Delivery of Cervical and Colorectal Cancer Screenings During the Pandemic in Community Health Centers: Practice Changes and Recovery Strategies.

BACKGROUND: The coronavirus disease 2019 pandemic led to clinical practice changes, which affected cancer preventive care delivery. OBJECTIVES: To investigate the impact of the coronavirus disease 2019 pandemic on the delivery of colorectal cancer (CRC) and cervical cancer (CVC) screenings. RESEARCH DESIGN: Parallel mixed methods design using electronic health record data (extracted between January 2019 and July 2021). Study results focused on 3 pandemic-related periods: March-May 2020, June-October 2020, and November 2020-September 2021. SUBJECTS: Two hundred seventeen community health centers located in 13 states and 29 semistructured interviews from 13 community health centers. MEASURES: Monthly up-to-date CRC and CVC screening rates and monthly rates of completed colonoscopies, fecal immunochemical test (FIT)/fecal occult blood test (FOBT) procedures, Papanicolaou tests among age and sex-eligible patients. Analysis used generalized estimating equations Poisson modeling. Qualitative analysts developed case summaries and created a cross-case data display for comparison. RESULTS: The results showed a reduction of 75% for colonoscopy [rate ratio (RR) = 0.250, 95% CI: 0.224-0.279], 78% for FIT/FOBT (RR = 0.218, 95% CI: 0.208-0.230), and 87% for Papanicolaou (RR = 0.130, 95% CI: 0.125-0.136) rates after the start of the pandemic. During this early pandemic period, CRC screening was impacted by hospitals halting services. Clinic staff moved toward FIT/FOBT screenings. CVC screening was impacted by guidelines encouraging pausing CVC screening, patient reluctance, and concerns about exposure. During the recovery period, leadership-driven preventive care prioritization and quality improvement capacity influenced CRC and CVC screening maintenance and recovery. CONCLUSIONS: Efforts supporting quality improvement capacity could be key actionable elements for these health centers to endure major disruptions to their care delivery system and to drive rapid recovery.

Implementation Support for a Social Risk Screening and Referral Process in Community Health Centers.

Evidence is needed about how to effectively support health care providers in implementing screening for social risks (adverse social determinants of health) and providing related referrals meant to address identified social risks. This need is greatest in underresourced care settings. The authors tested whether an implementation support intervention (6 months of technical assistance and coaching study clinics through a five-step implementation process) improved adoption of social risk activities in community health centers (CHCs). Thirty-one CHC clinics were block-randomized to six wedges that occurred sequentially. Over the 45-month study period from March 2018 to December 2021, data were collected for 6 or more months preintervention, the 6-month intervention period, and 6 or more months postintervention. The authors calculated clinic-level monthly rates of social risk screening results that were entered at in-person encounters and rates of social risk-related referrals. Secondary analyses measured impacts on diabetes-related outcomes. Intervention impact was assessed by comparing clinic performance based on whether they had versus had not yet received the intervention in the preintervention period compared with the intervention and postintervention periods. In assessing the results, the authors note that five clinics withdrew from the study for various bandwidth-related reasons. Of the remaining 26, a total of 19 fully or partially completed all 5 implementation steps, and 7 fully or partially completed at least the first 3 steps. Social risk screening was 2.45 times (95% confidence interval [CI], 1.32-4.39) higher during the intervention period compared with the preintervention period; this impact was not sustained postintervention (rate ratio, 2.16; 95% CI, 0.64-7.27). No significant difference was seen in social risk referral rates during the intervention or postintervention periods. The intervention was associated with greater blood pressure control among patients with diabetes and lower rates of diabetes biomarker screening postintervention. All results must be interpreted considering that the Covid-19 pandemic began midway through the trial, which affected care delivery generally and patients at CHCs particularly. Finally, the study results show that adaptive implementation support was effective at temporarily increasing social risk screening. It is possible that the intervention did not adequately address barriers to sustained implementation or that 6 months was not long enough to cement this change. Underresourced clinics may struggle to participate in support activities over longer periods without adequate resources, even if lengthier support is needed. As policies start requiring documentation of social risk activities, safety-net clinics may be unable to meet these requirements without adequate financial and coaching/technical support.

Prevalence of Pre-existing Conditions Among Community Health Center Patients With COVID-19: Implications for the Patient Protection and Affordable Care Act.

BACKGROUND: Short- and long-term effects of COVID-19 will likely be designated pre-existing conditions. We describe the prevalence of pre-existing conditions among community health center patients overall and those with COVID-19 by race/ethnicity. MATERIALS AND METHODS: This cross-sectional study used electronic health record data from OCHIN, a network of 396 community health centers across 14 states. RESULTS: Among all patients with COVID-19, 33% did not have a pre-existing condition before the pandemic. Up to half of COVID-19-positive non-Hispanic Asians (51%), Hispanic (36%), and non-Hispanic black (28%) patients did not have a pre-existing condition before the pandemic. CONCLUSIONS: The future of the Patient Protection and Affordable Care Act is uncertain, and the long-term health effects of COVID-19 are largely unknown; therefore, ensuring people with pre-existing conditions can acquire health insurance is essential to achieving health equity.

A Practice-Based Research Network (PBRN) Roadmap for Evaluating COVID-19 in Community Health Centers: A Report From the OCHIN PBRN.

BACKGROUND: Primary care practice-based research networks (PBRNs) are critical laboratories for generating evidence from real-world settings, including studying natural experiments. Primary care's response to the novel coronavirus-19 (COVID-19) pandemic is arguably the most impactful natural experiment in our lifetime. EVALUATING THE IMPACT OF COVID-19: We briefly describe the OCHIN PBRN of community health centers (CHCs), its partnership with implementation scientists, and how we are leveraging this infrastructure and expertise to create a rapid research response evaluating how CHCs across the country responded to the COVID-19 pandemic. COVID-19 RESEARCH ROADMAP: Our research agenda focuses on asking: How has care delivery in CHCs changed due to COVID-19? What impact has COVID-19 had on the delivery of preventive services in CHCs? Which PBRN services (e.g., data surveillance, training, evidence synthesis) are most impactful to real-world practices? What decision-making strategies were used in the PBRN and its practices to make real-time changes in response to the pandemic? What critical factors in successfully and sustainably transforming primary care are illuminated by pandemic-driven changes? DISCUSSION AND CONCLUSIONS: PBRNs enable real-world evaluation of practice change and natural experiments, and thus are ideal laboratories for implementation science research. We present a real-time example of how a PBRN Implementation Laboratory activated a response to study a historic natural experiment, to help other PBRNs charting a course through this pandemic.