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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.

INTRODUCTION: Although smoking prevalence is lower among Hispanic adults than among non-Hispanic White adults, smoking remains a leading cause of preventable death among older Hispanics. This study examines the differences in tobacco assessment and smoking-cessation assistance among older patients seen in community health centers by ethnicity and language preference. METHODS: Electronic health record data were extracted from the Accelerating Data Value Across a National Community Health Center Network of community health centers from patients aged 55–80 years with ≥1 primary care visit between January 1, 2017 and December 31, 2018. Binary outcomes included tobacco use assessment and, among those with ≥1 status indicating current smoking, having a smoking-cessation medication ordered. The independent variable combined ethnicity and language preference, categorized as non-Hispanic White (reference), Spanish-preferring Hispanic, and English-preferring Hispanic. Multivariable generalized estimating equation logistic regressions, clustering by primary care clinic using an exchangeable working correlation structure, modeled the odds of tobacco use assessment and cessation medication orders by ethnicity/preferred language, adjusting for patient covariates, health system, and clinic location. Analyses were conducted in 2021. RESULTS: The study included 116,328 patients. Spanish-preferring Hispanic patients had significantly lower odds of having tobacco use assessed than non-Hispanic White patients (AOR=0.89, 95% CI=0.82, 0.95). Both Spanish- and English-preferring Hispanic patients had lower odds of having a smoking-cessation medication ordered (AOR=0.53, 95% CI=0.47, 0.60; AOR=0.77, 95% CI=0.67, 0.89, respectively) than non-Hispanic White patients. CONCLUSIONS: Significant disparities were found in tobacco assessment and cessation assistance by ethnicity and language preference among older adults seen in safety-net clinics. Future research is needed to understand the etiology of these smoking-related disparities.

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

OBJECTIVE The purpose of the study is to examine diabetes screening and monitoring among Latino individuals as compared with non-Latino White individuals and to better understand how we can use neighborhood data to address diabetes care inequities. RESEARCH DESIGN AND METHODS This is a retrospective observational study linked with neighborhood-level Latino subgroup data obtained from the American Community Survey. We used generalized estimating equation negative binomial and logistic regression models adjusted for patient-level covariates to compare annual rates of glycated hemoglobin (HbA1c) monitoring for those with diabetes and odds of HbA1c screening for those without diabetes by ethnicity and among Latinos living in neighborhoods with low (0.0–22.0%), medium (22.0–55.7%), and high (55.7–98.0%) population percent of Mexican origin. RESULTS Latino individuals with diabetes had 18% higher rates of HbA1c testing than non-Latino White individuals with diabetes (adjusted rate ratio [aRR] 1.18 [95% CI 1.07–1.29]), and Latinos without diabetes had 25% higher odds of screening (adjusted odds ratio 1.25 [95% CI 1.15–1.36]) than non-Latino White individuals without diabetes. In the analyses in which neighborhood-level percent Mexican population was the main independent variable, all Latinos without diabetes had higher odds of HbA1c screening compared with non-Latino White individuals, yet only those living in low percent Mexican-origin neighborhoods had increased monitoring rates (aRR 1.31 [95% CI 1.15–1.49]). CONCLUSIONS These findings reveal novel variation in health care utilization according to Latino subgroup neighborhood characteristics and could inform the delivery of diabetes care for a growing and increasingly diverse Latino patient population. Clinicians and researchers whose work focuses on diabetes care should take steps to improve equity in diabetes and prevent inequity in treatment.

