Community Health Center Setting Research Articles

Analysis of factor structure of the 42-item Ryff Psychological Well-Being Scale in a sample of African American women in a community health center

ABSTRACT Well-being measures often favor individualistic (i.e. autonomy) over collectivistic themes (i.e. communalism). Research with African American (AA) communities has identified collective coping, spirituality, and racial identity as important for psychological well-being (PWB). Moreover, individuals with intersecting identities, such as low socioeconomic status AA women, experience unique stressors negatively affecting PWB. This study aims to examine the factor structure of the PWBS-42 scale in a sample of AA women with depressive symptoms in a community health center setting. Seventy-three AA women were recruited from a pilot study through a community health center in a metropolitan city. PWB was assessed using the 42-item Ryff Psychological Well-being (PWBS-42) scale containing six subscales. An exploratory factor analysis revealed three factors in our sample: Self-Efficacy, Locus of Control, and Relational Satisfaction. Measures of reliability and validity were acceptable. Together, the factors explained 42% of PWB variance. Our results indicate that the original factor structure does not capture the unique factors of well-being in our sample of AA women. Our findings underscore the importance of developing culturally relevant psychometric instruments for groups that have been marginalized, such as AA women.

1582. Dolutegravir/Rilpivirine STR Switch Study in Persons with HIV-1 and Chronic Kidney Disease: 48-week Assessment of Viral Suppression, Treatment Adherence and Quality of Life

Abstract Background Single tablet regimens (STRs) are widely utilized in HIV treatment in the Western world largely because they improve convenience of oral regimens and eliminate differential adherence. US Blacks are disproportionately impacted by HIV, and are also disproportionately affected by chronic kidney disease (CKD) for a variety of reasons, especially in their later years. For PWH and CKD, STR options are limited due to pharmacokinetic considerations. We evaluate the impact on viral suppression, adherence, treatment satisfaction and quality of life (QOL) of switching to DTG/RPV STR for a largely Black aging US cohort with HIV and CKD. Methods In this 48-week open label single arm switch study conducted in a community health center setting, adults with HIV, a GFR< 60 mL/min/1.73m2, an HIV RNA < 50 copies/mL and no known prior resistance to DTG or RPV were switched to DTG/RPV STR. HIV RNA and CD4 were monitored per standard national clinical guidance following switch. Standardized tools for medication adherence, treatment satisfaction and QOL were administered at baseline, 24 weeks and 48 weeks. We present final 48-week data. Results Between August 2019 and December 2021, 35 participants were enrolled. One dropped out after 19 weeks and one after 22 weeks due to drug-drug interaction concerns following renal transplantation. 94% of participants were Black, 57% were female and 43% were 65 years and older. At baseline, 20% had a GFR < 30 mL/min/1.73m2 per race-based calculation (36% per race-free calculation). At 48 weeks, 97% of participants maintained viral suppression with an HIV RNA < 50 copies/mL in a per protocol analysis (91% in an intent-to-treat analysis). One participant with an HIV RNA of 62 copies/mL at 48 weeks subsequently re-suppressed on DTG/RPV. 69% reported an improvement in adherence, 77% noted an improvement in treatment satisfaction and 66% reported an improvement in QOL. The only adverse event reported in >5% of participants was nausea (5.7%). There were no serious adverse events. Conclusion For this diverse aging cohort with HIV and CKD in a real-life community health center setting, DTG/RPV STR was efficacious, well-tolerated and associated with improvements in adherence, treatment satisfaction and QOL, sustained over 48 weeks. DTG/RPV is a feasible oral ARV option for PWH and CKD. Disclosures Helena Kwakwa, MD, MPH, ViiV Healthcare: Grant/Research Support

Nurse Standing Orders for Buprenorphine Follow-Up Care in a Community Health Center Network.

