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.

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.

Finding meaning: a realist-informed perspective on social risk screening and relationships as mechanisms of change.

Background: Social risk screening rates in many US primary care settings remain low. This realist-informed evaluation explored the mechanisms through which a tailored coaching and technical training intervention impacted social risk screening uptake in 26 community clinics across the United States. Methods: Evaluation data sources included the documented content of interactions between the clinics and implementation support team and electronic health record (EHR) data. Following the realist approach, analysis was composed of iterative cycles of developing, testing and refining program theories about how the intervention did-or didn't-work, for whom, under what circumstances. Normalization Process Theory was applied to the realist program theories to enhance the explanatory power and transferability of the results. Results: Analysis identified three overarching realist program theories. First, clinic staff perceptions about the role of standardized social risk screening in person-centered care-considered "good" care and highly valued-strongly impacted receptivity to the intervention. Second, the physicality of the intervention materials facilitated collaboration and impacted clinic leaders' perception of the legitimacy of the social risk screening implementation work. Third, positive relationships between the implementation support team members, between the support team and clinic champions, and between clinic champions and staff motivated and inspired clinic staff to engage with the intervention and to tailor workflows to their settings' needs. Study clinics did not always exhibit the social risk screening patterns anticipated by the program theories due to discrepant definitions of success between clinic staff (improved ability to provide contextualized, person-centered care) and the trial (increased rates of EHR-documented social risk screening). Aligning the realist program theories with Normalization Process Theory constructs clarified that the intervention as implemented emphasized preparation over operationalization and appraisal, providing insight into why the intervention did not successfully embed sustained systematic social risk screening in participating clinics. Conclusion: The realist program theories highlighted the effectiveness and importance of intervention components and implementation strategies that support trusting relationships as mechanisms of change. This may be particularly important in social determinants of health work, which requires commitment and humility from health care providers and vulnerability on the part of patients.

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.

Implementation Support for a Social Risk Screening and Referral Process in Community Health Centers.

Evidence is needed about how to effectively support health care providers in implementing screening for social risks (adverse social determinants of health) and providing related referrals meant to address identified social risks. This need is greatest in underresourced care settings. The authors tested whether an implementation support intervention (6 months of technical assistance and coaching study clinics through a five-step implementation process) improved adoption of social risk activities in community health centers (CHCs). Thirty-one CHC clinics were block-randomized to six wedges that occurred sequentially. Over the 45-month study period from March 2018 to December 2021, data were collected for 6 or more months preintervention, the 6-month intervention period, and 6 or more months postintervention. The authors calculated clinic-level monthly rates of social risk screening results that were entered at in-person encounters and rates of social risk-related referrals. Secondary analyses measured impacts on diabetes-related outcomes. Intervention impact was assessed by comparing clinic performance based on whether they had versus had not yet received the intervention in the preintervention period compared with the intervention and postintervention periods. In assessing the results, the authors note that five clinics withdrew from the study for various bandwidth-related reasons. Of the remaining 26, a total of 19 fully or partially completed all 5 implementation steps, and 7 fully or partially completed at least the first 3 steps. Social risk screening was 2.45 times (95% confidence interval [CI], 1.32-4.39) higher during the intervention period compared with the preintervention period; this impact was not sustained postintervention (rate ratio, 2.16; 95% CI, 0.64-7.27). No significant difference was seen in social risk referral rates during the intervention or postintervention periods. The intervention was associated with greater blood pressure control among patients with diabetes and lower rates of diabetes biomarker screening postintervention. All results must be interpreted considering that the Covid-19 pandemic began midway through the trial, which affected care delivery generally and patients at CHCs particularly. Finally, the study results show that adaptive implementation support was effective at temporarily increasing social risk screening. It is possible that the intervention did not adequately address barriers to sustained implementation or that 6 months was not long enough to cement this change. Underresourced clinics may struggle to participate in support activities over longer periods without adequate resources, even if lengthier support is needed. As policies start requiring documentation of social risk activities, safety-net clinics may be unable to meet these requirements without adequate financial and coaching/technical support.

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.

Social Risk Screening and Response Equity: Assessment by Race, Ethnicity, and Language in Community Health Centers.

