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J Ambulatory Care Manage Vol. 37, No. 3, pp. 250–257 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Identifying Key Patient Demographics and Organizational Factors That Contribute to Health Center Participation in Research Peter Shin, PhD, MPH; Jessica Sharac, MSc, MPH; Tishra Beeson, MPH; Michelle Proser, MPP; Michelle Jester, MA Abstract: Federally Qualified Health Centers are well positioned for translational research given their diverse patient population, unique characteristics, and community knowledge. This was the first national survey that assessed their research activities. Those with research experience were more likely to be urban and Health Care for the Homeless grantees and had more patients, minority patients, and physicians relative to nonphysician providers, enabling services providers, Medicaid revenues per Medicaid patient, and total revenues per patient than health centers with no experience and no future interest in research. Only enabling services providers to patient ratios and total patients remained significant after controlling for other factors. Key words: community-engaged research, community health centers, Federally Qualified Health Centers, research capacity, translational research
Author Affiliations: Geiger Gibson/RCHN Community Health Foundation Research, New York, New York (Dr Shin); Department of Health Policy, The Milken Institute School of Public Health, George Washington University, Washington, District of Columbia (Dr Shin and Mss Sharac and Beeson); and, Public Policy and Research, National Association of Community Health Centers, Washington, District of Columbia (Mss Proser and Jester). This project was supported by the Clinical and Translational Science Institute at Children’s National Medical Center and The George Washington University (through the NIH CTSA program # UL1TR000075) with additional support from the RCHN Community Health Foundation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health. The authors thank individuals at the Community Health Applied Research Network (CHARN), the South Carolina Primary Health Care Association (SCPHCA), and the University of South Carolina (USC) for their partnership in designing and fielding the survey
instrument. Special thanks goes to Vicki Young, PhD, and Dayna Campbell, MS (SCPHCA); Heather Brandt, PhD, and Tisha Felder, PhD (USC); and Rosy Chang Weir, PhD, Shelly Enos, MPH, Suzanne Gillespie, MA, MS, Stefan Massimino, MS, Reesa Laws, Christine Nelson, PhD, RN, Mary Oneha, PhD, Thu Quach, PhD, ShaoChee Sim, PhD, Robbie Singal, MPH, Hui Song, MPH, MS, and Fikirte Wagaw, MPH (CHARN). The authors also thank the following individuals for their input on designing the survey instrument and/or providing feedback on the analysis: Franco Basanti, PharmD (Urban Health Plan, Inc), Mickey Eder, PhD (Access Community Health Network), William Hobston, MS (WATTS Healthcare Corporation), Paloma Hernandez, MPH, MS (Urban Health Plan, Inc), Vanesscia John, MSW, MPA (California Primary care Association), Patrick McShane (Beaufort-Jasper Hampton Comprehensive Health Services), Chaya Merrill, MPH, DrPH (Children’s National Medical Center), Mark Minier, MD (Unity Health Care, Inc.), Greg Nycz (Family Health Center of Marshfield, Inc), Luis Padilla, MD (Unity Health Care, Inc), Perry Payne, MD, MJ, MPP (The George Washington University), Sara Rosenbaum, JD (The George Washington University), Sarena Seifer, MD (Community-Campus Partnership
250 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Identifying Key Patient Demographics and Organizational Factors
W
ITH MORE THAN 9000 health care delivery sites that serve more than 21 million low-income and underserved patients in every state and territory in the United States (Bureau of Primary Health Care, 2013), Federally Qualified Health Centers are not only an essential source of comprehensive primary care but are also a largely untapped wealth of community-based resources, knowledge, and expertise for public health and health services research. Federally Qualified Health Centers are commonly referred to as Community, Migrant, Homeless, and Public Housing Health Centers. Not only do health centers provide highquality and culturally competent health care to populations that experience the most severe health disparities, they also understand their local community and have a deep, significant knowledge of the people they serve (Richard et al., 2012). In fact, federal law mandates that health centers be run by patient-majority governing boards. Health center–based research often builds off of health centers’ existing experience and skills in conducting formal and regular needs assessments, engaging in quality improvement activities, mining electronic health data for trends, and participating in various networks. Furthermore, health centers balance their mission of delivering quality health services in high-need communities with often limited funding and scarce resources, which requires them to seek innovative operating strategies and clinical interventions to improve the health of their communities. These unique characteristics of health centers’ mission, clin-
for Health), Jonathan Tobin, PhD (Clinical Directors Network, Inc), Rosy Chang Weir, PhD (Association of Asian Pacific Community Health Organizations), and Vicki Young, PhD (South Carolina Primary Health Care Association). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Peter Shin, PhD, MPH, Department of Health Policy, The Milken Institute School of Public Health, George Washington University, 2021 K St., NW Ste 800, Washington, DC 20006 ([email protected]). DOI: 10.1097/JAC.0000000000000006
