Background:Unhealthy alcohol and drug use have significant health-related sequelae. Given racial and ethnic disparities in complications of substance use, successful screening and medication prescribing for addictions are important in community health settings serving diverse populations. Objective:To evaluate alcohol and drug use screening and prescribing of medications for addiction treatment in adults by race, ethnicity, and language preference. Design, Setting, and Participants:This cohort study included US adults seen between 2012 and 2020 in a multistate electronic health record (EHR) network (1394 primary care clinics). Analyses were completed October 2024. Exposure:Race and ethnicity with language preference groups: non-Hispanic White, non-Hispanic Black, Latino with Spanish language preferred, and Latino with English language preferred. Main Outcome(s) and Measures:Multivariable logistic regression estimated covariate-adjusted odds ratios (aOR) of receipt of alcohol and drug screening and EHR-documented prescription of medication for alcohol (AUD) or opioid use disorders (OUD). Results:There were 2 191 945 patients across 25 states (mean (SD) age, 41.3 [15.2] years; 1 236 818 female [56.4%]); 416 607 identified as non-Hispanic Black (19.0%), 1 015 066 non-Hispanic White (46.3%), 474 389 Latino with Spanish-language preference (21.6%), and 285 883 Latino with English-language preference (13.0%). Over the study period, 869 609 (39.7%) had documented completed alcohol screening, and 862 263 (39.3%) completed drug screening-113 629 (5.2%) had a diagnosis of AUD and 247 530 (11.3%) had an OUD diagnosis. Spanish-preferring Latino patients had 59% increased odds of screening compared with non-Hispanic White patients (aOR, 1.59; 95% CI, 1.31-1.93). All minoritized race and ethnicity with language preference groups had lower odds of prescribed medications for addictions treatment compared with non-Hispanic White patients; non-Hispanic Black patients had the lowest odds of any group (AUD: aOR, 0.55; 95% CI, 0.43-0.69; OUD: aOR, 0.38; 95% CI, 0.31-0.46). Conclusions and Relevance:In this cohort study, there was an overall low likelihood of completed screening for alcohol and drug use among all minoritized race and ethnicity with language preference groups. All minoritized groups had lower odds of receipt of medications for addiction treatment compared with the non-Hispanic White group. Improving screening and addressing this emerging treatment inequity should be prioritized.

Introduction:The clustering of smoking, alcohol use disorder, and depression is associated with increased health risks and mortality. The COVID-19 pandemic caused significant disruption, with unknown implications for alcohol use disorder and depression diagnoses among patients who smoke. This study assessed changes in the prevalence of alcohol use disorder and depression diagnoses in patients at community-based healthcare organizations before and during the COVID-19 public health emergency, by smoking status and sex. Methods:A retrospective cohort study was conducted using electronic health record data from community-based primary care and behavioral health clinics (n=766 clinics in 19 states) in the U.S. Outcomes included the covariate-adjusted probability of alcohol use disorder diagnosis, depression diagnosis, and comorbid diagnoses in 2019 and 2022, stratified by smoking status and sex. Results:In both years, alcohol use disorder and depression diagnoses were higher among patients who were smoking (n=57,351 patients) than among those who were not (n=304,405 patients). The likelihood of alcohol use disorder, depression, or co-occurring alcohol use disorder and depression diagnoses increased from 2019 to 2022 among both sexes and all smoking statuses, with larger increases seen among patients who were smoking. The largest change was in depression among currently smoking females, rising from 35.2% to 41.7% (absolute difference=6.4%, 95% CI=5.8%, 7.1%). Conclusions:The COVID-19 pandemic was associated with a greater burden of alcohol use disorder and depression diagnoses among patients seen in community-based clinics, with larger differences among those who currently smoke than among those who do not. Males had the largest increase in alcohol use disorder diagnoses, and females had the largest increase in depression diagnoses. These results support the need for a coordinated, integrated healthcare approach addressing the clustering of smoking, alcohol use, and depression in populations already facing elevated social and health risks, particularly during times of high stress, such as pandemics and other public health emergencies.

