Study protocol: a mixed-methods study of women's healthcare in the safety net after Affordable Care Act implementation - EVERYWOMAN.

BACKGROUND: Evidence-based reproductive care reduces morbidity and mortality for women and their children, decreases health disparities and saves money. Community health centres (CHCs) are a key point of access to reproductive and primary care services for women who are publicly insured, uninsured or unable to pay for care. Women of reproductive age (15-44 years) comprise just of a quarter (26%) of the total CHC patient population, with higher than average proportions of women of colour, women with lower income and educational status and social challenges (e.g. housing). Such factors are associated with poorer reproductive health outcomes across contraceptive, preventive and pregnancy-related services. The Affordable Care Act (ACA) prioritised reproductive health as an essential component of women's preventive services to counter these barriers and increase women's access to care. In 2012, the United States Supreme Court ruled ACA implementation through Medicaid expansion as optional, creating a natural experiment to measure the ACA's impact on women's reproductive care delivery and health outcomes. METHODS: This paper describes a 5-year, mixed-methods study comparing women's contraceptive, preventive, prenatal and postpartum care before and after ACA implementation and between Medicaid expansion and non-expansion states. Quantitative assessment will leverage electronic health record data from the ADVANCE Clinical Research Network, a network of over 130 CHCs in 24 states, to describe care and identify patient, practice and state-level factors associated with provision of recommended evidence-based care. Qualitative assessment will include patient, provider and practice level interviews to understand perceptions and utilisation of reproductive healthcare in CHC settings. DISCUSSION: To our knowledge, this will be the first study using patient level electronic health record data from multiple states to assess the impact of ACA implementation in conjunction with other practice and policy level factors such as Title X funding or 1115 Medicaid waivers. Findings will be relevant to policy and practice, informing efforts to enhance the provision of timely, evidence-based reproductive care, improve health outcomes and reduce disparities among women. Patient, provider and practice-level interviews will serve to contextualise our findings and develop subsequent studies and interventions to support women's healthcare provision in CHC settings.

Clinic factors associated with utilization of a pregnancy-intention screening tool in community health centers.

OBJECTIVE: Routine pregnancy-intention screening in the primary care setting is a promising practice to help patients achieve their reproductive goals. We aim to describe the utilization of a pregnancy-intention screening tool integrated in the electronic health record (EHR) of a national network of community health centers (CHCs) and identify clinic-level factors associated with tool use. STUDY DESIGN: We conducted a clinic-level retrospective observational study to assess tool utilization during the first 3 years after the tool was made available in the EHR (November 2015 to October 2018). We describe characteristics of clinics with higher tool utilization (≥90th percentile) versus lower utilization (<90th percentile) and the types of providers who used the tool. We then employ negative binomial regression to identify independent clinic-level factors associated with tool utilization. RESULTS: Across 194 clinics in our study sample which served 289,754 eligible female patients, the tool was used for 113,116 (39%). Medical assistants performed 60.3% of screenings and clinicians performed 11.2%. CHCs with higher tool utilization rates were more likely to be located in rural settings (RR 1.75, 95% CI 1.07-2.87) and serve patient populations with higher proportions of women (RR 1.32, 95% CI 1.24-1.41) and lower proportions of patients with non-English language preference (RR 0.92, 95% CI 0.89-0.95). CONCLUSIONS: Many health centers utilized pregnancy-intention screening after an EHR-based tool was made available, though overall screening rates were low. IMPLICATIONS: Additional study of implementation strategies and effectiveness of pregnancy-intention screening tools is needed. Implementation of future pregnancy-intention screening interventions must be tailored to address clinic-level barriers and facilitators to screening.

Impacts of the Affordable Care Act on Receipt of Women's Preventive Services in Community Health Centers in Medicaid Expansion and Nonexpansion States.

BACKGROUND: The Affordable Care Act (ACA) increased health insurance coverage throughout the United States and improved care delivery for some services. We assess whether ACA implementation and Medicaid expansion were followed by greater receipt of recommended preventive services among women and girls in a large network of community health centers. METHODS: Using electronic health record data from 354 community health centers in 14 states (10 expansion, 4 nonexpansion), we used generalized estimating equations and difference-in-difference methods to compare receipt of six recommended preventive services (cervical cancer screening, human papilloma virus vaccination, chlamydia screening, influenza vaccination, human immunodeficiency virus screening, and blood pressure screening) among active female patients ages 11 to 65 (N = 711,121) before and after ACA implementation and between states that expanded versus did not expand Medicaid. RESULTS: Except for blood pressure screening, receipt of all examined preventive services increased after ACA implementation in both Medicaid expansion and nonexpansion states. Influenza vaccination and blood pressure screening increased more in expansion states (adjusted absolute prevalence difference-in-difference, 1.55; 95% confidence interval, 0.51-2.60; and 1.98; 95% confidence interval, 0.91-3.05, respectively). Chlamydia screening increased more in nonexpansion states (adjusted absolute prevalence difference-in-difference: -4.21; 95% confidence interval, -6.98 to -1.45). Increases in cervical cancer screening, human immunodeficiency virus screening, and human papilloma virus vaccination did not differ significantly between expansion and nonexpansion states. CONCLUSIONS: Among female patients at community health centers, receipt of recommended preventive care improved after ACA implementation in both Medicaid expansion and nonexpansion states, although the overall rates remained low. Continued support is needed to overcome barriers to preventive care in this population.

Patient-, organization-, and system-level barriers and facilitators to preventive oral health care: a convergent mixed-methods study in primary dental care.

BACKGROUND: Dental caries is the most common chronic disease of adult and childhood, a largely preventable yet widespread, costly public health problem. This study identified patient-, organization-, and system-level factors influencing routine delivery of recommended care for prevention and management of caries in primary dental care. METHODS: A convergent mixed-methods design assessed six guidance-recommended behaviours to prevent and manage caries (recording risk, risk-based recall intervals, applying fluoride varnish, placing preventive fissure sealants, demonstrating oral health maintenance, taking dental x-rays). A diagnostic questionnaire assessing current practice, beliefs, and practice characteristics was sent to a random sample of 651 dentists in National Health Service (NHS) Scotland. Eight in-depth case studies comprising observation of routine dental visits and dental team member interviews were conducted. Patient feedback was collected from adult patients with recent checkups at case study practices. Key informant interviews were conducted with decision makers in policy, funding, education, and regulation. The Theoretical Domains Framework within the Behaviour Change Wheel was used to identify and describe patient-, organization-, and system-level barriers and facilitators to care. Findings were merged into a matrix describing theoretical domains salient to each behaviour. The matrix and Behaviour Change Wheel were used to prioritize behaviours for change and plan relevant intervention strategies. RESULTS: Theoretical domains associated with best practice were identified from the questionnaire (N-196), case studies (N = 8 practices, 29 interviews), and patient feedback (N = 19). Using the study matrix, key stakeholders identified priority behaviours (use of preventive fissure sealants among 6-12-year-olds) and strategies (audit and feedback, patient informational campaign) to improve guidance implementation. Proposed strategies were assessed as appropriate for immediate implementation and suitable for development with remaining behaviours. CONCLUSIONS: Specific, theoretically based, testable interventions to improve caries prevention and management were coproduced by patient-, practice-, and policy-level stakeholders. Findings emphasize duality of behavioural determinants as barriers and facilitators, patient influence on preventive care delivery, and benefits of integrating multi-level interests when planning interventions in a dynamic, resource-constrained environment. Interventions identified in this study are actively being used to support ongoing implementation initiatives including guidance, professional development, and oral health promotion.