251
ical operations, and community knowledge place health centers at the intersection where research translates to practice. Despite health centers’ substantial role in both local communities and in the broader safety net, very limited research has been conducted on the research experiences, infrastructure, or needs of health centers on a national basis, although many health centers have participated in local assessments. Many of these projects demonstrated that similar challenges, barriers, and facilitators of health centers’ engagement in research activities exist across the board. Several studies indicated that financial concerns, poor resource allocation, and inadequate reimbursement of services are among the most substantial challenges in health center–based research (Devoe et al., 2011; Riedy et al., 2007; Weiss et al., 2011). Studies have cited a lack of staff and dedicated training as predominant barriers, while others have indicated that obtaining the buy-in and commitment from clinic leadership, staff, and the community at large can be a challenge to conducting research in health center settings (Daniels et al., 2005; Riedy et al., 2007). Common strategies contributing to successful research partnerships within health centers have included a shared vision among all research partners, collaborations in recruitment and retention of patients, demonstrating feasibility and costeffectiveness, sharing systems and processes, and building infrastructure and capacity for research at health centers (Davis et al., 2009; Devoe et al., 2011; Khankari et al., 2007). Lemon et al. (2006) developed one of the more robust composite lists of both challenges and strategies to overcome barriers to conducting research by focusing on 2 urban community health centers in Massachusetts. The most frequently noted challenges were categorized by intervention level, including those experienced at the system level, which included data collection, scheduling, staffing, and communication issues; those at the provider level, which included perceptions, demands, and lack of key skills; and finally, those at the patient level, which included competing priorities, issues of mistrust,
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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lack of transportation, and communication challenges. Among the approaches used to mitigate these challenges, the authors cited several strategies on the basis of study design, recruitment and retention of participants, quality improvements, and training for providers and staff. Despite these barriers and in light of the promising strategies to mitigate such challenges, health centers remain an important piece of the community-driven research process. Moreover, recent studies indicate that health centers report a high interest in engaging further in community-based research. A recent study demonstrated that many community-based health organizations that serve specifically Asian American, Native Hawaiians, and Pacific Islanders are engaged in health-related research, and most reported that they were interested in building additional research capacity (Kwon et al., 2012). While the study focused on a particular patient population, it may be indicative of a similar sentiment across other health centers that would like to expand their engagement in research activities. While a few studies confirm what has been learned about barriers and facilitators of health center research at the local level, no national compendium of these key factors has been developed to date. Understanding the most substantial barriers to conducting research in health center settings and exploring the characteristics of successful health center research models will help to provide valuable insight on which resources are needed to continue building capacity for health centers to address high-priority community research questions. This article examines key factors that are associated with health center research capacity and seeks to identify potential policy levers for facilitating health center engagement in research. METHODS The analysis is based on the national survey of health centers conducted under the Clinical and Translational Science Institute at Children’s National Medical Center and The
George Washington University and in collaboration with the National Association of Community Health Centers, the Community Health Applied Research Network, the South Carolina Primary Health Care Association, and the University of South Carolina. The health center research survey was administered in 2011 to all 1124 federally funded health centers and had a response rate of 35.3% (n = 386). The survey sample is nationally representative with results from health centers in all 50 states, the District of Columbia, Puerto Rico, and the Virgin Islands. Health centers were classified by whether they conducted research, defined in the survey as A systematic investigation designed with the intention of (1) advancing knowledge (e.g., designed to draw conclusions or inferences), and (2) publishing or otherwise publicly disseminating the results to audiences outside the local community served. Research that is conducted in collaboration or partnership with others is also considered research for the purposes of this survey.
