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This study tested the preliminary effectiveness of an electronic health record (EHR)-automated population health management (PHM) intervention for smoking cessation among adult patients of a federally qualified health center in Chicago. Participants (N = 190; 64.7% women, 82.1% African American/Black, 8.4% Hispanic/Latino) were self-identified as smokers, as documented in the EHR, who completed the baseline survey of a longitudinal “needs assessment of health behaviors to strengthen health programs and services.” Four weeks later, participants were randomly assigned to the PHM intervention (N = 97) or enhanced usual care (EUC; N = 93). PHM participants were mailed a single-page self-determination theory (SDT)-informed letter that encouraged smoking cessation or reduction as an initial step. The letter also addressed low health literacy and low income. PHM participants also received automated text messages on days 1, 5, 8, 11, and 20 after the mailed letter. Two weeks after mailing, participants were called by the Illinois Tobacco Quitline. EUC participants were e-referred following a usual practice. Participants reached by the quitline were offered behavioral counseling and nicotine replacement therapy. Outcome assessments were conducted at weeks 6, 14, and 28 after the mailed letter. Primary outcomes were treatment engagement, utilization, and self-reported smoking cessation. In the PHM arm, 25.8% of participants engaged in treatment, 21.6% used treatment, and 16.3% were abstinent at 28 weeks. This contrasts with no quitline engagement among EUC participants, and a 6.4% abstinence rate. A PHM approach that can reach all patients who smoke and address unique barriers for low-income individuals may be a critical supplement to clinic-based care.

Objective To assess the impact of provider incentive policy on smoking status documentation. Data sources Primary data were extracted from structured electronic medical records (EMRs) from 15 community health centers (CHCs). Study design This was an observational study of data from 2006 to 2013, assessing changes in documentation of smoking status over time. Data extraction methods We extracted structured EMR data for patients age 18 and older with at least one primary care visit. Principal findings Rates of documented smoking status rose from 30 percent in 2006 to 90 percent in 2013; the largest increase occurred from 2011 to 2012 following policy changes (21.3% [95% CI, 8.2%, 34.4%] from the overall trend). Rates varied by clinic and across patient subgroups. Conclusions Documentation of smoking status improved markedly after introduction of new federal standards. Further improvement in documentation is still needed, especially for males, nonwhite patients, those using opioids, and HIV + patients. More research is needed to study whether changes in documentation lead to improvements in counseling, cessation, and patient outcomes.

Childhood obesity has increased significantly in the United States. Racial subgroups are often grouped into categories in research, limiting our understanding of disparities. This study describes the prevalence of obesity among youth of diverse racial and ethnic backgrounds receiving care at community health centers (CHCs). This cross-sectional study describes the prevalence of elevated body mass index (BMI) (≥85th percentile) and obesity (≥95th percentile) in youth aged 9 to 19 years receiving care in CHCs in 2014. Multilevel logistic regression estimated the prevalence of elevated BMI and obesity by age, race/ethnicity, and sex. Among 64 925 youth, 40% had elevated BMI and 22% were obese. By race, obesity was lowest in the combined Asian/Pacific Islander category (13%); however, when subgroups were separated, the highest prevalence was among Native Hawaiians (33%) and Other Pacific Islanders (42%) and the lowest in Asians. By sex, Black females and Hispanic and Asian males were more likely to be obese. By age, the highest prevalence of obesity was among those aged 9 to 10 years (25%). Youth served by CHCs have a high prevalence of obesity, with significant differences observed by race, sex, and age. Combining race categories obscures disparities. The heterogeneity of communities warrants research that describes different populations to address obesity.

Fecal occult blood testing (FOBT) is a pragmatic screening option for many community health centers (CHCs), but FOBT screening programs will not reduce mortality if patients with positive results do not undergo diagnostic colonoscopy (DC). This study was conducted to investigate DC completion among CHC patients. This retrospective cohort study used data from three CHCs in the Midwest and Southwest. The primary study outcome was DC completion within 6 months of positive FOBT among adults age 50–75. Patient data was collected using automated electronic queries. Manual chart reviews were conducted if queries produced no evidence of DC. Poisson regression models described adjusted relative risks (RRs) of DC completion. The study included 308 patients; 63.3 % were female, 48.7 % were Spanish speakers and 35.7 % were uninsured. Based on combined query and chart review findings, 51.5 % completed DC. Spanish speakers were more likely than English speakers to complete DC [RR 1.19; 95 % confidence interval (CI) 1.04–1.36; P = 0.009], and DC completion was lower among patients with 0 visits than those with 1–2 visits (RR 2.81; 95% CI 1.83–4.33; P

