Engaging Trusted Messengers to Increase COVID-19 Pediatric Vaccine Uptake in Philadelphia: Lessons from the VaxUpPhillyFamilies program.

INTRODUCTION: Communities of color had higher rates of Coronavirus (COVID-19) infection and lower rates of COVID-19 vaccination during the pandemic. Parental concern about the safety and necessity of pediatric COVID-19 vaccines contribute to low childhood vaccination. Enlisting parents and caregivers as trusted messengers is an evidence-based approach to mitigate this challenge. VaxUpPhillyFamilies was formed to engage parents and caregivers as vaccine ambassadors to increase vaccination rates in children of color. This study aimed to understand the key benefits, challenges, and lessons learned from the VaxUpPhillyFamilies program. METHODS: Three online debriefing sessions with ambassadors were conducted between September 7 and October 24, 2022, to share best practices, address challenges, receive emerging vaccine information, and provide support. Thematic analysis was utilized to develop broad themes and subthemes. RESULTS: Four themes with corresponding subthemes were identified: 1) Motivations to Become an Ambassador: a) improving the health of the community and b) personal satisfaction; 2) Defining Success: a) community interactions and b) influencing opinions; 3) Best Approaches: a) being mentally prepared with facts, b) addressing community health needs beyond COVID-19, c) demonstrating empathy, d) "meeting them where they're at" by motivational interviewing, and e) building trust and connection; 4) Challenges: a) changes in vaccine guidelines, b) vaccine misinformation, c) varied perceptions of severity of COVID-19 illness and benefits of the vaccine, d) breakdown of communication from trusted sources, and e) structural barriers to engagement. CONCLUSION: Parents and caregivers were a resource for delivering evidence-based messaging about COVID-19 and other health challenges. To effectively equip parents and caregivers as public health ambassadors, it is critical to offer training in engagement strategies, to identify and combat misinformation, and to provide support in navigating challenges. VaxUpPhillyFamilies program is a model for future public health campaigns.

Black women's perspectives on bladder health: Social-ecological and life course contexts.

AIMS: This paper explores Black women's perspectives on bladder health using a social-ecological conceptual framework and life course perspective. METHODS: We conducted a directed content analysis of data from the Study of Habits, Attitudes, Realities, and Experiences (SHARE), a focus group study by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. Analysis was conducted on data from five focus groups and a member-checking session where all participants self-identified as Black or African American. RESULTS: Forty-two participants aged 11-14 or 45+ years reported life course experiences with their bladder. The intersection of race and gender was the lens through which participants viewed bladder health. Participants' accounts of their perspectives on bladder health explicitly and implicitly revealed structural racism as an explanatory overarching theme. Participants described (a) historically-rooted and still pervasive practices of discrimination and segregation, engendering inequitable access to quality medical care and public facilities, (b) institutional barriers to toileting autonomy in educational and occupational settings, promoting unhealthy voiding habits, (c) internalized expectations of Black women's stereotyped role as family caregiver, compromising caregiver health, (d) lack of reliable information on bladder health, leading to unhealthy bladder behaviors, and (e) potentially stress-related comorbid chronic conditions and associated medication use, causing or exacerbating bladder problems. CONCLUSIONS: Bladder health promotion interventions should address social-ecological and life course factors shaping Black women's bladder health, including social and structural barriers to accessing equitable health information and medical care.

Preferences for Public Health Messaging Related to Bladder Health in Adolescent and Adult Women.

Objective: The purpose of this analysis was to explore adolescent and adult women's preferences for the content and delivery of public health messaging around bladder health. Materials and Methods: This was a directed content analysis of focus group data from the Study of Habits, Attitudes, Realities, and Experiences, which explored adolescent and adult women's experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health and function across the life course. This article reports an analysis of the "Public Health Messaging" code, which includes participants' views on what information is needed about bladder health, attributes of messaging, and preferred locations and delivery methods. Results: Forty-four focus groups were conducted with 360 participants (ages 11-93 years) organized into six age groups. Across age groups, participants wanted messaging on maintaining bladder health and preventing bladder problems. They offered suggestions for a wide variety of methods to deliver bladder health information. Ideas for delivery methods fell into three broad categories: (1) traditional in-person modes of delivery, which included individual communication with providers in clinical settings and group-based methods in schools and other community settings where adolescent and adult women naturally gather; (2) internet-based website and social media delivery methods; and (3) static (noninteractive) modes of delivery such as pamphlets. Participants recommended the development of multiple delivery methods to be tailored for specific audiences. Conclusions: These findings can inform development of broad ranging public health messaging tailored to audiences of all ages with a goal of engaging adolescent and adult women across the bladder health risk spectrum.

