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Few have studied the COVID-19 pandemic’s impact on tobacco use status assessment and cessation counseling. Electronic health record data from 217 primary care clinics were examined from January 1, 2019 to July 31, 2021. Data included telehealth and in-person visits for 759,138 adult patients (aged ≥18 years). Monthly rates of tobacco assessment per 1,000 patients were calculated. From March 2020 to May 2020, tobacco assessment monthly rates declined by 50% and increased from June 2020 to May 2021 but remained 33.5% lower than pre-pandemic levels. Rates of tobacco cessation assistance changed less, but remain low. These findings are significant given the relevance of tobacco use to increased severity of COVID-19.

Background: The fee-for-service reimbursement system that dominates health care throughout the United States links payment to a billable office visit with a physician or advanced practice provider. Under Oregon’s Alternative Payment and Advanced Care Model (APCM), initiated in 2013, participating community health centers (CHCs) received per-member-per-month payments for empaneled Medicaid patients in lieu of standard fee-for-service Medicaid payments. With Medicaid revenue under APCM no longer tied solely to the volume of visits, the Oregon Health Authority needed a way to document the full range of care and services that CHCs were providing to their patients, including nontraditional patient encounters taking place outside of traditional face-to-face visits with a billable provider. Toward this end, program leadership defined 18 visit and nonvisit-based care activities—“Care Services That Engage Patients” (Care STEPs)—that APCM CHCs were asked to document in the electronic health record to demonstrate continued empanelment. Objective: To describe trends in rates of traditional face-to-face office visits and Care STEPs documentation among CHCs involved in the first 3 phases of APCM implementation. Research Design: The study population included the 9 CHCs involved in the first 3 phases of APCM implementation. Using data from the electronic health record, quarterly summary rates for office visits and Care STEPs were calculated for the first 18 quarters of implementation (March 1, 2013 to June 30, 2017). Results: Among participating CHCs, the mean rate of face-to-face visits with billable providers declined from 635 ± 128 to 461 ± 109 visits/1000 patients/quarter (mean difference, −174; 95% CI, −255, −94). Care STEPs documentation increased from 831 ± 174 to 1017 ± 369 Care Steps/1000 patients/quarter, but the difference was not statistically significant. Care STEPs within the category of New Visit Types were documented most frequently. There were significant increases in documentation of Patient Care Coordination and Integration and a small, albeit significant, increase in Reducing Barriers to Health. There was a significant decline in the documentation of Care STEPs by physicians and advanced practice providers an increase in documentation by ancillary staff. Conclusions: These findings suggest that APCM is increasing CHCs’ capacity to experiment with new ways of providing care beyond the traditional face-to-face office visit with a physician or advanced practice provider. However, CHCs may choose different ways to change the delivery of care and some CHCs have implemented these changes more quickly than others. Future mixed-methods research is needed to understand barriers and facilitators to changing the delivery of care after APCM implementation.

The patient-centered medical home model aspires to fundamentally restructure care processes, but a volume-based payment system may hinder such transformations. In 2013 Oregon’s Medicaid program cha...

Purpose: In an age of value-based payment, primary care providers are increasingly scrutinized on performance metrics that assess quality of care, including the outcomes of their patient population in key areas such as diabetes control. Although such measures often adjust for patient clinical risk factors or clinical complexity, most do not account for the social complexity of patient populations, despite research demonstrating the strong association between social factors and health. Methods: Using patient electronic health record data from 2 large community health center networks serving safety net patients, we assessed the effect of both clinical and social risk factors on poor glucose control among diabetics. Logistic regression results were used to estimate the impact of adjusting for both clinical and social complexity on provider performance metrics. Clinical complexity was measured at the patient-level using the Charlson Comorbidity Index. Social complexity was measured at the community-level using the Social Deprivation Index. Results: Clinical complexity alone was not consistently associated with poor diabetes control (ie, HbA1c > 9%) in diabetic patients with HbA1c testing during the study period. However, increasing social complexity was significantly associated with higher rates of poor diabetic control in both cohorts. After adding adjustment for social complexity down to the national median score, our models suggest that approximately 25% of providers would have 1 to 2% improvement in the assessment of their diabetes control measures, with 45% showing a 2 to 5% improvement, and 5% showing more than a 5% improvement. Conclusions: Providers caring for patients with greater social risk factors may benefit from having their performance metrics adjusted for the social complexity of their patient populations.

BACKGROUND: Electronic health records (EHRs) provide rich data on many domains not routinely available in other data, as such, they are a promising source to study changes in health outcomes using longitudinal study designs (eg, cohort studies, natural experiments, etc.). Yet, patient attrition rates in these data are unknown. OBJECTIVE: The objective of this study was to estimate overall and among adults with diabetes or hypertension: (1) patient attrition over a 3-year period at community health centers; and (2) the likelihood that patients with Medicaid permanently switched their source of primary care. RESEARCH DESIGN: A retrospective cohort study of 2012–2017 data from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) Clinical Data Research Network of community health centers were used to assess EHR data attrition. Oregon Medicaid enrollment and claims data were used to estimate the likelihood of changing the source of primary care. SUBJECTS: A total of 827,657 patients aged 19–64 with ≥ 1 ambulatory visit from 76 community health center systems across 20 states. In all, 232,891 Oregon Medicaid enrollees (aged 19–64) with a gap of ≥ 6 months following a claim for a visit billed to a primary care source. MEASURES: Percentage of patients not returning within 3 years of their qualifying visit (attrition). The probability that a patient with Medicaid permanently changed their primary care source. RESULTS: Attrition over the 3 years averaged 33.5%; attrition rates were lower (< 25%) among patients with diabetes and/or hypertension. Among Medicaid enrollees, the percentage of provider change after a 6-month gap between visits was 12% for community health center patients compared with 39% for single-provider practice patients. Over 3 years, the likelihood of a patient changing to a new provider increased with length of time since their last visit but remained lowest among community health center patients. CONCLUSION: This study demonstrates the use of the EHR dataset is a reliable source of data to support longitudinal studies while highlighting variability in attrition by primary care source and chronic conditions.

OBJECTIVE To compare trends in Medicaid expenditures among adults with diabetes who were newly eligible due to the Affordable Care Act (ACA) Medicaid expansion to trends among those previously eligible. RESEARCH DESIGN AND METHODS Using Oregon Medicaid administrative data from 1 January 2014 to 30 September 2016, a retrospective cohort study was conducted with propensity score–matched Medicaid eligibility groups (newly and previously eligible). Outcome measures included total per-member per-month (PMPM) Medicaid expenditures and PMPM expenditures in the following 12 categories: inpatient visits, emergency department visits, primary care physician visits, specialist visits, prescription drugs, transportation services, tests, imaging and echography, procedures, durable medical equipment, evaluation and management, and other or unknown services. RESULTS Total PMPM Medicaid expenditures for newly eligible enrollees with diabetes were initially considerably lower compared with PMPM expenditures for matched previously eligible enrollees during the first postexpansion quarter (mean values $561 vs. $793 PMPM, P = 0.018). Within the first three postexpansion quarters, PMPM expenditures of the newly eligible increased to a similar but slightly lower level. Afterward, PMPM expenditures of both groups continued to increase steadily. Most of the overall PMPM expenditure increase among the newly eligible was due to rapidly increasing prescription drug expenditures. CONCLUSIONS Newly eligible Medicaid enrollees with diabetes had slightly lower PMPM expenditures than previously eligible Medicaid enrollees. The increase in PMPM prescription drug expenditures suggests greater access to treatment over time.

