Since 2020, US drug manufacturers have restricted the use of the 340B Drug Pricing Program, leading to unexpected increases in medication costs for individuals with type 2 diabetes engaged in care in community health centers. To explore experiences of individuals with diabetes regarding medication access in the era of 340B Drug Pricing Program restrictions. Qualitative study using direct content analysis grounded in Andersen’s Behavioral Model of Health Services Use. Uninsured and underinsured adults who speak English or Spanish and are receiving care for type 2 diabetes in a health center setting. Semi-structured interviews, transcribed and analyzed using the constant comparative method by a bilingual and multiprofessional coding team. We achieved thematic saturation after 25 interviews conducted July–August 2024. Individuals described multilayered barriers to medication access during a time of 340B Drug Pricing Program restrictions. Three themes emerged: (1) participants perceived they navigate medication access alone, (2) loved ones (family, peers) shaped participants’ approach to medications and lifestyle changes for diabetes treatment, and (3) language and culture of pharmacy staff are enablers of medication access. Findings build on the Andersen model by demonstrating how pharmacy policies and practice impact all four of the model’s domains. In the era of 340B Drug Pricing Program restrictions, individuals with diabetes perceive that navigation resources are needed to facilitate access to medications. Pharmacy programs that target family and community units may better resonate with individuals with diabetes than those that target individual patients. Cultural and structural competence among pharmacy staff are important drivers of individuals’ choice of pharmacy.

Real-time or synchronous telemedicine can be a valuable adjunctive strategy for chronic disease management, but few studies have assessed its impact on hypertension control among safety-net populations. To evaluate whether telemedicine is associated with blood pressure (BP) control. Retrospective cohort study. Mixed-effects logistic regression models clustered by the patient estimated associations between telemedicine and BP control after adjusting for patient factors and neighborhood context. Patients seeking care at an urban, multisite community health center with hypertension and ≥1 BP measurement between 2020 and 2022 (3663 patient-year observations across 2086 unique patients). The primary outcome was BP control defined as a binary variable. We used the Centers for Medicare Medicaid Services’ Controlling High Blood Pressure quality measure criteria of systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg in the most recent recording in the measurement year. Among the 2086 patients with hypertension in our sample, there were 1257 (60.3

Unhealthy alcohol use is a common, often unaddressed behavior associated with increased risk for acquisition of HIV and may also be associated with decreased adherence to oral pre-exposure prophylaxis (PrEP) among gay, bisexual, and other men who have sex with men (MSM) living in the United States. To inform future alcohol-reduction interventions among individuals engaging in PrEP care, we sought to explore perspectives on alcohol use, PrEP adherence, and the acceptability of alcohol use treatment options for MSM prescribed oral formulations of PrEP in the Northeastern United States. Between February 2019 and July 2020, we conducted semi-structured interviews with 15 MSM without HIV who were prescribed PrEP and screened positive for unhealthy alcohol use with AUDIT-C ≥ 4 and were receiving care in Providence, Rhode Island or New Haven, Connecticut. Interviews were coded and analyzed using thematic analysis. Three themes emerged: 1) Consequences of fluctuations in drinking 2) Alcohol use negatively impacts health and relationships; and 3) Desire for a multimodal approach to treatment of unhealthy alcohol use. Our findings support the need to raise awareness of potential alcohol-related harms, address the spectrum of unhealthy alcohol use among MSM prescribed PrEP, and the acceptability and preferences for alcohol reduction interventions within PrEP programs.

