Don't Let Perfect Be the Enemy of Good: A Proof of Concept for a Custom National Data Repository of Quality Measures for Free and Charitable Clinics.

Purpose: Free and charitable clinics (FCCs), nonprofits that utilize volunteer licensed health care professionals to provide health services at no cost or a small fee to low-income uninsured patients who are disproportionately from underrepresented communities, have been part of the safety net for over a century. Approximately 1400 known FCCs serve two million patients annually. Despite their longevity and sizable number, evidence regarding the quality of care in FCCs is lacking. We report new evidence generated by a national initiative, the Roadmap to Health Equity. Established in 2017, this consortium is co-led by two national organizations serving FCCs and an academic institution. It has involved more than 150 FCC stakeholders with the shared goal of improving the quality of care and reducing inequities. The centerpiece is a custom national data repository of 15 validated clinical quality measures and patient-level characteristics. Methods: Fifty FCCs pilot tested the data repository. Clinics submitted patient-level data on two blood pressure (BP) measures and at least one additional measure. Descriptive statistics were stratified by sex, race, ethnicity, and language. Results: In 2021, 33 pilot FCCs from 21 states reported data across 13 of the 15 clinical measures, representing 34,359 unique patients. For example, on average, 60% of patients had controlled BP, but Black patients had lower rates of BP control than Hispanic and White patients (55.9% vs. 62.1% and 63.0%, respectively). Conclusion: Our findings demonstrate a proof of concept. By standardizing quality measures alongside patient characteristics, clinics can become aware of racial/ethnic inequalities in health outcomes. This information can motivate clinics to investigate the causes and implement solutions. In an environment where outcome data from FCCs are scarce, the new national data repository lays the foundation for routine stratified reporting of a range of quality outcomes for an important safety net for the uninsured.

Location, Location, Location: The Affordable Care Act's Impact on Free Clinics Depends on What State They're In.

Little is known about how nonprofit volunteer-led free and charitable clinics, which deliver free or low-cost health services to approximately two million uninsured annually, have fared following the Affordable Care Act's (ACA's) Medicaid coverage expansions. In late 2014 we surveyed 156 clinics that are partners of Americares, a key stakeholder, about the impact of the ACA. We used clinics' responses to create outcome measures reflecting 1) how well clinics fared in terms of fundraising, staffing levels, volunteer hours, scope of services, and trends in patients and visits; and 2) their tendency to modify clinic operations, such as integrating new technology, changing the clinic flow, adding new services, or billing patients. In multivariable negative binomial regression models we examined associations between location in a Medicaid expansion state and the two outcomes. Location in an expansion state was significantly and positively associated with experiencing negative impacts and making major operational changes.

A Comparison of Different Intensities of Patient Navigation After Abnormal Mammography.

Background. Patient navigation is a practice strategy to address barriers to timely diagnosis and treatment of cancer. The aim of this study was to examine the effectiveness of varying intensities of patient navigation and timely diagnostic resolution after abnormal mammography. Method. This is a secondary analysis of a subset of women with an abnormal screening or diagnostic mammogram who participated in the "patient navigation in medically underserved areas" 5-year randomized trial. We compared timely diagnostic resolution in women assigned to different intensities of patient navigation including, full navigation intervention, no contact with navigators, or limited contact with navigators. Results. The sample included 1,725 women with abnormal mammogram results. Women who interacted with patient navigators had significantly fewer days to diagnostic resolution after abnormal mammography compared with women who did not interact with patient navigators. Discussion. Results from our study suggest that even limited contact with navigators encourages women to seek more timely diagnostic resolution after an abnormal mammogram, which may offer a low-cost practice strategy to improve timely diagnosis for disadvantaged and underserved women.

Patient Navigation Improves Subsequent Breast Cancer Screening After a Noncancerous Result: Evidence from the Patient Navigation in Medically Underserved Areas Study.

