Safety-net Primary Care Clinic Research Articles

319 Barriers to Colorectal Cancer Screening With FIT in a Safety-Net Primary Care Clinic

INTRODUCTION: Colorectal cancer (CRC) screening participation remains suboptimal, particularly among underserved populations. The Fecal Immunochemical Test (FIT) is the primary CRC screening test utilized in the primary care clinic at our large safety-net hospital. The clinic’s surveillance data shows that there is only a 20% FIT return rate within 4-6 weeks. To identify key barriers to FIT completion, we adopted a community-based participatory research (CBPR) approach to identify challenges to FIT completion in this safety net setting. METHODS: The CBPR approach included forming relationships with pertinent stakeholders including patients, resident physicians, nursing leadership, clinic directors and staff, and laboratory personnel. An eight-item survey assessing patient awareness of CRC screening and barriers to FIT completion was administered to randomly selected patients between the ages of 50-75 in the primary care clinic. A process map for FIT collection was subsequently devised after conducting interviews with the aforementioned stakeholders. RESULTS: The study population (n = 126) was comprised of a diverse population: 73% Hispanic (n = 93), 9% Black (n = 11), 9% White (n = 11), and 9% other races/ethnicities (n = 11). Among the cohort, 60.3% (n = 76) were up-to-date with FIT screening. 57% (n = 72) preferred Spanish when speaking to a healthcare provider. 22% (n = 27) reported not knowing the purpose of a FIT while 33% (n = 42) reported that their provider had not spoken to them about a FIT. We did not find a statistically significant difference among patients who completed and did not complete their FIT when analyzing for language barriers, lack of awareness, lack of provider communication, and understanding of instructions. When asked how the FIT could be made easier, 22% (n = 23) preferred to complete the FIT on the same day as their appointment. A discrepancy was found between the clinic-reported and patient-reported one-year FIT completion rates (60.3% vs. 76.7%, respectively). We found that the discordance was due to mislabeled/expired FITs which were discarded by the lab without notifying providers. CONCLUSION: By using CBPR grounded methods, the study identified potential areas of improvement to increase the FIT return rate, including proper handling of FITs and implementing a same-day FIT return policy. Interventions informed by this study are currently underway to increase same-day and same-week FIT return.

Improving hepatitis C screening and diagnosis in patients born between 1945 and 1965 in a safety-net primary care clinic

Individuals born between 1945–1965 represent 81% of all persons chronically infected with hepatitis C virus (HCV) in the USA and are largely unaware of their positive status. The baseline HCV...

Interventions to Improve Blood Pressure Control Among Socioeconomically Disadvantaged Patients With CKD: Kidney Awareness Registry and Education Pilot Randomized Controlled Trial

Sustainable interventions that enhance chronic kidney disease (CKD) management are not often studied in safety-net primary care, in which populations bear a disproportionate burden of disease and experience translational gaps between research and practice. We tested the feasibility of implementing and the impact of 2 technology-enhanced interventions designed to enhance CKD care delivery. A 2×2 randomized controlled pilot trial. Primary care provider teams (n= 6) and 137 patients with CKD aged 18 to 75 years from 2 safety-net primary care clinics, 2013 to2015. Primary care provider teams were randomly assigned to access a CKD registry with point-of-care notifications and quarterly feedback or a usual-care registry for 12 months. Patients within provider teams were randomly assigned to participate in a CKD self-management support program or usual care for 12 months. We examined recruitment, randomization, and participation in each intervention. We also examined the impact of each intervention and their combination on change in systolic blood pressure (SBP), albuminuria, and patient self-reported behavioral measures after 12 months. Among potentially eligible patients identified using the electronic health record, 24% were eligible for study participation, of whom 35% (n= 137) were enrolled. Mean age was 55 years, 41% were non-English speaking, and 93% were of racial/ethnic minority. Mean baseline estimated glomerular filtration rate was 70.5 (SD= 30.3) mL/min/1.73m2; mean baseline SBP was 131 (SD= 21.8) mm Hg. Nearly 90% of clinicians reported that the CKD registry influenced their CKD management. More than 95% of patients randomly assigned to CKD self-management support engaged regularly with the intervention. Estimated changes in SBP over 1 year were nonstatistically different in each of the 3 intervention groups compared with usual care: (usual care: 0.5 [95% CI,-5.2 to 6.3] mm Hg; CKD registry only:-5.4 [95% CI,-12.2 to 1.4] mm Hg; CKD self-management support only:-6.4 [95% CI,-13.7 to 1.0] mm Hg; and CKD registry plus CKD self-management support:-0.5 [-5.5 to 4.5] mm Hg), though differences were larger among those with baseline SBPs > 140/90mm Hg. Decreases in albuminuria were similarly nonstatistically different in each of the intervention groups compared with usual care. No differences were observed in patient self-reported behaviors. Single health system. Patient and provider interventions to improve CKD care are feasible to implement in low-income settings with promising results among those with uncontrolled blood pressure. National Institute of Diabetes and Digestive and Kidney Diseases. ClinicalTrials.gov, number: NCT01530958.

