Participant Perspectives on the Effects of an African American Faith-Based Health Promotion Educational Intervention: a Qualitative Study.

BACKGROUND: In the USA, African Americans (AAs) experience a greater burden of mortality and morbidity from chronic health conditions including obesity, diabetes, and heart disease. Faith-based programs are a culturally sensitive approach that potentially can address the burden of chronic health conditions in the AA community. OBJECTIVE: The primary objective was to assess (i) the perceptions of participants of Live Well by Faith (LWBF)-a government supported faith-based program to promote healthy living across several AA churches-on the effectiveness of the program in promoting overall wellness among AAs. A secondary objective was to explore the role of the church as an intervention unit for health promotion among AAs. METHODS: Guided by the socio-ecological model, data were collected through 21 in-depth interviews (71% women) with six AA church leaders, 10 LWBF lifestyle coaches, and five LWBF program participants. Interviews were audio-recorded, transcribed verbatim, and analyzed by three of the researchers. FINDINGS: Several themes emerged suggesting there was an effect of the program at multiple levels: the intrapersonal, interpersonal, organizational, and community levels. Most participants reported increased awareness about chronic health conditions, better social supports to facilitate behavior change, and creation of health networks within the community. CONCLUSION: Our study suggests that one approach to address multilevel factors in a culturally sensitive manner could include developing government-community partnership to co-create interventions.

The Impact of Meaningful Use and Electronic Health Records on Hospital Patient Safety.

The HITECH Act aimed to leverage Electronic Health Records (EHRs) to improve efficiency, quality, and patient safety. Patient safety and EHR use have been understudied, making it difficult to determine if EHRs improve patient safety. The objective of this study was to determine the impact of EHRs and attesting to Meaningful Use (MU) on Patient Safety Indicators (PSIs). A multivariate regression analysis was performed using a generalized linear model method to examine the impact of EHR use on PSIs. Fully implemented EHRs not attesting to MU had a positive impact on three PSIs, and hospitals that attested to MU had a positive impact on two. Attesting to MU or having a fully implemented EHR were not drivers of PSI-90 composite score, suggesting that hospitals may not see significant differences in patient safety with the use of EHR systems as hospitals move towards pay-for-performance models. Policy and practice may want to focus on defining metrics and PSIs that are highly preventable to avoid penalizing hospitals through reimbursement, and work toward adopting advanced analytics to better leverage EHR data. These findings will assist hospital leaders to find strategies to better leverage EHRs, rather than relying on achieving benchmarks of MU objectives.

Impact of Florida's prescription drug monitoring program on drug- related fatal vehicle crashes: a difference-in-differences approach.

BACKGROUND: Prescription drug use has soared in the USA within the last two decades. Prescription drugs can impair motor skills essential for the safe operation of a motor vehicle, and therefore can affect traffic safety. As one of the epicentres of the opioid epidemic, Florida has been struck by high opioid misuse and overdose rates, and has concurrently suffered major threats to traffic disruptions safety caused by driving under the influence of drugs. To prevent prescription opioid misuse in Florida, Prescription Drug Monitoring Programs (PDMPs) were implemented in September 2011. OBJECTIVE: To examine the impact of Florida's implementation of a mandatory PDMP on drug-related MVCs occurring on public roads. METHODS: We employed a difference-in-differences approach to estimate the difference in prescription drug-related fatal crashes in Florida associated with its 2011 PDMP implementation relative to those in Georgia, which did not use PDMPs during the same period (2009-2013). The analyses were conducted in 2020. RESULTS: In Florida, there was a significant decline in drug-related vehicle crashes during the 22 months post-PDMP. PDMP implementation was associated with approximately two (-2.21; 95% CI -4.04 to -0.37; p<0.05) fewer prescribed opioid-related fatal crashes every month, indicating 25% reduction in the number of monthly crashes. We conducted sensitivity analyses to investigate the impact of PDMP implementation on central nervous system depressants and stimulants as well as cocaine and marijuana-related fatal crashes but found no robust significant reductions. CONCLUSIONS: The implementation of PDMPs in Florida provided important benefits for traffic safety, reducing the rates of prescription opioid-related vehicle crashes.

