Associations between food insecurity and other social risk factors among U.S. adults.

BACKGROUND: Food insecurity (FI) often co-exists with other social risk factors, which makes addressing it particularly challenging. The degree of association between FI and other social risk factors across different levels of income and before and during the COVID-19 pandemic is currently unknown, impeding the ability to design effective interventions for addressing these co-existing social risk factors. OBJECTIVE: To determine the association between FI and other social risk factors overall and across different levels of income-poverty ratios and before (2019) and during (2020-2021) the pandemic. DESIGN: We used nationally representative data from the 2019-2021 National Health Interview Survey for our cross-sectional analysis. Social risk factors available in NHIS included difficulties paying for medical bills, difficulties paying for medications, receiving income assistance, receiving rental assistance, and "not working last week". SUBJECTS: 93,047 adults (≥18 years old). KEY RESULTS: Individuals with other social risk factors (except receiving income assistance) were more likely to report FI, even after adjusting for income and education inequalities. While poverty leads to a higher prevalence of FI, associations between FI and other social risk factors were stronger among people with higher incomes, which may be related to their ineligibility for social safety net programs. Associations were similar before and during the pandemic, perhaps due to the extensive provision of social safety net programs during the pandemic. CONCLUSIONS: Future research should explore how access to a variety of social safety net programs may impact the association between social risk factors. With the expiration of most pandemic-related social supports, further research and monitoring are also needed to examine FI in the context of increasing food and housing costs. Our findings may also have implications for the expansion of income-based program eligibility criteria and screening for social risk factors across all patients and not only low-income people.

Perspectives of Primary Care Clinicians on the Diagnosis and Treatment of Pediatric Hypertension.

The purpose of this study was to contextualize the challenges of diagnosing and managing pediatric hypertension (pHTN) in federally qualified health centers. We conducted a survey among primary care clinicians (N = 72) who treat children (3-17 years old) in a national network of health centers. Clinicians reported practices of blood pressure (BP) measurement, barriers to diagnosis and management of pHTN, and use of population health tools. Most clinicians (83%) used electronic devices to measure BP, only 49% used manual BP readings for follow-up measurements, and more than half measured BP at each encounter. The highest-rated barrier to pHTN management was lack of comfort with antihypertensive medications (71% of respondents). Few clinicians (10%) had used population health tools, but most (78%) indicated they would like to use them for pHTN. These results offer clinician-level insights regarding implementation of the pHTN guideline in pediatric primary care settings.

Exploring experiences of COVID-19-positive individuals from social media posts.

AIMS: This study aimed to explore the experience of individuals who claimed to be COVID-19 positive via their Twitter feeds. BACKGROUND: Public social media data are valuable to understanding people's experiences of public health phenomena. To improve care to those with COVID-19, this study explored themes from Twitter feeds, generated by individuals who self-identified as COVID-19 positive. DESIGN: This study utilized a descriptive design for text analysis for social media data. METHODS: This study analysed social media text retrieved by tweets of individuals in the United States who self-reported being COVID-19 positive and posted on Twitter in English between April 2, 2020, and April 24, 2020. In extracting embedded topics from tweets, we applied topic modelling approach based on latent Dirichlet allocation and visualized the results via LDAvis, a related web-based interactive visualization tool. RESULTS: Three themes were mined from 721 eligible tweets: (i) recognizing the seriousness of the condition in COVID-19 pandemic; (ii) having symptoms of being COVID-19 positive; and (iii) sharing the journey of being COVID-19 positive. CONCLUSION: Leveraging the knowledge and context of study themes, we present experiences that may better reflect patient needs while experiencing COVID-19. The findings offer more descriptive support for public health nursing and other translational public health efforts during a global pandemic.

Intellectual Property Rights and Access in Crisis.

