Connect: Cultivating Academic-Community Partnerships to Address Our Communities' Complex Needs During Public Health Crises.

BACKGROUND: Black and Latino communities have been disproportionately impacted by coronavirus disease 2019 and we sought to understand perceptions and attitudes in four heavily impacted New Jersey counties to develop and evaluate engagement strategies to enhance access to testing. OBJECTIVE: To establish a successful academic/community partnership team during a public health emergency by building upon longstanding relationships and using principles from community engaged research. METHODS: We present a case study illustrating multiple levels of engagement, showing how we successfully aligned expectations, developed a commitment of cooperation, and implemented a research study, with community-based and health care organizations at the center of community engagement and recruitment. LESSONS LEARNED: This paper describes successful approaches to relationship building including information sharing and feedback to foster reciprocity, diverse dissemination strategies to enhance engagement, and intergenerational interaction to ensure sustainability. CONCLUSIONS: This model demonstrates how academic/community partnerships can work together during public health emergencies to develop sustainable relationships.

Association of Medicaid enrollee characteristics and primary care utilization with cancer outcomes for the period spanning Medicaid expansion in New Jersey.

BACKGROUND: Cancer outcomes for Medicaid enrollees may be affected by patients' primary care (PC) utilization and complex Medicaid enrollment dynamics, which have recently changed for many states under the Affordable Care Act. METHODS: With New Jersey State Cancer Registry and linked Medicaid claims data, a retrospective cohort study was conducted for patients with incident breast, colorectal, or invasive cervical cancer (aged 21-64 years) diagnosed in 2012-2014. Associations of Medicaid enrollment factors and PC utilization with the stage at diagnosis and treatment delays were examined with multivariate logistic regression models. RESULTS: The study included 19,209 total cancer cases and 3253 linked Medicaid cases. Medicaid cases were more likely to be diagnosed at a late stage and to experience treatment delays in comparison with non-Medicaid cases. In adjusted analyses, Medicaid cases with 1 or more PC visits before the diagnosis had lower odds of a late-stage diagnosis (odds ratio, 0.47; 95% confidence interval, 0.33-0.67) in comparison with Medicaid cases with no outpatient visits. New enrollees (<6 months) and longer term enrollees in fee-for-service (FFS) Medicaid had greater odds of a late-stage diagnosis and treatment delays in comparison with those in Medicaid managed care. CONCLUSIONS: Medicaid patients with cancer diagnosed just before and in the initial year of eligibility expansion had worse outcomes than non-Medicaid cases. Poor outcomes were especially pronounced among new enrollees, those without outpatient visits before their diagnosis, and FFS enrollees. Targeted strategies to enhance care continuity, including access to PC providers before the diagnosis and a better understanding of pathways to cancer care upon Medicaid enrollment, are needed to improve outcomes in this population.

Lessons Learned Recruiting Minority Participants for Research in Urban Community Health Centers.

To help understand and mitigate health disparities, it is important to conduct research with underserved and underrepresented minority populations under real world settings. There is a gap in the literature detailing real-time research staff experience, particularly in their own words, while conducting in-person patient recruitment in urban community health centers. This paper describes challenges faced at the clinic, staff, and patient levels, our lessons learned, and strategies implemented by research staff while recruiting predominantly low-income African-American women for an interviewer-administered survey study in four urban Federally Qualified Health Centers in New Jersey. Using a series of immersion-crystallization cycles, fieldnotes and research reflections written by recruiters, along with notes from team meetings during the study, were qualitatively analyzed. Clinic level barriers included: physical layout of clinic, very low or high patient census, limited private space, and long wait times for patients. Staff level barriers included: unengaged staff, overburdened staff, and provider and staff turnover. Patient level barriers included: disinterested patients, patient mistrust and concerns over confidentiality, no-shows or lack of patient time, and language barrier. We describe strategies used to overcome these barriers and provide recommendations for in-person recruitment of underserved populations into research studies. To help mitigate health disparities, disseminating recruiters' experiences, challenges, and effective strategies used will allow other researchers to build upon these experience in order to increase recruitment success of underserved and underrepresented minority populations into research studies.

