Current Practices and Attitudes of Community Health Centers Toward the Use of Algorithmic Logic to Identify Patients with Undiagnosed Hypertension.

Treating patients with uncontrolled hypertension is a powerful intervention for reducing the risk of heart attack and stroke. Leveraging health information technology to identify patients with undiagnosed hypertension using algorithmic logic can be an effective approach for reaching hypertensive patients who may otherwise be overlooked. Despite evidence that this strategy can support favorable cardiovascular health outcomes in the safety-net healthcare setting, little is known about its implementation outside of targeted practice and research environments. In 2021-2022, Community Clinic Association of Los Angeles County and the Los Angeles County Department of Public Health collaborated on a mixed methods, organizational assessment of community health centers to better understand their practices and attitudes toward the use of algorithmic logic to identify patients with undiagnosed hypertension. Results from the assessment suggest that awareness and use of this approach are limited; numerous challenges are associated with its adoption and implementation.

Using a Cohort-Based Quality Improvement Coaching Model to Optimize Chronic Disease Management for Federally Qualified Health Center Patients.

CONTEXT: In fall 2020, Community Clinic Association of Los Angeles County, in collaboration with the Los Angeles County Department of Public Health, launched a 3-year, cohort-based quality improvement (QI) coaching program to assist Federally Qualified Health Centers (FQHCs) in improving their clinical management of hypertension, high blood cholesterol, diabetes, and chronic kidney disease. PROGRAM: The QI program utilized a cohort-based coaching model in which 5 FQHCs were each assigned a practice transformation coach who provided them with guidance and support to monitor clinical quality measures. These measures were then used to facilitate changes and improvements in clinical workflows and approaches to patient care. To encourage peer learning and promote inter-organizational collaboration, the coaching team hosted quarterly cohort check-ins and an online group messaging board where the participating FQHCs could share lessons learned. Throughout the program, the FQHCs were provided trainings and resources to advance their clinical quality measures of choice. IMPLEMENTATION: To implement the program, each FQHC selected 2 clinical quality measures to focus on, completing a minimum of 1 Plan-Do-Study-Act cycle per year for each measure. Throughout, the coaches met regularly with FQHC staff to discuss progress, strategize on how best to address challenges encountered, and identify training or resource needs for their clinic sites. EVALUATION: To drive implementation of QI interventions and monitor overall progress, the FQHCs reported quarterly on the clinical quality measures being addressed. By program's end, all 5 FQHCs reached their 10% improvement goals. DISCUSSION: This QI coaching program allowed participating FQHCs to build new competencies and achieve measurable improvements in how they managed their patients' chronic diseases. This model of practice serves as a promising approach for achieving sustainable clinical improvements in these FQHCs.

Clinical Study of Continuous Non-Invasive Blood Pressure Monitoring in Neonates.

The continuous monitoring of arterial blood pressure (BP) is vital for assessing and treating cardiovascular instability in a sick infant. Currently, invasive catheters are inserted into an artery to monitor critically-ill infants. Catheterization requires skill, is time consuming, prone to complications, and often painful. Herein, we report on the feasibility and accuracy of a non-invasive, wearable device that is easy to place and operate and continuously monitors BP without the need for external calibration. The device uses capacitive sensors to acquire pulse waveform measurements from the wrist and/or foot of preterm and term infants. Systolic, diastolic, and mean arterial pressures are inferred from the recorded pulse waveform data using algorithms trained using artificial neural network (ANN) techniques. The sensor-derived, continuous, non-invasive BP data were compared with corresponding invasive arterial line (IAL) data from 81 infants with a wide variety of pathologies to conclude that inferred BP values meet FDA-level accuracy requirements for these critically ill, yet normotensive term and preterm infants.

Addressing Challenges to Coordinating the Implementation of Place-Based Chronic Disease Prevention Interventions in Los Angeles.

CONTEXT: Chronic disease prevention initiatives have traditionally been structured to address a single disease, potentially limiting the scope of health impacts. In the past decade, initiatives have increasingly adopted a coordinated approach, in which multiple interventions are intended to work synergistically-often in a bounded geographic area-to address interrelated risk factors and diseases. However, despite increased interest in this coordinated approach, few examples exist of how coordination has been operationalized in local public health practice. IMPLEMENTATION: In 2014, the Los Angeles County Department of Public Health launched the 4-year Chronic Disease Prevention Strategy (CDPS). Through CDPS, the Los Angeles County Department of Public Health implemented a range of environmental, lifestyle change, and health system interventions intended to collectively reduce chronic disease among adults in Los Angeles, with concentrated implementation occurring in 1 high-need neighborhood. EVALUATION: This case study examined the activities undertaken to coordinate across CDPS interventions and documented challenges to these efforts. Data were collected via a document review of programmatic materials and structured conversations with staff leading implementation of CDPS interventions. RESULTS: Document review and structured conversations with staff identified 3 primary coordination activities: (1) collaborating on outreach materials to unify messaging, (2) developing a network of common partners, and (3) investing in shared data collection. Operational challenges identified were disparate short-term objectives across interventions, minimal alignment between clinical practice and CDPS goals, restrictions around bidirectional referrals between organizations, and limited bandwidth among new partners to engage with multiple CDPS interventions. Contextual challenges identified were competing social and political issues, and geographic fluidity regarding where community members sought health resources. CONCLUSION: Developing an initiative-specific coordination plan prior to implementation may help reduce challenges to coordination. Modifications in how health initiatives are funded and structured may be needed: greater flexibility in how funding is administered, and the inclusion of coordination-specific metrics, may enable more robust coordination.

