Identifying virtual care modality in electronic health record data.

Background: Virtual care increased dramatically during the COVID-19 pandemic. The specific modality of virtual care (video, audio, eVisits, eConsults, and remote patient monitoring) has important implications for the accessibility and quality of care, but rates of use are relatively unknown. Methods for identifying virtual care modalities, especially in electronic health records (EHR) are inconsistent. This study (a) developed a method to identify virtual care modalities using EHR data and (b) described the distribution of these modalities over a 3-year study period. Methods: EHR data from 316 primary care safety net clinics throughout the study period (4/1/2020-3/31/2023) were included. Visit type (in-person vs virtual) by adults >18 years old were classified. Expert consultation informed the development of two algorithms to classify virtual care visit modalities; these algorithms prioritized different EHR data elements. We conducted descriptive analyses comparing algorithms and the frequency of virtual care modalities. Results: Agreement between the algorithms was 96.5% for all visits and 89.3% for virtual care visits. The majority of disagreement between the algorithms was among encounters scheduled as audio-only but billed as a video visit. Restricting to visits where the algorithms agreed on visit modality, there were 2-fold more audio-only than video visits. Conclusion: Visit modality classification varies depending upon which data in the EHR are prioritized. Regardless of which algorithm is utilized, safety net clinics rely on audio-only and video visits to provide care in virtual visits. Elimination of reimbursement for audio visits may exacerbate existing inequities in care for low-income patients.

Association between ethnicity, language and metformin prescriptions in U.S. community health center patients with diabetes.

BACKGROUND: Metformin treatment is a recommended first-line medication for patients with type 2 diabetes. Latino patients are subject to factors that may modify their level of diabetes care, including medication prescription. We evaluated the odds of and times to metformin prescription among non-Latino whites, English-preferring Latinos, and Spanish-preferring Latinos with diabetes. METHODS: We constructed a retrospective cohort of 154,368 adult patients from 835 community health centers (CHCs) across 20 states who were diagnosed with diabetes during the study. Patients were from non-Latino white, English-preferring Latino, and Spanish-preferring Latino ethnic/language groups. We modeled adjusted odds of metformin prescription and adjusted hazards (time-to-event) of metformin prescription after diabetes diagnosis and high hemoglobin A1c (HbA1c > 9) test results. RESULTS: English-preferring Latinos had similar odds of metformin prescription (Odds Ratio (OR) = 1.01 (95% CI = 0.93, 1.09)), slightly lower time to metformin prescription after diabetes diagnosis (Hazard Ratio (HR) = 1.06(95% CI = 1.04, 1.09)), and similar time to metformin prescription after a high HbA1c result (HR = 1.04 (0.99, 1.09)) compared to non-Latino whites. Spanish-preferring Latinos had higher odds of metformin prescription (OR) = 1.42 (95% CI = 1.33, 1.52), and less time to prescription after diabetes diagnosis (HR = 1.18 (1.15, 1.20)) and after a high HbA1c result (HR = 1.15 (1.11, 1.20)). CONCLUSIONS: Our analysis of metformin prescription patterns among non-Latino whites, English-preferring Latinos, and Spanish-preferring Latinos did not suggest a lower or slower tendency to prescribe metformin in Latino patients. Understanding disparities in diabetes diagnosis may require further investigation of medication adherence barriers, diet and exercise counseling, and multi-level influences on diabetes outcomes in Latino patients.

Atherosclerotic Cardiovascular Disease Primary and Secondary Prevention in Latino Subgroups.

BACKGROUND: Studies assessing equity in the prevention of atherosclerotic cardiovascular disease (ASCVD) for Latinos living in the USA collectively yield mixed results. Latino persons are diverse in many ways that may influence cardiovascular health. The intersection of Latino nativity and ASCVD prevention is understudied. OBJECTIVE: To determine whether disparities in ASCVD screening, detection, and prescribing differ for US Latinos by country of birth. DESIGN: A retrospective cohort design utilizing 2014-2020 electronic health record data from a network of 320 community health centers across 12 states. Analyses occurred October 1, 2022, to September 30, 2023. PARTICIPANTS: Non-Hispanic White and Latino adults age 20-75 years, born in Cuba, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, and the USA. EXPOSURES: Ethnicity and country of birth. MAIN MEASURES: Outcome measures included prevalence of statin eligibility, of having insufficient data to establish eligibility, odds of having a documented statin prescription, and rates of statin prescriptions and refills. We used covariate-adjusted logistic and generalized estimating equations logistic and negative binomial regressions to generate absolute and relative measures. KEY RESULTS: Among 108,672 adults, 23% (n = 25,422) were statin eligible for primary or secondary prevention of ASCVD using American College of Cardiology/American Heart Association guidelines. Latinos, born in and outside the USA were more likely eligible than Non-Hispanic White patients were (US-born Latino OR = 1.55 (95% CI = 1.37-1.75); non-US-born Latino OR = 1.63 (95% CI = 1.34-1.98)). The eligibility criteria that was met differed by ethnicity and nativity. Latinos overall were less likely missing data to establish eligibility and differences were again observed by specific non-US country of origin. Among those eligible, we observed no statistical difference in statin prescribing between US-born Latinos and non-Hispanic White persons; however, disparities varied by specific non-US country of origin. CONCLUSION: Efforts to improve Latino health in the USA will require approaches for preventing and reversing cardiovascular risk factors, and statin initiation that are Latino subgroup specific.

