha Nason
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Cynthia L Gay
- School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Karen Kotloff
- School of Medicine, University of Maryland, Baltimore, MD, USA
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Martwick J, Kaufmann J, Bailey S, Angier H, Huguet N, Heintzman J, O’Malley J, Moreno L, DeVoe JE. Impact of Healthcare Location Concordance on Receipt of Preventive Care Among Children Whose Parents have a Substance Use and/or Mental Health Diagnosis. J Prim Care Community Health 2024; 15:21501319241229925. [PMID: 38323431 PMCID: PMC10851724 DOI: 10.1177/21501319241229925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 02/08/2024] Open
Abstract
AIMS Children of parents with substance use and/or other mental health (SU/MH) diagnoses are at increased risk for health problems. It is unknown whether these children benefit from receiving primary care at the same clinic as their parents. Thus, among children of parents with >1 SU/MH diagnosis, we examined the association of parent-child clinic concordance with rates of well-child checks (WCCs) and childhood vaccinations. DESIGN Retrospective cohort study using electronic health record (EHR) data from the OCHIN network of community health organizations (CHOs), 2010-2018. Setting: 280 CHOs across 17 states. PARTICIPANTS/CASES 41,413 parents with >1 SU/MH diagnosis, linked to 65,417 children aged 0 to 17 years, each with >1 visit to an OCHIN clinic during the study period. MEASUREMENTS Dependent variables: rates of WCCs during (1) the first 15 months of life, and (2) ages 3 to 17 years; vaccine completeness (3) by the age of 2, and (4) before the age of 18. Estimates were attained using generalized estimating equations Poisson or logistic regression. FINDINGS Among children utilizing the same clinic as their parent versus children using a different clinic (reference group), we observed greater WCC rates in the first 15 months of life [adjusted rate ratio (aRR) = 1.06; 95% confidence interval (CI) = 1.02-1.10]; no difference in WCC rates in ages 3 to 17; higher odds for vaccine completion before age 2 [adjusted odds ratio (aOR) = 1.12; 95% CI = 1.03-1.21]; and lower odds for vaccine completion before age 18 (aOR = 0.88; 95% CI = 0.81-0.95). CONCLUSION Among children whose parents have at least one SU/MH diagnosis, parent-child clinic concordance was associated with greater rates of WCCs and higher odds of completed vaccinations for children in the youngest age groups, but not the older children. This suggests the need for greater emphasis on family-oriented healthcare for young children of parents with SU/MH diagnoses; this may be less important for older children.
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Affiliation(s)
| | | | | | - Heather Angier
- Oregon Health & Science University, Portland, OR, USA
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | | | - John Heintzman
- Oregon Health & Science University, Portland, OR, USA
- OCHIN, Inc., Portland, OR, USA
| | | | - Laura Moreno
- Oregon Health & Science University, Portland, OR, USA
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Huang Y, Zhang L, Karuna S, Andrew P, Juraska M, Weiner JA, Angier H, Morgan E, Azzam Y, Swann E, Edupuganti S, Mgodi NM, Ackerman ME, Donnell D, Gama L, Anderson PL, Koup RA, Hural J, Cohen MS, Corey L, McElrath MJ, Gilbert PB, Lemos MP. Adults on pre-exposure prophylaxis (tenofovir-emtricitabine) have faster clearance of anti-HIV monoclonal antibody VRC01. Nat Commun 2023; 14:7813. [PMID: 38016958 PMCID: PMC10684488 DOI: 10.1038/s41467-023-43399-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/08/2023] [Indexed: 11/30/2023] Open
Abstract
Broadly neutralizing monoclonal antibodies (mAbs) are being developed for HIV-1 prevention. Hence, these mAbs and licensed oral pre-exposure prophylaxis (PrEP) (tenofovir-emtricitabine) can be concomitantly administered in clinical trials. In 48 US participants (men and transgender persons who have sex with men) who received the HIV-1 mAb VRC01 and remained HIV-free in an antibody-mediated-prevention trial (ClinicalTrials.gov #NCT02716675), we conduct a post-hoc analysis and find that VRC01 clearance is 0.08 L/day faster (p = 0.005), and dose-normalized area-under-the-curve of VRC01 serum concentration over-time is 0.29 day/mL lower (p < 0.001) in PrEP users (n = 24) vs. non-PrEP users (n = 24). Consequently, PrEP users are predicted to have 14% lower VRC01 neutralization-mediated prevention efficacy against circulating HIV-1 strains. VRC01 clearance is positively associated (r = 0.33, p = 0.03) with levels of serum intestinal Fatty Acid Binding protein (I-FABP), a marker of epithelial intestinal permeability, which is elevated upon starting PrEP (p = 0.04) and after months of self-reported use (p = 0.001). These findings have implications for the evaluation of future HIV-1 mAbs and postulate a potential mechanism for mAb clearance in the context of PrEP.
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Affiliation(s)
- Yunda Huang
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA.
- Department of Global Health, University of Washington, Seattle, WA, 98196, USA.
| | - Lily Zhang
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Shelly Karuna
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | | | - Michal Juraska
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Joshua A Weiner
- Thayer School of Engineering, Dartmouth College, Hanover, NH, 03755, USA
| | - Heather Angier
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Evgenii Morgan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Yasmin Azzam
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Edith Swann
- Vaccine Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Rockville, MD, 46340, USA
| | - Srilatha Edupuganti
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Nyaradzo M Mgodi
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | | | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Lucio Gama
- Vaccine Research Center (VRC), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Peter L Anderson
- Colorado Antiviral Pharmacology Laboratory and Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado-AMC, Aurora, CO, 80045, USA
| | - Richard A Koup
- Vaccine Research Center (VRC), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John Hural
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Myron S Cohen
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lawrence Corey
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
- Departments of Medicine and Laboratory Medicine, University of Washington, Seattle, WA, 98195, USA
| | - M Juliana McElrath
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
- Department of Global Health, University of Washington, Seattle, WA, 98196, USA
- Departments of Medicine and Laboratory Medicine, University of Washington, Seattle, WA, 98195, USA
| | - Peter B Gilbert
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
- Department of Biostatistics, University of Washington, Seattle, WA, 98195, USA
| | - Maria P Lemos
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
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5
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Heintzman J, Springer R, Marino M, Kaufmann J, Giebultowicz S, Warren N, Devoe J, Liu S, Angier H. Latino Adolescent-Mother Language Concordance, Neighborhood Deprivation, and Vaccinations in Community Health Centers. Matern Child Health J 2023; 27:2026-2037. [PMID: 37468799 DOI: 10.1007/s10995-023-03742-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Latino adolescents may face numerous barriers) to recommended vaccinations. There is little research on the association between Latino adolescent-mother preferred language concordance and vaccination completion and if it varies by neighborhood. To better understand the social/family factors associated with Latino adolescent vaccination, we studied the association of adolescent-mother language concordance and neighborhood social deprivation with adolescent vaccination completion. METHODS We employed a multistate, electronic health record (EHR) based dataset of community health center patients to compare three Latino groups: (1) English-preferring adolescents with English-preferring mothers, (2) Spanish-preferring adolescents with Spanish-preferring mothers, and (3) English-preferring adolescents with Spanish-preferring mothers with non-Hispanic white adolescent-mother pairs for human papilloma virus (HPV), meningococcal, and influenza vaccinations. We adjusted for mother and adolescent demographics and care utilization and stratified by the social deprivation of the family's neighborhood. RESULTS Our sample included 56,542 adolescent-mother dyads. Compared with non-Hispanic white dyads, all three groups of Latino dyads had higher odds of adolescent HPV and meningococcal vaccines and higher rates of flu vaccines. Latino dyads with Spanish-preferring mothers had higher vaccination odds/rates than Latino dyads with English-preferring mothers. The effects of variation by neighborhood social deprivation in influenza vaccination rates were minor in comparison to differences by ethnicity/language concordance. CONCLUSION In a multistate analysis of vaccinations among Latino and non-Latino adolescents, English-preferring adolescents with Spanish-preferring mothers had the highest completion rates and English-preferring non-Hispanic white dyads the lowest. Further research can seek to understand why this language dyad may have an advantage in adolescent vaccination completion.
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Affiliation(s)
- John Heintzman
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
| | - Rachel Springer
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Miguel Marino
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Jorge Kaufmann
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | | | | | - Jennifer Devoe
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Shuling Liu
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
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Easterling DV, Jacob RR, Brownson RC, Haire-Joshu D, Gundersen DA, Angier H, DeVoe JE, Likumahuwa-Ackman S, Vu T, Glasgow RE, Schnoll R. Participatory logic modeling in a multi-site initiative to advance implementation science. Implement Sci Commun 2023; 4:106. [PMID: 37644495 PMCID: PMC10466752 DOI: 10.1186/s43058-023-00468-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/12/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Logic models map the short-term and long-term outcomes that are expected to occur with a program, and thus are an essential tool for evaluation. Funding agencies, especially in the United States (US), have encouraged the use of logic models among their grantees. They also use logic models to clarify expectations for their own funding initiatives. It is increasingly recognized that logic models should be developed through a participatory approach which allows input from those who carry out the program being evaluated. While there are many positive examples of participatory logic modeling, funders have generally not engaged grantees in developing the logic model associated with their own initiatives. This article describes an instance where a US funder of a multi-site initiative fully engaged the funded organizations in developing the initiative logic model. The focus of the case study is Implementation Science Centers in Cancer Control (ISC3), a multi-year initiative funded by the National Cancer Institute. METHODS The reflective case study was collectively constructed by representatives of the seven centers funded under ISC3. Members of the Cross-Center Evaluation (CCE) Work Group jointly articulated the process through which the logic model was developed and refined. Individual Work Group members contributed descriptions of how their respective centers reviewed and used the logic model. Cross-cutting themes and lessons emerged through CCE Work Group meetings and the writing process. RESULTS The initial logic model for ISC3 changed in significant ways as a result of the input of the funded groups. Authentic participation in the development of the logic model led to strong buy-in among the centers, as evidenced by their utilization. The centers shifted both their evaluation design and their programmatic strategy to better accommodate the expectations reflected in the initiative logic model. CONCLUSIONS The ISC3 case study demonstrates how participatory logic modeling can be mutually beneficial to funders, grantees and evaluators of multi-site initiatives. Funded groups have important insights about what is feasible and what will be required to achieve the initiative's stated objectives. They can also help identify the contextual factors that either inhibit or facilitate success, which can then be incorporated into both the logic model and the evaluation design. In addition, when grantees co-develop the logic model, they have a better understanding and appreciation of the funder's expectations and thus are better positioned to meet those expectations.