Importance:Stricter opioid prescribing guidelines have increased prescriptions of skeletal muscle relaxants (SMRs) for chronic pain, but the efficacy of long-term use of SMRs for chronic pain is unknown. Objective:To systematically review the effectiveness or efficacy of long-term use of SMRs for chronic pain. Evidence Review:Two reviewers systematically searched Ovid MEDLINE, Embase (Ovid), Web of Science, CINAHL, and Cochrane through December 4, 2023. They included articles published in English, Spanish, or Italian. Only randomized clinical trials (RCTs) and cohort studies with comparator groups evaluating at least 1-month duration of SMRs for chronic pain were included. The reviewers dually reviewed data abstraction, risk-of-bias, and quality. They characterized studies by chronic pain syndrome: low back pain, fibromyalgia, headaches, painful cramps or spasticity, and other syndromes. Findings:A total of 30 RCTs with 1314 participants and 14 cohort studies with 1168 participants assessed SMRs for chronic pain. Studies were primarily short-term (4-6 weeks). Nine unique SMRs were represented by the studies identified. Eleven studies (25%) examined baclofen, 8 (18%) examined tizanidine, and 7 (16%) examined cyclobenzaprine. Evidence for effectiveness was strongest for SMRs used for trigeminal neuralgia, neck pain, and painful cramps; evidence suggested SMRs for fibromyalgia, low back pain, and other syndromes were not more beneficial than placebo. The most common adverse effects were sedation and dry mouth. RCTs had a low to moderate risk of bias, and the quality of cohort studies was fair to good. Conclusions and Relevance:In this systematic review of long-term use of SMRs for chronic pain, findings suggest that their long-term use may benefit patients with painful spasms or cramps and neck pain; their long-term use for low back pain, fibromyalgia, and headaches did not appear to be beneficial. Clinicians should be vigilant for adverse effects and consider deprescribing if pain-related goals are not met.

Importance Health centers are vital primary care safety nets for underserved populations, but optimal clinician staffing associated with quality care is unclear. Understanding the association of clinician staffing patterns with quality of care may inform care delivery, scope-of-practice policy, and resource allocation. Objective To describe the association of clinician staffing models and ratios with quality-of-care metrics in health centers. Design, Setting, and Participants This cross-sectional study of US health centers used data from the 2022 Health Resources and Services Administration Uniform Data System (UDS). Exposure Clinician staffing ratios, expressed as the fraction of full-time equivalents (FTEs) per 1000 visits of physicians, advanced practice registered nurses (APRNs), and physician associates (PAs) to total clinician FTEs at each health center. Main outcomes and measures Percentage of eligible patients receiving the corresponding service or outcome for 14 individual clinical quality metrics collected by the UDS, including infant immunizations; screening for cancer, depression, tobacco use, hypertension, HIV, and glycated hemoglobin levels; weight and body mass index (BMI) assessment; and appropriate statin, aspirin, and/or antiplatelet therapy. Results This analysis of 791 health centers serving 16 114 842 patients (56.6% female) identified 5 clinician staffing models: balanced (similar FTEs of physicians, APRNs, and PAs; 152 [19.2%] of health centers), higher FTEs of APRNs than physicians (174 [22.0%]), higher FTEs of physicians than APRNs (160 [20.2%]), approximately equal FTEs of physicians and APRNs (263 [33.2%]), and large scale (42 [5.3%]). Adjusted linear models showed positive associations between physician FTEs per 1000 visits and cervical (beta, 14.9; 95% CI, 3.1-26.7), breast (beta, 15.7; 95% CI, 3.2-28.1), and colorectal (beta, 18.3; 95% CI, 6.0-30.6) cancer screening. Generalized additive models showed nonlinear positive associations beginning at a physician FTE ratio of 0.45 (95% CI, 0.02-6.22) for infant vaccinations, 0.39 (95% CI, 0.05-2.21) for cervical cancer screening, 0.39 (95% CI, 0.02-1.67) for breast cancer screening, 0.47 (95% CI, 0.00-5.76) for HIV testing, and 0.70 (95% CI, 0.18-19.96) for depression in remission; APRN FTE ratio of 0.45 (95% CI, 0.17-7.46) for adult BMI assessment; and PA FTE ratio of 0.16 (95% CI, 0.11-3.88) for infant vaccinations. Staffing models were not associated with 7 of the 14 metrics analyzed. Conclusions and Relevance In this cross-sectional study of health centers, physician FTE ratio was associated with higher performance in cancer screening, infant vaccinations, and HIV testing; APRN FTE ratio was associated with higher performance in preventative health assessments; and PA FTE ratio was associated with higher performance in infant vaccination. These findings suggest that targeted staffing strategies may be associated with quality of care in certain domains and that tailored approaches to health center staffing based on community-specific needs are warranted.

