Heather Holderness

Objectives: This study assesses whether expanding Medicaid eligibility to low-income adults aged 50 and older regardless of immigration status improved the prevalence of smoking cessation assistance and lung cancer screening among Latino patients receiving care at community clinics. Methods: This retrospective study used electronic health record data from clinics in Oregon and California who expanded Medicaid eligibility by 2021. Data included 1,741 Latino and non-Hispanic white patients aged 50–64 uninsured at baseline who were documented as current or former smokers and had visits both pre-amendment (2018–2019) and post-amendment (2021–2023). Results: Few patients received lung cancer screening during the study period (4% of n=1,242). There was no significant difference in the prevalence of lung cancer screening between groups from pre-to-post period (ATT=-2.29; 95%CI: -4.90, 0.33). Latinos (9.5%) had lower prevalence of smoking cessation assistance than the non-Hispanic White group (16.2%) in the pre-period. There was no significant group difference from pre-to-post eligibility expansion (ATT=-4.92; 95%CI: -11.21, 2.57). Conclusions: Medicaid eligibility expansion regardless of immigration status was not associated with improved up-to-date lung cancer screening or receipt of smoking cessation assistance in Latino patients. Insurance access is not sufficient to improve lung cancer screening uptake and facilitate smoking cessation.

Cancer is the top leading cause of death among Latino people. Lack of health insurance is a significant contributor to inadequate cancer detection and treatment. Despite healthcare policy expansions such as the Affordable Care Act, Latino people persistently maintain the highest uninsured rate among any ethnic and racial group in the US, especially among Latino individuals who are immigrants or part of a mixed immigration status household. Recognizing that immigration status is a critical factor in the ability of Latino community members to seek health insurance and access healthcare services, a few US states and the District of Columbia have implemented policies that have expanded coverage to children and adults regardless of immigration status. Expansion of Medicaid eligibility regardless of immigration status may significantly benefit Latino communities, however the facilitators and barriers to enrolling in these programs need to be evaluated to ensure reach and achieve health equity across the cancer control continuum for all Latinos.

Objective: To describe telemedicine use patterns and understand clinic’s approaches to shifting care delivery during the COVID-19 pandemic. Methods: We used electronic health record data from 203 community health centers across 13 states between 01/01/2019 and 6/31/2021 to describe trends in telemedicine visit rates over time. Qualitative data were collected from 13 of those community health centers to understand factors influencing adoption and implementation of telemedicine. Results: Most clinics in our sample were in urban areas (n = 176) and served a majority of uninsured and publicly insured patients (12.8% and 44.4%, respectively) across racial and ethnic minority groups (16.6% Black and 29.3% Hispanic). During our analysis period there was a 791% increase in telemedicine visits from before the pandemic (.06% pre- vs 47.5% during). A latent class growth analysis was used to examine differences in patterns of adoption of telemedicine across the 203 CHCs. The model resulted in 6 clusters representing various levels of telemedicine adoption. A mixed methods approach streamlined these clusters into 4 final groups. Clinics that reported rapid adoption of telemedicine attributed this change to leadership prioritization of telemedicine, robust quality improvement processes (eg, using PDSA processes), and emphasis on training and technology support. Conclusions: In response to the COVID-19 pandemic, telemedicine adoption rates varied across clinics. Our study highlight that organizational factors contributed to the clinic’s ability to rapidly uptake and use telemedicine services throughout the pandemic. These approaches could inform future non-pandemic practice change and care delivery.