To identify and assess factors that affect health center engagement, this survey was linked to health center organizational administrative data reports, which are annually submitted under the Health Resources and Services Administration’s Uniform Data System. Variables of interest included health center characteristics such as urban or rural location, electronic health record adoption, as well as characteristics of their patient populations and provider mix. Statistical analyses (t tests, χ 2 tests, and binary logistic regression) were run to assess differences between the 2 groups on the basis of research engagement. FINDINGS The analysis examined key operational and patient variables on health center research engagement across 2 levels of research participation: those that are actively engaged in sponsored research (N = 216; note that most results refer to 213 centers because 3 health centers were look-alikes and do not have Uniform Data System data) and health centers
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JACM
JACM-D-13-00074
May 20, 2014
17:13
Identifying Key Patient Demographics and Organizational Factors that have not engaged in funded research activities and remain uninterested in doing so (N = 117). Table 1 shows the proportion of health centers located in urban and rural settings as well as other key organizational characteristics. Health centers engaged in research are more likely to be located in urban communities and to be a Health Care for the Homeless grantee. Both groups of health centers similarly receive migrant health and public housing primary care grants and have adopted full or partial electronic health record. Table 2 shows the patient and performance profile of each group of health centers. While both groups of health centers share many similarities, health centers that are engaged in sponsored research are more likely to have a greater proportion of minority patients. Differences in financial stability (calculated by dividing total revenue by total expenditures), total revenue from Bureau of Primary Health Care (BPHC) grants, and total revenue from Medicaid were not found to be significant. On average, health centers that are actively engaged in sponsored research tend to be larger than their counterparts. Health centers that have done research serve an average of 27 515 patients, nearly twice as many as their counterparts (15 537). Given the larger prac-
253
tice size of health centers engaged in research, it was not surprising to find that those centers also reported greater numbers of full-time equivalent staff (206 compared with 99, respectively). Health centers that had done research had a higher physician-to-nonphysician provider (ie, nurse practitioner, physician assistant, certified nurse midwife) ratios and a higher-enabling services providers-to-patients ratio than health centers that had not done research. Table 3 presents results from the bivariate logistic regression that used the variables of large health center size (measured by total patients), urban location, proportion of minority patients, and status as a Health Care for the Homeless grantee, enabling services provider-to-patient ratio, the ratio of physicians-to-nonphysician providers, Medicaid revenue per Medicaid patient, and total revenue per patient. Health center size and enabling services providers per 10 000 patients were found to be the leading drivers of health center participation in research. While racial and ethnic diversity may also contribute to health center participation in research, the model indicates that it is not significant when controlling for other factors. As shown in Table 2, although Medicaid patients as a proportion of total patients was not significant,
Table 1. Location, Grantee Type, and Research Interests and Partnershipsa
Number of CHCs Location (n = 330) Rural Urban EHR adoption (n = 330) Full or partial EHR adoption No EHR adoption Grantee type (n = 330) Migrant health center grantee Health Care for the Homeless grantee Public housing primary care grantee
Have Done Research
Have Not Done Research and Not Interested
216
117
39.0% 61.0%
58.1% 41.9%
85.0% 15.0%
82.9% 17.1%
15.5% 24.4% 7.5%
13.7% 12.0% 5.1%
χ 2 Significance .001
.621
.657 .007 .406
Abbreviations: CHCs, community health centers; EHR, electronic health record. a Bold values indicate significant differences. From 2011 UDS data and the 2011 CHC Research Survey.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Table 2. Characteristics of Health Centers by Research Engagementa