Cardiovascular disease preventive services (aspirin use, blood pressure control, and smoking-cessation support) are crucial to controlling cardiovascular diseases. This study draws from 1,248 small-to-medium-sized primary care practices participating in the EvidenceNOW Initiative from 2015-2016 across 12 states to provide practice-level aspirin use, blood pressure control, and smoking-cessation support estimates; report the percentage of practices that meet Million Hearts targets; and identify the practice characteristics associated with better performance.This cross-sectional study utilized linear regression modeling (analyzed in 2020-2021) to examine the association of aspirin use, blood pressure control, and smoking-cessation support performance with practice characteristics that included structural attributes (e.g., size, ownership, rurality), practice capacity and contextual characteristics, health information technology, and patient panel demographics.On average, practice performance on aspirin use, blood pressure control, and smoking-cessation support quality measures was 64% for aspirin, 63% for blood pressure, and 62% for smoking-cessation support. The 2012 Million Hearts goal of achieving the rates of 70% was achieved by 52% (aspirin), 32% (blood pressure), and 54% (smoking) of practices. Practice characteristics associated with aspirin use, blood pressure control, and smoking-cessation support performance included ownership (hospital/health system-owned practices had 11% higher aspirin performance than clinician-owned practices [p=0.001]), rurality (rural practices had lower performance than urban practices in all aspirin use, blood pressure control, and smoking-cessation support quality metrics [difference in aspirin=11.1%, p=0.001; blood pressure=4.2%, p=0.022; smoking=14.4%, p=0.009]), and disruptions (practices that experienced1 major disruption showed lower aspirin performance [-7.1%, p0.001]).Achieving the Million Hearts targets may be assisted by collecting and reporting practice-level performance, which can promote change at the practice level and identify areas where additional support is needed to achieve initiative goals.

Cancer survivors face increased risk for chronic diseases resulting from cancer, preexisting conditions, and cancer treatment. Having an established primary care clinic or health insurance may influence patients' receipt of recommended preventive care necessary to manage, treat, or diagnose new conditions. This study sought to understand receipt of healthcare in community health centers (CHCs) before and after cancer diagnosis among cancer survivors. We also examined the type of care received and assessed whether being established with a CHC or the type of health insurance affected the use of services.Using electronic health record data and linked cancer registries from 5,649 CHC patients in three states from 2012 through 2018, we obtained monthly rates of primary care and mental health/behavioral health (MHBH) visits and the probability of receipt of care before and after a cancer diagnosis.Seventy-five percent of CHC patients diagnosed with cancer returned to their primary CHC for care within 2-years of their diagnosis. Among those who returned, there was a sharp increase in primary and MHBH care shortly before their diagnosis. Significantly more primary care (pre: 19.6%, post: 21.9%, p 0.001) and MHBH care (pre: 1.2%, post: 1.6%, p 0.001) was received after diagnosis than before. However, uninsured patients had fewer visits after their diagnosis than before.Use of preventive care for cancer survivors is particularly important. Having an established primary care clinic may help to ensure survivors receive recommended screening and care.

PURPOSE: Previous work has shown that asthma-related emergency department (ED) use is greatest among Black and Latine populations, but it is unknown whether health care use for exacerbations differs across settings (outpatient, ED, inpatient) and correlates with use of routine outpatient services. We aimed to measure disparities by race, ethnicity, and language in pediatric acute asthma care using data from US primary care community health centers. METHODS: In an observational study using electronic health records from community health centers in 18 states, we compared non-Hispanic Black, English-preferring Latine, Spanish-preferring Latine, and non-Hispanic White children aged 3 to 17 years on visits for clinic-coded asthma exacerbations (2012-2018). We further evaluated asthma-related ED use and inpatient admissions in a subsample of Oregon-Medicaid recipients. Covariate-adjusted odds ratios (ORs) and rate ratios (RRs) were derived using logistic or negative binomial regression analysis with generalized estimating equations. RESULTS: Among 41,276 children with asthma, Spanish-preferring Latine children had higher odds of clinic visits for asthma exacerbation than non-Hispanic White peers (OR = 1.10; 95% CI, 1.02-1.18). Among the subsample of 6,555 children insured under Oregon-Medicaid, non-Hispanic Black children had higher odds and rates of asthma-related ED use than non-Hispanic White peers (OR = 1.40; 95% CI, 1.04-1.89 and RR = 1.49; 95% CI, 1.09-2.04, respectively). We observed no differences between groups in asthma-related inpatient admissions. CONCLUSIONS: This study is the first to show that patterns of clinic and ED acute-care use differ for non-Hispanic Black and Spanish-preferring Latine children when compared with non-Hispanic White peers. Non-Hispanic Black children had lower use of clinics, whereas Spanish-preferring Latine children had higher use, including for acute exacerbations. These patterns of clinic use were accompanied by higher ED use among Black children. Ensuring adequate care in clinics may be important in mitigating disparities in asthma outcomes. VISUAL ABSTRACT

