A comparison of electronic health records and the Oregon state immunization registry for human papilloma virus vaccine delivery (2005-2022).

INTRODUCTION: Immunization Information Systems (IIS) play an important information-sharing role at the point of care, and provide vital vaccination data for research studies and policy-makers. Previous validation studies comparing the accuracy of state registry data to health records have had mixed results. METHODS: We conducted a retrospective review of EHR vaccination data for 9-17 year-old patients from 10 Oregon primary care clinics who had at least one ambulatory care visit in the past 3 years from the date of validation data collection. Data on 100 age eligible youth were captured per clinic. We compared HPV and Tdap vaccinations captured in the EHR to the Oregon ALERT IIS. All clinics were located in rural areas with both family medicine (n = 7) and pediatric (n = 3) primary care clinics. RESULTS: Overall agreement for HPV vaccination between EHR and ALERT IIS was 89.4 % (k = 0.83; p < 0.05). For Tdap vaccination overall agreement was 80.8 % (k = 0.60; p < 0.05). Pediatric clinics showed a higher overall vaccine agreement for both HPV at 93.3 % (k = 0.89; p < 0.05) and Tdap at 95.3 % (k = 0.90; p < 0.05). Among clinics that used bidirectional data exchange (only family medicine clinics), HPV agreement was higher at 91 % (k = 0.85) versus 88 % (k = 0.81; p < 0.05) and was lower for Tdap 75 % with bidirectional data exchange (k = 0.50) versus 86 % without bidirectional data exchange (k = 0.70; p < 0.05). When the EHR and ALERT IIS disagreed, ALERT ISS usually had additional vaccines. CONCLUSIONS: ALERT IIS data provides more accurate data than EHRs can provide when measuring vaccine delivery among adolescents in rural Oregon.

Impact of the COVID-19 vaccination mandate on the primary care workforce and differences between rural and urban settings to inform future policy decision-making.

INTRODUCTION: Little is known about the impact of mandated vaccination policies on the primary care clinic workforce in the United States or differences between rural and urban settings, especially for COVID-19. With the continued pandemic and an anticipated increase in novel disease outbreaks and emerging vaccines, healthcare systems need additional information on how vaccine mandates impact the healthcare workforce to aid in future decision-making. METHODS: We conducted a cross-sectional survey of Oregon primary care clinic staff between October 28, 2021- November 18, 2021, following implementation of a COVID-19 vaccination mandate for healthcare personnel. The survey consisted of 19 questions that assessed the clinic-level impacts of the vaccination mandate. Outcomes included job loss among staff, receipt of an approved vaccination waiver, new vaccination among staff, and the perceived significance of the policy on clinic staffing. We used univariable descriptive statistics to compare outcomes between rural and urban clinics. The survey also included three open-ended questions that were analyzed using a template analysis approach. RESULTS: Staff from 80 clinics across 28 counties completed surveys, representing 38 rural and 42 urban clinics. Clinics reported job loss (46%), use of vaccination waivers (51%), and newly vaccinated staff (60%). Significantly more rural clinics (compared to urban) utilized medical and/or religious vaccination waivers (71% vs 33%, p = 0.04) and reported significant impact on clinic staffing (45% vs 21%, p = 0.048). There was also a non-significant trend toward more job loss for rural compared to urban clinics (53% vs. 41%, p = 0.547). Qualitative analysis highlighted a decline in clinic morale, small but meaningful detriments to patient care, and mixed opinions of the vaccination mandate. CONCLUSIONS: Oregon's COVID-19 vaccination mandate increased healthcare personnel vaccination rates, yet amplified staffing challenges with disproportionate impacts in rural areas. Staffing impacts in primary care clinics were greater than reported previously in hospital settings and with other vaccination mandates. Mitigating primary care staffing impacts, particularly in rural areas, will be critical in response to the continued pandemic and novel viruses in the future.

Improving screening, treatment, and intervention for unhealthy alcohol use in primary care through clinic, practice-based research network, and health plan partnerships: Protocol of the ANTECEDENT study.

BACKGROUND: Unhealthy alcohol use (UAU) is a leading cause of morbidity and mortality in the United States, contributing to 95,000 deaths annually. When offered in primary care, screening, brief intervention, referral to treatment (SBIRT), and medication-assisted treatment for alcohol use disorder (MAUD) can effectively address UAU. However, these interventions are not yet routine in primary care clinics. Therefore, our study evaluates tailored implementation support to increase SBIRT and MAUD in primary care. METHODS: ANTECEDENT is a pragmatic implementation study designed to support 150 primary care clinics in Oregon adopting and optimizing SBIRT and MAUD workflows to address UAU. The study is a partnership between the Oregon Health Authority Transformation Center-state leaders in Medicaid health system transformation-SBIRT Oregon and the Oregon Rural Practice-based Research Network. We recruited clinics providing primary care in Oregon and prioritized reaching clinics that were small to medium in size (<10 providers). All participating clinics receive foundational support (i.e., a baseline assessment, exit assessment, and access to the online SBIRT Oregon materials) and may opt to receive tailored implementation support delivered by a practice facilitator over 12 months. Tailored implementation support is designed to address identified needs and may include health information technology support, peer-to-peer learning, workflow mapping, or expert consultation via academic detailing. The study aims are to 1) engage, recruit, and conduct needs assessments with 150 primary care clinics and their regional Medicaid health plans called Coordinated Care Organizations within the state of Oregon, 2) implement and evaluate the impact of foundational and supplemental implementation support on clinic change in SBIRT and MAUD, and 3) describe how practice facilitators tailor implementation support based on context and personal expertise. Our convergent parallel mixed-methods analysis uses RE-AIM (reach, effectiveness, adoption, implementation, maintenance). It is informed by a hybrid of the i-PARIHS (integrated Promoting Action on Research Implementation in Health Services) and the Dynamic Sustainability Framework. DISCUSSION: This study will explore how primary care clinics implement SBIRT and MAUD in routine practice and how practice facilitators vary implementation support across diverse clinic settings. Findings will inform how to effectively align implementation support to context, advance our understanding of practice facilitator skill development over time, and ultimately improve detection and treatment of UAU across diverse primary care clinics.