Characteristics (Means) Total patients Physician FTEs per 10 000 patients Nonphysician provider FTEs per 10 000 patients Physician-to-nonphysician provider ratio Dental provider FTEs per 10 000 patients Behavioral health provider FTEs per 10 000 patients Enabling services providers FTEs per 10 000 patients Patients uninsured Total patients on Medicaid Patients younger than 18 y Female patients Minority patients Operating margin Total revenue from Medicaid Total revenue from BPHC grants Medicaid revenue/Medicaid patient Total revenue/patient Two-year olds immunized Women with Pap tests Children and adolescents aged 3-17 y with a BMI percentile, and counseling on nutrition and physical activity documented for the current year Patients ≥18 y with (1) BMI charted and (2) follow-up plan documented if patients are overweight or underweight Patients queried about tobacco use one or more times in the measurement year or prior year Tobacco users ≥18 y who have received cessation advice or medication Patients aged 5-40 y diagnosed with asthma who have an acceptable pharmacological treatment plan Having first prenatal visit in first trimester
Have Done Research (n = 213)
Have Not Done Research and Not Interested (n = 117)
T Test Significance
27 515 4.7 4.4
15 537 4.2 4.3
.000 .061 .844
1.8
1.3
.002
5.2
5.3
.742
5.4
3.3
.391
8.7
5.1
.000
38.2% 35.6% 29.5% 57.6% 59.6% 1.04 31.6% 21.5% $668
35.7% 34.7% 28.5% 58.3% 46.1% 1.05 31.8% 24.0% $573
.230 .611 .427 .339 .000 .691 .940 .145 .021
$795 41.1% 55.6% 34.9%
$644 39.4% 52.4% 28.3%
.001 .584 .113 .027
39.1%
33.9%
.041
80.9%
79.4%
.574
55.8%
50.9%
.117
72.6%
73.6%
.703
72.2%
71.8%
.865 (continues)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Table 2. Characteristics of Health Centers by Research Engagement (Continued)
Characteristics (Means) Low and very low birth weight Hypertensive patients with blood pressure
JACM-D-13-00074
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J Ambulatory Care Manage Vol. 37, No. 3, pp. 250–257 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Identifying Key Patient Demographics and Organizational Factors That Contribute to Health Center Participation in Research Peter Shin, PhD, MPH; Jessica Sharac, MSc, MPH; Tishra Beeson, MPH; Michelle Proser, MPP; Michelle Jester, MA Abstract: Federally Qualified Health Centers are well positioned for translational research given their diverse patient population, unique characteristics, and community knowledge. This was the first national survey that assessed their research activities. Those with research experience were more likely to be urban and Health Care for the Homeless grantees and had more patients, minority patients, and physicians relative to nonphysician providers, enabling services providers, Medicaid revenues per Medicaid patient, and total revenues per patient than health centers with no experience and no future interest in research. Only enabling services providers to patient ratios and total patients remained significant after controlling for other factors. Key words: community-engaged research, community health centers, Federally Qualified Health Centers, research capacity, translational research
Author Affiliations: Geiger Gibson/RCHN Community Health Foundation Research, New York, New York (Dr Shin); Department of Health Policy, The Milken Institute School of Public Health, George Washington University, Washington, District of Columbia (Dr Shin and Mss Sharac and Beeson); and, Public Policy and Research, National Association of Community Health Centers, Washington, District of Columbia (Mss Proser and Jester). This project was supported by the Clinical and Translational Science Institute at Children’s National Medical Center and The George Washington University (through the NIH CTSA program # UL1TR000075) with additional support from the RCHN Community Health Foundation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health. The authors thank individuals at the Community Health Applied Research Network (CHARN), the South Carolina Primary Health Care Association (SCPHCA), and the University of South Carolina (USC) for their partnership in designing and fielding the survey
instrument. Special thanks goes to Vicki Young, PhD, and Dayna Campbell, MS (SCPHCA); Heather Brandt, PhD, and Tisha Felder, PhD (USC); and Rosy Chang Weir, PhD, Shelly Enos, MPH, Suzanne Gillespie, MA, MS, Stefan Massimino, MS, Reesa Laws, Christine Nelson, PhD, RN, Mary Oneha, PhD, Thu Quach, PhD, ShaoChee Sim, PhD, Robbie Singal, MPH, Hui Song, MPH, MS, and Fikirte Wagaw, MPH (CHARN). The authors also thank the following individuals for their input on designing the survey instrument and/or providing feedback on the analysis: Franco Basanti, PharmD (Urban Health Plan, Inc), Mickey Eder, PhD (Access Community Health Network), William Hobston, MS (WATTS Healthcare Corporation), Paloma Hernandez, MPH, MS (Urban Health Plan, Inc), Vanesscia John, MSW, MPA (California Primary care Association), Patrick McShane (Beaufort-Jasper Hampton Comprehensive Health Services), Chaya Merrill, MPH, DrPH (Children’s National Medical Center), Mark Minier, MD (Unity Health Care, Inc.), Greg Nycz (Family Health Center of Marshfield, Inc), Luis Padilla, MD (Unity Health Care, Inc), Perry Payne, MD, MJ, MPP (The George Washington University), Sara Rosenbaum, JD (The George Washington University), Sarena Seifer, MD (Community-Campus Partnership