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Affiliation(s)
- Douglas V Easterling
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.
| | - Rebekah R Jacob
- Prevention Research Center, Brown School, Washington University in St. Louis, One Brookings Drive, Campus, Box 1196, St. Louis, MO, 63130, USA
| | - Ross C Brownson
- Prevention Research Center, Brown School, Washington University in St. Louis, One Brookings Drive, Campus, Box 1196, St. Louis, MO, 63130, USA
- Department of Surgery (Division of Public Health Sciences) and Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, 63130, USA
| | - Debra Haire-Joshu
- Center for Diabetes Translation Research, Washington University in St. Louis, 1 Brookings Drive, Campus, Box 1196, St. Louis, MO, 63117, USA
- Department of Medicine, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, 63130, USA
| | - Daniel A Gundersen
- Division of Population Sciences, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Heather Angier
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Sonja Likumahuwa-Ackman
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Thuy Vu
- Health Promotion Research Center, Department of Health Systems and Population Health, University of Washington, Seattle, WA, 98195, USA
| | - Russell E Glasgow
- Department of Family Medicine, University of Colorado, 1890 N Revere Ct, 3Rd Floor, Aurora, CO, 80045, USA
| | - Robert Schnoll
- Department of Psychiatry and Abramson Cancer Center, University of Pennsylvania, 3535 Market Street, 4Th Floor, Philadelphia, PA, 19104, USA
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7
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Seaton KE, Huang Y, Karuna S, Heptinstall JR, Brackett C, Chiong K, Zhang L, Yates NL, Sampson M, Rudnicki E, Juraska M, deCamp AC, Edlefsen PT, Mullins JI, Williamson C, Rossenkhan R, Giorgi EE, Kenny A, Angier H, Randhawa A, Weiner JA, Rojas M, Sarzotti-Kelsoe M, Zhang L, Sawant S, Ackerman ME, McDermott AB, Mascola JR, Hural J, McElrath MJ, Andrew P, Hidalgo JA, Clark J, Laher F, Orrell C, Frank I, Gonzales P, Edupuganti S, Mgodi N, Corey L, Morris L, Montefiori D, Cohen MS, Gilbert PB, Tomaras GD. Pharmacokinetic serum concentrations of VRC01 correlate with prevention of HIV-1 acquisition. EBioMedicine 2023; 93:104590. [PMID: 37300931 PMCID: PMC10363420 DOI: 10.1016/j.ebiom.2023.104590] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND The phase 2b proof-of-concept Antibody Mediated Prevention (AMP) trials showed that VRC01, an anti-HIV-1 broadly neutralising antibody (bnAb), prevented acquisition of HIV-1 sensitive to VRC01. To inform future study design and dosing regimen selection of candidate bnAbs, we investigated the association of VRC01 serum concentration with HIV-1 acquisition using AMP trial data. METHODS The case-control sample included 107 VRC01 recipients who acquired HIV-1 and 82 VRC01 recipients who remained without HIV-1 during the study. We measured VRC01 serum concentrations with a qualified pharmacokinetic (PK) Binding Antibody Multiplex Assay. We employed nonlinear mixed effects PK modelling to estimate daily-grid VRC01 concentrations. Cox regression models were used to assess the association of VRC01 concentration at exposure and baseline body weight, with the hazard of HIV-1 acquisition and prevention efficacy as a function of VRC01 concentration. We also compared fixed dosing vs. body weight-based dosing via simulations. FINDINGS Estimated VRC01 concentrations in VRC01 recipients without HIV-1 were higher than those in VRC01 recipients who acquired HIV-1. Body weight was inversely associated with HIV-1 acquisition among both placebo and VRC01 recipients but did not modify the prevention efficacy of VRC01. VRC01 concentration was inversely correlated with HIV-1 acquisition, and positively correlated with prevention efficacy of VRC01. Simulation studies suggest that fixed dosing may be comparable to weight-based dosing in overall predicted prevention efficacy. INTERPRETATION These findings suggest that bnAb serum concentration may be a useful marker for dosing regimen selection, and operationally efficient fixed dosing regimens could be considered for future trials of HIV-1 bnAbs. FUNDING Was provided by the National Institutes of Health, National Institute of Allergy and Infectious Diseases (NIAID) (UM1 AI068614, to the HIV Vaccine Trials Network [HVTN]; UM1 AI068635, to the HVTN Statistical Data and Management Center [SDMC], Fred Hutchinson Cancer Center [FHCC]; 2R37 054165 to the FHCC; UM1 AI068618, to HVTN Laboratory Center, FHCC; UM1 AI068619, to the HPTN Leadership and Operations Center; UM1 AI068613, to the HIV Prevention Trials Network [HPTN] Laboratory Center; UM1 AI068617, to the HPTN SDMC; and P30 AI027757, to the Center for AIDS Research, Duke University (AI P30 AI064518) and University of Washington (P30 AI027757) Centers for AIDS Research; R37AI054165 from NIAID to the FHCC; and OPP1032144 CA-VIMC Bill & Melinda Gates Foundation.
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Affiliation(s)
- Kelly E Seaton
- Duke Center for Human Systems Immunology, Departments of Surgery, Immunology, Molecular Genetics and Microbiology, Durham, NC, 27710, USA.
| | - Yunda Huang
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA; Department of Global Health, University of Washington, Seattle, WA, 98195, USA.
| | - Shelly Karuna
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Jack R Heptinstall
- Duke Center for Human Systems Immunology, Departments of Surgery, Immunology, Molecular Genetics and Microbiology, Durham, NC, 27710, USA
| | - Caroline Brackett
- Duke Center for Human Systems Immunology, Departments of Surgery, Immunology, Molecular Genetics and Microbiology, Durham, NC, 27710, USA
| | - Kelvin Chiong
- Duke Center for Human Systems Immunology, Departments of Surgery, Immunology, Molecular Genetics and Microbiology, Durham, NC, 27710, USA
| | - Lily Zhang
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Nicole L Yates
- Duke Center for Human Systems Immunology, Departments of Surgery, Immunology, Molecular Genetics and Microbiology, Durham, NC, 27710, USA
| | - Mark Sampson
- Duke Center for Human Systems Immunology, Departments of Surgery, Immunology, Molecular Genetics and Microbiology, Durham, NC, 27710, USA
| | - Erika Rudnicki
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Michal Juraska
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Allan C deCamp
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Paul T Edlefsen
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - James I Mullins
- Department of Global Health, University of Washington, Seattle, WA, 98195, USA; Departments of Microbiology and Medicine, University of Washington, Seattle, WA, 98195, USA
| | - Carolyn Williamson
- Division of Medical Virology, Institute of Infectious Disease & Molecular Medicine, University of Cape Town and National Health Laboratory Service, South Africa
| | - Raabya Rossenkhan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Elena E Giorgi
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Avi Kenny
- Department of Biostatistics, University of Washington, Seattle, WA, 98195, USA
| | - Heather Angier
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - April Randhawa
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Joshua A Weiner
- Thayer School of Engineering, Dartmouth College, Hanover, NH, 03755, USA
| | - Michelle Rojas
- Duke Center for Human Systems Immunology, Departments of Surgery, Immunology, Molecular Genetics and Microbiology, Durham, NC, 27710, USA
| | - Marcella Sarzotti-Kelsoe
- Duke Center for Human Systems Immunology, Departments of Surgery, Immunology, Molecular Genetics and Microbiology, Durham, NC, 27710, USA
| | - Lu Zhang
- Duke Center for Human Systems Immunology, Departments of Surgery, Immunology, Molecular Genetics and Microbiology, Durham, NC, 27710, USA
| | - Sheetal Sawant
- Duke Center for Human Systems Immunology, Departments of Surgery, Immunology, Molecular Genetics and Microbiology, Durham, NC, 27710, USA
| | | | | | | | - John Hural
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - M Julianna McElrath
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | | | | | - Jesse Clark
- Department of Medicine, Division of Infectious Disease and Department of Family Medicine in the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Fatima Laher
- Perinatal HIV Research Unit (PHRU), Wits Health Consortium, Soweto, Johannesburg, South Africa
| | - Catherine Orrell
- Desmond Tutu Health Foundation, University of Cape Town (Institute of Infectious Disease and Molecular Medicine, and Department of Medicine), Observatory, 7925, Cape Town, South Africa
| | - Ian Frank
- Penn Center for AIDS Research, Infectious Disease Division, University of Pennsylvania, 3400 Civic Center Boulevard Building 421, Philadelphia, PA, 19104, USA
| | - Pedro Gonzales
- Asociacion Civil Impacta Salud y Educación, San Miguel Clinical Research Center, Lima, Peru
| | - Srilatha Edupuganti
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Nyaradzo Mgodi
- University of Zimbabwe-University of California San Francisco (UZ-UCSF) Collaborative Research Programme, Harare, Zimbabwe, South Africa
| | - Lawrence Corey
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA; Departments of Medicine and Laboratory Medicine, University of Washington, Seattle, WA, 98195, USA; Division of Medical Virology, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Lynn Morris
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, 2192, South Africa; Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2000, South Africa; Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, 4041, South Africa
| | - David Montefiori
- Duke Center for Human Systems Immunology, Departments of Surgery, Immunology, Molecular Genetics and Microbiology, Durham, NC, 27710, USA
| | - Myron S Cohen
- Institute of Global Health and Infectious Diseases, The University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Peter B Gilbert
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA; Departments of Microbiology and Medicine, University of Washington, Seattle, WA, 98195, USA
| | - Georgia D Tomaras
- Duke Center for Human Systems Immunology, Departments of Surgery, Immunology, Molecular Genetics and Microbiology, Durham, NC, 27710, USA.
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Easterling D, Jacob RR, Brownson RC, Haire-Joshu D, Gundersen DA, Angier H, DeVoe JE, Likumahuwa-Ackman S, Vu T, Glasgow RE, Schnoll R. Participatory Logic Modeling in a Multi-Site Initiative to Advance Implementation Science. RESEARCH SQUARE 2023:rs.3.rs-2846665. [PMID: 37292912 PMCID: PMC10246100 DOI: 10.21203/rs.3.rs-2846665/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background: It is increasingly being recognized that logic models should be developed through a participatory approach which allows input from those who carry out the program being evaluated. While there are many positive examples of participatory logic modeling, funders have generally not used this approach in the context of multi-site initiatives. This article describes an instance where the funder and evaluator of a multi-site initiative fully engaged the funded organizations in developing the initiative logic model. The focus of the case study is Implementation Science Centers in Cancer Control (ISC 3 ), a multi-year initiative funded by the National Cancer Institute (NCI). Methods: The case study was collectively constructed by representatives of the seven centers funded under ISC 3 . Members of the Cross-Center Evaluation (CCE) Work Group jointly articulated the process through which the logic model was developed and refined. Individual Work Group members contributed descriptions of how their respective centers reviewed and used the logic model. Cross-cutting themes and lessons emerged through CCE Work Group meetings and the writing process. Results: The initial logic model for ISC 3 changed in significant ways as a result of the input of the funded groups. Authentic participation in the development of the logic model led to strong buy-in among the centers, as evidenced by their utilization. The centers shifted both their evaluation design and their programmatic strategy to better accommodate the expectations reflected in the initiative logic model. Conclusions: The ISC 3 case study provides a positive example of how participatory logic modeling can be mutually beneficial to funders, grantees and evaluators of multi-site initiatives. Funded groups have important insights about what is feasible and what will be required to achieve the initiative's stated objectives. They can also help identify the contextual factors that either inhibit or facilitate success, which can then be incorporated into both the logic model and the evaluation design. In addition, when grantees co-develop the logic model, they have a better understanding and appreciation of the funder's expectations, and thus are better positioned to meet those expectations.
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Affiliation(s)
| | - Rebekah R Jacob
- Washington University In St Louis: Washington University in St Louis
| | - Ross C Brownson
- Washington University In St Louis: Washington University in St Louis
| | - Debra Haire-Joshu
- Washington University In St Louis: Washington University in St Louis
| | | | | | | | | | - Thuy Vu
- University of Washington Seattle Campus: University of Washington
| | - Russell E Glasgow
- University of Colorado School of Medicine: University of Colorado Anschutz Medical Campus School of Medicine
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9
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Bailey SR, Wyte-Lake T, Lucas JA, Williams S, Cantone RE, Garvey BT, Hallock-Koppelman L, Angier H, Cohen DJ. Use of Telehealth for Opioid Use Disorder Treatment in Safety Net Primary Care Settings: A Mixed-Methods Study. Subst Use Misuse 2023; 58:1143-1151. [PMID: 37170596 PMCID: PMC10396057 DOI: 10.1080/10826084.2023.2212378] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Background: The COVID-19 pandemic resulted in a marked increase in telehealth for the provision of primary care-based opioid use disorder (OUD) treatment. This mixed methods study examines characteristics associated with having the majority of OUD-related visits via telehealth versus in-person, and changes in mode of delivery (in-person, telephone, video) over time. Methods: Logistic regression was performed using electronic health record data from patients with ≥1 visit with an OUD diagnosis to ≥1 of the two study clinics (Rural Health Clinic; urban Federally Qualified Health Center) and ≥1 OUD medication ordered from 3/8/2020-9/1/2021, with >50% of OUD visits via telehealth (vs. >50% in-person) as the dependent variable and patient characteristics as independent variables. Changes in visit type over time were also examined. Inductive coding was used to analyze data from interviews with clinical team members (n = 10) who provide OUD care to understand decision-making around visit type. Results: New patients (vs. returning; OR = 0.47;95%CI:0.27-0.83), those with ≥1 psychiatric diagnosis (vs. none; OR = 0.49,95%CI:0.29-0.82), and rural clinic patients (vs. urban; OR = 0.05; 95%CI:0.03-0.08) had lower odds of having the majority of visits via telehealth than in-person. Patterns of visit type varied over time by clinic, with the majority of telehealth visits delivered via telephone. Team members described flexibility for patients as a key telehealth benefit, but described in-person visits as more conducive to building rapport with new patients and those with increased psychological burden. Conclusion: Understanding how and why telehealth is used for OUD treatment is critical for ensuring access to care and informing OUD-related policy decisions.
