Pregnancy health in a multi-state U.S. population of systemically underserved patients and their children: PROMISE cohort design and baseline characteristics.

BACKGROUND: Gestational weight gain (GWG) is a routinely monitored aspect of pregnancy health, yet critical gaps remain about optimal GWG in pregnant people from socially marginalized groups, or with pre-pregnancy body mass index (BMI) in the lower or upper extremes. The PROMISE study aims to determine overall and trimester-specific GWG associated with the lowest risk of adverse birth outcomes and detrimental infant and child growth in these underrepresented subgroups. This paper presents methods used to construct the PROMISE cohort using electronic health record data from a network of community-based healthcare organizations and characterize the cohort with respect to baseline characteristics, longitudinal data availability, and GWG. METHODS: We developed an algorithm to identify and date pregnancies based on outpatient clinical data for patients 15 years or older. The cohort included pregnancies delivered in 2005-2020 with gestational age between 20 weeks, 0 days and 42 weeks, 6 days; and with known height and adequate weight measures needed to examine GWG patterns. We linked offspring data from birth records and clinical records. We defined study variables with attention to timing relative to pregnancy and clinical data collection processes. Descriptive analyses characterize the sociodemographic, baseline, and longitudinal data characteristics of the cohort, overall and within BMI categories. RESULTS: The cohort includes 77,599 pregnancies: 53% had incomes below the federal poverty level, 82% had public insurance, and the largest race and ethnicity groups were Hispanic (56%), non-Hispanic White (23%) and non-Hispanic Black (12%). Pre-pregnancy BMI groups included 2% underweight, 34% normal weight, 31% overweight, and 19%, 8%, and 5% Class I, II, and III obesity. Longitudinal data enable the calculation of trimester-specific GWG; e.g., a median of 2, 4, and 6 valid weight measures were available in the first, second, and third trimesters, respectively. Weekly rate of GWG was 0.00, 0.46, and 0.51 kg per week in the first, second, and third trimesters; differences in GWG between BMI groups were greatest in the second trimester. CONCLUSIONS: The PROMISE cohort enables characterization of GWG patterns and estimation of effects on child growth in underrepresented subgroups, ultimately improving the representativeness of GWG evidence and corresponding guidelines.

Differences in up-to-date colorectal and cervical cancer screening rates by ethnicity and preferred language: An analysis across patient-, clinic-, and area-level data sources.

Research objective: There is interest in using clinic- and area-level data to inform cancer control, but it is unclear what value these sources may add in combination with patient-level data sources. This study aimed to investigate associations of up-to-date colorectal and cervical cancer screenings at community health centers (CHCs) with ethnicity and language variables at patient-, clinic-, and area-levels, while exploring whether patient-level associations differed based on clinic-level patient language and ethnicity distributions. Study design: This was a cross-sectional study using data from multiple sources, including electronic health records, clinic patient panel data, and area-level demographic data. The study sample included English-preferring Hispanic, Spanish-preferring Hispanic, English-preferring non-Hispanic, and non-English-preferring non-Hispanic patients eligible for either colorectal cancer (N = 98,985) or cervical cancer (N = 129,611) screenings in 2019 from 130 CHCs in the OCHIN network in CA, OR, and WA. Population studied: The study population consisted of adults aged 45+ eligible for colorectal cancer screening and adults with a cervix aged 25-65 eligible for cervical cancer screening. Principal findings: Spanish-preferring Hispanic patients were significantly more likely to be up-to-date with colorectal and cervical cancer screenings than other groups. Patients seen at clinics with higher concentrations of Spanish-preferring Hispanics were significantly more likely to be up-to-date, as were individuals residing in areas with higher percentages of Spanish-speaking residents. Differential associations between patient ethnicity and language and up-to-date colorectal cancer screenings were greater among patients seen at clinics with higher concentrations of Spanish-preferring Hispanics. Conclusions: The findings highlight that Spanish-speaking Hispanics seen in CHCs have higher rates of up-to-date cervical and colorectal cancer screenings than other groups and that this relationship is stronger at clinics with higher percentages of Spanish-preferring Hispanic patients. Our findings suggest area-level variables are not good substitutions for patient-level data, but variables at the clinic patient panel-level are more informative.

