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Synchronous home-based telemedicine for primary care experienced growth during the coronavirus disease 2019 pandemic. A review was conducted on the evidence reporting on the feasibility of synchronous telemedicine implementation within primary care, barriers and facilitators to implementation and use, patient characteristics associated with use or nonuse, and quality and cost/revenue-related outcomes. Initial database searches yielded 1,527 articles, of which 22 studies fulfilled the inclusion criteria. Synchronous telemedicine was considered appropriate for visits not requiring a physical examination. Benefits included decreased travel and wait times, and improved access to care. For certain services, visit quality was comparable to in-person care, and patient and provider satisfaction was high. Facilitators included proper technology, training, and reimbursement policies that created payment parity between telemedicine and in-person care. Barriers included technological issues, such as low technical literacy and poor internet connectivity among certain patient populations, and communication barriers for patients requiring translators or additional resources to communicate. [ABSTRACT FROM AUTHOR]

Background: Studies specifically focused on patients' perspectives on telemedicine visits in primary and behavioral health care are fairly limited and have often focused on highly selected populations or used overall satisfaction surveys. Objective: To examine patient perspectives on the shift to telemedicine, the remote delivery of health care via the use of electronic information and communications technology, in primary and behavioral health care in Federally Qualified Health Centers (FQHCs) during COVID-19. Design: Semi-structured interviews were conducted using video conference with patients and caregivers between October and December 2020. Participants: Providers from 6 FQHCs nominated participants. Eighteen patients and caregivers were interviewed: 6 patients with only primary care visits; 5 with only behavioral health visits; 3 with both primary care and behavioral health visits; and 4 caregivers of children with pediatric visits. Approach: Using a protocol-driven, rapid qualitative methodology, we analyzed the interview data and assessed the quality of care, benefits and challenges of telemedicine, and use of telemedicine post-pandemic. Key Results: Respondents broadly supported the option of home-based synchronous telemedicine visits in primary and behavioral health care. Nearly all respondents appreciated remote visits, largely because such visits provided a safe option during the pandemic. Patients were generally satisfied with telemedicine and believed the quality of visits to be similar to in-person visits, especially when delivered by a provider with whom they had established rapport. Although most respondents planned to return to mostly in-person visits when considered safe to do so, they remained supportive of the continued option for remote visits as remote care addresses some of the typical barriers faced by low-income patients. Conclusions: Addressing digital literacy challenges, enhancing remote visit privacy, and improving practice workflows will help ensure equitable access to all patients as we move to a new post-COVID-19 "normal" marked by increased reliance on telemedicine and technology. [ABSTRACT FROM AUTHOR]

Many health care providers and systems are developing and implementing processes to screen patients for social determinants of health and to refer patients to appropriate nonclinical and community-based resources. The largest public health care system in the United States, New York City Health + Hospitals, piloted such a program in 2017. A qualitative evaluation yielded insights into the implementation and feasibility of such screening and referral programs in health care systems serving low-income, minority, immigrant, and underserved populations. [ABSTRACT FROM AUTHOR]

The article discusses research which examines the challenges facing small urban practices serving low-income patients when they attempt to become recognized by the U.S. National Committee for Quality Assurance (NCQA) as patient-centered medical homes (PCMH). It analyzes the dimensions of the PCMH model that exist in practices participating in the Primary Care Information Project (PCIP). It reveals that many of such practices achieved the spirit of the law in terms of PCMH' key dimensions.

The article discusses the viability of externally funded partnerships developed in response to targeted funding opportunity in New York City. It notes that the Department of Health and Mental Hygiene (DOHMH) created the New York City Childhood Asthma Initiative (NYCCAI) for community awareness, understanding and capacity around childhood asthma to lessen prevalence and morbidity. It notes that the contracts of DOHMH offer funds for sustainability plan creation and delivery.

Increasing the representation of Spanish-speaking study participants requires development and dissemination of reliable and valid translated scales. In the current study the construct validity was assessed of the Spanish version of the Crisis in Family Systems-Revised, a measure of contemporary life stressors, with a convenience sample of 377 parents interviewed in a study of childhood asthma, although over half of the respondents did not have children with asthma. Most respondents were foreign-born women between 20 to 60 years old (M = 35, SD = 7). 52% had not completed high school or its equivalent, and 55% reported a household income of $15,000 or less. For a subsample of 25 respondents test-retest reliability was .86 over 2 wk. Reporting more life stressors was associated with greater depressive symptomatology, poorer physical and mental health function, and lower household income. These relationships support the construct validity of the test in Spanish. This study provided strong evidence that this version is a valid and reliable measure of life stressors for a Spanish-speaking population living in the United States. [ABSTRACT FROM AUTHOR]

Examines the efficacy of child development services provided by Medicaid managed care organizations in the U.S. Importance of good nutrition and during the first three years of life for optimal growth and development; Details on child development programs for low income families; Family education on developmental progress of children.

Focuses on the validation of the Crisis in Family Systems-Revised as a contemporary measure of life stressors. Measure of socioeconomic status; Depressive symptomatology; Comparisons by urban residential status.

Abstract. Objective. We sought to understand why certain Medicaid managed care organizations (MMCOs) implemented child development services or programs and how they had done so. We also sought to identify barriers and facilitators to successful initiation and implementation of child development programs. Methods. We conducted 9 key informant interviews and 4 site visits, and performed qualitative analyses to identify major themes across responses. Results. We identified a small number of MMCOs with child development services. High-level support was crucial for program initiation; physician buy-in, staff support, and strong working relationships with outside health professionals or agencies were principal factors in successful program implementation. Conclusions. MMCOs that were committed to implementing child development services were successful in doing so, without external funding or regulatory mandate. The results provide valuable strategies for MMCOs interested in developing programs and for researchers and advocates interested in promoting child development services for low-income children. Pediatrics 2000; 106:191-198; Medicaid managed care, child development services. [ABSTRACT FROM AUTHOR]