Trust and virtual communication during the COVID-19 pandemic for adults with asthma from low-income neighborhoods: What have we learned?

BACKGROUND: Low-income and marginalized adults disproportionately bear the burden of poor asthma outcomes. One consequence of the structural racism that preserves these inequities is decreased trust in government and health care institutions. OBJECTIVE: We examined whether such distrust extended to health care providers during the pandemic. METHODS: We enrolled adults living in low-income neighborhoods who had required a hospitalization, an emergency department visit, or a prednisone course for asthma in the prior year. Trust was a dichotomized measure derived from a 5-item questionnaire with a 5-point Likert scale response. The items were translated to the binary variable "strong" versus "weak" trust. Communication was measured using a 13-item questionnaire with a 5-point Likert scale. Logistic regression was used to examine the association between communication and trust, controlling for potential confounders. RESULTS: We enrolled 102 patients, aged 18 to 78 years; 87% were female, 90% were Black, 60% had some post-high school education, and 57% were receiving Medicaid. Of the 102 patients, 58 were enrolled before the March 12, 2020, pandemic start date, and 70 (69%) named doctors as their most trusted source of health information. Strong trust was associated with a negative response to the statement "It is hard to reach a person in my doctor's office by phone." There was no evidence of an association between the overall communication scores and trust. Satisfaction with virtual messaging was weaker among those with less trust. CONCLUSIONS: These patients trust their physicians, value their advice, and need to have accessible means of communication.

Impact of Stigma on Clinician Training for Opioid Use Disorder Care: A Qualitative Study in a Primary Care Learning Collaborative.

PURPOSE: We undertook a study to examine how stigma influences the uptake of training on medication for opioid use disorder (MOUD) in primary care academic programs. METHODS: We conducted a qualitative study of 23 key stakeholders responsible for implementing MOUD training in their academic primary care training programs that were participants in a learning collaborative in 2018. We assessed barriers to and facilitators of successful program implementation and used an integrated approach to develop a codebook and analyze the data. RESULTS: Participants represented the family medicine, internal medicine, and physician assistant fields, and they included trainees. Most participants described clinician and institutional attitudes, misperceptions, and biases that enabled or hindered MOUD training. Perceptions included concerns that patients with OUD are "manipulative" or "drug seeking." Elements of stigma in the origin domain (ie, beliefs by primary care clinicians or the community that OUD is a choice and not a disease), the enacted domain (eg, hospital bylaws banning MOUD and clinicians declining to obtain an X-Waiver to prescribe MOUD), and the intersectional domain (eg, inadequate attention to patient needs) were perceived as major barriers to MOUD training by most respondents. Participants described strategies that improved the uptake of training, including giving attention to clinician concerns, clarifying the biology of OUD, and ameliorating clinician fears of being ill equipped to provide care for patients. CONCLUSIONS: OUD-related stigma was commonly reported in training programs and impeded the uptake of MOUD training. Potential strategies to address stigma in the training context, beyond providing content on effective evidence-based treatments, include addressing the concerns of primary care clinicians and incorporating the chronic care framework into OUD treatment.

Need for Public Health Messaging Related to Bladder Health from Adolescence to Advanced Age.

