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We used a collective impact model to form a statewide diabetes quality improvement collaborative to improve diabetes outcomes and advance diabetes health equity. Between 2020 and 2022, in collaboration with the Ohio Department of Medicaid, Medicaid Managed Care Plans, and Ohio's seven medical schools, we recruited 20 primary care practices across the state. The percentage of patients with hemoglobin A1c greater than 9% improved from 25% to 20% over two years. Applying our model more broadly could accelerate improvement in diabetes outcomes. (Am J Public Health. 2023;113(12):1254–1257. https://doi.org/10.2105/AJPH.2023.307410) [ABSTRACT FROM AUTHOR]

Background: Evidence on the effects of neighborhood socioeconomic disadvantage on dementia risk in racially and ethically diverse populations is limited. Our objective was to evaluate the relative extent to which neighborhood disadvantage accounts for racial/ethnic variation in dementia incidence rates. Secondarily, we evaluated the spatial relationship between neighborhood disadvantage and dementia risk. Methods: In this retrospective study using electronic health records (EHR) at two regional health systems in Northeast Ohio, participants included 253,421 patients aged >60 years who had an outpatient primary care visit between January 1, 2005 and December 31, 2015. The date of the first qualifying visit served as the study baseline. Cumulative incidence of composite dementia outcome, defined as EHR‐documented dementia diagnosis or dementia‐related death, stratified by neighborhood socioeconomic deprivation (as measured by Area Deprivation Index) was determined by competing‐risk regression analysis, with non‐dementia‐related death as the competing risk. Fine‐Gray sub‐distribution hazard ratios were determined for neighborhood socioeconomic deprivation, race/ethnicity, and clinical risk factors. The degree to which neighborhood socioeconomic position accounted for racial/ethnic disparities in the incidence of composite dementia outcome was evaluated via mediation analysis with Poisson rate models. Results: Increasing neighborhood disadvantage was associated with increased risk of EHR‐documented dementia diagnosis or dementia‐related death (most vs. least disadvantaged ADI quintile HR = 1.76, 95% confidence interval = 1.69–1.84) after adjusting for age and sex. The effect of neighborhood disadvantage on this composite dementia outcome remained after accounting for known medical risk factors of dementia. Mediation analysis indicated that neighborhood disadvantage accounted for 34% and 29% of the elevated risk for composite dementia outcome in Hispanic and Black patients compared to White patients, respectively. Conclusion: Neighborhood disadvantage is related to the risk of EHR‐documented dementia diagnosis or dementia‐related death and accounts for a portion of racial/ethnic differences in dementia burden, even after adjustment for clinically important confounders. [ABSTRACT FROM AUTHOR]

Background: Proton pump inhibitors (PPIs) are potent inhibitors of acid secretion and are the mainstay of therapy for gastroesophageal reflux disease (GERD). Initially designed to be taken 30 min before the first daily meal, these agents are commonly used suboptimally, which adversely affects symptom relief. No study to date has assessed whether correcting dosing regimens would improve symptom control. The objective of this study was to determine whether patients with persistent GERD symptoms on suboptimal omeprazole dosing experience symptomatic improvement when randomized to commonly recommended dosing regimen and to evaluate the economic impact of suboptimal PPI dosing in GERD patients.Methods: Patients with persistent heartburn symptoms ≥ 3 times per week treated with omeprazole 20 mg daily were enrolled and randomized to commonly recommended dosing or continued suboptimal dosing of omeprazole. The primary outcomes were changes in symptom, frequency, and severity, as determined using the Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS) 4 weeks after the intervention was administered. In secondary analysis, an alternative measure of symptom load was used to infer potential costs.Results: Sixty-four patients were enrolled. GSAS symptom, frequency, and severity scores were significantly better when dosing was optimized for overall and heartburn-specific symptoms (P < 0.01 for all parameters). Cost savings resulting from reduced medical care and workplace absenteeism were estimated to be $159.60 per treated patient, with cost savings potentially exceeding $4 billion annually in the USA.Discussion: Low-cost efforts to promote commonly recommended PPI dosing can dramatically reduce GERD symptoms and related economic costs. ClinicalTrials.gov, number: NCT02623816. [ABSTRACT FROM AUTHOR]

