Expand and extend postpartum Medicaid to support maternal and child health.

Most early maternal deaths are preventable, with many occurring within the first year postpartum (we use the terms "maternal" and "mother" broadly to include all individuals who experience pregnancy or postpartum and frame our recognition of need and policy recommendations in gender-neutral terms. To acknowledge limitations inherent in existing policy and the composition of samples in prior research, we use the term "women" when applicable). Black, Hispanic, and Native American individuals are at the most significant risk of pregnancy-related death. They are more commonly covered by Medicaid, highlighting likely contributions of structural racism and consequent social inequities. State-level length and eligibility requirements for postpartum Medicaid vary considerably. Federal policy requires 60 days of Medicaid continuation postpartum, risking healthcare coverage loss during a critical period of heightened morbidity and mortality risk. This policy position paper aims to outline urgent risks to maternal health, detail existing federal and state-level efforts, summarize proposed legislation addressing the issue, and offer policy recommendations for legislative consideration and future study. A team of maternal health researchers and clinicians reviewed and summarized recent research and current policy pertaining to postpartum Medicaid continuation coverage, proposing policy solutions to address this critical issue. Multiple legislative avenues currently exist to support and advance relevant policy to improve and sustain maternal health for those receiving Medicaid during pregnancy, including legislation aligned with the Biden-Harris Maternal Health Blueprint, state-focused options via the American Rescue Plan of 2021 (Public Law 117-2), and recently proposed acts (HR3407, S1542) which were last reintroduced in 2021. Recommendations include (i) reintroducing previously considered legislation requiring states to provide 12 months of continuous postpartum coverage, regardless of pregnancy outcome, and (ii) enacting a revised, permanent federal mandate equalizing Medicaid eligibility across states to ensure consistent access to postpartum healthcare offerings nationwide.

Many maternal deaths happen within the first year postpartum and can be prevented. Black, Hispanic, and Native American mothers are at more risk for many reasons, including unfair systems and insufficient healthcare coverage from government insurance (Medicaid). Rules for getting Medicaid can be very different across states and in postpartum compared to pregnancy. The US government only requires states to continue providing Medicaid for 60 days postpartum, after which it is up to each state. If mothers are required to re-qualify for Medicaid shortly after giving birth, they could lose healthcare when they are at more risk of dying or getting sick. In this policy position paper, a team of maternal health researchers and clinicians reviewed and summarized recent research and current laws related to postpartum Medicaid to propose future laws that could address these issues. Some proposed laws would expand Medicaid coverage during postpartum, but lawmakers have not recently discussed them. This position paper recommends that lawmakers (i) consider laws that require states to provide 12 months of postpartum healthcare coverage and (ii) have the US government make the same rules to qualify for postpartum Medicaid across all states.

Contextualizing the experiences of Black pregnant women during the COVID-19 pandemic: 'It's been a lonely ride'.

The emergence of the COVID-19 pandemic significantly changed the prenatal care experience, specifically regarding medical appointments and social opportunities. It is critical to capture this change through the narratives of pregnant people, particularly those of marginalized populations, whose voices may often be underrepresented in the literature. This mixed-methods paper summarizes the experiences of 40 pregnant Black/African American (AA) women during the COVID-19 pandemic. A cross-sectional, online survey was administered between 2020 and 2021 to assess prenatal health and the impacts of the COVID-19 pandemic on patients' pregnancy experience. Coping behaviors during the pandemic were self-reported using the COPE-IS. Univariate analyses were conducted. An additional analysis of participants (n = 4) was explored through a week-long qualitative exercise using a photo documentation procedure. Photo-Elicitation Interviews (PEI) were conducted to capture and center their pandemic pregnancy experiences. Sources of stress during the pandemic varied, with the most common being financial concerns (n = 19, 47.5%). Over half of the sample (n = 18, 54.5%) self-reported increases in their positive coping behaviors during the pandemic, such as communicating with friends and family, talking to healthcare providers, listening to music, and engaging in spiritual practices-such as prayer. The four PEI study participants reflected on the impacts of social distancing on their prenatal experience and mentioned hospital and provider-related weariness due to their race. The findings of this study suggest that during the COVID-19 pandemic, Black/AA pregnant women in Charlotte, NC used social support, mindfulness practices, self-advocacy, and health literacy to navigate challenges present during their prenatal health experience. This paper highlights the personal, social, and structural experiences of pregnant women during a public health crisis so that responsive and effective programs or policies can be planned in the future.

