Positive Predictive Value of a Single Assessment of Estimated GFR in the Diagnosis of Chronic Kidney Disease.

OBJECTIVES: The positive predictive value (PPV) of a single assessment of estimated glomerular filtration rate (eGFR) in the diagnosis of chronic kidney disease (CKD) is not known. Our objective was to determine the PPV of a single assessment of eGFR among adults with at least one eGFR <60 mL/min in their lifetime, using the Distributed Area Research and Therapeutics Network CKD natural history dataset. METHODS: In all, 47,104 adults who were cared for by 113 practices in the United States were included. Proportions of patients in eGFR categories at baseline were calculated using the following categories: <15 mL/min, 15 to 29.99 mL/min, 30 to 44.99 mL/min, and 45 to 59.99 mL/min. Comparisons were then made between the baseline and the endpoint to identify patients who had a follow-up eGFR that remained at <60 mL/min. The proportions of patients in each eGFR category were compared baseline to endpoint using cross-tabulations. To test the proposed cutpoint, the proportions of patients who had an eGFR that remained at <60 mL/min were measured, using the cutpoints that included the highest cumulative proportion of patients. The sensitivity and specificity of that cutpoint were calculated. RESULTS: A cutpoint of <45 mL/min was identified, yielding a PPV of 93% with a sensitivity of 28% and a specificity of 94%. CONCLUSIONS: A valid cutpoint to screen for CKD was identified. This cutpoint may prove important to early screening for CKD while reducing the burden on the healthcare system and patients suspected of having CKD.

Does oral health goal setting during medical visits improve parents' oral health behaviors?

OBJECTIVES: The Rocky Mountain Network for Oral Health (RoMoNOH) promotes the delivery of preventive oral health services (POHS) to children receiving care at community health centers (CHCs) in Arizona, Colorado, Montana, and Wyoming. One POHS is oral health goal setting (OHGS). This study aimed to evaluate the effect of OHGS during medical visits on parent/caregiver-reported oral health behaviors (OHBs). METHODS: The RoMoNOH implementation team trained CHC healthcare providers in POHS, including caries risk assessment, oral health education, fluoride varnish application, dental referrals, and parent/caregiver oral health engagement. To promote parents' oral health engagement, healthcare providers were trained in motivational interviewing (MI) with OHGS at medical visits. To evaluate the impact of MI with OHGS on parent/caregiver OHBs, a healthcare team member invited parents/caregivers to complete a baseline survey after their medical visits. The evaluation team sent a follow-up survey after 10-14 days. The surveys measured parents/caregivers' goals, confidence in goal attainment, OHBs, and sociodemographics; the follow-up survey also measured OHGS attainment. Improvement in parent/caregiver-reported OHBs was tested with a paired t-test and unadjusted and adjusted multiple linear regression. RESULTS: In total, 426 parents/caregivers completed the baseline survey; 184 completed both surveys. OHBs, including toothbrushing frequency, stopping bed bottles, drinking tap water, and brushing with fluoride toothpaste improved over the evaluation interval. After adjusting for covariates, brushing with fluoride toothpaste (p = 0.01), drinking tap water (p = 0.03), and removing bed bottles (p = 0.03) improved significantly. CONCLUSION: MI with OHGS with parents/caregivers during medical visits has potential to improve OHBs on behalf of their children.

Embedding Dental Hygienists into Medical Care Teams: Implementation and evaluation of a medical-dental integration approach in Colorado.

