Societal costs of untreated perinatal mood and anxiety disorders in Vermont.

PURPOSE: To estimate the societal costs of untreated perinatal mood and anxiety disorders (PMADs) in Vermont for the 2018-2020 average annual birth cohort from conception through five years postpartum. METHODS: We developed a cost analysis model to calculate the excess cases of outcomes attributed to PMADs in the state of Vermont. Then, we modeled the associated costs of each outcome incurred by birthing parents and their children, projected five years for birthing parents who do not achieve remission by the end of the first year postpartum. RESULTS: We estimated that the total societal cost of untreated PMADs in Vermont could reach $48 million for an annual birth cohort from conception to five years postpartum, amounting to $35,910 in excess societal costs per birthing parent with an untreated PMAD and their child. CONCLUSION: Our model provides evidence of the high costs of untreated PMADs for birthing parents and their children in Vermont. Our estimates for Vermont are slightly higher but comparable to national estimates, which are $35,500 per birthing parent-child pair, adjusted to 2021 US dollars. Investing in perinatal mental health prevention and treatment could improve health outcomes and reduce economic burden of PMADs on individuals, families, employers, and the state.

Using Insurance Claims Data to Estimate Blastomycosis Incidence, Vermont, USA, 2011-2020.

The epidemiology of blastomycosis in Vermont, USA, is poorly understood. Using insurance claims data, we estimated the mean annual blastomycosis incidence was 1.8 patients/100,000 persons during 2011-2020. Incidence and disease severity were highest in north-central counties. Our findings highlight a need for improved clinical awareness and expanded surveillance.

The Potential of Real-Time Behavior and Well-Being Assessments to Improve Medical Student Wellness.

PROBLEM: Medical students experience psychological distress more frequently than age-matched peers. Tracking medical student well-being has typically been limited to once- or twice-per-year questionnaires. Ongoing, real-time assessment of student behavior and well-being could facilitate individualized, timely interventions. APPROACH: Faculty at the University of Vermont, in conjunction with the Larner College of Medicine Office of Medical Education, developed a novel smartphone app in 2021 called WE MD to track and support medical student wellness. The app included the following features: (1) nightly surveys assessing wellness-related behaviors (e.g., social interaction, sleep, exercise) and outcomes (i.e., mood, focus, stress, overall well-being); (2) health reports that enabled users to graph various combinations of their own behaviors and outcomes, allowing them to visualize trends and understand possible correlations between behaviors and outcomes; (3) a resource library with articles and educational videos related to specific wellness behaviors or outcomes; and (4) research-based "insights" or brief tips intended to promote healthy habits. Participants also received virtual "coins" for interacting with the app that could be exchanged for various items in an online store. OUTCOMES: The WE MD program enrolled a substantial portion of the medical school population (43%); most of the students used the app on a regular basis. Students found the app to be acceptable and appreciated many features and also provided feedback on how to improve the app. Information from the nightly survey data converged with established measures but also identified variability over time in wellness behaviors and outcomes. NEXT STEPS: Data from the WE MD program suggest that app-based daily tracking of wellness behaviors and outcomes is a feasible, promising approach to promote student wellness and identify real-time patterns and risk periods for medical students. The app will be revised based on student feedback and adapted for use by students, residents, and faculty.

An ethnographic study of a community dentistry network serving Latine migrant farmworkers in Vermont: Barriers and access to care during the COVID-19 pandemic and beyond.

BACKGROUND AND OBJECTIVES: Primary dental healthcare services are not accessible for a majority of Latino/a/e migrant farmworkers in the United States. Unmet dental health needs are well documented in larger states like California, Florida and New York, but the dental healthcare picture in smaller states is not well understood. The goal of this qualitative ethnographic study was to understand the delivery model of a free dentistry network serving Latine farmworkers in rural Vermont and specific barriers experienced at the network during the COVID-19 pandemic. METHODS: Semi-structured ethnographic interviews were carried out with clinicians and transcripts were analysed using the constant comparison method to identify salient concerns and recommendations about barriers and delivery of care. RESULTS: Clinicians highlighted structural issues including farmworkers' lack of time off work and absence of transportation to attend appointments, concerns about COVID-19 safety, concerns about immigration surveillance and language barriers. Providers outlined steps for improved service delivery including mobile care at local farms, enhanced intercultural training for providers, recognizing dentistry as essential healthcare at the state level and the leverage of existing appointments for preventive health. Drawing on anthropological frameworks of place-based care and deservingness of healthcare, our ethnographic findings emphasize the role of community dentistry in bridging gaps in migrant healthcare during and beyond the COVID-19 pandemic.