Latino-White Disparities in Identification and Control of Elevated Blood Pressure Among Adults With Hypertension.

BACKGROUND: Studies analyzing blood pressure (BP) management using the hypertension control cascade have consistently shown disparities in hypertension awareness, treatment, and BP control between Latino patients and non-Latino White patients. We analyze this cascade using electronic health record data from a multistate network of community health centers. METHODS AND RESULTS: Data from 790 clinics in 23 US states from 2012 to 2020, including 1 270 174 patients, were analyzed to compare BP documentation in the electronic health record, clinician acknowledgment (diagnosis or treatment) of incident hypertension (BP ≥140/90), medication prescription, and BP control between non-Latino White patients, English-preferring Latino patients, and Spanish-preferring Latino patients, adjusted for patient-level covariates, and clustered on patients' primary clinics. Among the 429 182 patients with elevated BP (≥140/90) during ambulatory visits from 2012 to 2020, we found that clinician acknowledgment of hypertension was more likely in Spanish-preferring and English-preferring Latino patients versus non-Latino White patients (adjusted odds ratio [aOR], 1.17 [95% CI, 1.11-1.24]; aOR, 1.07 [95% CI, 1.02-1.12], respectively). In addition, Spanish-preferring Latino patients were more likely to receive a medication versus non-Latino White patients (aOR, 1.21 [95% CI, 1.16-1.28]). Among those receiving medication, Latino patients were as likely as non-Latino White patients to have their BP controlled (<140/90). CONCLUSIONS: In a large retrospective study of community health center patients with incident hypertension, the expected disparities in hypertension management between Spanish-preferring Latino, English-preferring Latino, and non-Latino White patients were not identified. These findings add to the hypertension control cascade by examining robust electronic health record data from community health centers and may provide clues to reducing disparities in hypertension management.

Association of neighbourhood walkability and haemoglobin A1c levels among Latino and non-Hispanic White patients with diabetes.

BACKGROUND: Neighbourhood walkability can benefit cardiovascular health. Latino patients are more likely than non-Hispanic White patients to have diabetes, and evidence has shown better diabetes-related outcomes for patients living in neighbourhoods conducive to physical activity. Our objective was to determine whether neighbourhood walkability was associated with haemoglobin A1c (HbA1c) levels among English- and Spanish-preferring Latino patients compared to non-Hispanic White patients. METHODS: We used electronic health record data from patients in the OCHIN, Inc. network of community health centres (CHC) linked to public walkability data. Patients included those age ≥ 18 with ≥ 1 address recorded, with a study clinic visit from 2012 to 2020, and a type 2 diabetes diagnosis (N = 159,289). Generalized estimating equations logistic regression, adjusted for relevant covariates, was used to model the primary binary outcome of always having HbA1c < 7 by language/ethnicity and walkability score. RESULTS: For all groups, the walkability score was not associated with higher odds and prevalence of always having HbA1c < 7. Non-Hispanic White patients were most likely to have HbA1c always < 7 (prevalence ranged from 32.8% [95%CI = 31.2-34.1] in the least walkable neighbourhoods to 33.4% [95% CI 34.4-34.7] in the most walkable), followed by English-preferring Latinos (28.6% [95%CI = 25.4-31.8]-30.7% [95% CI 29.0-32.3]) and Spanish-preferring Latinos (28.3% [95% CI 26.1-30.4]-29.3% [95% CI 28.2-30.3]). CONCLUSIONS: While walkability score was not significantly associated with glycaemic control, control appeared to increase with walkability, suggesting other built environment factors, and their interaction with walkability and clinical care, may play key roles. Latino patients had a lower likelihood of HbA1c always < 7, demonstrating an opportunity for equity improvements in diabetes care.