The Tech4Rest Randomized Controlled Trial: Applying the Hierarchy of Controls to Advance the Sleep, Health, and Well-being of Team Truck Drivers.

OBJECTIVE: The aim of the study was to evaluate the effectiveness of interventions to improve sleep, reduce fatigue, and advance the well-being of team truck drivers. METHODS: In a randomized controlled trial ( k = 24 teams; N = 49 drivers; 61.3% of planned sample), intervention teams were exposed to baseline (3-4 weeks), cab enhancements (active suspension seat, therapeutic mattress; 3-4 weeks), and cab enhancements plus a behavioral sleep-health program (1-2 months). Control teams worked as usual during the same period. RESULTS: Trends in sleep-related outcomes favored the intervention. Large and statistically significant intervention effects were observed for objectively measured physical activity (a behavioral program target). The discussion of results addresses effect sizes, statistical power, intervention exposure, and work organization. CONCLUSIONS: Trends, effect sizes, and significant findings in this rare trial provide valuable guidance for future efforts to improve working conditions and outcomes for team drivers.

Latino Adolescent-Mother Language Concordance, Neighborhood Deprivation, and Vaccinations in Community Health Centers.

INTRODUCTION: Latino adolescents may face numerous barriers) to recommended vaccinations. There is little research on the association between Latino adolescent-mother preferred language concordance and vaccination completion and if it varies by neighborhood. To better understand the social/family factors associated with Latino adolescent vaccination, we studied the association of adolescent-mother language concordance and neighborhood social deprivation with adolescent vaccination completion. METHODS: We employed a multistate, electronic health record (EHR) based dataset of community health center patients to compare three Latino groups: (1) English-preferring adolescents with English-preferring mothers, (2) Spanish-preferring adolescents with Spanish-preferring mothers, and (3) English-preferring adolescents with Spanish-preferring mothers with non-Hispanic white adolescent-mother pairs for human papilloma virus (HPV), meningococcal, and influenza vaccinations. We adjusted for mother and adolescent demographics and care utilization and stratified by the social deprivation of the family's neighborhood. RESULTS: Our sample included 56,542 adolescent-mother dyads. Compared with non-Hispanic white dyads, all three groups of Latino dyads had higher odds of adolescent HPV and meningococcal vaccines and higher rates of flu vaccines. Latino dyads with Spanish-preferring mothers had higher vaccination odds/rates than Latino dyads with English-preferring mothers. The effects of variation by neighborhood social deprivation in influenza vaccination rates were minor in comparison to differences by ethnicity/language concordance. CONCLUSION: In a multistate analysis of vaccinations among Latino and non-Latino adolescents, English-preferring adolescents with Spanish-preferring mothers had the highest completion rates and English-preferring non-Hispanic white dyads the lowest. Further research can seek to understand why this language dyad may have an advantage in adolescent vaccination completion.

Latino adolescents may face numerous barriers to preventive care­especially routine immunizations, but analyses often focus on single or few factors that may affect the utilization of these services. Our analysis of not only the language preference of Latino adolescents, but the preferred language of their mothers and their neighborhood social adversity demonstrates that English-preferring Latino adolescents with Spanish preferring mothers were most likely to utilize all immunizations we studied, and there were differences in utilization among Latino families by language concordance. This adds to our knowledge of Latino adolescent health care utilization by demonstrating the differences in Latino families, and suggesting that many of these families may have assets for service utilization from which we can learn.

How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?

INTRODUCTION: To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care. METHODS: Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable: Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach. RESULTS: Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001) and smoking performance (+6.43%, P = .003). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes. DISCUSSION: Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.

Effective Facilitator Strategies for Supporting Primary Care Practice Change: A Mixed Methods Study.