Mapping Rural and Urban Veterans' Spatial Access to Primary Care Following the MISSION Act.

BACKGROUND: The 2018 MISSION Act sought to improve Veterans' access to primary care by allowing Veterans living more than 30 min from VA care to utilize non-VA clinics. The impact of this legislation may vary for rural compared to urban Veterans. OBJECTIVE: Assess the extent to which the 2018 MISSION Act facilitates spatial access to primary care for Veterans living in rural versus urban Oregon. DESIGN: We identified locations of all VA and non-VA primary care clinics in Oregon then calculated 30-min drive-time catchment areas from census tract centroids to the nearest clinics. We compared measures of spatial access to primary care for Veterans in rural, micropolitan, and urban areas. PARTICIPANTS: American Community Survey data representing Oregon adults. MAIN MEASURES: Two measures of spatial access focusing on the number of clinics (supply), and an access index based on the two-step floating catchment area method (2SFCA) which accounts for number of clinics (supply) and population size (demand). KEY RESULTS: Compared to only 13.0% of rural Veterans, 83.6% of urban Veterans lived within 30 min' drive time of VA primary care. Given the MISSION Act's eligibility criteria, 81.6% of rural Veterans and ~ 97% of urban and micropolitan Veterans had spatial access to primary care. When accounting for both supply and demand, rural areas had significantly higher access scores (p < 0.05) compared to urban areas. CONCLUSIONS: Using MISSION Act guidelines for Veteran access to primary care, rural compared to urban Veterans had less spatial access based on clinic number (supply), but more access when considering clinic number and population size (supply and demand). Geographic Information System (GIS) spatial techniques may help to assess changes in access to care. However, these methods do not incorporate all dimensions of access and work is needed to understand whether utilization and quality of care is improved.

Consolidated Framework for Collaboration Research derived from a systematic review of theories, models, frameworks and principles for cross-sector collaboration.

Cross-sector collaboration is needed to address root causes of persistent public health challenges. We conducted a systematic literature review to identify studies describing theories, models, frameworks and principles for cross-sector collaboration and synthesized collaboration constructs into the Consolidated Framework for Collaboration Research (CFCR). Ninety-five articles were included in the review. Constructs were abstracted from articles and grouped into seven domains within the framework: community context; group composition; structure and internal processes; group dynamics; social capital; activities that influence or take place within the collaboration; activities that influence or take place within the broader community; and activities that influence or take place both in the collaboration and in the community. Community engagement strategies employed by collaborations are discussed, as well as recommendations for using systems science methods for testing specific mechanisms of how constructs identified in the review influence one another. Researchers, funders, and collaboration members can use the consolidated framework to articulate components of collaboration and test mechanisms explaining how collaborations function. By working from a consolidated framework of collaboration terms and using systems science methods, researchers can advance evidence for the efficacy of cross-sector collaborations.

Mailed FIT (fecal immunochemical test), navigation or patient reminders? Using microsimulation to inform selection of interventions to increase colorectal cancer screening in Medicaid enrollees.

Colorectal cancer (CRC) can be effectively prevented or detected with guideline concordant screening, yet Medicaid enrollees experience disparities. We used microsimulation to project CRC screening patterns, CRC cases averted, and life-years gained in the population of 68,077 Oregon Medicaid enrollees 50-64 over a five year period starting in January 2019. The simulation estimated the cost-effectiveness of five intervention scenarios - academic detailing plus provider audit and feedback (Detailing+), patient reminders (Reminders), mailing a Fecal Immunochemical Test (FIT) directly to the patient's home (Mailed FIT), patient navigation (Navigation), and mailed FIT with Navigation (Mailed FIT + Navigation) - compared to usual care. Each intervention scenario raised CRC screening rates compared to usual care, with improvements as high as 11.6 percentage points (Mailed FIT + Navigation) and as low as 2.5 percentage points (Reminders) after one year. Compared to usual care, Mailed FIT + Navigation would raise CRC screening rates 20.2 percentage points after five years - averting nearly 77 cancer cases (a reduction of 113 per 100,000) and exceeding national screening targets. Over a five year period, Reminders, Mailed FIT and Mailed FIT + Navigation were expected to be cost effective if stakeholders were willing to pay $230 or less per additional year up-to-date (at a cost of $22, $59, and $227 respectively), whereas Detailing+ and Navigation were more costly for the same benefits. To approach national CRC screening targets, health system stakeholders are encouraged to implement Mailed FIT with or without Navigation and Reminders.