Atherosclerotic Cardiovascular Disease Primary and Secondary Prevention in Latino Subgroups.

BACKGROUND: Studies assessing equity in the prevention of atherosclerotic cardiovascular disease (ASCVD) for Latinos living in the USA collectively yield mixed results. Latino persons are diverse in many ways that may influence cardiovascular health. The intersection of Latino nativity and ASCVD prevention is understudied. OBJECTIVE: To determine whether disparities in ASCVD screening, detection, and prescribing differ for US Latinos by country of birth. DESIGN: A retrospective cohort design utilizing 2014-2020 electronic health record data from a network of 320 community health centers across 12 states. Analyses occurred October 1, 2022, to September 30, 2023. PARTICIPANTS: Non-Hispanic White and Latino adults age 20-75 years, born in Cuba, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, and the USA. EXPOSURES: Ethnicity and country of birth. MAIN MEASURES: Outcome measures included prevalence of statin eligibility, of having insufficient data to establish eligibility, odds of having a documented statin prescription, and rates of statin prescriptions and refills. We used covariate-adjusted logistic and generalized estimating equations logistic and negative binomial regressions to generate absolute and relative measures. KEY RESULTS: Among 108,672 adults, 23% (n = 25,422) were statin eligible for primary or secondary prevention of ASCVD using American College of Cardiology/American Heart Association guidelines. Latinos, born in and outside the USA were more likely eligible than Non-Hispanic White patients were (US-born Latino OR = 1.55 (95% CI = 1.37-1.75); non-US-born Latino OR = 1.63 (95% CI = 1.34-1.98)). The eligibility criteria that was met differed by ethnicity and nativity. Latinos overall were less likely missing data to establish eligibility and differences were again observed by specific non-US country of origin. Among those eligible, we observed no statistical difference in statin prescribing between US-born Latinos and non-Hispanic White persons; however, disparities varied by specific non-US country of origin. CONCLUSION: Efforts to improve Latino health in the USA will require approaches for preventing and reversing cardiovascular risk factors, and statin initiation that are Latino subgroup specific.

Latino-White Disparities in Identification and Control of Elevated Blood Pressure Among Adults With Hypertension.

BACKGROUND: Studies analyzing blood pressure (BP) management using the hypertension control cascade have consistently shown disparities in hypertension awareness, treatment, and BP control between Latino patients and non-Latino White patients. We analyze this cascade using electronic health record data from a multistate network of community health centers. METHODS AND RESULTS: Data from 790 clinics in 23 US states from 2012 to 2020, including 1 270 174 patients, were analyzed to compare BP documentation in the electronic health record, clinician acknowledgment (diagnosis or treatment) of incident hypertension (BP ≥140/90), medication prescription, and BP control between non-Latino White patients, English-preferring Latino patients, and Spanish-preferring Latino patients, adjusted for patient-level covariates, and clustered on patients' primary clinics. Among the 429 182 patients with elevated BP (≥140/90) during ambulatory visits from 2012 to 2020, we found that clinician acknowledgment of hypertension was more likely in Spanish-preferring and English-preferring Latino patients versus non-Latino White patients (adjusted odds ratio [aOR], 1.17 [95% CI, 1.11-1.24]; aOR, 1.07 [95% CI, 1.02-1.12], respectively). In addition, Spanish-preferring Latino patients were more likely to receive a medication versus non-Latino White patients (aOR, 1.21 [95% CI, 1.16-1.28]). Among those receiving medication, Latino patients were as likely as non-Latino White patients to have their BP controlled (<140/90). CONCLUSIONS: In a large retrospective study of community health center patients with incident hypertension, the expected disparities in hypertension management between Spanish-preferring Latino, English-preferring Latino, and non-Latino White patients were not identified. These findings add to the hypertension control cascade by examining robust electronic health record data from community health centers and may provide clues to reducing disparities in hypertension management.

Association of neighbourhood walkability and haemoglobin A1c levels among Latino and non-Hispanic White patients with diabetes.