Objective To assess and compare electronic health record (EHR) documentation of chronic disease in problem lists and encounter diagnosis records among Community Health Center (CHC) patients. Materials and methods We assessed patient EHR data in a large clinical research network during 2012–2019. We included CHCs who provided outpatient, older adult primary care to patients age ≥45 years, with ≥2 office visits during the study. Our study sample included 1 180 290 patients from 545 CHCs across 22 states. We used diagnosis codes from 39 Chronic Condition Warehouse algorithms to identify chronic conditions from encounter diagnoses only and compared against problem list records. We measured correspondence including agreement, kappa, prevalence index, bias index, and prevalence-adjusted bias-adjusted kappa. Results Overlap of encounter diagnosis and problem list ascertainment was 59.4% among chronic conditions identified, with 12.2% of conditions identified only in encounters and 28.4% identified only in problem lists. Rates of coidentification varied by condition from 7.1% to 84.4%. Greatest agreement was found in diabetes (84.4%), HIV (78.1%), and hypertension (74.7%). Sixteen conditions had Discussion Agreement between the 2 sources varied substantially. Conditions requiring regular management in primary care settings may have a higher agreement than those diagnosed and treated in specialty care. Conclusion Relying on EHR encounter data to identify chronic conditions without reference to patient problem lists may under-capture conditions among CHC patients in the United States.

Introduction National reports suggest that Hispanic patients may underutilize influenza and pneumococcal vaccination, although studies sometimes conflict on this point. A clearer picture of adult immunization utilization in older Hispanic patients is necessary to ensure equity in adult vaccinations. Methods Using electronic health records from 648 community health centers (CHCs) across 21 states, we compared English-preferring Hispanic patients, Spanish-preferring Hispanic patients, and Non-Hispanic White (NHW) adults aged ≥50 years across five outcomes between 2012-2017: (1) Odds of ever receiving pneumococcal vaccination after age 65, (2) Odds of ever receiving ≥2 pneumococcal vaccinations for those ≥65, (3) odds of vaccination between the ages of 50 and 64 for those with diabetes or heart disease, (4) odds of influenza vaccine, and (5) annual rate of influenza vaccination. Results Of our total study sample (N = 143,869), 85,562 were age 50-64 during the entire study period, and 65,977 were ≥65 at some point during the study period. In patients aged 50-64, Spanish-preferring Hispanic patients were more likely to have ever had an influenza vaccination (covariate-adjusted odds ratio [aOR] = 1.33, 95% CI = 1.29-1.37), had higher rates of annual influenza vaccination (covariate-adjusted rate ratio [aRR] = 1.41, 95% CI = 1.38-1.44), and higher odds of pneumococcal vaccination (aOR = 1.87, 95% CI = 1.76-1.98) than NHW patients. These findings were similar in Spanish-preferring Hispanic patients ≥65. English-preferring Hispanics ≥65 were less likely than NHW patients to ever have an influenza vaccination (aOR = 0.91, 95% CI = 0.85-0.98) and to have ever received at least one (aOR = 0.92, 95% CI = 0.86-0.99) or two (aOR = 0.86, 95% CI = 0.77-0.95) pneumococcal vaccine doses. Conclusions In a multistate CHC network, Spanish-preferring Hispanic patients were more likely to receive influenza and pneumococcal vaccinations than NHW patients; older English-preferring Hispanic patients were often less likely than NHW patients to receive these vaccinations. In vaccine initiatives, English-preferring Hispanic patients may be at higher risk of vaccination inequity.

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.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.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.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.

IntroductionSocial risks (e.g., food/transportation insecurity) can hamper type 2 diabetes mellitus (T2DM) self-management, leading to poor outcomes. To determine the extent to which high-quality care can overcome social risks' health impacts, this study assessed the associations between reported social risks, receipt of guideline-based T2DM care, and T2DM outcomes when care is up to date among community health center patients.MethodsA cross-sectional study of adults aged ≥18 years (N=73,484) seen at 186 community health centers, with T2DM and ≥1 year of observation between July 2016 and February 2020. Measures of T2DM care included up-to-date HbA1c, microalbuminuria, low-density lipoprotein screening, and foot examination, and active statin prescription when indicated. Measures of T2DM outcomes among patients with up-to-date care included blood pressure, HbA1c, and low-density lipoprotein control on or within 6‒12 months of an index encounter. Analyses were conducted in 2021.ResultsIndividuals reporting transportation or housing insecurity were less likely to have up-to-date low-density lipoprotein screening; no other associations were seen between social risks and clinical care quality. Among individuals with up-to-date care, food insecurity was associated with lower adjusted rates of controlled HbA1c (79% vs 75%, p