Background: The coronavirus disease 2019 pandemic led to clinical practice changes, which affected cancer preventive care delivery. Objectives: To investigate the impact of the coronavirus disease 2019 pandemic on the delivery of colorectal cancer (CRC) and cervical cancer (CVC) screenings. Research Design: Parallel mixed methods design using electronic health record data (extracted between January 2019 and July 2021). Study results focused on 3 pandemic-related periods: March–May 2020, June–October 2020, and November 2020–September 2021. Subjects: Two hundred seventeen community health centers located in 13 states and 29 semistructured interviews from 13 community health centers. Measures: Monthly up-to-date CRC and CVC screening rates and monthly rates of completed colonoscopies, fecal immunochemical test (FIT)/fecal occult blood test (FOBT) procedures, Papanicolaou tests among age and sex-eligible patients. Analysis used generalized estimating equations Poisson modeling. Qualitative analysts developed case summaries and created a cross-case data display for comparison. Results: The results showed a reduction of 75% for colonoscopy [rate ratio (RR) = 0.250, 95% CI: 0.224–0.279], 78% for FIT/FOBT (RR = 0.218, 95% CI: 0.208–0.230), and 87% for Papanicolaou (RR = 0.130, 95% CI: 0.125–0.136) rates after the start of the pandemic. During this early pandemic period, CRC screening was impacted by hospitals halting services. Clinic staff moved toward FIT/FOBT screenings. CVC screening was impacted by guidelines encouraging pausing CVC screening, patient reluctance, and concerns about exposure. During the recovery period, leadership-driven preventive care prioritization and quality improvement capacity influenced CRC and CVC screening maintenance and recovery. Conclusions: Efforts supporting quality improvement capacity could be key actionable elements for these health centers to endure major disruptions to their care delivery system and to drive rapid recovery.

Previous reviews of strategies to increase cervical cancer screening are more than 10 years old, the U.S. continues to fall short of the Healthy People 2030 cervical cancer screening goal, and guidelines were revised in 2018, therefore an updated review of the existing literature is needed. We conducted a scoping review using electronic databases PubMed, Scopus, and Ovid Medline that included publication dates between 2012 and 2021 to answer the question, “Which strategies implemented in U.S. primary care settings have been most successful in increasing rates of cervical cancer screening since the 2012 US Preventative Services Task Force cervical cancer screening guidelines were published?” We mapped findings to pre-specified implementation strategy categories. After initially identifying 399 articles, we excluded 350 due to duplicates or not meeting review criteria, leaving 49 articles for full review. We excluded 37 of these during full-text review and identified 2 additional articles from the manual search of reference lists for a total of 14 studies for abstraction. Eleven articles reported on strategies resulting in increased cervical cancer screening, and 3 did not. Clinic workflow re-design strategies showed the greatest promise in improving cervical cancer screening rates, education strategies for patients had mixed results, and quality management strategies were not effective. These findings suggest clinical workflow re-structures and patient education strategies can increase cervical cancer screening in primary care settings. Results are particularly important in settings that care for underserved populations, as these settings may need additional implementation strategies to decrease cervical cancer screening disparities.

Background: Previous studies suggest the newly Medicaid insured are more likely to use the emergency department (ED) however they did not differentiate between patients established or not established with primary care. Objectives: To understand where Oregon Medicaid beneficiaries sought care after the Patient Protection and Affordable Care Act (PPACA) Medicaid expansion (ED, primary care, or specialist) and the interaction between primary care establishment and outpatient care utilization. Research design: A retrospective cohort study. Subjects: Adults continuously insured from 2014 through 2015 who were either newly, returning, or continuously insured post-PPACA. Measures: Site of first and last outpatient visit, established with primary care status, and outpatient care utilization. Results: The odds of being established with primary care at their first visit were lower among newly [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.18–0.19] and returning insured (OR, 0.22; 95% CI, 0.22–0.23) than the continuously insured. Continuously insured, new patients with primary care had higher odds of visiting the ED (OR, 2.15; 95% CI, 2.01–2.30) at their first visit than newly or returning insured. Patients established with a single primary care provider in all insurance groups had lower rates of ED visit, whereas those established with multiple primary care providers had the highest ED visit rates. Conclusions: Most newly and returning insured Medicaid enrollees sought primary care rather than ED services and most became established with primary care. Our findings suggest that both insurance and primary care continuity play a role in where patients seek health care services.