The importance of access to intellectual property rights (IPR) protected subject-matter in two crucial areas - public health, and educational and cultural engagement - has been extensively demonstrated during the COVID-19 pandemic. Although they involve separate legal areas, patent and copyright, the common thread linking the two is intellectual property's difficult relationship with access in the public interest. This paper examines the tensions caused by access barriers, the tools used to reduce them and their effectiveness. It is clear that the access barriers magnified by COVID-19 are not restricted to narrow or specific contexts but are widespread. They are created by, and are a feature of, our existing IPR frameworks. Open movements provide limited remedies because they are not designed to, nor can adequately address the wide range of access barriers necessary to promote the public interest. Existing legislative mechanisms designed to remove access barriers similarly fail to effectively remedy access needs. These existing options are premised on the assumption that there is a singular "public" motivated by homogenous "interests", which fails to reflect the plurality and cross-border reality of the public(s) interest(s) underpinning the welfare goals of IPR. We conclude that a systemic re-evaluation is required and call for positive and equitable legal measures protective of the public(s) interest(s) to be built within IPR frameworks that also address non-IPR barriers. The current pandemic and development of a "new normal" provides a crucial opportunity to comprehensively consider the public(s) interest(s), not just during a global health crisis, but on an ongoing basis.

Implementing a Social Determinants Screening and Referral Infrastructure During Routine Emergency Department Visits, Utah, 2017-2018.

PURPOSE AND OBJECTIVES: Emergency departments see a disproportionate share of low-income and uninsured patients. We developed and evaluated a process for identifying social needs among emergency department patients, for facilitating access to community-based resources, and for integrating clinical and community-based data. INTERVENTION APPROACH: We leveraged an academic-community partnership to develop a social needs screening tool and referral process. EVALUATION METHODS: In a 25-day feasibility trial incorporating rapid improvement cycles, emergency department staff screened 210 patients for social needs. Observational and interview notes were analyzed, and data were linked from patient screenings, the United Way of Salt Lake 2-1-1 consumer information system, and electronic health records. RESULTS: Domains uncovered during pilot testing included screening based on appearance or insurance; discomfort asking stigmatizing questions; and lack of clarity regarding the screening's purpose. During the trial, 61% (n = 129) of patients reported 1 or more need, 52% (n = 67) of whom wanted follow-up. Of the 65 patients with complete data who wanted referrals, 49% (n = 32) were ultimately reached by 2-1-1, which provided an average of 4 community referrals (eg, pharmacy programs, utility assistance). Service usage 3 months before versus 3 months after emergency department index dates demonstrated that patients with social needs experienced a significant increase in emergency department use compared with those without needs (1.07 vs 1.36, P = .03), while patients with no needs experienced increases in primary care visits compared with those patients with unmet needs (0.24 vs 0.56, P = .03). IMPLICATIONS FOR PUBLIC HEALTH: We demonstrated the ability to systematically screen and refer for emergency department patients' unmet social needs by using existing resources and to link screening results, service referral details, and health service data. However, our experiences demonstrate that widespread implementation efforts should thoughtfully address staff perceptions and patient communication challenges.

An Overview of Research and Evaluation Designs for Dissemination and Implementation.

The wide variety of dissemination and implementation designs now being used to evaluate and improve health systems and outcomes warrants review of the scope, features, and limitations of these designs. This article is one product of a design workgroup that was formed in 2013 by the National Institutes of Health to address dissemination and implementation research, and whose members represented diverse methodologic backgrounds, content focus areas, and health sectors. These experts integrated their collective knowledge on dissemination and implementation designs with searches of published evaluations strategies. This article emphasizes randomized and nonrandomized designs for the traditional translational research continuum or pipeline, which builds on existing efficacy and effectiveness trials to examine how one or more evidence-based clinical/prevention interventions are adopted, scaled up, and sustained in community or service delivery systems. We also mention other designs, including hybrid designs that combine effectiveness and implementation research, quality improvement designs for local knowledge, and designs that use simulation modeling.

A quality improvement initiative to reduce central line infection in neonates using checklists.

