Primary Care and Community-Based Partnerships to Enhance HPV Vaccine Delivery.

INTRODUCTION/OBJECTIVES: With growing vaccination misinformation and mistrust, strategies to improve vaccination communication across community-based settings are needed. METHODS: The Rural Adolescent Vaccine Enterprise (RAVE), a 5-year (2018-2022) stepped-wedge cluster randomized study, tested a clinic-based practice facilitation intervention designed to improve HPV vaccination. An exploratory aim sought to explore the use of partnerships between primary care clinics and a community partner of their choosing, to implement a social marketing campaign related to HPV immunization. We assessed perceptions about the value and success of the partnership, and barriers and facilitators to its implementation using a 29-item community partner survey, key informant interviews, and field notes from practice facilitators. RESULTS: Of the initial 45 clinics participating in RAVE, 9 were unable to either start or complete the study, and 36 participants (80.0%) were actively engaged. Of these, 16/36 clinics (44.4%) reported establishing successful partnerships, 10 reported attempting to develop partnerships (27.8%), and another 10 reported not developing a partnership (27.8%), which were often caused by the COVID-19 pandemic. The most common partnership was with public health departments at 27.3%. Other partnerships involved libraries, school districts, and local businesses. More than half (63.7%) reported that creating messages regarding getting HPV vaccination was moderately to very challenging. Just under half reported (45.5%) that messaging was hard because of a lack of understanding about the seriousness of diseases caused by HPV, parents being against vaccines because of safety concerns, and religious values that result in a lack of openness to HPV vaccines. Community partners' health priorities changed as a result of RAVE, with 80% prioritizing childhood immunizations as a result of the RAVE partnership. CONCLUSIONS: Community groups want to partner with primary care organizations to serve their patients and populations. More research is needed on how best to bring these groups together.

An Exploratory Study of Rural Parents' Knowledge and Attitudes About HPV Vaccination Following a Healthcare Visit With Their Child's Primary Care Provider.

INTRODUCTION/OBJECTIVES: Annually, HPV infections result in $775 million in direct medical costs and approximately 46 000 new cases of HPV-associated cancers. Safe and highly effective vaccines have been available to prevent HPV for children/adolescents since 2006. Vaccination rates remain low, especially in rural areas. Parental attitudes and beliefs affect HPV vaccination rates. METHODS: We developed, tested, and administered a survey that asked how parents and healthcare providers interacted about the HPV vaccine following a healthcare visit with an age-eligible child, as part of a multicomponent randomized controlled trial designed to improve HPV vaccination rates in rural Oregon. The 21-item survey assessed parents' information-seeking behavior, knowledge about HPV cancer risk reduction, the HPV vaccine series, and their vaccine confidence. RESULTS: Forty-three participants (59.7%) were in the intervention group; 29 (40.3%) were controls. Over 90% of healthcare visits were illness, injury, sports physical, or well-child visits (n = 67 or 93.1%), and 6.9% of visits were vaccine-specific. No statistically significant differences were found between study groups for healthcare visits. Over half the parents reported having discussions about HPV and the HPV vaccine (54.5%) with their care providers, 31.3% had recently learned about HPV, HPV risks, and the HPV vaccine prior to the visit, 83.1% were knowledgeable about cancers associated with HPV, and 79.2% were considering vaccinating their child(ren), which did not differ between study groups. CONCLUSIONS: Knowledge about HPV-related cancers and consideration for vaccinating children was higher than expected, but not associated with the intervention tested.

Landscape of Pregnancy Care in US Community Health Centers.