Determining Unmet Needs Among Workers' Compensation Stakeholders to Prevent Work Disability in the State of Vermont.

PURPOSE: Vermont has high rates of young people receiving federal disability benefits leading to substantial gaps in the workforce. The purpose of this project was to determine the unmet needs of interested parties in the workers' compensation (WC) process. METHODS: A type of focus group, experience groups, was used to elicit key parties' experiences in the WC system. Facilitators used open-ended prompts to encourage discussion among participants about their experience with the WC system. Data were analyzed using thematic coding procedures to identify common motifs. RESULTS: Common themes emerged including challenges in navigating the WC system, lack of communication among stakeholders, and providing and receiving appropriate health care to facilitate RTW. CONCLUSIONS: Understanding unmet needs of interested parties in the WC process allows for the creation of targeted, high-value, early intervention strategies to reduce long-term work disability.

Pharmacy benefit considerations for continuous glucose monitoring acquisition: Vermont Medicaid experience.

Many individuals with diabetes are not achieving their glycemic goals. Use of continuous glucose monitoring (CGM) improves diabetes management. Access to CGM is often hindered when individuals must acquire their supplies through the traditional durable medical device channel. Vermont Medicaid transitioned CGM coverage from a medical/durable medical equipment benefit to a pharmacy benefit. This improved access and lessened the burden on prescribing health care providers. We describe the process the Vermont Medicaid program implemented to make this transition. DISCLOSURES: Funding for editorial assistance in the development of this manuscript was provided by Abbott Diabetes Care. The funder had no input in the manuscript content. The authors received no compensation.

Statewide Assessment of the Hepatitis C Virus Care Cascade for Incarcerated Persons in Vermont.

OBJECTIVES: Incarcerated persons in the United States have a high burden of hepatitis C virus (HCV) infection. This study assessed the impact of a statewide effort in Vermont to treat HCV in this group. METHODS: We performed a retrospective, observational cohort study of all HCV-infected persons who were imprisoned in Vermont during the 19-month study period (December 2018-June 2020). The cascade of care comprised opt-out HCV screening, full access to direct-acting antiviral treatment (without hepatic fibrosis-based treatment restrictions), HCV specialist involvement, and medication-assisted treatment for patients with opioid use disorder. The primary outcome was sustained virologic response at 12 weeks after treatment completion (SVR12). RESULTS: The study included 217 HCV-infected patients; the median age was 35 years (range, 18-73 years), 89% were male, 76% had opioid use disorder, 67% had a psychiatric comorbidity, and 9% had cirrhosis. Of the 217 patients, 98% had a liver fibrosis assessment, 59% started direct-acting antiviral treatment, 55% completed direct-acting antiviral treatment, and 51% achieved documented SVR12. Of the 129 HCV-infected persons who started direct-acting antiviral treatment, 92% completed therapy and 86% achieved documented SVR12. Psychiatric comorbidity was not significantly associated with achieving SVR12 (odds ratio = 0.67; 95% CI, 0.27-1.65; P = .38), nor was receiving medication-assisted treatment for patients with opioid use disorder (odds ratio = 1.45; 95% CI, 0.62-2.56; P = .45). CONCLUSIONS: This study reports the highest SVR12 rate achieved in a state incarcerated population to date. HCV treatment in incarcerated populations is a practical and efficacious strategy that should serve a foundational role in HCV elimination.

Vermont-wide assessment of anthropogenic background concentrations of perfluoroalkyl substances in surface soils.