Objectives This study aimed to describe addiction treatment facilities by their offerings of medications for alcohol use disorder (MAUD) and/or for opioid use disorder (MOUD), and by their offering services to groups with barriers to care: uninsured and publicly insured, youth, seniors, individuals preferring to receive care in Spanish, and sexual minority individuals. Methods We examined addiction treatment facility survey data in 6 US states. We performed bivariate analyses comparing facilities that offered MAUD, MOUD, and both (main outcomes). We then constructed a multivariable model to identify predictors of offering MAUD, MOUD, or both, including exposures that demonstrate programming for special populations. Results Among 2474 facilities, 1228 (50%) responded between October 2019 and January 2020. Programs were offered for youth (30%), elderly (40%), Spanish-speaking (37%), and sexual minority populations (39%), with 58% providing MAUD, 67% providing MOUD, and 56% providing both. Among those providing MAUD, MOUD, or both, a majority (>60% for all exposures) offered programming to vulnerable populations. With Delaware as reference, Louisiana (adjusted odds ratio [aOR], 0.28; 95% confidence interval [CI], 0.12–0.67) and North Carolina (aOR, 0.33; 95% CI, 0.15–0.72) facilities had lesser odds of offering both MAUD and MOUD. All exposures identifying facilities offering treatment to vulnerable groups were associated with offerings of MAUD and/or MOUD except for offerings to youth; these facilities had less odds of offering MOUD (aOR, 0.31; 95% CI, 0.31–0.62). Conclusions There are facility-level disparities in providing MAUD and MOUD by state, and facilities with youth programming have lesser odds of offering MOUD than other facilities.

Psychoeducation, where clinicians teach problem-solving skills in a supportive environment, can help address families' social vulnerabilities and promote well-being. Group well-child care (GWCC) may provide unique opportunities for pediatric residents to improve their skills in psychoeducation. Our aim was to characterize pediatric residents' perspectives and experiences of communication while conducting both individual well-child care and GWCC. We used a longitudinal qualitative study design to conduct 15 semistructured interviews with five pediatric residents who facilitated GWCC. Using the constant comparative method, we characterized pediatric residents' perspectives and experiences of communication while conducting both individual well-child care and GWCC. Four themes emerged. Residents perceived that GWCC (i) enabled families to honestly share their knowledge and parenting practices, (ii) allowed time and a space for families to share personal stories and scenarios, (iii) facilitated discussions of maternal health and psychosocial matters, toward which residents felt ambivalence, and (iv) fostered skills in psychoeducation that transferred to the rest of their clinical practice. When pediatric residents lead GWCC, they perceive that they can facilitate key aspects of psychoeducation, enabling them to assist families in meeting complex social needs. Residents describe that they transfer psychoeducation skills learned in GWCC to the rest of their practice.

