Primary care clinicians' opinions before and after implementation of cancer screening and prevention clinical decision support in a clinic cluster-randomized control trial: a survey research study.

BACKGROUND: Electronic health record (EHR)-linked clinical decision support (CDS) may impact primary care clinicians' (PCCs') clinical care opinions. As part of a clinic cluster-randomized control trial (RCT) testing a cancer prevention and screening CDS system with patient and PCC printouts (with or without shared decision-making tools [SDMT]) for patients due for breast, cervical, colorectal, and lung cancer screening and/or human papillomavirus (HPV) vaccination compared to usual care (UC), we surveyed PCCs at study clinics pre- and post-CDS implementation. Our primary aim was to learn if PCCs' opinions changed over time within study arms. Secondary aims including examining whether PCCs' opinions in study arms differed both pre- and post-implementation, and gauging PCCs' opinions on the CDS in the two intervention arms. METHODS: This study was conducted within a healthcare system serving an upper Midwestern population. We administered pre-implementation (11/2/2017-1/24/2018) and post-implementation (2/2/2020-4/9/2020) cross-sectional electronic surveys to PCCs practicing within a RCT arm: UC; CDS; or CDS + SDMT. Bivariate analyses compared responses between study arms at both time periods and longitudinally within study arms. RESULTS: Pre-implementation (53%, n = 166) and post-implementation (57%, n = 172) response rates were similar. No significant differences in PCC responses were seen between study arms on cancer prevention and screening questions pre-implementation, with few significant differences found between study arms post-implementation. However, significantly fewer intervention arm clinic PCCs reported being very comfortable with discussing breast cancer screening options with patients compared to UC post-implementation, as well as compared to the same intervention arms pre-implementation. Other significant differences were noted within arms longitudinally. For intervention arms, these differences related to CDS areas like EHR alerts, risk calculators, and ordering screening. Most intervention arm PCCs noted the CDS provided overdue screening alerts to which they were unaware. Few PCCs reported using the CDS, but most would recommend it to colleagues, expressed high CDS satisfaction rates, and thought patients liked the CDS's information and utility. CONCLUSIONS: While appreciated by PCCs with high satisfaction rates, the CDS may lower PCCs' confidence regarding discussing patients' breast cancer screening options and may be used irregularly. Future research will evaluate the impact of the CDS on cancer prevention and screening rates. TRIAL REGISTRATION: clinicaltrials.gov , NCT02986230, December 6, 2016.

Assessing the implementation of a clinical decision support tool in primary care for diabetes prevention: a qualitative interview study using the Consolidated Framework for Implementation Science.

BACKGROUND: In this paper we describe the use of the Consolidated Framework for Implementation Research (CFIR) to study implementation of a web-based, point-of-care, EHR-linked clinical decision support (CDS) tool designed to identify and provide care recommendations for adults with prediabetes (Pre-D CDS). METHODS: As part of a large NIH-funded clinic-randomized trial, we identified a convenience sample of interview participants from 22 primary care clinics in Minnesota, North Dakota, and Wisconsin that were randomly allocated to receive or not receive a web-based EHR-integrated prediabetes CDS intervention. Participants included 11 clinicians, 6 rooming staff, and 7 nurse or clinic managers recruited by study staff to participate in telephone interviews conducted by an expert in qualitative methods. Interviews were recorded and transcribed, and data analysis was conducted using a constructivist version of grounded theory. RESULTS: Implementing a prediabetes CDS tool into primary care clinics was useful and well received. The intervention was integrated with clinic workflows, supported primary care clinicians in clearly communicating prediabetes risk and management options with patients, and in identifying actionable care opportunities. The main barriers to CDS use were time and competing priorities. Finally, while the implementation process worked well, opportunities remain in engaging the care team more broadly in CDS use. CONCLUSIONS: The use of CDS tools for engaging patients and providers in care improvement opportunities for prediabetes is a promising and potentially effective strategy in primary care settings. A workflow that incorporates the whole care team in the use of such tools may optimize the implementation of CDS tools like these in primary care settings. Trial registration Name of the registry: Clinicaltrial.gov. TRIAL REGISTRATION NUMBER: NCT02759055. Date of registration: 05/03/2016. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT02759055 Prospectively registered.