Central line associated blood stream infections (CLABSI) are the most common complication of central catheters in neonates. These infections increase length of hospital stay, hospital costs and impact on mortality and morbidities. We performed a quasi-experimental study, over 24 months, utilising a pre-post design to determine the impact checklists had on central line infections. We introduced checklists for insertion, daily maintenance and procedural access based on the existing clinical guideline. Infections and compliance were monitored and reported back to the unit each month. We utilised the interrupted time series analysis to evaluate the impact of introduction of the checklists. Over the 24 months, 318 infants were included with a total of 509 central lines inserted. In the post intervention phase, definite CLABSI rates declined by 41%, from 13.8 definite CLABSIs per 1000 central-line days to 7.8 definite CLABSIs per 1000 central-line days. There was significant change in the mean levels in the post intervention phase (coefficient crude -0.01015; 95% CI -0.01980-0.00051, p value 0.039). Checklist compliance for insertion was 70%, and daily maintenance compliance overall mean was 66%. CONCLUSION: Our quality improvement initiative using checklists, supported with education and feedback, significantly reduced CLABSI in our neonatal unit. What is Known: • Central line associated blood stream infection (CLABSI) continue to cause mortality and morbidity in the neonatal population. • Bundles of intervention use quality improvement methodology to reduce CLABSI and checklists can assist with the introduction of these. What is New: • Checklists assist with reducing central line infection. • To ensure the success of checklists, robust education, leadership and continuous feedback are vital.

Diabetes self-management: using the Colored Eco-Genetic Relationship Map to assess social support.

BACKGROUND: The positive association between individual social support and diabetes health outcomes is well established. However, most tools for assessing social support are highly structured and are rarely used in clinical settings and/or clinical outcomes research. A novel tool that has been shown to engage patients in the identification and use of their social networks is the Colored Eco-Genetic Relationship Map (CEGRM). OBJECTIVE: The purpose of this pilot study was to explore the feasibility of using the CEGRM adapted for eliciting information about how individuals with diabetes use their social networks to support their self-management efforts. METHODS: A sample of 18 adult patients with diabetes completed the newly created diabetes-CEGRM (D-CEGRM) alongside structured questions regarding social support for diabetes self-management. RESULTS: Whereas structured questions elicited information about participants' use of social networks, the D-CEGRM expanded on answers from structured questions by identifying both positive and negative aspects of social support, additional individual and community-based resources, and nuanced interpersonal information about the individuals involved. DISCUSSION: The D-CEGRM appears to be feasible and useful in assessing the social networks of adults with diabetes and how they are used to support tasks related to self-management. The information elicited by completing the D-CEGRM expanded on information collected through structured questions about social support in a way that might better address research questions and inform clinical decision making.

Recurrence of severe diverticulitis is associated with age and birth decade.

BACKGROUND: The risk of recurrence is an important consideration when deciding to treat patients medically or with elective colectomy after recovery from diverticulitis. It is unclear whether age is associated with recurrence. This study aimed to examine the relationship between age and the risk of recurrent diverticulitis while considering important epidemiologic factors, such as birth decade. METHODS: The Utah Population Database was used to identify individuals with incident severe diverticulitis, defined as requiring an emergency department visit or hospitalization, between 1998 and 2018. This study measured the relationship between age and recurrent severe diverticulitis after adjusting for birth decade and other important variables, such as sex, urban/rural status, complicated diverticulitis, and body mass index using a Cox proportional hazards model. RESULTS: The cohort included 8606 individuals with a median age of 61 years at index diverticulitis diagnosis. After adjustment, among individuals born in the same birth decade, increasing age at diverticulitis onset was associated with an increased risk of recurrent diverticulitis (hazard ratio [HR] for 10 years, 1.8; 95% CI, 1.5-2.1). Among individuals with the same age of onset, those born in a more recent birth decade were also at greater risk of recurrent diverticulitis (HR, 1.9; 95% CI, 1.6-2.3). CONCLUSION: Among individuals with an index episode of severe diverticulitis, recurrence was associated with increasing age and more recent birth decade. Clinicians may wish to employ age-specific strategies when counseling patients regarding treatment options after a diverticulitis diagnosis.

