One-Stop-Shop Cancer Screening Clinic: Acceptability Testing.

Cancer screenings aid in the early detection of cancer and can help reduce cancer-related mortality. The current model of care for cancer screening is often siloed, based on the targeted cancer site. We tested the acceptability of a new model of care, called the One-Stop-Shop Cancer Screening Clinic, that centralizes cancer screenings and offers patients the option to complete all their recommended cancer screenings within one to two visits. We administered surveys to 59 community members and 26 healthcare providers to gather feedback about the One-Stop-Shop model of care. Both community members and providers identified potential benefits (e.g., decreased patient burden, increased completion of cancer screenings) and also potential challenges (e.g., challenges with workflow and timing of care) of the model of care. The results of the study support the acceptability of the model of care. Of the community members surveyed, 89.5% said, if offered, they would be interested in participating in the One-Stop-Shop Cancer Screening Clinic. Future studies are needed to formally evaluate the impact and cost effectiveness of the One-Stop-Shop Cancer Screening Clinic.

Recent Telehealth Utilization at a Large Federally Qualified Health Center System: Evidence of Disparities Even Within Telehealth Modalities.

Objective: To explore overall trends as well as racial/ethnic disparities in utilization of different telehealth modalities (telephone vs. televideo) at federally qualified health centers (FQHCs) during the COVID-19 pandemic. Methods: Using electronic health record data from a large New York-based FQHC system, we aggregated (separately) Behavioral Health and Family Practice visits per month occurring in-person, by telephone, or by televideo and graphed monthly trends in visits across the pre-pandemic, peak-pandemic, and post-peak-pandemic periods. We calculated fractions of visits conducted by modality for each patient demographic (race/ethnicity, primary language, age, gender, insurance type, and geography) and conducted bivariate assessments to test relationships between patient characteristics and modality. Results: Our data contained 121,072 unique patients and 811,105 visits overall. Telehealth use peaked in April 2020 but continued to account for a significant fraction of FQHC visits-nearly 25% (N = 4,908) of monthly Family Practice visits and a massive 98% (N = 14,173) of Behavioral Health visits as late as June 2021. Of all telehealth visits, nearly half were by telephone. Moreover, demographic factors differed between FQHC patients using telephone visits versus those using televideo: Black, non-English speaking, older, and Medicaid patients had significantly higher utilization of telephone visits than televideo visits (e.g., 25.9% of all Black patients' visits were via telephone vs. 17.1% via televideo; p < 0.001). In contrast, younger, Asian, and privately insured patients had significantly higher televideo visits. Conclusions: Our results suggest that telephone visits remain critical to the provision of health care for FQHC patients. They also suggest that disparities extend beyond the telehealth versus in-person dichotomy and inequities exist even within the type of telehealth used. This has implications for patient health, FQHC quality outcomes, as well as optimal Medicaid telehealth reimbursement policy.

Pediatric Blood Lead Levels Within New York City Public Versus Private Housing, 2003-2017.

Objectives. To compare blood lead levels (BLLs) among children residing in public and private housing in New York City and examine the implications for lead identification and remediation policies. Methods. We examined electronic medical records for BLLs among 4693 children receiving care at a multisite Federally Qualified Health Center during 2003 to 2017. We plotted home addresses against city housing data to assess BLL differences between children living in public housing and private housing. Results. Only 0.25% of children residing in public housing had BLLs exceeding the upper reference limit of 5 micrograms per deciliter, as compared with 2.76% of children residing in private housing. After adjustment for age, gender, and race/ethnicity, public housing was associated with 92% lower odds of having a BLL of 5 micrograms per deciliter or above (odds ratio [OR] = 0.08; 95% confidence interval [CI] = 0.02, 0.33; P = .001). Decreases in BLLs were observed in both public and private housing over time. Conclusions. Children living in public housing in New York City were significantly less likely to have elevated BLLs than were children living in private housing. Decreases in BLLs over time were likely a result of lead reduction legislation.