PURPOSE: Community health centers (CHCs) provide critical health care access for people who experience high risks during and after pregnancy, however it is unclear to what extent they provide prenatal care. This study seeks to describe clinic and patient characteristics associated with longitudinal prenatal care delivery in CHC settings. METHODS: This retrospective cohort study utilized electronic health record (EHR) data from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) between 2018 to 2019 to describe prenatal care provision among CHCs (n = 408), and pregnant CHC patients (n = 28,578) and compared characteristics of patients who received longitudinal prenatal care at CHCs versus those who did not. RESULTS: 41% of CHCs provided longitudinal prenatal care; these CHCs were more likely to be larger, have multidisciplinary teams, and serve higher proportions of nonwhite or non-English speaking patients. Patients who received longitudinal prenatal care at CHCs were racially and ethnically diverse and many had comorbidities. Patients who received longitudinal prenatal care at CHCs (compared with pregnant patients who did not) were more likely to be white or Latinx and more likely to have non-English language preference. CONCLUSIONS: Many CHCs in this national network provide prenatal care and serve pregnant patients at high risk of pregnancy-related complications, including people of color, those with low income, and those with comorbidities. CHCs provide critical access to care for vulnerable populations and will be an important partner in work addressing inequities in maternal morbidity and mortality.

Impact of the COVID-19 vaccination mandate on the primary care workforce and differences between rural and urban settings to inform future policy decision-making.

INTRODUCTION: Little is known about the impact of mandated vaccination policies on the primary care clinic workforce in the United States or differences between rural and urban settings, especially for COVID-19. With the continued pandemic and an anticipated increase in novel disease outbreaks and emerging vaccines, healthcare systems need additional information on how vaccine mandates impact the healthcare workforce to aid in future decision-making. METHODS: We conducted a cross-sectional survey of Oregon primary care clinic staff between October 28, 2021- November 18, 2021, following implementation of a COVID-19 vaccination mandate for healthcare personnel. The survey consisted of 19 questions that assessed the clinic-level impacts of the vaccination mandate. Outcomes included job loss among staff, receipt of an approved vaccination waiver, new vaccination among staff, and the perceived significance of the policy on clinic staffing. We used univariable descriptive statistics to compare outcomes between rural and urban clinics. The survey also included three open-ended questions that were analyzed using a template analysis approach. RESULTS: Staff from 80 clinics across 28 counties completed surveys, representing 38 rural and 42 urban clinics. Clinics reported job loss (46%), use of vaccination waivers (51%), and newly vaccinated staff (60%). Significantly more rural clinics (compared to urban) utilized medical and/or religious vaccination waivers (71% vs 33%, p = 0.04) and reported significant impact on clinic staffing (45% vs 21%, p = 0.048). There was also a non-significant trend toward more job loss for rural compared to urban clinics (53% vs. 41%, p = 0.547). Qualitative analysis highlighted a decline in clinic morale, small but meaningful detriments to patient care, and mixed opinions of the vaccination mandate. CONCLUSIONS: Oregon's COVID-19 vaccination mandate increased healthcare personnel vaccination rates, yet amplified staffing challenges with disproportionate impacts in rural areas. Staffing impacts in primary care clinics were greater than reported previously in hospital settings and with other vaccination mandates. Mitigating primary care staffing impacts, particularly in rural areas, will be critical in response to the continued pandemic and novel viruses in the future.

Clinic-level differences in human papillomavirus vaccination rates among rural and urban Oregon primary care clinics.

PURPOSE: Human papillomavirus (HPV) infection contributes to vaccine-preventable malignancies. Rural populations experience lower HPV vaccination rates despite similar rates of other childhood vaccinations. Individual- and clinic-level characteristics likely contribute to this disparity, but little is known about the separate roles of each. We compared clinic-level HPV vaccination rates among rural versus urban primary care clinics, identified factors associated with HPV vaccination, and separately assessed the impact of individual- and clinic-level characteristics on rural disparities in HPV vaccination. METHODS: This cross-sectional study included 537 Oregon primary care clinics participating in the Vaccines for Children (VFC) program during 2019. Vaccination status was assessed using Oregon's ALERT Immunization Information System and included HPV vaccine ≥ 1 dose for ages 11 and 12; HPV vaccination up to date (UTD) for ages 13-17, and coadministration with tetanus, diphtheria, and acellular pertussis (Tdap). Rural versus urban clinic-level outcomes were assessed using negative binomial regression. FINDINGS: Participating clinics were 24.5% rural and 75.6% urban. Family medicine clinics comprised 71.1%; pediatrics, 16.9%; and mixed, 12.1%. Across clinics, the average proportion of patients qualifying for VFC was 43%, and non-White patients were 14.1%. The mean rate of HPV vaccine ≥1 dose was lower among rural clinics (46.9% vs 51.1%, P = .039), as was vaccination UTD (40.5% vs 49.9%, P < .001). Adjusting for differences in individual- and clinic-level characteristics, rural disparities were no longer statistically significant. CONCLUSIONS: Both individual- and clinic-level characteristics play a role in rural disparities in HPV vaccination, and modifiable clinic-level differences may be opportune targets to address these disparities.