A primary barrier to translation of clinical research discoveries into care delivery and population health is the lack of sustainable infrastructure bringing researchers, policymakers, practitioners, and communities together to reduce silos in knowledge and action. As National Institutes of Health's (NIH) mechanism to advance translational research, Clinical and Translational Science Award (CTSA) awardees are uniquely positioned to bridge this gap. Delivering on this promise requires sustained collaboration and alignment between research institutions and public health and healthcare programs and services. We describe the collaboration of seven CTSA hubs with city, county, and state healthcare and public health organizations striving to realize this vision together. Partnership representatives convened monthly to identify key components, common and unique themes, and barriers in academic-public collaborations. All partnerships aligned the activities of the CTSA programs with the needs of the city/county/state partners, by sharing resources, responding to real-time policy questions and training needs, promoting best practices, and advancing community-engaged research, and dissemination and implementation science to narrow the knowledge-to-practice gap. Barriers included competing priorities, differing timelines, bureaucratic hurdles, and unstable funding. Academic-public health/health system partnerships represent a unique and underutilized model with potential to enhance community and population health.

Background Little is known about statin underutilization among diabetes mellitus patients cared for in community health centers, which tend to serve socioeconomically disadvantaged populations. Implications of the American College of Cardiology/American Heart Association ( ACC / AHA ) guidelines on preexisting gaps in statin treatment in this population are unclear. Methods and Results We included 32 440 adults (45% male, 63% nonwhite, 29% uninsured/Medicaid) aged 40 to 75 years with diabetes mellitus who received care within 16 community health center groups in 11 states in the Community Health Applied Research Network during 2013. Statin prescribing was analyzed as a function of concordance with the National Cholesterol Education Program Adult Treatment Panel 2001 and ACC / AHA 2013 guidelines. More patients’ treatments were concordant with the ACC / AHA (52.8%) versus the National Cholesterol Education Program Adult Treatment Panel (36.2%) guideline. Female sex was associated with lower concordance for both (odds ratio [ OR ] 0.90, CI 0.85‐0.94; and OR 0.84, CI 0.80‐0.88, respectively). Being insured, an Asian/Pacific Islander, or primarily Spanish speaking were associated with greater concordance for both guidelines: 35.5% (11 526/32 440) were concordant with neither guideline, the majority (79.7%) having no statin prescribed; 28.2% (9168/32 440) were concordant with ACC / AHA but not the National Cholesterol Education Program Adult Treatment Panel. 8.7% of these patients had a low‐density lipoprotein cholesterol >160 mg/dL despite having a moderate‐ or high‐intensity statin prescribed. And 11.6% (3772/32 440) were concordant with the National Cholesterol Education Program Adult Treatment Panel but not with ACC / AHA . Most of these patients had a low‐density lipoprotein cholesterol between 70 and 99 mg/dL with no or a low‐intensity statin prescribed. Conclusions Opportunities exist to improve cholesterol management in diabetes mellitus patients in community health centers. Addressing care gaps could improve cardiovascular disease prevention in this high‐risk population.

Pediatric hypertension is a risk for adult cardiovascular disease, making early detection important. The prevalence of pediatric essential hypertension is rising due to the increased prevalence of obesity. Though guidelines for screening, diagnosis, evaluation, and management are available, there are barriers to accurate diagnosis of pediatric hypertension, including lack of knowledge and complexity of blood pressure standards. We aimed to gain insights into reasons for low rates of diagnosis and treatment from primary care providers. As part of a multisite randomized controlled trial, we interviewed 8 providers in a community health center network. We used a grounded theoretical approach to analyze transcripts. Providers reflected on numerous barriers to diagnosis, management, and follow-up; recommendations for educational content; and how community health center systems can be improved. Findings informed development of a multifaceted intervention. Despite lack of training on essential hypertension, providers were comfortable recommending lifestyle changes to promote healthier weight and reduced blood pressure.

Introduction: Little is known about statin underuse among diabetes (DM) patients cared for in community health centers (CHCs), which tend to serve socioeconomically disadvantaged populations. Implications of the recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines on preexisting gaps in statin treatment in this population are unclear. Hypothesis: Substantial statin underutilization will exist regardless of differences between guidelines. Methods: We included 32,440 adults (45% male, 63% non-white, 28% uninsured/Medicaid) with DM aged 40 to 75 years who received care within 16 CHC groups in eleven states in the Community Health Applied Research Network (CHARN) during 2013. Statin prescribing was analyzed as a function of concordance with the National Cholesterol Education Program Adult Treatment Panel (ATPIII) 2001 guideline and ACC/AHA 2013 guideline. Results: More patients were concordant with the ACC/AHA (52.8%) versus ATPIII (36.2%) guideline. Female gender was independently associated with lower concordance for both guidelines [OR 0.90 CI (0.85-0.94) and OR 0.84 CI (0.80-0.88) respectively]. Black race was associated with lower concordance with ATPIII but not ACC/AHA. Being insured, Asian/Pacific Islander or primarily Spanish speaking were associated with greater concordance for both guidelines. 35% (11526/32440) of the cohort were concordant with neither guideline (Figure), the majority (80%) having no statin prescribed. 28% (9168/32440) were concordant with ACC/AHA guidelines but not ATPIII guidelines. 8.5% of these patients had an LDL >160 despite having a medium or high intensity statin prescribed. 12% (3772/32440) were concordant with ATPIII but not ACC/AHA guidelines. Most of these patients had an LDL between 70-99 mg/dl with no or a low intensity statin prescribed. Conclusions: Opportunities exist to improve cholesterol management in DM patients in CHCs. Addressing care gaps could improve cardiovascular disease prevention in this high risk population.