BACKGROUND: Neighbourhood walkability can benefit cardiovascular health. Latino patients are more likely than non-Hispanic White patients to have diabetes, and evidence has shown better diabetes-related outcomes for patients living in neighbourhoods conducive to physical activity. Our objective was to determine whether neighbourhood walkability was associated with haemoglobin A1c (HbA1c) levels among English- and Spanish-preferring Latino patients compared to non-Hispanic White patients. METHODS: We used electronic health record data from patients in the OCHIN, Inc. network of community health centres (CHC) linked to public walkability data. Patients included those age ≥ 18 with ≥ 1 address recorded, with a study clinic visit from 2012 to 2020, and a type 2 diabetes diagnosis (N = 159,289). Generalized estimating equations logistic regression, adjusted for relevant covariates, was used to model the primary binary outcome of always having HbA1c < 7 by language/ethnicity and walkability score. RESULTS: For all groups, the walkability score was not associated with higher odds and prevalence of always having HbA1c < 7. Non-Hispanic White patients were most likely to have HbA1c always < 7 (prevalence ranged from 32.8% [95%CI = 31.2-34.1] in the least walkable neighbourhoods to 33.4% [95% CI 34.4-34.7] in the most walkable), followed by English-preferring Latinos (28.6% [95%CI = 25.4-31.8]-30.7% [95% CI 29.0-32.3]) and Spanish-preferring Latinos (28.3% [95% CI 26.1-30.4]-29.3% [95% CI 28.2-30.3]). CONCLUSIONS: While walkability score was not significantly associated with glycaemic control, control appeared to increase with walkability, suggesting other built environment factors, and their interaction with walkability and clinical care, may play key roles. Latino patients had a lower likelihood of HbA1c always < 7, demonstrating an opportunity for equity improvements in diabetes care.

Healthcare utilization for asthma exacerbation among children of migrant and seasonal farmworkers.

Latino children of Migrant and Seasonal Farmworkers (MSFWs) with asthma are at risk for poor health outcomes due to medical access barriers. We compared differences in acute care utilization for asthma exacerbations among migrant and non-migrant Latino and non-Hispanic white (NHW) children at U.S. community health centers. A retrospective observational study utilizing electronic health record data from the ADVANCE Clinical Research Network of United States community health centers included 13,423 children ages 3-17 with a primary care visit between 2005 and 2017 from eight states. Emergency department (ED) and hospitalization data came from Oregon Medicaid claims. Outcomes included acute clinic visits, ED visits, and hospitalizations for asthma exacerbation. Regression analyses adjusted for patient-level covariates. Latino children had higher odds of acute clinic visits for asthma exacerbation compared to NHW children (MSFW odds ratio [OR] = 1.17, 95 % CI = 1.03-1.33; without migrant status OR = 1.13, 95 % CI = 1.03-1.23). MSFW children using Oregon Medicaid had fewer ED visits (rate ratio [RR] = 0.72, 95 % CI = 0.52-0.99) and hospitalizations (RR = 0.47, 95 % CI = 0.26-0.86) compared to NHW children. Increased community health center visits may help mitigate disparities in acute asthma care for MSFW children.

Association of Early Childhood Wheeze and Asthma Diagnosis Documentation by Race, Ethnicity, and Language in Children.

OBJECTIVE: To determine whether electronic health record (EHR) documentation of certain early childhood risk factors for asthma, such as wheeze differ by race, ethnicity, and language group, and whether these children have different subsequent asthma prevalences. METHODS: We used EHR data from the Accelerating Data Value Across a National Community Health Center (ADVANCE) Clinical Research Network from children receiving care in US community health centers (n = 71,259 children) across 21 states to examine the presence of ICD-coded documentation of early childhood wheeze and its association with subsequent asthma diagnosis documentation in the EHR by race/ethnicity/language. RESULTS: ICD-coded wheeze was present in 2 to 3% of each race/ethnicity/language group. Among the total sample, 18.5% had asthma diagnosed after age 4. The adjusted prevalence of subsequent asthma diagnosis was greater in children with wheeze than those without. Odds of asthma diagnosis did not differ among children in all race/ethnicity/language groups with early childhood wheeze. Non-Latino Black children without wheeze had higher odds of asthma (OR = 1.19, 95% CI = 1.08-1.32) compared with non-Latino White children without wheeze. DISCUSSION: In US community health centers which serve medically underserved populations, EHR documentation of early childhood wheeze was uncommon and did not differ significantly among race/ethnicity/language groups. Differences in asthma diagnosis in Latinos may not stem from differences in early-life wheeze documentation. However, our findings suggest that there may be opportunities for improvement in early asthma symptom recognition for non-Latino Black children, especially in those without early childhood wheeze.

