Faculty Bibliography

OBJECTIVE:To examine associations between patient-reported health-related social needs (HRSNs) and clinical quality measure (CQM) performance in an urban federally qualified health center (FQHC) network. METHODS:This cross-sectional study included adult patients (≥18 years) screened for HRSNs at a general internal medicine clinic, Clinic-1, and a prenatal healthcare clinic, Clinic-2, within a FQHC network, between January 1, 2018, and July 31, 2022. HRSNs were assessed across 9 domains. Performance was assessed for 13 process and 2 outcome-based CQMs at Clinic-1 and 5 process-based CQMs at Clinic-2. Prevalence ratios (PR) were estimated using logistic regression to compare CQM performance by HRSN status, adjusted for relevant demographic, clinical, and clinician factors. RESULTS:At Clinic-1, reporting a HRSN was associated with lower hemoglobin A1c control (PR, 0.81; 95%CI, 0.69, 0.95). At Clinic-2, reporting a HRSN was associated with higher cervical cancer screening (PR, 1.07; 95%CI, 1.03, 1.11). No other CQMs differed significantly by HRSN status. CONCLUSIONS:HRSNs were not associated with differences in performance for most CQMs at this FQHC network. Exceptions were observed negative associations with diabetes A1c control and positive associations with cervical cancer screening. Further research is needed to elucidate mechanisms through which unmet HRSNs impact CQMs across care settings.

IMPORTANCE/OBJECTIVE:Patients with poor glycaemic control have a high risk for major cardiovascular events. Improving glycaemic monitoring in patients with diabetes can improve morbidity and mortality. OBJECTIVE:To assess the effectiveness of a patient portal message in prompting patients with poorly controlled diabetes without a recent glycated haemoglobin (HbA1c) result to have their HbA1c repeated. DESIGN/METHODS:A pragmatic, randomised clinical trial. SETTING/METHODS:A large academic health system consisting of over 350 ambulatory practices. PARTICIPANTS/METHODS:Patients who had an HbA1c greater than 10% who had not had a repeat HbA1c in the prior 6 months. EXPOSURES/METHODS:A single electronic health record (EHR)-based patient portal message to prompt patients to have a repeat HbA1c test versus usual care. MAIN OUTCOMES/RESULTS:The primary outcome was a follow-up HbA1c test result within 90 days of randomisation. RESULTS:The study included 2573 patients with a mean (SD) HbA1c of 11.2%. Among 1317 patients in the intervention group, 24.2% had follow-up HbA1c tests completed within 90 days, versus 21.1% of 1256 patients in the control group (p=0.07). Patients in the intervention group were more likely to log into the patient portal within 60 days as compared with the control group (61.2% vs 52.3%, p<0.001). CONCLUSIONS:Among patients with poorly controlled diabetes and no recent HbA1c result, a brief patient portal message did not significantly increase follow-up testing but did increase patient engagement with the patient portal. Automated patient messages could be considered as a part of multipronged efforts to involve patients in their diabetes care.

BACKGROUND:Building a learning health system (LHS) at a federally qualified health center (FQHC) can generate research with diverse communities. However, FQHCs face challenges in integrating research with their mission to deliver high-quality primary care to vulnerable populations. OBJECTIVE:Our FQHC serves over 110,000 patients annually and partners with an academic medical center. We have implemented LHS strategies to align research with health care service priorities, enable clinician involvement in research, support data analysis, disseminate findings, and seek research funding. Drawing on the Consolidated Framework for Implementation Research, we identify contextual factors that impeded or facilitated our LHS implementation. Lessons can inform LHS practice in safety-net primary care. DESIGN/METHODS:Case study of LHS development at an FQHC. STAKEHOLDERS/UNASSIGNED:FQHC leaders, clinicians, staff, and academic partners.  APPROACH: Descriptive analysis of 168 research proposals and 13 grant-funded studies. Review of procedures to approve, implement, and disseminate research. RESULTS:Supportive leadership, preexisting culture of continuous QI, academic partners who understand the FQHC mission, and investment in research infrastructure (e.g., structured research review and access to data) facilitated the implementation of our strategies to integrate research with health care delivery as part of building an LHS. Inherent characteristics of research can pose challenges for research-practice integration, e.g., research often runs on longer timelines than quality improvement initiatives. Importantly, our approach is modular and iterative: we selectively and progressively launched strategies for LHS development, beginning with essential processes to review research, administer grants, provide data, and share findings. Alongside continually enhancing these processes, our work ahead includes building clinician and staff competencies for research, extending data analyst capacity, and establishing an organizational policy on equitable patient and community engagement in research. CONCLUSIONS:Taking a modular approach and iterating LHS activities can enable FQHCs to integrate research with health care service delivery in safety-net primary care.

INTRODUCTION/BACKGROUND:The impact of remote patient monitoring (RPM) for hypertension (HTN) on cardiovascular health (CVH) remains ill-defined. This study characterized the association between a RPM, team-based HTN intervention and CVH markers. METHODS:This retrospective, single-arm cohort study included patients with uncontrolled HTN enrolled February 2022-July 2024 in the ALTA trial (clinicaltrials.gov NCT03713515) at five safety-net practices. The ALTA intervention involves RPM supported by a virtual clinic including a nurse practitioner (NP), registered nurse, and community health worker. Demographics, ALTA utilization, and CVH markers (blood pressure [BP], lipids, glycemic indicators, body mass index [BMI], and smoking) at baseline and 12 months were collected. Five markers were scored (0=poor, 1=intermediate, 2=ideal) and summed into a CVH score. The primary endpoint was the 12-month CVH score change in patients with baseline score ≤7. Secondary endpoints included individual non-BP marker changes in patients with baseline derangements. RESULTS:Among 568 patients (mean age: 56 years), most were female, non-Hispanic Black, and English-speaking. NP visits were more common among females (p=0.04); no other demographics predicted ALTA utilization. The CVH score improved from 4.5 to 5.2 (n=196, p<0.001), independent of ALTA utilization. Total cholesterol (n=86, p<0.001), LDL (n=128, p<0.001), and triglycerides (n=51, p=0.004) improved. Hemoglobin A1c (n=195) dropped among patients with ≥1 NP visit (p=0.02). Fasting glucose (n=135) and BMI (n=289) decreased in the highest tertile of NP visits (p=0.03) and RPM (p=0.02), respectively. 4 of 27 patients quit smoking. CONCLUSIONS:RPM with team-based support was associated with CVH improvements. Benefits may depend on intervention utilization.