Clinician perceptions of a clinical decision support system to reduce cardiovascular risk among prediabetes patients in a predominantly rural healthcare system.

BACKGROUND: The early detection and management of uncontrolled cardiovascular risk factors among prediabetes patients can prevent cardiovascular disease (CVD). Prediabetes increases the risk of CVD, which is a leading cause of death in the United States. CVD clinical decision support (CDS) in primary care settings has the potential to reduce cardiovascular risk in patients with prediabetes while potentially saving clinicians time. The objective of this study is to understand primary care clinician (PCC) perceptions of a CDS system designed to reduce CVD risk in adults with prediabetes. METHODS: We administered pre-CDS implementation (6/30/2016 to 8/25/2016) (n = 183, 61% response rate) and post-CDS implementation (6/12/2019 to 8/7/2019) (n = 131, 44.5% response rate) independent cross-sectional electronic surveys to PCCs at 36 randomized primary care clinics participating in a federally funded study of a CVD risk reduction CDS tool. Surveys assessed PCC demographics, experiences in delivering prediabetes care, perceptions of CDS impact on shared decision making, perception of CDS impact on control of major CVD risk factors, and overall perceptions of the CDS tool when managing cardiovascular risk. RESULTS: We found few significant differences when comparing pre- and post-implementation responses across CDS intervention and usual care (UC) clinics. A majority of PCCs felt well-prepared to discuss CVD risk factor control with patients both pre- and post-implementation. About 73% of PCCs at CDS intervention clinics agreed that the CDS helped improve risk control, 68% reported the CDS added value to patient clinic visits, and 72% reported they would recommend use of this CDS system to colleagues. However, most PCCs disagreed that the CDS saves time talking about preventing diabetes or CVD, and most PCCs also did not find the clinical domains useful, nor did PCCs believe that the clinical domains were useful in getting patients to take action. Finally, only about 38% reported they were satisfied with the CDS. CONCLUSIONS: These results improve our understanding of CDS user experience and can be used to guide iterative improvement of the CDS. While most PCCs agreed the CDS improves CVD and diabetes risk factor control, they were generally not satisfied with the CDS. Moreover, only 40-50% agreed that specific suggestions on clinical domains helped patients to take action. In spite of this, an overwhelming majority reported they would recommend the CDS to colleagues, pointing for the need to improve upon the current CDS. TRIAL REGISTRATION: NCT02759055 03/05/2016.

The impact of personalized clinical decision support on primary care patients' views of cancer prevention and screening: a cross-sectional survey.

BACKGROUND: Few studies have assessed the impact of clinical decision support (CDS), with or without shared decision-making tools (SDMTs), on patients' perceptions of cancer screening or prevention in primary care settings. This cross-sectional survey was conducted to understand primary care patient's perceptions on cancer screening or prevention. METHODS: We mailed surveys (10/2018-1/2019) to 749 patients aged 18 to 75 years within 15 days after an index clinical encounter at 36 primary care clinics participating in a clinic-randomized control trial of a CDS system for cancer prevention. All patients were overdue for cancer screening or human papillomavirus vaccination. The survey compared respondents' answers by study arm: usual care; CDS; or CDS + SDMT. RESULTS: Of 387 respondents (52% response rate), 73% reported having enough time to discuss cancer prevention options with their primary care provider (PCP), 64% reported their PCP explained the benefits of the cancer screening choice very well, and 32% of obese patients reported discussing weight management, with two-thirds reporting selecting a weight management intervention. Usual care respondents were significantly more likely to decide on colorectal cancer screening than CDS respondents (p < 0.01), and on tobacco cessation than CDS + SDMT respondents (p = 0.02) and both CDS and CDS + SDMT respondents (p < 0.001). CONCLUSIONS: Most patients reported discussing cancer prevention needs with PCPs, with few significant differences between the three study arms in patient-reported cancer prevention care. Upcoming research will assess differences in screening and vaccination rates between study arms during the post-intervention follow-up period. TRIAL REGISTRATION: clinicaltrials.gov , NCT02986230 , December 6, 2016.