Impact of Healthcare Location Concordance on Receipt of Preventive Care Among Children Whose Parents have a Substance Use and/or Mental Health Diagnosis.

AIMS: Children of parents with substance use and/or other mental health (SU/MH) diagnoses are at increased risk for health problems. It is unknown whether these children benefit from receiving primary care at the same clinic as their parents. Thus, among children of parents with >1 SU/MH diagnosis, we examined the association of parent-child clinic concordance with rates of well-child checks (WCCs) and childhood vaccinations. DESIGN: Retrospective cohort study using electronic health record (EHR) data from the OCHIN network of community health organizations (CHOs), 2010-2018. Setting: 280 CHOs across 17 states. PARTICIPANTS/CASES: 41,413 parents with >1 SU/MH diagnosis, linked to 65,417 children aged 0 to 17 years, each with >1 visit to an OCHIN clinic during the study period. MEASUREMENTS: Dependent variables: rates of WCCs during (1) the first 15 months of life, and (2) ages 3 to 17 years; vaccine completeness (3) by the age of 2, and (4) before the age of 18. Estimates were attained using generalized estimating equations Poisson or logistic regression. FINDINGS: Among children utilizing the same clinic as their parent versus children using a different clinic (reference group), we observed greater WCC rates in the first 15 months of life [adjusted rate ratio (aRR) = 1.06; 95% confidence interval (CI) = 1.02-1.10]; no difference in WCC rates in ages 3 to 17; higher odds for vaccine completion before age 2 [adjusted odds ratio (aOR) = 1.12; 95% CI = 1.03-1.21]; and lower odds for vaccine completion before age 18 (aOR = 0.88; 95% CI = 0.81-0.95). CONCLUSION: Among children whose parents have at least one SU/MH diagnosis, parent-child clinic concordance was associated with greater rates of WCCs and higher odds of completed vaccinations for children in the youngest age groups, but not the older children. This suggests the need for greater emphasis on family-oriented healthcare for young children of parents with SU/MH diagnoses; this may be less important for older children.

Healthcare utilization for asthma exacerbation among children of migrant and seasonal farmworkers.

Latino children of Migrant and Seasonal Farmworkers (MSFWs) with asthma are at risk for poor health outcomes due to medical access barriers. We compared differences in acute care utilization for asthma exacerbations among migrant and non-migrant Latino and non-Hispanic white (NHW) children at U.S. community health centers. A retrospective observational study utilizing electronic health record data from the ADVANCE Clinical Research Network of United States community health centers included 13,423 children ages 3-17 with a primary care visit between 2005 and 2017 from eight states. Emergency department (ED) and hospitalization data came from Oregon Medicaid claims. Outcomes included acute clinic visits, ED visits, and hospitalizations for asthma exacerbation. Regression analyses adjusted for patient-level covariates. Latino children had higher odds of acute clinic visits for asthma exacerbation compared to NHW children (MSFW odds ratio [OR] = 1.17, 95 % CI = 1.03-1.33; without migrant status OR = 1.13, 95 % CI = 1.03-1.23). MSFW children using Oregon Medicaid had fewer ED visits (rate ratio [RR] = 0.72, 95 % CI = 0.52-0.99) and hospitalizations (RR = 0.47, 95 % CI = 0.26-0.86) compared to NHW children. Increased community health center visits may help mitigate disparities in acute asthma care for MSFW children.

Association of Early Childhood Wheeze and Asthma Diagnosis Documentation by Race, Ethnicity, and Language in Children.

OBJECTIVE: To determine whether electronic health record (EHR) documentation of certain early childhood risk factors for asthma, such as wheeze differ by race, ethnicity, and language group, and whether these children have different subsequent asthma prevalences. METHODS: We used EHR data from the Accelerating Data Value Across a National Community Health Center (ADVANCE) Clinical Research Network from children receiving care in US community health centers (n = 71,259 children) across 21 states to examine the presence of ICD-coded documentation of early childhood wheeze and its association with subsequent asthma diagnosis documentation in the EHR by race/ethnicity/language. RESULTS: ICD-coded wheeze was present in 2 to 3% of each race/ethnicity/language group. Among the total sample, 18.5% had asthma diagnosed after age 4. The adjusted prevalence of subsequent asthma diagnosis was greater in children with wheeze than those without. Odds of asthma diagnosis did not differ among children in all race/ethnicity/language groups with early childhood wheeze. Non-Latino Black children without wheeze had higher odds of asthma (OR = 1.19, 95% CI = 1.08-1.32) compared with non-Latino White children without wheeze. DISCUSSION: In US community health centers which serve medically underserved populations, EHR documentation of early childhood wheeze was uncommon and did not differ significantly among race/ethnicity/language groups. Differences in asthma diagnosis in Latinos may not stem from differences in early-life wheeze documentation. However, our findings suggest that there may be opportunities for improvement in early asthma symptom recognition for non-Latino Black children, especially in those without early childhood wheeze.

