November 9, 2020

In his first few years working as a clinician in Clackamas County, Oregon, Dr. John Heintzman, MD, MPH, Lead Clinician Scientist at OCHIN and Affiliate Investigator at Oregon Health & Science University (OHSU), realized that many patients do not have equal access to lifelong, high-quality primary care.

Curious to learn more about these health disparities, Dr. Heintzman pursued further public health and research training to study what drives health inequity, especially for Latino patients accessing primary care services in community health centers.

Today, Dr. Heintzman collaborates with other researchers at OCHIN and OHSU Family Medicine to use electronic health records to better understand some of these inequalities in care. His most recent study, “Asthma Care Quality, Language and Ethnicity in a Multi-State Network of Low-Income Children,” was published in the Journal of the American Board of Family Medicine in October 2020. 

Read on to learn more about this study and his ongoing research that uses data from the ADVANCE Collaborative—the only community health center (CHC) focused Clinical Research Network within the PCORI-funded National Patient-Centered Clinical Research Network (PCORnet).

Q: Tell us more about your recent study,  Asthma Care Quality, Language and Ethnicity in a Multi-State Network of Low-Income Children. Why do you think a study like this is important?

A: The project is about the differences in asthma care across a nationwide network of CHCs. We used data from the ADVANCE network, which is unique because it focuses on ambulatory care in CHC settings, rather than academic or private payer datasets used in traditional research. The study compares the common primary care measures for asthma – one of the most common chronic diseases in childhood – and the varying data about the outcomes for Latino and Latina children with asthma.

The reason that I think this is important is that, if you think about chronic disease, there are several access points for primary care interventions to better help patients with the disease. I am interested in how care is utilized from the very first visit, how diseases present, how they are diagnosed, and then managed: the whole spectrum of primary care. This holistic framing is extremely understudied, but it speaks to the differing needs of diverse patients and the crucial role that community health centers play to bridge the gap in effective care delivery. If we can understand more about asthma management among different racial and ethnic groups, for example, we may be able to gain some insight into broader implications for managing other chronic diseases.

Q: What are some of your most significant findings?

A: Based on our research, we know that we cannot make blanket statements about any one ethnic or racial group. There are many important layers and variables to consider in evaluating potential barriers to health equity, and our job as researchers is to really drill down and better understand those. For example, one of the things we did in the asthma research study is that we differentiated English-preferring Latino children and Spanish-preferring Latino children. What we found is that English-preferring Latino children use primary care services like non-Hispanic white children and that, in many cases, Spanish-preferring Latino children utilize care more consistently – meaning that they are getting the medications and immunizations they need and have more appointments. For example, the study noted that Spanish-preferring Latino patients were significantly more likely to receive prescriptions for albuterol, corticosteroids, and oral steroids to treat asthma compared with non-Hispanic white children.

On the other hand, both Spanish- and English-preferring Latino children were less likely to have their asthma diagnosed at their first visit compared to non-Hispanic white children, which leads us to ask how to improve timely asthma diagnosis for Latino children. Additionally, the study’s results will give us opportunities to examine what successful providers and communities are already doing well, so that these practices can be replicated to improve patient care.

Q: What challenges do you face in your research?

A: There is always the challenge of taking the data that we have and trying to make those findings, and the discussion about those findings, as real-world and applicable as possible. Even in health equity research, it is easy to be abstract and not granular enough to be helpful to the people on the ground doing the work. As a clinician, I always want to know where the care gaps are for the patient in front of me. For example, I do not just want to know if the “asthma is worse.” I want to know if the patient is less likely to have a timely follow-up visit or if they are not receiving a certain vaccination or medication. This leads me to ask what we need to pay particular attention to in order to address patient care. However, that can also be tough to translate into a research project, which is why we are working to design projects to start meeting more of the needs on the ground.

Q:  What advice would you give to others interested in studying health equity?

A: We have been fortunate that our team at OCHIN and OHSU is a successful collaborative model, with a lot of people weighing in about research design and data collection, such as my colleague Miguel Marino, PhD, from OHSU. Dr. Marino co-leads these projects and is specifically pioneering ways to identify how Latinos from different national origins access care in chronic disease and how we might study this more effectively. Especially in health equity research, it is so important to have a great team and get a lot of different input on your work to make it stronger.

Q: What else are you working on? What’s next?

A: We are in the process of submitting a grant through OCHIN to study asthma in adults and we have a couple of other ongoing projects. I am interested in common primary care conditions between non-Hispanic patients and Latino patients, so most of our upcoming projects are related to how primary care is being delivered to different groups of people, such as studying preventive care in older adults or looking at cardiovascular disease prevention. We also have the opportunity, in the latter project, to understand how COVID-19 testing, positivity, and related changes in primary care visits, like more video encounters, may affect this screening. Further research to understand what really drives health disparities in the primary care setting is an important part of our team’s and OCHIN’s overall mission to advance health equity by improving access to care for those who need it most.