Enhancing the pediatric dentistry skills and knowledge of general dentists.

The purpose of this study was to evaluate the outcomes of a training initiative aimed at enhancing general dentists' knowledge and clinical skills in pediatric dentistry. Data were gathered from participants in 2-day didactic and preclinical training courses offered at Nicklaus Children's Hospital from December 2015 through December 2016. Clinical knowledge was measured with a 30-item questionnaire, and self-efficacy was measured with standardized instruments. The participants' satisfaction with the course was measured at the end of the program. Data on patterns of treatment were collected pretraining and 3 months posttraining via a follow-up survey. During the study period, 38 general dentists participated in the training program and reported statistically significant increases in knowledge and cognitive skills (P < 0.05). All of the respondents to the follow-up survey reported an increase in the number of children treated and scope of services provided, and all respondents expressed satisfaction with the course (response rate = 34.2%). Training initiatives seeking to enhance the clinical skills and knowledge of general dentists may be an effective tool for modifying patterns of treatment, increasing access to care for children, and maximizing the capacity of the safety net system.

Pre-implementation adaptation of primary care cancer prevention clinical decision support in a predominantly rural healthcare system.

BACKGROUND: Cancer is a leading cause of death in the United States. Primary care providers (PCPs) juggle patient cancer prevention and screening along with managing acute and chronic health problems. However, clinical decision support (CDS) may assist PCPs in addressing patients' cancer prevention and screening needs during short clinic visits. In this paper, we describe pre-implementation study design and cancer screening and prevention CDS changes made to maximize utilization and better fit a healthcare system's goals and culture. We employed the Consolidated Framework for Implementation Research (CFIR), useful for evaluating the implementation of CDS interventions in primary care settings, in understanding barriers and facilitators that led to those changes. METHODS: In a three-arm, pragmatic, 36 clinic cluster-randomized control trial, we integrated cancer screening and prevention CDS and shared decision-making tools (SDMT) into an existing electronic medical record-linked cardiovascular risk management CDS system. The integrated CDS is currently being tested within a predominately rural upper Midwestern healthcare system. Prior to CDS implementation, we catalogued pre-implementation changes made from 2016 to 2018 based on: pre-implementation site engagement; key informant interviews with healthcare system rooming staff, providers, and leadership; and pilot testing. We identified influential barriers, facilitators, and changes made in response through qualitative content analysis of meeting minutes and supportive documents. We then coded pre-implementation changes made and associated barriers and facilitators using the CFIR. RESULTS: Based on our findings from system-wide pre-implementation engagement, pilot testing, and key informant interviews, we made changes to accommodate the needs of the healthcare system based on barriers and facilitators that fell within the Intervention Characteristics, Inner Setting, and Outer Setting CFIR domains. Changes included replacing the expansion of medical assistant roles in one intervention arm with targeted SDMT, as well as altering cancer prevention CDS and study design elements. CONCLUSIONS: Pre-implementation changes to CDS may help meet healthcare systems' evolving needs and optimize the intervention by being responsive to real-world implementation barriers and facilitators. Frameworks like the CFIR are useful tools for identifying areas where pre-implementation barriers and facilitators may result in design changes, both to research studies and CDS systems. TRIAL REGISTRATION: NCT02986230.

Barriers and facilitators to implementing cancer prevention clinical decision support in primary care: a qualitative study.

