A Clinical-Community Partnership to Address Food Insecurity and Reduce Emergency Department Utilization Among Medicaid-Insured Patients in North Carolina.

CONTEXT: Socioeconomic risk factors have the greatest impact on overall health trajectory. Patients with Medicaid insurance are more likely to experience food insecurity, in addition to poor health and increased health care utilization. Targeted food and produce prescription programs can reduce food insecurity, but sustainable implementation is challenging and evidence demonstrating the impact on clinical utilization outcomes is lacking. PROGRAM: In 2021, a cross-sector collaboration between Mecklenburg County Public Health, Reinvestment Partners, and Atrium Health initiated a food prescription program in urban North Carolina. A low-cost mass text message campaign was used to identify and enroll Medicaid-insured patients with a history of emergency department (ED) utilization. METHODS: A nonrandomized before/after evaluation design was used with a 12-month data collection window (6 months before/after program enrollment) for 711 patients enrolled between June 2021 and 2022. Changes in the odds of nonadmission ED utilization were modeled using logistic regression, adjusting for race/ethnicity, gender, age, comorbidity, and dose, along with interaction by comorbidity. RESULTS: A majority of the sample was non-Hispanic Black (61%; n = 436), female (90%; n = 643), with "none to mild" chronic disease comorbidity (81%; n = 573). The unadjusted and adjusted odds of nonadmission ED utilization significantly reduced between time periods, along with significant interaction by comorbidity. Among the subsamples, patients with "none to mild" comorbidity showed 34% reduction in odds of nonadmission ED utilization (OR = 0.64; 95% CI, 0.47-0.86). DISCUSSION: Food prescription programming targeting Medicaid-insured patients may reduce ED utilization, particularly among those without severe comorbidity. Retrospective data collection and sample homogeneity reduced the quality of evidence, but results offer a pragmatic example that can be replicated for further study. Additional research is needed to strengthen the body of evidence and support cross-sector investment in food and produce prescription programming.

School-Based Telemedicine and Reduced Avoidable Emergency Care Among Rural Pediatric Patients.

Objective: Children living in rural communities have disparate access to preventive health care, shifting the burden of care delivery to emergency services. This study examined the association of school-based telemedicine (SBT) and avoidable emergency department (ED) utilization in rural historically underserved pediatric patients served through an SBT program. Methods: A retrospective analysis was conducted using electronic medical records and claims data from a large integrated health care system serving as the majority health care provider in the area. Participants included all pediatric patients served through an SBT program between 2017 and 2020 across three rural North Carolina counties. The study was a quasi-experimental before/after design comparing 12-month time periods before and after a patient's index virtual care visit. A subset of patients served 12 months before the start of the coronavirus 2019 (COVID-19) pandemic in 2020 was extracted and analyzed separately for a sensitivity analysis. Results: The complete sample included 1,236 patients. The odds of having an avoidable ED visit were reduced by 33% between time periods, and the estimated count of visits was reduced by 26%. (Models were adjusted for race/ethnicity, gender, age, and insurance payer.) No significant differences in unavoidable ED utilization were observed. The sensitivity analysis showed similar trends. Conclusions: Results demonstrate that telemedicine can improve access to health care and may offset the burden of avoidable care through emergency health services. Policy changes and increased use during the COVID-19 pandemic have created an optimal environment for telemedicine expansion to reduce health care access disparities.

An equity-focused approach to improving access to COVID-19 vaccination using mobile health clinics.

This article describes the implementation of an equity-focused strategy to increase the uptake of COVID-19 vaccination among communities of color and in traditionally underserved geographic areas using mobile health clinics (MHCs). The MHC Vaccination Program was implemented through a large integrated healthcare system in North Carolina using a grassroots development and engagement strategy along with a robust model for data-informed decision support to prioritize vulnerable communities. Several valuable lessons from this work can replicated for future outreach initiatives and community-based programming: •Health systems can no longer operate under the assumption that community members will come to them, particularly those experiencing compounding social and economic challenges. The MHC model had to be a proactive outreach to community members, rather than a responsive delivery mechanism. •Barriers to access included financial, legal, and logistical challenges, in addition to mistrust among historically underserved and marginalized communities. •A MHC model can be adaptable and responsive to data-informed decision-making approaches for targeted service delivery. •A MHC model is not a one-dimensional solution to access, but part of a broader strategy to create diverse points of entry into the healthcare system that fall within the rhythm of life of community members.