INTRODUCTION: Little has previously been reported about the implementation of social risk screening across racial/ethnic/language groups. To address this knowledge gap, the associations between race/ethnicity/language, social risk screening, and patient-reported social risks were examined among adult patients at community health centers. METHODS: Patient- and encounter-level data from 2016 to 2020 from 651 community health centers in 21 U.S. states were used; data were extracted from a shared Epic electronic health record and analyzed between December 2020 and February 2022. In adjusted logistic regression analyses stratified by language, robust sandwich variance SE estimators were applied with clustering on patient's primary care facility. RESULTS: Social risk screening occurred at 30% of health centers; 11% of eligible adult patients were screened. Screening and reported needs varied significantly by race/ethnicity/language. Black Hispanic and Black non-Hispanic patients were approximately twice as likely to be screened, and Hispanic White patients were 28% less likely to be screened than non-Hispanic White patients. Hispanic Black patients were 87% less likely to report social risks than non-Hispanic White patients. Among patients who preferred a language other than English or Spanish, Black Hispanic patients were 90% less likely to report social needs than non-Hispanic White patients. CONCLUSIONS: Social risk screening documentation and patient reports of social risks differed by race/ethnicity/language in community health centers. Although social care initiatives are intended to promote health equity, inequitable screening practices could inadvertently undermine this goal. Future implementation research should explore strategies for equitable screening and related interventions.

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.

Role of ethnicity/language in documented rates of pediatric asthma prescription refills.

OBJECTIVE: Medication maintenance is critical in the management of asthma. We investigated the differences in electronic health record (EHR) documentation of medication refills for Spanish- and English-speaking Latino children and non-Hispanic white children by examining rates of albuterol rescue inhaler refills from 2005 to 2017, and and inhaled corticosteroid refills from 2015 to 2017 in a multi-state network of community health centers (CHCs). METHODS: We used data from the ADVANCE network of CHCs. Our sample consisted of children aged 3-17, with a diagnosis of asthma and either albuterol or inhaled corticosteroid prescriptions (n = 39,162; n = 4,738 children, respectively). Negative binomial regression was used to calculate rates of refills per prescription adjusted for relevant patient-level covariates. Analyses stratified by asthma severity were also conducted. RESULTS: English-speaking Latino children had lower rates of albuterol refills compared with non-Hispanic white children (rate ratio [RR] = 0.88, 95% confidence interval [CI]: 0.80-0.98), a trend that persisted among children with moderate/severe persistent asthma severity (RR = 0.85, 95% CI: 0.76-0.95). Spanish-speaking Latino and non-Hispanic white children had similar albuterol refills. Inhaled corticosteroid refill rates were comparable between all groups. CONCLUSIONS: In a multi-state network, these findings suggest that CHCs deliver equitable asthma care related to prescription refills between their Latino and white patients, but there is still opportunity for providers to ensure that their English-speaking Latino patients have access to necessary emergency asthma medication.

Racial, ethnic, and language differences in screening measures for statin therapy following a major guideline change.

Atherosclerotic cardiovascular disease (ASCVD) disproportionally affects racial and ethnic minority populations. Statin prescribing guidelines changed in 2013 to improve ASCVD prevention. It is unknown whether risk screening for statin eligibility differed across race and ethnicity over this guideline change. We examine racial/ethnic/language differences in screening measure prevalence for period-specific statin consideration using a retrospective cohort design and linked electronic health records from 635 community health centers in 24 U.S. states. Adults 50+ years, without known ASCVD, and ≥ 1 visit in 2009-2013 and/or 2014-2018 were included, grouped as: Asian, Latino, Black, or White further distinguished by language preference. Outcomes included screening measure prevalence for statin consideration, 2009-2013: low-density lipoprotein (LDL), 2014-2018: pooled cohort equation (PCE) components age, sex, race, systolic blood pressure, total cholesterol, high-density lipoprotein, smoking status. Among patients seen both periods, change in period-specific measure prevalence was assessed. Adjusting for sociodemographic and clinical factors, compared to English-preferring White patients, all other groups were more likely to have LDL documented (2009-2013, n = 195,061) and all PCE components documented (2014-2018, n = 344,504). Among patients seen in both periods (n = 128,621), all groups had lower odds of PCE components versus LDL documented in the measures' respective period; English-preferring Black adults experienced a greater decline compared to English-preferring White adults (OR 0.81; 95% CI: 0.72-0.91). Racial/ethnic/language disparities in documented screening measures that guide statin therapy for ASCVD prevention were unaffected by a major guideline change advising this practice. It is important to understand whether the newer guidelines have altered disparate prescribing and morbidity/mortality for this disease.

