COVID-19 Vaccine Hesitancy and Uptake among Firefighters: An Application of the Health Belief Model.

OBJECTIVE: To assess COVID-19 vaccination prevalence and explore whether health beliefs were associated with vaccination among firefighters. METHODS: A cross-sectional online survey was distributed to Minnesota firefighters in March - April 2022. Survey questions included demographics, vaccination status, and beliefs about COVID-19 and vaccines. RESULTS: Of the survey respondents (N = 974, 91% male, 89% White), 76% were fully vaccinated and 53% were boosted. Firefighters were less likely to be vaccinated if they reported more perceived barriers (OR = 0.42, p < .001), greater decision-making ease (OR = 0.42, p < .001), and greater autonomy (OR = 0.65, p = .04). Greater perceived benefits (OR = 2.63, p < .001) and social norms (OR = 2.10, p < .001) were associated with a greater likelihood of being vaccinated. Similar results were seen predicting booster status. CONCLUSIONS: Firefighters had similar vaccination rates as the general population, despite high exposure risks. Health beliefs are strongly related to vaccination status.

Depression and anxiety among K-12 teachers in the United States: A systematic review.

Teachers experience high levels of stress and burnout; however, it is less clear whether teachers also experience high levels of depression and anxiety. The purpose of this systematic review was to describe the literature examining depression and anxiety among K-12 teachers in the United States, with a focus on (a) identifying factors that may be associated with and (b) describing interventions aimed at improving depression and/or anxiety among teachers. A literature search was conducted in January 2022 using APA PsycInfo, ERIC, CINAHL, Web of Science, and PubMed. Studies were eligible if they (a) measured U.S. K-12 teachers as an outcome; (b) measured teacher depression or anxiety; (c) were available in English; and (d) were published between 2000 and 2021. Two coders extracted key study information and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies and the U.S. Preventive Services Task Force checklist for clinical trials. This review included 19 studies (10 cross-sectional, four longitudinal, and five interventions). Studies indicated that teachers may experience greater levels of depression and anxiety than the general population. High perceived stress, poor coping skills, more student problem behaviors, and poor school climate were associated with greater depression and anxiety among teachers. Interventions achieved small to large reductions in depression and anxiety. This review suggests that several factors are related to depression and anxiety among teachers and is limited by the few studies that met the inclusion criteria. Interventions that use multilevel approaches to improve teacher mental health may be needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Data quality in a survey of registered medical cannabis users with cancer: nonresponse and measurement error.

Cannabis use among individuals with cancer is best understood using survey self-report. As cannabis remains federally illegal, surveys could be subject to nonresponse and measurement issues impacting data quality. We surveyed individuals using medical cannabis for a cancer-related condition in the Minnesota Medical Cannabis Program (MCP). Although survey responders are older, there are no differences by race and ethnicity, gender, or receipt of reduced cannabis registry enrollment fee. Responders made a more recent purchase and more recently completed an independent symptom assessment for the registry than nonresponders, suggesting some opportunity for nonresponse error. Among responders, self-report and MCP administrative data with respect to age, race, gender, registry certification, and cannabis purchase history were similar. Responders were less likely to report receipt of Medicaid than would be expected based on registry low-income enrollment eligibility. Although attention should be paid to potential for nonresponse error, surveys are a reliable tool to ascertain cannabis behavior patterns in this population.

In Their Own Words: Content Analysis of Open-Ended Survey Responses for a More Nuanced, Local Understanding of Mental Illness Stigma.

This content analysis seeks to extend what is already known in nursing and public health about the stigma attached to mental illness, and further understand the following evaluation question: How do members of communities targeted by Make It OK, a community initiative to reduce mental illness stigma, describe that stigma? The analysis of responses to open-ended questions included in a community-based survey followed deductive and inductive coding based on published frameworks and survey responses. The domains of stigma were categorized as actions toward people living with mental illness, beliefs about mental illness, and beliefs about people living with mental illness. These identified constructs build on the existing literature base of mental illness stigma in nursing and public health, illuminate the nuance of stigma, and can help tailor anti-stigma efforts.