Screening for Hepatitis C Among Community Health Center Patients by Ethnicity and Language Preference.

Introduction: Hepatitis C virus is associated with high morbidity and mortality-chronic liver disease is a leading cause of death among Latinos in the U.S. Screening for hepatitis C virus in community health center settings, which serve a disproportionate percentage of Latinos, is essential to eradicating hepatitis C virus infection. We assessed hepatitis C virus screening disparities in adults served by community health centers by ethnicity and language preference. Methods: This was an observational cohort study (spanning 2013-2017) of adults born in 1945-1965 in the Accelerating Data Value Across a National Community Health Center Network electronic health record data set. Our exposure of interest was race/ethnicity and language preference (non-Hispanic White, Latino English preferred, Latino Spanish preferred). Our primary outcome was the relative hazard of hepatitis C virus screening, estimated using multivariate Cox proportional hazards regression. Results: A total of 182,002 patients met the study criteria and included 60% non-Hispanic Whites, 29% Latino Spanish preferred, and 11% Latino English preferred. In total, 9% received hepatitis C virus screening, and 2.4% were diagnosed with hepatitis C virus. Latino English-preferred patients had lower rates of screening than both non-Hispanic Whites and Latino Spanish preferred (5.5% vs 9.4% vs 9.6%, respectively). Latino English preferred had lower hazards of hepatitis C virus screening than non-Hispanic Whites (adjusted hazard ratio=0.56, 95% CI=0.44, 0.72), and Latino Spanish preferred had similar hazards of hepatitis C virus screening (adjusted hazard ratio=1.11, 95% CI=0.88, 1.41). Conclusions: We found that in a large community health center network, adult Latinos who preferred English had lower hazards of hepatitis C virus screening than non-Hispanic Whites, whereas Latinos who preferred Spanish had hazards of screening similar to those of non-Hispanic Whites. The overall prevalence of hepatitis C virus screening was low. Further work on the role of language preference in hepatitis C virus screening is needed to better equip primary care providers to provide this recommended preventive service in culturally relevant ways.

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

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

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

Quality of Care for Latinx Children with Asthma: Associations with Language Concordance and Continuity of Care.

BACKGROUND: Language concordance between Latinx patients and their clinicians has been shown to affect health outcomes. In addition, there is evidence that consistent continuity of care (COC) can improve health care outcomes. The relationship between language concordance and COC and their association with health equity in chronic disease is less clear. Our aim was to study the moderating effect of clinician and patient language concordance on the association between COC and asthma care quality in Latinx children. METHODS: We utilized an electronic health record dataset from a multistate network of community health centers to compare influenza vaccinations and inhaled steroid prescriptions, by ethnicity and language concordance groups overall and stratified by COC. RESULTS: We analyzed electronic health records for children with asthma (n = 38,442) age 3 to 17 years with ≥2 office visits between 2005 to 2017. Overall, 64% of children had low COC (defined as COC < 0.5) while 21% had high COC (defined as >0.75). All Latinx children had higher rates and odds of receiving influenza vaccination compared with non-Hispanic White children. In addition, Spanish-preferring Latinx children had higher rates and odds of being prescribed inhaled steroids while English-preferring Latinx children had lower odds (OR = 0.85 95%CI = 0.73,0.98) compared with non-Hispanic White children. CONCLUSION: Overall, Latinx children regardless of COC category or language concordance were more likely to receive the influenza vaccine. English-preferring Latinx children with persistent asthma received fewer inhaled steroid prescriptions compared with non-Hispanic White children. Panel chart review and seeing a practice partner might be one way to combat these inequities.