Improving screening, treatment, and intervention for unhealthy alcohol use in primary care through clinic, practice-based research network, and health plan partnerships: Protocol of the ANTECEDENT study.

BACKGROUND: Unhealthy alcohol use (UAU) is a leading cause of morbidity and mortality in the United States, contributing to 95,000 deaths annually. When offered in primary care, screening, brief intervention, referral to treatment (SBIRT), and medication-assisted treatment for alcohol use disorder (MAUD) can effectively address UAU. However, these interventions are not yet routine in primary care clinics. Therefore, our study evaluates tailored implementation support to increase SBIRT and MAUD in primary care. METHODS: ANTECEDENT is a pragmatic implementation study designed to support 150 primary care clinics in Oregon adopting and optimizing SBIRT and MAUD workflows to address UAU. The study is a partnership between the Oregon Health Authority Transformation Center-state leaders in Medicaid health system transformation-SBIRT Oregon and the Oregon Rural Practice-based Research Network. We recruited clinics providing primary care in Oregon and prioritized reaching clinics that were small to medium in size (<10 providers). All participating clinics receive foundational support (i.e., a baseline assessment, exit assessment, and access to the online SBIRT Oregon materials) and may opt to receive tailored implementation support delivered by a practice facilitator over 12 months. Tailored implementation support is designed to address identified needs and may include health information technology support, peer-to-peer learning, workflow mapping, or expert consultation via academic detailing. The study aims are to 1) engage, recruit, and conduct needs assessments with 150 primary care clinics and their regional Medicaid health plans called Coordinated Care Organizations within the state of Oregon, 2) implement and evaluate the impact of foundational and supplemental implementation support on clinic change in SBIRT and MAUD, and 3) describe how practice facilitators tailor implementation support based on context and personal expertise. Our convergent parallel mixed-methods analysis uses RE-AIM (reach, effectiveness, adoption, implementation, maintenance). It is informed by a hybrid of the i-PARIHS (integrated Promoting Action on Research Implementation in Health Services) and the Dynamic Sustainability Framework. DISCUSSION: This study will explore how primary care clinics implement SBIRT and MAUD in routine practice and how practice facilitators vary implementation support across diverse clinic settings. Findings will inform how to effectively align implementation support to context, advance our understanding of practice facilitator skill development over time, and ultimately improve detection and treatment of UAU across diverse primary care clinics.

Emotional and Behavioral Problems in Youth with Autism: High Prevalence and Impact on Functioning.

OBJECTIVE: Emotional and behavioral problems (EBPs) may co-occur with autism spectrum disorder (ASD) and impair children's functioning beyond autism symptomatology. We compared the prevalence of EBPs in youths with or without ASD and evaluated their unique contribution to impairment in ASD. METHODS: We surveyed 1267 children (79.4% boys, mean age: 9.2 years, range: 3-17) recruited at 3 sites in Kaiser Permanente and OCHIN primary care clinical networks, with confirmed International Classification of Diseases-10th ed. diagnosis of ASD (N = 564), asthma (N = 468), or neither (N = 429). Children from the 2 comparison groups were age-matched and sex-matched to the ASD group. EBPs and impairment were measured by the Strengths and Difficulties Questionnaire and autism symptomatology by the Social Responsiveness Scale in the ASD group only. RESULTS: EBPs and impairment mean scores were significantly (p < 0.001) higher in participants with ASD compared with children from the 2 comparison groups, across sexes and age groups, with no significant difference between the asthma and control groups. Among children with ASD, both EBPs and autistic symptoms were significantly correlated with impairment (r = 0.64 and r = 0.65, respectively) and explained a significant proportion of impairment variance (R2 = 0.525; p < 0.001) in multiple linear regression. In the relative importance analysis, EBPs and autistic symptoms explained comparable proportions of impairment variance (46% and 52%, respectively) with no significant difference between their relative weights (mean difference: 0.03; 95% confidence interval: -0.049 to 0.114). CONCLUSION: Among youth with ASD, high levels of EBPs impair daily functioning as much as autistic symptoms. Systematic detection and management of EBPs may improve functioning and outcomes in youth with ASD.