Less than 20% of individuals with opioid use disorder (OUD) are receiving a medication treatment for OUD in the United States. Though nurses can assume critical roles in outpatient models of OUD care, there are no published reports of buprenorphine standing orders for nurses that guide a nuanced response for patients returning as expected versus those re-engaging after a treatment lapse, without requiring real-time prescriber consultation. Standing orders for buprenorphine were created with multiple stakeholders within an urban community health center that includes traditional clinics as well as non-traditional homeless care sites. After more than two years of use, an anonymous survey assessed staff perception of usability and safety of the standing orders using the validated system usability scale (SUS) and a 5-item Likert scale. Patient retention rates at 12 and 18 months were compared for sites that were early- and late-adopters of the standing orders. Of 24 clinicians and 7 nurses who responded to the survey, 46% had used the standing orders. More than 85% reported a perception that the standing orders improved team-based care and increased access to buprenorphine refills. None reported any safety concerns. The median SUS score was 75.0 (SD 15.4), rated as "excellent". There was no statistically significant difference in 12- or 18-month retention rates between early- and late-adopter sites of the standing orders. Nurse standing orders for buprenorphine follow-up and re-engagement care are feasible, usable and perceived as safe in varied community health center settings.

Palliative Care in an Urban Community Health Center Setting: A Needs Assessment (QI118)

Palliative Care in an Urban Community Health Center Setting: A Needs Assessment (QI118)

Ethnicity, Language, and HIV Screening in Older Adult Safety-Net Patients

HIV screening should occur for all adults at least once by age 65 years. Older adults have low screening rates. Latinos, with historically low screening rates, have worse HIV outcomes than non-Hispanic White patients. Electronic health record data from a multistate network of community health centers were used to examine whether there are differences in HIV screening for Latino (English and Spanish preferring) and non-Hispanic White older adults. Data were from the Accelerating Data Value Across a National Community Health Center Network Clinical Research Network of PCORnet from 21 states in 2012-2021 among an open cohort of patients aged 50-65 years. Relative odds of ever having received HIV screening comparing Latinos with non-Hispanic Whites using generalized estimating equation logistic regression modeling were calculated, adjusting for relevant patient-level covariates. Analyses were conducted in 2022. Among 251,645 patients, the covariate-adjusted odds of ever receiving HIV screening were 18% higher for English-preferring Latino patients (OR=1.18, 95% CI=1.11, 1.25) and 32% higher for Spanish-preferring Latinos than for non-Hispanic Whites (OR=1.32, 95% CI=1.24, 1.42). Latinos seen in community health centers, regardless of language spoken, are more likely to be screened at least once for HIV than non-Hispanic Whites. This increased screening may be due at least in part to the community health center setting, a setting known to mitigate disparities, as well as due to participation efforts by community health centers in public health campaigns. Future research can prioritize understanding the cause of this relative advantage.

Screening for Hepatitis C Among Community Health Center Patients by Ethnicity and Language Preference

Hepatitis C virus is associated with high morbidity and mortality-chronic liver disease is a leading cause of death among Latinos in the U.S. Screening for hepatitis C virus in community health center settings, which serve a disproportionate percentage of Latinos, is essential to eradicating hepatitis C virus infection. We assessed hepatitis C virus screening disparities in adults served by community health centers by ethnicity and language preference. This was an observational cohort study (spanning 2013-2017) of adults born in 1945-1965 in the Accelerating Data Value Across a National Community Health Center Network electronic health record data set. Our exposure of interest was race/ethnicity and language preference (non-Hispanic White, Latino English preferred, Latino Spanish preferred). Our primary outcome was the relative hazard of hepatitis C virus screening, estimated using multivariate Cox proportional hazards regression. A total of 182,002 patients met the study criteria and included 60% non-Hispanic Whites, 29% Latino Spanish preferred, and 11% Latino English preferred. In total, 9% received hepatitis C virus screening, and 2.4% were diagnosed with hepatitis C virus. Latino English-preferred patients had lower rates of screening than both non-Hispanic Whites and Latino Spanish preferred (5.5% vs 9.4% vs 9.6%, respectively). Latino English preferred had lower hazards of hepatitis C virus screening than non-Hispanic Whites (adjusted hazard ratio=0.56, 95% CI=0.44, 0.72), and Latino Spanish preferred had similar hazards of hepatitis C virus screening (adjusted hazard ratio=1.11, 95% CI=0.88, 1.41). We found that in a large community health center network, adult Latinos who preferred English had lower hazards of hepatitis C virus screening than non-Hispanic Whites, whereas Latinos who preferred Spanish had hazards of screening similar to those of non-Hispanic Whites. The overall prevalence of hepatitis C virus screening was low. Further work on the role of language preference in hepatitis C virus screening is needed to better equip primary care providers to provide this recommended preventive service in culturally relevant ways.