A Toolbox Approach to Obesity Treatment in Urban Safety-Net Primary Care Clinics: a Pragmatic Clinical Trial.

There is a need for new strategies to improve the success of obesity treatment within the primary care setting. To determine if patients offered low out-of-pocket cost weight management tools achieved more weight loss compared to usual care. Twelve-month pragmatic clinical weight loss trial with a registry-based comparator group performed in primary care clinics of an urban safety-net hospital. From a large clinical registry, we randomly selected 428 patients to have the opportunity to receive the intervention. Medical weight management tools-partial meal replacements, recreation center vouchers, pharmacotherapy, commercial weight loss program vouchers, and a group behavioral weight loss program-for $5 or $10 monthly. Patients chose their tools, could switch tools, and could add a second tool at 6months. The primary outcome was the proportion of intervention-eligible patients who achieved ≥ 5% weight loss. The main secondary outcome was the proportion of on-treatment patients who achieved ≥ 5% weight loss. Overall, 71.3% (305 of 428) had available weight measurement data/PCP visit data to observe the primary outcome. At 12months, 23.3% (71 of 305) of intervention-eligible participants and 15.7% (415 of 2640) of registry-based comparators had achieved 5% weight loss (p < 0.001). Of the on-treatment participants, 34.5% (39 of 113) achieved 5% weight loss. Mean percentage weight loss was - 3.15% ± 6.41% for on-treatment participants and - 0.30% ± 6.10% for comparators (p < 0.001). The initially preferred tools were meal replacements, pharmacotherapy, and recreation center passes. Access to a variety of low out-of-pocket cost weight management tools within primary care resulted in ≥ 5% body weight loss in approximately one quarter of low-income patients with obesity. https://clinicaltrials.gov/ct2/show/NCT01922934.

Addressing Diabetes in Primary Care: Hybrid Effectiveness-Implementation Study of Lifestyle Redesign® Occupational Therapy.

Primary health care is rapidly developing as an occupational therapy practice area. Yet, to date, little evidence supports occupational therapy's feasibility and efficacy in primary care settings. To report on the implementation and preliminary clinical outcomes of a Lifestyle Redesign® (LR)-occupational therapy (LR-OT) diabetes management intervention in a primary care clinic. Patients were randomized to be offered LR-OT or to a no-contact comparison group (data not reported). We assessed implementation outcomes using mixed methods. Safety-net primary care clinic. Clinic providers and staff; English- or Spanish-speaking clinic patients ages 18-75 yr with diabetes and a current hemoglobin A1c (HbA1c) ≥ 9.0%. Eight 1-hr individual sessions of LR-OT focused on diabetes management. Clinical and health behavior outcomes were assessed via electronic medical record (EMR) review and self-report surveys of patients receiving LR-OT at initial evaluation and discharge. We assessed implementation outcomes (acceptability, appropriateness, feasibility, fidelity, efficiency, and timeliness) using patient and staff surveys, interviews, focus groups, and observations. Seventy-three patients were offered LR-OT: 51 completed one or more sessions, and 38 completed the program. Clinical outcomes among program completers indicate beneficial changes in HbA1c, diabetes self-care, and health status. Implementation challenges included a need for patient and staff education, securing adequate workspace, and establishing a referral process. Factors contributing to implementation success included strong buy-in from clinic leadership, colocation, and shared EMR documentation. LR-OT is a feasible approach to enhancing service delivery and clinical outcomes in primary care. This study provides insight into factors that may create challenges or contribute to the success of implementing occupational therapy services within primary health care settings. In addition, this study provides preliminary evidence of occupational therapy's effectiveness in improving clinical outcomes among ethnically diverse, low-income patients with diabetes in a safety-net primary care setting.