The Impact of Electronic Health Records and Meaningful Use on Inpatient Quality.

ABSTRACT: It is unclear if national investments of the HITECH Act have resulted in significant improvements in care processes and outcomes by making "Meaningful Use (MU)" of Electronic Health Record (EHR) systems. The objective of this study is to determine the impact of EHRs and MU on inpatient quality. We used inpatient hospitalization data, American Hospital Association annual survey, and the Centers for Medicare and Medicaid Services attestation records to study the impact of EHRs on inpatient quality composite scores. Agency for Healthcare Research and Quality Inpatient Quality Indicator (IQI) software version 5.0 was used to compute the hospital-level risk-adjusted standardized rates for IQI indicators and composite scores. After adjusting for confounding factors, EHRs that attested to MU had a positive impact on IQI 90 and IQI 91 composite scores with an 8% decrease in composites for mortality for selected procedures and 18% decrease in composites for mortality for selected conditions. Meaningful Use attestation may be an important driver related to inpatient quality. Health care leaders may need to focus on quality improvement initiatives and advanced analytics to better leverage their EHRs to improve IQI 90 composite score for mortality for selected procedures, because we observed a lesser impact on IQI 90 compared with IQI 91.

The Link Between Medicaid Expansion and School Absenteeism: Evidence From the Southern United States.

BACKGROUND: Parental Medicaid eligibility has been shown to be linked to positive academic and school outcomes for children. However, the impact of adult Medicaid expansion on children's school absenteeism is largely unexplored in the literature. The aim of this study was to examine whether Medicaid expansion for adults under the Affordable Care Act (ACA), affected school absenteeism of children. METHODS: This study used data from the National Survey of Children's Health 2016 to 2017 and the difference-in-differences method. RESULTS: The decrease in the predicted probability of missing 11 or more school days in Louisiana, after Medicaid expansion, among school-going children from low-income families, was greater by 18 percentage points (p = .007), as compared to the decrease in the predicted probability of missing 11 or more school days in the neighboring nonexpansion states of Texas and Mississippi. CONCLUSION: The positive impacts of Medicaid expansion are not limited to adults, but also extend to children's school absenteeism.

Association of Post-discharge Service Types and Timing with 30-Day Readmissions, Length of Stay, and Costs.

BACKGROUND: Although early follow-up after discharge from an index admission (IA) has been postulated to reduce 30-day readmission, some researchers have questioned its efficacy, which may depend upon the likelihood of readmission at a given time and the health conditions contributing to readmissions. OBJECTIVE: To investigate the relationship between post-discharge services utilization of different types and at different timepoints and unplanned 30-day readmission, length of stay (LOS), and inpatient costs. DESIGN, SETTING, AND PARTICIPANTS: The study sample included 583,199 all-cause IAs among 2014 Medicare fee-for-service beneficiaries that met IA inclusion criteria. MAIN MEASURES: The outcomes were probability of 30-day readmission, average readmission LOS per IA discharge, and average readmission inpatient cost per IA discharge. The primary independent variables were 7 post-discharge health services (institutional outpatient, primary care physician, specialist, non-physician provider, emergency department (ED), home health care, skilled nursing facility) utilized within 7 days, 14 days, and 30 days of IA discharge. To examine the association with post-discharge services utilization, we employed multivariable logistic regressions for 30-day readmissions and two-part models for LOS and inpatient costs. KEY RESULTS: Among all IA discharges, the probability of unplanned 30-day readmission was 0.1176, the average readmission LOS per discharge was 0.67 days, and the average inpatient cost per discharge was $5648. Institutional outpatient, home health care, and primary care physician visits at all timepoints were associated with decreased readmission and resource utilization. Conversely, 7-day and 14-day specialist visits were positively associated with all three outcomes, while 30-day visits were negatively associated. ED visits were strongly associated with increases in all three outcomes at all timepoints. CONCLUSION: Post-discharge services of different types and at different timepoints have varying impacts on 30-day readmission, LOS, and costs. These impacts should be considered when coordinating post-discharge follow-up, and their drivers should be further explored to reduce readmission throughout the health care system.