Association of parent influenza vaccination and early childhood vaccinations using linked electronic health record data.

INTRODUCTION: Parent and child vaccination behavior is related for human papillomavirus (HPV) and flu vaccine. Thus, it is likely that parental vaccination status is also associated with their children's adherence to guideline-concordant childhood vaccination schedules. We hypothesized that parent influenza (flu) vaccination would be associated with their child's vaccination status at age two. METHODS: We used electronic health record data to identify children and linked parents seen in a community health center (CHC) within the OCHIN network (292 CHCs in 16 states). We randomly selected a child aged <2 years with ≥1 ambulatory visit between 2009-2018. Employing a retrospective, cohort study design, we used general estimating equations logistic regression to estimate the odds of a child being up-to-date on vaccinations based on their linked parents' flu vaccination status. We adjusted for relevant parent and child covariates and stratified by mother only, father only, and two-parent samples. RESULTS: The study included 40,007 family-units: mother only = 35,444, father only = 2,784, and two parents = 1,779. A higher percentage of children were fully vaccinated if their parent or parents received a flu vaccine. Children in the two-parent sample whose parents both received a flu vaccine had more than twice the odds of being fully vaccinated, and two and a half times the odds of being fully vaccinated except flu vaccine compared to children with two parents who did not receive a flu vaccine (covariate-adjusted odds ratio [aOR] = 2.39, 95% CI = 1.67, 3.43 and aOR = 2.54, 95% CI = 1.54, 4.19, respectively). CONCLUSIONS: Parent flu vaccination is associated with routine child vaccination. Future research is needed to understand if this relationship persists over time and in different settings.

Cross-Sectional Associations: Social Risks and Diabetes Care Quality, Outcomes.

INTRODUCTION: Social risks (e.g., food/transportation insecurity) can hamper type 2 diabetes mellitus (T2DM) self-management, leading to poor outcomes. To determine the extent to which high-quality care can overcome social risks' health impacts, this study assessed the associations between reported social risks, receipt of guideline-based T2DM care, and T2DM outcomes when care is up to date among community health center patients. METHODS: A cross-sectional study of adults aged ≥18 years (N=73,484) seen at 186 community health centers, with T2DM and ≥1 year of observation between July 2016 and February 2020. Measures of T2DM care included up-to-date HbA1c, microalbuminuria, low-density lipoprotein screening, and foot examination, and active statin prescription when indicated. Measures of T2DM outcomes among patients with up-to-date care included blood pressure, HbA1c, and low-density lipoprotein control on or within 6‒12 months of an index encounter. Analyses were conducted in 2021. RESULTS: Individuals reporting transportation or housing insecurity were less likely to have up-to-date low-density lipoprotein screening; no other associations were seen between social risks and clinical care quality. Among individuals with up-to-date care, food insecurity was associated with lower adjusted rates of controlled HbA1c (79% vs 75%, p<0.001), and transportation insecurity was associated with lower rates of controlled HbA1c (79% vs 74%, p=0.005), blood pressure (74% vs 72%, p=0.025), and low-density lipoprotein (61% vs 57%, p=0.009) than among those with no reported need. CONCLUSIONS: Community health center patients received similar care regardless of the presence of social risks. However, even among those up to date on care, social risks were associated with worse T2DM control. Future research should identify strategies for improving HbA1c control for individuals with social risks. TRIAL REGISTRATION: This study is registered at www. CLINICALTRIALS: gov NCT03607617.

Diabetes Screening and Monitoring Among Older Mexican-Origin Populations in the U.S.

OBJECTIVE: The purpose of the study is to examine diabetes screening and monitoring among Latino individuals as compared with non-Latino White individuals and to better understand how we can use neighborhood data to address diabetes care inequities. RESEARCH DESIGN AND METHODS: This is a retrospective observational study linked with neighborhood-level Latino subgroup data obtained from the American Community Survey. We used generalized estimating equation negative binomial and logistic regression models adjusted for patient-level covariates to compare annual rates of glycated hemoglobin (HbA1c) monitoring for those with diabetes and odds of HbA1c screening for those without diabetes by ethnicity and among Latinos living in neighborhoods with low (0.0-22.0%), medium (22.0-55.7%), and high (55.7-98.0%) population percent of Mexican origin. RESULTS: Latino individuals with diabetes had 18% higher rates of HbA1c testing than non-Latino White individuals with diabetes (adjusted rate ratio [aRR] 1.18 [95% CI 1.07-1.29]), and Latinos without diabetes had 25% higher odds of screening (adjusted odds ratio 1.25 [95% CI 1.15-1.36]) than non-Latino White individuals without diabetes. In the analyses in which neighborhood-level percent Mexican population was the main independent variable, all Latinos without diabetes had higher odds of HbA1c screening compared with non-Latino White individuals, yet only those living in low percent Mexican-origin neighborhoods had increased monitoring rates (aRR 1.31 [95% CI 1.15-1.49]). CONCLUSIONS: These findings reveal novel variation in health care utilization according to Latino subgroup neighborhood characteristics and could inform the delivery of diabetes care for a growing and increasingly diverse Latino patient population. Clinicians and researchers whose work focuses on diabetes care should take steps to improve equity in diabetes and prevent inequity in treatment.