Background: New York City (NYC) was the first COVID-19 epicenter in the United States and home to one of the country's largest contact tracing programs, NYC Test & Trace (T2). Understanding points of attrition along the stages of program implementation and follow-up can inform contact tracing efforts for future epidemics or pandemics. The objective of this study was to evaluate the completeness and timeliness of T2 case and contact notification and monitoring using a "cascade of care" approach. Methods: This cross-sectional study included all SARS-CoV-2 cases and contacts reported to T2 from May 31, 2020 to January 1, 2022. Attrition along the "cascade of care" was defined as: (1) attempted, (2) reached, (3) completed intake (main outcome), (4) eligible for monitoring, and (5) successfully monitored. Timeliness was assessed: (1) by median days from a case's date of testing until their positive result was reported to T2, (2) from result until the case was notified by T2, and (3) from a case report of a contact until notification of the contact. Results: A total of 1.45 million cases and 1.38 million contacts were reported to T2 during this period. For cases, attrition occurred evenly across the first three cascade steps (~-12%) and did not change substantially until the Omicron wave in December 2021. During the Omicron wave, the proportion of cases attempted dropped precipitously. For contacts, the largest attrition occurred between attempting and reaching (-27%), and attrition rose with each COVID-19 wave as contact volumes increased. Attempts to reach contacts discontinued entirely during the Omicron wave. Overall, 67% of cases and 49% of contacts completed intake interviews (79% and 57% prior to Omicron). T2 was timely, with a median of 1 day to receive lab results, 2 days to notify cases, and < 1 day to notify contacts. Conclusions: T2 provided a large volume of NYC residents with timely notification and monitoring. Engagement in the program was lower for contacts than cases, with the largest gap coming from inability to reach individuals during call attempts. To strengthen future test-and-trace efforts, strategies are needed to encourage acceptance of local contact tracer outreach attempts. [ABSTRACT FROM AUTHOR]

Develops a measure of contemporary life stressors. Psychometric properties of the instrument called Crisis in Family Systems; Phases of instrument development.

Examines the impact of residency training on physicians' attitudes toward AIDS. Analysis of cohorts of surgeons training in the same six residency programs; Willingness to treat people with AIDS; Concern about exposure to HIV; Perceived benefits of treating AIDS.

Understanding the impact of training on the development of physicians' attitudes toward AIDS is important to furthering our knowledge of the mechanisms through which socialization affects professional outlook, as well as promoting an adequate supply of providers to treat people with AIDS (PWAs). This prospective panel study collected data on 383 physicians at two critical stages: as fourth-year medical students and as third-year residents. Aspects of residency training (e.g., residents' morale and positive faculty role models) were the most powerful predictors of increase in willingness to treat PWAs. Decline in willingness was primarily a product of negative social attitudes--homophobia and IVDU-phobia (aversion to intravenous drug users). Cynicism toward patient care acted as a trigger, activating the negative effects of IVDU-phobia; having an acquaintance who is HIV positive mediated the negative impact of homophobia. Notably, cynicism was associated with basic aspects of training (specific characteristics of the faculty and of the educational milieu). The findings support a view of socialization as a pervasive process implicating intrinsic aspects of training and having an impact on a broad spectrum of outlooks. Accordingly, interventions must address structural characteristics that transcend AIDS-specific concerns. [ABSTRACT FROM AUTHOR]

To evaluate the incidence of gender-affirming phalloplasty and postoperative complications in a large population-based dataset. Retrospective cohort study was done using the California Department of Health Care Access and Information datasets which include patient-level data from all licensed hospitals, emergency departments, and ambulatory surgery facilities in California. Adult patients 18 years or older undergoing gender-affirming phalloplasty in California from January 1, 2009 to December 31, 2019 were included. We examined phalloplasty-related complications using International Classification of Disease diagnosis and procedure codes and Current Procedural Terminology codes. Unique record linkage number identifiers were used to follow patients longitudinally. Statistical analysis included Kaplan-Meier survival analysis and Cox proportional hazards analysis. We identified 766 patients who underwent gender-affirming phalloplasty in 23 facilities. Of 475 patients with record linkage numbers, 253 (55.3%) had subsequent re-presentations to the inpatient, emergency department, and ambulatory surgery settings related to phalloplasty complications. Survival analysis indicated that 50% of patients re-presented by 1 year post-phalloplasty. Asian/Pacific Islander patients had lower risk of complications, and California residents had higher risk of complications. This population-based study confirms that gender-affirming phalloplasty has a high complication rate, and demonstrates for the first time an association with high rates of return to hospitals, emergency departments, and ambulatory surgery centers. These findings provide additional higher-level evidence that may aid patient counseling, shared surgical decision-making, and institutional and government policy. [ABSTRACT FROM AUTHOR]

Purpose: Small independent primary care practices (SIPs) often lack the resources to implement system changes. HealthyHearts NYC, funded through the EvidenceNOW initiative of the Agency for Healthcare Research and Quality, studied the effectiveness of practice facilitation to improve cardiovascular disease- related care in 257 SIPs. We sought to understand SIP clinicians' perspectives on the benefits of practice facilitation.Methods: We conducted in-depth interviews with 19 SIP clinicians enrolled in HealthyHearts NYC. Interviews were transcribed and coded using deductive and inductive approaches. To understand whether the perceived benefits of practice facilitation differ based on the availability of internal staff for quality improvement (QI), we compared themes pertaining to benefits between practices with 3 or fewer office staff vs more than 3 office staff.Results: Clinicians perceived 2 main benefits of practice facilitation. First, facilitators served as a connection to the external health care environment for SIPs, often through teaching and information sharing. Second, facilitators provided electronic health record (EHR)/data expertise, often by teaching functionality and completing technical assistance and tasks. SIPs with more than 3 office staff felt that facilitators provided benefits primarily through teaching, whereas SIPs with 3 or fewer staff felt that facilitators also provided hands-on support. At the intersections of these benefits, there emerged 3 central practice facilitation benefits: (1) creating awareness of quality gaps, (2) connecting practices to information, resources, and strategies, and (3) optimizing the EHR for QI goals.Conclusions: SIP clinicians perceived practice facilitation to be an important resource for connecting their practice to the external health care environment and resources, and helping their practice build QI capacity through teaching, hands-on support, and EHR-driven solutions. [ABSTRACT FROM AUTHOR]