The influence of dermatologist and primary care physician visits on melanoma outcomes among Medicare beneficiaries.

BACKGROUND: Ambulatory visits to dermatologists and primary care physicians (PCPs) may improve melanoma outcomes through early detection. We sought to measure the effect of dermatologist and PCP visits on melanoma stage at diagnosis and mortality. METHODS: We used data from the database linking Surveillance Epidemiology and End Results (SEER) and Medicare data (1994 to 2005) to examine patterns of dermatologist and PCP ambulatory visits before diagnosis for 18,884 Medicare beneficiaries with invasive melanoma or unknown stage at diagnosis. Visits were assessed during the 2-year time interval before the month of diagnosis. We examined whether dermatologist and PCP visits were associated with diagnosis of thinner melanomas (defined as local stage tumors having Breslow thickness <1 mm) and lower melanoma mortality. RESULTS: Medicare beneficiaries visiting both a dermatologist and PCP before diagnosis had greater odds of diagnosis of a thin melanoma (adjusted odds ratio, 1.26; 95% confidence interval, 1.12-1.41) and lower melanoma mortality (adjusted hazard ratio 0.66, 95% confidence interval, 0.57-0.76) compared with those without such visits. The mortality findings were attenuated once stage at diagnosis was adjusted for in the multivariable model. CONCLUSION: Improved melanoma outcomes among Medicare beneficiaries may depend on adequate access and use of dermatologist and PCP services.

Primary care utilization and colorectal cancer incidence and mortality among Medicare beneficiaries: a population-based, case-control study.

BACKGROUND: Utilization of primary care may decrease colorectal cancer (CRC) incidence and death through greater receipt of CRC screening tests. OBJECTIVE: To examine the association of primary care utilization with CRC incidence, CRC deaths, and all-cause mortality. DESIGN: Population-based, case-control study. SETTING: Medicare program. PARTICIPANTS: Persons aged 67 to 85 years diagnosed with CRC between 1994 and 2005 in U.S. Surveillance, Epidemiology, and End Results (SEER) regions matched with control patients (n = 205,804 for CRC incidence, 54,160 for CRC mortality, and 121,070 for all-cause mortality). MEASUREMENTS: Primary care visits in the 4- to 27-month period before CRC diagnosis, CRC incidence, CRC mortality, and all-cause mortality. RESULTS: Compared with persons having 0 or 1 primary care visit, persons with 5 to 10 visits had lower CRC incidence (adjusted odds ratio [OR], 0.94 [95% CI, 0.91 to 0.96]) and mortality (adjusted OR, 0.78 [CI, 0.75 to 0.82]) and lower all-cause mortality (adjusted OR, 0.79 [CI, 0.76 to 0.82]). Associations were stronger in patients with late-stage CRC diagnosis, distal lesions, and diagnosis in more recent years when there was greater Medicare screening coverage. Ever receipt of CRC screening and polypectomy mediated the association of primary care utilization with CRC incidence. LIMITATION: This study used administrative data, which made it difficult to identify potential confounders and prevented examination of the content of primary care visits. CONCLUSION: Medicare beneficiaries with higher utilization of primary care have lower CRC incidence and mortality and lower overall mortality. Increasing and promoting access to primary care in the United States for Medicare beneficiaries may help decrease the national burden of CRC. PRIMARY FUNDING SOURCE: American Cancer Society.

The effects of primary care on breast cancer mortality and incidence among Medicare beneficiaries.