Association of Parent Preventive Care with their Child's Recommended Well-Child Visits.

BACKGROUND: Receipt of recommended well-child care is lowest for children without insurance, many of whom receive care in community health centers (CHCs). OBJECTIVE: To understand if there is an association between parent preventive care and their children's well-child visits. METHODS: We used electronic health record data to identify children and link them to parents both seen in an OCHIN network (CHC; n = 363 clinics from 17 states), randomly selected a child aged 3 to 17 with ≥1 ambulatory visit between 2015 and 2018. We employed a retrospective, cohort study design and used general estimating equations Poisson regression to estimate yearly rates of well-child visits based on parent preventive care adjusted for relevant covariates and stratified by child age for 3 linked samples: mother only, father only, and two parents. RESULTS: We included 75,398 linked mother only pairs, 12,438 in our father only, and 4,156 in our 2-parent sample. Children in the mother only sample had a 6% greater rate of yearly well-child visits when their mother received preventive care (adjusted rate ratio [ARR] = 1.06; 95% CI = 1.03-1.08) compared to no preventive care. Children in the father only sample had a 7% greater rate of yearly well-child visits when their father received preventive care (ARR = 1.07; 95% CI = 1.04-1.11) versus no preventive care. Children in the two parent sample had an 11% greater rate of yearly well-child visits when both parents received preventive care (ARR = 1.11; 95% CI = 1.03-1.19) compared to neither receiving preventive care. CONCLUSIONS: These findings suggest focusing on receipt of healthcare for the whole family may improve well-child visit rates.

Racial and Ethnic Disparities in Acute Care Use for Pediatric Asthma.

PURPOSE: Previous work has shown that asthma-related emergency department (ED) use is greatest among Black and Latine populations, but it is unknown whether health care use for exacerbations differs across settings (outpatient, ED, inpatient) and correlates with use of routine outpatient services. We aimed to measure disparities by race, ethnicity, and language in pediatric acute asthma care using data from US primary care community health centers. METHODS: In an observational study using electronic health records from community health centers in 18 states, we compared non-Hispanic Black, English-preferring Latine, Spanish-preferring Latine, and non-Hispanic White children aged 3 to 17 years on visits for clinic-coded asthma exacerbations (2012-2018). We further evaluated asthma-related ED use and inpatient admissions in a subsample of Oregon-Medicaid recipients. Covariate-adjusted odds ratios (ORs) and rate ratios (RRs) were derived using logistic or negative binomial regression analysis with generalized estimating equations. RESULTS: Among 41,276 children with asthma, Spanish-preferring Latine children had higher odds of clinic visits for asthma exacerbation than non-Hispanic White peers (OR = 1.10; 95% CI, 1.02-1.18). Among the subsample of 6,555 children insured under Oregon-Medicaid, non-Hispanic Black children had higher odds and rates of asthma-related ED use than non-Hispanic White peers (OR = 1.40; 95% CI, 1.04-1.89 and RR = 1.49; 95% CI, 1.09-2.04, respectively). We observed no differences between groups in asthma-related inpatient admissions. CONCLUSIONS: This study is the first to show that patterns of clinic and ED acute-care use differ for non-Hispanic Black and Spanish-preferring Latine children when compared with non-Hispanic White peers. Non-Hispanic Black children had lower use of clinics, whereas Spanish-preferring Latine children had higher use, including for acute exacerbations. These patterns of clinic use were accompanied by higher ED use among Black children. Ensuring adequate care in clinics may be important in mitigating disparities in asthma outcomes.VISUAL ABSTRACT.

Asthma Ambulatory Care Quality in Foreign-Born Latino Children in the United States.

