Community-Based Health Care Navigation's Impact on Access to Primary Care for Low-Income Latinos.

INTRODUCTION: Despite the Affordable Care Act's insurance expansion, low-income Latinos are less likely to have a primary care provider compared with other racial/ethnic and income groups. We examined if community-based health care navigation could improve access to primary care in this population. METHODS: We surveyed adult clients of a community-based navigation program serving predominantly low-income Latinos throughout Los Angeles County in 2019. We used multivariable logistic regression models, adjusting for sociodemographic characteristics, to calculate odds ratios for differences in access to primary care and barriers to care between clients who had experienced approximately 1 year of navigation services (intervention group) and clients who were just introduced to navigation (comparison group). RESULTS: Clients in the intervention group were more likely to report having a primary care clinic than the comparison group (Adjusted Odds Ratio [aOR] 3.0, 95%CI: 1.7, 5.4). The intervention group was also significantly less likely to experience several barriers to care, such as not having insurance, not being able to pay for a visit, and not having transportation. CONCLUSIONS: Community-based navigation has the potential to reduce barriers and improve access to primary care for low-income Latinos. In addition to expanding insurance coverage, policymakers should invest in health care navigation to reduce disparities in primary care.

From the hospital to the streets: Bringing care to the unsheltered homeless in Los Angeles.

Homelessness is a neglected crisis throughout the United States. In Los Angeles (L.A.) County, nearly 59,000 residents are homeless, and the vast majority are unsheltered. An academic institution and L.A county's largest public hospital formed a partnership to launch a Street Medicine (SM) program. SM assists the inpatient team with discharge planning and builds rapport with the patient experiencing homelessness. After discharge, the SM team follows up and brings care to the patient on the streets, often developing a trusting relationship and establishing continuity of primary care. During a 12-month period, SM provided inpatient consults for 206 unsheltered homeless patients.

Allocation of scarce resources in a pandemic: rapid systematic review update of strategies for policymakers.

OBJECTIVE: In pandemics like COVID-19, the need for medical resources quickly outpaces available supply. policymakers need strategies to inform decisions about allocating scarce resources. STUDY DESIGN AND SETTING: We updated a systematic review on evidence-based approaches and searched databases through May 2020 for evaluation of strategies for policymakers. RESULTS: The 201 identified studies evaluated reducing demand for healthcare, optimizing existing resources, augmenting resources, and adopting crisis standards of care. Most research exists to reduce demand (n = 149); 39 higher quality studies reported benefits of contact tracing, school closures, travel restrictions, and mass vaccination. Of 28 strategies to augment resources, 6 higher quality studies reported effectiveness of establishing temporary facilities, use of volunteers, and decision support software. Of 23 strategies to optimize existing resources, 12 higher quality studies reported successful scope of work expansions and building on existing interagency agreements. Of 15 COVID-19 studies, 5 higher quality studies reported on combinations of policies and benefits of community-wide mask policies. CONCLUSION: Despite the volume, the evidence base is limited; few strategies were empirically tested in robust study designs. The review provides a comprehensive overview of the effects of strategies to allocate resources and provides critical appraisal to identify the best available evidence.

Program Evaluation of Environmental and Policy Approaches to Physical Activity Promotion in a Lower Income Latinx School District in Southeast Los Angeles.

There is alarming population wide prevalence of low adolescent physical activity as this represents a risk factor for later chronic disease development. There is evidence to suggest that schools with strong wellness policies have students that are more frequently active. We designed an intervention to enhance students' physical activity levels in five majority Latinx, underserved school districts. Evaluation consisted of assessment of written quality of school-district wellness policies; observation of student's physical activity during leisure times; and after-school program practices and policies. We examined one of these district's results more closely, the only participating district with a community coalition, and extracted lessons learned. On the physical activity section of the wellness policy, this district covered a moderate extent of recommended content areas using weak language. Compared to previous reports, we identified low vigorous activity levels for girls and boys at baseline (respectively, 12% and 18%). Finally, we identified that of four after school program sites assessed at baseline, no program reported the recommended 50% or more of program time dedicated to physical activity. Based on these evaluation findings, additional strategies are urgently needed to encourage all students and particularly more girls to be physically active throughout the school day.

