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Introduction: Multimorbidity - having 2 or more chronic diseases - is a national public health concern that entails burdensome and costly care for patients, their families, and public health programs. Adults residing in socially deprived areas often have limited access to social and material resources. They also experience a greater multimorbidity burden., Methods: We conducted a retrospective cohort analysis of electronic health record (EHR) data from 678 community-based health centers (CHCs) in 27 states from the Accelerating Data Value Across a National Community Health Center (ADVANCE) Network, a clinical research network, from 2012-2019. We used mixed-effects Poisson regression to examine the relationship of area-level social deprivation (eg, educational attainment, household income, unemployment) to chronic disease accumulation among a sample of patients aged 45 years or older (N = 816,921) residing across 9,362 zip code tabulation areas and receiving care in safety-net health organizations., Results: We observed high rates of chronic disease among this national sample. Prevalence of multimorbidity varied considerably by geographic location, both within and between states. People in more socially deprived areas with Social Deprivation Index (SDI) scores in quartiles 2, 3, and 4 had greater initial chronic disease counts - 17.1%, 17.7%, and 18.0%, respectively - but a slower rate of accumulation compared with people in the least-deprived quartile. Our findings were consistent for models of the composite SDI and those evaluating disaggregated measures of area-level educational attainment, household income, and unemployment., Conclusion: Social factors play an important role in the development and progression of multimorbidity, which suggests that an assessment and understanding of area-level social deprivation is necessary for developing public health strategies to address multimorbidity.

Objective: To pilot test the COMmunity of Practice And Safety Support for Navigating Pain (COMPASS-NP) intervention for home care workers experiencing chronic pain., Methods: Home care workers with chronic pain participated (n = 19; 2 groups) in a 10-week online group program focused on workplace safety and pain self-management. Primary outcomes were changes in pain interference with work and life. Other outcomes related to ergonomics, pain levels, opioid misuse risk, mental health, sleep, and physical activity., Results: The intervention produced a large reduction in pain interference with life ( d = -0.85) and a moderate reduction in pain interference with work time demands ( d = -0.61). Secondary outcomes showed favorable effect sizes, including a substantial increase in the use of ergonomic tools and techniques ( d = 1.47)., Conclusion: Findings were strongly encouraging. The effectiveness of COMPASS-NP will be evaluated in a future randomized controlled trial., Competing Interests: Conflict of interest: None declared., (Copyright © 2024 American College of Occupational and Environmental Medicine.)

Background: Metformin treatment is a recommended first-line medication for patients with type 2 diabetes. Latino patients are subject to factors that may modify their level of diabetes care, including medication prescription. We evaluated the odds of and times to metformin prescription among non-Latino whites, English-preferring Latinos, and Spanish-preferring Latinos with diabetes., Methods: We constructed a retrospective cohort of 154,368 adult patients from 835 community health centers (CHCs) across 20 states who were diagnosed with diabetes during the study. Patients were from non-Latino white, English-preferring Latino, and Spanish-preferring Latino ethnic/language groups. We modeled adjusted odds of metformin prescription and adjusted hazards (time-to-event) of metformin prescription after diabetes diagnosis and high hemoglobin A1c (HbA1c > 9) test results., Results: English-preferring Latinos had similar odds of metformin prescription (Odds Ratio (OR) = 1.01 (95% CI = 0.93, 1.09)), slightly lower time to metformin prescription after diabetes diagnosis (Hazard Ratio (HR) = 1.06(95% CI = 1.04, 1.09)), and similar time to metformin prescription after a high HbA1c result (HR = 1.04 (0.99, 1.09)) compared to non-Latino whites. Spanish-preferring Latinos had higher odds of metformin prescription (OR) = 1.42 (95% CI = 1.33, 1.52), and less time to prescription after diabetes diagnosis (HR = 1.18 (1.15, 1.20)) and after a high HbA1c result (HR = 1.15 (1.11, 1.20))., Conclusions: Our analysis of metformin prescription patterns among non-Latino whites, English-preferring Latinos, and Spanish-preferring Latinos did not suggest a lower or slower tendency to prescribe metformin in Latino patients. Understanding disparities in diabetes diagnosis may require further investigation of medication adherence barriers, diet and exercise counseling, and multi-level influences on diabetes outcomes in Latino patients., Competing Interests: Declaration of competing interest The authors have no relevant financial or non-financial interests to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Studies assessing equity in the prevention of atherosclerotic cardiovascular disease (ASCVD) for Latinos living in the USA collectively yield mixed results. Latino persons are diverse in many ways that may influence cardiovascular health. The intersection of Latino nativity and ASCVD prevention is understudied., Objective: To determine whether disparities in ASCVD screening, detection, and prescribing differ for US Latinos by country of birth., Design: A retrospective cohort design utilizing 2014-2020 electronic health record data from a network of 320 community health centers across 12 states. Analyses occurred October 1, 2022, to September 30, 2023., Participants: Non-Hispanic White and Latino adults age 20-75 years, born in Cuba, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, and the USA., Exposures: Ethnicity and country of birth., Main Measures: Outcome measures included prevalence of statin eligibility, of having insufficient data to establish eligibility, odds of having a documented statin prescription, and rates of statin prescriptions and refills. We used covariate-adjusted logistic and generalized estimating equations logistic and negative binomial regressions to generate absolute and relative measures., Key Results: Among 108,672 adults, 23% (n = 25,422) were statin eligible for primary or secondary prevention of ASCVD using American College of Cardiology/American Heart Association guidelines. Latinos, born in and outside the USA were more likely eligible than Non-Hispanic White patients were (US-born Latino OR = 1.55 (95% CI = 1.37-1.75); non-US-born Latino OR = 1.63 (95% CI = 1.34-1.98)). The eligibility criteria that was met differed by ethnicity and nativity. Latinos overall were less likely missing data to establish eligibility and differences were again observed by specific non-US country of origin. Among those eligible, we observed no statistical difference in statin prescribing between US-born Latinos and non-Hispanic White persons; however, disparities varied by specific non-US country of origin., Conclusion: Efforts to improve Latino health in the USA will require approaches for preventing and reversing cardiovascular risk factors, and statin initiation that are Latino subgroup specific., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: Nontuberculous mycobacteria are environmental organisms that are increasingly causing chronic and debilitating pulmonary infections, of which Mycobacterium avium complex (MAC) is the most common pathogen. MAC pulmonary disease (MAC-PD) is often difficult to treat, often requiring long-term multidrug antibiotic therapy., Research Question: Is there an association between various guideline-based three-drug therapy (GBT) regimens and (1) therapy-associated adverse events or (2) regimen change/discontinuation, within 12 months of therapy initiation?, Study Design and Methods: In a retrospective cohort study, we examined tolerability outcomes of GBT regimens for MAC-PD in 4,626 US Medicare beneficiaries with bronchiectasis, who were prescribed a GBT as initial antibiotic treatment for presumed MAC-PD during 2006 to 2014. Using multivariable Cox proportional hazard regression, we estimated adjusted hazard ratios (aHRs) to compare the risk of adverse events and regimen change/discontinuations within 12 months of therapy initiation in various GBT regimens., Results: The cohort had a mean age ± SD of 77.9 ± 6.1 years at treatment start, were mostly female (77.7%), and were mostly non-Hispanic White (87.2%). The risk of regimen change/discontinuation within 12 months of therapy was higher for clarithromycin-based regimens than azithromycin-based regimens (aHR, 1.12; 95% CI, 1.04-1.20 with rifampin; aHR, 1.11; 95% CI, 0.93-1.32 with rifabutin as the companion rifamycin), and for rifabutin-containing regimens than rifampin-containing regimens (aHR, 1.49; 95% CI, 1.33-1.68 with azithromycin; aHR, 1.47; 95% CI, 1.27-1.70 with clarithromycin as the companion macrolide). The aHR comparing regimen change/discontinuation with clarithromycin-ethambutol-rifabutin and azithromycin-ethambutol-rifampin was 1.64 (95% CI, 1.43-1.64)., Interpretation: Overall, an azithromycin-based regimen was less likely to be changed or discontinued than a clarithromycin-based regimen, and a rifampin-containing regimen was less likely to be changed or discontinued than a rifabutin-containing regimen within 12 months of therapy start. Our work provides a population-based assessment on the tolerability of multidrug antibiotic regimens used for the treatment of MAC-PD., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: E. H. has served on an advisory board for AN2 pharmaceuticals and received consult fees. K. L. W. has grants or contracts from Insmed; and has received consulting fees from Insmed, Paratek, RedHill Biopharma, Spero Therapeutics, and AN2 pharmaceuticals. T. K. M. has grants or contracts from Insmed, the Centered Outcomes Research Institute, and the Lung Health Foundation; has received consulting fees from Insmed, RedHill Biopharma, and Spero Therapeutics; has received payment or honoraria from France Foundation, Astra Zeneca, Novartis, and Insmed; and has a leadership or fiduciary role in the Toronto NTM patient group. None declared (J. H. K., K. F. C., M. M., S. K. B.)., (Copyright © 2023 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Machine learning (ML) approaches could expand the usefulness and application of implementation science methods in clinical medicine and public health settings. The aim of this viewpoint is to introduce a roadmap for applying ML techniques to address implementation science questions, such as predicting what will work best, for whom, under what circumstances, and with what predicted level of support, and what and when adaptation or deimplementation are needed. We describe how ML approaches could be used and discuss challenges that implementation scientists and methodologists will need to consider when using ML throughout the stages of implementation., (©Nathalie Huguet, Jinying Chen, Ravi B Parikh, Miguel Marino, Susan A Flocke, Sonja Likumahuwa-Ackman, Justin Bekelman, Jennifer E DeVoe. Originally published in the Online Journal of Public Health Informatics (https://ojphi.jmir.org/), 22.04.2024.)

