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

INTRODUCTION:Despite evidence supporting clinic-community linked hypertension interventions for socially disadvantaged populations, sustaining these interventions in real-world primary care has been challenging. The objective of this work was to identify shared potential priorities for redesigning hypertension care using a structured Double Diamond co-design framework across health systems and community-based organizations (CBOs) serving census tracts with a high prevalence of hypertension. METHODS:We used the Double-Diamond design strategy to co-create hypertension care redesign priorities with four diverse health systems and multiple CBOs from our target census tracts. We established two co-design working groups: one for data and evaluation elements, and one for community engagement and health equity elements. Fourteen structured co-design meetings followed the Double Diamond phases (discover, define, develop, deliver) to identify needs and refine priorities. We used thematic analysis and triangulated findings from meeting summaries, fieldwork observations, existing community health needs assessments and geospatial data assessments of the priority census tracts to identify shared priorities for quality improvement (QI) efforts across health systems. RESULTS:Our target census tracts had greater socioeconomic disadvantages compared to surrounding tracts. Stakeholders identified actionable redesign priorities, including improving data usability and standardizing data across health systems; incorporating the lived experiences of patients; enhancing interoperability and the real-time availability of CBO resources; and fostering cross-system team-based care and collaboration. CONCLUSIONS:A multi-component Double-Diamond design approach facilitated the development of primary care redesign priorities grounded in the reality of health systems and CBOs and offers a practical pathway for transitioning from co-design to measurable QI efforts. PATIENT OR PUBLIC CONTRIBUTION:Community members and representatives from community-based organizations (CBOs) were involved throughout the co-design process as partners rather than as research participants. Community members and CBO representatives participated in the community engagement working group, contributed to fieldwork in high-priority census tracts, and helped interpret findings from community health needs assessments and geospatial analyses to identify locally relevant priorities. Their lived experience informed the development of quality improvement (QI) priorities for clinic-community linked hypertension care. Stakeholder input focused on system-level design considerations, rather than individual clinical encounters and will continue through a patient advocacy team composed of individuals living with hypertension from the target neighbourhoods to guide subsequent QI efforts. Coauthor Marquita Rockamore is a community member who leads a community health worker training programme at a local community college and serves as the chair of the steering committee for this work.

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.

BACKGROUND AND AIMS:Females are disproportionately affected by gastroparesis. Sex hormones play a significant role. The aim of this study was to investigate the effects of combined oral contraceptives (COC) on the development of gastroparesis and its related symptoms, medication use, and diagnostic testing in pre-menopausal women. METHODS:A population-based cohort study was conducted utilizing the TriNetX platform. The study group included pre-menopausal women. The effect of developing gastroparesis at least 30 days after initiating COC was assessed by comparing it to pre-menopausal women not on contraceptive therapy. A 1:1 propensity score matching was performed to adjust for age, race, ethnicity, body mass index, and diabetes mellitus. Exclusion criteria included upper gut and bariatric surgery, functional dyspepsia, cyclic vomiting syndrome, gastro-esophageal reflux disease, irritable bowel syndrome, cannabis dependence and opiate use. Odds ratios with 95 % confidence intervals were calculated. P-value <0.05 was considered statistically significant. RESULTS:After propensity matching, 1,370,274 patients were included in the study for each cohort. A total of 1,050 pre-menopausal women developed gastroparesis at least 30 days after being prescribed COC compared to 815 pre-menopausal women not prescribed COC (OR 1.29 [1.176-1.412] p-value<0.0001). These associations persisted in sensitivity analysis over 5 years (OR 1.31 [1.097-1.575] p-value=0.0029). COC were associated with increased gastrointestinal symptoms including early satiety (OR 2.31 [2.08-2.577] p-value<0.0001) and prokinetic medications including metoclopramide (OR 1.30 [1.285-1.316] p-value<0.0001). Gastrointestinal diagnostic tests including esophagogastroduodenoscopy (OR 1.611 [1.561-1.663] p-value<0.0001) and gastric emptying scintigraphy (OR 1.89 [1.717-2.085] p-value<0.0001) were more likely to be performed in pre-menopausal women who were prescribed COC. CONCLUSIONS:COC is associated with an increased risk of developing gastroparesis, which persists over time. Furthermore, COC is associated with developing gastrointestinal symptoms, increased prokinetic usage, and diagnostic testing.

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.

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.