PURPOSE: Practice facilitation is an evidence-informed implementation strategy to support quality improvement (QI) and aid practices in aligning with best evidence. Few studies, particularly of this size and scope, identify strategies that contribute to facilitator effectiveness. METHODS: We conducted a sequential mixed methods study, analyzing data from EvidenceNOW, a large-scale QI initiative. Seven regional cooperatives employed 162 facilitators to work with 1,630 small or medium-sized primary care practices. Main analyses were based on facilitators who worked with at least 4 practices. Facilitators were defined as more effective if at least 75% of their practices improved on at least 1 outcome measure-aspirin use, blood pressure control, smoking cessation counseling (ABS), or practice change capacity, measured using Change Process Capability Questionnaire-from baseline to follow-up. Facilitators were defined as less effective if less than 50% of their practices improved on these outcomes. Using an immersion crystallization and comparative approach, we analyzed observational and interview data to identify strategies associated with more effective facilitators. RESULTS: Practices working with more effective facilitators had a 3.6% greater change in the mean percentage of patients meeting the composite ABS measure compared with practices working with less effective facilitators (P <.001). More effective facilitators cultivated motivation by tailoring QI work and addressing resistance, guided practices to think critically, and provided accountability to support change, using these strategies in combination. They were able to describe their work in detail. In contrast, less effective facilitators seldom used these strategies and described their work in general terms. Facilitator background, experience, and work on documentation did not differentiate between more and less effective facilitators. CONCLUSIONS: Facilitation strategies that differentiate more and less effective facilitators have implications for enhancing facilitator development and training, and can assist all facilitators to more effectively support practice changes.

How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?

INTRODUCTION: To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care. METHODS: Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable: Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach. RESULTS: Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001) and smoking performance (+6.43%, P = .003). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes. DISCUSSION: Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.

Improving Delivery of Cardiovascular Disease Preventive Services in Small-to-Medium Primary Care Practices.

BACKGROUND: The EvidenceNOW initiative provided smaller primary care practices with external support interventions to implement quality improvement strategies focused on cardiovascular disease prevention. This manuscript reports effectiveness of EvidenceNOW interventions in improving quality metrics. METHODS: Seven regional Cooperatives delivered external support interventions (practice facilitation, health information technology support to assist with audit and feedback, performance benchmarking, learning collaboratives, and establishing community linkages) to 1278 smaller primary care practices. Outcomes included proportion of eligible patients meeting Centers for Medicaid and Medicare Services-specified ABCS metrics, that is, Aspirin for those at risk of ischemic vascular disease; achieving target Blood pressure among hypertensives; prescribing statin for those with elevated Cholesterol, diabetes, or increased cardiovascular disease risk; and screening for Smoking and providing cessation counseling. An event study compared prepost changes in outcomes among intervention practices and a difference-in-differences design compared intervention practices to 688 external comparison practices. RESULTS: Mean baseline outcomes ranged from 61.5% (cholesterol) to 64.9% (aspirin). In the event study, outcomes improved significantly (aspirin: +3.39 percentage points, 95% CI, 0.61-6.17; blood pressure: +1.59, 95% CI, 0.12-3.06; cholesterol: +4.43, 95% CI, 0.33-8.53; smoking: +7.33, 95% CI, 4.70-9.96). Difference-in-differences estimates were similar in magnitude but statistically significant for smoking alone. Preintervention trends were significant for smoking, but parallel-trends tests were not significant. CONCLUSIONS: EvidenceNOW Cooperatives improved cardiovascular prevention quality metrics among small and medium sized primary care practices across the US. While estimated improvements were small, they reflected average changes across a large and diverse sample of practices.

Cardiovascular Disease Preventive Services Among Smaller Primary Care Practices.

