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Introduction: 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.Methods: 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.Results: 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 experienced >1 major disruption showed lower aspirin performance [-7.1%, p<0.001]).Conclusions: 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective Asthma care is negatively impacted by neighbourhood social and environmental factors, and moving is associated with undesirable asthma outcomes. However, little is known about how movement into and living in areas of high deprivation relate to primary care use. We examined associations between neighbourhood characteristics, mobility and primary care utilisation of children with asthma to explore the relevance of these social factors in a primary care setting. Design In this cohort study, we conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient- level covariates. Setting We used data from community health centres in 15 OCHIN states. Participants The sample included 23 773 children with asthma aged 3--17 across neighbourhoods with different levels of social deprivation from 2012 to 2017. We conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient- level covariates. Results Clinic visit rates were higher among children living in or moving to areas with higher deprivation than those living in areas with low deprivation (rate ratio (RR) 1.09, 95% CI 1.02 to 1.17; RR 1.05, 95% CI 1.00 to 1.11). Children moving across neighbourhoods with similarly high levels of deprivation had increased RRs of influenza vaccination (RR 1.13, 95% CI 1.03 to 1.23) than those who moved but stayed in neighbourhoods of low deprivation. Conclusions Movement into and living within areas of high deprivation is associated with more primary care use, and presumably greater opportunity to reduce undesirable asthma outcomes. These results highlight the need to attend to patient movement in primary care visits, and increase neighbourhood- targeted population management to improve equity and care for children with asthma. [ABSTRACT FROM AUTHOR]

For example, if a patient does not mail in the FOBT kit because they were uncomfortable with specimen collection, we would say that these missing data are MNAR; anytime the missing data are related to what is missing is an indication of MNAR. Inverse probability weighting and multiple imputation approaches are generally recommended as they often assume a MAR missing data mechanism and thus can use supplementary information about the missing data in the final analysis. Performing data checks regularly during the conduct of the study can identify missing data issues and prompt action to address missing data. Dealing with missing data in the conduct phase (during the study) For study designs with prospective data collection, missing data can also occur during the study (prior to analysis). [Extracted from the article]

Purpose: Improving primary care quality is a national priority, but little is known about the extent to which small to medium-size practices use quality improvement (QI) strategies to improve care. We examined variations in use of QI strategies among 1,181 small to medium-size primary care practices engaged in a national initiative spanning 12 US states to improve quality of care for heart health and assessed factors associated with those variations.Methods: In this cross-sectional study, practice characteristics were assessed by surveying practice leaders. Practice use of QI strategies was measured by the validated Change Process Capability Questionnaire (CPCQ) Strategies Scale (scores range from -28 to 28, with higher scores indicating more use of QI strategies). Multivariable linear regression was used to examine the association between practice characteristics and the CPCQ strategies score.Results: The mean CPCQ strategies score was 9.1 (SD = 12.2). Practices that participated in accountable care organizations and those that had someone in the practice to configure clinical quality reports from electronic health records (EHRs), had produced quality reports, or had discussed clinical quality data during meetings had higher CPCQ strategies scores. Health system-owned practices and those experiencing major disruptive changes, such as implementing a new EHR system or clinician turnover, had lower CPCQ strategies scores.Conclusion: There is substantial variation in the use of QI strategies among small to medium-size primary care practices across 12 US states. Findings suggest that practices may need external support to strengthen their ability to do QI and to be prepared for new payment and delivery models. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses articles within the issue on topics including a nationally disseminated readmission reduction program, virtual community of practice among primary health professionals, and stepped-wedge trial.