BACKGROUND: Past efforts to assess patient navigation on cancer screening utilization have focused on one-time uptake, which may not be sufficient in the long term. This is partially due to limited resources for in-person, longitudinal patient navigation. We examine the effectiveness of a low-intensity phone- and mail-based navigation on multiple screening episodes with a focus on screening uptake after receiving noncancerous results during a previous screening episode. METHODS: The is a secondary analysis of patients who participated in a randomized controlled patient navigation trial in Chicago. Participants include women referred for a screening mammogram, aged 50-74 years, and with a history of benign/normal screening results. Navigation services focused on identification of barriers and intervention via shared decision-making processes. A multivariable logistic regression intent-to-treat model was used to examine differences in odds of obtaining a screening mammogram within 2 years of the initial mammogram (yes/no) between navigated and non-navigated women. Sensitivity analyses were conducted to explore patterns across subsets of participants (e.g., navigated women successfully contacted before the initial appointment; women receiving care at Hospital C). RESULTS: The final sample included 2,536 women (741 navigated, 1,795 non-navigated). Navigated women exhibited greater odds of obtaining subsequent screenings relative to women in the standard care group in adjusted models and analyses including women who received navigation before the initial appointment. CONCLUSIONS: Our findings suggest that low-intensity navigation services can improve follow-up screening among women who receive a noncancerous result. Further investigation is needed to confirm navigation's impacts on longitudinal screening.

Patient Navigation in Medically Underserved Areas study design: A trial with implications for efficacy, effect modification, and full continuum assessment.

BACKGROUND: The Patient Navigation in Medically Underserved Areas study objectives are to assess if navigation improves: 1) care uptake and time to diagnosis; and 2) outcomes depending on patients' residential medically underserved area (MUA) status. Secondary objectives include the efficacy of navigation across 1) different points of the care continuum among patients diagnosed with breast cancer; and 2) multiple regular screening episodes among patients who did not obtain breast cancer diagnoses. DESIGN/METHODS: Our randomized controlled trial was implemented in three community hospitals in South Chicago. Eligible participants were: 1) female, 2) 18+years old, 3) not pregnant, 4) referred from a primary care provider for a screening or diagnostic mammogram based on an abnormal clinical breast exam. Participants were randomized to 1) control care or 2) receive longitudinal navigation, through treatment if diagnosed with cancer or across multiple years if asymptomatic, by a lay health worker. Participants' residential areas were identified as: 1) established MUA (before 1998), 2) new MUA (after 1998), 3) eligible/but not designated as MUA, and 4) affluent/ineligible for MUA. Primary outcomes include days to initially recommended care after randomization and days to diagnosis for women with abnormal results. Secondary outcomes concern days to treatment initiation following a diagnosis and receipt of subsequent screening following normal/benign results. DISCUSSION: This intervention aims to assess the efficacy of patient navigation on breast cancer care uptake across the continuum. If effective, the program may improve rates of early cancer detection and breast cancer morbidity.

The impact of patient navigation on the delivery of diagnostic breast cancer care in the National Patient Navigation Research Program: a prospective meta-analysis.

Patient navigation is emerging as a standard in breast cancer care delivery, yet multi-site data on the impact of navigation at reducing delays along the continuum of care are lacking. The purpose of this study was to determine the effect of navigation on reaching diagnostic resolution at specific time points after an abnormal breast cancer screening test among a national sample. A prospective meta-analysis estimated the adjusted odds of achieving timely diagnostic resolution at 60, 180, and 365 days. Exploratory analyses were conducted on the pooled sample to identify which groups had the most benefit from navigation. Clinics from six medical centers serving vulnerable populations participated in the Patient Navigation Research Program. Women with an abnormal breast cancer screening test between 2007 and 2009 were included and received the patient navigation intervention or usual care. Patient navigators worked with patients and their care providers to address patient-specific barriers to care to prevent delays in diagnosis. A total of 4675 participants included predominantly racial/ethnic minorities (74 %) with public insurance (40 %) or no insurance (31 %). At 60 days and 180 days, there was no statistically significant effect of navigation on achieving timely diagnostic care, but a benefit of navigation was seen at 365 days (aOR 2.12, CI 1.36-3.29). We found an equal benefit of navigation across all groups, regardless of race/ethnicity, language, insurance status, and type of screening abnormality. Patient navigation resulted in more timely diagnostic resolution at 365 days among a diverse group of minority, low-income women with breast cancer screening abnormalities. Trial registrations clinicaltrials.gov Identifiers: NCT00613275, NCT00496678, NCT00375024, NCT01569672.