A Framework for Addressing Diabetes-Related Disparities in US Latino Populations.

Despite national efforts to redress racial/ethnic disparities, Latino Americans continue to share a disproportionate burden of diabetes-related morbidity and mortality. A better understanding of underlying causes and influencing factors is needed to guide future efforts to eliminate racial/ethnic disparities in diabetes control. The objectives of this review are: (1) to summarize our understanding of determinants and modifiable predictors of glycemic control; (2) to provide an overview of existing strategies to reduce diabetes-related disparities; and (3) to identify gaps in the literature regarding whether these interventions effectively address disparities in US Latino populations. Key findings include evidence that diabetes care services can be designed to accommodate heterogeneity within the Latino American community by addressing key modifiable predictors of poor glycemic control, including insurance status, diabetes care utilization, patient self-management, language access, culturally appropriate care, and social support services. Future research efforts should evaluate the effect of structurally tailored interventions that address these key modifiable predictors by targeting patients, providers, and health care delivery systems.

Effect of an electronic alert on treatment of skin and soft tissue infections.

This is a prospective intervention study conducted between 2007 and 2011 to evaluate whether an electronic alert can influence provider practice in treatment of skin and soft tissue infections (SSTIs). A best-practice alert (BPA) was programmed to appear for intervention ICD-9 SSTI diagnoses. Controls were patients who had other SSTI ICD-9 codes where the BPA was not programmed to fire. Rate of culture taken in patients was compared between patients in the intervention and control groups. We found that cultures were taken among 13.5% of the intervention group and 5.4% of the control group (p <.0001). A logistic regression analysis controlling for covariates showed the odds of the intervention group having a culture taken was 2.6 times that of the control group. The results of this study support the use of BPAs for improving the management of SSTIs.

Becoming a patient-centered medical home: a 9-year transition for a network of Federally Qualified Health Centers.

PURPOSE: The patient-centered medical home (PCMH) model has great potential for optimizing the care of chronically ill patients, yet there is much to be learned about various implementations of this model and their impact on patient care processes and outcomes. METHODS: We examined changes in patterns of health care use in a network of Federally Qualified Health Centers throughout a 9-year period of practice transformation that included recognition of all centers by the National Committee for Quality Assurance (NCQA) as Level 3 PCMH practices. We analyzed deidentified data from electronic health records for the period 2003 to 2011 to identify patterns of service use for all 4,595 patients with diabetes. We also examined a subsample of 545 patients who were in care throughout the study period to track improvement in glycated hemoglobin levels as a clinical measure over time. RESULTS: Through the transition to a PCMH, the mean number of encounters with outreach, diabetes educators, and psychosocial services increased for all diabetic patients; virtually all patients had visits with a primary care clinician, but the mean number of visits decreased slightly. Among patients in the subsample, mean annual levels of glycated hemoglobin decreased steadily during the 9-year study period, mainly driven by a reduction in patients having baseline levels exceeding 9%. CONCLUSIONS: This retrospective study conducted in a real-world setting using electronic health record data demonstrates a shift in resource use by diabetic patients from the primary care clinician to other members of the care team. The findings suggest that PCMH implementation has the potential to alter processes of care and improve outcomes of care, especially among those with higher disease burden.

Evaluation of a pilot respiratory virus surveillance system linking electronic health record and diagnostic data.