Evidence to support health system prioritization of health behaviors in the COVID-19 era.

BACKGROUND: Since the COVID-19 pandemic health systems have shifted necessarily from chronic to infectious disease treatment, but chronic disease remains critical. One large health system uniquely tracks member health behaviors. This analysis compares data from select months of an ongoing monthly cross-sectional survey before and during the pandemic. METHODS: Responses in April 2019 (pre-pandemic), April 2020 (early pandemic) or April 2021 (later pandemic) were included in the primary analysis (N = 252). Differences in meeting health behavior guidelines were analyzed via logistic regression. RESULTS: A significant decline was seen for physical activity (19% not meeting guidelines pre-pandemic vs. 41% later pandemic) but not fruit/vegetable, alcohol, or sleep from early to later pandemic. Prevalence of women not meeting tobacco guidelines increased from early (5%) to later pandemic (10%) while prevalence in men decreased (10% vs 4% respectively). The percent of people not thinking about the good things that happen to them fluctuated closely with reports of new COVID-19 cases. CONCLUSIONS: Findings show the nuance of changing health behaviors throughout the pandemic. Results should be used by health systems to tailor support based on insights from the pandemic experience.

Don't Say "Beans" When Promoting Plant Protein to Family Meal Planners.

PURPOSE: To identify "headlines" that would engage recipients to consider plant protein over red meat. DESIGN: Mail and web survey. SETTING: Urban Minnesota community. SUBJECTS: 144 survey respondents from our health plan and community program distribution lists who live with at least 1 other person and eat meat. INTERVENTION: We asked respondents how likely they would be to click on each of 24 headlines with a motivator (eating plant protein for health vs for environmental reasons) and a barrier (family preferences, knowledge about plant proteins, or cooking skills). 16 headlines contained the word "beans". MEASURES: We created categorical variables for each headline construct: (1) motivator, (2) barrier, and (3) reference to beans. Using a mixed model with random effects, we compared, for each construct, respondents' self-reported likelihood to click on a headline. RESULTS: Health-related headlines performed significantly better than environmental headlines (P = .0019, 95% CI .01, .11). Family-oriented headlines performed slightly better than skills-oriented (P = .0927, 95% CI -.01, .11) and knowledge-oriented (P = .0960, 95% CI -.01, .11) headlines. Headlines containing the word "beans" performed significantly worse than those not containing "beans" (P < .0001, 95% CI -.22, -.12). CONCLUSIONS: The population represented by our survey respondents report being most likely to click on headlines that emphasize health and family. They report they are significantly less likely to click on headlines that promote beans.

The Impact of Text Messaging to Promote Patient Reported Outcome Measures (PROMs) Completion in Orthopedic Practice: Findings From a Randomized Controlled Study.

It is difficult to achieve high response rates to Patient Reported Outcome Measures (PROMs) surveys collected as part of clinical care. However, they are operationally and clinically important. To understand the impact of text message reminders on response rates to PROMs collected via email as part of routine care for hip or knee replacement surgery, initial nonresponders were randomized to receive a text reminder or not at 7 and 12 days, if needed. At day 7, the overall survey response rate was 63%. Model-derived estimates for survey return after this point were 51.1% (95% confidence interval [CI], 48.0%-54.2%) in the text arm compared to 34.5% (95% CI, 31.6%-37.6%) in the no text arm. The effect of text messages on response rates did not vary by subpopulations considered nor were there differences in rates of key outcomes between the 2 groups, suggesting that it did not impact any underlying response bias. Given the relative low cost of text messages, they can be an efficient means to increase response rates.

Qualitative Interviews to Add Patient Perspectives in Colorectal Cancer Screening: Improvements in a Learning Health System.