Mental Health Care Use by Ethnicity and Preferred Language in a National Cohort of Community Health Center Patients.

OBJECTIVE: Disparities in U.S. mental health care by race and ethnicity have long been documented. The authors sought to compare specialty mental health service use among non-Hispanic White, English-preferring Hispanic, and Spanish-preferring Hispanic patients who accessed care in community health centers (CHCs). METHODS: Retrospective electronic medical records data were extracted for patients ages ≥18 years who received care in 2012-2020 at a national CHC network. Zero-inflated Poisson regression models were used to estimate the likelihood of receiving mental health services, which was compared with expected annual rates of mental health service use. RESULTS: Of the 1,498,655 patients who received care at a CHC during the study, 14.4% (N=215,098) received any specialty mental health services. English- and Spanish-preferring Hispanic patients were less likely to have had a mental health visit (OR=0.69, 95% CI=0.61-0.77, and OR=0.65, 95% CI=0.54-0.78, respectively). Compared with non-Hispanic White patients, Spanish-preferring Hispanic patients had an estimated annualized rate of 0.59 (95% CI=0.46-0.76) mental health visits. CONCLUSIONS: Among patients who were likely to receive specialty mental health services, Spanish-preferring patients had a significantly lower rate of mental health care use. Although overall access to mental health care is improving, unequal access to recurring specialty mental health care remains among patients who do not prefer to use English.

Screening for Hepatitis C Among Community Health Center Patients by Ethnicity and Language Preference.

Introduction: Hepatitis C virus is associated with high morbidity and mortality-chronic liver disease is a leading cause of death among Latinos in the U.S. Screening for hepatitis C virus in community health center settings, which serve a disproportionate percentage of Latinos, is essential to eradicating hepatitis C virus infection. We assessed hepatitis C virus screening disparities in adults served by community health centers by ethnicity and language preference. Methods: This was an observational cohort study (spanning 2013-2017) of adults born in 1945-1965 in the Accelerating Data Value Across a National Community Health Center Network electronic health record data set. Our exposure of interest was race/ethnicity and language preference (non-Hispanic White, Latino English preferred, Latino Spanish preferred). Our primary outcome was the relative hazard of hepatitis C virus screening, estimated using multivariate Cox proportional hazards regression. Results: A total of 182,002 patients met the study criteria and included 60% non-Hispanic Whites, 29% Latino Spanish preferred, and 11% Latino English preferred. In total, 9% received hepatitis C virus screening, and 2.4% were diagnosed with hepatitis C virus. Latino English-preferred patients had lower rates of screening than both non-Hispanic Whites and Latino Spanish preferred (5.5% vs 9.4% vs 9.6%, respectively). Latino English preferred had lower hazards of hepatitis C virus screening than non-Hispanic Whites (adjusted hazard ratio=0.56, 95% CI=0.44, 0.72), and Latino Spanish preferred had similar hazards of hepatitis C virus screening (adjusted hazard ratio=1.11, 95% CI=0.88, 1.41). Conclusions: We found that in a large community health center network, adult Latinos who preferred English had lower hazards of hepatitis C virus screening than non-Hispanic Whites, whereas Latinos who preferred Spanish had hazards of screening similar to those of non-Hispanic Whites. The overall prevalence of hepatitis C virus screening was low. Further work on the role of language preference in hepatitis C virus screening is needed to better equip primary care providers to provide this recommended preventive service in culturally relevant ways.

The role of language in mammography orders among low-income Latinas over a 10-year period.

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

Latino Adolescent-Mother Language Concordance, Neighborhood Deprivation, and Vaccinations in Community Health Centers.