BACKGROUND: Primary care physician (PCP) services may have an impact on breast cancer mortality and incidence, possibly through greater use of screening mammography. METHODS: The authors conducted a retrospective, 1:1 matching case-control study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database to examine use of PCP services and their association with breast cancer mortality and incidence. SEER cases representing the 3 outcomes of interest (breast cancer mortality, all-cause mortality among women diagnosed with breast cancer, and breast cancer incidence) were matched to unaffected controls from the 5% Medicare random sample. Conditional logistic regression was used to examine associations between physician visits and breast cancer outcomes while controlling for other covariates. RESULTS: Women who had 2 or more PCP visits during the 24-month assessment interval had lower odds of breast cancer mortality, all-cause mortality, and late-stage breast cancer diagnosis compared with women who had no PCP visits or 1 PCP visit while adjusting for other covariates, including mammography and non-PCP visits. Women who had 5 to 10 PCP visits had 0.69 times the odds of breast cancer mortality (95% confidence interval, 0.63-0.75), 0.83 times the odds of death from any cause having been diagnosed with breast cancer (95% confidence interval, 0.79-0.87), and 0.67 times the odds of a late-stage breast cancer diagnosis (95% confidence interval, 0.61-0.73) compared with those who had no PCP visits or 1 PCP visit. CONCLUSIONS: The current findings suggest that PCPs play an important role in reducing breast cancer mortality among the Medicare population. Further research is needed to better understand the impact of primary care on breast cancer and other cancers that are amendable to prevention or early detection.

Influence of primary care on breast cancer outcomes among Medicare beneficiaries.

PURPOSE: We used the Surveillance Epidemiology and End Results (SEER)-Medicare database to explore the association between primary care and breast cancer outcomes. METHODS: Using a retrospective cohort study of 105,105 female Medicare beneficiaries with a diagnosis of breast cancer in SEER registries during the years 1994-2005, we examined the total number of office visits to primary care physicians and non-primary care physicians in a 24-month period before cancer diagnosis. For women with invasive cancers, we examined the odds of diagnosis of late-stage disease, according to the American Joint Commission on Cancer (AJCC) (stages III and IV vs stages I and II), and survival (breast cancer specific and all cause) using logistic regression and proportional hazards models, respectively. We also explored whether including noninvasive cancers, such as ductal carcinoma in situ (DCIS), would alter results and whether prior mammography was a potential mediator of associations. RESULTS: Primary care physician visits were associated with improved breast cancer outcomes, including greater use of mammography, reduced odds of late-stage diagnosis, and lower breast cancer and overall mortality. Prior mammography (and resultant earlier stage diagnosis) mediated these associations in part, but not completely. Similar results were seen for non-primary care physician visits. Results were similar when women with DCIS were included in the analysis. CONCLUSIONS: Medicare beneficiaries with breast cancer had better outcomes if they made greater use of a primary care physician's ambulatory services. These findings suggest adequate primary medical care may be an important factor in achieving optimal breast cancer outcomes.

Primary care utilization and colorectal cancer outcomes among Medicare beneficiaries.

BACKGROUND: Primary medical care may improve colorectal cancer (CRC) outcomes through increased use of CRC screening tests and earlier diagnosis. We examined the association between primary care utilization and CRC screening, stage at diagnosis, CRC mortality, and all-cause mortality. METHODS: We conducted a retrospective cohort study of patients, aged 67 to 85 years, diagnosed as having CRC between 1994 and 2005 in the Surveillance, Epidemiology, and End Results-Medicare-linked database. Association of the number of visits to primary care physicians (PCPs) in the 3- to 27-month period before the CRC diagnosis and CRC screening, early-stage diagnosis, CRC mortality, and all-cause mortality were examined using multivariable logistic regression and Cox proportional hazards models. RESULTS: The odds of CRC screening and early-stage diagnosis increased with increasing number of PCP visits (P < .001 for trend). Compared with persons having 0 or 1 PCP visit, patients with 5 to 10 visits had increased odds of ever receiving CRC screening at least 3 months before diagnosis (adjusted odds ratio, 2.60; 95% CI, 2.48-2.72) and early-stage diagnosis (1.35; 1.29-1.42). Persons with 5 to 10 visits had 16% lower CRC mortality (adjusted hazard ratio [AHR], 0.84; 95% CI, 0.80-0.88) and 6% lower all-cause mortality (0.94; 0.91-0.97) compared with persons with 0 or 1 visit. CONCLUSIONS: Medicare beneficiaries with CRC have better outcomes if they have greater utilization of primary care before diagnosis. Revitalization of primary care in the United States may help strengthen the national efforts to reduce the burden of CRC.