Effect of patient navigation on satisfaction with cancer-related care.

PURPOSE: Despite growing popularity of patient navigation (PN) as a means to improve cancer care quality and reduce cancer-related disparities, there are few well-designed controlled trials assessing the impact of PN on patient outcomes like satisfaction with care. The present controlled study examined effect of PN on satisfaction with cancer-related care. METHODS: Patients who presented with a symptom or abnormal screening test (n = 1788) or definitive diagnosis (n = 445) of breast, cervical, colorectal, or prostate cancer from eight Patient Navigator Research Program sites were included in one of two groups: intervention (PN) or comparison (usual care or usual care plus cancer educational materials). Trained patient navigators met with intervention group participants to help them assess and identify resources to address barriers to cancer diagnostic or treatment care. Using a validated instrument, we assessed participants' satisfaction with their cancer diagnostic or treatment care up to 3 months after diagnostic resolution of a cancer-related abnormality or within 3 months of initiation of cancer treatment. RESULTS: Overall, patients reported high satisfaction with diagnostic care and cancer treatment. There were no statistically significant differences between PN and control groups in satisfaction with cancer-related care (p > 0.05). Hispanic and African American participants were less likely to report high satisfaction with cancer care when compared to White patients. Middle-aged participants with higher education, higher household income, private insurance, owning their own home, working full-time, and those whose primary language is English had higher satisfaction with cancer-related diagnostic care. CONCLUSIONS: PN had no statistically significant effect on patients' satisfaction with cancer-related care. Further research is needed to define the patient populations who might benefit from PN, content of PN that is most useful, and services that might enhance PN. TRIAL REGISTRATIONS: clinicaltrials.gov identifiers: NCT00613275 , NCT00496678 , NCT00375024 , NCT01569672.

Barriers to health care contribute to delays in follow-up among women with abnormal cancer screening: Data from the Patient Navigation Research Program.

BACKGROUND: There is limited understanding of the association between barriers to care and clinical outcomes within patient navigation programs. METHODS: Secondary analyses of data from the intervention arms of the Patient Navigation Research Program were performed, which included navigated participants with abnormal breast and cervical cancer screening tests from 2007 to 2010. Independent variables were: 1) the number of unique barriers to care (0, 1, 2, or ≥3) documented during patient navigation encounters; and 2) the presence of socio-legal barriers originating from social policy (yes/no). The median time to diagnostic resolution of index screening abnormalities was estimated using Kaplan-Meier cumulative incidence curves. Multivariable Cox proportional hazards regression examined the impact of barriers on time to resolution, controlling for sociodemographics and stratifying by study center. RESULTS: Among 2600 breast screening participants, approximately 75% had barriers to care documented (25% had 1 barrier, 16% had 2 barriers, and 34% had ≥3 barriers). Among 1387 cervical screening participants, greater than one-half had barriers documented (31% had 1 barrier, 11% had 2 barriers, and 13% had ≥3 barriers). Among breast screening participants, the presence of barriers was associated with less timely resolution for any number of barriers compared with no barriers. Among cervical screening participants, only the presence of ≥2 barriers was found to be associated with less timely resolution. Both types of barriers, socio-legal and other barriers, were found to be associated with delay among breast and cervical screening participants. CONCLUSIONS: Navigated women with barriers resolved cancer screening abnormalities at a slower rate compared with navigated women with no barriers. Further innovations in navigation care are necessary to maximize the impact of patient navigation programs nationwide.

Succession planning in local health departments: results from a national survey.