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Affiliation(s)
- Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Tamar Wyte-Lake
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Jennifer A Lucas
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Shannon Williams
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Rebecca E Cantone
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Brian T Garvey
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
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10
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Huguet N, Green BB, Voss RW, Larson AE, Angier H, Miguel M, Liu S, Latkovic-Taber M, DeVoe JE. Factors Associated With Blood Pressure Control Among Patients in Community Health Centers. Am J Prev Med 2023; 64:631-641. [PMID: 36609093 PMCID: PMC10121771 DOI: 10.1016/j.amepre.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/12/2022] [Accepted: 11/07/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Understanding the multilevel factors associated with controlled blood pressure is important to determine modifiable factors for future interventions, especially among populations living in poverty. This study identified clinically important factors associated with blood pressure control among patients receiving care in community health centers. METHODS This study includes 31,089 patients with diagnosed hypertension by 2015 receiving care from 103 community health centers; aged 19-64 years; and with ≥1 yearly visit with ≥1 recorded blood pressure in 2015, 2016, and 2017. Blood pressure control was operationalized as an average of all blood pressure measurements during all the 3 years and categorized as controlled (blood pressure <140/90), partially controlled (mixture of controlled and uncontrolled blood pressure), or never controlled. Multinomial mixed-effects logistic regression models, conducted in 2022, were used to calculate unadjusted ORs and AORs of being in the never- or partially controlled blood pressure groups versus in the always-controlled group. RESULTS A total of 50.5% had always controlled, 39.7% had partially controlled, and 9.9% never had controlled blood pressure during the study period. The odds of being partially or never in blood pressure control were higher for patients without continuous insurance (AOR=1.09; 95% CI=1.03, 1.16; AOR=1.18; 95% CI=1.07, 1.30, respectively), with low provider continuity (AOR=1.24; 95% CI=1.15, 1.34; AOR=1.28; 95% CI=1.13, 1.45, respectively), with a recent diagnosis of hypertension (AOR=1.34; 95% CI=1.20, 1.49; AOR=1.19; 95% CI=1.00, 1.42), with inconsistent antihypertensive medications (AOR=1.19; 95% CI=1.11, 1.27; AOR=1.26; 95% CI=1.13, 1.41, respectively), and with fewer blood pressure checks (AOR=2.14; 95% CI=1.97, 2.33; AOR=2.17; 95% CI=1.90, 2.48, respectively) than for their counterparts. CONCLUSIONS Efforts targeting continuous and consistent access to care, antihypertensive medications, and regular blood pressure monitoring may improve blood pressure control among populations living in poverty.
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Affiliation(s)
- Nathalie Huguet
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon.
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | | | | | - Heather Angier
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington; Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Marino Miguel
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Shuling Liu
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon; Biostatistics Group, Oregon Health & Science University, Portland, Oregon
| | | | - Jennifer E DeVoe
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
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11
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Cheng AM, Dollar E, Angier H. Outpatient Management of COVID-19: Rapid Evidence Review. Am Fam Physician 2023; 107:370-381. [PMID: 37054413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
New COVID-19 variants of concern continue to develop. Incubation period, transmissibility, immune escape, and treatment effectiveness differ by variants of concern. Physicians should be aware that the characteristics of the predominant variants of concern determine aspects of diagnosis and treatment. Multiple testing modalities exist; the most appropriate testing strategy varies depending on the clinical scenario, with factors of test sensitivity, turnaround time, and the expertise required for specimen collection. Three types of vaccines are available in the United States, and all people six months and older should be encouraged to receive one because vaccination is effective in reducing the incidence of and hospitalizations and deaths associated with COVID-19. Vaccination may also reduce the incidence of post-acute sequelae of SARS-CoV-2 infection (i.e., long COVID). Consider medications, such as nirmatrelvir/ritonavir, as first-line treatment for eligible patients diagnosed with COVID-19 unless logistical or supply constraints occur. National Institutes of Health guidelines and local health care partner resources can be used to determine eligibility. Long-term health effects of having COVID-19 are under investigation.
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Affiliation(s)
| | - Emily Dollar
- Oregon Health and Science University, Portland, Oregon
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12
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Angier H, Bonuck KJ, McCrimmon S, Wiser AL, Huguet N, Carney PA. An Exploratory Study of Primary Care Clinicians' Perspectives on 2021 New and Updated Cancer Screening Guidelines. J Prim Care Community Health 2023; 14:21501319231164910. [PMID: 37026464 PMCID: PMC10087640 DOI: 10.1177/21501319231164910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Cancer screening rates remain low in rural, racial and ethnic minority, low-income, and uninsured populations. Prior studies showed that cancer screening recommendations vary based on clinicians' factors. We conducted an exploratory study on primary care clinicians' beliefs about new or updated cancer screening guidelines according to clinician demographics. METHODS This cross-sectional study involved administering a web-based survey in July and August of 2021 to primary care clinicians practicing in diverse ambulatory settings in the Pacific Northwest belonging to the same health system. The survey assessed clinician demographics, attitudes about the impact of cancer screening on mortality, and how clinicians stay up-to-date with guidelines. RESULTS Of the 191 clinicians, 81 responded (42.4%), after removing 13 incomplete surveys, we analyzed 68 (35.6%). The majority agreed/strongly agreed that breast (76.1%), colorectal (95.5%), and cervical (90.9%) cancer screening, and HPV vaccination (85.1%) prevent early cancer mortality: there were no differences according to clinician gender or years in practice. Female compared to male clinicians were more likely to agree/strongly agree that tobacco smoking cessation (female: 100% vs male: 86.4%, P = .01) prevents early cancer mortality, whereas male compared to female clinicians were more likely to agree/strongly agree that lung cancer screening (male: 86.4% vs female: 57.8%, P = .04) prevents early cancer mortality. One-third (33.3%) of clinicians were unaware of the 2021 update on lung cancer screening and females were more likely than males to say they did not know about this change (females: 43.2% vs males: 13.6%, P = .02). CONCLUSIONS This study suggests that clinicians' attitudes are not likely the primary factor affecting low cancer screening rates in some populations and that few differences exist in beliefs based on gender, and none based on years in practice.
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Affiliation(s)
- Heather Angier
- Oregon Health & Science University, Portland, OR, USA
- Fred Hutchinson Cancer Center, Seattle, WA, USA
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13
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Bonuck KJ, Angier H, McCrimmon S, Holderness H, Erroba J, Huguet N, DeVoe JE, Carney PA. A Scoping Literature Review on Evidence-Based Strategies to Increase Cervical Cancer Screening. J Prim Care Community Health 2023; 14:21501319231220994. [PMID: 38131106 DOI: 10.1177/21501319231220994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Previous reviews of strategies to increase cervical cancer screening are more than 10 years old, the U.S. continues to fall short of the Healthy People 2030 cervical cancer screening goal, and guidelines were revised in 2018, therefore an updated review of the existing literature is needed. We conducted a scoping review using electronic databases PubMed, Scopus, and Ovid Medline that included publication dates between 2012 and 2021 to answer the question, "Which strategies implemented in U.S. primary care settings have been most successful in increasing rates of cervical cancer screening since the 2012 US Preventative Services Task Force cervical cancer screening guidelines were published?" We mapped findings to pre-specified implementation strategy categories. After initially identifying 399 articles, we excluded 350 due to duplicates or not meeting review criteria, leaving 49 articles for full review. We excluded 37 of these during full-text review and identified 2 additional articles from the manual search of reference lists for a total of 14 studies for abstraction. Eleven articles reported on strategies resulting in increased cervical cancer screening, and 3 did not. Clinic workflow re-design strategies showed the greatest promise in improving cervical cancer screening rates, education strategies for patients had mixed results, and quality management strategies were not effective. These findings suggest clinical workflow re-structures and patient education strategies can increase cervical cancer screening in primary care settings. Results are particularly important in settings that care for underserved populations, as these settings may need additional implementation strategies to decrease cervical cancer screening disparities.
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Affiliation(s)
| | | | | | | | - Jeremy Erroba
- Oregon Health & Science University, Portland, OR, USA
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14
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Rdesinski R, Chamine I, Valenzuela S, Marino M, Schmidt T, Larson A, Huguet N, Angier H. Impact of the Affordable Care Act Medicaid Expansion on Weight Loss among Community Health Center Patients with Obesity. Ann Fam Med 2023; 21:3731. [PMID: 38226942 PMCID: PMC10549626 DOI: 10.1370/afm.21.s1.3731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
Context: Obesity affects over 40% of the US population and is linked to multiple preventable health conditions which can cause premature morbidity and mortality. Weight loss of at least 5% in patients with obesity reduces their risk of comorbid conditions and leads to improvement in some conditions, such as diabetes. Patients with obesity from underserved populations are less likely to access primary and preventive care services. The Affordable Care Act (ACA) improved access to care, which may in turn improve access to obesity prevention and treatment and assist with weight loss. Objective: Assess whether the proportion of patients with a weight loss ≥5% was higher in states that expanded Medicaid relative to non-expansion states among patients with obesity receiving care in community health centers (CHCs) which provide health care to underserved patients. Study Design: Retrospective observational cohort study. Setting: Electronic health record data from the ADVANCE (Advancing Data Value Across a National Community Health Center) clinical research network, during years 2012-2017. Population Studied: Patients from 346 CHCs age 19-64 with a body mass index of ≥ 30 kg/m2 during the pre-ACA period (n=34,027). Outcome measures: Proportion of patients with weight loss >5% (WL5+) from pre- to post-ACA. Medicaid expansion status (expansion vs. non-expansion states) stratified by pattern of insurance (uninsured, continuously insured, newly insured, discontinuously insured) and race and ethnicity. Results: The proportion of patients with WL5+ for newly insured patients was greater in expansion (26%) than non-expansion states (20%) (χ2=9.75, p=0.002). Among newly insured patients, Hispanic (22%) and Black (29%) patients residing in expansion states, had larger proportion of patients with WL5+ than those in non-expansion states (20% and 18%, respectively). No differences were observed among non-Hispanic White patients (expansion 28% vs non-expansion 27%). Conclusions: The findings suggest greater improvement in weight management among patients residing in expansion states than those in non-expansion states, especially among racial and ethnic minorities receiving care in CHCs.
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15
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Green BB, Larson AE, Huguet N, Angier H, Valenzuela S, Marino M. High Blood Pressure Reduction, Health Insurance Status, and Social Deprivation Index in U.S. Community Health Centers. AJPM Focus 2022; 1:100018. [PMID: 37791238 PMCID: PMC10546572 DOI: 10.1016/j.focus.2022.100018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction Lack of health insurance is a risk factor for uncontrolled hypertension, but it is unknown whether health insurance or neighborhood-level social deprivation is associated with greater reductions in blood pressure over time. Methods We estimated the association of health insurance and social deprivation index on blood pressure reduction over time using electronic health record data from 2012 to 2017. We included patients aged 19-64 years with an initial systolic blood pressure ≥150 mmHg or diastolic blood pressure ≥100 mmHg and ≥1 additional visit from 93 community health centers in states that expanded Medicaid in 2014. Results We included 66,207 patients: 20.1% uninsured, 64.8% publicly insured, and 15.1% privately insured. Adjusting for patient characteristics and baseline blood pressure, systolic blood pressure/diastolic blood pressure declined over the study period by 21.3/11.2 mmHg, 22.0/11.4 mmHg, and 21.1/10.7 mmHg among uninsured, publicly insured, and privately insured individuals, respectively. There were small but significantly greater reductions in systolic blood pressure among patients with public insurance than among those who were uninsured (difference= -1.3, 95% CI= -1.6, -1.0) but none associated with social deprivation index. There were no differences in diastolic blood pressure reductions over time by insurance status or social deprivation index. Blood pressure control (systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg) was significantly greater among publicly or commercially insured individuals than among uninsured individuals (51.7%, 51.5%, 44.6% respectively, both comparisons p<0.001), with no associations between blood pressure control and social deprivation index. Conclusions Reductions in blood pressure were large but mostly not associated with insurance type or social deprivation index. Additional research is needed to understand the factors that lead to blood pressure reduction in community health center settings.