Colorectal cancer screening among primary care patients: does risk affect screening behavior?

Lifestyle factors including smoking, obesity, and diabetes can increase colorectal cancer (CRC) risk. Controversy exists regarding screening rates in individuals at increased CRC risk. To examine the effect of risk on CRC screening in primary care, cross-sectional data collected during January 2006-July 2007 from 720 participants in 24 New Jersey primary care practices were analyzed. Participants were stratified by risk: high (personal/family history of CRC, history of polyps, inflammatory bowel disease), increased (obesity, Type II diabetes, current/former smokers), and average. Outcomes were up-to-date with CRC screening, receiving a physician recommendation for screening, and recommendation adherence. Chi-square and generalized linear modeling were used to determine the effect of independent variables on risk group and risk group on outcomes. Thirty-seven percent of participants were high-risk, 46% increased-risk, and 17% average-risk. Age, race, insurance, education, and health status were related to risk. High-risk participants had increased odds of being up-to-date with screening (OR 3.14 95% CI 1.85-5.32) and adhering to physician recommendation (OR 7.18 95% CI 3.58-14.4) compared to average-risk. Increased-risk participants had 32% decreased odds of screening (OR 0.68, 95% CI 0.42-1.08). Low screening rates among increased-risk individuals highlight the need for screening interventions targeting these patients.

Translating the patient navigator approach to meet the needs of primary care.

BACKGROUND: Helping patients navigate the complex and fragmented US health care system and coordinating their care are central to the patient-centered medical home. We evaluated the pilot use of a patient navigator (PN), someone who helps patients use the health care system effectively and efficiently, in primary care practices. METHODS: This study was a cross-case comparative analysis of 4 community practices that implemented patient navigation. Project meeting notes, PN activity logs and debriefings, physician interviews, and patient/family member interviews were analyzed using a grounded approach. RESULTS: Seventy-five mostly female, elderly patients received navigation services from a social worker. The PN typically helped patients obtain social services and navigate health coverage and complex referrals. Availability of workspace for PN, interaction with practice members, and processes used for selecting and referring patients affected PN collaboration with and integration into practices. Patients found PN services very helpful, and physicians viewed the PN as someone carrying out new tasks that the practice was not previously doing. CONCLUSIONS: Patient navigation in community primary care practices is useful for patients who have complex needs. Integrating such services into primary care settings will require new practice and payment models to realize the full potential of integrated patient navigation services in this setting.

Principles of the patient-centered medical home and preventive services delivery.

PURPOSE: Limited research exists examining the principles of the patient-centered medical home (PCMH) and improved outcomes. We examined whether PCMH principles (personal physician, physician-directed team, whole-person orientation, coordination of care, quality and safety, and enhanced access) are associated with receipt of preventive services. METHODS: We undertook cross-sectional analyses using baseline patient and practice member surveys and chart audits from a quality improvement trial in 24 primary care offices. Association of PCMH principles with preventive services (receipt of cancer screening, lipid screening, influenza vaccination, and behavioral counseling) was examined using hierarchical linear modeling. RESULTS: Higher global PCMH scores were associated with receipt of preventive services (beta = 2.3; P <.001). Positive associations were found with principles of personal physician (beta = 3.7; P <.001), in particular, continuity with the same physician (beta = 4.4; P = .002) and number of visits within 2 years (15% higher for patients with 13 or more visits; P <.001); and whole-person orientation (beta = 5.6; P <.001), particularly, having a well-visit within 5 years (beta = 12.3; P <.001) and being treated for chronic diseases (6% higher if more than 3 chronic diseases; P = .002). Having referral systems to link patients to community programs for preventive counseling (beta = 8.0; P <.001) and use of clinical decision-support tools (beta = 5.0; P = .04) were also associated with receipt of preventive services. CONCLUSIONS: Relationship-centered aspects of PCMH are more highly correlated with preventive services delivery in community primary care practices than are information technology capabilities. Demonstration projects and tools that measure PCMH principles should have greater emphasis on these key primary care attributes.