A Secondary Data Analysis of Technology Access as a Determinant of Health and Impediment in Social Needs Screening and Referral Processes.

Introduction: Although health systems increasingly integrate social needs screening and referrals into routine care, the effectiveness of these interventions and for whom they work remains unclear. Methods: Patients (N=4,608) seen in the emergency department were screened for social needs (e.g., transportation, housing, food) and offered an opportunity to receive outreach from community service specialists. Results: Among 453 patients with 1 or more social needs who requested assistance, outreach specialists connected with 95 (21.0%). Patients preferred to be contacted through their telephone (n=21, 60.2%), email (n=126, 28.0%), someone else's telephone (n=30, 6.7%), or first by telephone followed by email (n=23, 5.1%). Preferred contact method varied by patient age; endorsement of unmet transportation, housing, and utility needs; receipt of service outreach; and differences in emergency department utilization from the 6 months before the index visit to the 6 months after. Conclusions: Because limited access to a stable telephone or internet connection may prevent patients from connecting with resource referrals, social needs interventions may not benefit the most underserved populations who are at the highest risk of negative health outcomes. Future research should investigate whether communication preferences are an important indicator of needs and how to adapt social needs screening and referral processes so that they are more accessible to populations who may experience more frequent disruptions in methods utilized for digital communication.

Influence of patient characteristics on assessment of diabetes self-management support.

BACKGROUND: Factors contributing to patient-reported experiences of diabetes self-management support are not understood well, particularly over time. OBJECTIVES: The aim of the study was to identify the contribution of patient characteristics to patient-reported quality of SMS. METHODS: Using secondary data from a prospective clinical trial (n = 339) comparing three approaches of providing diabetes self-management support (Group Medical Visits, Automated Telephone Support, and Usual Care) in a diverse, underserved population, the influence of patient characteristics (e.g., age, gender, income, and health status) was examined on Patient Assessment of Chronic Illness Care ratings. RESULTS: At baseline, older age (p = .014), being female (p = .038), and having lower income (p = .001) were associated with lower ratings. Income and interactions involving income combined explained 12% of the variance in baseline ratings. Compared with White patients, African American and Asian patients tended to have higher baseline ratings (p = .076 and p = .045, respectively). Race or ethnicity influenced perceptions throughout the trial, explaining 5% of the variance at baseline and 2% of the variance in 1-year changes in Patient Assessment of Chronic Illness Care ratings. As expected, over 1 year, ratings increased more for patients in both intervention groups compared with the control group (p < .001). DISCUSSION: Ratings of healthcare quality are influenced by patient characteristics independent of the nature of the care provided. Understanding more precisely how these differences are associated with differences in clinical processes will be particularly important for efforts aiming to integrate patient-reported measures into assessments of healthcare quality during routine clinical care and clinical trials.

Indications of food insecurity in the content of telephone calls to a community referral system.