OBJECTIVE:The burden of atherosclerotic cardiovascular disease (ASCVD) may differ based on the country of birth in Latinos, therefore, we aimed to examine differences in the utilization of ASCVD screening services, which have not been studied using large healthcare datasets. METHODS:Data included electronic health record (EHR) data from a multistate network of United States (U.S.) community health centers from 2014 to 2020. The study population (N = 49,177) was foreign-born Latinos (from ten different Latin countries) and U.S.-born Latino patients aged 40-83 years seeking care at 149 U.S. community health centers across 14 states. To compare the prevalence of documented medical record data necessary for ASCVD risk calculation, we performed a cross-sectional anlaysis, using logistic regression, adjusted for demographic and health services utilization factors. RESULTS:The adjusted odds ratio (aOR) comparing foreign-born to U.S.-born Latinos was 1.17 (95 % CI = 1.01, 1.35). When stratifying by country of birth, patients from specific countries had higher odds of documented data when compared to their U.S.-born counterparts (Dominican Republic: aOR = 1.13, 95 % CI = 1.03, 1.24; El Salvador: aOR = 1.26, 95 % CI = 1.08, 1.47; Guatemala: aOR = 1.17, 95 % CI = 1.02, 1.34; Mexico: aOR = 1.19, 95 % CI = 1.01, 1.41). CONCLUSIONS:Foreign-born Latinos from El Salvador, Guatemala, the Dominican Republic, and Mexico are more likely to have documented information in their EHR necessary to assess cardiovascular risk. These findings underscore the clinical importance of data disaggregation in Latino patients as specific national birthplace may be associated with the adequacy of cardiovascular screening.

PURPOSE:Latino pediatric patients have a higher prevalence of obesity, but less is known about how factors related to nativity are associated with obesity in youth. We examined the prevalence of childhood and adolescent obesity in primary care over time by nativity status for Latino and non-Hispanic White children. METHODS:In this serial cross-sectional analysis, we used electronic health records from a multi-state network of community health centers which included data from clinics in 21 US states for patients aged 9 to 17 years from 2012 through 2020 in at least 1 of 4 nonmutually exclusive cross sections. We estimated the adjusted odds and prevalence of having obesity (ie, body mass index [BMI] at the 95th percentile or greater for age and sex) at all encounters during each cross section by ethnicity and nativity status. RESULTS:The sample included a total of 147,376 patients. In the 2012-2013 cross section, 38,697 children and adolescents had at least 1 BMI measurement recorded compared with 72,747 in the 2018-2020 cross section. US-born Latino children had higher odds of having obesity than non-Hispanic White children. Foreign-born Latino and non-Hispanic White children had lower prevalence of obesity in each cross section compared with US-born Latino children (with a range from 20.4% [95% CI, 16.9%-23.8%] to 32.7% [95% CI, 31.6%-33.9%]). CONCLUSIONS:Differences in the prevalence of documented childhood and adolescent obesity by nativity status exist in this sample of community health center patients. This demonstrates opportunity for primary care practice to further consider patients' background and culture when providing obesity care and cardiovascular and metabolic disease prevention.

OBJECTIVE:Accumulation of cardiovascular risks begins early in life. Some experts recommend cholesterol screening for children aged nine to 11. Latinos living in the U.S. have a high burden of cardiovascular disease and risk factors, and this is further influenced by birthplace, yet information on early screening for cardiovascular disease in this group is sparse. METHODS:We used electronic health records from a national network including 771 community-based clinics across 21 states from 2012 to 2020, from 310,297 foreign-born Latino, US-born Latino, Latino with unknown birthplace, and non-Hispanic white patients aged nine to 17 years. Logistic regression including demographic and clinical covariates was conducted to estimate prevalence of cholesterol testing, stratified by obesity. RESULTS:Latino children, regardless of nativity status, had higher adjusted prevalence of cholesterol screening compared to non-Hispanic white children for those with and without obesity. The highest prevalence of screening among those with obesity was in foreign-born Latinos (34.8 %), and among those who were not obese, US-born Latinos had the highest screening prevalence (16.8 %). CONCLUSIONS:Cholesterol screening was low overall in these community-based clinic patients but differed by ethnicity and nativity status. There is opportunity for further research on outcomes in Latino children to inform guidelines for early screening for cardiovascular health.

INTRODUCTION:United States Preventive Service Task Force guidelines recommend annual low-dose computed tomography for lung cancer screening (LCS) for people with significant history of cigarette use. While the national prevalence of lung cancer screening remains low, with known racial and ethnic disparities, studies have yet to examine LCS screening disparities by nativity among Latino patients. METHODS:We evaluated the documentation and prevalence of LCS orders in the electronic health record in Latino patients, by place of birth, in a multistate network of community health centers, over a 10-year study period (2013 to 2022), adjusting for patient and clinical demographic factors. RESULTS:Among patients who reported current or former cigarette use (n = 126,528), the prevalence of a LCS order was 7.3%. Among 62,483 patients with a documented 30+ year pack-history, US-born Latinos had equal odds as non-Latino Whites to have LCS ordered (OR = 0.71, 95% CI = 0.42-1.21), while odds were lower for both foreign-born Latinos (OR = 0.47, 95% CI = 0.29 to 0.75) and Latinos without a place of birth recorded (OR = 0.63, 95% CI = 0.54-0.73). CONCLUSION:The prevalence of LCS was low overall in a large sample of Latino and non-Hispanic White patients with cigarette smoking history. Foreign-born Latino and Latino patients without a country of birth noted in the record had significantly lower odds of having LCS ordered; this should be considered in clinical screening workflows. Nativity and pack-year history were not documented in most patients. More complete documentation of nativity and pack-year history is necessary to fully assess LCS need and equity in Latino patients of heterogeneous nativity.

