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INTRODUCTION: Latinas in the United States have higher mortality from breast cancer, but longitudinal studies of mammography ordering (a crucial initial step towards screening) in primary care are lacking. METHODS: We conducted an analysis of mammography order rates in Latinas (by language preference) and non-Latina white women (N = 181,755) over a > 10 year period in a multi-state network of community health centers (CHCs). We evaluated two outcomes (ever having a mammogram order and annual rate of mammography orders) using generalized estimating equation modeling. RESULTS: Approximately one-third of all patients had ever had a mammogram order. Among those receiving mammogram orders, English-preferring Latinas had lower mammogram order rates than non-Hispanic white women (RR = 0.92, 95% CI = 0.89-0.95). Spanish-preferring Latinas had higher odds of ever having a mammogram ordered than non-Hispanic whites (odds ratio = 2.12, 95% CI = 2.06-2.18) and, if ever ordered, had a higher rate of annual mammogram orders (rate ratio = 1.53, 95% CI = 1.50-1.56). CONCLUSION: These findings suggest that breast cancer detection barriers in low-income Latinas may not stem from a lack of orders in primary care, but in the subsequent accessibility of receiving ordered services.

INTRODUCTION: Little has previously been reported about the implementation of social risk screening across racial/ethnic/language groups. To address this knowledge gap, the associations between race/ethnicity/language, social risk screening, and patient-reported social risks were examined among adult patients at community health centers. METHODS: Patient- and encounter-level data from 2016 to 2020 from 651 community health centers in 21 U.S. states were used; data were extracted from a shared Epic electronic health record and analyzed between December 2020 and February 2022. In adjusted logistic regression analyses stratified by language, robust sandwich variance SE estimators were applied with clustering on patients primary care facility. RESULTS: Social risk screening occurred at 30% of health centers; 11% of eligible adult patients were screened. Screening and reported needs varied significantly by race/ethnicity/language. Black Hispanic and Black non-Hispanic patients were approximately twice as likely to be screened, and Hispanic White patients were 28% less likely to be screened than non-Hispanic White patients. Hispanic Black patients were 87% less likely to report social risks than non-Hispanic White patients. Among patients who preferred a language other than English or Spanish, Black Hispanic patients were 90% less likely to report social needs than non-Hispanic White patients. CONCLUSIONS: Social risk screening documentation and patient reports of social risks differed by race/ethnicity/language in community health centers. Although social care initiatives are intended to promote health equity, inequitable screening practices could inadvertently undermine this goal. Future implementation research should explore strategies for equitable screening and related interventions.

Evidence is needed about how to effectively support health care providers in implementing screening for social risks (adverse social determinants of health) and providing related referrals meant to address identified social risks. This need is greatest in underresourced care settings. The authors tested whether an implementation support intervention (6 months of technical assistance and coaching study clinics through a five-step implementation process) improved adoption of social risk activities in community health centers (CHCs). Thirty-one CHC clinics were block-randomized to six wedges that occurred sequentially. Over the 45-month study period from March 2018 to December 2021, data were collected for 6 or more months preintervention, the 6-month intervention period, and 6 or more months postintervention. The authors calculated clinic-level monthly rates of social risk screening results that were entered at in-person encounters and rates of social risk-related referrals. Secondary analyses measured impacts on diabetes-related outcomes. Intervention impact was assessed by comparing clinic performance based on whether they had versus had not yet received the intervention in the preintervention period compared with the intervention and postintervention periods. In assessing the results, the authors note that five clinics withdrew from the study for various bandwidth-related reasons. Of the remaining 26, a total of 19 fully or partially completed all 5 implementation steps, and 7 fully or partially completed at least the first 3 steps. Social risk screening was 2.45 times (95% confidence interval [CI], 1.32-4.39) higher during the intervention period compared with the preintervention period; this impact was not sustained postintervention (rate ratio, 2.16; 95% CI, 0.64-7.27). No significant difference was seen in social risk referral rates during the intervention or postintervention periods. The intervention was associated with greater blood pressure control among patients with diabetes and lower rates of diabetes biomarker screening postintervention. All results must be interpreted considering that the Covid-19 pandemic began midway through the trial, which affected care delivery generally and patients at CHCs particularly. Finally, the study results show that adaptive implementation support was effective at temporarily increasing social risk screening. It is possible that the intervention did not adequately address barriers to sustained implementation or that 6 months was not long enough to cement this change. Underresourced clinics may struggle to participate in support activities over longer periods without adequate resources, even if lengthier support is needed. As policies start requiring documentation of social risk activities, safety-net clinics may be unable to meet these requirements without adequate financial and coaching/technical support.