The Impact of Medicaid Expansion for Adults Under the Affordable Care Act on Preventive Care for Children: Evidence From the Southern United States.

INTRODUCTION: The Affordable Care Act of 2010 expanded Medicaid to low-income adults at or below 138% of the Federal Poverty Level (FPL). The aim of this study was to examine if expanding Medicaid to adults had an impact on preventive health care utilization of children from low-income families (focusing on families with annual incomes 0%-99% and 100%-199% of the FPL). METHODS: This study used data from the 2016 and 2017 National Survey of Children's Health and a quasi-experimental difference-in-differences method. The dependent variable was the number of preventive care visits in the past year and the primary independent variable was the Medicaid expansion status of the state. Louisiana expanded Medicaid in 2016 (treatment group) and neighboring nonexpansion states of Texas and Mississippi constituted the control group. Differences in dependent variable were calculated between survey years 2016 and 2017. RESULTS: In Louisiana, the change in the predicted probability of at least 1 preventive care visit among children of ages 0-17 years, from 0% to 99% FPL families, was higher by 26 percentage points after Medicaid was expanded (2017 vs. 2016), as compared with the change in the predicted probability (2017 vs. 2016) of at least 1 preventive care visit among children of ages 0-17 years, from 0% to 99% FPL families in the nonexpansion states, Texas and Mississippi. CONCLUSIONS: Children in poverty residing in a Medicaid expansion state, Louisiana, had increased likelihood of having an annual preventive care visit after expansion of Medicaid eligibility under the Affordable Care Act, as compared with children in nonexpansion states. Thus, this study showed that the implications of the public health insurance expansion for adults were not limited to adult health outcomes, but extended to children's health care utilization.

Differences in regional distribution and inequality in health-resource allocation at hospital and primary health centre levels: a longitudinal study in Shanghai, China.

OBJECTIVES: To analyse differences in regional distribution and inequality in health-resource allocation at the hospital and primary health centre (PHC) levels in Shanghai over 7 years. DESIGN: A longitudinal survey using 2010-2016 data, which were collected for analysis. SETTING: The study was conducted at the hospital and PHC levels in Shanghai, China. OUTCOME MEASURES: Ten health-resource indicators were used to measure health-resource distribution at the hospital and PHC levels. In addition, the Theil Index was calculated to measure inequality in health-resource allocation. RESULTS: All quantities of healthcare resources per 1000 people in hospitals and PHCs increased across Shanghai districts from 2010 to 2016. Relative to suburban districts, the central districts had higher ratios, both in terms of doctors and equipment, and had faster growth in the doctor indicator and slower growth in the equipment indicator in hospitals and PHCs. The Theil Indices of all health-resource allocation in hospitals had higher values compared with those in PHCs every year from 2010 to 2016; furthermore, the Theil Indices of the indicators, except for technicians and doctors in hospitals, all exhibited downward time trends in hospitals and PHCs. CONCLUSIONS: Increased healthcare resources and reduced inequality of health-resource allocation in Shanghai during the 7 years indicated that measures taken by the Shanghai government to deepen the new round of healthcare reform in China since 2009 had been successful. Meanwhile there still existed regional difference between urban and rural areas and inequality across different medical institutions. To solve these problems, we prescribe increased wages, improved working conditions, and more open access to career development for doctors and nurses; reduced investments in redundant equipment in hospitals; and other incentives for balancing the health workforce between hospitals and PHCs.

Relative Costs of Surgical and Transcatheter Aortic Valve Replacement and Medical Therapy.