Effectiveness and Cost of Organized Outreach for Colorectal Cancer Screening: A Randomized, Controlled Trial

Colorectal cancer (CRC) screening remains underused, especially in safety-net systems. The objective of this study was to determine the effectiveness, costs, and cost-effectiveness of organized outreach using fecal immunochemical tests (FITs) compared with usual care. Patients age 50-75 years eligible for CRC screening from eight participating primary care safety-net clinics were randomlyassigned to outreach intervention with usual care vs usual care alone. The intervention included a mailed postcard and call, followed by a mailed FIT kit, and a reminder phone call if the FIT kit was not returned. The primary outcome was screening participation at 1 year and a microcosting analysis of the outreach activities with embedded long-term cost-effectiveness of outreach. All statistical tests were two-sided. A total of 5386 patients were randomly assigned to the intervention group and 5434 to usual care. FIT screening was statistically significantly higher in the intervention group than in the control group (57.9% vs 37.4%, P < .001; difference = 20.5%, 95% confidence interval = 18.6% to 22.4%). In the intervention group, FIT completion rate was higher in patients who had previously completed a FIT vs those who had not (71.9% vs 35.7%, P < .001). There was evidence of effect modification of the intervention by language, and clinic. Outreach cost approximately $23 per patient and $112 per additional patient screened. Projecting long-term outcomes, outreach was estimated to cost $9200 per quality-adjusted life-year gained vs usual care. Population-based management with organized FIT outreach statistically significantly increased CRC screening and was cost-effective in a safety-net system. The sustainability of the program and any impact of economies of scale remain to be determined.

Design, Implementation, and Evaluation of an Integrative Pain Management Program in a Primary Care Safety-Net Clinic.

To design, implement, and evaluate a comprehensive Integrative Pain Management Program (IPMP) for patients with chronic pain in a safety-net primary care clinic. We used a quality improvement "Plan Do Study Act" (PDSA) framework to design, refine, and evaluate an integrative chronic pain program. An urban federally qualified health center located in a community with high rates of chronic pain, substance use, and opioid overdose. Eligible participants included individuals with pain for greater than 3 months who were prescribed opioid therapy. We designed IPMP using a PDSA framework that promotes continuous evaluation and adaptation of the program to meet the needs of the clinical system. We assessed feasibility and acceptability with program referrals and attendance and evaluated program satisfaction. The IPMP delivered a 12-week group-based intervention that involved group support, education on pain etiology and treatments, movement-based interventions, mindfulness-based therapies, acupuncture, and massage therapy. One hundred forty-six patients were referred to IPMP; 58 individuals participated in one of the first three cohorts of the program. Sixty-two percent of participants attended at least half of the sessions. Staff and participants reported high levels of satisfaction with IPMP and demand for longitudinal services. An IPMP delivered within a safety-net primary care clinic could be implemented in a way feasible and acceptable to staff and participants with the support of the local health care system. The application of a PDSA cycle allowed for rigorous implementation and evaluation of a multimodal pain program. Quality improvement frameworks are a strategy to improve and expand the delivery of high-quality patient-centered integrative pain treatments.

Patient-Reported Outcomes of an Integrative Pain Management Program Implemented in a Primary Care Safety Net Clinic: a Quasi-experimental Study.

Patient-Reported Outcomes of an Integrative Pain Management Program Implemented in a Primary Care Safety Net Clinic: a Quasi-experimental Study.

Electronic medical record documentation of tobacco cessation support at eight community safety-net clinics with a high prevalence of tobacco use.