250 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Identifying Key Patient Demographics and Organizational Factors
W
ITH MORE THAN 9000 health care delivery sites that serve more than 21 million low-income and underserved patients in every state and territory in the United States (Bureau of Primary Health Care, 2013), Federally Qualified Health Centers are not only an essential source of comprehensive primary care but are also a largely untapped wealth of community-based resources, knowledge, and expertise for public health and health services research. Federally Qualified Health Centers are commonly referred to as Community, Migrant, Homeless, and Public Housing Health Centers. Not only do health centers provide highquality and culturally competent health care to populations that experience the most severe health disparities, they also understand their local community and have a deep, significant knowledge of the people they serve (Richard et al., 2012). In fact, federal law mandates that health centers be run by patient-majority governing boards. Health center–based research often builds off of health centers’ existing experience and skills in conducting formal and regular needs assessments, engaging in quality improvement activities, mining electronic health data for trends, and participating in various networks. Furthermore, health centers balance their mission of delivering quality health services in high-need communities with often limited funding and scarce resources, which requires them to seek innovative operating strategies and clinical interventions to improve the health of their communities. These unique characteristics of health centers’ mission, clin-
for Health), Jonathan Tobin, PhD (Clinical Directors Network, Inc), Rosy Chang Weir, PhD (Association of Asian Pacific Community Health Organizations), and Vicki Young, PhD (South Carolina Primary Health Care Association). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Peter Shin, PhD, MPH, Department of Health Policy, The Milken Institute School of Public Health, George Washington University, 2021 K St., NW Ste 800, Washington, DC 20006 ([email protected]). DOI: 10.1097/JAC.0000000000000006
251
ical operations, and community knowledge place health centers at the intersection where research translates to practice. Despite health centers’ substantial role in both local communities and in the broader safety net, very limited research has been conducted on the research experiences, infrastructure, or needs of health centers on a national basis, although many health centers have participated in local assessments. Many of these projects demonstrated that similar challenges, barriers, and facilitators of health centers’ engagement in research activities exist across the board. Several studies indicated that financial concerns, poor resource allocation, and inadequate reimbursement of services are among the most substantial challenges in health center–based research (Devoe et al., 2011; Riedy et al., 2007; Weiss et al., 2011). Studies have cited a lack of staff and dedicated training as predominant barriers, while others have indicated that obtaining the buy-in and commitment from clinic leadership, staff, and the community at large can be a challenge to conducting research in health center settings (Daniels et al., 2005; Riedy et al., 2007). Common strategies contributing to successful research partnerships within health centers have included a shared vision among all research partners, collaborations in recruitment and retention of patients, demonstrating feasibility and costeffectiveness, sharing systems and processes, and building infrastructure and capacity for research at health centers (Davis et al., 2009; Devoe et al., 2011; Khankari et al., 2007). Lemon et al. (2006) developed one of the more robust composite lists of both challenges and strategies to overcome barriers to conducting research by focusing on 2 urban community health centers in Massachusetts. The most frequently noted challenges were categorized by intervention level, including those experienced at the system level, which included data collection, scheduling, staffing, and communication issues; those at the provider level, which included perceptions, demands, and lack of key skills; and finally, those at the patient level, which included competing priorities, issues of mistrust,