Shallow surface soils from 66 suburban sampling locations across Vermont were analyzed for 17 different perfluoroalkyl acids (PFAA). PFAA were detected in all 66 surface soils, with a total concentration of PFAA ranging from 540 to 36,000 ng/kg dry soil weight (dw). Despite the complexity of site-specific factors, some general trends and correlations in PFAA concentrations were observed. For instance, perfluoro-1-octanesulfonate (PFOS) dominated in all soil samples while seven other PFAA, including perfluoro-n-nonanoic acid, perfluoro-n-octanoic acid, perfluoro-n-hexanoic acid, perfluoro-n-heptanoic acid, perfluoro-n-decanoic acid, perfluoro-n-undecanoic acid, perfluoro-1-butanesulfonate, and perfluoro-1-hexanesulfonate (PFNA, PFOA, PFHxA, PFHpA, PFDA, PFUnDA, and PFBS, respectively), were identified at more than 50 % of the locations. Perfluoroalkyl carboxylic acids (PFCA) showed a positive correlation with total organic carbon, whereas no clear correlation was observed for perfluoroalkyl sulfonate acids (PFSA). In addition, variations in geographical distributions of PFAA were observed, with relatively higher total PFAA in northern regions when compared to Southern Vermont. Moreover, PFHxA, PFNA, PFDA, PFUnDA, PFOS, and total PFAA were positively correlated to land-use types in Northern Vermont. These results are useful for understanding unique behaviors of PFCA vs. PFSA in geospatially distributed surface soils and for providing anthropogenic background data for setting PFAS cleanup standards for surface soils.

Centering equity in flavored tobacco ban policies: Implications for tobacco control researchers.

To achieve equity in protection from poor health outcomes due to tobacco use, tobacco control policies and interventions need to affect socially disadvantaged groups more strongly than advantaged groups. Flavored tobacco bans have been seen as a policy with this potential. However, tobacco control researchers, in close concert with policy advocates, need to consider how to center equity throughout the policy process to achieve equitable outcomes from banning flavored tobacco. In this commentary, we outline the rationale for how and why tobacco control researchers should consider equity throughout the policy process to help fully achieve the potential of flavored tobacco ban policies. These recommendations emerged from a presentation at the Vermont Center on Behavior and Health 2021 Conference. Specifically, we focus on recommendations for tobacco control researchers to center equity including partnering with communities in agenda setting, examining how various policy formulations or exemptions may increase or decrease disparities, determining where flavor policies need to reach and whether policies are equitably reaching all populations disproportionately burdened by flavored tobacco, assessing whether policy implementation/enforcement is carried out equitably to maximize policy benefits, and evaluating policy impact with as much granularity as possible. Considering the entire policy process is central to enhancing equitable outcomes from banning flavored tobacco. Tobacco control researchers can play a key role in ensuring that these policies are viewed through an equity lens to, not just improve population health, but also to reduce harms to those disproportionately burdened by use of flavored products.

Gradual adoption of needle biopsy for breast lesions in a rural state.

BACKGROUND: Minimally invasive breast biopsy (MIBB) is the standard of care for the diagnosis of breast cancer, with consensus guidelines suggesting MIBB goals of 90% of total biopsies. In a previous study of patients in the rural state of Vermont, USA (population size of 640,000), rural breast cancer patients had open biopsies 42% of the time compared to 29% of urban breast cancer patients. The aim of this study was to assess overall population-based biopsy trends in Vermont. METHODS: The Vermont Breast Cancer Surveillance System (VBCSS) was used to identify women receiving MIBB and excisional breast biopsies in Vermont. Patient zip code at the time of initial biopsy was used to determine the patient residence rurality by rural-urban commuting area codes (RUCA 2.0™). RESULTS: There were 9122 diagnostic episodes from 1999 to 2018. MIBB was the initial biopsy method in 7524 (82.5%) cases, while surgical excision was the initial biopsy method in 1598 (17.5%) cases. A linear trend fit estimated an increase of 1.3% per year (p < 0.001, 95% CI 1.1%-1.5%) in the fraction of patients undergoing MIBB. Patients living in rural areas were less likely to receive MIBB (78.5%) than those living in urban areas (94.9%), p < 0.001. Multivariate analysis showed that urban patients and those patients in the years 2014-2018 were more likely to receive MIBB (OR 5.00, 95% CI 4.13-6.05 [p < 0.05] and OR 4.41, 95%CI 3.68-5.28 [p < 0.05], respectively). The rate of MIBB for rural patients increased and met the 90% quality standard in 2013 and ultimately matched urban patient rates of MIBB in 2018. CONCLUSIONS: For the first time, we show that MIBB usage is above 90% in the state of Vermont and that there no longer exist disparities in breast biopsies between urban and rural patients or rural/urban facilities in the state, overall.