Background: Inequality in health outcomes in relation to Americans' socioeconomic position is rising.Objective: First, to evaluate the spatial relationship between neighborhood disadvantage and major atherosclerotic cardiovascular disease (ASCVD)-related events; second, to evaluate the relative extent to which neighborhood disadvantage and physiologic risk account for neighborhood-level variation in ASCVD event rates.Design: Observational cohort analysis of geocoded longitudinal electronic health records.Setting: A single academic health center and surrounding neighborhoods in northeastern Ohio.Patients: 109 793 patients from the Cleveland Clinic Health System (CCHS) who had an outpatient lipid panel drawn between 2007 and 2010. The date of the first qualifying lipid panel served as the study baseline.Measurements: Time from baseline to the first occurrence of a major ASCVD event (myocardial infarction, stroke, or cardiovascular death) within 5 years, modeled as a function of a locally derived neighborhood disadvantage index (NDI) and the predicted 5-year ASCVD event rate from the Pooled Cohort Equations Risk Model (PCERM) of the American College of Cardiology and American Heart Association. Outcome data were censored if no CCHS encounters occurred for 2 consecutive years or when state death data were no longer available (that is, from 2014 onward).Results: The PCERM systematically underpredicted ASCVD event risk among patients from disadvantaged communities. Model discrimination was poorer among these patients (concordance index [C], 0.70 [95% CI, 0.67 to 0.74]) than those from the most affluent communities (C, 0.80 [CI, 0.78 to 0.81]). The NDI alone accounted for 32.0% of census tract-level variation in ASCVD event rates, compared with 10.0% accounted for by the PCERM.Limitations: Patients from affluent communities were overrepresented. Outcomes of patients who received treatment for cardiovascular disease at Cleveland Clinic were assumed to be independent of whether the patients came from a disadvantaged or an affluent neighborhood.Conclusion: Neighborhood disadvantage may be a powerful regulator of ASCVD event risk. In addition to supplemental risk models and clinical screening criteria, population-based solutions are needed to ameliorate the deleterious effects of neighborhood disadvantage on health outcomes.Primary Funding Source: The Clinical and Translational Science Collaborative of Cleveland and National Institutes of Health. [ABSTRACT FROM AUTHOR]

Importance: Hypertension in middle-aged adults (35-50 years) is associated with poorer health outcomes in late life. Understanding how hypertension varies by race and ethnicity across levels of neighborhood disadvantage may allow for better characterization of persistent disparities., Objective: To evaluate spatial patterns of hypertension diagnosis and treatment by neighborhood socioeconomic position and racial and ethnic composition., Design, Setting, and Participants: In this cross-sectional study of middle-aged adults in Cuyahoga County, Ohio, who encountered primary care in 2019, geocoded electronic health record data were linked to the area deprivation index (ADI), a neighborhood disadvantage measure, at the US Census Block Group level (ie, neighborhood). Neighborhoods were stratified by ADI quintiles, with the highest quintile indicating the most disadvantage. Data were analyzed between August 7, 2023, and June 1, 2024., Exposure: Essential hypertension., Main Outcomes and Measures: The primary outcome was a clinician diagnosis of essential hypertension. Spatial analysis was used to characterize neighborhood-level patterns of hypertension prevalence and treatment. Interaction analysis was used to compare hypertension prevalence by racial and ethnic group within similar ADI quintiles., Results: A total of 56 387 adults (median [IQR] age, 43.1 [39.1-46.9] years; 59.8% female) across 1157 neighborhoods, which comprised 3.4% Asian, 31.1% Black, 5.5% Hispanic, and 60.0% White patients, were analyzed. A gradient of hypertension prevalence across ADI quintiles was observed, with the highest vs lowest ADI quintile neighborhoods having a higher hypertension rate (50.7% vs 25.5%) and a lower treatment rate (61.3% vs 64.5%). Of the 315 neighborhoods with predominantly Black (>75%) patient populations, 200 (63%) had a hypertension rate greater than 35% combined with a treatment rate of less than 70%; only 31 of 263 neighborhoods (11.8%) comprising 5% or less Black patient populations met this same criterion. Compared with a spatial model without covariates, inclusion of ADI and percentage of Black patients accounted for 91% of variation in hypertension diagnosis prevalence among men and 98% among women. Men had a higher prevalence of hypertension than women across race and ADI quintiles, but the association of ADI and hypertension risk was stronger in women. Sex prevalence differences were smallest between Black men and women, particularly in the highest ADI quintile (1689 [60.0%] and 2592 [56.0%], respectively)., Conclusions and Relevance: These findings show an association between neighborhood deprivation and hypertension prevalence, with disparities observed particularly among Black patients, emphasizing a need for structural interventions to improve community health.