New enrollment under the affordable care act: leading the way for community health centers in Southern California.

BACKGROUND: The Affordable Care Act (ACA) has improved healthcare access in the community health centers that have played a critical role in enrolling low income and minority patients. This study examined the ACA enrollment for one of the largest federally qualified community health centers in the country. METHODS: An exploratory sequential mixed method study was used as the main qualitative and quantitative approach for this study. Key stakeholders (n = 6) were interviewed as part of the qualitative component, and information about barriers and best practices were acquired. As part of the quantitative analysis, we examined cross-sectional data among 59,272 AltaMed enrollees in 2013-2015. We analyzed data on age, gender, language, ethnicity, and enrollment periods. The interviews were conducted first and followed by the data analysis. RESULTS: AltaMed was the top enroller of patients in ACA insurance plans in California (2013-14 and 2014-15) through the state exchange and Medicaid expansion. Using key stakeholder interviews, 5 main barriers were identified and 5 innovative solutions that allowed AltaMed to enroll people into the state exchange and Medicaid expansion. Barriers to enrollment included training, new workflows, and enrollment of Young Invincibles, and these enrollment barriers were overcome with community health workers. CONCLUSION: Enrollment barriers were overcome through AltaMed's community-based approach and long term community partnerships.

Primary care team- and clinic level factors affecting HPV vaccine uptake.

OBJECTIVE: This study examined patient-, care team- and clinic-level factors associated with human papillomavirus (HPV) vaccine initiation and completion. METHODS: HPV vaccine initiation and completion rates among adolescents aged 9-18years were assessed using administrative data (n=38,277) from a large federally qualified health center serving predominantly Latino patients. Four clinics with particularly high and low adolescent HPV vaccine uptake were selected for in-depth case study analyses. Semi-structured interviews with clinic leaders, providers, and support staff in these clinics (n=36) examined multilevel factors perceived as affecting vaccine initiation and completion. RESULTS: On average, less than half (45%) of patients had initiated the HPV vaccine; of these, 52% of patients completed all recommended doses. Vaccine uptake varied significantly across clinics but was higher among patients seen by providers specializing in pediatrics. Qualitative findings confirmed the importance of provider communication strategies but indicated that other health care team structures and processes also play an important role in vaccine uptake. Care team members in higher performing clinics were more likely to describe vaccination as a team effort rather than solely the provider's responsibility. Support staff in higher performing clinics also spent more time reviewing patient preventive care needs and preparing patients for the provider encounter. Clinic-level factors such as performance management systems and the use of immunization champions were described as important for developing an organizational climate supportive of vaccination. Tracking and reminder systems were described as important but insufficient for ensuring vaccine uptake in the absence of other supports. CONCLUSIONS: Efforts to improve HPV initiation and completion could benefit from additional attention to factors at the health care team and clinic levels. Interventions that target factors at multiple levels of influence are most likely to achieve higher vaccination rates. Quality monitoring programs may influence clinic investment in improving vaccination rates.

Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations.

Starfield and colleagues have suggested four overarching attributes of good primary care: "first-contact access for each need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere." As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives. This need is particularly urgent for high-needs, high-cost (HNHC) populations. By definition, HNHC patients require extensive attention and consume a disproportionate share of resources, and as a result they strain traditional office-based primary care practices. In this essay, we offer a clinical vignette highlighting the challenges of caring for HNHC populations. We then describe two categories of primary care-based approaches for managing HNHC populations: complex case management, and specialized clinics focused on HNHC patients. Although complex case management programs can be incorporated into or superimposed on the traditional primary care system, such efforts often fail to engage primary care clinicians and HNHC patients, and proven benefits have been modest to date. In contrast, specialized clinics for HNHC populations are more disruptive, as care for HNHC patients must be transferred to a multidisciplinary team that can offer enhanced care coordination and other support. Such specialized clinics may produce more substantial benefits, though rigorous evaluation of these programs is needed. We conclude by suggesting policy reforms to improve care for HNHC populations.

Fostering a Commitment to Quality: Best Practices in Safety-net Hospitals.