Objective: Disparities in U.S. mental health care by race and ethnicity have long been documented. The authors sought to compare specialty mental health service use among non-Hispanic White, English-preferring Hispanic, and Spanish-preferring Hispanic patients who accessed care in community health centers (CHCs)., Methods: Retrospective electronic medical records data were extracted for patients ages ≥18 years who received care in 2012-2020 at a national CHC network. Zero-inflated Poisson regression models were used to estimate the likelihood of receiving mental health services, which was compared with expected annual rates of mental health service use., Results: Of the 1,498,655 patients who received care at a CHC during the study, 14.4% (N=215,098) received any specialty mental health services. English- and Spanish-preferring Hispanic patients were less likely to have had a mental health visit (OR=0.69, 95% CI=0.61-0.77, and OR=0.65, 95% CI=0.54-0.78, respectively). Compared with non-Hispanic White patients, Spanish-preferring Hispanic patients had an estimated annualized rate of 0.59 (95% CI=0.46-0.76) mental health visits., Conclusions: Among patients who were likely to receive specialty mental health services, Spanish-preferring patients had a significantly lower rate of mental health care use. Although overall access to mental health care is improving, unequal access to recurring specialty mental health care remains among patients who do not prefer to use English., Competing Interests: Dr. Byhoff reports receiving fees from the Patient-Centered Outcomes Research Institute and Kaiser Permanente. Dr. Heintzman reports being a contract employee with OCHIN, Inc. The other authors report no financial relationships with commercial interests.

Background: Neighbourhood walkability can benefit cardiovascular health. Latino patients are more likely than non-Hispanic White patients to have diabetes, and evidence has shown better diabetes-related outcomes for patients living in neighbourhoods conducive to physical activity. Our objective was to determine whether neighbourhood walkability was associated with haemoglobin A1c (HbA1c) levels among English- and Spanish-preferring Latino patients compared to non-Hispanic White patients., Methods: We used electronic health record data from patients in the OCHIN, Inc. network of community health centres (CHC) linked to public walkability data. Patients included those age ≥ 18 with ≥ 1 address recorded, with a study clinic visit from 2012 to 2020, and a type 2 diabetes diagnosis (N = 159,289). Generalized estimating equations logistic regression, adjusted for relevant covariates, was used to model the primary binary outcome of always having HbA1c < 7 by language/ethnicity and walkability score., Results: For all groups, the walkability score was not associated with higher odds and prevalence of always having HbA1c < 7. Non-Hispanic White patients were most likely to have HbA1c always < 7 (prevalence ranged from 32.8% [95%CI = 31.2-34.1] in the least walkable neighbourhoods to 33.4% [95% CI 34.4-34.7] in the most walkable), followed by English-preferring Latinos (28.6% [95%CI = 25.4-31.8]-30.7% [95% CI 29.0-32.3]) and Spanish-preferring Latinos (28.3% [95% CI 26.1-30.4]-29.3% [95% CI 28.2-30.3])., Conclusions: While walkability score was not significantly associated with glycaemic control, control appeared to increase with walkability, suggesting other built environment factors, and their interaction with walkability and clinical care, may play key roles. Latino patients had a lower likelihood of HbA1c always < 7, demonstrating an opportunity for equity improvements in diabetes care., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Studies analyzing blood pressure (BP) management using the hypertension control cascade have consistently shown disparities in hypertension awareness, treatment, and BP control between Latino patients and non-Latino White patients. We analyze this cascade using electronic health record data from a multistate network of community health centers., Methods and Results: Data from 790 clinics in 23 US states from 2012 to 2020, including 1 270 174 patients, were analyzed to compare BP documentation in the electronic health record, clinician acknowledgment (diagnosis or treatment) of incident hypertension (BP ≥140/90), medication prescription, and BP control between non-Latino White patients, English-preferring Latino patients, and Spanish-preferring Latino patients, adjusted for patient-level covariates, and clustered on patients' primary clinics. Among the 429 182 patients with elevated BP (≥140/90) during ambulatory visits from 2012 to 2020, we found that clinician acknowledgment of hypertension was more likely in Spanish-preferring and English-preferring Latino patients versus non-Latino White patients (adjusted odds ratio [aOR], 1.17 [95% CI, 1.11-1.24]; aOR, 1.07 [95% CI, 1.02-1.12], respectively). In addition, Spanish-preferring Latino patients were more likely to receive a medication versus non-Latino White patients (aOR, 1.21 [95% CI, 1.16-1.28]). Among those receiving medication, Latino patients were as likely as non-Latino White patients to have their BP controlled (<140/90)., Conclusions: In a large retrospective study of community health center patients with incident hypertension, the expected disparities in hypertension management between Spanish-preferring Latino, English-preferring Latino, and non-Latino White patients were not identified. These findings add to the hypertension control cascade by examining robust electronic health record data from community health centers and may provide clues to reducing disparities in hypertension management.

Latino children of Migrant and Seasonal Farmworkers (MSFWs) with asthma are at risk for poor health outcomes due to medical access barriers. We compared differences in acute care utilization for asthma exacerbations among migrant and non-migrant Latino and non-Hispanic white (NHW) children at U.S. community health centers. A retrospective observational study utilizing electronic health record data from the ADVANCE Clinical Research Network of United States community health centers included 13,423 children ages 3-17 with a primary care visit between 2005 and 2017 from eight states. Emergency department (ED) and hospitalization data came from Oregon Medicaid claims. Outcomes included acute clinic visits, ED visits, and hospitalizations for asthma exacerbation. Regression analyses adjusted for patient-level covariates. Latino children had higher odds of acute clinic visits for asthma exacerbation compared to NHW children (MSFW odds ratio [OR] = 1.17, 95 % CI = 1.03-1.33; without migrant status OR = 1.13, 95 % CI = 1.03-1.23). MSFW children using Oregon Medicaid had fewer ED visits (rate ratio [RR] = 0.72, 95 % CI = 0.52-0.99) and hospitalizations (RR = 0.47, 95 % CI = 0.26-0.86) compared to NHW children. Increased community health center visits may help mitigate disparities in acute asthma care for MSFW children., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Objective: To determine whether electronic health record (EHR) documentation of certain early childhood risk factors for asthma, such as wheeze differ by race, ethnicity, and language group, and whether these children have different subsequent asthma prevalences., Methods: We used EHR data from the Accelerating Data Value Across a National Community Health Center (ADVANCE) Clinical Research Network from children receiving care in US community health centers (n = 71,259 children) across 21 states to examine the presence of ICD-coded documentation of early childhood wheeze and its association with subsequent asthma diagnosis documentation in the EHR by race/ethnicity/language., Results: ICD-coded wheeze was present in 2 to 3% of each race/ethnicity/language group. Among the total sample, 18.5% had asthma diagnosed after age 4. The adjusted prevalence of subsequent asthma diagnosis was greater in children with wheeze than those without. Odds of asthma diagnosis did not differ among children in all race/ethnicity/language groups with early childhood wheeze. Non-Latino Black children without wheeze had higher odds of asthma (OR = 1.19, 95% CI = 1.08-1.32) compared with non-Latino White children without wheeze., Discussion: In US community health centers which serve medically underserved populations, EHR documentation of early childhood wheeze was uncommon and did not differ significantly among race/ethnicity/language groups. Differences in asthma diagnosis in Latinos may not stem from differences in early-life wheeze documentation. However, our findings suggest that there may be opportunities for improvement in early asthma symptom recognition for non-Latino Black children, especially in those without early childhood wheeze., Competing Interests: Conflict of interest: The authors have no conflicts of interest., (© Copyright by the American Board of Family Medicine.)