Health systems are interested in increasing colorectal cancer (CRC) screening rates as CRC is a leading cause of preventable cancer death. Learning health systems are ones that use data to continually improve care. Data can and should include qualitative local perspectives to improve patient and provider education and care. This study sought to understand local perspectives on CRC screening to inform future strategies to increase screening rates across our integrated health system. Health insurance plan members who were eligible for CRC screening were invited to participate in semi-structured phone interviews. Qualitative content analysis was conducted using an inductive approach. Forty member interviews were completed and analyzed. Identified barriers included ambivalence about screening options (e.g., "If it had the same performance, I'd rather do home fecal sample test. But I'm just too skeptical [so I do the colonoscopy]."), negative prior CRC screening experiences, and competing priorities. Identified facilitators included a positive general attitude towards health (e.g., "I'm a rule follower. There are certain things I'll bend rules. But certain medical things, you just got to do."), social support, a perceived risk of developing CRC, and positive prior CRC screening experiences. Study findings were used by the health system leaders to inform the selection of CRC screening outreach and education strategies to be tested in a future simulation model. For example, the identified barrier related to ambivalence about screening options led to a proposed revision of outreach materials that describe screening types more clearly.

Is There Room for Individual Patient-Specified Preferences in the Patient-Reported Outcome Measurement Revolution?

Purpose: The study aim was to test the feasibility of collecting qualitative patient-preferred outcomes or goals and the degree of their attainment as an addition to a standardized process for collecting quantitative composite patient-reported outcome measures (PROMs) from patients undergoing knee joint replacement. Methods: Patients of a large Midwestern medical group scheduled to have total replacement of their knee joint have been asked to complete a PROMs survey preoperatively and at 3 and 12 months after surgery since 2014. In March 2020, an open-ended question about their most important preferred outcome was added to the existing questionnaire. The responses for all 3 time periods from the first 6 months of this addition were summarized quantitatively and analyzed by 2 reviewers. Results: During that 6-month period, 1481 people completed the main survey while 1463 (98.8%) also completed the open-ended question. At baseline, 90.8% of the 590 baseline respondents identified a preferred outcome. If multiple-choice categories had been used, 82.7% of the responses would have lost some or a large amount of their preferred goals' meaning. Of the 144 who completed surveys at both baseline and 3 months, 86.1% reported another outcome in addition to pain relief, while 54.2% reported "Complete or Mostly" achieving their self-identified preferred outcome. Conclusions: Most people who have joint replacement surgery and respond to a quantitative PROMs survey are willing to report on their other preferred outcomes as well. Adding an open-ended question to PROMs surveys may increase clinician focus on addressing outcomes important to each patient.

Care coordination in primary care: mapping the territory.

OBJECTIVE: To document the current approaches to care coordination among different types of care systems in Minnesota. STUDY DESIGN: Observational survey of leaders of most of the care systems in Minnesota that have implemented care coordination. METHODS: Survey questions about organizational structure, size, and approach to care coordination were sent to the leaders of 42 care systems with a total of 327 primary care clinics. RESULTS: Surveys were completed by leaders at every care system participating in this study (100% response rate); 16 small care systems (each with 1-2 clinics) had a total of 26 primary care clinics, 15 medium care systems (3-9 clinics) had 57 clinics, and 11 large care systems (> 9 clinics) had 244 clinics. The large care systems had larger clinics (clinicians per clinic, 8.6 in large vs 4.3 in small and 5.2 in medium; P = .03) and more clinicians per care coordinator (5.7 vs 3.3 and 4.0; P = .04). They also more frequently included a social worker in their care coordination team: 82% vs 25% of small and 40% of medium care systems (P = .01). However, the services provided and complexity tools used were similar. Nearly all reported addressing both medical and social needs for their complex patients with multiple chronic conditions. CONCLUSIONS: Although there are large differences in resources and capabilities between large and small care systems, they were not associated with much difference in the approach taken to care coordination. This map of the care coordination territory in Minnesota has the potential to be valuable to researchers and care system leaders for understanding current implementation trends and directing further evaluations.

Survey-based Evaluation of a Fish Consumption Information Dissemination Campaign Within an Integrated Health System: Learnings From ChooseYourFish.