Assessing patient-level knowledge of precision medicine in a community health center setting.

As precision medicine approaches are implemented, cancer treatment decisions have come to require comprehension of genetic tests and their role in risk stratification and treatment options. Acceptance and implementation of precision medicine requires patient understanding of numeracy, genetic literacy, health literacy, and medical trust. Implementing precision medicine in a US federally qualified community health center (FQCHC) setting has received little attention. Using a mixed-methods approach, we sought to identify patient-level factors influencing the understanding of cancer risk and precision medicine among FQCHC patients. We enrolled 26 English-speaking adults aged 40-79years. Participants enrolled in focus groups and completed surveys to assess patient-level understanding of precision medicine, numeracy, and health literacy. The majority of participants were female (77%) and self-identified as African American (89%). Approximately one-third reported having a high school degree or less. While health literacy was generally high, 42% felt that genes or genetics had little impact on health and most (69%) reported little familiarity with precision medicine. Many participants reported that trust in their providers was extremely or very important when receiving genetic tests. Numeracy levels were moderate, with nearly half reporting some discomfort working with fractions and 38% finding numerical information only occasionally useful. Findings suggest that patients may lack familiarity with precision medicine concepts relevant for understanding cancer treatment decisions. Future educational efforts may help bridge the gap in patient understanding and facilitate equitable opportunities for precision medicine for all patients, including those seeking care from community health centers.

Patient Portal Perceptions in an Urban Community Health Center Setting: Insights for Telehealth

Introduction
 Patient portals are the “front door” to telehealth - online scheduling, video visit links, and digital after visit summaries are often conveyed via the patient portal. Patient portal tools often require similar patient skills and attitudes as telehealth adoption. Analyzing patients’ perceptions and beliefs around this digital patient engagement tool may lead to insights regarding telehealth, particularly in historically underrepresented patient populations.
 
 Methods
 Participants from a Federally Qualified Health Center (FQHC) in Chicago, IL were surveyed on general technology use, healthcare-specific technology use, and barriers and facilitators to patient portal use.
 
 Results
 The 149 respondents (81% response rate) represented a unique population base with 96% African American, 74% with educational attainment of some college or less, and 48% with at least one chronic medical condition. Technology access and use were high with 78% computer ownership, 98% mobile phone ownership (with 75% smartphone ownership). In terms of patient portal perception, 75% rated Perceived Usefulness (U) as high. Perceived Ease of Use (E) domains similarly had 70% or higher agreement from patients, and potential barriers and facilitators in the Attitudes Toward Use (A) section included a preference to calling their doctor, and minority of patients viewing the portal as unsafe way to communication, too complicated to use, or taking too much time. Additional stratification analysis by demographic variables (age, gender, educational attainment, and number of chronic conditions) revealed differences in portal perception across the Usefulness, Ease of Use, and Attitudes domains.
 
 Discussion
 Insights from barriers, attitudes, and capacity to use patient portal tools deliver important insight into overall adoption of other digital health modalities, including telehealth. In an urban historically underserved patient population, technology access and use is quite high, and mobile phones access was nearly ubiquitous with a large majority using the internet function on their mobile device. Different age groups, genders, levels of educational attainment, or degree of multi-morbidity have different values and needs. Therefore, each subpopulation needs targeted messaging of different portal benefits.
 
 Conclusion
 Our research provides initial insights into patient-level factors influencing patient portal attitudes, with implications toward telehealth adoption. Demographic differences have a significant impact on attitudes toward technology adoption. Equitable uptake of portal and telehealth services will require tailored messaging, training, and multiple modes of communication, including web-based and mobile.

Effect of Dolutegravir on Plasma Glucose Among Human Immunodeficiency Virus Patients in a Community Health Center Setting.