Cancer is the top leading cause of death among Latino people. Lack of health insurance is a significant contributor to inadequate cancer detection and treatment. Despite healthcare policy expansions such as the Affordable Care Act, Latino people persistently maintain the highest uninsured rate among any ethnic and racial group in the US, especially among Latino individuals who are immigrants or part of a mixed immigration status household. Recognizing that immigration status is a critical factor in the ability of Latino community members to seek health insurance and access healthcare services, a few US states and the District of Columbia have implemented policies that have expanded coverage to children and adults regardless of immigration status. Expansion of Medicaid eligibility regardless of immigration status may significantly benefit Latino communities, however the facilitators and barriers to enrolling in these programs need to be evaluated to ensure reach and achieve health equity across the cancer control continuum for all Latinos., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To describe telemedicine use patterns and understand clinic's approaches to shifting care delivery during the COVID-19 pandemic., Methods: We used electronic health record data from 203 community health centers across 13 states between 01/01/2019 and 6/31/2021 to describe trends in telemedicine visit rates over time. Qualitative data were collected from 13 of those community health centers to understand factors influencing adoption and implementation of telemedicine., Results: Most clinics in our sample were in urban areas (n = 176) and served a majority of uninsured and publicly insured patients (12.8% and 44.4%, respectively) across racial and ethnic minority groups (16.6% Black and 29.3% Hispanic). During our analysis period there was a 791% increase in telemedicine visits from before the pandemic (.06% pre- vs 47.5% during). A latent class growth analysis was used to examine differences in patterns of adoption of telemedicine across the 203 CHCs. The model resulted in 6 clusters representing various levels of telemedicine adoption. A mixed methods approach streamlined these clusters into 4 final groups. Clinics that reported rapid adoption of telemedicine attributed this change to leadership prioritization of telemedicine, robust quality improvement processes (eg, using PDSA processes), and emphasis on training and technology support., Conclusions: In response to the COVID-19 pandemic, telemedicine adoption rates varied across clinics. Our study highlight that organizational factors contributed to the clinic's ability to rapidly uptake and use telemedicine services throughout the pandemic. These approaches could inform future non-pandemic practice change and care delivery., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction/objectives: With growing vaccination misinformation and mistrust, strategies to improve vaccination communication across community-based settings are needed., Methods: The Rural Adolescent Vaccine Enterprise (RAVE), a 5-year (2018-2022) stepped-wedge cluster randomized study, tested a clinic-based practice facilitation intervention designed to improve HPV vaccination. An exploratory aim sought to explore the use of partnerships between primary care clinics and a community partner of their choosing, to implement a social marketing campaign related to HPV immunization. We assessed perceptions about the value and success of the partnership, and barriers and facilitators to its implementation using a 29-item community partner survey, key informant interviews, and field notes from practice facilitators., Results: Of the initial 45 clinics participating in RAVE, 9 were unable to either start or complete the study, and 36 participants (80.0%) were actively engaged. Of these, 16/36 clinics (44.4%) reported establishing successful partnerships, 10 reported attempting to develop partnerships (27.8%), and another 10 reported not developing a partnership (27.8%), which were often caused by the COVID-19 pandemic. The most common partnership was with public health departments at 27.3%. Other partnerships involved libraries, school districts, and local businesses. More than half (63.7%) reported that creating messages regarding getting HPV vaccination was moderately to very challenging. Just under half reported (45.5%) that messaging was hard because of a lack of understanding about the seriousness of diseases caused by HPV, parents being against vaccines because of safety concerns, and religious values that result in a lack of openness to HPV vaccines. Community partners' health priorities changed as a result of RAVE, with 80% prioritizing childhood immunizations as a result of the RAVE partnership., Conclusions: Community groups want to partner with primary care organizations to serve their patients and populations. More research is needed on how best to bring these groups together., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives. To provide initial findings from Community Engagement Alliance (CEAL), a multistate effort funded by the National Institutes of Health, to conduct urgent community-engaged research and outreach focused on COVID-19 awareness, education, and evidence-based response. Methods. We collected survey data (November 2020-November 2022) from 21 CEAL teams from 29 state and regional CEAL sites spanning 19 US states, the District of Columbia, and Puerto Rico, which covered priority populations served and trusted sources of information about COVID-19, including prevention behaviors, vaccination, and clinical trials. Results. A disproportionate number of respondents were Latino (45%) or Black (40%). There was considerable variability between CEAL sites regarding trusted sources of information, COVID-19 prevention, and COVID-19 vaccination. For example, more respondents (70%) reported health care providers as a trusted source of COVID-19 information than any other source (ranging from 6% to 87% by site). Conclusions. CEAL rapidly developed novel infrastructure to engage academic, public health, and community organizations to address COVID-19's impacts on underserved communities. CEAL provides an example of how to respond in future public health emergencies to quickly promote trustworthy, evidence-based information in ways that advance health equity. ( Am J Public Health . 2024;114(S1):S112-S123. https://doi.org/10.2105/AJPH.2023.307504).

Objectives. To examine whether workplace interventions to increase workplace flexibility and supervisor support and decrease work-family conflict can reduce cardiometabolic risk. Methods. We randomly assigned employees from information technology (n = 555) and long-term care (n = 973) industries in the United States to the Work, Family and Health Network intervention or usual practice (we collected the data 2009-2013). We calculated a validated cardiometabolic risk score (CRS) based on resting blood pressure, HbA 1c (glycated hemoglobin), HDL (high-density lipoprotein) and total cholesterol, height and weight (body mass index), and tobacco consumption. We compared changes in baseline CRS to 12-month follow-up. Results. There was no significant main effect on CRS associated with the intervention in either industry. However, significant interaction effects revealed that the intervention improved CRS at the 12-month follow-up among intervention participants in both industries with a higher baseline CRS. Age also moderated intervention effects: older employees had significantly larger reductions in CRS at 12 months than did younger employees. Conclusions. The intervention benefited employee health by reducing CRS equivalent to 5 to 10 years of age-related changes for those with a higher baseline CRS and for older employees. Trial Registration. ClinicalTrials.gov Identifier: NCT02050204. ( Am J Public Health. 2023;113(12):1322-1331. https://doi.org/10.2105/AJPH.2023.307413).

Objective: The aim of the study was to evaluate the effectiveness of interventions to improve sleep, reduce fatigue, and advance the well-being of team truck drivers., Methods: In a randomized controlled trial ( k = 24 teams; N = 49 drivers; 61.3% of planned sample), intervention teams were exposed to baseline (3-4 weeks), cab enhancements (active suspension seat, therapeutic mattress; 3-4 weeks), and cab enhancements plus a behavioral sleep-health program (1-2 months). Control teams worked as usual during the same period., Results: Trends in sleep-related outcomes favored the intervention. Large and statistically significant intervention effects were observed for objectively measured physical activity (a behavioral program target). The discussion of results addresses effect sizes, statistical power, intervention exposure, and work organization., Conclusions: Trends, effect sizes, and significant findings in this rare trial provide valuable guidance for future efforts to improve working conditions and outcomes for team drivers., Competing Interests: Conflicts of interest: P.W.J. is the Chief Executive Officer of Suspension Systems Technologies, a company that owns the intellectual property rights to a vibration-reducing seat technology. This technology was not studied in the current project. Oregon Health & Science University has a significant financial interest in Northwest Education Training and Assessment (or NwETA), a company that may have a commercial interest in the results of this research and technology used in the current article. This potential institutional conflict of interest has been reviewed and managed by Oregon Health & Science University., (Copyright © 2023 American College of Occupational and Environmental Medicine.)

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., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Patients have varying levels of chronic conditions and health insurance patterns as they become Medicare age-eligible. Understanding these dynamics will inform policies and reforms that direct capacity and resources for primary care clinics to care for these aging patients. This study 1) determined changes in chronic condition rates following Medicare age eligibility among patients with different insurance patterns and 2) estimated the number of chronically ill patients who remain inadequately insured post-Medicare eligibility among patients receiving care in community health centers., Method: We used retrospective electronic health record data from 45,527 patients aged 62 to 68 from 990 community health centers in 25 states in 2014 to 2019. Insurance patterns (continuously insured, continuously uninsured, uninsured/discontinuously insured who gained insurance after age 65, lost insurance after age 65, discontinuously insured) and diagnosis of chronic conditions were defined at each visit pre- and post-Medicare eligibility. Difference-in-differences Poisson GEE models estimated changes of chronic condition rates by insurance groups pre- to post-Medicare age eligibility., Results: Post-Medicare eligibility, 72% patients were continuously insured, 14% gained insurance; and 14% were uninsured or discontinuously insured. The prevalence of multimorbidity (≥2 chronic conditions) was 77%. Those who gained insurance had a significantly larger increase in the rate of documented chronic conditions from pre- to post-Medicare (DID: 1.06, 95%CI:1.05-1.07) compared with the continuously insured group., Conclusions: Post-Medicare age eligibility, a significant proportion of patients were diagnosed with new conditions leading to high burden of disease. One in 4 older adults continue to have inadequate health care coverage in their older age., Competing Interests: Conflict of interest: None., (© Copyright by the American Board of Family Medicine.)

Objective: To develop and validate prediction models for inference of Latino nativity to advance health equity research., Data Sources/study Setting: This study used electronic health records (EHRs) from 19,985 Latino children with self-reported country of birth seeking care from January 1, 2012 to December 31, 2018 at 456 community health centers (CHCs) across 15 states along with census-tract geocoded neighborhood composition and surname data., Study Design: We constructed and evaluated the performance of prediction models within a broad machine learning framework (Super Learner) for the estimation of Latino nativity. Outcomes included binary indicators denoting nativity (US vs. foreign-born) and Latino country of birth (Mexican, Cuban, Guatemalan). The performance of these models was compared using the area under the receiver operating characteristics curve (AUC) from an externally withheld patient sample., Data Collection/extraction Methods: Census surname lists, census neighborhood composition, and Forebears administrative data were linked to EHR data., Principal Findings: Of the 19,985 Latino patients, 10.7% reported a non-US country of birth (5.1% Mexican, 4.7% Guatemalan, 0.8% Cuban). Overall, prediction models for nativity showed outstanding performance with external validation (US-born vs. foreign: AUC = 0.90; Mexican vs. non-Mexican: AUC = 0.89; Guatemalan vs. non-Guatemalan: AUC = 0.95; Cuban vs. non-Cuban: AUC = 0.99)., Conclusions: Among challenges facing health equity researchers in health services is the absence of methods for data disaggregation, and the specific ability to determine Latino country of birth (nativity) to inform disparities. Recent interest in more robust health equity research has called attention to the importance of data disaggregation. In a multistate network of CHCs using multilevel inputs from EHR data linked to surname and community data, we developed and validated novel prediction models for the use of available EHR data to infer Latino nativity for health disparities research in primary care and health services research, which is a significant potential methodologic advance in studying this population., (© 2023 Health Research and Educational Trust.)