IntroductionSocial risks (e.g., food/transportation insecurity) can hamper type 2 diabetes mellitus (T2DM) self-management, leading to poor outcomes. To determine the extent to which high-quality care can overcome social risks' health impacts, this study assessed the associations between reported social risks, receipt of guideline-based T2DM care, and T2DM outcomes when care is up to date among community health center patients.MethodsA cross-sectional study of adults aged ≥18 years (N=73,484) seen at 186 community health centers, with T2DM and ≥1 year of observation between July 2016 and February 2020. Measures of T2DM care included up-to-date HbA1c, microalbuminuria, low-density lipoprotein screening, and foot examination, and active statin prescription when indicated. Measures of T2DM outcomes among patients with up-to-date care included blood pressure, HbA1c, and low-density lipoprotein control on or within 6‒12 months of an index encounter. Analyses were conducted in 2021.ResultsIndividuals reporting transportation or housing insecurity were less likely to have up-to-date low-density lipoprotein screening; no other associations were seen between social risks and clinical care quality. Among individuals with up-to-date care, food insecurity was associated with lower adjusted rates of controlled HbA1c (79% vs 75%, p

Las comunidades aborígenes que habitan las regiones andinas se caracterizan por haber conservado elementos lingüísticos originarios en sus apellidos. Estos han sufrido procesos de “occidentalización”, manteniendo, no obstante, rasgos etnia-específicos. Tal situación permite disponer de un criterio simple para identificar con cierto grado de certeza la ancestralidad de un individuo. Con el objeto de evaluar el grado de correlación entre este marcador cultural y marcadores genéticos hemos llevado a cabo una investigación con individuos varones no relacionados provenientes de las provincias de Río Negro y Chubut (N=136). Los donantes se seleccionaron de acuerdo a la presencia de elementos lingüísticos Mapuche en sus apellidos e individuos con apellidos europeos. Se emplearon tres criterios de clasificación: apellidos, presencia del haplogrupo Q-M3 y presencia de Haplogrupos mitocondriales amerindios (ABCD). Los grupos clasificados de acuerdo con estos criterios fueron analizados mediante 15 STRs autosómicos y 9 Y-STRs. En ambas provincias más del 95% de los individuos portadores de apellidos Mapuche exhibían hgs matri y/o patrilineales amerindios. Por otro lado, en Río Negro y Chubut sólo 18 y 17%, respectivamente, no exhibieron ni apellidos ni marcadores genéticos asociables con ancestros amerindios; en éstos los hgmt más representados fueron H (6.5%), U5 (4.3%) y K (2.8%), seguidos por T (1.4%), V (0.7%), X (0.7%) y M (0.7%). También fue detectado el hg Africano en baja frecuencia (1.4%). Nuestros resultados confirman una correlación estrecha entre apellidos Mapuche y polimorfismos genéticos étnia-específicos.

El análisis de linajes uniparentales permitió, anteriormente, establecer el aporte relevante de las poblaciones originarias al acervo génico de la actual población argentina. Para investigar si nuestra población se encuentra subestructurada analizamos un conjunto de 15 STRs autosómicos (N=5.282) y 9 Y-STRs (N=1.136). Las muestras fueron tomadas de áreas urbanas de 10 provincias: Buenos Aires, Santa Fe, Mendoza, Río Negro, Chubut, Misiones, Formosa, Chaco, Corrientes y Salta, incluyéndose además muestras de Pilagá, Toba y Guaraníes, con fines comparativos. Determinamos las frecuencias alélicas, genotípicas y haplotípicas, evaluándose el equilibrio de Hardy-Weinberg en los sistemas autosómicos. Evaluamos la Varianza Molecular (AMOVA) y determinamos la distancia genética mediante Fst, entre las poblaciones muestreadas. Los resultados emergentes del análisis de marcadores autosómicos indican que las distancias genéticas no presentan diferencias significativas entre la mayoría de las poblaciones analizadas, siendo Salta la única que difiere significativamente con respecto a las demás provincias (Fst: 0.00484-0.01601, p: 0.0498-0.0000). A partir de los resultados de Y-STRs determinamos una Diversidad Haplotípica de 0.9967, que exhibe además una notable homogeneidad en la distribución haplotípica determinada por AMOVA, no obstante, cierto grado de subestructura genética pudo ser detectada en la región Norte, en particular en la provincia de Salta, coincidiendo con los resultados de autosómicos. El análisis de distancia genética permite establecer tres grupos uno de los cuales incluye a la población de Salta junto con los grupos amerindios analizados. Los resultados obtenidos resaltan el interés de las poblaciones del NOA en las que se destaca el componente autóctono de nuestra población.

