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Armin Munevar [a] Miguel A. Marino [b] Abstract A modeling approach is developed to evaluate the potential for artificial recharge on alluvial fans in the Salinas Valley, California, using limited [...]

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: 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 adolescentmother 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 Spanishpreferring 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 Spanishpreferring 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. [ABSTRACT FROM AUTHOR]

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 =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 nonexpansion) states throughout the study period. Trends in acute complication rates were not parallel over time between expansion and non-expansion states (p<0.01), with a larger decline in expansion (compared to non-expansion) states immediately following the ACA (relative rate change from 2013 to 2015: -41% in expansion vs -1% in non-expansion). Conclusions: Our findings suggest that increased access to health insurance following the ACA was associated with a reduction in acute complications among patients with diabetes in states that expanded Medicaid. [ABSTRACT FROM AUTHOR]

Introduction: Latino adolescents may face numerous barriers) to 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. To better understand the social/family factors associated with Latino adolescent vaccination, we studied the association of adolescent-mother language concordance and neighborhood social deprivation with adolescent vaccination completion. Methods: We employed a multistate, electronic health record (EHR) based dataset of community health center patients to compare three Latino groups: (1) English-preferring adolescents with English-preferring mothers, (2) Spanish-preferring adolescents with Spanish-preferring mothers, and (3) English-preferring adolescents with Spanish-preferring mothers with non-Hispanic white adolescent-mother pairs for human papilloma virus (HPV), meningococcal, and influenza vaccinations. We adjusted for mother and adolescent demographics and care utilization and stratified by the social deprivation of the family's neighborhood. 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. Latino dyads with Spanish-preferring mothers had higher vaccination odds/rates than Latino dyads with English-preferring mothers. The effects of variation by neighborhood social deprivation in influenza vaccination rates were minor in comparison to differences by ethnicity/language concordance. Conclusion: 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 the lowest. Further research can seek to understand why this language dyad may have an advantage in adolescent vaccination completion. Significance: Latino adolescents may face numerous barriers to preventive care—especially routine immunizations, but analyses often focus on single or few factors that may affect the utilization of these services. Our analysis of not only the language preference of Latino adolescents, but the preferred language of their mothers and their neighborhood social adversity demonstrates that English-preferring Latino adolescents with Spanish preferring mothers were most likely to utilize all immunizations we studied, and there were differences in utilization among Latino families by language concordance. This adds to our knowledge of Latino adolescent health care utilization by demonstrating the differences in Latino families, and suggesting that many of these families may have assets for service utilization from which we can learn. [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 and Objectives: The In-training Examination (ITE) is a frequently used method to evaluate family medicine residents' clinical knowledge. We compared family medicine ITE scores among residents who trained in the 14 programs that participated in the Preparing the Personal Physician for Practice (P4) Project to national averages over time, and according to educational innovations.Methods: The ITE scores of 802 consenting P4 residents who trained in 2007 through 2011 were obtained from the American Board of Family Medicine. The primary analysis involved comparing scores within each academic year (2007 through 2011), according to program year (PGY) for P4 residents to all residents nationally. A secondary analysis compared ITE scores among residents in programs that experimented with length of training and compared scores among residents in programs that offered individualized education options with those that did not.Results: Release of ITE scores was consented to by 95.5% of residents for this study. Scores of P4 residents were higher compared to national scores in each year. For example, in 2011, the mean P4 score for PGY1 was 401.2, compared to the national average of 386. For PGY2, the mean P4 score was 443.1, compared to the national average of 427, and for PGY3, the mean P4 score was 477.0, compared to the national PGY3 score of 456. Scores of residents in programs that experimented with length of training were similar to those in programs that did not. Scores were also similar between residents in programs with and without individualized education options.Conclusions: Family medicine residency programs undergoing substantial educational changes, including experiments in length of training and individualized education, did not appear to experience a negative effect on resident's clinical knowledge, as measured by ITE scores. Further research is needed to study the effect of a wide range of residency training innovations on ITE scores over time. [ABSTRACT FROM AUTHOR]