Background: It is uncertain if the American College of Cardiology/American Heart Association (ACC/AHA) 2013 guidelines for the use of HMGCoA reductase inhibitors (statins) were associated with increased statin eligibility and prescribing across underserved groups., Objective: To analyze, by race, ethnicity, and preferred language, patients with indications for and presence of a statin prescription before and after the guideline change., Design: Retrospective cohort study., Setting: Multistate community health center (CHC) network with linked electronic health records., Patients: Low-income patients aged ≥ 50 with a primary care visit in 2009-2013 or 2014-2018., Main Measures: (1) Odds of each race/ethnicity/language group meeting statin eligibility via the National Cholesterol Education Program Adult Treatment Panel III Guidelines in 2009-2013 or the ACC/AHA guidelines in 2014-2018. (2) Among those eligible, odds of each group in each period with a statin prescription., Key Results: In 2009-2013 (n = 109,330), non-English-preferring Latino (OR = 1.10, 95% CI = 1.03, 1.17), White (OR = 1.41, 95% CI = 1.16, 1.72), and Black patients (OR = 1.25, 95% CI = 1.11, 1.42), were more likely than English-preferring non-Hispanic Whites to meet guideline criteria for statins. Non-English-preferring Black patients, when eligible, were no more likely than non-Hispanic Whites to have statin prescriptions (OR = 1.16, 95% CI = 0.88, 1.54). In 2014-2018 (n = 319,904), English-preferring Latino patients (OR = 1.02, 95% CI = 0.96-1.07) and non-English-preferring Black patients (OR = 1.08, 95% CI = 0.98, 1.19) had similar odds of statin prescription to English-preferring non-Hispanic White patients. English-preferring Black patients were less likely (OR = 0.95, 95% CI = 0.91-0.99) to have a prescription than English-preferring non-Hispanic Whites., Conclusion: Across the 2013 ACC/AHA guideline change in CHCs serving low-income patients, non-English-preferring patients were consistently more likely to be eligible for and have been prescribed statins. English-preferring Latino and English-preferring Black patients experienced reduced prescribing, comparatively, after the guideline change. Further work should explore the contextual factors that may influence guideline effectiveness and care equity., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Introduction: Latinas in the United States have higher mortality from breast cancer, but longitudinal studies of mammography ordering (a crucial initial step towards screening) in primary care are lacking., Methods: We conducted an analysis of mammography order rates in Latinas (by language preference) and non-Latina white women (N = 181,755) over a > 10 year period in a multi-state network of community health centers (CHCs). We evaluated two outcomes (ever having a mammogram order and annual rate of mammography orders) using generalized estimating equation modeling., Results: Approximately one-third of all patients had ever had a mammogram order. Among those receiving mammogram orders, English-preferring Latinas had lower mammogram order rates than non-Hispanic white women (RR = 0.92, 95% CI = 0.89-0.95). Spanish-preferring Latinas had higher odds of ever having a mammogram ordered than non-Hispanic whites (odds ratio = 2.12, 95% CI = 2.06-2.18) and, if ever ordered, had a higher rate of annual mammogram orders (rate ratio = 1.53, 95% CI = 1.50-1.56)., Conclusion: These findings suggest that breast cancer detection barriers in low-income Latinas may not stem from a lack of orders in primary care, but in the subsequent accessibility of receiving ordered services., Competing Interests: Declaration of Competing Interest The authors have no possible, perceived or real financial conflicts of interest., (Copyright © 2023. Published by Elsevier Inc.)

Objective: To examine analgesic methadone prescriptions among community health center (CHC) patients with chronic pain., Design: Observational; two cross-sectional periods., Setting: Oregon and California CHCs., Patients: Chronic pain patients with ≥1 visit in 2012-2013 or 2017-2018 (N = 158,239)., Outcomes: Changes in adjusted relative rates (aRRs) of receiving no opioids, short-acting only, long-acting only other than methadone, and methadone; characteristics associated with ≥1 methadone prescription., Results: Opioid prescribing declined over time, with the largest decrease in methadone (aRR = 0.19, 95 percent confidence interval: 0.14-0.27). Among patients receiving ≥1 long-acting opioid, variables associated with methadone prescribing included being aged <65 years, having nonprivate insurance, and an opioid use disorder (OUD) diagnosis. From 2012-2013 to 2017-2018, aRR increased among patients with OUD and decreased for those aged 18-30 (vs ≥65), uninsured and Medicaid-insured (vs private), and race/ethnicity other than non-Hispanic Black (vs non-Hispanic White)., Conclusions: Methadone prescribing decreased in CHCs but remained elevated for several high-risk demographic groups.

Background: Language concordance between Latinx patients and their clinicians has been shown to affect health outcomes. In addition, there is evidence that consistent continuity of care (COC) can improve health care outcomes. The relationship between language concordance and COC and their association with health equity in chronic disease is less clear. Our aim was to study the moderating effect of clinician and patient language concordance on the association between COC and asthma care quality in Latinx children., Methods: We utilized an electronic health record dataset from a multistate network of community health centers to compare influenza vaccinations and inhaled steroid prescriptions, by ethnicity and language concordance groups overall and stratified by COC., Results: We analyzed electronic health records for children with asthma (n = 38,442) age 3 to 17 years with ≥2 office visits between 2005 to 2017. Overall, 64% of children had low COC (defined as COC < 0.5) while 21% had high COC (defined as >0.75). All Latinx children had higher rates and odds of receiving influenza vaccination compared with non-Hispanic White children. In addition, Spanish-preferring Latinx children had higher rates and odds of being prescribed inhaled steroids while English-preferring Latinx children had lower odds (OR = 0.85 95%CI = 0.73,0.98) compared with non-Hispanic White children., Conclusion: Overall, Latinx children regardless of COC category or language concordance were more likely to receive the influenza vaccine. English-preferring Latinx children with persistent asthma received fewer inhaled steroid prescriptions compared with non-Hispanic White children. Panel chart review and seeing a practice partner might be one way to combat these inequities., Competing Interests: Conflict of interest: The authors have no conflicting or competing interests to declare., (© Copyright by the American Board of Family Medicine.)

Objective: To examine how social deprivation and residential mobility are associated with primary care use in children seeking care at community health centers (CHCs) overall and stratified by race and ethnicity., Study Design: We used electronic health record open cohort data from 152 896 children receiving care from 15 U S CHCs belonging to the OCHIN network. Patients were aged 3-17 years, with ≥2 primary care visits during 2012-2017 and had geocoded address data. We used negative binomial regression to calculate adjusted rates of primary care encounters and influenza vaccinations relative to neighborhood-level social deprivation., Results: Higher rates of clinic utilization were observed for children who always lived in highly deprived neighborhoods (RR = 1.11, 95% CI = 1.05-1.17) and those who moved from low-to-high deprivation neighborhoods (RR = 1.05, 95% CI = 1.01-1.09) experienced higher rates of CHC encounters compared with children who always lived in the low-deprivation neighborhoods. This trend was similar for influenza vaccinations. When analyses were stratified by race and ethnicity, we found these relationships were similar for Latino children and non-Latino White children who always lived in highly deprived neighborhoods. Residential mobility was associated with lower rates of primary care., Conclusions: These findings suggest that children living in or moving to neighborhoods with high levels of social deprivation used more primary care CHC services than children who lived in areas with low deprivation, but moving itself was associated with less care. Clinician and delivery system awareness of patient mobility and its impacts are important to addressing equity in primary care., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Importance: Practice-level evidence is needed to clarify the value of population-based clinical decision support (CDS) tools in reducing racial and sex disparities in cardiovascular care., Objective: To evaluate the association between CDS tools and racial and sex disparities in the aspirin use, blood pressure control, cholesterol management, and smoking cessation (ABCS) care quality metrics among smaller primary care practices., Design, Setting, and Participants: This cross-sectional study used practice-level data from the Agency for Healthcare Research and Quality-funded EvidenceNOW initiative. The national initiative from May 1, 2015, to April 30, 2021, spanned 12 US states and focused on improving cardiovascular preventive care by providing quality improvement support to smaller primary care practices. A total of 576 primary care practices in EvidenceNOW submitted both survey data and electronic health record (EHR)-derived ABCS data stratified by race and sex., Main Outcomes and Measures: Practice-level estimates of disparities between Black and White patients and between male and female patients were calculated as the difference in proportions of eligible patients within each practice meeting ABCS care quality metrics. The association between CDS tools (EHR prompts, standing orders, and clinical registries) and disparities was evaluated by multiply imputed multivariable models for each CDS tool, adjusted for practice rurality, ownership, and size., Results: Across the 576 practices included in the analysis, 219 (38.0%) had patient panels that were more than half White and 327 (56.8%) had panels that were more than half women. The proportion of White compared with Black patients meeting metrics for blood pressure (difference, 5.16% [95% CI, 4.29%-6.02%]; P < .001) and cholesterol management (difference, 1.49% [95% CI, 0.04%-2.93%] P = .04) was higher; the proportion of men meeting metrics for aspirin use (difference, 4.36% [95% CI, 3.34%-5.38%]; P < .001) and cholesterol management (difference, 3.88% [95% CI, 3.14%-4.63%]; P < .001) was higher compared with women. Conversely, the proportion of women meeting practice blood pressure control (difference, -1.80% [95% CI, -2.32% to -1.28%]; P < .001) and smoking cessation counseling (difference, -1.67% [95% CI, -2.38% to -0.95%]; P < .001) metrics was higher compared with men. Use of CDS tools was not associated with differences in race or sex disparities except for the smoking metric. Practices using CDS tools showed a higher proportion of men meeting the smoking counseling metric than women (coefficient, 3.82 [95% CI, 0.95-6.68]; P = .009)., Conclusions and Relevance: The findings of this cross-sectional study suggest that practices using CDS tools had small disparities that were not statistically significant, but CDS tools were not associated with reductions in disparities. More research is needed on effective practice-level interventions to mitigate disparities.

