Factors Influencing the Referral of Patients with Prediabetes to a Diabetes Prevention Program in the Bronx, New York.

INTRODUCTION: Disparate engagement in the Diabetes Prevention Program (DPP) may occur as early as the point of referral for certain subgroups, including Black and Hispanic men. We aimed to determine patient demographic and provider characteristics associated with referrals to a health system DPP in the Bronx, New York. METHODS: Patient and health system characteristics for DPP-eligible patients seen in primary care between July 1, 2015, and December 31, 2017, were obtained through the electronic health record. Generalized mixed-effects modeling was used to test the association between referral rate and clinical and sociodemographic variables. RESULTS: Of 26,727 eligible patients, 66% were female, 46% were Hispanic, and 39% were non-Hispanic Black. Only 10% (n = 2,785) of eligible patients were referred to DPP. In the adjusted analyses, lower odds of referral were observed for men versus women (OR = 0.60; 95% CI, 0.52-0.66), for non-Hispanic White versus Hispanic patients (OR = 0.53; 95% CI, 0.40-0.71), and for uninsured patients versus Medicaid patients (OR = 0.66; 95% CI, 0.54-0.80). The odds were higher for patients in the highest versus lowest hemoglobin A1c (OR = 2.49; 95% CI, 2.27-2.72) category; for those in the highest versus lowest body mass index categories (OR = 1.61; 95% CI, 1.45-1.79); for middle-aged patients (aged 45-64 y) versus those aged 18-26 y (OR =1.63; 95% CI, 1.33-2.00); and for patients being seen by a family versus an internal medicine physician (OR = 1.65; 95% CI, 1.22-2.22). CONCLUSION: We identified under-referral for men and highlighted other patient and health system factors associated with referral rates. Interventions to address bias in referrals and increase referrals for men at high risk for diabetes, not typically represented in DPP, are recommended.

Social Needs Assessment and Linkage to Community Health Workers in a Large Urban Hospital System.

OBJECTIVES: Identifying social needs is a growing priority in primary care, but there is significant variation in how patients access services to meet such needs. This study identifies predictors of successful linkage with a community health worker (CHW) among patients with social needs seen in an outpatient setting. METHODS: This study uses a cross-sectional analysis of social needs assessments administered in an urban health system between April 2018 and December 2019. Social needs included: food insecurity, housing quality, housing instability, healthcare cost, healthcare related transportation, utilities, care for dependents, legal assistance, safety, and getting along with household members. Patients with at least 1 social need and accepting help were included in the analysis. On contact with a CHW, patients were entered into a separate database. The primary outcome was successful "linkage," defined by having a positive social needs assessment in the medical record and a corresponding record in the CHW database. Multivariate logistic regression was used to assess predictors of linkage. RESULTS: Among patients with at least 1 social need accepting help, 25% (758/3064) were linked to a CHW. Positive predictors included female gender (OR 1.28 [95% CI 1.01-1.63]), Spanish language preference compared to English (1.51 [1.14-1.03]), and having a food related need (1.35 [1.03-1.79]). Negative predictors included age 18 to 65 (0.34 [0.17-0.71] for age 18-24) and 0 to 5 (0.45 [0.24-0.78]) compared to over 65, non-Hispanic White race compared to Hispanic race (0.39 [0.18-0.84]), and having needs of getting along with household members (0.52 [0.38-0.71]) and safety (0.64 [0.42-0.98]). CONCLUSIONS: Twenty-five percent of patients who had at least 1 social need and were accepting help had a successful CHW linkage. Predictors of linkage suggest areas of further system-level improvements to screening and referral interventions to target at risk patients and communities.

Impact of state scope-of-practice laws on nurse practitioner-provided home visits.

Millions of older Americans receive nurse practitioner (NP)-provided home based primary care (HBPC). Little is known about how state scope-of- practice (SOP) laws may impact use of NP-home visits. Using 2017 Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File (PUF), we examined the impact of state SOP laws on the use of NP-home visits. The PUF file was merged with the 2017 American Community Survey to assess area-level median income. Over 4.4 million home visits were provided to 1.6 million Medicare beneficiaries. NPs represented the largest share of providers (47.5%). In states with restricted SOP laws, compared to NPs, physicians and physician assistants had higher odds of providing HBPC. In states with reduced SOP laws, compared to NPs, physicians and PAs had decreased odds of providing HBPC. Our study provides evidence that SOP restrictions are associated with decreased utilization of NP-provided HBPC.

The association of race and COVID-19 mortality.

BACKGROUND: COVID-19 mortality disproportionately affects the Black population in the United States (US). To explore this association a cohort study was undertaken. METHODS: We assembled a cohort of 505,992 patients receiving ambulatory care at Bronx Montefiore Health System (BMHS) between 1/1/18 and 1/1/20 to evaluate the relative risk of hospitalization and death in two time-periods, the pre-COVID time-period (1/1/20-2/15/20) and COVID time-period (3/1/20-4/15/20). COVID testing, hospitalization and mortality were determined with the Black and Hispanic patient population compared separately to the White population using logistic modeling. Evaluation of the interaction of pre-COVID and COVID time periods and race, with respect to mortality was completed. FINDINGS: A total of 9,286/505,992 (1.8%) patients were hospitalized during either or both pre-COVID or COVID periods. Compared to Whites the relative risk of hospitalization of Black patients did not increase in the COVID period (p for interaction=0.12). In the pre- COVID period, compared to Whites, the odds of death for Blacks and Hispanics adjusted for comorbidity was statistically equivalent. In the COVID period compared to Whites the adjusted odds of death for Blacks was 1.6 (95% CI 1.2-2.0, p = 0.001). There was a significant increase in Black mortality risk from pre-COVID to COVID periods (p for interaction=0.02). Adjustment for relevant clinical and social indices attenuated but did not fully explain the observed difference in Black mortality. INTERPRETATION: The BMHS COVID experience demonstrates that Blacks do have a higher mortality with COVID incompletely explained by age, multiple reported comorbidities and available metrics of sociodemographic disparity. FUNDING: N/A.