BackgroundDolutegravir has become one of the initial backbones in antiretroviral therapy regimens for most patients with HIV in several recent clinical guidelines. However, dolutegravir has been associated with severe cases of hyperglycemia and the new-onset of diabetes in multiple case reports and clinical trials. A community health center noticed an increasing number of new-onset hyperglycemia incidences in patients on dolutegravir.MethodRetrospective chart review of patients who started on dolutegravir or dolutegravir combination regimen (Triumreq®, Juluca®, GlaxoSmithKline (GSK), Research Triangle Park, NC) between the dates of January 1st, 2013 and January 1st, 2018 who have been treated in community healthcare centers. Baseline blood sugar and/or hemoglobin A1C before starting dolutegravir, at three to six months of treatment, and at the end of the study were compared between subjects. Four hundred twenty-two subjects were enrolled.ResultsDolutegravir had little effect on plasma glucose among 72% of the subjects (n=305). However, 7% of the subjects (n=28) on dolutegravir treatment with no glucose intolerance met the criteria for prediabetes at three to six months of therapy. One of the subjects had developed diabetes three to six months after dolutegravir was initiated. In addition, at the end of the study, 13% of patients developed prediabetes (n=56) and 1.4% developed diabetes (n=6). Among the 24 subjects that had diabetes before dolutegravir was initiated, 83% required intensification of their diabetes regimen.ConclusionDolutegravir may cause a moderate increase in plasma sugar after three to six months of therapy. Further increases in plasma sugar have been noticed in up to 13% of subjects meeting the criteria for prediabetes. Due to the existence of confounding variables, patients with diabetes should not be switched from dolutegravir.

High Blood Pressure Reduction, Health Insurance Status, and Social Deprivation Index in U.S. Community Health Centers

Lack of health insurance is a risk factor for uncontrolled hypertension, but it is unknown whether health insurance or neighborhood-level social deprivation is associated with greater reductions in blood pressure over time. We estimated the association of health insurance and social deprivation index on blood pressure reduction over time using electronic health record data from 2012 to 2017. We included patients aged 19-64 years with an initial systolic blood pressure ≥150 mmHg or diastolic blood pressure ≥100 mmHg and ≥1 additional visit from 93 community health centers in states that expanded Medicaid in 2014. We included 66,207 patients: 20.1% uninsured, 64.8% publicly insured, and 15.1% privately insured. Adjusting for patient characteristics and baseline blood pressure, systolic blood pressure/diastolic blood pressure declined over the study period by 21.3/11.2 mmHg, 22.0/11.4 mmHg, and 21.1/10.7 mmHg among uninsured, publicly insured, and privately insured individuals, respectively. There were small but significantly greater reductions in systolic blood pressure among patients with public insurance than among those who were uninsured (difference= -1.3, 95% CI= -1.6, -1.0) but none associated with social deprivation index. There were no differences in diastolic blood pressure reductions over time by insurance status or social deprivation index. Blood pressure control (systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg) was significantly greater among publicly or commercially insured individuals than among uninsured individuals (51.7%, 51.5%, 44.6% respectively, both comparisons p<0.001), with no associations between blood pressure control and social deprivation index. Reductions in blood pressure were large but mostly not associated with insurance type or social deprivation index. Additional research is needed to understand the factors that lead to blood pressure reduction in community health center settings.

Effect of dolutegravir on plasma glucose among human immunodeficiency virus patients in a community health center setting

Background: Dolutegravir has become one of the initial backbone in antiretroviral therapy (ART) regimens for most patients with human immunodeficiency virus (HIV) in several recent clinical guidelines. However, dolutegravir has been associated with severe cases of hyperglycemia and new-onset of diabetes in multiple case reports and clinical trials. A community health center noticed an increasing number of new-onset hyperglycemia incidences in patients on dolutegravir.Methods: Retrospective chart review of patients who started on dolutegravir or dolutegavir combination regimen (Triumreq®, Juluca®) between the dates of 1 January 2013 to 1 January 2018 who have been treated in community healthcare centers. Baseline blood sugar and/or A1C before starting dolutegravir, at 3-6 months of treatment and at end of study were compared between subjects.Results: 422 subjects were enrolled. Dolutegravir had little effect on plasma glucose among 72% of the subjects (n=305). However, 7% of the subjects (n=28) on dolutegravir treatment with no glucose intolerance met criteria for prediabetes at 3-6 months of therapy. One subjects had developed diabetes at 3-6 months after dolutegravir was initiated. In addition, at the end of the study, thirteen percent of patients developed prediabetes (n=56) and 1.4% developed diabetes (n=6). Among the 24 subjects that had diabetes before dolutegravir was initiation, 83% required intensification of their diabetes regimen.Conclusions: Dolutegravir may cause a moderate increase in plasma sugar after 3-6 months of therapy. Further increase has been noticed up to 12%. Due to existence of confounding variables, patient with diabetes should not be switched from dolutegravir.