Early in the pandemic, New York City's public hospital system partnered with multiple philanthropic foundations to offer an unconditional cash transfer program for low-income New Yorkers affected by COVID-19. The $1000 cash transfers were designed to help people meet their most immediate health and social needs and were incorporated into healthcare delivery and contact tracing workflows as a response to the public health emergency. To better understand program recipients' experiences, researchers conducted 150 telephone surveys with randomly sampled cash transfer recipients and 20 in-depth qualitative interviews with purposefully sampled survey participants. Survey participants were predominantly Latinx (87%) and women (65%). The most common reported uses of the $1000 were food and rent. Most participants (79%) reported that without the $1000 cash transfer they would have had difficulty paying for basic expenses or making ends meet, with specific positive effects reported related to food, housing, and ability to work. The majority of survey participants reported that receiving the cash assistance somewhat or greatly improved their physical health (83%) and mental health (89%). Qualitative interview results generally supported the survey findings. [ABSTRACT FROM AUTHOR]

On June 1, 2020, NYC Health + Hospitals, in partnership with the NYC Department of Health and Mental Hygiene, other city agencies, and a large network of community partners, launched the New York City Test & Trace (T2) COVID-19 response program to identify and isolate cases, reduce transmission through contact tracing, and provide support to residents during isolation or quarantine periods. In this paper, we describe lessons learned with respect to planning and implementation of case notification and contact tracing. Our findings are based on extensive document review and analysis of 74 key informant interviews with T2 leadership and frontline staff, cases, and contacts conducted between January and September 2022. Interviews elicited respondent background, history of program development, program leadership and structure, goals of the program, program evolution, staffing, data systems, elements of community engagement, trust with community, program reach, timeliness, equity, general barriers and challenges, general facilitators and best practices, and recommendations/improvement for the program. Facilitators and barriers revealed in the interviews primarily revolved around hiring and managing staff, data and technology, and quality of interactions with the public. Based on these facilitators and barriers, we identify suggestions to support effective planning and response for future case notification and contact tracing programs, including recommendations for planning during latent periods, case management and data systems, and processes for outreach to cases and contacts. [ABSTRACT FROM AUTHOR]

Both community health workers and the Project ECHO model of specialist telementoring are innovative approaches to support primary care providers in the care of complex patients with diabetes. We studied the effect of an intervention that combined these 2 approaches on glycemic control. Patients with diabetes were recruited from 10 federally qualified health centers in New Mexico. We used electronic health record (EHR) data to compare HbA1c levels prior to intervention enrollment with HbA1c levels after 3 months (early follow-up) and 12 months (late follow-up) following enrollment. We propensity matched intervention patients to comparison patients from other sites within the same electronic health records databases to estimate the average treatment effect. Among 557 intervention patients with HbA1c data, mean HbA1c decreased from 10.5% to 9.3% in the pre- versus postintervention periods (P <.001). As compared to the comparison group, the intervention was associated with a change in HbA1c of −0.2% (95% confidence interval [CI] −0.4%-0.5%) and −0.3 (95% CI −0.5–0.0) in the early and late follow-up cohorts, respectively. The intervention was associated with a significant increase in percentage of patients with HbA1c <8% in the late follow-up cohort (8.1%, 95% CI 2.2%−13.9%) but not the early follow-up cohort (3.6%, 95% CI −1.5% to 8.7%) The intervention was associated with a substantial decrease in HbA1c in intervention patients, although this improvement was not different from matched comparison patients in early follow-up. Although combining community health workers with Project ECHO may hold promise for improving glycemic control, particularly in the longer term, further evaluations are needed. [ABSTRACT FROM AUTHOR]

The article focuses on a study which analyzes the impact of performance-improvement (PI)-based continuing medical education (CME) on the clinical care and outcomes of patients with type 2 diabetes in the U.S. Results suggest that self-assessment, improvement planning, implementation based on review of one's own data, and reassessment of the success of the improvement plan contribute to improvements in patient health. It also cites the benefits of clinicians from the PI-CME.

Abstract: Objective: To improve the quality of care for residents of long term care (LTC) facilities who have diabetes by (1) improving glycemic control, (2) increasing comprehensive diabetes management, (3) reducing fragmented care, and (4) empowering patient-care teams to educate patients and families regarding this disease. Design: Based on the Plan-Do-Study-Act principles of effective change, a baseline evaluation of contemporary care for residents with diabetes was conducted through focus-group interviews, a confidence survey, and chart review. Three live educational workshops provided guideline-recommended information addressing educational desires and needs of clinical staff, a tool for improving performance in key areas of need, and an opportunity for care teams to engage in dialogue about advances in diabetes with a national diabetes expert. Reassessment was performed via chart review twice at 3 and 5 months post education. Key lessons and tools for improvements were disseminated to other LTC communities through a CME-certified publication activity and follow-up teleconferences. Setting: Two skilled-nursing LTC communities. Participants: Physicians, administrators, nurses, certified nursing assistants, and nutrition staff. Intervention: Three live continuing education/continuing medical education-certified workshops attended by 83 health care professionals. Measurements: Twenty-five comprehensive clinical indicators of diabetes care and overall health were assessed for all residents with a diabetes diagnosis at baseline (n = 35), 3 months (n = 40), and 5 months (n = 27) post education. Results: The primary objective of improving glycemic control we reached through a statistically significant 18% reduction in the percentage of residents experiencing hypoglycemia from baseline to 3 months post education (31% at baseline, 13% at 3 months, P = .046). Low levels of hypoglycemia (11%) were maintained at 5 months post education. Positive changes in an additional 3 measures of patient health include improved daily blood glucose levels, reduced ranges of HbA1c, and improved low-density lipoprotein cholesterol concentrations. Improvements in 4 measures of clinician performance were also observed, namely comprehensive foot evaluations, referrals to specialists for foot care and eye exams, and improved use of physical activity. Conclusion: Diabetes care, particularly in elder adults, is complex and requires a multidisciplinary approach. Focused quality improvement activities within LTC communities offer care providers the information and tools required to make effective changes that have the ability to promote improved patient care. These efforts must be multidisciplinary and effectively engage all stakeholders. [Copyright &y& Elsevier]