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Affiliation(s)
- Beverly B. Green
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Washington Permanente Medical Group, Renton, Washington
| | | | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Steele Valenzuela
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
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16
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Kaufmann J, DeVoe JE, Angier H, Moreno L, Cahen V, Marino M. Association of parent influenza vaccination and early childhood vaccinations using linked electronic health record data. Vaccine 2022; 40:7097-7107. [PMID: 36404427 PMCID: PMC10202113 DOI: 10.1016/j.vaccine.2022.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Parent and child vaccination behavior is related for human papillomavirus (HPV) and flu vaccine. Thus, it is likely that parental vaccination status is also associated with their children's adherence to guideline-concordant childhood vaccination schedules. We hypothesized that parent influenza (flu) vaccination would be associated with their child's vaccination status at age two. METHODS We used electronic health record data to identify children and linked parents seen in a community health center (CHC) within the OCHIN network (292 CHCs in 16 states). We randomly selected a child aged <2 years with ≥1 ambulatory visit between 2009-2018. Employing a retrospective, cohort study design, we used general estimating equations logistic regression to estimate the odds of a child being up-to-date on vaccinations based on their linked parents' flu vaccination status. We adjusted for relevant parent and child covariates and stratified by mother only, father only, and two-parent samples. RESULTS The study included 40,007 family-units: mother only = 35,444, father only = 2,784, and two parents = 1,779. A higher percentage of children were fully vaccinated if their parent or parents received a flu vaccine. Children in the two-parent sample whose parents both received a flu vaccine had more than twice the odds of being fully vaccinated, and two and a half times the odds of being fully vaccinated except flu vaccine compared to children with two parents who did not receive a flu vaccine (covariate-adjusted odds ratio [aOR] = 2.39, 95% CI = 1.67, 3.43 and aOR = 2.54, 95% CI = 1.54, 4.19, respectively). CONCLUSIONS Parent flu vaccination is associated with routine child vaccination. Future research is needed to understand if this relationship persists over time and in different settings.
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Affiliation(s)
- Jorge Kaufmann
- Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR 97239, USA
| | - Jennifer E DeVoe
- Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR 97239, USA
| | - Heather Angier
- Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR 97239, USA
| | - Laura Moreno
- Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Viviane Cahen
- Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR 97239, USA
| | - Miguel Marino
- Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR 97239, USA
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 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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Chamine I, Hwang J, Valenzuela S, Marino M, Larson AE, Georgescu J, Latkovic-Taber M, Angier H, DeVoe JE, Huguet N. Acute and Chronic Diabetes-Related Complications Among Patients With Diabetes Receiving Care in Community Health Centers. Diabetes Care 2022; 45:e141-e143. [PMID: 35972244 PMCID: PMC9643147 DOI: 10.2337/dc22-0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/08/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Irina Chamine
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Jun Hwang
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Steele Valenzuela
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
- Department of Biostatistics, School of Public Health, Oregon Health & Science University–Portland
| | | | | | | | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Jennifer E. DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
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Angier H, Hodes T, Moreno L, O’Malley J, Marino M, DeVoe JE. An observational study of health insured visits for children following Medicaid eligibility expansion for adults among a linked cohort of parents and children. Medicine (Baltimore) 2022; 101:e30809. [PMID: 36197163 PMCID: PMC9509200 DOI: 10.1097/md.0000000000030809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Despite its focus on adults, the Affordable Care Act (ACA) Medicaid expansion led to increased health insurance enrollment for children in the United States. Previous studies looked at parent and child insurance changes separately, or used a single survey response item to understand changes in health insurance for parents and children. It is, however, important to understand the connection between parent and child insurance changes together (not individually) using data sources that account for insurance over time. Therefore, to understand the association of parental health insurance on their children's coverage, leveraging a cohort of linked families seen in community health centers (CHCs), we used electronic health records to link a cohort of parents and children with ≥1 visit to a CHC in a Medicaid expansion state pre- (1/1/2012-12/31/2013) and ≥1 visit post-ACA (1/1/2014-12/31/2018) and determined primary payer type for all visits. This observational, cohort study assessed the rate of insured visits for children pre- to post-ACA across four parental insurance groups (always insured, gained Medicaid, discontinuously insured, never insured) using Poisson mixed effects models. We included 335 CHCs across 7 United States. Insurance rates were highest (~95 insured visits/100 visits) for children of parents who were always insured; rates were lowest for children of parents who were never insured (~83 insured visits/100 visits). Children with a parent who gained Medicaid had 4.4% more insured visits post- compared to pre-ACA (adjusted relative rates = 1.044, 95% confidence interval: 1.014, 1.074). When comparing changes from pre- to post-ACA between parent insurance groups, children's insured visit rates were significantly higher for children of parents who gained Medicaid (reference) compared to children of parents who were always insured (adjusted ratio of rate ratio: 0.963, confidence interval: 0.935-0.992). Despite differences in Medicaid eligibility for children and adults, health insurance patterns were similar for linked families seen in CHCs. Findings suggest consideration should be paid to parent health insurance options when trying to increase children's coverage.
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Affiliation(s)
- Heather Angier
- Oregon Health & Science University, Portland, OR, USA
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Tahlia Hodes
- Oregon Health & Science University, Portland, OR, USA
| | - Laura Moreno
- Oregon Health & Science University, Portland, OR, USA
| | | | - Miguel Marino
- Oregon Health & Science University, Portland, OR, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 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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21
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Jacob RR, Korn AR, Huang GC, Easterling D, Gundersen DA, Ramanadhan S, Vu T, Angier H, Brownson RC, Haire-Joshu D, Oh AY, Schnoll R. Collaboration networks of the implementation science centers for cancer control: a social network analysis. Implement Sci Commun 2022; 3:41. [PMID: 35418309 PMCID: PMC9009020 DOI: 10.1186/s43058-022-00290-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/28/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Multi-center research initiatives offer opportunities to develop and strengthen connections among researchers. These initiatives often have goals of increased scientific collaboration which can be examined using social network analysis. METHODS The National Cancer Institute (NCI)-funded Implementation Science Centers in Cancer Control (ISC3) initiative conducted an online social network survey in its first year of funding (2020) to (1) establish baseline network measures including the extent of cross-center collaboration and (2) assess factors associated with a network member's access to the network such as one's implementation science (IS) expertise. Members of the seven funded centers and NCI program staff identified collaborations in planning/conducting research, capacity building, product development, scientific dissemination, and practice/policy dissemination. RESULTS Of the 192 invitees, 182 network members completed the survey (95%). The most prevalent roles were faculty (60%) and research staff (24%). Almost one-quarter (23%) of members reported advanced expertise in IS, 42% intermediate, and 35% beginner. Most members were female (69%) and white (79%). One-third (33%) of collaboration ties were among members from different centers. Across all collaboration activities, the network had a density of 14%, suggesting moderate cohesion. Degree centralization (0.33) and betweenness centralization (0.07) measures suggest a fairly dispersed network (no single or few central member(s) holding all connections). The most prevalent and densely connected collaboration was in planning/conducting research (1470 ties; 8% density). Practice/policy dissemination had the fewest collaboration, lowest density (284 ties' 3% density), and the largest number of non-connected members (n=43). Access to the ISC3 network varied significantly depending on members' level of IS expertise, role within the network, and racial/ethnic background. Across all collaboration activities, most connected members included those with advanced IS expertise, faculty and NCI staff, and Hispanic or Latino and white members. CONCLUSIONS Results establish a baseline for assessing the growth of cross-center collaborations, highlighting specific areas in need of particular growth in network collaborations such as increasing engagement of racial and ethnic minorities and trainees or those with less expertise in IS.
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Affiliation(s)
- Rebekah R Jacob
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130, USA.
| | - Ariella R Korn
- Cancer Prevention Fellowship Program, Implementation Science, Office of the Director, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA
| | - Grace C Huang
- Westat, 1600 Research Blvd., Rockville, MD, 20850, USA
| | - Douglas Easterling
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Daniel A Gundersen
- Dana-Farber Cancer Institute, Division of Population Sciences, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Shoba Ramanadhan
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Thuy Vu
- Health Promotion Research Center, Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, 98195, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Ross C Brownson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130, USA
- Department of Surgery (Division of Public Health Sciences) and Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, 63130, USA
| | - Debra Haire-Joshu
- Center for Diabetes Translation Research, Washington University in St. Louis, 1 Brookings Drive, Campus Box 1196, St. Louis, MO, 63117, USA
- Department of Medicine, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, 63130, USA
| | - April Y Oh
- Division of Cancer Control and Population Sciences, Implementation Science Team, National Cancer Institute, National Institutes of Health, 9609 Medical Center Drive, Rockville, MD, 20850, USA
| | - Robert Schnoll
- Department of Psychiatry and Abramson Cancer Center, University of Pennsylvania, 3535 Market Street, 4th Floor, Philadelphia, PA, 19104, USA
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22
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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] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 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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23
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Chamine I, Larson A, Huguet N, Angier H, Valenzuela S, Dinh D, Hwang J. Characterizing acute and chronic complications among patients with diabetes mellitus in community health centers. Ann Fam Med 2022; 20:2659. [PMID: 36857172 PMCID: PMC10548901 DOI: 10.1370/afm.20.s1.2659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Context: Diabetes mellitus affects about 10% of the world's population and can lead to serious complications, which reduce life quality and expectancy. People with low income have higher risk of diabetes complications than those with high income, but data on the trends of diabetes complications in underserved populations are scarce. Community health centers (CHCs) serve millions of patients in the United States regardless of their health insurance status and are an ideal setting for assessing the rate of diabetes complications in underserved populations. Objectives: To describe diabetes-related acute and chronic complications among patients served by CHCs. Study Design: Retrospective cohort study of electronic health record data from the ADVANCE clinical research network. Population studied: Patients with diabetes between ages 19 and 64 (excluding pregnant women) and ≥1 primary care ambulatory CHC visit in 2017 (N=85,442). Outcome Measures: Rates and type of diabetes-related acute and chronic complications recorded in 2017. Results: The incidence of acute complications among patients with diabetes in 2017 was 14%. Patients experiencing acute diabetes-related complications had on average 1.8 complications (range 1-33). The most common acute complications were infections (58.3%), abnormal blood glucose or related metabolic abnormalities (20.5%), and strokes or transient neurological deficits (6.8%). Patients with acute complications were proportionally more likely to be female, non-Hispanic white, have Medicaid insurance, out-of-control diabetes, a prescription for insulin, a diagnosis of substance use disorder, and co-occurring physical or mental conditions. For chronic complications, the prevalence in 2017 was 77% among patients with diabetes. Patients experiencing chronic diabetes-related complications had on average 2.3 complications (range 1-19). The most common chronic complications were cardiovascular disease (33.9%), endocrine/metabolic symptoms (22.8%), and neurological symptoms (13.0%). Patients with chronic complications were proportionally more likely to be male, non-Hispanic black, have health insurance, obesity, substance use disorder, longer period with diabetes diagnosis, and co-occurring conditions. Conclusions: The vast majority of patients with diabetes receiving care in CHCs had chronic complications. These findings are concerning, as diabetes-related complications are associated with greater healthcare utilization and patient morbidity.
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Angier H, Wyte-Lake T, Williams S, McCrimmon S, Moreno L, E DeVoe J, Cohen D. A Qualitative Study of Two Oregon Family Medicine Clinics to Explain Parent and Child Healthcare Initiation and Engagement. J Patient Exp 2022; 9:23743735221133654. [DOI: 10.1177/23743735221133654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Parental factors are associated with children's receipt of recommended care but not adequately described. Methods: We conducted a qualitative study of patients with at least two visits who were a primary caregiver for a child who also had at least two visits at the same clinic in 1/2018–12/2019 from two Oregon family medicine clinics. We stratified patients by child age and number of caregiver visits and randomly selected caregivers. Participants were interviewed in accordance with approval by our Institutional Review Board between 12/2020 and 4/2021. The data were analyzed using a grounded theory approach. Results: 12 caregivers (termed parents) were interviewed; half were single parents and three-quarters had a history of substance use disorder and/or a mental health condition. Parents focused on the importance of keeping themselves healthy to keep their families healthy. They described similar reasons for choosing to initiate and continue care for themselves and their children at the same clinic, including: convenience, trust, relationships, and receiving whole-person and whole-family care. Many valued having a healthcare “home” for their entire family. We developed a figure that highlights three themes that capture the interrelated factors parents identified as supporting healthcare use for themselves and their families. These overarching themes included: healthcare initiation; healthcare engagement and continuity; and parent bringing child to the same clinic for healthcare. Conclusion: Our data suggests that long-standing patient-clinic relationships for parents and children can support family-focused healthcare.
