Ohio ranks among the highest US states for cardiovascular disease (CVD) morbidity and mortality. Although interventions exist for managing CVD risk factors, adoption in primary care is often limited. The Agency for Healthcare Research and Quality funded four states to develop scalable, statewide models for implementing evidence-based practices to address these gaps. To evaluate the effectiveness of the Heart Healthy Ohio Initiative (HHOI), a statewide quality improvement (QI) initiative focused primarily on improving blood pressure (BP) control Pre-post, repeated cross-sectional QI study using electronic health record (EHR) data to compare patient outcomes 6 months pre- and post-intervention A total of 293,638 adult patients (aged ≥ 18 years) from 48 primary care clinics across 21 counties, of whom 107,216 (37 The primary outcome was BP control, defined as < 140/90 mmHg. Process measures included repeat BP measurement, timely follow-up, and medication intensification. Regression analyses evaluated the impact of process measures on BP control improvement. Secondary measures on smoking cessation included screening, quit advice, resource referrals, and medications prescribed. BP control improved from 67.7

Background and Objectives Adults in low-resource neighborhoods face greater burden of preventable diseases than the general population. Methodologies to measure the impact of population-level efforts to reduce neighborhood-level disparities in health outcomes are lacking. We introduce a simulation modeling approach for incident disease and mortality risk over the life course and apply the model to assess the impact of a hypothetical population health initiative to reduce neighborhood-level disparities.Research Design and Methods Using electronic health records, we constructed a probabilistic dynamic systems model that simulated the life course of each patient in a large primary care population, taking into account specific relationships by sex and Area Deprivation Index (ADI) quintile. The model predicted long-term incidence of 10 chronic conditions and all-cause mortality.Results The model was reliable, with strong discrimination (C-statistic for 10-year mortality: 0.871) and calibration. Predicted median life expectancy was nearly a decade lower for patients ages 40-45 who resided in the highest (ADI quintile 5) vs the lowest (quintile 1) deprivation neighborhoods (difference [95% CI]; women, 8.6 [8.2, 9.0] years; men, 10.0 [9.6, 10.3]. A hypothetical initiative to reduce the number of smokers by 10% had minimal effect on disparities in life expectancy when implemented in the general patient population (women, -0.4 years; men, -0.2), but meaningfully narrowed disparities when focused on high-deprivation neighborhoods (women, -0.8 years; men, -0.6).Discussion and Implications In a broad patient population, it was feasible to measure socioeconomic disparities in health outcomes and life expectancy and evaluate interventions to improve health equity.

Introduction:Growing research on adult development recognises socioeconomically adverse neighbourhood environments as sources of stress affecting immunohaematologic function (IHF), with implications for disease. However, little is known about IHF markers in youth across diverse neighbourhoods. One marker of IHF, red blood cell distribution width (RDW), has demonstrated prognostic value for multiple diseases across the life course. Methods:This retrospective cohort study analysed data from 771 well-child youth ages 5-21 without, and 5,385 sick-child youth with, observable pre-existing immune vulnerability seeking care at a metropolitan healthcare system in the Midwest United States. We employed linear mixed-effects models to examine RDW variation by quintile of neighbourhood socioeconomic position (SEP). Results:Among well-child youth, the effect of lower neighbourhood SEP diminished (fourth quintile β=0.28, 95 per cent CI [-0.04, 0.60], fifth quintile β=0.16, 95 per cent CI [-0.16, 0.48]) after accounting for youths' racial identity and adjusting for covariates. Among sick-child youth, the effect of lower neighbourhood SEP remained after covariate adjustment (fourth quintile β=0.24, 95 per cent CI [0.08, 0.39], fifth quintile β=0.31, 95 per cent CI [0.16, 0.46]). Across both cohorts, Black racial identity was associated with elevated RDW (well-child cohort β=0.51, 95 per cent CI [0.30, 0.72]; sick-child cohort β=0.65, 95 per cent CI [0.55, 0.74]) after adjusting for neighbourhood SEP, age and biological sex. Conclusion:Utilising a widely available and low-cost blood test, cellular consequences - as indexed by RDW - of early-life social-environmental adversity may be observable during childhood itself. The vulnerability of youth racialised as Black likely reflects socially produced health inequalities, and study findings evidence a cellular dimension of how structural factors may impact health from a young age.