Abstract: Challenges exist in the diagnosis and treatment of myelodysplastic syndromes (MDS). Early clinical presentation can be subtle, accurate classification requires careful consideration of pathologic features and cytogenetics, and treatment options vary based on disease severity. A performance improvement (PI) continuing medical education initiative was developed to strengthen physician practices and improve the quality of MDS patient care. Physician participants demonstrated significant gains in the diagnosis and classification of MDS and in the documentation of erythropoietin levels. Improvements related to patient communication and disease education were also observed and support the overall efficacy and value of PI in MDS patient care. [Copyright &y& Elsevier]

Purpose: In the United States, colorectal cancer (CRC) is the third leading cause of cancer after breast and prostate cancer. Numerous improvement programs have been implemented to increase CRC screening rates, but few have focused on improving the care and management of patients with a diagnosis of this malignancy. As national medical organizations focus on quality of care, efforts are necessary to provide clinicians the opportunity for self-assessment and methods for practice improvement. With this goal in mind, a national continuing medical education- certified performance improvement initiative was conceived. Methods: The initiative consisted of three stages: First, participants self-assessed their performance of predetermined topic measures through a review of patient charts. The topic areas included patient safety and supportive care, evidence-based surveillance, and evidenced-based treatment and were derived from current guidelines and other successful quality-improvement initiatives. Second, an actionable plan for practice improvement was developed in at least one of the three topic areas. Third, after a period of self-improvement, participants reassessed their performance of the same topic measures to determine tangible changes in patient care. Results: A total of 540 patient charts were reviewed by 27 clinicians. Notable results showed large gains in areas of supportive care, such as quantitative pain assessments and emotional well-being evaluations, which traditionally have been a minor focus of other quality-improvement initiatives. Participants also showed tangible improvements in the performance of leading measures of quality care. Conclusion: These findings support the need for continued efforts toward performance improvement in both established and emerging areas of CRC patient care. [ABSTRACT FROM AUTHOR]

Objectives. We examined racial and ethnic disparities in the total potential burden of asthma in low-income, racially/ethnically heterogeneous Chicago schools, Methods. We used the Brief Pediatric Asthma Screen Plus (BPAS+) and the Spanish BPAS+, validated, caregiver-completed respiratory questionnaires, to identify asthma and possible asthma among students in 14 racially/ethnically diverse public elementary schools. Results. Among 11 490 children, we demonstrated a high lifetime prevalence (12.2%) as well as racial and ethnic disparities in diagnosed asthma, but no disparities in prevalences of possible undiagnosed asthma. Possible asthma cases boost the total potential burden of asthma to more than 1 in 3 non-Hispanic Black and Puerto Rican children. Conclusions. There are significant racial and ethnic disparities in diagnosed asthma among inner-city schoolchildren in Chicago. However, possible undiagnosed asthma appears to have similar prevalences across racial/ethnic groups and contributes to a high total potential asthma burden in each group studied. A better understanding of underdiagnosis is needed to address gaps in asthma care and intervention for low-income communities. (Am J Public Health. 2006;96: 1599-1603. doi:10.2105/AJPH.2005.071514) [ABSTRACT FROM AUTHOR]

Background: Primary care practices have remained on the frontline of health care service delivery throughout the COVID-19 pandemic. The purpose of our study was to understand the early pandemic experience of primary care practices, how they adapted care processes for chronic disease management and preventive care, and the future potential of these practices' service delivery adaptations. Methods: We interviewed 44 providers and staff at 22 high-performing primary care practices located throughout the United States between March and May 2020. Interviews were transcribed and coded using a modified rapid assessment process due to the time-sensitive nature of the study. Results: Practices reported employing a variety of adaptations to care during the COVID-19 pandemic including maintaining safe and socially distanced access through increased use of telehealth visits, using disease registries to identify and proactively outreach to patients, providing remote patient education, and incorporating more home-based monitoring into care. Routine screening and testing slowed considerably, resulting in concerns about delayed detection. Patients with fewer resources, lower health literacy, and older adults were the most difficult to reach and manage during this time. Conclusion: Our findings indicate that primary care structures and processes developed for remote chronic disease management and preventive care are evolving rapidly. Emerging adapted care processes, most notably remote provision of care, are promising and may endure beyond the pandemic, but issues of equity must be addressed (e.g., through payment reform) to ensure vulnerable populations receive the same benefit. [ABSTRACT FROM AUTHOR]

Policy PointsTelehealth has many potential advantages during an infectious disease outbreak such as the COVID‐19 pandemic, and the COVID‐19 pandemic has accelerated the shift to telehealth as a prominent care delivery mode.Not all health care providers and patients are equally ready to take part in the telehealth revolution, which raises concerns for health equity during and after the COVID‐19 pandemic.Without proactive efforts to address both patient‐ and provider‐related digital barriers associated with socioeconomic status, the wide‐scale implementation of telehealth amid COVID‐19 may reinforce disparities in health access in already marginalized and underserved communities.To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them. Context: The COVID‐19 pandemic has catalyzed fundamental shifts across the US health care delivery system, including a rapid transition to telehealth. Telehealth has many potential advantages, including maintaining critical access to care while keeping both patients and providers safe from unnecessary exposure to the coronavirus. However, not all health care providers and patients are equally ready to take part in this digital revolution, which raises concerns for health equity during and after the COVID‐19 pandemic. Methods: The study analyzed data about small primary care practices' telehealth use and barriers to telehealth use collected from rapid‐response surveys administered by the New York City Department of Health and Mental Hygiene's Bureau of Equitable Health Systems and New York University from mid‐April through mid‐June 2020 as part of the city's efforts to understand how primary care practices were responding to the COVID‐19 pandemic following New York State's stay‐at‐home order on March 22. We focused on small primary care practices because they represent 40% of primary care providers and are disproportionately located in low‐income, minority or immigrant areas that were more severely impacted by COVID‐19. To examine whether telehealth use and barriers differed based on the socioeconomic characteristics of the communities served by these practices, we used the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to stratify respondents as being in high‐SVI or low‐SVI areas. We then characterized respondents' telehealth use and barriers to adoption by using means and proportions with 95% confidence intervals. In addition to a primary analysis using pooled data across the five waves of the survey, we performed sensitivity analyses using data from respondents who only took one survey, first wave only, and the last two waves only. Findings: While all providers rapidly shifted to telehealth, there were differences based on community characteristics in both the primary mode of telehealth used and the types of barriers experienced by providers. Providers in high‐SVI areas were almost twice as likely as providers in low‐SVI areas to use telephones as their primary telehealth modality (41.7% vs 23.8%; P <.001). The opposite was true for video, which was used as the primary telehealth modality by 18.7% of providers in high‐SVI areas and 33.7% of providers in low‐SVI areas (P <0.001). Providers in high‐SVI areas also faced more patient‐related barriers and fewer provider‐related barriers than those in low‐SVI areas. Conclusions: Between April and June 2020, telehealth became a prominent mode of primary care delivery in New York City. However, the transition to telehealth did not unfold in the same manner across communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them. [ABSTRACT FROM AUTHOR]