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Affiliation(s)
- Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Tamar Wyte-Lake
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Shannon Williams
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Sara McCrimmon
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Laura Moreno
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Deborah Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
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25
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Affiliation(s)
- Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Brian Garvey
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
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26
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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 DOI: 10.1093/ajh/hpab069] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [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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27
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Angier H, Giebultowicz S, Kaufmann J, Heintzman J, O’Malley J, Moreno L, DeVoe JE. Creation of a linked cohort of children and their parents in a large, national electronic health record dataset. Medicine (Baltimore) 2021; 100:e26950. [PMID: 34397948 PMCID: PMC8360479 DOI: 10.1097/md.0000000000026950] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 07/23/2021] [Indexed: 01/04/2023] Open
Abstract
To examine which parental health care and health factors are most strongly associated with a child's receipt of recommended care we must be able to link children to their parents in electronic health record data. Yet, there is not an easy way to link these data.To identify a national cohort of children that link to at least one parent in the same electronic health record dataset and describe their demographics.Methodology to link parents and children in electronic health records and descriptive sociodemographic data.Children with at least one encounter with a primary care clinician between Januray 1, 2007 and December 12, 2018 to a community health center in the OCHIN national network. We identified parents of these children who also had at least one encounter to a community health center in the network using emergency contact and guarantor record fields.A total of 227,552 children had parents with a linkable patient record. After exclusions, our final cohort included 213,513 distinct children with either one or two parent-links. 82% of children linked to a mother only, 14% linked to a father only, and 4% linked to both a mother and a father. Most families consisted of only one linked child (61%).We were able to link 33% of children to a parent in electronic health record data from a large network of community health centers across the United States. Further analyses utilizing these linkages will allow examination of the multi-level factors that impact a child's receipt of recommended health care.
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Affiliation(s)
| | | | | | - John Heintzman
- Oregon Health & Science University
- OCHIN, Inc., Portland, OR
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Hoopes M, Voss R, Angier H, Marino M, Schmidt T, DeVoe JE, Soule J, Huguet N. Assessing Cancer History Accuracy in Primary Care Electronic Health Records Through Cancer Registry Linkage. J Natl Cancer Inst 2021; 113:924-932. [PMID: 33377908 PMCID: PMC8246795 DOI: 10.1093/jnci/djaa210] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/23/2020] [Accepted: 12/14/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Many cancer survivors receive primary care in community health centers (CHCs). Cancer history is an important factor to consider in the provision of primary care, yet little is known about the completeness or accuracy of cancer history data contained in CHC electronic health records (EHRs). METHODS We probabilistically linked EHR data from more than1.5 million adult CHC patients to state cancer registries in California, Oregon, and Washington and estimated measures of agreement (eg, kappa, sensitivity, specificity). We compared demographic and clinical characteristics of cancer patients as estimated by each data source, evaluating distributional differences with absolute standardized mean differences. RESULTS A total 74 707 cancer patients were identified between the 2 sources (EHR only, n = 22 730; registry only, n = 23 616; both, n = 28 361). Nearly one-half of cancer patients identified in registries were missing cancer documentation in the EHR. Overall agreement of cancer ascertainment in the EHR vs cancer registries (gold standard) was moderate (kappa = 0.535). Cancer site-specific agreement ranged from substantial (eg, prostate and female breast; kappa > 0.60) to fair (melanoma and cervix; kappa < 0.40). Comparing population characteristics of cancer patients as ascertained from each data source, groups were similar for sex, age, and federal poverty level, but EHR-recorded cases showed greater medical complexity than those ascertained from cancer registries. CONCLUSIONS Agreement between EHR and cancer registry data was moderate and varied by cancer site. These findings suggest the need for strategies to improve capture of cancer history information in CHC EHRs to ensure adequate delivery of care and optimal health outcomes for cancer survivors.
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Affiliation(s)
| | | | - Heather Angier
- Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Miguel Marino
- Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA
| | | | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Jeffrey Soule
- Oregon State Cancer Registry, Oregon Health Authority, Portland, OR, USA
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA
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Bailey SR, Lucas JA, Angier H, Cantone RE, Fleishman J, Garvey B, Cohen DJ, Rdesinski RE, Gordon L. Associations of retention on buprenorphine for opioid use disorder with patient characteristics and models of care in the primary care setting. J Subst Abuse Treat 2021; 131:108548. [PMID: 34244013 DOI: 10.1016/j.jsat.2021.108548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 06/11/2021] [Accepted: 06/20/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Buprenorphine, a medication for opioid use disorder (OUD), can be administered within primary care; however, little is known about characteristics associated with retention on buprenorphine in these settings. This study examines patient correlates of buprenorphine retention and whether an integrated, interdisciplinary treatment model (buprenorphine and behavioral health) is associated with higher odds of buprenorphine retention than a primarily medication-only treatment model. METHODS Electronic health record data from adult patients with an OUD, ≥1 buprenorphine order and ≥1 visit to either of two primary care clinics between 9/2/2014-6/27/2018 were extracted (N = 494 patients). Two research team members reviewed the medication start and stop dates for each buprenorphine order and classified as retained (≥6 months of orders) or not retained (<6 months of orders). Logistic regressions estimated the odds of retention on buprenorphine by 1) patient characteristics and 2) timing of patient's engagement in buprenorphine treatment (pre- or post-implementation of an integrated treatment model). RESULTS Of the study sample, 53% had ≥6 months of buprenorphine orders. Almost two times higher odds of retention were found among patients with ≥1 psychiatric comorbidity (versus none) and among those with buprenorphine orders in the post- versus pre-period. CONCLUSIONS An integrated, interdisciplinary model of OUD treatment was associated with ≥6 months of buprenorphine orders among our study population. Continued research is needed in real-world primary care settings to understand the impact of OUD treatment models on patient outcomes. A more nuanced examination of the associations between psychiatric diagnoses and buprenorphine treatment retention is warranted.
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Affiliation(s)
- Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America.
| | - Jennifer A Lucas
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Rebecca E Cantone
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Joan Fleishman
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Brian Garvey
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Rebecca E Rdesinski
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Leah Gordon
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
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Angier H, Fleishman J, Gordon L, Cohen DJ, Cantone RE, Bailey SR. Tier-based treatment for opioid use disorder in the primary care setting. Fam Syst Health 2021; 39:345-350. [PMID: 34410776 DOI: 10.1037/fsh0000619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Background: Two primary care clinics implemented an opioid use disorder (OUD) treatment program that integrates behavioral health counseling with buprenorphine treatment and uses tiers. This project aimed to understand how patients moved through tiers in this program. Method: We purposively sampled 20 patients with at least 10 OUD-related treatment visits; we documented tier changes at all visits between September 1, 2016 and December 31, 2018 using a standard data collection instrument. These data were used to construct run-charts. Results: About 45% of sampled patients had at least one relapse noted and 60% of patients dropped in tier during the study. Reductions in tier often happened when the patient was navigating difficult psychosocial situations in their life, whereas increases in tier often accompanied positive life events. We also found variation in use of the tiers. Discussion: OUD treatment from two clinics by tier illustrates that recovery is an individualized process based on patient need that can fluctuate due to psychosocial triggers and significant life events. Having tiers can guide treatment and provide both clinicians and patients with information about what to expect during treatment while still allowing the flexibility to meet patients where they are. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Heather Angier
- Department of Family Medicine, Oregon Health & Science University
| | - Joan Fleishman
- Department of Family Medicine, Oregon Health & Science University
| | - Leah Gordon
- Department of Family Medicine, Oregon Health & Science University
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University
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31
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Lindner S, Kaufman MR, Marino M, O'Malley J, Angier H, Cottrell EK, McConnell KJ, DeVoe JE, Heintzman JR. A Medicaid Alternative Payment Model Program In Oregon Led To Reduced Volume Of Imaging Services. Health Aff (Millwood) 2021; 39:1194-1201. [PMID: 32634361 DOI: 10.1377/hlthaff.2019.01656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The patient-centered medical home model aspires to fundamentally restructure care processes, but a volume-based payment system may hinder such transformations. In 2013 Oregon's Medicaid program changed its reimbursement of traditional primary care services for selected community health centers (CHCs) from a per visit to a per patient rate. Using Oregon claims data, we analyzed the price-weighted volume of care for five service areas: traditional primary care services, including imaging, tests, and procedures; other services provided by CHCs that were carved out from the payment reform; emergency department visits; inpatient services; and other services of non-CHC providers. We further subdivided traditional primary care services using Berenson-Eggers Type of Service categories of care. We compared participating and nonparticipating CHCs in Oregon before and after the payment model was implemented. The payment reform was associated with a 42.4 percent relative reduction in price-weighted traditional primary care services, driven fully by decreased use of imaging services. Other outcomes remained unaffected. Oregon's initiative could provide lessons for other states interested in using payment reform to advance the patient-centered medical home model for the Medicaid population.
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Affiliation(s)
- Stephan Lindner
- Stephan Lindner is an assistant professor in the Center for Health Systems Effectiveness and in the Department of Emergency Medicine, both at Oregon Health & Science University, in Portland, Oregon
| | - Menolly R Kaufman
- Menolly R. Kaufman is a research associate in the Center for Health Systems Effectiveness, Oregon Health & Science University
| | - Miguel Marino
- Miguel Marino is an associate professor of biostatistics in the Department of Family Medicine, Oregon Health & Science University, and at the OHSU-Portland State University School of Public Health, in Portland
| | - Jean O'Malley
- Jean O'Malley is a biostatistician in the Research Department at Ochin, Inc., in Portland
| | - Heather Angier
- Heather Angier is an assistant professor in the Department of Family Medicine, Oregon Health & Science University
| | - Erika K Cottrell
- Erika K. Cottrell is an assistant professor in the Department of Family Medicine, Oregon Health & Science University, and an investigator at OCHIN, Inc
| | - K John McConnell
- K. John McConnell is director of the Center for Health Systems Effectiveness and a professor in the Department of Emergency Medicine, both at Oregon Health & Science University
| | - Jennifer E DeVoe
- Jennifer E. DeVoe is professor and chair in the Department of Family Medicine, Oregon Health & Science University
| | - John R Heintzman
- John R. Heintzman is an associate professor in the Department of Family Medicine, Oregon Health & Science University
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Ukhanova M, Marino M, Angier H, Jacob L, O'Malley J, Cottrell EK, Dambrun K, Heintzman J. The impact of capitated payment on preventive care utilization in community health clinics. Prev Med 2021; 145:106405. [PMID: 33388331 DOI: 10.1016/j.ypmed.2020.106405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 11/11/2020] [Accepted: 12/29/2020] [Indexed: 11/26/2022]
Abstract
Only half of the United States population regularly receives recommended preventive care services. Alternative payment models (e.g., a per-member-per-month capitated payment model) may encourage the delivery of preventive services when compared to a fee-for-service visitbased model; however, evaluation is lacking in the United States. This study assesses the impact of implementing Oregon's Alternative Payment Methodology (APM) on orders for preventive services within community health centers (CHCs). This retrospective cohort study uses electronic health record data from the OCHIN, Inc., 2012-2018, analyzed in 2018-2019. Twenty-seven CHCs which implemented APM in 2013-2016 were compared to six non-APM CHCs. Clinic-level quarterly rates of ordering nine preventive services in 2012-2018 were calculated. For each phase and preventive service, we used difference-in-differences analysis to assess the APM impact on ordering preventive care. We found greater increases for APM CHCs compared to non-APM CHCs for orders of mammograms (difference-in-differences estimates (DDs) across four phases:1.69-2.45). Both groups had decreases in ordering cervical cancer screenings, however, APM CHCs had smaller decreases (DDs:1.62-1.93). The APM CHCs had significantly greater decreases in influenza vaccinations (DDs:0.17-0.32). There were no consistent significant differences in pre-post changes in APM vs. non-APM CHCs for cardiometabolic risk screenings, smoking status and depression assessments. There was nonsignificant change in the proportion of nontraditional encounters in APM clinics compared to controls. Transition from fee-for-service to an APM did not negatively impact delivery of preventive care. Further studies are needed to understand how to change encounter structures to best deliver recommended preventive care.