Purpose Adequate access to and utilization of preventive services are vital among cancer survivors. This study examined preventive service utilization of cancer survivors compared to matched patients with no history of cancer among patients seeking care at community health centers (CHCs). Methods We utilized electronic health record data from the OCHIN network between 2014 and 2017. Cancer survivors (N = 20,538) ages ≥ 18 years were propensity score matched to three individuals with no history of cancer (N = 61,617) by age, sex, region, urban/rural, ethnicity, race, BMI, and Charlson Comorbidity Index. Preventive screenings included cancer, mental health and substance abuse, cardiovascular, and infectious disease screenings, and vaccinations. Patient-level preventive service indices were calculated for each screening as the total person-time covered divided by the total person-time eligible. Preventive service rate ratios comparing cancer survivors to patients with no history of cancer were estimated using negative binomial regression. Results Cancer survivors had higher overall preventive service utilization (incidence rate ratio = 1.11, 95% confidence interval = 1.09–1.13) and higher rates of cancer screenings (IRR = 1.16, 95% CI = 1.12–1.20). There was no difference between the two groups in mental health screenings. Conclusions Cancer survivors were more likely to be up-to-date with preventive care than their matched counterparts. However, mental health and substance abuse screenings were low in both groups, despite reports of increased mental health conditions among cancer survivors. Implications for Cancer Survivors With the growing number of cancer survivors in the USA, efforts are needed to ensure their access to and utilization of preventive services, especially related to behavioral and mental healthcare.

Eliminating health and health care inequities is a longstanding goal of multiple United States health agencies, but overwhelming scientific evidence suggests that health and health care inequities persist in the United States, despite decades of research and initiatives to alleviate them. Because of its comprehensiveness, studying health inequities in the context of primary care allows for the use of multiple paradigms and methodologic approaches to understanding almost any state of health, disease, social challenge, or societal circumstance a patient or group of patients might face. We argue in this special communication that the many features/advantages of primary care research have valuable contributions to make in reducing health inequity, and scientists, journals, and funders should increase the incorporation of primary care approaches and findings into their portfolios to better understand and end health inequity.

Background Developing effective implementation strategies requires adequate tracking and reporting on their application. Guidelines exist for defining and reporting on implementation strategy characteristics, but not for describing how strategies are adapted and modified in practice. We built on existing implementation science methods to provide novel methods for tracking strategy modifications. Methods These methods were developed within a stepped-wedge trial of an implementation strategy package designed to help community clinics adopt social determinants of health-related activities: in brief, an ‘Implementation Support Team’ supports clinics through a multi-step process. These methods involve five components: 1) describe planned strategy; 2) track its use; 3) monitor barriers; 4) describe modifications; and 5) identify / describe new strategies. We used the Expert Recommendations for Implementing Change taxonomy to categorize strategies, Proctor et al.’s reporting framework to describe them, the Consolidated Framework for Implementation Research to code barriers / contextual factors necessitating modifications, and elements of the Framework for Reporting Adaptations and Modifications-Enhanced to describe strategy modifications. Results We present three examples of the use of these methods: 1) modifications made to a facilitation-focused strategy (clinics reported that certain meetings were too frequent, so their frequency was reduced in subsequent wedges); 2) a clinic-level strategy addition which involved connecting one study clinic seeking help with community health worker-related workflows to another that already had such a workflow in place; 3) a study-level strategy addition which involved providing assistance in overcoming previously encountered (rather than de novo) challenges. Conclusions These methods for tracking modifications made to implementation strategies build on existing methods, frameworks, and guidelines; however, as none of these were a perfect fit, we made additions to several frameworks as indicated, and used certain frameworks’ components selectively. While these methods are time-intensive, and more work is needed to streamline them, they are among the first such methods presented to implementation science. As such, they may be used in research on assessing effective strategy modifications and for replication and scale-up of effective strategies. We present these methods to guide others seeking to document implementation strategies and modifications to their studies. Trial registration clinicaltrials.gov ID: NCT03607617 (first posted 31/07/2018).