Disparities in Level of Care and Outcomes Among Patients with COVID-19: Associations Between Race/Ethnicity, Social Determinants of Health and Virtual Hospitalization, Inpatient Hospitalization, Intensive Care, and Mortality.

OBJECTIVE: To examine the role of race/ethnicity and social determinants of health on COVID-19 care and outcomes for patients within a healthcare system that provided virtual hospital care. METHODS: This retrospective cohort study included 12,956 adults who received care for COVID-19 within an integrated healthcare system between 3/1/2020 and 8/31/2020. Multinomial models were used to examine associations between race/ethnicity, insurance, neighborhood deprivation measured by Area Deprivation Index (ADI), and outcomes of interest. Outcomes included (1) highest level of care: virtual observation (VOU), virtual hospitalization (VACU), or inpatient hospitalization; (2) intensive care (ICU); and (3) all-cause 30-day mortality. RESULTS: Patients were 41.8% White, 27.2% Black, and 31.0% Hispanic. Compared to White patients, Black patients had 1.86 higher odds of VACU admission and 1.43 higher odds of inpatient hospitalization (vs. VOU). Hispanic patients had 1.24 higher odds of inpatient hospitalization (vs. VOU). In models stratified by race/ethnicity, Hispanic and Black patients had higher odds of inpatient hospitalization (vs. VOU) if Medicaid insured compared to commercially insured. Hispanic patients living in the most deprived neighborhood had higher odds of inpatient hospitalization, compared to those in the least deprived neighborhood. Black and Hispanic patients had higher odds of ICU admission and 30-day mortality after adjustment for other social determinants. CONCLUSIONS: Insurance and ADI were associated with COVID-19 outcomes; however, associations varied by race/ethnicity. Racial/ethnic disparities in outcomes are not fully explained by measured social determinants of health, highlighting the need for further investigation into systemic causes of inequities in COVID-19 outcomes.

Residential Segregation and Emergency Department Utilization Among an Underserved Urban Emergency Department Sample in North Carolina.

BACKGROUND Residential segregation is a spatial manifestation of structural racism. Racial disparities in emergency department (ED) utilization mirror social inequity in the larger community. We evaluated associations between residential segregation and ED utilization in a community with known disparities and geographically concentrated social and health risk.METHODS Cross-sectional data were collected from electronic medical records of 101 060 adult ED patients living in Mecklenburg County, North Carolina in 2017. Community context was measured as residential segregation using the dissimilarity index, categorized into quintiles (Q1-Q5) using 2013-2017 American Community Survey estimates, and residency in a public health priority area (PHPA). The outcome was measured as total ED visits during the study period. Associations between community context and ED utilization were modeled using Anderson's behavioral model of health service utilization, and estimated using negative binomial regression, including interaction terms by race.RESULTS Compared to areas with the lowest proportions of Black residents (Q1), living in Q4 was associated with higher rates of ED utilization among Black/Other (AME = 0.11) and White (AME = 0.23) patients, while associations with living in Q5 were approximately equivalent (AME = 0.12). PHPA residency was associated with higher rates of ED utilization among Black/Other (AME = 0.10) and White patients (AME = 0.22).LIMITATIONS Associations should not be interpreted as causal, or be generalized to the larger community without ED utilization. Health system leakage is possible but limited.CONCLUSIONS Residential segregation is associated with higher rates of ED utilization, as are PHPA residency and other individual-level determinants.

Racial/Ethnic Disparities in Health Care Setting Choice for Adults Seeking Severe Acute Respiratory Syndrome Coronavirus 2 Testing.