The high prevalence of tobacco use at primary care safety-net clinics represents an opportunity to offer assistance with cessation. Documentation of smoking status, offering advice and medications, and referral to cessation services are important steps in supporting cessation attempts and are required elements by payors and accrediting agencies to demonstrate care quality. This study examines tobacco cessation support rates and patient characteristics using electronic medical record (EMR) data. This cross-sectional study engaged eight community health centers affiliated with a county hospital system in NE Ohio where adult tobacco use rates exceed 30%. EMR data from June 2014 through May 2016 were analysed to assess rates of tobacco cessation counselling, order of cessation medications, or both. The association of tobacco cessation support with patient characteristics and quit attempts was assessed using multivariable logistic regression models. Among 21702 current tobacco users, 74% had no intervention documented; 15.4% had counselling documented, 6.4% were prescribed tobacco cessation medication, and 4.2% had both documented. Males, those aged 18 to 34, and African Americans were more likely to have no documented intervention. Of current tobacco users with at least two visits, 5.6% had a quit attempt. Medication alone was associated with a greater likelihood of a quit attempt (AOR: 1.72 [95% CI: 1.36-2.17]) as well as counselling and medication combined (AOR: 1.95 [95% CI: 1.48-2.56]). Tobacco cessation support was lacking for 74% of current smokers and was less likely in subgroups including males, younger adults, and African Americans. Ordering tobacco cessation medication combined with counselling nearly doubled the likelihood of a quit attempt.

Primary care clinicians\u2019 perspectives about quality measurements in safety-net clinics and non-safety-net clinics

BackgroundQuality metrics, pay for performance (P4P), and value-based payments are prominent aspects of the current and future American healthcare system. However, linking clinic payment to clinic quality measures may financially disadvantage safety-net clinics and their patient population because safety-net clinics often have worse quality metric scores than non-safety net clinics. The Minnesota Safety Net Coalition’s Quality Measurement Enhancement Project sought to collect data from primary care providers’ (PCPs) experiences, which could assist Minnesota policymakers and state agencies as they create a new P4P system. Our research study aims are to identify PCPs’ perspectives about 1) quality metrics at safety net clinics and non-safety net clinics, 2) how clinic quality measures affect patients and patient care, and 3) how payment for quality measures may influence healthcare.MethodsQualitative interviews with 14 PCPs (4 individual interviews and 3 focus groups) who had worked at both safety net and non-safety net primary care clinics in Minneapolis-St Paul Minnesota USA metropolitan area. Qualitative analyses identified major themes.ResultsThree themes with sub-themes emerged. Theme #1: Minnesota’s current clinic quality scores are influenced more by patients and clinic systems than by clinicians. Theme #2: Collecting data for a set of specific quality measures is not the same as measuring quality healthcare. Subtheme #2.1: Current quality measures are not aligned with how patients and clinicians define quality healthcare. Theme #3: Current quality measures are a product of and embedded in social and structural inequities in the American health care system. Subtheme #3.1: The current inequitable healthcare system should not be reinforced with financial payments. Subtheme #3.2: Health equity requires new metrics and a new healthcare system. Overall, PCPs felt that the current inequitable quality metrics should be replaced by different metrics along with major changes to the healthcare system that could produce greater health equity.ConclusionAligning payment with the current quality metrics could perpetuate and exacerbate social inequities and health disparities. Policymakers should consider PCPs’ perspectives and create a quality-payment framework that does not disadvantage patients who are affected by social and structural inequities as well as the clinics and providers who serve them.

Characteristics of Patients in the Specialty Access for Uninsured Program

Background: The Specialty Access for Uninsured Program (SAUP) is a Milwaukee County health system collaborative in which safety-net primary care clinics are paired with hospital/health systems. The clinics provide primary care services, while the hospitals provide a network of specialists. All specialty services are “covered” under SAUP at no cost.

Implementation of evidence-based practices for complex mood disorders in primary care safety net clinics.