BACKGROUND: In the United States, primary care providers (PCPs) routinely balance acute, chronic, and preventive patient care delivery, including cancer prevention and screening, in time-limited visits. Clinical decision support (CDS) may help PCPs prioritize cancer prevention and screening with other patient needs. In a three-arm, pragmatic, clinic-randomized control trial, we are studying cancer prevention CDS in a large, upper Midwestern healthcare system. The web-based, electronic health record (EHR)-linked CDS integrates evidence-based primary and secondary cancer prevention and screening recommendations into an existing cardiovascular risk management CDS system. Our objective with this study was to identify adoption barriers and facilitators before implementation in primary care. METHODS: We conducted semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR) with 28 key informants employed by the healthcare organization in either leadership roles or the direct provision of clinical care. Transcribed interviews were analyzed using qualitative content analysis. RESULTS: EHR, CDS workflow, CDS users (providers and patients), training, and organizational barriers and facilitators were identified related to Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals CFIR domains. CONCLUSION: Identifying and addressing key informant-identified barriers and facilitators before implementing cancer prevention CDS in primary care may support a successful implementation and sustained use. The CFIR is a useful framework for understanding pre-implementation barriers and facilitators. Based on our findings, the research team developed and instituted specialized training, pilot testing, implementation plans, and post-implementation efforts to maximize identified facilitators and address barriers. TRIAL REGISTRATION: clinicaltrials.gov , NCT02986230 , December 6, 2016.

Understanding primary care providers' perceptions of cancer prevention and screening in a predominantly rural healthcare system in the upper Midwest.

BACKGROUND: Cancer is the leading cause of death in the United States, with the burden expected to rise in the coming decades, increasing the need for effective cancer prevention and screening options. The United States Preventive Services Task Force has suggested that a shared decision-making process be used when clinicians and patients discuss cancer screening. The electronic medical record (EMR) often provides only reminders or alerts to primary care providers (PCPs) when screenings are due, a strategy with limited efficacy. METHODS: We administered a cross-sectional electronic survey to PCPs (n = 165, 53% response rate) at 36 Essentia Health primary care clinics participating in a large, National Cancer Institute-funded study on a cancer prevention clinical decision support (CDS) tool. The survey assessed PCP demographics, perceptions of the EMR's ability to help assess and manage patients' cancer risk, and experience and comfort level discussing cancer screening and prevention with patients. RESULTS: In these predominantly rural clinics, only 49% of PCPs thought the EMR was well integrated to help assess and manage cancer risk. Both advanced care practitioners and physicians agreed that cancer screening and informed discussion of cancer risks are important; however, only 53% reported their patients gave cancer screening a high priority relative to other health issues. CONCLUSIONS: The impact of EMR-linked CDS delivered to both patients and PCPs may improve cancer screening, but only if it is easy to use and saves PCPs time.

Mapping suicide mortality in Ohio: A spatial epidemiological analysis of suicide clusters and area level correlates.

Previous studies have investigated spatial patterning and associations of area characteristics with suicide rates in Western and Asian countries, but few have been conducted in the United States. This ecological study aims to identify high-risk clusters of suicide in Ohio and assess area level correlates of these clusters. We estimated spatially smoothed standardized mortality ratios (SMR) using Bayesian conditional autoregressive models (CAR) for the period 2004 to 2013. Spatial and spatio-temporal scan statistics were used to detect high-risk clusters of suicide at the census tract level (N=2952). Logistic regression models were used to examine the association between area level correlates and suicide clusters. Nine statistically significant (p<0.05) high-risk spatial clusters and two space-time clusters were identified. We also identified several significant spatial clusters by method of suicide. The risk of suicide was up to 2.1 times higher in high-risk clusters than in areas outside of the clusters (relative risks ranged from 1.22 to 2.14 (p<0.01)). In the multivariate model, factors strongly associated with area suicide rates were socio-economic deprivation and lower provider densities. Efforts to reduce poverty and improve access to health and mental health medical services on the community level represent potentially important suicide prevention strategies.

Understanding Primary Care Provider Attitudes and Behaviors Regarding Cardiovascular Disease Risk and Diabetes Prevention in the Northern Midwest.