OBJECTIVES: Equitable access to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing is important for reducing disparities. We sought to examine differences in the health care setting choice for SARS-CoV-2 testing by race/ethnicity and insurance. Options included traditional health care settings and mobile testing units (MTUs) targeting communities experiencing disproportionately high coronavirus disease 2019 (COVID-19) rates. METHODS: We conducted a retrospective, observational study among patients in a large health system in the Southeastern US. Descriptive statistics and multinomial logistic regression analyses were employed to evaluate associations between patient characteristics and health care setting choice for SARS-CoV-2 testing, defined as: (1) outpatient (OP) care; (2) emergency department (ED); (3) urgent care (UC); and (4) MTUs. Patient characteristics included race/ethnicity, insurance, and the existence of an established relationship with the health care system. RESULTS: Our analytic sample included 105,386 adult patients tested for SARS-CoV-2. Overall, 55% of patients sought care at OP, 24% at ED, 12% at UC, and 9% at MTU. The sample was 58% White, 24% Black, 11% Hispanic, and 8% other race/ethnicity. Black patients had a higher likelihood of getting tested through the ED compared with White patients. Hispanic patients had the highest likelihood of testing at MTUs. Patients without a primary care provider had a higher relative risk of being tested through the ED and MTUs versus OP. CONCLUSIONS: Disparities by race/ethnicity were present in health care setting choice for SARS-CoV-2 testing. Health care systems may consider implementing mobile care delivery models to reach vulnerable populations. Our findings support the need for systemic change to increase primary care and health care access beyond short-term pandemic solutions.

A Replicable, Solution-Focused Approach to Cross-Sector Data Sharing for Evaluation of Community Violence Prevention Programming.

CONTEXT: Community violence is a public health problem that erodes social infrastructure. Structural racism contributes to the disparate concentration of violence in communities of color. In Mecklenburg County, North Carolina, increasing trends in community violence show racial and geographic disparities that emphasize the need for cross-sector, data-driven approaches to program and policy change. Cross-sector collaborations are challenged by data sharing barriers that hinder implementation. PROGRAM: In response to community advocacy, Mecklenburg County Public Health (MCPH) launched a Community Violence Prevention Plan with evidence-based programming. The Cure Violence (CV) model, a public health approach to disrupting violence through equitable resource provision, network building, and changing norms, was implemented at the community level. The Health Alliance for Violence Intervention (HAVI) model, a hospital-based screening and case management intervention for victims of violence, was implemented at Carolinas Medical Center in Charlotte, the region's only level I trauma center. METHODS: A data collaborative was created to optimize evaluation of CV and HAVI programs including MCPH, the city of Charlotte, Atrium Health, Charlotte-Mecklenburg Schools, Johnson C. Smith University, and the University of North Carolina Charlotte. A comprehensive approach to facilitate data sharing was designed with a focus on engaging stakeholders and generating solutions to commonly reported barriers. Structured interviews were used to inform a solution-focused strategy. RESULTS: Stakeholders reported perceptions of their organization's barriers and facilitators to cross-sector data sharing. Common technology, legal, and governance barriers were addressed through partnership with a local integrated data system. Solutions for trust and motivational challenges were built into ongoing collaborative processes. DISCUSSION: Data silos inhibit the understanding of complex public health issues such as community violence, along with the design and evaluation of collective impact efforts. This approach can be replicated and scaled to support cross-sector collaborations seeking to influence social and health inequities stemming from structural racism.

Social and demographic characteristics of frequent or high-charge emergency department users: A quantile regression application.

OBJECTIVE: Heavy users of the emergency department (ED) are a heterogeneous population. Few studies have captured the social and demographic complexity of patients with the largest burden of ED use. Our objective was to model associations between social and demographic patient characteristics and quantiles of the distributions of ED use, defined as frequent and high-charge. METHODS: We conducted a cross-sectional analysis of electronic health and billing records of 99 637 adults residing in an urban North Carolina county who visited an ED within Atrium Health, a large integrated health care system, in 2017. Mid-quantile and standard quantile regression models were used for count and continuous responses, respectively. Frequent and high-charge use outcomes were defined as the median (0.50) and upper quantiles (0.75, 0.95, 0.99) of the outcome distributions for total billed ED visits and associated charges during the study period. Patient characteristic predictors were: insurance coverage (Medicaid, Medicare, private, uninsured), total visits to ambulatory care during the study period (0, 1, >1), and patient demographics: age, gender, race, ethnicity, and living in an underprivileged community called a public health priority area (PHPA). RESULTS: Results showed heterogeneous relationships that were stronger at higher quantiles. Having Medicaid or Medicare insurance was positively associated with ED visits and ED charges at most quantiles. Racial and geographic disparities were observed. Black patients had more ED visits and lower ED charges than their White counterparts at most quantiles of the outcome distributions. Patients living in PHPAs, had lower charges than their counterparts at the median but higher charges at the 0.95 and 0.99 quantiles. CONCLUSIONS: The relationships between patient characteristics and frequent and high-charge use of the ED vary based on the level of use. These findings can be used to inform targeted interventions, tailored policy, and population health management initiatives.