INTRODUCTION/OBJECTIVES: Safe fish consumption is important for people who are or could become pregnant. A health system in Minnesota partnered with the Minnesota Department of Health to develop and disseminate messages to promote safe fish consumption for this population via the ChooseYourFish initiative. The ChooseYourFish message was delivered through 5 channels: the Healthy Pregnancy Program (HPP) with phone-based coaching, a clinic brochure, in the clinic after visit summary (AVS), direct mailing of the brochure with a letter, and in images on clinic waiting room monitors. METHODS: We designed a pragmatic evaluation to understand the likelihood that each channel would result in awareness of the message and increase a recipient's intent to act on the information. We surveyed 1050 women aged 18 to 40 in March-May 2020. Results are reported with descriptive statistics. RESULTS: The survey was completed by 524 respondents (51%). Respondents receiving the ChooseYourFish message through any channel except clinic monitors reported a higher awareness of recommendations about eating fish (42%-56%) than respondents in the no-message comparison group (21%). The after visit summary and Healthy Pregnancy Program channels had more confidence in following recommendations (50%-54%) and showed more intention to eat fish (61%-62%) compared to lower-intensity channels (24%-31% and 19%-32%, respectively). CONCLUSIONS: Messages delivered by an often-trusted source (eg, healthcare provider) were more likely to increase confidence and intent. Despite the trend toward online health information, physical brochures still have large reach. Repetition of exposure may be important. Because all communication channels have advantages and drawbacks, using multiple delivery channels is appropriate in communication campaigns.

America's Racial Reckoning Within Perinatal Communication: A Rapid Review Using Sociotechnical Systems Theory to Compare Publications Before and After 2020.

Perinatal communication is one factor driving racial disparities in maternal and infant morbidity. The murder of George Floyd in May 2020, in addition to the disproportionate impacts of the Covid-19 pandemic on communities of color, was a catalyst for American society to address racial injustices with a renewed sense of urgency. Drawing upon sociotechnical systems (STS) theory, this rapid review describes changes in the literature regarding the organizational, social, technical, and external subsystems that affect communication between perinatal providers and their Black patients. The goal of this work is to support health system optimization of health communication initiatives and, as a result, improve patient experience and parent and child outcomes. As part of a multi-year project designed to improve health communications about safe fish consumption during pregnancy, and in response to racial disparities among our health system's patient population related to receipt of nutrition messages during prenatal visits, we conducted a rapid review of literature on Black parents' experience of all communication while receiving perinatal care. A search of PubMed identified relevant articles published in English since 2000. Articles were screened to include articles that focused on Black people receiving perinatal care. Article content was then coded using deductive content analysis guided by STS theory to inform healthcare system improvement efforts. Differences in the prevalence of codes pre- and post-2020 are compared using chi-square statistics. The search in PubMed yielded 2419 articles. After screening, 172 articles were included in the rapid review. There was an increased recognition of communication as a key component of quality perinatal care after 2020 (P = .012) and of the limitations of standardized technical communication (P = .002) after 2020. Emerging literature suggests improving perinatal health communication and relationships with Black parents would address disparities in perinatal patient and baby outcomes. Healthcare systems must address the racial disparities in maternal and child outcomes. Since 2020, public attention and published research on this issue has increased. Understanding perinatal communication using STS theory aligns subsystems in service of racial justice.

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.

Comparing Pharmacist-Led Telehealth Care and Clinic-Based Care for Uncontrolled High Blood Pressure: The Hyperlink 3 Pragmatic Cluster-Randomized Trial.