This case report describes the implementation approach and evaluation of a medical-dental integration (MDI) project in Colorado that embedded dental hygienists (DHs) into 10 medical practice settings. Through the MDI Learning Collaborative, DHs were integrated into primary care medical care practices to provide full-scope dental hygiene care to patients. Dental hygienists were trained to collect quality-improvement metrics on all encounters, including untreated tooth decay, and referred patients with restorative needs to partnering dentists. Cross-sectional, aggregated clinic-level oral health metrics were submitted monthly from 2019-2022. Descriptive statistics were used to describe the population receiving MDI care and interviews were conducted with MDI staff to describe their perspectives on this approach to comprehensive care. A logistic regression model, adjusted for time and practice, compared untreated dental caries in established vs new MDI patient-visits. From 2019-2021, integrated DHs completed 13,458 visits to low-income patients, Medicaid (70%, n=9,421), uninsured (24%, n=3,230), SCHIP (3%, n=404), private (3%, n=404), of various ages: 0-5 (29%, n=3,838), 6-18 (17%, n=2,266), 18-64 (51%, n=6,825), >65 (4%, n=529). A total of 912 visits were provided to pregnant patients. Services included caries risk assessment (n=9,329), fluoride varnish (n=6,722), dental sealants (n=1,391), silver diamine fluoride (n=382), x-rays (n=5,465) and scaling/root-planing (n=2,882). Improvement was found in untreated decay of established vs. new patient-visits in four of the practices. Dental hygienists integrated into medical teams provided full-scope dental hygiene care to patients and expanded access to dental services. Medical-dental integration (MDI) care was variably associated with reduction in untreated decay. Integrating dental hygienists into primary care medical practices has potential to improve oral health-related outcomes, however access to restorative dental care remains a challenge.

The impact of enhancing self-management support for diabetes in Community Health Centers through patient engagement and relationship building: a primary care pragmatic cluster-randomized trial.

Type 2 diabetes (T2DM) self-management support (SMS) programs can yield improved clinical outcomes but may be limited in application or impact without considering individuals' unique social and personal challenges that may impede successful diabetes outcomes. The current study compares an evidence-based SMS program with an enhanced version that adds a patient engagement protocol, to elicit and address unique patient-level challenges to support improved SMS and diabetes outcomes. Staff from 12 Community Health Center (CHC) clinical sites were trained on and delivered: Connection to Health (CTH; 6 sites), including a health survey and collaborative action planning, or Enhanced Engagement CTH (EE-CTH; 6 sites), including additional relationship building training/support. Impact of CTH and EE-CTH on behavioral self-management, psychological outcomes, and modifiable social risks was examined using general linear mixed effects. Clinics enrolled 734 individuals with T2DM (CTH = 408; EE-CTH = 326). At 6- to 12-month postenrollment, individuals in both programs reported significant improvements in self-management behaviors (sugary beverages, missed medications), psychological outcomes (stress, health-related distress), and social risks (food security, utilities; all p < .05). Compared with CTH, individuals in EE-CTH reported greater decreases in high fat foods, salt, stress and health-related distress; and depression symptoms improved within EE-CTH (all p < .05). CTH and EE-CTH demonstrated positive behavioral, psychological, and social risk impacts for T2DM in CHCs delivered within existing clinical work flows and a range of clinical roles. Given the greater improvements in psychological outcomes and behavioral self-management in EE-CTH, increased attention to relationship building strategies within SMS programs is warranted.

An Interprofessional Approach to Chronic Pain Management and Education.

BACKGROUND AND OBJECTIVES: The opioid epidemic highlights the importance of evidence-based practices in the management of chronic pain and the need for improved resident education focused on chronic pain treatment and controlled substance use. We present the development, implementation, and outcomes of a novel, long-standing interprofessional safe prescribing committee (SPC) and resulting policy, protocol, and longitudinal curriculum to address patient care and educational gaps in chronic pain management for residents in training. METHODS: The SPC developed and implemented an opioid prescribing policy, protocol, and longitudinal curriculum in a single, community-based residency program. We conducted a postcurriculum survey for resident graduates to assess impact of knowledge gained. We conducted a retrospective chart review for patients on chronic opioid therapy to assess change in morphine equivalent dosing (MED) and pain scores pre- and postintervention. RESULTS: A postcurriculum survey was completed by 20/26 (77%) graduates; 18/20 (90%) felt well-equipped to manage chronic pain based on their residency training experience. We completed a retrospective chart review on 57 patients. We found a significant decrease in MED (-20.34 [SE 5.12], P<.0001) at intervention visit with MED reductions maintained through the postintervention period (-9.43 per year additional decrease [SE 5.25], P=.073). We observed improvement in postintervention pain scores (P=.017). CONCLUSIONS: Our study illustrates the effectiveness of an interprofessional committee in lowering prescribed opioid doses and enhancing chronic pain education in a community-based residency setting.

Relationship Between Social Vulnerability Indicators and Trial Participant Attrition: Findings From the HYVALUE Trial.