The Association of Mobility, Social Deprivation, and Pediatric Primary Care Outcomes in Community Health Centers.

OBJECTIVE: To examine how social deprivation and residential mobility are associated with primary care use in children seeking care at community health centers (CHCs) overall and stratified by race and ethnicity. STUDY DESIGN: We used electronic health record open cohort data from 152 896 children receiving care from 15 U S CHCs belonging to the OCHIN network. Patients were aged 3-17 years, with ≥2 primary care visits during 2012-2017 and had geocoded address data. We used negative binomial regression to calculate adjusted rates of primary care encounters and influenza vaccinations relative to neighborhood-level social deprivation. RESULTS: Higher rates of clinic utilization were observed for children who always lived in highly deprived neighborhoods (RR = 1.11, 95% CI = 1.05-1.17) and those who moved from low-to-high deprivation neighborhoods (RR = 1.05, 95% CI = 1.01-1.09) experienced higher rates of CHC encounters compared with children who always lived in the low-deprivation neighborhoods. This trend was similar for influenza vaccinations. When analyses were stratified by race and ethnicity, we found these relationships were similar for Latino children and non-Latino White children who always lived in highly deprived neighborhoods. Residential mobility was associated with lower rates of primary care. CONCLUSIONS: These findings suggest that children living in or moving to neighborhoods with high levels of social deprivation used more primary care CHC services than children who lived in areas with low deprivation, but moving itself was associated with less care. Clinician and delivery system awareness of patient mobility and its impacts are important to addressing equity in primary care.

Answering calls for rigorous health equity research: a cross-sectional study leveraging electronic health records for data disaggregation in Latinos.

INTRODUCTION: Country of birth/nativity information may be crucial to understanding health equity in Latino populations and is routinely called for in health services literature assessing cardiovascular disease and risk, but is not thought to co-occur with longitudinal, objective health information such as that found in electronic health records (EHRs). METHODS: We used a multistate network of community health centres to describe the extent to which country of birth is recorded in EHRs in Latinos, and to describe demographic features and cardiovascular risk profiles by country of birth. We compared geographical/demographic/clinical characteristics, from 2012 to 2020 (9 years of data), of 914 495 Latinos recorded as US-born, non-US-born and without a country of birth recorded. We also described the state in which these data were collected. RESULTS: Country of birth was collected for 127 138 Latinos in 782 clinics in 22 states. Compared with those with a country of birth recorded, Latinos without this record were more often uninsured and less often preferred Spanish. While covariate adjusted prevalence of heart disease and risk factors were similar between the three groups, when results were disaggregated to five specific Latin countries (Mexico, Guatemala, Dominican Republic, Cuba, El Salvador), significant variation was observed, especially in diabetes, hypertension and hyperlipidaemia. CONCLUSIONS: In a multistate network, thousands of non-US-born, US-born and patients without a country of birth recorded had differing demographic characteristics, but clinical variation was not observed until data was disaggregated into specific country of origin. State policies that enhance the safety of immigrant populations may enhance the collection of health equity related data. Rigorous and effective health equity research using Latino country of birth information paired with longitudinal healthcare information found in EHRs might have significant potential for aiding clinical and public health practice, but it depends on increased, widespread and accurate availability of this information, co-occurring with other robust demographic and clinical data nativity.

Disaggregating Latino nativity in equity research using electronic health records.