CONTEXT: During the onset of 2009 pandemic influenza A (H1N1) (pH1N1), the New York City Department of Health and Mental Hygiene implemented a pilot respiratory virus surveillance system. OBJECTIVES: We evaluated the performance of this pilot system, which linked electronic health record (EHR) clinical, epidemiologic, and diagnostic data to monitor influenza-like illness (ILI) in the community. DESIGN: Surveillance was conducted at 9 community health centers with EHRs. Clinical decision support system alerts encouraged diagnostic testing of patients. Rapid influenza diagnostic testing (RIDT) and multiplex polymerase chain reaction assay (MassTag PCR) were performed sequentially. SETTING: Nine Institute for Family Health (IFH) clinics in Manhattan and the Bronx during May 26 to June 30, 2009, the pH1N1 outbreak peak. PARTICIPANTS: Adult and pediatric patients presenting to IFH clinics during May 26 to June 30, 2009. MAIN OUTCOME MEASURES: By using Centers for Disease Control and Prevention guidelines, we evaluated the system's completeness, sensitivity, timeliness, and epidemiologic usefulness. RESULTS: Of 537 ILI visits (5.7% of all visits), 17% underwent diagnostic testing. Of the 132 specimens with both a RIDT and MassTag PCR result, 90 (68%) had a MassTag PCR-identified respiratory virus, most commonly pH1N1 (n = 69; 77%). Of the 81 specimens that met the ILI case definition, 58 (72%) were positive for a respiratory virus tested for by MassTag PCR; 48 (59%) were positive for pH1N1. Ninety-four percent of ILI patients positive for pH1N1 were 45 years or younger. Sensitivity and specificity of RIDT (29% and 94%) and ILI case definition (70% and 48%) for pH1N1 were calculated using MassTag PCR as the standard. Results of RIDT took a median of 6 days. CONCLUSIONS: Despite low RIDT sensitivity for pH1N1 and limited timeliness, integration of EHR and diagnostic data has potential to provide valuable epidemiologic information, guide public health response, and represents a new model for community surveillance for influenza and respiratory viruses.

Strengthening public health and primary care collaboration through electronic health records.

Electronic health records (EHRs) have great potential to serve as a catalyst for more effective coordination between public health departments and primary care providers (PCP) in maintaining healthy communities. As a system for documenting patient health data, EHRs can be harnessed to improve public health surveillance for communicable and chronic illnesses. EHRs facilitate clinical alerts informed by public health goals that guide primary care physicians in real time in their diagnosis and treatment of patients. As health departments reassess their public health agendas, the use of EHRs to facilitate this agenda in primary care settings should be considered. PCPs and EHR vendors, in turn, will need to configure their EHR systems and practice workflows to align with public health priorities as these agendas include increased involvement of primary care providers in addressing public health concerns.

Impact of integrating public health clinical decision support alerts into electronic health records on testing for gastrointestinal illness.

Laboratory testing by clinicians is essential to outbreak investigations. Electronic health records may increase testing through clinical decision support that alerts providers about existing outbreaks and facilitates laboratory ordering. The impact on laboratory testing was evaluated for foodborne disease outbreaks between 2006 and 2009. After controlling for standard public health messaging and season, decision support resulted in a significant increase in laboratory testing and may be useful in enhancing public health messaging and provider action.

Effects of Testing and Disclosing Ancestry-Specific Genetic Risk for Kidney Failure on Patients and Health Care Professionals: A Randomized Clinical Trial.