Background Asthma, a common chronic airway disorder, affects an estimated 25 million persons in the United States and 330 million persons worldwide. Although many asthma patient registries exist, the ability to link and compare data across registries is hindered by a lack of harmonization in the outcome measures collected by each registry. Objectives The purpose of this project was to develop a minimum set of patient- and provider-relevant standardized outcome measures that could be collected in asthma patient registries and clinical practice. Methods Asthma registries were identified through multiple sources and invited to join the workgroup and submit outcome measures. Additional measures were identified through literature searches and reviews of quality measures and consensus statements. Outcome measures were categorized by using the Agency for Healthcare Research and Quality's supported Outcome Measures Framework. A minimum set of broadly relevant measures was identified. Measure definitions were harmonized through in-person and virtual meetings. Results Forty-six outcome measures, including those identified from 13 registries, were curated and harmonized into a minimum set of 21 measures in the Outcome Measures Framework categories of survival, clinical response, events of interest, patient-reported outcomes, resource utilization, and experience of care. The harmonized definitions build on existing consensus statements and are appropriate for adult and pediatric patients. Conclusions The harmonized measures represent a minimum set of outcomes that are relevant in asthma research and clinical practice. Routine and consistent collection of these measures in registries and other systems would support creation of a national research infrastructure to efficiently address new questions and improve patient management and outcomes.

Background In 2015, the United States Preventive Services Task Force (USPSTF) recommended targeted screening for prediabetes and diabetes (dysglycemia) in adults who are aged 40 to 70 y old and overweight or obese. Given increasing prevalence of dysglycemia at younger ages and lower body weight, particularly among racial/ethnic minorities, we sought to determine whether the current screening criteria may fail to identify some high-risk population subgroups. Methods and Findings We investigated the performance of the 2015 USPSTF screening recommendation in detecting dysglycemia among US community health center patients. A retrospective analysis of electronic health record (EHR) data from 50,515 adult primary care patients was conducted. Longitudinal EHR data were collected in six health centers in the Midwest and Southwest. Patients with a first office visit between 2008 and 2010 were identified and followed for up to 3 y through 2013. We excluded patients who had dysglycemia at baseline and those with fewer than two office visits during the follow-up period. The exposure of interest was eligibility for screening according to the 2015 USPSTF criteria. The primary outcome was development of dysglycemia during follow-up, determined by: (1) laboratory results (fasting/2-h postload/random glucose ≥ 100/140/200 mg/dL [5.55/7.77/11.10 mmol/L] or hemoglobin A1C ≥ 5.7% [39 mmol/mol]); (2) diagnosis codes for prediabetes or type 2 diabetes; or (3) antidiabetic medication order. At baseline, 18,846 (37.3%) participants were aged ≥40 y, 33,537 (66.4%) were overweight or obese, and 39,061 (77.3%) were racial/ethnic minorities (34.6% Black, 33.9% Hispanic/Latino, and 8.7% Other). Overall, 29,946 (59.3%) patients had a glycemic test within 3 y of follow-up, and 8,478 of them developed dysglycemia. Only 12,679 (25.1%) patients were eligible for screening according to the 2015 USPSTF criteria, which demonstrated the following sensitivity and specificity (95% CI): 45.0% (43.9%–46.1%) and 71.9% (71.3%–72.5%), respectively. Racial/ethnic minorities were significantly less likely to be eligible for screening yet had higher odds of developing dysglycemia than whites (odds ratio [95% CI]: Blacks 1.24 [1.09–1.40]; Hispanics 1.46 [1.30–1.64]; and Other 1.33 [1.16–1.54]). In addition, the screening criteria had lower sensitivity in all racial/ethnic minority groups compared to whites. Limitations of this study include the ascertainment of dysglycemia only among patients with available test results and findings that may not be generalizable at the population level. Conclusions Targeted diabetes screening based on new USPSTF criteria may detect approximately half of adult community health center patients with undiagnosed dysglycemia and proportionately fewer racial/ethnic minorities than whites. Future research is needed to estimate the performance of these screening criteria in population-based samples., New diabetes screening criteria in the United States do not fully diagnose all patients with dysglycemia, Matthew O'Brien and colleagues report., Author Summary Why Was This Study Done? In October 2015, the United States Preventive Services Task Force (USPSTF) issued a new diabetes screening recommendation for adults who are aged 40–70 y and overweight or obese. These screening criteria may miss high-risk groups who develop prediabetes and diabetes (together called dysglycemia) at younger ages or at a normal weight. What Did the Researchers Do and Find? We conducted a study of electronic health record data from adult primary care patients at US community health centers between 2008 through 2013. The goal of the study was to determine patient characteristics associated with being eligible for diabetes screening, receiving a screening test, and developing dysglycemia over a 3-y period. The USPSTF screening criteria identified approximately half of patients who developed dysglycemia and proportionately fewer cases of dysglycemia among racial/ethnic minorities than whites. What Do These Findings Mean? Primary care providers may miss a substantial proportion of patients with dysglycemia by following the current USPSTF screening recommendation. Providers may consider screening patients from racial/ethnic minority groups before the age and weight ranges recommended by the USPSTF. However, patients may incur out-of-pocket costs when their doctors obtain a diabetes screening test that does not follow the USPSTF recommendation.