Purpose: Triple negative breast cancer (TNBC) is an aggressive subtype of breast cancer (BC) with higher recurrence rates and poorer prognoses and most prevalent among non-Hispanic Black women. Studies of multiple health conditions and care processes suggest that neighborhood socioeconomic position is a key driver of health disparities. We examined roles of patients' neighborhood-level characteristics and race on prevalence, stage at diagnosis, and mortality among patients diagnosed with BC at a large safety-net healthcare system in Northeast Ohio., Methods: We used tumor registry to identify BC cases from 2007 to 2020 and electronic health records and American Community Survey for individual- and area-level factors. We performed multivariable regression analyses to estimate associations between neighborhood-level characteristics, measured by the Area Deprivation Index (ADI), race and comparative TNBC prevalence, stage at diagnosis, and total mortality., Results: TNBC was more common among non-Hispanic Black (53.7%) vs. non-Hispanic white patients (46.4%). Race and ADI were individually significant predictors of TNBC prevalence, stage at diagnosis, and total mortality. Race remained significantly associated with TNBC subtype, adjusting for covariates. Accounting for TNBC status, a more disadvantaged neighborhood was significantly associated with a worse stage at diagnosis and higher death rates., Conclusion: Our findings suggest that both neighborhood socioeconomic position and race are strongly associated with TNBC vs. other BC subtypes. The burden of TNBC appears to be highest among Black women in the most socioeconomically disadvantaged neighborhoods. Our study suggests a complex interplay of social conditions and biological disease characteristics contributing to racial disparities in BC outcomes., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Social and ecological differences in early SARS-CoV-2 pandemic screening and outcomes have been documented, but the means by which these differences have arisen are not well understood., Objective: To characterize socioeconomic and chronic disease-related mechanisms underlying these differences., Design: Observational cohort study., Setting: Outpatient and emergency care., Patients: 12900 Cleveland Clinic Health System patients referred for SARS-CoV-2 testing between March 17 and April 15, 2020., Interventions: Nasopharyngeal PCR test for SARS-CoV-2 infection., Measurements: Test location (emergency department, ED, vs. outpatient care), COVID-19 symptoms, test positivity and hospitalization among positive cases., Results: We identified six classes of symptoms, ranging in test positivity from 3.4% to 23%. Non-Hispanic Black race/ethnicity was disproportionately represented in the group with highest positivity rates. Non-Hispanic Black patients ranged from 1.81 [95% confidence interval: 0.91-3.59] times (at age 20) to 2.37 [1.54-3.65] times (at age 80) more likely to test positive for the SARS-CoV-2 virus than non-Hispanic White patients, while test positivity was not significantly different across the neighborhood income spectrum. Testing in the emergency department (OR: 5.4 [3.9, 7.5]) and cardiovascular disease (OR: 2.5 [1.7, 3.8]) were related to increased risk of hospitalization among the 1247 patients who tested positive., Limitations: Constraints on availability of test kits forced providers to selectively test for SARS-Cov-2., Conclusion: Non-Hispanic Black patients and patients from low-income neighborhoods tended toward more severe and prolonged symptom profiles and increased comorbidity burden. These factors were associated with higher rates of testing in the ED. Non-Hispanic Black patients also had higher test positivity rates., Competing Interests: The authors have declared that no competing interests exist.