Uno de los criterios de identificación vigente en los países occidentales es el determinado por el apellido. En ciertas regiones los apellidos pueden asociarse a grupos humanos definidos. Con el objeto de evaluar una posible correlación entre el origen étnico de diversas poblaciones se compararon las características genéticas de individuos cuyos apellidos incluyen elementos lingüísticos Mapuche con otros asociados a un origen europeo. En el presente trabajo se investigaron 168 individuos varones no relacionados, provenientes de las provincias patagónicas de Río Negro y Chubut, seleccionándose en cada provincia un número comparable de individuos con apellido Mapuche y europeo. Se analizaron 15 microsatélites (STRs) autosómicos, ampliamente usados en identificación humana. Los resultados obtenidos indican una diferencia significativa entre el grupo Mapuche y el europeo (Fst: 0.055; p < 0,05). Los resultados de distancias genéticas sugieren que el grupo Mapuche es genéticamente distante de las poblaciones con apellido no aborigen.

Argentina es considerada por sus habitantes como el país más europeo de América Latina. La supuesta baja densidad aborigen al momento de la conquista y las Campañas al Desierto permitieron considerar que la población de nuestro país estaba constituida por descendientes de inmigrantes europeos con mínimo componente amerindio. El empleo del ADN mitocondrial (ADNmt) y la región no recombinante del Cromosoma Y como marcadores permitieron el rastreo de linajes. Ambos sistemas exhiben características específicas en las poblaciones originarias de América. Para analizar la contribución amerindia a la población actual se seleccionaron 322 muestras de individuos varones no relacionados de nueve provincias agrupadas en tres grupos regionales. Se analizaron HVR I y II de la región de control y la ins/del de Región V del ADNmt, además se investigó la presencia de la transicion C-T en el locus DYS199 asi como 9 Y-STRs (DYS19, DYS385, DYS389 I y II, DYS390, DYS391, DYS392 y DYS393). Los resultados obtenidos indican que la contribución amerindia en los linajes maternos de nuestra población es superior al 50%, en tanto que la contribución de patrilineas amerindias se restringe al 20%, además un 10% de los individuos presentan ambos linajes amerindios. La contribución no amerindia se restringe a menos del 40%. Los resultados son semejantes en las regiones Nor-Noreste, Centro y Sur-SurOeste. Esta información confirmaría investigaciones previas aportadas por el análisis de grupos sanguíneos y otros marcadores serológicos. Este trabajo junto con otros aportes permitirán replantear la composición étnica de nuestro país redefiniendo su identidad.

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

BACKGROUND:National leaders recommend documenting social determinants of health and actions taken to address social determinants of health in electronic health records, and a growing body of evidence suggests the health benefits of doing so. However, little evidence exists to guide implementation of social determinants of health documentation/action. METHODS:This paper describes a 5-year, mixed-methods, stepped-wedge trial with realist evaluation, designed to test the impact of providing 30 community health centers with step-by-step guidance on implementing electronic health record-based social determinants of health documentation. This guidance will entail 6 months of tailored support from an interdisciplinary team, including training and technical assistance. We will report on tailored support provided at each of five implementation steps; impact of tailored implementation support; a method for tracking such tailoring; and context-specific pathways through which these tailored strategies effect change. We will track the competencies and resources needed to support the study clinics' implementation efforts. DISCUSSION:Results will inform how to tailor implementation strategies to meet local needs in real-world practice settings. Secondary analyses will assess impacts of social determinants of health documentation and referral-making on diabetes outcomes. By learning whether and how scalable, tailored implementation strategies help community health centers adopt social determinants of health documentation and action, this study will yield timely guidance to primary care providers. We are not aware of previous studies exploring implementation strategies that support adoption of social determinants of action using electronic health and interventions, despite the pressing need for such guidance. TRIAL REGISTRATION:clinicaltrials.gov, NCT03607617 , registration date: 7/31/2018-retrospectively registered.