BACKGROUND: Social vulnerability indicators are associated with health care inequities and may similarly impede ongoing participation in research studies. We evaluated the association of social vulnerability indicators and research participant attrition in a trial focused on reducing health disparities. METHODS: Self-identified White or Black adults enrolled in the HYVALUE trial (Hypertension and VALUEs), a randomized trial testing a values-affirmation intervention on medication adherence, from February 2017 to September 2019 were included. The self-reported measures of social vulnerability indicators included: (1) Black race; (2) female gender; (3) no health insurance; (4) unemployment; (5) a high school diploma or less; and (6) financial-resource strain. Full attrition was defined as not completing at least one 3- or 6-month follow-up study visit. Log-binomial regression models adjusted for age, gender, race, medical comorbidities, and the other social vulnerability indicators to estimate the relative risk of each social vulnerability indicator with study attrition. RESULTS: Among 825 participants, the mean age was 63.3 years (±11.7 years), 60% were women, 54% were Black, and 97% reported at least one social vulnerability. Overall, 21% participants had full attrition after study enrollment. After adjustment for all other social vulnerabilities, only financial-resource strain remained consistently associated with full attrition (relative risk, 1.71 [95% CI, 1.28-2.29]). In a secondary analysis of partial attrition (completed only one follow-up visit), financial-resource strain (relative risk, 1.40 [95% CI, 1.09-1.81]) and being uninsured (relative risk, 1.54 [95% CI, 1.01-2.34]) were associated with partial attrition. CONCLUSIONS: In a trial aimed at reducing disparities in medication adherence, participants who reported financial-resource strain had a higher risk of participant attrition independent of race or gender. Our findings suggest that efforts to retain diverse populations in clinical trials should extend beyond race and gender to consider other social vulnerability indicators. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03028597.

Pulse wave velocity and carotid atherosclerosis in white and Latino patients with hypertension.

BACKGROUND: Preventive cardiology has expanded beyond coronary heart disease towards prevention of a broader spectrum of cardiovascular diseases. Ethnic minorities are at proportionately greater risk for developing extracoronary vascular disease including heart failure and cerebrovascular disease. METHODS: We performed a cross sectional study of Latino and White hypertension patients in a safety-net healthcare system. Framingham risk factors, markers of inflammation (hsCRP, LPpLA2), arterial stiffness (Pulse wave velocity, augmentation index, and central aortic pressure), and endothelial function (brachial artery flow-mediated dilatation) were measured. Univariate and multivariable associations between these parameters and an index of extracoronary atherosclerosis (carotid intima media thickness) was performed. RESULTS: Among 177 subjects, mean age was 62 years, 67% were female, and 67% were Latino. In univariate analysis, markers associated with carotid intima media thickness (IMT) at p<0.25 included pulse wave velocity (PWV), augmentation index (AIx), central aortic pressure (cAP), and LpPLA2 activity rank. However, AIx, cAP, and LpPLA2 activity were not significantly associated with carotid IMT after adjusting for Framingham risk factors (all p>.10). Only PWV retained a significant association with carotid IMT independent of the Framingham general risk profile parameters (p=.016). No statistically significant interactions between Framingham and other independent variables with ethnicity (all p>.05) were observed. CONCLUSION: In this safety net cohort, PWV is a potentially useful adjunctive atherosclerotic risk marker independent of traditional risk factors and irrespective of ethnicity.

Smoking reduction for persons with mental illnesses: 6-month results from community-based interventions.

Persons with mental illnesses use tobacco at significantly higher and heavier rates than the general population, and suffer greater tobacco- related morbidity and mortality. However, there are few existing tobacco cessation interventions for these individuals. This study examined two tobacco cessation interventions, a telephonic quitline intervention (counseling and nicotine replacement therapy) and a community-based group counseling intervention with adults currently receiving community mental health services. At 6-month follow-up, both groups demonstrated significantly reduced tobacco use, but participants who received both quitline services and the group counseling intervention were significantly more likely to have a 50% tobacco use reduction. Across groups, the overall intent-to-treat cessation rate was 7%. Tobacco dependence, depression symptoms, and psychotic symptoms decreased significantly for all treatment groups, while health and mental health functioning increased. Findings suggest that common community tobacco cessation services are effective for this population.

'Presumptively Initiating Vaccines and Optimizing Talk with Motivational Interviewing' (PIVOT with MI) trial: a protocol for a cluster randomised controlled trial of a clinician vaccine communication intervention.

