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PURPOSE Practice facilitation is an evidence-informed implementation strategy to support quality improvement (QI) and aid practices in aligning with best evidence. Few studies, particularly of this size and scope, identify strategies that contribute to facilitator effectiveness. METHODS We conducted a sequential mixed methods study, analyzing data from EvidenceNOW, a large-scale QI initiative. Seven regional cooperatives employed 162 facilitators to work with 1,630 small or medium-sized primary care practices. Main analyses were based on facilitators who worked with at least 4 practices. Facilitators were defined as more effective if at least 75% of their practices improved on at least 1 outcome measure-aspirin use, blood pressure control, smoking cessation counseling (ABS), or practice change capacity, measured using Change Process Capability Questionnaire-from baseline to follow-up. Facilitators were defined as less effective if less than 50% of their practices improved on these outcomes. Using an immersion crystallization and comparative approach, we analyzed observational and interview data to identify strategies associated with more effective facilitators. RESULTS Practices working with more effective facilitators had a 3.6% greater change in the mean percentage of patients meeting the composite ABS measure compared with practices working with less effective facilitators (P CONCLUSIONS Facilitation strategies that differentiate more and less effective facilitators have implications for enhancing facilitator development and training, and can assist all facilitators to more effectively support practice changes. Key words: practice facilitation; quality improvement; large-scale initiative; capacity building; implementation facilitation; organizational change; organizational innovation, INTRODUCTION Practice facilitators are trained individuals who build medical practices' capacity to make meaningful operational changes aligned with current evidence. (1,2) Facilitators provide education, motivation, accountability, and guidance on organizational [...]

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 Ann Fam Med 2022;20:116-122. https://doi.org/10.1370/afm.2771, INTRODUCTION The prevalence of pediatric asthma in the United States remained relatively stable during 2001-2017, at about 8.5%, (1) and national surveys suggest roughly 45% of children with asthma experience [...]

PURPOSE We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care. METHODS We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in EvidenceNOW--a multisite cardiovascular disease prevention initiative. We calculated Clinical Quality Measure improvements, with targets of 10-point or greater absolute improvements in the proportion of patients with smoking screening and, if relevant, counseling and in the proportion of hypertensive patients with adequately controlled BP. We analyzed interview data to identify operational changes, transforming these into numeric data. We used Configurational Comparative Methods to assess the joint effects of multiple factors on outcomes. RESULTS In clinician-owned practices, implementing a workflow to routinely screen, counsel, and connect patients to smoking cessation resources, or implementing a documentation change or a referral to a resource alone led to an improvement of at least 10 points in the smoking outcome with a moderate level of facilitation support. These patterns did not manifest in health- or hospital system-owned practices or in Federally Qualified Health Centers, however. The BP outcome improved by at least 10 points among solo practices after medical assistants were trained to take an accurate BP. Among larger, clinician-owned practices, BP outcomes improved when practices implemented a second BP measurement when the first was elevated, and when staff learned where to document this information in the electronic health record. With 50 hours or more of facilitation, BP outcomes improved among larger and health- and hospital system-owned practices that implemented these operational changes. CONCLUSIONS There was no magic bullet for improving smoking or BP outcomes. Multiple combinations of operational changes led to improvements, but only in specific contexts of practice size and ownership, or dose of external facilitation. Key words: quality improvement; configurational comparative methods; mixed methods; cardiovascular prevention; smoking cessation; blood pressure management; organizational change; primary care; practice-based research, INTRODUCTION Cardiovascular disease (CVD) is the leading cause of death in the United States, with stroke or heart disease contributing to 1 out of every 3 deaths. (1) Primary risk [...]

