Clinical trial participation among underserved communities: Insights from the Louisiana Community Engagement Alliance

BACKGROUND

Diverse, equitable and inclusive participation in clinical research is needed to ensure evidence-based clinical practice and lessen disparities in health outcomes. Yet, clinical trial participation remains critically low in minoritized communities, particularly among Blacks. The Louisiana Community Engagement Alliance against COVID-19 Disparities (LA-CEAL) was launched in response to the disproportionate impact of COVID-19 on Black Louisianans to understand community barriers and preferences and increase inclusive participation in research. This study aims to understand perceptions regarding COVID-19 trial participation among underrepresented Louisianans.

METHODS

A rapid assessment integrating cross-sectional, surveys among federally qualified health center (FQHC) patients and community residents, and focus group discussions (FGDs) from community representatives was conducted in 2020-2021. Factors and perceptions underlying trial participation were identified using logistic regression models and thematic analyses, respectively.

RESULTS

Quantitative findings (FQHC: N=908, mean age=46.6 years, 66.4% Black; community: N=504, mean age=54.2 years, 93.7% Black) indicated that 0.9% and 3.6%, respectively, ever participated in a COVID-19 trial. Doctors/Healthcare providers were most trusted (FQHC=55.1%; community=59.3%) sources of information about trials. Advancing age was associated with increased odds of being very willing to participate (ORFQHC=1.03, 95% CI 1.02-1.05; ORCommunity=1.02, 95% CI 1.00-1.04). Qualitative data (6 FGDs, 29 attendees) revealed limited awareness, experimentation/exploitation-based fears, and minimal racial/ethnic representation among trialists as barriers to participation.

CONCLUSION

COVID-19 trial participation rates were low in our sample. Altruism was a key facilitator to participation; fear, mistrust, and low awareness were predominant barriers. Community-centered approaches, engaging informed providers and trusted community members, may facilitate inclusive trial participation.

Trends in Mental Health Utilization Before and During the COVID-19 Pandemic: Federally Qualified Health Centers As a Case Study

This study examined differential mental health utilization patterns before and during the COVID-19 pandemic. Data were obtained from 12 Federally Qualified Health Center (FQHC)-behavioral health clinics and included 65,561 visits between February 2019 and November 2020 for adults aged 18-64 years. To allow for a year-over-year comparison, the pre-COVID-19 period was flagged as visits between February 2019 and November 2019 and the peri-COVID-19 period as visits between February 2020 and November 2020. A difference-in-difference model with Poisson regression was used to predict racial/ethnic differences in the number of visits between the pre- and peri-COVID-19 periods. Overall, the average number of visits per patient increased from 5.45 visits in the pre-COVID period to 5.78 visits in the peri-COVID-19 period. Hispanics had +0.6 visits, Blacks had +0.3 visits, and other racial groups had +0.9 visits during the peri-COVID-19 period than the pre-COVID-19 period. In contrast, Whites (-0.6 visits) and Asians (-1.7 visits) were less likely to use mental health services in these FQHC clinics in the peri-COVID-19 period as compared with the pre-COVID-19 period. Peri-COVID-19 utilization rates were significantly higher for virtual visits (incident-rate ratio [IRR] = 1.15, P < 0.01) and residence in a metropolitan area (IRR = 1.14, P < 0.01), but lower for persons aged 55+ years (IRR = 0.92, P < 0.01) and males (IRR = 0.87, P < 0.01). Racial/ethnic minority patients, except Asians, were more likely to use mental health services during the COVID-19 pandemic than in the preceding year. This may be attributable to policy changes such as the CARES Act, which expanded health care access options to include telemedicine.

All of Us and the Promise of Precision Medicine: Achieving Equitable Access for Federally Qualified Health Center Patients

The United States National Institutes of Health's (NIH) All of Us (AoU) initiative recruits participants from diverse backgrounds to improve the makeup of biobanks, considering nearly all biospecimens used in research come from people of European ancestry. Participants who join AoU consent to provide samples of blood, urine, and/or saliva and to submit their electronic health record to the program. In addition to diversifying precision medicine research studies, AoU will return genetic results back to many participants, which may require further follow-up care (i.e., more frequent cancer screening or mastectomy after a BRCA result). To help achieve its goals, AoU has partnered with Federally Qualified Health Centers (FQHCs), which is a type of community health center whose patient base is comprised largely of people who are uninsured, underinsured, or on Medicaid. Our NIH-funded study convened FQHC providers involved in AoU to better understand precision medicine in community health settings. Drawing from our findings, we present barriers community health patients and their providers face when accessing diagnostics and specialty care after genetic results necessitate medical follow-up care. We also propose several policy and financial recommendations to help overcome the challenges discussed, stemming from a commitment to equitable access to precision medicine advances.