Introduction: Remote blood pressure (BP) monitoring use to improve hypertension control is increasing but can lead to alert fatigue and primary care physician (PCP) inaction. Hypothesis: The hypothesis is that team-based care with nurses attenuates remote monitoring alert fatigue in PCPs and that there are differences in the volume and outcomes of BP alerts by race and ethnicity. Methods: A retrospective cohort study was conducted with 405 patients that graduated from a virtual care disease management program (VCDM) at a Midwestern health system since 2021. The 12-week VCDM program included remote BP monitoring with weekly web-based education and team-based care supported by two nurses. Alerts were triggered for out of range BPs and reviewed by nurses every morning. PCPs received notifications if remote BPs demonstrated a trend of uncontrolled BPs over five or more consecutive days. Two investigators developed a codebook to classify alerts and their outcomes. Medication intensification data was extracted manually. Charts were reviewed until thematic saturation was achieved from reviewing the last 20 charts. Chi square test was used to determine association between alert outcomes and race/ethnicity. Results: Thematic saturation was reached after reviewing 100 patient charts (mean age 65 years, SD 12, 42% Black, 48% female). Of the total recorded 340 alerts, 90% were managed by nurses without need for PCP notification. The most common follow-up nurse action for alerts (85%) was to continue BP monitoring and education. Only 23 alerts led to PCP messages or visits. Medication intensification occurred in response to all PCP messages and visits, resulting in a total of 25 medication intensifications. There was no significant difference in alert volume by race and ethnicity and medication intensification was more frequent in Black participants compared to White participants. Conclusions: In conclusion, integrating nurse support in remote BP monitoring programs significantly reduces PCP alert fatigue, enabling PCPs to focus on more complex cases requiring medication adjustments or in-person visits. Nurse monitoring enhanced patient safety through timely responses to abnormal BP readings. A structured protocol for handling alerts was effective in managing 90% of remote monitoring alerts. Future research should explore long-term health outcomes and reimbursement structures to support team-based remote monitoring and improve hypertension outcomes.

Positive self-perceptions of aging are linked to better self-rated health, we examined the impact of clinical diagnoses (e.g., sleep disorders and comorbidities) and subjective factors (e.g., sleep appraisal, social and physical limitations) on self-rated health. Our cohort consisted of 1,523 older adults (65+) with at least two outpatient primary care visits and one Medicare Annual Wellness Visit. We used an ordered logistic regression model to predict self-rated health, which was rated on a five-point scale from “poor” to “excellent.” The regression analysis showed that older adults with sleep difficulties (based on the PHQ-9 sleep item) had poorer self-rated health than those without any sleep difficulties. However, there was no significant difference between those with and without a diagnosed sleep disorder. This suggests that subjective sleep appraisal is associated with self-rated health, while sleep disorder diagnosis is not. We also found that higher social limitations were linked to poorer health, while increased physical activity was associated with better self-rated health. Higher comorbidity scores were also associated with poorer health outcomes. Also, African Americans reported lower self-rated health compared to Whites and others. Our findings indicate that self-rated health is influenced by both subjective and objective factors, including perceived sleep difficulties, social and physical limitations, and physical health status (e.g., comorbidities). This study highlights the significance of physical functioning and social engagement in shaping perceived health among older adults

Background:Given the importance of medication adherence among individuals with bipolar disorder (BD), this analysis from an ongoing randomized controlled trial (RCT) examined the relationship between BD symptoms, functioning and adherence in 69 poorly adherent adults with BD. Method:Study inclusion criteria included being ≥ 18 years old with BD Type 1 or 2, difficulties with medication adherence and actively symptomatic as measured by Brief Psychiatric Rating Scale (BPRS) score ≥ 36, Young Mania Rating Scale (YMRS) > 8 or Montgomery Asberg Depression Rating Scale (MADRS) > 8. Adherence was measured in 2 ways: 1) the self-reported Tablets Routine Questionnaire (TRQ) and 2) electronic pill container monitoring (eCap pillbox). BD symptoms and functioning were measured with the MADRS, YMRS, Clinical Global Impressions Scale (CGI), and Global Assessment of Functioning (GAF). Only screening and baseline data were examined. Results:Mean age was 42.32 (SD = 12.99) years, with 72.46% (n = 50) female and 43.48% (n = 30) non-white. Mean past 7-day percentage of days with missed BD medications using TRQ was 40.63% (SD = 32.61) and 30.30% (SD = 30.41) at screening and baseline, respectively. Baseline adherence using eCap was 42.16% (SD = 35.85) in those with available eCap data (n = 41). Worse adherence based on TRQ was significantly associated with higher MADRS (p = 0.04) and CGI (p = .03) but lower GAF (p = 0.02). eCAP measured adherence was not significantly associated with clinical variables. Conclusion:While depression and functioning were approximate markers of adherence, reliance on patient self-report or BD symptom presentation may give an incomplete picture of medication-taking behaviors.