BACKGROUND: Food insecurity is a social determinant of health that impacts more than 10% of U.S. households every year. Many unexpected events make food-insecure people and those with unmet food needs seek information and help from both formal (e.g., community organizations) and informal (e.g., family/friends) resources. Food-related information seeking through telephone calls to a community referral system-211 network-has been used as a proxy for food insecurity but the context of these calls has not been characterized and the validity of this proxy measure is unknown. OBJECTIVE: To investigate the content of food-related telephone calls to 211 and explore the indications of food insecurity during these calls. METHODS: We conducted a secondary qualitative analysis on the transcripts of food-related calls to Utah's 211. From February to March 2022, 25 calls were sampled based on the location of callers to ensure the representation of rural residents. 13 calls from metropolitan and 12 calls from nonmetropolitan ZIP Codes were included. Using a purposive sampling approach, we also made sure that the sample varied with regard to race and ethnicity. Calls were transcribed and de-identified by our community partner-Utah's 211 and were analyzed using a thematic analysis approach by our research team. RESULTS: Three themes emerged from the qualitative analysis including referral to 211, reasons for food-related calls, and reasons for unmet food needs. Results highlight the complex social environment around 211 food-related callers, lack of knowledge about available food resources, and indications of food insecurity in calls. CONCLUSION: Information seeking for food-related resources through 211 is a problem-solving source for people living in a complex social environment. Indications of food insecurity through these calls validate the use of these calls as a proxy measure for food insecurity. Interventions should be designed to increase awareness about the available resources and address the co-existing social needs with food insecurity.

Feasibility and usefulness of the going home toolkit, an mhealth app, during hospital discharge: patient and clinician perspectives.

Feasibility and Usefulness of the Going Home Toolkit, an mHealth App, during Hospital Discharge: Patient and Clinician Perspectives. Objective Communication gaps during discharge planning contribute to post-discharge outcomes. mHealth Apps may allow health systems to provide resources to fill patients' needs. The study's purpose was to elicit feedback regarding The Going Home Toolkit (GHT), an App that aims to facilitate patient communication about discharge needs. Participants Twenty patients hospitalized within the past year, and seven case managers involved in discharge processes from an academic health sciences center. Methods Using tablets installed with the GHT prototype, remote engagement studio interviews were used to observe GHT use and perceptions about usefulness and feasibility. Results Patients successfully used the GHT to identify resources that they may not have known otherwise. Clinicians reported the GHT would support patient engagement during discharge. However, patients liked being able to search for resources, while clinicians focused on offering a list of information. This can be described as a pull vs. push approach to accessing resources. Participants recognized the GHT's unique focus on cognitive processes related to self-management vs. knowledge transfer. Conclusions The GHT represents a valuable tool for facilitating anticipatory planning and procurement of resources post-discharge. Future work should focus on refining the user interface and user experience of the app and creating seamless links to community resources.

Food Insecurity Disparities Among Immigrants in the U.S.

Introduction: Food insecurity negatively impacts public health and costs the U.S. healthcare system $53 billion annually. Immigrants are at higher risk of food insecurity. We sought to (1) characterize the prevalence of food insecurity among immigrants (i.e., noncitizens and naturalized citizens) and U.S.-born citizens and (2) determine whether Supplemental Nutrition Assistance Program utilization and income-poverty ratio levels impact the relationship between immigration status and food insecurity. Methods: Multivariable logistic regression models were used to determine the odds of food insecurity (dependent variables) using nationally representative data from the 2019-2020 National Health Interview Survey. Independent variables included immigration status, Supplemental Nutrition Assistance Program utilization, income-poverty ratio, and other important demographics. AORs with their 95% CIs are reported. Analysis was conducted in 2022. Results: After controlling for independent variables, noncitizens had 1.28 (95% CI=1.02, 1.61) times higher odds of food insecurity than U.S.-born citizens. There was no food insecurity disparity between naturalized citizens and U.S.-born citizens. However, the association between immigration status and food insecurity varied significantly at different levels of Supplemental Nutrition Assistance Program utilization and income-poverty ratio. There were no food insecurity disparities between immigrants and U.S.-born citizens when they utilized the Supplemental Nutrition Assistance Program and when they had an income below 200% federal poverty level. Noncitizens who did not utilize the Supplemental Nutrition Assistance Program or those with an income above 200% federal poverty level were more likely to report food insecurity than their U.S.-born counterparts (AOR=1.32, 95% CI=1.01, 1.73 and AOR=1.88, 95% CI=1.24, 2.86, respectively). Moreover, naturalized citizens with an income above 200% federal poverty level were also more likely to report food insecurity than their U.S.-born counterparts (AOR=1.61, 95% CI=1.21, 2.14). Conclusions: Supplemental Nutrition Assistance Program utilization may likely eliminate food insecurity disparities among immigrants and U.S.-born citizens. However, among non-Supplemental Nutrition Assistance Program utilizers, significant food insecurity disparities remained between noncitizens and U.S.-born citizens after adjusting for independent variables. In addition, among individuals with incomes above 200% federal poverty level, significant food insecurity disparities were observed between immigrants and U.S.-born citizens. More research is needed to further understand the role that fear of deportation, ineligibility or lack of awareness about eligibility for the Supplemental Nutrition Assistance Program, and other factors such as structural racism play in food insecurity disparities between immigrants and U.S.-born citizens.