Introduction: Little has previously been reported about the implementation of social risk screening across racial/ethnic/language groups. To address this knowledge gap, the associations between race/ethnicity/language, social risk screening, and patient-reported social risks were examined among adult patients at community health centers., Methods: Patient- and encounter-level data from 2016 to 2020 from 651 community health centers in 21 U.S. states were used; data were extracted from a shared Epic electronic health record and analyzed between December 2020 and February 2022. In adjusted logistic regression analyses stratified by language, robust sandwich variance SE estimators were applied with clustering on patient's primary care facility., Results: Social risk screening occurred at 30% of health centers; 11% of eligible adult patients were screened. Screening and reported needs varied significantly by race/ethnicity/language. Black Hispanic and Black non-Hispanic patients were approximately twice as likely to be screened, and Hispanic White patients were 28% less likely to be screened than non-Hispanic White patients. Hispanic Black patients were 87% less likely to report social risks than non-Hispanic White patients. Among patients who preferred a language other than English or Spanish, Black Hispanic patients were 90% less likely to report social needs than non-Hispanic White patients., Conclusions: Social risk screening documentation and patient reports of social risks differed by race/ethnicity/language in community health centers. Although social care initiatives are intended to promote health equity, inequitable screening practices could inadvertently undermine this goal. Future implementation research should explore strategies for equitable screening and related interventions., (Copyright © 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The coronavirus disease 2019 pandemic led to clinical practice changes, which affected cancer preventive care delivery., Objectives: To investigate the impact of the coronavirus disease 2019 pandemic on the delivery of colorectal cancer (CRC) and cervical cancer (CVC) screenings., Research Design: Parallel mixed methods design using electronic health record data (extracted between January 2019 and July 2021). Study results focused on 3 pandemic-related periods: March-May 2020, June-October 2020, and November 2020-September 2021., Subjects: Two hundred seventeen community health centers located in 13 states and 29 semistructured interviews from 13 community health centers., Measures: Monthly up-to-date CRC and CVC screening rates and monthly rates of completed colonoscopies, fecal immunochemical test (FIT)/fecal occult blood test (FOBT) procedures, Papanicolaou tests among age and sex-eligible patients. Analysis used generalized estimating equations Poisson modeling. Qualitative analysts developed case summaries and created a cross-case data display for comparison., Results: The results showed a reduction of 75% for colonoscopy [rate ratio (RR) = 0.250, 95% CI: 0.224-0.279], 78% for FIT/FOBT (RR = 0.218, 95% CI: 0.208-0.230), and 87% for Papanicolaou (RR = 0.130, 95% CI: 0.125-0.136) rates after the start of the pandemic. During this early pandemic period, CRC screening was impacted by hospitals halting services. Clinic staff moved toward FIT/FOBT screenings. CVC screening was impacted by guidelines encouraging pausing CVC screening, patient reluctance, and concerns about exposure. During the recovery period, leadership-driven preventive care prioritization and quality improvement capacity influenced CRC and CVC screening maintenance and recovery., Conclusions: Efforts supporting quality improvement capacity could be key actionable elements for these health centers to endure major disruptions to their care delivery system and to drive rapid recovery., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: HIV screening should occur for all adults at least once by age 65 years. Older adults have low screening rates. Latinos, with historically low screening rates, have worse HIV outcomes than non-Hispanic White patients. Electronic health record data from a multistate network of community health centers were used to examine whether there are differences in HIV screening for Latino (English and Spanish preferring) and non-Hispanic White older adults., Methods: Data were from the Accelerating Data Value Across a National Community Health Center Network Clinical Research Network of PCORnet from 21 states in 2012-2021 among an open cohort of patients aged 50-65 years. Relative odds of ever having received HIV screening comparing Latinos with non-Hispanic Whites using generalized estimating equation logistic regression modeling were calculated, adjusting for relevant patient-level covariates. Analyses were conducted in 2022., Results: Among 251,645 patients, the covariate-adjusted odds of ever receiving HIV screening were 18% higher for English-preferring Latino patients (OR=1.18, 95% CI=1.11, 1.25) and 32% higher for Spanish-preferring Latinos than for non-Hispanic Whites (OR=1.32, 95% CI=1.24, 1.42)., Conclusions: Latinos seen in community health centers, regardless of language spoken, are more likely to be screened at least once for HIV than non-Hispanic Whites. This increased screening may be due at least in part to the community health center setting, a setting known to mitigate disparities, as well as due to participation efforts by community health centers in public health campaigns. Future research can prioritize understanding the cause of this relative advantage., (Copyright © 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this research was to examine how different measurements of poverty (household-level and neighborhood-level) were associated with asthma care utilisation outcomes in a community health centre setting among Latino, non-Latino black and non-Latino white children., Design, Setting and Participants: We used 2012-2017 electronic health record data of an open cohort of children aged <18 years with asthma from the OCHIN, Inc. network. Independent variables included household-level and neighborhood-level poverty using income as a percent of federal poverty level (FPL). Covariate-adjusted generalised estimating equations logistic and negative binomial regression were used to model three outcomes: (1) ≥2 asthma visits/year, (2) albuterol prescription orders and (3) prescription of inhaled corticosteroids over the total study period., Results: The full sample (n=30 196) was 46% Latino, 26% non-Latino black, 31% aged 6-10 years at first clinic visit. Most patients had household FPL <100% (78%), yet more than half lived in a neighbourhood with >200% FPL (55%). Overall, neighbourhood poverty (<100% FPL) was associated with more asthma visits (covariate-adjusted OR 1.26, 95% CI 1.12 to 1.41), and living in a low-income neighbourhood (≥100% to <200% FPL) was associated with more albuterol prescriptions (covariate-adjusted rate ratio 1.07, 95% CI 1.02 to 1.13). When stratified by race/ethnicity, we saw differences in both directions in associations of household/neighbourhood income and care outcomes between groups., Conclusions: This study enhances understanding of measurements of race/ethnicity differences in asthma care utilisation by income, revealing different associations of living in low-income neighbourhoods and households for Latino, non-Latino white and non-Latino black children with asthma. This implies that markers of family and community poverty may both need to be considered when evaluating the association between economic status and healthcare utilisation. Tools to measure both kinds of poverty (family and community) may already exist within clinics, and can both be used to better tailor asthma care and reduce disparities in primary care safety net settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: This study estimates reductions in 10-year atherosclerotic cardiovascular disease (ASCVD) risk associated with EvidenceNOW, a multi-state initiative that sought to improve cardiovascular preventive care in the form of (A)spirin prescribing for high-risk patients, (B)lood pressure control for people with hypertension, (C)holesterol management, and (S)moking screening and cessation counseling (ABCS) among small primary care practices by providing supportive interventions such as practice facilitation., Design: We conducted an analytic modeling study that combined (1) data from 1,278 EvidenceNOW practices collected 2015 to 2017; (2) patient-level information of individuals ages 40 to 79 years who participated in the 2015 to 2016 National Health and Nutrition Examination Survey ( n = 1,295); and (3) 10-year ASCVD risk prediction equations., Measures: The primary outcome measure was 10-year ASCVD risk., Results: EvidenceNOW practices cared for an estimated 4 million patients ages 40 to 79 who might benefit from ABCS interventions. The average 10-year ASCVD risk of these patients before intervention was 10.11%. Improvements in ABCS due to EvidenceNOW reduced their 10-year ASCVD risk to 10.03% (absolute risk reduction: -0.08, P ≤ .001 ). This risk reduction would prevent 3,169 ASCVD events over 10 years and avoid $150 million in 90-day direct medical costs., Conclusion: Small preventive care improvements and associated reductions in absolute ASCVD risk levels can lead to meaningful life-saving benefits at the population level., Competing Interests: Conflict of interest: The authors have no conflicts of interest to declare., (© Copyright by the American Board of Family Medicine.)