BACKGROUND: The number of patients treated for aortic valve disease in the United States is increasing rapidly. Transcatheter aortic valve replacement (TAVR) is supplanting surgical aortic valve replacement (SAVR) and medical therapy (MT). The economic implications of these trends are unknown. Therefore, we undertook to determine the costs, inpatient days, and number of admissions associated with treating aortic valve disease with SAVR, TAVR, or MT. METHODS: Using the Nationwide Readmissions Database, we identified patients with aortic valve disease admitted 2012 to 2016 for SAVR, TAVR, and disease symptoms (congestive heart failure, unstable angina, non-ST-elevation myocardial infarction, syncope). Patients not undergoing SAVR or TAVR were classified as receiving MT. Beginning with the index admission, we estimated inpatient costs, days, and admissions over 6 months. RESULTS: Among 190 563 patients with aortic valve disease, the average aggregate 6-month inpatient costs were $59 743 for SAVR, $64 395 for TAVR, and $23 460 for MT. Mean index admission was longer for SAVR (10.0 days) than for TAVR (7.0 day) or MT (5.3 days), but the average number of unplanned readmission inpatient days was 2.0 for SAVR, 3.0 for TAVR, and 4.3 for MT; the average number of total admissions was 1.3 for SAVR, 1.5 for TAVR, and 1.7 for MT (P<0.01 for all). TAVR index admission costs decreased over time to become similar to SAVR costs by 2016. CONCLUSIONS: Aggregate costs were higher for TAVR than SAVR and were significantly more expensive than MT alone. However, TAVR costs decreased over time while SAVR and MT costs remained unchanged.

Utilisation of emergency departments of behavioural disorders and supply of workforce in Nebraska.

BACKGROUND: Emergency departments (EDs) have become entry points for treating behavioural health (BH) conditions, thereby rendering the evaluation of their utilisation necessary. OBJECTIVES: This study estimated behavioural-related hospital-based ED visits and outcomes of leaving against medical advice as well as the incurred charges within the primarily rural State of Nebraska. Also, the study correlated behavioural workforce distribution and location of EDs with ED utilisation. METHODS: Nebraska State Emergency Department Database provided information on utilisation of services, charges, diagnoses and demographic. Health Professional Tracking Services survey provided the distribution of EDs and BH workforce by region. To examine the effect of patient characteristics on discharge against medical advice, multivariable logistic regression modelling was used. FINDINGS: US$96.4 million were ED charges for 52 035 visits for BH disorders over 3 years. Of these, 35% and 50% were between 25 and 44-years old and privately insured, respectively. The uninsured (OR:1.53, p=0.0047) and 45-64 years old (OR:2.31, p<0.001) had higher odds of leaving against medical advice. The findings from this study identified ED outcomes among high-risk cohort. CONCLUSIONS: There were high ED rates among the limited number EDs facilities in rural Nebraska. Rural regions of Nebraska faced workforce shortages and had high numbers of ED visits at relatively few accessible EDs. CLINICAL IMPLICATIONS: Customised rural-centric public health programmes, which are based in clinical settings, can encourage patients to adhere to ED-treatment. Also, increasing the availability of BH workforce (either via telehealth or part-time presence) in rural areas can alleviate the problem and reduce ED revisits.

Development and Scoring of a Survey on Public Health Accreditation Capacity.

OBJECTIVES: Public health accreditation is a 7-step process that starts with a period of preapplication during which a health department assesses its readiness for accreditation. However, no tools with established reliability and validity that quantitatively measure a local health department's (LHD's) capacity for accreditation are available to complete this initial step. We developed and validated a survey to measure accreditation capacity for LHDs. METHODS: From January through April 2015, we administered a cross-sectional electronic survey instrument with 15 questions that tapped into domains of capacity for public health accreditation. We analyzed and grouped responses by using a confirmatory maximum likelihood factor analysis with oblique rotations. We assessed reliability by using Cronbach α, and we assessed validity by comparing responses with previously established instruments. We administered the survey to 174 LHD directors in Colorado, Kansas, and Nebraska, 153 (88%) of whom responded. RESULTS: The factor analysis produced a 3-factor model of accreditation capacity, suggesting that accreditation capacity depends on 3 distinct latent constructs: support for accreditation, preparation, and planning and approach. The model had good scale reliability (average Cronbach α = 0.7) and validity (average factor correlation = 0.43). CONCLUSIONS: The survey developed and scored in this analysis can be used by LHDs to inform the feasibility of initiating the time-intensive and costly process of accreditation.