Use quality improvement methods to implement evidence-based practices for bipolar depression and treatment-resistant depression in 6 Federally Qualified Health Centers. Following qualitative needs assessments, implementation teams comprised of front-line providers, patients, and content experts identified, adapted, and adopted evidence-based practices. With external facilitation, onsite clinical champions led the deployment of the evidence-based practices. Evaluation data were collected from 104 patients with probable bipolar disorder or treatment-resistant depression via chart review and an interactive voice response telephone system. Five practices were implemented: (a) screening for bipolar disorder, (b) telepsychiatric consultation, (c) prescribing guidelines, (d) online cognitive-behavioral therapy, and (e) online peer support. Implementation outcomes were as follows: (a) 15% of eligible patients were screened for bipolar disorder (interclinic range = 3%-70%), (b) few engaged in online psychotherapy or peer support, (c) 38% received telepsychiatric consultation (interclinic range = 0%-83%), and (d) 64% of patients with a consult were prescribed the recommended medication. Clinical outcomes were as follows: Of those screening at high risk or very high risk, 67% and 69%, respectively, were diagnosed with bipolar disorder. A third (32%) of patients were prescribed a new mood stabilizer, and 28% were prescribed a new antidepressant. Clinical response (50% reduction in depression symptoms), was observed in 21% of patients at 3-month follow-up. Quality improvement processes resulted in the implementation and evaluation of 5 detection and treatment processes. Though varying by site, screening improved detection and a substantial number of patients received consultations and medication adjustments; however, symptom improvement was modest. (PsycINFO Database Record

Abstract 3010: Biobanking and genomic research: Understanding and acceptance of safety-net patients, primary care providers and minority groups

Abstract Background: Disparities exists in recruitment in clinical trials and biorepositories among minority groups, rural residents and individuals with low SES.Objective. Identify barriers and facilitators to awareness, understanding and acceptance of clinical trials and biobanking among safety-net patients and providers and support group participants and African American (AA) social and church groups. Methods: We conducted 14 focus groups and 7 individual interviews January - May 2017 in urban and rural communities in Louisiana. Sites included safety-net oncology and primary care clinics, social service agencies, social and faith based groups. Themes were identified. Results: 103 individuals participated: 78 clinic patient and community participants, 25 providers; 24% participants lived in rural areas. Patients and community members ranged in age from 45-88; 85% were female, 78% AA. Participants had an increasing awareness of clinical trials and personalized medicine due to ads on TV. Low income and minority patients were open to participating in genomic trials and biobanking even if it would not benefit them directly. Cancer patients and Alzheimer family caregivers were highly interested in clinical trials that might benefit them or their family. Community participants were less trusting of clinical trials than patients. All said information and recommendations about clinical trials would be most effective and actionable if it comes from a trusted physician. Terms such as clinical trials and biobanking were scary to some and not understood - medical studies and a bank to store blood and tissue were clearer. African American participants indicated that a recruitment message needs to be “ALL people are needed for studies to improve treatments” rather than “AA have been underrepresented and most treatments based on whites” which raises suspicion. Some participants were concerned with who would see data and if it would be a barrier to jobs or insurance - despite being told of protections in place for confidentiality. Rural and urban providers (n=25) were interested in being more involved in clinical trials. They lacked time to identify trials and explain them to patients. They wanted brief, plain language handouts with talking points and a card to give patients to call for more information. Transportation to academic centers is a barrier to patient participation in clinical trials. Very few patients, caregivers or providers had looked for clinical trials on the internet or social media. Conclusions: African American and white adults were interested in clinical trials but not clear how to learn about them. Most were willing to participate but had never been asked. Recommendation to participate in a clinical trial is most effective coming from a trusted physician. Methods for getting community providers and the public useful information needs to be created with target audiences. Citation Format: Terry Davis, Connie Arnold, Lucio Miele, Glenn Mills. Biobanking and genomic research: Understanding and acceptance of safety-net patients, primary care providers and minority groups [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3010.

Social Determinant of Health Screening in a Safety Net Pediatric Primary Care Clinic

Social Determinant of Health Screening in a Safety Net Pediatric Primary Care Clinic

Psychiatric Case Review and Treatment Intensification in Collaborative Care Management for Depression in Primary Care.