IMPORTANCE: Risk variants in the apolipoprotein L1 (APOL1 [OMIM 603743]) gene on chromosome 22 are common in individuals of West African ancestry and confer increased risk of kidney failure for people with African ancestry and hypertension. Whether disclosing APOL1 genetic testing results to patients of African ancestry and their clinicians affects blood pressure, kidney disease screening, or patient behaviors is unknown. OBJECTIVE: To determine the effects of testing and disclosing APOL1 genetic results to patients of African ancestry with hypertension and their clinicians. DESIGN, SETTING, AND PARTICIPANTS: This pragmatic randomized clinical trial randomly assigned 2050 adults of African ancestry with hypertension and without existing chronic kidney disease in 2 US health care systems from November 1, 2014, through November 28, 2016; the final date of follow-up was January 16, 2018. Patients were randomly assigned to undergo immediate (intervention) or delayed (waiting list control group) APOL1 testing in a 7:1 ratio. Statistical analysis was performed from May 1, 2018, to July 31, 2020. INTERVENTIONS: Patients randomly assigned to the intervention group received APOL1 genetic testing results from trained staff; their clinicians received results through clinical decision support in electronic health records. Waiting list control patients received the results after their 12-month follow-up visit. MAIN OUTCOMES AND MEASURES: Coprimary outcomes were the change in 3-month systolic blood pressure and 12-month urine kidney disease screening comparing intervention patients with high-risk APOL1 genotypes and those with low-risk APOL1 genotypes. Secondary outcomes compared these outcomes between intervention group patients with high-risk APOL1 genotypes and controls. Exploratory analyses included psychobehavioral factors. RESULTS: Among 2050 randomly assigned patients (1360 women [66%]; mean [SD] age, 53 [10] years), the baseline mean (SD) systolic blood pressure was significantly higher in patients with high-risk APOL1 genotypes vs those with low-risk APOL1 genotypes and controls (137 [21] vs 134 [19] vs 133 [19] mm Hg; P = .003 for high-risk vs low-risk APOL1 genotypes; P = .001 for high-risk APOL1 genotypes vs controls). At 3 months, the mean (SD) change in systolic blood pressure was significantly greater in patients with high-risk APOL1 genotypes vs those with low-risk APOL1 genotypes (6 [18] vs 3 [18] mm Hg; P = .004) and controls (6 [18] vs 3 [19] mm Hg; P = .01). At 12 months, there was a 12% increase in urine kidney disease testing among patients with high-risk APOL1 genotypes (from 39 of 234 [17%] to 68 of 234 [29%]) vs a 6% increase among those with low-risk APOL1 genotypes (from 278 of 1561 [18%] to 377 of 1561 [24%]; P = .10) and a 7% increase among controls (from 33 of 255 [13%] to 50 of 255 [20%]; P = .01). In response to testing, patients with high-risk APOL1 genotypes reported more changes in lifestyle (a subjective measure that included better dietary and exercise habits; 129 of 218 [59%] vs 547 of 1468 [37%]; P < .001) and increased blood pressure medication use (21 of 218 [10%] vs 68 of 1468 [5%]; P = .005) vs those with low-risk APOL1 genotypes; 1631 of 1686 (97%) declared they would get tested again. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, disclosing APOL1 genetic testing results to patients of African ancestry with hypertension and their clinicians was associated with a greater reduction in systolic blood pressure, increased kidney disease screening, and positive self-reported behavior changes in those with high-risk genotypes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02234063.

Design and rationale of GUARDD-US: A pragmatic, randomized trial of genetic testing for APOL1 and pharmacogenomic predictors of antihypertensive efficacy in patients with hypertension.

RATIONALE AND OBJECTIVE: APOL1 risk alleles are associated with increased cardiovascular and chronic kidney disease (CKD) risk. It is unknown whether knowledge of APOL1 risk status motivates patients and providers to attain recommended blood pressure (BP) targets to reduce cardiovascular disease. STUDY DESIGN: Multicenter, pragmatic, randomized controlled clinical trial. SETTING AND PARTICIPANTS: 6650 individuals with African ancestry and hypertension from 13 health systems. INTERVENTION: APOL1 genotyping with clinical decision support (CDS) results are returned to participants and providers immediately (intervention) or at 6 months (control). A subset of participants are re-randomized to pharmacogenomic testing for relevant antihypertensive medications (pharmacogenomic sub-study). CDS alerts encourage appropriate CKD screening and antihypertensive agent use. OUTCOMES: Blood pressure and surveys are assessed at baseline, 3 and 6 months. The primary outcome is change in systolic BP from enrollment to 3 months in individuals with two APOL1 risk alleles. Secondary outcomes include new diagnoses of CKD, systolic blood pressure at 6 months, diastolic BP, and survey results. The pharmacogenomic sub-study will evaluate the relationship of pharmacogenomic genotype and change in systolic BP between baseline and 3 months. RESULTS: To date, the trial has enrolled 3423 participants. CONCLUSIONS: The effect of patient and provider knowledge of APOL1 genotype on systolic blood pressure has not been well-studied. GUARDD-US addresses whether blood pressure improves when patients and providers have this information. GUARDD-US provides a CDS framework for primary care and specialty clinics to incorporate APOL1 genetic risk and pharmacogenomic prescribing in the electronic health record. TRIAL REGISTRATION: ClinicalTrials.govNCT04191824.