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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lack of transportation, and communication challenges. Among the approaches used to mitigate these challenges, the authors cited several strategies on the basis of study design, recruitment and retention of participants, quality improvements, and training for providers and staff. Despite these barriers and in light of the promising strategies to mitigate such challenges, health centers remain an important piece of the community-driven research process. Moreover, recent studies indicate that health centers report a high interest in engaging further in community-based research. A recent study demonstrated that many community-based health organizations that serve specifically Asian American, Native Hawaiians, and Pacific Islanders are engaged in health-related research, and most reported that they were interested in building additional research capacity (Kwon et al., 2012). While the study focused on a particular patient population, it may be indicative of a similar sentiment across other health centers that would like to expand their engagement in research activities. While a few studies confirm what has been learned about barriers and facilitators of health center research at the local level, no national compendium of these key factors has been developed to date. Understanding the most substantial barriers to conducting research in health center settings and exploring the characteristics of successful health center research models will help to provide valuable insight on which resources are needed to continue building capacity for health centers to address high-priority community research questions. This article examines key factors that are associated with health center research capacity and seeks to identify potential policy levers for facilitating health center engagement in research. METHODS The analysis is based on the national survey of health centers conducted under the Clinical and Translational Science Institute at Children’s National Medical Center and The
George Washington University and in collaboration with the National Association of Community Health Centers, the Community Health Applied Research Network, the South Carolina Primary Health Care Association, and the University of South Carolina. The health center research survey was administered in 2011 to all 1124 federally funded health centers and had a response rate of 35.3% (n = 386). The survey sample is nationally representative with results from health centers in all 50 states, the District of Columbia, Puerto Rico, and the Virgin Islands. Health centers were classified by whether they conducted research, defined in the survey as A systematic investigation designed with the intention of (1) advancing knowledge (e.g., designed to draw conclusions or inferences), and (2) publishing or otherwise publicly disseminating the results to audiences outside the local community served. Research that is conducted in collaboration or partnership with others is also considered research for the purposes of this survey.
To identify and assess factors that affect health center engagement, this survey was linked to health center organizational administrative data reports, which are annually submitted under the Health Resources and Services Administration’s Uniform Data System. Variables of interest included health center characteristics such as urban or rural location, electronic health record adoption, as well as characteristics of their patient populations and provider mix. Statistical analyses (t tests, χ 2 tests, and binary logistic regression) were run to assess differences between the 2 groups on the basis of research engagement. FINDINGS The analysis examined key operational and patient variables on health center research engagement across 2 levels of research participation: those that are actively engaged in sponsored research (N = 216; note that most results refer to 213 centers because 3 health centers were look-alikes and do not have Uniform Data System data) and health centers
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JACM
JACM-D-13-00074
May 20, 2014
17:13