INTRODUCTION: Latino adolescents may face numerous barriers) to recommended vaccinations. There is little research on the association between Latino adolescent-mother preferred language concordance and vaccination completion and if it varies by neighborhood. To better understand the social/family factors associated with Latino adolescent vaccination, we studied the association of adolescent-mother language concordance and neighborhood social deprivation with adolescent vaccination completion. METHODS: We employed a multistate, electronic health record (EHR) based dataset of community health center patients to compare three Latino groups: (1) English-preferring adolescents with English-preferring mothers, (2) Spanish-preferring adolescents with Spanish-preferring mothers, and (3) English-preferring adolescents with Spanish-preferring mothers with non-Hispanic white adolescent-mother pairs for human papilloma virus (HPV), meningococcal, and influenza vaccinations. We adjusted for mother and adolescent demographics and care utilization and stratified by the social deprivation of the family's neighborhood. RESULTS: Our sample included 56,542 adolescent-mother dyads. Compared with non-Hispanic white dyads, all three groups of Latino dyads had higher odds of adolescent HPV and meningococcal vaccines and higher rates of flu vaccines. Latino dyads with Spanish-preferring mothers had higher vaccination odds/rates than Latino dyads with English-preferring mothers. The effects of variation by neighborhood social deprivation in influenza vaccination rates were minor in comparison to differences by ethnicity/language concordance. CONCLUSION: In a multistate analysis of vaccinations among Latino and non-Latino adolescents, English-preferring adolescents with Spanish-preferring mothers had the highest completion rates and English-preferring non-Hispanic white dyads the lowest. Further research can seek to understand why this language dyad may have an advantage in adolescent vaccination completion.

Latino adolescents may face numerous barriers to preventive care­especially routine immunizations, but analyses often focus on single or few factors that may affect the utilization of these services. Our analysis of not only the language preference of Latino adolescents, but the preferred language of their mothers and their neighborhood social adversity demonstrates that English-preferring Latino adolescents with Spanish preferring mothers were most likely to utilize all immunizations we studied, and there were differences in utilization among Latino families by language concordance. This adds to our knowledge of Latino adolescent health care utilization by demonstrating the differences in Latino families, and suggesting that many of these families may have assets for service utilization from which we can learn.

Comparison of associations of household-level and neighbourhood-level poverty markers with paediatric asthma care utilisation by race/ethnicity in an open cohort of community health centre patients.

OBJECTIVE: The objective of this research was to examine how different measurements of poverty (household-level and neighborhood-level) were associated with asthma care utilisation outcomes in a community health centre setting among Latino, non-Latino black and non-Latino white children. DESIGN, SETTING AND PARTICIPANTS: We used 2012-2017 electronic health record data of an open cohort of children aged <18 years with asthma from the OCHIN, Inc. network. Independent variables included household-level and neighborhood-level poverty using income as a percent of federal poverty level (FPL). Covariate-adjusted generalised estimating equations logistic and negative binomial regression were used to model three outcomes: (1) ≥2 asthma visits/year, (2) albuterol prescription orders and (3) prescription of inhaled corticosteroids over the total study period. RESULTS: The full sample (n=30 196) was 46% Latino, 26% non-Latino black, 31% aged 6-10 years at first clinic visit. Most patients had household FPL <100% (78%), yet more than half lived in a neighbourhood with >200% FPL (55%). Overall, neighbourhood poverty (<100% FPL) was associated with more asthma visits (covariate-adjusted OR 1.26, 95% CI 1.12 to 1.41), and living in a low-income neighbourhood (≥100% to <200% FPL) was associated with more albuterol prescriptions (covariate-adjusted rate ratio 1.07, 95% CI 1.02 to 1.13). When stratified by race/ethnicity, we saw differences in both directions in associations of household/neighbourhood income and care outcomes between groups. CONCLUSIONS: This study enhances understanding of measurements of race/ethnicity differences in asthma care utilisation by income, revealing different associations of living in low-income neighbourhoods and households for Latino, non-Latino white and non-Latino black children with asthma. This implies that markers of family and community poverty may both need to be considered when evaluating the association between economic status and healthcare utilisation. Tools to measure both kinds of poverty (family and community) may already exist within clinics, and can both be used to better tailor asthma care and reduce disparities in primary care safety net settings.

Quality of Care for Latinx Children with Asthma: Associations with Language Concordance and Continuity of Care.