Health Center Leadership Perspectives Regarding Barriers to and Facilitators of Providing Culturally Responsive Care for Sexual and Gender Minority Patients

Purpose: This study identified barriers and facilitators associated with providing culturally responsive care for sexual and gender minority (SGM) patients at federally qualified health centers (FQHCs) in the United States, from the perspective of clinical leadership. Methods: Between July and December 2018, 23 semistructured, in-depth qualitative interviews were held with clinical leaders representing six FQHCs residing in rural and urban settings. Stakeholders included Chief Executive Officer, Executive Director, Chief Medical Officer, Medical Director, Clinic Site Director, and Nurse Manager positions. Interview transcripts were analyzed using inductive thematic analysis. Results: Barriers included personnel factors related to lack of training and fear, competing priorities, and environments that focused on treating all patients similarly. Facilitators included established partnerships with external organizations, staff with prior SGM training and knowledge, and active initiatives in clinic settings targeting SGM care. Conclusions: Clinical leadership expressed strong support for evolving their FQHCs into organizations that provide culturally responsive care for their SGM patients. FQHC staff across all levels of clinical care would benefit from regularly occurring training sessions on culturally responsive care for SGM patients. To ensure sustainability, improve staff buy-in, and mitigate the impact of staff turnover, improving culturally competent care for SGM patients should be a shared goal and responsibility for leadership, medical providers, and administrative staff. CTN Registration: NCT03554785.

Utilization Gaps During the COVID-19 Pandemic: Racial and Ethnic Disparities in Telemedicine Uptake in Federally Qualified Health Center Clinics

BACKGROUND

The Coronavirus Aid, Relief, and Economic Security (CARES) Act led to the rapid implementation of telemedicine across healthcare office settings. This innovation has the potential to improve healthcare use and ensure continuity of care. However, this delivery model could have an unintended consequence of worsening racial/ethnic disparities in healthcare utilization if adoption varies across sub-populations.

OBJECTIVE

To examine associations between telemedicine use and race/ethnicity between 3/1/2020 and 11/30/2020, and the influence of other individual- and geographical-level factors on this relationship.

DESIGN

Cohort study PARTICIPANTS: EMR data from 55 clinics in a FQHC network MAIN MEASURES: The dependent variable was visit type (in-person vs. telemedicine). Predictors of interest were patient race and ethnicity. To account for repeated visits within each patient nested within clinic, a three-level, mixed-effects, multivariable, logistic regression model was used. Subgroup analyses examined correlates of telemedicine use in African American and Hispanic cohorts, separately.

KEY RESULTS

The analytic sample included 233,302 visits for 67,733 unique patients. African Americans (OR = 0.65, 95% CI: 0.61, 0.69), Asians (OR = 0.58, 95% CI: 0.52, 0.65), and American Indians / Alaska Natives and other Pacific Islanders (OR = 0.82, 95% CI: 0.70, 0.98) were significantly less likely to use telemedicine compared to Whites. Hispanics were also less likely to have a telemedicine visit (OR = 0.49, 95% CI: 0.47, 0.51) compared to non-Hispanics. Nonacute visits were more likely to be conducted via telemedicine. Distance to clinic exhibited a dose-response relationship such that patients who lived farthest from the clinics were most likely to have telemedicine visits. In the subgroup analyses to examine predictors of telemedicine use, the dose-response relationship between distance from clinic and telemedicine use persisted, with increasing distance associated with increasing likelihood of telemedicine use, in both African American and Hispanic cohorts. Nonacute visits were associated with telemedicine use in the Hispanic cohort, but not in the Black / African American cohort.

CONCLUSION

Racial/ethnic disparities in telemedicine use persisted among this cohort. However, telemedicine improved utilization for African Americans and Hispanics living farther away from the clinic.

A Lung Cancer Screening Education Program Impacts both Referral Rates and Provider and Medical Assistant Knowledge at Two Federally Qualified Health Centers

BACKGROUND

Federally Qualified Health Centers (FQHCs) serve minority and low-socioeconomic populations and provide care to high-risk smokers. These centers frequently experience barriers, including low provider and medical assistant (MA) knowledge around lung cancer screening (LCS). Subsequent low LCS referral rates by providers at FQHCs limit utilization of LCS in eligible, high-risk, underserved patients.

METHODS

Providers and MAs from two FQHCs participated in a LCS educational session. A pre-educational survey was administered at the start of the session and a post-educational survey at the end. The intervention included a presentation with education around non-small cell lung cancer, LCS, tobacco cessation, and shared-decision making. Both surveys were used to evaluate changes in provider and MA ability to determine eligible patients for LCS. The Pearson's Chi-squared test with Yates' continuity correction was used to measure the impact.

RESULTS

A total of 29 providers and 28 MAs enrolled in the study from two FQHCs. There was an improvement, P < .009 and P < .015 respectively, in provider and MA confidence in identifying patients for LCS. Additionally, one year prior to the program, 9 low-dose computed tomography (LDCTs) were ordered at one of the FQHCs and 0 at the other. After the program, over 100 LDCTs were ordered at each FQHC.