Objective: We examined drive times to outpatient substance use disorder treatment providers that provide contingency management (CM) and those that integrate CM with medication for opioid use disorder (MOUD) services in 6 US statesMethods: We completed cross-sectional geospatial analysis among census tracts in Delaware, Louisiana, Massachusetts, North Carolina, New York, and West Virginia. We excluded census tracts with a population of zero. Using data from the 2020 Shatterproof substance use treatment facility survey, our outcome was the minimum drive time in minutes from the census tract mean center of population to the nearest outpatient CM provider, outpatient CM provider with MOUD services, and federally qualified health centers (FQHC). We stratified census tracts by 2010 Rural-Urban Commuting Area codes and by state.Results: The population was greater than zero in 11,719 of 11,899 census tracts. The median drive time to the nearest CM provider was 12.2 [interquartile range (IQR), 7.0-23.5) minutes and the median drive time to the nearest CM provider increased from 9.7 (IQR, 6.0-15.0) minutes in urban census tracts to 38.8 (IQR, 25.4-53.0) minutes in rural (H = 3683, P < 0.001). The median drive time increased to the nearest CM provider with MOUD services [14.2 (IQR, 7.9-29.5) minutes, W = 18,877, P < 0.001] and decreased to the nearest FQHC [7.9 (IQR, 4.3-13.6) minutes, W = 11,555,894, P < 0.001].Conclusions: These results suggest limited availability of CM, particularly within rural communities and for patients needing concurrent CM and MOUD treatment. Our results suggest greater adoption of CM within FQHCs could reduce urban-rural disparities in CM availability.

OBJECTIVES:Patient experience and presence of evidence-based facility services are 2 dimensions of assessing quality of addiction treatment facilities. However, the relationship between these two is not well described. The objective of this study was to explore associations between patient experience measures and service offerings at addiction treatment facilities.METHODS:We used data from cross-sectional surveys of addiction treatment facilities and persons involved in treatment at corresponding facilities to identify facility services (eg, availability of medications for alcohol use disorder, assistance with obtaining social services, etc) and patient experience measures (overall facility rating, extent helped by treatment, ability to deal with daily problems after treatment), respectively. We used hierarchical multiple logistic regression to test for associations between top-box scores for each patient experience outcome and facility services.RESULTS:We analyzed 9191 patient experience surveys from 149 facilities. Assistance with obtaining social services (adjusted odds ratio [95% confidence interval], 0.43 [0.28-0.66]) was associated with lower overall treatment facility ratings. Childcare (2.00 [1.04-3.84]) was associated with top-box scores for extent helped. Availability of cognitive behavioral therapy (2.67 [1.25-5.73]) and childcare (1.77 [1.08-2.92]) were associated with top-box scores for ability to deal with daily problems after treatment. Assistance with obtaining social services (0.61 [0.41-0.90]) was associated with lower scores for ability to deal with problems after treatment.CONCLUSIONS:Few addiction treatment facility services were associated with patient experience measures. Future work should explore bridging the gap between evidence-based services and positive patient experiences.

Objective: To examine chronic diseases, clinical factors, and sociodemographic characteristics associated with telemedicine utilization among a safety-net population. Materials and Methods: We conducted a retrospective cohort study of adults seeking care in an urban, multisite community health center in the Northeast United States. We included adults with ≥1 outpatient in-person visit during the pre-COVID-19 period (March 1, 2019-February 29, 2020) and ≥1 outpatient visit (in-person or telemedicine) during the COVID-19 period (March 1, 2020-February 29, 2021). Multivariable logistic regression models estimated associations between clinical and sociodemographic factors and telemedicine use, classified as "any" (≥1 visit) and "high" (≥3 visits). Results: Among 5,793 patients who met inclusion criteria, 4,687 (80.9%) had any (≥1) telemedicine visit and 1,053 (18.2%) had high (≥3) telemedicine visits during the COVID-19 period. Older age and Medicare coverage were associated with having any telemedicine use. Older and White patients were more likely to have high telemedicine use. Uninsured patients were less likely to have high telemedicine use. Patients with increased health care utilization in the pre-COVID-19 period and those with hypertension, diabetes, substance use disorders, and depression were more likely to have high telemedicine engagement. Discussion: Chronic conditions, older patients, and White patients compared with Latinx patients, were associated with high telemedicine engagement after adjusting for prior health care utilization. Conclusion: Equity-focused approaches to telemedicine clinical strategies are needed for safety-net populations. Community health centers can adopt disease-specific telemedicine strategies with high patient engagement.