Ambulatory care, insurance, and avoidable emergency department utilization in North Carolina.

OBJECTIVE: To examine whether and how avoidable emergency department (ED) utilization is associated with ambulatory or primary care (APC) utilization, insurance, and interaction effects. DESIGN AND SAMPLE: A cross-sectional analysis of electronic health records from 70,870 adults residing in Mecklenburg County, North Carolina, who visited an ED within a large integrated healthcare system in 2017. METHODS: APC utilization was measured as total visits, categorized as: 0, 1, and > 1. Insurance was defined as the method of payment for the ED visit as: Medicaid, Medicare, private, or uninsured. Avoidable ED utilization was quantified as a score (aED), calculated as the sum of New York University Algorithm probabilities multiplied by 100. Quantile regression models were used to predict the 25th, 50th, 75th, 95th, and 99th percentiles of avoidable ED scores with APC visits and insurance as predictors (Model 1) and with an interaction term (Model 2). RESULTS: Having >1 APC visit was negatively associated with aED at the lower percentiles and positively associated at higher percentiles. A higher aED was associated with having Medicaid insurance and a lower aED was associated with having private insurance, compared to being uninsured. In stratified models, having >1 APC visit was negatively associated with aED at the 25th percentile for the uninsured and privately insured, but positively associated with aED at higher percentiles among the uninsured, Medicaid-insured, and privately insured. CONCLUSIONS: The association between APC utilization and avoidable ED utilization varied based on segments of the distribution of ED score and differed significantly by insurance type.

Development, Implementation, and Results from a COVID-19 Messaging Campaign to Promote Health Care Seeking Behaviors Among Community Clinic Patients.

Care-delays can further exacerbate racial and ethnic health disparities in novel coronavirus disease 2019 (COVID-19) related complications. The purpose of our study was to describe and evaluate a Patient Engagement Messaging campaign (PEM campaign) promoting health care seeking behaviors among community and rural clinic patients in North Carolina. Text and voice messages were delivered over 3-weeks. Messages encouraged patients to call a regional operation call center (ROC) line for information related to health care appointments and testing. A cross-sectional evaluation was conducted on the total population (n = 48,063) and a sample without recent health care contact (n = 29,214). Among the sample, logistic regression was used to model determinants of calls to the ROC-line and associations between calling the ROC-line and health care seeking behaviors (scheduling any health care appointment or receiving a COVID-19 test). 69.9% of text messages and 89% of voice messages were delivered. Overall, 95.4% of the total population received at least 1 message. Successful delivery was lower among Black patients and higher among patients with moderate health-risk comorbidities. Among the sample, 7.4% called the ROC-line, with higher odds of calling among minority patients (vs. White) and among Medicaid and uninsured (vs. private insurance). Calling the ROC-line was associated with higher odds of scheduling any health care appointment (OR: 4.14; 95% CI 2.93-5.80) and receiving a COVID-19 test (OR: 2.39; 95% CI 1.64-3.39). Messaging campaigns may help disconnected patients access health care resources and reduce disparities, but are likely still limited by existing barriers.

Using cloud-based, open-source technology to evaluate, improve, and rapidly disseminate community-based intervention data.