A collaboration between land trust and health care system organizations in Cleveland, Ohio seeks to enhance community health in historically disinvested neighborhoods by transforming vacant properties into vibrant green spaces. Greening interventions focus on four predominantly Black communities, aiming to bolster cardiovascular wellness and physical activity over time through environmental improvement.

BACKGROUND AND OBJECTIVES:Traumatic brain injury (TBI) is a leading cause of disability in the United States. Limited research exists on the influence of area-level socioeconomic status and outcomes after TBI. This study investigated the correlation between the Area Deprivation Index (ADI) and (1) 90-day hospital readmission rates, (2) facility discharge, and (3) prolonged (≥5 days) hospital length of stay (LOS). METHODS:Single-center retrospective review of adult (18 years or older) patients who were admitted for TBI during 2018 was performed. Patients were excluded if they were admitted for management of a chronic or subacute hematoma. We extracted relevant clinical and demographic data including sex, comorbidities, age, body mass index, smoking status, TBI mechanism, and national ADI. We categorized national ADI rankings into quartiles for analysis. Univariate, multivariate, and area under the receiver operating characteristic curve (AUROC) analyses were performed to assess the relationship between ADI and 90-day readmission, hospital LOS, and discharge disposition. RESULTS:A total of 523 patients were included in final analysis. Patients from neighborhoods in the fourth ADI quartile were more likely to be Black ( P = .007), have a body mass index ≥30 kg/m 2 ( P = .03), have a Charlson Comorbidity Index ≥5 ( P = .004), and have sustained a penetrating TBI ( P = .01). After controlling for confounders in multivariate analyses, being from a neighborhood in the fourth ADI quartile was independently predictive of 90-day hospital readmission (odds ratio [OR]: 1.35 [1.12-1.91], P = .011) (model AUROC: 0.82), discharge to a facility (OR: 1.46 [1.09-1.78], P = .03) (model AUROC: 0.79), and prolonged hospital LOS (OR: 1.95 [1.29-2.43], P = .015) (model AUROC: 0.85). CONCLUSION:After adjusting for confounders, including comorbidities, TBI mechanism/severity, and age, higher ADI was independently predictive of longer hospital LOS, increased risk of 90-day readmission, and nonhome discharge. These results may help establish targeted interventions to identify at-risk patients after TBI.

OBJECTIVE Evaluation of the Ohio Diabetes Quality Improvement Project (QIP) equity aim to reduce the percentage of Non-Hispanic Black (NHB) and Hispanic patients with an A1c >9% by 20% over 2 years. RESEARCH DESIGN AND METHODS Ohio’s Department of Medicaid, Government Resource Center, Medicaid Managed Care Plans and 7 medical schools formed a Diabetes Quality Improvement Project (QIP) collaborative using the collective impact model to improve diabetes outcomes and equity in 20 practices across 11 health systems. The QI strategies included data audit and feedback, peer-to-peer learning, QI coaching/practice facilitation, and subject matter expert consultation through coaching calls, monthly webinars, and annual virtual learning sessions. Electronic health record data was collected for pre-intervention (2019-2020) and intervention (2020-2022) periods. Improvements in A1c were based on prevalence of A1c >9% from pre-intervention, Year 1 and Year 2 stratified by race and ethnicity. RESULTS The Diabetes QIP included 7,689 (54% female) sociodemographically diverse patients, self-identifying as non-Hispanic White (NHW) (42%), NHB (43%), Hispanic (8%), non-Hispanic Asian (4%) and other (3%). In year 2 compared to baseline, there were decreases in the proportion of patients with A1c >9% in NHW, NHB and Hispanic patients (NHW 19% to 12% [37% reduction]; NHB 23% to 18% [22% reduction]; and Hispanic 29% to 23% [20% reduction]). CONCLUSIONS The Ohio Diabetes QIP focused on multisector collaborative approaches reduced the percentage of patients with A1c > 9% by 20% in NHW, NHB and Hispanic populations. Given the persistence of disparities, further equity-focused refinements are warranted to address disparities in diabetes control.