INTRODUCTION: Cardiovascular disease preventive services (aspirin use, blood pressure control, and smoking-cessation support) are crucial to controlling cardiovascular diseases. This study draws from 1,248 small-to-medium-sized primary care practices participating in the EvidenceNOW Initiative from 2015-2016 across 12 states to provide practice-level aspirin use, blood pressure control, and smoking-cessation support estimates; report the percentage of practices that meet Million Hearts targets; and identify the practice characteristics associated with better performance. METHODS: This cross-sectional study utilized linear regression modeling (analyzed in 2020-2021) to examine the association of aspirin use, blood pressure control, and smoking-cessation support performance with practice characteristics that included structural attributes (e.g., size, ownership, rurality), practice capacity and contextual characteristics, health information technology, and patient panel demographics. RESULTS: On average, practice performance on aspirin use, blood pressure control, and smoking-cessation support quality measures was 64% for aspirin, 63% for blood pressure, and 62% for smoking-cessation support. The 2012 Million Hearts goal of achieving the rates of 70% was achieved by 52% (aspirin), 32% (blood pressure), and 54% (smoking) of practices. Practice characteristics associated with aspirin use, blood pressure control, and smoking-cessation support performance included ownership (hospital/health system-owned practices had 11% higher aspirin performance than clinician-owned practices [p=0.001]), rurality (rural practices had lower performance than urban practices in all aspirin use, blood pressure control, and smoking-cessation support quality metrics [difference in aspirin=11.1%, p=0.001; blood pressure=4.2%, p=0.022; smoking=14.4%, p=0.009]), and disruptions (practices that experienced >1 major disruption showed lower aspirin performance [-7.1%, p<0.001]). CONCLUSIONS: Achieving the Million Hearts targets may be assisted by collecting and reporting practice-level performance, which can promote change at the practice level and identify areas where additional support is needed to achieve initiative goals.

Improving Smoking and Blood Pressure Outcomes: The Interplay Between Operational Changes and Local Context.

PURPOSE: We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care. METHODS: We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in EvidenceNOW-a multisite cardiovascular disease prevention initiative. We calculated Clinical Quality Measure improvements, with targets of 10-point or greater absolute improvements in the proportion of patients with smoking screening and, if relevant, counseling and in the proportion of hypertensive patients with adequately controlled BP. We analyzed interview data to identify operational changes, transforming these into numeric data. We used Configurational Comparative Methods to assess the joint effects of multiple factors on outcomes. RESULTS: In clinician-owned practices, implementing a workflow to routinely screen, counsel, and connect patients to smoking cessation resources, or implementing a documentation change or a referral to a resource alone led to an improvement of at least 10 points in the smoking outcome with a moderate level of facilitation support. These patterns did not manifest in health- or hospital system-owned practices or in Federally Qualified Health Centers, however. The BP outcome improved by at least 10 points among solo practices after medical assistants were trained to take an accurate BP. Among larger, clinician-owned practices, BP outcomes improved when practices implemented a second BP measurement when the first was elevated, and when staff learned where to document this information in the electronic health record. With 50 hours or more of facilitation, BP outcomes improved among larger and health- and hospital system-owned practices that implemented these operational changes. CONCLUSIONS: There was no magic bullet for improving smoking or BP outcomes. Multiple combinations of operational changes led to improvements, but only in specific contexts of practice size and ownership, or dose of external facilitation.

Cultural And Structural Features Of Zero-Burnout Primary Care Practices.

Although much attention has been focused on individual-level drivers of burnout in primary care settings, examining the structural and cultural factors of practice environments with no burnout could identify solutions. In this cross-sectional analysis of survey data from 715 small-to-medium-size primary care practices in the United States participating in the Agency for Healthcare Research and Quality's EvidenceNOW initiative, we found that zero-burnout practices had higher levels of psychological safety and adaptive reserve, a measure of practice capacity for learning and development. Compared with high-burnout practices, zero-burnout practices also reported using more quality improvement strategies, more commonly were solo and clinician owned, and less commonly had participated in accountable care organizations or other demonstration projects. Efforts to prevent burnout in primary care may benefit from focusing on enhancing organization and practice culture, including promoting leadership development and fostering practice agency.

Advancing the Safety, Health, and Well-Being of Commercial Driving Teams Who Sleep in Moving Semi-Trucks: The Tech4Rest Pilot Study.