Strengthening Linkages Between Public Health and Health Care in Nebraska.

INTRODUCTION: Effective collaboration between public health and the health care system is essential for connecting medical and community health-related resources and improving population health. We investigated the linkages between local health departments and primary care clinics in Nebraska. METHODS: We conducted a mixed-method study by using semistructured in-person and telephone interviews and surveys in 2017 and 2018 with directors of 19 Nebraska local health departments. Interviews and surveys assessed activities and programs that health departments implemented or planned with clinics in their jurisdictions. Barriers, benefits, and opportunities for building the linkages were identified. RESULTS: Strong linkages existed between local health departments and primary care clinics. Linkages focused on the control and prevention of chronic diseases and on traditional public health programs, including screening for cancer and other chronic diseases, vaccinations, worksite wellness programs, home visits, clinic and medication assistance referrals, health message development, electronic health records data analyses, staff education, and improvements in policies and procedures. The most frequently reported barrier was funding, and the most frequently reported benefit was patient behavior change. The opportunity most frequently reported was chronic disease health coaching. CONCLUSION: Extensive linkages exist between Nebraska local health departments and the health care systems in their areas. Additional funding, effective workforce management, community needs assessments, and program evaluation can support joint initiatives to address community health priorities.

The Evolving Management of Aortic Valve Disease: 5-Year Trends in SAVR, TAVR, and Medical Therapy.

Aortic stenosis (AS) and regurgitation (AR) may be treated with surgical aortic valve replacement (SAVR), transcatheter AVR (TAVR), or medical therapy (MT). Data are lacking regarding the usage of SAVR, TAVR, and MT for patients hospitalized with aortic valve disease and the characteristics of the patients and hospitals associated with each therapy. From the Nationwide Readmissions Database, we determined utilization trends for SAVR, TAVR, and MT in patients with aortic valve disease admitted from 2012 to 2016 for valve replacement, heart failure, unstable angina, non-ST-elevation myocardial infarction, or syncope. We also performed multinomial logistic regressions to investigate associations between patient and hospital characteristics and treatment. Among 366,909 patients hospitalized for aortic valve disease, there was a 48.1% annual increase from 2012 through 2016. Overall, 19.9%, 6.7%, and 73.4% of patients received SAVR, TAVR, and MT, respectively. SAVR decreased from 21.9% in 2012 to 18.5% in 2016, whereas TAVR increased from 2.6% to 12.5%, and MT decreased from 75.5% to 69.0%. Older age, female sex, greater severity of illness, more admission diagnoses, not-for-profit hospitals, large hospitals, and urban teaching hospitals were associated with greater use of TAVR. In multivariable analysis, likelihood of TAVR relative to SAVR increased 4.57-fold (95% confidence interval 4.21 to 4.97). TAVR has increased at the expense of both SAVR and MT, a novel finding. However, this increase in TAVR was distributed inequitably, with certain patients more likely to receive TAVR certain hospitals more likely to provide TAVR. With the expected expansion of indications, inequitable access to TAVR must be addressed.

Post-Discharge Services for Different Diagnoses Than Index Hospitalization Predict Decreased 30-Day Readmissions Among Medicare Beneficiaries.