Implementation of Coach McLungsSM into primary care using a cluster randomized stepped wedge trial design.

BACKGROUND: Asthma is a prevalent chronic disease that is difficult to manage and associated with marked disparities in outcomes. One promising approach to addressing disparities is shared decision making (SDM), a method by which the patient and provider cooperatively make a decision about asthma care. SDM is associated with improved outcomes for patients; however, time constraints and staff availability are noted implementation barriers. Use of health information technology (IT) solutions may facilitate the utilization of SDM. Coach McLungsSM is a collaborative web-based application that involves pediatric patients, their caregivers, and providers in a personalized experience while gathering patient-reported data. Background logic provides decision support so both audiences can develop a well-informed treatment plan together. The goal of this study is to evaluate the implementation of the Coach McLungsSM intervention into primary care. METHODS: Implementation will be evaluated using a stepped wedge randomized control study design at 21 pediatric and family medicine practices within a large, integrated, nonprofit healthcare system. We will measure changes in emergency department visits, hospitalizations, and oral steroid use, which serve as surrogate measures for patient-centered asthma outcomes. We will use a generalized linear mixed models with logit link to test the hypothesis for the reduction in exacerbation rates specifying the fixed effects of intervention and time and random effects for practice and practice*time. This design achieves 84% power to detect the hypothesized effect size difference of 10% in overall exacerbation between control (40%) and intervention (30%) periods (two-sided, p = 0.05). Implementation will be guided using the Expert Recommendations for Implementing Change (ERIC), a compilation of implementation strategies, and evaluated using the CFIR (Consolidated Framework for Implementation Research) and RE-AIM (Reach Effectiveness, Adoption, Implementation, Maintenance). DISCUSSION: We anticipate that a tailored implementation of Coach McLungsSM across diverse primary care practices will lead to a decrease in emergency department visits, hospitalizations, and oral steroid use for patients in the intervention group as compared to the control condition. TRIAL REGISTRATION: Clincaltrials.gov, NCT05059210. Registered 28 September 2021, https://www. CLINICALTRIALS: gov/ct2/show/NCT05059210.

Primary Care Evaluation of a Hepatitis C Virus (HCV) Screening Education Intervention.

INTRODUCTION: Increased screening efforts and the development of effective antiviral treatments have led to marked improvement in Hepatitis C (HCV) patient outcomes. However, many people in the US are believed to have undiagnosed HCV. Successful screening strategies and access to a coordinated system of care are critical for HCV affected adults. The objective of this study was to evaluate a primary care HCV screening education intervention that took place 2018 to 2019 to improve primary care training and management of patients after the implementation of the electronic medical record (EMR) screening alert. METHODS: Using 15 primary care practices located in vicinity of neighborhoods at-risk for higher rates of HCV infections, a stepped wedge randomized control study design was utilized to deliver an educational screening intervention. The education intervention was implemented sequentially with 5 practices being presented to every 3 months. Number of patients within the Baby Boomer cohort (birth years 1945-1965) were collected 3 months before the first practice receiving the intervention to 3 months after the last practice receiving the education intervention. The main outcome collected was the HCV screening. Generalized linear mixed models were used to test the hypothesis of improved screening rates after intervention implementation. RESULTS: There were a total of 85,697 patients within the Baby Boomer cohort seen at the 15 practices. Practices receiving the intervention had patients who were more likely to be screened for HCV (ß = 0.259, P < .001; Odds Ratio [OR] [95%CI] 1.296 [1.098-1.529]).In terms of demographics, results showed that females are less likely to be screened than males (ß = -0.141, P < .001; OR [95%CI] 0.868[0.813 to 0.927]), Baby Boomer patients aged less than 65 were more likely to be screened than Baby Boomer patients aged 65 and older (ß = 0.293, P < .001; OR [95%CI] 1.340[1.251 to 1.436]). DISCUSSION: This study looked at screening rates before and after an educational intervention which happened subsequent to the activation of an EMR alert. Whereas HCV EMR alerts showed an increase in HCV screenings before the education intervention, the addition of the education showed a modest increase in HCV screening rates for Baby Boomer patients.