Background/aims Evidence suggests that Medicaid beneficiaries in the United States are prescribed opioids more frequently than are people who are privately insured, but little is known about opioid prescribing patterns among Medicaid enrollees who gained coverage via the Affordable Care Act Medicaid expansions. This study compared the prevalence of receipt of opioid prescriptions and opioid use disorder (OUD), along with time from OUD diagnosis to medication-assisted treatment (MAT) receipt between Oregon residents who had been continuously insured by Medicaid, were newly insured after Medicaid expansion in 2014 or returned to Medicaid coverage after expansion. Design Cross-sectional study using inverse-propensity weights to adjust for differences among insurance groups. Setting Oregon. Participants A total of 225 295 Oregon Medicaid adult beneficiaries insured during 2014-15 and either: (1) newly enrolled, (2) returning in 2014 after a > 12-month gap or (3) continuously insured between 2013 and 2015. We excluded patients in hospice care or with cancer diagnoses. Measurements Any opioid-dispensed, chronic (> 90-days) and high-dose (> 90 daily morphine milligram equivalence) opioid use, documented OUD diagnosis and MAT receipt. Findings Compared with the continuously insured, newly and returning insured enrollees were less likely to be dispensed opioids [newly: 42.3%, 95% confidence interval (CI) = 42.0-42.7%; returning: 49.3%, 95% CI = 48.8-49.7%; continuously: 52.5%, 95% CI = 52.0-53.0%], use opioids chronically (newly: 12.8%, 95% CI = 12.4-13.1%; returning: 11.9%, 95% CI = 11.5-12.3%, continuously: 15.8%, 95% CI = 15.4-16.2%), have OUD diagnoses (newly: 3.6%, 95% CI = 3.4-3.7%; returning: 3.9%, 95% CI = 3.8-4.1%, continuously: 4.7%, 95% CI = 4.5-4.9%) and receive MAT after OUD diagnosis [hazard ratio newly: 0.57, 95% CI = 0.53-0.61; hazard ratio returning: 0.60, 95% CI = 0.56-0.65 (ref: continuously)]. Conclusions Residents of Oregon, United States who enrolled or re-enrolled in Medicaid health insurance after expansion of coverage in 2014 as a result of the Affordable Care Act were less likely than those already covered to receive opioids, use them chronically or receive medication-assisted treatment for opioid use disorder.

Background: In 2013, Oregon initiated an Alternative Payment Methodology (APM) Experiment for select health centers, initiating capitated payments for patients with Medicaid. Objective: To use electronic health record data to evaluate the impact of APM on visit and scheduling metrics in the first wave of experiment clinics. Research Design: Retrospective clinic cohort. Difference-in-differences analysis using generalized linear mixed modeling across 2 time thresholds: the initiation of APM and the start of the Affordable Care Act Medicaid expansion. Subjects: Eight primary clinics enrolled in APM on March 1, 2013 and 10 comparison clinics not enrolled in APM during the study period (July 1, 2012 to February 28, 2015). Measures: Independent variable: intervention status of the clinics (APM or comparison). Dependent variables: total patient encounters, total alternative encounters, new patient visits, provider appointment availability, number of appointment overbooks and no-shows/late cancellations. Results: Comparison clinics had smaller patient panels and more advanced practice providers than APM clinics, but both had similar proportions of Hispanic, Medicaid, and uninsured patients. APM clinics had a 20% greater increase in same-day openings than non-APM clinics across the APM implementation (Relative Ratio, 1.20; 95% CI, 1.02 to 1.42). Otherwise, there were minimal differences in APM clinics and control clinics in wait times, visit rates, patient no-shows, and overbooks. Conclusions: APM clinics experienced a greater increase in same-day visits over the course of this experiment, but did not significantly differ from comparators in other visit metrics. Further research into other impacts of this experiment are necessary and ongoing.

Background: Short- and long-term effects of COVID-19 will likely be designated pre-existing conditions. We describe the prevalence of pre-existing conditions among community health center patients overall and those with COVID-19 by race/ethnicity. Materials and Methods: This cross-sectional study used electronic health record data from OCHIN, a network of 396 community health centers across 14 states. Results: Among all patients with COVID-19, 33% did not have a pre-existing condition before the pandemic. Up to half of COVID-19-positive non-Hispanic Asians (51%), Hispanic (36%), and non-Hispanic black (28%) patients did not have a pre-existing condition before the pandemic. Conclusions: The future of the Patient Protection and Affordable Care Act is uncertain, and the long-term health effects of COVID-19 are largely unknown; therefore, ensuring people with pre-existing conditions can acquire health insurance is essential to achieving health equity.

This study uses electronic health record data to describe primary care services offered by US community health centers in March through May 2020, including SARS-CoV-2 testing, well-child visits, HbA(1c) testing, and cancer screening.

Health insurance coverage facilitates access to preventive screenings and other essential health care services, and is linked to improved health outcomes; therefore, it is critical to understand how well coverage information is documented in the electronic health record (EHR) and which characteristics are associated with accurate documentation. Our objective was to evaluate the validity of EHR data for monitoring longitudinal Medicaid coverage and assess variation by patient demographics, visit types, and clinic characteristics. We conducted a retrospective, observational study comparing Medicaid status agreement between Oregon community health center EHR data linked at the patient-level to Medicaid enrollment data (gold standard). We included adult patients with a Medicaid identification number and ≥1 clinic visit between 1/1/2013–12/31/2014 [>1 million visits (n = 135,514 patients)]. We estimated statistical correspondence between EHR and Medicaid data at each visit (visit-level) and for different insurance cohorts over time (patient-level). Data were collected in 2016 and analyzed 2017–2018. We observed excellent agreement between EHR and Medicaid data for health insurance information: kappa (>0.80), sensitivity (>0.80), and specificity (>0.85). Several characteristics were associated with agreement; at the visit-level, agreement was lower for patients who preferred a non-English language and for visits missing income information. At the patient-level, agreement was lower for black patients and higher for older patients seen in primary care community health centers. Community health center EHR data are a valid source of Medicaid coverage information. Agreement varied with several characteristics, something researchers and clinic staff should consider when using health insurance information from EHR data. Keywords: Electronic health records, Medicaid, Health policy, Health insurance

BACKGROUND: There is interest in assessing healthcare utilization and expenditures among new Medicaid enrollees after the 2014 Medicaid expansion. Recent studies have not differentiated between newly enrolled individuals and those returning after coverage gaps. OBJECTIVES: To assess healthcare expenditures among Medicaid enrollees in the 24 months after Oregon’s 2014 Medicaid expansions and examine whether expenditure patterns were different among the newly, returning, and continuously insured. RESEARCH DESIGN: Retrospective cohort study using inverse-propensity weights to adjust for differences between groups. SUBJECTS: Oregon adult Medicaid beneficiaries insured continuously from 2014-2015 who were either newly, returning, or continuously insured. MEASURES: Monthly expenditures for inpatient care, prescription drugs, total outpatient care, and subdivisions of outpatient care: emergency department (ED), dental, mental and behavioral health (MBH), primary care (PC), and specialist care. RESULTS: After initial increases, newly and returning insured outpatient expenditures dropped below continuously insured. Expenditures for ED and dental services among the returning insured remained higher than among the newly insured. Newly insured MBH, PC, and specialist expenditures plateaued higher than returning insured. Prescription drug expenditures increased over time for all groups, with continuously insured highest and returning insured lowest. All groups had similar inpatient expenditures over 24 months post-Medicaid expansion. CONCLUSIONS: Our findings reveal that outpatient expenditures for new non-pregnant, non-dual-eligible Oregon Medicaid recipients stabilized over time after meeting pent-up demand, and prior insurance history affected the mix of services that individuals received. Policy evaluations should consider expenditures over at least 24 months and should account for enrollees’ prior insurance histories.

