Alex Krist

Virginia Commonwealth University | VCU · Department of Family Practice and Population Health

This Viewpoint discusses the Whole Health System of care led by the US Department of Veterans Affairs.

Background Recruiting underrepresented people and communities in research is essential for generalizable findings. Ensuring representative participants can be particularly challenging for practice-level dissemination and implementation trials. Novel use of real-world data about practices and the communities they serve could promote more equitable a...

Objective: Clinical practice guidelines are often created through collaboration among organizations. Use of inconsistent terminology may cause poor communication and delays. This study aimed to develop a glossary of terms related to collaboration in guideline development. Study design and setting: A literature review of collaborative guidelines...

Introduction : There were over 100,000 fatal drug overdoses in the US in 2021 alone. In recent years, there has been a shift in opioid mortality from predominantly White rural communities to Black urban communities. This study aimed to identify Virginia communities disproportionately affected by the overdose crisis and to better understand systemic...

Purpose: The US Preventive Services Task Force (USPSTF) is an independent body that makes evidence-based recommendations regarding preventive services to improve health for people nationwide. Here, we summarize current USPSTF methods, describe how methods are evolving to address preventive health equity, and define evidence gaps for future researc...

Background: Electronic health records (EHRs) have been connected to excessive workload and physician burnout. Little is known about variation in physician experience with different EHRs, however. Objective: To analyze variation in reported usability and satisfaction across EHRs. Design: Internet-based survey available between December 2021 and...

Context: Patients with MCC have a range of needs that extend beyond traditional medical care including behavioral, mental health, and social needs. While primary care does its best to address these needs, few practices can undertake a systematic approach without broader health system and coordinated community support. We are conducting a randomized...

BACKGROUND Nearly one third of those with diabetes are poorly controlled (hemoglobin A1c of ≥9.0%). Identifying at-risk individuals and providing them with effective treatment is an important strategy for preventing poor control. OBJECTIVE The objective is to assess how clinicians and staff would use a clinical decision support tool based on artif...

Background Nearly one-third of patients with diabetes are poorly controlled (hemoglobin A1c≥9%). Identifying at-risk individuals and providing them with effective treatment is an important strategy for preventing poor control. Objective This study aims to assess how clinicians and staff members would use a clinical decision support tool based on a...

Our objective was to externally validate 2 simple risk scores for mortality among a mostly inpatient population with COVID-19 in Canada (588 patients for COVID-NoLab and 479 patients for COVID-SimpleLab). The mortality rates in the low-, moderate-, and high-risk groups for COVID-NoLab were 1.1%, 9.6%, and 21.2%, respectively. The mortality rates fo...

Objectives: To help better control chronic conditions we need to address root causes of poor health like unhealthy behaviors, mental health, and social needs. However, addressing these needs in primary care is difficult. One solution may be connecting patients with a navigator for support creating a personal care goal. Methods: As part of an RCT...

Purpose: Primary care is the foundation of the health care workforce and the only part that extends life and improves health equity. Previous research on the geographic and specialty distribution of physicians has relied on the American Medical Association's Masterfile, but these data have limitations that overestimate the workforce. Methods: We...

Introduction It is not realistic for most clinicians to perform the multitude of recommended preventive primary care services. This is especially true in low resource and rural settings, creating challenges to delivering high-quality care. This study collected stakeholder input from clinicians on which services they most need to improve. Methods T...

Background: Developmental disabilities (DD) affect over 10% of children 0-5 years of age, and early interventions are known to improve outcomes, yet barriers remain in connecting children to these services. Objective: To identify gaps in services for young children with DD and established risk conditions in Virginia. Methods: Data from the 201...

Purpose: Gun violence is a growing public health epidemic that disproportionately affects underserved and minority communities. Our study sought to document patient experiences of community gun violence as a theme that emerged in the context of interviews exploring community-level factors influencing patients' engagement in primary care within the...

Background: Addressing social needs, health behaviors, and mental health may help patients more than traditional medical care. However, these root causes of poor health are difficult to address and the role of primary care is unclear. This qualitative study assesses patient’s willingness and motivations to discuss and accept assistance for these ne...

Importance: Glaucoma affects an estimated 2.7 million people in the US. It is the second-leading cause of irreversible blindness in the US and the leading cause of blindness in Black and Hispanic/Latino persons. Objective: To update its 2013 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evalua...