Comparing race and ethnicity across safety-net and non-safety net practices pre- and post-an HIV screening alert.

CONTEXT: Societal and economic burdens of human immunodeficiency virus (HIV) continue to grow, even as treatments and prevention for this disease becomes more readily available and efficacious. HIV screening is more likely to be performed in minority (including Black) patient populations compared to whites. The likelihood of getting screened also depends on primary care practice attributes. OBJECTIVE: Evaluate HIV screening demographics by safety-net and non-safety net practices. STUDY DESIGN and ANALYSIS: Pre-post analysis. SETTING: Atrium Health is a non-profit, vertically integrated healthcare system with approximately 16 million patient encounters per year across the Southeast US. POPULATION STUDIED: Twelve primary care practices, including four safety-net practices serving predominantly Medicaid and uninsured patients, with over 115,00 patients between the ages of 18 and 64 were selected for the educational intervention. INTERVENTION/INSTRUMENT: A system-wide electronic medical record alert prompting HIV screening was implemented in October 2017 targeting adults between 18-64 years old. In addition to the system alert, a provider peer-to-peer educational program detailing HIV disease epidemiology, screening recommendations, and algorithms to guide screening efforts was developed. OUTCOME MEASURES: HIV screenings. RESULTS: From October 2016- April 2017, 3,413 patients were screened for HIV at the twelve participating primary care practices. Immediately after the HIV alert activation, from October 2017 - April 2018, 6,256 patients were screened, resulting in an 83% increase in screening. However, increases were different based on practice type, race and ethnicity. Black patients in safety net clinics had higher screening rates prior to the alert and showed less of an increase in screening (37%) compared to whites (102%) after the alert was activated. Hispanic/Latino patients showed similar increases at both safety net (99%) and non-safety net (108%) practices. Both Black and white patients showed larger increases of 99% and 139% in non-safety net clinics. Chi-squared analysis comparing the percentage of patients screened during these time periods was significantly different (p=0.001). CONCLUSION: While race and practice characteristics influence the likelihood of HIV screening, EMR modifications and provider education can significantly enhance screening and care for patients with HIV regardless of race and practice type.

Using the Consolidated Framework for Implementation Research (CFIR) to evaluate implementation effectiveness of a facilitated approach to an asthma shared decision making intervention.

OBJECTIVE: To describe the evaluation of implementation effectiveness of an asthma shared decision making (SDM) intervention at the 10 individual facilitator-led primary care practices in the ADAPT-NC Study using the Consolidated Framework for Implementation Research (CFIR). METHODS: Practices were scored across 40 CFIR constructs within 5 domains using a previously published scoring system of -2 to +2. Based on overall construct scores, practices were then classified as high, medium, or low adopters. To evaluate clinical outcomes, changes in asthma exacerbations were assessed for emergency department (ED) visits, hospitalizations, and oral steroid prescription orders. Using regression analysis, the absolute change in percent for each outcome relative to the CFIR score for each practice was analyzed. (Trial registration #NCT02047929). RESULTS: Implementation effectiveness was reflected in CFIR score differences with 7 high, 1 medium, and 2 low adopter practices. High adopters mostly scored well across all domains. Weaknesses were consistent amongst the 2 low adopters with lower scores in the Inner Setting, Characteristics of Individuals, and Process domains. While no significant correlations were seen between the practices' CFIR scores and the absolute change in ED visits, hospitalizations, or oral steroid prescription orders, practices with higher percentages of children had greater improvements in clinical outcomes. CONCLUSIONS: The CFIR was used to evaluate the asthma SDM intervention implementation at 10 facilitator-led practices. While there was no significant correlation between higher implementation effectiveness and greater improvement in clinical outcomes, practices with a higher proportion of pediatric patients did experience a significant reduction in overall exacerbations post-implementation.