Asthma 1-2-3 is a newly-developed low-literacy multimedia education tool designed to promote asthma self-care concepts among African American adults. An expert panel (n = 10) informed content development for the tool. The video script and storyboard imagery were shown to 30 African Americans recruited from the American Lung Association, whose reactions and comments guided further revisions. The final version was pilot tested in three diverse community settings in Chicago to determine the efficacy of Asthma 1-2-3 at improving patient understanding of asthma and its symptoms. In all, 130 adults participated in the pilot test. Knowledge scores significantly improved from pretest to posttest following presentation of the developed tool for subjects across all literacy levels (Pretest: Mean = 4.2 [SD = 1.6]; Posttest: M = 6.8 [SD = 2.0], P < 0.001). Symptom pathophysiology concepts were the least understood. Individuals with low literacy had less total knowledge score gains compared to those with marginal and adequate literacy (1.8, 2.6, and 3.2 respectively; P = 0.002). The multimedia tool significantly improved understanding of asthma. Individuals with limited literacy may require additional instruction, repeated viewing, or added tangible cues (i.e. supplementary print materials) to support knowledge retention. In general, feedback from the target population was particularly helpful in the development of the tool and its initial evaluation, and should be considered as a necessary step in the creation of other patient education materials.

Background: Low-income African-American adolescents suffer a disproportionate burden of asthma morbidity.Purpose: To evaluate the ability of our intervention, the Adolescents’ Disease Empowerment and Persistency Technology (ADEPT) for asthma, to increase asthma knowledge in our target population.Methods: This was a 14-week (2-week run-in and 12-week treatment) randomized, double-blind, placebo-controlled pilot study in which 28 inner-city African-American adolescents with asthma, between 10 and 18 years of age, were randomized to receive (1) celebrity asthma messages (experimental group), or (2) general health messages (control group) between music tracks on an MP3 player. The asthma messages were recorded by famous athletes, musicians, and other celebrities popular among this group of teenagers. Asthma knowledge, assessed by the ZAP Asthma Knowledge instrament, was collected pre- and post-intervention.Results: Mean improvement in ZAP score was significantly higher in the experimental group (8.1%, SD 7.2%) than the control group (0.4%, SD 7.2%) (p = 0.05).Conclusion: These findings suggest that this may be an innovative and promising new approach to improving asthma outcomes in this difficult-to-reach population.

Background . This study was conducted to validate use of electronic health record (EHR) data for measuring colorectal cancer (CRC) screening rates at community health centers (CHCs). Methods . Electronic health records were queried to assess screening via colonoscopy, flexible sigmoidoscopy, or fecal occult blood testing (FOBT) in 2011. Results . Multiple iterations were required to maximize query accuracy. Manual chart reviews, stratified by screening modality, confirmed query results for 112 of 113 (99.1%) reviewed colonoscopies, 110 of 110 (100%) reviewed FOBTs, and 111 of 120 (92.5%) unscreened patients. At participating CHCs, CRC screening rates ranged from 9.7% to 67.2% (median, 30.6%). Adherence to annual FOBT ranged from 3.3% to 59.0% (median, 18.6%). Most screening was done by colonoscopy. Conclusions . Colorectal cancer screening varies substantially across CHCs. Electronic health record data can validly measure CRC screening, but repeated assessments of programming accuracy are required. Community health centers may need support to measure quality using EHR data and increase screening.