Although much attention has been focused on individual-level drivers of burnout in primary care settings, examining the structural and cultural factors of practice environments with no burnout could identify solutions. In this cross-sectional analysis of survey data from 715 small-to-medium-size primary care practices in the United States participating in the Agency for Healthcare Research and Quality's EvidenceNOW initiative, we found that zero-burnout practices had higher levels of psychological safety and adaptive reserve, a measure of practice capacity for learning and development. Compared with high-burnout practices, zero-burnout practices also reported using more quality improvement strategies, more commonly were solo and clinician owned, and less commonly had participated in accountable care organizations or other demonstration projects. Efforts to prevent burnout in primary care may benefit from focusing on enhancing organization and practice culture, including promoting leadership development and fostering practice agency.

IntroductionCountry 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).MethodsWe 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.ResultsCountry 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.ConclusionsIn 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.

ImportanceHealth-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.ObjectivesTo 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 ParticipantsThis 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.ExposuresRace and ethnicity, age, insurance coverage, and federal poverty level (FPL).Main Outcomes and MeasuresPatient-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.ResultsThe 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 RelevanceThis 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.

ImportanceWork environments and practice structural features are associated with both burnout and the ability of practices to enhance quality of care.ObjectiveTo characterize factors associated with primary care practices successfully improving quality scores without increasing clinician and staff burnout.Design, Setting, and ParticipantsThis 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 MeasuresThe 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.ResultsOf 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 RelevanceIn 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.

Nontuberculous mycobacteria infection is increasing in incidence and can lead to chronic, debilitating pulmonary disease. We investigated the accuracy of diagnosis code-based nontuberculous mycobacteria lung disease claims among Medicare beneficiaries in the United States. We observed that these claims have moderate validity, but given their low sensitivity, incidence might be underestimated.

Background Many cancer survivors receive primary care in community health centers (CHCs). Cancer history is an important factor to consider in the provision of primary care, yet little is known about the completeness or accuracy of cancer history data contained in CHC electronic health records (EHRs). Methods We probabilistically linked EHR data from more than1.5 million adult CHC patients to state cancer registries in California, Oregon, and Washington and estimated measures of agreement (eg, kappa, sensitivity, specificity). We compared demographic and clinical characteristics of cancer patients as estimated by each data source, evaluating distributional differences with absolute standardized mean differences. Results A total 74 707 cancer patients were identified between the 2 sources (EHR only, n = 22 730; registry only, n = 23 616; both, n = 28 361). Nearly one-half of cancer patients identified in registries were missing cancer documentation in the EHR. Overall agreement of cancer ascertainment in the EHR vs cancer registries (gold standard) was moderate (kappa = 0.535). Cancer site–specific agreement ranged from substantial (eg, prostate and female breast; kappa > 0.60) to fair (melanoma and cervix; kappa < 0.40). Comparing population characteristics of cancer patients as ascertained from each data source, groups were similar for sex, age, and federal poverty level, but EHR-recorded cases showed greater medical complexity than those ascertained from cancer registries. Conclusions Agreement between EHR and cancer registry data was moderate and varied by cancer site. These findings suggest the need for strategies to improve capture of cancer history information in CHC EHRs to ensure adequate delivery of care and optimal health outcomes for cancer survivors.

Background: The purpose of the study is to examine diabetes screening and monitoring among Latino individuals as compared to non-Latino white individuals, and to better understand how we can use neighborhood data to address diabetes care inequities. Research Design and Methods: This is a retrospective observational study linked with neighborhood-level Latino subgroup data obtained from the American Community Survey. We used generalized estimating equations negative binomial and logistic regression models adjusted for patient-level covariates to compare annual rates of glycated hemoglobin (HbA1c) monitoring for those with diabetes and odds of HbA1c screening for those without diabetes by ethnicity, and among Latinos living in neighborhoods with low (0.0-22.0%), medium (22.0-55.7%), and high (55.7-98.0%) population percent Mexican-origin. Results: Latino individuals with diabetes had 18% higher rates of HbA1c testing than non-Latino white individuals with diabetes (aRR=1.18, 95%CI=1.07-1.29), and Latinos without diabetes had 25% higher odds of screening (aOR=1.25, 95%CI=1.15-1.36) than non-Latino white individuals without diabetes. In the analyses where neighborhood-level percent Mexican population was the main independent variable, all Latinos without diabetes had higher odds of HbA1c screening compared to non-Latino white individuals, yet only those living in low percent Mexican-origin neighborhoods had increased monitoring rates (aRR=1.31, 95%CI=1.15-1.49). Conclusions: These findings reveal novel variation in healthcare utilization according to Latino subgroup neighborhood characteristics and could inform the delivery of diabetes care for a growing and increasingly diverse Latino patient population. Clinicians and researchers whose work focuses on diabetes care should take steps to improve equity in diabetes and prevent inequity in treatment.

Community health centers are a crucial source of health care for reproductive-age women. Some community health centers receive funding from the federal Title X program, which provides funding for family planning services for low-income women. We describe the provision of the most effective (intrauterine devices and implants) and moderately effective (short-acting hormonal methods) contraceptive methods in a large network of 384 community health center clinics across twenty states in 2016-18. Title X clinics provided more most and moderately effective contraception at all time points and for all age groups (adolescent, young adult, and adult). They provided 52 percent more of the most effective contraceptives to women at risk for pregnancy than clinics not funded by Title X. This finding was especially notable for adolescents (58 percent more). Title X clinics play a key role in access to effective contraception across the US safety net. Strengthening the Title X program should continue to be a policy priority for public health for the Biden-Harris administration.

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.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 aged2 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.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).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.

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.

To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care.Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720).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,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.

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.

Objective To test the feasibility, acceptability, and potential effectiveness of engineering and behavioral interventions to improve the sleep, health, and well-being of team truck drivers (dyads) who sleep in moving semi-trucks. Methods Drivers (n = 16) were exposed to Condition A: a new innerspring mattress, and Condition B: a novel therapeutic mattress. A subsample of drivers (n = 8) were also exposed to Condition C: use of their preferred mattress (all chose to keep B), switching to an active suspension driver's seat, and completing a behavioral sleep-health program. Primary outcomes were sleep duration, sleep quality, and fatigue. Behavioral program targets included physical activity and sleep hygiene. Results Self-reported sleep and fatigue improved with mattress A, and improved further with mattress B which altered vibration exposures and was universally preferred and kept by all drivers. Condition C improved additional targets and produced larger effect sizes for most outcomes. Conclusions Results support these interventions as promising for advancing team truck drivers' sleep, health, and well-being.

INTRODUCTION: Prior research has documented disparities in asthma outcomes between Latino children and non-Hispanic whites, but little research directly examines the care provided to Latino children over time in clinical settings. METHODS: We utilized an electronic health record-based dataset to study basic asthma care utilization (timely diagnosis documentation and medication prescription) between Latino (Spanish preferring and English preferring) and Non-Hispanic white children over a 13-year study period. RESULTS: In our study population (n = 37,614), Latino children were more likely to have Medicaid, be low income, and be obese than non-Hispanic white children. Latinos (Spanish preferring and English preferring) had lower odds than non-Hispanic whites of having their asthma recorded on their problem list on the first day the diagnosis was noted (odds ratio [OR] = 0.83; 95% CI, 0.77 to 0.89 Spanish preferring; OR = 0.93; 95% CI, 0.87 to 0.99 English preferring). Spanish-preferring Latinos had higher odds of ever receiving a prescription for albuterol (OR = 1.96; 95% CI, 1.52 to 2.52), inhaled corticosteroids (OR = 1.45; 95% CI, 1.01 to 2.09), or oral steroids (OR = 1.48; 95% CI, 1.07 to 2.04) than non-Hispanic whites. Among those with any prescription, Spanish-preferring Latinos had higher rates of albuterol prescriptions compared with non-Hispanic whites (adjusted rate ratio [aRR] = 1.0; 95% CI, 1.01 to 1.13). CONCLUSIONS: In a multi-state network of clinics, Latino children were less likely to have their asthma entered on their problem list the first day it was noted than non-Hispanic white children, but otherwise did not receive inferior care to non-Hispanic white children in other measures. Further research can examine other parts of the asthma care continuum to better understand asthma disparities. (J Am Board Fam Med 2020;33:707–715.)

The patient-centered medical home model aspires to fundamentally restructure care processes, but a volume-based payment system may hinder such transformations. In 2013 Oregon’s Medicaid program cha...