Physicians' responses to AIDS at different career stages and in different specialties were studied by surveying house staff (N = 438), faculty (N = 363), and applicants (N = 487) at six residency programs in internal medicine and six in surgery. House staff had more negative outlooks than senior medical students and faculty, reporting greater fear of exposure to AIDS and greater unwillingness to treat AIDS patients. Surgeons were more negative than internists on these dimensions. For all groups, concern about possible negative educational consequences of treating AIDS patients was largely a function of their amount of contact with AIDS patients. Comparing willingness to treat AIDS and nine other conditions, AIDS consistently ranked low, along with Alzheimer's disease, alcoholism, and drug dependency. The findings have practical implications for hospitals and training programs. In addition, they raise issues concerning the impact of training on professional socialization, and call into question physicians' commitment to the professional norm of treating all patients regardless of provider self-interest, patient social characteristics, or medical uncertainty. [ABSTRACT FROM AUTHOR]

Introduction: Practice facilitation is a promising practice transformation strategy, but further examination of its effectiveness in improving adoption of guidelines for multiple cardiovascular disease risk factors is needed. The objective of the study is to determine whether practice facilitation is effective in increasing the proportion of patients meeting the Million Hearts ABCS outcomes: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation intervention.Study Design: The study used a stepped-wedge cluster RCT design with 4 intervention waves. Data were extracted for 13 quarters between January 1, 2015 and March 31, 2018, which encompassed the control, intervention, and follow-up periods for all waves, and analyzed in 2019.Setting/participants: A total of 257 small independent primary care practices in New York City were randomized into 1 of 4 waves.Intervention: The intervention consisted of practice facilitators conducting at least 13 practice visits over 1 year, focused on capacity building and implementing system and workflow changes to meet cardiovascular disease care guidelines.Main Outcome Measures: The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (1) proportion of tobacco users who received a cessation intervention (smokers counseled) and (2) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite).Results: The S measure improved when comparing follow-up with the control period (incidence rate ratio=1.152, 95% CI=1.072, 1.238, p<0.001) and when comparing follow-up with intervention (incidence rate ratio=1.060, 95% CI=1.013, 1.109, p=0.007). Smokers counseled improved when comparing the intervention period with control (incidence rate ratio=1.121, 95% CI=1.037, 1.211, p=0.002).Conclusions: Increasing the impact of practice facilitation programs that target multiple risk factors may require a longer, more intense intervention and greater attention to external policy and practice context.Trial Registration: This study is registered at www.clinicaltrials.gov NCT02646488. [ABSTRACT FROM AUTHOR]

Background: Practice facilitation is an implementation strategy used to build practice capacity and support practice changes to improve health care outcomes. Yet, few studies have investigated how practice facilitation strategies are tailored to different primary care contexts.Objective: To identify contextual factors that drive facilitators' strategies to meet practice improvement goals, and how these strategies are tailored to practice context.Design: Semi-structured, qualitative interviews analyzed using inductive (open coding) and deductive (thematic) approaches. This study was conducted as part of a larger study, HealthyHearts New York City, which evaluated the impact of practice facilitation on adoption of cardiovascular disease prevention and treatment guidelines.Participants: 15 facilitators working in two practice contexts: small independent practices (SIPs) and Federally Qualified Health Centers (FQHCs).Main Measures: Strategies facilitators use to support and promote practice changes and contextual factors that impact this approach.Key Results: Contextual factors were described similarly across settings and included the policy environment, patient needs, site characteristics, leadership engagement, and competing priorities. We identified four facilitation strategies used to tailor to contextual factors and support practice change: (a) remain flexible to align with practice and organizational priorities; (b) build relationships; (c) provide value through information technology expertise; and (d) build capacity and create efficiencies. Facilitators in SIPs and FQHCs described using the same strategies, often in combination, but tailored to their specific contexts.Conclusions: Despite significant infrastructure and resource differences between SIPs and FQHCs, the contextual factors that influenced the facilitator's change process and the strategies used to address those factors were remarkably similar. The findings emphasize that facilitators require multidisciplinary skills to support sustainable practice improvement in the context of varying complex health care delivery settings. [ABSTRACT FROM AUTHOR]