CONTEXT: Succession planning has received scant attention in the public health sector, despite its potential to generate operational efficiencies in a sector facing chronic budgetary pressures and an aging workforce. OBJECTIVES: We examined the extent to which local health departments (LHDs) are engaged in succession planning and assessed the factors associated with having a succession plan. DESIGN: We conducted a national cross-sectional Web-based survey of workforce recruitment and retention activities in a sample of LHDs responding to the National Association of County & City Health Officials' 2010 Profile Study and then linked these data sets to fit a multivariable logistic regression model to explain why some LHDs have succession plans and others do not. SETTING AND PARTICIPANTS: Top executives in a national sample of LHDs. MAIN OUTCOME MEASURE: Presence or absence of succession planning. RESULTS: Two hundred twenty-five LHDs responded to the survey, yielding a 43.3% response rate, but no statistically significant differences between respondents and nonrespondents were detected. Only 39.5% reported having a succession plan. Performance evaluation activities are more common in LHDs with a succession plan than in LHDs without a plan. In adjusted analyses, the largest LHDs were 7 times more likely to have a succession plan than the smallest. Compared with state-governed LHDs, locally governed LHDs were 3.5 times more likely, and shared governance LHDs were 6 times more likely, to have a succession plan. Every additional year of experience by the top executive was associated with a 5% increase in the odds of having a succession plan. Local health departments that report high levels of concern about retaining staff (vs low concern) had 2.5 times higher adjusted odds of having a succession plan. CONCLUSIONS: This study provides the first national data on succession planning in LHDs and sheds light on LHDs' readiness to meet the workforce-related accreditation standards.

Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program.

PURPOSE: Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care. PATIENTS AND METHODS: Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants. RESULTS: Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297). CONCLUSION: We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.

Impact of patient navigation on timely cancer care: the Patient Navigation Research Program.

BACKGROUND: Patient navigation is a promising intervention to address cancer disparities but requires a multisite controlled trial to assess its effectiveness. METHODS: The Patient Navigation Research Program compared patient navigation with usual care on time to diagnosis or treatment for participants with breast, cervical, colorectal, or prostate screening abnormalities and/or cancers between 2007 and 2010. Patient navigators developed individualized strategies to address barriers to care, with the focus on preventing delays in care. To assess timeliness of diagnostic resolution, we conducted a meta-analysis of center- and cancer-specific adjusted hazard ratios (aHRs) comparing patient navigation vs usual care. To assess initiation of cancer therapy, we calculated a single aHR, pooling data across all centers and cancer types. We conducted a metaregression to evaluate variability across centers. All statistical tests were two-sided. RESULTS: The 10521 participants with abnormal screening tests and 2105 with a cancer or precancer diagnosis were predominantly from racial/ethnic minority groups (73%) and publically insured (40%) or uninsured (31%). There was no benefit during the first 90 days of care, but a benefit of navigation was seen from 91 to 365 days for both diagnostic resolution (aHR = 1.51; 95% confidence interval [CI] = 1.23 to 1.84; P < .001)) and treatment initiation (aHR = 1.43; 95% CI = 1.10 to 1.86; P < .007). Metaregression revealed that navigation had its greatest benefits within centers with the greatest delays in follow-up under usual care. CONCLUSIONS: Patient navigation demonstrated a moderate benefit in improving timely cancer care. These results support adoption of patient navigation in settings that serve populations at risk of being lost to follow-up.

Patient barriers to follow-up care for breast and cervical cancer abnormalities.

BACKGROUND: Women with breast or cervical cancer abnormalities can experience barriers to timely follow-up care, resulting in delays in cancer diagnosis. Patient navigation programs that identify and remove barriers to ensure timely receipt of care are proliferating nationally. The study used a systematic framework to describe barriers, including differences between African American and Latina women; to determine recurrence of barriers; and to examine factors associated with barriers to follow-up care. METHODS: Data originated from 250 women in the intervention arm of the Chicago Patient Navigation Research Program (PNRP). The women had abnormal cancer screening findings and navigator encounters. Women were recruited from a community health center and a publicly owned medical center. After describing proportions of African American and Latina women experiencing particular barriers, logistic regression was used to explore associations between patient characteristics, such as race/ethnicity, and type of barriers. RESULTS: The most frequent barriers occurred at the intrapersonal level (e.g., insurance issues and fear), while institutional-level barriers such as system problems with scheduling care were the most commonly recurring over time (29%). The majority of barriers (58%) were reported in the first navigator encounter. Latinas (81%) reported barriers more often than African American women (19%). Differences in race/ethnicity and employment status were associated with types of barriers. Compared to African American women, Latinas were more likely to report an intrapersonal level barrier. Unemployed women were more likely to report an institutional level barrier. CONCLUSION: In a sample of highly vulnerable women, there is no single characteristic (e.g., uninsured) that predicts what kinds of barriers a woman is likely to have. Nevertheless, navigators appear able to easily resolve intrapersonal-level barriers, but ongoing navigation is needed to address system-level barriers. Patient navigation programs can adopt the PNRP barriers framework to assist their efforts in assuring timely follow-up care.