Context: Neighborhood characteristics play an important role in health outcomes, especially for people who access care in community health centers (CHCs). Objective: This study evaluates rates of patient-level multimorbidity ([greater than or equal to] 2 chronic diseases) among CHC patients living in different areas of community-level social deprivation. Study Design and Analysis: Retrospective cohort study using Poisson mixed effects regression of the rates of morbidities by patient- and community- level characteristics including the social deprivation index (SDI). SDI is a composite measure of community-level income, education, employment, housing, household characteristics, transportation, and demographics. Morbidities included 22 chronic diseases recommended by the Department of Health and Human Services Multiple Chronic Conditions framework. Setting or Dataset: 1,412,038 patients from 9,362 Zip Code Tabulation Areas (ZCTAs) living in 27 states. Population Studied: Patients, [greater than or equal to] 45 years from the OCHIN and HCN practice-based research networks. Intervention/Instrument: SDI (0-100) was categorized into quartiles using the patient's ZCTA at last known address. Higher SDI quartiles denote more deprivation. Outcome Measures: Rates of morbidities at date of last known address. Results: Overall, patients averaged 2.50 morbidities (standard deviation [SD] = 2.20). Most patients were 45-54 years of age (38.2%), female (56.0%), non-Hispanic White (37.4%), spoke English (69.8%), continuously, Presenters Katherine Peak, Miguel Marino, PhD, Steele Valenzuela, MSc, Robert Voss, MS, Ana Quinones, [...]

Context: Latino adolescents face multilevel barriers (e.g. language, neighborhood deprivation) to preventive care, including 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 deprivation. Objective: To better understand the social/family factors associated with Latino adolescent vaccination completion by studying the association of adolescent-mother language concordance and neighborhood social deprivation with adolescent vaccination completion. Study Design and Analysis: Retrospective observational study comparing human papilloma virus (HPV), meningococcal, and influenza vaccination rates in dyads from Latino families of three types (English-preferring Latino adolescents with English-preferring mothers, Spanish-preferring Latino adolescents with Spanish-preferring mothers, and English-preferring Latino adolescents with Spanish-preferring mothers) with those of English-preferring non-Hispanic white adolescent- mother pairs, adjusting for mother and adolescent demographics and healthcare utilization and stratifying by social deprivation of the family's neighborhood. Setting: Multistate electronic health record (EHR)-based dataset of patients from 389 community health centers (CHCs) across 17 states from the OCHIN Network. Population Studied: Latino and non-Latino adolescent-mother dyads. Outcome Measures: Adolescent HPV and meningococcal vaccinations and yearly influenza vaccination rate. 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, and Latino dyads with Spanish-preferring mothers had higher vaccination odds/rates than did Latino dyads with English-preferring mothers. While there was some evidence of variation by neighborhood social deprivation in influenza vaccination rates, these effects were minor in comparison to differences by ethnicity and language concordance. Conclusions: 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 had the lowest. Further research can seek to understand why this language dyad may have an advantage in adolescent vaccination completion., Presenters Rachel Springer, MS, John Heintzman, MD, MPH, Jorge Kaufmann, MS, Sophia Giebultowicz, MA, Miguel Marino, PhD, Nathaniel Warren, MPH, Heather Angier, PhD, [...]

Electronic health record (EHR) tools such as documentation shortcuts and ordering templates are designed to enhance both the efficiency and quality of care delivery. Use of such tools vary widely in primary care. Understanding patterns of use as a means to identify priority areas for improvement are lacking. Objective: This study is designed to identify and understand patterns of EHR efficiency use among primary care clinicians as a means to inform training support needs. Study Design: Retrospective observational study. Setting or Dataset: 340 Community Health Centers (CHCs) across 48 US states from the OCHIN Network. Population Studied: The OCHIN's network and 2033 primary care clinicians engaged in patient care at least 2 days a week during DEC 2019-FEB 2020. Methods: Six EHR efficiency indicators were drawn from the Epic EHR Signal efficiency indicators which are automatically generated monthly for clinicians. Indicators include: use of quick actions, preference lists, level of service and diagnosis speed buttons and chart search functions and notes written with smart tools. A weighted score of these indicators represented overall EHR proficiency with a possible range of 0- 10 with higher scores suggesting higher efficiency. Latent profile analysis (LPA) was used to identify clusters of clinicians defined by distinct patterns of efficiency indicators. Results: The median EHR proficiency score was 4 and ranged from 0 to 9.5. The 9 cluster LPA solution the best overall fit. Clusters represented different patterns with notable strengths and deficiencies in EHR use efficiency. Cluster 2 was large (n=518) and characterized by being low on all indicators except for chart search. In contrast, cluster 9 was very small (n=12) and characterized by high scores for 4/6 indicators and low on quick actions. Conclusions: Substantial variation in EHR use efficiency among primary care clinicians was observed and can be represented by nine different patterns of indicators. These patterns show strengths and deficiencies in EHR use efficiency and could guide a tailored training approach to improve EHR efficiency., Presenters Jeremy Erroba, Miguel Marino, PhD, Rachel Gold, PhD, MPH, Rachel Springer, MS, Jennifer DeVoe, MD, DrPH, FAAFP, DPhil, Susan Flocke, PhD, David Boston, MD, [...]