Objective: The purpose of this analysis was to explore adolescent and adult women's interest in public health messaging around bladder health and perceptions of its usefulness. Materials and Methods: Directed content analysis of focus group data from the Study of Habits, Attitudes, Realities, and Experiences, which explored adolescent and adult women's experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health across the life course. This article reports an analysis of the "Public Health Messaging" code, which included participants' desire or need for information about bladder health and recommendations for appropriate priority audiences. Results: Forty-four focus groups were conducted with 360 participants organized into six age groups (11-93 years). There was consensus across age groups that more information about the bladder is wanted and needed throughout the life course, as there is currently a lack of reliable educational resources. Information on bladder health was seen as useful and important because it enables people to anticipate negative changes in bladder health and act to prevent these. Several priority audiences were identified based on their risk of developing symptoms, but participants also saw value in educating the general public regardless of risk status. They also recommended education for parents and teachers who are in positions to control bathroom access. Conclusions: Results indicate a uniform desire for information on women's bladder health and a need for more research to develop individual prevention strategies and public health messaging for women of all ages, as well as guidance for organizations with a role in supporting bladder health.

A community-engaged approach to the design of a population-based prospective cohort study to promote bladder health.

INTRODUCTION: Community engagement is increasingly recognized as a critical component of research, but few studies provide details on how to successfully incorporate community perspectives in urological research. This manuscript describes the community engagement strategy used by the Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS) to design RISE FOR HEALTH (RISE), a multicenter, population-based, prospective cohort study to promote bladder health. METHODS AND RESULTS: The PLUS Community Engagement Subcommittee, guided by a set of antiracist community engagement principles and practices, organized, implemented, and communicated findings for all RISE community engagement activities. Community engagement was conducted through a diverse network of community partners at PLUS clinical research centers called Rapid Assessment Partners (RAPs). Via online surveys (4), virtual discussion groups (14), and one-on-one interviews (12), RAPs provided input on RISE processes and materials, including in-person visit procedures, specimen collection instructions, survey data collection instruments, recruitment materials, the study website, and the study name. This process resulted in significant changes to these aspects of the study design with reciprocal benefits for the community partners. DISCUSSION: Meaningful community engagement improved the design and implementation of RISE. PLUS will continue to engage community partners to interpret the RISE study results, disseminate RISE findings, and inform other PLUS studies toward the development of interventions to promote bladder health. Future urological studies would also benefit from community participation in determining priority research questions to address.

RISE FOR HEALTH: Rationale and protocol for a prospective cohort study of bladder health in women.

INTRODUCTION: The spectrum of bladder health and the factors that promote bladder health and prevent lower urinary tract symptoms (LUTS) among women are not well understood. This manuscript describes the rationale, aims, study design, sampling strategy, and data collection for the RISE FOR HEALTH (RISE) study, a novel study of bladder health in women conducted by the Prevention of Lower Urinary Tract Symptom (PLUS) Research Consortium. METHODS AND RESULTS: RISE is a population-based, multicenter, prospective longitudinal cohort study of community-dwelling, English- and Spanish-speaking adult women based in the United States. Its goal is to inform the distribution of bladder health and the individual factors (biologic, behavioral, and psychosocial) and multilevel factors (interpersonal, institutional, community, and societal) that promote bladder health and/or prevent LUTS in women across the life course. Key study development activities included the: (1) development of a conceptual framework and philosophy to guide subsequent activities, (2) creation of a study design and sampling strategy, prioritizing diversity, equity, and inclusion, and (3) selection and development of data collection components. Community members and cross-cultural experts shaped and ensured the appropriateness of all study procedures and materials. RISE participants will be selected by simple random sampling of individuals identified by a marketing database who reside in the 50 counties surrounding nine PLUS clinical research centers. Participants will complete self-administered surveys at baseline (mailed paper or electronic) to capture bladder health and LUTS, knowledge about bladder health, and factors hypothesized to promote bladder health and prevent LUTS. A subset of participants will complete an in-person assessment to augment data with objective measures including urogenital microbiome specimens. Initial longitudinal follow-up is planned at 1 year. DISCUSSION: Findings from RISE will begin to build the necessary evidence base to support much-needed, new bladder health promotion and LUTS prevention interventions in women.

Reducing Falls in Older Women with Urinary Incontinence.

Urinary incontinence is common in older women and doubles the risk of falls in this population. The association between urinary incontinence, especially urgency urinary incontinence, and falls is multifactorial and likely the result of a complex interaction between physical, mental, social, and environmental factors. As a result of this multifactorial etiology and based on existing evidence, the integration of different fall prevention strategies including strength and resistance exercises, bladder training, and home hazard reduction have the potential to decrease the risk of falls in older women with urinary incontinence. Given the prevalence of urinary incontinence and the significant morbidity associated with falls, effective interventions to reduce fall risk in older women with urinary incontinence is of high public health significance.