Correlates of Receiving Guideline-Concordant Postpartum Health Services in the Community Health Center Setting.

Introduction: New clinical guidelines recommend comprehensive and timely postpartum services across 3 months after birth. Research is needed to characterize correlates of receiving guideline-concordant, quality postpartum care in federally qualified health centers serving marginalized populations.Methods: We abstracted electronic health record data from patients who received prenatal health care at three health centers in North Carolina to characterize quality postpartum care practices and to identify correlates of receiving quality care. We used multivariable log-binomial regression to estimate associations between patient, provider, and health center characteristics and two quality postpartum care outcomes: (1) timely care, defined as an initial assessment within the first 3 weeks and at least one additional visit within the first 3 months postpartum; and (2) comprehensive care, defined as receipt of services addressing family planning, infant feeding, chronic health, mood, and physical recovery across the first 3 months.Results: In a cohort of 253 patients, 60.5% received comprehensive postpartum care and 30.8% received timely care. Several prenatal factors (adequate care use, an engaged patient–provider relationship) and postpartum factors (early appointment scheduling, exclusive breastfeeding, and use of enabling services) were associated with timely postpartum care. The most important correlate of comprehensive services was having more than one postpartum visit during the first 3 months postpartum.Discussion: Identifying best practices for quality postpartum care in the health center setting can inform strategies to reduce health inequities. Future research should engage community stakeholders to define patient-centered measures of quality postpartum care and to identify community-centered ways of delivering this care.

Medical-Dental Integration in a Rural Community Health Center: A Qualitative Program Evaluation.

A community health center (CHC) implemented a medical-dental integration (MDI) program where children were seen at a pediatric medical clinic or women, infants, and children program location by medical and dental providers in the same visit. Our study aims were to elicit the perspectives and experiences of providers and administrators involved in the MDI program to assess the acceptability, feasibility, and success of a CHC integration strategy in Eastern Washington. This is a qualitative study where we conducted semistructured interviews over the phone over a period of 2 months with 12 medical and dental providers and clinical administrators who were involved with the MDI program. Questions addressed perspectives on workflow, patient identification and engagement, leadership support, and barriers and facilitators of the initiative. Qualitative data were analyzed, and emergent themes were identified. The emergent themes included (a) the MDI program is feasible and acceptable albeit with key considerations regarding the setting, including charting and service integration, progressive leadership and effective communication, and appropriate providers; (b) implementation included structural, systemic, and individual behavior barriers, (c) the program is seen as a benefit to the clinic and patients and a success to date as a way to increase access to quality care. Findings from this study helped identify facilitators, such as cultural relevancy and progressive office systems, as well as barriers, such as reimbursement, associated with integrating medical and dental care in a rural CHC setting, is acceptable by providers, and can inform future studies and implementation strategies for others wishing to integrate these services.

Barriers and Facilitators to Implementing Bundled Acupuncture and Yoga Therapy to Treat Chronic Pain in Community Healthcare Settings: A Feasibility Pilot.

Objective: To identify factors associated with implementing bundled group acupuncture and yoga therapy (YT) to treat underserved patients with chronic pain in community health center (CHC) settings. This is not an implementation science study, but rather an organized approach for identification of barriers and facilitators to implementing these therapies as a precursor to a future implementation science study.Design: This study was part of a single-arm feasibility trial, which aimed to test the feasibility of bundling GA and YT for chronic pain in CHCs. Treatment outcomes were measured before and after the 10-week intervention period. Implementation feasibility was assessed through weekly research team meetings, weekly yoga provider meetings, monthly acupuncture provider meetings, and weekly provider surveys.Settings: The study was conducted in New York City at two Montefiore Medical Group (MMG) sites in the Bronx, and one Institute for Family Health (IFH) site in Harlem.Subjects: Participants in the feasibility trial were recruited from IFH and MMG sites, and needed to have had lower back, neck, or osteoarthritis pain for >3 months. Implementation stakeholders included the research team, providers of acupuncture and YT, referring providers, and CHC staff.Results: Implementation of these therapies was assessed using the Consolidated Framework for Implementation Research. We identified issues associated with scheduling, treatment fidelity, communication, the three-way disciplinary interaction of acupuncture, yoga, and biomedicine, space adaptation, site-specific logistical and operational requirements, and patient-provider language barriers. Issues varied as to their frequency and resolution difficulty.Conclusions: This feasibility trial identified implementation issues and resolution strategies that could be further explored in future implementation studies.Clinical Trial Registration No.: NCT04296344.