Context: Obesity affects over 40% of the US population and is linked to multiple preventable health conditions which can cause premature morbidity and mortality. Weight loss of at least 5% in patients with obesity reduces their risk of comorbid conditions and leads to improvement in some conditions, such as diabetes. Patients with obesity from underserved populations are less likely to access primary and preventive care services. The Affordable Care Act (ACA) improved access to care, which may in turn improve access to obesity prevention and treatment and assist with weight loss. Objective: Assess whether the proportion of patients with a weight loss [greater than or equal to] 5% was higher in states that expanded Medicaid relative to non-expansion states among patients with obesity receiving care in community health centers (CHCs) which provide health care to underserved patients. Study Design: Retrospective observational cohort study. Setting: Electronic health record data from the ADVANCE (Advancing Data Value Across a National Community Health Center) clinical research network, during years 2012-2017. Population Studied: Patients from 346 CHCs age 19-64 with a body mass index of [greater than or equal to] 30 kg/m2 during the pre-ACA period (n=34,027). Outcome measures: Proportion of patients with weight loss >5% (WL5+) from pre- to post-ACA. Medicaid expansion status (expansion vs. non- expansion states) stratified by pattern of insurance (uninsured, continuously insured, newly insured, discontinuously insured) and race and ethnicity. Results: The proportion of patients with WL5+ for newly insured patients was greater in expansion (26%) than non-expansion states (20%) ([chi square] =9.75, p=0.002). Among newly insured patients, Hispanic (22%) and Black (29%) patients residing in expansion states, had larger proportion of patients with WL5+ than those in non-expansion states (20% and 18%, respectively). No differences were observed among non-Hispanic White patients (expansion 28% vs non-expansion 27%). Conclusions: The findings suggest greater improvement in weight management among patients residing in expansion states than those in non-expansion states, especially among racial and ethnic minorities receiving care in CHCs., Presenters Rebecca Rdesinski, MPH, MSW, Irina Chamine, PhD, Steele Valenzuela, MSc, Miguel Marino, PhD, Teresa Schmidt, PhD, Annie Larson, PhD, MPH, Nathalie Huguet, PhD, Heather Angier, PhD, [...]

Context: Acute complications are responsible for the majority of morbidity and mortality of patients with diabetes. Health insurance increases access to needed healthcare and receipt of diabetes-related preventive care. The Affordable Care Act (ACA) Medicaid eligibility provision was enacted in 2014 with the goal of expanding coverage to all US citizens and legal residents. The ACA led to improvement in healthcare access and health outcomes among patients with diabetes. Objective: To understand whether patients with diabetes in states that expanded Medicaid had greater reductions in the rate of acute complications post-ACA than those in states that did not expand Medicaid. Study Design: Retrospective observational cohort study. Setting or Dataset: Electronic health record data: 274 community health centers from the Accelerating Data Value Across a National Community Health Center Network clinical research network. Population Studied: Non-pregnant adults (n=5,176) aged 19-64 without Medicare coverage history, newly diagnosed with diabetes in 2013 with [greater than or equal to] 1 visit in each of the following periods: 2013, 2014-2016, 2017-2019. Outcome Measures: Rates of acute complications identified using ICD-9/10-CM codes and counted distinctly if the interval between each diagnosis was at least 10 days. Patients' annual acute complication rates were compared using a covariate-adjusted GEE Poisson model clustering on patients assuming an exchangeable working correlation. Outcome trends over time between expansion and non-expansion states were tested using interaction terms for time and expansion status. Results: From 2013 through 2019, annual acute complication rates declined overall for patients in both expansion (2013: 0.35; 2019: 0.18) and non- expansion (2013: 0.13; 2019: 0.10) states, with higher observed rates of acute complications in expansion (compared to non-expansion) states throughout the study period. Trends in acute complication rates were not parallel over time between expansion and non-expansion states (p, Presenters Nathalie Huguet, PhD, Dang Dinh, MSc, Hojun Hwang, MS, Miguel Marino, PhD, Heather Angier, PhD, MPH, Annie Larson, PhD, MPH, Irina Chamine, PhD, Jennifer DeVoe, MD, DrPH, FAAFP, DPhil, [...]

