Study protocol for "Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET)": a pragmatic trial comparing implementation strategies.

Background: Little research has directly compared the effectiveness of implementation strategies in any setting, and we know of no prior trials directly comparing how effectively different combinations of strategies support implementation in community health centers. This paper outlines the protocol of the Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET), a trial designed to compare the effectiveness of several common strategies for supporting implementation of an intervention and explore contextual factors that impact the strategies' effectiveness in the community health center setting.

Methods/design: This cluster-randomized trial compares how three increasingly hands-on implementation strategies support adoption of an evidence-based diabetes quality improvement intervention in 29 community health centers, managed by 12 healthcare organizations.

Community Health Center Use After Oregon's Randomized Medicaid Experiment.

Purpose: There is debate about whether community health centers (CHCs) will experience increased demand from patients gaining coverage through Affordable Care Act Medicaid expansions. To better understand the effect of new Medicaid coverage on CHC use over time, we studied Oregon's 2008 randomized Medicaid expansion (the "Oregon Experiment").

Methods: We probabilistically matched demographic data from adults (aged 19-64 years) participating in the Oregon Experiment to electronic health record data from 108 Oregon CHCs within the OCHIN community health information network (originally the Oregon Community Health Information Network) (N = 34,849).

Feasibility and impact of implementing a private care system's diabetes quality improvement intervention in the safety net: a cluster-randomized trial.

Background: Integrated health care delivery systems devote considerable resources to developing quality improvement (QI) interventions. Clinics serving vulnerable populations rarely have the resources for such development but might benefit greatly from implementing approaches shown to be effective in other settings. Little trial-based research has assessed the feasibility and impact of such cross-setting translation and implementation in community health centers (CHCs).

Prognostic significance of mammographic density change after initiation of tamoxifen for ER-positive breast cancer.

Background: A prior analysis of postmenopausal breast cancer patients linked a decline in mammographic density (MD) following the initiation of tamoxifen treatment with improved survival, but excluded premenopausal women, for whom tamoxifen is the primary anti-endocrine therapy. Therefore, we evaluated change in MD after tamoxifen and breast cancer death among patients age 32 to 87 years.

Methods: This case-control study included 349 estrogen receptor (ER)-positive breast cancer patients who were treated with tamoxifen at Kaiser Permanente Northwest (1990-2008): 97 who died from breast cancer (case patients) and 252 who did not (control patients), matched on age and year at diagnosis and disease stage.

An early look at rates of uninsured safety net clinic visits after the Affordable Care Act.

Purpose: The Affordable Care Act of 2010 supports marked expansions in Medicaid coverage in the United States. As of January 1, 2014, a total of 25 states and the District of Columbia expanded their Medicaid programs. We tested the hypothesis that rates of uninsured safety net clinic visits would significantly decrease in states that implemented Medicaid expansion, compared with states that did not.

The importance of considering different healthcare settings when estimating the burden of Clostridium difficile.

Background: Traditional surveillance methods may underestimate the true burden of Clostridium difficile infection (CDI) because they fail to capture cases brought to medical attention in outpatient settings or diagnosed during non-face-to-face patient-provider interactions.

Methods: We identified CDIs diagnosed among Kaiser Permanente Northwest patients between 1 June 2005 and 30 December 2012. We categorized infections by whether they were diagnosed during an inpatient or outpatient encounter and whether they were diagnosed during a face-to-face (eg, hospitalization, outpatient visit) or non-face-to-face encounter (eg, phone, e-mail).

Receipt of diabetes preventive services differs by insurance status at visit.

Background: Lack of insurance is associated with suboptimal receipt of diabetes preventive care. One known reason for this is an access barrier to obtaining healthcare visits; however, little is known about whether insurance status is associated with differential rates of receipt of diabetes care during visits.

Purpose: To examine the association between health insurance and receipt of diabetes preventive care during an office visit.

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.

Automating assessment of lifestyle counseling in electronic health records.

Background: Numerous population-based surveys indicate that overweight and obese patients can benefit from lifestyle counseling during routine clinical care.

Purpose: To determine if natural language processing (NLP) could be applied to information in the electronic health record (EHR) to automatically assess delivery of weight management-related counseling in clinical healthcare encounters.

Methods: The MediClass system with NLP capabilities was used to identify weight-management counseling in EHRs.

Estimating demand for care after a medicaid expansion: lessons from Oregon.

To estimate how the Affordable Care Act's Medicaid expansions will affect demand for services, we measured ambulatory care utilization among adult patients who gained insurance during Oregon's 2008 Medicaid expansion. Using electronic health record data from 67 community health centers, we assessed pre- and postcoverage utilization among patients who gained insurance, compared with patients continuously insured or uninsured. In comparisons of the pre- and postcoverage periods, mean annual encounters among persons who gained insurance increased 22% to 35%, but declined in the comparison groups.

Does change in the neighborhood environment prevent obesity in older women?

Neighborhood environment is consistently associated with obesity; changes to modifiable aspects of the neighborhood environment may curb the growth of obesity in the US and other developed nations. However, currently the majority of studies are cross-sectional and thus not appropriate for evaluating causality. The goal of this study was to evaluate the effect of a neighborhood-changing intervention on changes in obesity among older women.