BACKGROUND: Efforts to reduce hospital readmissions include post-discharge interventions related to the illness treated during the index hospitalization (IH). These efforts may be inadequate because readmissions are precipitated by a wide range of health conditions unrelated to the primary diagnosis of the IH. OBJECTIVE: To investigate the relationship between post-discharge health services utilization for the same or a different diagnosis than the IH and unplanned 30-day readmission. DESIGN AND PARTICIPANTS: The study sample included 583,199 all-cause IHs among 2014 Medicare fee-for-service beneficiaries. For all-cause IH, as well as individually for heart failure, myocardial infarction, and pneumonia IH, we used multivariable logistic regressions to investigate the association between post-discharge services utilization and readmission. MAIN MEASURES: The outcome was unplanned 30-day readmission. Primary independent variables were post-discharge services utilization, including institutional outpatient, office-based primary care, office-based specialist, office-based non-physician practitioner, emergency department, home health care, and skilled nursing facility providers. KEY RESULTS: Among all-cause IH, 11.7% resulted in unplanned 30-day readmissions, and only 18.1% of readmissions occurred for the same primary diagnosis as IH. A substantial majority of post-discharge health services were utilized for a primary diagnosis differing from IH. Compared with no visit, institutional outpatient visits for the same primary diagnosis as IH (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.31-0.34) and for a different primary diagnosis than IH (OR, 0.36; 95% CI, 0.35-0.37) were similarly strongly associated with decreased unplanned 30-day readmission. Primary care physician, specialist, non-physician practitioner, and home health care showed similar patterns. IH for heart failure, myocardial infarction, and pneumonia manifested similar patterns to all-cause IH both in terms of post-discharge services utilization and in terms of its impact on readmission. CONCLUSIONS: To reduce unplanned 30-day readmission more effectively, discharge planning should include post-discharge services to address health conditions beyond the primary cause of the IH.

Improving behavioral health workforce supply and needs estimates using active surveillance data.

INTRODUCTION: Previous studies show that supply of behavioral health professionals in rural areas is inadequate to meet the need. Measuring shortage using licensure data on psychiatrists is a common approach. Although inexpensive, the licensure data have many limitations. An alternative is to implement an active surveillance system, which uses licensure data in addition to active data collection to obtain timely and detailed information. METHODS: Nebraska Health Professions Tracking Service (HPTS) data were used to examine differences in workforce supply estimates between the passive (licensure data only) and active (HPTS data) surveillance systems. The impact of these differences on the designation of psychiatric professional shortage areas has been described. Information regarding the number of psychiatrists, advanced practice registered nurses and physician assistants specializing in psychiatry was not available from the licensure database, unlike HPTS. RESULTS: Using licensure data versus HPTS data to estimate workforce, the counts of professionals actively practicing in psychiatry and behavioral health were overestimated by 24.1-57.1%. Ignoring work status, the workforce was overestimated by 10.0-17.4%. Providers spent 54-78% of time seeing patients. Based on primary practice location, 87% of counties did not have a psychiatrist and 9.6% were at or above the Health Professional Shortage Area designation ratio of psychiatrists to population. CONCLUSION: Enumeration methods such as ongoing surveillance, in addition to licensure data, curtails the issues and improves identification of shortage areas and future behavioral workforce related planning and implementation strategies.

Predictors and Costs of 30-Day Readmissions After Index Hospitalizations for Alcohol-Related Disorders in U.S. Adults.

BACKGROUND: In 2015, the Hospital Readmissions Reduction Program mandated financial penalties to hospitals with greater rates of readmissions for certain conditions. Alcohol-related disorders (ARD) are the fourth leading cause of 30-day readmissions. Yet, there is a dearth of national-level research to identify high-risk patient populations and predictors of 30-day readmission. This study examined patient- and hospital-level predictors for index hospitalizations with principal diagnosis of ARD and predicted the cost of 30-day readmissions. METHODS: The 2014 Nationwide Readmissions Database was used to identify ARD-related index hospitalizations. Multivariable logistic regression was used to estimate patient- and hospital-level predictors for readmissions, and a 2-part model was used to predict the incremental cost conditional upon readmission. RESULTS: In 2014, 285,767 index hospitalizations for ARD were recorded, and 18.9% of ARD-associated hospitalizations resulted in at least one 30-day readmission. Patients who were males, aged 45 to 64 years, Medicaid enrollees, living in urban and low-income areas, or with 1 to 2 comorbidities had high risk of readmission. Index hospitalization costs were higher among readmitted patients ($8,840 vs. $8,036, p < 0.01). Predicted mean costs for readmissions on index stay with ARD were greater among those aged 45 to 64 years ($1,908, p < 0.001), Medicare enrollees ($2,133, p < 0.001), rural residents ($1,841, p < 0.01), living in high-income areas ($1,876, p < 0.001), with 4 or more comorbidities ($2,415, p < 0.001), or admitted in large metropolitan hospitals ($2,032, p < 0.001), with large number of beds ($1,964, p < 0.001), with government ownership ($2,109, p < 0.001), or with low volume of ARD cases ($2,155, p < 0.001). CONCLUSIONS: One in 5 ARD-related index hospitalizations resulted in a 30-day readmission. Overall, costs of index hospitalizations for ARD were $2.3 billion, of which $512 million were spent on hospitalizations that resulted in at least 1 readmission. There is a need to develop patient-centric health programs to reduce readmission rates and costs among ARD patients.

