Health centres and social determinants of health: an analysis of enabling services provision and clinical quality.

OBJECTIVE: It is well known that social determinants of health (SDOH), including poverty, education, transportation and housing, are important predictors of health outcomes. Health Resources and Services Administration (HRSA)-funded health centres serve a patient population with high vulnerability to barriers posed by SDOH and are required to provide services that enable health centre service utilisation and assist patients in navigating barriers to care. This study explores whether health centres with higher percentages of patients using these enabling services experience better clinical performance and outcomes. DESIGN AND SETTING: The analysis uses organisational characteristics, patient demographics and clinical quality measures from HRSA's 2018 Uniform Data System. Health centres (n=875) were sorted into quartiles with quartile 1 (Q1) representing the lowest utilisation of enabling services and quartile 4 (Q4) representing the highest. The researchers calculated a service area social deprivation score weighted by the number of patients for each health centre and used ordinary least squares to create adjusted values for each of the clinical quality process and outcome measures. Analysis of variance was used to test differences across enabling services quartiles. RESULTS: After adjusting for patient characteristics, health centre size and social deprivation, authors found statistically significant differences for all clinical quality process measures across enabling services quartiles, with Q4 health centres performing significantly better than Q1 health centres for several clinical process measures. However, these Q4 health centres performed poorer in outcome measures, including blood pressure and haemoglobin A1c control. CONCLUSION: These findings emphasise the importance of how enabling services (eg, translation services, transportation) can address unmet social needs, improve utilisation of health services and reaffirm the challenges inherent in overcoming SDOH to improve health outcomes.

A Novel Mixed Methods Approach Combining Geospatial Mapping and Qualitative Inquiry to Identify Multilevel Policy Targets: The Focused Rapid Assessment Process (fRAP) Applied to Cancer Survivorship.

Multi-level perspectives across communities, medical systems and policy environments are needed, but few methods are available for health services researchers with limited resources. We developed a mixed method health policy approach, the focused Rapid Assessment Process (fRAP), that is designed to uncover multi-level modifiable barriers and facilitators contributing to public health issues. We illustrate with a study applying fRAP to the issue of cancer survivorship care. Through this multi-level investigation we identified two major modifiable areas impacting high-quality cancer survivorship care: 1) the importance of cancer survivorship guidelines/data, 2) the need for improved oncology-primary care relationships. This article contributes to the mixed methods literature by coupling geospatial mapping to qualitative rapid assessment to efficiently identify policy change targets.

Identifying health centers in areas with low COVID-19 vaccination rates & high rates of vaccine hesitancy.

Context: Large numbers of US adults are vaccinated, but COVID-19 vaccine hesitancy remains high. Health centers funded by the Health Resources and Services Administration (HRSA) have played a major role in COVID-19 vaccinations and have the potential to vaccinate even larger numbers of people. Objective: To identify U.S. counties with low COVID-19 vaccination rates and high rates of vaccine hesitancy, explore the characteristics of these counties and health center presence in these areas, and identify priority health centers for targeted vaccine outreach. Study Design: Cross-sectional geospatial analysis of county-level COVID-19 vaccination rates and COVID-19 vaccination hesitancy. Bivariate Local Moran's I using GeoDa software to identify clusters of counties with low COVID-19 vaccination rates and high rates of COVID-19 vaccine hesitancy. Geographic Information Systems (GIS) mapping to overlay health centers with county-level data. Setting or Dataset: U.S. counties; vaccine hesitancy data from U.S. Department of Health & Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE); vaccination rates from the Centers for Disease Control and Prevention (CDC); and data on Health Center Program awardees from the HRSA. Population studied: U.S. Counties (n=2,825) for which data on COVID-19 vaccination and COVID-19 vaccine hesitancy are available; and HRSA-funded health centers, excluding Puerto Rico and Pacific Islands (n=1,559). Outcome Measures: COVID-19 vaccine hesitancy and COVID-19 vaccination rates. Results: We identified 219 counties that are part of clusters of high rates of vaccine hesitancy and low COVID-19 vaccination rates. In general, these counties have higher rates of poverty, larger percentages of black and Hispanic populations, and are located in the Southeast (Alabama, Georgia) and West Virginia. Sixty health center awardees are located within these counties, serving almost 700,000 patients. Conclusions: While almost one-half of US adults have been vaccinated, younger adults have much lower rates of vaccination and large numbers are still unvaccinated. Further, vaccine rates vary by race and ethnicity, with less than one-fifth of Hispanic and black adults having been vaccinated. Targeting areas with high rates of vaccine hesitancy and low vaccination rates supports strategic planning, optimizes finite resources, and better assists health centers in creating culturally competent outreach addressing vaccine hesitancy.

Exploring the association of social determinants of health and clinical quality measures and performance in HRSA-funded health centres.