IN BRIEF We sought to fill critical gaps in understanding primary care providers' (PCPs') beliefs regarding diabetes prevention and cardiovascular disease risk in the prediabetes population, including through comparison of attitudes between rural and non-rural PCPs. We used data from a 2016 cross-sectional survey sent to 299 PCPs practicing in 36 primary clinics that are part of a randomized control trial in a predominately rural northern Midwestern integrated health care system. Results showed a few significant, but clinically marginal, differences between rural and non-rural PCPs. Generally, PCPs agreed with the importance of screening for prediabetes and thoroughly and clearly discussing CV risk with high-risk patients.

Passive Observer Instruction on Parental Satisfaction in a Dental Setting.

PURPOSE: To assess the effect of a single pre-operative instruction given to parents to be a passive observer on satisfaction with their child's dental visit. STUDY DESIGN: Parents of 105 healthy three to nine year-old patients presenting for their first restorative appointment were randomly assigned to the test or control group. The former received an oral instruction at the beginning of the appointment from the treating dentist to be a passive observer while the latter received a mock instruction. The dentist assessed whether the parent remained a passive observer during the visit. Parents completed a survey assessing satisfaction with their child's dental visit. RESULTS: More parents were rated as passive in the test group than in the control group, 67.3% vs. 32.1%, (P<0.01). However, no statistically significant difference was found in parental satisfaction between the test and the control group. CONCLUSION: Asking parents to act as passive observers may help preserve the advantages of parental presence in the operatory while eliminating many of the disadvantages. A single preoperative instruction given orally by the treating dentist to be a passive observer was effective and did not lead to a reduction in parental satisfaction.

A cross-sectional study on health differences between rural and non-rural U.S. counties using the County Health Rankings.

BACKGROUND: By examining 2013 County Health Rankings and Roadmaps data from the University of Wisconsin and the Robert Wood Johnson Foundation, this paper seeks to add to the available literature on health variances between United States residents living in rural and non-rural areas. We believe this is the first study to use the Rankings data to measure rural and urban health differences across the United States and therefore highlights the national need to address shortfalls in rural healthcare and overall health. The data indicates that U.S. residents living in rural counties are generally in poorer health than their urban counterparts. METHODS: We used 2013 County Health Rankings data to evaluate differences across the six domains of interest (mortality, morbidity, health behaviors, clinical care, social and economic factors, and physical environment) for rural and non-rural U.S. counties. This is a cross-sectional study employing chi-square analysis and logit regression. RESULTS: We found that residents living in rural U.S. counties are more likely to have poorer health outcomes along a variety of measurements that comprise the County Health Rankings' indexed domains of health quality. These populations have statistically significantly (p ≤ 0.05) lower scores in such areas as health behavior, morbidity factors, clinical care, and the physical environment. We attribute the differences to a variety of factors including limitations in infrastructure, socioeconomic differences, insurance coverage deficiencies, and higher rates of traffic fatalities and accidents. DISCUSSIONS: The largest differences between rural and non-rural counties were in the indexed domains of mortality and clinical care. CONCLUSIONS: Our analysis revealed differences in health outcomes in the County Health Rankings' indexed domains between rural and non-rural U.S. counties. We also describe limitations and offer commentary on the need for more uniform measurements in the classification of the terms rural and non-rural. These results can influence practitioners and policy makers in guiding future research and when deciding on funding allocation.

Job Satisfaction and Relocation Desire among Pediatric Dentists in Puerto Rico.