Evaluation of a shared decision-making intervention for pediatric patients with asthma in the emergency department.

BACKGROUND: Asthma is a difficult-to-manage chronic disease marked with associated outcome disparities including an increase rate of emergency department (ED) visits for uncontrolled asthma among patients who are most at-risk. Shared decision making (SDM) is a process by which the patient and provider jointly make a healthcare choice. SDM improves patient outcomes; however, implementation barriers of time constraints and staff availability are limitations. The use of health IT solutions may increase the adoption of SDM, but best practices for implementation are not well understood. The Consolidated Framework for Implementation Research (CFIR) is a flexible comprehensive model used to identify barriers and facilitators influencing implementation. The goal of this study is to implement an innovative web-based pediatric SDM tool in the real-world setting of two large healthcare system EDs through the following aims: (1) convene a patient, research, and ED stakeholder advisory board to oversee review of protocol and study materials prior to implementation, (2) implement the SDM intervention where providers and staff will be trained to incorporate use of this SDM intervention, (3) conduct on-going evaluation of barriers, facilitators, and implementation outcomes to tailor implementation in the EDs, (4) evaluate patient-centered outcomes of primary care utilization and changes in ED visits and hospitalizations before and after the SDM intervention, and (5) understand and document best practices for ED implementation. METHODS: The CFIR model will guide the implementation evaluation. Researchers will administer surveys to the clinical team and patients at baseline, 3, 6, and 12 months to inform implementation design, determine barriers and facilitators, and resource-needs to allow for real-time process adjustments within the EDs. Focus group or key-informant interviews and analysis will provide additional feedback to the stakeholder team to iterate the implementation process. Researchers will track patient-centered outcomes including increased primary care, ED, and inpatient utilization over the duration of the study. DISCUSSION: To advance asthma care and the field of implementation science, further research is needed to assess best practices for incorporating SDM into high-need healthcare settings such as the ED. This knowledge will facilitate improved outcomes and appropriate policy changes towards further use of SDM interventions in local and national acute care settings.

Research nurses as practice facilitators to disseminate an asthma shared decision making intervention.