Background: Persons with HIV (PWH) and opioid use disorder (OUD) can have poor health outcomes. We assessed whether intensity of behavioral treatment for OUD (BOUD) with and without medication for OUD (MOUD) is associated with improved HIV clinical outcomes. Methods: We used Veterans Aging Cohort Study (VACS) data from 2008 to 2017 to identify PWH and OUD with 0.01). VL, CD4 count and VACS Index 2.0 did not differ by BOUD or 6 months of MOUD treatment. Conclusion: Among PWH and OUD who initiated BOUD, higher intensity BOUD was associated with improved ART initiation and adherence, but neither BOUD alone nor BOUD plus >6 months MOUD was associated with improvements in VL, CD4 count or VACS Index 2.0.

BACKGROUND:Heavy episodic drinking (HED) is a risk factor for opioid-related overdose and negatively impacts HIV disease progression. Among a national cohort of patients with HIV (PWH), we examined sociodemographic and clinical correlates of concomitant HED and self-reported opioid use.METHODS:We used data collected from 2002 through 2018 from the Veterans Aging Cohort Study, a prospective cohort including PWH in care at eight US Veterans Health Administration sites. HED was defined as consuming six or more drinks at least once in the year prior to survey collection. We examined the relationship between HED and self-reported opioid use and created a 4-level composite variable of HED and opioid use. We used multinomial logistic regression to estimate odds of reporting concomitant HED and self-reported opioid use.RESULTS:Among 3702 PWH, 1458 (39.4%) reported HED during the study period and 350 (9.5%) reported opioid use. In the multinomial model, compared to reporting neither HED nor opioid use, lifetime housing instability (adjusted odds ratio [aOR] 1.54, 95% confidence interval [CI] 1.01 to 2.35), Veterans Aging Cohort Study Index 2.0 (a measure of disease severity; aOR 1.14, 95% CI 1.02 to 1.28), depressive symptoms (aOR 2.27, 95% CI 1.42 to 3.62), past-year cigarette smoking (aOR 3.06, 95% CI 1.53 to 6.14), cannabis use (aOR 1.69, 95% CI 1.09 to 2.62), and cocaine/stimulant use (aOR 11.54, 95% CI 7.40 to 17.99) were independently associated with greater odds of concomitant HED and self-reported opioid use. Compared to having attended no college, having some college or more (aOR 0.39, 95% CI 0.26 to 0.59) was associated with lower odds of concomitant HED and self-reported opioid use.CONCLUSIONS:Among PWH, concomitant HED and self-reported opioid use are more common among individuals with depressive symptoms and substance use, structural vulnerabilities, and greater illness severity. Efforts to minimize opioid-related risk should address high-risk drinking as a modifiable risk factor for harm among these groups.

This study sought to describe the cost of hospital care for ambulatory care-sensitive conditions (ACSCs) and to identify independent predictors of high-cost hospital encounters related to an ACSC among an urban community health center cohort. The authors conducted a retrospective cohort study of individuals engaged in care in a large, multisite community health center in New Haven, Connecticut, with any Medicaid claims between June 1, 2018 and March 31, 2020. Prevention Quality Indicators of the Agency for Healthcare Research and Quality were used to identify ACSCs. The primary outcome was a high-cost episode of care for an ACSC (in the top quartile within a 7-day period). Multivariable logistic regression was used to identify independent predictors of high-cost episodes by ACSCs among sociodemographic and clinical variables as covariates. Among 8019 included individuals, a total of 751 episodes of hospital care involving ACSCs were identified. The median episode cost was $793, with the highest median cost of care related to heart failure ($4992), followed by diabetes ($1162), and chronic obstructive pulmonary disease ($1141). In adjusted analyses, male gender (P < 0.01), increasing age (P = 0.02), and ACSC type (P < 0.01) were associated with higher costs of care; race/ethnicity was not. Community health centers in urban settings seeking to reduce the cost of care of potentially preventable hospitalizations may target disease-/condition-specific groups, particularly individuals of increasing age with congestive heart failure and diabetes mellitus. These findings may inform return-on-investment calculations for care coordination and other enabling services programming.