RATIONALE:Continuous positive airway pressure (CPAP) improves excessive daytime sleepiness, but there is insufficient evidence that CPAP prevents long-term clinically important adverse outcomes such as cardiovascular events and cognitive functioning particularly among diverse populations. This lack of evidence is particularly concerning for African American patients who face disproportionate barriers to care. GOALS:To determine the perceptions of African American patients with OSA and their bed partners regarding participating in clinical trials evaluating the effects of CPAP on long-term outcomes. METHODS:We interviewed African American patients of an urban safety-net health care system with OSA who were prescribed CPAP and their bed partners. Recruitment continued until theoretical saturation was achieved. Transcripts were analyzed using the principles of thematic analysis. RESULTS:We interviewed 18 OSA patients and 18 bed partners. We identified six themes pertaining to patients' and bed partners' perspectives of the benefits and risks to participation in clinical trials about CPAP effectiveness, and characteristics of optimal trial design. Participants described learning the true efficacy of CPAP as essentially the only benefit of participation, while emphasizing the jeopardization of health and navigating mistrust and deception as costs of participation. Participants encouraged the integration of patient voices, the participation of diverse investigators, the involvement of bed partners, and the incorporation of patient education on CPAP adherence in designing optimal clinical trials. CONCLUSIONS:African American patients with OSA and their bed partners expressed several concerns regarding participation in clinical trials and offered suggestions for improving the design of clinical trials in this population.

Background Traumatic brain injury (TBI) is a multifaceted condition associated with occupational, social, physical, cognitive, academic, and economic burdens. Mild TBI including traumatic intracranial hemorrhage (tICH), is commonly discharged from the emergency department (ED). Despite the complexity of factors contributing to TBI outcomes, patient education and comprehensive follow-up plans are frequently lacking. We examined health trajectories, recidivism, and follow-up patterns of patients discharged from the ED with tICH to identify opportunities to improve care. Methods We conducted an IRB approved retrospective observational study at a large urban Level 1 trauma center from January 2017 to July 2022. We identified patients (n = 117) discharged from the ED with acute tICH, using IDC 9/10 codes and confirmed by imaging review. Exclusions were hospital admission, chronic ICH, and age under 18. The primary outcome was an ED-revisit within 180 days. Secondary outcomes included any return TBI visit, scheduled specialty TBI provider visit, and post-TBI mental health disorder diagnoses. Age, gender, race, ethnicity, pre-TBI mental health disorders, and socioeconomic status (SES) were analyzed. SES was measured using area deprivation index (ADI). Statistical analysis was performed with logistic regression and Chi-squared tests. Results The average age of enrolled patients was 53 ± 20 years with 39 % female, 26 % Black, 69 % White, and 6 % Hispanic. Overall follow-up rates were low, with 49 % of patients having at least one scheduled follow-up visit within 180 days. Only 16 % of Black patients saw a TBI specialty provider visit within 180 days compared to 36 % of White patients (p = .03). ED recidivism rate was 18 %, with 25 % of patients overall having an unscheduled TBI visit. Lower SES was a significant predictor of any TBI revisit (OR 1.39, CI 1.06, 1.82). New mental health diagnoses following tICH occurred in 15 % of patients; depression and anxiety were most common. There was no association between SES, age, gender, race, or ethnicity and new mental health diagnoses. Conclusion We observed racial and SES differences in follow-up care from the ED for patients with TBI. Individualized discharge planning and formulation of care pathways that account for the mental health and social needs of all patients may improve long-term outcomes. Further understanding of health disparities present in ED TBI care is needed.

Exposure to intimate partner violence (IPV) places children at risk for negative developmental outcomes. However, many IPV-exposed (eIPV) children exhibit resilience, which is promoted by protective factors including positive, caring relationships. Sibling relationships can buffer eIPV children from poor adjustment outcomes but have scarcely been studied. This study explored how eIPV children in middle childhood understood and made meaning of their sibling relationships. Six eIPV sibling dyads were recruited for individual interviews and participation in a video-recorded play session. A descriptive phenomenological analysis was conducted using both forms of data. Five main themes of eIPV sibling relationships emerged and were presented through textual and structural descriptions. Implications for practice and policy and areas for future research are discussed.