Understanding the impact of health insurance is critical, particularly in the era of Affordable Care Act Medicaid expansion. The electronic health record (EHR) provides new opportunities to quantify health outcomes. To assess changes in biomarkers of chronic disease among community health center (CHC) patients who gained Medicaid coverage with the Oregon Medicaid expansion (2008–2011). Prospective cohort. Patients were followed for 24 months, and rate of mean biomarker change was calculated. Time to a controlled follow-up measurement was compared using Cox regression models. Using EHR data from OCHIN (a non-profit network of CHCs) linked to state Medicaid data, we identified three cohorts of patients with uncontrolled chronic conditions (diabetes, hypertension, and hyperlipidemia). Within these cohorts, we included patients who gained Medicaid coverage along with a propensity score-matched comparison group who remained uninsured (diabetes n = 608; hypertension n = 1244; hyperlipidemia n = 546). Hemoglobin A1c (HbA1c) for the diabetes cohort, systolic and diastolic blood pressure (SBP and DBP, respectively) for the hypertension cohort, and low-density lipoprotein (LDL) for the hyperlipidemia cohort. All cohorts improved over time. Compared to matched uninsured patients, adults in the diabetes and hypertension cohorts who gained Medicaid coverage were significantly more likely to have a follow-up controlled measurement (hazard ratio [HR] =1.26, p = 0.020; HR = 1.35, p

Primary care patient-centered medical homes (PCMHs) are an effective healthcare delivery model. Evidence regarding the most effective payment models for increased coordination efforts is sparse. This protocol paper describes the evaluation of an Alternative Payment Methodology (APM) implemented in a subset of Oregon community health centers (CHCs), using a prospective matched observational design. The APM is a primary care payment reform intervention that changed Oregon’s Medicaid payment for several CHCs from fee-for-service reimbursement to a per-member-per-month capitated payment. We will implement a difference-in-difference analytic approach to evaluate pre-post APM changes between intervention and control groups, including: 1) clinic-level outcomes, 2) patient-level clinical outcomes, and 3) patient-level econometric outcomes. Findings from the project will be of national significance, as there is a need for evidence regarding how novel payment methods might enhance PCMH capabilities and support their capacity to produce better quality and outcomes. If this capitated payment method is proven effective, study findings will inform dissemination of similar APMs nationwide.

BACKGROUND: Previous studies suggest the newly Medicaid insured are more likely to use the emergency department (ED) however they did not differentiate between patients established or not established with primary care. OBJECTIVES: To understand where Oregon Medicaid beneficiaries sought care after the Patient Protection and Affordable Care Act (PPACA) Medicaid expansion (ED, primary care, or specialist) and the interaction between primary care establishment and outpatient care utilization. RESEARCH DESIGN: A retrospective cohort study. SUBJECTS: Adults continuously insured from 2014 through 2015 who were either newly, returning, or continuously insured post-PPACA. MEASURES: Site of first and last outpatient visit, established with primary care status, and outpatient care utilization. RESULTS: The odds of being established with primary care at their first visit were lower among newly [odds ratio (OR), 0.18; 95% confidence interval (Cl), 0.18–0.19] and returning insured (OR, 0.22; 95% Cl, 0.22–0.23) than the continuously insured. Continuously insured, new patients with primary care had higher odds of visiting the ED (OR, 2.15; 95% Q, 2.01–2.30) at their first visit than newly or returning insured. Patients established with a single primary care provider in all insurance groups had lower rates of ED visit, whereas those established with multiple primary care providers had the highest ED visit rates. CONCLUSIONS: Most newly and returning insured Medicaid enrollees sought primary care rather than ED services and most became established with primary care. Our findings suggest that both insurance and primary care continuity play a role in where patients seek health care services.

OBJECTIVE We sought to understand how Affordable Care Act (ACA) Medicaid expansion insurance coverage gains are associated with changes in diabetes-related biomarkers. RESEARCH DESIGN AND METHODS This was a retrospective observational cohort study using electronic health record data from 178 community health centers (CHCs) in the ADVANCE (Accelerating Data Value Across a National Community Health Center Network) network. We assessed changes in diabetes-related biomarkers among adult patients with diabetes in 10 Medicaid expansion states (n = 25,279), comparing newly insured with continuously insured, discontinuously insured, and continuously uninsured patients pre– to post–ACA expansion. Primary outcomes included changes from 24 months pre- to 24 months post-ACA in glycosylated hemoglobin (HbA1c), systolic (SBP) and diastolic (DBP) blood pressure, and LDL cholesterol levels. RESULTS Newly insured patients exhibited a reduction in adjusted mean HbA1c levels (8.24% [67 mmol/mol] to 8.17% [66 mmol/mol]), which was significantly different from continuously uninsured patients, whose HbA1c levels increased (8.12% [65 mmol/mol] to 8.29% [67 mmol/mol]; difference-in-differences [DID] −0.24%; P < 0.001). Newly insured patients showed greater reductions than continuously uninsured patients in adjusted mean SBP (DID −1.8 mmHg; P < 0.001), DBP (DID −1.0 mmHg; P < 0.001), and LDL (DID −3.3 mg/dL; P < 0.001). Among patients with elevated HbA1c in the 3 months prior to expansion, newly insured patients were more likely than continuously uninsured patients to have a controlled HbA1c measurement by 24 months post-ACA (hazard ratio 1.25; 95% CI 1.02–1.54]. CONCLUSIONS Post-ACA, newly insured patients had greater improvements in diabetes-related biomarkers than continuously uninsured, discontinuously insured, or continuously insured patients. Findings suggest that health insurance gain via ACA facilitates access to appropriate diabetes care, leading to improvements in diabetes-related biomarkers.