Importance: Impairment of visual acuity is a serious public health problem in older adults. The number of persons 60 years or older with impaired visual acuity (defined as best corrected visual acuity worse than 20/40 but better than 20/200) was estimated at 2.91 million in 2015, and the number who are blind (defined as best corrected visual acuit...

Importance: Cardiovascular disease (CVD) is the leading cause of mortality in the US, accounting for more than 1 in 4 deaths. Each year, an estimated 605 000 people in the US have a first myocardial infarction and an estimated 610 000 experience a first stroke. Objective: To update its 2016 recommendation, the US Preventive Services Task Force (...

Objectives An accurate prognostic score to predict mortality for adults with COVID-19 infection is needed to understand who would benefit most from hospitalizations and more intensive support and care. We aimed to develop and validate a two-step score system for patient triage, and to identify patients at a relatively low level of mortality risk us...

The COVID-19 pandemic led to an increased need to conduct research and community engagement using digital methods. Unfortunately, the shift away from in-person research activities can make it difficult to engage and recruit participants from under-resourced communities that lack adequate digital infrastructure. At the beginning of the pandemic, our...

Introduction: A multitude of preventive services is recommended for primary care to conduct – too many for most clinicians to realistically perform. This is especially true in low resource and rural settings, creating challenges to delivering high-quality care. This study collected stakeholder input from clinicians on which services they most need...

Context: There were 50,000 U.S. opioid overdose deaths in 2019. Millions suffer from opioid addiction. Identifying protective factors for low community opioid mortality may have important implications for addressing the opioid epidemic. This study was funded through the Virginia (VA) Department of Medical Assistance Services (DMAS) through a SUPPO...

Background: In order to evaluate the capacity of primary care to provide comprehensive, coordinated, continuous care, a description of the primary care workforce is necessary. There have been prior efforts to describe the distribution of primary care, however, an accurate and timely description of which clinicians are in what location has been lack...

Introduction: Health behaviors, mental health, and social needs impact health, but addressing these needs is difficult. Clinicians can partner with community programs to provide patients support. The relationship between program location and community need is uncertain. Methods: We identified and geolocated community programs in Richmond, Virgin...

Community-engaged research (CEnR) is now an established research approach. The current research seeks to pilot the systematic and automated identification and categorization of CEnR to facilitate longitudinal tracking using administrative data. We inductively analyzed and manually coded a sample of Institutional Review Board (IRB) protocols. Compar...

Background: Primary care is crucial to the health of individuals and communities, but it faces numerous structural and systemic challenges. Our study assessed the state of primary care in Virginia to prepare for Medicaid expansion. It also provides insight into the frontline of health care prior to an unprecedented global COVID-19 pandemic. Method...

Importance US life expectancy and health outcomes for preventable causes of disease have continued to lag in many populations that experience racism. Objective To propose iterative changes to US Preventive Services Task Force (USPSTF) processes, methods, and recommendations and enact a commitment to eliminate health inequities for people affected...

To contribute to the national effort to combat the opioid crisis, the United States Preventive Services Task Force (USPSTF) commissioned a scoping review to describe the state of evidence for the primary prevention of opioid misuse or use disorder in persons not yet prescribed opioids or not yet misusing opioids. Patnode CD et al., 2021 As found by...

Clinical preventive service recommendations from the US Preventive Services Task Force (USPSTF) are based on transparent, systematic, and rigorous methods that consider the certainty of the evidence and magnitude of net benefit. These guidelines aim to address the needs of diverse populations. Biological sex and gender identity are sources of diver...

This report describes how stakeholder groups informed a web-based care planning tool’s development for addressing root causes of poor health. Stakeholders included community members (n=6), researchers (n=6), community care providers (n=9), and patients (n=17). Feedback was solicited through focus groups, semi-structured interviews, and user-experie...

Background and objectives: The American Academy of Pediatrics recommends against the routine use of β-agonists, corticosteroids, antibiotics, chest radiographs, and viral testing in bronchiolitis, but use of these modalities continues. Our objective for this study was to determine the patient, provider, and health care system characteristics that...

A National Academies of Sciences, Engineering, and Medicine committee developed a plan to implement high-quality primary care. One of the 5 key objectives was designing information technology that serves the patient, family, and interprofessional care team. The committee defined high-quality primary care as the provision of whole person, integrated...