Objectives: One in 5 people in the United States lives with chronic pain. Many patients with chronic pain experience a subset of specific co-occurring pain conditions that may share a common pain mechanism and that have been designated as chronic overlapping pain conditions (COPCs). Little is known about chronic opioid prescribing patterns among patients with COPCs in primary care settings, especially among socioeconomically vulnerable patients. This study aims to evaluate opioid prescribing among patients with COPCs in US community health centers and to identify individual COPCs and their combinations that are associated with long-term opioid treatment (LOT)., Study Design: Retrospective cohort study., Methods: We conducted analyses of more than 1 million patients 18 years and older based on electronic health record data from 449 US community health centers across 17 states between January 1, 2009, and December 31, 2018. Logistic regression models were used to assess the relationship between COPCs and LOT., Results: Individuals with COPCs were prescribed LOT 4 times more often than individuals without a COPC (16.9% vs 4.0%). The presence of chronic low back pain, migraine headache, fibromyalgia, or irritable bowel syndrome combined with any of the other COPCs increased the odds of LOT prescribing compared with the presence of a single COPC., Conclusions: Although LOT prescribing has declined over time, it remains relatively high among patients with certain COPCs and for those with multiple COPCs. These study findings suggest target populations for future interventions to manage chronic pain among socioeconomically vulnerable patients.

Introduction: Country of birth/nativity information may be crucial to understanding health equity in Latino populations and is routinely called for in health services literature assessing cardiovascular disease and risk, but is not thought to co-occur with longitudinal, objective health information such as that found in electronic health records (EHRs)., Methods: We used a multistate network of community health centres to describe the extent to which country of birth is recorded in EHRs in Latinos, and to describe demographic features and cardiovascular risk profiles by country of birth. We compared geographical/demographic/clinical characteristics, from 2012 to 2020 (9 years of data), of 914 495 Latinos recorded as US-born, non-US-born and without a country of birth recorded. We also described the state in which these data were collected., Results: Country of birth was collected for 127 138 Latinos in 782 clinics in 22 states. Compared with those with a country of birth recorded, Latinos without this record were more often uninsured and less often preferred Spanish. While covariate adjusted prevalence of heart disease and risk factors were similar between the three groups, when results were disaggregated to five specific Latin countries (Mexico, Guatemala, Dominican Republic, Cuba, El Salvador), significant variation was observed, especially in diabetes, hypertension and hyperlipidaemia., Conclusions: In a multistate network, thousands of non-US-born, US-born and patients without a country of birth recorded had differing demographic characteristics, but clinical variation was not observed until data was disaggregated into specific country of origin. State policies that enhance the safety of immigrant populations may enhance the collection of health equity related data. Rigorous and effective health equity research using Latino country of birth information paired with longitudinal healthcare information found in EHRs might have significant potential for aiding clinical and public health practice, but it depends on increased, widespread and accurate availability of this information, co-occurring with other robust demographic and clinical data nativity., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Clinical decision support (CDS) tools that provide point-of-care reminders of patients' care needs may improve rates of guideline-concordant cervical cancer screening. However, uptake of such electronic health record (EHR)-based tools in primary care practices is often low. This study describes the frequency of factors associated with, and barriers and facilitators to adoption of a cervical cancer screening CDS tool (CC-tool) implemented in a network of community health centers., Methods: This mixed-methods sequential explanatory study reports on CC-tool use among 480 community-based clinics, located across 18 states. Adoption of the CC-tool was measured as any instance of tool use (i.e., entry of cervical cancer screening results or follow-up plan) and as monthly tool use rates from November 1, 2018 (tool release date) to December 31, 2020. Adjusted odds and rates of tool use were evaluated using logistic and negative-binomial regression. Feedback from nine clinic staff representing six clinics during user-centered design sessions and semi-structured interviews with eight clinic staff from two additional clinics were conducted to assess barriers and facilitators to tool adoption., Results: The CC-tool was used ≥1 time in 41% of study clinics during the analysis period. Clinics that ever used the tool and those with greater monthly tool use had, on average, more encounters, more patients from households at >138% federal poverty level, fewer pediatric encounters, higher up-to-date cervical cancer screening rates, and higher rates of abnormal cervical cancer screening results. Qualitative data indicated barriers to tool adoption, including lack of knowledge of the tool's existence, understanding of its functionalities, and training on its use., Conclusion: Without effective systems for informing users about new EHR functions, new or updated EHR tools are unlikely to be widely adopted, reducing their potential to improve health care quality and outcomes., Competing Interests: None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: Chronic pain is a prevalent and costly problem that often has occupational origins. Home care workers (HCWs) are at high risk for work-related injuries, pain, and disability. Current treatments for chronic pain emphasize medications, which are an inadequate stand-alone treatment and can produce significant adverse effects., Methods: In this translational study, we will adapt an established work-based injury prevention and health promotion program (COMmunity of Practice And Safety Support: COMPASS) to address the needs of HCWs experiencing chronic pain. COMPASS employs peer-led, scripted group meetings that include educational content, activities, goal setting, and structured social support. The translated intervention, named COMPASS for Navigating Pain (COMPASS-NP), will be delivered in an online group format. Safety protections will be strengthened through an ergonomic self-assessment and vouchers for purchasing ergonomic tools. Educational content will integrate a self-management approach to chronic pain using proven cognitive-behavioral therapy (CBT) principles. We will use a mixed-methods hybrid type 2 evaluation approach to assess effectiveness and implementation. A cluster-randomized waitlist control design will involve 14 groups of 10 HCWs (n = 140) recruited from Washington, Oregon, and Idaho. Half of the groups will be randomly selected to complete the intervention during the first 10 weeks, while the waitlist groups serve as controls. During weeks 10-20, the waitlist groups will complete the intervention while the original intervention groups complete a follow-up period without further intervention. Our primary hypothesis is that COMPASS-NP will reduce pain interference with work and life. Secondary outcomes include injury and pain prevention behaviors, pain severity, changes in medication use, risk for opioid misuse, well-being, physical activity, and sleep. Qualitative data, including phone interviews with group facilitators and organizational partners, will evaluate the implementation and guide dissemination., Discussion: The results will advance the use and knowledge of secondary prevention interventions such as ergonomic tools and cognitive behavior therapy, to reduce injury, pain, and disability and to encourage appropriate uses of analgesic medications among HCWs., Trial Registration: ClinicalTrials.gov NCT05492903. Registered on 08 August 2022., (© 2023. The Author(s).)

Importance: Health-related consequences of multimorbidity (≥2 chronic diseases) are well documented. However, the extent and rate of accumulation of chronic diseases among US patients seeking care in safety-net clinics are not well understood. These insights are needed to enable clinicians, administrators, and policy makers to mobilize resources for prevention of disease escalations in this population., Objectives: To identify the patterns and rate of chronic disease accumulation among middle-aged and older patients seeking care in community health centers, as well as any sociodemographic differences., Design, Setting, and Participants: This cohort study used electronic health record data from January 1, 2012, to December 31, 2019, on 725 107 adults aged 45 years or older with 2 or more ambulatory care visits in 2 or more distinct years at 657 primary care clinics in the Advancing Data Value Across a National Community Health Center network in 26 US states. Statistical analysis was performed from September 2021 to February 2023., Exposures: Race and ethnicity, age, insurance coverage, and federal poverty level (FPL)., Main Outcomes and Measures: Patient-level chronic disease burden, operationalized as the sum of 22 chronic diseases recommended by the Multiple Chronic Conditions Framework. Linear mixed models with patient-level random effects adjusted for demographic characteristics and ambulatory visit frequency with time interactions were estimated to compare accrual by race and ethnicity, age, income, and insurance coverage., Results: The analytic sample included 725 107 patients (417 067 women [57.5%]; 359 255 [49.5%] aged 45-54 years, 242 571 [33.5%] aged 55-64 years, and 123 281 [17.0%] aged ≥65 years). On average, patients started with a mean (SD) of 1.7 (1.7) morbidities and ended with 2.6 (2.0) morbidities over a mean (SD) of 4.2 (2.0) years of follow-up. Compared with non-Hispanic White patients, patients in racial and ethnic minoritized groups had marginally lower adjusted annual rates of accrual of conditions (-0.03 [95% CI, -0.03 to -0.03] for Spanish-preferring Hispanic patients; -0.02 [95% CI, -0.02 to -0.01] for English-preferring Hispanic patients; -0.01 [95% CI, -0.01 to -0.01] for non-Hispanic Black patients; and -0.04 [95% CI, -0.05 to -0.04] for non-Hispanic Asian patients). Older patients accrued conditions at higher annual rates compared with patients 45 to 50 years of age (0.03 [95% CI, 0.02-0.03] for 50-55 years; 0.03 [95% CI, 0.03-0.04] for 55-60 years; 0.04 [95% CI, 0.04-0.04] for 60-65 years; and 0.05 [95% CI, 0.05-0.05] for ≥65 years). Compared with those with higher income (always ≥138% of the FPL), patients with income less than 138% of the FPL (0.04 [95% CI, 0.04-0.05]), mixed income (0.01 [95% CI, 0.01-0.01]), or unknown income levels (0.04 [95% CI, 0.04-0.04]) had higher annual accrual rates. Compared with continuously insured patients, continuously uninsured and discontinuously insured patients had lower annual accrual rates (continuously uninsured, -0.003 [95% CI, -0.005 to -0.001]; discontinuously insured, -0.004 [95% CI, -0.005 to -0.003])., Conclusions and Relevance: This cohort study of middle-aged patients seeking care in community health centers suggests that disease accrued at high rates for patients' chronological age. Targeted efforts for chronic disease prevention are needed for patients near or below the poverty line.