BACKGROUND:Hybrid models of care (ie, telehealth and in-person care delivery options) have been incorporated into primary care clinics to increase patient access to care. We examine the effects of these approaches on the work experiences and wellness of primary care clinical team members providing team-based care to patients. METHODS:In this qualitative study, we conducted semistructured interviews with clinical team members (primary care clinicians, behavioral health consultants, registered nurse) at 2 primary care practices at 2 time points (late 2021-mid 2022 (n = 14); midlate 2023 (n = 11)). We used an inductive approach to analyze data. KEY RESULTS:Benefits of hybrid models of care included increased patient access and personal flexibility; however, it was noted that the fragmented in-clinic schedules that emerged from the hybrid model resulted in reduced in-clinic interactions. This led to less information sharing among team members and a degradation of informal support networks that could adversely impact patient care. To mitigate these challenges, many preferred that most of their clinical shifts occurred in-person, in the clinic, with 1 to 2 sessions per week for in-home (telework) shifts. CONCLUSIONS:In team-based primary care clinics, hybrid care models can impact interactions among clinical team members and shape the day-to-day environment in which clinical teams work. To optimize hybrid care approaches in the primary care setting, organization leaders must consider the impact of hybrid care models on clinic and team culture, and the well-being of clinical team members.

Lung cancer is a leading cause of cancer death among Hispanic men and women in the United States. Smoking rates vary among Hispanic subgroups, with higher rates among those with indicators (e.g., language preference, nativity) of greater acculturation. It is recommended that clinicians ask about tobacco use and provide cessation treatment, as warranted. While studies in health care settings note disparities in tobacco-related care by ethnicity and acculturation proxies, we are unaware of studies that have evaluated these relationships among adult patients within community-based health care clinics (CHCs), key settings for provision of care for Hispanic patients. To examine rates of tobacco use assessment and cessation medication orders among Hispanic patients by language and nativity compared to non-Hispanic White patients in CHCs. Retrospective observational study using electronic health record (EHR) data. 1,016,391 adult patients with ≥ 1 primary care visit to a study CHC between 9/1/2020–9/1/2022. Outcomes included tobacco use assessment and, among those identified as using tobacco, having a cessation medication ordered. The primary independent variable combined ethnicity and language preference, with sensitivity analyses combining ethnicity and nativity. We used separate generalized estimating equation regressions for each sex to estimate risk differences of each outcome by patient subgroups, adjusting for covariates. Compared with non-Hispanic White patients, Spanish-preferring Hispanic males and females and English-preferring Hispanic males had higher rates of having tobacco use assessed (covariate-adjusted risk differences [aRD] = 2.23

INTRODUCTION:Prescription opioid dose reductions can raise the risk of adverse events for patients on long-term opioid therapy for noncancer pain. Evidence on whether risks differ by age or sex is needed to support tailored clinical decision-making. METHODS:In 2024, a secondary analysis of an observational cohort study was conducted across 8 U.S. healthcare systems analyzing electronic health records and claims data from a prescription opioid registry (excluding buprenorphine prescriptions) between January 1, 2012, and December 31, 2018, including adults with stable prescription opioid use and a subsequent ≥2-month dose reduction period (n=60,040), yielding 600,234 dose reduction periods as the analytic sample. Differences in the association between dose reduction level (1% to <15%, 15% to <30%, 30% to <100%, and 100% from baseline) and potential adverse events (emergency department visits, opioid overdose, all-cause mortality, and benzodiazepine prescription fills) in the month after dose reduction by sex and age group were examined by including interaction terms in logistic regression models. RESULTS:Of the 600,234 dose reduction periods, 346,733 were among women, with a mean age of 57.5 (SD=13.2) years for women and 56.7 (SD=12.1) years for men. Associations between dose reduction levels and potential adverse events did not differ significantly by sex, but differed by age for emergency department visits: patients aged 40-64 and ≥65 years with dose reductions of 30% to <100% had lower odds than those aged 19-39 years (adjusted ratio of OR=0.87, CI=0.80, 0.96; adjusted ratio of OR=0.82, CI=0.74, 0.91, respectively). CONCLUSIONS:Patients aged <40 years may benefit from closer monitoring in the month after dose reduction, given their higher odds of an emergency department visit.