Background Sensitive general cardiometabolic risk assessment tools of modifiable risk factors would be helpful and practical in a range of primary prevention interventions or for preventive health maintenance. Purpose To develop and validate a cumulative general cardiometabolic risk score that focuses on non-self-reported modifiable risk factors such as glycosylated hemoglobin (HbA1c) and BMI so as to be sensitive to small changes across a span of major modifiable risk factors, which may not individually cross clinical cut-off points for risk categories. Methods We prospectively followed 2,359 cardiovascular disease (CVD)-free subjects from the Framingham offspring cohort over a 14-year follow-up. Baseline (fifth offspring examination cycle) included HbA1c and cholesterol measurements. Gender-specific Cox proportional hazards models were considered to evaluate the effects of non-self-reported modifiable risk factors (blood pressure, total cholesterol, high-density lipoprotein cholesterol, smoking, BMI, and HbA1c) on general CVD risk. We constructed 10-year general cardiometabolic risk score functions and evaluated its predictive performance in 2012-2013. Results HbA1c was significantly related to general CVD risk. The proposed cardiometabolic general CVD risk model showed good predictive performance as determined by cross-validated discrimination (male C-index=0.703, 95% CI=0.668, 0.734; female C-index=0.762, 95% CI=0.726, 0.801) and calibration (lack-of-fit chi-square=9.05 [p=0.338] and 12.54 [p=0.128] for men and women, respectively). Conclusions This study presents a risk factor algorithm that provides a convenient and informative way to quantify cardiometabolic risk on the basis of modifiable risk factors that can motivate an individual's commitment to prevention and intervention. [ABSTRACT FROM AUTHOR]

Introduction: Initiating tobacco use in adolescence increases the risk of nicotine dependence and continued use into adulthood. Primary care visits provide opportunities for the assessment and treatment of tobacco use; however, little is known about prevalence and correlates of assessing smoking status and current use among adolescents in these settings.Aims and Methods: Using electronic health record data from the OCHIN network, we identified adolescents with greater than or equal to one primary care visit to a study clinic (n = 366 clinics from 15 US states) during January 1, 2016 to December 31, 2017. We estimated odds ratios of smoking assessment and current smoking status by patient covariates.Results: Of 140 887 patients, 87.4% were assessed for smoking. Being Latino or Black (adjusted odds ratio = 1.22, 95% confidence interval: 1.13-1.32; adjusted odds ratio = 1.17, 95% confidence interval: 1.07-1.29, respectively, vs. non-Hispanic White), publicly insured, having more visits, and having an asthma diagnosis or other respiratory symptoms were associated with higher odds of assessment. Odds were lower if the patient was male and uninsured. Of those assessed, 1.6% identified as current smokers. Being older, having more visits, an asthma diagnosis, other respiratory symptoms, and lower household income was associated with higher odds of being a current smoker. Latinos and Blacks had lower odds than non-Hispanic Whites.Conclusions: Although some commonly reported tobacco-related disparities were not present, smoking assessment and current smoking status differed significantly by most patient demographics. Implementation of adolescent tobacco assessment protocols and the development of interventions to target subpopulations of adolescents with higher rates of smoking could mitigate disparate rates of assessment and smoking, respectively.Implications: Clinical guidelines recommend screening adolescents for tobacco use in primary care settings. We found that most adolescents seen in US safety-net primary care clinics were assessed for smoking. We also found that smoking assessment and current smoking status differed significantly by most patient demographics. Implementing tobacco assessment protocols specific to adolescents could mitigate disparate rates of assessment and ensure accurate documentation of all forms of tobacco use, given the evolution of alternative tobacco products and poly use among adolescents. Interventions to target subpopulations of adolescents with higher smoking rates are needed to prevent the negative health effects of continued smoking. [ABSTRACT FROM AUTHOR]