INTRODUCTION: A key contributor to underimmunisation is parental refusal or delay of vaccines due to vaccine concerns. Many clinicians lack confidence in communicating with vaccine-hesitant parents (VHP) and perceive that their discussions will do little to change parents' minds. Improving clinician communication with VHPs is critical to increasing childhood vaccine uptake. METHODS AND ANALYSIS: We describe the protocol for a cluster randomised controlled trial to test the impact of a novel, multifaceted clinician vaccine communication strategy on child immunisation status. The trial will be conducted in 24 primary care practices in two US states (Washington and Colorado). The strategy is called Presumptively Initiating Vaccines and Optimizing Talk with Motivational Interviewing (PIVOT with MI), and involves clinicians initiating the vaccine conversation with all parents of young children using the presumptive format, and among those parents who resist vaccines, pivoting to using MI. Our primary outcome is the immunisation status of children of VHPs at 19 months, 0 day of age expressed as the percentage of days underimmunised from birth to 19 months for 22 doses of eight vaccines recommended during this interval. Secondary outcomes include clinician experience communicating with VHPs, parent visit experience and clinician adherence to the PIVOT with MI communication strategy. ETHICS AND DISSEMINATION: This study is approved by the following institutional review boards: Colorado Multiple Institutional Review Board, Washington State Institutional Review Board and Swedish Health Services Institutional Review Board. Results will be disseminated through peer-reviewed manuscripts and conference presentations. TRIAL REGISTRATION NUMBER: NCT03885232.

Increasing colon cancer testing in rural Colorado: evaluation of the exposure to a community-based awareness campaign.

BACKGROUND: Despite effective prevention and early detection screening methods, colorectal cancer is the second leading cause of cancer death in the United States. Colorectal cancer screening community-based interventions are rare, and the literature lacks information about community-based intervention processes. Using participatory research methods, the High Plains Research Network developed a community-based awareness and educational intervention to increase colorectal cancer screening rates in rural northeastern Colorado. This study describes the program components and implementation and explores whether the target population was exposed to the intervention, the reach of the individual intervention components, and the effect on screening intentions. METHODS: A random digit dial survey was conducted of residents age 40 and older in the first 3 communities to receive the intervention to estimate exposure to the intervention and its effect on colorectal cancer screening intentions. RESULTS: Exposure to at least intervention component was reported by 68% of respondents (n = 460). As the level of exposure increased, intentions to talk to a doctor about colorectal cancer screening increased significantly more in respondents who had not been tested in the past 5 years than those who had (p = .025). Intentions to get tested increased significantly in both groups at the same rate as level of exposure increased (p < .001). CONCLUSION: Using local community members led to the successful implementation of the intervention. Program materials and messages reached a high percentage of the target population and increased colorectal cancer screening intentions.

Colorado Residency PCMH Project: Results From a 6-Year Transformation Effort.

BACKGROUND AND OBJECTIVES: Our objective was to describe the results of a 6-year patient-centered medical home (PCMH) transformation program in 11 Colorado primary care residency practices. METHODS: We used a parallel qualitative and quantitative evaluation including cross-sectional surveys of practice staff and clinicians, group and individual interviews, meeting notes, and longitudinal practice facilitator field notes. Survey analyses assessed change over time, adjusting for practice-level random effects. Qualitative data analysis used iterative template coding and matrix analyses to synthesize data over time and across cases. RESULTS: There were significant improvements in clinicians' self-reported routine delivery of patient-centered care, team-based care, self-management support, and use of information systems (P<.0001). Clinicians and staff reported significant gains in practice change culture (P=.001). Self-reported practice-level assessments pointed to additional significant improvements in quality improvement (QI) processes, continuity of care, self-management support/care coordination, and the use of data and population management (P≤.0215). Practices and their practice facilitators reported important changes in how practices operated, significantly improving their QI processes, shared leadership, change culture, and achieving Level III PCMH NCQA Recognition. Important barriers to further progress remain, including inadequate payment models, inflexible staff roles, and difficult access to clinical data. CONCLUSIONS: The success of these 11 primary care residency practices in making significant improvements in their delivery of patient-centered care, team-based care, self-management support, and use of information systems took time, effort, and external support. Further practice redesign for advanced primary care models will take sustained sources of well-aligned support, flexibility, shared leadership, and partnerships across residency programs for collaborative learning to assist in their transformation efforts.