Validation of field assessment stroke triage for emergency destination for prehospital use in a rural EMS system.

BACKGROUND: Field Assessment Stroke Triage for Emergency Destination (FAST-ED) is a simple and accurate prehospital stroke severity scale that has been shown to have comparable accuracy to the gold standard National Institutes of Health Stroke Scale (NIHSS) but requires further field validation for use by emergency medical services (EMS), particularly in rural systems. FAST-ED scores ≥4 are considered high probability for large vessel occlusion (LVO) strokes, while scores <4 are low to moderate probability for LVO. The objective of this study was to assess inter-rater reliability of the EMS FAST-ED (EMS) score to the emergency department FAST-ED (ED-MD) scores. METHODS: EMS calculated FAST-ED scores prior to transport to the emergency department (ED) on patients with a positive prehospital stroke screen. EDMD calculated FAST-ED scores for the same patients upon arrival to the ED. Interrater reliability and test characteristics were calculated. RESULTS: A total of 95 patients were included in this study and 14 were subsequently diagnosed with an LVO. EMS assigned 34 patients (35.8%) a FAST-ED score of ≥4. EDMD assigned 25 patients (26.3%) a FAST-ED score of ≥4. Using the clinical cut-points of FAST-ED scores <4 and ≥ 4, a linearly weighted Cohen's kappa coefficient showed moderate interrater reliability when comparing EMS and EDMD scores (kw 0.44, 95% CI 0.25-0.63). At ≥4, EMS FAST-ED scores had a sensitivity 0.48, specificity 0.75, PPV 0.62, NPV 0.62 for predicting an LVO, while EDMD FAST-ED scores had a sensitivity 0.36, specificity 0.82, PPV 0.64, NPV 0.60. Comparable receiver operator curve area under the curve values were obtained. CONCLUSIONS: EMS and EDMD FAST-ED scores were moderately comparable in a rural EMS system. Similar NPVs compared to EDMD suggest the use of FAST-ED as an appropriate screening tool for EMS to predict the probability of LVO in the prehospital setting and make destination determinations regarding primary transport to a thrombectomy-capable stroke center.

Influence of Opioid Prescription Policy on Overdoses and Related Adverse Effects in a Primary Care Population.

BACKGROUND: In response to the opioid epidemic, many states have enacted policies limiting opioid prescriptions. There is a paucity of evidence of the impact of opioid prescribing interventions in primary care populations, including whether unintended consequences arise from limiting the availability of prescribed opioids. OBJECTIVE: Our aim was to compare changes in opioid overdose and related adverse effects rate among primary care patients following the implementation of state-level prescribing policies. DESIGN: A cohort of primary care patients within an interrupted time series model. PARTICIPANTS: Electronic medical record data for 62,776 adult (18+ years) primary care patients from a major medical center in Vermont from January 1, 2016, to June 30, 2018. INTERVENTIONS: State-level opioid prescription policy changes limiting dose and duration. MAIN MEASURES: Changes in (1) opioid overdose rate and (2) opioid-related adverse effects rate per 100,000 person-months following the July 1, 2017, prescription policy change. KEY RESULTS: Among primary care patients, there was no change in opioid overdose rate following implementation of the prescribing policy (incidence rate ratio; IRR: 0.64, 95% confidence interval; CI: 0.22-1.88). There was a 78% decrease in the opioid-related adverse effects rate following the prescribing policy (IRR: 0.22, 95%CI: 0.09-0.51). This association was moderated by opioid prescription history, with decreases observed among opioid-naïve patients (IRR: 0.18, 95%CI: 0.06-0.59) and among patients receiving chronic opioid prescriptions (IRR: 0.17, 95%CI: 0.03-0.99), but not among those with intermittent opioid prescriptions (IRR: 0.51, 95%CI: 0.09-2.82). CONCLUSIONS: Limiting prescription opioids did not change the opioid overdose rate among primary care patients, but it reduced the rate of opioid-related adverse effects in the year following the state-level policy change, particularly among patients with chronic opioid prescription history and opioid-naïve patients. Limiting the quantity and duration of opioid prescriptions may have beneficial effects among primary care patients.

Precarious Essential Work, Immigrant Dairy Farmworkers, and Occupational Health Experiences in Vermont.