Syndromic surveillance during pandemic (H1N1) 2009 outbreak, New York, New York, USA.

We compared emergency department and ambulatory care syndromic surveillance systems during the pandemic (H1N1) 2009 outbreak in New York City. Emergency departments likely experienced increases in influenza-like-illness significantly earlier than ambulatory care facilities because more patients sought care at emergency departments, differences in case definitions existed, or a combination thereof.

Use of an electronic patient portal among disadvantaged populations.

BACKGROUND: Electronic patient portals give patients access to information from their electronic health record and the ability to message their providers. These tools are becoming more widely used and are expected to promote patient engagement with health care. OBJECTIVE: To quantify portal usage and explore potential differences in adoption and use according to patients' socioeconomic and clinical characteristics in a network of federally qualified health centers serving New York City and neighboring counties. DESIGN: Retrospective analysis of data from portal and electronic health records. PARTICIPANTS: 74,368 adult patients seen between April 2008 and April 2010. MAIN MEASURES: Odds of receiving an access code to the portal, activating the account, and using the portal more than once KEY RESULTS: Over the 2 years of the study, 16% of patients (n = 11,903) received an access code. Of these, 60% (n = 7138) activated the account, and 49% (n = 5791) used the account two or more times. Patients with chronic conditions were more likely to receive an access code and to become repeat users. In addition, the odds of receiving an access code were significantly higher for whites, women, younger patients, English speakers, and the insured. The odds of repeat portal use, among those with activated accounts, increased with white race, English language, and private insurance or Medicaid compared to no insurance. Racial disparities were small but persisted in models that controlled for language, insurance, and health status. CONCLUSIONS: We found good early rates of adoption and use of an electronic patient portal during the first 2 years of its deployment among a predominantly low-income population, especially among patients with chronic diseases. Disparities in access to and usage of the portal were evident but were smaller than those reported recently in other populations. Continued efforts will be needed to ensure that portals are usable for and used by disadvantaged groups so that all patients benefit equally from these technologies.

Got low-fat milk? How a community-based coalition changed school milk policy in New York City.

In 2006, New York City, the largest school district in the country, eliminated whole milk and reduced the availability of sweetened milk in 1,579 schools. Despite pressure from the American Dairy Council, skepticism from school food administrators and elected officials, and the difficulties inherent in changing a system that serves 120,000,000 containers of milk per year, a community-led coalition prevailed. This article describes how parents, educational leaders, advocates, and health professionals collaborated to educate school children and their families to choose low-fat milk, and created change at a system, policy, and environmental level to promote health in the community.

Syndromic surveillance using ambulatory electronic health records.

OBJECTIVE: To assess the performance of electronic health record data for syndromic surveillance and to assess the feasibility of broadly distributed surveillance. DESIGN: Two systems were developed to identify influenza-like illness and gastrointestinal infectious disease in ambulatory electronic health record data from a network of community health centers. The first system used queries on structured data and was designed for this specific electronic health record. The second used natural language processing of narrative data, but its queries were developed independently from this health record. Both were compared to influenza isolates and to a verified emergency department chief complaint surveillance system. MEASUREMENTS: Lagged cross-correlation and graphs of the three time series. RESULTS: For influenza-like illness, both the structured and narrative data correlated well with the influenza isolates and with the emergency department data, achieving cross-correlations of 0.89 (structured) and 0.84 (narrative) for isolates and 0.93 and 0.89 for emergency department data, and having similar peaks during influenza season. For gastrointestinal infectious disease, the structured data correlated fairly well with the emergency department data (0.81) with a similar peak, but the narrative data correlated less well (0.47). CONCLUSIONS: It is feasible to use electronic health records for syndromic surveillance. The structured data performed best but required knowledge engineering to match the health record data to the queries. The narrative data illustrated the potential performance of a broadly disseminated system and achieved mixed results.