This cohort study characterizes changes in buprenorphine prescribing among community health center clinicians between 2016 and 2021.

Introduction: The COVID-19 pandemic dramatically altered patterns of healthcare delivery. Smoking remains an important risk factor for multiple chronic conditions and may exacerbate more severe symptoms of COVID-19. Thus, it is important to understand how pandemic-induced changes in primary care practice patterns affected smoking assessment and cessation assistance. Aims and Methods: Electronic health record data from eight community health centers were examined from March 1, 2019 to February 28, 2022. Data include both telehealth (phone and video) and in-person office visits and represent 310 388 visits by adult patients. Rates of smoking assessment, provision of referral to counseling, and orders for smoking cessation medications were calculated. Comparisons by visit mode and time period were examined using generalized estimating equations and logistic regression. Results: The proportion of telehealth visits was < 0.1% 1 year prior to COVID-19 onset and, 54.5% and 34.1% 1 and 2 years after. The odds of asking about smoking status and offering a referral to smoking cessation counseling were significantly higher during in-person versus telehealth visits; adjusted odds ratios (AOR) (95% CI) = 15.0 (14.7 to 15.4) and AOR (95% CI) = 6.5 (3.0 to 13.9), respectively. The interaction effect of visit type * time period was significant for ordering smoking cessation medications. Conclusions: Telehealth visits were significantly less likely to include smoking status assessment and referral to smoking cessation counseling compared to in-person visits. Given that smoking assessment and cessation assistance do not require face-to-face interactions with health care providers, continued efforts are needed to ensure provision at all visits, regardless of modality. Implications: The COVID-19 pandemic dramatically altered patterns of healthcare-seeking and delivery with a considerable rise in telehealth visits. This study examined 1 year prior to the onset of COVID-19 and 2 years after to evaluate the assessment of tobacco use and assistance with tobacco cessation and differences during in-person versus telehealth visits. Tobacco assessment was 15 times more likely during in-person versus telehealth visits in the 2 years post onset of COVID-19. Given that telehealth visits are likely to continue, ensuring that patients are regularly assessed for tobacco regardless of visit modality is an important concern for health systems.

Background Opioid use disorder (OUD) is a chronic condition that requires regular visits and care continuity. Telehealth implementation has created multiple visit modalities for OUD care. There is limited knowledge of patients’ and clinicians’ perceptions and experiences related to multi-modality care and when different modalities might be best employed. Objective To identify patients’ and clinicians’ experiences with multiple visit modalities for OUD treatment in primary care. Design Comparative case study, using video- and telephone-based semi-structured interviews. Participants Patients being treated for OUD ( n = 19) and clinicians who provided OUD care ( n = 15) from two primary care clinics within the same healthcare system. Approach Using an inductive approach, interviews were analyzed to identify patients’ and clinicians’ experiences with receiving/delivering OUD care via different visit modalities. Clinicians’ and patients’ experiences were compared using a group analytical process. Key Results Patients and clinicians valued having multiple modalities available for care, with flexibility identified as a key benefit. Patients highlighted the decreased burden of travel and less social anxiety with telehealth visits. Similarly, clinicians reported that telehealth decreased medical intrusion into the lives of patients stable in recovery. Patients and clinicians saw the value of in-person visits when establishing care and for patients needing additional support. In-person visits allowed the ability to conduct urine drug testing, and to foster relationships and trust building, which were more difficult, but not impossible via a telehealth visit. Patients preferred telephone over video visits, as these were more private and more convenient. Clinicians identified benefits of video, including being able to both hear and see the patient, but often deferred to patient preference. Conclusions Considerations for utilization of visit modalities for OUD care were identified based on patients’ needs and preferences, which often changed over the course of treatment. Continued research is needed determine how visit modalities impact patient outcomes.

