What is the best approach to the evaluation of resting tachycardia for an adult?

The best evidence about the diagnostic evaluation of resting tachycardias in adults is currently outlined by practice guidelines. 1 Initial evaluation includes clinical history, physical examination, and 12-lead electrocardiogram (ECG). If the initial evaluation suggests a sinus tachycardia with narrow QRS complexes and no identifiable secondary cause, a 24-hour Holter monitor is usually recommended (strength of recommendation: C, based on expert opinion)

What are appropriate screening tests for adolescents?

Screen all women of childbearing age, including adolescents, for rubella susceptibility (strength of recommendation [SOR]: B). Screen all sexually active adolescent females for chlamydia (SOR: A), gonorrhea (SOR: B), and cervical cancer (SOR: A). High-risk, sexually active adolescents should be screened for HIV and syphilis (SOR: A). Screen all adolescents at risk for tuberculosis (TB) infection (SOR: A)

What are appropriate screening tests for infants and children?

There is adequate evidence for screening neonates for hemoglobinopathies, congenital hypothyroidism, phenylketonuria (strength of recommendation [SOR]: A), and cystic fibrosis (SOR: B). Vision screening should be done for those younger than age 5 years (SOR: B). High-risk children should be tested for tuberculosis (TB) (SOR: B) and lead toxicity (SOR: B). Few data exist to guide frequency and timing of these screening tests, so the following timing recommendations are based on consensus opinion (SOR: C): test for visual acuity yearly starting at age 3 years; test for TB and lead once between the ages of 9 and 12 months, and repeat for high risk or exposure

Citizenship Documentation Requirement for Medical Eligibility: Effects on Oregon Children

BACKGROUND AND OBJECTIVES: The Deficit Reduction Act (DRA) of 2005 mandated Medicaid beneficiaries to document citizenship. Using a prospective cohort (n=104,375), we aimed to (1) determine characteristics of affected children, (2) describe effects on health insurance coverage and access to needed health care, and (3) model the causal relationship between this new policy, known determinants of health care access, and receipt of needed health care. METHODS: We identified a stratified random sample of children shortly after the DRA was implemented and used state records and surveys to compare three groups: children denied Medicaid for inability to document citizenship, children denied for other reasons, and children accepted for coverage. To combat survey nonresponse, we used Medicaid records to identify differences between responders and nonrespondents and created survey weights to account for these differences. Weighted simple and multivariable logistic regression described the complete, originally identified population. RESULTS: Children denied Medicaid for inability to document citizenship were likely to be US citizens, were medically and socially more vulnerable than their peers, and went on to have gaps in health insurance coverage and unmet health care needs. The DRA led to persistent loss of insurance coverage, which decreased access to needed health care. Having a usual source of care was an effect modifier in this relationship. CONCLUSIONS: Our findings demonstrate the negative consequences of the DRA and support the use of automated methods of citizenship verification allowed under the Patient Protection and Affordable Care Act

Oregon Medicaid Expenditures after the 2014 Affordable Care Act Medicaid Expansion: Over-time Differences among New, Returning, and Continuously Insured Enrollees

Background—There is interest in assessing healthcare utilization and expenditures among new Medicaid enrollees after the 2014 Medicaid expansion. Recent studies have not differentiated between newly enrolled individuals and those returning after coverage gaps. Objectives—To assess healthcare expenditures among Medicaid enrollees in the 24 months after Oregon’s 2014 Medicaid expansions and examine whether expenditure patterns were different among the newly, returning, and continuously insured. Research Design—Retrospective cohort study using inverse-propensity weights to adjust for differences between groups. Subjects—Oregon adult Medicaid beneficiaries insured continuously from 2014-2015 who were either newly, returning, or continuously insured. Measures—Monthly expenditures for inpatient care, prescription drugs, total outpatient care, and subdivisions of outpatient care: emergency department (ED), dental, mental and behavioral health (MBH), primary care (PC), and specialist care. Results—After initial increases, newly and returning insured outpatient expenditures dropped below continuously insured. Expenditures for ED and dental services among the returning insured remained higher than among the newly insured. Newly insured MBH, PC, and specialist expenditures plateaued higher than returning insured. Prescription drug expenditures increased over time for all groups, with continuously insured highest and returning insured lowest. All groups had similar inpatient expenditures over 24 months post-Medicaid expansion. Conclusions—Our findings reveal that outpatient expenditures for new non-pregnant, non-dual-eligible Oregon Medicaid recipients stabilized over time after meeting pent-up demand, and prior insurance history affected the mix of services that individuals received. Policy evaluations should consider expenditures over at least 24 months and should account for enrollees’ prior insurance histories