BACKGROUND: Practice facilitation is a method of introducing and sustaining organizational change. It involves the use of skilled healthcare professionals called practice facilitators (PFs) to help address the challenges associated with implementing evidence-based guidelines and complex interventions into practice. PFs provide a framework for translating research into practice by building relationships, improving communication, fostering change, and sharing resources. Nurses are well positioned to serve as PFs for the implementation of complex interventions, however, there is little evidence currently available to describe nurses in this role. Additionally, the best strategies to implement complex interventions into practices are still not fully understood. Combining practice facilitation with the train-the-trainer model has the potential to spread knowledge and skills. Shared decision making (SDM), which involves patients and providers jointly engaging in decisions around treatment options, has been shown to improve outcomes for patients with asthma. The goal of this manuscript is to describe and evaluate the practice facilitation process from the ADAPT-NC Study which successfully utilized research nurses to implement a complex asthma SDM toolkit intervention into primary care practices. METHODS: As part of a larger study, 10 primary care practices were recruited for a facilitator-led dissemination intervention involving a 12-week rollout of an asthma SDM toolkit (trial registration: 1.28.2014, #NCT02047929). An experienced lead PF trained research nurses as PFs from each of the 4 participating practice-based research networks (PBRNs) in a train-the-trainer model utilizing a one-day training event and subsequent remote meetings. Evaluation of PF engagement was measured through process improvement surveys. RESULTS: Overall, the asthma SDM intervention was successfully implemented within the 4 PBRNs. All 10 facilitator-led practices remained engaged with their PFs, with 8 out of the 10 practices able to incorporate and sustain SDM visits or clinics. Responses from the surveys for process improvement yielded improved PF communication and team dynamics over time. CONCLUSIONS: This study demonstrated effective use of research nurses as practice facilitators during the dissemination of an asthma SDM intervention into primary care practices, adding to the knowledge of best practices by describing a model of large-scale implementation of a complex intervention through practice facilitation with nurses. TRIAL REGISTRATION: "Comparing Traditional and Participatory Dissemination of a Shared Decision Making Intervention" was retrospectively registered at https://clinicaltrials.gov/ on January 28th, 2014 (NCT02047929).

Novel Models to Identify Census Tracts for Hepatitis C Screening Interventions.

BACKGROUND: Increased screening efforts and the development of effective antiviral treatments have led to marked improvement in hepatitis C (HCV) patient outcomes. However, many people in the United States are still believed to have undiagnosed HCV. Geospatial modeling using variables representing at-risk populations in need of screening for HCV and social determinants of health (SDOH) provide opportunities to identify populations at risk of HCV. METHODS: A literature review was conducted to identify variables associated with patients at risk for HCV infection. Two sets of variables were collected: HCV Transmission Risk and SDOH Level of Need. The variables were combined into indices for each group and then mapped at the census tract level (n = 233). Multiple linear regression analysis and the Pearson correlation coefficient were used to validate the models. RESULTS: A total of 4 HCV Transmission Risk variables and 12 SDOH Level of Need variables were identified. Between the 2 indexes, 21 high-risk census tracts were identified that scored at least 2 standard deviations above the mean. The regression analysis showed a significant relationship with HCV infection rate and prevalence of drug use (B = 0.78, P < .001). A significant relationship also existed with the HCV infection rate for households with no/limited English use (B = -0.24, P = .001), no car use (B = 0.036, P < .001), living below the poverty line (B = 0.014, P = .009), and median household income (B = -0.00, P = .009). CONCLUSIONS: Geospatial models identified high-priority census tracts that can be used to map high-risk HCV populations that may otherwise be unrecognized. This will allow future targeted screening and linkage-to-care interventions for patients at high risk of HCV.

What types of dissemination of information occurred between researchers, providers and clinical staff while implementing an asthma shared decision-making intervention: a directed content analysis.

OBJECTIVE: To qualitatively analyse different types of dissemination of information during monthly group calls between researchers, providers and clinical staff used to establish best practices for implementing an asthma shared decision-making (SDM) intervention. Evaluating dissemination of information can provide a better understanding of how best practices are shared, informing implementation approaches to improve the uptake of new evidence and overcome barriers. SETTING: 10 primary care practices in North Carolina. PARTICIPANTS: Providers and clinical staff participated in monthly group phone calls with researchers to share best practices during implementation of a SDM intervention for asthma patients. DESIGN: The research team transcribed and coded statements using content analysis into three different knowledge types: Knowledge Position, Knowledge Form and Knowledge Object. Knowledge Objects were further classified using directed content analysis where the research team interpreted the content objects through a classification process of identifying themes or patterns to describe three different types of dissemination of information: (A) Confirmation of Existing Knowledge, (B) Generation of New Knowledge and (C) Spreading of New Knowledge. RESULTS: Across the 8 transcripts, 4 Knowledge Positions, 7 Knowledge Forms and 18 types of Knowledge Objects were identified. From the Knowledge Objects, Confirmation of Existing Knowledge occurred during the training of participating practices. The review also identified Generation of New Knowledge by providers and clinical staff raised in these calls. This Generation of New Knowledge was later documented being used by other practices with the identification of Spreading of New Knowledge. CONCLUSION: The research team described the types of dissemination of information that occurred between researchers, providers and clinical staff during implementation of an asthma SDM intervention. Both Confirmation of Existing Knowledge and Generation of New Knowledge in response to barriers occurred. These exploratory dissemination of information results provide additional mechanisms for evaluating implementation science. TRIAL REGISTRATION NUMBER: NCT02047929; Post-results.