Purpose Implausible anthropometric measures are typically identified using population outlier definitions, conflating implausible and extreme measures. We determined the impact of a longitudinal outlier approach on prevalence of body mass index (BMI) categories and mean change in anthropometric measures in pediatric electronic health record data. Methods We examined 996,131 observations from 147,375 children (10–18 years) in the ADVANCE Clinical Data Research Network, a national network of community health centers. Sex-stratified, mixed effects, linear spline regression modeled weight, height, and BMI as a function of age. Longitudinal outliers were defined as observations with studentized residual greater than |6|; population outliers were defined by Centers for Disease Control-defined z-score thresholds. Results At least 99.7% of anthropometric measures were not extreme by longitudinal or population definitions (agreement ≥ 0.995). BMI category prevalence after excluding longitudinal or population outliers differed by less than 0.1%. Among children greater than 85th percentile at baseline, annual mean changes in anthropometric measures were larger in data that excluded longitudinal (girls: 1.24 inches, 12.39 pounds, 1.53 kg/m2; boys: 2.34, 14.08, 1.07) versus population outliers (girls: 0.61 inches, 8.22 pounds, 0.75 kg/m2; boys: 1.53, 11.61, 0.48). Conclusions Longitudinal outlier methods may reduce underestimation of anthropometric change in children with elevated baseline values.

Only half of the United States population regularly receives recommended preventive care services. Alternative payment models (e.g., a per-member-per-month capitated payment model) may encourage the delivery of preventive services when compared to a fee-for-service visitbased model; however, evaluation is lacking in the United States. This study assesses the impact of implementing Oregon's Alternative Payment Methodology (APM) on orders for preventive services within community health centers (CHCs). This retrospective cohort study uses electronic health record data from the OCHIN, Inc., 2012-2018, analyzed in 2018-2019. Twenty-seven CHCs which implemented APM in 2013-2016 were compared to six non-APM CHCs. Clinic-level quarterly rates of ordering nine preventive services in 2012-2018 were calculated. For each phase and preventive service, we used difference-in-differences analysis to assess the APM impact on ordering preventive care. We found greater increases for APM CHCs compared to non-APM CHCs for orders of mammograms (difference-in-differences estimates (DDs) across four phases:1.69-2.45). Both groups had decreases in ordering cervical cancer screenings, however, APM CHCs had smaller decreases (DDs:1.62-1.93). The APM CHCs had significantly greater decreases in influenza vaccinations (DDs:0.17-0.32). There were no consistent significant differences in pre-post changes in APM vs. non-APM CHCs for cardiometabolic risk screenings, smoking status and depression assessments. There was nonsignificant change in the proportion of nontraditional encounters in APM clinics compared to controls. Transition from fee-for-service to an APM did not negatively impact delivery of preventive care. Further studies are needed to understand how to change encounter structures to best deliver recommended preventive care.

Objective To examine trends in health insurance type among US children and their parents. Methods Using the Medical Expenditure Panel Survey (1998–2011), we linked each child (n = 120,521; weighted n ≈ 70 million) with his or her parent or parents and assessed patterns of full-year health insurance type, stratified by income. We examined longitudinal insurance trends using joinpoint regression and further explored these trends with adjusted regression models. Results When comparing 1998 to 2011, the percentage of low-income families with both child and parent or parents privately insured decreased from 29.2% to 19.1%, with an estimated decline of −0.86 (95% confidence interval, −1.10, −0.63) unadjusted percentage points per year; middle-income families experienced a drop from 74.5% to 66.3%, a yearly unadjusted percentage point decrease of −0.73 (95% confidence interval, −0.98, −0.48). The discordant pattern of publicly insured children with uninsured parents increased from 10.4% to 27.2% among low-income families and from 1.4% to 6.7% among middle-income families. Results from adjusted models were similar to joinpoint regression findings. Conclusions During the past decade, low- and middle-income US families experienced a decrease in the percentage of child–parent pairs with private health insurance and pairs without insurance. Concurrently, there was a rise in discordant coverage patterns—mainly publicly insured children with uninsured parents.

Background Children with health insurance have increased access to healthcare and receive higher quality care. However, despite recent initiatives expanding children’s coverage, many remain uninsured. New technologies present opportunities for helping clinics provide enrollment support for patients. We developed and tested electronic health record (EHR)-based tools to help clinics provide children’s insurance assistance. Methods We used mixed methods to understand tool adoption, and to assess impact of tool use on insurance coverage, healthcare utilization, and receipt of recommended care. We conducted intent-to-treat (ITT) analyses comparing pediatric patients in 4 intervention clinics (n = 15,024) to those at 4 matched control clinics (n = 12,227). We conducted effect-of-treatment-on-the-treated (ETOT) analyses comparing intervention clinic patients with tool use (n = 2240) to intervention clinic patients without tool use (n = 12,784). Results Tools were used for only 15% of eligible patients. Qualitative data indicated that tool adoption was limited by: (1) concurrent initiatives that duplicated the work associated with the tools, and (2) inability to obtain accurate insurance coverage data and end dates. The ITT analyses showed that intervention clinic patients had higher odds of gaining insurance coverage (adjusted odds ratio [aOR] = 1.32, 95% confidence interval [95%CI] 1.14–1.51) and lower odds of losing coverage (aOR = 0.77, 95%CI 0.68–0.88), compared to control clinic patients. Similarly, ETOT findings showed that intervention clinic patients with tool use had higher odds of gaining insurance (aOR = 1.83, 95%CI 1.64–2.04) and lower odds of losing coverage (aOR = 0.70, 95%CI 0.53–0.91), compared to patients without tool use. The ETOT analyses also showed higher rates of receipt of return visits, well-child visits, and several immunizations among patients for whom the tools were used. Conclusions This pragmatic trial, the first to evaluate EHR-based insurance assistance tools, suggests that it is feasible to create and implement tools that help clinics provide insurance enrollment support to pediatric patients. While ITT findings were limited by low rates of tool use, ITT and ETOT findings suggest tool use was associated with better odds of gaining and keeping coverage. Further, ETOT findings suggest that use of such tools may positively impact healthcare utilization and quality of pediatric care. Trial registration ClinicalTrials.gov, NCT02298361; retrospectively registered on November 5, 2014. Electronic supplementary material The online version of this article (10.1186/s12913-018-3159-x) contains supplementary material, which is available to authorized users.

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 Medic- aid 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 informa- tion 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 analy- ses 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 vari- able 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 ser- vices will increase as patients gain Medicaid through Affordable Care Act expan- sions. 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.

Objective To validate electronic health record (EHR) insurance information for low-income pediatric patients at Oregon community health centers (CHCs), compared to reimbursement data and Medicaid coverage data.Materials and Methods Subjects Children visiting any of 96 CHCs (N = 69 189) from 2011 to 2012. Analysis The authors measured correspondence (whether or not the visit was covered by Medicaid) between EHR coverage data and (i) reimbursement data and (ii) coverage data from Medicaid.Results Compared to reimbursement data and Medicaid coverage data, EHR coverage data had high agreement (87% and 95%, respectively), sensitivity (0.97 and 0.96), positive predictive value (0.88 and 0.98), but lower kappa statistics (0.32 and 0.49), specificity (0.27 and 0.60), and negative predictive value (0.66 and 0.45). These varied among clinics.Discussion/Conclusions EHR coverage data for children had a high overall correspondence with Medicaid data and reimbursement data, suggesting that in some systems EHR data could be utilized to promote insurance stability in their patients. Future work should attempt to replicate these analyses in other settings.