OBJECTIVE: To test the feasibility, acceptability, and potential effectiveness of engineering and behavioral interventions to improve the sleep, health, and well-being of team truck drivers (dyads) who sleep in moving semi-trucks. METHODS: Drivers (n = 16) were exposed to Condition A: a new innerspring mattress, and Condition B: a novel therapeutic mattress. A subsample of drivers (n = 8) were also exposed to Condition C: use of their preferred mattress (all chose to keep B), switching to an active suspension driver's seat, and completing a behavioral sleep-health program. Primary outcomes were sleep duration, sleep quality, and fatigue. Behavioral program targets included physical activity and sleep hygiene. RESULTS: Self-reported sleep and fatigue improved with mattress A, and improved further with mattress B which altered vibration exposures and was universally preferred and kept by all drivers. Condition C improved additional targets and produced larger effect sizes for most outcomes. CONCLUSIONS: Results support these interventions as promising for advancing team truck drivers' sleep, health, and well-being.

The Affordable Care Act: Effects of Insurance on Diabetes Biomarkers.

OBJECTIVE: We sought to understand how Affordable Care Act (ACA) Medicaid expansion insurance coverage gains are associated with changes in diabetes-related biomarkers. RESEARCH DESIGN AND METHODS: This was a retrospective observational cohort study using electronic health record data from 178 community health centers (CHCs) in the ADVANCE (Accelerating Data Value Across a National Community Health Center Network) network. We assessed changes in diabetes-related biomarkers among adult patients with diabetes in 10 Medicaid expansion states (n = 25,279), comparing newly insured with continuously insured, discontinuously insured, and continuously uninsured patients pre- to post-ACA expansion. Primary outcomes included changes from 24 months pre- to 24 months post-ACA in glycosylated hemoglobin (HbA1c), systolic (SBP) and diastolic (DBP) blood pressure, and LDL cholesterol levels. RESULTS: Newly insured patients exhibited a reduction in adjusted mean HbA1c levels (8.24% [67 mmol/mol] to 8.17% [66 mmol/mol]), which was significantly different from continuously uninsured patients, whose HbA1c levels increased (8.12% [65 mmol/mol] to 8.29% [67 mmol/mol]; difference-in-differences [DID] -0.24%; P < 0.001). Newly insured patients showed greater reductions than continuously uninsured patients in adjusted mean SBP (DID -1.8 mmHg; P < 0.001), DBP (DID -1.0 mmHg; P < 0.001), and LDL (DID -3.3 mg/dL; P < 0.001). Among patients with elevated HbA1c in the 3 months prior to expansion, newly insured patients were more likely than continuously uninsured patients to have a controlled HbA1c measurement by 24 months post-ACA (hazard ratio 1.25; 95% CI 1.02-1.54]. CONCLUSIONS: Post-ACA, newly insured patients had greater improvements in diabetes-related biomarkers than continuously uninsured, discontinuously insured, or continuously insured patients. Findings suggest that health insurance gain via ACA facilitates access to appropriate diabetes care, leading to improvements in diabetes-related biomarkers.

The Affordable Care Act improved health insurance coverage and cardiovascular-related screening rates for cancer survivors seen in community health centers.

BACKGROUND: This study assessed the impact of Affordable Care Act (ACA) Medicaid expansion on health insurance rates and receipt of cardiovascular-related preventive screenings (body mass index, glycated hemoglobin [HbA1c], low-density lipoproteins, and blood pressure) for cancer survivors seen in community health centers (CHCs). METHODS: This study identified cancer survivors aged 19 to 64 years with at least 3 CHC visits in 13 states from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE). Via inverse probability of treatment weighting multilevel multinomial modeling, insurance rates before and after the ACA were estimated by whether a patient lived in a state that expanded Medicaid, and changes between a pre-ACA time period and 2 post-ACA time periods were assessed. RESULTS: The weighted estimated sample size included 409 cancer survivors in nonexpansion states and 2650 in expansion states. In expansion states, the proportion of uninsured cancer survivors decreased significantly from 20.3% in 2012-2013 to 4.5%in 2016-2017, and the proportion of those with Medicaid coverage increased significantly from 38.8% to 55.6%. In nonexpansion states, there was a small decrease in uninsurance rates (from 33.6% in 2012-2013 to 22.5% in 2016-2017). Cardiovascular-related preventive screening rates increased over time in both expansion and nonexpansion states: HbA1c rates nearly doubled from the pre-ACA period (2012-2013) to the post-ACA period (2016-2017) in expansion states (from 7.2% to 12.8%) and nonexpansion states (from 9.3% to 16.8%). CONCLUSIONS: This study found a substantial decline in uninsured visits among cancer survivors in Medicaid expansion states. Yet, 1 in 5 cancer survivors living in a state that did not expand Medicaid remained uninsured. Several ACA provisions likely worked together to increase cardiovascular-related preventive screening rates for cancer survivors seen in CHCs.