Exploring Facilitators and Barriers to Initiation and Completion of the Human Papillomavirus (HPV) Vaccine Series among Parents of Girls in a Safety Net System.

Objective: To assess, among parents of predominantly minority, low-income adolescent girls who had either not initiated (NI) or not completed (NC) the HPV vaccine series, attitudes and other factors important in promoting the series, and whether attitudes differed by language preference. Design/Methods: From August 2013-October 2013, we conducted a mail survey among parents of girls aged 12-15 years randomly selected from administrative data in a Denver safety net system; 400 parents from each group (NI and NC) were targeted. Surveys were in English or Spanish. RESULTS: The response rate was 37% (244/660; 140 moved or gone elsewhere; 66% English-speaking, 34% Spanish-speaking). Safety attitudes of NIs and NCs differed, with 40% NIs vs. 14% NC's reporting they thought HPV vaccine was unsafe (p < 0.0001) and 43% NIs vs. 21% NCs that it may cause long-term health problems (p < 0.001). Among NCs, 42% reported they did not know their daughter needed more shots (English-speaking, 20%, Spanish-speaking 52%) and 39% reported that "I wasn't worried about the safety of the HPV vaccine before, but now I am" (English-speaking, 23%, Spanish-speaking, 50%). Items rated as very important among NIs in the decision regarding vaccination included: more information about safety (74%), more information saying it prevents cancer (70%), and if they knew HPV was spread mainly by sexual contact (61%). Conclusions: Safety concerns, being unaware of the need for multiple doses, and low perceived risk of infection remain significant barriers to HPV vaccination for at-risk adolescents. Some parents' safety concerns do not appear until initial vaccination.

RCT of Centralized Vaccine Reminder/Recall for Adults.

INTRODUCTION: A proven, but underutilized, method to increase current low vaccination rates is reminder/recall. Centralized reminder/recall using an Immunization Information System reduces the burden of an individual practice conducting reminder/recall. The objectives were to assess the effectiveness of centralized vaccine reminder/recall on improving adult vaccination rates using Colorado's Immunization Information System. STUDY DESIGN: This study is a pragmatic RCT. SETTING/PARTICIPANTS: Denver Health patients were divided into three strata: 25,039 individuals aged 19-64 years without a high-risk condition for pneumococcal disease, 16,897 individuals aged 19-64 years with a high-risk condition, and 5,332 individuals aged ≥65 years. Data were collected from October 2015 to April 2016 and analyzed between September 2016 and June 2017. INTERVENTION: Adults aged 19-64 years without a high-risk condition who needed influenza or tetanus, diphtheria, acellular pertussis vaccine or both, and adults with a high-risk condition and adults aged ≥65 years who needed influenza, or tetanus, diphtheria, acellular pertussis, or pneumococcal vaccine, or all three vaccines were randomized to receive up to three reminder/recalls or usual care. MAIN OUTCOME MEASURES: Documentation of receipt of any needed vaccine in Immunization Information System ≤6 months after the reminder/recall was the primary outcome. A secondary outcome included implementation costs of the reminder/recall effort. A mixed effects model assessed the association between the intervention and receipt of any needed vaccine while controlling for gender, age, race, ethnicity, insurance type, and history of vaccine refusal. RESULTS: The intervention was associated with receipt of any needed vaccine in the adults aged ≥65 years population (AOR=1.15, 95% CI=1.02, 1.30), but not the other two populations. Influenza vaccine was the source of this difference, with 32.0% receiving a vaccine in intervention versus 28.6% in usual-care groups (p≤0.01). Start-up and implementation costs per person were $0.86. In the population aged ≥65 years, 29.4 patients would need to be contacted to gain one additional vaccination. CONCLUSIONS: Centralized reminder/recall was effective at increasing influenza vaccination rates in adults aged ≥65 years over a short time period, without burdening the practices, and at a reasonable cost. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT02133391.

Extracting Deep Phenotypes for Chronic Kidney Disease Using Electronic Health Records.