CONCLUSIONS

A targeted LCS educational program improves provider and MAs' ability to identify eligible LCS patients and is associated with an increase in the number of patients referred to LDCT at FQHCs.

Integration is opening the door to a new journey toward oral health value-based care

Oral health is a key component of overall health and there is a cost to not including it in the value-based transformation conversation. Health care needs to break down the silos that exist between dentistry and medicine so we can leverage integration to achieve value-based care.

Much More than a Clinic: Chicago's Free Health Centers 1968-1972

Drawing on archival evidence, I document the emergence and florescence of three free health clinics in Chicago in the late 1960s. I trace the centers' forceful removal by the city's Board of Health, and their subsequent replacement by Federally Qualified Health Centers (FHQCs). I argue that the demise of the free centers is exemplary of a broader trend in US health policy of regulating and diminishing the health care options of poor Americans. By highlighting the stark contrast between Chicago's free health centers of the 1960s and the health care services offered by contemporary FQHCs, I reveal a gradual shift from health care rights to accessing care in the US health care safety net.

An Assessment Model for Evaluating Outcomes in Federally Qualified Health Centers' Dental Departments: Results of a 5 Year Study

PURPOSE

The purpose of this report was to establish baseline data on 10 oral health performance indicators over 5 fiscal years (2007 to 2008 through 2011 to 2012) for an Iowa health center. The baseline data provides an assessment model and reports outcomes based on the use of the model. Performance indicators show evidence of provider performance, accountability to stakeholders and provide the benchmarks required for dental management to develop future goals to improve oral health outcomes for atrisk populations.

METHODS

Using descriptive statistic, this report extrapolated data from the Iowa Health Center's computer management systems software, HealthPro, and Centricity electronic medical records, and analyzed using IBM® SPSS® 19. This report describes the change in utilization for number and type of visits for uninsured and Medicaid patients over 5 fiscal years (a fiscal year is measured from November 1 through October 31).

RESULTS

The number of patients receiving at least 1 dental visit in a measurement year showed n=81,673 procedures with 21% (17,167) being unduplicated patients. Preventive averaged 46%, restorative 18%, urgent care 22% and other procedures 14%.

CONCLUSION

Federally qualified health centers (FQHCs) with a dental component serve populations with the greatest health disparities. This population includes ethnic and racial minorities, uninsured, underinsured, rural residents, Medicaid and Medicare. Establishing baseline data for FQHCs provides a foundational tool that will allow dental management to analyze successes as well as deficiencies in the goal to provide increased utilization to oral health care for at-risk populations.

An Assessment Model for Evaluating Outcomes in Federally Qualified Health Centers' Dental Departments: Results of a 5 Year Study

PURPOSE

The purpose of this report was to establish baseline data on 10 oral health performance indicators over 5 fiscal years (2007 to 2008 through 2011 to 2012) for an Iowa health center. The baseline data provides an assessment model and reports outcomes based on the use of the model. Performance indicators show evidence of provider performance, accountability to stakeholders and provide the benchmarks required for dental management to develop future goals to improve oral health outcomes for at-risk populations.

METHODS

Using descriptive statistic, this report extrapolated data from the Iowa Health Center's computer management systems software, HealthPro, and Centricity electronic medical records, and analyzed using IBM® SPSS® 19. This report describes the change in utilization for number and type of visits for uninsured and Medicaid patients over 5 fiscal years (a fiscal year is measured from November 1 through October 31).

RESULTS

The number of patients receiving at least 1 dental visit in a measurement year showed n=81,673 procedures with 21% (17,167) being unduplicated patients. Preventive averaged 46%, restorative 18%, urgent care 22% and other procedures 14%.

CONCLUSION

Federally qualified health centers (FQHCs) with a dental component serve populations with the greatest health disparities. This population includes ethnic and racial minorities, uninsured, underinsured, rural residents, Medicaid and Medicare. Establishing baseline data for FQHCs provides a foundational tool that will allow dental management to analyze successes as well as deficiencies in the goal to provide increased utilization to oral health care for at-risk populations.

Community health center efficiency: the role of grant revenues in health center efficiency

OBJECTIVE

To test the relationship between external environments, organizational characteristics, and technical efficiency in federally qualified health centers (FQHCs). We tested the relationship between grant revenue and technical efficiency in FQHCs.

DATA SOURCES/STUDY DESIGN

Secondary data were collected in each year from the Uniform Data System (UDS) on 644 eligible U.S.-based FQHCs between 2005 and 2007. The study employs a retrospective longitudinal cohort design with instrumental variables.

PRINCIPAL FINDINGS

Increased grant revenues did not increase the probability that a health center would be on the efficiency frontier. However, increased grant revenues had a negative association with technical efficiency for health centers that were not fully efficient.

CONCLUSION

If all health centers were operating efficiently, anywhere from 39 to 45 million patient encounters could have been delivered instead of the actual total of 29 million in 2007. Policy makers should consider tying grant revenues to performance indicators, and future work is needed to understand the mechanisms through which diseconomies of scale are present in FQHCs.