This study examined whether psychiatric case review was associated with depression medication modification in a large implementation program of collaborative care for depression in safety-net primary care clinics. Registry data were examined from an implementation of the collaborative care model in Washington State. A total of 14,960 adults from 178 primary care clinics who initiated care between January 1, 2008, and September 30, 2014, and who had a baseline Patient Health Questionnaire-9 (PHQ-9) score of 10 or higher were included. Rates of psychiatric case reviews and receipt of new depression medications were extracted from the registry for all patients and for a subset of patients who did not improve by eight weeks of treatment (did not achieve a PHQ-9 score of less than 10 or a reduction in PHQ-9 score of 50% or more, compared with baseline). One-half of patients received a new depression medication. Psychiatric case review in any given month was associated with a doubling of the probability of receiving a new medication in the following month. Among patients who did not improve by eight weeks of treatment, a psychiatric case review during weeks 8-12 was associated with a higher rate of receipt of new medications during weeks 8-16 or weeks 8-20. In a collaborative care program, psychiatric case review was associated with higher rates of subsequent receipt of a new depression medication. This finding supports the importance of psychiatric case review in reducing clinical inertia in collaborative care treatment of depression.

Introducing Primary Care Telephone Visits: An Urban Safety-Net Community Clinic Experience.

Background: Telephone consultation is widely used in primary care and can provide an effective and efficient alternative for the in-person visit. Gouverneur Health, a safety-net primary care practice in New York City serving a predominately immigrant population, evaluated the feasibility and physician and patient acceptability of a telephone visit initiative in 2015. Measures: Patient and physician surveys, and physician focus groups. Results: Though only 85 of 270 scheduled telephone visits (31%) were completed, 84% of patients reported being highly satisfied with their telephone visit. Half of physicians opted to participate in the pilot. Among participating physicians, all reported they were able to communicate adequately and safely care for patients over the telephone. Conclusions: Participating patients and physicians in a linguistically and culturally diverse urban safety-net primary care clinic were highly satisfied with the use of telephone visits, though completion of the visits was low. Lessons learned from this implementation can be used to expand access and provision of high-quality primary care to other vulnerable populations.

Perspectives of low-income chronically ill patients on complex care management.

Low-income, chronically ill adults disproportionately experience poor health outcomes despite increased health care use and costs. Complex care management (CCM) programs are an innovative approach to improving outcomes for these patients, but little is known about the patients' experiences in CCM programs in safety net primary care settings. The authors conducted semistructured interviews with 13 CCM participants in a safety net primary care clinic to explore their perceptions of their health and their experiences with CCM. Interviews were recorded, transcribed, independently coded, and analyzed through an iterative process using grounded theory methodology to identify themes in the participants' experiences. From our interviews, 3 themes emerged-(a) participants mourned the loss of physical function and social well-being as a result of poor health; (b) participants reported increased health-related motivation due to relationships with the care team; and (c) participants experienced a newfound sense of control as a result of improved care navigation and self-management. Complex care management improved health-related motivation and provided a renewed sense of control for study participants, who were experiencing the loss of physical function and social well-being due to their chronic diseases. These findings support the importance of relationship-centered care models in programs for low-income, chronically ill patients. Future research should focus on identifying and spreading best practices that effectively empower patients to feel more in control of their health. (PsycINFO Database Record

Improving OSA screening and diagnosis in patients with hypertension in an academic safety net primary care clinic: quality improvement project.