INTRODUCTION: As chronic kidney disease (CKD) is among the most prevalent chronic diseases in the world with various rate of progression among patients, identifying its phenotypic subtypes is important for improving risk stratification and providing more targeted therapy and specific treatments for patients having different trajectories of the disease progression. PROBLEM DEFINITION AND DATA: The rapid growth and adoption of electronic health records (EHR) technology has created a unique opportunity to leverage the abundant clinical data, available as EHRs, to find meaningful phenotypic subtypes for CKD. In this study, we focus on extracting disease severity profiles for CKD while accounting for other confounding factors. PROBABILISTIC SUBTYPING MODEL: We employ a probabilistic model to identify precise phenotypes from EHR data of patients who have chronic kidney disease. Using this model, patient's eGFR trajectory is decomposed as a combination of four different components including disease subtype effect, covariate effect, individual long-term effect and individual short-term effect. EXPERIMENTAL RESULTS: The discovered disease subtypes obtained by Probabilistic Subtyping Model for CKD are presented and their clinical relevance is analyzed. DISCUSSION: Several clinical health markers that were found associated with disease subtypes are presented with suggestion for further investigation on their use as risk predictors. Several assumptions in the study are also clarified and discussed. CONCLUSION: The large dataset of EHRs can be used to identify deep phenotypes retrospectively. Directions for further expansion of the model are also discussed.

Predictors of tobacco use among persons with mental illnesses in a statewide population.

OBJECTIVE: This study used statewide administrative data sets to estimate the prevalence of tobacco use among persons with mental illnesses who were accessing public-sector mental health care in Colorado and to determine the relationships between tobacco use and primary diagnosis and alcohol and drug use. METHODS: This study utilized the Colorado Client Assessment Record to examine predictors of tobacco use among 111,984 persons with mental illnesses who were receiving services in the public mental health system. RESULTS: Thirty-nine percent of the sample (N=43,508) used tobacco. Multiple logistic regression analysis found that schizophrenia, schizoaffective disorder, and bipolar disorder (p<.001 for all), and depression or dysthymia (p<.01) were associated with greater tobacco use than other diagnoses. Significant differences in tobacco use existed across gender, age group, race or ethnicity, and substance use categories. CONCLUSIONS: Findings suggest that an administrative database is a low-burden means of identifying persons at high risk of tobacco use to inform resource allocation.

Developmental Screening Disparities for Languages Other than English and Spanish.

BACKGROUND: Limited English proficiency (LEP) is a known barrier to preventive care. Children from families with LEP face socioeconomic circumstances associated with increased odds of developmental delays and decreased participation in early care and education programs. Little is known about developmental surveillance and screening for children from families who speak languages other than English and Spanish. We sought to compare developmental surveillance and screening at well-child visits (WCVs) by preferred parental language. METHODS: Using a retrospective cohort (n = 15,320) of children aged 8 to 40 months with ≥2 WCVs from January 1, 2006, to July 1, 2010, in a community health system, 450 children from 3 language groups (150 English, 150 Spanish, and 150 non-English, non-Spanish) were randomly selected. Chart review assessed 2 primary outcomes, developmental surveillance at 100% of WCVs and screened with a standardized developmental screening tool, and also determined whether children were referred for diagnostic developmental evaluation. Bivariate and multiple logistic regression analyses were conducted. RESULTS: Compared to the English-speaking group, the non-English, non-Spanish group had lower odds of receiving developmental surveillance at 100% of WCVs (odds ratio, 0.3; 95% confidence interval, 0.2, 0.5) and of being screened with a standardized developmental screening tool (odds ratio, 0.1; 95% confidence interval, 0.1, 0.2). There were no differences between the English- and Spanish-speaking groups. Though underpowered, no differences were found for referral. CONCLUSIONS: Improved developmental surveillance and screening are needed for children from families who speak languages other than English and Spanish. Lack of statistically significant differences between English- and Spanish-speaking groups suggests that improved translation and interpretation resources may decrease disparities.

School-Based Health Centers as Medical Homes: Parents' and Adolescents' Perspectives.