Community-Based COVID-19 Vaccine Clinics in Medically Underserved Neighborhoods to Improve Access and Equity, Philadelphia, 2021-2022.

Vaccination remains key to reducing the risk of COVID-19-related severe illness and death. Because of historic medical exclusion and barriers to access, Black communities have had lower rates of COVID-19 vaccination than White communities. We describe the efforts of an academic medical institution to implement community-based COVID-19 vaccine clinics in medically underserved neighborhoods in Philadelphia, Pennsylvania. Over a 13-month period (April 2021-April 2022), the initiative delivered 9038 vaccine doses to community members, a majority of whom (57%) identified as Black. (Am J Public Health. 2022;112(12):1721-1725. https://doi.org/10.2105/AJPH.2022.307030).

Design, Implementation, and Outcomes of a Volunteer-Staffed Case Investigation and Contact Tracing Initiative at an Urban Academic Medical Center.

Importance: The COVID-19 pandemic has claimed nearly 6 million lives globally as of February 2022. While pandemic control efforts, including contact tracing, have traditionally been the purview of state and local health departments, the COVID-19 pandemic outpaced health department capacity, necessitating actions by private health systems to investigate and control outbreaks, mitigate transmission, and support patients and communities. Objective: To investigate the process of designing and implementing a volunteer-staffed contact tracing program at a large academic health system from April 2020 to May 2021, including program structure, lessons learned through implementation, results of case investigation and contact tracing efforts, and reflections on how constrained resources may be best allocated in the current pandemic or future public health emergencies. Design, Setting, and Participants: This case series study was conducted among patients at the University of Pennsylvania Health System and in partnership with the Philadelphia Department of Public Health. Patients who tested positive for COVID-19 were contacted to counsel them regarding safe isolation practices, identify and support quarantine of their close contacts, and provide resources, such as food and medicine, needed during isolation or quarantine. Results: Of 5470 individuals who tested positive for COVID-19 and received calls from a volunteer, 2982 individuals (54.5%; median [range] age, 42 [18-97] years; 1628 [59.4%] women among 2741 cases with sex data) were interviewed; among 2683 cases with race data, there were 110 Asian individuals (3.9%), 1476 Black individuals (52.7%), and 817 White individuals (29.2%), and among 2667 cases with ethnicity data, there were 366 Hispanic individuals (13.1%) and 2301 individuals who were not Hispanic (82.6%). Most individuals lived in a household with 2 to 5 people (2125 of 2904 individuals with household data [71.6%]). Of 3222 unique contacts, 1780 close contacts (55.2%; median [range] age, 40 [18-97] years; 866 [55.3%] women among 1565 contacts with sex data) were interviewed; among 1523 contacts with race data, there were 69 Asian individuals (4.2%), 705 Black individuals (43.2%), and 573 White individuals (35.1%), and among 1514 contacts with ethnicity data, there were 202 Hispanic individuals (12.8%) and 1312 individuals (83.4%) who were not Hispanic. Most contacts lived in a household with 2 to 5 people (1123 of 1418 individuals with household data [79.2%]). Of 3324 cases and contacts who completed a questionnaire on unmet social needs, 907 (27.3%) experienced material hardships that would make it difficult for them to isolate or quarantine safely. Such hardship was significantly less common among White compared with Black participants (odds ratio, 0.20; 95% CI, 0.16-0.25). Conclusions and Relevance: These findings demonstrate the feasibility and challenges of implementing a case investigation and contact tracing program at an academic health system. In addition to successfully engaging most assigned COVID-19 cases and close contacts, contact tracers shared health information and material resources to support isolation and quarantine, thus filling local public health system gaps and supporting local pandemic control.

Clinic navigation and home visits to improve asthma care in low income adults with poorly controlled asthma: Before and during the pandemic.