Disparities in food insecurity between sexual minority and heterosexual adults - a higher burden on bisexual individuals.

Background: Sexual minorities-individuals who identify as gay/lesbian, bisexual, or other non-heterosexual individuals-experience higher rates of food insecurity (FI) compared to heterosexual individuals. During the COVID-19 pandemic, discrimination and structural racism, which are known risk factors for food insecurity, were perpetuated against sexual and racial/ethnic minorities. However, to our knowledge, a nationally representative analysis of the impact of the pandemic on food insecurity by sexual minority status and based on race/ethnicity is missing. We aimed to determine the degree of association between FI and sexual minority adults overall, before (2019) and during (2020-2021) the pandemic, and stratified by race/ethnicity. Methods: We used nationally representative data from the 2019-2021 National Health Interview Survey (NHIS). We specified multivariable logistic regression models to determine the association between FI and identifying as a sexual minority adult (≥18 years old), including gay/lesbian, bisexual, and other non-heterosexual individuals. Results: Overall, we only observed FI disparities between bisexuals and heterosexuals (aOR 1.61 [95% CI 1.31-1.99]). Stratified by year, this association was significant only during the pandemic. Stratified by race/ethnicity, non-Hispanic white and non-Hispanic black individuals identifying as bisexual also experienced a significantly higher FI rate than their heterosexual counterparts. Conclusion: Our results may be a manifestation of the disproportionate impact of discrimination on bisexual individuals' FI experiences. With the growing number of legislative bills targeting the rights of sexual minorities, we expect to see a higher burden of FI among bisexuals, particularly, bisexual people of color. Future intersectional research regarding FI among bisexual and racial/ethnic minority individuals would further elucidate how membership in multiple minority groups may contribute to a higher risk of FI.

Mixed-methods study examining family carers' perceptions of the relationship between intrahospital transitions and patient readiness for discharge.

INTRODUCTION: Intrahospital transitions (IHTs) represent movements of patients during hospitalisation. While transitions are often clinically necessary, such as a transfer from the emergency department to an intensive care unit, transitions may disrupt care coordination, such as discharge planning. Family carers often serve as liaisons between the patient and healthcare professionals. However, carers frequently experience exclusion from care planning during IHTs, potentially decreasing their awareness of patients' clinical status, postdischarge needs and carer preparation. The purpose of this study was to explore family carers' perceptions about IHTs, patient and carer ratings of patient discharge readiness and carer self-perception of preparation to engage in at home care. METHODS: Sequential, explanatory mixed-methods study involving retrospective analysis of hospital inpatients from a parent study (1R01HS026248; PI Wallace) for whom patient and family carer Readiness for Hospital Discharge Scale (RHDS) score frequency of IHTs and patient and caregiver characteristics were available. Maximum variation sampling was used to recruit a subsample of carers with diverse backgrounds and experiences for the participation in semistructured interviews to understand their views of how IHTs influenced preparation for discharge. RESULTS: Of discharged patients from July 2020 to April 2021, a total of 268 had completed the RHDS and 23 completed the semistructured interviews. Most patients experienced 0-2 IHTs and reported high levels of discharge readiness. During quantitative analysis, no association was found between IHTs and patients' RHDS scores. However, carers' perceptions of patient discharge readiness were negatively associated with increased IHTs. Moreover, non-spouse carers reported lower RHDS scores than spousal carers. During interviews, carers shared barriers experienced during IHTs and discussed the importance of inclusion during discharge care planning. CONCLUSIONS: IHTs often represent disruptive events that may influence carers' understanding of patient readiness for discharge to home and, thus, their own preparation for discharge. Further consideration is needed regarding how to support carers during IHT to facilitate high-quality discharge planning.