Introduction: HealthyHearts NYC (HHNYC), a cooperative in the EvidenceNOW initiative, tested the effectiveness of practice facilitation (PF) on the adoption of the Million Hearts ABCS cardiovascular disease evidence-based guidelines (EBG) in small independent practices (SIPs): aspirin in high-risk individuals (A); blood pressure (BP) control and management (B); cholesterol management (C); and screening for tobacco use and, if a smoker, providing cessation services (S). HHNYC also adapted the Million Hearts EBGs to develop two unique measures: 1) a disaggregation of the smoking measure quantifying the proportion of tobacco users who received cessation counseling or a pharmacologic intervention ("smokers counseled"); and 2) the proportion of patients with a history of atherosclerotic cardiovascular disease who met all treatment targets for the A, B, and C outcomes ("ABC composite"). Methods: HHNYC used a cluster randomized stepped-wedge design to test the effect of PF (12 month intervention) on the Million Hearts EBGs in SIPs in NYC. To estimate the impact of the PF intervention, we used Poisson generalized linear mixed-effects models with (1) repeated measures nested within one of 255 SIPs, (2) randomly varying intercepts across SIPs, and (3) an observation-level random effect to address overdispersion. Results: Implementation of the intervention led to an increase in the proportion of smokers counseled (IRR=1.12, 95% CI=1.04-1.19, p=<.001). There were no other statistically significant PF effects. Discussion: SIPs started the intervention with high rates of EBG care—meeting or exceeding Million Hearts goals (i.e. 70% or greater)—which may explain why we did not observe significant improvements in most measures. Indeed, SIPs performed well in the screening part of the smoking measure before PF—the average screening rate during the baseline period across SIPs was 77%—but the increased proportion of smokers counseled suggests room for improvement in this aspect of the smoking measure. We recommend adding the proportion of smokers counseled to other performance measures of EBG care for cardiovascular disease prevention in SIPs. [ABSTRACT FROM AUTHOR]

Project Extension for Community Healthcare Outcomes (Project ECHO) offers an innovative and low-cost approach to enhancing the management of complex conditions among primary care providers. The NYC Health + Hospitals Buprenorphine ECHO (H + H ECHO) program offers primary care providers (PCPs) training and support in managing opioid use disorder (OUD). This exploratory study assessed the feasibility of a 16-session video conferencing platform led by Addiction Medicine experts in improving addiction knowledge, perceived self-efficacy, and buprenorphine prescribing among PCPs located in 17 publicly-funded ambulatory care clinics. A pre- and post-training survey assessed changes in knowledge and self-efficacy. Buprenorphine prescribing patterns were also captured pre-post training. Training sessions consisted of a review of the agenda by the H + H ECHO hub team, 15-30 min didactic lectures led by specialists, followed by a patient case presentation. Participants attended an average of 9 lectures (range, 1-15 sessions) and 53% of trainees attended at least 10 of the 16 sessions. Perceived self-efficacy improved post-H + H ECHO (73.2%) versus pre-training survey results (58.1%). There were minimal increases in knowledge post-training (58.4%) versus pre-training (51.4%). Only three additional providers reported prescribing Buprenorphine post-training (n = 10) versus pre-training (n = 7). Suggestions for improving H + H ECHO included trainings addressing stigma, administrative support, improved referrals to office-based opioid treatment (OBOT), integration of non-physician staff (i.e., case management, social work), and combining multimodal learning strategies (i.e., podcasts, web-based modules) with videoconferencing. This study demonstrates the feasibility of H + H ECHO among PCPs in publicly-funded clinics and improvements in self-efficacy. Studies are needed to identify alternative strategies to improve knowledge and prescribing of buprenorphine post-H + H ECHO. [ABSTRACT FROM AUTHOR]

An estimated 3 to 5 million Americans are chronically infected with hepatitis C virus (HCV), and approximately 75% of those persons were born between 1945 and 1965 (the so-called baby boomer generation). Because of the largely asymptomatic nature of HCV, up to 50% of those infected are unaware of their disease. Risk-based testing has been largely ineffective. Based on prevalence data, the Centers for Disease Control and Prevention and other organizations recommend a onetime HCV antibody test for all baby boomers. However, uptake of this recommendation requires significant changes in clinical practice for already busy primary care clinicians. We studied the effectiveness of a quality improvement initiative based on continuous audit and feedback combined with education for improving testing in alignment with guidelines; the control group was a cohort of clinicians whose only reminder was an institution-wide electronic health record prompt. Our data show improved testing rates among all clinician groups, but more significant improvement occurred among providers who received continuous feedback about their clinical performance coupled with education. [ABSTRACT FROM AUTHOR]

Purpose: We wanted to describe small, independent primary care practices' performance in meeting the Million Hearts ABCSs (aspirin use, blood pressure control, cholesterol management, and smoking screening and counseling), as well as on a composite measure that captured the extent to which multiple clinical targets are achieved for patients with a history of arteriosclerotic cardiovascular disease (ASCVD). We also explored relationships between practice characteristics and ABCS measures.Methods: We conducted a cross-sectional, bivariate analysis using baseline data from 134 practices in New York City. ABCS data were extracted from practices' electronic health records and aggregated to the site level. Practice characteristics were obtained from surveys of clinicians and staff at each practice.Results: The proportion of at-risk patients meeting clinical goals for each of the ABCS measures was 73.0% for aspirin use, 69.6% for blood pressure, 66.7% for cholesterol management, and 74.2% screened for smoking and counseled. For patients with a history of ASCVD, only 49% were meeting all ABC (aspirin use, blood pressure control, cholesterol management) targets (ie, composite measure). Solo practices were more likely to meet clinical guidelines for aspirin (risk ratio [RR] =1.17, P =.007) and composite (RR=1.29, P = .011) than practices with multiple clinicians.Conclusion: Achieving targets for ABCS measures varied considerably across practices; however, small practices were meeting or exceeding Million Hearts goals (ie, 70% or greater). Practices were less likely to meet consistently clinical targets that apply to patients with a history of ASCVD risk factors. Greater emphasis is needed on providing support for small practices to address the complexity of managing patients with multiple risk factors for primary and secondary ASCVD. [ABSTRACT FROM AUTHOR]

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation. [ABSTRACT FROM AUTHOR]