OBJECTIVE: To develop and validate prediction models for inference of Latino nativity to advance health equity research. DATA SOURCES/STUDY SETTING: This study used electronic health records (EHRs) from 19,985 Latino children with self-reported country of birth seeking care from January 1, 2012 to December 31, 2018 at 456 community health centers (CHCs) across 15 states along with census-tract geocoded neighborhood composition and surname data. STUDY DESIGN: We constructed and evaluated the performance of prediction models within a broad machine learning framework (Super Learner) for the estimation of Latino nativity. Outcomes included binary indicators denoting nativity (US vs. foreign-born) and Latino country of birth (Mexican, Cuban, Guatemalan). The performance of these models was compared using the area under the receiver operating characteristics curve (AUC) from an externally withheld patient sample. DATA COLLECTION/EXTRACTION METHODS: Census surname lists, census neighborhood composition, and Forebears administrative data were linked to EHR data. PRINCIPAL FINDINGS: Of the 19,985 Latino patients, 10.7% reported a non-US country of birth (5.1% Mexican, 4.7% Guatemalan, 0.8% Cuban). Overall, prediction models for nativity showed outstanding performance with external validation (US-born vs. foreign: AUC = 0.90; Mexican vs. non-Mexican: AUC = 0.89; Guatemalan vs. non-Guatemalan: AUC = 0.95; Cuban vs. non-Cuban: AUC = 0.99). CONCLUSIONS: Among challenges facing health equity researchers in health services is the absence of methods for data disaggregation, and the specific ability to determine Latino country of birth (nativity) to inform disparities. Recent interest in more robust health equity research has called attention to the importance of data disaggregation. In a multistate network of CHCs using multilevel inputs from EHR data linked to surname and community data, we developed and validated novel prediction models for the use of available EHR data to infer Latino nativity for health disparities research in primary care and health services research, which is a significant potential methodologic advance in studying this population.

Implications of missingness in self-reported data for estimating racial and ethnic disparities in Medicaid quality measures.

OBJECTIVE: To assess the feasibility and implications of imputing race and ethnicity for quality and utilization measurement in Medicaid. DATA SOURCES AND STUDY SETTING: 2017 Oregon Medicaid claims from the Oregon Health Authority and electronic health records (EHR) from OCHIN, a clinical data research network, were used. STUDY DESIGN: We cross-sectionally assessed Hispanic-White, Black-White, and Asian-White disparities in 22 quality and utilization measures, comparing self-reported race and ethnicity to imputed values from the Bayesian Improved Surname Geocoding (BISG) algorithm. DATA COLLECTION: Race and ethnicity were obtained from self-reported data and imputed using BISG. PRINCIPAL FINDINGS: 42.5%/4.9% of claims/EHR were missing self-reported data; BISG estimates were available for >99% of each and had good concordance (0.87-0.95) with Asian, Black, Hispanic, and White self-report. All estimated racial and ethnic disparities were statistically similar in self-reported and imputed EHR-based measures. However, within claims, BISG estimates and incomplete self-reported data yielded substantially different disparities in almost half of the measures, with BISG-based Black-White disparities generally larger than self-reported race and ethnicity data. CONCLUSIONS: BISG imputation methods are feasible for Medicaid claims data and reduced missingness to <1%. Disparities may be larger than what is estimated using self-reported data with high rates of missingness.

Diabetes Screening and Monitoring Among Older Mexican-Origin Populations in the U.S.

OBJECTIVE: The purpose of the study is to examine diabetes screening and monitoring among Latino individuals as compared with non-Latino White individuals and to better understand how we can use neighborhood data to address diabetes care inequities. RESEARCH DESIGN AND METHODS: This is a retrospective observational study linked with neighborhood-level Latino subgroup data obtained from the American Community Survey. We used generalized estimating equation negative binomial and logistic regression models adjusted for patient-level covariates to compare annual rates of glycated hemoglobin (HbA1c) monitoring for those with diabetes and odds of HbA1c screening for those without diabetes by ethnicity and among Latinos living in neighborhoods with low (0.0-22.0%), medium (22.0-55.7%), and high (55.7-98.0%) population percent of Mexican origin. RESULTS: Latino individuals with diabetes had 18% higher rates of HbA1c testing than non-Latino White individuals with diabetes (adjusted rate ratio [aRR] 1.18 [95% CI 1.07-1.29]), and Latinos without diabetes had 25% higher odds of screening (adjusted odds ratio 1.25 [95% CI 1.15-1.36]) than non-Latino White individuals without diabetes. In the analyses in which neighborhood-level percent Mexican population was the main independent variable, all Latinos without diabetes had higher odds of HbA1c screening compared with non-Latino White individuals, yet only those living in low percent Mexican-origin neighborhoods had increased monitoring rates (aRR 1.31 [95% CI 1.15-1.49]). CONCLUSIONS: These findings reveal novel variation in health care utilization according to Latino subgroup neighborhood characteristics and could inform the delivery of diabetes care for a growing and increasingly diverse Latino patient population. Clinicians and researchers whose work focuses on diabetes care should take steps to improve equity in diabetes and prevent inequity in treatment.