Cardiovascular disease (CVD) remains a major national health challenge with significant disparities linked to socioeconomic status, race, ethnicity, sex, and geography, prompting federal efforts to build statewide primary care quality improvement (QI) cooperatives to improve heart health. To be effective, cooperatives require high levels of member engagement and leaders need ways to assess engagement. The objective of this study was to develop and validate a novel Cooperative Member Survey to assess cooperative member engagement and assess the value of the cooperative to members across three statewide heart health QI cooperatives. The 14-item survey included fixed-response and open-ended questions and was developed through multiple iterative rounds across the three cooperatives to gain consensus on the wording of final items using a Delphi process. The survey then was administered to the key stakeholders in the three cooperatives. Findings from both the quantitative and qualitative items were analyzed and reported based on frequencies and emerging themes. The survey was then analyzed to determine factor structure and validity. Analysis revealed a two-factor structure which the research team identified as: (1) Cooperative Engagement, consisting of 11 items that measured how well the cooperative functioned overall, and (2) Cooperative Value, consisting of two items that assessed the perceived value of mutual learning and respect within the cooperative. This two-factor structure indicated that the Cooperative Member Survey successfully captured both the practical aspects of how the cooperative operates and the members' perceived benefits of their involvement. Successful QI cooperatives not only require efficient operations but also a sense of shared value among members. These findings suggest that cooperatives designed to improve public health outcomes may benefit from focusing not only on practical aspects of engagement but also on cultivating mutual respect and collective learning.

Healthcare systems and providers have increasingly acknowledged the role and impact of social determinants in overall health. However, gender-diverse individuals face persistent health disparities due to their identities. There is limited research on the impact of clinical and sociodemographic characteristics on mood and quality of life (QoL) for transgender (TG) individuals. Our study aims to understand and better elucidate social and clinical characteristics of transmasculine (TM) and transfeminine (TF) individuals and their impact on quality of life and depressive symptoms. In this cross-sectional study, 298 TF and TM individuals on gender-affirming hormone therapy (GAHT) were surveyed about their demographic characteristics (age, gender identity, body mass index (BMI), and education), social needs, mood, and quality of life. Multivariable regression modelling was performed to assess the effect of each variable listed above on three domains of QoL (psychological, environmental, and physical) as well as depressive symptoms. We find that QoL scores are similar between TM and TF individuals, with scores in the psychological domain particularly low in both cohorts. TM individuals report higher rates of stress and restroom avoidance than TF individuals. In particular, psychological well-being (measured by the psychological domain of QoL and depressive symptoms) is significantly associated with increased BMI, financial instability, and stress in TM individuals while for TF individuals, psychological well-being is associated with stress and social integration. These data suggest that social circumstances are key drivers of QoL and psychological well-being among gender-diverse individuals receiving GAHT with specific differences between TF and TM individuals. This information may be utilized by healthcare providers and policymakers to address and improve clinical care and social policies to improve health equity for gender-diverse individuals.

Importance Hypertension in middle-aged adults (35-50 years) is associated with poorer health outcomes in late life. Understanding how hypertension varies by race and ethnicity across levels of neighborhood disadvantage may allow for better characterization of persistent disparities. Objective To evaluate spatial patterns of hypertension diagnosis and treatment by neighborhood socioeconomic position and racial and ethnic composition. Design, Setting, and Participants In this cross-sectional study of middle-aged adults in Cuyahoga County, Ohio, who encountered primary care in 2019, geocoded electronic health record data were linked to the area deprivation index (ADI), a neighborhood disadvantage measure, at the US Census Block Group level (ie, neighborhood). Neighborhoods were stratified by ADI quintiles, with the highest quintile indicating the most disadvantage. Data were analyzed between August 7, 2023, and June 1, 2024. Exposure Essential hypertension. Main Outcomes and Measures The primary outcome was a clinician diagnosis of essential hypertension. Spatial analysis was used to characterize neighborhood-level patterns of hypertension prevalence and treatment. Interaction analysis was used to compare hypertension prevalence by racial and ethnic group within similar ADI quintiles. Results A total of 56 387 adults (median [IQR] age, 43.1 [39.1-46.9] years; 59.8% female) across 1157 neighborhoods, which comprised 3.4% Asian, 31.1% Black, 5.5% Hispanic, and 60.0% White patients, were analyzed. A gradient of hypertension prevalence across ADI quintiles was observed, with the highest vs lowest ADI quintile neighborhoods having a higher hypertension rate (50.7% vs 25.5%) and a lower treatment rate (61.3% vs 64.5%). Of the 315 neighborhoods with predominantly Black (>75%) patient populations, 200 (63%) had a hypertension rate greater than 35% combined with a treatment rate of less than 70%; only 31 of 263 neighborhoods (11.8%) comprising 5% or less Black patient populations met this same criterion. Compared with a spatial model without covariates, inclusion of ADI and percentage of Black patients accounted for 91% of variation in hypertension diagnosis prevalence among men and 98% among women. Men had a higher prevalence of hypertension than women across race and ADI quintiles, but the association of ADI and hypertension risk was stronger in women. Sex prevalence differences were smallest between Black men and women, particularly in the highest ADI quintile (1689 [60.0%] and 2592 [56.0%], respectively). Conclusions and Relevance These findings show an association between neighborhood deprivation and hypertension prevalence, with disparities observed particularly among Black patients, emphasizing a need for structural interventions to improve community health.