BACKGROUND: A team approach is one of the most effective ways to lower blood pressure (BP) in uncontrolled hypertension, but different models for organizing team-based care have not been compared directly. METHODS: A pragmatic, cluster-randomized trial compared 2 interventions in adult patients with moderately severe hypertension (BP≥150/95 mm Hg): (1) clinic-based care using best practices and face-to-face visits with physicians and medical assistants; and (2) telehealth care using best practices and adding home BP telemonitoring with home-based care coordinated by a clinical pharmacist or nurse practitioner. The primary outcome was change in systolic BP over 12 months. Secondary outcomes were change in patient-reported outcomes over 6 months. RESULTS: Participants (N=3071 in 21 primary care clinics) were on average 60 years old, 47% male, and 19% Black. Protocol-specified follow-up within 6 weeks was 32% in clinic-based care and 27% in telehealth care. BP decreased significantly during 12 months of follow-up in both groups, from 157/92 to 139/82 mm Hg in clinic-based care patients (adjusted mean difference -18/-10 mm Hg) and 157/91 to 139/81 mm Hg in telehealth care patients (adjusted mean difference -19/-10 mm Hg), with no significant difference in systolic BP change between groups (-0.8 mm Hg [95% CI, -2.84 to 1.32]). Telehealth care patients were significantly more likely than clinic-based care patients to report frequent home BP measurement, rate their BP care highly, and report that BP care visits were convenient. CONCLUSIONS: Telehealth care that includes extended team care is an effective and safe alternative to clinic-based care for improving patient-centered care for hypertension. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02996565.

Is the Promise of PROMs Being Realized? Implementation Experience in a Large Orthopedic Practice.

Patient-reported outcome measures (PROMs), increasingly used for research and quality measurement, are lauded for their potential to improve patient-centered care, both through aggregate reporting and when integrated into clinical practice. However, there are few published studies of the resultant use of PROMs in clinical practice. This case study describes the implementation and use of PROMS in a Midwestern multispecialty medical group orthopedic practice among patients undergoing total knee and hip surgery. Specifically, rates of PROMs use by care teams are tracked over time once made available in the electronic health record. During this time, the orthopedics department achieved a patient PROMS survey response rate of 68% at baseline, 58% 3 months post-surgery, and 55% 12 months post-surgery. However, these data were only accessed by the care teams for fewer than 1% of associated clinical encounters. This suggests that making PROMs available for care team review in the electronic health record, even when coupled with relatively high response rates from patients and departmental leadership support is not enough to encourage integration of PROMs into clinical care for patients. Additional effort is required to identify barriers to PROMs use in clinical care and to test methods to enhance use.

FINDINGS AND FUTURE DIRECTIONS FROM A SMOKING CESSATION TRIAL UTILIZING A CLINICAL DECISION SUPPORT TOOL.

BACKGROUND: Tobacco smoking is the leading cause of disease, death, and disability in the United States. Dental practitioners are advised to provide evidence-based smoking cessation interventions to their patients, yet dental practitioners frequently fail to deliver brief smoking cessation advice. OBJECTIVES: To test whether giving dental practitioners a clinical decisions support (CDS) system embedded in their electronic dental record would increase the rate at which patients who smoke (1) report receiving a brief intervention or referral to treatment during a recent dental visit, (2) taking action related to smoking cessation within 7 days of visit, and (3) stop smoking for 1 day or more or reduce the amount smoked by 50% within 6 months. METHODS: Two-group, parallel arm, cluster-randomized trial. From March through December 2019, 15 nonacademic primary care dental clinics were randomized via covariate adaptive randomization to either a usual care arm or the CDS arm. Adult smokers completed an initial telephone survey within 7 days of their visit and another survey after 6 months. RESULTS: Forty-three patients from 5 CDS and 13 patients from 2 usual care clinics completed the 7-day survey. While the proportion of patients who reported receipt of a brief intervention or referral to treatment was significantly greater in the CDS arm than the usual care arm (84.3% vs 58.6%; P = .005), the differences in percentage of patients who took any action related to smoking cessation within 7 days (44.4% vs 22.3%; P = .077), or stopped smoking for one day or more and/or reduced amount smoked by 50% within 6 months (63.1% vs 46.2%; P = .405) were large but not statistically significant. CONCLUSIONS: Despite interruption by COVID-19, these results demonstrate a promising approach to assist dental practitioners in providing their patients with smoking cessation screening, brief intervention and referral to treatment.