Background Lack of insurance is associated with suboptimal receipt of diabetes preventive care. One known reason for this is an access barrier to obtaining healthcare visits; however, little is known about whether insurance status is associated with differential rates of receipt of diabetes care during visits. Purpose To examine the association between health insurance and receipt of diabetes preventive care during an office visit. Methods This retrospective cohort study used electronic health record and Medicaid data from 38 Oregon community health centers. Logistic regression was used to test the association between insurance and receipt of four diabetes services during an office visit among patients who were continuously uninsured ( n =1,117); continuously insured ( n =1,466); and discontinuously insured ( n =336) in 2006–2007. Generalized estimating equations were used to account for within-patient correlation. Data were analyzed in 2013. Results Overall, continuously uninsured patients had lower odds of receiving services at visits when due, compared to those who were continuously insured (AOR=0.73, 95% CI=0.66, 0.80). Among the discontinuously insured, being uninsured at a visit was associated with lower odds of receipt of services due at that visit (AOR=0.77, 95% CI=0.64, 0.92) than being insured at a visit. Conclusions Lack of insurance is associated with a lower probability of receiving recommended services that are due during a clinic visit. Thus, the association between being uninsured and receiving fewer preventive services may not be completely mediated by access to clinic visits.

It is hypothesized that Affordable Care Act (ACA) Medicaid expansions could substantially improve access to health insurance and healthcare services for patients at risk for diabetes mellitus (DM), with pre-DM, or already diagnosed with DM. The ACA called for every state to expand Medicaid coverage by 2014. In a 2012 legal challenge, the US Supreme Court ruled that states were not required to implement Medicaid expansions. This 'natural experiment' presents a unique opportunity to learn whether and to what extent Medicaid expansion can affect healthcare access and services for patients with DM risk, pre-DM, or DM. Data from electronic health records (EHRs) from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) clinical data research network, which has data from >700 community health centers (CHCs), was included in the study. EHR data will be linked to Oregon Medicaid claims data. Data collection will include information on changes in health insurance, service receipt, and health outcomes, spanning 9 years (pre- and post-expansion), comparing states that expanded Medicaid, and those that did not. Patients included in this study will be diagnosed with DM, be at risk for DM, or have pre-DM, between the ages of 19 and 64, with ≥1 ambulatory visit. Sample size is estimated to be roughly 275,000 patients. Biostatistical analyses will include the difference-in-differences (DID) methodology and a generalized linear mixed model. Econometric analyses will include a DID two-part method to calculate the difference in Medicaid expenditures in Oregon among newly insured CHC patients. Findings will have national relevance on DM health services and outcomes and will be shared through national conferences and publications. The findings will provide information needed to impact the policy as it is related to access to health insurance and receipt of healthcare among a vulnerable population. This project is registered with ClinicalTrials.gov ( NCT02685384 ). Registered 18 May 2016.

Introduction Low-income populations have elevated exposure to early life risk factors for obesity, but are understudied in longitudinal research. Our objective was to assess the utility of a cohort derived from electronic health record data from safety net clinics for investigation of obesity emerging in early life. Methods We examined data from the PCORNet ADVANCE Clinical Data Research Network, a national network of Federally-Qualified Health Centers serving 1.7 million safety net patients across the US. This cohort includes patients who, in 2012-2014, had ≥1 valid body mass index measure when they were 0-5 years of age. We characterized the cohort with respect to factors required for early life obesity research in vulnerable subgroups: sociodemographic diversity, weight status based on World Health Organization (2 years) or Centers for Disease Control (≥2 years) growth curves, and data longitudinality. Results The cohort includes 216,473 children and is racially/ethnically diverse (e.g., 17.9% Black, 45.4% Hispanic). A majority (56.9%) had family incomes below the Federal Poverty Level (FPL); 32% were50% of FPL. Among children 2 years, 7.6 and 5.3% had high and low weight-for-length, respectively. Among children 2-5 years, 15.0, 12.7 and 2.4% were overweight, obese, and severely obese, respectively; 5.3% were underweight. In the study period, 79.2% of children had ≥2 BMI measures. Among 4-5 year olds, 21.9% had 1 BMI measure when they were2 years. Discussion The ADVANCE Early Life cohort offers unique opportunities to investigate early life determinants of obesity in the understudied population of low income and minority children.

Purpose: The purpose of this study was to examine associations between the number and types of patients9 chronic diseases and being up to date for breast, cervical, and colorectal cancer screening. Methods: Data were abstracted from medical charts at 4 primary care clinics located in 2 rural Oregon communities. Eligibility criteria included being at least 55 years old and having at least 1 clinic visit in the past 2 years. Results: Of 3433 patients included, 503 (15%) had no chronic illness, 646 (19%) had 1, 786 (23%) had 2, and 1498 (44%) had ≥3 chronic conditions. Women with asthma/chronic lung disease and with cardiovascular disease were less likely to be up o date for mammography screening (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.43–0.80), and those with chronic digestive disorders were more likely to be up to date for mammography (OR, 1.31; 95% CI, 1.03–1.66) compared with those without chronic conditions. Women with arthritis, diabetes mellitus, and hypertension were less likely to be up to date for cervical cancer screening (OR, 0.38; 95% CI, 0.21–0.68) compared with those without chronic conditions. Men with cardiovascular disease were less likely to be up to date for colorectal cancer screening (adjusted OR, 0.59; 95% CI, 0.44–0.80), and women with depression were less likely to be up to date (OR, 0.71; 95% CI, 0.56–0.91) compared with men and women without chronic conditions. Conclusion: Specific chronic conditions were found to be associated with up-to-date status for cancer screening. This finding may help practices to identify patients who need to receive cancer screening.

Background Previous research on ascertainment of cancer family history and cancer screening has been conducted in urban settings. Purpose To examine whether documented family history of breast or colorectal cancer is associated with breast or colorectal cancer screening. Methods Medical record reviews were conducted on 3433 patients aged 55 and older from four primary care practices in two rural Oregon communities. Data collected included patient demographic and risk information, including any documentation of family history of breast or colorectal cancer, and receipt of screening for these cancers. Results A positive breast cancer family history was associated with an increased likelihood of being up-to-date for mammography screening (OR 2.09, 95% CI 1.45–3.00 relative to a recorded negative history). A positive family history for colorectal cancer was associated with an increased likelihood of being up-to-date with colorectal cancer screening according to U.S. Preventive Services Task Force low risk guidelines for males (OR 2.89, 95% CI 1.15–7.29) and females (OR 2.47, 95% CI 1.32–4.64) relative to a recorded negative family history. The absence of any recorded family cancer history was associated with a decreased likelihood of being up-to-date for mammography screening (OR 0.70, 95% CI 0.56–0.88 relative to recorded negative history) or for colorectal cancer screening (OR 0.75, 95% CI 0.60–0.96 in females, OR 0.68, 95% CI 0.53–0.88 in males relative to recorded negative history). Conclusion Further research is needed to determine if establishing routines to document family history of cancer would improve appropriate use of cancer screening.