Association of Parent Preventive Care with their Child's Recommended Well-Child Visits.

BACKGROUND: Receipt of recommended well-child care is lowest for children without insurance, many of whom receive care in community health centers (CHCs). OBJECTIVE: To understand if there is an association between parent preventive care and their children's well-child visits. METHODS: We used electronic health record data to identify children and link them to parents both seen in an OCHIN network (CHC; n = 363 clinics from 17 states), randomly selected a child aged 3 to 17 with ≥1 ambulatory visit between 2015 and 2018. We employed a retrospective, cohort study design and used general estimating equations Poisson regression to estimate yearly rates of well-child visits based on parent preventive care adjusted for relevant covariates and stratified by child age for 3 linked samples: mother only, father only, and two parents. RESULTS: We included 75,398 linked mother only pairs, 12,438 in our father only, and 4,156 in our 2-parent sample. Children in the mother only sample had a 6% greater rate of yearly well-child visits when their mother received preventive care (adjusted rate ratio [ARR] = 1.06; 95% CI = 1.03-1.08) compared to no preventive care. Children in the father only sample had a 7% greater rate of yearly well-child visits when their father received preventive care (ARR = 1.07; 95% CI = 1.04-1.11) versus no preventive care. Children in the two parent sample had an 11% greater rate of yearly well-child visits when both parents received preventive care (ARR = 1.11; 95% CI = 1.03-1.19) compared to neither receiving preventive care. CONCLUSIONS: These findings suggest focusing on receipt of healthcare for the whole family may improve well-child visit rates.

Racial and Ethnic Disparities in Acute Care Use for Pediatric Asthma.

PURPOSE: Previous work has shown that asthma-related emergency department (ED) use is greatest among Black and Latine populations, but it is unknown whether health care use for exacerbations differs across settings (outpatient, ED, inpatient) and correlates with use of routine outpatient services. We aimed to measure disparities by race, ethnicity, and language in pediatric acute asthma care using data from US primary care community health centers. METHODS: In an observational study using electronic health records from community health centers in 18 states, we compared non-Hispanic Black, English-preferring Latine, Spanish-preferring Latine, and non-Hispanic White children aged 3 to 17 years on visits for clinic-coded asthma exacerbations (2012-2018). We further evaluated asthma-related ED use and inpatient admissions in a subsample of Oregon-Medicaid recipients. Covariate-adjusted odds ratios (ORs) and rate ratios (RRs) were derived using logistic or negative binomial regression analysis with generalized estimating equations. RESULTS: Among 41,276 children with asthma, Spanish-preferring Latine children had higher odds of clinic visits for asthma exacerbation than non-Hispanic White peers (OR = 1.10; 95% CI, 1.02-1.18). Among the subsample of 6,555 children insured under Oregon-Medicaid, non-Hispanic Black children had higher odds and rates of asthma-related ED use than non-Hispanic White peers (OR = 1.40; 95% CI, 1.04-1.89 and RR = 1.49; 95% CI, 1.09-2.04, respectively). We observed no differences between groups in asthma-related inpatient admissions. CONCLUSIONS: This study is the first to show that patterns of clinic and ED acute-care use differ for non-Hispanic Black and Spanish-preferring Latine children when compared with non-Hispanic White peers. Non-Hispanic Black children had lower use of clinics, whereas Spanish-preferring Latine children had higher use, including for acute exacerbations. These patterns of clinic use were accompanied by higher ED use among Black children. Ensuring adequate care in clinics may be important in mitigating disparities in asthma outcomes.VISUAL ABSTRACT.