BACKGROUND: Language concordance between Latinx patients and their clinicians has been shown to affect health outcomes. In addition, there is evidence that consistent continuity of care (COC) can improve health care outcomes. The relationship between language concordance and COC and their association with health equity in chronic disease is less clear. Our aim was to study the moderating effect of clinician and patient language concordance on the association between COC and asthma care quality in Latinx children. METHODS: We utilized an electronic health record dataset from a multistate network of community health centers to compare influenza vaccinations and inhaled steroid prescriptions, by ethnicity and language concordance groups overall and stratified by COC. RESULTS: We analyzed electronic health records for children with asthma (n = 38,442) age 3 to 17 years with ≥2 office visits between 2005 to 2017. Overall, 64% of children had low COC (defined as COC < 0.5) while 21% had high COC (defined as >0.75). All Latinx children had higher rates and odds of receiving influenza vaccination compared with non-Hispanic White children. In addition, Spanish-preferring Latinx children had higher rates and odds of being prescribed inhaled steroids while English-preferring Latinx children had lower odds (OR = 0.85 95%CI = 0.73,0.98) compared with non-Hispanic White children. CONCLUSION: Overall, Latinx children regardless of COC category or language concordance were more likely to receive the influenza vaccine. English-preferring Latinx children with persistent asthma received fewer inhaled steroid prescriptions compared with non-Hispanic White children. Panel chart review and seeing a practice partner might be one way to combat these inequities.

The Association of Mobility, Social Deprivation, and Pediatric Primary Care Outcomes in Community Health Centers.

OBJECTIVE: To examine how social deprivation and residential mobility are associated with primary care use in children seeking care at community health centers (CHCs) overall and stratified by race and ethnicity. STUDY DESIGN: We used electronic health record open cohort data from 152 896 children receiving care from 15 U S CHCs belonging to the OCHIN network. Patients were aged 3-17 years, with ≥2 primary care visits during 2012-2017 and had geocoded address data. We used negative binomial regression to calculate adjusted rates of primary care encounters and influenza vaccinations relative to neighborhood-level social deprivation. RESULTS: Higher rates of clinic utilization were observed for children who always lived in highly deprived neighborhoods (RR = 1.11, 95% CI = 1.05-1.17) and those who moved from low-to-high deprivation neighborhoods (RR = 1.05, 95% CI = 1.01-1.09) experienced higher rates of CHC encounters compared with children who always lived in the low-deprivation neighborhoods. This trend was similar for influenza vaccinations. When analyses were stratified by race and ethnicity, we found these relationships were similar for Latino children and non-Latino White children who always lived in highly deprived neighborhoods. Residential mobility was associated with lower rates of primary care. CONCLUSIONS: These findings suggest that children living in or moving to neighborhoods with high levels of social deprivation used more primary care CHC services than children who lived in areas with low deprivation, but moving itself was associated with less care. Clinician and delivery system awareness of patient mobility and its impacts are important to addressing equity in primary care.

Answering calls for rigorous health equity research: a cross-sectional study leveraging electronic health records for data disaggregation in Latinos.

INTRODUCTION: Country of birth/nativity information may be crucial to understanding health equity in Latino populations and is routinely called for in health services literature assessing cardiovascular disease and risk, but is not thought to co-occur with longitudinal, objective health information such as that found in electronic health records (EHRs). METHODS: We used a multistate network of community health centres to describe the extent to which country of birth is recorded in EHRs in Latinos, and to describe demographic features and cardiovascular risk profiles by country of birth. We compared geographical/demographic/clinical characteristics, from 2012 to 2020 (9 years of data), of 914 495 Latinos recorded as US-born, non-US-born and without a country of birth recorded. We also described the state in which these data were collected. RESULTS: Country of birth was collected for 127 138 Latinos in 782 clinics in 22 states. Compared with those with a country of birth recorded, Latinos without this record were more often uninsured and less often preferred Spanish. While covariate adjusted prevalence of heart disease and risk factors were similar between the three groups, when results were disaggregated to five specific Latin countries (Mexico, Guatemala, Dominican Republic, Cuba, El Salvador), significant variation was observed, especially in diabetes, hypertension and hyperlipidaemia. CONCLUSIONS: In a multistate network, thousands of non-US-born, US-born and patients without a country of birth recorded had differing demographic characteristics, but clinical variation was not observed until data was disaggregated into specific country of origin. State policies that enhance the safety of immigrant populations may enhance the collection of health equity related data. Rigorous and effective health equity research using Latino country of birth information paired with longitudinal healthcare information found in EHRs might have significant potential for aiding clinical and public health practice, but it depends on increased, widespread and accurate availability of this information, co-occurring with other robust demographic and clinical data nativity.

Trajectories of Chronic Disease and Multimorbidity Among Middle-aged and Older Patients at Community Health Centers.