This retrospective cohort study examined prosocial skills development in child welfare-involved children, how intimate partner violence (IPV) exposure explained heterogeneity in children's trajectories of prosocial skill development, and the degree to which protective factors across children's ecologies promoted prosocial skill development. Data were from 1,678 children from the National Survey of Child and Adolescent Well-being I, collected between 1999 and 2007. Cohort-sequential growth mixture models were estimated to identify patterns of prosocial skill development between the ages of 3 to 10 years. Four diverse pathways were identified, including two groups that started high (high subtle-decreasing; high decreasing-to-increasing) and two groups that started low (low stable; low increasing-to-decreasing). Children with prior history of child welfare involvement, preschool-age IPV exposure, school-age IPV exposure, or family income below the federal poverty level had higher odds of being in the high decreasing-to-increasing group compared with the high subtle-decreasing group. Children with a mother with greater than high school education or higher maternal responsiveness had higher odds of being in the low increasing-to-decreasing group compared with the low stable group. The importance of maternal responsiveness in fostering prosocial skill development underlines the need for further assessment and intervention. Recommendations for clinical assessment and parenting programs are provided.

Abstract Recent discoveries have established conceptual and empirical linkages between the social characteristics of communities, biological and physiological variation and disease onset and outcomes. Cellular and molecular markers appear to be at least partially indicative of an accelerated aging process. We are approaching the widespread availability of “Super Ages”, highly accurate biosocial estimates of the aging of a human person. Super Ages have more predictive validity for disease and disability than chronological age. As compared with chronological age, Super Age estimates can be described as having an accelerated (hyper-aging) or decelerated (hypo-aging) character. We ask: What types of social changes– beneficial or detrimental– might be postulated based upon a shift toward incorporating biosocial measures of aging in age-graded policy and care delivery? We present case-based scenarios illustrative of the coming biosocial dilemma. Consider two matched neighborhoods each containing 400 adults with a chronological age between 40 and 50 years who have aged in place (Neighborhood A and Neighborhood B). All persons in Neighborhood A experience uniform social and environmental hazards while hazards are minimal in Neighborhood B. Molecular analyses find Neighborhood A adults experience hyper-aging of chronological age plus 4 to 7 years. Neighborhood B are as much as 3 to 5 years “younger” creating between community biosocial age gap of 9.5 years. Both neighborhoods experience equal access to health services. Guideline-based screening (i.e. breast, lung and colon cancer screening) is age-graded but Neighborhood A is more vulnerable. Super Age estimates are fraught with new policy and care delivery challenges.

Abstract Introduction The PHQ-9, a common screening tool for depression, asks about sleep and fatigue. An under-recognized concern is the overlap between sleep and fatigue depressive symptoms and sleep disturbances. We investigated whether elevated depression screening scores were due to sleep disorders rather than depression itself in older adults. Methods The study cohort included 2,257 adults (65+) with at least two outpatient primary care visits and at least one Medicare Annual Wellness Visit, who initially screened positive on the PHQ-2 (≥2) and completed the PHQ-9. A multiple indicator multiple cause (MIMIC) analysis was used to examine differential item functioning of the sleep and fatigue items of the PHQ-9, attributable to sleep disorders, based on diagnosis codes. Results The MIMIC analysis revealed a positive association between sleep disorders and depression (β = 0.19, p < 0.001), and a small positive effect on the “feeling tired” fatigue item of the PHQ-9 (β = 0.06, p < 0.001). No significant relationship was observed between sleep disorders and the PHQ-9 “sleep” item. The model exhibited a good fit, with RMSEA=0.040 (90% CI: 0.034-0.047), CFI=0.99, TLI=0.99, and SRMR=0.04. Discussion Sleep disorders and depressive symptoms are associated but no meaningful differential item functioning was detected in this sample of older adults. The PHQ-9 is an adequate screening tool for depression in older adults with sleep disorders.