Disparities in HbA1c testing between aging US Latino and non-Latino white primary care patients.

US Latinos disproportionately face diabetes-related disparities compared to non-Latino Whites. A number of barriers, including linguistic and cultural discordance, have been consistently linked to these disparities. Glycated hemoglobin (HbA1c) testing is used to assess glycemic control among individuals living with diabetes. This study aimed to compare HbA1c levels and corresponding testing rates among non-Latino Whites and Latinos with both English and Spanish preference from a national cohort of primary care patients within community health centers. We analyzed electronic health records from patients who turned 50 years of age (n = 66,921) and were diagnosed with diabetes during or prior to the study period. They also must have been under observation for at least one year from January 1, 2013 to December 31, 2017. We calculated the rates of HbA1c tests each person received over the number of years observed and used covariate-adjusted negative binomial regression to estimate incidence rate ratios for Spanish preferring Latinos and English preferring Latinos compared to non-Latino Whites. Spanish preferring Latinos (rate ratio = 1.23, 95% CI = 1.16-1.30), regardless of HbA1c level, had higher testing rates than non-Latino Whites and English preferring Latinos. English preferring Latinos with controlled HbA1c levels had higher rates of HbA1c testing compared to non-Latino whites. Overall, the Latinos with Spanish preference maintained higher HbA1c testing rates and had disproportionately higher rates of uncontrolled HbA1c levels compared to non-Latino whites. Future efforts should focus on understanding effective approaches to increasing engagement among Spanish preferring Latinos and addressing organizational-level barriers, given HbA1c disparities.

Influenza and pneumococcal vaccination delivery in older Hispanic populations in the United States.

INTRODUCTION: National reports suggest that Hispanic patients may underutilize influenza and pneumococcal vaccination, although studies sometimes conflict on this point. A clearer picture of adult immunization utilization in older Hispanic patients is necessary to ensure equity in adult vaccinations. METHODS: Using electronic health records from 648 community health centers (CHCs) across 21 states, we compared English-preferring Hispanic patients, Spanish-preferring Hispanic patients, and Non-Hispanic White (NHW) adults aged ≥50 years across five outcomes between 2012-2017: (1) Odds of ever receiving pneumococcal vaccination after age 65, (2) Odds of ever receiving ≥2 pneumococcal vaccinations for those ≥65, (3) odds of vaccination between the ages of 50 and 64 for those with diabetes or heart disease, (4) odds of influenza vaccine, and (5) annual rate of influenza vaccination. RESULTS: Of our total study sample (N = 143,869), 85,562 were age 50-64 during the entire study period, and 65,977 were ≥65 at some point during the study period. In patients aged 50-64, Spanish-preferring Hispanic patients were more likely to have ever had an influenza vaccination (covariate-adjusted odds ratio [aOR] = 1.33, 95% CI = 1.29-1.37), had higher rates of annual influenza vaccination (covariate-adjusted rate ratio [aRR] = 1.41, 95% CI = 1.38-1.44), and higher odds of pneumococcal vaccination (aOR = 1.87, 95% CI = 1.76-1.98) than NHW patients. These findings were similar in Spanish-preferring Hispanic patients ≥65. English-preferring Hispanics ≥65 were less likely than NHW patients to ever have an influenza vaccination (aOR = 0.91, 95% CI = 0.85-0.98) and to have ever received at least one (aOR = 0.92, 95% CI = 0.86-0.99) or two (aOR = 0.86, 95% CI = 0.77-0.95) pneumococcal vaccine doses. CONCLUSIONS: In a multistate CHC network, Spanish-preferring Hispanic patients were more likely to receive influenza and pneumococcal vaccinations than NHW patients; older English-preferring Hispanic patients were often less likely than NHW patients to receive these vaccinations. In vaccine initiatives, English-preferring Hispanic patients may be at higher risk of vaccination inequity.

Asthma Ambulatory Care Quality in Foreign-Born Latino Children in the United States.