Follow-up and timeliness after an abnormal cancer screening among underserved, urban women in a patient navigation program.

BACKGROUND: We evaluated the efficacy of a Chicago-based cancer patient navigation program developed to increase the proportion of patients reaching diagnostic resolution and reduce the time from abnormal screening test to definitive diagnostic resolution. METHODS: Women with an abnormal breast (n = 352) or cervical (n = 545) cancer screening test were recruited for the quasi-experimental study. Navigation subjects originated from five federally qualified health center sites and one safety net hospital. Records-based concurrent control subjects were selected from 20 sites. Control sites had similar characteristics to the navigated sites in terms of patient volume, racial/ethnic composition, and payor mix. Mixed-effects logistic regression and Cox proportional hazard regression analyses were conducted to compare navigation and control patients reaching diagnostic resolution by 60 days and time to resolution, adjusting for demographic covariates and site. RESULTS: Compared with controls, the breast navigation group had shorter time to diagnostic resolution (aHR = 1.65, CI = 1.20-2.28) and the cervical navigation group had shorter time to diagnostic resolution for those who resolved after 30 days (aHR = 2.31, CI = 1.75-3.06), with no difference before 30 days (aHR = 1.42, CI = 0.83-2.43). Variables significantly associated with longer time to resolution for breast cancer screening abnormalities were being older, never partnered, abnormal mammogram and BI-RADS 3, and being younger and Black for cervical abnormalities. CONCLUSIONS: Patient navigation reduces time from abnormal cancer finding to definitive diagnosis in underserved women. IMPACT: Results support efforts to use patient navigation as a strategy to reduce cancer disparities among socioeconomically disadvantaged women.

Analysis of combined data from heterogeneous study designs: an applied example from the patient navigation research program.

BACKGROUND: The Patient Navigation Research Program (PNRP) is a cooperative effort of nine research projects, with similar clinical criteria but with different study designs. To evaluate projects such as PNRP, it is desirable to perform a pooled analysis to increase power relative to the individual projects. There is no agreed-upon prospective methodology, however, for analyzing combined data arising from different study designs. Expert opinions were thus solicited from the members of the PNRP Design and Analysis Committee. PURPOSE: To review possible methodologies for analyzing combined data arising from heterogeneous study designs. METHODS: The Design and Analysis Committee critically reviewed the pros and cons of five potential methods for analyzing combined PNRP project data. The conclusions were based on simple consensus. The five approaches reviewed included the following: (1) analyzing and reporting each project separately, (2) combining data from all projects and performing an individual-level analysis, (3) pooling data from projects having similar study designs, (4) analyzing pooled data using a prospective meta-analytic technique, and (5) analyzing pooled data utilizing a novel simulated group-randomized design. RESULTS: Methodologies varied in their ability to incorporate data from all PNRP projects, to appropriately account for differing study designs, and to accommodate differing project sample sizes. LIMITATIONS: The conclusions reached were based on expert opinion and not derived from actual analyses performed. CONCLUSIONS: The ability to analyze pooled data arising from differing study designs may provide pertinent information to inform programmatic, budgetary, and policy perspectives. Multisite community-based research may not lend itself well to the more stringent explanatory and pragmatic standards of a randomized controlled trial design. Given our growing interest in community-based population research, the challenges inherent in the analysis of heterogeneous study design are likely to become more salient. Discussion of the analytic issues faced by the PNRP and the methodological approaches we considered may be of value to other prospective community-based research programs.

What is the role of free clinics in the safety net?