Behaviors, Beliefs, and Recommendations to Optimize Promotion of Safe Fish Consumption Before and During Pregnancy: A Physician Survey.

INTRODUCTION: Eating fish before and during pregnancy is important but care must be taken to choose fish which maximize developmental outcomes. Physicians, a trusted health information source, could provide this nuanced communication. This cross-sectional survey of a representative sample of 400 family medicine and obstetrics and gynecology (OB-GYN) physicians in Minnesota was designed to understand physician behaviors and beliefs about safe fish consumption, describe barriers to physician-patient conversations about safe fish consumption generally and as part of prenatal care and to identify resources to help facilitate conversations on this topic. METHODS: Data was collected January to April 2020. Two hundred nineteen surveys were completed (55% response rate) with 194 reporting seeing patients at least 1 day a week. Descriptive survey results from all were summarized and analyzed overall and by physician specialty. Responses to 3 open-ended questions were thematically coded to enrich the quantitative results. RESULTS: While 62% of these reported discussing nutrition topics, only about one-third reported discussing with patients the benefits and about one-quarter the risks of eating fish. Despite the relative infrequency of fish discussions, almost all (>90%) respondents agreed that it is important to discuss fish consumption with people who are or may become pregnant. The largest reported barrier to these conversations was time (82%), and the most endorsed resource to overcome identified barriers was talking points (72%). CONCLUSIONS: Because physicians report limited time, resources that facilitate fish consumption should be succinct while serving to both nudge the message and direct clinicians and their patients to robust information.

Comparison of explanatory and pragmatic design choices in a cluster-randomized hypertension trial: effects on enrollment, participant characteristics, and adherence.

BACKGROUND: Explanatory trials are designed to assess intervention efficacy under ideal conditions, while pragmatic trials are designed to assess whether research-proven interventions are effective in "real-world" settings without substantial research support. METHODS: We compared two trials (Hyperlink 1 and 3) that tested a pharmacist-led telehealth intervention in adults with uncontrolled hypertension. We applied PRagmatic Explanatory Continuum Indicator Summary-2 (PRECIS-2) scores to describe differences in the way these studies were designed and enrolled study-eligible participants, and the effect of these differences on participant characteristics and adherence to study interventions. RESULTS: PRECIS-2 scores demonstrated that Hyperlink 1 was more explanatory and Hyperlink 3 more pragmatic. Recruitment for Hyperlink 1 was conducted by study staff, and 2.9% of potentially eligible patients enrolled. Enrollees were older, and more likely to be male and White than non-enrollees. Study staff scheduled the initial pharmacist visit and adherence to attending this visit was 98%. Conversely for Hyperlink 3, recruitment was conducted by clinic staff at routine encounters and 81% of eligible patients enrolled. Enrollees were younger, and less likely to be male and White than non-enrollees. Study staff did not assist with scheduling the initial pharmacist visit and adherence to attending this visit was only 27%. Compared to Hyperlink 1, patients in Hyperlink 3 were more likely to be female, and Asian or Black, had lower socioeconomic indicators, and were more likely to have comorbidities. Owing to a lower BP for eligibility in Hyperlink 1 (>140/90 mm Hg) than in Hyperlink 3 (>150/95 mm Hg), mean baseline BP was 148/85 mm Hg in Hyperlink 1 and 158/92 mm Hg in Hyperlink 3. CONCLUSION: The pragmatic design features of Hyperlink 3 substantially increased enrollment of study-eligible patients and of those traditionally under-represented in clinical trials (women, minorities, and patients with less education and lower income), and demonstrated that identification and enrollment of a high proportion of study-eligible subjects could be done by usual primary care clinic staff. However, the trade-off was much lower adherence to the telehealth intervention than in Hyperlink 1, which is likely to reflect uptake under real-word conditions and substantially dilute intervention effect on BP. TRIAL REGISTRATION: The Hyperlink 1 study (NCT00781365) and the Hyperlink 3 study (NCT02996565) are registered at ClinicalTrials.gov.

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.