Addressing Organizational Barriers to Adolescent Access to High-Quality, Low-Cost, Confidential Sexual and Reproductive Health Services in a Community Health Center.

Adolescents face a number of barriers to accessing high-quality, confidential sexual and reproductive health (SRH) services. Although federally qualified health centers (FQHCs), a type of community health center (CHC), are a critical source of health care for medically underserved adolescents, they often lack the capacity and resources to provide specialized SRH services to adolescents. In this article, we describe the development and implementation of an initiative aimed at improving an FQHC's capacity to provide high-quality confidential SRH services to adolescents. For this initiative, a team of clinical and quality improvement staff developed a set of six strategies to improve adolescent SRH services at an FQHC: (1) building community relationships and galvanizing internal organizational support to improve adolescent access to confidential SRH services, (2) developing a long-acting reversible contraception (LARC) program, (3) training clinic staff on SRH and adolescent health topics, (4) adapting the adolescent patient workflow to improve SRH service delivery during appointments, (5) updating and implementing a universal adolescent health assessment tool, and (6) developing billing and registration policies that allow adolescents to receive confidential SRH services. We identified several factors that we believe were key to the successful implementation of our approach in other CHC settings, including encouraging cross-sector collaboration and community focus, providing training as a tool to engage and empower staff as agents of change, involving interdisciplinary staff, piloting on a small scale, and establishing consistent meetings with a clinic champion and improvement team.

Abstract PO-272: COVID-19 adaptations to patient navigation services for follow-up colonoscopy after an abnormal fecal test result in a community health center setting

Abstract The PRECISE study tests the effectiveness of a targeted patient navigation program for follow-up colonoscopy after an abnormal fecal test result in a community health center setting. We present adaptations and mid-study learnings related to the COVID-19 pandemic. Colorectal cancer (CRC) screening by annual fecal immunochemical test (FIT) is an accessible and cost-effective strategy to lower CRC incidence and mortality. However, this mode of screening depends on follow-up colonoscopy after an abnormal FIT result to prevent CRC or find it in early, treatable forms. Unfortunately, almost half of patients with an abnormal FIT result fail to complete this essential screening component, negating any benefit of FIT screening. Patient navigation can provide much needed support for patients to complete a follow-up colonoscopy. PRECISE is a patient-randomized trial of patient navigation vs usual care for follow-up colonoscopy that will enroll 1,200 patients across 28 community health center clinics in Washington state (anticipated 37% Latinx). As part of the study, we trained a bilingual (English and Spanish) patient navigator using an intensive 8-week program, based on the New Hampshire Colorectal Cancer Screening Program. The program included multiday trainings on CRC health information, colonoscopy steps, patient navigator skills, the navigation protocol, data reporting; a full-day motivational interviewing training delivered by a professional trainer; and in-person meetings with schedulers at local gastroenterology (GI) offices. On March 13, 2020, study enrollment for PRECISE was suspended due to the COVID-19 pandemic during which time all non-urgent medical procedures, including colonoscopies, were canceled or delayed. We trained our patient navigator to outreach to all randomized patients for whom navigation was in process at the time of study suspension. We developed COVID-19-specific talking points, and the outreach protocol was modified to address colonoscopy scheduling delays. To-date, 252 patients have been randomized (124 to navigation and 128 to usual care). Navigator conversations with local GI offices revealed several COVID-related GI practice changes: the pre-procedure consultation is generally delivered as a telehealth (phone-based) visit and COVID-19 testing is required prior to the colonoscopy. Furthermore, many practices mandate the use of face masks by patients and their escorts, and prohibit escorts from accompanying the patient in the pre-procedure area. We adapted navigator messages to address fear and anxiety about getting medical care during the peak COVID-19 pandemic. This innovative clinical trial highlights the importance of patient navigation to improve CRC screening in community health centers and examines COVID-19 adaptions to the navigation intervention. Citation Format: Jamie Thompson, Jennifer Rivelli, Amanda Petrik, Jennifer Schneider, Neha Yadav, Hanna Dinh, Cindy Pulido, Shirley Mendez, DeeDee Torres, Lakshmi Penimarthi, Gloria Coronado. COVID-19 adaptations to patient navigation services for follow-up colonoscopy after an abnormal fecal test result in a community health center setting [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-272.