Importance: Health-related consequences of multimorbidity (≥2 chronic diseases) are well documented. However, the extent and rate of accumulation of chronic diseases among US patients seeking care in safety-net clinics are not well understood. These insights are needed to enable clinicians, administrators, and policy makers to mobilize resources for prevention of disease escalations in this population. Objectives: To identify the patterns and rate of chronic disease accumulation among middle-aged and older patients seeking care in community health centers, as well as any sociodemographic differences. Design, Setting, and Participants: This cohort study used electronic health record data from January 1, 2012, to December 31, 2019, on 725 107 adults aged 45 years or older with 2 or more ambulatory care visits in 2 or more distinct years at 657 primary care clinics in the Advancing Data Value Across a National Community Health Center network in 26 US states. Statistical analysis was performed from September 2021 to February 2023. Exposures: Race and ethnicity, age, insurance coverage, and federal poverty level (FPL). Main Outcomes and Measures: Patient-level chronic disease burden, operationalized as the sum of 22 chronic diseases recommended by the Multiple Chronic Conditions Framework. Linear mixed models with patient-level random effects adjusted for demographic characteristics and ambulatory visit frequency with time interactions were estimated to compare accrual by race and ethnicity, age, income, and insurance coverage. Results: The analytic sample included 725 107 patients (417 067 women [57.5%]; 359 255 [49.5%] aged 45-54 years, 242 571 [33.5%] aged 55-64 years, and 123 281 [17.0%] aged ≥65 years). On average, patients started with a mean (SD) of 1.7 (1.7) morbidities and ended with 2.6 (2.0) morbidities over a mean (SD) of 4.2 (2.0) years of follow-up. Compared with non-Hispanic White patients, patients in racial and ethnic minoritized groups had marginally lower adjusted annual rates of accrual of conditions (-0.03 [95% CI, -0.03 to -0.03] for Spanish-preferring Hispanic patients; -0.02 [95% CI, -0.02 to -0.01] for English-preferring Hispanic patients; -0.01 [95% CI, -0.01 to -0.01] for non-Hispanic Black patients; and -0.04 [95% CI, -0.05 to -0.04] for non-Hispanic Asian patients). Older patients accrued conditions at higher annual rates compared with patients 45 to 50 years of age (0.03 [95% CI, 0.02-0.03] for 50-55 years; 0.03 [95% CI, 0.03-0.04] for 55-60 years; 0.04 [95% CI, 0.04-0.04] for 60-65 years; and 0.05 [95% CI, 0.05-0.05] for ≥65 years). Compared with those with higher income (always ≥138% of the FPL), patients with income less than 138% of the FPL (0.04 [95% CI, 0.04-0.05]), mixed income (0.01 [95% CI, 0.01-0.01]), or unknown income levels (0.04 [95% CI, 0.04-0.04]) had higher annual accrual rates. Compared with continuously insured patients, continuously uninsured and discontinuously insured patients had lower annual accrual rates (continuously uninsured, -0.003 [95% CI, -0.005 to -0.001]; discontinuously insured, -0.004 [95% CI, -0.005 to -0.003]). Conclusions and Relevance: This cohort study of middle-aged patients seeking care in community health centers suggests that disease accrued at high rates for patients' chronological age. Targeted efforts for chronic disease prevention are needed for patients near or below the poverty line.

Statin Eligibility and Prescribing Across Racial, Ethnic, and Language Groups over the 2013 ACC/AHA Guideline Change: a Retrospective Cohort Analysis from 2009 to 2018.

BACKGROUND: It is uncertain if the American College of Cardiology/American Heart Association (ACC/AHA) 2013 guidelines for the use of HMGCoA reductase inhibitors (statins) were associated with increased statin eligibility and prescribing across underserved groups. OBJECTIVE: To analyze, by race, ethnicity, and preferred language, patients with indications for and presence of a statin prescription before and after the guideline change. DESIGN: Retrospective cohort study. SETTING: Multistate community health center (CHC) network with linked electronic health records. PATIENTS: Low-income patients aged ≥ 50 with a primary care visit in 2009-2013 or 2014-2018. MAIN MEASURES: (1) Odds of each race/ethnicity/language group meeting statin eligibility via the National Cholesterol Education Program Adult Treatment Panel III Guidelines in 2009-2013 or the ACC/AHA guidelines in 2014-2018. (2) Among those eligible, odds of each group in each period with a statin prescription. KEY RESULTS: In 2009-2013 (n = 109,330), non-English-preferring Latino (OR = 1.10, 95% CI = 1.03, 1.17), White (OR = 1.41, 95% CI = 1.16, 1.72), and Black patients (OR = 1.25, 95% CI = 1.11, 1.42), were more likely than English-preferring non-Hispanic Whites to meet guideline criteria for statins. Non-English-preferring Black patients, when eligible, were no more likely than non-Hispanic Whites to have statin prescriptions (OR = 1.16, 95% CI = 0.88, 1.54). In 2014-2018 (n = 319,904), English-preferring Latino patients (OR = 1.02, 95% CI = 0.96-1.07) and non-English-preferring Black patients (OR = 1.08, 95% CI = 0.98, 1.19) had similar odds of statin prescription to English-preferring non-Hispanic White patients. English-preferring Black patients were less likely (OR = 0.95, 95% CI = 0.91-0.99) to have a prescription than English-preferring non-Hispanic Whites. CONCLUSION: Across the 2013 ACC/AHA guideline change in CHCs serving low-income patients, non-English-preferring patients were consistently more likely to be eligible for and have been prescribed statins. English-preferring Latino and English-preferring Black patients experienced reduced prescribing, comparatively, after the guideline change. Further work should explore the contextual factors that may influence guideline effectiveness and care equity.