Migrant dairy workers in Vermont face a wide range of occupational and health hazards at work. This research examines the environmental risks, occupational health hazards, and health outcomes experienced by migrant dairy farm workers in Vermont. This research draws on a triangulation of sources including analysis of data-surveys and interviews with migrant dairy farmworkers gathered by the organization Migrant Justice since 2015 as well as relevant key informant interviews with community organizations across the state to characterize the occupational health experiences of migrant dairy workers in Vermont. Our results show that Vermont migrant dairy farmworkers received poor health and safety training and lacked sufficient protective gear. Over three quarters of the respondents reported experiencing harm from chemical and biological risks. Close to half the survey respondents reported headaches, itchy eyes and cough; a quarter reported breathing difficulties; three fourths reported being hurt by animal-related risks. These exposures and existing health concerns are avoidable. Migrant workers require better social representation and advocates to negotiate better work-related protection and training, access to health services, and social welfare to ensure their health and safety.

Assessment of Day-7 Postexposure Testing of Asymptomatic Contacts of COVID-19 Patients to Evaluate Early Release from Quarantine - Vermont, May-November 2020.

On May 8, 2020, the Vermont Department of Health (VDH) issued a Health Update* recommending shortening the duration of quarantine for persons exposed to SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Exposed persons who were in quarantine could be tested by polymerase chain reaction (PCR) on or after quarantine day 7. Those who had remained asymptomatic throughout quarantine and who received a negative SARS-CoV-2 PCR test result on or after day 7 could end quarantine. This policy was based on a report suggesting that symptom onset occurs within this time frame in approximately three quarters of COVID-19 cases (1) and on consultation of the Vermont Health Commissioner with the U.S. Surgeon General. VDH implemented this policy to minimize restrictions on state residents, recognizing that some reduction could occur in the prevention benefit of quarantine to contain the spread of SARS-CoV-2. State-run SARS-CoV-2 testing sites were made available to increase access to no-cost testing and facilitate implementation of this policy. During August 1-December 1, among persons seeking testing at a VDH SARS-CoV-2 testing site, 36% stated that their reason for seeking testing was to end quarantine early (VDH, unpublished data, December 7, 2020), indicating that persons were aware of and following the policy and using the testing services provided. To assess the effectiveness of this policy, VDH analyzed testing data for contacts of persons with a COVID-19 diagnosis. During May 8-November 16, VDH identified 8,798 exposed contacts of COVID-19 patients; 3,983 (45%) had sought testing within 14 days of their exposure, with day 0 defined as the date of last exposure noted in the case investigation record. Among these persons, 2,200 (55%) who received testing on days 7-10 were included in this analysis; 977 (44.9%) of these contacts had a specimen collected for testing on day 7. Among these, 34 (3%) had test results that were positive, 940 (96%) had results that were negative, and three (<1%) had results that were indeterminate (Table). Among the 34 contacts who received a positive SARS-CoV-2 PCR test result on day 7 after exposure, 12 (35%) were asymptomatic. The remaining 22 contacts with positive test results were symptomatic at the time of testing; approximately one half had developed symptoms on days 4-7 after exposure. Among the 940 contacts who received negative test results on specimens collected on day 7 after exposure, 154 (16%) had a subsequent test within the next 7 days (i.e., days 8-14); among these, 152 (99%) had tests that remained negative, and two (1%) had results that were indeterminate.

Life Cycle Assessment of Urine Diversion and Conversion to Fertilizer Products at the City Scale.

Urine diversion has been proposed as an approach for producing renewable fertilizers and reducing nutrient loads to wastewater treatment plants. Life cycle assessment was used to compare environmental impacts of the operations phase of urine diversion and fertilizer processing systems [via (1) a urine concentration alternative and (2) a struvite precipitation and ion exchange alternative] at a city scale to conventional systems. Scenarios in Vermont, Michigan, and Virginia were modeled, along with additional sensitivity analyses to understand the importance of key parameters, such as the electricity grid and wastewater treatment method. Both urine diversion technologies had better environmental performance than the conventional system and led to reductions of 29-47% in greenhouse gas emissions, 26-41% in energy consumption, approximately half the freshwater use, and 25-64% in eutrophication potential, while acidification potential ranged between a 24% decrease to a 90% increase. In some situations, wastewater treatment chemical requirements were eliminated. The environmental performance improvement was usually dependent on offsetting the production of synthetic fertilizers. This study suggests that urine diversion could be applied broadly as a strategy for both improving wastewater management and decarbonization.