Background: HealthyHearts NYC (HHNYC) will evaluate the effectiveness of practice facilitation as a quality improvement strategy for implementing the Million Hearts' ABCS treatment guidelines for reducing cardiovascular disease (CVD) among high-risk patients who receive care in primary care practices in New York City. ABCS refers to (A) aspirin in high-risk individuals; (B) blood pressure control; (C) cholesterol management; and (S) smoking cessation. The long-term goal is to create a robust infrastructure for implementing and disseminating evidence-based practice guidelines (EBPG) in primary care practices.Methods/design: We are using a stepped-wedge cluster randomized controlled trial design to evaluate the implementation process and the impact of practice facilitation (PF) versus usual care on ABCS outcomes in 250 small primary care practices. Randomization is at the practice site level, all of which begin as part of the control condition. The intervention consists of one year of PF that includes a combination of one-on-one onsite visits and shared learning across practice sites. PFs will focus on helping sites implement evidence-based components of patient-centered medical home (PCMH) and the chronic care model (CCM), which include decision support, provider feedback, self-management tools and resources, and linkages to community-based services.Discussion: We hypothesize that practice facilitation will result in superior clinical outcomes compared to usual care; that the effects of practice facilitation will be mediated by greater adoption of system changes in accord with PCMH and CCM; and that there will be increased adaptive reserve and change capacity.Trial Registration: NCT02646488. [ABSTRACT FROM AUTHOR]

The article discusses the confidence and knowledge outcomes of shared medical visits and continuing medical education workshops in the clinical practice of American Association of Clinical Endocrinologists and American Diabetes Association members. The objectives of the study for evaluation of the educational approach to management of type 2 diabetes patients are stated. Improvements are noted in confidence with knowledge questions while interaction with and among patients is also cited.

Background: Osteoporosis is a widespread but largely preventable disease. Improved adherence to screening and treatment recommendations is needed to reduce fracture and mortality rates. Additionally, clinicians face increasing demands to demonstrate proficient quality patient care aligning with evidence-based standards. Methods: A three-stage, clinician-focused performance improvement (PI) continuing medical education (CME) initiative was developed to enhance clinician awareness and execution of evidence-based standards of osteoporosis care. Clinician performance was evaluated through a retrospective chart analysis of patients at risk or with a diagnosis of osteoporosis. Results: Seventy-five participants reported their patient practices on a total of 1875 patients before and 1875 patients after completing a PI initiative. Significant gains were made in the use of Fracture Risk Assessment Tool (FRAX) (stage A, 26%, n=1769 vs. stage C, 51%, n=1762; p<0.001), assessment of fall risk (stage A, 46%, n=1276 vs. stage C, 89%, n=1190; p<0.001), calcium levels (stage A, 62%, n=1451 vs. stage C, 89%, n=1443; p<0.001), vitamin D levels (stage A, 79%, n=1438 vs. stage C, 93%, n=1439; p<0.001), and medication adherence (stage A, 88%, n=1136 vs. stage C, 96%, n=1106; p<0.001). Conclusions: Gains in patient screening, treatment, and adherence were associated with an initiative promoting self-evaluation and goal setting. Clinicians must assess their performance to improve patient care and maintain certification. PI CME is a valid, useful educational tool for accomplishing these standards. [ABSTRACT FROM AUTHOR]

Objectives. We sought to determine whether low acculturation among Mexican American caregivers protects their children against asthma. Methods. Data were obtained from an observational study of urban pediatric asthma. Dependent variables were children's diagnosed asthma and total (diagnosed plus possible) asthma. Regression models were controlled for caregivers' level of acculturation, education, marital status, depression, life stress, and social support and children's insurance. Results. Caregivers' level of acculturation was associated with children's diagnosed asthma (P=.025) and total asthma (P=.078) in bivariate analyses. In multivariate models, protective effects of caregivers' level of acculturation were mediated by the other covariates. Independent predictors of increased diagnosed asthma included caregivers' life stress (odds ratio [OR]= 1.12, P=.005) and children's insurance, both public (OR=4.71, P=.009) and private (OR = 2.87, P=.071). Only caregiver's life stress predicted increased total asthma (OR = 1.21, P=.001). Conclusions. The protective effect of caregivers' level of acculturation on diagnosed and total asthma for Mexican American children was mediated by social factors, especially caregivers' life stress. Among acculturation measures, foreign birth was more predictive of disease status than was language use or years in country. Increased acculturation among immigrant groups does not appear to lead to greater asthma risk. (Am J Public Health. 2007;97:1290-1296.) [ABSTRACT FROM AUTHOR]

Background: Patients receiving diabetes specialty care experience higher quality care, fewer complications and improved survival; however, access to specialists is limited in medically underserved areas. The Endo ECHO program connects specialists at academic medical centers with PCPs through virtual clinics. We report the comparability of quality measures between Endo ECHO patients and those receiving diabetes specialty care. Methods: Patients with complex diabetes from 10 Endo ECHO clinics in NM completed surveys assessing healthcare quality one year after program enrollment. Patients at the University of New Mexico Diabetes Comprehensive Care Center (DCCC) served as a comparison group and completed the same survey. Results: Five hundred thirty-three ECHO patients and 139 DCCC patients completed surveys. ECHO patients were much less likely to identify English as their primary language (69% ECHO vs. 91% DCCC, p<0.0001) and reported lower levels of educational attainment (40% ECHO with at least some college vs. 60% DCCC, p<0.0001). DCCC patients were more likely to report a positive overall health status (42% ECHO vs. 68% DCCC, p<0.0001), yet there was no difference in overall concern about health across groups. ECHO patients reported more frequent visits to their usual source of diabetes care (72% ECHO with 4 or more annual visits vs. 58% DCCC, p<0.0001). There were no differences in the frequency of A1C testing or feet checks by a provider; however, more DCCC patients reported regular eye exams (69% ECHO vs. 87% DCCC, p<0.0001) and that their provider had assessed smoking status (70% ECHO vs. 82% DCCC, p<0.0001). Conclusions: Endo ECHO patients faced greater medical literacy barriers yet reported similar outcomes for several, but not all, diabetes care quality measures as compared to those reported by patients at the DCCC. Endo ECHO may be a suitable alternative to specialty care for patients in medically underserved areas; ongoing evaluation will determine its impact on clinical outcomes. Disclosure: M.M. Paul: None. A. Davila Saad: None. J. Billings: None. S. Blecker: Advisory Panel; Self; Medtronic. M.F. Bouchonville: None. B. Hager: None. S. Arora: None. C. Berry: None. Funding: The Leona M. and Harry B. Helmsley Charitable Trust [ABSTRACT FROM AUTHOR]