Electronic medical record alert activation increase hepatitis C and HIV screening rates in primary care practices within a large healthcare system.

Societal and economic burdens of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) continue to grow. The Centers for Disease Control and Prevention recommends a one-time HCV screen for individuals in the Baby Boomer population (those born between 1945 and 1965) and a one-time HIV screen for all individuals between ages 13-64 years regardless of risk factors, with more frequent screening for both conditions based on individual risk factors. This study took place at Atrium Health, a healthcare system with approximately 12 million patient encounters per year. The aims of this study were to assess the impact of the HCV and HIV electronic medical record (EMR) alerts recently implemented on screening rates and linkage to care. Data were collected from 12 primary care practices. Implementation of EMR alerts increased HCV and HIV screening from 1,934 of 59,632 (3.2%) to 13,726 of 60,422 (22.7%) and 6,950 of 112,813 (6.2%) to 12,379 of 109,173 (11.3%) respectively. The HCV screening resulted in an increase of patients with antibody positive results having a subsequent RNA test from 68% (122/179) to 98% (430/442). 74 of 81 (91%) of HCV and 15 of 15 (100%) of HIV positive patients were linked into care. The addition of an EMR alert was associated with improved screening for HCV and HIV in primary care practices. Screening all patients decreases testing stigma since there is a lowered risk of disease transmission for those who test positive. However, post-intervention screening rates indicate further opportunities exist for additional interventions to increase screening rates.

Asthma dissemination around patient-centered treatments in North Carolina (ADAPT-NC): a cluster randomized control trial evaluating dissemination of an evidence-based shared decision-making intervention for asthma management.

Objective: To compare three dissemination approaches for implementing an asthma shared decision-making (SDM) intervention into primary care practices. Methods: We randomized thirty practices into three study arms: (1) a facilitator-led approach to implementing SDM; (2) a one-hour lunch-and-learn training on SDM; and (3) a control group with no active intervention. Patient perceptions of SDM were assessed in the active intervention arms using a one-question anonymous survey. Logistic regression models compared the frequency of asthma exacerbations (emergency department (ED) visits, hospitalizations, and oral steroid prescriptions) between the three arms. Results: We collected 705 surveys from facilitator-led sites and 523 from lunch-and-learn sites. Patients were more likely to report that they participated equally with the provider in making the treatment decision in the facilitator-led sites (75% vs. 66%, p = 0.001). Comparisons of outcomes for patients in the facilitator-led (n = 1,658) and lunch-and-learn (n = 2,613) arms respectively vs. control (n = 2,273) showed no significant differences for ED visits (Odds Ratio [OR] [95%CI] = 0.77[0.57-1.04]; 0.83[0.66-1.07]), hospitalizations (OR [95%CI] = 1.30[0.59-2.89]; 1.40 [0.68-3.06]), or oral steroids (OR [95%CI] =0.95[0.79-1.15]; 1.03[0.81-1.06]). Conclusion: Facilitator-led dissemination was associated with a significantly higher proportion of patients sharing equally in decision-making with the provider compared to a traditional lunch-and-learn approach. While there was no significant difference in health outcomes between the three arms, the results were most likely confounded by a concurrent statewide asthma initiative and the pragmatic implementation of the intervention. These results offer support for the use of structured approaches such as facilitator-led dissemination of complex interventions into primary care practices.