Impact of COVID-19 visitation policies and hospital capacity on discharge readiness in medicine patients.

Background: COVID-19 impacted the experience of being hospitalized with the widespread adoption of strict visitation policies to ensure healthcare worker safety. One result was decreased time of caregivers at the bedside of hospitalized patients. Objective: To understand the impact of pandemic-related system effects on patient-reported discharge preparation. Design: This mixed methods study included interviews with a sample of discharged patients during April 2020, and quantitative hospital data from April 2020 to February 2021. Participants: 616 patients completed a measure of discharge readiness on their day of discharge and 38 patients completed interviews about their discharge experiences. Main measures: Readiness for discharge (RHDS), visitation policies, ward structure changes, COVID-19-unit census, time into the COVID-19 pandemic, patient characteristics (age, sex, race/ethnicity), admission type (planned/unplanned, for COVID-19), and discharge destination (home, home health, skilled nursing). Key results: Adult patients aged 30-45 (vs. young and older adult patients) and those being discharged to places other than home (e.g., skilled nursing facility) or to out-of-state residences report lower readiness (p < 0.05) on RHDS. Patient interviews revealed some gaps in discharge communication but, overall, patients expressed high discharge readiness and few concerns about how COVID-19 system changes impacted their discharge preparation. Conclusions: While there is some evidence that visitation policies and unit census may impact patient perceptions of discharge preparation, personal characteristics contributed more significantly to discharge readiness than system changes during COVID-19. Participant interviews demonstrated agreement, as most participants were discharged home and identified strong personal feelings of readiness for discharge.Clinical trials registration: ClinicalTrials.gov ID NCT04248738, https://clinicaltrials.gov/ct2/show/NCT04248738. Supplementary Information: The online version contains supplementary material available at 10.1007/s44250-023-00060-8.

Social Risk Factors are Associated with Risk for Hospitalization in Home Health Care: A Natural Language Processing Study.

OBJECTIVE: This study aimed to develop a natural language processing (NLP) system that identified social risk factors in home health care (HHC) clinical notes and to examine the association between social risk factors and hospitalization or an emergency department (ED) visit. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: We used standardized assessments and clinical notes from one HHC agency located in the northeastern United States. This included 86,866 episodes of care for 65,593 unique patients. Patients received HHC services between 2015 and 2017. METHODS: Guided by HHC experts, we created a vocabulary of social risk factors that influence hospitalization or ED visit risk in the HHC setting. We then developed an NLP system to automatically identify social risk factors documented in clinical notes. We used an adjusted logistic regression model to examine the association between the NLP-based social risk factors and hospitalization or an ED visit. RESULTS: On the basis of expert consensus, the following social risk factors emerged: Social Environment, Physical Environment, Education and Literacy, Food Insecurity, Access to Care, and Housing and Economic Circumstances. Our NLP system performed "very good" with an F score of 0.91. Approximately 4% of clinical notes (33% episodes of care) documented a social risk factor. The most frequently documented social risk factors were Physical Environment and Social Environment. Except for Housing and Economic Circumstances, all NLP-based social risk factors were associated with higher odds of hospitalization and ED visits. CONCLUSIONS AND IMPLICATIONS: HHC clinicians assess and document social risk factors associated with hospitalizations and ED visits in their clinical notes. Future studies can explore the social risk factors documented in HHC to improve communication across the health care system and to predict patients at risk for being hospitalized or visiting the ED.