Background: Individuals living with complex diabetes in medically underserved areas face additional barriers to accessing needed services and support. This study used photo elicitation interviews (PEI) to develop a rich understanding of everyday life among individuals with complex diabetes living in such areas of New Mexico (NM). Methods: Five individuals with T1DM and 3 with complex T2DM receiving care through Endo ECHO in NM received digital cameras and the task of taking photographs about their experience of living with diabetes, and then participated in interviews with our team, during which they selected 10 photos from their collections to discuss. Interviews were recorded and transcribed, and then coded using Grounded Theory in an iterative process. Results: Six family-codes emerged: Self-management, health care, support, complications, food, and coping strategies. Three overarching axial codes were identified: Rural living, body self-knowledge, and diabetes burden. A picture of the relentless and never-ending nature of managing diabetes emerged in the analysis. Over half of the photos were of food, both healthy and forbidden; food is an overriding concern, and participants' understanding of healthy food varied greatly. Participants noted important sources of support and optimism, and the joy of activities beyond diabetes care such as online gaming, raising chickens, or hiking. Conclusions: Participants shared their unique perspectives; however, regardless of participants' age, diabetes diagnosis, and gender, they uniformly expressed acute awareness of the permanent burden of their condition, the challenges of self-management, and the need to overcome the barriers of living in medically underserved areas. PEI proved to be a valuable method for ascertaining a deep understanding of individuals' daily experience of living with complex diabetes. Disclosure: M.M. Paul: None. A. Davila Saad: None. M. Tagliaferro: None. J. Billings: None. S. Blecker: Advisory Panel; Self; Medtronic. C. Berry: None. Funding: The Leona M. and Harry B. Helmsley Charitable Trust [ABSTRACT FROM AUTHOR]

Background: Poorly controlled diabetes can be difficult to manage, particularly in high-risk patients and in settings without an endocrinologist. Project ECHO is a case-based learning and tele-mentoring model that connects primary care providers (PCPs) with specialists. We evaluated the impact of the ECHO model on healthcare utilization and care for Medicaid patients with diabetes in New Mexico (NM). Methods: Between January 2015 and April 2017, patients with complex diabetes from 10 federally qualified health centers in NM were recruited to receive diabetes care from a PCP and community health worker upskilled via weekly Endo ECHO sessions. We included patients with 6 months of continuous enrollment in the NM Medicaid claims database and performed 5:1 propensity matching of participants to comparison Medicaid beneficiaries. We used a difference-in-difference (DID) approach to compare utilization and processes of care between study participants and controls. Results: Of 539 Medicaid patients enrolled in Endo ECHO, 235 met inclusion criteria and were successfully matched to comparison patients. Outpatient visits increased for study participants in the pre- versus post-enrollment period (801 vs. 1056 per 1,000 patients/month) but not for comparators (785 vs. 680 per 1000 patients/month, DID p<0.01). We observed no difference in inpatient (131 vs. 134 per 1,000 patients/month) or ED utilization (24 vs. 26 per 1,000) in the pre- versus post-enrollment period for study participants. The intervention was associated with increased metformin utilization (DID 15.2%, p=0.01), but had no effect on expenditures, statin utilization, or ACE inhibitor/ARB utilization for hypertension. Discussion: Patient enrollment in Endo ECHO was associated with increased outpatient utilization and increased compliance with some, but not all, process measures. No impact was observed on hospitalizations or ED visits. Ongoing evaluation will determine the impact of the ECHO model on clinical outcomes. Disclosure: S. Blecker: Advisory Panel; Self; Medtronic. E. Lemieux: None. M. Paul: None. C. Berry: None. M.F. Bouchonville: None. B. Hager: None. S. Arora: None. J. Billings: None. Funding: The Leona M. and Harry B. Helmsley Charitable Trust [ABSTRACT FROM AUTHOR]

Introduction: HealthyHearts NYC (HHNYC), a cooperative in the Agency for Healthcare Research and Quality EvidenceNOW initiative, tested the effect of practice facilitation (PF) on practice-level blood pressure (BP) control in 255 small independent practices (SIPs). Few studies of interventions to improve BP control have considered the implications of seasonal variation when analyzing BP outcomes Methods: HHNYC used a cluster randomized stepped-wedge design to test the effect of PF (12 month intervention) on the proportion of patients meeting the Million Hearts BP target (≥70% BP controlled) among SIPs in NYC. BP data were extracted from SIPs' electronic health records. We used Poisson generalized linear mixed-effects models, with repeated measures nested within one of 255 SIPs and randomly varying intercepts across SIPs to assess the intervention effect. We did a second analysis that adapted the Poisson model to include (1) an observation-level random effect to address overdispersion (more variance in the counts than expected for a Poisson distribution) and (2) two terms in the fixed-effects portion of the model to separately contrast quarter one and then quarter three with quarters two and four, to address BP seasonality. Results: The first model found a significant negative association between PF and BP control (i.e., BP control declined) (IRR=0.98, 95% CI=0.96-0.99, p=<.001). In the full model (i.e., addressing seasonal changes) PF had no effect on BP control (IRR = 0.99, 95% CI=0.97-1.0, p=.19). The rate of BP control was significantly lower in quarter one (IRR = 0.97; 95% CI: 0.96-0.98, p<.01) and higher in quarter three (IRR=1.02; 95% CI: 1.01-1.03, p<.01) when compared with quarters two and four. Discussion: Many SIPs already met or exceeded national estimates of BP control and the Million Hearts BP performance target before the intervention, perhaps challenging further improvement without additional patient level intervention components that were not part of HHNYC. BP seasonality has strong study design implications. For stepped-wedge trials, sufficient waves are required to ensure the expected timing of intervention impact is spread evenly over quarters so the seasonality and any intervention impact can be more easily disentangled. [ABSTRACT FROM AUTHOR]