Building Uplifted Families (BUF) is a cross-sector community initiative to improve health and economic disparities in Charlotte, North Carolina. A formative evaluation strategy was used to support iterative process improvement and collaborative engagement of cross-sector partners. To address challenges with electronic data collection through REDCap Cloud, we developed the BUF Rapid Dissemination (BUF-RD) model, a multistage data governance system supplemented by open-source technologies, such as: Stage 1) data collection; Stage 2) data integration and analysis; and Stage 3) dissemination. In Stage 3, results were disseminated through an interactive dashboard developed in RStudio using RShiny and Shiny Server solutions. The BUF-RD model was successfully deployed in a 6-month beta test to reduce the time lapse between data collection and dissemination from 3 months to 2 weeks. Having up-to-date preliminary results led to improved BUF implementation, enhanced stakeholder engagement, and greater responsiveness and alignment of program resources to specific participant needs.

Effectiveness of a Playground Intervention for Antisocial, Prosocial, and Physical Activity Behaviors.

BACKGROUND: We examined the effectiveness of Peaceful Playgrounds™ (P2) to decrease antisocial behaviors (ASB) while increasing physical activity (PA) and prosocial behaviors (PSB) in elementary school children. METHODS: A longitudinal, cluster-randomized design was employed in 4 elementary school playgrounds where students (third to fifth) from 2 intervention and 2 control schools were observed during recess periods. The intervention included environmental changes (eg, marked surfaces) and student education. Data were collected using systematic observations of youth behavior and semistructured interviews conducted with key informants. Mixed-effects regression models controlling for scans nested within days nested within schools estimated the interaction of measurement period and treatment condition on children's PA, PSB, and ASB. It was hypothesized that children in intervention, but not control schools, would demonstrate increased PA/PSB and decreased ASB. RESULTS: Contrary to the hypotheses, intervention and control schools showed favorable changes for all dependent variables except for PSB, but 1 intervention and 1 control school drove these effects. Follow-up interviews indicated variability in implementation and lack of adherence to the control condition. CONCLUSIONS: P2 may promote increased PA during recess, but these results demonstrate the complexity of intervention implementation and the need for rigor when measuring intervention fidelity in real-world settings.

Addressing obesity with pediatric patients and their families in a primary care office.

Pediatric obesity is a prevalent condition that has devastating health consequences for children. If left untreated, it can result in adult obesity and related chronic health conditions. Special considerations need to be made for treatment in the pediatric population including an adjustment of treatment goals (weight maintenance vs weight loss) and treatment methodologies. Special emphasis needs to be made to support a child's development of healthy behavior choices. The use of medications should be avoided when possible because long-term health effects of pharmacotherapy treatment in children are unknown.

Playground Safety is Associated With Playground, Park, and Neighborhood Characteristics.

BACKGROUND: More than 200,000 children each year are treated at emergency departments for injuries occurring on playgrounds. Empirically derived data are needed to elucidate factors associated with playground safety and reduce injury rates. OBJECTIVE: Determine if neighborhood, park and playground characteristics are significantly associated with playground safety. METHODS: A 24-item report card developed by the National Program for Playground Safety was used to assess playground safety at 41 public parks in a small to midsized, Midwestern city. Trained assessors evaluated the parks and playgrounds in June/July and used a standardized method to count the numbers of users. Data from the 2010 U.S. Census were used to describe the neighborhoods surrounding the parks. RESULTS: The average safety score for all playgrounds was 77.4% which denotes acceptable safety levels. However, 17.1% of the playgrounds were potentially hazardous and in need of corrective measures. Playgrounds were safer in neighborhoods with more youth (< 18 years of age) and educated adults and in parks with better quality features. Playgrounds with fewer amenities were relatively less safe. CONCLUSIONS: Park safety levels need to be improved to reduce the risk of physical injuries. Future studies examining cause-effect associations between environmental features and playground safety are warranted.

Bicycling policy indirectly associated with overweight/obesity.