Agreement of Medicaid claims and electronic health records for assessing preventive care quality among adults.

To compare the agreement of electronic health record (EHR) data versus Medicaid claims data in documenting adult preventive care. Insurance claims are commonly used to measure care quality. EHR data could serve this purpose, but little information exists about how this source compares in service documentation.

Diabetes care quality is highly correlated with patient panel characteristics.

Introduction: Health care reimbursement is increasingly based on quality. Little is known about how clinic-level patient characteristics affect quality, particularly in community health centers (CHCs).

Methods: Using data from electronic health records for 4019 diabetic patients from 23 primary care CHCs in the OCHIN practice-based research network, we calculated correlations between a clinic's patient panel characteristics and rates of delivery of diabetes preventive services in 2007.

Use of online sources of information by dental practitioners: findings from The Dental Practice-Based Research Network.

Objective: Estimate the proportion of dental practitioners who use online sources of information for practice guidance.

Methods: From a survey of 657 dental practitioners in The Dental Practice-Based Research Network, four indicators of online use for practice guidance were calculated: read journals online, obtained continuing education (CDE) through online sources, rated an online source as most influential, and reported frequently using an online source for guidance. Demographics, journals read, and use of various sources of information for practice guidance in terms of frequency and influence were ascertained for each.

Collaborative development of a randomized study to adapt a diabetes quality improvement initiative for federally qualified health centers.

This case study describes how we are translating a diabetes care quality improvement initiative from an insured (HMO) setting into federally qualified health centers (FQHCs). We outline the innovative collaborative processes whereby researchers and FQHC providers adapted this initiative, which includes health information technology tools, to meet the FQHCs' needs.

Hearing, mobility, and pain predict mortality: a longitudinal population-based study.

Objective: Measures of health-related quality of life (HRQL), including the Health Utilities Index Mark 3 (HUI3) are predictive of mortality. HUI3 includes eight attributes, vision, hearing, speech, ambulation, dexterity, cognition, emotion, and pain and discomfort, with five or six levels per attribute that vary from no to severe disability. This study examined associations between individual HUI3 attributes and mortality.

Receipt of diabetes preventive care among safety net patients associated with differing levels of insurance coverage.

Background: Patients receive care in safety net clinics regardless of insurance status; however, receipt of diabetes preventive care might vary among patients with differing levels of insurance continuity.

Methods: In a retrospective cohort study, using electronic health record data from adults with diabetes who were receiving care in 50 safety net clinics in Oregon in 2005 to 2007, we conducted adjusted logistic regressions to model the associations between amount of time with insurance and rates of receipt of lipid screening, influenza vaccination, nephropathy screening (urine microalbumin), and HbA1c (glycohemoglobin) screening.

Results: Of 3384 adults with diabetes, 711 were partially insured (covered 1% to 99% of the 3-year study period), 909 had no coverage, and 1764 were continuously insured.

Completion and timing of the three-dose human papillomavirus vaccine series among adolescents attending school-based health centers in Oregon.

Objective: Many adolescents do not complete the 3-dose human papillomavirus vaccine series in the recommended time frame, or at all. Given the challenges of administering a multi-dose vaccine to adolescents, especially those in vulnerable populations, we evaluated completion of the human papillomavirus vaccine series in 19 of Oregon's school-based health centers.

Methods: Among persons aged 0-17 who initiated the human papillomavirus vaccine series at a study school-based health center in 2007, we identified all subsequent human papillomavirus doses administered at the school-based health centers, or found in Oregon's immunization information system, in 2007-2008.

Screening rarely screened women: time-to-service and 24-month outcomes of tailored interventions.

Background: Managed care organizations and others reaching out to underscreened women seek strategies to encourage mammogram and Pap screening.

Methods: Female HMO members aged 50-69 years and overdue for a mammogram and a Pap test (n = 501) were followed for 24 months after interventions began. An Outreach intervention (tailored letters and motivational telephone interviews), an Inreach intervention (motivational interview delivered in clinics), and a Combined Inreach/Outreach intervention were compared to Usual Care at 24 months.

Screening HMO women overdue for both mammograms and pap tests.

Background: Regular screening has the potential to reduce breast and cervical cancer mortality, but despite health plan programs to encourage screening, many women remain unscreened. Tailored communications have been identified as a promising approach to promote mammography and Pap test screening.

Methods: The study used a four-group randomized design to compare with Usual Care the separate and combined effects of two tailored, motivational interventions to increase screening-a clinical office In-reach intervention and a sequential letter/telephone Outreach intervention.

Health care costs associated with escalation of drug treatment in type 2 diabetes mellitus.

The cost of different intensities of therapy in HMO patients with type 2 diabetes mellitus was studied. Health care utilization data from 1995 were obtained for 12,200 registrants from the Kaiser Permanente Northwest Diabetes Registry who had type 2 diabetes mellitus. The data were used to determine costs associated with the escalation of antidiabetic therapies in persons with type 2 diabetes mellitus.