OBJECTIVE: To determine the levels of satisfaction, license status, and desire to relocate of pediatric dentists in Puerto Rico. METHODS: Pediatric dentists in Puerto Rico were surveyed via telephone interviews. Data were collected through a 34-item questionnaire that explored satisfaction as related to income, continuing education, professional goals, and participation in the Mi Salud program. Frequencies, chi-square analysis, and Fisher's exact 2-tailed t-test were utilized to determine the relationships between satisfaction and the demographics of the pediatric dentists. RESULTS: Sixty pediatric dentists participated in our survey-77% of the total number of pediatric dentists practicing in Puerto Rico. Overall, 65% of the participating pediatric dentists expressed dissatisfaction. Male pediatric dentists were more dissatisfied than their female colleagues were. Most pediatric dentists participating in Mi Salud expressed dissatisfaction. When asked about whether or not they had considered migrating to the mainland, those who were dissatisfied were more likely to have considered that idea than were those who were satisfied. Overall, 57% of the pediatric dentists comprising our sample had considered relocating to the continental United States. CONCLUSION: In general, the pediatric dentists who participated in our study expressed dissatisfaction in most areas except when asked about their ability to reach professional goals. Determining the levels of satisfaction of health care providers is important in the maintaining of an adequate workforce. As current levels of dissatisfaction are high, it is important to determine what variables are related to satisfaction so that corrective measures can be taken to ensure that retention rates improve, thereby maintaining an adequate pediatric dental workforce.

A population-based study of edentulism in the US: does depression and rural residency matter after controlling for potential confounders?

BACKGROUND: Oral health is an integral component of general health and well-being. While edentulism has been examined in relation to socioeconomic status, rural residency, chronic disease and mental health, no study that we know of has examined edentulism and these factors together. The objective of this study was to determine whether depression and rural residency were significantly associated with partial and full edentulism in US adults after controlling for potential confounders. METHODS: 2006 Behavioral Risk Factor Surveillance Survey (BRFSS) data were analyzed to identify factors associated with increased odds of partial or full edentulism. This year of BRFSS data was chosen for analysis because in this year the standardized and validated Personal Health Questionnaire-8 (PHQ-8) was used to measure current depression. This measure was part of the optional questions BRFSS asks, and in 2006 33 states and/or territories included them in their annual surveillance data collection. Bivariate and logistic regression analyses were performed on weighted BRFSS data. RESULTS: Logistic regression analysis using either full or partial edentulism as the dependent variable yielded that rural residency or living in a rural locale, low and/or middle socioeconomic status (SES), depression as measured by the PHQ-8, and African American race/ethnicity were all independent risk factors when controlling for these and a number of additional covariates. CONCLUSIONS: This study adds to the epidemiological literature by assessing partial and full edentulism in the US utilizing data from the CDC's Behavioral Risk Factor Surveillance System (BRFSS). Examining data collected through a large national surveillance system such as BRFSS allows for an analysis that incorporates an array of covariates not available from clinically-based data alone. This study demonstrated that current depression and rural residency are important factors related to partial and full edentulism after controlling for potential confounders.

Pediatric dentistry workforce in Puerto Rico: results of a 2011 survey.

OBJECTIVE: Determine the socio-demographic and educational characteristics of and develop a profile of practice for Pediatric Dentists (PDs) in Puerto Rico. METHODS: A 34-item questionnaire assessing 3 dimensions: socio-demographic and education, practice profile, and level of satisfaction/desire to relocate, was developed and pre-tested for comprehensiveness, validity, and reliability. Data were collected through telephone interviews by a calibrated interviewer, entered and tabulated using Excel (Microsoft Office 2010) and exported to SPSS v. 17 (SPSS Inc., Chicago, IL). Descriptive statistical analyses were conducted. RESULTS: Eighty percent (80%) of all of the licensed PDs in PR participated in our study. The typical PD in PR has been in practice for 19 years, is 48 years old, and spends 31 hours/week providing clinical care. Female PDs, who comprise 70% of the PD workforce, devote more time to clinical and managerial activities than do their male counterparts. Seventy-three percent (73%) of the current PD workforce will be retiring within the next 20 years and 70% are solo-practitioners. Most PDs (65%) participate in the government-subsidized dental insurance program "Mi Salud," which represents as much as 48% of their income. PDs beginning or ending their careers were more likely to be participating providers for "Mi Salud" than were those in mid-career. CONCLUSION: In evaluating the adequacy of the pediatric dentistry workforce in Puerto Rico, the socio-demographic information of the PDs and the characteristics of their practices must be taken into account. These variables must be examined in relation to epidemiological indicators as well as environmental factors, including the comprehensiveness of dental benefits and the adequacy of reimbursement levels by third-party payers, which when inadequate may lead to decreased access to care.