In 2007, the Martin Luther King, Jr.-Harbor Hospital (MLK-Harbor), which served a large safety-net population in South Los Angeles, closed due to quality challenges. Shortly thereafter, an agreement was made to establish a new hospital, Martin Luther King, Jr. Community Hospital (MLKCH), to serve the unmet needs of the community. To assist the newly appointed MLKCH Board of Directors in building a culture of quality, we conducted a series of interviews with five high-performing hospital systems. In this report, we describe our findings. The hospitals we interviewed achieved a culture of quality by: 1) developing guiding principles that foster quality; 2) hiring and retaining personnel who are stewards of quality; 3) promoting efficient resource utilization; 4) developing a well-organized quality improvement infrastructure; and 5) cultivating integrated, patient-centric care. The institutions highlighted in this report provide important lessons for MLKCH and other safety-net institutions.

Comparing Unmet Needs to Optimize Quality: Characterizing Inpatient and Outpatient Palliative Care Populations.

CONTEXT: Palliative care (PC) consultation services are available in most hospitals; outpatient services are rapidly growing to meet the needs of patients at earlier stages of the disease trajectory. OBJECTIVES: We aimed to compare the unmet needs of PC patients by location of care to better characterize these populations. METHODS: This cross-sectional secondary analysis examined patients receiving hospital and outpatient-based PC across 10 community and academic organizations in the Global Palliative Care Quality Alliance. We identified unmet symptom, advance care planning, and functional needs within our database from October 23, 2012 to January 22, 2015. Kruskal-Wallis, chi-square, and Fisher exact tests were performed. RESULTS: We evaluated 633 unique patients. Inpatients (n = 216) were older than outpatients (n = 417; 73 vs. 64 years, P < 0.0001). Seventy-six inpatients (38%) had a Palliative Performance Scale score ≤30%; no outpatients did (P < 0.0001). More inpatients rated their quality of life as poor compared with outpatients (39% vs. 21%, P = 0.0001). We found that outpatients presented with more unresolved pain than inpatients (58.5% vs. 4.1%, P < 0.0001). Conversely, more inpatients presented with unresolved anorexia (52.3% vs. 35.8%, P = 0.002) and dysphagia (28.1% vs. 5.4%, P < 0.0001) than outpatients. We found that inpatient setting was independently associated with lower performance status (odds ratio = 0.068, 95% confidence interval = 0.038-0.120, P < 0.0001). CONCLUSION: Compared with inpatients, outpatients are more burdened by pain at first PC encounter yet experience higher quality of life and better performance status. These findings suggest different clinician skillsets, and assessments are needed depending on the setting of PC consultation.

Characteristics of published comparative effectiveness studies of medications.

CONTEXT: Policy makers and physician organizations have recently called for more comparative effectiveness (CE) research, yet little is known about existing CE studies. OBJECTIVE: To describe the characteristics of recently published CE studies evaluating medications. DESIGN, SETTING, AND PARTICIPANTS: Analysis of all randomized trials, observational studies, and meta-analyses involving medications published in the 6 general medicine and internal medicine journals with the highest impact factor between June 1, 2008, and September 30, 2009. MAIN OUTCOME MEASURES: The prevalence and characteristics of CE studies (those comparing existing, active treatments) and non-CE studies (those involving novel therapies or those using an inactive control). RESULTS: We identified 328 studies evaluating medications, 104 of which were CE studies. Among the CE studies, 45 (43%; 95% confidence interval [CI], 34%-53%) compared different medications, 11 (11%; 95% CI, 5%-18%) compared medications with nonpharmacologic interventions, 32 (31%; 95% CI, 22%-41%) compared different pharmacologic strategies, and 16 (15%; 95% CI, 9%-24%) compared different medication dosing schedules. Twenty (19%; 95% CI, 12%-28%) CE studies focused on safety and 2 (2%; 95% CI, 0%-7%) included cost-effectiveness analyses. Comparative effectiveness studies were less likely than non-CE studies to have been exclusively commercially funded: 13% (95% CI, 8%-22%) vs 45% (95% CI, 38%-52%), respectively (P < .001). In total, 90 (87%; 95% CI, 78%-92%) of the CE studies received noncommercial funding, including 66 that received government funding (63%; 95% CI, 53%-73%). Of 212 randomized trials, 97 (46%; 95% CI, 39%-63%) used an active comparator; the rest used an inactive control. Active-comparator trials were less likely than trials with inactive controls to report positive results: 44% (95% CI, 33%-55%) vs 66% (95% CI, 57%-75%), respectively (P = .002). CONCLUSIONS: In these high-impact general medicine journals, approximately one-third of studies evaluating medications were CE studies. Of these studies, only a minority compared pharmacologic and nonpharmacologic therapies, few focused on safety or cost, and most were funded by noncommercial funding sources.