Asthma-related deaths, hospitalizations, and emergency visits are more numerous among low-income patients, yet management guidelines do not address this high-risk group's special needs. We recently demonstrated feasibility, acceptability, and preliminary evidence of effectiveness of two interventions to improve access to care, patient-provider communication, and asthma outcomes: 1) Clinic Intervention (CI): study staff facilitated patient preparations for office visits, attended visits, and afterwards confirmed patient understanding of physician recommendations, and 2) Home Visit (HV) by community health workers for care coordination and informing clinicians of home barriers to managing asthma. The current project, denominated "HAP3," combines these interventions for greater effectiveness, delivery of guideline-based asthma care, and asthma control for low-income patients recruited from 6 primary care and 3 asthma specialty practices. We assess whether patients of clinicians receiving guideline-relevant, real-time feedback on patient health and home status have better asthma outcomes. In a pragmatic factorial longitudinal trial, HAP3 enrolls 400 adults with uncontrolled asthma living in low-income urban neighborhoods. 100 participants will be randomized to each of four interventions: (1) CI, (2) CI with HVs, (3) CI and real-time feedback to asthma clinician of guideline-relevant elements of patients' current care, or (4) both (2) and (3). The outcomes are asthma control, quality of life, ED visits, hospitalizations, prednisone bursts, and intervention costs. The COVID-19 pandemic struck 6.5 months into recruitment. We describe study development, design, methodology, planned analysis, baseline findings and adaptions to achieve the original aims of improving patient-clinician communication and asthma outcomes despite the markedly changed pandemic environment.

Survey of lower urinary tract symptoms in United States women using the new lower urinary tract dysfunction research Network-Symptom Index 29 (LURN-SI-29) and a national research registry.

PURPOSE: An online bladder health survey was administered to national registry volunteers to: (1) determine the feasibility of using ResearchMatch for studying lower urinary tract symptoms (LUTS); (2) pilot the new, comprehensive Lower Urinary Tract Dysfunction Research Network Symptom Index-29 (LURN-SI-29) and determine its ability to detect known associations with LUTS; and (3) explore novel areas of bladder health in community-based women. METHODS: A cross-sectional web-based survey was administered to a random sample of ResearchMatch adult female, transgender and non-binary volunteers. Participant demographics, health characteristics, the LURN-SI-29, and LUTS-related experiences were collected. RESULTS: A total of 1725 ReseachMatch volunteers with a mean age of 44.0 years completed the study and were eligible for the analysis. Participants were primarily white, cisgendered, highly educated, nulliparous, and premenopausal. The median LURN-SI-29 score was 17 (interquartile range: 11-26). More than half the sample reported urinary urgency (71.0%), nocturia (65.7%), and stress incontinence (52.3%) a "few times" or more in the last 7 days. Approximately half reported sensation of incomplete bladder emptying (49.6%) with one-third reporting urgency incontinence (37.6%); notably, 52.6% of respondents reported being at least "somewhat" bothered by LUTS. LURN-SI-29 scores increased with age, body mass index, decrements in self-reported health, medical comorbidity, parity, menopausal status, and urinary symptom bother, providing evidence of convergent validity. LURN-SI-29 scores varied by race and education, with the lowest scores in Asian and highly educated women. CONCLUSION: Overall, the prevalence and spectrum of LUTS in an online research registry of women volunteers were high and comparable to other population-based samples. The new LURN-SI-29 demonstrated its ability to detect expected associations with demographic and health characteristics in a nonclinical population.

Evaluation of a Contact Tracing Training Program and Field Experience.

Introduction: The study objective was to evaluate a contact tracing training program and the role of contact tracing on volunteers' professional development. Methods: A COVID-19 contact tracing program was conducted at an urban academic medical center, in collaboration with the local health department, between March 2020 and May 2021. Contact tracers, most of whom were health professions students, completed pretraining and post-training surveys to assess knowledge and self-efficacy to conduct contact tracing, plus an 18-month follow-up survey regarding career impacts. Results: We observed statistically significant post-training increases in knowledge and self-efficacy to conduct contact tracing. Contact tracers described benefiting from training regarding cultural humility, empathy, and trauma-informed interviewing. They also expressed a deeper understanding of COVID-19 inequities and their structural causes and reported that the work was emotionally demanding. Conclusions: Key to pandemic preparedness is having a trained and supported workforce. This study showed how contact tracing training and field experience strengthened students' education in the health professions by sharpening interpersonal skills and structural competency and by generating insights regarding current gaps in both public health infrastructure and support for vulnerable populations.