Understanding Health Need and Services Received by Youth in Foster Care in Community Safety-Net Health Centers in Oregon.

Youth in foster care have significant unmet health needs. We assessed health needs and health service use among youth in foster care in Oregon using electronic health record data from 258 community health centers and Medicaid enrollment data from 2014-2016. We identified 2,140 youth in foster care and a matched comparison group of 6,304 youth from the same clinics who were not in foster care, and compared the groups on demographic characteristics, health needs, and health service use. Youth in foster care were significantly more likely to have at least one chronic health condition, at least one mental health condition, and at least one mental health service compared with controls. Youth in foster care were significantly less likely to have a primary care visit. Despite significant mental health needs among youth in foster care, few received mental health care; this lack was greater among African American and Hispanic youth.

The Importance of Practice Facilitation in Primary Care When Pandemic Takes Hold: Relationships of Resilience.

The COVID-19 pandemic is unprecedented in recent history as radically and forcefully changing healthcare delivery. Practice facilitators, who often use tools of improvement science, have long played a critical role in supporting routine primary care practice transformation when healthcare system and policy changes occur. However, current events have taken many healthcare systems to the brink of collapse. Our practice facilitation team, which has a long history of sustained primary care partnerships in rural under-resourced settings, is finding creative solutions to carry forward work in research and quality improvement, and the tools of improvement science are well-suited to address rapidly changing demands of primary care during such a crisis. We reflect here on practice facilitation through the pandemic-the value of applied improvement science, and the critical necessity of strong relationships, flexibility, and creativity to support ongoing primary care partnerships.

Uptake of Preventive Services Among Patients With and Without Multimorbidity.

INTRODUCTION: Patients with multiple chronic conditions (multimorbidity) are seen commonly in primary care practices and often have suboptimal uptake of preventive care owing to competing treatment demands. The complexity of multimorbidity patterns and their impact on receiving preventive services is not fully understood. This study identifies multimorbidity combinations associated with low receipt of preventive services. METHODS: This was a retrospective cohort study of U.S. community health center patients aged ≥19 years. Electronic health record data from 209 community health centers for the January 1, 2014-December 31, 2017 study period were analyzed in 2018-2019. Multimorbidity patterns included physical only, mental health only, and physical and mental health multimorbidity patterns, with no multimorbidity as a reference category. Electronic health record-based preventive ratios (number of months services were up-to-date/total months the patient was eligible for services) were calculated for the 14 preventive services. Negative binomial regression models assessed the relationship between multimorbidity physical and/or mental health patterns and the preventive ratio for each service. RESULTS: There was a variation in receipt of preventive care between multimorbidity groups: individuals with mental health only multimorbidity were less likely to be up-to-date with cardiometabolic and cancer screenings than the no multimorbidity group or groups with physical health conditions, and the physical only multimorbidity group had low rates of depression screening. CONCLUSIONS: This study provided critical insights into receipt of preventive service among adults with multimorbidity using a more precise method for measuring up-to-date preventive care delivery. Findings would be useful to identify target populations for future intervention programs to improve preventive care.

Use of a Preventive Index to Examine Clinic-Level Factors Associated With Delivery of Preventive Care.