BACKGROUND: Foreign-born Latino children in the United States (US) have poor asthma outcomes, but the role of routine care utilization in these outcomes is unclear. Our objective was to compare select ambulatory care utilization measures for asthma between foreign-born Latino, US-born Latino, and non-Hispanic white children. METHODS: Using a multistate network of clinics with a linked electronic health record, we compared the International Classification of Disease (ICD)-coded asthma diagnosis among those with respiratory symptoms, electronic health records documentation of diagnosis, prescriptions, and influenza vaccination of foreign-born and US-born Latino children, and non-Hispanic white children over a 10+ year study period. We also examined outcomes by country of birth in children from Mexico, Cuba, and Guatemala. RESULTS: Among our study population (n = 155,902), 134,570 were non-Hispanic white, 19,143 were US-born Latino, and 2189 were foreign-born Latino. Among those with suspicious respiratory symptoms, there was no difference between these groups in the predicted probability of an ICD-coded asthma diagnosis. US-born Latino children with asthma were less likely to have asthma documented on their problem list, more likely to have an albuterol prescription, and less likely to have an inhaled steroid prescribed. All Latino children had higher rates of influenza vaccination than non-Hispanic white children. CONCLUSIONS: In a national network, there were few disparities between Latino (US- and foreign-born) children and non-Hispanic white comparators in many common asthma care services, except some measures in US-born Latino children. Providers should understand that their US-born Latino children may be at elevated risk for not receiving adequate asthma care.

Creation of a linked cohort of children and their parents in a large, national electronic health record dataset.

ABSTRACT: To examine which parental health care and health factors are most strongly associated with a child's receipt of recommended care we must be able to link children to their parents in electronic health record data. Yet, there is not an easy way to link these data.To identify a national cohort of children that link to at least one parent in the same electronic health record dataset and describe their demographics.Methodology to link parents and children in electronic health records and descriptive sociodemographic data.Children with at least one encounter with a primary care clinician between Januray 1, 2007 and December 12, 2018 to a community health center in the OCHIN national network. We identified parents of these children who also had at least one encounter to a community health center in the network using emergency contact and guarantor record fields.A total of 227,552 children had parents with a linkable patient record. After exclusions, our final cohort included 213,513 distinct children with either one or two parent-links. 82% of children linked to a mother only, 14% linked to a father only, and 4% linked to both a mother and a father. Most families consisted of only one linked child (61%).We were able to link 33% of children to a parent in electronic health record data from a large network of community health centers across the United States. Further analyses utilizing these linkages will allow examination of the multi-level factors that impact a child's receipt of recommended health care.

Mobility and social deprivation on primary care utilisation among paediatric patients with asthma.

OBJECTIVE: Asthma care is negatively impacted by neighbourhood social and environmental factors, and moving is associated with undesirable asthma outcomes. However, little is known about how movement into and living in areas of high deprivation relate to primary care use. We examined associations between neighbourhood characteristics, mobility and primary care utilisation of children with asthma to explore the relevance of these social factors in a primary care setting. DESIGN: In this cohort study, we conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient-level covariates. SETTING: We used data from community health centres in 15 OCHIN states. PARTICIPANTS: The sample included 23 773 children with asthma aged 3-17 across neighbourhoods with different levels of social deprivation from 2012 to 2017. We conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient-level covariates. RESULTS: Clinic visit rates were higher among children living in or moving to areas with higher deprivation than those living in areas with low deprivation (rate ratio (RR) 1.09, 95% CI 1.02 to 1.17; RR 1.05, 95% CI 1.00 to 1.11). Children moving across neighbourhoods with similarly high levels of deprivation had increased RRs of influenza vaccination (RR 1.13, 95% CI 1.03 to 1.23) than those who moved but stayed in neighbourhoods of low deprivation. CONCLUSIONS: Movement into and living within areas of high deprivation is associated with more primary care use, and presumably greater opportunity to reduce undesirable asthma outcomes. These results highlight the need to attend to patient movement in primary care visits, and increase neighbourhood-targeted population management to improve equity and care for children with asthma.