Primary language and the electronic health record patient portal: Barriers to use among Spanish-speaking adults with asthma.

OBJECTIVES: To assess electronic health record patient portal use among Spanish-speaking patients with asthma compared to English-speaking patients and identify barriers to use. METHODS: Using data collected for a PCORI-funded randomized controlled trial to increase patient portal use in low-income adults with uncontrolled asthma, we estimated the association between portal use, measured using surveys and actual user login data, and primary language. Open-ended survey responses were grouped into common themes. RESULTS: Among 301 adults with asthma: age 18-87, 90% female, 17% Spanish speakers; 44% had no portal use during the study. Spanish speakers were less likely to have ever heard of the patient portal than English speakers (p=.001) and reported more difficulty navigating the portal (p<.001). Spanish speakers with low health literacy had less portal use (31%) than their English-speaking counterparts (51%) (p=.02). Compared to high-literacy English speakers, the odds of using the portal for low-literacy Spanish speakers were 0.34 (95% CI 0.14, 0.84) (p=.02). Three-quarters of Spanish speakers cited barriers to portal use compared to one-quarter of English speakers, and many suggested creating a Spanish version to improve user-friendliness. CONCLUSIONS: English-only patient portals may not meet the needs of Spanish-speaking patients with uncontrolled asthma. Health systems serving Spanish-speaking communities should implement patient portals in Spanish.

Acute pain and self-directed discharge among hospitalized patients with opioid-related diagnoses: a cohort study.

BACKGROUND: Patients with substance use disorders are more likely than those without to have a self-directed hospital discharge, putting them at risk for poor health outcomes including progressing illness, readmissions, and death. Inadequate pain management has been identified as a potential motivator of self-directed discharge in this patient population. The objective of this study was to describe the association between acute pain and self-directed discharges among persons with opioid-related conditions; the presence of chronic pain in self-directed discharges was likewise considered. METHODS: We employed a large database of all hospitalizations at acute care hospitals during 2017 in the city of Philadelphia to identify adults with opioid-related conditions and compare the characteristics of admissions ending with routine discharge versus those ending in self-directed discharge. We examined all adult discharges with an ICD-10 diagnoses related to opioid use or poisoning and inspected the diagnostic data to systematically identify acute pain for the listed primary diagnosis and explore patterning in chronic pain diagnoses with respect to discharge outcomes. RESULTS: Sixteen percent of the 7972 admissions involving opioid-related conditions culminated in self-directed discharge, which was more than five times higher than in the general population. Self-directed discharge rates were positively associated with polysubstance use, nicotine dependence, depression, and homelessness. Among the 955 patients with at least one self-directed discharge, 15.4% had up to 16 additional self-directed discharges during the 12-month observation period. Those admitted with an acutely painful diagnosis were almost twice as likely to complete a self-directed discharge, and for patients with multiple admissions, rates of acutely painful diagnoses increased with each admission coinciding with a cascading pattern of worsening infectious morbidity over time. Chronic pain diagnoses were inconsistent for those patients with multiple admissions, appearing, for the same patient, in one admission but not others; those with inconsistent documentation of chronic pain were substantially more likely to self-discharge. CONCLUSIONS: These findings underscore the importance of pain care in disrupting a process of self-directed discharge, intensifying harm, and preventable financial cost and suffering. Each admission represents a potential opportunity to provide harm reduction and treatment interventions addressing both substance use and pain.

Stability of food insecurity status in paediatric primary care.