Using Enhanced Primary Care Services in High-risk Latino Populations to Reduce Disparities in Glycemic Control.

OBJECTIVE: To determine whether enhanced primary care services delivered preferentially to high-risk patients with diabetes (HbA1c >9%) can effectively reduce racial/ethnic disparities in glycemic control. METHODS: This retrospective study analyzed electronic health records to examine changes in pre-vs. post-intervention disparities in HbA1c among Hispanics/Latinos relative to non-Hispanic Whites. RESULTS: Mean HbA1c and prevalence of poorly controlled diabetes improved in both racial/ethnic groups, but to a greater extent among Hispanics/Latinos. Mean HbA1c dropped 0.43 points further among Hispanics/Latinos than non-Hispanic Whites (95% CI, - 0.57 to - 0.29, p<.001). The change in disparity in prevalence of poorly controlled diabetes, measured as the ratio of post-vs. pre-intervention prevalence ratios, was 0.89 (95% CI, 0.84 to 0.94, p<.001). Both measures indicated greater reduction among Hispanics/Latinos relative to non-Hispanic Whites. DISCUSSION: Enhanced primary care services directed at high-risk patients may improve glycemic control and reduce racial/ethnic disparities in diabetes-related outcomes in medically underserved communities.

A risk-based intervention approach to eliminate diabetes health disparities.

Type 2 diabetes plays a major role in racial/ethnic health disparities. We conducted the first study to examine whether multifaceted interventions targeting patients with poorly controlled diabetes (HgbA1c >9%) can reduce racial/ethnic disparities in diabetes control. Among 4595 patients with diabetes at a Federally Qualified Health Center in New York, a higher percentage of blacks (32%) and Hispanics/Latinos (32%) had poorly controlled diabetes than whites (25%) at baseline (prevalence ratio, 1.28; 95% CI, 1.14-1.43; P<0.001). After four years, this percentage was reduced in all groups (blacks, 21%; Hispanics/Latinos, 20%; whites, 20%; P<0.001 for each relative to baseline). Disparities in diabetes control also were significantly reduced (change in disparity relative to whites: blacks, P=0.03; Hispanics/Latinos, P=0.008). In this diverse population, interventions targeting patients with poorly controlled diabetes not only improved diabetes control in all racial/ethnic groups, but significantly reduced disparities. This approach warrants further testing and may help reduce disparities in other populations.

Implementation of Care Management: An Analysis of Recent AHRQ Research.

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

The role of faith-based institutions in addressing health disparities: a case study of an initiative in the southwest Bronx.

Although many public health initiatives have been implemented through collaborations with faith-based institutions, little is known about best practices for developing such programs. Using a community-based participatory approach, this case study examines the implementation of an initiative in the Bronx, New York, that is designed to educate community members about health promotion and disease management and to mobilize church members to seek equal access to health care services. The study used qualitative methods, including the collaborative development of a logic model for the initiative, focus groups, interviews, analysis of program reports, and participant observation. The paper examines three key aspects of the initiative's implementation: (1) the engagement of the church leadership; (2) the use of church structures as venues for education and intervention; and (3) changes in church policies. Key findings include the importance of pre-existing relationships within the community and the prominent agenda-setting role played by key pastors, and the strength of the Coalition's dual focus on health behaviors and health disparities. Given the churches' demonstrated ability to pull people together, to motivate and to inspire, there is great potential for faith-based interventions, and models developed through such interventions, to address health disparities.