BACKGROUND: Policies to enhance bicycling are correlated with health outcomes. Research has yet to provide an adequate, empirically derived explanation for this finding. PURPOSE: To examine a comprehensive model of a pathway potentially linking bicycle policies to overweight/obesity. METHODS: Data representing multiple years between 2006 and 2012 from CDC, U.S. Census Bureau, U.S. Department of Transportation, and the Alliance for Biking and Walking were subjected to bivariate and multivariate analyses in 2013. A path model was created to explain the relationship between bicycle policies and overweight/obesity in the 48 largest U.S. cities. RESULTS: Zero-order correlations were significant between the number of bicycle policies and the percentage of workers bicycling to work and rates of overweight/obesity. These relationships did not remain statistically significant in the multivariate analysis. However, more bicycle policies were associated with a greater number of bicycle infrastructure components (p<0.005). In turn, bicycling infrastructure components were positively related to the percentage of workers bicycling to work (p<0.001), which was inversely associated with overweight/obesity rates (p<0.05). CONCLUSIONS: The results of this study suggest that large cities with more policies aimed at promoting bicycling have fewer overweight/obese residents, partially because the policies are related to supportive bicycling infrastructures that promote bicycling to work.

Community development corporations could potentially improve research on causal associations between environmental features and physical activity.

BACKGROUND: Community development corporations (CDC) are worldwide entities that create environments facilitating physical activity. At the same time, researchers face challenges conducting cost-effective, longitudinal studies on how environmental changes affect physical activity. OBJECTIVE: To provide evidence suggesting that CDC initiatives could potentially be integrated into a research framework for examining the influence of environmental improvements on physical activity. METHODS: Quality of Life Plans (QLP) developed by a CDC and stakeholders from 6 lower-income neighborhoods were systematically reviewed to obtain data about environmental features targeted for change and the strategies used to bring about those changes. Strategies were deemed pro-physical activity if previous studies suggested they have the potential to affect physical activity. RESULTS: A total of 348 strategies were proposed of which 164 were pro-physical activity. Six environmental features were targeted including crime (57 strategies), aesthetics (39), facilities (30), walkability (17), destinations (14), and programs (5). Strategies involved implementing (90 strategies), planning (33), assessing (26), and securing funding (13). Progress reports indicated that 37.4% of the pro-physical activity strategies were implemented 1 year following the development of the QLPs. CONCLUSIONS: These results suggest that activities of CDCs could potentially be systematically integrated into the scientific study of environmental influences on physical activity.

Outcomes from an urban pediatric obesity program targeting minority youth: the Healthy Hawks program.

BACKGROUND: The aim of this study was to describe the outcomes of a family-based behavioral group treatment program with a group of urban, minority, low-income families. METHODS: Two hundred and ten families enrolled in a 12-week family-based behavioral group treatment program for pediatric obesity. The program was offered in English and in Spanish and targeted the enrollment of low-income highly diverse youth and families. Primary outcome measures included child BMI z-score (zBMI), maternal BMI, 3-day diet record, and accelerometer. RESULTS: Seventy-one percent of enrolled families completed the 12-week program. Significant 12-week outcomes were achieved for child zBMI (p<0.001) and for maternal BMI (p<0.001), as well as for child kcals (p<0.001), sugar-sweetened beverages (p=0.017), and red foods (p<0.001). Only change in child zBMI remained significant at 1 year (p<0.05). Physical activity outcomes were not significant and not in the expected direction. There were no differences in outcome by race/ethnicity, but by age, younger children had higher zBMI at baseline and were also more likely to decrease zBMI during the intervention. CONCLUSIONS: It is possible to enroll and maintain urban, minority, low-income families in a family-based behavioral group treatment program for pediatric obesity. Outcome data indicate that these families achieve significant outcomes on zBMI, and that children who remain available for assessment maintain this at 1 year, which is an improvement over previous research using other intervention methodologies with this population.

Relations between perceptions of environmental features and physical activity.

Studies have examined associations between environmental features and physical activity, but there has been no exploration of adult perceptions about the influence environmental features have on physical activity. This study assessed associations between perceptions of environmental features and physical activity. 305 women and 229 men (18-91 years of age) were interviewed in their homes. Questions elicited self-report data on physical activities they performed in their neighborhood (sidewalks near home) and perceptions about neighborhood environmental features. Women (86.4%) were more likely than men (79.3%) to be active in their neighborhoods and view the features as influential. The influences features were perceived to have on physical activity were associated with activity performed in the neighborhood, but perceptions of the conditions of features were not. Interviewers of adults about relationships between environmental features and physical activity should consider perceptions about the influence the feature exerts on activity levels.