Introduction: Preventive care delivery is an important quality outcome, and electronic data reports are being used increasingly to track these services. It is highly informative when electronic data sources are compared to information manually extracted from medical charts to assess validity and completeness.Methods: This cross-sectional study used a random sample of Medicaid-insured patients seen at 43 community health centers in 2011 to calculate standard measures of correspondence between manual chart review and two automated sources (electronic health records [EHRs] and Medicaid claims), comparing documentation of orders for and receipt of ten preventive services (n=150 patients/service). Data were analyzed in 2015.Results: Using manual chart review as the gold standard, automated EHR extraction showed near-perfect to perfect agreement (κ=0.96-1.0) for services received within the primary care setting (e.g., BMI, blood pressure). Receipt of breast and colorectal cancer screenings, services commonly referred out, showed moderate (κ=0.42) to substantial (κ=0.62) agreement, respectively. Automated EHR extraction showed near-perfect agreement (κ=0.83-0.97) for documentation of ordered services. Medicaid claims showed near-perfect agreement (κ=0.87) for hyperlipidemia and diabetes screening, and substantial agreement (κ=0.67-0.80) for receipt of breast, cervical, and colorectal cancer screenings, and influenza vaccination. Claims showed moderate agreement (κ=0.59) for chlamydia screening receipt. Medicaid claims did not capture ordered or unbilled services.Conclusions: Findings suggest that automated EHR and claims data provide valid sources for measuring receipt of most preventive services; however, ordered and unbilled services were primarily captured via EHR data and completed referrals were more often documented in claims data. [ABSTRACT FROM AUTHOR]

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 <.001). More effective facilitators cultivated motivation by tailoring QI work and addressing resistance, guided practices to think critically, and provided accountability to support change, using these strategies in combination. They were able to describe their work in detail. In contrast, less effective facilitators seldom used these strategies and described their work in general terms. Facilitator background, experience, and work on documentation did not differentiate between more and less effective facilitators.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. [ABSTRACT FROM AUTHOR]

It is uncertain if disparities in asthma diagnosis between Latino and non-Hispanic white children stem from differences in diagnosis over time among children presenting with similar clinical scenarios suggestive of asthma. We evaluated the odds of International Classification of Disease (ICD)-coded asthma diagnosis in Latino (English and Spanish preferring) and non-Hispanic white children, overall (N = 524,456) and among those presenting with possible asthma indicators (N = 85,516) over a 13-year period, using electronic health record data from a multi-state network of community health centers. Among those with possible asthma indicators, Spanish-preferring Latinos had lower adjusted odds of ICD-coded asthma diagnosis compared to non-Hispanic whites (OR = 0.87, 95%CI = 0.77-0.99); English-preferring Latinos did not differ from non-Hispanic whites. Differences in ICD-coded diagnosis between ethnicity/language groups varied by presenting symptom. Spanish-preferring Latino children may be less-likely to have ICD-coded asthma documented in the EHR when presenting with certain clinical indicators suggestive of asthma. Clinicians should be cognizant of the need for the follow-up of these indicators in Spanish-preferring Latino children. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Primary care providers must understand the use patterns, clinical complexity, and primary care needs of cancer survivors to provide quality health care services. However, to the authors' knowledge, little is known regarding the prevalence and health care needs of this growing population, particularly in safety net settings.Methods: The authors identified adults with a history of cancer documented in primary care electronic health records within a network of community health centers (CHCs) in 19 states. The authors estimated cancer history prevalence among >1.2 million patients and compared sex-specific site distributions with national estimates. Each survivor was matched to 3 patients without cancer from the same set of clinics. The demographic characteristics, primary care use, and comorbidity burden then were compared between the 2 groups, assessing differences with absolute standardized mean differences (ASMDs). ASMD values >0.1 denote meaningful differences between groups. Generalized estimating equations yielded adjusted odds ratios (aORs) for select indicators.Results: A total of 40,266 cancer survivors were identified (prevalence of 3.0% of adult CHC patients). Compared with matched cancer-free patients, a higher percentage of survivors had ≥6 primary care visits across 3 years (62% vs 48%) and were insured (83% vs 74%) (ASMD, >0.1 for both). Cancer survivors had excess medical complexity, including a higher prevalence of depression, asthma/chronic obstructive pulmonary disease, and liver disease (ASMD, >0.1 for all). Survivors had higher odds of any opioid prescription (aOR, 1.23; 95% CI, 1.19-1.27) and chronic opioid therapy (aOR, 1.27; 95% CI, 1.23-1.32) compared with matched controls (P < .001 for all).Conclusions: Identifying cancer survivors and understanding their patterns of utilization and physical and mental comorbidities present an opportunity to tailor primary health care services to this population. [ABSTRACT FROM AUTHOR]

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. 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. 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). 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. [ABSTRACT FROM AUTHOR]