OBJECTIVE: This paper explores the impact of service area-level social deprivation on health centre clinical quality measures. DESIGN: Cross-sectional data analysis of Health Resources and Services Administration (HRSA)-funded health centres. We created a weighted service area social deprivation score for HRSA-funded health centres as a proxy measure for social determinants of health, and then explored adjusted and unadjusted clinical quality measures by weighted service area Social Deprivation Index quartiles for health centres. SETTINGS: HRSA-funded health centres in the USA. PARTICIPANTS: Our analysis included a subset of 1161 HRSA-funded health centres serving more than 22 million mostly low-income patients across the country. RESULTS: Higher levels of social deprivation are associated with statistically significant poorer outcomes for all clinical quality outcome measures (both unadjusted and adjusted), including rates of blood pressure control, uncontrolled diabetes and low birth weight. The adjusted and unadjusted results are mixed for clinical quality process measures as higher levels of social deprivation are associated with better quality for some measures including cervical cancer screening and child immunisation status but worse quality for other such as colorectal cancer screening and early entry into prenatal care. CONCLUSIONS: This research highlights the importance of incorporating community characteristics when evaluating clinical outcomes. We also present an innovative method for capturing health centre service area-level social deprivation and exploring its relationship to health centre clinical quality measures.

Improving Access to Treatment for Opioid Use Disorder in High-Need Areas: The Role of HRSA Health Centers.

Introduction: Despite the opioid epidemic adversely affecting areas across the U.S. for more than two decades and increasing evidence that medication-assisted treatment (MAT) is effective for patients with opioid use disorder (OUD), access to treatment is still limited. The limited access to treatment holds true in the Appalachia region despite being disproportionately affected by the crisis, particularly in rural, central Appalachia. Purpose: This research identifies opportunities for health centers located in high-need areas based on drug poisoning mortality to better meet MAT care gaps. We also provide an in-depth look at health center MAT capacity relative to need in the Appalachia region. Methods: The analysis included county-level drug poisoning mortality data (2013-2015) from the National Center for Health Statistics (NCHS) and Health Center Program Awardee and Look-Alike data (2017) on the number of providers with a DATA waiver to provide medication-assisted treatment (MAT) and the number of patients receiving MAT for the U.S. Several geospatial methods were used including an Empirical Bayes approach to estimate drug poisoning mortality, excess risk maps to identify outliers, and the Local Moran's I tool to identify clusters of high drug poisoning mortality counties. Results: High-need counties were disproportionately located in the Appalachia region. More than 6 in 10 health centers in high-need counties have the potential to expand MAT delivery to patients. Implications: The results indicate an opportunity to increase health center capacity for providing treatment for opioid use disorder in high-need areas, particularly in central and northern Appalachia.

Molecular Cytogenetic Characterization of a Three-way t(8;14;22)(q24;q32;q11.2) with Involvement of MYC/IGH/IGL in a Case of a Diffuse Large B-cell Lymphoma (DLBCL).

OBJECTIVES: Diffuse large B-cell lymphoma (DLBCL) is a non-Hodgkin's lymphoma (NHL) that is the most common and the most aggressive or fast-growing form of NHL. It can lead to death if left untreated. Cytogenetic abnormalities include rearrangements of the IgH and BCL2 genes. Herein we described a t(8;14;22)(q24;q32;q11.2) within the context of a complex karyotype involving MYC/IGH/IGL in a three-way translocation that was characterized by molecular cytogenetics. The t(8;14)(q24;q32) is a recurrent chromosome abnormality described in non-Hodgkin lymphomas (NHL), especially in 80% of Burkitt lymphoma (BL) and diffuse large B-cell lymphomas. The variant t(8;22) (q24;q11) is also seen in these cases. MYC rearrangements have been observed in up to 10% of cases of diffuse large B-cell lymphomas (DLBCL) and is usually associated with a complex pattern of genetic alterations. This particular pattern with IGH-MYC rearrangements within the context of complex karyotypes is seen in diffuse large B-cell lymphomas. Complex karyotypes are associated with genomic instability and a poor prognosis.

Clinicians' Overestimation of Their Geographic Service Area.

In this study, we evaluated family physicians' ability to estimate the service area of their patient panel-a critical first step in contextual population-based primary care. We surveyed 14 clinicians and administrators from 6 practices. Participants circled their estimated service area on county maps that were compared with the actual service area containing 70% of the practice's patients. Accuracy was ascertained from overlap and the amount of estimated census tracts that were not part of the actual service area. Average overlap was 75%, but participants overestimated their service area by an average of 166 square miles. Service area overestimation impedes implementation of targeted community interventions by practices.

Identifying Priority and "Bright-Spot" Counties for Diabetes Preventive Care in Appalachia: An Exploratory Analysis.

