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Nontuberculous mycobacteria (NTM) infection is an illness of increasing incidence caused by environmental organisms and can lead to chronic pulmonary disease (1-5). The accuracy of International Classification of Diseases (ICD) [...]

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, [...]

BackgroundHealth care outcomes have been increasingly assessed through health-related quality of life (HRQoL) measures. While the introduction of nitrogen-scavenging medications has improved survival in patients with urea cycle disorders (UCDs), they are often associated with side effects that may affect patient compliance and outcomes.MethodsSymptoms commonly associated with nitrogen-scavenging medications were evaluated in 100 adult and pediatric participants using a non-validated UCD-specific questionnaire. Patients or their caregivers responded to a pre-defined list of symptoms known to be associated with the use of these medications. Responses were collected at baseline (while patients were receiving sodium phenylbutyrate [NaPBA]) and during treatment with glycerol phenylbutyrate (GPB).ResultsAfter 3 months of GPB dosing, there were significant reductions in the proportion of patients with treatment-associated symptoms (69% vs. 46%; p

PurposeThe aim of this study was to examine predictors of ammonia exposure and hyperammonemic crises in patients with urea cycle disorders.MethodsThe relationships between fasting ammonia, daily ammonia exposure, and hyperammonemic crises were analyzed in >100 patients with urea cycle disorders.ResultsFasting ammonia correlated strongly with daily ammonia exposure (r = 0.764; P < 0.001). For patients with fasting ammonia concentrations 200% (P < 0.0001), respectively. The relationship between ammonia and hyperammonemic crisis risk seemed to be independent of treatment, age, urea cycle disorder subtype, dietary protein intake, or blood urea nitrogen. Fasting glutamine correlated weakly with daily ammonia exposure assessed as 24-hour area under the curve and was not a significant predictor of hyperammonemic crisis.ConclusionFasting ammonia correlates strongly and positively with daily ammonia exposure and with the risk and rate of hyperammonemic crises, suggesting that patients with urea cycle disorder may benefit from tight ammonia control.

Disparities in U.S. mental health care by race and ethnicity have long been documented. The authors sought to compare specialty mental health service use among non-Hispanic White, English-preferring Hispanic, and Spanish-preferring Hispanic patients who accessed care in community health centers (CHCs). Retrospective electronic medical records data were extracted for patients ages ≥18 years who received care in 2012–2020 at a national CHC network. Zero-inflated Poisson regression models were used to estimate the likelihood of receiving mental health services, which was compared with expected annual rates of mental health service use. Of the 1,498,655 patients who received care at a CHC during the study, 14.4% (N=215,098) received any specialty mental health services. English- and Spanish-preferring Hispanic patients were less likely to have had a mental health visit (OR=0.69, 95% CI=0.61–0.77, and OR=0.65, 95% CI=0.54–0.78, respectively). Compared with non-Hispanic White patients, Spanish-preferring Hispanic patients had an estimated annualized rate of 0.59 (95% CI=0.46–0.76) mental health visits. Among patients who were likely to receive specialty mental health services, Spanish-preferring patients had a significantly lower rate of mental health care use. Although overall access to mental health care is improving, unequal access to recurring specialty mental health care remains among patients who do not prefer to use English. [ABSTRACT FROM AUTHOR]

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 [...]