Rationale: Mutations in fibrillin-1 are associated with thoracic aortic aneurysm (TAA) in Marfan syndrome. Genome-wide association studies also implicate fibrillin-1 in sporadic TAA. Fragmentation of the aortic elastic lamellae is characteristic of TAA. Objective: Immunoassays were generated to test whether circulating fragments of fibrillin-1, or other microfibril fragments, are associated with TAA and dissection. Methods and Results: Plasma samples were obtained from 1265 patients with aortic aneurysm or dissection and from 125 control subjects. Concentrations of fibrillin-1, fibrillin-2, and fibulin-4 were measured with novel immunoassays. One hundred and seventy-four patients (13%) had aneurysms with only abdominal aortic involvement (abdominal aortic aneurysm), and 1091 (86%) had TAA. Of those with TAA, 300 patients (27%) had chronic dissection and 109 (10%) had acute or subacute dissection. Associations of fragment concentrations with TAA (versus abdominal aortic aneurysm) or with dissection (versus no dissection) were estimated with odds ratios (OR) and 95% confidence intervals (CI) adjusted for age, sex, and smoking. Compared with controls, significantly higher percentages of aneurysm patients had detectable levels of fibrillin fragments. TAA was significantly more common (than abdominal aortic aneurysm) in the highest compared with lowest quartile of fibrillin-1 concentration (OR=2.9; 95% CI, 1.6–5.0). Relative to TAA without dissection, acute or subacute dissection (OR=2.9; 95% CI, 1.6–5.3), but not chronic dissection, was more frequent in the highest compared with lowest quartile of fibrillin-1 concentration. Neither TAA nor dissection was associated with fibrillin-2 or fibulin-4. Conclusions: Circulating fibrillin-1 fragments represent a new potential biomarker for TAA and acute aortic dissection.

Although past research demonstrated that Medicaid expansions were associated with increased emergency department (ED) and primary care (PC) utilization, little is known about how long this increased utilization persists or whether postcoverage utilization is affected by prior insurance status.(1) To assess changes in ED, PC, mental and behavioral health care, and specialist care visit rates among individuals gaining Medicaid over 24 months postinsurance gain; and (2) to evaluate the association of previous insurance with utilization.Using claims data, we conducted a retrospective cohort analysis of adults insured for 24 months following Oregon's 2008 Medicaid expansion. Utilization rates among 1124 new and 1587 returning enrollees were compared with those among 5126 enrollees with continuous Medicaid coverage (≥1 y preexpansion). Visit rates were adjusted for propensity score classes and geographic region.PC visit rates in both newly and returning insured individuals significantly exceeded those in the continuously insured in months 4 through 12, but were not significantly elevated in the second year. In contrast, ED utilization rates were significantly higher in returning insured compared with newly or continuously insured individuals and remained elevated over time. New visits to PC and specialist care were higher among those who gained Medicaid compared with the continuously insured throughout the study period.Predicting the effect of insurance expansion on health care utilization should account for the prior coverage history of new enrollees. In addition, utilization of outpatient services changes with time after insurance, so expansion evaluations should allow for rate stabilization.

Background/Objective Our objective was to obtain follow-up pulmonary function testing and assessment of clinical respiratory outcomes, at 1-2 years, in preterm infants whose mothers were randomized to a single rescue course of antenatal steroids (AS) versus placebo. Methods Follow-up of a randomized, double-blinded trial. In the original trial pregnant women ≥14 days after initial course of AS were randomized to rescue AS or placebo. Pulmonary function testing and a standardized respiratory questionnaire were obtained at 1-2 years of corrected age. Respiratory compliance (Crs) was measured with the single-breath occlusion and functional residual capacity (FRC) with the nitrogen washout method. Analysis was by intention-to-treat. Results A total of 96 (87%) of available survivors were administered a respiratory questionnaire. Seventy-seven percent of available patients had pulmonary function testing performed. There was no significant difference between groups in incidence of wheezing, asthma, respiratory syncytial virus infection, respiratory readmissions, use of bronchodilators or other medications, or in measurements of pulmonary function. There was also no significant difference in corrected age at study, race, gender, or length at the time of pulmonary function testing. Infants in the rescue group had a comparable mean FRC (249.4 mL vs 246.2 mL; adjusted 95%CI for difference −15.45, 38.20; P = 0.37) versus placebo. There were no differences in tidal volume or Crs. Conclusion A rescue course of AS significantly increases Crs within 72 h of age and decreases oxygen need in newborn infants, without an adverse impact on pulmonary function or clinical respiratory outcomes at 1-2 years of age [NCT00669383].

Community health center (CHC) patients have high rates of smoking. Insurance coverage for smoking cessation assistance, such as that mandated by the Affordable Care Act, may aid in smoking cessation in this vulnerable population. We aimed to determine if uninsured CHC patients who gain Medicaid coverage experience greater primary care utilization, receive more cessation medication orders, and achieve higher quit rates, compared to continuously uninsured smokers. Longitudinal observational cohort study using electronic health record data from a network of Oregon CHCs linked to Oregon Medicaid enrollment data. Cohort of patients who smoke and who gained Medicaid coverage in 2008–2011 after ≥ 6 months of being uninsured and with ≥ 1 smoking assessment in the 24-month follow-up period from the baseline smoking status date. This group was propensity score matched to a cohort of continuously uninsured CHC patients who smoke (n = 4140 matched pairs; 8280 patients). Gaining Medicaid after being uninsured for ≥ 6 months. ‘Quit’ smoking status (baseline smoking status was ‘current every day’ or ‘some day’ and status change to ‘former smoker’ at a subsequent visit), smoking cessation medication order, and ≥ 6 documented visits (yes/no variables) at ≥ 1 smoking status assessment within the 24-month follow-up period. The newly insured had 40 % increased odds of quitting smoking (aOR = 1.40, 95 % CI:1.24, 1.58), nearly triple the odds of having a medication ordered (aOR = 2.94, 95 % CI:2.61, 3.32), and over twice the odds of having ≥ 6 follow-up visits (aOR = 2.12, 95 % CI:1.94, 2.32) compared to their uninsured counterparts. Newly insured patients had increased odds of quit smoking status over 24 months of follow-up than those who remained uninsured. Providing insurance coverage to vulnerable populations may have a significant impact on smoking cessation.

Objective The future of the Children’s Health Insurance Program (CHIP) is uncertain after 2017. Survey-based research shows positive associations between CHIP expansions and children’s healthcare utilization. To build on this prior work, we used electronic health record (EHR) data to assess temporal patterns of healthcare utilization after Oregon’s 2009–2010 CHIP expansion. We hypothesized increased post-expansion utilization among children who gained public insurance. Methods Using EHR data from 154 Oregon community health centers, we conducted a retrospective cohort study of pediatric patients (2–18 years old) who gained public insurance coverage during the Oregon expansion (n = 3054), compared to those who were continuously publicly insured (n = 10,946) or continuously uninsured (n = 10,307) during the 2-year study period. We compared pre-post rates of primary care visits, well-child visits, and dental visits within- and between-groups. We also conducted longitudinal analysis of monthly visit rates, comparing the three insurance groups. Results After Oregon’s 2009–2010 CHIP expansions, newly insured patients’ utilization rates were more than double their pre-expansion rates [adjusted rate ratios (95 % confidence intervals); increases ranged from 2.10 (1.94–2.26) for primary care visits to 2.77 (2.56–2.99) for dental visits]. Utilization among the newly insured spiked shortly after coverage began, then leveled off, but remained higher than the uninsured group. Conclusions This study used EHR data to confirm that CHIP expansions are associated with increased utilization of essential pediatric primary and preventive care. These findings are timely to pending policy decisions that could impact children’s access to public health insurance in the United States.