Objective: Our objective was to examine perceptions of adequacy in team-based care training during residency and whether this influences practice choice post- residency training.Methods: We analyzed self-administered survey data from recent residency graduates collected as part of the Preparing Personal Physicians for Practice (P4) Project to characterize residents' perceptions of adequacy of training they received on team-based care. Multivariable logistic regression was used to assess the association between adequacy of team-based care training and joining practices that use team-based care after residency graduation, adjusting for differences in demographics.Results: A total of 241 residency graduates were included in these analyses with response rates to surveys of 80.8%-98.1%. They reported practicing in 31 different US states or districts and four other countries. Over 82% of residency graduates reported being adequately trained in team-based care, 9.5% reported being overtrained, and 7.9% reported receiving no team-based care training over the study period. Seventy-six percent of P4 graduates joined practices that used team-based care in 2011, which increased to 86% (81/94) in 2013. The adjusted odds of practicing in settings with team-based care was 5.7 times higher for residents who reported being adequately prepared for team-based care compared to those who reported receiving no team-based care training and was 12.5 times higher for those who reported being over-prepared compared to those who reported no training/under-prepared.Conclusions: The majority of residency graduates perceive they were well trained in team-based care, which is significantly associated with joining practices that use team-based care post graduation. [ABSTRACT FROM AUTHOR]

Background and Objectives: Little is known about how the patient-centered medical home (PCMH) is being implemented in residency practices. We describe both the trends in implementation of PCMH features and the influence that working with PCMH features has on resident attitudes toward their importance in 14 family medicine residencies associated with the P4 Project.Methods: We assessed 24 residency continuity clinics annually between 2007-2011 on presence or absence of PCMH features. Annual resident surveys (n=690) assessed perceptions of importance of PCMH features using a 4-point scale (not at all important to very important). We used generalized estimating equations logistic regression to assess trends and ordinal-response proportional odds regression models to determine if resident ratings of importance were associated with working with those features during training.Results: Implementation of electronic health record (EHR) features increased significantly from 2007-2011, such as email communication with patients (33% to 67%), preventive services registries (23% to 64%), chronic disease registries (63% to 82%), and population-based quality assurance (46% to 79%). Team-based care was the only process of care feature to change significantly (54% to 93%). Residents with any exposure to EHR-based features had higher odds of rating the features more important compared to those with no exposure. We observed consistently lower odds of the resident rating process of care features as more important with any exposure compared to no exposure.Conclusions: Residencies engaged in educational transformation were more successful in implementing EHR-based PCMH features, and exposure during training appears to positively influence resident ratings of importance, while exposure to process of care features are slower to implement with less influence on importance ratings. [ABSTRACT FROM AUTHOR]

Background and Objectives: Primary care residencies are undergoing dramatic changes because of changing health care systems and evolving demands for updated training models. We examined the relationships between residents' exposures to patient-centered medical home (PCMH) features in their assigned continuity clinics and their satisfaction with training.Methods: Longitudinal surveys were collected annually from residents evaluating satisfaction with training using a 5-point Likert-type scale (1=very unsatisfied to 5=very satisfied) from 2007 through 2011, and the presence or absence of PCMH features were collected from 24 continuity clinics during the same time period. Odds ratios on residents' overall satisfaction were compared according to whether they had no exposure to PCMH features, some exposure (1-2 years), or full exposure (all 3 or more years).Results: Fourteen programs and 690 unique residents provided data to this study. Resident satisfaction with training was highest with full exposure for integrated case management compared to no exposure, which occurred in 2010 (OR=2.85, 95% CI=1.40, 5.80). Resident satisfaction was consistently statistically lower with any or full exposure (versus none) to expanded clinic hours in 2007 and 2009 (eg, OR for some exposure in 2009 was 0.31 95% CI=0.19, 0.51, and OR for full exposure 0.28 95% CI=0.16, 0.49). Resident satisfaction for many electronic health record (EHR)-based features tended to be significantly lower with any exposure (some or full) versus no exposure over the study period. For example, the odds ratio for resident satisfaction was significantly lower with any exposure to electronic health records in continuity practice in 2008, 2009, and 2010 (OR for some exposure in 2008 was 0.36; 95% CI=0.19, 0.70, with comparable results in 2009, 2010).Conclusions: Resident satisfaction with training was inconsistently correlated with exposure to features of PCMH. No correlation between PCMH exposure and resident satisfaction was sustained over time. [ABSTRACT FROM AUTHOR]