Digging deeper: quality of patient-provider communication across Hispanic subgroups

<p>Abstract</p> <p>Background</p> <p>Recent research suggests that ethnic subgroup designation plays an important role in health-related disparities among Hispanics. Our objective was to examine the influence of Hispanics' self-reported ethnic subgroup designation on perceptions of their health care providers' communication behaviors.</p> <p>Methods</p> <p>Cross-sectional analysis of the 2005 Medical Expenditure Panel Survey (MEPS). Participants included non-institutionalized Hispanics (n = 5197; US population estimate = 27,070,906), aged ≥18 years, reporting visiting a health care provider within the past 12 months. Six (n = 6) items were used to capture respondents' perceptions of their health care providers' communication behaviors.</p> <p>Results</p> <p>After controlling for socio-demographic covariates, compared to Other Hispanics (reference group), very few differences in perceptions of health care providers communication emerged across ethnic subgroups. Puerto Ricans were more likely to report that their health care provider "always" showed respect for what they had to say (OR = 2.16, 95% CI 1.16-4.03). Both Puerto Ricans (OR = 2.28, 95% CI 1.06-4.92) and Mexicans (OR = 1.88, 95% CI 1.02-3.46) were more likely to indicate that their health care provider "always" spent enough time with them as compared to Other Hispanics.</p> <p>Conclusions</p> <p>We observed very few differences among Hispanics respondents in their perceived quality of interactions with health care providers as a function of their ethnic subgroup designation. While our findings somewhat contradict previous research, they do suggest that other underlying factors may influence the quality of perceived interactions with health care providers.</p

The Five Phases of Pandemic Care for Primary Care

During a pandemic, many more patients than usual are likely to have symptoms, and many of them will seek care. Nearly all will need primary care, and primary care will need to be there to help them. In 2014, the CDC issued a framework to address the influenza pandemia, describing six intervals, from investigation of cases of novel influenza through preparation for future pandemic waves. This is a great public health framework, but it does not address the specific needs of primary care practices. We propose a framework, in waves, that parallels the CDC's. All communities in the US will go through all waves, but to different degrees and at different times. There may be others that we do not anticipate, some will happen simultaneously, some will repeat themselves, and the cycle will happen again as COVID-19 changes and re-infects our communities. With each wave, primary care will need to continuously reinvent and transform itself. And throughout, primary care will need to provide usual care, including managing chronic conditions, addressing new acute problems, and promoting prevention. One thing is clear: if primary care does not do well in this crisis, the system will be completely overwhelmed. If primary care does everything perfectly, the system will just be overwhelmed. Either way, there is a tough road ahead, and there are thousands of natural experiments occurring across the nation. It is critical to learn from these experiences and to be prepared for next time. The transformations present an opportunity for our health system to evolve, build informatics infrastructure, expand digital health, support diverse multidisciplinary teams to care for patients across settings, fix payment to enable comprehensive, continuous care, and convert to a true community-based focus for patient-centered and population-focused care that helps all in need.https://deepblue.lib.umich.edu/bitstream/2027.42/154687/1/Krist_deepblue.pd

Maintaining public health insurance benefits: How primary care clinics help keep low-income patients insured