Health Care Expenditures Among Adults With Diabetes After Oregon's Medicaid Expansion.

OBJECTIVE: To compare trends in Medicaid expenditures among adults with diabetes who were newly eligible due to the Affordable Care Act (ACA) Medicaid expansion to trends among those previously eligible. RESEARCH DESIGN AND METHODS: Using Oregon Medicaid administrative data from 1 January 2014 to 30 September 2016, a retrospective cohort study was conducted with propensity score-matched Medicaid eligibility groups (newly and previously eligible). Outcome measures included total per-member per-month (PMPM) Medicaid expenditures and PMPM expenditures in the following 12 categories: inpatient visits, emergency department visits, primary care physician visits, specialist visits, prescription drugs, transportation services, tests, imaging and echography, procedures, durable medical equipment, evaluation and management, and other or unknown services. RESULTS: Total PMPM Medicaid expenditures for newly eligible enrollees with diabetes were initially considerably lower compared with PMPM expenditures for matched previously eligible enrollees during the first postexpansion quarter (mean values $561 vs. $793 PMPM, P = 0.018). Within the first three postexpansion quarters, PMPM expenditures of the newly eligible increased to a similar but slightly lower level. Afterward, PMPM expenditures of both groups continued to increase steadily. Most of the overall PMPM expenditure increase among the newly eligible was due to rapidly increasing prescription drug expenditures. CONCLUSIONS: Newly eligible Medicaid enrollees with diabetes had slightly lower PMPM expenditures than previously eligible Medicaid enrollees. The increase in PMPM prescription drug expenditures suggests greater access to treatment over time.

Where Do Oregon Medicaid Enrollees Seek Outpatient Care Post-affordable Care Act Medicaid Expansion?

BACKGROUND: Previous studies suggest the newly Medicaid insured are more likely to use the emergency department (ED) however they did not differentiate between patients established or not established with primary care. OBJECTIVES: To understand where Oregon Medicaid beneficiaries sought care after the Patient Protection and Affordable Care Act (PPACA) Medicaid expansion (ED, primary care, or specialist) and the interaction between primary care establishment and outpatient care utilization. RESEARCH DESIGN: A retrospective cohort study. SUBJECTS: Adults continuously insured from 2014 through 2015 who were either newly, returning, or continuously insured post-PPACA. MEASURES: Site of first and last outpatient visit, established with primary care status, and outpatient care utilization. RESULTS: The odds of being established with primary care at their first visit were lower among newly [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.18-0.19] and returning insured (OR, 0.22; 95% CI, 0.22-0.23) than the continuously insured. Continuously insured, new patients with primary care had higher odds of visiting the ED (OR, 2.15; 95% CI, 2.01-2.30) at their first visit than newly or returning insured. Patients established with a single primary care provider in all insurance groups had lower rates of ED visit, whereas those established with multiple primary care providers had the highest ED visit rates. CONCLUSIONS: Most newly and returning insured Medicaid enrollees sought primary care rather than ED services and most became established with primary care. Our findings suggest that both insurance and primary care continuity play a role in where patients seek health care services.

Does Ownership Make a Difference in Primary Care Practice?