Background: Severe acute respiratory syndrome coronavirus (SARS-CoV-2) and the associated coronavirus disease of 2019 (COVID-19) have presented immense challenges for health care systems. Many regions have struggled to adapt to disruptions to health care practice and use systems that effectively manage the demand for services., Methods: This was a cohort study using electronic health records at a health care system in northeast Ohio that examined the effectiveness of the first 5 weeks of a 24/7 physician-staffed COVID-19 hotline including social care referrals for patients required to self-isolate. We describe clinical diagnosis, patient characteristics (age, sex race/ethnicity, smoking status, insurance status), and visit disposition. We use logistic regression to evaluate associations between patient characteristics, visit disposition and subsequent emergency department use, hospitalization, and SARS-Cov-2 PCR testing., Participants: In 5 weeks, 10,112 patients called the hotline (callers). Of these, 4213 (42%) were referred for a physician telehealth visit (telehealth patients). Mean age of callers was 42 years; 67% were female, 51% white, and 46% were on Medicaid/uninsured., Results: Common caller concerns included cough, fever, and shortness of breath. Most telehealth patients (79%) were advised to self-isolate at home, 14% were determined to be unlikely to have COVID-19, 3% were advised to seek emergency care, and 4% had miscellaneous other dispositions. A total of 287 patients (7%) had a subsequent emergency department visit, and 44 (1%) were hospitalized with a COVID-19 diagnosis. Of the callers, 482 (5%) had a COVID-19 test reported, with 69 (14%) testing positive. Among patients advised to stay at home, 83% had no further face-to-face visits. In multivariable results, only a physician recommendation to seek emergency care was associated with emergency department use (odds ratio = 4.73, 95% confidence interval = 1.37-16.39, P = .014). Only older age was associated with having a positive test result. Patients with social needs and interest in receiving help were offered services to meet their needs including food deliveries (n = 92), behavioral health telephone visits (n = 49), and faith-based comfort calls from pastoral care personnel (n = 37)., Conclusions and Relevance: Robust, physician-directed telehealth services can meet a wide range of clinical and social needs during the acute phase of a pandemic, conserving scarce resources such as personal protective equipment and testing supplies and preventing the spread of infections to patients and health care workers., (© Copyright 2021 by the American Board of Family Medicine.)

Aim: To better understand the type and range of health issues initiated by patients and providers in 'high-quality' primary-care for adults with diabetes and low socio-economic status (SES)., Background: Although quality of care guidelines are straightforward, diabetes visits in primary care are often more complex than adhering to guidelines, especially in adults with low SES who experience many financial and environmental barriers to good care., Methods: We conducted a qualitative study using direct observation of primary-care diabetes visits at an exemplar safety net practice in 2009-2010. Findings In a mainly African American (93%) low-income population with fair cardiovascular control (mean A1c 7.5%, BP 134/81 mmHg, and low-density lipoprotein cholesterol 100 mg/dL), visits addressed a variety of bio-psychosocial health issues [median: 25 problems/visit (range 13-32)]. Physicians most frequently initiated discussions about chronic diseases, prevention, and health behavior. Patients most frequently initiated discussions about social environment and acute symptoms followed by prevention and health behavior., Conclusions: Primary-care visits by diabetes patients with low SES address a surprising number and diversity of problems. Emerging new models of primary-care delivery and quality measurement should allow adequate time and resources to address the range of tasks necessary for integrating biomedical and psychosocial concerns to improve the health of socio-economically disadvantaged patients.

Objective: A previous study determined that multiple questions on a 360-degree evaluation instrument were highly correlated, suggesting possible redundancy in what was being measured, and that some questions may be eliminated. The current study uses factor analysis and examines a larger data set to further explore this question., Design: To evaluate the structure of the questionnaire, a factor analysis was performed on 3 yrs of data from a 19-item resident 360-degree evaluation. The number of factors was determined by examining the scree plot of eigenvalues for each item in the instrument, with a cutoff where the slope changes from rapid to slow decline. A reliability analysis was performed with the indicated number of factors, with deletion of each variable to evaluate its influence on overall reliability (Cronbach alpha)., Results: There were 299 evaluations with complete responses to all 19 questions. The scree plot supported a single factor model. The reliability of the full, single factor survey was excellent (Cronbach α = 0.99). The three items with the highest loading on the factor were retained, which related to humanistic, moral/ethical, and professional responsibility behaviors. The reliability for these final three items remained excellent (Cronbach α = 0.96)., Conclusions: The factor analysis suggests that one overall opinion of the evaluated resident was informing the responses of the evaluator. Shortening the instrument to the three items responsible for the greatest influence on the survey does not result in a large decrease in reliability as measured by Cronbach alpha. It is possible that time limitations prevent residents from putting thought into the evaluation of their peers, which results in unidimensional responses. Shortening the instrument may improve evaluations and should be studied in the future.