News media coverage of medication research: reporting pharmaceutical company funding and use of generic medication names.

CONTEXT: The news media are an important source of information about medical research for patients and even some physicians. Little is known about how frequently news articles report when medication research has received funding from pharmaceutical companies or how frequently news articles use generic vs brand medication names. OBJECTIVES: To assess the reporting of pharmaceutical company funding and generic medication name use in news articles about medication studies and to determine the views of newspaper editors about these issues. DESIGN, SETTING, AND PARTICIPANTS: We reviewed US news articles from newspaper and online sources about all pharmaceutical company-funded medication studies published in the 5 most prominent general medical journals between April 1, 2004, and April 30, 2008. We also surveyed editors at the 100 most widely circulated newspapers in the United States. MAIN OUTCOME MEASURES: The percentage of news articles indicating when studies have been pharmaceutical company-funded and the percentage that refer to medications by their generic vs brand names. Also the percentage of newspaper editors who indicate that their articles report pharmaceutical company funding; the percentage of editors who indicate that their articles refer to medications by generic names; and the percentage of newspapers with policies about these issues. RESULTS: Of the 306 news articles about medication research identified,130 (42%; 95% confidence interval [CI], 37%-48%) did not report that the research had received company funding. Of the 277 of these articles reporting on medications with both generic and brand names, 186 (67%; 95% CI, 61%-73%) referred to the study medications by their brand names in at least half of the medication references. Eighty-two of the 93 (88%) newspaper editors who responded to our survey reported that articles from their publications always or often indicated when studies had received company funding (95% CI, 80%-94%), and 71 of 92 (77%) responding editors also reported that articles from their publications always or often referred to medications by the generic names (95% CI, 67%-85%). However, only 3 of 92 newspapers (3%) had written policies stating that company funding sources of medical studies be reported (95% CI 1%-9%), and 2 of 93 (2%) newspapers had written policies stating that medications should be referred to by their generic names (95% CI 1%-8%). CONCLUSION: News articles reporting on medication studies often fail to report pharmaceutical company funding and frequently refer to medications by their brand names despite newspaper editors' contention that this is not the case.

Attitudes of preclinical and clinical medical students toward interactions with the pharmaceutical industry.

PURPOSE: Medical school is a critical time for physicians in training to learn the professional norms of interacting with the pharmaceutical industry, yet little is known about how students' attitudes vary during the course of training. This study sought to determine students' opinions about pharmaceutical industry interactions with medical students and whether these opinions differ between preclinical and clinical students. METHOD: The authors surveyed medical students at Harvard Medical School (HMS) from November 2003 through January 2004 using a six-question survey. The authors then analyzed how responses differed among the classes. RESULTS: Out of 723 questionnaires, 418 were returned--an overall response rate of 58%. A total of 107 (26%) students believed that it is appropriate for medical students to accept gifts from pharmaceutical companies, and 76 (18%) agreed that the medical school curriculum should include events sponsored by the pharmaceutical industry. Many students--253 (61%)--reported that they do not feel adequately educated about pharmaceutical industry-medical professionals' interactions. Preclinical and clinical students had similar opinions for the majority of their responses. Finally, students who reported feeling better educated about pharmaceutical industry interactions tended to be less skeptical of the industry and more likely to view interactions with the industry as appropriate. CONCLUSIONS: Students' opinions about interactions with the pharmaceutical industry were similar between preclinical and clinical students, suggesting that the current medical school experience may have limited impact on students' views about interactions with the pharmaceutical industry.