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Affiliation(s)
- Maria Ukhanova
- 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; Department of Public Health and Preventive Medicine, Division of Biostatistics, Oregon Health and Science University, Portland, Oregon, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | | | | | - Erika K Cottrell
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA; OCHIN, Inc., Portland, Oregon, USA
| | | | - John Heintzman
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA; OCHIN, Inc., Portland, Oregon, USA
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Angier H, Huguet N, Ezekiel-Herrera D, Marino M, Schmidt T, Green BB, DeVoe JE. New hypertension and diabetes diagnoses following the Affordable Care Act Medicaid expansion. Fam Med Community Health 2020; 8:e000607. [PMID: 33334850 PMCID: PMC7747613 DOI: 10.1136/fmch-2020-000607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To assess the Affordable Care Act (ACA) Medicaid expansion's impact on new hypertension and diabetes diagnoses in community health centres (CHCs). DESIGN Rates of new hypertension and diabetes diagnoses were computed using generalised estimating equation Poisson models and we tested the difference-in-difference (DID) pre-ACA versus post-ACA in states that expanded Medicaid compared with those that did not. SETTING We used electronic health record data (pre-ACA: 1 January 2012-31 December 2013-post-ACA: 1 January 2014-31 December 2016) from the Accelerating Data Value Across a National Community Health Center Network clinical data network. We included clinics with ≥50 patients contributing to person-time-at risk in each study year. PARTICIPANTS Patients aged 19-64 with ≥1 ambulatory visit in the study period were included. We then excluded patients who were pregnant during the study period (N=127 530). For the hypertension outcome, we excluded individuals with a diagnosis of hypertension prior to the start of the study period, those who had a hypertension diagnosis on their first visit to a clinic or their first visit after 3 years without a visit, and those who had a diagnosis more than 3 years after their last visit (pre-ACA non-expansion N=130 973; expansion N=193 198; post-ACA non-expansion N=186 341; expansion N=251 015). For the diabetes analysis, we excluded patients with a diabetes diagnosis prior to study start, on their first visit or first visit after inactive patient status, and diagnosis while not an active patient (pre-ACA non-expansion N=145 435; expansion N=198 558; post-ACA non-expansion N=215 039; expansion N=264 644). RESULTS In non-expansion states, adjusted hypertension diagnosis rates saw a relative decrease of 6%, while in expansion states, the adjusted rates saw a relative increase of 7% (DID 1.14, 95% CI 1.11 to 1.18). For diabetes diagnosis, adjusted rates in non-expansion states experienced a significant relative increase of 28% and in expansion states the relative increase was 25%; yet these differences were not significant pre-ACA to post-ACA comparing expansion and non-expansion states (DID 0.98, 95% CI 0.91 to 1.05). CONCLUSION There was a differential impact of Medicaid expansion for hypertension and diabetes diagnoses. Moderate increases were found in diabetes diagnosis rates among all patients served by CHCs post-ACA (both in expansion and non-expansion states). These increases suggest that ACA-related opportunities to gain health insurance (such as marketplaces and the Medicaid expansion) may have facilitated access to diagnostic tests for this population. The study found a small change in hypertension diagnosis rates from pre-ACA to post-ACA (a decrease in non-expansion and an increase in expansion states). Despite the significant difference between expansion and non-expansion states, the small change from pre-ACA to post-ACA suggests that the diagnosis of hypertension is likely documented for patients, regardless of health insurance availability. Future studies are needed to understand the impact of the ACA on hypertension and diabetes treatment and control.
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Affiliation(s)
- Heather Angier
- Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Nathalie Huguet
- Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Miguel Marino
- Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Biostatistics Group, Oregon Health & Science University - Portland State University School of Public Health, Portland, Oregon, USA
| | | | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Jennifer E DeVoe
- Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Bailey SR, Marino M, Ezekiel-Herrera D, Schmidt T, Angier H, Hoopes MJ, DeVoe JE, Heintzman J, Huguet N. Tobacco Cessation in Affordable Care Act Medicaid Expansion States Versus Non-expansion States. Nicotine Tob Res 2020; 22:1016-1022. [PMID: 31123754 DOI: 10.1093/ntr/ntz087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 05/21/2019] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Community health centers (CHCs) care for vulnerable patients who use tobacco at higher than national rates. States that expanded Medicaid eligibility under the Affordable Care Act (ACA) provided insurance coverage to tobacco users not previously Medicaid-eligible, thereby potentially increasing their odds of receiving cessation assistance. We examined if tobacco users in Medicaid expansion states had increased quit rates, cessation medications ordered, and greater health care utilization compared to patients in non-expansion states. METHODS Using electronic health record (EHR) data from 219 CHCs in 10 states that expanded Medicaid as of January 1, 2014, we identified patients aged 19-64 with tobacco use status documented in the EHR within 6 months prior to ACA Medicaid expansion and ≥1 visit with tobacco use status assessed within 24 months post-expansion (January 1, 2014 to December 31, 2015). We propensity score matched these patients to tobacco users from 108 CHCs in six non-expansion states (n = 27 670 matched pairs; 55 340 patients). Using a retrospective observational cohort study design, we compared odds of having a quit status, cessation medication ordered, and ≥6 visits within the post-expansion period among patients in expansion versus non-expansion states. RESULTS Patients in expansion states had increased adjusted odds of quitting (adjusted odds ratio [aOR] = 1.35, 95% confidence interval [CI]: 1.28-1.43), having a medication ordered (aOR = 1.53, 95% CI: 1.44-1.62), and having ≥6 follow-up visits (aOR = 1.34, 95% CI: 1.28-1.41) compared to patients from non-expansion states. CONCLUSIONS Increased access to insurance via the ACA Medicaid expansion likely led to increased quit rates within this vulnerable population. IMPLICATIONS CHCs care for vulnerable patients at higher risk of tobacco use than the general population. Medicaid expansion via the ACA provided insurance coverage to a large number of tobacco users not previously Medicaid-eligible. We found that expanded insurance coverage was associated with increased cessation assistance and higher odds of tobacco cessation. Continued provision of insurance coverage could lead to increased quit rates among high-risk populations, resulting in improvements in population health outcomes and reduced total health care costs.
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Affiliation(s)
- Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,Division of Biostatistics, School of Public Health, Oregon Health & Science University - Portland State University, Portland, OR
| | | | | | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | | | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Inc., Portland, OR
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Tilhou AS, Huguet N, DeVoe J, Angier H. The Affordable Care Act Medicaid Expansion Positively Impacted Community Health Centers and Their Patients. J Gen Intern Med 2020; 35:1292-1295. [PMID: 31898120 PMCID: PMC7174462 DOI: 10.1007/s11606-019-05571-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022]
Abstract
Community health centers (CHCs) provide primary care for underserved children and adults. The Patient Protection and Affordable Care Act (ACA) aimed to strengthen the CHC network by increasing federal funds and expanding Medicaid eligibility. The ACA also aimed to boost preventive and mental health services and to reduce health and healthcare disparities. Here, we summarize our results to-date as experts in investigating the impact of ACA Medicaid expansion on CHCs and the patients they serve. We found the ACA Medicaid expansion increased access to care and preventive services, primarily in Medicaid expansion states. Rates of physical and mental health conditions rose substantially from pre- to post-ACA in expansion states, suggesting underdiagnosis pre-ACA. Disparities in health insurance coverage by race/ethnicity decreased at CHCs, yet some remain. These findings indicate that the ACA Medicaid expansion significantly helped CHCs and patients. Insurance expansion buoyed CHCs' financial viability by increasing reimbursement. Therefore, the ACA Medicaid expansion enhanced the health of underserved patients and repeal would jeopardize these advances for CHCs and their patients.
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Affiliation(s)
- Alyssa Shell Tilhou
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA. .,Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
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Lindner SR, Marino M, O'Malley J, Angier H, Bailey SR, Hoopes M, Springer R, McConnell KJ, DeVoe J, Huguet N. Health Care Expenditures Among Adults With Diabetes After Oregon's Medicaid Expansion. Diabetes Care 2020; 43:572-579. [PMID: 31857442 PMCID: PMC7035584 DOI: 10.2337/dc19-1343] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/27/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare trends in Medicaid expenditures among adults with diabetes who were newly eligible due to the Affordable Care Act (ACA) Medicaid expansion to trends among those previously eligible. RESEARCH DESIGN AND METHODS Using Oregon Medicaid administrative data from 1 January 2014 to 30 September 2016, a retrospective cohort study was conducted with propensity score-matched Medicaid eligibility groups (newly and previously eligible). Outcome measures included total per-member per-month (PMPM) Medicaid expenditures and PMPM expenditures in the following 12 categories: inpatient visits, emergency department visits, primary care physician visits, specialist visits, prescription drugs, transportation services, tests, imaging and echography, procedures, durable medical equipment, evaluation and management, and other or unknown services. RESULTS Total PMPM Medicaid expenditures for newly eligible enrollees with diabetes were initially considerably lower compared with PMPM expenditures for matched previously eligible enrollees during the first postexpansion quarter (mean values $561 vs. $793 PMPM, P = 0.018). Within the first three postexpansion quarters, PMPM expenditures of the newly eligible increased to a similar but slightly lower level. Afterward, PMPM expenditures of both groups continued to increase steadily. Most of the overall PMPM expenditure increase among the newly eligible was due to rapidly increasing prescription drug expenditures. CONCLUSIONS Newly eligible Medicaid enrollees with diabetes had slightly lower PMPM expenditures than previously eligible Medicaid enrollees. The increase in PMPM prescription drug expenditures suggests greater access to treatment over time.
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Affiliation(s)
- Stephan R Lindner
- Center for Health Systems Effectiveness and Department of Emergency Medicine, Oregon Health & Science University, Portland, OR .,OHSU-PSU School of Public Health, Portland, OR
| | - Miguel Marino
- OHSU-PSU School of Public Health, Portland, OR.,Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | | | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | | | - Rachel Springer
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - K John McConnell
- Center for Health Systems Effectiveness and Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.,OHSU-PSU School of Public Health, Portland, OR
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
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Hoopes M, Schmidt T, Huguet N, Winters-Stone K, Angier H, Marino M, Shannon J, DeVoe J. Reply to Patients with incurable cancer as a separate group of survivors in the primary care setting. Cancer 2019; 125:4542-4543. [PMID: 31568589 DOI: 10.1002/cncr.32471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Nathalie Huguet
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kerri Winters-Stone
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon.,School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Heather Angier
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon
| | - Miguel Marino
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon.,School of Public Health, Oregon Health and Science University-Portland State University, Portland, Oregon
| | - Jackilen Shannon
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon.,School of Public Health, Oregon Health and Science University-Portland State University, Portland, Oregon
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Hoopes M, Angier H, Raynor LA, Suchocki A, Muench J, Marino M, Rivera P, Huguet N. Development of an algorithm to link electronic health record prescriptions with pharmacy dispense claims. J Am Med Inform Assoc 2019; 25:1322-1330. [PMID: 30113681 DOI: 10.1093/jamia/ocy095] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 06/27/2018] [Indexed: 11/14/2022] Open
Abstract
Objective Medication adherence is an important aspect of chronic disease management. Electronic health record (EHR) data are often not linked to dispensing data, limiting clinicians' understanding of which of their patients fill their medications, and how to tailor care appropriately. We aimed to develop an algorithm to link EHR prescribing to claims-based dispensing data and use the results to quantify how often patients with diabetes filled prescribed chronic disease medications. Materials and Methods We developed an algorithm linking EHR prescribing data (RxNorm terminology) to claims-based dispensing data (NDC terminology), within sample of adult (19-64) community health center (CHC) patients with diabetes from a network of CHCs across 12 states. We demonstrate an application of the method by calculating dispense rates for a set of commonly prescribed diabetes and cardio-protective medications. To further inform clinical care, we computed adjusted odds ratios of dispense by patient-, encounter-, and clinic-level characteristics. Results Seventy-six percent of cardio-protective medication prescriptions and 74% of diabetes medications were linked to a dispensing record. Age, income, ethnicity, insurance, assigned primary care provider, comorbidity, time on EHR, and clinic size were significantly associated with odds of dispensing. Discussion EHR prescriptions and pharmacy dispense data can be linked at the record level across different terminologies. Dispensing rates in this low-income population with diabetes were similar to other populations. Conclusion Record linkage resulted in the finding that CHC patients with diabetes largely had their chronic disease medications dispensed. Understanding factors associated with dispensing rates highlight barriers and opportunities for optimal disease management.