Obstructive pulmonary disease outcomes in the United States differ between Latinos and non-Hispanic whites. There is little objective data about diagnosis prevalence and primary care visit frequency in these disease processes. We used electronic health record data to perform a retrospective cohort analysis of 34,849 low-income patients seen at Oregon community health centers between 2009 and 2013 to assess joint racial/ethnic and insurance disparities in diagnosis and visit rates between Latino and non-Hispanic white patients. The overall study prevalence of obstructive lung disease was 18%. Latinos had lower odds of obstructive lung disease diagnosis (OR 0.37, 95% CI 0.30–0.44). Among those diagnosed prior to 2009, the uninsured (regardless of race/ethnicity) had lower visit rates during 2009–2013 than the insured. This study identified racial/ethnic disparities in the diagnosis of obstructive pulmonary disease between Latinos and non-Hispanic Whites, confirming trends observed in survey research but controlling for important confounders. Health insurance was associated with basic care utilization, suggesting that lack of health insurance could lessen the quality of care for obstructive pulmonary disease in Latino and non-Hispanic white patients. [ABSTRACT FROM AUTHOR]

Objectives. To examine associations between patient factors and smoking cessation assistance in US safety-net clinics. Methods. Using electronic health record data from the OCHIN network, we identified adults with at least 1 primary care visit to a study clinic (n = 143 clinics in 12 states) with at least 1 documented "current smoker" status during 2014 to 2016 (n = 136 314; 29.8%). We estimated odds ratios (ORs) of smoking cessation assistance receipt (none [reference], counseling, medication, or both) by patient covariates. Results. For all cessation assistance categories, odds of assistance were higher among women, those with more visits, those assessed and ready to quit, and patients with asthma or chronic obstructive pulmonary disease and hyperlipidemia. Odds of receiving both counseling and medication were lower among uninsured patients (OR = 0.56; 95% confidence interval [CI] = 0.48, 0.64), those of a race/ethnicity other than non-Hispanic White (OR range = 0.65-0.82), and those with diabetes (OR = 0.85; 95% CI = 0.79, 0.92), and higher among older patients and those with a comorbidity, with few exceptions. Conclusions. Disparities in smoking cessation assistance receipt exist in safety-net settings, in particular by health insurance coverage and across race/ethnicity, even after control for other socioeconomic and demographic factors. [ABSTRACT FROM AUTHOR]

Background: The Agency for Healthcare Research and Quality (AHRQ) launched the EvidenceNOW Initiative to rapidly disseminate and implement evidence-based cardiovascular disease (CVD) preventive care in smaller primary care practices. AHRQ funded eight grantees (seven regional Cooperatives and one independent national evaluation) to participate in EvidenceNOW. The national evaluation examines quality improvement efforts and outcomes for more than 1500 small primary care practices (restricted to those with fewer than ten physicians per clinic). Examples of external support include practice facilitation, expert consultation, performance feedback, and educational materials and activities. This paper describes the study protocol for the EvidenceNOW national evaluation, which is called Evaluating System Change to Advance Learning and Take Evidence to Scale (ESCALATES).Methods: This prospective observational study will examine the portfolio of EvidenceNOW Cooperatives using both qualitative and quantitative data. Qualitative data include: online implementation diaries, observation and interviews at Cooperatives and practices, and systematic assessment of context from the perspective of Cooperative team members. Quantitative data include: practice-level performance on clinical quality measures (aspirin prescribing, blood pressure and cholesterol control, and smoking cessation; ABCS) collected by Cooperatives from electronic health records (EHRs); practice and practice member surveys to assess practice capacity and other organizational and structural characteristics; and systematic tracking of intervention delivery. Quantitative, qualitative, and mixed methods analyses will be conducted to examine how Cooperatives organize to provide external support to practices, to compare effectiveness of the dissemination and implementation approaches they implement, and to examine how regional variations and other organization and contextual factors influence implementation and effectiveness.Discussion: ESCALATES is a national evaluation of an ambitious large-scale dissemination and implementation effort focused on transforming smaller primary care practices. Insights will help to inform the design of national health care practice extension systems aimed at supporting practice transformation efforts in the USA.Clinical Trial Registration: NCT02560428 (09/21/15). [ABSTRACT FROM AUTHOR]