Low-income families struggle to obtain and maintain public health insurance. We identified strategies used by Community Health Centers (CHCs) to assist patients with insurance applications, and assessed patients’ receptivity to these efforts. Observational cross-case comparative study with four CHCs in Oregon. We observed insurance assistance processes, and interviewed 26 clinic staff and 18 patients/family members. Qualitative data were analyzed using a grounded theory approach. Patients’ understanding of eligibility status, reapplication schedules, and how to apply, were major barriers to insurance enrollment. Clinic staff addressed these barriers by reminding patients when applications were due, assisting with applications as needed, and tracking submitted applications to ensure approval. Families trusted clinic staff with insurance enrollment support, and appreciated it. CHCs are effective at helping patients with public health insurance. Access to insurance expiration data, tools enabling enrollment activities, and compensation are needed to support enrollment services in CHCs

The ADVANCE network: accelerating data value across a national community health center network

The ADVANCE (Accelerating Data Value Across a National Community Health Center Network) clinical data research network (CDRN) is led by the OCHIN Community Health Information Network in partnership with Health Choice Network and Fenway Health. The ADVANCE CDRN will ‘horizontally’ integrate outpatient electronic health record data for over one million federally qualified health center patients, and ‘vertically’ integrate hospital, health plan, and community data for these patients, often under-represented in research studies. Patient investigators, community investigators, and academic investigators with diverse expertise will work together to meet project goals related to data integration, patient engagement and recruitment, and the development of streamlined regulatory policies. By enhancing the data and research infrastructure of participating organizations, the ADVANCE CDRN will serve as a ‘community laboratory’ for including disadvantaged and vulnerable patients in patient-centered outcomes research that is aligned with the priorities of patients, clinics, and communities in our network

Creating research-ready partnerships: The initial development of seven implementation laboratories to advance cancer control

BACKGROUND: In 2019-2020, with National Cancer Institute funding, seven implementation laboratory (I-Lab) partnerships between scientists and stakeholders in \u27real-world\u27 settings working to implement evidence-based interventions were developed within the Implementation Science Centers in Cancer Control (ISC3) consortium. This paper describes and compares approaches to the initial development of seven I-Labs in order to gain an understanding of the development of research partnerships representing various implementation science designs. METHODS: In April-June 2021, members of the ISC3 Implementation Laboratories workgroup interviewed research teams involved in I-Lab development in each center. This cross-sectional study used semi-structured interviews and case-study-based methods to collect and analyze data about I-Lab designs and activities. Interview notes were analyzed to identify a set of comparable domains across sites. These domains served as the framework for seven case descriptions summarizing design decisions and partnership elements across sites. RESULTS: Domains identified from interviews as comparable across sites included engagement of community and clinical I-Lab members in research activities, data sources, engagement methods, dissemination strategies, and health equity. The I-Labs use a variety of research partnership designs to support engagement including participatory research, community-engaged research, and learning health systems of embedded research. Regarding data, I-Labs in which members use common electronic health records (EHRs) leverage these both as a data source and a digital implementation strategy. I-Labs without a shared EHR among partners also leverage other sources for research or surveillance, most commonly qualitative data, surveys, and public health data systems. All seven I-Labs use advisory boards or partnership meetings to engage with members; six use stakeholder interviews and regular communications. Most (70%) tools or methods used to engage I-Lab members such as advisory groups, coalitions, or regular communications, were pre-existing. Think tanks, which two I-Labs developed, represented novel engagement approaches. To disseminate research results, all centers developed web-based products, and most (n = 6) use publications, learning collaboratives, and community forums. Important variations emerged in approaches to health equity, ranging from partnering with members serving historically marginalized populations to the development of novel methods. CONCLUSIONS: The development of the ISC3 implementation laboratories, which represented a variety of research partnership designs, offers the opportunity to advance understanding of how researchers developed and built partnerships to effectively engage stakeholders throughout the cancer control research lifecycle. In future years, we will be able to share lessons learned for the development and sustainment of implementation laboratories