PURPOSE The Patient Protection and Affordable Care Act (ACA) has improved access to health insurance, yet millions remain uninsured. Many patients who remain uninsured access care at community health centers (CHCs); however, little is known about their health conditions and health care use. We assessed ambulatory care use and diagnosed health conditions among a cohort of CHC patients uninsured before enactment of the ACA (pre-ACA: January 1, 2012 to December 31, 2013) and followed them after enactment (post-ACA: January 1, 2014 to December 31, 2015). METHODS This retrospective cohort analysis used electronic health record data from CHCs in 11 US states that expanded Medicaid eligibility. We assessed ambulatory care visits and documented health conditions among a cohort of 138,246 patients (aged 19 to 64 years) who were uninsured pre-ACA and either remained uninsured, gained Medicaid, gained other health insurance, or did not have a visit post-ACA. We estimated adjusted predicted probabilities of ambulatory care use using an ordinal logistic mixed-effects regression model. RESULTS Post-ACA, 20.9% of patients remained uninsured, 15.0% gained Medicaid, 12.4% gained other insurance, and 51.7% did not have a visit. The majority of patients had [greater than or equal to]1 diagnosed health condition. The adjusted proportion of patients with high use ([greater than or equal to]6 visits over 2 years) increased from pre-ACA to post-ACA among those who gained Medicaid (pre-ACA: 23%, post-ACA: 34%, P CONCLUSIONS A significant percentage of CHC patients remained uninsured; many who remained uninsured had diagnosed health conditions, and one-half continued to have [greater than or equal to]3 visits to CHCs. CHCs continue to be essential providers for uninsured patients., INTRODUCTION In 2010, the Patient Protection and Affordable Care Act (ACA) was enacted with the goal of expanding health insurance coverage to all US citizens and legal residents. (1) The [...]

The COVID-19 pandemic has tested many aspects of society, but has also reminded us anew of the limitations and challenges of our scientific approaches. Take the example of randomized trials. [...]

Context Many factors can influence asthma outcomes and care, and these can differ by race/ethnicity and patient-preferred language. It is well known that early childhood wheeze is a predictor for the development of asthma later in childhood, yet there is still uncertainty about how this early childhood risk factor differs among race/ethnicity/language groups. US community health centers (CHCs) have been shown to mitigate disparities in care. CHCs are an ideal setting in which to study nuanced differences in care quality, as they provide asthma care to a large number of racially and ethnically diverse children. Objective To determine how clinician-diagnosed wheeze before age four years of age is associated with the subsequent asthma diagnosis documented in the electronic health record (EHR) among Latino (Spanish or English preferring), non-Latino Black, and non-Latino white children. Study design and Analysis Retrospective observational study. Dataset EHR data from 21 states in the the ADVANCE Clinical Research Network. Population Studied English-preferring Latino, Spanish-preferring Latino, non-Latino Black, and non-Latino white children (<18 years old) who received care at CHCs from 2005-2017 (N=81,921). Outcome Measure Asthma diagnosis after the child's fourth birthday. We used generalized estimating equations logistic regression with interaction terms for wheeze before age four and race/ethnicity/language groups, and adjusted for patient-level covariates. Results Compared to non-Latino white children without wheeze, all groups with wheeze had higher odds of asthma development after age four (English-preferring Latino odds ratio [OR]=2.01, 95% CI=1.55-2.61; Spanish-preferring Latino OR=1.76, 95% CI=1.50-2.06; non-Latino Black OR=2.68, 95% CI=1.93-3.71; non-Latino white OR=2.01, 95% CI=1.55-2.60), as did non-Latino Black children without wheeze (OR=1.92, 95% CI=1.08-1.32). Conclusions In this study, wheeze before age four was associated with asthma diagnosis after age four in all racial/ethnic groups, without major difference between the groups in the odds of diagnosis. This suggests that in CHCs, differences in asthma outcomes between these groups do not stem from differing early life-symptom course or disparate underdiagnosis in this age range between groups. Further research can explore other features of initial asthma presentation in childhood that may affect overall course and health equity. [ABSTRACT FROM AUTHOR]