Objective: Patients with hepatitis C virus (HCV) are advised to refrain from alcohol consumption. A questionnaire was developed to measure concepts associated with alcohol use for individuals with HCV., Method: Subjects with HCV (N = 527) completed a telephone survey. Eligible respondents had screened negative for current abuse/dependence disorders (Alcohol Use Disorders Identification Test [AUDIT] ≤ 10). Measures of personality, self-efficacy, knowledge, readiness, coping styles, stigma, and symptoms were examined for associations with alcohol use., Results: Factor analysis supported a measurement structure of 105 items in 35 subdomains. A total of 26 subdomains had significant bivariate associations with alcohol use. Higher self-efficacy for resisting drinking in social situations was associated with lower alcohol use (r = -.68, p < .001), as was knowledge of alcohol and HCV (r = -.27, p < .001). Although agreeableness and marital status are typically associated with lower current drinking in samples of those with alcohol use problems, in our study agreeableness (β = .13, p < .01) and marital status (β = .08, p < .05) were modestly associated with higher current drinking. The final multivariate R² was .55., Conclusions: The pattern of associations suggests the importance of the social aspects of drinking for drinking decisions. Existing brief interventions will need to be tailored to a contextualized psychosocial model for medical patients with HCV and AUDIT scores ≤ 10 to optimize effectiveness. Such future interventions should emphasize the potential medical hazards of drinking for persons with HCV, the maintenance of social relationships in the absence of alcohol use, and strategies for building confidence for resisting drinking in specific situations.

Background: Abstaining from alcohol consumption is generally recommended for patients with Hepatitis C(HCV). However, mixed research findings coupled with a lack of consistent guidelines on alcohol consumption and HCV may influence what healthcare providers tell their HCV patients about drinking. This may be more problematic when advising nonharmful drinkers with HCV, a population for whom consumption would not bea problem in the absence of their HCV diagnosis., Objective: This study explores what healthcare providers advise their HCV patients who are drinking alcohol at nonharmful levels about alcohol use and what these patients actually hear., Design: We conducted separate focus groups and interviews about alcohol use and HCV with nonharmful drinkers with HCV (N=50) and healthcare providers (N=14) at a metropolitan teaching hospital. All focus groups and interviews were audio-taped, transcribed, and analyzed using NVivo, a qualitative data management and analysis program., Results: We found similar themes about HCV and alcohol consumption (stop completely, occasional drink is ok, cut down, and provision of mixed/ambiguous messages), reported by both providers and patients.Patient respondents who reported hearing “stop completely”were more likely to have had their last medical visit at the gastroenterology (GI) clinic as opposed to the internal medicine (IM) clinic. Furthermore, IM providers were more likely to give their recommendations in“medical language” than were GI providers., Conclusions: To make the best health-related decisions about their disease, HCV patients need consistent information about alcohol consumption. Departments of Internal Medicine can increase provider knowledge about HCV and alcohol use by providing more education and training on HCV.

Aims: Little is known about how non-problematic drinkers respond to advice to reduce alcohol consumption as part of disease management. In this article, we examine patient reports of drinking behaviour after being diagnosed with chronic hepatitis C, a condition for which alcohol consumption is contraindicated., Methods: In this qualitative study, we analyzed transcripts of semi-structured interviews with hepatitis C virus+ (HCV+) patients whose level of alcohol consumption would not be considered problematic in the absence of their diagnosis., Results: Most respondents reported some instances of adherence, but only half adhered to the advice to limit drinking consistently over time. Respondents who did not stop drinking often modified their behaviour by changing the type of alcohol consumed or limiting drinking to particular occasions., Conclusion: Most informants understood the risks of drinking after HCV infection, particularly in the presence of symptoms, with the onset of complications, or when undergoing treatment. But some believed they could monitor their bodies for evidence of disease progression or that drinking was acceptable during early, asymptomatic stages of infection. Our results also identified situations in which patients need support in adhering to intentions not to drink, including social pressures, stressful situations, or environmental triggers.