Adapting a clinical decision support system to improve identification of pediatric hypertension in a rural health system: Design of a pragmatic trial.

BACKGROUND: Identifying hypertension (HTN) early is crucial in preventing and lowering the long-term risk of heart disease, yet HTN in children often goes undiagnosed. An electronic health record linked, web-based clinical decision support (CDS) called PedsBP can help address this care gap and has been previously shown to increase recognition of HTN by primary care clinicians. OBJECTIVES: To adapt the PedsBP tool for use in a mostly rural health system and then to evaluate the effectiveness of PedsBP for repeat of hypertensive level blood pressure (BP) measurements and HTN recognition among youth 6-17 years of age in primary care settings, comparing low-intensity and high-intensity implementation approaches. METHODS AND DESIGN: PedsBP was evaluated through a pragmatic, clinic-randomized trial. The tool was piloted in 2 primary care clinics and modified prior to the full trial. Forty community-based, primary care clinics (or clusters of clinics) were randomly allocated in a 1:1:1 ratio to usual care, low-intensity implementation (CDS only), or high-intensity implementation (CDS plus in-person training, monthly use reports, and ongoing communication between study staff and clinics). Accrual of eligible patients started on August 1, 2022 and will continue for 18 months. Primary outcomes include repeating hypertensive level BP measurements at office visits and clinical recognition of HTN. Secondary outcomes include lifestyle counseling, dietician referral, and BP at follow-up. CONCLUSION: This report focuses on the design and feasibility of adapting and implementing PedsBP in a rural primary care setting. The trial and analysis are ongoing with main results expected in mid-2024.

Does place of residence affect risk of suicide? a spatial epidemiologic investigation in Kentucky from 1999 to 2008.

BACKGROUND: Approximately 32,000 people take their own lives every year in the United States. In Kentucky, suicide mortality rates have been steadily increasing since 1999. Few studies in the United States have assessed spatial clustering of suicides. The purpose of this study was to identify high-risk clusters of suicide at the county level in Kentucky and assess the characteristics of those suicide cases within the clusters. METHODS: A spatial epidemiological study was undertaken using suicide data for the period January 1, 1999 to December 31, 2008, obtained from the Kentucky Office of Vital Statistics. Descriptive analyses using Pearson's chi-square test and t-test were performed to determine whether differences existed in age, marital status, year, season, and suicide method between males and females, and between cases inside and outside high-risk spatial clusters. Annual age-adjusted cumulative incidence rates were also calculated. Suicide incidence rates were spatially smoothed using the Spatial Empirical Bayesian technique. Kulldorff's spatial scan statistic was applied on all suicide cases at the county level to identify counties with the highest risks of suicide. Temporal cluster analysis was also performed. RESULTS: There were a total of 5,551 suicide cases in Kentucky from 1999 to 2008, of which 5,237 (94%) were included in our analyses. The majority of suicide cases were males (82%). The average age of suicide victims was 45.4 years. Two statistically significant (p < 0.05) high-risk spatial clusters, involving 15 counties, were detected. The county level cumulative incidence rate in the most likely high-risk cluster ranged from 12.4 to 21.6 suicides per 100,000 persons. The counties inside both high-risk clusters had relative risks ranging from 1.24 to 1.38. CONCLUSIONS: Statistically significant high-risk spatial clusters of suicide were detected at the county level. This study may be useful for guiding future research and intervention efforts. Future studies will need to focus on these high-risk clusters to investigate reasons for these occurrences.

Comparison of Cavity Preparation Times Using Conventional High-Speed Handpiece Versus Er, Cr:YSGG Laser: A Pilot Study with Pediatric Dental Residents.

