健康的社会决定因素在初级卫生保健中的融入路径

健康的社会决定因素（SDH）指非临床上的可以影响患者健康的因素,如社会地位、经济状况及邻里资源等。WHO将其定义为人们出生、成长、工作、生活、衰老的环境,以及广义上的塑造这些日常生活条件的力量和系统。SDH与疾病发病率、死亡率及其他健康指标相关,且其对人群健康的影响大于医疗服务。

家庭医学：加速患者与人群健康提升的突破性革新

本文由参加第4届G.Gayle Stephens研讨会的作者于会后撰写,这些作者同时也是家庭医学与美国健康(FMAHealth)委员会的成员。文章将现阶段FMAHealth所做的战略与沟通工作的志向与会议得出的理念进行了关联。FMAHealth项目由8个国家家庭医学机构赞助,力图在最初的家庭医学未来项目的基础上进行开展。此项目的目标之一是使实力充足的家庭医生队伍在持续改善的医疗之家模式中工作,并且由足够维持医疗之家和私人医生与患者保持联系的综合付费模式支持。

Comparison of associations of household-level and neighbourhood-level poverty markers with paediatric asthma care utilisation by race/ethnicity in an open cohort of community health centre patients

Objective The objective of this research was to examine how different measurements of poverty(household-level and neighborhood-level)were associated with asthma care utilisation outcomes in a community health centre setting among Latino,non-Latino black and non-Latino white children.Design,setting and participants We used 2012–2017 electronic health record data of an open cohort of children aged<18 years with asthma from the OCHIN,Inc.network.Independent variables included household-level and neighborhood-level poverty using income as a percent of federal poverty level(FPL).Covariate-adjusted generalised estimating equations logistic and negative binomial regression were used to model three outcomes:(1)≥2 asthma visits/year,(2)albuterol prescription orders and(3)prescription of inhaled corticosteroids over the total study period.Results The full sample(n=30196)was 46%Latino,26%non-Latino black,31%aged 6–10 years at first clinic visit.Most patients had household FPL<100%(78%),yet more than half lived in a neighbourhood with>200%FPL(55%).Overall,neighbourhood poverty(<100%FPL)was associated with more asthma visits(covariate-adjusted OR 1.26,95%CI 1.12 to 1.41),and living in a low-income neighbourhood(≥100%to<200%FPL)was associated with more albuterol prescriptions(covariate-adjusted rate ratio 1.07,95%CI 1.02 to 1.13).When stratified by race/ethnicity,we saw differences in both directions in associations of household/neighbourhood income and care outcomes between groups.Conclusions This study enhances understanding of measurements of race/ethnicity differences in asthma care utilisation by income,revealing different associations of living in low-income neighbourhoods and households for Latino,non-Latino white and non-Latino black children with asthma.This implies that markers of family and community poverty may both need to be considered when evaluating the association between economic status and healthcare utilisation.Tools to measure both kinds of poverty(family and community)may already exist within clinics,and can both be used to better tailor asthma care and reduce disparities in primary care safety net settings.

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 914495 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 127138 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.

A new role for primary care teams in the United States after“Obamacare:”Track and improve health insurance coverage rates

Maintaining continuous health insurance coverage is important.With recent expansions in access to coverage in the United States after“Obamacare,”primary care teams have a new role in helping to track and improve coverage rates and to provide outreach to patients.We describe efforts to longitudinally track health insurance rates using data from the electronic health record(EHR)of a primary care network and to use these data to support practice-based insurance outreach and assistance.Although we highlight a few examples from one network,we believe there is great potential for doing this type of work in a broad range of family medicine and community health clinics that provide continuity of care.By partnering with researchers through practice-based research networks and other similar collaboratives,primary care practices can greatly expand the use of EHR data and EHR-based tools targeting improvements in health insurance and quality health care.

New hypertension and diabetes diagnoses following the Affordable Care Act Medicaid expansion

Objective To assess the Affordable Care Act(ACA)Medicaid expansion’s impact on new hypertension and diabetes diagnoses in community health centres(CHCs).Design Rates of new hypertension and diabetes diagnoses were computed using generalised estimating equation Poisson models and we tested the difference-in difference(DID)pre-ACA versus post-ACA in states that expanded Medicaid compared with those that did not.Setting We used electronic health record data(pre-ACA:1 January 2012-31 December 2013-post-ACA:1 January 2014-31 December 2016)from the Accelerating Data Value Across a National Community Health Center Network clinical data network.We included clinics with≥50 patients contributing to person-time at risk in each study year.Participants Patients aged 19-64 with≥1 ambulatory visit in the study period were included.We then excluded patients who were pregnant during the study period(N=127530).For the hypertension outcome,we excluded individuals with a diagnosis of hypertension prior to the start of the study period,those who had a hypertension diagnosis on their first visit to a clinic or their first visit after 3 years without a visit,and those who had a diagnosis more than 3 years after their last visit(pre-ACA non-expansion N=130973;expansion N=193198;post-ACA non-expansion N=186341;expansion N=251015).For the diabetes analysis,we excluded patients with a diabetes diagnosis prior to study start,on their first visit or first visit after inactive patient status,and diagnosis while not an active patient(pre-ACA non-expansion N=145435;expansion N=198558;post-ACA non-expansion N=215039;expansion N=264644).Results In non-expansion states,adjusted hypertension diagnosis rates saw a relative decrease of 6%,while in expansion states,the adjusted rates saw a relative increase of 7%(DID 1.14,95%CI 1.11 to 1.18).For diabetes diagnosis,adjusted rates in non-expansion states experienced a significant relative increase of 28%and in expansion states the relative increase was 25%;yet these differences were not significant pre-ACA to post-ACA comparing expansion and non-expansion states(DID 0.98,95%CI 0.91 to 1.05).Conclusion There was a differential impact of Medicaid expansion for hypertension and diabetes diagnoses.Moderate increases were found in diabetes diagnosis rates among all patients served by CHCs post-ACA(both in expansion and non-expansion states).These increases suggest that ACA-related opportunities to gain health insurance(such as marketplaces and the Medicaid expansion)may have facilitated access to diagnostic tests for this population.The study found a small change in hypertension diagnosis rates from pre-ACA to post-ACA(a decrease in non-expansion and an increase in expansion states).Despite the significant difference between expansion and non-expansion states,the small change from pre-ACA to post-ACA suggests that the diagnosis of hypertension is likely documented for patients,regardless of health insurance availability.Future studies are needed to understand the impact of the ACA on hypertension and diabetes treatment and control.

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 23773 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.