Purpose▶To assess the impact of a multicomponent intervention on 30-day hospital readmissions in a group of primary care practices that undertook practice transformation, compared with rates in usual-care practices that admitted patients to the same hospital service. Methods▶Four primary care clinics enhanced patient care coordination with care managers and inpatient care teams, and developed and used hospital readmission reports to monitor readmission rates. Patient readmissions to the hospital were analyzed over a 12-month period from May 2012 through April 2013, among patients who fell into 2 groups. Group 1 patients were those cared for by the primary care clinics that implemented transformation activities and who were admitted to the hospital associated with the practices. Group 2 patients were seen at clinics in the same catchment area that did not undertake any known practice redesign activities (usual care group). Results▶A total of 961 patients were included in analyses; 685 (71.3%) were in Group 1, and 276 (28.7%) were in Group 2. Readmissions among Group 1 patients decreased from 27% to 7.1% (P=.02), and readmissions in Group 2 were variable with a nonsignificant trend (P=.53). The unadjusted regression model model that compared the interaction between Group 1 and Group 2 patients found a significant difference in readmissions (P=.05). Conclusion▶Developing a multicomponent intervention appears to have a significant impact on reducing hospital readmissions. Primary care groups seeking to reduce hospital readmissions should consider implementing similar processes. [ABSTRACT FROM AUTHOR]

Research Objective: Cardiovascular disease (CVD) such as heart failure and stroke has been the top cause of death for over 90 years. The beneficial effects of four simple treatment options ‐‐ aspirin prescription, blood pressure control, cholesterol management and smoking screening and cessation counseling (ABCS) ‐‐ in reducing mortality are well established. Yet, delivering the ABCS at optimal levels continues to be challenging for primary care practices, where the majority of patients receive care. In 2015, the Agency for Healthcare Research and Quality (AHRQ) launched EvidenceNOW: Advancing Heart Health in Primary Care, a national, 110 million dollar initiative focused on providing external support interventions (e.g., practice facilitation or health information technology support) to 1500 small‐to‐medium sized primary care practices with over eight million patients. The research objective of this study was to estimate EvidenceNOW‐related reductions in the risk of experiencing an adverse CVD event. Study Design: Study Design: We developed a new methodology to calculate CVD risk using (i) ABCS levels of EvidenceNOW practices; (ii) patient‐level information from the National Health and Nutrition Examination Survey (NHANES); and (iii) information about CVD risk over a 10‐year period developed by the American College of Cardiology and the American Heart Association. We estimated 10‐year CVD risk at baseline, just before EvidenceNOW started, and reductions to risk due to EvidenceNOW‐related improvements in the ABCS. Population Studied: Primary care practices participating in EvidenceNOW and NHANES study participants. Principal Findings: The average 10‐year CVD risk at baseline was estimated to be 10.3 percent among patients of practices participating in the initiative. Improvements in the ABCS due to EvidenceNow reduced this risk by about 0.1 percentage points, or approximately 1.0 percent relative to baseline. Two patient populations had the biggest CVD risk reduction: those with hypertension and those with multiple comorbidities who have a high CVD risk. According to these estimates, EvidenceNOW prevented about 4000 CVD events at a cost of approximately $29,000 per event. Conclusions: EvidenceNOW successfully reduced CVD events among patients of practices participating in the initiative, although overall reductions were small. Risk reductions were stronger for high‐risk patients, such as those with multiple comorbidities. Implications for Policy or Practice: Preventive care efforts to reduce cardiovascular disease in primary care practices are cost effective even for a large patient population with moderate CVD risk and therefore should be implemented more widely. Targeting specific patient population can be a valuable policy to improve the health of high‐risk populations. Primary Funding Source: Agency for Healthcare Research and Quality. [ABSTRACT FROM AUTHOR]