Patient and Family Engagement in the Design of a Mobile Health Solution for Pediatric Asthma: Development and Feasibility Study.

BACKGROUND: Asthma is a highly prevalent, chronic disease with significant morbidity, cost, and disparities in health outcomes. While adherence to asthma treatment guidelines can improve symptoms and decrease exacerbations, most patients receive care that is not guideline-based. New approaches that incorporate shared decision-making (SDM) and health information technology (IT) are needed to positively impact asthma management. Despite the promise of health IT to improve efficiency and outcomes in health care, new IT solutions frequently suffer from a lack of widespread adoption and do not achieve desired results, as a consequence of not involving end-users in design. OBJECTIVE: To describe a case study of a pediatric asthma SDM health IT solution's development and demonstrate a methodology for engaging actual patients and families in IT development. Perspectives are shared from the vantage point of the research team and a parent of a child with asthma, who participated on the development team. METHODS: We adapted user-centric design principles to engage actual users across three main development phases: project initiation, ideation, and usability testing. To facilitate the necessary level of user engagement, our approach included: (1) a Development Workgroup consisting of patients, caregivers, and providers who met regularly with the research team; and (2) "real-world users" consisting of patients, caregivers, and providers recruited from a variety of care locations, including safety-net clinics. RESULTS: Using this methodology, we successful partnered with asthma patients and families to create an interactive, digital solution called Carolinas Asthma Coach. Carolinas Asthma Coach incorporates SDM principles to elicit patient information, including goals and preferences, and provides health-literate, tailored education with specific guideline-based recommendations for patients and their providers. Of the patients, caregivers, and providers surveyed, 100% (n=60) said they would recommend Carolinas Asthma Coach to a friend or colleague. Qualitative feedback from users provided support for the usability and engaging nature of the app. CONCLUSIONS: This project demonstrates the feasibility and benefits of deploying user-centric design methods that engage real patients and caregivers throughout the health IT design process.

Impact of shared decision making on asthma quality of life and asthma control among children.

OBJECTIVE: Few studies have examined the effectiveness of shared decision making (SDM) in clinical practice. This study evaluated the impact of SDM on quality of life and symptom control in children with asthma. METHODS: We conducted a prospective 3-year study in six community-based practices serving a low-income patient population. Practices received training on SDM using an evidence-based toolkit. Patients aged 2-17 with a diagnosis of asthma were identified from scheduling and billing data. At approximate 6-month intervals, patients completed a survey consisting of the Mini Pediatric Asthma Quality of Life Questionnaire (range 1-7) and the control domain of the Pediatric Asthma Therapy Assessment Questionnaire (range 0-7). We used propensity scores to match 46 children receiving SDM to 46 children receiving usual care with decision support. Included children had completed a baseline survey and at least one follow-up survey. Random coefficient models incorporated repeated measures to assess the effect of SDM on asthma quality of life and asthma control. RESULTS: The sample was primarily of non-White patients (94.6%) with Medicaid insurance (92.4%). Receipt of SDM using an evidence-based toolkit was associated with higher asthma quality of life [mean difference 0.9; 95% confidence interval (CI) 0.4-1.4] and fewer asthma control problems (mean difference -0.9; 95% CI -1.6--0.2) compared to usual care with decision support. CONCLUSIONS: Implementation of SDM within clinical practices using a standardized toolkit is associated with improved asthma quality of life and asthma control for low-income children with asthma when compared to usual care with decision support.

Results from a pragmatic prospective cohort study: Shared decision making improves outcomes for children with asthma.