OBJECTIVE: Preventive health services are underutilized by US adolescents, especially those from low-income populations. School-based health centers (SBHCs) have been endorsed as primary medical homes for adolescents. This study was undertaken to determine how adolescent SBHC users and their parents perceive SBHCs, particularly whether SBHCs fulfill each of the elements of a medical home as defined by the American Academy of Pediatrics. METHODS: Middle and high school adolescents who had been enrolled in a SBHC in a major metropolitan school district for a minimum of 1 year were interviewed about their perceptions of and experiences with SBHCs. English- and Spanish-speaking parents of SBHC-enrolled adolescents also participated in focus groups on this topic. RESULTS: Four focus groups with parents (n = 30) and 62 interviews with adolescents were completed. Both adolescents and parents indicated satisfaction with the quality and utilization of SBHC services, reporting that SBHCs were highly accessible and family centered. Many students preferred to access care at their SBHC instead of their primary care practice because of the convenience, perceived trustworthiness, compassion, and high quality of care at the SBHC. A few parents reported unmet medical needs from their adolescent's SBHC, and some differences emerged between English- and Spanish-speaking parents. CONCLUSIONS: Adolescents' and parents' perceptions of care received at these SBHCs are consistent with features of the medical home model. These findings suggest that SBHCs can provide coordinated, compassionate care to students in a large, urban school system and may be perceived as more accessible than traditional primary care settings.

Success in the Achieving CARdiovascular Excellence in Colorado (A CARE) Home Blood Pressure Monitoring Program: A Report from the Shared Networks of Colorado Ambulatory Practices and Partners (SNOCAP).

BACKGROUND: Blood pressure (BP) control among primary care patients with hypertension is suboptimal. Home BP monitoring (HBPM) has been shown to be effective but is underused. METHODS: This study was a quasi-experimental evaluation of the impact of the A CARE HBPM program on hypertension control. Nonpregnant adults with hypertension or cardiovascular disease risk factors were given validated home BP monitors and reported monthly average home BP readings by Internet or phone. Patients and providers received feedback. Change in average home and office BP and the percentage of patients achieving target BP were assessed based on patient HBPM reports and a chart audit of office BPs. RESULTS: A total of 3578 patients were enrolled at 26 urban and rural primary care practices. Of these, 36% of participants submitted ≥2 HBPM reports. These active participants submitted a mean of 13.5 average HBPM reports, with a mean of 19.3 BP readings per report. The mean difference in home BP between initial and final HBPM reports for active participants was -6.5/-4.4 mmHg (P < .001) and -6.7/-4.7 mmHg (P < .001) for those with diabetes. The percentage of active participants at or below target BP increased from 34.5% to 53.3% (P < .001) and increased 24.6% to 40.0% (P < .001) for those with diabetes. The mean difference in office BP over 1 year between participants and nonparticipants was -5.4/-2.7 mmHg (P < .001 for systolic BP, P = .01 for diastolic BP) for all participants and -8.5/-1.5 mmHg (P = .014 for systolic BP, P = .405 for diastolic BP) for those with diabetes. CONCLUSIONS: An HBPM program with patient and provider feedback can be successfully implemented in a range of primary care practices and can play a significant role in BP control and decreased cardiovascular disease risk in patients with hypertension.

School-located influenza vaccination with third-party billing: outcomes, cost, and reimbursement.

OBJECTIVE: To assess rates of immunization; costs of conducting clinics; and reimbursements for a school-located influenza vaccination (SLIV) program that billed third-party payers. METHODS: SLIV clinics were conducted in 19 elementary schools in the Denver Public School district (September 2010 to February 2011). School personnel obtained parental consent, and a community vaccinator conducted clinics and performed billing. Vaccines For Children vaccine was available for eligible students. Parents were not billed for any fees. Data were collected regarding implementation costs and vaccine cost was calculated using published private sector prices. Reimbursement amounts were compared to costs. RESULTS: Overall, 30% of students (2784 of 9295) received ≥1 influenza vaccine; 39% (1079 of 2784) needed 2 doses and 80% received both. Excluding vaccine costs, implementation costs were $24.69 per vaccination. The percentage of vaccine costs reimbursed was 62% overall (82% from State Child Health Insurance Program (SCHIP), 50% from private insurance). The percentage of implementation costs reimbursed was 19% overall (23% from private, 27% from Medicaid, 29% from SCHIP and 0% among uninsured). Overall, 25% of total costs (implementation plus vaccine) were reimbursed. CONCLUSIONS: A SLIV program resulted in vaccination of nearly one third of elementary students. Reimbursement rates were limited by 1) school restrictions on charging parents fees, 2) low payments for vaccine administration from public payers and 3) high rates of denials from private insurers. Some of these problems might be reduced by provisions in the Affordable Care Act.