BACKGROUND: Free clinics play an important role in the safety net but little is known about what factors drive their existence within a given community. The anecdotal literature suggests that they exist due to growing numbers of uninsured and a lack of affordable care. OBJECTIVE: To determine whether unmet needs explain the existence of free clinics. MATERIALS AND METHODS: The relationship between demographics, Medicaid policy, and ambulatory safety-net care on the geographical distribution of all known free clinics (n=1007) across all metropolitan statistical areas (n=361) in the United States is investigated cross sectionally. Drawing from numerous secondary data sources and an original dataset of all known free clinics, a negative binomial model is used to examine whether free clinic prevalence is higher in communities with larger proportions of uninsured patients, poor adults, and African Americans and is lower in communities with greater availability of federally qualified health centers (FQHCs), FQHC look-alikes, and health departments, and more generous Medicaid eligibility for working parents and Medicaid beneficiary/provider payment levels. RESULTS AND DISCUSSION: None of the demographic variables has a positive, statistically significant relationship to the number of free clinics in a metropolitan statistical area. However, the number of FQHC grantees per 10,000 uninsured individuals [incidence rate ratios (IRR)=0.69, P<0.05], the number of FQHC look-alike sites per 10,000 uninsured individuals (IRR=0.46, P<0.05), Medicaid beneficiary payments (IRR=0.9998, P<0.05), and Medicaid eligibility levels (IRR=0.998, P<0.10) are negatively associated with the number of free clinics. Thus, free clinics seem to respond to particular gaps left by safety-net providers and Medicaid but do not seem to respond to direct need.

Structural and reliability analysis of a patient satisfaction with cancer-related care measure: a multisite patient navigation research program study.

BACKGROUND: Patient satisfaction is an important outcome measure of quality of cancer care and 1 of the 4 core study outcomes of the National Cancer Institute (NCI)-sponsored Patient Navigation Research Program to reduce race/ethnicity-based disparities in cancer care. There is no existing patient satisfaction measure that spans the spectrum of cancer-related care. The objective of this study was to develop a Patient Satisfaction With Cancer Care measure that is relevant to patients receiving diagnostic/therapeutic cancer-related care. METHODS: The authors developed a conceptual framework, an operational definition of Patient Satisfaction With Cancer Care, and an item pool based on literature review, expert feedback, group discussion, and consensus. The 35-item Patient Satisfaction With Cancer Care measure was administered to 891 participants from the multisite NCI-sponsored Patient Navigation Research Program. Principal components analysis (PCA) was conducted for latent structure analysis. Internal consistency was assessed using Cronbach coefficient alpha (α). Divergent analysis was performed using correlation analyses between the Patient Satisfaction With Cancer Care, the Communication and Attitudinal Self-Efficacy-Cancer, and demographic variables. RESULTS: The PCA revealed a 1-dimensional measure with items forming a coherent set explaining 62% of the variance in patient satisfaction. Reliability assessment revealed high internal consistency (α ranging from 0.95 to 0.96). The Patient Satisfaction With Cancer Care demonstrated good face validity, convergent validity, and divergent validity, as indicated by moderate correlations with subscales of the Communication and Attitudinal Self-Efficacy-Cancer (all P < .01) and nonsignificant correlations with age, primary language, marital status, and scores on the Rapid Estimate of Adult Literacy in Medicine Long Form (all P > .05). CONCLUSIONS: The Patient Satisfaction With Cancer Care is a valid tool for assessing satisfaction with cancer-related care for this sample.

Free clinics in the United States: a nationwide survey.

BACKGROUND: Since an increasing proportion of the US population is without health insurance, a network of free clinics has gradually developed to provide care for the uninsured. Despite widespread concern about the uninsured and the viability of the safety net, free clinics have been overlooked and poorly studied, leaving old assumptions and beliefs largely unchallenged. As a result, policy discussions have been forestalled and potentially fruitful collaborations between free clinics and other safety net providers have been hindered. The objective of this study is to describe the attributes of free clinics and measure their contribution to the safety net. METHODS: National mail survey of all known free clinics in the United States. The main outcome measures were organizational structures, operations, revenue sources, patient profiles, services, and staffing. RESULTS: The study represents the first census of free clinics in 40 years and garnered a 75.9% response rate. Overall, 1007 free clinics operated in 49 states and the District of Columbia. Annually, these clinics provided care for 1.8 million individuals, accounting for 3.5 million medical and dental visits. The mean operating budget was $287,810. Overall, 58.7% received no government revenue. Clinics were open a mean of 18 hours per week and generally provided chronic disease management (73.2%), physical examinations (81.4%), urgent/acute care (62.3%), and medications (86.5%). CONCLUSIONS: Free clinics operate largely outside of the safety net system. However, they have become an established and meaningful contributor to it. Policymakers should consider integrating the free clinic network with other safety net providers or providing direct financial support.