Abstract D086: Assessing patient-level knowledge of precision medicine in a community health center setting

Abstract Factors influencing cancer treatment decisions require comprehension of genetic tests, risk stratification, and treatment options. This comprehension in turn requires understanding of numeracy, genetic literacy, health literacy, and medical trust, all important for acceptance and implementation of precision medicine. Using a mixed methods approach, we sought to identify patient-level factors influencing the understanding of cancer risk and precision medicine among community health center patients. At a community health center in Nashville, Tennessee we enrolled 26 English-speaking patients between the ages of 40-79 years who were either a cancer patient (n=4), had a family member with cancer (n=20), and/or were previously a caregiver for a cancer patient (n=15). The participants enrolled in one of four focus groups, and also completed surveys to assess patient-level understanding of precision medicine, numeracy, and health literacy. We used a three-item health literacy screening questionnaire and the Subjective Numeracy Scale to assess health literacy and numeracy, respectively. Participants were median age 60, 89% African American and 77% female, with 35% having a high school degree or less and 35% a household income of ≤$15,000. While health literacy was generally high (≤15% reported low confidence in filling out medical forms, understanding medical information, or needing help to read the information), 42% felt that genes or genetics had little impact on health and most reported little familiarity with precision medicine (69%), pharmacogenetics (77%), biomarkers (81%) or biobanks (81%). The majority of participants reported that trust in their providers was extremely or very important when receiving genetic tests (77%) and over 60% felt receiving genetic test results was extremely important. Numeracy levels were moderate, with nearly half reporting some discomfort working with fractions and 38% finding numerical information only occasionally useful. The findings suggest that many patients lack familiarity with precision medicine concepts relevant for understanding cancer treatment decisions. Future efforts in digital technologies may be able to help bridge the gap in patient understanding and allow medically underserved populations to have equitable opportunities for precision medicine. Citation Format: Melinda C Aldrich, William J Blot. Assessing patient-level knowledge of precision medicine in a community health center setting [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D086.

Abstract C125: Identifying barriers to follow-up colonoscopy completion after an abnormal fecal test: Interviews with gastroenterology staff