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Affiliation(s)
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Andrew Suchocki
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - John Muench
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA.,School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon, USA
| | | | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Angier H, Ezekiel-Herrera D, Marino M, Hoopes M, Jacobs EA, DeVoe JE, Huguet N. Racial/Ethnic Disparities in Health Insurance and Differences in Visit Type for a Population of Patients with Diabetes after Medicaid Expansion. J Health Care Poor Underserved 2019; 30:116-130. [PMID: 30827973 DOI: 10.1353/hpu.2019.0011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
This quasi-experimental study evaluated racial/ethnic disparities in health insurance and differences in visits post-versus pre-Affordable Care Act (ACA) Medicaid expansion. We utilized electronic health record data from a population of patients with diabetes aged 19-64 seen in community health centers (CHCs). We used generalized estimating equation Poisson models to estimate incidence rates of insurance type and visits post-(1/1/2014-12/31/2015) versus pre-(1/1/13-12/31/13) ACA, stratified by racial/ethnic group. We assessed difference-in-differences (DD) and difference-in-difference-in-differences (DDD). The relative disparity in uninsured visits increased between Hispanic and non-Hispanic Whites in expansion states (DD=1.93; 95% CI=1.41, 2.64); the magnitude was greater in expansion compared with non-expansion states (DDD=1.84, 95% CI=1.32, 2.56), yet uninsured rates were lower in expansion compared with non-expansion states. We found few changes in visits. Results suggest that the ACA Medicaid expansion increased health insurance coverage and that while some racial/ethnic disparities were improved, some remained.
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Huguet N, Angier H, Hoopes MJ, Marino M, Heintzman J, Schmidt T, DeVoe JE. Prevalence of Pre-existing Conditions Among Community Health Center Patients Before and After the Affordable Care Act. J Am Board Fam Med 2019; 32:883-889. [PMID: 31704757 PMCID: PMC7001872 DOI: 10.3122/jabfm.2019.06.190087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/03/2019] [Accepted: 06/21/2019] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To assess the prevalence of pre-existing conditions for community health center (CHC) patients who gained insurance coverage post-Affordable Care Act (ACA). METHODS We analyzed electronic health record data from 78,059 patients aged 19 to 64 uninsured at their last visit pre-ACA from 386 CHCs in 19 states. We compared the prevalence and types of pre-existing conditions pre-ACA (2012 to 2013) and post-ACA (2014 to 2015), by insurance status and race/ethnicity. RESULTS Pre-ACA, >50% of patients in the cohort had ≥1 Pre-existing condition. Post-ACA, >70% of those who gained insurance coverage had ≥1 condition. Post-ACA, all racial/ethnic subgroups showed an increase in the number of pre-existing conditions, with non-Hispanic Black and Hispanic patients experiencing the largest increases (adjusted prevalence difference, 18.9; 95% CI, 18.2 to 19.6 and 18.3; 95% CI, 17.8 to 18.7, respectively). The most common conditions post-ACA were mental health disorders with the highest prevalence among patients who gained Medicaid (45.6%) and lowest among those who gained private coverage (30.5%). CONCLUSIONS This study emphasizes the high prevalence of pre-existing conditions among CHC patients and the large increase in the proportion of patients with at least 1 of these diagnoses post-ACA. Given how common these conditions are, repealing pre-existing condition protections could be extremely harmful to millions of patients and would likely exacerbate health care and health disparities.
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Affiliation(s)
- Nathalie Huguet
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM).
| | - Heather Angier
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Megan J Hoopes
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Miguel Marino
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - John Heintzman
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Teresa Schmidt
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Jennifer E DeVoe
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
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Springer R, Marino M, Bailey SR, Angier H, O’Malley JP, Hoopes M, Lindner S, DeVoe JE, Huguet N. Prescription opioid use patterns, use disorder diagnoses and addiction treatment receipt after the 2014 Medicaid expansion in Oregon. Addiction 2019; 114:1775-1784. [PMID: 31106483 PMCID: PMC6731997 DOI: 10.1111/add.14667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/07/2018] [Accepted: 05/14/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND/AIMS Evidence suggests that Medicaid beneficiaries in the United States are prescribed opioids more frequently than are people who are privately insured, but little is known about opioid prescribing patterns among Medicaid enrollees who gained coverage via the Affordable Care Act Medicaid expansions. This study compared the prevalence of receipt of opioid prescriptions and opioid use disorder (OUD), along with time from OUD diagnosis to medication-assisted treatment (MAT) receipt between Oregon residents who had been continuously insured by Medicaid, were newly insured after Medicaid expansion in 2014 or returned to Medicaid coverage after expansion. DESIGN Cross-sectional study using inverse-propensity weights to adjust for differences among insurance groups. SETTING Oregon. PARTICIPANTS A total of 225 295 Oregon Medicaid adult beneficiaries insured during 2014-15 and either: (1) newly enrolled, (2) returning in 2014 after a > 12-month gap or (3) continuously insured between 2013 and 2015. We excluded patients in hospice care or with cancer diagnoses. MEASUREMENTS Any opioid-dispensed, chronic (> 90-days) and high-dose (> 90 daily morphine milligram equivalence) opioid use, documented OUD diagnosis and MAT receipt. FINDINGS Compared with the continuously insured, newly and returning insured enrollees were less likely to be dispensed opioids [newly: 42.3%, 95% confidence interval (CI) = 42.0-42.7%; returning: 49.3%, 95% CI = 48.8-49.7%; continuously: 52.5%, 95% CI = 52.0-53.0%], use opioids chronically (newly: 12.8%, 95% CI = 12.4-13.1%; returning: 11.9%, 95% CI = 11.5-12.3%, continuously: 15.8%, 95% CI = 15.4-16.2%), have OUD diagnoses (newly: 3.6%, 95% CI = 3.4-3.7%; returning: 3.9%, 95% CI = 3.8-4.1%, continuously: 4.7%, 95% CI = 4.5-4.9%) and receive MAT after OUD diagnosis [hazard ratio newly: 0.57, 95% CI = 0.53-0.61; hazard ratio returning: 0.60, 95% CI = 0.56-0.65 (ref: continuously)]. CONCLUSIONS Residents of Oregon, United States who enrolled or re-enrolled in Medicaid health insurance after expansion of coverage in 2014 as a result of the Affordable Care Act were less likely than those already covered to receive opioids, use them chronically or receive medication-assisted treatment for opioid use disorder.
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Affiliation(s)
- Rachel Springer
- Department of Family Medicine, Oregon Health & Science
University, Portland, OR USA.,Corresponding Author: Rachel Springer, MS,
Biostatistician, Department of Family Medicine, Mailcode: FM, Oregon Health
& Science University, 3181 SW Sam Jackson Park Rd, Portland OR 97239,
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science
University, Portland, OR USA.,School of Public Health, Oregon Health & Science
University-Portland State University, Portland, OR USA
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science
University, Portland, OR USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science
University, Portland, OR USA
| | - Jean P O’Malley
- Department of Family Medicine, Oregon Health & Science
University, Portland, OR USA.,OCHIN, Portland OR USA
| | | | - Stephan Lindner
- School of Public Health, Oregon Health & Science
University-Portland State University, Portland, OR USA.,Center for Health Systems Effectiveness, Oregon Health
& Science University, Portland, OR USA
| | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science
University, Portland, OR USA.,OCHIN, Portland OR USA
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science
University, Portland, OR USA
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Huguet N, Valenzuela S, Marino M, Angier H, Hatch B, Hoopes M, DeVoe JE. Following Uninsured Patients Through Medicaid Expansion: Ambulatory Care Use and Diagnosed Conditions. Ann Fam Med 2019; 17:336-344. [PMID: 31285211 PMCID: PMC6827641 DOI: 10.1370/afm.2385] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/15/2019] [Accepted: 02/28/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The Patient Protection and Affordable Care Act (ACA) has improved access to health insurance, yet millions remain uninsured. Many patients who remain uninsured access care at community health centers (CHCs); however, little is known about their health conditions and health care use. We assessed ambulatory care use and diagnosed health conditions among a cohort of CHC patients uninsured before enactment of the ACA (pre-ACA: January 1, 2012 to December 31, 2013) and followed them after enactment (post-ACA: January 1, 2014 to December 31, 2015). METHODS This retrospective cohort analysis used electronic health record data from CHCs in 11 US states that expanded Medicaid eligibility. We assessed ambulatory care visits and documented health conditions among a cohort of 138,246 patients (aged 19 to 64 years) who were uninsured pre-ACA and either remained uninsured, gained Medicaid, gained other health insurance, or did not have a visit post-ACA. We estimated adjusted predicted probabilities of ambulatory care use using an ordinal logistic mixed-effects regression model. RESULTS Post-ACA, 20.9% of patients remained uninsured, 15.0% gained Medicaid, 12.4% gained other insurance, and 51.7% did not have a visit. The majority of patients had ≥1 diagnosed health condition. The adjusted proportion of patients with high use (≥6 visits over 2 years) increased from pre-ACA to post-ACA among those who gained Medicaid (pre-ACA: 23%, post-ACA: 34%, P <.001) or gained other insurance (pre-ACA: 29%, post-ACA: 48%, P <.001), whereas the percentage fell slightly for those continuously uninsured. CONCLUSIONS A significant percentage of CHC patients remained uninsured; many who remained uninsured had diagnosed health conditions, and one-half continued to have ≥3 visits to CHCs. CHCs continue to be essential providers for uninsured patients.
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Affiliation(s)
- Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Steele Valenzuela
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.,Division of Biostatistics, School of Public Health, Oregon Health & Science University, Portland State University, Portland, Oregon
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Brigit Hatch
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.,Research Department, OCHIN Inc, Portland, Oregon
| | - Megan Hoopes
- Research Department, OCHIN Inc, Portland, Oregon
| | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
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Hoopes M, Schmidt T, Huguet N, Winters-Stone K, Angier H, Marino M, Shannon J, DeVoe J. Identifying and characterizing cancer survivors in the US primary care safety net. Cancer 2019; 125:3448-3456. [PMID: 31174231 DOI: 10.1002/cncr.32295] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Primary care providers must understand the use patterns, clinical complexity, and primary care needs of cancer survivors to provide quality health care services. However, to the authors' knowledge, little is known regarding the prevalence and health care needs of this growing population, particularly in safety net settings. METHODS The authors identified adults with a history of cancer documented in primary care electronic health records within a network of community health centers (CHCs) in 19 states. The authors estimated cancer history prevalence among >1.2 million patients and compared sex-specific site distributions with national estimates. Each survivor was matched to 3 patients without cancer from the same set of clinics. The demographic characteristics, primary care use, and comorbidity burden then were compared between the 2 groups, assessing differences with absolute standardized mean differences (ASMDs). ASMD values >0.1 denote meaningful differences between groups. Generalized estimating equations yielded adjusted odds ratios (aORs) for select indicators. RESULTS A total of 40,266 cancer survivors were identified (prevalence of 3.0% of adult CHC patients). Compared with matched cancer-free patients, a higher percentage of survivors had ≥6 primary care visits across 3 years (62% vs 48%) and were insured (83% vs 74%) (ASMD, >0.1 for both). Cancer survivors had excess medical complexity, including a higher prevalence of depression, asthma/chronic obstructive pulmonary disease, and liver disease (ASMD, >0.1 for all). Survivors had higher odds of any opioid prescription (aOR, 1.23; 95% CI, 1.19-1.27) and chronic opioid therapy (aOR, 1.27; 95% CI, 1.23-1.32) compared with matched controls (P < .001 for all). CONCLUSIONS Identifying cancer survivors and understanding their patterns of utilization and physical and mental comorbidities present an opportunity to tailor primary health care services to this population.