Patient-Centered Medical Home Measurement in School-Based Health Centers.

School-based health centers (SBHCs) have been suggested as potential medical homes, yet minimal attention has been paid to measuring their patient-centered medical home (PCMH) implementation. The purposes of this article were to (1) develop an index to measure PCMH attributes in SBHCs, (2) use the SBHC PCMH Index to compare PCMH capacity between PCMH certified and non-PCMH SBHCs, and (3) examine differences in index scores between SBHCs based in schools with and without adolescents. A total of six PCMH dimensions in the SBHC PCMH Index were identified through factor analysis. These dimensions were collapsed into two domains: care quality and comprehensive care. SBHCs recognized as PCMHs had higher scores on the index, both domains, and four dimensions. SBHCs based in schools with just young children and those with adolescents scored similarly on the overall index, but analysis of individual index items shows their strengths and weaknesses in PCMH implementation.

An Examination of Multilevel Factors Influencing Colorectal Cancer Screening in Primary Care Accountable Care Organization Settings: A Mixed-Methods Study.

OBJECTIVE: To identify patient, provider, and delivery system-level factors associated with colorectal cancer (CRC) screening and validate findings across multiple data sets. DESIGN: A concurrent mixed-methods design using electronic health records, provider survey, and provider interview. SETTING: Eight primary care accountable care organization clinics in Nebraska. MEASURES: Patients' demographic/social characteristics, health utilization behaviors, and perceptions toward CRC screening; provider demographics and practice patterns; and clinics' delivery systems (eg, reminder system). ANALYSIS: Quantitative (frequencies, logistic regression, and t tests) and qualitative analyses (thematic coding). RESULTS: At the patient level, being 65 years of age and older (odds ratio [OR] = 1.34, P < .001), being non-Hispanic white (OR = 1.93, P < .001), having insurance (OR = 1.90, P = .01), having an annual physical examination (OR = 2.36, P < .001), and having chronic conditions (OR = 1.65 for 1-2 conditions, P < .001) were associated positively with screening, compared with their counterparts. The top 5 patient-level barriers included discomfort/pain of the procedure (60.3%), finance/cost (57.4%), other priority health issues (39.7%), lack of awareness (36.8%), and health literacy (26.5%). At the provider level, being female (OR = 1.88, P < .001), having medical doctor credentials (OR = 3.05, P < .001), and having a daily patient load less than 15 (OR = 1.50, P = .01) were positively related to CRC screening. None of the delivery system factors were significant except the reminder system. Interview data provided in-depth information on how these factors help or hinder CRC screening. Discrepancies in findings were observed in chronic condition, colonoscopy performed by primary doctors, and the clinic-level system factors. CONCLUSIONS: This study informs practitioners and policy makers on the effective multilevel strategies to promote CRC screening in primary care accountable care organization or equivalent settings. Some inconsistent findings between data sources require additional prospective cohort studies to validate those identified factors in question. The strategies may include (1) developing programs targeting relatively younger age groups or racial/ethnic minorities, (2) adapting multilevel/multicomponent interventions to address low demands and access of local population, (3) promoting annual physical examination as a cost-effective strategy, and (4) supporting organizational capacity and infrastructure (eg, IT system) to facilitate implementation of evidence-based interventions.