OBJECTIVE: Patient/provider shared decision making (SDM) improves asthma control in a pragmatic clinical trial setting. This study evaluated the impact of an evidence-based SDM toolkit on outcomes for patients with asthma implemented by providers in a real world setting. We hypothesized that these patients with asthma would demonstrate improved outcomes such as reduced emergency department (ED) visits, hospitalizations, and oral steroid use in the 12 months following a SDM visit compared to those who did not receive the intervention. METHODS: Patients with asthma were identified within six primary care practices that serve vulnerable populations in Charlotte, NC (746 children; 718 adult patients). Propensity scores were used to match 200 children and 206 adults for analysis. The primary outcome variable was asthma exacerbation defined as an ED visit or hospitalization for asthma or outpatient prescription of an oral steroid. Patients were monitored at 3, 6, and 12 months after the intervention date. The outcome variables of ED visits, hospitalizations, and oral steroids were compared between intervention and matched control patients. RESULTS: The proportion of pediatric patients with one or more exacerbations was significantly lower in the SDM intervention group compared to controls during 12 months after exposure to the intervention (33% vs. 47%, p = 0.023). For adults, there was not a strong association between use of the SDM intervention and outcomes improvement. CONCLUSIONS: The evidence-based SDM intervention implemented in this study was associated with improved asthma outcomes for pediatric patients but not adult patients in a real world clinical setting.

Evaluation of a Pilot Asthma Care Program for Electronic Communication between School Health and a Healthcare System's Electronic Medical Record.

OBJECTIVE: Asthma is a common childhood chronic lung disease affecting greater than 10% of children in the United States. School nurses are in a unique position to close gaps in care. Indeed, effective asthma management is more likely to result when providers, family, and schools work together to optimize the patient's treatment plan. Currently, effective communication between schools and healthcare systems through electronic medical record (EMR) systems remains a challenge. The goal of this feasibility pilot was to link the school-based care team with primary care providers in the healthcare system network via electronic communication through the EMR, on behalf of pediatric asthma patients who had been hospitalized for an asthma exacerbation. The implementation process and the potential impact of the communication with providers on the reoccurrence of asthma exacerbations with the linked patients were evaluated. METHODS: By engaging stakeholders from the school system and the healthcare system, we were able to collaboratively design a communication process and implement a pilot which demonstrated the feasibility of electronic communication between school nurses and primary care providers. Outcomes data was collected from the electronic medical record to examine the frequency of asthma exacerbations among patients with a message from their school nurse. The percent of exacerbations in the 12 months before and after electronic communication was compared using McNemar's test. RESULTS: The pilot system successfully established communication between the school nurse and primary care provider for 33 students who had been hospitalized for asthma and a decrease in hospital admissions was observed with students whose school nurse communicated through the EMR with the primary care provider. CONCLUSIONS: Findings suggest a collaborative model of care that is enhanced through electronic communication via the EMR could positively impact the health of children with asthma or other chronic illnesses.

The use of carbon thirteen nuclear magnetic resonance spectra to predict dioxin and furan binding affinities to the aryl hydrocarbon receptor.

Four spectroscopic data-activity relationship (SDAR) models for polychlorinated dibenzofurans (PCDFs) and dibenzodioxins (PCDDs) binding to the aryl hydrocarbon receptor (AhR) have been developed based on simulated 13C nuclear magnetic resonance (NMR) data. Models were developed using discriminant function analysis of the compounds' spectral data. An SDAR model with two classifications for 26 PCDF compounds had a leave-one-out (LOO) cross-validation accuracy of 89%. A two-classification SDAR model for 14 PCDD compounds had LOO cross-validation accuracy of 95%. A two-classification SDAR model combining 14 PCDD and 26 PCDF compounds had LOO cross-validation accuracy of 88%, while a four-classification SDAR model based on the same 14 PCDD and 26 PCDF compounds had LOO cross-validation accuracy of 92%. We used each appropriate SDAR model to classify 41 PCDD and/or 121 PCDF compounds with unknown binding affinities to the AhR. The SDAR models provide a rapid, simple, and valid way to model the PCDF and PCDD binding activity in relation to the AhR.