Identifying Key Patient Demographics and Organizational Factors that have not engaged in funded research activities and remain uninterested in doing so (N = 117). Table 1 shows the proportion of health centers located in urban and rural settings as well as other key organizational characteristics. Health centers engaged in research are more likely to be located in urban communities and to be a Health Care for the Homeless grantee. Both groups of health centers similarly receive migrant health and public housing primary care grants and have adopted full or partial electronic health record. Table 2 shows the patient and performance profile of each group of health centers. While both groups of health centers share many similarities, health centers that are engaged in sponsored research are more likely to have a greater proportion of minority patients. Differences in financial stability (calculated by dividing total revenue by total expenditures), total revenue from Bureau of Primary Health Care (BPHC) grants, and total revenue from Medicaid were not found to be significant. On average, health centers that are actively engaged in sponsored research tend to be larger than their counterparts. Health centers that have done research serve an average of 27 515 patients, nearly twice as many as their counterparts (15 537). Given the larger prac-
253
tice size of health centers engaged in research, it was not surprising to find that those centers also reported greater numbers of full-time equivalent staff (206 compared with 99, respectively). Health centers that had done research had a higher physician-to-nonphysician provider (ie, nurse practitioner, physician assistant, certified nurse midwife) ratios and a higher-enabling services providers-to-patients ratio than health centers that had not done research. Table 3 presents results from the bivariate logistic regression that used the variables of large health center size (measured by total patients), urban location, proportion of minority patients, and status as a Health Care for the Homeless grantee, enabling services provider-to-patient ratio, the ratio of physicians-to-nonphysician providers, Medicaid revenue per Medicaid patient, and total revenue per patient. Health center size and enabling services providers per 10 000 patients were found to be the leading drivers of health center participation in research. While racial and ethnic diversity may also contribute to health center participation in research, the model indicates that it is not significant when controlling for other factors. As shown in Table 2, although Medicaid patients as a proportion of total patients was not significant,
Table 1. Location, Grantee Type, and Research Interests and Partnershipsa
Number of CHCs Location (n = 330) Rural Urban EHR adoption (n = 330) Full or partial EHR adoption No EHR adoption Grantee type (n = 330) Migrant health center grantee Health Care for the Homeless grantee Public housing primary care grantee
Have Done Research
Have Not Done Research and Not Interested
216
117
39.0% 61.0%
58.1% 41.9%
85.0% 15.0%
82.9% 17.1%
15.5% 24.4% 7.5%
13.7% 12.0% 5.1%
χ 2 Significance .001
.621
.657 .007 .406
Abbreviations: CHCs, community health centers; EHR, electronic health record. a Bold values indicate significant differences. From 2011 UDS data and the 2011 CHC Research Survey.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Table 2. Characteristics of Health Centers by Research Engagementa
Characteristics (Means) Total patients Physician FTEs per 10 000 patients Nonphysician provider FTEs per 10 000 patients Physician-to-nonphysician provider ratio Dental provider FTEs per 10 000 patients Behavioral health provider FTEs per 10 000 patients Enabling services providers FTEs per 10 000 patients Patients uninsured Total patients on Medicaid Patients younger than 18 y Female patients Minority patients Operating margin Total revenue from Medicaid Total revenue from BPHC grants Medicaid revenue/Medicaid patient Total revenue/patient Two-year olds immunized Women with Pap tests Children and adolescents aged 3-17 y with a BMI percentile, and counseling on nutrition and physical activity documented for the current year Patients ≥18 y with (1) BMI charted and (2) follow-up plan documented if patients are overweight or underweight Patients queried about tobacco use one or more times in the measurement year or prior year Tobacco users ≥18 y who have received cessation advice or medication Patients aged 5-40 y diagnosed with asthma who have an acceptable pharmacological treatment plan Having first prenatal visit in first trimester
Have Done Research (n = 213)
Have Not Done Research and Not Interested (n = 117)
T Test Significance
27 515 4.7 4.4
15 537 4.2 4.3
.000 .061 .844
1.8
1.3
.002
5.2
5.3
.742
5.4
3.3
.391
8.7
5.1
.000
38.2% 35.6% 29.5% 57.6% 59.6% 1.04 31.6% 21.5% $668
35.7% 34.7% 28.5% 58.3% 46.1% 1.05 31.8% 24.0% $573
.230 .611 .427 .339 .000 .691 .940 .145 .021
$795 41.1% 55.6% 34.9%
$644 39.4% 52.4% 28.3%
.001 .584 .113 .027
39.1%
33.9%
.041
80.9%
79.4%
.574
55.8%
50.9%
.117
72.6%
73.6%
.703
72.2%
71.8%
.865 (continues)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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255
Table 2. Characteristics of Health Centers by Research Engagement (Continued)
Characteristics (Means) Low and very low birth weight Hypertensive patients with blood pressure