Abstract Background Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. Fecal immunochemical tests (FITs) are an accepted way to identify patients at risk for CRC. However, patients who receive an abnormal FIT result must obtain a follow-up colonoscopy. Rates of follow-up colonoscopy are low in most healthcare settings, particularly in federally qualified health centers (FQHCs). FQHC patients who need a follow-up colonoscopy must undergo several steps, including obtaining a referral to a gastroenterology specialist (GIs), and preparing for and attending the procedure. Interventions such as patient navigation may improve follow-up colonoscopy adherence for FQHC patients, yet little is known about the system-level barriers to the colonoscopy process. Methods As part of the Predicting and Addressing Colonoscopy Non-adherence in Community Settings (PRECISE) study, we interviewed care coordinators and GIs who receive referrals from local FQHCs for follow-up colonoscopies from abnormal FIT tests. Our goal was to understand their referral processes and what they perceive to be the primary barriers for patients completing the follow-up colonoscopy. Two trained qualitative staff conducted the interviews by telephone, and content analyzed the data from interview notes and transcribed recordings. Results We interviewed 12 GI and care coordinator staff across 7 different GI practices. Six of the seven GI practices attempted to facilitate the follow-up colonoscopy by not making a pre-procedure visit mandatory but rather allowing completion by telephone, if the patient is healthy and of low risk. Most GI practices identified using the same type of bowel preparation with community referred patients as it is inexpensive, covered by most insurance plans, and considered safe. The greatest barrier to colonoscopy completion by referred community patients stated by all GI practices was not having transportation to and from the appointment or understanding the need for an escort to be present, particularly at the completion of the colonoscopy. Lack of understanding the bowel preparation process was also a very common barrier, including when to start the process, what foods to avoid, and the need to consume the entire preparation. Faxed referrals from FQHCs lacking proper documentation of the abnormal FIT or incomplete patient medical information for the referral was also cited as hindrances to timely follow-up colonoscopy completion. Most GI practices reported limited resources and time for helping patients address structural challenges pertaining to transportation, escorts, or a private place to complete the preparation. Conclusion Our findings identify key areas where patient navigated efforts are needed, and inform the educational and structural challenges facing FQHC patients when interfacing with GI specialists for a follow-up colonoscopy. These findings can further inform the design and implementation of patient navigation programs in the community health center setting. Citation Format: Jennifer S Rivelli, Jennifer L Schneider, Jamie H Thompson, Amanda F Petrik, DeeDee Torres, Gloria D Coronado. Identifying barriers to follow-up colonoscopy completion after an abnormal fecal test: Interviews with gastroenterology staff [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C125.

Organizational Factors Influencing the Early Implementation Process of Diabetes Group Visits by Five Midwestern Community Health Centers: A Multisite Case Study Analysis.

The objective was to identify facilitators and challenges of implementing diabetes group visits in 5 Midwestern community health center (CHC) settings that care for diverse patient populations. Interview data were collected from July to August 2015. An interview guide was developed to explore health center teams' initial experiences with diabetes group visit implementation. Interviews were conducted with 14 individuals who participated in a training prior to diabetes group visit implementation. Four levels of coding (open, in vivo, categorical, and thematic) were used to identify characteristics of group visit implementation in 5 CHCs. A semi-structured model encouraged interprofessional teamwork across all CHC teams. Self-appointed or chosen team champions were the "pulse" or central driving force of implementation. A designated time in the clinic for patients to receive education and psychosocial support enhanced engagement in diabetes self-management. Early buy-in from upper leadership was critical to securing fiscal and human resources as unexpected needs emerged during group visit implementation. Time commitment of clinic staff and providers for ongoing operations, socioeconomic challenges of patients, staff turnover, and billing were reported as challenges in the initial implementation process. This study acknowledges the influence of administrative and sociocultural factors on successful implementation of diabetes group visits. Future research should further explore how these factors influence successful adoption of diabetes group visits in health centers across the United States and the impact of group visit implementation on staff and patient outcomes.

Pregnancy Intention, Ambivalence, and Contraceptive use in Community Health Center (CHC) Populations

Abstract Introduction: Understanding the complexity of pregnancy intentions and resulting behaviors is essential to ensuring high quality, patient-centered reproductive health services that meet the needs of women and their partners. Community Health Centers (CHCs) play an important role in providing family planning care for traditionally underserved women, who may be at increased risk of experiencing unintended pregnancy. This study presents emerging findings on pregnancy intentions, ambivalence, and contraceptive behaviors among patients in CHC settings. Methods: This study employed a national survey (n=1,557) of women of reproductive age (18-44 years), sampled from 19 different CHC sites. The survey gathered information on patient characteristics, experiences with care, decision-making criteria and utilization of contraceptive services. Pregnancy intention was measured using the One Key Question®. Results: Approximately 12% of women reported that they wanted to become pregnant in the next year, while 88% were not actively seeking to become pregnant. Nearly 30% of those who did not desire a pregnancy reported not using contraception at the time of the survey. 1-in-4 women were pregnancy ambivalent and used contraception at approximately the same rates as women seeking to become pregnant. Conclusions: Women who express pregnancy ambivalence use contraception at similar rates to those who intend to become pregnant in the next year, potentially increasing their risk for unintended pregnancy. Understanding the characteristics and behaviors of underserved patients across different pregnancy intentions may help ensure that women receive the information, services, and support they need to achieve their reproductive health goals. Keywords: pregnancy intentions, family planning, community health centers, CHC, One Key Question®