Evidence is needed about how to effectively support health care providers in implementing screening for social risks (adverse social determinants of health) and providing related referrals meant to address identified social risks. This need is greatest in underresourced care settings. The authors tested whether an implementation support intervention (6 months of technical assistance and coaching study clinics through a five-step implementation process) improved adoption of social risk activities in community health centers (CHCs). Thirty-one CHC clinics were block-randomized to six wedges that occurred sequentially. Over the 45-month study period from March 2018 to December 2021, data were collected for 6 or more months preintervention , the 6-month intervention period , and 6 or more months postintervention . The authors calculated clinic-level monthly rates of social risk screening results that were entered at in-person encounters and rates of social risk-related referrals. Secondary analyses measured impacts on diabetes-related outcomes. Intervention impact was assessed by comparing clinic performance based on whether they had versus had not yet received the intervention in the preintervention period compared with the intervention and postintervention periods. In assessing the results, the authors note that five clinics withdrew from the study for various bandwidth-related reasons. Of the remaining 26, a total of 19 fully or partially completed all 5 implementation steps, and 7 fully or partially completed at least the first 3 steps. Social risk screening was 2.45 times (95% confidence interval [CI], 1.32-4.39) higher during the intervention period compared with the preintervention period; this impact was not sustained postintervention (rate ratio, 2.16; 95% CI, 0.64-7.27). No significant difference was seen in social risk referral rates during the intervention or postintervention periods. The intervention was associated with greater blood pressure control among patients with diabetes and lower rates of diabetes biomarker screening postintervention. All results must be interpreted considering that the Covid-19 pandemic began midway through the trial, which affected care delivery generally and patients at CHCs particularly. Finally, the study results show that adaptive implementation support was effective at temporarily increasing social risk screening. It is possible that the intervention did not adequately address barriers to sustained implementation or that 6 months was not long enough to cement this change. Underresourced clinics may struggle to participate in support activities over longer periods without adequate resources, even if lengthier support is needed. As policies start requiring documentation of social risk activities, safety-net clinics may be unable to meet these requirements without adequate financial and coaching/technical support.

Importance: Work environments and practice structural features are associated with both burnout and the ability of practices to enhance quality of care., Objective: To characterize factors associated with primary care practices successfully improving quality scores without increasing clinician and staff burnout., Design, Setting, and Participants: This cross-sectional study assessed small- to medium-sized primary care practices that participated in the EvidenceNOW: Advancing Heart Health initiative using surveys that were administered at baseline (September 2015 to April 2017) and after the intervention (January 2017 to October 2018). Data were analyzed from February 2022 to January 2023., Main Outcomes and Measures: The primary outcome of being a quality and well-being positive deviant practice was defined as a practice with a stable or improved percentage of clinicians and staff reporting burnout over the study period and with practice-level improvement in all 3 cardiovascular quality measures: aspirin prescribing, blood pressure control, and smoking cessation counseling., Results: Of 727 practices with complete burnout and aspirin prescribing, blood pressure control, and smoking cessation counseling data, 18.3% (n = 133) met the criteria to be considered quality and well-being positive deviant practices. In analyses adjusted for practice location, accountable care organization and demonstration project participation, and practice specialty composition, clinician-owned practices had greater odds of being a positive deviant practice (odds ratio, 2.02; 95% CI, 1.16-3.54) than practices owned by a hospital or health system., Conclusions and Relevance: In this cross-sectional study, clinician-owned practices were more likely to achieve improvements in cardiovascular quality outcomes without increasing staff member burnout than were practices owned by a hospital or health system. Given increasing health care consolidation, our findings suggest the value of studying cultural features of clinician-owned practices that may be associated with positive quality and experience outcomes.

Purpose: Human papillomavirus (HPV) infection contributes to vaccine-preventable malignancies. Rural populations experience lower HPV vaccination rates despite similar rates of other childhood vaccinations. Individual- and clinic-level characteristics likely contribute to this disparity, but little is known about the separate roles of each. We compared clinic-level HPV vaccination rates among rural versus urban primary care clinics, identified factors associated with HPV vaccination, and separately assessed the impact of individual- and clinic-level characteristics on rural disparities in HPV vaccination., Methods: This cross-sectional study included 537 Oregon primary care clinics participating in the Vaccines for Children (VFC) program during 2019. Vaccination status was assessed using Oregon's ALERT Immunization Information System and included HPV vaccine ≥ 1 dose for ages 11 and 12; HPV vaccination up to date (UTD) for ages 13-17, and coadministration with tetanus, diphtheria, and acellular pertussis (Tdap). Rural versus urban clinic-level outcomes were assessed using negative binomial regression., Findings: Participating clinics were 24.5% rural and 75.6% urban. Family medicine clinics comprised 71.1%; pediatrics, 16.9%; and mixed, 12.1%. Across clinics, the average proportion of patients qualifying for VFC was 43%, and non-White patients were 14.1%. The mean rate of HPV vaccine ≥1 dose was lower among rural clinics (46.9% vs 51.1%, P = .039), as was vaccination UTD (40.5% vs 49.9%, P < .001). Adjusting for differences in individual- and clinic-level characteristics, rural disparities were no longer statistically significant., Conclusions: Both individual- and clinic-level characteristics play a role in rural disparities in HPV vaccination, and modifiable clinic-level differences may be opportune targets to address these disparities., (© 2022 National Rural Health Association.)

Background and Objective: The associations between training length and clinical knowledge are unknown. We compared family medicine in-training examination (ITE) scores among residents who trained in 3- versus 4-year programs and to national averages over time., Methods: In this prospective case-control study, we compared the ITE scores of 318 consenting residents in 3-year programs to 243 who completed 4 years of training between 2013 through 2019. We obtained scores from the American Board of Family Medicine. The primary analyses involved comparing scores within each academic year according to length of training. We used multivariable linear mixed effects regression models adjusted for covariates. We performed simulation models to predict ITE scores after 4 years of training among residents who underwent only 3 years of training., Results: At baseline postgraduate year-1 (PGY1), the estimated mean ITE scores were 408.5 for 4-year programs and 386.5 for 3-year programs, a 21.9 point difference (95% CI=10.1-33.8). At PGY2 and PGY3, 4-year programs scored 15.0 points higher and 15.6 points higher, respectively. When extrapolating an estimated mean ITE score for 3-year programs, 4-year programs would still score 29.4 points higher (95% CI=15.0-43.8). Our trend analysis revealed those in 4-year programs had a slightly lesser slope increase compared to 3-year programs in the first 2 years. Their drop-off in ITE scores is less steep in later years, though these differences were not statistically significant., Conclusions: While we found significantly higher absolute ITE scores in 4 versus 3-year programs, these increases in PGY2, PGY3 and PGY4 may be due to initial differences in PGY1 scores. Additional research is needed to support a decision to change the length of family medicine training.