PURPOSE: We assessed differences in structural characteristics, quality improvement processes, and cardiovascular preventive care by ownership type among 989 small to medium primary care practices. METHODS: This cross-sectional analysis used electronic health record and survey data collected between September 2015 and April 2017 as part of an evaluation of the EvidenceNOW: Advancing Heart Health in Primary Care Initiative by the Agency for Health Care Research and Quality. We compared physician-owned practices, health system or medical group practices, and Federally Qualified Health Centers (FQHC) by using 15 survey-based practice characteristic measures, 9 survey-based quality improvement process measures, and 4 electronic health record-based cardiovascular disease prevention quality measures, namely, aspirin prescription, blood pressure control, cholesterol management, and smoking cessation support (ABCS). RESULTS: Physician-owned practices were more likely to be solo (45.0% compared with 8.1%, P < .001 for health system practices and 12.8%, P = .009 for FQHCs) and less likely to have experienced a major change (eg, moved to a new location) in the last year (43.1% vs 65.4%, P = .01 and 72.1%, P = .001, respectively). FQHCs reported the highest use of quality improvement processes, followed by health system practices. ABCS performance was similar across ownership type, with the exception of smoking cessation support (51.0% for physician-owned practices vs 67.3%, P = .004 for health system practices and 69.3%, P = .004 for FQHCs). CONCLUSIONS: Primary care practice ownership was associated with differences in quality improvement process measures, with FQHCs reporting the highest use of such quality-improvement strategies. ABCS were mostly unrelated to ownership, suggesting a complex path between quality improvement strategies and outcomes.

Prescription opioid use patterns, use disorder diagnoses and addiction treatment receipt after the 2014 Medicaid expansion in Oregon.

BACKGROUND/AIMS: Evidence suggests that Medicaid beneficiaries in the United States are prescribed opioids more frequently than are people who are privately insured, but little is known about opioid prescribing patterns among Medicaid enrollees who gained coverage via the Affordable Care Act Medicaid expansions. This study compared the prevalence of receipt of opioid prescriptions and opioid use disorder (OUD), along with time from OUD diagnosis to medication-assisted treatment (MAT) receipt between Oregon residents who had been continuously insured by Medicaid, were newly insured after Medicaid expansion in 2014 or returned to Medicaid coverage after expansion. DESIGN: Cross-sectional study using inverse-propensity weights to adjust for differences among insurance groups. SETTING: Oregon. PARTICIPANTS: A total of 225 295 Oregon Medicaid adult beneficiaries insured during 2014-15 and either: (1) newly enrolled, (2) returning in 2014 after a > 12-month gap or (3) continuously insured between 2013 and 2015. We excluded patients in hospice care or with cancer diagnoses. MEASUREMENTS: Any opioid-dispensed, chronic (> 90-days) and high-dose (> 90 daily morphine milligram equivalence) opioid use, documented OUD diagnosis and MAT receipt. FINDINGS: Compared with the continuously insured, newly and returning insured enrollees were less likely to be dispensed opioids [newly: 42.3%, 95% confidence interval (CI) = 42.0-42.7%; returning: 49.3%, 95% CI = 48.8-49.7%; continuously: 52.5%, 95% CI = 52.0-53.0%], use opioids chronically (newly: 12.8%, 95% CI = 12.4-13.1%; returning: 11.9%, 95% CI = 11.5-12.3%, continuously: 15.8%, 95% CI = 15.4-16.2%), have OUD diagnoses (newly: 3.6%, 95% CI = 3.4-3.7%; returning: 3.9%, 95% CI = 3.8-4.1%, continuously: 4.7%, 95% CI = 4.5-4.9%) and receive MAT after OUD diagnosis [hazard ratio newly: 0.57, 95% CI = 0.53-0.61; hazard ratio returning: 0.60, 95% CI = 0.56-0.65 (ref: continuously)]. CONCLUSIONS: Residents of Oregon, United States who enrolled or re-enrolled in Medicaid health insurance after expansion of coverage in 2014 as a result of the Affordable Care Act were less likely than those already covered to receive opioids, use them chronically or receive medication-assisted treatment for opioid use disorder.