Analgesic efficacy and safety of morphine in the Procedural Pain in Premature Infants (Poppi) study: randomised placebo-controlled trial.

BACKGROUND: Infant pain has immediate and long-term effects but is undertreated because of a paucity of evidence-based analgesics. Although morphine is often used to sedate ventilated infants, its analgesic efficacy is unclear. We aimed to establish whether oral morphine could provide effective and safe analgesia in non-ventilated premature infants for acute procedural pain. METHODS: In this single-centre masked trial, 31 infants at the John Radcliffe Hospital, Oxford, UK, were randomly allocated using a web-based facility with a minimisation algorithm to either 100 µg/kg oral morphine sulphate or placebo 1 h before a clinically required heel lance and retinopathy of prematurity screening examination, on the same occasion. Eligible infants were born prematurely at less than 32 weeks' gestation or with a birthweight lower than 1501 g and had a gestational age of 34-42 weeks at the time of the study. The co-primary outcome measures were the Premature Infant Pain Profile-Revised (PIPP-R) score after retinopathy of prematurity screening and the magnitude of noxious-evoked brain activity after heel lancing. Secondary outcome measures assessed physiological stability and safety. This trial is registered with the European Clinical Trials Database (number 2014-003237-25). FINDINGS: Between Oct 30, 2016, and Nov 17, 2017, 15 infants were randomly allocated to morphine and 16 to placebo; one infant assigned placebo was withdrawn from the study before monitoring began. The predefined stopping boundary was crossed, and trial recruitment stopped because of profound respiratory adverse effects of morphine without suggestion of analgesic efficacy. None of the co-primary outcome measures differed significantly between groups. PIPP-R score after retinopathy of prematurity screening was mean 11·1 (SD 3·2) with morphine and 10·5 (3·4) with placebo (mean difference 0·5, 95% CI -2·0 to 3·0; p=0·66). Noxious-evoked brain activity after heel lancing was median 0·99 (IQR 0·40-1·56) with morphine and 0·75 (0·33-1·22) with placebo (median difference 0·25, 95% CI -0·16 to 0·80; p=0·25). INTERPRETATION: Administration of oral morphine (100 µg/kg) to non-ventilated premature infants has the potential for harm without analgesic efficacy. We do not recommend oral morphine for retinopathy of prematurity screening and strongly advise caution if considering its use for other acute painful procedures in non-ventilated premature infants. FUNDING: Wellcome Trust and National Institute for Health Research.

Understanding the Density and Distribution of Restaurants in Los Angeles County to Inform Local Public Health Practice.

INTRODUCTION: To describe the potential reach of restaurant-based strategies that seek to improve the healthfulness of menu options, it is important to understand the local restaurant environment, including the extent to which restaurants subject to policy mandates are located in communities disproportionately affected by diet-related diseases. METHODS: This cross-sectional study examined the restaurant environment in Los Angeles County, a large jurisdiction with diverse geographic and socioeconomic characteristics, specifically 1) the number and characteristics of restaurants; 2) the association between neighborhood sociodemographics and restaurant density; and 3) the association between neighborhood sociodemographics and restaurant characteristics, including chain status (large chain, small chain, independent restaurant). Data sources were 1) industry data on restaurant location and characteristics (N = 24,292 restaurants) and 2) US Census data on neighborhood sociodemographics (N = 247 neighborhoods). We conducted descriptive and bivariate analyses at the restaurant and neighborhood level. RESULTS: Countywide, only 26.5% of all restaurants were part of a large chain (a chain with ≥20 locations). We found positive associations between restaurant density and neighborhood proportions of non-Hispanic white residents and residents with more than a high school education. We found limited support to suggest a greater density of large chains in neighborhoods with lower socioeconomic status. CONCLUSION: Results highlight the potentially limited reach of strategies targeting chain restaurants and point to the importance of including small chain restaurants and independent restaurants in public health efforts to improve the healthfulness of restaurants. Understanding where restaurants are in relation to priority populations is a critical step to planning strategies that address diet-related disparities.

Delivery of Comprehensive Medication Management and Other Clinical Services via Telehealth by Pharmacy Type.