OBJECTIVE:Individuals with bipolar disorder (BD) have high rates of suboptimal medication adherence, medical illness, and premature mortality, largely from cardiovascular causes. This study examined the association between adherence to antihypertensive, adherence to BD medications, and clinical symptoms in patients with BD and comorbid hypertension (HTN). Participants were involved in an ongoing clinical trial. METHOD:Inclusion criteria were a BD diagnosis, treatment with antihypertensives, adherence challenges, and poorly controlled HTN. Adherence was measured via self-report using the Tablets Routine Questionnaire and using eCAP, an electronic pill bottle that captures openings. Average systolic blood pressure (SBP) was calculated from 12 readings over one week. The Montgomery-Asberg Depression Rating Scale (MADRS) and the Brief Psychiatric Rating Scale (BPRS) assessed BD symptoms. RESULTS:A total of 83 participants with BD and HTN were included. Adherence to BD medications and antihypertensive medications were positively correlated. eCAP openings showed more missed doses than participants self-reported for antihypertensive adherence. BD medication adherence was positively correlated with BPRS at baseline, whereas antihypertensive adherence was negatively correlated with SBP at screening. Antihypertensive adherence improved and SBP decreased between screening and baseline. CONCLUSIONS:Adherence levels fluctuated over time and differed based on measurement method in participants with comorbid BD and HTN. Self-reported BD adherence was positively related to global psychiatric symptoms and antihypertensive adherence was related to better SBP control. Monitoring both medication and blood pressure led to a change in self-reported adherence. BD symptom severity may interfere with medication adherence in patients with BD and should be considered in treatment planning.

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.

Background Hypertension control is critical to reducing cardiovascular disease, challenging to achieve, and exacerbated by socioeconomic inequities. Few states have established statewide quality improvement (QI) infrastructures to improve blood pressure (BP) control across economically disadvantaged populations. In this study, we aimed to improve BP control by 15% for all Medicaid recipients and by 20% for non-Hispanic Black participants. Methodology This QI study used repeated cross-sections of electronic health record data and, for Medicaid enrollees, linked Medicaid claims data for 17,672 adults with hypertension seen at one of eight high-volume Medicaid primary care practices in Ohio from 2017 to 2019. Evidence-based strategies included (1) accurate BP measurement; (2) timely follow-up; (3) outreach; (4) a standardized treatment algorithm; and (5) effective communication. Payers focused on a 90-day supply (vs. 30-day) of BP medications, home BP monitor access, and outreach. Implementation efforts included an in-person kick-off followed by monthly QI coaching and monthly webinars. Weighted generalized estimating equations were used to estimate the baseline, one-year, and two-year implementation change in the proportion of visits with BP control (<140/90 mm Hg) stratified by race/ethnicity. Results For all practices, the percentage of participants with controlled BP increased from 52% in 2017 to 60% in 2019. Among non-Hispanic Whites, the odds of achieving BP control in year one and year two were 1.24 times (95% confidence interval: 1.14, 1.34) and 1.50 times (1.38, 1.63) higher relative to baseline, respectively. Among non-Hispanic Blacks, the odds for years one and two were 1.18 times (1.10, 1.27) and 1.34 times (1.24, 1.45) higher relative to baseline, respectively. Conclusions A hypertension QI project as part of establishing a statewide QI infrastructure improved BP control in practices with a high volume of disadvantaged patients. Future efforts should investigate ways to reduce inequities in BP control and further explore factors associated with greater BP improvements and sustainability.

We used a collective impact model to form a statewide diabetes quality improvement collaborative to improve diabetes outcomes and advance diabetes health equity. Between 2020 and 2022, in collaboration with the Ohio Department of Medicaid, Medicaid Managed Care Plans, and Ohio’s seven medical schools, we recruited 20 primary care practices across the state. The percentage of patients with hemoglobin A1c greater than 9% improved from 25% to 20% over two years. Applying our model more broadly could accelerate improvement in diabetes outcomes. (Am J Public Health. 2023;113(12):1254–1257. https://doi.org/10.2105/AJPH.2023.307410 )