Research Objective: Cardiovascular disease (CVD) such as heart failure and stroke has been the top cause of death for over 90 years. The beneficial effects of four simple treatment options ‐‐ aspirin prescription, blood pressure control, cholesterol management and smoking screening and cessation counseling (ABCS) ‐‐ in reducing mortality are well established. Yet, delivering the ABCS at optimal levels continues to be challenging for primary care practices, where the majority of patients receive care. In 2015, the Agency for Healthcare Research and Quality (AHRQ) launched EvidenceNOW: Advancing Heart Health in Primary Care, a national, 110 million dollar initiative focused on providing external support interventions (e.g., practice facilitation or health information technology support) to 1500 small‐to‐medium sized primary care practices with over eight million patients. The research objective of this study was to estimate EvidenceNOW‐related reductions in the risk of experiencing an adverse CVD event. Study Design: Study Design: We developed a new methodology to calculate CVD risk using (i) ABCS levels of EvidenceNOW practices; (ii) patient‐level information from the National Health and Nutrition Examination Survey (NHANES); and (iii) information about CVD risk over a 10‐year period developed by the American College of Cardiology and the American Heart Association. We estimated 10‐year CVD risk at baseline, just before EvidenceNOW started, and reductions to risk due to EvidenceNOW‐related improvements in the ABCS. Population Studied: Primary care practices participating in EvidenceNOW and NHANES study participants. Principal Findings: The average 10‐year CVD risk at baseline was estimated to be 10.3 percent among patients of practices participating in the initiative. Improvements in the ABCS due to EvidenceNow reduced this risk by about 0.1 percentage points, or approximately 1.0 percent relative to baseline. Two patient populations had the biggest CVD risk reduction: those with hypertension and those with multiple comorbidities who have a high CVD risk. According to these estimates, EvidenceNOW prevented about 4000 CVD events at a cost of approximately $29,000 per event. Conclusions: EvidenceNOW successfully reduced CVD events among patients of practices participating in the initiative, although overall reductions were small. Risk reductions were stronger for high‐risk patients, such as those with multiple comorbidities. Implications for Policy or Practice: Preventive care efforts to reduce cardiovascular disease in primary care practices are cost effective even for a large patient population with moderate CVD risk and therefore should be implemented more widely. Targeting specific patient population can be a valuable policy to improve the health of high‐risk populations. Primary Funding Source: Agency for Healthcare Research and Quality. [ABSTRACT FROM AUTHOR]

We appreciate Buiting and Bolt for their insightful letter regarding our article[1] and the unique primary care needs of cancer survivors. For example, optimal primary care for a posttreatment survivor of early-stage cancer will vary tremendously from that of a patient undergoing curative cancer treatment or from one undergoing palliative care for advanced disease. With this information, we call for continued technological innovations to facilitate the availability of relevant cancer history data within primary care EHRs, which ultimately will improve patient-centered care for all cancer survivors. [Extracted from the article]

Objectives: To test the effectiveness of a comprehensive team-based intervention to improve human papillomavirus (HPV) vaccination completion rates and reduce missed opportunities to vaccinate in rural Oregon.Design: Stepped-wedge cluster randomized trial.Participants: Forty family physicians and pediatricians who are members of the Oregon Rural Practice-based Research Network.Intervention: Tailored to individual practice needs, components will include (1) practice facilitation with clinicians, nurses, front office staff, and others who have patient contact to redesign patient care and communication strategies to optimize HPV vaccine series completion; (2) workflow mapping adapted to practice context to support HPV vaccine delivery; (3) a practice improvement model designed to firmly establish reminder and recall systems and then standing orders; (4) education for patients and parents that underscores HPV vaccination is safe, effective, and an important approach for reducing cancer risk; and (5) partnering with community organizations to plan and implement a social marketing campaign on HPV vaccination.Main Outcome Measures: Initiation and completion of the HPV vaccine series as well as reduction in rates of missed opportunities to vaccinate derived from Oregon Immunization Program data.Trial Registration: ClinicalTrials.govPRS, NCT03604393 : .Trial was registered on July 11, 2018. The first participant was enrolled on September 11, 2018. [ABSTRACT FROM AUTHOR]