BACKGROUND: The recent coronavirus pandemic accelerated the need to deliver pharmacy-related services remotely. OBJECTIVE: To describe experiences with providing comprehensive medication management (CMM) and other clinical services via telehealth by pharmacy type, before and during the COVID-19 pandemic. METHODS: An online survey of pharmacists, representing 27 pharmacies, was conducted to capture telehealth usage in three pharmacy types: independently owned, integrated into a clinical setting, and retail chain. A sub-analysis was performed to assess if providing CMM services via telehealth helped, resulted in no change, or worsened the care of different patient groups (e.g., those with diabetes, were low-income, aged 65+ years). RESULTS: During the pandemic, telehealth usage among independently owned pharmacies and those integrated into a clinical setting increased, but no change occurred among retail chain pharmacies. This usage increase in the first two pharmacy types occurred despite limited investments in connectivity-related resources to support telehealth services. Pharmacists from both independently owned pharmacies (63%) and those integrated into a clinical setting (89%) reported CMM via telehealth reached patients they would not otherwise have been able to reach during the pandemic. Most pharmacists/pharmacies found telehealth to be a feasible and acceptable method of delivering CMM. CONCLUSION: Pharmacists and pharmacies are now experienced with and have interest in continuing CMM via telehealth, even as the pandemic recedes. However, investments in telecommunications resources, training support, technical assistance, and continued telehealth reimbursement from health plans are needed to sustain this service delivery model.

Building bi-directional referral and communication pathways across the community-clinic divide: Experiences from a systems-informed innovation project in Los Angeles.

Bi-directional communication and referral pathways (BCRPs) between clinics and community-based organizations could promote well-being among vulnerable populations with complex and overlapping health and social needs. While BCRPs are promising, establishing them is complex, involving system and process changes across diverse organizational settings. To date, few models have been implemented or empirically tested. This article describes an innovation and planning project to build a BCRP, linking patients in safety net primary care clinics to a comprehensive suite of community-based health and wellness supports in Los Angeles. During a year-long process, a multi-sector team iteratively engaged data to facilitate learning and improvement. The project proceeded through three distinct, but overlapping, phases: (1) Discovery, (2) Systems Mapping, and (3) BCRP Re-design and Testing, which were coordinated through frequent collaborative meetings. By using a stepwise systems-informed approach to collect and examine data, the team was able to generate new change ideas, dispel assumptions, and make transparent and informed decisions. It was critical to have engagement from both internal partners with knowledge of "on-the-ground" practice realities, and external stakeholders with the fresh perspective needed to identify opportunities and define an improvement agenda. These efforts represent first steps towards implementing sustainable BCRPs and realizing their full potential to dynamically bridge the community-clinic divide and improve population health. Other jurisdictions can learn from and adapt the practical data-driven approach used in Los Angeles to build BCRPs that will be thoroughly operationalized, consistently implemented, and optimized within their own unique contexts.

Early life inflammation is associated with spinal cord excitability and nociceptive sensitivity in human infants.

Immune function and sensitivity to pain are closely related, but the association between early life inflammation and sensory nervous system development is poorly understood-especially in humans. Here, in term-born infants, we measure brain activity and reflex withdrawal activity (using EEG and EMG) and behavioural and physiological activity (using the PIPP-R score) to assess the impact of suspected early-onset neonatal infection on tactile- and noxious-evoked responses. We present evidence that neonatal inflammation (assessed by measuring C-reactive protein levels) is associated with increased spinal cord excitability and evoked brain activity following both tactile and noxious stimulation. There are early indications that this hyperalgesia could be maintained post-inflammation, supporting pre-clinical reports of early-life immune dysfunction influencing pain sensitivity in adults.

Current practices, facilitators, and barriers experienced by program providers implementing the National Diabetes Prevention Program in Los Angeles County.

Individuals with prediabetes can lower their diabetes risk by participating in the National Diabetes Prevention Program (National DPP), an evidence-based, group lifestyle change program that is taught by a certified lifestyle coach. To date, studies have not explicitly compared National DPP implementation across multiple settings (i.e., types of organizations) to understand comparative setting advantages or challenges to engaging priority groups. The purpose of this study was to gain an in-depth understanding of: (a) the variation in National DPP implementation across clinic, community-based, and digital settings and (b) associated facilitators and barriers. The study focused on three core implementation domains: recruitment, retention, and data reporting. This study used a descriptive, qualitative approach to identify current practices, facilitators, and barriers to National DPP implementation by conducting semistructured key informant interviews in spring 2018 with 12 organizations delivering the National DPP in Los Angeles County. There was a general commonality between in-person settings (clinics and community-based), while the experiences of digital providers were relatively distinct. Recruitment and retention were widely described by all settings as labor- and time-intensive, while data reporting was seen as relatively less burdensome. All respondents reported using multiple recruitment strategies. Lifestyle coaches were seen as key to retention, and they spent substantial time engaging with participants outside of class, which often was not accounted for in program costs. Data reporting was easier for organizations that invested in sophisticated data management systems and had staff with sufficient data experience. This study advances knowledge around the translation of the National DPP in diverse settings in the nation's largest county and highlights opportunities for targeted, setting-specific support.