Rapid Deployment of National Guard Alternative Healthcare Facility With Isolation Unit Capabilities in Response to COVID-19.

At the direction of Governor Phil Scott, the Vermont National Guard rapidly erected a 400-bed alternative healthcare facility field hospital to increase the state's medical capacity early in the COVID-19 pandemic when information was limited and cases were rapidly rising across the country. This case study reviews the preparation and management of the alternative healthcare facility's first COVID-19-positive patient assigned to the 50-bed COVID-19 isolation ward. Despite austere conditions with rudimentary improvements to a nonstandard facility, the ad hoc team composed entirely of members of the Vermont National Guard successfully oversaw patient care from admission to discharge while maintaining a zero-percent transmission rate to staff. While the local civilian medical infrastructure was never overwhelmed and patient census at the facility remained low, this case study highlights the capability of the National Guard enterprise as a community response to pandemic crises.

Geographic Coverage and Verification of Trauma Centers in a Rural State: Highlighting the Utility of Location Allocationfor Trauma System Planning.

BACKGROUND: Care at verified trauma centers has improved survival and functional outcomes, yet determining the appropriate location of potential trauma centers is often driven by factors other than optimizing system-level patient care. Given the importance of transport time in trauma, we analyzed trauma transport patterns in a rural state lacking an organized trauma system and implemented a geographic information system to inform potential future trauma center locations. STUDY DESIGN: Data were collected on trauma ground transport during a 3-year period (2014 through 2016) from the Statewide Incident Reporting Network database. Geographic information system mapping and location-allocation modeling of the best-fit facility for trauma center verification was computed using trauma transport patterns, population density, road network layout, and 60-minute emergency medical services transport time based on current transport protocols. RESULTS: Location-allocation modeling identified 2 regional facilities positioned to become the next verified trauma centers. The proportion of the Vermont population without access to trauma center care within 60 minutes would be reduced from the current 29.68% to 5.81% if the identified facilities become verified centers. CONCLUSIONS: Through geospatial mapping and location-allocation modeling, we were able to identify gaps and suggest optimal trauma center locations to maximize population coverage in a rural state lacking a formal, organized trauma system. These findings could inform future decision-making for targeted capacity improvement and system design that emphasizes more equitable access to trauma center care in Vermont.

Patients' and Caregivers' Experiences with the Multi-Payer Advanced Primary Care Practice Demonstration.

BACKGROUND: The patient-centered medical home (PCMH) model aims to improve primary health care using a patient-centered approach. Little qualitative research has investigated how the PCMH model affects patient experience with care. OBJECTIVE: To understand Medicaid and Medicare patient and caregiver experiences with PCMHs participating in the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration. DESIGN: Qualitative study. PARTICIPANTS: Medicare, Medicaid, and dually eligible patients who were patients in primary care practices participating in the MAPCP Demonstration and caregivers of such patients (N = 490). APPROACH: From July through November 2014, a trained facilitator conducted 81 focus groups in the eight states participating in the MAPCP Demonstration. Separate groups were held for Medicare high-risk, Medicare low-risk, Medicaid, and dually eligible beneficiaries, their caregivers, and caregivers of Medicaid children (or, in Vermont, with patients participating in the Support and Services at Home program), in two different geographical areas in each state. Focus group discussions were recorded, transcribed, and analyzed using NVivo qualitative data analysis software. RESULTS: Participants' experiences with care were generally consistent with the expectations of a PCMH, although some exceptions were noted. Medicaid only and dually eligible beneficiaries generally had less-positive experiences than Medicare beneficiaries. Most participants said their practices had not solicited feedback from them about their experiences with care. Few participants knew what the term "medical home" meant or were aware that their practices were working to become PCMHs, but many had noticed changes in recent years, primarily related to the conversion to electronic health records. CONCLUSIONS: Most participants had positive experiences with their care. Opportunities exist, however, to improve care for Medicaid and dually eligible beneficiaries, and enhance patient awareness of and involvement in PCMH practice transformation.