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Affiliation(s)
| | | | - Nathalie Huguet
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kerri Winters-Stone
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon.,School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Heather Angier
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon
| | - Miguel Marino
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon.,School of Public Health, Oregon Health and Science University-Portland State University, Portland, Oregon
| | - Jackilen Shannon
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon.,School of Public Health, Oregon Health and Science University-Portland State University, Portland, Oregon
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon
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Cottrell EK, Gold R, Likumahuwa S, Angier H, Huguet N, Cohen DJ, Clark KD, Gottlieb LM, DeVoe JE. Using Health Information Technology to Bring Social Determinants of Health into Primary Care: A Conceptual Framework to Guide Research. J Health Care Poor Underserved 2019; 29:949-963. [PMID: 30122675 DOI: 10.1353/hpu.2018.0071] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Several recent national initiatives have called for increased efforts to integrate social determinants of health (SDH) into health care settings using health information technology (HIT). However, there is limited evidence to guide the implementation of these recommendations in practice. Research is needed to understand what SDH information is most important to collect, how SDH information can be used to inform clinical care and referrals, and ultimately, whether and how integrating SDH screening and action into primary care affects individual and population health. We recently proposed a conceptual framework to illustrate how HIT can be used to bring SDH information into primary care. In this paper, we describe how we are putting this conceptual model into practice within the OCHIN network of community health centers by highlighting examples of ongoing research, identifying knowledge gaps, and outlining a roadmap of future research to move the field forward.
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Angier H, Huguet N, Marino M, Green B, Holderness H, Gold R, Hoopes M, DeVoe J. Observational study protocol for evaluating control of hypertension and the effects of social determinants. BMJ Open 2019; 9:e025975. [PMID: 30878987 PMCID: PMC6429873 DOI: 10.1136/bmjopen-2018-025975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Hypertension is a common chronic health condition. Having health insurance reduces hypertension risk; health insurance coverage could improve hypertension screening, treatment and management. The Medicaid eligibility expansion of the Affordable Care Act was ruled not to be required by the US Supreme Court. Subsequently, a 'natural experiment' was produced with some states expanding Medicaid eligibility while others did not. This presents a unique opportunity to learn whether and to what extent Medicaid expansion can affect healthcare access and services for patients at risk for and diagnosed with hypertension, and patients with undiagnosed hypertension. Additionally, social determinants of health (SDH), at both the individual- and community-level, influence diagnosis and care for hypertension and it is important to understand how they interact with health insurance coverage changes. METHODS/DESIGN We will use electronic health record (EHR) data from the Accelerating Data Value Across a National Community Health Center Network clinical data research network, which has data from community health centres in 22 states, some that did and some that did not expand Medicaid. Data include information on changes in health insurance, service receipt and health outcomes from 2012 through the most recent data available. We will include patients between the ages of 19 and 64 years (n=1 524 241) with ≥1 ambulatory visit to a community health centre. We will estimate differences in outcomes using difference-in-difference and difference-in-difference-in-difference approaches. We will test three-way interactions with insurance group, time and social determinants of health factors to compare the potential effect of gaining insurance on our proposed outcomes. ETHICS AND DISSEMINATION This study uses secondary data analysis and therefore approval for consent to participate was waived. The Institutional Review Board for OHSU approved this study. Approval reference number is: IRB00011858. We plan to disseminate our findings at relevant conferences, meetings and through peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03545763.
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Affiliation(s)
- Heather Angier
- Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Nathalie Huguet
- Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Miguel Marino
- Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Beverly Green
- Research, Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Heather Holderness
- Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | - Jennifer DeVoe
- Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Angier H, Jacobs EA, Huguet N, Likumahuwa-Ackman S, Robert S, DeVoe JE. Progress towards using community context with clinical data in primary care. Fam Med Community Health 2018; 7:e000028. [PMID: 32148692 PMCID: PMC6951248 DOI: 10.1136/fmch-2018-000028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 11/03/2022] Open
Abstract
Community-level factors have significant impacts on health. There is renewed enthusiasm for integrating these data with electronic health record (EHR) data for use in primary care to improve health equity in the USA. Thus, it is valuable to reflect on what has been published to date. Specifically, we comment on: (1) recommendations about combining community-level factors in EHRs for use in primary care; (2) examples of how these data have been combined and used; and (3) the impact of using combined data on healthcare, patient health and health equity. We found publications discussing the potential of combined data to inform clinical care, target interventions, track population health and spark community partnerships with the goal of reducing health disparities and improving health equity. Although there is great enthusiasm and potential for using these data to inform primary care, there is little evidence of improved healthcare, patient health or health equity.
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Affiliation(s)
- Heather Angier
- Oregon Health & Science University, Portland, Oregon, USA
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Marino M, Angier H, Valenzuela S, Hoopes M, Killerby M, Blackburn B, Huguet N, Heintzman J, Hatch B, O'Malley JP, DeVoe JE. Medicaid coverage accuracy in electronic health records. Prev Med Rep 2018; 11:297-304. [PMID: 30116701 PMCID: PMC6082971 DOI: 10.1016/j.pmedr.2018.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 07/19/2018] [Accepted: 07/21/2018] [Indexed: 01/21/2023] Open
Abstract
Health insurance coverage facilitates access to preventive screenings and other essential health care services, and is linked to improved health outcomes; therefore, it is critical to understand how well coverage information is documented in the electronic health record (EHR) and which characteristics are associated with accurate documentation. Our objective was to evaluate the validity of EHR data for monitoring longitudinal Medicaid coverage and assess variation by patient demographics, visit types, and clinic characteristics. We conducted a retrospective, observational study comparing Medicaid status agreement between Oregon community health center EHR data linked at the patient-level to Medicaid enrollment data (gold standard). We included adult patients with a Medicaid identification number and ≥1 clinic visit between 1/1/2013-12/31/2014 [>1 million visits (n = 135,514 patients)]. We estimated statistical correspondence between EHR and Medicaid data at each visit (visit-level) and for different insurance cohorts over time (patient-level). Data were collected in 2016 and analyzed 2017-2018. We observed excellent agreement between EHR and Medicaid data for health insurance information: kappa (>0.80), sensitivity (>0.80), and specificity (>0.85). Several characteristics were associated with agreement; at the visit-level, agreement was lower for patients who preferred a non-English language and for visits missing income information. At the patient-level, agreement was lower for black patients and higher for older patients seen in primary care community health centers. Community health center EHR data are a valid source of Medicaid coverage information. Agreement varied with several characteristics, something researchers and clinic staff should consider when using health insurance information from EHR data.
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Affiliation(s)
- Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Steele Valenzuela
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | | | - Marie Killerby
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Brenna Blackburn
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Brigit Hatch
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,OCHIN, Portland, OR, USA
| | - Jean P O'Malley
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,OCHIN, Portland, OR, USA
| | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,OCHIN, Portland, OR, USA
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DeVoe JE, Hoopes M, Nelson CA, Cohen DJ, Sumic A, Hall J, Angier H, Marino M, O'Malley JP, Gold R. Electronic health record tools to assist with children's insurance coverage: a mixed methods study. BMC Health Serv Res 2018; 18:354. [PMID: 29747644 PMCID: PMC5946500 DOI: 10.1186/s12913-018-3159-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 04/26/2018] [Indexed: 11/11/2022] Open
Abstract
Background Children with health insurance have increased access to healthcare and receive higher quality care. However, despite recent initiatives expanding children’s coverage, many remain uninsured. New technologies present opportunities for helping clinics provide enrollment support for patients. We developed and tested electronic health record (EHR)-based tools to help clinics provide children’s insurance assistance. Methods We used mixed methods to understand tool adoption, and to assess impact of tool use on insurance coverage, healthcare utilization, and receipt of recommended care. We conducted intent-to-treat (ITT) analyses comparing pediatric patients in 4 intervention clinics (n = 15,024) to those at 4 matched control clinics (n = 12,227). We conducted effect-of-treatment-on-the-treated (ETOT) analyses comparing intervention clinic patients with tool use (n = 2240) to intervention clinic patients without tool use (n = 12,784). Results Tools were used for only 15% of eligible patients. Qualitative data indicated that tool adoption was limited by: (1) concurrent initiatives that duplicated the work associated with the tools, and (2) inability to obtain accurate insurance coverage data and end dates. The ITT analyses showed that intervention clinic patients had higher odds of gaining insurance coverage (adjusted odds ratio [aOR] = 1.32, 95% confidence interval [95%CI] 1.14–1.51) and lower odds of losing coverage (aOR = 0.77, 95%CI 0.68–0.88), compared to control clinic patients. Similarly, ETOT findings showed that intervention clinic patients with tool use had higher odds of gaining insurance (aOR = 1.83, 95%CI 1.64–2.04) and lower odds of losing coverage (aOR = 0.70, 95%CI 0.53–0.91), compared to patients without tool use. The ETOT analyses also showed higher rates of receipt of return visits, well-child visits, and several immunizations among patients for whom the tools were used. Conclusions This pragmatic trial, the first to evaluate EHR-based insurance assistance tools, suggests that it is feasible to create and implement tools that help clinics provide insurance enrollment support to pediatric patients. While ITT findings were limited by low rates of tool use, ITT and ETOT findings suggest tool use was associated with better odds of gaining and keeping coverage. Further, ETOT findings suggest that use of such tools may positively impact healthcare utilization and quality of pediatric care. Trial registration ClinicalTrials.gov, NCT02298361; retrospectively registered on November 5, 2014. Electronic supplementary material The online version of this article (10.1186/s12913-018-3159-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jennifer E DeVoe
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA.,Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Road, Mail Code FM, Portland, OR, 97239, USA
| | - Megan Hoopes
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA
| | | | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Road, Mail Code FM, Portland, OR, 97239, USA
| | | | - Jennifer Hall
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Road, Mail Code FM, Portland, OR, 97239, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Road, Mail Code FM, Portland, OR, 97239, USA
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Road, Mail Code FM, Portland, OR, 97239, USA
| | - Jean P O'Malley
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Road, Mail Code FM, Portland, OR, 97239, USA
| | - Rachel Gold
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA.,Kaiser Permanente Northwest Center for Health Research, 3800 N Interstate Avenue, Portland, OR, 97211, USA
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Duru OK, Mangione CM, Rodriguez HP, Ross-Degnan D, Wharam JF, Black B, Kho A, Huguet N, Angier H, Mayer V, Siscovick D, Kraschnewski JL, Shi L, Nauman E, Gregg EW, Ali MK, Thornton P, Clauser S. Introductory Overview of the Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network: Examining the Impact of US Health Policies and Practices to Prevent Diabetes and Its Complications. Curr Diab Rep 2018; 18:8. [PMID: 29399715 PMCID: PMC8910460 DOI: 10.1007/s11892-018-0977-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Diabetes incidence is rising among vulnerable population subgroups including minorities and individuals with limited education. Many diabetes-related programs and public policies are unevaluated while others are analyzed with research designs highly susceptible to bias which can result in flawed conclusions. The Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network includes eight research centers and three funding agencies using rigorous methods to evaluate natural experiments in health policy and program delivery. RECENT FINDINGS NEXT-D2 research studies use quasi-experimental methods to assess three major areas as they relate to diabetes: health insurance expansion; healthcare financing and payment models; and innovations in care coordination. The studies will report on preventive processes, achievement of diabetes care goals, and incidence of complications. Some studies assess healthcare utilization while others focus on patient-reported outcomes. NEXT-D2 examines the effect of public and private policies on diabetes care and prevention at a critical time, given ongoing and rapid shifts in the US health policy landscape.
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Affiliation(s)
- O Kenrik Duru
- Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine, UCLA, 10940 Wilshire Blvd., Suite 700, Los Angeles, CA, 90024, USA.
| | - Carol M Mangione
- David Geffen School of Medicine at UCLA and Fielding School of Public Health, UCLA, Los Angeles, CA, USA
| | - Hector P Rodriguez
- School of Public Health - Health Policy and Management, University of California, Berkeley, Berkeley, CA, USA
| | - Dennis Ross-Degnan
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - J Frank Wharam
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Bernard Black
- Pritzker School of Law, Institute for Policy Research, and Kellogg School of Management, Northwestern University, Evanston, IL, USA
| | - Abel Kho
- Institute of Public Health & Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Victoria Mayer
- Department of Population Health Science and Policy, Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Jennifer L Kraschnewski
- Department of Medicine, Pediatrics and Public Health Sciences, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Lizheng Shi
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | | | - Edward W Gregg
- Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, GA, USA
| | - Mohammed K Ali
- Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Pamela Thornton
- Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, MD, USA
| | - Steven Clauser
- Health Care Delivery and Disparities Research Program, Patient-Centered Outcomes Research Institute, Washington, DC, USA
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