Program Goals: During the COVID-19 pandemic, anticipatory guidance, developmental surveillance andimmunizations may be postponed At Fair Haven Community Health Care (FHCHC), a multi-site communityhealth center (CHC) in New Haven, CT, serving approximately 18,000 patients (9,000 children), weimplemented cohorting during the period of greatest local impact of the pandemic Our goals were to (1)prioritize well-child care for children due for immunizations, (2) increase the capacity for telemedicine forpatients with chronic illness or acute complaints, and (3) implement on-site COVID-19 testing with socialdeterminants screening Evaluation: We implemented cohorting for pediatric patients at FHCHC on March 12,2020 (for reference, Connecticut's stay-at-home order was signed March 23) Previously scheduled well childcare (WCC) for key age groups - birth to 24 months and 4 to 5 years - were moved to a “clean” site where onlyWCC and prenatal care were offered All other children received telemedicine visits, which could be converted to same-day in-person visits at the discretion of the clinician School-based health center providers were re-purposed to call patients with asthma in need of follow-up using a chronic care model On April 22, 2020,shortly after the neighborhood surrounding FHCHC's main site was identied as a COVID-19 “hot-spot,” weimplemented on-site testing regardless of symptoms, exposure, or prior use of FHCHC services Patientstested on-site were seen prior to their test via telemedicine for symptom assessment and to be screened forsocial determinants using the Accountable Health Communities instrument They were given locally-specicinformation to meet social needs generated by the NowPow platform From March 12 through April 30, wecompleted 3,302 visits for children 0 through 22 years;1,595 (48%) were via telemedicine Younger childrenages 0-5 years had a greater proportion of visits in-person (634, 60%) than children 6-12 years (438, 46%) oradolescents 12-22 years (635, 49%) Visit counts by time, stratied by visit-type, are shown in the Figure FromApril 22 through 30, 2020, we have scheduled 317 visits for on-site testing, 243 (77%) of which werecompleted, 36 of whom were children, all of whom were screened for social determinants of health Discussion: CHCs can cohort children to ensure that preventive care and vaccinations happen in a timelyfashion in the context of an epidemic Responding to local epidemiologic data, CHCs can provide trustingenvironments for surveillance testing Testing for COVID-19 represents a feasible opportunity to screen forsocial determinants of health and facilitate community linkages to meet social needs using electronicplatforms After the COVID-19 pandemic has subsided, CHCs can offer episodic telemedicine visits for children,and can screen for social determinants at various points of contact with families

Gabapentin is commonly prescribed for chronic pain, including to patients with HIV (PWH). There is growing concern regarding gabapentin's potential for harm, particularly in combination with opioids. Among PWH, we examined factors associated with higher doses of gabapentin receipt and determined if receipt varied by opioid use. We examined data from the Veterans Aging Cohort Study, a national prospective cohort including PWH, from 2002 through 2017. Covariates included prescribed opioid dose, self-reported past year opioid use, and other sociodemographic and clinical variables. We used multinomial logistic regression to determine independent predictors of gabapentin receipt. Among 3,702 PWH, 902 (24%) received any gabapentin during the study period at a mean daily dose of 1,469 mg. In the multinomial model, high-dose gabapentin receipt was associated with high-dose benzodiazepine receipt (adjusted odds ratio [aOR], 95% confidence interval [CI]= 1.53, [1.03-2.27]), pain interference (1.65 [1.39-1.95]), and hand or foot pain (1.81, [1.45-2.26]). High-dose gabapentin receipt was associated with prescribed high-dose opioids receipt (2.66 [1.95-3.62]) but not self-reported opioid use (1.03 [0.89-1.21]). PWH prescribed gabapentin at higher doses are more likely to receive high-dose opioids and high-dose benzodiazepines, raising safety concerns.

Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention.