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Abstract:Small primary care practices are critical to advancing Affordable Care Act (ACA) aims, yet their efforts and experiences remain little studied. We examine two strategies derived from ACA population-health provisions—enhanced use of electronic health records (EHRs) and community health worker (CHW)–led peer coaching—for hypertension control in sixteen small practices serving South Asian immigrant communities in New York City. Based on interviews with physicians, staff, and CHWs, we analyze "street-level" dilemmas encountered in implementing the strategies. Findings indicate that the strategies reinforce clinic-community social ties but present distinct challenges for small practices: internal management constraints that impede formal CHW-physician contact, and external incentives linked to EHR tools that, physicians and staff perceive, do not meet immigrant communities' needs and expectations in medical encounters.

AbstractBackground:Rates of breastfeeding remain disproportionately low among young mothers in the United States. Although breastfeeding behavior may be most directly related to breastfeeding intention, little is known about breastfeeding intentions among young women who are expecting a baby.Subjects and Methods:Pregnant adolescents and young adults (14–21 years old) and their male partners were recruited for participation. Females were asked if they intended to breastfeed, and their partners were asked if they wanted their partners to breastfeed; participants indicated reasons for their responses. Logistic regression modeling was used to determine the associations between breastfeeding intentions and sociodemographic characteristics, relationship characteristics, and partner's intention to breastfeed.Results:Approximately 73% of females reported intending to breastfeed, and 80% of males reported wanting his partner to breastfeed, most commonly because it is “healthier for the baby” and “a more natural way to feed the baby.” Sociodemographic and relationship characteristics explained a small amount of variance of breastfeeding intention (15% and 4% among females, respectively, and 8% and 4% among males, respectively). Partner intention explained an additional 23% and 24% of the variance in individual intention for females and males, respectively. Females who had experienced intimate partner violence (IPV) from their current partner had lower odds of intending to breastfeed (odds ratio=0.37; 95% confidence interval=0.16, 0.84). Race/ethnicity modified associations among both genders.Conclusions:These findings emphasize the importance of dyadic approaches and suggest strategies for improving breastfeeding intentions and behavior among young couples expecting a baby. These results are also among the first to document the relationship between IPV and breastfeeding intentions among young women.

Background:Project IMPACT, a CDC-funded 5-year modified stepped wedge quasi-experimental study, was launched to test the impact of integrating an electronic health record (EHR)-based intervention with a community health worker intervention to improve hypertension control among patients in small NYC practices (n=14) with a large proportion of South Asian patients. The EHR intervention included provider and staff training on using health registry, alerts, and order sets with culturally-tailored health education materials. Results of the EHR intervention at 12 months post-intervention implementation suggested a significant positive association to improve average BP and hypertension control. Literature on long-term outcomes of health information technology interventions are sparse. This presentation responds to that gap by testing the effect of this intervention on BP outcomes 18-months after implementation.Methods:Aggregate practice-level EHR data were extracted every six months. The primary practice-level outcome was change in proportion of hypertensive patients with controlled BP among all patients with hypertension. Patient-level EHR and claims data were extracted for patients with Healthfirst insurance and had at least one diagnosis of hypertension at a clinic visit in 2015 (n=1,219). The main individual-level outcome for this study was average systolic BP and diastolic BP at last clinic visit. A secondary individual-level outcome was proportion of patients with controlled BP at last clinic visit, among all Healthfirst hypertensive patients.Results:At the practice level, there was a significant improvement in hypertension control through 18 months post-intervention implementation, adjusting for age and sex (aRR: 1.15, 95% CI: 1.07-1.25). Among Healthfirst patients, we observed a significant impact on average systolic BP and diabolic BP adjusting for time, age, and sex, with a decrease of 1.22 mmHg and 1.40 mmHg, respectively. The proportion of Healthfirst patients with well-controlled BP improved after adjusting for demographics (aOR: 1.25, 95% CI: 1.00-1.57).Conclusion:Early results suggest that practice-level outcome improvements are sustainable through 18-months post-intervention implementation.

Introduction:The Million Hearts Initiative aims to prevent heart disease in the U.S. with a focus on improving hypertension (HTN) control. Yet, HTN control in ethnic/minority communities remains suboptimal, pointing to the need for sustainable, culturally-adapted community-clinical linkage strategies.Objective:We report results from a randomized control trial implemented in immigrant-serving primary care practices designed to test the efficacy of community health workers (CHWs) to improve HTN control among South Asians in New York City. We hypothesize that treatment group individuals will have a greater change in blood pressure (BP) and BP control compared to control group individuals.Methods:A total of 2,480 participants with uncontrolled HTN were identified via electronic health records at 14 primary care practices and were mailed invitations to participate in the intervention. CHWs followed-up via phone and onsite at clinics, completing screening with 895 individuals. A total of 304 (34%) eligible individuals were enrolled and completed a CHW-led education session on HTN control, and were then randomized to either treatment (N = 159) or wait-list control groups (N = 145). Individuals in the treatment group participated in four additional culturally-adapted education sessions on diet, exercise, cardiovascular disease, and stress management, as well as bi-monthly health coaching via phone to improve diet and physical activity behaviors.Results:A total of 277 individuals completed baseline and 8-month follow-up surveys; 274 of these individuals had systolic (SBP) and diastolic (DBP) BP measurements at both time points. Among the intervention group, there was a mean change of -4.5 mmHg in SBP (p<0.001) and -3.7 mmHg in DBP (p<0.001). In contrast, mean SBP and DBP increased slightly in the control group (changes were not significant). The intervention effect (adjusted for age and sex) for SBP and DBP was significant (p<0.001). In the intervention group, BP control (BP<140/90) increased from 37.3% at baseline to 69.7% at endpoint (p<0.001), while in the control group, BP control did not change (40.8% at both time points).Conclusions:Study findings can provide replicable models to address health disparities in ethnic/minority communities.