Introduction Many surgeons require patients to quit smoking prior to elective surgeries to reduce the risk of postoperative complications. Our aim was to qualitatively evaluate the communication and care experiences of patients and clinicians involved in conversations about quitting smoking prior to elective orthopedic surgery.Aims and Methods A qualitative interview study of rural-residing Veterans, primary care providers (PCP), and Veterans Administration (VA) orthopedic surgery staff and pharmacists, who care for rural Veterans. We performed a combination of deductive and inductive approaches to support conventional content analysis using a Patient-centered care (PCC) framework.Results Patients appreciated a shared approach with their PCP on the plan and reasons for cessation. Despite not knowing if the motivation for elective surgeries served as a teachable moment to facilitate long-term abstinence, almost all clinicians believed it typically helped in the short term. There was a lack of standardized workflow between primary care and surgery, especially when patients used care delivered outside of the VA.Conclusions While clinician-provided information about the reasons behind the requirement to quit smoking preoperatively was beneficial, patients appreciated the opportunity to collaborate with their care teams on developing a plan for cessation and abstinence. Other aspects of PCC need to be leveraged, such as the therapeutic alliance or patient-as-person, to build trust and improve communication surrounding tobacco use treatment. System-level changes may need to be made to improve coordination and connection of clinicians within and across disciplines.Implications This study included perspectives from patients, primary care teams, and surgical teams and found that, in addition to providing information, clinicians need to address other aspects of PCC such as the therapeutic alliance and patient-as-person domains to promote patient engagement in tobacco use treatment. This, in turn, could enhance the potential of surgery as a teachable moment and patient success in quitting smoking.

Background: Most patients in opioid treatment programs (OTPs) attend daily for observed dosing. A Stage IA (create and adapt) and a Stage IB (feasibility and pilot) mixed method studies tested a web-application (app) designed to facilitate access to take-home methadone.Methods: A Stage IA, intervention development study, used qualitative interviews to assess the usability (ease of use) and feasibility (ability to implement) of a take-home methadone app. The Stage IA market research was a two-week test with 96 patient participants from four OTPs. Qualitative interviews were completed with 20 systematically selected individuals who used the take-home app and 20 OTP clinicians (five each from the four OTPs). The Stage IB Small Business Innovation Research (SBIR) study (24 patients and 8 clinicians in a single OTP) included quantitative assessments of the app's usability, acceptability, appropriateness, and feasibility. Thematic analysis coded participant and staff assessments of the take-home app.Results: Stage IA patients (mean age = 41 years; 52 % men, 57 % White) and IB patients (mean age = 38 years, 54 % men, 79 % White) described the app as "easy to use." Compared to unsupervised take-homes, some patients preferred using the take-home app. In Stage IB, patients rated the app highly on standardized measures of usability, acceptability, appropriateness, and feasibility. Clinician ratings were more ambivalent. Patients rated in clinic dosing as more disruptive than unsupervised take-homes and take-homes using the app.Discussion: A Stage IA study informed the development and maturation of a Stage IB feasibility pilot study. Overall, the take-home app's usability, acceptability, appropriateness, and feasibility were rated positively. Clinical staff ratings were less positive, but individuals commented that using the app a) enhanced patient quality of life, b) provided new tools for counselors, and c) offered competitive advantages. The SBIR award enhanced market research with more complete and systematic data collection and analysis.

INTRODUCTION:Primary care delivery in the United States, including tobacco treatment, was negatively impacted by the COVID-19 public health emergency, leading to pandemic-related cessation disparities. Early in the public health emergency, rates of tobacco assessment during telehealth visits were substantially lower than during in-person visits. It is unknown if these changes persisted. METHODS:Electronic health record data were extracted and analyzed in 2024 from adult patients with ≥1 primary care visit to a primary care community-based health clinic between 01/01/2019 and 05/31/2023 (N=1,792,934 patients from 541 clinics in 17 states). The monthly percentage of visits with smoking assessment (yes/no) were examined overall and by visit modality. RESULTS:Prior to March 2020, <1% of visits were via telehealth. In the months following, >50% were via telehealth, leveling to 25% in the later study months. Prior to the public health emergency, >95% of all visits included smoking assessment; the highest monthly percentage after the public health emergency declaration was 77%. For in-person visits, assessments occurred at >95% of visits in each study month prior to March 2020, with subsequent percentages ranging from 46% (April 2020) to 95% (May 2023). In contrast, assessment during telehealth visits reached a maximum of 9% in late 2022. CONCLUSIONS:Smoking assessment remained consistently lower during the public health emergency compared with the months prior, primarily driven by lack of assessment during telehealth visits. Concerted efforts are needed to ensure that telehealth visits are leveraged to promote equitable smoking assessment and delivery of evidence-based tobacco treatment among a patient population with high rates of tobacco use.

This Viewpoint discusses learnings from implementation of an Oregon guideline requiring that Medicaid-insured patients abstain from cigarette smoking for at least 4 weeks before most elective surgeries.