Introduction: Type 2 diabetes mellitus (T2DM) prevalence and mortality in Appalachian counties is substantially higher when compared to non-Appalachian counties, although there is significant variation within Appalachia. Purpose: The objectives of this research were to identify low-performing (priority) and high-performing (bright spot) counties with respect to improving T2DM preventive care. Methods: Using data from the Centers for Medicare and Medicaid (CMS), the Dartmouth Atlas of Health Care, and the Appalachia Regional Commission, conditional maps were created using county-level estimates for T2DM prevalence, mortality, and annual hemoglobin A1c (HbA1c) testing rates. Priority counties were identified using the following criteria: top 33rd percentile for T2DM mortality; top 33rd percentile for T2DM prevalence; bottom 50th percentile for A1c testing rates. Bright spot counties were identified as counties in the bottom 33rd percentile for T2DM mortality, the top 33rd percentile for T2DM prevalence; and the top 50th percentile for HbA1c testing rates. Results: Forty-one priority counties were identified (those with high T2DM mortality, high T2DM prevalence, and low HbA1c testing rates), which were located primarily in Central and North Central Appalachia; and 17 bright spot counties were identified (high T2DM prevalence, low T2DM mortality, and high HbA1c testing rates), which were scattered throughout Appalachia. Eight of the 17 bright spot counties were adjacent to priority counties. Implications: By employing conditional mapping to T2DM, multiple variables can be summarized into a single, easily interpretable map. This could be valuable for T2DM-prevention programs seeking to prioritize diagnostic and intervention resources for the management of T2DM in Appalachia.

Living in "Cold Spot" Communities Is Associated with Poor Health and Health Quality.

PURPOSE: Little is known about incorporating community data into clinical care. This study sought to understand the clinical associations of cold spots (census tracts with worse income, education, and composite deprivation). METHODS: Across 12 practices, we assessed the relationship between cold spots and clinical outcomes (obesity, uncontrolled diabetes, pneumonia vaccination, cancer screening-colon, cervical, and prostate-and aspirin chemoprophylaxis) for 152,962 patients. We geocoded and linked addresses to census tracts and assessed, at the census tract level, the percentage earning less than 200% of the Federal Poverty Level, without high school diplomas, and the social deprivation index (SDI). We labeled those census tracts in the worst quartiles as cold spots and conducted bivariate and logistic regression. RESULTS: There was a 10-fold difference in the proportion of patients in cold spots between the highest (29.1%) and lowest practices (2.6%). Except for aspirin, all outcomes were influenced by cold spots. Fifteen percent of low-education cold-spot patients had uncontrolled diabetes compared with 13% of noncold-spot patients (P < .05). In regression, those in poverty, low education, and SDI cold spots were less likely to receive colon cancer screening (odds ratio [CI], 0.88 [0.83-0.93], 0.87 [0.82-0.92], and 0.89 [0.83-0.95], respectively) although cold-spot patients were more likely to receive cervical cancer screening. CONCLUSION: Living in cold spots is associated with worse chronic conditions and quality for some screening tests. Practices can use neighborhood data to allocate resources and identify those at risk for poor outcomes.

FPs lower hospital readmission rates and costs.

Hospital readmission after discharge is often a costly failing of the U.S. health care system to adequately manage patients who are ill. Increasing the numbers of family physicians (FPs) is associated with significant reductions in hospital readmissions and substantial cost savings.

Absence of interleukin-3 does not affect the severity of local and systemic anaphylaxis but does enhance eosinophil infiltration in a mouse model of allergic peritonitis.

Interleukin-3 (IL-3), which is derived from T cells and other sources, can promote the differentiation, proliferation, and migration of mast cells, basophils, and eosinophils. However, little is known about the ability of IL-3 to regulate the function of these cells in IgE-dependent and -independent allergic responses in vivo. Therefore, we sought to investigate the extent to which endogenously produced IL-3 can influence mast cell secretory function, the expression of local and systemic anaphylactic responses, and ragweed-induced eosinophilic peritonitis. We found that peritoneal mast cells from IL-3 deficient (IL-3 -/-) mice released less serotonin following challenge with low doses of anti-IgE antibody or antigen ex vivo than do cells isolated from corresponding wild-type (IL-3 +/+) mice. Both IL-3 -/- and +/+ mice expressed equivalent IgE-dependent passive cutaneous anaphylaxis responses following challenge with specific antigen and exhibited equivalent active systemic anaphylaxis responses to ovalbumin as assessed by changes in body temperature, death rates, total IgE production, and histamine release. In contrast, ragweed allergen immunization and peritoneal allergen challenge resulted in eosinophil recruitment that was greater in IL-3 -/- mice than in IL-3 +/+ mice. Our data demonstrates that IL-3 does not appear to be essential for local or systemic anaphylaxis. However, IL-3 production in vivo was found to enhance the mediator release from freshly isolated peritoneal mast cells stimulated ex vivo, and, unexpectedly, to inhibit the accumulation of eosinophils associated with a ragweed-induced allergic peritonitis model.