Background: Nontuberculous mycobacteria are environmental organisms that cause infections leading to chronic, debilitating pulmonary disease, among which Mycobacterium avium complex (MAC) is the most common species., Methods: We described patterns of macrolide-based multidrug antibiotic therapies for MAC pulmonary disease (MAC-PD) in US Medicare beneficiaries with bronchiectasis between January 2006 and December 2014. MAC therapy was defined as a multidrug regimen containing a macrolide plus ≥1 other drug targeting MAC-PD (rifamycin, ethambutol, fluoroquinolone, or amikacin) prescribed concomitantly for >28 days., Results: We identified 9189 new MAC therapy users, with a mean age (standard deviation) of 74 (6 years) at the start of therapy; 75% female and 87% non-Hispanic white. A guideline-based regimen (a macrolide, ethambutol, and rifamycin, with or without amikacin) was prescribed for 51% of new MAC therapy users at treatment start, of whom 41% were continuing guideline-based therapy at 6 months, and only 18% at 12 months. Of all new MAC therapy users, by 18 months only 11% were still receiving MAC treatment, 55% had discontinued therapy, and 34% were censored owing to death or the end of the study period., Conclusions: Overall, nearly half of new MAC therapy users were prescribed a non-guideline-recommended macrolide-based therapy, including regimens commonly associated with promoting macrolide resistance. Treatment discontinuation was common, and once discontinued, only a few beneficiaries resumed therapy at a later time. Our study adds important data to the current literature on treatment patterns for MAC-PD among older US populations. Future research should examine treatment patterns using more contemporary data sources., Competing Interests: Potential conflicts of interest. J. H. K. has received research grants from Moderna and GlaxoSmithKline, paid to the institution. E. H. has served on advisory board for AN2 Pharmaceuticals and received consulting fees. S. K. B. reports grants or contracts from Insmed, outside the submitted work and paid to the institution, as site subinvestigator for a clinical trial in nontuberculous mycobacteria (NTM) lung disease; payment or honoraria paid to institution from Boehringer Ingelheim; and membership on the executive committee for The Union–North American Region. T. K. M. has received grants or contracts from the Ontario Thoracic Society/Lung Foundation for a study on preventing the recurrence of Mycobacterium avium (MAC) lung disease, from Insmed as site investigator for a clinical trial on MAC lung disease, and from the Oregon Health & Science University/Patient Centered Outcomes Research Institute as site investigator for clinical trial of MAC lung disease, all paid to the institution, and from the Lung Health Foundation. T. K. M. has received consulting fees from Insmed, RedHill Biopharma, and Spero, including for MAC lung disease study design, paid to the institution; payment or honoraria from Astra Zeneca and Novartis for CME in NTM lung disease, paid to the institution; and support for attending meetings and/or travel from NTM Info & Research (NTMir) and hotel accommodation for presentation at the NTMir annual meeting for patients and providers associated with the American Thoracic Society Annual Conference in May 2019. T. K. M. has also served as chair of the data safety monitoring board for clofazimine monotherapy in MAC lung disease and has a leadership/fiduciary role as an advisor to the Toronto NTM lung disease patient support group. K. L. W. has grants or contracts and consulting fees from Paratek, AN2 Pharmaceuticals, Insmed, and Red Hill Biopharma and consulting fees from Spero Therapeutics. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Hepatitis C virus is associated with high morbidity and mortality-chronic liver disease is a leading cause of death among Latinos in the U.S. Screening for hepatitis C virus in community health center settings, which serve a disproportionate percentage of Latinos, is essential to eradicating hepatitis C virus infection. We assessed hepatitis C virus screening disparities in adults served by community health centers by ethnicity and language preference., Methods: This was an observational cohort study (spanning 2013-2017) of adults born in 1945-1965 in the Accelerating Data Value Across a National Community Health Center Network electronic health record data set. Our exposure of interest was race/ethnicity and language preference (non-Hispanic White, Latino English preferred, Latino Spanish preferred). Our primary outcome was the relative hazard of hepatitis C virus screening , estimated using multivariate Cox proportional hazards regression., Results: A total of 182,002 patients met the study criteria and included 60% non-Hispanic Whites, 29% Latino Spanish preferred, and 11% Latino English preferred. In total, 9% received hepatitis C virus screening, and 2.4% were diagnosed with hepatitis C virus. Latino English-preferred patients had lower rates of screening than both non-Hispanic Whites and Latino Spanish preferred (5.5% vs 9.4% vs 9.6%, respectively). Latino English preferred had lower hazards of hepatitis C virus screening than non-Hispanic Whites (adjusted hazard ratio=0.56, 95% CI=0.44, 0.72), and Latino Spanish preferred had similar hazards of hepatitis C virus screening (adjusted hazard ratio=1.11, 95% CI=0.88, 1.41)., Conclusions: We found that in a large community health center network, adult Latinos who preferred English had lower hazards of hepatitis C virus screening than non-Hispanic Whites, whereas Latinos who preferred Spanish had hazards of screening similar to those of non-Hispanic Whites. The overall prevalence of hepatitis C virus screening was low. Further work on the role of language preference in hepatitis C virus screening is needed to better equip primary care providers to provide this recommended preventive service in culturally relevant ways., (© 2023 The Authors.)

Objective: Medication maintenance is critical in the management of asthma. We investigated the differences in electronic health record (EHR) documentation of medication refills for Spanish- and English-speaking Latino children and non-Hispanic white children by examining rates of albuterol rescue inhaler refills from 2005 to 2017, and and inhaled corticosteroid refills from 2015 to 2017 in a multi-state network of community health centers (CHCs)., Methods: We used data from the ADVANCE network of CHCs. Our sample consisted of children aged 3-17, with a diagnosis of asthma and either albuterol or inhaled corticosteroid prescriptions ( n  = 39,162; n  = 4,738 children, respectively). Negative binomial regression was used to calculate rates of refills per prescription adjusted for relevant patient-level covariates. Analyses stratified by asthma severity were also conducted., Results: English-speaking Latino children had lower rates of albuterol refills compared with non-Hispanic white children (rate ratio [RR] = 0.88, 95% confidence interval [CI]: 0.80-0.98), a trend that persisted among children with moderate/severe persistent asthma severity (RR = 0.85, 95% CI: 0.76-0.95). Spanish-speaking Latino and non-Hispanic white children had similar albuterol refills. Inhaled corticosteroid refill rates were comparable between all groups., Conclusions: In a multi-state network, these findings suggest that CHCs deliver equitable asthma care related to prescription refills between their Latino and white patients, but there is still opportunity for providers to ensure that their English-speaking Latino patients have access to necessary emergency asthma medication.

Objective: This study evaluates whether patients residing in expansion states have a greater increase in outpatient diagnoses of acute diabetes complications than those living in non-expansion states following the implementation of the Affordable Care Act (ACA)., Methods: This retrospective cohort study uses electronic health records (EHR) from 10,665 non-pregnant patients, aged 19 to 64 years old who were diagnosed with diabetes in 2012 or 2013 from 347 community health centers (CHCs) across 16 states (11 expansion and 5 non-expansion states). Patients included had ≥1 outpatient ambulatory visit in each of these periods: pre-ACA: 2012 to 2013, post-ACA: 2014 to 2016, and post-ACA: 2017 to 2019. Acute diabetes-related complications were identified using International Classification Diseases (ICD-9-CM and ICD-10-CM) codes classification and could occur on or after diagnosis of diabetes. We performed difference-in-differences (DID) analysis using a generalized estimating equation to compare the change in rates of acute diabetes complications by year and by Medicaid expansion status., Results: There was a greater increase after year 2015 in visits related to abnormal blood glucose among patient living in Medicaid expansion states than in non-expansion states (2017 DID = 0.041, 95% CI = 0.027-0.056). Although both visits due to any acute diabetes complications and infection-related diabetes complications were higher among patients living in Medicaid expansion states, there was no difference in the trend overtime between expansion and non-expansion states., Conclusion: We found a significantly greater rate of visits for abnormal blood glucose in patients receiving care in expansion states relative to patients in CHCs in non-expansion states starting in 2015. Additional resources for these clinics, such as the ability to provide blood glucose monitoring devices or mailed/delivered medications, could substantially benefit patients with diabetes.

We typed 1541 Y-STR haplotypes from reference samples along forensic casework investigations. In three haplotypes, we detected a variant allele designed as 16.3 at locus DYS533. This was confirmed by amplification using two commercial kits. Sanger sequencing revealing a novel motif corresponding to [TATC] 12 repeats with a 19-bp insertion in the flanking upstream region. We propose its origin as an insertion at - 9.1 upstream of the repeat motifs. We searched other local databases and found this allele in various geographical areas of Argentina and neighbouring countries. The haplotypes share a common core of 10 Y-STRs (DYS389-I/13; DYS389-II/30; DYS19/14; DYS481/22; DYS438/12; DYS437/16; DYS635/23; DYS392/13; DYS393/13; GATA H4/11) and belong to the R1b haplogroup. This 16.3 allele is restricted to southern South America, which allows us to propose a local and relatively recent origin. The sequence described herein constitutes a novelty that could be considered in future criteria for the nomenclature of STRs based on massively parallel sequencing., Competing Interests: Conflict of interest The authors declare no competing interests., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Introduction: To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care., Methods: Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable : Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach., Results: Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04 ), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001 ) and smoking performance (+6.43%, P = .003 ). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes., Discussion: Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes., Competing Interests: Conflict of interest: The authors of this manuscript have no conflicts of interest to report., (© Copyright by the American Board of Family Medicine.)

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., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Multimorbidity (≥ 2 chronic diseases) is associated with greater disability and higher treatment burden, as well as difficulty coordinating self-management tasks for adults with complex multimorbidity patterns. Comparatively little work has focused on assessing multimorbidity patterns among patients seeking care in community health centers (CHCs)., Objective: To identify and characterize prevalent multimorbidity patterns in a multi-state network of CHCs over a 5-year period., Design: A cohort study of the 2014-2019 ADVANCE multi-state CHC clinical data network. We identified the most prevalent multimorbidity combination patterns and assessed the frequency of patterns throughout a 5-year period as well as the demographic characteristics of patient panels by prevalent patterns., Participants: The study included data from 838,642 patients aged ≥ 45 years who were seen in 337 CHCs across 22 states between 2014 and 2019., Main Measures: Prevalent multimorbidity patterns of somatic, mental health, and mental-somatic combinations of 22 chronic diseases based on the U.S. Department of Health and Human Services Multiple Chronic Conditions framework: anxiety, arthritis, asthma, autism, cancer, cardiac arrhythmia, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), congestive heart failure, coronary artery disease, dementia, depression, diabetes, hepatitis, human immunodeficiency virus (HIV), hyperlipidemia, hypertension, osteoporosis, post-traumatic stress disorder (PTSD), schizophrenia, substance use disorder, and stroke., Key Results: Multimorbidity is common among middle-aged and older patients seen in CHCs: 40% have somatic, 6% have mental health, and 24% have mental-somatic multimorbidity patterns. The most frequently occurring pattern across all years is hyperlipidemia-hypertension. The three most frequent patterns are various iterations of hyperlipidemia, hypertension, and diabetes and are consistent in rank of occurrence across all years. CKD-hyperlipidemia-hypertension and anxiety-depression are both more frequent in later study years., Conclusions: CHCs are increasingly seeing more complex multimorbidity patterns over time; these most often involve mental health morbidity and advanced cardiometabolic-renal morbidity., (© 2021. Society of General Internal Medicine.)