Importance Chlamydia and gonorrhea are among the most common sexually transmitted infections in the US. Infection rates are highest among adolescents and young adults of both sexes. Chlamydial and gonococcal infections in women are usually asymptomatic and may lead to pelvic inflammatory disease and its associated complications. Newborns of pregnan...

Importance In its mission to improve health, the US Preventive Services Task Force (USPSTF) recognizes the strong relationship between a person’s health and social and economic circumstances as well as persistent inequities in health care delivery. Objective To assess how social risks have been considered in USPSTF recommendation statements and id...

Importance An estimated 13% of all US adults (18 years or older) have diabetes, and 34.5% meet criteria for prediabetes. The prevalences of prediabetes and diabetes are higher in older adults. Estimates of the risk of progression from prediabetes to diabetes vary widely, perhaps because of differences in the definition of prediabetes or the heterog...

BACKGROUND Community-Engaged Research (CEnR) is a research approach in which scholars partner with community organizations or individuals with whom they share an interest in the study topic, typically with the goal of supporting that community’s wellbeing. CEnR is well-established in numerous disciplines including the clinical and social sciences....

Background Community-engaged research (CEnR) is a research approach in which scholars partner with community organizations or individuals with whom they share an interest in the study topic, typically with the goal of supporting that community’s well-being. CEnR is well-established in numerous disciplines including the clinical and social sciences....

Importance The prevalence of overweight and obesity is increasing among persons of childbearing age and pregnant persons. In 2015, almost half of all persons began pregnancy with overweight (24%) or obesity (24%). Reported rates of overweight and obesity are higher among Black, Alaska Native/American Indian, and Hispanic women and lower among White...

Importance Colorectal cancer is the third leading cause of cancer death for both men and women, with an estimated 52 980 persons in the US projected to die of colorectal cancer in 2021. Colorectal cancer is most frequently diagnosed among persons aged 65 to 74 years. It is estimated that 10.5% of new colorectal cancer cases occur in persons younger...

Introduction: Clinical preventive services can reduce mortality and morbidity, but Americans receive only half of the recommended care. Although wellness visits protect time for clinicians to review needs and discuss care with patients, studies have not shown that having a wellness visit improves health outcomes. This study seeks to understand the...

Importance: Hypertension is a prevalent condition that affects approximately 45% of the adult US population and is the most commonly diagnosed condition at outpatient office visits. Hypertension is a major contributing risk factor for heart failure, myocardial infarction, stroke, and chronic kidney disease. Objective: To reaffirm its 2015 recomm...

Importance Vitamin D is a fat-soluble vitamin that performs an important role in calcium homeostasis and bone metabolism and also affects many other cellular regulatory functions outside the skeletal system. Vitamin D requirements may vary by individual; thus, no one serum vitamin D level cutpoint defines deficiency, and no consensus exists regardi...

Background Patients with type 2 diabetes require recommendations for self-management education and support. Objective In this study, we aim to design the Diabetes Engagement and Activation Platform (DEAP)—an automated patient education tool integrated into primary care workflow—and examine its implementation and effectiveness. Methods We invited...

Importance Age-related sensorineural hearing loss is a common health problem among adults. Nearly 16% of US adults 18 years or older report difficulty hearing. The prevalence of perceived hearing loss increases with age. Hearing loss can adversely affect an individual’s quality of life and ability to function independently and has been associated w...

Importance Lung cancer is the second most common cancer and the leading cause of cancer death in the US. In 2020, an estimated 228 820 persons were diagnosed with lung cancer, and 135 720 persons died of the disease. The most important risk factor for lung cancer is smoking. Increasing age is also a risk factor for lung cancer. Lung cancer has a ge...

Importance: Carotid artery stenosis is atherosclerotic disease that affects extracranial carotid arteries. Asymptomatic carotid artery stenosis refers to stenosis in persons without a history of ischemic stroke, transient ischemic attack, or other neurologic symptoms referable to the carotid arteries. The prevalence of asymptomatic carotid artery...

Purpose: Develop and validate simple risk scores based on initial clinical data and no or minimal laboratory testing to predict mortality in hospitalized adults with COVID-19. Methods: We gathered clinical and initial laboratory variables on consecutive inpatients with COVID-19 who had either died or been discharged alive at 6 US health centers....