Context: Atherosclerotic cardiovascular disease (ASCVD) disproportionally affects racial and ethnic minority populations. HMG-CoA reductase inhibitors (statins) have long been first-line pharmacotherapy for ASCVD prevention. Measures recommended to guide statin indication changed in 2013 guidelines aimed at improving ASCVD prevention and reducing ASCVD disparities. It is unknown whether risk screening for initiating statins for primary prevention of ASCVD differs across race and ethnicity. Objective: Examine racial/ethnic/language differences in electronic health record (EHR) prevalence of ASCVD screening measures used for statin consideration. Specifically, compare Asian, Latino, non-Hispanic Black, and non-Hispanic White adults further distinguished by language preference. Design: Retrospective cohort study. Setting: ADVANCE (Advancing Data Value Across a National Community Health Center) network-a PCORNet data network-635 community health centers (CHCs) in 24 US states with a shared EHR platform. Population: Adults 50+ years with =1 primary care encounter in the network 2009-2013, and/or 2014-2018. Outcome measures: Prevalence of period-specific guideline concordant screening measures for statin consideration in 2009-2013: low-density lipoprotein (LDL) and 2014-2018: pooled cohort equation (PCE) components of age, sex, race, systolic blood pressure, total cholesterol, high-density lipoprotein, smoking status. For patients seen in both periods, we assessed change in period-specific measure prevalence. Outcomes were analyzed using GEE logistic regression to measure the association between race/ethnicity/language and measurement prevalence. Results: Adjusting for sociodemographic and clinical factors, compared to English-preferring non-Hispanic White patients, all other groups were more likely to have LDL documented (2009-2013, N=195,061) and all PCE components documented (2014-2018, N=344,504). Among those seen in both periods (N=128,621), all groups had lower odds of having PCE components vs. LDL documented in the measures' respective period; English-preferring non-Hispanic Black adults experienced a greater decline in measure documentation across the two periods compared to English-preferring non-Hispanic White adults (odds ratio 0.81; 95% confidence interval 0.72-0.91). Conclusions: CHCs may mitigate racial/ethnic/language disparities in the collection of screening measures for ASCVD prevention, which did not improve after the 2013 guideline change. [ABSTRACT FROM AUTHOR]

Context: Racial and ethnic minorities in the United States have higher mortality/morbidity from cardiovascular disease (CVD) compared to non-Hispanic whites, and some evidence has suggested that poor risk factor control, including appropriate prescribing of statins for lipid disorders and CVD risk reduction, contributes to these disparities. It is uncertain if the 2013 American Heart Association (AHA)/American College of Cardiology (ACC) guideline change for statin prescription affected this disparity. Objective: To compare the prevalence of patients with guideline indications for statin prescribing, and to compare prescribing prevalence before and after this major guideline change between racial and ethnic groups, by preferred language. Study Design: Retrospective, cohort study. Setting/Dataset: A national network of community health centers (CHCs) linked by a common electronic health record dataset. Population studied: Patients were age 50-73, and had =1 primary care visit in 2009-2013 and/or 2014-2018. Outcomes: By period, 1) proportion with period-specific indications for statin initiation 2) proportion with a statin prescription if indicated. Results: In the 2009-2013 period (N=109,330), non-English preferring White (OR=1.41, 95% CI 1.15-1.72), Black (OR=1.25, 95% CI 1.10-1.41), and Latino patients (OR=1.09, 95% CI 1.02-1.16) had higher odds of meeting guideline indications for statins than Non-Hispanic White English preferring patients, and of those meeting indications, all except Black non-English patients had higher odds of statin prescription. In the 2014-2018 period (N=319,094), all groups except Latino English-preferred and White Non-English preferred patients had higher odds of meeting the new guideline indications for statin prescription. Of those meeting indications in this period, Latino English speakers had similar odds of statin prescription as non-Hispanic whites; English preferring Black patients had lower odds (OR=0.95, 95% CI 0.91-0.99). Conclusions: CHCs provide CVD screening and statin prescriptions for thousands of racial, ethnic, and language minorities, even more so than some non-Hispanic white English speakers. However, disparities appeared for English preferring Latino and Black patients after the 2013 ACC/AHA guideline change. The evaluation of major clinical guideline changes should account for their impact on racial and ethnic disparities. [ABSTRACT FROM AUTHOR]