INTRODUCTION: There is an increasing need for the development of new methods to understand factors affecting delivery of preventive care. This study applies a new measurement approach and assesses clinic-level factors associated with preventive care delivery. METHODS: This retrospective longitudinal cohort study of 94 community health centers used electronic health record data from the OCHIN community health information network, 2014-2015. Clinic-level preventive ratios (time covered by a preventive service/time eligible for a preventive service) were calculated in 2017 for 12 preventive services with A or B recommendations from the U.S. Preventive Services Task Force along with an aggregate preventive index for all services combined. For each service, multivariable negative binomial regression modeling and calculated rate ratios assessed the association between clinic-level variables and delivery of care. RESULTS: Of ambulatory community health center visits, 59.8% were Medicaid-insured and 10.4% were uninsured. Ambulatory community health centers served 16.9% patients who were Hispanic, 13.1% who were nonwhite, and 68.7% who had household incomes <138% of the federal poverty line. Clinic-level preventive ratios ranged from 3% (hepatitis C screening) to 93% (blood pressure screening). The aggregate preventive index including all screening measures was 47% (IQR, 42%-50%). At the clinic level, having a higher percentage of uninsured visits was associated with lower preventive ratios for most (7 of 12) preventive services. CONCLUSIONS: Approaches that use individual preventive ratios and aggregate prevention indices are promising for understanding and improving preventive service delivery over time. Health insurance remains strongly associated with access to needed preventive care, even for safety net clinic populations.

Measuring Preventive Care Delivery: Comparing Rates Across Three Data Sources.

INTRODUCTION: Preventive care delivery is an important quality outcome, and electronic data reports are being used increasingly to track these services. It is highly informative when electronic data sources are compared to information manually extracted from medical charts to assess validity and completeness. METHODS: This cross-sectional study used a random sample of Medicaid-insured patients seen at 43 community health centers in 2011 to calculate standard measures of correspondence between manual chart review and two automated sources (electronic health records [EHRs] and Medicaid claims), comparing documentation of orders for and receipt of ten preventive services (n=150 patients/service). Data were analyzed in 2015. RESULTS: Using manual chart review as the gold standard, automated EHR extraction showed near-perfect to perfect agreement (κ=0.96-1.0) for services received within the primary care setting (e.g., BMI, blood pressure). Receipt of breast and colorectal cancer screenings, services commonly referred out, showed moderate (κ=0.42) to substantial (κ=0.62) agreement, respectively. Automated EHR extraction showed near-perfect agreement (κ=0.83-0.97) for documentation of ordered services. Medicaid claims showed near-perfect agreement (κ=0.87) for hyperlipidemia and diabetes screening, and substantial agreement (κ=0.67-0.80) for receipt of breast, cervical, and colorectal cancer screenings, and influenza vaccination. Claims showed moderate agreement (κ=0.59) for chlamydia screening receipt. Medicaid claims did not capture ordered or unbilled services. CONCLUSIONS: Findings suggest that automated EHR and claims data provide valid sources for measuring receipt of most preventive services; however, ordered and unbilled services were primarily captured via EHR data and completed referrals were more often documented in claims data.

Citizenship documentation requirement for Medicaid eligibility: effects on Oregon children.

BACKGROUND AND OBJECTIVES: The Deficit Reduction Act (DRA) of 2005 mandated Medicaid beneficiaries to document citizenship. Using a prospective cohort (n=104,375), we aimed to (1) determine characteristics of affected children, (2) describe effects on health insurance coverage and access to needed health care, and (3) model the causal relationship between this new policy, known determinants of health care access, and receipt of needed health care. METHODS: We identified a stratified random sample of children shortly after the DRA was implemented and used state records and surveys to compare three groups: children denied Medicaid for inability to document citizenship, children denied for other reasons, and children accepted for coverage. To combat survey nonresponse, we used Medicaid records to identify differences between responders and nonrespondents and created survey weights to account for these differences. Weighted simple and multivariable logistic regression described the complete, originally identified population. RESULTS: Children denied Medicaid for inability to document citizenship were likely to be US citizens, were medically and socially more vulnerable than their peers, and went on to have gaps in health insurance coverage and unmet health care needs. The DRA led to persistent loss of insurance coverage, which decreased access to needed health care. Having a usual source of care was an effect modifier in this relationship. CONCLUSIONS: Our findings demonstrate the negative consequences of the DRA and support the use of automated methods of citizenship verification allowed under the Patient Protection and Affordable Care Act.