PURPOSE Previous work has shown that asthma-related emergency department (ED) use is greatest among Black and Latine populations, but it is unknown whether health care use for exacerbations differs across settings (outpatient, ED, inpatient) and correlates with use of routine outpatient services. We aimed to measure disparities by race, ethnicity, and language in pediatric acute asthma care using data from US primary care community health centers. METHODS In an observational study using electronic health records from community health centers in 18 states, we compared non-Hispanic Black, English-preferring Latine, Spanish-preferring Latine, and non-Hispanic White children aged 3 to 17 years on visits for clinic-coded asthma exacerbations (2012-2018). We further evaluated asthma-related ED use and inpatient admissions in a subsample of Oregon-Medicaid recipients. Covariate-adjusted odds ratios (ORs) and rate ratios (RRs) were derived using logistic or negative binomial regression analysis with generalized estimating equations. RESULTS Among 41,276 children with asthma, Spanish-preferring Latine children had higher odds of clinic visits for asthma exacerbation than non-Hispanic White peers (OR = 1.10; 95% CI, 1.02-1.18). Among the subsample of 6,555 children insured under Oregon-Medicaid, non-Hispanic Black children had higher odds and rates of asthma-related ED use than non-Hispanic White peers (OR = 1.40; 95% CI, 1.04-1.89 and RR = 1.49; 95% CI, 1.09-2.04, respectively). We observed no differences between groups in asthma-related inpatient admissions. CONCLUSIONS This study is the first to show that patterns of clinic and ED acute-care use differ for non-Hispanic Black and Spanish-preferring Latine children when compared with non-Hispanic White peers. Non-Hispanic Black children had lower use of clinics, whereas Spanish-preferring Latine children had higher use, including for acute exacerbations. These patterns of clinic use were accompanied by higher ED use among Black children. Ensuring adequate care in clinics may be important in mitigating disparities in asthma outcomes. VISUAL ABSTRACT Ann Fam Med 2022;20:116-122. https://doi.org/10.1370/afm.2771, INTRODUCTION The prevalence of pediatric asthma in the United States remained relatively stable during 2001-2017, at about 8.5%, (1) and national surveys suggest roughly 45% of children with asthma experience [...]

Abstract Background Following the ACA, millions of people gained Medicaid insurance. Most electronic health record (EHR) tools to date provide clinical-decision support and tracking of clinical biomarkers, we developed an EHR tool to support community health center (CHC) staff in assisting patients with health insurance enrollment documents and tracking insurance application steps. The objective of this study was to test the effectiveness of the health insurance support tool in (1) assisting uninsured patients gaining insurance coverage, (2) ensuring insurance continuity for patients with Medicaid insurance (preventing coverage gaps between visits); and (3) improving receipt of cancer preventive care. Methods In this quasi-experimental study, twenty-three clinics received the intervention (EHR-based insurance support tool) and were matched to 23 comparison clinics. CHCs were recruited from the OCHIN network. EHR data were linked to Medicaid enrollment data. The primary outcomes were rates of uninsured and Medicaid visits. The secondary outcomes were receipt of recommended breast, cervical, and colorectal cancer screenings. A comparative interrupted time-series using Poisson generalized estimated equation (GEE) modeling was performed to evaluate the effectiveness of the EHR-based tool on the primary and secondary outcomes. Results Immediately following implementation of the enrollment tool, the uninsured visit rate decreased by 21.0% (Adjusted Rate Ratio [RR] = 0.790, 95% CI = 0.621–1.005, p = .055) while Medicaid-insured visits increased by 4.5% (ARR = 1.045, 95% CI = 1.013–1.079) in the intervention group relative to comparison group. Cervical cancer preventive ratio increased 5.0% (ARR = 1.050, 95% CI = 1.009–1.093) immediately following implementation of the enrollment tool in the intervention group relative to comparison group. Among patients with a tool use, 81% were enrolled in Medicaid 12 months after tool use. For the 19% who were never enrolled in Medicaid following tool use, most were uninsured (44%) at the time of tool use. Conclusions A health insurance support tool embedded within the EHR can effectively support clinic staff in assisting patients in maintaining their Medicaid coverage. Such tools may also have an indirect impact on evidence-based practice interventions, such as cancer screening. Trial registration This study was retrospectively registered on February 4th, 2015 with Clinicaltrials.gov (#NCT02355262). The registry record can be found at https://www.clinicaltrials.gov/ct2/show/NCT02355262 .

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