Obstructive sleep apnoea (OSA) is more prevalent in patients with hypertension (HTN), and associated morbidities include stroke, heart failure and premature death. In the Internal Medicine Clinic (IMC), over 70% of the patients had a diagnosis of HTN and obesity. We identified a lack of OSA screening in patients with HTN. The aim of this quality improvement (QI) was to increase OSA diagnosis to 5% from the baseline rate of less than 1% in patients with HTN between the ages of 18 and 75 years over 6 months at IMC. We used the Plan-Do-Study-Act (PDSA) method. The QI team performed root cause analysis to identify materials/methods, provider and patient-related barriers. PDSA cycle included: (1) integration of customised workflow of loud Snoring, Tiredness, Observed apnea, high blood Pressure (STOP)-Body mass index (BMI), Age, Neck circumference, and Gender (BANG) OSA screening tool in the electronic health record (EHR); (2) physician education of OSA and EHR workflow; and (3) completion of STOP survey by patients, which was facilitated by nursing staff. The outcome measure was the percentage of OSA diagnosis in patients with HTN. The process measures included the percentage of patients with HTN screened for OSA and the increase in sleep study referrals in hypertensive patients with STOP-BANG score of ≥3. Increase in patient wait time and cost of sleep study were the balance measures. Data analysis was performed using weekly statistical process control chart. The average increase in OSA screening rate using the STOP-BANG tool was 3.88%. The significant variation seen in relation to PDSA cycles was not sustainable. 32% of patients scored ≥3 on the STOP-BANG tool, and 10.4% had a confirmed diagnosis of OSA. STOP-BANG tool integration in the EHR and a team approach did not result in a sustainable increase in OSA screening. OSA diagnosis was increased to 3.3% in IMC patient population within the 6-month period. The team identified multiple barriers to screening and diagnosis of OSA in the IMC.

A geographic information system-based method for estimating cancer rates in non-censusdefined geographical areas.

To address locally relevant cancer-related health issues, health departments frequently need data beyond that contained in standard census area-based statistics. We describe a geographic information system-based method for calculating age-standardized cancer incidence rates in non-censusdefined geographical areas using publically available data. Aggregated records of cancer cases diagnosed from 2009 through 2013 in each of Chicago's 77 census-defined community areas were obtained from the Illinois State Cancer Registry. Areal interpolation through dasymetric mapping of census blocks was used to redistribute populations and case counts from community areas to Chicago's 50 politically defined aldermanic wards, and ward-level age-standardized 5-year cumulative incidence rates were calculated. Potential errors in redistributing populations between geographies were limited to <1.5% of the total population, and agreement between our ward population estimates and those from a frequently cited reference set of estimates was high (Pearson correlation r=0.99, mean difference=-4 persons). A map overlay of safety-net primary care clinic locations and ward-level incidence rates for advanced-staged cancers revealed potential pathways for prevention. Areal interpolation through dasymetric mapping can estimate cancer rates in non-census defined geographies. This can address gaps in local cancer-related health data, inform health resource advocacy, and guide community-centered cancer prevention and control.

Food security is related to adult type 2 diabetes control over time in a United States safety net primary care clinic population

Background/Objectives:Successful Type 2 diabetes management requires adopting a high nutrient-density diet made up of food items that both meet dietary needs and preferences and can be feasibly obtained on a regular basis. However, access to affordable, nutrient-dense foods often is lacking in poorer neighbourhoods. Therefore, low food security should directly impair glucose control, even when patients have full access to and utilize comprehensive medical management. The present study sought to determine whether food security is related longitudinally to glucose control, over-and-above ongoing medication management, among Type 2 diabetes patients receiving comprehensive care at a Midwestern multi-site federally qualified health centre (FQHC).Subjects/Methods:In this longitudinal observational study, we completed a baseline assessment of patients’ food security (using the US Household Food Security Module), demographics (via Census items), and diabetes history/management (using a structured clinical encounter form) when patients began receiving diabetes care at the health centre. We then recorded those patients’ A1C levels several times during a 24-month follow-up period. Three hundred and ninety-nine patients (56% with low food security) had a baseline A1c measurement; a subsample of 336 (median age=52 years; 56% female; 60% Hispanic, 27% African American, and 9% White) also had at least one follow-up A1c measurement.Results:Patients with lower (vs higher) food security were more likely to be on insulin and have higher A1c levels at baseline. Moreover, the disparity in glucose control by food security status persisted throughout the next 2 years.Conclusions:Although results were based on one multi-site FQHC, potentially limiting their generalizability, they seem to suggest that among Type 2 diabetes patients, low food security directly impairs glucose control—even when patients receive full access to comprehensive medical management—thereby increasing their long-term risks of high morbidity, early mortality, and high health-care utilization and cost.