PURPOSE: The purpose of this study was to compare pediatric dental residents' comfort levels and cavity preparation time using an Er, Cr:YSGG laser versus a conventional high-speed handpiece. METHODS: This cross-sectional study was conducted on residents with no past restorative dental laser experience. A mixed-effects model was used to evaluate the difference in total time and comfort level between the laser and high-speed handpiece groups. RESULTS: A total of 131 teeth (high-speed handpiece group equals 79; laser group equals 52) were completed. The adjusted result showed that the estimated average difference in preparation time among the laser group was 1.92 minutes longer per tooth compared to the high-speed handpiece group. Similarly, when using a laser, residents had a 0.74 times lower rate of comfort compared to the high-speed handpiece group. CONCLUSIONS: The total preparation time required for restorative treatment with a laser was significantly higher than the total time with a high-speed handpiece. Additionally, the comfort level was also lower using a laser compared to a high-speed preparation.

Motivational Interviewing to Improve Pediatric Dental Recall Attendance after General Anesthesia.

Purpose: To determine the effect of motivational interviewing (MI) to improve recall attendance after dental treatment under general anesthesia (GA).
Methods: The sample consisted of parents of randomly selected pediatric patients who had oral rehabilitation under GA at a children's hospital. An 18-item questionnaire that included demographics, education, language, country of birth and age was administered prior to the GA appointment. A five-minute MI phone call three months after the procedure and a second MI phone call after the first recall was conducted by a standardized interviewer. The primary outcomes were attendance at the six- and 12-month recall visits. Data were compared to a historical control group of participants who did not receive the MI phone call during the same date range.
Results: Of 100 patients, 72 participated in the first phone call and 51 participated in the second phone call. All children had public insurance. The estimated odds of a six-month recall visit for parents receiving a single motivational interview was 2.52 times (95 percent confidence interval [95% CI]=1.43 to 4.44, P =0.001) higher compared to the control. The estimated odds of a 12-month recall visit for parents receiving two motivational interviews was 2.40 times greater (95% CI=1.27 to 4.54, P =0.006) compared to the historical control.
Conclusion: A brief intervention using MI led to an improvement in attendance at both the six- and 12-month recall visits.

Clinical Decision Support with or without Shared Decision Making to Improve Preventive Cancer Care: A Cluster-Randomized Trial.

BACKGROUND: Innovative interventions are needed to address gaps in preventive cancer care, especially in rural areas. This study evaluated the impact of clinical decision support (CDS) with and without shared decision making (SDM) on cancer-screening completion. METHODS: In this 3-arm, parallel-group, cluster-randomized trial conducted at a predominantly rural medical group, 34 primary care clinics were randomized to clinical decision support (CDS), CDS plus shared decision making (CDS+SDM), or usual care (UC). The CDS applied web-based clinical algorithms identifying patients overdue for United States Preventive Services Task Force-recommended preventive cancer care and presented evidence-based recommendations to patients and providers on printouts and on the electronic health record interface. Patients in the CDS+SDM clinic also received shared decision-making tools (SDMTs). The primary outcome was a composite indicator of the proportion of patients overdue for breast, cervical, or colorectal cancer screening at index who were up to date on these 1 y later. RESULTS: From August 1, 2018, to March 15, 2019, 69,405 patients aged 21 to 74 y had visits at study clinics and 25,198 were overdue for 1 or more cancer screening tests at an index visit. At 12-mo follow-up, 9,543 of these (37.9%) were up to date on the composite endpoint. The adjusted, model-derived percentage of patients up to date was 36.5% (95% confidence interval [CI]: 34.0-39.1) in the UC group, 38.1% (95% CI: 35.5-40.9) in the CDS group, and 34.4% (95% CI: 31.8-37.2) in the CDS+SDM group. For all comparisons, the screening rates were higher than UC in the CDS group and lower than UC in the CDS+SDM group, although these differences did not reach statistical significance. CONCLUSION: The CDS did not significantly increase cancer-screening rates. Exploratory analyses suggest a deeper understanding of how SDM and CDS interact to affect cancer prevention decisions is needed. Trial registration: ClinicalTrials.gov ID: NCT02986230, December 6, 2016.