Remote patient monitoring (RPM) has been shown to support adults with treated but uncontrolled hypertension (HTN) outside the clinic setting, yielding significant benefits in the treatment and control of blood pressure (BP). Despite its proven efficacy and recommendation as guideline-concordant care, adoption of RPM is suboptimal, particularly among marginalized populations, who face structural barriers to HTN control. A barrier to equitable adoption among marginalized populations is the lack of digital inclusivity in the design and deployment of RPM. Digitally inclusive tools consider factors such as affordability, access, digital literacy, and skills. To address this challenge, the authors describe a digitally inclusive model of RPM for HTN management within the Family Health Centers (FHCs) at NYU Langone, a federally qualified health center (FQHC) that serves more than 110,000 patients each year. The model uses protocols from the Target: BP initiative in combination with team-based care and digitally inclusive strategies to improve HTN control. Specifically, care teams work collaboratively to identify patients with uncontrolled HTN and order RPM using electronic health record-embedded clinical decision support; provide patients with free home BP monitors and training in accurate BP measurement; deliver language-concordant health coaching and optimize the antihypertensive regimen via a virtual high-risk clinic (VHRC); and monitor patient progress through shared communications. Patients also receive support from community health workers (CHWs) to address digital barriers and unmet social needs. The authors present utilization and preliminary outcome data of their model, involving 429 patients who were enrolled in RPM and the VHRC across five FHC practices between January 1, 2022, and December 31, 2023. Enrolled patients attended a mean of 4.9 (standard deviation [SD]: 0.5) visits with a nurse practitioner for medication adjustments and counseling; 5.7 (SD: 0.5) health coaching visits with a nurse; and 1 visit (SD: 0.2) with a CHW for digital and social needs over a mean of 5.7 months (SD: 0.8). Enrolled patients sent a mean number of 65 BP readings (SD: 96.4) over their period of participation. On average, enrolled patients exhibited a -13.5/-8.0 mmHg reduction from their enrollment date to the date that they were discharged from the VHRC (approximately 5.7 months). This is in comparison to a -0.5/+0.6 mmHg change in mean BP exhibited by patients with uncontrolled HTN not enrolled in the Advancing Long-term Improvements in Hypertension Outcomes through a Team-based Care Approach (ALTA) program and receiving care at the practices during the same period (n=2,843). Across the practices, BP control had also increased from the pre-ALTA baseline period (January 1, 2021, to December 31, 2021) of 68.44%-82.99%, by the end of December 31, 2023, among all patients with uncontrolled HTN. While the implementation of this digitally inclusive RPM model has shown success in a large FQHC that cares for a diverse population of patients, there remain digital inequity barriers that must be addressed at the policy level to ensure this efficacious approach reaches all patients.

PURPOSE/UNASSIGNED:We aimed to determine whether implementation of clinical decision support (CDS) tool integrated into the electronic health record of a multisite academic medical center increased the proportion of patients with AUA "high-risk" microscopic hematuria (MH) who receive guideline concordant evaluations. MATERIALS AND METHODS/UNASSIGNED:We conducted a two-arm cluster randomized quality improvement project in which 202 ambulatory sites from a large health system were randomized to either have their physicians receive at time of test results an automated CDS alert for patients with "high-risk" MH with associated recommendations for imaging and cystoscopy (intervention) or usual care (control). Primary outcome was met if a patient underwent both imaging and cystoscopy within 180 days from MH result. Secondary outcomes assessed individual completion of imaging, cystoscopy, or placement of imaging orders. RESULTS/UNASSIGNED:= .09). CONCLUSIONS/UNASSIGNED:Implementing an electronic health record-integrated CDS tool to promote evaluation of patients with high-risk MH did not lead to improvements in patient completion of a full guideline-concordant evaluation. The development of an algorithm to trigger a CDS alert was demonstrated to be feasible and effective. Further multilevel assessment of barriers to evaluation is necessary to continue to improve the approach to evaluating high-risk patients with MH.

OBJECTIVE/UNASSIGNED:To examine the transition to telemental health within the behavioral health program of a large federally qualified health center, The Family Health Centers at NYU Langone, in the 3 months following the onset of the COVID-19 pandemic-specifically impacts on show rates and access to care. METHODS/UNASSIGNED:Demographic and clinical information for all scheduled visits was collected for two time periods: the telemental health period, March 16, 2020-July 16, 2020 (46,878 visits, 5,183 patients), and a comparison period, March 15, 2019-July 16, 2019 (47,335 visits, 5,190 patients). Data collected included modality, appointments scheduled/completed/cancelled/no-showed, age, gender, race, language, and diagnosis. Generalized estimating equations with a compound symmetry correlation structure and logit link were used for analysis. RESULTS/UNASSIGNED:= 0.01), which was eliminated by implementation of telemental health. CONCLUSIONS/UNASSIGNED:This study supports the use telemental health to increase access for all patients, including those from under-represented, lower socioeconomic status backgrounds.