PURPOSE There is debate about whether community health centers (CHCs) will experience increased demand from patients gaining coverage through Affordable Care Act Medicaid expansions. To better understand the effect of new Medicaid coverage on CHC use over time, we studied Oregon's 2008 randomized Medicaid expansion (the "Oregon Experiment"). METHODS We probabilistically matched demographic data from adults (aged 19-64 years) participating in the Oregon Experiment to electronic health record data from 108 Oregon CHCs within the OCHIN community health information network (originally the Oregon Community Health Information Network) (N = 34,849). We performed intent-to-treat analyses using zero-inflated Poisson regression models to compare 36-month (2008-2011) usage rates among those selected to apply for Medicaid vs not selected, and instrumental variable analyses to estimate the effect of gaining Medicaid coverage on use. Use outcomes included primary care visits, behavioral/mental health visits, laboratory tests, referrals, immunizations, and imaging. RESULTS The intent-to-treat analyses revealed statistically significant differences in rates of behavioral/mental health visits, referrals, and imaging between patients randomly selected to apply for Medicaid vs those not selected. In instrumental variable analyses, gaining Medicaid coverage significantly increased the rate of primary care visits, laboratory tests, referrals, and imaging; rate ratios ranged from 1.27 (95% CI, 1.05-1.55) for laboratory tests to 1.58 (95% CI, 1.10-2.28) for referrals. CONCLUSIONS Our results suggest that use of many different types of CHC services will increase as patients gain Medicaid through Affordable Care Act expansions. To maximize access to critical health services, it will be important to ensure that the health care system can support increasing demands by providing more resources to CHCs and other primary care settings. [ABSTRACT FROM AUTHOR]

Purpose: The Affordable Care Act of 2010 supports marked expansions in Medicaid coverage in the United States. As of January 1, 2014, a total of 25 states and the District of Columbia expanded their Medicaid programs. We tested the hypothesis that rates of uninsured safety net clinic visits would significantly decrease in states that implemented Medicaid expansion, compared with states that did not.Methods: We undertook a longitudinal observational study of coverage status for adult visits in community health centers, from 12 months before Medicaid expansion (January 1, 2013 to December 31, 2013) through 6 months after expansion (January 1, 2014 to June 30, 2014). We analyzed data from 156 clinics in the OCHIN practice-based research network, with a shared electronic health record, located in 9 states (5 expanded Medicaid coverage and 4 did not).Results: Analyses were based on 333,655 nonpregnant adult patients and their 1,276,298 in-person billed encounters. Overall, clinics in the expansion states had a 40% decrease in the rate of uninsured visits in the postexpansion period and a 36% increase in the rate of Medicaid-covered visits. In contrast, clinics in the nonexpansion states had a significant 16% decline in the rate of uninsured visits but no change in the rate of Medicaid-covered visits.Conclusions: There was a substantial decrease in uninsured community health center visits and a significant increase in Medicaid-covered visits in study clinics in states that expanded Medicaid in 2014, whereas study clinics in states opting out of the expansion continued to have a high rate of uninsured visits. These findings suggest that Affordable Care Act-related Medicaid expansions have successfully decreased the number of uninsured safety net patients in the United States. [ABSTRACT FROM AUTHOR]