OBJECTIVE: The American Academy of Pediatrics recommends screening for food insecurity (FI) at all well-child visits due to well-documented negative effects of experiencing FI in childhood. Before age 3, children have twelve recommended primary care visits at which screening could occur. Little is known regarding the stability of FI status at this frequency of screening. DESIGN: Data derived from electronic health records were used to retrospectively examine the stability of household FI status. Age-stratified (infant v. toddler) analyses accounted for age-based differences in visit frequency. Regression models with time since last screening as the predictor of FI transitions were estimated via generalised estimating equations adjusting for age and race/ethnicity. SETTING: A paediatric primary care practice in Philadelphia. PARTICIPANTS: 3451 distinct patients were identified whose health record documented two or more household FI screens between April 1, 2012 and July 31, 2018 and were aged 0-3 years at first screen. RESULTS: Overall, 9·5 % of patients had a transition in household FI status, with a similar frequency of transitioning from food insecure to secure (5·0 %) and from food secure to insecure (4·5 %). Families of toddlers whose last screen was more than a year ago were more likely to experience a transition to FI compared with those screened 0-6 months prior (OR 1·91 (95 % CI 1·05, 3·47)). CONCLUSIONS: Screening more than annually may not contribute substantially to the identification of transitions to FI.

Patient Advocates for Low-Income Adults with Moderate to Severe Asthma: A Randomized Clinical Trial.

BACKGROUND: Few interventions have targeted low-income adults with moderate to severe asthma despite their high mortality. OBJECTIVE: To assess whether a patient advocate (PA) intervention improves asthma outcomes over usual care (UC). METHODS: This 2-armed randomized clinical trial recruited adults with moderate to severe asthma from primary care and asthma-specialty practices serving low-income neighborhoods. Patients were randomized to 6 months of a PA intervention or UC. PAs were recent college graduates anticipating health care careers, who coached, modeled, and assisted participants with preparations for asthma-related medical visits, attended visits, and confirmed participants' understanding of provider recommendations. Participants were followed for at least a year for patient-centered asthma outcomes: asthma control (primary outcome), quality of life, prednisone requirements, emergency department visits, and hospitalizations. RESULTS: There were 312 participants. Their mean age was 51 years (range, 19-93 years), 69% were women, 66% African American, 8% Hispanic/Latino, 62% reported hospitalization for asthma in the year before randomization, 21% had diabetes, and 61% had a body mass index of 30 or more. Asthma control improved over 12 months, more in the intervention group (-0.45 [95% CI, -0.67 to -0.21]) than in the UC group (-0.26 [95% CI, -0.53 to -0.01]), and was sustained at 24 months but with no statistical difference between groups. The 6-month rate of emergency department visits decreased in the intervention (-0.90 [95% CI, -1.56 to -0.42]) and UC (-0.42 [95% CI, -0.72 to -0.06]) groups over 12 months. The cost of the PA program was $1521 per patient. Only 64% of those assigned had a PA visit. CONCLUSIONS: A PA may be a promising intervention to improve and sustain outcomes in this high-risk population if expanded to address factors that make keeping appointments difficult.

Who, What, and Where: Transforming Primary Care Education to Advance Health Equity.

To transform primary care with the goal of achieving health equity, changes in the way the health care workforce is selected, trained, and ultimately delivers care should be expedited. Research has repeatedly shown the immense impact of the social determinants of health and the gaps related to health equity in the United States. Despite this knowledge, health care education and delivery systems have been slow to evolve. The Health Resources and Services Administration established the Academic Units for Primary Care Training and Enhancement to work towards strengthening the primary care workforce. Through their research, the six individual Academic Units (AU) have identified gaps related to health equity in their areas of focus. This article provides recommendations from the AUs on ways primary care health professions education can be transformed to advance health equity and serves as background for the articles to follow in the remainder of the supplement.

Treatment for Opioid Use Disorder in Primary Care: Opportunities and Challenges for Sustainable Training Programs.

Drug overdose death rates from opioid use have risen steadily since 1999 and reached epidemic levels, slowing for the first time in 2018, though not for many forms of opioid use. Yet evidence-based approaches to combating OUD, such as medication-assisted treatment for OUD (MT-OUD), are still inaccessible to many. Primary care providers are well-positioned to offer these services; however, training and education in OUD care remains inadequate. The National Center for Integrated Behavioral Health interviewed the Health Resources Service Administration (HRSA) awardees of federal funding to implement an MT-OUD curriculum in their primary care residency training programs to identify barriers and facilitators to implementation. Awardees were interviewed at program launch and one year later. Results showed the importance of leadership willingness to participate, effective treatment integration into existing workflow, curriculum and clinical flexibility, and supportive interdisciplinary and community partnerships. Recommendations for best practices of MT-OUD training in primary care are identified.