Adherence to the 2017 Clinical Practice Guidelines for Pediatric Hypertension in Safety-Net Clinics.

Importance: The 2017 Clinical Practice Guideline (CPG) for the diagnosis and management of pediatric hypertension (PHTN) categorizes a greater proportion of children with elevated blood pressure and PHTN, yet several barriers to CPG adherence have been noted. Objective: To assess adherence to the 2017 CPG for the diagnosis and management of PHTN and use of a clinical decision support (CDS) tool to calculate blood pressure percentiles. Design, Setting, and Participants: This cross-sectional study used electronic health record-extracted data from January 1, 2018, to December 31, 2019, among patients visiting 1 of 74 federally qualified health centers in AllianceChicago, a national Health Center Controlled Network. Children and adolescents (aged 3-17 years; hereinafter referred to as children) who attended at least 1 visit and had at least 1 blood pressure reading at or above the 90th percentile or diagnosis of elevated blood pressure or PHTN were eligible for data to be included in the analysis. Data were analyzed from September 1, 2020, to February 21, 2023. Exposures: Blood pressure at or above the 90th or 95th percentile. Main Outcomes and Measures: Diagnosis of PHTN (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10], code I10) or elevated blood pressure (ICD-10 code R03.0) and CDS tool use; blood pressure management (antihypertensive medication, lifestyle counseling, referral); and follow-up visit attendance. Descriptive statistics described the sample and rates of guideline adherence. Logistic regression analyses identified patient- and clinic-level associations with guideline adherence. Results: The sample consisted of 23 334 children (54.9% boys; 58.6% White race; median age, 8 [IQR, 4-12] years). Guideline-adherent diagnosis was observed in 8810 children (37.8%) with blood pressure at or above the 90th percentile and 146 of 2542 (5.7%) with blood pressure at or above the 95th percentile at 3 or more visits. The CDS tool was used to calculate blood pressure percentiles in 10 524 cases (45.1%) and was associated with significantly greater odds of PHTN diagnosis (odds ratio, 2.14 [95% CI, 1.10-4.15]). Among 15 422 children with blood pressure at or above the 95th percentile, antihypertensive medication was prescribed to 831 (5.4%), lifestyle counseling was provided to 14 841 (96.2%), and blood pressure-related referrals were given to 848 (5.5%). Guideline-adherent follow-up was observed in 8651 of 19 049 children (45.4%) with blood pressure at or above the 90th percentile and 2598 of 15 164 (17.1%) with blood pressure at or above the 95th percentile. Differences in guideline adherence by patient- and clinic-level factors were observed. Conclusions and Relevance: In this study, fewer than 50% of children with elevated blood pressure had a guideline-adherent diagnosis code or attended guideline-adherent follow-up. Using a CDS tool was associated with guideline-adherent diagnosis, but the tool was underused. Further work is needed to understand how to best support implementation of tools promoting PHTN diagnosis, management, and follow-up.

Applying a Health Access Framework to Understand and Address Food Insecurity.

The prevalence of food insecurity (FI) in United States households has fluctuated between 10% and 15% for the past two decades, well above the Healthy People 2030 goal. FI is associated with increased use of healthcare services and the prevalence of multiple health conditions. Our current efforts to address FI may be limited by measures that lack granularity, timeliness, and consideration of larger food access barriers (e.g., availability of food providers and lack of knowledge regarding where to obtain food). If the Healthy People 2030 goal of reducing FI to 6% is to be met, we need better and faster methods for monitoring and tracking FI in order to produce timely interventions. In this paper, we review key contributors of FI from an access barrier perspective, investigate the limitations of current FI measures, and explore how data from one nonprofit organization may enhance our understanding of FI and facilitate access to resources at the local level. We also propose a conceptual framework illustrating how nonprofit organizations may play an important role in understanding and addressing FI and its intertwined social needs, such as housing and healthcare problems.