BACKGROUND: Foreign-born Latino children in the United States (US) have poor asthma outcomes, but the role of routine care utilization in these outcomes is unclear. Our objective was to compare select ambulatory care utilization measures for asthma between foreign-born Latino, US-born Latino, and non-Hispanic white children. METHODS: Using a multistate network of clinics with a linked electronic health record, we compared the International Classification of Disease (ICD)-coded asthma diagnosis among those with respiratory symptoms, electronic health records documentation of diagnosis, prescriptions, and influenza vaccination of foreign-born and US-born Latino children, and non-Hispanic white children over a 10+ year study period. We also examined outcomes by country of birth in children from Mexico, Cuba, and Guatemala. RESULTS: Among our study population (n = 155,902), 134,570 were non-Hispanic white, 19,143 were US-born Latino, and 2189 were foreign-born Latino. Among those with suspicious respiratory symptoms, there was no difference between these groups in the predicted probability of an ICD-coded asthma diagnosis. US-born Latino children with asthma were less likely to have asthma documented on their problem list, more likely to have an albuterol prescription, and less likely to have an inhaled steroid prescribed. All Latino children had higher rates of influenza vaccination than non-Hispanic white children. CONCLUSIONS: In a national network, there were few disparities between Latino (US- and foreign-born) children and non-Hispanic white comparators in many common asthma care services, except some measures in US-born Latino children. Providers should understand that their US-born Latino children may be at elevated risk for not receiving adequate asthma care.

Creation of a linked cohort of children and their parents in a large, national electronic health record dataset.

ABSTRACT: To examine which parental health care and health factors are most strongly associated with a child's receipt of recommended care we must be able to link children to their parents in electronic health record data. Yet, there is not an easy way to link these data.To identify a national cohort of children that link to at least one parent in the same electronic health record dataset and describe their demographics.Methodology to link parents and children in electronic health records and descriptive sociodemographic data.Children with at least one encounter with a primary care clinician between Januray 1, 2007 and December 12, 2018 to a community health center in the OCHIN national network. We identified parents of these children who also had at least one encounter to a community health center in the network using emergency contact and guarantor record fields.A total of 227,552 children had parents with a linkable patient record. After exclusions, our final cohort included 213,513 distinct children with either one or two parent-links. 82% of children linked to a mother only, 14% linked to a father only, and 4% linked to both a mother and a father. Most families consisted of only one linked child (61%).We were able to link 33% of children to a parent in electronic health record data from a large network of community health centers across the United States. Further analyses utilizing these linkages will allow examination of the multi-level factors that impact a child's receipt of recommended health care.

Role of social deprivation on asthma care quality among a cohort of children in US community health centres.

OBJECTIVE: Social deprivation is associated with worse asthma outcomes. The Social Deprivation Index is a composite measure of social determinants of health used to identify neighbourhood-level disadvantage in healthcare. Our objective was to determine if higher neighbourhood-level social deprivation is associated with documented asthma care quality measures among children treated at community health centres (CHCs). METHODS SETTING, PARTICIPANTS, OUTCOME MEASURES: We used data from CHCs in 15 states in the Accelerating Data Value Across a National Community Health Center Network (ADVANCE). The sample included 34 266 children with asthma from 2008 to 2017, aged 3-17 living in neighbourhoods with differing levels of social deprivation measured using quartiles of the Social Deprivation Index score. We conducted logistic regression to examine the odds of problem list documentation of asthma and asthma severity, and negative binomial regression for rates of albuterol, inhaled steroid and oral steroid prescription adjusted for patient-level covariates. RESULTS: Children from the most deprived neighbourhoods had increased rates of albuterol (rate ratio (RR)=1.22, 95% CI 1.13 to 1.32) compared with those in the least deprived neighbourhoods, while the point estimate for inhaled steroids was higher, but fell just short of significance at the alpha=0.05 level (RR=1.16, 95% CI 0.99 to 1.34). We did not observe community-level differences in problem list documentation of asthma or asthma severity. CONCLUSIONS: Higher neighbourhood-level social deprivation was associated with more albuterol and inhaled steroid prescriptions among children with asthma, while problem list documentation of asthma and asthma severity varied little across neighbourhoods with differing deprivation scores. While the homogeneity of the CHC safety net setting studied may mitigate variation in diagnosis and documentation of asthma, enhanced clinician awareness of differences in community risk could help target paediatric patients at risk of lower quality asthma care.