Importance Tobacco use is the leading preventable cause of disease, disability, and death in the US. In 2014, it was estimated that 480 000 deaths annually are attributed to cigarette smoking, including second hand smoke exposure. Smoking during pregnancy can increase the risk of numerous adverse pregnancy outcomes (eg, miscarriage and congenital a...

Background: There is no commonly accepted comprehensive framework for describing the practical specifics of external support for practice change. Our goal was to develop such a taxonomy that could be used by both external groups or researchers and health care leaders. Methods: The leaders of 8 grants from Agency for Research and Quality for the...

Introduction: In December 2013, cholesterol treatment guidelines changed the approach to statin therapy by recommending fixed doses of low-, medium-, or high-intensity statins based on cardiovascular risk. We sought to evaluate the guideline's adoption in a diverse group of practices. Methods: Using a mixed-methods approach, we analyzed electron...

UNSTRUCTURED Aims: To help patients with type 2 diabetes receive recommended self-management education and support (DSMES), we designed the Diabetes Engagement and Activation Platform (DEAP) – an automated patient education tool integrated into primary care workflow – and examined its implementation and effectiveness. Methods: We invited patients a...

Importance An estimated 862 000 persons in the US are living with chronic infection with hepatitis B virus (HBV). Persons born in regions with a prevalence of HBV infection of 2% or greater, such as countries in Africa and Asia, the Pacific Islands, and parts of South America, often become infected at birth and account for up to 95% of newly report...

Objective Prenatal care (PNC) and well child visit (WCV) attendance are associated with improved health outcomes. We aimed to determine if the factors affecting maternal and child attendance are similar or different. Methods We conducted a retrospective case control study at Virginia Commonwealth University Health System. We used the Adequacy of P...

Importance Cardiovascular disease (CVD) is a leading cause of death in the US. Known modifiable risk factors for CVD include smoking, overweight and obesity, diabetes, elevated blood pressure or hypertension, dyslipidemia, lack of physical activity, and unhealthy diet. Adults who adhere to national guidelines for a healthy diet and physical activit...

Context: Many patients with multiple chronic conditions (MCC’s) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical interventions provide limited benefit when patients are struggling to address these other needs. Health systems increasingly recognize the need to address these needs through connecting patients wi...

Context: Many patients with multiple chronic conditions (MCC) have social risks, mental health needs, and/or unhealthy behaviors. These needs interfere with patients’ ability to manage their MCC. The ability of these patients to manage their MCC may be improved by supporting primary care clinicians and patients to create care plans and collaborate...

Context: Many patients with poorly controlled chronic conditions also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical interventions may have limited benefit if patients are struggling to address these needs. We are studying an Enhanced Care Planning process using the My Own Health Report (MOHR) risk assessment an...

Importance Prevalence of hypertension (both primary and secondary) in children and adolescents in the US ranges from 3% to 4%. Primary hypertension in children and adolescents occurs primarily in children older than 13 years and has no known cause but is associated with several risk factors, including family history and higher body mass index. Seco...

The 20th century heralded major advancements in pediatric health care including vaccinations, antibiotics, and sophisticated radiographic studies. These interventions led to substantial improvements in child mortality. Yet, as medical interventions became more commonplace, concerns about negative health effects developed. As a result, many of the c...

Introduction: Screening for colorectal cancer is beneficial. Yet, screening remains suboptimal, and underserved populations are at greater risk for not being appropriately screened. Although many barriers to screening are understood, less is known about how the decision-making process on whether to receive colonoscopy or stool testing influences s...

Importance Approximately 20 million new cases of bacterial or viral sexually transmitted infections (STIs) occur each year in the US, and about one-half of these cases occur in persons aged 15 to 24 years. Rates of chlamydial, gonococcal, and syphilis infection continue to increase in all regions. Sexually transmitted infections are frequently asym...

Background: Many patients with multiple chronic conditions (MCC) have social risks, mental health needs, and/or unhealthy behaviors which interfere with patients’ ability to manage their MCC. A care planning tool to be used collectively by patients, clinicians, patient navigators, and community health workers was created to help patients address th...

The purpose of the U.S. Preventive Services Task Force (USPSTF) is to provide evidence-b