Food frequency questionnaires (FFQs) are less time consuming and inexpensive instruments for collecting dietary intake when compared with 24-h dietary recalls or double-labelled water; however, the validation of FFQ is important as incorrect information may lead to biased conclusions about associations. Therefore, the relative validity of the Block Kids Food Screener (BKFS) developed for use with children was examined in a convenience sample of 99 youth recruited from the Portland, OR metropolitan area. Three 24-h dietary recalls served as the reference. The relative validity was analysed after natural log transformation of all variables except glycaemic index prior to correlation analysis. Daily cup equivalent totals from the BKFS and 'servings' from 24-h recalls were used to compute average daily intake of fruits, vegetables, potatoes, whole grains, legumes, meat/fish/poultry and dairy. Protein grams (g), total kcalories, glycaemic index (glucose reference), glycaemic load (glucose reference), total saturated fat (g) and added sugar (g) were also calculated by each instrument. The correlation between data obtained from the two instruments was corrected for the within-subject variation in food intake reported by the 24-h recalls using standard nutritional assessment methodology. The de-attenuated correlations in nutritional intake between the two dietary assessment instruments ranged from 0.526 for vegetables, to 0.878 for potatoes. The 24-h recall estimated higher levels of saturated fat and added sugar consumption, higher glycaemic loads and glycaemic indices; the de-attenuatted correlations of these measures ranged from 0.478 to 0.768. Assessment of Bland-Altman plots indicated no systematic difference between the two instruments for vegetable, dairy and meat/fish/poultry fat consumption. BKFS is a useful dietary assessment instrument for the nutrients and food groups it was designed to assess in children age 10-17 years.

Background: Assessment of patient safety culture has recently expanded in inpatient settings, but the majority of medical encounters occurs in office settings, and less is known about the determinants of perceived quality and safety in ambulatory care. The Medical Office Survey of Patient Safety was developed to assess perceived quality of care and patient safety culture in medical offices, including a domain to assess the quality criteria as defined by the Institute of Medicine: patient-centered, effective, timely, efficient, and equitable. Methods: We surveyed 6534 clinicians and staff in 306 medical practices from 11 practice based research networks (PBRNs) in 16 states. We collected data on office size, ownership, and use of health information technologies (HIT) and assessed perceived patient safety and quality of care with the Medical Office Survey of Patient Safety9s overall quality domain. Using a mixed model that adjusted for the role of respondents, we examined the relationship between perceived safety and quality of care and office size, ownership, and the degree of implementation of HIT. Results: Small practices (3–15 personnel) reported the highest proportion of positive perceptions of quality and safety. The lowest proportion of positive perceptions of quality and safety occurred in large (41–70 personnel) and very large practices (>70 personnel). After controlling for office size, we found no relationship between perceived quality and safety and practice ownership. The relationship of HIT implementation to perceived quality and safety was not clear. We found the highest proportion of positive perceptions in practices with the least HIT and those with the most HIT and the lowest proportion in practices with intermediate levels of HIT. Conclusions: Personnel in small practices reported the highest overall quality and safety of care, and perceived quality and safety declined with increasing office size. No clear relationship was found between perceived quality and safety and implementation of HIT.

BACKGROUND: The current study was performed to determine, in rural settings, the relation between the type and status of insurance coverage and being up-to-date for breast, cervical, and colorectal cancer screening. METHODS: Four primary care practices in 2 rural Oregon communities participated. Medical chart reviews that were conducted between October 2008 and August 2009 assessed insurance coverage and up-to-date status for breast, cervical, and colorectal cancer screening. Inclusion criteria involved having at least 1 health care visit within the past 5 years and being aged ≥ 55 years. RESULTS: The majority of patients were women aged 55 years to 70 years, employed or retired, and who had private health insurance and an average of 2.5 comorbid conditions. The overall percentage of eligible women who were up-to-date for cervical cancer screening was 30%; approximately 27% of women were up-to-date for clinical breast examination, 37% were up-to-date for mammography, and 19% were up-to-date for both mammography and clinical breast examination. Approximately 38% of men and 35% of women were up-to-date for colorectal cancer screening using any test at appropriate screening intervals. In general, having any insurance versus being uninsured was associated with undergoing cancer screening. For each type of screening, patients who had at least 1 health maintenance visit were significantly more likely to be up-to-date compared with those with no health maintenance visits. A significant interaction was found between having health maintenance visits, having any health insurance, and being up-to-date for cancer screening tests. CONCLUSIONS: Overall, the percentage of patients who were up-to-date for any cancer screening, especially cervical cancer screening, was found to be very low in rural Oregon. Patients with some form of health insurance were more likely to have had a health maintenance visit within the previous 2 years and to be up-to-date for breast, cervical, and/or colorectal cancer screening. Cancer 2012. © 2012 American Cancer Society.

Objectives The objectives of this study were to describe sleep quality and evaluate the association of sleep quality with delirium onset among patients enrolled in hospice. Design The study utilized secondary data from a prospective, observational, longitudinal study. Setting Veterans enrolled in hospice were recruited from the Portland Veterans Affairs Medical Center, Portland, Oregon. Participants The cohort consisted of 105 patients, of whom 73% had at least one sleep measurement. Measurements Sleep quality was measured with the Pittsburgh Sleep Quality Index. Delirium was measured with the Confusion Assessment Method. Other important variables were recorded from the medical record and/or longitudinal interviews with patients and their caregivers. Cox regression was used to estimate hazard ratios (HRs) to measure the association between sleep quality and delirium onset. Results Of the patients who could be assessed, 44% had poor average sleep quality and 58% reported at least one episode of poor sleep. Overall, sleep quality did not appear to worsen as patients neared death although an increasing number of patients were unable to report on sleep quality. Poor sleep quality was associated with an increased risk of developing delirium, with an HR of 2.37 (95% CI: 1.50–3.74), for every one point worsening in the sleep quality score on a 4-point scale. Conclusions Poor sleep quality was common among Veteran patients enrolled in hospice. These findings may help guide decision making between clinicians, patients, and families regarding the likely impact of sleep disturbance and may help identify patients at higher risk of developing delirium.

This study described utilization of specialty treatment for posttraumatic stress disorder (PTSD) at U.S. Department of Veterans Affairs (VA) facilities among veterans of Operation Enduring Freedom (OEF), in Afghanistan, or of Operation Iraqi Freedom (OIF), in Iraq, and non-OEF-OIF veterans recently diagnosed as having PTSD. It also identified predictors of receiving minimally adequate specialty treatment, defined as attending at least nine clinic visits within 365 days of screening positive for PTSD.VA administrative data were obtained for 869 veterans who screened positive for PTSD between November 7, 2006, and September 30, 2008, received a diagnosis of PTSD, and visited a PTSD specialty clinic operated by the VA in the Pacific Northwest at least once within a year of screening positive.A total of 286 (33%) of the 852 veterans for whom complete data were available received minimally adequate specialty treatment; OEF-OIF veterans were less likely than non-OEF-OIF veterans to receive minimally adequate specialty treatment (29% versus 36%, p=.021) and attended fewer mean±SD visits to a PTSD clinic (8.2±11.4 versus 9.9±13.5, p=.045). Predictors of receiving minimally adequate specialty treatment included attending a PTSD clinic visit within 30 days of a positive screen, living in an urban location, and having psychiatric comorbidities.Most veterans with new PTSD diagnoses who initiated VA PTSD specialty care did not receive minimally adequate specialty treatment. Future studies should examine factors that lead to premature discontinuation of PTSD treatment and to what extent specialty treatment for PTSD is necessary.