The Impact of the Affordable Care Act (ACA) Medicaid Expansion on Visit Rates for Diabetes in Safety Net Health Centers.

OBJECTIVE: To (1) compare clinic-level uninsured, Medicaid-insured, and privately insured visit rates within and between expansion and nonexpansion states before and after the Affordable Care Act (ACA) Medicaid expansion among the 3 cohorts of patient populations; and (2) assess whether there was a change in clinic-level overall, primary care visits, preventive care visits, and diabetes screening rates in expansion versus nonexpansion states from pre-ACA to post-ACA Medicaid expansion. METHODS: Electronic health record data on nonpregnant patients aged 19 to 64 years, with ≥1 ambulatory visit between 01/01/2012 and 12/31/2015 (n = 483,912 in expansion states; n = 388,466 in nonexpansion states) from 198 primary care community health centers were analyzed. Using a difference-in-difference methodology, we assessed changes in visit rates pre-ACA versus post-ACA among a cohort of patients with diabetes, prediabetes, and no diabetes. RESULTS: Rates of uninsured visits decreased for all cohorts in expansion and nonexpansion states. For all cohorts, Medicaid-insured visit rates increased significantly more in expansion compared with nonexpansion states, especially among prediabetic patients (+71%). In nonexpansion states, privately insured visit rates more than tripled for the prediabetes cohort and doubled for the diabetes and no diabetes cohorts. Rates for glycosylated hemoglobin screenings increased in all groups, with the largest changes among no diabetes (rate ratio, 2.26; 95% CI, 1.97-2.56) and prediabetes cohorts (rate ratio, 2.00; 95% CI, 1.80-2.19) in expansion states. CONCLUSION: The ACA reduced uninsurance and increased access to preventive care for vulnerable patients, especially those with prediabetes. These findings are important to consider when making decisions regarding altering the ACA.

Burnout Among Physicians, Advanced Practice Clinicians and Staff in Smaller Primary Care Practices.

BACKGROUND: Burnout among primary care physicians, advanced practice clinicians (nurse practitioners and physician assistants [APCs]), and staff is common and associated with negative consequences for patient care, but the association of burnout with characteristics of primary care practices is unknown. OBJECTIVE: To examine the association between physician-, APC- and staff-reported burnout and specific structural, organizational, and contextual characteristics of smaller primary care practices. DESIGN: Cross-sectional analysis of survey data collected from 9/22/2015-6/19/2017. SETTING: Sample of smaller primary care practices in the USA participating in a national initiative focused on improving the delivery of cardiovascular preventive services. PARTICIPANTS: 10,284 physicians, APCs and staff from 1380 primary care practices. MAIN MEASURE: Burnout was assessed with a validated single-item measure. KEY RESULTS: Burnout was reported by 20.4% of respondents overall. In a multivariable analysis, burnout was slightly more common among physicians and APCs (physician vs. non-clinical staff, adjusted odds ratio [aOR] = 1.26; 95% confidence interval [CI], 1.05-1.49, APC vs. non-clinical staff, aOR = 1.34, 95% CI, 1.10-1.62). Other multivariable correlates of burnout included non-solo practice (2-5 physician/APCs vs. solo practice, aOR = 1.71; 95% CI, 1.35-2.16), health system affiliation (vs. physician/APC-owned practice, aOR = 1.42; 95%CI, 1.16-1.73), and Federally Qualified Health Center status (vs. physician/APC-owned practice, aOR = 1.36; 95%CI, 1.03-1.78). Neither the proportion of patients on Medicare or Medicaid, nor practice-level patient volume (patient visits per physician/APC per day) were significantly associated with burnout. In analyses stratified by professional category, practice size was not associated with burnout for APCs, and participation in an accountable care organization was associated with burnout for clinical and non-clinical staff. CONCLUSIONS: Burnout is prevalent among physicians, APCs, and staff in smaller primary care practices. Members of solo practices less commonly report burnout, while members of health system-owned practices and Federally Qualified Health Centers more commonly report burnout, suggesting that practice level autonomy may be a critical determinant of burnout.