Disaggregating Latino nativity in equity research using electronic health records.

OBJECTIVE: To develop and validate prediction models for inference of Latino nativity to advance health equity research. DATA SOURCES/STUDY SETTING: This study used electronic health records (EHRs) from 19,985 Latino children with self-reported country of birth seeking care from January 1, 2012 to December 31, 2018 at 456 community health centers (CHCs) across 15 states along with census-tract geocoded neighborhood composition and surname data. STUDY DESIGN: We constructed and evaluated the performance of prediction models within a broad machine learning framework (Super Learner) for the estimation of Latino nativity. Outcomes included binary indicators denoting nativity (US vs. foreign-born) and Latino country of birth (Mexican, Cuban, Guatemalan). The performance of these models was compared using the area under the receiver operating characteristics curve (AUC) from an externally withheld patient sample. DATA COLLECTION/EXTRACTION METHODS: Census surname lists, census neighborhood composition, and Forebears administrative data were linked to EHR data. PRINCIPAL FINDINGS: Of the 19,985 Latino patients, 10.7% reported a non-US country of birth (5.1% Mexican, 4.7% Guatemalan, 0.8% Cuban). Overall, prediction models for nativity showed outstanding performance with external validation (US-born vs. foreign: AUC = 0.90; Mexican vs. non-Mexican: AUC = 0.89; Guatemalan vs. non-Guatemalan: AUC = 0.95; Cuban vs. non-Cuban: AUC = 0.99). CONCLUSIONS: Among challenges facing health equity researchers in health services is the absence of methods for data disaggregation, and the specific ability to determine Latino country of birth (nativity) to inform disparities. Recent interest in more robust health equity research has called attention to the importance of data disaggregation. In a multistate network of CHCs using multilevel inputs from EHR data linked to surname and community data, we developed and validated novel prediction models for the use of available EHR data to infer Latino nativity for health disparities research in primary care and health services research, which is a significant potential methodologic advance in studying this population.

Ethnicity, Language, and HIV Screening in Older Adult Safety-Net Patients.

INTRODUCTION: HIV screening should occur for all adults at least once by age 65 years. Older adults have low screening rates. Latinos, with historically low screening rates, have worse HIV outcomes than non-Hispanic White patients. Electronic health record data from a multistate network of community health centers were used to examine whether there are differences in HIV screening for Latino (English and Spanish preferring) and non-Hispanic White older adults. METHODS: Data were from the Accelerating Data Value Across a National Community Health Center Network Clinical Research Network of PCORnet from 21 states in 2012-2021 among an open cohort of patients aged 50-65 years. Relative odds of ever having received HIV screening comparing Latinos with non-Hispanic Whites using generalized estimating equation logistic regression modeling were calculated, adjusting for relevant patient-level covariates. Analyses were conducted in 2022. RESULTS: Among 251,645 patients, the covariate-adjusted odds of ever receiving HIV screening were 18% higher for English-preferring Latino patients (OR=1.18, 95% CI=1.11, 1.25) and 32% higher for Spanish-preferring Latinos than for non-Hispanic Whites (OR=1.32, 95% CI=1.24, 1.42). CONCLUSIONS: Latinos seen in community health centers, regardless of language spoken, are more likely to be screened at least once for HIV than non-Hispanic Whites. This increased screening may be due at least in part to the community health center setting, a setting known to mitigate disparities, as well as due to participation efforts by community health centers in public health campaigns. Future research can prioritize understanding the cause of this relative advantage.