A major goal of human immunodeficiency virus type 1 (HIV-1) vaccine efforts is the design of Envelope (Env)-based immunogens effective at eliciting heterologous or broad neutralizing antibodies (NAbs). We hypothesized that programming the B-cell response could be achieved by sequentially exposing the host to a collection of env variants representing the viral quasispecies members isolated from an individual that developed broad NAbs over time. This ordered vaccine approach (sequential) was compared to exposure to a cocktail of env clones (mixture) and to a single env variant (clonal). The three strategies induced comparable levels of the autologous and heterologous neutralization of tier 1 pseudoviruses. Sequential and mixture exposure to quasispecies led to epitope targeting similar to that observed in the simian-human immunodeficiency virus (SHIV)-infected animal from which the env variants were cloned, while clonal and sequential exposure led to greater antibody maturation than the mixture. Therefore, the sequential vaccine approach best replicated the features of the NAb response observed in that animal. This study is the first to explore the use of a collection of HIV-1 env quasispecies variants as immunogens and to present evidence that it is possible to educate the B-cell response by sequential exposure to native HIV-1 quasispecies env variants derived from an individual with a broadened NAb response.

We describe seizure laterality and temporal seizure patterns in six subjects with bilateral temporal lobe epilepsy (bTLE) implanted with bilateral hippocampal depth electrodes and the NeuroPace RNS™ system over 84 consecutive days. Seizures were disproportionate in laterality in three subjects and disproportionate in time for two subjects. Clustering of seizures did not clearly affect laterality. Some but not all subjects with bTLE displayed nonrandom temporal or lateral clustering of seizures.

To determine the extent to which third-year medical students are exposed to elements of the patient-centered medical home (PCMH) during required family medicine (FM) clerkships and how this exposure varies among a sample of medical schools.In 2008, the authors conducted a cross-sectional survey of 104 ambulatory teaching practices that host required third-year FM clerkship students from nine U.S. medical schools. Descriptive statistics characterized learning settings and the status of PCMH features, and generalized linear mixed models examined variation among medical schools (as the 104 clinics were nested within nine medical schools).Participating schools captured data on 104 eligible clerkship sites (44%). These practices were primarily community-based, single-specialty clinics (n = 48; 46%), and more than half (n = 55; 53%) were part of integrated health systems. Electronic health records (EHRs) were in place in 60 (58%), and no significant difference existed in EHR use according to medical school, despite up to a 10-fold variation from school to school in other PCMH features. Among sites with EHRs, 8 (14%) did not allow access to medical students. Preceptor attitudes about how practice transformation and new information technology are affecting the quality of medical education differ widely from site to site.Primary care transformation toward the PCMH is already well under way in a national sample of FM teaching sites, and this transformation is having important effects on medical student education.

In vivo(1)H magnetic resonance spectroscopy (MRS) can be used to directly monitor brain ethanol. Previously, studies of human subjects have lead to the suggestion that the ethanol methyl (1)H MRS signal intensity relates to tolerance to ethanol's intoxicating effects. More recently, the ethanol (1)H MRS signal intensity has been recognized to vary between brain gray matter (GM), white matter (WM), and cerebrospinal fluid (CSF) due to differences in T(2) within these environments. The methods presented here extend ethanol MRS techniques to non-human primate subjects. Twelve monkeys were administered ethanol while sedated and positioned within a 3T MRI system. Chemical shift imaging (CSI) measurements were performed following intravenous infusion of 1g/kg ethanol. Magnetic resonance imaging (MRI) data were also recorded for each monkey to provide volume fractions of GM, WM, and CSF for each CSI spectrum. To estimate co-variance of ethanol MRS intensity with GM, WM, and CSF volume fractions, the relative contribution of each tissue subtype was determined following corrections for radiofrequency pulse profile non-uniformity, chemical shift artifacts, and differences between the point spread function in the CSI data and the imaging data. The ethanol MRS intensity per unit blood ethanol concentration was found to differ between GM, WM, and CSF. Individual differences in MRS intensity were larger in GM than WM. This methodology demonstrates the feasibility of ethanol MRS experiments and analysis in non-human primate subjects, and suggests GM may be a site of significant variation in ethanol MRS intensity between individuals.

To assess the association between a child’s and their parent’s public health insurance status during a time when children had access to coverage independent of policies that impacted adults’ access. Secondary data from the Oregon Health Plan (OHP) [Oregon’s Medicaid and Children’s Health Insurance Programs] for families with at least one parent and one child with OHP coverage at any time during the study period (2002–2010). We linked children to their parents in the OHP data set and examined longitudinal associations between the coverage patterns for children and their parents, controlling for several demographic and economic confounders. We tested for differences in the strength of associations in monthly coverage status in five time periods throughout the nine-year study period. The odds of a child being insured by the OHP in months in which at least one parent had OHP coverage were significantly higher than among children whose parents were not enrolled at that time. Children with at least one parent who maintained or gained OHP coverage in a given month had a much higher probability of being enrolled in the OHP in that month, compared to children who had no covered parents in the given month or the month prior. Despite implementation of policies that differentially affected eligibility requirements for children and adults, strong associations persisted between coverage continuity for parents and children enrolled in Oregon public health insurance programs.

The lack of evidence regarding functional and quality of life benefits resulting from tone reduction with intrathecal baclofen (ITB) infusion treatment relates to the lack of validated and responsive measures. We integrated our scale/questionnaire, developed from chart review, with the non-validated Caregiver Questionnaire (CQ) to yield a final document, the Care and Comfort Hypertonicity Questionnaire (CCHQ). Convergent validity was achieved by administering the CCHQ to 47 patients with spastic/dystonic cerebral palsy (CP) who were being evaluated for tone management. The population studied included 18 females and 29 males (mean age 10y [SD 4y 10mo]; range 3y 1mo-21y 1mo). Twenty-five patients were subsequently referred for botulinum toxin (BTX-A) injections (mean Gross Motor Function Classification System [GMFCS] 3.2); 11 patients were referred for ITB (mean GMFCS 4.4); four were referred for orthopedic surgery (mean GMFCS 3.3); 3 were referred for selective dorsal rhizotomy (mean GMFCS 2.7); one was recommended for oral baclofen (GMFCS 5); and three were recommended for no treatment (mean GMFCS 3.7). Blinded to the score, those with the highest scores (severe hypertonicity) were recommended for ITB; those with the lowest scores were recommended for BTX-A injections. Responsiveness of the CCHQ was established by administering the questionnaire to patients who already had an implanted ITB pump. The children with the largest dose increase demonstrated a statistically significant improvement in the CCHQ score. This scale can be used to document the efficacy of treating severe hypertonicity both in clinical and research protocols.